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I COUGH for Prevention of Postop Pulmonary Complications
Clinical question
Does implementation of the I COUGH strategy improve pulmonary outcomes in postoperative patients?
Bottom line
Although not statistically significant, data from this before-and-after trial shows that the I COUGH strategy (emphasizing lung expansion, early mobilization, oral hygiene, and patient and provider education) may decrease postoperative pulmonary complications in hospitalized patients. (LOE = 2c)
Reference
Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: Reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg 2013;148(8):740-745.
Study design
Other
Funding source
Unknown/not stated
Allocation
Uncertain
Setting
Inpatient (any location)
Synopsis
Data from the National Surgical Quality Improvement Program (NQSIP) showed that the Boston Medical Center was a high outlier for postoperative pulmonary complications. To address this, a pulmonary care working group including surgeons, internists, nurses, and respiratory therapists was formed. The group reviewed the literature on preventing postoperative pulmonary complications and devised the I COUGH strategy: (1) Incentive spirometry, (2) Coughing and deep breathing, (3) Oral care, (4) Understanding (patient and family education), (5) Getting out of bed, and (6) Head-of-bed elevation. Postoperative pain control was also emphasized. Educational materials including videos and brochures were developed for patients and families and distributed in surgery and perioperative clinics. Incentive spirometry technique was taught and reinforced in the preoperative setting. Frontline nurses and physicians also received education regarding the baseline outcomes data and the reasons for developing the program. Finally, standardized order sets outlining the components of I COUGH were created. The I COUGH strategy was implemented for all hospitalized general and vascular surgery patients in the institution. More patients were out of bed postintervention than preintervention (70% vs 20%; P < .001). Similarly, more patients had incentive spirometry available and within reach postintervention (77% vs 53%; P < .001). Note, however, that the preintervention audits were unannounced observations of nursing practices whereas postintervention audits were by review of nursing documentation only. Although not statistically significant, the NSQIP data revealed trends toward decreased incidences of postoperative pneumonia (2.6% vs 1.6%; P = .09) and unplanned intubations (2.0% vs 1.2%; P = .09) after I COUGH implementation. National averages for postoperative pneumonias and unplanned intubations for comparable hospitals during this period were 1.4% to 1.7% and 1.4% to 1.6%, respectively.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Does implementation of the I COUGH strategy improve pulmonary outcomes in postoperative patients?
Bottom line
Although not statistically significant, data from this before-and-after trial shows that the I COUGH strategy (emphasizing lung expansion, early mobilization, oral hygiene, and patient and provider education) may decrease postoperative pulmonary complications in hospitalized patients. (LOE = 2c)
Reference
Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: Reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg 2013;148(8):740-745.
Study design
Other
Funding source
Unknown/not stated
Allocation
Uncertain
Setting
Inpatient (any location)
Synopsis
Data from the National Surgical Quality Improvement Program (NQSIP) showed that the Boston Medical Center was a high outlier for postoperative pulmonary complications. To address this, a pulmonary care working group including surgeons, internists, nurses, and respiratory therapists was formed. The group reviewed the literature on preventing postoperative pulmonary complications and devised the I COUGH strategy: (1) Incentive spirometry, (2) Coughing and deep breathing, (3) Oral care, (4) Understanding (patient and family education), (5) Getting out of bed, and (6) Head-of-bed elevation. Postoperative pain control was also emphasized. Educational materials including videos and brochures were developed for patients and families and distributed in surgery and perioperative clinics. Incentive spirometry technique was taught and reinforced in the preoperative setting. Frontline nurses and physicians also received education regarding the baseline outcomes data and the reasons for developing the program. Finally, standardized order sets outlining the components of I COUGH were created. The I COUGH strategy was implemented for all hospitalized general and vascular surgery patients in the institution. More patients were out of bed postintervention than preintervention (70% vs 20%; P < .001). Similarly, more patients had incentive spirometry available and within reach postintervention (77% vs 53%; P < .001). Note, however, that the preintervention audits were unannounced observations of nursing practices whereas postintervention audits were by review of nursing documentation only. Although not statistically significant, the NSQIP data revealed trends toward decreased incidences of postoperative pneumonia (2.6% vs 1.6%; P = .09) and unplanned intubations (2.0% vs 1.2%; P = .09) after I COUGH implementation. National averages for postoperative pneumonias and unplanned intubations for comparable hospitals during this period were 1.4% to 1.7% and 1.4% to 1.6%, respectively.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Does implementation of the I COUGH strategy improve pulmonary outcomes in postoperative patients?
Bottom line
Although not statistically significant, data from this before-and-after trial shows that the I COUGH strategy (emphasizing lung expansion, early mobilization, oral hygiene, and patient and provider education) may decrease postoperative pulmonary complications in hospitalized patients. (LOE = 2c)
Reference
Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: Reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg 2013;148(8):740-745.
Study design
Other
Funding source
Unknown/not stated
Allocation
Uncertain
Setting
Inpatient (any location)
Synopsis
Data from the National Surgical Quality Improvement Program (NQSIP) showed that the Boston Medical Center was a high outlier for postoperative pulmonary complications. To address this, a pulmonary care working group including surgeons, internists, nurses, and respiratory therapists was formed. The group reviewed the literature on preventing postoperative pulmonary complications and devised the I COUGH strategy: (1) Incentive spirometry, (2) Coughing and deep breathing, (3) Oral care, (4) Understanding (patient and family education), (5) Getting out of bed, and (6) Head-of-bed elevation. Postoperative pain control was also emphasized. Educational materials including videos and brochures were developed for patients and families and distributed in surgery and perioperative clinics. Incentive spirometry technique was taught and reinforced in the preoperative setting. Frontline nurses and physicians also received education regarding the baseline outcomes data and the reasons for developing the program. Finally, standardized order sets outlining the components of I COUGH were created. The I COUGH strategy was implemented for all hospitalized general and vascular surgery patients in the institution. More patients were out of bed postintervention than preintervention (70% vs 20%; P < .001). Similarly, more patients had incentive spirometry available and within reach postintervention (77% vs 53%; P < .001). Note, however, that the preintervention audits were unannounced observations of nursing practices whereas postintervention audits were by review of nursing documentation only. Although not statistically significant, the NSQIP data revealed trends toward decreased incidences of postoperative pneumonia (2.6% vs 1.6%; P = .09) and unplanned intubations (2.0% vs 1.2%; P = .09) after I COUGH implementation. National averages for postoperative pneumonias and unplanned intubations for comparable hospitals during this period were 1.4% to 1.7% and 1.4% to 1.6%, respectively.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Inpatient Smoking Cessation Strategy Promising, but Effects Aren't Long Lasting
Clinical question
How effective is intensive smoking cessation support for hospitalized patients?
Bottom line
Therapy provided by highly trained smoking cessation practitioners, combined with pharmacotherapy and community support referrals upon discharge, may increase short-term quit rates among hospitalized smokers. However, this effect did not persist at 6 months. Moreover, this study did not address the cost-effectiveness of such an intensive strategy. (LOE = 1b-)
Reference
Study design
Randomized controlled trial (nonblinded)
Funding source
Government
Allocation
Concealed
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
Investigators at a large teaching hospital in the United Kingdom randomized 18 medical wards, using concealed allocation, to deliver either usual care for smoking cessation or the intervention strategy. Almost 500 patients were enrolled in the study and received smoking cessation treatment based on the allocation of their admission ward. The intervention consisted of identification of smokers upon admission, followed by delivery of smoking advice and offer of cessation support. Patients who accepted the support received daily in-hospital counseling by a trained smoking cessation practitioner. Initial sessions lasted 20 minutes to 30 minutes; subsequent sessions were 10 minutes long. Patients were also prescribed dual nicotine replacement therapy (transdermal patch plus either gum, lozenge, or nasal spray) or varenicline therapy, if preferred. Additionally, intervention patients received referrals to community cessation support services upon discharge. Patients on the usual care ward received cessation advice and support according to the usual practices of the providers involved in their care. The intervention group patients were younger and more likely to be male. Additionally, because of randomization by admission ward, the majority of intervention patients came from cardiac wards, whereas the majority of usual care patients came from respiratory wards. Finally, many eligible oncology patients were not included in the trial because of their doctors’ reluctance to have the study team approach these terminally ill patients. All patients in the intervention group received advice to quit compared with less than half of the patients in the usual care group. The use of pharmacotherapy and cessation support therapy, both in the hospital and upon discharge, was greater in the intervention group. The quit rate at 4 weeks, defined as self-reported smoking cessation validated by exhaled carbon monoxide measurement, favored the intervention group (38% vs 17%; P = .06), but did not quite reach statistical significance. When oncology patients (n = 45) were excluded from the analysis retrospectively, however, the result was significant (42% quit rate in the intervention group vs 17% in the usual care group; P = .006). Six-month cessation rates, though also higher in the intervention group, were not statistically different (19% vs 9%; P = .37).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
How effective is intensive smoking cessation support for hospitalized patients?
Bottom line
Therapy provided by highly trained smoking cessation practitioners, combined with pharmacotherapy and community support referrals upon discharge, may increase short-term quit rates among hospitalized smokers. However, this effect did not persist at 6 months. Moreover, this study did not address the cost-effectiveness of such an intensive strategy. (LOE = 1b-)
Reference
Study design
Randomized controlled trial (nonblinded)
Funding source
Government
Allocation
Concealed
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
Investigators at a large teaching hospital in the United Kingdom randomized 18 medical wards, using concealed allocation, to deliver either usual care for smoking cessation or the intervention strategy. Almost 500 patients were enrolled in the study and received smoking cessation treatment based on the allocation of their admission ward. The intervention consisted of identification of smokers upon admission, followed by delivery of smoking advice and offer of cessation support. Patients who accepted the support received daily in-hospital counseling by a trained smoking cessation practitioner. Initial sessions lasted 20 minutes to 30 minutes; subsequent sessions were 10 minutes long. Patients were also prescribed dual nicotine replacement therapy (transdermal patch plus either gum, lozenge, or nasal spray) or varenicline therapy, if preferred. Additionally, intervention patients received referrals to community cessation support services upon discharge. Patients on the usual care ward received cessation advice and support according to the usual practices of the providers involved in their care. The intervention group patients were younger and more likely to be male. Additionally, because of randomization by admission ward, the majority of intervention patients came from cardiac wards, whereas the majority of usual care patients came from respiratory wards. Finally, many eligible oncology patients were not included in the trial because of their doctors’ reluctance to have the study team approach these terminally ill patients. All patients in the intervention group received advice to quit compared with less than half of the patients in the usual care group. The use of pharmacotherapy and cessation support therapy, both in the hospital and upon discharge, was greater in the intervention group. The quit rate at 4 weeks, defined as self-reported smoking cessation validated by exhaled carbon monoxide measurement, favored the intervention group (38% vs 17%; P = .06), but did not quite reach statistical significance. When oncology patients (n = 45) were excluded from the analysis retrospectively, however, the result was significant (42% quit rate in the intervention group vs 17% in the usual care group; P = .006). Six-month cessation rates, though also higher in the intervention group, were not statistically different (19% vs 9%; P = .37).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
How effective is intensive smoking cessation support for hospitalized patients?
Bottom line
Therapy provided by highly trained smoking cessation practitioners, combined with pharmacotherapy and community support referrals upon discharge, may increase short-term quit rates among hospitalized smokers. However, this effect did not persist at 6 months. Moreover, this study did not address the cost-effectiveness of such an intensive strategy. (LOE = 1b-)
Reference
Study design
Randomized controlled trial (nonblinded)
Funding source
Government
Allocation
Concealed
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
Investigators at a large teaching hospital in the United Kingdom randomized 18 medical wards, using concealed allocation, to deliver either usual care for smoking cessation or the intervention strategy. Almost 500 patients were enrolled in the study and received smoking cessation treatment based on the allocation of their admission ward. The intervention consisted of identification of smokers upon admission, followed by delivery of smoking advice and offer of cessation support. Patients who accepted the support received daily in-hospital counseling by a trained smoking cessation practitioner. Initial sessions lasted 20 minutes to 30 minutes; subsequent sessions were 10 minutes long. Patients were also prescribed dual nicotine replacement therapy (transdermal patch plus either gum, lozenge, or nasal spray) or varenicline therapy, if preferred. Additionally, intervention patients received referrals to community cessation support services upon discharge. Patients on the usual care ward received cessation advice and support according to the usual practices of the providers involved in their care. The intervention group patients were younger and more likely to be male. Additionally, because of randomization by admission ward, the majority of intervention patients came from cardiac wards, whereas the majority of usual care patients came from respiratory wards. Finally, many eligible oncology patients were not included in the trial because of their doctors’ reluctance to have the study team approach these terminally ill patients. All patients in the intervention group received advice to quit compared with less than half of the patients in the usual care group. The use of pharmacotherapy and cessation support therapy, both in the hospital and upon discharge, was greater in the intervention group. The quit rate at 4 weeks, defined as self-reported smoking cessation validated by exhaled carbon monoxide measurement, favored the intervention group (38% vs 17%; P = .06), but did not quite reach statistical significance. When oncology patients (n = 45) were excluded from the analysis retrospectively, however, the result was significant (42% quit rate in the intervention group vs 17% in the usual care group; P = .006). Six-month cessation rates, though also higher in the intervention group, were not statistically different (19% vs 9%; P = .37).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Improving diagnosis of otitis media
The diagnosis of otitis media absolutely requires visualization of the tympanic membrane. So it may be time to upgrade your tools to do a better job in diagnosing. Think about how often you use your otoscope. Are you using the best available technology, or are you using the otoscope you got in medical school, perhaps quite a few years ago? It may be time for an upgrade. Considering how often you might use an otoscope, you can afford it. You deserve it.
The improved features of new otoscopes include remarkably better illumination. The quality of the light not only has to do with the lumens, but also the color of the light. Also there is a version of an otoscope called a Macro View (Welch Allyn, Skaneateles Falls, N.Y.). It allows you to increase the magnification on the tympanic membrane (TM) as needed. There is an option to purchase a lighter and smaller handle for the scope, and that can improve ease of use for persons with small hands.
For all otoscopes, the bulb should be replaced when illumination begins to fade and you cannot get back the intensity of light with a battery recharge. For most primary care practitioners, bulbs usually require replacement annually.
Speculum size is key to getting the most light onto the TM; the bigger the speculum, the better. Advancing the speculum as far into the external ear canal as you can without causing discomfort helps improve the intensity of the light shone on the TM. While it is convenient to use disposable specula, they are not as good as reusable ones because the finish on the inside of disposable specula is duller than on reusable specula, thus decreasing the amount of light shone on the TM. Also, disposable specula often are too short, and that too reduces the light shone on the TM.
Many clinicians have not been trained on using pneumatic otoscopy, or even if trained, they find it inconvenient and/or problematic to use because it requires a seal of the speculum against the external auditory canal; this makes children cry. The problem is that you really need to use pneumatic otoscopy in some cases to determine if the TM is retracted (no acute infection) or bulging (acute infection, or AOM). I use pneumatic otoscopy in about one-third of cases, and to this day I am surprised sometimes when the negative pressure pulls a retracted TM forward when I was pretty sure the TM more likely was bulging. There are specula with a semisoft sleeve midway down the shaft, but I have not found they are any less likely to cause the child to cry, because as anyone knows who has stuck a Q-tip swab into their ear canal, it is sensitive skin.
Then there is the wax! Clinical studies show that about half of children have wax in their external auditory canal blocking 25% of the view, and one-quarter have wax blocking 50% of the view. The best tool I have found to clear the wax is a plastic cerumen spoon (called a safe ear curette) made by Bionix Medical Technologies (Toledo, Ohio). I use the white ones as they are the most flexible. Ninety percent of the time I can scoop the wax out of the way and get a good view. For the remaining difficult cases, the ear canal needs to be irrigated with warm water (code 69210), and then the remaining wax can be scooped out.
Tympanometry (code 92567) is another tool to aid in accurate diagnosis and follow-up of otitis media. A key aspect of the diagnostic algorithm advocated by the American Academy of Pediatrics is a determination of whether the TM is bulging (AOM) or not (no AOM). A retracted TM is inconsistent with the diagnosis of AOM. Tympanometry requires a seal with the external auditory canal because a pressure is applied to the TM to determine TM movement. After positive and negative pressure are applied by the instrument, the readout will be a positive peaked curve (bulging), a negative peaked curve (retracted), a normal peaked curve (normal), or flat, no curve (stiff TM).
The first three readouts are very helpful in distinguishing AOM from no AOM. The flat curve indicates three possibilities: The TM is stiff, perhaps due to thickening; the TM is not moving because the middle ear space is filled with pus behind it, meaning it is AOM; or the TM is not moving because the middle ear space is filled with effusion fluid behind it, meaning the patient has otitis media with effusion. In the case of a flat readout, the tie breaker should come from the visual exam and/or the use of spectral gradient acoustic reflectometry (code 92567).
These better tools and techniques should improve your diagnosis of otitis media.
Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester General Hospital, N.Y. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no financial disclosures relevant to this article. To comment, e-mail him at [email protected].
The diagnosis of otitis media absolutely requires visualization of the tympanic membrane. So it may be time to upgrade your tools to do a better job in diagnosing. Think about how often you use your otoscope. Are you using the best available technology, or are you using the otoscope you got in medical school, perhaps quite a few years ago? It may be time for an upgrade. Considering how often you might use an otoscope, you can afford it. You deserve it.
The improved features of new otoscopes include remarkably better illumination. The quality of the light not only has to do with the lumens, but also the color of the light. Also there is a version of an otoscope called a Macro View (Welch Allyn, Skaneateles Falls, N.Y.). It allows you to increase the magnification on the tympanic membrane (TM) as needed. There is an option to purchase a lighter and smaller handle for the scope, and that can improve ease of use for persons with small hands.
For all otoscopes, the bulb should be replaced when illumination begins to fade and you cannot get back the intensity of light with a battery recharge. For most primary care practitioners, bulbs usually require replacement annually.
Speculum size is key to getting the most light onto the TM; the bigger the speculum, the better. Advancing the speculum as far into the external ear canal as you can without causing discomfort helps improve the intensity of the light shone on the TM. While it is convenient to use disposable specula, they are not as good as reusable ones because the finish on the inside of disposable specula is duller than on reusable specula, thus decreasing the amount of light shone on the TM. Also, disposable specula often are too short, and that too reduces the light shone on the TM.
Many clinicians have not been trained on using pneumatic otoscopy, or even if trained, they find it inconvenient and/or problematic to use because it requires a seal of the speculum against the external auditory canal; this makes children cry. The problem is that you really need to use pneumatic otoscopy in some cases to determine if the TM is retracted (no acute infection) or bulging (acute infection, or AOM). I use pneumatic otoscopy in about one-third of cases, and to this day I am surprised sometimes when the negative pressure pulls a retracted TM forward when I was pretty sure the TM more likely was bulging. There are specula with a semisoft sleeve midway down the shaft, but I have not found they are any less likely to cause the child to cry, because as anyone knows who has stuck a Q-tip swab into their ear canal, it is sensitive skin.
Then there is the wax! Clinical studies show that about half of children have wax in their external auditory canal blocking 25% of the view, and one-quarter have wax blocking 50% of the view. The best tool I have found to clear the wax is a plastic cerumen spoon (called a safe ear curette) made by Bionix Medical Technologies (Toledo, Ohio). I use the white ones as they are the most flexible. Ninety percent of the time I can scoop the wax out of the way and get a good view. For the remaining difficult cases, the ear canal needs to be irrigated with warm water (code 69210), and then the remaining wax can be scooped out.
Tympanometry (code 92567) is another tool to aid in accurate diagnosis and follow-up of otitis media. A key aspect of the diagnostic algorithm advocated by the American Academy of Pediatrics is a determination of whether the TM is bulging (AOM) or not (no AOM). A retracted TM is inconsistent with the diagnosis of AOM. Tympanometry requires a seal with the external auditory canal because a pressure is applied to the TM to determine TM movement. After positive and negative pressure are applied by the instrument, the readout will be a positive peaked curve (bulging), a negative peaked curve (retracted), a normal peaked curve (normal), or flat, no curve (stiff TM).
The first three readouts are very helpful in distinguishing AOM from no AOM. The flat curve indicates three possibilities: The TM is stiff, perhaps due to thickening; the TM is not moving because the middle ear space is filled with pus behind it, meaning it is AOM; or the TM is not moving because the middle ear space is filled with effusion fluid behind it, meaning the patient has otitis media with effusion. In the case of a flat readout, the tie breaker should come from the visual exam and/or the use of spectral gradient acoustic reflectometry (code 92567).
These better tools and techniques should improve your diagnosis of otitis media.
Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester General Hospital, N.Y. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no financial disclosures relevant to this article. To comment, e-mail him at [email protected].
The diagnosis of otitis media absolutely requires visualization of the tympanic membrane. So it may be time to upgrade your tools to do a better job in diagnosing. Think about how often you use your otoscope. Are you using the best available technology, or are you using the otoscope you got in medical school, perhaps quite a few years ago? It may be time for an upgrade. Considering how often you might use an otoscope, you can afford it. You deserve it.
The improved features of new otoscopes include remarkably better illumination. The quality of the light not only has to do with the lumens, but also the color of the light. Also there is a version of an otoscope called a Macro View (Welch Allyn, Skaneateles Falls, N.Y.). It allows you to increase the magnification on the tympanic membrane (TM) as needed. There is an option to purchase a lighter and smaller handle for the scope, and that can improve ease of use for persons with small hands.
For all otoscopes, the bulb should be replaced when illumination begins to fade and you cannot get back the intensity of light with a battery recharge. For most primary care practitioners, bulbs usually require replacement annually.
Speculum size is key to getting the most light onto the TM; the bigger the speculum, the better. Advancing the speculum as far into the external ear canal as you can without causing discomfort helps improve the intensity of the light shone on the TM. While it is convenient to use disposable specula, they are not as good as reusable ones because the finish on the inside of disposable specula is duller than on reusable specula, thus decreasing the amount of light shone on the TM. Also, disposable specula often are too short, and that too reduces the light shone on the TM.
Many clinicians have not been trained on using pneumatic otoscopy, or even if trained, they find it inconvenient and/or problematic to use because it requires a seal of the speculum against the external auditory canal; this makes children cry. The problem is that you really need to use pneumatic otoscopy in some cases to determine if the TM is retracted (no acute infection) or bulging (acute infection, or AOM). I use pneumatic otoscopy in about one-third of cases, and to this day I am surprised sometimes when the negative pressure pulls a retracted TM forward when I was pretty sure the TM more likely was bulging. There are specula with a semisoft sleeve midway down the shaft, but I have not found they are any less likely to cause the child to cry, because as anyone knows who has stuck a Q-tip swab into their ear canal, it is sensitive skin.
Then there is the wax! Clinical studies show that about half of children have wax in their external auditory canal blocking 25% of the view, and one-quarter have wax blocking 50% of the view. The best tool I have found to clear the wax is a plastic cerumen spoon (called a safe ear curette) made by Bionix Medical Technologies (Toledo, Ohio). I use the white ones as they are the most flexible. Ninety percent of the time I can scoop the wax out of the way and get a good view. For the remaining difficult cases, the ear canal needs to be irrigated with warm water (code 69210), and then the remaining wax can be scooped out.
Tympanometry (code 92567) is another tool to aid in accurate diagnosis and follow-up of otitis media. A key aspect of the diagnostic algorithm advocated by the American Academy of Pediatrics is a determination of whether the TM is bulging (AOM) or not (no AOM). A retracted TM is inconsistent with the diagnosis of AOM. Tympanometry requires a seal with the external auditory canal because a pressure is applied to the TM to determine TM movement. After positive and negative pressure are applied by the instrument, the readout will be a positive peaked curve (bulging), a negative peaked curve (retracted), a normal peaked curve (normal), or flat, no curve (stiff TM).
The first three readouts are very helpful in distinguishing AOM from no AOM. The flat curve indicates three possibilities: The TM is stiff, perhaps due to thickening; the TM is not moving because the middle ear space is filled with pus behind it, meaning it is AOM; or the TM is not moving because the middle ear space is filled with effusion fluid behind it, meaning the patient has otitis media with effusion. In the case of a flat readout, the tie breaker should come from the visual exam and/or the use of spectral gradient acoustic reflectometry (code 92567).
These better tools and techniques should improve your diagnosis of otitis media.
Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester General Hospital, N.Y. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no financial disclosures relevant to this article. To comment, e-mail him at [email protected].
Pseudofolliculitis barbae – tips for patients
Pseudofolliculitis barbae (PFB) is a common complaint among darker-skinned patients with coarse curly hair. Patients present with follicular papules in the beard from ingrown hairs that can eventually result in postinflammatory pigmentary alternation and scarring. While these symptoms are most common in men, women may be affected as well, as PFB is not limited to the beard area; it may occur in any other area with thick, coarse curly hair, including the bikini area and axillae.
Some tips for treating PFB:
If the patient doesn’t mind growing a beard, advise him to grow one! The chances of having ingrown hairs that stimulate this condition are less if the hairs are not plucked or shaved, or are kept at least a few millimeters long.
If hair removal/grooming is a must, options include clipping the hairs with a protector; using a self-cleaning electric razor (replacing the blades at least every 2 years); and using thick shaving gel with either a single or twin blade razor, or a chemical depilatory.
Laser hair removal is also an option in the right candidate, particularly with longer pulsed (1,064 nm or 810 nm) lasers in darker-skinned individuals. Eflornithine 12% twice daily for 16 weeks has been shown to work synergistically with laser hair removal. Electrolysis may be helpful for hairs that do not respond to laser hair removal with longer pulsed lasers, such as grey hairs.
If shaving is a must, advise patients to:
• Apply warm compresses to the beard area for a few minutes prior to shaving. In addition, using a mild exfoliant or loofah or toothbrush in a circular motion will help allow any ingrown hairs to be more easily plucked or released at the skin surface.
• Use shaving gel and a sharp razor each time.
• Do not pull the skin taut.
• Do not shave against the direction of hair growth.
• Take short strokes and do not shave back and forth over the same areas.
• After shaving, use a soothing aftershave or hydrocortisone 1% lotion.
Products such as PFB Vanish, which contain salicylic, glycolic, and/or lactic acid, are helpful in some patients after hair removal to prevent ingrown hairs. One version of PFB Vanish contains antipigment ingredients to also address hyperpigmentation.
If inflammatory papules or pustules are present, a combination benzoyl peroxide/clindamycin topical gels (such as Benzaclin, Duac, or Acanya) can be used. Patients with severe inflammation may require oral antibiotics.
Using a topical retinoid at night or a combination retinoid product with hydroquinone can be helpful especially in cases of postinflammatory hyperpigmentation. However, use caution when prescribing retinoids for patients with darker skin, as irritation from these products may lead to postinflammatory pigmentary alteration. Remind patients to avoid drying products, such as toners, if topical retinoids are used.
For severe or refractory postinflammatory hyperpigmentation or inflammatory papules, chemical peels with 20%-30% salicylic acid can be helpful.
What are your PFB solutions? The more we share our clinical insights, the better we will be able to achieve improved treatment results for our patients.
Dr. Wesley practices dermatology in Beverly Hills, Calif. Do you have questions about treating patients with dark skin? If so, send them to [email protected].
Pseudofolliculitis barbae (PFB) is a common complaint among darker-skinned patients with coarse curly hair. Patients present with follicular papules in the beard from ingrown hairs that can eventually result in postinflammatory pigmentary alternation and scarring. While these symptoms are most common in men, women may be affected as well, as PFB is not limited to the beard area; it may occur in any other area with thick, coarse curly hair, including the bikini area and axillae.
Some tips for treating PFB:
If the patient doesn’t mind growing a beard, advise him to grow one! The chances of having ingrown hairs that stimulate this condition are less if the hairs are not plucked or shaved, or are kept at least a few millimeters long.
If hair removal/grooming is a must, options include clipping the hairs with a protector; using a self-cleaning electric razor (replacing the blades at least every 2 years); and using thick shaving gel with either a single or twin blade razor, or a chemical depilatory.
Laser hair removal is also an option in the right candidate, particularly with longer pulsed (1,064 nm or 810 nm) lasers in darker-skinned individuals. Eflornithine 12% twice daily for 16 weeks has been shown to work synergistically with laser hair removal. Electrolysis may be helpful for hairs that do not respond to laser hair removal with longer pulsed lasers, such as grey hairs.
If shaving is a must, advise patients to:
• Apply warm compresses to the beard area for a few minutes prior to shaving. In addition, using a mild exfoliant or loofah or toothbrush in a circular motion will help allow any ingrown hairs to be more easily plucked or released at the skin surface.
• Use shaving gel and a sharp razor each time.
• Do not pull the skin taut.
• Do not shave against the direction of hair growth.
• Take short strokes and do not shave back and forth over the same areas.
• After shaving, use a soothing aftershave or hydrocortisone 1% lotion.
Products such as PFB Vanish, which contain salicylic, glycolic, and/or lactic acid, are helpful in some patients after hair removal to prevent ingrown hairs. One version of PFB Vanish contains antipigment ingredients to also address hyperpigmentation.
If inflammatory papules or pustules are present, a combination benzoyl peroxide/clindamycin topical gels (such as Benzaclin, Duac, or Acanya) can be used. Patients with severe inflammation may require oral antibiotics.
Using a topical retinoid at night or a combination retinoid product with hydroquinone can be helpful especially in cases of postinflammatory hyperpigmentation. However, use caution when prescribing retinoids for patients with darker skin, as irritation from these products may lead to postinflammatory pigmentary alteration. Remind patients to avoid drying products, such as toners, if topical retinoids are used.
For severe or refractory postinflammatory hyperpigmentation or inflammatory papules, chemical peels with 20%-30% salicylic acid can be helpful.
What are your PFB solutions? The more we share our clinical insights, the better we will be able to achieve improved treatment results for our patients.
Dr. Wesley practices dermatology in Beverly Hills, Calif. Do you have questions about treating patients with dark skin? If so, send them to [email protected].
Pseudofolliculitis barbae (PFB) is a common complaint among darker-skinned patients with coarse curly hair. Patients present with follicular papules in the beard from ingrown hairs that can eventually result in postinflammatory pigmentary alternation and scarring. While these symptoms are most common in men, women may be affected as well, as PFB is not limited to the beard area; it may occur in any other area with thick, coarse curly hair, including the bikini area and axillae.
Some tips for treating PFB:
If the patient doesn’t mind growing a beard, advise him to grow one! The chances of having ingrown hairs that stimulate this condition are less if the hairs are not plucked or shaved, or are kept at least a few millimeters long.
If hair removal/grooming is a must, options include clipping the hairs with a protector; using a self-cleaning electric razor (replacing the blades at least every 2 years); and using thick shaving gel with either a single or twin blade razor, or a chemical depilatory.
Laser hair removal is also an option in the right candidate, particularly with longer pulsed (1,064 nm or 810 nm) lasers in darker-skinned individuals. Eflornithine 12% twice daily for 16 weeks has been shown to work synergistically with laser hair removal. Electrolysis may be helpful for hairs that do not respond to laser hair removal with longer pulsed lasers, such as grey hairs.
If shaving is a must, advise patients to:
• Apply warm compresses to the beard area for a few minutes prior to shaving. In addition, using a mild exfoliant or loofah or toothbrush in a circular motion will help allow any ingrown hairs to be more easily plucked or released at the skin surface.
• Use shaving gel and a sharp razor each time.
• Do not pull the skin taut.
• Do not shave against the direction of hair growth.
• Take short strokes and do not shave back and forth over the same areas.
• After shaving, use a soothing aftershave or hydrocortisone 1% lotion.
Products such as PFB Vanish, which contain salicylic, glycolic, and/or lactic acid, are helpful in some patients after hair removal to prevent ingrown hairs. One version of PFB Vanish contains antipigment ingredients to also address hyperpigmentation.
If inflammatory papules or pustules are present, a combination benzoyl peroxide/clindamycin topical gels (such as Benzaclin, Duac, or Acanya) can be used. Patients with severe inflammation may require oral antibiotics.
Using a topical retinoid at night or a combination retinoid product with hydroquinone can be helpful especially in cases of postinflammatory hyperpigmentation. However, use caution when prescribing retinoids for patients with darker skin, as irritation from these products may lead to postinflammatory pigmentary alteration. Remind patients to avoid drying products, such as toners, if topical retinoids are used.
For severe or refractory postinflammatory hyperpigmentation or inflammatory papules, chemical peels with 20%-30% salicylic acid can be helpful.
What are your PFB solutions? The more we share our clinical insights, the better we will be able to achieve improved treatment results for our patients.
Dr. Wesley practices dermatology in Beverly Hills, Calif. Do you have questions about treating patients with dark skin? If so, send them to [email protected].
Physician online communities
The doctors’ lounge: A hallowed space for sharing challenging cases and discussing the Affordable Care Act or a place to catch a nap and commiserate? It can (and likely should) be both. Unfortunately, doctors’ lounges are a thing of the past for many of today’s physicians. Whether you’re in private practice or work in a place that simply has no social space for physicians, it can be difficult to connect and share professional and personal information with colleagues.
Technology is offering a solution. In the last few years, physician-only online communities have burgeoned. Sermo, the largest of these communities, boasts more than 125,000 licensed physicians from more than 65 specialties as members. Other big players include Medscape Physician Connect and Doximity. Many smaller specialty-specific communities have surfaced as well, such as OrthoMind.com and MomMD.com, social networks exclusively for orthopedic surgeons and women in medicine (including nurses and residents), respectively.
Unlike open social forums such as Facebook and Twitter, these physician communities are closed social networks, which means that only credentialed members can join and participate. This exclusivity has been a large draw for physicians otherwise skeptical of using social networks. However, it’s worth noting that several sites allow access to other health care providers, including nurses, residents, and medical students.
Ideally, these close social networks exist to help physicians maximize benefits (collaborating and networking) and reduce risks (liability and online reputation). To allay concerns of risk, some sites, including Sermo and Medscape, allow confirmed physicians to choose an alias. On the upside, such anonymous posting allows for franker discussions; on the downside, it can lend itself to unprofessionalism, such as posting inappropriate or incendiary comments.
How many physicians are using these online physician communities? Between 25% and 28%, according to a 2011 study from QuantialMD, and a 2012 study from the Journal of Medical Internet Research. These numbers continue to grow.
If you’ve wondered whether to join a physician-only online community, here are six potential benefits:
• Curbside consults. These communities provide access to thousands of physicians, including specialists, which offers you a tremendous opportunity to get a curbside consult for that difficult patient. Often you can get both diagnostic and treatment suggestions quickly and cost free.
• Current event information. Missed a journal or a conference? These communities are great ways for you to stay informed. You can ask questions or simply follow conversations based on particular topics.
• Help with patient management. We’ve all had to work with difficult patients; the truth is some of us are better at it than others. These communities allow you to ask for advice (anonymously if you’re more comfortable with that) from other professionals who have navigated similar situations successfully and wish to help.
• The ability to share best practice information. Whether it’s a new medication or an office management solution, online communities are rich resources for sharing best practices. Many sites also allow you to poll fellow members, which yields personalized, instantaneous, real feedback.
• The ability to become a thought leader/expert. Whether you’re an established expert in your field or are building your reputation, these communities are effective vehicles for identifying people who stand out from the pack. Establishing yourself as a respected leader in a community can also lead to professional opportunities such as speaking invitations or other leadership roles.
• Networking. Sometimes we physicians forget that it’s beneficial to simply be social. These communities don’t always have to be about improving office efficiency or diagnosing difficult cases; sometimes they can simply be a place to hang out and connect with like-minded people. It’s not uncommon for online relationships to develop into real-life ones, such as connecting at a conference or collaborating on a volunteer project.
Remember, like any worthwhile network, these sites are only as valuable as your participation in them. And before posting questionable material, make sure it’s content that you would be comfortable sharing with a physician in person.
If you belong to a physician-only online community, please share your thoughts with us online, via the Skin & Allergy News Facebook page, or via e-mail ([email protected]). What benefits or drawbacks have you encountered?
The next time you need advice on a challenging case or simply feel like connecting with colleagues, consider joining a physician online community. Just realize that there won’t be any hot coffee and donuts.
Dr. Jeffrey Benabio is a practicing dermatologist and Physician Director of Healthcare Transformation at Kaiser Permanente in San Diego. Connect with him on Twitter @Dermdoc or drop him a line at [email protected].
The doctors’ lounge: A hallowed space for sharing challenging cases and discussing the Affordable Care Act or a place to catch a nap and commiserate? It can (and likely should) be both. Unfortunately, doctors’ lounges are a thing of the past for many of today’s physicians. Whether you’re in private practice or work in a place that simply has no social space for physicians, it can be difficult to connect and share professional and personal information with colleagues.
Technology is offering a solution. In the last few years, physician-only online communities have burgeoned. Sermo, the largest of these communities, boasts more than 125,000 licensed physicians from more than 65 specialties as members. Other big players include Medscape Physician Connect and Doximity. Many smaller specialty-specific communities have surfaced as well, such as OrthoMind.com and MomMD.com, social networks exclusively for orthopedic surgeons and women in medicine (including nurses and residents), respectively.
Unlike open social forums such as Facebook and Twitter, these physician communities are closed social networks, which means that only credentialed members can join and participate. This exclusivity has been a large draw for physicians otherwise skeptical of using social networks. However, it’s worth noting that several sites allow access to other health care providers, including nurses, residents, and medical students.
Ideally, these close social networks exist to help physicians maximize benefits (collaborating and networking) and reduce risks (liability and online reputation). To allay concerns of risk, some sites, including Sermo and Medscape, allow confirmed physicians to choose an alias. On the upside, such anonymous posting allows for franker discussions; on the downside, it can lend itself to unprofessionalism, such as posting inappropriate or incendiary comments.
How many physicians are using these online physician communities? Between 25% and 28%, according to a 2011 study from QuantialMD, and a 2012 study from the Journal of Medical Internet Research. These numbers continue to grow.
If you’ve wondered whether to join a physician-only online community, here are six potential benefits:
• Curbside consults. These communities provide access to thousands of physicians, including specialists, which offers you a tremendous opportunity to get a curbside consult for that difficult patient. Often you can get both diagnostic and treatment suggestions quickly and cost free.
• Current event information. Missed a journal or a conference? These communities are great ways for you to stay informed. You can ask questions or simply follow conversations based on particular topics.
• Help with patient management. We’ve all had to work with difficult patients; the truth is some of us are better at it than others. These communities allow you to ask for advice (anonymously if you’re more comfortable with that) from other professionals who have navigated similar situations successfully and wish to help.
• The ability to share best practice information. Whether it’s a new medication or an office management solution, online communities are rich resources for sharing best practices. Many sites also allow you to poll fellow members, which yields personalized, instantaneous, real feedback.
• The ability to become a thought leader/expert. Whether you’re an established expert in your field or are building your reputation, these communities are effective vehicles for identifying people who stand out from the pack. Establishing yourself as a respected leader in a community can also lead to professional opportunities such as speaking invitations or other leadership roles.
• Networking. Sometimes we physicians forget that it’s beneficial to simply be social. These communities don’t always have to be about improving office efficiency or diagnosing difficult cases; sometimes they can simply be a place to hang out and connect with like-minded people. It’s not uncommon for online relationships to develop into real-life ones, such as connecting at a conference or collaborating on a volunteer project.
Remember, like any worthwhile network, these sites are only as valuable as your participation in them. And before posting questionable material, make sure it’s content that you would be comfortable sharing with a physician in person.
If you belong to a physician-only online community, please share your thoughts with us online, via the Skin & Allergy News Facebook page, or via e-mail ([email protected]). What benefits or drawbacks have you encountered?
The next time you need advice on a challenging case or simply feel like connecting with colleagues, consider joining a physician online community. Just realize that there won’t be any hot coffee and donuts.
Dr. Jeffrey Benabio is a practicing dermatologist and Physician Director of Healthcare Transformation at Kaiser Permanente in San Diego. Connect with him on Twitter @Dermdoc or drop him a line at [email protected].
The doctors’ lounge: A hallowed space for sharing challenging cases and discussing the Affordable Care Act or a place to catch a nap and commiserate? It can (and likely should) be both. Unfortunately, doctors’ lounges are a thing of the past for many of today’s physicians. Whether you’re in private practice or work in a place that simply has no social space for physicians, it can be difficult to connect and share professional and personal information with colleagues.
Technology is offering a solution. In the last few years, physician-only online communities have burgeoned. Sermo, the largest of these communities, boasts more than 125,000 licensed physicians from more than 65 specialties as members. Other big players include Medscape Physician Connect and Doximity. Many smaller specialty-specific communities have surfaced as well, such as OrthoMind.com and MomMD.com, social networks exclusively for orthopedic surgeons and women in medicine (including nurses and residents), respectively.
Unlike open social forums such as Facebook and Twitter, these physician communities are closed social networks, which means that only credentialed members can join and participate. This exclusivity has been a large draw for physicians otherwise skeptical of using social networks. However, it’s worth noting that several sites allow access to other health care providers, including nurses, residents, and medical students.
Ideally, these close social networks exist to help physicians maximize benefits (collaborating and networking) and reduce risks (liability and online reputation). To allay concerns of risk, some sites, including Sermo and Medscape, allow confirmed physicians to choose an alias. On the upside, such anonymous posting allows for franker discussions; on the downside, it can lend itself to unprofessionalism, such as posting inappropriate or incendiary comments.
How many physicians are using these online physician communities? Between 25% and 28%, according to a 2011 study from QuantialMD, and a 2012 study from the Journal of Medical Internet Research. These numbers continue to grow.
If you’ve wondered whether to join a physician-only online community, here are six potential benefits:
• Curbside consults. These communities provide access to thousands of physicians, including specialists, which offers you a tremendous opportunity to get a curbside consult for that difficult patient. Often you can get both diagnostic and treatment suggestions quickly and cost free.
• Current event information. Missed a journal or a conference? These communities are great ways for you to stay informed. You can ask questions or simply follow conversations based on particular topics.
• Help with patient management. We’ve all had to work with difficult patients; the truth is some of us are better at it than others. These communities allow you to ask for advice (anonymously if you’re more comfortable with that) from other professionals who have navigated similar situations successfully and wish to help.
• The ability to share best practice information. Whether it’s a new medication or an office management solution, online communities are rich resources for sharing best practices. Many sites also allow you to poll fellow members, which yields personalized, instantaneous, real feedback.
• The ability to become a thought leader/expert. Whether you’re an established expert in your field or are building your reputation, these communities are effective vehicles for identifying people who stand out from the pack. Establishing yourself as a respected leader in a community can also lead to professional opportunities such as speaking invitations or other leadership roles.
• Networking. Sometimes we physicians forget that it’s beneficial to simply be social. These communities don’t always have to be about improving office efficiency or diagnosing difficult cases; sometimes they can simply be a place to hang out and connect with like-minded people. It’s not uncommon for online relationships to develop into real-life ones, such as connecting at a conference or collaborating on a volunteer project.
Remember, like any worthwhile network, these sites are only as valuable as your participation in them. And before posting questionable material, make sure it’s content that you would be comfortable sharing with a physician in person.
If you belong to a physician-only online community, please share your thoughts with us online, via the Skin & Allergy News Facebook page, or via e-mail ([email protected]). What benefits or drawbacks have you encountered?
The next time you need advice on a challenging case or simply feel like connecting with colleagues, consider joining a physician online community. Just realize that there won’t be any hot coffee and donuts.
Dr. Jeffrey Benabio is a practicing dermatologist and Physician Director of Healthcare Transformation at Kaiser Permanente in San Diego. Connect with him on Twitter @Dermdoc or drop him a line at [email protected].
Review your insurance
Insurance – so goes the hoary cliché – is the one product you buy hoping never to use. While no one enjoys foreseeing unforeseeable calamities, regular meetings with your insurance broker are important. Overinsuring is a waste of money, but underinsuring can prove even more costly, should the unforeseeable happen.
Malpractice premiums continue to rise. If yours are getting out of hand, ask your broker about alternatives.
"Occurrence" policies remain the coverage of choice where they are available and affordable, but they are becoming an endangered species as fewer insurers are willing to write them. "Claims-made" policies are usually cheaper, and provide the same coverage as long as you remain in practice. You will need "tail" coverage against belated claims after you retire, but many companies provide free tail coverage after you’ve been insured for a minimum period (usually 5 years).
Other alternatives are gaining popularity as the demand for more reasonably priced insurance increases. The most common, known as reciprocal exchanges, are very similar to traditional insurers, but differ in certain aspects of funding and operations. For example, most exchanges require policyholders to make capital contributions in addition to payment of premiums, at least in their early stages. You get your investment back, with interest, when (if) the exchange becomes solvent.
Another option, called a captive, is an insurance company formed by several noninsurance entities (such as medical practices) to write their own insurance policies. All participants are shareholders, and all premiums (less administrative expenses) go toward building the security of the captive. Most captives purchase reinsurance to protect against catastrophic losses. If all goes well, individual owners sell their shares at retirement for a nice profit, which has grown tax free in the interim.
Risk Retention Groups (RRGs) are a combination of exchanges and captives, in that capital investments are usually required, and the owners are the insureds themselves; but all responsibility for management and adequate funding falls on the insureds’ shoulders, and reinsurance is rarely an option. Most medical malpractice RRGs are licensed in Vermont or South Carolina, because of favorable laws in those states, but they can be based in any state that allows them.
Exchanges, captives, and RRGs all carry risk: A few large claims can eat up all the profits, and may even put you in a financial hole. But of course, traditional malpractice policies offer zero profit opportunity.
If your financial situation has changed since your last insurance review, your life insurance needs have probably changed, too. As your retirement savings accumulate, less insurance is necessary. And if you own any expensive whole life policies, you can probably convert them to much cheaper term insurance.
Disability insurance is not something to skimp on, but if you are approaching retirement age, you may be able to decrease your coverage, or even eliminate it entirely, if your retirement plan is far enough along.
Liability insurance is likewise no place to pinch pennies, but you might be able to add an umbrella policy providing comprehensive catastrophic coverage, which may allow you to decrease your regular coverage, or raise your deductible limits.
One additional policy to consider is Employment Practices Liability Insurance, which protects you from lawsuits brought by militant or disgruntled employees. More on that next month.
Health insurance premiums continue to soar; Obamacare might offer a favorable alternative for your office policy. Open enrollment began Oct. 1, with coverage scheduled to begin Jan. 1, 2014. If you are considering such an option, go to the Center for Consumer Information and Insurance Oversight and pick a plan for your employees to enroll in.
Workers’ compensation insurance is mandatory in most states, and heavily regulated, so there is little room for cutting expenses. However, some states do not require you, as the employer, to cover yourself, and eliminating that coverage could save you a substantial amount. This is only worth considering, of course, if you have adequate health and disability policies in place.
If you’re over 50 years old, look into long-term care insurance as well. It’s relatively inexpensive if you buy it while you’re still healthy, and it could save you and your heirs a load of money on the other end. If you have shouldered the expense of a chronically ill parent or grandparent, you know what I’m talking about.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J., and has been a long-time monthly columnist for Dermatology News.
Insurance – so goes the hoary cliché – is the one product you buy hoping never to use. While no one enjoys foreseeing unforeseeable calamities, regular meetings with your insurance broker are important. Overinsuring is a waste of money, but underinsuring can prove even more costly, should the unforeseeable happen.
Malpractice premiums continue to rise. If yours are getting out of hand, ask your broker about alternatives.
"Occurrence" policies remain the coverage of choice where they are available and affordable, but they are becoming an endangered species as fewer insurers are willing to write them. "Claims-made" policies are usually cheaper, and provide the same coverage as long as you remain in practice. You will need "tail" coverage against belated claims after you retire, but many companies provide free tail coverage after you’ve been insured for a minimum period (usually 5 years).
Other alternatives are gaining popularity as the demand for more reasonably priced insurance increases. The most common, known as reciprocal exchanges, are very similar to traditional insurers, but differ in certain aspects of funding and operations. For example, most exchanges require policyholders to make capital contributions in addition to payment of premiums, at least in their early stages. You get your investment back, with interest, when (if) the exchange becomes solvent.
Another option, called a captive, is an insurance company formed by several noninsurance entities (such as medical practices) to write their own insurance policies. All participants are shareholders, and all premiums (less administrative expenses) go toward building the security of the captive. Most captives purchase reinsurance to protect against catastrophic losses. If all goes well, individual owners sell their shares at retirement for a nice profit, which has grown tax free in the interim.
Risk Retention Groups (RRGs) are a combination of exchanges and captives, in that capital investments are usually required, and the owners are the insureds themselves; but all responsibility for management and adequate funding falls on the insureds’ shoulders, and reinsurance is rarely an option. Most medical malpractice RRGs are licensed in Vermont or South Carolina, because of favorable laws in those states, but they can be based in any state that allows them.
Exchanges, captives, and RRGs all carry risk: A few large claims can eat up all the profits, and may even put you in a financial hole. But of course, traditional malpractice policies offer zero profit opportunity.
If your financial situation has changed since your last insurance review, your life insurance needs have probably changed, too. As your retirement savings accumulate, less insurance is necessary. And if you own any expensive whole life policies, you can probably convert them to much cheaper term insurance.
Disability insurance is not something to skimp on, but if you are approaching retirement age, you may be able to decrease your coverage, or even eliminate it entirely, if your retirement plan is far enough along.
Liability insurance is likewise no place to pinch pennies, but you might be able to add an umbrella policy providing comprehensive catastrophic coverage, which may allow you to decrease your regular coverage, or raise your deductible limits.
One additional policy to consider is Employment Practices Liability Insurance, which protects you from lawsuits brought by militant or disgruntled employees. More on that next month.
Health insurance premiums continue to soar; Obamacare might offer a favorable alternative for your office policy. Open enrollment began Oct. 1, with coverage scheduled to begin Jan. 1, 2014. If you are considering such an option, go to the Center for Consumer Information and Insurance Oversight and pick a plan for your employees to enroll in.
Workers’ compensation insurance is mandatory in most states, and heavily regulated, so there is little room for cutting expenses. However, some states do not require you, as the employer, to cover yourself, and eliminating that coverage could save you a substantial amount. This is only worth considering, of course, if you have adequate health and disability policies in place.
If you’re over 50 years old, look into long-term care insurance as well. It’s relatively inexpensive if you buy it while you’re still healthy, and it could save you and your heirs a load of money on the other end. If you have shouldered the expense of a chronically ill parent or grandparent, you know what I’m talking about.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J., and has been a long-time monthly columnist for Dermatology News.
Insurance – so goes the hoary cliché – is the one product you buy hoping never to use. While no one enjoys foreseeing unforeseeable calamities, regular meetings with your insurance broker are important. Overinsuring is a waste of money, but underinsuring can prove even more costly, should the unforeseeable happen.
Malpractice premiums continue to rise. If yours are getting out of hand, ask your broker about alternatives.
"Occurrence" policies remain the coverage of choice where they are available and affordable, but they are becoming an endangered species as fewer insurers are willing to write them. "Claims-made" policies are usually cheaper, and provide the same coverage as long as you remain in practice. You will need "tail" coverage against belated claims after you retire, but many companies provide free tail coverage after you’ve been insured for a minimum period (usually 5 years).
Other alternatives are gaining popularity as the demand for more reasonably priced insurance increases. The most common, known as reciprocal exchanges, are very similar to traditional insurers, but differ in certain aspects of funding and operations. For example, most exchanges require policyholders to make capital contributions in addition to payment of premiums, at least in their early stages. You get your investment back, with interest, when (if) the exchange becomes solvent.
Another option, called a captive, is an insurance company formed by several noninsurance entities (such as medical practices) to write their own insurance policies. All participants are shareholders, and all premiums (less administrative expenses) go toward building the security of the captive. Most captives purchase reinsurance to protect against catastrophic losses. If all goes well, individual owners sell their shares at retirement for a nice profit, which has grown tax free in the interim.
Risk Retention Groups (RRGs) are a combination of exchanges and captives, in that capital investments are usually required, and the owners are the insureds themselves; but all responsibility for management and adequate funding falls on the insureds’ shoulders, and reinsurance is rarely an option. Most medical malpractice RRGs are licensed in Vermont or South Carolina, because of favorable laws in those states, but they can be based in any state that allows them.
Exchanges, captives, and RRGs all carry risk: A few large claims can eat up all the profits, and may even put you in a financial hole. But of course, traditional malpractice policies offer zero profit opportunity.
If your financial situation has changed since your last insurance review, your life insurance needs have probably changed, too. As your retirement savings accumulate, less insurance is necessary. And if you own any expensive whole life policies, you can probably convert them to much cheaper term insurance.
Disability insurance is not something to skimp on, but if you are approaching retirement age, you may be able to decrease your coverage, or even eliminate it entirely, if your retirement plan is far enough along.
Liability insurance is likewise no place to pinch pennies, but you might be able to add an umbrella policy providing comprehensive catastrophic coverage, which may allow you to decrease your regular coverage, or raise your deductible limits.
One additional policy to consider is Employment Practices Liability Insurance, which protects you from lawsuits brought by militant or disgruntled employees. More on that next month.
Health insurance premiums continue to soar; Obamacare might offer a favorable alternative for your office policy. Open enrollment began Oct. 1, with coverage scheduled to begin Jan. 1, 2014. If you are considering such an option, go to the Center for Consumer Information and Insurance Oversight and pick a plan for your employees to enroll in.
Workers’ compensation insurance is mandatory in most states, and heavily regulated, so there is little room for cutting expenses. However, some states do not require you, as the employer, to cover yourself, and eliminating that coverage could save you a substantial amount. This is only worth considering, of course, if you have adequate health and disability policies in place.
If you’re over 50 years old, look into long-term care insurance as well. It’s relatively inexpensive if you buy it while you’re still healthy, and it could save you and your heirs a load of money on the other end. If you have shouldered the expense of a chronically ill parent or grandparent, you know what I’m talking about.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J., and has been a long-time monthly columnist for Dermatology News.
In pursuit of happiness (or a life well-lived)
A few weeks ago I had to take some days off work because I was sick. I had just come back from visiting family in Las Vegas and I suspect I caught something from my brother-in-law. The brief vacation, plus sick days and two weekends in between, meant that I did not work for 10 days.
By the end of that period, I was ready to go back to work. It did not matter that I was not 100% better. I was better, and as grateful as I was for the rest, I couldn’t wait to get back.
Now, I often joke about feeling burnt out (and, as I am very fond of saying, jokes are half-meant), so for me to feel that way came as a surprise to me.
First, let me explain why, after only 4 years of full-time practice, I am feeling a bit burnt out. Frustration seems to be an almost daily occurrence now. I get frustrated when there are delays in the treatment I prescribe because of insurance companies. I am frustrated by patients who are habitually late or noncompliant, or worse, drug seeking. I get frustrated when I think my office staff is not doing things efficiently.
I get frustrated when my judgment is questioned not on the basis of its lack of merit, but on the basis of a mistrust of my age, gender, race, and stature. I’ll bet neither one of my bosses gets called "honey" or "little girl," nor, I suspect, are they regularly asked for their age. My guess is that I get more overt signs of disrespect than they do as well. A patient once said that I could not wear heels and not expect people to stare, as if my fashion sense negates my medical degree and training.
I get frustrated when I can’t help patients: When their osteoarthritis is so far advanced that nothing helps; when I’ve tried every single approved biologic but their psoriatic arthritis is not responding; when those with polymyalgia rheumatica can’t get below 9 mg of prednisone; and when they somatize and have hyperbolic symptoms that are wildly disproportionate to the degree of arthritis.
For all the vagaries of our chosen profession, I have more than once wondered at my boss’s resilience and admired his ability to let things slide off his back when I constantly find myself at the brink of collapsing under the weight of the world’s expectations of me, including my expectations of myself. (Who’s being hyperbolic now?)
But when I missed those 10 days of work and was so eager to return, I realized the inescapable reality that, to a degree that I had not previously appreciated, my doctorhood defines me.
Doctoring is a privilege. We would not be here if we didn’t possess the gifts of intellect, talent, industry, and altruism. Because we have those qualities, we are in a unique position to belong to such a noble profession, to belong to the ranks of people making other people better, to stand on the shoulders of the giants who came before us, looking at a horizon that they could not have imagined.
If you consume pop culture like I do, you are familiar with the injunction to "find your happiness," as if happiness is a good that can be acquired. I’ve long struggled with this concept. I’ve wondered what, if anything, I was missing. I wondered if I was being disingenuous by not pursuing an appropriately low-paying-but-oh-so-antiestablishment job that was purportedly my passion (writer, musician, artist, organic farmer?).
But I think I’ve finally figured it out. Happiness is not a good, it is a byproduct of a life well-lived: to make a difference in our patients’ lives, to earn the trust of colleagues whom we respect, and to treat people with kindness and generosity. This is a meaningful life from which happiness derives.
Dr. Chan practices rheumatology in Pawtucket, R.I.
A few weeks ago I had to take some days off work because I was sick. I had just come back from visiting family in Las Vegas and I suspect I caught something from my brother-in-law. The brief vacation, plus sick days and two weekends in between, meant that I did not work for 10 days.
By the end of that period, I was ready to go back to work. It did not matter that I was not 100% better. I was better, and as grateful as I was for the rest, I couldn’t wait to get back.
Now, I often joke about feeling burnt out (and, as I am very fond of saying, jokes are half-meant), so for me to feel that way came as a surprise to me.
First, let me explain why, after only 4 years of full-time practice, I am feeling a bit burnt out. Frustration seems to be an almost daily occurrence now. I get frustrated when there are delays in the treatment I prescribe because of insurance companies. I am frustrated by patients who are habitually late or noncompliant, or worse, drug seeking. I get frustrated when I think my office staff is not doing things efficiently.
I get frustrated when my judgment is questioned not on the basis of its lack of merit, but on the basis of a mistrust of my age, gender, race, and stature. I’ll bet neither one of my bosses gets called "honey" or "little girl," nor, I suspect, are they regularly asked for their age. My guess is that I get more overt signs of disrespect than they do as well. A patient once said that I could not wear heels and not expect people to stare, as if my fashion sense negates my medical degree and training.
I get frustrated when I can’t help patients: When their osteoarthritis is so far advanced that nothing helps; when I’ve tried every single approved biologic but their psoriatic arthritis is not responding; when those with polymyalgia rheumatica can’t get below 9 mg of prednisone; and when they somatize and have hyperbolic symptoms that are wildly disproportionate to the degree of arthritis.
For all the vagaries of our chosen profession, I have more than once wondered at my boss’s resilience and admired his ability to let things slide off his back when I constantly find myself at the brink of collapsing under the weight of the world’s expectations of me, including my expectations of myself. (Who’s being hyperbolic now?)
But when I missed those 10 days of work and was so eager to return, I realized the inescapable reality that, to a degree that I had not previously appreciated, my doctorhood defines me.
Doctoring is a privilege. We would not be here if we didn’t possess the gifts of intellect, talent, industry, and altruism. Because we have those qualities, we are in a unique position to belong to such a noble profession, to belong to the ranks of people making other people better, to stand on the shoulders of the giants who came before us, looking at a horizon that they could not have imagined.
If you consume pop culture like I do, you are familiar with the injunction to "find your happiness," as if happiness is a good that can be acquired. I’ve long struggled with this concept. I’ve wondered what, if anything, I was missing. I wondered if I was being disingenuous by not pursuing an appropriately low-paying-but-oh-so-antiestablishment job that was purportedly my passion (writer, musician, artist, organic farmer?).
But I think I’ve finally figured it out. Happiness is not a good, it is a byproduct of a life well-lived: to make a difference in our patients’ lives, to earn the trust of colleagues whom we respect, and to treat people with kindness and generosity. This is a meaningful life from which happiness derives.
Dr. Chan practices rheumatology in Pawtucket, R.I.
A few weeks ago I had to take some days off work because I was sick. I had just come back from visiting family in Las Vegas and I suspect I caught something from my brother-in-law. The brief vacation, plus sick days and two weekends in between, meant that I did not work for 10 days.
By the end of that period, I was ready to go back to work. It did not matter that I was not 100% better. I was better, and as grateful as I was for the rest, I couldn’t wait to get back.
Now, I often joke about feeling burnt out (and, as I am very fond of saying, jokes are half-meant), so for me to feel that way came as a surprise to me.
First, let me explain why, after only 4 years of full-time practice, I am feeling a bit burnt out. Frustration seems to be an almost daily occurrence now. I get frustrated when there are delays in the treatment I prescribe because of insurance companies. I am frustrated by patients who are habitually late or noncompliant, or worse, drug seeking. I get frustrated when I think my office staff is not doing things efficiently.
I get frustrated when my judgment is questioned not on the basis of its lack of merit, but on the basis of a mistrust of my age, gender, race, and stature. I’ll bet neither one of my bosses gets called "honey" or "little girl," nor, I suspect, are they regularly asked for their age. My guess is that I get more overt signs of disrespect than they do as well. A patient once said that I could not wear heels and not expect people to stare, as if my fashion sense negates my medical degree and training.
I get frustrated when I can’t help patients: When their osteoarthritis is so far advanced that nothing helps; when I’ve tried every single approved biologic but their psoriatic arthritis is not responding; when those with polymyalgia rheumatica can’t get below 9 mg of prednisone; and when they somatize and have hyperbolic symptoms that are wildly disproportionate to the degree of arthritis.
For all the vagaries of our chosen profession, I have more than once wondered at my boss’s resilience and admired his ability to let things slide off his back when I constantly find myself at the brink of collapsing under the weight of the world’s expectations of me, including my expectations of myself. (Who’s being hyperbolic now?)
But when I missed those 10 days of work and was so eager to return, I realized the inescapable reality that, to a degree that I had not previously appreciated, my doctorhood defines me.
Doctoring is a privilege. We would not be here if we didn’t possess the gifts of intellect, talent, industry, and altruism. Because we have those qualities, we are in a unique position to belong to such a noble profession, to belong to the ranks of people making other people better, to stand on the shoulders of the giants who came before us, looking at a horizon that they could not have imagined.
If you consume pop culture like I do, you are familiar with the injunction to "find your happiness," as if happiness is a good that can be acquired. I’ve long struggled with this concept. I’ve wondered what, if anything, I was missing. I wondered if I was being disingenuous by not pursuing an appropriately low-paying-but-oh-so-antiestablishment job that was purportedly my passion (writer, musician, artist, organic farmer?).
But I think I’ve finally figured it out. Happiness is not a good, it is a byproduct of a life well-lived: to make a difference in our patients’ lives, to earn the trust of colleagues whom we respect, and to treat people with kindness and generosity. This is a meaningful life from which happiness derives.
Dr. Chan practices rheumatology in Pawtucket, R.I.
Improving Patient Outcomes through Advanced Pain Management Techniques
Mentoring at a Community Hospital
The literature focusing on physician mentoring is limited principally to programs at academic medical centers.[1, 2, 3, 4, 5] Traditionally, physicians at academic medical centers who are engaged in research have one or more such advisors. However, many clinical faculties are not engaged in research. Further, little has been written about mentoring initiatives among physicians in full‐time clinical practice.[6] Such initiatives have been suggested as one way of reducing physician stress and improving professional satisfaction, issues of great concern among practicing physicians, particularly hospitalists and primary care physicians.[7]
A mentoring program was initiated at the Western Connecticut Health Network (WCHN) in January 2012. WCHN is a healthcare system comprised of the Danbury and New Milford Hospitals, with 371 licensed beds and a network of salaried primary care and specialty physicians. At Danbury, residency programs are in place in all specialties, and medical students from the University of Vermont rotate through the major clinical specialties.
This article describes the mentoring program at WCHN and gives a preliminary assessment of its value based on a survey of the participants after the first year of the program.
PROGRAM DESCRIPTION
Although the mentoring program was offered to all physicians of the WCHN, the principal groups of interest were the salaried primary care physicians (n=46) and the hospitalists (n=24). The program is a formal system of mentorship and career support, whose goal is to maximize the potential and career satisfaction of each member of the medical staff.
Eight senior physicians from the Departments of Medicine and Surgery served as mentors in their free time. They were selected based on their high regard as members of the medical staff who reflected the attributes of satisfactory mentorsgood listeners who are supportive, nonjudgmental, practical, and enthusiastic.[8] They received informal training through meetings with the program consultant (corresponding author) who had previously established mentoring programs at Massachusetts General Hospital, Boston, Massachusetts and the University of Rochester Medical Center, Rochester, New York.
Mentees were principally hospitalists and primary care physicians in full‐time clinical practice. Practice experiences varied from 2 or 3 to 20 years or more. All hospitalists and some primary care physicians were engaged in teaching residents and/or medical students. Mentees were asked to complete a 1‐page form indicating their goals for the coming year, what issues they would like to discuss with a mentor, and which mentor they wish to meet with. The sessions were scheduled during free time of both mentor and mentee, held in a quiet setting, were confidential, and lasted an hour or more. At the end of each session, mentee and mentor agreed on what was discussed and what next steps each had responsibility for. The mentor subsequently wrote up a summary of the meeting and reviewed it with the mentee for accuracy. Ongoing contacts were in person, phone, or e‐mail initiated either by the mentor or the mentee. Examples of next steps included helping a mentee obtain further training, observe and comment on the mentee's teaching skills, sponsor the mentee for advancement to fellowship in his/her specialty society, or assist the mentee in the preparation of an article for publication. Frequency of meetings varied from a single session on a self‐limited issue to multiple sessions throughout the year.
At the end of the first year of the program, the participants were surveyed by e‐mail about their perceptions of the program. The survey was a structured instrument asking them to indicate what the principal issue or issues were that led them to seek a mentor, whether they felt the mentoring program had been helpful, if so in what way, and if not why not.
SURVEY RESULTS
Twenty‐seven of the 39 participants responded to the survey (69%). Hospitalists were the most likely to participate in the mentoring program (18 of 24) and to respond to the survey. Career planning (52%), balance among personal and professional life (43%), and leadership development (38%) were the most common reasons given for meeting with a mentor. Twenty percent of mentees had no agenda. They simply wanted to talk. Fifteen percent had a specific project in mind about which they needed advice and counsel. All but one survey respondent felt the mentoring program met their expectations by setting goals (62%), planning next steps in their career (60%), gaining new insights (52%), completing a long‐deferred goal (30%), reducing stress (19%), and improving self‐confidence (19%).
Without exception, mentees indicated that their mentors met the criteria used to define a good mentor.[8]
DISCUSSION
One marker of the program's success is that all but 1 of the respondents felt the mentoring sessions met their expectations. Planning next career steps was a principle interest among the hospitalist group. This is not surprising given that many hospitalists are recent graduates of training programs, and their long‐term career plans may not be well defined. The mentoring program helped 3 hospitalists obtain fellowship training. About 1 in 5 mentees indicated that a reduction in stress was an outcome of their mentoring sessions. Recent studies of physician burnout have shown that physicians of first contact are at greatest risk of burnout.[9] Two‐thirds of the physicians participating in the mentoring program fell into this category. In a recent survey of physicians from all specialties across the country, mentoring was suggested as 1 of a number of strategies that organizations could provide to reduce stress and burnout.[7]
Important lessons learned over the first year of the program were that (1) mentees should have protected time to participate; (2) mentor and mentee should be in touch no less often than every 3 to 6 months, even if there is not an ongoing issue they are working on; and (3) substantive improvements in the program resulted from frequent (eg, every 2 months) meetings of the mentors.
In conclusion, although the survey sample in our study was small, the findings suggest directions and strategies for similar hospitals and health systems. Health systems that seek to improve the professional satisfaction of their physicians should be interested in this description of the physician mentoring program at the WCHN and its perceived value by the participants.
Disclosures
Disclosures: Dr. Griner received a consulting fee from the Western Connecticut Health System for his role in developing the mentoring program and participating in the writing of the article. The authors report no conflicts of interest.
- . . . . Support‐challenge‐vision: a model for faculty mentoring. Med Teach. 1998;20:595–597.
- , , , . A descriptive cross‐sectional study of formal mentoring for faculty. Fam Med. 1996;28:434–438.
- Advisor, teacher, role model, friend: on being a mentor to students in science and engineering. Washington, DC: National Academy Press; 1997. Available at: http://www.nap.edu/readingroom/books/mentor. Accessed 5/13/2013.
- , , , . Helping medical school faculty realize their dreams: an innovative, collaborative, mentoring program. Acad Med. 2002;77:377–384.
- , , , . A needs assessment of medical school faculty: caring for the caretakers. J Contin Educ Health Prof. 2003;23:21–29.
- , . Personal and rofessional learning plans—an evaluation of mentoring in general practice. Educ Gen Pract. 1998;9:261–263.
- . Burnout in health care providers. Integr Med. 2013;12:22–24.
- , , . Defining the ideal qualities of mentorship. Am J Med. 2011;124:453–458.
- , , , et al. Burnout and satisfaction with work‐life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377–1385.
The literature focusing on physician mentoring is limited principally to programs at academic medical centers.[1, 2, 3, 4, 5] Traditionally, physicians at academic medical centers who are engaged in research have one or more such advisors. However, many clinical faculties are not engaged in research. Further, little has been written about mentoring initiatives among physicians in full‐time clinical practice.[6] Such initiatives have been suggested as one way of reducing physician stress and improving professional satisfaction, issues of great concern among practicing physicians, particularly hospitalists and primary care physicians.[7]
A mentoring program was initiated at the Western Connecticut Health Network (WCHN) in January 2012. WCHN is a healthcare system comprised of the Danbury and New Milford Hospitals, with 371 licensed beds and a network of salaried primary care and specialty physicians. At Danbury, residency programs are in place in all specialties, and medical students from the University of Vermont rotate through the major clinical specialties.
This article describes the mentoring program at WCHN and gives a preliminary assessment of its value based on a survey of the participants after the first year of the program.
PROGRAM DESCRIPTION
Although the mentoring program was offered to all physicians of the WCHN, the principal groups of interest were the salaried primary care physicians (n=46) and the hospitalists (n=24). The program is a formal system of mentorship and career support, whose goal is to maximize the potential and career satisfaction of each member of the medical staff.
Eight senior physicians from the Departments of Medicine and Surgery served as mentors in their free time. They were selected based on their high regard as members of the medical staff who reflected the attributes of satisfactory mentorsgood listeners who are supportive, nonjudgmental, practical, and enthusiastic.[8] They received informal training through meetings with the program consultant (corresponding author) who had previously established mentoring programs at Massachusetts General Hospital, Boston, Massachusetts and the University of Rochester Medical Center, Rochester, New York.
Mentees were principally hospitalists and primary care physicians in full‐time clinical practice. Practice experiences varied from 2 or 3 to 20 years or more. All hospitalists and some primary care physicians were engaged in teaching residents and/or medical students. Mentees were asked to complete a 1‐page form indicating their goals for the coming year, what issues they would like to discuss with a mentor, and which mentor they wish to meet with. The sessions were scheduled during free time of both mentor and mentee, held in a quiet setting, were confidential, and lasted an hour or more. At the end of each session, mentee and mentor agreed on what was discussed and what next steps each had responsibility for. The mentor subsequently wrote up a summary of the meeting and reviewed it with the mentee for accuracy. Ongoing contacts were in person, phone, or e‐mail initiated either by the mentor or the mentee. Examples of next steps included helping a mentee obtain further training, observe and comment on the mentee's teaching skills, sponsor the mentee for advancement to fellowship in his/her specialty society, or assist the mentee in the preparation of an article for publication. Frequency of meetings varied from a single session on a self‐limited issue to multiple sessions throughout the year.
At the end of the first year of the program, the participants were surveyed by e‐mail about their perceptions of the program. The survey was a structured instrument asking them to indicate what the principal issue or issues were that led them to seek a mentor, whether they felt the mentoring program had been helpful, if so in what way, and if not why not.
SURVEY RESULTS
Twenty‐seven of the 39 participants responded to the survey (69%). Hospitalists were the most likely to participate in the mentoring program (18 of 24) and to respond to the survey. Career planning (52%), balance among personal and professional life (43%), and leadership development (38%) were the most common reasons given for meeting with a mentor. Twenty percent of mentees had no agenda. They simply wanted to talk. Fifteen percent had a specific project in mind about which they needed advice and counsel. All but one survey respondent felt the mentoring program met their expectations by setting goals (62%), planning next steps in their career (60%), gaining new insights (52%), completing a long‐deferred goal (30%), reducing stress (19%), and improving self‐confidence (19%).
Without exception, mentees indicated that their mentors met the criteria used to define a good mentor.[8]
DISCUSSION
One marker of the program's success is that all but 1 of the respondents felt the mentoring sessions met their expectations. Planning next career steps was a principle interest among the hospitalist group. This is not surprising given that many hospitalists are recent graduates of training programs, and their long‐term career plans may not be well defined. The mentoring program helped 3 hospitalists obtain fellowship training. About 1 in 5 mentees indicated that a reduction in stress was an outcome of their mentoring sessions. Recent studies of physician burnout have shown that physicians of first contact are at greatest risk of burnout.[9] Two‐thirds of the physicians participating in the mentoring program fell into this category. In a recent survey of physicians from all specialties across the country, mentoring was suggested as 1 of a number of strategies that organizations could provide to reduce stress and burnout.[7]
Important lessons learned over the first year of the program were that (1) mentees should have protected time to participate; (2) mentor and mentee should be in touch no less often than every 3 to 6 months, even if there is not an ongoing issue they are working on; and (3) substantive improvements in the program resulted from frequent (eg, every 2 months) meetings of the mentors.
In conclusion, although the survey sample in our study was small, the findings suggest directions and strategies for similar hospitals and health systems. Health systems that seek to improve the professional satisfaction of their physicians should be interested in this description of the physician mentoring program at the WCHN and its perceived value by the participants.
Disclosures
Disclosures: Dr. Griner received a consulting fee from the Western Connecticut Health System for his role in developing the mentoring program and participating in the writing of the article. The authors report no conflicts of interest.
The literature focusing on physician mentoring is limited principally to programs at academic medical centers.[1, 2, 3, 4, 5] Traditionally, physicians at academic medical centers who are engaged in research have one or more such advisors. However, many clinical faculties are not engaged in research. Further, little has been written about mentoring initiatives among physicians in full‐time clinical practice.[6] Such initiatives have been suggested as one way of reducing physician stress and improving professional satisfaction, issues of great concern among practicing physicians, particularly hospitalists and primary care physicians.[7]
A mentoring program was initiated at the Western Connecticut Health Network (WCHN) in January 2012. WCHN is a healthcare system comprised of the Danbury and New Milford Hospitals, with 371 licensed beds and a network of salaried primary care and specialty physicians. At Danbury, residency programs are in place in all specialties, and medical students from the University of Vermont rotate through the major clinical specialties.
This article describes the mentoring program at WCHN and gives a preliminary assessment of its value based on a survey of the participants after the first year of the program.
PROGRAM DESCRIPTION
Although the mentoring program was offered to all physicians of the WCHN, the principal groups of interest were the salaried primary care physicians (n=46) and the hospitalists (n=24). The program is a formal system of mentorship and career support, whose goal is to maximize the potential and career satisfaction of each member of the medical staff.
Eight senior physicians from the Departments of Medicine and Surgery served as mentors in their free time. They were selected based on their high regard as members of the medical staff who reflected the attributes of satisfactory mentorsgood listeners who are supportive, nonjudgmental, practical, and enthusiastic.[8] They received informal training through meetings with the program consultant (corresponding author) who had previously established mentoring programs at Massachusetts General Hospital, Boston, Massachusetts and the University of Rochester Medical Center, Rochester, New York.
Mentees were principally hospitalists and primary care physicians in full‐time clinical practice. Practice experiences varied from 2 or 3 to 20 years or more. All hospitalists and some primary care physicians were engaged in teaching residents and/or medical students. Mentees were asked to complete a 1‐page form indicating their goals for the coming year, what issues they would like to discuss with a mentor, and which mentor they wish to meet with. The sessions were scheduled during free time of both mentor and mentee, held in a quiet setting, were confidential, and lasted an hour or more. At the end of each session, mentee and mentor agreed on what was discussed and what next steps each had responsibility for. The mentor subsequently wrote up a summary of the meeting and reviewed it with the mentee for accuracy. Ongoing contacts were in person, phone, or e‐mail initiated either by the mentor or the mentee. Examples of next steps included helping a mentee obtain further training, observe and comment on the mentee's teaching skills, sponsor the mentee for advancement to fellowship in his/her specialty society, or assist the mentee in the preparation of an article for publication. Frequency of meetings varied from a single session on a self‐limited issue to multiple sessions throughout the year.
At the end of the first year of the program, the participants were surveyed by e‐mail about their perceptions of the program. The survey was a structured instrument asking them to indicate what the principal issue or issues were that led them to seek a mentor, whether they felt the mentoring program had been helpful, if so in what way, and if not why not.
SURVEY RESULTS
Twenty‐seven of the 39 participants responded to the survey (69%). Hospitalists were the most likely to participate in the mentoring program (18 of 24) and to respond to the survey. Career planning (52%), balance among personal and professional life (43%), and leadership development (38%) were the most common reasons given for meeting with a mentor. Twenty percent of mentees had no agenda. They simply wanted to talk. Fifteen percent had a specific project in mind about which they needed advice and counsel. All but one survey respondent felt the mentoring program met their expectations by setting goals (62%), planning next steps in their career (60%), gaining new insights (52%), completing a long‐deferred goal (30%), reducing stress (19%), and improving self‐confidence (19%).
Without exception, mentees indicated that their mentors met the criteria used to define a good mentor.[8]
DISCUSSION
One marker of the program's success is that all but 1 of the respondents felt the mentoring sessions met their expectations. Planning next career steps was a principle interest among the hospitalist group. This is not surprising given that many hospitalists are recent graduates of training programs, and their long‐term career plans may not be well defined. The mentoring program helped 3 hospitalists obtain fellowship training. About 1 in 5 mentees indicated that a reduction in stress was an outcome of their mentoring sessions. Recent studies of physician burnout have shown that physicians of first contact are at greatest risk of burnout.[9] Two‐thirds of the physicians participating in the mentoring program fell into this category. In a recent survey of physicians from all specialties across the country, mentoring was suggested as 1 of a number of strategies that organizations could provide to reduce stress and burnout.[7]
Important lessons learned over the first year of the program were that (1) mentees should have protected time to participate; (2) mentor and mentee should be in touch no less often than every 3 to 6 months, even if there is not an ongoing issue they are working on; and (3) substantive improvements in the program resulted from frequent (eg, every 2 months) meetings of the mentors.
In conclusion, although the survey sample in our study was small, the findings suggest directions and strategies for similar hospitals and health systems. Health systems that seek to improve the professional satisfaction of their physicians should be interested in this description of the physician mentoring program at the WCHN and its perceived value by the participants.
Disclosures
Disclosures: Dr. Griner received a consulting fee from the Western Connecticut Health System for his role in developing the mentoring program and participating in the writing of the article. The authors report no conflicts of interest.
- . . . . Support‐challenge‐vision: a model for faculty mentoring. Med Teach. 1998;20:595–597.
- , , , . A descriptive cross‐sectional study of formal mentoring for faculty. Fam Med. 1996;28:434–438.
- Advisor, teacher, role model, friend: on being a mentor to students in science and engineering. Washington, DC: National Academy Press; 1997. Available at: http://www.nap.edu/readingroom/books/mentor. Accessed 5/13/2013.
- , , , . Helping medical school faculty realize their dreams: an innovative, collaborative, mentoring program. Acad Med. 2002;77:377–384.
- , , , . A needs assessment of medical school faculty: caring for the caretakers. J Contin Educ Health Prof. 2003;23:21–29.
- , . Personal and rofessional learning plans—an evaluation of mentoring in general practice. Educ Gen Pract. 1998;9:261–263.
- . Burnout in health care providers. Integr Med. 2013;12:22–24.
- , , . Defining the ideal qualities of mentorship. Am J Med. 2011;124:453–458.
- , , , et al. Burnout and satisfaction with work‐life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377–1385.
- . . . . Support‐challenge‐vision: a model for faculty mentoring. Med Teach. 1998;20:595–597.
- , , , . A descriptive cross‐sectional study of formal mentoring for faculty. Fam Med. 1996;28:434–438.
- Advisor, teacher, role model, friend: on being a mentor to students in science and engineering. Washington, DC: National Academy Press; 1997. Available at: http://www.nap.edu/readingroom/books/mentor. Accessed 5/13/2013.
- , , , . Helping medical school faculty realize their dreams: an innovative, collaborative, mentoring program. Acad Med. 2002;77:377–384.
- , , , . A needs assessment of medical school faculty: caring for the caretakers. J Contin Educ Health Prof. 2003;23:21–29.
- , . Personal and rofessional learning plans—an evaluation of mentoring in general practice. Educ Gen Pract. 1998;9:261–263.
- . Burnout in health care providers. Integr Med. 2013;12:22–24.
- , , . Defining the ideal qualities of mentorship. Am J Med. 2011;124:453–458.
- , , , et al. Burnout and satisfaction with work‐life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377–1385.
Hospitalist Sign‐out
Hospital medicine is a main component of healthcare in the United States and is growing.[1] In 1995, 9% of inpatient care performed by general internists to Medicare patients was provided by hospitalists; by 2006, this had increased to 37%.[2] The estimated 30,000 practicing hospitalists account for 19% of all practicing general internists[2, 3, 4] and have had a major impact on the treatment of inpatients at US hospitals.[5] Other specialties are adopting the hospital‐based physician model.[6, 7] The hospitalist model does have unique challenges. One notable aspect of hospitalist care, which is frequently shift based, is the transfer of care among providers at shift change.
The Society of Hospital Medicine recognizes patient handoffs/sign‐outs as a core competency for hospitalists,[8] but there is little literature evaluating hospitalist sign‐out quality.[9] A systematic review in 2009 found no studies of hospitalist handoffs.[8] Furthermore, early work suggests that hospitalist handoffs are not consistently effective.[10] In a recent survey, 13% of hospitalists reported they had received an incomplete handoff, and 16% of hospitalists reported at least 1 near‐miss attributed to incomplete communication.[11] Last, hospitalists perform no better than housestaff on evaluations of sign‐out quality.[12]
Cross‐coverage situations, in which sign‐out is key, have been shown to place patients at risk.[13, 14] One study showed 7.1 problems related to sign‐out per 100 patient‐days.[15] Failure during sign‐out can ultimately threaten patient safety.[16] Therefore, evaluating the quality of hospitalist sign‐outs by assessing how well the sign‐out prepares the night team for overnight events is necessary to improve hospitalist sign‐outs and ultimately increase patient safety.
METHODS
Study Setting
The study took place at YaleNew Haven Hospital (YNHH), the primary teaching affiliate for the Yale School of Medicine, in New Haven, Connecticut. YNHH is a 966‐bed, urban, academic medical center. The Hospitalist Service is a nonteaching service composed of 56.1 full‐time‐equivalent (FTE) attending physicians and 26.8 FTE midlevel providers. In fiscal year 2012, the YNHH Hospitalist Service cared for 13,764 discharges, or approximately 70% of general medical discharges. Similar patients are cared for by both hospitalists and housestaff. Patients on the hospitalist service are assigned an attending physician as well as a midlevel provider during the daytime. Between the departure of the day team and the arrival of the night team, typically a 2‐hour window, a skeleton crew covers the entire service and admits patients. The same skeleton crew coverage plan exists in the approximately 2.5‐hour morning gap between the departure of the night team and arrival of the day team. Overnight, care is generally provided by attending hospitalist physicians alone. Clinical fellows and internal medicine residents occasionally fill the night hospitalist role.
Sign‐out Procedure
The YNHH Hospitalist Service uses a written sign‐out[17] created via template built into the electronic health record (EHR), Sunrise Clinical Manager (version 5.5; Allscripts, Chicago, IL) and is the major mechanism for shift‐to‐shift information transfer. A free text summary of the patient's medical course and condition is created by the provider preparing the sign‐out, as is a separate list of to do items. The free text box is titled History (general hospital course, new events of the day, overall clinical condition). A representative narrative example is, 87 y/o gentleman PMHx AF on coumadin, diastolic CHF (EF 40%), NIDDM2, first degree AV block, GIB in setting of supratherapeutic INR, depression, COPD p/w worsening low back pain in setting of L1 compression frx of? age. HD stable. An option exists to include a medication list pulled from the active orders in the EHR when the sign‐out report is printed. The sign‐out is typically created by the hospitalist attending on the day of admission and then updated daily by the mid‐level provider under the supervision of the attending physician, in accordance with internal standards set by the service. Formal sign‐out training is included as part of orientation for new hires, and ongoing sign‐out education is provided, as needed, by a physician assistant charged with continuous quality improvement for the entire service. The service maintains an expectation for the entire team to provide accurate and updated sign‐out at every shift change. Attending hospitalists or mid‐level providers update the sign‐out on weekends. Because the day team has generally left the hospital prior to the arrival of the night team, verbal sign‐out occurs rarely. Should a verbal sign‐out be given to the night team, it will be provided by the daytime team directly to the night team either via telephone or the day team member staying in the hospital until arrival of the night team.
Participants
All full‐time and regularly scheduled part‐time attending physicians on the YNHH hospitalist night team were eligible to participate. We excluded temporary physicians on service, including clinical fellows and resident moonlighters. Hospitalists could not participate more than once. Written informed consent was obtained of all hospitalists at the start of their shift.
Data Collection
Hospitalists who consented were provided a single pocket card during their shift. For every inquiry that involved a patient that the hospitalist was covering, the hospitalist recorded who originated the inquiry, the clinical significance, the sufficiency of written sign‐out, which information was used other than the written sign‐out, and information regarding the anticipation of the event by the daytime team (Figure 1).
Data were collected on 6 days and distributed from April 30, 2012 through June 12, 2012. Dates were chosen based on staffing to maximize the number of eligible physicians each night and included both weekdays and weekend days. The written sign‐out for the entire service was printed for each night data collection took place.
Main Predictors
Our main predictor variables were characteristics of the inquiry (topic area, clinical importance of the inquiry as assessed by the hospitalist), characteristics of the patient (days since admission), and characteristics of the written sign‐out (whether it included any anticipatory guidance and a composite quality score). We identified elements of the composite quality score based on prior research and expert recommendations.[8, 18, 19, 20] To create the composite quality score, we gave 1 point for each of the following elements: diagnosis or presenting symptoms, general hospital course (a description of any event occurring during hospitalization but prior to date of data collection), current clinical condition (a description of objective data, symptoms, or stability/trajectory in the last 24 hours), and whether the sign‐out had been updated within the last 24 hours. The composite score could range from 0 to 4.
Main Outcome Measures
Our primary outcome measure was the quality and utility of the written‐only sign‐out as defined via a subjective assessment of sufficiency by the covering physician (ie, whether the written sign‐out was adequate to answer the query without seeking any supplemental information). For this outcome, we excluded inquiries for which hospitalists had determined a sign‐out was not necessary to address the inquiry or event.
Statistical Analysis
Data analysis was conducted using SAS 9.2 (SAS Institute, Cary, NC). We used a cutoff of P<0.05 for statistical significance; all tests were 2‐tailed. We assessed characteristics of overnight inquiries using descriptive statistics and determined the association of the main predictors with sufficient sign‐out using 2 tests. We constructed a multivariate logistic regression model using a priori‐determined clinically relevant predictors to test predictors of sign‐out sufficiency. The study was approved by the Human Investigation Committee of Yale University.
RESULTS
Hospitalists recorded 124 inquiries about 96 patients. Altogether, 15 of 19 (79%) eligible hospitalists returned surveys. Of the 96 patients, we obtained the written sign‐out for 68 (71%). The remainder were new patients for whom the sign‐out had not yet been prepared, or patients who had not yet been assigned to the hospitalist service at the time the sign‐out report was printed.
Hospitalists referenced the sign‐out for 89 (74%) inquiries, and the sign‐out was considered sufficient to respond to 27 (30%) of these inquiries (ie, the sign‐out was adequate to answer the inquiry without any supplemental information). Hospitalists physically saw the patient for 14 (12%) inquiries. Nurses were the originator for most inquiries (102 [82%]). The most common inquiry topics were medications (55 [45%]), plan of care (26 [21%]) and clinical changes (26 [21%]). Ninety‐five (77%) inquiries were considered to be somewhat or very clinically important by the hospitalist (Table 1).
| Inquiry originator, No. (% of 124) | |
| Nurse | 102 (82) |
| Patient | 13 (10) |
| Consultant | 6 (5) |
| Respiratory therapy | 3 (2) |
| Inquiry subject, No. (% of 122) | |
| Medication | 55 (45) |
| Plan of care | 26 (21) |
| Clinical change | 26 (21) |
| Order reconciliation | 15 (12) |
| Missing | 2 |
| Clinical importance of inquiry, No. (% of 123) | |
| Very | 33 (27) |
| Somewhat | 62 (50) |
| Not at all | 28 (23) |
| Missing | 1 |
| Sufficiency of sign‐out alone in answering inquiry, No. (% of 121) | |
| Yes | 27 (22) |
| No | 62 (51) |
| Sign‐out not necessary for inquiry | 32 (26) |
| Missing | 3 |
| Days since admission, No. (% of 124) | |
| Less than 2 | 69 (44.4) |
| 2 or more | 55 (55.6) |
| Reference(s) used when sign‐out insufficient, No. (% of 62) | |
| Physician notes | 37 (60) |
| Nurse | 11 (18) |
| Labs/studies | 10 (16) |
| Orders | 9 (15) |
| Patient | 7 (11) |
| Other | 7 (11) |
| Was the event predicted by the primary team? No. (% of 119) | |
| Yes | 17 (14) |
| No | 102 (86) |
| Missing | 5 |
| If no, could this event have been predicted, No. (% of 102) | |
| Yes | 47 (46) |
| No | 55 (54) |
| Of all events that could have been predicted, how many were predicted? No. (% of 64) | |
| Predicted | 17 (27) |
| Not predicted | 47 (73) |
| Did you physically see the patient? No. (% of 117) | |
| Yes | 14 (12) |
| No | 103 (88) |
| Missing | 7 |
| Composite score, No. (% of 68) | |
| 0 or 1 | 0 (0) |
| 2 | 3 (4) |
| 3 | 31 (46) |
| 4 | 34 (50) |
| Anticipatory guidance/to‐do tasks, No. (% of 96) | |
| 0 | 69(72) |
| 1 | 21 (22) |
| 2 or more | 6 (6) |
No written sign‐outs had a composite score of 0 or 1; 3 (4%) had a composite score of 2; 31 (46%) had a composite score of 3; and 34 (50%) had a composite score of 4. Seventy‐two percent of written sign‐outs included neither anticipatory guidance nor tasks, 21% had 1 anticipatory guidance item or task, and 6% had 2 or more anticipatory guidance items and/or tasks.
The primary team caring for a patient did not predict 102 (86%) inquiries, and hospitalists rated 47 (46%) of those unpredicted events as possible for the primary team to predict. Five responses to this question were incomplete and excluded. Of the 64 events predicted by the primary team or rated as predictable by the night hospitalists, 17 (27%) were predicted by the primary team (Table 1).
Sign‐out was considered sufficient in isolation to answer the majority of order reconciliation inquiries (5 [71%]), but was less effective at helping to answer inquiries about clinical change (7 [29%]), medications (10 [28%]), and plan of care (5 [24%]) (P=0.001). (Table 2) Ninety‐five events were rated as either very or somewhat clinically important, but this did not affect the likelihood of sign‐out being sufficient in isolation relative to the not at all clinically important group. Specifically, 33% of sign‐outs were rated sufficient in the very important group, 19% in the somewhat important group, and 50% in the not at all group (P=0.059).
| Predictor | Number of inquiries (%) for which sign‐out was sufficient in isolationb | p value | |
|---|---|---|---|
| |||
| Question topic | 0.001 | ||
| Order reconciliation (oxygen/telemetry) | 5/7 (71) | ||
| Clinical change (vitals, symptoms, labs) | 7/24 (29) | ||
| Medicationa (with clinical question) | 10/36 (28) | ||
| Plan of care (discharge, goals of care, procedure) | 5/21 (24) | ||
| Clinically important | 0.059 | ||
| Not at all | 8 (50) | ||
| Somewhat | 8 (19) | ||
| Very | 10 (33) | ||
| Days since admission | 0.015 | ||
| Less than 2 days | 21 (40) | ||
| 2 or more days | 6 (16) | ||
| Anticipatory guidance and tasks | 0.006 | ||
| 2 or more | 3 (60) | ||
| 1 | 3 (14) | ||
| 0 | 21 (34) | ||
| Composite score | 0.144 | ||
| <4 | 5 (15) | ||
| 4 | 10 (29) | ||
Sign‐out was considered sufficient in isolation more frequently for inquiries about patients admitted <2 days prior to data collection than for inquiries about patients admitted more than 2 days prior to data collection (21 [40%] vs 6 [16%], respectively) (P=0.015) (Table 2).
Sign‐outs with 2 or more anticipatory guidance items were considered sufficient in isolation more often than sign‐outs with 1 or fewer anticipatory guidance item (60% for 2 or more, 14% for 1, 34% for 0; P=0.006) (Table 2). The composite score was grouped into 2 categoriesscore <4 and score=4with no statistical difference in sign‐out sufficiency between the 2 groups (P=0.22) (Table 2).
In multivariable analysis, no predictor variable was significantly associated with sufficient sign‐out (Table 3).
| Adjusted OR (95% CI) | p value | ||
|---|---|---|---|
| Question topic | 0.58 | ||
| Order reconciliation (oxygen/telemetry) | Reference | ||
| Clinical change (vitals, symptoms, labs) | 0.29 (0.01 6.70) | ||
| Medication (+/‐ vitals or symptoms) | 0.17 (0.01 3.83) | ||
| Plan of care (discharge, goals of care, IV, CPAP, procedure) | 0.15 (0.01 3.37) | ||
| Clinically important | 0.85 | ||
| Not at All | Reference | ||
| Somewhat | 0.69 (0.12 4.04) | ||
| Very | 0.57 (0.08 3.88) | ||
| Days since admission | 0.332 (0.09 1.19) | 0.074 | |
| Anticipatory guidance and tasks | 0.26 | ||
| 2 or more | Reference | ||
| 1 | 0.13 (0.01 1.51) | ||
| 0 | 0.21 (0.02 2.11) | ||
| Composite Score | 0.22 | ||
| <4 | Reference | ||
| 4 | 2.2 (0.62 7.77) |
DISCUSSION
In this study of written sign‐out among hospitalists and physician‐extenders on a hospitalist service, we found that the sign‐out was used to answer three‐quarters of overnight inquiries, despite the advanced level of training (completion of all postgraduate medical education) of the covering clinicians and the presence of a robust EHR. The effectiveness of the written sign‐out, however, was not as consistently high as its use. Overall, the sign‐out was sufficient to answer less than a third of inquiries in which it was referenced. Thus, although most studies of sign‐out quality have focused on trainees, our results make it clear that hospitalists also rely on sign‐out, and its effectiveness can be improved.
There are few studies of attending‐level sign‐outs. Hinami et al. found that nearly 1 in 5 hospitalists was uncertain of the care plan after assuming care of a new set of patients, despite having received a handoff from the departing hospitalist.[11] Handoffs between emergency physicians and hospitalists have repeatedly been noted to have content omissions and to contribute to adverse events.[7, 12, 21, 22] Ilan et al. videotaped attending handoffs in the intensive care unit and found that they did not follow any of 3 commonly recommended structures; however, this study did not assess the effectiveness of the handoffs.[23] Williams et al. found that the transfer of patient information among surgical team members, including attending surgeons, was suboptimal, and these problems were commonly related to decreased surgeon familiarity with a particular patient, a theme common to hospital medicine, and a contributor to adverse events and decreased efficiency.[24]
This study extends the literature in several ways. By studying overnight events, we generate a comprehensive view of the information sources hospitalists use to care for patients overnight. Interestingly, our results were similar to the overnight information‐gathering habits of trainees in a study of pediatric trainees.[25] Furthermore, by linking each inquiry to the accompanying written sign‐out, we are able to analyze which characteristics of a written sign‐out are associated with sign‐out effectiveness, and we are able to describe the utility of written sign‐out to answer different types of clinical scenarios.
Our data show that hospitalists rely heavily on written sign‐out to care for patients overnight, with the physician note being the most‐utilized secondary reference used by covering physicians. The written sign‐out was most useful for order clarification compared to other topics, and the patient was only seen for 12% of inquiries. Most notable, however, was the suggestion that sign‐outs with more anticipatory guidance were more likely to be effective for overnight care, as were sign‐outs created earlier in the hospital course. Future efforts to improve the utility of the written sign‐out might focus on these items, whether through training or audit/feedback.
The use of electronic handoff tools has been shown to increase the ease of use, efficiency, and perceptions of patient safety and quality in several studies.[3, 26, 27] This study relied on an electronic tool as the only means of information transfer during sign‐out. Without the confounding effect of verbal information transfer, we are better able to understand the efficacy of the written component alone. Nonetheless, most expert opinion statements as well as The Joint Commission include a recommendation for verbal and written components to handoff communication.[8, 20, 28, 29, 30] It is possible that sign‐outs would more often have been rated sufficient if the handoff process had reliably included verbal handoff. Future studies are warranted to compare written‐only to written‐plus‐verbal sign‐out, to determine the added benefit of verbal communication. With a robust EHR, it is also an open question whether sign‐out needs to be sufficient to answer overnight inquiries or whether it would be acceptable or even preferable to have overnight staff consistently review the EHR directly, especially as the physician notes are the most common nonsign‐out reference used. Nonetheless, the fact that hospitalists rely heavily on written sign‐out despite the availability of other information sources suggests that hospitalists find specific benefit in written sign‐out.
Limitations of this study include the relatively small sample size, the limited collection time period, and the single‐site nature. The YNHH Hospitalist Service uses only written documents to sign out, so the external validity to programs that use verbal sign‐out is limited. The written‐only nature, however, removes the variable of the discussion at time of sign‐out, improving the purity of the written sign‐out assessment. We did not assess workload, which might have affected sign‐out quality. The interpretation of the composite score is limited, due to little variation in scoring in our sample, as well as lack of validation in other studies. An additional limitation is that sign‐outs are not entirely drafted by the hospitalist attendings. Hospitalists draft the initial sign‐out document, but it is updated on subsequent days by the mid‐level provider under the direction of the hospitalist attending. It is therefore possible that sign‐outs maintained directly by hospitalists would have been of different quality. In this regard it is interesting to note that in a different study of verbal sign‐out we were not able to detect a difference in quality among hospitalists, trainees, and midlevels.[12] Last, hindsight bias may be present, as the covering physician's perspective of the event includes more information than available to the provider creating the sign‐out document.
Overall, we found that attending hospitalists rely heavily on written sign‐out documents to address overnight inquiries, but those sign‐outs are not reliably effective. Future work to better understand the roles of written and verbal components in sign‐out is needed to help improve the safety of overnight care.
Disclosures
Disclosures: Dr. Horwitz is supported by the National Institute on Aging (K08 AG038336) and by the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program. Dr. Horwitz is also a Pepper Scholar with support from the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (#P30AG021342 NIH/NIA). Dr. Fogerty had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The authors do not have conflicts of interest to report. Dr. Schoenfeld was a medical student at the Yale University School of Medicine, New Haven, Connecticut at the time of the study. She is now a resident at Massachusetts General Hospital in Boston, Massachusetts.
- , , , . The status of hospital medicine groups in the United States. J Hosp Med. 2006;1(2):75–80.
- , , , . Growth in the care of older patients by hospitalists in the United States. N Engl J Med. 2009;360(11):1102–1112.
- , , , et al. The Veterans Affairs shift change physician‐to‐physician handoff project. Jt Comm J Qual Patient Saf. 2010;36(2):62–71.
- , . The evolution and future of hospital medicine. Mt Sinai J Med. 2008;75(5):418–423.
- . The hospitalist movement—time to move on. N Engl J Med. 2007;357(25):2627–2629.
- , , . Invited article: is it time for neurohospitalists? Neurology. 2008;70(15):1282–1288.
- , , , . Survey of obstetric and gynecologic hospitalists and laborists. Am J Obstet Gynecol. 2010;203(2):177.e171–e174.
- , , , , , . Hospitalist handoffs: a systematic review and task force recommendations. J Hosp Med. 2009;4(7):433–440.
- , , , , . Core competencies in hospital medicine: development and methodology. J Hosp Med. 2006;1(1):48–56.
- , , , , . Gaining efficiency and satisfaction in the handoff process. J Hosp Med. 2010;5(9):547–552.
- , , , . Understanding communication during hospitalist service changes: a mixed methods study. J Hosp Med. 2009;4(9):535–540.
- , , , et al. Development of a handoff evaluation tool for shift‐to‐shift physician handoffs: the handoff CEX. J Hosp Med. 2013;8(4):191–200.
- , , , , . Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121(11):866–872.
- , , , et al. Effect of short call admission on length of stay and quality of care for acute decompensated heart failure. Circulation. 2008;117(20):2637–2644.
- , , , , . Consequences of inadequate sign‐out for patient care. Arch Intern Med. 2008;168(16):1755–1760.
- , , , , . Communication failures in patient sign‐out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14(6):401–407.
- , , , et al. An institution‐wide handoff task force to standardise and improve physician handoffs. BMJ Qual Saf. 2012;21(10):863–871.
- , , , , . What are covering doctors told about their patients? Analysis of sign‐out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248–255.
- , , , . Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166(11):1173–1177.
- , , , . A theoretical framework and competency‐based approach to improving handoffs. Qual Saf Health Care. 2008;17(1):11–14.
- , , . Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007;14(10):884–894.
- , , , , , . Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med. 2009;53(6):701–710.e704.
- , , , , , . Handover patterns: an observational study of critical care physicians. BMC Health Serv Res. 2012;12:11.
- , , , et al. Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care. Ann Surg. 2007;245(2):159–169.
- , , , , . Answering questions on call: Pediatric resident physicians' use of handoffs and other resources. J Hosp Med. 2013;8:328–333.
- , , , , . A randomized, controlled trial evaluating the impact of a computerized rounding and sign‐out system on continuity of care and resident work hours. J Am Coll Surg. 2005;200(4):538–545.
- , , , et al. Resident sign‐out and patient hand‐offs: opportunities for improvement. Teach Learn Med. 2011;23(2):105–111.
- , . A model for building a standardized hand‐off protocol. Jt Comm J Qual Patient Saf. 2006;32(11):646–655.
- , , , et al. The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care. Acad Med. 2012;87(4):411–418.
- The Joint Commission. 2013 Comprehensive Accreditation Manuals. Oak Brook, IL: The Joint Commission; 2012.
Hospital medicine is a main component of healthcare in the United States and is growing.[1] In 1995, 9% of inpatient care performed by general internists to Medicare patients was provided by hospitalists; by 2006, this had increased to 37%.[2] The estimated 30,000 practicing hospitalists account for 19% of all practicing general internists[2, 3, 4] and have had a major impact on the treatment of inpatients at US hospitals.[5] Other specialties are adopting the hospital‐based physician model.[6, 7] The hospitalist model does have unique challenges. One notable aspect of hospitalist care, which is frequently shift based, is the transfer of care among providers at shift change.
The Society of Hospital Medicine recognizes patient handoffs/sign‐outs as a core competency for hospitalists,[8] but there is little literature evaluating hospitalist sign‐out quality.[9] A systematic review in 2009 found no studies of hospitalist handoffs.[8] Furthermore, early work suggests that hospitalist handoffs are not consistently effective.[10] In a recent survey, 13% of hospitalists reported they had received an incomplete handoff, and 16% of hospitalists reported at least 1 near‐miss attributed to incomplete communication.[11] Last, hospitalists perform no better than housestaff on evaluations of sign‐out quality.[12]
Cross‐coverage situations, in which sign‐out is key, have been shown to place patients at risk.[13, 14] One study showed 7.1 problems related to sign‐out per 100 patient‐days.[15] Failure during sign‐out can ultimately threaten patient safety.[16] Therefore, evaluating the quality of hospitalist sign‐outs by assessing how well the sign‐out prepares the night team for overnight events is necessary to improve hospitalist sign‐outs and ultimately increase patient safety.
METHODS
Study Setting
The study took place at YaleNew Haven Hospital (YNHH), the primary teaching affiliate for the Yale School of Medicine, in New Haven, Connecticut. YNHH is a 966‐bed, urban, academic medical center. The Hospitalist Service is a nonteaching service composed of 56.1 full‐time‐equivalent (FTE) attending physicians and 26.8 FTE midlevel providers. In fiscal year 2012, the YNHH Hospitalist Service cared for 13,764 discharges, or approximately 70% of general medical discharges. Similar patients are cared for by both hospitalists and housestaff. Patients on the hospitalist service are assigned an attending physician as well as a midlevel provider during the daytime. Between the departure of the day team and the arrival of the night team, typically a 2‐hour window, a skeleton crew covers the entire service and admits patients. The same skeleton crew coverage plan exists in the approximately 2.5‐hour morning gap between the departure of the night team and arrival of the day team. Overnight, care is generally provided by attending hospitalist physicians alone. Clinical fellows and internal medicine residents occasionally fill the night hospitalist role.
Sign‐out Procedure
The YNHH Hospitalist Service uses a written sign‐out[17] created via template built into the electronic health record (EHR), Sunrise Clinical Manager (version 5.5; Allscripts, Chicago, IL) and is the major mechanism for shift‐to‐shift information transfer. A free text summary of the patient's medical course and condition is created by the provider preparing the sign‐out, as is a separate list of to do items. The free text box is titled History (general hospital course, new events of the day, overall clinical condition). A representative narrative example is, 87 y/o gentleman PMHx AF on coumadin, diastolic CHF (EF 40%), NIDDM2, first degree AV block, GIB in setting of supratherapeutic INR, depression, COPD p/w worsening low back pain in setting of L1 compression frx of? age. HD stable. An option exists to include a medication list pulled from the active orders in the EHR when the sign‐out report is printed. The sign‐out is typically created by the hospitalist attending on the day of admission and then updated daily by the mid‐level provider under the supervision of the attending physician, in accordance with internal standards set by the service. Formal sign‐out training is included as part of orientation for new hires, and ongoing sign‐out education is provided, as needed, by a physician assistant charged with continuous quality improvement for the entire service. The service maintains an expectation for the entire team to provide accurate and updated sign‐out at every shift change. Attending hospitalists or mid‐level providers update the sign‐out on weekends. Because the day team has generally left the hospital prior to the arrival of the night team, verbal sign‐out occurs rarely. Should a verbal sign‐out be given to the night team, it will be provided by the daytime team directly to the night team either via telephone or the day team member staying in the hospital until arrival of the night team.
Participants
All full‐time and regularly scheduled part‐time attending physicians on the YNHH hospitalist night team were eligible to participate. We excluded temporary physicians on service, including clinical fellows and resident moonlighters. Hospitalists could not participate more than once. Written informed consent was obtained of all hospitalists at the start of their shift.
Data Collection
Hospitalists who consented were provided a single pocket card during their shift. For every inquiry that involved a patient that the hospitalist was covering, the hospitalist recorded who originated the inquiry, the clinical significance, the sufficiency of written sign‐out, which information was used other than the written sign‐out, and information regarding the anticipation of the event by the daytime team (Figure 1).
Data were collected on 6 days and distributed from April 30, 2012 through June 12, 2012. Dates were chosen based on staffing to maximize the number of eligible physicians each night and included both weekdays and weekend days. The written sign‐out for the entire service was printed for each night data collection took place.
Main Predictors
Our main predictor variables were characteristics of the inquiry (topic area, clinical importance of the inquiry as assessed by the hospitalist), characteristics of the patient (days since admission), and characteristics of the written sign‐out (whether it included any anticipatory guidance and a composite quality score). We identified elements of the composite quality score based on prior research and expert recommendations.[8, 18, 19, 20] To create the composite quality score, we gave 1 point for each of the following elements: diagnosis or presenting symptoms, general hospital course (a description of any event occurring during hospitalization but prior to date of data collection), current clinical condition (a description of objective data, symptoms, or stability/trajectory in the last 24 hours), and whether the sign‐out had been updated within the last 24 hours. The composite score could range from 0 to 4.
Main Outcome Measures
Our primary outcome measure was the quality and utility of the written‐only sign‐out as defined via a subjective assessment of sufficiency by the covering physician (ie, whether the written sign‐out was adequate to answer the query without seeking any supplemental information). For this outcome, we excluded inquiries for which hospitalists had determined a sign‐out was not necessary to address the inquiry or event.
Statistical Analysis
Data analysis was conducted using SAS 9.2 (SAS Institute, Cary, NC). We used a cutoff of P<0.05 for statistical significance; all tests were 2‐tailed. We assessed characteristics of overnight inquiries using descriptive statistics and determined the association of the main predictors with sufficient sign‐out using 2 tests. We constructed a multivariate logistic regression model using a priori‐determined clinically relevant predictors to test predictors of sign‐out sufficiency. The study was approved by the Human Investigation Committee of Yale University.
RESULTS
Hospitalists recorded 124 inquiries about 96 patients. Altogether, 15 of 19 (79%) eligible hospitalists returned surveys. Of the 96 patients, we obtained the written sign‐out for 68 (71%). The remainder were new patients for whom the sign‐out had not yet been prepared, or patients who had not yet been assigned to the hospitalist service at the time the sign‐out report was printed.
Hospitalists referenced the sign‐out for 89 (74%) inquiries, and the sign‐out was considered sufficient to respond to 27 (30%) of these inquiries (ie, the sign‐out was adequate to answer the inquiry without any supplemental information). Hospitalists physically saw the patient for 14 (12%) inquiries. Nurses were the originator for most inquiries (102 [82%]). The most common inquiry topics were medications (55 [45%]), plan of care (26 [21%]) and clinical changes (26 [21%]). Ninety‐five (77%) inquiries were considered to be somewhat or very clinically important by the hospitalist (Table 1).
| Inquiry originator, No. (% of 124) | |
| Nurse | 102 (82) |
| Patient | 13 (10) |
| Consultant | 6 (5) |
| Respiratory therapy | 3 (2) |
| Inquiry subject, No. (% of 122) | |
| Medication | 55 (45) |
| Plan of care | 26 (21) |
| Clinical change | 26 (21) |
| Order reconciliation | 15 (12) |
| Missing | 2 |
| Clinical importance of inquiry, No. (% of 123) | |
| Very | 33 (27) |
| Somewhat | 62 (50) |
| Not at all | 28 (23) |
| Missing | 1 |
| Sufficiency of sign‐out alone in answering inquiry, No. (% of 121) | |
| Yes | 27 (22) |
| No | 62 (51) |
| Sign‐out not necessary for inquiry | 32 (26) |
| Missing | 3 |
| Days since admission, No. (% of 124) | |
| Less than 2 | 69 (44.4) |
| 2 or more | 55 (55.6) |
| Reference(s) used when sign‐out insufficient, No. (% of 62) | |
| Physician notes | 37 (60) |
| Nurse | 11 (18) |
| Labs/studies | 10 (16) |
| Orders | 9 (15) |
| Patient | 7 (11) |
| Other | 7 (11) |
| Was the event predicted by the primary team? No. (% of 119) | |
| Yes | 17 (14) |
| No | 102 (86) |
| Missing | 5 |
| If no, could this event have been predicted, No. (% of 102) | |
| Yes | 47 (46) |
| No | 55 (54) |
| Of all events that could have been predicted, how many were predicted? No. (% of 64) | |
| Predicted | 17 (27) |
| Not predicted | 47 (73) |
| Did you physically see the patient? No. (% of 117) | |
| Yes | 14 (12) |
| No | 103 (88) |
| Missing | 7 |
| Composite score, No. (% of 68) | |
| 0 or 1 | 0 (0) |
| 2 | 3 (4) |
| 3 | 31 (46) |
| 4 | 34 (50) |
| Anticipatory guidance/to‐do tasks, No. (% of 96) | |
| 0 | 69(72) |
| 1 | 21 (22) |
| 2 or more | 6 (6) |
No written sign‐outs had a composite score of 0 or 1; 3 (4%) had a composite score of 2; 31 (46%) had a composite score of 3; and 34 (50%) had a composite score of 4. Seventy‐two percent of written sign‐outs included neither anticipatory guidance nor tasks, 21% had 1 anticipatory guidance item or task, and 6% had 2 or more anticipatory guidance items and/or tasks.
The primary team caring for a patient did not predict 102 (86%) inquiries, and hospitalists rated 47 (46%) of those unpredicted events as possible for the primary team to predict. Five responses to this question were incomplete and excluded. Of the 64 events predicted by the primary team or rated as predictable by the night hospitalists, 17 (27%) were predicted by the primary team (Table 1).
Sign‐out was considered sufficient in isolation to answer the majority of order reconciliation inquiries (5 [71%]), but was less effective at helping to answer inquiries about clinical change (7 [29%]), medications (10 [28%]), and plan of care (5 [24%]) (P=0.001). (Table 2) Ninety‐five events were rated as either very or somewhat clinically important, but this did not affect the likelihood of sign‐out being sufficient in isolation relative to the not at all clinically important group. Specifically, 33% of sign‐outs were rated sufficient in the very important group, 19% in the somewhat important group, and 50% in the not at all group (P=0.059).
| Predictor | Number of inquiries (%) for which sign‐out was sufficient in isolationb | p value | |
|---|---|---|---|
| |||
| Question topic | 0.001 | ||
| Order reconciliation (oxygen/telemetry) | 5/7 (71) | ||
| Clinical change (vitals, symptoms, labs) | 7/24 (29) | ||
| Medicationa (with clinical question) | 10/36 (28) | ||
| Plan of care (discharge, goals of care, procedure) | 5/21 (24) | ||
| Clinically important | 0.059 | ||
| Not at all | 8 (50) | ||
| Somewhat | 8 (19) | ||
| Very | 10 (33) | ||
| Days since admission | 0.015 | ||
| Less than 2 days | 21 (40) | ||
| 2 or more days | 6 (16) | ||
| Anticipatory guidance and tasks | 0.006 | ||
| 2 or more | 3 (60) | ||
| 1 | 3 (14) | ||
| 0 | 21 (34) | ||
| Composite score | 0.144 | ||
| <4 | 5 (15) | ||
| 4 | 10 (29) | ||
Sign‐out was considered sufficient in isolation more frequently for inquiries about patients admitted <2 days prior to data collection than for inquiries about patients admitted more than 2 days prior to data collection (21 [40%] vs 6 [16%], respectively) (P=0.015) (Table 2).
Sign‐outs with 2 or more anticipatory guidance items were considered sufficient in isolation more often than sign‐outs with 1 or fewer anticipatory guidance item (60% for 2 or more, 14% for 1, 34% for 0; P=0.006) (Table 2). The composite score was grouped into 2 categoriesscore <4 and score=4with no statistical difference in sign‐out sufficiency between the 2 groups (P=0.22) (Table 2).
In multivariable analysis, no predictor variable was significantly associated with sufficient sign‐out (Table 3).
| Adjusted OR (95% CI) | p value | ||
|---|---|---|---|
| Question topic | 0.58 | ||
| Order reconciliation (oxygen/telemetry) | Reference | ||
| Clinical change (vitals, symptoms, labs) | 0.29 (0.01 6.70) | ||
| Medication (+/‐ vitals or symptoms) | 0.17 (0.01 3.83) | ||
| Plan of care (discharge, goals of care, IV, CPAP, procedure) | 0.15 (0.01 3.37) | ||
| Clinically important | 0.85 | ||
| Not at All | Reference | ||
| Somewhat | 0.69 (0.12 4.04) | ||
| Very | 0.57 (0.08 3.88) | ||
| Days since admission | 0.332 (0.09 1.19) | 0.074 | |
| Anticipatory guidance and tasks | 0.26 | ||
| 2 or more | Reference | ||
| 1 | 0.13 (0.01 1.51) | ||
| 0 | 0.21 (0.02 2.11) | ||
| Composite Score | 0.22 | ||
| <4 | Reference | ||
| 4 | 2.2 (0.62 7.77) |
DISCUSSION
In this study of written sign‐out among hospitalists and physician‐extenders on a hospitalist service, we found that the sign‐out was used to answer three‐quarters of overnight inquiries, despite the advanced level of training (completion of all postgraduate medical education) of the covering clinicians and the presence of a robust EHR. The effectiveness of the written sign‐out, however, was not as consistently high as its use. Overall, the sign‐out was sufficient to answer less than a third of inquiries in which it was referenced. Thus, although most studies of sign‐out quality have focused on trainees, our results make it clear that hospitalists also rely on sign‐out, and its effectiveness can be improved.
There are few studies of attending‐level sign‐outs. Hinami et al. found that nearly 1 in 5 hospitalists was uncertain of the care plan after assuming care of a new set of patients, despite having received a handoff from the departing hospitalist.[11] Handoffs between emergency physicians and hospitalists have repeatedly been noted to have content omissions and to contribute to adverse events.[7, 12, 21, 22] Ilan et al. videotaped attending handoffs in the intensive care unit and found that they did not follow any of 3 commonly recommended structures; however, this study did not assess the effectiveness of the handoffs.[23] Williams et al. found that the transfer of patient information among surgical team members, including attending surgeons, was suboptimal, and these problems were commonly related to decreased surgeon familiarity with a particular patient, a theme common to hospital medicine, and a contributor to adverse events and decreased efficiency.[24]
This study extends the literature in several ways. By studying overnight events, we generate a comprehensive view of the information sources hospitalists use to care for patients overnight. Interestingly, our results were similar to the overnight information‐gathering habits of trainees in a study of pediatric trainees.[25] Furthermore, by linking each inquiry to the accompanying written sign‐out, we are able to analyze which characteristics of a written sign‐out are associated with sign‐out effectiveness, and we are able to describe the utility of written sign‐out to answer different types of clinical scenarios.
Our data show that hospitalists rely heavily on written sign‐out to care for patients overnight, with the physician note being the most‐utilized secondary reference used by covering physicians. The written sign‐out was most useful for order clarification compared to other topics, and the patient was only seen for 12% of inquiries. Most notable, however, was the suggestion that sign‐outs with more anticipatory guidance were more likely to be effective for overnight care, as were sign‐outs created earlier in the hospital course. Future efforts to improve the utility of the written sign‐out might focus on these items, whether through training or audit/feedback.
The use of electronic handoff tools has been shown to increase the ease of use, efficiency, and perceptions of patient safety and quality in several studies.[3, 26, 27] This study relied on an electronic tool as the only means of information transfer during sign‐out. Without the confounding effect of verbal information transfer, we are better able to understand the efficacy of the written component alone. Nonetheless, most expert opinion statements as well as The Joint Commission include a recommendation for verbal and written components to handoff communication.[8, 20, 28, 29, 30] It is possible that sign‐outs would more often have been rated sufficient if the handoff process had reliably included verbal handoff. Future studies are warranted to compare written‐only to written‐plus‐verbal sign‐out, to determine the added benefit of verbal communication. With a robust EHR, it is also an open question whether sign‐out needs to be sufficient to answer overnight inquiries or whether it would be acceptable or even preferable to have overnight staff consistently review the EHR directly, especially as the physician notes are the most common nonsign‐out reference used. Nonetheless, the fact that hospitalists rely heavily on written sign‐out despite the availability of other information sources suggests that hospitalists find specific benefit in written sign‐out.
Limitations of this study include the relatively small sample size, the limited collection time period, and the single‐site nature. The YNHH Hospitalist Service uses only written documents to sign out, so the external validity to programs that use verbal sign‐out is limited. The written‐only nature, however, removes the variable of the discussion at time of sign‐out, improving the purity of the written sign‐out assessment. We did not assess workload, which might have affected sign‐out quality. The interpretation of the composite score is limited, due to little variation in scoring in our sample, as well as lack of validation in other studies. An additional limitation is that sign‐outs are not entirely drafted by the hospitalist attendings. Hospitalists draft the initial sign‐out document, but it is updated on subsequent days by the mid‐level provider under the direction of the hospitalist attending. It is therefore possible that sign‐outs maintained directly by hospitalists would have been of different quality. In this regard it is interesting to note that in a different study of verbal sign‐out we were not able to detect a difference in quality among hospitalists, trainees, and midlevels.[12] Last, hindsight bias may be present, as the covering physician's perspective of the event includes more information than available to the provider creating the sign‐out document.
Overall, we found that attending hospitalists rely heavily on written sign‐out documents to address overnight inquiries, but those sign‐outs are not reliably effective. Future work to better understand the roles of written and verbal components in sign‐out is needed to help improve the safety of overnight care.
Disclosures
Disclosures: Dr. Horwitz is supported by the National Institute on Aging (K08 AG038336) and by the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program. Dr. Horwitz is also a Pepper Scholar with support from the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (#P30AG021342 NIH/NIA). Dr. Fogerty had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The authors do not have conflicts of interest to report. Dr. Schoenfeld was a medical student at the Yale University School of Medicine, New Haven, Connecticut at the time of the study. She is now a resident at Massachusetts General Hospital in Boston, Massachusetts.
Hospital medicine is a main component of healthcare in the United States and is growing.[1] In 1995, 9% of inpatient care performed by general internists to Medicare patients was provided by hospitalists; by 2006, this had increased to 37%.[2] The estimated 30,000 practicing hospitalists account for 19% of all practicing general internists[2, 3, 4] and have had a major impact on the treatment of inpatients at US hospitals.[5] Other specialties are adopting the hospital‐based physician model.[6, 7] The hospitalist model does have unique challenges. One notable aspect of hospitalist care, which is frequently shift based, is the transfer of care among providers at shift change.
The Society of Hospital Medicine recognizes patient handoffs/sign‐outs as a core competency for hospitalists,[8] but there is little literature evaluating hospitalist sign‐out quality.[9] A systematic review in 2009 found no studies of hospitalist handoffs.[8] Furthermore, early work suggests that hospitalist handoffs are not consistently effective.[10] In a recent survey, 13% of hospitalists reported they had received an incomplete handoff, and 16% of hospitalists reported at least 1 near‐miss attributed to incomplete communication.[11] Last, hospitalists perform no better than housestaff on evaluations of sign‐out quality.[12]
Cross‐coverage situations, in which sign‐out is key, have been shown to place patients at risk.[13, 14] One study showed 7.1 problems related to sign‐out per 100 patient‐days.[15] Failure during sign‐out can ultimately threaten patient safety.[16] Therefore, evaluating the quality of hospitalist sign‐outs by assessing how well the sign‐out prepares the night team for overnight events is necessary to improve hospitalist sign‐outs and ultimately increase patient safety.
METHODS
Study Setting
The study took place at YaleNew Haven Hospital (YNHH), the primary teaching affiliate for the Yale School of Medicine, in New Haven, Connecticut. YNHH is a 966‐bed, urban, academic medical center. The Hospitalist Service is a nonteaching service composed of 56.1 full‐time‐equivalent (FTE) attending physicians and 26.8 FTE midlevel providers. In fiscal year 2012, the YNHH Hospitalist Service cared for 13,764 discharges, or approximately 70% of general medical discharges. Similar patients are cared for by both hospitalists and housestaff. Patients on the hospitalist service are assigned an attending physician as well as a midlevel provider during the daytime. Between the departure of the day team and the arrival of the night team, typically a 2‐hour window, a skeleton crew covers the entire service and admits patients. The same skeleton crew coverage plan exists in the approximately 2.5‐hour morning gap between the departure of the night team and arrival of the day team. Overnight, care is generally provided by attending hospitalist physicians alone. Clinical fellows and internal medicine residents occasionally fill the night hospitalist role.
Sign‐out Procedure
The YNHH Hospitalist Service uses a written sign‐out[17] created via template built into the electronic health record (EHR), Sunrise Clinical Manager (version 5.5; Allscripts, Chicago, IL) and is the major mechanism for shift‐to‐shift information transfer. A free text summary of the patient's medical course and condition is created by the provider preparing the sign‐out, as is a separate list of to do items. The free text box is titled History (general hospital course, new events of the day, overall clinical condition). A representative narrative example is, 87 y/o gentleman PMHx AF on coumadin, diastolic CHF (EF 40%), NIDDM2, first degree AV block, GIB in setting of supratherapeutic INR, depression, COPD p/w worsening low back pain in setting of L1 compression frx of? age. HD stable. An option exists to include a medication list pulled from the active orders in the EHR when the sign‐out report is printed. The sign‐out is typically created by the hospitalist attending on the day of admission and then updated daily by the mid‐level provider under the supervision of the attending physician, in accordance with internal standards set by the service. Formal sign‐out training is included as part of orientation for new hires, and ongoing sign‐out education is provided, as needed, by a physician assistant charged with continuous quality improvement for the entire service. The service maintains an expectation for the entire team to provide accurate and updated sign‐out at every shift change. Attending hospitalists or mid‐level providers update the sign‐out on weekends. Because the day team has generally left the hospital prior to the arrival of the night team, verbal sign‐out occurs rarely. Should a verbal sign‐out be given to the night team, it will be provided by the daytime team directly to the night team either via telephone or the day team member staying in the hospital until arrival of the night team.
Participants
All full‐time and regularly scheduled part‐time attending physicians on the YNHH hospitalist night team were eligible to participate. We excluded temporary physicians on service, including clinical fellows and resident moonlighters. Hospitalists could not participate more than once. Written informed consent was obtained of all hospitalists at the start of their shift.
Data Collection
Hospitalists who consented were provided a single pocket card during their shift. For every inquiry that involved a patient that the hospitalist was covering, the hospitalist recorded who originated the inquiry, the clinical significance, the sufficiency of written sign‐out, which information was used other than the written sign‐out, and information regarding the anticipation of the event by the daytime team (Figure 1).
Data were collected on 6 days and distributed from April 30, 2012 through June 12, 2012. Dates were chosen based on staffing to maximize the number of eligible physicians each night and included both weekdays and weekend days. The written sign‐out for the entire service was printed for each night data collection took place.
Main Predictors
Our main predictor variables were characteristics of the inquiry (topic area, clinical importance of the inquiry as assessed by the hospitalist), characteristics of the patient (days since admission), and characteristics of the written sign‐out (whether it included any anticipatory guidance and a composite quality score). We identified elements of the composite quality score based on prior research and expert recommendations.[8, 18, 19, 20] To create the composite quality score, we gave 1 point for each of the following elements: diagnosis or presenting symptoms, general hospital course (a description of any event occurring during hospitalization but prior to date of data collection), current clinical condition (a description of objective data, symptoms, or stability/trajectory in the last 24 hours), and whether the sign‐out had been updated within the last 24 hours. The composite score could range from 0 to 4.
Main Outcome Measures
Our primary outcome measure was the quality and utility of the written‐only sign‐out as defined via a subjective assessment of sufficiency by the covering physician (ie, whether the written sign‐out was adequate to answer the query without seeking any supplemental information). For this outcome, we excluded inquiries for which hospitalists had determined a sign‐out was not necessary to address the inquiry or event.
Statistical Analysis
Data analysis was conducted using SAS 9.2 (SAS Institute, Cary, NC). We used a cutoff of P<0.05 for statistical significance; all tests were 2‐tailed. We assessed characteristics of overnight inquiries using descriptive statistics and determined the association of the main predictors with sufficient sign‐out using 2 tests. We constructed a multivariate logistic regression model using a priori‐determined clinically relevant predictors to test predictors of sign‐out sufficiency. The study was approved by the Human Investigation Committee of Yale University.
RESULTS
Hospitalists recorded 124 inquiries about 96 patients. Altogether, 15 of 19 (79%) eligible hospitalists returned surveys. Of the 96 patients, we obtained the written sign‐out for 68 (71%). The remainder were new patients for whom the sign‐out had not yet been prepared, or patients who had not yet been assigned to the hospitalist service at the time the sign‐out report was printed.
Hospitalists referenced the sign‐out for 89 (74%) inquiries, and the sign‐out was considered sufficient to respond to 27 (30%) of these inquiries (ie, the sign‐out was adequate to answer the inquiry without any supplemental information). Hospitalists physically saw the patient for 14 (12%) inquiries. Nurses were the originator for most inquiries (102 [82%]). The most common inquiry topics were medications (55 [45%]), plan of care (26 [21%]) and clinical changes (26 [21%]). Ninety‐five (77%) inquiries were considered to be somewhat or very clinically important by the hospitalist (Table 1).
| Inquiry originator, No. (% of 124) | |
| Nurse | 102 (82) |
| Patient | 13 (10) |
| Consultant | 6 (5) |
| Respiratory therapy | 3 (2) |
| Inquiry subject, No. (% of 122) | |
| Medication | 55 (45) |
| Plan of care | 26 (21) |
| Clinical change | 26 (21) |
| Order reconciliation | 15 (12) |
| Missing | 2 |
| Clinical importance of inquiry, No. (% of 123) | |
| Very | 33 (27) |
| Somewhat | 62 (50) |
| Not at all | 28 (23) |
| Missing | 1 |
| Sufficiency of sign‐out alone in answering inquiry, No. (% of 121) | |
| Yes | 27 (22) |
| No | 62 (51) |
| Sign‐out not necessary for inquiry | 32 (26) |
| Missing | 3 |
| Days since admission, No. (% of 124) | |
| Less than 2 | 69 (44.4) |
| 2 or more | 55 (55.6) |
| Reference(s) used when sign‐out insufficient, No. (% of 62) | |
| Physician notes | 37 (60) |
| Nurse | 11 (18) |
| Labs/studies | 10 (16) |
| Orders | 9 (15) |
| Patient | 7 (11) |
| Other | 7 (11) |
| Was the event predicted by the primary team? No. (% of 119) | |
| Yes | 17 (14) |
| No | 102 (86) |
| Missing | 5 |
| If no, could this event have been predicted, No. (% of 102) | |
| Yes | 47 (46) |
| No | 55 (54) |
| Of all events that could have been predicted, how many were predicted? No. (% of 64) | |
| Predicted | 17 (27) |
| Not predicted | 47 (73) |
| Did you physically see the patient? No. (% of 117) | |
| Yes | 14 (12) |
| No | 103 (88) |
| Missing | 7 |
| Composite score, No. (% of 68) | |
| 0 or 1 | 0 (0) |
| 2 | 3 (4) |
| 3 | 31 (46) |
| 4 | 34 (50) |
| Anticipatory guidance/to‐do tasks, No. (% of 96) | |
| 0 | 69(72) |
| 1 | 21 (22) |
| 2 or more | 6 (6) |
No written sign‐outs had a composite score of 0 or 1; 3 (4%) had a composite score of 2; 31 (46%) had a composite score of 3; and 34 (50%) had a composite score of 4. Seventy‐two percent of written sign‐outs included neither anticipatory guidance nor tasks, 21% had 1 anticipatory guidance item or task, and 6% had 2 or more anticipatory guidance items and/or tasks.
The primary team caring for a patient did not predict 102 (86%) inquiries, and hospitalists rated 47 (46%) of those unpredicted events as possible for the primary team to predict. Five responses to this question were incomplete and excluded. Of the 64 events predicted by the primary team or rated as predictable by the night hospitalists, 17 (27%) were predicted by the primary team (Table 1).
Sign‐out was considered sufficient in isolation to answer the majority of order reconciliation inquiries (5 [71%]), but was less effective at helping to answer inquiries about clinical change (7 [29%]), medications (10 [28%]), and plan of care (5 [24%]) (P=0.001). (Table 2) Ninety‐five events were rated as either very or somewhat clinically important, but this did not affect the likelihood of sign‐out being sufficient in isolation relative to the not at all clinically important group. Specifically, 33% of sign‐outs were rated sufficient in the very important group, 19% in the somewhat important group, and 50% in the not at all group (P=0.059).
| Predictor | Number of inquiries (%) for which sign‐out was sufficient in isolationb | p value | |
|---|---|---|---|
| |||
| Question topic | 0.001 | ||
| Order reconciliation (oxygen/telemetry) | 5/7 (71) | ||
| Clinical change (vitals, symptoms, labs) | 7/24 (29) | ||
| Medicationa (with clinical question) | 10/36 (28) | ||
| Plan of care (discharge, goals of care, procedure) | 5/21 (24) | ||
| Clinically important | 0.059 | ||
| Not at all | 8 (50) | ||
| Somewhat | 8 (19) | ||
| Very | 10 (33) | ||
| Days since admission | 0.015 | ||
| Less than 2 days | 21 (40) | ||
| 2 or more days | 6 (16) | ||
| Anticipatory guidance and tasks | 0.006 | ||
| 2 or more | 3 (60) | ||
| 1 | 3 (14) | ||
| 0 | 21 (34) | ||
| Composite score | 0.144 | ||
| <4 | 5 (15) | ||
| 4 | 10 (29) | ||
Sign‐out was considered sufficient in isolation more frequently for inquiries about patients admitted <2 days prior to data collection than for inquiries about patients admitted more than 2 days prior to data collection (21 [40%] vs 6 [16%], respectively) (P=0.015) (Table 2).
Sign‐outs with 2 or more anticipatory guidance items were considered sufficient in isolation more often than sign‐outs with 1 or fewer anticipatory guidance item (60% for 2 or more, 14% for 1, 34% for 0; P=0.006) (Table 2). The composite score was grouped into 2 categoriesscore <4 and score=4with no statistical difference in sign‐out sufficiency between the 2 groups (P=0.22) (Table 2).
In multivariable analysis, no predictor variable was significantly associated with sufficient sign‐out (Table 3).
| Adjusted OR (95% CI) | p value | ||
|---|---|---|---|
| Question topic | 0.58 | ||
| Order reconciliation (oxygen/telemetry) | Reference | ||
| Clinical change (vitals, symptoms, labs) | 0.29 (0.01 6.70) | ||
| Medication (+/‐ vitals or symptoms) | 0.17 (0.01 3.83) | ||
| Plan of care (discharge, goals of care, IV, CPAP, procedure) | 0.15 (0.01 3.37) | ||
| Clinically important | 0.85 | ||
| Not at All | Reference | ||
| Somewhat | 0.69 (0.12 4.04) | ||
| Very | 0.57 (0.08 3.88) | ||
| Days since admission | 0.332 (0.09 1.19) | 0.074 | |
| Anticipatory guidance and tasks | 0.26 | ||
| 2 or more | Reference | ||
| 1 | 0.13 (0.01 1.51) | ||
| 0 | 0.21 (0.02 2.11) | ||
| Composite Score | 0.22 | ||
| <4 | Reference | ||
| 4 | 2.2 (0.62 7.77) |
DISCUSSION
In this study of written sign‐out among hospitalists and physician‐extenders on a hospitalist service, we found that the sign‐out was used to answer three‐quarters of overnight inquiries, despite the advanced level of training (completion of all postgraduate medical education) of the covering clinicians and the presence of a robust EHR. The effectiveness of the written sign‐out, however, was not as consistently high as its use. Overall, the sign‐out was sufficient to answer less than a third of inquiries in which it was referenced. Thus, although most studies of sign‐out quality have focused on trainees, our results make it clear that hospitalists also rely on sign‐out, and its effectiveness can be improved.
There are few studies of attending‐level sign‐outs. Hinami et al. found that nearly 1 in 5 hospitalists was uncertain of the care plan after assuming care of a new set of patients, despite having received a handoff from the departing hospitalist.[11] Handoffs between emergency physicians and hospitalists have repeatedly been noted to have content omissions and to contribute to adverse events.[7, 12, 21, 22] Ilan et al. videotaped attending handoffs in the intensive care unit and found that they did not follow any of 3 commonly recommended structures; however, this study did not assess the effectiveness of the handoffs.[23] Williams et al. found that the transfer of patient information among surgical team members, including attending surgeons, was suboptimal, and these problems were commonly related to decreased surgeon familiarity with a particular patient, a theme common to hospital medicine, and a contributor to adverse events and decreased efficiency.[24]
This study extends the literature in several ways. By studying overnight events, we generate a comprehensive view of the information sources hospitalists use to care for patients overnight. Interestingly, our results were similar to the overnight information‐gathering habits of trainees in a study of pediatric trainees.[25] Furthermore, by linking each inquiry to the accompanying written sign‐out, we are able to analyze which characteristics of a written sign‐out are associated with sign‐out effectiveness, and we are able to describe the utility of written sign‐out to answer different types of clinical scenarios.
Our data show that hospitalists rely heavily on written sign‐out to care for patients overnight, with the physician note being the most‐utilized secondary reference used by covering physicians. The written sign‐out was most useful for order clarification compared to other topics, and the patient was only seen for 12% of inquiries. Most notable, however, was the suggestion that sign‐outs with more anticipatory guidance were more likely to be effective for overnight care, as were sign‐outs created earlier in the hospital course. Future efforts to improve the utility of the written sign‐out might focus on these items, whether through training or audit/feedback.
The use of electronic handoff tools has been shown to increase the ease of use, efficiency, and perceptions of patient safety and quality in several studies.[3, 26, 27] This study relied on an electronic tool as the only means of information transfer during sign‐out. Without the confounding effect of verbal information transfer, we are better able to understand the efficacy of the written component alone. Nonetheless, most expert opinion statements as well as The Joint Commission include a recommendation for verbal and written components to handoff communication.[8, 20, 28, 29, 30] It is possible that sign‐outs would more often have been rated sufficient if the handoff process had reliably included verbal handoff. Future studies are warranted to compare written‐only to written‐plus‐verbal sign‐out, to determine the added benefit of verbal communication. With a robust EHR, it is also an open question whether sign‐out needs to be sufficient to answer overnight inquiries or whether it would be acceptable or even preferable to have overnight staff consistently review the EHR directly, especially as the physician notes are the most common nonsign‐out reference used. Nonetheless, the fact that hospitalists rely heavily on written sign‐out despite the availability of other information sources suggests that hospitalists find specific benefit in written sign‐out.
Limitations of this study include the relatively small sample size, the limited collection time period, and the single‐site nature. The YNHH Hospitalist Service uses only written documents to sign out, so the external validity to programs that use verbal sign‐out is limited. The written‐only nature, however, removes the variable of the discussion at time of sign‐out, improving the purity of the written sign‐out assessment. We did not assess workload, which might have affected sign‐out quality. The interpretation of the composite score is limited, due to little variation in scoring in our sample, as well as lack of validation in other studies. An additional limitation is that sign‐outs are not entirely drafted by the hospitalist attendings. Hospitalists draft the initial sign‐out document, but it is updated on subsequent days by the mid‐level provider under the direction of the hospitalist attending. It is therefore possible that sign‐outs maintained directly by hospitalists would have been of different quality. In this regard it is interesting to note that in a different study of verbal sign‐out we were not able to detect a difference in quality among hospitalists, trainees, and midlevels.[12] Last, hindsight bias may be present, as the covering physician's perspective of the event includes more information than available to the provider creating the sign‐out document.
Overall, we found that attending hospitalists rely heavily on written sign‐out documents to address overnight inquiries, but those sign‐outs are not reliably effective. Future work to better understand the roles of written and verbal components in sign‐out is needed to help improve the safety of overnight care.
Disclosures
Disclosures: Dr. Horwitz is supported by the National Institute on Aging (K08 AG038336) and by the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program. Dr. Horwitz is also a Pepper Scholar with support from the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (#P30AG021342 NIH/NIA). Dr. Fogerty had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The authors do not have conflicts of interest to report. Dr. Schoenfeld was a medical student at the Yale University School of Medicine, New Haven, Connecticut at the time of the study. She is now a resident at Massachusetts General Hospital in Boston, Massachusetts.
- , , , . The status of hospital medicine groups in the United States. J Hosp Med. 2006;1(2):75–80.
- , , , . Growth in the care of older patients by hospitalists in the United States. N Engl J Med. 2009;360(11):1102–1112.
- , , , et al. The Veterans Affairs shift change physician‐to‐physician handoff project. Jt Comm J Qual Patient Saf. 2010;36(2):62–71.
- , . The evolution and future of hospital medicine. Mt Sinai J Med. 2008;75(5):418–423.
- . The hospitalist movement—time to move on. N Engl J Med. 2007;357(25):2627–2629.
- , , . Invited article: is it time for neurohospitalists? Neurology. 2008;70(15):1282–1288.
- , , , . Survey of obstetric and gynecologic hospitalists and laborists. Am J Obstet Gynecol. 2010;203(2):177.e171–e174.
- , , , , , . Hospitalist handoffs: a systematic review and task force recommendations. J Hosp Med. 2009;4(7):433–440.
- , , , , . Core competencies in hospital medicine: development and methodology. J Hosp Med. 2006;1(1):48–56.
- , , , , . Gaining efficiency and satisfaction in the handoff process. J Hosp Med. 2010;5(9):547–552.
- , , , . Understanding communication during hospitalist service changes: a mixed methods study. J Hosp Med. 2009;4(9):535–540.
- , , , et al. Development of a handoff evaluation tool for shift‐to‐shift physician handoffs: the handoff CEX. J Hosp Med. 2013;8(4):191–200.
- , , , , . Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121(11):866–872.
- , , , et al. Effect of short call admission on length of stay and quality of care for acute decompensated heart failure. Circulation. 2008;117(20):2637–2644.
- , , , , . Consequences of inadequate sign‐out for patient care. Arch Intern Med. 2008;168(16):1755–1760.
- , , , , . Communication failures in patient sign‐out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14(6):401–407.
- , , , et al. An institution‐wide handoff task force to standardise and improve physician handoffs. BMJ Qual Saf. 2012;21(10):863–871.
- , , , , . What are covering doctors told about their patients? Analysis of sign‐out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248–255.
- , , , . Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166(11):1173–1177.
- , , , . A theoretical framework and competency‐based approach to improving handoffs. Qual Saf Health Care. 2008;17(1):11–14.
- , , . Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007;14(10):884–894.
- , , , , , . Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med. 2009;53(6):701–710.e704.
- , , , , , . Handover patterns: an observational study of critical care physicians. BMC Health Serv Res. 2012;12:11.
- , , , et al. Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care. Ann Surg. 2007;245(2):159–169.
- , , , , . Answering questions on call: Pediatric resident physicians' use of handoffs and other resources. J Hosp Med. 2013;8:328–333.
- , , , , . A randomized, controlled trial evaluating the impact of a computerized rounding and sign‐out system on continuity of care and resident work hours. J Am Coll Surg. 2005;200(4):538–545.
- , , , et al. Resident sign‐out and patient hand‐offs: opportunities for improvement. Teach Learn Med. 2011;23(2):105–111.
- , . A model for building a standardized hand‐off protocol. Jt Comm J Qual Patient Saf. 2006;32(11):646–655.
- , , , et al. The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care. Acad Med. 2012;87(4):411–418.
- The Joint Commission. 2013 Comprehensive Accreditation Manuals. Oak Brook, IL: The Joint Commission; 2012.
- , , , . The status of hospital medicine groups in the United States. J Hosp Med. 2006;1(2):75–80.
- , , , . Growth in the care of older patients by hospitalists in the United States. N Engl J Med. 2009;360(11):1102–1112.
- , , , et al. The Veterans Affairs shift change physician‐to‐physician handoff project. Jt Comm J Qual Patient Saf. 2010;36(2):62–71.
- , . The evolution and future of hospital medicine. Mt Sinai J Med. 2008;75(5):418–423.
- . The hospitalist movement—time to move on. N Engl J Med. 2007;357(25):2627–2629.
- , , . Invited article: is it time for neurohospitalists? Neurology. 2008;70(15):1282–1288.
- , , , . Survey of obstetric and gynecologic hospitalists and laborists. Am J Obstet Gynecol. 2010;203(2):177.e171–e174.
- , , , , , . Hospitalist handoffs: a systematic review and task force recommendations. J Hosp Med. 2009;4(7):433–440.
- , , , , . Core competencies in hospital medicine: development and methodology. J Hosp Med. 2006;1(1):48–56.
- , , , , . Gaining efficiency and satisfaction in the handoff process. J Hosp Med. 2010;5(9):547–552.
- , , , . Understanding communication during hospitalist service changes: a mixed methods study. J Hosp Med. 2009;4(9):535–540.
- , , , et al. Development of a handoff evaluation tool for shift‐to‐shift physician handoffs: the handoff CEX. J Hosp Med. 2013;8(4):191–200.
- , , , , . Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121(11):866–872.
- , , , et al. Effect of short call admission on length of stay and quality of care for acute decompensated heart failure. Circulation. 2008;117(20):2637–2644.
- , , , , . Consequences of inadequate sign‐out for patient care. Arch Intern Med. 2008;168(16):1755–1760.
- , , , , . Communication failures in patient sign‐out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14(6):401–407.
- , , , et al. An institution‐wide handoff task force to standardise and improve physician handoffs. BMJ Qual Saf. 2012;21(10):863–871.
- , , , , . What are covering doctors told about their patients? Analysis of sign‐out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248–255.
- , , , . Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166(11):1173–1177.
- , , , . A theoretical framework and competency‐based approach to improving handoffs. Qual Saf Health Care. 2008;17(1):11–14.
- , , . Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007;14(10):884–894.
- , , , , , . Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med. 2009;53(6):701–710.e704.
- , , , , , . Handover patterns: an observational study of critical care physicians. BMC Health Serv Res. 2012;12:11.
- , , , et al. Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care. Ann Surg. 2007;245(2):159–169.
- , , , , . Answering questions on call: Pediatric resident physicians' use of handoffs and other resources. J Hosp Med. 2013;8:328–333.
- , , , , . A randomized, controlled trial evaluating the impact of a computerized rounding and sign‐out system on continuity of care and resident work hours. J Am Coll Surg. 2005;200(4):538–545.
- , , , et al. Resident sign‐out and patient hand‐offs: opportunities for improvement. Teach Learn Med. 2011;23(2):105–111.
- , . A model for building a standardized hand‐off protocol. Jt Comm J Qual Patient Saf. 2006;32(11):646–655.
- , , , et al. The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care. Acad Med. 2012;87(4):411–418.
- The Joint Commission. 2013 Comprehensive Accreditation Manuals. Oak Brook, IL: The Joint Commission; 2012.
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