Mixed Topics

The 2018 annual meeting of the American Society of Hematology n San Diego included research presentations on more than 3,000 abstracts. In this special meetings edition of the MDedge Daily News we hear from Dr. Arok Khorana of the Cleveland Clinic on rivaroxaban for the prevention of VTE in cancer patients. We also hear from Dr. Ify Osunkwo of the Levine Cancer Institute on recent advances in sickle cell disease.
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The 2018 annual meeting of the American Society of Hematology n San Diego included research presentations on more than 3,000 abstracts. In this special meetings edition of the MDedge Daily News we hear from Dr. Arok Khorana of the Cleveland Clinic on rivaroxaban for the prevention of VTE in cancer patients. We also hear from Dr. Ify Osunkwo of the Levine Cancer Institute on recent advances in sickle cell disease.
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Apple Podcasts
Google Podcasts
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The 2018 annual meeting of the American Society of Hematology n San Diego included research presentations on more than 3,000 abstracts. In this special meetings edition of the MDedge Daily News we hear from Dr. Arok Khorana of the Cleveland Clinic on rivaroxaban for the prevention of VTE in cancer patients. We also hear from Dr. Ify Osunkwo of the Levine Cancer Institute on recent advances in sickle cell disease.
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Apple Podcasts
Google Podcasts
Spotify
 

If you are not doing Schwartz Rounds, get them started. ASAP.

I recently completed a 4-year tenure as physician moderator for our hospital’s Schwartz Rounds. An amazing team at my hospital helped pull the bimonthly sessions together. These compassionate care rounds are a national initiative to help foster empathy and compassion in the health care setting.

We gather a panel of two to three people involved in our patient presentation who share and move quickly through the clinical details, and head on toward the thornier ethical issues, emotional triggers, and responses. The best sessions are when the audience’s voice is heard for the bulk of the time.

The emotional cadence flows from boiling in frustration, drowning in tears, followed by comfort, and ending in thoughts for the next session. It is a more powerful arc than an episode of the television program “This is Us.” Largely, because this was us. This was real life. Real-time catharsis in the hospital.

In the daily grind, we often skip the step of processing our frustration, sadness, and anger, moving right on to the next patient and walking into the next room with that stoic layer of equanimity. I walk the hallways and find I grab my phone to catch up on emails, walking to the wrong floor because I’m not paying attention. Always something to do, someone to talk to, a family to call, pagers going off, phone calls. When do we sit and reflect?

These Schwartz Rounds are those moments of reflection – a slowdown in the day to think more deeply about the case. We talk about everything and anything. We have discussions with opposing views:

“Everything should have been done!”

“How did you not stop care?!”

“I agree with the doctors.”

“I can see the patient’s view more clearly now.”

Our first Schwartz Rounds tended to be end-of-life stories, particularly regarding the family mantra of “Do everything.” The health care team watches the suffering of a patient, a family, in a seemingly futile situation. Conversations around the end of life, choices, and quality of life are cut short daily by family members who simply recite, “Do everything.”

After several of these sessions, a case swings us in the other direction. The elderly gentleman with treatable cancer, who could easily survive another 20 years, declines treatment. “I’m fine, doc; I’ve lived long enough.” His wife at his bedside, shaking her head, tells us, “I don’t know why he wants to give up. He’s been as stubborn as a mule since the day I met him.” I spend 30 minutes convincing him to stay. The nurse does the same. Now we have a patient with a “Do nothing.” The patient’s decisions conflict with the family and the health care team.

Every day in the hospital provides a new ethical dilemma, a frustrating case, a challenging patient. Fodder for rounds.

Read the full post at hospitalleader.org.
 

Dr. Messler is a hospitalist at Morton Plant Hospitalist group in Clearwater, Fla. He previously chaired SHM’s Quality and Patient Safety Committee and has been active in several SHM mentoring programs, most recently with Project BOOST and Glycemic Control.

Also on The Hospital Leader

• Incubating Success: How We Used Structured Feedback to Reduce A Dangerous Practice by Rich Bottner, PA-C & Victoria Valencia, MPH
• New SoHM Report Provides Unique Window into Hospital Medicine Practice Trends by Leslie Flores, MHA, SFHM
• IGNITE Change: Improving Care via Interprofessional Clinical Learning Environments by Vineet Arora, MD, MAPP, MHM

If you are not doing Schwartz Rounds, get them started. ASAP.

I recently completed a 4-year tenure as physician moderator for our hospital’s Schwartz Rounds. An amazing team at my hospital helped pull the bimonthly sessions together. These compassionate care rounds are a national initiative to help foster empathy and compassion in the health care setting.

We gather a panel of two to three people involved in our patient presentation who share and move quickly through the clinical details, and head on toward the thornier ethical issues, emotional triggers, and responses. The best sessions are when the audience’s voice is heard for the bulk of the time.

The emotional cadence flows from boiling in frustration, drowning in tears, followed by comfort, and ending in thoughts for the next session. It is a more powerful arc than an episode of the television program “This is Us.” Largely, because this was us. This was real life. Real-time catharsis in the hospital.

In the daily grind, we often skip the step of processing our frustration, sadness, and anger, moving right on to the next patient and walking into the next room with that stoic layer of equanimity. I walk the hallways and find I grab my phone to catch up on emails, walking to the wrong floor because I’m not paying attention. Always something to do, someone to talk to, a family to call, pagers going off, phone calls. When do we sit and reflect?

These Schwartz Rounds are those moments of reflection – a slowdown in the day to think more deeply about the case. We talk about everything and anything. We have discussions with opposing views:

“Everything should have been done!”

“How did you not stop care?!”

“I agree with the doctors.”

“I can see the patient’s view more clearly now.”

Our first Schwartz Rounds tended to be end-of-life stories, particularly regarding the family mantra of “Do everything.” The health care team watches the suffering of a patient, a family, in a seemingly futile situation. Conversations around the end of life, choices, and quality of life are cut short daily by family members who simply recite, “Do everything.”

After several of these sessions, a case swings us in the other direction. The elderly gentleman with treatable cancer, who could easily survive another 20 years, declines treatment. “I’m fine, doc; I’ve lived long enough.” His wife at his bedside, shaking her head, tells us, “I don’t know why he wants to give up. He’s been as stubborn as a mule since the day I met him.” I spend 30 minutes convincing him to stay. The nurse does the same. Now we have a patient with a “Do nothing.” The patient’s decisions conflict with the family and the health care team.

Every day in the hospital provides a new ethical dilemma, a frustrating case, a challenging patient. Fodder for rounds.

Read the full post at hospitalleader.org.
 

Dr. Messler is a hospitalist at Morton Plant Hospitalist group in Clearwater, Fla. He previously chaired SHM’s Quality and Patient Safety Committee and has been active in several SHM mentoring programs, most recently with Project BOOST and Glycemic Control.

Also on The Hospital Leader

• Incubating Success: How We Used Structured Feedback to Reduce A Dangerous Practice by Rich Bottner, PA-C & Victoria Valencia, MPH
• New SoHM Report Provides Unique Window into Hospital Medicine Practice Trends by Leslie Flores, MHA, SFHM
• IGNITE Change: Improving Care via Interprofessional Clinical Learning Environments by Vineet Arora, MD, MAPP, MHM

If you are not doing Schwartz Rounds, get them started. ASAP.

I recently completed a 4-year tenure as physician moderator for our hospital’s Schwartz Rounds. An amazing team at my hospital helped pull the bimonthly sessions together. These compassionate care rounds are a national initiative to help foster empathy and compassion in the health care setting.

We gather a panel of two to three people involved in our patient presentation who share and move quickly through the clinical details, and head on toward the thornier ethical issues, emotional triggers, and responses. The best sessions are when the audience’s voice is heard for the bulk of the time.

The emotional cadence flows from boiling in frustration, drowning in tears, followed by comfort, and ending in thoughts for the next session. It is a more powerful arc than an episode of the television program “This is Us.” Largely, because this was us. This was real life. Real-time catharsis in the hospital.

In the daily grind, we often skip the step of processing our frustration, sadness, and anger, moving right on to the next patient and walking into the next room with that stoic layer of equanimity. I walk the hallways and find I grab my phone to catch up on emails, walking to the wrong floor because I’m not paying attention. Always something to do, someone to talk to, a family to call, pagers going off, phone calls. When do we sit and reflect?

These Schwartz Rounds are those moments of reflection – a slowdown in the day to think more deeply about the case. We talk about everything and anything. We have discussions with opposing views:

“Everything should have been done!”

“How did you not stop care?!”

“I agree with the doctors.”

“I can see the patient’s view more clearly now.”

Our first Schwartz Rounds tended to be end-of-life stories, particularly regarding the family mantra of “Do everything.” The health care team watches the suffering of a patient, a family, in a seemingly futile situation. Conversations around the end of life, choices, and quality of life are cut short daily by family members who simply recite, “Do everything.”

After several of these sessions, a case swings us in the other direction. The elderly gentleman with treatable cancer, who could easily survive another 20 years, declines treatment. “I’m fine, doc; I’ve lived long enough.” His wife at his bedside, shaking her head, tells us, “I don’t know why he wants to give up. He’s been as stubborn as a mule since the day I met him.” I spend 30 minutes convincing him to stay. The nurse does the same. Now we have a patient with a “Do nothing.” The patient’s decisions conflict with the family and the health care team.

Every day in the hospital provides a new ethical dilemma, a frustrating case, a challenging patient. Fodder for rounds.

Read the full post at hospitalleader.org.
 

Dr. Messler is a hospitalist at Morton Plant Hospitalist group in Clearwater, Fla. He previously chaired SHM’s Quality and Patient Safety Committee and has been active in several SHM mentoring programs, most recently with Project BOOST and Glycemic Control.

Also on The Hospital Leader

• Incubating Success: How We Used Structured Feedback to Reduce A Dangerous Practice by Rich Bottner, PA-C & Victoria Valencia, MPH
• New SoHM Report Provides Unique Window into Hospital Medicine Practice Trends by Leslie Flores, MHA, SFHM
• IGNITE Change: Improving Care via Interprofessional Clinical Learning Environments by Vineet Arora, MD, MAPP, MHM

Carol Bernstein, MD, joins Nick Andrews to talk about the difference between physician burnout and depression. Dr. Bernstein is a professor at NYU Langone in New York City and has been a guest on the MDedge Psychcast.
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Carol Bernstein, MD, joins Nick Andrews to talk about the difference between physician burnout and depression. Dr. Bernstein is a professor at NYU Langone in New York City and has been a guest on the MDedge Psychcast.
Apple Podcasts
Google Podcasts


 

Carol Bernstein, MD, joins Nick Andrews to talk about the difference between physician burnout and depression. Dr. Bernstein is a professor at NYU Langone in New York City and has been a guest on the MDedge Psychcast.
Apple Podcasts
Google Podcasts


 

A new proposal aims to move clinicians away from the keyboard and back to face time with patients. Also today, diuretics are linked to diabetic amputations in type 2 diabetes, pausing direct acting oral anticoagulants show favorable outcomes for atrial fibrillation, and while therapy has matured for patients with HCV, there are still issues with access.

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Apple Podcasts

Google Podcasts

Spotify
 

A new proposal aims to move clinicians away from the keyboard and back to face time with patients. Also today, diuretics are linked to diabetic amputations in type 2 diabetes, pausing direct acting oral anticoagulants show favorable outcomes for atrial fibrillation, and while therapy has matured for patients with HCV, there are still issues with access.

Amazon Alexa

Apple Podcasts

Google Podcasts

Spotify
 

A new proposal aims to move clinicians away from the keyboard and back to face time with patients. Also today, diuretics are linked to diabetic amputations in type 2 diabetes, pausing direct acting oral anticoagulants show favorable outcomes for atrial fibrillation, and while therapy has matured for patients with HCV, there are still issues with access.

Amazon Alexa

Apple Podcasts

Google Podcasts

Spotify
 

This article is part of a series that illustrates strategies intended to redesign primary care education at the Veterans Health Administration (VHA), using interprofessional workplace learning. All have been implemented in the VA Centers of Excellence in Primary Care Education (CoEPCE). These models embody visionary transformation of clinical and educational environments that have potential for replication and dissemination throughout VA and other primary care clinical educational environments. For an introduction to the series see Klink K. Transforming primary care clinical learning environments to optimize education, outcomes, and satisfaction. Fed Pract. 2018;35(9):8-10.

Background

In 2011, 5 US Department of Veterans Affairs (VA) medical centers (VAMCs) were selected by the Office of Academic Affiliations (OAA) to establish CoEPCE. Part of the VA New Models of Care initiative, the 5 Centers of Excellence (CoE) in Boise, Idaho; Cleveland, Ohio; San Francisco, California; Seattle, Washington; and West Haven, Connecticut, are utilizing VA primary care settings to develop and test innovative approaches to prepare physician residents and students, advanced practice nurse residents and undergraduate nursing students, and other professions of health trainees (eg, pharmacy, social work, psychology, physician assistants [PAs]) for primary care practice in the 21st century.

The Boise CoE developed and implemented a practice-based learning model. Nurse practitioner (NP) students and residents, physician residents, pharmacy residents, psychology interns, and psychology postdoctoral fellows participate in a comprehensive curriculum and practice together for 1 to 3 years. The goal is to produce providers who are able to lead and practice health care in patient-centered primary care and rural care environments. All core curricula are interprofessionally coauthored and cotaught.¹

Methods

In 2015, OAA evaluators reviewed background documents and conducted open-ended interviews with 10 CoE staff, participating trainees, VA faculty, VA facility leadership, and affiliate faculty. In response to questions focused on their experiences, informants described lessons learned, challenges encountered, and benefits for participants, veterans, and the VA. Using a qualitative and quantitative approach, this case study draws on those interviews, surveys of PACT ICU (patient aligned care team interprofessional care update) participants, and analysis of presented patients to examine PACT ICU outcomes.

Related: Hypoglycemia Safety Initiative: Working With PACT Clinical Pharmacy Specialists to Individualize HbA1c Goals

Interprofessional Education and Care

A key CoEPCE aim is to create more clinical opportunities for CoE trainees from a variety of professions to work as a team in ways that anticipate and address the care needs of veterans. This emphasis on workplace learning is needed since most current health care professional education programs lack settings where trainees from different professions can learn and work together with their clinic partners to provide care for patients. With the emphasis on patient-centered medical homes (PCMH) and team-based care in the Affordable Care Act, there is an imperative to develop new training models that address this gap in the preparation of future health professionals. Along with this imperative, clinicians are increasingly required to optimize the health of complex patients who consequently require a multidisciplinary approach to care, particularly high-risk, high-needs patients inappropriately using services, such as frequent emergency department (ED) use.

Addressing Complex Needs

In 2010, the Boise VA Medical Center (VAMC) phased in patient aligned care teams (PACTs), the VA-mandated version of PCMH that consist of a physician or NP primary care provider (PCP), a registered nurse (RN) care manager, a licensed vocational nurse (LVN), and a medical support assistant (MSA). 

The PACT ICU also serves as a venue in which trainees and supervisors from different professions use a patient-centered framework to collaborate on these specific patient cases. The PACT ICU is easily applied to a range of health conditions, such as diabetes mellitus (DM), mental and behavioral health, lack of social support, and delivery system issues, such as ED use. The goals of PACT ICU are to improve the quality and satisfaction of patient care for high-risk patients; encourage appropriate use of health care resources by prioritizing continuity with the PACT team; and enhance interprofessional PACT team function, decreasing PCP and staff stress.

Planning and Implementation

In January 2013, Boise VAMC and the Caldwell, Idaho community-based outpatient clinic (CBOC) implemented PACT ICU. Other nonteaching clinics followed later in the year. Planning and executing PACT ICU took about 10 hours of CoE staff time and required no change in Boise VAMC policy. Program leadership approval was necessary for participation of CoE residents and postdocs. Service-line leadership support was required to protect clinic staff time (nurse care manager, social workers, chaplaincy, and ethics service). At the Caldwell CBOC, the section chief approved the program, and it took about 1 month to initiate a similar version of PACT ICU.

Curriculum

PACT ICU is a workplace clinical activity with roots in the case conference model, specifically the EFECT model (Elicit the narrative of illness, Facilitate a group meeting, Evidence-based gap analysis, Care plan, and Track changes).³ PACT ICU emphasizes a patient-centered approach to developing care plans. Staff review the 5 highest risk patients who are identified by the VA Care Assessment Need (CAN) registry. The CAN is an analytic tool that is available throughout VA and estimates patients’ risk of mortality or hospitalization in the following 90 days. Physician and NP residents choose 1 of the 5 patients to discuss in PACT ICU, while the remaining 4 serve as case-control comparisons to examine long-term patient outcomes. All trainees, faculty, and staff are provided patient data that can be discussed on a secure website.

The PACT ICU combines didactic teaching with workplace learning. For example, the patient’s medical issues may lead to a formal presentation about a topic, such as secondary stroke medication prophylaxis. The workplace learning occurs as the trainees observe and participate in the decision making toward a treatment plan. Interprofessional interactions are role-modeled by clinical faculty and staff during these discussions, and the result impact the patients care. PACT ICU embodies the core domains that shape the CoEPCE curriculum: Interprofessional collaboration (IPC), performance improvement (PI), sustained relationships (SR), and shared decision making (SDM) (Table 1). 

There have been some changes to the PACT ICU model over time. Initially, conferences took place on a weekly basis, to build momentum among the team and to normalize processes. After about 2 years, this decreased to every other week to reduce the time burden. Additionally, the CoE has strengthened the “tracking changes” component of the EFECT model—trainees now present a 5-minute update on the last patient they presented at the prior PACT ICU case conference. Most recently, psychology postdoctoral candidates have instituted preconference calls with patients to further improve the teams understanding of the patients’ perspective and narrative.

Related: Improving Team-Based Care Coordination Delivery and Documentation in the Health Record

Resources

The CoE faculty participate in an education program concerning facilitation of interprofessional meetings. All faculty are expected to role model collaborative behavior and mentor trainees on the cases they present.

The PACT ICU requires a room large enough to accommodate at least 12 people. One staff member is required to review patient cases prior to the case conferences (usually about 1 hour of preparation per case conference). Another staff person creates and shares a spreadsheet stored with VA-approved information security with data fields to include the site, PACT ICU date, patient identifier, the CAN score, and a checkbox for whether the patient was selected or part of a control group. Logistic support is required for reserving the room and sending information to presenters. A clinic-based RN with training in interprofessional care case management uses an online schedule to facilitate selection and review of patients. The RN care managers can use a secure management tool to track patient care and outreach.

The RN care manager also needs to be available to attend the PACT ICU case conferences. The Boise CoE built a website to share and standardize resources, such as a presenter schedule, PACT ICU worksheet, and provider questionnaire. (Contact Boise CoE staff for access.) For the initial evaluation of impact, PACT ICU utilized staff data support in the form of a data manager and biostatistician to identify, collect, and analyze data. While optional, this was helpful in refining the approach and demonstrating the impact of the project. Other resource-related requirements for exporting PACT ICU include:

• Staff members, usually RN care managers who coordinate meetings with participants and identify appropriate patients using a registry, such as CAN;
• Meeting facilitators who enforce use of the EFECT model and interprofessional participation to ensure that the interprofessional care plan is carried out by the presenting provider; and
• Interprofessional trainees and faculty who participate in PACT ICU and complete surveys after the first conference.

Monitoring and Assessment

The CoE staff have analyzed the evaluation of PACT ICU with participant self-evaluation, consultation referral patterns, and utilization data, combination of ED and episodic care visits along with hospitalizations).⁴ Pharmacy faculty are exploring the use polypharmacy registries, and psychology will use registries of poor psychosocial function.

Partnerships

Beyond support and engagement from VA CoEPCE and affiliate faculty, PACT ICU has greatly benefited from partnerships with VA facility department and CBOC leadership. The CoEPCE codirector and faculty are in facility committees, such as the PACT Strategic Planning Committee.

Academic affiliates are integral partners who assist with NP student and resident recruitment as well as participate in the planning and refinement of CoEPCE components. PACT ICU supports their mandate to encourage interprofessional teamwork. Faculty members from Gonzaga University (NP affiliate) were involved in the initial discussion on PACT ICU and consider it a “learning laboratory” to work through challenging problems. Gonzaga CoEPCE NP trainees are asked to talk about their PACT ICU experience—its strengths, weaknesses, and challenges—to other Gonzaga students who don’t have exposure to the team experience.

Challenges and Solutions

The demand for direct patient care puts pressure on indirect patient care approaches like PACT ICU, which is a time-intensive process with high impact on only a small number of patients. The argument for deploying strategies such as PACT ICU is that managing chronic conditions and encouraging appropriate use of services will improve outcomes for the highest risk patients and save important system resources in the long-run. However, in the short-term, a strong case must be made for the diversion of resources from usual clinic flow, particularly securing recurring blocks of provider time and clinic staff members. In addition, issues about team communication and understanding of appropriate team-based care can overflow to complex patients not presented in the PACT ICU conference.

Providing a facilitated interprofessional venue to discuss how to appropriately coordinate care improves the participation and perceived value of different team members. This approach has led to improved engagement of the team for patients discussed in the PACT ICU, as well as in general care within the participating clinic. With recent changes, the VA does see a workload benefit, and participants get encounter credit through “Non face-to-face prolonged service” codes (CPT 99358/99359), and other possibilities exist related to clinical team conference codes (CPT 99367-8) and complex chronic care management codes (CPT 99487-89). More information on documentation, scheduling and encountering/billing can be found at boisevacoe.org under Products. Other challenges include logistic challenges of finding appropriate patients and distributing sensitive patient information among the team. Additionally, PACT ICU has to wrestle with staffing shortages and episodic participation by some professions that are chronically understaffed. We have addressed many of these problems by receiving buy-in from both leadership and participants. Leadership have allowed time for participation in clinic staff schedules, and each participant has committed to recruiting a substitute in case of a schedule conflict.

Factors for Success

The commitment from the Boise VAMC facility, primary care clinic leadership and affiliated training programs to support staff and trainee participation also has been critical. Additionally, VA facility leadership commitment to ongoing improvements to PACT implementation was a key facilitating factor. Colocation of trainees and clinic staff on the academic PACT team facilitates communication between PACT ICU case conferences, while also supporting team dynamics and sustained relationships with patients. Many of these patients can and will typically seek care using the interdisciplinary trainees, and trainees were motivated to proactively coordinate warm handoffs and other models of transfer of care. PACT ICU has been successfully replicated and sustained at 4 of the 5 CoEPCE sites. The Caldwell CBOC PACT ICU has been up and running for 2 years, and 2 other nonacademic clinics have piloted PACT ICU managed care conferences thus far. Experience regarding the implementation at other academic sites has been published.⁵

Accomplishments and Benefits

There is evidence that PACT ICU is achieving its goals of improving trainee learning and patient outcomes. Trainees are using team skills to provide patient-centered care; trainees are strengthening their overall clinical skills by learning how to improve their responses to high-risk patients. There is also evidence of an increase in interprofessional warm handoffs within the clinic, in which “a clinician directly introduces a patient to another clinician at the time of the patient’s visit, and often a brief encounter between the patient and the health care professional occurs.”^4,6

Unlike a traditional didactic with classroom case conferences on interprofessional collaboration, PACT ICU is an opportunity for health care professionals to both learn and work together providing care in a clinic. Moreover, colocation of diverse trainee and faculty professions during the case conferences better prepares trainees to work with other professions and supports all participants to work and communicate as a team.

CoE staff have assessed educational outcomes before and after attendance in PACT ICU. On average, trainees (n = 30) said they found the PACT ICU case conferences to be “very helpful” in developing treatment plans. 

Interprofessional Collaboration

Team building and colocating trainees, faculty, and clinic staff from different professions are a primary focus of PACT ICU. The case conferences are designed to break down silos and foster a team approach to care. Trainees learn how the team works and the ways other professionals can help them take care of the patient. For example, trainees learn early about the contributions and expertise that the pharmacist and psychologist offer in terms of their scope of practice and referral opportunities. Additionally, the RN care manager increases the integration with the PACT clinical team by sharing pertinent information on individual patients. Based on recent trainee survey findings, the CoE has observed a positive change in the team dynamic and trainee ability to interface between professions. PACT ICU participants were more likely to make referrals to other members within the PACT team, such as a warm handoff during a clinic appointment, while they were less likely to seek a consult outside the team.⁷

Clinical Performance

The PACT ICU is an opportunity for a trainee to increase clinical expertise. It provides exposure to a variety of patientsand their care needs and serves as an opportunity to present a high-risk, challenging patient to colleagues of various professions. As of June 2018, 96 physician resident and NP residents have presented complex patient cases.

In addition, a structured forum for discussing patients and their care options strengthens team clinical performance, which supports people to work to the full scope of their practice. Trainees learn and apply team skills, such as communication and the warm handoff.

An interprofessional care plan that is delineated during the meeting supports the trainee and is carried out with help from consultants as needed. These consultants often facilitate plans for a covisit or warm handoff at the next clinic visit, a call from the RN care manager, a virtual clinic appointment, or other nontraditional visits. The clinic staff can get information from PCPs about patient’s plan of care, and PCPs get a more complete picture of a patient’s situation (eg, history, communications, and life-style factors). In addition, surveys of PACT ICU participants suggest the curriculum’s effectiveness at encouraging use of PACT principles within the clinic team and improving appropriate referrals to other members of the PACT team, such as pharmacy and behavioral health.

Patients presented at PACT ICU can be particularly challenging, so there may be a psychological benefit to working with a team to develop a new care plan. The PCPs who feel they are overwhelmed and have exhausted every option step back, get input, and look at the patient in a new light.

Related: Interprofessional Education in Patient Aligned Care Team Primary Care-Mental Health Integration

CoEPCE Function

The PACT ICU is flexible and has been adapted to different ambulatory care settings. Currently, PACT ICU case conferences take place at Boise VAMC, the Caldwell CBOCs, and more recently at a smaller CBOC in Burns, Oregon. The PACT ICU structure is slightly different in the clinic settings since the VA primary care clinic has different resources to draw upon, such as hospital and specialty services. The Caldwell CBOC was unable to protect time for PCPs, so it holds a monthly PACT ICU case conference. In addition to continuing expansion in other nonacademic PACT clinics and collaboration with other CoEPCE sites, work is underway to disseminate generalizable principles for interprofessional education, as well as exporting the model for implementation in non-VA settings.

Primary Care Services

The PACT ICU has the potential to create efficiencies in busy clinic settings. It strengthens communication between PCPs and is an opportunity to touch base on the patient, delegate care, and keep track of high-risk patients who might otherwise receive attention only when having an acute problem. Nurses gain a deeper understanding of the patients presented at PACT ICU.

PACT ICU leverages and builds on existing PACT resources in an achievable and sustainable manner benefiting primary care. CoE trainees, who are part of the Silver Team, tap in to the information that team nurses gain from checking in with these high-risk patients biweekly. Moreover, the integration with the Silver Team improves continuity, which helps enhance a patient’s level of trust. The relationship strengthened between primary care and behavioral health at the Caldwell CBOC, providing improved patient access and increased professional sharing.

Patient Outcomes

The PACT ICU provides a forum for input beyond that of the PCP. This feature results in a more robust treatment plan than might be developed by individual PCPs who might not have time to consider options that are outside their scope of practice. Formulating an enriched care plan, informed by multiple professions, has the potential to improve utilization and provide better care.

The Boise VAMC PACT ICU has presented 219 patients as of June 2018. While clinical outcomes data are difficult to collect, the CoE has data on utilization differences on all patients presented at the PACT ICU case conferences. This includes 4 control patients from the same PCP, with similarly high risk based on CAN scores at the time of selection. A single control patient is selected based on gender, closest age, and CAN score; this serves as a comparator for subsequent utilization analysis.

Data from the first 2 years of this study demonstrate that compared with the high-risk control group, there was an increase in contacts with PACT team members, including behavioral health, clinical pharmacists, and nurse care management, persisting up to 6 months following the PACT ICU presentation.⁴ However, PACT ICU participation did not increase the number of visits with the PCP, indicating better engagement with the entire team. Participation was associated with significantly decreased hospitalizations and a trend toward decreased ED visits. These findings persisted when compared with controls in the PCP’s panel with similar CAN scores, making “regression to the mean” often seen in these studies much less likely.

Analysis of patients early in the project suggests the possibility of improved glycemic control in patients with DM and improved blood pressure control in hypertensive patients presented at the PACT ICU compared with that of non-PACT ICU patients.⁸ Another potential benefit includes better team-based coordination. Because the patient now has a team focusing on care, this new dynamic results in improving outreach, identifying patients who could receive care by a telephone, and better preparing team members to establish rapport when the patient calls or comes in for a visit.

The Future

In stage 2 of the CoEPCE program, a multi-site trial of PACT ICU was completed to better understand which elements are critical to success, with the goal of facilitating broader exportability.⁵ The trial focused on 3 intertwined elements: structure, delivery, and evaluation. Using local implementation and the multisite trial, the most effective practices have been documented as part of an implementation kit, available at boisevacoe.org. The goal of the implementation kit is to facilitate step-by-step implementation of PACT ICU to other settings beyond the multisite study. Since the open-ended structure of PACT ICU enables accommodating different professions and specialties beyond the model’s Boise VAMC participants, it could be easily adapted to potentially support a variety of implementations elsewhere (Appendix).

Another opportunity for expansion is increased patient involvement. Currently, PACT ICU patients have the opportunity to review and ask questions about their multidisciplinary care plans before starting. 

This article is part of a series that illustrates strategies intended to redesign primary care education at the Veterans Health Administration (VHA), using interprofessional workplace learning. All have been implemented in the VA Centers of Excellence in Primary Care Education (CoEPCE). These models embody visionary transformation of clinical and educational environments that have potential for replication and dissemination throughout VA and other primary care clinical educational environments. For an introduction to the series see Klink K. Transforming primary care clinical learning environments to optimize education, outcomes, and satisfaction. Fed Pract. 2018;35(9):8-10.

Background

In 2011, 5 US Department of Veterans Affairs (VA) medical centers (VAMCs) were selected by the Office of Academic Affiliations (OAA) to establish CoEPCE. Part of the VA New Models of Care initiative, the 5 Centers of Excellence (CoE) in Boise, Idaho; Cleveland, Ohio; San Francisco, California; Seattle, Washington; and West Haven, Connecticut, are utilizing VA primary care settings to develop and test innovative approaches to prepare physician residents and students, advanced practice nurse residents and undergraduate nursing students, and other professions of health trainees (eg, pharmacy, social work, psychology, physician assistants [PAs]) for primary care practice in the 21st century.

The Boise CoE developed and implemented a practice-based learning model. Nurse practitioner (NP) students and residents, physician residents, pharmacy residents, psychology interns, and psychology postdoctoral fellows participate in a comprehensive curriculum and practice together for 1 to 3 years. The goal is to produce providers who are able to lead and practice health care in patient-centered primary care and rural care environments. All core curricula are interprofessionally coauthored and cotaught.¹

Methods

In 2015, OAA evaluators reviewed background documents and conducted open-ended interviews with 10 CoE staff, participating trainees, VA faculty, VA facility leadership, and affiliate faculty. In response to questions focused on their experiences, informants described lessons learned, challenges encountered, and benefits for participants, veterans, and the VA. Using a qualitative and quantitative approach, this case study draws on those interviews, surveys of PACT ICU (patient aligned care team interprofessional care update) participants, and analysis of presented patients to examine PACT ICU outcomes.

Related: Hypoglycemia Safety Initiative: Working With PACT Clinical Pharmacy Specialists to Individualize HbA1c Goals

Interprofessional Education and Care

A key CoEPCE aim is to create more clinical opportunities for CoE trainees from a variety of professions to work as a team in ways that anticipate and address the care needs of veterans. This emphasis on workplace learning is needed since most current health care professional education programs lack settings where trainees from different professions can learn and work together with their clinic partners to provide care for patients. With the emphasis on patient-centered medical homes (PCMH) and team-based care in the Affordable Care Act, there is an imperative to develop new training models that address this gap in the preparation of future health professionals. Along with this imperative, clinicians are increasingly required to optimize the health of complex patients who consequently require a multidisciplinary approach to care, particularly high-risk, high-needs patients inappropriately using services, such as frequent emergency department (ED) use.

Addressing Complex Needs

In 2010, the Boise VA Medical Center (VAMC) phased in patient aligned care teams (PACTs), the VA-mandated version of PCMH that consist of a physician or NP primary care provider (PCP), a registered nurse (RN) care manager, a licensed vocational nurse (LVN), and a medical support assistant (MSA). 

The PACT ICU also serves as a venue in which trainees and supervisors from different professions use a patient-centered framework to collaborate on these specific patient cases. The PACT ICU is easily applied to a range of health conditions, such as diabetes mellitus (DM), mental and behavioral health, lack of social support, and delivery system issues, such as ED use. The goals of PACT ICU are to improve the quality and satisfaction of patient care for high-risk patients; encourage appropriate use of health care resources by prioritizing continuity with the PACT team; and enhance interprofessional PACT team function, decreasing PCP and staff stress.

Planning and Implementation

In January 2013, Boise VAMC and the Caldwell, Idaho community-based outpatient clinic (CBOC) implemented PACT ICU. Other nonteaching clinics followed later in the year. Planning and executing PACT ICU took about 10 hours of CoE staff time and required no change in Boise VAMC policy. Program leadership approval was necessary for participation of CoE residents and postdocs. Service-line leadership support was required to protect clinic staff time (nurse care manager, social workers, chaplaincy, and ethics service). At the Caldwell CBOC, the section chief approved the program, and it took about 1 month to initiate a similar version of PACT ICU.

Curriculum

PACT ICU is a workplace clinical activity with roots in the case conference model, specifically the EFECT model (Elicit the narrative of illness, Facilitate a group meeting, Evidence-based gap analysis, Care plan, and Track changes).³ PACT ICU emphasizes a patient-centered approach to developing care plans. Staff review the 5 highest risk patients who are identified by the VA Care Assessment Need (CAN) registry. The CAN is an analytic tool that is available throughout VA and estimates patients’ risk of mortality or hospitalization in the following 90 days. Physician and NP residents choose 1 of the 5 patients to discuss in PACT ICU, while the remaining 4 serve as case-control comparisons to examine long-term patient outcomes. All trainees, faculty, and staff are provided patient data that can be discussed on a secure website.

The PACT ICU combines didactic teaching with workplace learning. For example, the patient’s medical issues may lead to a formal presentation about a topic, such as secondary stroke medication prophylaxis. The workplace learning occurs as the trainees observe and participate in the decision making toward a treatment plan. Interprofessional interactions are role-modeled by clinical faculty and staff during these discussions, and the result impact the patients care. PACT ICU embodies the core domains that shape the CoEPCE curriculum: Interprofessional collaboration (IPC), performance improvement (PI), sustained relationships (SR), and shared decision making (SDM) (Table 1). 

There have been some changes to the PACT ICU model over time. Initially, conferences took place on a weekly basis, to build momentum among the team and to normalize processes. After about 2 years, this decreased to every other week to reduce the time burden. Additionally, the CoE has strengthened the “tracking changes” component of the EFECT model—trainees now present a 5-minute update on the last patient they presented at the prior PACT ICU case conference. Most recently, psychology postdoctoral candidates have instituted preconference calls with patients to further improve the teams understanding of the patients’ perspective and narrative.

Related: Improving Team-Based Care Coordination Delivery and Documentation in the Health Record

Resources

The CoE faculty participate in an education program concerning facilitation of interprofessional meetings. All faculty are expected to role model collaborative behavior and mentor trainees on the cases they present.

The PACT ICU requires a room large enough to accommodate at least 12 people. One staff member is required to review patient cases prior to the case conferences (usually about 1 hour of preparation per case conference). Another staff person creates and shares a spreadsheet stored with VA-approved information security with data fields to include the site, PACT ICU date, patient identifier, the CAN score, and a checkbox for whether the patient was selected or part of a control group. Logistic support is required for reserving the room and sending information to presenters. A clinic-based RN with training in interprofessional care case management uses an online schedule to facilitate selection and review of patients. The RN care managers can use a secure management tool to track patient care and outreach.

The RN care manager also needs to be available to attend the PACT ICU case conferences. The Boise CoE built a website to share and standardize resources, such as a presenter schedule, PACT ICU worksheet, and provider questionnaire. (Contact Boise CoE staff for access.) For the initial evaluation of impact, PACT ICU utilized staff data support in the form of a data manager and biostatistician to identify, collect, and analyze data. While optional, this was helpful in refining the approach and demonstrating the impact of the project. Other resource-related requirements for exporting PACT ICU include:

• Staff members, usually RN care managers who coordinate meetings with participants and identify appropriate patients using a registry, such as CAN;
• Meeting facilitators who enforce use of the EFECT model and interprofessional participation to ensure that the interprofessional care plan is carried out by the presenting provider; and
• Interprofessional trainees and faculty who participate in PACT ICU and complete surveys after the first conference.

Monitoring and Assessment

The CoE staff have analyzed the evaluation of PACT ICU with participant self-evaluation, consultation referral patterns, and utilization data, combination of ED and episodic care visits along with hospitalizations).⁴ Pharmacy faculty are exploring the use polypharmacy registries, and psychology will use registries of poor psychosocial function.

Partnerships

Beyond support and engagement from VA CoEPCE and affiliate faculty, PACT ICU has greatly benefited from partnerships with VA facility department and CBOC leadership. The CoEPCE codirector and faculty are in facility committees, such as the PACT Strategic Planning Committee.

Academic affiliates are integral partners who assist with NP student and resident recruitment as well as participate in the planning and refinement of CoEPCE components. PACT ICU supports their mandate to encourage interprofessional teamwork. Faculty members from Gonzaga University (NP affiliate) were involved in the initial discussion on PACT ICU and consider it a “learning laboratory” to work through challenging problems. Gonzaga CoEPCE NP trainees are asked to talk about their PACT ICU experience—its strengths, weaknesses, and challenges—to other Gonzaga students who don’t have exposure to the team experience.

Challenges and Solutions

The demand for direct patient care puts pressure on indirect patient care approaches like PACT ICU, which is a time-intensive process with high impact on only a small number of patients. The argument for deploying strategies such as PACT ICU is that managing chronic conditions and encouraging appropriate use of services will improve outcomes for the highest risk patients and save important system resources in the long-run. However, in the short-term, a strong case must be made for the diversion of resources from usual clinic flow, particularly securing recurring blocks of provider time and clinic staff members. In addition, issues about team communication and understanding of appropriate team-based care can overflow to complex patients not presented in the PACT ICU conference.

Providing a facilitated interprofessional venue to discuss how to appropriately coordinate care improves the participation and perceived value of different team members. This approach has led to improved engagement of the team for patients discussed in the PACT ICU, as well as in general care within the participating clinic. With recent changes, the VA does see a workload benefit, and participants get encounter credit through “Non face-to-face prolonged service” codes (CPT 99358/99359), and other possibilities exist related to clinical team conference codes (CPT 99367-8) and complex chronic care management codes (CPT 99487-89). More information on documentation, scheduling and encountering/billing can be found at boisevacoe.org under Products. Other challenges include logistic challenges of finding appropriate patients and distributing sensitive patient information among the team. Additionally, PACT ICU has to wrestle with staffing shortages and episodic participation by some professions that are chronically understaffed. We have addressed many of these problems by receiving buy-in from both leadership and participants. Leadership have allowed time for participation in clinic staff schedules, and each participant has committed to recruiting a substitute in case of a schedule conflict.

Factors for Success

The commitment from the Boise VAMC facility, primary care clinic leadership and affiliated training programs to support staff and trainee participation also has been critical. Additionally, VA facility leadership commitment to ongoing improvements to PACT implementation was a key facilitating factor. Colocation of trainees and clinic staff on the academic PACT team facilitates communication between PACT ICU case conferences, while also supporting team dynamics and sustained relationships with patients. Many of these patients can and will typically seek care using the interdisciplinary trainees, and trainees were motivated to proactively coordinate warm handoffs and other models of transfer of care. PACT ICU has been successfully replicated and sustained at 4 of the 5 CoEPCE sites. The Caldwell CBOC PACT ICU has been up and running for 2 years, and 2 other nonacademic clinics have piloted PACT ICU managed care conferences thus far. Experience regarding the implementation at other academic sites has been published.⁵

Accomplishments and Benefits

There is evidence that PACT ICU is achieving its goals of improving trainee learning and patient outcomes. Trainees are using team skills to provide patient-centered care; trainees are strengthening their overall clinical skills by learning how to improve their responses to high-risk patients. There is also evidence of an increase in interprofessional warm handoffs within the clinic, in which “a clinician directly introduces a patient to another clinician at the time of the patient’s visit, and often a brief encounter between the patient and the health care professional occurs.”^4,6

Unlike a traditional didactic with classroom case conferences on interprofessional collaboration, PACT ICU is an opportunity for health care professionals to both learn and work together providing care in a clinic. Moreover, colocation of diverse trainee and faculty professions during the case conferences better prepares trainees to work with other professions and supports all participants to work and communicate as a team.

CoE staff have assessed educational outcomes before and after attendance in PACT ICU. On average, trainees (n = 30) said they found the PACT ICU case conferences to be “very helpful” in developing treatment plans. 

Interprofessional Collaboration

Team building and colocating trainees, faculty, and clinic staff from different professions are a primary focus of PACT ICU. The case conferences are designed to break down silos and foster a team approach to care. Trainees learn how the team works and the ways other professionals can help them take care of the patient. For example, trainees learn early about the contributions and expertise that the pharmacist and psychologist offer in terms of their scope of practice and referral opportunities. Additionally, the RN care manager increases the integration with the PACT clinical team by sharing pertinent information on individual patients. Based on recent trainee survey findings, the CoE has observed a positive change in the team dynamic and trainee ability to interface between professions. PACT ICU participants were more likely to make referrals to other members within the PACT team, such as a warm handoff during a clinic appointment, while they were less likely to seek a consult outside the team.⁷

Clinical Performance

The PACT ICU is an opportunity for a trainee to increase clinical expertise. It provides exposure to a variety of patientsand their care needs and serves as an opportunity to present a high-risk, challenging patient to colleagues of various professions. As of June 2018, 96 physician resident and NP residents have presented complex patient cases.

In addition, a structured forum for discussing patients and their care options strengthens team clinical performance, which supports people to work to the full scope of their practice. Trainees learn and apply team skills, such as communication and the warm handoff.

An interprofessional care plan that is delineated during the meeting supports the trainee and is carried out with help from consultants as needed. These consultants often facilitate plans for a covisit or warm handoff at the next clinic visit, a call from the RN care manager, a virtual clinic appointment, or other nontraditional visits. The clinic staff can get information from PCPs about patient’s plan of care, and PCPs get a more complete picture of a patient’s situation (eg, history, communications, and life-style factors). In addition, surveys of PACT ICU participants suggest the curriculum’s effectiveness at encouraging use of PACT principles within the clinic team and improving appropriate referrals to other members of the PACT team, such as pharmacy and behavioral health.

Patients presented at PACT ICU can be particularly challenging, so there may be a psychological benefit to working with a team to develop a new care plan. The PCPs who feel they are overwhelmed and have exhausted every option step back, get input, and look at the patient in a new light.

Related: Interprofessional Education in Patient Aligned Care Team Primary Care-Mental Health Integration

CoEPCE Function

The PACT ICU is flexible and has been adapted to different ambulatory care settings. Currently, PACT ICU case conferences take place at Boise VAMC, the Caldwell CBOCs, and more recently at a smaller CBOC in Burns, Oregon. The PACT ICU structure is slightly different in the clinic settings since the VA primary care clinic has different resources to draw upon, such as hospital and specialty services. The Caldwell CBOC was unable to protect time for PCPs, so it holds a monthly PACT ICU case conference. In addition to continuing expansion in other nonacademic PACT clinics and collaboration with other CoEPCE sites, work is underway to disseminate generalizable principles for interprofessional education, as well as exporting the model for implementation in non-VA settings.

Primary Care Services

The PACT ICU has the potential to create efficiencies in busy clinic settings. It strengthens communication between PCPs and is an opportunity to touch base on the patient, delegate care, and keep track of high-risk patients who might otherwise receive attention only when having an acute problem. Nurses gain a deeper understanding of the patients presented at PACT ICU.

PACT ICU leverages and builds on existing PACT resources in an achievable and sustainable manner benefiting primary care. CoE trainees, who are part of the Silver Team, tap in to the information that team nurses gain from checking in with these high-risk patients biweekly. Moreover, the integration with the Silver Team improves continuity, which helps enhance a patient’s level of trust. The relationship strengthened between primary care and behavioral health at the Caldwell CBOC, providing improved patient access and increased professional sharing.

Patient Outcomes

The PACT ICU provides a forum for input beyond that of the PCP. This feature results in a more robust treatment plan than might be developed by individual PCPs who might not have time to consider options that are outside their scope of practice. Formulating an enriched care plan, informed by multiple professions, has the potential to improve utilization and provide better care.

The Boise VAMC PACT ICU has presented 219 patients as of June 2018. While clinical outcomes data are difficult to collect, the CoE has data on utilization differences on all patients presented at the PACT ICU case conferences. This includes 4 control patients from the same PCP, with similarly high risk based on CAN scores at the time of selection. A single control patient is selected based on gender, closest age, and CAN score; this serves as a comparator for subsequent utilization analysis.

Data from the first 2 years of this study demonstrate that compared with the high-risk control group, there was an increase in contacts with PACT team members, including behavioral health, clinical pharmacists, and nurse care management, persisting up to 6 months following the PACT ICU presentation.⁴ However, PACT ICU participation did not increase the number of visits with the PCP, indicating better engagement with the entire team. Participation was associated with significantly decreased hospitalizations and a trend toward decreased ED visits. These findings persisted when compared with controls in the PCP’s panel with similar CAN scores, making “regression to the mean” often seen in these studies much less likely.

Analysis of patients early in the project suggests the possibility of improved glycemic control in patients with DM and improved blood pressure control in hypertensive patients presented at the PACT ICU compared with that of non-PACT ICU patients.⁸ Another potential benefit includes better team-based coordination. Because the patient now has a team focusing on care, this new dynamic results in improving outreach, identifying patients who could receive care by a telephone, and better preparing team members to establish rapport when the patient calls or comes in for a visit.

The Future

In stage 2 of the CoEPCE program, a multi-site trial of PACT ICU was completed to better understand which elements are critical to success, with the goal of facilitating broader exportability.⁵ The trial focused on 3 intertwined elements: structure, delivery, and evaluation. Using local implementation and the multisite trial, the most effective practices have been documented as part of an implementation kit, available at boisevacoe.org. The goal of the implementation kit is to facilitate step-by-step implementation of PACT ICU to other settings beyond the multisite study. Since the open-ended structure of PACT ICU enables accommodating different professions and specialties beyond the model’s Boise VAMC participants, it could be easily adapted to potentially support a variety of implementations elsewhere (Appendix).

Another opportunity for expansion is increased patient involvement. Currently, PACT ICU patients have the opportunity to review and ask questions about their multidisciplinary care plans before starting. 

This article is part of a series that illustrates strategies intended to redesign primary care education at the Veterans Health Administration (VHA), using interprofessional workplace learning. All have been implemented in the VA Centers of Excellence in Primary Care Education (CoEPCE). These models embody visionary transformation of clinical and educational environments that have potential for replication and dissemination throughout VA and other primary care clinical educational environments. For an introduction to the series see Klink K. Transforming primary care clinical learning environments to optimize education, outcomes, and satisfaction. Fed Pract. 2018;35(9):8-10.

Background

In 2011, 5 US Department of Veterans Affairs (VA) medical centers (VAMCs) were selected by the Office of Academic Affiliations (OAA) to establish CoEPCE. Part of the VA New Models of Care initiative, the 5 Centers of Excellence (CoE) in Boise, Idaho; Cleveland, Ohio; San Francisco, California; Seattle, Washington; and West Haven, Connecticut, are utilizing VA primary care settings to develop and test innovative approaches to prepare physician residents and students, advanced practice nurse residents and undergraduate nursing students, and other professions of health trainees (eg, pharmacy, social work, psychology, physician assistants [PAs]) for primary care practice in the 21st century.

The Boise CoE developed and implemented a practice-based learning model. Nurse practitioner (NP) students and residents, physician residents, pharmacy residents, psychology interns, and psychology postdoctoral fellows participate in a comprehensive curriculum and practice together for 1 to 3 years. The goal is to produce providers who are able to lead and practice health care in patient-centered primary care and rural care environments. All core curricula are interprofessionally coauthored and cotaught.¹

Methods

In 2015, OAA evaluators reviewed background documents and conducted open-ended interviews with 10 CoE staff, participating trainees, VA faculty, VA facility leadership, and affiliate faculty. In response to questions focused on their experiences, informants described lessons learned, challenges encountered, and benefits for participants, veterans, and the VA. Using a qualitative and quantitative approach, this case study draws on those interviews, surveys of PACT ICU (patient aligned care team interprofessional care update) participants, and analysis of presented patients to examine PACT ICU outcomes.

Related: Hypoglycemia Safety Initiative: Working With PACT Clinical Pharmacy Specialists to Individualize HbA1c Goals

Interprofessional Education and Care

A key CoEPCE aim is to create more clinical opportunities for CoE trainees from a variety of professions to work as a team in ways that anticipate and address the care needs of veterans. This emphasis on workplace learning is needed since most current health care professional education programs lack settings where trainees from different professions can learn and work together with their clinic partners to provide care for patients. With the emphasis on patient-centered medical homes (PCMH) and team-based care in the Affordable Care Act, there is an imperative to develop new training models that address this gap in the preparation of future health professionals. Along with this imperative, clinicians are increasingly required to optimize the health of complex patients who consequently require a multidisciplinary approach to care, particularly high-risk, high-needs patients inappropriately using services, such as frequent emergency department (ED) use.

Addressing Complex Needs

In 2010, the Boise VA Medical Center (VAMC) phased in patient aligned care teams (PACTs), the VA-mandated version of PCMH that consist of a physician or NP primary care provider (PCP), a registered nurse (RN) care manager, a licensed vocational nurse (LVN), and a medical support assistant (MSA). 

The PACT ICU also serves as a venue in which trainees and supervisors from different professions use a patient-centered framework to collaborate on these specific patient cases. The PACT ICU is easily applied to a range of health conditions, such as diabetes mellitus (DM), mental and behavioral health, lack of social support, and delivery system issues, such as ED use. The goals of PACT ICU are to improve the quality and satisfaction of patient care for high-risk patients; encourage appropriate use of health care resources by prioritizing continuity with the PACT team; and enhance interprofessional PACT team function, decreasing PCP and staff stress.

Planning and Implementation

In January 2013, Boise VAMC and the Caldwell, Idaho community-based outpatient clinic (CBOC) implemented PACT ICU. Other nonteaching clinics followed later in the year. Planning and executing PACT ICU took about 10 hours of CoE staff time and required no change in Boise VAMC policy. Program leadership approval was necessary for participation of CoE residents and postdocs. Service-line leadership support was required to protect clinic staff time (nurse care manager, social workers, chaplaincy, and ethics service). At the Caldwell CBOC, the section chief approved the program, and it took about 1 month to initiate a similar version of PACT ICU.

Curriculum

PACT ICU is a workplace clinical activity with roots in the case conference model, specifically the EFECT model (Elicit the narrative of illness, Facilitate a group meeting, Evidence-based gap analysis, Care plan, and Track changes).³ PACT ICU emphasizes a patient-centered approach to developing care plans. Staff review the 5 highest risk patients who are identified by the VA Care Assessment Need (CAN) registry. The CAN is an analytic tool that is available throughout VA and estimates patients’ risk of mortality or hospitalization in the following 90 days. Physician and NP residents choose 1 of the 5 patients to discuss in PACT ICU, while the remaining 4 serve as case-control comparisons to examine long-term patient outcomes. All trainees, faculty, and staff are provided patient data that can be discussed on a secure website.

The PACT ICU combines didactic teaching with workplace learning. For example, the patient’s medical issues may lead to a formal presentation about a topic, such as secondary stroke medication prophylaxis. The workplace learning occurs as the trainees observe and participate in the decision making toward a treatment plan. Interprofessional interactions are role-modeled by clinical faculty and staff during these discussions, and the result impact the patients care. PACT ICU embodies the core domains that shape the CoEPCE curriculum: Interprofessional collaboration (IPC), performance improvement (PI), sustained relationships (SR), and shared decision making (SDM) (Table 1). 

There have been some changes to the PACT ICU model over time. Initially, conferences took place on a weekly basis, to build momentum among the team and to normalize processes. After about 2 years, this decreased to every other week to reduce the time burden. Additionally, the CoE has strengthened the “tracking changes” component of the EFECT model—trainees now present a 5-minute update on the last patient they presented at the prior PACT ICU case conference. Most recently, psychology postdoctoral candidates have instituted preconference calls with patients to further improve the teams understanding of the patients’ perspective and narrative.

Related: Improving Team-Based Care Coordination Delivery and Documentation in the Health Record

Resources

The CoE faculty participate in an education program concerning facilitation of interprofessional meetings. All faculty are expected to role model collaborative behavior and mentor trainees on the cases they present.

The PACT ICU requires a room large enough to accommodate at least 12 people. One staff member is required to review patient cases prior to the case conferences (usually about 1 hour of preparation per case conference). Another staff person creates and shares a spreadsheet stored with VA-approved information security with data fields to include the site, PACT ICU date, patient identifier, the CAN score, and a checkbox for whether the patient was selected or part of a control group. Logistic support is required for reserving the room and sending information to presenters. A clinic-based RN with training in interprofessional care case management uses an online schedule to facilitate selection and review of patients. The RN care managers can use a secure management tool to track patient care and outreach.

The RN care manager also needs to be available to attend the PACT ICU case conferences. The Boise CoE built a website to share and standardize resources, such as a presenter schedule, PACT ICU worksheet, and provider questionnaire. (Contact Boise CoE staff for access.) For the initial evaluation of impact, PACT ICU utilized staff data support in the form of a data manager and biostatistician to identify, collect, and analyze data. While optional, this was helpful in refining the approach and demonstrating the impact of the project. Other resource-related requirements for exporting PACT ICU include:

• Staff members, usually RN care managers who coordinate meetings with participants and identify appropriate patients using a registry, such as CAN;
• Meeting facilitators who enforce use of the EFECT model and interprofessional participation to ensure that the interprofessional care plan is carried out by the presenting provider; and
• Interprofessional trainees and faculty who participate in PACT ICU and complete surveys after the first conference.

Monitoring and Assessment

The CoE staff have analyzed the evaluation of PACT ICU with participant self-evaluation, consultation referral patterns, and utilization data, combination of ED and episodic care visits along with hospitalizations).⁴ Pharmacy faculty are exploring the use polypharmacy registries, and psychology will use registries of poor psychosocial function.

Partnerships

Beyond support and engagement from VA CoEPCE and affiliate faculty, PACT ICU has greatly benefited from partnerships with VA facility department and CBOC leadership. The CoEPCE codirector and faculty are in facility committees, such as the PACT Strategic Planning Committee.

Academic affiliates are integral partners who assist with NP student and resident recruitment as well as participate in the planning and refinement of CoEPCE components. PACT ICU supports their mandate to encourage interprofessional teamwork. Faculty members from Gonzaga University (NP affiliate) were involved in the initial discussion on PACT ICU and consider it a “learning laboratory” to work through challenging problems. Gonzaga CoEPCE NP trainees are asked to talk about their PACT ICU experience—its strengths, weaknesses, and challenges—to other Gonzaga students who don’t have exposure to the team experience.

Challenges and Solutions

The demand for direct patient care puts pressure on indirect patient care approaches like PACT ICU, which is a time-intensive process with high impact on only a small number of patients. The argument for deploying strategies such as PACT ICU is that managing chronic conditions and encouraging appropriate use of services will improve outcomes for the highest risk patients and save important system resources in the long-run. However, in the short-term, a strong case must be made for the diversion of resources from usual clinic flow, particularly securing recurring blocks of provider time and clinic staff members. In addition, issues about team communication and understanding of appropriate team-based care can overflow to complex patients not presented in the PACT ICU conference.

Providing a facilitated interprofessional venue to discuss how to appropriately coordinate care improves the participation and perceived value of different team members. This approach has led to improved engagement of the team for patients discussed in the PACT ICU, as well as in general care within the participating clinic. With recent changes, the VA does see a workload benefit, and participants get encounter credit through “Non face-to-face prolonged service” codes (CPT 99358/99359), and other possibilities exist related to clinical team conference codes (CPT 99367-8) and complex chronic care management codes (CPT 99487-89). More information on documentation, scheduling and encountering/billing can be found at boisevacoe.org under Products. Other challenges include logistic challenges of finding appropriate patients and distributing sensitive patient information among the team. Additionally, PACT ICU has to wrestle with staffing shortages and episodic participation by some professions that are chronically understaffed. We have addressed many of these problems by receiving buy-in from both leadership and participants. Leadership have allowed time for participation in clinic staff schedules, and each participant has committed to recruiting a substitute in case of a schedule conflict.

Factors for Success

The commitment from the Boise VAMC facility, primary care clinic leadership and affiliated training programs to support staff and trainee participation also has been critical. Additionally, VA facility leadership commitment to ongoing improvements to PACT implementation was a key facilitating factor. Colocation of trainees and clinic staff on the academic PACT team facilitates communication between PACT ICU case conferences, while also supporting team dynamics and sustained relationships with patients. Many of these patients can and will typically seek care using the interdisciplinary trainees, and trainees were motivated to proactively coordinate warm handoffs and other models of transfer of care. PACT ICU has been successfully replicated and sustained at 4 of the 5 CoEPCE sites. The Caldwell CBOC PACT ICU has been up and running for 2 years, and 2 other nonacademic clinics have piloted PACT ICU managed care conferences thus far. Experience regarding the implementation at other academic sites has been published.⁵

Accomplishments and Benefits

There is evidence that PACT ICU is achieving its goals of improving trainee learning and patient outcomes. Trainees are using team skills to provide patient-centered care; trainees are strengthening their overall clinical skills by learning how to improve their responses to high-risk patients. There is also evidence of an increase in interprofessional warm handoffs within the clinic, in which “a clinician directly introduces a patient to another clinician at the time of the patient’s visit, and often a brief encounter between the patient and the health care professional occurs.”^4,6

Unlike a traditional didactic with classroom case conferences on interprofessional collaboration, PACT ICU is an opportunity for health care professionals to both learn and work together providing care in a clinic. Moreover, colocation of diverse trainee and faculty professions during the case conferences better prepares trainees to work with other professions and supports all participants to work and communicate as a team.

CoE staff have assessed educational outcomes before and after attendance in PACT ICU. On average, trainees (n = 30) said they found the PACT ICU case conferences to be “very helpful” in developing treatment plans. 

Interprofessional Collaboration

Team building and colocating trainees, faculty, and clinic staff from different professions are a primary focus of PACT ICU. The case conferences are designed to break down silos and foster a team approach to care. Trainees learn how the team works and the ways other professionals can help them take care of the patient. For example, trainees learn early about the contributions and expertise that the pharmacist and psychologist offer in terms of their scope of practice and referral opportunities. Additionally, the RN care manager increases the integration with the PACT clinical team by sharing pertinent information on individual patients. Based on recent trainee survey findings, the CoE has observed a positive change in the team dynamic and trainee ability to interface between professions. PACT ICU participants were more likely to make referrals to other members within the PACT team, such as a warm handoff during a clinic appointment, while they were less likely to seek a consult outside the team.⁷

Clinical Performance

The PACT ICU is an opportunity for a trainee to increase clinical expertise. It provides exposure to a variety of patientsand their care needs and serves as an opportunity to present a high-risk, challenging patient to colleagues of various professions. As of June 2018, 96 physician resident and NP residents have presented complex patient cases.

In addition, a structured forum for discussing patients and their care options strengthens team clinical performance, which supports people to work to the full scope of their practice. Trainees learn and apply team skills, such as communication and the warm handoff.

An interprofessional care plan that is delineated during the meeting supports the trainee and is carried out with help from consultants as needed. These consultants often facilitate plans for a covisit or warm handoff at the next clinic visit, a call from the RN care manager, a virtual clinic appointment, or other nontraditional visits. The clinic staff can get information from PCPs about patient’s plan of care, and PCPs get a more complete picture of a patient’s situation (eg, history, communications, and life-style factors). In addition, surveys of PACT ICU participants suggest the curriculum’s effectiveness at encouraging use of PACT principles within the clinic team and improving appropriate referrals to other members of the PACT team, such as pharmacy and behavioral health.

Patients presented at PACT ICU can be particularly challenging, so there may be a psychological benefit to working with a team to develop a new care plan. The PCPs who feel they are overwhelmed and have exhausted every option step back, get input, and look at the patient in a new light.

Related: Interprofessional Education in Patient Aligned Care Team Primary Care-Mental Health Integration

CoEPCE Function

The PACT ICU is flexible and has been adapted to different ambulatory care settings. Currently, PACT ICU case conferences take place at Boise VAMC, the Caldwell CBOCs, and more recently at a smaller CBOC in Burns, Oregon. The PACT ICU structure is slightly different in the clinic settings since the VA primary care clinic has different resources to draw upon, such as hospital and specialty services. The Caldwell CBOC was unable to protect time for PCPs, so it holds a monthly PACT ICU case conference. In addition to continuing expansion in other nonacademic PACT clinics and collaboration with other CoEPCE sites, work is underway to disseminate generalizable principles for interprofessional education, as well as exporting the model for implementation in non-VA settings.

Primary Care Services

The PACT ICU has the potential to create efficiencies in busy clinic settings. It strengthens communication between PCPs and is an opportunity to touch base on the patient, delegate care, and keep track of high-risk patients who might otherwise receive attention only when having an acute problem. Nurses gain a deeper understanding of the patients presented at PACT ICU.

PACT ICU leverages and builds on existing PACT resources in an achievable and sustainable manner benefiting primary care. CoE trainees, who are part of the Silver Team, tap in to the information that team nurses gain from checking in with these high-risk patients biweekly. Moreover, the integration with the Silver Team improves continuity, which helps enhance a patient’s level of trust. The relationship strengthened between primary care and behavioral health at the Caldwell CBOC, providing improved patient access and increased professional sharing.

Patient Outcomes

The PACT ICU provides a forum for input beyond that of the PCP. This feature results in a more robust treatment plan than might be developed by individual PCPs who might not have time to consider options that are outside their scope of practice. Formulating an enriched care plan, informed by multiple professions, has the potential to improve utilization and provide better care.

The Boise VAMC PACT ICU has presented 219 patients as of June 2018. While clinical outcomes data are difficult to collect, the CoE has data on utilization differences on all patients presented at the PACT ICU case conferences. This includes 4 control patients from the same PCP, with similarly high risk based on CAN scores at the time of selection. A single control patient is selected based on gender, closest age, and CAN score; this serves as a comparator for subsequent utilization analysis.

Data from the first 2 years of this study demonstrate that compared with the high-risk control group, there was an increase in contacts with PACT team members, including behavioral health, clinical pharmacists, and nurse care management, persisting up to 6 months following the PACT ICU presentation.⁴ However, PACT ICU participation did not increase the number of visits with the PCP, indicating better engagement with the entire team. Participation was associated with significantly decreased hospitalizations and a trend toward decreased ED visits. These findings persisted when compared with controls in the PCP’s panel with similar CAN scores, making “regression to the mean” often seen in these studies much less likely.

Analysis of patients early in the project suggests the possibility of improved glycemic control in patients with DM and improved blood pressure control in hypertensive patients presented at the PACT ICU compared with that of non-PACT ICU patients.⁸ Another potential benefit includes better team-based coordination. Because the patient now has a team focusing on care, this new dynamic results in improving outreach, identifying patients who could receive care by a telephone, and better preparing team members to establish rapport when the patient calls or comes in for a visit.

The Future

In stage 2 of the CoEPCE program, a multi-site trial of PACT ICU was completed to better understand which elements are critical to success, with the goal of facilitating broader exportability.⁵ The trial focused on 3 intertwined elements: structure, delivery, and evaluation. Using local implementation and the multisite trial, the most effective practices have been documented as part of an implementation kit, available at boisevacoe.org. The goal of the implementation kit is to facilitate step-by-step implementation of PACT ICU to other settings beyond the multisite study. Since the open-ended structure of PACT ICU enables accommodating different professions and specialties beyond the model’s Boise VAMC participants, it could be easily adapted to potentially support a variety of implementations elsewhere (Appendix).

Another opportunity for expansion is increased patient involvement. Currently, PACT ICU patients have the opportunity to review and ask questions about their multidisciplinary care plans before starting. 

The evaluation of acute kidney injury (AKI) often starts with the classic prerenal, renal, and postrenal causalities, delineating a practical workable approach in its differential diagnosis. Accordingly, the history, physical examination, urinalysis, and kidney-bladder sonography are standard resources in the initial approach to renal disease assessment. Ultrasonography has a well-established role as an important adjuvant for postrenal diagnosis of renal failure. Nevertheless, most of the causes of AKI are prerenal and renal.

Some etiologies of kidney injury are sequelae of systemic diseases in which sonography can be diagnostically analogous to the history and physical examination. Furthermore, ultrasonography may be informative in various clinical scenarios, for example, patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). In this narrative review, the contribution of point-of-care (POC) sonography to the evaluation and management of AKI, CKD, and associated diseases are explored beyond the traditional sonogram uses for kidney biopsy, central catheter placement, and/or screening of hydronephrosis.

Two important elements made possible the incorporation of POC sonography into nephrology practice.^1,2 First, the development of handheld reliable and portable ultrasound devices and, second, the derived capacity of POC sonography to obtain objective signs of physiologic and/or pathophysiologic phenomena. The latter clinical application is realized through the incorporation of POC protocols into the modified focused assessment with sonography for trauma (FAST) examination in conjunction with limited echocardiography and lung sonography (Figure 1). 

These protocols have allowed the evaluation of extracellular volume, which is important to measure for the diagnosis and management of renal diseases. For example, the evaluation of lung water by POC ultrasonography for patients with ESRD is emerging as a promising tool. In a study of patients with ESRD undergoing hemodialysis, POC ultrasonography detected moderate-to-severe lung congestion in 45% of patients, most of whom (71%) were asymptomatic. Two years of follow-up of patients was associated with 3 to 4 times greater risk of heart attack and death, respectively, compared with individuals without congestion on sonography.^4-6 Thus, ultrasound assessment of lung water in patients with ESRD may prove to be an essential tool to assure an adequate ultrafiltration and improve patient outcomes.

Related: Nephrogenic Systemic Fibrosis in a Patient With Multiple Inflammatory Disorders

Acute Kidney Injury

Prerenal

The physical examination provides evaluation of effective arterial circulatory flow (EACF) and is clinically useful in the evaluation of prerenal azotemia. The utility is more obvious in the extremes of EACF. However, in the case of blood volume losses of > 10% or the physiologic equivalent, heart rate, blood pressure, skin turgor, urinary output, and capillary refill may be within normal limits. Obvious changes in these parameters during the physical examination are considered relatively late manifestations.^7-10 Therefore, prerenal failure is frequently diagnosed retrospectively after correction of the EACF through use of crystalloids, blood products, vasopressors, inotropic agents, discontinuation of antihypertensive agents, or treatment of its prerenal causes. Certain sonographic maneuvers, performed at the bedside during acute renal injury, may be useful in many patients to evaluate a multitude of prerenal causes of AKI.

Sonographic inferior vena cava (IVC) luminal diameter and inspiratory collapsibility together serve as a surrogate marker of preload venous return and right side heart function. Such imaging results have been shown to be more accurate than jugular venous distension on physical examination but only modestly helpful as a surrogate for central venous pressure (CVP), with more accuracy in the lower values of the CVP.¹¹ However, this procedure can be repeated often after volume resuscitation to achieve a 1.5- to 2.5-cm diameter dimension of the IVC and < 25% inspiratory collapsibility as a goal.

An IVC with a diameter > 2.5 cm in the context of a suspected prerenal AKI is more likely the consequence of heart failure (HF) rather than hypovolemia. The caveat to this finding is that pulmonary hypertension may induce false-positive results.^12,13 Hepatic vein dilation is another sign of HF and/or pulmonary hypertension. Furthermore, sonographic images of the left ventricle either from the parasternal long axis or subxiphoid approach can identify supranormal left ventricular ejection fraction (LVEF) or hyperdynamic heart as an important clue of the absolute or relative decrease of EACF.¹⁴ Conversely, a decrease in EACF in patients with low LVEF can be assessed qualitatively at the bedside in patients with systolic HF. Supporting evidence of prerenal azotemia as the result of HF can be suggested by the presence of pleural effusions and bilateral comet/rockets tails or B lines in lung sonography.¹⁵

The easily recognizable hypoechoic ascitic fluid in the presence of small, hyperechoic gross changes in the echocardiographic texture of liver may indicate a hepatorenal component as the cause of prerenal failure. A small increase of > 20% in the diameter of the portal vein with deep inspiration indicates portal hypertension, with a sensitivity of 80% and a specificity of 100%.^15,16 Other clinical scenarios leading to AKI in association with systemic hypotension may be identified quickly with the aid of POC sonography. These scenarios include cardiac tamponade, tension pneumothorax, right ventricular dysfunction (as a surrogate of pulmonary embolism), or an acute coronary event.^16,17 Alternatively, identifying the presence of severe left ventricular hypertrophy through POC ultrasonography in a patient with AKI and normal or low normal blood pressures may alert clinicians to the diagnosis of normotensive renal failure in individuals with previously unrecognized severe hypertension. In this clinical context, keeping mean arterial pressures higher than usual with vasopressors may improve renal function while decreasing dialysis utilization.^18-21

Likewise, in clinical scenarios of shock with AKI, POC ultrasonography has proven to be an indispensable tool. For example, rapid exploration of the biliary tree demonstrating anterior gallbladder wall thickening, a stone or sludge, common bile duct dilation, or perigallbladder inflammation suggests acute cholecystitis and/or cholangitis as the cause. The presence of dyspnea in association with hypotension and unilateral signs of a higher proportion of comet tails and/or a lung consolidation suggests pneumonia. Rapid differentiation between acute respiratory distress syndrome (ARDS) and pulmonary edema from HF is possible with ultrasonography. When pleural line abnormalities are seen, ARDS is a common cause.

POC ultrasonography will be key in management of ARDS, as ultrasound results will help avoid the use of excessive diuretics, which can result in renal hypoperfusion and AKI.²² In trauma patients, the ultrasound examination will identify free fluid (bleeding) as the source of the prerenal failure, along with its cause (aortic dissection, hepatic hemorrhage, splenic hemorrhage, ectopic pregnancy, etc).²³ Sonographic free air observed in the abdomen can provide the clue of a perforated viscus.²⁴ The sonographic image of an inflamed pancreas can suggest pancreatitis as the cause of the systemic hypotension. Ultimately, intravascular losses in the hypoechoic edematous bowel wall in obstruction, ileus, pseudomembranous, or infectious or autoimmune enterocolitis can lead to significant decreases in the EACF and cause prerenal injury.

Related: Prevalence of Suspicious Ultrasound Features in Hot Thyroid Nodules

Intrinsic Renal Disease

In intrinsic AKI, acute tubular necrosis (ATN), glomerulonephritis, and interstitial nephritis are the typical causes. Although no signs are specific to each of the potential causes, a poor corticomedullary differentiation, kidney size < 9 cm, and cortex size < 1 cm help to distinguish CKD from AKI, especially if no previous serum creatinine values are available. The early diagnosis of ATN continues to be clinically relevant in the management of acute renal failure. Despite not being a practical tool for POC sonography currently, the use of bedside Doppler repetitive renal vasculature measures of resistive index predict occurrence and severity of ATN in the critical care setting and are an independent risk factor for poor survival in arterial hypertension and HF.^25-30

Other POC sonographic evaluations of intrinsic AKI have been helpful in the following clinical scenarios. The presence of an ultrasonographic sign of sinusitis in the context of nephritic sediment and a rapid decline of renal function suggest antineutrophil cytoplasmic antibody (ANCA)-related vasculitis. Likewise, in younger adults, nephritic sediment and bilateral sonographic lung interstitial fluid in the absence of infection and a normal POC echocardiogram without significant edema elsewhere suggest glomerulonephritis in the category of pulmonary lung syndrome caused by antiglomerular basement membrane antibodies.

In the elderly, a similar systemic presentation suggests an ANCA vasculitis. Pleural effusion, synovitis, proteinuria, and/or hematuria will suggest lupus nephritis. Another important cause of acute renal failure in the critical care setting is intra-abdominal compartment syndrome. Here, bladder pressure measurement protocols are the standard of care. A human model evaluated the predictive value of intra-abdominal compartment syndrome pressures using the IVC square surface. In this study, a normal surface area of the IVC of > 1 cm²/m² excluded the presence of intra-abdominal hypertension 87.5% of the time. However, the sensitivity of detection of the intra-abdominal hypertension was only 67.5% when the surface area of the IVC was < 1 cm²/m².³¹

CKD and Associated Diseases

The diagnostic validity of ultrasonography is well established in adult-onset polycystic kidney disease. Bedside visualization of a parathyroid adenoma may be an important clue for a patient with CKD, echogenic kidneys, or nephrolithiasis with or without hypercalcemia to diagnose primary hyperparathyroidism. The sonographic diagnosis of abnormal parathyroid gland compared with parathyroid surgical exploration had a sensitivity, specificity, and positive predictive value of 74%, 96%, and 90%, respectively.³² In the clinical presentation of severe hypertension with headaches, ultrasonography at bedside can provide valuable diagnostic and risk assessment information of endocranial hypertension from measuring the optic nerve sheath. Sensitivity and specificity of papilledema was 90% and 79%, respectively, when 3.3 mm was the cutoff of the nerve sheath with a 30-degrees sign.³³ The carotid artery intima media thickness measured on sonography correlates with the future development of atherogenesis, left ventricular hypertrophy, cognition deficits, CKD, and cardiovascular disease in asymptomatic patients. An intima media thickness of > 1.1 mm has been associated with a higher cardiovascular mortality.

Early initiation of antihypertensive medications and/or statins has been suggested to lower risk in these asymptomatic patients.³⁴ The size and contour (smooth or irregular) of kidneys may provide clues to reflux nephropathy, dysplastic kidneys, radiation nephritis, or chronic pyelonephritis. The presence of nephrotic syndrome and abnormal free light chains ratio with a bedside echocardiogram showing the typical refractile myocardial walls with a peculiar speckled pattern is strongly suggestive of amyloidosis.³⁵ Conditions associated with chronic hypercalcemia, medullary sponge kidney, milk alkali syndrome, sarcoidosis, and distal renal tubular acidosis are causes of nephrocalcinosis. Some degree of CKD is a constant feature in nephrocalcinosis. The initial imaging of choice in nephrocalcinosis and specially the medullary type is ultrasonography preferable to X-ray and perhaps to computed tomography.³⁶

End-Stage Renal Disease

In a patient undergoing peritoneal dialysis with exit-site infection, the presence of > 1 mm radiolucent rim around the subcutaneous catheter after antibiotics has a bad prognosis and prompts catheter removal. This sonographic sign has a positive and negative predictive value for a tunneled infection of 84.6% and 94.1%, respectively.^37,38 A risk factor for peritonitis in peritoneal dialysis is air in the peritoneum, which can be seen in one-third of patients. These individuals have 2.4 times more risk of peritonitis compared with patients without pneumoperitoneum. The sensitivity and specificity of sonographic detection of pneumoperitoneum is 94% and 100%, respectively, using the scissor technique.³⁹ Proper training in performing home peritoneal dialysis decreases the incidence of pneumoperitoneum. Although not formally assessed, patient education and change in procedure techniques may decrease the incidence of pneumoperitoneum and peritonitis. The use of prelaparoscopic ultrasonography before insertion of the peritoneal dialysis catheter has detected intra-abdominal adhesions (visceral slide sign) with a sensitivity of 90% to 92%.⁴⁰

History and physical examination are frequently helpful in the diagnosis of malfunctioning arteriovenous fistulas (AVF) for inflow or outflow disturbances, with sensitivity ranging from 70% to 100% and specificity ranging from 71% to 93% compared with angiography. Frequently, POC limited ultrasound can be helpful for a problematic AVF, either for cannulation or diagnosis. The congruence of duplex sonography with arteriogram is 85% to 96%. Various etiologies of a dysfunctional AVF (pseudo- or true aneurysm, poor development, stenosis, thrombi, or accessory veins) can be observed in the dialysis unit through limited sonography.^41-44

After placement of a hemodialysis catheter using real-time ultrasonography, pneumohemothorax can be diagnosed reliably and rapidly. Catheter misplacement outside of the right atrium was detected by thoracic echocardiogram with a sensitivity of 96%, a specificity of 83%, and a positive predictive value of 98%.^45,46 Ultimately, ultrasonography may replace chest X-ray in most cases after central vein dialysis catheter placement in the acute care setting.

Postrenal Failure

The sensitivity of ultrasonography to detect dilation to hydronephrosis of the pelvicaliceal system is well established. Sonography is the diagnostic examination of choice in pregnancy and the initial screening test for the nonpregnant patient. Computed tomography is the preferred imaging study in nephroureterolithiasis; however, due to ionizing radiation and cost, ultrasonography is gaining popularity for initial and/or follow-up evaluations. The ureteral jet is a relatively unexplored color and Doppler sonographic methodology that can provide insight into pelvicalyceal peristalsis, potentially yielding evidence of functional obstruction.^47-51 Postvoid bladder residual volumes and bladder wall hypertrophy may provide important clues as to the cause(s) of the obstructive uropathy.

Telenephrology

In our institution, sonography is used in the evaluation of IVC, lungs, and kidneys via telemedicine. The probe is handled by trained nurses at the distant site. 

Cardiac Arrest in ESRD

Patients with ESRD may have sudden cardiac arrest as a result of several etiologies. During the advance cardiac life support algorithm, there is a brief period of evaluation of the electrical rhythm in which echocardiography can be helpful with the diagnosis immediately after the 2 initial minutes of cardiopulmonary resuscitation. An enlarged right ventricular cavity (> 2/3 of the left ventricle) is a sonographic sign of a pulmonary embolism.

Bedside sonography has the potential to alter the current guidelines of advance cardiac life support management. For example, if the bedside echo shows a significant pericardial effusion, a pericardiocentesis could be performed faster as it would be diagnosed faster. In addition, at times the heart may appear to be beating rapidly but there is a small amount of fluid (blood) within the cardiac chambers. This may be from an extreme case of dehydration for which rapid administration of IV fluids may help manage. Therefore, a quick bedside point of care echocardiography may reveal a cardiac anomaly that may be able to be restored in a efficient manner. 

Related: General Applications of Ultrasound in Rheumatology Practice

Conclusion

Ultrasonography at the POC provides an important and continuously expanding tool to improve nephrological diagnostic accuracy in concert with history and physical examination. Extracellular fluid evaluation is paramount in all kidney disease conditions. Recent clinical studies in lung ultrasonography suggest that the learning curve for the medical provider is quicker than with other organs. Because POC sonography in association with limited bedside echocardiography may reveal discriminatory signs of pneumonia and differentiate between cardiogenic vs noncardiogenic pulmonary edema, such imaging may be important cost-effective strategies in the management of dyspnea and in the categorization/etiology of AKI. Therefore, incorporation of POC sonography into clinical practice will require that medical schools, residency programs, and nephrology fellowship programs design teaching strategies within their respective curricula. Research studies with outcomes regarding diagnosis, morbidity, and mortality are necessary in these areas.

The evaluation of acute kidney injury (AKI) often starts with the classic prerenal, renal, and postrenal causalities, delineating a practical workable approach in its differential diagnosis. Accordingly, the history, physical examination, urinalysis, and kidney-bladder sonography are standard resources in the initial approach to renal disease assessment. Ultrasonography has a well-established role as an important adjuvant for postrenal diagnosis of renal failure. Nevertheless, most of the causes of AKI are prerenal and renal.

Some etiologies of kidney injury are sequelae of systemic diseases in which sonography can be diagnostically analogous to the history and physical examination. Furthermore, ultrasonography may be informative in various clinical scenarios, for example, patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). In this narrative review, the contribution of point-of-care (POC) sonography to the evaluation and management of AKI, CKD, and associated diseases are explored beyond the traditional sonogram uses for kidney biopsy, central catheter placement, and/or screening of hydronephrosis.

Two important elements made possible the incorporation of POC sonography into nephrology practice.^1,2 First, the development of handheld reliable and portable ultrasound devices and, second, the derived capacity of POC sonography to obtain objective signs of physiologic and/or pathophysiologic phenomena. The latter clinical application is realized through the incorporation of POC protocols into the modified focused assessment with sonography for trauma (FAST) examination in conjunction with limited echocardiography and lung sonography (Figure 1). 

These protocols have allowed the evaluation of extracellular volume, which is important to measure for the diagnosis and management of renal diseases. For example, the evaluation of lung water by POC ultrasonography for patients with ESRD is emerging as a promising tool. In a study of patients with ESRD undergoing hemodialysis, POC ultrasonography detected moderate-to-severe lung congestion in 45% of patients, most of whom (71%) were asymptomatic. Two years of follow-up of patients was associated with 3 to 4 times greater risk of heart attack and death, respectively, compared with individuals without congestion on sonography.^4-6 Thus, ultrasound assessment of lung water in patients with ESRD may prove to be an essential tool to assure an adequate ultrafiltration and improve patient outcomes.

Related: Nephrogenic Systemic Fibrosis in a Patient With Multiple Inflammatory Disorders

Acute Kidney Injury

Prerenal

The physical examination provides evaluation of effective arterial circulatory flow (EACF) and is clinically useful in the evaluation of prerenal azotemia. The utility is more obvious in the extremes of EACF. However, in the case of blood volume losses of > 10% or the physiologic equivalent, heart rate, blood pressure, skin turgor, urinary output, and capillary refill may be within normal limits. Obvious changes in these parameters during the physical examination are considered relatively late manifestations.^7-10 Therefore, prerenal failure is frequently diagnosed retrospectively after correction of the EACF through use of crystalloids, blood products, vasopressors, inotropic agents, discontinuation of antihypertensive agents, or treatment of its prerenal causes. Certain sonographic maneuvers, performed at the bedside during acute renal injury, may be useful in many patients to evaluate a multitude of prerenal causes of AKI.

Sonographic inferior vena cava (IVC) luminal diameter and inspiratory collapsibility together serve as a surrogate marker of preload venous return and right side heart function. Such imaging results have been shown to be more accurate than jugular venous distension on physical examination but only modestly helpful as a surrogate for central venous pressure (CVP), with more accuracy in the lower values of the CVP.¹¹ However, this procedure can be repeated often after volume resuscitation to achieve a 1.5- to 2.5-cm diameter dimension of the IVC and < 25% inspiratory collapsibility as a goal.

An IVC with a diameter > 2.5 cm in the context of a suspected prerenal AKI is more likely the consequence of heart failure (HF) rather than hypovolemia. The caveat to this finding is that pulmonary hypertension may induce false-positive results.^12,13 Hepatic vein dilation is another sign of HF and/or pulmonary hypertension. Furthermore, sonographic images of the left ventricle either from the parasternal long axis or subxiphoid approach can identify supranormal left ventricular ejection fraction (LVEF) or hyperdynamic heart as an important clue of the absolute or relative decrease of EACF.¹⁴ Conversely, a decrease in EACF in patients with low LVEF can be assessed qualitatively at the bedside in patients with systolic HF. Supporting evidence of prerenal azotemia as the result of HF can be suggested by the presence of pleural effusions and bilateral comet/rockets tails or B lines in lung sonography.¹⁵

The easily recognizable hypoechoic ascitic fluid in the presence of small, hyperechoic gross changes in the echocardiographic texture of liver may indicate a hepatorenal component as the cause of prerenal failure. A small increase of > 20% in the diameter of the portal vein with deep inspiration indicates portal hypertension, with a sensitivity of 80% and a specificity of 100%.^15,16 Other clinical scenarios leading to AKI in association with systemic hypotension may be identified quickly with the aid of POC sonography. These scenarios include cardiac tamponade, tension pneumothorax, right ventricular dysfunction (as a surrogate of pulmonary embolism), or an acute coronary event.^16,17 Alternatively, identifying the presence of severe left ventricular hypertrophy through POC ultrasonography in a patient with AKI and normal or low normal blood pressures may alert clinicians to the diagnosis of normotensive renal failure in individuals with previously unrecognized severe hypertension. In this clinical context, keeping mean arterial pressures higher than usual with vasopressors may improve renal function while decreasing dialysis utilization.^18-21

Likewise, in clinical scenarios of shock with AKI, POC ultrasonography has proven to be an indispensable tool. For example, rapid exploration of the biliary tree demonstrating anterior gallbladder wall thickening, a stone or sludge, common bile duct dilation, or perigallbladder inflammation suggests acute cholecystitis and/or cholangitis as the cause. The presence of dyspnea in association with hypotension and unilateral signs of a higher proportion of comet tails and/or a lung consolidation suggests pneumonia. Rapid differentiation between acute respiratory distress syndrome (ARDS) and pulmonary edema from HF is possible with ultrasonography. When pleural line abnormalities are seen, ARDS is a common cause.

POC ultrasonography will be key in management of ARDS, as ultrasound results will help avoid the use of excessive diuretics, which can result in renal hypoperfusion and AKI.²² In trauma patients, the ultrasound examination will identify free fluid (bleeding) as the source of the prerenal failure, along with its cause (aortic dissection, hepatic hemorrhage, splenic hemorrhage, ectopic pregnancy, etc).²³ Sonographic free air observed in the abdomen can provide the clue of a perforated viscus.²⁴ The sonographic image of an inflamed pancreas can suggest pancreatitis as the cause of the systemic hypotension. Ultimately, intravascular losses in the hypoechoic edematous bowel wall in obstruction, ileus, pseudomembranous, or infectious or autoimmune enterocolitis can lead to significant decreases in the EACF and cause prerenal injury.

Related: Prevalence of Suspicious Ultrasound Features in Hot Thyroid Nodules

Intrinsic Renal Disease

In intrinsic AKI, acute tubular necrosis (ATN), glomerulonephritis, and interstitial nephritis are the typical causes. Although no signs are specific to each of the potential causes, a poor corticomedullary differentiation, kidney size < 9 cm, and cortex size < 1 cm help to distinguish CKD from AKI, especially if no previous serum creatinine values are available. The early diagnosis of ATN continues to be clinically relevant in the management of acute renal failure. Despite not being a practical tool for POC sonography currently, the use of bedside Doppler repetitive renal vasculature measures of resistive index predict occurrence and severity of ATN in the critical care setting and are an independent risk factor for poor survival in arterial hypertension and HF.^25-30

Other POC sonographic evaluations of intrinsic AKI have been helpful in the following clinical scenarios. The presence of an ultrasonographic sign of sinusitis in the context of nephritic sediment and a rapid decline of renal function suggest antineutrophil cytoplasmic antibody (ANCA)-related vasculitis. Likewise, in younger adults, nephritic sediment and bilateral sonographic lung interstitial fluid in the absence of infection and a normal POC echocardiogram without significant edema elsewhere suggest glomerulonephritis in the category of pulmonary lung syndrome caused by antiglomerular basement membrane antibodies.

In the elderly, a similar systemic presentation suggests an ANCA vasculitis. Pleural effusion, synovitis, proteinuria, and/or hematuria will suggest lupus nephritis. Another important cause of acute renal failure in the critical care setting is intra-abdominal compartment syndrome. Here, bladder pressure measurement protocols are the standard of care. A human model evaluated the predictive value of intra-abdominal compartment syndrome pressures using the IVC square surface. In this study, a normal surface area of the IVC of > 1 cm²/m² excluded the presence of intra-abdominal hypertension 87.5% of the time. However, the sensitivity of detection of the intra-abdominal hypertension was only 67.5% when the surface area of the IVC was < 1 cm²/m².³¹

CKD and Associated Diseases

The diagnostic validity of ultrasonography is well established in adult-onset polycystic kidney disease. Bedside visualization of a parathyroid adenoma may be an important clue for a patient with CKD, echogenic kidneys, or nephrolithiasis with or without hypercalcemia to diagnose primary hyperparathyroidism. The sonographic diagnosis of abnormal parathyroid gland compared with parathyroid surgical exploration had a sensitivity, specificity, and positive predictive value of 74%, 96%, and 90%, respectively.³² In the clinical presentation of severe hypertension with headaches, ultrasonography at bedside can provide valuable diagnostic and risk assessment information of endocranial hypertension from measuring the optic nerve sheath. Sensitivity and specificity of papilledema was 90% and 79%, respectively, when 3.3 mm was the cutoff of the nerve sheath with a 30-degrees sign.³³ The carotid artery intima media thickness measured on sonography correlates with the future development of atherogenesis, left ventricular hypertrophy, cognition deficits, CKD, and cardiovascular disease in asymptomatic patients. An intima media thickness of > 1.1 mm has been associated with a higher cardiovascular mortality.

Early initiation of antihypertensive medications and/or statins has been suggested to lower risk in these asymptomatic patients.³⁴ The size and contour (smooth or irregular) of kidneys may provide clues to reflux nephropathy, dysplastic kidneys, radiation nephritis, or chronic pyelonephritis. The presence of nephrotic syndrome and abnormal free light chains ratio with a bedside echocardiogram showing the typical refractile myocardial walls with a peculiar speckled pattern is strongly suggestive of amyloidosis.³⁵ Conditions associated with chronic hypercalcemia, medullary sponge kidney, milk alkali syndrome, sarcoidosis, and distal renal tubular acidosis are causes of nephrocalcinosis. Some degree of CKD is a constant feature in nephrocalcinosis. The initial imaging of choice in nephrocalcinosis and specially the medullary type is ultrasonography preferable to X-ray and perhaps to computed tomography.³⁶

End-Stage Renal Disease

In a patient undergoing peritoneal dialysis with exit-site infection, the presence of > 1 mm radiolucent rim around the subcutaneous catheter after antibiotics has a bad prognosis and prompts catheter removal. This sonographic sign has a positive and negative predictive value for a tunneled infection of 84.6% and 94.1%, respectively.^37,38 A risk factor for peritonitis in peritoneal dialysis is air in the peritoneum, which can be seen in one-third of patients. These individuals have 2.4 times more risk of peritonitis compared with patients without pneumoperitoneum. The sensitivity and specificity of sonographic detection of pneumoperitoneum is 94% and 100%, respectively, using the scissor technique.³⁹ Proper training in performing home peritoneal dialysis decreases the incidence of pneumoperitoneum. Although not formally assessed, patient education and change in procedure techniques may decrease the incidence of pneumoperitoneum and peritonitis. The use of prelaparoscopic ultrasonography before insertion of the peritoneal dialysis catheter has detected intra-abdominal adhesions (visceral slide sign) with a sensitivity of 90% to 92%.⁴⁰

History and physical examination are frequently helpful in the diagnosis of malfunctioning arteriovenous fistulas (AVF) for inflow or outflow disturbances, with sensitivity ranging from 70% to 100% and specificity ranging from 71% to 93% compared with angiography. Frequently, POC limited ultrasound can be helpful for a problematic AVF, either for cannulation or diagnosis. The congruence of duplex sonography with arteriogram is 85% to 96%. Various etiologies of a dysfunctional AVF (pseudo- or true aneurysm, poor development, stenosis, thrombi, or accessory veins) can be observed in the dialysis unit through limited sonography.^41-44

After placement of a hemodialysis catheter using real-time ultrasonography, pneumohemothorax can be diagnosed reliably and rapidly. Catheter misplacement outside of the right atrium was detected by thoracic echocardiogram with a sensitivity of 96%, a specificity of 83%, and a positive predictive value of 98%.^45,46 Ultimately, ultrasonography may replace chest X-ray in most cases after central vein dialysis catheter placement in the acute care setting.

Postrenal Failure

The sensitivity of ultrasonography to detect dilation to hydronephrosis of the pelvicaliceal system is well established. Sonography is the diagnostic examination of choice in pregnancy and the initial screening test for the nonpregnant patient. Computed tomography is the preferred imaging study in nephroureterolithiasis; however, due to ionizing radiation and cost, ultrasonography is gaining popularity for initial and/or follow-up evaluations. The ureteral jet is a relatively unexplored color and Doppler sonographic methodology that can provide insight into pelvicalyceal peristalsis, potentially yielding evidence of functional obstruction.^47-51 Postvoid bladder residual volumes and bladder wall hypertrophy may provide important clues as to the cause(s) of the obstructive uropathy.

Telenephrology

In our institution, sonography is used in the evaluation of IVC, lungs, and kidneys via telemedicine. The probe is handled by trained nurses at the distant site. 

Cardiac Arrest in ESRD

Patients with ESRD may have sudden cardiac arrest as a result of several etiologies. During the advance cardiac life support algorithm, there is a brief period of evaluation of the electrical rhythm in which echocardiography can be helpful with the diagnosis immediately after the 2 initial minutes of cardiopulmonary resuscitation. An enlarged right ventricular cavity (> 2/3 of the left ventricle) is a sonographic sign of a pulmonary embolism.

Bedside sonography has the potential to alter the current guidelines of advance cardiac life support management. For example, if the bedside echo shows a significant pericardial effusion, a pericardiocentesis could be performed faster as it would be diagnosed faster. In addition, at times the heart may appear to be beating rapidly but there is a small amount of fluid (blood) within the cardiac chambers. This may be from an extreme case of dehydration for which rapid administration of IV fluids may help manage. Therefore, a quick bedside point of care echocardiography may reveal a cardiac anomaly that may be able to be restored in a efficient manner. 

Related: General Applications of Ultrasound in Rheumatology Practice

Conclusion

Ultrasonography at the POC provides an important and continuously expanding tool to improve nephrological diagnostic accuracy in concert with history and physical examination. Extracellular fluid evaluation is paramount in all kidney disease conditions. Recent clinical studies in lung ultrasonography suggest that the learning curve for the medical provider is quicker than with other organs. Because POC sonography in association with limited bedside echocardiography may reveal discriminatory signs of pneumonia and differentiate between cardiogenic vs noncardiogenic pulmonary edema, such imaging may be important cost-effective strategies in the management of dyspnea and in the categorization/etiology of AKI. Therefore, incorporation of POC sonography into clinical practice will require that medical schools, residency programs, and nephrology fellowship programs design teaching strategies within their respective curricula. Research studies with outcomes regarding diagnosis, morbidity, and mortality are necessary in these areas.

The evaluation of acute kidney injury (AKI) often starts with the classic prerenal, renal, and postrenal causalities, delineating a practical workable approach in its differential diagnosis. Accordingly, the history, physical examination, urinalysis, and kidney-bladder sonography are standard resources in the initial approach to renal disease assessment. Ultrasonography has a well-established role as an important adjuvant for postrenal diagnosis of renal failure. Nevertheless, most of the causes of AKI are prerenal and renal.

Some etiologies of kidney injury are sequelae of systemic diseases in which sonography can be diagnostically analogous to the history and physical examination. Furthermore, ultrasonography may be informative in various clinical scenarios, for example, patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). In this narrative review, the contribution of point-of-care (POC) sonography to the evaluation and management of AKI, CKD, and associated diseases are explored beyond the traditional sonogram uses for kidney biopsy, central catheter placement, and/or screening of hydronephrosis.

Two important elements made possible the incorporation of POC sonography into nephrology practice.^1,2 First, the development of handheld reliable and portable ultrasound devices and, second, the derived capacity of POC sonography to obtain objective signs of physiologic and/or pathophysiologic phenomena. The latter clinical application is realized through the incorporation of POC protocols into the modified focused assessment with sonography for trauma (FAST) examination in conjunction with limited echocardiography and lung sonography (Figure 1). 

These protocols have allowed the evaluation of extracellular volume, which is important to measure for the diagnosis and management of renal diseases. For example, the evaluation of lung water by POC ultrasonography for patients with ESRD is emerging as a promising tool. In a study of patients with ESRD undergoing hemodialysis, POC ultrasonography detected moderate-to-severe lung congestion in 45% of patients, most of whom (71%) were asymptomatic. Two years of follow-up of patients was associated with 3 to 4 times greater risk of heart attack and death, respectively, compared with individuals without congestion on sonography.^4-6 Thus, ultrasound assessment of lung water in patients with ESRD may prove to be an essential tool to assure an adequate ultrafiltration and improve patient outcomes.

Related: Nephrogenic Systemic Fibrosis in a Patient With Multiple Inflammatory Disorders

Acute Kidney Injury

Prerenal

The physical examination provides evaluation of effective arterial circulatory flow (EACF) and is clinically useful in the evaluation of prerenal azotemia. The utility is more obvious in the extremes of EACF. However, in the case of blood volume losses of > 10% or the physiologic equivalent, heart rate, blood pressure, skin turgor, urinary output, and capillary refill may be within normal limits. Obvious changes in these parameters during the physical examination are considered relatively late manifestations.^7-10 Therefore, prerenal failure is frequently diagnosed retrospectively after correction of the EACF through use of crystalloids, blood products, vasopressors, inotropic agents, discontinuation of antihypertensive agents, or treatment of its prerenal causes. Certain sonographic maneuvers, performed at the bedside during acute renal injury, may be useful in many patients to evaluate a multitude of prerenal causes of AKI.

Sonographic inferior vena cava (IVC) luminal diameter and inspiratory collapsibility together serve as a surrogate marker of preload venous return and right side heart function. Such imaging results have been shown to be more accurate than jugular venous distension on physical examination but only modestly helpful as a surrogate for central venous pressure (CVP), with more accuracy in the lower values of the CVP.¹¹ However, this procedure can be repeated often after volume resuscitation to achieve a 1.5- to 2.5-cm diameter dimension of the IVC and < 25% inspiratory collapsibility as a goal.

An IVC with a diameter > 2.5 cm in the context of a suspected prerenal AKI is more likely the consequence of heart failure (HF) rather than hypovolemia. The caveat to this finding is that pulmonary hypertension may induce false-positive results.^12,13 Hepatic vein dilation is another sign of HF and/or pulmonary hypertension. Furthermore, sonographic images of the left ventricle either from the parasternal long axis or subxiphoid approach can identify supranormal left ventricular ejection fraction (LVEF) or hyperdynamic heart as an important clue of the absolute or relative decrease of EACF.¹⁴ Conversely, a decrease in EACF in patients with low LVEF can be assessed qualitatively at the bedside in patients with systolic HF. Supporting evidence of prerenal azotemia as the result of HF can be suggested by the presence of pleural effusions and bilateral comet/rockets tails or B lines in lung sonography.¹⁵

The easily recognizable hypoechoic ascitic fluid in the presence of small, hyperechoic gross changes in the echocardiographic texture of liver may indicate a hepatorenal component as the cause of prerenal failure. A small increase of > 20% in the diameter of the portal vein with deep inspiration indicates portal hypertension, with a sensitivity of 80% and a specificity of 100%.^15,16 Other clinical scenarios leading to AKI in association with systemic hypotension may be identified quickly with the aid of POC sonography. These scenarios include cardiac tamponade, tension pneumothorax, right ventricular dysfunction (as a surrogate of pulmonary embolism), or an acute coronary event.^16,17 Alternatively, identifying the presence of severe left ventricular hypertrophy through POC ultrasonography in a patient with AKI and normal or low normal blood pressures may alert clinicians to the diagnosis of normotensive renal failure in individuals with previously unrecognized severe hypertension. In this clinical context, keeping mean arterial pressures higher than usual with vasopressors may improve renal function while decreasing dialysis utilization.^18-21

Likewise, in clinical scenarios of shock with AKI, POC ultrasonography has proven to be an indispensable tool. For example, rapid exploration of the biliary tree demonstrating anterior gallbladder wall thickening, a stone or sludge, common bile duct dilation, or perigallbladder inflammation suggests acute cholecystitis and/or cholangitis as the cause. The presence of dyspnea in association with hypotension and unilateral signs of a higher proportion of comet tails and/or a lung consolidation suggests pneumonia. Rapid differentiation between acute respiratory distress syndrome (ARDS) and pulmonary edema from HF is possible with ultrasonography. When pleural line abnormalities are seen, ARDS is a common cause.

POC ultrasonography will be key in management of ARDS, as ultrasound results will help avoid the use of excessive diuretics, which can result in renal hypoperfusion and AKI.²² In trauma patients, the ultrasound examination will identify free fluid (bleeding) as the source of the prerenal failure, along with its cause (aortic dissection, hepatic hemorrhage, splenic hemorrhage, ectopic pregnancy, etc).²³ Sonographic free air observed in the abdomen can provide the clue of a perforated viscus.²⁴ The sonographic image of an inflamed pancreas can suggest pancreatitis as the cause of the systemic hypotension. Ultimately, intravascular losses in the hypoechoic edematous bowel wall in obstruction, ileus, pseudomembranous, or infectious or autoimmune enterocolitis can lead to significant decreases in the EACF and cause prerenal injury.

Related: Prevalence of Suspicious Ultrasound Features in Hot Thyroid Nodules

Intrinsic Renal Disease

In intrinsic AKI, acute tubular necrosis (ATN), glomerulonephritis, and interstitial nephritis are the typical causes. Although no signs are specific to each of the potential causes, a poor corticomedullary differentiation, kidney size < 9 cm, and cortex size < 1 cm help to distinguish CKD from AKI, especially if no previous serum creatinine values are available. The early diagnosis of ATN continues to be clinically relevant in the management of acute renal failure. Despite not being a practical tool for POC sonography currently, the use of bedside Doppler repetitive renal vasculature measures of resistive index predict occurrence and severity of ATN in the critical care setting and are an independent risk factor for poor survival in arterial hypertension and HF.^25-30

Other POC sonographic evaluations of intrinsic AKI have been helpful in the following clinical scenarios. The presence of an ultrasonographic sign of sinusitis in the context of nephritic sediment and a rapid decline of renal function suggest antineutrophil cytoplasmic antibody (ANCA)-related vasculitis. Likewise, in younger adults, nephritic sediment and bilateral sonographic lung interstitial fluid in the absence of infection and a normal POC echocardiogram without significant edema elsewhere suggest glomerulonephritis in the category of pulmonary lung syndrome caused by antiglomerular basement membrane antibodies.

In the elderly, a similar systemic presentation suggests an ANCA vasculitis. Pleural effusion, synovitis, proteinuria, and/or hematuria will suggest lupus nephritis. Another important cause of acute renal failure in the critical care setting is intra-abdominal compartment syndrome. Here, bladder pressure measurement protocols are the standard of care. A human model evaluated the predictive value of intra-abdominal compartment syndrome pressures using the IVC square surface. In this study, a normal surface area of the IVC of > 1 cm²/m² excluded the presence of intra-abdominal hypertension 87.5% of the time. However, the sensitivity of detection of the intra-abdominal hypertension was only 67.5% when the surface area of the IVC was < 1 cm²/m².³¹

CKD and Associated Diseases

The diagnostic validity of ultrasonography is well established in adult-onset polycystic kidney disease. Bedside visualization of a parathyroid adenoma may be an important clue for a patient with CKD, echogenic kidneys, or nephrolithiasis with or without hypercalcemia to diagnose primary hyperparathyroidism. The sonographic diagnosis of abnormal parathyroid gland compared with parathyroid surgical exploration had a sensitivity, specificity, and positive predictive value of 74%, 96%, and 90%, respectively.³² In the clinical presentation of severe hypertension with headaches, ultrasonography at bedside can provide valuable diagnostic and risk assessment information of endocranial hypertension from measuring the optic nerve sheath. Sensitivity and specificity of papilledema was 90% and 79%, respectively, when 3.3 mm was the cutoff of the nerve sheath with a 30-degrees sign.³³ The carotid artery intima media thickness measured on sonography correlates with the future development of atherogenesis, left ventricular hypertrophy, cognition deficits, CKD, and cardiovascular disease in asymptomatic patients. An intima media thickness of > 1.1 mm has been associated with a higher cardiovascular mortality.

Early initiation of antihypertensive medications and/or statins has been suggested to lower risk in these asymptomatic patients.³⁴ The size and contour (smooth or irregular) of kidneys may provide clues to reflux nephropathy, dysplastic kidneys, radiation nephritis, or chronic pyelonephritis. The presence of nephrotic syndrome and abnormal free light chains ratio with a bedside echocardiogram showing the typical refractile myocardial walls with a peculiar speckled pattern is strongly suggestive of amyloidosis.³⁵ Conditions associated with chronic hypercalcemia, medullary sponge kidney, milk alkali syndrome, sarcoidosis, and distal renal tubular acidosis are causes of nephrocalcinosis. Some degree of CKD is a constant feature in nephrocalcinosis. The initial imaging of choice in nephrocalcinosis and specially the medullary type is ultrasonography preferable to X-ray and perhaps to computed tomography.³⁶

End-Stage Renal Disease

In a patient undergoing peritoneal dialysis with exit-site infection, the presence of > 1 mm radiolucent rim around the subcutaneous catheter after antibiotics has a bad prognosis and prompts catheter removal. This sonographic sign has a positive and negative predictive value for a tunneled infection of 84.6% and 94.1%, respectively.^37,38 A risk factor for peritonitis in peritoneal dialysis is air in the peritoneum, which can be seen in one-third of patients. These individuals have 2.4 times more risk of peritonitis compared with patients without pneumoperitoneum. The sensitivity and specificity of sonographic detection of pneumoperitoneum is 94% and 100%, respectively, using the scissor technique.³⁹ Proper training in performing home peritoneal dialysis decreases the incidence of pneumoperitoneum. Although not formally assessed, patient education and change in procedure techniques may decrease the incidence of pneumoperitoneum and peritonitis. The use of prelaparoscopic ultrasonography before insertion of the peritoneal dialysis catheter has detected intra-abdominal adhesions (visceral slide sign) with a sensitivity of 90% to 92%.⁴⁰

History and physical examination are frequently helpful in the diagnosis of malfunctioning arteriovenous fistulas (AVF) for inflow or outflow disturbances, with sensitivity ranging from 70% to 100% and specificity ranging from 71% to 93% compared with angiography. Frequently, POC limited ultrasound can be helpful for a problematic AVF, either for cannulation or diagnosis. The congruence of duplex sonography with arteriogram is 85% to 96%. Various etiologies of a dysfunctional AVF (pseudo- or true aneurysm, poor development, stenosis, thrombi, or accessory veins) can be observed in the dialysis unit through limited sonography.^41-44

After placement of a hemodialysis catheter using real-time ultrasonography, pneumohemothorax can be diagnosed reliably and rapidly. Catheter misplacement outside of the right atrium was detected by thoracic echocardiogram with a sensitivity of 96%, a specificity of 83%, and a positive predictive value of 98%.^45,46 Ultimately, ultrasonography may replace chest X-ray in most cases after central vein dialysis catheter placement in the acute care setting.

Postrenal Failure

The sensitivity of ultrasonography to detect dilation to hydronephrosis of the pelvicaliceal system is well established. Sonography is the diagnostic examination of choice in pregnancy and the initial screening test for the nonpregnant patient. Computed tomography is the preferred imaging study in nephroureterolithiasis; however, due to ionizing radiation and cost, ultrasonography is gaining popularity for initial and/or follow-up evaluations. The ureteral jet is a relatively unexplored color and Doppler sonographic methodology that can provide insight into pelvicalyceal peristalsis, potentially yielding evidence of functional obstruction.^47-51 Postvoid bladder residual volumes and bladder wall hypertrophy may provide important clues as to the cause(s) of the obstructive uropathy.

Telenephrology

In our institution, sonography is used in the evaluation of IVC, lungs, and kidneys via telemedicine. The probe is handled by trained nurses at the distant site. 

Cardiac Arrest in ESRD

Patients with ESRD may have sudden cardiac arrest as a result of several etiologies. During the advance cardiac life support algorithm, there is a brief period of evaluation of the electrical rhythm in which echocardiography can be helpful with the diagnosis immediately after the 2 initial minutes of cardiopulmonary resuscitation. An enlarged right ventricular cavity (> 2/3 of the left ventricle) is a sonographic sign of a pulmonary embolism.

Bedside sonography has the potential to alter the current guidelines of advance cardiac life support management. For example, if the bedside echo shows a significant pericardial effusion, a pericardiocentesis could be performed faster as it would be diagnosed faster. In addition, at times the heart may appear to be beating rapidly but there is a small amount of fluid (blood) within the cardiac chambers. This may be from an extreme case of dehydration for which rapid administration of IV fluids may help manage. Therefore, a quick bedside point of care echocardiography may reveal a cardiac anomaly that may be able to be restored in a efficient manner. 

Related: General Applications of Ultrasound in Rheumatology Practice

Conclusion

Ultrasonography at the POC provides an important and continuously expanding tool to improve nephrological diagnostic accuracy in concert with history and physical examination. Extracellular fluid evaluation is paramount in all kidney disease conditions. Recent clinical studies in lung ultrasonography suggest that the learning curve for the medical provider is quicker than with other organs. Because POC sonography in association with limited bedside echocardiography may reveal discriminatory signs of pneumonia and differentiate between cardiogenic vs noncardiogenic pulmonary edema, such imaging may be important cost-effective strategies in the management of dyspnea and in the categorization/etiology of AKI. Therefore, incorporation of POC sonography into clinical practice will require that medical schools, residency programs, and nephrology fellowship programs design teaching strategies within their respective curricula. Research studies with outcomes regarding diagnosis, morbidity, and mortality are necessary in these areas.

Although patients with multiple myeloma (MM) have an increased risk of developing venous thromboembolism (VTE), no validated model exists that predicts VTE in MM. To help health care providers better assess the risks and the appropriateness of thromboprophylaxis, a team of researchers have developed the IMPEDE VTE risk assessment tool.

According to Kristen M. Sanfilippo, MD, of Washington University School of Medicine and the St. Louis Veterans Affairs Medical Center in Missouri, who presented the paper at the American Society of Hematology meeting last week in San Diego, this is the first effort to build a tool that is both internally and externally validated. The goal was to develop a model that outperformed current National Comprehensive Cancer Network (NCCN) guidelines for VTE that are based on expert opinion and were not specific to patients with multiple myeloma.

“We evaluated the performance of the current NCCN and International Myeloma Working Group guidelines with the VA data and our model outperformed these guidelines. Our recommendations is that our IMPEDE VTE should be considered to replace them,” said Sanfilippo. "I think we can improve our predictability of thrombosis in myeloma by adding novel predictors to the model, but that would have to be assessed in a prospective manner.”

Using the VA Central Cancer Registry, the researchers identified 4,448 patients diagnosed with MM between 1999 and 2014 and retrospectively followed the patients for 180 days after start of MM chemotherapy. Using beta coefficients, the researchers developed a risk score by dividing by a common divisor and rounding to the nearest integer. The risk score for each patient was the sum of all scores for each predictor variable.

The factors associated with VTE were combined to develop the IMPEDE VTE score. The factors were: Immunomodulatory drugs, 3 points; BMI > 25,  1 point; Pathologic fracture pelvis/femur 2 points; Erythropoiesis-stimulating agents, 1 point, Dexamethasone (High-dose 4 points; low-dose 2 points)/Doxorubicin 2 points; Asian Ethnicity, -3 points; history of VTE, 3 points; Tunneled line/ central venous catheter, 2 points). In addition, use of therapeutic anticoagulation (-5 points) with warfarin or low molecular weight heparin (LWMH) and use of prophylactic LMWH or aspirin (-2 points) were associated with a decreased risk of VTE. The risk score then identifies patients’ VTE risk as low (≤ 3), intermediate (4-6), or high (≥ 7).

According to Sanfilippo, the model showed satisfactory discrimination in both the derivation cohort (Harrell’s c-statistic = 0.66) and in the bootstrap validation, c-statistic = 0.66 (95% CI: 0.63 – 0.70). Within the first 6-months of starting chemotherapy, the rate of VTE was 3.5% compared to > 10% for high-risk patients.

The researchers hoped that the risk prediction model for VTE in MM would allow for use of thromboprophylaxis in MM patients at high-risk of VTE while sparing those at low risk. 

Although patients with multiple myeloma (MM) have an increased risk of developing venous thromboembolism (VTE), no validated model exists that predicts VTE in MM. To help health care providers better assess the risks and the appropriateness of thromboprophylaxis, a team of researchers have developed the IMPEDE VTE risk assessment tool.

According to Kristen M. Sanfilippo, MD, of Washington University School of Medicine and the St. Louis Veterans Affairs Medical Center in Missouri, who presented the paper at the American Society of Hematology meeting last week in San Diego, this is the first effort to build a tool that is both internally and externally validated. The goal was to develop a model that outperformed current National Comprehensive Cancer Network (NCCN) guidelines for VTE that are based on expert opinion and were not specific to patients with multiple myeloma.

“We evaluated the performance of the current NCCN and International Myeloma Working Group guidelines with the VA data and our model outperformed these guidelines. Our recommendations is that our IMPEDE VTE should be considered to replace them,” said Sanfilippo. "I think we can improve our predictability of thrombosis in myeloma by adding novel predictors to the model, but that would have to be assessed in a prospective manner.”

Using the VA Central Cancer Registry, the researchers identified 4,448 patients diagnosed with MM between 1999 and 2014 and retrospectively followed the patients for 180 days after start of MM chemotherapy. Using beta coefficients, the researchers developed a risk score by dividing by a common divisor and rounding to the nearest integer. The risk score for each patient was the sum of all scores for each predictor variable.

The factors associated with VTE were combined to develop the IMPEDE VTE score. The factors were: Immunomodulatory drugs, 3 points; BMI > 25,  1 point; Pathologic fracture pelvis/femur 2 points; Erythropoiesis-stimulating agents, 1 point, Dexamethasone (High-dose 4 points; low-dose 2 points)/Doxorubicin 2 points; Asian Ethnicity, -3 points; history of VTE, 3 points; Tunneled line/ central venous catheter, 2 points). In addition, use of therapeutic anticoagulation (-5 points) with warfarin or low molecular weight heparin (LWMH) and use of prophylactic LMWH or aspirin (-2 points) were associated with a decreased risk of VTE. The risk score then identifies patients’ VTE risk as low (≤ 3), intermediate (4-6), or high (≥ 7).

According to Sanfilippo, the model showed satisfactory discrimination in both the derivation cohort (Harrell’s c-statistic = 0.66) and in the bootstrap validation, c-statistic = 0.66 (95% CI: 0.63 – 0.70). Within the first 6-months of starting chemotherapy, the rate of VTE was 3.5% compared to > 10% for high-risk patients.

The researchers hoped that the risk prediction model for VTE in MM would allow for use of thromboprophylaxis in MM patients at high-risk of VTE while sparing those at low risk. 

Although patients with multiple myeloma (MM) have an increased risk of developing venous thromboembolism (VTE), no validated model exists that predicts VTE in MM. To help health care providers better assess the risks and the appropriateness of thromboprophylaxis, a team of researchers have developed the IMPEDE VTE risk assessment tool.

According to Kristen M. Sanfilippo, MD, of Washington University School of Medicine and the St. Louis Veterans Affairs Medical Center in Missouri, who presented the paper at the American Society of Hematology meeting last week in San Diego, this is the first effort to build a tool that is both internally and externally validated. The goal was to develop a model that outperformed current National Comprehensive Cancer Network (NCCN) guidelines for VTE that are based on expert opinion and were not specific to patients with multiple myeloma.

“We evaluated the performance of the current NCCN and International Myeloma Working Group guidelines with the VA data and our model outperformed these guidelines. Our recommendations is that our IMPEDE VTE should be considered to replace them,” said Sanfilippo. "I think we can improve our predictability of thrombosis in myeloma by adding novel predictors to the model, but that would have to be assessed in a prospective manner.”

Using the VA Central Cancer Registry, the researchers identified 4,448 patients diagnosed with MM between 1999 and 2014 and retrospectively followed the patients for 180 days after start of MM chemotherapy. Using beta coefficients, the researchers developed a risk score by dividing by a common divisor and rounding to the nearest integer. The risk score for each patient was the sum of all scores for each predictor variable.

The factors associated with VTE were combined to develop the IMPEDE VTE score. The factors were: Immunomodulatory drugs, 3 points; BMI > 25,  1 point; Pathologic fracture pelvis/femur 2 points; Erythropoiesis-stimulating agents, 1 point, Dexamethasone (High-dose 4 points; low-dose 2 points)/Doxorubicin 2 points; Asian Ethnicity, -3 points; history of VTE, 3 points; Tunneled line/ central venous catheter, 2 points). In addition, use of therapeutic anticoagulation (-5 points) with warfarin or low molecular weight heparin (LWMH) and use of prophylactic LMWH or aspirin (-2 points) were associated with a decreased risk of VTE. The risk score then identifies patients’ VTE risk as low (≤ 3), intermediate (4-6), or high (≥ 7).

According to Sanfilippo, the model showed satisfactory discrimination in both the derivation cohort (Harrell’s c-statistic = 0.66) and in the bootstrap validation, c-statistic = 0.66 (95% CI: 0.63 – 0.70). Within the first 6-months of starting chemotherapy, the rate of VTE was 3.5% compared to > 10% for high-risk patients.

The researchers hoped that the risk prediction model for VTE in MM would allow for use of thromboprophylaxis in MM patients at high-risk of VTE while sparing those at low risk. 

This week, apixaban edges out other DOACs for octogenarians, methotrexate fails to cut cardiovascular events in a large trial, withdrawing heart failure medications after recovery leads to relapse, and showing patients their own atherosclerosis may reduce their cardiovascular event risk.

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This week, apixaban edges out other DOACs for octogenarians, methotrexate fails to cut cardiovascular events in a large trial, withdrawing heart failure medications after recovery leads to relapse, and showing patients their own atherosclerosis may reduce their cardiovascular event risk.

Subscribe to Cardiocast wherever you get your podcasts.
Amazon Alexa
Apple Podcasts






 

This week, apixaban edges out other DOACs for octogenarians, methotrexate fails to cut cardiovascular events in a large trial, withdrawing heart failure medications after recovery leads to relapse, and showing patients their own atherosclerosis may reduce their cardiovascular event risk.

Subscribe to Cardiocast wherever you get your podcasts.
Amazon Alexa
Apple Podcasts






 

Anesthesia care is provided by physician anesthesiologists, certified registered nurse anesthetists (CRNAs), anesthesiology residents, and anesthesiologist assistants. These providers may practice alone (anesthesiologists or CRNAs) or in various combinations of supervised roles and teams. Previous studies reveal mixed findings regarding whether patient outcomes differ by anesthesia practice models.^1-7However, little is known about the prevalence of various anesthesia models in the US.

Background

In recent years, anesthesiology has undergone substantial expansion in its scope of services provided, the settings in which it is provided, and the diversity of its workforce.⁸As the field continues to evolve, especially within the context of value-based health care reform, it is imperative to evaluate how anesthesia care models are used in health systems and how these models may optimize care delivery.

The Veterans Health Administration (VHA) is the largest integrated health care system in the US, providing surgical care in 110 inpatient medical centers and 27 ambulatory surgery centers. Despite national integration, anesthesia practices vary widely among facilities. The question of which model of anesthesia care is associated with the best outcomes and offers the most value is widely debated.^1,5,7,9 As an important first step in understanding anesthesia care delivery, a baseline assessment of the practice patterns of anesthesia providers is necessary and may benefit future studies of the impact of these care models on outcomes. Thus, the aim of this work was to understand and describe the previously unassessed landscape of anesthesia care delivery within the VHA.

Methods

As part of a larger evaluation of anesthesia care delivery in the VHA, an observational assessment of anesthesia provider practice patterns was conducted using retrospective surgical data. This project complies with VHA policy pertaining to nonresearch operational activities and did not require institutional review board approval and adheres to the EQUATOR Network guidelines described in Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).¹⁰

Data were obtained from the VHA Managerial Cost Accounting National Data Extract for Surgery package for all surgical procedures (n = 726,706) between October 1, 2013 and March 31, 2015. There were 420 facilities represented in these surgical data. The VHA facility records were used to specifically identify inpatient and ambulatory surgery facilities for inclusion. Additionally, to ensure facilities were valid surgical sites with sufficient surgical volume, those with 100 or fewer cases during the period were excluded. In total, 288 facilities with 9,434 surgical cases (representing 1% of cases) were excluded. These excluded facilities included nursing homes (38%), domiciliaries (26%), outpatient clinics (11%), rehabilitation programs (9%), other nonsurgical facilities (8%), and medical centers (8%). The majority (80%) of excluded medical centers had 30 or fewer surgical cases.

In 6 instances, data from subfacilities were combined with their organizationally affiliated main facilities. The final sample included 125 facilities. The VHA assigns a complexity level designation to facilities, defined as follows: 1a (most complex), 1b, 1c, 2, and 3 (least complex).¹¹ Facilities with 1a designation perform the most complex surgical cases, such as cardiovascular surgery or neurosurgery and have more staff and resource support, whereas levels 2 and 3 facilities perform fewer and less complex cases.

Surgical records were excluded when the primary Current Procedural Terminology (CPT) code was missing (n = 85,748, or 12% of cases). This resulted in 631,524 remaining cases. The surgical CPT codes were mapped to anesthesia CPT codes to obtain the associated base unit (BU) values via a published crosswalk by the American Society of Anesthesiologists (ASA).¹² A higher number of associated BUs indicates a more complex procedure. For example, procedures such as biopsies, arthroscopies, and laparoscopies receive 3 to 4 BUs, whereas a venous thrombectomy of the leg and a transurethral resection of the prostate are both 5 BUs, a total knee arthroplasty is 7 BUs, a craniotomy is 10 BUs, and a coronary artery bypass receives 18 BUs. Surgical case complexity was defined as low (3 or 4 BUs), medium (5 BUs), and high (≥ 6 BUs). Although the VHA has an existing case complexity assignment process based on CPT codes, it defines complexity differently for inpatient facilities and ambulatory surgery centers. Thus, the BU-defined complexity permitted a standardized complexity categorization across all facilities. Categorization of BUs similar to this has previously been used in the literature as a proxy for case complexity.^13,14

Patient-level information included the ASA physical status classification, a measure of overall health status determined by an anesthesia provider preoperatively.¹⁵ These classifications included ASA I (healthy), ASA II (mild systemic disease), ASA III (severe systemic disease), ASA IV (severe systemic disease that is a constant threat to life), and ASA V (moribund patient who is not expected to survive without surgery). The last classification, ASA VI: brain-dead with planned organ donation, was excluded. The “E” subcategory denoting “emergency” was subsumed within the corresponding ASA category (eg, ASA V-E was combined with ASA V).

Provider data identified the principal and supervising (if present) anesthetists involved in the case. The provision of anesthesia care was categorized into 3 models: Model 1—a physician anesthesiologist supervising a CRNA; Model 2—a physician anesthesiologist practicing independently or supervising an anesthesiology resident; and Model 3—a CRNA without supervision. Surgical cases were excluded when there was no anesthesia provider (n = 95,795, or 15% of remaining cases), or a nonanesthesia provider (n = 51,647, or 8% of remaining cases) on record. The final sample was 484,082 surgical cases conducted at 125 facilities.

Related: Improving Care and Reducing Length of Stay in Patients Undergoing Total Knee Replacement

Statistical Analysis

The percentage of surgical cases in each anesthesia care model was calculated overall and by the following characteristics: surgical case complexity, ASA classification, and facility complexity. The anesthesia model was determined for each case and summed at the facility level, yielding a total number of cases attributed to each model for each facility, thus identifying the predominant anesthesia model for each facility. The facilities were geographically displayed by their predominant anesthesia model and total number of surgical cases during the period. Because the aim was to present a descriptive representation of anesthesia care models, rather than infer significance, statistical testing was not included.

Results

A total of 484,082 surgical cases met inclusion criteria (Table). These cases were from 109 inpatient facilities and 16 ambulatory surgery facilities. 

The percentage of cases in Model 1 was similar across the levels of surgical case complexity. However, a higher proportion of highly complex cases had a physician anesthesiologist (Model 2, 38.8%) than a CRNA (Model 3, 6.4%) as the primary anesthesia provider. Patients in each ASA classification were most likely to receive anesthesia care via Model 1. As ASA level increased, fewer patients had their anesthesia managed by a CRNA without supervision (Model 3: 18.4% of ASA 1 patients vs 8.3% of ASA 4 patients).

Facility complexity demonstrated notable differences in the proportions of surgical cases within each model. More than half of surgical cases in the largest, most complex facilities used Model 1 (64.9%, 58.2%, and 57.7% of cases in 1a, 1b, and 1c facilities, respectively). In comparison, Model 3 was found almost exclusively among surgical cases in smaller facilities with lower complexity (52% and 74% of cases in level 2 and 3 facilities, respectively).

The Figure displays the 125 facilities by their predominant model of anesthesia care. The diameter of the dots is relative to the facility’s total number of surgical cases. For each facility, the predominant model accounted for about half or more of cases but was not necessarily the only model of care used at a particular facility. 

Related: Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) Polypharmacy Clinic

Discussion

Anesthesia care in more than half of surgical cases in VHA facilities was delivered by physician anesthesiologists supervising CRNAs. This model of anesthesia care was the dominant model in 54% of the facilities included in the sample. Consistent with a study of non-VHA facilities, this assessment found that the type of facility may influence the model of anesthesia care, with smaller, less complex facilities more often using a CRNA without supervision model.⁴ In these data, it was noted that among the 28 facilities that predominantly used Model 3, half had 12% or fewer cases that indicated a physician anesthesiologist model of care, and 6 had no cases with physician anesthesiologist involvement. These findings may reflect the limited scope of surgical services offered at lower complexity facilities and/or the reduced availability and/or utilization of physician anesthesiologists in these facilities.

Limitations

We recognize limitations in our assessment of anesthesia care. The documented presence or absence of a supervising anesthesia provider on the surgical record may not adequately characterize the model of anesthesia care in use at a facility, thus limiting an understanding of care delivery relationships among anesthesia providers. In addition, the patterns of anesthesia care delivery are likely influenced by factors not accounted for in this assessment, including the labor market share and economic forces.^16,17 The veteran population tends to be older, male, and with substantial chronic disease burden, thus may have differing surgical needs and experiences than that of the general public.^18,19 The surgical services offered in VHA facilities as well as the policies and practice environment surrounding anesthesia care also may vary from those found in nongovernmental facilities. However, as the largest health care system in the US, the VHA provides a diverse and robust surgical program. Many VHA facilities are large teaching hospitals with academic affiliations that would parallel some in the public sector. For example, studies have demonstrated similar surgical outcomes for patients in VHA vs non-VHA facilities.²⁰ Therefore, the findings regarding anesthesia care models in VHA are likely relevant to non-VHA surgical sites.

Related: Improving Team-Based Care Coordination Delivery and Documentation in the Health Record

Conclusion

This preliminary assessment of the different models of anesthesia care demonstrates that although primarily relying on teams of anesthesiologists and CRNAs, the VA also uses unsupervised CRNAs to meet veterans’ surgical care needs. Although CRNA practice without supervision represented only 12% of surgical cases in our data, we identified 28 facilities (22%) that predominantly used CRNAs without supervision. Thus, CRNAs with and without supervision deliver a substantial portion of anesthesia care in the VA. The prevalence of CRNAs in documented VA surgical records and among surgical facilities nationwide highlights the importance of further examining their supervised and unsupervised roles in anesthesia care delivery.²¹ As the practice of anesthesiology continues to evolve, it is imperative that research efforts further investigate ways anesthesia care models may optimize care delivery, benefit anesthesia providers, and improve health outcomes for patients.

Anesthesia care is provided by physician anesthesiologists, certified registered nurse anesthetists (CRNAs), anesthesiology residents, and anesthesiologist assistants. These providers may practice alone (anesthesiologists or CRNAs) or in various combinations of supervised roles and teams. Previous studies reveal mixed findings regarding whether patient outcomes differ by anesthesia practice models.^1-7However, little is known about the prevalence of various anesthesia models in the US.

Background

In recent years, anesthesiology has undergone substantial expansion in its scope of services provided, the settings in which it is provided, and the diversity of its workforce.⁸As the field continues to evolve, especially within the context of value-based health care reform, it is imperative to evaluate how anesthesia care models are used in health systems and how these models may optimize care delivery.

The Veterans Health Administration (VHA) is the largest integrated health care system in the US, providing surgical care in 110 inpatient medical centers and 27 ambulatory surgery centers. Despite national integration, anesthesia practices vary widely among facilities. The question of which model of anesthesia care is associated with the best outcomes and offers the most value is widely debated.^1,5,7,9 As an important first step in understanding anesthesia care delivery, a baseline assessment of the practice patterns of anesthesia providers is necessary and may benefit future studies of the impact of these care models on outcomes. Thus, the aim of this work was to understand and describe the previously unassessed landscape of anesthesia care delivery within the VHA.

Methods

As part of a larger evaluation of anesthesia care delivery in the VHA, an observational assessment of anesthesia provider practice patterns was conducted using retrospective surgical data. This project complies with VHA policy pertaining to nonresearch operational activities and did not require institutional review board approval and adheres to the EQUATOR Network guidelines described in Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).¹⁰

Data were obtained from the VHA Managerial Cost Accounting National Data Extract for Surgery package for all surgical procedures (n = 726,706) between October 1, 2013 and March 31, 2015. There were 420 facilities represented in these surgical data. The VHA facility records were used to specifically identify inpatient and ambulatory surgery facilities for inclusion. Additionally, to ensure facilities were valid surgical sites with sufficient surgical volume, those with 100 or fewer cases during the period were excluded. In total, 288 facilities with 9,434 surgical cases (representing 1% of cases) were excluded. These excluded facilities included nursing homes (38%), domiciliaries (26%), outpatient clinics (11%), rehabilitation programs (9%), other nonsurgical facilities (8%), and medical centers (8%). The majority (80%) of excluded medical centers had 30 or fewer surgical cases.

In 6 instances, data from subfacilities were combined with their organizationally affiliated main facilities. The final sample included 125 facilities. The VHA assigns a complexity level designation to facilities, defined as follows: 1a (most complex), 1b, 1c, 2, and 3 (least complex).¹¹ Facilities with 1a designation perform the most complex surgical cases, such as cardiovascular surgery or neurosurgery and have more staff and resource support, whereas levels 2 and 3 facilities perform fewer and less complex cases.

Surgical records were excluded when the primary Current Procedural Terminology (CPT) code was missing (n = 85,748, or 12% of cases). This resulted in 631,524 remaining cases. The surgical CPT codes were mapped to anesthesia CPT codes to obtain the associated base unit (BU) values via a published crosswalk by the American Society of Anesthesiologists (ASA).¹² A higher number of associated BUs indicates a more complex procedure. For example, procedures such as biopsies, arthroscopies, and laparoscopies receive 3 to 4 BUs, whereas a venous thrombectomy of the leg and a transurethral resection of the prostate are both 5 BUs, a total knee arthroplasty is 7 BUs, a craniotomy is 10 BUs, and a coronary artery bypass receives 18 BUs. Surgical case complexity was defined as low (3 or 4 BUs), medium (5 BUs), and high (≥ 6 BUs). Although the VHA has an existing case complexity assignment process based on CPT codes, it defines complexity differently for inpatient facilities and ambulatory surgery centers. Thus, the BU-defined complexity permitted a standardized complexity categorization across all facilities. Categorization of BUs similar to this has previously been used in the literature as a proxy for case complexity.^13,14

Patient-level information included the ASA physical status classification, a measure of overall health status determined by an anesthesia provider preoperatively.¹⁵ These classifications included ASA I (healthy), ASA II (mild systemic disease), ASA III (severe systemic disease), ASA IV (severe systemic disease that is a constant threat to life), and ASA V (moribund patient who is not expected to survive without surgery). The last classification, ASA VI: brain-dead with planned organ donation, was excluded. The “E” subcategory denoting “emergency” was subsumed within the corresponding ASA category (eg, ASA V-E was combined with ASA V).

Provider data identified the principal and supervising (if present) anesthetists involved in the case. The provision of anesthesia care was categorized into 3 models: Model 1—a physician anesthesiologist supervising a CRNA; Model 2—a physician anesthesiologist practicing independently or supervising an anesthesiology resident; and Model 3—a CRNA without supervision. Surgical cases were excluded when there was no anesthesia provider (n = 95,795, or 15% of remaining cases), or a nonanesthesia provider (n = 51,647, or 8% of remaining cases) on record. The final sample was 484,082 surgical cases conducted at 125 facilities.

Related: Improving Care and Reducing Length of Stay in Patients Undergoing Total Knee Replacement

Statistical Analysis

The percentage of surgical cases in each anesthesia care model was calculated overall and by the following characteristics: surgical case complexity, ASA classification, and facility complexity. The anesthesia model was determined for each case and summed at the facility level, yielding a total number of cases attributed to each model for each facility, thus identifying the predominant anesthesia model for each facility. The facilities were geographically displayed by their predominant anesthesia model and total number of surgical cases during the period. Because the aim was to present a descriptive representation of anesthesia care models, rather than infer significance, statistical testing was not included.

Results

A total of 484,082 surgical cases met inclusion criteria (Table). These cases were from 109 inpatient facilities and 16 ambulatory surgery facilities. 

The percentage of cases in Model 1 was similar across the levels of surgical case complexity. However, a higher proportion of highly complex cases had a physician anesthesiologist (Model 2, 38.8%) than a CRNA (Model 3, 6.4%) as the primary anesthesia provider. Patients in each ASA classification were most likely to receive anesthesia care via Model 1. As ASA level increased, fewer patients had their anesthesia managed by a CRNA without supervision (Model 3: 18.4% of ASA 1 patients vs 8.3% of ASA 4 patients).

Facility complexity demonstrated notable differences in the proportions of surgical cases within each model. More than half of surgical cases in the largest, most complex facilities used Model 1 (64.9%, 58.2%, and 57.7% of cases in 1a, 1b, and 1c facilities, respectively). In comparison, Model 3 was found almost exclusively among surgical cases in smaller facilities with lower complexity (52% and 74% of cases in level 2 and 3 facilities, respectively).

The Figure displays the 125 facilities by their predominant model of anesthesia care. The diameter of the dots is relative to the facility’s total number of surgical cases. For each facility, the predominant model accounted for about half or more of cases but was not necessarily the only model of care used at a particular facility. 

Related: Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) Polypharmacy Clinic

Discussion

Anesthesia care in more than half of surgical cases in VHA facilities was delivered by physician anesthesiologists supervising CRNAs. This model of anesthesia care was the dominant model in 54% of the facilities included in the sample. Consistent with a study of non-VHA facilities, this assessment found that the type of facility may influence the model of anesthesia care, with smaller, less complex facilities more often using a CRNA without supervision model.⁴ In these data, it was noted that among the 28 facilities that predominantly used Model 3, half had 12% or fewer cases that indicated a physician anesthesiologist model of care, and 6 had no cases with physician anesthesiologist involvement. These findings may reflect the limited scope of surgical services offered at lower complexity facilities and/or the reduced availability and/or utilization of physician anesthesiologists in these facilities.

Limitations

We recognize limitations in our assessment of anesthesia care. The documented presence or absence of a supervising anesthesia provider on the surgical record may not adequately characterize the model of anesthesia care in use at a facility, thus limiting an understanding of care delivery relationships among anesthesia providers. In addition, the patterns of anesthesia care delivery are likely influenced by factors not accounted for in this assessment, including the labor market share and economic forces.^16,17 The veteran population tends to be older, male, and with substantial chronic disease burden, thus may have differing surgical needs and experiences than that of the general public.^18,19 The surgical services offered in VHA facilities as well as the policies and practice environment surrounding anesthesia care also may vary from those found in nongovernmental facilities. However, as the largest health care system in the US, the VHA provides a diverse and robust surgical program. Many VHA facilities are large teaching hospitals with academic affiliations that would parallel some in the public sector. For example, studies have demonstrated similar surgical outcomes for patients in VHA vs non-VHA facilities.²⁰ Therefore, the findings regarding anesthesia care models in VHA are likely relevant to non-VHA surgical sites.

Related: Improving Team-Based Care Coordination Delivery and Documentation in the Health Record

Conclusion

This preliminary assessment of the different models of anesthesia care demonstrates that although primarily relying on teams of anesthesiologists and CRNAs, the VA also uses unsupervised CRNAs to meet veterans’ surgical care needs. Although CRNA practice without supervision represented only 12% of surgical cases in our data, we identified 28 facilities (22%) that predominantly used CRNAs without supervision. Thus, CRNAs with and without supervision deliver a substantial portion of anesthesia care in the VA. The prevalence of CRNAs in documented VA surgical records and among surgical facilities nationwide highlights the importance of further examining their supervised and unsupervised roles in anesthesia care delivery.²¹ As the practice of anesthesiology continues to evolve, it is imperative that research efforts further investigate ways anesthesia care models may optimize care delivery, benefit anesthesia providers, and improve health outcomes for patients.

Anesthesia care is provided by physician anesthesiologists, certified registered nurse anesthetists (CRNAs), anesthesiology residents, and anesthesiologist assistants. These providers may practice alone (anesthesiologists or CRNAs) or in various combinations of supervised roles and teams. Previous studies reveal mixed findings regarding whether patient outcomes differ by anesthesia practice models.^1-7However, little is known about the prevalence of various anesthesia models in the US.

Background

In recent years, anesthesiology has undergone substantial expansion in its scope of services provided, the settings in which it is provided, and the diversity of its workforce.⁸As the field continues to evolve, especially within the context of value-based health care reform, it is imperative to evaluate how anesthesia care models are used in health systems and how these models may optimize care delivery.

The Veterans Health Administration (VHA) is the largest integrated health care system in the US, providing surgical care in 110 inpatient medical centers and 27 ambulatory surgery centers. Despite national integration, anesthesia practices vary widely among facilities. The question of which model of anesthesia care is associated with the best outcomes and offers the most value is widely debated.^1,5,7,9 As an important first step in understanding anesthesia care delivery, a baseline assessment of the practice patterns of anesthesia providers is necessary and may benefit future studies of the impact of these care models on outcomes. Thus, the aim of this work was to understand and describe the previously unassessed landscape of anesthesia care delivery within the VHA.

Methods

As part of a larger evaluation of anesthesia care delivery in the VHA, an observational assessment of anesthesia provider practice patterns was conducted using retrospective surgical data. This project complies with VHA policy pertaining to nonresearch operational activities and did not require institutional review board approval and adheres to the EQUATOR Network guidelines described in Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).¹⁰

Data were obtained from the VHA Managerial Cost Accounting National Data Extract for Surgery package for all surgical procedures (n = 726,706) between October 1, 2013 and March 31, 2015. There were 420 facilities represented in these surgical data. The VHA facility records were used to specifically identify inpatient and ambulatory surgery facilities for inclusion. Additionally, to ensure facilities were valid surgical sites with sufficient surgical volume, those with 100 or fewer cases during the period were excluded. In total, 288 facilities with 9,434 surgical cases (representing 1% of cases) were excluded. These excluded facilities included nursing homes (38%), domiciliaries (26%), outpatient clinics (11%), rehabilitation programs (9%), other nonsurgical facilities (8%), and medical centers (8%). The majority (80%) of excluded medical centers had 30 or fewer surgical cases.

In 6 instances, data from subfacilities were combined with their organizationally affiliated main facilities. The final sample included 125 facilities. The VHA assigns a complexity level designation to facilities, defined as follows: 1a (most complex), 1b, 1c, 2, and 3 (least complex).¹¹ Facilities with 1a designation perform the most complex surgical cases, such as cardiovascular surgery or neurosurgery and have more staff and resource support, whereas levels 2 and 3 facilities perform fewer and less complex cases.

Surgical records were excluded when the primary Current Procedural Terminology (CPT) code was missing (n = 85,748, or 12% of cases). This resulted in 631,524 remaining cases. The surgical CPT codes were mapped to anesthesia CPT codes to obtain the associated base unit (BU) values via a published crosswalk by the American Society of Anesthesiologists (ASA).¹² A higher number of associated BUs indicates a more complex procedure. For example, procedures such as biopsies, arthroscopies, and laparoscopies receive 3 to 4 BUs, whereas a venous thrombectomy of the leg and a transurethral resection of the prostate are both 5 BUs, a total knee arthroplasty is 7 BUs, a craniotomy is 10 BUs, and a coronary artery bypass receives 18 BUs. Surgical case complexity was defined as low (3 or 4 BUs), medium (5 BUs), and high (≥ 6 BUs). Although the VHA has an existing case complexity assignment process based on CPT codes, it defines complexity differently for inpatient facilities and ambulatory surgery centers. Thus, the BU-defined complexity permitted a standardized complexity categorization across all facilities. Categorization of BUs similar to this has previously been used in the literature as a proxy for case complexity.^13,14

Patient-level information included the ASA physical status classification, a measure of overall health status determined by an anesthesia provider preoperatively.¹⁵ These classifications included ASA I (healthy), ASA II (mild systemic disease), ASA III (severe systemic disease), ASA IV (severe systemic disease that is a constant threat to life), and ASA V (moribund patient who is not expected to survive without surgery). The last classification, ASA VI: brain-dead with planned organ donation, was excluded. The “E” subcategory denoting “emergency” was subsumed within the corresponding ASA category (eg, ASA V-E was combined with ASA V).

Provider data identified the principal and supervising (if present) anesthetists involved in the case. The provision of anesthesia care was categorized into 3 models: Model 1—a physician anesthesiologist supervising a CRNA; Model 2—a physician anesthesiologist practicing independently or supervising an anesthesiology resident; and Model 3—a CRNA without supervision. Surgical cases were excluded when there was no anesthesia provider (n = 95,795, or 15% of remaining cases), or a nonanesthesia provider (n = 51,647, or 8% of remaining cases) on record. The final sample was 484,082 surgical cases conducted at 125 facilities.

Related: Improving Care and Reducing Length of Stay in Patients Undergoing Total Knee Replacement

Statistical Analysis

The percentage of surgical cases in each anesthesia care model was calculated overall and by the following characteristics: surgical case complexity, ASA classification, and facility complexity. The anesthesia model was determined for each case and summed at the facility level, yielding a total number of cases attributed to each model for each facility, thus identifying the predominant anesthesia model for each facility. The facilities were geographically displayed by their predominant anesthesia model and total number of surgical cases during the period. Because the aim was to present a descriptive representation of anesthesia care models, rather than infer significance, statistical testing was not included.

Results

A total of 484,082 surgical cases met inclusion criteria (Table). These cases were from 109 inpatient facilities and 16 ambulatory surgery facilities. 

The percentage of cases in Model 1 was similar across the levels of surgical case complexity. However, a higher proportion of highly complex cases had a physician anesthesiologist (Model 2, 38.8%) than a CRNA (Model 3, 6.4%) as the primary anesthesia provider. Patients in each ASA classification were most likely to receive anesthesia care via Model 1. As ASA level increased, fewer patients had their anesthesia managed by a CRNA without supervision (Model 3: 18.4% of ASA 1 patients vs 8.3% of ASA 4 patients).

Facility complexity demonstrated notable differences in the proportions of surgical cases within each model. More than half of surgical cases in the largest, most complex facilities used Model 1 (64.9%, 58.2%, and 57.7% of cases in 1a, 1b, and 1c facilities, respectively). In comparison, Model 3 was found almost exclusively among surgical cases in smaller facilities with lower complexity (52% and 74% of cases in level 2 and 3 facilities, respectively).

The Figure displays the 125 facilities by their predominant model of anesthesia care. The diameter of the dots is relative to the facility’s total number of surgical cases. For each facility, the predominant model accounted for about half or more of cases but was not necessarily the only model of care used at a particular facility. 

Related: Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) Polypharmacy Clinic

Discussion

Anesthesia care in more than half of surgical cases in VHA facilities was delivered by physician anesthesiologists supervising CRNAs. This model of anesthesia care was the dominant model in 54% of the facilities included in the sample. Consistent with a study of non-VHA facilities, this assessment found that the type of facility may influence the model of anesthesia care, with smaller, less complex facilities more often using a CRNA without supervision model.⁴ In these data, it was noted that among the 28 facilities that predominantly used Model 3, half had 12% or fewer cases that indicated a physician anesthesiologist model of care, and 6 had no cases with physician anesthesiologist involvement. These findings may reflect the limited scope of surgical services offered at lower complexity facilities and/or the reduced availability and/or utilization of physician anesthesiologists in these facilities.

Limitations

We recognize limitations in our assessment of anesthesia care. The documented presence or absence of a supervising anesthesia provider on the surgical record may not adequately characterize the model of anesthesia care in use at a facility, thus limiting an understanding of care delivery relationships among anesthesia providers. In addition, the patterns of anesthesia care delivery are likely influenced by factors not accounted for in this assessment, including the labor market share and economic forces.^16,17 The veteran population tends to be older, male, and with substantial chronic disease burden, thus may have differing surgical needs and experiences than that of the general public.^18,19 The surgical services offered in VHA facilities as well as the policies and practice environment surrounding anesthesia care also may vary from those found in nongovernmental facilities. However, as the largest health care system in the US, the VHA provides a diverse and robust surgical program. Many VHA facilities are large teaching hospitals with academic affiliations that would parallel some in the public sector. For example, studies have demonstrated similar surgical outcomes for patients in VHA vs non-VHA facilities.²⁰ Therefore, the findings regarding anesthesia care models in VHA are likely relevant to non-VHA surgical sites.

Related: Improving Team-Based Care Coordination Delivery and Documentation in the Health Record

Conclusion

This preliminary assessment of the different models of anesthesia care demonstrates that although primarily relying on teams of anesthesiologists and CRNAs, the VA also uses unsupervised CRNAs to meet veterans’ surgical care needs. Although CRNA practice without supervision represented only 12% of surgical cases in our data, we identified 28 facilities (22%) that predominantly used CRNAs without supervision. Thus, CRNAs with and without supervision deliver a substantial portion of anesthesia care in the VA. The prevalence of CRNAs in documented VA surgical records and among surgical facilities nationwide highlights the importance of further examining their supervised and unsupervised roles in anesthesia care delivery.²¹ As the practice of anesthesiology continues to evolve, it is imperative that research efforts further investigate ways anesthesia care models may optimize care delivery, benefit anesthesia providers, and improve health outcomes for patients.

A relatively recent practice catching on in many different hospitalist groups is geographic cohorting, or unit-based assignments. Traditionally, most hospitalists have had patients assigned on multiple different units. Unit-based assignments have been touted as a way of improving interdisciplinary communication and provider and patient satisfaction.¹

How frequently are hospital medicine groups using unit-based assignments? SHM sought to quantify this trend in the recently published 2018 State of Hospital Medicine Report. Overall, among hospital medicine groups serving adults only, a little over one-third (36.4%) of groups reported utilizing unit-based assignments. However, there was significant variation, particularly dependent on group size. Geographic cohorting was used only in 7.6% of groups with 4 or fewer full-time equivalents, and in 68.8% of groups with 30 or more FTE. These data seem logical, as the potential gains from cohorting likely increase with group/hospital size, where physicians would otherwise round on an increasingly large number of units.

As has been shared in the hospital medicine literature, groups have experienced variable success with geographic cohorting. Improvements have been achieved in interprofessional collaboration, efficiency, nursing satisfaction,² and, in some instances, length of stay. Unit-based assignments have allowed some groups to pilot other interventions, such as interdisciplinary rounds.

But geographic cohorting comes with its implementation challenges, too. For example, in many hospitals, some units have differing telemetry or nursing capabilities. And, in other institutions, there are units providing specialized care, such as care for neurology or oncology patients. The workload for hospitalists caring for particular types of patients may vary, and with specialty units, it may be more difficult to keep a similar census assigned to each hospitalist.

While some groups have noted increased professional satisfaction, others have noted decreases in satisfaction. One reason is that, while the frequency of paging may decrease, this is replaced by an increase in face-to-face interruptions. Also, unit-based assignments in some groups have resulted in hospitalists perceiving they are working in silos because of a decrease in interactions and camaraderie among providers in the same hospital medicine group.

At my home institution, University of California, San Diego, geographic cohorting has largely been a successful and positively perceived change. Our efforts have been particularly successful at one of our two campuses where most units have telemetry capabilities and where we have a dedicated daytime admitter (there are data on this in the Report as well, and a dedicated daytime admitter is the topic of a future Survey Insights column). Unit-based assignments have allowed the implementation of what we’ve termed focused interdisciplinary rounds.

Our unit-based assignments are not perfect – we re-cohort each week when new hospitalists come on service, and some hospitalists are assigned a small number of patients off their home unit. Our internal data have shown a significant increase in patient satisfaction scores, but we have not realized a decrease in length of stay. Despite an overall positive perception, hospitalists have sometimes noted an imbalanced workload – we have a particularly challenging oncology/palliative unit and a daytime admitter that is at times very busy. Our system also requires the use of physician time to assign patients each morning and each week.

In contrast, while we’ve aimed to achieve the same success with unit-based assignments at our other campus, we’ve faced more challenges there. Our other facility is older, and fewer units have telemetry capabilities. A more traditional teaching structure also means that teams take turns with on-call admitting days, as opposed to a daytime admitter structure, and there may not be beds available in the unit assigned to the admitting team of the day.

Overall, geographic cohorting is likely to be considered or implemented in many hospital medicine groups, and efforts have met with varying success. There are certainly pros and cons to every model, and if your group is looking at redesigning services to include unit-based assignments, it’s worth examining the intended outcomes. While unit-based assignments are not for every group, there’s no doubt that this trend has been driven by our specialty’s commitment to outcome-driven process improvement.

Addendum added Feb. 15, 2019: The impact of UC San Diego's efforts discussed in this article are the author's own opinions through limited participation in focused interdisciplinary rounds, and have not been validated with formal data analysis. More study is in progress on the impact of focused interdiscplinary rounds on communication, utilization, and quality metrics. Sarah Horman, MD ([email protected]), Daniel Bouland, MD ([email protected]), and William Frederick, MD ([email protected]), have led efforts at UC San Diego to develop and implement focused interdisciplinary rounds, and may be contacted for further information.

Dr. Huang is physician advisor for care management and associate clinical professor in the division of hospital medicine at the University of California, San Diego. He is a member of SHM’s practice analysis subcommittee.

References

1. O’Leary KJ et al. Interdisciplinary teamwork in hospitals: A review and practical recommendations for improvement. J Hosp Med. 2012 Jan;7(1):48-54.

2. Kara A et al. Hospital-based clinicians’ perceptions of geographic cohorting: Identifying opportunities for improvement. Am J Med Qual. 2018 May/Jun;33(3):303-12.

A relatively recent practice catching on in many different hospitalist groups is geographic cohorting, or unit-based assignments. Traditionally, most hospitalists have had patients assigned on multiple different units. Unit-based assignments have been touted as a way of improving interdisciplinary communication and provider and patient satisfaction.¹

How frequently are hospital medicine groups using unit-based assignments? SHM sought to quantify this trend in the recently published 2018 State of Hospital Medicine Report. Overall, among hospital medicine groups serving adults only, a little over one-third (36.4%) of groups reported utilizing unit-based assignments. However, there was significant variation, particularly dependent on group size. Geographic cohorting was used only in 7.6% of groups with 4 or fewer full-time equivalents, and in 68.8% of groups with 30 or more FTE. These data seem logical, as the potential gains from cohorting likely increase with group/hospital size, where physicians would otherwise round on an increasingly large number of units.

As has been shared in the hospital medicine literature, groups have experienced variable success with geographic cohorting. Improvements have been achieved in interprofessional collaboration, efficiency, nursing satisfaction,² and, in some instances, length of stay. Unit-based assignments have allowed some groups to pilot other interventions, such as interdisciplinary rounds.

But geographic cohorting comes with its implementation challenges, too. For example, in many hospitals, some units have differing telemetry or nursing capabilities. And, in other institutions, there are units providing specialized care, such as care for neurology or oncology patients. The workload for hospitalists caring for particular types of patients may vary, and with specialty units, it may be more difficult to keep a similar census assigned to each hospitalist.

While some groups have noted increased professional satisfaction, others have noted decreases in satisfaction. One reason is that, while the frequency of paging may decrease, this is replaced by an increase in face-to-face interruptions. Also, unit-based assignments in some groups have resulted in hospitalists perceiving they are working in silos because of a decrease in interactions and camaraderie among providers in the same hospital medicine group.

At my home institution, University of California, San Diego, geographic cohorting has largely been a successful and positively perceived change. Our efforts have been particularly successful at one of our two campuses where most units have telemetry capabilities and where we have a dedicated daytime admitter (there are data on this in the Report as well, and a dedicated daytime admitter is the topic of a future Survey Insights column). Unit-based assignments have allowed the implementation of what we’ve termed focused interdisciplinary rounds.

Our unit-based assignments are not perfect – we re-cohort each week when new hospitalists come on service, and some hospitalists are assigned a small number of patients off their home unit. Our internal data have shown a significant increase in patient satisfaction scores, but we have not realized a decrease in length of stay. Despite an overall positive perception, hospitalists have sometimes noted an imbalanced workload – we have a particularly challenging oncology/palliative unit and a daytime admitter that is at times very busy. Our system also requires the use of physician time to assign patients each morning and each week.

In contrast, while we’ve aimed to achieve the same success with unit-based assignments at our other campus, we’ve faced more challenges there. Our other facility is older, and fewer units have telemetry capabilities. A more traditional teaching structure also means that teams take turns with on-call admitting days, as opposed to a daytime admitter structure, and there may not be beds available in the unit assigned to the admitting team of the day.

Overall, geographic cohorting is likely to be considered or implemented in many hospital medicine groups, and efforts have met with varying success. There are certainly pros and cons to every model, and if your group is looking at redesigning services to include unit-based assignments, it’s worth examining the intended outcomes. While unit-based assignments are not for every group, there’s no doubt that this trend has been driven by our specialty’s commitment to outcome-driven process improvement.

Addendum added Feb. 15, 2019: The impact of UC San Diego's efforts discussed in this article are the author's own opinions through limited participation in focused interdisciplinary rounds, and have not been validated with formal data analysis. More study is in progress on the impact of focused interdiscplinary rounds on communication, utilization, and quality metrics. Sarah Horman, MD ([email protected]), Daniel Bouland, MD ([email protected]), and William Frederick, MD ([email protected]), have led efforts at UC San Diego to develop and implement focused interdisciplinary rounds, and may be contacted for further information.

Dr. Huang is physician advisor for care management and associate clinical professor in the division of hospital medicine at the University of California, San Diego. He is a member of SHM’s practice analysis subcommittee.

References

1. O’Leary KJ et al. Interdisciplinary teamwork in hospitals: A review and practical recommendations for improvement. J Hosp Med. 2012 Jan;7(1):48-54.

2. Kara A et al. Hospital-based clinicians’ perceptions of geographic cohorting: Identifying opportunities for improvement. Am J Med Qual. 2018 May/Jun;33(3):303-12.

A relatively recent practice catching on in many different hospitalist groups is geographic cohorting, or unit-based assignments. Traditionally, most hospitalists have had patients assigned on multiple different units. Unit-based assignments have been touted as a way of improving interdisciplinary communication and provider and patient satisfaction.¹

How frequently are hospital medicine groups using unit-based assignments? SHM sought to quantify this trend in the recently published 2018 State of Hospital Medicine Report. Overall, among hospital medicine groups serving adults only, a little over one-third (36.4%) of groups reported utilizing unit-based assignments. However, there was significant variation, particularly dependent on group size. Geographic cohorting was used only in 7.6% of groups with 4 or fewer full-time equivalents, and in 68.8% of groups with 30 or more FTE. These data seem logical, as the potential gains from cohorting likely increase with group/hospital size, where physicians would otherwise round on an increasingly large number of units.

As has been shared in the hospital medicine literature, groups have experienced variable success with geographic cohorting. Improvements have been achieved in interprofessional collaboration, efficiency, nursing satisfaction,² and, in some instances, length of stay. Unit-based assignments have allowed some groups to pilot other interventions, such as interdisciplinary rounds.

But geographic cohorting comes with its implementation challenges, too. For example, in many hospitals, some units have differing telemetry or nursing capabilities. And, in other institutions, there are units providing specialized care, such as care for neurology or oncology patients. The workload for hospitalists caring for particular types of patients may vary, and with specialty units, it may be more difficult to keep a similar census assigned to each hospitalist.

While some groups have noted increased professional satisfaction, others have noted decreases in satisfaction. One reason is that, while the frequency of paging may decrease, this is replaced by an increase in face-to-face interruptions. Also, unit-based assignments in some groups have resulted in hospitalists perceiving they are working in silos because of a decrease in interactions and camaraderie among providers in the same hospital medicine group.

At my home institution, University of California, San Diego, geographic cohorting has largely been a successful and positively perceived change. Our efforts have been particularly successful at one of our two campuses where most units have telemetry capabilities and where we have a dedicated daytime admitter (there are data on this in the Report as well, and a dedicated daytime admitter is the topic of a future Survey Insights column). Unit-based assignments have allowed the implementation of what we’ve termed focused interdisciplinary rounds.

Our unit-based assignments are not perfect – we re-cohort each week when new hospitalists come on service, and some hospitalists are assigned a small number of patients off their home unit. Our internal data have shown a significant increase in patient satisfaction scores, but we have not realized a decrease in length of stay. Despite an overall positive perception, hospitalists have sometimes noted an imbalanced workload – we have a particularly challenging oncology/palliative unit and a daytime admitter that is at times very busy. Our system also requires the use of physician time to assign patients each morning and each week.

In contrast, while we’ve aimed to achieve the same success with unit-based assignments at our other campus, we’ve faced more challenges there. Our other facility is older, and fewer units have telemetry capabilities. A more traditional teaching structure also means that teams take turns with on-call admitting days, as opposed to a daytime admitter structure, and there may not be beds available in the unit assigned to the admitting team of the day.

Overall, geographic cohorting is likely to be considered or implemented in many hospital medicine groups, and efforts have met with varying success. There are certainly pros and cons to every model, and if your group is looking at redesigning services to include unit-based assignments, it’s worth examining the intended outcomes. While unit-based assignments are not for every group, there’s no doubt that this trend has been driven by our specialty’s commitment to outcome-driven process improvement.

Addendum added Feb. 15, 2019: The impact of UC San Diego's efforts discussed in this article are the author's own opinions through limited participation in focused interdisciplinary rounds, and have not been validated with formal data analysis. More study is in progress on the impact of focused interdiscplinary rounds on communication, utilization, and quality metrics. Sarah Horman, MD ([email protected]), Daniel Bouland, MD ([email protected]), and William Frederick, MD ([email protected]), have led efforts at UC San Diego to develop and implement focused interdisciplinary rounds, and may be contacted for further information.

Dr. Huang is physician advisor for care management and associate clinical professor in the division of hospital medicine at the University of California, San Diego. He is a member of SHM’s practice analysis subcommittee.

References

1. O’Leary KJ et al. Interdisciplinary teamwork in hospitals: A review and practical recommendations for improvement. J Hosp Med. 2012 Jan;7(1):48-54.

2. Kara A et al. Hospital-based clinicians’ perceptions of geographic cohorting: Identifying opportunities for improvement. Am J Med Qual. 2018 May/Jun;33(3):303-12.