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Pediatric Practice Profile
Contact
Windy Lammers Stevenson, MD
Inpatient Pediatric Service
Doernbecher Children’s Hospital
Oregon Health & Science University
707 SW Gaines St. CDRCP
Portland, Oregon 97239
Phone: 503-494-6513 Fax: 503-494-4953
E-mail: [email protected]
Start Up
2003
Hospitalists
Tracy Bumsted, MD, MPH
Carrie Phillipi, MD, PhD
Windy Lammers Stevenson, MD
General Pediatricians
Cynthia Ferrell, MD, MSEd
Arthur Jaff e, MD
C. Wayne Sells, MD, MPH
Scott Shipman, MD, MPH
Joseph Zenel, MD
The Program
The pediatric inpatient service at Doernbecher Children’s Hospital is a newly formed multidisciplinary team designed to creatively approach the continually evolving challenges of providing excellent inpatient care in the current financial environment.
Three pediatric hospitalists have joined forces with four general pediatricians and an adolescent specialist to assume care for all patients on the general pediatric inpatient service at this tertiary care academic medical center. A pediatric case manager and a nursing director complete our team. The eight board-certified physicians are members of the Division of General Pediatrics in the Department of Pediatrics at Oregon Health & Science University.
Implementation
Our care model was introduced in a step-wise approach over 10 months beginning in the fall of 2003. Subspecialists who had been providing rotating coverage on the general pediatric service were replaced on the wards as each new hospitalist was hired. With staffing now complete, the subspecialists can focus on other clinical and research endeavors. Doernbecher’s open staff policy allows community physicians to admit and follow their own patients; however, most community providers choose to admit their patients to the hospitalist service.
Schedule
The three hospitalists are scheduled in blocks of 3-7 days, each attending the equivalent of 13 weeks per year, weekends included. The general pediatricians provide coverage for the remaining weeks. Average daily census is 6-12, with a peak-season census of 10-16. The hospitalists are the primary attendings for the general pediatric patients and are available for consultation to any of 12 pediatric subspecialty and surgery services, as well as the emergency department. House staff presence allows for nighttime call from home. Additional off-service clinical responsibilities include supervision of resident clinic and attending in the newborn nursery.
Teaching
Our hospitalists are committed to education. We are responsible for the inpatient education of third-year medical students as well as first- and third-year pediatric and family practice residents. We play key roles in clerkship direction. We welcome sub-interns from our own institution and from across the country. We have embarked on formal and informal education efforts for nurses, as well, and we are striving to provide all members of our team with quality feedback.
Successes
We are fortunate to have had the incredible support of an experienced case manager and talented nursing director in implementing change on the inpatient unit. Together we have decreased length of stay by 500 bed days in 11 months, redesigned morning flow on the wards, and tackled systems challenges. We are proud of our successes in solidifying a sense of identity on the unit, and improving morale for physicians, nurses, and ancillary staff. We are grateful for the continued support of our colleagues in the PICU, on our subspecialty and surgery teams, and on our Kaiser inpatient pediatric service.
Challenges
Progress toward long-term fiscal independence is one of our biggest challenges. Hospitalists are salaried through hospital and school of medicine funds; like most academic programs with teaching missions, ours will need continued support.
Marketing efforts are underway to facilitate excellent communication with our referring physicians, improve access to care at our institution, and improve payer mix.
Future Directions
We are excited about the continued development of our young program. We are working on increasing collaboration with our subspecialty and surgical colleagues, as well as using evidence-based methods to implement additional best-practice guidelines. We are about to launch our new computer program for notes, billing, and data collection, with hopes of continuing to document decreases in length of stay and other financial benefits for the hospital. We are enthusiastic about implementing competency-based education and evaluation, and we look forward to interactions with others contributing to the pediatric hospitalist movement.
Contact
Windy Lammers Stevenson, MD
Inpatient Pediatric Service
Doernbecher Children’s Hospital
Oregon Health & Science University
707 SW Gaines St. CDRCP
Portland, Oregon 97239
Phone: 503-494-6513 Fax: 503-494-4953
E-mail: [email protected]
Start Up
2003
Hospitalists
Tracy Bumsted, MD, MPH
Carrie Phillipi, MD, PhD
Windy Lammers Stevenson, MD
General Pediatricians
Cynthia Ferrell, MD, MSEd
Arthur Jaff e, MD
C. Wayne Sells, MD, MPH
Scott Shipman, MD, MPH
Joseph Zenel, MD
The Program
The pediatric inpatient service at Doernbecher Children’s Hospital is a newly formed multidisciplinary team designed to creatively approach the continually evolving challenges of providing excellent inpatient care in the current financial environment.
Three pediatric hospitalists have joined forces with four general pediatricians and an adolescent specialist to assume care for all patients on the general pediatric inpatient service at this tertiary care academic medical center. A pediatric case manager and a nursing director complete our team. The eight board-certified physicians are members of the Division of General Pediatrics in the Department of Pediatrics at Oregon Health & Science University.
Implementation
Our care model was introduced in a step-wise approach over 10 months beginning in the fall of 2003. Subspecialists who had been providing rotating coverage on the general pediatric service were replaced on the wards as each new hospitalist was hired. With staffing now complete, the subspecialists can focus on other clinical and research endeavors. Doernbecher’s open staff policy allows community physicians to admit and follow their own patients; however, most community providers choose to admit their patients to the hospitalist service.
Schedule
The three hospitalists are scheduled in blocks of 3-7 days, each attending the equivalent of 13 weeks per year, weekends included. The general pediatricians provide coverage for the remaining weeks. Average daily census is 6-12, with a peak-season census of 10-16. The hospitalists are the primary attendings for the general pediatric patients and are available for consultation to any of 12 pediatric subspecialty and surgery services, as well as the emergency department. House staff presence allows for nighttime call from home. Additional off-service clinical responsibilities include supervision of resident clinic and attending in the newborn nursery.
Teaching
Our hospitalists are committed to education. We are responsible for the inpatient education of third-year medical students as well as first- and third-year pediatric and family practice residents. We play key roles in clerkship direction. We welcome sub-interns from our own institution and from across the country. We have embarked on formal and informal education efforts for nurses, as well, and we are striving to provide all members of our team with quality feedback.
Successes
We are fortunate to have had the incredible support of an experienced case manager and talented nursing director in implementing change on the inpatient unit. Together we have decreased length of stay by 500 bed days in 11 months, redesigned morning flow on the wards, and tackled systems challenges. We are proud of our successes in solidifying a sense of identity on the unit, and improving morale for physicians, nurses, and ancillary staff. We are grateful for the continued support of our colleagues in the PICU, on our subspecialty and surgery teams, and on our Kaiser inpatient pediatric service.
Challenges
Progress toward long-term fiscal independence is one of our biggest challenges. Hospitalists are salaried through hospital and school of medicine funds; like most academic programs with teaching missions, ours will need continued support.
Marketing efforts are underway to facilitate excellent communication with our referring physicians, improve access to care at our institution, and improve payer mix.
Future Directions
We are excited about the continued development of our young program. We are working on increasing collaboration with our subspecialty and surgical colleagues, as well as using evidence-based methods to implement additional best-practice guidelines. We are about to launch our new computer program for notes, billing, and data collection, with hopes of continuing to document decreases in length of stay and other financial benefits for the hospital. We are enthusiastic about implementing competency-based education and evaluation, and we look forward to interactions with others contributing to the pediatric hospitalist movement.
Contact
Windy Lammers Stevenson, MD
Inpatient Pediatric Service
Doernbecher Children’s Hospital
Oregon Health & Science University
707 SW Gaines St. CDRCP
Portland, Oregon 97239
Phone: 503-494-6513 Fax: 503-494-4953
E-mail: [email protected]
Start Up
2003
Hospitalists
Tracy Bumsted, MD, MPH
Carrie Phillipi, MD, PhD
Windy Lammers Stevenson, MD
General Pediatricians
Cynthia Ferrell, MD, MSEd
Arthur Jaff e, MD
C. Wayne Sells, MD, MPH
Scott Shipman, MD, MPH
Joseph Zenel, MD
The Program
The pediatric inpatient service at Doernbecher Children’s Hospital is a newly formed multidisciplinary team designed to creatively approach the continually evolving challenges of providing excellent inpatient care in the current financial environment.
Three pediatric hospitalists have joined forces with four general pediatricians and an adolescent specialist to assume care for all patients on the general pediatric inpatient service at this tertiary care academic medical center. A pediatric case manager and a nursing director complete our team. The eight board-certified physicians are members of the Division of General Pediatrics in the Department of Pediatrics at Oregon Health & Science University.
Implementation
Our care model was introduced in a step-wise approach over 10 months beginning in the fall of 2003. Subspecialists who had been providing rotating coverage on the general pediatric service were replaced on the wards as each new hospitalist was hired. With staffing now complete, the subspecialists can focus on other clinical and research endeavors. Doernbecher’s open staff policy allows community physicians to admit and follow their own patients; however, most community providers choose to admit their patients to the hospitalist service.
Schedule
The three hospitalists are scheduled in blocks of 3-7 days, each attending the equivalent of 13 weeks per year, weekends included. The general pediatricians provide coverage for the remaining weeks. Average daily census is 6-12, with a peak-season census of 10-16. The hospitalists are the primary attendings for the general pediatric patients and are available for consultation to any of 12 pediatric subspecialty and surgery services, as well as the emergency department. House staff presence allows for nighttime call from home. Additional off-service clinical responsibilities include supervision of resident clinic and attending in the newborn nursery.
Teaching
Our hospitalists are committed to education. We are responsible for the inpatient education of third-year medical students as well as first- and third-year pediatric and family practice residents. We play key roles in clerkship direction. We welcome sub-interns from our own institution and from across the country. We have embarked on formal and informal education efforts for nurses, as well, and we are striving to provide all members of our team with quality feedback.
Successes
We are fortunate to have had the incredible support of an experienced case manager and talented nursing director in implementing change on the inpatient unit. Together we have decreased length of stay by 500 bed days in 11 months, redesigned morning flow on the wards, and tackled systems challenges. We are proud of our successes in solidifying a sense of identity on the unit, and improving morale for physicians, nurses, and ancillary staff. We are grateful for the continued support of our colleagues in the PICU, on our subspecialty and surgery teams, and on our Kaiser inpatient pediatric service.
Challenges
Progress toward long-term fiscal independence is one of our biggest challenges. Hospitalists are salaried through hospital and school of medicine funds; like most academic programs with teaching missions, ours will need continued support.
Marketing efforts are underway to facilitate excellent communication with our referring physicians, improve access to care at our institution, and improve payer mix.
Future Directions
We are excited about the continued development of our young program. We are working on increasing collaboration with our subspecialty and surgical colleagues, as well as using evidence-based methods to implement additional best-practice guidelines. We are about to launch our new computer program for notes, billing, and data collection, with hopes of continuing to document decreases in length of stay and other financial benefits for the hospital. We are enthusiastic about implementing competency-based education and evaluation, and we look forward to interactions with others contributing to the pediatric hospitalist movement.
Other Literature of Interest
1. Annane D, Bellissant E, Briegel J, et al. Corticosteroids for severe sepsis and septic shock: a systematic review and metaanalysis. BMJ. 2004;329:480.
Severe sepsis is a common cause of ICU admissions and continues to have mortality rates as high as 30%. As research has evolved, the role of corticosteroids in sepsis has changed. Annane and colleagues systematically reviewed corticosteroid treatment for severe sepsis and septic shock. The authors found 15 randomized trials that evaluated their main outcome of all-cause mortality at 28 days. When these results were pooled there was no significant improvement in mortality (RR 0.98; 0.87 to 1.10). However, the analysis showed very significant heterogeneity, so the authors appropriately performed a sensitivity analysis based on an a priori hypothesis that low-dose, long-course steroids (≤ 300 mg hydrocortisone/day and ≥ 5 days) would provide greater benefit than short-course, high-dose corticosteroids. The sensitivity analysis of five studies with low-dose, long-course corticosteroids showed a clear reduction in 28-day mortality (RR 0.80; 0.67 to 0.95) with no heterogeneity. There was no statistically significant difference in GI bleeds, superinfections, and hyperglycemia.
This is a very well-done review, which included an exhaustive search for all available evidence. The authors conclude based on the findings of an individual study in the review that patients with septic shock should undergo adrenal insufficiency testing prior to starting empiric therapy with low-dose hydrocortisone (200-300 mg/day). Hydrocortisone should then be stopped if there is no evidence of adrenal insufficiency. However, none of the studies in this review were limited to patients with adrenal insufficiency. Also, although none of the studies individually showed a statistically significant improvement with corticosteroids, they all favored the steroid treatment group with RRs < 1. Although there is good evidence that septic shock patients with adrenal insufficiency should be treated with corticosteroids, it remains unclear if therapy should be generalized to all septic patients. The ongoing European CORTICUS trial should help answer some of these questions.
2. Baddour L.,Yu, V. and the International Pneumococcal Study Group. Combination antibiotic therapy lowers mortality among severely ill patients with pneumococcal bacteremia. Am J Resp Crit Care Med; 2004;170:440-444.
Three retrospective studies indicate that patients with pneumococcal bacteremia are less likely to die if treated with combination antibiotics. The combination of a beta-lactam and a macrolide appear to be especially protective. Based upon this soft data, multiple societies now recommend combination antibiotic therapy with a beta-lactam and a macrolide as first-line therapy for hospitalized patients with CAP. This large, multi-center, prospective observational study analyzed outcomes for all patients with pneumococcal bacteremia. Critically ill patients were eight times more likely to die than non-critically ill patients (mortality: 54.6% vs. 7.3%, p=0.0001). Combination therapy was defined as any two or more antibiotics used concurrently: multiple different regimens were used. The 14-day mortality difference between pneumococcal bacteremic patients receiving monotherapy vs. those receiving combination therapy was not significant (10.4 vs. 11.5%, p-value not disclosed) However, in critically ill patients, combination antibiotic therapy was associated with a marked decrease in mortality (23.4 vs. 55.3%, p=0.0015).
This study has significant limitations. It is not randomized, combination therapy was broadly defined as any two or more antibiotics, and 16% of critically ill patients received only one antibiotic, a major deviation from the standard of care. Nonetheless, this is the first prospective trial that attempts to ascertain which patients with pneumococcal bacteremia benefit from combination therapy. The marked mortality reduction in critically ill patients who received combination therapy reinforces the current recommendation that septic patients with pneumococcal bacteremia should receive combination therapy. However, these findings also underscore the fact that current guidelines for the treatment of an exceedingly common and serious disease are based upon weak retrospective data. Further randomized prospective trials are needed to determine which patients with pneumococcal pneumonia may actually benefit from combination antimicrobial therapy and what combination is most efficacious.
3. Fernandez-Avilles F, Alsonso J, Castro-Beivas A, et al, on behalf of the GRACIA (Grupo de Analisis de la Cardiopatio Isquemica Aguda) Group. Routine invasive strategy within 24 hours of thrombolysis versus ischemia-guided conservative approach for acute myocardial infarction with ST-segment elevation (GRACIA-1). Lancet;2004;364:045-1053
In the last ACC/AHA guidelines for acute myocardial infarction (1999), angioplasty soon after thrombolysis is strongly discouraged (class III) because studies to date showed no significant difference in outcomes and propensity for adverse events, i.e. bleeding. However, as stated in these last recommendations, the benefits of early post-thrombolysis percutaneous transluminal coronary angioplasty (PTCA) with stenting should be reassessed as interventional strategies mature. In the current era of stents and newer antiplatelet therapies, it looks as if now is the time to take another look.
The GRACIA-1 was a randomized, multi-centered trial to assess early intervention following thrombolysis in ST-elevation myocardial infarction (STEMI). Five hundred patients were enrolled and randomized to receive either fibrin-specific thrombolytics alone in the conservative group or thrombolysis combined with early PTCA. The primary endpoint was a combined rate of death, non-fatal reinfarction, or ischemia-induced revascularization at 1 year. Pre-discharge PTCA and stenting in those demonstrating recurrent ischemia in the conservative group (n=52) was analyzed as a secondary endpoint. One-year follow-up was completed in 98% of patients. Both groups had similar major cardiac events at 30 days, with the one-year endpoint demonstrating no difference in mortality. Significant differences were seen in the primary endpoint at one year [23 (9%) in the invasive group vs. 51 (21%) in the conservative group (RR-0.44, 95% CI 0.28-0.70 p=0.00008)].
A major limitation of this study was the low-risk profile of its patients, and the fact that it was not powered to differentiate between mortality and reinfarction. It will be interesting to see if these results are replicated in future studies (CARESS-2005) and their clinical impact on the management of acute myocardial infarction in centers without interventional support.
4. Hitcho EB, Krauss MJ, Birge S, et al. Characteristics and circumstances of falls in a hospital setting: a prospective analysis. J Gen Intern Med.2004;19:732-739.
Falls in hospital patients are common and persistent problems in hospitals across the country, with significant impact on patient safety, morbidity, and health care cost. Previous studies have reported up to 30% of inpatient falls result in injury, with 4-6% resulting in serious injury. Most studies on falls are retrospective reviews. This paper detailed a prospective observational study designed to identify and analyze the patient characteristics or the circumstances that contribute to falls. Using an online adverse event reporting system, patient falls were identified. Once identified, additional data sources, including the patients’ medical records, electronic nursing records, and interviews with patient or family members and nurses, were used to collect information. A total of 183 patients fell during the study period, with 85% of the falls occurring in the patient’s room.
Half of the falls involved bowel or bladder elimination and were more likely to occur in patients over 65 years in age (adjusted odds ratio 2.4; 95% confidence interval 1.1 to 5.3). Most of the falls (59%) occurred during the evening/overnight. 58% of the patients who fell had received agents with central nervous system activity in the 24 hours prior to a fall. 12% of the patients who fell received sedative-hypnotics. Repeat fallers were more likely to be men than women (11/86 [13%] vs 4/97 [4%]; p=0.03). 42% of the falls resulted in some type of injury, ranging from pain/swelling (34%) to cardiac arrest/death (0.5%). In multivariate analysis, only elimination-related falls remained a significant predictor of being injured from a fall (aOR , 2.4; 95% CI 1.1 to 5.3). Interestingly, patients who were confused or disoriented were less likely to be injured than alert and oriented patients (crude OR, 0.5; 95% CI, 0.3 to 0.98). When examined by services, medicine and neurology had the highest fall rate at 6.12 falls per 1000 patient days and had the highest patient-to-nurse ratio of 6.5 and 5.3, respectively.
While specific independent risk factors for prevention of falls could not be determined in this study due to a lack of a control group, their findings are consistent with previously identified risk factors for falling, including weakness, poor cognitive status including medication-related changes, and altered elimination. Potential interventions to prevent falls include toileting schedules for high-risk elderly patients and review of medication lists to minimize centrally acting, psychotropic, or sedating agents.
5. Kagansky N, Knobler H, Rimon E, Ozer Z, Levy S. Safety of anticoagulation therapy in well-informed older patients. Arch Intern Med; 2004;164:2044-2050
Elderly patients are increasingly likely to require long-term anticoagulation. Despite this, physicians often withhold long-term anticoagulation due to perceived risk factors for bleeding, including age, comorbidity, and cognitive or functional impairment.
This combination retrospective and prospective observational study evaluated the safety and quality of anticoagulation in elderly patients. Over a three-year span, 323 elderly patients were discharged on warfarin from a large Israeli hospital. These patients were frail and potentially “at risk”; 54% were older than age 80, 81% were uneducated, and 84% had low income. 47% were considered cognitively intact (according to MMSE) and only 34% were functionally independent. Using a multivariate analysis, the authors determined that only poor quality of anticoagulation education (OR: 8.83; 95% CI: 2.0-50.2), polypharmacy (OR: 6.14; 95% CI 1.2-42.4) and INR >3 (OR: 1.08; 95% CI 1.03-1.14) were associated with major bleeding.
This study of a “real world” population of frail, at-risk elderly patients provides important insights into risks for major bleeding resulting from warfarin therapy. Surprisingly, advanced age, cognitive impairment and markers for frailty did not confer elevated risk for major bleeding. Importantly, the study did not explicitly address patient fall risk, an often-cited reason for withholding anticoagulation therapy. Supratherapeutic anticoagulation is associated with a statistically but not clinically significant bleeding risk. Polypharmacy is increasingly unavoidable in elderly patients. However, appropriate anticoagulation therapy should be the standard of care. This study makes it clear that we need to focus our efforts on ensuring that elderly patients and their caregivers receive appropriate anticoagulation education prior to discharge from the hospital.
6. Prinssen M, Verhoeven E, Buth J, et al. A Randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. NEJM. 2004;351:1607-18.
Endovascular repair of abdominal aortic aneurysm, which involves percutaneous introduction of a graft to bridge an aortic aneurysm, has been available since the early 1990s. This procedure was initially used in patients who were felt to be at high risk for the traditional open procedure. This selection bias may have affected the outcome of earlier studies. Therefore, the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial was designed to assess outcomes in patients deemed fit to undergo either open or endovascular repair. The study was conducted at 24 centers in the Netherlands and four centers in Belgium. Three hundred and forty-five patients had abdominal aortic aneurysms of at least 5 cm and were considered eligible for either open or endovascular repair. Patients were then randomized to undergo one procedure or the other.
Surgeons experienced in both endovascular and open repair performed the procedures. Primary outcomes were 30-day mortality (defined as death during the primary hospital admission or within 30 days), severe complications, and the combination of the two. The operative mortality rate was 4.6% in the open-repair group and 1.2% in the endovascular repair group, with a risk ratio of 3.9 (95% CI, 0.9-32.9). The combined endpoint of mortality and severe complication was 9.8% in the open-repair group and 4.7% in the endovascular repair group, with a risk ratio of 2.1 (95% CI, 0.9 to 5.4). It should be noted that 90% of study patients were men. These findings indicate that endovascular repair of aortic aneurysm results in less short-term morbidity and mortality than open repair. Larger studies with longer follow up are indicated.
7. Spargias K, Alexopoulos E, Kyrzopoulos S. Ascorbic acid prevents contrast-mediated nephropathy in patients with renal dysfunction undergoing coronary angiography or intervention. Circulation.110(18)2837-42
In this study, a team of Greek researchers studied the use of vitamin C in patients with renal insufficiency (creatinine >1.2) undergoing coronary catheterization or intervention to determine if it prevented contrast-mediated nephropathy (CMN). Although the etiology of CMN is unknown, ischemic insults to the renal medulla and free radical release have been implicated. Since vitamin C has been shown in animal studies to attenuate nephropathy when administered with known renal toxins, a similar effect was postulated when administered with IV contrast.
Two hundred and twenty patients electively admitted for coronary catheterization or intervention were randomized to placebo or to receive 3 grams of vitamin C 2 hours prior to the dye load followed by 2 gm that night and the morning after. The two groups were balanced for presence of hypertension, diabetes, tobacco use, and use of commonly prescribed medications. Intravenous hydration was given to all at variable rates depending on left ventricular ejection fraction. The catheterization team chose the type of contrast agent. Creatinine was measured at baseline (up to 3 months prior to dye load) and 2-5 days afterwards. CMN was defined as a rise in total serum creatinine by 0.5 mg/dL or by 25%. Using these criteria, 9% of the vitamin C group developed CMN as opposed to 20% in the controls (NNT 9; 95% CI: 5-53). Logistical regression was performed to account for differences in age, initial serum creatinine, or both, and always yielded significant differences. The treatment group was slightly older, had higher rates of isoosmolar contrast administration (reno-protective), and had slightly higher baseline creatinines, so the true protective effect was thought even higher than reported.
This study is limited by small sample size, an overwhelmingly male patient base (90%), and the suspected presence of atherosclerotic heart disease in all patients. The amount and rate of delivery of contrast was not noted. The vitamin C preparation used was not described, implying that all preparations were bioequivalent. No mention was made of whether these results could be extrapolated to other procedures involving contrast. Given the low cost and high tolerability of vitamin C, however, further studies would certainly be welcome.
8. Yadav J, Wholey M, Kuntz R, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. NEJM.2004;351:1493-1501.
Carotid angioplasty has been available for the past decade, but, due to possible complications such as plaque embolization and stent compression, the procedure had been limited to patients unsuitable for surgical endarterectomy. Recently, the introduction of crush-resistant nitinol stents and emboli protection devices has made the procedure safer. This study was designed to test the hypothesis that angioplasty and stenting is not inferior to endarterectomy. Three hundred and thirty-four patients at 29 centers had either a symptomatic carotid lesion greater than 50% or asymptomatic lesion greater than 80% and were deemed to be suitable candidates for either carotid endarterectomy or angioplasty. Patients were then randomized to one of the treatment groups. Surgeons, cardiologists, or interventional radiologists performed angioplasty. The primary endpoint was a composite of death, stroke, or MI within 30 days of the procedure, or death or stroke between 31 days and one year.
Secondary endpoints were the need for revascularization and cranial-nerve palsy at one year. During the first month after procedure, 4.8% of patients in the stent group and 9.8% of patients in the surgical group reached the primary endpoint. In the subsequent year, 12.2% of stent patients and 20.1% of surgical patients reached the primary endpoint (absolute risk reduction of 7.9, CI 0.7-16.4 and NNT 14). Cranial nerve palsy at one year was 0% vs. 4.9% in the stent vs. surgical group. Need for revascularization at one year was 0.6% vs. 4.3% for stent vs. surgical group. Although this study was designed to show the non-inferiority of angioplasty vs. carotid endarterectomy in patients deemed suitable for either procedure, it actually was statistically significant for superiority of stenting. It also implied a lower complication rate in terms of cranial nerve palsy and the need for revascularization at one year made the procedure safer. This study was designed to test the hypothesis that angioplasty and stenting is not inferior to endarterectomy. Three hundred and thirty-four patients at 29 centers had either a symptomatic carotid lesion greater than 50% or asymptomatic lesion greater than 80% and were deemed to be suitable candidates for either carotid endarterectomy or angioplasty. Patients were then randomized to one of the treatment groups. Surgeons, cardiologists, or interventional radiologists performed angioplasty. The primary endpoint was a composite of death, stroke, or MI within 30 days of the procedure, or death or stroke between 31 days and one year.
Secondary endpoints were the need for revascularization and cranial-nerve palsy at one year. During the first month after procedure, 4.8% of patients in the stent group and 9.8% of patients in the surgical group reached the primary endpoint. In the subsequent year, 12.2% of stent patients and 20.1% of surgical patients reached the primary endpoint (absolute risk reduction of 7.9, CI 0.7-16.4 and NNT 14). Cranial nerve palsy at one year was 0% vs. 4.9% in the stent vs. surgical group. Need for revascularization at one year was 0.6% vs. 4.3% for stent vs. surgical group. Although this study was designed to show the non-inferiority of angioplasty vs. carotid endarterectomy in patients deemed suitable for either procedure, it actually was statistically significant for superiority of stenting. It also implied a lower complication rate in terms of cranial nerve palsy and the need for revascularization at one year.
1. Annane D, Bellissant E, Briegel J, et al. Corticosteroids for severe sepsis and septic shock: a systematic review and metaanalysis. BMJ. 2004;329:480.
Severe sepsis is a common cause of ICU admissions and continues to have mortality rates as high as 30%. As research has evolved, the role of corticosteroids in sepsis has changed. Annane and colleagues systematically reviewed corticosteroid treatment for severe sepsis and septic shock. The authors found 15 randomized trials that evaluated their main outcome of all-cause mortality at 28 days. When these results were pooled there was no significant improvement in mortality (RR 0.98; 0.87 to 1.10). However, the analysis showed very significant heterogeneity, so the authors appropriately performed a sensitivity analysis based on an a priori hypothesis that low-dose, long-course steroids (≤ 300 mg hydrocortisone/day and ≥ 5 days) would provide greater benefit than short-course, high-dose corticosteroids. The sensitivity analysis of five studies with low-dose, long-course corticosteroids showed a clear reduction in 28-day mortality (RR 0.80; 0.67 to 0.95) with no heterogeneity. There was no statistically significant difference in GI bleeds, superinfections, and hyperglycemia.
This is a very well-done review, which included an exhaustive search for all available evidence. The authors conclude based on the findings of an individual study in the review that patients with septic shock should undergo adrenal insufficiency testing prior to starting empiric therapy with low-dose hydrocortisone (200-300 mg/day). Hydrocortisone should then be stopped if there is no evidence of adrenal insufficiency. However, none of the studies in this review were limited to patients with adrenal insufficiency. Also, although none of the studies individually showed a statistically significant improvement with corticosteroids, they all favored the steroid treatment group with RRs < 1. Although there is good evidence that septic shock patients with adrenal insufficiency should be treated with corticosteroids, it remains unclear if therapy should be generalized to all septic patients. The ongoing European CORTICUS trial should help answer some of these questions.
2. Baddour L.,Yu, V. and the International Pneumococcal Study Group. Combination antibiotic therapy lowers mortality among severely ill patients with pneumococcal bacteremia. Am J Resp Crit Care Med; 2004;170:440-444.
Three retrospective studies indicate that patients with pneumococcal bacteremia are less likely to die if treated with combination antibiotics. The combination of a beta-lactam and a macrolide appear to be especially protective. Based upon this soft data, multiple societies now recommend combination antibiotic therapy with a beta-lactam and a macrolide as first-line therapy for hospitalized patients with CAP. This large, multi-center, prospective observational study analyzed outcomes for all patients with pneumococcal bacteremia. Critically ill patients were eight times more likely to die than non-critically ill patients (mortality: 54.6% vs. 7.3%, p=0.0001). Combination therapy was defined as any two or more antibiotics used concurrently: multiple different regimens were used. The 14-day mortality difference between pneumococcal bacteremic patients receiving monotherapy vs. those receiving combination therapy was not significant (10.4 vs. 11.5%, p-value not disclosed) However, in critically ill patients, combination antibiotic therapy was associated with a marked decrease in mortality (23.4 vs. 55.3%, p=0.0015).
This study has significant limitations. It is not randomized, combination therapy was broadly defined as any two or more antibiotics, and 16% of critically ill patients received only one antibiotic, a major deviation from the standard of care. Nonetheless, this is the first prospective trial that attempts to ascertain which patients with pneumococcal bacteremia benefit from combination therapy. The marked mortality reduction in critically ill patients who received combination therapy reinforces the current recommendation that septic patients with pneumococcal bacteremia should receive combination therapy. However, these findings also underscore the fact that current guidelines for the treatment of an exceedingly common and serious disease are based upon weak retrospective data. Further randomized prospective trials are needed to determine which patients with pneumococcal pneumonia may actually benefit from combination antimicrobial therapy and what combination is most efficacious.
3. Fernandez-Avilles F, Alsonso J, Castro-Beivas A, et al, on behalf of the GRACIA (Grupo de Analisis de la Cardiopatio Isquemica Aguda) Group. Routine invasive strategy within 24 hours of thrombolysis versus ischemia-guided conservative approach for acute myocardial infarction with ST-segment elevation (GRACIA-1). Lancet;2004;364:045-1053
In the last ACC/AHA guidelines for acute myocardial infarction (1999), angioplasty soon after thrombolysis is strongly discouraged (class III) because studies to date showed no significant difference in outcomes and propensity for adverse events, i.e. bleeding. However, as stated in these last recommendations, the benefits of early post-thrombolysis percutaneous transluminal coronary angioplasty (PTCA) with stenting should be reassessed as interventional strategies mature. In the current era of stents and newer antiplatelet therapies, it looks as if now is the time to take another look.
The GRACIA-1 was a randomized, multi-centered trial to assess early intervention following thrombolysis in ST-elevation myocardial infarction (STEMI). Five hundred patients were enrolled and randomized to receive either fibrin-specific thrombolytics alone in the conservative group or thrombolysis combined with early PTCA. The primary endpoint was a combined rate of death, non-fatal reinfarction, or ischemia-induced revascularization at 1 year. Pre-discharge PTCA and stenting in those demonstrating recurrent ischemia in the conservative group (n=52) was analyzed as a secondary endpoint. One-year follow-up was completed in 98% of patients. Both groups had similar major cardiac events at 30 days, with the one-year endpoint demonstrating no difference in mortality. Significant differences were seen in the primary endpoint at one year [23 (9%) in the invasive group vs. 51 (21%) in the conservative group (RR-0.44, 95% CI 0.28-0.70 p=0.00008)].
A major limitation of this study was the low-risk profile of its patients, and the fact that it was not powered to differentiate between mortality and reinfarction. It will be interesting to see if these results are replicated in future studies (CARESS-2005) and their clinical impact on the management of acute myocardial infarction in centers without interventional support.
4. Hitcho EB, Krauss MJ, Birge S, et al. Characteristics and circumstances of falls in a hospital setting: a prospective analysis. J Gen Intern Med.2004;19:732-739.
Falls in hospital patients are common and persistent problems in hospitals across the country, with significant impact on patient safety, morbidity, and health care cost. Previous studies have reported up to 30% of inpatient falls result in injury, with 4-6% resulting in serious injury. Most studies on falls are retrospective reviews. This paper detailed a prospective observational study designed to identify and analyze the patient characteristics or the circumstances that contribute to falls. Using an online adverse event reporting system, patient falls were identified. Once identified, additional data sources, including the patients’ medical records, electronic nursing records, and interviews with patient or family members and nurses, were used to collect information. A total of 183 patients fell during the study period, with 85% of the falls occurring in the patient’s room.
Half of the falls involved bowel or bladder elimination and were more likely to occur in patients over 65 years in age (adjusted odds ratio 2.4; 95% confidence interval 1.1 to 5.3). Most of the falls (59%) occurred during the evening/overnight. 58% of the patients who fell had received agents with central nervous system activity in the 24 hours prior to a fall. 12% of the patients who fell received sedative-hypnotics. Repeat fallers were more likely to be men than women (11/86 [13%] vs 4/97 [4%]; p=0.03). 42% of the falls resulted in some type of injury, ranging from pain/swelling (34%) to cardiac arrest/death (0.5%). In multivariate analysis, only elimination-related falls remained a significant predictor of being injured from a fall (aOR , 2.4; 95% CI 1.1 to 5.3). Interestingly, patients who were confused or disoriented were less likely to be injured than alert and oriented patients (crude OR, 0.5; 95% CI, 0.3 to 0.98). When examined by services, medicine and neurology had the highest fall rate at 6.12 falls per 1000 patient days and had the highest patient-to-nurse ratio of 6.5 and 5.3, respectively.
While specific independent risk factors for prevention of falls could not be determined in this study due to a lack of a control group, their findings are consistent with previously identified risk factors for falling, including weakness, poor cognitive status including medication-related changes, and altered elimination. Potential interventions to prevent falls include toileting schedules for high-risk elderly patients and review of medication lists to minimize centrally acting, psychotropic, or sedating agents.
5. Kagansky N, Knobler H, Rimon E, Ozer Z, Levy S. Safety of anticoagulation therapy in well-informed older patients. Arch Intern Med; 2004;164:2044-2050
Elderly patients are increasingly likely to require long-term anticoagulation. Despite this, physicians often withhold long-term anticoagulation due to perceived risk factors for bleeding, including age, comorbidity, and cognitive or functional impairment.
This combination retrospective and prospective observational study evaluated the safety and quality of anticoagulation in elderly patients. Over a three-year span, 323 elderly patients were discharged on warfarin from a large Israeli hospital. These patients were frail and potentially “at risk”; 54% were older than age 80, 81% were uneducated, and 84% had low income. 47% were considered cognitively intact (according to MMSE) and only 34% were functionally independent. Using a multivariate analysis, the authors determined that only poor quality of anticoagulation education (OR: 8.83; 95% CI: 2.0-50.2), polypharmacy (OR: 6.14; 95% CI 1.2-42.4) and INR >3 (OR: 1.08; 95% CI 1.03-1.14) were associated with major bleeding.
This study of a “real world” population of frail, at-risk elderly patients provides important insights into risks for major bleeding resulting from warfarin therapy. Surprisingly, advanced age, cognitive impairment and markers for frailty did not confer elevated risk for major bleeding. Importantly, the study did not explicitly address patient fall risk, an often-cited reason for withholding anticoagulation therapy. Supratherapeutic anticoagulation is associated with a statistically but not clinically significant bleeding risk. Polypharmacy is increasingly unavoidable in elderly patients. However, appropriate anticoagulation therapy should be the standard of care. This study makes it clear that we need to focus our efforts on ensuring that elderly patients and their caregivers receive appropriate anticoagulation education prior to discharge from the hospital.
6. Prinssen M, Verhoeven E, Buth J, et al. A Randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. NEJM. 2004;351:1607-18.
Endovascular repair of abdominal aortic aneurysm, which involves percutaneous introduction of a graft to bridge an aortic aneurysm, has been available since the early 1990s. This procedure was initially used in patients who were felt to be at high risk for the traditional open procedure. This selection bias may have affected the outcome of earlier studies. Therefore, the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial was designed to assess outcomes in patients deemed fit to undergo either open or endovascular repair. The study was conducted at 24 centers in the Netherlands and four centers in Belgium. Three hundred and forty-five patients had abdominal aortic aneurysms of at least 5 cm and were considered eligible for either open or endovascular repair. Patients were then randomized to undergo one procedure or the other.
Surgeons experienced in both endovascular and open repair performed the procedures. Primary outcomes were 30-day mortality (defined as death during the primary hospital admission or within 30 days), severe complications, and the combination of the two. The operative mortality rate was 4.6% in the open-repair group and 1.2% in the endovascular repair group, with a risk ratio of 3.9 (95% CI, 0.9-32.9). The combined endpoint of mortality and severe complication was 9.8% in the open-repair group and 4.7% in the endovascular repair group, with a risk ratio of 2.1 (95% CI, 0.9 to 5.4). It should be noted that 90% of study patients were men. These findings indicate that endovascular repair of aortic aneurysm results in less short-term morbidity and mortality than open repair. Larger studies with longer follow up are indicated.
7. Spargias K, Alexopoulos E, Kyrzopoulos S. Ascorbic acid prevents contrast-mediated nephropathy in patients with renal dysfunction undergoing coronary angiography or intervention. Circulation.110(18)2837-42
In this study, a team of Greek researchers studied the use of vitamin C in patients with renal insufficiency (creatinine >1.2) undergoing coronary catheterization or intervention to determine if it prevented contrast-mediated nephropathy (CMN). Although the etiology of CMN is unknown, ischemic insults to the renal medulla and free radical release have been implicated. Since vitamin C has been shown in animal studies to attenuate nephropathy when administered with known renal toxins, a similar effect was postulated when administered with IV contrast.
Two hundred and twenty patients electively admitted for coronary catheterization or intervention were randomized to placebo or to receive 3 grams of vitamin C 2 hours prior to the dye load followed by 2 gm that night and the morning after. The two groups were balanced for presence of hypertension, diabetes, tobacco use, and use of commonly prescribed medications. Intravenous hydration was given to all at variable rates depending on left ventricular ejection fraction. The catheterization team chose the type of contrast agent. Creatinine was measured at baseline (up to 3 months prior to dye load) and 2-5 days afterwards. CMN was defined as a rise in total serum creatinine by 0.5 mg/dL or by 25%. Using these criteria, 9% of the vitamin C group developed CMN as opposed to 20% in the controls (NNT 9; 95% CI: 5-53). Logistical regression was performed to account for differences in age, initial serum creatinine, or both, and always yielded significant differences. The treatment group was slightly older, had higher rates of isoosmolar contrast administration (reno-protective), and had slightly higher baseline creatinines, so the true protective effect was thought even higher than reported.
This study is limited by small sample size, an overwhelmingly male patient base (90%), and the suspected presence of atherosclerotic heart disease in all patients. The amount and rate of delivery of contrast was not noted. The vitamin C preparation used was not described, implying that all preparations were bioequivalent. No mention was made of whether these results could be extrapolated to other procedures involving contrast. Given the low cost and high tolerability of vitamin C, however, further studies would certainly be welcome.
8. Yadav J, Wholey M, Kuntz R, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. NEJM.2004;351:1493-1501.
Carotid angioplasty has been available for the past decade, but, due to possible complications such as plaque embolization and stent compression, the procedure had been limited to patients unsuitable for surgical endarterectomy. Recently, the introduction of crush-resistant nitinol stents and emboli protection devices has made the procedure safer. This study was designed to test the hypothesis that angioplasty and stenting is not inferior to endarterectomy. Three hundred and thirty-four patients at 29 centers had either a symptomatic carotid lesion greater than 50% or asymptomatic lesion greater than 80% and were deemed to be suitable candidates for either carotid endarterectomy or angioplasty. Patients were then randomized to one of the treatment groups. Surgeons, cardiologists, or interventional radiologists performed angioplasty. The primary endpoint was a composite of death, stroke, or MI within 30 days of the procedure, or death or stroke between 31 days and one year.
Secondary endpoints were the need for revascularization and cranial-nerve palsy at one year. During the first month after procedure, 4.8% of patients in the stent group and 9.8% of patients in the surgical group reached the primary endpoint. In the subsequent year, 12.2% of stent patients and 20.1% of surgical patients reached the primary endpoint (absolute risk reduction of 7.9, CI 0.7-16.4 and NNT 14). Cranial nerve palsy at one year was 0% vs. 4.9% in the stent vs. surgical group. Need for revascularization at one year was 0.6% vs. 4.3% for stent vs. surgical group. Although this study was designed to show the non-inferiority of angioplasty vs. carotid endarterectomy in patients deemed suitable for either procedure, it actually was statistically significant for superiority of stenting. It also implied a lower complication rate in terms of cranial nerve palsy and the need for revascularization at one year made the procedure safer. This study was designed to test the hypothesis that angioplasty and stenting is not inferior to endarterectomy. Three hundred and thirty-four patients at 29 centers had either a symptomatic carotid lesion greater than 50% or asymptomatic lesion greater than 80% and were deemed to be suitable candidates for either carotid endarterectomy or angioplasty. Patients were then randomized to one of the treatment groups. Surgeons, cardiologists, or interventional radiologists performed angioplasty. The primary endpoint was a composite of death, stroke, or MI within 30 days of the procedure, or death or stroke between 31 days and one year.
Secondary endpoints were the need for revascularization and cranial-nerve palsy at one year. During the first month after procedure, 4.8% of patients in the stent group and 9.8% of patients in the surgical group reached the primary endpoint. In the subsequent year, 12.2% of stent patients and 20.1% of surgical patients reached the primary endpoint (absolute risk reduction of 7.9, CI 0.7-16.4 and NNT 14). Cranial nerve palsy at one year was 0% vs. 4.9% in the stent vs. surgical group. Need for revascularization at one year was 0.6% vs. 4.3% for stent vs. surgical group. Although this study was designed to show the non-inferiority of angioplasty vs. carotid endarterectomy in patients deemed suitable for either procedure, it actually was statistically significant for superiority of stenting. It also implied a lower complication rate in terms of cranial nerve palsy and the need for revascularization at one year.
1. Annane D, Bellissant E, Briegel J, et al. Corticosteroids for severe sepsis and septic shock: a systematic review and metaanalysis. BMJ. 2004;329:480.
Severe sepsis is a common cause of ICU admissions and continues to have mortality rates as high as 30%. As research has evolved, the role of corticosteroids in sepsis has changed. Annane and colleagues systematically reviewed corticosteroid treatment for severe sepsis and septic shock. The authors found 15 randomized trials that evaluated their main outcome of all-cause mortality at 28 days. When these results were pooled there was no significant improvement in mortality (RR 0.98; 0.87 to 1.10). However, the analysis showed very significant heterogeneity, so the authors appropriately performed a sensitivity analysis based on an a priori hypothesis that low-dose, long-course steroids (≤ 300 mg hydrocortisone/day and ≥ 5 days) would provide greater benefit than short-course, high-dose corticosteroids. The sensitivity analysis of five studies with low-dose, long-course corticosteroids showed a clear reduction in 28-day mortality (RR 0.80; 0.67 to 0.95) with no heterogeneity. There was no statistically significant difference in GI bleeds, superinfections, and hyperglycemia.
This is a very well-done review, which included an exhaustive search for all available evidence. The authors conclude based on the findings of an individual study in the review that patients with septic shock should undergo adrenal insufficiency testing prior to starting empiric therapy with low-dose hydrocortisone (200-300 mg/day). Hydrocortisone should then be stopped if there is no evidence of adrenal insufficiency. However, none of the studies in this review were limited to patients with adrenal insufficiency. Also, although none of the studies individually showed a statistically significant improvement with corticosteroids, they all favored the steroid treatment group with RRs < 1. Although there is good evidence that septic shock patients with adrenal insufficiency should be treated with corticosteroids, it remains unclear if therapy should be generalized to all septic patients. The ongoing European CORTICUS trial should help answer some of these questions.
2. Baddour L.,Yu, V. and the International Pneumococcal Study Group. Combination antibiotic therapy lowers mortality among severely ill patients with pneumococcal bacteremia. Am J Resp Crit Care Med; 2004;170:440-444.
Three retrospective studies indicate that patients with pneumococcal bacteremia are less likely to die if treated with combination antibiotics. The combination of a beta-lactam and a macrolide appear to be especially protective. Based upon this soft data, multiple societies now recommend combination antibiotic therapy with a beta-lactam and a macrolide as first-line therapy for hospitalized patients with CAP. This large, multi-center, prospective observational study analyzed outcomes for all patients with pneumococcal bacteremia. Critically ill patients were eight times more likely to die than non-critically ill patients (mortality: 54.6% vs. 7.3%, p=0.0001). Combination therapy was defined as any two or more antibiotics used concurrently: multiple different regimens were used. The 14-day mortality difference between pneumococcal bacteremic patients receiving monotherapy vs. those receiving combination therapy was not significant (10.4 vs. 11.5%, p-value not disclosed) However, in critically ill patients, combination antibiotic therapy was associated with a marked decrease in mortality (23.4 vs. 55.3%, p=0.0015).
This study has significant limitations. It is not randomized, combination therapy was broadly defined as any two or more antibiotics, and 16% of critically ill patients received only one antibiotic, a major deviation from the standard of care. Nonetheless, this is the first prospective trial that attempts to ascertain which patients with pneumococcal bacteremia benefit from combination therapy. The marked mortality reduction in critically ill patients who received combination therapy reinforces the current recommendation that septic patients with pneumococcal bacteremia should receive combination therapy. However, these findings also underscore the fact that current guidelines for the treatment of an exceedingly common and serious disease are based upon weak retrospective data. Further randomized prospective trials are needed to determine which patients with pneumococcal pneumonia may actually benefit from combination antimicrobial therapy and what combination is most efficacious.
3. Fernandez-Avilles F, Alsonso J, Castro-Beivas A, et al, on behalf of the GRACIA (Grupo de Analisis de la Cardiopatio Isquemica Aguda) Group. Routine invasive strategy within 24 hours of thrombolysis versus ischemia-guided conservative approach for acute myocardial infarction with ST-segment elevation (GRACIA-1). Lancet;2004;364:045-1053
In the last ACC/AHA guidelines for acute myocardial infarction (1999), angioplasty soon after thrombolysis is strongly discouraged (class III) because studies to date showed no significant difference in outcomes and propensity for adverse events, i.e. bleeding. However, as stated in these last recommendations, the benefits of early post-thrombolysis percutaneous transluminal coronary angioplasty (PTCA) with stenting should be reassessed as interventional strategies mature. In the current era of stents and newer antiplatelet therapies, it looks as if now is the time to take another look.
The GRACIA-1 was a randomized, multi-centered trial to assess early intervention following thrombolysis in ST-elevation myocardial infarction (STEMI). Five hundred patients were enrolled and randomized to receive either fibrin-specific thrombolytics alone in the conservative group or thrombolysis combined with early PTCA. The primary endpoint was a combined rate of death, non-fatal reinfarction, or ischemia-induced revascularization at 1 year. Pre-discharge PTCA and stenting in those demonstrating recurrent ischemia in the conservative group (n=52) was analyzed as a secondary endpoint. One-year follow-up was completed in 98% of patients. Both groups had similar major cardiac events at 30 days, with the one-year endpoint demonstrating no difference in mortality. Significant differences were seen in the primary endpoint at one year [23 (9%) in the invasive group vs. 51 (21%) in the conservative group (RR-0.44, 95% CI 0.28-0.70 p=0.00008)].
A major limitation of this study was the low-risk profile of its patients, and the fact that it was not powered to differentiate between mortality and reinfarction. It will be interesting to see if these results are replicated in future studies (CARESS-2005) and their clinical impact on the management of acute myocardial infarction in centers without interventional support.
4. Hitcho EB, Krauss MJ, Birge S, et al. Characteristics and circumstances of falls in a hospital setting: a prospective analysis. J Gen Intern Med.2004;19:732-739.
Falls in hospital patients are common and persistent problems in hospitals across the country, with significant impact on patient safety, morbidity, and health care cost. Previous studies have reported up to 30% of inpatient falls result in injury, with 4-6% resulting in serious injury. Most studies on falls are retrospective reviews. This paper detailed a prospective observational study designed to identify and analyze the patient characteristics or the circumstances that contribute to falls. Using an online adverse event reporting system, patient falls were identified. Once identified, additional data sources, including the patients’ medical records, electronic nursing records, and interviews with patient or family members and nurses, were used to collect information. A total of 183 patients fell during the study period, with 85% of the falls occurring in the patient’s room.
Half of the falls involved bowel or bladder elimination and were more likely to occur in patients over 65 years in age (adjusted odds ratio 2.4; 95% confidence interval 1.1 to 5.3). Most of the falls (59%) occurred during the evening/overnight. 58% of the patients who fell had received agents with central nervous system activity in the 24 hours prior to a fall. 12% of the patients who fell received sedative-hypnotics. Repeat fallers were more likely to be men than women (11/86 [13%] vs 4/97 [4%]; p=0.03). 42% of the falls resulted in some type of injury, ranging from pain/swelling (34%) to cardiac arrest/death (0.5%). In multivariate analysis, only elimination-related falls remained a significant predictor of being injured from a fall (aOR , 2.4; 95% CI 1.1 to 5.3). Interestingly, patients who were confused or disoriented were less likely to be injured than alert and oriented patients (crude OR, 0.5; 95% CI, 0.3 to 0.98). When examined by services, medicine and neurology had the highest fall rate at 6.12 falls per 1000 patient days and had the highest patient-to-nurse ratio of 6.5 and 5.3, respectively.
While specific independent risk factors for prevention of falls could not be determined in this study due to a lack of a control group, their findings are consistent with previously identified risk factors for falling, including weakness, poor cognitive status including medication-related changes, and altered elimination. Potential interventions to prevent falls include toileting schedules for high-risk elderly patients and review of medication lists to minimize centrally acting, psychotropic, or sedating agents.
5. Kagansky N, Knobler H, Rimon E, Ozer Z, Levy S. Safety of anticoagulation therapy in well-informed older patients. Arch Intern Med; 2004;164:2044-2050
Elderly patients are increasingly likely to require long-term anticoagulation. Despite this, physicians often withhold long-term anticoagulation due to perceived risk factors for bleeding, including age, comorbidity, and cognitive or functional impairment.
This combination retrospective and prospective observational study evaluated the safety and quality of anticoagulation in elderly patients. Over a three-year span, 323 elderly patients were discharged on warfarin from a large Israeli hospital. These patients were frail and potentially “at risk”; 54% were older than age 80, 81% were uneducated, and 84% had low income. 47% were considered cognitively intact (according to MMSE) and only 34% were functionally independent. Using a multivariate analysis, the authors determined that only poor quality of anticoagulation education (OR: 8.83; 95% CI: 2.0-50.2), polypharmacy (OR: 6.14; 95% CI 1.2-42.4) and INR >3 (OR: 1.08; 95% CI 1.03-1.14) were associated with major bleeding.
This study of a “real world” population of frail, at-risk elderly patients provides important insights into risks for major bleeding resulting from warfarin therapy. Surprisingly, advanced age, cognitive impairment and markers for frailty did not confer elevated risk for major bleeding. Importantly, the study did not explicitly address patient fall risk, an often-cited reason for withholding anticoagulation therapy. Supratherapeutic anticoagulation is associated with a statistically but not clinically significant bleeding risk. Polypharmacy is increasingly unavoidable in elderly patients. However, appropriate anticoagulation therapy should be the standard of care. This study makes it clear that we need to focus our efforts on ensuring that elderly patients and their caregivers receive appropriate anticoagulation education prior to discharge from the hospital.
6. Prinssen M, Verhoeven E, Buth J, et al. A Randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. NEJM. 2004;351:1607-18.
Endovascular repair of abdominal aortic aneurysm, which involves percutaneous introduction of a graft to bridge an aortic aneurysm, has been available since the early 1990s. This procedure was initially used in patients who were felt to be at high risk for the traditional open procedure. This selection bias may have affected the outcome of earlier studies. Therefore, the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial was designed to assess outcomes in patients deemed fit to undergo either open or endovascular repair. The study was conducted at 24 centers in the Netherlands and four centers in Belgium. Three hundred and forty-five patients had abdominal aortic aneurysms of at least 5 cm and were considered eligible for either open or endovascular repair. Patients were then randomized to undergo one procedure or the other.
Surgeons experienced in both endovascular and open repair performed the procedures. Primary outcomes were 30-day mortality (defined as death during the primary hospital admission or within 30 days), severe complications, and the combination of the two. The operative mortality rate was 4.6% in the open-repair group and 1.2% in the endovascular repair group, with a risk ratio of 3.9 (95% CI, 0.9-32.9). The combined endpoint of mortality and severe complication was 9.8% in the open-repair group and 4.7% in the endovascular repair group, with a risk ratio of 2.1 (95% CI, 0.9 to 5.4). It should be noted that 90% of study patients were men. These findings indicate that endovascular repair of aortic aneurysm results in less short-term morbidity and mortality than open repair. Larger studies with longer follow up are indicated.
7. Spargias K, Alexopoulos E, Kyrzopoulos S. Ascorbic acid prevents contrast-mediated nephropathy in patients with renal dysfunction undergoing coronary angiography or intervention. Circulation.110(18)2837-42
In this study, a team of Greek researchers studied the use of vitamin C in patients with renal insufficiency (creatinine >1.2) undergoing coronary catheterization or intervention to determine if it prevented contrast-mediated nephropathy (CMN). Although the etiology of CMN is unknown, ischemic insults to the renal medulla and free radical release have been implicated. Since vitamin C has been shown in animal studies to attenuate nephropathy when administered with known renal toxins, a similar effect was postulated when administered with IV contrast.
Two hundred and twenty patients electively admitted for coronary catheterization or intervention were randomized to placebo or to receive 3 grams of vitamin C 2 hours prior to the dye load followed by 2 gm that night and the morning after. The two groups were balanced for presence of hypertension, diabetes, tobacco use, and use of commonly prescribed medications. Intravenous hydration was given to all at variable rates depending on left ventricular ejection fraction. The catheterization team chose the type of contrast agent. Creatinine was measured at baseline (up to 3 months prior to dye load) and 2-5 days afterwards. CMN was defined as a rise in total serum creatinine by 0.5 mg/dL or by 25%. Using these criteria, 9% of the vitamin C group developed CMN as opposed to 20% in the controls (NNT 9; 95% CI: 5-53). Logistical regression was performed to account for differences in age, initial serum creatinine, or both, and always yielded significant differences. The treatment group was slightly older, had higher rates of isoosmolar contrast administration (reno-protective), and had slightly higher baseline creatinines, so the true protective effect was thought even higher than reported.
This study is limited by small sample size, an overwhelmingly male patient base (90%), and the suspected presence of atherosclerotic heart disease in all patients. The amount and rate of delivery of contrast was not noted. The vitamin C preparation used was not described, implying that all preparations were bioequivalent. No mention was made of whether these results could be extrapolated to other procedures involving contrast. Given the low cost and high tolerability of vitamin C, however, further studies would certainly be welcome.
8. Yadav J, Wholey M, Kuntz R, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. NEJM.2004;351:1493-1501.
Carotid angioplasty has been available for the past decade, but, due to possible complications such as plaque embolization and stent compression, the procedure had been limited to patients unsuitable for surgical endarterectomy. Recently, the introduction of crush-resistant nitinol stents and emboli protection devices has made the procedure safer. This study was designed to test the hypothesis that angioplasty and stenting is not inferior to endarterectomy. Three hundred and thirty-four patients at 29 centers had either a symptomatic carotid lesion greater than 50% or asymptomatic lesion greater than 80% and were deemed to be suitable candidates for either carotid endarterectomy or angioplasty. Patients were then randomized to one of the treatment groups. Surgeons, cardiologists, or interventional radiologists performed angioplasty. The primary endpoint was a composite of death, stroke, or MI within 30 days of the procedure, or death or stroke between 31 days and one year.
Secondary endpoints were the need for revascularization and cranial-nerve palsy at one year. During the first month after procedure, 4.8% of patients in the stent group and 9.8% of patients in the surgical group reached the primary endpoint. In the subsequent year, 12.2% of stent patients and 20.1% of surgical patients reached the primary endpoint (absolute risk reduction of 7.9, CI 0.7-16.4 and NNT 14). Cranial nerve palsy at one year was 0% vs. 4.9% in the stent vs. surgical group. Need for revascularization at one year was 0.6% vs. 4.3% for stent vs. surgical group. Although this study was designed to show the non-inferiority of angioplasty vs. carotid endarterectomy in patients deemed suitable for either procedure, it actually was statistically significant for superiority of stenting. It also implied a lower complication rate in terms of cranial nerve palsy and the need for revascularization at one year made the procedure safer. This study was designed to test the hypothesis that angioplasty and stenting is not inferior to endarterectomy. Three hundred and thirty-four patients at 29 centers had either a symptomatic carotid lesion greater than 50% or asymptomatic lesion greater than 80% and were deemed to be suitable candidates for either carotid endarterectomy or angioplasty. Patients were then randomized to one of the treatment groups. Surgeons, cardiologists, or interventional radiologists performed angioplasty. The primary endpoint was a composite of death, stroke, or MI within 30 days of the procedure, or death or stroke between 31 days and one year.
Secondary endpoints were the need for revascularization and cranial-nerve palsy at one year. During the first month after procedure, 4.8% of patients in the stent group and 9.8% of patients in the surgical group reached the primary endpoint. In the subsequent year, 12.2% of stent patients and 20.1% of surgical patients reached the primary endpoint (absolute risk reduction of 7.9, CI 0.7-16.4 and NNT 14). Cranial nerve palsy at one year was 0% vs. 4.9% in the stent vs. surgical group. Need for revascularization at one year was 0.6% vs. 4.3% for stent vs. surgical group. Although this study was designed to show the non-inferiority of angioplasty vs. carotid endarterectomy in patients deemed suitable for either procedure, it actually was statistically significant for superiority of stenting. It also implied a lower complication rate in terms of cranial nerve palsy and the need for revascularization at one year.
Practice Profile
Contact Information
Stacy Goldsholl, MD, BC IM (1/03-present)
Medical Director, Covenant Healthcare Hospital Medicine Program
Covenant Healthcare
1447 North Harrison
Saginaw, MI 48602
Holly Krenz
Hospitalist Support Associate
Phone: 989-583-4220
Fax: 989-583-4287
Start Up
May 2003
Hospitals Served
Covenant HealthCare, Saginaw, Michigan
Physician Staff
Abdo Alward, MD, BC IM (8/04)
Anu Gollapudi, MD, BC IM (5/03)
Noel Lucas, DO, BC IM (5/03)
Iris Mangulabnan, MD BC IM (8/03)
Hassan Nasser, MD, BC IM (5/03-5/04)
Sayed Naqvi, MD, BC IM (4/04)
Shelene Ruggio, MD, BC, IM (9/03)
Devanshu Thakore, MD, BC FP (7/03-8/04)
Support Staff
Holly Krenz, Hospitalist Support Associate
Mary Burr, Certified Coder
Physician Training
Eight of the physicians are board certified in internal medicine; one is board certified in family practice.
The Health System
Covenant HealthCare is a nonprofit regional tertiary health care system serving 18 counties throughout East Central Michigan, offering high-quality medical care with 20 inpatient and outpatient facilities, including two acute care hospitals with 643 licensed beds and 40 adult critical care beds, 20 short-term skilled nursing beds, and 41 inpatient rehabilitation beds. A 30-bed long-term acute care hospital also rents space on the hospital main campus. Covenant’s new state-of-the-science Emergency Care Center provides critical and trauma care with an annual volume in excess of 73,000 patient visits and offers a helicopter service that was added in January 2004. Additionally, Covenant provides comprehensive medical services in cardiovascular, neurosciences, surgery, orthopedics, obstetrics, and all ancillary services. Covenant HealthCare also features Michigan’s northernmost regional neonatal and pediatric/pediatric intensive care units to serve the needs of children.
As Michigan’s sixth largest hospital and most comprehensive health care facility north of Detroit, Covenant HealthCare has been nationally recognized for its superior service, having received such distinctions as a Solucient Top 100 Hospital for cardiac care and orthopedics from 1999 to 2003. Covenant is the recipient of the 2003 Governor’s Award of Excellence for Improving Care in the Hospital and Emergency Department for Heart Attack, Heart Failure, and Pneumonia, and is a five-time recipient of the National Research Corporation’s Consumer’s Choice Award. Covenant HealthCare ranks among the top 5% of hospitals its size nationwide for patient satisfaction.
Employment Arrangement
All of the physicians and staff are employed by Covenant HealthCare. Pediatric services for the pediatric patients of the family practice physicians utilizing the hospitalist program are provided by a contractual arrangement with Synergy Medical Alliance Family Practice residency program, an affiliate of Michigan State University.
Management and Operational Structure
An on-site Medical Director is responsible for all administrative aspects of the Hospital Medicine Program. Clinical responsibilities vary according to the service needs. The Medical Director reports to the Vice President of Medical Affairs. All team members report directly to the program’s Medical Director.
A full-time support associate (M-F) is responsible for all communications with primary care physicians, other hospital departments, and general office maintenance. A part-time certified coder is available twice weekly for charge capture reconciliation, billing, and documentation audit and physician education.
Multidisciplinary rounds are conducted daily (M-F) at 9 a.m. with all rounding physicians, the program director, case managers, and liaisons from skilled nursing, inpatient rehabilitation units, and home health/hospice. During this time, patient status is updated, and discharge planning is initiated. Case managers also bring non-hospitalist patient medical necessity reviews to the director/hospitalists who also serve as physician advisors to case management.
Staffing
The CHC Hospital Medicine Program is a 24-hour in-house service that operates in a shift-based (7a-7p) block model. There is one nocturnalist that covers 15 night shifts per month. Hospitalists are scheduled 15-18 12-hour shifts per month and are paid for additional shift coverage. Sign-in/out is face-to-face at 7 a.m. and 7 p.m. Day-time shifts are covered by two physicians 7 days per week, with an additional 0.5 FTE available M-F (medical director). Night shifts have single-physician coverage. Beginning in January 2005, day-time coverage will expand by one FTE.
Compensation/Benefits
All physicians are salaried. An annual bonus of up to 10% base salary is available at each physician’s anniversary date. The bonus is based heavily upon quality/FCCS certification (30%), team and referral physician satisfaction (20%), Press Ganey Patient-Physician Satisfaction scores (15%), and operational efficiency/organizational benefit (35%).
Standard benefits are provided, including malpractice coverage with tail, health, dental, vision, life insurance, 403b and 457b plans, short- and long-term disability. CME/Professional fee allowances of $3000 are provided. Initially, all physicians received 37 days of paid time off while contracting for 18 shifts/month. This has evolved into a 15-shifts/month schedule with no additional PTO.
Patient Census/Population
Patients are admitted to the Covenant HealthCare Hospital Medicine Service from three main avenues: unassigned emergency department admissions, private admitting relationships, and direct regional referrals. The hospitalists cover approximately 85% off all ED unassigned admissions. In addition, the service admits exclusively (all-or-none) for 35 local and regional primary care physicians. Covenant HealthCare serves as the tertiary referral for a number of small rural and critical access hospitals. These regional partners have ease of access with a “one pager” call number for the admitting hospitalist. Additionally, the hospitalists co-manage patients with various surgical specialties (orthopedics, neurosurgery, general surgery) and offer a medical consultation service. All of the Covenant Hospitalists have ACLS and Fundamentals of Critical Care Support certification, allowing them to serve as intensivist extenders (ICUs are open). As such, the service acts as Code Blue attending and the Medical Response Team for pre-code emergencies.
The average daily census is 30 with an average of 8-10 admissions per day. The Case Mix Index is 1.2617.
Communication Strategies
Communication was emphasized as a priority with the development of this new program. The position of a hospitalist support associate was created to serve as the point person for all external and internal communication. This is a full-time equivalent Monday through Friday. Hospitalist dictations are expedited via medical records transcription and faxed to the hospitalist office. All primary care physicians receive a notification of patient admission by fax on the morning following admission. This notification identifies the hospitalist attending, accompanies the dictated history and physical, and makes a request for pertinent outpatient information. Follow-up appointments are arranged by the hospitalist support associate prior to patient discharge. Discharge summaries are completed in real-time and faxed to the primary care office at the time of discharge.
Each hospitalist carries their own designated pager. A universal pager is passed between day and night physicians and is the “one call” direct contact for both the hospitalists’ private admitting relationships and regional referrals. Primary care physicians also have the opportunity to identify their preferred subspecialty consultants on enrollment to the hospitalist service. Laboratory and Radiology also utilize the universal pager for communication of critical values.
In conjunction with business development, primary care physician enrollment packets, patient brochures, hospitalist fliers, a regional referral manual, and DVD have all been compiled to assist in the education of patients, staff, and physicians.
Challenges
The greatest challenge to our program has been the facilitation of a culture of direct communication between the hospitalists and the medical staff consultants. Additionally, in our system the emergency department physicians routinely write admitting orders (“bridging orders”) for the private medical staff attending admissions. It has been a shift in culture to request the emergency physicians not to write bridging orders for the hospitalist admissions but to allow the hospitalist physician the opportunity to evaluate and admit hospitalist patients in real time in the emergency department.
First-Year Experience (fiscal 2004)
Admissions: 1747
Discharges: 1541
Observation: 289
Code Blue (CPR/critical care): 107
The Covenant Hospital Medicine Program was initiated with single-physician (four MDs) coverage 24 hours per day, 7 days per week in May 2003. The Medical Director was on-site for institutional and medical staff education, consensus building, physician and practice recruitment, and program planning for 4 months prior to program opening. Initially, the service admitted 90% of all unassigned emergency department medical admissions and enrolled two family practices as private admitting relationships. Over the course of the first year, the service grew to attend for 25% of all internal medicine admissions, and expanded the private admitting relationships to over 30 physician practices. Three additional FTE hospitalist physicians were added by September of 2003. Length of stay (2.94 CMI) and cost per case was reduced by 33% and 14%, respectively, versus the internal medicine physician admissions (nonhospitalist). Hospitalist inpatient mortality was 17.5% less than expected mortality as calculated by the Michigan Hospital Association database. The hospitalist readmission rate was 25% less than the internal medicine physician group (non-hospitalist). Profitability, as defined by net patient revenue minus total cost, was $707 for each hospitalist case compared to-$80 for each patient cared for by general internal medicine (non-hospitalist).
An intensive outreach program to our rural regional hospitals and critical access hospitals resulted in growth of regional referrals from 5% to 15% of the total hospital medicine program census over the course of the first year. Additionally, the medical consultation service, which was not offered at the initial start-up in order to control growth, now accounts for an additional 15% of the service volume.
Hospitalist Retention
The Covenant Hospital Medicine Program has a 78% retention rate for hospitalists in the first year. No physicians recruited to the program have had previous hospitalist experience. Two of the physicians left after one year; one to join a large hospitalist group in the West and the other to initiate a hospitalist program on the East coast.
Goals and Future Plans
Physician recruitment is the rate-limiting step for further growth and expansion. Two FTE hospitalists will be starting in January 2005 to accommodate the growth of the service to date. Two additional physicians will allow expansion to our off-site transitional care unit and inpatient rehabilitation unit to further provide for continuity and quality of care over the continuum. A fifth hospitalist is also sought to serve as an emergency department designated hospitalist in attempt to maximize daytime physician workflow.
Contact Information
Stacy Goldsholl, MD, BC IM (1/03-present)
Medical Director, Covenant Healthcare Hospital Medicine Program
Covenant Healthcare
1447 North Harrison
Saginaw, MI 48602
Holly Krenz
Hospitalist Support Associate
Phone: 989-583-4220
Fax: 989-583-4287
Start Up
May 2003
Hospitals Served
Covenant HealthCare, Saginaw, Michigan
Physician Staff
Abdo Alward, MD, BC IM (8/04)
Anu Gollapudi, MD, BC IM (5/03)
Noel Lucas, DO, BC IM (5/03)
Iris Mangulabnan, MD BC IM (8/03)
Hassan Nasser, MD, BC IM (5/03-5/04)
Sayed Naqvi, MD, BC IM (4/04)
Shelene Ruggio, MD, BC, IM (9/03)
Devanshu Thakore, MD, BC FP (7/03-8/04)
Support Staff
Holly Krenz, Hospitalist Support Associate
Mary Burr, Certified Coder
Physician Training
Eight of the physicians are board certified in internal medicine; one is board certified in family practice.
The Health System
Covenant HealthCare is a nonprofit regional tertiary health care system serving 18 counties throughout East Central Michigan, offering high-quality medical care with 20 inpatient and outpatient facilities, including two acute care hospitals with 643 licensed beds and 40 adult critical care beds, 20 short-term skilled nursing beds, and 41 inpatient rehabilitation beds. A 30-bed long-term acute care hospital also rents space on the hospital main campus. Covenant’s new state-of-the-science Emergency Care Center provides critical and trauma care with an annual volume in excess of 73,000 patient visits and offers a helicopter service that was added in January 2004. Additionally, Covenant provides comprehensive medical services in cardiovascular, neurosciences, surgery, orthopedics, obstetrics, and all ancillary services. Covenant HealthCare also features Michigan’s northernmost regional neonatal and pediatric/pediatric intensive care units to serve the needs of children.
As Michigan’s sixth largest hospital and most comprehensive health care facility north of Detroit, Covenant HealthCare has been nationally recognized for its superior service, having received such distinctions as a Solucient Top 100 Hospital for cardiac care and orthopedics from 1999 to 2003. Covenant is the recipient of the 2003 Governor’s Award of Excellence for Improving Care in the Hospital and Emergency Department for Heart Attack, Heart Failure, and Pneumonia, and is a five-time recipient of the National Research Corporation’s Consumer’s Choice Award. Covenant HealthCare ranks among the top 5% of hospitals its size nationwide for patient satisfaction.
Employment Arrangement
All of the physicians and staff are employed by Covenant HealthCare. Pediatric services for the pediatric patients of the family practice physicians utilizing the hospitalist program are provided by a contractual arrangement with Synergy Medical Alliance Family Practice residency program, an affiliate of Michigan State University.
Management and Operational Structure
An on-site Medical Director is responsible for all administrative aspects of the Hospital Medicine Program. Clinical responsibilities vary according to the service needs. The Medical Director reports to the Vice President of Medical Affairs. All team members report directly to the program’s Medical Director.
A full-time support associate (M-F) is responsible for all communications with primary care physicians, other hospital departments, and general office maintenance. A part-time certified coder is available twice weekly for charge capture reconciliation, billing, and documentation audit and physician education.
Multidisciplinary rounds are conducted daily (M-F) at 9 a.m. with all rounding physicians, the program director, case managers, and liaisons from skilled nursing, inpatient rehabilitation units, and home health/hospice. During this time, patient status is updated, and discharge planning is initiated. Case managers also bring non-hospitalist patient medical necessity reviews to the director/hospitalists who also serve as physician advisors to case management.
Staffing
The CHC Hospital Medicine Program is a 24-hour in-house service that operates in a shift-based (7a-7p) block model. There is one nocturnalist that covers 15 night shifts per month. Hospitalists are scheduled 15-18 12-hour shifts per month and are paid for additional shift coverage. Sign-in/out is face-to-face at 7 a.m. and 7 p.m. Day-time shifts are covered by two physicians 7 days per week, with an additional 0.5 FTE available M-F (medical director). Night shifts have single-physician coverage. Beginning in January 2005, day-time coverage will expand by one FTE.
Compensation/Benefits
All physicians are salaried. An annual bonus of up to 10% base salary is available at each physician’s anniversary date. The bonus is based heavily upon quality/FCCS certification (30%), team and referral physician satisfaction (20%), Press Ganey Patient-Physician Satisfaction scores (15%), and operational efficiency/organizational benefit (35%).
Standard benefits are provided, including malpractice coverage with tail, health, dental, vision, life insurance, 403b and 457b plans, short- and long-term disability. CME/Professional fee allowances of $3000 are provided. Initially, all physicians received 37 days of paid time off while contracting for 18 shifts/month. This has evolved into a 15-shifts/month schedule with no additional PTO.
Patient Census/Population
Patients are admitted to the Covenant HealthCare Hospital Medicine Service from three main avenues: unassigned emergency department admissions, private admitting relationships, and direct regional referrals. The hospitalists cover approximately 85% off all ED unassigned admissions. In addition, the service admits exclusively (all-or-none) for 35 local and regional primary care physicians. Covenant HealthCare serves as the tertiary referral for a number of small rural and critical access hospitals. These regional partners have ease of access with a “one pager” call number for the admitting hospitalist. Additionally, the hospitalists co-manage patients with various surgical specialties (orthopedics, neurosurgery, general surgery) and offer a medical consultation service. All of the Covenant Hospitalists have ACLS and Fundamentals of Critical Care Support certification, allowing them to serve as intensivist extenders (ICUs are open). As such, the service acts as Code Blue attending and the Medical Response Team for pre-code emergencies.
The average daily census is 30 with an average of 8-10 admissions per day. The Case Mix Index is 1.2617.
Communication Strategies
Communication was emphasized as a priority with the development of this new program. The position of a hospitalist support associate was created to serve as the point person for all external and internal communication. This is a full-time equivalent Monday through Friday. Hospitalist dictations are expedited via medical records transcription and faxed to the hospitalist office. All primary care physicians receive a notification of patient admission by fax on the morning following admission. This notification identifies the hospitalist attending, accompanies the dictated history and physical, and makes a request for pertinent outpatient information. Follow-up appointments are arranged by the hospitalist support associate prior to patient discharge. Discharge summaries are completed in real-time and faxed to the primary care office at the time of discharge.
Each hospitalist carries their own designated pager. A universal pager is passed between day and night physicians and is the “one call” direct contact for both the hospitalists’ private admitting relationships and regional referrals. Primary care physicians also have the opportunity to identify their preferred subspecialty consultants on enrollment to the hospitalist service. Laboratory and Radiology also utilize the universal pager for communication of critical values.
In conjunction with business development, primary care physician enrollment packets, patient brochures, hospitalist fliers, a regional referral manual, and DVD have all been compiled to assist in the education of patients, staff, and physicians.
Challenges
The greatest challenge to our program has been the facilitation of a culture of direct communication between the hospitalists and the medical staff consultants. Additionally, in our system the emergency department physicians routinely write admitting orders (“bridging orders”) for the private medical staff attending admissions. It has been a shift in culture to request the emergency physicians not to write bridging orders for the hospitalist admissions but to allow the hospitalist physician the opportunity to evaluate and admit hospitalist patients in real time in the emergency department.
First-Year Experience (fiscal 2004)
Admissions: 1747
Discharges: 1541
Observation: 289
Code Blue (CPR/critical care): 107
The Covenant Hospital Medicine Program was initiated with single-physician (four MDs) coverage 24 hours per day, 7 days per week in May 2003. The Medical Director was on-site for institutional and medical staff education, consensus building, physician and practice recruitment, and program planning for 4 months prior to program opening. Initially, the service admitted 90% of all unassigned emergency department medical admissions and enrolled two family practices as private admitting relationships. Over the course of the first year, the service grew to attend for 25% of all internal medicine admissions, and expanded the private admitting relationships to over 30 physician practices. Three additional FTE hospitalist physicians were added by September of 2003. Length of stay (2.94 CMI) and cost per case was reduced by 33% and 14%, respectively, versus the internal medicine physician admissions (nonhospitalist). Hospitalist inpatient mortality was 17.5% less than expected mortality as calculated by the Michigan Hospital Association database. The hospitalist readmission rate was 25% less than the internal medicine physician group (non-hospitalist). Profitability, as defined by net patient revenue minus total cost, was $707 for each hospitalist case compared to-$80 for each patient cared for by general internal medicine (non-hospitalist).
An intensive outreach program to our rural regional hospitals and critical access hospitals resulted in growth of regional referrals from 5% to 15% of the total hospital medicine program census over the course of the first year. Additionally, the medical consultation service, which was not offered at the initial start-up in order to control growth, now accounts for an additional 15% of the service volume.
Hospitalist Retention
The Covenant Hospital Medicine Program has a 78% retention rate for hospitalists in the first year. No physicians recruited to the program have had previous hospitalist experience. Two of the physicians left after one year; one to join a large hospitalist group in the West and the other to initiate a hospitalist program on the East coast.
Goals and Future Plans
Physician recruitment is the rate-limiting step for further growth and expansion. Two FTE hospitalists will be starting in January 2005 to accommodate the growth of the service to date. Two additional physicians will allow expansion to our off-site transitional care unit and inpatient rehabilitation unit to further provide for continuity and quality of care over the continuum. A fifth hospitalist is also sought to serve as an emergency department designated hospitalist in attempt to maximize daytime physician workflow.
Contact Information
Stacy Goldsholl, MD, BC IM (1/03-present)
Medical Director, Covenant Healthcare Hospital Medicine Program
Covenant Healthcare
1447 North Harrison
Saginaw, MI 48602
Holly Krenz
Hospitalist Support Associate
Phone: 989-583-4220
Fax: 989-583-4287
Start Up
May 2003
Hospitals Served
Covenant HealthCare, Saginaw, Michigan
Physician Staff
Abdo Alward, MD, BC IM (8/04)
Anu Gollapudi, MD, BC IM (5/03)
Noel Lucas, DO, BC IM (5/03)
Iris Mangulabnan, MD BC IM (8/03)
Hassan Nasser, MD, BC IM (5/03-5/04)
Sayed Naqvi, MD, BC IM (4/04)
Shelene Ruggio, MD, BC, IM (9/03)
Devanshu Thakore, MD, BC FP (7/03-8/04)
Support Staff
Holly Krenz, Hospitalist Support Associate
Mary Burr, Certified Coder
Physician Training
Eight of the physicians are board certified in internal medicine; one is board certified in family practice.
The Health System
Covenant HealthCare is a nonprofit regional tertiary health care system serving 18 counties throughout East Central Michigan, offering high-quality medical care with 20 inpatient and outpatient facilities, including two acute care hospitals with 643 licensed beds and 40 adult critical care beds, 20 short-term skilled nursing beds, and 41 inpatient rehabilitation beds. A 30-bed long-term acute care hospital also rents space on the hospital main campus. Covenant’s new state-of-the-science Emergency Care Center provides critical and trauma care with an annual volume in excess of 73,000 patient visits and offers a helicopter service that was added in January 2004. Additionally, Covenant provides comprehensive medical services in cardiovascular, neurosciences, surgery, orthopedics, obstetrics, and all ancillary services. Covenant HealthCare also features Michigan’s northernmost regional neonatal and pediatric/pediatric intensive care units to serve the needs of children.
As Michigan’s sixth largest hospital and most comprehensive health care facility north of Detroit, Covenant HealthCare has been nationally recognized for its superior service, having received such distinctions as a Solucient Top 100 Hospital for cardiac care and orthopedics from 1999 to 2003. Covenant is the recipient of the 2003 Governor’s Award of Excellence for Improving Care in the Hospital and Emergency Department for Heart Attack, Heart Failure, and Pneumonia, and is a five-time recipient of the National Research Corporation’s Consumer’s Choice Award. Covenant HealthCare ranks among the top 5% of hospitals its size nationwide for patient satisfaction.
Employment Arrangement
All of the physicians and staff are employed by Covenant HealthCare. Pediatric services for the pediatric patients of the family practice physicians utilizing the hospitalist program are provided by a contractual arrangement with Synergy Medical Alliance Family Practice residency program, an affiliate of Michigan State University.
Management and Operational Structure
An on-site Medical Director is responsible for all administrative aspects of the Hospital Medicine Program. Clinical responsibilities vary according to the service needs. The Medical Director reports to the Vice President of Medical Affairs. All team members report directly to the program’s Medical Director.
A full-time support associate (M-F) is responsible for all communications with primary care physicians, other hospital departments, and general office maintenance. A part-time certified coder is available twice weekly for charge capture reconciliation, billing, and documentation audit and physician education.
Multidisciplinary rounds are conducted daily (M-F) at 9 a.m. with all rounding physicians, the program director, case managers, and liaisons from skilled nursing, inpatient rehabilitation units, and home health/hospice. During this time, patient status is updated, and discharge planning is initiated. Case managers also bring non-hospitalist patient medical necessity reviews to the director/hospitalists who also serve as physician advisors to case management.
Staffing
The CHC Hospital Medicine Program is a 24-hour in-house service that operates in a shift-based (7a-7p) block model. There is one nocturnalist that covers 15 night shifts per month. Hospitalists are scheduled 15-18 12-hour shifts per month and are paid for additional shift coverage. Sign-in/out is face-to-face at 7 a.m. and 7 p.m. Day-time shifts are covered by two physicians 7 days per week, with an additional 0.5 FTE available M-F (medical director). Night shifts have single-physician coverage. Beginning in January 2005, day-time coverage will expand by one FTE.
Compensation/Benefits
All physicians are salaried. An annual bonus of up to 10% base salary is available at each physician’s anniversary date. The bonus is based heavily upon quality/FCCS certification (30%), team and referral physician satisfaction (20%), Press Ganey Patient-Physician Satisfaction scores (15%), and operational efficiency/organizational benefit (35%).
Standard benefits are provided, including malpractice coverage with tail, health, dental, vision, life insurance, 403b and 457b plans, short- and long-term disability. CME/Professional fee allowances of $3000 are provided. Initially, all physicians received 37 days of paid time off while contracting for 18 shifts/month. This has evolved into a 15-shifts/month schedule with no additional PTO.
Patient Census/Population
Patients are admitted to the Covenant HealthCare Hospital Medicine Service from three main avenues: unassigned emergency department admissions, private admitting relationships, and direct regional referrals. The hospitalists cover approximately 85% off all ED unassigned admissions. In addition, the service admits exclusively (all-or-none) for 35 local and regional primary care physicians. Covenant HealthCare serves as the tertiary referral for a number of small rural and critical access hospitals. These regional partners have ease of access with a “one pager” call number for the admitting hospitalist. Additionally, the hospitalists co-manage patients with various surgical specialties (orthopedics, neurosurgery, general surgery) and offer a medical consultation service. All of the Covenant Hospitalists have ACLS and Fundamentals of Critical Care Support certification, allowing them to serve as intensivist extenders (ICUs are open). As such, the service acts as Code Blue attending and the Medical Response Team for pre-code emergencies.
The average daily census is 30 with an average of 8-10 admissions per day. The Case Mix Index is 1.2617.
Communication Strategies
Communication was emphasized as a priority with the development of this new program. The position of a hospitalist support associate was created to serve as the point person for all external and internal communication. This is a full-time equivalent Monday through Friday. Hospitalist dictations are expedited via medical records transcription and faxed to the hospitalist office. All primary care physicians receive a notification of patient admission by fax on the morning following admission. This notification identifies the hospitalist attending, accompanies the dictated history and physical, and makes a request for pertinent outpatient information. Follow-up appointments are arranged by the hospitalist support associate prior to patient discharge. Discharge summaries are completed in real-time and faxed to the primary care office at the time of discharge.
Each hospitalist carries their own designated pager. A universal pager is passed between day and night physicians and is the “one call” direct contact for both the hospitalists’ private admitting relationships and regional referrals. Primary care physicians also have the opportunity to identify their preferred subspecialty consultants on enrollment to the hospitalist service. Laboratory and Radiology also utilize the universal pager for communication of critical values.
In conjunction with business development, primary care physician enrollment packets, patient brochures, hospitalist fliers, a regional referral manual, and DVD have all been compiled to assist in the education of patients, staff, and physicians.
Challenges
The greatest challenge to our program has been the facilitation of a culture of direct communication between the hospitalists and the medical staff consultants. Additionally, in our system the emergency department physicians routinely write admitting orders (“bridging orders”) for the private medical staff attending admissions. It has been a shift in culture to request the emergency physicians not to write bridging orders for the hospitalist admissions but to allow the hospitalist physician the opportunity to evaluate and admit hospitalist patients in real time in the emergency department.
First-Year Experience (fiscal 2004)
Admissions: 1747
Discharges: 1541
Observation: 289
Code Blue (CPR/critical care): 107
The Covenant Hospital Medicine Program was initiated with single-physician (four MDs) coverage 24 hours per day, 7 days per week in May 2003. The Medical Director was on-site for institutional and medical staff education, consensus building, physician and practice recruitment, and program planning for 4 months prior to program opening. Initially, the service admitted 90% of all unassigned emergency department medical admissions and enrolled two family practices as private admitting relationships. Over the course of the first year, the service grew to attend for 25% of all internal medicine admissions, and expanded the private admitting relationships to over 30 physician practices. Three additional FTE hospitalist physicians were added by September of 2003. Length of stay (2.94 CMI) and cost per case was reduced by 33% and 14%, respectively, versus the internal medicine physician admissions (nonhospitalist). Hospitalist inpatient mortality was 17.5% less than expected mortality as calculated by the Michigan Hospital Association database. The hospitalist readmission rate was 25% less than the internal medicine physician group (non-hospitalist). Profitability, as defined by net patient revenue minus total cost, was $707 for each hospitalist case compared to-$80 for each patient cared for by general internal medicine (non-hospitalist).
An intensive outreach program to our rural regional hospitals and critical access hospitals resulted in growth of regional referrals from 5% to 15% of the total hospital medicine program census over the course of the first year. Additionally, the medical consultation service, which was not offered at the initial start-up in order to control growth, now accounts for an additional 15% of the service volume.
Hospitalist Retention
The Covenant Hospital Medicine Program has a 78% retention rate for hospitalists in the first year. No physicians recruited to the program have had previous hospitalist experience. Two of the physicians left after one year; one to join a large hospitalist group in the West and the other to initiate a hospitalist program on the East coast.
Goals and Future Plans
Physician recruitment is the rate-limiting step for further growth and expansion. Two FTE hospitalists will be starting in January 2005 to accommodate the growth of the service to date. Two additional physicians will allow expansion to our off-site transitional care unit and inpatient rehabilitation unit to further provide for continuity and quality of care over the continuum. A fifth hospitalist is also sought to serve as an emergency department designated hospitalist in attempt to maximize daytime physician workflow.
Update from the Public Policy Committee
The Public Policy Committee has spent a great deal of time in recent months learning about the current reimbursement issues facing hospitalists. It is our belief that hospitalists bring something unique to the bedside that is not being recognized by our current payor system. This recognition will be a long-term project for the committee, but we have a number of short-term goals. The short-term goals are to educate our membership about using the currently available codes to optimize their practice; working with payors or intermediaries; and negotiating with the facilities to receive remuneration. We will investigate the possibility of coordinating with pilot projects being conducted by the Center for Medicare and Medicaid Services. These pilots may be able to demonstrate further the value of having a hospitalist manage the care of the hospitalized patient. We monitor closely any proposed changes in the Medicare fee schedule and work to preserve the current schedule as much as possible. However, longer term, we need to identify and design a model that rewards hospitalists for the quality and efficiency that they bring to their patients and facilities.
This may involve working with a number of other organizations as our allies. To this end, the Public Policy Committee recommended, and the SHM Board approved, that SHM’s government affairs contractor, Medical Advocacy Services, Inc. (MASI), draft a White Paper regarding the consideration of hospitalists as a specialty. Organizations draft such papers to thoroughly examine a particular topic. White Papers are typically used as an advocacy tool and can be presented to other organizations and to policymakers to make the case for a policy. The committee will work with MASI during the writing process, and a final paper will be released in 2005.
The Public Policy Committee also recently updated SHM’s “Guiding Principles,” which outline SHM’s position on numerous current health policy issues. The principles were first drafted by MASI and the Public Policy Committee in 2003. They enable MASI and me to make quick decisions on whether or not to sign SHM onto joint letters to Congress or the Administration. They cover areas such as medical liability, regulatory relief, and access to care. The principles will be particularly useful as health issues arise when the 109th Congress convenes in January. The updated Guiding Principles, approved by the Board in October, can be viewed on the SHM Advocacy Web site, under “Where We Stand.” We will update them regularly to address emerging and evolving issue areas.
For more information about SHM’s public policy positions, please visit the Advocacy section of the SHM Web site at www.hospitalmedicine.org.
The Public Policy Committee has spent a great deal of time in recent months learning about the current reimbursement issues facing hospitalists. It is our belief that hospitalists bring something unique to the bedside that is not being recognized by our current payor system. This recognition will be a long-term project for the committee, but we have a number of short-term goals. The short-term goals are to educate our membership about using the currently available codes to optimize their practice; working with payors or intermediaries; and negotiating with the facilities to receive remuneration. We will investigate the possibility of coordinating with pilot projects being conducted by the Center for Medicare and Medicaid Services. These pilots may be able to demonstrate further the value of having a hospitalist manage the care of the hospitalized patient. We monitor closely any proposed changes in the Medicare fee schedule and work to preserve the current schedule as much as possible. However, longer term, we need to identify and design a model that rewards hospitalists for the quality and efficiency that they bring to their patients and facilities.
This may involve working with a number of other organizations as our allies. To this end, the Public Policy Committee recommended, and the SHM Board approved, that SHM’s government affairs contractor, Medical Advocacy Services, Inc. (MASI), draft a White Paper regarding the consideration of hospitalists as a specialty. Organizations draft such papers to thoroughly examine a particular topic. White Papers are typically used as an advocacy tool and can be presented to other organizations and to policymakers to make the case for a policy. The committee will work with MASI during the writing process, and a final paper will be released in 2005.
The Public Policy Committee also recently updated SHM’s “Guiding Principles,” which outline SHM’s position on numerous current health policy issues. The principles were first drafted by MASI and the Public Policy Committee in 2003. They enable MASI and me to make quick decisions on whether or not to sign SHM onto joint letters to Congress or the Administration. They cover areas such as medical liability, regulatory relief, and access to care. The principles will be particularly useful as health issues arise when the 109th Congress convenes in January. The updated Guiding Principles, approved by the Board in October, can be viewed on the SHM Advocacy Web site, under “Where We Stand.” We will update them regularly to address emerging and evolving issue areas.
For more information about SHM’s public policy positions, please visit the Advocacy section of the SHM Web site at www.hospitalmedicine.org.
The Public Policy Committee has spent a great deal of time in recent months learning about the current reimbursement issues facing hospitalists. It is our belief that hospitalists bring something unique to the bedside that is not being recognized by our current payor system. This recognition will be a long-term project for the committee, but we have a number of short-term goals. The short-term goals are to educate our membership about using the currently available codes to optimize their practice; working with payors or intermediaries; and negotiating with the facilities to receive remuneration. We will investigate the possibility of coordinating with pilot projects being conducted by the Center for Medicare and Medicaid Services. These pilots may be able to demonstrate further the value of having a hospitalist manage the care of the hospitalized patient. We monitor closely any proposed changes in the Medicare fee schedule and work to preserve the current schedule as much as possible. However, longer term, we need to identify and design a model that rewards hospitalists for the quality and efficiency that they bring to their patients and facilities.
This may involve working with a number of other organizations as our allies. To this end, the Public Policy Committee recommended, and the SHM Board approved, that SHM’s government affairs contractor, Medical Advocacy Services, Inc. (MASI), draft a White Paper regarding the consideration of hospitalists as a specialty. Organizations draft such papers to thoroughly examine a particular topic. White Papers are typically used as an advocacy tool and can be presented to other organizations and to policymakers to make the case for a policy. The committee will work with MASI during the writing process, and a final paper will be released in 2005.
The Public Policy Committee also recently updated SHM’s “Guiding Principles,” which outline SHM’s position on numerous current health policy issues. The principles were first drafted by MASI and the Public Policy Committee in 2003. They enable MASI and me to make quick decisions on whether or not to sign SHM onto joint letters to Congress or the Administration. They cover areas such as medical liability, regulatory relief, and access to care. The principles will be particularly useful as health issues arise when the 109th Congress convenes in January. The updated Guiding Principles, approved by the Board in October, can be viewed on the SHM Advocacy Web site, under “Where We Stand.” We will update them regularly to address emerging and evolving issue areas.
For more information about SHM’s public policy positions, please visit the Advocacy section of the SHM Web site at www.hospitalmedicine.org.
OTHER PEDIATRIC LITERATURE OF INTEREST
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Calcitonin Precursors and IL-8 as a Screening Panel for Bacterial Sepsis
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Practice Guidelines for the Management of Bacterial Meningitis
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Issues in Determining Appropriate Levels of Hospitalist Staffing
Introduction
A major challenge for leaders of hospital medicine programs is determining appropriate staffing levels. Specifically, every hospitalist leader must answer the following question:
- What is the correct number of physician staff needed to meet the requirements of the work environment?
The Board of Directors of the Society of Hospital Medicine (SHM) asked the Benchmarks Committee to prepare a “white paper” on this subject. The Committee discussed hospitalist staffing and agreed that there is no simple formula or process for answering the question cited above. Instead, the Committee decided to prepare a paper that outlines the issues and suggests best practices for determining appropriate hospitalist staffing levels. A member of the Benchmarks Committee, Gale Ashbrener, Sr., Performance Consultant, Kaiser Permanente-Hawaii, has prepared a model for hospitalist staffing in her organization, and her work is the basis of this document.
NOTE: Most of the examples used in this document are from Kaiser-Hawaii. As such, the numbers cited are reflective of that particular organizational environment (i.e., a group model HMO). Readers should focus on the concepts and processes that are presented, recognizing that the numbers may be different for their environment.
Overview of the Issues
A process or simplistic model for determining the appropriate level of hospitalist staffing is summarized in Figure 1.
Staffing
Staffing is driven by demand: how many and what types of patients will the program expect to see in the upcoming year? Demand can then be converted to work: the tasks that the hospital medicine program must perform in order to treat these patients (the model must also quantify non-patient work). Once the total amount of work is described and quantified, the capacity of a hospitalist must be defined (e.g., in annual work hours). Then the number of hospitalists required to complete the projected work load can be computed.
Demand
The best practices for projecting patient demand are summarized in Box 1.
Hospitalist leaders should involve key stakeholders in the information gathering process. This helps establish the foundation for buy-in of the model down the road. You may want to pull together members of the hospitalist team and/or hospital administration to brainstorm on factors that may affect patient demand for inpatient services. At this point, keep an open mind for all considerations.
It is also critical to perform a comprehensive analysis of historical inpatient data. The analysis should examine all medical admissions at the hospital and specifically, in detail, those admissions cared for by the hospital medicine program. This analysis must look beyond the number of admissions and average length of stay (LOS). Several key characteristics of the hospitalized patients should be evaluated: age, diagnosis/severity, payer, and referring physician.
- Age: There are significant differences in inpatient utilization by age categories. It is important to further segment the “senior” Medicare (over age 65) population into several subgroups. Figure 2 (page 49) is based on data from Kaiser Permanente-Hawaii. As expected, there is a major difference in hospital utilization between the under age 65 population (15.9 admissions and 84 days per 1000) and the over age 65 population (167.9 admissions and 1,090 days per 1000). However, the differences within the Medicare subgroups are also substantial. For example, compare utilization by the population that is 65-69 years old (96.0 admissions and 621 days per 1000) with the population that is over age 85 (358.2 admissions and 2,111 days per 1000):
- Diagnoses/severity: There are acknowledged differences in LOS based on the patient’s reason for admission and many ways to characterize the reason of admission, including diagnosis and diagnostics-related groups (DRGs). Furthermore, patients with co-morbidities clearly require more coordination and patient management. There are several proprietary grouping methodologies that characterize the severity and intensity of an inpatient case, which include an assessment of co-morbidities. In analyzing historical data, the hospitalist leader should select a scheme that is used within the institution while minimizing the number of categories.
- Payer: In analyzing inpatient demand, it is also important to have an understanding of historical differences by payer (including uninsured patients). Health plans (or Medicaid programs) that are increasing or decreasing in size could affect the number of patients seen by a hospital medicine program.
- Referring physician: Community physicians (primary care, specialists, and surgeons) are a major source of inpatient cases for hospital medicine programs. It is important to analyze the historical impact of specific physicians or group practices on the patient load of the hospital medicine program.
The best way to project inpatient demand for hospitalist services is to identify and quantify what may change in the next year: what trends could increase or decrease the number of cases that will need to be treated? These change factors include the following:
- Population trends: Is the community growing? It there an influx of new residents? Is the community aging? Is it likely that there will be more seniors requiring inpatient services? Health plans and medical groups often can more easily assess population trends because they treat an enrolled population.
- Local health care factors: Will a hospital in the region be closing, resulting in additional inpatient demand? Is there a shortage of nursing home beds in the community that may affect the need for inpatient care? Is Medicaid reducing the number of covered recipients, potentially increasing the demand from uninsured patients?
- Changing referral patterns from community physicians: Do you expect additional community physicians to stop/start referring patients to the hospital medicine program? Are referring medical groups increasing or decreasing in size?
- Institution-specific factors: Does the hospital medicine program expect to assume new responsibilities in the next year – e.g., in the emergency department (ED), in the intensive care unit (ICU), providing night coverage, doing surgical co‑management, etc.?
Work
The best practices for measuring hospitalist output (work) are summarized in Box 2.
Determining how to quantify the labor of hospitalists can be the most controversial component of developing a staffing model. To ensure buy-in of these modeling decisions, participation by hospitalists and other key players (e.g., other physicians, physician leadership, and hospital/medical group administration) is crucial. Hospitalists and other key individuals must understand and agree on the quantification of time and labor.
It is critical that the analysis include ALL elements of work. Brainstorming with hospitalists can be helpful in this process. To build physician acceptance of and trust in the model, it is important to acknowledge the full set of hospitalist responsibilities in the initial stages of model development.
The services provided by a hospitalist team can vary from program to program and hospital to hospital. For example, at Kaiser Permanente-Hawaii, the dedicated hospitalist triage physician may direct patients coming from the clinic or ED to the ambulatory treatment center. A hospitalist then sees the patient in the center and an admission is often avoided. This physician labor must be captured in the model even though an admission did not occur. If your program includes a day team and a night team, you may want to handle these two teams as separate models.
Based on an analysis performed at Kaiser Permanente-Hawaii, some examples of hospitalist labor components are noted in Box 3 (page 50).
To measure the work performed by hospitalists, the model needs to recognize that there are differences in the labor components that have been identified (i.e., they are “weighted” differently). “Conventional wisdom” describes the work that hospitalists perform in terms of the number of patients seen per day (e.g., 15 patients per day). However, the work involved in a hospitalist seeing the following categories of patients is very different:
- Admitting a patient
- Rounding on a patient already admitted
- Discharging a patient
- Performing a consultation
Kaiser Permanente Hawaii developed the example in Box 4 to illustrate differences in the work required for admissions, rounding, and discharges, and how reductions in LOS do not lead to corresponding reductions in physician staffing levels.
There are basically two options in weighting the different elements of work performed by a hospitalist: time or relative value units (RVUs). Although the amount of time it takes to do a task seems to be the most sensible measurement of labor, it can be fraught with obstacles. The amount of time it takes a physician to round on a patient, for example, is not straightforward:
- Are all the patients located on one floor?
- Does the physician have to chase down test results routinely?
- Are all physicians the same, taking the same average amount of time to see a patient?
- Are all patients the same? Do older patients take more time due to social and medical complexity?
These are all factors that affect time. Furthermore, individuals are limited by their own experiences and frame of reference. Acceptance of a specific time allocation (e.g., a discharge takes 45 minutes) by those not doing the work is subjective. Despite these obstacles, it is valuable for hospitalist leaders to attempt to quantify the amount of time required to do inpatient work. Figure 3 shows example times used by a Kaiser Permanente-Hawaii medical group.
A hospital medicine program leader can use RVUs as a compliment to or as an alternative to time as the basis of weighting the work components performed by hospitalists. RVUs may account for patient acuity in a way that is hard to measure using time as the basis of measurement. Figure 4 illustrates RVUs by CPT-IV code.
Physician Capacity
The best practices for determining physician capacity are summarized in Box 5.
When determining the work capacity for a hospitalist (typically defined by the number of hours worked per year), it is critical to clearly define the unique aspects of the hospital medicine program that affect work capacity. These factors include:
- Staffing model: shift vs. call
- Scheduling approach: number of days on/off
- Non-patient care responsibilities: teaching, research, committees, etc.
- Staffing philosophy: part-time vs. full-time preference
Benchmark information is extremely helpful in determining physician capacity for a hospital medicine program. These benchmarks provide a point of comparison for hospitalist leaders developing staffing models. Medians for inpatient, non-patient, and on-call hours from the 2004 SHM Productivity and Compensation Survey are documented in Figure 5 (page 52).
The simplified example in Box 6, based on Kaiser time estimates, illustrates how demand, work, and physician capacity can be used to determine the number of hospitalists required to support a program.
As an alternative methodology or for comparative purposes, RVUs can be used rather than time. Box 7 uses RVUs from Figure 4 (initial hospital care: 1.28 RVUs; subsequent hospital care: .64 RVUs; hospital discharge < 30 minutes: 1.28 RVUs). The lowest level RVU values are used because they are consistent with the Kaiser example. Also, the median RVUs per year from Figure 5 are used (2961 for a hospital-based program).
Understand Your Work Environment
When a hospitalist program leader begins the process of developing a staffing model, it is important that he or she understands how the unique goals and characteristics of the program affects staffing. For example:
- Hospitalist-only groups are often driven by revenue. It is likely that these programs will expect hospitalists to do more billable work (i.e., see more patients)
- Academic programs typically have a broad range of other, non-patient care responsibilities, including teaching, research, and committee work. The hospitalists in these programs may see fewer patients.
The data from the 2004 SHM Productivity and Compensation Survey (Figure 5) confirms these differences. For inpatient hours worked, the national medians for these two different employment models differ by 23% (1700 vs. 2210). For RVUs worked, the national medians for the two different employment models differ by 17% (3000 vs. 3600).
Summary
Determining the right level of hospitalist staffing is important because it can positively or negatively affect the hospital medicine program and the hospital. Understaffing can lead to physician burn-out and adversely affect physician performance and hospital utilization. Overstaffing can affect the program’s financial performance and undercut the credibility of the program. The right staffing models and formulas, however, can help create a successful hospitalist work environment.
Summary of Recommendations
- There is no industry standard for a hospitalist staffing model. The analysis can be time-based or RVU-based, census driven, or based on any combination of output measures.
- Inpatient utilization drives the requirements for hospitalist staffing. A thorough analysis of historical inpatient utilization data is critical to developing a staffing model.
- In addition to understanding past utilization, projecting future inpatient demand is also important. Critical change factors include trends in: 1) the age and severity of patients; 2) population growth or decline; 3) payer sources; and 4) referral patterns.
- The services (work) performed by the hospital medicine program should be clearly identified and factored into the staffing formula. Brainstorming with the hospitalist group can be an effective technique for ensuring that the analysis is credible.
- Stakeholders should be involved early and often in developing a staffing model and in making staffing decisions.
- In developing a staffing model, particularly in the beginning stages, focus on the process and the methodology and not on the outcome (i.e., “my program needs 6 physicians”).
- Understand how the unique goals and characteristics of your hospital medicine program affect your staffing model.
Introduction
A major challenge for leaders of hospital medicine programs is determining appropriate staffing levels. Specifically, every hospitalist leader must answer the following question:
- What is the correct number of physician staff needed to meet the requirements of the work environment?
The Board of Directors of the Society of Hospital Medicine (SHM) asked the Benchmarks Committee to prepare a “white paper” on this subject. The Committee discussed hospitalist staffing and agreed that there is no simple formula or process for answering the question cited above. Instead, the Committee decided to prepare a paper that outlines the issues and suggests best practices for determining appropriate hospitalist staffing levels. A member of the Benchmarks Committee, Gale Ashbrener, Sr., Performance Consultant, Kaiser Permanente-Hawaii, has prepared a model for hospitalist staffing in her organization, and her work is the basis of this document.
NOTE: Most of the examples used in this document are from Kaiser-Hawaii. As such, the numbers cited are reflective of that particular organizational environment (i.e., a group model HMO). Readers should focus on the concepts and processes that are presented, recognizing that the numbers may be different for their environment.
Overview of the Issues
A process or simplistic model for determining the appropriate level of hospitalist staffing is summarized in Figure 1.
Staffing
Staffing is driven by demand: how many and what types of patients will the program expect to see in the upcoming year? Demand can then be converted to work: the tasks that the hospital medicine program must perform in order to treat these patients (the model must also quantify non-patient work). Once the total amount of work is described and quantified, the capacity of a hospitalist must be defined (e.g., in annual work hours). Then the number of hospitalists required to complete the projected work load can be computed.
Demand
The best practices for projecting patient demand are summarized in Box 1.
Hospitalist leaders should involve key stakeholders in the information gathering process. This helps establish the foundation for buy-in of the model down the road. You may want to pull together members of the hospitalist team and/or hospital administration to brainstorm on factors that may affect patient demand for inpatient services. At this point, keep an open mind for all considerations.
It is also critical to perform a comprehensive analysis of historical inpatient data. The analysis should examine all medical admissions at the hospital and specifically, in detail, those admissions cared for by the hospital medicine program. This analysis must look beyond the number of admissions and average length of stay (LOS). Several key characteristics of the hospitalized patients should be evaluated: age, diagnosis/severity, payer, and referring physician.
- Age: There are significant differences in inpatient utilization by age categories. It is important to further segment the “senior” Medicare (over age 65) population into several subgroups. Figure 2 (page 49) is based on data from Kaiser Permanente-Hawaii. As expected, there is a major difference in hospital utilization between the under age 65 population (15.9 admissions and 84 days per 1000) and the over age 65 population (167.9 admissions and 1,090 days per 1000). However, the differences within the Medicare subgroups are also substantial. For example, compare utilization by the population that is 65-69 years old (96.0 admissions and 621 days per 1000) with the population that is over age 85 (358.2 admissions and 2,111 days per 1000):
- Diagnoses/severity: There are acknowledged differences in LOS based on the patient’s reason for admission and many ways to characterize the reason of admission, including diagnosis and diagnostics-related groups (DRGs). Furthermore, patients with co-morbidities clearly require more coordination and patient management. There are several proprietary grouping methodologies that characterize the severity and intensity of an inpatient case, which include an assessment of co-morbidities. In analyzing historical data, the hospitalist leader should select a scheme that is used within the institution while minimizing the number of categories.
- Payer: In analyzing inpatient demand, it is also important to have an understanding of historical differences by payer (including uninsured patients). Health plans (or Medicaid programs) that are increasing or decreasing in size could affect the number of patients seen by a hospital medicine program.
- Referring physician: Community physicians (primary care, specialists, and surgeons) are a major source of inpatient cases for hospital medicine programs. It is important to analyze the historical impact of specific physicians or group practices on the patient load of the hospital medicine program.
The best way to project inpatient demand for hospitalist services is to identify and quantify what may change in the next year: what trends could increase or decrease the number of cases that will need to be treated? These change factors include the following:
- Population trends: Is the community growing? It there an influx of new residents? Is the community aging? Is it likely that there will be more seniors requiring inpatient services? Health plans and medical groups often can more easily assess population trends because they treat an enrolled population.
- Local health care factors: Will a hospital in the region be closing, resulting in additional inpatient demand? Is there a shortage of nursing home beds in the community that may affect the need for inpatient care? Is Medicaid reducing the number of covered recipients, potentially increasing the demand from uninsured patients?
- Changing referral patterns from community physicians: Do you expect additional community physicians to stop/start referring patients to the hospital medicine program? Are referring medical groups increasing or decreasing in size?
- Institution-specific factors: Does the hospital medicine program expect to assume new responsibilities in the next year – e.g., in the emergency department (ED), in the intensive care unit (ICU), providing night coverage, doing surgical co‑management, etc.?
Work
The best practices for measuring hospitalist output (work) are summarized in Box 2.
Determining how to quantify the labor of hospitalists can be the most controversial component of developing a staffing model. To ensure buy-in of these modeling decisions, participation by hospitalists and other key players (e.g., other physicians, physician leadership, and hospital/medical group administration) is crucial. Hospitalists and other key individuals must understand and agree on the quantification of time and labor.
It is critical that the analysis include ALL elements of work. Brainstorming with hospitalists can be helpful in this process. To build physician acceptance of and trust in the model, it is important to acknowledge the full set of hospitalist responsibilities in the initial stages of model development.
The services provided by a hospitalist team can vary from program to program and hospital to hospital. For example, at Kaiser Permanente-Hawaii, the dedicated hospitalist triage physician may direct patients coming from the clinic or ED to the ambulatory treatment center. A hospitalist then sees the patient in the center and an admission is often avoided. This physician labor must be captured in the model even though an admission did not occur. If your program includes a day team and a night team, you may want to handle these two teams as separate models.
Based on an analysis performed at Kaiser Permanente-Hawaii, some examples of hospitalist labor components are noted in Box 3 (page 50).
To measure the work performed by hospitalists, the model needs to recognize that there are differences in the labor components that have been identified (i.e., they are “weighted” differently). “Conventional wisdom” describes the work that hospitalists perform in terms of the number of patients seen per day (e.g., 15 patients per day). However, the work involved in a hospitalist seeing the following categories of patients is very different:
- Admitting a patient
- Rounding on a patient already admitted
- Discharging a patient
- Performing a consultation
Kaiser Permanente Hawaii developed the example in Box 4 to illustrate differences in the work required for admissions, rounding, and discharges, and how reductions in LOS do not lead to corresponding reductions in physician staffing levels.
There are basically two options in weighting the different elements of work performed by a hospitalist: time or relative value units (RVUs). Although the amount of time it takes to do a task seems to be the most sensible measurement of labor, it can be fraught with obstacles. The amount of time it takes a physician to round on a patient, for example, is not straightforward:
- Are all the patients located on one floor?
- Does the physician have to chase down test results routinely?
- Are all physicians the same, taking the same average amount of time to see a patient?
- Are all patients the same? Do older patients take more time due to social and medical complexity?
These are all factors that affect time. Furthermore, individuals are limited by their own experiences and frame of reference. Acceptance of a specific time allocation (e.g., a discharge takes 45 minutes) by those not doing the work is subjective. Despite these obstacles, it is valuable for hospitalist leaders to attempt to quantify the amount of time required to do inpatient work. Figure 3 shows example times used by a Kaiser Permanente-Hawaii medical group.
A hospital medicine program leader can use RVUs as a compliment to or as an alternative to time as the basis of weighting the work components performed by hospitalists. RVUs may account for patient acuity in a way that is hard to measure using time as the basis of measurement. Figure 4 illustrates RVUs by CPT-IV code.
Physician Capacity
The best practices for determining physician capacity are summarized in Box 5.
When determining the work capacity for a hospitalist (typically defined by the number of hours worked per year), it is critical to clearly define the unique aspects of the hospital medicine program that affect work capacity. These factors include:
- Staffing model: shift vs. call
- Scheduling approach: number of days on/off
- Non-patient care responsibilities: teaching, research, committees, etc.
- Staffing philosophy: part-time vs. full-time preference
Benchmark information is extremely helpful in determining physician capacity for a hospital medicine program. These benchmarks provide a point of comparison for hospitalist leaders developing staffing models. Medians for inpatient, non-patient, and on-call hours from the 2004 SHM Productivity and Compensation Survey are documented in Figure 5 (page 52).
The simplified example in Box 6, based on Kaiser time estimates, illustrates how demand, work, and physician capacity can be used to determine the number of hospitalists required to support a program.
As an alternative methodology or for comparative purposes, RVUs can be used rather than time. Box 7 uses RVUs from Figure 4 (initial hospital care: 1.28 RVUs; subsequent hospital care: .64 RVUs; hospital discharge < 30 minutes: 1.28 RVUs). The lowest level RVU values are used because they are consistent with the Kaiser example. Also, the median RVUs per year from Figure 5 are used (2961 for a hospital-based program).
Understand Your Work Environment
When a hospitalist program leader begins the process of developing a staffing model, it is important that he or she understands how the unique goals and characteristics of the program affects staffing. For example:
- Hospitalist-only groups are often driven by revenue. It is likely that these programs will expect hospitalists to do more billable work (i.e., see more patients)
- Academic programs typically have a broad range of other, non-patient care responsibilities, including teaching, research, and committee work. The hospitalists in these programs may see fewer patients.
The data from the 2004 SHM Productivity and Compensation Survey (Figure 5) confirms these differences. For inpatient hours worked, the national medians for these two different employment models differ by 23% (1700 vs. 2210). For RVUs worked, the national medians for the two different employment models differ by 17% (3000 vs. 3600).
Summary
Determining the right level of hospitalist staffing is important because it can positively or negatively affect the hospital medicine program and the hospital. Understaffing can lead to physician burn-out and adversely affect physician performance and hospital utilization. Overstaffing can affect the program’s financial performance and undercut the credibility of the program. The right staffing models and formulas, however, can help create a successful hospitalist work environment.
Summary of Recommendations
- There is no industry standard for a hospitalist staffing model. The analysis can be time-based or RVU-based, census driven, or based on any combination of output measures.
- Inpatient utilization drives the requirements for hospitalist staffing. A thorough analysis of historical inpatient utilization data is critical to developing a staffing model.
- In addition to understanding past utilization, projecting future inpatient demand is also important. Critical change factors include trends in: 1) the age and severity of patients; 2) population growth or decline; 3) payer sources; and 4) referral patterns.
- The services (work) performed by the hospital medicine program should be clearly identified and factored into the staffing formula. Brainstorming with the hospitalist group can be an effective technique for ensuring that the analysis is credible.
- Stakeholders should be involved early and often in developing a staffing model and in making staffing decisions.
- In developing a staffing model, particularly in the beginning stages, focus on the process and the methodology and not on the outcome (i.e., “my program needs 6 physicians”).
- Understand how the unique goals and characteristics of your hospital medicine program affect your staffing model.
Introduction
A major challenge for leaders of hospital medicine programs is determining appropriate staffing levels. Specifically, every hospitalist leader must answer the following question:
- What is the correct number of physician staff needed to meet the requirements of the work environment?
The Board of Directors of the Society of Hospital Medicine (SHM) asked the Benchmarks Committee to prepare a “white paper” on this subject. The Committee discussed hospitalist staffing and agreed that there is no simple formula or process for answering the question cited above. Instead, the Committee decided to prepare a paper that outlines the issues and suggests best practices for determining appropriate hospitalist staffing levels. A member of the Benchmarks Committee, Gale Ashbrener, Sr., Performance Consultant, Kaiser Permanente-Hawaii, has prepared a model for hospitalist staffing in her organization, and her work is the basis of this document.
NOTE: Most of the examples used in this document are from Kaiser-Hawaii. As such, the numbers cited are reflective of that particular organizational environment (i.e., a group model HMO). Readers should focus on the concepts and processes that are presented, recognizing that the numbers may be different for their environment.
Overview of the Issues
A process or simplistic model for determining the appropriate level of hospitalist staffing is summarized in Figure 1.
Staffing
Staffing is driven by demand: how many and what types of patients will the program expect to see in the upcoming year? Demand can then be converted to work: the tasks that the hospital medicine program must perform in order to treat these patients (the model must also quantify non-patient work). Once the total amount of work is described and quantified, the capacity of a hospitalist must be defined (e.g., in annual work hours). Then the number of hospitalists required to complete the projected work load can be computed.
Demand
The best practices for projecting patient demand are summarized in Box 1.
Hospitalist leaders should involve key stakeholders in the information gathering process. This helps establish the foundation for buy-in of the model down the road. You may want to pull together members of the hospitalist team and/or hospital administration to brainstorm on factors that may affect patient demand for inpatient services. At this point, keep an open mind for all considerations.
It is also critical to perform a comprehensive analysis of historical inpatient data. The analysis should examine all medical admissions at the hospital and specifically, in detail, those admissions cared for by the hospital medicine program. This analysis must look beyond the number of admissions and average length of stay (LOS). Several key characteristics of the hospitalized patients should be evaluated: age, diagnosis/severity, payer, and referring physician.
- Age: There are significant differences in inpatient utilization by age categories. It is important to further segment the “senior” Medicare (over age 65) population into several subgroups. Figure 2 (page 49) is based on data from Kaiser Permanente-Hawaii. As expected, there is a major difference in hospital utilization between the under age 65 population (15.9 admissions and 84 days per 1000) and the over age 65 population (167.9 admissions and 1,090 days per 1000). However, the differences within the Medicare subgroups are also substantial. For example, compare utilization by the population that is 65-69 years old (96.0 admissions and 621 days per 1000) with the population that is over age 85 (358.2 admissions and 2,111 days per 1000):
- Diagnoses/severity: There are acknowledged differences in LOS based on the patient’s reason for admission and many ways to characterize the reason of admission, including diagnosis and diagnostics-related groups (DRGs). Furthermore, patients with co-morbidities clearly require more coordination and patient management. There are several proprietary grouping methodologies that characterize the severity and intensity of an inpatient case, which include an assessment of co-morbidities. In analyzing historical data, the hospitalist leader should select a scheme that is used within the institution while minimizing the number of categories.
- Payer: In analyzing inpatient demand, it is also important to have an understanding of historical differences by payer (including uninsured patients). Health plans (or Medicaid programs) that are increasing or decreasing in size could affect the number of patients seen by a hospital medicine program.
- Referring physician: Community physicians (primary care, specialists, and surgeons) are a major source of inpatient cases for hospital medicine programs. It is important to analyze the historical impact of specific physicians or group practices on the patient load of the hospital medicine program.
The best way to project inpatient demand for hospitalist services is to identify and quantify what may change in the next year: what trends could increase or decrease the number of cases that will need to be treated? These change factors include the following:
- Population trends: Is the community growing? It there an influx of new residents? Is the community aging? Is it likely that there will be more seniors requiring inpatient services? Health plans and medical groups often can more easily assess population trends because they treat an enrolled population.
- Local health care factors: Will a hospital in the region be closing, resulting in additional inpatient demand? Is there a shortage of nursing home beds in the community that may affect the need for inpatient care? Is Medicaid reducing the number of covered recipients, potentially increasing the demand from uninsured patients?
- Changing referral patterns from community physicians: Do you expect additional community physicians to stop/start referring patients to the hospital medicine program? Are referring medical groups increasing or decreasing in size?
- Institution-specific factors: Does the hospital medicine program expect to assume new responsibilities in the next year – e.g., in the emergency department (ED), in the intensive care unit (ICU), providing night coverage, doing surgical co‑management, etc.?
Work
The best practices for measuring hospitalist output (work) are summarized in Box 2.
Determining how to quantify the labor of hospitalists can be the most controversial component of developing a staffing model. To ensure buy-in of these modeling decisions, participation by hospitalists and other key players (e.g., other physicians, physician leadership, and hospital/medical group administration) is crucial. Hospitalists and other key individuals must understand and agree on the quantification of time and labor.
It is critical that the analysis include ALL elements of work. Brainstorming with hospitalists can be helpful in this process. To build physician acceptance of and trust in the model, it is important to acknowledge the full set of hospitalist responsibilities in the initial stages of model development.
The services provided by a hospitalist team can vary from program to program and hospital to hospital. For example, at Kaiser Permanente-Hawaii, the dedicated hospitalist triage physician may direct patients coming from the clinic or ED to the ambulatory treatment center. A hospitalist then sees the patient in the center and an admission is often avoided. This physician labor must be captured in the model even though an admission did not occur. If your program includes a day team and a night team, you may want to handle these two teams as separate models.
Based on an analysis performed at Kaiser Permanente-Hawaii, some examples of hospitalist labor components are noted in Box 3 (page 50).
To measure the work performed by hospitalists, the model needs to recognize that there are differences in the labor components that have been identified (i.e., they are “weighted” differently). “Conventional wisdom” describes the work that hospitalists perform in terms of the number of patients seen per day (e.g., 15 patients per day). However, the work involved in a hospitalist seeing the following categories of patients is very different:
- Admitting a patient
- Rounding on a patient already admitted
- Discharging a patient
- Performing a consultation
Kaiser Permanente Hawaii developed the example in Box 4 to illustrate differences in the work required for admissions, rounding, and discharges, and how reductions in LOS do not lead to corresponding reductions in physician staffing levels.
There are basically two options in weighting the different elements of work performed by a hospitalist: time or relative value units (RVUs). Although the amount of time it takes to do a task seems to be the most sensible measurement of labor, it can be fraught with obstacles. The amount of time it takes a physician to round on a patient, for example, is not straightforward:
- Are all the patients located on one floor?
- Does the physician have to chase down test results routinely?
- Are all physicians the same, taking the same average amount of time to see a patient?
- Are all patients the same? Do older patients take more time due to social and medical complexity?
These are all factors that affect time. Furthermore, individuals are limited by their own experiences and frame of reference. Acceptance of a specific time allocation (e.g., a discharge takes 45 minutes) by those not doing the work is subjective. Despite these obstacles, it is valuable for hospitalist leaders to attempt to quantify the amount of time required to do inpatient work. Figure 3 shows example times used by a Kaiser Permanente-Hawaii medical group.
A hospital medicine program leader can use RVUs as a compliment to or as an alternative to time as the basis of weighting the work components performed by hospitalists. RVUs may account for patient acuity in a way that is hard to measure using time as the basis of measurement. Figure 4 illustrates RVUs by CPT-IV code.
Physician Capacity
The best practices for determining physician capacity are summarized in Box 5.
When determining the work capacity for a hospitalist (typically defined by the number of hours worked per year), it is critical to clearly define the unique aspects of the hospital medicine program that affect work capacity. These factors include:
- Staffing model: shift vs. call
- Scheduling approach: number of days on/off
- Non-patient care responsibilities: teaching, research, committees, etc.
- Staffing philosophy: part-time vs. full-time preference
Benchmark information is extremely helpful in determining physician capacity for a hospital medicine program. These benchmarks provide a point of comparison for hospitalist leaders developing staffing models. Medians for inpatient, non-patient, and on-call hours from the 2004 SHM Productivity and Compensation Survey are documented in Figure 5 (page 52).
The simplified example in Box 6, based on Kaiser time estimates, illustrates how demand, work, and physician capacity can be used to determine the number of hospitalists required to support a program.
As an alternative methodology or for comparative purposes, RVUs can be used rather than time. Box 7 uses RVUs from Figure 4 (initial hospital care: 1.28 RVUs; subsequent hospital care: .64 RVUs; hospital discharge < 30 minutes: 1.28 RVUs). The lowest level RVU values are used because they are consistent with the Kaiser example. Also, the median RVUs per year from Figure 5 are used (2961 for a hospital-based program).
Understand Your Work Environment
When a hospitalist program leader begins the process of developing a staffing model, it is important that he or she understands how the unique goals and characteristics of the program affects staffing. For example:
- Hospitalist-only groups are often driven by revenue. It is likely that these programs will expect hospitalists to do more billable work (i.e., see more patients)
- Academic programs typically have a broad range of other, non-patient care responsibilities, including teaching, research, and committee work. The hospitalists in these programs may see fewer patients.
The data from the 2004 SHM Productivity and Compensation Survey (Figure 5) confirms these differences. For inpatient hours worked, the national medians for these two different employment models differ by 23% (1700 vs. 2210). For RVUs worked, the national medians for the two different employment models differ by 17% (3000 vs. 3600).
Summary
Determining the right level of hospitalist staffing is important because it can positively or negatively affect the hospital medicine program and the hospital. Understaffing can lead to physician burn-out and adversely affect physician performance and hospital utilization. Overstaffing can affect the program’s financial performance and undercut the credibility of the program. The right staffing models and formulas, however, can help create a successful hospitalist work environment.
Summary of Recommendations
- There is no industry standard for a hospitalist staffing model. The analysis can be time-based or RVU-based, census driven, or based on any combination of output measures.
- Inpatient utilization drives the requirements for hospitalist staffing. A thorough analysis of historical inpatient utilization data is critical to developing a staffing model.
- In addition to understanding past utilization, projecting future inpatient demand is also important. Critical change factors include trends in: 1) the age and severity of patients; 2) population growth or decline; 3) payer sources; and 4) referral patterns.
- The services (work) performed by the hospital medicine program should be clearly identified and factored into the staffing formula. Brainstorming with the hospitalist group can be an effective technique for ensuring that the analysis is credible.
- Stakeholders should be involved early and often in developing a staffing model and in making staffing decisions.
- In developing a staffing model, particularly in the beginning stages, focus on the process and the methodology and not on the outcome (i.e., “my program needs 6 physicians”).
- Understand how the unique goals and characteristics of your hospital medicine program affect your staffing model.
Resident Work Hours, Hospitalist Programs, and Academic Medical Centers
In July of 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented new rules that restricted resident work hours to no more than 80 per week and restricted continuous duty to no more than 30 hours (24 hours plus 6 hours for transfer of care, the “24+6” rule). As a result, many major academic medical centers face the problem of handling increasing inpatient volume and ensuring compliance with these new work-hours regulations. The problem has become more pressing as several major academic centers have been cited for work-hours violations by the ACGME, and significant public attention has focused on the impact of excessive work hours on patient safety (1, 2).
Given the success of hospitalists in efficiently managing patents in many non-academic environments, one proposed solution has been the creation of hospitalist services to care for patients independent of residents. These services reduce the volume on resident-based services and therefore reduce resident work hours. We have recently implemented our own non-housestaff service at the University of Michigan and in this article describe the challenges and lessons learned.
Planning a Program
The first step for any institution contemplating the creation of a non-resident service is to establish clear goals. Frequently, decisions on the level and scope of uncovered services are made without any rigorous analysis of the data or without a clear idea of what it is that your program should be doing.
Goals for Resident-Service Census and Volume
The first task for any program is to understand what patient volume must be removed to ensure work-hours compliance without impeding the educational experience of the housestaff . Unfortunately, there is little published opinion on optimal resident workload, and the ACGME is surprisingly silent on this vital issue. While the ACGME does proscribe exceeding theoretical maximum workloads for internal medicine, they cite no minimum or ideal patient census (3). In the absence of firm guidelines, it is important to gather data on both the day-to-day variation of inpatient admissions and volume along with peak admission times (usually early evening). The residency program is likely to offer monthly data or a rough guess at what they think is needed. This can be misleading and does not appreciate the variability of patient flow. It is the “peaks’ that are often remembered, whereas the “troughs” are easily forgotten. Vital data elements that should be obtained include the daily admission volume for each resident-service over the course of the past year. We used this data to calculate average per-intern admission volumes and to project what future volume would be under a variety of possible scenarios, including removing a fixed number of patients per day, creating intern-admissions caps or alternating admissions between residents and hospitalists. We then discussed these models and their projected impact on the residents with residency leadership before settling upon our final model.
Structural Reform of the Resident Services
Besides the question of volume, there is also the issue of whether the new service will also be used to create other structural changes in the resident services. Some areas that programs may consider include modification of the existing call rotation such as reducing or eliminating short-call, changing the frequency of long-call, or implementing limitations on night-time admissions to the housestaff.
Each of these possibilities comes with its own structural needs, so it is vital to decide whether any of these changes are to be attempted.
Patient Complexity
There is significant temptation to use established hospitalist workload standards and apply them to non-resident services in academia. To do so is to invite disaster. The complexity of patients on most academic internal medicine services is quite different from the average community service. One big variable to address here is whether or not the new hospitalist service will have a selected patient population (such as low-complexity or “non-teaching” cases). Without specifically selected low-complexity cases, most hospitalist programs will realize that established community work standards do not apply.
Academic Inefficiencies and Workload
Much of what residents do on a day-to-day basis involves pushing their patients through the inefficient and complex maze of an academic medical center. It seems ridiculous to think that one faculty member can replace the work that was previously performed by an attending, a senior resident, and two interns, yet this is what many programs are actually proposing when they suggest that the “established” work load of 15 patients per day per hospitalist could work in academia.
What is an ideal workload in academia? Our answer is based both on our experience and on work-flow analysis of residents, which suggests that less than 20% of their time is actually spent in direct educational activities (4). We suggest that the acceptable workload for a hospitalist in a major academic center managing patients of equivalent complexity as the residents is slightly higher than what a senior resident alone can reasonably handle. In our institution we have had a service without interns, staffed with senior residents and one attending for several years. In institutions without this structure, one could look at what senior residents do on their intern’s days off. In our experience approximately 8-10 patients/day seems to be an acceptable workload that allowed the residents to provide quality care within the confines of a 10 to 12 hour day. This translates into an attending workload of 9-11 patients/day. We acknowledge that with time, an attending may develop more efficient practices than a senior resident but do not think a workload much higher than this is reasonable during the start-up phase.
The Role of Physician Extenders
Many hospitalists rely on physician extenders such as physician assistants and nurse practitioners. In academia, physician extenders have traditionally worked only in specialty areas of inpatient care such as orthopedics, oncology, or cardiology. The great unknown, however, is how extenders perform in an environment where they are asked to work with both complex and varied patients. We have seen that the training of many extenders is often not enough for them to take on the role envisioned for them in this kind of service. Over time they may develop the skill set, but there is much on-the-job learning that requires dedicated physician time. A realistic census for a physician assistant (PA) taking care of complex academic medical patients is likely to be 4 to 6. The incremental impact of extenders on a service’s total work capacity is not entirely additive, given the need for physician oversight and the need to maximize revenue by using shared visit billing. Despite these limitations, however, we believe that extenders are helpful, especially given the inefficiencies of day-to-day patient care in academic centers.
The University of Michigan
Medicine Faculty Hospitalist Service
Our own program was designed around an original goal of moving 2000 patients from the resident services. This figure was derived from a per-intern workload target of 25 to 30 admissions per month. Based on our modeling of various ways to share admissions, we ultimately settled on a system that alternates admissions with the resident services after each service admits a “baseline” number of patients. This allowed us to variably offload patients based on day-to-day variation in admission volumes. Our service is staffed 24 hours a day with a total of eight full-time physicians and four physician assistants. We have three physicians and two‑three physician assistants during the day (7 a.m. to 7 p.m.) to coincide with the bulk of the workload. There is one doctor at night (7 p.m. to 7 a.m.) for our entire service, and our hospitalists work an average of 50-55 hours a week during 18 shifts a month. Each hospitalist (working with a PA) averages from 8 to 12 billable encounters a day. We maintain a maximum daily census of 30-35 patients and admit up to 10 patients a day. Given these workloads, we do not come close to financial self-sufficiency, but this is not unique to our program.
Funding and Finances
For most institutions a non-resident service represents incremental faculty members without any significant incremental professional fee revenue. The billings on the new service really are just a shift in revenue from the resident services. In addition, given the high clinical workload and current market conditions, the salaries of hospitalists hired for such services tend to be on average $15,000 to $20,000 above that of hospitalists hired onto a traditional resident-based service. There is some opportunity for increased revenue capture because of 24-hour attending presence, but the incremental gain is unlikely to be enough to create financial self-sufficiency. In our program there has been an increase in department-wide consultative revenue as specialized patients are now placed on our general medical service where they were previously cared for by residents and a specialty attending. In addition, we have improved our charge capture by a small margin. This extra revenue will not, however, come close to offsetting our overall cost. Many programs therefore require hospital support to be viable. Given the strong incentives for hospitals to ensure compliance with ACGME rules and maintain maximal inpatient occupancy, many hospitals can be convinced to provide funding.
We argue strongly that the creation of programs developed primarily to deal with residency work hours should be viewed separately from the funding of existing or new resident-based hospitalist programs. Similar to how resident salaries are paid for by the hospital (via federal graduate medical education funding), the cost of a new hospitalist service that is created to replace residents should come from the hospital. Programs should exercise caution in using existing paradigms such as reduction in LOS or decrease in cost as a basis for funding. There is little data comparing resident-based care to non-resident-based hospital care in a tertiary center, and what little that exists does not necessarily suggest a cost benefit (5). In addition, there is a significant future risk if such proposed benefits do not become a reality
New Roles and Responsibilities
Once established, many programs will be asked to take on additional tasks that were previously performed by trainees or other faculty. This is especially true of nighttime tasks. Many programs are asked to run code-blue teams, supervise procedures at night, supervise sedation in radiology, triage patients in the ER, provide emergent patient coverage for other services: the list can go on and on. The challenge is accepting some and rejecting others without being seen as non-cooperative.
We strongly believe that taking on some of these tasks provides significant added value for non-resident programs, something that becomes vital in the long-run once the urgency of work-hours compliance has passed. Programs should pick wisely and move slowly when adding additional roles. Whatever roles are added, it is vital that ample consideration is given to the impact on workload and faculty satisfaction. Many of these roles may also present an opportunity to garner additional revenue, whether through billing or direct payment from the hospital.
The Challenges of Academia: Separate and Unequal
The greatest challenge that all major academic hospitalist programs will face will be how to create satisfying long-term faculty positions that involve providing direct inpatient care without the assistance of housestaff (6). There is already a growing problem of physician dissatisfaction among clinical-track faculty in many academic centers where the emphasis on clinical productivity has usurped the missions of teaching and research. The challenges faced by academic hospitalists working without residents are even greater than those faced by existing clinical faculty.
The first consideration for academic programs is whether to create two classes of hospitalists within the same program: those that work primarily with residents and those that do not. In our program we had an already established group of classic hospitalist-educators who worked only on resident-staffed services when we were asked to create a non-resident service. Our easiest option, therefore, was to hire new faculty whose sole responsibility is staffing a non-resident service. With this has come a significant struggle on how to ensure faculty satisfaction and avoid creating a split within the hospitalist program. We also struggle with how to administer such a program and whether leadership should have clinical roles on both services (we currently do not).
For many new programs, it may be easier to create one uniform faculty role that mixes non-resident-based and resident-based service duties and avoids the appearance of two classes of hospitalists. For many mature programs, however, the only option may be to hire new faculty who predominantly work on non-resident services. For these groups, we believe that differences in the positions must be addressed. One solution to this problem is creating viable teaching roles for these new faculty. Options that we are examing include medical student teaching, training allied-health professionals, and some involvement in resident education during the night and at regularly scheduled daytime lectures. Each of these roles requires time and will come at the expense of efficiency or work capacity. We also have struggled to create program-level rapport. We have encouraged weekly meetings and have found that clinically oriented collaboration such as case conferences and quality-improvement initiatives seem to provide the best way for the entire faculty to interact. Another solution that has been offered is to create a vigorous inpatient research agenda that uses the non-resident services as the laboratory; we encourage this approach but feel that it may not be a realistic near-term goal for many programs.
In the end, however, while creating these roles will add to faculty satisfaction and long-term viability, there will be ongoing problems similar to those faced by academic primary care faculty who have limited interactions with residents. Our program relies on junior-level faculty who are in transition between residency and further training or faculty who aspire to eventually grow into more traditional academic teaching roles and take on a more hybridized role. There is likely to be value in this variety, and we imagine that large academic programs will have faculty that run the gamut from those who are primarily research focused to those who spend most of their time in direct front-line patient care.
Results: Work Hours Success
Since the implementation of our non-housestaff service, we have seen dramatic improvements in resident work-hours compliance. Prior to our service, 40% of residents were in violation of the 80-hour week and the “24+6” hour shift limit. After successfully removing 15% of the total inpatient (non-ICU) census from resident-coverage, there have been only sporadic violations during the first 3 months of operation. Therefore, violations of the 80-hour work week rules have been virtually eliminated. Our residents have widely praised the new service and overall morale in the residency program has improved. Yet despite what has been perceived as a significant reduction in resident patient load, there are continued violations of the “24+6”-hour shift rule. In fact many have suggested that violation of the “24+6”-hour rule is a reflection of the competing tension between compliance with external regulation and our residents’ professionalism and dedication to patients. While further reductions in volume might help (although even our residents say that this might jeopardize their education), the more likely solution to this problem is both culture change over time and some re-engineering of the timing of resident shifts.
Conclusions
We envision that in the next few years, non-resident services will exist in almost every major medical center. As our experience highlights, these services can be an effective solution to the resident work-hours problem. We caution, however, that implementation is not an easy task. To be successful, programs should invest significant time in the planning stages and have clear goals in mind. Staffing and finances are likely to remain challenging as is the creation of academically viable roles. Eventually, however, we believe these services will succeed. Their growth will add to the future standing of hospital medicine in academic centers by creating a more diverse group of hospitalist faculty who focus on research, education, and, increasingly, quality patient care.
References
- Croasdale, M. “Johns Hopkins penalized for resident hour violations.” AMNews. Sept. 15, 2003.
- Mehes, A. “Med school could forfeit residency accreditation.” Yale Daily News. Oct. 25, 2002.
- Accreditation Council on Graduate Medical Education: Program Requirements for Residency Education in Internal Medicine. July, 2004. http://www.acgme.org/acWebsite/RRC_140/140_prIndex.asp. Last accessed November 17, 2004.
- Boex JR, Leahy PJ. Understanding residents’ work: moving beyond counting hours to assessing educational value. Acad Med. 2003;78:939-944.
- Halasyamani L, Valenstein P, Friedlander M, Cowen M. A comparison of two hospitalist models with traditional care in a community teaching hospital. Society of Hospital Medicine Annual Meeting (Abstract), April 2004.
- Saint S, Flanders SA. Hospitalists in teaching hospitals: opportunities but not without danger. J Gen Intern Med. 2004;Apr;19(4):392-3.
Dr. Parekh can be contacted at [email protected].
Dr. Flanders can be contacted at [email protected].
In July of 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented new rules that restricted resident work hours to no more than 80 per week and restricted continuous duty to no more than 30 hours (24 hours plus 6 hours for transfer of care, the “24+6” rule). As a result, many major academic medical centers face the problem of handling increasing inpatient volume and ensuring compliance with these new work-hours regulations. The problem has become more pressing as several major academic centers have been cited for work-hours violations by the ACGME, and significant public attention has focused on the impact of excessive work hours on patient safety (1, 2).
Given the success of hospitalists in efficiently managing patents in many non-academic environments, one proposed solution has been the creation of hospitalist services to care for patients independent of residents. These services reduce the volume on resident-based services and therefore reduce resident work hours. We have recently implemented our own non-housestaff service at the University of Michigan and in this article describe the challenges and lessons learned.
Planning a Program
The first step for any institution contemplating the creation of a non-resident service is to establish clear goals. Frequently, decisions on the level and scope of uncovered services are made without any rigorous analysis of the data or without a clear idea of what it is that your program should be doing.
Goals for Resident-Service Census and Volume
The first task for any program is to understand what patient volume must be removed to ensure work-hours compliance without impeding the educational experience of the housestaff . Unfortunately, there is little published opinion on optimal resident workload, and the ACGME is surprisingly silent on this vital issue. While the ACGME does proscribe exceeding theoretical maximum workloads for internal medicine, they cite no minimum or ideal patient census (3). In the absence of firm guidelines, it is important to gather data on both the day-to-day variation of inpatient admissions and volume along with peak admission times (usually early evening). The residency program is likely to offer monthly data or a rough guess at what they think is needed. This can be misleading and does not appreciate the variability of patient flow. It is the “peaks’ that are often remembered, whereas the “troughs” are easily forgotten. Vital data elements that should be obtained include the daily admission volume for each resident-service over the course of the past year. We used this data to calculate average per-intern admission volumes and to project what future volume would be under a variety of possible scenarios, including removing a fixed number of patients per day, creating intern-admissions caps or alternating admissions between residents and hospitalists. We then discussed these models and their projected impact on the residents with residency leadership before settling upon our final model.
Structural Reform of the Resident Services
Besides the question of volume, there is also the issue of whether the new service will also be used to create other structural changes in the resident services. Some areas that programs may consider include modification of the existing call rotation such as reducing or eliminating short-call, changing the frequency of long-call, or implementing limitations on night-time admissions to the housestaff.
Each of these possibilities comes with its own structural needs, so it is vital to decide whether any of these changes are to be attempted.
Patient Complexity
There is significant temptation to use established hospitalist workload standards and apply them to non-resident services in academia. To do so is to invite disaster. The complexity of patients on most academic internal medicine services is quite different from the average community service. One big variable to address here is whether or not the new hospitalist service will have a selected patient population (such as low-complexity or “non-teaching” cases). Without specifically selected low-complexity cases, most hospitalist programs will realize that established community work standards do not apply.
Academic Inefficiencies and Workload
Much of what residents do on a day-to-day basis involves pushing their patients through the inefficient and complex maze of an academic medical center. It seems ridiculous to think that one faculty member can replace the work that was previously performed by an attending, a senior resident, and two interns, yet this is what many programs are actually proposing when they suggest that the “established” work load of 15 patients per day per hospitalist could work in academia.
What is an ideal workload in academia? Our answer is based both on our experience and on work-flow analysis of residents, which suggests that less than 20% of their time is actually spent in direct educational activities (4). We suggest that the acceptable workload for a hospitalist in a major academic center managing patients of equivalent complexity as the residents is slightly higher than what a senior resident alone can reasonably handle. In our institution we have had a service without interns, staffed with senior residents and one attending for several years. In institutions without this structure, one could look at what senior residents do on their intern’s days off. In our experience approximately 8-10 patients/day seems to be an acceptable workload that allowed the residents to provide quality care within the confines of a 10 to 12 hour day. This translates into an attending workload of 9-11 patients/day. We acknowledge that with time, an attending may develop more efficient practices than a senior resident but do not think a workload much higher than this is reasonable during the start-up phase.
The Role of Physician Extenders
Many hospitalists rely on physician extenders such as physician assistants and nurse practitioners. In academia, physician extenders have traditionally worked only in specialty areas of inpatient care such as orthopedics, oncology, or cardiology. The great unknown, however, is how extenders perform in an environment where they are asked to work with both complex and varied patients. We have seen that the training of many extenders is often not enough for them to take on the role envisioned for them in this kind of service. Over time they may develop the skill set, but there is much on-the-job learning that requires dedicated physician time. A realistic census for a physician assistant (PA) taking care of complex academic medical patients is likely to be 4 to 6. The incremental impact of extenders on a service’s total work capacity is not entirely additive, given the need for physician oversight and the need to maximize revenue by using shared visit billing. Despite these limitations, however, we believe that extenders are helpful, especially given the inefficiencies of day-to-day patient care in academic centers.
The University of Michigan
Medicine Faculty Hospitalist Service
Our own program was designed around an original goal of moving 2000 patients from the resident services. This figure was derived from a per-intern workload target of 25 to 30 admissions per month. Based on our modeling of various ways to share admissions, we ultimately settled on a system that alternates admissions with the resident services after each service admits a “baseline” number of patients. This allowed us to variably offload patients based on day-to-day variation in admission volumes. Our service is staffed 24 hours a day with a total of eight full-time physicians and four physician assistants. We have three physicians and two‑three physician assistants during the day (7 a.m. to 7 p.m.) to coincide with the bulk of the workload. There is one doctor at night (7 p.m. to 7 a.m.) for our entire service, and our hospitalists work an average of 50-55 hours a week during 18 shifts a month. Each hospitalist (working with a PA) averages from 8 to 12 billable encounters a day. We maintain a maximum daily census of 30-35 patients and admit up to 10 patients a day. Given these workloads, we do not come close to financial self-sufficiency, but this is not unique to our program.
Funding and Finances
For most institutions a non-resident service represents incremental faculty members without any significant incremental professional fee revenue. The billings on the new service really are just a shift in revenue from the resident services. In addition, given the high clinical workload and current market conditions, the salaries of hospitalists hired for such services tend to be on average $15,000 to $20,000 above that of hospitalists hired onto a traditional resident-based service. There is some opportunity for increased revenue capture because of 24-hour attending presence, but the incremental gain is unlikely to be enough to create financial self-sufficiency. In our program there has been an increase in department-wide consultative revenue as specialized patients are now placed on our general medical service where they were previously cared for by residents and a specialty attending. In addition, we have improved our charge capture by a small margin. This extra revenue will not, however, come close to offsetting our overall cost. Many programs therefore require hospital support to be viable. Given the strong incentives for hospitals to ensure compliance with ACGME rules and maintain maximal inpatient occupancy, many hospitals can be convinced to provide funding.
We argue strongly that the creation of programs developed primarily to deal with residency work hours should be viewed separately from the funding of existing or new resident-based hospitalist programs. Similar to how resident salaries are paid for by the hospital (via federal graduate medical education funding), the cost of a new hospitalist service that is created to replace residents should come from the hospital. Programs should exercise caution in using existing paradigms such as reduction in LOS or decrease in cost as a basis for funding. There is little data comparing resident-based care to non-resident-based hospital care in a tertiary center, and what little that exists does not necessarily suggest a cost benefit (5). In addition, there is a significant future risk if such proposed benefits do not become a reality
New Roles and Responsibilities
Once established, many programs will be asked to take on additional tasks that were previously performed by trainees or other faculty. This is especially true of nighttime tasks. Many programs are asked to run code-blue teams, supervise procedures at night, supervise sedation in radiology, triage patients in the ER, provide emergent patient coverage for other services: the list can go on and on. The challenge is accepting some and rejecting others without being seen as non-cooperative.
We strongly believe that taking on some of these tasks provides significant added value for non-resident programs, something that becomes vital in the long-run once the urgency of work-hours compliance has passed. Programs should pick wisely and move slowly when adding additional roles. Whatever roles are added, it is vital that ample consideration is given to the impact on workload and faculty satisfaction. Many of these roles may also present an opportunity to garner additional revenue, whether through billing or direct payment from the hospital.
The Challenges of Academia: Separate and Unequal
The greatest challenge that all major academic hospitalist programs will face will be how to create satisfying long-term faculty positions that involve providing direct inpatient care without the assistance of housestaff (6). There is already a growing problem of physician dissatisfaction among clinical-track faculty in many academic centers where the emphasis on clinical productivity has usurped the missions of teaching and research. The challenges faced by academic hospitalists working without residents are even greater than those faced by existing clinical faculty.
The first consideration for academic programs is whether to create two classes of hospitalists within the same program: those that work primarily with residents and those that do not. In our program we had an already established group of classic hospitalist-educators who worked only on resident-staffed services when we were asked to create a non-resident service. Our easiest option, therefore, was to hire new faculty whose sole responsibility is staffing a non-resident service. With this has come a significant struggle on how to ensure faculty satisfaction and avoid creating a split within the hospitalist program. We also struggle with how to administer such a program and whether leadership should have clinical roles on both services (we currently do not).
For many new programs, it may be easier to create one uniform faculty role that mixes non-resident-based and resident-based service duties and avoids the appearance of two classes of hospitalists. For many mature programs, however, the only option may be to hire new faculty who predominantly work on non-resident services. For these groups, we believe that differences in the positions must be addressed. One solution to this problem is creating viable teaching roles for these new faculty. Options that we are examing include medical student teaching, training allied-health professionals, and some involvement in resident education during the night and at regularly scheduled daytime lectures. Each of these roles requires time and will come at the expense of efficiency or work capacity. We also have struggled to create program-level rapport. We have encouraged weekly meetings and have found that clinically oriented collaboration such as case conferences and quality-improvement initiatives seem to provide the best way for the entire faculty to interact. Another solution that has been offered is to create a vigorous inpatient research agenda that uses the non-resident services as the laboratory; we encourage this approach but feel that it may not be a realistic near-term goal for many programs.
In the end, however, while creating these roles will add to faculty satisfaction and long-term viability, there will be ongoing problems similar to those faced by academic primary care faculty who have limited interactions with residents. Our program relies on junior-level faculty who are in transition between residency and further training or faculty who aspire to eventually grow into more traditional academic teaching roles and take on a more hybridized role. There is likely to be value in this variety, and we imagine that large academic programs will have faculty that run the gamut from those who are primarily research focused to those who spend most of their time in direct front-line patient care.
Results: Work Hours Success
Since the implementation of our non-housestaff service, we have seen dramatic improvements in resident work-hours compliance. Prior to our service, 40% of residents were in violation of the 80-hour week and the “24+6” hour shift limit. After successfully removing 15% of the total inpatient (non-ICU) census from resident-coverage, there have been only sporadic violations during the first 3 months of operation. Therefore, violations of the 80-hour work week rules have been virtually eliminated. Our residents have widely praised the new service and overall morale in the residency program has improved. Yet despite what has been perceived as a significant reduction in resident patient load, there are continued violations of the “24+6”-hour shift rule. In fact many have suggested that violation of the “24+6”-hour rule is a reflection of the competing tension between compliance with external regulation and our residents’ professionalism and dedication to patients. While further reductions in volume might help (although even our residents say that this might jeopardize their education), the more likely solution to this problem is both culture change over time and some re-engineering of the timing of resident shifts.
Conclusions
We envision that in the next few years, non-resident services will exist in almost every major medical center. As our experience highlights, these services can be an effective solution to the resident work-hours problem. We caution, however, that implementation is not an easy task. To be successful, programs should invest significant time in the planning stages and have clear goals in mind. Staffing and finances are likely to remain challenging as is the creation of academically viable roles. Eventually, however, we believe these services will succeed. Their growth will add to the future standing of hospital medicine in academic centers by creating a more diverse group of hospitalist faculty who focus on research, education, and, increasingly, quality patient care.
References
- Croasdale, M. “Johns Hopkins penalized for resident hour violations.” AMNews. Sept. 15, 2003.
- Mehes, A. “Med school could forfeit residency accreditation.” Yale Daily News. Oct. 25, 2002.
- Accreditation Council on Graduate Medical Education: Program Requirements for Residency Education in Internal Medicine. July, 2004. http://www.acgme.org/acWebsite/RRC_140/140_prIndex.asp. Last accessed November 17, 2004.
- Boex JR, Leahy PJ. Understanding residents’ work: moving beyond counting hours to assessing educational value. Acad Med. 2003;78:939-944.
- Halasyamani L, Valenstein P, Friedlander M, Cowen M. A comparison of two hospitalist models with traditional care in a community teaching hospital. Society of Hospital Medicine Annual Meeting (Abstract), April 2004.
- Saint S, Flanders SA. Hospitalists in teaching hospitals: opportunities but not without danger. J Gen Intern Med. 2004;Apr;19(4):392-3.
Dr. Parekh can be contacted at [email protected].
Dr. Flanders can be contacted at [email protected].
In July of 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented new rules that restricted resident work hours to no more than 80 per week and restricted continuous duty to no more than 30 hours (24 hours plus 6 hours for transfer of care, the “24+6” rule). As a result, many major academic medical centers face the problem of handling increasing inpatient volume and ensuring compliance with these new work-hours regulations. The problem has become more pressing as several major academic centers have been cited for work-hours violations by the ACGME, and significant public attention has focused on the impact of excessive work hours on patient safety (1, 2).
Given the success of hospitalists in efficiently managing patents in many non-academic environments, one proposed solution has been the creation of hospitalist services to care for patients independent of residents. These services reduce the volume on resident-based services and therefore reduce resident work hours. We have recently implemented our own non-housestaff service at the University of Michigan and in this article describe the challenges and lessons learned.
Planning a Program
The first step for any institution contemplating the creation of a non-resident service is to establish clear goals. Frequently, decisions on the level and scope of uncovered services are made without any rigorous analysis of the data or without a clear idea of what it is that your program should be doing.
Goals for Resident-Service Census and Volume
The first task for any program is to understand what patient volume must be removed to ensure work-hours compliance without impeding the educational experience of the housestaff . Unfortunately, there is little published opinion on optimal resident workload, and the ACGME is surprisingly silent on this vital issue. While the ACGME does proscribe exceeding theoretical maximum workloads for internal medicine, they cite no minimum or ideal patient census (3). In the absence of firm guidelines, it is important to gather data on both the day-to-day variation of inpatient admissions and volume along with peak admission times (usually early evening). The residency program is likely to offer monthly data or a rough guess at what they think is needed. This can be misleading and does not appreciate the variability of patient flow. It is the “peaks’ that are often remembered, whereas the “troughs” are easily forgotten. Vital data elements that should be obtained include the daily admission volume for each resident-service over the course of the past year. We used this data to calculate average per-intern admission volumes and to project what future volume would be under a variety of possible scenarios, including removing a fixed number of patients per day, creating intern-admissions caps or alternating admissions between residents and hospitalists. We then discussed these models and their projected impact on the residents with residency leadership before settling upon our final model.
Structural Reform of the Resident Services
Besides the question of volume, there is also the issue of whether the new service will also be used to create other structural changes in the resident services. Some areas that programs may consider include modification of the existing call rotation such as reducing or eliminating short-call, changing the frequency of long-call, or implementing limitations on night-time admissions to the housestaff.
Each of these possibilities comes with its own structural needs, so it is vital to decide whether any of these changes are to be attempted.
Patient Complexity
There is significant temptation to use established hospitalist workload standards and apply them to non-resident services in academia. To do so is to invite disaster. The complexity of patients on most academic internal medicine services is quite different from the average community service. One big variable to address here is whether or not the new hospitalist service will have a selected patient population (such as low-complexity or “non-teaching” cases). Without specifically selected low-complexity cases, most hospitalist programs will realize that established community work standards do not apply.
Academic Inefficiencies and Workload
Much of what residents do on a day-to-day basis involves pushing their patients through the inefficient and complex maze of an academic medical center. It seems ridiculous to think that one faculty member can replace the work that was previously performed by an attending, a senior resident, and two interns, yet this is what many programs are actually proposing when they suggest that the “established” work load of 15 patients per day per hospitalist could work in academia.
What is an ideal workload in academia? Our answer is based both on our experience and on work-flow analysis of residents, which suggests that less than 20% of their time is actually spent in direct educational activities (4). We suggest that the acceptable workload for a hospitalist in a major academic center managing patients of equivalent complexity as the residents is slightly higher than what a senior resident alone can reasonably handle. In our institution we have had a service without interns, staffed with senior residents and one attending for several years. In institutions without this structure, one could look at what senior residents do on their intern’s days off. In our experience approximately 8-10 patients/day seems to be an acceptable workload that allowed the residents to provide quality care within the confines of a 10 to 12 hour day. This translates into an attending workload of 9-11 patients/day. We acknowledge that with time, an attending may develop more efficient practices than a senior resident but do not think a workload much higher than this is reasonable during the start-up phase.
The Role of Physician Extenders
Many hospitalists rely on physician extenders such as physician assistants and nurse practitioners. In academia, physician extenders have traditionally worked only in specialty areas of inpatient care such as orthopedics, oncology, or cardiology. The great unknown, however, is how extenders perform in an environment where they are asked to work with both complex and varied patients. We have seen that the training of many extenders is often not enough for them to take on the role envisioned for them in this kind of service. Over time they may develop the skill set, but there is much on-the-job learning that requires dedicated physician time. A realistic census for a physician assistant (PA) taking care of complex academic medical patients is likely to be 4 to 6. The incremental impact of extenders on a service’s total work capacity is not entirely additive, given the need for physician oversight and the need to maximize revenue by using shared visit billing. Despite these limitations, however, we believe that extenders are helpful, especially given the inefficiencies of day-to-day patient care in academic centers.
The University of Michigan
Medicine Faculty Hospitalist Service
Our own program was designed around an original goal of moving 2000 patients from the resident services. This figure was derived from a per-intern workload target of 25 to 30 admissions per month. Based on our modeling of various ways to share admissions, we ultimately settled on a system that alternates admissions with the resident services after each service admits a “baseline” number of patients. This allowed us to variably offload patients based on day-to-day variation in admission volumes. Our service is staffed 24 hours a day with a total of eight full-time physicians and four physician assistants. We have three physicians and two‑three physician assistants during the day (7 a.m. to 7 p.m.) to coincide with the bulk of the workload. There is one doctor at night (7 p.m. to 7 a.m.) for our entire service, and our hospitalists work an average of 50-55 hours a week during 18 shifts a month. Each hospitalist (working with a PA) averages from 8 to 12 billable encounters a day. We maintain a maximum daily census of 30-35 patients and admit up to 10 patients a day. Given these workloads, we do not come close to financial self-sufficiency, but this is not unique to our program.
Funding and Finances
For most institutions a non-resident service represents incremental faculty members without any significant incremental professional fee revenue. The billings on the new service really are just a shift in revenue from the resident services. In addition, given the high clinical workload and current market conditions, the salaries of hospitalists hired for such services tend to be on average $15,000 to $20,000 above that of hospitalists hired onto a traditional resident-based service. There is some opportunity for increased revenue capture because of 24-hour attending presence, but the incremental gain is unlikely to be enough to create financial self-sufficiency. In our program there has been an increase in department-wide consultative revenue as specialized patients are now placed on our general medical service where they were previously cared for by residents and a specialty attending. In addition, we have improved our charge capture by a small margin. This extra revenue will not, however, come close to offsetting our overall cost. Many programs therefore require hospital support to be viable. Given the strong incentives for hospitals to ensure compliance with ACGME rules and maintain maximal inpatient occupancy, many hospitals can be convinced to provide funding.
We argue strongly that the creation of programs developed primarily to deal with residency work hours should be viewed separately from the funding of existing or new resident-based hospitalist programs. Similar to how resident salaries are paid for by the hospital (via federal graduate medical education funding), the cost of a new hospitalist service that is created to replace residents should come from the hospital. Programs should exercise caution in using existing paradigms such as reduction in LOS or decrease in cost as a basis for funding. There is little data comparing resident-based care to non-resident-based hospital care in a tertiary center, and what little that exists does not necessarily suggest a cost benefit (5). In addition, there is a significant future risk if such proposed benefits do not become a reality
New Roles and Responsibilities
Once established, many programs will be asked to take on additional tasks that were previously performed by trainees or other faculty. This is especially true of nighttime tasks. Many programs are asked to run code-blue teams, supervise procedures at night, supervise sedation in radiology, triage patients in the ER, provide emergent patient coverage for other services: the list can go on and on. The challenge is accepting some and rejecting others without being seen as non-cooperative.
We strongly believe that taking on some of these tasks provides significant added value for non-resident programs, something that becomes vital in the long-run once the urgency of work-hours compliance has passed. Programs should pick wisely and move slowly when adding additional roles. Whatever roles are added, it is vital that ample consideration is given to the impact on workload and faculty satisfaction. Many of these roles may also present an opportunity to garner additional revenue, whether through billing or direct payment from the hospital.
The Challenges of Academia: Separate and Unequal
The greatest challenge that all major academic hospitalist programs will face will be how to create satisfying long-term faculty positions that involve providing direct inpatient care without the assistance of housestaff (6). There is already a growing problem of physician dissatisfaction among clinical-track faculty in many academic centers where the emphasis on clinical productivity has usurped the missions of teaching and research. The challenges faced by academic hospitalists working without residents are even greater than those faced by existing clinical faculty.
The first consideration for academic programs is whether to create two classes of hospitalists within the same program: those that work primarily with residents and those that do not. In our program we had an already established group of classic hospitalist-educators who worked only on resident-staffed services when we were asked to create a non-resident service. Our easiest option, therefore, was to hire new faculty whose sole responsibility is staffing a non-resident service. With this has come a significant struggle on how to ensure faculty satisfaction and avoid creating a split within the hospitalist program. We also struggle with how to administer such a program and whether leadership should have clinical roles on both services (we currently do not).
For many new programs, it may be easier to create one uniform faculty role that mixes non-resident-based and resident-based service duties and avoids the appearance of two classes of hospitalists. For many mature programs, however, the only option may be to hire new faculty who predominantly work on non-resident services. For these groups, we believe that differences in the positions must be addressed. One solution to this problem is creating viable teaching roles for these new faculty. Options that we are examing include medical student teaching, training allied-health professionals, and some involvement in resident education during the night and at regularly scheduled daytime lectures. Each of these roles requires time and will come at the expense of efficiency or work capacity. We also have struggled to create program-level rapport. We have encouraged weekly meetings and have found that clinically oriented collaboration such as case conferences and quality-improvement initiatives seem to provide the best way for the entire faculty to interact. Another solution that has been offered is to create a vigorous inpatient research agenda that uses the non-resident services as the laboratory; we encourage this approach but feel that it may not be a realistic near-term goal for many programs.
In the end, however, while creating these roles will add to faculty satisfaction and long-term viability, there will be ongoing problems similar to those faced by academic primary care faculty who have limited interactions with residents. Our program relies on junior-level faculty who are in transition between residency and further training or faculty who aspire to eventually grow into more traditional academic teaching roles and take on a more hybridized role. There is likely to be value in this variety, and we imagine that large academic programs will have faculty that run the gamut from those who are primarily research focused to those who spend most of their time in direct front-line patient care.
Results: Work Hours Success
Since the implementation of our non-housestaff service, we have seen dramatic improvements in resident work-hours compliance. Prior to our service, 40% of residents were in violation of the 80-hour week and the “24+6” hour shift limit. After successfully removing 15% of the total inpatient (non-ICU) census from resident-coverage, there have been only sporadic violations during the first 3 months of operation. Therefore, violations of the 80-hour work week rules have been virtually eliminated. Our residents have widely praised the new service and overall morale in the residency program has improved. Yet despite what has been perceived as a significant reduction in resident patient load, there are continued violations of the “24+6”-hour shift rule. In fact many have suggested that violation of the “24+6”-hour rule is a reflection of the competing tension between compliance with external regulation and our residents’ professionalism and dedication to patients. While further reductions in volume might help (although even our residents say that this might jeopardize their education), the more likely solution to this problem is both culture change over time and some re-engineering of the timing of resident shifts.
Conclusions
We envision that in the next few years, non-resident services will exist in almost every major medical center. As our experience highlights, these services can be an effective solution to the resident work-hours problem. We caution, however, that implementation is not an easy task. To be successful, programs should invest significant time in the planning stages and have clear goals in mind. Staffing and finances are likely to remain challenging as is the creation of academically viable roles. Eventually, however, we believe these services will succeed. Their growth will add to the future standing of hospital medicine in academic centers by creating a more diverse group of hospitalist faculty who focus on research, education, and, increasingly, quality patient care.
References
- Croasdale, M. “Johns Hopkins penalized for resident hour violations.” AMNews. Sept. 15, 2003.
- Mehes, A. “Med school could forfeit residency accreditation.” Yale Daily News. Oct. 25, 2002.
- Accreditation Council on Graduate Medical Education: Program Requirements for Residency Education in Internal Medicine. July, 2004. http://www.acgme.org/acWebsite/RRC_140/140_prIndex.asp. Last accessed November 17, 2004.
- Boex JR, Leahy PJ. Understanding residents’ work: moving beyond counting hours to assessing educational value. Acad Med. 2003;78:939-944.
- Halasyamani L, Valenstein P, Friedlander M, Cowen M. A comparison of two hospitalist models with traditional care in a community teaching hospital. Society of Hospital Medicine Annual Meeting (Abstract), April 2004.
- Saint S, Flanders SA. Hospitalists in teaching hospitals: opportunities but not without danger. J Gen Intern Med. 2004;Apr;19(4):392-3.
Dr. Parekh can be contacted at [email protected].
Dr. Flanders can be contacted at [email protected].
Taking Your Best Shot at the Flu
In a year when the United States has been riddled with bad news, confusion, and even threats of fines and incarceration (1) surrounding the use of influenza vaccines, the last thing you may be interested in thinking about is instituting a comprehensive inpatient influenza vaccination initiative. Despite the chaos, it is important to remember that, on average, 36,000 (2) people die and 226,000 (3) people are hospitalized annually from influenza, or “the flu,” and its complications. Additionally, a significant proportion of patients hospitalized will have co-morbid illness or be old enough to be considered in the highest risk category for complications of flu (4). Hospitalists are poised to act centrally in improving vaccination rates given the intensity of their patient contact and their expertise in developing best-practices-based systems.
What follows is a step-wise plan to help you begin an inpatient influenza vaccination initiative at your institution. Clearly, elements of this plan will need to be modified based on institutional structure and preference.
1. Define the problem locally. It is important to identify if any inpatient vaccination systems are already in place for any other vaccination (e.g., pneumococcal vaccination for splenectomy patients; tetanus for trauma patients, etc). If such a system already exists, review its successes and see if any of them may be borrowed for the influenza plan. Also determine if influenza vaccines have ever (even in a random, sptty fashion) been given out on your institution’s inpatient service. Understanding this history will help you address the issues of the “culture” of the institution.
2. Talk with your administration about making influenza vaccination a quality goal. One of the barriers ahead may be the mindset that vaccinations should only live in the world of outpatient physicians. By obtaining “buyin” from administration (e.g., the Chief Medical Officer), you may have some additional resources made available to you, and you may also be able to leverage the weight of the administration in recruiting help for the program. Remember, the 2005 Disease-Specific Patient Safety Goals from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) state that it is important to “develop and implement a protocol for administration and documentation of the flu vaccine.” (5)
3. Identify key players and meet with them. This plan cannot be sustained successfully as a one-person show. Ideally, you should create an influenza vaccination committee that has representatives of all the inpatient services (medicine, family medicine, surgery, obstetrics and gynecology, and pediatrics), as well as nursing leadership, infection control, pharmacy, information technology (for computerized order entry systems), and quality assurance. In academic institutions, you might also consider including a house officer and/or medical student. The initial meeting should review your findings with #1 and #2 above, as well as assessing this committee’s concerns about implementing an inpatient vaccination scheme. You should plan to initiate committee activities at least two to three months in advance of the anticipated availability of the vaccine.
4. Create a culture of vaccination. Vaccines are often not on the radar screen of most inpatient physicians as they deal with the more acute reasons for hospitalization. It is therefore important to begin introducing a culture change, demonstrating the importance of vaccinations to your staff, and shifting the prevalent mindset towards active engagement with your vaccination program. Identifying foreseeable problems and developing action plans will assist this process. Some issues may include:
- Physician and nurse attitudes and education about influenza and the vaccine (e.g., dispelling flu shot rumors, educating staff on the low risk of re-vaccinating a patient already vaccinated previously this season, explaining the lack of requirements for written informed consent for flu vaccination, encouraging health care workers to get flu shots themselves (6), etc.)
- Reminder systems for physicians to reinforce the need to vaccinate (posters, screen savers, emails, buttons)
- Communication with primary care physicians about patients who have been vaccinated
- Patient misconceptions about the vaccine’s side effects
5. Set a goal. It may be helpful to assess your inpatient service’s demographics for the past few years to identify the approximate denominator of eligible candidates for the vaccine based on age and key diagnoses. However, if your institution does not already have a history of active influenza vaccination on the inpatient service, start with a humble goal. It is attractive to assume that every patient who qualifies will be vaccinated. It is just not so. Have your influenza committee pick an achievable goal for your first flu season and stretch it in subsequent seasons. To achieve the goal, make sure each clinical area has an identifiable “champion” who can gently remind clinicians about the importance of vaccination. The higher the profile of the local champion the better, assuming the champion has the time and can offer the effort required to do the periodic reminders. Also make sure your pharmacy tracking and distributions systems are prepared to handle the increase in requests for the vaccines. Of note, many patients who are candidates for flu shots are also candidates for pneumococcal vaccines and both may be given together. Consider adding the pneumococcal vaccine to your efforts in appropriate patients.
6. Develop an “Opt Out” system. The CDC’s Advisory Committee on Immunization Practices recommends developing standing orders for both influenza and pneumococcal vaccinations (7). In computerized order entry, this suggestion may lead to a pre-selected order-set being built into the discharge orders that requires the physician to actively opt-out of the order. Paper-based systems may include standing printed orders, again, which require a physician to decline the order specifically. Such opt out systems have been shown to improve rates of vaccination significantly (8). Opt-out programs, however, still require that the clinician ordering the vaccine discusses the vaccine with the patient before it is administered.
7. Roll it out with a bang. Make sure the commencement of your flu shot program gets some press. Announce it at departmental meetings, on system-wide emails, and in hospital publications. Remember, this program is a demonstrable way of improving your patients’ health and an excellent way for hospitalists to show their systems-oriented approaches. Begin your roll-out as early as recommended by the local Department of Public Health so that your patients, many of whom will be at very high risk for complications of the flu, get early vaccination.
8. Give frequent feedback. Obtain vaccine distribution and utilization data at least twice monthly during the first two or three months. This period corresponds to the most critical period of the program as it is when flu shots must be delivered to ensure their efficacy come December-February when flu season typically peaks (9). Some groups may find that a bit of healthy competition (e.g., between services or between nursing units) may offer that edge to keep people vaccinating. Nonetheless, it is critical to keep your clinical areas updated with their performance, with public appreciation being expressed for the top notable clinical areas and low performers receiving extra encouragement and assistance. After the first few months, monthly reports and feedback will suffice, with the program running through the end of March.
9. Remain aware of the local and national flu scene. With the vaccine production problems of the current flu season and with the panic about the high mortality rates of the Fujian strain that was not included in the vaccine last season, it is clear that the flu news scene can be volatile and controversial. It is important to remain up to date on the current facts and be able to dispel any misinformation that may circulate. The following resources may prove helpful:
- The CDC’s influenza home page: http://www.cdc.gov/flu/
- The WHO’s influenza site: http://www.who.int/csr/disease/influenza/en/
- The state Department of Public Health
10. Plan for next season. At the end of flu season, reconvene the influenza committee and debrief. It is important to keep a log of the successes and failures of the season’s flu vaccine initiative to permit growth in subsequent seasons.
The CDC’s program, Healthy People 2010, has set a goal for influenza and pneumococcal vaccination of appropriate non-institutionalized individuals of 90% (10). This goal is achievable if all available resources for reaching out to such patients are utilized. The Massachusetts Hospital Association reports:
“Inpatient hospital stays are among the many missed opportunities for flu and pneumonia vaccination across health care settings. Up to 46% of subsequent influenza-related hospitalizations and 2/3 of influenza-related deaths occur among the elderly who have been previously hospitalized during the flu season. Up to 2/3 of patients hospitalized with serious pneumococcal infections have been hospitalized at least once within the previous 3-5 years (8).”
Hospitalists must take advantage of the opportunity that hospitalization affords our patients to receive the vaccines they need to stay healthy. Appropriate vaccine delivery is no longer solely the purview of the primary care physician – hospitalists must share this goal as well.
References
- The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health. Revised order to establish rules and priorities for the distribution and use of influenza vaccine. Available at: http://www.mass.gov/dph/cdc/epii/flu/flu_order.htm. Accessed November 3, 2004.
- Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA.2003;289:179-86.
- Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United States. JAMA. 2004;292:1333-40.
- CDC. Interim Influenza Vaccination Recommendations – 2004-2005 Season. Available at: http://www.cdc.gov/flu/protect/whoshouldget.htm. Accessed November 3, 2004.
- JCAHO. 2005 Disease-specific care national patient safety goals. Available at: http://www.jcaho.org/accredited+organizations/patient+safety/05+npsg/05_npsg_dsc.htm. Accessed November 3, 2004.
- Martinello RA, Jones L, Topal JE. Correlation between healthcare workers’ knowledge of influenza vaccine and vaccine receipt. Infect Control Hosp Epidemiol. 2003.Nov;24(11):799-800.
- CDC. Prevention and Control of Influenza Recommendations of the Advisory Committee on Immunization Practices (ACIP). Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5306a1.htm. Accessed November 8, 2004.
- Massachusetts Hospital Association. Opt-Out Standing Orders for Pneumonia and Influenza Vaccination for Hospital Inpatients: Best Practice Adoption Proposal to Improve Massachusetts Hospital Performance and Public Health. Available at: http://www.masspro.org/publications/pubs/misc/PNEUMHA2.pdf.
- CDC. Influenza: the disease. Available at: http://www.cdc.gov/flu/about/disease.htm. Accessed November 8, 2004.
- CDC. Healthy People 2010. Immunization and Infectious Diseases. Section 14-29a. Available at: http://www.healthypeople.gov/document/html/volume1/14immunization.htm. Accessed November 8, 2004.
In a year when the United States has been riddled with bad news, confusion, and even threats of fines and incarceration (1) surrounding the use of influenza vaccines, the last thing you may be interested in thinking about is instituting a comprehensive inpatient influenza vaccination initiative. Despite the chaos, it is important to remember that, on average, 36,000 (2) people die and 226,000 (3) people are hospitalized annually from influenza, or “the flu,” and its complications. Additionally, a significant proportion of patients hospitalized will have co-morbid illness or be old enough to be considered in the highest risk category for complications of flu (4). Hospitalists are poised to act centrally in improving vaccination rates given the intensity of their patient contact and their expertise in developing best-practices-based systems.
What follows is a step-wise plan to help you begin an inpatient influenza vaccination initiative at your institution. Clearly, elements of this plan will need to be modified based on institutional structure and preference.
1. Define the problem locally. It is important to identify if any inpatient vaccination systems are already in place for any other vaccination (e.g., pneumococcal vaccination for splenectomy patients; tetanus for trauma patients, etc). If such a system already exists, review its successes and see if any of them may be borrowed for the influenza plan. Also determine if influenza vaccines have ever (even in a random, sptty fashion) been given out on your institution’s inpatient service. Understanding this history will help you address the issues of the “culture” of the institution.
2. Talk with your administration about making influenza vaccination a quality goal. One of the barriers ahead may be the mindset that vaccinations should only live in the world of outpatient physicians. By obtaining “buyin” from administration (e.g., the Chief Medical Officer), you may have some additional resources made available to you, and you may also be able to leverage the weight of the administration in recruiting help for the program. Remember, the 2005 Disease-Specific Patient Safety Goals from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) state that it is important to “develop and implement a protocol for administration and documentation of the flu vaccine.” (5)
3. Identify key players and meet with them. This plan cannot be sustained successfully as a one-person show. Ideally, you should create an influenza vaccination committee that has representatives of all the inpatient services (medicine, family medicine, surgery, obstetrics and gynecology, and pediatrics), as well as nursing leadership, infection control, pharmacy, information technology (for computerized order entry systems), and quality assurance. In academic institutions, you might also consider including a house officer and/or medical student. The initial meeting should review your findings with #1 and #2 above, as well as assessing this committee’s concerns about implementing an inpatient vaccination scheme. You should plan to initiate committee activities at least two to three months in advance of the anticipated availability of the vaccine.
4. Create a culture of vaccination. Vaccines are often not on the radar screen of most inpatient physicians as they deal with the more acute reasons for hospitalization. It is therefore important to begin introducing a culture change, demonstrating the importance of vaccinations to your staff, and shifting the prevalent mindset towards active engagement with your vaccination program. Identifying foreseeable problems and developing action plans will assist this process. Some issues may include:
- Physician and nurse attitudes and education about influenza and the vaccine (e.g., dispelling flu shot rumors, educating staff on the low risk of re-vaccinating a patient already vaccinated previously this season, explaining the lack of requirements for written informed consent for flu vaccination, encouraging health care workers to get flu shots themselves (6), etc.)
- Reminder systems for physicians to reinforce the need to vaccinate (posters, screen savers, emails, buttons)
- Communication with primary care physicians about patients who have been vaccinated
- Patient misconceptions about the vaccine’s side effects
5. Set a goal. It may be helpful to assess your inpatient service’s demographics for the past few years to identify the approximate denominator of eligible candidates for the vaccine based on age and key diagnoses. However, if your institution does not already have a history of active influenza vaccination on the inpatient service, start with a humble goal. It is attractive to assume that every patient who qualifies will be vaccinated. It is just not so. Have your influenza committee pick an achievable goal for your first flu season and stretch it in subsequent seasons. To achieve the goal, make sure each clinical area has an identifiable “champion” who can gently remind clinicians about the importance of vaccination. The higher the profile of the local champion the better, assuming the champion has the time and can offer the effort required to do the periodic reminders. Also make sure your pharmacy tracking and distributions systems are prepared to handle the increase in requests for the vaccines. Of note, many patients who are candidates for flu shots are also candidates for pneumococcal vaccines and both may be given together. Consider adding the pneumococcal vaccine to your efforts in appropriate patients.
6. Develop an “Opt Out” system. The CDC’s Advisory Committee on Immunization Practices recommends developing standing orders for both influenza and pneumococcal vaccinations (7). In computerized order entry, this suggestion may lead to a pre-selected order-set being built into the discharge orders that requires the physician to actively opt-out of the order. Paper-based systems may include standing printed orders, again, which require a physician to decline the order specifically. Such opt out systems have been shown to improve rates of vaccination significantly (8). Opt-out programs, however, still require that the clinician ordering the vaccine discusses the vaccine with the patient before it is administered.
7. Roll it out with a bang. Make sure the commencement of your flu shot program gets some press. Announce it at departmental meetings, on system-wide emails, and in hospital publications. Remember, this program is a demonstrable way of improving your patients’ health and an excellent way for hospitalists to show their systems-oriented approaches. Begin your roll-out as early as recommended by the local Department of Public Health so that your patients, many of whom will be at very high risk for complications of the flu, get early vaccination.
8. Give frequent feedback. Obtain vaccine distribution and utilization data at least twice monthly during the first two or three months. This period corresponds to the most critical period of the program as it is when flu shots must be delivered to ensure their efficacy come December-February when flu season typically peaks (9). Some groups may find that a bit of healthy competition (e.g., between services or between nursing units) may offer that edge to keep people vaccinating. Nonetheless, it is critical to keep your clinical areas updated with their performance, with public appreciation being expressed for the top notable clinical areas and low performers receiving extra encouragement and assistance. After the first few months, monthly reports and feedback will suffice, with the program running through the end of March.
9. Remain aware of the local and national flu scene. With the vaccine production problems of the current flu season and with the panic about the high mortality rates of the Fujian strain that was not included in the vaccine last season, it is clear that the flu news scene can be volatile and controversial. It is important to remain up to date on the current facts and be able to dispel any misinformation that may circulate. The following resources may prove helpful:
- The CDC’s influenza home page: http://www.cdc.gov/flu/
- The WHO’s influenza site: http://www.who.int/csr/disease/influenza/en/
- The state Department of Public Health
10. Plan for next season. At the end of flu season, reconvene the influenza committee and debrief. It is important to keep a log of the successes and failures of the season’s flu vaccine initiative to permit growth in subsequent seasons.
The CDC’s program, Healthy People 2010, has set a goal for influenza and pneumococcal vaccination of appropriate non-institutionalized individuals of 90% (10). This goal is achievable if all available resources for reaching out to such patients are utilized. The Massachusetts Hospital Association reports:
“Inpatient hospital stays are among the many missed opportunities for flu and pneumonia vaccination across health care settings. Up to 46% of subsequent influenza-related hospitalizations and 2/3 of influenza-related deaths occur among the elderly who have been previously hospitalized during the flu season. Up to 2/3 of patients hospitalized with serious pneumococcal infections have been hospitalized at least once within the previous 3-5 years (8).”
Hospitalists must take advantage of the opportunity that hospitalization affords our patients to receive the vaccines they need to stay healthy. Appropriate vaccine delivery is no longer solely the purview of the primary care physician – hospitalists must share this goal as well.
References
- The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health. Revised order to establish rules and priorities for the distribution and use of influenza vaccine. Available at: http://www.mass.gov/dph/cdc/epii/flu/flu_order.htm. Accessed November 3, 2004.
- Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA.2003;289:179-86.
- Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United States. JAMA. 2004;292:1333-40.
- CDC. Interim Influenza Vaccination Recommendations – 2004-2005 Season. Available at: http://www.cdc.gov/flu/protect/whoshouldget.htm. Accessed November 3, 2004.
- JCAHO. 2005 Disease-specific care national patient safety goals. Available at: http://www.jcaho.org/accredited+organizations/patient+safety/05+npsg/05_npsg_dsc.htm. Accessed November 3, 2004.
- Martinello RA, Jones L, Topal JE. Correlation between healthcare workers’ knowledge of influenza vaccine and vaccine receipt. Infect Control Hosp Epidemiol. 2003.Nov;24(11):799-800.
- CDC. Prevention and Control of Influenza Recommendations of the Advisory Committee on Immunization Practices (ACIP). Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5306a1.htm. Accessed November 8, 2004.
- Massachusetts Hospital Association. Opt-Out Standing Orders for Pneumonia and Influenza Vaccination for Hospital Inpatients: Best Practice Adoption Proposal to Improve Massachusetts Hospital Performance and Public Health. Available at: http://www.masspro.org/publications/pubs/misc/PNEUMHA2.pdf.
- CDC. Influenza: the disease. Available at: http://www.cdc.gov/flu/about/disease.htm. Accessed November 8, 2004.
- CDC. Healthy People 2010. Immunization and Infectious Diseases. Section 14-29a. Available at: http://www.healthypeople.gov/document/html/volume1/14immunization.htm. Accessed November 8, 2004.
In a year when the United States has been riddled with bad news, confusion, and even threats of fines and incarceration (1) surrounding the use of influenza vaccines, the last thing you may be interested in thinking about is instituting a comprehensive inpatient influenza vaccination initiative. Despite the chaos, it is important to remember that, on average, 36,000 (2) people die and 226,000 (3) people are hospitalized annually from influenza, or “the flu,” and its complications. Additionally, a significant proportion of patients hospitalized will have co-morbid illness or be old enough to be considered in the highest risk category for complications of flu (4). Hospitalists are poised to act centrally in improving vaccination rates given the intensity of their patient contact and their expertise in developing best-practices-based systems.
What follows is a step-wise plan to help you begin an inpatient influenza vaccination initiative at your institution. Clearly, elements of this plan will need to be modified based on institutional structure and preference.
1. Define the problem locally. It is important to identify if any inpatient vaccination systems are already in place for any other vaccination (e.g., pneumococcal vaccination for splenectomy patients; tetanus for trauma patients, etc). If such a system already exists, review its successes and see if any of them may be borrowed for the influenza plan. Also determine if influenza vaccines have ever (even in a random, sptty fashion) been given out on your institution’s inpatient service. Understanding this history will help you address the issues of the “culture” of the institution.
2. Talk with your administration about making influenza vaccination a quality goal. One of the barriers ahead may be the mindset that vaccinations should only live in the world of outpatient physicians. By obtaining “buyin” from administration (e.g., the Chief Medical Officer), you may have some additional resources made available to you, and you may also be able to leverage the weight of the administration in recruiting help for the program. Remember, the 2005 Disease-Specific Patient Safety Goals from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) state that it is important to “develop and implement a protocol for administration and documentation of the flu vaccine.” (5)
3. Identify key players and meet with them. This plan cannot be sustained successfully as a one-person show. Ideally, you should create an influenza vaccination committee that has representatives of all the inpatient services (medicine, family medicine, surgery, obstetrics and gynecology, and pediatrics), as well as nursing leadership, infection control, pharmacy, information technology (for computerized order entry systems), and quality assurance. In academic institutions, you might also consider including a house officer and/or medical student. The initial meeting should review your findings with #1 and #2 above, as well as assessing this committee’s concerns about implementing an inpatient vaccination scheme. You should plan to initiate committee activities at least two to three months in advance of the anticipated availability of the vaccine.
4. Create a culture of vaccination. Vaccines are often not on the radar screen of most inpatient physicians as they deal with the more acute reasons for hospitalization. It is therefore important to begin introducing a culture change, demonstrating the importance of vaccinations to your staff, and shifting the prevalent mindset towards active engagement with your vaccination program. Identifying foreseeable problems and developing action plans will assist this process. Some issues may include:
- Physician and nurse attitudes and education about influenza and the vaccine (e.g., dispelling flu shot rumors, educating staff on the low risk of re-vaccinating a patient already vaccinated previously this season, explaining the lack of requirements for written informed consent for flu vaccination, encouraging health care workers to get flu shots themselves (6), etc.)
- Reminder systems for physicians to reinforce the need to vaccinate (posters, screen savers, emails, buttons)
- Communication with primary care physicians about patients who have been vaccinated
- Patient misconceptions about the vaccine’s side effects
5. Set a goal. It may be helpful to assess your inpatient service’s demographics for the past few years to identify the approximate denominator of eligible candidates for the vaccine based on age and key diagnoses. However, if your institution does not already have a history of active influenza vaccination on the inpatient service, start with a humble goal. It is attractive to assume that every patient who qualifies will be vaccinated. It is just not so. Have your influenza committee pick an achievable goal for your first flu season and stretch it in subsequent seasons. To achieve the goal, make sure each clinical area has an identifiable “champion” who can gently remind clinicians about the importance of vaccination. The higher the profile of the local champion the better, assuming the champion has the time and can offer the effort required to do the periodic reminders. Also make sure your pharmacy tracking and distributions systems are prepared to handle the increase in requests for the vaccines. Of note, many patients who are candidates for flu shots are also candidates for pneumococcal vaccines and both may be given together. Consider adding the pneumococcal vaccine to your efforts in appropriate patients.
6. Develop an “Opt Out” system. The CDC’s Advisory Committee on Immunization Practices recommends developing standing orders for both influenza and pneumococcal vaccinations (7). In computerized order entry, this suggestion may lead to a pre-selected order-set being built into the discharge orders that requires the physician to actively opt-out of the order. Paper-based systems may include standing printed orders, again, which require a physician to decline the order specifically. Such opt out systems have been shown to improve rates of vaccination significantly (8). Opt-out programs, however, still require that the clinician ordering the vaccine discusses the vaccine with the patient before it is administered.
7. Roll it out with a bang. Make sure the commencement of your flu shot program gets some press. Announce it at departmental meetings, on system-wide emails, and in hospital publications. Remember, this program is a demonstrable way of improving your patients’ health and an excellent way for hospitalists to show their systems-oriented approaches. Begin your roll-out as early as recommended by the local Department of Public Health so that your patients, many of whom will be at very high risk for complications of the flu, get early vaccination.
8. Give frequent feedback. Obtain vaccine distribution and utilization data at least twice monthly during the first two or three months. This period corresponds to the most critical period of the program as it is when flu shots must be delivered to ensure their efficacy come December-February when flu season typically peaks (9). Some groups may find that a bit of healthy competition (e.g., between services or between nursing units) may offer that edge to keep people vaccinating. Nonetheless, it is critical to keep your clinical areas updated with their performance, with public appreciation being expressed for the top notable clinical areas and low performers receiving extra encouragement and assistance. After the first few months, monthly reports and feedback will suffice, with the program running through the end of March.
9. Remain aware of the local and national flu scene. With the vaccine production problems of the current flu season and with the panic about the high mortality rates of the Fujian strain that was not included in the vaccine last season, it is clear that the flu news scene can be volatile and controversial. It is important to remain up to date on the current facts and be able to dispel any misinformation that may circulate. The following resources may prove helpful:
- The CDC’s influenza home page: http://www.cdc.gov/flu/
- The WHO’s influenza site: http://www.who.int/csr/disease/influenza/en/
- The state Department of Public Health
10. Plan for next season. At the end of flu season, reconvene the influenza committee and debrief. It is important to keep a log of the successes and failures of the season’s flu vaccine initiative to permit growth in subsequent seasons.
The CDC’s program, Healthy People 2010, has set a goal for influenza and pneumococcal vaccination of appropriate non-institutionalized individuals of 90% (10). This goal is achievable if all available resources for reaching out to such patients are utilized. The Massachusetts Hospital Association reports:
“Inpatient hospital stays are among the many missed opportunities for flu and pneumonia vaccination across health care settings. Up to 46% of subsequent influenza-related hospitalizations and 2/3 of influenza-related deaths occur among the elderly who have been previously hospitalized during the flu season. Up to 2/3 of patients hospitalized with serious pneumococcal infections have been hospitalized at least once within the previous 3-5 years (8).”
Hospitalists must take advantage of the opportunity that hospitalization affords our patients to receive the vaccines they need to stay healthy. Appropriate vaccine delivery is no longer solely the purview of the primary care physician – hospitalists must share this goal as well.
References
- The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health. Revised order to establish rules and priorities for the distribution and use of influenza vaccine. Available at: http://www.mass.gov/dph/cdc/epii/flu/flu_order.htm. Accessed November 3, 2004.
- Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA.2003;289:179-86.
- Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United States. JAMA. 2004;292:1333-40.
- CDC. Interim Influenza Vaccination Recommendations – 2004-2005 Season. Available at: http://www.cdc.gov/flu/protect/whoshouldget.htm. Accessed November 3, 2004.
- JCAHO. 2005 Disease-specific care national patient safety goals. Available at: http://www.jcaho.org/accredited+organizations/patient+safety/05+npsg/05_npsg_dsc.htm. Accessed November 3, 2004.
- Martinello RA, Jones L, Topal JE. Correlation between healthcare workers’ knowledge of influenza vaccine and vaccine receipt. Infect Control Hosp Epidemiol. 2003.Nov;24(11):799-800.
- CDC. Prevention and Control of Influenza Recommendations of the Advisory Committee on Immunization Practices (ACIP). Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5306a1.htm. Accessed November 8, 2004.
- Massachusetts Hospital Association. Opt-Out Standing Orders for Pneumonia and Influenza Vaccination for Hospital Inpatients: Best Practice Adoption Proposal to Improve Massachusetts Hospital Performance and Public Health. Available at: http://www.masspro.org/publications/pubs/misc/PNEUMHA2.pdf.
- CDC. Influenza: the disease. Available at: http://www.cdc.gov/flu/about/disease.htm. Accessed November 8, 2004.
- CDC. Healthy People 2010. Immunization and Infectious Diseases. Section 14-29a. Available at: http://www.healthypeople.gov/document/html/volume1/14immunization.htm. Accessed November 8, 2004.