All of us who work with housestaff understand that a crucial component of teaching clinical medicine is to take the time to both supervise resident work and deliver constructive feedback on its quality. In the assessment of competence, trainees have “direct supervision” when an attending, senior resident, or other individual is physically present and guiding the care in real time or “indirect supervision” when work is being checked after the care has been administered.

Regardless of the level of supervision, checking in with direct observations (watching trainees do the actual work in real time) provides invaluable information for both patient care and resident assessment. Given that assessment and supervision are key components of the Accreditation Council for Graduate Medical Education’s (ACGME) Next Accreditation System, many programs are now placing particular emphasis on the time we spend observing our trainees.

How can faculty fit direct observation into an already busy day? Here are some ideas for how to adapt and leverage your workflow to create new opportunities for resident skills assessment.

Micro-Observations Matter

Gone are the days of sitting in a patient room for an hour observing a long history and physical performed by the resident or student that you are supervising. In spite of time constraints, you should aim to be at the bedside at the same time as the trainee as much as possible. Once there, take note of all that you see. For example, we often observe residents and students during bedside rounds or critical family discussions. Here are additional opportunities for trainee observation that might fit into your workflow:

• First thing in the morning, when the team is pre-rounding (this is perfect for when you are worried about a patient or are scheduled for a busy afternoon). Do NOT interrupt the resident workflow. Instruct them at the beginning of the rotation that you plan to observe unannounced. If they see you, they should continue with their normal activities. Pop in and out to catch key points, and gather the information necessary to guide patient care. Don’t take over to do teaching or feedback; that will come later in the day.
• During a procedure performed by a supervising resident who already has demonstrated technical competence. Bring a computer on wheels into the patient’s room, sit down, and catch up on charting while listening to and observing the explanations, teaching, and interaction between the patient and the resident. You can still intervene if necessary, but take appropriate steps to allow resident autonomy and the observation of high-level communication skills.
• At the bedside of a clinically unstable patient. If you are together with the team when a nurse calls with a concern, you can instruct the resident to go ahead and intervene with close follow-up in a few minutes. This allows residents to get a head start, gather information, and establish themselves as the decision-makers, while still providing an opportunity for close observation by the faculty.
• Finalizing a discharge first thing in the morning. With most hospitals focusing on discharge timeliness, faculty often discuss patients scheduled for discharge prior to or outside of formal rounds. Get to the patient! Observe the resident interacting with the patient and multidisciplinary team, confirming medication reconciliation, finalizing the discharge diagnosis and instructions, and inquiring further about barriers to adherence with the discharge regimen.

Vary Your Approach

Use a variety of formats to tell your learners what was observed. Specific, quick comments made in real time can be encouraging, and brief suggestions are usually welcome in the context of a particular patient. Other observations and feedback that need to be more sensitive or require more time are perfect to wrap up at the end of the day. Finally, the message function in the electronic medical record is another great and timely format for providing feedback on observations related to clinical documentation, differential diagnosis, and management plan.

Real-Time Recordkeeping

Record your observations as you go. Even though you are providing formative feedback throughout the month, you likely also will be expected to translate those observations into a summative end-of-rotation assessment. Whether it is on a notecard with the name of each trainee being supervised or on a printed blank copy of the end of the month assessment or other program-specific assessments, jotting down specific observations will help you recall key information.

When feedback is provided, note the date in order to guide your summative feedback discussion and the final assessment.

Keep in mind that program assessment tools often serve to remind faculty of specific behaviors that have not historically been evaluated. For example, faculty might be in the habit of providing feedback on communication skills after a family meeting but may not specifically listen for trainees to use “teach-back” concepts when explaining the plan for discharge or noting whether they actively seek input from the multidisciplinary team. A tool that lists “teach-back” or “seeks out interprofessional collaboration” as line items on the form can help to remind you of the qualities you are being asked to assess.

Although direct observation is essential in providing useful assessments during the course of supervision of trainees, there are additional ways that faculty can “see” how a trainee is doing. For example, faculty or supervising residents can “observe” an intern’s completed discharge summary in real time for important and key components. Checking this work enables you to provide an assessment of additional skills (i.e., medication reconciliation, medical knowledge, management of clinical conditions, and appropriate handoff to future care providers). As trainees progressively demonstrate competence, the degree of supervision evolves to the point of a quick verification rather than the initial detailed review.

In summary, supervising trainees well means both thinking critically about their care of patients and providing feedback. As much as we have adapted our clinical workflow to meet increasing regulatory, quality, or patient throughput requirements, we must also change our educational workflow to meet the needs of our learners.

This adaptation should not be onerous. A few simple adjustments, as outlined above, can lead to higher-quality assessments and increased satisfaction in your role as teacher. So, get back out on the wards and observe!

Dr. O’Malley is the internal medicine residency program director at Banner Good Samaritan in Phoenix, Ariz., and an assistant professor of medicine at the University of Arizona College of Medicine. She currently serves as SHM’s representative on the Alliance for Academic Internal Medicine’s Internal Medicine Education Redesign Advisory Board, along with Dr. Caverzagie, who is associate dean for educational strategy at the University of Nebraska College of Medicine in Omaha and vice president for education, clinical enterprise of the Nebraska Medical Center. Dr. Caverzagie also was a member of the ABIM and ACGME milestone writing groups.

All of us who work with housestaff understand that a crucial component of teaching clinical medicine is to take the time to both supervise resident work and deliver constructive feedback on its quality. In the assessment of competence, trainees have “direct supervision” when an attending, senior resident, or other individual is physically present and guiding the care in real time or “indirect supervision” when work is being checked after the care has been administered.

Regardless of the level of supervision, checking in with direct observations (watching trainees do the actual work in real time) provides invaluable information for both patient care and resident assessment. Given that assessment and supervision are key components of the Accreditation Council for Graduate Medical Education’s (ACGME) Next Accreditation System, many programs are now placing particular emphasis on the time we spend observing our trainees.

How can faculty fit direct observation into an already busy day? Here are some ideas for how to adapt and leverage your workflow to create new opportunities for resident skills assessment.

Micro-Observations Matter

Gone are the days of sitting in a patient room for an hour observing a long history and physical performed by the resident or student that you are supervising. In spite of time constraints, you should aim to be at the bedside at the same time as the trainee as much as possible. Once there, take note of all that you see. For example, we often observe residents and students during bedside rounds or critical family discussions. Here are additional opportunities for trainee observation that might fit into your workflow:

• First thing in the morning, when the team is pre-rounding (this is perfect for when you are worried about a patient or are scheduled for a busy afternoon). Do NOT interrupt the resident workflow. Instruct them at the beginning of the rotation that you plan to observe unannounced. If they see you, they should continue with their normal activities. Pop in and out to catch key points, and gather the information necessary to guide patient care. Don’t take over to do teaching or feedback; that will come later in the day.
• During a procedure performed by a supervising resident who already has demonstrated technical competence. Bring a computer on wheels into the patient’s room, sit down, and catch up on charting while listening to and observing the explanations, teaching, and interaction between the patient and the resident. You can still intervene if necessary, but take appropriate steps to allow resident autonomy and the observation of high-level communication skills.
• At the bedside of a clinically unstable patient. If you are together with the team when a nurse calls with a concern, you can instruct the resident to go ahead and intervene with close follow-up in a few minutes. This allows residents to get a head start, gather information, and establish themselves as the decision-makers, while still providing an opportunity for close observation by the faculty.
• Finalizing a discharge first thing in the morning. With most hospitals focusing on discharge timeliness, faculty often discuss patients scheduled for discharge prior to or outside of formal rounds. Get to the patient! Observe the resident interacting with the patient and multidisciplinary team, confirming medication reconciliation, finalizing the discharge diagnosis and instructions, and inquiring further about barriers to adherence with the discharge regimen.

Vary Your Approach

Use a variety of formats to tell your learners what was observed. Specific, quick comments made in real time can be encouraging, and brief suggestions are usually welcome in the context of a particular patient. Other observations and feedback that need to be more sensitive or require more time are perfect to wrap up at the end of the day. Finally, the message function in the electronic medical record is another great and timely format for providing feedback on observations related to clinical documentation, differential diagnosis, and management plan.

Real-Time Recordkeeping

Record your observations as you go. Even though you are providing formative feedback throughout the month, you likely also will be expected to translate those observations into a summative end-of-rotation assessment. Whether it is on a notecard with the name of each trainee being supervised or on a printed blank copy of the end of the month assessment or other program-specific assessments, jotting down specific observations will help you recall key information.

When feedback is provided, note the date in order to guide your summative feedback discussion and the final assessment.

Keep in mind that program assessment tools often serve to remind faculty of specific behaviors that have not historically been evaluated. For example, faculty might be in the habit of providing feedback on communication skills after a family meeting but may not specifically listen for trainees to use “teach-back” concepts when explaining the plan for discharge or noting whether they actively seek input from the multidisciplinary team. A tool that lists “teach-back” or “seeks out interprofessional collaboration” as line items on the form can help to remind you of the qualities you are being asked to assess.

Although direct observation is essential in providing useful assessments during the course of supervision of trainees, there are additional ways that faculty can “see” how a trainee is doing. For example, faculty or supervising residents can “observe” an intern’s completed discharge summary in real time for important and key components. Checking this work enables you to provide an assessment of additional skills (i.e., medication reconciliation, medical knowledge, management of clinical conditions, and appropriate handoff to future care providers). As trainees progressively demonstrate competence, the degree of supervision evolves to the point of a quick verification rather than the initial detailed review.

In summary, supervising trainees well means both thinking critically about their care of patients and providing feedback. As much as we have adapted our clinical workflow to meet increasing regulatory, quality, or patient throughput requirements, we must also change our educational workflow to meet the needs of our learners.

This adaptation should not be onerous. A few simple adjustments, as outlined above, can lead to higher-quality assessments and increased satisfaction in your role as teacher. So, get back out on the wards and observe!

Dr. O’Malley is the internal medicine residency program director at Banner Good Samaritan in Phoenix, Ariz., and an assistant professor of medicine at the University of Arizona College of Medicine. She currently serves as SHM’s representative on the Alliance for Academic Internal Medicine’s Internal Medicine Education Redesign Advisory Board, along with Dr. Caverzagie, who is associate dean for educational strategy at the University of Nebraska College of Medicine in Omaha and vice president for education, clinical enterprise of the Nebraska Medical Center. Dr. Caverzagie also was a member of the ABIM and ACGME milestone writing groups.

All of us who work with housestaff understand that a crucial component of teaching clinical medicine is to take the time to both supervise resident work and deliver constructive feedback on its quality. In the assessment of competence, trainees have “direct supervision” when an attending, senior resident, or other individual is physically present and guiding the care in real time or “indirect supervision” when work is being checked after the care has been administered.

Regardless of the level of supervision, checking in with direct observations (watching trainees do the actual work in real time) provides invaluable information for both patient care and resident assessment. Given that assessment and supervision are key components of the Accreditation Council for Graduate Medical Education’s (ACGME) Next Accreditation System, many programs are now placing particular emphasis on the time we spend observing our trainees.

How can faculty fit direct observation into an already busy day? Here are some ideas for how to adapt and leverage your workflow to create new opportunities for resident skills assessment.

Micro-Observations Matter

Gone are the days of sitting in a patient room for an hour observing a long history and physical performed by the resident or student that you are supervising. In spite of time constraints, you should aim to be at the bedside at the same time as the trainee as much as possible. Once there, take note of all that you see. For example, we often observe residents and students during bedside rounds or critical family discussions. Here are additional opportunities for trainee observation that might fit into your workflow:

• First thing in the morning, when the team is pre-rounding (this is perfect for when you are worried about a patient or are scheduled for a busy afternoon). Do NOT interrupt the resident workflow. Instruct them at the beginning of the rotation that you plan to observe unannounced. If they see you, they should continue with their normal activities. Pop in and out to catch key points, and gather the information necessary to guide patient care. Don’t take over to do teaching or feedback; that will come later in the day.
• During a procedure performed by a supervising resident who already has demonstrated technical competence. Bring a computer on wheels into the patient’s room, sit down, and catch up on charting while listening to and observing the explanations, teaching, and interaction between the patient and the resident. You can still intervene if necessary, but take appropriate steps to allow resident autonomy and the observation of high-level communication skills.
• At the bedside of a clinically unstable patient. If you are together with the team when a nurse calls with a concern, you can instruct the resident to go ahead and intervene with close follow-up in a few minutes. This allows residents to get a head start, gather information, and establish themselves as the decision-makers, while still providing an opportunity for close observation by the faculty.
• Finalizing a discharge first thing in the morning. With most hospitals focusing on discharge timeliness, faculty often discuss patients scheduled for discharge prior to or outside of formal rounds. Get to the patient! Observe the resident interacting with the patient and multidisciplinary team, confirming medication reconciliation, finalizing the discharge diagnosis and instructions, and inquiring further about barriers to adherence with the discharge regimen.

Vary Your Approach

Use a variety of formats to tell your learners what was observed. Specific, quick comments made in real time can be encouraging, and brief suggestions are usually welcome in the context of a particular patient. Other observations and feedback that need to be more sensitive or require more time are perfect to wrap up at the end of the day. Finally, the message function in the electronic medical record is another great and timely format for providing feedback on observations related to clinical documentation, differential diagnosis, and management plan.

Real-Time Recordkeeping

Record your observations as you go. Even though you are providing formative feedback throughout the month, you likely also will be expected to translate those observations into a summative end-of-rotation assessment. Whether it is on a notecard with the name of each trainee being supervised or on a printed blank copy of the end of the month assessment or other program-specific assessments, jotting down specific observations will help you recall key information.

When feedback is provided, note the date in order to guide your summative feedback discussion and the final assessment.

Keep in mind that program assessment tools often serve to remind faculty of specific behaviors that have not historically been evaluated. For example, faculty might be in the habit of providing feedback on communication skills after a family meeting but may not specifically listen for trainees to use “teach-back” concepts when explaining the plan for discharge or noting whether they actively seek input from the multidisciplinary team. A tool that lists “teach-back” or “seeks out interprofessional collaboration” as line items on the form can help to remind you of the qualities you are being asked to assess.

Although direct observation is essential in providing useful assessments during the course of supervision of trainees, there are additional ways that faculty can “see” how a trainee is doing. For example, faculty or supervising residents can “observe” an intern’s completed discharge summary in real time for important and key components. Checking this work enables you to provide an assessment of additional skills (i.e., medication reconciliation, medical knowledge, management of clinical conditions, and appropriate handoff to future care providers). As trainees progressively demonstrate competence, the degree of supervision evolves to the point of a quick verification rather than the initial detailed review.

In summary, supervising trainees well means both thinking critically about their care of patients and providing feedback. As much as we have adapted our clinical workflow to meet increasing regulatory, quality, or patient throughput requirements, we must also change our educational workflow to meet the needs of our learners.

This adaptation should not be onerous. A few simple adjustments, as outlined above, can lead to higher-quality assessments and increased satisfaction in your role as teacher. So, get back out on the wards and observe!

Dr. O’Malley is the internal medicine residency program director at Banner Good Samaritan in Phoenix, Ariz., and an assistant professor of medicine at the University of Arizona College of Medicine. She currently serves as SHM’s representative on the Alliance for Academic Internal Medicine’s Internal Medicine Education Redesign Advisory Board, along with Dr. Caverzagie, who is associate dean for educational strategy at the University of Nebraska College of Medicine in Omaha and vice president for education, clinical enterprise of the Nebraska Medical Center. Dr. Caverzagie also was a member of the ABIM and ACGME milestone writing groups.

He has aged a year since President Obama nominated him for U.S. Surgeon General in November 2013, but on Monday Boston hospitalist Vivek Murthy, MD, was confirmed as the highest physician in America.

According to multiple sources, Dr. Murthy’s outspoken support for stricter gun laws and belief that guns are a public health issue delayed his confirmation due to opposition from the National Rifle Association (NRA), which in a letter to Senate leadership in February said Dr. Murthy’s confirmation would be a “prescription for disaster for America’s gun owners.”

Despite this, Senate Democrats approved his four-year appointment in a 51-43 vote that cut along party lines. In his confirmation hearing in February, Dr. Murthy said he does not “intend to use the surgeon general’s office as a bully pulpit for gun control.”

Dr. Murthy, 37, earned his medical and business degrees from Yale and for the last decade has worked as both an internist and a hospitalist at Brigham and Women’s Hospital in Boston. He is the youngest surgeon general ever, and the first of Indian-American descent.

“On behalf of America's 44,000 hospitalists, I congratulate Dr. Murthy, a fellow hospitalist and one of our SHM members, on his historic appointment to U.S. Surgeon General,” says Society of Hospital Medicine President Burke Kealey, MD, SFHM. “Being America’s doctor requires many of the same traits required of hospitalists: leadership, sharp clinical skills, and the ability to engage with patients. And, like hospitalists in thousands of hospitals across the country, I am confident Dr. Murthy will become an agent of change to improve delivery of care in our country.”

In 2008, Dr. Murthy founded Doctors for Obama, a nonprofit, grassroots organization of 16,000 physicians and medical students dedicated to transforming the healthcare system. After the election, he changed the name of the organization to Doctors for America. He also started the software company TrialNetworks in 2007 to aid in drug development, and, in 1995, he started an HIV and AIDS education nonprofit in India called VISIONS Worldwide.

In a statement from the White House Monday, President Obama applauded the Senate for Dr. Murthy’s confirmation, saying: “Vivek’s confirmation makes us better positioned to save lives around the world and protect the American people here at home.”

Dr. Murthy replaces acting Surgeon General Boris Lushniak, who took over when Regina Benjamin resigned in July 2013. The surgeon general is the U.S.’ top spokesperson on all matters of public health and oversees the 6,700 members of the U.S. Public Health Service Commissioned Corps.

Kelly April Tyrrell is a freelance writer in Madison, Wis.

He has aged a year since President Obama nominated him for U.S. Surgeon General in November 2013, but on Monday Boston hospitalist Vivek Murthy, MD, was confirmed as the highest physician in America.

According to multiple sources, Dr. Murthy’s outspoken support for stricter gun laws and belief that guns are a public health issue delayed his confirmation due to opposition from the National Rifle Association (NRA), which in a letter to Senate leadership in February said Dr. Murthy’s confirmation would be a “prescription for disaster for America’s gun owners.”

Despite this, Senate Democrats approved his four-year appointment in a 51-43 vote that cut along party lines. In his confirmation hearing in February, Dr. Murthy said he does not “intend to use the surgeon general’s office as a bully pulpit for gun control.”

Dr. Murthy, 37, earned his medical and business degrees from Yale and for the last decade has worked as both an internist and a hospitalist at Brigham and Women’s Hospital in Boston. He is the youngest surgeon general ever, and the first of Indian-American descent.

“On behalf of America's 44,000 hospitalists, I congratulate Dr. Murthy, a fellow hospitalist and one of our SHM members, on his historic appointment to U.S. Surgeon General,” says Society of Hospital Medicine President Burke Kealey, MD, SFHM. “Being America’s doctor requires many of the same traits required of hospitalists: leadership, sharp clinical skills, and the ability to engage with patients. And, like hospitalists in thousands of hospitals across the country, I am confident Dr. Murthy will become an agent of change to improve delivery of care in our country.”

In 2008, Dr. Murthy founded Doctors for Obama, a nonprofit, grassroots organization of 16,000 physicians and medical students dedicated to transforming the healthcare system. After the election, he changed the name of the organization to Doctors for America. He also started the software company TrialNetworks in 2007 to aid in drug development, and, in 1995, he started an HIV and AIDS education nonprofit in India called VISIONS Worldwide.

In a statement from the White House Monday, President Obama applauded the Senate for Dr. Murthy’s confirmation, saying: “Vivek’s confirmation makes us better positioned to save lives around the world and protect the American people here at home.”

Dr. Murthy replaces acting Surgeon General Boris Lushniak, who took over when Regina Benjamin resigned in July 2013. The surgeon general is the U.S.’ top spokesperson on all matters of public health and oversees the 6,700 members of the U.S. Public Health Service Commissioned Corps.

Kelly April Tyrrell is a freelance writer in Madison, Wis.

He has aged a year since President Obama nominated him for U.S. Surgeon General in November 2013, but on Monday Boston hospitalist Vivek Murthy, MD, was confirmed as the highest physician in America.

According to multiple sources, Dr. Murthy’s outspoken support for stricter gun laws and belief that guns are a public health issue delayed his confirmation due to opposition from the National Rifle Association (NRA), which in a letter to Senate leadership in February said Dr. Murthy’s confirmation would be a “prescription for disaster for America’s gun owners.”

Despite this, Senate Democrats approved his four-year appointment in a 51-43 vote that cut along party lines. In his confirmation hearing in February, Dr. Murthy said he does not “intend to use the surgeon general’s office as a bully pulpit for gun control.”

Dr. Murthy, 37, earned his medical and business degrees from Yale and for the last decade has worked as both an internist and a hospitalist at Brigham and Women’s Hospital in Boston. He is the youngest surgeon general ever, and the first of Indian-American descent.

“On behalf of America's 44,000 hospitalists, I congratulate Dr. Murthy, a fellow hospitalist and one of our SHM members, on his historic appointment to U.S. Surgeon General,” says Society of Hospital Medicine President Burke Kealey, MD, SFHM. “Being America’s doctor requires many of the same traits required of hospitalists: leadership, sharp clinical skills, and the ability to engage with patients. And, like hospitalists in thousands of hospitals across the country, I am confident Dr. Murthy will become an agent of change to improve delivery of care in our country.”

In 2008, Dr. Murthy founded Doctors for Obama, a nonprofit, grassroots organization of 16,000 physicians and medical students dedicated to transforming the healthcare system. After the election, he changed the name of the organization to Doctors for America. He also started the software company TrialNetworks in 2007 to aid in drug development, and, in 1995, he started an HIV and AIDS education nonprofit in India called VISIONS Worldwide.

In a statement from the White House Monday, President Obama applauded the Senate for Dr. Murthy’s confirmation, saying: “Vivek’s confirmation makes us better positioned to save lives around the world and protect the American people here at home.”

Dr. Murthy replaces acting Surgeon General Boris Lushniak, who took over when Regina Benjamin resigned in July 2013. The surgeon general is the U.S.’ top spokesperson on all matters of public health and oversees the 6,700 members of the U.S. Public Health Service Commissioned Corps.

Kelly April Tyrrell is a freelance writer in Madison, Wis.

Before you fall asleep at the thought, consider the fact that sleep apnea has been identified as a major contributing factor in new onset atrial fibrillation (Afib), acute ischemic stroke, and heart failure. How well are inpatients, in particular those with heart failure, being screened and treated for sleep apnea?

To answer this question, the charts of 100 patients admitted with a known diagnosis of heart failure were retrospectively reviewed. Screening for sleep apnea was defined as the mention of the condition on a patient’s admitting history and physical. The average age was 73 years; two-thirds were male. Thirty-nine percent were identified as already having sleep apnea. Interestingly, 42% had a concurrent diagnosis of Afib; this group also had a higher 30-day readmission rate of 11%, versus 9% for the heart failure alone group.

While inpatient, approximately one-quarter of the sample used continuous positive airway pressure (CPAP) during their admission, with two thirds of these being previous users. Twenty patients had overnight oximetry testing; most often these tests were triggered by history and ordered by cardiology. A little over half of these tests were positive for sleep-disordered breathing, prompting recommendations for CPAP, nocturnal oxygen, and outpatient polysomnograms and lending support for testing in this heart failure population.

At discharge, how well were these sleep apnea test results and recommendations communicated to the primary care provider? Only half of patients with known or newly diagnosed sleep apnea had the diagnosis mentioned on their discharge summaries or received recommendations for further management.

From this review, one could conclude that sleep apnea is prevalent in the heart failure population and in those with concurrent Afib; that over half of those tested for sleep apnea while inpatient were found to have an indication for therapy or further testing, and that communication to primary providers is not sufficient.

Sleep apnea should be routinely addressed in the heart failure population, as it contributes to morbidity and is responsive to treatment. Improvements in the screening process could include adding a dedicated section on the electronic medical record to screen for sleep apnea on admission and a second section to track inpatient CPAP and nocturnal oxygen use.

Finally, a discharge section could identify those patients with new or previous sleep apnea to note any changes in their CPAP or oxygen therapy and to identify patients needing formal outpatient testing. Coordinating with primary care providers is essential for continuity and to reduce readmissions.

With these types of improvements, detection and treatment of sleep apnea can then become a standard target on the hospitalists’ radar.

–Rita McGauvran, CNP

Rapid City (S.D.) Regional Hospitalists

Before you fall asleep at the thought, consider the fact that sleep apnea has been identified as a major contributing factor in new onset atrial fibrillation (Afib), acute ischemic stroke, and heart failure. How well are inpatients, in particular those with heart failure, being screened and treated for sleep apnea?

To answer this question, the charts of 100 patients admitted with a known diagnosis of heart failure were retrospectively reviewed. Screening for sleep apnea was defined as the mention of the condition on a patient’s admitting history and physical. The average age was 73 years; two-thirds were male. Thirty-nine percent were identified as already having sleep apnea. Interestingly, 42% had a concurrent diagnosis of Afib; this group also had a higher 30-day readmission rate of 11%, versus 9% for the heart failure alone group.

While inpatient, approximately one-quarter of the sample used continuous positive airway pressure (CPAP) during their admission, with two thirds of these being previous users. Twenty patients had overnight oximetry testing; most often these tests were triggered by history and ordered by cardiology. A little over half of these tests were positive for sleep-disordered breathing, prompting recommendations for CPAP, nocturnal oxygen, and outpatient polysomnograms and lending support for testing in this heart failure population.

At discharge, how well were these sleep apnea test results and recommendations communicated to the primary care provider? Only half of patients with known or newly diagnosed sleep apnea had the diagnosis mentioned on their discharge summaries or received recommendations for further management.

From this review, one could conclude that sleep apnea is prevalent in the heart failure population and in those with concurrent Afib; that over half of those tested for sleep apnea while inpatient were found to have an indication for therapy or further testing, and that communication to primary providers is not sufficient.

Sleep apnea should be routinely addressed in the heart failure population, as it contributes to morbidity and is responsive to treatment. Improvements in the screening process could include adding a dedicated section on the electronic medical record to screen for sleep apnea on admission and a second section to track inpatient CPAP and nocturnal oxygen use.

Finally, a discharge section could identify those patients with new or previous sleep apnea to note any changes in their CPAP or oxygen therapy and to identify patients needing formal outpatient testing. Coordinating with primary care providers is essential for continuity and to reduce readmissions.

With these types of improvements, detection and treatment of sleep apnea can then become a standard target on the hospitalists’ radar.

–Rita McGauvran, CNP

Rapid City (S.D.) Regional Hospitalists

Before you fall asleep at the thought, consider the fact that sleep apnea has been identified as a major contributing factor in new onset atrial fibrillation (Afib), acute ischemic stroke, and heart failure. How well are inpatients, in particular those with heart failure, being screened and treated for sleep apnea?

To answer this question, the charts of 100 patients admitted with a known diagnosis of heart failure were retrospectively reviewed. Screening for sleep apnea was defined as the mention of the condition on a patient’s admitting history and physical. The average age was 73 years; two-thirds were male. Thirty-nine percent were identified as already having sleep apnea. Interestingly, 42% had a concurrent diagnosis of Afib; this group also had a higher 30-day readmission rate of 11%, versus 9% for the heart failure alone group.

While inpatient, approximately one-quarter of the sample used continuous positive airway pressure (CPAP) during their admission, with two thirds of these being previous users. Twenty patients had overnight oximetry testing; most often these tests were triggered by history and ordered by cardiology. A little over half of these tests were positive for sleep-disordered breathing, prompting recommendations for CPAP, nocturnal oxygen, and outpatient polysomnograms and lending support for testing in this heart failure population.

At discharge, how well were these sleep apnea test results and recommendations communicated to the primary care provider? Only half of patients with known or newly diagnosed sleep apnea had the diagnosis mentioned on their discharge summaries or received recommendations for further management.

From this review, one could conclude that sleep apnea is prevalent in the heart failure population and in those with concurrent Afib; that over half of those tested for sleep apnea while inpatient were found to have an indication for therapy or further testing, and that communication to primary providers is not sufficient.

Sleep apnea should be routinely addressed in the heart failure population, as it contributes to morbidity and is responsive to treatment. Improvements in the screening process could include adding a dedicated section on the electronic medical record to screen for sleep apnea on admission and a second section to track inpatient CPAP and nocturnal oxygen use.

Finally, a discharge section could identify those patients with new or previous sleep apnea to note any changes in their CPAP or oxygen therapy and to identify patients needing formal outpatient testing. Coordinating with primary care providers is essential for continuity and to reduce readmissions.

With these types of improvements, detection and treatment of sleep apnea can then become a standard target on the hospitalists’ radar.

–Rita McGauvran, CNP

Rapid City (S.D.) Regional Hospitalists

As the hysteria about Ebola spreads, hospitalists who have been running most of the country’s ICUs will find themselves at the forefront of treating these patients when more of them present at our different hospitals. It is now time for America to come into the age of Ebola and treat Ebola patients in Ebola centers, in specific prefabricated buildings designed for this specific pestilence. It has been done successfully in Africa—specifically, Nigeria.

Our hospitals in North America are not designed to handle the kind of elaborate decontamination protocols that we now know Ebola requires; we lack the isolation chambers for staff decontamination and the rapid throughput for hazardous material that guarantee minimal environmental exposure before incineration that we are told is required for Ebola waste.

One thing that is clear from the Dallas, Texas Presbyterian Hospital fiasco is not only that the staff was not really prepared to receive its first Ebola patient, despite the false sense of security it was lulled into by numerous drills and reenactments, but also that this lack of preparedness was not solely a staffing or staff-related issue. Ebola was being treated as if it were MRSA, TB, or C. diff. Ebola is none of those. The stories of equipment failure and the pileup of contaminated waste should have come as no surprise. This is a situation like no other. And, not surprisingly, the hospital administration was caught unaware. It could have happened with almost any other hospital.

In Nigeria, where the infection was successfully contained, an Ebola unit was erected in just two weeks. It had a patients’ unit, decontamination unit, and an outside incineration unit. The patients also had to go through elaborate head to toe decontamination before they were released back into the community. I suggest that we look into building such units in a few major cities in this country. It needn’t take more than a few days to erect such prefabricated units in fairly isolated areas with temporary outside incineration units attached for disposal of medical waste.

This effort would afford healthcare workers the ability to don full hazmat gear, including boots, and, after contact with Ebola patients at the end of the day, to go into decontamination chambers, wade with boots through chlorinated pools to reduce contamination, and rinse gloved hands in chlorinated water before commencing ‘directly observed’ degowning. This protocol cannot be effectively performed in our regular U.S. hospitals the way they’re designed now.

The sooner we get on board with this, the better. Ebola is like no other infection we have encountered before in the U.S.

–Ngozi Achebe, MD

Hospitalist, Sunnyside (Wash.) Community Hospital

As the hysteria about Ebola spreads, hospitalists who have been running most of the country’s ICUs will find themselves at the forefront of treating these patients when more of them present at our different hospitals. It is now time for America to come into the age of Ebola and treat Ebola patients in Ebola centers, in specific prefabricated buildings designed for this specific pestilence. It has been done successfully in Africa—specifically, Nigeria.

Our hospitals in North America are not designed to handle the kind of elaborate decontamination protocols that we now know Ebola requires; we lack the isolation chambers for staff decontamination and the rapid throughput for hazardous material that guarantee minimal environmental exposure before incineration that we are told is required for Ebola waste.

One thing that is clear from the Dallas, Texas Presbyterian Hospital fiasco is not only that the staff was not really prepared to receive its first Ebola patient, despite the false sense of security it was lulled into by numerous drills and reenactments, but also that this lack of preparedness was not solely a staffing or staff-related issue. Ebola was being treated as if it were MRSA, TB, or C. diff. Ebola is none of those. The stories of equipment failure and the pileup of contaminated waste should have come as no surprise. This is a situation like no other. And, not surprisingly, the hospital administration was caught unaware. It could have happened with almost any other hospital.

In Nigeria, where the infection was successfully contained, an Ebola unit was erected in just two weeks. It had a patients’ unit, decontamination unit, and an outside incineration unit. The patients also had to go through elaborate head to toe decontamination before they were released back into the community. I suggest that we look into building such units in a few major cities in this country. It needn’t take more than a few days to erect such prefabricated units in fairly isolated areas with temporary outside incineration units attached for disposal of medical waste.

This effort would afford healthcare workers the ability to don full hazmat gear, including boots, and, after contact with Ebola patients at the end of the day, to go into decontamination chambers, wade with boots through chlorinated pools to reduce contamination, and rinse gloved hands in chlorinated water before commencing ‘directly observed’ degowning. This protocol cannot be effectively performed in our regular U.S. hospitals the way they’re designed now.

The sooner we get on board with this, the better. Ebola is like no other infection we have encountered before in the U.S.

–Ngozi Achebe, MD

Hospitalist, Sunnyside (Wash.) Community Hospital

As the hysteria about Ebola spreads, hospitalists who have been running most of the country’s ICUs will find themselves at the forefront of treating these patients when more of them present at our different hospitals. It is now time for America to come into the age of Ebola and treat Ebola patients in Ebola centers, in specific prefabricated buildings designed for this specific pestilence. It has been done successfully in Africa—specifically, Nigeria.

Our hospitals in North America are not designed to handle the kind of elaborate decontamination protocols that we now know Ebola requires; we lack the isolation chambers for staff decontamination and the rapid throughput for hazardous material that guarantee minimal environmental exposure before incineration that we are told is required for Ebola waste.

One thing that is clear from the Dallas, Texas Presbyterian Hospital fiasco is not only that the staff was not really prepared to receive its first Ebola patient, despite the false sense of security it was lulled into by numerous drills and reenactments, but also that this lack of preparedness was not solely a staffing or staff-related issue. Ebola was being treated as if it were MRSA, TB, or C. diff. Ebola is none of those. The stories of equipment failure and the pileup of contaminated waste should have come as no surprise. This is a situation like no other. And, not surprisingly, the hospital administration was caught unaware. It could have happened with almost any other hospital.

In Nigeria, where the infection was successfully contained, an Ebola unit was erected in just two weeks. It had a patients’ unit, decontamination unit, and an outside incineration unit. The patients also had to go through elaborate head to toe decontamination before they were released back into the community. I suggest that we look into building such units in a few major cities in this country. It needn’t take more than a few days to erect such prefabricated units in fairly isolated areas with temporary outside incineration units attached for disposal of medical waste.

This effort would afford healthcare workers the ability to don full hazmat gear, including boots, and, after contact with Ebola patients at the end of the day, to go into decontamination chambers, wade with boots through chlorinated pools to reduce contamination, and rinse gloved hands in chlorinated water before commencing ‘directly observed’ degowning. This protocol cannot be effectively performed in our regular U.S. hospitals the way they’re designed now.

The sooner we get on board with this, the better. Ebola is like no other infection we have encountered before in the U.S.

–Ngozi Achebe, MD

Hospitalist, Sunnyside (Wash.) Community Hospital

“Super Bowl” of hospital medicine is less than three months away

If you haven’t registered for the largest event in the hospital medicine movement, now is the time. You can still take advantage of the early registration discount through Feb. 2. And pre-courses, many of which fill up ahead of time, are still available.

For hospitalists nationwide, HM15 is an unprecedented time to learn new clinical updates, network with colleagues, and hear from the leaders in healthcare. This year’s event takes place March 29 through April 1 at the Gaylord National Resort and Conference Center in National Harbor, Md., just minutes from Washington, D.C.

This year’s featured speakers represent the nation’s most forward-thinking leaders in providing the best possible care to hospitalized patients:

• Maureen Bisognano is president and CEO of the Institute for Healthcare Improvement (IHI), an independent, not-for-profit organization helping to lead the improvement of healthcare throughout the world. Join her for her featured address on “Leading Transformational Change.”

• Peter J. Pronovost, MD, PhD, FCCM, is a world-renowned patient safety champion and a practicing critical care physician. His scientific work in leveraging checklists to reduce catheter-related bloodstream infections has saved thousands of lives and earned him high-profile accolades, including being named one of the 100 Most Influential People in the World by Time magazine and receiving a coveted MacArthur Foundation “Genius Grant” in 2008. He is senior vice president for patient safety and quality and director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Hospital in Baltimore. Join him for his keynote address, “Taking Quality to the Next Level.”

• Robert M. Wachter, MD, MHM, national thought leader in healthcare quality improvement, will be addressing HM15 attendees, in his always-entertaining style, on how the computerization of medicine will transform your life or your practice. Join him for his closing address, “The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age.”

The benefits of attending HM15 don’t end with the final session, either. This year, SHM is offering a free, one-year membership for new members registering for HM15.

Brendon Shank is SHM’s associate vice president of communications.

“Super Bowl” of hospital medicine is less than three months away

If you haven’t registered for the largest event in the hospital medicine movement, now is the time. You can still take advantage of the early registration discount through Feb. 2. And pre-courses, many of which fill up ahead of time, are still available.

For hospitalists nationwide, HM15 is an unprecedented time to learn new clinical updates, network with colleagues, and hear from the leaders in healthcare. This year’s event takes place March 29 through April 1 at the Gaylord National Resort and Conference Center in National Harbor, Md., just minutes from Washington, D.C.

This year’s featured speakers represent the nation’s most forward-thinking leaders in providing the best possible care to hospitalized patients:

• Maureen Bisognano is president and CEO of the Institute for Healthcare Improvement (IHI), an independent, not-for-profit organization helping to lead the improvement of healthcare throughout the world. Join her for her featured address on “Leading Transformational Change.”

• Peter J. Pronovost, MD, PhD, FCCM, is a world-renowned patient safety champion and a practicing critical care physician. His scientific work in leveraging checklists to reduce catheter-related bloodstream infections has saved thousands of lives and earned him high-profile accolades, including being named one of the 100 Most Influential People in the World by Time magazine and receiving a coveted MacArthur Foundation “Genius Grant” in 2008. He is senior vice president for patient safety and quality and director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Hospital in Baltimore. Join him for his keynote address, “Taking Quality to the Next Level.”

• Robert M. Wachter, MD, MHM, national thought leader in healthcare quality improvement, will be addressing HM15 attendees, in his always-entertaining style, on how the computerization of medicine will transform your life or your practice. Join him for his closing address, “The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age.”

The benefits of attending HM15 don’t end with the final session, either. This year, SHM is offering a free, one-year membership for new members registering for HM15.

Brendon Shank is SHM’s associate vice president of communications.

“Super Bowl” of hospital medicine is less than three months away

If you haven’t registered for the largest event in the hospital medicine movement, now is the time. You can still take advantage of the early registration discount through Feb. 2. And pre-courses, many of which fill up ahead of time, are still available.

For hospitalists nationwide, HM15 is an unprecedented time to learn new clinical updates, network with colleagues, and hear from the leaders in healthcare. This year’s event takes place March 29 through April 1 at the Gaylord National Resort and Conference Center in National Harbor, Md., just minutes from Washington, D.C.

This year’s featured speakers represent the nation’s most forward-thinking leaders in providing the best possible care to hospitalized patients:

• Maureen Bisognano is president and CEO of the Institute for Healthcare Improvement (IHI), an independent, not-for-profit organization helping to lead the improvement of healthcare throughout the world. Join her for her featured address on “Leading Transformational Change.”

• Peter J. Pronovost, MD, PhD, FCCM, is a world-renowned patient safety champion and a practicing critical care physician. His scientific work in leveraging checklists to reduce catheter-related bloodstream infections has saved thousands of lives and earned him high-profile accolades, including being named one of the 100 Most Influential People in the World by Time magazine and receiving a coveted MacArthur Foundation “Genius Grant” in 2008. He is senior vice president for patient safety and quality and director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Hospital in Baltimore. Join him for his keynote address, “Taking Quality to the Next Level.”

• Robert M. Wachter, MD, MHM, national thought leader in healthcare quality improvement, will be addressing HM15 attendees, in his always-entertaining style, on how the computerization of medicine will transform your life or your practice. Join him for his closing address, “The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age.”

The benefits of attending HM15 don’t end with the final session, either. This year, SHM is offering a free, one-year membership for new members registering for HM15.

Brendon Shank is SHM’s associate vice president of communications.

Get your calendars out now and plan for a successful 2015 with SHM and the hospital medicine movement.

Leadership Academy

Oct. 19-22, 2015

Every day, thousands of hospitalists are confronted with challenges that weren’t addressed in medical school. Topics like effective management, leadership, finances, and physician engagement are all pressing issues for hospitalists, and, for years, hospitalists have turned to SHM’s Leadership Academy to develop the skill sets that can help them take their careers to the next level.

SHM’s 2015 Leadership Academy will be held Oct. 19-22 in Austin, Texas.

But register early. The 2014 Leadership Academy sold out quickly.

Visit www.hospitalmedicine.org/events to learn more.

Quality and Safety Educators Academy

May 7-9, 2015

The demand for medical education about quality and patient safety will continue in 2015. Hospitalists can be part of the solution for that demand by attending the Quality and Safety Educators Academy in May in Tempe, Ariz.

Visit www.hospitalmedicine.org/events to learn more.

Look for Physician in Training Events

SHM is working with medical schools across the country to host more events for physicians in 2015.

Visit www.hospitalmedicine.org and follow SHM on Twitter (www.twitter.com/SHMLive) for details.

Enroll in Project BOOST

Want to get the attention of your hospital’s leadership quickly? Tell them you have a plan for improving discharge processes and addressing readmissions. The first step: Enroll in SHM’s award-winning Project BOOST for one-on-one mentorship with national leaders in improving discharge. Learn more at www.hospitalmedicine.org/boost.

Deadline Reminder

The deadline to apply for Fellow in Hospital Medicine (FHM) and Senior Fellow in Hospital Medicine (SFHM) is January 9. Get your submissions in soon!

Get your calendars out now and plan for a successful 2015 with SHM and the hospital medicine movement.

Leadership Academy

Oct. 19-22, 2015

Every day, thousands of hospitalists are confronted with challenges that weren’t addressed in medical school. Topics like effective management, leadership, finances, and physician engagement are all pressing issues for hospitalists, and, for years, hospitalists have turned to SHM’s Leadership Academy to develop the skill sets that can help them take their careers to the next level.

SHM’s 2015 Leadership Academy will be held Oct. 19-22 in Austin, Texas.

But register early. The 2014 Leadership Academy sold out quickly.

Visit www.hospitalmedicine.org/events to learn more.

Quality and Safety Educators Academy

May 7-9, 2015

The demand for medical education about quality and patient safety will continue in 2015. Hospitalists can be part of the solution for that demand by attending the Quality and Safety Educators Academy in May in Tempe, Ariz.

Visit www.hospitalmedicine.org/events to learn more.

Look for Physician in Training Events

SHM is working with medical schools across the country to host more events for physicians in 2015.

Visit www.hospitalmedicine.org and follow SHM on Twitter (www.twitter.com/SHMLive) for details.

Enroll in Project BOOST

Want to get the attention of your hospital’s leadership quickly? Tell them you have a plan for improving discharge processes and addressing readmissions. The first step: Enroll in SHM’s award-winning Project BOOST for one-on-one mentorship with national leaders in improving discharge. Learn more at www.hospitalmedicine.org/boost.

Deadline Reminder

The deadline to apply for Fellow in Hospital Medicine (FHM) and Senior Fellow in Hospital Medicine (SFHM) is January 9. Get your submissions in soon!

Get your calendars out now and plan for a successful 2015 with SHM and the hospital medicine movement.

Leadership Academy

Oct. 19-22, 2015

Every day, thousands of hospitalists are confronted with challenges that weren’t addressed in medical school. Topics like effective management, leadership, finances, and physician engagement are all pressing issues for hospitalists, and, for years, hospitalists have turned to SHM’s Leadership Academy to develop the skill sets that can help them take their careers to the next level.

SHM’s 2015 Leadership Academy will be held Oct. 19-22 in Austin, Texas.

But register early. The 2014 Leadership Academy sold out quickly.

Visit www.hospitalmedicine.org/events to learn more.

Quality and Safety Educators Academy

May 7-9, 2015

The demand for medical education about quality and patient safety will continue in 2015. Hospitalists can be part of the solution for that demand by attending the Quality and Safety Educators Academy in May in Tempe, Ariz.

Visit www.hospitalmedicine.org/events to learn more.

Look for Physician in Training Events

SHM is working with medical schools across the country to host more events for physicians in 2015.

Visit www.hospitalmedicine.org and follow SHM on Twitter (www.twitter.com/SHMLive) for details.

Enroll in Project BOOST

Want to get the attention of your hospital’s leadership quickly? Tell them you have a plan for improving discharge processes and addressing readmissions. The first step: Enroll in SHM’s award-winning Project BOOST for one-on-one mentorship with national leaders in improving discharge. Learn more at www.hospitalmedicine.org/boost.

Deadline Reminder

The deadline to apply for Fellow in Hospital Medicine (FHM) and Senior Fellow in Hospital Medicine (SFHM) is January 9. Get your submissions in soon!

Hospitalists are good planners. They also are doers.

For hospitalists eager to get a jump on learning, earning CME credits, and improving their hospitals, there are lots of opportunities to get started now.

SHM’s popular Learning Portal continues to introduce hospitalists to some of the most pressing topics through CME-accredited modules. Most recently, the Learning Portal has launched “Pediatric Medical Knowledge Module II” and seven modules on anticoagulation, including:

• Anticoagulation for VTE and Management of VTE (modules one and two);
• Establishing Inpatient Programs to Improve Anticoagulation Management;
• Periprocedural Management of Anticoagulants;
• Reversal of New Oral Anticoagulants;
• Inpatient Management of Anticoagulation for Patients with Atrial Fibrillation; and
• Management of Target Specific Oral Anticoagulants (TSOACs) in the Inpatient and Perioperative Setting.

Hospitalists also can take on two new major challenges within the hospital, thanks to two new toolkits from SHM.

The Society of Hospital Medicine (SHM) Post-Acute Care Toolbox provides a wealth of resources to help optimize the transitions of care process between short-term acute care hospital stays (STACHs) and skilled nursing facilities stays (SNFs). The approach of the Toolbox is based on the principles of quality improvement applied to this specific transition. The interventions within the Toolbox are derived from both evidence-based medicine and the experiences of institutional experts.

In addition, the Toolbox includes a section on resources, programs, and innovations developed by professional societies, governmental agencies, and businesses.

To download the Post-Acute Care Toolbox, visit www.hospitalmedicine.org/PACT.

For hospitalists working to improve medication reconciliation within their hospitals, SHM has unveiled an update to the MARQUIS toolkit. In response to requirements from the Joint Commission, most hospitals already have implemented med-rec processes, but MARQUIS brings the best practices in the field to help develop new processes or improve existing ones.

To download the new manual and white paper from SHM’s experts, go to www.hospitalmedicine.org/MARQUIS.

For more about SHM’s Quality Improvement resources, visit www.hospitalmedicine.org/qi.

Hospitalists are good planners. They also are doers.

For hospitalists eager to get a jump on learning, earning CME credits, and improving their hospitals, there are lots of opportunities to get started now.

SHM’s popular Learning Portal continues to introduce hospitalists to some of the most pressing topics through CME-accredited modules. Most recently, the Learning Portal has launched “Pediatric Medical Knowledge Module II” and seven modules on anticoagulation, including:

• Anticoagulation for VTE and Management of VTE (modules one and two);
• Establishing Inpatient Programs to Improve Anticoagulation Management;
• Periprocedural Management of Anticoagulants;
• Reversal of New Oral Anticoagulants;
• Inpatient Management of Anticoagulation for Patients with Atrial Fibrillation; and
• Management of Target Specific Oral Anticoagulants (TSOACs) in the Inpatient and Perioperative Setting.

Hospitalists also can take on two new major challenges within the hospital, thanks to two new toolkits from SHM.

The Society of Hospital Medicine (SHM) Post-Acute Care Toolbox provides a wealth of resources to help optimize the transitions of care process between short-term acute care hospital stays (STACHs) and skilled nursing facilities stays (SNFs). The approach of the Toolbox is based on the principles of quality improvement applied to this specific transition. The interventions within the Toolbox are derived from both evidence-based medicine and the experiences of institutional experts.

In addition, the Toolbox includes a section on resources, programs, and innovations developed by professional societies, governmental agencies, and businesses.

To download the Post-Acute Care Toolbox, visit www.hospitalmedicine.org/PACT.

For hospitalists working to improve medication reconciliation within their hospitals, SHM has unveiled an update to the MARQUIS toolkit. In response to requirements from the Joint Commission, most hospitals already have implemented med-rec processes, but MARQUIS brings the best practices in the field to help develop new processes or improve existing ones.

To download the new manual and white paper from SHM’s experts, go to www.hospitalmedicine.org/MARQUIS.

For more about SHM’s Quality Improvement resources, visit www.hospitalmedicine.org/qi.

Hospitalists are good planners. They also are doers.

For hospitalists eager to get a jump on learning, earning CME credits, and improving their hospitals, there are lots of opportunities to get started now.

SHM’s popular Learning Portal continues to introduce hospitalists to some of the most pressing topics through CME-accredited modules. Most recently, the Learning Portal has launched “Pediatric Medical Knowledge Module II” and seven modules on anticoagulation, including:

• Anticoagulation for VTE and Management of VTE (modules one and two);
• Establishing Inpatient Programs to Improve Anticoagulation Management;
• Periprocedural Management of Anticoagulants;
• Reversal of New Oral Anticoagulants;
• Inpatient Management of Anticoagulation for Patients with Atrial Fibrillation; and
• Management of Target Specific Oral Anticoagulants (TSOACs) in the Inpatient and Perioperative Setting.

Hospitalists also can take on two new major challenges within the hospital, thanks to two new toolkits from SHM.

The Society of Hospital Medicine (SHM) Post-Acute Care Toolbox provides a wealth of resources to help optimize the transitions of care process between short-term acute care hospital stays (STACHs) and skilled nursing facilities stays (SNFs). The approach of the Toolbox is based on the principles of quality improvement applied to this specific transition. The interventions within the Toolbox are derived from both evidence-based medicine and the experiences of institutional experts.

In addition, the Toolbox includes a section on resources, programs, and innovations developed by professional societies, governmental agencies, and businesses.

To download the Post-Acute Care Toolbox, visit www.hospitalmedicine.org/PACT.

For hospitalists working to improve medication reconciliation within their hospitals, SHM has unveiled an update to the MARQUIS toolkit. In response to requirements from the Joint Commission, most hospitals already have implemented med-rec processes, but MARQUIS brings the best practices in the field to help develop new processes or improve existing ones.

To download the new manual and white paper from SHM’s experts, go to www.hospitalmedicine.org/MARQUIS.

For more about SHM’s Quality Improvement resources, visit www.hospitalmedicine.org/qi.

Insurers’ use of certain criteria to separate hospital stays into inpatient or observation status remains widespread. Observation status ensures provider reimbursement for hospitalizations deemed necessary by clinical judgment but not qualifying as inpatient care. Admission under observation status impacts the patient’s financial burden, as well, with observation admissions typically associated with increased out-of-pocket costs.

Although hospitals have always faced decreased reimbursement for observation admissions (compared to inpatient admissions), new penalties attached to readmission for patients discharged from an inpatient stay raise the potential to impact hospitalist practice by incentivizing increased use of observation status for hospitalizations in order to avoid readmission penalties.

Have readmission penalties associated with inpatient admissions actually led to increased use of observation status by hospitalist groups?

SHM’s 2014 State of Hospital Medicine report provides insight into this question. In groups serving adults only, observation discharges accounted for 16.1% of all discharges (see Figure 1). If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

In groups serving adults only, observation discharges accounted for 16.1% of all discharges. If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

–Dr. Smith

The question of determining whether to bill episodes as inpatient or observation status was asked in the 2012 survey, as well, though by a different methodology: 20% of admissions were billed as observation status by hospitalist practices seeing adults only. Even with some observation admissions in 2012 being converted to inpatient status later in the hospital stay (a factor accounted for in the 2014 survey by changing the wording of the survey so that it asks about status at discharge), not much overall change in hospitalist group practice can be appreciated.

Does the overall observation status use rate tell the whole story?

When 2012 and 2014 survey data are separated by academic status, a clear change in practice over time can be seen. Academic HMGs experienced an increase in use of observation status, from 15.3% of admissions in 2012 to 19.4% of discharges in 2014 (or 22.8% in 2014, if same-day hospital stay responses are added to the observation data). In comparison, nonacademic hospitalist practices reported a decrease in observation status utilization, from 20.4% of admissions in 2012 to 15.6% of discharges in 2014 (or 19.2%, accounting for same-day discharges as observation status).

Academic HMGs, which frequently rely on housestaff for the finer points of patient care documentation, must consequently rely on documentation largely written by providers with less experience and incentive to optimize documentation for billing, compared to experienced hospitalists. It’s plausible to speculate that the benefits associated with compensation for inpatient status for hospitals, compared to the risks of financial penalty associated with billing under inpatient status, could be different for academic than for nonacademic hospitalist groups, due to the differences in the quality of documentation between the two practice types, and that academic HMGs, or the hospitals they work with, see the risks associated with inpatient status billing as high enough to change billing practices. Nonacademic hospitalist groups, on the other hand, may rely on the experience of their retained hospitalists to document justification for inpatient status more effectively, and may thus maximize the financial benefit of inpatient status utilization sufficiently to overcome associated financial risks.

In an ever-changing reimbursement and political advocacy landscape, future SHM surveys will be pivotal in assessing what happens with trends surrounding use of observation status for episodes of hospital care.

Dr. Smith is a hospitalist and assistant professor at Northwestern University in Chicago, Ill., and a member of SHM’s Practice Analysis Committee.

Insurers’ use of certain criteria to separate hospital stays into inpatient or observation status remains widespread. Observation status ensures provider reimbursement for hospitalizations deemed necessary by clinical judgment but not qualifying as inpatient care. Admission under observation status impacts the patient’s financial burden, as well, with observation admissions typically associated with increased out-of-pocket costs.

Although hospitals have always faced decreased reimbursement for observation admissions (compared to inpatient admissions), new penalties attached to readmission for patients discharged from an inpatient stay raise the potential to impact hospitalist practice by incentivizing increased use of observation status for hospitalizations in order to avoid readmission penalties.

Have readmission penalties associated with inpatient admissions actually led to increased use of observation status by hospitalist groups?

SHM’s 2014 State of Hospital Medicine report provides insight into this question. In groups serving adults only, observation discharges accounted for 16.1% of all discharges (see Figure 1). If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

In groups serving adults only, observation discharges accounted for 16.1% of all discharges. If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

–Dr. Smith

The question of determining whether to bill episodes as inpatient or observation status was asked in the 2012 survey, as well, though by a different methodology: 20% of admissions were billed as observation status by hospitalist practices seeing adults only. Even with some observation admissions in 2012 being converted to inpatient status later in the hospital stay (a factor accounted for in the 2014 survey by changing the wording of the survey so that it asks about status at discharge), not much overall change in hospitalist group practice can be appreciated.

Does the overall observation status use rate tell the whole story?

When 2012 and 2014 survey data are separated by academic status, a clear change in practice over time can be seen. Academic HMGs experienced an increase in use of observation status, from 15.3% of admissions in 2012 to 19.4% of discharges in 2014 (or 22.8% in 2014, if same-day hospital stay responses are added to the observation data). In comparison, nonacademic hospitalist practices reported a decrease in observation status utilization, from 20.4% of admissions in 2012 to 15.6% of discharges in 2014 (or 19.2%, accounting for same-day discharges as observation status).

Academic HMGs, which frequently rely on housestaff for the finer points of patient care documentation, must consequently rely on documentation largely written by providers with less experience and incentive to optimize documentation for billing, compared to experienced hospitalists. It’s plausible to speculate that the benefits associated with compensation for inpatient status for hospitals, compared to the risks of financial penalty associated with billing under inpatient status, could be different for academic than for nonacademic hospitalist groups, due to the differences in the quality of documentation between the two practice types, and that academic HMGs, or the hospitals they work with, see the risks associated with inpatient status billing as high enough to change billing practices. Nonacademic hospitalist groups, on the other hand, may rely on the experience of their retained hospitalists to document justification for inpatient status more effectively, and may thus maximize the financial benefit of inpatient status utilization sufficiently to overcome associated financial risks.

In an ever-changing reimbursement and political advocacy landscape, future SHM surveys will be pivotal in assessing what happens with trends surrounding use of observation status for episodes of hospital care.

Dr. Smith is a hospitalist and assistant professor at Northwestern University in Chicago, Ill., and a member of SHM’s Practice Analysis Committee.

Insurers’ use of certain criteria to separate hospital stays into inpatient or observation status remains widespread. Observation status ensures provider reimbursement for hospitalizations deemed necessary by clinical judgment but not qualifying as inpatient care. Admission under observation status impacts the patient’s financial burden, as well, with observation admissions typically associated with increased out-of-pocket costs.

Although hospitals have always faced decreased reimbursement for observation admissions (compared to inpatient admissions), new penalties attached to readmission for patients discharged from an inpatient stay raise the potential to impact hospitalist practice by incentivizing increased use of observation status for hospitalizations in order to avoid readmission penalties.

Have readmission penalties associated with inpatient admissions actually led to increased use of observation status by hospitalist groups?

SHM’s 2014 State of Hospital Medicine report provides insight into this question. In groups serving adults only, observation discharges accounted for 16.1% of all discharges (see Figure 1). If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

In groups serving adults only, observation discharges accounted for 16.1% of all discharges. If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

–Dr. Smith

The question of determining whether to bill episodes as inpatient or observation status was asked in the 2012 survey, as well, though by a different methodology: 20% of admissions were billed as observation status by hospitalist practices seeing adults only. Even with some observation admissions in 2012 being converted to inpatient status later in the hospital stay (a factor accounted for in the 2014 survey by changing the wording of the survey so that it asks about status at discharge), not much overall change in hospitalist group practice can be appreciated.

Does the overall observation status use rate tell the whole story?

When 2012 and 2014 survey data are separated by academic status, a clear change in practice over time can be seen. Academic HMGs experienced an increase in use of observation status, from 15.3% of admissions in 2012 to 19.4% of discharges in 2014 (or 22.8% in 2014, if same-day hospital stay responses are added to the observation data). In comparison, nonacademic hospitalist practices reported a decrease in observation status utilization, from 20.4% of admissions in 2012 to 15.6% of discharges in 2014 (or 19.2%, accounting for same-day discharges as observation status).

Academic HMGs, which frequently rely on housestaff for the finer points of patient care documentation, must consequently rely on documentation largely written by providers with less experience and incentive to optimize documentation for billing, compared to experienced hospitalists. It’s plausible to speculate that the benefits associated with compensation for inpatient status for hospitals, compared to the risks of financial penalty associated with billing under inpatient status, could be different for academic than for nonacademic hospitalist groups, due to the differences in the quality of documentation between the two practice types, and that academic HMGs, or the hospitals they work with, see the risks associated with inpatient status billing as high enough to change billing practices. Nonacademic hospitalist groups, on the other hand, may rely on the experience of their retained hospitalists to document justification for inpatient status more effectively, and may thus maximize the financial benefit of inpatient status utilization sufficiently to overcome associated financial risks.

In an ever-changing reimbursement and political advocacy landscape, future SHM surveys will be pivotal in assessing what happens with trends surrounding use of observation status for episodes of hospital care.

Dr. Smith is a hospitalist and assistant professor at Northwestern University in Chicago, Ill., and a member of SHM’s Practice Analysis Committee.

Question: Charges of homicide have been successfully brought against doctors in the following situations except:

A. Withholding life-sustaining treatment.

B. Euthanasia.

C. Negligent treatment of a patient.

D. Overprescription of controlled substances.

Answer: A. Homicideis any act that causes the death of a human being with criminal intent and without legal justification. It comprises several crimes of varying severity, with murder being the most serious (requiring “malice aforethought”). Depending on the intent of the perpetrator and/or the presence of mitigating/aggravating circumstances, jurisdictions have subdivided homicide into categories such as first- and second-degree murder, voluntary and involuntary manslaughter, negligent homicide, and others.

Discontinuing futile medical treatment that ends with patient demise raises the specter of criminal prosecution for homicide. However, prosecution of doctors under such circumstances has failed. The seminal case is Barber v. Superior Court (147 Cal. App. 3d 1006 (1983)), in which the state of California brought murder charges against two doctors for discontinuing intravenous fluids and nutrition in a comatose patient.

The patient, a 55-year-old security guard, sustained a cardiopulmonary arrest following surgery for intestinal obstruction. Irreversible brain damage resulted, leaving him in a vegetative state. His family allegedly requested that life support measures and intravenous fluids be discontinued, to which the doctors complied, and the patient died 6 days later.

After a preliminary pretrial hearing, the magistrate dismissed the charges; but a trial court reinstated them. The court of appeals, however, viewed the defendant’s conduct in discontinuing intravenous fluids as an omission rather than an affirmative action, and found that a physician has no duty to continue treatment once it is proven to be ineffective.

The appeals court recognized that “a physician is authorized under the standards of medical practice to discontinue a form of therapy which in his medical judgment is useless. … If the treating physicians have determined that continued use of a respirator is useless, then they may decide to discontinue it without fear of civil or criminal liability.”

In rejecting the distinction between ordinary and extraordinary care, the court dismissed the prosecutor’s contention that unlike the respirator, fluids and nutrition represented ordinary care and therefore should never be withheld.

It concluded that “the petitioners’ omission to continue treatment under the circumstances, though intentional and with knowledge that the patient would die, was not an unlawful failure to perform a legal duty.” And because no criminal liability attaches for failure to act (i.e., an omission) unless there is a legal duty to act affirmatively, it issued a writ of prohibition restraining the lower court from taking any further action on the matter.

The U.S. Supreme Court has since validated the distinction between “letting die” and an affirmative action taken with the intention to cause death, such as the administration of a lethal injection. The former is ethical and legal, conforming to medical norms, while the latter amounts to murder (Vacco v. Quill (117 S. Ct. 2293 (1997)).

With these developments, physicians therefore need not worry about criminal prosecution for carrying out Barber-like noneuthanasia, end-of-life actions that result in the death of their patients.

On the other hand, those who act directly to end the life of a patient, even one who freely requests death, may face criminal prosecution.

The most notorious example is that of retired Michigan pathologist Dr. Jack Kevorkian, who was found guilty of the second-degree murder of Thomas Youk, a 52-year-old race-car driver with terminal Lou Gehrig’s disease. Dr. Kevorkian injected a lethal mixture of Seconal, Anectine, and potassium chloride to end the patient’s life.

At trial, Dr. Kevorkian dismissed his lawyer and served ineffectively in his own defense, never taking the witness stand. Found guilty by a jury and sentenced to 10-25 years in prison, he served just more than 8 years until 2007, when he was released for good behavior. Previous charges by the state of Michigan against Dr. Kevorkian for assisting in the suicide of some 130 patients had proven unsuccessful.

This case spawned a nationwide debate on physician-directed deaths, with a few states now legalizing physician-assisted suicide, although euthanasia remains illegal throughout the nation.

In general, the remedy sought in a medical wrongful death case lies in a malpractice civil lawsuit against the negligent doctor. Sometimes, the plaintiff may assert that there was gross negligence where the conduct was particularly blameworthy, and if proven, the jury may award punitive damages.

Rarely, however, does the level of misconduct rise to that of criminal negligence. Here, the burden of proof for a conviction requires evidence beyond reasonable doubt, rather than the lower “more probable than not” evidentiary standard required in a civil lawsuit.

However, in cases where the physician’s conduct has markedly deviated from the standard of care, doctors have been successfully prosecuted for their “criminal” conduct.

For example, in an English case, an anesthesiologist was convicted of manslaughter in the death of a patient undergoing surgery for a detached retina. During surgery, the patient’s ventilation was interrupted because of accidental disconnection of the endotracheal tube for 4 minutes, leading to a cardiac arrest. An alarm had apparently sounded but was not noticed. The injury would not have occurred had the doctor attended to the patient instead of being away from the operating room.

The tragic death of pop star Michael Jackson in 2009 is another example. Dr. Conrad Murray, a cardiologist who was Jackson’s personal physician, had used the surgical anesthetic propofol to treat Jackson’s insomnia in a bedroom setting without monitoring or resuscitation equipment. Concurrent use of the sedative lorazepam exacerbated the effect of propofol. The prosecution characterized Dr. Murray’s conduct as “egregious, unethical, and unconscionable,” which violated medical standards and amounted to criminal negligence. He was found guilty of involuntary manslaughter, and the state sentenced him to a 4-year prison term.

A new trend appears to be developing toward prosecuting doctors whose overprescription of controlled substances results in patient deaths.

According to a recent news report, New York for the first time convicted a doctor of manslaughter in the overdose deaths of patients from oxycodone and Xanax.¹ Some of the patients were reportedly prescribed as many as 500-800 pills over a 5-6 week period. Dr. Stan Li, an anesthesiologist and pain management specialist, allegedly saw up to 90 patients a day in his Queens, N.Y., weekend storefront clinic, charging them on a per-prescription basis. In his defense, Dr. Li claimed that he was simply trying to help suffering people who misused medications and who misled him (“tough patients and good liars”).

Meanwhile, a similar scenario played out in Oklahoma.² There, Dr. William Valuck, a pain management doctor, pleaded guilty to eight counts of second-degree murder in connection with several drug overdose deaths. He entered into a plea bargain with Oklahoma prosecutors and will serve 8 years in prison. Dr. Valuck had reportedly prescribed more controlled drugs than any other physician in the state of Oklahoma, which included hydrocodone, oxycodone, alprazolam, Valium, and Soma, sometimes as many as 600 pills at a time. He allegedly accepted only cash payment for the office visits, and review of his patient files revealed inadequate assessment of patient complaints or physical findings to justify the prescriptions.

Most physicians are unlikely to ever face the specter of criminal prosecution based on their medical performance. Only in the most egregious of circumstances have physicians been successfully prosecuted for homicide.

As requests for physicians to withhold or withdraw life-sustaining treatments grow, physicians may find themselves questioning what acts or omissions they may legally perform. Unless the legal landscape changes, however, it appears that the forgoing of life-sustaining treatments in the typical clinical context will not subject physicians to criminal prosecution.

References

1. “NY doctor convicted of manslaughter in 2 overdoses,” July 18, 2014 (http://bigstory.ap.org/article/ny-doctor-convicted-2-patients-overdose-deaths).

2. “Ex-doctor pleads guilty in overdose deaths,” Aug. 13, 2014 (www.usatoday.com/story/news/nation/2014/08/13/ex-doctor-guilty-deaths/14022735).

Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii, and directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

Question: Charges of homicide have been successfully brought against doctors in the following situations except:

A. Withholding life-sustaining treatment.

B. Euthanasia.

C. Negligent treatment of a patient.

D. Overprescription of controlled substances.

Answer: A. Homicideis any act that causes the death of a human being with criminal intent and without legal justification. It comprises several crimes of varying severity, with murder being the most serious (requiring “malice aforethought”). Depending on the intent of the perpetrator and/or the presence of mitigating/aggravating circumstances, jurisdictions have subdivided homicide into categories such as first- and second-degree murder, voluntary and involuntary manslaughter, negligent homicide, and others.

Discontinuing futile medical treatment that ends with patient demise raises the specter of criminal prosecution for homicide. However, prosecution of doctors under such circumstances has failed. The seminal case is Barber v. Superior Court (147 Cal. App. 3d 1006 (1983)), in which the state of California brought murder charges against two doctors for discontinuing intravenous fluids and nutrition in a comatose patient.

The patient, a 55-year-old security guard, sustained a cardiopulmonary arrest following surgery for intestinal obstruction. Irreversible brain damage resulted, leaving him in a vegetative state. His family allegedly requested that life support measures and intravenous fluids be discontinued, to which the doctors complied, and the patient died 6 days later.

After a preliminary pretrial hearing, the magistrate dismissed the charges; but a trial court reinstated them. The court of appeals, however, viewed the defendant’s conduct in discontinuing intravenous fluids as an omission rather than an affirmative action, and found that a physician has no duty to continue treatment once it is proven to be ineffective.

The appeals court recognized that “a physician is authorized under the standards of medical practice to discontinue a form of therapy which in his medical judgment is useless. … If the treating physicians have determined that continued use of a respirator is useless, then they may decide to discontinue it without fear of civil or criminal liability.”

In rejecting the distinction between ordinary and extraordinary care, the court dismissed the prosecutor’s contention that unlike the respirator, fluids and nutrition represented ordinary care and therefore should never be withheld.

It concluded that “the petitioners’ omission to continue treatment under the circumstances, though intentional and with knowledge that the patient would die, was not an unlawful failure to perform a legal duty.” And because no criminal liability attaches for failure to act (i.e., an omission) unless there is a legal duty to act affirmatively, it issued a writ of prohibition restraining the lower court from taking any further action on the matter.

The U.S. Supreme Court has since validated the distinction between “letting die” and an affirmative action taken with the intention to cause death, such as the administration of a lethal injection. The former is ethical and legal, conforming to medical norms, while the latter amounts to murder (Vacco v. Quill (117 S. Ct. 2293 (1997)).

With these developments, physicians therefore need not worry about criminal prosecution for carrying out Barber-like noneuthanasia, end-of-life actions that result in the death of their patients.

On the other hand, those who act directly to end the life of a patient, even one who freely requests death, may face criminal prosecution.

The most notorious example is that of retired Michigan pathologist Dr. Jack Kevorkian, who was found guilty of the second-degree murder of Thomas Youk, a 52-year-old race-car driver with terminal Lou Gehrig’s disease. Dr. Kevorkian injected a lethal mixture of Seconal, Anectine, and potassium chloride to end the patient’s life.

At trial, Dr. Kevorkian dismissed his lawyer and served ineffectively in his own defense, never taking the witness stand. Found guilty by a jury and sentenced to 10-25 years in prison, he served just more than 8 years until 2007, when he was released for good behavior. Previous charges by the state of Michigan against Dr. Kevorkian for assisting in the suicide of some 130 patients had proven unsuccessful.

This case spawned a nationwide debate on physician-directed deaths, with a few states now legalizing physician-assisted suicide, although euthanasia remains illegal throughout the nation.

In general, the remedy sought in a medical wrongful death case lies in a malpractice civil lawsuit against the negligent doctor. Sometimes, the plaintiff may assert that there was gross negligence where the conduct was particularly blameworthy, and if proven, the jury may award punitive damages.

Rarely, however, does the level of misconduct rise to that of criminal negligence. Here, the burden of proof for a conviction requires evidence beyond reasonable doubt, rather than the lower “more probable than not” evidentiary standard required in a civil lawsuit.

However, in cases where the physician’s conduct has markedly deviated from the standard of care, doctors have been successfully prosecuted for their “criminal” conduct.

For example, in an English case, an anesthesiologist was convicted of manslaughter in the death of a patient undergoing surgery for a detached retina. During surgery, the patient’s ventilation was interrupted because of accidental disconnection of the endotracheal tube for 4 minutes, leading to a cardiac arrest. An alarm had apparently sounded but was not noticed. The injury would not have occurred had the doctor attended to the patient instead of being away from the operating room.

The tragic death of pop star Michael Jackson in 2009 is another example. Dr. Conrad Murray, a cardiologist who was Jackson’s personal physician, had used the surgical anesthetic propofol to treat Jackson’s insomnia in a bedroom setting without monitoring or resuscitation equipment. Concurrent use of the sedative lorazepam exacerbated the effect of propofol. The prosecution characterized Dr. Murray’s conduct as “egregious, unethical, and unconscionable,” which violated medical standards and amounted to criminal negligence. He was found guilty of involuntary manslaughter, and the state sentenced him to a 4-year prison term.

A new trend appears to be developing toward prosecuting doctors whose overprescription of controlled substances results in patient deaths.

According to a recent news report, New York for the first time convicted a doctor of manslaughter in the overdose deaths of patients from oxycodone and Xanax.¹ Some of the patients were reportedly prescribed as many as 500-800 pills over a 5-6 week period. Dr. Stan Li, an anesthesiologist and pain management specialist, allegedly saw up to 90 patients a day in his Queens, N.Y., weekend storefront clinic, charging them on a per-prescription basis. In his defense, Dr. Li claimed that he was simply trying to help suffering people who misused medications and who misled him (“tough patients and good liars”).

Meanwhile, a similar scenario played out in Oklahoma.² There, Dr. William Valuck, a pain management doctor, pleaded guilty to eight counts of second-degree murder in connection with several drug overdose deaths. He entered into a plea bargain with Oklahoma prosecutors and will serve 8 years in prison. Dr. Valuck had reportedly prescribed more controlled drugs than any other physician in the state of Oklahoma, which included hydrocodone, oxycodone, alprazolam, Valium, and Soma, sometimes as many as 600 pills at a time. He allegedly accepted only cash payment for the office visits, and review of his patient files revealed inadequate assessment of patient complaints or physical findings to justify the prescriptions.

Most physicians are unlikely to ever face the specter of criminal prosecution based on their medical performance. Only in the most egregious of circumstances have physicians been successfully prosecuted for homicide.

As requests for physicians to withhold or withdraw life-sustaining treatments grow, physicians may find themselves questioning what acts or omissions they may legally perform. Unless the legal landscape changes, however, it appears that the forgoing of life-sustaining treatments in the typical clinical context will not subject physicians to criminal prosecution.

References

1. “NY doctor convicted of manslaughter in 2 overdoses,” July 18, 2014 (http://bigstory.ap.org/article/ny-doctor-convicted-2-patients-overdose-deaths).

2. “Ex-doctor pleads guilty in overdose deaths,” Aug. 13, 2014 (www.usatoday.com/story/news/nation/2014/08/13/ex-doctor-guilty-deaths/14022735).

Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii, and directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

Question: Charges of homicide have been successfully brought against doctors in the following situations except:

A. Withholding life-sustaining treatment.

B. Euthanasia.

C. Negligent treatment of a patient.

D. Overprescription of controlled substances.

Answer: A. Homicideis any act that causes the death of a human being with criminal intent and without legal justification. It comprises several crimes of varying severity, with murder being the most serious (requiring “malice aforethought”). Depending on the intent of the perpetrator and/or the presence of mitigating/aggravating circumstances, jurisdictions have subdivided homicide into categories such as first- and second-degree murder, voluntary and involuntary manslaughter, negligent homicide, and others.

Discontinuing futile medical treatment that ends with patient demise raises the specter of criminal prosecution for homicide. However, prosecution of doctors under such circumstances has failed. The seminal case is Barber v. Superior Court (147 Cal. App. 3d 1006 (1983)), in which the state of California brought murder charges against two doctors for discontinuing intravenous fluids and nutrition in a comatose patient.

The patient, a 55-year-old security guard, sustained a cardiopulmonary arrest following surgery for intestinal obstruction. Irreversible brain damage resulted, leaving him in a vegetative state. His family allegedly requested that life support measures and intravenous fluids be discontinued, to which the doctors complied, and the patient died 6 days later.

After a preliminary pretrial hearing, the magistrate dismissed the charges; but a trial court reinstated them. The court of appeals, however, viewed the defendant’s conduct in discontinuing intravenous fluids as an omission rather than an affirmative action, and found that a physician has no duty to continue treatment once it is proven to be ineffective.

The appeals court recognized that “a physician is authorized under the standards of medical practice to discontinue a form of therapy which in his medical judgment is useless. … If the treating physicians have determined that continued use of a respirator is useless, then they may decide to discontinue it without fear of civil or criminal liability.”

In rejecting the distinction between ordinary and extraordinary care, the court dismissed the prosecutor’s contention that unlike the respirator, fluids and nutrition represented ordinary care and therefore should never be withheld.

It concluded that “the petitioners’ omission to continue treatment under the circumstances, though intentional and with knowledge that the patient would die, was not an unlawful failure to perform a legal duty.” And because no criminal liability attaches for failure to act (i.e., an omission) unless there is a legal duty to act affirmatively, it issued a writ of prohibition restraining the lower court from taking any further action on the matter.

The U.S. Supreme Court has since validated the distinction between “letting die” and an affirmative action taken with the intention to cause death, such as the administration of a lethal injection. The former is ethical and legal, conforming to medical norms, while the latter amounts to murder (Vacco v. Quill (117 S. Ct. 2293 (1997)).

With these developments, physicians therefore need not worry about criminal prosecution for carrying out Barber-like noneuthanasia, end-of-life actions that result in the death of their patients.

On the other hand, those who act directly to end the life of a patient, even one who freely requests death, may face criminal prosecution.

The most notorious example is that of retired Michigan pathologist Dr. Jack Kevorkian, who was found guilty of the second-degree murder of Thomas Youk, a 52-year-old race-car driver with terminal Lou Gehrig’s disease. Dr. Kevorkian injected a lethal mixture of Seconal, Anectine, and potassium chloride to end the patient’s life.

At trial, Dr. Kevorkian dismissed his lawyer and served ineffectively in his own defense, never taking the witness stand. Found guilty by a jury and sentenced to 10-25 years in prison, he served just more than 8 years until 2007, when he was released for good behavior. Previous charges by the state of Michigan against Dr. Kevorkian for assisting in the suicide of some 130 patients had proven unsuccessful.

This case spawned a nationwide debate on physician-directed deaths, with a few states now legalizing physician-assisted suicide, although euthanasia remains illegal throughout the nation.

In general, the remedy sought in a medical wrongful death case lies in a malpractice civil lawsuit against the negligent doctor. Sometimes, the plaintiff may assert that there was gross negligence where the conduct was particularly blameworthy, and if proven, the jury may award punitive damages.

Rarely, however, does the level of misconduct rise to that of criminal negligence. Here, the burden of proof for a conviction requires evidence beyond reasonable doubt, rather than the lower “more probable than not” evidentiary standard required in a civil lawsuit.

However, in cases where the physician’s conduct has markedly deviated from the standard of care, doctors have been successfully prosecuted for their “criminal” conduct.

For example, in an English case, an anesthesiologist was convicted of manslaughter in the death of a patient undergoing surgery for a detached retina. During surgery, the patient’s ventilation was interrupted because of accidental disconnection of the endotracheal tube for 4 minutes, leading to a cardiac arrest. An alarm had apparently sounded but was not noticed. The injury would not have occurred had the doctor attended to the patient instead of being away from the operating room.

The tragic death of pop star Michael Jackson in 2009 is another example. Dr. Conrad Murray, a cardiologist who was Jackson’s personal physician, had used the surgical anesthetic propofol to treat Jackson’s insomnia in a bedroom setting without monitoring or resuscitation equipment. Concurrent use of the sedative lorazepam exacerbated the effect of propofol. The prosecution characterized Dr. Murray’s conduct as “egregious, unethical, and unconscionable,” which violated medical standards and amounted to criminal negligence. He was found guilty of involuntary manslaughter, and the state sentenced him to a 4-year prison term.

A new trend appears to be developing toward prosecuting doctors whose overprescription of controlled substances results in patient deaths.

According to a recent news report, New York for the first time convicted a doctor of manslaughter in the overdose deaths of patients from oxycodone and Xanax.¹ Some of the patients were reportedly prescribed as many as 500-800 pills over a 5-6 week period. Dr. Stan Li, an anesthesiologist and pain management specialist, allegedly saw up to 90 patients a day in his Queens, N.Y., weekend storefront clinic, charging them on a per-prescription basis. In his defense, Dr. Li claimed that he was simply trying to help suffering people who misused medications and who misled him (“tough patients and good liars”).

Meanwhile, a similar scenario played out in Oklahoma.² There, Dr. William Valuck, a pain management doctor, pleaded guilty to eight counts of second-degree murder in connection with several drug overdose deaths. He entered into a plea bargain with Oklahoma prosecutors and will serve 8 years in prison. Dr. Valuck had reportedly prescribed more controlled drugs than any other physician in the state of Oklahoma, which included hydrocodone, oxycodone, alprazolam, Valium, and Soma, sometimes as many as 600 pills at a time. He allegedly accepted only cash payment for the office visits, and review of his patient files revealed inadequate assessment of patient complaints or physical findings to justify the prescriptions.

Most physicians are unlikely to ever face the specter of criminal prosecution based on their medical performance. Only in the most egregious of circumstances have physicians been successfully prosecuted for homicide.

As requests for physicians to withhold or withdraw life-sustaining treatments grow, physicians may find themselves questioning what acts or omissions they may legally perform. Unless the legal landscape changes, however, it appears that the forgoing of life-sustaining treatments in the typical clinical context will not subject physicians to criminal prosecution.

References

1. “NY doctor convicted of manslaughter in 2 overdoses,” July 18, 2014 (http://bigstory.ap.org/article/ny-doctor-convicted-2-patients-overdose-deaths).

2. “Ex-doctor pleads guilty in overdose deaths,” Aug. 13, 2014 (www.usatoday.com/story/news/nation/2014/08/13/ex-doctor-guilty-deaths/14022735).

Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii, and directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

Clinical question: How are medical consultants used for hospitalized surgical patients, and how does this vary among regions and hospitals in the U.S.?

Background: Reimbursement for surgical procedures is moving toward bundled payments, making it increasingly important to understand the use of resources in order to improve efficiency and quality of care.

Study design: Observational, retrospective, cohort study.

Setting: Fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) at U.S. acute care hospitals.

Synopsis: Using the Medicare Provider Analysis and Review (MEDPAR) File, the Carrier File, and the 2007 American Hospital Association’s annual survey, researchers evaluated a sample of 91,684 colectomy patients at 930 hospitals and 339,319 THR patients at 1,589 hospitals between the ages of 65 and 99 who were enrolled in Medicare parts A and B between 2007 and 2010. Sixty-nine percent of colectomy patients saw a consultant (50% medicine and 56% specialists). Sixty-three percent of THR patients saw a consultant (53% medicine and 24% specialists).

Patient factors for consults included older age, comorbidities, and nonelective admission. Hospital factors for consults included Midwest location, nonteaching, for-profit status, and hospital size. Greater use of consultants was associated with higher rates of post-operative complications.

Additional research on the association between mortality after complications (including type and timing) and number of consultants may help to improve future efficiency and outcomes. Creating a consensus about the use of medical consultants in healthy patients would also be beneficial.

Limitations of the study include a lack of detail on consult indications, unknown effect of pre-operative outpatient medical consults, major differences in median visits by site and surgery type, and the sole use of administrative claims data.

Bottom line: With the procedural fee for service changing to bundled payments, guidelines may be necessary for appropriate use of consultants, to improve both efficiency and quality of care provided by hospitals.

Citation: Chen LM, Wilk AS, Thumma JR, Birkmeyer JD, Banerjee M. Use of medical consultants for hospitalized surgical patients: an observational cohort study. JAMA Intern Med. 2014;174(9):1470-1477.

Clinical question: How are medical consultants used for hospitalized surgical patients, and how does this vary among regions and hospitals in the U.S.?

Background: Reimbursement for surgical procedures is moving toward bundled payments, making it increasingly important to understand the use of resources in order to improve efficiency and quality of care.

Study design: Observational, retrospective, cohort study.

Setting: Fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) at U.S. acute care hospitals.

Synopsis: Using the Medicare Provider Analysis and Review (MEDPAR) File, the Carrier File, and the 2007 American Hospital Association’s annual survey, researchers evaluated a sample of 91,684 colectomy patients at 930 hospitals and 339,319 THR patients at 1,589 hospitals between the ages of 65 and 99 who were enrolled in Medicare parts A and B between 2007 and 2010. Sixty-nine percent of colectomy patients saw a consultant (50% medicine and 56% specialists). Sixty-three percent of THR patients saw a consultant (53% medicine and 24% specialists).

Patient factors for consults included older age, comorbidities, and nonelective admission. Hospital factors for consults included Midwest location, nonteaching, for-profit status, and hospital size. Greater use of consultants was associated with higher rates of post-operative complications.

Additional research on the association between mortality after complications (including type and timing) and number of consultants may help to improve future efficiency and outcomes. Creating a consensus about the use of medical consultants in healthy patients would also be beneficial.

Limitations of the study include a lack of detail on consult indications, unknown effect of pre-operative outpatient medical consults, major differences in median visits by site and surgery type, and the sole use of administrative claims data.

Bottom line: With the procedural fee for service changing to bundled payments, guidelines may be necessary for appropriate use of consultants, to improve both efficiency and quality of care provided by hospitals.

Citation: Chen LM, Wilk AS, Thumma JR, Birkmeyer JD, Banerjee M. Use of medical consultants for hospitalized surgical patients: an observational cohort study. JAMA Intern Med. 2014;174(9):1470-1477.

Clinical question: How are medical consultants used for hospitalized surgical patients, and how does this vary among regions and hospitals in the U.S.?

Background: Reimbursement for surgical procedures is moving toward bundled payments, making it increasingly important to understand the use of resources in order to improve efficiency and quality of care.

Study design: Observational, retrospective, cohort study.

Setting: Fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) at U.S. acute care hospitals.

Synopsis: Using the Medicare Provider Analysis and Review (MEDPAR) File, the Carrier File, and the 2007 American Hospital Association’s annual survey, researchers evaluated a sample of 91,684 colectomy patients at 930 hospitals and 339,319 THR patients at 1,589 hospitals between the ages of 65 and 99 who were enrolled in Medicare parts A and B between 2007 and 2010. Sixty-nine percent of colectomy patients saw a consultant (50% medicine and 56% specialists). Sixty-three percent of THR patients saw a consultant (53% medicine and 24% specialists).

Patient factors for consults included older age, comorbidities, and nonelective admission. Hospital factors for consults included Midwest location, nonteaching, for-profit status, and hospital size. Greater use of consultants was associated with higher rates of post-operative complications.

Additional research on the association between mortality after complications (including type and timing) and number of consultants may help to improve future efficiency and outcomes. Creating a consensus about the use of medical consultants in healthy patients would also be beneficial.

Limitations of the study include a lack of detail on consult indications, unknown effect of pre-operative outpatient medical consults, major differences in median visits by site and surgery type, and the sole use of administrative claims data.

Bottom line: With the procedural fee for service changing to bundled payments, guidelines may be necessary for appropriate use of consultants, to improve both efficiency and quality of care provided by hospitals.

Citation: Chen LM, Wilk AS, Thumma JR, Birkmeyer JD, Banerjee M. Use of medical consultants for hospitalized surgical patients: an observational cohort study. JAMA Intern Med. 2014;174(9):1470-1477.