Enteral nutrition is an essential component of the care plan for critically ill and injured patients. There is consensus that critically ill patients are at risk for malnutrition, and those who will be unable to consume adequate oral nutrition within 3 days should receive specialized enteral and/or parenteral nutrition therapy.[1] Multiple studies and reputable scientific societies support early initiation of enteral feedings within 24 to 48 hours of admission to the intensive care unit (ICU) to promote tolerance, minimize the risk of intestinal barrier dysfunction and infectious complications, and reduce the length of mechanical ventilation and hospital stay, as well as mortality.[2, 3, 4, 5] Although nasogastric feeding is appropriate for the majority of patients requiring short‐term nutrition support, there is a large group of patients in whom impaired gastric emptying presents challenges to feeding. The American Society for Parenteral and Enteral Nutrition, the American Thoracic Society, as well as the Infectious Diseases Society of America (IDSA), have published guidelines in support of postpyloric feeding in the ICU setting due to its association with reduced incidence of healthcare‐associated infections, specifically ventilator‐associated pneumonia (VAP).[2, 3, 6, 7] Four randomized clinical trials in the last 5 years have attempted to end the debate on the benefits of postpyloric feeding compared to intragastric feeding[5, 8, 9, 10]; 2 trials demonstrated an increase in calorie and protein intake and lower incidence of VAP in patients fed via the postpyloric route.[8, 10] One recent article[11] has suggested that severity of illness may play a role in the optimal selection of feeding route. Huang et al. randomly assigned patients to the nasogastric or nasoduodenal feeding route and documented the Acute Physiology and Chronic Health Evaluation II score as less than or greater than 20. Among more severely ill patients, those fed by the gastric route experienced longer ICU stay, more feeding complications, and lower calorie and protein intake than patients fed by the postpyloric route.[11] In an article comparing nutrition therapy recommendations among 3 major North American nutrition societies, the consensus was that critically ill patients at high risk for aspiration or feeding intolerance should be fed using small bowel access.[12] The Canadian Critical Care Guidelines Committee had the strongest recommendation for small bowel feeding stating that, if feasible, all critically ill patients should be fed via this route, based on the reduction in pneumonia.[12, 13]

When the decision is made to use postpyloric tube placement for nutrition therapy, the next decision is how to safely place the tube, ensure its postpyloric location, and minimize delays in feeding. Initiation of enteral formulas and timely advancement to nutrition goals is often delayed by unsuccessful feeding tube placement. Insertion of an enteral feeding tube into the postpyloric position is often done at the bedside by trained medical personnel without endoscopic or fluoroscopic guidance; however, the blind bedside approach is not without challenges. Success rates of this approach vary greatly depending on the patient population and provider expertise. The most challenging insertions may occur in patients who are endotracheally intubated, have depressed mental status, or impaired cough reflex.[14] Procedural complications from placement of nasoenteral feeding tubes by all methods can be as high as 10%,[15] with complication rates of 1% to 3%[16] for inadvertent placement of the feeding tube in the airway alone. The most common and serious complication is intubation of the bronchial tree with resulting pneumonitis, pneumonia, and pneumothorax, which reportedly occurs in 2.4% to 3.2% of tube insertions.[17, 18] It is recommended that radiographic confirmation of tube placement by any method occur prior to initiating feeding, thus eliminating any possibility of misplacement and administration of formula into the lungs.[18]

Historically, our institution advocated blind bedside placement of small bowel feeding tubes by trained ICU nurses, residents, and housestaff. Although not without risks, this method avoids the difficulty of coordinating endoscopic or fluoroscopic interventions that often necessitate transfer out of the ICU, with potential complications such as patient deterioration, and result in delays in initiating feeding.[19] However, like many other institutions, our level II medical center was interested in purchasing the Cortrak Enteral Access System (C‐EAS) (Viasys Medsystems, Wheeling, IL), which allows tracking of the small bowel feeding tube tip during placement. The C‐EAS uses an electromagnetic guide with a bedside monitor display to help providers observe the progress of the tube as it passes through the gastrointestinal tract. A receiver is placed on the patient's xiphoid process to detect the signal from the stylet that has an electromagnetic transmitter in the tip. The monitor displays the exact position of the postpyloric placement prior to removal of the tube guidewire. One early study by Ackerman and colleagues[20] found that the C‐EAS had a 100% success rate in avoiding lung placement and improves patient safety. The ability to monitor the location of the feeding tube tip in real time provides a safety feature for the clinician performing bedside insertions. In a recent study, the C‐EAS system was reported as not inferior to direct visualization of postpyloric placement via upper endoscopy.[21] In addition, several studies reported a reduction in mean time from physician order for tube placement to feeding initiation and fewer x‐rays for confirmation, thereby decreasing cost.[22] Not long after the C‐EAS system was purchased, Tiger 2 tubes (T2T) (Cook Inc., Bloomington, IN) were introduced in our facility for use in postpyloric feeding of ICU patients. The T2T system is a self‐advancing nasal jejunal feeding tube that uses a combination of intrinsic and stimulated gastric peristalsis with soft cilia‐like flaps in the side of the tube to propel the tube forward into the small bowel. Both tube systems have been studied over the past decade, with Gray et al.[22] reporting a 78% rate of successful small bowel placement using the electromagnetic‐guided device and Holzinger et al.[21] reporting an 89% success rate for jejunal placement using the same device. Davies and Bellomo[23] reported that their institution experienced a 100% success rate with small bowel placement of the T2T. Armed with 2 reputable, reliable modes of postpyloric tube placement, we encouraged all ICU staff to use these approaches for short‐term feeding for ICU patients whenever possible in conjunction with the ICU protocol for insertion and maintenance of small bowel feeding tubes. Both systems are preferred by our ICU physicians and nurses over other blind intubation systems (eg, Dobhoff tubes) and anecdotally, both appeared to have good success at initial postpyloric placement. However, having no objective data to support these observations, a clinical study was in order. The purpose of this retrospective review of small bowel feeding tube insertions was to determine which system achieves the objective of small bowel placement with the greatest accuracy on initial placement attempt, thus potentially improving patient outcomes and patient comfort for all future ICU patients.

METHODS

We conducted a retrospective chart review, examining the success of small bowel feeding tube placement in all ICU patients who received either a C‐EAS or a T2T from December 2009 through July 2013. Institutional review board approval was obtained, and due to the retrospective nature of the study, informed consent was waived. Neither manufacturer played any role in this study; the authors have no financial interests in either product and do not serve as consultants for either manufacturer.

Our ICU is a 20‐bed, mixed surgical and medical unit in a tertiary academic military medical center. To insert the C‐EAS tube, providers were required to take a three hour in‐service training session with the manufacturer's device representative. After initial training, providers were required to attempt 3 placements under the direct supervision of an expert user before they could independently place C‐EAS tubes. Competency was reviewed quarterly with hands‐on training. There are no designated tube insertion teams at our institution. All feeding tubes were inserted according to a current approved institutional protocol. Patients received a gastric motility agent (erythromycin 200 mg orally or intravenously) 30 minutes prior to tube insertion. C‐EAS patients received a confirmatory x‐ray, either anterior‐posterior (AP) portable chest x‐ray or portable abdominal film, when the provider felt the C‐EAS monitor tracing was consistent with postpyloric placement per the manufacturer's instructions. T2T patients received an AP portable chest x‐ray once the T2T had been inserted to 50 cm to ensure the tube was in the gastric system. The tube was advanced 10 cm every 30 to 60 minutes thereafter to a total distance of 90 cm per the manufacturer's recommendations, at which point a confirmatory portable abdominal film was taken for final location determination.

Patients who received small bowel feeding tubes were identified via electronic medical record data search; confirmation of tube placement was made with direct examination of the electronic medical record. Patients who received other small bowel feeding tubes, such as Dobbhoff tubes or endoscopically placed tubes of any type, were excluded. The date, time, and type of tube for initial insertion attempt were recorded, and radiographs, radiologic reports, and archived real‐time tracings (for C‐EAS) were compared. Tubes were considered successfully placed if the first confirmation film after completion of the procedure noted the tip of the tube in a postpyloric position. Tubes were considered unsuccessfully placed if the tip of the tube was noted anywhere proximal to the gastroduodenal junction. Insertions were excluded if investigator examination of the radiograph and the radiologic report were unable to identify the location of the tip of the tube. Complication rates, including endotracheal insertion, were recorded.

A power analysis was conducted a priori (SamplePower 3.0; IBM SPSS, Armonk, NY) by estimating successful placement with the C‐EAS tube on the first attempt at 80% and the T2T at 95% based on previous reports in the literature. A sample size of 75 patients was required in each group to achieve statistical significance at 0.80 power and at 0.05. The small bowel feeding tube placement success rate was analyzed using [2] and the Kappa coefficient.

RESULTS

During the 3‐year study period, 158 small bowel feeding tubes were placed in the ICU. Of these, 5 were Dobhoff tubes (3 blind insertions and 2 endoscopic placements), 72 T2T, and 81 C‐EAS tubes. Of the T2T and C‐EAS tubes, final position was unable to be determined via radiograph for 1 T2T (1%) and 7 C‐EAS (8%). These tubes (N=13) were excluded from data analysis, leaving a final study population of 145: 71 T2T and 74 C‐EAS. Demographics of the included patients are found in Table 1. Successful postpyloric placement on the first attempt was achieved in 44 (62%) of T2T and 32 (43%) of C‐EAS (P=0.03) (Figure 1).

Figure 1

Next, we compared the congruency of the real‐time C‐EAS tracings to the confirmation radiographs (Figures 2 and 3). Of the C‐EAS tracings that indicated postpyloric position (N=29), the radiograph confirmed postpyloric placement 83% (n=24) of the time. Of C‐EAS tracings that indicated a prepyloric position (N=45), the radiograph also demonstrated a prepyloric position 82% (n=37) with a Kappa coefficient of 0.638 (Table 2).

Figure 2

Figure 3

In addition to real‐time tracing archives, the C‐EAS system allows providers to designate their specialty. Of the 74 tubes placed, registered nurses and physicians placed the most tubes (36 each) and registered dieticians placed 2 tubes. Physicians and registered nurses successfully achieved postpyloric position on 17 (47%) and 14 (39%) initial attempts, respectively. Of the 2 registered dietician‐inserted tubes, only 1 tube was in the correct postpyloric position at the end of the initial attempt.

There were no endotracheal insertions or other complications noted during the study period with either small bowel feeding tube system.

CONCLUSION/DISCUSSION

Enteral nutrition is important for critically ill patients with early initiation of nutrition leading to decreased length of stay in the ICU and decreased mortality. The IDSA, North American nutrition societies, and Canadian Critical Care Guidelines recommend postpyloric nutrition to prevent frequent interruptions in feeding, allow for earlier feeding initiation, and to reduce the risk of aspiration. We evaluated 2 different enteral feeding tube systemsT2T and C‐EASto determine which system most commonly led to postpyloric placement on initial insertion attempt, thus facilitating postpyloric feeding.

Our results showed that there was a statistically significant difference favoring T2T over C‐EAS. This is in contrast to a study directly comparing the 2 systems, which demonstrated no statistically significant difference between the successful placement of either tube.[24] One reason for this difference may be that C‐EAS relies on user familiarity and dexterity with the electromagnetic guidance system. Our hospital does not have a specific team of trained providers who insert postpyloric tubes and thus may be more facile with this system. It would be interesting to see if a small team of trained providers could improve postpyloric C‐EAS placement over our current ICU staffing model, which allows RNs, physicians, and registered dieticians to place postpyloric feeding tubes. The T2T system is more simplistic in that no further training beyond basic feeding tube insertion is required, and we feel this may be the most important distinction that explains our results.

A reported advantage of the C‐EAS system is that direct visualization via the electromagnetic device replaces the need for confirmatory radiography. As expected, our results demonstrated a high positive predictive value for the C‐EAS tracing, although only 39% of tracings actually predicted postpyloric placement. Given the fact that 57% of C‐EAS tubes were not ultimately located in the postpyloric position, despite the inserting provider's interpretation of the tracing, we feel that confirmatory radiography is still required in our patient population. Again, this result likely points to the need for additional provider training on using the C‐EAS system and interpreting tracings, or a dedicated tube insertion team.

Limitations of this study are those inherent to retrospective research and include an inability to examine individual insertion technique and inability to record the inserting provider's interpretation of the C‐EAS tracing. Additionally, our electronic medical record did not facilitate data gathering regarding the time to completion of each procedure and initiation of enteral nutrition in our patients. It is possible that the speed with which the C‐EAS tube can be inserted and repositioned if prepyloric on initial confirmation, may lead to earlier initiation of enteral nutrition, versus the T2T protocol, which can take several hours until final insertion position is confirmed. In that case, the system that confers higher rates of initial postpyloric placement may be a less important mark than the overall time to completion of the insertion protocol. Finally, we did not perform a cost‐benefit analysis, which may have led to an advantage of 1 system over the other strictly from a resource management perspective.

In conclusion, given 2 small bowel feeding tube systems designed to facilitate postpyloric placement on initial insertion, the T2T tube proved a better system for use in our patient population with our current ICU staffing model. Additional training or designation of a tube insertion team might improve results with the C‐EAS system. Further prospective studies concerning timing of insertion protocols with respect to initiation of enteral nutrition and a complete cost‐benefit analysis comparing the 2 systems should be conducted.

Enteral nutrition is an essential component of the care plan for critically ill and injured patients. There is consensus that critically ill patients are at risk for malnutrition, and those who will be unable to consume adequate oral nutrition within 3 days should receive specialized enteral and/or parenteral nutrition therapy.[1] Multiple studies and reputable scientific societies support early initiation of enteral feedings within 24 to 48 hours of admission to the intensive care unit (ICU) to promote tolerance, minimize the risk of intestinal barrier dysfunction and infectious complications, and reduce the length of mechanical ventilation and hospital stay, as well as mortality.[2, 3, 4, 5] Although nasogastric feeding is appropriate for the majority of patients requiring short‐term nutrition support, there is a large group of patients in whom impaired gastric emptying presents challenges to feeding. The American Society for Parenteral and Enteral Nutrition, the American Thoracic Society, as well as the Infectious Diseases Society of America (IDSA), have published guidelines in support of postpyloric feeding in the ICU setting due to its association with reduced incidence of healthcare‐associated infections, specifically ventilator‐associated pneumonia (VAP).[2, 3, 6, 7] Four randomized clinical trials in the last 5 years have attempted to end the debate on the benefits of postpyloric feeding compared to intragastric feeding[5, 8, 9, 10]; 2 trials demonstrated an increase in calorie and protein intake and lower incidence of VAP in patients fed via the postpyloric route.[8, 10] One recent article[11] has suggested that severity of illness may play a role in the optimal selection of feeding route. Huang et al. randomly assigned patients to the nasogastric or nasoduodenal feeding route and documented the Acute Physiology and Chronic Health Evaluation II score as less than or greater than 20. Among more severely ill patients, those fed by the gastric route experienced longer ICU stay, more feeding complications, and lower calorie and protein intake than patients fed by the postpyloric route.[11] In an article comparing nutrition therapy recommendations among 3 major North American nutrition societies, the consensus was that critically ill patients at high risk for aspiration or feeding intolerance should be fed using small bowel access.[12] The Canadian Critical Care Guidelines Committee had the strongest recommendation for small bowel feeding stating that, if feasible, all critically ill patients should be fed via this route, based on the reduction in pneumonia.[12, 13]

When the decision is made to use postpyloric tube placement for nutrition therapy, the next decision is how to safely place the tube, ensure its postpyloric location, and minimize delays in feeding. Initiation of enteral formulas and timely advancement to nutrition goals is often delayed by unsuccessful feeding tube placement. Insertion of an enteral feeding tube into the postpyloric position is often done at the bedside by trained medical personnel without endoscopic or fluoroscopic guidance; however, the blind bedside approach is not without challenges. Success rates of this approach vary greatly depending on the patient population and provider expertise. The most challenging insertions may occur in patients who are endotracheally intubated, have depressed mental status, or impaired cough reflex.[14] Procedural complications from placement of nasoenteral feeding tubes by all methods can be as high as 10%,[15] with complication rates of 1% to 3%[16] for inadvertent placement of the feeding tube in the airway alone. The most common and serious complication is intubation of the bronchial tree with resulting pneumonitis, pneumonia, and pneumothorax, which reportedly occurs in 2.4% to 3.2% of tube insertions.[17, 18] It is recommended that radiographic confirmation of tube placement by any method occur prior to initiating feeding, thus eliminating any possibility of misplacement and administration of formula into the lungs.[18]

Historically, our institution advocated blind bedside placement of small bowel feeding tubes by trained ICU nurses, residents, and housestaff. Although not without risks, this method avoids the difficulty of coordinating endoscopic or fluoroscopic interventions that often necessitate transfer out of the ICU, with potential complications such as patient deterioration, and result in delays in initiating feeding.[19] However, like many other institutions, our level II medical center was interested in purchasing the Cortrak Enteral Access System (C‐EAS) (Viasys Medsystems, Wheeling, IL), which allows tracking of the small bowel feeding tube tip during placement. The C‐EAS uses an electromagnetic guide with a bedside monitor display to help providers observe the progress of the tube as it passes through the gastrointestinal tract. A receiver is placed on the patient's xiphoid process to detect the signal from the stylet that has an electromagnetic transmitter in the tip. The monitor displays the exact position of the postpyloric placement prior to removal of the tube guidewire. One early study by Ackerman and colleagues[20] found that the C‐EAS had a 100% success rate in avoiding lung placement and improves patient safety. The ability to monitor the location of the feeding tube tip in real time provides a safety feature for the clinician performing bedside insertions. In a recent study, the C‐EAS system was reported as not inferior to direct visualization of postpyloric placement via upper endoscopy.[21] In addition, several studies reported a reduction in mean time from physician order for tube placement to feeding initiation and fewer x‐rays for confirmation, thereby decreasing cost.[22] Not long after the C‐EAS system was purchased, Tiger 2 tubes (T2T) (Cook Inc., Bloomington, IN) were introduced in our facility for use in postpyloric feeding of ICU patients. The T2T system is a self‐advancing nasal jejunal feeding tube that uses a combination of intrinsic and stimulated gastric peristalsis with soft cilia‐like flaps in the side of the tube to propel the tube forward into the small bowel. Both tube systems have been studied over the past decade, with Gray et al.[22] reporting a 78% rate of successful small bowel placement using the electromagnetic‐guided device and Holzinger et al.[21] reporting an 89% success rate for jejunal placement using the same device. Davies and Bellomo[23] reported that their institution experienced a 100% success rate with small bowel placement of the T2T. Armed with 2 reputable, reliable modes of postpyloric tube placement, we encouraged all ICU staff to use these approaches for short‐term feeding for ICU patients whenever possible in conjunction with the ICU protocol for insertion and maintenance of small bowel feeding tubes. Both systems are preferred by our ICU physicians and nurses over other blind intubation systems (eg, Dobhoff tubes) and anecdotally, both appeared to have good success at initial postpyloric placement. However, having no objective data to support these observations, a clinical study was in order. The purpose of this retrospective review of small bowel feeding tube insertions was to determine which system achieves the objective of small bowel placement with the greatest accuracy on initial placement attempt, thus potentially improving patient outcomes and patient comfort for all future ICU patients.

METHODS

We conducted a retrospective chart review, examining the success of small bowel feeding tube placement in all ICU patients who received either a C‐EAS or a T2T from December 2009 through July 2013. Institutional review board approval was obtained, and due to the retrospective nature of the study, informed consent was waived. Neither manufacturer played any role in this study; the authors have no financial interests in either product and do not serve as consultants for either manufacturer.

Our ICU is a 20‐bed, mixed surgical and medical unit in a tertiary academic military medical center. To insert the C‐EAS tube, providers were required to take a three hour in‐service training session with the manufacturer's device representative. After initial training, providers were required to attempt 3 placements under the direct supervision of an expert user before they could independently place C‐EAS tubes. Competency was reviewed quarterly with hands‐on training. There are no designated tube insertion teams at our institution. All feeding tubes were inserted according to a current approved institutional protocol. Patients received a gastric motility agent (erythromycin 200 mg orally or intravenously) 30 minutes prior to tube insertion. C‐EAS patients received a confirmatory x‐ray, either anterior‐posterior (AP) portable chest x‐ray or portable abdominal film, when the provider felt the C‐EAS monitor tracing was consistent with postpyloric placement per the manufacturer's instructions. T2T patients received an AP portable chest x‐ray once the T2T had been inserted to 50 cm to ensure the tube was in the gastric system. The tube was advanced 10 cm every 30 to 60 minutes thereafter to a total distance of 90 cm per the manufacturer's recommendations, at which point a confirmatory portable abdominal film was taken for final location determination.

Patients who received small bowel feeding tubes were identified via electronic medical record data search; confirmation of tube placement was made with direct examination of the electronic medical record. Patients who received other small bowel feeding tubes, such as Dobbhoff tubes or endoscopically placed tubes of any type, were excluded. The date, time, and type of tube for initial insertion attempt were recorded, and radiographs, radiologic reports, and archived real‐time tracings (for C‐EAS) were compared. Tubes were considered successfully placed if the first confirmation film after completion of the procedure noted the tip of the tube in a postpyloric position. Tubes were considered unsuccessfully placed if the tip of the tube was noted anywhere proximal to the gastroduodenal junction. Insertions were excluded if investigator examination of the radiograph and the radiologic report were unable to identify the location of the tip of the tube. Complication rates, including endotracheal insertion, were recorded.

A power analysis was conducted a priori (SamplePower 3.0; IBM SPSS, Armonk, NY) by estimating successful placement with the C‐EAS tube on the first attempt at 80% and the T2T at 95% based on previous reports in the literature. A sample size of 75 patients was required in each group to achieve statistical significance at 0.80 power and at 0.05. The small bowel feeding tube placement success rate was analyzed using [2] and the Kappa coefficient.

RESULTS

During the 3‐year study period, 158 small bowel feeding tubes were placed in the ICU. Of these, 5 were Dobhoff tubes (3 blind insertions and 2 endoscopic placements), 72 T2T, and 81 C‐EAS tubes. Of the T2T and C‐EAS tubes, final position was unable to be determined via radiograph for 1 T2T (1%) and 7 C‐EAS (8%). These tubes (N=13) were excluded from data analysis, leaving a final study population of 145: 71 T2T and 74 C‐EAS. Demographics of the included patients are found in Table 1. Successful postpyloric placement on the first attempt was achieved in 44 (62%) of T2T and 32 (43%) of C‐EAS (P=0.03) (Figure 1).

Figure 1

Next, we compared the congruency of the real‐time C‐EAS tracings to the confirmation radiographs (Figures 2 and 3). Of the C‐EAS tracings that indicated postpyloric position (N=29), the radiograph confirmed postpyloric placement 83% (n=24) of the time. Of C‐EAS tracings that indicated a prepyloric position (N=45), the radiograph also demonstrated a prepyloric position 82% (n=37) with a Kappa coefficient of 0.638 (Table 2).

Figure 2

Figure 3

In addition to real‐time tracing archives, the C‐EAS system allows providers to designate their specialty. Of the 74 tubes placed, registered nurses and physicians placed the most tubes (36 each) and registered dieticians placed 2 tubes. Physicians and registered nurses successfully achieved postpyloric position on 17 (47%) and 14 (39%) initial attempts, respectively. Of the 2 registered dietician‐inserted tubes, only 1 tube was in the correct postpyloric position at the end of the initial attempt.

There were no endotracheal insertions or other complications noted during the study period with either small bowel feeding tube system.

CONCLUSION/DISCUSSION

Enteral nutrition is important for critically ill patients with early initiation of nutrition leading to decreased length of stay in the ICU and decreased mortality. The IDSA, North American nutrition societies, and Canadian Critical Care Guidelines recommend postpyloric nutrition to prevent frequent interruptions in feeding, allow for earlier feeding initiation, and to reduce the risk of aspiration. We evaluated 2 different enteral feeding tube systemsT2T and C‐EASto determine which system most commonly led to postpyloric placement on initial insertion attempt, thus facilitating postpyloric feeding.

Our results showed that there was a statistically significant difference favoring T2T over C‐EAS. This is in contrast to a study directly comparing the 2 systems, which demonstrated no statistically significant difference between the successful placement of either tube.[24] One reason for this difference may be that C‐EAS relies on user familiarity and dexterity with the electromagnetic guidance system. Our hospital does not have a specific team of trained providers who insert postpyloric tubes and thus may be more facile with this system. It would be interesting to see if a small team of trained providers could improve postpyloric C‐EAS placement over our current ICU staffing model, which allows RNs, physicians, and registered dieticians to place postpyloric feeding tubes. The T2T system is more simplistic in that no further training beyond basic feeding tube insertion is required, and we feel this may be the most important distinction that explains our results.

A reported advantage of the C‐EAS system is that direct visualization via the electromagnetic device replaces the need for confirmatory radiography. As expected, our results demonstrated a high positive predictive value for the C‐EAS tracing, although only 39% of tracings actually predicted postpyloric placement. Given the fact that 57% of C‐EAS tubes were not ultimately located in the postpyloric position, despite the inserting provider's interpretation of the tracing, we feel that confirmatory radiography is still required in our patient population. Again, this result likely points to the need for additional provider training on using the C‐EAS system and interpreting tracings, or a dedicated tube insertion team.

Limitations of this study are those inherent to retrospective research and include an inability to examine individual insertion technique and inability to record the inserting provider's interpretation of the C‐EAS tracing. Additionally, our electronic medical record did not facilitate data gathering regarding the time to completion of each procedure and initiation of enteral nutrition in our patients. It is possible that the speed with which the C‐EAS tube can be inserted and repositioned if prepyloric on initial confirmation, may lead to earlier initiation of enteral nutrition, versus the T2T protocol, which can take several hours until final insertion position is confirmed. In that case, the system that confers higher rates of initial postpyloric placement may be a less important mark than the overall time to completion of the insertion protocol. Finally, we did not perform a cost‐benefit analysis, which may have led to an advantage of 1 system over the other strictly from a resource management perspective.

In conclusion, given 2 small bowel feeding tube systems designed to facilitate postpyloric placement on initial insertion, the T2T tube proved a better system for use in our patient population with our current ICU staffing model. Additional training or designation of a tube insertion team might improve results with the C‐EAS system. Further prospective studies concerning timing of insertion protocols with respect to initiation of enteral nutrition and a complete cost‐benefit analysis comparing the 2 systems should be conducted.

Enteral nutrition is an essential component of the care plan for critically ill and injured patients. There is consensus that critically ill patients are at risk for malnutrition, and those who will be unable to consume adequate oral nutrition within 3 days should receive specialized enteral and/or parenteral nutrition therapy.[1] Multiple studies and reputable scientific societies support early initiation of enteral feedings within 24 to 48 hours of admission to the intensive care unit (ICU) to promote tolerance, minimize the risk of intestinal barrier dysfunction and infectious complications, and reduce the length of mechanical ventilation and hospital stay, as well as mortality.[2, 3, 4, 5] Although nasogastric feeding is appropriate for the majority of patients requiring short‐term nutrition support, there is a large group of patients in whom impaired gastric emptying presents challenges to feeding. The American Society for Parenteral and Enteral Nutrition, the American Thoracic Society, as well as the Infectious Diseases Society of America (IDSA), have published guidelines in support of postpyloric feeding in the ICU setting due to its association with reduced incidence of healthcare‐associated infections, specifically ventilator‐associated pneumonia (VAP).[2, 3, 6, 7] Four randomized clinical trials in the last 5 years have attempted to end the debate on the benefits of postpyloric feeding compared to intragastric feeding[5, 8, 9, 10]; 2 trials demonstrated an increase in calorie and protein intake and lower incidence of VAP in patients fed via the postpyloric route.[8, 10] One recent article[11] has suggested that severity of illness may play a role in the optimal selection of feeding route. Huang et al. randomly assigned patients to the nasogastric or nasoduodenal feeding route and documented the Acute Physiology and Chronic Health Evaluation II score as less than or greater than 20. Among more severely ill patients, those fed by the gastric route experienced longer ICU stay, more feeding complications, and lower calorie and protein intake than patients fed by the postpyloric route.[11] In an article comparing nutrition therapy recommendations among 3 major North American nutrition societies, the consensus was that critically ill patients at high risk for aspiration or feeding intolerance should be fed using small bowel access.[12] The Canadian Critical Care Guidelines Committee had the strongest recommendation for small bowel feeding stating that, if feasible, all critically ill patients should be fed via this route, based on the reduction in pneumonia.[12, 13]

When the decision is made to use postpyloric tube placement for nutrition therapy, the next decision is how to safely place the tube, ensure its postpyloric location, and minimize delays in feeding. Initiation of enteral formulas and timely advancement to nutrition goals is often delayed by unsuccessful feeding tube placement. Insertion of an enteral feeding tube into the postpyloric position is often done at the bedside by trained medical personnel without endoscopic or fluoroscopic guidance; however, the blind bedside approach is not without challenges. Success rates of this approach vary greatly depending on the patient population and provider expertise. The most challenging insertions may occur in patients who are endotracheally intubated, have depressed mental status, or impaired cough reflex.[14] Procedural complications from placement of nasoenteral feeding tubes by all methods can be as high as 10%,[15] with complication rates of 1% to 3%[16] for inadvertent placement of the feeding tube in the airway alone. The most common and serious complication is intubation of the bronchial tree with resulting pneumonitis, pneumonia, and pneumothorax, which reportedly occurs in 2.4% to 3.2% of tube insertions.[17, 18] It is recommended that radiographic confirmation of tube placement by any method occur prior to initiating feeding, thus eliminating any possibility of misplacement and administration of formula into the lungs.[18]

Historically, our institution advocated blind bedside placement of small bowel feeding tubes by trained ICU nurses, residents, and housestaff. Although not without risks, this method avoids the difficulty of coordinating endoscopic or fluoroscopic interventions that often necessitate transfer out of the ICU, with potential complications such as patient deterioration, and result in delays in initiating feeding.[19] However, like many other institutions, our level II medical center was interested in purchasing the Cortrak Enteral Access System (C‐EAS) (Viasys Medsystems, Wheeling, IL), which allows tracking of the small bowel feeding tube tip during placement. The C‐EAS uses an electromagnetic guide with a bedside monitor display to help providers observe the progress of the tube as it passes through the gastrointestinal tract. A receiver is placed on the patient's xiphoid process to detect the signal from the stylet that has an electromagnetic transmitter in the tip. The monitor displays the exact position of the postpyloric placement prior to removal of the tube guidewire. One early study by Ackerman and colleagues[20] found that the C‐EAS had a 100% success rate in avoiding lung placement and improves patient safety. The ability to monitor the location of the feeding tube tip in real time provides a safety feature for the clinician performing bedside insertions. In a recent study, the C‐EAS system was reported as not inferior to direct visualization of postpyloric placement via upper endoscopy.[21] In addition, several studies reported a reduction in mean time from physician order for tube placement to feeding initiation and fewer x‐rays for confirmation, thereby decreasing cost.[22] Not long after the C‐EAS system was purchased, Tiger 2 tubes (T2T) (Cook Inc., Bloomington, IN) were introduced in our facility for use in postpyloric feeding of ICU patients. The T2T system is a self‐advancing nasal jejunal feeding tube that uses a combination of intrinsic and stimulated gastric peristalsis with soft cilia‐like flaps in the side of the tube to propel the tube forward into the small bowel. Both tube systems have been studied over the past decade, with Gray et al.[22] reporting a 78% rate of successful small bowel placement using the electromagnetic‐guided device and Holzinger et al.[21] reporting an 89% success rate for jejunal placement using the same device. Davies and Bellomo[23] reported that their institution experienced a 100% success rate with small bowel placement of the T2T. Armed with 2 reputable, reliable modes of postpyloric tube placement, we encouraged all ICU staff to use these approaches for short‐term feeding for ICU patients whenever possible in conjunction with the ICU protocol for insertion and maintenance of small bowel feeding tubes. Both systems are preferred by our ICU physicians and nurses over other blind intubation systems (eg, Dobhoff tubes) and anecdotally, both appeared to have good success at initial postpyloric placement. However, having no objective data to support these observations, a clinical study was in order. The purpose of this retrospective review of small bowel feeding tube insertions was to determine which system achieves the objective of small bowel placement with the greatest accuracy on initial placement attempt, thus potentially improving patient outcomes and patient comfort for all future ICU patients.

METHODS

We conducted a retrospective chart review, examining the success of small bowel feeding tube placement in all ICU patients who received either a C‐EAS or a T2T from December 2009 through July 2013. Institutional review board approval was obtained, and due to the retrospective nature of the study, informed consent was waived. Neither manufacturer played any role in this study; the authors have no financial interests in either product and do not serve as consultants for either manufacturer.

Our ICU is a 20‐bed, mixed surgical and medical unit in a tertiary academic military medical center. To insert the C‐EAS tube, providers were required to take a three hour in‐service training session with the manufacturer's device representative. After initial training, providers were required to attempt 3 placements under the direct supervision of an expert user before they could independently place C‐EAS tubes. Competency was reviewed quarterly with hands‐on training. There are no designated tube insertion teams at our institution. All feeding tubes were inserted according to a current approved institutional protocol. Patients received a gastric motility agent (erythromycin 200 mg orally or intravenously) 30 minutes prior to tube insertion. C‐EAS patients received a confirmatory x‐ray, either anterior‐posterior (AP) portable chest x‐ray or portable abdominal film, when the provider felt the C‐EAS monitor tracing was consistent with postpyloric placement per the manufacturer's instructions. T2T patients received an AP portable chest x‐ray once the T2T had been inserted to 50 cm to ensure the tube was in the gastric system. The tube was advanced 10 cm every 30 to 60 minutes thereafter to a total distance of 90 cm per the manufacturer's recommendations, at which point a confirmatory portable abdominal film was taken for final location determination.

Patients who received small bowel feeding tubes were identified via electronic medical record data search; confirmation of tube placement was made with direct examination of the electronic medical record. Patients who received other small bowel feeding tubes, such as Dobbhoff tubes or endoscopically placed tubes of any type, were excluded. The date, time, and type of tube for initial insertion attempt were recorded, and radiographs, radiologic reports, and archived real‐time tracings (for C‐EAS) were compared. Tubes were considered successfully placed if the first confirmation film after completion of the procedure noted the tip of the tube in a postpyloric position. Tubes were considered unsuccessfully placed if the tip of the tube was noted anywhere proximal to the gastroduodenal junction. Insertions were excluded if investigator examination of the radiograph and the radiologic report were unable to identify the location of the tip of the tube. Complication rates, including endotracheal insertion, were recorded.

A power analysis was conducted a priori (SamplePower 3.0; IBM SPSS, Armonk, NY) by estimating successful placement with the C‐EAS tube on the first attempt at 80% and the T2T at 95% based on previous reports in the literature. A sample size of 75 patients was required in each group to achieve statistical significance at 0.80 power and at 0.05. The small bowel feeding tube placement success rate was analyzed using [2] and the Kappa coefficient.

RESULTS

During the 3‐year study period, 158 small bowel feeding tubes were placed in the ICU. Of these, 5 were Dobhoff tubes (3 blind insertions and 2 endoscopic placements), 72 T2T, and 81 C‐EAS tubes. Of the T2T and C‐EAS tubes, final position was unable to be determined via radiograph for 1 T2T (1%) and 7 C‐EAS (8%). These tubes (N=13) were excluded from data analysis, leaving a final study population of 145: 71 T2T and 74 C‐EAS. Demographics of the included patients are found in Table 1. Successful postpyloric placement on the first attempt was achieved in 44 (62%) of T2T and 32 (43%) of C‐EAS (P=0.03) (Figure 1).

Figure 1

Next, we compared the congruency of the real‐time C‐EAS tracings to the confirmation radiographs (Figures 2 and 3). Of the C‐EAS tracings that indicated postpyloric position (N=29), the radiograph confirmed postpyloric placement 83% (n=24) of the time. Of C‐EAS tracings that indicated a prepyloric position (N=45), the radiograph also demonstrated a prepyloric position 82% (n=37) with a Kappa coefficient of 0.638 (Table 2).

Figure 2

Figure 3

In addition to real‐time tracing archives, the C‐EAS system allows providers to designate their specialty. Of the 74 tubes placed, registered nurses and physicians placed the most tubes (36 each) and registered dieticians placed 2 tubes. Physicians and registered nurses successfully achieved postpyloric position on 17 (47%) and 14 (39%) initial attempts, respectively. Of the 2 registered dietician‐inserted tubes, only 1 tube was in the correct postpyloric position at the end of the initial attempt.

There were no endotracheal insertions or other complications noted during the study period with either small bowel feeding tube system.

CONCLUSION/DISCUSSION

Enteral nutrition is important for critically ill patients with early initiation of nutrition leading to decreased length of stay in the ICU and decreased mortality. The IDSA, North American nutrition societies, and Canadian Critical Care Guidelines recommend postpyloric nutrition to prevent frequent interruptions in feeding, allow for earlier feeding initiation, and to reduce the risk of aspiration. We evaluated 2 different enteral feeding tube systemsT2T and C‐EASto determine which system most commonly led to postpyloric placement on initial insertion attempt, thus facilitating postpyloric feeding.

Our results showed that there was a statistically significant difference favoring T2T over C‐EAS. This is in contrast to a study directly comparing the 2 systems, which demonstrated no statistically significant difference between the successful placement of either tube.[24] One reason for this difference may be that C‐EAS relies on user familiarity and dexterity with the electromagnetic guidance system. Our hospital does not have a specific team of trained providers who insert postpyloric tubes and thus may be more facile with this system. It would be interesting to see if a small team of trained providers could improve postpyloric C‐EAS placement over our current ICU staffing model, which allows RNs, physicians, and registered dieticians to place postpyloric feeding tubes. The T2T system is more simplistic in that no further training beyond basic feeding tube insertion is required, and we feel this may be the most important distinction that explains our results.

A reported advantage of the C‐EAS system is that direct visualization via the electromagnetic device replaces the need for confirmatory radiography. As expected, our results demonstrated a high positive predictive value for the C‐EAS tracing, although only 39% of tracings actually predicted postpyloric placement. Given the fact that 57% of C‐EAS tubes were not ultimately located in the postpyloric position, despite the inserting provider's interpretation of the tracing, we feel that confirmatory radiography is still required in our patient population. Again, this result likely points to the need for additional provider training on using the C‐EAS system and interpreting tracings, or a dedicated tube insertion team.

Limitations of this study are those inherent to retrospective research and include an inability to examine individual insertion technique and inability to record the inserting provider's interpretation of the C‐EAS tracing. Additionally, our electronic medical record did not facilitate data gathering regarding the time to completion of each procedure and initiation of enteral nutrition in our patients. It is possible that the speed with which the C‐EAS tube can be inserted and repositioned if prepyloric on initial confirmation, may lead to earlier initiation of enteral nutrition, versus the T2T protocol, which can take several hours until final insertion position is confirmed. In that case, the system that confers higher rates of initial postpyloric placement may be a less important mark than the overall time to completion of the insertion protocol. Finally, we did not perform a cost‐benefit analysis, which may have led to an advantage of 1 system over the other strictly from a resource management perspective.

In conclusion, given 2 small bowel feeding tube systems designed to facilitate postpyloric placement on initial insertion, the T2T tube proved a better system for use in our patient population with our current ICU staffing model. Additional training or designation of a tube insertion team might improve results with the C‐EAS system. Further prospective studies concerning timing of insertion protocols with respect to initiation of enteral nutrition and a complete cost‐benefit analysis comparing the 2 systems should be conducted.

Increasingly, there is a focus on prevention of hospital‐acquired conditions including venous thromboembolism (VTE). Many studies have evaluated pulmonary embolism (PE) and lower extremity deep vein thrombosis (LEDVT), but despite increasing recognition of upper extremity deep vein thrombosis (UEDVT),[1, 2, 3, 4] less is known about this condition in hospitalized patients.

UEDVTs may be classified as primary, including disorders such as Paget‐Schroetter syndrome or other structural abnormality, or may be idiopathic; the majority are secondary clots.[5] Conventional risk factors for LEDVT including older age and obesity have been found to be less commonly associated,[1, 2, 5, 6, 7] and patients with UEDVT are generally younger, leaner, and a higher proportion are men. They are more likely to have malignancy or history of VTE and have undergone recent surgery or intensive care unit stay.[1, 2, 6] Central venous catheters (CVCs), often used in hospitalized patients, remain among the biggest known risks for UEDVT[1, 2, 3, 7, 8, 9, 10]; concomitant malignancy, VTE history, severe infection, surgery lasting >1 hour, and length of stay (LOS) >10 days confer additional risks with CVCs.[6, 7, 8, 11]

UEDVTs, once thought to be relatively benign, are now recognized to result in complications including PE, progression, recurrence, and post‐thrombotic syndrome.[2, 4, 12, 13] Despite extensive efforts to increase appropriate VTE prophylaxis in inpatients,[14] the role of chemoprophylaxis to prevent UEDVT remains undefined. Current guidelines recommend anticoagulation for treatment and complication prevention,[13, 15] but to date the evidence derives largely from observational studies or is extrapolated from the LEDVT literature.[2, 13]

To improve understanding of UEDVT at our institution, we set out to (1) determine UEDVT incidence in hospitalized patients, (2) describe associated risks and outcomes, and (3) assess management during hospitalization and at discharge.

METHODS

We identified all consecutive adult patients diagnosed with Doppler ultrasound‐confirmed UEDVT during hospitalization at Harborview Medical Center between September 2011 and November 2012. For patients who were readmitted during the study period, the first of their hospitalizations was used to describe associated factors, management, and outcomes. We present characteristics of all other hospitalizations during this time period for comparison. Harborview is a 413‐bed academic tertiary referral center and the only level 1 trauma center in a 5‐state area. Patients with UEDVT were identified using an information technology (IT) tool (the Harborview VTE tool) (Figure 1), which captures VTE events from vascular laboratory and radiology studies using natural language processing. Doppler ultrasound to assess for deep vein thrombosis (DVT) and computed tomographic scans to diagnose PE were ordered by inpatient physicians for symptomatic patients. The reason for obtaining the study is included in the ultrasound reports. We do not routinely screen for UEDVT at our institution. UEDVT included clots in the deep veins of the upper extremities including internal jugular, subclavian, axillary, and brachial veins. Superficial thrombosis and thrombophlebitis were excluded. We previously compared VTE events captured by this tool with administrative billing data and found that all VTE events that were coded were captured with the tool.

Figure 1

The VTE tool (Figure 1) displays imaging results together with demographic, clinical, and medication data and links this information with admission, discharge, and death summaries as well as CVC insertion procedure notes from the electronic health record (EHR). Additional data, including comorbid conditions, primary reason for hospitalization, past medical history such as prior VTE events, and cause of death (if not available in the admission note or discharge/death summaries), were obtained from EHR abstraction by 1 of the investigators. A 10% random sample of charts was rereviewed by another investigator with complete concordance. Supplementary data about date of CVC insertion if placed at an outside facility, date of CVC removal if applicable, clinical assessments regarding whether a clot was CVC‐associated, and contraindications to therapeutic anticoagulation were also abstracted directly from the EHR. Administrative data were used to identify the case mix index, an indicator of severity of illness.

Pharmacologic VTE prophylaxis included all chemical prophylaxis specified on our institutional guideline, most commonly subcutaneous unfractionated heparin 5000 units every 8 hours or low molecular weight heparin (LMWH), either enoxaparin 40 mg every 12 or 24 hours or dalteparin 5000 units every 24 hours. Mechanical prophylaxis was defined as use of sequential compression devices (SCDs) when pharmacologic prophylaxis was contraindicated. Prophylaxis was considered to be appropriate if it was applied according to our guideline for >90% of hospital days prior to UEDVT diagnosis. Therapeutic anticoagulation included heparin bridging (most commonly continuous heparin infusion, LMWH 1 mg/kg or dalteparin) as well as oral vitamin K antagonists. The VTE tool (Figure 1) allows identification of pharmacologic prophylaxis and therapy that is actually administered (not just ordered) directly from our pharmacy IT system. SCD application (not just ordered SCDs) is electronically integrated into the tool from nursing documentation.

CVCs included internal jugular or subclavian triple lumen catheters, tunneled dialysis catheters, or peripherally inserted central catheters (PICCs), single or double lumen. Criteria used to identify that a UEDVT was CVC‐associated included temporal relationship (CVC was placed prior to clot diagnosis), plausibility (ipsilateral clot), evidence of clot surrounding CVC on ultrasound, and physician designation of association (as documented in progress notes or discharge summary).

Simple percentages of patient characteristics, associated factors, management, and outcomes were calculated using counts as the numerator and number of patients as the denominator. For information about UEDVTs, we used total number of UEDVTs as the denominator. Line days were day counts from insertion until removal if applicable. The CVC placement date was available in our mandated central line placement procedure notes (directly accessed from the VTE tool) for all lines placed at our institution; date of removal (if applicable) was determined from chart abstraction. For the vast majority of patients whose CVCs were placed at outside facilities, date of placement was available in the EHR (often in the admission note or in the ultrasound report/reason for study). If date of line placement at an outside facility was not known, date of admission was used. The University of Washington Human Subjects Board approved this review.

RESULTS

DISCUSSION

UEDVT is increasingly recognized in hospitalized patients.[3, 9] At our medical center, 0.2% of symptomatic inpatients were diagnosed with UEDVT over 14 months. These patients were predominantly men with high rates of CVCs, malignancy, VTE history, severe infection, and renal disease. Interestingly, although the literature suggests that some proportion of patients with UEDVT have anatomic abnormalities, such as Paget‐Schroetter syndrome,[15] none of the patients in our study were found to have these anomalies. In our review, hospitalized patients with UEDVT were critically ill, with a long LOS and high morbidity and mortality, suggesting that in addition to just being a complication of hospitalization,[1, 6] UEDVT may be a marker of severe illness.

In our institution, clinical presentation was consistent with what has been described with the majority of patients presenting with upper extremity swelling.[1, 3] The internal jugular veins were the most common anatomic UEDVT site, followed by brachial then axillary veins. In other series including both in‐ and outpatients, subclavian clots were most commonly diagnosed, reflecting in part higher rates of CVC association and CVC location in those studies.[3, 9] Concurrent DVT and PE rates were similar to those reported.[1, 3, 10]

Although many studies have focused on prevention of LEDVT and PE, few trials have specifically targeted UEDVT. Among our patients with UEDVTs that were not present on admission, VTE prophylaxis rates were considerably higher than what has been reported,[1, 6] suggesting that in these critically ill patients' prophylaxis may not prevent symptomatic UEDVT. It is unknown how many UEDVTs were prevented with prophylaxis, as only patients with symptomatic UEDVT were included. Adequacy of prophylaxis at outside hospitals for patients transferred in could not be assessed. Nonetheless, low numbers of UEDVT at a trauma referral center with many high‐risk patients raise the question of whether prophylaxis makes a difference. Additional study is needed to further define the role of chemoprophylaxis to prevent UEDVT in hospitalized patients.

In our inpatient group, 84% required CVCs; 44% of patients were thought to have CVC‐associated UEDVTs. Careful patient selection and attention to potentially modifiable risks, such as insertion site, catheter type, and tip position, may need further examination in this population.[3, 11, 16] Catheter duration was long; focus on removing CVCs when no longer necessary is important. Interestingly, almost 10% in our study underwent diagnostic ultrasound because a new CVC could not be successfully placed suggesting that UEDVT may develop in critically ill patients regardless of CVCs.

In our study, there were high rates of guideline‐recommended pharmacologic treatment; surprisingly the majority of CVCs with associated clot were removed. Guidelines currently support 3 months of anticoagulation for treatment of UEDVT[2, 13, 17]; evidence derives from observational trials or is largely extrapolated from LEDVT literature.[2, 13] Routine CVC removal is not specifically recommended for CVC‐associated UEDVT, particularly if lines remain functional and medically necessary; systemic anticoagulation should be provided.[13]

In our review, no hospitalized patients with UEDVT developed complications or were readmitted to our medical center within 30 days for clot progression, new PE, or post‐thrombotic syndrome, which is lower than rates reported over longer time periods.[2, 6, 10, 12] Ten percent died during hospitalization, all from their primary disease rather than from complications of VTE or VTE treatment, and no additional patients died at our institution within 30 days. Although these rates are lower than have been otherwise reported,[2, 10] the inpatient mortality rate is similar to a recent study that included inpatients; however, all patients who died in that study had cancer and CVCs.[3] In the latter study, 6.4% died within 30 days of discharge.

CONCLUSIONS

Among hospitalized patients, UEDVT is increasingly recognized. In our medical center, hospitalized patients diagnosed with UEDVT were more likely to have CVCs, malignancy, renal disease, and severe infection. Many of these patients were transferred critically ill, had prolonged LOS, and had high in‐hospital mortality. Most developed UEDVT despite prophylaxis, and the majority of UEDVTs were treated even in the absence of concurrent LEDVT or PE. As we move toward an era of increasing accountability, with a focus on preventing hospital‐acquired conditions including VTE, additional research is needed to identify modifiable risks, explore opportunities for effective prevention, and optimize outcomes such as prevention of complications or readmissions, particularly in critically ill patients with UEDVT.

Increasingly, there is a focus on prevention of hospital‐acquired conditions including venous thromboembolism (VTE). Many studies have evaluated pulmonary embolism (PE) and lower extremity deep vein thrombosis (LEDVT), but despite increasing recognition of upper extremity deep vein thrombosis (UEDVT),[1, 2, 3, 4] less is known about this condition in hospitalized patients.

UEDVTs may be classified as primary, including disorders such as Paget‐Schroetter syndrome or other structural abnormality, or may be idiopathic; the majority are secondary clots.[5] Conventional risk factors for LEDVT including older age and obesity have been found to be less commonly associated,[1, 2, 5, 6, 7] and patients with UEDVT are generally younger, leaner, and a higher proportion are men. They are more likely to have malignancy or history of VTE and have undergone recent surgery or intensive care unit stay.[1, 2, 6] Central venous catheters (CVCs), often used in hospitalized patients, remain among the biggest known risks for UEDVT[1, 2, 3, 7, 8, 9, 10]; concomitant malignancy, VTE history, severe infection, surgery lasting >1 hour, and length of stay (LOS) >10 days confer additional risks with CVCs.[6, 7, 8, 11]

UEDVTs, once thought to be relatively benign, are now recognized to result in complications including PE, progression, recurrence, and post‐thrombotic syndrome.[2, 4, 12, 13] Despite extensive efforts to increase appropriate VTE prophylaxis in inpatients,[14] the role of chemoprophylaxis to prevent UEDVT remains undefined. Current guidelines recommend anticoagulation for treatment and complication prevention,[13, 15] but to date the evidence derives largely from observational studies or is extrapolated from the LEDVT literature.[2, 13]

To improve understanding of UEDVT at our institution, we set out to (1) determine UEDVT incidence in hospitalized patients, (2) describe associated risks and outcomes, and (3) assess management during hospitalization and at discharge.

METHODS

We identified all consecutive adult patients diagnosed with Doppler ultrasound‐confirmed UEDVT during hospitalization at Harborview Medical Center between September 2011 and November 2012. For patients who were readmitted during the study period, the first of their hospitalizations was used to describe associated factors, management, and outcomes. We present characteristics of all other hospitalizations during this time period for comparison. Harborview is a 413‐bed academic tertiary referral center and the only level 1 trauma center in a 5‐state area. Patients with UEDVT were identified using an information technology (IT) tool (the Harborview VTE tool) (Figure 1), which captures VTE events from vascular laboratory and radiology studies using natural language processing. Doppler ultrasound to assess for deep vein thrombosis (DVT) and computed tomographic scans to diagnose PE were ordered by inpatient physicians for symptomatic patients. The reason for obtaining the study is included in the ultrasound reports. We do not routinely screen for UEDVT at our institution. UEDVT included clots in the deep veins of the upper extremities including internal jugular, subclavian, axillary, and brachial veins. Superficial thrombosis and thrombophlebitis were excluded. We previously compared VTE events captured by this tool with administrative billing data and found that all VTE events that were coded were captured with the tool.

Figure 1

The VTE tool (Figure 1) displays imaging results together with demographic, clinical, and medication data and links this information with admission, discharge, and death summaries as well as CVC insertion procedure notes from the electronic health record (EHR). Additional data, including comorbid conditions, primary reason for hospitalization, past medical history such as prior VTE events, and cause of death (if not available in the admission note or discharge/death summaries), were obtained from EHR abstraction by 1 of the investigators. A 10% random sample of charts was rereviewed by another investigator with complete concordance. Supplementary data about date of CVC insertion if placed at an outside facility, date of CVC removal if applicable, clinical assessments regarding whether a clot was CVC‐associated, and contraindications to therapeutic anticoagulation were also abstracted directly from the EHR. Administrative data were used to identify the case mix index, an indicator of severity of illness.

Pharmacologic VTE prophylaxis included all chemical prophylaxis specified on our institutional guideline, most commonly subcutaneous unfractionated heparin 5000 units every 8 hours or low molecular weight heparin (LMWH), either enoxaparin 40 mg every 12 or 24 hours or dalteparin 5000 units every 24 hours. Mechanical prophylaxis was defined as use of sequential compression devices (SCDs) when pharmacologic prophylaxis was contraindicated. Prophylaxis was considered to be appropriate if it was applied according to our guideline for >90% of hospital days prior to UEDVT diagnosis. Therapeutic anticoagulation included heparin bridging (most commonly continuous heparin infusion, LMWH 1 mg/kg or dalteparin) as well as oral vitamin K antagonists. The VTE tool (Figure 1) allows identification of pharmacologic prophylaxis and therapy that is actually administered (not just ordered) directly from our pharmacy IT system. SCD application (not just ordered SCDs) is electronically integrated into the tool from nursing documentation.

CVCs included internal jugular or subclavian triple lumen catheters, tunneled dialysis catheters, or peripherally inserted central catheters (PICCs), single or double lumen. Criteria used to identify that a UEDVT was CVC‐associated included temporal relationship (CVC was placed prior to clot diagnosis), plausibility (ipsilateral clot), evidence of clot surrounding CVC on ultrasound, and physician designation of association (as documented in progress notes or discharge summary).

Simple percentages of patient characteristics, associated factors, management, and outcomes were calculated using counts as the numerator and number of patients as the denominator. For information about UEDVTs, we used total number of UEDVTs as the denominator. Line days were day counts from insertion until removal if applicable. The CVC placement date was available in our mandated central line placement procedure notes (directly accessed from the VTE tool) for all lines placed at our institution; date of removal (if applicable) was determined from chart abstraction. For the vast majority of patients whose CVCs were placed at outside facilities, date of placement was available in the EHR (often in the admission note or in the ultrasound report/reason for study). If date of line placement at an outside facility was not known, date of admission was used. The University of Washington Human Subjects Board approved this review.

RESULTS

DISCUSSION

UEDVT is increasingly recognized in hospitalized patients.[3, 9] At our medical center, 0.2% of symptomatic inpatients were diagnosed with UEDVT over 14 months. These patients were predominantly men with high rates of CVCs, malignancy, VTE history, severe infection, and renal disease. Interestingly, although the literature suggests that some proportion of patients with UEDVT have anatomic abnormalities, such as Paget‐Schroetter syndrome,[15] none of the patients in our study were found to have these anomalies. In our review, hospitalized patients with UEDVT were critically ill, with a long LOS and high morbidity and mortality, suggesting that in addition to just being a complication of hospitalization,[1, 6] UEDVT may be a marker of severe illness.

In our institution, clinical presentation was consistent with what has been described with the majority of patients presenting with upper extremity swelling.[1, 3] The internal jugular veins were the most common anatomic UEDVT site, followed by brachial then axillary veins. In other series including both in‐ and outpatients, subclavian clots were most commonly diagnosed, reflecting in part higher rates of CVC association and CVC location in those studies.[3, 9] Concurrent DVT and PE rates were similar to those reported.[1, 3, 10]

Although many studies have focused on prevention of LEDVT and PE, few trials have specifically targeted UEDVT. Among our patients with UEDVTs that were not present on admission, VTE prophylaxis rates were considerably higher than what has been reported,[1, 6] suggesting that in these critically ill patients' prophylaxis may not prevent symptomatic UEDVT. It is unknown how many UEDVTs were prevented with prophylaxis, as only patients with symptomatic UEDVT were included. Adequacy of prophylaxis at outside hospitals for patients transferred in could not be assessed. Nonetheless, low numbers of UEDVT at a trauma referral center with many high‐risk patients raise the question of whether prophylaxis makes a difference. Additional study is needed to further define the role of chemoprophylaxis to prevent UEDVT in hospitalized patients.

In our inpatient group, 84% required CVCs; 44% of patients were thought to have CVC‐associated UEDVTs. Careful patient selection and attention to potentially modifiable risks, such as insertion site, catheter type, and tip position, may need further examination in this population.[3, 11, 16] Catheter duration was long; focus on removing CVCs when no longer necessary is important. Interestingly, almost 10% in our study underwent diagnostic ultrasound because a new CVC could not be successfully placed suggesting that UEDVT may develop in critically ill patients regardless of CVCs.

In our study, there were high rates of guideline‐recommended pharmacologic treatment; surprisingly the majority of CVCs with associated clot were removed. Guidelines currently support 3 months of anticoagulation for treatment of UEDVT[2, 13, 17]; evidence derives from observational trials or is largely extrapolated from LEDVT literature.[2, 13] Routine CVC removal is not specifically recommended for CVC‐associated UEDVT, particularly if lines remain functional and medically necessary; systemic anticoagulation should be provided.[13]

In our review, no hospitalized patients with UEDVT developed complications or were readmitted to our medical center within 30 days for clot progression, new PE, or post‐thrombotic syndrome, which is lower than rates reported over longer time periods.[2, 6, 10, 12] Ten percent died during hospitalization, all from their primary disease rather than from complications of VTE or VTE treatment, and no additional patients died at our institution within 30 days. Although these rates are lower than have been otherwise reported,[2, 10] the inpatient mortality rate is similar to a recent study that included inpatients; however, all patients who died in that study had cancer and CVCs.[3] In the latter study, 6.4% died within 30 days of discharge.

CONCLUSIONS

Among hospitalized patients, UEDVT is increasingly recognized. In our medical center, hospitalized patients diagnosed with UEDVT were more likely to have CVCs, malignancy, renal disease, and severe infection. Many of these patients were transferred critically ill, had prolonged LOS, and had high in‐hospital mortality. Most developed UEDVT despite prophylaxis, and the majority of UEDVTs were treated even in the absence of concurrent LEDVT or PE. As we move toward an era of increasing accountability, with a focus on preventing hospital‐acquired conditions including VTE, additional research is needed to identify modifiable risks, explore opportunities for effective prevention, and optimize outcomes such as prevention of complications or readmissions, particularly in critically ill patients with UEDVT.

Increasingly, there is a focus on prevention of hospital‐acquired conditions including venous thromboembolism (VTE). Many studies have evaluated pulmonary embolism (PE) and lower extremity deep vein thrombosis (LEDVT), but despite increasing recognition of upper extremity deep vein thrombosis (UEDVT),[1, 2, 3, 4] less is known about this condition in hospitalized patients.

UEDVTs may be classified as primary, including disorders such as Paget‐Schroetter syndrome or other structural abnormality, or may be idiopathic; the majority are secondary clots.[5] Conventional risk factors for LEDVT including older age and obesity have been found to be less commonly associated,[1, 2, 5, 6, 7] and patients with UEDVT are generally younger, leaner, and a higher proportion are men. They are more likely to have malignancy or history of VTE and have undergone recent surgery or intensive care unit stay.[1, 2, 6] Central venous catheters (CVCs), often used in hospitalized patients, remain among the biggest known risks for UEDVT[1, 2, 3, 7, 8, 9, 10]; concomitant malignancy, VTE history, severe infection, surgery lasting >1 hour, and length of stay (LOS) >10 days confer additional risks with CVCs.[6, 7, 8, 11]

UEDVTs, once thought to be relatively benign, are now recognized to result in complications including PE, progression, recurrence, and post‐thrombotic syndrome.[2, 4, 12, 13] Despite extensive efforts to increase appropriate VTE prophylaxis in inpatients,[14] the role of chemoprophylaxis to prevent UEDVT remains undefined. Current guidelines recommend anticoagulation for treatment and complication prevention,[13, 15] but to date the evidence derives largely from observational studies or is extrapolated from the LEDVT literature.[2, 13]

To improve understanding of UEDVT at our institution, we set out to (1) determine UEDVT incidence in hospitalized patients, (2) describe associated risks and outcomes, and (3) assess management during hospitalization and at discharge.

METHODS

We identified all consecutive adult patients diagnosed with Doppler ultrasound‐confirmed UEDVT during hospitalization at Harborview Medical Center between September 2011 and November 2012. For patients who were readmitted during the study period, the first of their hospitalizations was used to describe associated factors, management, and outcomes. We present characteristics of all other hospitalizations during this time period for comparison. Harborview is a 413‐bed academic tertiary referral center and the only level 1 trauma center in a 5‐state area. Patients with UEDVT were identified using an information technology (IT) tool (the Harborview VTE tool) (Figure 1), which captures VTE events from vascular laboratory and radiology studies using natural language processing. Doppler ultrasound to assess for deep vein thrombosis (DVT) and computed tomographic scans to diagnose PE were ordered by inpatient physicians for symptomatic patients. The reason for obtaining the study is included in the ultrasound reports. We do not routinely screen for UEDVT at our institution. UEDVT included clots in the deep veins of the upper extremities including internal jugular, subclavian, axillary, and brachial veins. Superficial thrombosis and thrombophlebitis were excluded. We previously compared VTE events captured by this tool with administrative billing data and found that all VTE events that were coded were captured with the tool.

Figure 1

The VTE tool (Figure 1) displays imaging results together with demographic, clinical, and medication data and links this information with admission, discharge, and death summaries as well as CVC insertion procedure notes from the electronic health record (EHR). Additional data, including comorbid conditions, primary reason for hospitalization, past medical history such as prior VTE events, and cause of death (if not available in the admission note or discharge/death summaries), were obtained from EHR abstraction by 1 of the investigators. A 10% random sample of charts was rereviewed by another investigator with complete concordance. Supplementary data about date of CVC insertion if placed at an outside facility, date of CVC removal if applicable, clinical assessments regarding whether a clot was CVC‐associated, and contraindications to therapeutic anticoagulation were also abstracted directly from the EHR. Administrative data were used to identify the case mix index, an indicator of severity of illness.

Pharmacologic VTE prophylaxis included all chemical prophylaxis specified on our institutional guideline, most commonly subcutaneous unfractionated heparin 5000 units every 8 hours or low molecular weight heparin (LMWH), either enoxaparin 40 mg every 12 or 24 hours or dalteparin 5000 units every 24 hours. Mechanical prophylaxis was defined as use of sequential compression devices (SCDs) when pharmacologic prophylaxis was contraindicated. Prophylaxis was considered to be appropriate if it was applied according to our guideline for >90% of hospital days prior to UEDVT diagnosis. Therapeutic anticoagulation included heparin bridging (most commonly continuous heparin infusion, LMWH 1 mg/kg or dalteparin) as well as oral vitamin K antagonists. The VTE tool (Figure 1) allows identification of pharmacologic prophylaxis and therapy that is actually administered (not just ordered) directly from our pharmacy IT system. SCD application (not just ordered SCDs) is electronically integrated into the tool from nursing documentation.

CVCs included internal jugular or subclavian triple lumen catheters, tunneled dialysis catheters, or peripherally inserted central catheters (PICCs), single or double lumen. Criteria used to identify that a UEDVT was CVC‐associated included temporal relationship (CVC was placed prior to clot diagnosis), plausibility (ipsilateral clot), evidence of clot surrounding CVC on ultrasound, and physician designation of association (as documented in progress notes or discharge summary).

Simple percentages of patient characteristics, associated factors, management, and outcomes were calculated using counts as the numerator and number of patients as the denominator. For information about UEDVTs, we used total number of UEDVTs as the denominator. Line days were day counts from insertion until removal if applicable. The CVC placement date was available in our mandated central line placement procedure notes (directly accessed from the VTE tool) for all lines placed at our institution; date of removal (if applicable) was determined from chart abstraction. For the vast majority of patients whose CVCs were placed at outside facilities, date of placement was available in the EHR (often in the admission note or in the ultrasound report/reason for study). If date of line placement at an outside facility was not known, date of admission was used. The University of Washington Human Subjects Board approved this review.

RESULTS

DISCUSSION

UEDVT is increasingly recognized in hospitalized patients.[3, 9] At our medical center, 0.2% of symptomatic inpatients were diagnosed with UEDVT over 14 months. These patients were predominantly men with high rates of CVCs, malignancy, VTE history, severe infection, and renal disease. Interestingly, although the literature suggests that some proportion of patients with UEDVT have anatomic abnormalities, such as Paget‐Schroetter syndrome,[15] none of the patients in our study were found to have these anomalies. In our review, hospitalized patients with UEDVT were critically ill, with a long LOS and high morbidity and mortality, suggesting that in addition to just being a complication of hospitalization,[1, 6] UEDVT may be a marker of severe illness.

In our institution, clinical presentation was consistent with what has been described with the majority of patients presenting with upper extremity swelling.[1, 3] The internal jugular veins were the most common anatomic UEDVT site, followed by brachial then axillary veins. In other series including both in‐ and outpatients, subclavian clots were most commonly diagnosed, reflecting in part higher rates of CVC association and CVC location in those studies.[3, 9] Concurrent DVT and PE rates were similar to those reported.[1, 3, 10]

Although many studies have focused on prevention of LEDVT and PE, few trials have specifically targeted UEDVT. Among our patients with UEDVTs that were not present on admission, VTE prophylaxis rates were considerably higher than what has been reported,[1, 6] suggesting that in these critically ill patients' prophylaxis may not prevent symptomatic UEDVT. It is unknown how many UEDVTs were prevented with prophylaxis, as only patients with symptomatic UEDVT were included. Adequacy of prophylaxis at outside hospitals for patients transferred in could not be assessed. Nonetheless, low numbers of UEDVT at a trauma referral center with many high‐risk patients raise the question of whether prophylaxis makes a difference. Additional study is needed to further define the role of chemoprophylaxis to prevent UEDVT in hospitalized patients.

In our inpatient group, 84% required CVCs; 44% of patients were thought to have CVC‐associated UEDVTs. Careful patient selection and attention to potentially modifiable risks, such as insertion site, catheter type, and tip position, may need further examination in this population.[3, 11, 16] Catheter duration was long; focus on removing CVCs when no longer necessary is important. Interestingly, almost 10% in our study underwent diagnostic ultrasound because a new CVC could not be successfully placed suggesting that UEDVT may develop in critically ill patients regardless of CVCs.

In our study, there were high rates of guideline‐recommended pharmacologic treatment; surprisingly the majority of CVCs with associated clot were removed. Guidelines currently support 3 months of anticoagulation for treatment of UEDVT[2, 13, 17]; evidence derives from observational trials or is largely extrapolated from LEDVT literature.[2, 13] Routine CVC removal is not specifically recommended for CVC‐associated UEDVT, particularly if lines remain functional and medically necessary; systemic anticoagulation should be provided.[13]

In our review, no hospitalized patients with UEDVT developed complications or were readmitted to our medical center within 30 days for clot progression, new PE, or post‐thrombotic syndrome, which is lower than rates reported over longer time periods.[2, 6, 10, 12] Ten percent died during hospitalization, all from their primary disease rather than from complications of VTE or VTE treatment, and no additional patients died at our institution within 30 days. Although these rates are lower than have been otherwise reported,[2, 10] the inpatient mortality rate is similar to a recent study that included inpatients; however, all patients who died in that study had cancer and CVCs.[3] In the latter study, 6.4% died within 30 days of discharge.

CONCLUSIONS

Among hospitalized patients, UEDVT is increasingly recognized. In our medical center, hospitalized patients diagnosed with UEDVT were more likely to have CVCs, malignancy, renal disease, and severe infection. Many of these patients were transferred critically ill, had prolonged LOS, and had high in‐hospital mortality. Most developed UEDVT despite prophylaxis, and the majority of UEDVTs were treated even in the absence of concurrent LEDVT or PE. As we move toward an era of increasing accountability, with a focus on preventing hospital‐acquired conditions including VTE, additional research is needed to identify modifiable risks, explore opportunities for effective prevention, and optimize outcomes such as prevention of complications or readmissions, particularly in critically ill patients with UEDVT.

Since Wachter and Goldman coined the term hospitalist in 1996,[1] the number of hospitalists in the United States has grown rapidly, to more than 30,000 in recent estimates, with at least 80% of hospitals with 200 beds or more having hospital medicine programs.[2] A number of factors have led to the growth of such programs. First, hospital‐level incentives to use hospitalists exist to improve patient flow and maximize bed use, thereby reducing length of stay (LOS) and improving efficiency. Hospitals also employ hospitalists to address limitations on the number of hours that medical residents can work. Second, the use of hospitalists allows primary care physicians (PCPs) to focus their practices on outpatient care, thus avoiding the complexity of hospital‐based medicine, which requires both hospital‐focused clinical skills as well as institutional knowledge. Supporters of the hospitalist movement claim that hospitalists can improve efficiency and quality of care because hospitalists (1) have more experience managing inpatient care, (2) are more available to patients, and (3) have greater commitment to hospital quality improvements than (nonemployed) community PCPs.[3, 4, 5] On the other hand, criticisms of hospitalists include concerns related to (1) discontinuity in care and patient handoffs, (2) patient dissatisfaction at being treated by someone other than their PCP, (3) loss of acute care skills by PCPs, and (4) hospitalist burnout due to large workloads and poor institutional support.[3, 4, 5]

Hospitalists have been shown to have an effect on lowering total patient costs through better resource utilization and reduced LOS.[6, 7, 8, 9] There is no clear agreement, however, that hospitalists more often implement guideline‐recommended care.[10, 11, 12] In fact, most evaluations have found no significant differences between mortality and readmission rates among hospitalist and nonhospitalist groups.[12, 13, 14, 15, 16] The majority of these studies, however, were conducted in individual institutions or with small sample sizes, thus limiting their generalizability.

As 1 of the fastest‐growing medical specialties, hospitalists have assumed a significant role in inpatient care. The Centers for Medicare and Medicaid Services (CMS) have identified heart failure (HF), acute myocardial infarction (AMI), and pneumonia (PN) as important inpatient conditions associated with substantial morbidity and mortality among the Medicare population. Further, Jencks et al.[17] found that nearly one‐fifth of Medicare beneficiaries discharged from a hospital were readmitted within 30 days, which incurred an estimated cost to Medicare of $17.4 billion in 2004. Hospital readmission is of particular importance under healthcare reform because CMS introduced financial penalties in 2013 for hospitals with excessive readmission rates. The reimbursement penalty related to readmissions is included in the Patient Protection and Affordable Care Act and will be gradually expanded across many other outcomes.[18]

METHODS

RESULTS

DISCUSSION

Most previous studies have used patient‐level data from single institutions, and have shown inconsistent association between hospitalist care and clinical outcomes. Only a few studies have been conducted at the national level, and we know of only 1 that uses the same types of clinical outcomes as in our approach. In particular, Goodrich et al. conducted an in‐depth survey of hospitalist programs, and found that hospitalist presence had a significant association with HF readmissions.[29] Our results, similar to those of Goodrich et al., showed that the presence of hospitalists was not associated with risk‐standardized, 30‐day, all‐cause predicted excess mortality rates for Medicare patients hospitalized for any of these 3 conditions. The presence of hospitalists was, however, associated with lower‐risk standardized, 30‐day, all‐cause predicted excess readmission rates in our study. Our analyses resulted in somewhat different coefficients than Goodrich et al., but that is most likely due to: (1) different sample sizes, (2) use of similar yet not identical control variables, and (3) reporting error, as we used different sets of self‐reported data to indicate hospitalist services. The presence of a hospital‐level association with inconclusive patient‐level evidence suggests that there may be a more nuanced relationship between hospitalists and quality of care than has been previously explored.

This result may be explained by a number of reasons, the first of which is that hospitalists generally have more experience in the increasingly specialized practice of hospital‐based medicine than PCPs or nonhospitalists. For example, Meltzer et al.[30] found that hospitalists have more experience than nonhospitalists in treating acute manifestations of cardiovascular and respiratory diseases. Even though we might expect that greater experience with hospital‐based medicine would be associated with lower mortality rates, this outcome may not be captured because mortality is a rare event in the reported 30‐day postdischarge period and may be less preventable than readmission. There are a number of other factors possibly affecting hospital readmission, such as inadequate information transfer by discharge planners, poor patient compliance, inadequate follow‐up, insufficient use of family caregivers, deterioration of a patient's clinical condition, and medical errors.[31]

Studies have found that hospitalists have had positive effects related to managing case complexity and navigating the discharge process, perhaps due to their increased availability to patients and commitment to hospital quality improvements.[16, 32] Some determinants of patient outcomes may be difficult for hospitalists to influence, however, such as poor patient compliance or lack of support by family caregivers. Hospitalists who have extensive discharge experience may understand key challenges and adopt strategies to ameliorate these negative effects, for instance by using appropriate motivational strategies to encourage compliance and capitalizing on family caregivers.[33] Being located in the hospital, hospitalists are more available to deal with emergencies that occur during the hospitalization, and may be more available and active in discharge planning. Benbassat and Taragin[34] found that between 9% and 48% of all readmissions were preventable because they were associated with indicators of substandard care during the index hospitalization. They further estimated between 12% and 75% more readmissions could have been prevented by implementing patient education, predischarge assessment, and at‐home aftercare programs. Hospitalists are in a unique position to use their specialized training to improve transitions from hospital to home, communicate needs with the family and caregivers during the index hospitalization, and ensure that adequate postdischarge care is received. Although the use of hospitalists creates another handoff in the transition between inpatient and outpatient settings, hospitalist care may have a positive effect on many of the determinants of readmission sufficient to overcome that discontinuity.

Quality of care may also be affected by tertiary factors such as hospital administration or organizational culture. Lower AMI mortality has been associated with factors beyond cardiologist care, including organizational behavior and the appointment of physician and nurse champions.[35] Although the exact mechanism is unclear, better patient outcomes may be a result of this combination of direct clinical care, care transition management, and administrative or organizational factors. The models showed several hospital and community characteristics having coefficients larger in magnitude than the hospitalist variable, including classification as a teaching hospital, region, and hospital county median income. Teaching hospitals have been shown to have varying effects on quality of care depending on the type of care being provided, and teaching status may also be a proxy for factors related to organizational culture or mission.[36] Community‐level contextual factors including poverty and income have been shown previously to be related to readmission rates, possibly due to lack of social support and financial resources in the community to help discharged patients manage their healthcare needs in community settings.

CONCLUSION

Reducing medical errors and improving patient outcomes are becoming more important in light of increased reporting of hospital performance and outcome measures. Post‐discharge 30‐day mortality and hospital readmission represent 2 major undesirable patient outcomes, and Medicare's new pay‐for‐performance initiatives only provide further incentives for hospitals to take action in reducing these rates. Because the likelihood of receiving inpatient care provided by a hospitalist has significantly increased among Medicare patients since the 1990s,[39] hospitalists have become important players in potentially reducing mortality and readmission for patients discharged from inpatient settings. This study has shown that use of hospitalists may be associated with lower hospital readmissions, a clear quality measure, but are not associated with any changes in 30‐day mortality.

Further studies are needed, however, to better characterize and validate the observed associations, as well as to determine how hospitalist programs can be enhanced to improve inpatient care quality. Case studies could be carried out within hospitals with high‐ and low‐performing hospitalist services to help identify key aspects of hospitalist care most closely associated with desirable outcomes. Discharge and transitional care processes could also be standardized according to best practices, with their implementation tailored to individual hospital settings. Finally, as patient‐level data become increasingly available, researchers should merge these data with hospital‐level data to assess more robustly the multilevel effect of hospitalists on inpatient quality of care and individual patient outcomes. Such information will be valuable to policymakers and health administrators alike in the ongoing and volatile economic and political environment surrounding healthcare.

Since Wachter and Goldman coined the term hospitalist in 1996,[1] the number of hospitalists in the United States has grown rapidly, to more than 30,000 in recent estimates, with at least 80% of hospitals with 200 beds or more having hospital medicine programs.[2] A number of factors have led to the growth of such programs. First, hospital‐level incentives to use hospitalists exist to improve patient flow and maximize bed use, thereby reducing length of stay (LOS) and improving efficiency. Hospitals also employ hospitalists to address limitations on the number of hours that medical residents can work. Second, the use of hospitalists allows primary care physicians (PCPs) to focus their practices on outpatient care, thus avoiding the complexity of hospital‐based medicine, which requires both hospital‐focused clinical skills as well as institutional knowledge. Supporters of the hospitalist movement claim that hospitalists can improve efficiency and quality of care because hospitalists (1) have more experience managing inpatient care, (2) are more available to patients, and (3) have greater commitment to hospital quality improvements than (nonemployed) community PCPs.[3, 4, 5] On the other hand, criticisms of hospitalists include concerns related to (1) discontinuity in care and patient handoffs, (2) patient dissatisfaction at being treated by someone other than their PCP, (3) loss of acute care skills by PCPs, and (4) hospitalist burnout due to large workloads and poor institutional support.[3, 4, 5]

Hospitalists have been shown to have an effect on lowering total patient costs through better resource utilization and reduced LOS.[6, 7, 8, 9] There is no clear agreement, however, that hospitalists more often implement guideline‐recommended care.[10, 11, 12] In fact, most evaluations have found no significant differences between mortality and readmission rates among hospitalist and nonhospitalist groups.[12, 13, 14, 15, 16] The majority of these studies, however, were conducted in individual institutions or with small sample sizes, thus limiting their generalizability.

As 1 of the fastest‐growing medical specialties, hospitalists have assumed a significant role in inpatient care. The Centers for Medicare and Medicaid Services (CMS) have identified heart failure (HF), acute myocardial infarction (AMI), and pneumonia (PN) as important inpatient conditions associated with substantial morbidity and mortality among the Medicare population. Further, Jencks et al.[17] found that nearly one‐fifth of Medicare beneficiaries discharged from a hospital were readmitted within 30 days, which incurred an estimated cost to Medicare of $17.4 billion in 2004. Hospital readmission is of particular importance under healthcare reform because CMS introduced financial penalties in 2013 for hospitals with excessive readmission rates. The reimbursement penalty related to readmissions is included in the Patient Protection and Affordable Care Act and will be gradually expanded across many other outcomes.[18]

METHODS

RESULTS

DISCUSSION

Most previous studies have used patient‐level data from single institutions, and have shown inconsistent association between hospitalist care and clinical outcomes. Only a few studies have been conducted at the national level, and we know of only 1 that uses the same types of clinical outcomes as in our approach. In particular, Goodrich et al. conducted an in‐depth survey of hospitalist programs, and found that hospitalist presence had a significant association with HF readmissions.[29] Our results, similar to those of Goodrich et al., showed that the presence of hospitalists was not associated with risk‐standardized, 30‐day, all‐cause predicted excess mortality rates for Medicare patients hospitalized for any of these 3 conditions. The presence of hospitalists was, however, associated with lower‐risk standardized, 30‐day, all‐cause predicted excess readmission rates in our study. Our analyses resulted in somewhat different coefficients than Goodrich et al., but that is most likely due to: (1) different sample sizes, (2) use of similar yet not identical control variables, and (3) reporting error, as we used different sets of self‐reported data to indicate hospitalist services. The presence of a hospital‐level association with inconclusive patient‐level evidence suggests that there may be a more nuanced relationship between hospitalists and quality of care than has been previously explored.

This result may be explained by a number of reasons, the first of which is that hospitalists generally have more experience in the increasingly specialized practice of hospital‐based medicine than PCPs or nonhospitalists. For example, Meltzer et al.[30] found that hospitalists have more experience than nonhospitalists in treating acute manifestations of cardiovascular and respiratory diseases. Even though we might expect that greater experience with hospital‐based medicine would be associated with lower mortality rates, this outcome may not be captured because mortality is a rare event in the reported 30‐day postdischarge period and may be less preventable than readmission. There are a number of other factors possibly affecting hospital readmission, such as inadequate information transfer by discharge planners, poor patient compliance, inadequate follow‐up, insufficient use of family caregivers, deterioration of a patient's clinical condition, and medical errors.[31]

Studies have found that hospitalists have had positive effects related to managing case complexity and navigating the discharge process, perhaps due to their increased availability to patients and commitment to hospital quality improvements.[16, 32] Some determinants of patient outcomes may be difficult for hospitalists to influence, however, such as poor patient compliance or lack of support by family caregivers. Hospitalists who have extensive discharge experience may understand key challenges and adopt strategies to ameliorate these negative effects, for instance by using appropriate motivational strategies to encourage compliance and capitalizing on family caregivers.[33] Being located in the hospital, hospitalists are more available to deal with emergencies that occur during the hospitalization, and may be more available and active in discharge planning. Benbassat and Taragin[34] found that between 9% and 48% of all readmissions were preventable because they were associated with indicators of substandard care during the index hospitalization. They further estimated between 12% and 75% more readmissions could have been prevented by implementing patient education, predischarge assessment, and at‐home aftercare programs. Hospitalists are in a unique position to use their specialized training to improve transitions from hospital to home, communicate needs with the family and caregivers during the index hospitalization, and ensure that adequate postdischarge care is received. Although the use of hospitalists creates another handoff in the transition between inpatient and outpatient settings, hospitalist care may have a positive effect on many of the determinants of readmission sufficient to overcome that discontinuity.

Quality of care may also be affected by tertiary factors such as hospital administration or organizational culture. Lower AMI mortality has been associated with factors beyond cardiologist care, including organizational behavior and the appointment of physician and nurse champions.[35] Although the exact mechanism is unclear, better patient outcomes may be a result of this combination of direct clinical care, care transition management, and administrative or organizational factors. The models showed several hospital and community characteristics having coefficients larger in magnitude than the hospitalist variable, including classification as a teaching hospital, region, and hospital county median income. Teaching hospitals have been shown to have varying effects on quality of care depending on the type of care being provided, and teaching status may also be a proxy for factors related to organizational culture or mission.[36] Community‐level contextual factors including poverty and income have been shown previously to be related to readmission rates, possibly due to lack of social support and financial resources in the community to help discharged patients manage their healthcare needs in community settings.

CONCLUSION

Reducing medical errors and improving patient outcomes are becoming more important in light of increased reporting of hospital performance and outcome measures. Post‐discharge 30‐day mortality and hospital readmission represent 2 major undesirable patient outcomes, and Medicare's new pay‐for‐performance initiatives only provide further incentives for hospitals to take action in reducing these rates. Because the likelihood of receiving inpatient care provided by a hospitalist has significantly increased among Medicare patients since the 1990s,[39] hospitalists have become important players in potentially reducing mortality and readmission for patients discharged from inpatient settings. This study has shown that use of hospitalists may be associated with lower hospital readmissions, a clear quality measure, but are not associated with any changes in 30‐day mortality.

Further studies are needed, however, to better characterize and validate the observed associations, as well as to determine how hospitalist programs can be enhanced to improve inpatient care quality. Case studies could be carried out within hospitals with high‐ and low‐performing hospitalist services to help identify key aspects of hospitalist care most closely associated with desirable outcomes. Discharge and transitional care processes could also be standardized according to best practices, with their implementation tailored to individual hospital settings. Finally, as patient‐level data become increasingly available, researchers should merge these data with hospital‐level data to assess more robustly the multilevel effect of hospitalists on inpatient quality of care and individual patient outcomes. Such information will be valuable to policymakers and health administrators alike in the ongoing and volatile economic and political environment surrounding healthcare.

Since Wachter and Goldman coined the term hospitalist in 1996,[1] the number of hospitalists in the United States has grown rapidly, to more than 30,000 in recent estimates, with at least 80% of hospitals with 200 beds or more having hospital medicine programs.[2] A number of factors have led to the growth of such programs. First, hospital‐level incentives to use hospitalists exist to improve patient flow and maximize bed use, thereby reducing length of stay (LOS) and improving efficiency. Hospitals also employ hospitalists to address limitations on the number of hours that medical residents can work. Second, the use of hospitalists allows primary care physicians (PCPs) to focus their practices on outpatient care, thus avoiding the complexity of hospital‐based medicine, which requires both hospital‐focused clinical skills as well as institutional knowledge. Supporters of the hospitalist movement claim that hospitalists can improve efficiency and quality of care because hospitalists (1) have more experience managing inpatient care, (2) are more available to patients, and (3) have greater commitment to hospital quality improvements than (nonemployed) community PCPs.[3, 4, 5] On the other hand, criticisms of hospitalists include concerns related to (1) discontinuity in care and patient handoffs, (2) patient dissatisfaction at being treated by someone other than their PCP, (3) loss of acute care skills by PCPs, and (4) hospitalist burnout due to large workloads and poor institutional support.[3, 4, 5]

Hospitalists have been shown to have an effect on lowering total patient costs through better resource utilization and reduced LOS.[6, 7, 8, 9] There is no clear agreement, however, that hospitalists more often implement guideline‐recommended care.[10, 11, 12] In fact, most evaluations have found no significant differences between mortality and readmission rates among hospitalist and nonhospitalist groups.[12, 13, 14, 15, 16] The majority of these studies, however, were conducted in individual institutions or with small sample sizes, thus limiting their generalizability.

As 1 of the fastest‐growing medical specialties, hospitalists have assumed a significant role in inpatient care. The Centers for Medicare and Medicaid Services (CMS) have identified heart failure (HF), acute myocardial infarction (AMI), and pneumonia (PN) as important inpatient conditions associated with substantial morbidity and mortality among the Medicare population. Further, Jencks et al.[17] found that nearly one‐fifth of Medicare beneficiaries discharged from a hospital were readmitted within 30 days, which incurred an estimated cost to Medicare of $17.4 billion in 2004. Hospital readmission is of particular importance under healthcare reform because CMS introduced financial penalties in 2013 for hospitals with excessive readmission rates. The reimbursement penalty related to readmissions is included in the Patient Protection and Affordable Care Act and will be gradually expanded across many other outcomes.[18]

METHODS

RESULTS

DISCUSSION

Most previous studies have used patient‐level data from single institutions, and have shown inconsistent association between hospitalist care and clinical outcomes. Only a few studies have been conducted at the national level, and we know of only 1 that uses the same types of clinical outcomes as in our approach. In particular, Goodrich et al. conducted an in‐depth survey of hospitalist programs, and found that hospitalist presence had a significant association with HF readmissions.[29] Our results, similar to those of Goodrich et al., showed that the presence of hospitalists was not associated with risk‐standardized, 30‐day, all‐cause predicted excess mortality rates for Medicare patients hospitalized for any of these 3 conditions. The presence of hospitalists was, however, associated with lower‐risk standardized, 30‐day, all‐cause predicted excess readmission rates in our study. Our analyses resulted in somewhat different coefficients than Goodrich et al., but that is most likely due to: (1) different sample sizes, (2) use of similar yet not identical control variables, and (3) reporting error, as we used different sets of self‐reported data to indicate hospitalist services. The presence of a hospital‐level association with inconclusive patient‐level evidence suggests that there may be a more nuanced relationship between hospitalists and quality of care than has been previously explored.

This result may be explained by a number of reasons, the first of which is that hospitalists generally have more experience in the increasingly specialized practice of hospital‐based medicine than PCPs or nonhospitalists. For example, Meltzer et al.[30] found that hospitalists have more experience than nonhospitalists in treating acute manifestations of cardiovascular and respiratory diseases. Even though we might expect that greater experience with hospital‐based medicine would be associated with lower mortality rates, this outcome may not be captured because mortality is a rare event in the reported 30‐day postdischarge period and may be less preventable than readmission. There are a number of other factors possibly affecting hospital readmission, such as inadequate information transfer by discharge planners, poor patient compliance, inadequate follow‐up, insufficient use of family caregivers, deterioration of a patient's clinical condition, and medical errors.[31]

Studies have found that hospitalists have had positive effects related to managing case complexity and navigating the discharge process, perhaps due to their increased availability to patients and commitment to hospital quality improvements.[16, 32] Some determinants of patient outcomes may be difficult for hospitalists to influence, however, such as poor patient compliance or lack of support by family caregivers. Hospitalists who have extensive discharge experience may understand key challenges and adopt strategies to ameliorate these negative effects, for instance by using appropriate motivational strategies to encourage compliance and capitalizing on family caregivers.[33] Being located in the hospital, hospitalists are more available to deal with emergencies that occur during the hospitalization, and may be more available and active in discharge planning. Benbassat and Taragin[34] found that between 9% and 48% of all readmissions were preventable because they were associated with indicators of substandard care during the index hospitalization. They further estimated between 12% and 75% more readmissions could have been prevented by implementing patient education, predischarge assessment, and at‐home aftercare programs. Hospitalists are in a unique position to use their specialized training to improve transitions from hospital to home, communicate needs with the family and caregivers during the index hospitalization, and ensure that adequate postdischarge care is received. Although the use of hospitalists creates another handoff in the transition between inpatient and outpatient settings, hospitalist care may have a positive effect on many of the determinants of readmission sufficient to overcome that discontinuity.

Quality of care may also be affected by tertiary factors such as hospital administration or organizational culture. Lower AMI mortality has been associated with factors beyond cardiologist care, including organizational behavior and the appointment of physician and nurse champions.[35] Although the exact mechanism is unclear, better patient outcomes may be a result of this combination of direct clinical care, care transition management, and administrative or organizational factors. The models showed several hospital and community characteristics having coefficients larger in magnitude than the hospitalist variable, including classification as a teaching hospital, region, and hospital county median income. Teaching hospitals have been shown to have varying effects on quality of care depending on the type of care being provided, and teaching status may also be a proxy for factors related to organizational culture or mission.[36] Community‐level contextual factors including poverty and income have been shown previously to be related to readmission rates, possibly due to lack of social support and financial resources in the community to help discharged patients manage their healthcare needs in community settings.

CONCLUSION

Reducing medical errors and improving patient outcomes are becoming more important in light of increased reporting of hospital performance and outcome measures. Post‐discharge 30‐day mortality and hospital readmission represent 2 major undesirable patient outcomes, and Medicare's new pay‐for‐performance initiatives only provide further incentives for hospitals to take action in reducing these rates. Because the likelihood of receiving inpatient care provided by a hospitalist has significantly increased among Medicare patients since the 1990s,[39] hospitalists have become important players in potentially reducing mortality and readmission for patients discharged from inpatient settings. This study has shown that use of hospitalists may be associated with lower hospital readmissions, a clear quality measure, but are not associated with any changes in 30‐day mortality.

Further studies are needed, however, to better characterize and validate the observed associations, as well as to determine how hospitalist programs can be enhanced to improve inpatient care quality. Case studies could be carried out within hospitals with high‐ and low‐performing hospitalist services to help identify key aspects of hospitalist care most closely associated with desirable outcomes. Discharge and transitional care processes could also be standardized according to best practices, with their implementation tailored to individual hospital settings. Finally, as patient‐level data become increasingly available, researchers should merge these data with hospital‐level data to assess more robustly the multilevel effect of hospitalists on inpatient quality of care and individual patient outcomes. Such information will be valuable to policymakers and health administrators alike in the ongoing and volatile economic and political environment surrounding healthcare.