Effective communication among physicians during the hospital discharge process is critical to patient care. Patients are at high risk of having an adverse drug event,1 readmission, or death2 during the transition from hospital to home.3 Ineffective communication between inpatient and outpatient providers has been implicated as a leading cause of adverse events.35 Conversely, efforts to improve communication have been shown to improve compliance with follow‐up tests and decrease readmission rates.6, 7 Recently, the absence of several specific data elements in discharge documentation have been shown to be common and to have potential for patient harm, including test results that are pending at the time of discharge.8, 9 Unexplained discrepancies between preadmission and discharge medication regimens are also common and potentially dangerous.1

According to the Joint Commission for Accreditation of Healthcare Organizations (TJC), the following elements should be included in discharge summaries: the reason for hospitalization; significant findings; procedures performed and care, treatment, and services provided; the patient's condition at discharge; and information provided to the patient and family, as appropriate.10 TJC also advocates medication reconciliation, a process of identifying the most accurate list of all medications a patient is takingincluding name, dosage, frequency, and routeand using this list to provide correct medications for patients anywhere within the health care system.11

Despite the importance of complete communication among providers at hospital discharge, a recent systematic review showed that discharge summaries often lacked important information such as diagnostic test results (missing from 33%‐63%), treatment or hospital course (7%‐22%), discharge medications (2%‐40%), test results pending at discharge (65%), patient or family counseling (90%‐92%), and follow‐up plans (2%‐43%).1

Most of the studies addressing this issue have evaluated communication pitfalls between acute care hospitals and primary care physicians among patients discharged home.17 In contrast, the quality of discharge documentation among patients discharged to rehabilitation centers and other subacute care facilities has been less well studied, perhaps due to relatively smaller numbers of patients discharged to such facilities. This communication is as or more important because these patients are potentially more vulnerable and their medical conditions more active than for patients discharged home.12 Furthermore, discharge information from acute care hospitals will often form the basis for admission orders at subacute facilities. Last, these patients will have a second transition in care (from subacute facility to home) whose quality is dependent at least in part on the quality of communication during the first transition.

The aim of this study was to evaluate the quality of information transfer among patients discharged from acute hospitals to subacute facilities across an integrated healthcare delivery system. The long‐term goals of this effort were to determine the areas most in need of improvement, to guide interventions to address these problems, and to track improvements in these measures over time as interventions are implemented and refined.

Methods

This observational study was conducted as part of a quality improvement project evaluating the quality of information provided during the discharge process across Partners Health Care System. The institutional review boards of the participating institutions approved the study.

Results

A total of 1501 discharge documentation packets were reviewed, including 980 patients (65%) from a medical unit and 521 patients (35%) from a surgical unit. Based on 2007 data, these packets represent approximately 4% of all eligible discharges to subacute facilities. Patients discharged from 1 of the 2 academic medical centers represented 44% of the sample. A total of 644 discharge packets (43%) were reviewed at acute sites and 814 packets (54%) were reviewed at subacute sites. Information about reviewer site was missing in 43 discharge packets (3%). For the 29 charts independently reviewed by 2 reviewers, there was complete agreement for 331 out of 348 data elements (95.1%).

Only 1055 (70%) discharge summaries had all the information required by TJC (Table 2). Physical examination at admission (a component of significant findings, as noted above) and condition at discharge were the 2 elements most often missing. The defect‐free rate varied by site, with a range of 61% to 76% across the 5 acute care hospitals (data not shown).

The rates of inclusion of other (non‐TJC required) data elements are shown in Table 2. Most often missing were preadmission medication regimens, any documented reason for any difference between preadmission and discharge medications, pertinent laboratory results, and an adequate follow‐up plan (including who to follow up with, when to follow‐up, and a list of tasks to be accomplished at the follow‐up visit). Notation regarding significant test results that were pending at the time of transfer was missing in 160 of 341 applicable patients (47%), and in 162 patients (11%), physicians uncovered a significant condition that was not mentioned in the discharge documentation. Only 503 (33.5%) discharge documentation packets had all applicable measures present. In addition, the discharge summary was not received at all on the day of discharge according to the receiving site in 90 patients (6%).

Reviewers were asked in a separate question which missing data were necessary for patient care. Data elements most often cited were explanations for any medication discrepancies and test results pending at the time of the hospital discharge.

Community hospitals had a higher rate of inclusion of TJC‐required data elements when compared to academic medical centers (Table 3). Also, among non‐TJC required data elements, inclusion rates were higher among the community hospitals, especially regarding information about medication discrepancies, pending test results, and follow‐up information (Table 3).

Although no differences were found between medical and surgical services regarding compliance with TJC requirements, a difference was noted in documentation of explanations of medication discrepancies and pending test results, with medical services performing better in both measures (Table 3).

In general, reviewers at subacute sites more often evaluated packets as deficient than reviewers at acute sites, up to an absolute difference of 33% in the proportion of missing data, depending on the data element (see Appendix, Table 1).

Discussion

Our study evaluated the completeness of documentation in the discharge summaries of patients discharged from acute care to subacute care facilities. Our results for the inclusion of TJC‐required data elements were similar to those quoted in the literature for patients discharged home.6 Our results also demonstrated a high rate of other missing data elements that are arguably of equal or greater importance, including reasons for discrepancies between preadmission and discharge medication regimens and tests that are pending at the time of discharge.1, 8, 9 Our results also demonstrated the relatively poorer performance of academic centers compared to community hospitals regarding inclusion of information about medication reconciliation, follow‐up, pending test results, and complete information required by TJC. Finally, we found that patients discharged from surgical services more often lacked documentation of medication discrepancies and pending test results compared with patients from medical services.

To our knowledge, this is one of the first studies looking at the quality of information transfer in patients discharged to subacute care facilities. The results of this study are not surprising given the known problems with general information transfer at hospital discharge.1 The fact that community hospitals provided more complete information than academic medical centers for certain data elements may be due to the difference between residents and more senior physicians preparing discharge documentation. Such differences could reflect differences in experience, training, and degree of appreciation for the importance of discharge documentation, and/or restrictions in work hours among residents (eg, resulting in time‐pressure to complete discharge summaries and/or summaries being written by residents who know the patients less well). These hypotheses deserve further exploration. The differences between medical and surgical services should also be validated and explored in other healthcare systems, including both academic and community settings.

The results of this study should be viewed in light of the study's limitations. Packets evaluated by reviewers at subacute facilities were chosen by the reviewers and may not have been representative of all patients received by that facility (in contrast to those reviewed at the acute sites, which were chosen at random and more likely to be representative, although we did not formally test for this). It is possible that reviewers at subacute sites selected the worst discharge documentation packets for evaluation. Second, evaluations by reviewers at subacute sites did not distinguish between information missing from discharge documentation and failure to receive the documentation at all from the acute care hospital (again in contrast to reviewers at acute sites, who always had access to the documentation). Lastly, reviewers at acute and subacute sites may have graded packets differently due to their different clinical perspectives. These 3 factors may explain the relatively poorer results of discharge packets reviewed by reviewers at subacute sites. Further study would be needed to distinguish among these possibilities (eg, having acute and subacute reviewers answer the same questions for the same discharge packets to allow us to measure interrater reliability between the different kinds of reviewers; explicitly asking subacute reviewers about receipt of each piece of documentation; comparing the distribution of diagnosis‐related group [DRG] codes and hospital length of stay in evaluated vs. total discharge packets as a measure of representativeness). We also cannot rule out the possibility of reviewer bias, but all reviewers were trained in a standardized fashion and we know that reliability of assessments were high, at least among reviewers at acute sites. Last, we did not measure actual or potential adverse events caused by these information deficits.

As part of a Partners‐wide initiative to improve transitions in care, the results were presented to the administrations of each of the 5 acute care hospitals. The Partners High Performance Medicine Transition team then began work with a steering committee (composed of representatives from each hospital) to address these deficiencies. Since then, the hospitals have taken several steps to improve the quality of information transfer for discharged patients, including the following:

• 1

  Technological improvements to the hospitals' discharge ordering systems to actively solicit and/or autoimport the required information into discharge documentation.

• 2

  Creation of discharge templates to record the required information on paper.

• 3

  Provision of feedback to clinicians and their service chiefs regarding the ongoing quality of their discharge documentation.

• 4

  Creation of an online Partners‐wide curriculum on discharge summary authorship, with a mandatory quiz to be taken by all incoming clinicians.

In conclusion, we found room for improvement in the inclusion of data elements required for the safe transfer of patients from acute hospitals to subacute facilities, especially in areas such as medication reconciliation, pending test results, and adequate follow‐up plans. We also found variation by site and type of service. For patients discharged to rehabilitation and other subacute facilities, improvement is needed in the communication of clinically relevant information to those providing continuing care.

Effective communication among physicians during the hospital discharge process is critical to patient care. Patients are at high risk of having an adverse drug event,1 readmission, or death2 during the transition from hospital to home.3 Ineffective communication between inpatient and outpatient providers has been implicated as a leading cause of adverse events.35 Conversely, efforts to improve communication have been shown to improve compliance with follow‐up tests and decrease readmission rates.6, 7 Recently, the absence of several specific data elements in discharge documentation have been shown to be common and to have potential for patient harm, including test results that are pending at the time of discharge.8, 9 Unexplained discrepancies between preadmission and discharge medication regimens are also common and potentially dangerous.1

According to the Joint Commission for Accreditation of Healthcare Organizations (TJC), the following elements should be included in discharge summaries: the reason for hospitalization; significant findings; procedures performed and care, treatment, and services provided; the patient's condition at discharge; and information provided to the patient and family, as appropriate.10 TJC also advocates medication reconciliation, a process of identifying the most accurate list of all medications a patient is takingincluding name, dosage, frequency, and routeand using this list to provide correct medications for patients anywhere within the health care system.11

Despite the importance of complete communication among providers at hospital discharge, a recent systematic review showed that discharge summaries often lacked important information such as diagnostic test results (missing from 33%‐63%), treatment or hospital course (7%‐22%), discharge medications (2%‐40%), test results pending at discharge (65%), patient or family counseling (90%‐92%), and follow‐up plans (2%‐43%).1

Most of the studies addressing this issue have evaluated communication pitfalls between acute care hospitals and primary care physicians among patients discharged home.17 In contrast, the quality of discharge documentation among patients discharged to rehabilitation centers and other subacute care facilities has been less well studied, perhaps due to relatively smaller numbers of patients discharged to such facilities. This communication is as or more important because these patients are potentially more vulnerable and their medical conditions more active than for patients discharged home.12 Furthermore, discharge information from acute care hospitals will often form the basis for admission orders at subacute facilities. Last, these patients will have a second transition in care (from subacute facility to home) whose quality is dependent at least in part on the quality of communication during the first transition.

The aim of this study was to evaluate the quality of information transfer among patients discharged from acute hospitals to subacute facilities across an integrated healthcare delivery system. The long‐term goals of this effort were to determine the areas most in need of improvement, to guide interventions to address these problems, and to track improvements in these measures over time as interventions are implemented and refined.

Methods

This observational study was conducted as part of a quality improvement project evaluating the quality of information provided during the discharge process across Partners Health Care System. The institutional review boards of the participating institutions approved the study.

Results

A total of 1501 discharge documentation packets were reviewed, including 980 patients (65%) from a medical unit and 521 patients (35%) from a surgical unit. Based on 2007 data, these packets represent approximately 4% of all eligible discharges to subacute facilities. Patients discharged from 1 of the 2 academic medical centers represented 44% of the sample. A total of 644 discharge packets (43%) were reviewed at acute sites and 814 packets (54%) were reviewed at subacute sites. Information about reviewer site was missing in 43 discharge packets (3%). For the 29 charts independently reviewed by 2 reviewers, there was complete agreement for 331 out of 348 data elements (95.1%).

Only 1055 (70%) discharge summaries had all the information required by TJC (Table 2). Physical examination at admission (a component of significant findings, as noted above) and condition at discharge were the 2 elements most often missing. The defect‐free rate varied by site, with a range of 61% to 76% across the 5 acute care hospitals (data not shown).

The rates of inclusion of other (non‐TJC required) data elements are shown in Table 2. Most often missing were preadmission medication regimens, any documented reason for any difference between preadmission and discharge medications, pertinent laboratory results, and an adequate follow‐up plan (including who to follow up with, when to follow‐up, and a list of tasks to be accomplished at the follow‐up visit). Notation regarding significant test results that were pending at the time of transfer was missing in 160 of 341 applicable patients (47%), and in 162 patients (11%), physicians uncovered a significant condition that was not mentioned in the discharge documentation. Only 503 (33.5%) discharge documentation packets had all applicable measures present. In addition, the discharge summary was not received at all on the day of discharge according to the receiving site in 90 patients (6%).

Reviewers were asked in a separate question which missing data were necessary for patient care. Data elements most often cited were explanations for any medication discrepancies and test results pending at the time of the hospital discharge.

Community hospitals had a higher rate of inclusion of TJC‐required data elements when compared to academic medical centers (Table 3). Also, among non‐TJC required data elements, inclusion rates were higher among the community hospitals, especially regarding information about medication discrepancies, pending test results, and follow‐up information (Table 3).

Although no differences were found between medical and surgical services regarding compliance with TJC requirements, a difference was noted in documentation of explanations of medication discrepancies and pending test results, with medical services performing better in both measures (Table 3).

In general, reviewers at subacute sites more often evaluated packets as deficient than reviewers at acute sites, up to an absolute difference of 33% in the proportion of missing data, depending on the data element (see Appendix, Table 1).

Discussion

Our study evaluated the completeness of documentation in the discharge summaries of patients discharged from acute care to subacute care facilities. Our results for the inclusion of TJC‐required data elements were similar to those quoted in the literature for patients discharged home.6 Our results also demonstrated a high rate of other missing data elements that are arguably of equal or greater importance, including reasons for discrepancies between preadmission and discharge medication regimens and tests that are pending at the time of discharge.1, 8, 9 Our results also demonstrated the relatively poorer performance of academic centers compared to community hospitals regarding inclusion of information about medication reconciliation, follow‐up, pending test results, and complete information required by TJC. Finally, we found that patients discharged from surgical services more often lacked documentation of medication discrepancies and pending test results compared with patients from medical services.

To our knowledge, this is one of the first studies looking at the quality of information transfer in patients discharged to subacute care facilities. The results of this study are not surprising given the known problems with general information transfer at hospital discharge.1 The fact that community hospitals provided more complete information than academic medical centers for certain data elements may be due to the difference between residents and more senior physicians preparing discharge documentation. Such differences could reflect differences in experience, training, and degree of appreciation for the importance of discharge documentation, and/or restrictions in work hours among residents (eg, resulting in time‐pressure to complete discharge summaries and/or summaries being written by residents who know the patients less well). These hypotheses deserve further exploration. The differences between medical and surgical services should also be validated and explored in other healthcare systems, including both academic and community settings.

The results of this study should be viewed in light of the study's limitations. Packets evaluated by reviewers at subacute facilities were chosen by the reviewers and may not have been representative of all patients received by that facility (in contrast to those reviewed at the acute sites, which were chosen at random and more likely to be representative, although we did not formally test for this). It is possible that reviewers at subacute sites selected the worst discharge documentation packets for evaluation. Second, evaluations by reviewers at subacute sites did not distinguish between information missing from discharge documentation and failure to receive the documentation at all from the acute care hospital (again in contrast to reviewers at acute sites, who always had access to the documentation). Lastly, reviewers at acute and subacute sites may have graded packets differently due to their different clinical perspectives. These 3 factors may explain the relatively poorer results of discharge packets reviewed by reviewers at subacute sites. Further study would be needed to distinguish among these possibilities (eg, having acute and subacute reviewers answer the same questions for the same discharge packets to allow us to measure interrater reliability between the different kinds of reviewers; explicitly asking subacute reviewers about receipt of each piece of documentation; comparing the distribution of diagnosis‐related group [DRG] codes and hospital length of stay in evaluated vs. total discharge packets as a measure of representativeness). We also cannot rule out the possibility of reviewer bias, but all reviewers were trained in a standardized fashion and we know that reliability of assessments were high, at least among reviewers at acute sites. Last, we did not measure actual or potential adverse events caused by these information deficits.

As part of a Partners‐wide initiative to improve transitions in care, the results were presented to the administrations of each of the 5 acute care hospitals. The Partners High Performance Medicine Transition team then began work with a steering committee (composed of representatives from each hospital) to address these deficiencies. Since then, the hospitals have taken several steps to improve the quality of information transfer for discharged patients, including the following:

• 1

  Technological improvements to the hospitals' discharge ordering systems to actively solicit and/or autoimport the required information into discharge documentation.

• 2

  Creation of discharge templates to record the required information on paper.

• 3

  Provision of feedback to clinicians and their service chiefs regarding the ongoing quality of their discharge documentation.

• 4

  Creation of an online Partners‐wide curriculum on discharge summary authorship, with a mandatory quiz to be taken by all incoming clinicians.

In conclusion, we found room for improvement in the inclusion of data elements required for the safe transfer of patients from acute hospitals to subacute facilities, especially in areas such as medication reconciliation, pending test results, and adequate follow‐up plans. We also found variation by site and type of service. For patients discharged to rehabilitation and other subacute facilities, improvement is needed in the communication of clinically relevant information to those providing continuing care.

Effective communication among physicians during the hospital discharge process is critical to patient care. Patients are at high risk of having an adverse drug event,1 readmission, or death2 during the transition from hospital to home.3 Ineffective communication between inpatient and outpatient providers has been implicated as a leading cause of adverse events.35 Conversely, efforts to improve communication have been shown to improve compliance with follow‐up tests and decrease readmission rates.6, 7 Recently, the absence of several specific data elements in discharge documentation have been shown to be common and to have potential for patient harm, including test results that are pending at the time of discharge.8, 9 Unexplained discrepancies between preadmission and discharge medication regimens are also common and potentially dangerous.1

According to the Joint Commission for Accreditation of Healthcare Organizations (TJC), the following elements should be included in discharge summaries: the reason for hospitalization; significant findings; procedures performed and care, treatment, and services provided; the patient's condition at discharge; and information provided to the patient and family, as appropriate.10 TJC also advocates medication reconciliation, a process of identifying the most accurate list of all medications a patient is takingincluding name, dosage, frequency, and routeand using this list to provide correct medications for patients anywhere within the health care system.11

Despite the importance of complete communication among providers at hospital discharge, a recent systematic review showed that discharge summaries often lacked important information such as diagnostic test results (missing from 33%‐63%), treatment or hospital course (7%‐22%), discharge medications (2%‐40%), test results pending at discharge (65%), patient or family counseling (90%‐92%), and follow‐up plans (2%‐43%).1

Most of the studies addressing this issue have evaluated communication pitfalls between acute care hospitals and primary care physicians among patients discharged home.17 In contrast, the quality of discharge documentation among patients discharged to rehabilitation centers and other subacute care facilities has been less well studied, perhaps due to relatively smaller numbers of patients discharged to such facilities. This communication is as or more important because these patients are potentially more vulnerable and their medical conditions more active than for patients discharged home.12 Furthermore, discharge information from acute care hospitals will often form the basis for admission orders at subacute facilities. Last, these patients will have a second transition in care (from subacute facility to home) whose quality is dependent at least in part on the quality of communication during the first transition.

The aim of this study was to evaluate the quality of information transfer among patients discharged from acute hospitals to subacute facilities across an integrated healthcare delivery system. The long‐term goals of this effort were to determine the areas most in need of improvement, to guide interventions to address these problems, and to track improvements in these measures over time as interventions are implemented and refined.

Methods

This observational study was conducted as part of a quality improvement project evaluating the quality of information provided during the discharge process across Partners Health Care System. The institutional review boards of the participating institutions approved the study.

Results

A total of 1501 discharge documentation packets were reviewed, including 980 patients (65%) from a medical unit and 521 patients (35%) from a surgical unit. Based on 2007 data, these packets represent approximately 4% of all eligible discharges to subacute facilities. Patients discharged from 1 of the 2 academic medical centers represented 44% of the sample. A total of 644 discharge packets (43%) were reviewed at acute sites and 814 packets (54%) were reviewed at subacute sites. Information about reviewer site was missing in 43 discharge packets (3%). For the 29 charts independently reviewed by 2 reviewers, there was complete agreement for 331 out of 348 data elements (95.1%).

Only 1055 (70%) discharge summaries had all the information required by TJC (Table 2). Physical examination at admission (a component of significant findings, as noted above) and condition at discharge were the 2 elements most often missing. The defect‐free rate varied by site, with a range of 61% to 76% across the 5 acute care hospitals (data not shown).

The rates of inclusion of other (non‐TJC required) data elements are shown in Table 2. Most often missing were preadmission medication regimens, any documented reason for any difference between preadmission and discharge medications, pertinent laboratory results, and an adequate follow‐up plan (including who to follow up with, when to follow‐up, and a list of tasks to be accomplished at the follow‐up visit). Notation regarding significant test results that were pending at the time of transfer was missing in 160 of 341 applicable patients (47%), and in 162 patients (11%), physicians uncovered a significant condition that was not mentioned in the discharge documentation. Only 503 (33.5%) discharge documentation packets had all applicable measures present. In addition, the discharge summary was not received at all on the day of discharge according to the receiving site in 90 patients (6%).

Reviewers were asked in a separate question which missing data were necessary for patient care. Data elements most often cited were explanations for any medication discrepancies and test results pending at the time of the hospital discharge.

Community hospitals had a higher rate of inclusion of TJC‐required data elements when compared to academic medical centers (Table 3). Also, among non‐TJC required data elements, inclusion rates were higher among the community hospitals, especially regarding information about medication discrepancies, pending test results, and follow‐up information (Table 3).

Although no differences were found between medical and surgical services regarding compliance with TJC requirements, a difference was noted in documentation of explanations of medication discrepancies and pending test results, with medical services performing better in both measures (Table 3).

In general, reviewers at subacute sites more often evaluated packets as deficient than reviewers at acute sites, up to an absolute difference of 33% in the proportion of missing data, depending on the data element (see Appendix, Table 1).

Discussion

Our study evaluated the completeness of documentation in the discharge summaries of patients discharged from acute care to subacute care facilities. Our results for the inclusion of TJC‐required data elements were similar to those quoted in the literature for patients discharged home.6 Our results also demonstrated a high rate of other missing data elements that are arguably of equal or greater importance, including reasons for discrepancies between preadmission and discharge medication regimens and tests that are pending at the time of discharge.1, 8, 9 Our results also demonstrated the relatively poorer performance of academic centers compared to community hospitals regarding inclusion of information about medication reconciliation, follow‐up, pending test results, and complete information required by TJC. Finally, we found that patients discharged from surgical services more often lacked documentation of medication discrepancies and pending test results compared with patients from medical services.

To our knowledge, this is one of the first studies looking at the quality of information transfer in patients discharged to subacute care facilities. The results of this study are not surprising given the known problems with general information transfer at hospital discharge.1 The fact that community hospitals provided more complete information than academic medical centers for certain data elements may be due to the difference between residents and more senior physicians preparing discharge documentation. Such differences could reflect differences in experience, training, and degree of appreciation for the importance of discharge documentation, and/or restrictions in work hours among residents (eg, resulting in time‐pressure to complete discharge summaries and/or summaries being written by residents who know the patients less well). These hypotheses deserve further exploration. The differences between medical and surgical services should also be validated and explored in other healthcare systems, including both academic and community settings.

The results of this study should be viewed in light of the study's limitations. Packets evaluated by reviewers at subacute facilities were chosen by the reviewers and may not have been representative of all patients received by that facility (in contrast to those reviewed at the acute sites, which were chosen at random and more likely to be representative, although we did not formally test for this). It is possible that reviewers at subacute sites selected the worst discharge documentation packets for evaluation. Second, evaluations by reviewers at subacute sites did not distinguish between information missing from discharge documentation and failure to receive the documentation at all from the acute care hospital (again in contrast to reviewers at acute sites, who always had access to the documentation). Lastly, reviewers at acute and subacute sites may have graded packets differently due to their different clinical perspectives. These 3 factors may explain the relatively poorer results of discharge packets reviewed by reviewers at subacute sites. Further study would be needed to distinguish among these possibilities (eg, having acute and subacute reviewers answer the same questions for the same discharge packets to allow us to measure interrater reliability between the different kinds of reviewers; explicitly asking subacute reviewers about receipt of each piece of documentation; comparing the distribution of diagnosis‐related group [DRG] codes and hospital length of stay in evaluated vs. total discharge packets as a measure of representativeness). We also cannot rule out the possibility of reviewer bias, but all reviewers were trained in a standardized fashion and we know that reliability of assessments were high, at least among reviewers at acute sites. Last, we did not measure actual or potential adverse events caused by these information deficits.

As part of a Partners‐wide initiative to improve transitions in care, the results were presented to the administrations of each of the 5 acute care hospitals. The Partners High Performance Medicine Transition team then began work with a steering committee (composed of representatives from each hospital) to address these deficiencies. Since then, the hospitals have taken several steps to improve the quality of information transfer for discharged patients, including the following:

• 1

  Technological improvements to the hospitals' discharge ordering systems to actively solicit and/or autoimport the required information into discharge documentation.

• 2

  Creation of discharge templates to record the required information on paper.

• 3

  Provision of feedback to clinicians and their service chiefs regarding the ongoing quality of their discharge documentation.

• 4

  Creation of an online Partners‐wide curriculum on discharge summary authorship, with a mandatory quiz to be taken by all incoming clinicians.

In conclusion, we found room for improvement in the inclusion of data elements required for the safe transfer of patients from acute hospitals to subacute facilities, especially in areas such as medication reconciliation, pending test results, and adequate follow‐up plans. We also found variation by site and type of service. For patients discharged to rehabilitation and other subacute facilities, improvement is needed in the communication of clinically relevant information to those providing continuing care.

Insulin is designated a high‐alert medication because of its potential to result in harm if it is used incorrectly.1 Despite this, changes in insulin regimens made in the inpatient setting are often poorly communicated to either the patient or his primary care physician at the time of discharge.2 Poor communication of medication instructions at the time of hospital discharge has been linked to medication errors and adverse drug events.3

We conducted a quality improvement project to improve and standardize the communication of insulin instructions to patients (and/or their caregivers) at hospital discharge. Specifically, we developed and implemented a standardized discharge instructions for insulin (DIFI) form and compared the comprehensiveness of insulin instructions and diabetes‐related readmissions before and after the introduction of the form.

Methods

A multidisciplinary team4 created the DIFI form. Page 1 (Figure 1) includes sections for entering all insulin types and doses and the frequency of glucose monitoring and a space for specific diabetes instructions. Page 2 provides general information on symptom recognition and management of hyperglycemia and hypoglycemia. Page 3 is a blank glucose log.

Figure 1

We retrospectively reviewed the records of patients discharged to home on insulin from a general medicine unit during the 3‐month period before availability of the DIFI form and during the 3‐month period afterward. Approval for this project was obtained from the hospital's quality improvement review committee. The percentages of orders with specific instructions for the timing and dosing of basal, prandial, and correction insulin and home glucose monitoring were calculated. The number of patients readmitted within 2 weeks of discharge for a diabetes‐related problem was also determined. Fisher's exact tests were used to compare demographics and indicators in the preimplementation and postimplementation groups.

Results

Chart review was performed for 67 patients with insulin orders at discharge prior to the DIFI form and for 27 patients after implementation. There were no group differences in gender (female gender: 63% pre‐DIFI vs. 63% post‐DIFI, P = 0.49), previous history of diabetes (98.5% vs. 92.6%, P = 0.20), diabetes‐related admitting diagnosis (20.1% vs. 37%, P = 0.12), or insulin use prior to admission (95.5% vs. 85.2%, P = 0.10).

More orders written with the DIFI form contained specific instructions for timing and dosing of basal (67% vs. 100%, P = 0.0003), prandial (51% vs. 100%, P = 0.0008), and correction insulin (14% vs. 95%, P < 0.0001) and for glucose monitoring (17.9% vs. 88.9%, P < 0.0001). There were 4 diabetes‐related readmissions in the preimplementation group and none in the postimplementation group (P = not significant).

Discussion

It is important that patients receive clear directions at the time of hospital discharge to ensure a safe transition of care from the inpatient setting to the outpatient setting. This is particularly true for insulin regimens, which frequently consist of at least 2 different types of insulin and often include instructions for modifying doses on the basis of home glucose readings. The day of hospital discharge is not conducive to recall of verbal communication concerning complicated medication regimens.5 Additionally, our hospital's standard discharge form was not a satisfactory tool for providing detailed directions. We found that the DIFI form prompted a more consistent provision of specific instructions for insulin therapy and glucose monitoring in comparison with previous practice.

Insulin is designated a high‐alert medication because of its potential to result in harm if it is used incorrectly.1 Despite this, changes in insulin regimens made in the inpatient setting are often poorly communicated to either the patient or his primary care physician at the time of discharge.2 Poor communication of medication instructions at the time of hospital discharge has been linked to medication errors and adverse drug events.3

We conducted a quality improvement project to improve and standardize the communication of insulin instructions to patients (and/or their caregivers) at hospital discharge. Specifically, we developed and implemented a standardized discharge instructions for insulin (DIFI) form and compared the comprehensiveness of insulin instructions and diabetes‐related readmissions before and after the introduction of the form.

Methods

A multidisciplinary team4 created the DIFI form. Page 1 (Figure 1) includes sections for entering all insulin types and doses and the frequency of glucose monitoring and a space for specific diabetes instructions. Page 2 provides general information on symptom recognition and management of hyperglycemia and hypoglycemia. Page 3 is a blank glucose log.

Figure 1

We retrospectively reviewed the records of patients discharged to home on insulin from a general medicine unit during the 3‐month period before availability of the DIFI form and during the 3‐month period afterward. Approval for this project was obtained from the hospital's quality improvement review committee. The percentages of orders with specific instructions for the timing and dosing of basal, prandial, and correction insulin and home glucose monitoring were calculated. The number of patients readmitted within 2 weeks of discharge for a diabetes‐related problem was also determined. Fisher's exact tests were used to compare demographics and indicators in the preimplementation and postimplementation groups.

Results

Chart review was performed for 67 patients with insulin orders at discharge prior to the DIFI form and for 27 patients after implementation. There were no group differences in gender (female gender: 63% pre‐DIFI vs. 63% post‐DIFI, P = 0.49), previous history of diabetes (98.5% vs. 92.6%, P = 0.20), diabetes‐related admitting diagnosis (20.1% vs. 37%, P = 0.12), or insulin use prior to admission (95.5% vs. 85.2%, P = 0.10).

More orders written with the DIFI form contained specific instructions for timing and dosing of basal (67% vs. 100%, P = 0.0003), prandial (51% vs. 100%, P = 0.0008), and correction insulin (14% vs. 95%, P < 0.0001) and for glucose monitoring (17.9% vs. 88.9%, P < 0.0001). There were 4 diabetes‐related readmissions in the preimplementation group and none in the postimplementation group (P = not significant).

Discussion

It is important that patients receive clear directions at the time of hospital discharge to ensure a safe transition of care from the inpatient setting to the outpatient setting. This is particularly true for insulin regimens, which frequently consist of at least 2 different types of insulin and often include instructions for modifying doses on the basis of home glucose readings. The day of hospital discharge is not conducive to recall of verbal communication concerning complicated medication regimens.5 Additionally, our hospital's standard discharge form was not a satisfactory tool for providing detailed directions. We found that the DIFI form prompted a more consistent provision of specific instructions for insulin therapy and glucose monitoring in comparison with previous practice.

Insulin is designated a high‐alert medication because of its potential to result in harm if it is used incorrectly.1 Despite this, changes in insulin regimens made in the inpatient setting are often poorly communicated to either the patient or his primary care physician at the time of discharge.2 Poor communication of medication instructions at the time of hospital discharge has been linked to medication errors and adverse drug events.3

We conducted a quality improvement project to improve and standardize the communication of insulin instructions to patients (and/or their caregivers) at hospital discharge. Specifically, we developed and implemented a standardized discharge instructions for insulin (DIFI) form and compared the comprehensiveness of insulin instructions and diabetes‐related readmissions before and after the introduction of the form.

Methods

A multidisciplinary team4 created the DIFI form. Page 1 (Figure 1) includes sections for entering all insulin types and doses and the frequency of glucose monitoring and a space for specific diabetes instructions. Page 2 provides general information on symptom recognition and management of hyperglycemia and hypoglycemia. Page 3 is a blank glucose log.

Figure 1

We retrospectively reviewed the records of patients discharged to home on insulin from a general medicine unit during the 3‐month period before availability of the DIFI form and during the 3‐month period afterward. Approval for this project was obtained from the hospital's quality improvement review committee. The percentages of orders with specific instructions for the timing and dosing of basal, prandial, and correction insulin and home glucose monitoring were calculated. The number of patients readmitted within 2 weeks of discharge for a diabetes‐related problem was also determined. Fisher's exact tests were used to compare demographics and indicators in the preimplementation and postimplementation groups.

Results

Chart review was performed for 67 patients with insulin orders at discharge prior to the DIFI form and for 27 patients after implementation. There were no group differences in gender (female gender: 63% pre‐DIFI vs. 63% post‐DIFI, P = 0.49), previous history of diabetes (98.5% vs. 92.6%, P = 0.20), diabetes‐related admitting diagnosis (20.1% vs. 37%, P = 0.12), or insulin use prior to admission (95.5% vs. 85.2%, P = 0.10).

More orders written with the DIFI form contained specific instructions for timing and dosing of basal (67% vs. 100%, P = 0.0003), prandial (51% vs. 100%, P = 0.0008), and correction insulin (14% vs. 95%, P < 0.0001) and for glucose monitoring (17.9% vs. 88.9%, P < 0.0001). There were 4 diabetes‐related readmissions in the preimplementation group and none in the postimplementation group (P = not significant).

Discussion

It is important that patients receive clear directions at the time of hospital discharge to ensure a safe transition of care from the inpatient setting to the outpatient setting. This is particularly true for insulin regimens, which frequently consist of at least 2 different types of insulin and often include instructions for modifying doses on the basis of home glucose readings. The day of hospital discharge is not conducive to recall of verbal communication concerning complicated medication regimens.5 Additionally, our hospital's standard discharge form was not a satisfactory tool for providing detailed directions. We found that the DIFI form prompted a more consistent provision of specific instructions for insulin therapy and glucose monitoring in comparison with previous practice.

The United States spends a larger share of its gross domestic product (GDP) on healthcare than any other major industrialized country.1 Expenditures for healthcare represent nearly one‐seventh of the nation's GDP, and they continue to be one of the fastest growing components of the federal budget.1 Drug expenditures are one of the most rapidly growing components of total healthcare expenditures.2 Two of the biggest drivers behind this explosive growth of rising drug expenditures are price and use.2, 3

Acid‐suppressive therapy (AST), including histamine‐2 (H2) receptor antagonists and proton pump inhibitors (PPIs), is used extensively in the hospitalized population.4 One of the most common uses of AST in hospitalized patients has been in preventing gastric mucosal damage and bleeding.5 However, published data suggest that the use of AST will be beneficial only in a well‐defined group of critical care patients in preventing stress ulcers and bleeding.68 This perception of benefit has been extrapolated to hospitalized patients in general, with little or no evidence to support its use.7, 9

There have only been limited studies on the overall use or the appropriateness of use of AST in hospitalized patients.7, 9 Also, there have been no studies that have looked at patient or physician factors which can predict the appropriateness of initiation and use of AST in hospitalized patients. The aim of our study was to identify:

• 1

  The appropriateness of acid suppressive therapy in hospitalized patients admitted to a tertiary teaching institution and the associated cost of inappropriate AST use to the patient.

• 2

  Patient and physician characteristics which can predict the inappropriate initiation and use of AST in patients.

Methods

This study was conducted at a 308‐bed tertiary academic medical center. On an average, there are approximately 800 to 1000 discharges every month from this hospital. All consecutive discharges over a period of 8 consecutive days were selected for inclusion in the study. All patients were assessed for the use of AST during their hospitalization. Use was defined as any prescription of an acid‐suppressive medication, regardless of dosage regimen, in which the patient received at least 1 dose during their hospitalization.7 The class of agents prescribed for AST was also noted. Ranitidine is the preferred H2 receptor antagonist and pantoprazole is the preferred PPI on the hospital formulary. It was also recorded whether the patient was on the medication at the time of admission. If the patient was on AST prior to admission, the records of the patient were reviewed for the indication for initiation of the AST. The discharge records of all these patients were also reviewed to determine if the patient was continued on AST even after discharge. Patients who were readmitted during the study period were not recounted.

Since the aim of our study was to evaluate the inappropriate initiation of AST in hospitalized patients, the following patients were excluded from the analysis: patients who were on AST prior to admission; patients who had a valid therapeutic indication for AST; and patients who met valid therapeutic indications for AST, such as intensive care unit (ICU) transfers.

Two physicians reviewed the records in order to determine whether there was any indication for AST use. If there was discordance between the 2 physicians, a third physician reviewed the records to assess the appropriateness of AST. Patient and prescribing physician characteristics were collected to assess the predictors of the use of AST.

We used the guidelines published by the American Society of Health‐System Pharmacists (ASHP) to determine appropriateness of gastrointestinal (GI) prophylaxis in patients.10

GI prophylaxis was defined as appropriate if: Patient was in the ICU plus 1 of the following10:

• 1

  Coagulopathy (ie, platelet count of <50,000 mm³ or international normalized ratio of 1.5, or an activated partial thromboplastin 2 times normal);

• 2

  Mechanical ventilation for >48 hours;

• 3

  History of GI ulceration or bleeding within 1 year of admission;

• 4

  Glasgow coma score of 10;

• 5

  Thermal injury to >35% of body surface area;

• 6

  Partial hepatectomy;

• 7

  Multiple trauma (injury severity score of 16);

• 8

  Transplantation perioperatively in the ICU;

• 9

  Spinal cord injury;

• 10

  Hepatic failure;

• 11

  Two or more of the following risk factors: sepsis; ICU stay of >1 week; occult bleeding lasting at least 6 days; and high‐dose corticosteroids (>250 mg/day of hydrocortisone or equivalent steroid).

Other indications for the appropriate use of AST were as follows: any documentation of current or past gastroesophageal reflux disease (GERD); active peptic ulcer disease or maintenance therapy in patients with peptic ulcer disease; treatment of esophagitis/gastritis/duodenitis; or patients admitted with upper GI bleeding or melena.

Ranitidine is the preferred H2 receptor antagonist used at this medical center. The cost to the patient of oral ranitidine was $8.54 per day while the cost of intravenous therapy was $135.00 per day. Pantoprazole is the preferred PPI used in this hospital. The cost of oral pantoprazole was $10.57 per day while the cost of intravenous therapy was $57.00 per day (Dr. Joel Reddish, PharmD, Truman Medical Center, Kansas City, MO; Pharmacy Staff; personal communication, September 25, 2007). The cost of intravenous ranitidine was higher than intravenous pantoprazole since ranitidine had to be infused 3 times per day. The cost of AST was calculated by calculating the total number of days during the admission the person was on AST.

Results

There were 207 patients in our study cohort. Of the 207 patients, 103 (49.8%) were males and 71 (34.3%) were Caucasians. Of the 207 patients, AST was used in 164 (79.2%) of the patients. PPI therapy was used in 126 (60.9%) of the patients while 38 (18.4%) of the patients were put on H2 receptor antagonists. In the study cohort, 51 (24.6%) of the patients had a current or a past diagnosis of GERD. Of the 207 patients, 35 patients were on a PPI prior to admission and 16 were on a H2 blocker prior to admission. Table 1 describes the demographic characteristics of the patients.

The most common primary admitting diagnosis was either cardiovascular or gastrointestinal. Table 2 outlines the most common admitting diagnoses of the patients.

To determine the predictors of inappropriate initiation of AST in hospitalized patients, excluding the patients as described in the Methods section, there were 133 patients who met the inclusion criteria for analysis. The reason for inappropriate use of AST in all of the 133 patients included for analysis in our study was for stress ulcer prophylaxis in low‐risk patients. AST was inappropriately used in 92 of the 133 patients (69.2%). On univariate analysis, physician characteristics predictive for inappropriate AST use were being in an early stage of training, physicians in the medicine specialty and physicians who were international medical graduates (Table 3). As far as patient characteristics were concerned, only a higher hemoglobin value was associated with the inappropriate use of AST (see Table 3 for details).

On multivariate analysis, as far as patient characteristics were concerned only a higher hemoglobin value was associated with inappropriate AST use. Residents who were in their first year of training as well as physicians with a MD degree were more likely to prescribe AST inappropriately (Table 4).

The direct calculated patient cost for AST during this time period was $8026. The estimated projected cost for AST over a period of 1 year was $366,000.

Out of the 92 patients in whom AST was used inappropriately, 6 (6.5%) of the patients were discharged on an H2 receptor antagonist while 7 (7.6%) of the patients were discharged on PPI therapy.

Discussion

Prescription drug expenditures are the most rapidly growing component of health care expenditures.2 Two of the biggest drivers behind this explosive growth of rising drug expenditures are price and use.2, 3 PPIs have constantly figured in the national top 20 drug lists for dispensed prescription and drug sales.2

This study found a very high frequency of overuse of acid suppressive therapy in hospitalized patients for stress ulcer prophylaxis. Unfortunately, a large majority (69.2%) of these patients were not at an increased risk of stress‐related mucosal ulceration. One of the reasons for this widespread use of AST is the overestimation of the risk of stress‐related mucosal ulceration in hospitalized patients. However, the fear of stress‐ulcer bleeding seems to largely unjustified, as overall rates of bleeding, as reported previously, have been very low.11 Our results are consistent with the few reports on the overuse of AST reported previously. Nardino et al.,7 in a study of 226 patients, found that 65% of the patients received AST inappropriately. Also in a study from Italy, Parente et al.9 found, in a cohort of 799 hospitalized patients, 68% of the prescriptions for AST were not appropriate.

To date, there has been limited information available on the prescribing characteristics of the physicians, which may help to clarify the inappropriate use of AST. This study was conducted at a tertiary academic medical center and all the admissions are done by residents. This study is the first study that has tried to examine the physician and patient characteristics behind this phenomenon. In multivariate analysis, we found that residents who were in their first year of residency training were more likely to initiate AST inappropriately. This could be secondary to the fact that most of the residents in their first year of training are given blanket orders to put all patients on stress‐ulcer prophylaxis. In a study done by Liberman and Whelan12 at the University of Chicago Hospitals, it was found that house officers learned about stress‐ulcer prophylaxis from their supervising residents. Thus, it is possible that as residents progress through their training, the incidence of inappropriate initiation of stress ulcer prophylaxis decreases. We also found that physicians with an MD degree were more likely to initiate AST inappropriately. The reason behind this not clear, though there may be a difference in the medical education that possibly contributes to this.

One curious finding that was associated with an increased use of AST was a higher hemoglobin level. One possibility is that patients with a low hemoglobin value were more likely to be put on AST appropriately. This could be the reason behind the association of a higher hemoglobin value with inappropriate AST use.

One of the reasons for the widespread use of AST is that most practitioners view AST as harmless.6 However, the use of AST is not without risks. Multiple studies in the past have found an increased risk of Clostridium difficileassociated disease in patients on AST.1316 Also, AST has been associated with an increased risk of community‐acquired pneumonia17 as well as a risk of hip fractures.18 These studies demonstrate that the use of AST is not without its risks and there is a potential for increased morbidity as well as indirect costs for the patient and the community as a whole associated with its use.

The direct cost for this inappropriate use of AST over a period of 8 days was $8026 in our study, with an estimated annual cost close to $366,000. This did not include the cost of patients who were discharged inappropriately with AST. Also, this did not include the indirect costs including the increased risk of community‐acquired pneumonias, hip fractures, and Clostridium infections. Thus, it is possible that the costs of inappropriate use of AST may be much higher than reported.

One of the limitations of our study was that this study was conducted at a single teaching hospital; thus, it is possible that the results could be biased by the prescribing habits of a relatively few physicians. However, since we looked at all specialties, we had a large cohort of physicians in our study. Also, previous multicenter studies as well as single center studies have demonstrated similar results in terms of overprescription.7, 9, 19 Also, the economic impact has been calculated by assessing the cost that is billed to the patients. This may be different from the cost of the medicines to the hospital and insurers.

Conclusions

AST was inappropriately used in 69.2% of the patients studied, leading to an increased direct patient cost of $8026 and projected estimated direct healthcare costs of approximately $366,000 over 1 year. Residents in their first year of training and physicians with an MD degree are more likely to initiate AST inappropriately in patients. Curtailing the inappropriate use of AST therapy may reduce overall costs for the patient and institution.

The United States spends a larger share of its gross domestic product (GDP) on healthcare than any other major industrialized country.1 Expenditures for healthcare represent nearly one‐seventh of the nation's GDP, and they continue to be one of the fastest growing components of the federal budget.1 Drug expenditures are one of the most rapidly growing components of total healthcare expenditures.2 Two of the biggest drivers behind this explosive growth of rising drug expenditures are price and use.2, 3

Acid‐suppressive therapy (AST), including histamine‐2 (H2) receptor antagonists and proton pump inhibitors (PPIs), is used extensively in the hospitalized population.4 One of the most common uses of AST in hospitalized patients has been in preventing gastric mucosal damage and bleeding.5 However, published data suggest that the use of AST will be beneficial only in a well‐defined group of critical care patients in preventing stress ulcers and bleeding.68 This perception of benefit has been extrapolated to hospitalized patients in general, with little or no evidence to support its use.7, 9

There have only been limited studies on the overall use or the appropriateness of use of AST in hospitalized patients.7, 9 Also, there have been no studies that have looked at patient or physician factors which can predict the appropriateness of initiation and use of AST in hospitalized patients. The aim of our study was to identify:

• 1

  The appropriateness of acid suppressive therapy in hospitalized patients admitted to a tertiary teaching institution and the associated cost of inappropriate AST use to the patient.

• 2

  Patient and physician characteristics which can predict the inappropriate initiation and use of AST in patients.

Methods

This study was conducted at a 308‐bed tertiary academic medical center. On an average, there are approximately 800 to 1000 discharges every month from this hospital. All consecutive discharges over a period of 8 consecutive days were selected for inclusion in the study. All patients were assessed for the use of AST during their hospitalization. Use was defined as any prescription of an acid‐suppressive medication, regardless of dosage regimen, in which the patient received at least 1 dose during their hospitalization.7 The class of agents prescribed for AST was also noted. Ranitidine is the preferred H2 receptor antagonist and pantoprazole is the preferred PPI on the hospital formulary. It was also recorded whether the patient was on the medication at the time of admission. If the patient was on AST prior to admission, the records of the patient were reviewed for the indication for initiation of the AST. The discharge records of all these patients were also reviewed to determine if the patient was continued on AST even after discharge. Patients who were readmitted during the study period were not recounted.

Since the aim of our study was to evaluate the inappropriate initiation of AST in hospitalized patients, the following patients were excluded from the analysis: patients who were on AST prior to admission; patients who had a valid therapeutic indication for AST; and patients who met valid therapeutic indications for AST, such as intensive care unit (ICU) transfers.

Two physicians reviewed the records in order to determine whether there was any indication for AST use. If there was discordance between the 2 physicians, a third physician reviewed the records to assess the appropriateness of AST. Patient and prescribing physician characteristics were collected to assess the predictors of the use of AST.

We used the guidelines published by the American Society of Health‐System Pharmacists (ASHP) to determine appropriateness of gastrointestinal (GI) prophylaxis in patients.10

GI prophylaxis was defined as appropriate if: Patient was in the ICU plus 1 of the following10:

• 1

  Coagulopathy (ie, platelet count of <50,000 mm³ or international normalized ratio of 1.5, or an activated partial thromboplastin 2 times normal);

• 2

  Mechanical ventilation for >48 hours;

• 3

  History of GI ulceration or bleeding within 1 year of admission;

• 4

  Glasgow coma score of 10;

• 5

  Thermal injury to >35% of body surface area;

• 6

  Partial hepatectomy;

• 7

  Multiple trauma (injury severity score of 16);

• 8

  Transplantation perioperatively in the ICU;

• 9

  Spinal cord injury;

• 10

  Hepatic failure;

• 11

  Two or more of the following risk factors: sepsis; ICU stay of >1 week; occult bleeding lasting at least 6 days; and high‐dose corticosteroids (>250 mg/day of hydrocortisone or equivalent steroid).

Other indications for the appropriate use of AST were as follows: any documentation of current or past gastroesophageal reflux disease (GERD); active peptic ulcer disease or maintenance therapy in patients with peptic ulcer disease; treatment of esophagitis/gastritis/duodenitis; or patients admitted with upper GI bleeding or melena.

Ranitidine is the preferred H2 receptor antagonist used at this medical center. The cost to the patient of oral ranitidine was $8.54 per day while the cost of intravenous therapy was $135.00 per day. Pantoprazole is the preferred PPI used in this hospital. The cost of oral pantoprazole was $10.57 per day while the cost of intravenous therapy was $57.00 per day (Dr. Joel Reddish, PharmD, Truman Medical Center, Kansas City, MO; Pharmacy Staff; personal communication, September 25, 2007). The cost of intravenous ranitidine was higher than intravenous pantoprazole since ranitidine had to be infused 3 times per day. The cost of AST was calculated by calculating the total number of days during the admission the person was on AST.

Results

There were 207 patients in our study cohort. Of the 207 patients, 103 (49.8%) were males and 71 (34.3%) were Caucasians. Of the 207 patients, AST was used in 164 (79.2%) of the patients. PPI therapy was used in 126 (60.9%) of the patients while 38 (18.4%) of the patients were put on H2 receptor antagonists. In the study cohort, 51 (24.6%) of the patients had a current or a past diagnosis of GERD. Of the 207 patients, 35 patients were on a PPI prior to admission and 16 were on a H2 blocker prior to admission. Table 1 describes the demographic characteristics of the patients.

The most common primary admitting diagnosis was either cardiovascular or gastrointestinal. Table 2 outlines the most common admitting diagnoses of the patients.

To determine the predictors of inappropriate initiation of AST in hospitalized patients, excluding the patients as described in the Methods section, there were 133 patients who met the inclusion criteria for analysis. The reason for inappropriate use of AST in all of the 133 patients included for analysis in our study was for stress ulcer prophylaxis in low‐risk patients. AST was inappropriately used in 92 of the 133 patients (69.2%). On univariate analysis, physician characteristics predictive for inappropriate AST use were being in an early stage of training, physicians in the medicine specialty and physicians who were international medical graduates (Table 3). As far as patient characteristics were concerned, only a higher hemoglobin value was associated with the inappropriate use of AST (see Table 3 for details).

On multivariate analysis, as far as patient characteristics were concerned only a higher hemoglobin value was associated with inappropriate AST use. Residents who were in their first year of training as well as physicians with a MD degree were more likely to prescribe AST inappropriately (Table 4).

The direct calculated patient cost for AST during this time period was $8026. The estimated projected cost for AST over a period of 1 year was $366,000.

Out of the 92 patients in whom AST was used inappropriately, 6 (6.5%) of the patients were discharged on an H2 receptor antagonist while 7 (7.6%) of the patients were discharged on PPI therapy.

Discussion

Prescription drug expenditures are the most rapidly growing component of health care expenditures.2 Two of the biggest drivers behind this explosive growth of rising drug expenditures are price and use.2, 3 PPIs have constantly figured in the national top 20 drug lists for dispensed prescription and drug sales.2

This study found a very high frequency of overuse of acid suppressive therapy in hospitalized patients for stress ulcer prophylaxis. Unfortunately, a large majority (69.2%) of these patients were not at an increased risk of stress‐related mucosal ulceration. One of the reasons for this widespread use of AST is the overestimation of the risk of stress‐related mucosal ulceration in hospitalized patients. However, the fear of stress‐ulcer bleeding seems to largely unjustified, as overall rates of bleeding, as reported previously, have been very low.11 Our results are consistent with the few reports on the overuse of AST reported previously. Nardino et al.,7 in a study of 226 patients, found that 65% of the patients received AST inappropriately. Also in a study from Italy, Parente et al.9 found, in a cohort of 799 hospitalized patients, 68% of the prescriptions for AST were not appropriate.

To date, there has been limited information available on the prescribing characteristics of the physicians, which may help to clarify the inappropriate use of AST. This study was conducted at a tertiary academic medical center and all the admissions are done by residents. This study is the first study that has tried to examine the physician and patient characteristics behind this phenomenon. In multivariate analysis, we found that residents who were in their first year of residency training were more likely to initiate AST inappropriately. This could be secondary to the fact that most of the residents in their first year of training are given blanket orders to put all patients on stress‐ulcer prophylaxis. In a study done by Liberman and Whelan12 at the University of Chicago Hospitals, it was found that house officers learned about stress‐ulcer prophylaxis from their supervising residents. Thus, it is possible that as residents progress through their training, the incidence of inappropriate initiation of stress ulcer prophylaxis decreases. We also found that physicians with an MD degree were more likely to initiate AST inappropriately. The reason behind this not clear, though there may be a difference in the medical education that possibly contributes to this.

One curious finding that was associated with an increased use of AST was a higher hemoglobin level. One possibility is that patients with a low hemoglobin value were more likely to be put on AST appropriately. This could be the reason behind the association of a higher hemoglobin value with inappropriate AST use.

One of the reasons for the widespread use of AST is that most practitioners view AST as harmless.6 However, the use of AST is not without risks. Multiple studies in the past have found an increased risk of Clostridium difficileassociated disease in patients on AST.1316 Also, AST has been associated with an increased risk of community‐acquired pneumonia17 as well as a risk of hip fractures.18 These studies demonstrate that the use of AST is not without its risks and there is a potential for increased morbidity as well as indirect costs for the patient and the community as a whole associated with its use.

The direct cost for this inappropriate use of AST over a period of 8 days was $8026 in our study, with an estimated annual cost close to $366,000. This did not include the cost of patients who were discharged inappropriately with AST. Also, this did not include the indirect costs including the increased risk of community‐acquired pneumonias, hip fractures, and Clostridium infections. Thus, it is possible that the costs of inappropriate use of AST may be much higher than reported.

One of the limitations of our study was that this study was conducted at a single teaching hospital; thus, it is possible that the results could be biased by the prescribing habits of a relatively few physicians. However, since we looked at all specialties, we had a large cohort of physicians in our study. Also, previous multicenter studies as well as single center studies have demonstrated similar results in terms of overprescription.7, 9, 19 Also, the economic impact has been calculated by assessing the cost that is billed to the patients. This may be different from the cost of the medicines to the hospital and insurers.

Conclusions

AST was inappropriately used in 69.2% of the patients studied, leading to an increased direct patient cost of $8026 and projected estimated direct healthcare costs of approximately $366,000 over 1 year. Residents in their first year of training and physicians with an MD degree are more likely to initiate AST inappropriately in patients. Curtailing the inappropriate use of AST therapy may reduce overall costs for the patient and institution.

The United States spends a larger share of its gross domestic product (GDP) on healthcare than any other major industrialized country.1 Expenditures for healthcare represent nearly one‐seventh of the nation's GDP, and they continue to be one of the fastest growing components of the federal budget.1 Drug expenditures are one of the most rapidly growing components of total healthcare expenditures.2 Two of the biggest drivers behind this explosive growth of rising drug expenditures are price and use.2, 3

Acid‐suppressive therapy (AST), including histamine‐2 (H2) receptor antagonists and proton pump inhibitors (PPIs), is used extensively in the hospitalized population.4 One of the most common uses of AST in hospitalized patients has been in preventing gastric mucosal damage and bleeding.5 However, published data suggest that the use of AST will be beneficial only in a well‐defined group of critical care patients in preventing stress ulcers and bleeding.68 This perception of benefit has been extrapolated to hospitalized patients in general, with little or no evidence to support its use.7, 9

There have only been limited studies on the overall use or the appropriateness of use of AST in hospitalized patients.7, 9 Also, there have been no studies that have looked at patient or physician factors which can predict the appropriateness of initiation and use of AST in hospitalized patients. The aim of our study was to identify:

• 1

  The appropriateness of acid suppressive therapy in hospitalized patients admitted to a tertiary teaching institution and the associated cost of inappropriate AST use to the patient.

• 2

  Patient and physician characteristics which can predict the inappropriate initiation and use of AST in patients.

Methods

This study was conducted at a 308‐bed tertiary academic medical center. On an average, there are approximately 800 to 1000 discharges every month from this hospital. All consecutive discharges over a period of 8 consecutive days were selected for inclusion in the study. All patients were assessed for the use of AST during their hospitalization. Use was defined as any prescription of an acid‐suppressive medication, regardless of dosage regimen, in which the patient received at least 1 dose during their hospitalization.7 The class of agents prescribed for AST was also noted. Ranitidine is the preferred H2 receptor antagonist and pantoprazole is the preferred PPI on the hospital formulary. It was also recorded whether the patient was on the medication at the time of admission. If the patient was on AST prior to admission, the records of the patient were reviewed for the indication for initiation of the AST. The discharge records of all these patients were also reviewed to determine if the patient was continued on AST even after discharge. Patients who were readmitted during the study period were not recounted.

Since the aim of our study was to evaluate the inappropriate initiation of AST in hospitalized patients, the following patients were excluded from the analysis: patients who were on AST prior to admission; patients who had a valid therapeutic indication for AST; and patients who met valid therapeutic indications for AST, such as intensive care unit (ICU) transfers.

Two physicians reviewed the records in order to determine whether there was any indication for AST use. If there was discordance between the 2 physicians, a third physician reviewed the records to assess the appropriateness of AST. Patient and prescribing physician characteristics were collected to assess the predictors of the use of AST.

We used the guidelines published by the American Society of Health‐System Pharmacists (ASHP) to determine appropriateness of gastrointestinal (GI) prophylaxis in patients.10

GI prophylaxis was defined as appropriate if: Patient was in the ICU plus 1 of the following10:

• 1

  Coagulopathy (ie, platelet count of <50,000 mm³ or international normalized ratio of 1.5, or an activated partial thromboplastin 2 times normal);

• 2

  Mechanical ventilation for >48 hours;

• 3

  History of GI ulceration or bleeding within 1 year of admission;

• 4

  Glasgow coma score of 10;

• 5

  Thermal injury to >35% of body surface area;

• 6

  Partial hepatectomy;

• 7

  Multiple trauma (injury severity score of 16);

• 8

  Transplantation perioperatively in the ICU;

• 9

  Spinal cord injury;

• 10

  Hepatic failure;

• 11

  Two or more of the following risk factors: sepsis; ICU stay of >1 week; occult bleeding lasting at least 6 days; and high‐dose corticosteroids (>250 mg/day of hydrocortisone or equivalent steroid).

Other indications for the appropriate use of AST were as follows: any documentation of current or past gastroesophageal reflux disease (GERD); active peptic ulcer disease or maintenance therapy in patients with peptic ulcer disease; treatment of esophagitis/gastritis/duodenitis; or patients admitted with upper GI bleeding or melena.

Ranitidine is the preferred H2 receptor antagonist used at this medical center. The cost to the patient of oral ranitidine was $8.54 per day while the cost of intravenous therapy was $135.00 per day. Pantoprazole is the preferred PPI used in this hospital. The cost of oral pantoprazole was $10.57 per day while the cost of intravenous therapy was $57.00 per day (Dr. Joel Reddish, PharmD, Truman Medical Center, Kansas City, MO; Pharmacy Staff; personal communication, September 25, 2007). The cost of intravenous ranitidine was higher than intravenous pantoprazole since ranitidine had to be infused 3 times per day. The cost of AST was calculated by calculating the total number of days during the admission the person was on AST.

Results

There were 207 patients in our study cohort. Of the 207 patients, 103 (49.8%) were males and 71 (34.3%) were Caucasians. Of the 207 patients, AST was used in 164 (79.2%) of the patients. PPI therapy was used in 126 (60.9%) of the patients while 38 (18.4%) of the patients were put on H2 receptor antagonists. In the study cohort, 51 (24.6%) of the patients had a current or a past diagnosis of GERD. Of the 207 patients, 35 patients were on a PPI prior to admission and 16 were on a H2 blocker prior to admission. Table 1 describes the demographic characteristics of the patients.

The most common primary admitting diagnosis was either cardiovascular or gastrointestinal. Table 2 outlines the most common admitting diagnoses of the patients.

To determine the predictors of inappropriate initiation of AST in hospitalized patients, excluding the patients as described in the Methods section, there were 133 patients who met the inclusion criteria for analysis. The reason for inappropriate use of AST in all of the 133 patients included for analysis in our study was for stress ulcer prophylaxis in low‐risk patients. AST was inappropriately used in 92 of the 133 patients (69.2%). On univariate analysis, physician characteristics predictive for inappropriate AST use were being in an early stage of training, physicians in the medicine specialty and physicians who were international medical graduates (Table 3). As far as patient characteristics were concerned, only a higher hemoglobin value was associated with the inappropriate use of AST (see Table 3 for details).

On multivariate analysis, as far as patient characteristics were concerned only a higher hemoglobin value was associated with inappropriate AST use. Residents who were in their first year of training as well as physicians with a MD degree were more likely to prescribe AST inappropriately (Table 4).

The direct calculated patient cost for AST during this time period was $8026. The estimated projected cost for AST over a period of 1 year was $366,000.

Out of the 92 patients in whom AST was used inappropriately, 6 (6.5%) of the patients were discharged on an H2 receptor antagonist while 7 (7.6%) of the patients were discharged on PPI therapy.

Discussion

Prescription drug expenditures are the most rapidly growing component of health care expenditures.2 Two of the biggest drivers behind this explosive growth of rising drug expenditures are price and use.2, 3 PPIs have constantly figured in the national top 20 drug lists for dispensed prescription and drug sales.2

This study found a very high frequency of overuse of acid suppressive therapy in hospitalized patients for stress ulcer prophylaxis. Unfortunately, a large majority (69.2%) of these patients were not at an increased risk of stress‐related mucosal ulceration. One of the reasons for this widespread use of AST is the overestimation of the risk of stress‐related mucosal ulceration in hospitalized patients. However, the fear of stress‐ulcer bleeding seems to largely unjustified, as overall rates of bleeding, as reported previously, have been very low.11 Our results are consistent with the few reports on the overuse of AST reported previously. Nardino et al.,7 in a study of 226 patients, found that 65% of the patients received AST inappropriately. Also in a study from Italy, Parente et al.9 found, in a cohort of 799 hospitalized patients, 68% of the prescriptions for AST were not appropriate.

To date, there has been limited information available on the prescribing characteristics of the physicians, which may help to clarify the inappropriate use of AST. This study was conducted at a tertiary academic medical center and all the admissions are done by residents. This study is the first study that has tried to examine the physician and patient characteristics behind this phenomenon. In multivariate analysis, we found that residents who were in their first year of residency training were more likely to initiate AST inappropriately. This could be secondary to the fact that most of the residents in their first year of training are given blanket orders to put all patients on stress‐ulcer prophylaxis. In a study done by Liberman and Whelan12 at the University of Chicago Hospitals, it was found that house officers learned about stress‐ulcer prophylaxis from their supervising residents. Thus, it is possible that as residents progress through their training, the incidence of inappropriate initiation of stress ulcer prophylaxis decreases. We also found that physicians with an MD degree were more likely to initiate AST inappropriately. The reason behind this not clear, though there may be a difference in the medical education that possibly contributes to this.

One curious finding that was associated with an increased use of AST was a higher hemoglobin level. One possibility is that patients with a low hemoglobin value were more likely to be put on AST appropriately. This could be the reason behind the association of a higher hemoglobin value with inappropriate AST use.

One of the reasons for the widespread use of AST is that most practitioners view AST as harmless.6 However, the use of AST is not without risks. Multiple studies in the past have found an increased risk of Clostridium difficileassociated disease in patients on AST.1316 Also, AST has been associated with an increased risk of community‐acquired pneumonia17 as well as a risk of hip fractures.18 These studies demonstrate that the use of AST is not without its risks and there is a potential for increased morbidity as well as indirect costs for the patient and the community as a whole associated with its use.

The direct cost for this inappropriate use of AST over a period of 8 days was $8026 in our study, with an estimated annual cost close to $366,000. This did not include the cost of patients who were discharged inappropriately with AST. Also, this did not include the indirect costs including the increased risk of community‐acquired pneumonias, hip fractures, and Clostridium infections. Thus, it is possible that the costs of inappropriate use of AST may be much higher than reported.

One of the limitations of our study was that this study was conducted at a single teaching hospital; thus, it is possible that the results could be biased by the prescribing habits of a relatively few physicians. However, since we looked at all specialties, we had a large cohort of physicians in our study. Also, previous multicenter studies as well as single center studies have demonstrated similar results in terms of overprescription.7, 9, 19 Also, the economic impact has been calculated by assessing the cost that is billed to the patients. This may be different from the cost of the medicines to the hospital and insurers.

Conclusions

AST was inappropriately used in 69.2% of the patients studied, leading to an increased direct patient cost of $8026 and projected estimated direct healthcare costs of approximately $366,000 over 1 year. Residents in their first year of training and physicians with an MD degree are more likely to initiate AST inappropriately in patients. Curtailing the inappropriate use of AST therapy may reduce overall costs for the patient and institution.

Originally championed in the form of large multibed wards by Florence Nightingale in the nineteenth century, multioccupancy hospital rooms have recently been criticized for concerns about their cost, safety, lack of privacy, and unpopularity among patients.13 Specifically, they have been linked to longer hospital stays and the morbidity that those stays produceinfections, falls, and medical errors.13 In 2006, the Health Guidelines Revision Committee, the body that establishes guidelines for the construction of healthcare facilities in the United States, moved to a position recommending private rooms as the minimum standard for medical/surgical and postpartum hospital beds. The evidence supporting their position, however, has remained limited. Given the substantial cost and effort involved in converting hospital rooms, it is important to understand the impact of such policies on patients.

In a recent literature review by van de Glind et al.,4 the authors were able to identify only 4 randomized controlled trials comparing private and shared rooms. While they found that private rooms had a moderately positive impact on patient satisfaction and privacy, data on infection control was mixed, and data on patient safety was lacking.48 Though suggested, the association between private rooms and shortened hospital stays has not clearly been shown.13, 9 Certain advantages of shared rooms, such as decreased loneliness and increased patient social interaction, have also been identified.10 In addition, specialized multioccupancy wards for dementia and delirium have been demonstrated to be useful in the management of inpatients with those conditions, partly because of increased nursing presence.11 Finally, an additional theoretical benefit of shared rooms is the possibility of assistance between roommates in emergency situations.

For the sake of providing high‐quality patient‐centered care, patient concerns and preferences are also important to consider when establishing health policy regarding rooms. Previously, patient surveys and interviews have been helpful in identifying issues of concern to patients and understanding their preferences. Kirk12 identified privacy, quiet, improved sleep, and ability to have a family member stay in the room as reasons why 18 of 24 hospice patients preferred private hospice rooms.12 Conversely, in a 2002 Welsh survey of palliative patients, 68% wanted to be in an open area (4‐bed bay), identifying companionship as the major reason.13 Most recently, palliative care patients in the United Kingdom expressed a preference for shared rooms while well enough to interact with others but preferred private rooms when very ill or dying.14 These findings, given the lack of solid medical justification for 1 room type, raise multiple concerns about whether universal adherence to 1 room type will lead to the best patient care in the United States, and more specifically the veteran population. First, nearly all of the preference data described has been collected outside of the United States and veteran's populations. Second, studies have targeted highly‐specialized patient populations, and their applicability in a general medical/surgical population is unknown.10, 1217 Finally, the diversity of preferences exhibited in these studies underscores the difficulty in applying preference data to outside populations, such as the veteran population.

With 7.8 million patients enrolled in its healthcare system and operating 153 medical centers, the U.S. Department of Veterans Affairs has a large interest in the ongoing debate about shared vs. private hospital rooms. Because veterans share a common military background, they may place a higher value on companionship relative to privacy, and so they are an important group to study separately from the general U.S. population. To date, we have been unable to identify any studies that have looked at veterans' experiences and preferences in regards to room type. Through an anonymous survey, we sought to learn about these experiences and preferences and assess whether previously found advantages of each room type (eg, companionship in shared rooms, privacy in private rooms) could be confirmed in the veteran population. By doing so, we also aimed to better inform public policy about a general continued role for shared hospital rooms in the United States.

Methods

Our study used a point prevalence survey to examine patient preferences and experiences with shared (2‐person or 3‐person occupancy) vs. private rooms.

Results

A total of 162 surveys were completed with a participation rate of approximately 73%. Eighty three patients (51%) reported a shared room stay, while 70 patients (43%) reported a private room stay (17 of which were isolation). Nine did not report room type (Figure 1). Excluding isolation patients and those respondents who did not indicate room type, 5% of respondents reported age less than 45 years, 56% between 45 and 65 years, and 39% greater than 65 years. Sixty percent of patients identified themselves as African‐American, 28% as white, and 5% as other (7% did not answer). The majority (56%) reported having some formal higher education after high school. Median total household income was between $11,000 and $20,000.

Figure 1

Discussion

In this observational study of U.S. veterans, we found that patients in private rooms were more satisfied with privacy than their shared‐room counterparts, a finding consistent with previous studies.4, 5 We also found that private room patients were more likely to feel that nursing was available, a finding that had not previously been reported. Although increased loneliness and fear of death had been noted in private room patients before, our study did not support such findings.10 We found a strong overall preference for private rooms, adding to previously mixed evidence about patient room preferences.10, 1217 Although we had hypothesized a substantial demand for shared rooms among veterans based upon their common military experience, we found the demand modest at best.

The increased satisfaction with privacy among private room patients was expected.4, 5 That nearly one‐half of the patients in shared rooms found the privacy to be inadequate, however, was a strong finding that points to a fundamental problem with these rooms. That private room patient also felt more that nurses were available was surprising, since the higher number of patients in shared rooms might have been expected to generate a more visible nursing presence. Whether this finding is reproducible and whether it is based upon an objective difference in nursing behavior is something that should be studied further. It may simply have been a marker of increased satisfaction among the private room patients.

Although loneliness and increased fear of death had previously been identified as possible drawbacks of private rooms, our survey found no such suggestion.10 This may have been because our survey instrument simply asked patients to answer yes or no whether they had experienced the particular feelings; the previous study had used interviews. A more sensitive survey instrument would be needed to investigate questions of loneliness and fear of death further.

Except for the problem of privacy, the shared room experience generally appeared to be a positive one for patients, particularly in the exchange of conversation and help. A genuine value of these interactions to the patients was suggested by the finding that patients in shared rooms were more likely to prefer shared rooms than patients in private rooms. It is possible that once in them, patients found shared rooms to be better than expected, or that they warmed to them as a matter of resolving cognitive dissonance between their preconceptions and their placement. Although peace and quiet was a frequently cited reason for preferring private rooms, relatively few patients reported being bothered by their roommates. The high rate of assistance among roommates was perhaps the most surprising positive about the shared room experience, even if patients recalled helping others more than they remembered being helped themselves.

Preference for private rooms was greater than that found in previous studies, and appears to have been based largely upon concerns for privacy.1217 We suspect it may reflect changing societal values that have placed an increased priority on personal privacy; this is suggested by the greater willingness of elderly patients to stay in shared rooms. Whether the preference for private rooms is even higher in the general nonveteran population is something that should be assessed with future studies.

Our study was limited by a number of factors. While room assignments were based on bed availability, it is possible that patients requested particular rooms or were moved due to other factors. By selecting a study population of male veterans of the armed services, we limited the extent to which our results can be generalized. However, this particular population is an important one to study due to the size of the VA healthcare system, the prevalence of shared rooms in VA hospitals, and the unique cultural values of veterans. We were unable to obtain information from approximately 27% of our target population because they were unable or unwilling to participate, thus excluding a population subset from analysis and potentially biasing our results. Although a high prevalence of preference for private rooms was seen, the strength of the preference was not assessed, and patients were unable to convey if they had no preference regarding room type. The survey instrument was designed for the purposes of this study and has not been validated. Some patients were assisted with filling out their surveys and may have responded more positively about their roommates if they thought their roommates could overhear their answers to questions. Because patient enrollment was slower than expected, fewer patients were enrolled than planned and the power achieved was insufficient for detecting differences of 20% or less between groups. This is unlikely to have affected our positive findings, but may have prevented us from detecting additional differences among the study groups.

Our data shows that for a population of veteran patients, private rooms are preferred, and that increased privacy is a primary advantage. It also demonstrates that multioccupancy rooms have several positive aspects. Given the need for sound public policy in regard to this issue, further research is needed to better evaluate objective outcomes of room type, such as fall rates, nosocomial infection rates, and lengths of hospitalization. In the meantime, efforts should be taken to address some of the known problems of shared rooms. For instance, establishing more substantial dividers between beds would be an intervention that could increase privacy, reduce noise, and minimize unwelcome smells. Additionally, given that patients have a wide variety of feelings toward multioccupancy rooms, incorporating patient choice into room assignments when logistically feasible is a step that could lead to increased patient satisfaction with hospitalization.

Originally championed in the form of large multibed wards by Florence Nightingale in the nineteenth century, multioccupancy hospital rooms have recently been criticized for concerns about their cost, safety, lack of privacy, and unpopularity among patients.13 Specifically, they have been linked to longer hospital stays and the morbidity that those stays produceinfections, falls, and medical errors.13 In 2006, the Health Guidelines Revision Committee, the body that establishes guidelines for the construction of healthcare facilities in the United States, moved to a position recommending private rooms as the minimum standard for medical/surgical and postpartum hospital beds. The evidence supporting their position, however, has remained limited. Given the substantial cost and effort involved in converting hospital rooms, it is important to understand the impact of such policies on patients.

In a recent literature review by van de Glind et al.,4 the authors were able to identify only 4 randomized controlled trials comparing private and shared rooms. While they found that private rooms had a moderately positive impact on patient satisfaction and privacy, data on infection control was mixed, and data on patient safety was lacking.48 Though suggested, the association between private rooms and shortened hospital stays has not clearly been shown.13, 9 Certain advantages of shared rooms, such as decreased loneliness and increased patient social interaction, have also been identified.10 In addition, specialized multioccupancy wards for dementia and delirium have been demonstrated to be useful in the management of inpatients with those conditions, partly because of increased nursing presence.11 Finally, an additional theoretical benefit of shared rooms is the possibility of assistance between roommates in emergency situations.

For the sake of providing high‐quality patient‐centered care, patient concerns and preferences are also important to consider when establishing health policy regarding rooms. Previously, patient surveys and interviews have been helpful in identifying issues of concern to patients and understanding their preferences. Kirk12 identified privacy, quiet, improved sleep, and ability to have a family member stay in the room as reasons why 18 of 24 hospice patients preferred private hospice rooms.12 Conversely, in a 2002 Welsh survey of palliative patients, 68% wanted to be in an open area (4‐bed bay), identifying companionship as the major reason.13 Most recently, palliative care patients in the United Kingdom expressed a preference for shared rooms while well enough to interact with others but preferred private rooms when very ill or dying.14 These findings, given the lack of solid medical justification for 1 room type, raise multiple concerns about whether universal adherence to 1 room type will lead to the best patient care in the United States, and more specifically the veteran population. First, nearly all of the preference data described has been collected outside of the United States and veteran's populations. Second, studies have targeted highly‐specialized patient populations, and their applicability in a general medical/surgical population is unknown.10, 1217 Finally, the diversity of preferences exhibited in these studies underscores the difficulty in applying preference data to outside populations, such as the veteran population.

With 7.8 million patients enrolled in its healthcare system and operating 153 medical centers, the U.S. Department of Veterans Affairs has a large interest in the ongoing debate about shared vs. private hospital rooms. Because veterans share a common military background, they may place a higher value on companionship relative to privacy, and so they are an important group to study separately from the general U.S. population. To date, we have been unable to identify any studies that have looked at veterans' experiences and preferences in regards to room type. Through an anonymous survey, we sought to learn about these experiences and preferences and assess whether previously found advantages of each room type (eg, companionship in shared rooms, privacy in private rooms) could be confirmed in the veteran population. By doing so, we also aimed to better inform public policy about a general continued role for shared hospital rooms in the United States.

Methods

Our study used a point prevalence survey to examine patient preferences and experiences with shared (2‐person or 3‐person occupancy) vs. private rooms.

Results

A total of 162 surveys were completed with a participation rate of approximately 73%. Eighty three patients (51%) reported a shared room stay, while 70 patients (43%) reported a private room stay (17 of which were isolation). Nine did not report room type (Figure 1). Excluding isolation patients and those respondents who did not indicate room type, 5% of respondents reported age less than 45 years, 56% between 45 and 65 years, and 39% greater than 65 years. Sixty percent of patients identified themselves as African‐American, 28% as white, and 5% as other (7% did not answer). The majority (56%) reported having some formal higher education after high school. Median total household income was between $11,000 and $20,000.

Figure 1

Discussion

In this observational study of U.S. veterans, we found that patients in private rooms were more satisfied with privacy than their shared‐room counterparts, a finding consistent with previous studies.4, 5 We also found that private room patients were more likely to feel that nursing was available, a finding that had not previously been reported. Although increased loneliness and fear of death had been noted in private room patients before, our study did not support such findings.10 We found a strong overall preference for private rooms, adding to previously mixed evidence about patient room preferences.10, 1217 Although we had hypothesized a substantial demand for shared rooms among veterans based upon their common military experience, we found the demand modest at best.

The increased satisfaction with privacy among private room patients was expected.4, 5 That nearly one‐half of the patients in shared rooms found the privacy to be inadequate, however, was a strong finding that points to a fundamental problem with these rooms. That private room patient also felt more that nurses were available was surprising, since the higher number of patients in shared rooms might have been expected to generate a more visible nursing presence. Whether this finding is reproducible and whether it is based upon an objective difference in nursing behavior is something that should be studied further. It may simply have been a marker of increased satisfaction among the private room patients.

Although loneliness and increased fear of death had previously been identified as possible drawbacks of private rooms, our survey found no such suggestion.10 This may have been because our survey instrument simply asked patients to answer yes or no whether they had experienced the particular feelings; the previous study had used interviews. A more sensitive survey instrument would be needed to investigate questions of loneliness and fear of death further.

Except for the problem of privacy, the shared room experience generally appeared to be a positive one for patients, particularly in the exchange of conversation and help. A genuine value of these interactions to the patients was suggested by the finding that patients in shared rooms were more likely to prefer shared rooms than patients in private rooms. It is possible that once in them, patients found shared rooms to be better than expected, or that they warmed to them as a matter of resolving cognitive dissonance between their preconceptions and their placement. Although peace and quiet was a frequently cited reason for preferring private rooms, relatively few patients reported being bothered by their roommates. The high rate of assistance among roommates was perhaps the most surprising positive about the shared room experience, even if patients recalled helping others more than they remembered being helped themselves.

Preference for private rooms was greater than that found in previous studies, and appears to have been based largely upon concerns for privacy.1217 We suspect it may reflect changing societal values that have placed an increased priority on personal privacy; this is suggested by the greater willingness of elderly patients to stay in shared rooms. Whether the preference for private rooms is even higher in the general nonveteran population is something that should be assessed with future studies.

Our study was limited by a number of factors. While room assignments were based on bed availability, it is possible that patients requested particular rooms or were moved due to other factors. By selecting a study population of male veterans of the armed services, we limited the extent to which our results can be generalized. However, this particular population is an important one to study due to the size of the VA healthcare system, the prevalence of shared rooms in VA hospitals, and the unique cultural values of veterans. We were unable to obtain information from approximately 27% of our target population because they were unable or unwilling to participate, thus excluding a population subset from analysis and potentially biasing our results. Although a high prevalence of preference for private rooms was seen, the strength of the preference was not assessed, and patients were unable to convey if they had no preference regarding room type. The survey instrument was designed for the purposes of this study and has not been validated. Some patients were assisted with filling out their surveys and may have responded more positively about their roommates if they thought their roommates could overhear their answers to questions. Because patient enrollment was slower than expected, fewer patients were enrolled than planned and the power achieved was insufficient for detecting differences of 20% or less between groups. This is unlikely to have affected our positive findings, but may have prevented us from detecting additional differences among the study groups.

Our data shows that for a population of veteran patients, private rooms are preferred, and that increased privacy is a primary advantage. It also demonstrates that multioccupancy rooms have several positive aspects. Given the need for sound public policy in regard to this issue, further research is needed to better evaluate objective outcomes of room type, such as fall rates, nosocomial infection rates, and lengths of hospitalization. In the meantime, efforts should be taken to address some of the known problems of shared rooms. For instance, establishing more substantial dividers between beds would be an intervention that could increase privacy, reduce noise, and minimize unwelcome smells. Additionally, given that patients have a wide variety of feelings toward multioccupancy rooms, incorporating patient choice into room assignments when logistically feasible is a step that could lead to increased patient satisfaction with hospitalization.

Originally championed in the form of large multibed wards by Florence Nightingale in the nineteenth century, multioccupancy hospital rooms have recently been criticized for concerns about their cost, safety, lack of privacy, and unpopularity among patients.13 Specifically, they have been linked to longer hospital stays and the morbidity that those stays produceinfections, falls, and medical errors.13 In 2006, the Health Guidelines Revision Committee, the body that establishes guidelines for the construction of healthcare facilities in the United States, moved to a position recommending private rooms as the minimum standard for medical/surgical and postpartum hospital beds. The evidence supporting their position, however, has remained limited. Given the substantial cost and effort involved in converting hospital rooms, it is important to understand the impact of such policies on patients.

In a recent literature review by van de Glind et al.,4 the authors were able to identify only 4 randomized controlled trials comparing private and shared rooms. While they found that private rooms had a moderately positive impact on patient satisfaction and privacy, data on infection control was mixed, and data on patient safety was lacking.48 Though suggested, the association between private rooms and shortened hospital stays has not clearly been shown.13, 9 Certain advantages of shared rooms, such as decreased loneliness and increased patient social interaction, have also been identified.10 In addition, specialized multioccupancy wards for dementia and delirium have been demonstrated to be useful in the management of inpatients with those conditions, partly because of increased nursing presence.11 Finally, an additional theoretical benefit of shared rooms is the possibility of assistance between roommates in emergency situations.

For the sake of providing high‐quality patient‐centered care, patient concerns and preferences are also important to consider when establishing health policy regarding rooms. Previously, patient surveys and interviews have been helpful in identifying issues of concern to patients and understanding their preferences. Kirk12 identified privacy, quiet, improved sleep, and ability to have a family member stay in the room as reasons why 18 of 24 hospice patients preferred private hospice rooms.12 Conversely, in a 2002 Welsh survey of palliative patients, 68% wanted to be in an open area (4‐bed bay), identifying companionship as the major reason.13 Most recently, palliative care patients in the United Kingdom expressed a preference for shared rooms while well enough to interact with others but preferred private rooms when very ill or dying.14 These findings, given the lack of solid medical justification for 1 room type, raise multiple concerns about whether universal adherence to 1 room type will lead to the best patient care in the United States, and more specifically the veteran population. First, nearly all of the preference data described has been collected outside of the United States and veteran's populations. Second, studies have targeted highly‐specialized patient populations, and their applicability in a general medical/surgical population is unknown.10, 1217 Finally, the diversity of preferences exhibited in these studies underscores the difficulty in applying preference data to outside populations, such as the veteran population.

With 7.8 million patients enrolled in its healthcare system and operating 153 medical centers, the U.S. Department of Veterans Affairs has a large interest in the ongoing debate about shared vs. private hospital rooms. Because veterans share a common military background, they may place a higher value on companionship relative to privacy, and so they are an important group to study separately from the general U.S. population. To date, we have been unable to identify any studies that have looked at veterans' experiences and preferences in regards to room type. Through an anonymous survey, we sought to learn about these experiences and preferences and assess whether previously found advantages of each room type (eg, companionship in shared rooms, privacy in private rooms) could be confirmed in the veteran population. By doing so, we also aimed to better inform public policy about a general continued role for shared hospital rooms in the United States.

Methods

Our study used a point prevalence survey to examine patient preferences and experiences with shared (2‐person or 3‐person occupancy) vs. private rooms.

Results

A total of 162 surveys were completed with a participation rate of approximately 73%. Eighty three patients (51%) reported a shared room stay, while 70 patients (43%) reported a private room stay (17 of which were isolation). Nine did not report room type (Figure 1). Excluding isolation patients and those respondents who did not indicate room type, 5% of respondents reported age less than 45 years, 56% between 45 and 65 years, and 39% greater than 65 years. Sixty percent of patients identified themselves as African‐American, 28% as white, and 5% as other (7% did not answer). The majority (56%) reported having some formal higher education after high school. Median total household income was between $11,000 and $20,000.

Figure 1

Discussion

In this observational study of U.S. veterans, we found that patients in private rooms were more satisfied with privacy than their shared‐room counterparts, a finding consistent with previous studies.4, 5 We also found that private room patients were more likely to feel that nursing was available, a finding that had not previously been reported. Although increased loneliness and fear of death had been noted in private room patients before, our study did not support such findings.10 We found a strong overall preference for private rooms, adding to previously mixed evidence about patient room preferences.10, 1217 Although we had hypothesized a substantial demand for shared rooms among veterans based upon their common military experience, we found the demand modest at best.

The increased satisfaction with privacy among private room patients was expected.4, 5 That nearly one‐half of the patients in shared rooms found the privacy to be inadequate, however, was a strong finding that points to a fundamental problem with these rooms. That private room patient also felt more that nurses were available was surprising, since the higher number of patients in shared rooms might have been expected to generate a more visible nursing presence. Whether this finding is reproducible and whether it is based upon an objective difference in nursing behavior is something that should be studied further. It may simply have been a marker of increased satisfaction among the private room patients.

Although loneliness and increased fear of death had previously been identified as possible drawbacks of private rooms, our survey found no such suggestion.10 This may have been because our survey instrument simply asked patients to answer yes or no whether they had experienced the particular feelings; the previous study had used interviews. A more sensitive survey instrument would be needed to investigate questions of loneliness and fear of death further.

Except for the problem of privacy, the shared room experience generally appeared to be a positive one for patients, particularly in the exchange of conversation and help. A genuine value of these interactions to the patients was suggested by the finding that patients in shared rooms were more likely to prefer shared rooms than patients in private rooms. It is possible that once in them, patients found shared rooms to be better than expected, or that they warmed to them as a matter of resolving cognitive dissonance between their preconceptions and their placement. Although peace and quiet was a frequently cited reason for preferring private rooms, relatively few patients reported being bothered by their roommates. The high rate of assistance among roommates was perhaps the most surprising positive about the shared room experience, even if patients recalled helping others more than they remembered being helped themselves.

Preference for private rooms was greater than that found in previous studies, and appears to have been based largely upon concerns for privacy.1217 We suspect it may reflect changing societal values that have placed an increased priority on personal privacy; this is suggested by the greater willingness of elderly patients to stay in shared rooms. Whether the preference for private rooms is even higher in the general nonveteran population is something that should be assessed with future studies.

Our study was limited by a number of factors. While room assignments were based on bed availability, it is possible that patients requested particular rooms or were moved due to other factors. By selecting a study population of male veterans of the armed services, we limited the extent to which our results can be generalized. However, this particular population is an important one to study due to the size of the VA healthcare system, the prevalence of shared rooms in VA hospitals, and the unique cultural values of veterans. We were unable to obtain information from approximately 27% of our target population because they were unable or unwilling to participate, thus excluding a population subset from analysis and potentially biasing our results. Although a high prevalence of preference for private rooms was seen, the strength of the preference was not assessed, and patients were unable to convey if they had no preference regarding room type. The survey instrument was designed for the purposes of this study and has not been validated. Some patients were assisted with filling out their surveys and may have responded more positively about their roommates if they thought their roommates could overhear their answers to questions. Because patient enrollment was slower than expected, fewer patients were enrolled than planned and the power achieved was insufficient for detecting differences of 20% or less between groups. This is unlikely to have affected our positive findings, but may have prevented us from detecting additional differences among the study groups.

Our data shows that for a population of veteran patients, private rooms are preferred, and that increased privacy is a primary advantage. It also demonstrates that multioccupancy rooms have several positive aspects. Given the need for sound public policy in regard to this issue, further research is needed to better evaluate objective outcomes of room type, such as fall rates, nosocomial infection rates, and lengths of hospitalization. In the meantime, efforts should be taken to address some of the known problems of shared rooms. For instance, establishing more substantial dividers between beds would be an intervention that could increase privacy, reduce noise, and minimize unwelcome smells. Additionally, given that patients have a wide variety of feelings toward multioccupancy rooms, incorporating patient choice into room assignments when logistically feasible is a step that could lead to increased patient satisfaction with hospitalization.

Effective communication between healthcare providers is essential to patient safety and quality of care.1, 2 Numeric pagers are commonly used communication devices in healthcare, but cannot convey important information such as the reason for the page, urgency of the page, or sender name. Physicians must respond to numeric pages, often disrupting patient encounters or educational activities.36 In a study of medical interns, disruptions to patient care occurred with up to 65% of pages received, two‐thirds of which were not felt to be urgent.5 In addition to causing frustration, frequent disruptions can contribute to medical errors.7, 8

Alphanumeric pagers can display both numbers and text, and may address some of the communication problems associated with numeric pagers. They also lay the groundwork for other patient safety initiatives such as automated paging of critical laboratory values9 and real‐time reporting of user‐requested laboratory data.10 Implementation of alphanumeric paging on a general surgery teaching service reduced disruptions to patient care and the number of pages requiring a return call.11

Our primary aim was to implement an alphanumeric paging system. We will describe our implementation strategies and barriers identified. We evaluated the implementation of alphanumeric paging by measuring (1) the proportion of pages sent as text pages, (2) the source of the pages (other physicians or from the general medicine [GM] ward), (3) the content of the text pages, (4) the number of pages that disrupted scheduled education activities, and (5) satisfaction with the alphanumeric paging system.

Materials and Methods

Implementation Process

We provided alphanumeric pagers to the residents on the General Internal Medicine service in July 2006. Alphanumeric pagers were limited, so each resident traded their numeric pager for an alphanumeric pager at the start of each rotation. Once their rotation ended, they returned their alphanumeric pager for their original numeric pager. The communications department coordinated this process. The chief medical resident spent 10 minutes to teach the residents how to use the system at the beginning of the rotation. In August and September 2006, a member of the communications department trained the nurses on the 4 GM wards how to send a text page using the Internet‐based paging application. We scheduled these 15‐minute sessions throughout the day and evening in order to capture as many nurses as possible. We encouraged the nurses to include standardized information in the text message (eg, patient ID, issue, level of urgency, sender name, call‐back number).

We used rapid‐cycle change methods12 to implement the alphanumeric system (Figure 1). The first change cycle in August 2006 consisted of providing pagers to residents and training the nurses and physicians to send text pages. Users reported that the paging interface was difficult to use. For the second change cycle in September 2006, the communications department modified the paging interface to improve usability and created shortcut icons on the GM ward computers. While the system was easier to access, the nurses reported that 1‐time training was insufficient. For the next change cycle in September 2006, we developed Internet‐based tutorials that could be accessed at any time, and made expert users (charge nurses) available for just‐in‐time training. We asked these charge nurses what they believed would encourage adoption of the system. They suggested that contests worked well with other initiatives. For the final change cycle in October and November 2006, we held a contest and rewarded the GM ward that sent the highest percentage of text pages with a team lunch.

Figure 1

Our results from November 2006 were presented to our hospital medical leaders, who approved widespread implementation of alphanumeric pagers for all residents and medical students in all programs. The cost of this upgrade was approximately $35,000 per year to lease 500 alphanumeric pagers. By July 2007, all residents and students in our hospital had alphanumeric pagers.

Results

Paging Patterns Before, During, and After Implementation

The number of pages per resident was similar before and during implementation, but higher afterwards. (46 16 pages/resident/week in November 2005, 47 20 pages/resident/week in November 2006, and 59 27 pages/resident/week in January 2008; P = 0.17; Table 1). The mean number of admissions per night was 8.0 2.7 before implementation, compared to 10.2 3.5 after implementation (P = 0.009).

Table 1.Paging Patterns Before, During, and After Implementation of an Alphanumeric Paging System

	Before Implementation (all residents had numeric pagers)	During Implementation (all residents had alphanumeric pagers)		After Implementation (all residents had alphanumeric pagers)
Paging Characteristics	November 2005	October 2006	November 2006	January 2008	P Value
Abbreviations: Doc, physician; GM, general medicine; SD, standard deviation. * Student t test comparing November 2005 with January 2008. Fisher's Exact Test comparing November 2005 with January 2008.
Total number of pages	1431	1879	1813	1269
Total number of resident weeks worked	29	33	33	21
Pages per resident week, mean (SD)	46.2 (16.3)	57.9 (19.2)	46.5 (20.2)	59.0 (26.5)	0.17*
Number of patients admitted per night, mean (SD)	8.0 (2.7)	10.2 (3.5)	11.0 (2.9)	10.2 (3.5)	0.009*
Type of page, n (%)
Numeric pages	751 (53)	462 (25)	580 (32)	374 (30)	<0.001
GM wards‐to‐Doc	584 (41)	393 (21)	538 (30)	352 (28)	<0.001
Doc‐to‐Doc	167 (12)	69 (4)	42 (2)	22 (2)	<0.001
Non‐GM ward/Doc pages	680 (47)	1107 (59)	809 (45)	487 (38)	<0.001
Text pages	0 (0)	310 (16)	424 (23)	408 (32)	<0.001
GM wards‐to‐Doc	0 (0)	175 (9)	221 (12)	129 (10)	<0.001
Doc‐to‐Doc	0 (0)	135 (7)	203 (11)	279 (22)	<0.001

We observed a significant and sustained increase in the use of text paging during the study (Table 1). After implementation, 32% of all pages sent to our residents were text messages (P < 0.001). Physicians almost exclusively sent text pages by the end of implementation (increase from 0% to 83% text paging rate during implementation, and 93% after implementation; P < 0.001; Figure 2). GM ward text paging rates also increased from 0% to 29% during implementation, and 27% after implementation (P < 0.001; Figure 2). The alphanumeric paging system was used to a greater degree by physicians compared to other workers on the GM ward after full implementation (93% vs. 27%; P < 0.001). We explored the proportion of GM ward‐to‐Doc pages sent as text from different GM wards during implementation, and found significant variation, ranging from 14% to 57% (P < 0.001).

Figure 2

The most common reasons for text paging from GM wards were to request a patient assessment or for notification of a patient's clinical status (25%), to clarify written orders (20%), and to request a medication prescription (13%) (Table 2). Among physicians, the most common reasons for text paging were to set up meetings for work or teaching rounds (33%), to relay patient‐care related messages (27%), and to sign‐over patients at the end of the day (23%) (Table 3). The remainder of the other Doc‐to‐Doc pages (18%) were mostly personal messages or team communication that was not related to clinical work.

Table 2.Reasons for Paging the Physicians (GM ward‐to‐Doc)

Reason for Paging	Number (%)	Examples
NOTE: Represents data from November 2006. Abbreviations: BP, blood pressure; CXR, chest X‐ray; Doc, physician; GM, general medicine; INR, international normalized ratio; NG, nasogastric tube.
Requests for patient assessment or notification of a patient's clinical status	55 (25)	Patient X. Temp 38.5. No other symptoms. [Nurse's name].
		The repeat CXR on Patient X has been completed. Please call [ward] if NG can be used. Thank you.
Clarification of a written order	45 (20)	Would you like Patient X to get a second dose of Lasix? He has already had 100 mg and his output thus far is 500 cc. [Nurse's name]
		Patient X. BP = 100/62, pulse 54. Patient is supposed to have metoprolol 50 mg tonight. Do you want me to hold it? [Nurse's name]
Request for a medication prescription	28 (13)	Patient X needs an analgesic for pain in his arms and legs. Please call [ward].
		Patient X has a daily coumadin order. INR 2.14. Please call with dosage for 1800. Ask for [Nurse].
Cosigning written order	25 (11)	Please co‐sign neurology suggested orders for Patient X. [Nurse's name]
		Not urgent at your leisure, please co‐sign Patient X orders on [ward] for medical student. Thanks.
Notification of a recent laboratory result	23 (11)	Patient X's potassium is 3.0 today. Please call [ward].
		Patient X. Sodium 163. Troponin unchanged at 1.54. [ward].
Arranging meetings with patients and/or family	18 (8)	Meeting with Patient X's family and social worker at 2 pm tomorrow on [ward].
		[Social worker] is here. [Physiotherapist] expected any minute. We are going to meet in family room for Patient X.
Request to complete paperwork	15 (7)	Patient X is ready to go home, and just needs discharge orders and prescriptions
		Referral form for community palliative doctor on the front of the chart fill in where marked by arrows. Can you please put on form prognosis as well? [Social worker]
Other	12 (6)
Total	221 (100)

Table 3.Reasons for Paging Among Physicians (Doc‐to‐Doc)

Reason for Paging	Number (%)	Examples
NOTE: Represents data from November 2006. Abbreviations: cath, catheterization; CHF, congestive heart failure; Cr, creatinine; DKA, diabetic ketoacidosis; IV, intravenous; Lytes, electrolytes; NS, normal saline; US, ultrasound; WE, weakend.
Setting up meetings for work or teaching rounds	67 (33)	Confirmed diabetes teaching at 1400 hr in [room]. Please let medical students know. Thanks.
		Please come to [lecture theatre] if you can in the next 10 minutes for the teleconferenced noon rounds. Thanks.
We are in the Emergency Department with [attending staff]. Come to meet us here if you can.
Relaying patient‐care related messages	54 (27)	Patient X US query cholangitis, can we ask for a surgical consult. He may benefit from surgery or percutaneous drain. Please repeat his blood work.
		Patient X in [room X]. Presented with DKA. pH 7.2. pCO2 23, bicarbonate 9. Lytes pending. Got IV insulin and NS. Need to check to clinical stability. [Resident]
Signing‐over patients at the end of the day	46 (23)	I'm ready to sign out to you. Where are you? [Resident].
		Patient X is back from cardiac cath, and is stable. Please check Cr over WE, and watch for CHF.
Other	36 (18)
Total	203 (100)

Discussion

We successfully implemented an alphanumeric paging system on a resident inpatient internal medicine teaching service, with 42% of pages from our GM wards or physicians sent as text pages during implementation period. Six months after widespread use of alphanumeric pagers at our hospital (and 14 months after the initial implementation on the General Internal Medicine service) the text paging rate was 52%. Physicians have nearly universally adopted the use of alphanumeric paging as a means of communicating with one another, while the adoption by nursing staff was modest. The implementation of the alphanumeric paging system was associated with a significant reduction in disruptive pages.

We could identify only one prior study of alphanumeric paging implementation in a hospital setting. A general surgery teaching service in the United States demonstrated that 35% of all pages received by residents were text pages 3 months after implementation,11 similar to our result of 32% text paging rate after full implementation. We found a greater use of text paging among physicians in our study (93% of Doc‐to‐Doc pages were text), compared to 55% in this prior study. This difference may be partially explained by varied methods for identifying Doc‐to‐Doc pages between the studies.

A number of factors influence the adoption of new technology, such as the technology's features, end‐user characteristics, and dissemination strategies.14 During the implementation, even though the web‐based paging system was deemed easy to use, there was a lack of computers available to send text messages at each of our nursing stations. Residents were generally more familiar with technology and the use of computers for communication than nurses, and therefore more likely to use the technology. The presence of innovators influenced the success of adoption, evidenced by the fact that the GM ward that sent the highest percentage of pages as text was also the GM ward where the project leader (B.W.) worked as the attending staff during the implementation period.

Our study has several limitations. First, our method for classifying the source of numeric pages was imperfect. Our method systematically underestimates Doc‐to‐Doc numeric pages, because we assumed that all pages from GM ward phone numbers were not from physicians. We also may have misclassified the origin of some text messages. These limitations would not affect our conclusion that text messaging increased, but may overestimate the increase in Doc‐to‐Doc text messaging, and underestimate the increase in GM ward‐to‐Doc text messaging. The reasons for paging are not known for the numeric pages. The number of pages received per resident increased after implementation, so it is possible that alphanumeric pages increased calls for certain nonurgent issues, such as co‐signing orders. Finally, we assumed that residents were attending scheduled educational rounds, but were unable to confirm attendance, so we cannot be sure that disruptions actually were reduced.

In summary, we implemented an alphanumeric paging system, and observed a sustained use of text messaging after 1 year. The implementation of alphanumeric paging was associated with a reduction in disruptive pages sent during scheduled educational rounds.