Peripherally inserted central catheters (PICCs) are being used with greater frequency than ever before for intravenous access in hospitals, and PICCs may offer advantages in safety over traditional central venous catheters (CVCs). Despite these potential advantages, a large number of CVCs are still being placed. In a recent 1‐day survey of 6 large urban teaching hospitals, 29% of all patients had a CVC in place (59.3% of intensive care unit [ICU] patients and 23.7% of non‐ICU patients).1 Most catheters were inserted in the subclavian (55%) or jugular (22%) veins, with femoral (6%) and peripheral (15%) sites less commonly used. Even in the non‐ICU setting, only 20% of all central catheters were PICCs.

PICCs may offer advantages over centrally‐inserted intravenous catheters, such as the reduced risks of pneumothorax,2 arterial puncture, uncontrolled bleeding of large central veins, central lineassociated bloodstream infections (CLAB),3, 4 and lower cost.5 In addition, central venous pressure monitoring can now be performed with the larger‐bore PICCs.6

The low risk of mechanical complications for PICC insertion has been well documented.7, 8 In contrast, femoral or retroperitoneal hematoma occurs in up to 1.3% of cases following femoral catheter insertion,9 and pneumothorax occurs in 1.5% to 2.3% of subclavian catheter insertions.10 However, there are only limited data to suggest that the risk of PICC‐related bacteremia is lower than that of centrally‐placed catheters.11, 12

The benefit of PICCs over centrally‐placed catheters in terms of venous thromboembolism (VTE) is also not as easy to show, and in fact the rate may be greater in PICCs. The reported incidence of PICC‐related VTE has been between 0.3% and 56.0%, and the wide variation in rates is likely related to the method of diagnosis.1315 It is likely that most patients with PICC‐related VTE are asymptomatic, and that its incidence is underestimated.16

In many hospitals PICCs are placed by a certified nurse, or by an interventional radiologist if the nurse is unsuccessful.17 There are few reports of PICCs being placed by nonradiology physicians. In one report of 894 patients referred to a critical care specialist for PICC insertion, venous access was achieved 100% of the time, there were no referrals to interventional radiology, and there were no incidents of pneumothorax or bleeding.8 In a university‐affiliated community hospital, we carried out a retrospective review of our experience with training hospital physicians to place PICCs.

Methods

In July 2006 our community hospital, which is affiliated with the University of Pittsburgh Medical Center, instituted a hospitalist program. Prior to the hospitalist program, 1 house physician was available to place PICCs in the antecubital vein without the aid of ultrasound, and there was no PICC‐certified nurse in the hospital. An interventional radiologist was available to place PICCs that could not be placed by the house physician. After July 2006 under the hospitalist service, 3 of the 5 physicians were trained to place PICCs in the deep veins of the arm with the use of ultrasound guidance.

Training included 1 day with the PICC training nurse at the tertiary hospital, followed by supervised placements in the community hospital until proficiency was obtained. Proficiency was relative and cumulative. Approximately 3 supervised procedures were necessary before the physician was able to place PICCs by him or herself. All PICCs were placed using 5 barrier precautions, with chlorhexidine cleansing, and with a time‐out prior to the procedure.

Retrospective hospital data for central catheter placement were examined for the 18 months prior to and following the start of the hospitalist program. These data were collected routinely by the hospital infection control nurse for purposes of quality improvement and patient safety. The data included central catheters placed by all physicians in the hospital; however, the vast majority of these were placed by the hospitalists. The catheters were placed throughout the hospital, both on the medical floors, cardiac step‐down unit, and the ICU. Information regarding the number of central catheters placed and the specific type of catheter (subclavian, jugular, femoral, or PICC) was available from July 2005 through December 2007. Also available from January 2005 were the numbers of femoral and nonfemoral catheter days (number of catheters multiplied by number of days in place) and the central catheterassociated bacteremia rates (number per 1000 catheter days) for femoral and nonfemoral catheters. The Centers for Disease Control and Prevention (CDC) definition of central lineassociated bacteremia was used, which is any documented bloodstream infection within 48 hours of the presence of a CVC in the absence of an alternate source of infection. Data for other complications such as pneumothorax and major bleeding were not consistently recorded.

Results

Figure 1 shows the number of internal jugular, subclavian, femoral, PICC, and total catheter placements from July 2005 through December 2007. The data are grouped into 3‐month increments for visual convenience. Comparing the periods before and after the inception of the hospitalist PICC service (Figure 1, dotted vertical line), the rate of PICC placements rose 4‐fold and the rate of total catheter placements approximately doubled. The rates of femoral and subclavian catheter placements decreased by approximately 50% and the rate of internal jugular catheter placement was roughly unchanged.

Figure 1

Figure 2 shows the numbers of femoral and nonfemoral catheter days by month for 2005 through 2007. The nonfemoral catheter days began to rise prior to the start of the hospitalist program and continued to rise afterward, showing an approximately 3‐fold increase by the end of the study period. The number of femoral catheters days was highly variable, but seemed to decrease by approximately 50%.

Figure 2

Figure 3 shows the rates of femoral and nonfemoral catheter‐associated bacteremia by month for 2005 through 2007. The absolute number of infections in both periods was low and is shown at the top of each bar in the figure.

Figure 3

To our knowledge, there were no episodes of pneumothorax or major bleeding with PICC placement. There were 3 inadvertent arterial punctures, each of which was easily controlled with local pressure. There was 1 incident of a coiled guidewire that could not be removed at the bedside and had to be removed in interventional radiology with no significant consequence to the patient.

Discussion

The complications associated with central catheter insertion continue to place the hospitalized patient at risk. PICCs may offer significant advantages over other types of central catheters in terms of decreased rates of mechanical and infectious complications. Despite this, hospital physicians have not traditionally been trained to place PICCs. We have shown in our small, university‐affiliated community hospital that training hospital physicians to place PICCs was associated with a decrease in the placement of centrally‐inserted venous catheters and a reduced rate of femoral catheter days. At the same time, the rate of central catheterrelated bacteremia remained low.

There are many limitations to our study. Since the analysis was retrospective and uncontrolled, it is not possible to attribute the decrease in femoral catheter days and the low infection rates solely to the use of PICCs. There may have been other factors, either related or unrelated to the transition to a hospitalist service, that influenced the results, such as improved hand hygiene, attention to the use of 5 barrier precautions, and the use of chlorhexidine cleansing. Also, since the study was descriptive and outcome measures were either not available or the numbers small, we cannot prove that there was benefit to the patients or that the changes in rates were statistically significant.

Training hospital physicians to place PICCs in our study was associated with a 2‐fold increase in the overall rate of catheter placements. The reason for this increase in the total number of catheter placements is not clear, but it is likely related to the ease of PICC placement and the increasing number of patients with difficult intravenous access. It is unclear if an equivalent number of traditional central catheters would have been placed were the hospitalists not trained in PICC placement. However, this increase in total number of catheters did not appear to result in an increase in catheter‐related bacteremia or in mechanical complications.

We observed no apparent decrease in the insertion rate of internal jugular catheters in our study, despite a decrease in the rates of subclavian and femoral catheter placements. Although the current CDC guideline recommends using the subclavian vein as the preferred site, the UK National Institute for Clinical Excellence (NICE) is now recommending the use of real‐time ultrasound with each placement,18 and we find that this is best done in the internal jugular vein. Also, the rate of placement of femoral catheters remained higher than that of subclavian cathetersmost likely because the femoral vein remained the site of choice for emergently‐placed cathetersas PICC, more so than subclavian, became the preferred site for elective catheters.

Training physicians to place PICCs was not a simple task. In our experience, the availability of trainers at the tertiary care hospital was limited and the distractions of other duties of the hospitalist complicated the learning process. Two of our 5 physicians could not schedule time with the training nurse and were not able to acquire the skill. However, after training, the 3 hospitalists found that there was such a demand for PICCs that with time it was easy to maintain and even refine this skill. Since we only had 3 of 5 hospitalists trained in PICC placement, we could not have a PICC‐trained hospitalist on site 24 hours a day and the remaining 2 physicians had to rely on centrally‐placed catheters for access or have 1 of the trained physicians come to the hospital from home.

In summary, PICCs may be a safe and easy alternative to centrally‐placed catheters for the hospital physician attempting to secure central intravenous access and may lead to a decrease in the need for more risky CVC insertions. More definitive, controlled investigation, with patient outcome data, will be required before this can be advocated as a universal recommendation.

Peripherally inserted central catheters (PICCs) are being used with greater frequency than ever before for intravenous access in hospitals, and PICCs may offer advantages in safety over traditional central venous catheters (CVCs). Despite these potential advantages, a large number of CVCs are still being placed. In a recent 1‐day survey of 6 large urban teaching hospitals, 29% of all patients had a CVC in place (59.3% of intensive care unit [ICU] patients and 23.7% of non‐ICU patients).1 Most catheters were inserted in the subclavian (55%) or jugular (22%) veins, with femoral (6%) and peripheral (15%) sites less commonly used. Even in the non‐ICU setting, only 20% of all central catheters were PICCs.

PICCs may offer advantages over centrally‐inserted intravenous catheters, such as the reduced risks of pneumothorax,2 arterial puncture, uncontrolled bleeding of large central veins, central lineassociated bloodstream infections (CLAB),3, 4 and lower cost.5 In addition, central venous pressure monitoring can now be performed with the larger‐bore PICCs.6

The low risk of mechanical complications for PICC insertion has been well documented.7, 8 In contrast, femoral or retroperitoneal hematoma occurs in up to 1.3% of cases following femoral catheter insertion,9 and pneumothorax occurs in 1.5% to 2.3% of subclavian catheter insertions.10 However, there are only limited data to suggest that the risk of PICC‐related bacteremia is lower than that of centrally‐placed catheters.11, 12

The benefit of PICCs over centrally‐placed catheters in terms of venous thromboembolism (VTE) is also not as easy to show, and in fact the rate may be greater in PICCs. The reported incidence of PICC‐related VTE has been between 0.3% and 56.0%, and the wide variation in rates is likely related to the method of diagnosis.1315 It is likely that most patients with PICC‐related VTE are asymptomatic, and that its incidence is underestimated.16

In many hospitals PICCs are placed by a certified nurse, or by an interventional radiologist if the nurse is unsuccessful.17 There are few reports of PICCs being placed by nonradiology physicians. In one report of 894 patients referred to a critical care specialist for PICC insertion, venous access was achieved 100% of the time, there were no referrals to interventional radiology, and there were no incidents of pneumothorax or bleeding.8 In a university‐affiliated community hospital, we carried out a retrospective review of our experience with training hospital physicians to place PICCs.

Methods

In July 2006 our community hospital, which is affiliated with the University of Pittsburgh Medical Center, instituted a hospitalist program. Prior to the hospitalist program, 1 house physician was available to place PICCs in the antecubital vein without the aid of ultrasound, and there was no PICC‐certified nurse in the hospital. An interventional radiologist was available to place PICCs that could not be placed by the house physician. After July 2006 under the hospitalist service, 3 of the 5 physicians were trained to place PICCs in the deep veins of the arm with the use of ultrasound guidance.

Training included 1 day with the PICC training nurse at the tertiary hospital, followed by supervised placements in the community hospital until proficiency was obtained. Proficiency was relative and cumulative. Approximately 3 supervised procedures were necessary before the physician was able to place PICCs by him or herself. All PICCs were placed using 5 barrier precautions, with chlorhexidine cleansing, and with a time‐out prior to the procedure.

Retrospective hospital data for central catheter placement were examined for the 18 months prior to and following the start of the hospitalist program. These data were collected routinely by the hospital infection control nurse for purposes of quality improvement and patient safety. The data included central catheters placed by all physicians in the hospital; however, the vast majority of these were placed by the hospitalists. The catheters were placed throughout the hospital, both on the medical floors, cardiac step‐down unit, and the ICU. Information regarding the number of central catheters placed and the specific type of catheter (subclavian, jugular, femoral, or PICC) was available from July 2005 through December 2007. Also available from January 2005 were the numbers of femoral and nonfemoral catheter days (number of catheters multiplied by number of days in place) and the central catheterassociated bacteremia rates (number per 1000 catheter days) for femoral and nonfemoral catheters. The Centers for Disease Control and Prevention (CDC) definition of central lineassociated bacteremia was used, which is any documented bloodstream infection within 48 hours of the presence of a CVC in the absence of an alternate source of infection. Data for other complications such as pneumothorax and major bleeding were not consistently recorded.

Results

Figure 1 shows the number of internal jugular, subclavian, femoral, PICC, and total catheter placements from July 2005 through December 2007. The data are grouped into 3‐month increments for visual convenience. Comparing the periods before and after the inception of the hospitalist PICC service (Figure 1, dotted vertical line), the rate of PICC placements rose 4‐fold and the rate of total catheter placements approximately doubled. The rates of femoral and subclavian catheter placements decreased by approximately 50% and the rate of internal jugular catheter placement was roughly unchanged.

Figure 1

Figure 2 shows the numbers of femoral and nonfemoral catheter days by month for 2005 through 2007. The nonfemoral catheter days began to rise prior to the start of the hospitalist program and continued to rise afterward, showing an approximately 3‐fold increase by the end of the study period. The number of femoral catheters days was highly variable, but seemed to decrease by approximately 50%.

Figure 2

Figure 3 shows the rates of femoral and nonfemoral catheter‐associated bacteremia by month for 2005 through 2007. The absolute number of infections in both periods was low and is shown at the top of each bar in the figure.

Figure 3

To our knowledge, there were no episodes of pneumothorax or major bleeding with PICC placement. There were 3 inadvertent arterial punctures, each of which was easily controlled with local pressure. There was 1 incident of a coiled guidewire that could not be removed at the bedside and had to be removed in interventional radiology with no significant consequence to the patient.

Discussion

The complications associated with central catheter insertion continue to place the hospitalized patient at risk. PICCs may offer significant advantages over other types of central catheters in terms of decreased rates of mechanical and infectious complications. Despite this, hospital physicians have not traditionally been trained to place PICCs. We have shown in our small, university‐affiliated community hospital that training hospital physicians to place PICCs was associated with a decrease in the placement of centrally‐inserted venous catheters and a reduced rate of femoral catheter days. At the same time, the rate of central catheterrelated bacteremia remained low.

There are many limitations to our study. Since the analysis was retrospective and uncontrolled, it is not possible to attribute the decrease in femoral catheter days and the low infection rates solely to the use of PICCs. There may have been other factors, either related or unrelated to the transition to a hospitalist service, that influenced the results, such as improved hand hygiene, attention to the use of 5 barrier precautions, and the use of chlorhexidine cleansing. Also, since the study was descriptive and outcome measures were either not available or the numbers small, we cannot prove that there was benefit to the patients or that the changes in rates were statistically significant.

Training hospital physicians to place PICCs in our study was associated with a 2‐fold increase in the overall rate of catheter placements. The reason for this increase in the total number of catheter placements is not clear, but it is likely related to the ease of PICC placement and the increasing number of patients with difficult intravenous access. It is unclear if an equivalent number of traditional central catheters would have been placed were the hospitalists not trained in PICC placement. However, this increase in total number of catheters did not appear to result in an increase in catheter‐related bacteremia or in mechanical complications.

We observed no apparent decrease in the insertion rate of internal jugular catheters in our study, despite a decrease in the rates of subclavian and femoral catheter placements. Although the current CDC guideline recommends using the subclavian vein as the preferred site, the UK National Institute for Clinical Excellence (NICE) is now recommending the use of real‐time ultrasound with each placement,18 and we find that this is best done in the internal jugular vein. Also, the rate of placement of femoral catheters remained higher than that of subclavian cathetersmost likely because the femoral vein remained the site of choice for emergently‐placed cathetersas PICC, more so than subclavian, became the preferred site for elective catheters.

Training physicians to place PICCs was not a simple task. In our experience, the availability of trainers at the tertiary care hospital was limited and the distractions of other duties of the hospitalist complicated the learning process. Two of our 5 physicians could not schedule time with the training nurse and were not able to acquire the skill. However, after training, the 3 hospitalists found that there was such a demand for PICCs that with time it was easy to maintain and even refine this skill. Since we only had 3 of 5 hospitalists trained in PICC placement, we could not have a PICC‐trained hospitalist on site 24 hours a day and the remaining 2 physicians had to rely on centrally‐placed catheters for access or have 1 of the trained physicians come to the hospital from home.

In summary, PICCs may be a safe and easy alternative to centrally‐placed catheters for the hospital physician attempting to secure central intravenous access and may lead to a decrease in the need for more risky CVC insertions. More definitive, controlled investigation, with patient outcome data, will be required before this can be advocated as a universal recommendation.

Peripherally inserted central catheters (PICCs) are being used with greater frequency than ever before for intravenous access in hospitals, and PICCs may offer advantages in safety over traditional central venous catheters (CVCs). Despite these potential advantages, a large number of CVCs are still being placed. In a recent 1‐day survey of 6 large urban teaching hospitals, 29% of all patients had a CVC in place (59.3% of intensive care unit [ICU] patients and 23.7% of non‐ICU patients).1 Most catheters were inserted in the subclavian (55%) or jugular (22%) veins, with femoral (6%) and peripheral (15%) sites less commonly used. Even in the non‐ICU setting, only 20% of all central catheters were PICCs.

PICCs may offer advantages over centrally‐inserted intravenous catheters, such as the reduced risks of pneumothorax,2 arterial puncture, uncontrolled bleeding of large central veins, central lineassociated bloodstream infections (CLAB),3, 4 and lower cost.5 In addition, central venous pressure monitoring can now be performed with the larger‐bore PICCs.6

The low risk of mechanical complications for PICC insertion has been well documented.7, 8 In contrast, femoral or retroperitoneal hematoma occurs in up to 1.3% of cases following femoral catheter insertion,9 and pneumothorax occurs in 1.5% to 2.3% of subclavian catheter insertions.10 However, there are only limited data to suggest that the risk of PICC‐related bacteremia is lower than that of centrally‐placed catheters.11, 12

The benefit of PICCs over centrally‐placed catheters in terms of venous thromboembolism (VTE) is also not as easy to show, and in fact the rate may be greater in PICCs. The reported incidence of PICC‐related VTE has been between 0.3% and 56.0%, and the wide variation in rates is likely related to the method of diagnosis.1315 It is likely that most patients with PICC‐related VTE are asymptomatic, and that its incidence is underestimated.16

In many hospitals PICCs are placed by a certified nurse, or by an interventional radiologist if the nurse is unsuccessful.17 There are few reports of PICCs being placed by nonradiology physicians. In one report of 894 patients referred to a critical care specialist for PICC insertion, venous access was achieved 100% of the time, there were no referrals to interventional radiology, and there were no incidents of pneumothorax or bleeding.8 In a university‐affiliated community hospital, we carried out a retrospective review of our experience with training hospital physicians to place PICCs.

Methods

In July 2006 our community hospital, which is affiliated with the University of Pittsburgh Medical Center, instituted a hospitalist program. Prior to the hospitalist program, 1 house physician was available to place PICCs in the antecubital vein without the aid of ultrasound, and there was no PICC‐certified nurse in the hospital. An interventional radiologist was available to place PICCs that could not be placed by the house physician. After July 2006 under the hospitalist service, 3 of the 5 physicians were trained to place PICCs in the deep veins of the arm with the use of ultrasound guidance.

Training included 1 day with the PICC training nurse at the tertiary hospital, followed by supervised placements in the community hospital until proficiency was obtained. Proficiency was relative and cumulative. Approximately 3 supervised procedures were necessary before the physician was able to place PICCs by him or herself. All PICCs were placed using 5 barrier precautions, with chlorhexidine cleansing, and with a time‐out prior to the procedure.

Retrospective hospital data for central catheter placement were examined for the 18 months prior to and following the start of the hospitalist program. These data were collected routinely by the hospital infection control nurse for purposes of quality improvement and patient safety. The data included central catheters placed by all physicians in the hospital; however, the vast majority of these were placed by the hospitalists. The catheters were placed throughout the hospital, both on the medical floors, cardiac step‐down unit, and the ICU. Information regarding the number of central catheters placed and the specific type of catheter (subclavian, jugular, femoral, or PICC) was available from July 2005 through December 2007. Also available from January 2005 were the numbers of femoral and nonfemoral catheter days (number of catheters multiplied by number of days in place) and the central catheterassociated bacteremia rates (number per 1000 catheter days) for femoral and nonfemoral catheters. The Centers for Disease Control and Prevention (CDC) definition of central lineassociated bacteremia was used, which is any documented bloodstream infection within 48 hours of the presence of a CVC in the absence of an alternate source of infection. Data for other complications such as pneumothorax and major bleeding were not consistently recorded.

Results

Figure 1 shows the number of internal jugular, subclavian, femoral, PICC, and total catheter placements from July 2005 through December 2007. The data are grouped into 3‐month increments for visual convenience. Comparing the periods before and after the inception of the hospitalist PICC service (Figure 1, dotted vertical line), the rate of PICC placements rose 4‐fold and the rate of total catheter placements approximately doubled. The rates of femoral and subclavian catheter placements decreased by approximately 50% and the rate of internal jugular catheter placement was roughly unchanged.

Figure 1

Figure 2 shows the numbers of femoral and nonfemoral catheter days by month for 2005 through 2007. The nonfemoral catheter days began to rise prior to the start of the hospitalist program and continued to rise afterward, showing an approximately 3‐fold increase by the end of the study period. The number of femoral catheters days was highly variable, but seemed to decrease by approximately 50%.

Figure 2

Figure 3 shows the rates of femoral and nonfemoral catheter‐associated bacteremia by month for 2005 through 2007. The absolute number of infections in both periods was low and is shown at the top of each bar in the figure.

Figure 3

To our knowledge, there were no episodes of pneumothorax or major bleeding with PICC placement. There were 3 inadvertent arterial punctures, each of which was easily controlled with local pressure. There was 1 incident of a coiled guidewire that could not be removed at the bedside and had to be removed in interventional radiology with no significant consequence to the patient.

Discussion

The complications associated with central catheter insertion continue to place the hospitalized patient at risk. PICCs may offer significant advantages over other types of central catheters in terms of decreased rates of mechanical and infectious complications. Despite this, hospital physicians have not traditionally been trained to place PICCs. We have shown in our small, university‐affiliated community hospital that training hospital physicians to place PICCs was associated with a decrease in the placement of centrally‐inserted venous catheters and a reduced rate of femoral catheter days. At the same time, the rate of central catheterrelated bacteremia remained low.

There are many limitations to our study. Since the analysis was retrospective and uncontrolled, it is not possible to attribute the decrease in femoral catheter days and the low infection rates solely to the use of PICCs. There may have been other factors, either related or unrelated to the transition to a hospitalist service, that influenced the results, such as improved hand hygiene, attention to the use of 5 barrier precautions, and the use of chlorhexidine cleansing. Also, since the study was descriptive and outcome measures were either not available or the numbers small, we cannot prove that there was benefit to the patients or that the changes in rates were statistically significant.

Training hospital physicians to place PICCs in our study was associated with a 2‐fold increase in the overall rate of catheter placements. The reason for this increase in the total number of catheter placements is not clear, but it is likely related to the ease of PICC placement and the increasing number of patients with difficult intravenous access. It is unclear if an equivalent number of traditional central catheters would have been placed were the hospitalists not trained in PICC placement. However, this increase in total number of catheters did not appear to result in an increase in catheter‐related bacteremia or in mechanical complications.

We observed no apparent decrease in the insertion rate of internal jugular catheters in our study, despite a decrease in the rates of subclavian and femoral catheter placements. Although the current CDC guideline recommends using the subclavian vein as the preferred site, the UK National Institute for Clinical Excellence (NICE) is now recommending the use of real‐time ultrasound with each placement,18 and we find that this is best done in the internal jugular vein. Also, the rate of placement of femoral catheters remained higher than that of subclavian cathetersmost likely because the femoral vein remained the site of choice for emergently‐placed cathetersas PICC, more so than subclavian, became the preferred site for elective catheters.

Training physicians to place PICCs was not a simple task. In our experience, the availability of trainers at the tertiary care hospital was limited and the distractions of other duties of the hospitalist complicated the learning process. Two of our 5 physicians could not schedule time with the training nurse and were not able to acquire the skill. However, after training, the 3 hospitalists found that there was such a demand for PICCs that with time it was easy to maintain and even refine this skill. Since we only had 3 of 5 hospitalists trained in PICC placement, we could not have a PICC‐trained hospitalist on site 24 hours a day and the remaining 2 physicians had to rely on centrally‐placed catheters for access or have 1 of the trained physicians come to the hospital from home.

In summary, PICCs may be a safe and easy alternative to centrally‐placed catheters for the hospital physician attempting to secure central intravenous access and may lead to a decrease in the need for more risky CVC insertions. More definitive, controlled investigation, with patient outcome data, will be required before this can be advocated as a universal recommendation.

Since publication of the first randomized controlled trial of insulin infusion therapy in surgical intensive care unit (ICU) patients,1 most institutions have implemented insulin infusion protocols (IIP) for tight glycemic control in their ICUs.29 The major problem with tight glycemic control is the risk of hypoglycemia. In the randomized controlled trial involving medical ICU patients, 18.7% patients experienced at least 1 episode of blood glucose (BG) <40 mg/dL.10 Recently, a major insulin infusion trial involving patients with severe sepsis was stopped due to unacceptably high risk of hypoglycemia.11 Potential benefits of BG control may be offset by potential risks of hypoglycemia. While there can be multiple factors that could contribute to the risk of hypoglycemia, suboptimal protocol implementation is relatively amenable to correction.

Most IIPs are nurse driven. Nurses monitor BG levels every 30 to 60 minutes and make adjustments in insulin infusion rates. Each point of care testing and insulin dose adjustment takes about 5 minutes of nursing time.12 Given the numerous other nursing responsibilities for monitoring and documentation in very sick patients, nurses may not always be able check BGs at the recommended times. We investigated whether a delay in BG monitoring during insulin infusion therapy is associated with higher risk of hypoglycemia.

Methods

Data were collected for 50 consecutive patients treated with Brigham and Women's Hospital's insulin infusion protocol (BHIP) between September 27, 2006 and October 13, 2006. The investigation was part of the hospital's ongoing diabetes quality improvement program. Partners‐Health Human Research Committee approved the study. Patient demographics, history of diabetes mellitus, and glycosylated hemoglobin (A1C) were obtained from paper and electronic medical records. Point‐of‐care BG values were obtained from the bedside paper flow sheets. The exact times of individual BG measurements were ascertained from Point of Care Precision Web (QCM3.0; Abbott, Inc.).

Target BG range with BHIP is 80 to 110 mg/dL. BHIP requires BG testing every 60 minutes unless a BG value of <60 mg/dL is obtained; in which case, testing is required every 30 minutes. A time violation was assumed to have occurred if the BG was measured >70 minutes after a previous value of 60 mg/dL or >40 minutes after a previous BG value of <60 mg/dL (ie, >10 minutes after the recommended time for measurement). Although the choice of 10 minutes was arbitrary, we think it is a reasonable and practical time frame for getting a BG measurement. If a measurement was obtained earlier than the recommended time, it was not considered a time violation. However, measurements obtained within 30 minutes of a previous BG value (overwhelmingly drawn for confirmation of a previous BG value) were excluded from analysis.

BG values were divided into 2 categories: values following time violation and values following no time violation. The numbers of values in different BG ranges (<80, 80110, >110 mg/dL) were compared in the 2 categories using a chi square test. Data are presented as mean standard deviation (SD), median and numbers with percentage. Statistical significance was set at P < 0.05.

Results

Mean age of the 50 patients treated with BHIP was 64.0 13.6 years. There were 27 men and 23 women. Eighteen patients had preexisting diabetes (1 had type 1 and 17 had type 2 diabetes, mean A1C 7.1 1.7%) and 32 patients had no previous history of diabetes (mean A1C 5.9 0.9%). Mean serum creatinine was 1.34 1.0 mg/dL. Mean BG at the start of BHIP was 173 69.6 mg/dL; median 167.5 mg/dL. Mean BG during insulin infusion was 117.3 43.1 mg/dL; median 107 mg/dL. Mean BG during insulin infusion was higher in diabetic patients compared to nondiabetic patients (125.2 57.8 versus 113.4 38.8 mg/dL; P < 0.01). Monitoring for BGs was done with similar frequency in all patients. Overall, 40.2% of the total 2,605 BG values were in a range of 80 to 110 mg/dL. A total of 1.5% of values were below 60 mg/dL; only 4 values were <40 mg/dL.

A total of 2,309 values could be studied for time violations. The remaining 296 values were either obtained within 30 minutes of the previous test or the exact time of measurement could not be ascertained. A total of 1,474 (63.9%) measurements had been obtained at the recommended time or earlier than the recommended time; 835 (36.1%) measurements had been obtained >10 minutes after the recommended time for measurement (time violation). The proportion of BG values below the target (<80 mg/dL) was significantly higher following the time violation as compared to no time violation (Table 1). On the other hand, values >110 mg/dL were not more common following a time violation, compared to instances when no time violation occurred.

Frequency of time violation was similar in subgroups of patients divided according to gender, presence of diabetes and the type of ICU (Table 2). Comparison among subgroups of admission diagnoses was not possible due to the small number of patients. Overall, the proportion of low BG values was lower in diabetic patients compared to nondiabetic patients (11.9% versus 15.0%, P = 0.03). An increased rate of hypoglycemia following time violations was present in all subgroups except for the diabetic subgroup (Table 3).

Discussion

Our study shows that a delay in BG testing during BHIP is associated with higher chances of a low BG value. This effect was consistent in multiple subgroups. However, the effect was nonsignificant in diabetic patients, probably due to higher mean BG levels and less frequent low BG values. Over one‐third of all BG measurements were obtained after a time violation. Protocol violations in our study are no different from those reported by others.7, 13, 14 Our patient characteristics of severe hypoglycemic episodes and the overall BG control achieved with BHIP were also similar to those reported by others with similar protocols.5, 7, 1517 While the results of this study may still be specific to BHIP, we think they are applicable to other similar protocols.

Because a delay in testing by itself is unlikely to cause hypoglycemia, a more likely explanation for these results is that hypoglycemia occurred when insulin infusion adjustments were not made in a timely fashion due to prolonged BG monitoring intervals. Insulin infusions are the preferred treatment in rapidly changing clinical settings because changes in insulin doses can be made frequently. Most IIPs are designed with the assumption that insulin dose adjustments will be made regularly and frequently, based on BG measurements. Although there is no gold standard for the optimal BG test frequency, in most protocols BG testing is performed every hour in order to ensure safety as well as efficacy. Our results are consistent with the intuitive assumption that a timely measurement of the BG is important for successful implementation of an IIP.

It was somewhat surprising that high BG values were not more frequent following a time violation. We can only speculate as to the reason for this. It is possible that critically ill patients are near maximally insulin resistant and, once an effective insulin infusion rate is achieved, further increases are not as frequently required. On the other hand, insulin requirements may decrease rapidly as contributors to insulin resistance resolve. Another possibility is that there may be a limit to hepatic glucose production during acute illness making patients more prone to hypoglycemia. It is also possible that the nurses tend to test more promptly when the BG levels are running high. Thus, the insulin doses may be increased at proper times until BG levels are in the target range. However, when BG levels are in the target range, nurses may become less vigilant, leading to a delay in testing. As a result a decrease in insulin dose, when required, does not happen as promptly as an increase in dose.

In our study the absolute risk of hypoglycemia associated with time violation was 6%. Avoiding this hypoglycemia may have an impact on glycemic control in the ICU and may change clinical outcomes. Moreover, this is 1 of the few factors that are potentially amenable to correction. Therefore, measures to improve adherence to protocols, eg, prompts for BG testing and better nurse training regarding importance of timely testing, may reduce the risk of hypoglycemia.

Since publication of the first randomized controlled trial of insulin infusion therapy in surgical intensive care unit (ICU) patients,1 most institutions have implemented insulin infusion protocols (IIP) for tight glycemic control in their ICUs.29 The major problem with tight glycemic control is the risk of hypoglycemia. In the randomized controlled trial involving medical ICU patients, 18.7% patients experienced at least 1 episode of blood glucose (BG) <40 mg/dL.10 Recently, a major insulin infusion trial involving patients with severe sepsis was stopped due to unacceptably high risk of hypoglycemia.11 Potential benefits of BG control may be offset by potential risks of hypoglycemia. While there can be multiple factors that could contribute to the risk of hypoglycemia, suboptimal protocol implementation is relatively amenable to correction.

Most IIPs are nurse driven. Nurses monitor BG levels every 30 to 60 minutes and make adjustments in insulin infusion rates. Each point of care testing and insulin dose adjustment takes about 5 minutes of nursing time.12 Given the numerous other nursing responsibilities for monitoring and documentation in very sick patients, nurses may not always be able check BGs at the recommended times. We investigated whether a delay in BG monitoring during insulin infusion therapy is associated with higher risk of hypoglycemia.

Methods

Data were collected for 50 consecutive patients treated with Brigham and Women's Hospital's insulin infusion protocol (BHIP) between September 27, 2006 and October 13, 2006. The investigation was part of the hospital's ongoing diabetes quality improvement program. Partners‐Health Human Research Committee approved the study. Patient demographics, history of diabetes mellitus, and glycosylated hemoglobin (A1C) were obtained from paper and electronic medical records. Point‐of‐care BG values were obtained from the bedside paper flow sheets. The exact times of individual BG measurements were ascertained from Point of Care Precision Web (QCM3.0; Abbott, Inc.).

Target BG range with BHIP is 80 to 110 mg/dL. BHIP requires BG testing every 60 minutes unless a BG value of <60 mg/dL is obtained; in which case, testing is required every 30 minutes. A time violation was assumed to have occurred if the BG was measured >70 minutes after a previous value of 60 mg/dL or >40 minutes after a previous BG value of <60 mg/dL (ie, >10 minutes after the recommended time for measurement). Although the choice of 10 minutes was arbitrary, we think it is a reasonable and practical time frame for getting a BG measurement. If a measurement was obtained earlier than the recommended time, it was not considered a time violation. However, measurements obtained within 30 minutes of a previous BG value (overwhelmingly drawn for confirmation of a previous BG value) were excluded from analysis.

BG values were divided into 2 categories: values following time violation and values following no time violation. The numbers of values in different BG ranges (<80, 80110, >110 mg/dL) were compared in the 2 categories using a chi square test. Data are presented as mean standard deviation (SD), median and numbers with percentage. Statistical significance was set at P < 0.05.

Results

Mean age of the 50 patients treated with BHIP was 64.0 13.6 years. There were 27 men and 23 women. Eighteen patients had preexisting diabetes (1 had type 1 and 17 had type 2 diabetes, mean A1C 7.1 1.7%) and 32 patients had no previous history of diabetes (mean A1C 5.9 0.9%). Mean serum creatinine was 1.34 1.0 mg/dL. Mean BG at the start of BHIP was 173 69.6 mg/dL; median 167.5 mg/dL. Mean BG during insulin infusion was 117.3 43.1 mg/dL; median 107 mg/dL. Mean BG during insulin infusion was higher in diabetic patients compared to nondiabetic patients (125.2 57.8 versus 113.4 38.8 mg/dL; P < 0.01). Monitoring for BGs was done with similar frequency in all patients. Overall, 40.2% of the total 2,605 BG values were in a range of 80 to 110 mg/dL. A total of 1.5% of values were below 60 mg/dL; only 4 values were <40 mg/dL.

A total of 2,309 values could be studied for time violations. The remaining 296 values were either obtained within 30 minutes of the previous test or the exact time of measurement could not be ascertained. A total of 1,474 (63.9%) measurements had been obtained at the recommended time or earlier than the recommended time; 835 (36.1%) measurements had been obtained >10 minutes after the recommended time for measurement (time violation). The proportion of BG values below the target (<80 mg/dL) was significantly higher following the time violation as compared to no time violation (Table 1). On the other hand, values >110 mg/dL were not more common following a time violation, compared to instances when no time violation occurred.

Frequency of time violation was similar in subgroups of patients divided according to gender, presence of diabetes and the type of ICU (Table 2). Comparison among subgroups of admission diagnoses was not possible due to the small number of patients. Overall, the proportion of low BG values was lower in diabetic patients compared to nondiabetic patients (11.9% versus 15.0%, P = 0.03). An increased rate of hypoglycemia following time violations was present in all subgroups except for the diabetic subgroup (Table 3).

Discussion

Our study shows that a delay in BG testing during BHIP is associated with higher chances of a low BG value. This effect was consistent in multiple subgroups. However, the effect was nonsignificant in diabetic patients, probably due to higher mean BG levels and less frequent low BG values. Over one‐third of all BG measurements were obtained after a time violation. Protocol violations in our study are no different from those reported by others.7, 13, 14 Our patient characteristics of severe hypoglycemic episodes and the overall BG control achieved with BHIP were also similar to those reported by others with similar protocols.5, 7, 1517 While the results of this study may still be specific to BHIP, we think they are applicable to other similar protocols.

Because a delay in testing by itself is unlikely to cause hypoglycemia, a more likely explanation for these results is that hypoglycemia occurred when insulin infusion adjustments were not made in a timely fashion due to prolonged BG monitoring intervals. Insulin infusions are the preferred treatment in rapidly changing clinical settings because changes in insulin doses can be made frequently. Most IIPs are designed with the assumption that insulin dose adjustments will be made regularly and frequently, based on BG measurements. Although there is no gold standard for the optimal BG test frequency, in most protocols BG testing is performed every hour in order to ensure safety as well as efficacy. Our results are consistent with the intuitive assumption that a timely measurement of the BG is important for successful implementation of an IIP.

It was somewhat surprising that high BG values were not more frequent following a time violation. We can only speculate as to the reason for this. It is possible that critically ill patients are near maximally insulin resistant and, once an effective insulin infusion rate is achieved, further increases are not as frequently required. On the other hand, insulin requirements may decrease rapidly as contributors to insulin resistance resolve. Another possibility is that there may be a limit to hepatic glucose production during acute illness making patients more prone to hypoglycemia. It is also possible that the nurses tend to test more promptly when the BG levels are running high. Thus, the insulin doses may be increased at proper times until BG levels are in the target range. However, when BG levels are in the target range, nurses may become less vigilant, leading to a delay in testing. As a result a decrease in insulin dose, when required, does not happen as promptly as an increase in dose.

In our study the absolute risk of hypoglycemia associated with time violation was 6%. Avoiding this hypoglycemia may have an impact on glycemic control in the ICU and may change clinical outcomes. Moreover, this is 1 of the few factors that are potentially amenable to correction. Therefore, measures to improve adherence to protocols, eg, prompts for BG testing and better nurse training regarding importance of timely testing, may reduce the risk of hypoglycemia.

Since publication of the first randomized controlled trial of insulin infusion therapy in surgical intensive care unit (ICU) patients,1 most institutions have implemented insulin infusion protocols (IIP) for tight glycemic control in their ICUs.29 The major problem with tight glycemic control is the risk of hypoglycemia. In the randomized controlled trial involving medical ICU patients, 18.7% patients experienced at least 1 episode of blood glucose (BG) <40 mg/dL.10 Recently, a major insulin infusion trial involving patients with severe sepsis was stopped due to unacceptably high risk of hypoglycemia.11 Potential benefits of BG control may be offset by potential risks of hypoglycemia. While there can be multiple factors that could contribute to the risk of hypoglycemia, suboptimal protocol implementation is relatively amenable to correction.

Most IIPs are nurse driven. Nurses monitor BG levels every 30 to 60 minutes and make adjustments in insulin infusion rates. Each point of care testing and insulin dose adjustment takes about 5 minutes of nursing time.12 Given the numerous other nursing responsibilities for monitoring and documentation in very sick patients, nurses may not always be able check BGs at the recommended times. We investigated whether a delay in BG monitoring during insulin infusion therapy is associated with higher risk of hypoglycemia.

Methods

Data were collected for 50 consecutive patients treated with Brigham and Women's Hospital's insulin infusion protocol (BHIP) between September 27, 2006 and October 13, 2006. The investigation was part of the hospital's ongoing diabetes quality improvement program. Partners‐Health Human Research Committee approved the study. Patient demographics, history of diabetes mellitus, and glycosylated hemoglobin (A1C) were obtained from paper and electronic medical records. Point‐of‐care BG values were obtained from the bedside paper flow sheets. The exact times of individual BG measurements were ascertained from Point of Care Precision Web (QCM3.0; Abbott, Inc.).

Target BG range with BHIP is 80 to 110 mg/dL. BHIP requires BG testing every 60 minutes unless a BG value of <60 mg/dL is obtained; in which case, testing is required every 30 minutes. A time violation was assumed to have occurred if the BG was measured >70 minutes after a previous value of 60 mg/dL or >40 minutes after a previous BG value of <60 mg/dL (ie, >10 minutes after the recommended time for measurement). Although the choice of 10 minutes was arbitrary, we think it is a reasonable and practical time frame for getting a BG measurement. If a measurement was obtained earlier than the recommended time, it was not considered a time violation. However, measurements obtained within 30 minutes of a previous BG value (overwhelmingly drawn for confirmation of a previous BG value) were excluded from analysis.

BG values were divided into 2 categories: values following time violation and values following no time violation. The numbers of values in different BG ranges (<80, 80110, >110 mg/dL) were compared in the 2 categories using a chi square test. Data are presented as mean standard deviation (SD), median and numbers with percentage. Statistical significance was set at P < 0.05.

Results

Mean age of the 50 patients treated with BHIP was 64.0 13.6 years. There were 27 men and 23 women. Eighteen patients had preexisting diabetes (1 had type 1 and 17 had type 2 diabetes, mean A1C 7.1 1.7%) and 32 patients had no previous history of diabetes (mean A1C 5.9 0.9%). Mean serum creatinine was 1.34 1.0 mg/dL. Mean BG at the start of BHIP was 173 69.6 mg/dL; median 167.5 mg/dL. Mean BG during insulin infusion was 117.3 43.1 mg/dL; median 107 mg/dL. Mean BG during insulin infusion was higher in diabetic patients compared to nondiabetic patients (125.2 57.8 versus 113.4 38.8 mg/dL; P < 0.01). Monitoring for BGs was done with similar frequency in all patients. Overall, 40.2% of the total 2,605 BG values were in a range of 80 to 110 mg/dL. A total of 1.5% of values were below 60 mg/dL; only 4 values were <40 mg/dL.

A total of 2,309 values could be studied for time violations. The remaining 296 values were either obtained within 30 minutes of the previous test or the exact time of measurement could not be ascertained. A total of 1,474 (63.9%) measurements had been obtained at the recommended time or earlier than the recommended time; 835 (36.1%) measurements had been obtained >10 minutes after the recommended time for measurement (time violation). The proportion of BG values below the target (<80 mg/dL) was significantly higher following the time violation as compared to no time violation (Table 1). On the other hand, values >110 mg/dL were not more common following a time violation, compared to instances when no time violation occurred.

Frequency of time violation was similar in subgroups of patients divided according to gender, presence of diabetes and the type of ICU (Table 2). Comparison among subgroups of admission diagnoses was not possible due to the small number of patients. Overall, the proportion of low BG values was lower in diabetic patients compared to nondiabetic patients (11.9% versus 15.0%, P = 0.03). An increased rate of hypoglycemia following time violations was present in all subgroups except for the diabetic subgroup (Table 3).

Discussion

Our study shows that a delay in BG testing during BHIP is associated with higher chances of a low BG value. This effect was consistent in multiple subgroups. However, the effect was nonsignificant in diabetic patients, probably due to higher mean BG levels and less frequent low BG values. Over one‐third of all BG measurements were obtained after a time violation. Protocol violations in our study are no different from those reported by others.7, 13, 14 Our patient characteristics of severe hypoglycemic episodes and the overall BG control achieved with BHIP were also similar to those reported by others with similar protocols.5, 7, 1517 While the results of this study may still be specific to BHIP, we think they are applicable to other similar protocols.

Because a delay in testing by itself is unlikely to cause hypoglycemia, a more likely explanation for these results is that hypoglycemia occurred when insulin infusion adjustments were not made in a timely fashion due to prolonged BG monitoring intervals. Insulin infusions are the preferred treatment in rapidly changing clinical settings because changes in insulin doses can be made frequently. Most IIPs are designed with the assumption that insulin dose adjustments will be made regularly and frequently, based on BG measurements. Although there is no gold standard for the optimal BG test frequency, in most protocols BG testing is performed every hour in order to ensure safety as well as efficacy. Our results are consistent with the intuitive assumption that a timely measurement of the BG is important for successful implementation of an IIP.

It was somewhat surprising that high BG values were not more frequent following a time violation. We can only speculate as to the reason for this. It is possible that critically ill patients are near maximally insulin resistant and, once an effective insulin infusion rate is achieved, further increases are not as frequently required. On the other hand, insulin requirements may decrease rapidly as contributors to insulin resistance resolve. Another possibility is that there may be a limit to hepatic glucose production during acute illness making patients more prone to hypoglycemia. It is also possible that the nurses tend to test more promptly when the BG levels are running high. Thus, the insulin doses may be increased at proper times until BG levels are in the target range. However, when BG levels are in the target range, nurses may become less vigilant, leading to a delay in testing. As a result a decrease in insulin dose, when required, does not happen as promptly as an increase in dose.

In our study the absolute risk of hypoglycemia associated with time violation was 6%. Avoiding this hypoglycemia may have an impact on glycemic control in the ICU and may change clinical outcomes. Moreover, this is 1 of the few factors that are potentially amenable to correction. Therefore, measures to improve adherence to protocols, eg, prompts for BG testing and better nurse training regarding importance of timely testing, may reduce the risk of hypoglycemia.

Early diagnosis of peripheral neuropathies can lead to life‐saving or limb‐saving intervention. While infrequently a cause for concern in the hospital setting, peripheral neuropathies are commonoccurring in up to 10% of the general population.1 The hospitalist needs to expeditiously identify acute and life‐threatening or limb‐threatening causes among an immense set of differentials. Fortunately, with an informed and careful approach, most neuropathies in need of urgent intervention can be readily identified. A thorough history and examination, with the addition of electrodiagnostic testing, comprise the mainstays of this process. Inpatient neurology consultation should be sought for any rapidly progressing or acute onset neuropathy. The aim of this review is to equip the general hospitalist with a solid framework for efficiently evaluating peripheral neuropathies in urgent cases.

Literature Review

A General Approach for the Hospitalist

Pattern recognition and employing the essentials outlined above are key tools in the hospitalist's evaluation of peripheral neuropathy. Pattern recognition relies on a familiarity with the more common acute and severe neuropathies. For circumstances in which the diagnosis is not immediately recognizable, a systematic approach expedites evaluation. Figure 1 presents an algorithm for evaluating peripheral neuropathies in the acutely ill patient.

Figure 1

A Systematic Evaluation

When the etiology is not immediately evident, the essential questions identified in the review above are useful, and can be simplified for the hospitalist. First, understand the onset and timing of symptoms. Second, localize the symptoms to and within the peripheral nervous system (including classifying the distribution of nerve involvement). For acute, rapidly progressing or multifocal neuropathies urgent inpatient electrodiagnostic testing and neurology consultation should be obtained. Further testing, including laboratory testing, should be directed by these first steps.

Early diagnosis of peripheral neuropathies can lead to life‐saving or limb‐saving intervention. While infrequently a cause for concern in the hospital setting, peripheral neuropathies are commonoccurring in up to 10% of the general population.1 The hospitalist needs to expeditiously identify acute and life‐threatening or limb‐threatening causes among an immense set of differentials. Fortunately, with an informed and careful approach, most neuropathies in need of urgent intervention can be readily identified. A thorough history and examination, with the addition of electrodiagnostic testing, comprise the mainstays of this process. Inpatient neurology consultation should be sought for any rapidly progressing or acute onset neuropathy. The aim of this review is to equip the general hospitalist with a solid framework for efficiently evaluating peripheral neuropathies in urgent cases.

Literature Review

A General Approach for the Hospitalist

Pattern recognition and employing the essentials outlined above are key tools in the hospitalist's evaluation of peripheral neuropathy. Pattern recognition relies on a familiarity with the more common acute and severe neuropathies. For circumstances in which the diagnosis is not immediately recognizable, a systematic approach expedites evaluation. Figure 1 presents an algorithm for evaluating peripheral neuropathies in the acutely ill patient.

Figure 1

A Systematic Evaluation

When the etiology is not immediately evident, the essential questions identified in the review above are useful, and can be simplified for the hospitalist. First, understand the onset and timing of symptoms. Second, localize the symptoms to and within the peripheral nervous system (including classifying the distribution of nerve involvement). For acute, rapidly progressing or multifocal neuropathies urgent inpatient electrodiagnostic testing and neurology consultation should be obtained. Further testing, including laboratory testing, should be directed by these first steps.

Early diagnosis of peripheral neuropathies can lead to life‐saving or limb‐saving intervention. While infrequently a cause for concern in the hospital setting, peripheral neuropathies are commonoccurring in up to 10% of the general population.1 The hospitalist needs to expeditiously identify acute and life‐threatening or limb‐threatening causes among an immense set of differentials. Fortunately, with an informed and careful approach, most neuropathies in need of urgent intervention can be readily identified. A thorough history and examination, with the addition of electrodiagnostic testing, comprise the mainstays of this process. Inpatient neurology consultation should be sought for any rapidly progressing or acute onset neuropathy. The aim of this review is to equip the general hospitalist with a solid framework for efficiently evaluating peripheral neuropathies in urgent cases.

Literature Review

A General Approach for the Hospitalist

Pattern recognition and employing the essentials outlined above are key tools in the hospitalist's evaluation of peripheral neuropathy. Pattern recognition relies on a familiarity with the more common acute and severe neuropathies. For circumstances in which the diagnosis is not immediately recognizable, a systematic approach expedites evaluation. Figure 1 presents an algorithm for evaluating peripheral neuropathies in the acutely ill patient.

Figure 1

A Systematic Evaluation

When the etiology is not immediately evident, the essential questions identified in the review above are useful, and can be simplified for the hospitalist. First, understand the onset and timing of symptoms. Second, localize the symptoms to and within the peripheral nervous system (including classifying the distribution of nerve involvement). For acute, rapidly progressing or multifocal neuropathies urgent inpatient electrodiagnostic testing and neurology consultation should be obtained. Further testing, including laboratory testing, should be directed by these first steps.

A 32‐year‐old male presented to the emergency department complaining of pain and swelling in the right knee and left hand, along with a skin rash on both feet. He denied any fever or recent history of travel. Symptoms started 1 week before presentation. Recent medical history was significant for Chlamydia trachomatis urethritis 10 weeks prior, which had been successfully treated.

Physical examination revealed right knee effusion, dactylitis manifested by both swelling of the digits of the left hand and finger‐tip ulcerations (Figure 1), as well as hyperkeratotic plaques with erythematous bases on the soles of both feet, consistent with keratoderma blenorrhagica (Figure 2). Furthermore, scaly erythematous lesions over the penis and the scrotum were recognized, indicating circinate balanitis (Figure 3).

Figure 1

Figure 2

Figure 3

Laboratory tests including human immunodeficiency virus (HIV) were unremarkable aside from an elevated sedimentation rate and positive human leukocyte antigen (HLA)‐B27.

The patient was diagnosed with reactive arthritis (Reiter's syndrome). A treatment regimen was initiated consisting of nonsteroidal antiinflammatory drugs (NSAIDs), prednisone, and sulfasalazine. Close outpatient follow‐up was established. Four months later, the patient remained debilitated by the disease, and etanercept was added resulting in significant improvement.

Reactive arthritis, also known as Reiter's syndrome, is an autoimmune disease that usually develops 2 to 4 weeks after a genitourinary or gastrointestinal infection. The classic triad of arthritis, urethritis, and conjunctivitis does not occur in all patients. Diagnosis is made by medical history and clinical findings. Numerous therapeutic modalities have been used with variable success, including short‐term antibiotics, NSAIDs, systemic corticosteroids, sulfasalazine, methotrexate, cyclosporine, etretinate, and tumor‐necrosis factor (TNF) inhibitors.

A 32‐year‐old male presented to the emergency department complaining of pain and swelling in the right knee and left hand, along with a skin rash on both feet. He denied any fever or recent history of travel. Symptoms started 1 week before presentation. Recent medical history was significant for Chlamydia trachomatis urethritis 10 weeks prior, which had been successfully treated.

Physical examination revealed right knee effusion, dactylitis manifested by both swelling of the digits of the left hand and finger‐tip ulcerations (Figure 1), as well as hyperkeratotic plaques with erythematous bases on the soles of both feet, consistent with keratoderma blenorrhagica (Figure 2). Furthermore, scaly erythematous lesions over the penis and the scrotum were recognized, indicating circinate balanitis (Figure 3).

Figure 1

Figure 2

Figure 3

Laboratory tests including human immunodeficiency virus (HIV) were unremarkable aside from an elevated sedimentation rate and positive human leukocyte antigen (HLA)‐B27.

The patient was diagnosed with reactive arthritis (Reiter's syndrome). A treatment regimen was initiated consisting of nonsteroidal antiinflammatory drugs (NSAIDs), prednisone, and sulfasalazine. Close outpatient follow‐up was established. Four months later, the patient remained debilitated by the disease, and etanercept was added resulting in significant improvement.

Reactive arthritis, also known as Reiter's syndrome, is an autoimmune disease that usually develops 2 to 4 weeks after a genitourinary or gastrointestinal infection. The classic triad of arthritis, urethritis, and conjunctivitis does not occur in all patients. Diagnosis is made by medical history and clinical findings. Numerous therapeutic modalities have been used with variable success, including short‐term antibiotics, NSAIDs, systemic corticosteroids, sulfasalazine, methotrexate, cyclosporine, etretinate, and tumor‐necrosis factor (TNF) inhibitors.

A 32‐year‐old male presented to the emergency department complaining of pain and swelling in the right knee and left hand, along with a skin rash on both feet. He denied any fever or recent history of travel. Symptoms started 1 week before presentation. Recent medical history was significant for Chlamydia trachomatis urethritis 10 weeks prior, which had been successfully treated.

Physical examination revealed right knee effusion, dactylitis manifested by both swelling of the digits of the left hand and finger‐tip ulcerations (Figure 1), as well as hyperkeratotic plaques with erythematous bases on the soles of both feet, consistent with keratoderma blenorrhagica (Figure 2). Furthermore, scaly erythematous lesions over the penis and the scrotum were recognized, indicating circinate balanitis (Figure 3).

Figure 1

Figure 2

Figure 3

Laboratory tests including human immunodeficiency virus (HIV) were unremarkable aside from an elevated sedimentation rate and positive human leukocyte antigen (HLA)‐B27.

The patient was diagnosed with reactive arthritis (Reiter's syndrome). A treatment regimen was initiated consisting of nonsteroidal antiinflammatory drugs (NSAIDs), prednisone, and sulfasalazine. Close outpatient follow‐up was established. Four months later, the patient remained debilitated by the disease, and etanercept was added resulting in significant improvement.

Reactive arthritis, also known as Reiter's syndrome, is an autoimmune disease that usually develops 2 to 4 weeks after a genitourinary or gastrointestinal infection. The classic triad of arthritis, urethritis, and conjunctivitis does not occur in all patients. Diagnosis is made by medical history and clinical findings. Numerous therapeutic modalities have been used with variable success, including short‐term antibiotics, NSAIDs, systemic corticosteroids, sulfasalazine, methotrexate, cyclosporine, etretinate, and tumor‐necrosis factor (TNF) inhibitors.

The Institute of Medicine report linking between 48,000 and 98,000 deaths annually to medical errors1 has raised awareness about medical errors across all areas of medicine. In pediatrics, medical errors in hospitalized children are associated with significant increases in length of stay, healthcare costs, and death.2, 3 While much attention has been paid to the use of hospital systems to prevent medical errors, there has been considerably less focus on the experiences of patients and their potential role in preventing errors.

Studies have suggested that a significant majority of adult patients are concerned about medical errors during hospitalization.4, 5 However, a similar assessment of parents' concerns about medical errors in pediatrics is lacking. Admittedly, for concern to be constructive it must be linked to action. The Joint Commission and the Agency for Healthcare Research and Quality (AHRQ) currently recommend that parents help prevent errors by becoming active, involved and informed members of their healthcare team and taking part in every decision about (their) child's health care.6, 7 However, the extent to which parental concern about medical errors is related to a parent's self‐efficacy, or confidence, interacting with physicians is unknown.

Self‐efficacy is a construct used in social cognitive theory to explain behavior change.8 It refers to an individual's belief in (his/her) capabilities to organize and execute the courses of action required to produce given attainments or a desired outcome.9 Self‐efficacy is not a general concept; it must be discussed in reference to a specific activity. In healthcare it has been associated not only with willingness to adopt preventive strategies,10 but also with treatment adherence,11, 12 behavior change,13 and with greater patient participation in healthcare decision‐making.14, 15

In this study we had 2 objectives. First, we sought to assess the proportion of parents of hospitalized children who are concerned about medical errors. Second, we attempted to examine whether a parent's self‐efficacy interacting with physicians was associated with their concern about medical errors for their child. Given that parents with greater self‐efficacy interacting with physicians might feel more empowered to prevent errors and, as such, be more inclined to take an active role to do so, we hypothesized that such parents would be less concerned about medical errors during a pediatric hospitalization.

Subjects and Methods

Results

During the time period of our study, 278 parents were eligible to participate. Eighty‐five parents could not be surveyed either because they could not be reached despite multiple attempts (eg, out of the room, speaking with physicians) or because the child had already been discharged. Of the 193 parents approached, 130 agreed to take the survey. Two parents who agreed to complete the survey forgot to return it before their children were discharged. Demographics of respondents and nonparticipants are presented in Table 1. The distribution of self‐efficacy scores was skewed, with a mean score of 45 (median 46, range 5‐50) on a 50‐point scale, consistent with previous studies in adults.18

Eighty‐two parents (63% of respondents) Agreed or Strongly Agreed with the statement When my child is in the hospital I feel that I need to watch over his/her care in order to make sure that mistakes aren't made (Figure 1). In bivariate analyses, non‐white race (Table 2) and English proficiency (P = 0.002) were significantly associated with parental concern about medical errors. Notably, all respondents who were not very comfortable with English agreed that they felt the need to watch over their child's care to ensure that mistakes do not happen. The association between self‐efficacy with physician interactions and concern was nearly significant (Table 2).

Figure 1

In multivariate analysis, self‐efficacy was independently associated with parental report about the need to watch over a child's care (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.72‐0.92). In prediction models, with self‐efficacy scores of 44 (25th percentile), 46 (50th percentile), and 49 (75th percentile), about 72.2% (59.1‐82.3), 64.2% (51.8‐75.0), and 50.8% (35.3‐66.2) of parents, respectively, would feel the need to watch over their child's care to prevent medical errors.

While respondents of non‐white race had the greatest independent odds of reporting a concern for medical errors occurring while their child was hospitalized (OR, 4.9; 95% CI, 1.19‐20.4), we could not reliably determine how much of this effect was due to language instead of to race because the vast majority of parents who reported being less than very comfortable with English were also non‐white (non‐white 90.5% vs. white 9.5%, P < 0.001). In additional analyses we were unable to find a difference in concern about medical errors between white and non‐white parents who were very comfortable with English (data not shown).

Of note, while having 1 hospitalization compared to none was significantly associated with having decreased concern about medical errors (Table 2), the variable hospitalizations was not significant in the model (P = 0.07).

In post‐hoc analysis, we found no association between hospitalization for >3 days after birth, previous hospitalization for >1 week, parents' experience with the hospital system, and overall perception of child's health, previous hospitalizations for other children. While rating of care that child received was significantly associated with parents' concern about medical errors in the bivariate analysis, it did not remain significant in multivariate analysis and did not substantially change the magnitude or significance of previous associations.

Discussion

In our study, we found that nearly two‐thirds of parents of children admitted to the general pediatric service of a tertiary care children's hospital felt the need to watch over their child's care to ensure that mistakes would not be made. We also found that a parent's self‐efficacy interacting with physicians was associated with less parental concern for medical errors.

To our knowledge, this is the first study to systematically survey parents' concerns about medical errors during a child's hospitalization and to evaluate factors associated with this concern. The immediate question prompted by our findings is whether the fact that 63% of parents are concerned is alarming because it is too low or too high. Some might contend that concern about medical errors is an appropriate and desirable response because it may motivate parents to become more vigilant about the medical care that their child is receiving. However, others may challenge that such concern may indicate a feeling of powerlessness to act to prevent potential errors. In our study, the relationship between higher self‐efficacy and less parental concern raises the possibility that parents with higher levels of self‐efficacy with physician interactions may feel more comfortable communicating with physicians, which in turn may temper parents' concerns about medical errors during hospitalization.

It is equally plausible that concern about medical errors during hospitalization may motivate parents to become involved in their child's medical care and, in turn, lead them to feel empowered to prevent medical errors and so ease their concerns. It is conceivable that experience with past medical errors may fuel a parent's need to watch over their child's care to prevent additional medical errors. Future studies should address the independent effect of past medical errors on parental concern about medical errors.

In this study, all parents who reported being very uncomfortable with English and parents of non‐white race felt the need to watch over their child's care to help prevent errors. A previous survey of a nationally representative sample of U.S. adults found greater proportion of non‐white adults were very concerned about errors or mistakes happening when receiving care at a hospital (blacks 62%, Hispanics 57%, whites 44%).26 However, in our study, the relationship between race and concern is likely mediated by language since many of the parents who described themselves as other than white also reported being not very comfortable with English and we could not find an effect of race on concern among parents who were very comfortable with English. Indeed, previous studies have linked decreased English proficiency to medical errors with potential clinical consequence.27

Given our previous investigation of the relationship between self‐efficacy and parent participation in medical decisions during a child's hospitalization, we conducted post‐hoc analyses exploring the association between parents' self‐report of participation in medical decisions and concern about medical errors during their child's hospitalization.16 Using a simple logistic regression we did not find any association. However, we advise caution in interpreting and generalizing these results because the study was not powered to adequately evaluate this association.

There are additional limitations in our study to be noted. First, this question has not been used previously to assess parental concern about medical errors, so future work will need to focus on assessing its reliability and validity. Second, it is also possible that parents' concern for medical errors is mitigated by the complexity of their child's healthcare.5 We attempted to address this issue by controlling for the child's number of chronic illnesses. However, it is possible that our metric did not capture the level of complexity associated with different types of chronic conditions. Moreover, additional variables such as health insurance type, parental physical and mental health, and quality of interactions with the nursing staff may confound the relationships that we observed. Future studies should examine the effect of these variables on parents' self‐efficacy and their concern about medical errors.

Third, we surveyed parents at a single institution and, as such, differences in demographics and hospital‐specific practices related to patient‐physician interactions may prevent generalization of our findings to other institutions. For example, the parents in our survey had a higher average education level than the general population and the racial makeup of our population was not nationally representative. Also, due to HIPAA constraints, we were unable to collect extensive demographic information on parents and children who were missed or those who refused to participate in the study, which also could conceivably influence the strength of our findings.

Fourth, we adapted a validated adult measure of self‐efficacy for use in pediatrics. The patient‐physician self‐efficacy scale, the PEPPI, did have a skewed distribution in our study, although this performance is consistent with adult studies18 and in post‐hoc analyses, outlier PEPPI scores did not have a significant effect on the magnitude of the relationship we observed between self‐efficacy and parental concern about medical errors. However, the reading level of this instrument is ninth grade, which may impact the generalization of our findings to populations with lower literacy levels.

Fifth, we excluded parents who were unsure about their concern from our analyses. In post‐hoc multivariate regression analyses, reassignment of unsure responses to either agree or disagree did not result in any change in odds ratio for any endpoint.

Finally, it is possible that parental concern was influenced by social desirability bias in that parents may have been less likely to report concern about medical errors during a hospitalization because of fear of the implications it might have for their child's care. We attempted to control for this effect by adjusting for social desirability bias using the Marlowe‐Crowne scale. This scale is commonly used in behavioral science research to account for such response bias and has been recommended by the NIH Consortium on Behavior Change for use in behavioral change research related to health.24

Within the context of these limitations, we feel that our study contributes an important first step toward characterizing the scope of parental concern about medical errors during pediatric hospitalizations and understanding the relationship of self‐efficacy with physician interactions to this concern. Devising a quality initiative program to improve parents' self‐efficacy interacting with physicians might help to temper parents' concerns about medical errors while also encouraging their involvement in their child's medical care. Such a program would likely prove most beneficial if it sought to improve self‐efficacy among parents with lower English proficiency given that this group had the highest concern for medical errors. Possible interventions might include more ready access to interpreters or use of visual aids.

The Institute of Medicine report linking between 48,000 and 98,000 deaths annually to medical errors1 has raised awareness about medical errors across all areas of medicine. In pediatrics, medical errors in hospitalized children are associated with significant increases in length of stay, healthcare costs, and death.2, 3 While much attention has been paid to the use of hospital systems to prevent medical errors, there has been considerably less focus on the experiences of patients and their potential role in preventing errors.

Studies have suggested that a significant majority of adult patients are concerned about medical errors during hospitalization.4, 5 However, a similar assessment of parents' concerns about medical errors in pediatrics is lacking. Admittedly, for concern to be constructive it must be linked to action. The Joint Commission and the Agency for Healthcare Research and Quality (AHRQ) currently recommend that parents help prevent errors by becoming active, involved and informed members of their healthcare team and taking part in every decision about (their) child's health care.6, 7 However, the extent to which parental concern about medical errors is related to a parent's self‐efficacy, or confidence, interacting with physicians is unknown.

Self‐efficacy is a construct used in social cognitive theory to explain behavior change.8 It refers to an individual's belief in (his/her) capabilities to organize and execute the courses of action required to produce given attainments or a desired outcome.9 Self‐efficacy is not a general concept; it must be discussed in reference to a specific activity. In healthcare it has been associated not only with willingness to adopt preventive strategies,10 but also with treatment adherence,11, 12 behavior change,13 and with greater patient participation in healthcare decision‐making.14, 15

In this study we had 2 objectives. First, we sought to assess the proportion of parents of hospitalized children who are concerned about medical errors. Second, we attempted to examine whether a parent's self‐efficacy interacting with physicians was associated with their concern about medical errors for their child. Given that parents with greater self‐efficacy interacting with physicians might feel more empowered to prevent errors and, as such, be more inclined to take an active role to do so, we hypothesized that such parents would be less concerned about medical errors during a pediatric hospitalization.

Subjects and Methods

Results

During the time period of our study, 278 parents were eligible to participate. Eighty‐five parents could not be surveyed either because they could not be reached despite multiple attempts (eg, out of the room, speaking with physicians) or because the child had already been discharged. Of the 193 parents approached, 130 agreed to take the survey. Two parents who agreed to complete the survey forgot to return it before their children were discharged. Demographics of respondents and nonparticipants are presented in Table 1. The distribution of self‐efficacy scores was skewed, with a mean score of 45 (median 46, range 5‐50) on a 50‐point scale, consistent with previous studies in adults.18

Eighty‐two parents (63% of respondents) Agreed or Strongly Agreed with the statement When my child is in the hospital I feel that I need to watch over his/her care in order to make sure that mistakes aren't made (Figure 1). In bivariate analyses, non‐white race (Table 2) and English proficiency (P = 0.002) were significantly associated with parental concern about medical errors. Notably, all respondents who were not very comfortable with English agreed that they felt the need to watch over their child's care to ensure that mistakes do not happen. The association between self‐efficacy with physician interactions and concern was nearly significant (Table 2).

Figure 1

In multivariate analysis, self‐efficacy was independently associated with parental report about the need to watch over a child's care (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.72‐0.92). In prediction models, with self‐efficacy scores of 44 (25th percentile), 46 (50th percentile), and 49 (75th percentile), about 72.2% (59.1‐82.3), 64.2% (51.8‐75.0), and 50.8% (35.3‐66.2) of parents, respectively, would feel the need to watch over their child's care to prevent medical errors.

While respondents of non‐white race had the greatest independent odds of reporting a concern for medical errors occurring while their child was hospitalized (OR, 4.9; 95% CI, 1.19‐20.4), we could not reliably determine how much of this effect was due to language instead of to race because the vast majority of parents who reported being less than very comfortable with English were also non‐white (non‐white 90.5% vs. white 9.5%, P < 0.001). In additional analyses we were unable to find a difference in concern about medical errors between white and non‐white parents who were very comfortable with English (data not shown).

Of note, while having 1 hospitalization compared to none was significantly associated with having decreased concern about medical errors (Table 2), the variable hospitalizations was not significant in the model (P = 0.07).

In post‐hoc analysis, we found no association between hospitalization for >3 days after birth, previous hospitalization for >1 week, parents' experience with the hospital system, and overall perception of child's health, previous hospitalizations for other children. While rating of care that child received was significantly associated with parents' concern about medical errors in the bivariate analysis, it did not remain significant in multivariate analysis and did not substantially change the magnitude or significance of previous associations.

Discussion

In our study, we found that nearly two‐thirds of parents of children admitted to the general pediatric service of a tertiary care children's hospital felt the need to watch over their child's care to ensure that mistakes would not be made. We also found that a parent's self‐efficacy interacting with physicians was associated with less parental concern for medical errors.

To our knowledge, this is the first study to systematically survey parents' concerns about medical errors during a child's hospitalization and to evaluate factors associated with this concern. The immediate question prompted by our findings is whether the fact that 63% of parents are concerned is alarming because it is too low or too high. Some might contend that concern about medical errors is an appropriate and desirable response because it may motivate parents to become more vigilant about the medical care that their child is receiving. However, others may challenge that such concern may indicate a feeling of powerlessness to act to prevent potential errors. In our study, the relationship between higher self‐efficacy and less parental concern raises the possibility that parents with higher levels of self‐efficacy with physician interactions may feel more comfortable communicating with physicians, which in turn may temper parents' concerns about medical errors during hospitalization.

It is equally plausible that concern about medical errors during hospitalization may motivate parents to become involved in their child's medical care and, in turn, lead them to feel empowered to prevent medical errors and so ease their concerns. It is conceivable that experience with past medical errors may fuel a parent's need to watch over their child's care to prevent additional medical errors. Future studies should address the independent effect of past medical errors on parental concern about medical errors.

In this study, all parents who reported being very uncomfortable with English and parents of non‐white race felt the need to watch over their child's care to help prevent errors. A previous survey of a nationally representative sample of U.S. adults found greater proportion of non‐white adults were very concerned about errors or mistakes happening when receiving care at a hospital (blacks 62%, Hispanics 57%, whites 44%).26 However, in our study, the relationship between race and concern is likely mediated by language since many of the parents who described themselves as other than white also reported being not very comfortable with English and we could not find an effect of race on concern among parents who were very comfortable with English. Indeed, previous studies have linked decreased English proficiency to medical errors with potential clinical consequence.27

Given our previous investigation of the relationship between self‐efficacy and parent participation in medical decisions during a child's hospitalization, we conducted post‐hoc analyses exploring the association between parents' self‐report of participation in medical decisions and concern about medical errors during their child's hospitalization.16 Using a simple logistic regression we did not find any association. However, we advise caution in interpreting and generalizing these results because the study was not powered to adequately evaluate this association.

There are additional limitations in our study to be noted. First, this question has not been used previously to assess parental concern about medical errors, so future work will need to focus on assessing its reliability and validity. Second, it is also possible that parents' concern for medical errors is mitigated by the complexity of their child's healthcare.5 We attempted to address this issue by controlling for the child's number of chronic illnesses. However, it is possible that our metric did not capture the level of complexity associated with different types of chronic conditions. Moreover, additional variables such as health insurance type, parental physical and mental health, and quality of interactions with the nursing staff may confound the relationships that we observed. Future studies should examine the effect of these variables on parents' self‐efficacy and their concern about medical errors.

Third, we surveyed parents at a single institution and, as such, differences in demographics and hospital‐specific practices related to patient‐physician interactions may prevent generalization of our findings to other institutions. For example, the parents in our survey had a higher average education level than the general population and the racial makeup of our population was not nationally representative. Also, due to HIPAA constraints, we were unable to collect extensive demographic information on parents and children who were missed or those who refused to participate in the study, which also could conceivably influence the strength of our findings.

Fourth, we adapted a validated adult measure of self‐efficacy for use in pediatrics. The patient‐physician self‐efficacy scale, the PEPPI, did have a skewed distribution in our study, although this performance is consistent with adult studies18 and in post‐hoc analyses, outlier PEPPI scores did not have a significant effect on the magnitude of the relationship we observed between self‐efficacy and parental concern about medical errors. However, the reading level of this instrument is ninth grade, which may impact the generalization of our findings to populations with lower literacy levels.

Fifth, we excluded parents who were unsure about their concern from our analyses. In post‐hoc multivariate regression analyses, reassignment of unsure responses to either agree or disagree did not result in any change in odds ratio for any endpoint.

Finally, it is possible that parental concern was influenced by social desirability bias in that parents may have been less likely to report concern about medical errors during a hospitalization because of fear of the implications it might have for their child's care. We attempted to control for this effect by adjusting for social desirability bias using the Marlowe‐Crowne scale. This scale is commonly used in behavioral science research to account for such response bias and has been recommended by the NIH Consortium on Behavior Change for use in behavioral change research related to health.24

Within the context of these limitations, we feel that our study contributes an important first step toward characterizing the scope of parental concern about medical errors during pediatric hospitalizations and understanding the relationship of self‐efficacy with physician interactions to this concern. Devising a quality initiative program to improve parents' self‐efficacy interacting with physicians might help to temper parents' concerns about medical errors while also encouraging their involvement in their child's medical care. Such a program would likely prove most beneficial if it sought to improve self‐efficacy among parents with lower English proficiency given that this group had the highest concern for medical errors. Possible interventions might include more ready access to interpreters or use of visual aids.

The Institute of Medicine report linking between 48,000 and 98,000 deaths annually to medical errors1 has raised awareness about medical errors across all areas of medicine. In pediatrics, medical errors in hospitalized children are associated with significant increases in length of stay, healthcare costs, and death.2, 3 While much attention has been paid to the use of hospital systems to prevent medical errors, there has been considerably less focus on the experiences of patients and their potential role in preventing errors.

Studies have suggested that a significant majority of adult patients are concerned about medical errors during hospitalization.4, 5 However, a similar assessment of parents' concerns about medical errors in pediatrics is lacking. Admittedly, for concern to be constructive it must be linked to action. The Joint Commission and the Agency for Healthcare Research and Quality (AHRQ) currently recommend that parents help prevent errors by becoming active, involved and informed members of their healthcare team and taking part in every decision about (their) child's health care.6, 7 However, the extent to which parental concern about medical errors is related to a parent's self‐efficacy, or confidence, interacting with physicians is unknown.

Self‐efficacy is a construct used in social cognitive theory to explain behavior change.8 It refers to an individual's belief in (his/her) capabilities to organize and execute the courses of action required to produce given attainments or a desired outcome.9 Self‐efficacy is not a general concept; it must be discussed in reference to a specific activity. In healthcare it has been associated not only with willingness to adopt preventive strategies,10 but also with treatment adherence,11, 12 behavior change,13 and with greater patient participation in healthcare decision‐making.14, 15

In this study we had 2 objectives. First, we sought to assess the proportion of parents of hospitalized children who are concerned about medical errors. Second, we attempted to examine whether a parent's self‐efficacy interacting with physicians was associated with their concern about medical errors for their child. Given that parents with greater self‐efficacy interacting with physicians might feel more empowered to prevent errors and, as such, be more inclined to take an active role to do so, we hypothesized that such parents would be less concerned about medical errors during a pediatric hospitalization.

Subjects and Methods

Results

During the time period of our study, 278 parents were eligible to participate. Eighty‐five parents could not be surveyed either because they could not be reached despite multiple attempts (eg, out of the room, speaking with physicians) or because the child had already been discharged. Of the 193 parents approached, 130 agreed to take the survey. Two parents who agreed to complete the survey forgot to return it before their children were discharged. Demographics of respondents and nonparticipants are presented in Table 1. The distribution of self‐efficacy scores was skewed, with a mean score of 45 (median 46, range 5‐50) on a 50‐point scale, consistent with previous studies in adults.18

Eighty‐two parents (63% of respondents) Agreed or Strongly Agreed with the statement When my child is in the hospital I feel that I need to watch over his/her care in order to make sure that mistakes aren't made (Figure 1). In bivariate analyses, non‐white race (Table 2) and English proficiency (P = 0.002) were significantly associated with parental concern about medical errors. Notably, all respondents who were not very comfortable with English agreed that they felt the need to watch over their child's care to ensure that mistakes do not happen. The association between self‐efficacy with physician interactions and concern was nearly significant (Table 2).

Figure 1

In multivariate analysis, self‐efficacy was independently associated with parental report about the need to watch over a child's care (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.72‐0.92). In prediction models, with self‐efficacy scores of 44 (25th percentile), 46 (50th percentile), and 49 (75th percentile), about 72.2% (59.1‐82.3), 64.2% (51.8‐75.0), and 50.8% (35.3‐66.2) of parents, respectively, would feel the need to watch over their child's care to prevent medical errors.

While respondents of non‐white race had the greatest independent odds of reporting a concern for medical errors occurring while their child was hospitalized (OR, 4.9; 95% CI, 1.19‐20.4), we could not reliably determine how much of this effect was due to language instead of to race because the vast majority of parents who reported being less than very comfortable with English were also non‐white (non‐white 90.5% vs. white 9.5%, P < 0.001). In additional analyses we were unable to find a difference in concern about medical errors between white and non‐white parents who were very comfortable with English (data not shown).

Of note, while having 1 hospitalization compared to none was significantly associated with having decreased concern about medical errors (Table 2), the variable hospitalizations was not significant in the model (P = 0.07).

In post‐hoc analysis, we found no association between hospitalization for >3 days after birth, previous hospitalization for >1 week, parents' experience with the hospital system, and overall perception of child's health, previous hospitalizations for other children. While rating of care that child received was significantly associated with parents' concern about medical errors in the bivariate analysis, it did not remain significant in multivariate analysis and did not substantially change the magnitude or significance of previous associations.

Discussion

In our study, we found that nearly two‐thirds of parents of children admitted to the general pediatric service of a tertiary care children's hospital felt the need to watch over their child's care to ensure that mistakes would not be made. We also found that a parent's self‐efficacy interacting with physicians was associated with less parental concern for medical errors.

To our knowledge, this is the first study to systematically survey parents' concerns about medical errors during a child's hospitalization and to evaluate factors associated with this concern. The immediate question prompted by our findings is whether the fact that 63% of parents are concerned is alarming because it is too low or too high. Some might contend that concern about medical errors is an appropriate and desirable response because it may motivate parents to become more vigilant about the medical care that their child is receiving. However, others may challenge that such concern may indicate a feeling of powerlessness to act to prevent potential errors. In our study, the relationship between higher self‐efficacy and less parental concern raises the possibility that parents with higher levels of self‐efficacy with physician interactions may feel more comfortable communicating with physicians, which in turn may temper parents' concerns about medical errors during hospitalization.

It is equally plausible that concern about medical errors during hospitalization may motivate parents to become involved in their child's medical care and, in turn, lead them to feel empowered to prevent medical errors and so ease their concerns. It is conceivable that experience with past medical errors may fuel a parent's need to watch over their child's care to prevent additional medical errors. Future studies should address the independent effect of past medical errors on parental concern about medical errors.

In this study, all parents who reported being very uncomfortable with English and parents of non‐white race felt the need to watch over their child's care to help prevent errors. A previous survey of a nationally representative sample of U.S. adults found greater proportion of non‐white adults were very concerned about errors or mistakes happening when receiving care at a hospital (blacks 62%, Hispanics 57%, whites 44%).26 However, in our study, the relationship between race and concern is likely mediated by language since many of the parents who described themselves as other than white also reported being not very comfortable with English and we could not find an effect of race on concern among parents who were very comfortable with English. Indeed, previous studies have linked decreased English proficiency to medical errors with potential clinical consequence.27

Given our previous investigation of the relationship between self‐efficacy and parent participation in medical decisions during a child's hospitalization, we conducted post‐hoc analyses exploring the association between parents' self‐report of participation in medical decisions and concern about medical errors during their child's hospitalization.16 Using a simple logistic regression we did not find any association. However, we advise caution in interpreting and generalizing these results because the study was not powered to adequately evaluate this association.

There are additional limitations in our study to be noted. First, this question has not been used previously to assess parental concern about medical errors, so future work will need to focus on assessing its reliability and validity. Second, it is also possible that parents' concern for medical errors is mitigated by the complexity of their child's healthcare.5 We attempted to address this issue by controlling for the child's number of chronic illnesses. However, it is possible that our metric did not capture the level of complexity associated with different types of chronic conditions. Moreover, additional variables such as health insurance type, parental physical and mental health, and quality of interactions with the nursing staff may confound the relationships that we observed. Future studies should examine the effect of these variables on parents' self‐efficacy and their concern about medical errors.

Third, we surveyed parents at a single institution and, as such, differences in demographics and hospital‐specific practices related to patient‐physician interactions may prevent generalization of our findings to other institutions. For example, the parents in our survey had a higher average education level than the general population and the racial makeup of our population was not nationally representative. Also, due to HIPAA constraints, we were unable to collect extensive demographic information on parents and children who were missed or those who refused to participate in the study, which also could conceivably influence the strength of our findings.

Fourth, we adapted a validated adult measure of self‐efficacy for use in pediatrics. The patient‐physician self‐efficacy scale, the PEPPI, did have a skewed distribution in our study, although this performance is consistent with adult studies18 and in post‐hoc analyses, outlier PEPPI scores did not have a significant effect on the magnitude of the relationship we observed between self‐efficacy and parental concern about medical errors. However, the reading level of this instrument is ninth grade, which may impact the generalization of our findings to populations with lower literacy levels.

Fifth, we excluded parents who were unsure about their concern from our analyses. In post‐hoc multivariate regression analyses, reassignment of unsure responses to either agree or disagree did not result in any change in odds ratio for any endpoint.

Finally, it is possible that parental concern was influenced by social desirability bias in that parents may have been less likely to report concern about medical errors during a hospitalization because of fear of the implications it might have for their child's care. We attempted to control for this effect by adjusting for social desirability bias using the Marlowe‐Crowne scale. This scale is commonly used in behavioral science research to account for such response bias and has been recommended by the NIH Consortium on Behavior Change for use in behavioral change research related to health.24

Within the context of these limitations, we feel that our study contributes an important first step toward characterizing the scope of parental concern about medical errors during pediatric hospitalizations and understanding the relationship of self‐efficacy with physician interactions to this concern. Devising a quality initiative program to improve parents' self‐efficacy interacting with physicians might help to temper parents' concerns about medical errors while also encouraging their involvement in their child's medical care. Such a program would likely prove most beneficial if it sought to improve self‐efficacy among parents with lower English proficiency given that this group had the highest concern for medical errors. Possible interventions might include more ready access to interpreters or use of visual aids.