Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Who doesn’t know and love Consumer Reports? I personally have used this product to help me make a wide range of purchases, from child-care products to a new automobile. Consumer Reports has enjoyed a relatively unblemished reputation since its inception as an unbiased repository of invaluable information for consumers. This nonprofit advocacy organization advises consumers looking to purchase anything from small, menial items (e.g. blenders and toasters) to large, expensive ones (e.g. computers, lawn mowers, cars). It has been categorizing and publishing large-scale consumer feedback and in-house testing since 1936. According to Wikipedia, Consumer Reports has more than 7 million subscribers and runs a budget in excess of $21 million annually.

One of the reasons for its longstanding success is that it does not appear to have any hidden agenda. It does not have any partiality to a specific company or service, and therefore has maintained its impartial stance during testing and evaluation of any good or service. Its Consumer Reports magazine houses no advertisements in order to maintain its objectivity. Its only agenda is to reflect the interests and opinions of the consumers themselves, and its mission is to provide a “fair, just, and safe marketplace for all consumers and to empower consumers to protect themselves.”¹ A perfect agent from which to seek advice.

And as a company, it has grown with the times, as it now hosts a variety of platforms from which consumers can seek advice. It has long hosted a website (ConsumerReports.org). Now it has Consumer Reports Television and The Consumerist blog, the latter of which accepts “tips” from anyone on what stories to cover, helpful tips for consumers, or interesting pictures. For a few years, there was also Consumer Reports WebWatch, which was aimed at improving the credibility of websites through rigorous investigative reporting.

So it seems that Consumer Reports could be a good avenue to seek advice on where to “consume” health care. And, in fact, it is now in the business of rating the health-care industry. Recent blog posts from Consumer Reports have entailed topics as wide-ranging as the number of uninsured in the U.S. to the number and types of recalls of food products.

The health part of the website covers beauty and personal care (sunscreens and anti-wrinkle serums), exercise and fitness (bikes and diet plans), foods (coffee to frozen meals), home medical supplies (heart rate and blood pressure monitors), vitamins, supplements, and, last but not least, health services. This last section rates health insurance, heart surgeons, heart screening tests, and hospitals.

It even goes so far as to “rate” medications; its Best Buy Drugs compares the cost and effectiveness of a variety of prescription drugs ranging from anti-hypertensives to diabetic agents.

In Focus: Hospitals

Consumer Reports’ latest foray into the health-care industry now includes reporting on the quality of hospitals. The current ratings evaluated more than 2,000 acute-care hospitals in the U.S. and came up with several rankings.

The first rating includes “patient outcomes,” which is a conglomerate of hospital-acquired central-line-associated bloodstream infection (CLABSI) rates, select surgical-site-infection [SSI] rates, 30-day readmission rates (for acute MI [AMI], congestive heart failure [CHF], and pneumonia), and eight “Patient Safety Indicators” (derived from definitions from the Agency for Healthcare Research & Quality [AHRQ], and includes pressure ulcers, pneumothorax, CLABSI, accidental puncture injury during surgery, and four postoperative complications, including VTE, sepsis, hip fracture, and wound dehiscence).

It also includes ratings of the patient experience (from a subset of HCAHPS questions) and two measures of hospital practices, including the use of electronic health records (from the American Hospital Association) and the use of “double scans” (simultaneous thoracic and abdominal CT scans).

From all of these ratings, Consumer Reports combined some of the metrics to arrive at a “Safety Score,” which ranges from 0 to 100 (100 being the safest), based on five categories, including infections (CLABSI and SSI), readmission rates (for AMI, CHF, and pneumonia), patient ratings of communication about their medications and about their discharge process, rate of double scans, and avoidance of the aforementioned AHRQ Patient Safety Indicators.

As to how potential patients are supposed to use this information, Consumer Reports gives the following advice to those wanting to know how the ratings can help a patient get better care: “They can help you compare hospitals in your area so you can choose the one that’s best for you. Even if you don’t have a choice of hospitals, our ratings can alert you to particular concerns so you can take steps to prevent problems no matter which hospital you go to. For example, if a hospital scores low in communicating with patients about what to do when they’re discharged, you should ask about discharge planning at the hospital you choose and make sure you know what to do when you leave.”

Overall, the average Safety Score for included hospitals was a 49, with a range from 14 to 74 across the U.S. Teaching hospitals were among the lowest scorers, with two-thirds of them rated below average.

At first blush, the numbers seem humbling, even startling, but it is not clear if they reflect bad care or bad metrics. Consumer Reports, similar to many other rating scales, has glued together a hodge-podge of different metrics and converted them into a summary score that may or may not line up with other organizational ratings (e.g. U.S. News and World Report, Leapfrog Group, Healthgrades, etc). Consumer Reports does acknowledge that none of the information for their rankings is actually collected from Consumer Reports but from other sources, such as the Centers for Medicare & Medicaid Services (CMS) and the American Hospital Association (AHA).

The Bottom Line

Despite all this attention from Consumer Reports and others, online ratings are only used by about 14% of consumers to review hospitals or health-care facilities and by about 17% of consumers to review physicians or other health-care providers.² Although the uptick is relatively low for use of online ratings to seek health care, that likely will change as the measurements get better and are more reflective of true care quality.

The bottom line for consumers is: Where do I want to be hospitalized when I get sick, and can I tell at the front end in which aspects a hospital is going to do well?

I think the answer for consumers should be to stay informed, always have an advocate at your side, and never stop asking questions.And for now, relegate Consumer Reports to purchases, not health care.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Consumer Reports. How we rate hospitals. Consumer Reports website. Available at: http://www.consumerreports.org/cro/2012/10/how-we-rate-hospitals/index.htm. Accessed May 12, 2013.
2. Pew Internet & American Life Project. Peer-to-peer health care. Pew Internet website. Available at: http://www.pewinternet.org/Reports/2013/Health-online/Part-Two/Section-2.aspx. Accessed May 12, 2013.

Who doesn’t know and love Consumer Reports? I personally have used this product to help me make a wide range of purchases, from child-care products to a new automobile. Consumer Reports has enjoyed a relatively unblemished reputation since its inception as an unbiased repository of invaluable information for consumers. This nonprofit advocacy organization advises consumers looking to purchase anything from small, menial items (e.g. blenders and toasters) to large, expensive ones (e.g. computers, lawn mowers, cars). It has been categorizing and publishing large-scale consumer feedback and in-house testing since 1936. According to Wikipedia, Consumer Reports has more than 7 million subscribers and runs a budget in excess of $21 million annually.

One of the reasons for its longstanding success is that it does not appear to have any hidden agenda. It does not have any partiality to a specific company or service, and therefore has maintained its impartial stance during testing and evaluation of any good or service. Its Consumer Reports magazine houses no advertisements in order to maintain its objectivity. Its only agenda is to reflect the interests and opinions of the consumers themselves, and its mission is to provide a “fair, just, and safe marketplace for all consumers and to empower consumers to protect themselves.”¹ A perfect agent from which to seek advice.

And as a company, it has grown with the times, as it now hosts a variety of platforms from which consumers can seek advice. It has long hosted a website (ConsumerReports.org). Now it has Consumer Reports Television and The Consumerist blog, the latter of which accepts “tips” from anyone on what stories to cover, helpful tips for consumers, or interesting pictures. For a few years, there was also Consumer Reports WebWatch, which was aimed at improving the credibility of websites through rigorous investigative reporting.

So it seems that Consumer Reports could be a good avenue to seek advice on where to “consume” health care. And, in fact, it is now in the business of rating the health-care industry. Recent blog posts from Consumer Reports have entailed topics as wide-ranging as the number of uninsured in the U.S. to the number and types of recalls of food products.

The health part of the website covers beauty and personal care (sunscreens and anti-wrinkle serums), exercise and fitness (bikes and diet plans), foods (coffee to frozen meals), home medical supplies (heart rate and blood pressure monitors), vitamins, supplements, and, last but not least, health services. This last section rates health insurance, heart surgeons, heart screening tests, and hospitals.

It even goes so far as to “rate” medications; its Best Buy Drugs compares the cost and effectiveness of a variety of prescription drugs ranging from anti-hypertensives to diabetic agents.

In Focus: Hospitals

Consumer Reports’ latest foray into the health-care industry now includes reporting on the quality of hospitals. The current ratings evaluated more than 2,000 acute-care hospitals in the U.S. and came up with several rankings.

The first rating includes “patient outcomes,” which is a conglomerate of hospital-acquired central-line-associated bloodstream infection (CLABSI) rates, select surgical-site-infection [SSI] rates, 30-day readmission rates (for acute MI [AMI], congestive heart failure [CHF], and pneumonia), and eight “Patient Safety Indicators” (derived from definitions from the Agency for Healthcare Research & Quality [AHRQ], and includes pressure ulcers, pneumothorax, CLABSI, accidental puncture injury during surgery, and four postoperative complications, including VTE, sepsis, hip fracture, and wound dehiscence).

It also includes ratings of the patient experience (from a subset of HCAHPS questions) and two measures of hospital practices, including the use of electronic health records (from the American Hospital Association) and the use of “double scans” (simultaneous thoracic and abdominal CT scans).

From all of these ratings, Consumer Reports combined some of the metrics to arrive at a “Safety Score,” which ranges from 0 to 100 (100 being the safest), based on five categories, including infections (CLABSI and SSI), readmission rates (for AMI, CHF, and pneumonia), patient ratings of communication about their medications and about their discharge process, rate of double scans, and avoidance of the aforementioned AHRQ Patient Safety Indicators.

As to how potential patients are supposed to use this information, Consumer Reports gives the following advice to those wanting to know how the ratings can help a patient get better care: “They can help you compare hospitals in your area so you can choose the one that’s best for you. Even if you don’t have a choice of hospitals, our ratings can alert you to particular concerns so you can take steps to prevent problems no matter which hospital you go to. For example, if a hospital scores low in communicating with patients about what to do when they’re discharged, you should ask about discharge planning at the hospital you choose and make sure you know what to do when you leave.”

Overall, the average Safety Score for included hospitals was a 49, with a range from 14 to 74 across the U.S. Teaching hospitals were among the lowest scorers, with two-thirds of them rated below average.

At first blush, the numbers seem humbling, even startling, but it is not clear if they reflect bad care or bad metrics. Consumer Reports, similar to many other rating scales, has glued together a hodge-podge of different metrics and converted them into a summary score that may or may not line up with other organizational ratings (e.g. U.S. News and World Report, Leapfrog Group, Healthgrades, etc). Consumer Reports does acknowledge that none of the information for their rankings is actually collected from Consumer Reports but from other sources, such as the Centers for Medicare & Medicaid Services (CMS) and the American Hospital Association (AHA).

The Bottom Line

Despite all this attention from Consumer Reports and others, online ratings are only used by about 14% of consumers to review hospitals or health-care facilities and by about 17% of consumers to review physicians or other health-care providers.² Although the uptick is relatively low for use of online ratings to seek health care, that likely will change as the measurements get better and are more reflective of true care quality.

The bottom line for consumers is: Where do I want to be hospitalized when I get sick, and can I tell at the front end in which aspects a hospital is going to do well?

I think the answer for consumers should be to stay informed, always have an advocate at your side, and never stop asking questions.And for now, relegate Consumer Reports to purchases, not health care.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Consumer Reports. How we rate hospitals. Consumer Reports website. Available at: http://www.consumerreports.org/cro/2012/10/how-we-rate-hospitals/index.htm. Accessed May 12, 2013.
2. Pew Internet & American Life Project. Peer-to-peer health care. Pew Internet website. Available at: http://www.pewinternet.org/Reports/2013/Health-online/Part-Two/Section-2.aspx. Accessed May 12, 2013.

Who doesn’t know and love Consumer Reports? I personally have used this product to help me make a wide range of purchases, from child-care products to a new automobile. Consumer Reports has enjoyed a relatively unblemished reputation since its inception as an unbiased repository of invaluable information for consumers. This nonprofit advocacy organization advises consumers looking to purchase anything from small, menial items (e.g. blenders and toasters) to large, expensive ones (e.g. computers, lawn mowers, cars). It has been categorizing and publishing large-scale consumer feedback and in-house testing since 1936. According to Wikipedia, Consumer Reports has more than 7 million subscribers and runs a budget in excess of $21 million annually.

One of the reasons for its longstanding success is that it does not appear to have any hidden agenda. It does not have any partiality to a specific company or service, and therefore has maintained its impartial stance during testing and evaluation of any good or service. Its Consumer Reports magazine houses no advertisements in order to maintain its objectivity. Its only agenda is to reflect the interests and opinions of the consumers themselves, and its mission is to provide a “fair, just, and safe marketplace for all consumers and to empower consumers to protect themselves.”¹ A perfect agent from which to seek advice.

And as a company, it has grown with the times, as it now hosts a variety of platforms from which consumers can seek advice. It has long hosted a website (ConsumerReports.org). Now it has Consumer Reports Television and The Consumerist blog, the latter of which accepts “tips” from anyone on what stories to cover, helpful tips for consumers, or interesting pictures. For a few years, there was also Consumer Reports WebWatch, which was aimed at improving the credibility of websites through rigorous investigative reporting.

So it seems that Consumer Reports could be a good avenue to seek advice on where to “consume” health care. And, in fact, it is now in the business of rating the health-care industry. Recent blog posts from Consumer Reports have entailed topics as wide-ranging as the number of uninsured in the U.S. to the number and types of recalls of food products.

The health part of the website covers beauty and personal care (sunscreens and anti-wrinkle serums), exercise and fitness (bikes and diet plans), foods (coffee to frozen meals), home medical supplies (heart rate and blood pressure monitors), vitamins, supplements, and, last but not least, health services. This last section rates health insurance, heart surgeons, heart screening tests, and hospitals.

It even goes so far as to “rate” medications; its Best Buy Drugs compares the cost and effectiveness of a variety of prescription drugs ranging from anti-hypertensives to diabetic agents.

In Focus: Hospitals

Consumer Reports’ latest foray into the health-care industry now includes reporting on the quality of hospitals. The current ratings evaluated more than 2,000 acute-care hospitals in the U.S. and came up with several rankings.

The first rating includes “patient outcomes,” which is a conglomerate of hospital-acquired central-line-associated bloodstream infection (CLABSI) rates, select surgical-site-infection [SSI] rates, 30-day readmission rates (for acute MI [AMI], congestive heart failure [CHF], and pneumonia), and eight “Patient Safety Indicators” (derived from definitions from the Agency for Healthcare Research & Quality [AHRQ], and includes pressure ulcers, pneumothorax, CLABSI, accidental puncture injury during surgery, and four postoperative complications, including VTE, sepsis, hip fracture, and wound dehiscence).

It also includes ratings of the patient experience (from a subset of HCAHPS questions) and two measures of hospital practices, including the use of electronic health records (from the American Hospital Association) and the use of “double scans” (simultaneous thoracic and abdominal CT scans).

From all of these ratings, Consumer Reports combined some of the metrics to arrive at a “Safety Score,” which ranges from 0 to 100 (100 being the safest), based on five categories, including infections (CLABSI and SSI), readmission rates (for AMI, CHF, and pneumonia), patient ratings of communication about their medications and about their discharge process, rate of double scans, and avoidance of the aforementioned AHRQ Patient Safety Indicators.

As to how potential patients are supposed to use this information, Consumer Reports gives the following advice to those wanting to know how the ratings can help a patient get better care: “They can help you compare hospitals in your area so you can choose the one that’s best for you. Even if you don’t have a choice of hospitals, our ratings can alert you to particular concerns so you can take steps to prevent problems no matter which hospital you go to. For example, if a hospital scores low in communicating with patients about what to do when they’re discharged, you should ask about discharge planning at the hospital you choose and make sure you know what to do when you leave.”

Overall, the average Safety Score for included hospitals was a 49, with a range from 14 to 74 across the U.S. Teaching hospitals were among the lowest scorers, with two-thirds of them rated below average.

At first blush, the numbers seem humbling, even startling, but it is not clear if they reflect bad care or bad metrics. Consumer Reports, similar to many other rating scales, has glued together a hodge-podge of different metrics and converted them into a summary score that may or may not line up with other organizational ratings (e.g. U.S. News and World Report, Leapfrog Group, Healthgrades, etc). Consumer Reports does acknowledge that none of the information for their rankings is actually collected from Consumer Reports but from other sources, such as the Centers for Medicare & Medicaid Services (CMS) and the American Hospital Association (AHA).

The Bottom Line

Despite all this attention from Consumer Reports and others, online ratings are only used by about 14% of consumers to review hospitals or health-care facilities and by about 17% of consumers to review physicians or other health-care providers.² Although the uptick is relatively low for use of online ratings to seek health care, that likely will change as the measurements get better and are more reflective of true care quality.

The bottom line for consumers is: Where do I want to be hospitalized when I get sick, and can I tell at the front end in which aspects a hospital is going to do well?

I think the answer for consumers should be to stay informed, always have an advocate at your side, and never stop asking questions.And for now, relegate Consumer Reports to purchases, not health care.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Consumer Reports. How we rate hospitals. Consumer Reports website. Available at: http://www.consumerreports.org/cro/2012/10/how-we-rate-hospitals/index.htm. Accessed May 12, 2013.
2. Pew Internet & American Life Project. Peer-to-peer health care. Pew Internet website. Available at: http://www.pewinternet.org/Reports/2013/Health-online/Part-Two/Section-2.aspx. Accessed May 12, 2013.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

Legend has it that Alexander the Great once was confronted with an intricate knot tying up a sacred ox cart in the palace of the Phrygians, whom he was trying to conquer. When his attempts to untie the knot proved unsuccessful, he drew his sword and sliced it in half, thus providing a rapid if inelegant solution.

Pediatric hospital medicine (PHM) now finds itself facing a similar dilemma in its attempts to define its “kingdom.” The question: Who will become citizens of this kingdom—and who will be left outside the gates? And will this intricate knot be unraveled or simply cut?

In some ways, the mere posing of this question signifies the success PHM has forged for itself over the past decade. At its core, the question of how to define the identity, and thus the training, of a pediatric hospitalist is rooted in noble ideals: excellence in the management of hospitalized children, robust training in quality improvement, patient safety, and cost-effective care.¹ Yet this question also stirs up more base feelings frequently articulated in many a physician lounge: territoriality, inadequacy, feeling excluded.

Nevertheless, the question must be answered.

In many ways, the situation in which PHM finds itself mirrors the dilemma facing pediatrics itself in its infancy. As Borden Veeder, the first president of the American Board of Pediatrics (ABP), wrote in the 1930s, “There were no legal or medical requirements relating to the training and education of specialists—all a man licensed to practice medicine had to do was to announce himself as a surgeon, internist, pediatrician, etc., as he preferred.”² In 1933, the ABP was incorporated, with representatives from the American Academy of Pediatrics (AAP), the American Medical Association (AMA) section on pediatrics, and the American Pediatric Society.

Facing a similar state of confusion, hospitalist leaders of the PHM community in 2010 formed the Strategic Planning Committee (STP) to evaluate training and certification options for PHM as a distinct discipline.³ Co-chairs of the STP Committee were chosen by consensus from a group composed of one representative each from the AAP Section on Hospital Medicine (AAP SOHM), the Academic Pediatric Association (APA), and SHM. The STP identified various training and/or certification options that could define PHM as a subspecialty. A survey with these options was distributed to the PHM community via the listservs of the APA, the AAP SOHM, and the AAP. The results:³

• 33% of respondents preferred Recognition of Focused Practice through the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC);
• 30% preferred a two-year fellowship; and
• 17% suggested an HM track within pediatric residency.

Yet at the PHM Leaders Conference in Chapel Hill, N.C., in April, “there was overwhelming consensus that an MOC program could not provide the rigor to insure [sic] that all pediatric hospitalists would meet a standard.”⁴ Further, “there was overwhelming consensus that a standardized training program resulting in certification was the best option to assure adequate training in the PHM Core Competencies and provide the public with a meaningful definition of a pediatric hospitalist” and “that the duration of such training should be two years.” Why, one might ask, would those present feel so strongly that the MOC model would be inadequate?

Many concerns regarding MOC were voiced, including whether MOC addresses a knowledge gap after residency (which it does to some extent through ongoing recertification requirements), whether it ensures public trust (but it had “positive potential”), and whether it addressed core competencies (to which the leadership present answered “yes, if rigorous”).⁴

The perception that the Focused Practice in Hospital Medicine (FPHM) MOC was “not a successful model so far in adult hospital medicine” seemed to weigh heavily on the minds of those in attendance. This perception may have arisen from data showing a somewhat low number of adult hospitalists (363 completed, 527 in process) having successfully completed the FPHM MOC to date. Of note, the possibility of a FPHM MOC for PHM was considered a “non-starter” by the ABP representatives, who in turn attributed this determination to the American Board of Medical Specialties (ABMS).⁵

There are, of course, many reasons for the low turnout for adult FPHM MOC. Candidates must have been previously certified in internal medicine of family medicine, and thus entry into the FPHM MOC would only arise at recertification or if one decided to seek FPHM certification “early”—that is, prior to the need for recertification. Being not only a Procrastination Club president but also a client, I was not among the 67 virtuous hospitalists who were among the first class of FPHM diplomates in 2011.⁶ The FPHM MOC also initially was more rigorous than the traditional IM recertification, in that it required completion of a practice-improvement module (PIM) every three years versus every 10 years (in 2014, both the traditional IM and FPHM MOC programs will require PIM completion every 5 years). Without a clearly mandated requirement from most HM groups, at the inception of the FPHM MOC one would be entering a more rigorous recertification process without a clear benefit.

This lack of a requirement from adult HM groups for completion or entry into the FPHM MOC, in turn, arises from a straightforward issue: workforce. Requiring all hospitalists in your HM group to have completed or entered FPHM MOC is a bar most directors and chiefs are not prepared to raise given its potential to shrink their applicant pool. With only 32 to 35 graduates of pediatric HM fellowship programs yearly, workforce issues should clearly be of concern to the PHM community given the current estimates that pediatric hospitalists number anywhere from 1,500 to 3,000.^6,7

Is the adult FPHM MOC process perfect? Nothing created by so many committees and professional societies could ever be, but as a first iteration, it certainly created a relatively sturdy straw man. Could the PHM community create a FPHM MOC upon this model that was refined and tailored to their needs? Creating and requiring completion of a robust PHM-specific curriculum via required self-evaluation modules, requiring not only patient encounter thresholds but also evidence of quality care, and developing PIMs specific to PHM would all go a long way to making a FPHM MOC an acceptable alternative for pediatric hospitalist “designation.”

In any case, the gauntlet seems to have been thrown down already in Chapel Hill in favor of a two-year fellowship leading to certification. I admire those present for advocating a training and certification that provides the least compromise in defining the path of future pediatric hospitalists. But I suspect that the answer to the problem of PHM’s future may not be so simple as a single sharp-edged solution and might lie in a more complex array of options for future pediatric hospitalists.

Dr. Chang is pediatric editor of The Hospitalist. He is associate clinical professor of medicine and pediatrics at the University of California at San Diego (UCSD) School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. Send comments and questions to [email protected].

References

1. Maniscalco J, Fisher ES. Pediatric hospital medicine and education: why we can’t stand still. JAMA Pediatr. 2013;167:412-413.
2. Brownlee RC. The American Board of Pediatrics: its origin and early history. Pediatrics. 1994;94:732-735.
3. Maloney CG, Mendez SS, Quinonez RA, et al. The Strategic Planning Committee report: the first step in a journey to recognize pediatric hospital medicine as a distinct discipline. Hospital Pediatrics. 2012;2:187-190.
4. Strategic Planning Committee. Strategic planning for the future of pediatric hospital medicine. Strategic Planning Committee website. Available at: http://stpcommittee.blogspot.com/2013/04/phm-leadership-conference-april-4-5.htmlfiles/97/phm-leadership-conference-april-4-5.html. Accessed July 4, 2013.
5. Fisher ES. (2013) Email sent to Chang WW. 25 June.
6. Carris J. Defining moment: focused practice in HM. The Hospitalist website. Available at: http://www.the-hospitalist.org/details/article/1018793/Defining_Moment_Focused_Practice_in_HM.html. Accessed June 15, 2013.
7. American Academy of Pediatrics. PHM fellowship info. American Academy of Pediatrics website. Available at: http://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Section-on-Hospital-Medicine.html. Accessed June 15, 2013.
8. Rauch DA, Lye PS, Carlson D, et al. Pediatric hospital medicine: a strategic planning roundtable to chart the future. J Hosp Med. 2012;7:329-334.

Legend has it that Alexander the Great once was confronted with an intricate knot tying up a sacred ox cart in the palace of the Phrygians, whom he was trying to conquer. When his attempts to untie the knot proved unsuccessful, he drew his sword and sliced it in half, thus providing a rapid if inelegant solution.

Pediatric hospital medicine (PHM) now finds itself facing a similar dilemma in its attempts to define its “kingdom.” The question: Who will become citizens of this kingdom—and who will be left outside the gates? And will this intricate knot be unraveled or simply cut?

In some ways, the mere posing of this question signifies the success PHM has forged for itself over the past decade. At its core, the question of how to define the identity, and thus the training, of a pediatric hospitalist is rooted in noble ideals: excellence in the management of hospitalized children, robust training in quality improvement, patient safety, and cost-effective care.¹ Yet this question also stirs up more base feelings frequently articulated in many a physician lounge: territoriality, inadequacy, feeling excluded.

Nevertheless, the question must be answered.

In many ways, the situation in which PHM finds itself mirrors the dilemma facing pediatrics itself in its infancy. As Borden Veeder, the first president of the American Board of Pediatrics (ABP), wrote in the 1930s, “There were no legal or medical requirements relating to the training and education of specialists—all a man licensed to practice medicine had to do was to announce himself as a surgeon, internist, pediatrician, etc., as he preferred.”² In 1933, the ABP was incorporated, with representatives from the American Academy of Pediatrics (AAP), the American Medical Association (AMA) section on pediatrics, and the American Pediatric Society.

Facing a similar state of confusion, hospitalist leaders of the PHM community in 2010 formed the Strategic Planning Committee (STP) to evaluate training and certification options for PHM as a distinct discipline.³ Co-chairs of the STP Committee were chosen by consensus from a group composed of one representative each from the AAP Section on Hospital Medicine (AAP SOHM), the Academic Pediatric Association (APA), and SHM. The STP identified various training and/or certification options that could define PHM as a subspecialty. A survey with these options was distributed to the PHM community via the listservs of the APA, the AAP SOHM, and the AAP. The results:³

• 33% of respondents preferred Recognition of Focused Practice through the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC);
• 30% preferred a two-year fellowship; and
• 17% suggested an HM track within pediatric residency.

Yet at the PHM Leaders Conference in Chapel Hill, N.C., in April, “there was overwhelming consensus that an MOC program could not provide the rigor to insure [sic] that all pediatric hospitalists would meet a standard.”⁴ Further, “there was overwhelming consensus that a standardized training program resulting in certification was the best option to assure adequate training in the PHM Core Competencies and provide the public with a meaningful definition of a pediatric hospitalist” and “that the duration of such training should be two years.” Why, one might ask, would those present feel so strongly that the MOC model would be inadequate?

Many concerns regarding MOC were voiced, including whether MOC addresses a knowledge gap after residency (which it does to some extent through ongoing recertification requirements), whether it ensures public trust (but it had “positive potential”), and whether it addressed core competencies (to which the leadership present answered “yes, if rigorous”).⁴

The perception that the Focused Practice in Hospital Medicine (FPHM) MOC was “not a successful model so far in adult hospital medicine” seemed to weigh heavily on the minds of those in attendance. This perception may have arisen from data showing a somewhat low number of adult hospitalists (363 completed, 527 in process) having successfully completed the FPHM MOC to date. Of note, the possibility of a FPHM MOC for PHM was considered a “non-starter” by the ABP representatives, who in turn attributed this determination to the American Board of Medical Specialties (ABMS).⁵

There are, of course, many reasons for the low turnout for adult FPHM MOC. Candidates must have been previously certified in internal medicine of family medicine, and thus entry into the FPHM MOC would only arise at recertification or if one decided to seek FPHM certification “early”—that is, prior to the need for recertification. Being not only a Procrastination Club president but also a client, I was not among the 67 virtuous hospitalists who were among the first class of FPHM diplomates in 2011.⁶ The FPHM MOC also initially was more rigorous than the traditional IM recertification, in that it required completion of a practice-improvement module (PIM) every three years versus every 10 years (in 2014, both the traditional IM and FPHM MOC programs will require PIM completion every 5 years). Without a clearly mandated requirement from most HM groups, at the inception of the FPHM MOC one would be entering a more rigorous recertification process without a clear benefit.

This lack of a requirement from adult HM groups for completion or entry into the FPHM MOC, in turn, arises from a straightforward issue: workforce. Requiring all hospitalists in your HM group to have completed or entered FPHM MOC is a bar most directors and chiefs are not prepared to raise given its potential to shrink their applicant pool. With only 32 to 35 graduates of pediatric HM fellowship programs yearly, workforce issues should clearly be of concern to the PHM community given the current estimates that pediatric hospitalists number anywhere from 1,500 to 3,000.^6,7

Is the adult FPHM MOC process perfect? Nothing created by so many committees and professional societies could ever be, but as a first iteration, it certainly created a relatively sturdy straw man. Could the PHM community create a FPHM MOC upon this model that was refined and tailored to their needs? Creating and requiring completion of a robust PHM-specific curriculum via required self-evaluation modules, requiring not only patient encounter thresholds but also evidence of quality care, and developing PIMs specific to PHM would all go a long way to making a FPHM MOC an acceptable alternative for pediatric hospitalist “designation.”

In any case, the gauntlet seems to have been thrown down already in Chapel Hill in favor of a two-year fellowship leading to certification. I admire those present for advocating a training and certification that provides the least compromise in defining the path of future pediatric hospitalists. But I suspect that the answer to the problem of PHM’s future may not be so simple as a single sharp-edged solution and might lie in a more complex array of options for future pediatric hospitalists.

Dr. Chang is pediatric editor of The Hospitalist. He is associate clinical professor of medicine and pediatrics at the University of California at San Diego (UCSD) School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. Send comments and questions to [email protected].

References

1. Maniscalco J, Fisher ES. Pediatric hospital medicine and education: why we can’t stand still. JAMA Pediatr. 2013;167:412-413.
2. Brownlee RC. The American Board of Pediatrics: its origin and early history. Pediatrics. 1994;94:732-735.
3. Maloney CG, Mendez SS, Quinonez RA, et al. The Strategic Planning Committee report: the first step in a journey to recognize pediatric hospital medicine as a distinct discipline. Hospital Pediatrics. 2012;2:187-190.
4. Strategic Planning Committee. Strategic planning for the future of pediatric hospital medicine. Strategic Planning Committee website. Available at: http://stpcommittee.blogspot.com/2013/04/phm-leadership-conference-april-4-5.htmlfiles/97/phm-leadership-conference-april-4-5.html. Accessed July 4, 2013.
5. Fisher ES. (2013) Email sent to Chang WW. 25 June.
6. Carris J. Defining moment: focused practice in HM. The Hospitalist website. Available at: http://www.the-hospitalist.org/details/article/1018793/Defining_Moment_Focused_Practice_in_HM.html. Accessed June 15, 2013.
7. American Academy of Pediatrics. PHM fellowship info. American Academy of Pediatrics website. Available at: http://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Section-on-Hospital-Medicine.html. Accessed June 15, 2013.
8. Rauch DA, Lye PS, Carlson D, et al. Pediatric hospital medicine: a strategic planning roundtable to chart the future. J Hosp Med. 2012;7:329-334.

Legend has it that Alexander the Great once was confronted with an intricate knot tying up a sacred ox cart in the palace of the Phrygians, whom he was trying to conquer. When his attempts to untie the knot proved unsuccessful, he drew his sword and sliced it in half, thus providing a rapid if inelegant solution.

Pediatric hospital medicine (PHM) now finds itself facing a similar dilemma in its attempts to define its “kingdom.” The question: Who will become citizens of this kingdom—and who will be left outside the gates? And will this intricate knot be unraveled or simply cut?

In some ways, the mere posing of this question signifies the success PHM has forged for itself over the past decade. At its core, the question of how to define the identity, and thus the training, of a pediatric hospitalist is rooted in noble ideals: excellence in the management of hospitalized children, robust training in quality improvement, patient safety, and cost-effective care.¹ Yet this question also stirs up more base feelings frequently articulated in many a physician lounge: territoriality, inadequacy, feeling excluded.

Nevertheless, the question must be answered.

In many ways, the situation in which PHM finds itself mirrors the dilemma facing pediatrics itself in its infancy. As Borden Veeder, the first president of the American Board of Pediatrics (ABP), wrote in the 1930s, “There were no legal or medical requirements relating to the training and education of specialists—all a man licensed to practice medicine had to do was to announce himself as a surgeon, internist, pediatrician, etc., as he preferred.”² In 1933, the ABP was incorporated, with representatives from the American Academy of Pediatrics (AAP), the American Medical Association (AMA) section on pediatrics, and the American Pediatric Society.

Facing a similar state of confusion, hospitalist leaders of the PHM community in 2010 formed the Strategic Planning Committee (STP) to evaluate training and certification options for PHM as a distinct discipline.³ Co-chairs of the STP Committee were chosen by consensus from a group composed of one representative each from the AAP Section on Hospital Medicine (AAP SOHM), the Academic Pediatric Association (APA), and SHM. The STP identified various training and/or certification options that could define PHM as a subspecialty. A survey with these options was distributed to the PHM community via the listservs of the APA, the AAP SOHM, and the AAP. The results:³

• 33% of respondents preferred Recognition of Focused Practice through the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC);
• 30% preferred a two-year fellowship; and
• 17% suggested an HM track within pediatric residency.

Yet at the PHM Leaders Conference in Chapel Hill, N.C., in April, “there was overwhelming consensus that an MOC program could not provide the rigor to insure [sic] that all pediatric hospitalists would meet a standard.”⁴ Further, “there was overwhelming consensus that a standardized training program resulting in certification was the best option to assure adequate training in the PHM Core Competencies and provide the public with a meaningful definition of a pediatric hospitalist” and “that the duration of such training should be two years.” Why, one might ask, would those present feel so strongly that the MOC model would be inadequate?

Many concerns regarding MOC were voiced, including whether MOC addresses a knowledge gap after residency (which it does to some extent through ongoing recertification requirements), whether it ensures public trust (but it had “positive potential”), and whether it addressed core competencies (to which the leadership present answered “yes, if rigorous”).⁴

The perception that the Focused Practice in Hospital Medicine (FPHM) MOC was “not a successful model so far in adult hospital medicine” seemed to weigh heavily on the minds of those in attendance. This perception may have arisen from data showing a somewhat low number of adult hospitalists (363 completed, 527 in process) having successfully completed the FPHM MOC to date. Of note, the possibility of a FPHM MOC for PHM was considered a “non-starter” by the ABP representatives, who in turn attributed this determination to the American Board of Medical Specialties (ABMS).⁵

There are, of course, many reasons for the low turnout for adult FPHM MOC. Candidates must have been previously certified in internal medicine of family medicine, and thus entry into the FPHM MOC would only arise at recertification or if one decided to seek FPHM certification “early”—that is, prior to the need for recertification. Being not only a Procrastination Club president but also a client, I was not among the 67 virtuous hospitalists who were among the first class of FPHM diplomates in 2011.⁶ The FPHM MOC also initially was more rigorous than the traditional IM recertification, in that it required completion of a practice-improvement module (PIM) every three years versus every 10 years (in 2014, both the traditional IM and FPHM MOC programs will require PIM completion every 5 years). Without a clearly mandated requirement from most HM groups, at the inception of the FPHM MOC one would be entering a more rigorous recertification process without a clear benefit.

This lack of a requirement from adult HM groups for completion or entry into the FPHM MOC, in turn, arises from a straightforward issue: workforce. Requiring all hospitalists in your HM group to have completed or entered FPHM MOC is a bar most directors and chiefs are not prepared to raise given its potential to shrink their applicant pool. With only 32 to 35 graduates of pediatric HM fellowship programs yearly, workforce issues should clearly be of concern to the PHM community given the current estimates that pediatric hospitalists number anywhere from 1,500 to 3,000.^6,7

Is the adult FPHM MOC process perfect? Nothing created by so many committees and professional societies could ever be, but as a first iteration, it certainly created a relatively sturdy straw man. Could the PHM community create a FPHM MOC upon this model that was refined and tailored to their needs? Creating and requiring completion of a robust PHM-specific curriculum via required self-evaluation modules, requiring not only patient encounter thresholds but also evidence of quality care, and developing PIMs specific to PHM would all go a long way to making a FPHM MOC an acceptable alternative for pediatric hospitalist “designation.”

In any case, the gauntlet seems to have been thrown down already in Chapel Hill in favor of a two-year fellowship leading to certification. I admire those present for advocating a training and certification that provides the least compromise in defining the path of future pediatric hospitalists. But I suspect that the answer to the problem of PHM’s future may not be so simple as a single sharp-edged solution and might lie in a more complex array of options for future pediatric hospitalists.

Dr. Chang is pediatric editor of The Hospitalist. He is associate clinical professor of medicine and pediatrics at the University of California at San Diego (UCSD) School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. Send comments and questions to [email protected].

References

1. Maniscalco J, Fisher ES. Pediatric hospital medicine and education: why we can’t stand still. JAMA Pediatr. 2013;167:412-413.
2. Brownlee RC. The American Board of Pediatrics: its origin and early history. Pediatrics. 1994;94:732-735.
3. Maloney CG, Mendez SS, Quinonez RA, et al. The Strategic Planning Committee report: the first step in a journey to recognize pediatric hospital medicine as a distinct discipline. Hospital Pediatrics. 2012;2:187-190.
4. Strategic Planning Committee. Strategic planning for the future of pediatric hospital medicine. Strategic Planning Committee website. Available at: http://stpcommittee.blogspot.com/2013/04/phm-leadership-conference-april-4-5.htmlfiles/97/phm-leadership-conference-april-4-5.html. Accessed July 4, 2013.
5. Fisher ES. (2013) Email sent to Chang WW. 25 June.
6. Carris J. Defining moment: focused practice in HM. The Hospitalist website. Available at: http://www.the-hospitalist.org/details/article/1018793/Defining_Moment_Focused_Practice_in_HM.html. Accessed June 15, 2013.
7. American Academy of Pediatrics. PHM fellowship info. American Academy of Pediatrics website. Available at: http://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Section-on-Hospital-Medicine.html. Accessed June 15, 2013.
8. Rauch DA, Lye PS, Carlson D, et al. Pediatric hospital medicine: a strategic planning roundtable to chart the future. J Hosp Med. 2012;7:329-334.

Dr. Hospitalist

Dear Dr. Hospitalist:

Our group is considering hiring another nocturnist. This may reduce the number of shifts that hospitalists will be able to work per month—we have some who work 20 or more shifts per month. While the vast majority of hospitalists would welcome a nocturnist in order to decrease the number of night shifts required, some who work a lot of shifts are concerned that their income will be affected since there won’t necessarily be any day shifts available to compensate for the decrease in night shifts.

I am wondering if there is a maximum number of shifts per month that a hospitalist should not exceed. We work 12-hour shifts. In other words, is there a tipping point when too many shifts starts to negatively impact the quality of work, increase length of stay, decrease patient satisfaction, and lead to physician burnout? Are there any studies or data to look at this question?

Your feedback is very much appreciated.

–Donna Ting, MD, MPH

Dr. Hospitalist responds:

Although many jobs (i.e. air-traffic controllers, truck drivers) use hours worked as a gauge of operator fatigue, physicians traditionally have not used these criteria to judge one’s ability to be effective. That being said, we all know of occasions when we were physically and/or mentally exhausted and not performing at our best.

Multiple studies have shown that physicians tend to work an average of 60 hours a week. Of course, this does not take into consideration the typical hospitalist, who still tends to work 12-hour shifts on a seven-on/seven-off schedule, although there is a trend away from this type of block scheduling. A recent study also showed that physicians in practice less than five years were more likely to work hours in agreement with the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty-hour regulations for physicians in training. The authors speculated that this was due to this group having trained under the new ACGME guidelines and being of Generation X, whose members tend to favor more work-life balance than their predecessors.

Several studies have examined physician work hours in relationship to fatigue and patient safety. Volp et al examined two large studies and found no change in mortality among Medicare patients for the first two years after implementation of the ACGME duty-hour regulations. However, they did find that mortality decreased for four common medical conditions in a VA hospital. Fletcher et al performed a systematic review and found no conclusive evidence that the decreased resident work hours had any affect on patient safety.

This is what I would have expected: inconclusive data. Most studies of this type are surveys, which have well-known limitations. Each of us has our own individual stamina, tolerance for fatigue, and desire for work-life balance. We intuitively know that most individuals are not at their best when tired or stressed, but to capture the true effect of these variables on patient satisfaction, morbidity, mortality, and other clinical metrics will be very difficult.

There are several ways I would approach a group that is contemplating another nocturnist. Because most hospitalists don’t want to work nights, the group members who feel their moonlighting income would be affected should commit to covering a certain portion or all of the available nights. If only some of the nights are covered, then you can hire a part-time nocturnist.

This is easier than you might imagine, as my very large hospitalist group has four nocturnists and none work a full FTE. I think three to four extra shifts a month are reasonable on a routine basis. We have, however, allowed physicians who wanted to have a month off to work seven extra days the months before and after to get their desired time off. We would not allow that to occur on a regular basis.

Ultimately, your group has to decide its own tolerance for fatigue and burnout, and have some mechanism to monitor the quality of work. After all, we owe it to our patients to not place their safety in jeopardy.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

Dear Dr. Hospitalist:

Our group is considering hiring another nocturnist. This may reduce the number of shifts that hospitalists will be able to work per month—we have some who work 20 or more shifts per month. While the vast majority of hospitalists would welcome a nocturnist in order to decrease the number of night shifts required, some who work a lot of shifts are concerned that their income will be affected since there won’t necessarily be any day shifts available to compensate for the decrease in night shifts.

I am wondering if there is a maximum number of shifts per month that a hospitalist should not exceed. We work 12-hour shifts. In other words, is there a tipping point when too many shifts starts to negatively impact the quality of work, increase length of stay, decrease patient satisfaction, and lead to physician burnout? Are there any studies or data to look at this question?

Your feedback is very much appreciated.

–Donna Ting, MD, MPH

Dr. Hospitalist responds:

Although many jobs (i.e. air-traffic controllers, truck drivers) use hours worked as a gauge of operator fatigue, physicians traditionally have not used these criteria to judge one’s ability to be effective. That being said, we all know of occasions when we were physically and/or mentally exhausted and not performing at our best.

Multiple studies have shown that physicians tend to work an average of 60 hours a week. Of course, this does not take into consideration the typical hospitalist, who still tends to work 12-hour shifts on a seven-on/seven-off schedule, although there is a trend away from this type of block scheduling. A recent study also showed that physicians in practice less than five years were more likely to work hours in agreement with the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty-hour regulations for physicians in training. The authors speculated that this was due to this group having trained under the new ACGME guidelines and being of Generation X, whose members tend to favor more work-life balance than their predecessors.

Several studies have examined physician work hours in relationship to fatigue and patient safety. Volp et al examined two large studies and found no change in mortality among Medicare patients for the first two years after implementation of the ACGME duty-hour regulations. However, they did find that mortality decreased for four common medical conditions in a VA hospital. Fletcher et al performed a systematic review and found no conclusive evidence that the decreased resident work hours had any affect on patient safety.

This is what I would have expected: inconclusive data. Most studies of this type are surveys, which have well-known limitations. Each of us has our own individual stamina, tolerance for fatigue, and desire for work-life balance. We intuitively know that most individuals are not at their best when tired or stressed, but to capture the true effect of these variables on patient satisfaction, morbidity, mortality, and other clinical metrics will be very difficult.

There are several ways I would approach a group that is contemplating another nocturnist. Because most hospitalists don’t want to work nights, the group members who feel their moonlighting income would be affected should commit to covering a certain portion or all of the available nights. If only some of the nights are covered, then you can hire a part-time nocturnist.

This is easier than you might imagine, as my very large hospitalist group has four nocturnists and none work a full FTE. I think three to four extra shifts a month are reasonable on a routine basis. We have, however, allowed physicians who wanted to have a month off to work seven extra days the months before and after to get their desired time off. We would not allow that to occur on a regular basis.

Ultimately, your group has to decide its own tolerance for fatigue and burnout, and have some mechanism to monitor the quality of work. After all, we owe it to our patients to not place their safety in jeopardy.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

Dear Dr. Hospitalist:

Our group is considering hiring another nocturnist. This may reduce the number of shifts that hospitalists will be able to work per month—we have some who work 20 or more shifts per month. While the vast majority of hospitalists would welcome a nocturnist in order to decrease the number of night shifts required, some who work a lot of shifts are concerned that their income will be affected since there won’t necessarily be any day shifts available to compensate for the decrease in night shifts.

I am wondering if there is a maximum number of shifts per month that a hospitalist should not exceed. We work 12-hour shifts. In other words, is there a tipping point when too many shifts starts to negatively impact the quality of work, increase length of stay, decrease patient satisfaction, and lead to physician burnout? Are there any studies or data to look at this question?

Your feedback is very much appreciated.

–Donna Ting, MD, MPH

Dr. Hospitalist responds:

Although many jobs (i.e. air-traffic controllers, truck drivers) use hours worked as a gauge of operator fatigue, physicians traditionally have not used these criteria to judge one’s ability to be effective. That being said, we all know of occasions when we were physically and/or mentally exhausted and not performing at our best.

Multiple studies have shown that physicians tend to work an average of 60 hours a week. Of course, this does not take into consideration the typical hospitalist, who still tends to work 12-hour shifts on a seven-on/seven-off schedule, although there is a trend away from this type of block scheduling. A recent study also showed that physicians in practice less than five years were more likely to work hours in agreement with the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty-hour regulations for physicians in training. The authors speculated that this was due to this group having trained under the new ACGME guidelines and being of Generation X, whose members tend to favor more work-life balance than their predecessors.

Several studies have examined physician work hours in relationship to fatigue and patient safety. Volp et al examined two large studies and found no change in mortality among Medicare patients for the first two years after implementation of the ACGME duty-hour regulations. However, they did find that mortality decreased for four common medical conditions in a VA hospital. Fletcher et al performed a systematic review and found no conclusive evidence that the decreased resident work hours had any affect on patient safety.

This is what I would have expected: inconclusive data. Most studies of this type are surveys, which have well-known limitations. Each of us has our own individual stamina, tolerance for fatigue, and desire for work-life balance. We intuitively know that most individuals are not at their best when tired or stressed, but to capture the true effect of these variables on patient satisfaction, morbidity, mortality, and other clinical metrics will be very difficult.

There are several ways I would approach a group that is contemplating another nocturnist. Because most hospitalists don’t want to work nights, the group members who feel their moonlighting income would be affected should commit to covering a certain portion or all of the available nights. If only some of the nights are covered, then you can hire a part-time nocturnist.

This is easier than you might imagine, as my very large hospitalist group has four nocturnists and none work a full FTE. I think three to four extra shifts a month are reasonable on a routine basis. We have, however, allowed physicians who wanted to have a month off to work seven extra days the months before and after to get their desired time off. We would not allow that to occur on a regular basis.

Ultimately, your group has to decide its own tolerance for fatigue and burnout, and have some mechanism to monitor the quality of work. After all, we owe it to our patients to not place their safety in jeopardy.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

I was receiving PT for a shoulder problem. Jenna, my physical therapist, asked if I injured it working. I said no, my work involves writing and lecturing on Lean management, quality, and things related. Has Lean made it to this health center? I asked. Nodding, she replied impishly, “You said a bad word.”

After a late start in health care, Lean has cut a wide swath in the sector. Health care took its Lean lessons from industry, which had imported just-in-time (JIT) production from Japan in the 1980s, then renamed it Lean manufacturing in the 1990s. Off-the-mark tendencies for Lean as applied in manufacturing have, unfortunately, been carried over into health care. Sensible corrective measures are needed to ensure that Lean in health care does not suffer pain and an early death. Actually, the metaphor is apt in that Lean’s most beneficial outcome is reduction of wait times, and when it comes to health care, long wait times surely can and do kill people.

Since Lean’s introduction in the West three decades ago, it has been redefined, amended, and appended to the point some its lesser features have trumped what is meaningful to patients. Manufacturing has the excuse that end customers are nowhere in sight. Health care, on the other hand, is customer-facing. Lean’s customer-centered primary effects should make it doubly suitable in the health-care sector.

Although Lean manufacturing generally is viewed as a success story, my own multiyear “Leanness studies” reveal dominant patterns of good results followed by backsliding. A likely reason: Most present Lean in operational terms, so manufacturing executives delegate it down the hierarchy to the operations contingent. The same is generally the case where Lean has been applied in health care.

Corrective action calls for making it clear that Lean’s main effects are not operational so much as competitive and strategic. That is, the primary role and outcomes are delivering ever-quicker, more flexible, higher-quality, higher-value response to customer needs, demands, orders, and usage. Rather than seeing Lean this way, industry generally has adopted the view that Lean mainly is about reduction of the “seven wastes.” Falling in line, health care, too, has adopted waste elimination as Lean’s mantra.

That won’t do.

Rather than being Lean’s essence, waste reduction is akin to spaghetti diagrams, the five whys, value-stream mapping, and non-value-add analysis. All are worthy ways of framing the Lean pursuit but are not among the methodologies that act on the processes to change them from fat to lean. Over the years, some have done a better job implementing Lean, spending less time on framing and more on training employees in organization by product family or customer family, quick setup, cross-training/job rotation, trouble lights, and more, then saying, “Go do it.”

In getting it done, Lean delivers quick response as the dominant customer-sensitive effect: Nearly every change that Lean elicits reduces waiting times and waiting lines, and the sum total of those reductions through the processes can speed up customer response by an order of magnitude.

In delivering quick response in any setting, Lean relies on flexibility and quality. Given the norm—that customer demands and needs are highly variable, both in type and quantity—quick response requires flexibility so as to ensure immediate readiness for the next customer or need. Lean provides flexibility through a cross-trained or on-call workforce, plus fast-change or standby equipment. As for quality, without it, response is slowed or stopped for rework. Or abandoned entirely, with the customer seeking service elsewhere. Or the patient dies waiting.

There are reasons why waste reduction has been elevated to its high status—in some quarters, almost as the definition of Lean: operations people can readily learn to recognize and measure the wastes, and devise ways to reduce them. And it works—it does make operations quicker and more flexible, with better quality and value.

But if Lean is to maintain good health, waste reduction cannot be the driver and must be seen as a useful enabler. Lean must be defined and promoted for its strategic purpose—delivering flexibly quick, high-quality service everywhere along the value chain to patients. Seen this way, Lean can implant itself as a permanent organizational strategy.

Jenna, my physical therapist, may have been like many in health care, viewing Lean as something of a pedestrian imposition, and that training time would be better spent on patient care. At a more recent visit to PT with a different therapist, I spotted Jenna across the room. She called over to me and said, “I changed my mind. Now I like Lean!” That’s great, I thought. She’s happily chasing down wastes. Now, if only the facility’s leadership can come to understand Lean’s customer-side purpose and build it in as a fixed element of strategic management.

Richard J. Schonberger, PhD, president of Schonberger & Associates in Seattle, is the author of more than 170 articles and papers, as well as several books.

I was receiving PT for a shoulder problem. Jenna, my physical therapist, asked if I injured it working. I said no, my work involves writing and lecturing on Lean management, quality, and things related. Has Lean made it to this health center? I asked. Nodding, she replied impishly, “You said a bad word.”

After a late start in health care, Lean has cut a wide swath in the sector. Health care took its Lean lessons from industry, which had imported just-in-time (JIT) production from Japan in the 1980s, then renamed it Lean manufacturing in the 1990s. Off-the-mark tendencies for Lean as applied in manufacturing have, unfortunately, been carried over into health care. Sensible corrective measures are needed to ensure that Lean in health care does not suffer pain and an early death. Actually, the metaphor is apt in that Lean’s most beneficial outcome is reduction of wait times, and when it comes to health care, long wait times surely can and do kill people.

Since Lean’s introduction in the West three decades ago, it has been redefined, amended, and appended to the point some its lesser features have trumped what is meaningful to patients. Manufacturing has the excuse that end customers are nowhere in sight. Health care, on the other hand, is customer-facing. Lean’s customer-centered primary effects should make it doubly suitable in the health-care sector.

Although Lean manufacturing generally is viewed as a success story, my own multiyear “Leanness studies” reveal dominant patterns of good results followed by backsliding. A likely reason: Most present Lean in operational terms, so manufacturing executives delegate it down the hierarchy to the operations contingent. The same is generally the case where Lean has been applied in health care.

Corrective action calls for making it clear that Lean’s main effects are not operational so much as competitive and strategic. That is, the primary role and outcomes are delivering ever-quicker, more flexible, higher-quality, higher-value response to customer needs, demands, orders, and usage. Rather than seeing Lean this way, industry generally has adopted the view that Lean mainly is about reduction of the “seven wastes.” Falling in line, health care, too, has adopted waste elimination as Lean’s mantra.

That won’t do.

Rather than being Lean’s essence, waste reduction is akin to spaghetti diagrams, the five whys, value-stream mapping, and non-value-add analysis. All are worthy ways of framing the Lean pursuit but are not among the methodologies that act on the processes to change them from fat to lean. Over the years, some have done a better job implementing Lean, spending less time on framing and more on training employees in organization by product family or customer family, quick setup, cross-training/job rotation, trouble lights, and more, then saying, “Go do it.”

In getting it done, Lean delivers quick response as the dominant customer-sensitive effect: Nearly every change that Lean elicits reduces waiting times and waiting lines, and the sum total of those reductions through the processes can speed up customer response by an order of magnitude.

In delivering quick response in any setting, Lean relies on flexibility and quality. Given the norm—that customer demands and needs are highly variable, both in type and quantity—quick response requires flexibility so as to ensure immediate readiness for the next customer or need. Lean provides flexibility through a cross-trained or on-call workforce, plus fast-change or standby equipment. As for quality, without it, response is slowed or stopped for rework. Or abandoned entirely, with the customer seeking service elsewhere. Or the patient dies waiting.

There are reasons why waste reduction has been elevated to its high status—in some quarters, almost as the definition of Lean: operations people can readily learn to recognize and measure the wastes, and devise ways to reduce them. And it works—it does make operations quicker and more flexible, with better quality and value.

But if Lean is to maintain good health, waste reduction cannot be the driver and must be seen as a useful enabler. Lean must be defined and promoted for its strategic purpose—delivering flexibly quick, high-quality service everywhere along the value chain to patients. Seen this way, Lean can implant itself as a permanent organizational strategy.

Jenna, my physical therapist, may have been like many in health care, viewing Lean as something of a pedestrian imposition, and that training time would be better spent on patient care. At a more recent visit to PT with a different therapist, I spotted Jenna across the room. She called over to me and said, “I changed my mind. Now I like Lean!” That’s great, I thought. She’s happily chasing down wastes. Now, if only the facility’s leadership can come to understand Lean’s customer-side purpose and build it in as a fixed element of strategic management.

Richard J. Schonberger, PhD, president of Schonberger & Associates in Seattle, is the author of more than 170 articles and papers, as well as several books.

I was receiving PT for a shoulder problem. Jenna, my physical therapist, asked if I injured it working. I said no, my work involves writing and lecturing on Lean management, quality, and things related. Has Lean made it to this health center? I asked. Nodding, she replied impishly, “You said a bad word.”

After a late start in health care, Lean has cut a wide swath in the sector. Health care took its Lean lessons from industry, which had imported just-in-time (JIT) production from Japan in the 1980s, then renamed it Lean manufacturing in the 1990s. Off-the-mark tendencies for Lean as applied in manufacturing have, unfortunately, been carried over into health care. Sensible corrective measures are needed to ensure that Lean in health care does not suffer pain and an early death. Actually, the metaphor is apt in that Lean’s most beneficial outcome is reduction of wait times, and when it comes to health care, long wait times surely can and do kill people.

Since Lean’s introduction in the West three decades ago, it has been redefined, amended, and appended to the point some its lesser features have trumped what is meaningful to patients. Manufacturing has the excuse that end customers are nowhere in sight. Health care, on the other hand, is customer-facing. Lean’s customer-centered primary effects should make it doubly suitable in the health-care sector.

Although Lean manufacturing generally is viewed as a success story, my own multiyear “Leanness studies” reveal dominant patterns of good results followed by backsliding. A likely reason: Most present Lean in operational terms, so manufacturing executives delegate it down the hierarchy to the operations contingent. The same is generally the case where Lean has been applied in health care.

Corrective action calls for making it clear that Lean’s main effects are not operational so much as competitive and strategic. That is, the primary role and outcomes are delivering ever-quicker, more flexible, higher-quality, higher-value response to customer needs, demands, orders, and usage. Rather than seeing Lean this way, industry generally has adopted the view that Lean mainly is about reduction of the “seven wastes.” Falling in line, health care, too, has adopted waste elimination as Lean’s mantra.

That won’t do.

Rather than being Lean’s essence, waste reduction is akin to spaghetti diagrams, the five whys, value-stream mapping, and non-value-add analysis. All are worthy ways of framing the Lean pursuit but are not among the methodologies that act on the processes to change them from fat to lean. Over the years, some have done a better job implementing Lean, spending less time on framing and more on training employees in organization by product family or customer family, quick setup, cross-training/job rotation, trouble lights, and more, then saying, “Go do it.”

In getting it done, Lean delivers quick response as the dominant customer-sensitive effect: Nearly every change that Lean elicits reduces waiting times and waiting lines, and the sum total of those reductions through the processes can speed up customer response by an order of magnitude.

In delivering quick response in any setting, Lean relies on flexibility and quality. Given the norm—that customer demands and needs are highly variable, both in type and quantity—quick response requires flexibility so as to ensure immediate readiness for the next customer or need. Lean provides flexibility through a cross-trained or on-call workforce, plus fast-change or standby equipment. As for quality, without it, response is slowed or stopped for rework. Or abandoned entirely, with the customer seeking service elsewhere. Or the patient dies waiting.

There are reasons why waste reduction has been elevated to its high status—in some quarters, almost as the definition of Lean: operations people can readily learn to recognize and measure the wastes, and devise ways to reduce them. And it works—it does make operations quicker and more flexible, with better quality and value.

But if Lean is to maintain good health, waste reduction cannot be the driver and must be seen as a useful enabler. Lean must be defined and promoted for its strategic purpose—delivering flexibly quick, high-quality service everywhere along the value chain to patients. Seen this way, Lean can implant itself as a permanent organizational strategy.

Jenna, my physical therapist, may have been like many in health care, viewing Lean as something of a pedestrian imposition, and that training time would be better spent on patient care. At a more recent visit to PT with a different therapist, I spotted Jenna across the room. She called over to me and said, “I changed my mind. Now I like Lean!” That’s great, I thought. She’s happily chasing down wastes. Now, if only the facility’s leadership can come to understand Lean’s customer-side purpose and build it in as a fixed element of strategic management.

Richard J. Schonberger, PhD, president of Schonberger & Associates in Seattle, is the author of more than 170 articles and papers, as well as several books.

Dementia affects 34 million people globally, with the most common cause of dementia, Alzheimer’s disease (AD), affecting 5.5 million Americans.^1,2 The connection between cerebrovascular disorders and AD means that antihypertensive agents may play a role in dementia prophylaxis and management.^1,2

Hypertension increases the risk of intellectual dysfunction by increasing susceptibility to heart disease, ischemic brain injury, and cerebrovascular pathology.¹ In addition to senile plaques, ischemic brain lesions are observed in autopsies of AD patients,¹ and brain infarctions are more common among AD patients than among controls.² Brain pathology suggestive of AD was found in 30% to 50% of postmortem examinations of patients with vascular dementia.¹

It is useful to note that dihydropyridines, a subgroup of calcium channel blockers, may inhibit amyloidogenesis.³

Hypertension and cognition

Hypertension-induced hyperdense lesions in cerebral white matter reflect pathology in small vessels, inflammatory change, and disruption of the blood-brain barrier, which may precede cognitive decline.¹ Even subclinical ischemic changes may increase the probability of developing dementia.² Hypertension also reduces cerebral perfusion, especially in the hippocampus, which may promote degeneration of memory function.¹ Prolonged cerebral hypoxia increases amyloid precursor protein production and β-secretase activity.^1,2 Patients who died of brain ischemia show prominent β-amyloid protein and apolipoprotein E in histopathologic analysis of the hippocampus.¹ Compression of vessels by â-amyloid protein further augments this degenerative process.¹

Inhibition of amyloidogenesis

Long-term administration of antihypertensive medications in patients age <75 decreases the probability of dementia by 8% each year.¹ Calcium channel blockers protect neurons by lowering blood pressure and reversing cellular-level calcium channel dysfunction that occurs with age, cerebral infarction, and AD.

Select dihydropyridines may inhibit amyloidogenesis in apolipoprotein E carriers:

•  amlodipine and nilvadipine reduce β-secretase activity and amyloid precursor protein-β production³

•  nilvadipine and nitrendipine limit β-amyloid protein synthesis in the brain and promote their clearance through the blood-brain barrier³

•  nilvadipine-treated apolipoprotein E carriers experience cognitive stabilization compared with cognitive decreases seen in non-treated subjects.

Dihydropyridines can produce therapeutic effects for both AD and cerebrovascular dementia patients, indicating the potential that certain agents in this class have for treating both conditions.

Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Dementia affects 34 million people globally, with the most common cause of dementia, Alzheimer’s disease (AD), affecting 5.5 million Americans.^1,2 The connection between cerebrovascular disorders and AD means that antihypertensive agents may play a role in dementia prophylaxis and management.^1,2

Hypertension increases the risk of intellectual dysfunction by increasing susceptibility to heart disease, ischemic brain injury, and cerebrovascular pathology.¹ In addition to senile plaques, ischemic brain lesions are observed in autopsies of AD patients,¹ and brain infarctions are more common among AD patients than among controls.² Brain pathology suggestive of AD was found in 30% to 50% of postmortem examinations of patients with vascular dementia.¹

It is useful to note that dihydropyridines, a subgroup of calcium channel blockers, may inhibit amyloidogenesis.³

Hypertension and cognition

Hypertension-induced hyperdense lesions in cerebral white matter reflect pathology in small vessels, inflammatory change, and disruption of the blood-brain barrier, which may precede cognitive decline.¹ Even subclinical ischemic changes may increase the probability of developing dementia.² Hypertension also reduces cerebral perfusion, especially in the hippocampus, which may promote degeneration of memory function.¹ Prolonged cerebral hypoxia increases amyloid precursor protein production and β-secretase activity.^1,2 Patients who died of brain ischemia show prominent β-amyloid protein and apolipoprotein E in histopathologic analysis of the hippocampus.¹ Compression of vessels by â-amyloid protein further augments this degenerative process.¹

Inhibition of amyloidogenesis

Long-term administration of antihypertensive medications in patients age <75 decreases the probability of dementia by 8% each year.¹ Calcium channel blockers protect neurons by lowering blood pressure and reversing cellular-level calcium channel dysfunction that occurs with age, cerebral infarction, and AD.

Select dihydropyridines may inhibit amyloidogenesis in apolipoprotein E carriers:

•  amlodipine and nilvadipine reduce β-secretase activity and amyloid precursor protein-β production³

•  nilvadipine and nitrendipine limit β-amyloid protein synthesis in the brain and promote their clearance through the blood-brain barrier³

•  nilvadipine-treated apolipoprotein E carriers experience cognitive stabilization compared with cognitive decreases seen in non-treated subjects.

Dihydropyridines can produce therapeutic effects for both AD and cerebrovascular dementia patients, indicating the potential that certain agents in this class have for treating both conditions.

Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Dementia affects 34 million people globally, with the most common cause of dementia, Alzheimer’s disease (AD), affecting 5.5 million Americans.^1,2 The connection between cerebrovascular disorders and AD means that antihypertensive agents may play a role in dementia prophylaxis and management.^1,2

Hypertension increases the risk of intellectual dysfunction by increasing susceptibility to heart disease, ischemic brain injury, and cerebrovascular pathology.¹ In addition to senile plaques, ischemic brain lesions are observed in autopsies of AD patients,¹ and brain infarctions are more common among AD patients than among controls.² Brain pathology suggestive of AD was found in 30% to 50% of postmortem examinations of patients with vascular dementia.¹

It is useful to note that dihydropyridines, a subgroup of calcium channel blockers, may inhibit amyloidogenesis.³

Hypertension and cognition

Hypertension-induced hyperdense lesions in cerebral white matter reflect pathology in small vessels, inflammatory change, and disruption of the blood-brain barrier, which may precede cognitive decline.¹ Even subclinical ischemic changes may increase the probability of developing dementia.² Hypertension also reduces cerebral perfusion, especially in the hippocampus, which may promote degeneration of memory function.¹ Prolonged cerebral hypoxia increases amyloid precursor protein production and β-secretase activity.^1,2 Patients who died of brain ischemia show prominent β-amyloid protein and apolipoprotein E in histopathologic analysis of the hippocampus.¹ Compression of vessels by â-amyloid protein further augments this degenerative process.¹

Inhibition of amyloidogenesis

Long-term administration of antihypertensive medications in patients age <75 decreases the probability of dementia by 8% each year.¹ Calcium channel blockers protect neurons by lowering blood pressure and reversing cellular-level calcium channel dysfunction that occurs with age, cerebral infarction, and AD.

Select dihydropyridines may inhibit amyloidogenesis in apolipoprotein E carriers:

•  amlodipine and nilvadipine reduce β-secretase activity and amyloid precursor protein-β production³

•  nilvadipine and nitrendipine limit β-amyloid protein synthesis in the brain and promote their clearance through the blood-brain barrier³

•  nilvadipine-treated apolipoprotein E carriers experience cognitive stabilization compared with cognitive decreases seen in non-treated subjects.

Dihydropyridines can produce therapeutic effects for both AD and cerebrovascular dementia patients, indicating the potential that certain agents in this class have for treating both conditions.

Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

ANSWER
The correct interpretation of this patient’s ECG is atrial flutter with variable atrioventricular block. Atrial flutter is a macro re-entrant supraventricular arrhythmia arising in the right atrium and usually (but not always!) identified by saw-tooth–appearing flutter waves.

The atrial rate in atrial flutter typically ranges from 200 to 350 beats/min. The QRS appearance will be narrow and similar to that of sinus rhythm, because conduction occurs normally down the atrioventricular node unless there is aberrant conduction.

The ventricular rate is dependent on the ability of the node to control rapid conduction. In this case, there appear to be three flutter waves for each QRS complex (3:1 flutter). If the ventricular rate is 80 beats/min, the rate in the atrium is approximately 240 beats/min. A regular ventricular rate of 150 beats/min should make you suspicious for atrial flutter (2:1 flutter). 

The variable atrioventricular block on this ECG is evidenced by the presence of two, rather than three, flutter waves per QRS complex (seen after the fourth, fifth, and 10th QRS complexes on the rhythm strip). This case illustrates that flutter may be present with a ventricular rate of less than 100 beats/min.

ANSWER
The correct interpretation of this patient’s ECG is atrial flutter with variable atrioventricular block. Atrial flutter is a macro re-entrant supraventricular arrhythmia arising in the right atrium and usually (but not always!) identified by saw-tooth–appearing flutter waves.

The atrial rate in atrial flutter typically ranges from 200 to 350 beats/min. The QRS appearance will be narrow and similar to that of sinus rhythm, because conduction occurs normally down the atrioventricular node unless there is aberrant conduction.

The ventricular rate is dependent on the ability of the node to control rapid conduction. In this case, there appear to be three flutter waves for each QRS complex (3:1 flutter). If the ventricular rate is 80 beats/min, the rate in the atrium is approximately 240 beats/min. A regular ventricular rate of 150 beats/min should make you suspicious for atrial flutter (2:1 flutter). 

The variable atrioventricular block on this ECG is evidenced by the presence of two, rather than three, flutter waves per QRS complex (seen after the fourth, fifth, and 10th QRS complexes on the rhythm strip). This case illustrates that flutter may be present with a ventricular rate of less than 100 beats/min.

ANSWER
The correct interpretation of this patient’s ECG is atrial flutter with variable atrioventricular block. Atrial flutter is a macro re-entrant supraventricular arrhythmia arising in the right atrium and usually (but not always!) identified by saw-tooth–appearing flutter waves.

The atrial rate in atrial flutter typically ranges from 200 to 350 beats/min. The QRS appearance will be narrow and similar to that of sinus rhythm, because conduction occurs normally down the atrioventricular node unless there is aberrant conduction.

The ventricular rate is dependent on the ability of the node to control rapid conduction. In this case, there appear to be three flutter waves for each QRS complex (3:1 flutter). If the ventricular rate is 80 beats/min, the rate in the atrium is approximately 240 beats/min. A regular ventricular rate of 150 beats/min should make you suspicious for atrial flutter (2:1 flutter). 

The variable atrioventricular block on this ECG is evidenced by the presence of two, rather than three, flutter waves per QRS complex (seen after the fourth, fifth, and 10th QRS complexes on the rhythm strip). This case illustrates that flutter may be present with a ventricular rate of less than 100 beats/min.

ANSWER
The correct answer is fungal infection (choice “a”). If this condition had been fungal, it would have responded to one or more of the medications used to treat it. In this case, treatment failure demanded consideration of alternate diagnostic possibilities.

Lichen simplex chronicus (choice “b”), also known as neurodermatitis, was a good possibility, since it is the consequence of chronic rubbing or scratching in response to the itching caused by, for example, eczema.

Psoriasis (choice “c”) usually has adherent white scale on its surface, unless it’s in an intertriginous (skin on skin) area where scale gets rubbed off by friction.

The patient’s actual diagnosis, however, turned out to be Paget’s disease (choice “d”). See the Discussion for relevant details.

DISCUSSION
Biopsy showed changes consistent with a type of skin cancer called extramammary Paget’s disease (EMPD), an intradermal adenocarcinoma that tends to develop in areas where apocrine glands are found (eg, the anogenital and axillary areas).

The majority of EMPD cases represent adenocarcinoma in situ with extension from adnexal structures. Intraepidermal metastasis from noncutaneous adenocarcinomas (via local or lymphatic routes) accounts for a significant minority of cases 
(< 25%). Urogenital and colorectal carcinomas are the most common.

EMPD is more common in women and is rare before age 40. In addition to the usual intertriginous areas, other sites in which it may be found include eyelids and ears. The lesions typically itch but rarely hurt; they do, however, inevitably grow larger and more extensive.

The histologic changes of EMPD are identical to those seen in mammary Paget’s disease, though the latter virtually always involves the areola and nipple. It also signals the presence of an underlying intraductal breast cancer.

The main teaching point to be gleaned from this case is the concept of “cancer presenting as a rash,” of which there are several examples: cutaneous T-cell lymphoma, B-cell lymphoma, metastatic breast cancer, superficial basal cell carcinoma, and intraepidermal squamous cell carcinoma (Bowen’s disease).

EMPD is especially prone to being overlooked, not only because groin rashes are so common but also because most skin cancers are “lesional” (ie, they take the form of a papule or nodule). Any rash that proves to be unresponsive to ordinary treatment should be either referred to dermatology or biopsied.

TREATMENT
This patient was prescribed imiquimod 5% cream, to be applied three times a week, which has a good chance of clearing the condition (but only after three to four months of application). If this fails, the patient will be referred for Mohs surgery.

Even so, recurrences are common. About 25% of EMPD patients with underlying malignancies eventually die of their disease. For these reasons, the patient was referred back to his primary care provider for workup for a possible underlying malignancy. 

ANSWER
The correct answer is fungal infection (choice “a”). If this condition had been fungal, it would have responded to one or more of the medications used to treat it. In this case, treatment failure demanded consideration of alternate diagnostic possibilities.

Lichen simplex chronicus (choice “b”), also known as neurodermatitis, was a good possibility, since it is the consequence of chronic rubbing or scratching in response to the itching caused by, for example, eczema.

Psoriasis (choice “c”) usually has adherent white scale on its surface, unless it’s in an intertriginous (skin on skin) area where scale gets rubbed off by friction.

The patient’s actual diagnosis, however, turned out to be Paget’s disease (choice “d”). See the Discussion for relevant details.

DISCUSSION
Biopsy showed changes consistent with a type of skin cancer called extramammary Paget’s disease (EMPD), an intradermal adenocarcinoma that tends to develop in areas where apocrine glands are found (eg, the anogenital and axillary areas).

The majority of EMPD cases represent adenocarcinoma in situ with extension from adnexal structures. Intraepidermal metastasis from noncutaneous adenocarcinomas (via local or lymphatic routes) accounts for a significant minority of cases 
(< 25%). Urogenital and colorectal carcinomas are the most common.

EMPD is more common in women and is rare before age 40. In addition to the usual intertriginous areas, other sites in which it may be found include eyelids and ears. The lesions typically itch but rarely hurt; they do, however, inevitably grow larger and more extensive.

The histologic changes of EMPD are identical to those seen in mammary Paget’s disease, though the latter virtually always involves the areola and nipple. It also signals the presence of an underlying intraductal breast cancer.

The main teaching point to be gleaned from this case is the concept of “cancer presenting as a rash,” of which there are several examples: cutaneous T-cell lymphoma, B-cell lymphoma, metastatic breast cancer, superficial basal cell carcinoma, and intraepidermal squamous cell carcinoma (Bowen’s disease).

EMPD is especially prone to being overlooked, not only because groin rashes are so common but also because most skin cancers are “lesional” (ie, they take the form of a papule or nodule). Any rash that proves to be unresponsive to ordinary treatment should be either referred to dermatology or biopsied.

TREATMENT
This patient was prescribed imiquimod 5% cream, to be applied three times a week, which has a good chance of clearing the condition (but only after three to four months of application). If this fails, the patient will be referred for Mohs surgery.

Even so, recurrences are common. About 25% of EMPD patients with underlying malignancies eventually die of their disease. For these reasons, the patient was referred back to his primary care provider for workup for a possible underlying malignancy. 

ANSWER
The correct answer is fungal infection (choice “a”). If this condition had been fungal, it would have responded to one or more of the medications used to treat it. In this case, treatment failure demanded consideration of alternate diagnostic possibilities.

Lichen simplex chronicus (choice “b”), also known as neurodermatitis, was a good possibility, since it is the consequence of chronic rubbing or scratching in response to the itching caused by, for example, eczema.

Psoriasis (choice “c”) usually has adherent white scale on its surface, unless it’s in an intertriginous (skin on skin) area where scale gets rubbed off by friction.

The patient’s actual diagnosis, however, turned out to be Paget’s disease (choice “d”). See the Discussion for relevant details.

DISCUSSION
Biopsy showed changes consistent with a type of skin cancer called extramammary Paget’s disease (EMPD), an intradermal adenocarcinoma that tends to develop in areas where apocrine glands are found (eg, the anogenital and axillary areas).

The majority of EMPD cases represent adenocarcinoma in situ with extension from adnexal structures. Intraepidermal metastasis from noncutaneous adenocarcinomas (via local or lymphatic routes) accounts for a significant minority of cases 
(< 25%). Urogenital and colorectal carcinomas are the most common.

EMPD is more common in women and is rare before age 40. In addition to the usual intertriginous areas, other sites in which it may be found include eyelids and ears. The lesions typically itch but rarely hurt; they do, however, inevitably grow larger and more extensive.

The histologic changes of EMPD are identical to those seen in mammary Paget’s disease, though the latter virtually always involves the areola and nipple. It also signals the presence of an underlying intraductal breast cancer.

The main teaching point to be gleaned from this case is the concept of “cancer presenting as a rash,” of which there are several examples: cutaneous T-cell lymphoma, B-cell lymphoma, metastatic breast cancer, superficial basal cell carcinoma, and intraepidermal squamous cell carcinoma (Bowen’s disease).

EMPD is especially prone to being overlooked, not only because groin rashes are so common but also because most skin cancers are “lesional” (ie, they take the form of a papule or nodule). Any rash that proves to be unresponsive to ordinary treatment should be either referred to dermatology or biopsied.

TREATMENT
This patient was prescribed imiquimod 5% cream, to be applied three times a week, which has a good chance of clearing the condition (but only after three to four months of application). If this fails, the patient will be referred for Mohs surgery.

Even so, recurrences are common. About 25% of EMPD patients with underlying malignancies eventually die of their disease. For these reasons, the patient was referred back to his primary care provider for workup for a possible underlying malignancy. 

CASE: Mute and unresponsive

Mrs. K, a 42-year-old Haitian who is 31 weeks pregnant, presents with a 4-week history of progressive mutism and psychomotor retardation. At inpatient admission, she is awake and alert but does not speak and resists the treatment team’s attempts to engage her. Mrs. K’s eyes are open, but she has a vacant stare and avoids eye contact. Her affect is flat and nonreactive and she appears internally preoccupied. Mrs. K exhibits motoric immobility, displays a rigid posture, and resists attempts to get her to move. Features of catatonic excitement, echo phenomena, posturing, stereotypies, and mannerisms are absent during the initial evaluation.

Mrs. K’s husband reports that they had been on vacation for 6 days before he brought her for psychiatric evaluation. He denies any recent evidence of psychosis or mood disturbance, stating that his wife was excited when she learned of the pregnancy, and attended all prenatal appointments. He reports that when this episode began, Mrs. K stopped talking to her 3-year-old daughter, did not respond to her name, and did not pay attention to those around her.

According to her husband, a similar episode occurred 2 years earlier, during which Mrs. K was selectively mute for approximately 1 month. She did not eat for 5 days and neglected the care of her daughter. There were 2 additional brief periods of prominent psychomotor retardation for which she was hospitalized in Haiti. According to the patient’s aunt, Mrs. K complained that her husband had cast a “voodoo spell” on her because he wanted sole custody of their daughter. Her husband recounted an episode, when they lived in Haiti, during which his wife became paranoid, left the house, and wandered the streets for 2 days.

The medical history is significant for a cervical polyp that was removed 2 years ago. Mrs. K has no history of substance abuse. She was born and raised in Haiti where she studied medicine. Her family reports that Mrs. K’s husband is “controlling,” which causes her distress.

The authors' observations

Catatonia is a neuropsychiatric syndrome that can occur in schizophrenia, mood disorders, mental retardation, neurologic disease, metabolic conditions, and drug intoxication.¹ Catatonia can present in several ways, from catatonic stupor to extreme purposeless agitation; more than 60 catatonic signs and symptoms have been described.¹ According to DSM-5² catatonia is characterized by 3 or more of the following symptoms:

•  stupor 

•  catalepsy

•  waxy flexibility

•  mutism

•  negativism

•  posturing

•  mannerism

•  stereotypy

•  agitation, not influenced by external stimuli

•  grimacing

•  echolalia

•  echopraxia.

Mrs. K exhibited stupor, mutism, posturing, and grimacing (Table 1).² We thought that her catatonic features were secondary to schizophrenia because she had paranoid delusions and displayed disorganized behavior while in Haiti. There was no evidence of past or current mood disorder, metabolic condition, neurologic illness, or substance abuse.

Catatonia and pregnancy

There is little available information to guide clinicians who are treating a pregnant woman who has a catatonic syndrome. Espinola-Nadurille and co-workers described a 22-year-old pregnant (21 weeks) woman from rural Mexico who was hospitalized with agitation, disorganized speech, restlessness, and hallucinations after several weeks of alternating agitation and withdrawal with mutism and refusal to eat or drink.³ This patient developed malignant catatonia with creatine phosphokinase elevation and leukocytosis and eventually responded to treatment with lorazepam and electroconvulsive therapy (ECT). She was given a diagnosis of schizophreniform disorder. Treating her catatonic symptoms did not result in any adverse effects on the pregnancy or the fetus.

Exacerbation of schizophrenia during pregnancy can lead to neglect of pregnancy and prenatal care,⁴ imminent harm to the fetus because of malnutrition and dehydration, and risk of preterm delivery and low weight at birth. Prolonged catatonia can cause medical complications such as decubitus ulcers, incontinence, recurrent urinary tract infections, aspiration pneumonia, increased risk of deep venous thrombosis, malnutrition, and ocular complications because of prolonged staring and reduced blinking (Table 2^5-10). For these reasons, it is important to treat this condition early and aggressively to improve pregnancy outcome and infant well-being.

EVALUATION: Flat affect

The mental status examination on admission describes a tall, black, Haitian woman with unkempt hair and fair hygiene. Mrs. K has a prominent abdomen, consistent with a 31-week pregnancy. She exhibits a blank stare without direct eye contact; she is mute, and exhibits flat affect. We cannot evaluate her thought processes and content because Mrs. K is mute, although she does appear internally preoccupied.

Physical examination on admission is unremarkable; vital signs are stable and within normal limits. Laboratory work-up reveals a urinary tract infection, which is treated with ceftriaxone. Mrs. K also has macrocytic anemia (hemoglobin, 11.7 g/dL; hematocrit, 34.7%; mean corpuscular volume, 99.2 μm³). Albumin is low at 2.6 g/dL. Urine drug toxicology screen is negative. Fingerstick glucose reading is 139 mg/dL. Mrs. K is given a presumptive diagnosis of schizophrenia with catatonia.

Mrs. K’s BFCRS¹¹ score is 22 at admission. She is mute, holds postures for longer than a minute, and is resistant to repositioning. She also has extreme hypoactivity and does not interact with others. She has a fixed, blank stare, and exhibits mild grimacing.

The authors' observations

BFCRS defines each catatonic sign, rates its severity, and provides a standardized schema for clinical examination.¹¹ The BFCRS is preferred for routine use because of its validity, reliability, and ease of administration.¹² The treatment team rated Mrs. K at admission, during the course of treatment, and at discharge, showing a substantial improvement at the end of the hospitalization (Figure).

The authors' observations

Benzodiazepines (particularly lorazepam) and ECT are considered the treatment of choice for catatonic symptoms.¹¹ More than 72% of patients with catatonic symptoms remit after a trial of a benzodiazepine.¹ ECT is considered when patients do not respond to a benzodiazepine after 48 to 72 hours.³ Several cases of complete resolution of catatonic symptoms have been linked to ECT (Table 3).^13-18

A recent retrospective review revealed that patients who do not respond to loraze­pam are more likely to come from a rural setting, have a longer duration of illness, exhibit mutism, and exhibit third-person auditory hallucinations and made phenomena (the feeling that some aspect of the individual is under the external control of others).¹⁹ Case reports of treatment of catatonic patients with ECT vs lorazepam are listed in Table 3.^13-18

In pregnancy, ECT can be considered early in the course of illness. A review of the literature on ECT during pregnancy reported at least partial remission in 78% of studies reporting efficacy data.²⁰ Among these 339 patients, there were 25 fetal or neonatal complications—only 11 of these were related to ECT—and 20 maternal complications, of which 18 were related to ECT. The authors of this review concluded that 1) ECT is an effective treatment for severe mental illness during pregnancy and 2) the risks to fetus and mother are low.

A 2007 study identified 1,979 infants whose mothers reported use of benzodiazepines or hypnotic benzodiazepine-receptor agonists during early pregnancy.²¹ An additional 401 infants born to mothers who were prescribed these medications during late pregnancy also were included in this study. Women who took these medications were at an increased risk for preterm birth and low birth weight. The rate of congenital malformations in this study was moderately increased among infants exposed in early pregnancy (adjusted odds ratio = 1.24 [95% confidence interval, 1.00 to 1.55]).

Because catatonic symptoms can appear during the course of schizophrenia, several antipsychotics have been used to treat this condition. The efficacy and safety of antipsychotics for treating catatonia remains largely unknown, however.¹

OUTCOME: Recovery, baby girl

We begin oral haloperidol, 10 mg/d, for Mrs. K, which we then increase to 20 mg/d. Because she shows little response to haloperidol, we suggest a trial of ECT, but her husband refuses to consent. She is started on IM lorazepam, 6 mg/d.

Mrs. K gradually improves and increases her intake of food and liquids. After 10 days of lorazepam treatment, her BFCRS score decreases to 13. Mrs. K begins to speak and her gaze is less fixed. Negativistic behaviors are nearly absent.

Because we are concerned about Mrs. K’s pregnancy, lab tests are repeated. A complete metabolic panel shows an elevated glucose level (122 mg/dL); urinalysis reveals glycosuria (glucose, 1,000 mg/dL), proteinuria (protein, 10 mg/dL), and ketonuria, (ketones, 20 mg/dL). She is transferred to the obstetrics service for evaluation of gestational diabetes.

Psychotropics are continued while Mrs. K is on the obstetrics service; she returns to the inpatient psychiatric unit on an insulin regimen. IM lorazepam is increased to 8 mg/d, and haloperidol is decreased from 20 mg/d, to 10 mg/d, to prevent worsening of catatonia, which can occur when catatonic patients receive a psychotropic.¹¹ Three days later, Mrs. K’s BFCRS score is 12 and she shows only mild rigidity. Mrs. K briefly interacts with staff, particularly when she wants something.

Lorazepam is decreased to 1 mg/d in anticipation of cesarean delivery. Mrs. K becomes more adherent with her medications; often, she takes the oral dose of haloperidol, rather than the IM formulation. On mental status examination she exhibits poor eye contact, rather than a fixed gaze, and her BFCRS score decreases to 7 by day 25.

By the end of lorazepam treatment, Mrs. K has fully recovered from her catatonic state. She interacts with staff, engages with the treatment team, and is excited to go home. At discharge, she is given a diagnosis of schizophrenia with catatonia, and is taking haloperidol, 5 mg, twice a day. She gives birth to a healthy girl.

The authors' observations

Mrs. K was treated initially with haloperidol for several reasons. Haloperidol is relatively safe during pregnancy (FDA pregnancy category C) as shown by a recent multicenter, prospective, cohort study in which babies exposed in utero to haloperidol showed a congenital malformation (limb defect) rate within the expected baseline risk for the general population.²² Lorazepam is FDA category D for use in pregnancy and can cause preterm delivery,²³ floppy infant syndrome, and withdrawal syndromes.²⁴ We did not use a second-generation antipsychotic (SGA) because it could have made Mrs. K’s hyperglycemia worse. SGAs can induce gestational diabetes and increase the incidence of large-for-gestational-age newborns, compared with first-generation antipsychotics.²⁴ Last, Mrs. K’s family rejected ECT.

Because of Mrs. K’s poor response to haloperidol, the treatment team decided to start IM lorazepam, which eventually was increased to 8 mg/d. The haloperidol dose was reduced by half to avoid worsening of catatonia and reduce the risk of neuroleptic malignant syndrome.^1,25 When clinical response was achieved, lorazepam was tapered and Mrs. K was discharged with only haloperidol.

In the absence of well-designed prospective follow-up studies, information on the potential impact of prenatal exposure to antipsychotics and benzodiazepines on a child’s cognitive development is limited.²⁶ This case adds to the scant literature on the treatment of catatonia during pregnancy and illustrates how the BFCRS can be utilized during serial patient evaluations to monitor clinical improvement.

Bottom Line

Psychosis and catatonia during pregnancy are associated with complications to mother and child. The Bush-Francis Catatonia Rating Scale can be used to identify and track catatonic symptoms. Lorazepam and electroconvulsive therapy have been used safely and with good outcomes in mentally ill pregnant women when used appropriately.

Related Resources

• Fink M. Catatonia: a syndrome appears, disappears, and is rediscovered. Can J Psychiatry. 2009;54(7):437-445.
• Seethalakshmi R, Dhavale S, Suggu K, et al. Catatonic syndrome: importance of detection and treatment with lorazepam. Ann Clin Psychiatry. 2008;20(1):5-8.
• Salam S, Kilzieh N. Lorazepam treatment of psychogenic catatonia: an update. J Clin Psychiatry, 1988;49(suppl):16-21.

Drug Brand Names

Ceftriaxone • Rocephin                 Olanzapine • Zyprexa

Haloperidol • Haldol                     Short-acting Insulin • Novolin, Humulin

Lorazepam • Ativan 

Disclosures

Dr. Runyan receives grant support from Lippincott, Williams, & Wilkins. Drs. Durant, Prudent, and Sotelo report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE: Mute and unresponsive

Mrs. K, a 42-year-old Haitian who is 31 weeks pregnant, presents with a 4-week history of progressive mutism and psychomotor retardation. At inpatient admission, she is awake and alert but does not speak and resists the treatment team’s attempts to engage her. Mrs. K’s eyes are open, but she has a vacant stare and avoids eye contact. Her affect is flat and nonreactive and she appears internally preoccupied. Mrs. K exhibits motoric immobility, displays a rigid posture, and resists attempts to get her to move. Features of catatonic excitement, echo phenomena, posturing, stereotypies, and mannerisms are absent during the initial evaluation.

Mrs. K’s husband reports that they had been on vacation for 6 days before he brought her for psychiatric evaluation. He denies any recent evidence of psychosis or mood disturbance, stating that his wife was excited when she learned of the pregnancy, and attended all prenatal appointments. He reports that when this episode began, Mrs. K stopped talking to her 3-year-old daughter, did not respond to her name, and did not pay attention to those around her.

According to her husband, a similar episode occurred 2 years earlier, during which Mrs. K was selectively mute for approximately 1 month. She did not eat for 5 days and neglected the care of her daughter. There were 2 additional brief periods of prominent psychomotor retardation for which she was hospitalized in Haiti. According to the patient’s aunt, Mrs. K complained that her husband had cast a “voodoo spell” on her because he wanted sole custody of their daughter. Her husband recounted an episode, when they lived in Haiti, during which his wife became paranoid, left the house, and wandered the streets for 2 days.

The medical history is significant for a cervical polyp that was removed 2 years ago. Mrs. K has no history of substance abuse. She was born and raised in Haiti where she studied medicine. Her family reports that Mrs. K’s husband is “controlling,” which causes her distress.

The authors' observations

Catatonia is a neuropsychiatric syndrome that can occur in schizophrenia, mood disorders, mental retardation, neurologic disease, metabolic conditions, and drug intoxication.¹ Catatonia can present in several ways, from catatonic stupor to extreme purposeless agitation; more than 60 catatonic signs and symptoms have been described.¹ According to DSM-5² catatonia is characterized by 3 or more of the following symptoms:

•  stupor 

•  catalepsy

•  waxy flexibility

•  mutism

•  negativism

•  posturing

•  mannerism

•  stereotypy

•  agitation, not influenced by external stimuli

•  grimacing

•  echolalia

•  echopraxia.

Mrs. K exhibited stupor, mutism, posturing, and grimacing (Table 1).² We thought that her catatonic features were secondary to schizophrenia because she had paranoid delusions and displayed disorganized behavior while in Haiti. There was no evidence of past or current mood disorder, metabolic condition, neurologic illness, or substance abuse.

Catatonia and pregnancy

There is little available information to guide clinicians who are treating a pregnant woman who has a catatonic syndrome. Espinola-Nadurille and co-workers described a 22-year-old pregnant (21 weeks) woman from rural Mexico who was hospitalized with agitation, disorganized speech, restlessness, and hallucinations after several weeks of alternating agitation and withdrawal with mutism and refusal to eat or drink.³ This patient developed malignant catatonia with creatine phosphokinase elevation and leukocytosis and eventually responded to treatment with lorazepam and electroconvulsive therapy (ECT). She was given a diagnosis of schizophreniform disorder. Treating her catatonic symptoms did not result in any adverse effects on the pregnancy or the fetus.

Exacerbation of schizophrenia during pregnancy can lead to neglect of pregnancy and prenatal care,⁴ imminent harm to the fetus because of malnutrition and dehydration, and risk of preterm delivery and low weight at birth. Prolonged catatonia can cause medical complications such as decubitus ulcers, incontinence, recurrent urinary tract infections, aspiration pneumonia, increased risk of deep venous thrombosis, malnutrition, and ocular complications because of prolonged staring and reduced blinking (Table 2^5-10). For these reasons, it is important to treat this condition early and aggressively to improve pregnancy outcome and infant well-being.

EVALUATION: Flat affect

The mental status examination on admission describes a tall, black, Haitian woman with unkempt hair and fair hygiene. Mrs. K has a prominent abdomen, consistent with a 31-week pregnancy. She exhibits a blank stare without direct eye contact; she is mute, and exhibits flat affect. We cannot evaluate her thought processes and content because Mrs. K is mute, although she does appear internally preoccupied.

Physical examination on admission is unremarkable; vital signs are stable and within normal limits. Laboratory work-up reveals a urinary tract infection, which is treated with ceftriaxone. Mrs. K also has macrocytic anemia (hemoglobin, 11.7 g/dL; hematocrit, 34.7%; mean corpuscular volume, 99.2 μm³). Albumin is low at 2.6 g/dL. Urine drug toxicology screen is negative. Fingerstick glucose reading is 139 mg/dL. Mrs. K is given a presumptive diagnosis of schizophrenia with catatonia.

Mrs. K’s BFCRS¹¹ score is 22 at admission. She is mute, holds postures for longer than a minute, and is resistant to repositioning. She also has extreme hypoactivity and does not interact with others. She has a fixed, blank stare, and exhibits mild grimacing.

The authors' observations

BFCRS defines each catatonic sign, rates its severity, and provides a standardized schema for clinical examination.¹¹ The BFCRS is preferred for routine use because of its validity, reliability, and ease of administration.¹² The treatment team rated Mrs. K at admission, during the course of treatment, and at discharge, showing a substantial improvement at the end of the hospitalization (Figure).

The authors' observations

Benzodiazepines (particularly lorazepam) and ECT are considered the treatment of choice for catatonic symptoms.¹¹ More than 72% of patients with catatonic symptoms remit after a trial of a benzodiazepine.¹ ECT is considered when patients do not respond to a benzodiazepine after 48 to 72 hours.³ Several cases of complete resolution of catatonic symptoms have been linked to ECT (Table 3).^13-18

A recent retrospective review revealed that patients who do not respond to loraze­pam are more likely to come from a rural setting, have a longer duration of illness, exhibit mutism, and exhibit third-person auditory hallucinations and made phenomena (the feeling that some aspect of the individual is under the external control of others).¹⁹ Case reports of treatment of catatonic patients with ECT vs lorazepam are listed in Table 3.^13-18

In pregnancy, ECT can be considered early in the course of illness. A review of the literature on ECT during pregnancy reported at least partial remission in 78% of studies reporting efficacy data.²⁰ Among these 339 patients, there were 25 fetal or neonatal complications—only 11 of these were related to ECT—and 20 maternal complications, of which 18 were related to ECT. The authors of this review concluded that 1) ECT is an effective treatment for severe mental illness during pregnancy and 2) the risks to fetus and mother are low.

A 2007 study identified 1,979 infants whose mothers reported use of benzodiazepines or hypnotic benzodiazepine-receptor agonists during early pregnancy.²¹ An additional 401 infants born to mothers who were prescribed these medications during late pregnancy also were included in this study. Women who took these medications were at an increased risk for preterm birth and low birth weight. The rate of congenital malformations in this study was moderately increased among infants exposed in early pregnancy (adjusted odds ratio = 1.24 [95% confidence interval, 1.00 to 1.55]).

Because catatonic symptoms can appear during the course of schizophrenia, several antipsychotics have been used to treat this condition. The efficacy and safety of antipsychotics for treating catatonia remains largely unknown, however.¹

OUTCOME: Recovery, baby girl

We begin oral haloperidol, 10 mg/d, for Mrs. K, which we then increase to 20 mg/d. Because she shows little response to haloperidol, we suggest a trial of ECT, but her husband refuses to consent. She is started on IM lorazepam, 6 mg/d.

Mrs. K gradually improves and increases her intake of food and liquids. After 10 days of lorazepam treatment, her BFCRS score decreases to 13. Mrs. K begins to speak and her gaze is less fixed. Negativistic behaviors are nearly absent.

Because we are concerned about Mrs. K’s pregnancy, lab tests are repeated. A complete metabolic panel shows an elevated glucose level (122 mg/dL); urinalysis reveals glycosuria (glucose, 1,000 mg/dL), proteinuria (protein, 10 mg/dL), and ketonuria, (ketones, 20 mg/dL). She is transferred to the obstetrics service for evaluation of gestational diabetes.

Psychotropics are continued while Mrs. K is on the obstetrics service; she returns to the inpatient psychiatric unit on an insulin regimen. IM lorazepam is increased to 8 mg/d, and haloperidol is decreased from 20 mg/d, to 10 mg/d, to prevent worsening of catatonia, which can occur when catatonic patients receive a psychotropic.¹¹ Three days later, Mrs. K’s BFCRS score is 12 and she shows only mild rigidity. Mrs. K briefly interacts with staff, particularly when she wants something.

Lorazepam is decreased to 1 mg/d in anticipation of cesarean delivery. Mrs. K becomes more adherent with her medications; often, she takes the oral dose of haloperidol, rather than the IM formulation. On mental status examination she exhibits poor eye contact, rather than a fixed gaze, and her BFCRS score decreases to 7 by day 25.

By the end of lorazepam treatment, Mrs. K has fully recovered from her catatonic state. She interacts with staff, engages with the treatment team, and is excited to go home. At discharge, she is given a diagnosis of schizophrenia with catatonia, and is taking haloperidol, 5 mg, twice a day. She gives birth to a healthy girl.

The authors' observations

Mrs. K was treated initially with haloperidol for several reasons. Haloperidol is relatively safe during pregnancy (FDA pregnancy category C) as shown by a recent multicenter, prospective, cohort study in which babies exposed in utero to haloperidol showed a congenital malformation (limb defect) rate within the expected baseline risk for the general population.²² Lorazepam is FDA category D for use in pregnancy and can cause preterm delivery,²³ floppy infant syndrome, and withdrawal syndromes.²⁴ We did not use a second-generation antipsychotic (SGA) because it could have made Mrs. K’s hyperglycemia worse. SGAs can induce gestational diabetes and increase the incidence of large-for-gestational-age newborns, compared with first-generation antipsychotics.²⁴ Last, Mrs. K’s family rejected ECT.

Because of Mrs. K’s poor response to haloperidol, the treatment team decided to start IM lorazepam, which eventually was increased to 8 mg/d. The haloperidol dose was reduced by half to avoid worsening of catatonia and reduce the risk of neuroleptic malignant syndrome.^1,25 When clinical response was achieved, lorazepam was tapered and Mrs. K was discharged with only haloperidol.

In the absence of well-designed prospective follow-up studies, information on the potential impact of prenatal exposure to antipsychotics and benzodiazepines on a child’s cognitive development is limited.²⁶ This case adds to the scant literature on the treatment of catatonia during pregnancy and illustrates how the BFCRS can be utilized during serial patient evaluations to monitor clinical improvement.

Bottom Line

Psychosis and catatonia during pregnancy are associated with complications to mother and child. The Bush-Francis Catatonia Rating Scale can be used to identify and track catatonic symptoms. Lorazepam and electroconvulsive therapy have been used safely and with good outcomes in mentally ill pregnant women when used appropriately.

Related Resources

• Fink M. Catatonia: a syndrome appears, disappears, and is rediscovered. Can J Psychiatry. 2009;54(7):437-445.
• Seethalakshmi R, Dhavale S, Suggu K, et al. Catatonic syndrome: importance of detection and treatment with lorazepam. Ann Clin Psychiatry. 2008;20(1):5-8.
• Salam S, Kilzieh N. Lorazepam treatment of psychogenic catatonia: an update. J Clin Psychiatry, 1988;49(suppl):16-21.

Drug Brand Names

Ceftriaxone • Rocephin                 Olanzapine • Zyprexa

Haloperidol • Haldol                     Short-acting Insulin • Novolin, Humulin

Lorazepam • Ativan 

Disclosures

Dr. Runyan receives grant support from Lippincott, Williams, & Wilkins. Drs. Durant, Prudent, and Sotelo report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE: Mute and unresponsive

Mrs. K, a 42-year-old Haitian who is 31 weeks pregnant, presents with a 4-week history of progressive mutism and psychomotor retardation. At inpatient admission, she is awake and alert but does not speak and resists the treatment team’s attempts to engage her. Mrs. K’s eyes are open, but she has a vacant stare and avoids eye contact. Her affect is flat and nonreactive and she appears internally preoccupied. Mrs. K exhibits motoric immobility, displays a rigid posture, and resists attempts to get her to move. Features of catatonic excitement, echo phenomena, posturing, stereotypies, and mannerisms are absent during the initial evaluation.

Mrs. K’s husband reports that they had been on vacation for 6 days before he brought her for psychiatric evaluation. He denies any recent evidence of psychosis or mood disturbance, stating that his wife was excited when she learned of the pregnancy, and attended all prenatal appointments. He reports that when this episode began, Mrs. K stopped talking to her 3-year-old daughter, did not respond to her name, and did not pay attention to those around her.

According to her husband, a similar episode occurred 2 years earlier, during which Mrs. K was selectively mute for approximately 1 month. She did not eat for 5 days and neglected the care of her daughter. There were 2 additional brief periods of prominent psychomotor retardation for which she was hospitalized in Haiti. According to the patient’s aunt, Mrs. K complained that her husband had cast a “voodoo spell” on her because he wanted sole custody of their daughter. Her husband recounted an episode, when they lived in Haiti, during which his wife became paranoid, left the house, and wandered the streets for 2 days.

The medical history is significant for a cervical polyp that was removed 2 years ago. Mrs. K has no history of substance abuse. She was born and raised in Haiti where she studied medicine. Her family reports that Mrs. K’s husband is “controlling,” which causes her distress.

The authors' observations

Catatonia is a neuropsychiatric syndrome that can occur in schizophrenia, mood disorders, mental retardation, neurologic disease, metabolic conditions, and drug intoxication.¹ Catatonia can present in several ways, from catatonic stupor to extreme purposeless agitation; more than 60 catatonic signs and symptoms have been described.¹ According to DSM-5² catatonia is characterized by 3 or more of the following symptoms:

•  stupor 

•  catalepsy

•  waxy flexibility

•  mutism

•  negativism

•  posturing

•  mannerism

•  stereotypy

•  agitation, not influenced by external stimuli

•  grimacing

•  echolalia

•  echopraxia.

Mrs. K exhibited stupor, mutism, posturing, and grimacing (Table 1).² We thought that her catatonic features were secondary to schizophrenia because she had paranoid delusions and displayed disorganized behavior while in Haiti. There was no evidence of past or current mood disorder, metabolic condition, neurologic illness, or substance abuse.

Catatonia and pregnancy

There is little available information to guide clinicians who are treating a pregnant woman who has a catatonic syndrome. Espinola-Nadurille and co-workers described a 22-year-old pregnant (21 weeks) woman from rural Mexico who was hospitalized with agitation, disorganized speech, restlessness, and hallucinations after several weeks of alternating agitation and withdrawal with mutism and refusal to eat or drink.³ This patient developed malignant catatonia with creatine phosphokinase elevation and leukocytosis and eventually responded to treatment with lorazepam and electroconvulsive therapy (ECT). She was given a diagnosis of schizophreniform disorder. Treating her catatonic symptoms did not result in any adverse effects on the pregnancy or the fetus.

Exacerbation of schizophrenia during pregnancy can lead to neglect of pregnancy and prenatal care,⁴ imminent harm to the fetus because of malnutrition and dehydration, and risk of preterm delivery and low weight at birth. Prolonged catatonia can cause medical complications such as decubitus ulcers, incontinence, recurrent urinary tract infections, aspiration pneumonia, increased risk of deep venous thrombosis, malnutrition, and ocular complications because of prolonged staring and reduced blinking (Table 2^5-10). For these reasons, it is important to treat this condition early and aggressively to improve pregnancy outcome and infant well-being.

EVALUATION: Flat affect

The mental status examination on admission describes a tall, black, Haitian woman with unkempt hair and fair hygiene. Mrs. K has a prominent abdomen, consistent with a 31-week pregnancy. She exhibits a blank stare without direct eye contact; she is mute, and exhibits flat affect. We cannot evaluate her thought processes and content because Mrs. K is mute, although she does appear internally preoccupied.

Physical examination on admission is unremarkable; vital signs are stable and within normal limits. Laboratory work-up reveals a urinary tract infection, which is treated with ceftriaxone. Mrs. K also has macrocytic anemia (hemoglobin, 11.7 g/dL; hematocrit, 34.7%; mean corpuscular volume, 99.2 μm³). Albumin is low at 2.6 g/dL. Urine drug toxicology screen is negative. Fingerstick glucose reading is 139 mg/dL. Mrs. K is given a presumptive diagnosis of schizophrenia with catatonia.

Mrs. K’s BFCRS¹¹ score is 22 at admission. She is mute, holds postures for longer than a minute, and is resistant to repositioning. She also has extreme hypoactivity and does not interact with others. She has a fixed, blank stare, and exhibits mild grimacing.

The authors' observations

BFCRS defines each catatonic sign, rates its severity, and provides a standardized schema for clinical examination.¹¹ The BFCRS is preferred for routine use because of its validity, reliability, and ease of administration.¹² The treatment team rated Mrs. K at admission, during the course of treatment, and at discharge, showing a substantial improvement at the end of the hospitalization (Figure).

The authors' observations

Benzodiazepines (particularly lorazepam) and ECT are considered the treatment of choice for catatonic symptoms.¹¹ More than 72% of patients with catatonic symptoms remit after a trial of a benzodiazepine.¹ ECT is considered when patients do not respond to a benzodiazepine after 48 to 72 hours.³ Several cases of complete resolution of catatonic symptoms have been linked to ECT (Table 3).^13-18

A recent retrospective review revealed that patients who do not respond to loraze­pam are more likely to come from a rural setting, have a longer duration of illness, exhibit mutism, and exhibit third-person auditory hallucinations and made phenomena (the feeling that some aspect of the individual is under the external control of others).¹⁹ Case reports of treatment of catatonic patients with ECT vs lorazepam are listed in Table 3.^13-18

In pregnancy, ECT can be considered early in the course of illness. A review of the literature on ECT during pregnancy reported at least partial remission in 78% of studies reporting efficacy data.²⁰ Among these 339 patients, there were 25 fetal or neonatal complications—only 11 of these were related to ECT—and 20 maternal complications, of which 18 were related to ECT. The authors of this review concluded that 1) ECT is an effective treatment for severe mental illness during pregnancy and 2) the risks to fetus and mother are low.

A 2007 study identified 1,979 infants whose mothers reported use of benzodiazepines or hypnotic benzodiazepine-receptor agonists during early pregnancy.²¹ An additional 401 infants born to mothers who were prescribed these medications during late pregnancy also were included in this study. Women who took these medications were at an increased risk for preterm birth and low birth weight. The rate of congenital malformations in this study was moderately increased among infants exposed in early pregnancy (adjusted odds ratio = 1.24 [95% confidence interval, 1.00 to 1.55]).

Because catatonic symptoms can appear during the course of schizophrenia, several antipsychotics have been used to treat this condition. The efficacy and safety of antipsychotics for treating catatonia remains largely unknown, however.¹

OUTCOME: Recovery, baby girl

We begin oral haloperidol, 10 mg/d, for Mrs. K, which we then increase to 20 mg/d. Because she shows little response to haloperidol, we suggest a trial of ECT, but her husband refuses to consent. She is started on IM lorazepam, 6 mg/d.

Mrs. K gradually improves and increases her intake of food and liquids. After 10 days of lorazepam treatment, her BFCRS score decreases to 13. Mrs. K begins to speak and her gaze is less fixed. Negativistic behaviors are nearly absent.

Because we are concerned about Mrs. K’s pregnancy, lab tests are repeated. A complete metabolic panel shows an elevated glucose level (122 mg/dL); urinalysis reveals glycosuria (glucose, 1,000 mg/dL), proteinuria (protein, 10 mg/dL), and ketonuria, (ketones, 20 mg/dL). She is transferred to the obstetrics service for evaluation of gestational diabetes.

Psychotropics are continued while Mrs. K is on the obstetrics service; she returns to the inpatient psychiatric unit on an insulin regimen. IM lorazepam is increased to 8 mg/d, and haloperidol is decreased from 20 mg/d, to 10 mg/d, to prevent worsening of catatonia, which can occur when catatonic patients receive a psychotropic.¹¹ Three days later, Mrs. K’s BFCRS score is 12 and she shows only mild rigidity. Mrs. K briefly interacts with staff, particularly when she wants something.

Lorazepam is decreased to 1 mg/d in anticipation of cesarean delivery. Mrs. K becomes more adherent with her medications; often, she takes the oral dose of haloperidol, rather than the IM formulation. On mental status examination she exhibits poor eye contact, rather than a fixed gaze, and her BFCRS score decreases to 7 by day 25.

By the end of lorazepam treatment, Mrs. K has fully recovered from her catatonic state. She interacts with staff, engages with the treatment team, and is excited to go home. At discharge, she is given a diagnosis of schizophrenia with catatonia, and is taking haloperidol, 5 mg, twice a day. She gives birth to a healthy girl.

The authors' observations

Mrs. K was treated initially with haloperidol for several reasons. Haloperidol is relatively safe during pregnancy (FDA pregnancy category C) as shown by a recent multicenter, prospective, cohort study in which babies exposed in utero to haloperidol showed a congenital malformation (limb defect) rate within the expected baseline risk for the general population.²² Lorazepam is FDA category D for use in pregnancy and can cause preterm delivery,²³ floppy infant syndrome, and withdrawal syndromes.²⁴ We did not use a second-generation antipsychotic (SGA) because it could have made Mrs. K’s hyperglycemia worse. SGAs can induce gestational diabetes and increase the incidence of large-for-gestational-age newborns, compared with first-generation antipsychotics.²⁴ Last, Mrs. K’s family rejected ECT.

Because of Mrs. K’s poor response to haloperidol, the treatment team decided to start IM lorazepam, which eventually was increased to 8 mg/d. The haloperidol dose was reduced by half to avoid worsening of catatonia and reduce the risk of neuroleptic malignant syndrome.^1,25 When clinical response was achieved, lorazepam was tapered and Mrs. K was discharged with only haloperidol.

In the absence of well-designed prospective follow-up studies, information on the potential impact of prenatal exposure to antipsychotics and benzodiazepines on a child’s cognitive development is limited.²⁶ This case adds to the scant literature on the treatment of catatonia during pregnancy and illustrates how the BFCRS can be utilized during serial patient evaluations to monitor clinical improvement.

Bottom Line

Psychosis and catatonia during pregnancy are associated with complications to mother and child. The Bush-Francis Catatonia Rating Scale can be used to identify and track catatonic symptoms. Lorazepam and electroconvulsive therapy have been used safely and with good outcomes in mentally ill pregnant women when used appropriately.

Related Resources

• Fink M. Catatonia: a syndrome appears, disappears, and is rediscovered. Can J Psychiatry. 2009;54(7):437-445.
• Seethalakshmi R, Dhavale S, Suggu K, et al. Catatonic syndrome: importance of detection and treatment with lorazepam. Ann Clin Psychiatry. 2008;20(1):5-8.
• Salam S, Kilzieh N. Lorazepam treatment of psychogenic catatonia: an update. J Clin Psychiatry, 1988;49(suppl):16-21.

Drug Brand Names

Ceftriaxone • Rocephin                 Olanzapine • Zyprexa

Haloperidol • Haldol                     Short-acting Insulin • Novolin, Humulin

Lorazepam • Ativan 

Disclosures

Dr. Runyan receives grant support from Lippincott, Williams, & Wilkins. Drs. Durant, Prudent, and Sotelo report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.