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Is Hospitalist Proficiency in Bedside Procedures in Decline?
It’s 3:30 p.m. You’ve seen your old patients, holdovers, and an admission, but you haven’t finished your notes yet. Lunch was an afterthought between emails about schedule changes for the upcoming year. Two pages ring happily from your belt, the first from you-know-who in the ED, and the next from a nurse: “THORA SUPPLIES AT BEDSIDE SINCE THIS AM—WHEN WILL THIS HAPPEN?” The phone number on the wall for the on-call radiologist beckons...
An all-too-familiar situation for hospitalists across the country, this awkward moment raises a series of difficult questions:
Should I set aside time from my day to perform a procedure that could be time-consuming?
- Do I feel confident I can perform this procedure safely?
- Am I really the best physician to provide this service?
- As hospitalists are tasked with an ever-increasing array of responsibilities, answering the call of duty for bedside procedures is becoming more difficult for some.
A Core Competency
“The Core Competencies in Hospital Medicine,” authored by a group of HM thought leaders, was published as a supplement to the January/February 2006 issue of the Journal of Hospital Medicine. The core competencies include such bedside procedures as arthrocentesis, paracentesis, thoracentesis, lumbar puncture, and vascular (arterial and central venous) access (see “Core Competencies in Hospital Medicine: Procedures,” below). Although the authors stressed that the core competencies are to be viewed as a resource rather than as a set of requirements, the inclusion of bedside procedures emphasized the importance of procedural skills for future hospitalists.
“[Hospitalists] are in a perfect spot to continue to perform procedures in a structured manner,” says Joshua Lenchus, DO, RPh, FACP, FHM, associate director of the University of Miami-Jackson Memorial Hospital (UM-JMH) Center for Patient Safety. “As agents of quality and safety, hospitalists should continue to perform this clinically necessary service.”
Jeffrey Barsuk, MD, FHM, associate professor of medicine at Northwestern Feinberg School of Medicine in Chicago and an academic hospitalist at Northwestern Memorial Hospital (NMH), not only agrees that bedside procedures should be a core competency, but he also says hospitalists are the most appropriate providers of these services.
“I think this is part of hospital medicine. We’re in the hospital, [and] that’s what we do,” Dr. Barsuk says. Other providers, such as interventional radiologists, “really don’t understand why I’m doing [a procedure]. They understand it’s safe to do it, but they might not understand all the indications for it, and they certainly don’t understand the interpretation of the tests they’re sending.”
Despite the goals set forth by the core competencies and authorities in procedural safety, the reality of who actually performs bedside procedures is somewhat murky and varies greatly by institution. Many point to HM program setting (urban vs. rural) or structure (academic vs. community) to explain variance, but often it is other factors that determine whether hospitalists are actually preforming bedside procedures regularly.
Where Does HM Perform Procedures?
Community hospitalists, with strong support from interventional radiologists and subspecialists, often find it more efficient—even necessary, considering their patient volumes—to leave procedures to others. Community hospitalists with ICU admitting privileges, intensivists, and other HM subgroups say that being able to perform procedures should be a prerequisite for employment. Hospitalists in rural communities say they are doing procedures because they are “the only game in town.”
“Sometimes you are the only one available, and you are called upon to stretch your abilities,” says Beatrice Szantyr, MD, FAAP, a community hospitalist and pediatrician in Lincoln, Maine, who has practiced most of her career in rural settings.
Academic hospitalists in large, research-based HM programs can, paradoxically, find themselves performing fewer procedures as residents often take the lead on the majority of such cases. Conversely, academic hospitalists in large, nonteaching programs often find themselves called on to perform more bedside procedures.
No matter the setting, the simplicity of being the physician to recognize the need for a procedure, perform it, and interpret the results is undeniably efficient and “clean,” according to authorities on inpatient bedside procedures. Having to consult other physicians, optimize the patient’s lab values to their standards (a common issue with interventional radiologists), and adhere to their work schedules can often delay procedures unnecessarily.
—Joshua Lenchus, DO, RPh, FACP, FHM, associate director, University of Miami-Jackson Memorial Hospital (UM-JMH) Center for Patient Safety
“Hospitalists care for floor and ICU patients in many hospitals, and the inability to perform bedside procedures delays patient care,” says Dr. Nilam Soni, an academic hospitalist at the University of Chicago and a recognized expert on procedural safety.
Dr. Soni notes that when it comes to current techniques, many hospitalists suffer from a knowledge deficit. “The introduction of ultrasound for guidance of bedside procedures has been shown to improve the success and safety of certain procedures,” he says, “but the majority of practicing hospitalists did not learn how to use ultrasound for procedure guidance during residency.”
Heterogeneity of Training, Experience, and Skill
While all hospitalists draw upon different bases of training and experience, the heterogeneity of training, confidence, and inherent skill is greatest when it comes to bedside procedures. Mirroring the heterogeneity at the individual level, hospitalist programs vary greatly on the requirements placed on their staffs in regards to procedural skill and privileging.
Such research-driven programs as Brigham and Women’s Hospital (BWH) in Boston often find requiring maintenance of privileges in bedside procedures to be difficult, says Sally Wang, MD, FHM, director of procedural education at BWH. In fact, a new procedure service being created there will be staffed mainly with ED physicians. On the flipside, most community hospitalist programs leave the task of procedural “policing” to the hospital’s medical staff affairs office.
At the University of California at San Diego (UCSD) Medical Center, the HM group is instituting a division standard in which hospitalists maintain privileging and proficiency in a core group of bedside procedures. Other large hospitalist groups have created “proceduralist” subgroups that shoulder the burden of trainee education, as well as provide a resource for less skilled or less experienced inpatient providers.
“If you have a big group, you could have a dedicated procedure service and have a core group of hospitalists who are experts in procedure,” Dr. Barsuk says. “But it needs to be self-sustaining.” Once started, Dr. Barsuk says, proceduralist groups would continue to provide hospitals with ongoing return-on-investment (ROI) benefit.
Variability in procedure volume and payor mix, however, can make it hard for HM groups to demonstrate to hospital leadership a satisfactory ROI for a proceduralist program. Financial backing from grant support or a high-volume procedure—such as paracentesis in hospitals with large hepatology programs—can nurture starting proceduralist programs until all procedural revenues can justify the costs. Lower ROI can also be justified by showing improvement in quality indices—such as CLABSI rates—reduced time to procedures, and reduced costs compared to other subspecialists offering similar services.
“I’m of the firm belief that we can reduce costs by doing the procedures at the bedside rather than referring them to departments such as interventional radiology (IR),” Dr. Barsuk says. “What you would have to do is show the institution that it costs more money to have IR do [bedside procedures].”
National Response
—Jeffrey Barsuk, MD, MS, FHM, associate professor of medicine, Northwestern Feinberg School of Medicine, academic hospitalist, Northwestern Memorial Hospital, Chicago
Filling in the procedural training gaps found on the local level, such national organizations as SHM have stepped in to provide education and support for hospitalists yearning for training. Since its inception, an SHM annual meeting pre-course that focuses on hand-held ultrasound and invasive procedures has consistently been one of the first to sell out. Other national organizations, such as ACP and its annual meeting, have seen similar interest in their courses on ultrasound-guided procedures.
The popularity of this continuing education bears out a worrisome trend: Hospitalists feel they are losing their procedural skills. An online survey conducted by The Hospitalist in May 2011 found that a majority of respondents (62%) had experienced deterioration of their procedural skills in the past five years; only 25% said they experienced improvement over the same period.
Historically, general internists have claimed bedside procedures as their domain. As stated dispassionately in the 1978 book The House of God, “There is no body cavity that cannot be reached with a #14G needle and a good strong arm.”1 Yet much has changed since Samuel Shem’s apocryphal description of medical residency training.
Most notably, the Accreditation Council of Graduate Medical Education (ACGME) has not only progressively restricted inpatient hours and patient loads for residents, but also increased the requirements for outpatient training. Some feel the balance of inpatient and outpatient training has tipped too far toward the latter in medicine residency programs, especially in light of the growing popularity of the hospitalist career path amongst new residency program graduates. This stands in contrast to ED training programs, which have embraced focused procedures training more readily.
“Adult care appears to be diverging into two career tacks as a result of external forces, of which we have limited control over, “ says Michael Beck, MD, a pediatric and adult hospitalist at Milton S. Hershey Medical Center in Hershey, Pa. “With new career choices emerging for graduates, the same square-peg, round-hole residency training should not exist.”
Dr. Beck advocates continuing an ongoing trend of “track” creation in residency programs, which allow trainees to focus training on their planned career path. Hospitalist tracks already exist in many medicine programs, including those at Cleveland Clinic and Northwestern. But many other factors limit the opportunity for trainees to obtain experience with bedside procedures, including competition with nurse practitioners and physician assistants. Even the increasing availability of ancillary phlebotomy and IV-start teams can increase a resident’s anxiety about procedures.
“By the time my residency was over [in 1993] and the work restrictions were beginning, hospital employees were doing all these tasks, making the residents less comfortable with hurting a patient when it was therapeutically necessary,” says Katharine Deiss, MD, assistant clinical professor of medicine at the University of Rochester Medical Center in New York. Interns who came from medical schools without extensive ancillary services in their teaching hospitals, she adds, were more comfortable with invasive procedures.
ACGME has sent a subtle message by decreasing emphasis on procedural skills by eradicating the requirement of showing manual proficiency in most bedside procedures as a requirement for certification. The omission has left individual residency programs and hospitalist groups to determine training and proficiency requirements for more invasive bedside procedures without a national standard.
In an editorial in the March 2007 issue of the Annals of Internal Medicine, F. Daniel Duffy, MD, and Eric Holmboe, MD, wrote that the American Board of Internal Medicine (ABIM) could only give a “qualified ‘yes’” to the question of whether residents should be trained in procedures they may not perform in practice. Although the authors asserted that the relaxed ABIM policy was “an important but small step toward revamping procedure skill training during residency,” others say it portrays an image of the ABIM de-emphasizing the importance of procedural training.
In addition, the recently established Focused Practice in Hospital Medicine (FPHM) pathway to ABIM Maintenance of Certification (MOC) has no requirement to show proficiency in bedside procedures.
“The absence of the procedural requirement in no way constitutes a statement that procedural skills are not important,” says Jeff Wiese, MD, FACP, SFHM, associate professor of medicine and residency program director at Tulane University Health Sciences Center in New Orleans, chair of the ABIM Hospital Medicine MOC Question Writing Committee, and former SHM president. “Rather, it is merely a practical issue with respect to making the MOC process applicable to all physicians engaged in hospital medicine (i.e. many hospitalists do not do procedures) while still making the MOC focused on the skill sets that are common for physicians doing hospital medicine.”
Once released into the world, even if trained well in residency, hospitalists can find it difficult to maintain their skills. In community and nonteaching settings, the pressure to admit and discharge in a timely manner can make procedures seem like the easiest corner to cut. Before long, it has been months since they have laid eyes on a needle of any sort. Many begin to develop performance anxiety.
In teaching hospitals, academic hospitalists often are called upon to participate in quality improvement (QI) and research efforts, which take time away from clinical rotations. Once there, it can be easy for a ward attending to rely upon a well-trained resident to supervise interns doing procedures. The lack of first-hand or even supervisory experience can lead to many academic hospitalists losing facility with procedures, with potentially disastrous results.
“In order to supervise a group of residents, the attending needs to be technically proficient and able to salvage a botched, or failed, procedure,” UM-JMH’s Dr. Lenchus says. “To this end, we strictly limit who can attend on the service.”
So what’s a residency or HM program director to do in the face of wavering support nationally, and sometimes locally, for maintaining procedural skills for hospitalists and trainees? Many hospitalists in teaching hospitals say it’s critical for clinicians to “get their own house in order,” to maintain procedural standards of proficiency with ongoing training, education, and verification.
“The profession now needs to redesign procedural training across the continuum of education and a lifetime of practice,” Drs. Duffy and Holmboe editorialized in the March 2007 Annals paper. “This approach would recognize the varied settings of internal-medicine practice and offer manual skills training to those whose practice settings require such skills.” Hospitalists can partner with medicine residency program leaders to provide procedural education and training to residents, either as a standalone elective or as a more general resource.
Hospitalists in such teaching hospitals as UCSD, Brigham and Women’s, UM-JMH, and Northwestern are leading efforts to provide procedural education to medical students, residents, and attendings. Training takes many forms, including formal procedural electives, required procedure rotations, or even brief one- or two-day courses in procedural skills at a simulation center.
Utilizing simulation training has been shown in many studies to be helpful in establishing procedural skills in learners of all training levels. Dr. Barsuk and his colleagues at Northwestern published studies in the Journal of Hospital Medicine in 2008 and 2009 showing that simulation training of residents was effective in improving skills in thoracentesis and central venous catheterization, respectively.3,4
In the community hospital setting, requirements for procedural skills can vary greatly based on the institution. For those community programs requiring procedural skills of their hospitalists, the clear definition of procedural training and requirements at the time of hiring is critical. Even after vetting a hospitalist’s procedural skills at hire, however, community programs should consider monitoring procedural skills and provide ongoing time and money for CME focused on procedural skills.
Currently, most hospitals depend on the honesty of individual physicians during the privileging process for bedside procedures. Even when the skills of physicians begin to wane, most are reluctant to voluntarily give up their procedure privileges.
“I think it would be pretty unusual for a hospitalist to relinquish their privileges,” Dr. Barsuk admits. But ideally, physicians who relinquish their privileges due to lack of experience could get retrained in simulation centers, then reproctored in order to regain their privileges. Northwestern established the Center for Simulation Technology and Immersive Learning as a resource for simulation training both locally and nationally.
Establishing an environment that supports hospitalists performing bedside procedures is critical. This includes the need to limit hospitalist workload to ensure adequate time to meet the procedural needs of patients. Providing easy access to the tools necessary to perform bedside procedures (e.g. portable ultrasound and pre-packaged procedure trays) helps avoid additional hurdles.
Academic hospitalist programs can serve as a regional resource by developing ongoing procedure mastery programs for hospitalists in their communities, as many smaller institutions do not have the resources to provide ongoing training in bedside procedures. This process can be tedious, but it should not be humiliating.
If the popularity of the SHM pre-course in bedside ultrasound and procedures is any indication, when given the opportunity to receive protected time for procedure training, most hospitalists will likely jump at the chance.
Dr. Chang is an associate clinical professor of medicine in the division of hospital medicine at Diego Medical Center. He is also a member of Team Hospitalist.
References
- Shem S. The House of God. New York: Dell Publishing; 1978.
- Duffy FD, Holmboe ES. What procedures should internists do? Ann Intern Med. 2007;146(5):392-393.
- Wayne DB, Barsuk JH, O’Leary KJ, Fudala MJ, McGaghie WC. Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. J Hosp Med. 2008;3(1):48-54.
- Barsuk JH, McGaghie WC, Cohen ER, Balachandran JS, Wayne DB. Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. J Hosp Med. 2009;4(7):397–403.
It’s 3:30 p.m. You’ve seen your old patients, holdovers, and an admission, but you haven’t finished your notes yet. Lunch was an afterthought between emails about schedule changes for the upcoming year. Two pages ring happily from your belt, the first from you-know-who in the ED, and the next from a nurse: “THORA SUPPLIES AT BEDSIDE SINCE THIS AM—WHEN WILL THIS HAPPEN?” The phone number on the wall for the on-call radiologist beckons...
An all-too-familiar situation for hospitalists across the country, this awkward moment raises a series of difficult questions:
Should I set aside time from my day to perform a procedure that could be time-consuming?
- Do I feel confident I can perform this procedure safely?
- Am I really the best physician to provide this service?
- As hospitalists are tasked with an ever-increasing array of responsibilities, answering the call of duty for bedside procedures is becoming more difficult for some.
A Core Competency
“The Core Competencies in Hospital Medicine,” authored by a group of HM thought leaders, was published as a supplement to the January/February 2006 issue of the Journal of Hospital Medicine. The core competencies include such bedside procedures as arthrocentesis, paracentesis, thoracentesis, lumbar puncture, and vascular (arterial and central venous) access (see “Core Competencies in Hospital Medicine: Procedures,” below). Although the authors stressed that the core competencies are to be viewed as a resource rather than as a set of requirements, the inclusion of bedside procedures emphasized the importance of procedural skills for future hospitalists.
“[Hospitalists] are in a perfect spot to continue to perform procedures in a structured manner,” says Joshua Lenchus, DO, RPh, FACP, FHM, associate director of the University of Miami-Jackson Memorial Hospital (UM-JMH) Center for Patient Safety. “As agents of quality and safety, hospitalists should continue to perform this clinically necessary service.”
Jeffrey Barsuk, MD, FHM, associate professor of medicine at Northwestern Feinberg School of Medicine in Chicago and an academic hospitalist at Northwestern Memorial Hospital (NMH), not only agrees that bedside procedures should be a core competency, but he also says hospitalists are the most appropriate providers of these services.
“I think this is part of hospital medicine. We’re in the hospital, [and] that’s what we do,” Dr. Barsuk says. Other providers, such as interventional radiologists, “really don’t understand why I’m doing [a procedure]. They understand it’s safe to do it, but they might not understand all the indications for it, and they certainly don’t understand the interpretation of the tests they’re sending.”
Despite the goals set forth by the core competencies and authorities in procedural safety, the reality of who actually performs bedside procedures is somewhat murky and varies greatly by institution. Many point to HM program setting (urban vs. rural) or structure (academic vs. community) to explain variance, but often it is other factors that determine whether hospitalists are actually preforming bedside procedures regularly.
Where Does HM Perform Procedures?
Community hospitalists, with strong support from interventional radiologists and subspecialists, often find it more efficient—even necessary, considering their patient volumes—to leave procedures to others. Community hospitalists with ICU admitting privileges, intensivists, and other HM subgroups say that being able to perform procedures should be a prerequisite for employment. Hospitalists in rural communities say they are doing procedures because they are “the only game in town.”
“Sometimes you are the only one available, and you are called upon to stretch your abilities,” says Beatrice Szantyr, MD, FAAP, a community hospitalist and pediatrician in Lincoln, Maine, who has practiced most of her career in rural settings.
Academic hospitalists in large, research-based HM programs can, paradoxically, find themselves performing fewer procedures as residents often take the lead on the majority of such cases. Conversely, academic hospitalists in large, nonteaching programs often find themselves called on to perform more bedside procedures.
No matter the setting, the simplicity of being the physician to recognize the need for a procedure, perform it, and interpret the results is undeniably efficient and “clean,” according to authorities on inpatient bedside procedures. Having to consult other physicians, optimize the patient’s lab values to their standards (a common issue with interventional radiologists), and adhere to their work schedules can often delay procedures unnecessarily.
—Joshua Lenchus, DO, RPh, FACP, FHM, associate director, University of Miami-Jackson Memorial Hospital (UM-JMH) Center for Patient Safety
“Hospitalists care for floor and ICU patients in many hospitals, and the inability to perform bedside procedures delays patient care,” says Dr. Nilam Soni, an academic hospitalist at the University of Chicago and a recognized expert on procedural safety.
Dr. Soni notes that when it comes to current techniques, many hospitalists suffer from a knowledge deficit. “The introduction of ultrasound for guidance of bedside procedures has been shown to improve the success and safety of certain procedures,” he says, “but the majority of practicing hospitalists did not learn how to use ultrasound for procedure guidance during residency.”
Heterogeneity of Training, Experience, and Skill
While all hospitalists draw upon different bases of training and experience, the heterogeneity of training, confidence, and inherent skill is greatest when it comes to bedside procedures. Mirroring the heterogeneity at the individual level, hospitalist programs vary greatly on the requirements placed on their staffs in regards to procedural skill and privileging.
Such research-driven programs as Brigham and Women’s Hospital (BWH) in Boston often find requiring maintenance of privileges in bedside procedures to be difficult, says Sally Wang, MD, FHM, director of procedural education at BWH. In fact, a new procedure service being created there will be staffed mainly with ED physicians. On the flipside, most community hospitalist programs leave the task of procedural “policing” to the hospital’s medical staff affairs office.
At the University of California at San Diego (UCSD) Medical Center, the HM group is instituting a division standard in which hospitalists maintain privileging and proficiency in a core group of bedside procedures. Other large hospitalist groups have created “proceduralist” subgroups that shoulder the burden of trainee education, as well as provide a resource for less skilled or less experienced inpatient providers.
“If you have a big group, you could have a dedicated procedure service and have a core group of hospitalists who are experts in procedure,” Dr. Barsuk says. “But it needs to be self-sustaining.” Once started, Dr. Barsuk says, proceduralist groups would continue to provide hospitals with ongoing return-on-investment (ROI) benefit.
Variability in procedure volume and payor mix, however, can make it hard for HM groups to demonstrate to hospital leadership a satisfactory ROI for a proceduralist program. Financial backing from grant support or a high-volume procedure—such as paracentesis in hospitals with large hepatology programs—can nurture starting proceduralist programs until all procedural revenues can justify the costs. Lower ROI can also be justified by showing improvement in quality indices—such as CLABSI rates—reduced time to procedures, and reduced costs compared to other subspecialists offering similar services.
“I’m of the firm belief that we can reduce costs by doing the procedures at the bedside rather than referring them to departments such as interventional radiology (IR),” Dr. Barsuk says. “What you would have to do is show the institution that it costs more money to have IR do [bedside procedures].”
National Response
—Jeffrey Barsuk, MD, MS, FHM, associate professor of medicine, Northwestern Feinberg School of Medicine, academic hospitalist, Northwestern Memorial Hospital, Chicago
Filling in the procedural training gaps found on the local level, such national organizations as SHM have stepped in to provide education and support for hospitalists yearning for training. Since its inception, an SHM annual meeting pre-course that focuses on hand-held ultrasound and invasive procedures has consistently been one of the first to sell out. Other national organizations, such as ACP and its annual meeting, have seen similar interest in their courses on ultrasound-guided procedures.
The popularity of this continuing education bears out a worrisome trend: Hospitalists feel they are losing their procedural skills. An online survey conducted by The Hospitalist in May 2011 found that a majority of respondents (62%) had experienced deterioration of their procedural skills in the past five years; only 25% said they experienced improvement over the same period.
Historically, general internists have claimed bedside procedures as their domain. As stated dispassionately in the 1978 book The House of God, “There is no body cavity that cannot be reached with a #14G needle and a good strong arm.”1 Yet much has changed since Samuel Shem’s apocryphal description of medical residency training.
Most notably, the Accreditation Council of Graduate Medical Education (ACGME) has not only progressively restricted inpatient hours and patient loads for residents, but also increased the requirements for outpatient training. Some feel the balance of inpatient and outpatient training has tipped too far toward the latter in medicine residency programs, especially in light of the growing popularity of the hospitalist career path amongst new residency program graduates. This stands in contrast to ED training programs, which have embraced focused procedures training more readily.
“Adult care appears to be diverging into two career tacks as a result of external forces, of which we have limited control over, “ says Michael Beck, MD, a pediatric and adult hospitalist at Milton S. Hershey Medical Center in Hershey, Pa. “With new career choices emerging for graduates, the same square-peg, round-hole residency training should not exist.”
Dr. Beck advocates continuing an ongoing trend of “track” creation in residency programs, which allow trainees to focus training on their planned career path. Hospitalist tracks already exist in many medicine programs, including those at Cleveland Clinic and Northwestern. But many other factors limit the opportunity for trainees to obtain experience with bedside procedures, including competition with nurse practitioners and physician assistants. Even the increasing availability of ancillary phlebotomy and IV-start teams can increase a resident’s anxiety about procedures.
“By the time my residency was over [in 1993] and the work restrictions were beginning, hospital employees were doing all these tasks, making the residents less comfortable with hurting a patient when it was therapeutically necessary,” says Katharine Deiss, MD, assistant clinical professor of medicine at the University of Rochester Medical Center in New York. Interns who came from medical schools without extensive ancillary services in their teaching hospitals, she adds, were more comfortable with invasive procedures.
ACGME has sent a subtle message by decreasing emphasis on procedural skills by eradicating the requirement of showing manual proficiency in most bedside procedures as a requirement for certification. The omission has left individual residency programs and hospitalist groups to determine training and proficiency requirements for more invasive bedside procedures without a national standard.
In an editorial in the March 2007 issue of the Annals of Internal Medicine, F. Daniel Duffy, MD, and Eric Holmboe, MD, wrote that the American Board of Internal Medicine (ABIM) could only give a “qualified ‘yes’” to the question of whether residents should be trained in procedures they may not perform in practice. Although the authors asserted that the relaxed ABIM policy was “an important but small step toward revamping procedure skill training during residency,” others say it portrays an image of the ABIM de-emphasizing the importance of procedural training.
In addition, the recently established Focused Practice in Hospital Medicine (FPHM) pathway to ABIM Maintenance of Certification (MOC) has no requirement to show proficiency in bedside procedures.
“The absence of the procedural requirement in no way constitutes a statement that procedural skills are not important,” says Jeff Wiese, MD, FACP, SFHM, associate professor of medicine and residency program director at Tulane University Health Sciences Center in New Orleans, chair of the ABIM Hospital Medicine MOC Question Writing Committee, and former SHM president. “Rather, it is merely a practical issue with respect to making the MOC process applicable to all physicians engaged in hospital medicine (i.e. many hospitalists do not do procedures) while still making the MOC focused on the skill sets that are common for physicians doing hospital medicine.”
Once released into the world, even if trained well in residency, hospitalists can find it difficult to maintain their skills. In community and nonteaching settings, the pressure to admit and discharge in a timely manner can make procedures seem like the easiest corner to cut. Before long, it has been months since they have laid eyes on a needle of any sort. Many begin to develop performance anxiety.
In teaching hospitals, academic hospitalists often are called upon to participate in quality improvement (QI) and research efforts, which take time away from clinical rotations. Once there, it can be easy for a ward attending to rely upon a well-trained resident to supervise interns doing procedures. The lack of first-hand or even supervisory experience can lead to many academic hospitalists losing facility with procedures, with potentially disastrous results.
“In order to supervise a group of residents, the attending needs to be technically proficient and able to salvage a botched, or failed, procedure,” UM-JMH’s Dr. Lenchus says. “To this end, we strictly limit who can attend on the service.”
So what’s a residency or HM program director to do in the face of wavering support nationally, and sometimes locally, for maintaining procedural skills for hospitalists and trainees? Many hospitalists in teaching hospitals say it’s critical for clinicians to “get their own house in order,” to maintain procedural standards of proficiency with ongoing training, education, and verification.
“The profession now needs to redesign procedural training across the continuum of education and a lifetime of practice,” Drs. Duffy and Holmboe editorialized in the March 2007 Annals paper. “This approach would recognize the varied settings of internal-medicine practice and offer manual skills training to those whose practice settings require such skills.” Hospitalists can partner with medicine residency program leaders to provide procedural education and training to residents, either as a standalone elective or as a more general resource.
Hospitalists in such teaching hospitals as UCSD, Brigham and Women’s, UM-JMH, and Northwestern are leading efforts to provide procedural education to medical students, residents, and attendings. Training takes many forms, including formal procedural electives, required procedure rotations, or even brief one- or two-day courses in procedural skills at a simulation center.
Utilizing simulation training has been shown in many studies to be helpful in establishing procedural skills in learners of all training levels. Dr. Barsuk and his colleagues at Northwestern published studies in the Journal of Hospital Medicine in 2008 and 2009 showing that simulation training of residents was effective in improving skills in thoracentesis and central venous catheterization, respectively.3,4
In the community hospital setting, requirements for procedural skills can vary greatly based on the institution. For those community programs requiring procedural skills of their hospitalists, the clear definition of procedural training and requirements at the time of hiring is critical. Even after vetting a hospitalist’s procedural skills at hire, however, community programs should consider monitoring procedural skills and provide ongoing time and money for CME focused on procedural skills.
Currently, most hospitals depend on the honesty of individual physicians during the privileging process for bedside procedures. Even when the skills of physicians begin to wane, most are reluctant to voluntarily give up their procedure privileges.
“I think it would be pretty unusual for a hospitalist to relinquish their privileges,” Dr. Barsuk admits. But ideally, physicians who relinquish their privileges due to lack of experience could get retrained in simulation centers, then reproctored in order to regain their privileges. Northwestern established the Center for Simulation Technology and Immersive Learning as a resource for simulation training both locally and nationally.
Establishing an environment that supports hospitalists performing bedside procedures is critical. This includes the need to limit hospitalist workload to ensure adequate time to meet the procedural needs of patients. Providing easy access to the tools necessary to perform bedside procedures (e.g. portable ultrasound and pre-packaged procedure trays) helps avoid additional hurdles.
Academic hospitalist programs can serve as a regional resource by developing ongoing procedure mastery programs for hospitalists in their communities, as many smaller institutions do not have the resources to provide ongoing training in bedside procedures. This process can be tedious, but it should not be humiliating.
If the popularity of the SHM pre-course in bedside ultrasound and procedures is any indication, when given the opportunity to receive protected time for procedure training, most hospitalists will likely jump at the chance.
Dr. Chang is an associate clinical professor of medicine in the division of hospital medicine at Diego Medical Center. He is also a member of Team Hospitalist.
References
- Shem S. The House of God. New York: Dell Publishing; 1978.
- Duffy FD, Holmboe ES. What procedures should internists do? Ann Intern Med. 2007;146(5):392-393.
- Wayne DB, Barsuk JH, O’Leary KJ, Fudala MJ, McGaghie WC. Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. J Hosp Med. 2008;3(1):48-54.
- Barsuk JH, McGaghie WC, Cohen ER, Balachandran JS, Wayne DB. Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. J Hosp Med. 2009;4(7):397–403.
It’s 3:30 p.m. You’ve seen your old patients, holdovers, and an admission, but you haven’t finished your notes yet. Lunch was an afterthought between emails about schedule changes for the upcoming year. Two pages ring happily from your belt, the first from you-know-who in the ED, and the next from a nurse: “THORA SUPPLIES AT BEDSIDE SINCE THIS AM—WHEN WILL THIS HAPPEN?” The phone number on the wall for the on-call radiologist beckons...
An all-too-familiar situation for hospitalists across the country, this awkward moment raises a series of difficult questions:
Should I set aside time from my day to perform a procedure that could be time-consuming?
- Do I feel confident I can perform this procedure safely?
- Am I really the best physician to provide this service?
- As hospitalists are tasked with an ever-increasing array of responsibilities, answering the call of duty for bedside procedures is becoming more difficult for some.
A Core Competency
“The Core Competencies in Hospital Medicine,” authored by a group of HM thought leaders, was published as a supplement to the January/February 2006 issue of the Journal of Hospital Medicine. The core competencies include such bedside procedures as arthrocentesis, paracentesis, thoracentesis, lumbar puncture, and vascular (arterial and central venous) access (see “Core Competencies in Hospital Medicine: Procedures,” below). Although the authors stressed that the core competencies are to be viewed as a resource rather than as a set of requirements, the inclusion of bedside procedures emphasized the importance of procedural skills for future hospitalists.
“[Hospitalists] are in a perfect spot to continue to perform procedures in a structured manner,” says Joshua Lenchus, DO, RPh, FACP, FHM, associate director of the University of Miami-Jackson Memorial Hospital (UM-JMH) Center for Patient Safety. “As agents of quality and safety, hospitalists should continue to perform this clinically necessary service.”
Jeffrey Barsuk, MD, FHM, associate professor of medicine at Northwestern Feinberg School of Medicine in Chicago and an academic hospitalist at Northwestern Memorial Hospital (NMH), not only agrees that bedside procedures should be a core competency, but he also says hospitalists are the most appropriate providers of these services.
“I think this is part of hospital medicine. We’re in the hospital, [and] that’s what we do,” Dr. Barsuk says. Other providers, such as interventional radiologists, “really don’t understand why I’m doing [a procedure]. They understand it’s safe to do it, but they might not understand all the indications for it, and they certainly don’t understand the interpretation of the tests they’re sending.”
Despite the goals set forth by the core competencies and authorities in procedural safety, the reality of who actually performs bedside procedures is somewhat murky and varies greatly by institution. Many point to HM program setting (urban vs. rural) or structure (academic vs. community) to explain variance, but often it is other factors that determine whether hospitalists are actually preforming bedside procedures regularly.
Where Does HM Perform Procedures?
Community hospitalists, with strong support from interventional radiologists and subspecialists, often find it more efficient—even necessary, considering their patient volumes—to leave procedures to others. Community hospitalists with ICU admitting privileges, intensivists, and other HM subgroups say that being able to perform procedures should be a prerequisite for employment. Hospitalists in rural communities say they are doing procedures because they are “the only game in town.”
“Sometimes you are the only one available, and you are called upon to stretch your abilities,” says Beatrice Szantyr, MD, FAAP, a community hospitalist and pediatrician in Lincoln, Maine, who has practiced most of her career in rural settings.
Academic hospitalists in large, research-based HM programs can, paradoxically, find themselves performing fewer procedures as residents often take the lead on the majority of such cases. Conversely, academic hospitalists in large, nonteaching programs often find themselves called on to perform more bedside procedures.
No matter the setting, the simplicity of being the physician to recognize the need for a procedure, perform it, and interpret the results is undeniably efficient and “clean,” according to authorities on inpatient bedside procedures. Having to consult other physicians, optimize the patient’s lab values to their standards (a common issue with interventional radiologists), and adhere to their work schedules can often delay procedures unnecessarily.
—Joshua Lenchus, DO, RPh, FACP, FHM, associate director, University of Miami-Jackson Memorial Hospital (UM-JMH) Center for Patient Safety
“Hospitalists care for floor and ICU patients in many hospitals, and the inability to perform bedside procedures delays patient care,” says Dr. Nilam Soni, an academic hospitalist at the University of Chicago and a recognized expert on procedural safety.
Dr. Soni notes that when it comes to current techniques, many hospitalists suffer from a knowledge deficit. “The introduction of ultrasound for guidance of bedside procedures has been shown to improve the success and safety of certain procedures,” he says, “but the majority of practicing hospitalists did not learn how to use ultrasound for procedure guidance during residency.”
Heterogeneity of Training, Experience, and Skill
While all hospitalists draw upon different bases of training and experience, the heterogeneity of training, confidence, and inherent skill is greatest when it comes to bedside procedures. Mirroring the heterogeneity at the individual level, hospitalist programs vary greatly on the requirements placed on their staffs in regards to procedural skill and privileging.
Such research-driven programs as Brigham and Women’s Hospital (BWH) in Boston often find requiring maintenance of privileges in bedside procedures to be difficult, says Sally Wang, MD, FHM, director of procedural education at BWH. In fact, a new procedure service being created there will be staffed mainly with ED physicians. On the flipside, most community hospitalist programs leave the task of procedural “policing” to the hospital’s medical staff affairs office.
At the University of California at San Diego (UCSD) Medical Center, the HM group is instituting a division standard in which hospitalists maintain privileging and proficiency in a core group of bedside procedures. Other large hospitalist groups have created “proceduralist” subgroups that shoulder the burden of trainee education, as well as provide a resource for less skilled or less experienced inpatient providers.
“If you have a big group, you could have a dedicated procedure service and have a core group of hospitalists who are experts in procedure,” Dr. Barsuk says. “But it needs to be self-sustaining.” Once started, Dr. Barsuk says, proceduralist groups would continue to provide hospitals with ongoing return-on-investment (ROI) benefit.
Variability in procedure volume and payor mix, however, can make it hard for HM groups to demonstrate to hospital leadership a satisfactory ROI for a proceduralist program. Financial backing from grant support or a high-volume procedure—such as paracentesis in hospitals with large hepatology programs—can nurture starting proceduralist programs until all procedural revenues can justify the costs. Lower ROI can also be justified by showing improvement in quality indices—such as CLABSI rates—reduced time to procedures, and reduced costs compared to other subspecialists offering similar services.
“I’m of the firm belief that we can reduce costs by doing the procedures at the bedside rather than referring them to departments such as interventional radiology (IR),” Dr. Barsuk says. “What you would have to do is show the institution that it costs more money to have IR do [bedside procedures].”
National Response
—Jeffrey Barsuk, MD, MS, FHM, associate professor of medicine, Northwestern Feinberg School of Medicine, academic hospitalist, Northwestern Memorial Hospital, Chicago
Filling in the procedural training gaps found on the local level, such national organizations as SHM have stepped in to provide education and support for hospitalists yearning for training. Since its inception, an SHM annual meeting pre-course that focuses on hand-held ultrasound and invasive procedures has consistently been one of the first to sell out. Other national organizations, such as ACP and its annual meeting, have seen similar interest in their courses on ultrasound-guided procedures.
The popularity of this continuing education bears out a worrisome trend: Hospitalists feel they are losing their procedural skills. An online survey conducted by The Hospitalist in May 2011 found that a majority of respondents (62%) had experienced deterioration of their procedural skills in the past five years; only 25% said they experienced improvement over the same period.
Historically, general internists have claimed bedside procedures as their domain. As stated dispassionately in the 1978 book The House of God, “There is no body cavity that cannot be reached with a #14G needle and a good strong arm.”1 Yet much has changed since Samuel Shem’s apocryphal description of medical residency training.
Most notably, the Accreditation Council of Graduate Medical Education (ACGME) has not only progressively restricted inpatient hours and patient loads for residents, but also increased the requirements for outpatient training. Some feel the balance of inpatient and outpatient training has tipped too far toward the latter in medicine residency programs, especially in light of the growing popularity of the hospitalist career path amongst new residency program graduates. This stands in contrast to ED training programs, which have embraced focused procedures training more readily.
“Adult care appears to be diverging into two career tacks as a result of external forces, of which we have limited control over, “ says Michael Beck, MD, a pediatric and adult hospitalist at Milton S. Hershey Medical Center in Hershey, Pa. “With new career choices emerging for graduates, the same square-peg, round-hole residency training should not exist.”
Dr. Beck advocates continuing an ongoing trend of “track” creation in residency programs, which allow trainees to focus training on their planned career path. Hospitalist tracks already exist in many medicine programs, including those at Cleveland Clinic and Northwestern. But many other factors limit the opportunity for trainees to obtain experience with bedside procedures, including competition with nurse practitioners and physician assistants. Even the increasing availability of ancillary phlebotomy and IV-start teams can increase a resident’s anxiety about procedures.
“By the time my residency was over [in 1993] and the work restrictions were beginning, hospital employees were doing all these tasks, making the residents less comfortable with hurting a patient when it was therapeutically necessary,” says Katharine Deiss, MD, assistant clinical professor of medicine at the University of Rochester Medical Center in New York. Interns who came from medical schools without extensive ancillary services in their teaching hospitals, she adds, were more comfortable with invasive procedures.
ACGME has sent a subtle message by decreasing emphasis on procedural skills by eradicating the requirement of showing manual proficiency in most bedside procedures as a requirement for certification. The omission has left individual residency programs and hospitalist groups to determine training and proficiency requirements for more invasive bedside procedures without a national standard.
In an editorial in the March 2007 issue of the Annals of Internal Medicine, F. Daniel Duffy, MD, and Eric Holmboe, MD, wrote that the American Board of Internal Medicine (ABIM) could only give a “qualified ‘yes’” to the question of whether residents should be trained in procedures they may not perform in practice. Although the authors asserted that the relaxed ABIM policy was “an important but small step toward revamping procedure skill training during residency,” others say it portrays an image of the ABIM de-emphasizing the importance of procedural training.
In addition, the recently established Focused Practice in Hospital Medicine (FPHM) pathway to ABIM Maintenance of Certification (MOC) has no requirement to show proficiency in bedside procedures.
“The absence of the procedural requirement in no way constitutes a statement that procedural skills are not important,” says Jeff Wiese, MD, FACP, SFHM, associate professor of medicine and residency program director at Tulane University Health Sciences Center in New Orleans, chair of the ABIM Hospital Medicine MOC Question Writing Committee, and former SHM president. “Rather, it is merely a practical issue with respect to making the MOC process applicable to all physicians engaged in hospital medicine (i.e. many hospitalists do not do procedures) while still making the MOC focused on the skill sets that are common for physicians doing hospital medicine.”
Once released into the world, even if trained well in residency, hospitalists can find it difficult to maintain their skills. In community and nonteaching settings, the pressure to admit and discharge in a timely manner can make procedures seem like the easiest corner to cut. Before long, it has been months since they have laid eyes on a needle of any sort. Many begin to develop performance anxiety.
In teaching hospitals, academic hospitalists often are called upon to participate in quality improvement (QI) and research efforts, which take time away from clinical rotations. Once there, it can be easy for a ward attending to rely upon a well-trained resident to supervise interns doing procedures. The lack of first-hand or even supervisory experience can lead to many academic hospitalists losing facility with procedures, with potentially disastrous results.
“In order to supervise a group of residents, the attending needs to be technically proficient and able to salvage a botched, or failed, procedure,” UM-JMH’s Dr. Lenchus says. “To this end, we strictly limit who can attend on the service.”
So what’s a residency or HM program director to do in the face of wavering support nationally, and sometimes locally, for maintaining procedural skills for hospitalists and trainees? Many hospitalists in teaching hospitals say it’s critical for clinicians to “get their own house in order,” to maintain procedural standards of proficiency with ongoing training, education, and verification.
“The profession now needs to redesign procedural training across the continuum of education and a lifetime of practice,” Drs. Duffy and Holmboe editorialized in the March 2007 Annals paper. “This approach would recognize the varied settings of internal-medicine practice and offer manual skills training to those whose practice settings require such skills.” Hospitalists can partner with medicine residency program leaders to provide procedural education and training to residents, either as a standalone elective or as a more general resource.
Hospitalists in such teaching hospitals as UCSD, Brigham and Women’s, UM-JMH, and Northwestern are leading efforts to provide procedural education to medical students, residents, and attendings. Training takes many forms, including formal procedural electives, required procedure rotations, or even brief one- or two-day courses in procedural skills at a simulation center.
Utilizing simulation training has been shown in many studies to be helpful in establishing procedural skills in learners of all training levels. Dr. Barsuk and his colleagues at Northwestern published studies in the Journal of Hospital Medicine in 2008 and 2009 showing that simulation training of residents was effective in improving skills in thoracentesis and central venous catheterization, respectively.3,4
In the community hospital setting, requirements for procedural skills can vary greatly based on the institution. For those community programs requiring procedural skills of their hospitalists, the clear definition of procedural training and requirements at the time of hiring is critical. Even after vetting a hospitalist’s procedural skills at hire, however, community programs should consider monitoring procedural skills and provide ongoing time and money for CME focused on procedural skills.
Currently, most hospitals depend on the honesty of individual physicians during the privileging process for bedside procedures. Even when the skills of physicians begin to wane, most are reluctant to voluntarily give up their procedure privileges.
“I think it would be pretty unusual for a hospitalist to relinquish their privileges,” Dr. Barsuk admits. But ideally, physicians who relinquish their privileges due to lack of experience could get retrained in simulation centers, then reproctored in order to regain their privileges. Northwestern established the Center for Simulation Technology and Immersive Learning as a resource for simulation training both locally and nationally.
Establishing an environment that supports hospitalists performing bedside procedures is critical. This includes the need to limit hospitalist workload to ensure adequate time to meet the procedural needs of patients. Providing easy access to the tools necessary to perform bedside procedures (e.g. portable ultrasound and pre-packaged procedure trays) helps avoid additional hurdles.
Academic hospitalist programs can serve as a regional resource by developing ongoing procedure mastery programs for hospitalists in their communities, as many smaller institutions do not have the resources to provide ongoing training in bedside procedures. This process can be tedious, but it should not be humiliating.
If the popularity of the SHM pre-course in bedside ultrasound and procedures is any indication, when given the opportunity to receive protected time for procedure training, most hospitalists will likely jump at the chance.
Dr. Chang is an associate clinical professor of medicine in the division of hospital medicine at Diego Medical Center. He is also a member of Team Hospitalist.
References
- Shem S. The House of God. New York: Dell Publishing; 1978.
- Duffy FD, Holmboe ES. What procedures should internists do? Ann Intern Med. 2007;146(5):392-393.
- Wayne DB, Barsuk JH, O’Leary KJ, Fudala MJ, McGaghie WC. Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. J Hosp Med. 2008;3(1):48-54.
- Barsuk JH, McGaghie WC, Cohen ER, Balachandran JS, Wayne DB. Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. J Hosp Med. 2009;4(7):397–403.
Project BOOST Helps California Hospital Improve Care
Soon, hospitals with unnecessary 30-day readmissions will be penalized. Some proactive hospitals are already tackling care transitions to reduce readmissions, improve patient care, and reduce costs.
Lodi Memorial Hospital in Northern California is one such hospital. The 214-bed facility has made preventing readmissions a key strategic goal for improving care, especially for vulnerable, frail elderly patients.
Lodi executives say readmissions are a challenge at the hospital because many different specialties and house staff are involved in the discharge process.
With many options from which to choose, Lodi selected SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions). Project BOOST, unlike other programs, focuses on first identifying system deficiencies, then building cohesive multidisciplinary teams.
“If you layer a clinical intervention onto a broken system,” says BOOST mentor Stephanie Rennke, MD, “success isn’t likely. Project BOOST helps the team map current processes, find deficiencies, assess resources, and redefine a culture of safety.
“BOOST starts with an assessment of how the system functions, and identifies its strengths and weaknesses so you can focus your efforts on critical areas for improvement and tailor the BOOST intervention to fit the unique dynamics of an institution,” she says.
Search for a Solution
No two institutions are exactly the same, especially when analyzing patient-safety culture. Project BOOST is customized to the needs of each BOOST site, which has proven useful to Lodi, as it found it had different needs than other hospitals.
“We chose Project BOOST because it seemed workable and implementable, while offering a less expensive and less complicated solution than competitors’ products,” says Valerie Cronin, Lodi’s director of utilization.
The BOOST mentor, key to this customization, provided Lodi with the reassurance that comes with working directly with someone who has faced similar challenges—not just theoretically, but also on the floor—and was willing to work with Lodi to develop practical solutions. The mentor provided reassurance, support, and perspective as Lodi walked through the BOOST implementation process.
Keys to Success
—Valerie Cronin, director of utilization, Lodi Memorial Hospital, California
Team-focused care, clear communication, and administrative support were keys to successful BOOST implementation at Lodi, says Cronin.
The house staff was overwhelmed, and adding a quality-improvement (QI) project to implement and manage might have seemed like an impossible challenge. By developing multidisciplinary teams, however, Lodi was able to distribute the tasks of implementation and began to recognize the value and benefit of Project BOOST, which already had strong support from hospital executives.
A 14-member multidisciplinary team was formed to oversee the Project BOOST implementation. The team then was divided into sub-groups to work on the main components of Project BOOST: Passport to Care Form, Target Assessment Tool, the Teachback process, and Follow-Up Phone Calls. The sub-groups’ main objectives were to ensure that BOOST effectively changed processes and work practices for a stronger and safer discharge process.
To support these teams and foster communication laterally among healthcare providers and vertically with hospital administration, Lodi established a structured meeting format, delegated task assignments for accountability, and appointed an implementation champion.
Capitalizing on the experience of its BOOST mentor, the Lodi multidisciplinary teams mapped out the process to assess threats to the system and opportunities for improvement, and began moving forward with implementable solutions for sustainable change.
“Evaluating the whole discharge process allowed us to see the gaps and discrepancies in the discharge process,” Cronin says. “Each discipline had their own set of procedures and materials, which proved lacking and inconsistent for our patients. It was an essential and eye-opening experience for Lodi to make change.”
One of the biggest revelations was learning how broken the discharge process was for the nurses. When Lodi looked at its current process of using case managers to handle high-risk patients and leaving the remaining patient discharges to the nurses, they found that the process was not strong enough to support patient load.
Knowledge Is Power
Cronin says Lodi has standardized its patient educational materials and started the patient education process as soon as patients are admitted. This step optimizes a patient’s understanding of diagnoses and care instructions when the time comes for discharge.
Through the Project BOOST assessment, Lodi ascertained that many of its patients were being discharged to skilled-nursing facilities, which heightens the complexity of post-care and introduces the potential for increased risks. Lodi is now working to better communicate with the skilled-nursing facilities using its Project BOOST training to streamline the discharge process.
The implementation of the Teach Back communication strategy has been critical in increasing patient knowledge and adherence to care instructions, official say. Based on the success of Project BOOST implementation, Teach Back has been incorporated into mandatory nurse training throughout the hospital.
Improved Care
More than 80 patients were discharged through the BOOST process in the first 90 days of implementation. Lodi is already experiencing the benefits of Project BOOST organizationally and
expects to see the financial impacts soon through a lower 30-day readmission rate.
“Lodi has experienced a shift in patient safety culture with improved communication through a team approach to care,” Cronin says. “Lodi expects high success through Project BOOST with the goal of implementing Project BOOST across all disease states and every discipline using Teachback.
“Project BOOST has been the ideal program to align with our strategic organizational goals to improve transitions of care and re-create the patient safety culture to make systemwide sustainable change,” she says.
For more information about Project BOOST, visit www.hospitalmedicine.org/boost.
Jacqui Petock, marketing project manager
Soon, hospitals with unnecessary 30-day readmissions will be penalized. Some proactive hospitals are already tackling care transitions to reduce readmissions, improve patient care, and reduce costs.
Lodi Memorial Hospital in Northern California is one such hospital. The 214-bed facility has made preventing readmissions a key strategic goal for improving care, especially for vulnerable, frail elderly patients.
Lodi executives say readmissions are a challenge at the hospital because many different specialties and house staff are involved in the discharge process.
With many options from which to choose, Lodi selected SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions). Project BOOST, unlike other programs, focuses on first identifying system deficiencies, then building cohesive multidisciplinary teams.
“If you layer a clinical intervention onto a broken system,” says BOOST mentor Stephanie Rennke, MD, “success isn’t likely. Project BOOST helps the team map current processes, find deficiencies, assess resources, and redefine a culture of safety.
“BOOST starts with an assessment of how the system functions, and identifies its strengths and weaknesses so you can focus your efforts on critical areas for improvement and tailor the BOOST intervention to fit the unique dynamics of an institution,” she says.
Search for a Solution
No two institutions are exactly the same, especially when analyzing patient-safety culture. Project BOOST is customized to the needs of each BOOST site, which has proven useful to Lodi, as it found it had different needs than other hospitals.
“We chose Project BOOST because it seemed workable and implementable, while offering a less expensive and less complicated solution than competitors’ products,” says Valerie Cronin, Lodi’s director of utilization.
The BOOST mentor, key to this customization, provided Lodi with the reassurance that comes with working directly with someone who has faced similar challenges—not just theoretically, but also on the floor—and was willing to work with Lodi to develop practical solutions. The mentor provided reassurance, support, and perspective as Lodi walked through the BOOST implementation process.
Keys to Success
—Valerie Cronin, director of utilization, Lodi Memorial Hospital, California
Team-focused care, clear communication, and administrative support were keys to successful BOOST implementation at Lodi, says Cronin.
The house staff was overwhelmed, and adding a quality-improvement (QI) project to implement and manage might have seemed like an impossible challenge. By developing multidisciplinary teams, however, Lodi was able to distribute the tasks of implementation and began to recognize the value and benefit of Project BOOST, which already had strong support from hospital executives.
A 14-member multidisciplinary team was formed to oversee the Project BOOST implementation. The team then was divided into sub-groups to work on the main components of Project BOOST: Passport to Care Form, Target Assessment Tool, the Teachback process, and Follow-Up Phone Calls. The sub-groups’ main objectives were to ensure that BOOST effectively changed processes and work practices for a stronger and safer discharge process.
To support these teams and foster communication laterally among healthcare providers and vertically with hospital administration, Lodi established a structured meeting format, delegated task assignments for accountability, and appointed an implementation champion.
Capitalizing on the experience of its BOOST mentor, the Lodi multidisciplinary teams mapped out the process to assess threats to the system and opportunities for improvement, and began moving forward with implementable solutions for sustainable change.
“Evaluating the whole discharge process allowed us to see the gaps and discrepancies in the discharge process,” Cronin says. “Each discipline had their own set of procedures and materials, which proved lacking and inconsistent for our patients. It was an essential and eye-opening experience for Lodi to make change.”
One of the biggest revelations was learning how broken the discharge process was for the nurses. When Lodi looked at its current process of using case managers to handle high-risk patients and leaving the remaining patient discharges to the nurses, they found that the process was not strong enough to support patient load.
Knowledge Is Power
Cronin says Lodi has standardized its patient educational materials and started the patient education process as soon as patients are admitted. This step optimizes a patient’s understanding of diagnoses and care instructions when the time comes for discharge.
Through the Project BOOST assessment, Lodi ascertained that many of its patients were being discharged to skilled-nursing facilities, which heightens the complexity of post-care and introduces the potential for increased risks. Lodi is now working to better communicate with the skilled-nursing facilities using its Project BOOST training to streamline the discharge process.
The implementation of the Teach Back communication strategy has been critical in increasing patient knowledge and adherence to care instructions, official say. Based on the success of Project BOOST implementation, Teach Back has been incorporated into mandatory nurse training throughout the hospital.
Improved Care
More than 80 patients were discharged through the BOOST process in the first 90 days of implementation. Lodi is already experiencing the benefits of Project BOOST organizationally and
expects to see the financial impacts soon through a lower 30-day readmission rate.
“Lodi has experienced a shift in patient safety culture with improved communication through a team approach to care,” Cronin says. “Lodi expects high success through Project BOOST with the goal of implementing Project BOOST across all disease states and every discipline using Teachback.
“Project BOOST has been the ideal program to align with our strategic organizational goals to improve transitions of care and re-create the patient safety culture to make systemwide sustainable change,” she says.
For more information about Project BOOST, visit www.hospitalmedicine.org/boost.
Jacqui Petock, marketing project manager
Soon, hospitals with unnecessary 30-day readmissions will be penalized. Some proactive hospitals are already tackling care transitions to reduce readmissions, improve patient care, and reduce costs.
Lodi Memorial Hospital in Northern California is one such hospital. The 214-bed facility has made preventing readmissions a key strategic goal for improving care, especially for vulnerable, frail elderly patients.
Lodi executives say readmissions are a challenge at the hospital because many different specialties and house staff are involved in the discharge process.
With many options from which to choose, Lodi selected SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions). Project BOOST, unlike other programs, focuses on first identifying system deficiencies, then building cohesive multidisciplinary teams.
“If you layer a clinical intervention onto a broken system,” says BOOST mentor Stephanie Rennke, MD, “success isn’t likely. Project BOOST helps the team map current processes, find deficiencies, assess resources, and redefine a culture of safety.
“BOOST starts with an assessment of how the system functions, and identifies its strengths and weaknesses so you can focus your efforts on critical areas for improvement and tailor the BOOST intervention to fit the unique dynamics of an institution,” she says.
Search for a Solution
No two institutions are exactly the same, especially when analyzing patient-safety culture. Project BOOST is customized to the needs of each BOOST site, which has proven useful to Lodi, as it found it had different needs than other hospitals.
“We chose Project BOOST because it seemed workable and implementable, while offering a less expensive and less complicated solution than competitors’ products,” says Valerie Cronin, Lodi’s director of utilization.
The BOOST mentor, key to this customization, provided Lodi with the reassurance that comes with working directly with someone who has faced similar challenges—not just theoretically, but also on the floor—and was willing to work with Lodi to develop practical solutions. The mentor provided reassurance, support, and perspective as Lodi walked through the BOOST implementation process.
Keys to Success
—Valerie Cronin, director of utilization, Lodi Memorial Hospital, California
Team-focused care, clear communication, and administrative support were keys to successful BOOST implementation at Lodi, says Cronin.
The house staff was overwhelmed, and adding a quality-improvement (QI) project to implement and manage might have seemed like an impossible challenge. By developing multidisciplinary teams, however, Lodi was able to distribute the tasks of implementation and began to recognize the value and benefit of Project BOOST, which already had strong support from hospital executives.
A 14-member multidisciplinary team was formed to oversee the Project BOOST implementation. The team then was divided into sub-groups to work on the main components of Project BOOST: Passport to Care Form, Target Assessment Tool, the Teachback process, and Follow-Up Phone Calls. The sub-groups’ main objectives were to ensure that BOOST effectively changed processes and work practices for a stronger and safer discharge process.
To support these teams and foster communication laterally among healthcare providers and vertically with hospital administration, Lodi established a structured meeting format, delegated task assignments for accountability, and appointed an implementation champion.
Capitalizing on the experience of its BOOST mentor, the Lodi multidisciplinary teams mapped out the process to assess threats to the system and opportunities for improvement, and began moving forward with implementable solutions for sustainable change.
“Evaluating the whole discharge process allowed us to see the gaps and discrepancies in the discharge process,” Cronin says. “Each discipline had their own set of procedures and materials, which proved lacking and inconsistent for our patients. It was an essential and eye-opening experience for Lodi to make change.”
One of the biggest revelations was learning how broken the discharge process was for the nurses. When Lodi looked at its current process of using case managers to handle high-risk patients and leaving the remaining patient discharges to the nurses, they found that the process was not strong enough to support patient load.
Knowledge Is Power
Cronin says Lodi has standardized its patient educational materials and started the patient education process as soon as patients are admitted. This step optimizes a patient’s understanding of diagnoses and care instructions when the time comes for discharge.
Through the Project BOOST assessment, Lodi ascertained that many of its patients were being discharged to skilled-nursing facilities, which heightens the complexity of post-care and introduces the potential for increased risks. Lodi is now working to better communicate with the skilled-nursing facilities using its Project BOOST training to streamline the discharge process.
The implementation of the Teach Back communication strategy has been critical in increasing patient knowledge and adherence to care instructions, official say. Based on the success of Project BOOST implementation, Teach Back has been incorporated into mandatory nurse training throughout the hospital.
Improved Care
More than 80 patients were discharged through the BOOST process in the first 90 days of implementation. Lodi is already experiencing the benefits of Project BOOST organizationally and
expects to see the financial impacts soon through a lower 30-day readmission rate.
“Lodi has experienced a shift in patient safety culture with improved communication through a team approach to care,” Cronin says. “Lodi expects high success through Project BOOST with the goal of implementing Project BOOST across all disease states and every discipline using Teachback.
“Project BOOST has been the ideal program to align with our strategic organizational goals to improve transitions of care and re-create the patient safety culture to make systemwide sustainable change,” she says.
For more information about Project BOOST, visit www.hospitalmedicine.org/boost.
Jacqui Petock, marketing project manager
A Winnable Battle
Redness, pain, and drainage from the skin around a catheter. Bloody, cloudy, or pungent urine and mental confusion. Severe diarrhea and a dilated colon: The potential symptoms of some of the most common hospital-acquired infections in the United States aren’t particularly pleasant.
The numbers don’t paint a pretty picture, either.
One widely cited study estimates that the nation’s hospitals report 1.7 million healthcare-associated infections (HAIs) every year, along with nearly 100,000 associated deaths.1 All told, the additional healthcare costs could tally $30 billion or more annually, according to a 2009 Centers for Disease Control and Prevention (CDC) analysis. Though some bright spots have emerged, healthcare advocates, including Kevin Kavanagh, MD, MS, FACS, director of Kentucky-based patient advocacy group Health Watch USA, contend that the overall size of the problem is likely underestimated. And unless brought under control, he says, emerging pathogens could make a bad situation worse.
The incredible variety of healthcare settings precludes any across-the-board solutions for hospitalists and other care providers. A recent survey of more than 1,200 healthcare professionals from 33 hospitals, however, revealed some common themes. According to the study authors, the data show that “hand hygiene is consistently identified as the greatest barrier to reducing HAIs, and that sustaining the necessary behavioral change to overcome this barrier is difficult.”2 In fact, the study highlighted a widespread belief that medical staff, and doctors in particular, are not fully engaged or in compliance with HAI reduction efforts. “The data suggest that physicians often do not adhere to protocols and guidelines; moreover, some respondents questioned whether many physicians are open to change,” the authors wrote.
So what can hospitalists do to help their colleagues embrace a culture of positive change and turn back a worsening healthcare epidemic? If simple answers are in short supply, studies aimed at central-line-associated bloodstream infections, catheter-associated urinary tract infections, and Clostridium difficile infections have at least highlighted some keys to a successful intervention.
In Focus: Central Lines
Central-line-associated bloodstream infections (CLABSIs) arguably have received the most attention of any HAI. Not coincidentally, most researchers point to the anti-CLABSI effort as the high point in the struggle to reduce infection rates.
In a landmark 2006 study led by hospitalist Peter Pronovost, MD, more than 100 ICUs in Michigan nearly eliminated CLABSIs over an 18-month period.3 The “remarkably successful” intervention, according to its authors, focused on changing provider behavior through education and collaboration with infection-control specialists. Nationwide, a recent CDC study estimated that absolute CLABSI numbers in ICUs dropped to 18,000 in 2009 from 43,000 in 2001, a 58% decline.4
Sheri Chernetsky Tejedor, MD, SFHM, assistant professor in the division of hospital medicine at Emory University School of Medicine in Atlanta, points out a major caveat in CLABSI prevention efforts, however: To date, she says, most have targeted insertion practices and ICU patients, which do little for the more than half of CLABSIs that occur on hospital wards. These wards thus represent “a ripe opportunity for intervention, especially the low-hanging, ‘low tech’ interventions of removing unnecessary devices,” she says.
Among a small random sample of patients with temporary central venous lines (CVCs), including peripherally inserted central catheters (PICCs), a study led by Dr. Chernetsky Tejedor found that 25% of all CVC days were “idle.”5 In other words, in 1 out of every 4 CVC days, the catheter was retained despite failing to meet standard justification criteria. In particular, the study suggested that PICCs were associated with longer catheter use and more idle days, fueling her group’s suspicion that increased PICC availability has changed CVC use patterns.
Among her group’s interventions, a patient safety checklist has been built, with questions about catheter use entered into a daily electronic progress note used by all services on the inpatient wards. One particularly successful strategy empowered nurses to determine whether continued catheter use seems justified and to ask physicians whether an “idle” CVC could be removed.
With a decline in CLABSI rates in ICUs and a shift in focus to the medical wards, Dr. Chernetsky Tejedor says, hospitalists are in a prime position to help reduce the inappropriate use of catheters and other invasive devices. More broadly, hospitalists may be well-suited to help change the culture of medicine toward a wider acceptance of proven interventions, such as central-line checklists.
Dr. Kavanagh argues that the slow and arduous process to move past what he calls “a huge resistance to checklists” and win universal adoption of such protocols “is not a good chapter in medicine.” He isn’t laying the blame at the feet of doctors alone, however. “In some institutions,” he says, “there needs to be a change from a profit-driven to a patient-centered culture.”
Greg Maynard, MD, MSc, SFHM, director of the University of California at San Diego Center for Innovation and Improvement Science and senior vice president of SHM’s Center for Hospital Innovation and Improvement, acknowledges the integral role of checklists in improvement efforts. He cautions, however, that they should be viewed as only one part of a multipronged approach.
As with hand hygiene, Dr. Maynard concedes that some facilities are still facing resistance from medical staff in integrating checklists into their routines, though he argues that an ingrained anti-checklist medical culture may not be solely at fault. “If you insert a checklist in such a way that it’s very inconvenient, that stops the flow of work,” he says, “you’re not going to have as much success as if you’ve thoughtfully designed it so that the checklist is called into play when it makes sense to bring it into play and made it easy to do, as opposed to difficult and awkward to do.”
In Focus: Catheter-Associated UTIs
Catheter-associated urinary tract infections (CAUTIs) account for roughly 1 in 3 healthcare-associated infections, according to the CDC. And yet many researchers say the “Rodney Dangerfield of HAIs” has long been overlooked.
A frequently cited study led by Sanjay Saint, MD, MPH, FHM, professor of internal medicine at the University of Michigan and the Ann Arbor VA Medical Center, found that nearly 40% of attending physicians were unaware that their patients even had an indwelling urinary catheter.6
Dr. Saint has dubbed the phenomenon “immaculate catheterization” to highlight the glaring discrepancy. “Because we also found, in a significant number of patients, there was no documentation anywhere in the medical record that the catheter existed,” he says. “It’s not in the physician’s notes, it’s not in the nursing notes, but we knew it was there because we could see it coming out of the patient.” Catheters that were inappropriately placed, he found, were more often “forgotten” than appropriate ones.
Perhaps more than anything else, the startling observation underscores the intense need for basic awareness of the two biggest UTI risk factors: whether a catheter is used, and how long it’s left in place. “You can get marked reductions by just taking care of those two factors,” Health Watch USA’s Dr. Kavanagh says.
At the Ann Arbor VA Hospital, one unit’s presence of a “Patient Safety Professional” to help ensure better oversight virtually brought the inappropriate use of indwelling catheters to a standstill. Dr. Saint and his colleagues are now gathering data to determine whether that decrease has translated to a drop in infections.
—Greg Maynard, MD, MSc, SFHM, director, University of California at San Diego Center for Innovation and Improvement Science, senior vice president, SHM Center for Hospital Innovation and Improvement
One fundamental key, he says, is paying close attention to whether a catheter is really in the patient’s best interests. “If we ask that question—‘If this was my family member, what would I want?’—we usually do the right thing,” Dr. Saint explains. Another key is leveraging the hospitalist’s core skill in communicating often and well with nurses to ensure that they are in sync during the “team sport” of CAUTI prevention.
With pockets of success in reducing inappropriate catheterization, the larger question now is how to scale up the individual interventions to achieve nationwide reductions. “How do you take what will work in one hospital, given its culture and microculture, and then apply it to hospitals across the state, or even across the country?” Dr. Saint asks.
Karen Clarke, MD, MS, MPH, a hospitalist and assistant professor of medicine at Emory University Hospital in Atlanta, is in the midst of tackling such issues. Using a bundled approach that included four interventions, she and colleagues reduced CAUTI rates by 70% at 276-bed West Georgia Medical Center in La Grange, Ga.7
The interventions were straightforward and inexpensive, Dr. Clarke says, meaning that they could be widely applied. “The only thing is that there has to be a champion overseeing the interventions to make sure that the steps are followed through on,” she says. Even at cash-strapped facilities, then, a similar approach could prove effective as long as someone assumes responsibility—and hospitalists would be a natural choice.
Based on her study’s promising results, Dr. Clarke hopes to begin implementing the intervention in at least one other hospital starting Jan. 1. If the success can be replicated, she says, the CAUTI-reduction protocol will branch out to include more regional hospitals.
In Focus: C. Diff-Associated Disease
Even as many hospitals are improving their CLABSI and CAUTI rates, hospital-acquired Clostridium difficile infections appear to be getting worse, particularly among older patients. In some facilities, the potentially fatal, diarrhea-causing microbe is now the top pathogen (see “Gut Reaction,” December 2011).
With a timely intervention, however, Kaiser Permanente Medical Center in Santa Clara, Calif., cut its own infection rates by one-third.8 In brainstorming how to improve the medical center’s rates, Susanne Mierendorf, MD, MS, FHM, a hospitalist and associate residency program director for internal medicine, joined colleagues in thinking through the barriers for healthcare providers. “It wasn’t ‘Why don’t they follow the infection-control guidelines?’ It was, ‘Why can’t they?’” Dr. Mierendorf says.
The thought exercise led to some eye-opening observations, including the realization that disposable gowns, gloves, and other personal protective equipment weren’t in the room and were hard to find. To help establish habits, Dr. Mierendorf’s team picked a consistent drawer in each patient’s room to stow the equipment and instructed that a wall-mounted holder be filled with gloves at all times.
The researchers also realized that the rooms of patients with suspected or confirmed C. diff infections had warning signs that were too simplistic at first, then overly wordy. Both were being ignored. The solution was simple signage with yellow color-coding and easily recognizable symbols that readily conveyed the infection-control message to staff: sterile gowns, gloves, hands with soap and water, bleach. Those messages were reinforced through a brief, simple, and mandatory educational module for all hospital workers who might come into contact with the patients.
National Implications
On a national scale, hospitalists have helped compile other educational packets and toolkits to address the spectrum of HAIs, from ventilator-associated pneumonia to methicillin-resistant Staphylococcus aureus (MRSA).
More help may be forthcoming through the American Hospital Association’s Health Research and Education Trust. The broad-based effort, funded by the federal Agency for Healthcare Research and Quality (AHRQ), is partnering with SHM and other professional societies to implement small HAI-reduction successes on ever-wider scales. The University of Michigan’s Dr. Saint, for example, is a key partner in the trust’s national initiative to reduce CAUTI rates and improve patient safety.
—Sanjay Saint, MD, MPH, FHM, professor of internal medicine, University of Michigan, Ann Arbor
Medicare has rolled out its own collection of carrots and sticks to address the problem. The largest carrot, the public-private Partnership for Patients, has joined with SHM, other professional societies, and roughly 3,000 hospitals, so far, and set the ambitious goal of reducing hospital-acquired conditions by 40% by the end of 2013, compared with 2010 tallies. Although applauding the program’s overall goals, physicians, including Dr. Maynard, are taking a wait-and-see attitude, pointing out that many of the details have yet to be ironed out.
Among the sticks, Medicare has begun withholding reimbursement payments for such HAIs as CLABSIs and CAUTIs. Due to intricacies in how hospitals bill under the current DRG system, Dr. Kavanagh says Medicare’s nonpayment policy has recouped relatively little money from its first full year: about $18.8 million in all.
“The policies that cover public reporting, however, do have much more of an impact,” he says. “It’s more of a perceptual sting. Believe me, it is more concerning to have data of bad results that are available to the public than to be penalized by the current financial incentives.”
Other financial policies could carry considerably more weight. The threat of nonpayment for hospital readmissions, Dr. Maynard says, “totally changed the game” by intensifying efforts to reduce those rates, addressing contributing factors such as HAIs in the process. In combination, he says, public accountability through mandated reporting plus financial penalties could prove more powerful than either tactic alone.
Regardless of how federal policy plays out, experts say a new era of accountability and transparency is on its way. As the champions of positive change, hospitalists have a distinct opportunity to help lead the way and bring about a culture that consistently embraces effective interventions—before things get really ugly.
Bryn Nelson is a freelance medical writer based in Seattle.
References
- Klevens RM, Edwards JR, Richards CL, Horan TC, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122:160-166.
- Flanagan ME, Welsh CA, Kiess C, Hoke S, et al. A national collaborative for reducing health care-associated infections: current initiatives, challenges, and opportunities. Am J Infect Control. 2011;39:685-689.
- Pronovost P, Needham D, Berenholtz S, Sinopoli D, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732.
- Srinivasan A, Wise M, Bell M, Cardo D, et al. Vital signs: central line-associated blood stream infections—United States, 2001, 2008, and 2009. MMWR. 2011;60(8):243-248.
- Chernetsky Tejedor S, Tong D, Stein J, Payne C, et al. Temporary central venous catheter utilization patterns in a large tertiary care center: tracking the “idle central venous catheter.” Infect Control Hosp Epidemiol. 2012;33(1): in press.
- Saint S, Wiese J, Amory JK, Bernstein ML, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000;109(6):476-480.
- Clarke K, Norrick B, Easley K, Pan Y, et al. Reduction of catheter-associated urinary tract infections through a bundled intervention in a community hospital. J Hosp Med. 2011;6(4):S22.
- Mierendorf S, Rushton M. Decreasing barriers in prevention of hospital-acquired Clostridium difficile colitis. J Hosp Med. 2011;6(4):S50-S51.
Redness, pain, and drainage from the skin around a catheter. Bloody, cloudy, or pungent urine and mental confusion. Severe diarrhea and a dilated colon: The potential symptoms of some of the most common hospital-acquired infections in the United States aren’t particularly pleasant.
The numbers don’t paint a pretty picture, either.
One widely cited study estimates that the nation’s hospitals report 1.7 million healthcare-associated infections (HAIs) every year, along with nearly 100,000 associated deaths.1 All told, the additional healthcare costs could tally $30 billion or more annually, according to a 2009 Centers for Disease Control and Prevention (CDC) analysis. Though some bright spots have emerged, healthcare advocates, including Kevin Kavanagh, MD, MS, FACS, director of Kentucky-based patient advocacy group Health Watch USA, contend that the overall size of the problem is likely underestimated. And unless brought under control, he says, emerging pathogens could make a bad situation worse.
The incredible variety of healthcare settings precludes any across-the-board solutions for hospitalists and other care providers. A recent survey of more than 1,200 healthcare professionals from 33 hospitals, however, revealed some common themes. According to the study authors, the data show that “hand hygiene is consistently identified as the greatest barrier to reducing HAIs, and that sustaining the necessary behavioral change to overcome this barrier is difficult.”2 In fact, the study highlighted a widespread belief that medical staff, and doctors in particular, are not fully engaged or in compliance with HAI reduction efforts. “The data suggest that physicians often do not adhere to protocols and guidelines; moreover, some respondents questioned whether many physicians are open to change,” the authors wrote.
So what can hospitalists do to help their colleagues embrace a culture of positive change and turn back a worsening healthcare epidemic? If simple answers are in short supply, studies aimed at central-line-associated bloodstream infections, catheter-associated urinary tract infections, and Clostridium difficile infections have at least highlighted some keys to a successful intervention.
In Focus: Central Lines
Central-line-associated bloodstream infections (CLABSIs) arguably have received the most attention of any HAI. Not coincidentally, most researchers point to the anti-CLABSI effort as the high point in the struggle to reduce infection rates.
In a landmark 2006 study led by hospitalist Peter Pronovost, MD, more than 100 ICUs in Michigan nearly eliminated CLABSIs over an 18-month period.3 The “remarkably successful” intervention, according to its authors, focused on changing provider behavior through education and collaboration with infection-control specialists. Nationwide, a recent CDC study estimated that absolute CLABSI numbers in ICUs dropped to 18,000 in 2009 from 43,000 in 2001, a 58% decline.4
Sheri Chernetsky Tejedor, MD, SFHM, assistant professor in the division of hospital medicine at Emory University School of Medicine in Atlanta, points out a major caveat in CLABSI prevention efforts, however: To date, she says, most have targeted insertion practices and ICU patients, which do little for the more than half of CLABSIs that occur on hospital wards. These wards thus represent “a ripe opportunity for intervention, especially the low-hanging, ‘low tech’ interventions of removing unnecessary devices,” she says.
Among a small random sample of patients with temporary central venous lines (CVCs), including peripherally inserted central catheters (PICCs), a study led by Dr. Chernetsky Tejedor found that 25% of all CVC days were “idle.”5 In other words, in 1 out of every 4 CVC days, the catheter was retained despite failing to meet standard justification criteria. In particular, the study suggested that PICCs were associated with longer catheter use and more idle days, fueling her group’s suspicion that increased PICC availability has changed CVC use patterns.
Among her group’s interventions, a patient safety checklist has been built, with questions about catheter use entered into a daily electronic progress note used by all services on the inpatient wards. One particularly successful strategy empowered nurses to determine whether continued catheter use seems justified and to ask physicians whether an “idle” CVC could be removed.
With a decline in CLABSI rates in ICUs and a shift in focus to the medical wards, Dr. Chernetsky Tejedor says, hospitalists are in a prime position to help reduce the inappropriate use of catheters and other invasive devices. More broadly, hospitalists may be well-suited to help change the culture of medicine toward a wider acceptance of proven interventions, such as central-line checklists.
Dr. Kavanagh argues that the slow and arduous process to move past what he calls “a huge resistance to checklists” and win universal adoption of such protocols “is not a good chapter in medicine.” He isn’t laying the blame at the feet of doctors alone, however. “In some institutions,” he says, “there needs to be a change from a profit-driven to a patient-centered culture.”
Greg Maynard, MD, MSc, SFHM, director of the University of California at San Diego Center for Innovation and Improvement Science and senior vice president of SHM’s Center for Hospital Innovation and Improvement, acknowledges the integral role of checklists in improvement efforts. He cautions, however, that they should be viewed as only one part of a multipronged approach.
As with hand hygiene, Dr. Maynard concedes that some facilities are still facing resistance from medical staff in integrating checklists into their routines, though he argues that an ingrained anti-checklist medical culture may not be solely at fault. “If you insert a checklist in such a way that it’s very inconvenient, that stops the flow of work,” he says, “you’re not going to have as much success as if you’ve thoughtfully designed it so that the checklist is called into play when it makes sense to bring it into play and made it easy to do, as opposed to difficult and awkward to do.”
In Focus: Catheter-Associated UTIs
Catheter-associated urinary tract infections (CAUTIs) account for roughly 1 in 3 healthcare-associated infections, according to the CDC. And yet many researchers say the “Rodney Dangerfield of HAIs” has long been overlooked.
A frequently cited study led by Sanjay Saint, MD, MPH, FHM, professor of internal medicine at the University of Michigan and the Ann Arbor VA Medical Center, found that nearly 40% of attending physicians were unaware that their patients even had an indwelling urinary catheter.6
Dr. Saint has dubbed the phenomenon “immaculate catheterization” to highlight the glaring discrepancy. “Because we also found, in a significant number of patients, there was no documentation anywhere in the medical record that the catheter existed,” he says. “It’s not in the physician’s notes, it’s not in the nursing notes, but we knew it was there because we could see it coming out of the patient.” Catheters that were inappropriately placed, he found, were more often “forgotten” than appropriate ones.
Perhaps more than anything else, the startling observation underscores the intense need for basic awareness of the two biggest UTI risk factors: whether a catheter is used, and how long it’s left in place. “You can get marked reductions by just taking care of those two factors,” Health Watch USA’s Dr. Kavanagh says.
At the Ann Arbor VA Hospital, one unit’s presence of a “Patient Safety Professional” to help ensure better oversight virtually brought the inappropriate use of indwelling catheters to a standstill. Dr. Saint and his colleagues are now gathering data to determine whether that decrease has translated to a drop in infections.
—Greg Maynard, MD, MSc, SFHM, director, University of California at San Diego Center for Innovation and Improvement Science, senior vice president, SHM Center for Hospital Innovation and Improvement
One fundamental key, he says, is paying close attention to whether a catheter is really in the patient’s best interests. “If we ask that question—‘If this was my family member, what would I want?’—we usually do the right thing,” Dr. Saint explains. Another key is leveraging the hospitalist’s core skill in communicating often and well with nurses to ensure that they are in sync during the “team sport” of CAUTI prevention.
With pockets of success in reducing inappropriate catheterization, the larger question now is how to scale up the individual interventions to achieve nationwide reductions. “How do you take what will work in one hospital, given its culture and microculture, and then apply it to hospitals across the state, or even across the country?” Dr. Saint asks.
Karen Clarke, MD, MS, MPH, a hospitalist and assistant professor of medicine at Emory University Hospital in Atlanta, is in the midst of tackling such issues. Using a bundled approach that included four interventions, she and colleagues reduced CAUTI rates by 70% at 276-bed West Georgia Medical Center in La Grange, Ga.7
The interventions were straightforward and inexpensive, Dr. Clarke says, meaning that they could be widely applied. “The only thing is that there has to be a champion overseeing the interventions to make sure that the steps are followed through on,” she says. Even at cash-strapped facilities, then, a similar approach could prove effective as long as someone assumes responsibility—and hospitalists would be a natural choice.
Based on her study’s promising results, Dr. Clarke hopes to begin implementing the intervention in at least one other hospital starting Jan. 1. If the success can be replicated, she says, the CAUTI-reduction protocol will branch out to include more regional hospitals.
In Focus: C. Diff-Associated Disease
Even as many hospitals are improving their CLABSI and CAUTI rates, hospital-acquired Clostridium difficile infections appear to be getting worse, particularly among older patients. In some facilities, the potentially fatal, diarrhea-causing microbe is now the top pathogen (see “Gut Reaction,” December 2011).
With a timely intervention, however, Kaiser Permanente Medical Center in Santa Clara, Calif., cut its own infection rates by one-third.8 In brainstorming how to improve the medical center’s rates, Susanne Mierendorf, MD, MS, FHM, a hospitalist and associate residency program director for internal medicine, joined colleagues in thinking through the barriers for healthcare providers. “It wasn’t ‘Why don’t they follow the infection-control guidelines?’ It was, ‘Why can’t they?’” Dr. Mierendorf says.
The thought exercise led to some eye-opening observations, including the realization that disposable gowns, gloves, and other personal protective equipment weren’t in the room and were hard to find. To help establish habits, Dr. Mierendorf’s team picked a consistent drawer in each patient’s room to stow the equipment and instructed that a wall-mounted holder be filled with gloves at all times.
The researchers also realized that the rooms of patients with suspected or confirmed C. diff infections had warning signs that were too simplistic at first, then overly wordy. Both were being ignored. The solution was simple signage with yellow color-coding and easily recognizable symbols that readily conveyed the infection-control message to staff: sterile gowns, gloves, hands with soap and water, bleach. Those messages were reinforced through a brief, simple, and mandatory educational module for all hospital workers who might come into contact with the patients.
National Implications
On a national scale, hospitalists have helped compile other educational packets and toolkits to address the spectrum of HAIs, from ventilator-associated pneumonia to methicillin-resistant Staphylococcus aureus (MRSA).
More help may be forthcoming through the American Hospital Association’s Health Research and Education Trust. The broad-based effort, funded by the federal Agency for Healthcare Research and Quality (AHRQ), is partnering with SHM and other professional societies to implement small HAI-reduction successes on ever-wider scales. The University of Michigan’s Dr. Saint, for example, is a key partner in the trust’s national initiative to reduce CAUTI rates and improve patient safety.
—Sanjay Saint, MD, MPH, FHM, professor of internal medicine, University of Michigan, Ann Arbor
Medicare has rolled out its own collection of carrots and sticks to address the problem. The largest carrot, the public-private Partnership for Patients, has joined with SHM, other professional societies, and roughly 3,000 hospitals, so far, and set the ambitious goal of reducing hospital-acquired conditions by 40% by the end of 2013, compared with 2010 tallies. Although applauding the program’s overall goals, physicians, including Dr. Maynard, are taking a wait-and-see attitude, pointing out that many of the details have yet to be ironed out.
Among the sticks, Medicare has begun withholding reimbursement payments for such HAIs as CLABSIs and CAUTIs. Due to intricacies in how hospitals bill under the current DRG system, Dr. Kavanagh says Medicare’s nonpayment policy has recouped relatively little money from its first full year: about $18.8 million in all.
“The policies that cover public reporting, however, do have much more of an impact,” he says. “It’s more of a perceptual sting. Believe me, it is more concerning to have data of bad results that are available to the public than to be penalized by the current financial incentives.”
Other financial policies could carry considerably more weight. The threat of nonpayment for hospital readmissions, Dr. Maynard says, “totally changed the game” by intensifying efforts to reduce those rates, addressing contributing factors such as HAIs in the process. In combination, he says, public accountability through mandated reporting plus financial penalties could prove more powerful than either tactic alone.
Regardless of how federal policy plays out, experts say a new era of accountability and transparency is on its way. As the champions of positive change, hospitalists have a distinct opportunity to help lead the way and bring about a culture that consistently embraces effective interventions—before things get really ugly.
Bryn Nelson is a freelance medical writer based in Seattle.
References
- Klevens RM, Edwards JR, Richards CL, Horan TC, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122:160-166.
- Flanagan ME, Welsh CA, Kiess C, Hoke S, et al. A national collaborative for reducing health care-associated infections: current initiatives, challenges, and opportunities. Am J Infect Control. 2011;39:685-689.
- Pronovost P, Needham D, Berenholtz S, Sinopoli D, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732.
- Srinivasan A, Wise M, Bell M, Cardo D, et al. Vital signs: central line-associated blood stream infections—United States, 2001, 2008, and 2009. MMWR. 2011;60(8):243-248.
- Chernetsky Tejedor S, Tong D, Stein J, Payne C, et al. Temporary central venous catheter utilization patterns in a large tertiary care center: tracking the “idle central venous catheter.” Infect Control Hosp Epidemiol. 2012;33(1): in press.
- Saint S, Wiese J, Amory JK, Bernstein ML, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000;109(6):476-480.
- Clarke K, Norrick B, Easley K, Pan Y, et al. Reduction of catheter-associated urinary tract infections through a bundled intervention in a community hospital. J Hosp Med. 2011;6(4):S22.
- Mierendorf S, Rushton M. Decreasing barriers in prevention of hospital-acquired Clostridium difficile colitis. J Hosp Med. 2011;6(4):S50-S51.
Redness, pain, and drainage from the skin around a catheter. Bloody, cloudy, or pungent urine and mental confusion. Severe diarrhea and a dilated colon: The potential symptoms of some of the most common hospital-acquired infections in the United States aren’t particularly pleasant.
The numbers don’t paint a pretty picture, either.
One widely cited study estimates that the nation’s hospitals report 1.7 million healthcare-associated infections (HAIs) every year, along with nearly 100,000 associated deaths.1 All told, the additional healthcare costs could tally $30 billion or more annually, according to a 2009 Centers for Disease Control and Prevention (CDC) analysis. Though some bright spots have emerged, healthcare advocates, including Kevin Kavanagh, MD, MS, FACS, director of Kentucky-based patient advocacy group Health Watch USA, contend that the overall size of the problem is likely underestimated. And unless brought under control, he says, emerging pathogens could make a bad situation worse.
The incredible variety of healthcare settings precludes any across-the-board solutions for hospitalists and other care providers. A recent survey of more than 1,200 healthcare professionals from 33 hospitals, however, revealed some common themes. According to the study authors, the data show that “hand hygiene is consistently identified as the greatest barrier to reducing HAIs, and that sustaining the necessary behavioral change to overcome this barrier is difficult.”2 In fact, the study highlighted a widespread belief that medical staff, and doctors in particular, are not fully engaged or in compliance with HAI reduction efforts. “The data suggest that physicians often do not adhere to protocols and guidelines; moreover, some respondents questioned whether many physicians are open to change,” the authors wrote.
So what can hospitalists do to help their colleagues embrace a culture of positive change and turn back a worsening healthcare epidemic? If simple answers are in short supply, studies aimed at central-line-associated bloodstream infections, catheter-associated urinary tract infections, and Clostridium difficile infections have at least highlighted some keys to a successful intervention.
In Focus: Central Lines
Central-line-associated bloodstream infections (CLABSIs) arguably have received the most attention of any HAI. Not coincidentally, most researchers point to the anti-CLABSI effort as the high point in the struggle to reduce infection rates.
In a landmark 2006 study led by hospitalist Peter Pronovost, MD, more than 100 ICUs in Michigan nearly eliminated CLABSIs over an 18-month period.3 The “remarkably successful” intervention, according to its authors, focused on changing provider behavior through education and collaboration with infection-control specialists. Nationwide, a recent CDC study estimated that absolute CLABSI numbers in ICUs dropped to 18,000 in 2009 from 43,000 in 2001, a 58% decline.4
Sheri Chernetsky Tejedor, MD, SFHM, assistant professor in the division of hospital medicine at Emory University School of Medicine in Atlanta, points out a major caveat in CLABSI prevention efforts, however: To date, she says, most have targeted insertion practices and ICU patients, which do little for the more than half of CLABSIs that occur on hospital wards. These wards thus represent “a ripe opportunity for intervention, especially the low-hanging, ‘low tech’ interventions of removing unnecessary devices,” she says.
Among a small random sample of patients with temporary central venous lines (CVCs), including peripherally inserted central catheters (PICCs), a study led by Dr. Chernetsky Tejedor found that 25% of all CVC days were “idle.”5 In other words, in 1 out of every 4 CVC days, the catheter was retained despite failing to meet standard justification criteria. In particular, the study suggested that PICCs were associated with longer catheter use and more idle days, fueling her group’s suspicion that increased PICC availability has changed CVC use patterns.
Among her group’s interventions, a patient safety checklist has been built, with questions about catheter use entered into a daily electronic progress note used by all services on the inpatient wards. One particularly successful strategy empowered nurses to determine whether continued catheter use seems justified and to ask physicians whether an “idle” CVC could be removed.
With a decline in CLABSI rates in ICUs and a shift in focus to the medical wards, Dr. Chernetsky Tejedor says, hospitalists are in a prime position to help reduce the inappropriate use of catheters and other invasive devices. More broadly, hospitalists may be well-suited to help change the culture of medicine toward a wider acceptance of proven interventions, such as central-line checklists.
Dr. Kavanagh argues that the slow and arduous process to move past what he calls “a huge resistance to checklists” and win universal adoption of such protocols “is not a good chapter in medicine.” He isn’t laying the blame at the feet of doctors alone, however. “In some institutions,” he says, “there needs to be a change from a profit-driven to a patient-centered culture.”
Greg Maynard, MD, MSc, SFHM, director of the University of California at San Diego Center for Innovation and Improvement Science and senior vice president of SHM’s Center for Hospital Innovation and Improvement, acknowledges the integral role of checklists in improvement efforts. He cautions, however, that they should be viewed as only one part of a multipronged approach.
As with hand hygiene, Dr. Maynard concedes that some facilities are still facing resistance from medical staff in integrating checklists into their routines, though he argues that an ingrained anti-checklist medical culture may not be solely at fault. “If you insert a checklist in such a way that it’s very inconvenient, that stops the flow of work,” he says, “you’re not going to have as much success as if you’ve thoughtfully designed it so that the checklist is called into play when it makes sense to bring it into play and made it easy to do, as opposed to difficult and awkward to do.”
In Focus: Catheter-Associated UTIs
Catheter-associated urinary tract infections (CAUTIs) account for roughly 1 in 3 healthcare-associated infections, according to the CDC. And yet many researchers say the “Rodney Dangerfield of HAIs” has long been overlooked.
A frequently cited study led by Sanjay Saint, MD, MPH, FHM, professor of internal medicine at the University of Michigan and the Ann Arbor VA Medical Center, found that nearly 40% of attending physicians were unaware that their patients even had an indwelling urinary catheter.6
Dr. Saint has dubbed the phenomenon “immaculate catheterization” to highlight the glaring discrepancy. “Because we also found, in a significant number of patients, there was no documentation anywhere in the medical record that the catheter existed,” he says. “It’s not in the physician’s notes, it’s not in the nursing notes, but we knew it was there because we could see it coming out of the patient.” Catheters that were inappropriately placed, he found, were more often “forgotten” than appropriate ones.
Perhaps more than anything else, the startling observation underscores the intense need for basic awareness of the two biggest UTI risk factors: whether a catheter is used, and how long it’s left in place. “You can get marked reductions by just taking care of those two factors,” Health Watch USA’s Dr. Kavanagh says.
At the Ann Arbor VA Hospital, one unit’s presence of a “Patient Safety Professional” to help ensure better oversight virtually brought the inappropriate use of indwelling catheters to a standstill. Dr. Saint and his colleagues are now gathering data to determine whether that decrease has translated to a drop in infections.
—Greg Maynard, MD, MSc, SFHM, director, University of California at San Diego Center for Innovation and Improvement Science, senior vice president, SHM Center for Hospital Innovation and Improvement
One fundamental key, he says, is paying close attention to whether a catheter is really in the patient’s best interests. “If we ask that question—‘If this was my family member, what would I want?’—we usually do the right thing,” Dr. Saint explains. Another key is leveraging the hospitalist’s core skill in communicating often and well with nurses to ensure that they are in sync during the “team sport” of CAUTI prevention.
With pockets of success in reducing inappropriate catheterization, the larger question now is how to scale up the individual interventions to achieve nationwide reductions. “How do you take what will work in one hospital, given its culture and microculture, and then apply it to hospitals across the state, or even across the country?” Dr. Saint asks.
Karen Clarke, MD, MS, MPH, a hospitalist and assistant professor of medicine at Emory University Hospital in Atlanta, is in the midst of tackling such issues. Using a bundled approach that included four interventions, she and colleagues reduced CAUTI rates by 70% at 276-bed West Georgia Medical Center in La Grange, Ga.7
The interventions were straightforward and inexpensive, Dr. Clarke says, meaning that they could be widely applied. “The only thing is that there has to be a champion overseeing the interventions to make sure that the steps are followed through on,” she says. Even at cash-strapped facilities, then, a similar approach could prove effective as long as someone assumes responsibility—and hospitalists would be a natural choice.
Based on her study’s promising results, Dr. Clarke hopes to begin implementing the intervention in at least one other hospital starting Jan. 1. If the success can be replicated, she says, the CAUTI-reduction protocol will branch out to include more regional hospitals.
In Focus: C. Diff-Associated Disease
Even as many hospitals are improving their CLABSI and CAUTI rates, hospital-acquired Clostridium difficile infections appear to be getting worse, particularly among older patients. In some facilities, the potentially fatal, diarrhea-causing microbe is now the top pathogen (see “Gut Reaction,” December 2011).
With a timely intervention, however, Kaiser Permanente Medical Center in Santa Clara, Calif., cut its own infection rates by one-third.8 In brainstorming how to improve the medical center’s rates, Susanne Mierendorf, MD, MS, FHM, a hospitalist and associate residency program director for internal medicine, joined colleagues in thinking through the barriers for healthcare providers. “It wasn’t ‘Why don’t they follow the infection-control guidelines?’ It was, ‘Why can’t they?’” Dr. Mierendorf says.
The thought exercise led to some eye-opening observations, including the realization that disposable gowns, gloves, and other personal protective equipment weren’t in the room and were hard to find. To help establish habits, Dr. Mierendorf’s team picked a consistent drawer in each patient’s room to stow the equipment and instructed that a wall-mounted holder be filled with gloves at all times.
The researchers also realized that the rooms of patients with suspected or confirmed C. diff infections had warning signs that were too simplistic at first, then overly wordy. Both were being ignored. The solution was simple signage with yellow color-coding and easily recognizable symbols that readily conveyed the infection-control message to staff: sterile gowns, gloves, hands with soap and water, bleach. Those messages were reinforced through a brief, simple, and mandatory educational module for all hospital workers who might come into contact with the patients.
National Implications
On a national scale, hospitalists have helped compile other educational packets and toolkits to address the spectrum of HAIs, from ventilator-associated pneumonia to methicillin-resistant Staphylococcus aureus (MRSA).
More help may be forthcoming through the American Hospital Association’s Health Research and Education Trust. The broad-based effort, funded by the federal Agency for Healthcare Research and Quality (AHRQ), is partnering with SHM and other professional societies to implement small HAI-reduction successes on ever-wider scales. The University of Michigan’s Dr. Saint, for example, is a key partner in the trust’s national initiative to reduce CAUTI rates and improve patient safety.
—Sanjay Saint, MD, MPH, FHM, professor of internal medicine, University of Michigan, Ann Arbor
Medicare has rolled out its own collection of carrots and sticks to address the problem. The largest carrot, the public-private Partnership for Patients, has joined with SHM, other professional societies, and roughly 3,000 hospitals, so far, and set the ambitious goal of reducing hospital-acquired conditions by 40% by the end of 2013, compared with 2010 tallies. Although applauding the program’s overall goals, physicians, including Dr. Maynard, are taking a wait-and-see attitude, pointing out that many of the details have yet to be ironed out.
Among the sticks, Medicare has begun withholding reimbursement payments for such HAIs as CLABSIs and CAUTIs. Due to intricacies in how hospitals bill under the current DRG system, Dr. Kavanagh says Medicare’s nonpayment policy has recouped relatively little money from its first full year: about $18.8 million in all.
“The policies that cover public reporting, however, do have much more of an impact,” he says. “It’s more of a perceptual sting. Believe me, it is more concerning to have data of bad results that are available to the public than to be penalized by the current financial incentives.”
Other financial policies could carry considerably more weight. The threat of nonpayment for hospital readmissions, Dr. Maynard says, “totally changed the game” by intensifying efforts to reduce those rates, addressing contributing factors such as HAIs in the process. In combination, he says, public accountability through mandated reporting plus financial penalties could prove more powerful than either tactic alone.
Regardless of how federal policy plays out, experts say a new era of accountability and transparency is on its way. As the champions of positive change, hospitalists have a distinct opportunity to help lead the way and bring about a culture that consistently embraces effective interventions—before things get really ugly.
Bryn Nelson is a freelance medical writer based in Seattle.
References
- Klevens RM, Edwards JR, Richards CL, Horan TC, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122:160-166.
- Flanagan ME, Welsh CA, Kiess C, Hoke S, et al. A national collaborative for reducing health care-associated infections: current initiatives, challenges, and opportunities. Am J Infect Control. 2011;39:685-689.
- Pronovost P, Needham D, Berenholtz S, Sinopoli D, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732.
- Srinivasan A, Wise M, Bell M, Cardo D, et al. Vital signs: central line-associated blood stream infections—United States, 2001, 2008, and 2009. MMWR. 2011;60(8):243-248.
- Chernetsky Tejedor S, Tong D, Stein J, Payne C, et al. Temporary central venous catheter utilization patterns in a large tertiary care center: tracking the “idle central venous catheter.” Infect Control Hosp Epidemiol. 2012;33(1): in press.
- Saint S, Wiese J, Amory JK, Bernstein ML, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000;109(6):476-480.
- Clarke K, Norrick B, Easley K, Pan Y, et al. Reduction of catheter-associated urinary tract infections through a bundled intervention in a community hospital. J Hosp Med. 2011;6(4):S22.
- Mierendorf S, Rushton M. Decreasing barriers in prevention of hospital-acquired Clostridium difficile colitis. J Hosp Med. 2011;6(4):S50-S51.
Policy Corner: An Inside Look at the Most Pressing Policy Issues
In early November, the Institute of Medicine (IOM) released a report on the current status of health information technology (HIT). Although the report was developed at the request of the Office of the National Coordinator (ONC), the arm within the Department of Health and Human Services (HHS) responsible for promoting the use of HIT, not everything in the report was positive—and could leave the impression that HIT is not quite as successful as some think.
The report recommends that the ONC should work with the private and public sectors to make comparative user experiences across vendors publicly available.
Many hospitalists have developed significant expertise with HIT, played significant roles in its effective implementation and use, and are acutely aware of implementation pitfalls. This practical experience could be very helpful in working with the ONC to develop solutions. It is for this reason that hospitalists should reach out to the ONC and offer their expertise instead of waiting for the ONC to act.
The report, “Patient Safety and Health IT: Building Safer Systems for Better Care,” did praise HIT’s potential for eventual cost savings and increased patient safety but stopped short of being a ringing endorsement of the pace HM is taking toward implementation initiatives, such as meaningful use. An overall theme of the report is that greater oversight of HIT is needed to protect patients from potential medical errors associated with its use.
A few of the recommendations given by the IOM to achieve a greater level of safety range from the establishment of a mechanism for vendors and users to report health IT-related deaths, injuries, or unsafe conditions to possible FDA regulation of the systems themselves.
Information-sharing and reporting in a nonpunitive environment, as recommended by the IOM, would go a long way when it comes to remedying or avoiding IT-related problems, and hospitalists probably have some ideas about how this could be done.
Unfortunately, IT vendor contracts often prevent the open sharing of information, so working toward doing away with such contract terms might be a worthy step before making a push toward overall FDA regulation and the unintended consequences that may come with it.
At first glance, FDA regulation seems like the easiest solution because the FDA can theoretically control every aspect of what might go wrong with HIT, but at what cost would such regulation come? FDA approval can be long, complicated and expensive. The whole process could result in cutting-edge technology becoming outdated by the time approval is granted or innovations being overlooked entirely because of a negative cost-benefit analysis. Furthermore, the expense associated with FDA approval could in turn increase the cost of already costly electronic health records (EHR).
Despite the myriad problems that can arise if implementation moves too fast, HIT holds promise and has shown success when done well.
SHM is currently working to position hospitalists as a resource for the ONC, so hospitalists with expertise in this area should not hesitate to come forward with ideas on how to make HIT work better and more safely. HIT is not going to go away, so the best option is to help make it better.
In early November, the Institute of Medicine (IOM) released a report on the current status of health information technology (HIT). Although the report was developed at the request of the Office of the National Coordinator (ONC), the arm within the Department of Health and Human Services (HHS) responsible for promoting the use of HIT, not everything in the report was positive—and could leave the impression that HIT is not quite as successful as some think.
The report recommends that the ONC should work with the private and public sectors to make comparative user experiences across vendors publicly available.
Many hospitalists have developed significant expertise with HIT, played significant roles in its effective implementation and use, and are acutely aware of implementation pitfalls. This practical experience could be very helpful in working with the ONC to develop solutions. It is for this reason that hospitalists should reach out to the ONC and offer their expertise instead of waiting for the ONC to act.
The report, “Patient Safety and Health IT: Building Safer Systems for Better Care,” did praise HIT’s potential for eventual cost savings and increased patient safety but stopped short of being a ringing endorsement of the pace HM is taking toward implementation initiatives, such as meaningful use. An overall theme of the report is that greater oversight of HIT is needed to protect patients from potential medical errors associated with its use.
A few of the recommendations given by the IOM to achieve a greater level of safety range from the establishment of a mechanism for vendors and users to report health IT-related deaths, injuries, or unsafe conditions to possible FDA regulation of the systems themselves.
Information-sharing and reporting in a nonpunitive environment, as recommended by the IOM, would go a long way when it comes to remedying or avoiding IT-related problems, and hospitalists probably have some ideas about how this could be done.
Unfortunately, IT vendor contracts often prevent the open sharing of information, so working toward doing away with such contract terms might be a worthy step before making a push toward overall FDA regulation and the unintended consequences that may come with it.
At first glance, FDA regulation seems like the easiest solution because the FDA can theoretically control every aspect of what might go wrong with HIT, but at what cost would such regulation come? FDA approval can be long, complicated and expensive. The whole process could result in cutting-edge technology becoming outdated by the time approval is granted or innovations being overlooked entirely because of a negative cost-benefit analysis. Furthermore, the expense associated with FDA approval could in turn increase the cost of already costly electronic health records (EHR).
Despite the myriad problems that can arise if implementation moves too fast, HIT holds promise and has shown success when done well.
SHM is currently working to position hospitalists as a resource for the ONC, so hospitalists with expertise in this area should not hesitate to come forward with ideas on how to make HIT work better and more safely. HIT is not going to go away, so the best option is to help make it better.
In early November, the Institute of Medicine (IOM) released a report on the current status of health information technology (HIT). Although the report was developed at the request of the Office of the National Coordinator (ONC), the arm within the Department of Health and Human Services (HHS) responsible for promoting the use of HIT, not everything in the report was positive—and could leave the impression that HIT is not quite as successful as some think.
The report recommends that the ONC should work with the private and public sectors to make comparative user experiences across vendors publicly available.
Many hospitalists have developed significant expertise with HIT, played significant roles in its effective implementation and use, and are acutely aware of implementation pitfalls. This practical experience could be very helpful in working with the ONC to develop solutions. It is for this reason that hospitalists should reach out to the ONC and offer their expertise instead of waiting for the ONC to act.
The report, “Patient Safety and Health IT: Building Safer Systems for Better Care,” did praise HIT’s potential for eventual cost savings and increased patient safety but stopped short of being a ringing endorsement of the pace HM is taking toward implementation initiatives, such as meaningful use. An overall theme of the report is that greater oversight of HIT is needed to protect patients from potential medical errors associated with its use.
A few of the recommendations given by the IOM to achieve a greater level of safety range from the establishment of a mechanism for vendors and users to report health IT-related deaths, injuries, or unsafe conditions to possible FDA regulation of the systems themselves.
Information-sharing and reporting in a nonpunitive environment, as recommended by the IOM, would go a long way when it comes to remedying or avoiding IT-related problems, and hospitalists probably have some ideas about how this could be done.
Unfortunately, IT vendor contracts often prevent the open sharing of information, so working toward doing away with such contract terms might be a worthy step before making a push toward overall FDA regulation and the unintended consequences that may come with it.
At first glance, FDA regulation seems like the easiest solution because the FDA can theoretically control every aspect of what might go wrong with HIT, but at what cost would such regulation come? FDA approval can be long, complicated and expensive. The whole process could result in cutting-edge technology becoming outdated by the time approval is granted or innovations being overlooked entirely because of a negative cost-benefit analysis. Furthermore, the expense associated with FDA approval could in turn increase the cost of already costly electronic health records (EHR).
Despite the myriad problems that can arise if implementation moves too fast, HIT holds promise and has shown success when done well.
SHM is currently working to position hospitalists as a resource for the ONC, so hospitalists with expertise in this area should not hesitate to come forward with ideas on how to make HIT work better and more safely. HIT is not going to go away, so the best option is to help make it better.
Professional Development Program Advances Hospitalist Leadership Skills
Akin to other doctors, hospitalists seek clinical and nonclinical continuing medical education (CME) opportunities in subjects that they hope will improve their professional skill set. But Emory School of Medicine’s Division of Hospital Medicine has tried to make this training more systematic for its 110 members. Since 2005, competitively awarded grants have supported faculty development training in the areas of administrative leadership, quality improvement and research, and education and training.
According to an abstract presented at HM11, Emory’s faculty development program has helped train 36 HM physicians. The upshot of the program: Thirty-three hospitalists now fill formal leadership positions in six Emory-affiliated hospitals. Examples include hospital chief medical officers, chief quality officers, and medical directors for care coordination.
“Hospital medicine is a young field, and we had a young group of clinicians lacking experience that other physicians might get in the course of a career,” says Daniel Dressler, MD, MSc, SFHM, director of education for the hospital medicine division of the Atlanta-based group. “If we were going to be asked to do things, leadershipwise, in the hospital, we needed to build a program to help individuals get additional training for them.”
The physicians pick courses in areas where they want to better themselves, either local educational offerings or national conferences. A committee applies a structured process for reviewing their applications, with funding coming from the department. “We ask the doctors to come back and report on what they learned,” says Dr. Dressler, an SHM board member.
Akin to other doctors, hospitalists seek clinical and nonclinical continuing medical education (CME) opportunities in subjects that they hope will improve their professional skill set. But Emory School of Medicine’s Division of Hospital Medicine has tried to make this training more systematic for its 110 members. Since 2005, competitively awarded grants have supported faculty development training in the areas of administrative leadership, quality improvement and research, and education and training.
According to an abstract presented at HM11, Emory’s faculty development program has helped train 36 HM physicians. The upshot of the program: Thirty-three hospitalists now fill formal leadership positions in six Emory-affiliated hospitals. Examples include hospital chief medical officers, chief quality officers, and medical directors for care coordination.
“Hospital medicine is a young field, and we had a young group of clinicians lacking experience that other physicians might get in the course of a career,” says Daniel Dressler, MD, MSc, SFHM, director of education for the hospital medicine division of the Atlanta-based group. “If we were going to be asked to do things, leadershipwise, in the hospital, we needed to build a program to help individuals get additional training for them.”
The physicians pick courses in areas where they want to better themselves, either local educational offerings or national conferences. A committee applies a structured process for reviewing their applications, with funding coming from the department. “We ask the doctors to come back and report on what they learned,” says Dr. Dressler, an SHM board member.
Akin to other doctors, hospitalists seek clinical and nonclinical continuing medical education (CME) opportunities in subjects that they hope will improve their professional skill set. But Emory School of Medicine’s Division of Hospital Medicine has tried to make this training more systematic for its 110 members. Since 2005, competitively awarded grants have supported faculty development training in the areas of administrative leadership, quality improvement and research, and education and training.
According to an abstract presented at HM11, Emory’s faculty development program has helped train 36 HM physicians. The upshot of the program: Thirty-three hospitalists now fill formal leadership positions in six Emory-affiliated hospitals. Examples include hospital chief medical officers, chief quality officers, and medical directors for care coordination.
“Hospital medicine is a young field, and we had a young group of clinicians lacking experience that other physicians might get in the course of a career,” says Daniel Dressler, MD, MSc, SFHM, director of education for the hospital medicine division of the Atlanta-based group. “If we were going to be asked to do things, leadershipwise, in the hospital, we needed to build a program to help individuals get additional training for them.”
The physicians pick courses in areas where they want to better themselves, either local educational offerings or national conferences. A committee applies a structured process for reviewing their applications, with funding coming from the department. “We ask the doctors to come back and report on what they learned,” says Dr. Dressler, an SHM board member.
IOM Report Outlines Health IT Concerns
The Institute of Medicine in November issued a new report, “Patient Safety and Health IT (HIT): Building Safer Systems for Better Care,” which identifies potential harm that could stem from a digital healthcare system and proposes 10 recommendations. Many of the suggestions are directed at the U.S. Secretary of Health and Human Services, urging the office to work with the private sector and research groups on patient safety, ensure the free exchange of information on healthcare information technology (HIT) issues, and create a process for reporting HIT-related deaths and injuries.
“Concerns about potential harm are emerging as providers increasingly rely on electronic medical records, secure patient portals, and other technologies to deliver care,” the report states, but there is a lack of published research quantifying the risks. For more on the HIT report, check out the Policy Corner.
The Institute of Medicine in November issued a new report, “Patient Safety and Health IT (HIT): Building Safer Systems for Better Care,” which identifies potential harm that could stem from a digital healthcare system and proposes 10 recommendations. Many of the suggestions are directed at the U.S. Secretary of Health and Human Services, urging the office to work with the private sector and research groups on patient safety, ensure the free exchange of information on healthcare information technology (HIT) issues, and create a process for reporting HIT-related deaths and injuries.
“Concerns about potential harm are emerging as providers increasingly rely on electronic medical records, secure patient portals, and other technologies to deliver care,” the report states, but there is a lack of published research quantifying the risks. For more on the HIT report, check out the Policy Corner.
The Institute of Medicine in November issued a new report, “Patient Safety and Health IT (HIT): Building Safer Systems for Better Care,” which identifies potential harm that could stem from a digital healthcare system and proposes 10 recommendations. Many of the suggestions are directed at the U.S. Secretary of Health and Human Services, urging the office to work with the private sector and research groups on patient safety, ensure the free exchange of information on healthcare information technology (HIT) issues, and create a process for reporting HIT-related deaths and injuries.
“Concerns about potential harm are emerging as providers increasingly rely on electronic medical records, secure patient portals, and other technologies to deliver care,” the report states, but there is a lack of published research quantifying the risks. For more on the HIT report, check out the Policy Corner.
HM’s Role in Helping Hospitals Profit
A new report shows that 1 in 5 community hospitals operates in the red, but the chief strategy officer of the firm that conducted the survey thinks hospitals can help change that.
The second annual survey from healthcare information technology (HIT) provider Anthelio and leadership group Community Hospital 100 found that 22% of community hospitals operate with margins below 2%; another 38% operate below 1%. Rick Kneipper, Anthelio’s cofounder and chief strategy officer, says that hospitalists can be at the forefront “of the creative changes needed” to reduce costs and improve profitability.
“Hospital medicine groups and hospitals could free up significant funds to devote to improved patient-care services if they focus on their core competency of patient care and farm out their non-core, back-office services to experts who can use leverage to provide more efficient services at significantly reduced costs,” Kneipper wrote in an email to The Hospitalist. “Financial pressures have historically forced most industries to stop trying to be vertically integrated [trying to be ‘all things to all people’] and instead to focus on their core competencies—it’s time for healthcare to do the same.”
—Rick Kneipper, cofounder, chief strategy officer, Anthelio
HM’s foothold at the intersection of clinical care and safety and QI positions the specialty to “respond to the new challenges of readmission penalties, evidenced-based medicine requirements, EMR implementation, and operation challenges,” Kneipper wrote.
For the full survey, please visit www.antheliohealth.com and search “survey.”
A new report shows that 1 in 5 community hospitals operates in the red, but the chief strategy officer of the firm that conducted the survey thinks hospitals can help change that.
The second annual survey from healthcare information technology (HIT) provider Anthelio and leadership group Community Hospital 100 found that 22% of community hospitals operate with margins below 2%; another 38% operate below 1%. Rick Kneipper, Anthelio’s cofounder and chief strategy officer, says that hospitalists can be at the forefront “of the creative changes needed” to reduce costs and improve profitability.
“Hospital medicine groups and hospitals could free up significant funds to devote to improved patient-care services if they focus on their core competency of patient care and farm out their non-core, back-office services to experts who can use leverage to provide more efficient services at significantly reduced costs,” Kneipper wrote in an email to The Hospitalist. “Financial pressures have historically forced most industries to stop trying to be vertically integrated [trying to be ‘all things to all people’] and instead to focus on their core competencies—it’s time for healthcare to do the same.”
—Rick Kneipper, cofounder, chief strategy officer, Anthelio
HM’s foothold at the intersection of clinical care and safety and QI positions the specialty to “respond to the new challenges of readmission penalties, evidenced-based medicine requirements, EMR implementation, and operation challenges,” Kneipper wrote.
For the full survey, please visit www.antheliohealth.com and search “survey.”
A new report shows that 1 in 5 community hospitals operates in the red, but the chief strategy officer of the firm that conducted the survey thinks hospitals can help change that.
The second annual survey from healthcare information technology (HIT) provider Anthelio and leadership group Community Hospital 100 found that 22% of community hospitals operate with margins below 2%; another 38% operate below 1%. Rick Kneipper, Anthelio’s cofounder and chief strategy officer, says that hospitalists can be at the forefront “of the creative changes needed” to reduce costs and improve profitability.
“Hospital medicine groups and hospitals could free up significant funds to devote to improved patient-care services if they focus on their core competency of patient care and farm out their non-core, back-office services to experts who can use leverage to provide more efficient services at significantly reduced costs,” Kneipper wrote in an email to The Hospitalist. “Financial pressures have historically forced most industries to stop trying to be vertically integrated [trying to be ‘all things to all people’] and instead to focus on their core competencies—it’s time for healthcare to do the same.”
—Rick Kneipper, cofounder, chief strategy officer, Anthelio
HM’s foothold at the intersection of clinical care and safety and QI positions the specialty to “respond to the new challenges of readmission penalties, evidenced-based medicine requirements, EMR implementation, and operation challenges,” Kneipper wrote.
For the full survey, please visit www.antheliohealth.com and search “survey.”
Six Ways You Can Help Reduce HAIs in Your Hospital
- Encourage good hand hygiene. This should be obvious, but hospitals are struggling to achieve compliance rates of even 50%. One study has found significant improvement by appealing to medical providers’ altruistic sense: “Hand hygiene prevents patients from catching diseases.”1
- Embrace checklists. If they work for airline pilots, they can work for you. Study after study has supported their effectiveness, particularly in preventing CLABSIs and CAUTIs when well-integrated into a multifaceted approach.
- Bundle up. A bundled approach that emphasized proper hand hygiene, disinfection, catheter avoidance, and timely removal cut CLABSI rates by morethan half, on average, in Veterans Administration ICUs throughout the U.S.2
- Team up. For a C. diff-reduction effort at Kaiser Permanente Medical Center in Santa Clara, Calif., success meant getting doctors, nurses, specialists, and administrators on board, both to brainstorm and to sustain momentum.
- Be a role model. Consistently following HAI-prevention protocols, such as contact precautions, can make adherence contagious—in a very good way.
- Be an innovator. By virtue of being ubiquitous in inpatient wards, hospitalists know what works and what doesn’t; your insight can be particularly valuable for a team-based, HAI-reduction effort.
References
- Grant AM, Hofmann DA. It’s not all about me: Motivating hospital hand hygiene by focusing on patients. Psychol Sci. 2011;22:1494-1499.
- Render ML, Hasselbeck R, Freyberg RW, Hofer TP, et al. Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement. BMJ Qual Saf. 2011;20(8):725-732.
- Encourage good hand hygiene. This should be obvious, but hospitals are struggling to achieve compliance rates of even 50%. One study has found significant improvement by appealing to medical providers’ altruistic sense: “Hand hygiene prevents patients from catching diseases.”1
- Embrace checklists. If they work for airline pilots, they can work for you. Study after study has supported their effectiveness, particularly in preventing CLABSIs and CAUTIs when well-integrated into a multifaceted approach.
- Bundle up. A bundled approach that emphasized proper hand hygiene, disinfection, catheter avoidance, and timely removal cut CLABSI rates by morethan half, on average, in Veterans Administration ICUs throughout the U.S.2
- Team up. For a C. diff-reduction effort at Kaiser Permanente Medical Center in Santa Clara, Calif., success meant getting doctors, nurses, specialists, and administrators on board, both to brainstorm and to sustain momentum.
- Be a role model. Consistently following HAI-prevention protocols, such as contact precautions, can make adherence contagious—in a very good way.
- Be an innovator. By virtue of being ubiquitous in inpatient wards, hospitalists know what works and what doesn’t; your insight can be particularly valuable for a team-based, HAI-reduction effort.
References
- Grant AM, Hofmann DA. It’s not all about me: Motivating hospital hand hygiene by focusing on patients. Psychol Sci. 2011;22:1494-1499.
- Render ML, Hasselbeck R, Freyberg RW, Hofer TP, et al. Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement. BMJ Qual Saf. 2011;20(8):725-732.
- Encourage good hand hygiene. This should be obvious, but hospitals are struggling to achieve compliance rates of even 50%. One study has found significant improvement by appealing to medical providers’ altruistic sense: “Hand hygiene prevents patients from catching diseases.”1
- Embrace checklists. If they work for airline pilots, they can work for you. Study after study has supported their effectiveness, particularly in preventing CLABSIs and CAUTIs when well-integrated into a multifaceted approach.
- Bundle up. A bundled approach that emphasized proper hand hygiene, disinfection, catheter avoidance, and timely removal cut CLABSI rates by morethan half, on average, in Veterans Administration ICUs throughout the U.S.2
- Team up. For a C. diff-reduction effort at Kaiser Permanente Medical Center in Santa Clara, Calif., success meant getting doctors, nurses, specialists, and administrators on board, both to brainstorm and to sustain momentum.
- Be a role model. Consistently following HAI-prevention protocols, such as contact precautions, can make adherence contagious—in a very good way.
- Be an innovator. By virtue of being ubiquitous in inpatient wards, hospitalists know what works and what doesn’t; your insight can be particularly valuable for a team-based, HAI-reduction effort.
References
- Grant AM, Hofmann DA. It’s not all about me: Motivating hospital hand hygiene by focusing on patients. Psychol Sci. 2011;22:1494-1499.
- Render ML, Hasselbeck R, Freyberg RW, Hofer TP, et al. Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement. BMJ Qual Saf. 2011;20(8):725-732.
Gut Reaction
At 480-bed Emory University Hospital Midtown in Atlanta, the physicians and staff seemingly are doing all the right things to foil one of hospital’s archenemies: Clostridium difficile. The bacteria, better known as C. diff, is responsible for a sharp rise in hospital-acquired infections over the past decade, rivaling even MRSA.
In 2010, Emory Midtown launched a campaign to boost awareness of the importance of hand washing before and after treating patients infected with C. diff and those likely to be infected. They also began using the polymerase-chain-reaction-based assay to detect the bacteria, a test with much higher sensitivity that helps to more efficiently identify those infected so control measures can be more prompt and targeted. They use a hypochlorite mixture to clean the rooms of those infected, which is considered a must. And a committee monitors the use of antibiotics to prevent overuse—often the scapegoat for the rise of the hard-to-kill bacteria.
Still, at Emory, the rate of C. diff is about the same as the national average, says hospitalist Ketino Kobaidze, MD, assistant professor at the Emory University School of Medicine and a member of the antimicrobial stewardship and infectious disease control committees at Midtown. While Dr. Kobaidze says her institution is doing a good job of trying to keep C. diff under control, she thinks hospitalists can do more.
“My feeling is that we are not as involved as we’re supposed to be,” she says. “I think we need to be a little bit more proactive, be involved in committees and research activities across the hospital.”
—Kevin Kavanagh, MD, founder, Health Watch USA
You Are Not Alone
The experience at Emory Midtown is far from unusual—healthcare facilities, and hospitalists, across the country have seen healthcare-related C. diff cases more than double since 2001 to between 400,000 and 500,000 a year, says Carolyn Gould, MD, a medical epidemiologist in the division of healthcare quality promotion at the Centers for Disease Control and Prevention (CDC) in Atlanta.
Hospitalists, whether they realize it or not, are intimately involved in how well the C. diff outbreak is controlled. Infectious-disease (ID) specialists say hospitalists are perfectly situated to make an impact in efforts to help curb the outbreak.
“Hospitalists are critical to this effort,” Dr. Gould says. “They’re in the hospital day in and day out, and they’re constantly interacting with the patients, staff, and administration. They’re often the first on the scene to see a patient who might have suddenly developed diarrhea; they’re the first to react. I think they’re in a prime position to play a leadership role to prevent C. diff infections.”
They’re also situated well to work with infection-control experts on antimicrobial stewardship programs, she says.
“I look at hospitalists just like I would have looked at internists managing their own patients 15 years ago,” says Stuart Cohen, MD, an ID expert with the University of California at Davis and a fellow with the Infectious Diseases Society of America who was lead author of the latest published IDSA guidelines on C. diff treatment. “And so they’re the first-line people.”
continued below...
Mayo Shows How a Simple Step Can Make Big Difference in C. Diff
Sometimes even when it comes to a huge problem like widespread bacterial infections, simplicity is best.
The Mayo Clinic, in a project to cut the rate of C. diff infections, asked its workers to do one extra thing: Wipe down high-touch areas with bleach wipes. The effort worked; infections were all but eradicated in units that had been having five to seven infections per month.
The results of the project, recently published in Infectious Control and Hospital Epidemiology, show the importance of simple steps as long as they’re carried out regularly and thoroughly.1
The project began when Robert Orenstein, DO, associate professor of medicine in infectious diseases who then worked in Rochester, Minn., established a surveillance network for C. diff infections at Mayo Clinic at the time when such infections were being noted more widely throughout the U.S. and Canada. The network began tracking the cases and found that one inpatient medical unit primarily composed of patients with gastrointestinal diseases had a C. diff rate 10 times higher than the rest of the hospital. Surveillance also showed that universally gloved hematology and oncology units had substantially lower rates of C. diff infection despite high-risk patients.
Dr. Orenstein knew he had to make a change in the GI unit, but it wasn’t feasible to institute universal gloving, so he turned to bleach wipes.
Twice a day, housekeeping staff wiped down all “high-touch” areas (light switches, toilet handles, bed rails) in all of the rooms. The wipes contain 0.55% sodium hypochlorite. Within six months, the number of C. diff cases fell to almost zero.
“We were just in shock,” Dr. Orenstein says. He attributed the improvement to a reduction in the “colonization pressure”—if a high concentration of patients with C. diff can cause abundant transmissions quickly, the opposite is also true.
The greatly improved figures were shared with housekeeping, which initially complained about the smell but were encouraged to keep doors open and rooms ventilated. The bleach wipes, which Dr. Orenstein acknowledges mean an additional expense, leave a white residue when dry, so the surfaces are wiped down with water after the recommended contact time.
Dr. Orenstein notes that the results came even without a change in hand hygiene, which he had deemed not feasible because of the hospital’s lack of sinks. He isn’t diminishing the importance of hand washing, but the project does show how effective a single step can be.
The key, Dr. Orenstein adds, might be that it was just one change involving just one group of staff. “Why we think it was so effective is it was really one group that had to change their behavior and we worked with them, educated them,” he says.
He emphasizes that the wipes don’t come at the expense of other measures, like thorough cleaning of all rooms and antibiotic stewardship programs.
“You do all of those and do them well,” he says, “then you get the reduction of C. diff in the hospital.”
A Tough Bug
Believed to be aided largely by the use of broad-spectrum antibiotics that knock out the colon’s natural flora, C. diff in the hospital—as well as nursing homes and acute-care facilities—has raged for much of the past decade. Its rise is tied to the emergence of a new hypervirulent strain known as BI/NAP1/027, or NAP1 for short. The strain is highly resistant to fluoroquinolones, such as ciprofloxacin and levofloxacin, which are used often in healthcare settings.
“A fluoroquinolone will wipe out a lot of your normal flora in your gut,” Dr. Gould says. “But it won’t wipe out C. diff, in particular this hypervirulent strain. And so this strain can flourish in the presence of fluoroquinolones.” The strain produces up to 15 to 20 times more toxins than other C. diff strains, according to some data, she adds.
Vancomycin (Vanconin) and metronidazole (Flagyl) are the most common antibiotics used to treat patients infected with C. diff. Mortality rates are higher among the elderly, largely because of their weaker immune system, Dr. Gould says. Studies have generally shown mortality rates of 10% or a bit lower.1
More recent studies have shown that the number of hospital-related C. diff cases might have begun to level off in 2008 and 2009. Dr. Gould says she thinks the leveling off is for real, but there is debate over what the immediate future holds.
“There’s a lot of work and initiatives, especially state-based initiatives, that are being done in hospitals. And there’s reason to believe they’re effective,” she says, adding it’s harder to get a good picture of the problem in long-term care facilities and in the community.
Dr. Cohen with the IDSA says it’s too soon to say whether the problem is hitting a plateau. “CDC data are always a couple of years behind,” he says. “Until you see another data point, you can’t tell whether that’s just a transient flattening and whether it’s going to keep going up or not.”
Kevin Kavanagh, MD, founder of the patient advocacy group Health Watch USA and a retired otolaryngologist in Kentucky who has taken a keen interest in the C. diff problem, says he doesn’t think the end of the tunnel is within view yet.
“I think C. diff is going to get worse before it gets better,” Dr. Kavanagh says. “And that’s not necessarily because the healthcare profession isn’t doing due diligence. This is a tough organism.—it can be tough to treat and can be very tough to kill.”
The Best Defense?
Because C. diff lives within protective spores, sound hand hygiene practices and room-cleaning practices are essential for keeping infections to a minimum. Alcohol-based hand sanitizers, effective against other organisms including MRSA, do not kill C. diff. The bacteria must be mechanically removed through hand washing.
And even hand washing might not be totally effective at getting rid of the spores, which means it’s important for healthcare workers to gown and glove in high-risk rooms.
Sodium hypochlorite solutions, or bleach mixtures, have to be used to clean rooms occupied by patients with C. diff, and the prevailing thought is to clean the rooms of patients suspected of having C. diff, even if those cases might not be confirmed.
Equally important to cleaning and hand washing is systemwide emphasis on antibiotic stewardship. A 2011 study at the State University of New York Buffalo found that the risk of a C. diff infection rose with the number of antibiotics taken.2
—Carolyn Gould, MD, medical epidemiologist, division of healthcare quality promotion, Centers of Disease Control and Prevention, Atlanta
While a broad-spectrum antibiotic might be necessary at first, once the results of cultures are received, the treatment should be finely tailored to kill only the problem bacteria so that the body’s natural defenses aren’t broken down, Dr. Gould explains.
“If someone is very sick and you’re not sure what is going on, it’s very reasonable to treat them empirically with broad-spectrum antibiotics,” she says. “The important thing is that you send the appropriate cultures before so that you know what you’re treating and you can optimize those antibiotics with daily assessments.”
It’s clear why an overreliance on broad-spectrum drugs prevails in U.S. health settings, Dr. Cohen acknowledges. Recent literature suggests treating critically ill patients with wide-ranging antimicrobials as the mortality rate can be twice as high with narrower options. “I think people have gotten very quick to give broad-spectrum therapy,” he says.
continued below...
Knocking Out Clostridium Difficile
Here are the guidelines on treatment of C. diff infections (CDI) as recommended by the Infectious Diseases Society of America:
First steps:
- Discontinue therapy with the inciting antimicrobial agent(s) as soon as possible as this may influence the risk of CDI recurrence.
- When severe or complicated CDI is suspected, initiate empirical treatment as soon as the diagnosis is suspected.
- If the stool toxin assay result is negative, the decision to initiate, stop, or continue treatment must be individualized.
- If possible, avoid use of antiperistaltic agents as they may obscure symptoms and precipitate toxic megacolon.
Treatment of initial episode:
- Metronidazole is the drug of choice for the initial episode of mild to moderate CDI. The dosage is 500 mg orally three times per day for 10 to 14 days.
- Vancomycin is the drug of choice for an initial episode of severe CDI. The dosage is 125 mg orally four times per day for 10 to 14 days.
- Vancomycin administered orally (and per rectum if ileus is present) with or without intravenously administered metronidazole is the regimen of choice for the treatment of severe complicated CDI. The vancomycin dosage is 500 mg orally four times per day and 500 mg in approximately 100 mL normal saline per rectum every six hours as a retention enema, and the metronidazole dosage is 500 mg intravenously every eight hours.
Severely ill patients:
Consider colectomy for severely ill patients. Monitoring the serum lactate level and the peripheral blood white blood cell count may be helpful in prompting a decision to operate because a serum lactate level rising to 5 mmol/L and a white blood cell count rising to 50,000 cells per mL have been associated with greatly increased perioperative mortality. If surgical management is necessary, perform subtotal colectomy with preservation of the rectum.
Treatment of recurrences:
- Treatment of the first recurrence of CDI is usually with the same regimen as for the initial episode but should be stratified by disease severity (mild-to-moderate, severe, or severe complicated) as is recommended for treatment of the initial CDI episode.
- Do not use metronidazole beyond the first recurrence of CDI or for long-term chronic therapy because of potential for cumulative neurotoxicity.
- Treatment of the second or later recurrence of CDI with vancomycin therapy using a tapered and/or pulse regimen is the preferred next strategy.
Probiotics:
Administration of currently available probiotics is not recommended to prevent primary CDI as there are limited data to support this approach and there is a potential risk of bloodstream infection.
Source: Cohen SH, Gerding DH, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology. 2010;31(5):431–455.
National Response, Localized Attention
Dr. Kavanagh of Health Watch USA says that more information about C. diff is needed, particularly publicly available numbers of infections at hospitals. Some states require those figures to be reported, but most don’t. And there is no current federal mandate on reporting of C. diff cases, although acute-care hospitals will be required to report C. diff infection rates starting in 2013.
“We really have scant data,” he says. “There is not a lot of reporting if you look at the nation on a whole. And I think that underscores one of the reasons why you need to have data for action. You need to have reporting of these organisms to the National Healthcare Safety Network so that the CDC can monitor and can make plans and can do effective interventions.
“You want to know where the areas of highest infection are,” he adds. “You want to know what interventions work and don’t work. If you don’t have a national coordinated reporting system, it really makes it difficult to address the problem. C. diff is going to be much harder to control than MRSA or other bacteria because it changes into a hard-to-kill dormant spore stage and then re-occurs at some point.”
The Centers for Medicare & Medicaid Services (CMS) has proposed adding C. diff infections to the list of hospital-acquired conditions that will not be reimbursable. It is widely hoped that such a measure will go a long way toward stamping out the problem.
Dr. Kobaidze of Emory notes that C. diff is a dynamic problem, always adapting and posing new challenges. And hospitalists should be more involved in answering these questions through research. One recent question, she points out, is whether proton pump inhibitor use is related to the rise of C. diff.
Ultimately, though, controlling C. diff in hospitals might come down to what is done day to day inside the hospital. And hospitalists can play a big role.
Danielle Scheurer, MD, MSCR, SFHM, a hospitalist and medical director of quality at the Medical University of South Carolina in Charleston, says that a full-time pharmacist on the hospital’s antimicrobial stewardship committee is always reviewing antibiotic prescriptions and is prepared to flag cases in which a broad-spectrum is used when one with a more narrow scope might be more appropriate.
The hospital has done its best, as part of its “renovation cycle,” to standardize the layouts of rooms “so that the second you open the door you know exactly where the alcohol gel is and where the soap and the sink is going to be.” The idea is to make compliance as “mindless” as possible. Such efforts can be hampered by structural limitations though, she says.
HM group leaders, she suggests, can play an important part simply by being good role models—gowning and gloving without complaint before entering high-risk rooms and reinforcing the message that such efforts have real effects on patient safety.
But she also acknowledges that “it always sounds easy....There has to be some level of redundancy built into the hospital system. This is more of a system thing than the individual hospitalist.”
One level of redundancy at MUSC that has been particularly effective, she says, are “secret shoppers” who keep an eye out for medical teams that might not be washing their hands as they go in and out of high-risk rooms. Each unit is responsible for their hand hygiene numbers—which include both self-reported figures and those obtained by the secret onlookers—and those numbers are made available to the hospital.
Those units with the best numbers are sometimes given a reward, such as a pizza party, but it’s colleagues’ knowledge of the numbers that matters most, she says.
“That, in and of itself, is a powerful motivator,” Dr. Scheurer says. “We bring it to all of our quality operations meetings, all the administrators, the CEO, the CMO. It’s very motivating for every unit. They don’t want to be the trailing unit.”
Tom Collins is a freelance medical writer based in Miami.
References
- Orenstein R, Aronhalt KC, McManus JE Jr., Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-1139.
- Stevens V, Dumyati G, Fine LS, Fisher SG, van Wijngaarden E. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis. 2011;53(1):42-48.
What Hospitalists Can Do
Here are suggestions, as provided by ID experts and hospitalist leaders, on what hospitalists can do to battle C. diff infections:
Short-term steps:
- Wash hands before entering and upon leaving rooms occupied by patients with C. diff infections and those strongly suspected of having C. diff infections.
- Continue using alcohol-based hand sanitizers in addition to hand washing to prevent other types of outbreaks.
- Ensure that infected patients, and those suspected of being infected, are isolated, possibly even for 48 hours after diarrhea resolves, as research shows the patients can still transmit the spores.
- In units with high C. diff rates, consider universal gloving, not just for patients with known infection.
- Use more highly sensitive tests, such as polymerase chain reaction, or PCR, rather than enzyme immunoassays to more efficiently identify affected patients.
- Avoid testing patients with formed stools.
- Ensure that rooms of infected patients and patients strongly suspected of being infected are cleaned with a hypochlorite solution.
- Taper the use of broad-spectrum antibiotics in non-C. diff patients after test results are obtained.
- Encourage patients to question their healthcare practitioners about hand hygiene and use of antibiotics.
Long-term steps:
- Be involved with your hospital’s antimicrobial stewardship program.
- Conduct research into C. diff to explore its causes and treatments.
- Be a good role model for the rest of your group, emphasizing good practices and a strong patient-safety message.
At 480-bed Emory University Hospital Midtown in Atlanta, the physicians and staff seemingly are doing all the right things to foil one of hospital’s archenemies: Clostridium difficile. The bacteria, better known as C. diff, is responsible for a sharp rise in hospital-acquired infections over the past decade, rivaling even MRSA.
In 2010, Emory Midtown launched a campaign to boost awareness of the importance of hand washing before and after treating patients infected with C. diff and those likely to be infected. They also began using the polymerase-chain-reaction-based assay to detect the bacteria, a test with much higher sensitivity that helps to more efficiently identify those infected so control measures can be more prompt and targeted. They use a hypochlorite mixture to clean the rooms of those infected, which is considered a must. And a committee monitors the use of antibiotics to prevent overuse—often the scapegoat for the rise of the hard-to-kill bacteria.
Still, at Emory, the rate of C. diff is about the same as the national average, says hospitalist Ketino Kobaidze, MD, assistant professor at the Emory University School of Medicine and a member of the antimicrobial stewardship and infectious disease control committees at Midtown. While Dr. Kobaidze says her institution is doing a good job of trying to keep C. diff under control, she thinks hospitalists can do more.
“My feeling is that we are not as involved as we’re supposed to be,” she says. “I think we need to be a little bit more proactive, be involved in committees and research activities across the hospital.”
—Kevin Kavanagh, MD, founder, Health Watch USA
You Are Not Alone
The experience at Emory Midtown is far from unusual—healthcare facilities, and hospitalists, across the country have seen healthcare-related C. diff cases more than double since 2001 to between 400,000 and 500,000 a year, says Carolyn Gould, MD, a medical epidemiologist in the division of healthcare quality promotion at the Centers for Disease Control and Prevention (CDC) in Atlanta.
Hospitalists, whether they realize it or not, are intimately involved in how well the C. diff outbreak is controlled. Infectious-disease (ID) specialists say hospitalists are perfectly situated to make an impact in efforts to help curb the outbreak.
“Hospitalists are critical to this effort,” Dr. Gould says. “They’re in the hospital day in and day out, and they’re constantly interacting with the patients, staff, and administration. They’re often the first on the scene to see a patient who might have suddenly developed diarrhea; they’re the first to react. I think they’re in a prime position to play a leadership role to prevent C. diff infections.”
They’re also situated well to work with infection-control experts on antimicrobial stewardship programs, she says.
“I look at hospitalists just like I would have looked at internists managing their own patients 15 years ago,” says Stuart Cohen, MD, an ID expert with the University of California at Davis and a fellow with the Infectious Diseases Society of America who was lead author of the latest published IDSA guidelines on C. diff treatment. “And so they’re the first-line people.”
continued below...
Mayo Shows How a Simple Step Can Make Big Difference in C. Diff
Sometimes even when it comes to a huge problem like widespread bacterial infections, simplicity is best.
The Mayo Clinic, in a project to cut the rate of C. diff infections, asked its workers to do one extra thing: Wipe down high-touch areas with bleach wipes. The effort worked; infections were all but eradicated in units that had been having five to seven infections per month.
The results of the project, recently published in Infectious Control and Hospital Epidemiology, show the importance of simple steps as long as they’re carried out regularly and thoroughly.1
The project began when Robert Orenstein, DO, associate professor of medicine in infectious diseases who then worked in Rochester, Minn., established a surveillance network for C. diff infections at Mayo Clinic at the time when such infections were being noted more widely throughout the U.S. and Canada. The network began tracking the cases and found that one inpatient medical unit primarily composed of patients with gastrointestinal diseases had a C. diff rate 10 times higher than the rest of the hospital. Surveillance also showed that universally gloved hematology and oncology units had substantially lower rates of C. diff infection despite high-risk patients.
Dr. Orenstein knew he had to make a change in the GI unit, but it wasn’t feasible to institute universal gloving, so he turned to bleach wipes.
Twice a day, housekeeping staff wiped down all “high-touch” areas (light switches, toilet handles, bed rails) in all of the rooms. The wipes contain 0.55% sodium hypochlorite. Within six months, the number of C. diff cases fell to almost zero.
“We were just in shock,” Dr. Orenstein says. He attributed the improvement to a reduction in the “colonization pressure”—if a high concentration of patients with C. diff can cause abundant transmissions quickly, the opposite is also true.
The greatly improved figures were shared with housekeeping, which initially complained about the smell but were encouraged to keep doors open and rooms ventilated. The bleach wipes, which Dr. Orenstein acknowledges mean an additional expense, leave a white residue when dry, so the surfaces are wiped down with water after the recommended contact time.
Dr. Orenstein notes that the results came even without a change in hand hygiene, which he had deemed not feasible because of the hospital’s lack of sinks. He isn’t diminishing the importance of hand washing, but the project does show how effective a single step can be.
The key, Dr. Orenstein adds, might be that it was just one change involving just one group of staff. “Why we think it was so effective is it was really one group that had to change their behavior and we worked with them, educated them,” he says.
He emphasizes that the wipes don’t come at the expense of other measures, like thorough cleaning of all rooms and antibiotic stewardship programs.
“You do all of those and do them well,” he says, “then you get the reduction of C. diff in the hospital.”
A Tough Bug
Believed to be aided largely by the use of broad-spectrum antibiotics that knock out the colon’s natural flora, C. diff in the hospital—as well as nursing homes and acute-care facilities—has raged for much of the past decade. Its rise is tied to the emergence of a new hypervirulent strain known as BI/NAP1/027, or NAP1 for short. The strain is highly resistant to fluoroquinolones, such as ciprofloxacin and levofloxacin, which are used often in healthcare settings.
“A fluoroquinolone will wipe out a lot of your normal flora in your gut,” Dr. Gould says. “But it won’t wipe out C. diff, in particular this hypervirulent strain. And so this strain can flourish in the presence of fluoroquinolones.” The strain produces up to 15 to 20 times more toxins than other C. diff strains, according to some data, she adds.
Vancomycin (Vanconin) and metronidazole (Flagyl) are the most common antibiotics used to treat patients infected with C. diff. Mortality rates are higher among the elderly, largely because of their weaker immune system, Dr. Gould says. Studies have generally shown mortality rates of 10% or a bit lower.1
More recent studies have shown that the number of hospital-related C. diff cases might have begun to level off in 2008 and 2009. Dr. Gould says she thinks the leveling off is for real, but there is debate over what the immediate future holds.
“There’s a lot of work and initiatives, especially state-based initiatives, that are being done in hospitals. And there’s reason to believe they’re effective,” she says, adding it’s harder to get a good picture of the problem in long-term care facilities and in the community.
Dr. Cohen with the IDSA says it’s too soon to say whether the problem is hitting a plateau. “CDC data are always a couple of years behind,” he says. “Until you see another data point, you can’t tell whether that’s just a transient flattening and whether it’s going to keep going up or not.”
Kevin Kavanagh, MD, founder of the patient advocacy group Health Watch USA and a retired otolaryngologist in Kentucky who has taken a keen interest in the C. diff problem, says he doesn’t think the end of the tunnel is within view yet.
“I think C. diff is going to get worse before it gets better,” Dr. Kavanagh says. “And that’s not necessarily because the healthcare profession isn’t doing due diligence. This is a tough organism.—it can be tough to treat and can be very tough to kill.”
The Best Defense?
Because C. diff lives within protective spores, sound hand hygiene practices and room-cleaning practices are essential for keeping infections to a minimum. Alcohol-based hand sanitizers, effective against other organisms including MRSA, do not kill C. diff. The bacteria must be mechanically removed through hand washing.
And even hand washing might not be totally effective at getting rid of the spores, which means it’s important for healthcare workers to gown and glove in high-risk rooms.
Sodium hypochlorite solutions, or bleach mixtures, have to be used to clean rooms occupied by patients with C. diff, and the prevailing thought is to clean the rooms of patients suspected of having C. diff, even if those cases might not be confirmed.
Equally important to cleaning and hand washing is systemwide emphasis on antibiotic stewardship. A 2011 study at the State University of New York Buffalo found that the risk of a C. diff infection rose with the number of antibiotics taken.2
—Carolyn Gould, MD, medical epidemiologist, division of healthcare quality promotion, Centers of Disease Control and Prevention, Atlanta
While a broad-spectrum antibiotic might be necessary at first, once the results of cultures are received, the treatment should be finely tailored to kill only the problem bacteria so that the body’s natural defenses aren’t broken down, Dr. Gould explains.
“If someone is very sick and you’re not sure what is going on, it’s very reasonable to treat them empirically with broad-spectrum antibiotics,” she says. “The important thing is that you send the appropriate cultures before so that you know what you’re treating and you can optimize those antibiotics with daily assessments.”
It’s clear why an overreliance on broad-spectrum drugs prevails in U.S. health settings, Dr. Cohen acknowledges. Recent literature suggests treating critically ill patients with wide-ranging antimicrobials as the mortality rate can be twice as high with narrower options. “I think people have gotten very quick to give broad-spectrum therapy,” he says.
continued below...
Knocking Out Clostridium Difficile
Here are the guidelines on treatment of C. diff infections (CDI) as recommended by the Infectious Diseases Society of America:
First steps:
- Discontinue therapy with the inciting antimicrobial agent(s) as soon as possible as this may influence the risk of CDI recurrence.
- When severe or complicated CDI is suspected, initiate empirical treatment as soon as the diagnosis is suspected.
- If the stool toxin assay result is negative, the decision to initiate, stop, or continue treatment must be individualized.
- If possible, avoid use of antiperistaltic agents as they may obscure symptoms and precipitate toxic megacolon.
Treatment of initial episode:
- Metronidazole is the drug of choice for the initial episode of mild to moderate CDI. The dosage is 500 mg orally three times per day for 10 to 14 days.
- Vancomycin is the drug of choice for an initial episode of severe CDI. The dosage is 125 mg orally four times per day for 10 to 14 days.
- Vancomycin administered orally (and per rectum if ileus is present) with or without intravenously administered metronidazole is the regimen of choice for the treatment of severe complicated CDI. The vancomycin dosage is 500 mg orally four times per day and 500 mg in approximately 100 mL normal saline per rectum every six hours as a retention enema, and the metronidazole dosage is 500 mg intravenously every eight hours.
Severely ill patients:
Consider colectomy for severely ill patients. Monitoring the serum lactate level and the peripheral blood white blood cell count may be helpful in prompting a decision to operate because a serum lactate level rising to 5 mmol/L and a white blood cell count rising to 50,000 cells per mL have been associated with greatly increased perioperative mortality. If surgical management is necessary, perform subtotal colectomy with preservation of the rectum.
Treatment of recurrences:
- Treatment of the first recurrence of CDI is usually with the same regimen as for the initial episode but should be stratified by disease severity (mild-to-moderate, severe, or severe complicated) as is recommended for treatment of the initial CDI episode.
- Do not use metronidazole beyond the first recurrence of CDI or for long-term chronic therapy because of potential for cumulative neurotoxicity.
- Treatment of the second or later recurrence of CDI with vancomycin therapy using a tapered and/or pulse regimen is the preferred next strategy.
Probiotics:
Administration of currently available probiotics is not recommended to prevent primary CDI as there are limited data to support this approach and there is a potential risk of bloodstream infection.
Source: Cohen SH, Gerding DH, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology. 2010;31(5):431–455.
National Response, Localized Attention
Dr. Kavanagh of Health Watch USA says that more information about C. diff is needed, particularly publicly available numbers of infections at hospitals. Some states require those figures to be reported, but most don’t. And there is no current federal mandate on reporting of C. diff cases, although acute-care hospitals will be required to report C. diff infection rates starting in 2013.
“We really have scant data,” he says. “There is not a lot of reporting if you look at the nation on a whole. And I think that underscores one of the reasons why you need to have data for action. You need to have reporting of these organisms to the National Healthcare Safety Network so that the CDC can monitor and can make plans and can do effective interventions.
“You want to know where the areas of highest infection are,” he adds. “You want to know what interventions work and don’t work. If you don’t have a national coordinated reporting system, it really makes it difficult to address the problem. C. diff is going to be much harder to control than MRSA or other bacteria because it changes into a hard-to-kill dormant spore stage and then re-occurs at some point.”
The Centers for Medicare & Medicaid Services (CMS) has proposed adding C. diff infections to the list of hospital-acquired conditions that will not be reimbursable. It is widely hoped that such a measure will go a long way toward stamping out the problem.
Dr. Kobaidze of Emory notes that C. diff is a dynamic problem, always adapting and posing new challenges. And hospitalists should be more involved in answering these questions through research. One recent question, she points out, is whether proton pump inhibitor use is related to the rise of C. diff.
Ultimately, though, controlling C. diff in hospitals might come down to what is done day to day inside the hospital. And hospitalists can play a big role.
Danielle Scheurer, MD, MSCR, SFHM, a hospitalist and medical director of quality at the Medical University of South Carolina in Charleston, says that a full-time pharmacist on the hospital’s antimicrobial stewardship committee is always reviewing antibiotic prescriptions and is prepared to flag cases in which a broad-spectrum is used when one with a more narrow scope might be more appropriate.
The hospital has done its best, as part of its “renovation cycle,” to standardize the layouts of rooms “so that the second you open the door you know exactly where the alcohol gel is and where the soap and the sink is going to be.” The idea is to make compliance as “mindless” as possible. Such efforts can be hampered by structural limitations though, she says.
HM group leaders, she suggests, can play an important part simply by being good role models—gowning and gloving without complaint before entering high-risk rooms and reinforcing the message that such efforts have real effects on patient safety.
But she also acknowledges that “it always sounds easy....There has to be some level of redundancy built into the hospital system. This is more of a system thing than the individual hospitalist.”
One level of redundancy at MUSC that has been particularly effective, she says, are “secret shoppers” who keep an eye out for medical teams that might not be washing their hands as they go in and out of high-risk rooms. Each unit is responsible for their hand hygiene numbers—which include both self-reported figures and those obtained by the secret onlookers—and those numbers are made available to the hospital.
Those units with the best numbers are sometimes given a reward, such as a pizza party, but it’s colleagues’ knowledge of the numbers that matters most, she says.
“That, in and of itself, is a powerful motivator,” Dr. Scheurer says. “We bring it to all of our quality operations meetings, all the administrators, the CEO, the CMO. It’s very motivating for every unit. They don’t want to be the trailing unit.”
Tom Collins is a freelance medical writer based in Miami.
References
- Orenstein R, Aronhalt KC, McManus JE Jr., Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-1139.
- Stevens V, Dumyati G, Fine LS, Fisher SG, van Wijngaarden E. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis. 2011;53(1):42-48.
What Hospitalists Can Do
Here are suggestions, as provided by ID experts and hospitalist leaders, on what hospitalists can do to battle C. diff infections:
Short-term steps:
- Wash hands before entering and upon leaving rooms occupied by patients with C. diff infections and those strongly suspected of having C. diff infections.
- Continue using alcohol-based hand sanitizers in addition to hand washing to prevent other types of outbreaks.
- Ensure that infected patients, and those suspected of being infected, are isolated, possibly even for 48 hours after diarrhea resolves, as research shows the patients can still transmit the spores.
- In units with high C. diff rates, consider universal gloving, not just for patients with known infection.
- Use more highly sensitive tests, such as polymerase chain reaction, or PCR, rather than enzyme immunoassays to more efficiently identify affected patients.
- Avoid testing patients with formed stools.
- Ensure that rooms of infected patients and patients strongly suspected of being infected are cleaned with a hypochlorite solution.
- Taper the use of broad-spectrum antibiotics in non-C. diff patients after test results are obtained.
- Encourage patients to question their healthcare practitioners about hand hygiene and use of antibiotics.
Long-term steps:
- Be involved with your hospital’s antimicrobial stewardship program.
- Conduct research into C. diff to explore its causes and treatments.
- Be a good role model for the rest of your group, emphasizing good practices and a strong patient-safety message.
At 480-bed Emory University Hospital Midtown in Atlanta, the physicians and staff seemingly are doing all the right things to foil one of hospital’s archenemies: Clostridium difficile. The bacteria, better known as C. diff, is responsible for a sharp rise in hospital-acquired infections over the past decade, rivaling even MRSA.
In 2010, Emory Midtown launched a campaign to boost awareness of the importance of hand washing before and after treating patients infected with C. diff and those likely to be infected. They also began using the polymerase-chain-reaction-based assay to detect the bacteria, a test with much higher sensitivity that helps to more efficiently identify those infected so control measures can be more prompt and targeted. They use a hypochlorite mixture to clean the rooms of those infected, which is considered a must. And a committee monitors the use of antibiotics to prevent overuse—often the scapegoat for the rise of the hard-to-kill bacteria.
Still, at Emory, the rate of C. diff is about the same as the national average, says hospitalist Ketino Kobaidze, MD, assistant professor at the Emory University School of Medicine and a member of the antimicrobial stewardship and infectious disease control committees at Midtown. While Dr. Kobaidze says her institution is doing a good job of trying to keep C. diff under control, she thinks hospitalists can do more.
“My feeling is that we are not as involved as we’re supposed to be,” she says. “I think we need to be a little bit more proactive, be involved in committees and research activities across the hospital.”
—Kevin Kavanagh, MD, founder, Health Watch USA
You Are Not Alone
The experience at Emory Midtown is far from unusual—healthcare facilities, and hospitalists, across the country have seen healthcare-related C. diff cases more than double since 2001 to between 400,000 and 500,000 a year, says Carolyn Gould, MD, a medical epidemiologist in the division of healthcare quality promotion at the Centers for Disease Control and Prevention (CDC) in Atlanta.
Hospitalists, whether they realize it or not, are intimately involved in how well the C. diff outbreak is controlled. Infectious-disease (ID) specialists say hospitalists are perfectly situated to make an impact in efforts to help curb the outbreak.
“Hospitalists are critical to this effort,” Dr. Gould says. “They’re in the hospital day in and day out, and they’re constantly interacting with the patients, staff, and administration. They’re often the first on the scene to see a patient who might have suddenly developed diarrhea; they’re the first to react. I think they’re in a prime position to play a leadership role to prevent C. diff infections.”
They’re also situated well to work with infection-control experts on antimicrobial stewardship programs, she says.
“I look at hospitalists just like I would have looked at internists managing their own patients 15 years ago,” says Stuart Cohen, MD, an ID expert with the University of California at Davis and a fellow with the Infectious Diseases Society of America who was lead author of the latest published IDSA guidelines on C. diff treatment. “And so they’re the first-line people.”
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Mayo Shows How a Simple Step Can Make Big Difference in C. Diff
Sometimes even when it comes to a huge problem like widespread bacterial infections, simplicity is best.
The Mayo Clinic, in a project to cut the rate of C. diff infections, asked its workers to do one extra thing: Wipe down high-touch areas with bleach wipes. The effort worked; infections were all but eradicated in units that had been having five to seven infections per month.
The results of the project, recently published in Infectious Control and Hospital Epidemiology, show the importance of simple steps as long as they’re carried out regularly and thoroughly.1
The project began when Robert Orenstein, DO, associate professor of medicine in infectious diseases who then worked in Rochester, Minn., established a surveillance network for C. diff infections at Mayo Clinic at the time when such infections were being noted more widely throughout the U.S. and Canada. The network began tracking the cases and found that one inpatient medical unit primarily composed of patients with gastrointestinal diseases had a C. diff rate 10 times higher than the rest of the hospital. Surveillance also showed that universally gloved hematology and oncology units had substantially lower rates of C. diff infection despite high-risk patients.
Dr. Orenstein knew he had to make a change in the GI unit, but it wasn’t feasible to institute universal gloving, so he turned to bleach wipes.
Twice a day, housekeeping staff wiped down all “high-touch” areas (light switches, toilet handles, bed rails) in all of the rooms. The wipes contain 0.55% sodium hypochlorite. Within six months, the number of C. diff cases fell to almost zero.
“We were just in shock,” Dr. Orenstein says. He attributed the improvement to a reduction in the “colonization pressure”—if a high concentration of patients with C. diff can cause abundant transmissions quickly, the opposite is also true.
The greatly improved figures were shared with housekeeping, which initially complained about the smell but were encouraged to keep doors open and rooms ventilated. The bleach wipes, which Dr. Orenstein acknowledges mean an additional expense, leave a white residue when dry, so the surfaces are wiped down with water after the recommended contact time.
Dr. Orenstein notes that the results came even without a change in hand hygiene, which he had deemed not feasible because of the hospital’s lack of sinks. He isn’t diminishing the importance of hand washing, but the project does show how effective a single step can be.
The key, Dr. Orenstein adds, might be that it was just one change involving just one group of staff. “Why we think it was so effective is it was really one group that had to change their behavior and we worked with them, educated them,” he says.
He emphasizes that the wipes don’t come at the expense of other measures, like thorough cleaning of all rooms and antibiotic stewardship programs.
“You do all of those and do them well,” he says, “then you get the reduction of C. diff in the hospital.”
A Tough Bug
Believed to be aided largely by the use of broad-spectrum antibiotics that knock out the colon’s natural flora, C. diff in the hospital—as well as nursing homes and acute-care facilities—has raged for much of the past decade. Its rise is tied to the emergence of a new hypervirulent strain known as BI/NAP1/027, or NAP1 for short. The strain is highly resistant to fluoroquinolones, such as ciprofloxacin and levofloxacin, which are used often in healthcare settings.
“A fluoroquinolone will wipe out a lot of your normal flora in your gut,” Dr. Gould says. “But it won’t wipe out C. diff, in particular this hypervirulent strain. And so this strain can flourish in the presence of fluoroquinolones.” The strain produces up to 15 to 20 times more toxins than other C. diff strains, according to some data, she adds.
Vancomycin (Vanconin) and metronidazole (Flagyl) are the most common antibiotics used to treat patients infected with C. diff. Mortality rates are higher among the elderly, largely because of their weaker immune system, Dr. Gould says. Studies have generally shown mortality rates of 10% or a bit lower.1
More recent studies have shown that the number of hospital-related C. diff cases might have begun to level off in 2008 and 2009. Dr. Gould says she thinks the leveling off is for real, but there is debate over what the immediate future holds.
“There’s a lot of work and initiatives, especially state-based initiatives, that are being done in hospitals. And there’s reason to believe they’re effective,” she says, adding it’s harder to get a good picture of the problem in long-term care facilities and in the community.
Dr. Cohen with the IDSA says it’s too soon to say whether the problem is hitting a plateau. “CDC data are always a couple of years behind,” he says. “Until you see another data point, you can’t tell whether that’s just a transient flattening and whether it’s going to keep going up or not.”
Kevin Kavanagh, MD, founder of the patient advocacy group Health Watch USA and a retired otolaryngologist in Kentucky who has taken a keen interest in the C. diff problem, says he doesn’t think the end of the tunnel is within view yet.
“I think C. diff is going to get worse before it gets better,” Dr. Kavanagh says. “And that’s not necessarily because the healthcare profession isn’t doing due diligence. This is a tough organism.—it can be tough to treat and can be very tough to kill.”
The Best Defense?
Because C. diff lives within protective spores, sound hand hygiene practices and room-cleaning practices are essential for keeping infections to a minimum. Alcohol-based hand sanitizers, effective against other organisms including MRSA, do not kill C. diff. The bacteria must be mechanically removed through hand washing.
And even hand washing might not be totally effective at getting rid of the spores, which means it’s important for healthcare workers to gown and glove in high-risk rooms.
Sodium hypochlorite solutions, or bleach mixtures, have to be used to clean rooms occupied by patients with C. diff, and the prevailing thought is to clean the rooms of patients suspected of having C. diff, even if those cases might not be confirmed.
Equally important to cleaning and hand washing is systemwide emphasis on antibiotic stewardship. A 2011 study at the State University of New York Buffalo found that the risk of a C. diff infection rose with the number of antibiotics taken.2
—Carolyn Gould, MD, medical epidemiologist, division of healthcare quality promotion, Centers of Disease Control and Prevention, Atlanta
While a broad-spectrum antibiotic might be necessary at first, once the results of cultures are received, the treatment should be finely tailored to kill only the problem bacteria so that the body’s natural defenses aren’t broken down, Dr. Gould explains.
“If someone is very sick and you’re not sure what is going on, it’s very reasonable to treat them empirically with broad-spectrum antibiotics,” she says. “The important thing is that you send the appropriate cultures before so that you know what you’re treating and you can optimize those antibiotics with daily assessments.”
It’s clear why an overreliance on broad-spectrum drugs prevails in U.S. health settings, Dr. Cohen acknowledges. Recent literature suggests treating critically ill patients with wide-ranging antimicrobials as the mortality rate can be twice as high with narrower options. “I think people have gotten very quick to give broad-spectrum therapy,” he says.
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Knocking Out Clostridium Difficile
Here are the guidelines on treatment of C. diff infections (CDI) as recommended by the Infectious Diseases Society of America:
First steps:
- Discontinue therapy with the inciting antimicrobial agent(s) as soon as possible as this may influence the risk of CDI recurrence.
- When severe or complicated CDI is suspected, initiate empirical treatment as soon as the diagnosis is suspected.
- If the stool toxin assay result is negative, the decision to initiate, stop, or continue treatment must be individualized.
- If possible, avoid use of antiperistaltic agents as they may obscure symptoms and precipitate toxic megacolon.
Treatment of initial episode:
- Metronidazole is the drug of choice for the initial episode of mild to moderate CDI. The dosage is 500 mg orally three times per day for 10 to 14 days.
- Vancomycin is the drug of choice for an initial episode of severe CDI. The dosage is 125 mg orally four times per day for 10 to 14 days.
- Vancomycin administered orally (and per rectum if ileus is present) with or without intravenously administered metronidazole is the regimen of choice for the treatment of severe complicated CDI. The vancomycin dosage is 500 mg orally four times per day and 500 mg in approximately 100 mL normal saline per rectum every six hours as a retention enema, and the metronidazole dosage is 500 mg intravenously every eight hours.
Severely ill patients:
Consider colectomy for severely ill patients. Monitoring the serum lactate level and the peripheral blood white blood cell count may be helpful in prompting a decision to operate because a serum lactate level rising to 5 mmol/L and a white blood cell count rising to 50,000 cells per mL have been associated with greatly increased perioperative mortality. If surgical management is necessary, perform subtotal colectomy with preservation of the rectum.
Treatment of recurrences:
- Treatment of the first recurrence of CDI is usually with the same regimen as for the initial episode but should be stratified by disease severity (mild-to-moderate, severe, or severe complicated) as is recommended for treatment of the initial CDI episode.
- Do not use metronidazole beyond the first recurrence of CDI or for long-term chronic therapy because of potential for cumulative neurotoxicity.
- Treatment of the second or later recurrence of CDI with vancomycin therapy using a tapered and/or pulse regimen is the preferred next strategy.
Probiotics:
Administration of currently available probiotics is not recommended to prevent primary CDI as there are limited data to support this approach and there is a potential risk of bloodstream infection.
Source: Cohen SH, Gerding DH, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology. 2010;31(5):431–455.
National Response, Localized Attention
Dr. Kavanagh of Health Watch USA says that more information about C. diff is needed, particularly publicly available numbers of infections at hospitals. Some states require those figures to be reported, but most don’t. And there is no current federal mandate on reporting of C. diff cases, although acute-care hospitals will be required to report C. diff infection rates starting in 2013.
“We really have scant data,” he says. “There is not a lot of reporting if you look at the nation on a whole. And I think that underscores one of the reasons why you need to have data for action. You need to have reporting of these organisms to the National Healthcare Safety Network so that the CDC can monitor and can make plans and can do effective interventions.
“You want to know where the areas of highest infection are,” he adds. “You want to know what interventions work and don’t work. If you don’t have a national coordinated reporting system, it really makes it difficult to address the problem. C. diff is going to be much harder to control than MRSA or other bacteria because it changes into a hard-to-kill dormant spore stage and then re-occurs at some point.”
The Centers for Medicare & Medicaid Services (CMS) has proposed adding C. diff infections to the list of hospital-acquired conditions that will not be reimbursable. It is widely hoped that such a measure will go a long way toward stamping out the problem.
Dr. Kobaidze of Emory notes that C. diff is a dynamic problem, always adapting and posing new challenges. And hospitalists should be more involved in answering these questions through research. One recent question, she points out, is whether proton pump inhibitor use is related to the rise of C. diff.
Ultimately, though, controlling C. diff in hospitals might come down to what is done day to day inside the hospital. And hospitalists can play a big role.
Danielle Scheurer, MD, MSCR, SFHM, a hospitalist and medical director of quality at the Medical University of South Carolina in Charleston, says that a full-time pharmacist on the hospital’s antimicrobial stewardship committee is always reviewing antibiotic prescriptions and is prepared to flag cases in which a broad-spectrum is used when one with a more narrow scope might be more appropriate.
The hospital has done its best, as part of its “renovation cycle,” to standardize the layouts of rooms “so that the second you open the door you know exactly where the alcohol gel is and where the soap and the sink is going to be.” The idea is to make compliance as “mindless” as possible. Such efforts can be hampered by structural limitations though, she says.
HM group leaders, she suggests, can play an important part simply by being good role models—gowning and gloving without complaint before entering high-risk rooms and reinforcing the message that such efforts have real effects on patient safety.
But she also acknowledges that “it always sounds easy....There has to be some level of redundancy built into the hospital system. This is more of a system thing than the individual hospitalist.”
One level of redundancy at MUSC that has been particularly effective, she says, are “secret shoppers” who keep an eye out for medical teams that might not be washing their hands as they go in and out of high-risk rooms. Each unit is responsible for their hand hygiene numbers—which include both self-reported figures and those obtained by the secret onlookers—and those numbers are made available to the hospital.
Those units with the best numbers are sometimes given a reward, such as a pizza party, but it’s colleagues’ knowledge of the numbers that matters most, she says.
“That, in and of itself, is a powerful motivator,” Dr. Scheurer says. “We bring it to all of our quality operations meetings, all the administrators, the CEO, the CMO. It’s very motivating for every unit. They don’t want to be the trailing unit.”
Tom Collins is a freelance medical writer based in Miami.
References
- Orenstein R, Aronhalt KC, McManus JE Jr., Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-1139.
- Stevens V, Dumyati G, Fine LS, Fisher SG, van Wijngaarden E. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis. 2011;53(1):42-48.
What Hospitalists Can Do
Here are suggestions, as provided by ID experts and hospitalist leaders, on what hospitalists can do to battle C. diff infections:
Short-term steps:
- Wash hands before entering and upon leaving rooms occupied by patients with C. diff infections and those strongly suspected of having C. diff infections.
- Continue using alcohol-based hand sanitizers in addition to hand washing to prevent other types of outbreaks.
- Ensure that infected patients, and those suspected of being infected, are isolated, possibly even for 48 hours after diarrhea resolves, as research shows the patients can still transmit the spores.
- In units with high C. diff rates, consider universal gloving, not just for patients with known infection.
- Use more highly sensitive tests, such as polymerase chain reaction, or PCR, rather than enzyme immunoassays to more efficiently identify affected patients.
- Avoid testing patients with formed stools.
- Ensure that rooms of infected patients and patients strongly suspected of being infected are cleaned with a hypochlorite solution.
- Taper the use of broad-spectrum antibiotics in non-C. diff patients after test results are obtained.
- Encourage patients to question their healthcare practitioners about hand hygiene and use of antibiotics.
Long-term steps:
- Be involved with your hospital’s antimicrobial stewardship program.
- Conduct research into C. diff to explore its causes and treatments.
- Be a good role model for the rest of your group, emphasizing good practices and a strong patient-safety message.
Is a Post-Discharge Clinic in Your Hospital's Future?
The hospitalist concept was established on the foundation of timely, informative handoffs to primary-care physicians (PCPs) once a patient’s hospital stay is complete. With sicker patients and shorter hospital stays, pending test results, and complex post-discharge medication regimens to sort out, this handoff is crucial to successful discharges. But what if a discharged patient can’t get in to see the PCP, or has no established PCP?
Recent research on hospital readmissions by the Dartmouth Atlas Project found that only 42% of hospitalized Medicare patients had any contact with a primary-care clinician within 14 days of discharge.1 For patients with ongoing medical needs, such missed connections are a major contributor to hospital readmissions, and thus a target for hospitals and HM groups wanting to control their readmission rates before Medicare imposes reimbursement penalties starting in October 2012 (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).
One proposed solution is the post-discharge clinic, typically located on or near a hospital’s campus and staffed by hospitalists, PCPs, or advanced-practice nurses. The patient can be seen once or a few times in the post-discharge clinic to make sure that health education started in the hospital is understood and followed, and that prescriptions ordered in the hospital are being taken on schedule.
—Lauren Doctoroff, MD, hospitalist, director, post-discharge clinic, Beth Israel Deaconess Medical Center, Boston
Mark V. Williams, MD, FACP, FHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, describes hospitalist-led post-discharge clinics as “Band-Aids for an inadequate primary-care system.” What would be better, he says, is focusing on the underlying problem and working to improve post-discharge access to primary care. Dr. Williams acknowledges, however, that sometimes a patch is needed to stanch the blood flow—e.g., to better manage care transitions—while waiting on healthcare reform and medical homes to improve care coordination throughout the system.
Working in a post-discharge clinic might seem like “a stretch for many hospitalists, especially those who chose this field because they didn’t want to do outpatient medicine,” says Lauren Doctoroff, MD, a hospitalist who directs a post-discharge clinic at Beth Israel Deaconess Medical Center (BIDMC) in Boston. “But there are times when it may be appropriate for hospital-based doctors to extend their responsibility out of the hospital.”
Dr. Doctoroff also says that working in such a clinic can be practice-changing for hospitalists. “All of a sudden, you have a different view of your hospitalized patients, and you start to ask different questions while they’re in the hospital than you ever did before,” she explains.
What is a Post-Discharge Clinic?
The post-discharge clinic, also known as a transitional-care clinic or after-care clinic, is intended to bridge medical coverage between the hospital and primary care. The clinic at BIDMC is for patients affiliated with its Health Care Associates faculty practice “discharged from either our hospital or another hospital, who need care that their PCP or specialist, because of scheduling conflicts, cannot provide within the needed time frame,” Dr. Doctoroff says.
Four hospitalists from BIDMC’s large HM group were selected to staff the clinic. The hospitalists work in one-month rotations (a total of three months on service per year), and are relieved of other responsibilities during their month in clinic. They provide five half-day clinic sessions per week, with a 40-minute-per-patient visit schedule. Thirty minutes are allotted for patients referred from the hospital’s ED who did not get admitted to the hospital but need clinical follow-up.
The clinic is based in a BIDMC-affiliated primary-care practice, “which allows us to use its administrative structure and logistical support,” Dr. Doctoroff explains. “A hospital-based administrative service helps set up outpatient visits prior to discharge using computerized physician order entry and a scheduling algorhythm.” (See Figure 1) Patients who can be seen by their PCP in a timely fashion are referred to the PCP office; if not, they are scheduled in the post-discharge clinic. “That helps preserve the PCP relationship, which I think is paramount,” she says.
The first two years were spent getting the clinic established, but in the near future, BIDMC will start measuring such outcomes as access to care and quality. “But not necessarily readmission rates,” Dr. Doctoroff adds. “I know many people think of post-discharge clinics in the context of preventing readmissions, although we don’t have the data yet to fully support that. In fact, some readmissions may result from seeing a doctor. If you get a closer look at some patients after discharge and they are doing badly, they are more likely to be readmitted than if they had just stayed home.” In such cases, readmission could actually be a better outcome for the patient, she notes.
Dr. Doctoroff describes a typical user of her post-discharge clinic as a non-English-speaking patient who was discharged from the hospital with severe back pain from a herniated disk. “He came back to see me 10 days later, still barely able to walk. He hadn’t been able to fill any of the prescriptions from his hospital stay. Within two hours after I saw him, we got his meds filled and outpatient services set up,” she says. “We take care of many patients like him in the hospital with acute pain issues, whom we discharge as soon as they can walk, and later we see them limping into outpatient clinics. It makes me think differently now about how I plan their discharges.”
—Shay Martinez, MD, hospitalist, medical director, Harborview Medical Center, Seattle
Who else needs these clinics? Dr. Doctoroff suggests two ways of looking at the question.
“Even for a simple patient admitted to the hospital, that can represent a significant change in the medical picture—a sort of sentinel event. In the discharge clinic, we give them an opportunity to review the hospitalization and answer their questions,” she says. “A lot of information presented to patients in the hospital is not well heard, and the initial visit may be their first time to really talk about what happened.” For other patients with conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or poorly controlled diabetes, treatment guidelines might dictate a pattern for post-discharge follow-up—for example, medical visits in seven or 10 days.
In Seattle, Harborview Medical Center established its After Care Clinic, staffed by hospitalists and nurse practitioners, to provide transitional care for patients discharged from inpatient wards or the ED in need of follow-up, says medical director and hospitalist Shay Martinez, MD. A second priority is to see any CHF patient within 48 hours of discharge.
“We try to limit patients to a maximum of three visits in our clinic,” she says. “At that point, we help them get established in a medical home, either here in one of our primary-care clinics, or in one of the many excellent community clinics in the area.
“This model works well with our patient population. We actually try to do primary care on the inpatient side as well. Our hospitalists are specialized in that approach, given our patient population. We see a lot of immigrants, non-English speakers, people with low health literacy, and the homeless, many of whom lack primary care,” Dr. Martinez says. “We do medication reconciliation, reassessments, and follow-ups with lab tests. We also try to assess who is more likely to be a no-show, and who needs more help with scheduling follow-up appointments.”
Clinical coverage of post-discharge clinics varies by setting, staffing, and scope. If demand is low, hospitalists or ED physicians can be called off the floor to see patients who return to the clinic, or they could staff the clinic after their hospitalist shift ends. Post-discharge clinic staff whose schedules are light can flex into providing primary-care visits in the clinic. Post-discharge can also could be provided in conjunction with—or as an alternative to—physician house calls to patients’ homes. Some post-discharge clinics work with medical call centers or telephonic case managers; some even use telemedicine.
It also could be a growth opportunity for hospitalist practices. “It is an exciting potential role for hospitalists interested in doing a little outpatient care,” Dr. Martinez says. “This is also a good way to be a safety net for your safety-net hospital.”
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What Do PCPs Think? It May Be Harder than It Looks
Although some PCPs instinctively will be suspicious of a hospitalist-run post-discharge clinic, it should be possible to clearly limit the service to short-term, immediate-post-hospital encounters focused on issues related to patients unable to get timely access to primary care, according to Dr. Doctoroff.
“I think there is a diversity of opinion by PCPs,” she says. “Some doctors really believe that it interferes with the patient-doctor relationship. But after we’ve been here for a couple of years, we’ve built up credibility with many providers.”
Charles Cutler, MD, FACP, a general internist with a practice in Norristown, Pa., and a member of the ACP’s Board of Regents, says the post-discharge clinic is “a novel idea.”
“I’d be very curious to see if this really is a way to provide better and more cost-effective care,” adds Dr. Cutler, who normally retains management of his own patients when they are hospitalized but agrees that hospitals need to find a solution for lapses in care transitions.
Even so, he says, establishing an outpatient clinic presence may be more difficult than many hospitalists appreciate. “You can’t just put a doc in a room. That physician needs equipment, scheduling, and support staff,” he says. “In our small practice, we employ one person just to ensure that each patient chart is up to date. The overhead necessary to replicate a typical medical office, even one merely providing a transition of care, could be substantial.”
Dr. Cutler emphasizes such office-based challenges as billing, which is distinctly different from hospital billing, and credentialing by insurance companies.
“There are many aspects that have to be thought through. If you see the patient, you need to make yourself available for follow-up calls, because you’ve created a relationship,” he says. “I’m a believer that hospital medicine requires a degree of specialization. But so does an office practice.”
Dr. Cutler acknowledges that some PCPs will be resentful of post-discharge clinics. “But if you don’t like a hospitalist-run discharge clinic, then you have a responsibility to rearrange your schedule to accommodate patients after their hospital discharge,” he says.
Partner with Community
Tallahassee (Fla.) Memorial Hospital (TMH) in February launched a transitional-care clinic in collaboration with faculty from Florida State University, community-based health providers, and the local Capital Health Plan. Hospitalists don’t staff the clinic, but the HM group is its major source of referrals, says Dean Watson, MD, chief medical officer at TMH. Patients can be followed for up to eight weeks, during which time they get comprehensive assessments, medication review and optimization, and referral by the clinic social worker to a PCP and to available community services.
“Three years ago, we came up with the idea for a patient population we know is at high risk for readmission. Why don’t we partner with organizations in the community, form a clinic, teach students and residents, and learn together?” Dr. Watson says. “In addition to the usual patients, TMH targets those who have been readmitted to the hospital three times or more in the past year.”
The clinic, open five days a week, is staffed by a physician, nurse practitioner, telephonic nurse, and social worker, and also has a geriatric assessment clinic.
“We set up a system to identify patients through our electronic health record, and when they come to the clinic, we focus on their social environment and other non-medical issues that might cause readmissions,” he says. The clinic has a pharmacy and funds to support medications for patients without insurance. “In our first six months, we reduced emergency room visits and readmissions for these patients by 68 percent.”
One key partner, Capital Health Plan, bought and refurbished a building, and made it available for the clinic at no cost. Capital’s motivation, says Tom Glennon, a senior vice president for the plan, is its commitment to the community and to community service.
“We’re a nonprofit HMO. We’re focused on what we can do to serve the community, and we’re looking at this as a way for the hospital to have fewer costly, unreimbursed bouncebacks,” Glennon says. “That’s a win-win for all of us.”
Most of the patients who use the clinic are not members of Capital Health Plan, Glennon adds. “If we see CHP members turning up at the transitions clinic, then we have a problem—a breakdown in our case management,” he explains. “Our goal is to have our members taken care of by primary-care providers.”
Hard Data? Not So Fast
How many post-discharge clinics are in operation today is not known. Fundamental financial data, too, are limited, but some say it is unlikely a post-discharge clinic will cover operating expenses from billing revenues alone.
Thus, such clinics will require funding from the hospital, HM group, health system, or health plans, based on the benefits the clinic provides to discharged patients and the impact on 30-day readmissions (for more about the logistical challenges post-discharge clinics present, see “What Do PCPs Think?”).
Some also suggest that many of the post-discharge clinics now in operation are too new to have demonstrated financial impact or return on investment. “We have not yet been asked to show our financial viability,” Dr. Doctoroff says. “I think the clinic leadership thinks we are fulfilling other goals for now, such as creating easier access for their patients after discharge.”
Amy Boutwell, MD, MPP, a hospitalist at Newton Wellesley Hospital in Massachusetts and founder of Collaborative Healthcare Strategies, is among the post-discharge skeptics. She agrees with Dr. Williams that the post-discharge concept is more of a temporary fix to the long-term issues in primary care. “I think the idea is getting more play than actual activity out there right now,” she says. “We need to find opportunities to manage transitions within our scope today and tomorrow while strategically looking at where we want to be in five years [as hospitals and health systems].”
Dr. Boutwell says she’s experienced the frustration of trying to make follow-up appointments with physicians who don’t have any open slots for hospitalized patients awaiting discharge. “We think of follow up as physician-led, but there are alternatives and physician extenders,” she says. “It is well-documented that our healthcare system underuses home health care and other services that might be helpful. We forget how many other opportunities there are in our communities to get another clinician to touch the patient.”
Hospitalists, as key players in the healthcare system, can speak out in support of strengthening primary-care networks and building more collaborative relationships with PCPs, according to Dr. Williams. “If you’re going to set up an outpatient clinic, ideally, have it staffed by PCPs who can funnel the patients into primary-care networks. If that’s not feasible, then hospitalists should proceed with caution, since this approach begins to take them out of their scope of practice,” he says.
With 13 years of experience in urban hospital settings, Dr. Williams is familiar with the dangers unassigned patients present at discharge. “But I don’t know that we’ve yet optimized the hospital discharge process at any hospital in the United States,” he says.
That said, Dr. Williams knows his hospital in downtown Chicago is now working to establish a post-discharge clinic. It will be staffed by PCPs and will target patients who don’t have a PCP, are on Medicaid, or lack insurance.
“Where it starts to make me uncomfortable,” Dr. Williams says, “is what happens when you follow patients out into the outpatient setting?
It’s hard to do just one visit and draw the line. Yes, you may prevent a readmission, but the patient is still left with chronic illness and the need for primary care.”
Larry Beresford is a freelance writer based in Oakland, Calif.
What Does the Research Say?
Post-discharge clinic advocates acknowledge that the research documenting outcomes from such clinics is scarce. A recent study from Northwestern University looked at 12 distinct care-transitions activities and their effect on readmission rates.2 Post-discharge clinics were not studied as a separate category, although they fit into the category of physician continuity across inpatient and outpatient settings.
“There’s definitely a hole in the literature regarding post-discharge care,” says lead author Luke Hansen, MD, MHS. The authors found that “no single intervention implemented alone was regularly associated with reduced risk for 30-day rehospitalizations.”
On the other hand, Misky et al found that discharged patients who lacked timely follow-up (within four weeks of discharge) were 10 times more likely to be readmitted than those who got the follow-up.3
Medical teams from around the world, including in Canada, the United Kingdom, Israel, and Australia, are studying readmission rates and care-transitions strategies. A study by physicians at National Taiwan University Hospital in Taipei describes its integrated transitional care to address post-discharge discontinuities and prevent rehospitalizations, including telephonic monitoring, hotline counseling, and referral to a hospital-run post-discharge clinic located within a hospitalist-managed ward.4 “Patients are treated primarily by the hospitalists who are familiar with them,” in a clinic open from 8 a.m. to 9 p.m., lead author Chin-Chung Shu, MD, wrote in an email. The clinic sees 15 to 30 patients per month; 80% of them are discharged patients without a PCP.
“We typically see patients one or two times in 30 days and then refer them to a suitable physician,” Dr. Shu says. In his study, patients who received post-discharge transitional care, including the post-discharge clinic, had lower rates of readmission and death within 30 days, 15% compared with 25% for a control group.
References
- Goodman, DC, Fisher ES, Chang C. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries. Dartmouth Atlas website. Available at: www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf. Accessed Nov. 3, 2011.
- Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 3-day rehospitalization: A systematic review. Ann Int Med. 2011;155(8): 520-528.
- Misky GJ, Wald HL, Coleman EA. Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5(7):392-397.
- Shu CC, Hsu NC, Lin YF, et al. Integrated post-discharge transitional care in Taiwan. BMC Medicine website. Available at: www.biomedcentral.com/1741-7015/9/96. Accessed Nov. 1, 2011.
The hospitalist concept was established on the foundation of timely, informative handoffs to primary-care physicians (PCPs) once a patient’s hospital stay is complete. With sicker patients and shorter hospital stays, pending test results, and complex post-discharge medication regimens to sort out, this handoff is crucial to successful discharges. But what if a discharged patient can’t get in to see the PCP, or has no established PCP?
Recent research on hospital readmissions by the Dartmouth Atlas Project found that only 42% of hospitalized Medicare patients had any contact with a primary-care clinician within 14 days of discharge.1 For patients with ongoing medical needs, such missed connections are a major contributor to hospital readmissions, and thus a target for hospitals and HM groups wanting to control their readmission rates before Medicare imposes reimbursement penalties starting in October 2012 (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).
One proposed solution is the post-discharge clinic, typically located on or near a hospital’s campus and staffed by hospitalists, PCPs, or advanced-practice nurses. The patient can be seen once or a few times in the post-discharge clinic to make sure that health education started in the hospital is understood and followed, and that prescriptions ordered in the hospital are being taken on schedule.
—Lauren Doctoroff, MD, hospitalist, director, post-discharge clinic, Beth Israel Deaconess Medical Center, Boston
Mark V. Williams, MD, FACP, FHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, describes hospitalist-led post-discharge clinics as “Band-Aids for an inadequate primary-care system.” What would be better, he says, is focusing on the underlying problem and working to improve post-discharge access to primary care. Dr. Williams acknowledges, however, that sometimes a patch is needed to stanch the blood flow—e.g., to better manage care transitions—while waiting on healthcare reform and medical homes to improve care coordination throughout the system.
Working in a post-discharge clinic might seem like “a stretch for many hospitalists, especially those who chose this field because they didn’t want to do outpatient medicine,” says Lauren Doctoroff, MD, a hospitalist who directs a post-discharge clinic at Beth Israel Deaconess Medical Center (BIDMC) in Boston. “But there are times when it may be appropriate for hospital-based doctors to extend their responsibility out of the hospital.”
Dr. Doctoroff also says that working in such a clinic can be practice-changing for hospitalists. “All of a sudden, you have a different view of your hospitalized patients, and you start to ask different questions while they’re in the hospital than you ever did before,” she explains.
What is a Post-Discharge Clinic?
The post-discharge clinic, also known as a transitional-care clinic or after-care clinic, is intended to bridge medical coverage between the hospital and primary care. The clinic at BIDMC is for patients affiliated with its Health Care Associates faculty practice “discharged from either our hospital or another hospital, who need care that their PCP or specialist, because of scheduling conflicts, cannot provide within the needed time frame,” Dr. Doctoroff says.
Four hospitalists from BIDMC’s large HM group were selected to staff the clinic. The hospitalists work in one-month rotations (a total of three months on service per year), and are relieved of other responsibilities during their month in clinic. They provide five half-day clinic sessions per week, with a 40-minute-per-patient visit schedule. Thirty minutes are allotted for patients referred from the hospital’s ED who did not get admitted to the hospital but need clinical follow-up.
The clinic is based in a BIDMC-affiliated primary-care practice, “which allows us to use its administrative structure and logistical support,” Dr. Doctoroff explains. “A hospital-based administrative service helps set up outpatient visits prior to discharge using computerized physician order entry and a scheduling algorhythm.” (See Figure 1) Patients who can be seen by their PCP in a timely fashion are referred to the PCP office; if not, they are scheduled in the post-discharge clinic. “That helps preserve the PCP relationship, which I think is paramount,” she says.
The first two years were spent getting the clinic established, but in the near future, BIDMC will start measuring such outcomes as access to care and quality. “But not necessarily readmission rates,” Dr. Doctoroff adds. “I know many people think of post-discharge clinics in the context of preventing readmissions, although we don’t have the data yet to fully support that. In fact, some readmissions may result from seeing a doctor. If you get a closer look at some patients after discharge and they are doing badly, they are more likely to be readmitted than if they had just stayed home.” In such cases, readmission could actually be a better outcome for the patient, she notes.
Dr. Doctoroff describes a typical user of her post-discharge clinic as a non-English-speaking patient who was discharged from the hospital with severe back pain from a herniated disk. “He came back to see me 10 days later, still barely able to walk. He hadn’t been able to fill any of the prescriptions from his hospital stay. Within two hours after I saw him, we got his meds filled and outpatient services set up,” she says. “We take care of many patients like him in the hospital with acute pain issues, whom we discharge as soon as they can walk, and later we see them limping into outpatient clinics. It makes me think differently now about how I plan their discharges.”
—Shay Martinez, MD, hospitalist, medical director, Harborview Medical Center, Seattle
Who else needs these clinics? Dr. Doctoroff suggests two ways of looking at the question.
“Even for a simple patient admitted to the hospital, that can represent a significant change in the medical picture—a sort of sentinel event. In the discharge clinic, we give them an opportunity to review the hospitalization and answer their questions,” she says. “A lot of information presented to patients in the hospital is not well heard, and the initial visit may be their first time to really talk about what happened.” For other patients with conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or poorly controlled diabetes, treatment guidelines might dictate a pattern for post-discharge follow-up—for example, medical visits in seven or 10 days.
In Seattle, Harborview Medical Center established its After Care Clinic, staffed by hospitalists and nurse practitioners, to provide transitional care for patients discharged from inpatient wards or the ED in need of follow-up, says medical director and hospitalist Shay Martinez, MD. A second priority is to see any CHF patient within 48 hours of discharge.
“We try to limit patients to a maximum of three visits in our clinic,” she says. “At that point, we help them get established in a medical home, either here in one of our primary-care clinics, or in one of the many excellent community clinics in the area.
“This model works well with our patient population. We actually try to do primary care on the inpatient side as well. Our hospitalists are specialized in that approach, given our patient population. We see a lot of immigrants, non-English speakers, people with low health literacy, and the homeless, many of whom lack primary care,” Dr. Martinez says. “We do medication reconciliation, reassessments, and follow-ups with lab tests. We also try to assess who is more likely to be a no-show, and who needs more help with scheduling follow-up appointments.”
Clinical coverage of post-discharge clinics varies by setting, staffing, and scope. If demand is low, hospitalists or ED physicians can be called off the floor to see patients who return to the clinic, or they could staff the clinic after their hospitalist shift ends. Post-discharge clinic staff whose schedules are light can flex into providing primary-care visits in the clinic. Post-discharge can also could be provided in conjunction with—or as an alternative to—physician house calls to patients’ homes. Some post-discharge clinics work with medical call centers or telephonic case managers; some even use telemedicine.
It also could be a growth opportunity for hospitalist practices. “It is an exciting potential role for hospitalists interested in doing a little outpatient care,” Dr. Martinez says. “This is also a good way to be a safety net for your safety-net hospital.”
continued below...
What Do PCPs Think? It May Be Harder than It Looks
Although some PCPs instinctively will be suspicious of a hospitalist-run post-discharge clinic, it should be possible to clearly limit the service to short-term, immediate-post-hospital encounters focused on issues related to patients unable to get timely access to primary care, according to Dr. Doctoroff.
“I think there is a diversity of opinion by PCPs,” she says. “Some doctors really believe that it interferes with the patient-doctor relationship. But after we’ve been here for a couple of years, we’ve built up credibility with many providers.”
Charles Cutler, MD, FACP, a general internist with a practice in Norristown, Pa., and a member of the ACP’s Board of Regents, says the post-discharge clinic is “a novel idea.”
“I’d be very curious to see if this really is a way to provide better and more cost-effective care,” adds Dr. Cutler, who normally retains management of his own patients when they are hospitalized but agrees that hospitals need to find a solution for lapses in care transitions.
Even so, he says, establishing an outpatient clinic presence may be more difficult than many hospitalists appreciate. “You can’t just put a doc in a room. That physician needs equipment, scheduling, and support staff,” he says. “In our small practice, we employ one person just to ensure that each patient chart is up to date. The overhead necessary to replicate a typical medical office, even one merely providing a transition of care, could be substantial.”
Dr. Cutler emphasizes such office-based challenges as billing, which is distinctly different from hospital billing, and credentialing by insurance companies.
“There are many aspects that have to be thought through. If you see the patient, you need to make yourself available for follow-up calls, because you’ve created a relationship,” he says. “I’m a believer that hospital medicine requires a degree of specialization. But so does an office practice.”
Dr. Cutler acknowledges that some PCPs will be resentful of post-discharge clinics. “But if you don’t like a hospitalist-run discharge clinic, then you have a responsibility to rearrange your schedule to accommodate patients after their hospital discharge,” he says.
Partner with Community
Tallahassee (Fla.) Memorial Hospital (TMH) in February launched a transitional-care clinic in collaboration with faculty from Florida State University, community-based health providers, and the local Capital Health Plan. Hospitalists don’t staff the clinic, but the HM group is its major source of referrals, says Dean Watson, MD, chief medical officer at TMH. Patients can be followed for up to eight weeks, during which time they get comprehensive assessments, medication review and optimization, and referral by the clinic social worker to a PCP and to available community services.
“Three years ago, we came up with the idea for a patient population we know is at high risk for readmission. Why don’t we partner with organizations in the community, form a clinic, teach students and residents, and learn together?” Dr. Watson says. “In addition to the usual patients, TMH targets those who have been readmitted to the hospital three times or more in the past year.”
The clinic, open five days a week, is staffed by a physician, nurse practitioner, telephonic nurse, and social worker, and also has a geriatric assessment clinic.
“We set up a system to identify patients through our electronic health record, and when they come to the clinic, we focus on their social environment and other non-medical issues that might cause readmissions,” he says. The clinic has a pharmacy and funds to support medications for patients without insurance. “In our first six months, we reduced emergency room visits and readmissions for these patients by 68 percent.”
One key partner, Capital Health Plan, bought and refurbished a building, and made it available for the clinic at no cost. Capital’s motivation, says Tom Glennon, a senior vice president for the plan, is its commitment to the community and to community service.
“We’re a nonprofit HMO. We’re focused on what we can do to serve the community, and we’re looking at this as a way for the hospital to have fewer costly, unreimbursed bouncebacks,” Glennon says. “That’s a win-win for all of us.”
Most of the patients who use the clinic are not members of Capital Health Plan, Glennon adds. “If we see CHP members turning up at the transitions clinic, then we have a problem—a breakdown in our case management,” he explains. “Our goal is to have our members taken care of by primary-care providers.”
Hard Data? Not So Fast
How many post-discharge clinics are in operation today is not known. Fundamental financial data, too, are limited, but some say it is unlikely a post-discharge clinic will cover operating expenses from billing revenues alone.
Thus, such clinics will require funding from the hospital, HM group, health system, or health plans, based on the benefits the clinic provides to discharged patients and the impact on 30-day readmissions (for more about the logistical challenges post-discharge clinics present, see “What Do PCPs Think?”).
Some also suggest that many of the post-discharge clinics now in operation are too new to have demonstrated financial impact or return on investment. “We have not yet been asked to show our financial viability,” Dr. Doctoroff says. “I think the clinic leadership thinks we are fulfilling other goals for now, such as creating easier access for their patients after discharge.”
Amy Boutwell, MD, MPP, a hospitalist at Newton Wellesley Hospital in Massachusetts and founder of Collaborative Healthcare Strategies, is among the post-discharge skeptics. She agrees with Dr. Williams that the post-discharge concept is more of a temporary fix to the long-term issues in primary care. “I think the idea is getting more play than actual activity out there right now,” she says. “We need to find opportunities to manage transitions within our scope today and tomorrow while strategically looking at where we want to be in five years [as hospitals and health systems].”
Dr. Boutwell says she’s experienced the frustration of trying to make follow-up appointments with physicians who don’t have any open slots for hospitalized patients awaiting discharge. “We think of follow up as physician-led, but there are alternatives and physician extenders,” she says. “It is well-documented that our healthcare system underuses home health care and other services that might be helpful. We forget how many other opportunities there are in our communities to get another clinician to touch the patient.”
Hospitalists, as key players in the healthcare system, can speak out in support of strengthening primary-care networks and building more collaborative relationships with PCPs, according to Dr. Williams. “If you’re going to set up an outpatient clinic, ideally, have it staffed by PCPs who can funnel the patients into primary-care networks. If that’s not feasible, then hospitalists should proceed with caution, since this approach begins to take them out of their scope of practice,” he says.
With 13 years of experience in urban hospital settings, Dr. Williams is familiar with the dangers unassigned patients present at discharge. “But I don’t know that we’ve yet optimized the hospital discharge process at any hospital in the United States,” he says.
That said, Dr. Williams knows his hospital in downtown Chicago is now working to establish a post-discharge clinic. It will be staffed by PCPs and will target patients who don’t have a PCP, are on Medicaid, or lack insurance.
“Where it starts to make me uncomfortable,” Dr. Williams says, “is what happens when you follow patients out into the outpatient setting?
It’s hard to do just one visit and draw the line. Yes, you may prevent a readmission, but the patient is still left with chronic illness and the need for primary care.”
Larry Beresford is a freelance writer based in Oakland, Calif.
What Does the Research Say?
Post-discharge clinic advocates acknowledge that the research documenting outcomes from such clinics is scarce. A recent study from Northwestern University looked at 12 distinct care-transitions activities and their effect on readmission rates.2 Post-discharge clinics were not studied as a separate category, although they fit into the category of physician continuity across inpatient and outpatient settings.
“There’s definitely a hole in the literature regarding post-discharge care,” says lead author Luke Hansen, MD, MHS. The authors found that “no single intervention implemented alone was regularly associated with reduced risk for 30-day rehospitalizations.”
On the other hand, Misky et al found that discharged patients who lacked timely follow-up (within four weeks of discharge) were 10 times more likely to be readmitted than those who got the follow-up.3
Medical teams from around the world, including in Canada, the United Kingdom, Israel, and Australia, are studying readmission rates and care-transitions strategies. A study by physicians at National Taiwan University Hospital in Taipei describes its integrated transitional care to address post-discharge discontinuities and prevent rehospitalizations, including telephonic monitoring, hotline counseling, and referral to a hospital-run post-discharge clinic located within a hospitalist-managed ward.4 “Patients are treated primarily by the hospitalists who are familiar with them,” in a clinic open from 8 a.m. to 9 p.m., lead author Chin-Chung Shu, MD, wrote in an email. The clinic sees 15 to 30 patients per month; 80% of them are discharged patients without a PCP.
“We typically see patients one or two times in 30 days and then refer them to a suitable physician,” Dr. Shu says. In his study, patients who received post-discharge transitional care, including the post-discharge clinic, had lower rates of readmission and death within 30 days, 15% compared with 25% for a control group.
References
- Goodman, DC, Fisher ES, Chang C. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries. Dartmouth Atlas website. Available at: www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf. Accessed Nov. 3, 2011.
- Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 3-day rehospitalization: A systematic review. Ann Int Med. 2011;155(8): 520-528.
- Misky GJ, Wald HL, Coleman EA. Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5(7):392-397.
- Shu CC, Hsu NC, Lin YF, et al. Integrated post-discharge transitional care in Taiwan. BMC Medicine website. Available at: www.biomedcentral.com/1741-7015/9/96. Accessed Nov. 1, 2011.
The hospitalist concept was established on the foundation of timely, informative handoffs to primary-care physicians (PCPs) once a patient’s hospital stay is complete. With sicker patients and shorter hospital stays, pending test results, and complex post-discharge medication regimens to sort out, this handoff is crucial to successful discharges. But what if a discharged patient can’t get in to see the PCP, or has no established PCP?
Recent research on hospital readmissions by the Dartmouth Atlas Project found that only 42% of hospitalized Medicare patients had any contact with a primary-care clinician within 14 days of discharge.1 For patients with ongoing medical needs, such missed connections are a major contributor to hospital readmissions, and thus a target for hospitals and HM groups wanting to control their readmission rates before Medicare imposes reimbursement penalties starting in October 2012 (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).
One proposed solution is the post-discharge clinic, typically located on or near a hospital’s campus and staffed by hospitalists, PCPs, or advanced-practice nurses. The patient can be seen once or a few times in the post-discharge clinic to make sure that health education started in the hospital is understood and followed, and that prescriptions ordered in the hospital are being taken on schedule.
—Lauren Doctoroff, MD, hospitalist, director, post-discharge clinic, Beth Israel Deaconess Medical Center, Boston
Mark V. Williams, MD, FACP, FHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, describes hospitalist-led post-discharge clinics as “Band-Aids for an inadequate primary-care system.” What would be better, he says, is focusing on the underlying problem and working to improve post-discharge access to primary care. Dr. Williams acknowledges, however, that sometimes a patch is needed to stanch the blood flow—e.g., to better manage care transitions—while waiting on healthcare reform and medical homes to improve care coordination throughout the system.
Working in a post-discharge clinic might seem like “a stretch for many hospitalists, especially those who chose this field because they didn’t want to do outpatient medicine,” says Lauren Doctoroff, MD, a hospitalist who directs a post-discharge clinic at Beth Israel Deaconess Medical Center (BIDMC) in Boston. “But there are times when it may be appropriate for hospital-based doctors to extend their responsibility out of the hospital.”
Dr. Doctoroff also says that working in such a clinic can be practice-changing for hospitalists. “All of a sudden, you have a different view of your hospitalized patients, and you start to ask different questions while they’re in the hospital than you ever did before,” she explains.
What is a Post-Discharge Clinic?
The post-discharge clinic, also known as a transitional-care clinic or after-care clinic, is intended to bridge medical coverage between the hospital and primary care. The clinic at BIDMC is for patients affiliated with its Health Care Associates faculty practice “discharged from either our hospital or another hospital, who need care that their PCP or specialist, because of scheduling conflicts, cannot provide within the needed time frame,” Dr. Doctoroff says.
Four hospitalists from BIDMC’s large HM group were selected to staff the clinic. The hospitalists work in one-month rotations (a total of three months on service per year), and are relieved of other responsibilities during their month in clinic. They provide five half-day clinic sessions per week, with a 40-minute-per-patient visit schedule. Thirty minutes are allotted for patients referred from the hospital’s ED who did not get admitted to the hospital but need clinical follow-up.
The clinic is based in a BIDMC-affiliated primary-care practice, “which allows us to use its administrative structure and logistical support,” Dr. Doctoroff explains. “A hospital-based administrative service helps set up outpatient visits prior to discharge using computerized physician order entry and a scheduling algorhythm.” (See Figure 1) Patients who can be seen by their PCP in a timely fashion are referred to the PCP office; if not, they are scheduled in the post-discharge clinic. “That helps preserve the PCP relationship, which I think is paramount,” she says.
The first two years were spent getting the clinic established, but in the near future, BIDMC will start measuring such outcomes as access to care and quality. “But not necessarily readmission rates,” Dr. Doctoroff adds. “I know many people think of post-discharge clinics in the context of preventing readmissions, although we don’t have the data yet to fully support that. In fact, some readmissions may result from seeing a doctor. If you get a closer look at some patients after discharge and they are doing badly, they are more likely to be readmitted than if they had just stayed home.” In such cases, readmission could actually be a better outcome for the patient, she notes.
Dr. Doctoroff describes a typical user of her post-discharge clinic as a non-English-speaking patient who was discharged from the hospital with severe back pain from a herniated disk. “He came back to see me 10 days later, still barely able to walk. He hadn’t been able to fill any of the prescriptions from his hospital stay. Within two hours after I saw him, we got his meds filled and outpatient services set up,” she says. “We take care of many patients like him in the hospital with acute pain issues, whom we discharge as soon as they can walk, and later we see them limping into outpatient clinics. It makes me think differently now about how I plan their discharges.”
—Shay Martinez, MD, hospitalist, medical director, Harborview Medical Center, Seattle
Who else needs these clinics? Dr. Doctoroff suggests two ways of looking at the question.
“Even for a simple patient admitted to the hospital, that can represent a significant change in the medical picture—a sort of sentinel event. In the discharge clinic, we give them an opportunity to review the hospitalization and answer their questions,” she says. “A lot of information presented to patients in the hospital is not well heard, and the initial visit may be their first time to really talk about what happened.” For other patients with conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or poorly controlled diabetes, treatment guidelines might dictate a pattern for post-discharge follow-up—for example, medical visits in seven or 10 days.
In Seattle, Harborview Medical Center established its After Care Clinic, staffed by hospitalists and nurse practitioners, to provide transitional care for patients discharged from inpatient wards or the ED in need of follow-up, says medical director and hospitalist Shay Martinez, MD. A second priority is to see any CHF patient within 48 hours of discharge.
“We try to limit patients to a maximum of three visits in our clinic,” she says. “At that point, we help them get established in a medical home, either here in one of our primary-care clinics, or in one of the many excellent community clinics in the area.
“This model works well with our patient population. We actually try to do primary care on the inpatient side as well. Our hospitalists are specialized in that approach, given our patient population. We see a lot of immigrants, non-English speakers, people with low health literacy, and the homeless, many of whom lack primary care,” Dr. Martinez says. “We do medication reconciliation, reassessments, and follow-ups with lab tests. We also try to assess who is more likely to be a no-show, and who needs more help with scheduling follow-up appointments.”
Clinical coverage of post-discharge clinics varies by setting, staffing, and scope. If demand is low, hospitalists or ED physicians can be called off the floor to see patients who return to the clinic, or they could staff the clinic after their hospitalist shift ends. Post-discharge clinic staff whose schedules are light can flex into providing primary-care visits in the clinic. Post-discharge can also could be provided in conjunction with—or as an alternative to—physician house calls to patients’ homes. Some post-discharge clinics work with medical call centers or telephonic case managers; some even use telemedicine.
It also could be a growth opportunity for hospitalist practices. “It is an exciting potential role for hospitalists interested in doing a little outpatient care,” Dr. Martinez says. “This is also a good way to be a safety net for your safety-net hospital.”
continued below...
What Do PCPs Think? It May Be Harder than It Looks
Although some PCPs instinctively will be suspicious of a hospitalist-run post-discharge clinic, it should be possible to clearly limit the service to short-term, immediate-post-hospital encounters focused on issues related to patients unable to get timely access to primary care, according to Dr. Doctoroff.
“I think there is a diversity of opinion by PCPs,” she says. “Some doctors really believe that it interferes with the patient-doctor relationship. But after we’ve been here for a couple of years, we’ve built up credibility with many providers.”
Charles Cutler, MD, FACP, a general internist with a practice in Norristown, Pa., and a member of the ACP’s Board of Regents, says the post-discharge clinic is “a novel idea.”
“I’d be very curious to see if this really is a way to provide better and more cost-effective care,” adds Dr. Cutler, who normally retains management of his own patients when they are hospitalized but agrees that hospitals need to find a solution for lapses in care transitions.
Even so, he says, establishing an outpatient clinic presence may be more difficult than many hospitalists appreciate. “You can’t just put a doc in a room. That physician needs equipment, scheduling, and support staff,” he says. “In our small practice, we employ one person just to ensure that each patient chart is up to date. The overhead necessary to replicate a typical medical office, even one merely providing a transition of care, could be substantial.”
Dr. Cutler emphasizes such office-based challenges as billing, which is distinctly different from hospital billing, and credentialing by insurance companies.
“There are many aspects that have to be thought through. If you see the patient, you need to make yourself available for follow-up calls, because you’ve created a relationship,” he says. “I’m a believer that hospital medicine requires a degree of specialization. But so does an office practice.”
Dr. Cutler acknowledges that some PCPs will be resentful of post-discharge clinics. “But if you don’t like a hospitalist-run discharge clinic, then you have a responsibility to rearrange your schedule to accommodate patients after their hospital discharge,” he says.
Partner with Community
Tallahassee (Fla.) Memorial Hospital (TMH) in February launched a transitional-care clinic in collaboration with faculty from Florida State University, community-based health providers, and the local Capital Health Plan. Hospitalists don’t staff the clinic, but the HM group is its major source of referrals, says Dean Watson, MD, chief medical officer at TMH. Patients can be followed for up to eight weeks, during which time they get comprehensive assessments, medication review and optimization, and referral by the clinic social worker to a PCP and to available community services.
“Three years ago, we came up with the idea for a patient population we know is at high risk for readmission. Why don’t we partner with organizations in the community, form a clinic, teach students and residents, and learn together?” Dr. Watson says. “In addition to the usual patients, TMH targets those who have been readmitted to the hospital three times or more in the past year.”
The clinic, open five days a week, is staffed by a physician, nurse practitioner, telephonic nurse, and social worker, and also has a geriatric assessment clinic.
“We set up a system to identify patients through our electronic health record, and when they come to the clinic, we focus on their social environment and other non-medical issues that might cause readmissions,” he says. The clinic has a pharmacy and funds to support medications for patients without insurance. “In our first six months, we reduced emergency room visits and readmissions for these patients by 68 percent.”
One key partner, Capital Health Plan, bought and refurbished a building, and made it available for the clinic at no cost. Capital’s motivation, says Tom Glennon, a senior vice president for the plan, is its commitment to the community and to community service.
“We’re a nonprofit HMO. We’re focused on what we can do to serve the community, and we’re looking at this as a way for the hospital to have fewer costly, unreimbursed bouncebacks,” Glennon says. “That’s a win-win for all of us.”
Most of the patients who use the clinic are not members of Capital Health Plan, Glennon adds. “If we see CHP members turning up at the transitions clinic, then we have a problem—a breakdown in our case management,” he explains. “Our goal is to have our members taken care of by primary-care providers.”
Hard Data? Not So Fast
How many post-discharge clinics are in operation today is not known. Fundamental financial data, too, are limited, but some say it is unlikely a post-discharge clinic will cover operating expenses from billing revenues alone.
Thus, such clinics will require funding from the hospital, HM group, health system, or health plans, based on the benefits the clinic provides to discharged patients and the impact on 30-day readmissions (for more about the logistical challenges post-discharge clinics present, see “What Do PCPs Think?”).
Some also suggest that many of the post-discharge clinics now in operation are too new to have demonstrated financial impact or return on investment. “We have not yet been asked to show our financial viability,” Dr. Doctoroff says. “I think the clinic leadership thinks we are fulfilling other goals for now, such as creating easier access for their patients after discharge.”
Amy Boutwell, MD, MPP, a hospitalist at Newton Wellesley Hospital in Massachusetts and founder of Collaborative Healthcare Strategies, is among the post-discharge skeptics. She agrees with Dr. Williams that the post-discharge concept is more of a temporary fix to the long-term issues in primary care. “I think the idea is getting more play than actual activity out there right now,” she says. “We need to find opportunities to manage transitions within our scope today and tomorrow while strategically looking at where we want to be in five years [as hospitals and health systems].”
Dr. Boutwell says she’s experienced the frustration of trying to make follow-up appointments with physicians who don’t have any open slots for hospitalized patients awaiting discharge. “We think of follow up as physician-led, but there are alternatives and physician extenders,” she says. “It is well-documented that our healthcare system underuses home health care and other services that might be helpful. We forget how many other opportunities there are in our communities to get another clinician to touch the patient.”
Hospitalists, as key players in the healthcare system, can speak out in support of strengthening primary-care networks and building more collaborative relationships with PCPs, according to Dr. Williams. “If you’re going to set up an outpatient clinic, ideally, have it staffed by PCPs who can funnel the patients into primary-care networks. If that’s not feasible, then hospitalists should proceed with caution, since this approach begins to take them out of their scope of practice,” he says.
With 13 years of experience in urban hospital settings, Dr. Williams is familiar with the dangers unassigned patients present at discharge. “But I don’t know that we’ve yet optimized the hospital discharge process at any hospital in the United States,” he says.
That said, Dr. Williams knows his hospital in downtown Chicago is now working to establish a post-discharge clinic. It will be staffed by PCPs and will target patients who don’t have a PCP, are on Medicaid, or lack insurance.
“Where it starts to make me uncomfortable,” Dr. Williams says, “is what happens when you follow patients out into the outpatient setting?
It’s hard to do just one visit and draw the line. Yes, you may prevent a readmission, but the patient is still left with chronic illness and the need for primary care.”
Larry Beresford is a freelance writer based in Oakland, Calif.
What Does the Research Say?
Post-discharge clinic advocates acknowledge that the research documenting outcomes from such clinics is scarce. A recent study from Northwestern University looked at 12 distinct care-transitions activities and their effect on readmission rates.2 Post-discharge clinics were not studied as a separate category, although they fit into the category of physician continuity across inpatient and outpatient settings.
“There’s definitely a hole in the literature regarding post-discharge care,” says lead author Luke Hansen, MD, MHS. The authors found that “no single intervention implemented alone was regularly associated with reduced risk for 30-day rehospitalizations.”
On the other hand, Misky et al found that discharged patients who lacked timely follow-up (within four weeks of discharge) were 10 times more likely to be readmitted than those who got the follow-up.3
Medical teams from around the world, including in Canada, the United Kingdom, Israel, and Australia, are studying readmission rates and care-transitions strategies. A study by physicians at National Taiwan University Hospital in Taipei describes its integrated transitional care to address post-discharge discontinuities and prevent rehospitalizations, including telephonic monitoring, hotline counseling, and referral to a hospital-run post-discharge clinic located within a hospitalist-managed ward.4 “Patients are treated primarily by the hospitalists who are familiar with them,” in a clinic open from 8 a.m. to 9 p.m., lead author Chin-Chung Shu, MD, wrote in an email. The clinic sees 15 to 30 patients per month; 80% of them are discharged patients without a PCP.
“We typically see patients one or two times in 30 days and then refer them to a suitable physician,” Dr. Shu says. In his study, patients who received post-discharge transitional care, including the post-discharge clinic, had lower rates of readmission and death within 30 days, 15% compared with 25% for a control group.
References
- Goodman, DC, Fisher ES, Chang C. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries. Dartmouth Atlas website. Available at: www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf. Accessed Nov. 3, 2011.
- Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 3-day rehospitalization: A systematic review. Ann Int Med. 2011;155(8): 520-528.
- Misky GJ, Wald HL, Coleman EA. Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5(7):392-397.
- Shu CC, Hsu NC, Lin YF, et al. Integrated post-discharge transitional care in Taiwan. BMC Medicine website. Available at: www.biomedcentral.com/1741-7015/9/96. Accessed Nov. 1, 2011.