Arthur T. Evans, MD, MPH

As hospitalists now care for expanding numbers of America's aging patients, many of whom have chronic, debilitating illnesses or are near the end of life, there is a burgeoning need for innovative approaches to optimize quality of care and control costs, especially in the last year of life.[1, 2] In the inaugural issue of the Journal of Hospital Medicine, an overview of how hospitalists and palliative care specialists can work hand‐in‐hand to care for these seriously ill, hospitalized patients was presented.[3, 4] This perspective highlighted a symbiotic and mutually beneficial relationship between the 2 specialties based on their shared values, missions, and complementary strengths.[3, 4] Since then, a number of collaborative ventures offering palliative care for seriously ill, hospitalized patients have been developed and examined in a variety of settings.[4, 5, 6]

A key collaborative undertaking for hospitalists and palliative care specialists is the appreciation of the unique trajectory of each chronic illness toward the end of life. For example, patients with cancer or neurodegenerative disease tend to have relatively stable functional status until the final months of rapid deterioration. On the other hand, the courses of patients with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), end‐stage renal disease, and human immunodeficiency virus/acquired immunodeficiency syndrome tend to be punctuated by episodes of acute exacerbation with often nearly complete return to previous status. Finally, dementia usually follows a slow course of gradual decline leading to death.[7] Ideally, active management of symptoms and discussion of prognosis and goals of care should happen in the early stages of these chronic illnesses, yet most often they are left until an acute hospitalization late in the disease course. The following case illustrates the point.

CASE 1

Mrs. M is an 89‐year‐old woman with Alzheimer's dementia diagnosed 7 years ago who has been cared for at home by family members. She is admitted to the hospital for urinary tract infection and volume depletion. She is bedbound, cachectic, and has a stage III decubitus ulcer. Her daughter describes a 6‐month history of feeding problems, 20‐lb weight loss, and 2 recent hospitalizations for aspiration pneumonia. She improves somewhat with hydration and intravenous antibiotics, and the physical therapist recommends rehabilitation. Mrs. M does not have decision‐making capacity, and her long‐time family physician has not inquired about care preferences or goals. The hospitalist team meets with family members to discuss the trajectory and prognosis of advanced dementia, and recommends against artificial nutrition and hydration, and for initiation of palliative care service at a skilled nursing facility.

In this example, the hospitalist team recognizes the advent of frequent infections and diminished oral intake in advanced dementia as signals of increased morbidity and mortality warranting palliative care intervention.[8] This, we suggest, represents a sentinel hospitalization, a hospitalization in the disease course that heralds a need to reassess prognosis, treatment options and intensity, and goals of care. Hospitalists are well positioned to recognize such transition points in the disease course by considering the patient's recent history of illness, to offer an impartial overview of illness progression, and to optimize patient care using principles of palliative care. Additionally, hospitalists have advantages of geographic convenience, readily available consultants, systemic support, and a detachment from the longitudinal patient‐physician relationship, which may enable more accurate medical prognostication.[9]

There are many ways to identify a sentinel hospitalization. For example, hospitalists can use the surprise question, Would you be surprised if the patient died within 12 months? on admission for the majority of cancer and dialysis patients. The answer No predicts a 3.5‐ to 7‐fold increase in 1‐year mortality.[10, 11] In a powerful predictive model for 1‐year mortality using readily available clinical, laboratory, and functional characteristics, medical inpatients in the highest quartiles have 1‐year mortality exceeding 60%.[12] Recently, several more complicated prognostic models have been derived and validated in large cohorts of medical inpatients, which predict short‐term (30‐day) and long‐term (0.5‐1 year) mortality with great accuracy.[13, 14] There are also many disease‐specific prognostic features (eg, diagnosis of metastatic disease with poor performance status or high symptom burden, progression of chronic kidney disease with consideration of hemodialysis, additional stroke in multi‐infarct dementia, and frequent exacerbation of severe COPD or severe CHF).[15, 16, 17, 18, 19, 20, 21] Finally, frequent readmissions and prolonged hospital or intensive care unit stay can also be used.[17, 19] These criteria are summarized in Table 1 with time frames.

Once a sentinel hospitalization is identified, hospitalists, with input from the patient's primary care physician and subspecialists, can then develop a comprehensive strategy to evaluate current disease management, to educate patient and family accordingly, and to actively integrate palliative care services as appropriate. The next challenge facing the care team is how to deliver the necessary palliative care since it is unnecessary and improper to ask for palliative care specialist consultation for every sentinel hospitalization. We believe that the best approach is for hospitalists to be the primary deliverers of basic palliative care in the hospital while consulting palliative care specialists for refractory symptoms and complex scenarios.[22] According to this generalist‐specialist palliative care model, physicians of all specialties should define and master a basic palliative care skill set for their patients. For hospitalists, the relevant skill set includes assessing and treating pain and other symptoms such as dyspnea, nausea and vomiting, and constipation, estimating prognosis, and initiating goals of care discussions.[22] The following case illustrates this point.

CASE 2

Ms S, a 21‐year‐old Hispanic woman with advanced, recurrent head and neck cancer, status post multiple surgeries, chemotherapy, and radiation therapy, is admitted to the hospitalist service for aspiration pneumonia, which responds to antibiotics rapidly. However, her cancer‐related somatic and neuropathic pain soon becomes refractory to opioids prescribed by the hospitalist team. She also develops significant dyspnea, xerostomia, depression, anxiety, and existential suffering. With the help of the interdisciplinary palliative care team, her pain is relieved by a patient‐controlled analgesia pump and methadone. A palliative care social worker and chaplain visit her and her family daily to address their distress. Eventually, the care team is able to provide a stable medical regimen for symptom control and to use it across the entire care continuum.

In this example, the hospitalist team, with the support of palliative care specialists, provided basic palliative care and longitudinal integration of palliative practices into the patient's overall treatment scheme. Hospitalists, given their scope of practice and sheer volume of patients, are well positioned to rapidly gain competencies in symptom management, empathic communication, and interdisciplinary teamwork.[23, 24] Hospitalists may benefit from innovative and collaborative palliative care education using interactive online modules, case simulation, communication workshops, and observed evaluation and feedback.[25] Several modes of collaboration between hospital medicine and palliative care have been developed including implementation of palliative care consult triggers on admission, palliative care participation in hospitalist interdisciplinary rounds, and disease specific, integrated management programs.[17, 26] These collaborations are particularly important, as the quality of inpatient care at the end of life is still suboptimal and more appropriate use of palliative care will be beneficial.[27] Recently, some hospitals have developed specialized inpatient palliative care units, combining intensive palliation with inpatient medical surgical level of care, as well as providing hospice care. Staffed by palliative care specialists or hospitalists, they provide efficient, cost‐saving care to patients with advanced chronic illness or terminal disease in need of intensive symptom management.[28] Finally, there is mounting evidence supporting the clinical effectiveness of palliative care in diverse specialties such as oncology, pulmonary and critical care, and nephrology.[29] For example, in the setting of metastatic non‐small cell lung cancer, early initiation of palliative care has been shown to improve symptom control and quality of life, reduce chemotherapy use at the end of life, and interestingly, prolong median survival by almost 3 months.[30] This has led to a position statement from American Society of Clinical Oncology encouraging early integration of palliative care into standard oncologic care for advanced disease.[31]

Recognizing a sentinel hospitalization allows palliative care to be integrated at transitions of care and carried forward. For patients with chronic debilitating illnesses who are approaching the end of life, appropriate care transitions will ensure that their short‐ and long‐term care matches their goals of care, assure timely clinical follow‐ups, and help reduce hospital readmission and healthcare resource utilization.[32] Importantly, timely and compassionate communication is a key to the success of both hospital medicine and palliative care. Many patients with life‐limiting diseases prefer to receive prognostic information and to discuss goals of care.[33] How this information is integrated and communicated through the care continuum is crucial, especially in the era of duty hour limits and frequent handoffs. The information exchange needs to facilitate active participation of primary care physicians who may not be involved in hospital care. Some of the innovative strategies for communication and transfer of palliative care information, such as prognosis, goals of care, family meeting consensus, and symptom control interventions, include a palliative care checklist in the electronic health record, incorporation of prognostic and family meeting information in the discharge summary, and links to the national Physician Orders for Life‐Sustaining Treatment advanced care planning program.[34] Of note, a pilot program in the United Kingdom adopting an electronic palliative care summary has reduced after‐hour emergency room visits and hospital readmissions.[35] The following case illustrates this point.

CASE 3

Mrs. K, an 82‐year‐old Russian‐speaking woman with newly diagnosed metastatic pancreatic cancer, is admitted for worsening obstructive jaundice and a second opinion about treatment. A biliary stent is placed and her jaundice slowly improves. The patient and family have requested chemotherapy. However, the oncologist determines that she would only qualify for a phase I trial given her poor performance status. The hospitalist team requests the help of the palliative care consult team to manage her severe pain, depression, and to provide support to the family. After several family meetings, the patient and family choose not to pursue chemotherapy. Given the lack of adequate support at home, she is discharged to a skilled nursing facility for short‐term rehabilitation with plans to transition to the in‐house hospice program. The hospitalist, palliative care attending physician, and the medical director of the rehabilitation facility have a 3‐way phone conference to confirm the plans of care and to ensure a smooth care transition.

In this case, the hospitalist team recognizes that this is a sentinel hospitalization for Mrs. K that requires extensive palliative care intervention. Often, transitioning to skilled nursing facilities (SNF) is the default pathway for patients needing hospice/palliative care, especially when patients and families are not yet ready to discuss prognosis realistically or to accept hospice, or there is not enough support available at home. A recent large cohort study showed that 30% of patients in their last 6‐month of life had used, and nearly 10% of such patients had died, under Medicare's posthospitalization SNF benefit.[36] Although the worsening disease trajectory may not be apparent at hospital discharge, it is more likely that the financial and practical limitation of the Medicare Hospice Benefit accounts for this observation, which includes limited home health aid hours, lack of coverage for room and board, and lower payments to SNFs.[36] Hospitalists can help address the issue of discharge location for patients needing palliative care. Sometimes this requires extensive communication before and after discharge to help enhance the transition from a rehabilitation facility to hospice/palliative care. Appropriately integrated palliative care at the time of care transitions, in the form of hospice or longitudinal home‐based palliative care rather than just routine clinic follow‐up, has the potential to reduce 30‐day readmission for chronically ill, elderly patients and for patients near the end of life.[37, 38] It is critical that national policy, suitable reimbursement, and financial incentives support this practice. A demonstration project, Better Outcomes by Optimizing Safe Transitions (BOOST), organized by the Society of Hospital Medicine, integrates palliative care evaluation into a comprehensive discharge assessment tool. This intervention has been shown to reduce readmissions to acute care hospitals.[39]

In this article, we define a sentinel hospitalization and suggest that its recognition provides an important opportunity for hospitalists to actively integrate palliative care into patients' chronic disease management programs, with inputs from patients, their families, their primary physicians and subspecialists, as well as palliative care specialists. We also recognize that within nonsentinel hospitalizations, there are important opportunities to discuss prognosis, goals of care, and advanced care planning. This approach allows the fresh eyes of hospitalists to assess the patient's current health status and prognosis, to communicate these relevant clinical issues with the patient and family, and to encourage discussions about goals of care and advanced care planning during the sentinel hospitalization. It also provides a structured vehicle for soliciting the patient's (and family's) perspectives and documenting them in the medical record. A compilation of sample items to guide discussion can be found in Table 2. Hospitalists, equipped with basic palliative care skills and supported by hospital‐ and community‐based palliative care teams, can thrive in this unique position of optimizing the quality of care for these patients.[40] Almost 20 years ago, the field of palliative care rose to national prominence on the findings of the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) study, which investigated the suboptimal end‐of‐life experiences of hospitalized adult patients.[41] Since then, the fields of both hospital medicine and palliative care have grown, yet the best is still to come for their collaborative excellence, mutual education, and shared care innovation at the forefront of medicine.

As hospitalists now care for expanding numbers of America's aging patients, many of whom have chronic, debilitating illnesses or are near the end of life, there is a burgeoning need for innovative approaches to optimize quality of care and control costs, especially in the last year of life.[1, 2] In the inaugural issue of the Journal of Hospital Medicine, an overview of how hospitalists and palliative care specialists can work hand‐in‐hand to care for these seriously ill, hospitalized patients was presented.[3, 4] This perspective highlighted a symbiotic and mutually beneficial relationship between the 2 specialties based on their shared values, missions, and complementary strengths.[3, 4] Since then, a number of collaborative ventures offering palliative care for seriously ill, hospitalized patients have been developed and examined in a variety of settings.[4, 5, 6]

A key collaborative undertaking for hospitalists and palliative care specialists is the appreciation of the unique trajectory of each chronic illness toward the end of life. For example, patients with cancer or neurodegenerative disease tend to have relatively stable functional status until the final months of rapid deterioration. On the other hand, the courses of patients with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), end‐stage renal disease, and human immunodeficiency virus/acquired immunodeficiency syndrome tend to be punctuated by episodes of acute exacerbation with often nearly complete return to previous status. Finally, dementia usually follows a slow course of gradual decline leading to death.[7] Ideally, active management of symptoms and discussion of prognosis and goals of care should happen in the early stages of these chronic illnesses, yet most often they are left until an acute hospitalization late in the disease course. The following case illustrates the point.

CASE 1

Mrs. M is an 89‐year‐old woman with Alzheimer's dementia diagnosed 7 years ago who has been cared for at home by family members. She is admitted to the hospital for urinary tract infection and volume depletion. She is bedbound, cachectic, and has a stage III decubitus ulcer. Her daughter describes a 6‐month history of feeding problems, 20‐lb weight loss, and 2 recent hospitalizations for aspiration pneumonia. She improves somewhat with hydration and intravenous antibiotics, and the physical therapist recommends rehabilitation. Mrs. M does not have decision‐making capacity, and her long‐time family physician has not inquired about care preferences or goals. The hospitalist team meets with family members to discuss the trajectory and prognosis of advanced dementia, and recommends against artificial nutrition and hydration, and for initiation of palliative care service at a skilled nursing facility.

In this example, the hospitalist team recognizes the advent of frequent infections and diminished oral intake in advanced dementia as signals of increased morbidity and mortality warranting palliative care intervention.[8] This, we suggest, represents a sentinel hospitalization, a hospitalization in the disease course that heralds a need to reassess prognosis, treatment options and intensity, and goals of care. Hospitalists are well positioned to recognize such transition points in the disease course by considering the patient's recent history of illness, to offer an impartial overview of illness progression, and to optimize patient care using principles of palliative care. Additionally, hospitalists have advantages of geographic convenience, readily available consultants, systemic support, and a detachment from the longitudinal patient‐physician relationship, which may enable more accurate medical prognostication.[9]

There are many ways to identify a sentinel hospitalization. For example, hospitalists can use the surprise question, Would you be surprised if the patient died within 12 months? on admission for the majority of cancer and dialysis patients. The answer No predicts a 3.5‐ to 7‐fold increase in 1‐year mortality.[10, 11] In a powerful predictive model for 1‐year mortality using readily available clinical, laboratory, and functional characteristics, medical inpatients in the highest quartiles have 1‐year mortality exceeding 60%.[12] Recently, several more complicated prognostic models have been derived and validated in large cohorts of medical inpatients, which predict short‐term (30‐day) and long‐term (0.5‐1 year) mortality with great accuracy.[13, 14] There are also many disease‐specific prognostic features (eg, diagnosis of metastatic disease with poor performance status or high symptom burden, progression of chronic kidney disease with consideration of hemodialysis, additional stroke in multi‐infarct dementia, and frequent exacerbation of severe COPD or severe CHF).[15, 16, 17, 18, 19, 20, 21] Finally, frequent readmissions and prolonged hospital or intensive care unit stay can also be used.[17, 19] These criteria are summarized in Table 1 with time frames.

Once a sentinel hospitalization is identified, hospitalists, with input from the patient's primary care physician and subspecialists, can then develop a comprehensive strategy to evaluate current disease management, to educate patient and family accordingly, and to actively integrate palliative care services as appropriate. The next challenge facing the care team is how to deliver the necessary palliative care since it is unnecessary and improper to ask for palliative care specialist consultation for every sentinel hospitalization. We believe that the best approach is for hospitalists to be the primary deliverers of basic palliative care in the hospital while consulting palliative care specialists for refractory symptoms and complex scenarios.[22] According to this generalist‐specialist palliative care model, physicians of all specialties should define and master a basic palliative care skill set for their patients. For hospitalists, the relevant skill set includes assessing and treating pain and other symptoms such as dyspnea, nausea and vomiting, and constipation, estimating prognosis, and initiating goals of care discussions.[22] The following case illustrates this point.

CASE 2

Ms S, a 21‐year‐old Hispanic woman with advanced, recurrent head and neck cancer, status post multiple surgeries, chemotherapy, and radiation therapy, is admitted to the hospitalist service for aspiration pneumonia, which responds to antibiotics rapidly. However, her cancer‐related somatic and neuropathic pain soon becomes refractory to opioids prescribed by the hospitalist team. She also develops significant dyspnea, xerostomia, depression, anxiety, and existential suffering. With the help of the interdisciplinary palliative care team, her pain is relieved by a patient‐controlled analgesia pump and methadone. A palliative care social worker and chaplain visit her and her family daily to address their distress. Eventually, the care team is able to provide a stable medical regimen for symptom control and to use it across the entire care continuum.

In this example, the hospitalist team, with the support of palliative care specialists, provided basic palliative care and longitudinal integration of palliative practices into the patient's overall treatment scheme. Hospitalists, given their scope of practice and sheer volume of patients, are well positioned to rapidly gain competencies in symptom management, empathic communication, and interdisciplinary teamwork.[23, 24] Hospitalists may benefit from innovative and collaborative palliative care education using interactive online modules, case simulation, communication workshops, and observed evaluation and feedback.[25] Several modes of collaboration between hospital medicine and palliative care have been developed including implementation of palliative care consult triggers on admission, palliative care participation in hospitalist interdisciplinary rounds, and disease specific, integrated management programs.[17, 26] These collaborations are particularly important, as the quality of inpatient care at the end of life is still suboptimal and more appropriate use of palliative care will be beneficial.[27] Recently, some hospitals have developed specialized inpatient palliative care units, combining intensive palliation with inpatient medical surgical level of care, as well as providing hospice care. Staffed by palliative care specialists or hospitalists, they provide efficient, cost‐saving care to patients with advanced chronic illness or terminal disease in need of intensive symptom management.[28] Finally, there is mounting evidence supporting the clinical effectiveness of palliative care in diverse specialties such as oncology, pulmonary and critical care, and nephrology.[29] For example, in the setting of metastatic non‐small cell lung cancer, early initiation of palliative care has been shown to improve symptom control and quality of life, reduce chemotherapy use at the end of life, and interestingly, prolong median survival by almost 3 months.[30] This has led to a position statement from American Society of Clinical Oncology encouraging early integration of palliative care into standard oncologic care for advanced disease.[31]

Recognizing a sentinel hospitalization allows palliative care to be integrated at transitions of care and carried forward. For patients with chronic debilitating illnesses who are approaching the end of life, appropriate care transitions will ensure that their short‐ and long‐term care matches their goals of care, assure timely clinical follow‐ups, and help reduce hospital readmission and healthcare resource utilization.[32] Importantly, timely and compassionate communication is a key to the success of both hospital medicine and palliative care. Many patients with life‐limiting diseases prefer to receive prognostic information and to discuss goals of care.[33] How this information is integrated and communicated through the care continuum is crucial, especially in the era of duty hour limits and frequent handoffs. The information exchange needs to facilitate active participation of primary care physicians who may not be involved in hospital care. Some of the innovative strategies for communication and transfer of palliative care information, such as prognosis, goals of care, family meeting consensus, and symptom control interventions, include a palliative care checklist in the electronic health record, incorporation of prognostic and family meeting information in the discharge summary, and links to the national Physician Orders for Life‐Sustaining Treatment advanced care planning program.[34] Of note, a pilot program in the United Kingdom adopting an electronic palliative care summary has reduced after‐hour emergency room visits and hospital readmissions.[35] The following case illustrates this point.

CASE 3

Mrs. K, an 82‐year‐old Russian‐speaking woman with newly diagnosed metastatic pancreatic cancer, is admitted for worsening obstructive jaundice and a second opinion about treatment. A biliary stent is placed and her jaundice slowly improves. The patient and family have requested chemotherapy. However, the oncologist determines that she would only qualify for a phase I trial given her poor performance status. The hospitalist team requests the help of the palliative care consult team to manage her severe pain, depression, and to provide support to the family. After several family meetings, the patient and family choose not to pursue chemotherapy. Given the lack of adequate support at home, she is discharged to a skilled nursing facility for short‐term rehabilitation with plans to transition to the in‐house hospice program. The hospitalist, palliative care attending physician, and the medical director of the rehabilitation facility have a 3‐way phone conference to confirm the plans of care and to ensure a smooth care transition.

In this case, the hospitalist team recognizes that this is a sentinel hospitalization for Mrs. K that requires extensive palliative care intervention. Often, transitioning to skilled nursing facilities (SNF) is the default pathway for patients needing hospice/palliative care, especially when patients and families are not yet ready to discuss prognosis realistically or to accept hospice, or there is not enough support available at home. A recent large cohort study showed that 30% of patients in their last 6‐month of life had used, and nearly 10% of such patients had died, under Medicare's posthospitalization SNF benefit.[36] Although the worsening disease trajectory may not be apparent at hospital discharge, it is more likely that the financial and practical limitation of the Medicare Hospice Benefit accounts for this observation, which includes limited home health aid hours, lack of coverage for room and board, and lower payments to SNFs.[36] Hospitalists can help address the issue of discharge location for patients needing palliative care. Sometimes this requires extensive communication before and after discharge to help enhance the transition from a rehabilitation facility to hospice/palliative care. Appropriately integrated palliative care at the time of care transitions, in the form of hospice or longitudinal home‐based palliative care rather than just routine clinic follow‐up, has the potential to reduce 30‐day readmission for chronically ill, elderly patients and for patients near the end of life.[37, 38] It is critical that national policy, suitable reimbursement, and financial incentives support this practice. A demonstration project, Better Outcomes by Optimizing Safe Transitions (BOOST), organized by the Society of Hospital Medicine, integrates palliative care evaluation into a comprehensive discharge assessment tool. This intervention has been shown to reduce readmissions to acute care hospitals.[39]

In this article, we define a sentinel hospitalization and suggest that its recognition provides an important opportunity for hospitalists to actively integrate palliative care into patients' chronic disease management programs, with inputs from patients, their families, their primary physicians and subspecialists, as well as palliative care specialists. We also recognize that within nonsentinel hospitalizations, there are important opportunities to discuss prognosis, goals of care, and advanced care planning. This approach allows the fresh eyes of hospitalists to assess the patient's current health status and prognosis, to communicate these relevant clinical issues with the patient and family, and to encourage discussions about goals of care and advanced care planning during the sentinel hospitalization. It also provides a structured vehicle for soliciting the patient's (and family's) perspectives and documenting them in the medical record. A compilation of sample items to guide discussion can be found in Table 2. Hospitalists, equipped with basic palliative care skills and supported by hospital‐ and community‐based palliative care teams, can thrive in this unique position of optimizing the quality of care for these patients.[40] Almost 20 years ago, the field of palliative care rose to national prominence on the findings of the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) study, which investigated the suboptimal end‐of‐life experiences of hospitalized adult patients.[41] Since then, the fields of both hospital medicine and palliative care have grown, yet the best is still to come for their collaborative excellence, mutual education, and shared care innovation at the forefront of medicine.

As hospitalists now care for expanding numbers of America's aging patients, many of whom have chronic, debilitating illnesses or are near the end of life, there is a burgeoning need for innovative approaches to optimize quality of care and control costs, especially in the last year of life.[1, 2] In the inaugural issue of the Journal of Hospital Medicine, an overview of how hospitalists and palliative care specialists can work hand‐in‐hand to care for these seriously ill, hospitalized patients was presented.[3, 4] This perspective highlighted a symbiotic and mutually beneficial relationship between the 2 specialties based on their shared values, missions, and complementary strengths.[3, 4] Since then, a number of collaborative ventures offering palliative care for seriously ill, hospitalized patients have been developed and examined in a variety of settings.[4, 5, 6]

A key collaborative undertaking for hospitalists and palliative care specialists is the appreciation of the unique trajectory of each chronic illness toward the end of life. For example, patients with cancer or neurodegenerative disease tend to have relatively stable functional status until the final months of rapid deterioration. On the other hand, the courses of patients with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), end‐stage renal disease, and human immunodeficiency virus/acquired immunodeficiency syndrome tend to be punctuated by episodes of acute exacerbation with often nearly complete return to previous status. Finally, dementia usually follows a slow course of gradual decline leading to death.[7] Ideally, active management of symptoms and discussion of prognosis and goals of care should happen in the early stages of these chronic illnesses, yet most often they are left until an acute hospitalization late in the disease course. The following case illustrates the point.

CASE 1

Mrs. M is an 89‐year‐old woman with Alzheimer's dementia diagnosed 7 years ago who has been cared for at home by family members. She is admitted to the hospital for urinary tract infection and volume depletion. She is bedbound, cachectic, and has a stage III decubitus ulcer. Her daughter describes a 6‐month history of feeding problems, 20‐lb weight loss, and 2 recent hospitalizations for aspiration pneumonia. She improves somewhat with hydration and intravenous antibiotics, and the physical therapist recommends rehabilitation. Mrs. M does not have decision‐making capacity, and her long‐time family physician has not inquired about care preferences or goals. The hospitalist team meets with family members to discuss the trajectory and prognosis of advanced dementia, and recommends against artificial nutrition and hydration, and for initiation of palliative care service at a skilled nursing facility.

In this example, the hospitalist team recognizes the advent of frequent infections and diminished oral intake in advanced dementia as signals of increased morbidity and mortality warranting palliative care intervention.[8] This, we suggest, represents a sentinel hospitalization, a hospitalization in the disease course that heralds a need to reassess prognosis, treatment options and intensity, and goals of care. Hospitalists are well positioned to recognize such transition points in the disease course by considering the patient's recent history of illness, to offer an impartial overview of illness progression, and to optimize patient care using principles of palliative care. Additionally, hospitalists have advantages of geographic convenience, readily available consultants, systemic support, and a detachment from the longitudinal patient‐physician relationship, which may enable more accurate medical prognostication.[9]

There are many ways to identify a sentinel hospitalization. For example, hospitalists can use the surprise question, Would you be surprised if the patient died within 12 months? on admission for the majority of cancer and dialysis patients. The answer No predicts a 3.5‐ to 7‐fold increase in 1‐year mortality.[10, 11] In a powerful predictive model for 1‐year mortality using readily available clinical, laboratory, and functional characteristics, medical inpatients in the highest quartiles have 1‐year mortality exceeding 60%.[12] Recently, several more complicated prognostic models have been derived and validated in large cohorts of medical inpatients, which predict short‐term (30‐day) and long‐term (0.5‐1 year) mortality with great accuracy.[13, 14] There are also many disease‐specific prognostic features (eg, diagnosis of metastatic disease with poor performance status or high symptom burden, progression of chronic kidney disease with consideration of hemodialysis, additional stroke in multi‐infarct dementia, and frequent exacerbation of severe COPD or severe CHF).[15, 16, 17, 18, 19, 20, 21] Finally, frequent readmissions and prolonged hospital or intensive care unit stay can also be used.[17, 19] These criteria are summarized in Table 1 with time frames.

Once a sentinel hospitalization is identified, hospitalists, with input from the patient's primary care physician and subspecialists, can then develop a comprehensive strategy to evaluate current disease management, to educate patient and family accordingly, and to actively integrate palliative care services as appropriate. The next challenge facing the care team is how to deliver the necessary palliative care since it is unnecessary and improper to ask for palliative care specialist consultation for every sentinel hospitalization. We believe that the best approach is for hospitalists to be the primary deliverers of basic palliative care in the hospital while consulting palliative care specialists for refractory symptoms and complex scenarios.[22] According to this generalist‐specialist palliative care model, physicians of all specialties should define and master a basic palliative care skill set for their patients. For hospitalists, the relevant skill set includes assessing and treating pain and other symptoms such as dyspnea, nausea and vomiting, and constipation, estimating prognosis, and initiating goals of care discussions.[22] The following case illustrates this point.

CASE 2

Ms S, a 21‐year‐old Hispanic woman with advanced, recurrent head and neck cancer, status post multiple surgeries, chemotherapy, and radiation therapy, is admitted to the hospitalist service for aspiration pneumonia, which responds to antibiotics rapidly. However, her cancer‐related somatic and neuropathic pain soon becomes refractory to opioids prescribed by the hospitalist team. She also develops significant dyspnea, xerostomia, depression, anxiety, and existential suffering. With the help of the interdisciplinary palliative care team, her pain is relieved by a patient‐controlled analgesia pump and methadone. A palliative care social worker and chaplain visit her and her family daily to address their distress. Eventually, the care team is able to provide a stable medical regimen for symptom control and to use it across the entire care continuum.

In this example, the hospitalist team, with the support of palliative care specialists, provided basic palliative care and longitudinal integration of palliative practices into the patient's overall treatment scheme. Hospitalists, given their scope of practice and sheer volume of patients, are well positioned to rapidly gain competencies in symptom management, empathic communication, and interdisciplinary teamwork.[23, 24] Hospitalists may benefit from innovative and collaborative palliative care education using interactive online modules, case simulation, communication workshops, and observed evaluation and feedback.[25] Several modes of collaboration between hospital medicine and palliative care have been developed including implementation of palliative care consult triggers on admission, palliative care participation in hospitalist interdisciplinary rounds, and disease specific, integrated management programs.[17, 26] These collaborations are particularly important, as the quality of inpatient care at the end of life is still suboptimal and more appropriate use of palliative care will be beneficial.[27] Recently, some hospitals have developed specialized inpatient palliative care units, combining intensive palliation with inpatient medical surgical level of care, as well as providing hospice care. Staffed by palliative care specialists or hospitalists, they provide efficient, cost‐saving care to patients with advanced chronic illness or terminal disease in need of intensive symptom management.[28] Finally, there is mounting evidence supporting the clinical effectiveness of palliative care in diverse specialties such as oncology, pulmonary and critical care, and nephrology.[29] For example, in the setting of metastatic non‐small cell lung cancer, early initiation of palliative care has been shown to improve symptom control and quality of life, reduce chemotherapy use at the end of life, and interestingly, prolong median survival by almost 3 months.[30] This has led to a position statement from American Society of Clinical Oncology encouraging early integration of palliative care into standard oncologic care for advanced disease.[31]

Recognizing a sentinel hospitalization allows palliative care to be integrated at transitions of care and carried forward. For patients with chronic debilitating illnesses who are approaching the end of life, appropriate care transitions will ensure that their short‐ and long‐term care matches their goals of care, assure timely clinical follow‐ups, and help reduce hospital readmission and healthcare resource utilization.[32] Importantly, timely and compassionate communication is a key to the success of both hospital medicine and palliative care. Many patients with life‐limiting diseases prefer to receive prognostic information and to discuss goals of care.[33] How this information is integrated and communicated through the care continuum is crucial, especially in the era of duty hour limits and frequent handoffs. The information exchange needs to facilitate active participation of primary care physicians who may not be involved in hospital care. Some of the innovative strategies for communication and transfer of palliative care information, such as prognosis, goals of care, family meeting consensus, and symptom control interventions, include a palliative care checklist in the electronic health record, incorporation of prognostic and family meeting information in the discharge summary, and links to the national Physician Orders for Life‐Sustaining Treatment advanced care planning program.[34] Of note, a pilot program in the United Kingdom adopting an electronic palliative care summary has reduced after‐hour emergency room visits and hospital readmissions.[35] The following case illustrates this point.

CASE 3

Mrs. K, an 82‐year‐old Russian‐speaking woman with newly diagnosed metastatic pancreatic cancer, is admitted for worsening obstructive jaundice and a second opinion about treatment. A biliary stent is placed and her jaundice slowly improves. The patient and family have requested chemotherapy. However, the oncologist determines that she would only qualify for a phase I trial given her poor performance status. The hospitalist team requests the help of the palliative care consult team to manage her severe pain, depression, and to provide support to the family. After several family meetings, the patient and family choose not to pursue chemotherapy. Given the lack of adequate support at home, she is discharged to a skilled nursing facility for short‐term rehabilitation with plans to transition to the in‐house hospice program. The hospitalist, palliative care attending physician, and the medical director of the rehabilitation facility have a 3‐way phone conference to confirm the plans of care and to ensure a smooth care transition.

In this case, the hospitalist team recognizes that this is a sentinel hospitalization for Mrs. K that requires extensive palliative care intervention. Often, transitioning to skilled nursing facilities (SNF) is the default pathway for patients needing hospice/palliative care, especially when patients and families are not yet ready to discuss prognosis realistically or to accept hospice, or there is not enough support available at home. A recent large cohort study showed that 30% of patients in their last 6‐month of life had used, and nearly 10% of such patients had died, under Medicare's posthospitalization SNF benefit.[36] Although the worsening disease trajectory may not be apparent at hospital discharge, it is more likely that the financial and practical limitation of the Medicare Hospice Benefit accounts for this observation, which includes limited home health aid hours, lack of coverage for room and board, and lower payments to SNFs.[36] Hospitalists can help address the issue of discharge location for patients needing palliative care. Sometimes this requires extensive communication before and after discharge to help enhance the transition from a rehabilitation facility to hospice/palliative care. Appropriately integrated palliative care at the time of care transitions, in the form of hospice or longitudinal home‐based palliative care rather than just routine clinic follow‐up, has the potential to reduce 30‐day readmission for chronically ill, elderly patients and for patients near the end of life.[37, 38] It is critical that national policy, suitable reimbursement, and financial incentives support this practice. A demonstration project, Better Outcomes by Optimizing Safe Transitions (BOOST), organized by the Society of Hospital Medicine, integrates palliative care evaluation into a comprehensive discharge assessment tool. This intervention has been shown to reduce readmissions to acute care hospitals.[39]

In this article, we define a sentinel hospitalization and suggest that its recognition provides an important opportunity for hospitalists to actively integrate palliative care into patients' chronic disease management programs, with inputs from patients, their families, their primary physicians and subspecialists, as well as palliative care specialists. We also recognize that within nonsentinel hospitalizations, there are important opportunities to discuss prognosis, goals of care, and advanced care planning. This approach allows the fresh eyes of hospitalists to assess the patient's current health status and prognosis, to communicate these relevant clinical issues with the patient and family, and to encourage discussions about goals of care and advanced care planning during the sentinel hospitalization. It also provides a structured vehicle for soliciting the patient's (and family's) perspectives and documenting them in the medical record. A compilation of sample items to guide discussion can be found in Table 2. Hospitalists, equipped with basic palliative care skills and supported by hospital‐ and community‐based palliative care teams, can thrive in this unique position of optimizing the quality of care for these patients.[40] Almost 20 years ago, the field of palliative care rose to national prominence on the findings of the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) study, which investigated the suboptimal end‐of‐life experiences of hospitalized adult patients.[41] Since then, the fields of both hospital medicine and palliative care have grown, yet the best is still to come for their collaborative excellence, mutual education, and shared care innovation at the forefront of medicine.

The focus on care transitions and readmissions is expanding beyond the development of risk scores based on objective clinical data to quality improvement interventions involving the key stakeholders in the process, namely the patients and their multidisciplinary providers.[1, 2] The Institute for Healthcare Improvement's State Action on Avoidable Rehospitalizations initiative promotes formulating a specific transition plan and developing multidisciplinary management strategies for all patients.[3] The Transition of Care Consensus Policy Statement developed by a coalition including the American College of Physicians and Society of Hospital Medicine emphasizes accountability, communication, and involvement of the patient and family members in plans of care.[4] Yet, interventions to reduce readmissions and improve the quality and safety of care transitions remain only modestly and inconsistently effective.

Successful interventions are those that are combined and coordinated, and shared across the hospital and community settings.[5] In this study, we sought to understand the issues leading to readmissions and barriers as perceived by patients, family members, physicians, nurses, and social workers. We compared and contrasted the perspectives by discipline and used this information to design a descriptive framework of a multidisciplinary, collaborative, and coordinated support network integral to effective care transitions, which we term a Patient Care Circle (PCC) (Figure 1).

Figure 1

METHODS

RESULTS

We recruited 43 interview and 28 focus group participants (Table 1). From our transcript analysis, we generated 22 codes and categorized them into 5 themes embodying the issues pertinent to readmissions from the perspective of the stakeholders: (1) teamwork, (2) health systems navigation and management, (3) illness severity and health needs, (4) psychosocial stability; and (5) medications (Table 2).

We applied these codes and themes to build a descriptive framework depicting what we believed is the essential foundation for successful care transitions, a collaborative unified patient‐centered network to address complex healthcare‐related issues across disciplines and across settings (Figure 1). Our model illustrates the interplay between the various physician and care‐provider roles as well as the relationship of the structure of the care circle to each theme.

DISCUSSION

We categorized our findings into5 principle themes that influence care transitions: teamwork, systems navigation and management, illness severity, and health needs, psychosocial stability, and medications. Many of these themes have been targeted in the literature for interventions to reduce readmissions and improve care transitions. An overarching theme of our study was the importance of the Patient Care Circle, a support system required to implement and execute comprehensive patient‐centered plans for safe and effective transitions across all settings.

Collectively, our themes emphasized that communication and comprehensive planning between all members of the PCC were instrumental to the circle's ability to address issues pertaining to the patient‐centered themes: systems navigation and management, illness severity and health needs, psychosocial stability, and medications. The strength of the bonds and collaboration within the PCC were directly dependent on the success of teamwork.

The interplay between the 4 patient‐centered themes and the degree to which they affect readmissions were variable and patient dependent. Complexities of the healthcare system and issues surrounding medications became more apparent with worsening disease severity and psychosocial instability. Complicated patients requiring more multidisciplinary interaction highlighted limitations of dispersed teams and staffing ratios. Patients faced with insurance restrictions, difficulties attending appointments, and obtaining medications required pooling the efforts of multiple PCC members to help them. Thus, these themes emphasized not only the importance of teamwork required for care coordination, but also guided the membership of the PCC to meet the patient's specific needs across the inpatient and outpatient settings.

When participants were asked to identify modifiable reasons for readmissions, the overwhelming collective response was inadequate communication and collaboration among PCC members. Clear role assignments and delegation of responsibility were also necessary to avoid gaps in care. Significant barriers to improvement included limited resources and inability to maintain the integrity of the support network needed for safe transitions.

Finally, we compared and contrasted the perceptions of the different disciplines on the factors contributing to each patient's readmission. Over all, there was substantial overlap. However, each perspective added additional layers of information allowing for a more comprehensive understanding of the problem. This demonstrated the utility of multidisciplinary patient‐centered interviews to examine readmissions and elucidate areas for intervention.

Several disciplines were not included in interviews or focus groups but were identified by our study participants as integral to a comprehensive Patient Care Circle. These include emergency medicine physicians, inpatient and outpatient pharmacists, and outpatient social workers. Some disciplines were not included due to challenges identifying discrete providers and with arranging interviews or focus groups. As their roles were mentioned several times in multiple forums, we have included them in our descriptive framework.

We designed this study with the hope of completing a full complement of patient‐specific interviews that included all stakeholders for 4 male and 4 female patients. For several reasons, we were unable to do so including challenges contacting providers and family members, and coordinating the timing of interviews with patient visits. Further, our focus on English‐speaking patients admitted to general medicine teams may limit generalizability to other vulnerable patient groups. Nevertheless, we believe we succeeded in interviewing a representative sample and obtained thematic saturation with the information obtained from our interviews and focus groups.

Last, the focus of this project was to obtain the perspectives of a full spectrum of stakeholders in the care transitions process to gain a better understanding of the reasons for readmissions. Although we did ask study participants to identify areas that may have been modifiable, we did not expand the discussion to include potential interventions, which will be the next step in our study.

CONCLUSION

Our article describes 5 main themes derived from the perspectives of multiple stakeholders involved in the care transitions process. An overarching theme was the importance of a multidisciplinary, coordinated collaborative care circle to ensure safe patient‐centered care in all settings.

The results of this study can be used by researchers and applied by care providers to improve the care transitions process. Researchers can build on our model by studying methods and interventions to improve the function of the care circle and design guidelines to create a more effective and integrated network. Institutions can adapt our methodology and tools to identify the needs of their own patient population and optimize membership in the PCC accordingly.

We feel that improving the structure and function of the care circle is necessary prior to designing interventions targeting the patient‐centered themes. Strengthening the teamwork of the PCC is fundamental to improving the quality of care transitions and reducing preventable readmissions.

The focus on care transitions and readmissions is expanding beyond the development of risk scores based on objective clinical data to quality improvement interventions involving the key stakeholders in the process, namely the patients and their multidisciplinary providers.[1, 2] The Institute for Healthcare Improvement's State Action on Avoidable Rehospitalizations initiative promotes formulating a specific transition plan and developing multidisciplinary management strategies for all patients.[3] The Transition of Care Consensus Policy Statement developed by a coalition including the American College of Physicians and Society of Hospital Medicine emphasizes accountability, communication, and involvement of the patient and family members in plans of care.[4] Yet, interventions to reduce readmissions and improve the quality and safety of care transitions remain only modestly and inconsistently effective.

Successful interventions are those that are combined and coordinated, and shared across the hospital and community settings.[5] In this study, we sought to understand the issues leading to readmissions and barriers as perceived by patients, family members, physicians, nurses, and social workers. We compared and contrasted the perspectives by discipline and used this information to design a descriptive framework of a multidisciplinary, collaborative, and coordinated support network integral to effective care transitions, which we term a Patient Care Circle (PCC) (Figure 1).

Figure 1

METHODS

RESULTS

We recruited 43 interview and 28 focus group participants (Table 1). From our transcript analysis, we generated 22 codes and categorized them into 5 themes embodying the issues pertinent to readmissions from the perspective of the stakeholders: (1) teamwork, (2) health systems navigation and management, (3) illness severity and health needs, (4) psychosocial stability; and (5) medications (Table 2).

We applied these codes and themes to build a descriptive framework depicting what we believed is the essential foundation for successful care transitions, a collaborative unified patient‐centered network to address complex healthcare‐related issues across disciplines and across settings (Figure 1). Our model illustrates the interplay between the various physician and care‐provider roles as well as the relationship of the structure of the care circle to each theme.

DISCUSSION

We categorized our findings into5 principle themes that influence care transitions: teamwork, systems navigation and management, illness severity, and health needs, psychosocial stability, and medications. Many of these themes have been targeted in the literature for interventions to reduce readmissions and improve care transitions. An overarching theme of our study was the importance of the Patient Care Circle, a support system required to implement and execute comprehensive patient‐centered plans for safe and effective transitions across all settings.

Collectively, our themes emphasized that communication and comprehensive planning between all members of the PCC were instrumental to the circle's ability to address issues pertaining to the patient‐centered themes: systems navigation and management, illness severity and health needs, psychosocial stability, and medications. The strength of the bonds and collaboration within the PCC were directly dependent on the success of teamwork.

The interplay between the 4 patient‐centered themes and the degree to which they affect readmissions were variable and patient dependent. Complexities of the healthcare system and issues surrounding medications became more apparent with worsening disease severity and psychosocial instability. Complicated patients requiring more multidisciplinary interaction highlighted limitations of dispersed teams and staffing ratios. Patients faced with insurance restrictions, difficulties attending appointments, and obtaining medications required pooling the efforts of multiple PCC members to help them. Thus, these themes emphasized not only the importance of teamwork required for care coordination, but also guided the membership of the PCC to meet the patient's specific needs across the inpatient and outpatient settings.

When participants were asked to identify modifiable reasons for readmissions, the overwhelming collective response was inadequate communication and collaboration among PCC members. Clear role assignments and delegation of responsibility were also necessary to avoid gaps in care. Significant barriers to improvement included limited resources and inability to maintain the integrity of the support network needed for safe transitions.

Finally, we compared and contrasted the perceptions of the different disciplines on the factors contributing to each patient's readmission. Over all, there was substantial overlap. However, each perspective added additional layers of information allowing for a more comprehensive understanding of the problem. This demonstrated the utility of multidisciplinary patient‐centered interviews to examine readmissions and elucidate areas for intervention.

Several disciplines were not included in interviews or focus groups but were identified by our study participants as integral to a comprehensive Patient Care Circle. These include emergency medicine physicians, inpatient and outpatient pharmacists, and outpatient social workers. Some disciplines were not included due to challenges identifying discrete providers and with arranging interviews or focus groups. As their roles were mentioned several times in multiple forums, we have included them in our descriptive framework.

We designed this study with the hope of completing a full complement of patient‐specific interviews that included all stakeholders for 4 male and 4 female patients. For several reasons, we were unable to do so including challenges contacting providers and family members, and coordinating the timing of interviews with patient visits. Further, our focus on English‐speaking patients admitted to general medicine teams may limit generalizability to other vulnerable patient groups. Nevertheless, we believe we succeeded in interviewing a representative sample and obtained thematic saturation with the information obtained from our interviews and focus groups.

Last, the focus of this project was to obtain the perspectives of a full spectrum of stakeholders in the care transitions process to gain a better understanding of the reasons for readmissions. Although we did ask study participants to identify areas that may have been modifiable, we did not expand the discussion to include potential interventions, which will be the next step in our study.

CONCLUSION

Our article describes 5 main themes derived from the perspectives of multiple stakeholders involved in the care transitions process. An overarching theme was the importance of a multidisciplinary, coordinated collaborative care circle to ensure safe patient‐centered care in all settings.

The results of this study can be used by researchers and applied by care providers to improve the care transitions process. Researchers can build on our model by studying methods and interventions to improve the function of the care circle and design guidelines to create a more effective and integrated network. Institutions can adapt our methodology and tools to identify the needs of their own patient population and optimize membership in the PCC accordingly.

We feel that improving the structure and function of the care circle is necessary prior to designing interventions targeting the patient‐centered themes. Strengthening the teamwork of the PCC is fundamental to improving the quality of care transitions and reducing preventable readmissions.

The focus on care transitions and readmissions is expanding beyond the development of risk scores based on objective clinical data to quality improvement interventions involving the key stakeholders in the process, namely the patients and their multidisciplinary providers.[1, 2] The Institute for Healthcare Improvement's State Action on Avoidable Rehospitalizations initiative promotes formulating a specific transition plan and developing multidisciplinary management strategies for all patients.[3] The Transition of Care Consensus Policy Statement developed by a coalition including the American College of Physicians and Society of Hospital Medicine emphasizes accountability, communication, and involvement of the patient and family members in plans of care.[4] Yet, interventions to reduce readmissions and improve the quality and safety of care transitions remain only modestly and inconsistently effective.

Successful interventions are those that are combined and coordinated, and shared across the hospital and community settings.[5] In this study, we sought to understand the issues leading to readmissions and barriers as perceived by patients, family members, physicians, nurses, and social workers. We compared and contrasted the perspectives by discipline and used this information to design a descriptive framework of a multidisciplinary, collaborative, and coordinated support network integral to effective care transitions, which we term a Patient Care Circle (PCC) (Figure 1).

Figure 1

METHODS

RESULTS

We recruited 43 interview and 28 focus group participants (Table 1). From our transcript analysis, we generated 22 codes and categorized them into 5 themes embodying the issues pertinent to readmissions from the perspective of the stakeholders: (1) teamwork, (2) health systems navigation and management, (3) illness severity and health needs, (4) psychosocial stability; and (5) medications (Table 2).

We applied these codes and themes to build a descriptive framework depicting what we believed is the essential foundation for successful care transitions, a collaborative unified patient‐centered network to address complex healthcare‐related issues across disciplines and across settings (Figure 1). Our model illustrates the interplay between the various physician and care‐provider roles as well as the relationship of the structure of the care circle to each theme.

DISCUSSION

We categorized our findings into5 principle themes that influence care transitions: teamwork, systems navigation and management, illness severity, and health needs, psychosocial stability, and medications. Many of these themes have been targeted in the literature for interventions to reduce readmissions and improve care transitions. An overarching theme of our study was the importance of the Patient Care Circle, a support system required to implement and execute comprehensive patient‐centered plans for safe and effective transitions across all settings.

Collectively, our themes emphasized that communication and comprehensive planning between all members of the PCC were instrumental to the circle's ability to address issues pertaining to the patient‐centered themes: systems navigation and management, illness severity and health needs, psychosocial stability, and medications. The strength of the bonds and collaboration within the PCC were directly dependent on the success of teamwork.

The interplay between the 4 patient‐centered themes and the degree to which they affect readmissions were variable and patient dependent. Complexities of the healthcare system and issues surrounding medications became more apparent with worsening disease severity and psychosocial instability. Complicated patients requiring more multidisciplinary interaction highlighted limitations of dispersed teams and staffing ratios. Patients faced with insurance restrictions, difficulties attending appointments, and obtaining medications required pooling the efforts of multiple PCC members to help them. Thus, these themes emphasized not only the importance of teamwork required for care coordination, but also guided the membership of the PCC to meet the patient's specific needs across the inpatient and outpatient settings.

When participants were asked to identify modifiable reasons for readmissions, the overwhelming collective response was inadequate communication and collaboration among PCC members. Clear role assignments and delegation of responsibility were also necessary to avoid gaps in care. Significant barriers to improvement included limited resources and inability to maintain the integrity of the support network needed for safe transitions.

Finally, we compared and contrasted the perceptions of the different disciplines on the factors contributing to each patient's readmission. Over all, there was substantial overlap. However, each perspective added additional layers of information allowing for a more comprehensive understanding of the problem. This demonstrated the utility of multidisciplinary patient‐centered interviews to examine readmissions and elucidate areas for intervention.

Several disciplines were not included in interviews or focus groups but were identified by our study participants as integral to a comprehensive Patient Care Circle. These include emergency medicine physicians, inpatient and outpatient pharmacists, and outpatient social workers. Some disciplines were not included due to challenges identifying discrete providers and with arranging interviews or focus groups. As their roles were mentioned several times in multiple forums, we have included them in our descriptive framework.

We designed this study with the hope of completing a full complement of patient‐specific interviews that included all stakeholders for 4 male and 4 female patients. For several reasons, we were unable to do so including challenges contacting providers and family members, and coordinating the timing of interviews with patient visits. Further, our focus on English‐speaking patients admitted to general medicine teams may limit generalizability to other vulnerable patient groups. Nevertheless, we believe we succeeded in interviewing a representative sample and obtained thematic saturation with the information obtained from our interviews and focus groups.

Last, the focus of this project was to obtain the perspectives of a full spectrum of stakeholders in the care transitions process to gain a better understanding of the reasons for readmissions. Although we did ask study participants to identify areas that may have been modifiable, we did not expand the discussion to include potential interventions, which will be the next step in our study.

CONCLUSION

Our article describes 5 main themes derived from the perspectives of multiple stakeholders involved in the care transitions process. An overarching theme was the importance of a multidisciplinary, coordinated collaborative care circle to ensure safe patient‐centered care in all settings.

The results of this study can be used by researchers and applied by care providers to improve the care transitions process. Researchers can build on our model by studying methods and interventions to improve the function of the care circle and design guidelines to create a more effective and integrated network. Institutions can adapt our methodology and tools to identify the needs of their own patient population and optimize membership in the PCC accordingly.

We feel that improving the structure and function of the care circle is necessary prior to designing interventions targeting the patient‐centered themes. Strengthening the teamwork of the PCC is fundamental to improving the quality of care transitions and reducing preventable readmissions.

Hand‐carried ultrasound echocardiography (HCUE) can help noncardiologists answer well‐defined questions at patients' bedsides in less than 10 minutes.1, 2 Indeed, intensivists3 and emergency department physicians4 already use HCUE to make rapid, point‐of‐care assessments. Since cardiovascular diagnoses are common among general medicine inpatients, HCUE may become an important skill for hospitalists to learn.5

However, uncertainty exists about the duration of HCUE training for hospitalists. In 2002, experts from the American Society of Echocardiography (ASE) published recommendations on training requirements for HCUE.6 With limited data on the safety or performance of HCUE training programs, which had just begun to emerge, the ASE borrowed from the proven training recommendations for standard echocardiography (SE). They recommended that all HCUE trainees, cardiologist and noncardiologist alike, complete level 1 SE training: 75 personally‐performed and 150 personally‐interpreted echocardiographic examinations. Since then, however, several HCUE training programs designed for noncardiologists have emerged.2, 5, 710 These alternative programs suggest that the ASE's recommended duration of training may be too long, particularly for focused HCUE that is limited to a few relatively simple assessments. It is important not to overshoot the requirements of HCUE training, because doing so may discourage groups of noncardiologists, like hospitalists, who may derive great benefits from HCUE.11

To address this uncertainty for hospitalists, we first developed a brief HCUE training program to assess 6 important cardiac abnormalities. We then studied the diagnostic accuracy of HCUE by hospitalists as a test of these 6 cardiac abnormalities assessed by SE.

Patients and Methods

Setting and Subjects

This prospective cohort study was performed at Stroger Hospital of Cook County, a 500‐bed public teaching hospital in Chicago, IL, from March through May of 2007. The cohort was adult inpatients who were referred for SE on weekdays from 3 distinct patient care units (Figure 1). We used 2 sampling modes to balance practical constraints (short‐stay unit [SSU] patients were more localized and, therefore, easier to study) with clinical diversity. We consecutively sampled patients from our SSU, where adults with provisional cardiovascular diagnoses are admitted if they might be eligible for discharge with in 3 days.12 But we used random number tables with a daily unique starting point to randomly sample patients from the general medical wards and the coronary care unit (CCU). Patients were excluded if repositioning them for HCUE was potentially harmful. The study was approved by our hospital's institutional review board, and we obtained written informed consent from all enrolled patients.

Figure 1

Results

During the 3 month study period, 654 patients were referred for SE from the 3 participating patient care units (Figure 1). Among these, 65 patients were ineligible because their SE was performed on the weekend and 178 other patients were not randomized from the general medical wards and CCU. From the remaining eligible patients, 322 underwent HCUE and 314 (98% of 322) underwent both SE and HCUE. Individual SE assessments were not interpretable (and therefore excluded) due to poor image quality for LA enlargement in 1 patient and IVC dilatation in 30 patients. Eighty‐three percent of patients who underwent SE (260/314) were referred to assess LV function (Table 3). The prevalence of the 6 clinically pertinent cardiac abnormalities under study ranged from 1% for moderate or large pericardial effusion to 25% for LV systolic dysfunction. Overall, 40% of patients had at least 1 out of 6 cardiac abnormalities.

Each hospitalist performed a similar total number of HCUE examinations (range, 3447). The median time difference between performance of SE and HCUE was 2.8 hours (25th75th percentiles, 1.45.1). Despite the high prevalence of chronic obstructive pulmonary disease and obesity, hospitalists considered HCUE assessments indeterminate in only 2% to 6% of the 6 assessments made for each patient (Table 4). Among the 38 patients (12% of 322) with any indeterminate HCUE assessment, 24 patients had only 1 out of 6 possible. Hospitalists completed HCUE in a median time of 28 minutes (25th‐75th percentiles, 2035), which included the time to record 7 best‐quality moving images and to fill out the research data collection form.

When HCUE results were analyzed as dichotomous values, positive likelihood ratios ranged from 2.5 to 21, and negative likelihood ratios ranged from 0 to 0.4 (Table 5). Positive and negative likelihood ratios were both sufficiency high and low to respectively increase and decrease by 5‐fold the prior odds of 3 out of 6 cardiac abnormalities: LV systolic dysfunction, moderate or severe MR regurgitation, and moderate or large pericardial effusion. Considering HCUE results as ordinal values for ROC analysis yielded additional diagnostic information (Figure 2). For example, the likelihood ratio of 1.0 (95% CI, 0.42.0) for borderline positive moderate or severe LA enlargement increased to 29 (range, 1362) for extreme positive results. Areas under the ROC curves were 0.9 for 4 out of 6 cardiac abnormalities.

Figure 2

LV systolic dysfunction and IVC dilatation were both prevalent enough to meet our criterion to examine interobserver variability; the mean number of abnormal patients per hospitalist was 10 patients for LV systolic dysfunction and 6 patients for IVC dilatation. For LV systolic dysfunction, SDs around mean sensitivity (84%) and specificity (87%) were 12% and 6%, respectively. For IVC dilatation, SDs around mean sensitivity (58%) and specificity (86%) were 24% and 7%, respectively.

Discussion

We found that, after a 27‐hour training program, hospitalists performed HCUE with moderate to excellent diagnostic accuracy for 6 important cardiac abnormalities. For example, hospitalists' assessments of LV systolic function yielded positive and negative likelihood ratios of 6.9 (95% CI, 4.99.8) and 0.2 (95% CI, 0.10.3), respectively. At the bedsides of patients with acute heart failure, therefore, hospitalists could use HCUE to lower or raise the 50:50 chance of LV systolic dysfunction30 to 15% or 85%, respectively. Whether or not these posttest likelihoods are extreme enough to cross important thresholds will depend on the clinical context. Yet these findings demonstrate how HCUE has the potential to provide hospitalists with valuable point‐of‐care data that are otherwise unavailableeither because routine clinical assessments are unreliable31 or because echocardiographic services are not immediately accessible.1

In fact, recent data from the Joint Commission on Accreditation of Healthcare Organizations shows how inaccessible SE may be. Approximately one‐quarter of hospitals in the United States send home about 10% of patients with acute heart failure without echocardiographic assessment of LV systolic function before, during, or immediately after hospitalization.32 In doing so, these hospitals leave unmet the 2002 National Quality Improvement Goal of universal assessment of LV systolic function for all heart failure patients. Hospitalists could close this quality gap with routine, 10‐minute HCUE assessments in all patients admitted with acute heart failure. (Our research HCUE protocol required a median time of 28 minutes, but this included time to assess 5 other cardiac abnormalities and collect data for research purposes). Until the clinical consequences of introducing hospitalist‐performed HCUE are studied, potential benefits like this are tentative. But our findings suggest that training hospitalists to accurately perform HCUE can be successfully accomplished in just 27 hours.

Other studies of HCUE training programs for noncardiologists have also challenged the opinion that learning to perform HCUE requires more than 100 hours of training.2, 711 Yet only 1 prior study has examined an HCUE training program for hospitalists.5 In this study by Martin et al.,5 hospitalists completed 5 supervised HCUE examinations and 6 hours of interpretation training before investigators scored their image acquisition and interpretation skills from 30 unsupervised HCUE examinations. To estimate their final skill levels at the completion of all 35 examinations by accounting for an initially steep learning curve, investigators then adjusted these scores with regression models. Despite these upward adjustments, hospitalists' image acquisition and interpretation scores were low in comparison to echocardiographic technicians and cardiology fellows. Besides these adjusted measurements of hospitalists' skills, however, Martin et al.5 unfortunately did not also report standard measures of diagnostic accuracy, like those proposed by the Standards for Reporting of Diagnostic Accuracy (STARD) initiative.33 Therefore, direct comparisons to the present study are difficult. Nevertheless, their findings suggest that a training program limited to 5 supervised HCUE examinations may be inadequate for hospitalists. In fact, the same group's earlier study of medical trainees suggested a minimum of 30 supervised HCUE examinations.9 We chose to design our hospitalist training program based on this minimum, though they surprisingly did not.5 As others continue to refine the components of hospitalist HCUE training programs, such as the optimal number of supervised examinations, our program could serve as a reasonable comparative example: more rigorous than the program designed by Martin et al.5 but more feasible than ASE level 1 training.

The number and complexity of assessments taught in HCUE training programs will determine their duration. With ongoing advancements in HCUE technology, there is a growing list of potential assessments to choose from. Although HCUE training programs ought to include assessments with proven clinical applications, there are no trials of HCUE‐directed care to inform such decisions. In their absence, therefore, we chose 6 assessments based on the following 3 criteria. First, our assessments were otherwise not reliably available from routine clinical data, such as the physical examination. Second, our assessments were straightforward: easy to learn and simple to perform. Here, we based our reasoning on an expectation that the value of HCUE lies not in highly complex, state‐of‐the‐art assessmentswhich are best left to echocardiographers equipped with SEbut in simple, routine assessments made with highly portable machines that grant noncardiologists newfound access to point‐of‐care data.34 Third, our assessments were clinically pertinent and, where appropriate, defined by cut‐points at levels of severity that often lead to changes in management. We suspect that setting high cut‐points has the salutary effects of making assessments easier to learn and more accurate, because distinguishing mild abnormalities is likely the most challenging aspect of echocardiographic interpretation.35 Whether or not our choices of assessments, and their cut‐points, are optimal has yet to be determined by future research designed to study how they affect patient outcomes. Given our hospitalists' performance in the present study, these assessments seem worthy of such future research.

Our study had several limitations. We studied physicians and patients from only 1 hospital; similar studies performed in different settings, particularly among patients with different proportions and manifestations of disease, may find different results. Nevertheless, our sampling method of prospectively enrolling consecutive patients strengthens our findings. Some echocardiographic measurement methods used by our hospitalists differed in subtle ways from echocardiography guideline recommendations.35 We chose our methods (Table 2) for 2 reasons. First, whenever possible, we chose methods of interpretation that coincided with our local cardiologists'. Second, we chose simplicity over precision. For example, the biplane method of disks, or modified Simpson's rule, is the preferred volumetric method of calculating LA size.35 This method requires tracing the contours of the LA in 2 planes and then dividing the LA volume into stacked oval disks for calculation. We chose instead to train our hospitalists in a simpler method based on 2 linear measurements. Any loss of precision, however, was balanced by a large gain in simplicity. Regardless, minor variations in LA size are not likely to affect hospitalists' bedside evaluations. Finally, we did not validate the results of our reference standard (SE) by documenting interobserver reliability. Yet, because SE is generally accurate for the 6 cardiac abnormalities under study, the effect of this bias should be small.

These limitations can be addressed best by controlled trials of HCUE‐directed care. These trials will determine the clinical impact of hospitalist‐performed HCUE and, in turn, inform our design of HCUE training programs. As the current study shows, training hospitalists to participate in such trials is feasible: like other groups of noncardiologists, hospitalists can accurately perform HCUE after a brief training program. Whether or not hospitalists should perform HCUE requires further study.

Hand‐carried ultrasound echocardiography (HCUE) can help noncardiologists answer well‐defined questions at patients' bedsides in less than 10 minutes.1, 2 Indeed, intensivists3 and emergency department physicians4 already use HCUE to make rapid, point‐of‐care assessments. Since cardiovascular diagnoses are common among general medicine inpatients, HCUE may become an important skill for hospitalists to learn.5

However, uncertainty exists about the duration of HCUE training for hospitalists. In 2002, experts from the American Society of Echocardiography (ASE) published recommendations on training requirements for HCUE.6 With limited data on the safety or performance of HCUE training programs, which had just begun to emerge, the ASE borrowed from the proven training recommendations for standard echocardiography (SE). They recommended that all HCUE trainees, cardiologist and noncardiologist alike, complete level 1 SE training: 75 personally‐performed and 150 personally‐interpreted echocardiographic examinations. Since then, however, several HCUE training programs designed for noncardiologists have emerged.2, 5, 710 These alternative programs suggest that the ASE's recommended duration of training may be too long, particularly for focused HCUE that is limited to a few relatively simple assessments. It is important not to overshoot the requirements of HCUE training, because doing so may discourage groups of noncardiologists, like hospitalists, who may derive great benefits from HCUE.11

To address this uncertainty for hospitalists, we first developed a brief HCUE training program to assess 6 important cardiac abnormalities. We then studied the diagnostic accuracy of HCUE by hospitalists as a test of these 6 cardiac abnormalities assessed by SE.

Patients and Methods

Setting and Subjects

This prospective cohort study was performed at Stroger Hospital of Cook County, a 500‐bed public teaching hospital in Chicago, IL, from March through May of 2007. The cohort was adult inpatients who were referred for SE on weekdays from 3 distinct patient care units (Figure 1). We used 2 sampling modes to balance practical constraints (short‐stay unit [SSU] patients were more localized and, therefore, easier to study) with clinical diversity. We consecutively sampled patients from our SSU, where adults with provisional cardiovascular diagnoses are admitted if they might be eligible for discharge with in 3 days.12 But we used random number tables with a daily unique starting point to randomly sample patients from the general medical wards and the coronary care unit (CCU). Patients were excluded if repositioning them for HCUE was potentially harmful. The study was approved by our hospital's institutional review board, and we obtained written informed consent from all enrolled patients.

Figure 1

Results

During the 3 month study period, 654 patients were referred for SE from the 3 participating patient care units (Figure 1). Among these, 65 patients were ineligible because their SE was performed on the weekend and 178 other patients were not randomized from the general medical wards and CCU. From the remaining eligible patients, 322 underwent HCUE and 314 (98% of 322) underwent both SE and HCUE. Individual SE assessments were not interpretable (and therefore excluded) due to poor image quality for LA enlargement in 1 patient and IVC dilatation in 30 patients. Eighty‐three percent of patients who underwent SE (260/314) were referred to assess LV function (Table 3). The prevalence of the 6 clinically pertinent cardiac abnormalities under study ranged from 1% for moderate or large pericardial effusion to 25% for LV systolic dysfunction. Overall, 40% of patients had at least 1 out of 6 cardiac abnormalities.

Each hospitalist performed a similar total number of HCUE examinations (range, 3447). The median time difference between performance of SE and HCUE was 2.8 hours (25th75th percentiles, 1.45.1). Despite the high prevalence of chronic obstructive pulmonary disease and obesity, hospitalists considered HCUE assessments indeterminate in only 2% to 6% of the 6 assessments made for each patient (Table 4). Among the 38 patients (12% of 322) with any indeterminate HCUE assessment, 24 patients had only 1 out of 6 possible. Hospitalists completed HCUE in a median time of 28 minutes (25th‐75th percentiles, 2035), which included the time to record 7 best‐quality moving images and to fill out the research data collection form.

When HCUE results were analyzed as dichotomous values, positive likelihood ratios ranged from 2.5 to 21, and negative likelihood ratios ranged from 0 to 0.4 (Table 5). Positive and negative likelihood ratios were both sufficiency high and low to respectively increase and decrease by 5‐fold the prior odds of 3 out of 6 cardiac abnormalities: LV systolic dysfunction, moderate or severe MR regurgitation, and moderate or large pericardial effusion. Considering HCUE results as ordinal values for ROC analysis yielded additional diagnostic information (Figure 2). For example, the likelihood ratio of 1.0 (95% CI, 0.42.0) for borderline positive moderate or severe LA enlargement increased to 29 (range, 1362) for extreme positive results. Areas under the ROC curves were 0.9 for 4 out of 6 cardiac abnormalities.

Figure 2

LV systolic dysfunction and IVC dilatation were both prevalent enough to meet our criterion to examine interobserver variability; the mean number of abnormal patients per hospitalist was 10 patients for LV systolic dysfunction and 6 patients for IVC dilatation. For LV systolic dysfunction, SDs around mean sensitivity (84%) and specificity (87%) were 12% and 6%, respectively. For IVC dilatation, SDs around mean sensitivity (58%) and specificity (86%) were 24% and 7%, respectively.

Discussion

We found that, after a 27‐hour training program, hospitalists performed HCUE with moderate to excellent diagnostic accuracy for 6 important cardiac abnormalities. For example, hospitalists' assessments of LV systolic function yielded positive and negative likelihood ratios of 6.9 (95% CI, 4.99.8) and 0.2 (95% CI, 0.10.3), respectively. At the bedsides of patients with acute heart failure, therefore, hospitalists could use HCUE to lower or raise the 50:50 chance of LV systolic dysfunction30 to 15% or 85%, respectively. Whether or not these posttest likelihoods are extreme enough to cross important thresholds will depend on the clinical context. Yet these findings demonstrate how HCUE has the potential to provide hospitalists with valuable point‐of‐care data that are otherwise unavailableeither because routine clinical assessments are unreliable31 or because echocardiographic services are not immediately accessible.1

In fact, recent data from the Joint Commission on Accreditation of Healthcare Organizations shows how inaccessible SE may be. Approximately one‐quarter of hospitals in the United States send home about 10% of patients with acute heart failure without echocardiographic assessment of LV systolic function before, during, or immediately after hospitalization.32 In doing so, these hospitals leave unmet the 2002 National Quality Improvement Goal of universal assessment of LV systolic function for all heart failure patients. Hospitalists could close this quality gap with routine, 10‐minute HCUE assessments in all patients admitted with acute heart failure. (Our research HCUE protocol required a median time of 28 minutes, but this included time to assess 5 other cardiac abnormalities and collect data for research purposes). Until the clinical consequences of introducing hospitalist‐performed HCUE are studied, potential benefits like this are tentative. But our findings suggest that training hospitalists to accurately perform HCUE can be successfully accomplished in just 27 hours.

Other studies of HCUE training programs for noncardiologists have also challenged the opinion that learning to perform HCUE requires more than 100 hours of training.2, 711 Yet only 1 prior study has examined an HCUE training program for hospitalists.5 In this study by Martin et al.,5 hospitalists completed 5 supervised HCUE examinations and 6 hours of interpretation training before investigators scored their image acquisition and interpretation skills from 30 unsupervised HCUE examinations. To estimate their final skill levels at the completion of all 35 examinations by accounting for an initially steep learning curve, investigators then adjusted these scores with regression models. Despite these upward adjustments, hospitalists' image acquisition and interpretation scores were low in comparison to echocardiographic technicians and cardiology fellows. Besides these adjusted measurements of hospitalists' skills, however, Martin et al.5 unfortunately did not also report standard measures of diagnostic accuracy, like those proposed by the Standards for Reporting of Diagnostic Accuracy (STARD) initiative.33 Therefore, direct comparisons to the present study are difficult. Nevertheless, their findings suggest that a training program limited to 5 supervised HCUE examinations may be inadequate for hospitalists. In fact, the same group's earlier study of medical trainees suggested a minimum of 30 supervised HCUE examinations.9 We chose to design our hospitalist training program based on this minimum, though they surprisingly did not.5 As others continue to refine the components of hospitalist HCUE training programs, such as the optimal number of supervised examinations, our program could serve as a reasonable comparative example: more rigorous than the program designed by Martin et al.5 but more feasible than ASE level 1 training.

The number and complexity of assessments taught in HCUE training programs will determine their duration. With ongoing advancements in HCUE technology, there is a growing list of potential assessments to choose from. Although HCUE training programs ought to include assessments with proven clinical applications, there are no trials of HCUE‐directed care to inform such decisions. In their absence, therefore, we chose 6 assessments based on the following 3 criteria. First, our assessments were otherwise not reliably available from routine clinical data, such as the physical examination. Second, our assessments were straightforward: easy to learn and simple to perform. Here, we based our reasoning on an expectation that the value of HCUE lies not in highly complex, state‐of‐the‐art assessmentswhich are best left to echocardiographers equipped with SEbut in simple, routine assessments made with highly portable machines that grant noncardiologists newfound access to point‐of‐care data.34 Third, our assessments were clinically pertinent and, where appropriate, defined by cut‐points at levels of severity that often lead to changes in management. We suspect that setting high cut‐points has the salutary effects of making assessments easier to learn and more accurate, because distinguishing mild abnormalities is likely the most challenging aspect of echocardiographic interpretation.35 Whether or not our choices of assessments, and their cut‐points, are optimal has yet to be determined by future research designed to study how they affect patient outcomes. Given our hospitalists' performance in the present study, these assessments seem worthy of such future research.

Our study had several limitations. We studied physicians and patients from only 1 hospital; similar studies performed in different settings, particularly among patients with different proportions and manifestations of disease, may find different results. Nevertheless, our sampling method of prospectively enrolling consecutive patients strengthens our findings. Some echocardiographic measurement methods used by our hospitalists differed in subtle ways from echocardiography guideline recommendations.35 We chose our methods (Table 2) for 2 reasons. First, whenever possible, we chose methods of interpretation that coincided with our local cardiologists'. Second, we chose simplicity over precision. For example, the biplane method of disks, or modified Simpson's rule, is the preferred volumetric method of calculating LA size.35 This method requires tracing the contours of the LA in 2 planes and then dividing the LA volume into stacked oval disks for calculation. We chose instead to train our hospitalists in a simpler method based on 2 linear measurements. Any loss of precision, however, was balanced by a large gain in simplicity. Regardless, minor variations in LA size are not likely to affect hospitalists' bedside evaluations. Finally, we did not validate the results of our reference standard (SE) by documenting interobserver reliability. Yet, because SE is generally accurate for the 6 cardiac abnormalities under study, the effect of this bias should be small.

These limitations can be addressed best by controlled trials of HCUE‐directed care. These trials will determine the clinical impact of hospitalist‐performed HCUE and, in turn, inform our design of HCUE training programs. As the current study shows, training hospitalists to participate in such trials is feasible: like other groups of noncardiologists, hospitalists can accurately perform HCUE after a brief training program. Whether or not hospitalists should perform HCUE requires further study.

Hand‐carried ultrasound echocardiography (HCUE) can help noncardiologists answer well‐defined questions at patients' bedsides in less than 10 minutes.1, 2 Indeed, intensivists3 and emergency department physicians4 already use HCUE to make rapid, point‐of‐care assessments. Since cardiovascular diagnoses are common among general medicine inpatients, HCUE may become an important skill for hospitalists to learn.5

However, uncertainty exists about the duration of HCUE training for hospitalists. In 2002, experts from the American Society of Echocardiography (ASE) published recommendations on training requirements for HCUE.6 With limited data on the safety or performance of HCUE training programs, which had just begun to emerge, the ASE borrowed from the proven training recommendations for standard echocardiography (SE). They recommended that all HCUE trainees, cardiologist and noncardiologist alike, complete level 1 SE training: 75 personally‐performed and 150 personally‐interpreted echocardiographic examinations. Since then, however, several HCUE training programs designed for noncardiologists have emerged.2, 5, 710 These alternative programs suggest that the ASE's recommended duration of training may be too long, particularly for focused HCUE that is limited to a few relatively simple assessments. It is important not to overshoot the requirements of HCUE training, because doing so may discourage groups of noncardiologists, like hospitalists, who may derive great benefits from HCUE.11

To address this uncertainty for hospitalists, we first developed a brief HCUE training program to assess 6 important cardiac abnormalities. We then studied the diagnostic accuracy of HCUE by hospitalists as a test of these 6 cardiac abnormalities assessed by SE.

Patients and Methods

Setting and Subjects

This prospective cohort study was performed at Stroger Hospital of Cook County, a 500‐bed public teaching hospital in Chicago, IL, from March through May of 2007. The cohort was adult inpatients who were referred for SE on weekdays from 3 distinct patient care units (Figure 1). We used 2 sampling modes to balance practical constraints (short‐stay unit [SSU] patients were more localized and, therefore, easier to study) with clinical diversity. We consecutively sampled patients from our SSU, where adults with provisional cardiovascular diagnoses are admitted if they might be eligible for discharge with in 3 days.12 But we used random number tables with a daily unique starting point to randomly sample patients from the general medical wards and the coronary care unit (CCU). Patients were excluded if repositioning them for HCUE was potentially harmful. The study was approved by our hospital's institutional review board, and we obtained written informed consent from all enrolled patients.

Figure 1

Results

During the 3 month study period, 654 patients were referred for SE from the 3 participating patient care units (Figure 1). Among these, 65 patients were ineligible because their SE was performed on the weekend and 178 other patients were not randomized from the general medical wards and CCU. From the remaining eligible patients, 322 underwent HCUE and 314 (98% of 322) underwent both SE and HCUE. Individual SE assessments were not interpretable (and therefore excluded) due to poor image quality for LA enlargement in 1 patient and IVC dilatation in 30 patients. Eighty‐three percent of patients who underwent SE (260/314) were referred to assess LV function (Table 3). The prevalence of the 6 clinically pertinent cardiac abnormalities under study ranged from 1% for moderate or large pericardial effusion to 25% for LV systolic dysfunction. Overall, 40% of patients had at least 1 out of 6 cardiac abnormalities.

Each hospitalist performed a similar total number of HCUE examinations (range, 3447). The median time difference between performance of SE and HCUE was 2.8 hours (25th75th percentiles, 1.45.1). Despite the high prevalence of chronic obstructive pulmonary disease and obesity, hospitalists considered HCUE assessments indeterminate in only 2% to 6% of the 6 assessments made for each patient (Table 4). Among the 38 patients (12% of 322) with any indeterminate HCUE assessment, 24 patients had only 1 out of 6 possible. Hospitalists completed HCUE in a median time of 28 minutes (25th‐75th percentiles, 2035), which included the time to record 7 best‐quality moving images and to fill out the research data collection form.

When HCUE results were analyzed as dichotomous values, positive likelihood ratios ranged from 2.5 to 21, and negative likelihood ratios ranged from 0 to 0.4 (Table 5). Positive and negative likelihood ratios were both sufficiency high and low to respectively increase and decrease by 5‐fold the prior odds of 3 out of 6 cardiac abnormalities: LV systolic dysfunction, moderate or severe MR regurgitation, and moderate or large pericardial effusion. Considering HCUE results as ordinal values for ROC analysis yielded additional diagnostic information (Figure 2). For example, the likelihood ratio of 1.0 (95% CI, 0.42.0) for borderline positive moderate or severe LA enlargement increased to 29 (range, 1362) for extreme positive results. Areas under the ROC curves were 0.9 for 4 out of 6 cardiac abnormalities.

Figure 2

LV systolic dysfunction and IVC dilatation were both prevalent enough to meet our criterion to examine interobserver variability; the mean number of abnormal patients per hospitalist was 10 patients for LV systolic dysfunction and 6 patients for IVC dilatation. For LV systolic dysfunction, SDs around mean sensitivity (84%) and specificity (87%) were 12% and 6%, respectively. For IVC dilatation, SDs around mean sensitivity (58%) and specificity (86%) were 24% and 7%, respectively.

Discussion

We found that, after a 27‐hour training program, hospitalists performed HCUE with moderate to excellent diagnostic accuracy for 6 important cardiac abnormalities. For example, hospitalists' assessments of LV systolic function yielded positive and negative likelihood ratios of 6.9 (95% CI, 4.99.8) and 0.2 (95% CI, 0.10.3), respectively. At the bedsides of patients with acute heart failure, therefore, hospitalists could use HCUE to lower or raise the 50:50 chance of LV systolic dysfunction30 to 15% or 85%, respectively. Whether or not these posttest likelihoods are extreme enough to cross important thresholds will depend on the clinical context. Yet these findings demonstrate how HCUE has the potential to provide hospitalists with valuable point‐of‐care data that are otherwise unavailableeither because routine clinical assessments are unreliable31 or because echocardiographic services are not immediately accessible.1

In fact, recent data from the Joint Commission on Accreditation of Healthcare Organizations shows how inaccessible SE may be. Approximately one‐quarter of hospitals in the United States send home about 10% of patients with acute heart failure without echocardiographic assessment of LV systolic function before, during, or immediately after hospitalization.32 In doing so, these hospitals leave unmet the 2002 National Quality Improvement Goal of universal assessment of LV systolic function for all heart failure patients. Hospitalists could close this quality gap with routine, 10‐minute HCUE assessments in all patients admitted with acute heart failure. (Our research HCUE protocol required a median time of 28 minutes, but this included time to assess 5 other cardiac abnormalities and collect data for research purposes). Until the clinical consequences of introducing hospitalist‐performed HCUE are studied, potential benefits like this are tentative. But our findings suggest that training hospitalists to accurately perform HCUE can be successfully accomplished in just 27 hours.

Other studies of HCUE training programs for noncardiologists have also challenged the opinion that learning to perform HCUE requires more than 100 hours of training.2, 711 Yet only 1 prior study has examined an HCUE training program for hospitalists.5 In this study by Martin et al.,5 hospitalists completed 5 supervised HCUE examinations and 6 hours of interpretation training before investigators scored their image acquisition and interpretation skills from 30 unsupervised HCUE examinations. To estimate their final skill levels at the completion of all 35 examinations by accounting for an initially steep learning curve, investigators then adjusted these scores with regression models. Despite these upward adjustments, hospitalists' image acquisition and interpretation scores were low in comparison to echocardiographic technicians and cardiology fellows. Besides these adjusted measurements of hospitalists' skills, however, Martin et al.5 unfortunately did not also report standard measures of diagnostic accuracy, like those proposed by the Standards for Reporting of Diagnostic Accuracy (STARD) initiative.33 Therefore, direct comparisons to the present study are difficult. Nevertheless, their findings suggest that a training program limited to 5 supervised HCUE examinations may be inadequate for hospitalists. In fact, the same group's earlier study of medical trainees suggested a minimum of 30 supervised HCUE examinations.9 We chose to design our hospitalist training program based on this minimum, though they surprisingly did not.5 As others continue to refine the components of hospitalist HCUE training programs, such as the optimal number of supervised examinations, our program could serve as a reasonable comparative example: more rigorous than the program designed by Martin et al.5 but more feasible than ASE level 1 training.

The number and complexity of assessments taught in HCUE training programs will determine their duration. With ongoing advancements in HCUE technology, there is a growing list of potential assessments to choose from. Although HCUE training programs ought to include assessments with proven clinical applications, there are no trials of HCUE‐directed care to inform such decisions. In their absence, therefore, we chose 6 assessments based on the following 3 criteria. First, our assessments were otherwise not reliably available from routine clinical data, such as the physical examination. Second, our assessments were straightforward: easy to learn and simple to perform. Here, we based our reasoning on an expectation that the value of HCUE lies not in highly complex, state‐of‐the‐art assessmentswhich are best left to echocardiographers equipped with SEbut in simple, routine assessments made with highly portable machines that grant noncardiologists newfound access to point‐of‐care data.34 Third, our assessments were clinically pertinent and, where appropriate, defined by cut‐points at levels of severity that often lead to changes in management. We suspect that setting high cut‐points has the salutary effects of making assessments easier to learn and more accurate, because distinguishing mild abnormalities is likely the most challenging aspect of echocardiographic interpretation.35 Whether or not our choices of assessments, and their cut‐points, are optimal has yet to be determined by future research designed to study how they affect patient outcomes. Given our hospitalists' performance in the present study, these assessments seem worthy of such future research.

Our study had several limitations. We studied physicians and patients from only 1 hospital; similar studies performed in different settings, particularly among patients with different proportions and manifestations of disease, may find different results. Nevertheless, our sampling method of prospectively enrolling consecutive patients strengthens our findings. Some echocardiographic measurement methods used by our hospitalists differed in subtle ways from echocardiography guideline recommendations.35 We chose our methods (Table 2) for 2 reasons. First, whenever possible, we chose methods of interpretation that coincided with our local cardiologists'. Second, we chose simplicity over precision. For example, the biplane method of disks, or modified Simpson's rule, is the preferred volumetric method of calculating LA size.35 This method requires tracing the contours of the LA in 2 planes and then dividing the LA volume into stacked oval disks for calculation. We chose instead to train our hospitalists in a simpler method based on 2 linear measurements. Any loss of precision, however, was balanced by a large gain in simplicity. Regardless, minor variations in LA size are not likely to affect hospitalists' bedside evaluations. Finally, we did not validate the results of our reference standard (SE) by documenting interobserver reliability. Yet, because SE is generally accurate for the 6 cardiac abnormalities under study, the effect of this bias should be small.

These limitations can be addressed best by controlled trials of HCUE‐directed care. These trials will determine the clinical impact of hospitalist‐performed HCUE and, in turn, inform our design of HCUE training programs. As the current study shows, training hospitalists to participate in such trials is feasible: like other groups of noncardiologists, hospitalists can accurately perform HCUE after a brief training program. Whether or not hospitalists should perform HCUE requires further study.

At times central venous catheters are essential to the delivery of appropriate medical care. Because catheter‐related complications are associated with limited operator experience,1 insertion technique,2 and venous site of insertion (eg, femoral, internal jugular, or subclavian vein),3 house staff training programs strive to provide their residents with appropriate training and oversight for this skill. Most quality improvement initiatives directed at reducing complications associated with central venous catheters have focused on patients in the intensive care unit (ICU).4, 5 However, in some hospitals more central venous catheters are inserted in patients not in the ICU,6 and practices that increase the risk of complications may be more common on wards.7

In our hospital, most catheters are placed in the femoral vein. Because femoral venous placement likely increases a patient's risk of thrombosis, hematoma, and bloodstream infection,8 we developed a program to change residents' choice of venous insertion site and improve their infection‐control practices during their general medicine ward rotation. The program provided simulated hands‐on experience in a simulation laboratory. We evaluated our intervention through a firm‐based clinical trial that compared the usual practice to our intervention. We compared infection‐control practices and resident choice of venous insertion site between the intervention and control groups; we also assessed residents' knowledge about catheter‐related complications, and we monitored patients for catheter‐related complications.

METHODS

RESULTS

DISCUSSION

An educational session designed to teach residents appropriate central venous catheter insertion practices that included simulated hands‐on training increased knowledge about insertion‐related complications and improved certain infection‐control practices. Although residents' confidence in inserting subclavian or internal jugular catheters initially improved, our training session did not change the choice of venous insertion site from femoral to subclavian or internal jugular veins, possibly because there were few opportunities for residents to insert a catheter during the 4‐week general medical ward rotations. Thus, although an active educational intervention improved the knowledge and confidence of residents, it had a minimal effect on behavior (only improved certain infection‐control practices). Catheter‐associated complications were infrequent and similar in the intervention and control groups.

Central venous catheter insertion is a skill that many general internists do not perform10; however, until recently the American Board of Internal Medicine considered it a requisite skill for internal medicine residents, and most residents at our hospital reported a desire to learn this skill. Although in our study complications were infrequent, suggesting that a change in venous insertion site is unlikely to dramatically improve patient safety, we believe that residents should become skilled at inserting catheters in internal jugular or subclavian veins, the currently recommended optimal venous insertion.8

There is evidence that single educational interventions are unlikely to result in substantial, sustained behavioral change, especially passive educational programs.11 However, a previous study documented a change in provider behavior and possibly a reduction in bloodstream infections after a single hands‐on training session.12 Our hands‐on educational format was very popular and likely improved some infection‐control practices but did not change provider behavior about choice of venous insertion site. In other institutions, mentoring residents on appropriate catheter insertion technique has been accomplished by establishing a procedure service13 or by resident rotation in a high‐volume location (eg, cardiac catheterization laboratory).14 Another option to facilitate behavioral change would be to provide a portable ultrasound machine, as requested by our residents, which may reduce complication rates.15, 16 At our hospital, we decided to supplement hands‐on training with expert bedside supervision during catheter insertion; the expert is provided through a procedure service that is led by hospitalists. The procedure service has a dedicated portable ultrasound machine to assist with internal jugular vein cannulation.

By the end of our study period, residents' confidence in subclavian or internal jugular catheter insertions had returned to presession levels; however, they reported increased confidence in femoral venous catheter insertions. These findings suggest that the session increased residents' confidence with catheter insertions in general, but not specifically for venous sites for which they had no previous experience. For subclavian or internal jugular catheter insertions, their confidence decayed to the presession baseline, likely because of few opportunities to insert catheters in patients; on average, each resident inserts 1 central venous catheter on the general medicine wards approximately every 4 months.

Our survey found that our intervention changed residents' attitudes about infection‐control practices. In particular, intervention‐group residents reported that they were more likely to remove unnecessary catheters and that they had used a mask and large drape during catheter insertion. Use of full‐barrier precautions (ie, sterile gloves and gown, large sterile drape, cap, and mask) has been shown to reduce the risk of bloodstream infection2 and is included in national guidelines.17 Adherence to these guidelines has been included in successful quality improvement initiatives.4, 5, 18 Compared to internists' adherence to recommendations for infection control reported in another survey,10 residents who attended our educational session reported more use of large sterile drapes (94% vs. 35%) or masks (75% vs. 66%); however, they were less likely to use a sterile gown (50% vs. 72%). Use of a large sterile drape is common in our hospital, likely because the drape is included in the central venous catheter package. We suspect that at our hospital, poor adherence to certain recommendations (eg, using a sterile gown) was due in part to difficulty accessing supplies. Another possibility is that use of a cap, compared to use of large drapes, is perceived as not giving the patient much additional protection. In fact, there is no evidence that using a cap provides benefit beyond that of other, more intuitively beneficial recommended infection‐control practices, such as using sterile gloves and a large sterile drape. The procedure service has addressed the supply problem by stocking hard‐to‐find items on a procedure cart.

Only 2 clinically evident complications associated with catheter insertion occurred (one patient with clinical sepsis and one with a hematoma). Although it is possible that we missed minor complications, our rates were similar to those reported by other investigators: clinically diagnosed venous thromboembolism, 0%2.2%3, 19, 20; pneumothorax, 1.4%21; catheter‐associated primary bloodstream infection, 1‐6/1000 catheter‐days.22, 23 Comparing complication rates was hindered by variability in definitions, methods of ascertainment, and populations evaluated. For example, the rate of venous thromboembolism was dramatically higher when routine diagnostic imaging was used, and detection of catheter‐associated infections likely increased when catheter‐tip cultures were routinely performed. We required clinical evidence of complications, and our study differs from others in that we evaluated general medicine ward patients.

This study had several limitations. Placement of central venous catheters on general medicine wards was less frequent than we anticipated based on a brief period of pilot data collection; therefore, our study was not powered to detect relatively small changes in venous insertion sites or differences in complications. Also, because direct observation was not possible, we relied on self‐reported adherence to infection‐control practices. However, intervention residents' self‐reported poor adherence to gown, glove, and cap use suggests that their responses were unbiased.

An educational session focused on central venous catheter insertion practices was well received by residents, increased their knowledge about complications, and improved infection‐control practices, but had no effect on increasing use of subclavian or internal jugular veins for catheter insertion. Despite continued frequent use of femoral venous catheters, clinically apparent complications were infrequent. However, we believe it is important to teach residents optimal catheter insertion techniques, including preferential placement of catheters in subclavian or internal jugular veins. Therefore, the section of hospital medicine at our hospital initiated a procedure service that provides expert bedside supervision, including use of a portable ultrasound machine, for catheter insertions.