In the last decade, natural disasters such as the Indonesian tsunami of 2004, Hurricane Katrina in 2004, and the Pakistani earthquake of 2005 have brought attention to the importance of diverse but complementary medical professional roles in humanitarian medical aid.14 Natural disasters that cause significant physical trauma to large populations often necessitate initial multidisciplinary responder teams comprised of surgeons, anesthesiologists, emergency medicine physicians, surgical technologists, nurses, psychiatrists, and public health specialists. Their roles are to manage life‐threatening injuries, provide immediate triage, help affected individuals deal with intense psychological shock, and address critical population‐based needs such as water, food, and sanitation. Meanwhile, general medical, pediatric, rehabilitative, and long‐term psychiatric services often constitute a secondary tier of disaster response, providing postsurgical care, managing acute medical illnesses, mitigating psychological trauma, rehabilitating injuries, and providing vaccinations to at‐risk individuals. Hospitalists can play an important role in postcatastrophe recovery services as experts in acute care, stewards of care transitions, and drivers of systems improvement.

The earthquake that occurred January 12, 2010 in Haiti is a dramatic illustration of the importance of a multidisciplinary approach to disaster relief. The 7.0‐magnitude earthquake near Port‐au‐Prince ravaged an already crippled health care system, severely damaging the country's primary academic medical center, and killed the entire class of second‐year nursing students. The death toll has been estimated to be nearly one‐quarter of a million people.5 Victims awaiting surgery, recovering from surgery, or in need of other immediate medical attention quickly inundated any existing health facilities. The following stories describe the authors' respective experiences in Haiti after the earthquake.

JC: I arrived 4 days after the earthquake to a hospital outside of Port‐au‐Prince, spared from destruction, but filled with hundreds of patients with crush injuries and severe fractures. On rounds with the surgical team, I observed that venous thromboembolism (VTE) prophylaxis had not yet been initiated, and I was concerned that patients might die from pulmonary embolism. In the overwhelming urgency of providing life‐saving surgery to as many patients as possible, this simple measure had been overlooked. After discussion with our team and our Haitian medical colleagues, we initiated subcutaneous heparin on all eligible patients and made arrangements to receive further shipments of heparin to accommodate the influx of patients.

A nearby school and church had been annexed into makeshift extensions of the hospital wards. The volume and pace of incoming injuries was such that as soon as a patient was taken to surgery, another patient would often take his or her place in the bed. The rapid movement of patients to and from x‐ray, surgery, and postsurgical care created challenges around effective and accurate communication among multiple care providers. We decided that nonsurgical personnel would triage newly arriving patients and round on patients daily. Each nonsurgical physician was responsible for staffing a particular location. This zone‐defense approach ensured that the surgeons maximized their time in the operating rooms. We also instituted a basic system of portable medical records kept with each patient at all times, allowing personnel to easily and quickly assess care given to date, and to write notes and orders.

Presurgical and postsurgical wound infections became a common event, with the risk of ensuing sepsis. Antibiotic use was dependent on the preferences of individual surgeons and also on the available supply. As a result, antimicrobial treatments were highly variable and sometimes inadequate. The internists on the team proposed standard antibiotic guidelines for open fractures, for contaminated wounds, and for postoperative wounds; these regimens were approved and implemented by Haitian staff and the rest of the team.

Internists recognized the first complications of rhabdomyolysis from crush injuries and delays in receiving medical attention. Malaise, oliguria, and volume overload were often the only clues we had for severe renal failure. We had a functional lab capable of checking complete blood counts, urinalysis and creatinine, but we had a limited supply of serum potassium assays. We only used the latter in confirmed cases of rhabdomyolysis, and on several occasions we diagnosed severe hyperkalemia. Using bedside automated electrical defibrillation devices for monitoring, we sustained these patients on calcium gluconate until they could be transferred to an external dialysis unit run by Mdecins Sans Frontires in Port‐au‐Prince.6 As the number of rhabdomyolysis cases increased, we instigated creatinine rounds on patients arriving with large crush injuries, and we evaluated urine output daily until patients were clinically stable from this threat. We also helped the Haitian staff treat the omnipresent problem of pain and advised renal dosing of medications in renal failure and elderly patients.

GH: The situation 3 months after the earthquake was medically less dire but highlights the evolving importance of generalists in the aftermath of the quake.710 For many Haitian patients, the earthquake had become a universal point of reference for their symptomatology. Anorexia, amenorrhea, headaches, epigastric pain, even fungating soft tissue masses, were all reported to be depi tranbleman t a (since the earthquake) and were often somatic manifestations of a psychologically devastating event. At a hospital in Carrefour, I cared for patients presenting with dramatic sequelae of chronic diseases that had been undertreated due to the destruction of the Haitian medical infrastructurehypertensive coma, diabetic ketoacidosis, cerebral malaria, decompensated liver disease, and severe chronic anemia (including a patient with a hemoglobin of 3 mg/dL). I encountered many patients with infections exacerbated by excessive crowding in tent communities, such as typhoid and tuberculosis. At this particular hospital, priorities appropriately placed on surgical and postsurgical care required the team to devise creative solutions for the care and placement of medical patients, such as restructuring the emergency department and creating a rehabilitation tent on the hospital grounds. While few Haitian internists were present, a number of Haitian obstetricians were on site and helped manage medical conditions within the scope of their experience, such as hypertension, abdominal pain, and genitourinary infections. The expatriate orthopedic surgeons on site sought the consultative skills of hospitalists for preoperative management, postoperative complications, and comorbid conditions.

This hospital was largely sustained by rotating teams of volunteers, which underscored the importance of establishing a flexible system that would accommodate the turnover of personnel and fluctuating levels of professional expertise. The team used a tiered model for acute care delivery designating responsibilities based on the number of nurses, physicians, and other providers available. We collaborated with Haitian physicians to establish a routine of handoff rounds. Finally, we created and centralized documentation such as clinical protocols, contact numbers, and helpful tips for our successors.

Hospitalists have valuable skills to offer in medical responses to natural catastrophes.5 Our fluency with acute care environments becomes a pluripotent asset in disaster relief. Our experiences in assessing acuity are vital in assisting with inpatient triage. Our familiarity with the comanagement model facilitates partnership with other disciplines to optimize the distribution of skill sets without neglecting the overall well‐being of patients. Our clinical expertise in treating the vulnerable elderly, VTE, renal failure, pain management, postoperative infections, sepsis, and many other conditions can bolster medical relief efforts, even when the foremost need is surgical. The hospitalist's core competencies in healthcare systems11 can support recovery initiatives in medical facilities, particularly in the domains of drug safety, resource allocation, information management, team‐based methods, and care transitions. Our respective experiences also suggest the potential value of hospitalists in domestic, in addition to international, disaster response initiatives. Since large‐scale calamities may result in the hospitalization of overwhelming numbers of victims,12 hospitalists may be well‐positioned to assist our emergency medicine and public health colleagues, who currently (and fittingly) lead domestic efforts in disaster relief.

Tragedies like the earthquake in Haiti serve as a sobering reminder that a comprehensive multidisciplinary approach is required as medical disaster relief shifts from a life‐saving focus to one of life‐preserving care.13, 14 Hospitalists can play a vital role in these restorative efforts.

In the last decade, natural disasters such as the Indonesian tsunami of 2004, Hurricane Katrina in 2004, and the Pakistani earthquake of 2005 have brought attention to the importance of diverse but complementary medical professional roles in humanitarian medical aid.14 Natural disasters that cause significant physical trauma to large populations often necessitate initial multidisciplinary responder teams comprised of surgeons, anesthesiologists, emergency medicine physicians, surgical technologists, nurses, psychiatrists, and public health specialists. Their roles are to manage life‐threatening injuries, provide immediate triage, help affected individuals deal with intense psychological shock, and address critical population‐based needs such as water, food, and sanitation. Meanwhile, general medical, pediatric, rehabilitative, and long‐term psychiatric services often constitute a secondary tier of disaster response, providing postsurgical care, managing acute medical illnesses, mitigating psychological trauma, rehabilitating injuries, and providing vaccinations to at‐risk individuals. Hospitalists can play an important role in postcatastrophe recovery services as experts in acute care, stewards of care transitions, and drivers of systems improvement.

The earthquake that occurred January 12, 2010 in Haiti is a dramatic illustration of the importance of a multidisciplinary approach to disaster relief. The 7.0‐magnitude earthquake near Port‐au‐Prince ravaged an already crippled health care system, severely damaging the country's primary academic medical center, and killed the entire class of second‐year nursing students. The death toll has been estimated to be nearly one‐quarter of a million people.5 Victims awaiting surgery, recovering from surgery, or in need of other immediate medical attention quickly inundated any existing health facilities. The following stories describe the authors' respective experiences in Haiti after the earthquake.

JC: I arrived 4 days after the earthquake to a hospital outside of Port‐au‐Prince, spared from destruction, but filled with hundreds of patients with crush injuries and severe fractures. On rounds with the surgical team, I observed that venous thromboembolism (VTE) prophylaxis had not yet been initiated, and I was concerned that patients might die from pulmonary embolism. In the overwhelming urgency of providing life‐saving surgery to as many patients as possible, this simple measure had been overlooked. After discussion with our team and our Haitian medical colleagues, we initiated subcutaneous heparin on all eligible patients and made arrangements to receive further shipments of heparin to accommodate the influx of patients.

A nearby school and church had been annexed into makeshift extensions of the hospital wards. The volume and pace of incoming injuries was such that as soon as a patient was taken to surgery, another patient would often take his or her place in the bed. The rapid movement of patients to and from x‐ray, surgery, and postsurgical care created challenges around effective and accurate communication among multiple care providers. We decided that nonsurgical personnel would triage newly arriving patients and round on patients daily. Each nonsurgical physician was responsible for staffing a particular location. This zone‐defense approach ensured that the surgeons maximized their time in the operating rooms. We also instituted a basic system of portable medical records kept with each patient at all times, allowing personnel to easily and quickly assess care given to date, and to write notes and orders.

Presurgical and postsurgical wound infections became a common event, with the risk of ensuing sepsis. Antibiotic use was dependent on the preferences of individual surgeons and also on the available supply. As a result, antimicrobial treatments were highly variable and sometimes inadequate. The internists on the team proposed standard antibiotic guidelines for open fractures, for contaminated wounds, and for postoperative wounds; these regimens were approved and implemented by Haitian staff and the rest of the team.

Internists recognized the first complications of rhabdomyolysis from crush injuries and delays in receiving medical attention. Malaise, oliguria, and volume overload were often the only clues we had for severe renal failure. We had a functional lab capable of checking complete blood counts, urinalysis and creatinine, but we had a limited supply of serum potassium assays. We only used the latter in confirmed cases of rhabdomyolysis, and on several occasions we diagnosed severe hyperkalemia. Using bedside automated electrical defibrillation devices for monitoring, we sustained these patients on calcium gluconate until they could be transferred to an external dialysis unit run by Mdecins Sans Frontires in Port‐au‐Prince.6 As the number of rhabdomyolysis cases increased, we instigated creatinine rounds on patients arriving with large crush injuries, and we evaluated urine output daily until patients were clinically stable from this threat. We also helped the Haitian staff treat the omnipresent problem of pain and advised renal dosing of medications in renal failure and elderly patients.

GH: The situation 3 months after the earthquake was medically less dire but highlights the evolving importance of generalists in the aftermath of the quake.710 For many Haitian patients, the earthquake had become a universal point of reference for their symptomatology. Anorexia, amenorrhea, headaches, epigastric pain, even fungating soft tissue masses, were all reported to be depi tranbleman t a (since the earthquake) and were often somatic manifestations of a psychologically devastating event. At a hospital in Carrefour, I cared for patients presenting with dramatic sequelae of chronic diseases that had been undertreated due to the destruction of the Haitian medical infrastructurehypertensive coma, diabetic ketoacidosis, cerebral malaria, decompensated liver disease, and severe chronic anemia (including a patient with a hemoglobin of 3 mg/dL). I encountered many patients with infections exacerbated by excessive crowding in tent communities, such as typhoid and tuberculosis. At this particular hospital, priorities appropriately placed on surgical and postsurgical care required the team to devise creative solutions for the care and placement of medical patients, such as restructuring the emergency department and creating a rehabilitation tent on the hospital grounds. While few Haitian internists were present, a number of Haitian obstetricians were on site and helped manage medical conditions within the scope of their experience, such as hypertension, abdominal pain, and genitourinary infections. The expatriate orthopedic surgeons on site sought the consultative skills of hospitalists for preoperative management, postoperative complications, and comorbid conditions.

This hospital was largely sustained by rotating teams of volunteers, which underscored the importance of establishing a flexible system that would accommodate the turnover of personnel and fluctuating levels of professional expertise. The team used a tiered model for acute care delivery designating responsibilities based on the number of nurses, physicians, and other providers available. We collaborated with Haitian physicians to establish a routine of handoff rounds. Finally, we created and centralized documentation such as clinical protocols, contact numbers, and helpful tips for our successors.

Hospitalists have valuable skills to offer in medical responses to natural catastrophes.5 Our fluency with acute care environments becomes a pluripotent asset in disaster relief. Our experiences in assessing acuity are vital in assisting with inpatient triage. Our familiarity with the comanagement model facilitates partnership with other disciplines to optimize the distribution of skill sets without neglecting the overall well‐being of patients. Our clinical expertise in treating the vulnerable elderly, VTE, renal failure, pain management, postoperative infections, sepsis, and many other conditions can bolster medical relief efforts, even when the foremost need is surgical. The hospitalist's core competencies in healthcare systems11 can support recovery initiatives in medical facilities, particularly in the domains of drug safety, resource allocation, information management, team‐based methods, and care transitions. Our respective experiences also suggest the potential value of hospitalists in domestic, in addition to international, disaster response initiatives. Since large‐scale calamities may result in the hospitalization of overwhelming numbers of victims,12 hospitalists may be well‐positioned to assist our emergency medicine and public health colleagues, who currently (and fittingly) lead domestic efforts in disaster relief.

Tragedies like the earthquake in Haiti serve as a sobering reminder that a comprehensive multidisciplinary approach is required as medical disaster relief shifts from a life‐saving focus to one of life‐preserving care.13, 14 Hospitalists can play a vital role in these restorative efforts.

In the last decade, natural disasters such as the Indonesian tsunami of 2004, Hurricane Katrina in 2004, and the Pakistani earthquake of 2005 have brought attention to the importance of diverse but complementary medical professional roles in humanitarian medical aid.14 Natural disasters that cause significant physical trauma to large populations often necessitate initial multidisciplinary responder teams comprised of surgeons, anesthesiologists, emergency medicine physicians, surgical technologists, nurses, psychiatrists, and public health specialists. Their roles are to manage life‐threatening injuries, provide immediate triage, help affected individuals deal with intense psychological shock, and address critical population‐based needs such as water, food, and sanitation. Meanwhile, general medical, pediatric, rehabilitative, and long‐term psychiatric services often constitute a secondary tier of disaster response, providing postsurgical care, managing acute medical illnesses, mitigating psychological trauma, rehabilitating injuries, and providing vaccinations to at‐risk individuals. Hospitalists can play an important role in postcatastrophe recovery services as experts in acute care, stewards of care transitions, and drivers of systems improvement.

The earthquake that occurred January 12, 2010 in Haiti is a dramatic illustration of the importance of a multidisciplinary approach to disaster relief. The 7.0‐magnitude earthquake near Port‐au‐Prince ravaged an already crippled health care system, severely damaging the country's primary academic medical center, and killed the entire class of second‐year nursing students. The death toll has been estimated to be nearly one‐quarter of a million people.5 Victims awaiting surgery, recovering from surgery, or in need of other immediate medical attention quickly inundated any existing health facilities. The following stories describe the authors' respective experiences in Haiti after the earthquake.

JC: I arrived 4 days after the earthquake to a hospital outside of Port‐au‐Prince, spared from destruction, but filled with hundreds of patients with crush injuries and severe fractures. On rounds with the surgical team, I observed that venous thromboembolism (VTE) prophylaxis had not yet been initiated, and I was concerned that patients might die from pulmonary embolism. In the overwhelming urgency of providing life‐saving surgery to as many patients as possible, this simple measure had been overlooked. After discussion with our team and our Haitian medical colleagues, we initiated subcutaneous heparin on all eligible patients and made arrangements to receive further shipments of heparin to accommodate the influx of patients.

A nearby school and church had been annexed into makeshift extensions of the hospital wards. The volume and pace of incoming injuries was such that as soon as a patient was taken to surgery, another patient would often take his or her place in the bed. The rapid movement of patients to and from x‐ray, surgery, and postsurgical care created challenges around effective and accurate communication among multiple care providers. We decided that nonsurgical personnel would triage newly arriving patients and round on patients daily. Each nonsurgical physician was responsible for staffing a particular location. This zone‐defense approach ensured that the surgeons maximized their time in the operating rooms. We also instituted a basic system of portable medical records kept with each patient at all times, allowing personnel to easily and quickly assess care given to date, and to write notes and orders.

Presurgical and postsurgical wound infections became a common event, with the risk of ensuing sepsis. Antibiotic use was dependent on the preferences of individual surgeons and also on the available supply. As a result, antimicrobial treatments were highly variable and sometimes inadequate. The internists on the team proposed standard antibiotic guidelines for open fractures, for contaminated wounds, and for postoperative wounds; these regimens were approved and implemented by Haitian staff and the rest of the team.

Internists recognized the first complications of rhabdomyolysis from crush injuries and delays in receiving medical attention. Malaise, oliguria, and volume overload were often the only clues we had for severe renal failure. We had a functional lab capable of checking complete blood counts, urinalysis and creatinine, but we had a limited supply of serum potassium assays. We only used the latter in confirmed cases of rhabdomyolysis, and on several occasions we diagnosed severe hyperkalemia. Using bedside automated electrical defibrillation devices for monitoring, we sustained these patients on calcium gluconate until they could be transferred to an external dialysis unit run by Mdecins Sans Frontires in Port‐au‐Prince.6 As the number of rhabdomyolysis cases increased, we instigated creatinine rounds on patients arriving with large crush injuries, and we evaluated urine output daily until patients were clinically stable from this threat. We also helped the Haitian staff treat the omnipresent problem of pain and advised renal dosing of medications in renal failure and elderly patients.

GH: The situation 3 months after the earthquake was medically less dire but highlights the evolving importance of generalists in the aftermath of the quake.710 For many Haitian patients, the earthquake had become a universal point of reference for their symptomatology. Anorexia, amenorrhea, headaches, epigastric pain, even fungating soft tissue masses, were all reported to be depi tranbleman t a (since the earthquake) and were often somatic manifestations of a psychologically devastating event. At a hospital in Carrefour, I cared for patients presenting with dramatic sequelae of chronic diseases that had been undertreated due to the destruction of the Haitian medical infrastructurehypertensive coma, diabetic ketoacidosis, cerebral malaria, decompensated liver disease, and severe chronic anemia (including a patient with a hemoglobin of 3 mg/dL). I encountered many patients with infections exacerbated by excessive crowding in tent communities, such as typhoid and tuberculosis. At this particular hospital, priorities appropriately placed on surgical and postsurgical care required the team to devise creative solutions for the care and placement of medical patients, such as restructuring the emergency department and creating a rehabilitation tent on the hospital grounds. While few Haitian internists were present, a number of Haitian obstetricians were on site and helped manage medical conditions within the scope of their experience, such as hypertension, abdominal pain, and genitourinary infections. The expatriate orthopedic surgeons on site sought the consultative skills of hospitalists for preoperative management, postoperative complications, and comorbid conditions.

This hospital was largely sustained by rotating teams of volunteers, which underscored the importance of establishing a flexible system that would accommodate the turnover of personnel and fluctuating levels of professional expertise. The team used a tiered model for acute care delivery designating responsibilities based on the number of nurses, physicians, and other providers available. We collaborated with Haitian physicians to establish a routine of handoff rounds. Finally, we created and centralized documentation such as clinical protocols, contact numbers, and helpful tips for our successors.

Hospitalists have valuable skills to offer in medical responses to natural catastrophes.5 Our fluency with acute care environments becomes a pluripotent asset in disaster relief. Our experiences in assessing acuity are vital in assisting with inpatient triage. Our familiarity with the comanagement model facilitates partnership with other disciplines to optimize the distribution of skill sets without neglecting the overall well‐being of patients. Our clinical expertise in treating the vulnerable elderly, VTE, renal failure, pain management, postoperative infections, sepsis, and many other conditions can bolster medical relief efforts, even when the foremost need is surgical. The hospitalist's core competencies in healthcare systems11 can support recovery initiatives in medical facilities, particularly in the domains of drug safety, resource allocation, information management, team‐based methods, and care transitions. Our respective experiences also suggest the potential value of hospitalists in domestic, in addition to international, disaster response initiatives. Since large‐scale calamities may result in the hospitalization of overwhelming numbers of victims,12 hospitalists may be well‐positioned to assist our emergency medicine and public health colleagues, who currently (and fittingly) lead domestic efforts in disaster relief.

Tragedies like the earthquake in Haiti serve as a sobering reminder that a comprehensive multidisciplinary approach is required as medical disaster relief shifts from a life‐saving focus to one of life‐preserving care.13, 14 Hospitalists can play a vital role in these restorative efforts.

If you wish to receive credit for this activity, which begins on the next page, please refer to the website: www.blackwellpublishing.com/cme.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this educational activity for a 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

Upon completion of this educational activity, participants will be better able to employ automated bed history data to examine outcomes of intra‐hospital transfers using all hospital admissions as the denominator.

Continuous participation in the Journal of Hospital Medicine CME program will enable learners to be better able to:

• Interpret clinical guidelines and their applications for higher quality and more efficient care for all hospitalized patients.

• Describe the standard of care for common illnesses and conditions treated in the hospital; such as pneumonia, COPD exacerbation, acute coronary syndrome, HF exacerbation, glycemic control, venous thromboembolic disease, stroke, etc.

• Discuss evidence‐based recommendations involving transitions of care, including the hospital discharge process.

• Gain insights into the roles of hospitalists as medical educators, researchers, medical ethicists, palliative care providers, and hospital‐based geriatricians.

• Incorporate best practices for hospitalist administration, including quality improvement, patient safety, practice management, leadership, and demonstrating hospitalist value.

• Identify evidence‐based best practices and trends for both adult and pediatric hospital medicine.

Instructions on Receiving Credit

For information on applicability and acceptance of continuing medical education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period that is noted on the title page.

Follow these steps to earn credit:

• Log on to www.blackwellpublishing.com/cme.

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

If you wish to receive credit for this activity, which begins on the next page, please refer to the website: www.blackwellpublishing.com/cme.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this educational activity for a 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

Upon completion of this educational activity, participants will be better able to employ automated bed history data to examine outcomes of intra‐hospital transfers using all hospital admissions as the denominator.

Continuous participation in the Journal of Hospital Medicine CME program will enable learners to be better able to:

• Interpret clinical guidelines and their applications for higher quality and more efficient care for all hospitalized patients.

• Describe the standard of care for common illnesses and conditions treated in the hospital; such as pneumonia, COPD exacerbation, acute coronary syndrome, HF exacerbation, glycemic control, venous thromboembolic disease, stroke, etc.

• Discuss evidence‐based recommendations involving transitions of care, including the hospital discharge process.

• Gain insights into the roles of hospitalists as medical educators, researchers, medical ethicists, palliative care providers, and hospital‐based geriatricians.

• Incorporate best practices for hospitalist administration, including quality improvement, patient safety, practice management, leadership, and demonstrating hospitalist value.

• Identify evidence‐based best practices and trends for both adult and pediatric hospital medicine.

Instructions on Receiving Credit

For information on applicability and acceptance of continuing medical education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period that is noted on the title page.

Follow these steps to earn credit:

• Log on to www.blackwellpublishing.com/cme.

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

If you wish to receive credit for this activity, which begins on the next page, please refer to the website: www.blackwellpublishing.com/cme.

Accreditation and Designation Statement

Blackwell Futura Media Services designates this educational activity for a 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Educational Objectives

Upon completion of this educational activity, participants will be better able to employ automated bed history data to examine outcomes of intra‐hospital transfers using all hospital admissions as the denominator.

Continuous participation in the Journal of Hospital Medicine CME program will enable learners to be better able to:

• Interpret clinical guidelines and their applications for higher quality and more efficient care for all hospitalized patients.

• Describe the standard of care for common illnesses and conditions treated in the hospital; such as pneumonia, COPD exacerbation, acute coronary syndrome, HF exacerbation, glycemic control, venous thromboembolic disease, stroke, etc.

• Discuss evidence‐based recommendations involving transitions of care, including the hospital discharge process.

• Gain insights into the roles of hospitalists as medical educators, researchers, medical ethicists, palliative care providers, and hospital‐based geriatricians.

• Incorporate best practices for hospitalist administration, including quality improvement, patient safety, practice management, leadership, and demonstrating hospitalist value.

• Identify evidence‐based best practices and trends for both adult and pediatric hospital medicine.

Instructions on Receiving Credit

For information on applicability and acceptance of continuing medical education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period that is noted on the title page.

Follow these steps to earn credit:

• Log on to www.blackwellpublishing.com/cme.

• Read the target audience, learning objectives, and author disclosures.

• Read the article in print or online format.

• Reflect on the article.

• Access the CME Exam, and choose the best answer to each question.

• Complete the required evaluation component of the activity.

Hospital readmissions pose a major problem both to the patient and the fiscal stability of our health care system.1 Many interventions have attempted to tackle this problem. Interventions exist that utilize transition coaches working intensively with hospitalized patients or nurses performing postdischarge home visits or phoning patients.2, 3 Although beneficial, these strategies are costly and require additional, highly trained personnel. Consequently, they have been difficult to sustain financially in a fee‐for‐service environment, and difficult to generalize at other locales. Recent policies to decrease hospital payments for readmissions will incentivize hospitals to implement discharge programs.4 However, all hospital systems will still want to do this in the most efficient manner possible.

One important way to maximize benefits and minimize costs is to target the most intensive, expensive interventions to the highest risk patients who are most likely to be rehospitalized. By targeting the highest risk patients, we could significantly reduce costs. However, models predicting rehospitalization have had limited accuracy, even for condition‐specific models such as heart failure. Two studies in this issue work to better identify high‐risk patients. Mudge and colleagues5 prospectively examined risk factors for recurrent readmissions in an Australian hospital and found that chronic disease, depression, and underweight were independent risk factors for repeat readmission. Allaudeen6 examined risk factors for readmission to their own institution among general medicine patients. In a retrospective analysis of administrative data, they found that several variables predicted hospital readmission, including black race, insurance coverage through Medicaid, prescription of steroids or narcotics, and diagnoses of heart failure, renal disease, cancer, anemia, and weight loss.

These studies raise two questions that are critical if we are to develop better predictive modeling of who will benefit most from intensive interventions to reduce readmissions. First, what are the risk factors for preventable hospitalizations? People with multiple readmissions seem an obvious target on which to focus. However, it may be that these individuals are just very sick with multiple comorbidities, and many of their readmissions may not be preventable. Rich and colleagues reported that a multidisciplinary discharge intervention reduced readmissions for heart failure by 56%.7 What is often forgotten is that in their pilot study they were not able to reduce admissions for the most severely ill, and their final study population excluded the sickest patients. By targeting moderate‐risk patients, they were able to reduce readmissions significantly.8 In the studies by Mudge et al.5 and Allaudeen,6 the fact that chronic diseases predicted rehospitalization is only moderately helpful. It is possible, perhaps likely, that many of the readmissions for heart failure were preventable while many of the readmissions for cancer were not. The challenge for researchers is to develop methods for classifying admissions/readmissions as preventable.9 Using a defined set of diagnostic categories to classify readmissions (eg, ambulatory care sensitive conditions) may misclassify many cases.10 Determining preventable hospitalizations through detailed chart review is expensive and may have limited interobserver reliability. Nevertheless, physician review and classification may be necessary for future research to advance the field.

Second, what predictor variables are causally related to preventable hospitalizations (and presumably actionable), and which are merely markers of true causal factors and therefore harder to interpret and more difficult to act upon? In addition to chronic disease, Mudge et al.5 found that depression and low body mass index were independent risk factors for readmission. These conditions often go hand in hand. Patients who are burdened with chronic disease may be depressed and not eat. Conversely, patients who are depressed may not eat and allow their chronic disease to worsen. But it seems that depression is the more likely of the two to be causal. Depression is an important predictor of medication nonadherence and worsening illness.11, 12 Screening hospitalized patients for depression could provide valuable information on which patients may need treatment or more rigorous postdischarge follow‐up. In contrast, being underweight may not truly cause readmissions, but could be a marker of frailty and difficulty in meeting activities of daily living.

Similarly, Allaudeen6 found that black race, Medicaid use, steroid use, and narcotic use were independently associated with hospital readmission (in addition to chronic diseases and weight loss). Can being on steroids or narcotics cause readmissions? Does enrollment in Medicaid or being of black race cause one to be readmitted? While these may be markers which are statistically significant, they are unlikely to be true causes of rehospitalization. It is more likely that these variables are markers for true causal factors, such as financial barriers to medications or access barriers to primary care. Many other studies have used administrative databases to examine variables linked to readmission. We need to drill deeper to determine what is actually causing readmissions. Did the patient misinterpret how to take their steroid taper or were they so sick that they needed to return to the hospital? Perhaps they decided to wait on taking the steroids until they spoke with their primary care physician. This deeper level of understanding cannot be ascertained through third party administrative data sets. Primary data collection is needed to correctly determine who to target and the specific foci of interventions.

Future research on risk factors for readmissions (and interventions to decrease readmissions) should begin with a theoretical framework that addresses the patient, the hospital, and the receiving outpatient primary care physician or specialist, and the interfaces between each pair that could lead to preventable readmissions (see Figure 1).

Figure 1

With every potential variable affecting readmission, we need to systematically evaluate whether they are causal and preventable. When a variable is both causal and modifiable, we can then develop interventions to target these variables. We designed Table 1 as a framework to consider when moving forward in creating and implementing interventions.

To advance this area, we need to be stringent about how we perform research and interpret findings. Studies that examine risk factors for readmission to a single hospital may be biased; for example, in the study by Allaudeen,6 it is possible that patients with Medicaid may have been equally likely to be readmitted to any hospital but more likely to be readmitted to the hospital that was the sole source of admission data. Even if findings from a single site are valid, they may not be generalizable. Ideally, studies of risk factors (and interventions to reduce readmissions) should be conducted in multiple sites that can track all hospitalizations and examine differences in risk factors for rehospitalization across hospitals. We have learned a tremendous amount over the last few years about risk markers for all‐cause readmission, and interventions to improve safety and quality of transitions in care. To advance further, multicenter studies are needed that focus on plausible causal variables of preventable readmissions and risk factors beyond the walls of the hospital (eg, access and quality of outpatient care for newly discharged patients). Only then will we better understand which patients can have their readmissions prevented and how to improve upon current strategies to improve outcomes.

Hospital readmissions pose a major problem both to the patient and the fiscal stability of our health care system.1 Many interventions have attempted to tackle this problem. Interventions exist that utilize transition coaches working intensively with hospitalized patients or nurses performing postdischarge home visits or phoning patients.2, 3 Although beneficial, these strategies are costly and require additional, highly trained personnel. Consequently, they have been difficult to sustain financially in a fee‐for‐service environment, and difficult to generalize at other locales. Recent policies to decrease hospital payments for readmissions will incentivize hospitals to implement discharge programs.4 However, all hospital systems will still want to do this in the most efficient manner possible.

One important way to maximize benefits and minimize costs is to target the most intensive, expensive interventions to the highest risk patients who are most likely to be rehospitalized. By targeting the highest risk patients, we could significantly reduce costs. However, models predicting rehospitalization have had limited accuracy, even for condition‐specific models such as heart failure. Two studies in this issue work to better identify high‐risk patients. Mudge and colleagues5 prospectively examined risk factors for recurrent readmissions in an Australian hospital and found that chronic disease, depression, and underweight were independent risk factors for repeat readmission. Allaudeen6 examined risk factors for readmission to their own institution among general medicine patients. In a retrospective analysis of administrative data, they found that several variables predicted hospital readmission, including black race, insurance coverage through Medicaid, prescription of steroids or narcotics, and diagnoses of heart failure, renal disease, cancer, anemia, and weight loss.

These studies raise two questions that are critical if we are to develop better predictive modeling of who will benefit most from intensive interventions to reduce readmissions. First, what are the risk factors for preventable hospitalizations? People with multiple readmissions seem an obvious target on which to focus. However, it may be that these individuals are just very sick with multiple comorbidities, and many of their readmissions may not be preventable. Rich and colleagues reported that a multidisciplinary discharge intervention reduced readmissions for heart failure by 56%.7 What is often forgotten is that in their pilot study they were not able to reduce admissions for the most severely ill, and their final study population excluded the sickest patients. By targeting moderate‐risk patients, they were able to reduce readmissions significantly.8 In the studies by Mudge et al.5 and Allaudeen,6 the fact that chronic diseases predicted rehospitalization is only moderately helpful. It is possible, perhaps likely, that many of the readmissions for heart failure were preventable while many of the readmissions for cancer were not. The challenge for researchers is to develop methods for classifying admissions/readmissions as preventable.9 Using a defined set of diagnostic categories to classify readmissions (eg, ambulatory care sensitive conditions) may misclassify many cases.10 Determining preventable hospitalizations through detailed chart review is expensive and may have limited interobserver reliability. Nevertheless, physician review and classification may be necessary for future research to advance the field.

Second, what predictor variables are causally related to preventable hospitalizations (and presumably actionable), and which are merely markers of true causal factors and therefore harder to interpret and more difficult to act upon? In addition to chronic disease, Mudge et al.5 found that depression and low body mass index were independent risk factors for readmission. These conditions often go hand in hand. Patients who are burdened with chronic disease may be depressed and not eat. Conversely, patients who are depressed may not eat and allow their chronic disease to worsen. But it seems that depression is the more likely of the two to be causal. Depression is an important predictor of medication nonadherence and worsening illness.11, 12 Screening hospitalized patients for depression could provide valuable information on which patients may need treatment or more rigorous postdischarge follow‐up. In contrast, being underweight may not truly cause readmissions, but could be a marker of frailty and difficulty in meeting activities of daily living.

Similarly, Allaudeen6 found that black race, Medicaid use, steroid use, and narcotic use were independently associated with hospital readmission (in addition to chronic diseases and weight loss). Can being on steroids or narcotics cause readmissions? Does enrollment in Medicaid or being of black race cause one to be readmitted? While these may be markers which are statistically significant, they are unlikely to be true causes of rehospitalization. It is more likely that these variables are markers for true causal factors, such as financial barriers to medications or access barriers to primary care. Many other studies have used administrative databases to examine variables linked to readmission. We need to drill deeper to determine what is actually causing readmissions. Did the patient misinterpret how to take their steroid taper or were they so sick that they needed to return to the hospital? Perhaps they decided to wait on taking the steroids until they spoke with their primary care physician. This deeper level of understanding cannot be ascertained through third party administrative data sets. Primary data collection is needed to correctly determine who to target and the specific foci of interventions.

Future research on risk factors for readmissions (and interventions to decrease readmissions) should begin with a theoretical framework that addresses the patient, the hospital, and the receiving outpatient primary care physician or specialist, and the interfaces between each pair that could lead to preventable readmissions (see Figure 1).

Figure 1

With every potential variable affecting readmission, we need to systematically evaluate whether they are causal and preventable. When a variable is both causal and modifiable, we can then develop interventions to target these variables. We designed Table 1 as a framework to consider when moving forward in creating and implementing interventions.

To advance this area, we need to be stringent about how we perform research and interpret findings. Studies that examine risk factors for readmission to a single hospital may be biased; for example, in the study by Allaudeen,6 it is possible that patients with Medicaid may have been equally likely to be readmitted to any hospital but more likely to be readmitted to the hospital that was the sole source of admission data. Even if findings from a single site are valid, they may not be generalizable. Ideally, studies of risk factors (and interventions to reduce readmissions) should be conducted in multiple sites that can track all hospitalizations and examine differences in risk factors for rehospitalization across hospitals. We have learned a tremendous amount over the last few years about risk markers for all‐cause readmission, and interventions to improve safety and quality of transitions in care. To advance further, multicenter studies are needed that focus on plausible causal variables of preventable readmissions and risk factors beyond the walls of the hospital (eg, access and quality of outpatient care for newly discharged patients). Only then will we better understand which patients can have their readmissions prevented and how to improve upon current strategies to improve outcomes.

Hospital readmissions pose a major problem both to the patient and the fiscal stability of our health care system.1 Many interventions have attempted to tackle this problem. Interventions exist that utilize transition coaches working intensively with hospitalized patients or nurses performing postdischarge home visits or phoning patients.2, 3 Although beneficial, these strategies are costly and require additional, highly trained personnel. Consequently, they have been difficult to sustain financially in a fee‐for‐service environment, and difficult to generalize at other locales. Recent policies to decrease hospital payments for readmissions will incentivize hospitals to implement discharge programs.4 However, all hospital systems will still want to do this in the most efficient manner possible.

One important way to maximize benefits and minimize costs is to target the most intensive, expensive interventions to the highest risk patients who are most likely to be rehospitalized. By targeting the highest risk patients, we could significantly reduce costs. However, models predicting rehospitalization have had limited accuracy, even for condition‐specific models such as heart failure. Two studies in this issue work to better identify high‐risk patients. Mudge and colleagues5 prospectively examined risk factors for recurrent readmissions in an Australian hospital and found that chronic disease, depression, and underweight were independent risk factors for repeat readmission. Allaudeen6 examined risk factors for readmission to their own institution among general medicine patients. In a retrospective analysis of administrative data, they found that several variables predicted hospital readmission, including black race, insurance coverage through Medicaid, prescription of steroids or narcotics, and diagnoses of heart failure, renal disease, cancer, anemia, and weight loss.

These studies raise two questions that are critical if we are to develop better predictive modeling of who will benefit most from intensive interventions to reduce readmissions. First, what are the risk factors for preventable hospitalizations? People with multiple readmissions seem an obvious target on which to focus. However, it may be that these individuals are just very sick with multiple comorbidities, and many of their readmissions may not be preventable. Rich and colleagues reported that a multidisciplinary discharge intervention reduced readmissions for heart failure by 56%.7 What is often forgotten is that in their pilot study they were not able to reduce admissions for the most severely ill, and their final study population excluded the sickest patients. By targeting moderate‐risk patients, they were able to reduce readmissions significantly.8 In the studies by Mudge et al.5 and Allaudeen,6 the fact that chronic diseases predicted rehospitalization is only moderately helpful. It is possible, perhaps likely, that many of the readmissions for heart failure were preventable while many of the readmissions for cancer were not. The challenge for researchers is to develop methods for classifying admissions/readmissions as preventable.9 Using a defined set of diagnostic categories to classify readmissions (eg, ambulatory care sensitive conditions) may misclassify many cases.10 Determining preventable hospitalizations through detailed chart review is expensive and may have limited interobserver reliability. Nevertheless, physician review and classification may be necessary for future research to advance the field.

Second, what predictor variables are causally related to preventable hospitalizations (and presumably actionable), and which are merely markers of true causal factors and therefore harder to interpret and more difficult to act upon? In addition to chronic disease, Mudge et al.5 found that depression and low body mass index were independent risk factors for readmission. These conditions often go hand in hand. Patients who are burdened with chronic disease may be depressed and not eat. Conversely, patients who are depressed may not eat and allow their chronic disease to worsen. But it seems that depression is the more likely of the two to be causal. Depression is an important predictor of medication nonadherence and worsening illness.11, 12 Screening hospitalized patients for depression could provide valuable information on which patients may need treatment or more rigorous postdischarge follow‐up. In contrast, being underweight may not truly cause readmissions, but could be a marker of frailty and difficulty in meeting activities of daily living.

Similarly, Allaudeen6 found that black race, Medicaid use, steroid use, and narcotic use were independently associated with hospital readmission (in addition to chronic diseases and weight loss). Can being on steroids or narcotics cause readmissions? Does enrollment in Medicaid or being of black race cause one to be readmitted? While these may be markers which are statistically significant, they are unlikely to be true causes of rehospitalization. It is more likely that these variables are markers for true causal factors, such as financial barriers to medications or access barriers to primary care. Many other studies have used administrative databases to examine variables linked to readmission. We need to drill deeper to determine what is actually causing readmissions. Did the patient misinterpret how to take their steroid taper or were they so sick that they needed to return to the hospital? Perhaps they decided to wait on taking the steroids until they spoke with their primary care physician. This deeper level of understanding cannot be ascertained through third party administrative data sets. Primary data collection is needed to correctly determine who to target and the specific foci of interventions.

Future research on risk factors for readmissions (and interventions to decrease readmissions) should begin with a theoretical framework that addresses the patient, the hospital, and the receiving outpatient primary care physician or specialist, and the interfaces between each pair that could lead to preventable readmissions (see Figure 1).

Figure 1

With every potential variable affecting readmission, we need to systematically evaluate whether they are causal and preventable. When a variable is both causal and modifiable, we can then develop interventions to target these variables. We designed Table 1 as a framework to consider when moving forward in creating and implementing interventions.

To advance this area, we need to be stringent about how we perform research and interpret findings. Studies that examine risk factors for readmission to a single hospital may be biased; for example, in the study by Allaudeen,6 it is possible that patients with Medicaid may have been equally likely to be readmitted to any hospital but more likely to be readmitted to the hospital that was the sole source of admission data. Even if findings from a single site are valid, they may not be generalizable. Ideally, studies of risk factors (and interventions to reduce readmissions) should be conducted in multiple sites that can track all hospitalizations and examine differences in risk factors for rehospitalization across hospitals. We have learned a tremendous amount over the last few years about risk markers for all‐cause readmission, and interventions to improve safety and quality of transitions in care. To advance further, multicenter studies are needed that focus on plausible causal variables of preventable readmissions and risk factors beyond the walls of the hospital (eg, access and quality of outpatient care for newly discharged patients). Only then will we better understand which patients can have their readmissions prevented and how to improve upon current strategies to improve outcomes.