Clinical

Clinical question: Do programs that systematically provide smoking cessation support to admitted patients improve smoking cessation rates?

Background: Hospitalization is a good setting for initiation of smoking cessation. It is well known that conventional behavioral and pharmacotherapy interventions are effective. Intensive behavioral intervention provided to willing hospitalized patients is known to be useful; however, there is no established systematic delivery of these interventions.

Study design: Open, cluster-randomized, controlled trial.

Setting: Acute medical wards in a large teaching hospital in the United Kingdom.

Synopsis: More than 1,000 patients admitted between October 2010 and August 2011 were eligible for the study, of which 264 were included in the intervention and 229 in the usual care group (determination of smoking status and non-obligatory offer of cessation support). All of those in intervention received advice to quit smoking, compared to only 46% in the usual care group. Four-week smoking cessation was achieved by 38% of patients from the intervention group, compared to 17% from the usual care group. Secondary outcomes (use of behavioral cessation support, pharmacotherapy, and referral to and use of the local stop smoking service) were all significantly higher in the intervention group compared to the usual care group (P<0.001 in all cases).

This study shows that simple measures, when systematically delivered, are effective in initiating smoking cessation.

Bottom line: In-hospital systematic delivery of smoking cessation strategies is effective.

Citation: Murray RL, Leonardi-Bee J, Marsh J, et al. Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial. BMJ. 2013;347:f4004.

Clinical question: Do programs that systematically provide smoking cessation support to admitted patients improve smoking cessation rates?

Background: Hospitalization is a good setting for initiation of smoking cessation. It is well known that conventional behavioral and pharmacotherapy interventions are effective. Intensive behavioral intervention provided to willing hospitalized patients is known to be useful; however, there is no established systematic delivery of these interventions.

Study design: Open, cluster-randomized, controlled trial.

Setting: Acute medical wards in a large teaching hospital in the United Kingdom.

Synopsis: More than 1,000 patients admitted between October 2010 and August 2011 were eligible for the study, of which 264 were included in the intervention and 229 in the usual care group (determination of smoking status and non-obligatory offer of cessation support). All of those in intervention received advice to quit smoking, compared to only 46% in the usual care group. Four-week smoking cessation was achieved by 38% of patients from the intervention group, compared to 17% from the usual care group. Secondary outcomes (use of behavioral cessation support, pharmacotherapy, and referral to and use of the local stop smoking service) were all significantly higher in the intervention group compared to the usual care group (P<0.001 in all cases).

This study shows that simple measures, when systematically delivered, are effective in initiating smoking cessation.

Bottom line: In-hospital systematic delivery of smoking cessation strategies is effective.

Citation: Murray RL, Leonardi-Bee J, Marsh J, et al. Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial. BMJ. 2013;347:f4004.

Clinical question: Do programs that systematically provide smoking cessation support to admitted patients improve smoking cessation rates?

Background: Hospitalization is a good setting for initiation of smoking cessation. It is well known that conventional behavioral and pharmacotherapy interventions are effective. Intensive behavioral intervention provided to willing hospitalized patients is known to be useful; however, there is no established systematic delivery of these interventions.

Study design: Open, cluster-randomized, controlled trial.

Setting: Acute medical wards in a large teaching hospital in the United Kingdom.

Synopsis: More than 1,000 patients admitted between October 2010 and August 2011 were eligible for the study, of which 264 were included in the intervention and 229 in the usual care group (determination of smoking status and non-obligatory offer of cessation support). All of those in intervention received advice to quit smoking, compared to only 46% in the usual care group. Four-week smoking cessation was achieved by 38% of patients from the intervention group, compared to 17% from the usual care group. Secondary outcomes (use of behavioral cessation support, pharmacotherapy, and referral to and use of the local stop smoking service) were all significantly higher in the intervention group compared to the usual care group (P<0.001 in all cases).

This study shows that simple measures, when systematically delivered, are effective in initiating smoking cessation.

Bottom line: In-hospital systematic delivery of smoking cessation strategies is effective.

Citation: Murray RL, Leonardi-Bee J, Marsh J, et al. Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial. BMJ. 2013;347:f4004.

Clinical question: How have opioid pain reliever (OPR) prescriptions affected drug misuse or abuse and drug overdose deaths for women in the past decade?

Background: Overdose deaths have increased steadily over the past decade. More men die from drug overdoses, but the percentage of women dying from drug misuse has increased substantially.

Study design: Retrospective analysis.

Setting: Data from the National Vital Statistics System (NVSS) and the Drug Abuse Warning Network (DAWN).

Synopsis: The CDC analyzed death rates based on NVSS multiple causes of death from 1999-2010. Type of drug involved (OPR, cocaine, heroin, benzodiazepines) was based on ICD 10 codes. Analysis showed that deaths from OPRs between 1999 and 2010 increased five-fold in women, compared to 3.6-fold in men.

The CDC also analyzed DAWN data from ED visits by women for drug misuse or abuse between 2004-2010. When compared to data from 2004, the ED visits related to misuse or abuse of OPR among women more than doubled, and the rate of OPR deaths among women increased by 70%.

Limitations of this study include the fact that all drugs used were not identified, and motivation to use was unclear. Also, medical or non-medical reason for use was not always available.

Bottom line: Healthcare providers prescribing OPRs to patients should use their state’s prescription drug monitoring program and regularly screen patients for psychological disorders and use of psychotherapeutic drugs, with or without a prescription.

Citation: Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers and other drugs among women—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2013;62:537-542.

Clinical question: How have opioid pain reliever (OPR) prescriptions affected drug misuse or abuse and drug overdose deaths for women in the past decade?

Background: Overdose deaths have increased steadily over the past decade. More men die from drug overdoses, but the percentage of women dying from drug misuse has increased substantially.

Study design: Retrospective analysis.

Setting: Data from the National Vital Statistics System (NVSS) and the Drug Abuse Warning Network (DAWN).

Synopsis: The CDC analyzed death rates based on NVSS multiple causes of death from 1999-2010. Type of drug involved (OPR, cocaine, heroin, benzodiazepines) was based on ICD 10 codes. Analysis showed that deaths from OPRs between 1999 and 2010 increased five-fold in women, compared to 3.6-fold in men.

The CDC also analyzed DAWN data from ED visits by women for drug misuse or abuse between 2004-2010. When compared to data from 2004, the ED visits related to misuse or abuse of OPR among women more than doubled, and the rate of OPR deaths among women increased by 70%.

Limitations of this study include the fact that all drugs used were not identified, and motivation to use was unclear. Also, medical or non-medical reason for use was not always available.

Bottom line: Healthcare providers prescribing OPRs to patients should use their state’s prescription drug monitoring program and regularly screen patients for psychological disorders and use of psychotherapeutic drugs, with or without a prescription.

Citation: Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers and other drugs among women—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2013;62:537-542.

Clinical question: How have opioid pain reliever (OPR) prescriptions affected drug misuse or abuse and drug overdose deaths for women in the past decade?

Background: Overdose deaths have increased steadily over the past decade. More men die from drug overdoses, but the percentage of women dying from drug misuse has increased substantially.

Study design: Retrospective analysis.

Setting: Data from the National Vital Statistics System (NVSS) and the Drug Abuse Warning Network (DAWN).

Synopsis: The CDC analyzed death rates based on NVSS multiple causes of death from 1999-2010. Type of drug involved (OPR, cocaine, heroin, benzodiazepines) was based on ICD 10 codes. Analysis showed that deaths from OPRs between 1999 and 2010 increased five-fold in women, compared to 3.6-fold in men.

The CDC also analyzed DAWN data from ED visits by women for drug misuse or abuse between 2004-2010. When compared to data from 2004, the ED visits related to misuse or abuse of OPR among women more than doubled, and the rate of OPR deaths among women increased by 70%.

Limitations of this study include the fact that all drugs used were not identified, and motivation to use was unclear. Also, medical or non-medical reason for use was not always available.

Bottom line: Healthcare providers prescribing OPRs to patients should use their state’s prescription drug monitoring program and regularly screen patients for psychological disorders and use of psychotherapeutic drugs, with or without a prescription.

Citation: Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers and other drugs among women—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2013;62:537-542.

Clinical question: Does the use of a standardized suite of post-operative pulmonary care guidelines decrease the incidence of adverse pulmonary outcomes in non-ventilated patients?

Background: Post-operative pulmonary complications are common and account for high costs and increased length of stay. Best practice guidelines for pulmonary care in general for patients undergoing non-cardiac surgery are scarce, compared to strategies to prevent ventilator-associated pneumonia (VAP).

Study design: Observational study.

Setting: Boston University Medical Center.

Synopsis: The I COUGH program emphasized Incentive spirometry, Coughing and deep breathing, Oral care, Understanding (patient and family education), Getting out of bed at least three times daily, and Head-of-bed elevation.

I COUGH was implemented for one year for all general surgery and vascular surgery patients, and results were compared with the year prior using National Surgical Quality Improvement Program (NSQIP) data. The program reduced the incidence of post-operative pneumonia to 1.6% from 2.6% and the incidence of unplanned intubations to 1.2% from 2.0%. The results did show a trend but did not achieve statistical significance.

Bottom line: Post-operative implementation of I COUGH through consistent education of staff, patients, and family might reduce post-operative pneumonia and unplanned intubations.

Citation: Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg. 2013;148:740-745.

Clinical question: Does the use of a standardized suite of post-operative pulmonary care guidelines decrease the incidence of adverse pulmonary outcomes in non-ventilated patients?

Background: Post-operative pulmonary complications are common and account for high costs and increased length of stay. Best practice guidelines for pulmonary care in general for patients undergoing non-cardiac surgery are scarce, compared to strategies to prevent ventilator-associated pneumonia (VAP).

Study design: Observational study.

Setting: Boston University Medical Center.

Synopsis: The I COUGH program emphasized Incentive spirometry, Coughing and deep breathing, Oral care, Understanding (patient and family education), Getting out of bed at least three times daily, and Head-of-bed elevation.

I COUGH was implemented for one year for all general surgery and vascular surgery patients, and results were compared with the year prior using National Surgical Quality Improvement Program (NSQIP) data. The program reduced the incidence of post-operative pneumonia to 1.6% from 2.6% and the incidence of unplanned intubations to 1.2% from 2.0%. The results did show a trend but did not achieve statistical significance.

Bottom line: Post-operative implementation of I COUGH through consistent education of staff, patients, and family might reduce post-operative pneumonia and unplanned intubations.

Citation: Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg. 2013;148:740-745.

Clinical question: Does the use of a standardized suite of post-operative pulmonary care guidelines decrease the incidence of adverse pulmonary outcomes in non-ventilated patients?

Background: Post-operative pulmonary complications are common and account for high costs and increased length of stay. Best practice guidelines for pulmonary care in general for patients undergoing non-cardiac surgery are scarce, compared to strategies to prevent ventilator-associated pneumonia (VAP).

Study design: Observational study.

Setting: Boston University Medical Center.

Synopsis: The I COUGH program emphasized Incentive spirometry, Coughing and deep breathing, Oral care, Understanding (patient and family education), Getting out of bed at least three times daily, and Head-of-bed elevation.

I COUGH was implemented for one year for all general surgery and vascular surgery patients, and results were compared with the year prior using National Surgical Quality Improvement Program (NSQIP) data. The program reduced the incidence of post-operative pneumonia to 1.6% from 2.6% and the incidence of unplanned intubations to 1.2% from 2.0%. The results did show a trend but did not achieve statistical significance.

Bottom line: Post-operative implementation of I COUGH through consistent education of staff, patients, and family might reduce post-operative pneumonia and unplanned intubations.

Citation: Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg. 2013;148:740-745.

Clinical question: What are physicians’ attitudes toward addressing healthcare costs and which strategies do they most enthusiastically support?

Background: Physicians are expected to take a lead role in containing healthcare costs, especially in the face of healthcare reform; however, their attitudes regarding this role are unknown.

Study design: Cross-sectional survey.

Setting: U.S. physicians randomly selected from the AMA master file.

Synopsis: Among 2,556 physicians who responded to the survey (response rate: 65%), most believed stakeholders other than physicians (e.g., lawyers, hospitals, insurers, pharmaceutical manufacturers, and patients) have a “major responsibility” for reducing healthcare costs. Most physicians were likely to support such quality initiatives as enhancing continuity of care and promoting chronic disease care coordination. Physicians were also enthusiastic with regard to expanding the use of electronic health records.

The majority of physicians expressed agreement about their responsibility to address healthcare costs by adhering to clinical guidelines, limiting unnecessary testing, and focusing on the individual patient’s best interest. However, a majority expressed limited enthusiasm for strategies that involved cost cutting to physicians, such as eliminating fee-for-service payment models, reducing compensation for the highest paid specialties, and allowing Medicare payment cuts to doctors.

Of note, in the multivariate model, physicians receiving salary-based compensation were more likely to be enthusiastic about eliminating fee-for-service.

Bottom line: Physicians expressed considerable enthusiasm for addressing healthcare costs and are in general agreement but are not enthusiastic about changes that involve physician payment cuts.

Citation: Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013;310:380-388.

Clinical question: What are physicians’ attitudes toward addressing healthcare costs and which strategies do they most enthusiastically support?

Background: Physicians are expected to take a lead role in containing healthcare costs, especially in the face of healthcare reform; however, their attitudes regarding this role are unknown.

Study design: Cross-sectional survey.

Setting: U.S. physicians randomly selected from the AMA master file.

Synopsis: Among 2,556 physicians who responded to the survey (response rate: 65%), most believed stakeholders other than physicians (e.g., lawyers, hospitals, insurers, pharmaceutical manufacturers, and patients) have a “major responsibility” for reducing healthcare costs. Most physicians were likely to support such quality initiatives as enhancing continuity of care and promoting chronic disease care coordination. Physicians were also enthusiastic with regard to expanding the use of electronic health records.

The majority of physicians expressed agreement about their responsibility to address healthcare costs by adhering to clinical guidelines, limiting unnecessary testing, and focusing on the individual patient’s best interest. However, a majority expressed limited enthusiasm for strategies that involved cost cutting to physicians, such as eliminating fee-for-service payment models, reducing compensation for the highest paid specialties, and allowing Medicare payment cuts to doctors.

Of note, in the multivariate model, physicians receiving salary-based compensation were more likely to be enthusiastic about eliminating fee-for-service.

Bottom line: Physicians expressed considerable enthusiasm for addressing healthcare costs and are in general agreement but are not enthusiastic about changes that involve physician payment cuts.

Citation: Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013;310:380-388.

Clinical question: What are physicians’ attitudes toward addressing healthcare costs and which strategies do they most enthusiastically support?

Background: Physicians are expected to take a lead role in containing healthcare costs, especially in the face of healthcare reform; however, their attitudes regarding this role are unknown.

Study design: Cross-sectional survey.

Setting: U.S. physicians randomly selected from the AMA master file.

Synopsis: Among 2,556 physicians who responded to the survey (response rate: 65%), most believed stakeholders other than physicians (e.g., lawyers, hospitals, insurers, pharmaceutical manufacturers, and patients) have a “major responsibility” for reducing healthcare costs. Most physicians were likely to support such quality initiatives as enhancing continuity of care and promoting chronic disease care coordination. Physicians were also enthusiastic with regard to expanding the use of electronic health records.

The majority of physicians expressed agreement about their responsibility to address healthcare costs by adhering to clinical guidelines, limiting unnecessary testing, and focusing on the individual patient’s best interest. However, a majority expressed limited enthusiasm for strategies that involved cost cutting to physicians, such as eliminating fee-for-service payment models, reducing compensation for the highest paid specialties, and allowing Medicare payment cuts to doctors.

Of note, in the multivariate model, physicians receiving salary-based compensation were more likely to be enthusiastic about eliminating fee-for-service.

Bottom line: Physicians expressed considerable enthusiasm for addressing healthcare costs and are in general agreement but are not enthusiastic about changes that involve physician payment cuts.

Citation: Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013;310:380-388.

Clinical question: What patient-risk factors predict superficial and deep/organ-space surgical site infections (SSIs) following colectomy procedures?

Background: SSIs are often targeted by policymakers for quality improvement and cost saving. Superficial and deep/organ-specific SSIs are traditionally considered a single entity for quality measurement, although they vary by anatomic location and clinical severity.

Study design: Retrospective cohort study.

Setting: American College of Surgeons National Surgical Quality Improvement program (ACS-NSQIP).

Synopsis: Researchers used the ACS-NSQIP registry to identify all patients who underwent colectomy procedures across 305 hospitals. Various patient variables, such as demographics, pre-operative risk factors, comorbidities, and operative information, were collected on all patients. The primary outcome was 30-day post-operative superficial SSI and deep/organ-space SSI.

Overall, 27,011 patients underwent colectomy procedures, of which 6.2% developed a superficial SSI and 4.7% developed deep/organ-space SSI. Open surgical approach (vs. laparoscopic) and current smoking were the only risk factors that predicted the occurrence of both superficial and deep/organ-space SSI. Other risk factors (e.g., post-operative diagnoses, disseminated cancer, and irradiation therapy) had a differential effect and only predicted the occurrence of deep/organ-space SSI. Elevated body mass index was strongly correlated with the occurrence of superficial SSI.

Key limitations of the study included unavailability of infection rates beyond 30 days and grouping of deep and organ-space SSIs, as the latter might vary in magnitude and significance.

Bottom Line: Risk factors that predict superficial and deep/organ-space SSI differ significantly, suggesting that future quality initiatives and reporting should evaluate different types of SSIs independently.

Citation: Lawson EH, Hall BL, Ko CY. Risk factors for superficial vs. deep/organ-space surgical site infections: implications for quality improvement initiatives [published online ahead of print July 17, 2013]. JAMA Surg.

Clinical question: What patient-risk factors predict superficial and deep/organ-space surgical site infections (SSIs) following colectomy procedures?

Background: SSIs are often targeted by policymakers for quality improvement and cost saving. Superficial and deep/organ-specific SSIs are traditionally considered a single entity for quality measurement, although they vary by anatomic location and clinical severity.

Study design: Retrospective cohort study.

Setting: American College of Surgeons National Surgical Quality Improvement program (ACS-NSQIP).

Synopsis: Researchers used the ACS-NSQIP registry to identify all patients who underwent colectomy procedures across 305 hospitals. Various patient variables, such as demographics, pre-operative risk factors, comorbidities, and operative information, were collected on all patients. The primary outcome was 30-day post-operative superficial SSI and deep/organ-space SSI.

Overall, 27,011 patients underwent colectomy procedures, of which 6.2% developed a superficial SSI and 4.7% developed deep/organ-space SSI. Open surgical approach (vs. laparoscopic) and current smoking were the only risk factors that predicted the occurrence of both superficial and deep/organ-space SSI. Other risk factors (e.g., post-operative diagnoses, disseminated cancer, and irradiation therapy) had a differential effect and only predicted the occurrence of deep/organ-space SSI. Elevated body mass index was strongly correlated with the occurrence of superficial SSI.

Key limitations of the study included unavailability of infection rates beyond 30 days and grouping of deep and organ-space SSIs, as the latter might vary in magnitude and significance.

Bottom Line: Risk factors that predict superficial and deep/organ-space SSI differ significantly, suggesting that future quality initiatives and reporting should evaluate different types of SSIs independently.

Citation: Lawson EH, Hall BL, Ko CY. Risk factors for superficial vs. deep/organ-space surgical site infections: implications for quality improvement initiatives [published online ahead of print July 17, 2013]. JAMA Surg.

Clinical question: What patient-risk factors predict superficial and deep/organ-space surgical site infections (SSIs) following colectomy procedures?

Background: SSIs are often targeted by policymakers for quality improvement and cost saving. Superficial and deep/organ-specific SSIs are traditionally considered a single entity for quality measurement, although they vary by anatomic location and clinical severity.

Study design: Retrospective cohort study.

Setting: American College of Surgeons National Surgical Quality Improvement program (ACS-NSQIP).

Synopsis: Researchers used the ACS-NSQIP registry to identify all patients who underwent colectomy procedures across 305 hospitals. Various patient variables, such as demographics, pre-operative risk factors, comorbidities, and operative information, were collected on all patients. The primary outcome was 30-day post-operative superficial SSI and deep/organ-space SSI.

Overall, 27,011 patients underwent colectomy procedures, of which 6.2% developed a superficial SSI and 4.7% developed deep/organ-space SSI. Open surgical approach (vs. laparoscopic) and current smoking were the only risk factors that predicted the occurrence of both superficial and deep/organ-space SSI. Other risk factors (e.g., post-operative diagnoses, disseminated cancer, and irradiation therapy) had a differential effect and only predicted the occurrence of deep/organ-space SSI. Elevated body mass index was strongly correlated with the occurrence of superficial SSI.

Key limitations of the study included unavailability of infection rates beyond 30 days and grouping of deep and organ-space SSIs, as the latter might vary in magnitude and significance.

Bottom Line: Risk factors that predict superficial and deep/organ-space SSI differ significantly, suggesting that future quality initiatives and reporting should evaluate different types of SSIs independently.

Citation: Lawson EH, Hall BL, Ko CY. Risk factors for superficial vs. deep/organ-space surgical site infections: implications for quality improvement initiatives [published online ahead of print July 17, 2013]. JAMA Surg.

Clinical question: Is apixaban non-inferior to standard therapy for treating acute VTE?

Background: Apixaban, a direct Xa inhibitor, has not been tested for efficacy and safety in treating acute VTE. Rivaroxaban, another direct Xa inhibitor, is already FDA-approved for acute VTE treatment.

Study design: Randomized, double-blinded trial.

Setting: International multi-center.

Synopsis: Researchers randomized 5400 patients with acute VTE to receive either apixaban (10 mg po bid x 7 days, then 5 mg po bid x 6 months) + placebo, or lovenox with transition to coumadin, with a goal of international normalized ratio 2-3. Recurrent VTE occurred in 2.3% of the apixaban group, compared with 2.7% in the conventional therapy group (apixaban noninferior). Major bleeding occurred less in the apixaban group than in the conventional therapy group (0.6% compared to 1.8%), as did clinically relevant non-major bleeding (3.8% compared to 8%).

Bottom line: Apixaban is a safe alternative for treating acute VTE (pending FDA approval).

Citation: Agnelli G, Buller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism. New Engl J Med. 2013;369:799-808.

Clinical question: Is apixaban non-inferior to standard therapy for treating acute VTE?

Background: Apixaban, a direct Xa inhibitor, has not been tested for efficacy and safety in treating acute VTE. Rivaroxaban, another direct Xa inhibitor, is already FDA-approved for acute VTE treatment.

Study design: Randomized, double-blinded trial.

Setting: International multi-center.

Synopsis: Researchers randomized 5400 patients with acute VTE to receive either apixaban (10 mg po bid x 7 days, then 5 mg po bid x 6 months) + placebo, or lovenox with transition to coumadin, with a goal of international normalized ratio 2-3. Recurrent VTE occurred in 2.3% of the apixaban group, compared with 2.7% in the conventional therapy group (apixaban noninferior). Major bleeding occurred less in the apixaban group than in the conventional therapy group (0.6% compared to 1.8%), as did clinically relevant non-major bleeding (3.8% compared to 8%).

Bottom line: Apixaban is a safe alternative for treating acute VTE (pending FDA approval).

Citation: Agnelli G, Buller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism. New Engl J Med. 2013;369:799-808.

Clinical question: Is apixaban non-inferior to standard therapy for treating acute VTE?

Background: Apixaban, a direct Xa inhibitor, has not been tested for efficacy and safety in treating acute VTE. Rivaroxaban, another direct Xa inhibitor, is already FDA-approved for acute VTE treatment.

Study design: Randomized, double-blinded trial.

Setting: International multi-center.

Synopsis: Researchers randomized 5400 patients with acute VTE to receive either apixaban (10 mg po bid x 7 days, then 5 mg po bid x 6 months) + placebo, or lovenox with transition to coumadin, with a goal of international normalized ratio 2-3. Recurrent VTE occurred in 2.3% of the apixaban group, compared with 2.7% in the conventional therapy group (apixaban noninferior). Major bleeding occurred less in the apixaban group than in the conventional therapy group (0.6% compared to 1.8%), as did clinically relevant non-major bleeding (3.8% compared to 8%).

Bottom line: Apixaban is a safe alternative for treating acute VTE (pending FDA approval).

Citation: Agnelli G, Buller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism. New Engl J Med. 2013;369:799-808.

Clinical question: Does loading clopidogrel with aspirin reduce recurrent stroke after moderate to high-risk transient ischemic attack (TIA) or minor stroke if started within 24 hours of primary event?

Background: Recurrent stroke risk is highest during the first few weeks after TIA or minor stroke.

Study design: Randomized, double-blinded, placebo-controlled trial.

Setting: Multi-center health system in China.

Synopsis: More than 5100 patients were randomized within 24 hours after minor ischemic stroke (NIHSS<=3) or high-risk TIA (ABCD2>= 4) to loading dose clopidogrel 300 mg, then 75 mg po daily x 90 days in addition to aspirin 75 mg daily for the first 21 days or aspirin 75 mg po daily x 90 days + placebo. Within 90 days, recurrent stroke was higher in aspirin + placebo group compared to aspirin + clopidogrel (11.7% event rate compared with 8.2%). Moderate to severe bleeding risk was the same (0.3%) in both groups.

Strict eligibility criteria in this study might limit generalizability to the general public. This study occurred in China, where the recurrent stroke rate was higher (near 10%) than the rate seen in primary stroke centers in more developed countries (3% to 5%), perhaps because of less emphasis on secondary risk prevention (including hypertension and hyperlipidemia) in China.

Also, the distribution of stroke subtype in China (more intracranial atherosclerosis than in other populations) might have affected the study outcomes. Because of these limitations, more research needs to be done to confirm these findings for other populations.

Bottom line: Adding clopidogrel to aspirin reduced recurrent cerebrovascular event after high-risk TIA or minor ischemic stroke in China, but generalizability to other patient populations is not clear.

Citation: Wang Y, Wang Y, Zhao X, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. New Engl J Med. 2013;369:11-19.

Clinical question: Does loading clopidogrel with aspirin reduce recurrent stroke after moderate to high-risk transient ischemic attack (TIA) or minor stroke if started within 24 hours of primary event?

Background: Recurrent stroke risk is highest during the first few weeks after TIA or minor stroke.

Study design: Randomized, double-blinded, placebo-controlled trial.

Setting: Multi-center health system in China.

Synopsis: More than 5100 patients were randomized within 24 hours after minor ischemic stroke (NIHSS<=3) or high-risk TIA (ABCD2>= 4) to loading dose clopidogrel 300 mg, then 75 mg po daily x 90 days in addition to aspirin 75 mg daily for the first 21 days or aspirin 75 mg po daily x 90 days + placebo. Within 90 days, recurrent stroke was higher in aspirin + placebo group compared to aspirin + clopidogrel (11.7% event rate compared with 8.2%). Moderate to severe bleeding risk was the same (0.3%) in both groups.

Strict eligibility criteria in this study might limit generalizability to the general public. This study occurred in China, where the recurrent stroke rate was higher (near 10%) than the rate seen in primary stroke centers in more developed countries (3% to 5%), perhaps because of less emphasis on secondary risk prevention (including hypertension and hyperlipidemia) in China.

Also, the distribution of stroke subtype in China (more intracranial atherosclerosis than in other populations) might have affected the study outcomes. Because of these limitations, more research needs to be done to confirm these findings for other populations.

Bottom line: Adding clopidogrel to aspirin reduced recurrent cerebrovascular event after high-risk TIA or minor ischemic stroke in China, but generalizability to other patient populations is not clear.

Citation: Wang Y, Wang Y, Zhao X, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. New Engl J Med. 2013;369:11-19.

Clinical question: Does loading clopidogrel with aspirin reduce recurrent stroke after moderate to high-risk transient ischemic attack (TIA) or minor stroke if started within 24 hours of primary event?

Background: Recurrent stroke risk is highest during the first few weeks after TIA or minor stroke.

Study design: Randomized, double-blinded, placebo-controlled trial.

Setting: Multi-center health system in China.

Synopsis: More than 5100 patients were randomized within 24 hours after minor ischemic stroke (NIHSS<=3) or high-risk TIA (ABCD2>= 4) to loading dose clopidogrel 300 mg, then 75 mg po daily x 90 days in addition to aspirin 75 mg daily for the first 21 days or aspirin 75 mg po daily x 90 days + placebo. Within 90 days, recurrent stroke was higher in aspirin + placebo group compared to aspirin + clopidogrel (11.7% event rate compared with 8.2%). Moderate to severe bleeding risk was the same (0.3%) in both groups.

Strict eligibility criteria in this study might limit generalizability to the general public. This study occurred in China, where the recurrent stroke rate was higher (near 10%) than the rate seen in primary stroke centers in more developed countries (3% to 5%), perhaps because of less emphasis on secondary risk prevention (including hypertension and hyperlipidemia) in China.

Also, the distribution of stroke subtype in China (more intracranial atherosclerosis than in other populations) might have affected the study outcomes. Because of these limitations, more research needs to be done to confirm these findings for other populations.

Bottom line: Adding clopidogrel to aspirin reduced recurrent cerebrovascular event after high-risk TIA or minor ischemic stroke in China, but generalizability to other patient populations is not clear.

Citation: Wang Y, Wang Y, Zhao X, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. New Engl J Med. 2013;369:11-19.

Click here to listen to more of our interview with Dr. Patel

Click here to listen to more of our interview with Dr. Patel

Click here to listen to more of our interview with Dr. Patel

Hospitals nationwide face significant capacity constraints in emergency departments. High hospitalization rates can have a ripple effect, leading to long wait times, frequent diversion of patients to other hospitals, and higher patient-care expenses. However, a sizable number of inpatient admissions can be prevented through dedicated clinical observation units, or COUs. Such a strategy is likely to be more efficient, can result in shorter lengths of stay, and can decrease health-care costs.¹

Also known as clinical decision units, “obs” units, or short-stay observation units, these hospital-based units lend themselves as a feasible solution. Many of the COU success stories come from “chest pain” units, along with ED-based observation units. Over time, the COUs have been expanded to include many more conditions and have enjoyed success when dealing with asthma exacerbations, transient ischemic attacks, bronchiolitis in pediatric populations, and congestive-heart-failure exacerbation, to name a few.

Most COUs use a window of six to 24 hours to carry out triaging, diagnosing, treating, and monitoring the patient response. Anytime before the 24-hour mark, a decision is made whether to discharge or admit the patient. The success of dedicated COUs relies heavily on strong leadership, strict treatment protocols, and well-defined inclusion/exclusion criteria.

COU utilization has been well received by several professional bodies. Both emergency medicine physicians and hospitalists are natural key players in the widespread utilization of COUs. SHM, in a white paper, concluded: “Collaboration between hospitalists, emergency physicians, hospital administrators, and academicians will serve not only to promote outstanding observation care, but also to focus quality improvement and research efforts for the observation unit of the 21st century.”² The American College of Emergency Physicians (ACEP), in its position statement, said the “observation of appropriate ED patients in a dedicated ED observation area, instead of a general inpatient bed or an acute care ED bed, is a ‘best practice’ that requires a commitment of staff and hospital resources.”³

As promising as the COUs appear, it is estimated that only one-third of hospitals have them in place.⁴ And while much of the COU story is good, there are concerns with the patient-care model.

The Good

Instinctively, a COU is a win-win proposition for all stakeholders. Essentially, many see these units as a fine blend of clinical care, fiscal responsibility, and patient accountability. Among the benefits:

Reduced admissions. On average, the admission rates from ED to inpatient services are 13.3%.⁵ In contrast, in hospitals that have a robust COU in place, the admission rates are much lower. As an example, Cook County Hospital in Chicago in the mid-1990s saw a decline in the admission rates from the emergency room following implementation of a COU, along with an increase in bed capacity due to the efficient, protocol-driven approach that goes along with successful ED observation units.⁶ With well-structured and managed observation units, such a reduction in hospitalization rates has been shown, is reproducible, and is achievable.

Improved case-mix multiplier. Inpatient reimbursements from the Centers for Medicare and Medicaid Services (CMS) and private insurers frequently are tied to the acuity of care a hospital provides. Critical to making that determination is the case mix that a given hospital sees. Usually, the more complex patients a hospital admits, the higher the reimbursements are. With a successful COU, a hospital can expect a case-mix multiplier representing patients with greater complexity and higher acuity.

What a successful COU essentially does is lead to the admission of patients with greater comorbidities—those who are sicker than the average patient. In doing so, COUs also facilitate safe discharges of the patients who do not necessarily need to be admitted. As an average, the cohort of patients who are admitted as inpatients then consists of patients who are sick enough and absolutely need to be admitted.

Resource utilization. When a patient is admitted from the ED to an inpatient floor, a lot of resources are utilized. These include expenses related to transportation, housekeeping, nursing, and ancillary services. Each of these additional resources comes with an expense. The more resources that are put in motion, the greater the expense a hospital incurs. With effective COUs, it is generally expected that suitable patients will get the care in a specific geographic area by the same set of providers. COUs tend to reduce unnecessary hospitalizations, redundancy of manpower utilization, and duplication of documentation—therefore reducing the expenses incurred by the hospital.

Infection control. The COUs operate based on minimizing the stay of the patients who can be safely discharged after a brief observation period. Decreased duration of stay also means decreased movement and unique provider contact/exposure—thus decreasing the chances for acquiring health-care-related infections. Besides, most COUs are restricted to a certain geographic area within the hospital, which helps to restrict patients to a limited area. This again may be helpful in better overall infection-control practices. More research is necessary to establish this association of the infection-control advantages of COUs. The hypothesis, however, does appear very promising.

Prompt and standardized care. Most COUs use an evidence-based, standardized approach toward the patients seen in the ED. Several professional bodies have endorsed the use of protocol-driven care for the conditions seen in the COU. Most professional organizations that have a key role in COUs advocate this approach, and include the ACEP, AHA, and SHM. When a COU has established itself, it likely is to use specific, expedited, protocol-driven approaches. This allows for care to be focused and standardized. This also is an opportunity to avoid redundant imaging and lab testing.

Patient safety. In its landmark publication “To Err is Human: Building a Safer Health System,” the Institute of Medicine identified communication error as one of the factors that lead to mistakes in patient care.⁷ COUs often tend to provide bulk of care at a given geographical area; this minimizes the transfer of patients from one place to another, thereby decreasing communication errors.

By providing more time to make decisions, COUs afford a greater diagnostic certainty. In the long run, this also helps a hospital minimize costly lawsuits.

The Bad

Not everything about COUs is great. There are certain areas that dull the luster of an observation unit.

Overzealous approaches. COUs are designed to allow more time to make clinical decisions when the triaging is in a gray area: whether to admit or not. Also, COUs provide clinicians with more time to follow the response to the care the patients receive in an emergent fashion. It needs to be emphasized that COUs are designed neither to replace hospitalization, nor to act as urgent care. As a corollary, there is a chance clinicians may be overzealous in discharging patients from COUs close to the 24-hour mark—even though it might not be clear whether the patient needs to be admitted or discharged. Overzealous discharging of COU patients can damage the premise of these units: to determine the need for admission and ensure patient safety. Having strict inclusion and exclusion criteria and good management can prevent these problems.

Staffing. Introduction of a COU can strain an already short-staffed ED. No different from any other novel approach, COU staffers need to be afforded a learning curve. This requires training personnel and establishing a robust team to staff COUs. It can be a strenuous process, at least in the beginning. Strong leadership and support of hospital, physician, and nursing leadership all play a role in the successful implementation and ongoing utilization of COUs.

Logistics. Coordination of people, facilities, and supplies that go into instituting a COU might be a challenge. Also, there may be times where patient ownership may not be very clear. Logistical concerns can include:

• Who owns the patient?
• How much of a role does a consulting service have?
• Who oversees the follow-up plans?

Although a popular COU setup is to have a dedicated observation unit adjacent to the ED, it is not a standard.

Reimbursement. Unfortunately, there is some degree of negative incentive built into reimbursements for COU operations. To understand why this is a bad thing for a hospital, let’s examine how hospitals are paid for services provided in a COU.

Frequently, COU patients are treated as “outpatients.” The operating formula is based on the Hospital Outpatient Prospective Payment System (OPPS), which is based on Ambulatory Payment Classification, or APC.⁸ Reimbursement differences in these two approaches can be quite sizable. Depending on what condition is being treated, the hospital reimbursement can be as little as half to a quarter of the payment for inpatient treatment.⁹ Essentially, the patient would have received very similar care, diagnostic work-up, antibiotics, imaging, lab work, and equally qualified clinicians as caretakers in both the settings. The payments need to account for the care in the COUs, which is usually more acute than in the ambulatory setting and potentially more efficient than an inpatient setting. The payments, therefore, should be sensitive to these factors.

The Ugly

COUs are intended to address many of the challenges facing the healthcare system, and in large part, that is what they do. However, some hospitals could be penalized for providing care through COUs. An efficient COU means that the patients who are admitted are, in fact, sicker. Logically, these patients will have a higher chance of being readmitted. Because the “not so sick” patients were successfully intervened and discharged from COUs, the patients that did get admitted must be pretty sick and must have higher comorbidities.

According to CMS, a readmission occurs if a patient has “an admission to a subsection hospital within 30 days of a discharge from the same or another subsection hospital.”¹⁰ The denominator here consists of all the patients who were discharged from the hospital inpatient stay. If a hospital does not have a robust COU, a large number of “not so sick” patients will be admitted as inpatients and will provide a larger denominator for calculating the readmission rates.

In contrast, a successful COU will allow for a large number of “not so sick” and “borderline” patients to be discharged, shrinking the denominator base, and “very sick” patients who are likely to be readmitted. This may erroneously cause the hospital to appear to have higher 30-day readmission rates. These hospitals may risk substantial readmission-related penalties.

This issue, along with a lopsided payment model, makes the COU landscape murky. With a greater share of pie being the “Il buono” in Il buono, il brutto, il cattivo, clinical observation units are certain to take a prominent position in addressing many of the issues that plague current healthcare facilities—capacity constraints, long ED wait times, limited inpatient beds, and soaring health-care expenditures.

Most important, COUs can lead to better and more efficient patient care.¹¹ It is, therefore, not surprising that the IOM, in its report “Hospital Based Emergency Care—At the Breaking Point,” has identified clinical decision units as a “particularly promising” technique to improve patient flow.¹²

Dr. Asudani is a hospitalist in the division of hospital medicine in the department of internal medicine at the University of California San Diego Health System. Dr. Tolia is director of observation medicine in the department of emergency medicine and internal medicine at UCSD Health System.

References

1. Baugh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur JD, Bohan JS. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Aff (Millwood). 2012;31(10):2314-2323.
2. Society of Hospital Medicine. The observation unit white paper. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=21890. Accessed April 3, 2013.
3. American College of Emergency Physicians. Emergency department observation services. American College of Emergency Physicians website. Available at: http://www.acep.org/Clinical—Practice-Management/Emergency-Department-Observation-Services. Accessed April 10, 2013.
4. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Hyattsville, Md.: National Center for Health Statistics; 2010.
5. Centers for Disease Control and Prevention. Fast stats. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/nchs/fastats/ervisits.htm. Accessed April 9, 2013.
6. Martinez E, Reilly BM, Evans AT, Roberts RR. The observation unit: a new interface between inpatient and outpatient care. Am J Med. 2001;110(4):274-277.
7. To err is human: building a safer health system. Institute of Medicine. Washington (DC): National Academies Press; 2000.
8. Centers for Medicare & Medicaid Services. Hospital outpatient prospective payment system. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/hospitaloutpaysysfctsht.pdf. Accessed April 2, 2013.
9. Runy L. Clinical observation units: Building a bridge between outpatient and inpatient services. Hospitals and Health Networks website. Available at: http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/PubsNewsArticle/data/2006March/0603HHN_FEA_gatefold&domain=HHNMAG. Accessed April 9, 2013.
10. Centers for Medicare & Medicaid Services. Readmissions reduction program. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed May 6, 2013.
11. Baugh CW, Venkatesh AK, Bohan JS. Emergency department observation nits: a clinical and financial benefit for hospitals. Health Care Manage Rev. 2011;36(1):28-37.
12. Institute of Medicine. Hospital-based emergency care: at the breaking point. Washington: National Academies Press; 2007.

Hospitals nationwide face significant capacity constraints in emergency departments. High hospitalization rates can have a ripple effect, leading to long wait times, frequent diversion of patients to other hospitals, and higher patient-care expenses. However, a sizable number of inpatient admissions can be prevented through dedicated clinical observation units, or COUs. Such a strategy is likely to be more efficient, can result in shorter lengths of stay, and can decrease health-care costs.¹

Also known as clinical decision units, “obs” units, or short-stay observation units, these hospital-based units lend themselves as a feasible solution. Many of the COU success stories come from “chest pain” units, along with ED-based observation units. Over time, the COUs have been expanded to include many more conditions and have enjoyed success when dealing with asthma exacerbations, transient ischemic attacks, bronchiolitis in pediatric populations, and congestive-heart-failure exacerbation, to name a few.

Most COUs use a window of six to 24 hours to carry out triaging, diagnosing, treating, and monitoring the patient response. Anytime before the 24-hour mark, a decision is made whether to discharge or admit the patient. The success of dedicated COUs relies heavily on strong leadership, strict treatment protocols, and well-defined inclusion/exclusion criteria.

COU utilization has been well received by several professional bodies. Both emergency medicine physicians and hospitalists are natural key players in the widespread utilization of COUs. SHM, in a white paper, concluded: “Collaboration between hospitalists, emergency physicians, hospital administrators, and academicians will serve not only to promote outstanding observation care, but also to focus quality improvement and research efforts for the observation unit of the 21st century.”² The American College of Emergency Physicians (ACEP), in its position statement, said the “observation of appropriate ED patients in a dedicated ED observation area, instead of a general inpatient bed or an acute care ED bed, is a ‘best practice’ that requires a commitment of staff and hospital resources.”³

As promising as the COUs appear, it is estimated that only one-third of hospitals have them in place.⁴ And while much of the COU story is good, there are concerns with the patient-care model.

The Good

Instinctively, a COU is a win-win proposition for all stakeholders. Essentially, many see these units as a fine blend of clinical care, fiscal responsibility, and patient accountability. Among the benefits:

Reduced admissions. On average, the admission rates from ED to inpatient services are 13.3%.⁵ In contrast, in hospitals that have a robust COU in place, the admission rates are much lower. As an example, Cook County Hospital in Chicago in the mid-1990s saw a decline in the admission rates from the emergency room following implementation of a COU, along with an increase in bed capacity due to the efficient, protocol-driven approach that goes along with successful ED observation units.⁶ With well-structured and managed observation units, such a reduction in hospitalization rates has been shown, is reproducible, and is achievable.

Improved case-mix multiplier. Inpatient reimbursements from the Centers for Medicare and Medicaid Services (CMS) and private insurers frequently are tied to the acuity of care a hospital provides. Critical to making that determination is the case mix that a given hospital sees. Usually, the more complex patients a hospital admits, the higher the reimbursements are. With a successful COU, a hospital can expect a case-mix multiplier representing patients with greater complexity and higher acuity.

What a successful COU essentially does is lead to the admission of patients with greater comorbidities—those who are sicker than the average patient. In doing so, COUs also facilitate safe discharges of the patients who do not necessarily need to be admitted. As an average, the cohort of patients who are admitted as inpatients then consists of patients who are sick enough and absolutely need to be admitted.

Resource utilization. When a patient is admitted from the ED to an inpatient floor, a lot of resources are utilized. These include expenses related to transportation, housekeeping, nursing, and ancillary services. Each of these additional resources comes with an expense. The more resources that are put in motion, the greater the expense a hospital incurs. With effective COUs, it is generally expected that suitable patients will get the care in a specific geographic area by the same set of providers. COUs tend to reduce unnecessary hospitalizations, redundancy of manpower utilization, and duplication of documentation—therefore reducing the expenses incurred by the hospital.

Infection control. The COUs operate based on minimizing the stay of the patients who can be safely discharged after a brief observation period. Decreased duration of stay also means decreased movement and unique provider contact/exposure—thus decreasing the chances for acquiring health-care-related infections. Besides, most COUs are restricted to a certain geographic area within the hospital, which helps to restrict patients to a limited area. This again may be helpful in better overall infection-control practices. More research is necessary to establish this association of the infection-control advantages of COUs. The hypothesis, however, does appear very promising.

Prompt and standardized care. Most COUs use an evidence-based, standardized approach toward the patients seen in the ED. Several professional bodies have endorsed the use of protocol-driven care for the conditions seen in the COU. Most professional organizations that have a key role in COUs advocate this approach, and include the ACEP, AHA, and SHM. When a COU has established itself, it likely is to use specific, expedited, protocol-driven approaches. This allows for care to be focused and standardized. This also is an opportunity to avoid redundant imaging and lab testing.

Patient safety. In its landmark publication “To Err is Human: Building a Safer Health System,” the Institute of Medicine identified communication error as one of the factors that lead to mistakes in patient care.⁷ COUs often tend to provide bulk of care at a given geographical area; this minimizes the transfer of patients from one place to another, thereby decreasing communication errors.

By providing more time to make decisions, COUs afford a greater diagnostic certainty. In the long run, this also helps a hospital minimize costly lawsuits.

The Bad

Not everything about COUs is great. There are certain areas that dull the luster of an observation unit.

Overzealous approaches. COUs are designed to allow more time to make clinical decisions when the triaging is in a gray area: whether to admit or not. Also, COUs provide clinicians with more time to follow the response to the care the patients receive in an emergent fashion. It needs to be emphasized that COUs are designed neither to replace hospitalization, nor to act as urgent care. As a corollary, there is a chance clinicians may be overzealous in discharging patients from COUs close to the 24-hour mark—even though it might not be clear whether the patient needs to be admitted or discharged. Overzealous discharging of COU patients can damage the premise of these units: to determine the need for admission and ensure patient safety. Having strict inclusion and exclusion criteria and good management can prevent these problems.

Staffing. Introduction of a COU can strain an already short-staffed ED. No different from any other novel approach, COU staffers need to be afforded a learning curve. This requires training personnel and establishing a robust team to staff COUs. It can be a strenuous process, at least in the beginning. Strong leadership and support of hospital, physician, and nursing leadership all play a role in the successful implementation and ongoing utilization of COUs.

Logistics. Coordination of people, facilities, and supplies that go into instituting a COU might be a challenge. Also, there may be times where patient ownership may not be very clear. Logistical concerns can include:

• Who owns the patient?
• How much of a role does a consulting service have?
• Who oversees the follow-up plans?

Although a popular COU setup is to have a dedicated observation unit adjacent to the ED, it is not a standard.

Reimbursement. Unfortunately, there is some degree of negative incentive built into reimbursements for COU operations. To understand why this is a bad thing for a hospital, let’s examine how hospitals are paid for services provided in a COU.

Frequently, COU patients are treated as “outpatients.” The operating formula is based on the Hospital Outpatient Prospective Payment System (OPPS), which is based on Ambulatory Payment Classification, or APC.⁸ Reimbursement differences in these two approaches can be quite sizable. Depending on what condition is being treated, the hospital reimbursement can be as little as half to a quarter of the payment for inpatient treatment.⁹ Essentially, the patient would have received very similar care, diagnostic work-up, antibiotics, imaging, lab work, and equally qualified clinicians as caretakers in both the settings. The payments need to account for the care in the COUs, which is usually more acute than in the ambulatory setting and potentially more efficient than an inpatient setting. The payments, therefore, should be sensitive to these factors.

The Ugly

COUs are intended to address many of the challenges facing the healthcare system, and in large part, that is what they do. However, some hospitals could be penalized for providing care through COUs. An efficient COU means that the patients who are admitted are, in fact, sicker. Logically, these patients will have a higher chance of being readmitted. Because the “not so sick” patients were successfully intervened and discharged from COUs, the patients that did get admitted must be pretty sick and must have higher comorbidities.

According to CMS, a readmission occurs if a patient has “an admission to a subsection hospital within 30 days of a discharge from the same or another subsection hospital.”¹⁰ The denominator here consists of all the patients who were discharged from the hospital inpatient stay. If a hospital does not have a robust COU, a large number of “not so sick” patients will be admitted as inpatients and will provide a larger denominator for calculating the readmission rates.

In contrast, a successful COU will allow for a large number of “not so sick” and “borderline” patients to be discharged, shrinking the denominator base, and “very sick” patients who are likely to be readmitted. This may erroneously cause the hospital to appear to have higher 30-day readmission rates. These hospitals may risk substantial readmission-related penalties.

This issue, along with a lopsided payment model, makes the COU landscape murky. With a greater share of pie being the “Il buono” in Il buono, il brutto, il cattivo, clinical observation units are certain to take a prominent position in addressing many of the issues that plague current healthcare facilities—capacity constraints, long ED wait times, limited inpatient beds, and soaring health-care expenditures.

Most important, COUs can lead to better and more efficient patient care.¹¹ It is, therefore, not surprising that the IOM, in its report “Hospital Based Emergency Care—At the Breaking Point,” has identified clinical decision units as a “particularly promising” technique to improve patient flow.¹²

Dr. Asudani is a hospitalist in the division of hospital medicine in the department of internal medicine at the University of California San Diego Health System. Dr. Tolia is director of observation medicine in the department of emergency medicine and internal medicine at UCSD Health System.

References

1. Baugh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur JD, Bohan JS. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Aff (Millwood). 2012;31(10):2314-2323.
2. Society of Hospital Medicine. The observation unit white paper. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=21890. Accessed April 3, 2013.
3. American College of Emergency Physicians. Emergency department observation services. American College of Emergency Physicians website. Available at: http://www.acep.org/Clinical—Practice-Management/Emergency-Department-Observation-Services. Accessed April 10, 2013.
4. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Hyattsville, Md.: National Center for Health Statistics; 2010.
5. Centers for Disease Control and Prevention. Fast stats. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/nchs/fastats/ervisits.htm. Accessed April 9, 2013.
6. Martinez E, Reilly BM, Evans AT, Roberts RR. The observation unit: a new interface between inpatient and outpatient care. Am J Med. 2001;110(4):274-277.
7. To err is human: building a safer health system. Institute of Medicine. Washington (DC): National Academies Press; 2000.
8. Centers for Medicare & Medicaid Services. Hospital outpatient prospective payment system. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/hospitaloutpaysysfctsht.pdf. Accessed April 2, 2013.
9. Runy L. Clinical observation units: Building a bridge between outpatient and inpatient services. Hospitals and Health Networks website. Available at: http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/PubsNewsArticle/data/2006March/0603HHN_FEA_gatefold&domain=HHNMAG. Accessed April 9, 2013.
10. Centers for Medicare & Medicaid Services. Readmissions reduction program. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed May 6, 2013.
11. Baugh CW, Venkatesh AK, Bohan JS. Emergency department observation nits: a clinical and financial benefit for hospitals. Health Care Manage Rev. 2011;36(1):28-37.
12. Institute of Medicine. Hospital-based emergency care: at the breaking point. Washington: National Academies Press; 2007.

Hospitals nationwide face significant capacity constraints in emergency departments. High hospitalization rates can have a ripple effect, leading to long wait times, frequent diversion of patients to other hospitals, and higher patient-care expenses. However, a sizable number of inpatient admissions can be prevented through dedicated clinical observation units, or COUs. Such a strategy is likely to be more efficient, can result in shorter lengths of stay, and can decrease health-care costs.¹

Also known as clinical decision units, “obs” units, or short-stay observation units, these hospital-based units lend themselves as a feasible solution. Many of the COU success stories come from “chest pain” units, along with ED-based observation units. Over time, the COUs have been expanded to include many more conditions and have enjoyed success when dealing with asthma exacerbations, transient ischemic attacks, bronchiolitis in pediatric populations, and congestive-heart-failure exacerbation, to name a few.

Most COUs use a window of six to 24 hours to carry out triaging, diagnosing, treating, and monitoring the patient response. Anytime before the 24-hour mark, a decision is made whether to discharge or admit the patient. The success of dedicated COUs relies heavily on strong leadership, strict treatment protocols, and well-defined inclusion/exclusion criteria.

COU utilization has been well received by several professional bodies. Both emergency medicine physicians and hospitalists are natural key players in the widespread utilization of COUs. SHM, in a white paper, concluded: “Collaboration between hospitalists, emergency physicians, hospital administrators, and academicians will serve not only to promote outstanding observation care, but also to focus quality improvement and research efforts for the observation unit of the 21st century.”² The American College of Emergency Physicians (ACEP), in its position statement, said the “observation of appropriate ED patients in a dedicated ED observation area, instead of a general inpatient bed or an acute care ED bed, is a ‘best practice’ that requires a commitment of staff and hospital resources.”³

As promising as the COUs appear, it is estimated that only one-third of hospitals have them in place.⁴ And while much of the COU story is good, there are concerns with the patient-care model.

The Good

Instinctively, a COU is a win-win proposition for all stakeholders. Essentially, many see these units as a fine blend of clinical care, fiscal responsibility, and patient accountability. Among the benefits:

Reduced admissions. On average, the admission rates from ED to inpatient services are 13.3%.⁵ In contrast, in hospitals that have a robust COU in place, the admission rates are much lower. As an example, Cook County Hospital in Chicago in the mid-1990s saw a decline in the admission rates from the emergency room following implementation of a COU, along with an increase in bed capacity due to the efficient, protocol-driven approach that goes along with successful ED observation units.⁶ With well-structured and managed observation units, such a reduction in hospitalization rates has been shown, is reproducible, and is achievable.

Improved case-mix multiplier. Inpatient reimbursements from the Centers for Medicare and Medicaid Services (CMS) and private insurers frequently are tied to the acuity of care a hospital provides. Critical to making that determination is the case mix that a given hospital sees. Usually, the more complex patients a hospital admits, the higher the reimbursements are. With a successful COU, a hospital can expect a case-mix multiplier representing patients with greater complexity and higher acuity.

What a successful COU essentially does is lead to the admission of patients with greater comorbidities—those who are sicker than the average patient. In doing so, COUs also facilitate safe discharges of the patients who do not necessarily need to be admitted. As an average, the cohort of patients who are admitted as inpatients then consists of patients who are sick enough and absolutely need to be admitted.

Resource utilization. When a patient is admitted from the ED to an inpatient floor, a lot of resources are utilized. These include expenses related to transportation, housekeeping, nursing, and ancillary services. Each of these additional resources comes with an expense. The more resources that are put in motion, the greater the expense a hospital incurs. With effective COUs, it is generally expected that suitable patients will get the care in a specific geographic area by the same set of providers. COUs tend to reduce unnecessary hospitalizations, redundancy of manpower utilization, and duplication of documentation—therefore reducing the expenses incurred by the hospital.

Infection control. The COUs operate based on minimizing the stay of the patients who can be safely discharged after a brief observation period. Decreased duration of stay also means decreased movement and unique provider contact/exposure—thus decreasing the chances for acquiring health-care-related infections. Besides, most COUs are restricted to a certain geographic area within the hospital, which helps to restrict patients to a limited area. This again may be helpful in better overall infection-control practices. More research is necessary to establish this association of the infection-control advantages of COUs. The hypothesis, however, does appear very promising.

Prompt and standardized care. Most COUs use an evidence-based, standardized approach toward the patients seen in the ED. Several professional bodies have endorsed the use of protocol-driven care for the conditions seen in the COU. Most professional organizations that have a key role in COUs advocate this approach, and include the ACEP, AHA, and SHM. When a COU has established itself, it likely is to use specific, expedited, protocol-driven approaches. This allows for care to be focused and standardized. This also is an opportunity to avoid redundant imaging and lab testing.

Patient safety. In its landmark publication “To Err is Human: Building a Safer Health System,” the Institute of Medicine identified communication error as one of the factors that lead to mistakes in patient care.⁷ COUs often tend to provide bulk of care at a given geographical area; this minimizes the transfer of patients from one place to another, thereby decreasing communication errors.

By providing more time to make decisions, COUs afford a greater diagnostic certainty. In the long run, this also helps a hospital minimize costly lawsuits.

The Bad

Not everything about COUs is great. There are certain areas that dull the luster of an observation unit.

Overzealous approaches. COUs are designed to allow more time to make clinical decisions when the triaging is in a gray area: whether to admit or not. Also, COUs provide clinicians with more time to follow the response to the care the patients receive in an emergent fashion. It needs to be emphasized that COUs are designed neither to replace hospitalization, nor to act as urgent care. As a corollary, there is a chance clinicians may be overzealous in discharging patients from COUs close to the 24-hour mark—even though it might not be clear whether the patient needs to be admitted or discharged. Overzealous discharging of COU patients can damage the premise of these units: to determine the need for admission and ensure patient safety. Having strict inclusion and exclusion criteria and good management can prevent these problems.

Staffing. Introduction of a COU can strain an already short-staffed ED. No different from any other novel approach, COU staffers need to be afforded a learning curve. This requires training personnel and establishing a robust team to staff COUs. It can be a strenuous process, at least in the beginning. Strong leadership and support of hospital, physician, and nursing leadership all play a role in the successful implementation and ongoing utilization of COUs.

Logistics. Coordination of people, facilities, and supplies that go into instituting a COU might be a challenge. Also, there may be times where patient ownership may not be very clear. Logistical concerns can include:

• Who owns the patient?
• How much of a role does a consulting service have?
• Who oversees the follow-up plans?

Although a popular COU setup is to have a dedicated observation unit adjacent to the ED, it is not a standard.

Reimbursement. Unfortunately, there is some degree of negative incentive built into reimbursements for COU operations. To understand why this is a bad thing for a hospital, let’s examine how hospitals are paid for services provided in a COU.

Frequently, COU patients are treated as “outpatients.” The operating formula is based on the Hospital Outpatient Prospective Payment System (OPPS), which is based on Ambulatory Payment Classification, or APC.⁸ Reimbursement differences in these two approaches can be quite sizable. Depending on what condition is being treated, the hospital reimbursement can be as little as half to a quarter of the payment for inpatient treatment.⁹ Essentially, the patient would have received very similar care, diagnostic work-up, antibiotics, imaging, lab work, and equally qualified clinicians as caretakers in both the settings. The payments need to account for the care in the COUs, which is usually more acute than in the ambulatory setting and potentially more efficient than an inpatient setting. The payments, therefore, should be sensitive to these factors.

The Ugly

COUs are intended to address many of the challenges facing the healthcare system, and in large part, that is what they do. However, some hospitals could be penalized for providing care through COUs. An efficient COU means that the patients who are admitted are, in fact, sicker. Logically, these patients will have a higher chance of being readmitted. Because the “not so sick” patients were successfully intervened and discharged from COUs, the patients that did get admitted must be pretty sick and must have higher comorbidities.

According to CMS, a readmission occurs if a patient has “an admission to a subsection hospital within 30 days of a discharge from the same or another subsection hospital.”¹⁰ The denominator here consists of all the patients who were discharged from the hospital inpatient stay. If a hospital does not have a robust COU, a large number of “not so sick” patients will be admitted as inpatients and will provide a larger denominator for calculating the readmission rates.

In contrast, a successful COU will allow for a large number of “not so sick” and “borderline” patients to be discharged, shrinking the denominator base, and “very sick” patients who are likely to be readmitted. This may erroneously cause the hospital to appear to have higher 30-day readmission rates. These hospitals may risk substantial readmission-related penalties.

This issue, along with a lopsided payment model, makes the COU landscape murky. With a greater share of pie being the “Il buono” in Il buono, il brutto, il cattivo, clinical observation units are certain to take a prominent position in addressing many of the issues that plague current healthcare facilities—capacity constraints, long ED wait times, limited inpatient beds, and soaring health-care expenditures.

Most important, COUs can lead to better and more efficient patient care.¹¹ It is, therefore, not surprising that the IOM, in its report “Hospital Based Emergency Care—At the Breaking Point,” has identified clinical decision units as a “particularly promising” technique to improve patient flow.¹²

Dr. Asudani is a hospitalist in the division of hospital medicine in the department of internal medicine at the University of California San Diego Health System. Dr. Tolia is director of observation medicine in the department of emergency medicine and internal medicine at UCSD Health System.

References

1. Baugh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur JD, Bohan JS. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Aff (Millwood). 2012;31(10):2314-2323.
2. Society of Hospital Medicine. The observation unit white paper. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=21890. Accessed April 3, 2013.
3. American College of Emergency Physicians. Emergency department observation services. American College of Emergency Physicians website. Available at: http://www.acep.org/Clinical—Practice-Management/Emergency-Department-Observation-Services. Accessed April 10, 2013.
4. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Hyattsville, Md.: National Center for Health Statistics; 2010.
5. Centers for Disease Control and Prevention. Fast stats. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/nchs/fastats/ervisits.htm. Accessed April 9, 2013.
6. Martinez E, Reilly BM, Evans AT, Roberts RR. The observation unit: a new interface between inpatient and outpatient care. Am J Med. 2001;110(4):274-277.
7. To err is human: building a safer health system. Institute of Medicine. Washington (DC): National Academies Press; 2000.
8. Centers for Medicare & Medicaid Services. Hospital outpatient prospective payment system. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/hospitaloutpaysysfctsht.pdf. Accessed April 2, 2013.
9. Runy L. Clinical observation units: Building a bridge between outpatient and inpatient services. Hospitals and Health Networks website. Available at: http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/PubsNewsArticle/data/2006March/0603HHN_FEA_gatefold&domain=HHNMAG. Accessed April 9, 2013.
10. Centers for Medicare & Medicaid Services. Readmissions reduction program. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed May 6, 2013.
11. Baugh CW, Venkatesh AK, Bohan JS. Emergency department observation nits: a clinical and financial benefit for hospitals. Health Care Manage Rev. 2011;36(1):28-37.
12. Institute of Medicine. Hospital-based emergency care: at the breaking point. Washington: National Academies Press; 2007.

Today marks the end of the second week of a three-month experiment we are embarking on to improve team-based care. The main elements of our experiment are two early career hospitalists dedicated to a single nursing unit who are present on the unit throughout the day, structured multidisciplinary rounds, pharmacists doing medication histories to help with medical reconciliation, and a veteran hospitalist serving as a coach, broadly overseeing care coordination and throughput on the unit. (I’m going to focus on multidisciplinary care and leave the coaching part for another day.)

Many have written about and many more have tried to establish unit-based hospitalist models, where a hospitalist is assigned to a single nursing unit. These models often incorporate multidisciplinary rounds, where the hospitalist, case management, social services, physical therapy, and perhaps pharmacy meet each day and review each patient’s progress through the hospitalization. The underlying premise for establishing a unit-based model is that all, or nearly all, of the hospitalist’s patients are located on the nursing unit.

It Can’t Be That Hard

Dedicated units and multidisciplinary rounds are designed to achieve better coordination between the hospitalists and the other members of the hospital team. Most healthcare professionals intuitively support this model; however, many hospitalists have concerns.

To provide the best care for their patients while maintaining career satisfaction, these hospitalists may feel the need for flexibility—the ability to be independent and roam unrestricted through the hallways and departments of the hospital. This goal can be at odds with being limited to a single nursing unit.

For these hospitalists to support the unit-based model, there had better be good reasons for doing so.

Measuring the Effects of Teamwork

Jody Hoffer Gittell, PhD, a professor of management at Brandeis University in Waltham, Mass., has studied relational coordination extensively in healthcare and other service industries. Relational coordination can be defined as “coordinating work through relationships of shared goals, shared knowledge and mutual respect, supported by frequent, timely, accurate, problem-solving communication.”¹

Dr. Gittell has developed a validated questionnaire to be completed by each member of the healthcare team, quantifying their perspective on these dimensions for others on the team. I think of relational coordination as a rigorous way of quantifying teamwork.

In 2008, Dr. Gittell published an observational study with SHM senior vice president Joe Miller and hospitalist leader Adrienne L. Bennett, MD, PhD, conducted at a suburban Boston hospital.² The study looked at relational coordination between members of the hospital team under hospitalist care compared to traditional, PCP-based hospital care. They measured relational coordination by asking the attending physician (hospitalist or PCP providing hospital care), medical resident, floor nurse, case manager, social worker, and therapist (occupational, physical, respiratory, speech) to complete questionnaires about the other team members for a cohort of patients.

The study concluded that relational coordination between other members of the team and the physician was significantly higher for patients treated by hospitalists than for patients treated by traditional PCPs. Further, they found that as relational coordination increased, for patients treated either by hospitalists or PCPs, length of stay, cost, and 30-day readmission rates decreased. I will add that the hospitalists were not unit-based in this study, but were assumed to be more available to the care team than traditional PCPs.

Subsequent studies of multidisciplinary rounds on a “hospitalist unit” conducted by Kevin O’Leary, MD, and colleagues at Northwestern University in Chicago have demonstrated a favorable effect on nurses’ ratings of teamwork and collaboration, as well as the rate of adverse events.^3,4 The former study did not, however, find decreased costs or length of stay.

Keys to Success

Before our current experiment, I’ve had the privilege to witness, both at my home institution and at a number of outside ones, many permutations of multidisciplinary rounds and unit-based hospitalists. I’ve seen failures, some mixed results, and occasional success stories. In all cases, participants seem to agree that it takes extra effort to execute on this model, especially once the initial enthusiasm wanes. So, for these arrangements to succeed over time, including our current experiment, I see the following four factors as critical:

1. Multidisciplinary rounds must be tightly organized, with case manager, nurse, and hospitalist providing input concisely. Average time per patient should not exceed about three minutes. The total time for rounds, no matter how many patients are under discussion, should not exceed one hour.
2. Each team member must be prepared to provide critical information for rounds. For example, hospitalists and nurses should have seen/reviewed their patients, case managers should know expected length of stay and key disposition information, and pharmacists should know medical histories and other pertinent information.
3. The fundamental concern of multidisciplinary rounds—that someone’s time is being wasted (when not talking about that team member’s patient at that moment)—must be mitigated one way or another. Solutions include rotating nurses or hospitalists in and out of rounds, and allowing hospitalists to enter orders and do other discreet multitasking during rounds. Careful attention to showing up for the rounds on time and on cue is crucial.
4. Hospitalist autonomy and need to roam has to be programmed in by allowing them time to get off the unit, see the broader world, and interact with colleagues.

At the conclusion of three months, as a QI project (as opposed to rigorous research), we will measure a number of things, including cost, throughput, patient satisfaction, and team member satisfaction with the model. If you have predictions, please e-mail me. I’ll report our results in a subsequent column.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. E-mail him at [email protected].

References

1. Relational Coordination Research Collaborative. Brandeis University website. Available at: http://rcrc.brandeis.edu/about-rc/What%20is%20Relational%20Coordination.html. Accessed September 23, 2013.
2. Gittell JH, Weinberg DB, Bennett AL, Miller JA. Is the doctor in? A relational approach to job design and the coordination of work. Hum Resource Manag J. 2008;47(4):729-755.
3. O’Leary KJ, Haviley C, Slade ME, Shah HM, Lee J, Williams MV. Improving teamwork: impact of structured interdisciplinary rounds on a hospitalist unit. J Hosp Med. 2011;6(2):88-93.
4. O’Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011;171(7):678-684.

Today marks the end of the second week of a three-month experiment we are embarking on to improve team-based care. The main elements of our experiment are two early career hospitalists dedicated to a single nursing unit who are present on the unit throughout the day, structured multidisciplinary rounds, pharmacists doing medication histories to help with medical reconciliation, and a veteran hospitalist serving as a coach, broadly overseeing care coordination and throughput on the unit. (I’m going to focus on multidisciplinary care and leave the coaching part for another day.)

Many have written about and many more have tried to establish unit-based hospitalist models, where a hospitalist is assigned to a single nursing unit. These models often incorporate multidisciplinary rounds, where the hospitalist, case management, social services, physical therapy, and perhaps pharmacy meet each day and review each patient’s progress through the hospitalization. The underlying premise for establishing a unit-based model is that all, or nearly all, of the hospitalist’s patients are located on the nursing unit.

It Can’t Be That Hard

Dedicated units and multidisciplinary rounds are designed to achieve better coordination between the hospitalists and the other members of the hospital team. Most healthcare professionals intuitively support this model; however, many hospitalists have concerns.

To provide the best care for their patients while maintaining career satisfaction, these hospitalists may feel the need for flexibility—the ability to be independent and roam unrestricted through the hallways and departments of the hospital. This goal can be at odds with being limited to a single nursing unit.

For these hospitalists to support the unit-based model, there had better be good reasons for doing so.

Measuring the Effects of Teamwork

Jody Hoffer Gittell, PhD, a professor of management at Brandeis University in Waltham, Mass., has studied relational coordination extensively in healthcare and other service industries. Relational coordination can be defined as “coordinating work through relationships of shared goals, shared knowledge and mutual respect, supported by frequent, timely, accurate, problem-solving communication.”¹

Dr. Gittell has developed a validated questionnaire to be completed by each member of the healthcare team, quantifying their perspective on these dimensions for others on the team. I think of relational coordination as a rigorous way of quantifying teamwork.

In 2008, Dr. Gittell published an observational study with SHM senior vice president Joe Miller and hospitalist leader Adrienne L. Bennett, MD, PhD, conducted at a suburban Boston hospital.² The study looked at relational coordination between members of the hospital team under hospitalist care compared to traditional, PCP-based hospital care. They measured relational coordination by asking the attending physician (hospitalist or PCP providing hospital care), medical resident, floor nurse, case manager, social worker, and therapist (occupational, physical, respiratory, speech) to complete questionnaires about the other team members for a cohort of patients.

The study concluded that relational coordination between other members of the team and the physician was significantly higher for patients treated by hospitalists than for patients treated by traditional PCPs. Further, they found that as relational coordination increased, for patients treated either by hospitalists or PCPs, length of stay, cost, and 30-day readmission rates decreased. I will add that the hospitalists were not unit-based in this study, but were assumed to be more available to the care team than traditional PCPs.

Subsequent studies of multidisciplinary rounds on a “hospitalist unit” conducted by Kevin O’Leary, MD, and colleagues at Northwestern University in Chicago have demonstrated a favorable effect on nurses’ ratings of teamwork and collaboration, as well as the rate of adverse events.^3,4 The former study did not, however, find decreased costs or length of stay.

Keys to Success

Before our current experiment, I’ve had the privilege to witness, both at my home institution and at a number of outside ones, many permutations of multidisciplinary rounds and unit-based hospitalists. I’ve seen failures, some mixed results, and occasional success stories. In all cases, participants seem to agree that it takes extra effort to execute on this model, especially once the initial enthusiasm wanes. So, for these arrangements to succeed over time, including our current experiment, I see the following four factors as critical:

1. Multidisciplinary rounds must be tightly organized, with case manager, nurse, and hospitalist providing input concisely. Average time per patient should not exceed about three minutes. The total time for rounds, no matter how many patients are under discussion, should not exceed one hour.
2. Each team member must be prepared to provide critical information for rounds. For example, hospitalists and nurses should have seen/reviewed their patients, case managers should know expected length of stay and key disposition information, and pharmacists should know medical histories and other pertinent information.
3. The fundamental concern of multidisciplinary rounds—that someone’s time is being wasted (when not talking about that team member’s patient at that moment)—must be mitigated one way or another. Solutions include rotating nurses or hospitalists in and out of rounds, and allowing hospitalists to enter orders and do other discreet multitasking during rounds. Careful attention to showing up for the rounds on time and on cue is crucial.
4. Hospitalist autonomy and need to roam has to be programmed in by allowing them time to get off the unit, see the broader world, and interact with colleagues.

At the conclusion of three months, as a QI project (as opposed to rigorous research), we will measure a number of things, including cost, throughput, patient satisfaction, and team member satisfaction with the model. If you have predictions, please e-mail me. I’ll report our results in a subsequent column.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. E-mail him at [email protected].

References

1. Relational Coordination Research Collaborative. Brandeis University website. Available at: http://rcrc.brandeis.edu/about-rc/What%20is%20Relational%20Coordination.html. Accessed September 23, 2013.
2. Gittell JH, Weinberg DB, Bennett AL, Miller JA. Is the doctor in? A relational approach to job design and the coordination of work. Hum Resource Manag J. 2008;47(4):729-755.
3. O’Leary KJ, Haviley C, Slade ME, Shah HM, Lee J, Williams MV. Improving teamwork: impact of structured interdisciplinary rounds on a hospitalist unit. J Hosp Med. 2011;6(2):88-93.
4. O’Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011;171(7):678-684.

Today marks the end of the second week of a three-month experiment we are embarking on to improve team-based care. The main elements of our experiment are two early career hospitalists dedicated to a single nursing unit who are present on the unit throughout the day, structured multidisciplinary rounds, pharmacists doing medication histories to help with medical reconciliation, and a veteran hospitalist serving as a coach, broadly overseeing care coordination and throughput on the unit. (I’m going to focus on multidisciplinary care and leave the coaching part for another day.)

Many have written about and many more have tried to establish unit-based hospitalist models, where a hospitalist is assigned to a single nursing unit. These models often incorporate multidisciplinary rounds, where the hospitalist, case management, social services, physical therapy, and perhaps pharmacy meet each day and review each patient’s progress through the hospitalization. The underlying premise for establishing a unit-based model is that all, or nearly all, of the hospitalist’s patients are located on the nursing unit.

It Can’t Be That Hard

Dedicated units and multidisciplinary rounds are designed to achieve better coordination between the hospitalists and the other members of the hospital team. Most healthcare professionals intuitively support this model; however, many hospitalists have concerns.

To provide the best care for their patients while maintaining career satisfaction, these hospitalists may feel the need for flexibility—the ability to be independent and roam unrestricted through the hallways and departments of the hospital. This goal can be at odds with being limited to a single nursing unit.

For these hospitalists to support the unit-based model, there had better be good reasons for doing so.

Measuring the Effects of Teamwork

Jody Hoffer Gittell, PhD, a professor of management at Brandeis University in Waltham, Mass., has studied relational coordination extensively in healthcare and other service industries. Relational coordination can be defined as “coordinating work through relationships of shared goals, shared knowledge and mutual respect, supported by frequent, timely, accurate, problem-solving communication.”¹

Dr. Gittell has developed a validated questionnaire to be completed by each member of the healthcare team, quantifying their perspective on these dimensions for others on the team. I think of relational coordination as a rigorous way of quantifying teamwork.

In 2008, Dr. Gittell published an observational study with SHM senior vice president Joe Miller and hospitalist leader Adrienne L. Bennett, MD, PhD, conducted at a suburban Boston hospital.² The study looked at relational coordination between members of the hospital team under hospitalist care compared to traditional, PCP-based hospital care. They measured relational coordination by asking the attending physician (hospitalist or PCP providing hospital care), medical resident, floor nurse, case manager, social worker, and therapist (occupational, physical, respiratory, speech) to complete questionnaires about the other team members for a cohort of patients.

The study concluded that relational coordination between other members of the team and the physician was significantly higher for patients treated by hospitalists than for patients treated by traditional PCPs. Further, they found that as relational coordination increased, for patients treated either by hospitalists or PCPs, length of stay, cost, and 30-day readmission rates decreased. I will add that the hospitalists were not unit-based in this study, but were assumed to be more available to the care team than traditional PCPs.

Subsequent studies of multidisciplinary rounds on a “hospitalist unit” conducted by Kevin O’Leary, MD, and colleagues at Northwestern University in Chicago have demonstrated a favorable effect on nurses’ ratings of teamwork and collaboration, as well as the rate of adverse events.^3,4 The former study did not, however, find decreased costs or length of stay.

Keys to Success

Before our current experiment, I’ve had the privilege to witness, both at my home institution and at a number of outside ones, many permutations of multidisciplinary rounds and unit-based hospitalists. I’ve seen failures, some mixed results, and occasional success stories. In all cases, participants seem to agree that it takes extra effort to execute on this model, especially once the initial enthusiasm wanes. So, for these arrangements to succeed over time, including our current experiment, I see the following four factors as critical:

1. Multidisciplinary rounds must be tightly organized, with case manager, nurse, and hospitalist providing input concisely. Average time per patient should not exceed about three minutes. The total time for rounds, no matter how many patients are under discussion, should not exceed one hour.
2. Each team member must be prepared to provide critical information for rounds. For example, hospitalists and nurses should have seen/reviewed their patients, case managers should know expected length of stay and key disposition information, and pharmacists should know medical histories and other pertinent information.
3. The fundamental concern of multidisciplinary rounds—that someone’s time is being wasted (when not talking about that team member’s patient at that moment)—must be mitigated one way or another. Solutions include rotating nurses or hospitalists in and out of rounds, and allowing hospitalists to enter orders and do other discreet multitasking during rounds. Careful attention to showing up for the rounds on time and on cue is crucial.
4. Hospitalist autonomy and need to roam has to be programmed in by allowing them time to get off the unit, see the broader world, and interact with colleagues.

At the conclusion of three months, as a QI project (as opposed to rigorous research), we will measure a number of things, including cost, throughput, patient satisfaction, and team member satisfaction with the model. If you have predictions, please e-mail me. I’ll report our results in a subsequent column.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. E-mail him at [email protected].

References

1. Relational Coordination Research Collaborative. Brandeis University website. Available at: http://rcrc.brandeis.edu/about-rc/What%20is%20Relational%20Coordination.html. Accessed September 23, 2013.
2. Gittell JH, Weinberg DB, Bennett AL, Miller JA. Is the doctor in? A relational approach to job design and the coordination of work. Hum Resource Manag J. 2008;47(4):729-755.
3. O’Leary KJ, Haviley C, Slade ME, Shah HM, Lee J, Williams MV. Improving teamwork: impact of structured interdisciplinary rounds on a hospitalist unit. J Hosp Med. 2011;6(2):88-93.
4. O’Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011;171(7):678-684.