Standardized order sets reduce medication errors and create efficiency for physicians, nurses, and pharmacists.1 A less recognized benefit may be that standardized orders promote equity in care and may help to mitigate disparities that occur along racial and ethnic lines. Patients admitted with an acute pain crisis secondary to sickle cell disease (SCD) are often suspected of drug-seeking behavior and may be treated in a cursory manner because they are “frequent flyers” on the medical service. In view of these factors, this patient group may benefit more than others from a standardized treatment protocol. Over the past year, hospitalists and other clinicians at Novant Health in Charlotte, N.C., have composed an admission order set for SCD pain crisis in an effort to improve care for this underserved group.

Novant Health

Novant Health is a multi-hospital, non-profit system serving 3.5 million people from Virginia to South Carolina. Presbyterian Hospital, a 531-bed facility in Charlotte, N.C., is the flagship hospital for Novant’s Southern Piedmont Region (SPR). Presbyterian Inpatient Care Specialists (PICS) is a 44-provider group that offers hospitalist services for adult patients at Presbyterian Hospital, two community hospitals in Matthews and Huntersville, and Presbyterian Orthopedic Hospital.2 In 2005, 180 adult patients were discharged from the Novant-SPR hospitals with a principal diagnosis of SCD, and most of these patients were managed by PICS. This cohort of 180 patients accounted for more than 600 hospitalizations for SCD-related illness at the Novant-SPR facilities in 2005.

Process and Procedure

Standardized order sets have been in widespread use at the Novant-SPR facilities for a number of years. The process of order set development begins with patient needs as perceived by medical staff. Once a physician has drafted an order set, the draft is reviewed by the Order Set Subcommittee, a multidisciplinary team chaired by Susan Smith, RPh, PharmD, with nurses, physicians, and other support staff represented as needed. Once the subcommittee has approved the draft, it goes to the Pharmacy and Therapeutics Committee for final approval. In this fashion, more than 600 order sets have been developed and made available on the hospital’s intranet. The PICS team has helped to develop a number of disease management order sets and protocols, including the general medical admission orders. In addition, PICS has assisted in developing disease-specific orders for community-acquired pneumonia (CAP), CVA/TIA, and other common diseases admitted by the hospitalist service.

click for large version

click for large version

click for large version

In the case of the adult SCD pain crisis order set, Stephen Wallenhaupt, MD, chief medical officer for Novant Health, recalls, “We recognize that SCD patients have unique needs in terms of pain management and that a standardized order set which incorporates aggressive pain management options is the best way to meet their needs.”

Fran Davis, RPh, PharmD, researched the pertinent literature and consulted the anesthesiologists on staff in an effort to tailor the pain management options for SCD patients. Using the recommendations of these specialists, the order set reflects the consensus that patients with a severe SCD pain crisis require parenteral opiate analgesia on admission.3

Because many patients admitted by PICS can be categorized as having severe pain, the order set contains choices for patient-controlled analgesia (PCA), in keeping with the recommendation for opiate administration at a fixed interval rather than on an as-needed basis.4 And because many hospitalists may not be familiar with ordering PCA, the SCD orders specify the dose ranges, as well as the lockout interval for morphine and hydromorphone PCA. With PCA options readily available, hospitalists need not delay therapy while awaiting a consultation from the pain management service. For all patients receiving opiates, the order set contains an automatic order for naloxone for respiratory depression manifested by a respiratory rate less than nine.

For patients with less severe pain, options for PRN (pro re nata, or as needed) bolus dose morphine and hydromorphone offer dose ranges that reflect the narcotic tolerance frequently observed in these patients. The order set includes options for non-opiate agents, including ketorolac and acetaminophen. Adjuvant therapies, including promethazine, zolpidem, and diphenhydramine, are also contained within the order set. Prompts for intravenous fluid replacement, oxygen therapy, and other supportive measures are incorporated into the orders as well.

The Novant-SPR hospitals have adopted a separate order set for the administration of pneumococcal vaccine. This order set allows for the automatic administration of pneumococcal vaccine, without a specific physician order, to every patient who meets criteria and who desires the vaccine. On admission, every patient is screened by a nurse regarding their need for pneumococcal vaccine; as a result, SCD patients who have not been immunized in the previous five years are offered the vaccine.

Day Hospital Model

In order to provide SCD patients with immediate and aggressive analgesic therapy and fluid replacement, some centers have adopted the Day Hospital (DH) model. The DH is a specific site at which patients with SCD pain crisis are treated by staff familiar with the patients and with their special analgesic needs.5 The DH model has been shown to provide rapid pain relief in an outpatient setting and to reduce the need for unnecessary hospitalizations. In addition, length of stay and cost per case are lower for DH patients admitted to the hospital than for patients not followed by DH staff. It has been suggested that the DH model is especially appropriate for centers with an emergency department too busy to begin treatment in a timely fashion.6

Novant Health has adopted the DH model in the urgent care setting. Patients with pain crises can be managed in one of Novant’s urgent care centers with a standard order set that includes options for IV hydration as well as parenteral morphine or hydromorphone. This outpatient order set parallels that designed for inpatients, because it prompts the physician to order aggressive analgesic therapy as well as adjuvant treatments for nausea and anxiety. Practitioners from Novant’s Sickle Cell Clinic often meet the patient at the urgent care center to assist with evaluation and management. In the past two years, approximately two-thirds of patients with SCD pain crisis have been discharged to home with good pain relief. The remaining one-third are referred to the hospital—usually to be admitted and managed by the PICS team.

Hope for the Future

It has been more than 50 years since the molecular defect in hemoglobin S was first described by Linus Pauling and 50 years since the genetic defect was first elucidated.7,8 Despite these and subsequent advances in understanding the pathogenesis of SCD at the cellular and molecular level, our treatment for SCD remains inadequate. It is akin to a “halfway technology” described by Lewis Thomas as, “the kinds of things that must be done … in order to compensate for the incapacitating effects of certain diseases whose course one is unable to do very much about. It is a technology designed to make up for disease, or to postpone death.”9

At present a number of agents designed to inhibit the sickling process are under investigation, including omega-3 fatty acids, Gardos channel blockers, and anti-adhesion therapies.10 In time, perhaps, one of these rational approaches to treatment will bridge the chasm in the halfway technology currently at our disposal. TH

Dr. Gardella is a board-certified internist and pulmonologist who currently serves as vice president for clinical improvement for Novant Health—Southern Piedmont Region.

Julie Swanger works with both pediatric and adult sickle cell populations through Presbyterian Community Care Services and Blume Pediatric Hematology and Oncology Clinic in Charlotte, N.C.

References

1. Conlan M. Therapeutic interventions frequent among hospital pharmacists. Drug Top Hosp Pharmacist Rep. 2000;14(9):38-39.
2. Piturro M. Top PICS: Presbyterian Inpatient Care Specialists bring high-quality hospitalist care to North Carolina. The Hospitalist. 2006;01(10):23-25.
3. Elander J, Midence K. A review of evidence about factors affecting quality of pain management in sickle cell disease. Clin J Pain. 1996 Sep;12(3):180-193.
4. Steinberg MH. Management of sickle cell disease. N Engl J Med. 1999;340:1021-1030.
5. Sickle Cell Disease Association of America, Inc., Web site. Outpatient management issues in sickle cell disease. Available at: www.sicklecelldisease.org/research/scd_manage3.phtml. Last accessed January 26, 2007.
6. Benjamin LJ, Swinson GI, Nagel RL. Sickle cell anemia day hospital: an approach for the management of uncomplicated painful crises. Blood. 2000 Feb;95(4):1130-1136.
7. Pauling L, Itano HA, Singer SJ, et al. Sickle cell anemia a molecular disease. Science. 1949 Nov 25;110:543-548.
8. Ingram VM. Gene mutations in human haemoglobin: the chemical difference between normal and sickle cell haemoglobin. Nature. 1957 Aug 17;180(4581):326-328.
9. Thomas L. The technology of medicine. In: The Lives of a Cell. New York: Viking Press; 1974:31-36.
10. Okpala IE. New therapies for sickle cell disease. Hematol Oncol Clin North Am. 2005 Oct;19(5):975-987.

Standardized order sets reduce medication errors and create efficiency for physicians, nurses, and pharmacists.1 A less recognized benefit may be that standardized orders promote equity in care and may help to mitigate disparities that occur along racial and ethnic lines. Patients admitted with an acute pain crisis secondary to sickle cell disease (SCD) are often suspected of drug-seeking behavior and may be treated in a cursory manner because they are “frequent flyers” on the medical service. In view of these factors, this patient group may benefit more than others from a standardized treatment protocol. Over the past year, hospitalists and other clinicians at Novant Health in Charlotte, N.C., have composed an admission order set for SCD pain crisis in an effort to improve care for this underserved group.

Novant Health

Novant Health is a multi-hospital, non-profit system serving 3.5 million people from Virginia to South Carolina. Presbyterian Hospital, a 531-bed facility in Charlotte, N.C., is the flagship hospital for Novant’s Southern Piedmont Region (SPR). Presbyterian Inpatient Care Specialists (PICS) is a 44-provider group that offers hospitalist services for adult patients at Presbyterian Hospital, two community hospitals in Matthews and Huntersville, and Presbyterian Orthopedic Hospital.2 In 2005, 180 adult patients were discharged from the Novant-SPR hospitals with a principal diagnosis of SCD, and most of these patients were managed by PICS. This cohort of 180 patients accounted for more than 600 hospitalizations for SCD-related illness at the Novant-SPR facilities in 2005.

Process and Procedure

Standardized order sets have been in widespread use at the Novant-SPR facilities for a number of years. The process of order set development begins with patient needs as perceived by medical staff. Once a physician has drafted an order set, the draft is reviewed by the Order Set Subcommittee, a multidisciplinary team chaired by Susan Smith, RPh, PharmD, with nurses, physicians, and other support staff represented as needed. Once the subcommittee has approved the draft, it goes to the Pharmacy and Therapeutics Committee for final approval. In this fashion, more than 600 order sets have been developed and made available on the hospital’s intranet. The PICS team has helped to develop a number of disease management order sets and protocols, including the general medical admission orders. In addition, PICS has assisted in developing disease-specific orders for community-acquired pneumonia (CAP), CVA/TIA, and other common diseases admitted by the hospitalist service.

click for large version

click for large version

click for large version

In the case of the adult SCD pain crisis order set, Stephen Wallenhaupt, MD, chief medical officer for Novant Health, recalls, “We recognize that SCD patients have unique needs in terms of pain management and that a standardized order set which incorporates aggressive pain management options is the best way to meet their needs.”

Fran Davis, RPh, PharmD, researched the pertinent literature and consulted the anesthesiologists on staff in an effort to tailor the pain management options for SCD patients. Using the recommendations of these specialists, the order set reflects the consensus that patients with a severe SCD pain crisis require parenteral opiate analgesia on admission.3

Because many patients admitted by PICS can be categorized as having severe pain, the order set contains choices for patient-controlled analgesia (PCA), in keeping with the recommendation for opiate administration at a fixed interval rather than on an as-needed basis.4 And because many hospitalists may not be familiar with ordering PCA, the SCD orders specify the dose ranges, as well as the lockout interval for morphine and hydromorphone PCA. With PCA options readily available, hospitalists need not delay therapy while awaiting a consultation from the pain management service. For all patients receiving opiates, the order set contains an automatic order for naloxone for respiratory depression manifested by a respiratory rate less than nine.

For patients with less severe pain, options for PRN (pro re nata, or as needed) bolus dose morphine and hydromorphone offer dose ranges that reflect the narcotic tolerance frequently observed in these patients. The order set includes options for non-opiate agents, including ketorolac and acetaminophen. Adjuvant therapies, including promethazine, zolpidem, and diphenhydramine, are also contained within the order set. Prompts for intravenous fluid replacement, oxygen therapy, and other supportive measures are incorporated into the orders as well.

The Novant-SPR hospitals have adopted a separate order set for the administration of pneumococcal vaccine. This order set allows for the automatic administration of pneumococcal vaccine, without a specific physician order, to every patient who meets criteria and who desires the vaccine. On admission, every patient is screened by a nurse regarding their need for pneumococcal vaccine; as a result, SCD patients who have not been immunized in the previous five years are offered the vaccine.

Day Hospital Model

In order to provide SCD patients with immediate and aggressive analgesic therapy and fluid replacement, some centers have adopted the Day Hospital (DH) model. The DH is a specific site at which patients with SCD pain crisis are treated by staff familiar with the patients and with their special analgesic needs.5 The DH model has been shown to provide rapid pain relief in an outpatient setting and to reduce the need for unnecessary hospitalizations. In addition, length of stay and cost per case are lower for DH patients admitted to the hospital than for patients not followed by DH staff. It has been suggested that the DH model is especially appropriate for centers with an emergency department too busy to begin treatment in a timely fashion.6

Novant Health has adopted the DH model in the urgent care setting. Patients with pain crises can be managed in one of Novant’s urgent care centers with a standard order set that includes options for IV hydration as well as parenteral morphine or hydromorphone. This outpatient order set parallels that designed for inpatients, because it prompts the physician to order aggressive analgesic therapy as well as adjuvant treatments for nausea and anxiety. Practitioners from Novant’s Sickle Cell Clinic often meet the patient at the urgent care center to assist with evaluation and management. In the past two years, approximately two-thirds of patients with SCD pain crisis have been discharged to home with good pain relief. The remaining one-third are referred to the hospital—usually to be admitted and managed by the PICS team.

Hope for the Future

It has been more than 50 years since the molecular defect in hemoglobin S was first described by Linus Pauling and 50 years since the genetic defect was first elucidated.7,8 Despite these and subsequent advances in understanding the pathogenesis of SCD at the cellular and molecular level, our treatment for SCD remains inadequate. It is akin to a “halfway technology” described by Lewis Thomas as, “the kinds of things that must be done … in order to compensate for the incapacitating effects of certain diseases whose course one is unable to do very much about. It is a technology designed to make up for disease, or to postpone death.”9

At present a number of agents designed to inhibit the sickling process are under investigation, including omega-3 fatty acids, Gardos channel blockers, and anti-adhesion therapies.10 In time, perhaps, one of these rational approaches to treatment will bridge the chasm in the halfway technology currently at our disposal. TH

Dr. Gardella is a board-certified internist and pulmonologist who currently serves as vice president for clinical improvement for Novant Health—Southern Piedmont Region.

Julie Swanger works with both pediatric and adult sickle cell populations through Presbyterian Community Care Services and Blume Pediatric Hematology and Oncology Clinic in Charlotte, N.C.

References

1. Conlan M. Therapeutic interventions frequent among hospital pharmacists. Drug Top Hosp Pharmacist Rep. 2000;14(9):38-39.
2. Piturro M. Top PICS: Presbyterian Inpatient Care Specialists bring high-quality hospitalist care to North Carolina. The Hospitalist. 2006;01(10):23-25.
3. Elander J, Midence K. A review of evidence about factors affecting quality of pain management in sickle cell disease. Clin J Pain. 1996 Sep;12(3):180-193.
4. Steinberg MH. Management of sickle cell disease. N Engl J Med. 1999;340:1021-1030.
5. Sickle Cell Disease Association of America, Inc., Web site. Outpatient management issues in sickle cell disease. Available at: www.sicklecelldisease.org/research/scd_manage3.phtml. Last accessed January 26, 2007.
6. Benjamin LJ, Swinson GI, Nagel RL. Sickle cell anemia day hospital: an approach for the management of uncomplicated painful crises. Blood. 2000 Feb;95(4):1130-1136.
7. Pauling L, Itano HA, Singer SJ, et al. Sickle cell anemia a molecular disease. Science. 1949 Nov 25;110:543-548.
8. Ingram VM. Gene mutations in human haemoglobin: the chemical difference between normal and sickle cell haemoglobin. Nature. 1957 Aug 17;180(4581):326-328.
9. Thomas L. The technology of medicine. In: The Lives of a Cell. New York: Viking Press; 1974:31-36.
10. Okpala IE. New therapies for sickle cell disease. Hematol Oncol Clin North Am. 2005 Oct;19(5):975-987.

Standardized order sets reduce medication errors and create efficiency for physicians, nurses, and pharmacists.1 A less recognized benefit may be that standardized orders promote equity in care and may help to mitigate disparities that occur along racial and ethnic lines. Patients admitted with an acute pain crisis secondary to sickle cell disease (SCD) are often suspected of drug-seeking behavior and may be treated in a cursory manner because they are “frequent flyers” on the medical service. In view of these factors, this patient group may benefit more than others from a standardized treatment protocol. Over the past year, hospitalists and other clinicians at Novant Health in Charlotte, N.C., have composed an admission order set for SCD pain crisis in an effort to improve care for this underserved group.

Novant Health

Novant Health is a multi-hospital, non-profit system serving 3.5 million people from Virginia to South Carolina. Presbyterian Hospital, a 531-bed facility in Charlotte, N.C., is the flagship hospital for Novant’s Southern Piedmont Region (SPR). Presbyterian Inpatient Care Specialists (PICS) is a 44-provider group that offers hospitalist services for adult patients at Presbyterian Hospital, two community hospitals in Matthews and Huntersville, and Presbyterian Orthopedic Hospital.2 In 2005, 180 adult patients were discharged from the Novant-SPR hospitals with a principal diagnosis of SCD, and most of these patients were managed by PICS. This cohort of 180 patients accounted for more than 600 hospitalizations for SCD-related illness at the Novant-SPR facilities in 2005.

Process and Procedure

Standardized order sets have been in widespread use at the Novant-SPR facilities for a number of years. The process of order set development begins with patient needs as perceived by medical staff. Once a physician has drafted an order set, the draft is reviewed by the Order Set Subcommittee, a multidisciplinary team chaired by Susan Smith, RPh, PharmD, with nurses, physicians, and other support staff represented as needed. Once the subcommittee has approved the draft, it goes to the Pharmacy and Therapeutics Committee for final approval. In this fashion, more than 600 order sets have been developed and made available on the hospital’s intranet. The PICS team has helped to develop a number of disease management order sets and protocols, including the general medical admission orders. In addition, PICS has assisted in developing disease-specific orders for community-acquired pneumonia (CAP), CVA/TIA, and other common diseases admitted by the hospitalist service.

click for large version

click for large version

click for large version

In the case of the adult SCD pain crisis order set, Stephen Wallenhaupt, MD, chief medical officer for Novant Health, recalls, “We recognize that SCD patients have unique needs in terms of pain management and that a standardized order set which incorporates aggressive pain management options is the best way to meet their needs.”

Fran Davis, RPh, PharmD, researched the pertinent literature and consulted the anesthesiologists on staff in an effort to tailor the pain management options for SCD patients. Using the recommendations of these specialists, the order set reflects the consensus that patients with a severe SCD pain crisis require parenteral opiate analgesia on admission.3

Because many patients admitted by PICS can be categorized as having severe pain, the order set contains choices for patient-controlled analgesia (PCA), in keeping with the recommendation for opiate administration at a fixed interval rather than on an as-needed basis.4 And because many hospitalists may not be familiar with ordering PCA, the SCD orders specify the dose ranges, as well as the lockout interval for morphine and hydromorphone PCA. With PCA options readily available, hospitalists need not delay therapy while awaiting a consultation from the pain management service. For all patients receiving opiates, the order set contains an automatic order for naloxone for respiratory depression manifested by a respiratory rate less than nine.

For patients with less severe pain, options for PRN (pro re nata, or as needed) bolus dose morphine and hydromorphone offer dose ranges that reflect the narcotic tolerance frequently observed in these patients. The order set includes options for non-opiate agents, including ketorolac and acetaminophen. Adjuvant therapies, including promethazine, zolpidem, and diphenhydramine, are also contained within the order set. Prompts for intravenous fluid replacement, oxygen therapy, and other supportive measures are incorporated into the orders as well.

The Novant-SPR hospitals have adopted a separate order set for the administration of pneumococcal vaccine. This order set allows for the automatic administration of pneumococcal vaccine, without a specific physician order, to every patient who meets criteria and who desires the vaccine. On admission, every patient is screened by a nurse regarding their need for pneumococcal vaccine; as a result, SCD patients who have not been immunized in the previous five years are offered the vaccine.

Day Hospital Model

In order to provide SCD patients with immediate and aggressive analgesic therapy and fluid replacement, some centers have adopted the Day Hospital (DH) model. The DH is a specific site at which patients with SCD pain crisis are treated by staff familiar with the patients and with their special analgesic needs.5 The DH model has been shown to provide rapid pain relief in an outpatient setting and to reduce the need for unnecessary hospitalizations. In addition, length of stay and cost per case are lower for DH patients admitted to the hospital than for patients not followed by DH staff. It has been suggested that the DH model is especially appropriate for centers with an emergency department too busy to begin treatment in a timely fashion.6

Novant Health has adopted the DH model in the urgent care setting. Patients with pain crises can be managed in one of Novant’s urgent care centers with a standard order set that includes options for IV hydration as well as parenteral morphine or hydromorphone. This outpatient order set parallels that designed for inpatients, because it prompts the physician to order aggressive analgesic therapy as well as adjuvant treatments for nausea and anxiety. Practitioners from Novant’s Sickle Cell Clinic often meet the patient at the urgent care center to assist with evaluation and management. In the past two years, approximately two-thirds of patients with SCD pain crisis have been discharged to home with good pain relief. The remaining one-third are referred to the hospital—usually to be admitted and managed by the PICS team.

Hope for the Future

It has been more than 50 years since the molecular defect in hemoglobin S was first described by Linus Pauling and 50 years since the genetic defect was first elucidated.7,8 Despite these and subsequent advances in understanding the pathogenesis of SCD at the cellular and molecular level, our treatment for SCD remains inadequate. It is akin to a “halfway technology” described by Lewis Thomas as, “the kinds of things that must be done … in order to compensate for the incapacitating effects of certain diseases whose course one is unable to do very much about. It is a technology designed to make up for disease, or to postpone death.”9

At present a number of agents designed to inhibit the sickling process are under investigation, including omega-3 fatty acids, Gardos channel blockers, and anti-adhesion therapies.10 In time, perhaps, one of these rational approaches to treatment will bridge the chasm in the halfway technology currently at our disposal. TH

Dr. Gardella is a board-certified internist and pulmonologist who currently serves as vice president for clinical improvement for Novant Health—Southern Piedmont Region.

Julie Swanger works with both pediatric and adult sickle cell populations through Presbyterian Community Care Services and Blume Pediatric Hematology and Oncology Clinic in Charlotte, N.C.

References

1. Conlan M. Therapeutic interventions frequent among hospital pharmacists. Drug Top Hosp Pharmacist Rep. 2000;14(9):38-39.
2. Piturro M. Top PICS: Presbyterian Inpatient Care Specialists bring high-quality hospitalist care to North Carolina. The Hospitalist. 2006;01(10):23-25.
3. Elander J, Midence K. A review of evidence about factors affecting quality of pain management in sickle cell disease. Clin J Pain. 1996 Sep;12(3):180-193.
4. Steinberg MH. Management of sickle cell disease. N Engl J Med. 1999;340:1021-1030.
5. Sickle Cell Disease Association of America, Inc., Web site. Outpatient management issues in sickle cell disease. Available at: www.sicklecelldisease.org/research/scd_manage3.phtml. Last accessed January 26, 2007.
6. Benjamin LJ, Swinson GI, Nagel RL. Sickle cell anemia day hospital: an approach for the management of uncomplicated painful crises. Blood. 2000 Feb;95(4):1130-1136.
7. Pauling L, Itano HA, Singer SJ, et al. Sickle cell anemia a molecular disease. Science. 1949 Nov 25;110:543-548.
8. Ingram VM. Gene mutations in human haemoglobin: the chemical difference between normal and sickle cell haemoglobin. Nature. 1957 Aug 17;180(4581):326-328.
9. Thomas L. The technology of medicine. In: The Lives of a Cell. New York: Viking Press; 1974:31-36.
10. Okpala IE. New therapies for sickle cell disease. Hematol Oncol Clin North Am. 2005 Oct;19(5):975-987.

In the nearly 10 years since the word “hospitalist” entered our consciousness, it has been inspiring to witness the dramatic growth in the specialty and, accompanying it, the growth in the membership of SHM.1 Over this same period, the healthcare system has made progress toward ensuring that it provides the safest, highest quality healthcare possible.

In my mind, the two phenomena are related. SHM itself and—more generally—the hospitalist field have played a vital role in promoting the use of evidence-based care, improved teamwork, and health information technology. Each of these efforts has made a significant difference in the care patients receive in hospitals. Similarly, the mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans. Both organizations are working to create positive change that will improve the health and healthcare of all patients.

As their numbers continue to grow, hospitalists are becoming integral members of the inpatient care team at many hospitals.

According to a recent survey conducted by SHM, a hospitalist averaged more than 2,300 inpatient encounters in 2005—a 7% increase over 2004.2 Today, hospital medicine groups practice not only in large metropolitan areas, but also in rural regions where one in three groups began operation during 2005.

In addition to their inpatient care responsibilities, the 15,000 hospitalists who practice today in the United States and Canada serve in key physician leadership roles that directly influence quality improvement and patient safety. Most hospitalists—86%—participate in quality improvement. More than half are involved in implementing information technology (54%) and teaching house staff (51%), and more than one-third—35%—are responsible for their organization’s rapid response team. The SHM survey found that nearly all hospital medicine groups provide round-the-clock patient care at their hospitals.

In this article I will emphasize two key areas relevant to improving patient safety for hospitalized patients: patient handoffs and communication.

Responsibility for Patient Handoffs

Hospitalists’ clinical and leadership roles are significant responsibilities for patient safety, including the critical period known as patient handoff or sign-out.

Patient handoffs refer to the interaction, communication, and planning required to achieve a seamless transition from one clinician to the next.3 When executed in a timely and thorough manner, patient handoffs can reduce the likelihood of medical errors and misinformation, prevent lost or missing clinical information, and maintain a high level of medical care.

Given today’s short hospital stays and the complex medical nature of the care necessary for many patients, timely and effective handoffs demand that hospitalists develop skills that extend beyond superior clinical care. They include:

• Communicating in an effective and efficient manner during patient sign-out;
• Demonstrating the use of “read-back” skills when communicating tasks;
• Developing oral and written patient summaries, including characteristics of the patient, provider, and time of the sign-out;
• Evaluating all medications for indication, dosing, and planned duration at the time of sign-out; and
• Anticipating what may go wrong with a patient after a transition in care occurs and clearly communicating this concern to the receiving clinician.

A Fumbled Handoff: A Case Study

A breakdown in communications—notably an error of omission in the patient handoff—contributed to a poor outcome for an elderly patient who was admitted to the hospital for an elective sigmoid resection.

The case, which was published in the AHRQ’s “Morbidity and Mortality Rounds on the Web” (developed by hospital medicine expert Robert Wachter, MD, and his team under contract to our agency), illustrates some of the challenges that face all clinicians in effectively transferring patient information and care responsibilities.4 It also underscores the need for close involvement by hospitalists in improving quality, teaching and supervising house staff, and implementing information systems.

According to the case study, a 73-year-old female patient with a history of hypertension, non-insulin dependent diabetes, and chronic renal insufficiency became tachycardic two days after surgery, despite receiving a low-dose beta-blocker. The same day, she informed her nurse that she had developed pain in her left leg.

Assuming the pain was related to the pre-operative epidural, the nurse contacted the anesthesia service, which responded by decreasing the epidural rate; the primary surgical team was not called. Late on the third day after surgery, the cross-covering intern was contacted about the patient’s left leg pain. No information about the intern’s findings was relayed to the primary team the following day.

On the fourth day, the patient complained to the nurse about mild chest discomfort, resulting in attention within 20 minutes by house staff and from the attending physician several hours later. The patient’s exam was unremarkable and a work-up was initiated.

Within an hour of the attending’s visit, the patient’s blood pressure dropped to 70/40, followed by a pulseless electrical activity arrest. The patient could not be resuscitated. A post-mortem examination revealed a pulmonary embolism.

Handoffs in an Era of Work-Hour Restrictions

Missing information about pain in the patient’s leg and a breakdown in communication between physicians contributed to the patient’s poor outcome. In this case, the breakdown may also have been influenced by the intern’s involvement on the third day. Like all medical residents this intern is subject to duty-hour restrictions.

Work-hour limits for all residents training in U.S. hospitals took effect in July 2003. Under these standards, created by the Accreditation Council for Graduate Medical Education (ACGME), residents are limited to a maximum of 30 consecutive work hours—known as the 30-hour rule, which includes time used for sign-out, teaching, and continuity of care. They are also prohibited from working more than 80 hours per week.

Despite the clear safety benefit of preventing fatigue-related mistakes, work-hour mandates have increased the number of patient handoffs and the potential for communication breakdowns.5 A survey of interns conducted at the hospital where this case study occurred identified a higher volume of sign-outs and the resulting potential for harm to patients as main concerns with the work-hour restrictions.6

Concerns about the quality and continuity of care that hospital patients receive are evident even among those medical residents whose work hours were restricted before the ACGME requirements took effect. (In New York state residents’ work hours have been restricted since 1998.)

A 2006 study of surgical residents at New York’s Beth Israel Hospital found that most believed that the quality of care patients received was either unchanged (63%) or worse (26%) since the work-hour restrictions took effect.7 Possible reasons for this perception include unresolved issues with continuity of care, miscommunication, and cross-coverage availability. The study concluded that interventions that target intern sign-out coverage constraints will be important for future efforts to improve the quality of care for hospital patients.

Written sign-outs appear to overcome some of the human errors that inevitably result from verbal patient summaries, such as disruptions and forgetfulness. Recent findings have, however, identified significant shortcomings in the quality and timeliness of written reports.

Critical information, such as code status and allergies, was missing in 80% of written sign-outs in one recent study.8 And in a 2006 study of the quality of discharge summaries, only 19% of hospital physicians with an outpatient practice reported being satisfied with the timeliness of discharge summaries. Only a third reported being satisfied with their quality of information. Most troubling, 41% believed that at least one of their patients hospitalized in the previous six months had experienced a preventable adverse event related to poor transfer of information at discharge.9

Use Redundancy and Simulation to Improve Safety

Given the clear challenges of providing quality and continuity of care in the inpatient setting, hospitalists are well positioned to identify strategies for safe and effective patient handoffs and advocate for a systems approach to their implementation.

Safety strategies that have been employed by industries outside of healthcare can provide a useful starting point. So-called “highly reliable” organizations use a variety of approaches to reduce the incidence of errors that occur during transitions in work staff. A recent review of transition methods used by NASA’s Johnson Space Center (Houston), Canadian nuclear power plants, and an ambulance dispatch center—organizations where lapses in transitions also have serious consequences—found that these entities used up to 21 handoff strategies.10 Techniques included verbal, face-to-face, and interactive questioning coordinated with written summaries just before a shift change.

Increasing redundancy is another technique used by highly reliable organizations to reduce the likelihood of missed, incomplete, or misinterpreted information. To create redundancy in clinical care, a physician would include more information at the outset of a procedure or medication order than is now typically provided. This additional information is then repeated and validated by other members of the care team throughout the process, reducing the likelihood of misinterpretation of an instruction or action based on incomplete information.

For example, if a physician always includes both the drug name and the condition for which it is prescribed, a medication order for “Celebrex, seizures,” instead of “Cerebyx, seizures,” would immediately indicate a mistake had occurred in ordering a pain medication instead of an anti-convulsant.11 Research has shown that increasing the amount of information about a medication order reduces the range of potentially valid clinical decisions.

Whether a hospital relies on verbal communication, written communication, computer-based communication, or a combination of all three, redundancy can be built into its sign-out processes. As PDAs become more widely used, structured sign-outs should incorporate redundancy into patient-specific checklists to include information on clinical status, recent and pending tests and study results, and similar, pertinent information.

Simulation-based training that incorporates redundancy and promotes read-back of patient information holds promise for error reduction, especially during patient handoffs.

AHRQ has recently funded research on simulation training projects that seek to:

• Reduce communication errors during patient handoffs in the emergency department by implementing a patient-specific checklist based on an electronic medical record and by testing the effect of companion simulation-based training; and
• Evaluate and improve safe communication and coordination between anesthesia providers and nurses during care transitions and during hand-offs between the operating room and the post-anesthesia care unit.12

The 24/7 role of hospital physicians brings unique experiences and insights to the challenges of patient safety that can test the feasibility of systems to reduce errors associated with care transitions. As their numbers and leadership roles expand, hospitalists are poised to make significant contributions to improving patient safety and outcomes.

We at AHRQ look forward to assisting hospitalists in making these contributions and to achieving these goals together. We also look forward to continuing our relationship with SHM and the hospitalist community as a whole. TH

Dr. Clancy is the director of the Agency for Healthcare Research and Quality.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996 Aug 15;335(7):514-517.
2. Impact of the nation’s hospitalists continues to grow new society of hospital medicine survey says [press release]. Society of Hospital Medicine. May 4, 2006.
3. Society of Hospital Medicine. The core competencies in hospital medicine: a framework for curriculum development by the society of hospital medicine. J Hosp Med. 2006;1;S1. Available at: http://onlinelibrary.wiley.com/doi/10.1002/jhm.72/pdf. Last accessed January 17, 2007.
4. Vidyarthi A [commentary]. Agency for Healthcare Research and Quality Web M&M: Morbidity and Mortality Rounds on the Web. Fumbled handoff. March 2004. Available at: www.webmm.ahrq.gov/case.aspx?caseID=55. Last accessed January 17, 2007.
5. Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. New York: Rugged Land LLG; 2004.
6. Vidyarthi A. Morbidity and Mortality Rounds on the Web, “Fumbled Handoff,” unpublished data, 2004.
7. Biller CK, Antonacci AC, Pelletier S, et al. The 80-hour work guidelines and resident survey perceptions of quality. J Surg Res. 2006 Oct;135(2):275-281. Epub 2006 Aug 24.
8. Lee LH, Levine JA, Schultz HJ. Utility of a standardized sign-out card for new medical interns. J Gen Intern Med. 1996;11(12):753-755.
9. O’Leary KJ, Leibovitz DM, Feinglass J, et al. Outpatient physicians’ satisfaction with discharge summaries and perceived need for an electronic discharge summary. J Hosp Med. 2006;1:317-320. Published online Oct. 11, 2006.
10. Reason JT. Managing the Risks of Organizational Accidents. Aldershot, England: Ashgate Publishing Company; 1997:135.
11. Bar-Yam Y. System care: multiscale analysis of medical errors–eliminating errors and improving organizational capabilities. New England Complex Systems Institute: Technical Report; Sept 2004. Available at: http://necsi.org/projects/yaneer/NECSITechnicalReport2004-09.pdf. Last accessed January 17, 2007.
12. Agency for Healthcare Research and Quality. Improving patient safety through simulation research. 2006 Simulation Projects. Available at: www.ahrq.gov/qual/simulproj.htm. Last accessed January 17, 2007.

In the nearly 10 years since the word “hospitalist” entered our consciousness, it has been inspiring to witness the dramatic growth in the specialty and, accompanying it, the growth in the membership of SHM.1 Over this same period, the healthcare system has made progress toward ensuring that it provides the safest, highest quality healthcare possible.

In my mind, the two phenomena are related. SHM itself and—more generally—the hospitalist field have played a vital role in promoting the use of evidence-based care, improved teamwork, and health information technology. Each of these efforts has made a significant difference in the care patients receive in hospitals. Similarly, the mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans. Both organizations are working to create positive change that will improve the health and healthcare of all patients.

As their numbers continue to grow, hospitalists are becoming integral members of the inpatient care team at many hospitals.

According to a recent survey conducted by SHM, a hospitalist averaged more than 2,300 inpatient encounters in 2005—a 7% increase over 2004.2 Today, hospital medicine groups practice not only in large metropolitan areas, but also in rural regions where one in three groups began operation during 2005.

In addition to their inpatient care responsibilities, the 15,000 hospitalists who practice today in the United States and Canada serve in key physician leadership roles that directly influence quality improvement and patient safety. Most hospitalists—86%—participate in quality improvement. More than half are involved in implementing information technology (54%) and teaching house staff (51%), and more than one-third—35%—are responsible for their organization’s rapid response team. The SHM survey found that nearly all hospital medicine groups provide round-the-clock patient care at their hospitals.

In this article I will emphasize two key areas relevant to improving patient safety for hospitalized patients: patient handoffs and communication.

Responsibility for Patient Handoffs

Hospitalists’ clinical and leadership roles are significant responsibilities for patient safety, including the critical period known as patient handoff or sign-out.

Patient handoffs refer to the interaction, communication, and planning required to achieve a seamless transition from one clinician to the next.3 When executed in a timely and thorough manner, patient handoffs can reduce the likelihood of medical errors and misinformation, prevent lost or missing clinical information, and maintain a high level of medical care.

Given today’s short hospital stays and the complex medical nature of the care necessary for many patients, timely and effective handoffs demand that hospitalists develop skills that extend beyond superior clinical care. They include:

• Communicating in an effective and efficient manner during patient sign-out;
• Demonstrating the use of “read-back” skills when communicating tasks;
• Developing oral and written patient summaries, including characteristics of the patient, provider, and time of the sign-out;
• Evaluating all medications for indication, dosing, and planned duration at the time of sign-out; and
• Anticipating what may go wrong with a patient after a transition in care occurs and clearly communicating this concern to the receiving clinician.

A Fumbled Handoff: A Case Study

A breakdown in communications—notably an error of omission in the patient handoff—contributed to a poor outcome for an elderly patient who was admitted to the hospital for an elective sigmoid resection.

The case, which was published in the AHRQ’s “Morbidity and Mortality Rounds on the Web” (developed by hospital medicine expert Robert Wachter, MD, and his team under contract to our agency), illustrates some of the challenges that face all clinicians in effectively transferring patient information and care responsibilities.4 It also underscores the need for close involvement by hospitalists in improving quality, teaching and supervising house staff, and implementing information systems.

According to the case study, a 73-year-old female patient with a history of hypertension, non-insulin dependent diabetes, and chronic renal insufficiency became tachycardic two days after surgery, despite receiving a low-dose beta-blocker. The same day, she informed her nurse that she had developed pain in her left leg.

Assuming the pain was related to the pre-operative epidural, the nurse contacted the anesthesia service, which responded by decreasing the epidural rate; the primary surgical team was not called. Late on the third day after surgery, the cross-covering intern was contacted about the patient’s left leg pain. No information about the intern’s findings was relayed to the primary team the following day.

On the fourth day, the patient complained to the nurse about mild chest discomfort, resulting in attention within 20 minutes by house staff and from the attending physician several hours later. The patient’s exam was unremarkable and a work-up was initiated.

Within an hour of the attending’s visit, the patient’s blood pressure dropped to 70/40, followed by a pulseless electrical activity arrest. The patient could not be resuscitated. A post-mortem examination revealed a pulmonary embolism.

Handoffs in an Era of Work-Hour Restrictions

Missing information about pain in the patient’s leg and a breakdown in communication between physicians contributed to the patient’s poor outcome. In this case, the breakdown may also have been influenced by the intern’s involvement on the third day. Like all medical residents this intern is subject to duty-hour restrictions.

Work-hour limits for all residents training in U.S. hospitals took effect in July 2003. Under these standards, created by the Accreditation Council for Graduate Medical Education (ACGME), residents are limited to a maximum of 30 consecutive work hours—known as the 30-hour rule, which includes time used for sign-out, teaching, and continuity of care. They are also prohibited from working more than 80 hours per week.

Despite the clear safety benefit of preventing fatigue-related mistakes, work-hour mandates have increased the number of patient handoffs and the potential for communication breakdowns.5 A survey of interns conducted at the hospital where this case study occurred identified a higher volume of sign-outs and the resulting potential for harm to patients as main concerns with the work-hour restrictions.6

Concerns about the quality and continuity of care that hospital patients receive are evident even among those medical residents whose work hours were restricted before the ACGME requirements took effect. (In New York state residents’ work hours have been restricted since 1998.)

A 2006 study of surgical residents at New York’s Beth Israel Hospital found that most believed that the quality of care patients received was either unchanged (63%) or worse (26%) since the work-hour restrictions took effect.7 Possible reasons for this perception include unresolved issues with continuity of care, miscommunication, and cross-coverage availability. The study concluded that interventions that target intern sign-out coverage constraints will be important for future efforts to improve the quality of care for hospital patients.

Written sign-outs appear to overcome some of the human errors that inevitably result from verbal patient summaries, such as disruptions and forgetfulness. Recent findings have, however, identified significant shortcomings in the quality and timeliness of written reports.

Critical information, such as code status and allergies, was missing in 80% of written sign-outs in one recent study.8 And in a 2006 study of the quality of discharge summaries, only 19% of hospital physicians with an outpatient practice reported being satisfied with the timeliness of discharge summaries. Only a third reported being satisfied with their quality of information. Most troubling, 41% believed that at least one of their patients hospitalized in the previous six months had experienced a preventable adverse event related to poor transfer of information at discharge.9

Use Redundancy and Simulation to Improve Safety

Given the clear challenges of providing quality and continuity of care in the inpatient setting, hospitalists are well positioned to identify strategies for safe and effective patient handoffs and advocate for a systems approach to their implementation.

Safety strategies that have been employed by industries outside of healthcare can provide a useful starting point. So-called “highly reliable” organizations use a variety of approaches to reduce the incidence of errors that occur during transitions in work staff. A recent review of transition methods used by NASA’s Johnson Space Center (Houston), Canadian nuclear power plants, and an ambulance dispatch center—organizations where lapses in transitions also have serious consequences—found that these entities used up to 21 handoff strategies.10 Techniques included verbal, face-to-face, and interactive questioning coordinated with written summaries just before a shift change.

Increasing redundancy is another technique used by highly reliable organizations to reduce the likelihood of missed, incomplete, or misinterpreted information. To create redundancy in clinical care, a physician would include more information at the outset of a procedure or medication order than is now typically provided. This additional information is then repeated and validated by other members of the care team throughout the process, reducing the likelihood of misinterpretation of an instruction or action based on incomplete information.

For example, if a physician always includes both the drug name and the condition for which it is prescribed, a medication order for “Celebrex, seizures,” instead of “Cerebyx, seizures,” would immediately indicate a mistake had occurred in ordering a pain medication instead of an anti-convulsant.11 Research has shown that increasing the amount of information about a medication order reduces the range of potentially valid clinical decisions.

Whether a hospital relies on verbal communication, written communication, computer-based communication, or a combination of all three, redundancy can be built into its sign-out processes. As PDAs become more widely used, structured sign-outs should incorporate redundancy into patient-specific checklists to include information on clinical status, recent and pending tests and study results, and similar, pertinent information.

Simulation-based training that incorporates redundancy and promotes read-back of patient information holds promise for error reduction, especially during patient handoffs.

AHRQ has recently funded research on simulation training projects that seek to:

• Reduce communication errors during patient handoffs in the emergency department by implementing a patient-specific checklist based on an electronic medical record and by testing the effect of companion simulation-based training; and
• Evaluate and improve safe communication and coordination between anesthesia providers and nurses during care transitions and during hand-offs between the operating room and the post-anesthesia care unit.12

The 24/7 role of hospital physicians brings unique experiences and insights to the challenges of patient safety that can test the feasibility of systems to reduce errors associated with care transitions. As their numbers and leadership roles expand, hospitalists are poised to make significant contributions to improving patient safety and outcomes.

We at AHRQ look forward to assisting hospitalists in making these contributions and to achieving these goals together. We also look forward to continuing our relationship with SHM and the hospitalist community as a whole. TH

Dr. Clancy is the director of the Agency for Healthcare Research and Quality.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996 Aug 15;335(7):514-517.
2. Impact of the nation’s hospitalists continues to grow new society of hospital medicine survey says [press release]. Society of Hospital Medicine. May 4, 2006.
3. Society of Hospital Medicine. The core competencies in hospital medicine: a framework for curriculum development by the society of hospital medicine. J Hosp Med. 2006;1;S1. Available at: http://onlinelibrary.wiley.com/doi/10.1002/jhm.72/pdf. Last accessed January 17, 2007.
4. Vidyarthi A [commentary]. Agency for Healthcare Research and Quality Web M&M: Morbidity and Mortality Rounds on the Web. Fumbled handoff. March 2004. Available at: www.webmm.ahrq.gov/case.aspx?caseID=55. Last accessed January 17, 2007.
5. Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. New York: Rugged Land LLG; 2004.
6. Vidyarthi A. Morbidity and Mortality Rounds on the Web, “Fumbled Handoff,” unpublished data, 2004.
7. Biller CK, Antonacci AC, Pelletier S, et al. The 80-hour work guidelines and resident survey perceptions of quality. J Surg Res. 2006 Oct;135(2):275-281. Epub 2006 Aug 24.
8. Lee LH, Levine JA, Schultz HJ. Utility of a standardized sign-out card for new medical interns. J Gen Intern Med. 1996;11(12):753-755.
9. O’Leary KJ, Leibovitz DM, Feinglass J, et al. Outpatient physicians’ satisfaction with discharge summaries and perceived need for an electronic discharge summary. J Hosp Med. 2006;1:317-320. Published online Oct. 11, 2006.
10. Reason JT. Managing the Risks of Organizational Accidents. Aldershot, England: Ashgate Publishing Company; 1997:135.
11. Bar-Yam Y. System care: multiscale analysis of medical errors–eliminating errors and improving organizational capabilities. New England Complex Systems Institute: Technical Report; Sept 2004. Available at: http://necsi.org/projects/yaneer/NECSITechnicalReport2004-09.pdf. Last accessed January 17, 2007.
12. Agency for Healthcare Research and Quality. Improving patient safety through simulation research. 2006 Simulation Projects. Available at: www.ahrq.gov/qual/simulproj.htm. Last accessed January 17, 2007.

In the nearly 10 years since the word “hospitalist” entered our consciousness, it has been inspiring to witness the dramatic growth in the specialty and, accompanying it, the growth in the membership of SHM.1 Over this same period, the healthcare system has made progress toward ensuring that it provides the safest, highest quality healthcare possible.

In my mind, the two phenomena are related. SHM itself and—more generally—the hospitalist field have played a vital role in promoting the use of evidence-based care, improved teamwork, and health information technology. Each of these efforts has made a significant difference in the care patients receive in hospitals. Similarly, the mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans. Both organizations are working to create positive change that will improve the health and healthcare of all patients.

As their numbers continue to grow, hospitalists are becoming integral members of the inpatient care team at many hospitals.

According to a recent survey conducted by SHM, a hospitalist averaged more than 2,300 inpatient encounters in 2005—a 7% increase over 2004.2 Today, hospital medicine groups practice not only in large metropolitan areas, but also in rural regions where one in three groups began operation during 2005.

In addition to their inpatient care responsibilities, the 15,000 hospitalists who practice today in the United States and Canada serve in key physician leadership roles that directly influence quality improvement and patient safety. Most hospitalists—86%—participate in quality improvement. More than half are involved in implementing information technology (54%) and teaching house staff (51%), and more than one-third—35%—are responsible for their organization’s rapid response team. The SHM survey found that nearly all hospital medicine groups provide round-the-clock patient care at their hospitals.

In this article I will emphasize two key areas relevant to improving patient safety for hospitalized patients: patient handoffs and communication.

Responsibility for Patient Handoffs

Hospitalists’ clinical and leadership roles are significant responsibilities for patient safety, including the critical period known as patient handoff or sign-out.

Patient handoffs refer to the interaction, communication, and planning required to achieve a seamless transition from one clinician to the next.3 When executed in a timely and thorough manner, patient handoffs can reduce the likelihood of medical errors and misinformation, prevent lost or missing clinical information, and maintain a high level of medical care.

Given today’s short hospital stays and the complex medical nature of the care necessary for many patients, timely and effective handoffs demand that hospitalists develop skills that extend beyond superior clinical care. They include:

• Communicating in an effective and efficient manner during patient sign-out;
• Demonstrating the use of “read-back” skills when communicating tasks;
• Developing oral and written patient summaries, including characteristics of the patient, provider, and time of the sign-out;
• Evaluating all medications for indication, dosing, and planned duration at the time of sign-out; and
• Anticipating what may go wrong with a patient after a transition in care occurs and clearly communicating this concern to the receiving clinician.

A Fumbled Handoff: A Case Study

A breakdown in communications—notably an error of omission in the patient handoff—contributed to a poor outcome for an elderly patient who was admitted to the hospital for an elective sigmoid resection.

The case, which was published in the AHRQ’s “Morbidity and Mortality Rounds on the Web” (developed by hospital medicine expert Robert Wachter, MD, and his team under contract to our agency), illustrates some of the challenges that face all clinicians in effectively transferring patient information and care responsibilities.4 It also underscores the need for close involvement by hospitalists in improving quality, teaching and supervising house staff, and implementing information systems.

According to the case study, a 73-year-old female patient with a history of hypertension, non-insulin dependent diabetes, and chronic renal insufficiency became tachycardic two days after surgery, despite receiving a low-dose beta-blocker. The same day, she informed her nurse that she had developed pain in her left leg.

Assuming the pain was related to the pre-operative epidural, the nurse contacted the anesthesia service, which responded by decreasing the epidural rate; the primary surgical team was not called. Late on the third day after surgery, the cross-covering intern was contacted about the patient’s left leg pain. No information about the intern’s findings was relayed to the primary team the following day.

On the fourth day, the patient complained to the nurse about mild chest discomfort, resulting in attention within 20 minutes by house staff and from the attending physician several hours later. The patient’s exam was unremarkable and a work-up was initiated.

Within an hour of the attending’s visit, the patient’s blood pressure dropped to 70/40, followed by a pulseless electrical activity arrest. The patient could not be resuscitated. A post-mortem examination revealed a pulmonary embolism.

Handoffs in an Era of Work-Hour Restrictions

Missing information about pain in the patient’s leg and a breakdown in communication between physicians contributed to the patient’s poor outcome. In this case, the breakdown may also have been influenced by the intern’s involvement on the third day. Like all medical residents this intern is subject to duty-hour restrictions.

Work-hour limits for all residents training in U.S. hospitals took effect in July 2003. Under these standards, created by the Accreditation Council for Graduate Medical Education (ACGME), residents are limited to a maximum of 30 consecutive work hours—known as the 30-hour rule, which includes time used for sign-out, teaching, and continuity of care. They are also prohibited from working more than 80 hours per week.

Despite the clear safety benefit of preventing fatigue-related mistakes, work-hour mandates have increased the number of patient handoffs and the potential for communication breakdowns.5 A survey of interns conducted at the hospital where this case study occurred identified a higher volume of sign-outs and the resulting potential for harm to patients as main concerns with the work-hour restrictions.6

Concerns about the quality and continuity of care that hospital patients receive are evident even among those medical residents whose work hours were restricted before the ACGME requirements took effect. (In New York state residents’ work hours have been restricted since 1998.)

A 2006 study of surgical residents at New York’s Beth Israel Hospital found that most believed that the quality of care patients received was either unchanged (63%) or worse (26%) since the work-hour restrictions took effect.7 Possible reasons for this perception include unresolved issues with continuity of care, miscommunication, and cross-coverage availability. The study concluded that interventions that target intern sign-out coverage constraints will be important for future efforts to improve the quality of care for hospital patients.

Written sign-outs appear to overcome some of the human errors that inevitably result from verbal patient summaries, such as disruptions and forgetfulness. Recent findings have, however, identified significant shortcomings in the quality and timeliness of written reports.

Critical information, such as code status and allergies, was missing in 80% of written sign-outs in one recent study.8 And in a 2006 study of the quality of discharge summaries, only 19% of hospital physicians with an outpatient practice reported being satisfied with the timeliness of discharge summaries. Only a third reported being satisfied with their quality of information. Most troubling, 41% believed that at least one of their patients hospitalized in the previous six months had experienced a preventable adverse event related to poor transfer of information at discharge.9

Use Redundancy and Simulation to Improve Safety

Given the clear challenges of providing quality and continuity of care in the inpatient setting, hospitalists are well positioned to identify strategies for safe and effective patient handoffs and advocate for a systems approach to their implementation.

Safety strategies that have been employed by industries outside of healthcare can provide a useful starting point. So-called “highly reliable” organizations use a variety of approaches to reduce the incidence of errors that occur during transitions in work staff. A recent review of transition methods used by NASA’s Johnson Space Center (Houston), Canadian nuclear power plants, and an ambulance dispatch center—organizations where lapses in transitions also have serious consequences—found that these entities used up to 21 handoff strategies.10 Techniques included verbal, face-to-face, and interactive questioning coordinated with written summaries just before a shift change.

Increasing redundancy is another technique used by highly reliable organizations to reduce the likelihood of missed, incomplete, or misinterpreted information. To create redundancy in clinical care, a physician would include more information at the outset of a procedure or medication order than is now typically provided. This additional information is then repeated and validated by other members of the care team throughout the process, reducing the likelihood of misinterpretation of an instruction or action based on incomplete information.

For example, if a physician always includes both the drug name and the condition for which it is prescribed, a medication order for “Celebrex, seizures,” instead of “Cerebyx, seizures,” would immediately indicate a mistake had occurred in ordering a pain medication instead of an anti-convulsant.11 Research has shown that increasing the amount of information about a medication order reduces the range of potentially valid clinical decisions.

Whether a hospital relies on verbal communication, written communication, computer-based communication, or a combination of all three, redundancy can be built into its sign-out processes. As PDAs become more widely used, structured sign-outs should incorporate redundancy into patient-specific checklists to include information on clinical status, recent and pending tests and study results, and similar, pertinent information.

Simulation-based training that incorporates redundancy and promotes read-back of patient information holds promise for error reduction, especially during patient handoffs.

AHRQ has recently funded research on simulation training projects that seek to:

• Reduce communication errors during patient handoffs in the emergency department by implementing a patient-specific checklist based on an electronic medical record and by testing the effect of companion simulation-based training; and
• Evaluate and improve safe communication and coordination between anesthesia providers and nurses during care transitions and during hand-offs between the operating room and the post-anesthesia care unit.12

The 24/7 role of hospital physicians brings unique experiences and insights to the challenges of patient safety that can test the feasibility of systems to reduce errors associated with care transitions. As their numbers and leadership roles expand, hospitalists are poised to make significant contributions to improving patient safety and outcomes.

We at AHRQ look forward to assisting hospitalists in making these contributions and to achieving these goals together. We also look forward to continuing our relationship with SHM and the hospitalist community as a whole. TH

Dr. Clancy is the director of the Agency for Healthcare Research and Quality.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996 Aug 15;335(7):514-517.
2. Impact of the nation’s hospitalists continues to grow new society of hospital medicine survey says [press release]. Society of Hospital Medicine. May 4, 2006.
3. Society of Hospital Medicine. The core competencies in hospital medicine: a framework for curriculum development by the society of hospital medicine. J Hosp Med. 2006;1;S1. Available at: http://onlinelibrary.wiley.com/doi/10.1002/jhm.72/pdf. Last accessed January 17, 2007.
4. Vidyarthi A [commentary]. Agency for Healthcare Research and Quality Web M&M: Morbidity and Mortality Rounds on the Web. Fumbled handoff. March 2004. Available at: www.webmm.ahrq.gov/case.aspx?caseID=55. Last accessed January 17, 2007.
5. Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. New York: Rugged Land LLG; 2004.
6. Vidyarthi A. Morbidity and Mortality Rounds on the Web, “Fumbled Handoff,” unpublished data, 2004.
7. Biller CK, Antonacci AC, Pelletier S, et al. The 80-hour work guidelines and resident survey perceptions of quality. J Surg Res. 2006 Oct;135(2):275-281. Epub 2006 Aug 24.
8. Lee LH, Levine JA, Schultz HJ. Utility of a standardized sign-out card for new medical interns. J Gen Intern Med. 1996;11(12):753-755.
9. O’Leary KJ, Leibovitz DM, Feinglass J, et al. Outpatient physicians’ satisfaction with discharge summaries and perceived need for an electronic discharge summary. J Hosp Med. 2006;1:317-320. Published online Oct. 11, 2006.
10. Reason JT. Managing the Risks of Organizational Accidents. Aldershot, England: Ashgate Publishing Company; 1997:135.
11. Bar-Yam Y. System care: multiscale analysis of medical errors–eliminating errors and improving organizational capabilities. New England Complex Systems Institute: Technical Report; Sept 2004. Available at: http://necsi.org/projects/yaneer/NECSITechnicalReport2004-09.pdf. Last accessed January 17, 2007.
12. Agency for Healthcare Research and Quality. Improving patient safety through simulation research. 2006 Simulation Projects. Available at: www.ahrq.gov/qual/simulproj.htm. Last accessed January 17, 2007.

On New Year’s Day while most men are engrossed in football, my 89-year-old father was sidelined by bilateral Achilles’ tendon ruptures—a rare complication of Levaquin therapy. Given my father’s age and his likely sedentary lifestyle, the orthopedist embarked upon conservative therapy. My father was disheartened to hear that he would need to have both ankles immobilized for many months, with only minimal weight bearing on one.

He thought that his life was over and became passive and dependent. He did what most people of his generation do in the hospital. He checked his independence at the door. He only did what the doctors or nurses told him to do, never asking to get up in the chair, never venturing outside his room, eating meals in bed unless nursing staff got him up.

A Musical Life

Until hospitalization, he had lived alone with his Brittany Spaniel in a two-story home with the full bath and bedroom on the second floor. He had even given music lessons in the basement. He had driven his car, bought groceries, walked his dog, and had been responsible for his own cooking, laundry, appointments, and medications, including warfarin.

Music, though, is the passion of his life. As a teenager in the 1930s, he learned to play the trombone by playing along with great players at night in the family car, which “had the best radio.” Later, he rode the train weekly from his home in Appleton, Wis., to Chicago to study with Jerry Chimera, a well-known master, and toured the Midwest with the region’s hottest bands while completing a Bachelor of Music degree at Lawrence University, Appleton, Wis.

At various times, he made a living as freelance trombonist in both New York City and Los Angeles. He was a studio musician with the NBC Orchestra and played lead with many great names, including Les Brown—and his Band of Renown!—and Doris Day during the Big Band Era, before embarking on an academic career. He completed his master’s degree at the University of Southern California (Los Angeles) and was a professor of music at universities in Montana and New York before settling in the Midwest to teach band to elementary and secondary students at public schools.

His personal life was filled with music. He was the principal trombonist with the Rochester (N.Y.) Symphony for 43 years, until macular degeneration made it impossible to continue. He also had an active schedule with a local jazz band, The Turkey River All-Stars, who have played a multitude of venues, both local and national. He has played with the Turkeys on the Delta Queen paddleboat, for four United States presidents, in Branson (Mo.), and at jazz festivals from here to New Orleans.

After “retirement” at age 70, he continued to give private music lessons for up to 42 students a week. At 89 he still gives private music lessons, though he now teaches on a less rigorous schedule with fewer students. When we ask him to tell us about his greatest source of satisfaction, he says, “The greatest achievement of my life was passing on my love of music to my sons. I am especially proud when they play together or Randy gets to play with the Rochester Orchestra.”

Dad’s Rehab

One of my first responsibilities after his hospitalization was to cancel his students’ lessons. One student, though, really needed some help with a piece for a competition. Because there was nothing wrong with Dad except his ankles, we wanted to help make that possible. We knew that Mayo hospitalists would support our goal of helping Dad to be as functional as possible. The staff needed to know—and Dad needed a reminder—that he wasn’t a typical 89-year-old.

My wife and I are both employed in healthcare professions. We knew of an outpatient examination room away from patient care areas that would provide good lighting and privacy. Isaac, a trombone student, brought his horn and his family for a visit. Dad left the floor for the most important hour of his therapy. He gave Isaac a lesson and then delighted us with his rendition of “Black Orpheus.”

After that lesson, he began to speak more positively of returning home. He is currently in a short-term rehabilitation facility for physical and occupational therapy. His goal is to return home after he learns to transfer safely and can navigate with a wheelchair.

Obviously, we have some work to do to prepare. We need to move his bedroom furniture and studio to the main floor. We need to acquire equipment and install grab bars. He may need assistance with dressing, housekeeping, bathing, transportation, and physical therapy for a few months. We are confident that a return home is on the horizon. Anything is possible with the right attitude. TH

Stroetz is a certified respiratory therapist at the Mayo Clinic. Lucinda Stroetz, PA, also contributed to this article.

On New Year’s Day while most men are engrossed in football, my 89-year-old father was sidelined by bilateral Achilles’ tendon ruptures—a rare complication of Levaquin therapy. Given my father’s age and his likely sedentary lifestyle, the orthopedist embarked upon conservative therapy. My father was disheartened to hear that he would need to have both ankles immobilized for many months, with only minimal weight bearing on one.

He thought that his life was over and became passive and dependent. He did what most people of his generation do in the hospital. He checked his independence at the door. He only did what the doctors or nurses told him to do, never asking to get up in the chair, never venturing outside his room, eating meals in bed unless nursing staff got him up.

A Musical Life

Until hospitalization, he had lived alone with his Brittany Spaniel in a two-story home with the full bath and bedroom on the second floor. He had even given music lessons in the basement. He had driven his car, bought groceries, walked his dog, and had been responsible for his own cooking, laundry, appointments, and medications, including warfarin.

Music, though, is the passion of his life. As a teenager in the 1930s, he learned to play the trombone by playing along with great players at night in the family car, which “had the best radio.” Later, he rode the train weekly from his home in Appleton, Wis., to Chicago to study with Jerry Chimera, a well-known master, and toured the Midwest with the region’s hottest bands while completing a Bachelor of Music degree at Lawrence University, Appleton, Wis.

At various times, he made a living as freelance trombonist in both New York City and Los Angeles. He was a studio musician with the NBC Orchestra and played lead with many great names, including Les Brown—and his Band of Renown!—and Doris Day during the Big Band Era, before embarking on an academic career. He completed his master’s degree at the University of Southern California (Los Angeles) and was a professor of music at universities in Montana and New York before settling in the Midwest to teach band to elementary and secondary students at public schools.

His personal life was filled with music. He was the principal trombonist with the Rochester (N.Y.) Symphony for 43 years, until macular degeneration made it impossible to continue. He also had an active schedule with a local jazz band, The Turkey River All-Stars, who have played a multitude of venues, both local and national. He has played with the Turkeys on the Delta Queen paddleboat, for four United States presidents, in Branson (Mo.), and at jazz festivals from here to New Orleans.

After “retirement” at age 70, he continued to give private music lessons for up to 42 students a week. At 89 he still gives private music lessons, though he now teaches on a less rigorous schedule with fewer students. When we ask him to tell us about his greatest source of satisfaction, he says, “The greatest achievement of my life was passing on my love of music to my sons. I am especially proud when they play together or Randy gets to play with the Rochester Orchestra.”

Dad’s Rehab

One of my first responsibilities after his hospitalization was to cancel his students’ lessons. One student, though, really needed some help with a piece for a competition. Because there was nothing wrong with Dad except his ankles, we wanted to help make that possible. We knew that Mayo hospitalists would support our goal of helping Dad to be as functional as possible. The staff needed to know—and Dad needed a reminder—that he wasn’t a typical 89-year-old.

My wife and I are both employed in healthcare professions. We knew of an outpatient examination room away from patient care areas that would provide good lighting and privacy. Isaac, a trombone student, brought his horn and his family for a visit. Dad left the floor for the most important hour of his therapy. He gave Isaac a lesson and then delighted us with his rendition of “Black Orpheus.”

After that lesson, he began to speak more positively of returning home. He is currently in a short-term rehabilitation facility for physical and occupational therapy. His goal is to return home after he learns to transfer safely and can navigate with a wheelchair.

Obviously, we have some work to do to prepare. We need to move his bedroom furniture and studio to the main floor. We need to acquire equipment and install grab bars. He may need assistance with dressing, housekeeping, bathing, transportation, and physical therapy for a few months. We are confident that a return home is on the horizon. Anything is possible with the right attitude. TH

Stroetz is a certified respiratory therapist at the Mayo Clinic. Lucinda Stroetz, PA, also contributed to this article.

On New Year’s Day while most men are engrossed in football, my 89-year-old father was sidelined by bilateral Achilles’ tendon ruptures—a rare complication of Levaquin therapy. Given my father’s age and his likely sedentary lifestyle, the orthopedist embarked upon conservative therapy. My father was disheartened to hear that he would need to have both ankles immobilized for many months, with only minimal weight bearing on one.

He thought that his life was over and became passive and dependent. He did what most people of his generation do in the hospital. He checked his independence at the door. He only did what the doctors or nurses told him to do, never asking to get up in the chair, never venturing outside his room, eating meals in bed unless nursing staff got him up.

A Musical Life

Until hospitalization, he had lived alone with his Brittany Spaniel in a two-story home with the full bath and bedroom on the second floor. He had even given music lessons in the basement. He had driven his car, bought groceries, walked his dog, and had been responsible for his own cooking, laundry, appointments, and medications, including warfarin.

Music, though, is the passion of his life. As a teenager in the 1930s, he learned to play the trombone by playing along with great players at night in the family car, which “had the best radio.” Later, he rode the train weekly from his home in Appleton, Wis., to Chicago to study with Jerry Chimera, a well-known master, and toured the Midwest with the region’s hottest bands while completing a Bachelor of Music degree at Lawrence University, Appleton, Wis.

At various times, he made a living as freelance trombonist in both New York City and Los Angeles. He was a studio musician with the NBC Orchestra and played lead with many great names, including Les Brown—and his Band of Renown!—and Doris Day during the Big Band Era, before embarking on an academic career. He completed his master’s degree at the University of Southern California (Los Angeles) and was a professor of music at universities in Montana and New York before settling in the Midwest to teach band to elementary and secondary students at public schools.

His personal life was filled with music. He was the principal trombonist with the Rochester (N.Y.) Symphony for 43 years, until macular degeneration made it impossible to continue. He also had an active schedule with a local jazz band, The Turkey River All-Stars, who have played a multitude of venues, both local and national. He has played with the Turkeys on the Delta Queen paddleboat, for four United States presidents, in Branson (Mo.), and at jazz festivals from here to New Orleans.

After “retirement” at age 70, he continued to give private music lessons for up to 42 students a week. At 89 he still gives private music lessons, though he now teaches on a less rigorous schedule with fewer students. When we ask him to tell us about his greatest source of satisfaction, he says, “The greatest achievement of my life was passing on my love of music to my sons. I am especially proud when they play together or Randy gets to play with the Rochester Orchestra.”

Dad’s Rehab

One of my first responsibilities after his hospitalization was to cancel his students’ lessons. One student, though, really needed some help with a piece for a competition. Because there was nothing wrong with Dad except his ankles, we wanted to help make that possible. We knew that Mayo hospitalists would support our goal of helping Dad to be as functional as possible. The staff needed to know—and Dad needed a reminder—that he wasn’t a typical 89-year-old.

My wife and I are both employed in healthcare professions. We knew of an outpatient examination room away from patient care areas that would provide good lighting and privacy. Isaac, a trombone student, brought his horn and his family for a visit. Dad left the floor for the most important hour of his therapy. He gave Isaac a lesson and then delighted us with his rendition of “Black Orpheus.”

After that lesson, he began to speak more positively of returning home. He is currently in a short-term rehabilitation facility for physical and occupational therapy. His goal is to return home after he learns to transfer safely and can navigate with a wheelchair.

Obviously, we have some work to do to prepare. We need to move his bedroom furniture and studio to the main floor. We need to acquire equipment and install grab bars. He may need assistance with dressing, housekeeping, bathing, transportation, and physical therapy for a few months. We are confident that a return home is on the horizon. Anything is possible with the right attitude. TH

Stroetz is a certified respiratory therapist at the Mayo Clinic. Lucinda Stroetz, PA, also contributed to this article.

The subject of perioperative glucocorticoid replacement certainly needs no extensive preamble or introduction. Hospitalists are routinely required to exercise the art and science of estimating the steroid requirement for patients on steroids undergoing surgical procedures. What follows is a brief review of the literature for fellow internists.

History: Full Circle

It has been almost 60 years since corticosteroids were first recognized for their anti-inflammatory and immunosuppressive properties, initially in rheumatologic diseases. The beneficial effects of steroids in rheumatoid arthritis were described in 1949 by Philip S. Hench and colleagues, a discovery for which he received (together with Edward C. Kendall and Tadeus Reichstein) the Nobel Prize in medicine in 1950.1,2

Barely three years later, Fraser and coworkers reported the death of a 34-year-old man after routine orthopedic surgery due to shock, adrenal insufficiency, and circulatory collapse.3 The patient had been on corticosteroids for rheumatoid arthritis, but the treatment had been stopped prior to surgery. The potentially fatal consequences of steroid withdrawal prior to surgery were thrown into even greater prominence by a similar report, presented by Lewis and colleagues within a year of the first incident.4 This occurrence involved an even younger patient: a 24-year-old woman, who had been on steroids for rheumatoid arthritis and who died after her therapy was stopped a day prior to surgery.

The first recommendations for perioperative steroid replacement soon appeared.4 When loosely interpreted, routine steroid doses were often quadrupled prior to surgery—a practice that sometimes led to mammoth amounts of steroids administered during the surgical period.5 Not surprisingly, adverse clinical results were soon noted: decreased tissue repair and healing, infections, and hyperglycemia, to name a few.5 While mortality related to acute steroid withdrawal and circulatory collapse might have decreased, morbidity related to poor surgical wound healing and subsequent complications increased.

Finally, in 1994, the problem of perioperative glucocorticoid replacement was reassessed, and fresh guidelines were provided by Salem and colleagues.5 These guidelines recognized the need for steroid coverage but in more moderate doses than had previously been used, and this is where we stand today—replacement, but in moderation.

Why Perioperative Steroid Coverage?

Acute stress activates the hypothalamic-pituitary-adrenal (HPA) axis, resulting in increased plasma adrenocorticotropic hormone (ACTH) and cortisol levels.6 This increase is believed to be an adaptive mechanism meant to enhance the body’s ability to combat stress by increasing its sensitivity to catecholamines; its cardiac contractility and output; and its mobilization of energy sources with gluconeogenesis, proteolysis, and lipolysis.6 It follows that lack of increase in cortisol production during stress would cause the host to succumb to it. On the other hand, too much cortisol would be detrimental, causing increased tissue breakdown, poor wound healing, and immunosuppression.

Surgery is one of the most potent stressors that can cause activation of the HPA axis.6,7 The degree of activation depends on the type and duration of surgery and anesthesia, with many other variables adding to the picture, including analgesics, antihypertensive medications, infections, and age.5-9 The maximum stimulation of the HPA axis in uncomplicated surgery has been assessed to occur during reversal of anesthesia and in the immediate postoperative period.6,9,10 Normal daily cortisol production is about 15 to 20 mg/day.6 These levels can go up to as much as 75–100 mg/day with surgical stress.6,11,12

Given this background, it is clear that any patient who has inadequate cortisol production in response to surgical stress will fare poorly in such a situation. This patient will need to be recognized, and his acute steroid requirement will have to be estimated and supplemented; in addition, over- or under-dosing must be avoided in order to achieve a good post-surgical outcome.

Mechanisms of Adrenal Insufficiency in the Perioperative Period

Adrenal insufficiency can be primary, in which the adrenal gland itself does not function properly. It can also be secondary or central, in which the hypothalamic/pituitary axis is functioning at sub-par levels. It is, in fact, secondary adrenal insufficiency that is most commonly encountered in clinical practice; this condition is caused by HPA axis suppression due to negative feedback from exogenous administration of corticosteroids.

click for large version

Who Needs Perioperative Steroid Replacement?

Following are situations in which perioperative steroid replacement should be considered:

• Any patient who has received more than 20 mg of prednisone daily (or an equivalent dose of other glucocorticoids) for more than five days in the previous year is at risk for HPA axis suppression;13,14
• Any patient who has clinical Cushing’s syndrome from any steroid dose should be considered to have a suppressed HPA axis;6 and
• Any steroid dose given at bedtime—even physiologic doses—is more likely to suppress the HPA axis than a similar dose given in the morning because, at nighttime, the negative feedback from steroids to ACTH and corticotropin-releasing hormone (CRH) is more prominent.6

Patients receiving doses equivalent to 5 mg of prednisone in the morning for any length of time are not associated with HPA axis suppression.13 If these patients are on steroid replacement for primary adrenal insufficiency, however, it is vital to realize that they do not have the capacity to compensate for increased stress, surgical or otherwise, and may need additional replacement depending upon the nature and duration of their stressors.14

Doses greater than physiologic range but less than 20 mg/day of prednisone can cause suppression of the HPA axis, but the demarcation of the time frame is not absolutely clear. It is said that doses closer to the physiologic range cause suppression after about one month, whereas doses closer to 20 mg/day can do so in five days or more.13, 14

For patients who cannot be clearly identified by these criteria, provocative testing is recommended, as discussed below.

Laboratory Testing for HPA Axis Function

The ACTH stimulation test is recommended to test for HPA axis adequacy in perioperative patients.5,13,14 It has been shown to correlate well with the insulin tolerance test. Exogenous corticosteroids have to be held for 24 hours prior to testing because they affect the measured cortisol level, with the exception of dexamethasone, which does not affect the results.13

The test involves the administration of 250 mcg of cosyntropin—synthetic ACTH—intramuscularly or intravenously, followed by measurement of peak cortisol levels after 30 minutes.5 Traditionally, a plasma cortisol level greater than 18–20 mcg/dl defines adequate adrenal function, as quoted from Salem and colleagues.5

Basal values and the calculation of delta max—the difference between basal and peak values—have not been shown to correlate with clinical outcome in routine surgical patients.13 Although these values have been demonstrated to be useful in the setting of septic shock, the subject is still under debate, and readers interested in this aspect of adrenal insufficiency may refer to articles by Annane, Hollenberg, Gonzalez and colleagues.15,16,17

Use of a 250-mcg dose of cosyntropin has often been criticized for being supraphysiologic, and use of a 1-mcg dose has been suggested instead. This test has not yet been characterized well enough, however.13,18 In addition, a standardized, commercial preparation of the 1-mcg dose is not available.13 Thus, the low-dose test is, as yet, not routinely advocated.

To Replace or Not to Replace?

It is interesting to note that biochemical evidence of HPA axis dysfunction does not necessarily translate into clinical problems with surgical stress.19 Additionally, patients on chronic steroid supplementation higher than 5 mg/day of prednisone—or equivalent—may not necessarily suffer inappropriate biochemical responses to stress.20 With these observations comes the following question: Even if HPA axis dysfunction exists, when does it matter clinically, or does it matter? The difficulty of this situation has been discussed in detail by Levy and Shaw.21,22

Shaw brings the topic to another level when he states that, given the evidence we have today, it is still prudent to consider perioperative steroid coverage.22 The benefit—avoiding life-threatening adrenal insufficiency—outweighs the risk of enhanced catabolism and immunosuppression, especially if the steroid coverage is physiologic and of a very short duration.

Perioperative Glucocorticoid Coverage

Current recommendations for steroid coverage take into account the normal physiologic response to routine surgery. The idea is to mimic the transient increase in cortisol levels during the surgical and postoperative period but not to exceed the levels or the duration of the physiologic response. Doses above the physiologic ranges offer no particular benefit in routine surgical stress.5

Most of the current recommendations stem from those proposed by Salem and colleagues in 1994.5

Conclusion

For almost 50 years after it was first recognized, the need for steroid replacement in surgical situations had been addressed with high doses that created new problems in the forms of poor tissue healing and immunosuppression, causing a major dilemma in the surgical world. Now, with a more conservative and physiologic approach, the adverse consequences of glucocorticoid supplementation can be minimized and perhaps even prevented. TH

References

1. Hench PS, Kendall EC, Slocumb CH, et al. The effect of a hormone of the adrenal cortex (17-hydroxy-11-dehydrocorticosterone; compound E) and of pituitary adrenocorticotropic hormone on rheumatoid arthritis. Proc Staff Meet Mayo Clin. 1949;24:181-197.
2. Hench PS, Slocumb CH, Polley HF, et al. Effect of cortisone and pituitary adrenocorticotropic hormone (ACTH) on rheumatic diseases. JAMA. 1950 Dec 16;144(16):1327-1335.
3. Fraser CG, Preuss FS, Bigford WD. Adrenal atrophy and irreversible shock associated with cortisone therapy. JAMA. 1952;149:1542-1543.
4. Lewis L, Robinson RF, Yee J, et al. Fatal adrenal cortical insufficiency precipitated by surgery during prolonged continuous cortisone treatment. Ann Intern Med. 1953; 39:116-126.
5. Salem M, Tainsh RE Jr, Bromberg J, et al. Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem. Ann Surg. 1994 Apr;219(4):416-425.
6. Jabbour SA. Steroids and the surgical patient. Med Clin North Am. 2001 Sep;85(5):1311-1317.
7. Hume DM, Bell CC, Bartter F. Direct measurement of adrenal secretion during operative trauma and convalescence. Surgery. 1962 Jul;52:174-187.
8. Chernow B, Alexander HR, Smallridge RC, et al. Hormonal responses to graded surgical stress. Arch Intern Med. 1987 Jul;147(4):1273-1278.
9. Raff H, Norton AJ, Flemma RJ, et al. Inhibition of the adrenocorticotropin response to surgery in humans: interaction between dexamethasone and fentanyl. J Clin Endocrinol Metab. 1987 Aug;65(2):295-298.
10. Udelsman R, Norton JA, Jelenich SE, et al. Responses of the hypothalamic-pituitary-adrenal and renin-angiotensin axes and the sympathetic system during controlled surgical and anesthetic stress. J Clin Endocrinol Metab. 1987 May;64(5):986-994.
11. Kehlet H. A rational approach to dosage and preparation of parenteral glucocorticoid substitution therapy during surgical procedures. A short review. Acta Anaesthesiol Scand. 1975;19(4):260-264.
12. Kehlet H. Clinical course and hypothalamic-pituitary-adrenocortical function in glucocorticoid-treated surgical patients. Copenhagen: FADL; 1976.
13. Axelrod L. Perioperative management of patients treated with glucocorticoids. Endocrinol Metab Clin North Am. 2003;32:367-383.
14. Connery LE, Coursin DB. Assessment and therapy of selected endocrine disorders. Anesthesiol Clin North America. 2004 Mar;22(1):93-123.
15. Annane D, Sebille V, Troche G, et al. A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA. 2000 Feb 23;283(8):1038-1045.
16. Hollenberg SM, Ahrens TS, Annane D, et al. Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. Crit Care Med. 2004 Sep;32(9):1928-1948.
17. Gonzalez H, Nardi O, Annane D. Relative adrenal failure in the ICU: an identifiable problem requiring treatment. Crit Care Clin. 2006 Jan;22(1):105-118.
18. Streeten DHP. Shortcomings in the low-dose (1 microg) ACTH test for the diagnosis of ACTH deficiency states. J Clin Endocrinol Metab. 1999 Mar;84(3):835-837.
19. Bromberg JS, Alfrey EJ, Barker CF, et al. Adrenal suppression and steroid supplementation in renal transplant recipients. Transplantation. 1991 Feb;51(2):385-390.
20. Friedman RJ, Schiff CF, Bromberg JS. Use of supplemental steroids in patients having orthopaedic operations. J Bone Joint Surg Am. 1995 Dec;77(12):1801-1806.
21. Levy A. Perioperative steroid cover. Lancet. 1996 Mar;347(9005):846-847.
22. Shaw M. When is perioperative ‘steroid coverage’ necessary? Available at: www.clevelandclinicmeded.com/ccjm/january2002/shaw.htm. Last accessed February 9, 2007.

The subject of perioperative glucocorticoid replacement certainly needs no extensive preamble or introduction. Hospitalists are routinely required to exercise the art and science of estimating the steroid requirement for patients on steroids undergoing surgical procedures. What follows is a brief review of the literature for fellow internists.

History: Full Circle

It has been almost 60 years since corticosteroids were first recognized for their anti-inflammatory and immunosuppressive properties, initially in rheumatologic diseases. The beneficial effects of steroids in rheumatoid arthritis were described in 1949 by Philip S. Hench and colleagues, a discovery for which he received (together with Edward C. Kendall and Tadeus Reichstein) the Nobel Prize in medicine in 1950.1,2

Barely three years later, Fraser and coworkers reported the death of a 34-year-old man after routine orthopedic surgery due to shock, adrenal insufficiency, and circulatory collapse.3 The patient had been on corticosteroids for rheumatoid arthritis, but the treatment had been stopped prior to surgery. The potentially fatal consequences of steroid withdrawal prior to surgery were thrown into even greater prominence by a similar report, presented by Lewis and colleagues within a year of the first incident.4 This occurrence involved an even younger patient: a 24-year-old woman, who had been on steroids for rheumatoid arthritis and who died after her therapy was stopped a day prior to surgery.

The first recommendations for perioperative steroid replacement soon appeared.4 When loosely interpreted, routine steroid doses were often quadrupled prior to surgery—a practice that sometimes led to mammoth amounts of steroids administered during the surgical period.5 Not surprisingly, adverse clinical results were soon noted: decreased tissue repair and healing, infections, and hyperglycemia, to name a few.5 While mortality related to acute steroid withdrawal and circulatory collapse might have decreased, morbidity related to poor surgical wound healing and subsequent complications increased.

Finally, in 1994, the problem of perioperative glucocorticoid replacement was reassessed, and fresh guidelines were provided by Salem and colleagues.5 These guidelines recognized the need for steroid coverage but in more moderate doses than had previously been used, and this is where we stand today—replacement, but in moderation.

Why Perioperative Steroid Coverage?

Acute stress activates the hypothalamic-pituitary-adrenal (HPA) axis, resulting in increased plasma adrenocorticotropic hormone (ACTH) and cortisol levels.6 This increase is believed to be an adaptive mechanism meant to enhance the body’s ability to combat stress by increasing its sensitivity to catecholamines; its cardiac contractility and output; and its mobilization of energy sources with gluconeogenesis, proteolysis, and lipolysis.6 It follows that lack of increase in cortisol production during stress would cause the host to succumb to it. On the other hand, too much cortisol would be detrimental, causing increased tissue breakdown, poor wound healing, and immunosuppression.

Surgery is one of the most potent stressors that can cause activation of the HPA axis.6,7 The degree of activation depends on the type and duration of surgery and anesthesia, with many other variables adding to the picture, including analgesics, antihypertensive medications, infections, and age.5-9 The maximum stimulation of the HPA axis in uncomplicated surgery has been assessed to occur during reversal of anesthesia and in the immediate postoperative period.6,9,10 Normal daily cortisol production is about 15 to 20 mg/day.6 These levels can go up to as much as 75–100 mg/day with surgical stress.6,11,12

Given this background, it is clear that any patient who has inadequate cortisol production in response to surgical stress will fare poorly in such a situation. This patient will need to be recognized, and his acute steroid requirement will have to be estimated and supplemented; in addition, over- or under-dosing must be avoided in order to achieve a good post-surgical outcome.

Mechanisms of Adrenal Insufficiency in the Perioperative Period

Adrenal insufficiency can be primary, in which the adrenal gland itself does not function properly. It can also be secondary or central, in which the hypothalamic/pituitary axis is functioning at sub-par levels. It is, in fact, secondary adrenal insufficiency that is most commonly encountered in clinical practice; this condition is caused by HPA axis suppression due to negative feedback from exogenous administration of corticosteroids.

click for large version

Who Needs Perioperative Steroid Replacement?

Following are situations in which perioperative steroid replacement should be considered:

• Any patient who has received more than 20 mg of prednisone daily (or an equivalent dose of other glucocorticoids) for more than five days in the previous year is at risk for HPA axis suppression;13,14
• Any patient who has clinical Cushing’s syndrome from any steroid dose should be considered to have a suppressed HPA axis;6 and
• Any steroid dose given at bedtime—even physiologic doses—is more likely to suppress the HPA axis than a similar dose given in the morning because, at nighttime, the negative feedback from steroids to ACTH and corticotropin-releasing hormone (CRH) is more prominent.6

Patients receiving doses equivalent to 5 mg of prednisone in the morning for any length of time are not associated with HPA axis suppression.13 If these patients are on steroid replacement for primary adrenal insufficiency, however, it is vital to realize that they do not have the capacity to compensate for increased stress, surgical or otherwise, and may need additional replacement depending upon the nature and duration of their stressors.14

Doses greater than physiologic range but less than 20 mg/day of prednisone can cause suppression of the HPA axis, but the demarcation of the time frame is not absolutely clear. It is said that doses closer to the physiologic range cause suppression after about one month, whereas doses closer to 20 mg/day can do so in five days or more.13, 14

For patients who cannot be clearly identified by these criteria, provocative testing is recommended, as discussed below.

Laboratory Testing for HPA Axis Function

The ACTH stimulation test is recommended to test for HPA axis adequacy in perioperative patients.5,13,14 It has been shown to correlate well with the insulin tolerance test. Exogenous corticosteroids have to be held for 24 hours prior to testing because they affect the measured cortisol level, with the exception of dexamethasone, which does not affect the results.13

The test involves the administration of 250 mcg of cosyntropin—synthetic ACTH—intramuscularly or intravenously, followed by measurement of peak cortisol levels after 30 minutes.5 Traditionally, a plasma cortisol level greater than 18–20 mcg/dl defines adequate adrenal function, as quoted from Salem and colleagues.5

Basal values and the calculation of delta max—the difference between basal and peak values—have not been shown to correlate with clinical outcome in routine surgical patients.13 Although these values have been demonstrated to be useful in the setting of septic shock, the subject is still under debate, and readers interested in this aspect of adrenal insufficiency may refer to articles by Annane, Hollenberg, Gonzalez and colleagues.15,16,17

Use of a 250-mcg dose of cosyntropin has often been criticized for being supraphysiologic, and use of a 1-mcg dose has been suggested instead. This test has not yet been characterized well enough, however.13,18 In addition, a standardized, commercial preparation of the 1-mcg dose is not available.13 Thus, the low-dose test is, as yet, not routinely advocated.

To Replace or Not to Replace?

It is interesting to note that biochemical evidence of HPA axis dysfunction does not necessarily translate into clinical problems with surgical stress.19 Additionally, patients on chronic steroid supplementation higher than 5 mg/day of prednisone—or equivalent—may not necessarily suffer inappropriate biochemical responses to stress.20 With these observations comes the following question: Even if HPA axis dysfunction exists, when does it matter clinically, or does it matter? The difficulty of this situation has been discussed in detail by Levy and Shaw.21,22

Shaw brings the topic to another level when he states that, given the evidence we have today, it is still prudent to consider perioperative steroid coverage.22 The benefit—avoiding life-threatening adrenal insufficiency—outweighs the risk of enhanced catabolism and immunosuppression, especially if the steroid coverage is physiologic and of a very short duration.

Perioperative Glucocorticoid Coverage

Current recommendations for steroid coverage take into account the normal physiologic response to routine surgery. The idea is to mimic the transient increase in cortisol levels during the surgical and postoperative period but not to exceed the levels or the duration of the physiologic response. Doses above the physiologic ranges offer no particular benefit in routine surgical stress.5

Most of the current recommendations stem from those proposed by Salem and colleagues in 1994.5

Conclusion

For almost 50 years after it was first recognized, the need for steroid replacement in surgical situations had been addressed with high doses that created new problems in the forms of poor tissue healing and immunosuppression, causing a major dilemma in the surgical world. Now, with a more conservative and physiologic approach, the adverse consequences of glucocorticoid supplementation can be minimized and perhaps even prevented. TH

References

1. Hench PS, Kendall EC, Slocumb CH, et al. The effect of a hormone of the adrenal cortex (17-hydroxy-11-dehydrocorticosterone; compound E) and of pituitary adrenocorticotropic hormone on rheumatoid arthritis. Proc Staff Meet Mayo Clin. 1949;24:181-197.
2. Hench PS, Slocumb CH, Polley HF, et al. Effect of cortisone and pituitary adrenocorticotropic hormone (ACTH) on rheumatic diseases. JAMA. 1950 Dec 16;144(16):1327-1335.
3. Fraser CG, Preuss FS, Bigford WD. Adrenal atrophy and irreversible shock associated with cortisone therapy. JAMA. 1952;149:1542-1543.
4. Lewis L, Robinson RF, Yee J, et al. Fatal adrenal cortical insufficiency precipitated by surgery during prolonged continuous cortisone treatment. Ann Intern Med. 1953; 39:116-126.
5. Salem M, Tainsh RE Jr, Bromberg J, et al. Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem. Ann Surg. 1994 Apr;219(4):416-425.
6. Jabbour SA. Steroids and the surgical patient. Med Clin North Am. 2001 Sep;85(5):1311-1317.
7. Hume DM, Bell CC, Bartter F. Direct measurement of adrenal secretion during operative trauma and convalescence. Surgery. 1962 Jul;52:174-187.
8. Chernow B, Alexander HR, Smallridge RC, et al. Hormonal responses to graded surgical stress. Arch Intern Med. 1987 Jul;147(4):1273-1278.
9. Raff H, Norton AJ, Flemma RJ, et al. Inhibition of the adrenocorticotropin response to surgery in humans: interaction between dexamethasone and fentanyl. J Clin Endocrinol Metab. 1987 Aug;65(2):295-298.
10. Udelsman R, Norton JA, Jelenich SE, et al. Responses of the hypothalamic-pituitary-adrenal and renin-angiotensin axes and the sympathetic system during controlled surgical and anesthetic stress. J Clin Endocrinol Metab. 1987 May;64(5):986-994.
11. Kehlet H. A rational approach to dosage and preparation of parenteral glucocorticoid substitution therapy during surgical procedures. A short review. Acta Anaesthesiol Scand. 1975;19(4):260-264.
12. Kehlet H. Clinical course and hypothalamic-pituitary-adrenocortical function in glucocorticoid-treated surgical patients. Copenhagen: FADL; 1976.
13. Axelrod L. Perioperative management of patients treated with glucocorticoids. Endocrinol Metab Clin North Am. 2003;32:367-383.
14. Connery LE, Coursin DB. Assessment and therapy of selected endocrine disorders. Anesthesiol Clin North America. 2004 Mar;22(1):93-123.
15. Annane D, Sebille V, Troche G, et al. A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA. 2000 Feb 23;283(8):1038-1045.
16. Hollenberg SM, Ahrens TS, Annane D, et al. Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. Crit Care Med. 2004 Sep;32(9):1928-1948.
17. Gonzalez H, Nardi O, Annane D. Relative adrenal failure in the ICU: an identifiable problem requiring treatment. Crit Care Clin. 2006 Jan;22(1):105-118.
18. Streeten DHP. Shortcomings in the low-dose (1 microg) ACTH test for the diagnosis of ACTH deficiency states. J Clin Endocrinol Metab. 1999 Mar;84(3):835-837.
19. Bromberg JS, Alfrey EJ, Barker CF, et al. Adrenal suppression and steroid supplementation in renal transplant recipients. Transplantation. 1991 Feb;51(2):385-390.
20. Friedman RJ, Schiff CF, Bromberg JS. Use of supplemental steroids in patients having orthopaedic operations. J Bone Joint Surg Am. 1995 Dec;77(12):1801-1806.
21. Levy A. Perioperative steroid cover. Lancet. 1996 Mar;347(9005):846-847.
22. Shaw M. When is perioperative ‘steroid coverage’ necessary? Available at: www.clevelandclinicmeded.com/ccjm/january2002/shaw.htm. Last accessed February 9, 2007.

The subject of perioperative glucocorticoid replacement certainly needs no extensive preamble or introduction. Hospitalists are routinely required to exercise the art and science of estimating the steroid requirement for patients on steroids undergoing surgical procedures. What follows is a brief review of the literature for fellow internists.

History: Full Circle

It has been almost 60 years since corticosteroids were first recognized for their anti-inflammatory and immunosuppressive properties, initially in rheumatologic diseases. The beneficial effects of steroids in rheumatoid arthritis were described in 1949 by Philip S. Hench and colleagues, a discovery for which he received (together with Edward C. Kendall and Tadeus Reichstein) the Nobel Prize in medicine in 1950.1,2

Barely three years later, Fraser and coworkers reported the death of a 34-year-old man after routine orthopedic surgery due to shock, adrenal insufficiency, and circulatory collapse.3 The patient had been on corticosteroids for rheumatoid arthritis, but the treatment had been stopped prior to surgery. The potentially fatal consequences of steroid withdrawal prior to surgery were thrown into even greater prominence by a similar report, presented by Lewis and colleagues within a year of the first incident.4 This occurrence involved an even younger patient: a 24-year-old woman, who had been on steroids for rheumatoid arthritis and who died after her therapy was stopped a day prior to surgery.

The first recommendations for perioperative steroid replacement soon appeared.4 When loosely interpreted, routine steroid doses were often quadrupled prior to surgery—a practice that sometimes led to mammoth amounts of steroids administered during the surgical period.5 Not surprisingly, adverse clinical results were soon noted: decreased tissue repair and healing, infections, and hyperglycemia, to name a few.5 While mortality related to acute steroid withdrawal and circulatory collapse might have decreased, morbidity related to poor surgical wound healing and subsequent complications increased.

Finally, in 1994, the problem of perioperative glucocorticoid replacement was reassessed, and fresh guidelines were provided by Salem and colleagues.5 These guidelines recognized the need for steroid coverage but in more moderate doses than had previously been used, and this is where we stand today—replacement, but in moderation.

Why Perioperative Steroid Coverage?

Acute stress activates the hypothalamic-pituitary-adrenal (HPA) axis, resulting in increased plasma adrenocorticotropic hormone (ACTH) and cortisol levels.6 This increase is believed to be an adaptive mechanism meant to enhance the body’s ability to combat stress by increasing its sensitivity to catecholamines; its cardiac contractility and output; and its mobilization of energy sources with gluconeogenesis, proteolysis, and lipolysis.6 It follows that lack of increase in cortisol production during stress would cause the host to succumb to it. On the other hand, too much cortisol would be detrimental, causing increased tissue breakdown, poor wound healing, and immunosuppression.

Surgery is one of the most potent stressors that can cause activation of the HPA axis.6,7 The degree of activation depends on the type and duration of surgery and anesthesia, with many other variables adding to the picture, including analgesics, antihypertensive medications, infections, and age.5-9 The maximum stimulation of the HPA axis in uncomplicated surgery has been assessed to occur during reversal of anesthesia and in the immediate postoperative period.6,9,10 Normal daily cortisol production is about 15 to 20 mg/day.6 These levels can go up to as much as 75–100 mg/day with surgical stress.6,11,12

Given this background, it is clear that any patient who has inadequate cortisol production in response to surgical stress will fare poorly in such a situation. This patient will need to be recognized, and his acute steroid requirement will have to be estimated and supplemented; in addition, over- or under-dosing must be avoided in order to achieve a good post-surgical outcome.

Mechanisms of Adrenal Insufficiency in the Perioperative Period

Adrenal insufficiency can be primary, in which the adrenal gland itself does not function properly. It can also be secondary or central, in which the hypothalamic/pituitary axis is functioning at sub-par levels. It is, in fact, secondary adrenal insufficiency that is most commonly encountered in clinical practice; this condition is caused by HPA axis suppression due to negative feedback from exogenous administration of corticosteroids.

click for large version

Who Needs Perioperative Steroid Replacement?

Following are situations in which perioperative steroid replacement should be considered:

• Any patient who has received more than 20 mg of prednisone daily (or an equivalent dose of other glucocorticoids) for more than five days in the previous year is at risk for HPA axis suppression;13,14
• Any patient who has clinical Cushing’s syndrome from any steroid dose should be considered to have a suppressed HPA axis;6 and
• Any steroid dose given at bedtime—even physiologic doses—is more likely to suppress the HPA axis than a similar dose given in the morning because, at nighttime, the negative feedback from steroids to ACTH and corticotropin-releasing hormone (CRH) is more prominent.6

Patients receiving doses equivalent to 5 mg of prednisone in the morning for any length of time are not associated with HPA axis suppression.13 If these patients are on steroid replacement for primary adrenal insufficiency, however, it is vital to realize that they do not have the capacity to compensate for increased stress, surgical or otherwise, and may need additional replacement depending upon the nature and duration of their stressors.14

Doses greater than physiologic range but less than 20 mg/day of prednisone can cause suppression of the HPA axis, but the demarcation of the time frame is not absolutely clear. It is said that doses closer to the physiologic range cause suppression after about one month, whereas doses closer to 20 mg/day can do so in five days or more.13, 14

For patients who cannot be clearly identified by these criteria, provocative testing is recommended, as discussed below.

Laboratory Testing for HPA Axis Function

The ACTH stimulation test is recommended to test for HPA axis adequacy in perioperative patients.5,13,14 It has been shown to correlate well with the insulin tolerance test. Exogenous corticosteroids have to be held for 24 hours prior to testing because they affect the measured cortisol level, with the exception of dexamethasone, which does not affect the results.13

The test involves the administration of 250 mcg of cosyntropin—synthetic ACTH—intramuscularly or intravenously, followed by measurement of peak cortisol levels after 30 minutes.5 Traditionally, a plasma cortisol level greater than 18–20 mcg/dl defines adequate adrenal function, as quoted from Salem and colleagues.5

Basal values and the calculation of delta max—the difference between basal and peak values—have not been shown to correlate with clinical outcome in routine surgical patients.13 Although these values have been demonstrated to be useful in the setting of septic shock, the subject is still under debate, and readers interested in this aspect of adrenal insufficiency may refer to articles by Annane, Hollenberg, Gonzalez and colleagues.15,16,17

Use of a 250-mcg dose of cosyntropin has often been criticized for being supraphysiologic, and use of a 1-mcg dose has been suggested instead. This test has not yet been characterized well enough, however.13,18 In addition, a standardized, commercial preparation of the 1-mcg dose is not available.13 Thus, the low-dose test is, as yet, not routinely advocated.

To Replace or Not to Replace?

It is interesting to note that biochemical evidence of HPA axis dysfunction does not necessarily translate into clinical problems with surgical stress.19 Additionally, patients on chronic steroid supplementation higher than 5 mg/day of prednisone—or equivalent—may not necessarily suffer inappropriate biochemical responses to stress.20 With these observations comes the following question: Even if HPA axis dysfunction exists, when does it matter clinically, or does it matter? The difficulty of this situation has been discussed in detail by Levy and Shaw.21,22

Shaw brings the topic to another level when he states that, given the evidence we have today, it is still prudent to consider perioperative steroid coverage.22 The benefit—avoiding life-threatening adrenal insufficiency—outweighs the risk of enhanced catabolism and immunosuppression, especially if the steroid coverage is physiologic and of a very short duration.

Perioperative Glucocorticoid Coverage

Current recommendations for steroid coverage take into account the normal physiologic response to routine surgery. The idea is to mimic the transient increase in cortisol levels during the surgical and postoperative period but not to exceed the levels or the duration of the physiologic response. Doses above the physiologic ranges offer no particular benefit in routine surgical stress.5

Most of the current recommendations stem from those proposed by Salem and colleagues in 1994.5

Conclusion

For almost 50 years after it was first recognized, the need for steroid replacement in surgical situations had been addressed with high doses that created new problems in the forms of poor tissue healing and immunosuppression, causing a major dilemma in the surgical world. Now, with a more conservative and physiologic approach, the adverse consequences of glucocorticoid supplementation can be minimized and perhaps even prevented. TH

References

1. Hench PS, Kendall EC, Slocumb CH, et al. The effect of a hormone of the adrenal cortex (17-hydroxy-11-dehydrocorticosterone; compound E) and of pituitary adrenocorticotropic hormone on rheumatoid arthritis. Proc Staff Meet Mayo Clin. 1949;24:181-197.
2. Hench PS, Slocumb CH, Polley HF, et al. Effect of cortisone and pituitary adrenocorticotropic hormone (ACTH) on rheumatic diseases. JAMA. 1950 Dec 16;144(16):1327-1335.
3. Fraser CG, Preuss FS, Bigford WD. Adrenal atrophy and irreversible shock associated with cortisone therapy. JAMA. 1952;149:1542-1543.
4. Lewis L, Robinson RF, Yee J, et al. Fatal adrenal cortical insufficiency precipitated by surgery during prolonged continuous cortisone treatment. Ann Intern Med. 1953; 39:116-126.
5. Salem M, Tainsh RE Jr, Bromberg J, et al. Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem. Ann Surg. 1994 Apr;219(4):416-425.
6. Jabbour SA. Steroids and the surgical patient. Med Clin North Am. 2001 Sep;85(5):1311-1317.
7. Hume DM, Bell CC, Bartter F. Direct measurement of adrenal secretion during operative trauma and convalescence. Surgery. 1962 Jul;52:174-187.
8. Chernow B, Alexander HR, Smallridge RC, et al. Hormonal responses to graded surgical stress. Arch Intern Med. 1987 Jul;147(4):1273-1278.
9. Raff H, Norton AJ, Flemma RJ, et al. Inhibition of the adrenocorticotropin response to surgery in humans: interaction between dexamethasone and fentanyl. J Clin Endocrinol Metab. 1987 Aug;65(2):295-298.
10. Udelsman R, Norton JA, Jelenich SE, et al. Responses of the hypothalamic-pituitary-adrenal and renin-angiotensin axes and the sympathetic system during controlled surgical and anesthetic stress. J Clin Endocrinol Metab. 1987 May;64(5):986-994.
11. Kehlet H. A rational approach to dosage and preparation of parenteral glucocorticoid substitution therapy during surgical procedures. A short review. Acta Anaesthesiol Scand. 1975;19(4):260-264.
12. Kehlet H. Clinical course and hypothalamic-pituitary-adrenocortical function in glucocorticoid-treated surgical patients. Copenhagen: FADL; 1976.
13. Axelrod L. Perioperative management of patients treated with glucocorticoids. Endocrinol Metab Clin North Am. 2003;32:367-383.
14. Connery LE, Coursin DB. Assessment and therapy of selected endocrine disorders. Anesthesiol Clin North America. 2004 Mar;22(1):93-123.
15. Annane D, Sebille V, Troche G, et al. A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA. 2000 Feb 23;283(8):1038-1045.
16. Hollenberg SM, Ahrens TS, Annane D, et al. Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. Crit Care Med. 2004 Sep;32(9):1928-1948.
17. Gonzalez H, Nardi O, Annane D. Relative adrenal failure in the ICU: an identifiable problem requiring treatment. Crit Care Clin. 2006 Jan;22(1):105-118.
18. Streeten DHP. Shortcomings in the low-dose (1 microg) ACTH test for the diagnosis of ACTH deficiency states. J Clin Endocrinol Metab. 1999 Mar;84(3):835-837.
19. Bromberg JS, Alfrey EJ, Barker CF, et al. Adrenal suppression and steroid supplementation in renal transplant recipients. Transplantation. 1991 Feb;51(2):385-390.
20. Friedman RJ, Schiff CF, Bromberg JS. Use of supplemental steroids in patients having orthopaedic operations. J Bone Joint Surg Am. 1995 Dec;77(12):1801-1806.
21. Levy A. Perioperative steroid cover. Lancet. 1996 Mar;347(9005):846-847.
22. Shaw M. When is perioperative ‘steroid coverage’ necessary? Available at: www.clevelandclinicmeded.com/ccjm/january2002/shaw.htm. Last accessed February 9, 2007.

Brief history: A 32-year-old female presents with dysphagia, dizziness, and dysarthria.

Salient findings: Chest X-ray demonstrates many embolization coils within both lungs. Photographs demonstrate superficial telangiectasias of the tongue and distal phalanx. These findings indicate the patient’s diagnosis: hereditary hemorrhagic telangiectasia (HHT), previously known as Osler-Weber-Rendu syndrome.

Patient population/natural history of disease: HHT is an autosomal dominant trait, so family members should be counseled on the implications of having a relative with the disease. HHT patients have abnormal vessels prone to bleeding and often develop arteriovenous malformations (AVMs). Diagnosis is made with 75% of the following symptoms:

• Epistaxis;
• Mucocutaneous telangiectasias;
• GI, pulmonary, or hepatic AVMs; and/or
• A first-degree relative with HHT.

Patients often present with dyspnea and hemoptysis. With pulmonary AVMs, the oxygenation and filtration functions of the lungs are bypassed, placing the patient at risk for hypoxia, polycythemia, paradoxical strokes, and brain abscesses.

Management: AVMs can be diagnosed and treated with angiography and embolization. In this patient the coils had been placed elsewhere. The use of coils larger than 3 mm in AVMs should be treated because they are associated with significantly increased morbidity and mortality. Steel coils are covered with thrombogenic fibers that induce clotting and sealing of the AVM; blood is no longer shunted through the right-to-left shunt. Unfortunately, a long-term complication of pulmonary AVMs treated by embolization therapy is the development of new pulmonary AVMs.

The patient in this case had many metallic coils visible on chest X-ray and because she had required multiple pulmonary angiograms and embolizations over the years.

It’s important to administer an ECG to all HHT patients prior to treatment; those with a left bundle branch block must have pacing mechanisms in place or at hand because catheter placement and manipulation within the right heart can induce right heart blockage. Take care to avoid air emboli in all lines due to right-to-left shunting in these patients.

Take-Home Points:

• Untreated pulmonary AVMs are associated with paradoxical strokes, brain abscesses, and hypoxia;
• HHT is associated with pulmonary AVMs;
• Coil embolization of pulmonary AVMs has been shown to improve dyspnea and oxygen saturation while decreasing right-to-left shunt fraction in HHT patients.
• Complications of embolization therapy may include development of new pulmonary AVMs; and
• All patients should undergo ECG prior to pulmonary angiography to screen for left bundle branch block. TH

Helena Summers is a radiology resident and Erik Summers is a hospitalist at the Mayo Clinic College of Medicine, Rochester, Minn.

References

• Swanson KL, Prakash UB, Stanson AW. Pulmonary arteriovenous fistulas: Mayo Clinic experience, 1982-1997. Mayo Clin Proc. 1999 Jul;74(7):671-680.
• Cottin V, Plauchu H, Bayle JY, et al. Pulmonary arteriovenous malformations in patients with hereditary hemorrhagic telangiectasia. Am J Respir Crit Care Med. 2004 May 1;169(9):994-1000. Epub 2004 Jan 23.

Brief history: A 32-year-old female presents with dysphagia, dizziness, and dysarthria.

Salient findings: Chest X-ray demonstrates many embolization coils within both lungs. Photographs demonstrate superficial telangiectasias of the tongue and distal phalanx. These findings indicate the patient’s diagnosis: hereditary hemorrhagic telangiectasia (HHT), previously known as Osler-Weber-Rendu syndrome.

Patient population/natural history of disease: HHT is an autosomal dominant trait, so family members should be counseled on the implications of having a relative with the disease. HHT patients have abnormal vessels prone to bleeding and often develop arteriovenous malformations (AVMs). Diagnosis is made with 75% of the following symptoms:

• Epistaxis;
• Mucocutaneous telangiectasias;
• GI, pulmonary, or hepatic AVMs; and/or
• A first-degree relative with HHT.

Patients often present with dyspnea and hemoptysis. With pulmonary AVMs, the oxygenation and filtration functions of the lungs are bypassed, placing the patient at risk for hypoxia, polycythemia, paradoxical strokes, and brain abscesses.

Management: AVMs can be diagnosed and treated with angiography and embolization. In this patient the coils had been placed elsewhere. The use of coils larger than 3 mm in AVMs should be treated because they are associated with significantly increased morbidity and mortality. Steel coils are covered with thrombogenic fibers that induce clotting and sealing of the AVM; blood is no longer shunted through the right-to-left shunt. Unfortunately, a long-term complication of pulmonary AVMs treated by embolization therapy is the development of new pulmonary AVMs.

The patient in this case had many metallic coils visible on chest X-ray and because she had required multiple pulmonary angiograms and embolizations over the years.

It’s important to administer an ECG to all HHT patients prior to treatment; those with a left bundle branch block must have pacing mechanisms in place or at hand because catheter placement and manipulation within the right heart can induce right heart blockage. Take care to avoid air emboli in all lines due to right-to-left shunting in these patients.

Take-Home Points:

• Untreated pulmonary AVMs are associated with paradoxical strokes, brain abscesses, and hypoxia;
• HHT is associated with pulmonary AVMs;
• Coil embolization of pulmonary AVMs has been shown to improve dyspnea and oxygen saturation while decreasing right-to-left shunt fraction in HHT patients.
• Complications of embolization therapy may include development of new pulmonary AVMs; and
• All patients should undergo ECG prior to pulmonary angiography to screen for left bundle branch block. TH

Helena Summers is a radiology resident and Erik Summers is a hospitalist at the Mayo Clinic College of Medicine, Rochester, Minn.

References

• Swanson KL, Prakash UB, Stanson AW. Pulmonary arteriovenous fistulas: Mayo Clinic experience, 1982-1997. Mayo Clin Proc. 1999 Jul;74(7):671-680.
• Cottin V, Plauchu H, Bayle JY, et al. Pulmonary arteriovenous malformations in patients with hereditary hemorrhagic telangiectasia. Am J Respir Crit Care Med. 2004 May 1;169(9):994-1000. Epub 2004 Jan 23.

Brief history: A 32-year-old female presents with dysphagia, dizziness, and dysarthria.

Salient findings: Chest X-ray demonstrates many embolization coils within both lungs. Photographs demonstrate superficial telangiectasias of the tongue and distal phalanx. These findings indicate the patient’s diagnosis: hereditary hemorrhagic telangiectasia (HHT), previously known as Osler-Weber-Rendu syndrome.

Patient population/natural history of disease: HHT is an autosomal dominant trait, so family members should be counseled on the implications of having a relative with the disease. HHT patients have abnormal vessels prone to bleeding and often develop arteriovenous malformations (AVMs). Diagnosis is made with 75% of the following symptoms:

• Epistaxis;
• Mucocutaneous telangiectasias;
• GI, pulmonary, or hepatic AVMs; and/or
• A first-degree relative with HHT.

Patients often present with dyspnea and hemoptysis. With pulmonary AVMs, the oxygenation and filtration functions of the lungs are bypassed, placing the patient at risk for hypoxia, polycythemia, paradoxical strokes, and brain abscesses.

Management: AVMs can be diagnosed and treated with angiography and embolization. In this patient the coils had been placed elsewhere. The use of coils larger than 3 mm in AVMs should be treated because they are associated with significantly increased morbidity and mortality. Steel coils are covered with thrombogenic fibers that induce clotting and sealing of the AVM; blood is no longer shunted through the right-to-left shunt. Unfortunately, a long-term complication of pulmonary AVMs treated by embolization therapy is the development of new pulmonary AVMs.

The patient in this case had many metallic coils visible on chest X-ray and because she had required multiple pulmonary angiograms and embolizations over the years.

It’s important to administer an ECG to all HHT patients prior to treatment; those with a left bundle branch block must have pacing mechanisms in place or at hand because catheter placement and manipulation within the right heart can induce right heart blockage. Take care to avoid air emboli in all lines due to right-to-left shunting in these patients.

Take-Home Points:

• Untreated pulmonary AVMs are associated with paradoxical strokes, brain abscesses, and hypoxia;
• HHT is associated with pulmonary AVMs;
• Coil embolization of pulmonary AVMs has been shown to improve dyspnea and oxygen saturation while decreasing right-to-left shunt fraction in HHT patients.
• Complications of embolization therapy may include development of new pulmonary AVMs; and
• All patients should undergo ECG prior to pulmonary angiography to screen for left bundle branch block. TH

Helena Summers is a radiology resident and Erik Summers is a hospitalist at the Mayo Clinic College of Medicine, Rochester, Minn.

References

• Swanson KL, Prakash UB, Stanson AW. Pulmonary arteriovenous fistulas: Mayo Clinic experience, 1982-1997. Mayo Clin Proc. 1999 Jul;74(7):671-680.
• Cottin V, Plauchu H, Bayle JY, et al. Pulmonary arteriovenous malformations in patients with hereditary hemorrhagic telangiectasia. Am J Respir Crit Care Med. 2004 May 1;169(9):994-1000. Epub 2004 Jan 23.

This is the second in a two-part series on providing constructive criticism to your hospitalist peers. Part 1 appeared in the March issue on p. 12.

Have concerns about a colleague’s work performance? Then you have two main options: You can bring it up in a formal peer review (if it’s a clinical issue) or you can approach the individual yourself.

“Medicine is an art and a science. Many problems relate to the art side—communications and relationships, primarily,” says Richard Rohr, MD, director, Hospitalist Service, Milford Hospital, Conn. “You may need to talk to a colleague about how they approach family members or how they communicate with patients. In this instance, you’d offer more of a coaching comment.”

While you may hesitate to point out another hospitalist’s problem areas, keep in mind that it is constructive criticism.

“Physicians love to run things past colleagues,” says Kenneth G. Simone, DO, founder and president of Hospitalist and Practice Solutions, Veazie, Maine, and a consultant to hospital medicine groups. “Informal feedback can provide an unbiased and objective perspective, as opposed to [a formal peer review].”

When to Offer Constructive Criticism

In some practices, or for some individuals, sharing constructive criticism with peers is part of the job. “Informal peer discussions should take place every day,” advises Dr. Rohr. “While handoffs pose a risk for losing vital information, they are also an opportunity to consider alternatives for diagnosis and treatment that may benefit patients greatly.”

If this seems like a natural thing to do within your hospital medicine group, follow Dr. Rohr’s advice: “These discussions should be frank but nonjudgmental. If someone has a problem discussing cases in this manner, then the group leader needs to get involved. If a life-threatening error is exposed, then the formal peer review system needs to be activated.”

Providing Peer Feedback

When there is no personal conflict, you may still consider offering constructive criticism if you feel it’s warranted. “I think [peer feedback] is extremely important—if it’s done correctly,” says Dr. Simone. “It provides a safe haven for discussion and can contribute to professional growth.”

According to Dr. Simone, appropriate topics to discuss regarding a colleague’s performance include logistical problems within the practice, such as a doctor who is chronically late for morning rounds; continuity issues, such as a physician who fails to provide detailed information when handing off patients; communication breakdowns, such as forgetting to check out the labs pending on a newly admitted unit-patient with chest pain; behavioral issues, such as a physician who’s verbally abusive to the nurses or disruptive at morning rounds; problems with work ethic, responsiveness, or availability, such as the doctor who never responds to his/her beeper (necessitating a call from nursing to an accommodating provider who’s always willing and available to help); and general team play.

If you believe you need to address one of these topics regarding a colleague’s performance, plan the logistics of the discussion. “This is a conversation best held one on one—in private,” stresses Dr. Simone. “Don’t discuss these issues in front of colleagues, nurses, patients, families … and don’t do it at the end of a long, difficult day.

“Ideally, do it after hours and out of the workplace, though that can be difficult. Remove the person from the hospital floor or the office, and the emotions and adrenaline associated with work,” continues Dr. Simone. “If the environment is stressful, it will raise their defenses, making them more likely to be resistant and argumentative.”

Talking Points

When you offer constructive criticism, approach the topic carefully. “Take a non-confrontational approach,” says Dr. Simone. “Don’t raise your voice, and don’t take the discussion to a personal level. Use objective data as much as possible. Avoid saying ‘I feel that you’re …’ and instead use ‘Coming in 15 minutes late throws everyone’s schedule off.’ ”

Keep the conversation as casual and as light as possible. “This is not a peer review meeting,” Dr. Simone stresses. “Use a soft approach, and you might have greater success. Stay away from power words such as ‘you shouldn’t’ or ‘don’t.’ ”

Some phrases you might use include:

• “I find it helpful if I … ”
• “This has worked for me.”
• “Have you considered … ?”

Even if you use careful wording, don’t be surprised if the other hospitalist doesn’t react well—at least initially. “Unless you’re seasoned at doing this, the individual may get defensive,” warns Dr. Simone. “If you’re consistent throughout the conversation, show support, and are astute enough to break down their defenses, you should be effective.”

Also, keep your cool: “Don’t respond to defensiveness in like [manner],” says Dr. Simone. Throughout the conversation, show your support. “Convey that your intent is to help the individual—not harm them. Ask if you can be of help, and offer to be a resource” to help them improve.

Also remember that your colleague is part of the conversation. “Allow responses,” adds Dr. Simone. “Give them a chance to express themselves.”

End the conversation with an offer to follow up or suggest a next step. “Offer your personal help or suggest a resource such as the employee assistance program,” advises Dr. Simone. “You can check in with them from time to time, but if you have an unwilling party this may be construed as meddlesome. You must consider the personality involved and if you think they’d be amenable to continued conversations.”

Even without a formal follow-up, be sure to voice your approval if you see their negative behavior change. “If you take the time to provide criticism, you should also offer positive feedback if warranted,” says Dr. Simone. “Tell them they’re doing a great job.”

One final piece of advice regarding informal peer feedback: “Avoid writing anything down,” says Dr. Simone. “This may make it discoverable in a court of law, and it’s not your place to put the discussion in writing. If the issue is that serious, take it to the powers that be.” TH

Jane Jerrard has written for The Hospitalist since 2005.

This is the second in a two-part series on providing constructive criticism to your hospitalist peers. Part 1 appeared in the March issue on p. 12.

Have concerns about a colleague’s work performance? Then you have two main options: You can bring it up in a formal peer review (if it’s a clinical issue) or you can approach the individual yourself.

“Medicine is an art and a science. Many problems relate to the art side—communications and relationships, primarily,” says Richard Rohr, MD, director, Hospitalist Service, Milford Hospital, Conn. “You may need to talk to a colleague about how they approach family members or how they communicate with patients. In this instance, you’d offer more of a coaching comment.”

While you may hesitate to point out another hospitalist’s problem areas, keep in mind that it is constructive criticism.

“Physicians love to run things past colleagues,” says Kenneth G. Simone, DO, founder and president of Hospitalist and Practice Solutions, Veazie, Maine, and a consultant to hospital medicine groups. “Informal feedback can provide an unbiased and objective perspective, as opposed to [a formal peer review].”

When to Offer Constructive Criticism

In some practices, or for some individuals, sharing constructive criticism with peers is part of the job. “Informal peer discussions should take place every day,” advises Dr. Rohr. “While handoffs pose a risk for losing vital information, they are also an opportunity to consider alternatives for diagnosis and treatment that may benefit patients greatly.”

If this seems like a natural thing to do within your hospital medicine group, follow Dr. Rohr’s advice: “These discussions should be frank but nonjudgmental. If someone has a problem discussing cases in this manner, then the group leader needs to get involved. If a life-threatening error is exposed, then the formal peer review system needs to be activated.”

Providing Peer Feedback

When there is no personal conflict, you may still consider offering constructive criticism if you feel it’s warranted. “I think [peer feedback] is extremely important—if it’s done correctly,” says Dr. Simone. “It provides a safe haven for discussion and can contribute to professional growth.”

According to Dr. Simone, appropriate topics to discuss regarding a colleague’s performance include logistical problems within the practice, such as a doctor who is chronically late for morning rounds; continuity issues, such as a physician who fails to provide detailed information when handing off patients; communication breakdowns, such as forgetting to check out the labs pending on a newly admitted unit-patient with chest pain; behavioral issues, such as a physician who’s verbally abusive to the nurses or disruptive at morning rounds; problems with work ethic, responsiveness, or availability, such as the doctor who never responds to his/her beeper (necessitating a call from nursing to an accommodating provider who’s always willing and available to help); and general team play.

If you believe you need to address one of these topics regarding a colleague’s performance, plan the logistics of the discussion. “This is a conversation best held one on one—in private,” stresses Dr. Simone. “Don’t discuss these issues in front of colleagues, nurses, patients, families … and don’t do it at the end of a long, difficult day.

“Ideally, do it after hours and out of the workplace, though that can be difficult. Remove the person from the hospital floor or the office, and the emotions and adrenaline associated with work,” continues Dr. Simone. “If the environment is stressful, it will raise their defenses, making them more likely to be resistant and argumentative.”

Talking Points

When you offer constructive criticism, approach the topic carefully. “Take a non-confrontational approach,” says Dr. Simone. “Don’t raise your voice, and don’t take the discussion to a personal level. Use objective data as much as possible. Avoid saying ‘I feel that you’re …’ and instead use ‘Coming in 15 minutes late throws everyone’s schedule off.’ ”

Keep the conversation as casual and as light as possible. “This is not a peer review meeting,” Dr. Simone stresses. “Use a soft approach, and you might have greater success. Stay away from power words such as ‘you shouldn’t’ or ‘don’t.’ ”

Some phrases you might use include:

• “I find it helpful if I … ”
• “This has worked for me.”
• “Have you considered … ?”

Even if you use careful wording, don’t be surprised if the other hospitalist doesn’t react well—at least initially. “Unless you’re seasoned at doing this, the individual may get defensive,” warns Dr. Simone. “If you’re consistent throughout the conversation, show support, and are astute enough to break down their defenses, you should be effective.”

Also, keep your cool: “Don’t respond to defensiveness in like [manner],” says Dr. Simone. Throughout the conversation, show your support. “Convey that your intent is to help the individual—not harm them. Ask if you can be of help, and offer to be a resource” to help them improve.

Also remember that your colleague is part of the conversation. “Allow responses,” adds Dr. Simone. “Give them a chance to express themselves.”

End the conversation with an offer to follow up or suggest a next step. “Offer your personal help or suggest a resource such as the employee assistance program,” advises Dr. Simone. “You can check in with them from time to time, but if you have an unwilling party this may be construed as meddlesome. You must consider the personality involved and if you think they’d be amenable to continued conversations.”

Even without a formal follow-up, be sure to voice your approval if you see their negative behavior change. “If you take the time to provide criticism, you should also offer positive feedback if warranted,” says Dr. Simone. “Tell them they’re doing a great job.”

One final piece of advice regarding informal peer feedback: “Avoid writing anything down,” says Dr. Simone. “This may make it discoverable in a court of law, and it’s not your place to put the discussion in writing. If the issue is that serious, take it to the powers that be.” TH

Jane Jerrard has written for The Hospitalist since 2005.

This is the second in a two-part series on providing constructive criticism to your hospitalist peers. Part 1 appeared in the March issue on p. 12.

Have concerns about a colleague’s work performance? Then you have two main options: You can bring it up in a formal peer review (if it’s a clinical issue) or you can approach the individual yourself.

“Medicine is an art and a science. Many problems relate to the art side—communications and relationships, primarily,” says Richard Rohr, MD, director, Hospitalist Service, Milford Hospital, Conn. “You may need to talk to a colleague about how they approach family members or how they communicate with patients. In this instance, you’d offer more of a coaching comment.”

While you may hesitate to point out another hospitalist’s problem areas, keep in mind that it is constructive criticism.

“Physicians love to run things past colleagues,” says Kenneth G. Simone, DO, founder and president of Hospitalist and Practice Solutions, Veazie, Maine, and a consultant to hospital medicine groups. “Informal feedback can provide an unbiased and objective perspective, as opposed to [a formal peer review].”

When to Offer Constructive Criticism

In some practices, or for some individuals, sharing constructive criticism with peers is part of the job. “Informal peer discussions should take place every day,” advises Dr. Rohr. “While handoffs pose a risk for losing vital information, they are also an opportunity to consider alternatives for diagnosis and treatment that may benefit patients greatly.”

If this seems like a natural thing to do within your hospital medicine group, follow Dr. Rohr’s advice: “These discussions should be frank but nonjudgmental. If someone has a problem discussing cases in this manner, then the group leader needs to get involved. If a life-threatening error is exposed, then the formal peer review system needs to be activated.”

Providing Peer Feedback

When there is no personal conflict, you may still consider offering constructive criticism if you feel it’s warranted. “I think [peer feedback] is extremely important—if it’s done correctly,” says Dr. Simone. “It provides a safe haven for discussion and can contribute to professional growth.”

According to Dr. Simone, appropriate topics to discuss regarding a colleague’s performance include logistical problems within the practice, such as a doctor who is chronically late for morning rounds; continuity issues, such as a physician who fails to provide detailed information when handing off patients; communication breakdowns, such as forgetting to check out the labs pending on a newly admitted unit-patient with chest pain; behavioral issues, such as a physician who’s verbally abusive to the nurses or disruptive at morning rounds; problems with work ethic, responsiveness, or availability, such as the doctor who never responds to his/her beeper (necessitating a call from nursing to an accommodating provider who’s always willing and available to help); and general team play.

If you believe you need to address one of these topics regarding a colleague’s performance, plan the logistics of the discussion. “This is a conversation best held one on one—in private,” stresses Dr. Simone. “Don’t discuss these issues in front of colleagues, nurses, patients, families … and don’t do it at the end of a long, difficult day.

“Ideally, do it after hours and out of the workplace, though that can be difficult. Remove the person from the hospital floor or the office, and the emotions and adrenaline associated with work,” continues Dr. Simone. “If the environment is stressful, it will raise their defenses, making them more likely to be resistant and argumentative.”

Talking Points

When you offer constructive criticism, approach the topic carefully. “Take a non-confrontational approach,” says Dr. Simone. “Don’t raise your voice, and don’t take the discussion to a personal level. Use objective data as much as possible. Avoid saying ‘I feel that you’re …’ and instead use ‘Coming in 15 minutes late throws everyone’s schedule off.’ ”

Keep the conversation as casual and as light as possible. “This is not a peer review meeting,” Dr. Simone stresses. “Use a soft approach, and you might have greater success. Stay away from power words such as ‘you shouldn’t’ or ‘don’t.’ ”

Some phrases you might use include:

• “I find it helpful if I … ”
• “This has worked for me.”
• “Have you considered … ?”

Even if you use careful wording, don’t be surprised if the other hospitalist doesn’t react well—at least initially. “Unless you’re seasoned at doing this, the individual may get defensive,” warns Dr. Simone. “If you’re consistent throughout the conversation, show support, and are astute enough to break down their defenses, you should be effective.”

Also, keep your cool: “Don’t respond to defensiveness in like [manner],” says Dr. Simone. Throughout the conversation, show your support. “Convey that your intent is to help the individual—not harm them. Ask if you can be of help, and offer to be a resource” to help them improve.

Also remember that your colleague is part of the conversation. “Allow responses,” adds Dr. Simone. “Give them a chance to express themselves.”

End the conversation with an offer to follow up or suggest a next step. “Offer your personal help or suggest a resource such as the employee assistance program,” advises Dr. Simone. “You can check in with them from time to time, but if you have an unwilling party this may be construed as meddlesome. You must consider the personality involved and if you think they’d be amenable to continued conversations.”

Even without a formal follow-up, be sure to voice your approval if you see their negative behavior change. “If you take the time to provide criticism, you should also offer positive feedback if warranted,” says Dr. Simone. “Tell them they’re doing a great job.”

One final piece of advice regarding informal peer feedback: “Avoid writing anything down,” says Dr. Simone. “This may make it discoverable in a court of law, and it’s not your place to put the discussion in writing. If the issue is that serious, take it to the powers that be.” TH

Jane Jerrard has written for The Hospitalist since 2005.

This year, interested physicians will participate in Medicare’s first ever pay-for-performance program. Legislation passed in late 2006 calls for a voluntary Medicare quality reporting program that financially rewards physicians reporting on specific quality measures. Those physicians may receive a bonus of 1.5% of their total Medicare payments during the reporting period. This adds a pay-for-performance component to the current Physician Voluntary Reporting Program (PVRP) that the Centers for Medicare and Medicaid Services (CMS) established in January 2006.

“Medicare is really serious about improving quality of care for beneficiaries, and they’re committed to pay for performance as the way to go about it,” says Patrick Torcson, MD, MMM, FACP, medical director, Hospital Medicine, St. Tammany Parish Hospital, Covington, La.

Performance Measures in the Works

The pay-for-performance quality reporting program will use the 66 unique clinical measures CMS announced in December 2006, with additional modifications to be made through April 2007 using a consensus process.

“From looking at the proposed list of 66 performance measures, we’ve identified seven that are going to be available to hospitalists to report,” says Dr. Torcson. “The seven involve stroke and [myocardial infarction] care.”

Most of the internal medicine-related measures of the 16 included in the original PVRP were designed for an outpatient, office-based practice, and that seems true of the expanded list as well.

The current 66 measures are slightly more relevant to the hospital setting and can potentially be reported by hospitalists, as Dr. Torcson specified. Specifically, quality measures have been added for giving beta-blockers upon admission (quality measure #29) and for stroke and stroke rehabilitation (quality measures #31-#36).

Other measures are expected to be added before the July implementation date, and some may be reportable by hospitalists. These include creation of an advance care plan (#47) and measures for emergency medicine services (#54-#59).

“Medicare plans to have specific performance measures for each of the 39 specialties that they recognize,” explains Dr. Torcson. “Hospital medicine is not yet a CMS-recognized specialty; we’re typically lumped under general internal medicine.”

You can view all the measures at www.cms.hhs.gov/PVRP/01_overview.asp.

How the Program Will Work

The initial reporting period set by the legislation is July 1 through December 31, 2007, and there will be an enrollment period before that for physicians who wish to participate. When a physician enrolls in the program, she will identify which measures apply to her. At that point, CMS will determine if a measure applies.

If less than three quality measures apply for a physician, then 80% reporting on those applicable measures is required to be eligible for the bonus. If four or more measures apply, the physician must report on at least three in order to be eligible.

Bonuses for voluntary reporting would be in a lump sum and won’t be paid until the first quarter of 2008. The method of payment may be subject to certain limits—and it may not offset the physicians’ administrative costs for reporting. Hospital medicine programs will have to consider whether the costs of reporting are worth the bonus.

SHM Involvement

SHM’s Public Policy Committee (PPC) and its Performance and Standards Task Force (PSTF) have been actively involved in getting measures included on the PRVP list that are applicable to hospitalists.

“SHM is a member of the AMA’s Physician Consortium for Performance Improvement (PCPI) and has representatives on work groups that have developed performance measures and will be revising and maintaining measures over time,” says Dr. Torcson. “We hope to eventually include measures that are specific to hospitalized patients.”

In addition to the PCPI, SHM is represented and has influence in the National Quality Forum and the Ambulatory Care Quality Alliance.

“SHM leadership—CEO Larry Wellikson, Eric Siegal, Public Policy chair, and Lakshmi Halasyamani, chair of the Hospital Quality and Patient Safety (HQPS) Committee—have been proactive in positioning SHM to be very involved in the national quality improvement agenda,” says Dr. Torcson. “It’s really a work in progress, but SHM is part of the work groups that are driving this process.”

The Effect on Hospitalists

As they can with the original PVRP, hospitalists can find a few applicable performance measures to report on, so they are eligible to participate—and SHM encourages them to do so.

“The amount of money will be small and the number of [applicable] measures will be limited and not truly representative of a hospitalist’s practice,” says Dr. Torcson, “but performance reporting should be something that every physician, including hospitalists, has as a skill set as their practice moves into the future.”

Moving Ahead

Details on the new program still need to be clarified by CMS in the first half of 2007. Regardless of the details still to be determined for this first major foray into Medicare pay for performance, one thing is clear: CMS is dedicated to the idea of tying financial reward to quality care. And they aren’t the only ones.

“Medicare is not as far along as private insurers,” says Dr. Torcson. “Commercial insurers are much more aggressive about pursuing physician-level performance and efficiency—I think we’ll see more impactful pay-for-performance plans from them first. However, the CMS model will affect 70 million patients, and commercial insurers have tended to use the CMS model for physician reimbursement.”

Dr. Torcson believes this program is simply a first step on that road. “We’re in the infancy of pay-for-performance models for physician reimbursement,” he says. “I think the ultimate model for physician-level value-based purchasing is going to look a lot different than the proposed CMS payment for reporting and payment for performance.”

In the immediate future, the PPC and PSTF will continue to participate in formulating the final quality measures for the CMS voluntary reporting program. Watch the SHM Web site for updates on the status of the program. TH

Jane Jerrard writes “Public Policy” for The Hospitalist.

This year, interested physicians will participate in Medicare’s first ever pay-for-performance program. Legislation passed in late 2006 calls for a voluntary Medicare quality reporting program that financially rewards physicians reporting on specific quality measures. Those physicians may receive a bonus of 1.5% of their total Medicare payments during the reporting period. This adds a pay-for-performance component to the current Physician Voluntary Reporting Program (PVRP) that the Centers for Medicare and Medicaid Services (CMS) established in January 2006.

“Medicare is really serious about improving quality of care for beneficiaries, and they’re committed to pay for performance as the way to go about it,” says Patrick Torcson, MD, MMM, FACP, medical director, Hospital Medicine, St. Tammany Parish Hospital, Covington, La.

Performance Measures in the Works

The pay-for-performance quality reporting program will use the 66 unique clinical measures CMS announced in December 2006, with additional modifications to be made through April 2007 using a consensus process.

“From looking at the proposed list of 66 performance measures, we’ve identified seven that are going to be available to hospitalists to report,” says Dr. Torcson. “The seven involve stroke and [myocardial infarction] care.”

Most of the internal medicine-related measures of the 16 included in the original PVRP were designed for an outpatient, office-based practice, and that seems true of the expanded list as well.

The current 66 measures are slightly more relevant to the hospital setting and can potentially be reported by hospitalists, as Dr. Torcson specified. Specifically, quality measures have been added for giving beta-blockers upon admission (quality measure #29) and for stroke and stroke rehabilitation (quality measures #31-#36).

Other measures are expected to be added before the July implementation date, and some may be reportable by hospitalists. These include creation of an advance care plan (#47) and measures for emergency medicine services (#54-#59).

“Medicare plans to have specific performance measures for each of the 39 specialties that they recognize,” explains Dr. Torcson. “Hospital medicine is not yet a CMS-recognized specialty; we’re typically lumped under general internal medicine.”

You can view all the measures at www.cms.hhs.gov/PVRP/01_overview.asp.

How the Program Will Work

The initial reporting period set by the legislation is July 1 through December 31, 2007, and there will be an enrollment period before that for physicians who wish to participate. When a physician enrolls in the program, she will identify which measures apply to her. At that point, CMS will determine if a measure applies.

If less than three quality measures apply for a physician, then 80% reporting on those applicable measures is required to be eligible for the bonus. If four or more measures apply, the physician must report on at least three in order to be eligible.

Bonuses for voluntary reporting would be in a lump sum and won’t be paid until the first quarter of 2008. The method of payment may be subject to certain limits—and it may not offset the physicians’ administrative costs for reporting. Hospital medicine programs will have to consider whether the costs of reporting are worth the bonus.

SHM Involvement

SHM’s Public Policy Committee (PPC) and its Performance and Standards Task Force (PSTF) have been actively involved in getting measures included on the PRVP list that are applicable to hospitalists.

“SHM is a member of the AMA’s Physician Consortium for Performance Improvement (PCPI) and has representatives on work groups that have developed performance measures and will be revising and maintaining measures over time,” says Dr. Torcson. “We hope to eventually include measures that are specific to hospitalized patients.”

In addition to the PCPI, SHM is represented and has influence in the National Quality Forum and the Ambulatory Care Quality Alliance.

“SHM leadership—CEO Larry Wellikson, Eric Siegal, Public Policy chair, and Lakshmi Halasyamani, chair of the Hospital Quality and Patient Safety (HQPS) Committee—have been proactive in positioning SHM to be very involved in the national quality improvement agenda,” says Dr. Torcson. “It’s really a work in progress, but SHM is part of the work groups that are driving this process.”

The Effect on Hospitalists

As they can with the original PVRP, hospitalists can find a few applicable performance measures to report on, so they are eligible to participate—and SHM encourages them to do so.

“The amount of money will be small and the number of [applicable] measures will be limited and not truly representative of a hospitalist’s practice,” says Dr. Torcson, “but performance reporting should be something that every physician, including hospitalists, has as a skill set as their practice moves into the future.”

Moving Ahead

Details on the new program still need to be clarified by CMS in the first half of 2007. Regardless of the details still to be determined for this first major foray into Medicare pay for performance, one thing is clear: CMS is dedicated to the idea of tying financial reward to quality care. And they aren’t the only ones.

“Medicare is not as far along as private insurers,” says Dr. Torcson. “Commercial insurers are much more aggressive about pursuing physician-level performance and efficiency—I think we’ll see more impactful pay-for-performance plans from them first. However, the CMS model will affect 70 million patients, and commercial insurers have tended to use the CMS model for physician reimbursement.”

Dr. Torcson believes this program is simply a first step on that road. “We’re in the infancy of pay-for-performance models for physician reimbursement,” he says. “I think the ultimate model for physician-level value-based purchasing is going to look a lot different than the proposed CMS payment for reporting and payment for performance.”

In the immediate future, the PPC and PSTF will continue to participate in formulating the final quality measures for the CMS voluntary reporting program. Watch the SHM Web site for updates on the status of the program. TH

Jane Jerrard writes “Public Policy” for The Hospitalist.

This year, interested physicians will participate in Medicare’s first ever pay-for-performance program. Legislation passed in late 2006 calls for a voluntary Medicare quality reporting program that financially rewards physicians reporting on specific quality measures. Those physicians may receive a bonus of 1.5% of their total Medicare payments during the reporting period. This adds a pay-for-performance component to the current Physician Voluntary Reporting Program (PVRP) that the Centers for Medicare and Medicaid Services (CMS) established in January 2006.

“Medicare is really serious about improving quality of care for beneficiaries, and they’re committed to pay for performance as the way to go about it,” says Patrick Torcson, MD, MMM, FACP, medical director, Hospital Medicine, St. Tammany Parish Hospital, Covington, La.

Performance Measures in the Works

The pay-for-performance quality reporting program will use the 66 unique clinical measures CMS announced in December 2006, with additional modifications to be made through April 2007 using a consensus process.

“From looking at the proposed list of 66 performance measures, we’ve identified seven that are going to be available to hospitalists to report,” says Dr. Torcson. “The seven involve stroke and [myocardial infarction] care.”

Most of the internal medicine-related measures of the 16 included in the original PVRP were designed for an outpatient, office-based practice, and that seems true of the expanded list as well.

The current 66 measures are slightly more relevant to the hospital setting and can potentially be reported by hospitalists, as Dr. Torcson specified. Specifically, quality measures have been added for giving beta-blockers upon admission (quality measure #29) and for stroke and stroke rehabilitation (quality measures #31-#36).

Other measures are expected to be added before the July implementation date, and some may be reportable by hospitalists. These include creation of an advance care plan (#47) and measures for emergency medicine services (#54-#59).

“Medicare plans to have specific performance measures for each of the 39 specialties that they recognize,” explains Dr. Torcson. “Hospital medicine is not yet a CMS-recognized specialty; we’re typically lumped under general internal medicine.”

You can view all the measures at www.cms.hhs.gov/PVRP/01_overview.asp.

How the Program Will Work

The initial reporting period set by the legislation is July 1 through December 31, 2007, and there will be an enrollment period before that for physicians who wish to participate. When a physician enrolls in the program, she will identify which measures apply to her. At that point, CMS will determine if a measure applies.

If less than three quality measures apply for a physician, then 80% reporting on those applicable measures is required to be eligible for the bonus. If four or more measures apply, the physician must report on at least three in order to be eligible.

Bonuses for voluntary reporting would be in a lump sum and won’t be paid until the first quarter of 2008. The method of payment may be subject to certain limits—and it may not offset the physicians’ administrative costs for reporting. Hospital medicine programs will have to consider whether the costs of reporting are worth the bonus.

SHM Involvement

SHM’s Public Policy Committee (PPC) and its Performance and Standards Task Force (PSTF) have been actively involved in getting measures included on the PRVP list that are applicable to hospitalists.

“SHM is a member of the AMA’s Physician Consortium for Performance Improvement (PCPI) and has representatives on work groups that have developed performance measures and will be revising and maintaining measures over time,” says Dr. Torcson. “We hope to eventually include measures that are specific to hospitalized patients.”

In addition to the PCPI, SHM is represented and has influence in the National Quality Forum and the Ambulatory Care Quality Alliance.

“SHM leadership—CEO Larry Wellikson, Eric Siegal, Public Policy chair, and Lakshmi Halasyamani, chair of the Hospital Quality and Patient Safety (HQPS) Committee—have been proactive in positioning SHM to be very involved in the national quality improvement agenda,” says Dr. Torcson. “It’s really a work in progress, but SHM is part of the work groups that are driving this process.”

The Effect on Hospitalists

As they can with the original PVRP, hospitalists can find a few applicable performance measures to report on, so they are eligible to participate—and SHM encourages them to do so.

“The amount of money will be small and the number of [applicable] measures will be limited and not truly representative of a hospitalist’s practice,” says Dr. Torcson, “but performance reporting should be something that every physician, including hospitalists, has as a skill set as their practice moves into the future.”

Moving Ahead

Details on the new program still need to be clarified by CMS in the first half of 2007. Regardless of the details still to be determined for this first major foray into Medicare pay for performance, one thing is clear: CMS is dedicated to the idea of tying financial reward to quality care. And they aren’t the only ones.

“Medicare is not as far along as private insurers,” says Dr. Torcson. “Commercial insurers are much more aggressive about pursuing physician-level performance and efficiency—I think we’ll see more impactful pay-for-performance plans from them first. However, the CMS model will affect 70 million patients, and commercial insurers have tended to use the CMS model for physician reimbursement.”

Dr. Torcson believes this program is simply a first step on that road. “We’re in the infancy of pay-for-performance models for physician reimbursement,” he says. “I think the ultimate model for physician-level value-based purchasing is going to look a lot different than the proposed CMS payment for reporting and payment for performance.”

In the immediate future, the PPC and PSTF will continue to participate in formulating the final quality measures for the CMS voluntary reporting program. Watch the SHM Web site for updates on the status of the program. TH

Jane Jerrard writes “Public Policy” for The Hospitalist.

A 36-year-old female with a recently treated sinus infection presents with an 18-hour history of severe right-sided headache and new-onset diplopia. Examination reveals the finding pictured below. Aside from tenderness on palpation over the frontal and maxillary sinuses, the remainder of her physical and neurologic exam is unremarkable. TH

What is the physical exam finding?

a) Anisocoria;

b) Facial nerve palsy;

c) Horner Syndrome;

d) Abducens palsy; or

e) Intranuclear ophthalmoplegia.

Discussion

The answer is D: Abducens palsy, or isolated right cranial nerve VI palsy. Extraocular muscle dysfunction results from insults to the muscle itself or from lesions of the motor nerve innervating the muscle. In this case, the lesion responsible is a cranial nerve VI palsy.

Cranial nerve VI innervates the lateral rectus muscle, which is responsible for eye abduction, or temporal gaze. Patients with dysfunction of the sixth cranial nerve complain of horizontal, binocular diplopia. Impaired abduction often indicates an ipsilateral cranial nerve VI lesion.

The sixth cranial nerve arises from the pons and courses through the subarachnoid space until it ascends the clivus and enters the cavernous sinus before exiting to the lateral rectus muscle. Palsies of the sixth cranial nerve may result from lesions anywhere along the anatomic course of the nerve. The most common cause of isolated sixth cranial nerve palsy in adults is ischemic injury—most often related to hypertension and/or diabetes. This is particularly true for older adults. In younger adults and children, it often occurs as a post-viral manifestation.

Isolated cranial nerve VI palsies occurring in adults over 50 require workup for ischemic vascular diseases or temporal arteritis. In patients younger than 50, MRI imaging is necessary to rule out intracranial processes. The majority of cranial nerve VI palsies that arise from ischemic or idiopathic causes will resolve spontaneously over a course of several months.

In this case, the cranial nerve VI palsy was caused by cavernous sinus thrombosis secondary to extension of a pre-existing sinus infection. Contents of the cavernous sinus include cranial nerves III, IV, and VI; the ophthalmic and maxillary divisions of cranial nerve V; and the internal carotid artery. Cavernous sinus thrombosis is usually the result of the extension of dental, sinus, or orbital infections, with the most common causative organism being Staphylococcus aureus, followed by anaerobes, Streptococcus species, and fungi.

Headache is the most common presenting symptom of cavernous sinus thrombosis, with later complaints including fever and cranial nerve involvement. Cavernous sinus thrombosis is a medical emergency requiring aggressive antimicrobial therapy and early surgical involvement. Patients with sinus infections may require urgent debridement of infected sinuses by ear, nose, and throat surgeons. The role of anticoagulation in cavernous sinus thrombosis is somewhat controversial, though it may be implemented to prevent clot propagation.

Although it is somewhat unusual for patients with cavernous sinus thrombosis to present with a mononeuropathy instead of multiple cranial nerve deficits, cavernous sinus thrombosis should be suspected in any patient complaining of a unilateral headache and horizontal diplopia, particularly in the setting of a sinus or dental infection. TH

A 36-year-old female with a recently treated sinus infection presents with an 18-hour history of severe right-sided headache and new-onset diplopia. Examination reveals the finding pictured below. Aside from tenderness on palpation over the frontal and maxillary sinuses, the remainder of her physical and neurologic exam is unremarkable. TH

What is the physical exam finding?

a) Anisocoria;

b) Facial nerve palsy;

c) Horner Syndrome;

d) Abducens palsy; or

e) Intranuclear ophthalmoplegia.

Discussion

The answer is D: Abducens palsy, or isolated right cranial nerve VI palsy. Extraocular muscle dysfunction results from insults to the muscle itself or from lesions of the motor nerve innervating the muscle. In this case, the lesion responsible is a cranial nerve VI palsy.

Cranial nerve VI innervates the lateral rectus muscle, which is responsible for eye abduction, or temporal gaze. Patients with dysfunction of the sixth cranial nerve complain of horizontal, binocular diplopia. Impaired abduction often indicates an ipsilateral cranial nerve VI lesion.

The sixth cranial nerve arises from the pons and courses through the subarachnoid space until it ascends the clivus and enters the cavernous sinus before exiting to the lateral rectus muscle. Palsies of the sixth cranial nerve may result from lesions anywhere along the anatomic course of the nerve. The most common cause of isolated sixth cranial nerve palsy in adults is ischemic injury—most often related to hypertension and/or diabetes. This is particularly true for older adults. In younger adults and children, it often occurs as a post-viral manifestation.

Isolated cranial nerve VI palsies occurring in adults over 50 require workup for ischemic vascular diseases or temporal arteritis. In patients younger than 50, MRI imaging is necessary to rule out intracranial processes. The majority of cranial nerve VI palsies that arise from ischemic or idiopathic causes will resolve spontaneously over a course of several months.

In this case, the cranial nerve VI palsy was caused by cavernous sinus thrombosis secondary to extension of a pre-existing sinus infection. Contents of the cavernous sinus include cranial nerves III, IV, and VI; the ophthalmic and maxillary divisions of cranial nerve V; and the internal carotid artery. Cavernous sinus thrombosis is usually the result of the extension of dental, sinus, or orbital infections, with the most common causative organism being Staphylococcus aureus, followed by anaerobes, Streptococcus species, and fungi.

Headache is the most common presenting symptom of cavernous sinus thrombosis, with later complaints including fever and cranial nerve involvement. Cavernous sinus thrombosis is a medical emergency requiring aggressive antimicrobial therapy and early surgical involvement. Patients with sinus infections may require urgent debridement of infected sinuses by ear, nose, and throat surgeons. The role of anticoagulation in cavernous sinus thrombosis is somewhat controversial, though it may be implemented to prevent clot propagation.

Although it is somewhat unusual for patients with cavernous sinus thrombosis to present with a mononeuropathy instead of multiple cranial nerve deficits, cavernous sinus thrombosis should be suspected in any patient complaining of a unilateral headache and horizontal diplopia, particularly in the setting of a sinus or dental infection. TH

A 36-year-old female with a recently treated sinus infection presents with an 18-hour history of severe right-sided headache and new-onset diplopia. Examination reveals the finding pictured below. Aside from tenderness on palpation over the frontal and maxillary sinuses, the remainder of her physical and neurologic exam is unremarkable. TH

What is the physical exam finding?

a) Anisocoria;

b) Facial nerve palsy;

c) Horner Syndrome;

d) Abducens palsy; or

e) Intranuclear ophthalmoplegia.

Discussion

The answer is D: Abducens palsy, or isolated right cranial nerve VI palsy. Extraocular muscle dysfunction results from insults to the muscle itself or from lesions of the motor nerve innervating the muscle. In this case, the lesion responsible is a cranial nerve VI palsy.

Cranial nerve VI innervates the lateral rectus muscle, which is responsible for eye abduction, or temporal gaze. Patients with dysfunction of the sixth cranial nerve complain of horizontal, binocular diplopia. Impaired abduction often indicates an ipsilateral cranial nerve VI lesion.

The sixth cranial nerve arises from the pons and courses through the subarachnoid space until it ascends the clivus and enters the cavernous sinus before exiting to the lateral rectus muscle. Palsies of the sixth cranial nerve may result from lesions anywhere along the anatomic course of the nerve. The most common cause of isolated sixth cranial nerve palsy in adults is ischemic injury—most often related to hypertension and/or diabetes. This is particularly true for older adults. In younger adults and children, it often occurs as a post-viral manifestation.

Isolated cranial nerve VI palsies occurring in adults over 50 require workup for ischemic vascular diseases or temporal arteritis. In patients younger than 50, MRI imaging is necessary to rule out intracranial processes. The majority of cranial nerve VI palsies that arise from ischemic or idiopathic causes will resolve spontaneously over a course of several months.

In this case, the cranial nerve VI palsy was caused by cavernous sinus thrombosis secondary to extension of a pre-existing sinus infection. Contents of the cavernous sinus include cranial nerves III, IV, and VI; the ophthalmic and maxillary divisions of cranial nerve V; and the internal carotid artery. Cavernous sinus thrombosis is usually the result of the extension of dental, sinus, or orbital infections, with the most common causative organism being Staphylococcus aureus, followed by anaerobes, Streptococcus species, and fungi.

Headache is the most common presenting symptom of cavernous sinus thrombosis, with later complaints including fever and cranial nerve involvement. Cavernous sinus thrombosis is a medical emergency requiring aggressive antimicrobial therapy and early surgical involvement. Patients with sinus infections may require urgent debridement of infected sinuses by ear, nose, and throat surgeons. The role of anticoagulation in cavernous sinus thrombosis is somewhat controversial, though it may be implemented to prevent clot propagation.

Although it is somewhat unusual for patients with cavernous sinus thrombosis to present with a mononeuropathy instead of multiple cranial nerve deficits, cavernous sinus thrombosis should be suspected in any patient complaining of a unilateral headache and horizontal diplopia, particularly in the setting of a sinus or dental infection. TH

The problem of hospital-acquired venous thromboembolism (VTE): Venous thromboembolic disease, ranging from asymptomatic deep vein thrombosis (DVT) to massive pulmonary embolism (PE), is a significant cause of morbidity and mortality in hospitalized patients. Almost all hospitalized patients are at risk for VTE, and the literature suggests that approximately half of all cases of VTE are hospital-acquired.1-4 PE is recognized as the cause of death for more than 100,000 hospitalized patients in the United States every year and is considered a contributing factor in the death of 100,000 more patients.1

Multiple clinical trials have provided irrefutable evidence that primary thromboprophylaxis reduces the incidence of DVT and PE.5 Unfortunately, numerous studies have also shown that the majority of hospitalized patients with risk factors for DVT do not receive appropriate prophylaxis.6-8

Hospitalists are ideally positioned to reduce the incidence of preventable VTE, both by using known best practices to improve care delivered to their own patients, and, more importantly, by leading hospital-wide QI efforts that improve care for all patients at their home institutions.

SHM is now accepting applications for the VTE Prevention Collaborative, a program that offers individualized assistance to hospitalists who wish to take the lead on this critical quality and patient safety issue. Participants can choose the option that best fits their needs: a full year of distance mentoring or a one-day evaluation and consultation visit to their site.

click for large version

The SHM Mentoring Program

The Mentoring Program is the perfect option for individuals who are interested in securing ongoing support for their planned or active VTE prevention projects. SHM mentors with VTE and QI experts who work with participants to tackle site-specific issues using proven QI techniques. Instruction is organized around the VTE QI Workbook, SHM’s step-by-step guide for developing a VTE prevention program. Mentoring occurs in eight telephone calls scheduled throughout the yearlong mentoring period. During the calls, mentors offer individualized assistance on any topics, tasks, and barriers that are encountered in the course of designing, implementing, and evaluating a VTE prevention project. As needed, participants can also interact with their mentors through e-mail and in ad hoc telephone calls. Participants receive assistance with:

• Securing institutional support for the project;
• Assembling and leading the project team;
• Developing project goals and aims;
• Mapping current processes for assessing VTE risk and bleeding risk;
• Evaluating current prophylaxis recommendations;
• Developing evidence-based risk assessment and prophylaxis recommendations;
• Redesigning care delivery processes to include high-reliability features that promote adherence to best practices;
• Developing educational/outreach plans to ensure buy-in from key stakeholders; and
• Collecting, analyzing, and reporting outcome data.

Individuals with relatively little QI leadership experience, as well as those whose VTE prevention projects are in the early planning stages, are encouraged to apply for the SHM Mentoring Program.

The SHM On-site Consultation Program

The On-site Consultation Program is the perfect option for individuals who are interested in securing expert evaluation and input on a VTE prevention program but don’t feel they need ongoing, longitudinal support. Through the SHM On-site Consultation Program, SHM consultants with VTE and QI expertise visit applicants’ hospitals to evaluate active or planned VTE prevention programs. The visits will be especially helpful to participants who have existing VTE prevention programs they wish to expand or improve upon.

The consultation visits feature a structured evaluation of the site’s strengths and resources, any potential barriers to improvement, and the design and functioning of active or proposed VTE prevention interventions. Specific consultation visit activities will vary according to participant goals and needs but may include meeting with the local project team, QI leaders, hospital administrators, and hospital medicine group leaders, as well as reviewing project documents—order sets, policies, and procedures—data, and data collection/management tools.

Following the visits, SHM consultants provide participants with a written report of findings and recommendations. Participants also receive one follow-up telephone consultation, which will occur 60-90 days after the visit.

SHM On-site Consultation Program visits will be available starting in May 2007, though interested parties are encouraged to apply early; enrollment is limited, and available slots are expected to fill quickly.

Which Option Is Right for You?

SHM welcomes participation from hospitalists who work in all types of facilities (large and small community hospitals, academic medical centers, public hospitals, and others) and all types of practice settings, including acute care hospitals, skilled nursing facilities, and rehabilitation hospitals. Both VTE Prevention Collaborative programs are appropriate for individuals with all levels of QI experience, from the novice embarking on his or her first QI project to the seasoned QI leader. Individuals who have not yet begun working on a VTE prevention project are encouraged to apply, as are those who wish to expand or improve upon an existing project.

There are no rigid prerequisites for either program, though we expect individuals whose local VTE prevention efforts are already partially developed to derive more benefit from the On-site Consultation option than would an applicant who has yet to start his or her project. Individuals who have not yet begun working on a VTE prevention project are encouraged to apply for the Mentoring Program, which will ensure access to expert assistance during key development and implementation tasks.

How to Apply

Participation in both the Mentoring and On-site Consultation programs is open to hospitalists who are leading proposed or active VTE prevention projects. Participation is free, but enrollment is limited; interested individuals are encouraged to apply early. SHM members can apply to either program by completing the online application available on the VTE Prevention Collaborative Web site: www.hospitalmedicine.org/vte-pc.

Direct questions about VTE Prevention Collaborative programs to [email protected].

References

1. Goldhaber SZ, Tapson VF. DVT FREE Steering Committee. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004;93:259-262.
2. Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J. 2000 Aug;21(16):1301-1336. Comment in: Eur Heart J. 2000 Aug; 21(16): 1289-1290.
3. Stein PD, Huang H, Afzal A, et al. Incidence of acute pulmonary embolism in a general hospital: relation to age, sex, and race. Chest. 1999 Oct;116(4):909-913.
4. Silverstein MD, Heit JA, Mohr DN, et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med. 1998 Mar 23;158(6):585-593.
5. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S. Comment in: Chest. 2005 Jun; 127(6):2297-2298.
6. Stratton MA, Anderson FA, Bussey HI, et al. Prevention of venous thromboembolism: adherence to the 1995 American College of Chest Physicians consensus guidelines for surgical patients. Arch Intern Med. 2000;160:334-340.
7. Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. Changing clinical practice. Prospective study of the impact of continuing medical education and quality assurance programs on use of prophylaxis for venous thromboembolism. Arch Intern Med. 1994 Mar 28;154(6):669-677.
8. Walker A, Campbell S, Grimshaw J. Implementation of a national guideline on prophylaxis of venous thromboembolism: a survey of acute services in Scotland. Thromboembolism Prevention Evaluation Study Group. Health Bull (Edinb). 1999 Mar;57(2):141-147.

Benchmarks Committee Update

By Burke Kealey, MD, chair, SHM Benchmarks Committee

The SHM Benchmarks Committee has had a busy schedule with its new special issues survey and wrapping up work on The Dashboard Project, a first-of-its-kind undertaking. Committee members (under the guidance of Editor Leslie Flores) wrote summaries of 10 sample performance metrics. Each article is designed around a given metric and includes an in-depth discussion of why it is important and where to obtain the necessary data. Sample graphs from other programs will also be included.

The intent is for hospitalist leaders and program managers to use The Dashboard Project to learn what kind of metrics their peers use to manage their respective programs. The final draft was reviewed by the entire committee and circulated to SHM leaders, including the board of directors. It will be published through SHM’s publication, The Hospitalist, and promoted at the SHM Annual Meeting in Dallas in May.

In a break from recent tradition, the SHM Benchmarks Committee (with approval from the SHM Board) has changed how it conducts surveys. The committee will now produce shorter, simpler surveys annually—rather than producing a mega-survey every other year. The committee will conduct an individual hospitalist compensation and productivity survey every other year (including later in 2007); in the alternate year (along with baseline practice demographics) the committee will address the special topics of interest discussed below.

With input from SHM’s Palliative Care Task Force, this year’s special interest survey (which was conducted in November and December of 2006) included questions on palliative care and its growing place in the world of hospital medicine. Night and off-hours coverage continue to be topics of interest for membership. Questions in this section examined the scope of night coverage, including providing ICU coverage for intensivists and getting paid for as well as paying providers for this work.

Issues for family medicine hospitalists are also addressed. Anecdotally, the Benchmarks Committee has heard of family medicine hospitalists running into difficulties securing work because they have been barred by hospital contracts and/or bylaws stating that only internal medicine or pediatrics board-certified physicians can occupy those slots. The survey was designed to capture the pervasiveness of this practice.

Finally, in this era of pay for performance and open reporting, quality measures and their relationship to physician revenue and compensation is a topic that every hospital medicine leader needs to understand. The survey contained a section that looked at the degree to which pay-for-performance programs are actually being seen in the hospitals we practice at, and then, even more important, how those dollars are tied to quality incentive programs between hospitals and hospital medicine groups.

The results of this special interest survey are currently being analyzed and will be published later this spring. TH

SHM is now accepting applications for the VTE Prevention Collaborative, a program that offers individualized assistance to hospitalists wishing to take the lead on this critical quality and patient safety issue.

SHM Behind the Scenes

Making your membership easier to manage: changes to shm’s renewal process to take effect in april

By Todd Von Deak

I’m excited to let you know about a change to SHM’s membership structure that was recently approved by the SHM Board of Directors. This is a change our Membership and Marketing Department recommended to the Board, one that we feel will be a positive development over the coming years.

These changes, which take effect on April 1, affect how membership renewals are handled and processed.

Under the new structure, memberships will be renewed 12 months from when a member last paid dues in order for the member to remain in good standing. In the previous system, memberships were renewed each year between July 1 and September 30—regardless of when the last membership payment had been made.

There were two key factors that led to this change:

• The need to simplify a membership structure in which it was possible for a member who joined on July 1 and another who joined on December 24 to pay the same dues rate; and
• A survey of those whose memberships had recently lapsed in which 46% of respondents indicated that they did not know that their membership had lapsed.

There were three underlying themes to this change. We believe you should expect all three of these themes from any membership organization that you belong to.

1. Transparency: We wanted to clear up any confusion surrounding how your membership works. Simplifying the current structure will reduce confusion;
2. Fairness: A $230 dues payment in December should result in the same 12 months of benefits as a $230 dues payment in July; and
3. Ease of understanding: With membership renewals now due exactly one year from when you last paid, it should be easier to keep track of your membership and to keep it current.

Current members shouldn’t see a major difference as a result of this change. Renewal notices will be sent during the first part of April, with payment required by July 31 in order to keep your membership current.

New members will be most affected by the change. Beginning in April, new members will renew 12 months from when they join—as opposed to the past practice of renewing between July and September.

Over the coming year, we plan to introduce even more benefits to membership in SHM, the only professional society devoted solely to hospital medicine. These benefits will utilize emerging technologies such as podcasting and will make it even easier to access the vital educational content for which SHM has become well respected over the course of the last 10 years.

Stay tuned to The Hospitalist, as well as to SHM’s e-Newsletter, over the next several months for more details of the switch to an anniversary membership structure and how it will impact you. Of course, if you have any questions, please do not hesitate to contact us at (800) 843-3360 or online at [email protected]. TH

The problem of hospital-acquired venous thromboembolism (VTE): Venous thromboembolic disease, ranging from asymptomatic deep vein thrombosis (DVT) to massive pulmonary embolism (PE), is a significant cause of morbidity and mortality in hospitalized patients. Almost all hospitalized patients are at risk for VTE, and the literature suggests that approximately half of all cases of VTE are hospital-acquired.1-4 PE is recognized as the cause of death for more than 100,000 hospitalized patients in the United States every year and is considered a contributing factor in the death of 100,000 more patients.1

Multiple clinical trials have provided irrefutable evidence that primary thromboprophylaxis reduces the incidence of DVT and PE.5 Unfortunately, numerous studies have also shown that the majority of hospitalized patients with risk factors for DVT do not receive appropriate prophylaxis.6-8

Hospitalists are ideally positioned to reduce the incidence of preventable VTE, both by using known best practices to improve care delivered to their own patients, and, more importantly, by leading hospital-wide QI efforts that improve care for all patients at their home institutions.

SHM is now accepting applications for the VTE Prevention Collaborative, a program that offers individualized assistance to hospitalists who wish to take the lead on this critical quality and patient safety issue. Participants can choose the option that best fits their needs: a full year of distance mentoring or a one-day evaluation and consultation visit to their site.

click for large version

The SHM Mentoring Program

The Mentoring Program is the perfect option for individuals who are interested in securing ongoing support for their planned or active VTE prevention projects. SHM mentors with VTE and QI experts who work with participants to tackle site-specific issues using proven QI techniques. Instruction is organized around the VTE QI Workbook, SHM’s step-by-step guide for developing a VTE prevention program. Mentoring occurs in eight telephone calls scheduled throughout the yearlong mentoring period. During the calls, mentors offer individualized assistance on any topics, tasks, and barriers that are encountered in the course of designing, implementing, and evaluating a VTE prevention project. As needed, participants can also interact with their mentors through e-mail and in ad hoc telephone calls. Participants receive assistance with:

• Securing institutional support for the project;
• Assembling and leading the project team;
• Developing project goals and aims;
• Mapping current processes for assessing VTE risk and bleeding risk;
• Evaluating current prophylaxis recommendations;
• Developing evidence-based risk assessment and prophylaxis recommendations;
• Redesigning care delivery processes to include high-reliability features that promote adherence to best practices;
• Developing educational/outreach plans to ensure buy-in from key stakeholders; and
• Collecting, analyzing, and reporting outcome data.

Individuals with relatively little QI leadership experience, as well as those whose VTE prevention projects are in the early planning stages, are encouraged to apply for the SHM Mentoring Program.

The SHM On-site Consultation Program

The On-site Consultation Program is the perfect option for individuals who are interested in securing expert evaluation and input on a VTE prevention program but don’t feel they need ongoing, longitudinal support. Through the SHM On-site Consultation Program, SHM consultants with VTE and QI expertise visit applicants’ hospitals to evaluate active or planned VTE prevention programs. The visits will be especially helpful to participants who have existing VTE prevention programs they wish to expand or improve upon.

The consultation visits feature a structured evaluation of the site’s strengths and resources, any potential barriers to improvement, and the design and functioning of active or proposed VTE prevention interventions. Specific consultation visit activities will vary according to participant goals and needs but may include meeting with the local project team, QI leaders, hospital administrators, and hospital medicine group leaders, as well as reviewing project documents—order sets, policies, and procedures—data, and data collection/management tools.

Following the visits, SHM consultants provide participants with a written report of findings and recommendations. Participants also receive one follow-up telephone consultation, which will occur 60-90 days after the visit.

SHM On-site Consultation Program visits will be available starting in May 2007, though interested parties are encouraged to apply early; enrollment is limited, and available slots are expected to fill quickly.

Which Option Is Right for You?

SHM welcomes participation from hospitalists who work in all types of facilities (large and small community hospitals, academic medical centers, public hospitals, and others) and all types of practice settings, including acute care hospitals, skilled nursing facilities, and rehabilitation hospitals. Both VTE Prevention Collaborative programs are appropriate for individuals with all levels of QI experience, from the novice embarking on his or her first QI project to the seasoned QI leader. Individuals who have not yet begun working on a VTE prevention project are encouraged to apply, as are those who wish to expand or improve upon an existing project.

There are no rigid prerequisites for either program, though we expect individuals whose local VTE prevention efforts are already partially developed to derive more benefit from the On-site Consultation option than would an applicant who has yet to start his or her project. Individuals who have not yet begun working on a VTE prevention project are encouraged to apply for the Mentoring Program, which will ensure access to expert assistance during key development and implementation tasks.

How to Apply

Participation in both the Mentoring and On-site Consultation programs is open to hospitalists who are leading proposed or active VTE prevention projects. Participation is free, but enrollment is limited; interested individuals are encouraged to apply early. SHM members can apply to either program by completing the online application available on the VTE Prevention Collaborative Web site: www.hospitalmedicine.org/vte-pc.

Direct questions about VTE Prevention Collaborative programs to [email protected].

References

1. Goldhaber SZ, Tapson VF. DVT FREE Steering Committee. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004;93:259-262.
2. Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J. 2000 Aug;21(16):1301-1336. Comment in: Eur Heart J. 2000 Aug; 21(16): 1289-1290.
3. Stein PD, Huang H, Afzal A, et al. Incidence of acute pulmonary embolism in a general hospital: relation to age, sex, and race. Chest. 1999 Oct;116(4):909-913.
4. Silverstein MD, Heit JA, Mohr DN, et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med. 1998 Mar 23;158(6):585-593.
5. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S. Comment in: Chest. 2005 Jun; 127(6):2297-2298.
6. Stratton MA, Anderson FA, Bussey HI, et al. Prevention of venous thromboembolism: adherence to the 1995 American College of Chest Physicians consensus guidelines for surgical patients. Arch Intern Med. 2000;160:334-340.
7. Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. Changing clinical practice. Prospective study of the impact of continuing medical education and quality assurance programs on use of prophylaxis for venous thromboembolism. Arch Intern Med. 1994 Mar 28;154(6):669-677.
8. Walker A, Campbell S, Grimshaw J. Implementation of a national guideline on prophylaxis of venous thromboembolism: a survey of acute services in Scotland. Thromboembolism Prevention Evaluation Study Group. Health Bull (Edinb). 1999 Mar;57(2):141-147.

Benchmarks Committee Update

By Burke Kealey, MD, chair, SHM Benchmarks Committee

The SHM Benchmarks Committee has had a busy schedule with its new special issues survey and wrapping up work on The Dashboard Project, a first-of-its-kind undertaking. Committee members (under the guidance of Editor Leslie Flores) wrote summaries of 10 sample performance metrics. Each article is designed around a given metric and includes an in-depth discussion of why it is important and where to obtain the necessary data. Sample graphs from other programs will also be included.

The intent is for hospitalist leaders and program managers to use The Dashboard Project to learn what kind of metrics their peers use to manage their respective programs. The final draft was reviewed by the entire committee and circulated to SHM leaders, including the board of directors. It will be published through SHM’s publication, The Hospitalist, and promoted at the SHM Annual Meeting in Dallas in May.

In a break from recent tradition, the SHM Benchmarks Committee (with approval from the SHM Board) has changed how it conducts surveys. The committee will now produce shorter, simpler surveys annually—rather than producing a mega-survey every other year. The committee will conduct an individual hospitalist compensation and productivity survey every other year (including later in 2007); in the alternate year (along with baseline practice demographics) the committee will address the special topics of interest discussed below.

With input from SHM’s Palliative Care Task Force, this year’s special interest survey (which was conducted in November and December of 2006) included questions on palliative care and its growing place in the world of hospital medicine. Night and off-hours coverage continue to be topics of interest for membership. Questions in this section examined the scope of night coverage, including providing ICU coverage for intensivists and getting paid for as well as paying providers for this work.

Issues for family medicine hospitalists are also addressed. Anecdotally, the Benchmarks Committee has heard of family medicine hospitalists running into difficulties securing work because they have been barred by hospital contracts and/or bylaws stating that only internal medicine or pediatrics board-certified physicians can occupy those slots. The survey was designed to capture the pervasiveness of this practice.

Finally, in this era of pay for performance and open reporting, quality measures and their relationship to physician revenue and compensation is a topic that every hospital medicine leader needs to understand. The survey contained a section that looked at the degree to which pay-for-performance programs are actually being seen in the hospitals we practice at, and then, even more important, how those dollars are tied to quality incentive programs between hospitals and hospital medicine groups.

The results of this special interest survey are currently being analyzed and will be published later this spring. TH

SHM is now accepting applications for the VTE Prevention Collaborative, a program that offers individualized assistance to hospitalists wishing to take the lead on this critical quality and patient safety issue.

SHM Behind the Scenes

Making your membership easier to manage: changes to shm’s renewal process to take effect in april

By Todd Von Deak

I’m excited to let you know about a change to SHM’s membership structure that was recently approved by the SHM Board of Directors. This is a change our Membership and Marketing Department recommended to the Board, one that we feel will be a positive development over the coming years.

These changes, which take effect on April 1, affect how membership renewals are handled and processed.

Under the new structure, memberships will be renewed 12 months from when a member last paid dues in order for the member to remain in good standing. In the previous system, memberships were renewed each year between July 1 and September 30—regardless of when the last membership payment had been made.

There were two key factors that led to this change:

• The need to simplify a membership structure in which it was possible for a member who joined on July 1 and another who joined on December 24 to pay the same dues rate; and
• A survey of those whose memberships had recently lapsed in which 46% of respondents indicated that they did not know that their membership had lapsed.

There were three underlying themes to this change. We believe you should expect all three of these themes from any membership organization that you belong to.

1. Transparency: We wanted to clear up any confusion surrounding how your membership works. Simplifying the current structure will reduce confusion;
2. Fairness: A $230 dues payment in December should result in the same 12 months of benefits as a $230 dues payment in July; and
3. Ease of understanding: With membership renewals now due exactly one year from when you last paid, it should be easier to keep track of your membership and to keep it current.

Current members shouldn’t see a major difference as a result of this change. Renewal notices will be sent during the first part of April, with payment required by July 31 in order to keep your membership current.

New members will be most affected by the change. Beginning in April, new members will renew 12 months from when they join—as opposed to the past practice of renewing between July and September.

Over the coming year, we plan to introduce even more benefits to membership in SHM, the only professional society devoted solely to hospital medicine. These benefits will utilize emerging technologies such as podcasting and will make it even easier to access the vital educational content for which SHM has become well respected over the course of the last 10 years.

Stay tuned to The Hospitalist, as well as to SHM’s e-Newsletter, over the next several months for more details of the switch to an anniversary membership structure and how it will impact you. Of course, if you have any questions, please do not hesitate to contact us at (800) 843-3360 or online at [email protected]. TH

The problem of hospital-acquired venous thromboembolism (VTE): Venous thromboembolic disease, ranging from asymptomatic deep vein thrombosis (DVT) to massive pulmonary embolism (PE), is a significant cause of morbidity and mortality in hospitalized patients. Almost all hospitalized patients are at risk for VTE, and the literature suggests that approximately half of all cases of VTE are hospital-acquired.1-4 PE is recognized as the cause of death for more than 100,000 hospitalized patients in the United States every year and is considered a contributing factor in the death of 100,000 more patients.1

Multiple clinical trials have provided irrefutable evidence that primary thromboprophylaxis reduces the incidence of DVT and PE.5 Unfortunately, numerous studies have also shown that the majority of hospitalized patients with risk factors for DVT do not receive appropriate prophylaxis.6-8

Hospitalists are ideally positioned to reduce the incidence of preventable VTE, both by using known best practices to improve care delivered to their own patients, and, more importantly, by leading hospital-wide QI efforts that improve care for all patients at their home institutions.

SHM is now accepting applications for the VTE Prevention Collaborative, a program that offers individualized assistance to hospitalists who wish to take the lead on this critical quality and patient safety issue. Participants can choose the option that best fits their needs: a full year of distance mentoring or a one-day evaluation and consultation visit to their site.

click for large version

The SHM Mentoring Program

The Mentoring Program is the perfect option for individuals who are interested in securing ongoing support for their planned or active VTE prevention projects. SHM mentors with VTE and QI experts who work with participants to tackle site-specific issues using proven QI techniques. Instruction is organized around the VTE QI Workbook, SHM’s step-by-step guide for developing a VTE prevention program. Mentoring occurs in eight telephone calls scheduled throughout the yearlong mentoring period. During the calls, mentors offer individualized assistance on any topics, tasks, and barriers that are encountered in the course of designing, implementing, and evaluating a VTE prevention project. As needed, participants can also interact with their mentors through e-mail and in ad hoc telephone calls. Participants receive assistance with:

• Securing institutional support for the project;
• Assembling and leading the project team;
• Developing project goals and aims;
• Mapping current processes for assessing VTE risk and bleeding risk;
• Evaluating current prophylaxis recommendations;
• Developing evidence-based risk assessment and prophylaxis recommendations;
• Redesigning care delivery processes to include high-reliability features that promote adherence to best practices;
• Developing educational/outreach plans to ensure buy-in from key stakeholders; and
• Collecting, analyzing, and reporting outcome data.

Individuals with relatively little QI leadership experience, as well as those whose VTE prevention projects are in the early planning stages, are encouraged to apply for the SHM Mentoring Program.

The SHM On-site Consultation Program

The On-site Consultation Program is the perfect option for individuals who are interested in securing expert evaluation and input on a VTE prevention program but don’t feel they need ongoing, longitudinal support. Through the SHM On-site Consultation Program, SHM consultants with VTE and QI expertise visit applicants’ hospitals to evaluate active or planned VTE prevention programs. The visits will be especially helpful to participants who have existing VTE prevention programs they wish to expand or improve upon.

The consultation visits feature a structured evaluation of the site’s strengths and resources, any potential barriers to improvement, and the design and functioning of active or proposed VTE prevention interventions. Specific consultation visit activities will vary according to participant goals and needs but may include meeting with the local project team, QI leaders, hospital administrators, and hospital medicine group leaders, as well as reviewing project documents—order sets, policies, and procedures—data, and data collection/management tools.

Following the visits, SHM consultants provide participants with a written report of findings and recommendations. Participants also receive one follow-up telephone consultation, which will occur 60-90 days after the visit.

SHM On-site Consultation Program visits will be available starting in May 2007, though interested parties are encouraged to apply early; enrollment is limited, and available slots are expected to fill quickly.

Which Option Is Right for You?

SHM welcomes participation from hospitalists who work in all types of facilities (large and small community hospitals, academic medical centers, public hospitals, and others) and all types of practice settings, including acute care hospitals, skilled nursing facilities, and rehabilitation hospitals. Both VTE Prevention Collaborative programs are appropriate for individuals with all levels of QI experience, from the novice embarking on his or her first QI project to the seasoned QI leader. Individuals who have not yet begun working on a VTE prevention project are encouraged to apply, as are those who wish to expand or improve upon an existing project.

There are no rigid prerequisites for either program, though we expect individuals whose local VTE prevention efforts are already partially developed to derive more benefit from the On-site Consultation option than would an applicant who has yet to start his or her project. Individuals who have not yet begun working on a VTE prevention project are encouraged to apply for the Mentoring Program, which will ensure access to expert assistance during key development and implementation tasks.

How to Apply

Participation in both the Mentoring and On-site Consultation programs is open to hospitalists who are leading proposed or active VTE prevention projects. Participation is free, but enrollment is limited; interested individuals are encouraged to apply early. SHM members can apply to either program by completing the online application available on the VTE Prevention Collaborative Web site: www.hospitalmedicine.org/vte-pc.

Direct questions about VTE Prevention Collaborative programs to [email protected].

References

1. Goldhaber SZ, Tapson VF. DVT FREE Steering Committee. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004;93:259-262.
2. Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J. 2000 Aug;21(16):1301-1336. Comment in: Eur Heart J. 2000 Aug; 21(16): 1289-1290.
3. Stein PD, Huang H, Afzal A, et al. Incidence of acute pulmonary embolism in a general hospital: relation to age, sex, and race. Chest. 1999 Oct;116(4):909-913.
4. Silverstein MD, Heit JA, Mohr DN, et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med. 1998 Mar 23;158(6):585-593.
5. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S. Comment in: Chest. 2005 Jun; 127(6):2297-2298.
6. Stratton MA, Anderson FA, Bussey HI, et al. Prevention of venous thromboembolism: adherence to the 1995 American College of Chest Physicians consensus guidelines for surgical patients. Arch Intern Med. 2000;160:334-340.
7. Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. Changing clinical practice. Prospective study of the impact of continuing medical education and quality assurance programs on use of prophylaxis for venous thromboembolism. Arch Intern Med. 1994 Mar 28;154(6):669-677.
8. Walker A, Campbell S, Grimshaw J. Implementation of a national guideline on prophylaxis of venous thromboembolism: a survey of acute services in Scotland. Thromboembolism Prevention Evaluation Study Group. Health Bull (Edinb). 1999 Mar;57(2):141-147.

Benchmarks Committee Update

By Burke Kealey, MD, chair, SHM Benchmarks Committee

The SHM Benchmarks Committee has had a busy schedule with its new special issues survey and wrapping up work on The Dashboard Project, a first-of-its-kind undertaking. Committee members (under the guidance of Editor Leslie Flores) wrote summaries of 10 sample performance metrics. Each article is designed around a given metric and includes an in-depth discussion of why it is important and where to obtain the necessary data. Sample graphs from other programs will also be included.

The intent is for hospitalist leaders and program managers to use The Dashboard Project to learn what kind of metrics their peers use to manage their respective programs. The final draft was reviewed by the entire committee and circulated to SHM leaders, including the board of directors. It will be published through SHM’s publication, The Hospitalist, and promoted at the SHM Annual Meeting in Dallas in May.

In a break from recent tradition, the SHM Benchmarks Committee (with approval from the SHM Board) has changed how it conducts surveys. The committee will now produce shorter, simpler surveys annually—rather than producing a mega-survey every other year. The committee will conduct an individual hospitalist compensation and productivity survey every other year (including later in 2007); in the alternate year (along with baseline practice demographics) the committee will address the special topics of interest discussed below.

With input from SHM’s Palliative Care Task Force, this year’s special interest survey (which was conducted in November and December of 2006) included questions on palliative care and its growing place in the world of hospital medicine. Night and off-hours coverage continue to be topics of interest for membership. Questions in this section examined the scope of night coverage, including providing ICU coverage for intensivists and getting paid for as well as paying providers for this work.

Issues for family medicine hospitalists are also addressed. Anecdotally, the Benchmarks Committee has heard of family medicine hospitalists running into difficulties securing work because they have been barred by hospital contracts and/or bylaws stating that only internal medicine or pediatrics board-certified physicians can occupy those slots. The survey was designed to capture the pervasiveness of this practice.

Finally, in this era of pay for performance and open reporting, quality measures and their relationship to physician revenue and compensation is a topic that every hospital medicine leader needs to understand. The survey contained a section that looked at the degree to which pay-for-performance programs are actually being seen in the hospitals we practice at, and then, even more important, how those dollars are tied to quality incentive programs between hospitals and hospital medicine groups.

The results of this special interest survey are currently being analyzed and will be published later this spring. TH

SHM is now accepting applications for the VTE Prevention Collaborative, a program that offers individualized assistance to hospitalists wishing to take the lead on this critical quality and patient safety issue.

SHM Behind the Scenes

Making your membership easier to manage: changes to shm’s renewal process to take effect in april

By Todd Von Deak

I’m excited to let you know about a change to SHM’s membership structure that was recently approved by the SHM Board of Directors. This is a change our Membership and Marketing Department recommended to the Board, one that we feel will be a positive development over the coming years.

These changes, which take effect on April 1, affect how membership renewals are handled and processed.

Under the new structure, memberships will be renewed 12 months from when a member last paid dues in order for the member to remain in good standing. In the previous system, memberships were renewed each year between July 1 and September 30—regardless of when the last membership payment had been made.

There were two key factors that led to this change:

• The need to simplify a membership structure in which it was possible for a member who joined on July 1 and another who joined on December 24 to pay the same dues rate; and
• A survey of those whose memberships had recently lapsed in which 46% of respondents indicated that they did not know that their membership had lapsed.

There were three underlying themes to this change. We believe you should expect all three of these themes from any membership organization that you belong to.

1. Transparency: We wanted to clear up any confusion surrounding how your membership works. Simplifying the current structure will reduce confusion;
2. Fairness: A $230 dues payment in December should result in the same 12 months of benefits as a $230 dues payment in July; and
3. Ease of understanding: With membership renewals now due exactly one year from when you last paid, it should be easier to keep track of your membership and to keep it current.

Current members shouldn’t see a major difference as a result of this change. Renewal notices will be sent during the first part of April, with payment required by July 31 in order to keep your membership current.

New members will be most affected by the change. Beginning in April, new members will renew 12 months from when they join—as opposed to the past practice of renewing between July and September.

Over the coming year, we plan to introduce even more benefits to membership in SHM, the only professional society devoted solely to hospital medicine. These benefits will utilize emerging technologies such as podcasting and will make it even easier to access the vital educational content for which SHM has become well respected over the course of the last 10 years.

Stay tuned to The Hospitalist, as well as to SHM’s e-Newsletter, over the next several months for more details of the switch to an anniversary membership structure and how it will impact you. Of course, if you have any questions, please do not hesitate to contact us at (800) 843-3360 or online at [email protected]. TH

We are in the midst of a true evolution of how hospitals will approach creating a culture of quality. The drivers for process improvement and management of resources have traditionally been more concerned with full occupancy and risk management, but now many external forces are raising quality improvement as a potential core competency for our nation’s hospitals.

With the push of the Institute for Healthcare Improvement (IHI), Leapfrog, and even Medicare, hospitals now must grapple with a culture change—one in which measurement and reporting of outcomes and processes will become, if not truly job one, at least in the top five. The fact that a hospital’s revenue stream through pay-for-performance (P4P) bonuses and its reputation by public reporting are at stake only serve to create a real immediacy in the coming years.

A recent SHM survey of the leaders of hospital medicine groups (HMGs) has shown that, once again, hospitalists find themselves right smack in the middle of quality improvement.

Survey Says

More than 41% of hospitalist leaders report that their HMG has a quality incentive program. This is even more prevalent at hospitals participating in P4P programs, where 60% of HMGs have quality incentives to align priorities. It is a hallmark of hospitalist groups to place a particular emphasis on the process and system improvement necessary for true measurable quality improvement. Many times, this improvement takes time away from direct and billable patient care.

Pointing to the relatively early stage in the adoption of P4P, this same survey reported that only 29% of HMGs were working in hospitals that participated in P4P programs, while 56% report their hospital did not have any P4P programs in place.

As we enter 2007, it is clear that while a small percentage of hospitals have embraced P4P the majority of hospitals are—at best—on the sidelines or still in planning mode. But those who are active in P4P have engaged their hospitalists to help them meet their goals. And everything that is coming out in the literature commonly read by the hospital C-suite promotes the promise of more reimbursement from the insurance industry and Medicare, leading to the conclusion that P4P and rewarding performance will increase in the near term.

What Can SHM Do for You?

Positioning hospitalists to play a key role in quality improvement, SHM has launched a number of initiatives and partnerships to provide hospitalists with the tools they need to help their hospitals to succeed.

As a framework of tools, SHM has now built six Web-based Quality Improvement Resource Rooms in VTE, Heart Failure, Stroke, Glycemic Control, Care Transitions in the Elderly, and Antibiotic Resistance. These practical tools and references are now available on the SHM Web site (www.hospitalmedicine.org) as are, in many cases, a comprehensive workbook that helps hospitalists to be the leaders of quality improvement change at their hospitals.

SHM realizes that, while this approach may work for the savvy, experienced quality improvement (QI) implementer, most young hospitalist leaders need a more personal, hands-on approach. With this in mind, SHM has launched its Mentored QI Implementation project. Centered around VTE prevention and supported by funding from Sanofi-Aventis, two senior hospitalist mentors will each work with 15 HMG leaders to take them step by step through the process of implementing a quality improvement process in 2007 and 2008.

To take this hands-on, supportive approach to the next level SHM (with support from a Kettering Foundation grant) will add the capability for on-site consultation—sort of a QI SWAT team that can show up at your hospital and work shoulder to shoulder with hospitalists and other members of the healthcare team to develop and implement processes that will improve patient care.

To further educate and energize hospitalist leaders who have been charged with leading this change, SHM developed the Leadership Academy. To date more than 400 hospitalist leaders have been trained in sold-out small-group sessions during the past two years. The most recent academy was held last month in Orlando, Fla.

SHM provides additional training for those who will implement quality improvement at the Quality Training precourse at the SHM Annual Meeting. In the precourse up to 100 change leaders get hands-on direction, tools, and tricks of the trade to allow them to succeed in their local efforts. The next Quality Training Precourse will be held in small group sessions on May 23, 2007, in Dallas.

The SHM Annual Meeting has consistently been a venue that allows hospitalists to hear from national thought leaders in the quality revolution. In 2006, hospitalists heard from Carolyn Clancy, MD, CEO of the Agency for Healthcare Research and Quality, and Jack Rowe, MD, CEO of Aetna Insurance Company.

At this year’s meeting Jonathan Perlin, MD, PhD, who led the cutting edge QI efforts at Veterans Affairs and who is now bringing innovation to HCA (Nashville, Tenn.), the nation’s largest hospital company, will share his ideas with us. In addition, hospitalists will hear from David Brailer, MD, PhD, President George W. Bush’s first appointee to head up national efforts for health information technology. In addition, SHM’s Bob Wachter, MD, a nationally recognized leader in QI and patient safety, will share his perspectives on hospital medicine. With Drs. Perlin, Brailer, and Wachter, SHM continues its tradition of placing innovations that are changing healthcare for the better front and center at our annual meeting.

As for the future, SHM has submitted a multi-year grant application to the Hartford Foundation (Conn.) to expand our efforts—specifically in developing implementation strategies to improve the care processes and outcomes for the senior population.

One of the key areas that emerged from SHM’s work with the Hartford Foundation is the importance of improving the transitions of care and better coordinating healthcare from the patient’s point of view. This has led SHM to partner with several national organizations to make sense of what has been a squishy subject. SHM is working closely with the American Board of Internal Medicine (ABIM) Foundation on its Stepping Up to the Plate consortium, a group of specialty physicians focusing on best practice strategies in patient-centered transitions, hand-offs, and information transfer.

In addition, SHM is working with the American College of Physicians, the AHRQ, the ABIM, the American Geriatrics Society (AGS), and the Society of General Internal Medicine to hold a National Consensus Conference in 2007 to establish policy on transitions of care. The conference will involve a broad range of stakeholders and may very well lead to the establishment of performance standards that can be applied directly to patient care.

Also SHM has been working with the Case Management Society of America to bring together the broader healthcare team on its National Transitions of Care Coalition (NTOCC) project. NTOCC includes pharmacists (American Society of Health-System Pharmacists), the C-suite (American College of Healthcare Executives), social workers (National Association of Social Workers), geriatricians (the AGS), the Joint Commission on Accreditation of Healthcare Organizations, and others. NTOCC plans to develop clear tools, guidelines, and pathways for consistent communication among patients, providers, and payers throughout the care continuum, and to look at aligning incentives for use of these tools and resources.

SHM has also worked with recognized leaders in action-oriented campaigns in QI, including the IHI—first on its “100,000 Lives Campaign,” and more recently on its “5 Million Lives Campaign.” In fact, leadership from only one medical professional society—SHM—was on the stage with Don Berwick for IHI’s national announcement at the December 2006 IHI national meeting in Orlando.

Hospitalists Lead the Charge

It is clear that our nation’s hospitals will be incentivized and mandated to create processes and produce outcomes based on national performance standards and data. This will require a re-engineering of the hospitals and their medical staffs. Hospitalists will be charged (as part of their job description) to be physician leaders in making this happen. Unfortunately, their training in medical school or residency has not provided them with all the skills in QI measurement or implementation that they will need. That is where SHM comes in.

Whether developing tools and workbooks or developing educational and implementation strategies, SHM will be innovative and on the cutting edge. Just as importantly, SHM will be on the lookout for like-minded organizations to partner with to raise the visibility and necessity of QI. We will not shy away from helping to set performance standards just because they may create initial discomfort with some of our members. We will not back off from developing creative strategies to push QI down to more than 4,000 acute care hospitals just because it is difficult and at times daunting.

Hospitalists are on the front line of change. Our patients, our institutions, our fellow physicians, and the other members of the healthcare team want and need a better system. There is no standing still. There is no turning back. The time is now. It is our turn, and hospitalists, with SHM’s help, are ready to step up and make it happen. TH

Dr. Wellikson has been CEO of SHM since 2000.

We are in the midst of a true evolution of how hospitals will approach creating a culture of quality. The drivers for process improvement and management of resources have traditionally been more concerned with full occupancy and risk management, but now many external forces are raising quality improvement as a potential core competency for our nation’s hospitals.

With the push of the Institute for Healthcare Improvement (IHI), Leapfrog, and even Medicare, hospitals now must grapple with a culture change—one in which measurement and reporting of outcomes and processes will become, if not truly job one, at least in the top five. The fact that a hospital’s revenue stream through pay-for-performance (P4P) bonuses and its reputation by public reporting are at stake only serve to create a real immediacy in the coming years.

A recent SHM survey of the leaders of hospital medicine groups (HMGs) has shown that, once again, hospitalists find themselves right smack in the middle of quality improvement.

Survey Says

More than 41% of hospitalist leaders report that their HMG has a quality incentive program. This is even more prevalent at hospitals participating in P4P programs, where 60% of HMGs have quality incentives to align priorities. It is a hallmark of hospitalist groups to place a particular emphasis on the process and system improvement necessary for true measurable quality improvement. Many times, this improvement takes time away from direct and billable patient care.

Pointing to the relatively early stage in the adoption of P4P, this same survey reported that only 29% of HMGs were working in hospitals that participated in P4P programs, while 56% report their hospital did not have any P4P programs in place.

As we enter 2007, it is clear that while a small percentage of hospitals have embraced P4P the majority of hospitals are—at best—on the sidelines or still in planning mode. But those who are active in P4P have engaged their hospitalists to help them meet their goals. And everything that is coming out in the literature commonly read by the hospital C-suite promotes the promise of more reimbursement from the insurance industry and Medicare, leading to the conclusion that P4P and rewarding performance will increase in the near term.

What Can SHM Do for You?

Positioning hospitalists to play a key role in quality improvement, SHM has launched a number of initiatives and partnerships to provide hospitalists with the tools they need to help their hospitals to succeed.

As a framework of tools, SHM has now built six Web-based Quality Improvement Resource Rooms in VTE, Heart Failure, Stroke, Glycemic Control, Care Transitions in the Elderly, and Antibiotic Resistance. These practical tools and references are now available on the SHM Web site (www.hospitalmedicine.org) as are, in many cases, a comprehensive workbook that helps hospitalists to be the leaders of quality improvement change at their hospitals.

SHM realizes that, while this approach may work for the savvy, experienced quality improvement (QI) implementer, most young hospitalist leaders need a more personal, hands-on approach. With this in mind, SHM has launched its Mentored QI Implementation project. Centered around VTE prevention and supported by funding from Sanofi-Aventis, two senior hospitalist mentors will each work with 15 HMG leaders to take them step by step through the process of implementing a quality improvement process in 2007 and 2008.

To take this hands-on, supportive approach to the next level SHM (with support from a Kettering Foundation grant) will add the capability for on-site consultation—sort of a QI SWAT team that can show up at your hospital and work shoulder to shoulder with hospitalists and other members of the healthcare team to develop and implement processes that will improve patient care.

To further educate and energize hospitalist leaders who have been charged with leading this change, SHM developed the Leadership Academy. To date more than 400 hospitalist leaders have been trained in sold-out small-group sessions during the past two years. The most recent academy was held last month in Orlando, Fla.

SHM provides additional training for those who will implement quality improvement at the Quality Training precourse at the SHM Annual Meeting. In the precourse up to 100 change leaders get hands-on direction, tools, and tricks of the trade to allow them to succeed in their local efforts. The next Quality Training Precourse will be held in small group sessions on May 23, 2007, in Dallas.

The SHM Annual Meeting has consistently been a venue that allows hospitalists to hear from national thought leaders in the quality revolution. In 2006, hospitalists heard from Carolyn Clancy, MD, CEO of the Agency for Healthcare Research and Quality, and Jack Rowe, MD, CEO of Aetna Insurance Company.

At this year’s meeting Jonathan Perlin, MD, PhD, who led the cutting edge QI efforts at Veterans Affairs and who is now bringing innovation to HCA (Nashville, Tenn.), the nation’s largest hospital company, will share his ideas with us. In addition, hospitalists will hear from David Brailer, MD, PhD, President George W. Bush’s first appointee to head up national efforts for health information technology. In addition, SHM’s Bob Wachter, MD, a nationally recognized leader in QI and patient safety, will share his perspectives on hospital medicine. With Drs. Perlin, Brailer, and Wachter, SHM continues its tradition of placing innovations that are changing healthcare for the better front and center at our annual meeting.

As for the future, SHM has submitted a multi-year grant application to the Hartford Foundation (Conn.) to expand our efforts—specifically in developing implementation strategies to improve the care processes and outcomes for the senior population.

One of the key areas that emerged from SHM’s work with the Hartford Foundation is the importance of improving the transitions of care and better coordinating healthcare from the patient’s point of view. This has led SHM to partner with several national organizations to make sense of what has been a squishy subject. SHM is working closely with the American Board of Internal Medicine (ABIM) Foundation on its Stepping Up to the Plate consortium, a group of specialty physicians focusing on best practice strategies in patient-centered transitions, hand-offs, and information transfer.

In addition, SHM is working with the American College of Physicians, the AHRQ, the ABIM, the American Geriatrics Society (AGS), and the Society of General Internal Medicine to hold a National Consensus Conference in 2007 to establish policy on transitions of care. The conference will involve a broad range of stakeholders and may very well lead to the establishment of performance standards that can be applied directly to patient care.

Also SHM has been working with the Case Management Society of America to bring together the broader healthcare team on its National Transitions of Care Coalition (NTOCC) project. NTOCC includes pharmacists (American Society of Health-System Pharmacists), the C-suite (American College of Healthcare Executives), social workers (National Association of Social Workers), geriatricians (the AGS), the Joint Commission on Accreditation of Healthcare Organizations, and others. NTOCC plans to develop clear tools, guidelines, and pathways for consistent communication among patients, providers, and payers throughout the care continuum, and to look at aligning incentives for use of these tools and resources.

SHM has also worked with recognized leaders in action-oriented campaigns in QI, including the IHI—first on its “100,000 Lives Campaign,” and more recently on its “5 Million Lives Campaign.” In fact, leadership from only one medical professional society—SHM—was on the stage with Don Berwick for IHI’s national announcement at the December 2006 IHI national meeting in Orlando.

Hospitalists Lead the Charge

It is clear that our nation’s hospitals will be incentivized and mandated to create processes and produce outcomes based on national performance standards and data. This will require a re-engineering of the hospitals and their medical staffs. Hospitalists will be charged (as part of their job description) to be physician leaders in making this happen. Unfortunately, their training in medical school or residency has not provided them with all the skills in QI measurement or implementation that they will need. That is where SHM comes in.

Whether developing tools and workbooks or developing educational and implementation strategies, SHM will be innovative and on the cutting edge. Just as importantly, SHM will be on the lookout for like-minded organizations to partner with to raise the visibility and necessity of QI. We will not shy away from helping to set performance standards just because they may create initial discomfort with some of our members. We will not back off from developing creative strategies to push QI down to more than 4,000 acute care hospitals just because it is difficult and at times daunting.

Hospitalists are on the front line of change. Our patients, our institutions, our fellow physicians, and the other members of the healthcare team want and need a better system. There is no standing still. There is no turning back. The time is now. It is our turn, and hospitalists, with SHM’s help, are ready to step up and make it happen. TH

Dr. Wellikson has been CEO of SHM since 2000.

We are in the midst of a true evolution of how hospitals will approach creating a culture of quality. The drivers for process improvement and management of resources have traditionally been more concerned with full occupancy and risk management, but now many external forces are raising quality improvement as a potential core competency for our nation’s hospitals.

With the push of the Institute for Healthcare Improvement (IHI), Leapfrog, and even Medicare, hospitals now must grapple with a culture change—one in which measurement and reporting of outcomes and processes will become, if not truly job one, at least in the top five. The fact that a hospital’s revenue stream through pay-for-performance (P4P) bonuses and its reputation by public reporting are at stake only serve to create a real immediacy in the coming years.

A recent SHM survey of the leaders of hospital medicine groups (HMGs) has shown that, once again, hospitalists find themselves right smack in the middle of quality improvement.

Survey Says

More than 41% of hospitalist leaders report that their HMG has a quality incentive program. This is even more prevalent at hospitals participating in P4P programs, where 60% of HMGs have quality incentives to align priorities. It is a hallmark of hospitalist groups to place a particular emphasis on the process and system improvement necessary for true measurable quality improvement. Many times, this improvement takes time away from direct and billable patient care.

Pointing to the relatively early stage in the adoption of P4P, this same survey reported that only 29% of HMGs were working in hospitals that participated in P4P programs, while 56% report their hospital did not have any P4P programs in place.

As we enter 2007, it is clear that while a small percentage of hospitals have embraced P4P the majority of hospitals are—at best—on the sidelines or still in planning mode. But those who are active in P4P have engaged their hospitalists to help them meet their goals. And everything that is coming out in the literature commonly read by the hospital C-suite promotes the promise of more reimbursement from the insurance industry and Medicare, leading to the conclusion that P4P and rewarding performance will increase in the near term.

What Can SHM Do for You?

Positioning hospitalists to play a key role in quality improvement, SHM has launched a number of initiatives and partnerships to provide hospitalists with the tools they need to help their hospitals to succeed.

As a framework of tools, SHM has now built six Web-based Quality Improvement Resource Rooms in VTE, Heart Failure, Stroke, Glycemic Control, Care Transitions in the Elderly, and Antibiotic Resistance. These practical tools and references are now available on the SHM Web site (www.hospitalmedicine.org) as are, in many cases, a comprehensive workbook that helps hospitalists to be the leaders of quality improvement change at their hospitals.

SHM realizes that, while this approach may work for the savvy, experienced quality improvement (QI) implementer, most young hospitalist leaders need a more personal, hands-on approach. With this in mind, SHM has launched its Mentored QI Implementation project. Centered around VTE prevention and supported by funding from Sanofi-Aventis, two senior hospitalist mentors will each work with 15 HMG leaders to take them step by step through the process of implementing a quality improvement process in 2007 and 2008.

To take this hands-on, supportive approach to the next level SHM (with support from a Kettering Foundation grant) will add the capability for on-site consultation—sort of a QI SWAT team that can show up at your hospital and work shoulder to shoulder with hospitalists and other members of the healthcare team to develop and implement processes that will improve patient care.

To further educate and energize hospitalist leaders who have been charged with leading this change, SHM developed the Leadership Academy. To date more than 400 hospitalist leaders have been trained in sold-out small-group sessions during the past two years. The most recent academy was held last month in Orlando, Fla.

SHM provides additional training for those who will implement quality improvement at the Quality Training precourse at the SHM Annual Meeting. In the precourse up to 100 change leaders get hands-on direction, tools, and tricks of the trade to allow them to succeed in their local efforts. The next Quality Training Precourse will be held in small group sessions on May 23, 2007, in Dallas.

The SHM Annual Meeting has consistently been a venue that allows hospitalists to hear from national thought leaders in the quality revolution. In 2006, hospitalists heard from Carolyn Clancy, MD, CEO of the Agency for Healthcare Research and Quality, and Jack Rowe, MD, CEO of Aetna Insurance Company.

At this year’s meeting Jonathan Perlin, MD, PhD, who led the cutting edge QI efforts at Veterans Affairs and who is now bringing innovation to HCA (Nashville, Tenn.), the nation’s largest hospital company, will share his ideas with us. In addition, hospitalists will hear from David Brailer, MD, PhD, President George W. Bush’s first appointee to head up national efforts for health information technology. In addition, SHM’s Bob Wachter, MD, a nationally recognized leader in QI and patient safety, will share his perspectives on hospital medicine. With Drs. Perlin, Brailer, and Wachter, SHM continues its tradition of placing innovations that are changing healthcare for the better front and center at our annual meeting.

As for the future, SHM has submitted a multi-year grant application to the Hartford Foundation (Conn.) to expand our efforts—specifically in developing implementation strategies to improve the care processes and outcomes for the senior population.

One of the key areas that emerged from SHM’s work with the Hartford Foundation is the importance of improving the transitions of care and better coordinating healthcare from the patient’s point of view. This has led SHM to partner with several national organizations to make sense of what has been a squishy subject. SHM is working closely with the American Board of Internal Medicine (ABIM) Foundation on its Stepping Up to the Plate consortium, a group of specialty physicians focusing on best practice strategies in patient-centered transitions, hand-offs, and information transfer.

In addition, SHM is working with the American College of Physicians, the AHRQ, the ABIM, the American Geriatrics Society (AGS), and the Society of General Internal Medicine to hold a National Consensus Conference in 2007 to establish policy on transitions of care. The conference will involve a broad range of stakeholders and may very well lead to the establishment of performance standards that can be applied directly to patient care.

Also SHM has been working with the Case Management Society of America to bring together the broader healthcare team on its National Transitions of Care Coalition (NTOCC) project. NTOCC includes pharmacists (American Society of Health-System Pharmacists), the C-suite (American College of Healthcare Executives), social workers (National Association of Social Workers), geriatricians (the AGS), the Joint Commission on Accreditation of Healthcare Organizations, and others. NTOCC plans to develop clear tools, guidelines, and pathways for consistent communication among patients, providers, and payers throughout the care continuum, and to look at aligning incentives for use of these tools and resources.

SHM has also worked with recognized leaders in action-oriented campaigns in QI, including the IHI—first on its “100,000 Lives Campaign,” and more recently on its “5 Million Lives Campaign.” In fact, leadership from only one medical professional society—SHM—was on the stage with Don Berwick for IHI’s national announcement at the December 2006 IHI national meeting in Orlando.

Hospitalists Lead the Charge

It is clear that our nation’s hospitals will be incentivized and mandated to create processes and produce outcomes based on national performance standards and data. This will require a re-engineering of the hospitals and their medical staffs. Hospitalists will be charged (as part of their job description) to be physician leaders in making this happen. Unfortunately, their training in medical school or residency has not provided them with all the skills in QI measurement or implementation that they will need. That is where SHM comes in.

Whether developing tools and workbooks or developing educational and implementation strategies, SHM will be innovative and on the cutting edge. Just as importantly, SHM will be on the lookout for like-minded organizations to partner with to raise the visibility and necessity of QI. We will not shy away from helping to set performance standards just because they may create initial discomfort with some of our members. We will not back off from developing creative strategies to push QI down to more than 4,000 acute care hospitals just because it is difficult and at times daunting.

Hospitalists are on the front line of change. Our patients, our institutions, our fellow physicians, and the other members of the healthcare team want and need a better system. There is no standing still. There is no turning back. The time is now. It is our turn, and hospitalists, with SHM’s help, are ready to step up and make it happen. TH

Dr. Wellikson has been CEO of SHM since 2000.