Staphylococcus aureus (S. aureus) is well recognized as a major cause of nosocomial and healthcare‐associated pneumonia (HCAP). These infections are associated with substantial morbidity and mortality, and generate high medical costs.14 The significance of S. aureus in community‐acquired pneumonia (CAP) is less clear. Historically, S. aureus has not been considered a common pathogen in CAP, usually arising in association with or following influenza or an influenza‐like syndrome.58 However, with the increasing prevalence of methicillin‐resistant S. aureus (MRSA) as a cause of HCAPand most recently, serious community‐acquired non‐pulmonary infectionsinterest in this pathogen and its impact beyond the hospital have been expanding. During the 2003 to 2004 influenza season, 15 cases of influenza‐associated MRSA CAP were identified.6 In January 2007, the US Centers for Disease Control and Prevention (CDC) received reports of an additional 10 cases of severe MRSA CAP, resulting in six deaths, among previously healthy children and adults in Louisiana and Georgia.7 Kallen et al.9 recently reported 51 cases from 19 states between November 2006 and April 2007. To the best of our knowledge, these reports represent the largest case series describing MRSA in CAP.

Earlier studies have suggested a relationship between the outcome of S. aureus infection and the presence of various patient and strain characteristics.1013 Most observations regarding the adverse impact of MRSA on patient outcomes have arisen from analyses of cohorts of patients with either mixed infections, bacteremias, or nosocomial infection. There is little information on outcomes in patients with S. aureus CAP. To address this issue, we conducted a retrospective study of patients with culture‐proven S. aureus pneumonia admitted to a large urban hospital.

Materials and Methods

Sample Selection

The source population for the study consisted of all admissions to Henry Ford Hospital between January 2005 and May 2008 (study period) Patients were included in the study sample if they had: (1) a discharge diagnosis (principal or secondary) of pneumonia (International Classification of Diseases 9th Edition, Clinical Modification [ICD‐9‐CM] diagnosis codes 481.X 486.X) on their discharge summary or in their medical record; (2) a positive chest x‐ray (ie, infiltrate, consolidation, pleural effusion) within 48 hours of hospital admission; (3) an abnormal temperature (>38.3C [101.0F] or <36C [96.8F]), an abnormal white blood count (WBC) (>12,000/mm³ or <4,000/mm³), or increased sputum production on their day of hospital admission; and (4) a positive blood or respiratory culture for S. aureus within 48 hours of hospital admission.

Among these identified patients, those with probable HCAP were excluded from the study sample, based on evidence of: (1) hospitalization for 2 days during the 90‐day period preceding the index hospitalization; (2) admission to hospital from a nursing home or long‐term care facility; (3) hemodialysis 30 days prior to hospital admission; (4) receipt of cancer chemotherapy, IV antibiotic therapy, or wound care 30 days prior to hospital admission; or (5) receipt of an immunosuppressant at the time of hospital admission. All remaining patients were assumed to have CAP.

Results

There were 282 admissions to Henry Ford Hospital between January 2005 and May 2008 of patients with pneumonia who had positive blood or respiratory cultures for S. aureus within 48 hours of admission. (The total number of admissions over this period of patients with a principal diagnosis of pneumonia was 3894). Twelve patients had a negative chest x‐ray or negative clinical findings for pneumonia on the day of hospital admission and were excluded from the analysis. An additional 142 (53%) patients had evidence of HCAP and were excluded from the analysis. The final study sample therefore consisted of 128 patients with S. aureus CAP; their demographic and clinical characteristics are presented in Table 1.

Mean (SD) age of study subjects was 60 (17.0) years; 72% were nonwhite, and 58% were males. Prevalence of selected comorbidities, including acute renal failure, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, diabetes, myocardial infarction, and peripheral vascular disease was high (>20%). Mean (SD) CURB score at admission was 1.8 (1.1); scores did not differ significantly between MRSA vs. MSSA patients. Eight patients (6%) had evidence of positive S. aureus cultures in the year prior to admission.

A total of 55 (43%) patients had positive MRSA cultures within the first 48 hours of admission, while the remainder (n = 73 [57%]) had cultures positive for MSSA. Among the 55 patients with MRSA, 23 (42%) had USA300 MRSA strains that produced PVL toxin. Only 18% of MRSA patients had MICs to vancomycin of 1 g/mL; most remaining patients (73%) had 1.5 g/mL MIC values. Thirty‐one patients (24%) died prior to hospital discharge (Table 2). Eighty‐eight (69%) patients received mechanical ventilation, and 79% were admitted to ICU; 25% of patients underwent thoracic surgery for pneumonia. Mean (SD) length of stay in hospital was 17.0 (15.7) days, and mean (SD) total charges per hospitalization were $127,922 ($154,605). (Mean length of stay in hospital was 5.8 days for all 3894 patients with a principal discharge diagnosis of pneumonia, and mean total charges were $29,448).

Notwithstanding the fact that patients with MRSA were more than twice as likely to receive inappropriate initial therapy (44% for MRSA vs. 18% for MSSA; odds ratio [OR], 3.57; 95% confidence interval [CI], 1.607.97; P = 0.0015), there were no statistically significant differences in in‐hospital mortality (26% for MSSA vs. 22% for MRSA; P = 0.678), surgery for pneumonia (26% vs. 24%; P = 0.838), or admission to ICU (82% vs. 74%; P = 0.382). Patients with MSSA CAP were more likely to receive mechanical ventilation (77% vs. 58%; P = 0.034). Mean (SD) total charges per admission did not differ between patients with MSSA vs. MRSA CAP ($135,784 [$170,046] vs $117,489 [$132,164], respectively [P = 0.510]). (30‐day mortality following hospital discharge was 24% for MRSA CAP patients and 30% for MSSA CAP patients.)

Among patients with MRSA CAP, there were no notable differences in outcomes between those with strains with the PVL toxin vs. those without it (Table 2). Mean (SD) length of stay in hospital, however, was significantly longer among the former patients (25 [22.6] days vs. 13 [7.7] days for those without PVL toxin; P = 0.020). Reflecting this difference, mean (SD) total charges per admission were $76,909 higher among MRSA patients with PVL‐positive strains vs. those with PVL‐negative strains ($162,124 [$186,923] vs. $85,215 [$57,957] respectively; P = 0.066).

Among MRSA patients with MICs to vancomycin of 1.5 g/mL, 17% died in hospital, 20% underwent surgery for pneumonia, 60% received mechanical ventilation, and 75% were admitted to ICU. Mean (SD) total charges per admission were $104,514 ($112,606) (Table 2).

Discussion

To the best of our knowledge, this is the largest observational study to date of outcomes in patients with S. aureus CAP. Our results indicate that MRSA represents almost one‐half of all such infections, with USA300 strains accounting for a substantial proportion of these cases. In addition, for most outcome measures, there were no significant differences between patients with MSSA vs. MRSA CAP. In patients with MRSA CAP, however, those with PVL‐positive strains had longer stays in the hospital and had higher total costs of hospitalization.

Our study highlights the significant clinical and economic burden of S. aureus CAP. In the US, the mortality rate in patients hospitalized with CAP is about 8%, while mean length of stay is approximately 5 days (it was 5.8 days in our institution among all patients with CAP). In contrast, we found that most patients with S. aureus CAP were admitted to ICU, and that nearly one in four died during hospitalization. One possible explanation for these findings is that patients with S. aureus CAP may often receive inappropriate initial antibiotic therapy, a major predictor of adverse outcome in infection. The overall rate of inappropriate treatment, however, was low in our study (although we note that optimal antibiotic treatment is not clearly defined for the USA300 strain, and as a result, we assumed that vancomycin would be appropriate for all MRSA infections). A more likely explanation for our findings is the severity of CAP associated with S. aureus, whether MRSA or MSSA. Given the nature of S. aureus infections, the need for prevention (and potentially, development of a vaccine) remains crucial.

While MRSA has been studied extensively as a cause of bacteremia, as well as HCAP and VAP, it has not been well studied in CAP. Patients with MRSA bacteremia have been shown to have a higher mortality risk and higher healthcare costs than those with MSSA infections, and a meta‐analysis of 31 studies of patients with S. aureus bloodstream infections demonstrated a significant increase in mortality among patients with MRSA vs. MSSA bacteremia.1820 Outcomes when comparing MRSA and MSSA in VAP are slightly more variable. A higher rate of mortality has been reported in patients with pneumonia caused by MRSA vs. MSSA, but others found no difference after controlling for potential confounders.21, 22 We found that case fatality, surgery for pneumonia, ICU admission, length of stay, and total hospital charges do not differ significantly between patients with MRSA vs. MSSA CAP. This suggests that appreciation of the burden of MRSA can only be done in the context of the syndrome in question, and that conclusions from analyses of bacteremia and VAP may not be generalizable to CAP.

In the US, an increasing number of community‐associated infections are due to MRSA. Skin and skin structure infections comprise the majority of community‐associated MRSA infections and are caused by a single pulsed field type, termed USA300. These strains are believed to have distinctive virulence and epidemiologic characteristics. USA300 isolates typically are resistant only to beta‐lactam and macrolide antimicrobial agents and contain genes for the PVL toxin, which typically are not present in strains of healthcare‐associated MRSA.23 Recent studies of acute pneumonia with animal models and in humans have suggested that the PVL toxinalone or in combination with other virulence factorsis associated with the development of necrotizing pneumonia.2430 In our study, 23 patients with MRSA CAP had strains that contained PVL toxin, and these patients had longer stays in hospital and higher total hospital charges than those with MRSA CAP not containing the PVL toxin. This is an important finding, as length of stay is an important proxy for morbidity and case severity. This also extends the finding of previous case studies reporting that MRSA CAP with PVL toxin is associated with worse outcomes.2430 Moreover, we clearly document that PVL‐positive strains are emerging as a cause of pulmonary infection in broader clinical scenarios. As such, physicians must remain vigilant for this toxin‐producing strain. The full extent of the impact of PVL‐positive strains in our study is unknown, as we cannot ascertain whether morbidity was worse because of the PVL toxin itself, or because most patients were not treated with clindamycin or linezolid, which inhibit toxin production.

We failed to observe a correlation between MICs to vancomycin and the outcomes we studied. The clinical significance of reduced susceptibility of S. aureus to vancomycin remains a controversial issue. In our study, there was no significant association between MICs to vancomycin and mortality, need for surgery, ICU admission, length of stay, or total hospital charges. Sakoulas et al.11 reported that as vancomycin MICs for MRSA isolates rose within the susceptible range from 0.5 mcg/mL to 2.0 mcg/mL, so too did the number of clinical failures among bacteremic patients receiving vancomycin. Moise‐Broder et al.31 reported a similar finding in a study of 63 patients with MRSA bacteremia, of whom 45 failed or were intolerant of vancomycin therapy. In a more recent report, Soriano et al.12 prospectively evaluated 414 episodes of bacteremia. The authors concluded that mortality in patients with MRSA bacteremia is significantly higher when the empiric antimicrobial agent is inappropriate and when vancomycin is used to treat infections involving strains with MICs >1.0 mcg/mL. In pneumonia, Hidayat et al.13 reported that patients with infections due to pathogens with higher MICs to vancomycin had a higher rate of mortality than those with lower MICs. Our findings likely differ from this report because of the proportion of subjects with PVL‐positive strains, and because of the skew in the distribution of vancomycin MICs. More specifically, the majority of patients had higher MIC strains, clustered around 1.5 mg/L, leaving us with few lower MIC strains and fewer strains with MICs of 2.0 mcg/mL for comparison, and therefore limited statistical power to assess the relationship between MICs and outcomes.

There were no clinical features that clearly distinguished patients with MRSA vs. MSSA CAP. This suggests that if physicians hope to ensure that patients with MRSA CAP receive appropriate initial antibiotic therapy, they cannot base therapeutic decision‐making (ie, use of an anti‐MRSA treatment) on clinical criteria. Presently, national guidelines recommend diagnostic testing only if the results might affect clinical decisions (eg, antimicrobial management).32 Furthermore, the IDSA/ATS guidelines recommend sputum cultures along with blood cultures and other diagnostic tests only in select cases (eg, those with severe disease). Since beginning optimal therapy quickly can reduce mortality in pneumonia,33 our results indicate a need for both rapid diagnostic tests to identify patients with MRSA, and reevaluation of current recommendations for diagnostic testing in CAP.

Our study has several important limitations. First, its retrospective design exposes it to many forms of bias. Second, because the diagnosis of pneumonia can be challenging, we required that all patients have both clinical and radiologic evidence of the disease. However, we may have thereby excluded some admissions for S. aureus pneumonia among the over 3000 pneumonia admissions to our hospital during the study period.

Third, we only included patients with culture evidence of infection. This was necessary by design, but as a result we may have failed to identify some patients with S. aureus infections because of the limitations of respiratory culture technology. Patients on general practice units often do not get cultured, and accordingly we may have missed those with milder disease caused by S. aureus.

Fourth, we used only one method of MIC testing to determine vancomycin susceptibility. It would have been of interest to have used automated dilution testing also and to have compared both methods. Comparison of laboratory methods was not among our study objectives, and most of the earlier studies examining epidemiology and outcomes used a single laboratory testing method only.

Finally, since the study was conducted at a large urban teaching hospital in a city with a long history of issues with MRSA and resistance, the generalizability of our results may be limited.

In summary, our study provides further evidence that S. aureus is an important pathogen in CAP. MRSA CAP has few obvious characteristics that differentiate it from MSSA CAP. MRSA and MSSA CAP are both very serious infections that should be treated aggressively to avoid poor outcomes.

Staphylococcus aureus (S. aureus) is well recognized as a major cause of nosocomial and healthcare‐associated pneumonia (HCAP). These infections are associated with substantial morbidity and mortality, and generate high medical costs.14 The significance of S. aureus in community‐acquired pneumonia (CAP) is less clear. Historically, S. aureus has not been considered a common pathogen in CAP, usually arising in association with or following influenza or an influenza‐like syndrome.58 However, with the increasing prevalence of methicillin‐resistant S. aureus (MRSA) as a cause of HCAPand most recently, serious community‐acquired non‐pulmonary infectionsinterest in this pathogen and its impact beyond the hospital have been expanding. During the 2003 to 2004 influenza season, 15 cases of influenza‐associated MRSA CAP were identified.6 In January 2007, the US Centers for Disease Control and Prevention (CDC) received reports of an additional 10 cases of severe MRSA CAP, resulting in six deaths, among previously healthy children and adults in Louisiana and Georgia.7 Kallen et al.9 recently reported 51 cases from 19 states between November 2006 and April 2007. To the best of our knowledge, these reports represent the largest case series describing MRSA in CAP.

Earlier studies have suggested a relationship between the outcome of S. aureus infection and the presence of various patient and strain characteristics.1013 Most observations regarding the adverse impact of MRSA on patient outcomes have arisen from analyses of cohorts of patients with either mixed infections, bacteremias, or nosocomial infection. There is little information on outcomes in patients with S. aureus CAP. To address this issue, we conducted a retrospective study of patients with culture‐proven S. aureus pneumonia admitted to a large urban hospital.

Materials and Methods

Sample Selection

The source population for the study consisted of all admissions to Henry Ford Hospital between January 2005 and May 2008 (study period) Patients were included in the study sample if they had: (1) a discharge diagnosis (principal or secondary) of pneumonia (International Classification of Diseases 9th Edition, Clinical Modification [ICD‐9‐CM] diagnosis codes 481.X 486.X) on their discharge summary or in their medical record; (2) a positive chest x‐ray (ie, infiltrate, consolidation, pleural effusion) within 48 hours of hospital admission; (3) an abnormal temperature (>38.3C [101.0F] or <36C [96.8F]), an abnormal white blood count (WBC) (>12,000/mm³ or <4,000/mm³), or increased sputum production on their day of hospital admission; and (4) a positive blood or respiratory culture for S. aureus within 48 hours of hospital admission.

Among these identified patients, those with probable HCAP were excluded from the study sample, based on evidence of: (1) hospitalization for 2 days during the 90‐day period preceding the index hospitalization; (2) admission to hospital from a nursing home or long‐term care facility; (3) hemodialysis 30 days prior to hospital admission; (4) receipt of cancer chemotherapy, IV antibiotic therapy, or wound care 30 days prior to hospital admission; or (5) receipt of an immunosuppressant at the time of hospital admission. All remaining patients were assumed to have CAP.

Results

There were 282 admissions to Henry Ford Hospital between January 2005 and May 2008 of patients with pneumonia who had positive blood or respiratory cultures for S. aureus within 48 hours of admission. (The total number of admissions over this period of patients with a principal diagnosis of pneumonia was 3894). Twelve patients had a negative chest x‐ray or negative clinical findings for pneumonia on the day of hospital admission and were excluded from the analysis. An additional 142 (53%) patients had evidence of HCAP and were excluded from the analysis. The final study sample therefore consisted of 128 patients with S. aureus CAP; their demographic and clinical characteristics are presented in Table 1.

Mean (SD) age of study subjects was 60 (17.0) years; 72% were nonwhite, and 58% were males. Prevalence of selected comorbidities, including acute renal failure, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, diabetes, myocardial infarction, and peripheral vascular disease was high (>20%). Mean (SD) CURB score at admission was 1.8 (1.1); scores did not differ significantly between MRSA vs. MSSA patients. Eight patients (6%) had evidence of positive S. aureus cultures in the year prior to admission.

A total of 55 (43%) patients had positive MRSA cultures within the first 48 hours of admission, while the remainder (n = 73 [57%]) had cultures positive for MSSA. Among the 55 patients with MRSA, 23 (42%) had USA300 MRSA strains that produced PVL toxin. Only 18% of MRSA patients had MICs to vancomycin of 1 g/mL; most remaining patients (73%) had 1.5 g/mL MIC values. Thirty‐one patients (24%) died prior to hospital discharge (Table 2). Eighty‐eight (69%) patients received mechanical ventilation, and 79% were admitted to ICU; 25% of patients underwent thoracic surgery for pneumonia. Mean (SD) length of stay in hospital was 17.0 (15.7) days, and mean (SD) total charges per hospitalization were $127,922 ($154,605). (Mean length of stay in hospital was 5.8 days for all 3894 patients with a principal discharge diagnosis of pneumonia, and mean total charges were $29,448).

Notwithstanding the fact that patients with MRSA were more than twice as likely to receive inappropriate initial therapy (44% for MRSA vs. 18% for MSSA; odds ratio [OR], 3.57; 95% confidence interval [CI], 1.607.97; P = 0.0015), there were no statistically significant differences in in‐hospital mortality (26% for MSSA vs. 22% for MRSA; P = 0.678), surgery for pneumonia (26% vs. 24%; P = 0.838), or admission to ICU (82% vs. 74%; P = 0.382). Patients with MSSA CAP were more likely to receive mechanical ventilation (77% vs. 58%; P = 0.034). Mean (SD) total charges per admission did not differ between patients with MSSA vs. MRSA CAP ($135,784 [$170,046] vs $117,489 [$132,164], respectively [P = 0.510]). (30‐day mortality following hospital discharge was 24% for MRSA CAP patients and 30% for MSSA CAP patients.)

Among patients with MRSA CAP, there were no notable differences in outcomes between those with strains with the PVL toxin vs. those without it (Table 2). Mean (SD) length of stay in hospital, however, was significantly longer among the former patients (25 [22.6] days vs. 13 [7.7] days for those without PVL toxin; P = 0.020). Reflecting this difference, mean (SD) total charges per admission were $76,909 higher among MRSA patients with PVL‐positive strains vs. those with PVL‐negative strains ($162,124 [$186,923] vs. $85,215 [$57,957] respectively; P = 0.066).

Among MRSA patients with MICs to vancomycin of 1.5 g/mL, 17% died in hospital, 20% underwent surgery for pneumonia, 60% received mechanical ventilation, and 75% were admitted to ICU. Mean (SD) total charges per admission were $104,514 ($112,606) (Table 2).

Discussion

To the best of our knowledge, this is the largest observational study to date of outcomes in patients with S. aureus CAP. Our results indicate that MRSA represents almost one‐half of all such infections, with USA300 strains accounting for a substantial proportion of these cases. In addition, for most outcome measures, there were no significant differences between patients with MSSA vs. MRSA CAP. In patients with MRSA CAP, however, those with PVL‐positive strains had longer stays in the hospital and had higher total costs of hospitalization.

Our study highlights the significant clinical and economic burden of S. aureus CAP. In the US, the mortality rate in patients hospitalized with CAP is about 8%, while mean length of stay is approximately 5 days (it was 5.8 days in our institution among all patients with CAP). In contrast, we found that most patients with S. aureus CAP were admitted to ICU, and that nearly one in four died during hospitalization. One possible explanation for these findings is that patients with S. aureus CAP may often receive inappropriate initial antibiotic therapy, a major predictor of adverse outcome in infection. The overall rate of inappropriate treatment, however, was low in our study (although we note that optimal antibiotic treatment is not clearly defined for the USA300 strain, and as a result, we assumed that vancomycin would be appropriate for all MRSA infections). A more likely explanation for our findings is the severity of CAP associated with S. aureus, whether MRSA or MSSA. Given the nature of S. aureus infections, the need for prevention (and potentially, development of a vaccine) remains crucial.

While MRSA has been studied extensively as a cause of bacteremia, as well as HCAP and VAP, it has not been well studied in CAP. Patients with MRSA bacteremia have been shown to have a higher mortality risk and higher healthcare costs than those with MSSA infections, and a meta‐analysis of 31 studies of patients with S. aureus bloodstream infections demonstrated a significant increase in mortality among patients with MRSA vs. MSSA bacteremia.1820 Outcomes when comparing MRSA and MSSA in VAP are slightly more variable. A higher rate of mortality has been reported in patients with pneumonia caused by MRSA vs. MSSA, but others found no difference after controlling for potential confounders.21, 22 We found that case fatality, surgery for pneumonia, ICU admission, length of stay, and total hospital charges do not differ significantly between patients with MRSA vs. MSSA CAP. This suggests that appreciation of the burden of MRSA can only be done in the context of the syndrome in question, and that conclusions from analyses of bacteremia and VAP may not be generalizable to CAP.

In the US, an increasing number of community‐associated infections are due to MRSA. Skin and skin structure infections comprise the majority of community‐associated MRSA infections and are caused by a single pulsed field type, termed USA300. These strains are believed to have distinctive virulence and epidemiologic characteristics. USA300 isolates typically are resistant only to beta‐lactam and macrolide antimicrobial agents and contain genes for the PVL toxin, which typically are not present in strains of healthcare‐associated MRSA.23 Recent studies of acute pneumonia with animal models and in humans have suggested that the PVL toxinalone or in combination with other virulence factorsis associated with the development of necrotizing pneumonia.2430 In our study, 23 patients with MRSA CAP had strains that contained PVL toxin, and these patients had longer stays in hospital and higher total hospital charges than those with MRSA CAP not containing the PVL toxin. This is an important finding, as length of stay is an important proxy for morbidity and case severity. This also extends the finding of previous case studies reporting that MRSA CAP with PVL toxin is associated with worse outcomes.2430 Moreover, we clearly document that PVL‐positive strains are emerging as a cause of pulmonary infection in broader clinical scenarios. As such, physicians must remain vigilant for this toxin‐producing strain. The full extent of the impact of PVL‐positive strains in our study is unknown, as we cannot ascertain whether morbidity was worse because of the PVL toxin itself, or because most patients were not treated with clindamycin or linezolid, which inhibit toxin production.

We failed to observe a correlation between MICs to vancomycin and the outcomes we studied. The clinical significance of reduced susceptibility of S. aureus to vancomycin remains a controversial issue. In our study, there was no significant association between MICs to vancomycin and mortality, need for surgery, ICU admission, length of stay, or total hospital charges. Sakoulas et al.11 reported that as vancomycin MICs for MRSA isolates rose within the susceptible range from 0.5 mcg/mL to 2.0 mcg/mL, so too did the number of clinical failures among bacteremic patients receiving vancomycin. Moise‐Broder et al.31 reported a similar finding in a study of 63 patients with MRSA bacteremia, of whom 45 failed or were intolerant of vancomycin therapy. In a more recent report, Soriano et al.12 prospectively evaluated 414 episodes of bacteremia. The authors concluded that mortality in patients with MRSA bacteremia is significantly higher when the empiric antimicrobial agent is inappropriate and when vancomycin is used to treat infections involving strains with MICs >1.0 mcg/mL. In pneumonia, Hidayat et al.13 reported that patients with infections due to pathogens with higher MICs to vancomycin had a higher rate of mortality than those with lower MICs. Our findings likely differ from this report because of the proportion of subjects with PVL‐positive strains, and because of the skew in the distribution of vancomycin MICs. More specifically, the majority of patients had higher MIC strains, clustered around 1.5 mg/L, leaving us with few lower MIC strains and fewer strains with MICs of 2.0 mcg/mL for comparison, and therefore limited statistical power to assess the relationship between MICs and outcomes.

There were no clinical features that clearly distinguished patients with MRSA vs. MSSA CAP. This suggests that if physicians hope to ensure that patients with MRSA CAP receive appropriate initial antibiotic therapy, they cannot base therapeutic decision‐making (ie, use of an anti‐MRSA treatment) on clinical criteria. Presently, national guidelines recommend diagnostic testing only if the results might affect clinical decisions (eg, antimicrobial management).32 Furthermore, the IDSA/ATS guidelines recommend sputum cultures along with blood cultures and other diagnostic tests only in select cases (eg, those with severe disease). Since beginning optimal therapy quickly can reduce mortality in pneumonia,33 our results indicate a need for both rapid diagnostic tests to identify patients with MRSA, and reevaluation of current recommendations for diagnostic testing in CAP.

Our study has several important limitations. First, its retrospective design exposes it to many forms of bias. Second, because the diagnosis of pneumonia can be challenging, we required that all patients have both clinical and radiologic evidence of the disease. However, we may have thereby excluded some admissions for S. aureus pneumonia among the over 3000 pneumonia admissions to our hospital during the study period.

Third, we only included patients with culture evidence of infection. This was necessary by design, but as a result we may have failed to identify some patients with S. aureus infections because of the limitations of respiratory culture technology. Patients on general practice units often do not get cultured, and accordingly we may have missed those with milder disease caused by S. aureus.

Fourth, we used only one method of MIC testing to determine vancomycin susceptibility. It would have been of interest to have used automated dilution testing also and to have compared both methods. Comparison of laboratory methods was not among our study objectives, and most of the earlier studies examining epidemiology and outcomes used a single laboratory testing method only.

Finally, since the study was conducted at a large urban teaching hospital in a city with a long history of issues with MRSA and resistance, the generalizability of our results may be limited.

In summary, our study provides further evidence that S. aureus is an important pathogen in CAP. MRSA CAP has few obvious characteristics that differentiate it from MSSA CAP. MRSA and MSSA CAP are both very serious infections that should be treated aggressively to avoid poor outcomes.

Staphylococcus aureus (S. aureus) is well recognized as a major cause of nosocomial and healthcare‐associated pneumonia (HCAP). These infections are associated with substantial morbidity and mortality, and generate high medical costs.14 The significance of S. aureus in community‐acquired pneumonia (CAP) is less clear. Historically, S. aureus has not been considered a common pathogen in CAP, usually arising in association with or following influenza or an influenza‐like syndrome.58 However, with the increasing prevalence of methicillin‐resistant S. aureus (MRSA) as a cause of HCAPand most recently, serious community‐acquired non‐pulmonary infectionsinterest in this pathogen and its impact beyond the hospital have been expanding. During the 2003 to 2004 influenza season, 15 cases of influenza‐associated MRSA CAP were identified.6 In January 2007, the US Centers for Disease Control and Prevention (CDC) received reports of an additional 10 cases of severe MRSA CAP, resulting in six deaths, among previously healthy children and adults in Louisiana and Georgia.7 Kallen et al.9 recently reported 51 cases from 19 states between November 2006 and April 2007. To the best of our knowledge, these reports represent the largest case series describing MRSA in CAP.

Earlier studies have suggested a relationship between the outcome of S. aureus infection and the presence of various patient and strain characteristics.1013 Most observations regarding the adverse impact of MRSA on patient outcomes have arisen from analyses of cohorts of patients with either mixed infections, bacteremias, or nosocomial infection. There is little information on outcomes in patients with S. aureus CAP. To address this issue, we conducted a retrospective study of patients with culture‐proven S. aureus pneumonia admitted to a large urban hospital.

Materials and Methods

Sample Selection

The source population for the study consisted of all admissions to Henry Ford Hospital between January 2005 and May 2008 (study period) Patients were included in the study sample if they had: (1) a discharge diagnosis (principal or secondary) of pneumonia (International Classification of Diseases 9th Edition, Clinical Modification [ICD‐9‐CM] diagnosis codes 481.X 486.X) on their discharge summary or in their medical record; (2) a positive chest x‐ray (ie, infiltrate, consolidation, pleural effusion) within 48 hours of hospital admission; (3) an abnormal temperature (>38.3C [101.0F] or <36C [96.8F]), an abnormal white blood count (WBC) (>12,000/mm³ or <4,000/mm³), or increased sputum production on their day of hospital admission; and (4) a positive blood or respiratory culture for S. aureus within 48 hours of hospital admission.

Among these identified patients, those with probable HCAP were excluded from the study sample, based on evidence of: (1) hospitalization for 2 days during the 90‐day period preceding the index hospitalization; (2) admission to hospital from a nursing home or long‐term care facility; (3) hemodialysis 30 days prior to hospital admission; (4) receipt of cancer chemotherapy, IV antibiotic therapy, or wound care 30 days prior to hospital admission; or (5) receipt of an immunosuppressant at the time of hospital admission. All remaining patients were assumed to have CAP.

Results

There were 282 admissions to Henry Ford Hospital between January 2005 and May 2008 of patients with pneumonia who had positive blood or respiratory cultures for S. aureus within 48 hours of admission. (The total number of admissions over this period of patients with a principal diagnosis of pneumonia was 3894). Twelve patients had a negative chest x‐ray or negative clinical findings for pneumonia on the day of hospital admission and were excluded from the analysis. An additional 142 (53%) patients had evidence of HCAP and were excluded from the analysis. The final study sample therefore consisted of 128 patients with S. aureus CAP; their demographic and clinical characteristics are presented in Table 1.

Mean (SD) age of study subjects was 60 (17.0) years; 72% were nonwhite, and 58% were males. Prevalence of selected comorbidities, including acute renal failure, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, diabetes, myocardial infarction, and peripheral vascular disease was high (>20%). Mean (SD) CURB score at admission was 1.8 (1.1); scores did not differ significantly between MRSA vs. MSSA patients. Eight patients (6%) had evidence of positive S. aureus cultures in the year prior to admission.

A total of 55 (43%) patients had positive MRSA cultures within the first 48 hours of admission, while the remainder (n = 73 [57%]) had cultures positive for MSSA. Among the 55 patients with MRSA, 23 (42%) had USA300 MRSA strains that produced PVL toxin. Only 18% of MRSA patients had MICs to vancomycin of 1 g/mL; most remaining patients (73%) had 1.5 g/mL MIC values. Thirty‐one patients (24%) died prior to hospital discharge (Table 2). Eighty‐eight (69%) patients received mechanical ventilation, and 79% were admitted to ICU; 25% of patients underwent thoracic surgery for pneumonia. Mean (SD) length of stay in hospital was 17.0 (15.7) days, and mean (SD) total charges per hospitalization were $127,922 ($154,605). (Mean length of stay in hospital was 5.8 days for all 3894 patients with a principal discharge diagnosis of pneumonia, and mean total charges were $29,448).

Notwithstanding the fact that patients with MRSA were more than twice as likely to receive inappropriate initial therapy (44% for MRSA vs. 18% for MSSA; odds ratio [OR], 3.57; 95% confidence interval [CI], 1.607.97; P = 0.0015), there were no statistically significant differences in in‐hospital mortality (26% for MSSA vs. 22% for MRSA; P = 0.678), surgery for pneumonia (26% vs. 24%; P = 0.838), or admission to ICU (82% vs. 74%; P = 0.382). Patients with MSSA CAP were more likely to receive mechanical ventilation (77% vs. 58%; P = 0.034). Mean (SD) total charges per admission did not differ between patients with MSSA vs. MRSA CAP ($135,784 [$170,046] vs $117,489 [$132,164], respectively [P = 0.510]). (30‐day mortality following hospital discharge was 24% for MRSA CAP patients and 30% for MSSA CAP patients.)

Among patients with MRSA CAP, there were no notable differences in outcomes between those with strains with the PVL toxin vs. those without it (Table 2). Mean (SD) length of stay in hospital, however, was significantly longer among the former patients (25 [22.6] days vs. 13 [7.7] days for those without PVL toxin; P = 0.020). Reflecting this difference, mean (SD) total charges per admission were $76,909 higher among MRSA patients with PVL‐positive strains vs. those with PVL‐negative strains ($162,124 [$186,923] vs. $85,215 [$57,957] respectively; P = 0.066).

Among MRSA patients with MICs to vancomycin of 1.5 g/mL, 17% died in hospital, 20% underwent surgery for pneumonia, 60% received mechanical ventilation, and 75% were admitted to ICU. Mean (SD) total charges per admission were $104,514 ($112,606) (Table 2).

Discussion

To the best of our knowledge, this is the largest observational study to date of outcomes in patients with S. aureus CAP. Our results indicate that MRSA represents almost one‐half of all such infections, with USA300 strains accounting for a substantial proportion of these cases. In addition, for most outcome measures, there were no significant differences between patients with MSSA vs. MRSA CAP. In patients with MRSA CAP, however, those with PVL‐positive strains had longer stays in the hospital and had higher total costs of hospitalization.

Our study highlights the significant clinical and economic burden of S. aureus CAP. In the US, the mortality rate in patients hospitalized with CAP is about 8%, while mean length of stay is approximately 5 days (it was 5.8 days in our institution among all patients with CAP). In contrast, we found that most patients with S. aureus CAP were admitted to ICU, and that nearly one in four died during hospitalization. One possible explanation for these findings is that patients with S. aureus CAP may often receive inappropriate initial antibiotic therapy, a major predictor of adverse outcome in infection. The overall rate of inappropriate treatment, however, was low in our study (although we note that optimal antibiotic treatment is not clearly defined for the USA300 strain, and as a result, we assumed that vancomycin would be appropriate for all MRSA infections). A more likely explanation for our findings is the severity of CAP associated with S. aureus, whether MRSA or MSSA. Given the nature of S. aureus infections, the need for prevention (and potentially, development of a vaccine) remains crucial.

While MRSA has been studied extensively as a cause of bacteremia, as well as HCAP and VAP, it has not been well studied in CAP. Patients with MRSA bacteremia have been shown to have a higher mortality risk and higher healthcare costs than those with MSSA infections, and a meta‐analysis of 31 studies of patients with S. aureus bloodstream infections demonstrated a significant increase in mortality among patients with MRSA vs. MSSA bacteremia.1820 Outcomes when comparing MRSA and MSSA in VAP are slightly more variable. A higher rate of mortality has been reported in patients with pneumonia caused by MRSA vs. MSSA, but others found no difference after controlling for potential confounders.21, 22 We found that case fatality, surgery for pneumonia, ICU admission, length of stay, and total hospital charges do not differ significantly between patients with MRSA vs. MSSA CAP. This suggests that appreciation of the burden of MRSA can only be done in the context of the syndrome in question, and that conclusions from analyses of bacteremia and VAP may not be generalizable to CAP.

In the US, an increasing number of community‐associated infections are due to MRSA. Skin and skin structure infections comprise the majority of community‐associated MRSA infections and are caused by a single pulsed field type, termed USA300. These strains are believed to have distinctive virulence and epidemiologic characteristics. USA300 isolates typically are resistant only to beta‐lactam and macrolide antimicrobial agents and contain genes for the PVL toxin, which typically are not present in strains of healthcare‐associated MRSA.23 Recent studies of acute pneumonia with animal models and in humans have suggested that the PVL toxinalone or in combination with other virulence factorsis associated with the development of necrotizing pneumonia.2430 In our study, 23 patients with MRSA CAP had strains that contained PVL toxin, and these patients had longer stays in hospital and higher total hospital charges than those with MRSA CAP not containing the PVL toxin. This is an important finding, as length of stay is an important proxy for morbidity and case severity. This also extends the finding of previous case studies reporting that MRSA CAP with PVL toxin is associated with worse outcomes.2430 Moreover, we clearly document that PVL‐positive strains are emerging as a cause of pulmonary infection in broader clinical scenarios. As such, physicians must remain vigilant for this toxin‐producing strain. The full extent of the impact of PVL‐positive strains in our study is unknown, as we cannot ascertain whether morbidity was worse because of the PVL toxin itself, or because most patients were not treated with clindamycin or linezolid, which inhibit toxin production.

We failed to observe a correlation between MICs to vancomycin and the outcomes we studied. The clinical significance of reduced susceptibility of S. aureus to vancomycin remains a controversial issue. In our study, there was no significant association between MICs to vancomycin and mortality, need for surgery, ICU admission, length of stay, or total hospital charges. Sakoulas et al.11 reported that as vancomycin MICs for MRSA isolates rose within the susceptible range from 0.5 mcg/mL to 2.0 mcg/mL, so too did the number of clinical failures among bacteremic patients receiving vancomycin. Moise‐Broder et al.31 reported a similar finding in a study of 63 patients with MRSA bacteremia, of whom 45 failed or were intolerant of vancomycin therapy. In a more recent report, Soriano et al.12 prospectively evaluated 414 episodes of bacteremia. The authors concluded that mortality in patients with MRSA bacteremia is significantly higher when the empiric antimicrobial agent is inappropriate and when vancomycin is used to treat infections involving strains with MICs >1.0 mcg/mL. In pneumonia, Hidayat et al.13 reported that patients with infections due to pathogens with higher MICs to vancomycin had a higher rate of mortality than those with lower MICs. Our findings likely differ from this report because of the proportion of subjects with PVL‐positive strains, and because of the skew in the distribution of vancomycin MICs. More specifically, the majority of patients had higher MIC strains, clustered around 1.5 mg/L, leaving us with few lower MIC strains and fewer strains with MICs of 2.0 mcg/mL for comparison, and therefore limited statistical power to assess the relationship between MICs and outcomes.

There were no clinical features that clearly distinguished patients with MRSA vs. MSSA CAP. This suggests that if physicians hope to ensure that patients with MRSA CAP receive appropriate initial antibiotic therapy, they cannot base therapeutic decision‐making (ie, use of an anti‐MRSA treatment) on clinical criteria. Presently, national guidelines recommend diagnostic testing only if the results might affect clinical decisions (eg, antimicrobial management).32 Furthermore, the IDSA/ATS guidelines recommend sputum cultures along with blood cultures and other diagnostic tests only in select cases (eg, those with severe disease). Since beginning optimal therapy quickly can reduce mortality in pneumonia,33 our results indicate a need for both rapid diagnostic tests to identify patients with MRSA, and reevaluation of current recommendations for diagnostic testing in CAP.

Our study has several important limitations. First, its retrospective design exposes it to many forms of bias. Second, because the diagnosis of pneumonia can be challenging, we required that all patients have both clinical and radiologic evidence of the disease. However, we may have thereby excluded some admissions for S. aureus pneumonia among the over 3000 pneumonia admissions to our hospital during the study period.

Third, we only included patients with culture evidence of infection. This was necessary by design, but as a result we may have failed to identify some patients with S. aureus infections because of the limitations of respiratory culture technology. Patients on general practice units often do not get cultured, and accordingly we may have missed those with milder disease caused by S. aureus.

Fourth, we used only one method of MIC testing to determine vancomycin susceptibility. It would have been of interest to have used automated dilution testing also and to have compared both methods. Comparison of laboratory methods was not among our study objectives, and most of the earlier studies examining epidemiology and outcomes used a single laboratory testing method only.

Finally, since the study was conducted at a large urban teaching hospital in a city with a long history of issues with MRSA and resistance, the generalizability of our results may be limited.

In summary, our study provides further evidence that S. aureus is an important pathogen in CAP. MRSA CAP has few obvious characteristics that differentiate it from MSSA CAP. MRSA and MSSA CAP are both very serious infections that should be treated aggressively to avoid poor outcomes.

There is a potential for discontinuity of care in the management of inpatients by hospitalists since many patients are cared for by more than one physician during their hospitalization. Previous studies have explored the impact of this type of discontinuity of care in residency programs. With the restrictions put in place by the Accreditation Council on Graduate Medical Education (ACGME) in 2003, there has been an increase in the fragmentation of care (FOC) that patients receive in the hospital. Studies have explored the impact of these changes on length of stay (LOS) and quality of care. The results have been mixed, with some studies showing that the increased FOC was associated with prolonged LOS,1, 2 as well as having a negative influence on quality.2, 3 Other studies have shown no change or a reduction in LOS,4 and an improvement in quality measures.46

There have been no prior studies on the impact of hospitalist care as the source of FOC on LOS. We therefore undertook a study to explore the impact of fragmented hospitalist care on LOS. Additionally, there has been some discussion on the impact of admission day of week on both FOC and LOS. Prior studies have mainly looked at day of the week in intensive care unit patients. One study found a modest increase in ICU LOS in patients admitted during the weekend.7 We therefore also looked at the impact of day of the week of admission on FOC in order to determine if fragmentation was just a proxy for admission day as the true indicator for increased LOS.

Methods

Results

Table 1 reviews the demographics of patients with DRG 89 (PNA) and DRG 127 (HF). A large proportion of patients with both DRGs experienced no fragmentation in their physician care during hospitalization; 4152 patients with HF (46.3%) and 685 patients with PNA (35.8%) had visits from only 1 hospitalist throughout their hospital stay, for a FOC Index of 0%. The mean fragmentation level was 21.9% for pneumonia patients, with the mean number of hospitalists seen during the stay at 2.05. For heart failure patients, the mean fragmentation level was 18.3 % and a mean of 1.78 hospitalists seen (Table 1).

Table 2 presents the results of the regression analysis on LOS. The association between fragmentation and LOS, adjusted for demographics, case mix and day of admission, was similar for PNA and HF patients. We found an increase in LOS of 0.39 days for each 10% increase in fragmentation level for pneumonia. Other variables that significantly increased LOS for PNA were larger ROM score, Sunday admission and more discharge diagnoses. Similarly, for heart failure patients, there was an increase in LOS of 0.30 days for each 10% increase in fragmentation level. Other variables associated with a significantly increase in LOS for PNA were larger ROM score, larger SOI category, more discharge diagnoses, and age. Figures 1 and 2 demonstrate the results graphically for LOS in each condition. They show the mean adjusted LOS by fragmentation level. Adjusted LOS was calculated for each patient based on the final model. For example, the average adjusted LOS for PNA patients with a fragmentation level of 20% to 30% is 8.06 days and 9.16 days for patients with a fragmentation level of 30% to 40%.

Figure 1

Figure 2

Discussion

This study demonstrated that there was a statistically significant association between FOC by hospitalist physicians and LOS for patients with DRG 89 (PNA) and DRG 127 (HF). As the percentage of fragmentation increased, the LOS increased significantly.

There are many ways in which to define FOC in the context of hospitalist care of inpatients. We chose to use an index similar to the Usual Provider of Care Index (UPC) which is a standard way to measure continuity of care in the primary care setting.9 The UPC measures the proportion of time spent with the primary provider. In the inpatient setting, we defined continuity of care as the proportion of visits by the primary hospitalist (the physician assuming the greatest number of days of the patient's care). The FOC Index is simply 1 minus the continuity of care. There are other potential measures of FOC, such as the number of handoffs or the number of physicians. We selected our measure based on its following strengths: (1) it does not have the simultaneity problem of measures such as the number of doctors or the number of handoffs that leads to endogeneitya correlation between the error term and the independent variable that biases the coefficient. Endogeneity can occur when the outcome variable and the independent variable are jointly determined, in this case, that an additional day in the hospital increases the likelihood of having an additional handoff as well as an additional handoff increasing the likelihood of an additional day; (2) fragmentation patterns that lead to handoffs on the weekend that then return to the primary hospitalist may be very different from fragmentation patterns that lead to new physicians at each transfer; (3) It provides a good comparison to other models of care where community physicians provide care to their own patients and have an effective FOC index of 0. Further research should be performed looking at different measures that may capture other aspects of care fragmentation.

This is one of the first studies to directly explore the relationship between FOC and LOS. Previous studies in the hospitalist literature have explored the impact of variables on LOS in which FOC may have been an indirect influence. For example, one study found a 13% shorter LOS among academic hospitalists at a teaching hospital who worked on a block rotation compared to a group of community hospitalists with a schedule involving more patient handoffs.10 Although there is little literature on FOC among hospitalists, the literature on medical residency programs is informative. The amount of discontinuity and the number of housestaff‐to‐housestaff transfers of responsibility has increased dramatically since the institution of more stringent work‐hour restrictions by the Accreditation Council for Graduate Medical Education (ACGME) in 2003.11 Horwitz et al.12 found that after the institution of work‐hour regulations, there was an 11% increase in number of transfers of care for a hypothetical patient admitted from Monday until Friday. They noted that programs with a night‐float system had a statistically significant increase in transitions of care compared to residencies without night float. Studies on the impact of the ACGME regulations on LOS have been mixed. One study found that LOS was reduced, and that there was improved adherence to quality indicators.4 A recent study found that there was a 44% increase in the median LOS when Short Call admitting teams were involved.2

There are several limitations to the findings of this study. The largest potential limitation is interpreting the direction of causality between FOC and LOS. This was a concurrent control study. Because the study was not randomized, there is a risk of confounding variables. Admission day of the week was 1 variable of concern for confounding due to the existence of a significant relationship between admission day LOS and between admission day and FOC. We included admission day in our modeling process. The coefficient estimates on FOC were stable, changing less than 1% when day of admission was added to the model. The risk of temporal trends was minimized by studying 1‐year's worth of data. Although we looked at variables that were potentially relevant in all hospitalized patients, every hospital and hospitalist practice has its own unique features that may impact both LOS and FOC. For example, for some hospitals, bed capacity may impact these measures. In many hospitals, hospitalist work force shortages may impact these measures by affecting the extent to which patients are cared for by full‐time hospitalists vs. locums tenens physicians. The large number of facilities in the study mitigates the influence of any individual hospital's LOS and FOC tendencies.

If increased FOC does result in prolonged LOS, the question arises as to how this fragmentation can be decreased. Although no physician can guarantee presence continually throughout a patient's inpatient stay, there are scheduling methods that reduce fragmentation and maximize the odds of a patient being followed by a single clinician. For example, the longer the block of days that a hospitalist is scheduled, the fewer hospitalists will need to care for a patient. Many of the top DRGs for patients cared for by hospitalists have lengths of stay between 4 and 5 days.13 Therefore, any schedule that has a hospitalist on for at least four days at a time will increase the likelihood that the same hospitalist will care for many of the patients throughout their stay. In making schedules, the goals of clinical efficiency and physician satisfaction must be weighed against the potential risks to the quality of patient care. For instance, the use of one hospitalist as the admitting physician for all patients may increase efficiency, but will also increase fragmentation.

A factor that may influence the impact of FOC on LOS is the quality of patient handoffs. The Joint Commission instituted this as a national patient safety goal in 2006.14 This goal was based on a Joint Commission analysis that 70% of sentinel events were caused by communication breakdowns, half of these occurring during handoffs.15

In conclusion, this study explored the relationship between FOC in patients cared for by hospitalists and LOS, using an FOC index. For every 10% increase in fragmentation, the LOS went up by 0.39 days for pneumonia and 0.30 days for heart failure. By adjusting for many variables that may impact LOS due to higher severity or complexity of illness, there is an increased likelihood that the FOC may have a causative relationship with the prolonged LOS.

There is a potential for discontinuity of care in the management of inpatients by hospitalists since many patients are cared for by more than one physician during their hospitalization. Previous studies have explored the impact of this type of discontinuity of care in residency programs. With the restrictions put in place by the Accreditation Council on Graduate Medical Education (ACGME) in 2003, there has been an increase in the fragmentation of care (FOC) that patients receive in the hospital. Studies have explored the impact of these changes on length of stay (LOS) and quality of care. The results have been mixed, with some studies showing that the increased FOC was associated with prolonged LOS,1, 2 as well as having a negative influence on quality.2, 3 Other studies have shown no change or a reduction in LOS,4 and an improvement in quality measures.46

There have been no prior studies on the impact of hospitalist care as the source of FOC on LOS. We therefore undertook a study to explore the impact of fragmented hospitalist care on LOS. Additionally, there has been some discussion on the impact of admission day of week on both FOC and LOS. Prior studies have mainly looked at day of the week in intensive care unit patients. One study found a modest increase in ICU LOS in patients admitted during the weekend.7 We therefore also looked at the impact of day of the week of admission on FOC in order to determine if fragmentation was just a proxy for admission day as the true indicator for increased LOS.

Methods

Results

Table 1 reviews the demographics of patients with DRG 89 (PNA) and DRG 127 (HF). A large proportion of patients with both DRGs experienced no fragmentation in their physician care during hospitalization; 4152 patients with HF (46.3%) and 685 patients with PNA (35.8%) had visits from only 1 hospitalist throughout their hospital stay, for a FOC Index of 0%. The mean fragmentation level was 21.9% for pneumonia patients, with the mean number of hospitalists seen during the stay at 2.05. For heart failure patients, the mean fragmentation level was 18.3 % and a mean of 1.78 hospitalists seen (Table 1).

Table 2 presents the results of the regression analysis on LOS. The association between fragmentation and LOS, adjusted for demographics, case mix and day of admission, was similar for PNA and HF patients. We found an increase in LOS of 0.39 days for each 10% increase in fragmentation level for pneumonia. Other variables that significantly increased LOS for PNA were larger ROM score, Sunday admission and more discharge diagnoses. Similarly, for heart failure patients, there was an increase in LOS of 0.30 days for each 10% increase in fragmentation level. Other variables associated with a significantly increase in LOS for PNA were larger ROM score, larger SOI category, more discharge diagnoses, and age. Figures 1 and 2 demonstrate the results graphically for LOS in each condition. They show the mean adjusted LOS by fragmentation level. Adjusted LOS was calculated for each patient based on the final model. For example, the average adjusted LOS for PNA patients with a fragmentation level of 20% to 30% is 8.06 days and 9.16 days for patients with a fragmentation level of 30% to 40%.

Figure 1

Figure 2

Discussion

This study demonstrated that there was a statistically significant association between FOC by hospitalist physicians and LOS for patients with DRG 89 (PNA) and DRG 127 (HF). As the percentage of fragmentation increased, the LOS increased significantly.

There are many ways in which to define FOC in the context of hospitalist care of inpatients. We chose to use an index similar to the Usual Provider of Care Index (UPC) which is a standard way to measure continuity of care in the primary care setting.9 The UPC measures the proportion of time spent with the primary provider. In the inpatient setting, we defined continuity of care as the proportion of visits by the primary hospitalist (the physician assuming the greatest number of days of the patient's care). The FOC Index is simply 1 minus the continuity of care. There are other potential measures of FOC, such as the number of handoffs or the number of physicians. We selected our measure based on its following strengths: (1) it does not have the simultaneity problem of measures such as the number of doctors or the number of handoffs that leads to endogeneitya correlation between the error term and the independent variable that biases the coefficient. Endogeneity can occur when the outcome variable and the independent variable are jointly determined, in this case, that an additional day in the hospital increases the likelihood of having an additional handoff as well as an additional handoff increasing the likelihood of an additional day; (2) fragmentation patterns that lead to handoffs on the weekend that then return to the primary hospitalist may be very different from fragmentation patterns that lead to new physicians at each transfer; (3) It provides a good comparison to other models of care where community physicians provide care to their own patients and have an effective FOC index of 0. Further research should be performed looking at different measures that may capture other aspects of care fragmentation.

This is one of the first studies to directly explore the relationship between FOC and LOS. Previous studies in the hospitalist literature have explored the impact of variables on LOS in which FOC may have been an indirect influence. For example, one study found a 13% shorter LOS among academic hospitalists at a teaching hospital who worked on a block rotation compared to a group of community hospitalists with a schedule involving more patient handoffs.10 Although there is little literature on FOC among hospitalists, the literature on medical residency programs is informative. The amount of discontinuity and the number of housestaff‐to‐housestaff transfers of responsibility has increased dramatically since the institution of more stringent work‐hour restrictions by the Accreditation Council for Graduate Medical Education (ACGME) in 2003.11 Horwitz et al.12 found that after the institution of work‐hour regulations, there was an 11% increase in number of transfers of care for a hypothetical patient admitted from Monday until Friday. They noted that programs with a night‐float system had a statistically significant increase in transitions of care compared to residencies without night float. Studies on the impact of the ACGME regulations on LOS have been mixed. One study found that LOS was reduced, and that there was improved adherence to quality indicators.4 A recent study found that there was a 44% increase in the median LOS when Short Call admitting teams were involved.2

There are several limitations to the findings of this study. The largest potential limitation is interpreting the direction of causality between FOC and LOS. This was a concurrent control study. Because the study was not randomized, there is a risk of confounding variables. Admission day of the week was 1 variable of concern for confounding due to the existence of a significant relationship between admission day LOS and between admission day and FOC. We included admission day in our modeling process. The coefficient estimates on FOC were stable, changing less than 1% when day of admission was added to the model. The risk of temporal trends was minimized by studying 1‐year's worth of data. Although we looked at variables that were potentially relevant in all hospitalized patients, every hospital and hospitalist practice has its own unique features that may impact both LOS and FOC. For example, for some hospitals, bed capacity may impact these measures. In many hospitals, hospitalist work force shortages may impact these measures by affecting the extent to which patients are cared for by full‐time hospitalists vs. locums tenens physicians. The large number of facilities in the study mitigates the influence of any individual hospital's LOS and FOC tendencies.

If increased FOC does result in prolonged LOS, the question arises as to how this fragmentation can be decreased. Although no physician can guarantee presence continually throughout a patient's inpatient stay, there are scheduling methods that reduce fragmentation and maximize the odds of a patient being followed by a single clinician. For example, the longer the block of days that a hospitalist is scheduled, the fewer hospitalists will need to care for a patient. Many of the top DRGs for patients cared for by hospitalists have lengths of stay between 4 and 5 days.13 Therefore, any schedule that has a hospitalist on for at least four days at a time will increase the likelihood that the same hospitalist will care for many of the patients throughout their stay. In making schedules, the goals of clinical efficiency and physician satisfaction must be weighed against the potential risks to the quality of patient care. For instance, the use of one hospitalist as the admitting physician for all patients may increase efficiency, but will also increase fragmentation.

A factor that may influence the impact of FOC on LOS is the quality of patient handoffs. The Joint Commission instituted this as a national patient safety goal in 2006.14 This goal was based on a Joint Commission analysis that 70% of sentinel events were caused by communication breakdowns, half of these occurring during handoffs.15

In conclusion, this study explored the relationship between FOC in patients cared for by hospitalists and LOS, using an FOC index. For every 10% increase in fragmentation, the LOS went up by 0.39 days for pneumonia and 0.30 days for heart failure. By adjusting for many variables that may impact LOS due to higher severity or complexity of illness, there is an increased likelihood that the FOC may have a causative relationship with the prolonged LOS.

There is a potential for discontinuity of care in the management of inpatients by hospitalists since many patients are cared for by more than one physician during their hospitalization. Previous studies have explored the impact of this type of discontinuity of care in residency programs. With the restrictions put in place by the Accreditation Council on Graduate Medical Education (ACGME) in 2003, there has been an increase in the fragmentation of care (FOC) that patients receive in the hospital. Studies have explored the impact of these changes on length of stay (LOS) and quality of care. The results have been mixed, with some studies showing that the increased FOC was associated with prolonged LOS,1, 2 as well as having a negative influence on quality.2, 3 Other studies have shown no change or a reduction in LOS,4 and an improvement in quality measures.46

There have been no prior studies on the impact of hospitalist care as the source of FOC on LOS. We therefore undertook a study to explore the impact of fragmented hospitalist care on LOS. Additionally, there has been some discussion on the impact of admission day of week on both FOC and LOS. Prior studies have mainly looked at day of the week in intensive care unit patients. One study found a modest increase in ICU LOS in patients admitted during the weekend.7 We therefore also looked at the impact of day of the week of admission on FOC in order to determine if fragmentation was just a proxy for admission day as the true indicator for increased LOS.

Methods

Results

Table 1 reviews the demographics of patients with DRG 89 (PNA) and DRG 127 (HF). A large proportion of patients with both DRGs experienced no fragmentation in their physician care during hospitalization; 4152 patients with HF (46.3%) and 685 patients with PNA (35.8%) had visits from only 1 hospitalist throughout their hospital stay, for a FOC Index of 0%. The mean fragmentation level was 21.9% for pneumonia patients, with the mean number of hospitalists seen during the stay at 2.05. For heart failure patients, the mean fragmentation level was 18.3 % and a mean of 1.78 hospitalists seen (Table 1).

Table 2 presents the results of the regression analysis on LOS. The association between fragmentation and LOS, adjusted for demographics, case mix and day of admission, was similar for PNA and HF patients. We found an increase in LOS of 0.39 days for each 10% increase in fragmentation level for pneumonia. Other variables that significantly increased LOS for PNA were larger ROM score, Sunday admission and more discharge diagnoses. Similarly, for heart failure patients, there was an increase in LOS of 0.30 days for each 10% increase in fragmentation level. Other variables associated with a significantly increase in LOS for PNA were larger ROM score, larger SOI category, more discharge diagnoses, and age. Figures 1 and 2 demonstrate the results graphically for LOS in each condition. They show the mean adjusted LOS by fragmentation level. Adjusted LOS was calculated for each patient based on the final model. For example, the average adjusted LOS for PNA patients with a fragmentation level of 20% to 30% is 8.06 days and 9.16 days for patients with a fragmentation level of 30% to 40%.

Figure 1

Figure 2

Discussion

This study demonstrated that there was a statistically significant association between FOC by hospitalist physicians and LOS for patients with DRG 89 (PNA) and DRG 127 (HF). As the percentage of fragmentation increased, the LOS increased significantly.

There are many ways in which to define FOC in the context of hospitalist care of inpatients. We chose to use an index similar to the Usual Provider of Care Index (UPC) which is a standard way to measure continuity of care in the primary care setting.9 The UPC measures the proportion of time spent with the primary provider. In the inpatient setting, we defined continuity of care as the proportion of visits by the primary hospitalist (the physician assuming the greatest number of days of the patient's care). The FOC Index is simply 1 minus the continuity of care. There are other potential measures of FOC, such as the number of handoffs or the number of physicians. We selected our measure based on its following strengths: (1) it does not have the simultaneity problem of measures such as the number of doctors or the number of handoffs that leads to endogeneitya correlation between the error term and the independent variable that biases the coefficient. Endogeneity can occur when the outcome variable and the independent variable are jointly determined, in this case, that an additional day in the hospital increases the likelihood of having an additional handoff as well as an additional handoff increasing the likelihood of an additional day; (2) fragmentation patterns that lead to handoffs on the weekend that then return to the primary hospitalist may be very different from fragmentation patterns that lead to new physicians at each transfer; (3) It provides a good comparison to other models of care where community physicians provide care to their own patients and have an effective FOC index of 0. Further research should be performed looking at different measures that may capture other aspects of care fragmentation.

This is one of the first studies to directly explore the relationship between FOC and LOS. Previous studies in the hospitalist literature have explored the impact of variables on LOS in which FOC may have been an indirect influence. For example, one study found a 13% shorter LOS among academic hospitalists at a teaching hospital who worked on a block rotation compared to a group of community hospitalists with a schedule involving more patient handoffs.10 Although there is little literature on FOC among hospitalists, the literature on medical residency programs is informative. The amount of discontinuity and the number of housestaff‐to‐housestaff transfers of responsibility has increased dramatically since the institution of more stringent work‐hour restrictions by the Accreditation Council for Graduate Medical Education (ACGME) in 2003.11 Horwitz et al.12 found that after the institution of work‐hour regulations, there was an 11% increase in number of transfers of care for a hypothetical patient admitted from Monday until Friday. They noted that programs with a night‐float system had a statistically significant increase in transitions of care compared to residencies without night float. Studies on the impact of the ACGME regulations on LOS have been mixed. One study found that LOS was reduced, and that there was improved adherence to quality indicators.4 A recent study found that there was a 44% increase in the median LOS when Short Call admitting teams were involved.2

There are several limitations to the findings of this study. The largest potential limitation is interpreting the direction of causality between FOC and LOS. This was a concurrent control study. Because the study was not randomized, there is a risk of confounding variables. Admission day of the week was 1 variable of concern for confounding due to the existence of a significant relationship between admission day LOS and between admission day and FOC. We included admission day in our modeling process. The coefficient estimates on FOC were stable, changing less than 1% when day of admission was added to the model. The risk of temporal trends was minimized by studying 1‐year's worth of data. Although we looked at variables that were potentially relevant in all hospitalized patients, every hospital and hospitalist practice has its own unique features that may impact both LOS and FOC. For example, for some hospitals, bed capacity may impact these measures. In many hospitals, hospitalist work force shortages may impact these measures by affecting the extent to which patients are cared for by full‐time hospitalists vs. locums tenens physicians. The large number of facilities in the study mitigates the influence of any individual hospital's LOS and FOC tendencies.

If increased FOC does result in prolonged LOS, the question arises as to how this fragmentation can be decreased. Although no physician can guarantee presence continually throughout a patient's inpatient stay, there are scheduling methods that reduce fragmentation and maximize the odds of a patient being followed by a single clinician. For example, the longer the block of days that a hospitalist is scheduled, the fewer hospitalists will need to care for a patient. Many of the top DRGs for patients cared for by hospitalists have lengths of stay between 4 and 5 days.13 Therefore, any schedule that has a hospitalist on for at least four days at a time will increase the likelihood that the same hospitalist will care for many of the patients throughout their stay. In making schedules, the goals of clinical efficiency and physician satisfaction must be weighed against the potential risks to the quality of patient care. For instance, the use of one hospitalist as the admitting physician for all patients may increase efficiency, but will also increase fragmentation.

A factor that may influence the impact of FOC on LOS is the quality of patient handoffs. The Joint Commission instituted this as a national patient safety goal in 2006.14 This goal was based on a Joint Commission analysis that 70% of sentinel events were caused by communication breakdowns, half of these occurring during handoffs.15

In conclusion, this study explored the relationship between FOC in patients cared for by hospitalists and LOS, using an FOC index. For every 10% increase in fragmentation, the LOS went up by 0.39 days for pneumonia and 0.30 days for heart failure. By adjusting for many variables that may impact LOS due to higher severity or complexity of illness, there is an increased likelihood that the FOC may have a causative relationship with the prolonged LOS.

Emergency Department (ED) overcrowding has become an important problem in North American hospitals.13 A national survey identified the prolonged length of stay of admitted patients in the ED as the most frequent reason for overcrowding.4 This complex problem occurs when hospital inpatient census increases and prevents admitted patients from being assigned and transported to hospital beds in a timely manner.5 The practice of holding admitted patients in the ED, known as boarding, is typically defined as the length of stay (LOS) in ED beginning 2 hours after the time of admission to the time of transfer to the wards.

In a study of daily mean ED LOS, Rathlev et al.6 concluded that a 5% increase in hospital occupancy resulted in 14 hours of holding time for all patients in the ED, and an observational study found that when hospital occupancy exceeds a threshold of 90%, the ED LOS for admitted patients correspondingly increased.7 Thus, efforts to decrease overcrowding will need to address both ED and hospital throughput and LOS. Most importantly, overcrowding has important consequences on physician and patient satisfaction and the quality of patient care.811

Between 1995 and 2005, ED visits rose 20% from 96.5 million to 115.3 million visits annually, while the number of hospital EDs decreased from 4176 to 3795, making an overall 7% increase in ED utilization rate.12 Similarly, there was a 12% increase in the total inpatient admissions for all registered hospitals in the United States from 31 million in 1995 to 35.3 million in 2005.13 However, despite this increase in demand of ED utilization and inpatient admissions, there had been a steady decline in the supply of hospital beds, from 874,000 in 1995, to 805,000 in 2006.13 These factors have exacerbated the problem of ED overcrowding and boarding.

Not only does boarding entail additional consumption of space, resources, equipment, and manpower, it also potentially compromises patient safety. Typically, hospitalists and inpatient medical teams are engaged in providing care to patients in the wards, while ED physicians and nurses are busy taking care of newly‐arrived ED patients. Non‐ED physicians may have the false impression that their boarded patients, while in the ED, are receiving continuous care and so may decide to delay seeing these patients, which can jeopardize the quality and timeliness of care. Studies have shown that ED overcrowding may potentially lead to poor patient care and outcomes and increased risk for medical errors.1416 ED overcrowding potentially causes multiple effects, including prolonging patient pain and suffering, long patient waiting time, patient dissatisfaction, ambulance diversions, decreased physician productivity, and increased frustration among medical staff.15 In a report by the Joint Commission Accreditation of Healthcare Organizations,17 ED overcrowding was cited as a significant contributing factor in sentinel event cases of patient death or permanent injury due to delays in treatment. Boarding critically ill patients who are physiologically vulnerable and unstable can allow them to be subjected to treatment delays at a pivotal point when time‐sensitive interventions are necessary, ie, sepsis or cardiogenic shockthe golden hour in trauma.16 Medical errors are usually not caused by individual errors but by complex hospital systems; and ED overcrowding is a prime example of a system problem that creates a high‐risk environment for medical errors and threatens patient safety.18

Our hospital commonly has 5 to 15 boarders and often has 20 to 30 boarders at any time. Approximately 90% of these patients are admitted to the Medical Service. In response to this challenge, our institution has designated a full‐time hospitalist to manage boarded patients. The primary goal of this new role is to ensure patient safety and the delivery of high‐quality care while admitted patients are in the ED (Table 1).

The objectives of the study were to determine: (1) the impact on quality of care by assessing laboratory results acted upon and medication follow‐up by the ED hospitalist, and (2) the impact on throughput by assessing the number of ED discharges and telemetry downgrades.

Methods

Results

During the study period, there were 4363 patients admitted to the Medicine Service and 3555 patients who qualified as boarders (mean of 29 boarders per 24 hours). The mean boarding time of admitted patients was 440 minutes. A total of 634 patients (17.8% of all boarded patients) were evaluated by the ED hospitalist. The mean daily number of patients seen by the ED hospitalist was 8.0.

The key elements of the delivery of care by the ED hospitalist are summarized in Table 2.

The care of boarded patients included follow‐up of laboratory tests for 74.5% (95% CI, 71‐78%) and medication orders for 79.8% (95% CI, 77‐83%) of patients. A total of 46 patients were discharged by the ED hospitalist (0.6 discharges/day) and telemetry was discontinued for 61 patients (0.8 downgrades/day). The discharge rate was 7.3% (95% CI, 5‐10%) and telemetry downgrade rate was 9.6% (95% CI, 8‐12%) of those patients assessed by the ED hospitalist. Expressed as a percentage of the total ED boarders (n = 3555), the combined discharge rate and the admissions avoided rate was 1.5%.

Table 3 shows the discharge diagnoses made from the ED. Chest pain was the most common diagnosis, followed by syncope, pneumonia, and chronic obstructive pulmonary disease (COPD).

Discussion

Our hospital has successfully implemented an innovative strategy utilizing a hospitalist to help provide seamless care to medical patients located in the ED. Other solutions at our hospital had previously been implemented, but had not adequately addressed the problem, including: (1) protocols to monitor length of stay patterns and deviations, (2) discharge planning activities, (3) organized computerized bed tracking, (4) improvement in the timeliness of ancillary services, (5) daily bed briefing among nurse managers, and (6) 24‐hour presence of a MAR to facilitate triage in the ED.

The current study demonstrates the potential for substantial impact on patient care. The substantial number of the assessed boarder patients for whom laboratory tests (74.5%) and medications (79.8%) were ordered by the ED hospitalists suggests that the quality and timeliness of care was enhanced by this initiative. In addition, the considerable number of patients discharged from the ED and downgraded from telemetry (1.5% and 1.8% of all boarder patients, respectively) suggests that an ED hospitalist may have a meaningful impact on bed utilization and thus decrease ED overcrowding. In 2007, there were 11,488 who qualified as boarders; our data suggest that an ED hospitalist would result in approximately 172 boarders not being admitted annually.

Though the ED LOS was higher during the study period compared to 2007, it was lower than the 2 months immediately preceding implementation of the ED hospitalist role. The ED LOS was 732 and 658 minutes for January and February 2008, respectively, which was markedly increased from 2007 (288 minutes), and prompted development of the ED hospitalist role. The ED LOS during the study period subsequently decreased to 440 minutes. Though the wide fluctuations in ED LOS and the short time period with high ED LOS prior to implementation preclude concluding that the ED hospitalist role decreased ED LOS, the data suggest that an ED hospitalist may be able to improve ED throughput.

The majority of the discharges made by the ED hospitalist are patients who had been admitted for chest pain, had improved, and had negative cardiac enzymes and stress tests. Patients with syncope who were discharged were likely patients without any comorbidities. The COPD and pneumonia admissions were likely patients who improved after aggressive treatment in the ED.

The impact of ED overcrowding on the quality of patient care and outcomes may be substantial. Hwang et al.19 found a direct correlation between ED census and time to pain assessment and administration of analgesic medication. A study at an academic medical center found that higher ED volume was associated with less likelihood of antibiotics being administered within 4 hours for patients with community‐acquired pneumonia.20 A comprehensive review of the literature identified 41 studies examining the effects of ED overcrowding on clinical outcomes and the investigators noted that ED overcrowding was associated with increased in‐hospital mortality.8

Causes of poor outcomes during periods of overcrowding may be the high volume of acute patients preventing adequate time and attention for each ED patient, as well as confusion during the transition from ED to ward physicians. For example, a patient may receive their initial dose of antibiotics from the ED physician, but subsequent doses may be overlooked in the transition of care from the ED physician to the inpatient team. In addition, having admitted patients located in the ED for extended periods of time may lead to these patients not being seen as frequently as patients admitted to the inpatient wards. Another potential consequence of prolonged ED stay for admitted patients is delay in inpatient management. Tests done in the ED may prompt further studies that may not be ordered promptly while patients remain in the ED, which subsequently increases LOS. Other potential issues may be an increase in confusion among geriatric patients in a noisy and crowded ED; decreased access to specialized nursing care that may be available on a hospital ward; decreased access to physical therapy and occupational therapy services; and decreased comfort and satisfaction as patients wait in overcrowded EDs for prolonged periods.

Several other potential innovative solutions to ED overcrowding have been proposed, studied, and tested. These measures generally are focused on improving the three interdependent components of ED workflow: INPUT THROUGHPUT OUTPUT.21, 22 However, process redesign and intervention on these 3 interdependent ED workflow components may be difficult to achieve, especially when hospital resources are limited and when inpatient hospital capacity is already maximized. In some institutions, efforts have been reported to successfully streamline the transfer of admitted ED patients to inpatient beds, through transfer‐to‐ward policy interventions (eg, physician coordinators for patient flow and bed management or transfers made within a defined period of time).2326 However, in a study by Quinn et al.,27 implementation of a rapid admission policy resulted in a decrease of only 10.1 minutes in the ED LOS. Several studies have demonstrated the benefits of an acute medical admissions unit in alleviating ED overcrowding.28, 29 Other unconventional solutions by some hospitals include sending admitted patients to the unit's hallways or placing discharged patients in the hallway while waiting for transportation so that the ED bed will be readily available.30

The ED hospitalist is well‐situated to have an impact on several key hospital outcomes. As the ED hospitalist role was shown to affect processes that relate to ED throughput, it is possible that the role will improve ED overcrowding and decrease ED LOS. Specifically, identifying patients who can be discharged and for whom telemetry is no longer indicated decreases unnecessary bed utilization and allows these beds to be available for other ED patients. This initiative also may promote patient satisfaction by assuring patients that their medical and concerns are being fully addressed while they are in the ED. Increased emphasis on hospital reporting will make patient satisfaction a priority for many hospitals, and the ED hospitalist will be in a unique position to meet and greet patients admitted to the Medicine Service and to reassure them that the medical team is present and addressing their concerns. The hospitalist's ability to facilitate diagnostic testing and treatment while patients remain in the ED may also help decrease the total LOS in the hospital. In addition, the ED hospitalist is also in position to recognize social factors at the earliest stage of admission so that they can be immediately addressed. Future studies will need to be done to determine if this model of transitional care impacts these important factors.

Our study has several important limitations. Most notably, the lack of a comparison interval for which a hospitalist was not assigned to this role prevents us from drawing any definitive conclusions on the benefits of the ED hospitalist model. Also, we collected only summary data and do not have demographic data on the patients managed by the ED hospitalist or information on the ED course of patients who were discharged or had telemetry downgraded. This prevents determination of whether discharged patients did not require admission initially or whose condition evolved over a prolonged ED stay. In addition, other key outcomes, such as patient satisfaction and satisfaction of the ED physicians and nursing staff have not yet been formally measured. Future studies will be needed to determine if an ED hospital model can improve important process and clinical outcomes.

The greatest challenge of this initiative was introducing and familiarizing this role to the key stakeholders, including the ED physicians and nursing staff, house staff, and private practice physicians. Though we did not perform structured surveys on satisfaction, through informal discussions we noted that the role was welcomed with enthusiasm by the ED physicians. Notably, several ED physicians expressed appreciation that they were able to focus their care on new ED patients rather than on the boarded ED patients. Through feedback, we noted soon after implementation that ED faculty and nurses needed further clarification about the potential overlapping roles of the ED hospitalist and ED physicians and ward physicians. These concerns were addressed by educational sessions and announcements, including presentations at ED faculty and staff meetings. The hospitalist assigned to the role each month received individualized orientation prior to assuming the role, and an ED Hospitalist Manual was distributed. Possibly due to these focused sessions, the hospitalists assigned to the role became quickly acclimated.

Conclusions

We have found that designating a hospitalist to directly address the care of ED boarders can enhance the quality and timeliness of care and decrease bed and telemetry utilization with the potential to impact ED and hospital LOS. Given the success of the pilot model, the role was expanded at our institution to 10 hours per day, 7 days per week. Hospitals struggling to address the needs of their admitted patients in the ED should consider incorporating an ED hospitalist to enhance clinical care and address issues relating to throughput. A follow‐up study is needed to more precisely describe the impact of the ED hospitalist model.

Emergency Department (ED) overcrowding has become an important problem in North American hospitals.13 A national survey identified the prolonged length of stay of admitted patients in the ED as the most frequent reason for overcrowding.4 This complex problem occurs when hospital inpatient census increases and prevents admitted patients from being assigned and transported to hospital beds in a timely manner.5 The practice of holding admitted patients in the ED, known as boarding, is typically defined as the length of stay (LOS) in ED beginning 2 hours after the time of admission to the time of transfer to the wards.

In a study of daily mean ED LOS, Rathlev et al.6 concluded that a 5% increase in hospital occupancy resulted in 14 hours of holding time for all patients in the ED, and an observational study found that when hospital occupancy exceeds a threshold of 90%, the ED LOS for admitted patients correspondingly increased.7 Thus, efforts to decrease overcrowding will need to address both ED and hospital throughput and LOS. Most importantly, overcrowding has important consequences on physician and patient satisfaction and the quality of patient care.811

Between 1995 and 2005, ED visits rose 20% from 96.5 million to 115.3 million visits annually, while the number of hospital EDs decreased from 4176 to 3795, making an overall 7% increase in ED utilization rate.12 Similarly, there was a 12% increase in the total inpatient admissions for all registered hospitals in the United States from 31 million in 1995 to 35.3 million in 2005.13 However, despite this increase in demand of ED utilization and inpatient admissions, there had been a steady decline in the supply of hospital beds, from 874,000 in 1995, to 805,000 in 2006.13 These factors have exacerbated the problem of ED overcrowding and boarding.

Not only does boarding entail additional consumption of space, resources, equipment, and manpower, it also potentially compromises patient safety. Typically, hospitalists and inpatient medical teams are engaged in providing care to patients in the wards, while ED physicians and nurses are busy taking care of newly‐arrived ED patients. Non‐ED physicians may have the false impression that their boarded patients, while in the ED, are receiving continuous care and so may decide to delay seeing these patients, which can jeopardize the quality and timeliness of care. Studies have shown that ED overcrowding may potentially lead to poor patient care and outcomes and increased risk for medical errors.1416 ED overcrowding potentially causes multiple effects, including prolonging patient pain and suffering, long patient waiting time, patient dissatisfaction, ambulance diversions, decreased physician productivity, and increased frustration among medical staff.15 In a report by the Joint Commission Accreditation of Healthcare Organizations,17 ED overcrowding was cited as a significant contributing factor in sentinel event cases of patient death or permanent injury due to delays in treatment. Boarding critically ill patients who are physiologically vulnerable and unstable can allow them to be subjected to treatment delays at a pivotal point when time‐sensitive interventions are necessary, ie, sepsis or cardiogenic shockthe golden hour in trauma.16 Medical errors are usually not caused by individual errors but by complex hospital systems; and ED overcrowding is a prime example of a system problem that creates a high‐risk environment for medical errors and threatens patient safety.18

Our hospital commonly has 5 to 15 boarders and often has 20 to 30 boarders at any time. Approximately 90% of these patients are admitted to the Medical Service. In response to this challenge, our institution has designated a full‐time hospitalist to manage boarded patients. The primary goal of this new role is to ensure patient safety and the delivery of high‐quality care while admitted patients are in the ED (Table 1).

The objectives of the study were to determine: (1) the impact on quality of care by assessing laboratory results acted upon and medication follow‐up by the ED hospitalist, and (2) the impact on throughput by assessing the number of ED discharges and telemetry downgrades.

Methods

Results

During the study period, there were 4363 patients admitted to the Medicine Service and 3555 patients who qualified as boarders (mean of 29 boarders per 24 hours). The mean boarding time of admitted patients was 440 minutes. A total of 634 patients (17.8% of all boarded patients) were evaluated by the ED hospitalist. The mean daily number of patients seen by the ED hospitalist was 8.0.

The key elements of the delivery of care by the ED hospitalist are summarized in Table 2.

The care of boarded patients included follow‐up of laboratory tests for 74.5% (95% CI, 71‐78%) and medication orders for 79.8% (95% CI, 77‐83%) of patients. A total of 46 patients were discharged by the ED hospitalist (0.6 discharges/day) and telemetry was discontinued for 61 patients (0.8 downgrades/day). The discharge rate was 7.3% (95% CI, 5‐10%) and telemetry downgrade rate was 9.6% (95% CI, 8‐12%) of those patients assessed by the ED hospitalist. Expressed as a percentage of the total ED boarders (n = 3555), the combined discharge rate and the admissions avoided rate was 1.5%.

Table 3 shows the discharge diagnoses made from the ED. Chest pain was the most common diagnosis, followed by syncope, pneumonia, and chronic obstructive pulmonary disease (COPD).

Discussion

Our hospital has successfully implemented an innovative strategy utilizing a hospitalist to help provide seamless care to medical patients located in the ED. Other solutions at our hospital had previously been implemented, but had not adequately addressed the problem, including: (1) protocols to monitor length of stay patterns and deviations, (2) discharge planning activities, (3) organized computerized bed tracking, (4) improvement in the timeliness of ancillary services, (5) daily bed briefing among nurse managers, and (6) 24‐hour presence of a MAR to facilitate triage in the ED.

The current study demonstrates the potential for substantial impact on patient care. The substantial number of the assessed boarder patients for whom laboratory tests (74.5%) and medications (79.8%) were ordered by the ED hospitalists suggests that the quality and timeliness of care was enhanced by this initiative. In addition, the considerable number of patients discharged from the ED and downgraded from telemetry (1.5% and 1.8% of all boarder patients, respectively) suggests that an ED hospitalist may have a meaningful impact on bed utilization and thus decrease ED overcrowding. In 2007, there were 11,488 who qualified as boarders; our data suggest that an ED hospitalist would result in approximately 172 boarders not being admitted annually.

Though the ED LOS was higher during the study period compared to 2007, it was lower than the 2 months immediately preceding implementation of the ED hospitalist role. The ED LOS was 732 and 658 minutes for January and February 2008, respectively, which was markedly increased from 2007 (288 minutes), and prompted development of the ED hospitalist role. The ED LOS during the study period subsequently decreased to 440 minutes. Though the wide fluctuations in ED LOS and the short time period with high ED LOS prior to implementation preclude concluding that the ED hospitalist role decreased ED LOS, the data suggest that an ED hospitalist may be able to improve ED throughput.

The majority of the discharges made by the ED hospitalist are patients who had been admitted for chest pain, had improved, and had negative cardiac enzymes and stress tests. Patients with syncope who were discharged were likely patients without any comorbidities. The COPD and pneumonia admissions were likely patients who improved after aggressive treatment in the ED.

The impact of ED overcrowding on the quality of patient care and outcomes may be substantial. Hwang et al.19 found a direct correlation between ED census and time to pain assessment and administration of analgesic medication. A study at an academic medical center found that higher ED volume was associated with less likelihood of antibiotics being administered within 4 hours for patients with community‐acquired pneumonia.20 A comprehensive review of the literature identified 41 studies examining the effects of ED overcrowding on clinical outcomes and the investigators noted that ED overcrowding was associated with increased in‐hospital mortality.8

Causes of poor outcomes during periods of overcrowding may be the high volume of acute patients preventing adequate time and attention for each ED patient, as well as confusion during the transition from ED to ward physicians. For example, a patient may receive their initial dose of antibiotics from the ED physician, but subsequent doses may be overlooked in the transition of care from the ED physician to the inpatient team. In addition, having admitted patients located in the ED for extended periods of time may lead to these patients not being seen as frequently as patients admitted to the inpatient wards. Another potential consequence of prolonged ED stay for admitted patients is delay in inpatient management. Tests done in the ED may prompt further studies that may not be ordered promptly while patients remain in the ED, which subsequently increases LOS. Other potential issues may be an increase in confusion among geriatric patients in a noisy and crowded ED; decreased access to specialized nursing care that may be available on a hospital ward; decreased access to physical therapy and occupational therapy services; and decreased comfort and satisfaction as patients wait in overcrowded EDs for prolonged periods.

Several other potential innovative solutions to ED overcrowding have been proposed, studied, and tested. These measures generally are focused on improving the three interdependent components of ED workflow: INPUT THROUGHPUT OUTPUT.21, 22 However, process redesign and intervention on these 3 interdependent ED workflow components may be difficult to achieve, especially when hospital resources are limited and when inpatient hospital capacity is already maximized. In some institutions, efforts have been reported to successfully streamline the transfer of admitted ED patients to inpatient beds, through transfer‐to‐ward policy interventions (eg, physician coordinators for patient flow and bed management or transfers made within a defined period of time).2326 However, in a study by Quinn et al.,27 implementation of a rapid admission policy resulted in a decrease of only 10.1 minutes in the ED LOS. Several studies have demonstrated the benefits of an acute medical admissions unit in alleviating ED overcrowding.28, 29 Other unconventional solutions by some hospitals include sending admitted patients to the unit's hallways or placing discharged patients in the hallway while waiting for transportation so that the ED bed will be readily available.30

The ED hospitalist is well‐situated to have an impact on several key hospital outcomes. As the ED hospitalist role was shown to affect processes that relate to ED throughput, it is possible that the role will improve ED overcrowding and decrease ED LOS. Specifically, identifying patients who can be discharged and for whom telemetry is no longer indicated decreases unnecessary bed utilization and allows these beds to be available for other ED patients. This initiative also may promote patient satisfaction by assuring patients that their medical and concerns are being fully addressed while they are in the ED. Increased emphasis on hospital reporting will make patient satisfaction a priority for many hospitals, and the ED hospitalist will be in a unique position to meet and greet patients admitted to the Medicine Service and to reassure them that the medical team is present and addressing their concerns. The hospitalist's ability to facilitate diagnostic testing and treatment while patients remain in the ED may also help decrease the total LOS in the hospital. In addition, the ED hospitalist is also in position to recognize social factors at the earliest stage of admission so that they can be immediately addressed. Future studies will need to be done to determine if this model of transitional care impacts these important factors.

Our study has several important limitations. Most notably, the lack of a comparison interval for which a hospitalist was not assigned to this role prevents us from drawing any definitive conclusions on the benefits of the ED hospitalist model. Also, we collected only summary data and do not have demographic data on the patients managed by the ED hospitalist or information on the ED course of patients who were discharged or had telemetry downgraded. This prevents determination of whether discharged patients did not require admission initially or whose condition evolved over a prolonged ED stay. In addition, other key outcomes, such as patient satisfaction and satisfaction of the ED physicians and nursing staff have not yet been formally measured. Future studies will be needed to determine if an ED hospital model can improve important process and clinical outcomes.

The greatest challenge of this initiative was introducing and familiarizing this role to the key stakeholders, including the ED physicians and nursing staff, house staff, and private practice physicians. Though we did not perform structured surveys on satisfaction, through informal discussions we noted that the role was welcomed with enthusiasm by the ED physicians. Notably, several ED physicians expressed appreciation that they were able to focus their care on new ED patients rather than on the boarded ED patients. Through feedback, we noted soon after implementation that ED faculty and nurses needed further clarification about the potential overlapping roles of the ED hospitalist and ED physicians and ward physicians. These concerns were addressed by educational sessions and announcements, including presentations at ED faculty and staff meetings. The hospitalist assigned to the role each month received individualized orientation prior to assuming the role, and an ED Hospitalist Manual was distributed. Possibly due to these focused sessions, the hospitalists assigned to the role became quickly acclimated.

Conclusions

We have found that designating a hospitalist to directly address the care of ED boarders can enhance the quality and timeliness of care and decrease bed and telemetry utilization with the potential to impact ED and hospital LOS. Given the success of the pilot model, the role was expanded at our institution to 10 hours per day, 7 days per week. Hospitals struggling to address the needs of their admitted patients in the ED should consider incorporating an ED hospitalist to enhance clinical care and address issues relating to throughput. A follow‐up study is needed to more precisely describe the impact of the ED hospitalist model.

Emergency Department (ED) overcrowding has become an important problem in North American hospitals.13 A national survey identified the prolonged length of stay of admitted patients in the ED as the most frequent reason for overcrowding.4 This complex problem occurs when hospital inpatient census increases and prevents admitted patients from being assigned and transported to hospital beds in a timely manner.5 The practice of holding admitted patients in the ED, known as boarding, is typically defined as the length of stay (LOS) in ED beginning 2 hours after the time of admission to the time of transfer to the wards.

In a study of daily mean ED LOS, Rathlev et al.6 concluded that a 5% increase in hospital occupancy resulted in 14 hours of holding time for all patients in the ED, and an observational study found that when hospital occupancy exceeds a threshold of 90%, the ED LOS for admitted patients correspondingly increased.7 Thus, efforts to decrease overcrowding will need to address both ED and hospital throughput and LOS. Most importantly, overcrowding has important consequences on physician and patient satisfaction and the quality of patient care.811

Between 1995 and 2005, ED visits rose 20% from 96.5 million to 115.3 million visits annually, while the number of hospital EDs decreased from 4176 to 3795, making an overall 7% increase in ED utilization rate.12 Similarly, there was a 12% increase in the total inpatient admissions for all registered hospitals in the United States from 31 million in 1995 to 35.3 million in 2005.13 However, despite this increase in demand of ED utilization and inpatient admissions, there had been a steady decline in the supply of hospital beds, from 874,000 in 1995, to 805,000 in 2006.13 These factors have exacerbated the problem of ED overcrowding and boarding.

Not only does boarding entail additional consumption of space, resources, equipment, and manpower, it also potentially compromises patient safety. Typically, hospitalists and inpatient medical teams are engaged in providing care to patients in the wards, while ED physicians and nurses are busy taking care of newly‐arrived ED patients. Non‐ED physicians may have the false impression that their boarded patients, while in the ED, are receiving continuous care and so may decide to delay seeing these patients, which can jeopardize the quality and timeliness of care. Studies have shown that ED overcrowding may potentially lead to poor patient care and outcomes and increased risk for medical errors.1416 ED overcrowding potentially causes multiple effects, including prolonging patient pain and suffering, long patient waiting time, patient dissatisfaction, ambulance diversions, decreased physician productivity, and increased frustration among medical staff.15 In a report by the Joint Commission Accreditation of Healthcare Organizations,17 ED overcrowding was cited as a significant contributing factor in sentinel event cases of patient death or permanent injury due to delays in treatment. Boarding critically ill patients who are physiologically vulnerable and unstable can allow them to be subjected to treatment delays at a pivotal point when time‐sensitive interventions are necessary, ie, sepsis or cardiogenic shockthe golden hour in trauma.16 Medical errors are usually not caused by individual errors but by complex hospital systems; and ED overcrowding is a prime example of a system problem that creates a high‐risk environment for medical errors and threatens patient safety.18

Our hospital commonly has 5 to 15 boarders and often has 20 to 30 boarders at any time. Approximately 90% of these patients are admitted to the Medical Service. In response to this challenge, our institution has designated a full‐time hospitalist to manage boarded patients. The primary goal of this new role is to ensure patient safety and the delivery of high‐quality care while admitted patients are in the ED (Table 1).

The objectives of the study were to determine: (1) the impact on quality of care by assessing laboratory results acted upon and medication follow‐up by the ED hospitalist, and (2) the impact on throughput by assessing the number of ED discharges and telemetry downgrades.

Methods

Results

During the study period, there were 4363 patients admitted to the Medicine Service and 3555 patients who qualified as boarders (mean of 29 boarders per 24 hours). The mean boarding time of admitted patients was 440 minutes. A total of 634 patients (17.8% of all boarded patients) were evaluated by the ED hospitalist. The mean daily number of patients seen by the ED hospitalist was 8.0.

The key elements of the delivery of care by the ED hospitalist are summarized in Table 2.

The care of boarded patients included follow‐up of laboratory tests for 74.5% (95% CI, 71‐78%) and medication orders for 79.8% (95% CI, 77‐83%) of patients. A total of 46 patients were discharged by the ED hospitalist (0.6 discharges/day) and telemetry was discontinued for 61 patients (0.8 downgrades/day). The discharge rate was 7.3% (95% CI, 5‐10%) and telemetry downgrade rate was 9.6% (95% CI, 8‐12%) of those patients assessed by the ED hospitalist. Expressed as a percentage of the total ED boarders (n = 3555), the combined discharge rate and the admissions avoided rate was 1.5%.

Table 3 shows the discharge diagnoses made from the ED. Chest pain was the most common diagnosis, followed by syncope, pneumonia, and chronic obstructive pulmonary disease (COPD).

Discussion

Our hospital has successfully implemented an innovative strategy utilizing a hospitalist to help provide seamless care to medical patients located in the ED. Other solutions at our hospital had previously been implemented, but had not adequately addressed the problem, including: (1) protocols to monitor length of stay patterns and deviations, (2) discharge planning activities, (3) organized computerized bed tracking, (4) improvement in the timeliness of ancillary services, (5) daily bed briefing among nurse managers, and (6) 24‐hour presence of a MAR to facilitate triage in the ED.

The current study demonstrates the potential for substantial impact on patient care. The substantial number of the assessed boarder patients for whom laboratory tests (74.5%) and medications (79.8%) were ordered by the ED hospitalists suggests that the quality and timeliness of care was enhanced by this initiative. In addition, the considerable number of patients discharged from the ED and downgraded from telemetry (1.5% and 1.8% of all boarder patients, respectively) suggests that an ED hospitalist may have a meaningful impact on bed utilization and thus decrease ED overcrowding. In 2007, there were 11,488 who qualified as boarders; our data suggest that an ED hospitalist would result in approximately 172 boarders not being admitted annually.

Though the ED LOS was higher during the study period compared to 2007, it was lower than the 2 months immediately preceding implementation of the ED hospitalist role. The ED LOS was 732 and 658 minutes for January and February 2008, respectively, which was markedly increased from 2007 (288 minutes), and prompted development of the ED hospitalist role. The ED LOS during the study period subsequently decreased to 440 minutes. Though the wide fluctuations in ED LOS and the short time period with high ED LOS prior to implementation preclude concluding that the ED hospitalist role decreased ED LOS, the data suggest that an ED hospitalist may be able to improve ED throughput.

The majority of the discharges made by the ED hospitalist are patients who had been admitted for chest pain, had improved, and had negative cardiac enzymes and stress tests. Patients with syncope who were discharged were likely patients without any comorbidities. The COPD and pneumonia admissions were likely patients who improved after aggressive treatment in the ED.

The impact of ED overcrowding on the quality of patient care and outcomes may be substantial. Hwang et al.19 found a direct correlation between ED census and time to pain assessment and administration of analgesic medication. A study at an academic medical center found that higher ED volume was associated with less likelihood of antibiotics being administered within 4 hours for patients with community‐acquired pneumonia.20 A comprehensive review of the literature identified 41 studies examining the effects of ED overcrowding on clinical outcomes and the investigators noted that ED overcrowding was associated with increased in‐hospital mortality.8

Causes of poor outcomes during periods of overcrowding may be the high volume of acute patients preventing adequate time and attention for each ED patient, as well as confusion during the transition from ED to ward physicians. For example, a patient may receive their initial dose of antibiotics from the ED physician, but subsequent doses may be overlooked in the transition of care from the ED physician to the inpatient team. In addition, having admitted patients located in the ED for extended periods of time may lead to these patients not being seen as frequently as patients admitted to the inpatient wards. Another potential consequence of prolonged ED stay for admitted patients is delay in inpatient management. Tests done in the ED may prompt further studies that may not be ordered promptly while patients remain in the ED, which subsequently increases LOS. Other potential issues may be an increase in confusion among geriatric patients in a noisy and crowded ED; decreased access to specialized nursing care that may be available on a hospital ward; decreased access to physical therapy and occupational therapy services; and decreased comfort and satisfaction as patients wait in overcrowded EDs for prolonged periods.

Several other potential innovative solutions to ED overcrowding have been proposed, studied, and tested. These measures generally are focused on improving the three interdependent components of ED workflow: INPUT THROUGHPUT OUTPUT.21, 22 However, process redesign and intervention on these 3 interdependent ED workflow components may be difficult to achieve, especially when hospital resources are limited and when inpatient hospital capacity is already maximized. In some institutions, efforts have been reported to successfully streamline the transfer of admitted ED patients to inpatient beds, through transfer‐to‐ward policy interventions (eg, physician coordinators for patient flow and bed management or transfers made within a defined period of time).2326 However, in a study by Quinn et al.,27 implementation of a rapid admission policy resulted in a decrease of only 10.1 minutes in the ED LOS. Several studies have demonstrated the benefits of an acute medical admissions unit in alleviating ED overcrowding.28, 29 Other unconventional solutions by some hospitals include sending admitted patients to the unit's hallways or placing discharged patients in the hallway while waiting for transportation so that the ED bed will be readily available.30

The ED hospitalist is well‐situated to have an impact on several key hospital outcomes. As the ED hospitalist role was shown to affect processes that relate to ED throughput, it is possible that the role will improve ED overcrowding and decrease ED LOS. Specifically, identifying patients who can be discharged and for whom telemetry is no longer indicated decreases unnecessary bed utilization and allows these beds to be available for other ED patients. This initiative also may promote patient satisfaction by assuring patients that their medical and concerns are being fully addressed while they are in the ED. Increased emphasis on hospital reporting will make patient satisfaction a priority for many hospitals, and the ED hospitalist will be in a unique position to meet and greet patients admitted to the Medicine Service and to reassure them that the medical team is present and addressing their concerns. The hospitalist's ability to facilitate diagnostic testing and treatment while patients remain in the ED may also help decrease the total LOS in the hospital. In addition, the ED hospitalist is also in position to recognize social factors at the earliest stage of admission so that they can be immediately addressed. Future studies will need to be done to determine if this model of transitional care impacts these important factors.

Our study has several important limitations. Most notably, the lack of a comparison interval for which a hospitalist was not assigned to this role prevents us from drawing any definitive conclusions on the benefits of the ED hospitalist model. Also, we collected only summary data and do not have demographic data on the patients managed by the ED hospitalist or information on the ED course of patients who were discharged or had telemetry downgraded. This prevents determination of whether discharged patients did not require admission initially or whose condition evolved over a prolonged ED stay. In addition, other key outcomes, such as patient satisfaction and satisfaction of the ED physicians and nursing staff have not yet been formally measured. Future studies will be needed to determine if an ED hospital model can improve important process and clinical outcomes.

The greatest challenge of this initiative was introducing and familiarizing this role to the key stakeholders, including the ED physicians and nursing staff, house staff, and private practice physicians. Though we did not perform structured surveys on satisfaction, through informal discussions we noted that the role was welcomed with enthusiasm by the ED physicians. Notably, several ED physicians expressed appreciation that they were able to focus their care on new ED patients rather than on the boarded ED patients. Through feedback, we noted soon after implementation that ED faculty and nurses needed further clarification about the potential overlapping roles of the ED hospitalist and ED physicians and ward physicians. These concerns were addressed by educational sessions and announcements, including presentations at ED faculty and staff meetings. The hospitalist assigned to the role each month received individualized orientation prior to assuming the role, and an ED Hospitalist Manual was distributed. Possibly due to these focused sessions, the hospitalists assigned to the role became quickly acclimated.

Conclusions

We have found that designating a hospitalist to directly address the care of ED boarders can enhance the quality and timeliness of care and decrease bed and telemetry utilization with the potential to impact ED and hospital LOS. Given the success of the pilot model, the role was expanded at our institution to 10 hours per day, 7 days per week. Hospitals struggling to address the needs of their admitted patients in the ED should consider incorporating an ED hospitalist to enhance clinical care and address issues relating to throughput. A follow‐up study is needed to more precisely describe the impact of the ED hospitalist model.

Communication failures are well‐recognized as causes of medical errors.1, 2 Specifically, handoffs of patient care responsibilities, which are increasingly prevalent in academic medical centers,3 have been cited as the most frequent cause of teamwork breakdown resulting in the harmful medical errors found in malpractice claims.1 The Institute of Medicine has recently identified patient handoffs as the moment where patient care errors are most likely to occur.4 A survey of 125 U.S. medical schools, however, found that only 8% specifically taught students how to hand off patient care.3

In July 2003, the American Council of Graduate Medical Education (ACGME) mandated that residency programs decrease resident work hours to improve patient care and safety by reducing fatigue,5 and a recent Institute of Medicine report suggests that they be decreased even further.4 Studies examining outcomes during the first 2 years after reducing duty hours did not find reductions in risk‐adjusted mortality.68 One proposed explanation for this lack of improvement is that the reduction in fatigue‐related medical errors is being offset by discontinuity of care with due to the increased number of patient handoffs resulting from shortened duty hours,911 one recent study found that omission of key information during patient sign outs frequently resulted in adverse patient care outcomes.12

In 2007, the Joint Commission developed a new National Patient Safety Goal that requires organizations to improve communication between caregivers.13 We recently developed an approach by which Internal Medicine residents hand off patient care using a structured process, written and verbal templates, formal training about handoffs, and direct attending supervision.14 Because fourth‐year medical students perform the duties of interns when working as subinterns, we recognized that education about handoffs should occur prior to the time students became interns. Accordingly, we developed a course designed to teach patient handoffs to medical students at the transition between their third and fourth years of training.

Setting

The Handoff Selective was developed by faculty of Denver Health and the University of Colorado Denver School of Medicine.

Program Description

The Selective was first offered in April 2007 as part of an Integrated Clinician's Course (ICC), a 2‐week course for students beginning their fourth year, which starts in April at the University of Colorado. The ICC includes both mandatory and selective sessions that are focused on developing clinical skills and preparing them for their subinternships. The Handoff Selective was conducted in a computerized teaching laboratory, lasted a total of 2 hours and consisted of 2 parts. Each of the 5 Denver Health Hospital Medicine faculty members versed in handoff education taught 2 sessions of 6 to 8 students.

Part 1: Didactic

During the first hour of class, the faculty presented a lecture that summarized the relevant literature on handoffs and explained the importance of the topic. The objectives of the didactic were to: (1) understand the importance of handoffs; (2) explore different communication elements and structures; (3) gain exposure to handoffs outside of healthcare; and (4) learn a structure for handoffs of patient care in hospitalized patients.

We used 3 video clips of handoffs from 2 football games to demonstrate the importance of practice, training, and 2‐way communications in handoffs. The first video clip showed a runner trying to make a spontaneous handoff while being tackled. The receiver was not expecting the handoff and was preoccupied with blocking another player. This attempted handoff resulted in a fumble, which we related to an adverse patient event.

The next 2 video clips showed 2 complex, seldom used, but well‐known football handoffsthe hook and lateral and the Statue of Liberty. Both handoffs were successfully executed presumably as a result of education, practice and the active participation of both players (handing off and receiving) in the process. We then related the teaching and practicing of complex communication to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO; now simply the Joint Commission) data suggesting that most sentinel events have their root cause in communication and training failures.2

Basic communication elements and process structures were then explored using scenarios from everyday life and evidence from fields outside of medicine. We emphasized that structures for communication (modes, vehicles, and settings) must be chosen according to the occasion and that handoffs are common and important in all occupations. In discussing modes (verbal, written, or nonverbal), vehicles (paper, telephone, or e‐mail), and settings (face‐to face, virtual, or disconnected), we emphasized that the most effective structures for communication (verbal, face‐to face meetings, with written materials and other visual aids at the patient's bedside) were also the most time‐consuming (Figure 1). While our standard for resident handoffs is a face‐to‐face verbal interaction with preprinted written materials as an aid, we also emphasized that for complex patients (eg, mental status changes, concern for an acute abdomen) more robust communication is often needed. Accordingly, a more time‐consuming bedside handoff with simultaneous, focused physical exam and history‐taking by both oncoming and off‐going providers may be most appropriate.

Figure 1

As real‐life examples, we asked our students to communicate a happy birthday wish to their mother, who lives in another state. Almost uniformly, in addition to a written aid (birthday card), they choose the telephone as a vehicle for their verbal mode in a virtual setting with 2‐way communication possible. In contrast, when asked to propose marriage to a significant other in another state, students felt that a face‐to‐face meeting with verbal and nonverbal (ie, ring) modes was appropriate. This time‐consuming mode of communication was felt to be necessary to create a sentiment of importance and avert any possible miscommunication.

The didactic session concluded by demonstrating how to use standardized written and verbal templates for handoffs of the care of a hospitalized patient. We explore the differentiation between written and verbal handoffs in our discussion below.

Program Evaluation

We developed a 2‐part survey to evaluate the effectiveness of the Selective and to solicit feedback about the didactic and practicum portions of the course. The first part of the survey (Table 2) contained 16 items to assess the students' knowledge of, and attitudes toward handing off patient care, along with their comfort with the handoff process. Responses to this section were scored using a 5‐point Likert scale with 1 indicating strongly disagree and 5 indicating strongly agree. This part of the survey was administered both prior to and after the Selective.

The second part (Table 3) contained 12 items and was designed to evaluate the perceived usefulness of the different components of the class. This section was only administered at the end of the Selective. It utilized a 4‐point Likert scale with 1 indicating that the component was not useful at all, and 4 indicating that it was extremely useful. The first 6 items of the second section allowed students to evaluate the didactic portion of the handoff. The second 6 items allowed students to evaluate the practicum. Responses to all 12 items were then combined to determine an overall composite usefulness for the Selective.

The Selective was also evaluated qualitatively through the use of open‐ended, written comments that were solicited at the end of the survey. All surveys were administered anonymously.

Results

More students chose the Selective than we had capacity to accommodate (60 of a class of 150). The pre‐ and postcourse survey response rate was 56 of 60 (93%) and 58 of 60 (97%), respectively. After the Selective, the mean score in response to whether handoffs are well taught in medical school increased from 1.6 to 3.5 (P < 0.003). Our students' self‐perceived skills and knowledge about handoffs improved after the Selective (Table 2). The greatest changes in perceived knowledge occurred in questions regarding the what, how, and when of read‐backs, and the knowledge of standard verbal and written handoff structures. The responses to the survey elements which assessed our students' attitudes regarding the importance of standardization and whether they felt handoffs were safer with faculty supervision did not change after the Selective (Table 2).

A total of 92% of the students felt that the course was extremely useful or useful. The role‐playing activity was thought to be more helpful than the didactic, but 84% of the students still rated the didactic portion as useful or extremely useful (Table 3). The element which was the least well received in the didactic portion was the use of video clips to demonstrate successful and unsuccessful (fumbled) college football handoffs, although the majority (64%) of students still found it useful.

The major theme generated from the comments section of the survey was that the Selective should be a required course.

Discussion

We know of no previously published literature that has addressed teaching handoffs to medical students. Horwitz et al.15 developed a sign‐out curriculum for Internal Medicine residents and found that none of their house‐staff had any previous training in handoffs during medical school, consistent with the finding that only 8% of U.S. medical schools provided formal instruction on handoffs.3 Prior to taking the Selective, our students had no knowledge of verbal or written templates for patient handoffs, although both before and after the course they felt that standardization was an important component of the process.

A number of verbal structures for handing off patient care have been described in the literature and there is not a consensus as to which functions best. Perhaps the most cited verbal communication format is SBAR (ie, situation, background, assessment and recommendation).16, 17 This tool was developed by Leonard et al.18 specifically for use by nurses to provide 1‐way communication to physicians pertaining to a change in patient status. We considered teaching the SBAR approach to the students but felt that it did not provide a suitable structure for handoffs because the transfer of care is not generally an event‐based situation and the literature on handoffs indicates that an optimal verbal system includes 2‐way communication.

Additional mnemonics for handoffs found in the literature include SIGNOUT (ie, Sick or DNR, Identifying information, General hospital course, New events of the day, Overall health status, Upcoming possibilities with plan, and Tasks to complete),14 I PASS the BATON (ie, Introduction, Patient, Assessment, Situation, Safety, Background, Actions, Timing, Ownership, Next)19 and the SAIF‐IR system (see boxed text).14

We developed the SAIF‐IR mnemonic to maximize efficiency and effectiveness while differentiating the verbal portion of the handoff from the written and incorporating 2‐way communication into its structure. In the Summary statement, we emphasize that this is not a history of present illness. We ask our students to summarize, in 1 to 3 sentences, the patient's presentation and working diagnosis. When discussing patient issues, we ask our students to only verbalize Active issues, although the written template has inactive, chronic issues listed. Here, we also ask our students to express their level of concern for the active issues and patient in general. If‐then's and Follow‐ups are usually verbalized together. Based on the offgoing provider's knowledge of the patient, we encourage the offgoing provider to anticipate potential problems and advise the oncoming provider on potential responses. Much of this advice is difficult to express in the written format and thus may not be found on the written handoff when the verbal handoff occurs. We encourage oncoming providers to take notes on the preprinted handoff sheet as part of the handoff process.

Through Interactive questioning and Read‐backs, we train our students and house‐staff to use the active listening techniques used outside of healthcare, in settings such as nuclear power plants and National Aeronautics and Space Administration mission control, where poor handoff communication may also result in safety concerns and adverse events.20 Interactive questioning allows the oncoming provider to correct or clarify any information given by the off‐going provider. Read‐backs are a method of confirming follow‐up activity or contingency plans. Together, the SAIF‐IR mnemonic builds a 2‐way communication structure into the patient handoff with both offgoing and oncoming providers having predefined roles.

Much of the information on our written handoff (patient identifying information, medications, language preference, code status, admission date) is not verbalized unless it is part of the active issues or the if‐then, follow‐ups (ie, medication titration for a patient admitted with an acute coronary syndrome or cor status in a patient newly made comfort care). By not reading extraneous information, we seek to emphasize the Active issues as well as the If‐then, Follow‐ups. We feel this emphasis maximizes the effectiveness of the handoff, while the purposeful nonverbalization of written materials such as identifying information maximizes its efficiency. Future work may examine which verbal and written structures for patient handoffs most benefit patient care and workflow through standard communication.

While our students found the Handoff Selective to be useful and to improve their self‐perceived ability to perform handoffs, we were not able to determine whether our program affected downstream outcomes such as adverse events relating to failures in handoff communication. Additionally, since we only taught and evaluated our Selective at the University of Colorado Denver School of Medicine, the response of our students may not generalize to other medical schools. Multicentered, prospective, randomized controlled trials may determine whether handoff education programs are successful in reducing patient adverse events related to transfers of care.

While handoffs occur frequently and are increasingly recognized as a vulnerable time in patient care, little is known about how to effectively teach handoffs to medical students during their clinical years. We developed a formal course to teach the importance of handoffs and how the process should be conducted. Our students reported that the Handoff Selective we developed improved their knowledge about the process and their perception of their ability to perform handoffs in a time‐appropriate and effective manner. In response to the feedback we received from our students, the Handoff Selective is the only course in the ICC that has been made mandatory for all students.

Communication failures are well‐recognized as causes of medical errors.1, 2 Specifically, handoffs of patient care responsibilities, which are increasingly prevalent in academic medical centers,3 have been cited as the most frequent cause of teamwork breakdown resulting in the harmful medical errors found in malpractice claims.1 The Institute of Medicine has recently identified patient handoffs as the moment where patient care errors are most likely to occur.4 A survey of 125 U.S. medical schools, however, found that only 8% specifically taught students how to hand off patient care.3

In July 2003, the American Council of Graduate Medical Education (ACGME) mandated that residency programs decrease resident work hours to improve patient care and safety by reducing fatigue,5 and a recent Institute of Medicine report suggests that they be decreased even further.4 Studies examining outcomes during the first 2 years after reducing duty hours did not find reductions in risk‐adjusted mortality.68 One proposed explanation for this lack of improvement is that the reduction in fatigue‐related medical errors is being offset by discontinuity of care with due to the increased number of patient handoffs resulting from shortened duty hours,911 one recent study found that omission of key information during patient sign outs frequently resulted in adverse patient care outcomes.12

In 2007, the Joint Commission developed a new National Patient Safety Goal that requires organizations to improve communication between caregivers.13 We recently developed an approach by which Internal Medicine residents hand off patient care using a structured process, written and verbal templates, formal training about handoffs, and direct attending supervision.14 Because fourth‐year medical students perform the duties of interns when working as subinterns, we recognized that education about handoffs should occur prior to the time students became interns. Accordingly, we developed a course designed to teach patient handoffs to medical students at the transition between their third and fourth years of training.

Setting

The Handoff Selective was developed by faculty of Denver Health and the University of Colorado Denver School of Medicine.

Program Description

The Selective was first offered in April 2007 as part of an Integrated Clinician's Course (ICC), a 2‐week course for students beginning their fourth year, which starts in April at the University of Colorado. The ICC includes both mandatory and selective sessions that are focused on developing clinical skills and preparing them for their subinternships. The Handoff Selective was conducted in a computerized teaching laboratory, lasted a total of 2 hours and consisted of 2 parts. Each of the 5 Denver Health Hospital Medicine faculty members versed in handoff education taught 2 sessions of 6 to 8 students.

Part 1: Didactic

During the first hour of class, the faculty presented a lecture that summarized the relevant literature on handoffs and explained the importance of the topic. The objectives of the didactic were to: (1) understand the importance of handoffs; (2) explore different communication elements and structures; (3) gain exposure to handoffs outside of healthcare; and (4) learn a structure for handoffs of patient care in hospitalized patients.

We used 3 video clips of handoffs from 2 football games to demonstrate the importance of practice, training, and 2‐way communications in handoffs. The first video clip showed a runner trying to make a spontaneous handoff while being tackled. The receiver was not expecting the handoff and was preoccupied with blocking another player. This attempted handoff resulted in a fumble, which we related to an adverse patient event.

The next 2 video clips showed 2 complex, seldom used, but well‐known football handoffsthe hook and lateral and the Statue of Liberty. Both handoffs were successfully executed presumably as a result of education, practice and the active participation of both players (handing off and receiving) in the process. We then related the teaching and practicing of complex communication to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO; now simply the Joint Commission) data suggesting that most sentinel events have their root cause in communication and training failures.2

Basic communication elements and process structures were then explored using scenarios from everyday life and evidence from fields outside of medicine. We emphasized that structures for communication (modes, vehicles, and settings) must be chosen according to the occasion and that handoffs are common and important in all occupations. In discussing modes (verbal, written, or nonverbal), vehicles (paper, telephone, or e‐mail), and settings (face‐to face, virtual, or disconnected), we emphasized that the most effective structures for communication (verbal, face‐to face meetings, with written materials and other visual aids at the patient's bedside) were also the most time‐consuming (Figure 1). While our standard for resident handoffs is a face‐to‐face verbal interaction with preprinted written materials as an aid, we also emphasized that for complex patients (eg, mental status changes, concern for an acute abdomen) more robust communication is often needed. Accordingly, a more time‐consuming bedside handoff with simultaneous, focused physical exam and history‐taking by both oncoming and off‐going providers may be most appropriate.

Figure 1

As real‐life examples, we asked our students to communicate a happy birthday wish to their mother, who lives in another state. Almost uniformly, in addition to a written aid (birthday card), they choose the telephone as a vehicle for their verbal mode in a virtual setting with 2‐way communication possible. In contrast, when asked to propose marriage to a significant other in another state, students felt that a face‐to‐face meeting with verbal and nonverbal (ie, ring) modes was appropriate. This time‐consuming mode of communication was felt to be necessary to create a sentiment of importance and avert any possible miscommunication.

The didactic session concluded by demonstrating how to use standardized written and verbal templates for handoffs of the care of a hospitalized patient. We explore the differentiation between written and verbal handoffs in our discussion below.

Program Evaluation

We developed a 2‐part survey to evaluate the effectiveness of the Selective and to solicit feedback about the didactic and practicum portions of the course. The first part of the survey (Table 2) contained 16 items to assess the students' knowledge of, and attitudes toward handing off patient care, along with their comfort with the handoff process. Responses to this section were scored using a 5‐point Likert scale with 1 indicating strongly disagree and 5 indicating strongly agree. This part of the survey was administered both prior to and after the Selective.

The second part (Table 3) contained 12 items and was designed to evaluate the perceived usefulness of the different components of the class. This section was only administered at the end of the Selective. It utilized a 4‐point Likert scale with 1 indicating that the component was not useful at all, and 4 indicating that it was extremely useful. The first 6 items of the second section allowed students to evaluate the didactic portion of the handoff. The second 6 items allowed students to evaluate the practicum. Responses to all 12 items were then combined to determine an overall composite usefulness for the Selective.

The Selective was also evaluated qualitatively through the use of open‐ended, written comments that were solicited at the end of the survey. All surveys were administered anonymously.

Results

More students chose the Selective than we had capacity to accommodate (60 of a class of 150). The pre‐ and postcourse survey response rate was 56 of 60 (93%) and 58 of 60 (97%), respectively. After the Selective, the mean score in response to whether handoffs are well taught in medical school increased from 1.6 to 3.5 (P < 0.003). Our students' self‐perceived skills and knowledge about handoffs improved after the Selective (Table 2). The greatest changes in perceived knowledge occurred in questions regarding the what, how, and when of read‐backs, and the knowledge of standard verbal and written handoff structures. The responses to the survey elements which assessed our students' attitudes regarding the importance of standardization and whether they felt handoffs were safer with faculty supervision did not change after the Selective (Table 2).

A total of 92% of the students felt that the course was extremely useful or useful. The role‐playing activity was thought to be more helpful than the didactic, but 84% of the students still rated the didactic portion as useful or extremely useful (Table 3). The element which was the least well received in the didactic portion was the use of video clips to demonstrate successful and unsuccessful (fumbled) college football handoffs, although the majority (64%) of students still found it useful.

The major theme generated from the comments section of the survey was that the Selective should be a required course.

Discussion

We know of no previously published literature that has addressed teaching handoffs to medical students. Horwitz et al.15 developed a sign‐out curriculum for Internal Medicine residents and found that none of their house‐staff had any previous training in handoffs during medical school, consistent with the finding that only 8% of U.S. medical schools provided formal instruction on handoffs.3 Prior to taking the Selective, our students had no knowledge of verbal or written templates for patient handoffs, although both before and after the course they felt that standardization was an important component of the process.

A number of verbal structures for handing off patient care have been described in the literature and there is not a consensus as to which functions best. Perhaps the most cited verbal communication format is SBAR (ie, situation, background, assessment and recommendation).16, 17 This tool was developed by Leonard et al.18 specifically for use by nurses to provide 1‐way communication to physicians pertaining to a change in patient status. We considered teaching the SBAR approach to the students but felt that it did not provide a suitable structure for handoffs because the transfer of care is not generally an event‐based situation and the literature on handoffs indicates that an optimal verbal system includes 2‐way communication.

Additional mnemonics for handoffs found in the literature include SIGNOUT (ie, Sick or DNR, Identifying information, General hospital course, New events of the day, Overall health status, Upcoming possibilities with plan, and Tasks to complete),14 I PASS the BATON (ie, Introduction, Patient, Assessment, Situation, Safety, Background, Actions, Timing, Ownership, Next)19 and the SAIF‐IR system (see boxed text).14

We developed the SAIF‐IR mnemonic to maximize efficiency and effectiveness while differentiating the verbal portion of the handoff from the written and incorporating 2‐way communication into its structure. In the Summary statement, we emphasize that this is not a history of present illness. We ask our students to summarize, in 1 to 3 sentences, the patient's presentation and working diagnosis. When discussing patient issues, we ask our students to only verbalize Active issues, although the written template has inactive, chronic issues listed. Here, we also ask our students to express their level of concern for the active issues and patient in general. If‐then's and Follow‐ups are usually verbalized together. Based on the offgoing provider's knowledge of the patient, we encourage the offgoing provider to anticipate potential problems and advise the oncoming provider on potential responses. Much of this advice is difficult to express in the written format and thus may not be found on the written handoff when the verbal handoff occurs. We encourage oncoming providers to take notes on the preprinted handoff sheet as part of the handoff process.

Through Interactive questioning and Read‐backs, we train our students and house‐staff to use the active listening techniques used outside of healthcare, in settings such as nuclear power plants and National Aeronautics and Space Administration mission control, where poor handoff communication may also result in safety concerns and adverse events.20 Interactive questioning allows the oncoming provider to correct or clarify any information given by the off‐going provider. Read‐backs are a method of confirming follow‐up activity or contingency plans. Together, the SAIF‐IR mnemonic builds a 2‐way communication structure into the patient handoff with both offgoing and oncoming providers having predefined roles.

Much of the information on our written handoff (patient identifying information, medications, language preference, code status, admission date) is not verbalized unless it is part of the active issues or the if‐then, follow‐ups (ie, medication titration for a patient admitted with an acute coronary syndrome or cor status in a patient newly made comfort care). By not reading extraneous information, we seek to emphasize the Active issues as well as the If‐then, Follow‐ups. We feel this emphasis maximizes the effectiveness of the handoff, while the purposeful nonverbalization of written materials such as identifying information maximizes its efficiency. Future work may examine which verbal and written structures for patient handoffs most benefit patient care and workflow through standard communication.

While our students found the Handoff Selective to be useful and to improve their self‐perceived ability to perform handoffs, we were not able to determine whether our program affected downstream outcomes such as adverse events relating to failures in handoff communication. Additionally, since we only taught and evaluated our Selective at the University of Colorado Denver School of Medicine, the response of our students may not generalize to other medical schools. Multicentered, prospective, randomized controlled trials may determine whether handoff education programs are successful in reducing patient adverse events related to transfers of care.

While handoffs occur frequently and are increasingly recognized as a vulnerable time in patient care, little is known about how to effectively teach handoffs to medical students during their clinical years. We developed a formal course to teach the importance of handoffs and how the process should be conducted. Our students reported that the Handoff Selective we developed improved their knowledge about the process and their perception of their ability to perform handoffs in a time‐appropriate and effective manner. In response to the feedback we received from our students, the Handoff Selective is the only course in the ICC that has been made mandatory for all students.

Communication failures are well‐recognized as causes of medical errors.1, 2 Specifically, handoffs of patient care responsibilities, which are increasingly prevalent in academic medical centers,3 have been cited as the most frequent cause of teamwork breakdown resulting in the harmful medical errors found in malpractice claims.1 The Institute of Medicine has recently identified patient handoffs as the moment where patient care errors are most likely to occur.4 A survey of 125 U.S. medical schools, however, found that only 8% specifically taught students how to hand off patient care.3

In July 2003, the American Council of Graduate Medical Education (ACGME) mandated that residency programs decrease resident work hours to improve patient care and safety by reducing fatigue,5 and a recent Institute of Medicine report suggests that they be decreased even further.4 Studies examining outcomes during the first 2 years after reducing duty hours did not find reductions in risk‐adjusted mortality.68 One proposed explanation for this lack of improvement is that the reduction in fatigue‐related medical errors is being offset by discontinuity of care with due to the increased number of patient handoffs resulting from shortened duty hours,911 one recent study found that omission of key information during patient sign outs frequently resulted in adverse patient care outcomes.12

In 2007, the Joint Commission developed a new National Patient Safety Goal that requires organizations to improve communication between caregivers.13 We recently developed an approach by which Internal Medicine residents hand off patient care using a structured process, written and verbal templates, formal training about handoffs, and direct attending supervision.14 Because fourth‐year medical students perform the duties of interns when working as subinterns, we recognized that education about handoffs should occur prior to the time students became interns. Accordingly, we developed a course designed to teach patient handoffs to medical students at the transition between their third and fourth years of training.

Setting

The Handoff Selective was developed by faculty of Denver Health and the University of Colorado Denver School of Medicine.

Program Description

The Selective was first offered in April 2007 as part of an Integrated Clinician's Course (ICC), a 2‐week course for students beginning their fourth year, which starts in April at the University of Colorado. The ICC includes both mandatory and selective sessions that are focused on developing clinical skills and preparing them for their subinternships. The Handoff Selective was conducted in a computerized teaching laboratory, lasted a total of 2 hours and consisted of 2 parts. Each of the 5 Denver Health Hospital Medicine faculty members versed in handoff education taught 2 sessions of 6 to 8 students.

Part 1: Didactic

During the first hour of class, the faculty presented a lecture that summarized the relevant literature on handoffs and explained the importance of the topic. The objectives of the didactic were to: (1) understand the importance of handoffs; (2) explore different communication elements and structures; (3) gain exposure to handoffs outside of healthcare; and (4) learn a structure for handoffs of patient care in hospitalized patients.

We used 3 video clips of handoffs from 2 football games to demonstrate the importance of practice, training, and 2‐way communications in handoffs. The first video clip showed a runner trying to make a spontaneous handoff while being tackled. The receiver was not expecting the handoff and was preoccupied with blocking another player. This attempted handoff resulted in a fumble, which we related to an adverse patient event.

The next 2 video clips showed 2 complex, seldom used, but well‐known football handoffsthe hook and lateral and the Statue of Liberty. Both handoffs were successfully executed presumably as a result of education, practice and the active participation of both players (handing off and receiving) in the process. We then related the teaching and practicing of complex communication to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO; now simply the Joint Commission) data suggesting that most sentinel events have their root cause in communication and training failures.2

Basic communication elements and process structures were then explored using scenarios from everyday life and evidence from fields outside of medicine. We emphasized that structures for communication (modes, vehicles, and settings) must be chosen according to the occasion and that handoffs are common and important in all occupations. In discussing modes (verbal, written, or nonverbal), vehicles (paper, telephone, or e‐mail), and settings (face‐to face, virtual, or disconnected), we emphasized that the most effective structures for communication (verbal, face‐to face meetings, with written materials and other visual aids at the patient's bedside) were also the most time‐consuming (Figure 1). While our standard for resident handoffs is a face‐to‐face verbal interaction with preprinted written materials as an aid, we also emphasized that for complex patients (eg, mental status changes, concern for an acute abdomen) more robust communication is often needed. Accordingly, a more time‐consuming bedside handoff with simultaneous, focused physical exam and history‐taking by both oncoming and off‐going providers may be most appropriate.

Figure 1

As real‐life examples, we asked our students to communicate a happy birthday wish to their mother, who lives in another state. Almost uniformly, in addition to a written aid (birthday card), they choose the telephone as a vehicle for their verbal mode in a virtual setting with 2‐way communication possible. In contrast, when asked to propose marriage to a significant other in another state, students felt that a face‐to‐face meeting with verbal and nonverbal (ie, ring) modes was appropriate. This time‐consuming mode of communication was felt to be necessary to create a sentiment of importance and avert any possible miscommunication.

The didactic session concluded by demonstrating how to use standardized written and verbal templates for handoffs of the care of a hospitalized patient. We explore the differentiation between written and verbal handoffs in our discussion below.

Program Evaluation

We developed a 2‐part survey to evaluate the effectiveness of the Selective and to solicit feedback about the didactic and practicum portions of the course. The first part of the survey (Table 2) contained 16 items to assess the students' knowledge of, and attitudes toward handing off patient care, along with their comfort with the handoff process. Responses to this section were scored using a 5‐point Likert scale with 1 indicating strongly disagree and 5 indicating strongly agree. This part of the survey was administered both prior to and after the Selective.

The second part (Table 3) contained 12 items and was designed to evaluate the perceived usefulness of the different components of the class. This section was only administered at the end of the Selective. It utilized a 4‐point Likert scale with 1 indicating that the component was not useful at all, and 4 indicating that it was extremely useful. The first 6 items of the second section allowed students to evaluate the didactic portion of the handoff. The second 6 items allowed students to evaluate the practicum. Responses to all 12 items were then combined to determine an overall composite usefulness for the Selective.

The Selective was also evaluated qualitatively through the use of open‐ended, written comments that were solicited at the end of the survey. All surveys were administered anonymously.

Results

More students chose the Selective than we had capacity to accommodate (60 of a class of 150). The pre‐ and postcourse survey response rate was 56 of 60 (93%) and 58 of 60 (97%), respectively. After the Selective, the mean score in response to whether handoffs are well taught in medical school increased from 1.6 to 3.5 (P < 0.003). Our students' self‐perceived skills and knowledge about handoffs improved after the Selective (Table 2). The greatest changes in perceived knowledge occurred in questions regarding the what, how, and when of read‐backs, and the knowledge of standard verbal and written handoff structures. The responses to the survey elements which assessed our students' attitudes regarding the importance of standardization and whether they felt handoffs were safer with faculty supervision did not change after the Selective (Table 2).

A total of 92% of the students felt that the course was extremely useful or useful. The role‐playing activity was thought to be more helpful than the didactic, but 84% of the students still rated the didactic portion as useful or extremely useful (Table 3). The element which was the least well received in the didactic portion was the use of video clips to demonstrate successful and unsuccessful (fumbled) college football handoffs, although the majority (64%) of students still found it useful.

The major theme generated from the comments section of the survey was that the Selective should be a required course.

Discussion

We know of no previously published literature that has addressed teaching handoffs to medical students. Horwitz et al.15 developed a sign‐out curriculum for Internal Medicine residents and found that none of their house‐staff had any previous training in handoffs during medical school, consistent with the finding that only 8% of U.S. medical schools provided formal instruction on handoffs.3 Prior to taking the Selective, our students had no knowledge of verbal or written templates for patient handoffs, although both before and after the course they felt that standardization was an important component of the process.

A number of verbal structures for handing off patient care have been described in the literature and there is not a consensus as to which functions best. Perhaps the most cited verbal communication format is SBAR (ie, situation, background, assessment and recommendation).16, 17 This tool was developed by Leonard et al.18 specifically for use by nurses to provide 1‐way communication to physicians pertaining to a change in patient status. We considered teaching the SBAR approach to the students but felt that it did not provide a suitable structure for handoffs because the transfer of care is not generally an event‐based situation and the literature on handoffs indicates that an optimal verbal system includes 2‐way communication.

Additional mnemonics for handoffs found in the literature include SIGNOUT (ie, Sick or DNR, Identifying information, General hospital course, New events of the day, Overall health status, Upcoming possibilities with plan, and Tasks to complete),14 I PASS the BATON (ie, Introduction, Patient, Assessment, Situation, Safety, Background, Actions, Timing, Ownership, Next)19 and the SAIF‐IR system (see boxed text).14

We developed the SAIF‐IR mnemonic to maximize efficiency and effectiveness while differentiating the verbal portion of the handoff from the written and incorporating 2‐way communication into its structure. In the Summary statement, we emphasize that this is not a history of present illness. We ask our students to summarize, in 1 to 3 sentences, the patient's presentation and working diagnosis. When discussing patient issues, we ask our students to only verbalize Active issues, although the written template has inactive, chronic issues listed. Here, we also ask our students to express their level of concern for the active issues and patient in general. If‐then's and Follow‐ups are usually verbalized together. Based on the offgoing provider's knowledge of the patient, we encourage the offgoing provider to anticipate potential problems and advise the oncoming provider on potential responses. Much of this advice is difficult to express in the written format and thus may not be found on the written handoff when the verbal handoff occurs. We encourage oncoming providers to take notes on the preprinted handoff sheet as part of the handoff process.

Through Interactive questioning and Read‐backs, we train our students and house‐staff to use the active listening techniques used outside of healthcare, in settings such as nuclear power plants and National Aeronautics and Space Administration mission control, where poor handoff communication may also result in safety concerns and adverse events.20 Interactive questioning allows the oncoming provider to correct or clarify any information given by the off‐going provider. Read‐backs are a method of confirming follow‐up activity or contingency plans. Together, the SAIF‐IR mnemonic builds a 2‐way communication structure into the patient handoff with both offgoing and oncoming providers having predefined roles.

Much of the information on our written handoff (patient identifying information, medications, language preference, code status, admission date) is not verbalized unless it is part of the active issues or the if‐then, follow‐ups (ie, medication titration for a patient admitted with an acute coronary syndrome or cor status in a patient newly made comfort care). By not reading extraneous information, we seek to emphasize the Active issues as well as the If‐then, Follow‐ups. We feel this emphasis maximizes the effectiveness of the handoff, while the purposeful nonverbalization of written materials such as identifying information maximizes its efficiency. Future work may examine which verbal and written structures for patient handoffs most benefit patient care and workflow through standard communication.

While our students found the Handoff Selective to be useful and to improve their self‐perceived ability to perform handoffs, we were not able to determine whether our program affected downstream outcomes such as adverse events relating to failures in handoff communication. Additionally, since we only taught and evaluated our Selective at the University of Colorado Denver School of Medicine, the response of our students may not generalize to other medical schools. Multicentered, prospective, randomized controlled trials may determine whether handoff education programs are successful in reducing patient adverse events related to transfers of care.

While handoffs occur frequently and are increasingly recognized as a vulnerable time in patient care, little is known about how to effectively teach handoffs to medical students during their clinical years. We developed a formal course to teach the importance of handoffs and how the process should be conducted. Our students reported that the Handoff Selective we developed improved their knowledge about the process and their perception of their ability to perform handoffs in a time‐appropriate and effective manner. In response to the feedback we received from our students, the Handoff Selective is the only course in the ICC that has been made mandatory for all students.

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

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

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

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.

Since its founding in 2006,1 the editors of the Journal of Hospital Medicine (JHM), strongly supported the ethical guidelines and uniform requirements for manuscripts established by the International Committee of Medical Journal Editors (ICMJE).2 These guidelines require authors to verify that they have followed appropriate standards in the conduct of research, meet criteria for authorship, disclose potential conflicts of interest, and respect existing copyrights. With recent publication of editorials in leading medical journals affirming this responsibility for all authors submitting their scholarly work,38 the editors of the Journal echo the importance of following these ethical standards, and wish to update authors and readers on our policies related to authorship and plagiarism.

Disclosure of Competing Interests

Scientific publications commonly require that authors disclose relationships, financial or otherwise, with commercial entities that might have an interest in the subject matter of the article. Historically, biomedical journals varied in the content and format of the information they requested from authors,9 yielding inconsistent reporting by authors depending on the journal. Lack of clarity regarding what relationships authors should report contributed to this variable reporting. For example, an author might submit an article on headache management, and not believe it necessary to report honoraria received from pharmaceutical firms for giving lectures on antibiotic management of pneumonia. Thus, many believed that only funding related to the subject matter in a manuscript needed to be disclosed. While general advice has been to err on the side of disclosure, many authors hesitated to do so.

To clarify and standardize reporting requirements, the ICMJE recommended a uniform format for disclosure of competing interests,3 which was updated recently.10 The document, available online at www.icmje.org asks authors to disclose separately the following types of relationships: (1) financial support to the author or institution for the work being submitted; (2) relevant financial relationships outside the submitted work; and (3) any other relationships or activities that could be perceived as relevant. All ICMJE journals, including the New England Journal of Medicine, JAMA, and Annals of Internal Medicine, now use the uniform disclosure format.

JHM strongly supports the ICMJE uniform requirements for manuscripts and has adopted the new form for disclosure of competing interests. Effective immediately, this documentation will be required for all types of manuscripts submitted to JHM. To help reduce the paperwork burden for authors, this documentation will be required only when authors are invited to revise and resubmit their work, after completion of the initial round of reviews. Typically at this stage, JHM also requests each author complete a Copyright Transfer Agreement (CTA). Thus, when a revision is requested by the Journal, we recommend that the corresponding author have each coauthor concurrently complete the CTA and disclosure of competing interests, and return all of the materials to JHM at the same time.

Criteria for Authorship

Authorship of scientific articles has important professional implications. In a field such as Hospital Medicine which explicitly values teamwork, it can sometimes be unclear which members of a team qualify for authorship on an article that may result from the group's work. The ICMJE provides the following guidance:2

• Authorship credit should be based on (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published. Authors should meet conditions 1, 2, and 3.

The ICMJE notes that authorship is not justified for individuals who simply obtain or provide funding, participate in data collection or general supervision of the research, or serve as head of the group. Members of the team who play roles such as these are more appropriately acknowledged, and their specific contributions noted. The corresponding author should obtain written permission as such acknowledgements may imply endorsement of the work or its conclusions.

Authors, too, should make note of their individual contributions to manuscripts submitted to JHM. The Journal will begin publishing these specific contributions with each article, as do other medical journals.11

Plagiarism

Perhaps the most serious ethical violation that journals confront is plagiarism of copyrighted work. In its 5 years, JHM has detected 4 episodes of plagiarism. Thankfully, the Committee on Publication Ethics (www.publicationethics.org.uk) provides clear guidance on how to manage these situations, and we have managed such cases in accordance with these international guidelines. We began by communicating with the corresponding or senior author, and then escalated to that individual's Chair or director as needed. Cases have ranged from copying of material from a reference text into a Case Report, to duplication of language from another researcher's previously published study. Our reviewers' thorough evaluations of submitted materials and reference lists allowed detection.

We recognize that other journals have needed to handle similar episodes of plagiarism,1215 and that self‐plagiarism (recycling of one's own published text) is also a concern.16, 17 Many methods exist to detect these practices.18 One powerful approach gaining popularity among medical journals utilizes CrossCheck. The CrossCheck service has 2 components: (1) a large, full‐text database of scholarly work from leading publishers, maintained by CrossRef (www.crossref.org); and (2) the iThenticate plagiarism checker (www.iThenticate.com), which compares a submitted manuscript to published work in this database and generates a similarity report. Manuscripts with a high similarity index are then reviewed manually by a member of the editorial staff to determine whether plagiarism has occurred, so that appropriate steps can be taken. JHM has adopted this capability via ScholarOne Manuscripts, the journal's web‐based submission site.

Any form of plagiarism is inexcusable, and, if detected, is immediately addressed. Additionally, any author who submits plagiarized work will be banned from submitting manuscripts to JHM in the future, and will not be allowed to serve the Journal as a reviewer or in any other capacity. Our notification in selected cases of the individual's supervisor or department chair may elicit additional adverse consequences.

Summary

As the Journal of Hospital Medicine continues to grow and evolve, we are extraordinarily grateful when authors choose to submit their scholarly work to us. But growth does not come without challenges and responsibilities, such as a requirement to uphold ethical standards of biomedical publishing. We believe that the uniform disclosure of competing interests, clear reporting of contributions for authorship, and monitoring for plagiarism will help JHM maintain the standards that its readership and contributing authors deserve. We look forward to your contributions during our next 5 years, and beyond.

Since its founding in 2006,1 the editors of the Journal of Hospital Medicine (JHM), strongly supported the ethical guidelines and uniform requirements for manuscripts established by the International Committee of Medical Journal Editors (ICMJE).2 These guidelines require authors to verify that they have followed appropriate standards in the conduct of research, meet criteria for authorship, disclose potential conflicts of interest, and respect existing copyrights. With recent publication of editorials in leading medical journals affirming this responsibility for all authors submitting their scholarly work,38 the editors of the Journal echo the importance of following these ethical standards, and wish to update authors and readers on our policies related to authorship and plagiarism.

Disclosure of Competing Interests

Scientific publications commonly require that authors disclose relationships, financial or otherwise, with commercial entities that might have an interest in the subject matter of the article. Historically, biomedical journals varied in the content and format of the information they requested from authors,9 yielding inconsistent reporting by authors depending on the journal. Lack of clarity regarding what relationships authors should report contributed to this variable reporting. For example, an author might submit an article on headache management, and not believe it necessary to report honoraria received from pharmaceutical firms for giving lectures on antibiotic management of pneumonia. Thus, many believed that only funding related to the subject matter in a manuscript needed to be disclosed. While general advice has been to err on the side of disclosure, many authors hesitated to do so.

To clarify and standardize reporting requirements, the ICMJE recommended a uniform format for disclosure of competing interests,3 which was updated recently.10 The document, available online at www.icmje.org asks authors to disclose separately the following types of relationships: (1) financial support to the author or institution for the work being submitted; (2) relevant financial relationships outside the submitted work; and (3) any other relationships or activities that could be perceived as relevant. All ICMJE journals, including the New England Journal of Medicine, JAMA, and Annals of Internal Medicine, now use the uniform disclosure format.

JHM strongly supports the ICMJE uniform requirements for manuscripts and has adopted the new form for disclosure of competing interests. Effective immediately, this documentation will be required for all types of manuscripts submitted to JHM. To help reduce the paperwork burden for authors, this documentation will be required only when authors are invited to revise and resubmit their work, after completion of the initial round of reviews. Typically at this stage, JHM also requests each author complete a Copyright Transfer Agreement (CTA). Thus, when a revision is requested by the Journal, we recommend that the corresponding author have each coauthor concurrently complete the CTA and disclosure of competing interests, and return all of the materials to JHM at the same time.

Criteria for Authorship

Authorship of scientific articles has important professional implications. In a field such as Hospital Medicine which explicitly values teamwork, it can sometimes be unclear which members of a team qualify for authorship on an article that may result from the group's work. The ICMJE provides the following guidance:2

• Authorship credit should be based on (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published. Authors should meet conditions 1, 2, and 3.

The ICMJE notes that authorship is not justified for individuals who simply obtain or provide funding, participate in data collection or general supervision of the research, or serve as head of the group. Members of the team who play roles such as these are more appropriately acknowledged, and their specific contributions noted. The corresponding author should obtain written permission as such acknowledgements may imply endorsement of the work or its conclusions.

Authors, too, should make note of their individual contributions to manuscripts submitted to JHM. The Journal will begin publishing these specific contributions with each article, as do other medical journals.11

Plagiarism

Perhaps the most serious ethical violation that journals confront is plagiarism of copyrighted work. In its 5 years, JHM has detected 4 episodes of plagiarism. Thankfully, the Committee on Publication Ethics (www.publicationethics.org.uk) provides clear guidance on how to manage these situations, and we have managed such cases in accordance with these international guidelines. We began by communicating with the corresponding or senior author, and then escalated to that individual's Chair or director as needed. Cases have ranged from copying of material from a reference text into a Case Report, to duplication of language from another researcher's previously published study. Our reviewers' thorough evaluations of submitted materials and reference lists allowed detection.

We recognize that other journals have needed to handle similar episodes of plagiarism,1215 and that self‐plagiarism (recycling of one's own published text) is also a concern.16, 17 Many methods exist to detect these practices.18 One powerful approach gaining popularity among medical journals utilizes CrossCheck. The CrossCheck service has 2 components: (1) a large, full‐text database of scholarly work from leading publishers, maintained by CrossRef (www.crossref.org); and (2) the iThenticate plagiarism checker (www.iThenticate.com), which compares a submitted manuscript to published work in this database and generates a similarity report. Manuscripts with a high similarity index are then reviewed manually by a member of the editorial staff to determine whether plagiarism has occurred, so that appropriate steps can be taken. JHM has adopted this capability via ScholarOne Manuscripts, the journal's web‐based submission site.

Any form of plagiarism is inexcusable, and, if detected, is immediately addressed. Additionally, any author who submits plagiarized work will be banned from submitting manuscripts to JHM in the future, and will not be allowed to serve the Journal as a reviewer or in any other capacity. Our notification in selected cases of the individual's supervisor or department chair may elicit additional adverse consequences.

Summary

As the Journal of Hospital Medicine continues to grow and evolve, we are extraordinarily grateful when authors choose to submit their scholarly work to us. But growth does not come without challenges and responsibilities, such as a requirement to uphold ethical standards of biomedical publishing. We believe that the uniform disclosure of competing interests, clear reporting of contributions for authorship, and monitoring for plagiarism will help JHM maintain the standards that its readership and contributing authors deserve. We look forward to your contributions during our next 5 years, and beyond.

Since its founding in 2006,1 the editors of the Journal of Hospital Medicine (JHM), strongly supported the ethical guidelines and uniform requirements for manuscripts established by the International Committee of Medical Journal Editors (ICMJE).2 These guidelines require authors to verify that they have followed appropriate standards in the conduct of research, meet criteria for authorship, disclose potential conflicts of interest, and respect existing copyrights. With recent publication of editorials in leading medical journals affirming this responsibility for all authors submitting their scholarly work,38 the editors of the Journal echo the importance of following these ethical standards, and wish to update authors and readers on our policies related to authorship and plagiarism.

Disclosure of Competing Interests

Scientific publications commonly require that authors disclose relationships, financial or otherwise, with commercial entities that might have an interest in the subject matter of the article. Historically, biomedical journals varied in the content and format of the information they requested from authors,9 yielding inconsistent reporting by authors depending on the journal. Lack of clarity regarding what relationships authors should report contributed to this variable reporting. For example, an author might submit an article on headache management, and not believe it necessary to report honoraria received from pharmaceutical firms for giving lectures on antibiotic management of pneumonia. Thus, many believed that only funding related to the subject matter in a manuscript needed to be disclosed. While general advice has been to err on the side of disclosure, many authors hesitated to do so.

To clarify and standardize reporting requirements, the ICMJE recommended a uniform format for disclosure of competing interests,3 which was updated recently.10 The document, available online at www.icmje.org asks authors to disclose separately the following types of relationships: (1) financial support to the author or institution for the work being submitted; (2) relevant financial relationships outside the submitted work; and (3) any other relationships or activities that could be perceived as relevant. All ICMJE journals, including the New England Journal of Medicine, JAMA, and Annals of Internal Medicine, now use the uniform disclosure format.

JHM strongly supports the ICMJE uniform requirements for manuscripts and has adopted the new form for disclosure of competing interests. Effective immediately, this documentation will be required for all types of manuscripts submitted to JHM. To help reduce the paperwork burden for authors, this documentation will be required only when authors are invited to revise and resubmit their work, after completion of the initial round of reviews. Typically at this stage, JHM also requests each author complete a Copyright Transfer Agreement (CTA). Thus, when a revision is requested by the Journal, we recommend that the corresponding author have each coauthor concurrently complete the CTA and disclosure of competing interests, and return all of the materials to JHM at the same time.

Criteria for Authorship

Authorship of scientific articles has important professional implications. In a field such as Hospital Medicine which explicitly values teamwork, it can sometimes be unclear which members of a team qualify for authorship on an article that may result from the group's work. The ICMJE provides the following guidance:2

• Authorship credit should be based on (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published. Authors should meet conditions 1, 2, and 3.

The ICMJE notes that authorship is not justified for individuals who simply obtain or provide funding, participate in data collection or general supervision of the research, or serve as head of the group. Members of the team who play roles such as these are more appropriately acknowledged, and their specific contributions noted. The corresponding author should obtain written permission as such acknowledgements may imply endorsement of the work or its conclusions.

Authors, too, should make note of their individual contributions to manuscripts submitted to JHM. The Journal will begin publishing these specific contributions with each article, as do other medical journals.11

Plagiarism

Perhaps the most serious ethical violation that journals confront is plagiarism of copyrighted work. In its 5 years, JHM has detected 4 episodes of plagiarism. Thankfully, the Committee on Publication Ethics (www.publicationethics.org.uk) provides clear guidance on how to manage these situations, and we have managed such cases in accordance with these international guidelines. We began by communicating with the corresponding or senior author, and then escalated to that individual's Chair or director as needed. Cases have ranged from copying of material from a reference text into a Case Report, to duplication of language from another researcher's previously published study. Our reviewers' thorough evaluations of submitted materials and reference lists allowed detection.

We recognize that other journals have needed to handle similar episodes of plagiarism,1215 and that self‐plagiarism (recycling of one's own published text) is also a concern.16, 17 Many methods exist to detect these practices.18 One powerful approach gaining popularity among medical journals utilizes CrossCheck. The CrossCheck service has 2 components: (1) a large, full‐text database of scholarly work from leading publishers, maintained by CrossRef (www.crossref.org); and (2) the iThenticate plagiarism checker (www.iThenticate.com), which compares a submitted manuscript to published work in this database and generates a similarity report. Manuscripts with a high similarity index are then reviewed manually by a member of the editorial staff to determine whether plagiarism has occurred, so that appropriate steps can be taken. JHM has adopted this capability via ScholarOne Manuscripts, the journal's web‐based submission site.

Any form of plagiarism is inexcusable, and, if detected, is immediately addressed. Additionally, any author who submits plagiarized work will be banned from submitting manuscripts to JHM in the future, and will not be allowed to serve the Journal as a reviewer or in any other capacity. Our notification in selected cases of the individual's supervisor or department chair may elicit additional adverse consequences.

Summary

As the Journal of Hospital Medicine continues to grow and evolve, we are extraordinarily grateful when authors choose to submit their scholarly work to us. But growth does not come without challenges and responsibilities, such as a requirement to uphold ethical standards of biomedical publishing. We believe that the uniform disclosure of competing interests, clear reporting of contributions for authorship, and monitoring for plagiarism will help JHM maintain the standards that its readership and contributing authors deserve. We look forward to your contributions during our next 5 years, and beyond.