Alpesh Amin, MD

Hand hygiene is a proven and guideline‐recommended safety practice, although clinicians and particularly physicians are unreliable at performing it.[1] Like hands, stethoscopes can carry pathogens from patient to patient. In 1 study, stethoscopes were as likely to be contaminated after use with methicillin‐resistant Staphylococcus aureuspositive patients as the provider's hands.[2] Furthermore, like hands, stethoscopes can be effectively decolonized with alcohol.[3, 4] However, although hand hygiene rates have been extensively studied,[1] and hand hygiene has been linked to reductions in nosocomial infection,[5] stethoscope hygiene is less well studied and emphasized less by guidelines.[6] Several surveys have documented low self‐reported compliance with stethoscope hygiene.[7, 8, 9, 10] Of 150 healthcare workers, 48% reported stethoscope hygiene between daily and weekly, 37% did stethoscope hygiene monthly, and 7% did stethoscope hygiene annually or never.[8] Of 1401 doctors asked about their stethoscope hygiene beliefs and practices, 76% believed that stethoscopes could transmit infection, but only 24% reported cleaning their scopes regularly.[9] Moreover, of 308 students, 22% had never done stethoscope hygiene, and <4% did it consistently.[10] However, we were unable to find any data on observed rates of stethoscope hygiene. Thus, we observed student and trainee physician stethoscope hygiene performance during hospital medicine rotations as part of the baseline data‐collection phase of a quality‐improvement effort linked to hand hygiene efforts.

METHODS

Attending hospitalists (I.H.J., B.M., and A.A.) and 1 graduate assistant (J.W.) at 3 sites observed stethoscope hygiene opportunities over an 11‐month period. Stethoscope hygiene was counted as performed if a patient‐specific stethoscope was used in an isolation room, or if any type of cleaning (alcohol gel, alcohol wipe, or cleansing cloth) was performed on a stethoscope carried out of the room. Observers also recorded whether stethoscope hygiene opportunities occurred in isolation rooms or nonisolation rooms, and noted if stethoscope hygiene was obviously triggered by an attending's stethoscope hygiene behavior (eg, a trainee asked an attending why he performed stethoscope hygiene, then performed it him or herself). Trainees were not aware that their stethoscope hygiene behaviors were being recorded.

RESULTS

We observed 352 opportunities for stethoscope hygiene, in which doctors or students used stethoscope hygiene in 58 encounters (16%). Twenty of the 58 stethoscope hygiene events occurred only after a trainee observed an attending physician perform stethoscope hygiene. Eliminating stethoscope hygiene events that were triggered by attending physicians, stethoscope hygiene was performed in 38 of 332 opportunities (11%). There was a significant difference between the rate of stethoscope hygiene performed in isolation versus nonisolation rooms: 24/29 (82.7%) versus 14 of 303 (4.6%) (P<0.001 by Pearson ² statistic). In isolation room stethoscope hygiene, in which the type of hygiene was recorded, 18 of 20 (90%) involved use of an isolation stethoscope, and 2 of 20 (10%) involved cleaning of a personal stethoscope.

DISCUSSION

Stethoscope hygiene is rarely performed by trainees. Stethoscope hygiene performance depends on the isolation status of the patient, with more than 80% performance in isolated patients and <5% in nonisolated patients.

Although little is known about the rate of infection related to stethoscopes, colonization of stethoscopes with nosocomial bacteria is well described.[2] Transmission of pathogens from patient to patient by stethoscopes could undermine the benefits of hand hygiene programs, as patients are commonly exposed to unclean stethoscopes.

Our observations are limited by several factors. We used a convenience sample of general medicine trainee behavior at academic medical centers; the behavior of attending physicians, ancillary staff, and nonacademic physicians may be different. Moreover, attending behavior may have prompted more episodes of stethoscope hygiene performance than we recorded, because we only noted when stethoscope hygiene was clearly related to attending behavior. The very low rate of stethoscope hygiene after contact with nonisolation patients represents a current and potentially serious safety threat. Future research might be able to quantify the risk associated with uncleaned stethoscopes or demonstrate the effectiveness of stethoscope hygiene programs. The effect of modeling on hand hygiene and stethoscope hygiene[10, 11] and on stethoscope hygiene in our data suggests a method for improving stethoscope hygiene.

Hand hygiene is a proven and guideline‐recommended safety practice, although clinicians and particularly physicians are unreliable at performing it.[1] Like hands, stethoscopes can carry pathogens from patient to patient. In 1 study, stethoscopes were as likely to be contaminated after use with methicillin‐resistant Staphylococcus aureuspositive patients as the provider's hands.[2] Furthermore, like hands, stethoscopes can be effectively decolonized with alcohol.[3, 4] However, although hand hygiene rates have been extensively studied,[1] and hand hygiene has been linked to reductions in nosocomial infection,[5] stethoscope hygiene is less well studied and emphasized less by guidelines.[6] Several surveys have documented low self‐reported compliance with stethoscope hygiene.[7, 8, 9, 10] Of 150 healthcare workers, 48% reported stethoscope hygiene between daily and weekly, 37% did stethoscope hygiene monthly, and 7% did stethoscope hygiene annually or never.[8] Of 1401 doctors asked about their stethoscope hygiene beliefs and practices, 76% believed that stethoscopes could transmit infection, but only 24% reported cleaning their scopes regularly.[9] Moreover, of 308 students, 22% had never done stethoscope hygiene, and <4% did it consistently.[10] However, we were unable to find any data on observed rates of stethoscope hygiene. Thus, we observed student and trainee physician stethoscope hygiene performance during hospital medicine rotations as part of the baseline data‐collection phase of a quality‐improvement effort linked to hand hygiene efforts.

METHODS

Attending hospitalists (I.H.J., B.M., and A.A.) and 1 graduate assistant (J.W.) at 3 sites observed stethoscope hygiene opportunities over an 11‐month period. Stethoscope hygiene was counted as performed if a patient‐specific stethoscope was used in an isolation room, or if any type of cleaning (alcohol gel, alcohol wipe, or cleansing cloth) was performed on a stethoscope carried out of the room. Observers also recorded whether stethoscope hygiene opportunities occurred in isolation rooms or nonisolation rooms, and noted if stethoscope hygiene was obviously triggered by an attending's stethoscope hygiene behavior (eg, a trainee asked an attending why he performed stethoscope hygiene, then performed it him or herself). Trainees were not aware that their stethoscope hygiene behaviors were being recorded.

RESULTS

We observed 352 opportunities for stethoscope hygiene, in which doctors or students used stethoscope hygiene in 58 encounters (16%). Twenty of the 58 stethoscope hygiene events occurred only after a trainee observed an attending physician perform stethoscope hygiene. Eliminating stethoscope hygiene events that were triggered by attending physicians, stethoscope hygiene was performed in 38 of 332 opportunities (11%). There was a significant difference between the rate of stethoscope hygiene performed in isolation versus nonisolation rooms: 24/29 (82.7%) versus 14 of 303 (4.6%) (P<0.001 by Pearson ² statistic). In isolation room stethoscope hygiene, in which the type of hygiene was recorded, 18 of 20 (90%) involved use of an isolation stethoscope, and 2 of 20 (10%) involved cleaning of a personal stethoscope.

DISCUSSION

Stethoscope hygiene is rarely performed by trainees. Stethoscope hygiene performance depends on the isolation status of the patient, with more than 80% performance in isolated patients and <5% in nonisolated patients.

Although little is known about the rate of infection related to stethoscopes, colonization of stethoscopes with nosocomial bacteria is well described.[2] Transmission of pathogens from patient to patient by stethoscopes could undermine the benefits of hand hygiene programs, as patients are commonly exposed to unclean stethoscopes.

Our observations are limited by several factors. We used a convenience sample of general medicine trainee behavior at academic medical centers; the behavior of attending physicians, ancillary staff, and nonacademic physicians may be different. Moreover, attending behavior may have prompted more episodes of stethoscope hygiene performance than we recorded, because we only noted when stethoscope hygiene was clearly related to attending behavior. The very low rate of stethoscope hygiene after contact with nonisolation patients represents a current and potentially serious safety threat. Future research might be able to quantify the risk associated with uncleaned stethoscopes or demonstrate the effectiveness of stethoscope hygiene programs. The effect of modeling on hand hygiene and stethoscope hygiene[10, 11] and on stethoscope hygiene in our data suggests a method for improving stethoscope hygiene.

Hand hygiene is a proven and guideline‐recommended safety practice, although clinicians and particularly physicians are unreliable at performing it.[1] Like hands, stethoscopes can carry pathogens from patient to patient. In 1 study, stethoscopes were as likely to be contaminated after use with methicillin‐resistant Staphylococcus aureuspositive patients as the provider's hands.[2] Furthermore, like hands, stethoscopes can be effectively decolonized with alcohol.[3, 4] However, although hand hygiene rates have been extensively studied,[1] and hand hygiene has been linked to reductions in nosocomial infection,[5] stethoscope hygiene is less well studied and emphasized less by guidelines.[6] Several surveys have documented low self‐reported compliance with stethoscope hygiene.[7, 8, 9, 10] Of 150 healthcare workers, 48% reported stethoscope hygiene between daily and weekly, 37% did stethoscope hygiene monthly, and 7% did stethoscope hygiene annually or never.[8] Of 1401 doctors asked about their stethoscope hygiene beliefs and practices, 76% believed that stethoscopes could transmit infection, but only 24% reported cleaning their scopes regularly.[9] Moreover, of 308 students, 22% had never done stethoscope hygiene, and <4% did it consistently.[10] However, we were unable to find any data on observed rates of stethoscope hygiene. Thus, we observed student and trainee physician stethoscope hygiene performance during hospital medicine rotations as part of the baseline data‐collection phase of a quality‐improvement effort linked to hand hygiene efforts.

METHODS

Attending hospitalists (I.H.J., B.M., and A.A.) and 1 graduate assistant (J.W.) at 3 sites observed stethoscope hygiene opportunities over an 11‐month period. Stethoscope hygiene was counted as performed if a patient‐specific stethoscope was used in an isolation room, or if any type of cleaning (alcohol gel, alcohol wipe, or cleansing cloth) was performed on a stethoscope carried out of the room. Observers also recorded whether stethoscope hygiene opportunities occurred in isolation rooms or nonisolation rooms, and noted if stethoscope hygiene was obviously triggered by an attending's stethoscope hygiene behavior (eg, a trainee asked an attending why he performed stethoscope hygiene, then performed it him or herself). Trainees were not aware that their stethoscope hygiene behaviors were being recorded.

RESULTS

We observed 352 opportunities for stethoscope hygiene, in which doctors or students used stethoscope hygiene in 58 encounters (16%). Twenty of the 58 stethoscope hygiene events occurred only after a trainee observed an attending physician perform stethoscope hygiene. Eliminating stethoscope hygiene events that were triggered by attending physicians, stethoscope hygiene was performed in 38 of 332 opportunities (11%). There was a significant difference between the rate of stethoscope hygiene performed in isolation versus nonisolation rooms: 24/29 (82.7%) versus 14 of 303 (4.6%) (P<0.001 by Pearson ² statistic). In isolation room stethoscope hygiene, in which the type of hygiene was recorded, 18 of 20 (90%) involved use of an isolation stethoscope, and 2 of 20 (10%) involved cleaning of a personal stethoscope.

DISCUSSION

Stethoscope hygiene is rarely performed by trainees. Stethoscope hygiene performance depends on the isolation status of the patient, with more than 80% performance in isolated patients and <5% in nonisolated patients.

Although little is known about the rate of infection related to stethoscopes, colonization of stethoscopes with nosocomial bacteria is well described.[2] Transmission of pathogens from patient to patient by stethoscopes could undermine the benefits of hand hygiene programs, as patients are commonly exposed to unclean stethoscopes.

Our observations are limited by several factors. We used a convenience sample of general medicine trainee behavior at academic medical centers; the behavior of attending physicians, ancillary staff, and nonacademic physicians may be different. Moreover, attending behavior may have prompted more episodes of stethoscope hygiene performance than we recorded, because we only noted when stethoscope hygiene was clearly related to attending behavior. The very low rate of stethoscope hygiene after contact with nonisolation patients represents a current and potentially serious safety threat. Future research might be able to quantify the risk associated with uncleaned stethoscopes or demonstrate the effectiveness of stethoscope hygiene programs. The effect of modeling on hand hygiene and stethoscope hygiene[10, 11] and on stethoscope hygiene in our data suggests a method for improving stethoscope hygiene.

Hyponatremia is an electrolyte disorder most commonly defined as a serum sodium concentration <135 mEq/L.1 Its exact definition can vary across studies, but typically ranges between <130 and <138 mEq/L.2, 3 Signs and symptoms of hyponatremia can include malaise, headache, disorientation, confusion, muscle weakness, and cramps. If severe, seizures, respiratory arrest, brainstem herniation, coma, and death may result.

The incidence of hyponatremia in the general hospitalized population has been reported to range between 1% and 6% when defined as <130135 mEq/L,4, 5 and its occurrence increases with a more prolonged hospital stay to 13%.6 A recent study reported that when hyponatremia was defined with a less stringent threshold of <138 mEq/L, the incidence at admission rose to 38%.3 Hyponatremia is a comorbid condition of multiple diseases, occurring in approximately 20% of patients with heart failure,7, 8 and 40% to 57% of patients with advanced cirrhosis.9, 10 The syndrome of the inappropriate release of antidiuretic hormone (SIADH) is additionally a predominant cause of hyponatremia, with a prevalence reported as high as 35% in hospitalized patients.11

Hyponatremia is not only widespread, but also an independent predictor of mortality. In a retrospective cohort analysis, Waikar et al reported that in comparison to patients who were normonatremic, patients with serum sodium concentrations <135 mEq/L had a risk of in‐hospital mortality as high as 47%, and that this risk doubled for patients with serum sodium concentrations between 125 and 129 mEq/L.6 In the study by Wald et al, which defined hyponatremia as <138 mEq/L, the risk of in‐hospital mortality was similar.3 In both of these studies, even mild hyponatremia (130137 mEq/L) was associated with increased risk of in‐hospital mortality.3, 6

The overall cost of hyponatremia is estimated to range between $1.6 and $3.6 billion for 2011.12, 13 Hospital readmissions are a significant contributor to total healthcare costs, with some being entirely avoidable with increased standards of care. The Centers for Medicare and Medicaid Services has begun to not only publicly report hospital readmission rates, but also penalize hospitals for early readmissions.14 Strategies to reduce hospital readmissions are currently being integrated into healthcare reform policy.14 In the present study, the incremental burden of hospitalized hyponatremic (HN) versus non‐HN patients in terms of hospital resource utilization, costs, and early hospital readmission in the real‐world was evaluated.

METHODS

RESULTS

DISCUSSION

This large‐scale, real‐world hospital database study provides healthcare utilization and cost data on the largest population of HN patients that has currently been studied. The results of this study are consistent with others in showing that HN patients use healthcare services more extensively, and represent a patient population which is more expensive to treat in the inpatient setting.5, 22 Additionally, this study yields new findings in that patients in the real‐world with hyponatremia resulting from various etiologies are more likely to be readmitted to the hospital than patients with similar demographics and characteristics who do not have hyponatremia. The results of the subgroup analysis were generally consistent with the results for the overall matched population, as the incremental burden estimates were directionally consistent. However, among the specific subgroups of patients, although it appears that hyponatremia is predictive of hospital readmission in patients with CHF, it did not necessarily correspond with hospital readmission rates among patients with CAP, UTI, or COPD. Therefore, hyponatremia, at least for patients with these latter conditions, may not be predictive of readmission, but remains associated with increased healthcare utilization during the initial hospitalization. Further evaluation of the incremental burden of hyponatremia among patients with specific disease conditions is needed to validate the findings.

The difference in hospital LOS at first admission between HN and non‐HN patients in this study was 1.1 days, and comparable to that reported by Shorr et al.23 In the study by Shorr et al, patients hospitalized for congestive heart failure (CHF), who were HN, had a 0.5 day increased LOS, and those who were severely HN had a 1.3 day increased LOS.23 Two other retrospective cohort analyses reported a 1.4 day5 and 2.0 day22 increased LOS for HN patients in comparison to non‐HN patients. Zilberberg et al and Callahan et al additionally reported that HN patients had a significantly greater need for ICU (4%10%).5, 22 In the present study, LOS in the ICU and associated costs were also compared among HN and non‐HN cohorts and, after adjustment for key patient characteristics, hyponatremia was associated with an incremental increase of 10.2% for ICU LOS and an 8.9% increase in ICU cost.

In this study, patients with hyponatremia of any severity were found to have a mean increase in hospital cost per admission of $1842, with multivariate analysis demonstrating an associated incremental increase of 8.2%. These results are also comparable to that reported in other retrospective cohort analyses. Shorr et al reported that in‐hospital costs attributed to hyponatremia were $509, and for severe hyponatremia were $1132.23 Callahan et al reported a $1200 increase in costs per admission for patients with mild‐to‐moderate hyponatremia, and a $3540 increase for patients with moderate‐to‐severe hyponatremia, in comparison to non‐HN patients.22

The Institute for Healthcare Improvement reports that hospitalizations account for nearly one‐third of the $882 billion spent on healthcare in the US in 2011, and that a substantial fraction of all hospitalizations are readmissions.13, 24 A recent meta‐analysis of 30‐day hospital readmission rates found 23.1% were classified as avoidable.25 Readmission rates of HN patients in comparison to non‐HN patients have been reported in 3 other studies, all of which were conducted on clinical trial patients with heart failure.7, 8, 26 Two of these studies, which evaluated only patients with acute class IV heart failure,8, 26 reported that hyponatremia was associated with a significant increase in readmission rates (up to 20% higher), and the other, which evaluated any patients hospitalized for heart failure, did not.7 The differences there may be partially attributed to the differences in heart failure severity among patient populations, as hyponatremia is an independent predictor of worsening heart failure. The only published study to date on the influence of hyponatremia on readmission rates in the real‐world was conducted by Scherz et al, who reported that the co‐occurrence of hyponatremia in patients with acute pulmonary embolism, discharged from 185 hospitals in Pennsylvania, was independently associated with an increased readmission rate of 19.3%.27 In the present study, hyponatremia was associated with an incremental increase ranging between 14% and 17% for hospital readmission for any cause. It was conducted on a patient population in which hyponatremia was resultant from many causes, and not all patients had a serious comorbid condition. Also, the HN and non‐HN cohorts were matched for comorbidity prevalence and disease severity, and in other studies they were not. Therefore, the results of this study importantly imply that hyponatremia, whether it is resultant from a serious disease or any other cause substantially increases the healthcare burden. The implementation of strategies to prevent hospital readmissions may play an important role in reducing the healthcare burden of hyponatremia, and future studies are warranted to evaluate this hypothesis alongside evaluation of the outpatient hyponatremia burden.

The limitations of this study include, firstly, that it is only representative of inpatient hospital costs, and excludes outpatient healthcare utilization and costs. Secondly, this study utilized the Premier Hospital Database for patient selection, and laboratory testing data for serum sodium level are not available in this database; therefore, the severity of hyponatremia could not be accurately established in the HN patient population. Thirdly, the occurrence of hyponatremia in patients with some diseases is a marker of disease severity, as is the case with congestive heart failure and cirrhosis.23, 28 Our study did not adjust for the specific disease (eg, CHF) severity, which may influence the results. Future research is needed to evaluate the impact of hyponatremia on underlying disease severity of other diseases, and how its co‐occurrence may influence healthcare resource utilization and cost in each case. Although the Premier Hospital Database contains information from a large number of hospitals across the US, it is possible that it may not be representative of the entire US population of HN patients. Additionally, billing and coding errors and missing data could potentially have occurred, although the large patient population size likely precludes a large impact on the results of this study. Finally, the frequency of use of fluid restriction in these hospital settings could not be chronicled, thus limiting the ability to assess therapies and treatment modalities in use.

Hyponatremia is an electrolyte disorder most commonly defined as a serum sodium concentration <135 mEq/L.1 Its exact definition can vary across studies, but typically ranges between <130 and <138 mEq/L.2, 3 Signs and symptoms of hyponatremia can include malaise, headache, disorientation, confusion, muscle weakness, and cramps. If severe, seizures, respiratory arrest, brainstem herniation, coma, and death may result.

The incidence of hyponatremia in the general hospitalized population has been reported to range between 1% and 6% when defined as <130135 mEq/L,4, 5 and its occurrence increases with a more prolonged hospital stay to 13%.6 A recent study reported that when hyponatremia was defined with a less stringent threshold of <138 mEq/L, the incidence at admission rose to 38%.3 Hyponatremia is a comorbid condition of multiple diseases, occurring in approximately 20% of patients with heart failure,7, 8 and 40% to 57% of patients with advanced cirrhosis.9, 10 The syndrome of the inappropriate release of antidiuretic hormone (SIADH) is additionally a predominant cause of hyponatremia, with a prevalence reported as high as 35% in hospitalized patients.11

Hyponatremia is not only widespread, but also an independent predictor of mortality. In a retrospective cohort analysis, Waikar et al reported that in comparison to patients who were normonatremic, patients with serum sodium concentrations <135 mEq/L had a risk of in‐hospital mortality as high as 47%, and that this risk doubled for patients with serum sodium concentrations between 125 and 129 mEq/L.6 In the study by Wald et al, which defined hyponatremia as <138 mEq/L, the risk of in‐hospital mortality was similar.3 In both of these studies, even mild hyponatremia (130137 mEq/L) was associated with increased risk of in‐hospital mortality.3, 6

The overall cost of hyponatremia is estimated to range between $1.6 and $3.6 billion for 2011.12, 13 Hospital readmissions are a significant contributor to total healthcare costs, with some being entirely avoidable with increased standards of care. The Centers for Medicare and Medicaid Services has begun to not only publicly report hospital readmission rates, but also penalize hospitals for early readmissions.14 Strategies to reduce hospital readmissions are currently being integrated into healthcare reform policy.14 In the present study, the incremental burden of hospitalized hyponatremic (HN) versus non‐HN patients in terms of hospital resource utilization, costs, and early hospital readmission in the real‐world was evaluated.

METHODS

RESULTS

DISCUSSION

This large‐scale, real‐world hospital database study provides healthcare utilization and cost data on the largest population of HN patients that has currently been studied. The results of this study are consistent with others in showing that HN patients use healthcare services more extensively, and represent a patient population which is more expensive to treat in the inpatient setting.5, 22 Additionally, this study yields new findings in that patients in the real‐world with hyponatremia resulting from various etiologies are more likely to be readmitted to the hospital than patients with similar demographics and characteristics who do not have hyponatremia. The results of the subgroup analysis were generally consistent with the results for the overall matched population, as the incremental burden estimates were directionally consistent. However, among the specific subgroups of patients, although it appears that hyponatremia is predictive of hospital readmission in patients with CHF, it did not necessarily correspond with hospital readmission rates among patients with CAP, UTI, or COPD. Therefore, hyponatremia, at least for patients with these latter conditions, may not be predictive of readmission, but remains associated with increased healthcare utilization during the initial hospitalization. Further evaluation of the incremental burden of hyponatremia among patients with specific disease conditions is needed to validate the findings.

The difference in hospital LOS at first admission between HN and non‐HN patients in this study was 1.1 days, and comparable to that reported by Shorr et al.23 In the study by Shorr et al, patients hospitalized for congestive heart failure (CHF), who were HN, had a 0.5 day increased LOS, and those who were severely HN had a 1.3 day increased LOS.23 Two other retrospective cohort analyses reported a 1.4 day5 and 2.0 day22 increased LOS for HN patients in comparison to non‐HN patients. Zilberberg et al and Callahan et al additionally reported that HN patients had a significantly greater need for ICU (4%10%).5, 22 In the present study, LOS in the ICU and associated costs were also compared among HN and non‐HN cohorts and, after adjustment for key patient characteristics, hyponatremia was associated with an incremental increase of 10.2% for ICU LOS and an 8.9% increase in ICU cost.

In this study, patients with hyponatremia of any severity were found to have a mean increase in hospital cost per admission of $1842, with multivariate analysis demonstrating an associated incremental increase of 8.2%. These results are also comparable to that reported in other retrospective cohort analyses. Shorr et al reported that in‐hospital costs attributed to hyponatremia were $509, and for severe hyponatremia were $1132.23 Callahan et al reported a $1200 increase in costs per admission for patients with mild‐to‐moderate hyponatremia, and a $3540 increase for patients with moderate‐to‐severe hyponatremia, in comparison to non‐HN patients.22

The Institute for Healthcare Improvement reports that hospitalizations account for nearly one‐third of the $882 billion spent on healthcare in the US in 2011, and that a substantial fraction of all hospitalizations are readmissions.13, 24 A recent meta‐analysis of 30‐day hospital readmission rates found 23.1% were classified as avoidable.25 Readmission rates of HN patients in comparison to non‐HN patients have been reported in 3 other studies, all of which were conducted on clinical trial patients with heart failure.7, 8, 26 Two of these studies, which evaluated only patients with acute class IV heart failure,8, 26 reported that hyponatremia was associated with a significant increase in readmission rates (up to 20% higher), and the other, which evaluated any patients hospitalized for heart failure, did not.7 The differences there may be partially attributed to the differences in heart failure severity among patient populations, as hyponatremia is an independent predictor of worsening heart failure. The only published study to date on the influence of hyponatremia on readmission rates in the real‐world was conducted by Scherz et al, who reported that the co‐occurrence of hyponatremia in patients with acute pulmonary embolism, discharged from 185 hospitals in Pennsylvania, was independently associated with an increased readmission rate of 19.3%.27 In the present study, hyponatremia was associated with an incremental increase ranging between 14% and 17% for hospital readmission for any cause. It was conducted on a patient population in which hyponatremia was resultant from many causes, and not all patients had a serious comorbid condition. Also, the HN and non‐HN cohorts were matched for comorbidity prevalence and disease severity, and in other studies they were not. Therefore, the results of this study importantly imply that hyponatremia, whether it is resultant from a serious disease or any other cause substantially increases the healthcare burden. The implementation of strategies to prevent hospital readmissions may play an important role in reducing the healthcare burden of hyponatremia, and future studies are warranted to evaluate this hypothesis alongside evaluation of the outpatient hyponatremia burden.

The limitations of this study include, firstly, that it is only representative of inpatient hospital costs, and excludes outpatient healthcare utilization and costs. Secondly, this study utilized the Premier Hospital Database for patient selection, and laboratory testing data for serum sodium level are not available in this database; therefore, the severity of hyponatremia could not be accurately established in the HN patient population. Thirdly, the occurrence of hyponatremia in patients with some diseases is a marker of disease severity, as is the case with congestive heart failure and cirrhosis.23, 28 Our study did not adjust for the specific disease (eg, CHF) severity, which may influence the results. Future research is needed to evaluate the impact of hyponatremia on underlying disease severity of other diseases, and how its co‐occurrence may influence healthcare resource utilization and cost in each case. Although the Premier Hospital Database contains information from a large number of hospitals across the US, it is possible that it may not be representative of the entire US population of HN patients. Additionally, billing and coding errors and missing data could potentially have occurred, although the large patient population size likely precludes a large impact on the results of this study. Finally, the frequency of use of fluid restriction in these hospital settings could not be chronicled, thus limiting the ability to assess therapies and treatment modalities in use.

Hyponatremia is an electrolyte disorder most commonly defined as a serum sodium concentration <135 mEq/L.1 Its exact definition can vary across studies, but typically ranges between <130 and <138 mEq/L.2, 3 Signs and symptoms of hyponatremia can include malaise, headache, disorientation, confusion, muscle weakness, and cramps. If severe, seizures, respiratory arrest, brainstem herniation, coma, and death may result.

The incidence of hyponatremia in the general hospitalized population has been reported to range between 1% and 6% when defined as <130135 mEq/L,4, 5 and its occurrence increases with a more prolonged hospital stay to 13%.6 A recent study reported that when hyponatremia was defined with a less stringent threshold of <138 mEq/L, the incidence at admission rose to 38%.3 Hyponatremia is a comorbid condition of multiple diseases, occurring in approximately 20% of patients with heart failure,7, 8 and 40% to 57% of patients with advanced cirrhosis.9, 10 The syndrome of the inappropriate release of antidiuretic hormone (SIADH) is additionally a predominant cause of hyponatremia, with a prevalence reported as high as 35% in hospitalized patients.11

Hyponatremia is not only widespread, but also an independent predictor of mortality. In a retrospective cohort analysis, Waikar et al reported that in comparison to patients who were normonatremic, patients with serum sodium concentrations <135 mEq/L had a risk of in‐hospital mortality as high as 47%, and that this risk doubled for patients with serum sodium concentrations between 125 and 129 mEq/L.6 In the study by Wald et al, which defined hyponatremia as <138 mEq/L, the risk of in‐hospital mortality was similar.3 In both of these studies, even mild hyponatremia (130137 mEq/L) was associated with increased risk of in‐hospital mortality.3, 6

The overall cost of hyponatremia is estimated to range between $1.6 and $3.6 billion for 2011.12, 13 Hospital readmissions are a significant contributor to total healthcare costs, with some being entirely avoidable with increased standards of care. The Centers for Medicare and Medicaid Services has begun to not only publicly report hospital readmission rates, but also penalize hospitals for early readmissions.14 Strategies to reduce hospital readmissions are currently being integrated into healthcare reform policy.14 In the present study, the incremental burden of hospitalized hyponatremic (HN) versus non‐HN patients in terms of hospital resource utilization, costs, and early hospital readmission in the real‐world was evaluated.

METHODS

RESULTS

DISCUSSION

This large‐scale, real‐world hospital database study provides healthcare utilization and cost data on the largest population of HN patients that has currently been studied. The results of this study are consistent with others in showing that HN patients use healthcare services more extensively, and represent a patient population which is more expensive to treat in the inpatient setting.5, 22 Additionally, this study yields new findings in that patients in the real‐world with hyponatremia resulting from various etiologies are more likely to be readmitted to the hospital than patients with similar demographics and characteristics who do not have hyponatremia. The results of the subgroup analysis were generally consistent with the results for the overall matched population, as the incremental burden estimates were directionally consistent. However, among the specific subgroups of patients, although it appears that hyponatremia is predictive of hospital readmission in patients with CHF, it did not necessarily correspond with hospital readmission rates among patients with CAP, UTI, or COPD. Therefore, hyponatremia, at least for patients with these latter conditions, may not be predictive of readmission, but remains associated with increased healthcare utilization during the initial hospitalization. Further evaluation of the incremental burden of hyponatremia among patients with specific disease conditions is needed to validate the findings.

The difference in hospital LOS at first admission between HN and non‐HN patients in this study was 1.1 days, and comparable to that reported by Shorr et al.23 In the study by Shorr et al, patients hospitalized for congestive heart failure (CHF), who were HN, had a 0.5 day increased LOS, and those who were severely HN had a 1.3 day increased LOS.23 Two other retrospective cohort analyses reported a 1.4 day5 and 2.0 day22 increased LOS for HN patients in comparison to non‐HN patients. Zilberberg et al and Callahan et al additionally reported that HN patients had a significantly greater need for ICU (4%10%).5, 22 In the present study, LOS in the ICU and associated costs were also compared among HN and non‐HN cohorts and, after adjustment for key patient characteristics, hyponatremia was associated with an incremental increase of 10.2% for ICU LOS and an 8.9% increase in ICU cost.

In this study, patients with hyponatremia of any severity were found to have a mean increase in hospital cost per admission of $1842, with multivariate analysis demonstrating an associated incremental increase of 8.2%. These results are also comparable to that reported in other retrospective cohort analyses. Shorr et al reported that in‐hospital costs attributed to hyponatremia were $509, and for severe hyponatremia were $1132.23 Callahan et al reported a $1200 increase in costs per admission for patients with mild‐to‐moderate hyponatremia, and a $3540 increase for patients with moderate‐to‐severe hyponatremia, in comparison to non‐HN patients.22

The Institute for Healthcare Improvement reports that hospitalizations account for nearly one‐third of the $882 billion spent on healthcare in the US in 2011, and that a substantial fraction of all hospitalizations are readmissions.13, 24 A recent meta‐analysis of 30‐day hospital readmission rates found 23.1% were classified as avoidable.25 Readmission rates of HN patients in comparison to non‐HN patients have been reported in 3 other studies, all of which were conducted on clinical trial patients with heart failure.7, 8, 26 Two of these studies, which evaluated only patients with acute class IV heart failure,8, 26 reported that hyponatremia was associated with a significant increase in readmission rates (up to 20% higher), and the other, which evaluated any patients hospitalized for heart failure, did not.7 The differences there may be partially attributed to the differences in heart failure severity among patient populations, as hyponatremia is an independent predictor of worsening heart failure. The only published study to date on the influence of hyponatremia on readmission rates in the real‐world was conducted by Scherz et al, who reported that the co‐occurrence of hyponatremia in patients with acute pulmonary embolism, discharged from 185 hospitals in Pennsylvania, was independently associated with an increased readmission rate of 19.3%.27 In the present study, hyponatremia was associated with an incremental increase ranging between 14% and 17% for hospital readmission for any cause. It was conducted on a patient population in which hyponatremia was resultant from many causes, and not all patients had a serious comorbid condition. Also, the HN and non‐HN cohorts were matched for comorbidity prevalence and disease severity, and in other studies they were not. Therefore, the results of this study importantly imply that hyponatremia, whether it is resultant from a serious disease or any other cause substantially increases the healthcare burden. The implementation of strategies to prevent hospital readmissions may play an important role in reducing the healthcare burden of hyponatremia, and future studies are warranted to evaluate this hypothesis alongside evaluation of the outpatient hyponatremia burden.

The limitations of this study include, firstly, that it is only representative of inpatient hospital costs, and excludes outpatient healthcare utilization and costs. Secondly, this study utilized the Premier Hospital Database for patient selection, and laboratory testing data for serum sodium level are not available in this database; therefore, the severity of hyponatremia could not be accurately established in the HN patient population. Thirdly, the occurrence of hyponatremia in patients with some diseases is a marker of disease severity, as is the case with congestive heart failure and cirrhosis.23, 28 Our study did not adjust for the specific disease (eg, CHF) severity, which may influence the results. Future research is needed to evaluate the impact of hyponatremia on underlying disease severity of other diseases, and how its co‐occurrence may influence healthcare resource utilization and cost in each case. Although the Premier Hospital Database contains information from a large number of hospitals across the US, it is possible that it may not be representative of the entire US population of HN patients. Additionally, billing and coding errors and missing data could potentially have occurred, although the large patient population size likely precludes a large impact on the results of this study. Finally, the frequency of use of fluid restriction in these hospital settings could not be chronicled, thus limiting the ability to assess therapies and treatment modalities in use.

The goal of this article is to explain how the first in a series of online resource rooms provides trainees and hospitalists with quality improvement tools that can be applied locally to improve inpatient care.1 During the emergence and explosive growth of hospital medicine, the SHM recognized the need to revise training relating to inpatient care and hospital process design to meet the evolving expectation of hospitalists that their performance will be measured, to actively set quality parameters, and to lead multidisciplinary teams to improve hospital performance.2 Armed with the appropriate skill set, hospitalists would be uniquely situated to lead and manage improvements in processes in the hospitals in which they work.

The content of the first Society of Hospital Medicine (SHM) Quality Improvement Resource Room (QI RR) supports hospitalists leading a multidisciplinary team dedicated to improving inpatient outcomes by preventing hospital‐acquired venous thromboembolism (VTE), a common cause of morbidity and mortality in hospitalized patients.3 The SHM developed this educational resource in the context of numerous reports on the incidence of medical errors in US hospitals and calls for action to improve the quality of health care.'47 Hospital report cards on quality measures are now public record, and hospitals will require uniformity in practice among physicians. Hospitalists are increasingly expected to lead initiatives that will implement national standards in key practices such as VTE prophylaxis2.

The QI RRs of the SHM are a collection of electronic tools accessible through the SHM Web site. They are designed to enhance the readiness of hospitalists and members of the multidisciplinary inpatient team to redesign care at the institutional level. Although all performance improvement is ultimately occurs locally, many QI methods and tools transcend hospital geography and disease topic. Leveraging a Web‐based platform, the SHM QI RRs present hospitalists with a general approach to QI, enriched by customizable workbooks that can be downloaded to best meet user needs. This resource is an innovation in practice‐based learning, quality improvement, and systems‐based practice.

METHODS

Development of the first QI RR followed a series of steps described in Curriculum Development for Medical Education8 (for process and timeline, see Table 1). Inadequate VTE prophylaxis was identified as an ongoing widespread problem of health care underutilization despite randomized clinical trials supporting the efficacy of prophylaxis.9, 10 Mirroring the AHRQ's assessment of underutilization of VTE prophylaxis as the single most important safety priority,6 the first QI RR focused on VTE, with plans to cover additional clinical conditions over time. As experts in the care of inpatients, hospitalists should be able to take custody of predictable complications of serious illness, identify and lower barriers to prevention, critically review prophylaxis options, utilize hospital‐specific data, and devise strategies to bridge the gap between knowledge and practice. Already leaders of multidisciplinary care teams, hospitalists are primed to lead multidisciplinary improvement teams as well.

Available data on the demographics of hospitalists and feedback from the SHM membership, leadership, and committees indicated that most learners would have minimal previous exposure to QI concepts and only a few years of management experience. Any previous quality improvement initiatives would tend to have been isolated, experimental, or smaller in scale. The resource rooms are designed to facilitate quality improvement learning among hospitalists that is practice‐based and immediately relevant to patient care. Measurable improvement in particular care processes or outcomes should correlate with actual learning.

The educational strategy of the SHM was predicated on ensuring that a quality and patient safety curriculum would retain clinical applicability in the hospital setting. This approach, grounded in adult learning principles and common to medical education, teaches general principles by framing the learning experience as problem centered.11 Several domains were identified as universally important to any quality improvement effort: raising awareness of a local performance gap, applying the best current evidence to practice, tapping the experience of others leading QI efforts, and using measurements derived from rapid‐cycle tests of change. Such a template delineates the components of successful QI planning, implementation, and evaluation and provides users with a familiar RR format applicable to improving any care process, not just VTE.

The Internet was chosen as the mechanism for delivering training on the basis of previous surveys of the SHM membership in which members expressed a preference for electronic and Web‐based forms of educational content delivery. Drawing from the example of other organizations teaching quality improvement, including the Institute for Healthcare Improvement and Intermountain Health Care, the SHM valued the ubiquity of a Web‐based educational resource. To facilitate on‐the‐job training, the first SHM QI RR provides a comprehensive tool kit to guide hospitalists through the process of advocating, developing, implementing, and evaluating a QI initiative for VTE.

Prior to launching the resource room, formative input was collected from SHM leaders, a panel of education and QI experts, and attendees of the society's annual meetings. Such input followed each significant step in the development of the RR curricula. For example, visitors at a kiosk at the 2005 SHM annual meeting completed surveys as they navigated through the VTE QI RR. This focused feedback shaped prelaunch development. The ultimate performance evaluation and feedback for the QI RR curricula will be gauged by user reports of measurable improvement in specific hospital process or outcomes measures. The VTE QI RR was launched in August 2005 and promoted at the SHM Web site.

RESULTS

The content and layout of the VTE QI RR are depicted in Figure 1. The self‐directed learner may navigate through the entire resource room or just select areas for study. Those likely to visit only a single area are individuals looking for guidance to support discrete roles on the improvement team: champion, clinical leader, facilitator of the QI process, or educator of staff or patient audiences (see Figure 2).

Figure 1

Figure 2

DISCUSSION

A case example, shown in Figure 3, demonstrates how content accessible through the SHM VTE QI RR may be used to catalyze a local quality improvement effort.

Figure 3

Hospitals will be measured on rates of VTE prophylaxis on medical and surgical services. Failure to standardize prophylaxis among different physician groups may adversely affect overall performance, with implications for both patient care and accreditation. The lack of a agreed‐on gold standard of what constitutes appropriate prophylaxis for a given patient does not absolve an institution of the duty to implement its own standards. The challenge of achieving local consensus on appropriate prophylaxis should not outweigh the urgency to address preventable in‐hospital deaths. In caring for increasing numbers of general medical and surgical patients, hospitalists are likely to be asked to develop and implement a protocol for VTE prophylaxis that can be used hospitalwide. In many instances hospitalists will accept this charge in the aftermath of previous hospital failures in which admission order sets or VTE assessment protocols were launched but never widely implemented. As the National Quality Forum or JCAHO regulations for uniformity among hospitals shift VTE prophylaxis from being voluntary to compulsory, hospitalists will need to develop improvement strategies that have greater reliability.

Hospitalists with no formal training in either vascular medicine or quality improvement may not be able to immediately cite the most current data about VTE prophylaxis rates and regimens and may not have the time to enroll in a training course on quality improvement. How would hospitalists determine baseline rates of appropriate VTE prophylaxis? How can medical education be used to build consensus and recruit support from other physicians? What should be the scope of the QI initiative, and what patient population should be targeted for intervention?

The goal of the SHM QI RR is to provide the tools and the framework to help hospitalists develop, implement, and manage a VTE prophylaxis quality improvement initiative. Suggested Steps to Action in the Awareness section depict exactly how a hospital medicine service can use the campaign's materials to raise institutional support for tackling this preventable problem. Hospital quality officers can direct the hospital's public relations department to the Awareness section for DVT Awareness Month materials, including public service announcements in audio, visual, and print formats. The hold music at the hospital can be temporarily replaced, television kiosks can be set up to run video loops, and banners can be printed and hung in central locations, all to get out the message simultaneously to patients and medical staff.

The Evidence section of the VTE QI RR references a key benchmark study, the DVT‐Free Prospective Registry.9 This study reported that at 183 sites in North America and Europe, more than twice as many medical patients as surgical patients failed to receive prophylaxis. The Evidence section includes the 7th American College of Chest Physicians Consensus Conference on Antithrombotic and Thrombolytic Therapy and also highlights 3 randomized placebo‐controlled clinical trials (MEDENOX 1999, ARTEMIS 2003, and PREVENT 2004) that have reported significant reduction of risk of VTE (50%‐60%) from pharmacologic prophylaxis in moderate‐risk medical inpatients.1315 Review of the data helps to determine which patient population to study first, which prophylaxis options a hospital could deploy appropriately, and the expected magnitude of the effect. Because the literature has already been narrowed and is kept current, hospitalists can save time in answering a range of questions, from the most commonly agreed‐on factors to stratify risk to which populations require alternative interventions.

The Experience section references the first clinical trial demonstrating improved patient outcomes from a quality improvement initiative aimed at improving utilization of VTE prophylaxis.10 At the large teaching hospital where the electronic alerts were studied, a preexisting wealth of educational information on the hospital Web site, in the form of multiple seminars and lectures on VTE prophylaxis by opinion leaders and international experts, had little impact on practice. For this reason, the investigators implemented a trial of how to change physician behavior by introducing a point‐of‐care intervention, the computer alerts. Clinicians prompted by an electronic alert to consider DVT prophylaxis for at‐risk patients employed nearly double the rate of pharmacologic prophylaxis and reduced the incidence of DVT or pulmonary embolism (PE) by 41%. This study suggests that a change introduced to the clinical workflow can improve evidence‐based VTE prophylaxis and also can reduce the incidence of VTE in acutely ill hospitalized patients.

We believe that if hospitalists use the current evidence and experience assembled in the VTE QI RR, they could develop and lead a systematic approach to improving utilization of VTE prophylaxis. Although there is no gold standard method for integrating VTE risk assessment into clinical workflow, the VTE QI RR presents key lessons both from the literature and real world experiences. The crucial take‐home message is that hospitalists can facilitate implementation of VTE risk assessments if they stress simplicity (ie, the sick, old, surgery benefit), link the risk assessment to a menu of evidence‐based prophylaxis options, and require assessment of VTE risk as part of a regular routine (on admission and at regular intervals). Although many hospitals do not yet have computerized entry of physician orders, the simple 4‐point VTE risk assessment described by Kucher et al might be applied to other hospitals.10 The 4‐point system would identify the patients at highest risk, a reasonable starting point for a QI initiative. Whatever the modelCPOE alerts of very high‐risk patients, CPOE‐forced VTE risk assessments, nursing assessments, or paper‐based order setsregular VTE risk assessment can be incorporated into the daily routine of hospital care.

The QI workbook sequences the steps of a multidisciplinary improvement team and prompts users to set specific goals, collect practical metrics, and conduct plan‐do‐study‐act (PDSA) cycles of learning and action (Figure 4). Hospitalists and other team members can use the information in the workbook to estimate the prevalence of use of the appropriate VTE prophylaxis and the incidence of hospital‐acquired VTE at their medical centers, develop a suitable VTE risk assessment model, and plan interventions. Starting with all patients admitted to one nurse on one unit, then expanding to an entire nursing unit, an improvement team could implement rapid PDSA cycles to iron out the wrinkles of a risk assessment protocol. After demonstrating a measurable benefit for the patients at highest risk, the team would then be expected to capture more patients at risk for VTE by modifying the risk assessment protocol to identify moderate‐risk patients (hospitalized patients with one risk factor), as in the MEDENOX, ARTEMIS, and PREVENT clinical trials. Within the first several months, the QI intervention could be expanded to more nursing units. An improvement report profiling a clinically important increase in the rate of appropriate VTE prophylaxis would advocate for additional local resources and projects.

Figure 4

As questions arise in assembling an improvement team, setting useful aims and metrics, choosing interventions, implementing and studying change, or collecting performance data, hospitalists can review answers to questions already posted and post their own questions in the Ask the Expert area. For example, one user asked whether there was a standard risk assessment tool for identifying patients at high risk of VTE. Another asked about the use of unfractionated heparin as a low‐cost alternative to low‐molecular‐weight heparin. Both these questions were answered within 24 hours by the content editor of the VTE QI RR and, for one question, also by 2 pharmacists and an international expert in VTE.

As other hospitalists begin de novo efforts of their own, success stories and strategies posted in the online forums of the VTE QI RR will be an evolving resource for basic know‐how and innovation.

Suggestions from a community of resource room users will be solicited, evaluated, and incorporated into the QI RR in order to improve its educational value and utility. The curricula could also be adapted or refined by others with an interest in systems‐based care or practice‐based learning, such as directors of residency training programs.

CONCLUSIONS

The QI RRs bring QI theory and practice to the hospitalist, when and wherever it is wanted, minimizing time away from patient care. The workbook links theory to practice and can be used to launch, sustain, and document a local VTE‐specific QI initiative. A range of experience is accommodated. Content is provided in a way that enables the user to immediately apply and adapt it to a local contextusers can access and download the subset of tools that best meet their needs. For practicing hospitalists, this QI resource offers an opportunity to bridge the training gap in systems‐based hospital care and should increase the quality and quantity of and support for opportunities to lead successful QI projects.

The Accreditation Council of Graduate Medical Education (ACGME) now requires education in health care systems, a requirement not previously mandated for traditional medical residency programs.17 Because the resource rooms should increase the number of hospitalists competently leading local efforts that achieve measurable gains in hospital outcomes, a wider potential constituency also includes residency program directors, internal medicine residents, physician assistants and nurse‐practitioners, nurses, hospital quality officers, and hospital medicine practice leaders.

Further research is needed to determine the clinical impact of the VTE QI workbook on outcomes for hospitalized patients. The effectiveness of such an educational method should be evaluated, at least in part, by documenting changes in clinically important process and outcome measures, in this case those specific to hospital‐acquired VTE. Investigation also will need to generate an impact assessment to see if the curricula are effective in meeting the strategic educational goals of the Society of Hospital Medicine. Further investigation will examine whether this resource can help residency training programs achieve ACGME goals for practice‐based learning and systems‐based care.

The goal of this article is to explain how the first in a series of online resource rooms provides trainees and hospitalists with quality improvement tools that can be applied locally to improve inpatient care.1 During the emergence and explosive growth of hospital medicine, the SHM recognized the need to revise training relating to inpatient care and hospital process design to meet the evolving expectation of hospitalists that their performance will be measured, to actively set quality parameters, and to lead multidisciplinary teams to improve hospital performance.2 Armed with the appropriate skill set, hospitalists would be uniquely situated to lead and manage improvements in processes in the hospitals in which they work.

The content of the first Society of Hospital Medicine (SHM) Quality Improvement Resource Room (QI RR) supports hospitalists leading a multidisciplinary team dedicated to improving inpatient outcomes by preventing hospital‐acquired venous thromboembolism (VTE), a common cause of morbidity and mortality in hospitalized patients.3 The SHM developed this educational resource in the context of numerous reports on the incidence of medical errors in US hospitals and calls for action to improve the quality of health care.'47 Hospital report cards on quality measures are now public record, and hospitals will require uniformity in practice among physicians. Hospitalists are increasingly expected to lead initiatives that will implement national standards in key practices such as VTE prophylaxis2.

The QI RRs of the SHM are a collection of electronic tools accessible through the SHM Web site. They are designed to enhance the readiness of hospitalists and members of the multidisciplinary inpatient team to redesign care at the institutional level. Although all performance improvement is ultimately occurs locally, many QI methods and tools transcend hospital geography and disease topic. Leveraging a Web‐based platform, the SHM QI RRs present hospitalists with a general approach to QI, enriched by customizable workbooks that can be downloaded to best meet user needs. This resource is an innovation in practice‐based learning, quality improvement, and systems‐based practice.

METHODS

Development of the first QI RR followed a series of steps described in Curriculum Development for Medical Education8 (for process and timeline, see Table 1). Inadequate VTE prophylaxis was identified as an ongoing widespread problem of health care underutilization despite randomized clinical trials supporting the efficacy of prophylaxis.9, 10 Mirroring the AHRQ's assessment of underutilization of VTE prophylaxis as the single most important safety priority,6 the first QI RR focused on VTE, with plans to cover additional clinical conditions over time. As experts in the care of inpatients, hospitalists should be able to take custody of predictable complications of serious illness, identify and lower barriers to prevention, critically review prophylaxis options, utilize hospital‐specific data, and devise strategies to bridge the gap between knowledge and practice. Already leaders of multidisciplinary care teams, hospitalists are primed to lead multidisciplinary improvement teams as well.

Available data on the demographics of hospitalists and feedback from the SHM membership, leadership, and committees indicated that most learners would have minimal previous exposure to QI concepts and only a few years of management experience. Any previous quality improvement initiatives would tend to have been isolated, experimental, or smaller in scale. The resource rooms are designed to facilitate quality improvement learning among hospitalists that is practice‐based and immediately relevant to patient care. Measurable improvement in particular care processes or outcomes should correlate with actual learning.

The educational strategy of the SHM was predicated on ensuring that a quality and patient safety curriculum would retain clinical applicability in the hospital setting. This approach, grounded in adult learning principles and common to medical education, teaches general principles by framing the learning experience as problem centered.11 Several domains were identified as universally important to any quality improvement effort: raising awareness of a local performance gap, applying the best current evidence to practice, tapping the experience of others leading QI efforts, and using measurements derived from rapid‐cycle tests of change. Such a template delineates the components of successful QI planning, implementation, and evaluation and provides users with a familiar RR format applicable to improving any care process, not just VTE.

The Internet was chosen as the mechanism for delivering training on the basis of previous surveys of the SHM membership in which members expressed a preference for electronic and Web‐based forms of educational content delivery. Drawing from the example of other organizations teaching quality improvement, including the Institute for Healthcare Improvement and Intermountain Health Care, the SHM valued the ubiquity of a Web‐based educational resource. To facilitate on‐the‐job training, the first SHM QI RR provides a comprehensive tool kit to guide hospitalists through the process of advocating, developing, implementing, and evaluating a QI initiative for VTE.

Prior to launching the resource room, formative input was collected from SHM leaders, a panel of education and QI experts, and attendees of the society's annual meetings. Such input followed each significant step in the development of the RR curricula. For example, visitors at a kiosk at the 2005 SHM annual meeting completed surveys as they navigated through the VTE QI RR. This focused feedback shaped prelaunch development. The ultimate performance evaluation and feedback for the QI RR curricula will be gauged by user reports of measurable improvement in specific hospital process or outcomes measures. The VTE QI RR was launched in August 2005 and promoted at the SHM Web site.

RESULTS

The content and layout of the VTE QI RR are depicted in Figure 1. The self‐directed learner may navigate through the entire resource room or just select areas for study. Those likely to visit only a single area are individuals looking for guidance to support discrete roles on the improvement team: champion, clinical leader, facilitator of the QI process, or educator of staff or patient audiences (see Figure 2).

Figure 1

Figure 2

DISCUSSION

A case example, shown in Figure 3, demonstrates how content accessible through the SHM VTE QI RR may be used to catalyze a local quality improvement effort.

Figure 3

Hospitals will be measured on rates of VTE prophylaxis on medical and surgical services. Failure to standardize prophylaxis among different physician groups may adversely affect overall performance, with implications for both patient care and accreditation. The lack of a agreed‐on gold standard of what constitutes appropriate prophylaxis for a given patient does not absolve an institution of the duty to implement its own standards. The challenge of achieving local consensus on appropriate prophylaxis should not outweigh the urgency to address preventable in‐hospital deaths. In caring for increasing numbers of general medical and surgical patients, hospitalists are likely to be asked to develop and implement a protocol for VTE prophylaxis that can be used hospitalwide. In many instances hospitalists will accept this charge in the aftermath of previous hospital failures in which admission order sets or VTE assessment protocols were launched but never widely implemented. As the National Quality Forum or JCAHO regulations for uniformity among hospitals shift VTE prophylaxis from being voluntary to compulsory, hospitalists will need to develop improvement strategies that have greater reliability.

Hospitalists with no formal training in either vascular medicine or quality improvement may not be able to immediately cite the most current data about VTE prophylaxis rates and regimens and may not have the time to enroll in a training course on quality improvement. How would hospitalists determine baseline rates of appropriate VTE prophylaxis? How can medical education be used to build consensus and recruit support from other physicians? What should be the scope of the QI initiative, and what patient population should be targeted for intervention?

The goal of the SHM QI RR is to provide the tools and the framework to help hospitalists develop, implement, and manage a VTE prophylaxis quality improvement initiative. Suggested Steps to Action in the Awareness section depict exactly how a hospital medicine service can use the campaign's materials to raise institutional support for tackling this preventable problem. Hospital quality officers can direct the hospital's public relations department to the Awareness section for DVT Awareness Month materials, including public service announcements in audio, visual, and print formats. The hold music at the hospital can be temporarily replaced, television kiosks can be set up to run video loops, and banners can be printed and hung in central locations, all to get out the message simultaneously to patients and medical staff.

The Evidence section of the VTE QI RR references a key benchmark study, the DVT‐Free Prospective Registry.9 This study reported that at 183 sites in North America and Europe, more than twice as many medical patients as surgical patients failed to receive prophylaxis. The Evidence section includes the 7th American College of Chest Physicians Consensus Conference on Antithrombotic and Thrombolytic Therapy and also highlights 3 randomized placebo‐controlled clinical trials (MEDENOX 1999, ARTEMIS 2003, and PREVENT 2004) that have reported significant reduction of risk of VTE (50%‐60%) from pharmacologic prophylaxis in moderate‐risk medical inpatients.1315 Review of the data helps to determine which patient population to study first, which prophylaxis options a hospital could deploy appropriately, and the expected magnitude of the effect. Because the literature has already been narrowed and is kept current, hospitalists can save time in answering a range of questions, from the most commonly agreed‐on factors to stratify risk to which populations require alternative interventions.

The Experience section references the first clinical trial demonstrating improved patient outcomes from a quality improvement initiative aimed at improving utilization of VTE prophylaxis.10 At the large teaching hospital where the electronic alerts were studied, a preexisting wealth of educational information on the hospital Web site, in the form of multiple seminars and lectures on VTE prophylaxis by opinion leaders and international experts, had little impact on practice. For this reason, the investigators implemented a trial of how to change physician behavior by introducing a point‐of‐care intervention, the computer alerts. Clinicians prompted by an electronic alert to consider DVT prophylaxis for at‐risk patients employed nearly double the rate of pharmacologic prophylaxis and reduced the incidence of DVT or pulmonary embolism (PE) by 41%. This study suggests that a change introduced to the clinical workflow can improve evidence‐based VTE prophylaxis and also can reduce the incidence of VTE in acutely ill hospitalized patients.

We believe that if hospitalists use the current evidence and experience assembled in the VTE QI RR, they could develop and lead a systematic approach to improving utilization of VTE prophylaxis. Although there is no gold standard method for integrating VTE risk assessment into clinical workflow, the VTE QI RR presents key lessons both from the literature and real world experiences. The crucial take‐home message is that hospitalists can facilitate implementation of VTE risk assessments if they stress simplicity (ie, the sick, old, surgery benefit), link the risk assessment to a menu of evidence‐based prophylaxis options, and require assessment of VTE risk as part of a regular routine (on admission and at regular intervals). Although many hospitals do not yet have computerized entry of physician orders, the simple 4‐point VTE risk assessment described by Kucher et al might be applied to other hospitals.10 The 4‐point system would identify the patients at highest risk, a reasonable starting point for a QI initiative. Whatever the modelCPOE alerts of very high‐risk patients, CPOE‐forced VTE risk assessments, nursing assessments, or paper‐based order setsregular VTE risk assessment can be incorporated into the daily routine of hospital care.

The QI workbook sequences the steps of a multidisciplinary improvement team and prompts users to set specific goals, collect practical metrics, and conduct plan‐do‐study‐act (PDSA) cycles of learning and action (Figure 4). Hospitalists and other team members can use the information in the workbook to estimate the prevalence of use of the appropriate VTE prophylaxis and the incidence of hospital‐acquired VTE at their medical centers, develop a suitable VTE risk assessment model, and plan interventions. Starting with all patients admitted to one nurse on one unit, then expanding to an entire nursing unit, an improvement team could implement rapid PDSA cycles to iron out the wrinkles of a risk assessment protocol. After demonstrating a measurable benefit for the patients at highest risk, the team would then be expected to capture more patients at risk for VTE by modifying the risk assessment protocol to identify moderate‐risk patients (hospitalized patients with one risk factor), as in the MEDENOX, ARTEMIS, and PREVENT clinical trials. Within the first several months, the QI intervention could be expanded to more nursing units. An improvement report profiling a clinically important increase in the rate of appropriate VTE prophylaxis would advocate for additional local resources and projects.

Figure 4

As questions arise in assembling an improvement team, setting useful aims and metrics, choosing interventions, implementing and studying change, or collecting performance data, hospitalists can review answers to questions already posted and post their own questions in the Ask the Expert area. For example, one user asked whether there was a standard risk assessment tool for identifying patients at high risk of VTE. Another asked about the use of unfractionated heparin as a low‐cost alternative to low‐molecular‐weight heparin. Both these questions were answered within 24 hours by the content editor of the VTE QI RR and, for one question, also by 2 pharmacists and an international expert in VTE.

As other hospitalists begin de novo efforts of their own, success stories and strategies posted in the online forums of the VTE QI RR will be an evolving resource for basic know‐how and innovation.

Suggestions from a community of resource room users will be solicited, evaluated, and incorporated into the QI RR in order to improve its educational value and utility. The curricula could also be adapted or refined by others with an interest in systems‐based care or practice‐based learning, such as directors of residency training programs.

CONCLUSIONS

The QI RRs bring QI theory and practice to the hospitalist, when and wherever it is wanted, minimizing time away from patient care. The workbook links theory to practice and can be used to launch, sustain, and document a local VTE‐specific QI initiative. A range of experience is accommodated. Content is provided in a way that enables the user to immediately apply and adapt it to a local contextusers can access and download the subset of tools that best meet their needs. For practicing hospitalists, this QI resource offers an opportunity to bridge the training gap in systems‐based hospital care and should increase the quality and quantity of and support for opportunities to lead successful QI projects.

The Accreditation Council of Graduate Medical Education (ACGME) now requires education in health care systems, a requirement not previously mandated for traditional medical residency programs.17 Because the resource rooms should increase the number of hospitalists competently leading local efforts that achieve measurable gains in hospital outcomes, a wider potential constituency also includes residency program directors, internal medicine residents, physician assistants and nurse‐practitioners, nurses, hospital quality officers, and hospital medicine practice leaders.

Further research is needed to determine the clinical impact of the VTE QI workbook on outcomes for hospitalized patients. The effectiveness of such an educational method should be evaluated, at least in part, by documenting changes in clinically important process and outcome measures, in this case those specific to hospital‐acquired VTE. Investigation also will need to generate an impact assessment to see if the curricula are effective in meeting the strategic educational goals of the Society of Hospital Medicine. Further investigation will examine whether this resource can help residency training programs achieve ACGME goals for practice‐based learning and systems‐based care.

The goal of this article is to explain how the first in a series of online resource rooms provides trainees and hospitalists with quality improvement tools that can be applied locally to improve inpatient care.1 During the emergence and explosive growth of hospital medicine, the SHM recognized the need to revise training relating to inpatient care and hospital process design to meet the evolving expectation of hospitalists that their performance will be measured, to actively set quality parameters, and to lead multidisciplinary teams to improve hospital performance.2 Armed with the appropriate skill set, hospitalists would be uniquely situated to lead and manage improvements in processes in the hospitals in which they work.

The content of the first Society of Hospital Medicine (SHM) Quality Improvement Resource Room (QI RR) supports hospitalists leading a multidisciplinary team dedicated to improving inpatient outcomes by preventing hospital‐acquired venous thromboembolism (VTE), a common cause of morbidity and mortality in hospitalized patients.3 The SHM developed this educational resource in the context of numerous reports on the incidence of medical errors in US hospitals and calls for action to improve the quality of health care.'47 Hospital report cards on quality measures are now public record, and hospitals will require uniformity in practice among physicians. Hospitalists are increasingly expected to lead initiatives that will implement national standards in key practices such as VTE prophylaxis2.

The QI RRs of the SHM are a collection of electronic tools accessible through the SHM Web site. They are designed to enhance the readiness of hospitalists and members of the multidisciplinary inpatient team to redesign care at the institutional level. Although all performance improvement is ultimately occurs locally, many QI methods and tools transcend hospital geography and disease topic. Leveraging a Web‐based platform, the SHM QI RRs present hospitalists with a general approach to QI, enriched by customizable workbooks that can be downloaded to best meet user needs. This resource is an innovation in practice‐based learning, quality improvement, and systems‐based practice.

METHODS

Development of the first QI RR followed a series of steps described in Curriculum Development for Medical Education8 (for process and timeline, see Table 1). Inadequate VTE prophylaxis was identified as an ongoing widespread problem of health care underutilization despite randomized clinical trials supporting the efficacy of prophylaxis.9, 10 Mirroring the AHRQ's assessment of underutilization of VTE prophylaxis as the single most important safety priority,6 the first QI RR focused on VTE, with plans to cover additional clinical conditions over time. As experts in the care of inpatients, hospitalists should be able to take custody of predictable complications of serious illness, identify and lower barriers to prevention, critically review prophylaxis options, utilize hospital‐specific data, and devise strategies to bridge the gap between knowledge and practice. Already leaders of multidisciplinary care teams, hospitalists are primed to lead multidisciplinary improvement teams as well.

Available data on the demographics of hospitalists and feedback from the SHM membership, leadership, and committees indicated that most learners would have minimal previous exposure to QI concepts and only a few years of management experience. Any previous quality improvement initiatives would tend to have been isolated, experimental, or smaller in scale. The resource rooms are designed to facilitate quality improvement learning among hospitalists that is practice‐based and immediately relevant to patient care. Measurable improvement in particular care processes or outcomes should correlate with actual learning.

The educational strategy of the SHM was predicated on ensuring that a quality and patient safety curriculum would retain clinical applicability in the hospital setting. This approach, grounded in adult learning principles and common to medical education, teaches general principles by framing the learning experience as problem centered.11 Several domains were identified as universally important to any quality improvement effort: raising awareness of a local performance gap, applying the best current evidence to practice, tapping the experience of others leading QI efforts, and using measurements derived from rapid‐cycle tests of change. Such a template delineates the components of successful QI planning, implementation, and evaluation and provides users with a familiar RR format applicable to improving any care process, not just VTE.

The Internet was chosen as the mechanism for delivering training on the basis of previous surveys of the SHM membership in which members expressed a preference for electronic and Web‐based forms of educational content delivery. Drawing from the example of other organizations teaching quality improvement, including the Institute for Healthcare Improvement and Intermountain Health Care, the SHM valued the ubiquity of a Web‐based educational resource. To facilitate on‐the‐job training, the first SHM QI RR provides a comprehensive tool kit to guide hospitalists through the process of advocating, developing, implementing, and evaluating a QI initiative for VTE.

Prior to launching the resource room, formative input was collected from SHM leaders, a panel of education and QI experts, and attendees of the society's annual meetings. Such input followed each significant step in the development of the RR curricula. For example, visitors at a kiosk at the 2005 SHM annual meeting completed surveys as they navigated through the VTE QI RR. This focused feedback shaped prelaunch development. The ultimate performance evaluation and feedback for the QI RR curricula will be gauged by user reports of measurable improvement in specific hospital process or outcomes measures. The VTE QI RR was launched in August 2005 and promoted at the SHM Web site.

RESULTS

The content and layout of the VTE QI RR are depicted in Figure 1. The self‐directed learner may navigate through the entire resource room or just select areas for study. Those likely to visit only a single area are individuals looking for guidance to support discrete roles on the improvement team: champion, clinical leader, facilitator of the QI process, or educator of staff or patient audiences (see Figure 2).

Figure 1

Figure 2

DISCUSSION

A case example, shown in Figure 3, demonstrates how content accessible through the SHM VTE QI RR may be used to catalyze a local quality improvement effort.

Figure 3

Hospitals will be measured on rates of VTE prophylaxis on medical and surgical services. Failure to standardize prophylaxis among different physician groups may adversely affect overall performance, with implications for both patient care and accreditation. The lack of a agreed‐on gold standard of what constitutes appropriate prophylaxis for a given patient does not absolve an institution of the duty to implement its own standards. The challenge of achieving local consensus on appropriate prophylaxis should not outweigh the urgency to address preventable in‐hospital deaths. In caring for increasing numbers of general medical and surgical patients, hospitalists are likely to be asked to develop and implement a protocol for VTE prophylaxis that can be used hospitalwide. In many instances hospitalists will accept this charge in the aftermath of previous hospital failures in which admission order sets or VTE assessment protocols were launched but never widely implemented. As the National Quality Forum or JCAHO regulations for uniformity among hospitals shift VTE prophylaxis from being voluntary to compulsory, hospitalists will need to develop improvement strategies that have greater reliability.

Hospitalists with no formal training in either vascular medicine or quality improvement may not be able to immediately cite the most current data about VTE prophylaxis rates and regimens and may not have the time to enroll in a training course on quality improvement. How would hospitalists determine baseline rates of appropriate VTE prophylaxis? How can medical education be used to build consensus and recruit support from other physicians? What should be the scope of the QI initiative, and what patient population should be targeted for intervention?

The goal of the SHM QI RR is to provide the tools and the framework to help hospitalists develop, implement, and manage a VTE prophylaxis quality improvement initiative. Suggested Steps to Action in the Awareness section depict exactly how a hospital medicine service can use the campaign's materials to raise institutional support for tackling this preventable problem. Hospital quality officers can direct the hospital's public relations department to the Awareness section for DVT Awareness Month materials, including public service announcements in audio, visual, and print formats. The hold music at the hospital can be temporarily replaced, television kiosks can be set up to run video loops, and banners can be printed and hung in central locations, all to get out the message simultaneously to patients and medical staff.

The Evidence section of the VTE QI RR references a key benchmark study, the DVT‐Free Prospective Registry.9 This study reported that at 183 sites in North America and Europe, more than twice as many medical patients as surgical patients failed to receive prophylaxis. The Evidence section includes the 7th American College of Chest Physicians Consensus Conference on Antithrombotic and Thrombolytic Therapy and also highlights 3 randomized placebo‐controlled clinical trials (MEDENOX 1999, ARTEMIS 2003, and PREVENT 2004) that have reported significant reduction of risk of VTE (50%‐60%) from pharmacologic prophylaxis in moderate‐risk medical inpatients.1315 Review of the data helps to determine which patient population to study first, which prophylaxis options a hospital could deploy appropriately, and the expected magnitude of the effect. Because the literature has already been narrowed and is kept current, hospitalists can save time in answering a range of questions, from the most commonly agreed‐on factors to stratify risk to which populations require alternative interventions.

The Experience section references the first clinical trial demonstrating improved patient outcomes from a quality improvement initiative aimed at improving utilization of VTE prophylaxis.10 At the large teaching hospital where the electronic alerts were studied, a preexisting wealth of educational information on the hospital Web site, in the form of multiple seminars and lectures on VTE prophylaxis by opinion leaders and international experts, had little impact on practice. For this reason, the investigators implemented a trial of how to change physician behavior by introducing a point‐of‐care intervention, the computer alerts. Clinicians prompted by an electronic alert to consider DVT prophylaxis for at‐risk patients employed nearly double the rate of pharmacologic prophylaxis and reduced the incidence of DVT or pulmonary embolism (PE) by 41%. This study suggests that a change introduced to the clinical workflow can improve evidence‐based VTE prophylaxis and also can reduce the incidence of VTE in acutely ill hospitalized patients.

We believe that if hospitalists use the current evidence and experience assembled in the VTE QI RR, they could develop and lead a systematic approach to improving utilization of VTE prophylaxis. Although there is no gold standard method for integrating VTE risk assessment into clinical workflow, the VTE QI RR presents key lessons both from the literature and real world experiences. The crucial take‐home message is that hospitalists can facilitate implementation of VTE risk assessments if they stress simplicity (ie, the sick, old, surgery benefit), link the risk assessment to a menu of evidence‐based prophylaxis options, and require assessment of VTE risk as part of a regular routine (on admission and at regular intervals). Although many hospitals do not yet have computerized entry of physician orders, the simple 4‐point VTE risk assessment described by Kucher et al might be applied to other hospitals.10 The 4‐point system would identify the patients at highest risk, a reasonable starting point for a QI initiative. Whatever the modelCPOE alerts of very high‐risk patients, CPOE‐forced VTE risk assessments, nursing assessments, or paper‐based order setsregular VTE risk assessment can be incorporated into the daily routine of hospital care.

The QI workbook sequences the steps of a multidisciplinary improvement team and prompts users to set specific goals, collect practical metrics, and conduct plan‐do‐study‐act (PDSA) cycles of learning and action (Figure 4). Hospitalists and other team members can use the information in the workbook to estimate the prevalence of use of the appropriate VTE prophylaxis and the incidence of hospital‐acquired VTE at their medical centers, develop a suitable VTE risk assessment model, and plan interventions. Starting with all patients admitted to one nurse on one unit, then expanding to an entire nursing unit, an improvement team could implement rapid PDSA cycles to iron out the wrinkles of a risk assessment protocol. After demonstrating a measurable benefit for the patients at highest risk, the team would then be expected to capture more patients at risk for VTE by modifying the risk assessment protocol to identify moderate‐risk patients (hospitalized patients with one risk factor), as in the MEDENOX, ARTEMIS, and PREVENT clinical trials. Within the first several months, the QI intervention could be expanded to more nursing units. An improvement report profiling a clinically important increase in the rate of appropriate VTE prophylaxis would advocate for additional local resources and projects.

Figure 4

As questions arise in assembling an improvement team, setting useful aims and metrics, choosing interventions, implementing and studying change, or collecting performance data, hospitalists can review answers to questions already posted and post their own questions in the Ask the Expert area. For example, one user asked whether there was a standard risk assessment tool for identifying patients at high risk of VTE. Another asked about the use of unfractionated heparin as a low‐cost alternative to low‐molecular‐weight heparin. Both these questions were answered within 24 hours by the content editor of the VTE QI RR and, for one question, also by 2 pharmacists and an international expert in VTE.

As other hospitalists begin de novo efforts of their own, success stories and strategies posted in the online forums of the VTE QI RR will be an evolving resource for basic know‐how and innovation.

Suggestions from a community of resource room users will be solicited, evaluated, and incorporated into the QI RR in order to improve its educational value and utility. The curricula could also be adapted or refined by others with an interest in systems‐based care or practice‐based learning, such as directors of residency training programs.

CONCLUSIONS

The QI RRs bring QI theory and practice to the hospitalist, when and wherever it is wanted, minimizing time away from patient care. The workbook links theory to practice and can be used to launch, sustain, and document a local VTE‐specific QI initiative. A range of experience is accommodated. Content is provided in a way that enables the user to immediately apply and adapt it to a local contextusers can access and download the subset of tools that best meet their needs. For practicing hospitalists, this QI resource offers an opportunity to bridge the training gap in systems‐based hospital care and should increase the quality and quantity of and support for opportunities to lead successful QI projects.

The Accreditation Council of Graduate Medical Education (ACGME) now requires education in health care systems, a requirement not previously mandated for traditional medical residency programs.17 Because the resource rooms should increase the number of hospitalists competently leading local efforts that achieve measurable gains in hospital outcomes, a wider potential constituency also includes residency program directors, internal medicine residents, physician assistants and nurse‐practitioners, nurses, hospital quality officers, and hospital medicine practice leaders.

Further research is needed to determine the clinical impact of the VTE QI workbook on outcomes for hospitalized patients. The effectiveness of such an educational method should be evaluated, at least in part, by documenting changes in clinically important process and outcome measures, in this case those specific to hospital‐acquired VTE. Investigation also will need to generate an impact assessment to see if the curricula are effective in meeting the strategic educational goals of the Society of Hospital Medicine. Further investigation will examine whether this resource can help residency training programs achieve ACGME goals for practice‐based learning and systems‐based care.