Delivering the highest possible quality of care is among the top priorities of all medical centers. That said, any quality innovation must be seen as adding value from a variety of perspectives. Especially in the current economic climate, a sound business case is paramount to the advancement of any quality innovation. Given the nature of their work, hospitalists are ideally suited to undertake system improvement innovations. To assist hospitalists in successfully implementing quality and safety initiatives, we have designed a framework of elements required for a business case. We describe our experience developing and implementing an electronic discharge summary and utilize a structured framework to articulate the business case for its implementation.

Defining a Business Case Framework

A business case is a structured proposal outlining the qualitative and quantitative factors that justify a course of action. An effective business case for a quality improvement initiative articulates how both factors are aligned with preexisting organizational goals. In modeling the business case framework for the electronic discharge summary, Figure 1 outlines the qualitative and quantitative costs and benefits that can affect institutional decision making.

Figure 1

The Business Case for an Electronic Discharge Summary at University of California San Francisco (UCSF)

Application of the Business Framework to the Case for an Electronic Discharge

Considering the potential improvements in care delivery, the argument for an electronic discharge summary may seem self‐evident. To realize its implementation, however, it is necessary to consider other aspects of organizational decision making. We employed the following structure to articulate a robust and sound business case for e‐discharge.

Qualitative Benefits

Quantitative Benefits

Qualitative Costs

Quantitative Costs

Quantitative Costs will be highly variable across institutions, geographical areas, and software platforms as the infrastructure of existing EMRs are highly variable. The cost of implementation depends heavily on whether inpatient documentation (and thus discharge documentation) is a feature of an institutional EMR, or whether a stand‐alone discharge documentation infrastructure is needed. An explanation of the differences between these types of EMRs and the importance to the cost of infrastructure implementation is further described in the following section. Rather than providing a direct accounting of costs, we have provided a tabular summary of costs that should be considered with the adoption of an electronic discharge summary based on the type of institutional EMR (Table 1).

Conclusion

While many QI initiatives have the potential to improve clinical care, resource limitations and competing priorities necessitate that hospital decision makers see the value of hospitalist driven improvements. A sound business case is the key to successfully influencing decision making and furthering necessary innovations. We have detailed the elements of a business case and applied them to a proposed innovationthe electronic discharge summary. While the cost of multifunctional EMR with full electronic care documentation may be impossible to implement given high initial costs and competing priorities, investing in an e‐discharge solution has real‐time benefits in the impact on patients, system improvements, qualitative benefits, and return on investment. Being able to articulate key qualitative and quantitative elements creates a sound business case that can be applied to QI initiatives in general, and assist hospitalists in garnering support and resources to continue to improve care.

Delivering the highest possible quality of care is among the top priorities of all medical centers. That said, any quality innovation must be seen as adding value from a variety of perspectives. Especially in the current economic climate, a sound business case is paramount to the advancement of any quality innovation. Given the nature of their work, hospitalists are ideally suited to undertake system improvement innovations. To assist hospitalists in successfully implementing quality and safety initiatives, we have designed a framework of elements required for a business case. We describe our experience developing and implementing an electronic discharge summary and utilize a structured framework to articulate the business case for its implementation.

Defining a Business Case Framework

A business case is a structured proposal outlining the qualitative and quantitative factors that justify a course of action. An effective business case for a quality improvement initiative articulates how both factors are aligned with preexisting organizational goals. In modeling the business case framework for the electronic discharge summary, Figure 1 outlines the qualitative and quantitative costs and benefits that can affect institutional decision making.

Figure 1

The Business Case for an Electronic Discharge Summary at University of California San Francisco (UCSF)

Application of the Business Framework to the Case for an Electronic Discharge

Considering the potential improvements in care delivery, the argument for an electronic discharge summary may seem self‐evident. To realize its implementation, however, it is necessary to consider other aspects of organizational decision making. We employed the following structure to articulate a robust and sound business case for e‐discharge.

Qualitative Benefits

Quantitative Benefits

Qualitative Costs

Quantitative Costs

Quantitative Costs will be highly variable across institutions, geographical areas, and software platforms as the infrastructure of existing EMRs are highly variable. The cost of implementation depends heavily on whether inpatient documentation (and thus discharge documentation) is a feature of an institutional EMR, or whether a stand‐alone discharge documentation infrastructure is needed. An explanation of the differences between these types of EMRs and the importance to the cost of infrastructure implementation is further described in the following section. Rather than providing a direct accounting of costs, we have provided a tabular summary of costs that should be considered with the adoption of an electronic discharge summary based on the type of institutional EMR (Table 1).

Conclusion

While many QI initiatives have the potential to improve clinical care, resource limitations and competing priorities necessitate that hospital decision makers see the value of hospitalist driven improvements. A sound business case is the key to successfully influencing decision making and furthering necessary innovations. We have detailed the elements of a business case and applied them to a proposed innovationthe electronic discharge summary. While the cost of multifunctional EMR with full electronic care documentation may be impossible to implement given high initial costs and competing priorities, investing in an e‐discharge solution has real‐time benefits in the impact on patients, system improvements, qualitative benefits, and return on investment. Being able to articulate key qualitative and quantitative elements creates a sound business case that can be applied to QI initiatives in general, and assist hospitalists in garnering support and resources to continue to improve care.

Delivering the highest possible quality of care is among the top priorities of all medical centers. That said, any quality innovation must be seen as adding value from a variety of perspectives. Especially in the current economic climate, a sound business case is paramount to the advancement of any quality innovation. Given the nature of their work, hospitalists are ideally suited to undertake system improvement innovations. To assist hospitalists in successfully implementing quality and safety initiatives, we have designed a framework of elements required for a business case. We describe our experience developing and implementing an electronic discharge summary and utilize a structured framework to articulate the business case for its implementation.

Defining a Business Case Framework

A business case is a structured proposal outlining the qualitative and quantitative factors that justify a course of action. An effective business case for a quality improvement initiative articulates how both factors are aligned with preexisting organizational goals. In modeling the business case framework for the electronic discharge summary, Figure 1 outlines the qualitative and quantitative costs and benefits that can affect institutional decision making.

Figure 1

The Business Case for an Electronic Discharge Summary at University of California San Francisco (UCSF)

Application of the Business Framework to the Case for an Electronic Discharge

Considering the potential improvements in care delivery, the argument for an electronic discharge summary may seem self‐evident. To realize its implementation, however, it is necessary to consider other aspects of organizational decision making. We employed the following structure to articulate a robust and sound business case for e‐discharge.

Qualitative Benefits

Quantitative Benefits

Qualitative Costs

Quantitative Costs

Quantitative Costs will be highly variable across institutions, geographical areas, and software platforms as the infrastructure of existing EMRs are highly variable. The cost of implementation depends heavily on whether inpatient documentation (and thus discharge documentation) is a feature of an institutional EMR, or whether a stand‐alone discharge documentation infrastructure is needed. An explanation of the differences between these types of EMRs and the importance to the cost of infrastructure implementation is further described in the following section. Rather than providing a direct accounting of costs, we have provided a tabular summary of costs that should be considered with the adoption of an electronic discharge summary based on the type of institutional EMR (Table 1).

Conclusion

While many QI initiatives have the potential to improve clinical care, resource limitations and competing priorities necessitate that hospital decision makers see the value of hospitalist driven improvements. A sound business case is the key to successfully influencing decision making and furthering necessary innovations. We have detailed the elements of a business case and applied them to a proposed innovationthe electronic discharge summary. While the cost of multifunctional EMR with full electronic care documentation may be impossible to implement given high initial costs and competing priorities, investing in an e‐discharge solution has real‐time benefits in the impact on patients, system improvements, qualitative benefits, and return on investment. Being able to articulate key qualitative and quantitative elements creates a sound business case that can be applied to QI initiatives in general, and assist hospitalists in garnering support and resources to continue to improve care.

While a general consensus exists that surface wound cultures have less utility than deeper cultures, surface cultures are nevertheless routinely used to guide empiric antibiotic administration. This is due in part to the ease with which surface cultures are obtained and the delay in obtaining deeper wound and bone cultures. The Infectious Diseases Society of America (IDSA) recommends routine culture of all diabetic infections before initiating empiric antibiotic therapy, despite caveats regarding undebrided wounds.1 Further examination of 2 additional societies, the European Society of Clinical Microbiology and Infectious Diseases and the Australasian Society for Infectious Diseases, reveals that they also do not describe guidelines on the role of surface wound cultures in skin, and skin structure infection (SSSI) management.2, 3

Surface wound cultures are used to aid in diagnosis and appropriate antibiotic treatment of lower extremity foot ulcers.4 Contaminated cultures from other body locations have shown little utility and may be wasteful of resources.5, 6 We hypothesize that given commensal skin flora, coupled with the additional flora that colonizes (chronic) lower extremity wounds, surface wound cultures provide poor diagnostic accuracy for determining the etiology of acute infection. In contrast, many believe that deep tissue cultures obtained at time of debridement or surgical intervention may provide more relevant information to guide antibiotic therapy, thus serving as a gold standard.13, 7, 8 Nevertheless, with the ease of obtaining these superficial cultures and the promptness of the results, surface wound cultures are still used as a surrogate for the information derived from deeper cultures.

Purpose

The frequency at which superficial wound cultures correlate with the data obtained from deeper cultures is needed to interpret the posttest likelihood of infection. However, the sensitivity and specificity of superficial wound culture as a diagnostic test is unclear. The purpose of this study is to conduct a systematic review of the existing literature in order to investigate the relationship between superficial wound cultures and the etiology of SSSI. Accordingly, we aim to describe any role that surface wound cultures may play in the treatment of lower extremity ulcers.

Materials and Methods

Data Sources

We identified eligible articles through an electronic search of the following databases: Medline through PubMed, Excerpta Medica Database (EMBASE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Scopus. We also hand searched the reference lists of key review articles identified by the electronic search and the reference lists of all eligible articles (Figure 1).

Figure 1

Results

Of 9032 unique citations, eight studies met all inclusion criteria (Figure 1). Inter‐rater reliability was substantial (Kappa = 0.78).12 Areas of initial disagreement generally involved whether a study adequately described an appropriate alternative culture method for comparison or whether data available in an article was sufficient for sensitivity and specificity calculation. Consensus was achieved once the full article was retrieved, reviewed and discussed.

The 8 studies evaluated in the review included a total number of 615 patients or samples (Table 1). Diabetic wounds were described in four studies.1316 Two studies described wounds associated with peripheral vascular disease,13, 17 while four involved traumatic wounds.13, 1719 One study did not identify the clinical circumstances concerning the wounds.20

The studies used several different methods for obtaining superficial cultures. Six studies obtained purulent wound drainage material through the application of sterile swabs.1316, 18, 19 One study obtained purulent drainage material using needle aspiration.18 Two studies obtained culture material from sinus tracts associated with the wounds, one through sinus tract washings17 and another by obtaining sinus tract discharge material.20

The types of comparison cultures used were equally divided between deep tissue biopsies1316 and bone biopsies,1720 each accounting for 50% (4 of 8) of studies.

In assessing the data from the eight studies, the pooled test sensitivity for superficial wound swabs was 49% (95% confidence interval [CI], 37‐61%) (Figure 2). The pooled specificity for superficial wound swabs was 62% (95% CI, 51‐74%), while the pooled positive and negative LRs were 1.1 (95% CI, 0.71‐1.5) and 0.67 (95% CI, 0.52‐0.82), respectively (Figure 2).

Figure 2

The median number of bacterial isolates reported for each culture type, superficial and comparison culture, was collected from each study (Table 2). The median value for number of bacterial isolates identified by superficial culture was 2.7 (interquartile range [IQR] 1.8‐3.2). The median value for number of bacterial isolates identified by comparison culture was 2.2 (IQR 1.7‐2.9). A Wilcoxon rank sum analysis showed that the number of isolates for surface wound cultures was not significantly different than the number of isolates for comparison cultures (P = 0.75) (Table 1).

Discussion

In performing this review, we discovered ambiguity in the literature regarding the utility of surface wound cultures. Some studies obtained findings to suggest the utility of surface wound cultures,8, 14, 17 while other studies in our review16, 18, 19 provided evidence against them. This variability confirmed the need for a meta‐analytic approach as provided by this review.

While we have tried to minimize bias through a well‐established methodology, we acknowledge that certain methodological limitations should be considered in interpreting the results. There may be publication bias in reviews that include only published articles; a funnel plot of sensitivity vs. sample size showed some asymmetry, suggesting bias. Our search strategy was limited to English‐only articles, which may result in publication bias.

Further, this review included a group of studies that were heterogeneous in several regards. Differences exist in culturing methods and laboratory technology, as exemplified by the variety of superficial culture methods used. We were not able to account for these laboratory differences, as methodologies in obtaining and isolating bacteria were not uniformly well described.

Additionally, the studies classified organisms in different ways. Three studies categorized organisms according to Gram's stain characteristics.13, 16, 18 One study described organisms primarily in terms of aerobic or anaerobic respiration.15 Two studies14, 19 discussed pathogens both in terms of respiration (aerobic/anaerobic) and Gram's stain characteristic, while another 2 studies17, 20 did not describe organisms in either terms. These inconsistencies limited our ability to provide sensitivity and specificity information for specific subclasses of organisms.

The clinical conditions in each study surrounding the wounds were also heterogeneous: most significantly in the issue of prior antibiotic administration. All but 1 study16 indicated that the patients had received antibiotics prior to having cultures obtained. The type of antibiotics (narrow‐spectrum or broad‐spectrum), the route of administration, and the cessation of antibiotics in relation to obtaining swabs and cultures all varied widely or were not well described. This degree of ambiguity will necessarily impact both the reliability of data regarding microbial growth as well as the component flora.

The inclusion of higher quality studies is likely to result in a more reliable meta‐analysis.21 We had hoped that antibiotic trials would contain uniform outcomes and thus strengthen our meta‐analysis through the inclusion of randomized‐controlled studies. Unfortunately, the majority of antibiotic trials did not use superficial wound cultures, did not report mean number of isolates, or did not provide microbiological data in sufficient detail to calculate concordance ratesand therefore, did not meet eligibility criteria. Randomized‐controlled trials were a minority among our included articles; the majority of study designs were retrospective cohorts and case‐controlled studies.

Despite these limitations, we were able to conclude that superficial wound culture provides mediocre sensitivity (49%) and specificity (62%). The positive LR of 1.1 is unhelpful in decision making, having a CI that includes 1. Interestingly, the negative LR of 0.67 could be somewhat helpful in medical decision making, modifying the pretest probability and assisting in ruling out a deeper bacterial infection. Although, according to Fagan's nomogram, a negative LR of 0.67 has only a mild effect on pretest odds.22

The bacterial bioburden assessed by the number of isolates obtained by culture method serves as a proxy for reliability of culture results14, 23 by suggesting that fewer organisms isolated from deep tissue or bone samples reflects a less contaminated specimen. Our assessment of the bioburden found that the median number of isolates was slightly higher in surface cultures than deeper cultures, though not to a significant degree (P = 0.75). This indicates that the degree of contamination in superficial cultures was neither significantly worse nor better than deep cultures.

We attempted to define a role for surface wound cultures; however, we found that these did not show any greater utility than deep cultures for identifying the microbiologic etiology of diabetic wound infections. While the negative LR provides some quantitative verification of the common clinical practice that a negative culture argues against infection, the finding is not especially robust.

Although for this meta‐analysis we grouped all organisms in the same way, we recognize that the sensitivity and specificity may differ according to various subclasses of bacteria. Interpretations of culture results also vary (eg, Gram positive vs. negative; aerobic vs. anaerobic); practitioners will not interpret superficial cultures of coagulase‐negative Staphylococcus in the same way as Pseudomonas. However, this study seeks to establish a reasonable starting point for the medical decision‐making process by providing quantitative values in an area with previously conflicting data. We anticipate that as laboratory techniques improve and research into superficial wounds continues, greater sensitivity of superficial wound cultures will result.

Ultimately, physicians use culture data to target therapy in an effort to use the least toxic and most effective antimicrobial agent possible to successfully treat infections. Clinical outcomes were not described in all included articles; in those that did, the endpoints were too dissimilar for meaningful comparison. Limiting our review to studies reporting treatment outcomes would have resulted in too few included studies. Thus, we were unable able to assess whether superficial wound cultures were associated with improved patient‐oriented outcomes in this meta‐analysis.

There is a significant paucity of trials evaluating the accurate concordance of superficial swabs to deep tissue culture. The current data shows poor sensitivity and specificity of superficial culture methods. The presumption that deeper cultures (such as a bone biopsy) should result in a less contaminated sample and more targeted culture results was also not borne out in our review. When presented with a patient with a wound infection, physicians mentally supply a pretest (or a pretreatment) probability as to the microbiologic etiology of the infection. Careful history will, of course, be critical in identifying extenuating circumstance or unusual exposures. From our meta‐analysis, we cannot recommend the routine use of superficial wound cultures to guide initial antibiotic therapy as this may result in poor resource utilization.5 While clinical outcomes from the use of routine superficial cultures are unclear, we suggest greater use of local antibiograms and methicillin‐resistant Staphylococcus aureus (MRSA) prevalence data to determine resistance patterns and guide the selection of empiric therapies.

While a general consensus exists that surface wound cultures have less utility than deeper cultures, surface cultures are nevertheless routinely used to guide empiric antibiotic administration. This is due in part to the ease with which surface cultures are obtained and the delay in obtaining deeper wound and bone cultures. The Infectious Diseases Society of America (IDSA) recommends routine culture of all diabetic infections before initiating empiric antibiotic therapy, despite caveats regarding undebrided wounds.1 Further examination of 2 additional societies, the European Society of Clinical Microbiology and Infectious Diseases and the Australasian Society for Infectious Diseases, reveals that they also do not describe guidelines on the role of surface wound cultures in skin, and skin structure infection (SSSI) management.2, 3

Surface wound cultures are used to aid in diagnosis and appropriate antibiotic treatment of lower extremity foot ulcers.4 Contaminated cultures from other body locations have shown little utility and may be wasteful of resources.5, 6 We hypothesize that given commensal skin flora, coupled with the additional flora that colonizes (chronic) lower extremity wounds, surface wound cultures provide poor diagnostic accuracy for determining the etiology of acute infection. In contrast, many believe that deep tissue cultures obtained at time of debridement or surgical intervention may provide more relevant information to guide antibiotic therapy, thus serving as a gold standard.13, 7, 8 Nevertheless, with the ease of obtaining these superficial cultures and the promptness of the results, surface wound cultures are still used as a surrogate for the information derived from deeper cultures.

Purpose

The frequency at which superficial wound cultures correlate with the data obtained from deeper cultures is needed to interpret the posttest likelihood of infection. However, the sensitivity and specificity of superficial wound culture as a diagnostic test is unclear. The purpose of this study is to conduct a systematic review of the existing literature in order to investigate the relationship between superficial wound cultures and the etiology of SSSI. Accordingly, we aim to describe any role that surface wound cultures may play in the treatment of lower extremity ulcers.

Materials and Methods

Data Sources

We identified eligible articles through an electronic search of the following databases: Medline through PubMed, Excerpta Medica Database (EMBASE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Scopus. We also hand searched the reference lists of key review articles identified by the electronic search and the reference lists of all eligible articles (Figure 1).

Figure 1

Results

Of 9032 unique citations, eight studies met all inclusion criteria (Figure 1). Inter‐rater reliability was substantial (Kappa = 0.78).12 Areas of initial disagreement generally involved whether a study adequately described an appropriate alternative culture method for comparison or whether data available in an article was sufficient for sensitivity and specificity calculation. Consensus was achieved once the full article was retrieved, reviewed and discussed.

The 8 studies evaluated in the review included a total number of 615 patients or samples (Table 1). Diabetic wounds were described in four studies.1316 Two studies described wounds associated with peripheral vascular disease,13, 17 while four involved traumatic wounds.13, 1719 One study did not identify the clinical circumstances concerning the wounds.20

The studies used several different methods for obtaining superficial cultures. Six studies obtained purulent wound drainage material through the application of sterile swabs.1316, 18, 19 One study obtained purulent drainage material using needle aspiration.18 Two studies obtained culture material from sinus tracts associated with the wounds, one through sinus tract washings17 and another by obtaining sinus tract discharge material.20

The types of comparison cultures used were equally divided between deep tissue biopsies1316 and bone biopsies,1720 each accounting for 50% (4 of 8) of studies.

In assessing the data from the eight studies, the pooled test sensitivity for superficial wound swabs was 49% (95% confidence interval [CI], 37‐61%) (Figure 2). The pooled specificity for superficial wound swabs was 62% (95% CI, 51‐74%), while the pooled positive and negative LRs were 1.1 (95% CI, 0.71‐1.5) and 0.67 (95% CI, 0.52‐0.82), respectively (Figure 2).

Figure 2

The median number of bacterial isolates reported for each culture type, superficial and comparison culture, was collected from each study (Table 2). The median value for number of bacterial isolates identified by superficial culture was 2.7 (interquartile range [IQR] 1.8‐3.2). The median value for number of bacterial isolates identified by comparison culture was 2.2 (IQR 1.7‐2.9). A Wilcoxon rank sum analysis showed that the number of isolates for surface wound cultures was not significantly different than the number of isolates for comparison cultures (P = 0.75) (Table 1).

Discussion

In performing this review, we discovered ambiguity in the literature regarding the utility of surface wound cultures. Some studies obtained findings to suggest the utility of surface wound cultures,8, 14, 17 while other studies in our review16, 18, 19 provided evidence against them. This variability confirmed the need for a meta‐analytic approach as provided by this review.

While we have tried to minimize bias through a well‐established methodology, we acknowledge that certain methodological limitations should be considered in interpreting the results. There may be publication bias in reviews that include only published articles; a funnel plot of sensitivity vs. sample size showed some asymmetry, suggesting bias. Our search strategy was limited to English‐only articles, which may result in publication bias.

Further, this review included a group of studies that were heterogeneous in several regards. Differences exist in culturing methods and laboratory technology, as exemplified by the variety of superficial culture methods used. We were not able to account for these laboratory differences, as methodologies in obtaining and isolating bacteria were not uniformly well described.

Additionally, the studies classified organisms in different ways. Three studies categorized organisms according to Gram's stain characteristics.13, 16, 18 One study described organisms primarily in terms of aerobic or anaerobic respiration.15 Two studies14, 19 discussed pathogens both in terms of respiration (aerobic/anaerobic) and Gram's stain characteristic, while another 2 studies17, 20 did not describe organisms in either terms. These inconsistencies limited our ability to provide sensitivity and specificity information for specific subclasses of organisms.

The clinical conditions in each study surrounding the wounds were also heterogeneous: most significantly in the issue of prior antibiotic administration. All but 1 study16 indicated that the patients had received antibiotics prior to having cultures obtained. The type of antibiotics (narrow‐spectrum or broad‐spectrum), the route of administration, and the cessation of antibiotics in relation to obtaining swabs and cultures all varied widely or were not well described. This degree of ambiguity will necessarily impact both the reliability of data regarding microbial growth as well as the component flora.

The inclusion of higher quality studies is likely to result in a more reliable meta‐analysis.21 We had hoped that antibiotic trials would contain uniform outcomes and thus strengthen our meta‐analysis through the inclusion of randomized‐controlled studies. Unfortunately, the majority of antibiotic trials did not use superficial wound cultures, did not report mean number of isolates, or did not provide microbiological data in sufficient detail to calculate concordance ratesand therefore, did not meet eligibility criteria. Randomized‐controlled trials were a minority among our included articles; the majority of study designs were retrospective cohorts and case‐controlled studies.

Despite these limitations, we were able to conclude that superficial wound culture provides mediocre sensitivity (49%) and specificity (62%). The positive LR of 1.1 is unhelpful in decision making, having a CI that includes 1. Interestingly, the negative LR of 0.67 could be somewhat helpful in medical decision making, modifying the pretest probability and assisting in ruling out a deeper bacterial infection. Although, according to Fagan's nomogram, a negative LR of 0.67 has only a mild effect on pretest odds.22

The bacterial bioburden assessed by the number of isolates obtained by culture method serves as a proxy for reliability of culture results14, 23 by suggesting that fewer organisms isolated from deep tissue or bone samples reflects a less contaminated specimen. Our assessment of the bioburden found that the median number of isolates was slightly higher in surface cultures than deeper cultures, though not to a significant degree (P = 0.75). This indicates that the degree of contamination in superficial cultures was neither significantly worse nor better than deep cultures.

We attempted to define a role for surface wound cultures; however, we found that these did not show any greater utility than deep cultures for identifying the microbiologic etiology of diabetic wound infections. While the negative LR provides some quantitative verification of the common clinical practice that a negative culture argues against infection, the finding is not especially robust.

Although for this meta‐analysis we grouped all organisms in the same way, we recognize that the sensitivity and specificity may differ according to various subclasses of bacteria. Interpretations of culture results also vary (eg, Gram positive vs. negative; aerobic vs. anaerobic); practitioners will not interpret superficial cultures of coagulase‐negative Staphylococcus in the same way as Pseudomonas. However, this study seeks to establish a reasonable starting point for the medical decision‐making process by providing quantitative values in an area with previously conflicting data. We anticipate that as laboratory techniques improve and research into superficial wounds continues, greater sensitivity of superficial wound cultures will result.

Ultimately, physicians use culture data to target therapy in an effort to use the least toxic and most effective antimicrobial agent possible to successfully treat infections. Clinical outcomes were not described in all included articles; in those that did, the endpoints were too dissimilar for meaningful comparison. Limiting our review to studies reporting treatment outcomes would have resulted in too few included studies. Thus, we were unable able to assess whether superficial wound cultures were associated with improved patient‐oriented outcomes in this meta‐analysis.

There is a significant paucity of trials evaluating the accurate concordance of superficial swabs to deep tissue culture. The current data shows poor sensitivity and specificity of superficial culture methods. The presumption that deeper cultures (such as a bone biopsy) should result in a less contaminated sample and more targeted culture results was also not borne out in our review. When presented with a patient with a wound infection, physicians mentally supply a pretest (or a pretreatment) probability as to the microbiologic etiology of the infection. Careful history will, of course, be critical in identifying extenuating circumstance or unusual exposures. From our meta‐analysis, we cannot recommend the routine use of superficial wound cultures to guide initial antibiotic therapy as this may result in poor resource utilization.5 While clinical outcomes from the use of routine superficial cultures are unclear, we suggest greater use of local antibiograms and methicillin‐resistant Staphylococcus aureus (MRSA) prevalence data to determine resistance patterns and guide the selection of empiric therapies.

While a general consensus exists that surface wound cultures have less utility than deeper cultures, surface cultures are nevertheless routinely used to guide empiric antibiotic administration. This is due in part to the ease with which surface cultures are obtained and the delay in obtaining deeper wound and bone cultures. The Infectious Diseases Society of America (IDSA) recommends routine culture of all diabetic infections before initiating empiric antibiotic therapy, despite caveats regarding undebrided wounds.1 Further examination of 2 additional societies, the European Society of Clinical Microbiology and Infectious Diseases and the Australasian Society for Infectious Diseases, reveals that they also do not describe guidelines on the role of surface wound cultures in skin, and skin structure infection (SSSI) management.2, 3

Surface wound cultures are used to aid in diagnosis and appropriate antibiotic treatment of lower extremity foot ulcers.4 Contaminated cultures from other body locations have shown little utility and may be wasteful of resources.5, 6 We hypothesize that given commensal skin flora, coupled with the additional flora that colonizes (chronic) lower extremity wounds, surface wound cultures provide poor diagnostic accuracy for determining the etiology of acute infection. In contrast, many believe that deep tissue cultures obtained at time of debridement or surgical intervention may provide more relevant information to guide antibiotic therapy, thus serving as a gold standard.13, 7, 8 Nevertheless, with the ease of obtaining these superficial cultures and the promptness of the results, surface wound cultures are still used as a surrogate for the information derived from deeper cultures.

Purpose

The frequency at which superficial wound cultures correlate with the data obtained from deeper cultures is needed to interpret the posttest likelihood of infection. However, the sensitivity and specificity of superficial wound culture as a diagnostic test is unclear. The purpose of this study is to conduct a systematic review of the existing literature in order to investigate the relationship between superficial wound cultures and the etiology of SSSI. Accordingly, we aim to describe any role that surface wound cultures may play in the treatment of lower extremity ulcers.

Materials and Methods

Data Sources

We identified eligible articles through an electronic search of the following databases: Medline through PubMed, Excerpta Medica Database (EMBASE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Scopus. We also hand searched the reference lists of key review articles identified by the electronic search and the reference lists of all eligible articles (Figure 1).

Figure 1

Results

Of 9032 unique citations, eight studies met all inclusion criteria (Figure 1). Inter‐rater reliability was substantial (Kappa = 0.78).12 Areas of initial disagreement generally involved whether a study adequately described an appropriate alternative culture method for comparison or whether data available in an article was sufficient for sensitivity and specificity calculation. Consensus was achieved once the full article was retrieved, reviewed and discussed.

The 8 studies evaluated in the review included a total number of 615 patients or samples (Table 1). Diabetic wounds were described in four studies.1316 Two studies described wounds associated with peripheral vascular disease,13, 17 while four involved traumatic wounds.13, 1719 One study did not identify the clinical circumstances concerning the wounds.20

The studies used several different methods for obtaining superficial cultures. Six studies obtained purulent wound drainage material through the application of sterile swabs.1316, 18, 19 One study obtained purulent drainage material using needle aspiration.18 Two studies obtained culture material from sinus tracts associated with the wounds, one through sinus tract washings17 and another by obtaining sinus tract discharge material.20

The types of comparison cultures used were equally divided between deep tissue biopsies1316 and bone biopsies,1720 each accounting for 50% (4 of 8) of studies.

In assessing the data from the eight studies, the pooled test sensitivity for superficial wound swabs was 49% (95% confidence interval [CI], 37‐61%) (Figure 2). The pooled specificity for superficial wound swabs was 62% (95% CI, 51‐74%), while the pooled positive and negative LRs were 1.1 (95% CI, 0.71‐1.5) and 0.67 (95% CI, 0.52‐0.82), respectively (Figure 2).

Figure 2

The median number of bacterial isolates reported for each culture type, superficial and comparison culture, was collected from each study (Table 2). The median value for number of bacterial isolates identified by superficial culture was 2.7 (interquartile range [IQR] 1.8‐3.2). The median value for number of bacterial isolates identified by comparison culture was 2.2 (IQR 1.7‐2.9). A Wilcoxon rank sum analysis showed that the number of isolates for surface wound cultures was not significantly different than the number of isolates for comparison cultures (P = 0.75) (Table 1).

Discussion

In performing this review, we discovered ambiguity in the literature regarding the utility of surface wound cultures. Some studies obtained findings to suggest the utility of surface wound cultures,8, 14, 17 while other studies in our review16, 18, 19 provided evidence against them. This variability confirmed the need for a meta‐analytic approach as provided by this review.

While we have tried to minimize bias through a well‐established methodology, we acknowledge that certain methodological limitations should be considered in interpreting the results. There may be publication bias in reviews that include only published articles; a funnel plot of sensitivity vs. sample size showed some asymmetry, suggesting bias. Our search strategy was limited to English‐only articles, which may result in publication bias.

Further, this review included a group of studies that were heterogeneous in several regards. Differences exist in culturing methods and laboratory technology, as exemplified by the variety of superficial culture methods used. We were not able to account for these laboratory differences, as methodologies in obtaining and isolating bacteria were not uniformly well described.

Additionally, the studies classified organisms in different ways. Three studies categorized organisms according to Gram's stain characteristics.13, 16, 18 One study described organisms primarily in terms of aerobic or anaerobic respiration.15 Two studies14, 19 discussed pathogens both in terms of respiration (aerobic/anaerobic) and Gram's stain characteristic, while another 2 studies17, 20 did not describe organisms in either terms. These inconsistencies limited our ability to provide sensitivity and specificity information for specific subclasses of organisms.

The clinical conditions in each study surrounding the wounds were also heterogeneous: most significantly in the issue of prior antibiotic administration. All but 1 study16 indicated that the patients had received antibiotics prior to having cultures obtained. The type of antibiotics (narrow‐spectrum or broad‐spectrum), the route of administration, and the cessation of antibiotics in relation to obtaining swabs and cultures all varied widely or were not well described. This degree of ambiguity will necessarily impact both the reliability of data regarding microbial growth as well as the component flora.

The inclusion of higher quality studies is likely to result in a more reliable meta‐analysis.21 We had hoped that antibiotic trials would contain uniform outcomes and thus strengthen our meta‐analysis through the inclusion of randomized‐controlled studies. Unfortunately, the majority of antibiotic trials did not use superficial wound cultures, did not report mean number of isolates, or did not provide microbiological data in sufficient detail to calculate concordance ratesand therefore, did not meet eligibility criteria. Randomized‐controlled trials were a minority among our included articles; the majority of study designs were retrospective cohorts and case‐controlled studies.

Despite these limitations, we were able to conclude that superficial wound culture provides mediocre sensitivity (49%) and specificity (62%). The positive LR of 1.1 is unhelpful in decision making, having a CI that includes 1. Interestingly, the negative LR of 0.67 could be somewhat helpful in medical decision making, modifying the pretest probability and assisting in ruling out a deeper bacterial infection. Although, according to Fagan's nomogram, a negative LR of 0.67 has only a mild effect on pretest odds.22

The bacterial bioburden assessed by the number of isolates obtained by culture method serves as a proxy for reliability of culture results14, 23 by suggesting that fewer organisms isolated from deep tissue or bone samples reflects a less contaminated specimen. Our assessment of the bioburden found that the median number of isolates was slightly higher in surface cultures than deeper cultures, though not to a significant degree (P = 0.75). This indicates that the degree of contamination in superficial cultures was neither significantly worse nor better than deep cultures.

We attempted to define a role for surface wound cultures; however, we found that these did not show any greater utility than deep cultures for identifying the microbiologic etiology of diabetic wound infections. While the negative LR provides some quantitative verification of the common clinical practice that a negative culture argues against infection, the finding is not especially robust.

Although for this meta‐analysis we grouped all organisms in the same way, we recognize that the sensitivity and specificity may differ according to various subclasses of bacteria. Interpretations of culture results also vary (eg, Gram positive vs. negative; aerobic vs. anaerobic); practitioners will not interpret superficial cultures of coagulase‐negative Staphylococcus in the same way as Pseudomonas. However, this study seeks to establish a reasonable starting point for the medical decision‐making process by providing quantitative values in an area with previously conflicting data. We anticipate that as laboratory techniques improve and research into superficial wounds continues, greater sensitivity of superficial wound cultures will result.

Ultimately, physicians use culture data to target therapy in an effort to use the least toxic and most effective antimicrobial agent possible to successfully treat infections. Clinical outcomes were not described in all included articles; in those that did, the endpoints were too dissimilar for meaningful comparison. Limiting our review to studies reporting treatment outcomes would have resulted in too few included studies. Thus, we were unable able to assess whether superficial wound cultures were associated with improved patient‐oriented outcomes in this meta‐analysis.

There is a significant paucity of trials evaluating the accurate concordance of superficial swabs to deep tissue culture. The current data shows poor sensitivity and specificity of superficial culture methods. The presumption that deeper cultures (such as a bone biopsy) should result in a less contaminated sample and more targeted culture results was also not borne out in our review. When presented with a patient with a wound infection, physicians mentally supply a pretest (or a pretreatment) probability as to the microbiologic etiology of the infection. Careful history will, of course, be critical in identifying extenuating circumstance or unusual exposures. From our meta‐analysis, we cannot recommend the routine use of superficial wound cultures to guide initial antibiotic therapy as this may result in poor resource utilization.5 While clinical outcomes from the use of routine superficial cultures are unclear, we suggest greater use of local antibiograms and methicillin‐resistant Staphylococcus aureus (MRSA) prevalence data to determine resistance patterns and guide the selection of empiric therapies.

A 6‐year‐old girl with a history of bilateral myringotomies, tonsillectomy, and adenoidectomy 6 and 8 months prior, presented with forehead swelling. Eight days prior, she developed right ear pain, sore throat and fever followed by eye pain and headache for which she was evaluated and diagnosed with viral illness. On the day of presentation she awoke with forehead swelling, persistent headache, and recurrent fever.

On exam she was afebrile. Central forehead swelling was noted without overlying erythema or fluctulence (Figure 1). Neurologic exam was normal. Noncontrast computed tomography (CT) scan of the head showed pan sinusitis with an extra‐axial fluid collection in the left frontal region (Figure 2).

Figure 1

Figure 2

Vancomycin, ceftriaxone, and metronidazole were started empirically. She underwent bilateral maxillary antrostomy, total ethmoidectomy, and burr‐hole evacuation of the epidural abscess. Operative specimen cultures grew out Group A streptococci, after‐which antibiotic therapy was narrowed down to ampicillin/sulbactam alone.

Pott's puffy tumor, or osteomyelitis of the frontal bone with subperiosteal abscess formation, is rare in children less than 7 years of age and usually the result of a delay in diagnosis or inadequate treatment of rhinosinusitis.1 Risk factors include frontal sinusitis, head trauma, and less commonly, cocaine use, dental infection, or delayed neurosurgical or sinus surgery complications.2, 3 Fever, vomiting, forehead tenderness, and headache are the most common complaints, though seizure and focal neurologic findings have been described.2 CT scanning is the imaging modality of choice. Most commonly cultured organisms include Streptococci, Haemophilus influenzae, Bacteroides, and less commonly, Staphylococcus aureus.2, 4 Treatment includes empiric broad‐spectrum antibiotics that penetrate the blood‐brain barrier with early surgical drainage of the abscess and debridement of the osteomyelitic bone.4

A 6‐year‐old girl with a history of bilateral myringotomies, tonsillectomy, and adenoidectomy 6 and 8 months prior, presented with forehead swelling. Eight days prior, she developed right ear pain, sore throat and fever followed by eye pain and headache for which she was evaluated and diagnosed with viral illness. On the day of presentation she awoke with forehead swelling, persistent headache, and recurrent fever.

On exam she was afebrile. Central forehead swelling was noted without overlying erythema or fluctulence (Figure 1). Neurologic exam was normal. Noncontrast computed tomography (CT) scan of the head showed pan sinusitis with an extra‐axial fluid collection in the left frontal region (Figure 2).

Figure 1

Figure 2

Vancomycin, ceftriaxone, and metronidazole were started empirically. She underwent bilateral maxillary antrostomy, total ethmoidectomy, and burr‐hole evacuation of the epidural abscess. Operative specimen cultures grew out Group A streptococci, after‐which antibiotic therapy was narrowed down to ampicillin/sulbactam alone.

Pott's puffy tumor, or osteomyelitis of the frontal bone with subperiosteal abscess formation, is rare in children less than 7 years of age and usually the result of a delay in diagnosis or inadequate treatment of rhinosinusitis.1 Risk factors include frontal sinusitis, head trauma, and less commonly, cocaine use, dental infection, or delayed neurosurgical or sinus surgery complications.2, 3 Fever, vomiting, forehead tenderness, and headache are the most common complaints, though seizure and focal neurologic findings have been described.2 CT scanning is the imaging modality of choice. Most commonly cultured organisms include Streptococci, Haemophilus influenzae, Bacteroides, and less commonly, Staphylococcus aureus.2, 4 Treatment includes empiric broad‐spectrum antibiotics that penetrate the blood‐brain barrier with early surgical drainage of the abscess and debridement of the osteomyelitic bone.4

A 6‐year‐old girl with a history of bilateral myringotomies, tonsillectomy, and adenoidectomy 6 and 8 months prior, presented with forehead swelling. Eight days prior, she developed right ear pain, sore throat and fever followed by eye pain and headache for which she was evaluated and diagnosed with viral illness. On the day of presentation she awoke with forehead swelling, persistent headache, and recurrent fever.

On exam she was afebrile. Central forehead swelling was noted without overlying erythema or fluctulence (Figure 1). Neurologic exam was normal. Noncontrast computed tomography (CT) scan of the head showed pan sinusitis with an extra‐axial fluid collection in the left frontal region (Figure 2).

Figure 1

Figure 2

Vancomycin, ceftriaxone, and metronidazole were started empirically. She underwent bilateral maxillary antrostomy, total ethmoidectomy, and burr‐hole evacuation of the epidural abscess. Operative specimen cultures grew out Group A streptococci, after‐which antibiotic therapy was narrowed down to ampicillin/sulbactam alone.

Pott's puffy tumor, or osteomyelitis of the frontal bone with subperiosteal abscess formation, is rare in children less than 7 years of age and usually the result of a delay in diagnosis or inadequate treatment of rhinosinusitis.1 Risk factors include frontal sinusitis, head trauma, and less commonly, cocaine use, dental infection, or delayed neurosurgical or sinus surgery complications.2, 3 Fever, vomiting, forehead tenderness, and headache are the most common complaints, though seizure and focal neurologic findings have been described.2 CT scanning is the imaging modality of choice. Most commonly cultured organisms include Streptococci, Haemophilus influenzae, Bacteroides, and less commonly, Staphylococcus aureus.2, 4 Treatment includes empiric broad‐spectrum antibiotics that penetrate the blood‐brain barrier with early surgical drainage of the abscess and debridement of the osteomyelitic bone.4

Hospital readmissions are common, costly in both economic and human terms, and often preventable. This perfect storm of attributes has placed hospital readmissions at the center of discourse among payers, providers, and policy makers, which is leading to innovations in care delivery. Evolving efforts to enhance discharge communication, to improve care coordination and accountability, and to meaningfully involve primary care, show promise of reducing readmissions.14 These pockets of success demonstrate that improving care transitions can increase quality of care while decreasing costs.

Within the hospital, it is now clear that the discharge process typically requires the same intensity of effort as admission. The hospitalist guides an interdisciplinary team, including nurses, pharmacists, case managers, and social workers, through a checklist of discharge tasks. Some tasks require substantial hospitalist involvement and expertise, such as medication reconciliationa detail‐oriented, time‐consuming process. Other tasks can be accomplished by team members, overseen by the hospitalist, such as scheduling timely follow‐up appointments, coordinating outpatient services, and assembling educational materials. Taken as a whole, significant time and effort must be devoted by the inpatient team to address the complex landscape of a patient's medical and psychosocial needs.

That of course, is only half of the equation, as patient care must be transferred to an equally invested outpatient team led by a primary care provider (PCP). Several influential medical societies have endorsed the medical home (a multidisciplinary care team led by a PCP) as the primary agent to coordinate patient care across settings.5 Indeed, promptly reconnecting with their PCP and primary care team after discharge can have profound meaning for patients, who may otherwise be unsupported with their postdischarge clinical needs. In this issue of the Journal of Hospital Medicine, 4 important articles provide evidence in support of an outpatient partner to actively assume patient care responsibility after hospital discharge.

van Walraven et al.6 conducted an elegant study to evaluate the impact of postdischarge PCP visits on readmissions. Following more than 5000 patients for nearly 6 months, they demonstrated that increased PCP follow‐up was significantly and independently associated with a decreased risk of hospital readmission. This confirms the positive impact that a primary care connection can have on postdischarge care. This study also highlights some challenges: 18% of the original cohort were excluded from the final analyses because they had only 1 or no PCP visit in the 6 months following discharge, indicating inadequate postdischarge follow‐up for a substantial sub‐group. Misky et al.7 similarly established that patients with timely PCP follow‐up (within one month of discharge) were 10 times less likely to be readmitted for the same condition as their index admission. These are also encouraging findings for those patients with PCP follow‐up. Yet among patients in their study, PCP follow‐up was even less common, with only 49% of patients having appointments within one month. Future studies should consider how more intensive outreach strategies might engage difficult‐to‐reach patients and communities.

PCP follow‐up may be beneficial because discharged patients often have ongoing issues that need to be addressed. Arora et al.8 surveyed inner city patients and their PCPs 2 weeks after hospital discharge to assess whether patients experienced any problems in the postdischarge period, and whether PCPs were aware of their patients' hospitalization. Nearly half of all patients recounted 1 or more postdischarge problems. The likelihood of reporting such a problem was twice as common among those patients whose PCP was unaware of their hospitalization. Again, this is strong validation of the importance of PCP involvement in posthospital care, but equally concerning is their finding that fully 3 in 10 PCPs were unaware of their patient's hospitalization.

Finally, Mitchell et al.9 further refine our understanding of risk factors for readmission. In an ethnically diverse inner city population, they screened 738 inpatients for depression. Among the 238 (32%) patients who screened positive, there was a marked 73% increase in hospital utilization (emergency department [ED] visits and readmissions) within 30 days of discharge.9 This confirms previous research that depression is a risk factor for rehospitalization.10 Depression, however, is amenable to treatment and receiving care through one's primary care practice can potentially mitigate how depression negatively affects patients' medication adherence, self‐care behavior, and ultimately readmission rates.

Collectively, these 4 articles give us reason to experience both despair and hope. It is discouraging that large numbers of patients do not have timely encounters with their PCP after discharge, confirming previous findings,11 and that too often PCPs are unaware of their patients' hospitalizations. In any other industry this sort of inefficiency and poor customer service would put a company out of business; that it persists in medicine is embarrassing. Because our medical system is not sufficiently incentivized by quality outcomes, such poor practices continue to be tolerated, and our patients suffer the consequences.

But we are also shown a way forward, with accumulating evidence complimenting existing studies that a primary care connection can improve the quality of postdischarge care and decrease readmissions.1214 Recognizing this central role of primary care, however, forces us to acknowledge the diminishing availability of primary care nationwide; in many inner city and rural locations, accessible primary care is largely nonexistent. This shortage must be corrected to attain needed access and to advance health care reform.

Postdischarge PCP involvement is particularly essential with shorter hospital stays, as patients will predictably have complex postdischarge needs as they complete their recuperation at home. Indeed, Arora et al.8 indicate that posthospitalization problems may be more the rule than the exception, and that specific types of problems can be foreseen. Most commonly reported were challenges obtaining follow‐up appointments, difficulties managing or obtaining medications, feeling unprepared for discharge, having unanswered questions, or needing an urgent reevaluation. While well organized predischarge efforts help to prepare patients, even the most perfect discharge process cannot anticipate all possible pitfalls. Fortunately, most postdischarge problems can be effectively handled by those who often know the patient best, the patient's primary care team. The outpatient team is ideally situated to assist patients with the logistics of accessing the care system, to provide ongoing education, and to help with such basic needs as transportation and social support. It makes sense that such personalized outreach can prevent small problems from blossoming into more serious issues that might ultimately require rehospitalization.

Upon discharge, patients and families are also often expected to assume new self‐care responsibilities, to implement new dietary restrictions, to use new medications, and to monitor and respond to new and evolving symptoms. Gaining the knowledge, the confidence, and the experience to adopt new behaviors is critical to successful postdischarge self‐care. Adult learning theory informs us that education is an ongoing process. Mastering new material occurs with repetition, over time, and under different circumstances. An ancient Chinese proverb encapsulates the key aspects of learning:

• I hear and I forget;

• I see and I remember;

• I do and I understand.

Thus, a single didactic discharge session in the hospital is unlikely to provide patients with sufficient depth of understanding that one attains through experiential learning. Hospital‐based discharge teaching is further compromised in the setting of patient fatigue, anxiety and illness: it is not surprising that patients comprehend and retain only 50% of the medical information discussed with their physicians.15

While teach back has been effectively used to ensure that information is registered when initially presented, it does not ensure that information has been internalized in such a way that it can be utilized hours or days later. Instead, it is the active engagement with the primary care team that provides opportunities for ongoing learning, personalized to the educational needs of each patient. With nurses, dieticians, pharmacists, and medical educators playing a central guiding role, patients can receive appropriately tailored instruction, as well as opportunities to practically apply their new knowledge.

The evolving partnership among hospitals, hospitalists, and primary care holds great promise to reduce avoidable readmissions, and the Patient Protection and Affordable Care Act of 2010 will provide financial incentives to support this partnership. Health care reform aims to adjust hospital payments based on rates of preventable Medicare readmissions; bundling payments (paying for episodes of illness based on outcomes) and accountable care organizations (ACOs) will ideally foster seamless care coordination.16 Nurturing and developing this collaboration between the inpatient and outpatient care teams will be essential as we seek to provide patients the safest transition possible from the hospital to home.

Hospital readmissions are common, costly in both economic and human terms, and often preventable. This perfect storm of attributes has placed hospital readmissions at the center of discourse among payers, providers, and policy makers, which is leading to innovations in care delivery. Evolving efforts to enhance discharge communication, to improve care coordination and accountability, and to meaningfully involve primary care, show promise of reducing readmissions.14 These pockets of success demonstrate that improving care transitions can increase quality of care while decreasing costs.

Within the hospital, it is now clear that the discharge process typically requires the same intensity of effort as admission. The hospitalist guides an interdisciplinary team, including nurses, pharmacists, case managers, and social workers, through a checklist of discharge tasks. Some tasks require substantial hospitalist involvement and expertise, such as medication reconciliationa detail‐oriented, time‐consuming process. Other tasks can be accomplished by team members, overseen by the hospitalist, such as scheduling timely follow‐up appointments, coordinating outpatient services, and assembling educational materials. Taken as a whole, significant time and effort must be devoted by the inpatient team to address the complex landscape of a patient's medical and psychosocial needs.

That of course, is only half of the equation, as patient care must be transferred to an equally invested outpatient team led by a primary care provider (PCP). Several influential medical societies have endorsed the medical home (a multidisciplinary care team led by a PCP) as the primary agent to coordinate patient care across settings.5 Indeed, promptly reconnecting with their PCP and primary care team after discharge can have profound meaning for patients, who may otherwise be unsupported with their postdischarge clinical needs. In this issue of the Journal of Hospital Medicine, 4 important articles provide evidence in support of an outpatient partner to actively assume patient care responsibility after hospital discharge.

van Walraven et al.6 conducted an elegant study to evaluate the impact of postdischarge PCP visits on readmissions. Following more than 5000 patients for nearly 6 months, they demonstrated that increased PCP follow‐up was significantly and independently associated with a decreased risk of hospital readmission. This confirms the positive impact that a primary care connection can have on postdischarge care. This study also highlights some challenges: 18% of the original cohort were excluded from the final analyses because they had only 1 or no PCP visit in the 6 months following discharge, indicating inadequate postdischarge follow‐up for a substantial sub‐group. Misky et al.7 similarly established that patients with timely PCP follow‐up (within one month of discharge) were 10 times less likely to be readmitted for the same condition as their index admission. These are also encouraging findings for those patients with PCP follow‐up. Yet among patients in their study, PCP follow‐up was even less common, with only 49% of patients having appointments within one month. Future studies should consider how more intensive outreach strategies might engage difficult‐to‐reach patients and communities.

PCP follow‐up may be beneficial because discharged patients often have ongoing issues that need to be addressed. Arora et al.8 surveyed inner city patients and their PCPs 2 weeks after hospital discharge to assess whether patients experienced any problems in the postdischarge period, and whether PCPs were aware of their patients' hospitalization. Nearly half of all patients recounted 1 or more postdischarge problems. The likelihood of reporting such a problem was twice as common among those patients whose PCP was unaware of their hospitalization. Again, this is strong validation of the importance of PCP involvement in posthospital care, but equally concerning is their finding that fully 3 in 10 PCPs were unaware of their patient's hospitalization.

Finally, Mitchell et al.9 further refine our understanding of risk factors for readmission. In an ethnically diverse inner city population, they screened 738 inpatients for depression. Among the 238 (32%) patients who screened positive, there was a marked 73% increase in hospital utilization (emergency department [ED] visits and readmissions) within 30 days of discharge.9 This confirms previous research that depression is a risk factor for rehospitalization.10 Depression, however, is amenable to treatment and receiving care through one's primary care practice can potentially mitigate how depression negatively affects patients' medication adherence, self‐care behavior, and ultimately readmission rates.

Collectively, these 4 articles give us reason to experience both despair and hope. It is discouraging that large numbers of patients do not have timely encounters with their PCP after discharge, confirming previous findings,11 and that too often PCPs are unaware of their patients' hospitalizations. In any other industry this sort of inefficiency and poor customer service would put a company out of business; that it persists in medicine is embarrassing. Because our medical system is not sufficiently incentivized by quality outcomes, such poor practices continue to be tolerated, and our patients suffer the consequences.

But we are also shown a way forward, with accumulating evidence complimenting existing studies that a primary care connection can improve the quality of postdischarge care and decrease readmissions.1214 Recognizing this central role of primary care, however, forces us to acknowledge the diminishing availability of primary care nationwide; in many inner city and rural locations, accessible primary care is largely nonexistent. This shortage must be corrected to attain needed access and to advance health care reform.

Postdischarge PCP involvement is particularly essential with shorter hospital stays, as patients will predictably have complex postdischarge needs as they complete their recuperation at home. Indeed, Arora et al.8 indicate that posthospitalization problems may be more the rule than the exception, and that specific types of problems can be foreseen. Most commonly reported were challenges obtaining follow‐up appointments, difficulties managing or obtaining medications, feeling unprepared for discharge, having unanswered questions, or needing an urgent reevaluation. While well organized predischarge efforts help to prepare patients, even the most perfect discharge process cannot anticipate all possible pitfalls. Fortunately, most postdischarge problems can be effectively handled by those who often know the patient best, the patient's primary care team. The outpatient team is ideally situated to assist patients with the logistics of accessing the care system, to provide ongoing education, and to help with such basic needs as transportation and social support. It makes sense that such personalized outreach can prevent small problems from blossoming into more serious issues that might ultimately require rehospitalization.

Upon discharge, patients and families are also often expected to assume new self‐care responsibilities, to implement new dietary restrictions, to use new medications, and to monitor and respond to new and evolving symptoms. Gaining the knowledge, the confidence, and the experience to adopt new behaviors is critical to successful postdischarge self‐care. Adult learning theory informs us that education is an ongoing process. Mastering new material occurs with repetition, over time, and under different circumstances. An ancient Chinese proverb encapsulates the key aspects of learning:

• I hear and I forget;

• I see and I remember;

• I do and I understand.

Thus, a single didactic discharge session in the hospital is unlikely to provide patients with sufficient depth of understanding that one attains through experiential learning. Hospital‐based discharge teaching is further compromised in the setting of patient fatigue, anxiety and illness: it is not surprising that patients comprehend and retain only 50% of the medical information discussed with their physicians.15

While teach back has been effectively used to ensure that information is registered when initially presented, it does not ensure that information has been internalized in such a way that it can be utilized hours or days later. Instead, it is the active engagement with the primary care team that provides opportunities for ongoing learning, personalized to the educational needs of each patient. With nurses, dieticians, pharmacists, and medical educators playing a central guiding role, patients can receive appropriately tailored instruction, as well as opportunities to practically apply their new knowledge.

The evolving partnership among hospitals, hospitalists, and primary care holds great promise to reduce avoidable readmissions, and the Patient Protection and Affordable Care Act of 2010 will provide financial incentives to support this partnership. Health care reform aims to adjust hospital payments based on rates of preventable Medicare readmissions; bundling payments (paying for episodes of illness based on outcomes) and accountable care organizations (ACOs) will ideally foster seamless care coordination.16 Nurturing and developing this collaboration between the inpatient and outpatient care teams will be essential as we seek to provide patients the safest transition possible from the hospital to home.

Hospital readmissions are common, costly in both economic and human terms, and often preventable. This perfect storm of attributes has placed hospital readmissions at the center of discourse among payers, providers, and policy makers, which is leading to innovations in care delivery. Evolving efforts to enhance discharge communication, to improve care coordination and accountability, and to meaningfully involve primary care, show promise of reducing readmissions.14 These pockets of success demonstrate that improving care transitions can increase quality of care while decreasing costs.

Within the hospital, it is now clear that the discharge process typically requires the same intensity of effort as admission. The hospitalist guides an interdisciplinary team, including nurses, pharmacists, case managers, and social workers, through a checklist of discharge tasks. Some tasks require substantial hospitalist involvement and expertise, such as medication reconciliationa detail‐oriented, time‐consuming process. Other tasks can be accomplished by team members, overseen by the hospitalist, such as scheduling timely follow‐up appointments, coordinating outpatient services, and assembling educational materials. Taken as a whole, significant time and effort must be devoted by the inpatient team to address the complex landscape of a patient's medical and psychosocial needs.

That of course, is only half of the equation, as patient care must be transferred to an equally invested outpatient team led by a primary care provider (PCP). Several influential medical societies have endorsed the medical home (a multidisciplinary care team led by a PCP) as the primary agent to coordinate patient care across settings.5 Indeed, promptly reconnecting with their PCP and primary care team after discharge can have profound meaning for patients, who may otherwise be unsupported with their postdischarge clinical needs. In this issue of the Journal of Hospital Medicine, 4 important articles provide evidence in support of an outpatient partner to actively assume patient care responsibility after hospital discharge.

van Walraven et al.6 conducted an elegant study to evaluate the impact of postdischarge PCP visits on readmissions. Following more than 5000 patients for nearly 6 months, they demonstrated that increased PCP follow‐up was significantly and independently associated with a decreased risk of hospital readmission. This confirms the positive impact that a primary care connection can have on postdischarge care. This study also highlights some challenges: 18% of the original cohort were excluded from the final analyses because they had only 1 or no PCP visit in the 6 months following discharge, indicating inadequate postdischarge follow‐up for a substantial sub‐group. Misky et al.7 similarly established that patients with timely PCP follow‐up (within one month of discharge) were 10 times less likely to be readmitted for the same condition as their index admission. These are also encouraging findings for those patients with PCP follow‐up. Yet among patients in their study, PCP follow‐up was even less common, with only 49% of patients having appointments within one month. Future studies should consider how more intensive outreach strategies might engage difficult‐to‐reach patients and communities.

PCP follow‐up may be beneficial because discharged patients often have ongoing issues that need to be addressed. Arora et al.8 surveyed inner city patients and their PCPs 2 weeks after hospital discharge to assess whether patients experienced any problems in the postdischarge period, and whether PCPs were aware of their patients' hospitalization. Nearly half of all patients recounted 1 or more postdischarge problems. The likelihood of reporting such a problem was twice as common among those patients whose PCP was unaware of their hospitalization. Again, this is strong validation of the importance of PCP involvement in posthospital care, but equally concerning is their finding that fully 3 in 10 PCPs were unaware of their patient's hospitalization.

Finally, Mitchell et al.9 further refine our understanding of risk factors for readmission. In an ethnically diverse inner city population, they screened 738 inpatients for depression. Among the 238 (32%) patients who screened positive, there was a marked 73% increase in hospital utilization (emergency department [ED] visits and readmissions) within 30 days of discharge.9 This confirms previous research that depression is a risk factor for rehospitalization.10 Depression, however, is amenable to treatment and receiving care through one's primary care practice can potentially mitigate how depression negatively affects patients' medication adherence, self‐care behavior, and ultimately readmission rates.

Collectively, these 4 articles give us reason to experience both despair and hope. It is discouraging that large numbers of patients do not have timely encounters with their PCP after discharge, confirming previous findings,11 and that too often PCPs are unaware of their patients' hospitalizations. In any other industry this sort of inefficiency and poor customer service would put a company out of business; that it persists in medicine is embarrassing. Because our medical system is not sufficiently incentivized by quality outcomes, such poor practices continue to be tolerated, and our patients suffer the consequences.

But we are also shown a way forward, with accumulating evidence complimenting existing studies that a primary care connection can improve the quality of postdischarge care and decrease readmissions.1214 Recognizing this central role of primary care, however, forces us to acknowledge the diminishing availability of primary care nationwide; in many inner city and rural locations, accessible primary care is largely nonexistent. This shortage must be corrected to attain needed access and to advance health care reform.

Postdischarge PCP involvement is particularly essential with shorter hospital stays, as patients will predictably have complex postdischarge needs as they complete their recuperation at home. Indeed, Arora et al.8 indicate that posthospitalization problems may be more the rule than the exception, and that specific types of problems can be foreseen. Most commonly reported were challenges obtaining follow‐up appointments, difficulties managing or obtaining medications, feeling unprepared for discharge, having unanswered questions, or needing an urgent reevaluation. While well organized predischarge efforts help to prepare patients, even the most perfect discharge process cannot anticipate all possible pitfalls. Fortunately, most postdischarge problems can be effectively handled by those who often know the patient best, the patient's primary care team. The outpatient team is ideally situated to assist patients with the logistics of accessing the care system, to provide ongoing education, and to help with such basic needs as transportation and social support. It makes sense that such personalized outreach can prevent small problems from blossoming into more serious issues that might ultimately require rehospitalization.

Upon discharge, patients and families are also often expected to assume new self‐care responsibilities, to implement new dietary restrictions, to use new medications, and to monitor and respond to new and evolving symptoms. Gaining the knowledge, the confidence, and the experience to adopt new behaviors is critical to successful postdischarge self‐care. Adult learning theory informs us that education is an ongoing process. Mastering new material occurs with repetition, over time, and under different circumstances. An ancient Chinese proverb encapsulates the key aspects of learning:

• I hear and I forget;

• I see and I remember;

• I do and I understand.

Thus, a single didactic discharge session in the hospital is unlikely to provide patients with sufficient depth of understanding that one attains through experiential learning. Hospital‐based discharge teaching is further compromised in the setting of patient fatigue, anxiety and illness: it is not surprising that patients comprehend and retain only 50% of the medical information discussed with their physicians.15

While teach back has been effectively used to ensure that information is registered when initially presented, it does not ensure that information has been internalized in such a way that it can be utilized hours or days later. Instead, it is the active engagement with the primary care team that provides opportunities for ongoing learning, personalized to the educational needs of each patient. With nurses, dieticians, pharmacists, and medical educators playing a central guiding role, patients can receive appropriately tailored instruction, as well as opportunities to practically apply their new knowledge.

The evolving partnership among hospitals, hospitalists, and primary care holds great promise to reduce avoidable readmissions, and the Patient Protection and Affordable Care Act of 2010 will provide financial incentives to support this partnership. Health care reform aims to adjust hospital payments based on rates of preventable Medicare readmissions; bundling payments (paying for episodes of illness based on outcomes) and accountable care organizations (ACOs) will ideally foster seamless care coordination.16 Nurturing and developing this collaboration between the inpatient and outpatient care teams will be essential as we seek to provide patients the safest transition possible from the hospital to home.

A 25 year‐old hitherto healthy female Asian immigrant presented with gradually worsening painful neck swelling for 5 weeks and a 40‐pound weight loss. Neck examination showed tender, firm, matted and fixed lymph nodes in left and right cervical chains. Contrast computed tomography of the neck confirmed extensive necrotic lymphadenopathy. Excisional lymph node biopsy revealed granulomatous lymphadenitis with microabscesses. Staining for acid‐fast bacilli was positive; tissue culture confirmed the diagnosis of Mycobacterium tuberculosis. She was started on rifampin 600 mg, isoniazid 300 mg, pyrazinamide 1000 mg, and ethambutol 800 mg; ethambutol was discontinued when the mycobacteria proved susceptible to isoniazid. Pyrazinamide was discontinued after 2 months and isoniazid and rifampin continued to complete 6 months of therapy.0, 0

Tuberculous lymphadenitisscrofula when occurring in the cervical regionis a common cause of extrapulmonary tuberculosis, especially in developing countries. In developed countries, tuberculous lymphadenitis occurs mainly in immigrants but can also arise in travelers to endemic areas and immunodeficient persons.1 Painless lymphadenopathy of the superficial lymph nodes is typical. Fine needle aspiration with microscopy, culture and polymerase chain reaction (PCR) may be used as an initial diagnostic tool.2 However, if the results are negative despite high clinical suspicion, excisional biopsy of the lymph node may be necessary. Various nontuberculous mycobacteria also cause adenitis, so definitive speciation is needed to determine optimal therapy.3

Recommended initial treatment for M. tuberculosis includes isoniazid, rifampin, pyrazinamide and ethambutol or streptomycin, based on local resistance patterns. The fourth drug is withdrawn when the isolate is found susceptible to the first 3 drugs; isoniazid and rifampin are used for a total of 6 months of treatment, while pyrazinamide is withdrawn after 2 months.4 Twice‐weekly directly observed therapy (DOT) can be as effective as daily therapy supervised weekly.5 DOT maximizes compliance and reduces treatment failure.

Figure 1

Figure 2

A 25 year‐old hitherto healthy female Asian immigrant presented with gradually worsening painful neck swelling for 5 weeks and a 40‐pound weight loss. Neck examination showed tender, firm, matted and fixed lymph nodes in left and right cervical chains. Contrast computed tomography of the neck confirmed extensive necrotic lymphadenopathy. Excisional lymph node biopsy revealed granulomatous lymphadenitis with microabscesses. Staining for acid‐fast bacilli was positive; tissue culture confirmed the diagnosis of Mycobacterium tuberculosis. She was started on rifampin 600 mg, isoniazid 300 mg, pyrazinamide 1000 mg, and ethambutol 800 mg; ethambutol was discontinued when the mycobacteria proved susceptible to isoniazid. Pyrazinamide was discontinued after 2 months and isoniazid and rifampin continued to complete 6 months of therapy.0, 0

Tuberculous lymphadenitisscrofula when occurring in the cervical regionis a common cause of extrapulmonary tuberculosis, especially in developing countries. In developed countries, tuberculous lymphadenitis occurs mainly in immigrants but can also arise in travelers to endemic areas and immunodeficient persons.1 Painless lymphadenopathy of the superficial lymph nodes is typical. Fine needle aspiration with microscopy, culture and polymerase chain reaction (PCR) may be used as an initial diagnostic tool.2 However, if the results are negative despite high clinical suspicion, excisional biopsy of the lymph node may be necessary. Various nontuberculous mycobacteria also cause adenitis, so definitive speciation is needed to determine optimal therapy.3

Recommended initial treatment for M. tuberculosis includes isoniazid, rifampin, pyrazinamide and ethambutol or streptomycin, based on local resistance patterns. The fourth drug is withdrawn when the isolate is found susceptible to the first 3 drugs; isoniazid and rifampin are used for a total of 6 months of treatment, while pyrazinamide is withdrawn after 2 months.4 Twice‐weekly directly observed therapy (DOT) can be as effective as daily therapy supervised weekly.5 DOT maximizes compliance and reduces treatment failure.

Figure 1

Figure 2

A 25 year‐old hitherto healthy female Asian immigrant presented with gradually worsening painful neck swelling for 5 weeks and a 40‐pound weight loss. Neck examination showed tender, firm, matted and fixed lymph nodes in left and right cervical chains. Contrast computed tomography of the neck confirmed extensive necrotic lymphadenopathy. Excisional lymph node biopsy revealed granulomatous lymphadenitis with microabscesses. Staining for acid‐fast bacilli was positive; tissue culture confirmed the diagnosis of Mycobacterium tuberculosis. She was started on rifampin 600 mg, isoniazid 300 mg, pyrazinamide 1000 mg, and ethambutol 800 mg; ethambutol was discontinued when the mycobacteria proved susceptible to isoniazid. Pyrazinamide was discontinued after 2 months and isoniazid and rifampin continued to complete 6 months of therapy.0, 0

Tuberculous lymphadenitisscrofula when occurring in the cervical regionis a common cause of extrapulmonary tuberculosis, especially in developing countries. In developed countries, tuberculous lymphadenitis occurs mainly in immigrants but can also arise in travelers to endemic areas and immunodeficient persons.1 Painless lymphadenopathy of the superficial lymph nodes is typical. Fine needle aspiration with microscopy, culture and polymerase chain reaction (PCR) may be used as an initial diagnostic tool.2 However, if the results are negative despite high clinical suspicion, excisional biopsy of the lymph node may be necessary. Various nontuberculous mycobacteria also cause adenitis, so definitive speciation is needed to determine optimal therapy.3

Recommended initial treatment for M. tuberculosis includes isoniazid, rifampin, pyrazinamide and ethambutol or streptomycin, based on local resistance patterns. The fourth drug is withdrawn when the isolate is found susceptible to the first 3 drugs; isoniazid and rifampin are used for a total of 6 months of treatment, while pyrazinamide is withdrawn after 2 months.4 Twice‐weekly directly observed therapy (DOT) can be as effective as daily therapy supervised weekly.5 DOT maximizes compliance and reduces treatment failure.

Figure 1

Figure 2