Clinical

LAS VEGAS—A record 3,600 hospitalists swarmed the Mandalay Bay Resort and Casino for four days of education and networking that wrapped with the “father of HM,” Bob Wachter, MD, MHM, dressed as Elton John, warbling a hospitalist-centric version of Sir Elton’s chart topper, “Your Song,” to a packed ballroom.

“[HM14] is just intoxicating,” said hospitalist Kevin Gilroy, MD, of Greenville (S.C.) Health System. “And it ends with our daddy getting up there and lighting it up as Elton John. What other conference does that?”

In perhaps the most tweeted line from HM14, keynote speaker Ian Morrison, PhD, compared the addictiveness of crack cocaine with physicians’ dedication to the fee-for-service payment system.

“It’s really hard to get off of it,” the national healthcare expert deadpanned to a packed ballroom at the Mandalay Bay Resort and Casino.

The zinger was one of the highlights of the annual meeting’s three plenary addresses, which alternately gave the record 3,600 hospitalists in attendance doses of sobriety about the difficulty of healthcare reform and comedy bits from Dr. Morrison and HM dean Robert Wachter, MD, MHM.

The keynote titled “Obamacare Is Here: What Does It Mean for You and Your Hospital?” featured a panel discussion among Centers for Medicare & Medicaid Services (CMS) chief medical officer Patrick Conway, MD, MSc, MHM, FAAP; executive director and CEO of the Medical University of South Carolina in Charleston and former SHM president Patrick Cawley, MD, MBA, MHM, FACP, FACHE; veteran healthcare executive Patrick Courneya, MD; and American Enterprise Institute resident fellow Scott Gottlieb, MD. The quartet—dubbed the Patricks and Scott by several emcees—followed their hour-long plenary with a question-and-answer session.

“I think this is ultimately going to hurt the financial standing of the hospital industry,” said Dr. Gottlieb, a newcomer to SHM’s annual meeting. “A lot of these hospitals that are taking on these capitated contracts, taking on risk, consolidating physicians, I think they’re going to get themselves into financial trouble in the next five years. That’s going to put pressure on the hospitalists.”

“A lot of these hospitals that are taking on these capitated contracts, taking on risk, consolidating physicians, I think they’re going to get themselves into financial trouble in the next five years. That’s going to put pressure on the hospitalists.”

–Dr. Gottlieb

Dr. Cawley said that just a few years ago, his institution subsidized five medical groups. Now it’s 25. He has a simple message for hospitalists not committed to providing better care at lower costs: “You’re not going to be on my good side.”

Dr. Wachter told medical students and residents that he sees no end in sight to the unrelenting pressure to provide that high-quality, low-cost care, while also making sure patient satisfaction rises. And he’s more than OK with that.

“It’s important to recognize that the goal we’re being asked to achieve—to deliver high-quality, satisfying, evidence-based care without undue variations, where we’re not harming people and doing it at a cost that doesn’t bankrupt society—is unambiguously right,” he said. “It’s such an obviously right goal that what is odd is that this was not our goal until recently. So the fact that our field has taken this on as our mantra is very satisfying and completely appropriate.”

The keynote addresses also highlighted another satisfying result: Immediate past SHM President Eric Howell, MD, SFHM, reached the goal he set at 2013’s annual meeting to double the society’s number of student and housestaff members from 500 to 1,000.

Newly minted SHM President Burke Kealey, MD, SFHM, has a goal that is a bit more abstract: He wants hospitalists to look at improving healthcare affordability, patient health, and the patient experience—as a single goal.

“We put the energy and the effort of the moment behind the squeaky wheel,” said Dr. Kealey, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”

Dr. Kealey’s tack for his one-year term is borrowed from the Institute of Healthcare Improvement, whose “triple aim” initiative has the same goals. But Dr. Kealey believes that focusing on any of the three areas while giving short shrift to the others misses the point of bettering the overall healthcare system.

“To improve health, but then people can’t afford that healthcare, is a nonstarter,” he said. “To make things finally affordable, but then people stay away because it’s a bad experience, makes no sense, either. We must do it all together.”

“What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”

–Dr. Kealey

And hospitalists are in the perfect position to do it, said Dr. Morrison, a founding partner of Strategic Health Perspectives, a forecasting service for the healthcare industry that includes joint venture partners Harris Interactive and the Harvard School of Public Health’s department of health policy and management. He sees hospitalist leaders as change agents, as the rigmarole of healthcare reform shakes out over the next few years.

Dr. Morrison, a native of Scotland whose delivery was half stand-up comic, half policy wonk (he introduced himself as Dr. Wachter’s Scottish caddy), said that while politicians and pundits dicker over how a generational shift in policies will be implemented, hospitalists will be the ones balancing that change with patients’ needs.

“This is the work of the future,” he said, “and it is not policy wonk work; it is clinical work. It is about the transformation of the delivery system. That is the central challenge of the future.

“We’ve got to integrate across the continuum of care, using all the innovation that both public and private sectors can deliver. This is not going to be determined by CMS, in my view, but by the kind of innovation that America is always good at.”

LAS VEGAS—A record 3,600 hospitalists swarmed the Mandalay Bay Resort and Casino for four days of education and networking that wrapped with the “father of HM,” Bob Wachter, MD, MHM, dressed as Elton John, warbling a hospitalist-centric version of Sir Elton’s chart topper, “Your Song,” to a packed ballroom.

“[HM14] is just intoxicating,” said hospitalist Kevin Gilroy, MD, of Greenville (S.C.) Health System. “And it ends with our daddy getting up there and lighting it up as Elton John. What other conference does that?”

In perhaps the most tweeted line from HM14, keynote speaker Ian Morrison, PhD, compared the addictiveness of crack cocaine with physicians’ dedication to the fee-for-service payment system.

“It’s really hard to get off of it,” the national healthcare expert deadpanned to a packed ballroom at the Mandalay Bay Resort and Casino.

The zinger was one of the highlights of the annual meeting’s three plenary addresses, which alternately gave the record 3,600 hospitalists in attendance doses of sobriety about the difficulty of healthcare reform and comedy bits from Dr. Morrison and HM dean Robert Wachter, MD, MHM.

The keynote titled “Obamacare Is Here: What Does It Mean for You and Your Hospital?” featured a panel discussion among Centers for Medicare & Medicaid Services (CMS) chief medical officer Patrick Conway, MD, MSc, MHM, FAAP; executive director and CEO of the Medical University of South Carolina in Charleston and former SHM president Patrick Cawley, MD, MBA, MHM, FACP, FACHE; veteran healthcare executive Patrick Courneya, MD; and American Enterprise Institute resident fellow Scott Gottlieb, MD. The quartet—dubbed the Patricks and Scott by several emcees—followed their hour-long plenary with a question-and-answer session.

“I think this is ultimately going to hurt the financial standing of the hospital industry,” said Dr. Gottlieb, a newcomer to SHM’s annual meeting. “A lot of these hospitals that are taking on these capitated contracts, taking on risk, consolidating physicians, I think they’re going to get themselves into financial trouble in the next five years. That’s going to put pressure on the hospitalists.”

“A lot of these hospitals that are taking on these capitated contracts, taking on risk, consolidating physicians, I think they’re going to get themselves into financial trouble in the next five years. That’s going to put pressure on the hospitalists.”

–Dr. Gottlieb

Dr. Cawley said that just a few years ago, his institution subsidized five medical groups. Now it’s 25. He has a simple message for hospitalists not committed to providing better care at lower costs: “You’re not going to be on my good side.”

Dr. Wachter told medical students and residents that he sees no end in sight to the unrelenting pressure to provide that high-quality, low-cost care, while also making sure patient satisfaction rises. And he’s more than OK with that.

“It’s important to recognize that the goal we’re being asked to achieve—to deliver high-quality, satisfying, evidence-based care without undue variations, where we’re not harming people and doing it at a cost that doesn’t bankrupt society—is unambiguously right,” he said. “It’s such an obviously right goal that what is odd is that this was not our goal until recently. So the fact that our field has taken this on as our mantra is very satisfying and completely appropriate.”

The keynote addresses also highlighted another satisfying result: Immediate past SHM President Eric Howell, MD, SFHM, reached the goal he set at 2013’s annual meeting to double the society’s number of student and housestaff members from 500 to 1,000.

Newly minted SHM President Burke Kealey, MD, SFHM, has a goal that is a bit more abstract: He wants hospitalists to look at improving healthcare affordability, patient health, and the patient experience—as a single goal.

“We put the energy and the effort of the moment behind the squeaky wheel,” said Dr. Kealey, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”

Dr. Kealey’s tack for his one-year term is borrowed from the Institute of Healthcare Improvement, whose “triple aim” initiative has the same goals. But Dr. Kealey believes that focusing on any of the three areas while giving short shrift to the others misses the point of bettering the overall healthcare system.

“To improve health, but then people can’t afford that healthcare, is a nonstarter,” he said. “To make things finally affordable, but then people stay away because it’s a bad experience, makes no sense, either. We must do it all together.”

“What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”

–Dr. Kealey

And hospitalists are in the perfect position to do it, said Dr. Morrison, a founding partner of Strategic Health Perspectives, a forecasting service for the healthcare industry that includes joint venture partners Harris Interactive and the Harvard School of Public Health’s department of health policy and management. He sees hospitalist leaders as change agents, as the rigmarole of healthcare reform shakes out over the next few years.

Dr. Morrison, a native of Scotland whose delivery was half stand-up comic, half policy wonk (he introduced himself as Dr. Wachter’s Scottish caddy), said that while politicians and pundits dicker over how a generational shift in policies will be implemented, hospitalists will be the ones balancing that change with patients’ needs.

“This is the work of the future,” he said, “and it is not policy wonk work; it is clinical work. It is about the transformation of the delivery system. That is the central challenge of the future.

“We’ve got to integrate across the continuum of care, using all the innovation that both public and private sectors can deliver. This is not going to be determined by CMS, in my view, but by the kind of innovation that America is always good at.”

LAS VEGAS—A record 3,600 hospitalists swarmed the Mandalay Bay Resort and Casino for four days of education and networking that wrapped with the “father of HM,” Bob Wachter, MD, MHM, dressed as Elton John, warbling a hospitalist-centric version of Sir Elton’s chart topper, “Your Song,” to a packed ballroom.

“[HM14] is just intoxicating,” said hospitalist Kevin Gilroy, MD, of Greenville (S.C.) Health System. “And it ends with our daddy getting up there and lighting it up as Elton John. What other conference does that?”

In perhaps the most tweeted line from HM14, keynote speaker Ian Morrison, PhD, compared the addictiveness of crack cocaine with physicians’ dedication to the fee-for-service payment system.

“It’s really hard to get off of it,” the national healthcare expert deadpanned to a packed ballroom at the Mandalay Bay Resort and Casino.

The zinger was one of the highlights of the annual meeting’s three plenary addresses, which alternately gave the record 3,600 hospitalists in attendance doses of sobriety about the difficulty of healthcare reform and comedy bits from Dr. Morrison and HM dean Robert Wachter, MD, MHM.

The keynote titled “Obamacare Is Here: What Does It Mean for You and Your Hospital?” featured a panel discussion among Centers for Medicare & Medicaid Services (CMS) chief medical officer Patrick Conway, MD, MSc, MHM, FAAP; executive director and CEO of the Medical University of South Carolina in Charleston and former SHM president Patrick Cawley, MD, MBA, MHM, FACP, FACHE; veteran healthcare executive Patrick Courneya, MD; and American Enterprise Institute resident fellow Scott Gottlieb, MD. The quartet—dubbed the Patricks and Scott by several emcees—followed their hour-long plenary with a question-and-answer session.

“I think this is ultimately going to hurt the financial standing of the hospital industry,” said Dr. Gottlieb, a newcomer to SHM’s annual meeting. “A lot of these hospitals that are taking on these capitated contracts, taking on risk, consolidating physicians, I think they’re going to get themselves into financial trouble in the next five years. That’s going to put pressure on the hospitalists.”

“A lot of these hospitals that are taking on these capitated contracts, taking on risk, consolidating physicians, I think they’re going to get themselves into financial trouble in the next five years. That’s going to put pressure on the hospitalists.”

–Dr. Gottlieb

Dr. Cawley said that just a few years ago, his institution subsidized five medical groups. Now it’s 25. He has a simple message for hospitalists not committed to providing better care at lower costs: “You’re not going to be on my good side.”

Dr. Wachter told medical students and residents that he sees no end in sight to the unrelenting pressure to provide that high-quality, low-cost care, while also making sure patient satisfaction rises. And he’s more than OK with that.

“It’s important to recognize that the goal we’re being asked to achieve—to deliver high-quality, satisfying, evidence-based care without undue variations, where we’re not harming people and doing it at a cost that doesn’t bankrupt society—is unambiguously right,” he said. “It’s such an obviously right goal that what is odd is that this was not our goal until recently. So the fact that our field has taken this on as our mantra is very satisfying and completely appropriate.”

The keynote addresses also highlighted another satisfying result: Immediate past SHM President Eric Howell, MD, SFHM, reached the goal he set at 2013’s annual meeting to double the society’s number of student and housestaff members from 500 to 1,000.

Newly minted SHM President Burke Kealey, MD, SFHM, has a goal that is a bit more abstract: He wants hospitalists to look at improving healthcare affordability, patient health, and the patient experience—as a single goal.

“We put the energy and the effort of the moment behind the squeaky wheel,” said Dr. Kealey, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. “What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”

Dr. Kealey’s tack for his one-year term is borrowed from the Institute of Healthcare Improvement, whose “triple aim” initiative has the same goals. But Dr. Kealey believes that focusing on any of the three areas while giving short shrift to the others misses the point of bettering the overall healthcare system.

“To improve health, but then people can’t afford that healthcare, is a nonstarter,” he said. “To make things finally affordable, but then people stay away because it’s a bad experience, makes no sense, either. We must do it all together.”

“What I would like us to do is all start thinking about all three at the same time, and with equal weight at all times. To me, this is the next evolution of the hospitalist.”

–Dr. Kealey

And hospitalists are in the perfect position to do it, said Dr. Morrison, a founding partner of Strategic Health Perspectives, a forecasting service for the healthcare industry that includes joint venture partners Harris Interactive and the Harvard School of Public Health’s department of health policy and management. He sees hospitalist leaders as change agents, as the rigmarole of healthcare reform shakes out over the next few years.

Dr. Morrison, a native of Scotland whose delivery was half stand-up comic, half policy wonk (he introduced himself as Dr. Wachter’s Scottish caddy), said that while politicians and pundits dicker over how a generational shift in policies will be implemented, hospitalists will be the ones balancing that change with patients’ needs.

“This is the work of the future,” he said, “and it is not policy wonk work; it is clinical work. It is about the transformation of the delivery system. That is the central challenge of the future.

“We’ve got to integrate across the continuum of care, using all the innovation that both public and private sectors can deliver. This is not going to be determined by CMS, in my view, but by the kind of innovation that America is always good at.”

At some point in residency, we all learn that time management and multitasking are vital to ward efficiency; however, it is important to note that efficiency as a hospitalist is as much about providing high quality clinical care as it is about maximizing resources, reducing waste, and avoiding redundancy in the process.

This article examines the pre-rounding, rounding, and follow-up phases of a hospitalist’s typical workday and provides suggestions to help streamline your work—and enhance both personal and system efficiency.

Pre-Rounding

While most would agree that preparing for rounds is essential to making them effective, longer patient lists may lead to hours of pre-rounding. Often, by the time you get to the “rounding stage,” things change. To make this a more productive exercise, we recommend “focused pre-rounding,” which allows you to organize your efforts as follows:

• For overnight admissions, skim through such data as presenting complaint, relevant past medical history, exam, labs, and radiology, looking for any critical values or findings that may need immediate attention. As you prioritize your order of rounding, you are also familiarizing yourself with the cases, which will reassure your new patients.
• For patients who are already on service, do a quick review of any acute overnight events or important management needs. For example, you may have to follow up on a CT head for a patient who fell overnight or check fasting blood sugars to modify a diabetic ketoacidosis patient’s morning insulin dose. These are time-sensitive issues that may need your attention before you actually lay eyes on the patient.
• Prioritize visits and learn to manage patient expectations. Organize your patient visits based on the data gathered from pre-rounding. Seeing potential discharges first helps the hospital open up beds early and facilitates patient throughput. As appealing as early discharge is to any hospital administrator, those working in a teaching setting might argue that first priority should go to night float admissions that have not been “staffed” by an attending yet.

Barring urgent patient care issues, we would recommend that patients who are ready for discharge pending a face-to-face visit or a morning lab should be seen first. You can attend to the new admissions next. In contrast, there is no rush to see potential discharges undergoing a procedure such as an esophagogastroduodenoscopy or stress test. Furthermore, if your decision-making hinges on these test results, timing your visit so that it occurs after the procedure makes your rounding even more efficient. In these situations, informing the patient the evening prior to rounding that you will be visiting them late the next day is not only professionally courteous, but also goes a long way in managing their expectations and enhancing patient satisfaction.

Rounding (The Patient Encounter)

Be professional. Introduce yourself and, if necessary, explain your role as a hospitalist. Sit down when possible. Studies have shown that just the act of sitting makes patients feel that you are communicating better and spending more time with them. If you normally walk or talk quickly, try to slow down temporarily while in the room. The art is for you to be cognizant of the time while avoiding the appearance of impatience.

Engage the patient and/or family. Interact with patients in a way that makes them feel included in their care. For example, show patients X-rays or use diagrams to explain their disease pathophysiology or any upcoming procedures. We feel that even the less educated patient will have a better understanding of her illness when it’s less abstract and more visually defined.

Set reasonable expectations. The patient or family may have many questions during rounds. If time does not permit, especially when you are rounding with housestaff, it is more efficient to say, “We need to move on for now, but one of us will return later to discuss all of this in more depth.”

For particularly demanding patients and families, manage expectations by communicating honestly about your other patient care responsibilities, while still acknowledging their needs. In these situations, setting up a family meeting to discuss plans of care early in the hospital course can be very productive.

Integrate inter-professional care when possible: Rounding with a care coordinator or the patient’s nurse allows you to share clinical information and plans of care in real time. This can help minimize interruptions and pages later in the day, while enhancing patient safety by limiting communication failures.

Perform tasks “as you go.” Entering orders and calling urgent consults as you round not only provides timely medical care but, by limiting unfinished tasks, also reduces the chances of medical errors.

Post Rounds (Follow-Up Care and Planning)

Start discharge planning on day 1. As you gain experience, predicting patients’ hospital stays and anticipating their discharge needs becomes part of your hospitalist “sixth sense.” Obtaining timely therapy, social work, and case management consults is fundamental to your efficiency as a hospitalist. It is also prudent to keep patients and their families updated on discharge plans.

Delegate responsibilities when possible. Efficiency can be fueled by sharing your workload, especially non-clinical tasks such as obtaining occupational safety and health records, completing SNF forms, or scheduling follow-up appointments. Potential resources include ward secretaries, nurses, or, for more clinical tasks, housestaff, nurse practitioners, or physician assistants. The availability of this support varies substantially between institutions. Still, your goal should be to advocate for a collaborative work environment where support staff are expected to contribute to team efficiency and, by corollary, patient satisfaction.

Document succinctly and in a timely manner. Your notes should reflect the patient’s clinical progress and your thought process. You don’t need to import every detail that can be found elsewhere in the EHR, and you should refrain from long, cut and pasted notes that are often meaningless “note bloat.” Likewise, discharge summaries should be high quality informative documents that list key elements, including discharge diagnoses, discharge medications, follow-up appointments, procedures, and a brief hospital course. These are best done in real time or even the day before, when the case is fresh in your memory. Spending an extra 15 - 30 minutes on this important task is well worth it. Do not let records pile up!

“Run the list.” Among the million other things you’re doing all day, this quick end-of-the-day review of your patient list helps you prepare for the next day. It’s an opportunity to ready things for potential next day discharges, discontinue redundant lab testing, remove unnecessary Foley catheters and lines, and identify any medication order errors.

In Sum

Many personal habits can improve the quality and efficiency of patient care, and hospitalist efficiency is intimately related to system performance. As hospitalists, each one of us can enhance the system, whether we do so by facilitating patient throughput, improving communication, or utilizing resources in a cost-conscious manner. Volunteering to serve on information technology or quality assurance committees is also a “big picture” way of contributing. It is our hope that the tips in this article will have a qualitative impact on both your work habits and your organization’s performance, thereby improving patient care and, ultimately, your own career satisfaction.

Dr. Chandra is assistant professor of medicine at Case Western Reserve University and chief of the division of general internal medicine, University Hospitals Case Medical Center in Cleveland, Ohio. Dr. Donahue is assistant professor of medicine at the University of Massachusetts Medical School in Worcester. Dr. Smith is a hospitalist at Aurora Medical Center in Summit, Wis.

At some point in residency, we all learn that time management and multitasking are vital to ward efficiency; however, it is important to note that efficiency as a hospitalist is as much about providing high quality clinical care as it is about maximizing resources, reducing waste, and avoiding redundancy in the process.

This article examines the pre-rounding, rounding, and follow-up phases of a hospitalist’s typical workday and provides suggestions to help streamline your work—and enhance both personal and system efficiency.

Pre-Rounding

While most would agree that preparing for rounds is essential to making them effective, longer patient lists may lead to hours of pre-rounding. Often, by the time you get to the “rounding stage,” things change. To make this a more productive exercise, we recommend “focused pre-rounding,” which allows you to organize your efforts as follows:

• For overnight admissions, skim through such data as presenting complaint, relevant past medical history, exam, labs, and radiology, looking for any critical values or findings that may need immediate attention. As you prioritize your order of rounding, you are also familiarizing yourself with the cases, which will reassure your new patients.
• For patients who are already on service, do a quick review of any acute overnight events or important management needs. For example, you may have to follow up on a CT head for a patient who fell overnight or check fasting blood sugars to modify a diabetic ketoacidosis patient’s morning insulin dose. These are time-sensitive issues that may need your attention before you actually lay eyes on the patient.
• Prioritize visits and learn to manage patient expectations. Organize your patient visits based on the data gathered from pre-rounding. Seeing potential discharges first helps the hospital open up beds early and facilitates patient throughput. As appealing as early discharge is to any hospital administrator, those working in a teaching setting might argue that first priority should go to night float admissions that have not been “staffed” by an attending yet.

Barring urgent patient care issues, we would recommend that patients who are ready for discharge pending a face-to-face visit or a morning lab should be seen first. You can attend to the new admissions next. In contrast, there is no rush to see potential discharges undergoing a procedure such as an esophagogastroduodenoscopy or stress test. Furthermore, if your decision-making hinges on these test results, timing your visit so that it occurs after the procedure makes your rounding even more efficient. In these situations, informing the patient the evening prior to rounding that you will be visiting them late the next day is not only professionally courteous, but also goes a long way in managing their expectations and enhancing patient satisfaction.

Rounding (The Patient Encounter)

Be professional. Introduce yourself and, if necessary, explain your role as a hospitalist. Sit down when possible. Studies have shown that just the act of sitting makes patients feel that you are communicating better and spending more time with them. If you normally walk or talk quickly, try to slow down temporarily while in the room. The art is for you to be cognizant of the time while avoiding the appearance of impatience.

Engage the patient and/or family. Interact with patients in a way that makes them feel included in their care. For example, show patients X-rays or use diagrams to explain their disease pathophysiology or any upcoming procedures. We feel that even the less educated patient will have a better understanding of her illness when it’s less abstract and more visually defined.

Set reasonable expectations. The patient or family may have many questions during rounds. If time does not permit, especially when you are rounding with housestaff, it is more efficient to say, “We need to move on for now, but one of us will return later to discuss all of this in more depth.”

For particularly demanding patients and families, manage expectations by communicating honestly about your other patient care responsibilities, while still acknowledging their needs. In these situations, setting up a family meeting to discuss plans of care early in the hospital course can be very productive.

Integrate inter-professional care when possible: Rounding with a care coordinator or the patient’s nurse allows you to share clinical information and plans of care in real time. This can help minimize interruptions and pages later in the day, while enhancing patient safety by limiting communication failures.

Perform tasks “as you go.” Entering orders and calling urgent consults as you round not only provides timely medical care but, by limiting unfinished tasks, also reduces the chances of medical errors.

Post Rounds (Follow-Up Care and Planning)

Start discharge planning on day 1. As you gain experience, predicting patients’ hospital stays and anticipating their discharge needs becomes part of your hospitalist “sixth sense.” Obtaining timely therapy, social work, and case management consults is fundamental to your efficiency as a hospitalist. It is also prudent to keep patients and their families updated on discharge plans.

Delegate responsibilities when possible. Efficiency can be fueled by sharing your workload, especially non-clinical tasks such as obtaining occupational safety and health records, completing SNF forms, or scheduling follow-up appointments. Potential resources include ward secretaries, nurses, or, for more clinical tasks, housestaff, nurse practitioners, or physician assistants. The availability of this support varies substantially between institutions. Still, your goal should be to advocate for a collaborative work environment where support staff are expected to contribute to team efficiency and, by corollary, patient satisfaction.

Document succinctly and in a timely manner. Your notes should reflect the patient’s clinical progress and your thought process. You don’t need to import every detail that can be found elsewhere in the EHR, and you should refrain from long, cut and pasted notes that are often meaningless “note bloat.” Likewise, discharge summaries should be high quality informative documents that list key elements, including discharge diagnoses, discharge medications, follow-up appointments, procedures, and a brief hospital course. These are best done in real time or even the day before, when the case is fresh in your memory. Spending an extra 15 - 30 minutes on this important task is well worth it. Do not let records pile up!

“Run the list.” Among the million other things you’re doing all day, this quick end-of-the-day review of your patient list helps you prepare for the next day. It’s an opportunity to ready things for potential next day discharges, discontinue redundant lab testing, remove unnecessary Foley catheters and lines, and identify any medication order errors.

In Sum

Many personal habits can improve the quality and efficiency of patient care, and hospitalist efficiency is intimately related to system performance. As hospitalists, each one of us can enhance the system, whether we do so by facilitating patient throughput, improving communication, or utilizing resources in a cost-conscious manner. Volunteering to serve on information technology or quality assurance committees is also a “big picture” way of contributing. It is our hope that the tips in this article will have a qualitative impact on both your work habits and your organization’s performance, thereby improving patient care and, ultimately, your own career satisfaction.

Dr. Chandra is assistant professor of medicine at Case Western Reserve University and chief of the division of general internal medicine, University Hospitals Case Medical Center in Cleveland, Ohio. Dr. Donahue is assistant professor of medicine at the University of Massachusetts Medical School in Worcester. Dr. Smith is a hospitalist at Aurora Medical Center in Summit, Wis.

At some point in residency, we all learn that time management and multitasking are vital to ward efficiency; however, it is important to note that efficiency as a hospitalist is as much about providing high quality clinical care as it is about maximizing resources, reducing waste, and avoiding redundancy in the process.

This article examines the pre-rounding, rounding, and follow-up phases of a hospitalist’s typical workday and provides suggestions to help streamline your work—and enhance both personal and system efficiency.

Pre-Rounding

While most would agree that preparing for rounds is essential to making them effective, longer patient lists may lead to hours of pre-rounding. Often, by the time you get to the “rounding stage,” things change. To make this a more productive exercise, we recommend “focused pre-rounding,” which allows you to organize your efforts as follows:

• For overnight admissions, skim through such data as presenting complaint, relevant past medical history, exam, labs, and radiology, looking for any critical values or findings that may need immediate attention. As you prioritize your order of rounding, you are also familiarizing yourself with the cases, which will reassure your new patients.
• For patients who are already on service, do a quick review of any acute overnight events or important management needs. For example, you may have to follow up on a CT head for a patient who fell overnight or check fasting blood sugars to modify a diabetic ketoacidosis patient’s morning insulin dose. These are time-sensitive issues that may need your attention before you actually lay eyes on the patient.
• Prioritize visits and learn to manage patient expectations. Organize your patient visits based on the data gathered from pre-rounding. Seeing potential discharges first helps the hospital open up beds early and facilitates patient throughput. As appealing as early discharge is to any hospital administrator, those working in a teaching setting might argue that first priority should go to night float admissions that have not been “staffed” by an attending yet.

Barring urgent patient care issues, we would recommend that patients who are ready for discharge pending a face-to-face visit or a morning lab should be seen first. You can attend to the new admissions next. In contrast, there is no rush to see potential discharges undergoing a procedure such as an esophagogastroduodenoscopy or stress test. Furthermore, if your decision-making hinges on these test results, timing your visit so that it occurs after the procedure makes your rounding even more efficient. In these situations, informing the patient the evening prior to rounding that you will be visiting them late the next day is not only professionally courteous, but also goes a long way in managing their expectations and enhancing patient satisfaction.

Rounding (The Patient Encounter)

Be professional. Introduce yourself and, if necessary, explain your role as a hospitalist. Sit down when possible. Studies have shown that just the act of sitting makes patients feel that you are communicating better and spending more time with them. If you normally walk or talk quickly, try to slow down temporarily while in the room. The art is for you to be cognizant of the time while avoiding the appearance of impatience.

Engage the patient and/or family. Interact with patients in a way that makes them feel included in their care. For example, show patients X-rays or use diagrams to explain their disease pathophysiology or any upcoming procedures. We feel that even the less educated patient will have a better understanding of her illness when it’s less abstract and more visually defined.

Set reasonable expectations. The patient or family may have many questions during rounds. If time does not permit, especially when you are rounding with housestaff, it is more efficient to say, “We need to move on for now, but one of us will return later to discuss all of this in more depth.”

For particularly demanding patients and families, manage expectations by communicating honestly about your other patient care responsibilities, while still acknowledging their needs. In these situations, setting up a family meeting to discuss plans of care early in the hospital course can be very productive.

Integrate inter-professional care when possible: Rounding with a care coordinator or the patient’s nurse allows you to share clinical information and plans of care in real time. This can help minimize interruptions and pages later in the day, while enhancing patient safety by limiting communication failures.

Perform tasks “as you go.” Entering orders and calling urgent consults as you round not only provides timely medical care but, by limiting unfinished tasks, also reduces the chances of medical errors.

Post Rounds (Follow-Up Care and Planning)

Start discharge planning on day 1. As you gain experience, predicting patients’ hospital stays and anticipating their discharge needs becomes part of your hospitalist “sixth sense.” Obtaining timely therapy, social work, and case management consults is fundamental to your efficiency as a hospitalist. It is also prudent to keep patients and their families updated on discharge plans.

Delegate responsibilities when possible. Efficiency can be fueled by sharing your workload, especially non-clinical tasks such as obtaining occupational safety and health records, completing SNF forms, or scheduling follow-up appointments. Potential resources include ward secretaries, nurses, or, for more clinical tasks, housestaff, nurse practitioners, or physician assistants. The availability of this support varies substantially between institutions. Still, your goal should be to advocate for a collaborative work environment where support staff are expected to contribute to team efficiency and, by corollary, patient satisfaction.

Document succinctly and in a timely manner. Your notes should reflect the patient’s clinical progress and your thought process. You don’t need to import every detail that can be found elsewhere in the EHR, and you should refrain from long, cut and pasted notes that are often meaningless “note bloat.” Likewise, discharge summaries should be high quality informative documents that list key elements, including discharge diagnoses, discharge medications, follow-up appointments, procedures, and a brief hospital course. These are best done in real time or even the day before, when the case is fresh in your memory. Spending an extra 15 - 30 minutes on this important task is well worth it. Do not let records pile up!

“Run the list.” Among the million other things you’re doing all day, this quick end-of-the-day review of your patient list helps you prepare for the next day. It’s an opportunity to ready things for potential next day discharges, discontinue redundant lab testing, remove unnecessary Foley catheters and lines, and identify any medication order errors.

In Sum

Many personal habits can improve the quality and efficiency of patient care, and hospitalist efficiency is intimately related to system performance. As hospitalists, each one of us can enhance the system, whether we do so by facilitating patient throughput, improving communication, or utilizing resources in a cost-conscious manner. Volunteering to serve on information technology or quality assurance committees is also a “big picture” way of contributing. It is our hope that the tips in this article will have a qualitative impact on both your work habits and your organization’s performance, thereby improving patient care and, ultimately, your own career satisfaction.

Dr. Chandra is assistant professor of medicine at Case Western Reserve University and chief of the division of general internal medicine, University Hospitals Case Medical Center in Cleveland, Ohio. Dr. Donahue is assistant professor of medicine at the University of Massachusetts Medical School in Worcester. Dr. Smith is a hospitalist at Aurora Medical Center in Summit, Wis.

Dear Ms. Bernstein:

I’m writing this letter to let you know about some of the things happening in hospital medicine, to ensure we are always improving the care we provide.

While we talked on New Year’s Eve, you reluctantly told me that you and many of your friends were not happy with the move toward hospital care being provided by hospitalists, rather than the PCP you know. I didn’t respond because we were having a nice lunch and I didn’t want to distract you from praising my kids and talking about your grandbaby and her sibling on the way. So I thought I’d respond by writing this open letter to you on the chance it might also be thought provoking for some of my hospitalist colleagues.

I think your reluctance to share with me the unflattering opinion you and many of your friends have of the hospitalist model of care stemmed from a desire not to offend me rather than any uncertainty in your conclusion. It isn’t difficult to find others, both healthcare providers and consumers, who share your opinion.

As I’ve told you before, outside of my own parents, you and Mr. B. are among the people who had the most influence on my upbringing, and your opinion still matters to me. So I’m writing this hoping to change your view, at least a little.

Updated Numbers of Hospitalists

Our field is now larger than many other specialties, and we are experiencing ever-increasing pressure to “get it right.” A 2012 survey of hospitals conducted by the American Hospital Association found more than 38,000 doctors who identify themselves as hospitalists. This number has been increasing rapidly for more than a decade. The Society of Hospital Medicine (SHM) estimates that the number has grown to more than 44,000 in 2014, and that there are hospitalists in 72% of U.S. hospitals—90% at hospitals with over 200 beds. In 1996, there were fewer than 1,000 hospitalists.

The rapid growth in our field has brought challenges, and we’re lucky to have attracted many dedicated and talented people who are helping all of us make strides to do better, both by providing better technical care (e.g. ensuring careful assessments and ordering the best tests and treatments) and by doing so in a way that ensures patients and their families are highly satisfied.

Tools to Support Ongoing Improvements in Hospitalist Practice

There are many outlets hospitalists can turn to for education on essentially any aspect of their practice. Several years ago, the SHM published “The Core Competencies in Hospital Medicine: A Framework for Curriculum Development,” a publication that continues to be valuable in guiding hospitalists’ professional scope of clinical skills as well as educational curricula for training programs and continuing education. SHM and other organizations generate a great deal of educational content for hospitalists, which is available in many forms, including in-person conferences, webinars, and written materials. And there are several scientific journals that have significant content for hospitalists, including SHM’s own Journal of Hospital Medicine.

Our field encourages and recognizes ongoing commitment to hospitalists’ growth and development in a number of ways. When it is time for a doctor to renew his/her board certification, the American Board of Internal Medicine (ABIM) offers the option to pursue “Focused Practice in Hospital Medicine.” And SHM’s designation of Fellow, Senior Fellow and Master in Hospital Medicine recognizes those who have “demonstrated a commitment to hospital medicine, system change, and quality improvement principles.” Many in our field have achieved one or both of these distinctions, and countless others are pursuing them now.

Through its foundation, the ABIM developed a campaign known as “Choosing Wisely” to “promote conversations between physicians and patients by helping patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.” SHM joined in this effort by developing separate criteria for hospitalists who care for adults or children.

New Tool Encourages High Performance

In February, an SHM workgroup published “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists,” a document meant to serve as a road map for hospitalist groups to follow to improve their performance. I’m particularly interested in this, since I have spent much of my career thinking about and working with hospitalist groups to improve the way they perform, and I helped develop the characteristics and co-authored the document. But the real value of the document comes from the input of hundreds of people within and outside of SHM who provided thoughtful advice and feedback to identify those attributes of hospitalist groups that are most likely to ensure success.

The document describes 47 characteristics grouped into 10 different categories (“principles”). Some of the principles that you as a patient might be most interested in are ones specifying that a hospitalist group:

— Implements a practice model that is patient- and family-centered, is team-based, and emphasizes care coordination and effective communication.

— Supports care coordination across care settings; and

— Plays a leadership role in addressing key clinical issues in the hospital and/or health system: teaching, quality, safety, efficiency, and the patient/family experience.

Current State of Hospital Medicine

If you’ve had a less than satisfactory experience with care by a hospitalist, the things I’ve described here might not improve your opinion of hospitalists, or that of your friends. But maybe you can take some measure of comfort in knowing that our field as a whole is working hard to continuously improve all aspects of what we do. We’re serious about being good at what we do.

And, since this is published in a magazine read by hospitalists, maybe some of them will be reminded of the many ways our field encourages, supports, and recognizes their professional development.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Dear Ms. Bernstein:

I’m writing this letter to let you know about some of the things happening in hospital medicine, to ensure we are always improving the care we provide.

While we talked on New Year’s Eve, you reluctantly told me that you and many of your friends were not happy with the move toward hospital care being provided by hospitalists, rather than the PCP you know. I didn’t respond because we were having a nice lunch and I didn’t want to distract you from praising my kids and talking about your grandbaby and her sibling on the way. So I thought I’d respond by writing this open letter to you on the chance it might also be thought provoking for some of my hospitalist colleagues.

I think your reluctance to share with me the unflattering opinion you and many of your friends have of the hospitalist model of care stemmed from a desire not to offend me rather than any uncertainty in your conclusion. It isn’t difficult to find others, both healthcare providers and consumers, who share your opinion.

As I’ve told you before, outside of my own parents, you and Mr. B. are among the people who had the most influence on my upbringing, and your opinion still matters to me. So I’m writing this hoping to change your view, at least a little.

Updated Numbers of Hospitalists

Our field is now larger than many other specialties, and we are experiencing ever-increasing pressure to “get it right.” A 2012 survey of hospitals conducted by the American Hospital Association found more than 38,000 doctors who identify themselves as hospitalists. This number has been increasing rapidly for more than a decade. The Society of Hospital Medicine (SHM) estimates that the number has grown to more than 44,000 in 2014, and that there are hospitalists in 72% of U.S. hospitals—90% at hospitals with over 200 beds. In 1996, there were fewer than 1,000 hospitalists.

The rapid growth in our field has brought challenges, and we’re lucky to have attracted many dedicated and talented people who are helping all of us make strides to do better, both by providing better technical care (e.g. ensuring careful assessments and ordering the best tests and treatments) and by doing so in a way that ensures patients and their families are highly satisfied.

Tools to Support Ongoing Improvements in Hospitalist Practice

There are many outlets hospitalists can turn to for education on essentially any aspect of their practice. Several years ago, the SHM published “The Core Competencies in Hospital Medicine: A Framework for Curriculum Development,” a publication that continues to be valuable in guiding hospitalists’ professional scope of clinical skills as well as educational curricula for training programs and continuing education. SHM and other organizations generate a great deal of educational content for hospitalists, which is available in many forms, including in-person conferences, webinars, and written materials. And there are several scientific journals that have significant content for hospitalists, including SHM’s own Journal of Hospital Medicine.

Our field encourages and recognizes ongoing commitment to hospitalists’ growth and development in a number of ways. When it is time for a doctor to renew his/her board certification, the American Board of Internal Medicine (ABIM) offers the option to pursue “Focused Practice in Hospital Medicine.” And SHM’s designation of Fellow, Senior Fellow and Master in Hospital Medicine recognizes those who have “demonstrated a commitment to hospital medicine, system change, and quality improvement principles.” Many in our field have achieved one or both of these distinctions, and countless others are pursuing them now.

Through its foundation, the ABIM developed a campaign known as “Choosing Wisely” to “promote conversations between physicians and patients by helping patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.” SHM joined in this effort by developing separate criteria for hospitalists who care for adults or children.

New Tool Encourages High Performance

In February, an SHM workgroup published “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists,” a document meant to serve as a road map for hospitalist groups to follow to improve their performance. I’m particularly interested in this, since I have spent much of my career thinking about and working with hospitalist groups to improve the way they perform, and I helped develop the characteristics and co-authored the document. But the real value of the document comes from the input of hundreds of people within and outside of SHM who provided thoughtful advice and feedback to identify those attributes of hospitalist groups that are most likely to ensure success.

The document describes 47 characteristics grouped into 10 different categories (“principles”). Some of the principles that you as a patient might be most interested in are ones specifying that a hospitalist group:

— Implements a practice model that is patient- and family-centered, is team-based, and emphasizes care coordination and effective communication.

— Supports care coordination across care settings; and

— Plays a leadership role in addressing key clinical issues in the hospital and/or health system: teaching, quality, safety, efficiency, and the patient/family experience.

Current State of Hospital Medicine

If you’ve had a less than satisfactory experience with care by a hospitalist, the things I’ve described here might not improve your opinion of hospitalists, or that of your friends. But maybe you can take some measure of comfort in knowing that our field as a whole is working hard to continuously improve all aspects of what we do. We’re serious about being good at what we do.

And, since this is published in a magazine read by hospitalists, maybe some of them will be reminded of the many ways our field encourages, supports, and recognizes their professional development.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Dear Ms. Bernstein:

I’m writing this letter to let you know about some of the things happening in hospital medicine, to ensure we are always improving the care we provide.

While we talked on New Year’s Eve, you reluctantly told me that you and many of your friends were not happy with the move toward hospital care being provided by hospitalists, rather than the PCP you know. I didn’t respond because we were having a nice lunch and I didn’t want to distract you from praising my kids and talking about your grandbaby and her sibling on the way. So I thought I’d respond by writing this open letter to you on the chance it might also be thought provoking for some of my hospitalist colleagues.

I think your reluctance to share with me the unflattering opinion you and many of your friends have of the hospitalist model of care stemmed from a desire not to offend me rather than any uncertainty in your conclusion. It isn’t difficult to find others, both healthcare providers and consumers, who share your opinion.

As I’ve told you before, outside of my own parents, you and Mr. B. are among the people who had the most influence on my upbringing, and your opinion still matters to me. So I’m writing this hoping to change your view, at least a little.

Updated Numbers of Hospitalists

Our field is now larger than many other specialties, and we are experiencing ever-increasing pressure to “get it right.” A 2012 survey of hospitals conducted by the American Hospital Association found more than 38,000 doctors who identify themselves as hospitalists. This number has been increasing rapidly for more than a decade. The Society of Hospital Medicine (SHM) estimates that the number has grown to more than 44,000 in 2014, and that there are hospitalists in 72% of U.S. hospitals—90% at hospitals with over 200 beds. In 1996, there were fewer than 1,000 hospitalists.

The rapid growth in our field has brought challenges, and we’re lucky to have attracted many dedicated and talented people who are helping all of us make strides to do better, both by providing better technical care (e.g. ensuring careful assessments and ordering the best tests and treatments) and by doing so in a way that ensures patients and their families are highly satisfied.

Tools to Support Ongoing Improvements in Hospitalist Practice

There are many outlets hospitalists can turn to for education on essentially any aspect of their practice. Several years ago, the SHM published “The Core Competencies in Hospital Medicine: A Framework for Curriculum Development,” a publication that continues to be valuable in guiding hospitalists’ professional scope of clinical skills as well as educational curricula for training programs and continuing education. SHM and other organizations generate a great deal of educational content for hospitalists, which is available in many forms, including in-person conferences, webinars, and written materials. And there are several scientific journals that have significant content for hospitalists, including SHM’s own Journal of Hospital Medicine.

Our field encourages and recognizes ongoing commitment to hospitalists’ growth and development in a number of ways. When it is time for a doctor to renew his/her board certification, the American Board of Internal Medicine (ABIM) offers the option to pursue “Focused Practice in Hospital Medicine.” And SHM’s designation of Fellow, Senior Fellow and Master in Hospital Medicine recognizes those who have “demonstrated a commitment to hospital medicine, system change, and quality improvement principles.” Many in our field have achieved one or both of these distinctions, and countless others are pursuing them now.

Through its foundation, the ABIM developed a campaign known as “Choosing Wisely” to “promote conversations between physicians and patients by helping patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.” SHM joined in this effort by developing separate criteria for hospitalists who care for adults or children.

New Tool Encourages High Performance

In February, an SHM workgroup published “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists,” a document meant to serve as a road map for hospitalist groups to follow to improve their performance. I’m particularly interested in this, since I have spent much of my career thinking about and working with hospitalist groups to improve the way they perform, and I helped develop the characteristics and co-authored the document. But the real value of the document comes from the input of hundreds of people within and outside of SHM who provided thoughtful advice and feedback to identify those attributes of hospitalist groups that are most likely to ensure success.

The document describes 47 characteristics grouped into 10 different categories (“principles”). Some of the principles that you as a patient might be most interested in are ones specifying that a hospitalist group:

— Implements a practice model that is patient- and family-centered, is team-based, and emphasizes care coordination and effective communication.

— Supports care coordination across care settings; and

— Plays a leadership role in addressing key clinical issues in the hospital and/or health system: teaching, quality, safety, efficiency, and the patient/family experience.

Current State of Hospital Medicine

If you’ve had a less than satisfactory experience with care by a hospitalist, the things I’ve described here might not improve your opinion of hospitalists, or that of your friends. But maybe you can take some measure of comfort in knowing that our field as a whole is working hard to continuously improve all aspects of what we do. We’re serious about being good at what we do.

And, since this is published in a magazine read by hospitalists, maybe some of them will be reminded of the many ways our field encourages, supports, and recognizes their professional development.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

There has been a fair amount of media coverage lately about “medical deserts.”¹ What exactly is a medical desert, and how big of a problem do they pose for hospital medicine? Wikipedia defines a desert as “a barren area of land where little precipitation occurs and consequently living conditions are hostile for plant and animal life.”² There are definitely areas in the U.S., both urban and rural, lacking adequate emergency and inpatient medical care.

Based on the latest American Hospital Association (AHA) statistics, there are still >5,700 registered hospitals in the U.S. with almost one million staffed beds combined, which accommodate >36 million admissions every year.³ However, of all U.S. hospitals, only about 35% are located in rural areas, and these tend to be the ones most likely affected by declining reimbursements and tight operating margins.¹

Here is some evidence:

— A recent study in the Annals of Emergency Medicine found that only half of the population in the state of Pennsylvania had access to appropriate care within 60 minutes for four time-sensitive conditions (i.e., STEMI, stroke, septic shock, and cardiac arrest).⁴

— Another study from the Office of Rural Health Policy estimates that approximately 20% of all residential areas do not have rapid access to an acute care medical facility.¹

— A recent online story about medical deserts described the devastating case of an 18-month-old girl who died of asphyxiation when a grape became lodged in her throat; their local county’s only hospital with an emergency room had closed months earlier, leaving the closest ED more than 20 miles away.¹ This particular hospital, Shelby Regional Medical Center, was a 54-bed hospital in Center, Texas, which suddenly closed in July 2013 amid allegations of fraud from CMS. In addition, a nearby 49-bed Texas hospital (Renaissance Hospital Groves), owned and operated by the same company, had closed in May 2013.

But the list of hospital closures in the past year goes on:

• Lakeside Memorial Hospital in Brockport, N.Y. (61-bed hospital);
• Earl K. Long Medical Center in Baton Rouge, La. (116-bed hospital);
• Stewart-Webster Hospital in Richland, Ga. (25-bed, critical access hospital);
• Calhoun Memorial Hospital in Arlington, Ga. (85-bed hospital);
• Charlton Memorial Hospital in Folkston, Ga. (25-bed hospital);
• The Los Angeles-based Pacific Health Corporation closed all four of its hospitals in California: Anaheim General Hospital (142 beds), Bellflower Medical Center (142 beds), Los Angeles Metropolitan Medical Center (212 beds), and Newport Specialty Hospital (177 beds).

As the CEO of Calhoun Memorial Hospital stated at the closure of his hospital: “It’s a sad day for the community it’s just a sign of the times.”⁵

Staff, Service Reductions

These hospital closures do not even start to address the nearly ubiquitous reductions in staff and services that many hospitals are resorting to, including workforce reductions experienced by many high-profile academic medical centers like Wake Forest, Denver Health, Emory Health, and Vanderbilt University Medical Centers. According to the Bureau of Labor Statistics, hospitals cut 4,400 jobs in July 2013 alone, while the U.S. overall added 162,000 jobs.¹

These acute medical care deserts are primarily a result of declining reimbursements from Medicare and Medicaid, combined with a lack of newly insured Americans, a group that was expected to increase at a much faster pace than it has. The introduction of high-dollar withholds tethered to pay-for-performance programs, such as value-based purchasing and readmission reduction penalties, has also contributed to the financial instability in some hospitals.

In addition, the reduction in disproportionate share hospital (DSH) payments has occurred long before any substantial increase in funded patients through the Affordable Care Act health exchanges. Particularly hard-hit are hospitals in the states that have still elected not to expand Medicaid (primarily in the Southeast and Midwest). And forecasters have every reason to believe that these medical deserts will expand, unless limping hospitals are merged and/or acquired by larger hospital systems.

Should You Be Concerned?

These statistics probably should raise some concern for hospitalists and hospital medicine groups, as the number of hospital-employed physicians is already relatively high (26% according to a recent survey) and rises every year, including an increase of 6% from 2012 to 2013 alone.⁶ In order to survive in these tenuous conditions, healthcare systems, including hospitalists, will have to be much more involved in the “spectrum of care,” including population health, as opposed to only being involved in discrete acute care episodes. There undoubtedly will be a heavy reliance on telemedicine, seamless electronic medical records, and alternative treatment settings to bridge the gap between medical oases and medical deserts. All of these acute medical care extensions will very likely involve hospitalists.

For the most part, as long as the specialty of hospital medicine keeps its ear to the ground on what is coming, ensuring that we can all be flexible and responsive in meeting the needs of the population we serve, our specialty will be prepped and ready for the “sign of the times.” That way, even when medical deserts do appear, they are not “hostile for life” but are reasonably connected to a suitable oasis.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Williams JP. What happens when a town’s only hospital shuts down? U.S. News and World Report online. November 8, 2013. Available at: http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2013/11/08/what-happens-when-the-only-hospital-closes. Accessed March 5, 2014.
2. Wikipedia. Desert. Available at: http://en.wikipedia.org/wiki/Desert. Accessed March 5, 2014.
3. American Hospital Association. Fast facts on U.S. hospitals. Available at: http://www.aha.org/research/rc/stat-studies/fast-facts.shtml. Accessed March 5, 2014.
4. Salhi RA, Edwards JM, Gaieski DF, Band RA, Abella BS, Carr BG. Access to Care for patients with time-sensitive conditions in Pennsylvania [published online ahead of print December 21, 2013]. Ann Emerg Med.
5. Parks JM. Calhoun Memorial Hospital shuts down. Albany Herald online. February 4, 2013. Available at: http://www.albanyherald.com/news/2013/feb/04/calhoun-memorial-hospital-shuts-down. Accessed March 5, 2014.
6. Vaidya A. Survey: number of hospital-employed physicians up 6%. Becker’s Hospital Review online. June 18, 2013. Available at: http://www.beckershospitalreview.com/hospital-physician-relationships/survey-number-of-hospital-employed-physicians-up-6.html. Accessed March 5, 2014.

There has been a fair amount of media coverage lately about “medical deserts.”¹ What exactly is a medical desert, and how big of a problem do they pose for hospital medicine? Wikipedia defines a desert as “a barren area of land where little precipitation occurs and consequently living conditions are hostile for plant and animal life.”² There are definitely areas in the U.S., both urban and rural, lacking adequate emergency and inpatient medical care.

Based on the latest American Hospital Association (AHA) statistics, there are still >5,700 registered hospitals in the U.S. with almost one million staffed beds combined, which accommodate >36 million admissions every year.³ However, of all U.S. hospitals, only about 35% are located in rural areas, and these tend to be the ones most likely affected by declining reimbursements and tight operating margins.¹

Here is some evidence:

— A recent study in the Annals of Emergency Medicine found that only half of the population in the state of Pennsylvania had access to appropriate care within 60 minutes for four time-sensitive conditions (i.e., STEMI, stroke, septic shock, and cardiac arrest).⁴

— Another study from the Office of Rural Health Policy estimates that approximately 20% of all residential areas do not have rapid access to an acute care medical facility.¹

— A recent online story about medical deserts described the devastating case of an 18-month-old girl who died of asphyxiation when a grape became lodged in her throat; their local county’s only hospital with an emergency room had closed months earlier, leaving the closest ED more than 20 miles away.¹ This particular hospital, Shelby Regional Medical Center, was a 54-bed hospital in Center, Texas, which suddenly closed in July 2013 amid allegations of fraud from CMS. In addition, a nearby 49-bed Texas hospital (Renaissance Hospital Groves), owned and operated by the same company, had closed in May 2013.

But the list of hospital closures in the past year goes on:

• Lakeside Memorial Hospital in Brockport, N.Y. (61-bed hospital);
• Earl K. Long Medical Center in Baton Rouge, La. (116-bed hospital);
• Stewart-Webster Hospital in Richland, Ga. (25-bed, critical access hospital);
• Calhoun Memorial Hospital in Arlington, Ga. (85-bed hospital);
• Charlton Memorial Hospital in Folkston, Ga. (25-bed hospital);
• The Los Angeles-based Pacific Health Corporation closed all four of its hospitals in California: Anaheim General Hospital (142 beds), Bellflower Medical Center (142 beds), Los Angeles Metropolitan Medical Center (212 beds), and Newport Specialty Hospital (177 beds).

As the CEO of Calhoun Memorial Hospital stated at the closure of his hospital: “It’s a sad day for the community it’s just a sign of the times.”⁵

Staff, Service Reductions

These hospital closures do not even start to address the nearly ubiquitous reductions in staff and services that many hospitals are resorting to, including workforce reductions experienced by many high-profile academic medical centers like Wake Forest, Denver Health, Emory Health, and Vanderbilt University Medical Centers. According to the Bureau of Labor Statistics, hospitals cut 4,400 jobs in July 2013 alone, while the U.S. overall added 162,000 jobs.¹

These acute medical care deserts are primarily a result of declining reimbursements from Medicare and Medicaid, combined with a lack of newly insured Americans, a group that was expected to increase at a much faster pace than it has. The introduction of high-dollar withholds tethered to pay-for-performance programs, such as value-based purchasing and readmission reduction penalties, has also contributed to the financial instability in some hospitals.

In addition, the reduction in disproportionate share hospital (DSH) payments has occurred long before any substantial increase in funded patients through the Affordable Care Act health exchanges. Particularly hard-hit are hospitals in the states that have still elected not to expand Medicaid (primarily in the Southeast and Midwest). And forecasters have every reason to believe that these medical deserts will expand, unless limping hospitals are merged and/or acquired by larger hospital systems.

Should You Be Concerned?

These statistics probably should raise some concern for hospitalists and hospital medicine groups, as the number of hospital-employed physicians is already relatively high (26% according to a recent survey) and rises every year, including an increase of 6% from 2012 to 2013 alone.⁶ In order to survive in these tenuous conditions, healthcare systems, including hospitalists, will have to be much more involved in the “spectrum of care,” including population health, as opposed to only being involved in discrete acute care episodes. There undoubtedly will be a heavy reliance on telemedicine, seamless electronic medical records, and alternative treatment settings to bridge the gap between medical oases and medical deserts. All of these acute medical care extensions will very likely involve hospitalists.

For the most part, as long as the specialty of hospital medicine keeps its ear to the ground on what is coming, ensuring that we can all be flexible and responsive in meeting the needs of the population we serve, our specialty will be prepped and ready for the “sign of the times.” That way, even when medical deserts do appear, they are not “hostile for life” but are reasonably connected to a suitable oasis.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Williams JP. What happens when a town’s only hospital shuts down? U.S. News and World Report online. November 8, 2013. Available at: http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2013/11/08/what-happens-when-the-only-hospital-closes. Accessed March 5, 2014.
2. Wikipedia. Desert. Available at: http://en.wikipedia.org/wiki/Desert. Accessed March 5, 2014.
3. American Hospital Association. Fast facts on U.S. hospitals. Available at: http://www.aha.org/research/rc/stat-studies/fast-facts.shtml. Accessed March 5, 2014.
4. Salhi RA, Edwards JM, Gaieski DF, Band RA, Abella BS, Carr BG. Access to Care for patients with time-sensitive conditions in Pennsylvania [published online ahead of print December 21, 2013]. Ann Emerg Med.
5. Parks JM. Calhoun Memorial Hospital shuts down. Albany Herald online. February 4, 2013. Available at: http://www.albanyherald.com/news/2013/feb/04/calhoun-memorial-hospital-shuts-down. Accessed March 5, 2014.
6. Vaidya A. Survey: number of hospital-employed physicians up 6%. Becker’s Hospital Review online. June 18, 2013. Available at: http://www.beckershospitalreview.com/hospital-physician-relationships/survey-number-of-hospital-employed-physicians-up-6.html. Accessed March 5, 2014.

There has been a fair amount of media coverage lately about “medical deserts.”¹ What exactly is a medical desert, and how big of a problem do they pose for hospital medicine? Wikipedia defines a desert as “a barren area of land where little precipitation occurs and consequently living conditions are hostile for plant and animal life.”² There are definitely areas in the U.S., both urban and rural, lacking adequate emergency and inpatient medical care.

Based on the latest American Hospital Association (AHA) statistics, there are still >5,700 registered hospitals in the U.S. with almost one million staffed beds combined, which accommodate >36 million admissions every year.³ However, of all U.S. hospitals, only about 35% are located in rural areas, and these tend to be the ones most likely affected by declining reimbursements and tight operating margins.¹

Here is some evidence:

— A recent study in the Annals of Emergency Medicine found that only half of the population in the state of Pennsylvania had access to appropriate care within 60 minutes for four time-sensitive conditions (i.e., STEMI, stroke, septic shock, and cardiac arrest).⁴

— Another study from the Office of Rural Health Policy estimates that approximately 20% of all residential areas do not have rapid access to an acute care medical facility.¹

— A recent online story about medical deserts described the devastating case of an 18-month-old girl who died of asphyxiation when a grape became lodged in her throat; their local county’s only hospital with an emergency room had closed months earlier, leaving the closest ED more than 20 miles away.¹ This particular hospital, Shelby Regional Medical Center, was a 54-bed hospital in Center, Texas, which suddenly closed in July 2013 amid allegations of fraud from CMS. In addition, a nearby 49-bed Texas hospital (Renaissance Hospital Groves), owned and operated by the same company, had closed in May 2013.

But the list of hospital closures in the past year goes on:

• Lakeside Memorial Hospital in Brockport, N.Y. (61-bed hospital);
• Earl K. Long Medical Center in Baton Rouge, La. (116-bed hospital);
• Stewart-Webster Hospital in Richland, Ga. (25-bed, critical access hospital);
• Calhoun Memorial Hospital in Arlington, Ga. (85-bed hospital);
• Charlton Memorial Hospital in Folkston, Ga. (25-bed hospital);
• The Los Angeles-based Pacific Health Corporation closed all four of its hospitals in California: Anaheim General Hospital (142 beds), Bellflower Medical Center (142 beds), Los Angeles Metropolitan Medical Center (212 beds), and Newport Specialty Hospital (177 beds).

As the CEO of Calhoun Memorial Hospital stated at the closure of his hospital: “It’s a sad day for the community it’s just a sign of the times.”⁵

Staff, Service Reductions

These hospital closures do not even start to address the nearly ubiquitous reductions in staff and services that many hospitals are resorting to, including workforce reductions experienced by many high-profile academic medical centers like Wake Forest, Denver Health, Emory Health, and Vanderbilt University Medical Centers. According to the Bureau of Labor Statistics, hospitals cut 4,400 jobs in July 2013 alone, while the U.S. overall added 162,000 jobs.¹

These acute medical care deserts are primarily a result of declining reimbursements from Medicare and Medicaid, combined with a lack of newly insured Americans, a group that was expected to increase at a much faster pace than it has. The introduction of high-dollar withholds tethered to pay-for-performance programs, such as value-based purchasing and readmission reduction penalties, has also contributed to the financial instability in some hospitals.

In addition, the reduction in disproportionate share hospital (DSH) payments has occurred long before any substantial increase in funded patients through the Affordable Care Act health exchanges. Particularly hard-hit are hospitals in the states that have still elected not to expand Medicaid (primarily in the Southeast and Midwest). And forecasters have every reason to believe that these medical deserts will expand, unless limping hospitals are merged and/or acquired by larger hospital systems.

Should You Be Concerned?

These statistics probably should raise some concern for hospitalists and hospital medicine groups, as the number of hospital-employed physicians is already relatively high (26% according to a recent survey) and rises every year, including an increase of 6% from 2012 to 2013 alone.⁶ In order to survive in these tenuous conditions, healthcare systems, including hospitalists, will have to be much more involved in the “spectrum of care,” including population health, as opposed to only being involved in discrete acute care episodes. There undoubtedly will be a heavy reliance on telemedicine, seamless electronic medical records, and alternative treatment settings to bridge the gap between medical oases and medical deserts. All of these acute medical care extensions will very likely involve hospitalists.

For the most part, as long as the specialty of hospital medicine keeps its ear to the ground on what is coming, ensuring that we can all be flexible and responsive in meeting the needs of the population we serve, our specialty will be prepped and ready for the “sign of the times.” That way, even when medical deserts do appear, they are not “hostile for life” but are reasonably connected to a suitable oasis.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Williams JP. What happens when a town’s only hospital shuts down? U.S. News and World Report online. November 8, 2013. Available at: http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2013/11/08/what-happens-when-the-only-hospital-closes. Accessed March 5, 2014.
2. Wikipedia. Desert. Available at: http://en.wikipedia.org/wiki/Desert. Accessed March 5, 2014.
3. American Hospital Association. Fast facts on U.S. hospitals. Available at: http://www.aha.org/research/rc/stat-studies/fast-facts.shtml. Accessed March 5, 2014.
4. Salhi RA, Edwards JM, Gaieski DF, Band RA, Abella BS, Carr BG. Access to Care for patients with time-sensitive conditions in Pennsylvania [published online ahead of print December 21, 2013]. Ann Emerg Med.
5. Parks JM. Calhoun Memorial Hospital shuts down. Albany Herald online. February 4, 2013. Available at: http://www.albanyherald.com/news/2013/feb/04/calhoun-memorial-hospital-shuts-down. Accessed March 5, 2014.
6. Vaidya A. Survey: number of hospital-employed physicians up 6%. Becker’s Hospital Review online. June 18, 2013. Available at: http://www.beckershospitalreview.com/hospital-physician-relationships/survey-number-of-hospital-employed-physicians-up-6.html. Accessed March 5, 2014.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Facecards improve familiarity with physician names, not satisfaction
2. Pre-operative beta-blockers may benefit some cardiac patients
3. Benefit of therapeutic hypothermia after cardiac arrest unclear
4. Patients prefer inpatient boarding to ED boarding
5. Triple rule outs for chest pain
6. Colloids vs. crystalloids for critically ill patients presenting with hypovolemic shock
7. Interdisciplinary intervention improves medication compliance, not blood pressure or LDL-C levels
8. Edoxaban is noninferior to warfarin in Afib patients
9. Beta blockers lower mortality after acute MI in COPD patients
10. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction

Facecards Improve Familiarity with Physician Names but Not Satisfaction

Clinical question: Do facecards improve patients’ familiarity with physicians and increase satisfaction, trust, and agreement with physicians?

Background: Facecards can improve patients’ knowledge of names and roles of physicians, but their impact on other outcomes is unclear. This pilot trial was designed to assess facecards’ impact on patient satisfaction, trust, or agreement with physicians.

Study design: Cluster, randomized controlled trial (RCT).

Setting: A large teaching hospital in the United States.

Synopsis: Patients (n=138) were randomized to receive either facecards with the name and picture of their hospitalists, as well as a brief description of the hospitalist’s role (n=66), or to receive traditional communication (n=72). There were no significant differences in patient age, sex, or race.

Patients who received a facecard were more likely to correctly identify their hospital physician (89.1% vs. 51.1%; P< 0.01) and were more likely to correctly identify the role of their hospital physician than those in the control group (67.4% vs. 16.3%; P<0.01).

Patients who received a facecard rated satisfaction, trust, and agreement slightly higher compared with those who had not received a card, but the results were not statistically significant (P values 0.27, 0.32, 0.37, respectively.) The authors note that larger studies may be needed to see a difference in these areas.

Bottom line: Facecards improve patients’ knowledge of the names and roles of hospital physicians but have no clear impact on satisfaction with, trust of, or agreement with physicians.

Citation: Simons Y, Caprio T, Furiasse N, Kriss, M, Williams MV, O’Leary KJ. The impact of facecards on patients’ knowledge, satisfaction, trust, and agreement with hospitalist physicians: a pilot study. J Hosp Med. 2014;9(3):137-141.

Pre-Operative Beta Blockers May Benefit Some Cardiac Patients

Clinical question: In patients with ischemic heart disease (IHD) undergoing non-cardiac surgery, do pre-operative beta blockers reduce post-operative major cardiovascular events (MACE) or mortality at 30 days?

Background: Peri-operative beta blocker use has become more restricted, as evidence about which patients derive benefit has become clearer. Opinions and practice vary regarding whether all patients with IHD, or only certain populations within this group, benefit from peri-operative beta blockers.

Study design: Retrospective, national registry-based cohort study.

Setting: Denmark, 2004-2009.

Synopsis: No benefit was found for the overall cohort of 28,263 patients. Patients with IHD and heart failure (n=7990) had lower risk of MACE (HR=0.75, 95% CI, 0.70-0.87) and mortality (HR=0.80, 95% CI, 0.70-0.92). Patients with IHD and myocardial infarction within two years (n=1664) had lower risk of MACE (HR=0.54, 95% CI, 0.37-0.78) but not mortality.

Beta blocker dose and compliance were unknown. Whether patients had symptoms or inducible ischemia was not clear.

This study supports the concept that higher-risk patients benefit more from peri-operative beta blockers, but it is not high-grade evidence.

Bottom line: Not all patients with IHD benefit from pre-operative beta blockers; those with concomitant heart failure or recent MI have a lower risk of MACE and/or mortality at 30 days with beta blockers.

Citation: Andersson C, Merie C, Jorgensen M, et al. Association of ß-blocker therapy with risks of adverse cardiovascular events and deaths in patients with ischemic heart disease undergoing non-cardiac surgery: a Danish nationwide cohort study. JAMA Intern Med. 2014;174(3):336-344.

Benefit of Therapeutic Hypothermia after Cardiac Arrest Unclear

Clinical question: Does targeted hypothermia (33°C) after cardiac arrest confer benefits compared with targeted temperature management at 36°C?

Background: Therapeutic hypothermia is a current recommendation in resuscitation guidelines after cardiac arrest. Fever develops in many patients after arrest, and it is unclear if the treatment benefit is due to hypothermia or due to the prevention of fever.

Study design: RCT.

Setting: ICUs in Europe and Australia.

Synopsis: The study authors randomized 950 patients who experienced out-of-hospital cardiac arrest to targeted temperature management at either 36°C or 33°C. The goal of this trial was to prevent fever in both groups during the first 36 hours after cardiac arrest. No statistically significant difference in outcomes between these two approaches was found. In the 33°C group, 54% died or had poor neurologic function, compared with 52% in the 36°C group (risk ratio 1.02; 95% CI 0.88 to 1.16; P=0.78).

Given the wide confidence interval, a trial with either more participants or more events might be able to determine whether a true difference in these management approaches exists.

Bottom line: Therapeutic hypothermia at 33°C after out-of-hospital cardiac arrest did not confer a benefit compared with targeted temperature management at 36°C.

Citation: Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013;369(23):2197-2206.

Patients Prefer Inpatient Boarding to Emergency Department Boarding

Clinical question: Do patients who experience overcrowding and long waits in the emergency department (ED) prefer boarding within ED hallways or within inpatient medical unit hallways?

Background: Boarding of admitted patients in EDs can be problematic, especially with regard to patient safety and patient satisfaction. Patient satisfaction data comparing boarding in the ED versus boarding in an inpatient unit hallway is limited.

Study design: Post-discharge, structured, telephone satisfaction survey.

Setting: Suburban, university-based teaching hospital.

Synopsis: A group of patients who experienced hallway boarding in the ED and then hallway boarding on the inpatient medical unit were identified. They were contacted by phone and asked to take a survey on their experience; 105 of 110 patients identified agreed. Patients were asked to rate their location preference with regard to various aspects of care. A five-point Likert scale consisting of the following answers was used: ED hallway much better, ED hallway better, no preference, inpatient hallway better, and inpatient hallway much better.

The inpatient hallway was the overall preferred location in 85% of respondents. Respondents preferred inpatient boarding with regard to multiple other parameters: rest, 85%; safety, 83%; confidentiality, 82%; treatment, 78%; comfort, 79%; quiet, 84%; staff availability, 84%; and privacy, 84%. For no item was there a preference for boarding in the ED.

Patient demographics in this hospital may differ from other settings and should be considered when applying the results. With Hospital Consumer Assessment of Healthcare Providers and Systems scores and ED throughput being publicly reported, further studies in this area would be valuable.

Bottom line: In a post-discharge telephone survey, patients preferred boarding in inpatient unit hallways rather than boarding in the ED.

Citation: Viccellio P, Zito JA, Sayage V, et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. J Emerg Med. 2013;45(6):942-946.

“Triple Rule Outs” for Chest Pain: A Tool to Evaluate the Coronaries but Not Pulmonary Embolism or Aortic Dissection

Clinical question: How does “triple rule out” (TRO) computed tomographic (CT) angiography compare to other imaging modalities in evaluating coronary and other life-threatening etiologies of chest pain, such as pulmonary embolism (PE) and aortic dissection?

Background: TRO CT angiography is a noninvasive technology that evaluates the coronary arteries, thoracic aorta, and pulmonary vasculature simultaneously. Comparison with other tests in the diagnosis of common clinical conditions is useful information for clinical practice.

Study design: Systematic review and meta-analysis.

Setting: Systematic review of 11 studies (one randomized, 10 observational).

Synopsis: Using an enrolled population of 3,539 patients, TRO CT was compared to other imaging modalities on the basis of image quality, diagnostic accuracy, radiation, and contrast volume. When TRO CT was compared to dedicated CT scans, no significant imaging difference was discovered. TRO CT detected CAD with a sensitivity of 94.3% (95% CI, 89.1% to 97.5%, I2=58.2%) and specificity of 97.4% (95% CI, 96.1% to 98.5%, I2=91.2%).

An insufficient number of patients with PE or aortic dissection were studied to generate diagnostic accuracy for these conditions. TRO CT involved greater radiation exposure and contrast exposure than non-TRO CT.

This study reports high accuracy of TRO CT in the diagnosis of coronary artery disease. Due to the low prevalence of patients with PE or aortic dissection (<1%), the data cannot be extrapolated to these conditions.

Bottom line: Although TRO CT is highly accurate for detecting coronary artery disease, there is insufficient data to recommend its use for the diagnosis of PE or aortic dissection.

Citation: Ayaram D, Bellolio MF, Murad MH, et al. Triple rule-out computed tomographic angiography for chest pain: a diagnostic systematic review and meta-analysis. Acad Emerg Med. 2013;20(9):861-871.

Colloids vs. Crystalloids for Critically Ill Patients Presenting with Hypovolemic Shock

Clinical question: In critically ill patients admitted to the ICU with hypovolemic shock, does the use of colloid for fluid resuscitation, compared with crystalloid, improve mortality?

Background: The current Surviving Sepsis Campaign guidelines recommend crystalloids as the preferred fluid for resuscitation of patients with hypovolemic shock; however, evidence supporting the choice of intravenous colloid vs. crystalloid solutions for management of hypovolemic shock is weak.

Study design: RCT.

Setting: International, multi-center study.

Synopsis: Researchers randomized 2,857 adult patients who were admitted to an ICU and required fluid resuscitation for acute hypovolemia to receive either crystalloids or colloids.

At 28 days, there were 359 deaths (25.4%) in the colloids group vs. 390 deaths (27.0%) in the crystalloids group (P=0.26). At 90 days, there were 434 deaths (30.7%) in the colloids group vs. 493 deaths (34.2%) in the crystalloids group (P=0.03).

Renal replacement therapy was used in 11.0% of the colloids group vs. 12.5% of the crystalloids group (P=0.19). There were more days alive without mechanical ventilation in the colloids group vs. the crystalloids group at seven days (P=0.01) and at 28 days (P=0.01), and there were more days alive without vasopressor therapy in the colloids group vs. the crystalloids group at seven days (P=0.04) and at 28 days (P=0.03).

Major limitations of the study included the use of open-labeled fluids during allocation, so the initial investigators were not blinded to the type of fluid. Moreover, the study compared two therapeutic strategies (colloid vs. crystalloids) rather than two types of molecules.

Bottom line: In ICU patients with hypovolemia requiring resuscitation, the use of colloids vs. crystalloids did not result in a significant difference in 28-day mortality; however, 90-day mortality was lower among patients receiving colloids.

Citation: Annane D, Siami S, Jaber S, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality of critically ill patients presenting with hypovolemic shock: the CRISTAL randomization trial. JAMA. 2013;310(17):1809-1817.

Interdisciplinary Intervention Improves Medication Compliance, Not Blood Pressure or LDL-C Levels

Clinical question: Can intervention by pharmacists and physicians improve compliance to cardio-protective medications?

Background: Adherence to cardio-protective medications in the year after hospitalization for acute coronary syndrome is poor.

Study design: RCT.

Setting: Four Department of Veterans Affairs medical centers.

Synopsis: The intervention consisted of pharmacist-led medication reconciliation, patient education, pharmacist and PCP +/- cardiologist collaboration, and voice messaging. The outcome measured was the proportion of patients adherent to medication regimens based on a mean proportion of days covered (PDC) >0.80 in the year after discharge, using pharmacy refill data for clopidogrel, beta blockers, statins, and ACEI/ARBs.

Two hundred forty-one patients (95.3%) completed the study. In the intervention group, 89.3% of patients were adherent vs. 73.9% in the usual care group (P=0.003). Mean PDC was higher in the intervention group (0.94 vs. 0.87; P<0.001). A greater proportion of intervention patients were adherent to clopidogrel (86.8% vs. 70.7%; P=0.03), statins (93.2% vs. 71.3%; P<0.001), and ACEI/ARBs (93.1% vs. 81.7%; P=0.03), but not beta blockers (88.1% vs. 84.8%; P=0.59). There were no statistically significant differences in the proportion of patients who achieved blood pressure and LDL-C level goals.

Bottom line: An interdisciplinary, multi-faceted intervention increased medication compliance in the year after discharge for ACS but did not improve blood pressure or LDL-C levels.

Citation: Ho PM, Lambert-Kerzner A, Carey EP, et al. Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge. JAMA Intern Med. 2014;174(2):186-193.

Edoxaban Is Noninferior to Warfarin in Patients with Atrial Fibrillation

Clinical question: What is the long-term efficacy and safety of edoxaban compared with warfarin in patients with atrial fibrillation (Afib)?

Background: Edoxaban is an oral factor Xa inhibitor approved for use in Japan for the prevention of venous thromboembolism after orthopedic surgery. No specific antidote for edoxaban exists, but hemostatic agents can reverse its anticoagulation effect.

Study design: RCT.

Setting: More than 1,300 centers in 46 countries.

Synopsis: Researchers randomized 21,105 patients in a 1:1:1 ratio to receive warfarin (goal INR of 2-3), low-dose edoxaban, or high-dose edoxoban. All patients received two sets of drugs, either active warfarin with placebo edoxaban or active edoxaban (high- or low-dose) and placebo warfarin (with sham INRs drawn), and were followed for a median of 2.8 years.

The annualized rate of stroke or systemic embolic event was 1.5% in the warfarin group, compared with 1.18% in the high-dose edoxaban group (hazard ratio 0.79; P<0.001) and 1.61% in the low-dose edoxaban group (hazard ratio 1.07; P=0.005). Annualized rate of major bleeding was 3.43% with warfarin, 2.75% with high-dose edoxoban (hazard ratio 0.80; P<0.001), and 1.61% with low-dose edoxaban (hazard ratio 0.47; P<0.001).

Both edoxaban regimens were noninferior to warfarin for the prevention of stroke or systemic emboli. The rates of cardiovascular events, bleeding, or death from any cause was lower with both doses of edoxaban as compared with warfarin.

Bottom line: Once-daily edoxaban is noninferior to warfarin for the prevention of stroke or systemic emboli and is associated with lower rates of bleeding and death.

Citation: Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. New Engl J Med. 2013;369(22):2093-2104.

Beta Blockers Lower Mortality after Acute Myocardial Infarction in COPD Patients

Clinical question: Does the use and timing of beta blockers in COPD patients experiencing a first myocardial infarction (MI) affect survival after the event?

Background: Beta blockers are effective in reducing mortality and reinfarction after an MI; however, concerns regarding the side effects of beta blockers, such as bronchospasm, continue to limit their use in patients with COPD.

Study design: Population-based cohort study.

Setting: The Myocardial Ischemia National Audit Project, linked to the General Practice Research Database, in the United Kingdom.

Synopsis: Researchers identified 1,063 patients over the age of 18 with COPD admitted to the hospital with a first acute MI. Use of beta blockers during hospitalization was associated with increased overall and one-year survival. Initiation of beta blockers during an MI had a mortality-adjusted hazard ratio of 0.50 (95% CI 0.36 to 0.69; P<0.001; median follow-up time=2.9 years).

Patients already on beta blockers prior to the MI had overall survival-adjusted hazard ratio of 0.59 (95% CI 0.44 to 0.79; P<0.001). Both scenarios showed survival benefits compared to COPD patients who were not prescribed beta blockers. Patients given beta blockers with COPD either during the MI hospitalization or before the event were younger and had fewer comorbidities. This may have accounted for some of the survival bias.

Bottom line: The use of beta blockers in patients with COPD started prior to, or at the time of, hospital admission for a first MI is associated with improved survival.

Citation: Quint JK, Herret E, Bhaskaran K, et al. Effect of ß blockers on mortality after myocardial infarction in adults with COPD: population-based cohort study of UK electronic healthcare records. BMJ. 2013;347:f6650.

Neither Low-Dose Dopamine nor Low-Dose Nesiritide Improves Renal Dysfunction in Acute Heart Failure Patients

Clinical question: Does low-dose dopamine or low-dose nesiritide added to diuretic therapy enhance pulmonary volume reduction and preserve renal function in patients with acute heart failure and renal dysfunction, compared to placebo?

Background: Small studies have suggested that low-dose dopamine or low-dose nesiritide may be beneficial in enhancing decongestion and improving renal dysfunction; however, there is ambiguity in overall benefit. Some observational studies suggest that dopamine and nesiritide are associated with higher length of stay, higher costs, and greater mortality.

Study Design: RCT.

Setting: Twenty-six hospital sites in the U.S. and Canada.

Synopsis: Three hundred sixty patients with acute heart failure and renal dysfunction were randomized to receive either nesiritide or dopamine within 24 hours of admission. Within each of these arms, patients were then randomized, in a double-blinded 2:1 fashion, into active treatment versus placebo groups. Treatment groups were compared to the pooled placebo groups.

Two main endpoints were urine output and change in serum cystatin C, from enrollment to 72 hours. Compared with placebo, low-dose dopamine had no significant effect on urine output or serum cystatin C level. Similarly, low-dose nesiritide had no significant effect on 72-hour urine output or serum cystatin C level.

Other studies have shown these drugs to be potentially harmful. Hospitalists should use caution and carefully interpret the relevant evidence when considering their use.

Bottom line: Neither low-dose nesiritide nor low-dose dopamine improved urine output or serum cystatin C levels at 72 hours in patients with acute heart failure and renal dysfunction.

Citation: Chen HH, Anstrom KJ, Givertz MM, et al. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction: The ROSE acute heart failure randomized trial. JAMA. 2013;310(23):2533-2543.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Facecards improve familiarity with physician names, not satisfaction
2. Pre-operative beta-blockers may benefit some cardiac patients
3. Benefit of therapeutic hypothermia after cardiac arrest unclear
4. Patients prefer inpatient boarding to ED boarding
5. Triple rule outs for chest pain
6. Colloids vs. crystalloids for critically ill patients presenting with hypovolemic shock
7. Interdisciplinary intervention improves medication compliance, not blood pressure or LDL-C levels
8. Edoxaban is noninferior to warfarin in Afib patients
9. Beta blockers lower mortality after acute MI in COPD patients
10. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction

Facecards Improve Familiarity with Physician Names but Not Satisfaction

Clinical question: Do facecards improve patients’ familiarity with physicians and increase satisfaction, trust, and agreement with physicians?

Background: Facecards can improve patients’ knowledge of names and roles of physicians, but their impact on other outcomes is unclear. This pilot trial was designed to assess facecards’ impact on patient satisfaction, trust, or agreement with physicians.

Study design: Cluster, randomized controlled trial (RCT).

Setting: A large teaching hospital in the United States.

Synopsis: Patients (n=138) were randomized to receive either facecards with the name and picture of their hospitalists, as well as a brief description of the hospitalist’s role (n=66), or to receive traditional communication (n=72). There were no significant differences in patient age, sex, or race.

Patients who received a facecard were more likely to correctly identify their hospital physician (89.1% vs. 51.1%; P< 0.01) and were more likely to correctly identify the role of their hospital physician than those in the control group (67.4% vs. 16.3%; P<0.01).

Patients who received a facecard rated satisfaction, trust, and agreement slightly higher compared with those who had not received a card, but the results were not statistically significant (P values 0.27, 0.32, 0.37, respectively.) The authors note that larger studies may be needed to see a difference in these areas.

Bottom line: Facecards improve patients’ knowledge of the names and roles of hospital physicians but have no clear impact on satisfaction with, trust of, or agreement with physicians.

Citation: Simons Y, Caprio T, Furiasse N, Kriss, M, Williams MV, O’Leary KJ. The impact of facecards on patients’ knowledge, satisfaction, trust, and agreement with hospitalist physicians: a pilot study. J Hosp Med. 2014;9(3):137-141.

Pre-Operative Beta Blockers May Benefit Some Cardiac Patients

Clinical question: In patients with ischemic heart disease (IHD) undergoing non-cardiac surgery, do pre-operative beta blockers reduce post-operative major cardiovascular events (MACE) or mortality at 30 days?

Background: Peri-operative beta blocker use has become more restricted, as evidence about which patients derive benefit has become clearer. Opinions and practice vary regarding whether all patients with IHD, or only certain populations within this group, benefit from peri-operative beta blockers.

Study design: Retrospective, national registry-based cohort study.

Setting: Denmark, 2004-2009.

Synopsis: No benefit was found for the overall cohort of 28,263 patients. Patients with IHD and heart failure (n=7990) had lower risk of MACE (HR=0.75, 95% CI, 0.70-0.87) and mortality (HR=0.80, 95% CI, 0.70-0.92). Patients with IHD and myocardial infarction within two years (n=1664) had lower risk of MACE (HR=0.54, 95% CI, 0.37-0.78) but not mortality.

Beta blocker dose and compliance were unknown. Whether patients had symptoms or inducible ischemia was not clear.

This study supports the concept that higher-risk patients benefit more from peri-operative beta blockers, but it is not high-grade evidence.

Bottom line: Not all patients with IHD benefit from pre-operative beta blockers; those with concomitant heart failure or recent MI have a lower risk of MACE and/or mortality at 30 days with beta blockers.

Citation: Andersson C, Merie C, Jorgensen M, et al. Association of ß-blocker therapy with risks of adverse cardiovascular events and deaths in patients with ischemic heart disease undergoing non-cardiac surgery: a Danish nationwide cohort study. JAMA Intern Med. 2014;174(3):336-344.

Benefit of Therapeutic Hypothermia after Cardiac Arrest Unclear

Clinical question: Does targeted hypothermia (33°C) after cardiac arrest confer benefits compared with targeted temperature management at 36°C?

Background: Therapeutic hypothermia is a current recommendation in resuscitation guidelines after cardiac arrest. Fever develops in many patients after arrest, and it is unclear if the treatment benefit is due to hypothermia or due to the prevention of fever.

Study design: RCT.

Setting: ICUs in Europe and Australia.

Synopsis: The study authors randomized 950 patients who experienced out-of-hospital cardiac arrest to targeted temperature management at either 36°C or 33°C. The goal of this trial was to prevent fever in both groups during the first 36 hours after cardiac arrest. No statistically significant difference in outcomes between these two approaches was found. In the 33°C group, 54% died or had poor neurologic function, compared with 52% in the 36°C group (risk ratio 1.02; 95% CI 0.88 to 1.16; P=0.78).

Given the wide confidence interval, a trial with either more participants or more events might be able to determine whether a true difference in these management approaches exists.

Bottom line: Therapeutic hypothermia at 33°C after out-of-hospital cardiac arrest did not confer a benefit compared with targeted temperature management at 36°C.

Citation: Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013;369(23):2197-2206.

Patients Prefer Inpatient Boarding to Emergency Department Boarding

Clinical question: Do patients who experience overcrowding and long waits in the emergency department (ED) prefer boarding within ED hallways or within inpatient medical unit hallways?

Background: Boarding of admitted patients in EDs can be problematic, especially with regard to patient safety and patient satisfaction. Patient satisfaction data comparing boarding in the ED versus boarding in an inpatient unit hallway is limited.

Study design: Post-discharge, structured, telephone satisfaction survey.

Setting: Suburban, university-based teaching hospital.

Synopsis: A group of patients who experienced hallway boarding in the ED and then hallway boarding on the inpatient medical unit were identified. They were contacted by phone and asked to take a survey on their experience; 105 of 110 patients identified agreed. Patients were asked to rate their location preference with regard to various aspects of care. A five-point Likert scale consisting of the following answers was used: ED hallway much better, ED hallway better, no preference, inpatient hallway better, and inpatient hallway much better.

The inpatient hallway was the overall preferred location in 85% of respondents. Respondents preferred inpatient boarding with regard to multiple other parameters: rest, 85%; safety, 83%; confidentiality, 82%; treatment, 78%; comfort, 79%; quiet, 84%; staff availability, 84%; and privacy, 84%. For no item was there a preference for boarding in the ED.

Patient demographics in this hospital may differ from other settings and should be considered when applying the results. With Hospital Consumer Assessment of Healthcare Providers and Systems scores and ED throughput being publicly reported, further studies in this area would be valuable.

Bottom line: In a post-discharge telephone survey, patients preferred boarding in inpatient unit hallways rather than boarding in the ED.

Citation: Viccellio P, Zito JA, Sayage V, et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. J Emerg Med. 2013;45(6):942-946.

“Triple Rule Outs” for Chest Pain: A Tool to Evaluate the Coronaries but Not Pulmonary Embolism or Aortic Dissection

Clinical question: How does “triple rule out” (TRO) computed tomographic (CT) angiography compare to other imaging modalities in evaluating coronary and other life-threatening etiologies of chest pain, such as pulmonary embolism (PE) and aortic dissection?

Background: TRO CT angiography is a noninvasive technology that evaluates the coronary arteries, thoracic aorta, and pulmonary vasculature simultaneously. Comparison with other tests in the diagnosis of common clinical conditions is useful information for clinical practice.

Study design: Systematic review and meta-analysis.

Setting: Systematic review of 11 studies (one randomized, 10 observational).

Synopsis: Using an enrolled population of 3,539 patients, TRO CT was compared to other imaging modalities on the basis of image quality, diagnostic accuracy, radiation, and contrast volume. When TRO CT was compared to dedicated CT scans, no significant imaging difference was discovered. TRO CT detected CAD with a sensitivity of 94.3% (95% CI, 89.1% to 97.5%, I2=58.2%) and specificity of 97.4% (95% CI, 96.1% to 98.5%, I2=91.2%).

An insufficient number of patients with PE or aortic dissection were studied to generate diagnostic accuracy for these conditions. TRO CT involved greater radiation exposure and contrast exposure than non-TRO CT.

This study reports high accuracy of TRO CT in the diagnosis of coronary artery disease. Due to the low prevalence of patients with PE or aortic dissection (<1%), the data cannot be extrapolated to these conditions.

Bottom line: Although TRO CT is highly accurate for detecting coronary artery disease, there is insufficient data to recommend its use for the diagnosis of PE or aortic dissection.

Citation: Ayaram D, Bellolio MF, Murad MH, et al. Triple rule-out computed tomographic angiography for chest pain: a diagnostic systematic review and meta-analysis. Acad Emerg Med. 2013;20(9):861-871.

Colloids vs. Crystalloids for Critically Ill Patients Presenting with Hypovolemic Shock

Clinical question: In critically ill patients admitted to the ICU with hypovolemic shock, does the use of colloid for fluid resuscitation, compared with crystalloid, improve mortality?

Background: The current Surviving Sepsis Campaign guidelines recommend crystalloids as the preferred fluid for resuscitation of patients with hypovolemic shock; however, evidence supporting the choice of intravenous colloid vs. crystalloid solutions for management of hypovolemic shock is weak.

Study design: RCT.

Setting: International, multi-center study.

Synopsis: Researchers randomized 2,857 adult patients who were admitted to an ICU and required fluid resuscitation for acute hypovolemia to receive either crystalloids or colloids.

At 28 days, there were 359 deaths (25.4%) in the colloids group vs. 390 deaths (27.0%) in the crystalloids group (P=0.26). At 90 days, there were 434 deaths (30.7%) in the colloids group vs. 493 deaths (34.2%) in the crystalloids group (P=0.03).

Renal replacement therapy was used in 11.0% of the colloids group vs. 12.5% of the crystalloids group (P=0.19). There were more days alive without mechanical ventilation in the colloids group vs. the crystalloids group at seven days (P=0.01) and at 28 days (P=0.01), and there were more days alive without vasopressor therapy in the colloids group vs. the crystalloids group at seven days (P=0.04) and at 28 days (P=0.03).

Major limitations of the study included the use of open-labeled fluids during allocation, so the initial investigators were not blinded to the type of fluid. Moreover, the study compared two therapeutic strategies (colloid vs. crystalloids) rather than two types of molecules.

Bottom line: In ICU patients with hypovolemia requiring resuscitation, the use of colloids vs. crystalloids did not result in a significant difference in 28-day mortality; however, 90-day mortality was lower among patients receiving colloids.

Citation: Annane D, Siami S, Jaber S, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality of critically ill patients presenting with hypovolemic shock: the CRISTAL randomization trial. JAMA. 2013;310(17):1809-1817.

Interdisciplinary Intervention Improves Medication Compliance, Not Blood Pressure or LDL-C Levels

Clinical question: Can intervention by pharmacists and physicians improve compliance to cardio-protective medications?

Background: Adherence to cardio-protective medications in the year after hospitalization for acute coronary syndrome is poor.

Study design: RCT.

Setting: Four Department of Veterans Affairs medical centers.

Synopsis: The intervention consisted of pharmacist-led medication reconciliation, patient education, pharmacist and PCP +/- cardiologist collaboration, and voice messaging. The outcome measured was the proportion of patients adherent to medication regimens based on a mean proportion of days covered (PDC) >0.80 in the year after discharge, using pharmacy refill data for clopidogrel, beta blockers, statins, and ACEI/ARBs.

Two hundred forty-one patients (95.3%) completed the study. In the intervention group, 89.3% of patients were adherent vs. 73.9% in the usual care group (P=0.003). Mean PDC was higher in the intervention group (0.94 vs. 0.87; P<0.001). A greater proportion of intervention patients were adherent to clopidogrel (86.8% vs. 70.7%; P=0.03), statins (93.2% vs. 71.3%; P<0.001), and ACEI/ARBs (93.1% vs. 81.7%; P=0.03), but not beta blockers (88.1% vs. 84.8%; P=0.59). There were no statistically significant differences in the proportion of patients who achieved blood pressure and LDL-C level goals.

Bottom line: An interdisciplinary, multi-faceted intervention increased medication compliance in the year after discharge for ACS but did not improve blood pressure or LDL-C levels.

Citation: Ho PM, Lambert-Kerzner A, Carey EP, et al. Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge. JAMA Intern Med. 2014;174(2):186-193.

Edoxaban Is Noninferior to Warfarin in Patients with Atrial Fibrillation

Clinical question: What is the long-term efficacy and safety of edoxaban compared with warfarin in patients with atrial fibrillation (Afib)?

Background: Edoxaban is an oral factor Xa inhibitor approved for use in Japan for the prevention of venous thromboembolism after orthopedic surgery. No specific antidote for edoxaban exists, but hemostatic agents can reverse its anticoagulation effect.

Study design: RCT.

Setting: More than 1,300 centers in 46 countries.

Synopsis: Researchers randomized 21,105 patients in a 1:1:1 ratio to receive warfarin (goal INR of 2-3), low-dose edoxaban, or high-dose edoxoban. All patients received two sets of drugs, either active warfarin with placebo edoxaban or active edoxaban (high- or low-dose) and placebo warfarin (with sham INRs drawn), and were followed for a median of 2.8 years.

The annualized rate of stroke or systemic embolic event was 1.5% in the warfarin group, compared with 1.18% in the high-dose edoxaban group (hazard ratio 0.79; P<0.001) and 1.61% in the low-dose edoxaban group (hazard ratio 1.07; P=0.005). Annualized rate of major bleeding was 3.43% with warfarin, 2.75% with high-dose edoxoban (hazard ratio 0.80; P<0.001), and 1.61% with low-dose edoxaban (hazard ratio 0.47; P<0.001).

Both edoxaban regimens were noninferior to warfarin for the prevention of stroke or systemic emboli. The rates of cardiovascular events, bleeding, or death from any cause was lower with both doses of edoxaban as compared with warfarin.

Bottom line: Once-daily edoxaban is noninferior to warfarin for the prevention of stroke or systemic emboli and is associated with lower rates of bleeding and death.

Citation: Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. New Engl J Med. 2013;369(22):2093-2104.

Beta Blockers Lower Mortality after Acute Myocardial Infarction in COPD Patients

Clinical question: Does the use and timing of beta blockers in COPD patients experiencing a first myocardial infarction (MI) affect survival after the event?

Background: Beta blockers are effective in reducing mortality and reinfarction after an MI; however, concerns regarding the side effects of beta blockers, such as bronchospasm, continue to limit their use in patients with COPD.

Study design: Population-based cohort study.

Setting: The Myocardial Ischemia National Audit Project, linked to the General Practice Research Database, in the United Kingdom.

Synopsis: Researchers identified 1,063 patients over the age of 18 with COPD admitted to the hospital with a first acute MI. Use of beta blockers during hospitalization was associated with increased overall and one-year survival. Initiation of beta blockers during an MI had a mortality-adjusted hazard ratio of 0.50 (95% CI 0.36 to 0.69; P<0.001; median follow-up time=2.9 years).

Patients already on beta blockers prior to the MI had overall survival-adjusted hazard ratio of 0.59 (95% CI 0.44 to 0.79; P<0.001). Both scenarios showed survival benefits compared to COPD patients who were not prescribed beta blockers. Patients given beta blockers with COPD either during the MI hospitalization or before the event were younger and had fewer comorbidities. This may have accounted for some of the survival bias.

Bottom line: The use of beta blockers in patients with COPD started prior to, or at the time of, hospital admission for a first MI is associated with improved survival.

Citation: Quint JK, Herret E, Bhaskaran K, et al. Effect of ß blockers on mortality after myocardial infarction in adults with COPD: population-based cohort study of UK electronic healthcare records. BMJ. 2013;347:f6650.

Neither Low-Dose Dopamine nor Low-Dose Nesiritide Improves Renal Dysfunction in Acute Heart Failure Patients

Clinical question: Does low-dose dopamine or low-dose nesiritide added to diuretic therapy enhance pulmonary volume reduction and preserve renal function in patients with acute heart failure and renal dysfunction, compared to placebo?

Background: Small studies have suggested that low-dose dopamine or low-dose nesiritide may be beneficial in enhancing decongestion and improving renal dysfunction; however, there is ambiguity in overall benefit. Some observational studies suggest that dopamine and nesiritide are associated with higher length of stay, higher costs, and greater mortality.

Study Design: RCT.

Setting: Twenty-six hospital sites in the U.S. and Canada.

Synopsis: Three hundred sixty patients with acute heart failure and renal dysfunction were randomized to receive either nesiritide or dopamine within 24 hours of admission. Within each of these arms, patients were then randomized, in a double-blinded 2:1 fashion, into active treatment versus placebo groups. Treatment groups were compared to the pooled placebo groups.

Two main endpoints were urine output and change in serum cystatin C, from enrollment to 72 hours. Compared with placebo, low-dose dopamine had no significant effect on urine output or serum cystatin C level. Similarly, low-dose nesiritide had no significant effect on 72-hour urine output or serum cystatin C level.

Other studies have shown these drugs to be potentially harmful. Hospitalists should use caution and carefully interpret the relevant evidence when considering their use.

Bottom line: Neither low-dose nesiritide nor low-dose dopamine improved urine output or serum cystatin C levels at 72 hours in patients with acute heart failure and renal dysfunction.

Citation: Chen HH, Anstrom KJ, Givertz MM, et al. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction: The ROSE acute heart failure randomized trial. JAMA. 2013;310(23):2533-2543.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Facecards improve familiarity with physician names, not satisfaction
2. Pre-operative beta-blockers may benefit some cardiac patients
3. Benefit of therapeutic hypothermia after cardiac arrest unclear
4. Patients prefer inpatient boarding to ED boarding
5. Triple rule outs for chest pain
6. Colloids vs. crystalloids for critically ill patients presenting with hypovolemic shock
7. Interdisciplinary intervention improves medication compliance, not blood pressure or LDL-C levels
8. Edoxaban is noninferior to warfarin in Afib patients
9. Beta blockers lower mortality after acute MI in COPD patients
10. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction

Facecards Improve Familiarity with Physician Names but Not Satisfaction

Clinical question: Do facecards improve patients’ familiarity with physicians and increase satisfaction, trust, and agreement with physicians?

Background: Facecards can improve patients’ knowledge of names and roles of physicians, but their impact on other outcomes is unclear. This pilot trial was designed to assess facecards’ impact on patient satisfaction, trust, or agreement with physicians.

Study design: Cluster, randomized controlled trial (RCT).

Setting: A large teaching hospital in the United States.

Synopsis: Patients (n=138) were randomized to receive either facecards with the name and picture of their hospitalists, as well as a brief description of the hospitalist’s role (n=66), or to receive traditional communication (n=72). There were no significant differences in patient age, sex, or race.

Patients who received a facecard were more likely to correctly identify their hospital physician (89.1% vs. 51.1%; P< 0.01) and were more likely to correctly identify the role of their hospital physician than those in the control group (67.4% vs. 16.3%; P<0.01).

Patients who received a facecard rated satisfaction, trust, and agreement slightly higher compared with those who had not received a card, but the results were not statistically significant (P values 0.27, 0.32, 0.37, respectively.) The authors note that larger studies may be needed to see a difference in these areas.

Bottom line: Facecards improve patients’ knowledge of the names and roles of hospital physicians but have no clear impact on satisfaction with, trust of, or agreement with physicians.

Citation: Simons Y, Caprio T, Furiasse N, Kriss, M, Williams MV, O’Leary KJ. The impact of facecards on patients’ knowledge, satisfaction, trust, and agreement with hospitalist physicians: a pilot study. J Hosp Med. 2014;9(3):137-141.

Pre-Operative Beta Blockers May Benefit Some Cardiac Patients

Clinical question: In patients with ischemic heart disease (IHD) undergoing non-cardiac surgery, do pre-operative beta blockers reduce post-operative major cardiovascular events (MACE) or mortality at 30 days?

Background: Peri-operative beta blocker use has become more restricted, as evidence about which patients derive benefit has become clearer. Opinions and practice vary regarding whether all patients with IHD, or only certain populations within this group, benefit from peri-operative beta blockers.

Study design: Retrospective, national registry-based cohort study.

Setting: Denmark, 2004-2009.

Synopsis: No benefit was found for the overall cohort of 28,263 patients. Patients with IHD and heart failure (n=7990) had lower risk of MACE (HR=0.75, 95% CI, 0.70-0.87) and mortality (HR=0.80, 95% CI, 0.70-0.92). Patients with IHD and myocardial infarction within two years (n=1664) had lower risk of MACE (HR=0.54, 95% CI, 0.37-0.78) but not mortality.

Beta blocker dose and compliance were unknown. Whether patients had symptoms or inducible ischemia was not clear.

This study supports the concept that higher-risk patients benefit more from peri-operative beta blockers, but it is not high-grade evidence.

Bottom line: Not all patients with IHD benefit from pre-operative beta blockers; those with concomitant heart failure or recent MI have a lower risk of MACE and/or mortality at 30 days with beta blockers.

Citation: Andersson C, Merie C, Jorgensen M, et al. Association of ß-blocker therapy with risks of adverse cardiovascular events and deaths in patients with ischemic heart disease undergoing non-cardiac surgery: a Danish nationwide cohort study. JAMA Intern Med. 2014;174(3):336-344.

Benefit of Therapeutic Hypothermia after Cardiac Arrest Unclear

Clinical question: Does targeted hypothermia (33°C) after cardiac arrest confer benefits compared with targeted temperature management at 36°C?

Background: Therapeutic hypothermia is a current recommendation in resuscitation guidelines after cardiac arrest. Fever develops in many patients after arrest, and it is unclear if the treatment benefit is due to hypothermia or due to the prevention of fever.

Study design: RCT.

Setting: ICUs in Europe and Australia.

Synopsis: The study authors randomized 950 patients who experienced out-of-hospital cardiac arrest to targeted temperature management at either 36°C or 33°C. The goal of this trial was to prevent fever in both groups during the first 36 hours after cardiac arrest. No statistically significant difference in outcomes between these two approaches was found. In the 33°C group, 54% died or had poor neurologic function, compared with 52% in the 36°C group (risk ratio 1.02; 95% CI 0.88 to 1.16; P=0.78).

Given the wide confidence interval, a trial with either more participants or more events might be able to determine whether a true difference in these management approaches exists.

Bottom line: Therapeutic hypothermia at 33°C after out-of-hospital cardiac arrest did not confer a benefit compared with targeted temperature management at 36°C.

Citation: Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013;369(23):2197-2206.

Patients Prefer Inpatient Boarding to Emergency Department Boarding

Clinical question: Do patients who experience overcrowding and long waits in the emergency department (ED) prefer boarding within ED hallways or within inpatient medical unit hallways?

Background: Boarding of admitted patients in EDs can be problematic, especially with regard to patient safety and patient satisfaction. Patient satisfaction data comparing boarding in the ED versus boarding in an inpatient unit hallway is limited.

Study design: Post-discharge, structured, telephone satisfaction survey.

Setting: Suburban, university-based teaching hospital.

Synopsis: A group of patients who experienced hallway boarding in the ED and then hallway boarding on the inpatient medical unit were identified. They were contacted by phone and asked to take a survey on their experience; 105 of 110 patients identified agreed. Patients were asked to rate their location preference with regard to various aspects of care. A five-point Likert scale consisting of the following answers was used: ED hallway much better, ED hallway better, no preference, inpatient hallway better, and inpatient hallway much better.

The inpatient hallway was the overall preferred location in 85% of respondents. Respondents preferred inpatient boarding with regard to multiple other parameters: rest, 85%; safety, 83%; confidentiality, 82%; treatment, 78%; comfort, 79%; quiet, 84%; staff availability, 84%; and privacy, 84%. For no item was there a preference for boarding in the ED.

Patient demographics in this hospital may differ from other settings and should be considered when applying the results. With Hospital Consumer Assessment of Healthcare Providers and Systems scores and ED throughput being publicly reported, further studies in this area would be valuable.

Bottom line: In a post-discharge telephone survey, patients preferred boarding in inpatient unit hallways rather than boarding in the ED.

Citation: Viccellio P, Zito JA, Sayage V, et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. J Emerg Med. 2013;45(6):942-946.

“Triple Rule Outs” for Chest Pain: A Tool to Evaluate the Coronaries but Not Pulmonary Embolism or Aortic Dissection

Clinical question: How does “triple rule out” (TRO) computed tomographic (CT) angiography compare to other imaging modalities in evaluating coronary and other life-threatening etiologies of chest pain, such as pulmonary embolism (PE) and aortic dissection?

Background: TRO CT angiography is a noninvasive technology that evaluates the coronary arteries, thoracic aorta, and pulmonary vasculature simultaneously. Comparison with other tests in the diagnosis of common clinical conditions is useful information for clinical practice.

Study design: Systematic review and meta-analysis.

Setting: Systematic review of 11 studies (one randomized, 10 observational).

Synopsis: Using an enrolled population of 3,539 patients, TRO CT was compared to other imaging modalities on the basis of image quality, diagnostic accuracy, radiation, and contrast volume. When TRO CT was compared to dedicated CT scans, no significant imaging difference was discovered. TRO CT detected CAD with a sensitivity of 94.3% (95% CI, 89.1% to 97.5%, I2=58.2%) and specificity of 97.4% (95% CI, 96.1% to 98.5%, I2=91.2%).

An insufficient number of patients with PE or aortic dissection were studied to generate diagnostic accuracy for these conditions. TRO CT involved greater radiation exposure and contrast exposure than non-TRO CT.

This study reports high accuracy of TRO CT in the diagnosis of coronary artery disease. Due to the low prevalence of patients with PE or aortic dissection (<1%), the data cannot be extrapolated to these conditions.

Bottom line: Although TRO CT is highly accurate for detecting coronary artery disease, there is insufficient data to recommend its use for the diagnosis of PE or aortic dissection.

Citation: Ayaram D, Bellolio MF, Murad MH, et al. Triple rule-out computed tomographic angiography for chest pain: a diagnostic systematic review and meta-analysis. Acad Emerg Med. 2013;20(9):861-871.

Colloids vs. Crystalloids for Critically Ill Patients Presenting with Hypovolemic Shock

Clinical question: In critically ill patients admitted to the ICU with hypovolemic shock, does the use of colloid for fluid resuscitation, compared with crystalloid, improve mortality?

Background: The current Surviving Sepsis Campaign guidelines recommend crystalloids as the preferred fluid for resuscitation of patients with hypovolemic shock; however, evidence supporting the choice of intravenous colloid vs. crystalloid solutions for management of hypovolemic shock is weak.

Study design: RCT.

Setting: International, multi-center study.

Synopsis: Researchers randomized 2,857 adult patients who were admitted to an ICU and required fluid resuscitation for acute hypovolemia to receive either crystalloids or colloids.

At 28 days, there were 359 deaths (25.4%) in the colloids group vs. 390 deaths (27.0%) in the crystalloids group (P=0.26). At 90 days, there were 434 deaths (30.7%) in the colloids group vs. 493 deaths (34.2%) in the crystalloids group (P=0.03).

Renal replacement therapy was used in 11.0% of the colloids group vs. 12.5% of the crystalloids group (P=0.19). There were more days alive without mechanical ventilation in the colloids group vs. the crystalloids group at seven days (P=0.01) and at 28 days (P=0.01), and there were more days alive without vasopressor therapy in the colloids group vs. the crystalloids group at seven days (P=0.04) and at 28 days (P=0.03).

Major limitations of the study included the use of open-labeled fluids during allocation, so the initial investigators were not blinded to the type of fluid. Moreover, the study compared two therapeutic strategies (colloid vs. crystalloids) rather than two types of molecules.

Bottom line: In ICU patients with hypovolemia requiring resuscitation, the use of colloids vs. crystalloids did not result in a significant difference in 28-day mortality; however, 90-day mortality was lower among patients receiving colloids.

Citation: Annane D, Siami S, Jaber S, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality of critically ill patients presenting with hypovolemic shock: the CRISTAL randomization trial. JAMA. 2013;310(17):1809-1817.

Interdisciplinary Intervention Improves Medication Compliance, Not Blood Pressure or LDL-C Levels

Clinical question: Can intervention by pharmacists and physicians improve compliance to cardio-protective medications?

Background: Adherence to cardio-protective medications in the year after hospitalization for acute coronary syndrome is poor.

Study design: RCT.

Setting: Four Department of Veterans Affairs medical centers.

Synopsis: The intervention consisted of pharmacist-led medication reconciliation, patient education, pharmacist and PCP +/- cardiologist collaboration, and voice messaging. The outcome measured was the proportion of patients adherent to medication regimens based on a mean proportion of days covered (PDC) >0.80 in the year after discharge, using pharmacy refill data for clopidogrel, beta blockers, statins, and ACEI/ARBs.

Two hundred forty-one patients (95.3%) completed the study. In the intervention group, 89.3% of patients were adherent vs. 73.9% in the usual care group (P=0.003). Mean PDC was higher in the intervention group (0.94 vs. 0.87; P<0.001). A greater proportion of intervention patients were adherent to clopidogrel (86.8% vs. 70.7%; P=0.03), statins (93.2% vs. 71.3%; P<0.001), and ACEI/ARBs (93.1% vs. 81.7%; P=0.03), but not beta blockers (88.1% vs. 84.8%; P=0.59). There were no statistically significant differences in the proportion of patients who achieved blood pressure and LDL-C level goals.

Bottom line: An interdisciplinary, multi-faceted intervention increased medication compliance in the year after discharge for ACS but did not improve blood pressure or LDL-C levels.

Citation: Ho PM, Lambert-Kerzner A, Carey EP, et al. Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge. JAMA Intern Med. 2014;174(2):186-193.

Edoxaban Is Noninferior to Warfarin in Patients with Atrial Fibrillation

Clinical question: What is the long-term efficacy and safety of edoxaban compared with warfarin in patients with atrial fibrillation (Afib)?

Background: Edoxaban is an oral factor Xa inhibitor approved for use in Japan for the prevention of venous thromboembolism after orthopedic surgery. No specific antidote for edoxaban exists, but hemostatic agents can reverse its anticoagulation effect.

Study design: RCT.

Setting: More than 1,300 centers in 46 countries.

Synopsis: Researchers randomized 21,105 patients in a 1:1:1 ratio to receive warfarin (goal INR of 2-3), low-dose edoxaban, or high-dose edoxoban. All patients received two sets of drugs, either active warfarin with placebo edoxaban or active edoxaban (high- or low-dose) and placebo warfarin (with sham INRs drawn), and were followed for a median of 2.8 years.

The annualized rate of stroke or systemic embolic event was 1.5% in the warfarin group, compared with 1.18% in the high-dose edoxaban group (hazard ratio 0.79; P<0.001) and 1.61% in the low-dose edoxaban group (hazard ratio 1.07; P=0.005). Annualized rate of major bleeding was 3.43% with warfarin, 2.75% with high-dose edoxoban (hazard ratio 0.80; P<0.001), and 1.61% with low-dose edoxaban (hazard ratio 0.47; P<0.001).

Both edoxaban regimens were noninferior to warfarin for the prevention of stroke or systemic emboli. The rates of cardiovascular events, bleeding, or death from any cause was lower with both doses of edoxaban as compared with warfarin.

Bottom line: Once-daily edoxaban is noninferior to warfarin for the prevention of stroke or systemic emboli and is associated with lower rates of bleeding and death.

Citation: Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. New Engl J Med. 2013;369(22):2093-2104.

Beta Blockers Lower Mortality after Acute Myocardial Infarction in COPD Patients

Clinical question: Does the use and timing of beta blockers in COPD patients experiencing a first myocardial infarction (MI) affect survival after the event?

Background: Beta blockers are effective in reducing mortality and reinfarction after an MI; however, concerns regarding the side effects of beta blockers, such as bronchospasm, continue to limit their use in patients with COPD.

Study design: Population-based cohort study.

Setting: The Myocardial Ischemia National Audit Project, linked to the General Practice Research Database, in the United Kingdom.

Synopsis: Researchers identified 1,063 patients over the age of 18 with COPD admitted to the hospital with a first acute MI. Use of beta blockers during hospitalization was associated with increased overall and one-year survival. Initiation of beta blockers during an MI had a mortality-adjusted hazard ratio of 0.50 (95% CI 0.36 to 0.69; P<0.001; median follow-up time=2.9 years).

Patients already on beta blockers prior to the MI had overall survival-adjusted hazard ratio of 0.59 (95% CI 0.44 to 0.79; P<0.001). Both scenarios showed survival benefits compared to COPD patients who were not prescribed beta blockers. Patients given beta blockers with COPD either during the MI hospitalization or before the event were younger and had fewer comorbidities. This may have accounted for some of the survival bias.

Bottom line: The use of beta blockers in patients with COPD started prior to, or at the time of, hospital admission for a first MI is associated with improved survival.

Citation: Quint JK, Herret E, Bhaskaran K, et al. Effect of ß blockers on mortality after myocardial infarction in adults with COPD: population-based cohort study of UK electronic healthcare records. BMJ. 2013;347:f6650.

Neither Low-Dose Dopamine nor Low-Dose Nesiritide Improves Renal Dysfunction in Acute Heart Failure Patients

Clinical question: Does low-dose dopamine or low-dose nesiritide added to diuretic therapy enhance pulmonary volume reduction and preserve renal function in patients with acute heart failure and renal dysfunction, compared to placebo?

Background: Small studies have suggested that low-dose dopamine or low-dose nesiritide may be beneficial in enhancing decongestion and improving renal dysfunction; however, there is ambiguity in overall benefit. Some observational studies suggest that dopamine and nesiritide are associated with higher length of stay, higher costs, and greater mortality.

Study Design: RCT.

Setting: Twenty-six hospital sites in the U.S. and Canada.

Synopsis: Three hundred sixty patients with acute heart failure and renal dysfunction were randomized to receive either nesiritide or dopamine within 24 hours of admission. Within each of these arms, patients were then randomized, in a double-blinded 2:1 fashion, into active treatment versus placebo groups. Treatment groups were compared to the pooled placebo groups.

Two main endpoints were urine output and change in serum cystatin C, from enrollment to 72 hours. Compared with placebo, low-dose dopamine had no significant effect on urine output or serum cystatin C level. Similarly, low-dose nesiritide had no significant effect on 72-hour urine output or serum cystatin C level.

Other studies have shown these drugs to be potentially harmful. Hospitalists should use caution and carefully interpret the relevant evidence when considering their use.

Bottom line: Neither low-dose nesiritide nor low-dose dopamine improved urine output or serum cystatin C levels at 72 hours in patients with acute heart failure and renal dysfunction.

Citation: Chen HH, Anstrom KJ, Givertz MM, et al. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction: The ROSE acute heart failure randomized trial. JAMA. 2013;310(23):2533-2543.

Concern about Copper’s Effectiveness in Preventing Hospital-Acquired Infections

As public knowledge about the benefits of antimicrobial copper touch surfaces in healthcare facilities continues to grow, questions about this tool naturally arise. Can this copper surface really continuously kill up to 83% of bacteria it comes in contact with? Can it really reduce patient infections by more than half? Can this metal really keep people safer? The answer is “yes,” as has been reported in the Journal of Infection Control, in Hospital Epidemiology, and in the Journal of Clinical Microbiology.

In his “Letter to the Editor (“Concern about Copper’s Effectiveness in Preventing Hospital-Acquired Infections,” November 2013), Dr. Rod Duraski voices cautions about human sensitivity to copper—noting that implanted copper-nickel alloy devices have the potential for severe allergic reactions; however, implanted devices are not part of the EPA-approved products list of antimicrobial copper and, therefore, are not being proposed for use in the fight against hospital infections. Although some patients might experience sensitivity to jewelry, zippers, or buttons, if made from nickel-containing copper alloys, these reactions will be the result of prolonged skin contact, and when removed, the sensitivity will dissipate. The touch-surface components proposed in Karen Appold’s story, “Copper,” (September 2013) come into very brief and intermittent contact with the skin. And, sensitivities are not life-threatening; hospital-acquired infections are.

In fact, three of the four major coin denominations (nickel, dime, quarter) are made from copper-nickel alloys. If these metals are suitable for the everyday exposure we all experience with coinage, they are just as safe when it comes to touch surface components in hospitals. In many instances, the benefits of copper outweigh the relative risk of a rash caused by nickel sensitivity.

Like any surface, copper alloys should be cleaned regularly—especially in hospitals. Copper alloys are compatible with all hospital grade cleaners and disinfectants when the cleaners are used according to manufacturer label instructions. But more importantly, the antimicrobial effect of this metal is not inhibited if the surfaces tarnish. In 2005, a study (www.antimicrobialcopper.com/media/69850/infectious_disease.pdf) found tarnish to be a non-issue when researchers tested the bacterial load on three separate copper alloys, all of which had developed tarnish over time. Additionally, manufacturers are offering components made from tarnish-resistant alloys.

—Harold Michels, PhD, senior vice president of technology and technical services, Copper Development Association, Inc.

Correction: April 4, 2014

A version of this article appeared in print in the April 2014 issue of The Hospitalist. Changes have since been made to the online article per the request of the author.

Concern about Copper’s Effectiveness in Preventing Hospital-Acquired Infections

As public knowledge about the benefits of antimicrobial copper touch surfaces in healthcare facilities continues to grow, questions about this tool naturally arise. Can this copper surface really continuously kill up to 83% of bacteria it comes in contact with? Can it really reduce patient infections by more than half? Can this metal really keep people safer? The answer is “yes,” as has been reported in the Journal of Infection Control, in Hospital Epidemiology, and in the Journal of Clinical Microbiology.

In his “Letter to the Editor (“Concern about Copper’s Effectiveness in Preventing Hospital-Acquired Infections,” November 2013), Dr. Rod Duraski voices cautions about human sensitivity to copper—noting that implanted copper-nickel alloy devices have the potential for severe allergic reactions; however, implanted devices are not part of the EPA-approved products list of antimicrobial copper and, therefore, are not being proposed for use in the fight against hospital infections. Although some patients might experience sensitivity to jewelry, zippers, or buttons, if made from nickel-containing copper alloys, these reactions will be the result of prolonged skin contact, and when removed, the sensitivity will dissipate. The touch-surface components proposed in Karen Appold’s story, “Copper,” (September 2013) come into very brief and intermittent contact with the skin. And, sensitivities are not life-threatening; hospital-acquired infections are.

In fact, three of the four major coin denominations (nickel, dime, quarter) are made from copper-nickel alloys. If these metals are suitable for the everyday exposure we all experience with coinage, they are just as safe when it comes to touch surface components in hospitals. In many instances, the benefits of copper outweigh the relative risk of a rash caused by nickel sensitivity.

Like any surface, copper alloys should be cleaned regularly—especially in hospitals. Copper alloys are compatible with all hospital grade cleaners and disinfectants when the cleaners are used according to manufacturer label instructions. But more importantly, the antimicrobial effect of this metal is not inhibited if the surfaces tarnish. In 2005, a study (www.antimicrobialcopper.com/media/69850/infectious_disease.pdf) found tarnish to be a non-issue when researchers tested the bacterial load on three separate copper alloys, all of which had developed tarnish over time. Additionally, manufacturers are offering components made from tarnish-resistant alloys.

—Harold Michels, PhD, senior vice president of technology and technical services, Copper Development Association, Inc.

Correction: April 4, 2014

A version of this article appeared in print in the April 2014 issue of The Hospitalist. Changes have since been made to the online article per the request of the author.

Concern about Copper’s Effectiveness in Preventing Hospital-Acquired Infections

As public knowledge about the benefits of antimicrobial copper touch surfaces in healthcare facilities continues to grow, questions about this tool naturally arise. Can this copper surface really continuously kill up to 83% of bacteria it comes in contact with? Can it really reduce patient infections by more than half? Can this metal really keep people safer? The answer is “yes,” as has been reported in the Journal of Infection Control, in Hospital Epidemiology, and in the Journal of Clinical Microbiology.

In his “Letter to the Editor (“Concern about Copper’s Effectiveness in Preventing Hospital-Acquired Infections,” November 2013), Dr. Rod Duraski voices cautions about human sensitivity to copper—noting that implanted copper-nickel alloy devices have the potential for severe allergic reactions; however, implanted devices are not part of the EPA-approved products list of antimicrobial copper and, therefore, are not being proposed for use in the fight against hospital infections. Although some patients might experience sensitivity to jewelry, zippers, or buttons, if made from nickel-containing copper alloys, these reactions will be the result of prolonged skin contact, and when removed, the sensitivity will dissipate. The touch-surface components proposed in Karen Appold’s story, “Copper,” (September 2013) come into very brief and intermittent contact with the skin. And, sensitivities are not life-threatening; hospital-acquired infections are.

In fact, three of the four major coin denominations (nickel, dime, quarter) are made from copper-nickel alloys. If these metals are suitable for the everyday exposure we all experience with coinage, they are just as safe when it comes to touch surface components in hospitals. In many instances, the benefits of copper outweigh the relative risk of a rash caused by nickel sensitivity.

Like any surface, copper alloys should be cleaned regularly—especially in hospitals. Copper alloys are compatible with all hospital grade cleaners and disinfectants when the cleaners are used according to manufacturer label instructions. But more importantly, the antimicrobial effect of this metal is not inhibited if the surfaces tarnish. In 2005, a study (www.antimicrobialcopper.com/media/69850/infectious_disease.pdf) found tarnish to be a non-issue when researchers tested the bacterial load on three separate copper alloys, all of which had developed tarnish over time. Additionally, manufacturers are offering components made from tarnish-resistant alloys.

—Harold Michels, PhD, senior vice president of technology and technical services, Copper Development Association, Inc.

Correction: April 4, 2014

A version of this article appeared in print in the April 2014 issue of The Hospitalist. Changes have since been made to the online article per the request of the author.

A new rule issued by the Centers for Medicare & Medicaid Services (CMS) is at the center of controversy fueled by competing interests and lack of clarity. And, for the fourth time since the two-midnight rule was introduced in the 2014 Hospital Inpatient Prospective Payment System, its implementation has been delayed. Hospitals and providers have until March 31, 2015, before auditors begin scrutinizing patient admission statuses for reimbursement determination.

The rule requires Medicare and Medicaid patients spending fewer than two midnights receiving hospital care to be classified as outpatient or under observation. Patients spending more than two midnights will be considered inpatient. Only physicians can make the determination, and the clock begins ticking the moment care begins.

The rule also cuts hospital inpatient reimbursement by 0.2%, because CMS believes the number of inpatient admissions will increase.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.”

–Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association

The rule pits private Medicare auditors (Medicare Administrative Contractors, MACs, and Recovery Audit Contractors, RACs), who have a financial stake in denying inpatient claims, against hospitals and physicians. It does little to clear confusion for patients when it comes time for them to pay their bills.

Patients generally are unaware whether they’ve been admitted or are under observation. But observation status leaves them on the hook for any skilled nursing care they receive following discharge and for the costs of routine maintenance drugs hospitals give them for chronic conditions.

Beneficiaries also are not eligible for Medicare Part A skilled nursing care coverage if they were an inpatient for fewer than 72 hours, and observation days do not count toward the three-day requirement. The two-midnight rule adds another “layer” to the equation, says Bradley Flansbaum, DO, MPH, FACP, a hospitalist and clinical assistant professor of medicine at NYU School of Medicine in New York City.

At the same time, hospitals now face penalties for patients readmitted within 30 days of discharge for a similar episode of care. Observation status offers a measure of protection in the event patients return.

The number of observation patients increased 69% between 2006 and 2011, according to federal data cited by Kaiser Health News, and the number of observation patients staying more than 48 hours increased from 3% to 8% during this same period.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed,” says Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.

“We feel time should not be the only factor taken into account,” Hiatt Kim adds. “It should be a decision a physician reaches based on a patient’s condition.”

Good Intentions

The rule states that hospital stays fewer than two midnights are generally medically inappropriate for inpatient designation. The services provided are not at issue, but CMS believes those administered during a short stay could be provided on a less expensive outpatient basis.

Dr. Flansbaum, a member of SHM’s Public Policy Committee, says the language of medical necessity that designates status is unclear, though CMS has given physicians the benefit of the doubt.

“We are looking for clear signals from providers for how we determine when someone is appropriately inpatient and when they’re observation,” he explains.

Although medical needs can be quantified, there are often other, nonmedical factors that put patients at risk and influence when and whether a patient is admitted. Physicians routinely weigh these factors on behalf of their patients.

“Risk isn’t necessarily implied by just a dangerous blood value,” Dr. Flansbaum says. “If something is not right in the transition zone or in the community, I think those [factors] need to be taken into account.”

Physicians are being given “a lot of latitude” in CMS’ new rule, he notes.

Clarification

In recent clarification, CMS highlighted exceptions to the rule. If “unforeseen circumstances” shorten the anticipated stay of someone initially deemed inpatient—transfer to another hospital, death, or clinical improvement in fewer than two midnights, for example—CMS can advise auditors to approve the inpatient claim.

Additionally, CMS will maintain a list of services considered “inpatient only,” regardless of stay duration.

But creating a list of every medically necessary service is an “administrative black hole,” says Dr. Flansbaum, though he believes that with enough time and clarity, compliance with the two-midnight rule is possible.

Kelly April Tyrrell is a freelance writer in Wilmington, Del.

A new rule issued by the Centers for Medicare & Medicaid Services (CMS) is at the center of controversy fueled by competing interests and lack of clarity. And, for the fourth time since the two-midnight rule was introduced in the 2014 Hospital Inpatient Prospective Payment System, its implementation has been delayed. Hospitals and providers have until March 31, 2015, before auditors begin scrutinizing patient admission statuses for reimbursement determination.

The rule requires Medicare and Medicaid patients spending fewer than two midnights receiving hospital care to be classified as outpatient or under observation. Patients spending more than two midnights will be considered inpatient. Only physicians can make the determination, and the clock begins ticking the moment care begins.

The rule also cuts hospital inpatient reimbursement by 0.2%, because CMS believes the number of inpatient admissions will increase.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.”

–Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association

The rule pits private Medicare auditors (Medicare Administrative Contractors, MACs, and Recovery Audit Contractors, RACs), who have a financial stake in denying inpatient claims, against hospitals and physicians. It does little to clear confusion for patients when it comes time for them to pay their bills.

Patients generally are unaware whether they’ve been admitted or are under observation. But observation status leaves them on the hook for any skilled nursing care they receive following discharge and for the costs of routine maintenance drugs hospitals give them for chronic conditions.

Beneficiaries also are not eligible for Medicare Part A skilled nursing care coverage if they were an inpatient for fewer than 72 hours, and observation days do not count toward the three-day requirement. The two-midnight rule adds another “layer” to the equation, says Bradley Flansbaum, DO, MPH, FACP, a hospitalist and clinical assistant professor of medicine at NYU School of Medicine in New York City.

At the same time, hospitals now face penalties for patients readmitted within 30 days of discharge for a similar episode of care. Observation status offers a measure of protection in the event patients return.

The number of observation patients increased 69% between 2006 and 2011, according to federal data cited by Kaiser Health News, and the number of observation patients staying more than 48 hours increased from 3% to 8% during this same period.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed,” says Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.

“We feel time should not be the only factor taken into account,” Hiatt Kim adds. “It should be a decision a physician reaches based on a patient’s condition.”

Good Intentions

The rule states that hospital stays fewer than two midnights are generally medically inappropriate for inpatient designation. The services provided are not at issue, but CMS believes those administered during a short stay could be provided on a less expensive outpatient basis.

Dr. Flansbaum, a member of SHM’s Public Policy Committee, says the language of medical necessity that designates status is unclear, though CMS has given physicians the benefit of the doubt.

“We are looking for clear signals from providers for how we determine when someone is appropriately inpatient and when they’re observation,” he explains.

Although medical needs can be quantified, there are often other, nonmedical factors that put patients at risk and influence when and whether a patient is admitted. Physicians routinely weigh these factors on behalf of their patients.

“Risk isn’t necessarily implied by just a dangerous blood value,” Dr. Flansbaum says. “If something is not right in the transition zone or in the community, I think those [factors] need to be taken into account.”

Physicians are being given “a lot of latitude” in CMS’ new rule, he notes.

Clarification

In recent clarification, CMS highlighted exceptions to the rule. If “unforeseen circumstances” shorten the anticipated stay of someone initially deemed inpatient—transfer to another hospital, death, or clinical improvement in fewer than two midnights, for example—CMS can advise auditors to approve the inpatient claim.

Additionally, CMS will maintain a list of services considered “inpatient only,” regardless of stay duration.

But creating a list of every medically necessary service is an “administrative black hole,” says Dr. Flansbaum, though he believes that with enough time and clarity, compliance with the two-midnight rule is possible.

Kelly April Tyrrell is a freelance writer in Wilmington, Del.

A new rule issued by the Centers for Medicare & Medicaid Services (CMS) is at the center of controversy fueled by competing interests and lack of clarity. And, for the fourth time since the two-midnight rule was introduced in the 2014 Hospital Inpatient Prospective Payment System, its implementation has been delayed. Hospitals and providers have until March 31, 2015, before auditors begin scrutinizing patient admission statuses for reimbursement determination.

The rule requires Medicare and Medicaid patients spending fewer than two midnights receiving hospital care to be classified as outpatient or under observation. Patients spending more than two midnights will be considered inpatient. Only physicians can make the determination, and the clock begins ticking the moment care begins.

The rule also cuts hospital inpatient reimbursement by 0.2%, because CMS believes the number of inpatient admissions will increase.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.”

–Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association

The rule pits private Medicare auditors (Medicare Administrative Contractors, MACs, and Recovery Audit Contractors, RACs), who have a financial stake in denying inpatient claims, against hospitals and physicians. It does little to clear confusion for patients when it comes time for them to pay their bills.

Patients generally are unaware whether they’ve been admitted or are under observation. But observation status leaves them on the hook for any skilled nursing care they receive following discharge and for the costs of routine maintenance drugs hospitals give them for chronic conditions.

Beneficiaries also are not eligible for Medicare Part A skilled nursing care coverage if they were an inpatient for fewer than 72 hours, and observation days do not count toward the three-day requirement. The two-midnight rule adds another “layer” to the equation, says Bradley Flansbaum, DO, MPH, FACP, a hospitalist and clinical assistant professor of medicine at NYU School of Medicine in New York City.

At the same time, hospitals now face penalties for patients readmitted within 30 days of discharge for a similar episode of care. Observation status offers a measure of protection in the event patients return.

The number of observation patients increased 69% between 2006 and 2011, according to federal data cited by Kaiser Health News, and the number of observation patients staying more than 48 hours increased from 3% to 8% during this same period.

“The concern is that [the two-midnight rule] sets an arbitrary time threshold that dictates where a patient should be placed,” says Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association. The AHA opposes aspects of the rule and was involved in legislation to delay implementation.

“We feel time should not be the only factor taken into account,” Hiatt Kim adds. “It should be a decision a physician reaches based on a patient’s condition.”

Good Intentions

The rule states that hospital stays fewer than two midnights are generally medically inappropriate for inpatient designation. The services provided are not at issue, but CMS believes those administered during a short stay could be provided on a less expensive outpatient basis.

Dr. Flansbaum, a member of SHM’s Public Policy Committee, says the language of medical necessity that designates status is unclear, though CMS has given physicians the benefit of the doubt.

“We are looking for clear signals from providers for how we determine when someone is appropriately inpatient and when they’re observation,” he explains.

Although medical needs can be quantified, there are often other, nonmedical factors that put patients at risk and influence when and whether a patient is admitted. Physicians routinely weigh these factors on behalf of their patients.

“Risk isn’t necessarily implied by just a dangerous blood value,” Dr. Flansbaum says. “If something is not right in the transition zone or in the community, I think those [factors] need to be taken into account.”

Physicians are being given “a lot of latitude” in CMS’ new rule, he notes.

Clarification

In recent clarification, CMS highlighted exceptions to the rule. If “unforeseen circumstances” shorten the anticipated stay of someone initially deemed inpatient—transfer to another hospital, death, or clinical improvement in fewer than two midnights, for example—CMS can advise auditors to approve the inpatient claim.

Additionally, CMS will maintain a list of services considered “inpatient only,” regardless of stay duration.

But creating a list of every medically necessary service is an “administrative black hole,” says Dr. Flansbaum, though he believes that with enough time and clarity, compliance with the two-midnight rule is possible.

Kelly April Tyrrell is a freelance writer in Wilmington, Del.

LAS VEGAS – Now that you're here, focus on the valuable opportunities that HM14 offers. Well, until dusk. Then get out of the hotel and focus on the opportunities that are Las Vegas.

The fun isn't just the famed Strip, says Zubin Damania, MD, founder of Turntable Health in Las Vegas, who might be better known for his comedic alter ego, ZDoggMD. It's the lesser-known side of Las Vegas, known locally as "downtown."

"When I have friends in town, I tell them not to go to the Strip and to come hang out with me downtown or in the suburbs of Vegas—where the real fun is to be had," says Dr. Damania, even though he realizes he can't tell that to 3,000 "rabid hospitalists looking to relive 'The Hangover 3.'"

His recommendations include:

• Chinatown. The district is along Spring Mountain Road, about four miles north of Mandalay Bay, and includes several enclosed shopping malls. Restaurants to try include Raku, which specializes in Japanese food, and Kabuto, which has "the best sushi" ZDoggMD's ever had.




• Red Rock Canyon National Conservation Area. Breathtaking views and hiking opportunities abound in natural Nevada.




• The Zappos factory. A tour of the firm’s downtown headquarters showcases the mindset of the millennial generation and potential lessons on workplace attitude that can be applied to HM.




• Turntable Health. Dr. Damania’s clinic is open to any hospitalists curious to visit. If you want to set up a tour, or want more personalized advice on what to do while in town, e-mail him at [email protected].

Visit our website for more of ZDoggMD's recommendations.

LAS VEGAS – Now that you're here, focus on the valuable opportunities that HM14 offers. Well, until dusk. Then get out of the hotel and focus on the opportunities that are Las Vegas.

The fun isn't just the famed Strip, says Zubin Damania, MD, founder of Turntable Health in Las Vegas, who might be better known for his comedic alter ego, ZDoggMD. It's the lesser-known side of Las Vegas, known locally as "downtown."

"When I have friends in town, I tell them not to go to the Strip and to come hang out with me downtown or in the suburbs of Vegas—where the real fun is to be had," says Dr. Damania, even though he realizes he can't tell that to 3,000 "rabid hospitalists looking to relive 'The Hangover 3.'"

His recommendations include:

• Chinatown. The district is along Spring Mountain Road, about four miles north of Mandalay Bay, and includes several enclosed shopping malls. Restaurants to try include Raku, which specializes in Japanese food, and Kabuto, which has "the best sushi" ZDoggMD's ever had.




• Red Rock Canyon National Conservation Area. Breathtaking views and hiking opportunities abound in natural Nevada.




• The Zappos factory. A tour of the firm’s downtown headquarters showcases the mindset of the millennial generation and potential lessons on workplace attitude that can be applied to HM.




• Turntable Health. Dr. Damania’s clinic is open to any hospitalists curious to visit. If you want to set up a tour, or want more personalized advice on what to do while in town, e-mail him at [email protected].

Visit our website for more of ZDoggMD's recommendations.

LAS VEGAS – Now that you're here, focus on the valuable opportunities that HM14 offers. Well, until dusk. Then get out of the hotel and focus on the opportunities that are Las Vegas.

The fun isn't just the famed Strip, says Zubin Damania, MD, founder of Turntable Health in Las Vegas, who might be better known for his comedic alter ego, ZDoggMD. It's the lesser-known side of Las Vegas, known locally as "downtown."

"When I have friends in town, I tell them not to go to the Strip and to come hang out with me downtown or in the suburbs of Vegas—where the real fun is to be had," says Dr. Damania, even though he realizes he can't tell that to 3,000 "rabid hospitalists looking to relive 'The Hangover 3.'"

His recommendations include:

• Chinatown. The district is along Spring Mountain Road, about four miles north of Mandalay Bay, and includes several enclosed shopping malls. Restaurants to try include Raku, which specializes in Japanese food, and Kabuto, which has "the best sushi" ZDoggMD's ever had.




• Red Rock Canyon National Conservation Area. Breathtaking views and hiking opportunities abound in natural Nevada.




• The Zappos factory. A tour of the firm’s downtown headquarters showcases the mindset of the millennial generation and potential lessons on workplace attitude that can be applied to HM.




• Turntable Health. Dr. Damania’s clinic is open to any hospitalists curious to visit. If you want to set up a tour, or want more personalized advice on what to do while in town, e-mail him at [email protected].

Visit our website for more of ZDoggMD's recommendations.

Hospitalist Vincent DeGennaro, Jr., MD, MPH, didn’t train as an oncologist. But during the course of his daily duties at the Hospital Bernard Mevs in Port-au-Prince, Haiti, he administers chemotherapy at the hospital’s women’s cancer center.

“Chemotherapy was outside the realm of my specialty, but under the training and remote consultation of U.S. oncologists, I have become more comfortable with it,” says Dr. DeGennaro, an assistant professor in the division of hospital medicine at the University of Florida College of Medicine in Gainesville. Along with performing echocardiograms and working in Haiti’s only ICU, it’s an example of how global health forces him to be a “true generalist.” That’s also true of hospital medicine. In fact, the flexible schedule hospital medicine offers was a deciding factor in his career choice. Shift work in a discrete time period would allow him, he reasoned, to also follow his passion of global health.

Volunteering in low-resource settings was something that “felt right to me from the beginning,” Dr. DeGennaro says. He worked in Honduras and the Dominican Republic during medical school, mostly through medical missions organizations. Work with Partners in Health during medical school and in Rwanda after residency exposed him to the capacity-building goals of that organization. He now spends seven months of the academic year in Haiti, where he is helping Project Medishare (www.projectmedishare.org) in its efforts to build capacity and infrastructure at the country’s major trauma hospital. In July, he will be supervising clinical fellows as the director of the University of Florida’s first HM global health fellowship program.

Haitian patients have to pay for their own tests, so Dr. DeGennaro must carefully choose those that will guide his management decisions for patients. “Low-resource utilization forces you to become a better clinician,” he says. “I think we have gotten intellectually lazy in the United States, where we can order a dozen tests and let the results guide us instead of using our clinical skills to narrow what tests to order.”

Delivering care in under-resourced countries, he adds, has changed him: “I’m a much better doctor for it.”

Gretchen Henkel is a freelance writer in California.

Hospitalist Vincent DeGennaro, Jr., MD, MPH, didn’t train as an oncologist. But during the course of his daily duties at the Hospital Bernard Mevs in Port-au-Prince, Haiti, he administers chemotherapy at the hospital’s women’s cancer center.

“Chemotherapy was outside the realm of my specialty, but under the training and remote consultation of U.S. oncologists, I have become more comfortable with it,” says Dr. DeGennaro, an assistant professor in the division of hospital medicine at the University of Florida College of Medicine in Gainesville. Along with performing echocardiograms and working in Haiti’s only ICU, it’s an example of how global health forces him to be a “true generalist.” That’s also true of hospital medicine. In fact, the flexible schedule hospital medicine offers was a deciding factor in his career choice. Shift work in a discrete time period would allow him, he reasoned, to also follow his passion of global health.

Volunteering in low-resource settings was something that “felt right to me from the beginning,” Dr. DeGennaro says. He worked in Honduras and the Dominican Republic during medical school, mostly through medical missions organizations. Work with Partners in Health during medical school and in Rwanda after residency exposed him to the capacity-building goals of that organization. He now spends seven months of the academic year in Haiti, where he is helping Project Medishare (www.projectmedishare.org) in its efforts to build capacity and infrastructure at the country’s major trauma hospital. In July, he will be supervising clinical fellows as the director of the University of Florida’s first HM global health fellowship program.

Haitian patients have to pay for their own tests, so Dr. DeGennaro must carefully choose those that will guide his management decisions for patients. “Low-resource utilization forces you to become a better clinician,” he says. “I think we have gotten intellectually lazy in the United States, where we can order a dozen tests and let the results guide us instead of using our clinical skills to narrow what tests to order.”

Delivering care in under-resourced countries, he adds, has changed him: “I’m a much better doctor for it.”

Gretchen Henkel is a freelance writer in California.

Hospitalist Vincent DeGennaro, Jr., MD, MPH, didn’t train as an oncologist. But during the course of his daily duties at the Hospital Bernard Mevs in Port-au-Prince, Haiti, he administers chemotherapy at the hospital’s women’s cancer center.

“Chemotherapy was outside the realm of my specialty, but under the training and remote consultation of U.S. oncologists, I have become more comfortable with it,” says Dr. DeGennaro, an assistant professor in the division of hospital medicine at the University of Florida College of Medicine in Gainesville. Along with performing echocardiograms and working in Haiti’s only ICU, it’s an example of how global health forces him to be a “true generalist.” That’s also true of hospital medicine. In fact, the flexible schedule hospital medicine offers was a deciding factor in his career choice. Shift work in a discrete time period would allow him, he reasoned, to also follow his passion of global health.

Volunteering in low-resource settings was something that “felt right to me from the beginning,” Dr. DeGennaro says. He worked in Honduras and the Dominican Republic during medical school, mostly through medical missions organizations. Work with Partners in Health during medical school and in Rwanda after residency exposed him to the capacity-building goals of that organization. He now spends seven months of the academic year in Haiti, where he is helping Project Medishare (www.projectmedishare.org) in its efforts to build capacity and infrastructure at the country’s major trauma hospital. In July, he will be supervising clinical fellows as the director of the University of Florida’s first HM global health fellowship program.

Haitian patients have to pay for their own tests, so Dr. DeGennaro must carefully choose those that will guide his management decisions for patients. “Low-resource utilization forces you to become a better clinician,” he says. “I think we have gotten intellectually lazy in the United States, where we can order a dozen tests and let the results guide us instead of using our clinical skills to narrow what tests to order.”

Delivering care in under-resourced countries, he adds, has changed him: “I’m a much better doctor for it.”

Gretchen Henkel is a freelance writer in California.