Editors’ note: This month we begin a new bimonthly column authored by John Nelson, MD. Dr. Nelson will cover practical, real-life topics and ideas for improving your practice in this space during the coming months.

Are you pretty sure your workload is in the sweet spot? That is, do you think you’re seeing the “right” number of patients? For most of us this isn’t an easy question to answer. My wife figured this out a long time ago. When she asked me “So how was it today?” at the end of the work day, I would nearly always answer “Too busy” or “Too slow.” On the rare occasion I enthusiastically said the day’s workload was “just right” she would nearly fall out of her chair. (Disclosure: Now the way I really answer her question most often is to say, “It was OK. How was your day?” I learned that the constant too busy/too slow answers are a downer and marital accord is served by other responses. I share this hoping you can benefit from my experience, but marital advice isn’t the point of this column.)

How you feel about your workload from day to day is terribly significant, but just how do you decide what the right workload is? More importantly, what can be done if you’re convinced you’re constantly working too hard or at an unsustainable pace?

This month I’ll offer thoughts for those who feel they’re seeing too many patients. In future installments of “Practice Management,” I’ll address those seemingly rare people who think their patient volume is too low.

Comparing Apples with Apples

If you think you’re seeing too many patients, you probably want to know the typical patient volume for hospitalists in practices similar to yours. So it is natural to turn to survey data, such as the SHM Compensation and Productivity Survey, which is published about every two years (results of the 2005-2006 are available to SHM members at www.hospitalmedicine.org).

You might think about how your practice differs from the average practice in the survey to explain why your volume should be higher or lower. Then you might talk with individual hospitalists from other practices, and even the colleagues in your own practice. What is their patient volume and do they think it is too high, too low, or the elusive just right?

So by comparing your workload with external benchmarks, you know the real answer to whether your patient volume is too high or not. Right? Not so fast. Who says you are average and should feel comfortable working at the average pace? Isn’t it possible that the right patient volume for you is different than for others? I think data from other hospitalists serve only as a rough guideline and starting point for deciding about your own volume. Ideally you should have significant latitude to decide where the sweet spot is for yourself. Kudos if you’re in that situation now.

Unfortunately, instead of having a lot of latitude to decide for themselves, many hospitalists complain that their hospital executive/employer insists that they see at least X wRVUs/visits/new encounters (where X is usually heavily influenced by the SHM survey or other database). And it is especially frustrating to have an executive who doesn’t know what it is like to work as a hospitalist decide about the right workload for you.

If you are in a practice where you have little say about how many patients you see, here is a strategy to secure a much greater degree of control over this decision: Offer to decide for yourself and accept the change in your salary that will occur as a result of your patient volume changes. For this to work you will need to have a compensation scheme that has a connection between your production and your income. (Details of such a salary are beyond the scope of this column, but let me assure you it isn’t as complicated or risky as you might fear.)

Case in Point

Let me briefly illustrate with a hypothetical example from an outpatient primary care practice. Doctor A opens a solo office and decides to work 4.5 days a week and see 22 patients each day (11 on the half day). He’s chosen this workload because it seems reasonable, safe for patient care, and rewards him with what he regards as a reasonable salary. In other words, he feels like he has found the sweet spot for workload and income (productivity and compensation).

Dr. A then recruits a partner, Doctor B, whom he pays the same salary as himself and tells Dr. B he must work 4.5 days a week and see the same patient volume as he does. Dr. B is able to conform to this, but isn’t so sure he’s working in his own productivity and compensation sweet spot. Over the next few years the group grows to 10 doctors, all making the same salary, working 4.5 days a week, and seeing the same number of patients each day.

Are all 10 doctors in this practice likely to be happy with their workload? I don’t think so. I’d recommend they look for a way to let each individual doctor decide independently (within some broad boundaries) to work different amounts, varying the number of days worked, or daily patient workload.

A single parent might work only three days a week when childcare is available; an energetic doctor might decide to work five full days a week, and so on. In fact, this is how most private primary care practices operate. And they do this despite complicated decisions about how to allocate overhead between doctors with different levels of productivity, an issue that is usually much less difficult for hospitalists than primary care offices.

But a significant number of hospitalists are in a practice that looks like Dr. A’s. They’re hired at a predetermined salary and then are urged, or required, to see a specified number of patients and work a specified number of days or shifts. A great deal of effort often goes into getting each doctor to handle a workload that is similar to others in the practice. This patient volume/workload target is usually vague until the hospitalists want to add a new doctor and the employer must be convinced the doctors are working very hard. At this point the SHM survey data and other tools often come into play, and patient volume expectations become much clearer through what is often a somewhat unpleasant negotiation.

So if you’re in a situation where a hospital executive or other employer decides the appropriate patient volume for you, think about changing to a compensation system that enables you to decide for yourself the sweet spot between patient volume, days or shifts worked (time off), and income. Most employers—especially hospital executives—are delighted to switch to production-based compensation and let you decide for yourself how many patients you see.

Switching to a salary based significantly—or entirely—on production often raises a number of questions that, again, I’ll address in a future column. But my point here is that it can be quite liberating because it lets you make your own decisions about productivity. It might be the thing that allows each member of your group to decide, within some generous boundaries, just how hard he or she wants to work. And the group as a whole can decide more independently when additional doctors should be added.

I encourage each group to operate in a way that maximizes individual doctors’ ability to decide where the patient volume sweet spot is—whether through a production-based salary or other methods. Don’t let this decision be based too heavily on things such as survey data and the decisions of hospital executives.

Closing Thoughts

My goal in writing this column is to stimulate your thinking about your own practice—not to provide a prescription for the one right way to operate a practice. After all, the best way to operate a practice varies from one place to the next.

I plan to address controversial topics regularly, hoping to achieve two objectives. The first is that some of my ramblings help you think about the best way to operate your own practice. The second is that some of you might decide to e-mail us (at [email protected]) your point of view—some of which can be printed here so that we can learn from each other about the options for operating a successful practice. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

Editors’ note: This month we begin a new bimonthly column authored by John Nelson, MD. Dr. Nelson will cover practical, real-life topics and ideas for improving your practice in this space during the coming months.

Are you pretty sure your workload is in the sweet spot? That is, do you think you’re seeing the “right” number of patients? For most of us this isn’t an easy question to answer. My wife figured this out a long time ago. When she asked me “So how was it today?” at the end of the work day, I would nearly always answer “Too busy” or “Too slow.” On the rare occasion I enthusiastically said the day’s workload was “just right” she would nearly fall out of her chair. (Disclosure: Now the way I really answer her question most often is to say, “It was OK. How was your day?” I learned that the constant too busy/too slow answers are a downer and marital accord is served by other responses. I share this hoping you can benefit from my experience, but marital advice isn’t the point of this column.)

How you feel about your workload from day to day is terribly significant, but just how do you decide what the right workload is? More importantly, what can be done if you’re convinced you’re constantly working too hard or at an unsustainable pace?

This month I’ll offer thoughts for those who feel they’re seeing too many patients. In future installments of “Practice Management,” I’ll address those seemingly rare people who think their patient volume is too low.

Comparing Apples with Apples

If you think you’re seeing too many patients, you probably want to know the typical patient volume for hospitalists in practices similar to yours. So it is natural to turn to survey data, such as the SHM Compensation and Productivity Survey, which is published about every two years (results of the 2005-2006 are available to SHM members at www.hospitalmedicine.org).

You might think about how your practice differs from the average practice in the survey to explain why your volume should be higher or lower. Then you might talk with individual hospitalists from other practices, and even the colleagues in your own practice. What is their patient volume and do they think it is too high, too low, or the elusive just right?

So by comparing your workload with external benchmarks, you know the real answer to whether your patient volume is too high or not. Right? Not so fast. Who says you are average and should feel comfortable working at the average pace? Isn’t it possible that the right patient volume for you is different than for others? I think data from other hospitalists serve only as a rough guideline and starting point for deciding about your own volume. Ideally you should have significant latitude to decide where the sweet spot is for yourself. Kudos if you’re in that situation now.

Unfortunately, instead of having a lot of latitude to decide for themselves, many hospitalists complain that their hospital executive/employer insists that they see at least X wRVUs/visits/new encounters (where X is usually heavily influenced by the SHM survey or other database). And it is especially frustrating to have an executive who doesn’t know what it is like to work as a hospitalist decide about the right workload for you.

If you are in a practice where you have little say about how many patients you see, here is a strategy to secure a much greater degree of control over this decision: Offer to decide for yourself and accept the change in your salary that will occur as a result of your patient volume changes. For this to work you will need to have a compensation scheme that has a connection between your production and your income. (Details of such a salary are beyond the scope of this column, but let me assure you it isn’t as complicated or risky as you might fear.)

Case in Point

Let me briefly illustrate with a hypothetical example from an outpatient primary care practice. Doctor A opens a solo office and decides to work 4.5 days a week and see 22 patients each day (11 on the half day). He’s chosen this workload because it seems reasonable, safe for patient care, and rewards him with what he regards as a reasonable salary. In other words, he feels like he has found the sweet spot for workload and income (productivity and compensation).

Dr. A then recruits a partner, Doctor B, whom he pays the same salary as himself and tells Dr. B he must work 4.5 days a week and see the same patient volume as he does. Dr. B is able to conform to this, but isn’t so sure he’s working in his own productivity and compensation sweet spot. Over the next few years the group grows to 10 doctors, all making the same salary, working 4.5 days a week, and seeing the same number of patients each day.

Are all 10 doctors in this practice likely to be happy with their workload? I don’t think so. I’d recommend they look for a way to let each individual doctor decide independently (within some broad boundaries) to work different amounts, varying the number of days worked, or daily patient workload.

A single parent might work only three days a week when childcare is available; an energetic doctor might decide to work five full days a week, and so on. In fact, this is how most private primary care practices operate. And they do this despite complicated decisions about how to allocate overhead between doctors with different levels of productivity, an issue that is usually much less difficult for hospitalists than primary care offices.

But a significant number of hospitalists are in a practice that looks like Dr. A’s. They’re hired at a predetermined salary and then are urged, or required, to see a specified number of patients and work a specified number of days or shifts. A great deal of effort often goes into getting each doctor to handle a workload that is similar to others in the practice. This patient volume/workload target is usually vague until the hospitalists want to add a new doctor and the employer must be convinced the doctors are working very hard. At this point the SHM survey data and other tools often come into play, and patient volume expectations become much clearer through what is often a somewhat unpleasant negotiation.

So if you’re in a situation where a hospital executive or other employer decides the appropriate patient volume for you, think about changing to a compensation system that enables you to decide for yourself the sweet spot between patient volume, days or shifts worked (time off), and income. Most employers—especially hospital executives—are delighted to switch to production-based compensation and let you decide for yourself how many patients you see.

Switching to a salary based significantly—or entirely—on production often raises a number of questions that, again, I’ll address in a future column. But my point here is that it can be quite liberating because it lets you make your own decisions about productivity. It might be the thing that allows each member of your group to decide, within some generous boundaries, just how hard he or she wants to work. And the group as a whole can decide more independently when additional doctors should be added.

I encourage each group to operate in a way that maximizes individual doctors’ ability to decide where the patient volume sweet spot is—whether through a production-based salary or other methods. Don’t let this decision be based too heavily on things such as survey data and the decisions of hospital executives.

Closing Thoughts

My goal in writing this column is to stimulate your thinking about your own practice—not to provide a prescription for the one right way to operate a practice. After all, the best way to operate a practice varies from one place to the next.

I plan to address controversial topics regularly, hoping to achieve two objectives. The first is that some of my ramblings help you think about the best way to operate your own practice. The second is that some of you might decide to e-mail us (at [email protected]) your point of view—some of which can be printed here so that we can learn from each other about the options for operating a successful practice. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

Editors’ note: This month we begin a new bimonthly column authored by John Nelson, MD. Dr. Nelson will cover practical, real-life topics and ideas for improving your practice in this space during the coming months.

Are you pretty sure your workload is in the sweet spot? That is, do you think you’re seeing the “right” number of patients? For most of us this isn’t an easy question to answer. My wife figured this out a long time ago. When she asked me “So how was it today?” at the end of the work day, I would nearly always answer “Too busy” or “Too slow.” On the rare occasion I enthusiastically said the day’s workload was “just right” she would nearly fall out of her chair. (Disclosure: Now the way I really answer her question most often is to say, “It was OK. How was your day?” I learned that the constant too busy/too slow answers are a downer and marital accord is served by other responses. I share this hoping you can benefit from my experience, but marital advice isn’t the point of this column.)

How you feel about your workload from day to day is terribly significant, but just how do you decide what the right workload is? More importantly, what can be done if you’re convinced you’re constantly working too hard or at an unsustainable pace?

This month I’ll offer thoughts for those who feel they’re seeing too many patients. In future installments of “Practice Management,” I’ll address those seemingly rare people who think their patient volume is too low.

Comparing Apples with Apples

If you think you’re seeing too many patients, you probably want to know the typical patient volume for hospitalists in practices similar to yours. So it is natural to turn to survey data, such as the SHM Compensation and Productivity Survey, which is published about every two years (results of the 2005-2006 are available to SHM members at www.hospitalmedicine.org).

You might think about how your practice differs from the average practice in the survey to explain why your volume should be higher or lower. Then you might talk with individual hospitalists from other practices, and even the colleagues in your own practice. What is their patient volume and do they think it is too high, too low, or the elusive just right?

So by comparing your workload with external benchmarks, you know the real answer to whether your patient volume is too high or not. Right? Not so fast. Who says you are average and should feel comfortable working at the average pace? Isn’t it possible that the right patient volume for you is different than for others? I think data from other hospitalists serve only as a rough guideline and starting point for deciding about your own volume. Ideally you should have significant latitude to decide where the sweet spot is for yourself. Kudos if you’re in that situation now.

Unfortunately, instead of having a lot of latitude to decide for themselves, many hospitalists complain that their hospital executive/employer insists that they see at least X wRVUs/visits/new encounters (where X is usually heavily influenced by the SHM survey or other database). And it is especially frustrating to have an executive who doesn’t know what it is like to work as a hospitalist decide about the right workload for you.

If you are in a practice where you have little say about how many patients you see, here is a strategy to secure a much greater degree of control over this decision: Offer to decide for yourself and accept the change in your salary that will occur as a result of your patient volume changes. For this to work you will need to have a compensation scheme that has a connection between your production and your income. (Details of such a salary are beyond the scope of this column, but let me assure you it isn’t as complicated or risky as you might fear.)

Case in Point

Let me briefly illustrate with a hypothetical example from an outpatient primary care practice. Doctor A opens a solo office and decides to work 4.5 days a week and see 22 patients each day (11 on the half day). He’s chosen this workload because it seems reasonable, safe for patient care, and rewards him with what he regards as a reasonable salary. In other words, he feels like he has found the sweet spot for workload and income (productivity and compensation).

Dr. A then recruits a partner, Doctor B, whom he pays the same salary as himself and tells Dr. B he must work 4.5 days a week and see the same patient volume as he does. Dr. B is able to conform to this, but isn’t so sure he’s working in his own productivity and compensation sweet spot. Over the next few years the group grows to 10 doctors, all making the same salary, working 4.5 days a week, and seeing the same number of patients each day.

Are all 10 doctors in this practice likely to be happy with their workload? I don’t think so. I’d recommend they look for a way to let each individual doctor decide independently (within some broad boundaries) to work different amounts, varying the number of days worked, or daily patient workload.

A single parent might work only three days a week when childcare is available; an energetic doctor might decide to work five full days a week, and so on. In fact, this is how most private primary care practices operate. And they do this despite complicated decisions about how to allocate overhead between doctors with different levels of productivity, an issue that is usually much less difficult for hospitalists than primary care offices.

But a significant number of hospitalists are in a practice that looks like Dr. A’s. They’re hired at a predetermined salary and then are urged, or required, to see a specified number of patients and work a specified number of days or shifts. A great deal of effort often goes into getting each doctor to handle a workload that is similar to others in the practice. This patient volume/workload target is usually vague until the hospitalists want to add a new doctor and the employer must be convinced the doctors are working very hard. At this point the SHM survey data and other tools often come into play, and patient volume expectations become much clearer through what is often a somewhat unpleasant negotiation.

So if you’re in a situation where a hospital executive or other employer decides the appropriate patient volume for you, think about changing to a compensation system that enables you to decide for yourself the sweet spot between patient volume, days or shifts worked (time off), and income. Most employers—especially hospital executives—are delighted to switch to production-based compensation and let you decide for yourself how many patients you see.

Switching to a salary based significantly—or entirely—on production often raises a number of questions that, again, I’ll address in a future column. But my point here is that it can be quite liberating because it lets you make your own decisions about productivity. It might be the thing that allows each member of your group to decide, within some generous boundaries, just how hard he or she wants to work. And the group as a whole can decide more independently when additional doctors should be added.

I encourage each group to operate in a way that maximizes individual doctors’ ability to decide where the patient volume sweet spot is—whether through a production-based salary or other methods. Don’t let this decision be based too heavily on things such as survey data and the decisions of hospital executives.

Closing Thoughts

My goal in writing this column is to stimulate your thinking about your own practice—not to provide a prescription for the one right way to operate a practice. After all, the best way to operate a practice varies from one place to the next.

I plan to address controversial topics regularly, hoping to achieve two objectives. The first is that some of my ramblings help you think about the best way to operate your own practice. The second is that some of you might decide to e-mail us (at [email protected]) your point of view—some of which can be printed here so that we can learn from each other about the options for operating a successful practice. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

C. Difficile Update

1. Loo VG, Poirier L, Miller MA, et al. A Predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med. 2005 Dec 8;353(23):2442-2449.
2. McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med. 2005 Dec 8;353(23):2433-2441.
3. Warny M, Pepin J, Fang A, et al. Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North American and Europe. Lancet. 2005 Sep 24-30;366(9491):1079-1084.

In 1978, Clostridium difficile was linked to antibiotic-associated diarrhea and pseudomembranous colitis. This spore-forming gram-positive rod causes disease through two toxins—A and B—which can be detected with cytotoxin assays. It colonizes a significant proportion of hospitalized patients, but causes disease in less than 1%. The primary risk factor for developing disease is antibiotic exposure, presumably through disruption of normal gut flora. Outcomes range from mild diarrhea to life-threatening pseudomembranous colitis requiring colectomy.

Since 2000 a number of hospitals in the United States and Canada have witnessed outbreaks of C. difficile characterized by increases in both the incidence and severity of disease. Three recent publications have shed light on the changes in microbiology that have contributed to those findings. All of the studies characterized C. difficile isolates from these outbreaks, and one included information about patient outcomes.

When isolates from the outbreaks were collected, all three studies identified a predominant strain of C. difficile known as NAP1/027. It accounted for 50%-82% of isolates from the outbreaks in these studies. In contrast, NAP1/027 was present in only 14 isolates from a database of more than 6,000 strains isolated in the United States prior to 2001.

NAP1/027 has a number of concerning microbiologic characteristics. It contains a deletion in the gene tcdC, which normally suppresses the production of toxins A and B. Warny, et al. found that the NAP1/027 strain produces levels of toxins A and B that are 16 and 23 times higher, respectively, than a historically dominant strain. NAP1/027 also produces a binary toxin previously uncommon in C. difficile isolates. The role of binary toxin is not well understood, but it may mediate increased pathogenicity. Finally, the NAP1/027 strain displays high levels of fluoroquinolone resistance, which is uncommon in previous strains of C. difficile.

Loo, et al. also studied patient outcomes in 1,703 patients with C. difficile disease outbreaks in 12 Canadian hospitals. The 30-day mortality rate attributable to C. difficile infection was 6.9%, compared with 0.5-5.5% in previous studies. Patients older than 80 had a higher risk of developing C. difficile infection. For those who did, the 30-day mortality rate attributable to C. difficile was more than 10%.

The discovery of the NAP1/027 strain should strengthen our resolve to use antibiotics judiciously, to recognize and treat C. difficile infections promptly, and to implement strict isolation when cases are discovered. Special attention should be given to elderly patients, who may be at higher risk. Finally, it stresses the importance of hospital epidemiology and infection control, areas in which hospitalists can take an active role.—SM

The Controversy of Thrombolytic Therapy in Hemodynamically Stable Patients with Acute PE

Söhne M, Ten Wolde M Boomsma F, et al. Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism. J Thromb Haemost. 2006 Mar;4(3):552-526.

The role of thrombolytic therapy in hemodynamically stable patients with acute pulmonary embolism is controversial. Right ventricular dysfunction can be an indication for thrombolytics in some patients, but clinical examination is limited and emergent echocardiography is unavailable in many institutions. Rapid measurement of brain natriuretic peptide (BNP) as a marker of right ventricular strain may assist with decision-making in the management of acute PE. Söhne, et al, hypothesized that BNP at presentation would predict the risk of recurrent venous thromboembolism (VTE), including fatal pulmonary embolism.

A nested-case control study was performed within a large, randomized-controlled study of initial treatment of pulmonary embolism. Patients with recurrent VTE within three months were each matched to three controls. BNP levels were drawn at baseline, and both hypertension and congestive heart failure were evaluated as potential confounders.

Cases had significantly higher baseline BNP values than controls (2.45 pmol/L versus 0.80 pmol/L). The odds ratio for each unit increase in the (log) BNP was 2.4 (95% CI: 1.5-3.7). Hypertension was not a confounding factor, but patients with a history of congestive heart failure had no association between elevated BNP and recurrent VTE. Using receiver-operating characteristic analysis, the optimal BNP cut-off of 1.25 pmol/L resulted in a sensitivity and specificity for recurrent VTE of 60% and 62%, respectively.

Three recent studies have suggested that BNP can be used to predict adverse outcomes in patients with pulmonary embolism, including mortality and eventual need for mechanical ventilation, cardiopulmonary resuscitation or thrombolysis. In this study, which included only hemodynamically stable patients with acute pulmonary embolism, however, BNP did not independently predict adverse outcomes. Nonetheless, BNP may be a useful adjunct to other clinical data in deciding whether or not to initiate thrombolytic therapy in pulmonary embolism patients without a history of congestive heart failure.—CR

Insulin Therapy in the ICU

Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006 Feb 2;354(5):449-461.

A landmark 2001 study by Van den Berghe, et al. compared tight versus liberal control of blood sugars in surgical ICU patients. The authors found that patients randomized to intensive insulin therapy had decreased mortality during intensive care compared to those receiving conventional treatment (ARR 3.4%, NNT 29).

In this follow-up study, Van den Berghe, et al., shifted the focus toward medical ICU patients. As their previous results were most dramatic in patients who stayed in the ICU for at least five days, they recruited patients expected to require at least three ICU days.

Twelve hundred patients were randomized to receive either conventional (goal BG 180-200 mg/dl) or intensive (goal BG 80-110 mg/dl) insulin treatment. The primary end point was all-cause mortality in the hospital. Secondary outcomes were also defined, including ICU mortality, 90-day mortality, days to weaning from mechanical ventilation, days in the ICU and in the hospital, renal failure, and incidence of bacteremia.

In the intention-to-treat analysis, there was no statistically significant difference in the primary end point of in-hospital mortality. Predefined subgroup analysis of patients who stayed in the ICU longer than three days showed a significant mortality benefit for the intensive insulin regimen (ARR 6.8%, NNT 15). However, in the subgroup of patients staying less than three days in the ICU, there was increased risk of death from all causes (ARI 8.2%, NNH 12). This finding did or did not meet statistical significance depending on the statistical method employed. Some secondary outcome measures assessing morbidity suggested a benefit of intensive insulin therapy. These included a reduction in kidney failure (ARR 3%, NNT 33), earlier weaning from mechanical ventilation, and earlier discharge from the ICU and from the hospital.

The results of this important study are sure to fuel more debate on ideal goals for blood sugar control in the critically ill. The study confirms previous findings that intensive insulin management improves mortality in patients with longer stays in the ICU. As length of stay in the ICU is difficult to predict in advance, the possibility of tight glycemic control increasing mortality in patients with short ICU stays complicates the decision to implement intensive insulin therapy. These results should especially give us pause in extrapolating the original study results to our sick floor patients.—RH

LMWH or UFH for High-Risk Patients with ACS

Mahaffey KW, Cohen M, Garg J, et al. High-risk patients with acute coronary syndromes treated with low-molecular-weight or unfractionated heparin: outcomes at 6 months and 1 year in the SYNERGY trial. JAMA. 2005 Nov 23;294(20):2594-2600.

In July 2004 the SYNERGY (Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors) trial reported 30-day post hospitalization data. This study compared low molecular weight heparin (LMWH) to unfractionated heparin (UFH) during acute coronary syndrome (ACS) and found it “at least as effective” as UFH. Further data extending to six months and 12 months was reported in November.

This prospective, randomized, open-labeled multicentered trial enrolled 9,978 patients and compared LMWH versus UFH in ACS. Enrolled patients had had active ischemic symptoms within 24 hours of enrollment, and met two of the following three criteria:

1. Age 60 or older;
2. Elevated cardiac enzymes; and
3. Ischemic ECG changes other than ST elevations.

All patients were treated with standard medical therapy with 50% in both groups receiving GIIb/IIIa inhibitors. Interventions were pursued equally in both groups of patients; 92% had angiograms within 24 hours, 47% had percutaneous interventions, and 19% underwent coronary artery bypass grafting during the index hospitalization.

Six-month and 12-month data confirmed that LMWH use was noninferior to UFH. At six months there was no significant difference between the groups in frequency of nonfatal MI, further revascularization, CVA, or hospitalization. At 12 months, all cause mortality was found to be equivalent between the two groups. Interestingly, nearly 18% died or experienced nonfatal MI through six months of follow-up and 7.4% died by one-year follow-up, despite aggressive coronary revascularization and high use of evidence-based therapies at the time of hospital discharge.

When compared with other trials, these higher than “normal” rates of death and MI were believed related to the high-risk patient population and a lower threshold of cardiac enzyme abnormality. In this high-risk group of patients, LMWH and UFH appear to be equally safe and efficacious for the treatment of ACS, with equivalent long-term outcomes.—RM TH

C. Difficile Update

1. Loo VG, Poirier L, Miller MA, et al. A Predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med. 2005 Dec 8;353(23):2442-2449.
2. McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med. 2005 Dec 8;353(23):2433-2441.
3. Warny M, Pepin J, Fang A, et al. Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North American and Europe. Lancet. 2005 Sep 24-30;366(9491):1079-1084.

In 1978, Clostridium difficile was linked to antibiotic-associated diarrhea and pseudomembranous colitis. This spore-forming gram-positive rod causes disease through two toxins—A and B—which can be detected with cytotoxin assays. It colonizes a significant proportion of hospitalized patients, but causes disease in less than 1%. The primary risk factor for developing disease is antibiotic exposure, presumably through disruption of normal gut flora. Outcomes range from mild diarrhea to life-threatening pseudomembranous colitis requiring colectomy.

Since 2000 a number of hospitals in the United States and Canada have witnessed outbreaks of C. difficile characterized by increases in both the incidence and severity of disease. Three recent publications have shed light on the changes in microbiology that have contributed to those findings. All of the studies characterized C. difficile isolates from these outbreaks, and one included information about patient outcomes.

When isolates from the outbreaks were collected, all three studies identified a predominant strain of C. difficile known as NAP1/027. It accounted for 50%-82% of isolates from the outbreaks in these studies. In contrast, NAP1/027 was present in only 14 isolates from a database of more than 6,000 strains isolated in the United States prior to 2001.

NAP1/027 has a number of concerning microbiologic characteristics. It contains a deletion in the gene tcdC, which normally suppresses the production of toxins A and B. Warny, et al. found that the NAP1/027 strain produces levels of toxins A and B that are 16 and 23 times higher, respectively, than a historically dominant strain. NAP1/027 also produces a binary toxin previously uncommon in C. difficile isolates. The role of binary toxin is not well understood, but it may mediate increased pathogenicity. Finally, the NAP1/027 strain displays high levels of fluoroquinolone resistance, which is uncommon in previous strains of C. difficile.

Loo, et al. also studied patient outcomes in 1,703 patients with C. difficile disease outbreaks in 12 Canadian hospitals. The 30-day mortality rate attributable to C. difficile infection was 6.9%, compared with 0.5-5.5% in previous studies. Patients older than 80 had a higher risk of developing C. difficile infection. For those who did, the 30-day mortality rate attributable to C. difficile was more than 10%.

The discovery of the NAP1/027 strain should strengthen our resolve to use antibiotics judiciously, to recognize and treat C. difficile infections promptly, and to implement strict isolation when cases are discovered. Special attention should be given to elderly patients, who may be at higher risk. Finally, it stresses the importance of hospital epidemiology and infection control, areas in which hospitalists can take an active role.—SM

The Controversy of Thrombolytic Therapy in Hemodynamically Stable Patients with Acute PE

Söhne M, Ten Wolde M Boomsma F, et al. Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism. J Thromb Haemost. 2006 Mar;4(3):552-526.

The role of thrombolytic therapy in hemodynamically stable patients with acute pulmonary embolism is controversial. Right ventricular dysfunction can be an indication for thrombolytics in some patients, but clinical examination is limited and emergent echocardiography is unavailable in many institutions. Rapid measurement of brain natriuretic peptide (BNP) as a marker of right ventricular strain may assist with decision-making in the management of acute PE. Söhne, et al, hypothesized that BNP at presentation would predict the risk of recurrent venous thromboembolism (VTE), including fatal pulmonary embolism.

A nested-case control study was performed within a large, randomized-controlled study of initial treatment of pulmonary embolism. Patients with recurrent VTE within three months were each matched to three controls. BNP levels were drawn at baseline, and both hypertension and congestive heart failure were evaluated as potential confounders.

Cases had significantly higher baseline BNP values than controls (2.45 pmol/L versus 0.80 pmol/L). The odds ratio for each unit increase in the (log) BNP was 2.4 (95% CI: 1.5-3.7). Hypertension was not a confounding factor, but patients with a history of congestive heart failure had no association between elevated BNP and recurrent VTE. Using receiver-operating characteristic analysis, the optimal BNP cut-off of 1.25 pmol/L resulted in a sensitivity and specificity for recurrent VTE of 60% and 62%, respectively.

Three recent studies have suggested that BNP can be used to predict adverse outcomes in patients with pulmonary embolism, including mortality and eventual need for mechanical ventilation, cardiopulmonary resuscitation or thrombolysis. In this study, which included only hemodynamically stable patients with acute pulmonary embolism, however, BNP did not independently predict adverse outcomes. Nonetheless, BNP may be a useful adjunct to other clinical data in deciding whether or not to initiate thrombolytic therapy in pulmonary embolism patients without a history of congestive heart failure.—CR

Insulin Therapy in the ICU

Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006 Feb 2;354(5):449-461.

A landmark 2001 study by Van den Berghe, et al. compared tight versus liberal control of blood sugars in surgical ICU patients. The authors found that patients randomized to intensive insulin therapy had decreased mortality during intensive care compared to those receiving conventional treatment (ARR 3.4%, NNT 29).

In this follow-up study, Van den Berghe, et al., shifted the focus toward medical ICU patients. As their previous results were most dramatic in patients who stayed in the ICU for at least five days, they recruited patients expected to require at least three ICU days.

Twelve hundred patients were randomized to receive either conventional (goal BG 180-200 mg/dl) or intensive (goal BG 80-110 mg/dl) insulin treatment. The primary end point was all-cause mortality in the hospital. Secondary outcomes were also defined, including ICU mortality, 90-day mortality, days to weaning from mechanical ventilation, days in the ICU and in the hospital, renal failure, and incidence of bacteremia.

In the intention-to-treat analysis, there was no statistically significant difference in the primary end point of in-hospital mortality. Predefined subgroup analysis of patients who stayed in the ICU longer than three days showed a significant mortality benefit for the intensive insulin regimen (ARR 6.8%, NNT 15). However, in the subgroup of patients staying less than three days in the ICU, there was increased risk of death from all causes (ARI 8.2%, NNH 12). This finding did or did not meet statistical significance depending on the statistical method employed. Some secondary outcome measures assessing morbidity suggested a benefit of intensive insulin therapy. These included a reduction in kidney failure (ARR 3%, NNT 33), earlier weaning from mechanical ventilation, and earlier discharge from the ICU and from the hospital.

The results of this important study are sure to fuel more debate on ideal goals for blood sugar control in the critically ill. The study confirms previous findings that intensive insulin management improves mortality in patients with longer stays in the ICU. As length of stay in the ICU is difficult to predict in advance, the possibility of tight glycemic control increasing mortality in patients with short ICU stays complicates the decision to implement intensive insulin therapy. These results should especially give us pause in extrapolating the original study results to our sick floor patients.—RH

LMWH or UFH for High-Risk Patients with ACS

Mahaffey KW, Cohen M, Garg J, et al. High-risk patients with acute coronary syndromes treated with low-molecular-weight or unfractionated heparin: outcomes at 6 months and 1 year in the SYNERGY trial. JAMA. 2005 Nov 23;294(20):2594-2600.

In July 2004 the SYNERGY (Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors) trial reported 30-day post hospitalization data. This study compared low molecular weight heparin (LMWH) to unfractionated heparin (UFH) during acute coronary syndrome (ACS) and found it “at least as effective” as UFH. Further data extending to six months and 12 months was reported in November.

This prospective, randomized, open-labeled multicentered trial enrolled 9,978 patients and compared LMWH versus UFH in ACS. Enrolled patients had had active ischemic symptoms within 24 hours of enrollment, and met two of the following three criteria:

1. Age 60 or older;
2. Elevated cardiac enzymes; and
3. Ischemic ECG changes other than ST elevations.

All patients were treated with standard medical therapy with 50% in both groups receiving GIIb/IIIa inhibitors. Interventions were pursued equally in both groups of patients; 92% had angiograms within 24 hours, 47% had percutaneous interventions, and 19% underwent coronary artery bypass grafting during the index hospitalization.

Six-month and 12-month data confirmed that LMWH use was noninferior to UFH. At six months there was no significant difference between the groups in frequency of nonfatal MI, further revascularization, CVA, or hospitalization. At 12 months, all cause mortality was found to be equivalent between the two groups. Interestingly, nearly 18% died or experienced nonfatal MI through six months of follow-up and 7.4% died by one-year follow-up, despite aggressive coronary revascularization and high use of evidence-based therapies at the time of hospital discharge.

When compared with other trials, these higher than “normal” rates of death and MI were believed related to the high-risk patient population and a lower threshold of cardiac enzyme abnormality. In this high-risk group of patients, LMWH and UFH appear to be equally safe and efficacious for the treatment of ACS, with equivalent long-term outcomes.—RM TH

C. Difficile Update

1. Loo VG, Poirier L, Miller MA, et al. A Predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med. 2005 Dec 8;353(23):2442-2449.
2. McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med. 2005 Dec 8;353(23):2433-2441.
3. Warny M, Pepin J, Fang A, et al. Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North American and Europe. Lancet. 2005 Sep 24-30;366(9491):1079-1084.

In 1978, Clostridium difficile was linked to antibiotic-associated diarrhea and pseudomembranous colitis. This spore-forming gram-positive rod causes disease through two toxins—A and B—which can be detected with cytotoxin assays. It colonizes a significant proportion of hospitalized patients, but causes disease in less than 1%. The primary risk factor for developing disease is antibiotic exposure, presumably through disruption of normal gut flora. Outcomes range from mild diarrhea to life-threatening pseudomembranous colitis requiring colectomy.

Since 2000 a number of hospitals in the United States and Canada have witnessed outbreaks of C. difficile characterized by increases in both the incidence and severity of disease. Three recent publications have shed light on the changes in microbiology that have contributed to those findings. All of the studies characterized C. difficile isolates from these outbreaks, and one included information about patient outcomes.

When isolates from the outbreaks were collected, all three studies identified a predominant strain of C. difficile known as NAP1/027. It accounted for 50%-82% of isolates from the outbreaks in these studies. In contrast, NAP1/027 was present in only 14 isolates from a database of more than 6,000 strains isolated in the United States prior to 2001.

NAP1/027 has a number of concerning microbiologic characteristics. It contains a deletion in the gene tcdC, which normally suppresses the production of toxins A and B. Warny, et al. found that the NAP1/027 strain produces levels of toxins A and B that are 16 and 23 times higher, respectively, than a historically dominant strain. NAP1/027 also produces a binary toxin previously uncommon in C. difficile isolates. The role of binary toxin is not well understood, but it may mediate increased pathogenicity. Finally, the NAP1/027 strain displays high levels of fluoroquinolone resistance, which is uncommon in previous strains of C. difficile.

Loo, et al. also studied patient outcomes in 1,703 patients with C. difficile disease outbreaks in 12 Canadian hospitals. The 30-day mortality rate attributable to C. difficile infection was 6.9%, compared with 0.5-5.5% in previous studies. Patients older than 80 had a higher risk of developing C. difficile infection. For those who did, the 30-day mortality rate attributable to C. difficile was more than 10%.

The discovery of the NAP1/027 strain should strengthen our resolve to use antibiotics judiciously, to recognize and treat C. difficile infections promptly, and to implement strict isolation when cases are discovered. Special attention should be given to elderly patients, who may be at higher risk. Finally, it stresses the importance of hospital epidemiology and infection control, areas in which hospitalists can take an active role.—SM

The Controversy of Thrombolytic Therapy in Hemodynamically Stable Patients with Acute PE

Söhne M, Ten Wolde M Boomsma F, et al. Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism. J Thromb Haemost. 2006 Mar;4(3):552-526.

The role of thrombolytic therapy in hemodynamically stable patients with acute pulmonary embolism is controversial. Right ventricular dysfunction can be an indication for thrombolytics in some patients, but clinical examination is limited and emergent echocardiography is unavailable in many institutions. Rapid measurement of brain natriuretic peptide (BNP) as a marker of right ventricular strain may assist with decision-making in the management of acute PE. Söhne, et al, hypothesized that BNP at presentation would predict the risk of recurrent venous thromboembolism (VTE), including fatal pulmonary embolism.

A nested-case control study was performed within a large, randomized-controlled study of initial treatment of pulmonary embolism. Patients with recurrent VTE within three months were each matched to three controls. BNP levels were drawn at baseline, and both hypertension and congestive heart failure were evaluated as potential confounders.

Cases had significantly higher baseline BNP values than controls (2.45 pmol/L versus 0.80 pmol/L). The odds ratio for each unit increase in the (log) BNP was 2.4 (95% CI: 1.5-3.7). Hypertension was not a confounding factor, but patients with a history of congestive heart failure had no association between elevated BNP and recurrent VTE. Using receiver-operating characteristic analysis, the optimal BNP cut-off of 1.25 pmol/L resulted in a sensitivity and specificity for recurrent VTE of 60% and 62%, respectively.

Three recent studies have suggested that BNP can be used to predict adverse outcomes in patients with pulmonary embolism, including mortality and eventual need for mechanical ventilation, cardiopulmonary resuscitation or thrombolysis. In this study, which included only hemodynamically stable patients with acute pulmonary embolism, however, BNP did not independently predict adverse outcomes. Nonetheless, BNP may be a useful adjunct to other clinical data in deciding whether or not to initiate thrombolytic therapy in pulmonary embolism patients without a history of congestive heart failure.—CR

Insulin Therapy in the ICU

Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006 Feb 2;354(5):449-461.

A landmark 2001 study by Van den Berghe, et al. compared tight versus liberal control of blood sugars in surgical ICU patients. The authors found that patients randomized to intensive insulin therapy had decreased mortality during intensive care compared to those receiving conventional treatment (ARR 3.4%, NNT 29).

In this follow-up study, Van den Berghe, et al., shifted the focus toward medical ICU patients. As their previous results were most dramatic in patients who stayed in the ICU for at least five days, they recruited patients expected to require at least three ICU days.

Twelve hundred patients were randomized to receive either conventional (goal BG 180-200 mg/dl) or intensive (goal BG 80-110 mg/dl) insulin treatment. The primary end point was all-cause mortality in the hospital. Secondary outcomes were also defined, including ICU mortality, 90-day mortality, days to weaning from mechanical ventilation, days in the ICU and in the hospital, renal failure, and incidence of bacteremia.

In the intention-to-treat analysis, there was no statistically significant difference in the primary end point of in-hospital mortality. Predefined subgroup analysis of patients who stayed in the ICU longer than three days showed a significant mortality benefit for the intensive insulin regimen (ARR 6.8%, NNT 15). However, in the subgroup of patients staying less than three days in the ICU, there was increased risk of death from all causes (ARI 8.2%, NNH 12). This finding did or did not meet statistical significance depending on the statistical method employed. Some secondary outcome measures assessing morbidity suggested a benefit of intensive insulin therapy. These included a reduction in kidney failure (ARR 3%, NNT 33), earlier weaning from mechanical ventilation, and earlier discharge from the ICU and from the hospital.

The results of this important study are sure to fuel more debate on ideal goals for blood sugar control in the critically ill. The study confirms previous findings that intensive insulin management improves mortality in patients with longer stays in the ICU. As length of stay in the ICU is difficult to predict in advance, the possibility of tight glycemic control increasing mortality in patients with short ICU stays complicates the decision to implement intensive insulin therapy. These results should especially give us pause in extrapolating the original study results to our sick floor patients.—RH

LMWH or UFH for High-Risk Patients with ACS

Mahaffey KW, Cohen M, Garg J, et al. High-risk patients with acute coronary syndromes treated with low-molecular-weight or unfractionated heparin: outcomes at 6 months and 1 year in the SYNERGY trial. JAMA. 2005 Nov 23;294(20):2594-2600.

In July 2004 the SYNERGY (Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors) trial reported 30-day post hospitalization data. This study compared low molecular weight heparin (LMWH) to unfractionated heparin (UFH) during acute coronary syndrome (ACS) and found it “at least as effective” as UFH. Further data extending to six months and 12 months was reported in November.

This prospective, randomized, open-labeled multicentered trial enrolled 9,978 patients and compared LMWH versus UFH in ACS. Enrolled patients had had active ischemic symptoms within 24 hours of enrollment, and met two of the following three criteria:

1. Age 60 or older;
2. Elevated cardiac enzymes; and
3. Ischemic ECG changes other than ST elevations.

All patients were treated with standard medical therapy with 50% in both groups receiving GIIb/IIIa inhibitors. Interventions were pursued equally in both groups of patients; 92% had angiograms within 24 hours, 47% had percutaneous interventions, and 19% underwent coronary artery bypass grafting during the index hospitalization.

Six-month and 12-month data confirmed that LMWH use was noninferior to UFH. At six months there was no significant difference between the groups in frequency of nonfatal MI, further revascularization, CVA, or hospitalization. At 12 months, all cause mortality was found to be equivalent between the two groups. Interestingly, nearly 18% died or experienced nonfatal MI through six months of follow-up and 7.4% died by one-year follow-up, despite aggressive coronary revascularization and high use of evidence-based therapies at the time of hospital discharge.

When compared with other trials, these higher than “normal” rates of death and MI were believed related to the high-risk patient population and a lower threshold of cardiac enzyme abnormality. In this high-risk group of patients, LMWH and UFH appear to be equally safe and efficacious for the treatment of ACS, with equivalent long-term outcomes.—RM TH

Look at hospitalists and you’ll find more gray hair, crow’s feet, and accumulated wisdom than you might expect. While many hospitalists are physicians fresh from residency, the average age of a hospitalist is actually 40—in part because some hospitalist are docs who have left office practices in favor of hospital work.

These docs, who we’ll call “mid-career hospitalists,” take diverse paths to this change. Some miss the adrenaline rush of acute care. Others have become weary of the flat reimbursements and high patient volumes needed to maintain office practices today. Whatever their paths, they’re an interesting lot.

The most common scenario by which mid-career hospitalists make a transition is when hospital administrators recruit their own. That’s how Robert Brannon, MD, an Ob/Gyn in private practice since 1968, became a hospitalist at Presbyterian Hospital of Dallas in July 2005. Shrinking reimbursements, the costs of running an office, having to cover night call, and a national request for proposal (RFP) by the hospital precipitated Dr. Brannon’s career move.

He and nine other Ob/Gyns submitted a proposal in response to the RFP; hospital administrators awarded the group, OB on Call, LLP, a contract to start a hospitalist service for a largely indigent population in a hospital with more than 7,000 births annually.

I had already started to phase out the office practice and was working in a Medicaid clinic and an osteoporosis clinic when the hospital decided it had to do better with its indigent patients, particularly the 80 to 90 each month who came in with no prenatal care,” says Dr. Brannon. “The medical staff knew that resident work rules precluded their work off hours, so patient needs indicated that full-time hospitalists were in order.”

Now Dr. Brannon has the camaraderie of working with other hospitalists and neonatologists, delivering many babies, but still eliminating on-call obligations when he’s off duty.

“I’m doing more significant obstetrics work, re-honing my skills, and doing high-risk deliveries,” he says. “I’m doing what I love without the administrative hassles of a private practice.”

Jeffrey Frank, MD, had an even bigger nut to crack when he switched from an office-based practice to start a hospitalist medicine service at Doctors Medical Center (DMC) in San Pablo, Calif. The 45-year-old internist graduated from medical school in 1987 and worked in a four-person medical group in the area he describes as “very industrial, with oil refineries all around and the home base of the Hells Angels.”

Helping to cover hospitalized patients for five HMOs precipitated his career change. “That was a mini-hospitalist assignment, and I felt I could adapt to full-time,” says Dr. Frank.

On DMC’s medical staff for years, Dr. Frank saw the hospital go from first in market share to a distant second after entrepreneurial doctors built a newer hospital north of town. Dr. Frank’s patients were aging and the prospects for improving the office practice were poor. Then there was Dr. Frank’s 800-pound gorilla: Kaiser-Permanente, a giant with 45% market share, with plans geared to younger patients, and physician salaries that his group couldn’t match. DMC continued slowly downhill, with closure a real risk.

In 2004, with his family’s acceptance of the long hours that launching a hospitalist program would take, Dr. Frank initiated discussions with hospital administrators to become its first chief hospitalist. Rather than leaving the office practice and launching a hospitalist service simultaneously, Dr. Frank approached established vendors for help. He chose IPC for its technology infrastructure and electronic medical records, competitive salaries, and the hope of attracting more physicians, whom Dr. Frank eventually recruited locally.

He built the hospitalist patient base by admitting all patients of the two largest medical groups. His entrepreneurial spirit intrigued both IPC and the hospital’s chief financial officer by reducing the average length of stay from 5.3 to 4.0 days, which improved the bottom line. Dr. Frank’s salary then increased by 30%. He says he loves doing acute care again and sees many of his former patients because the medical group has transferred hospital work to the hospitalists.

I was worried about being at the hospital all the time. I’m 45 years old, but energetic because there’s lots of work. I can keep up with three of the hospitalists just out of residency. Seeing my old patients also connects me to my old practice.

—Jeffrey Frank, MD

“I was worried about being at the hospital all the time,” says Dr. Frank. “I’m 45 years old, but energetic because there’s lots of work. I can keep up with three of the hospitalists just out of residency. Seeing my old patients also connects me to my old practice.”

Across the country in Hollywood, Fla., Scott Oxenhandler, MD, a geriatrician, couldn’t be happier with his mid-career change from office-based doctor to hospitalist. He left a thriving practice of eight physicians he helped start in 1987 to be chief hospitalist at Hollywood Memorial Regional Hospital (Fla.). Seeing five to eight hospitalized patients every day as their primary physician, he knew the hospital’s inner workings and how to start a hospitalist program—largely for unassigned patients.

“I wanted a free hand practicing acute care medicine, good compensation and benefits, lack of paperwork hassles, and a great schedule,” says Dr. Oxenhandler.

When he started in July 2004 Dr. Oxenhandler had no problem structuring a hospital medicine service that attracted physicians with competitive salaries and schedules to accommodate individual needs. He now has 21 full- and part-time hospitalists. They mostly work 8 a.m. to 5 p.m. with an average daily census of 12 to 15 and several consults. A nocturnist admits patients from 8 p.m. to 8 a.m., and 10 doctors handle 5 p.m. to 8 p.m. short call four times per month.

Overall, the transition for the 48-year-old veteran was surprisingly easy. “I was in the hospital all the time anyway, and the way internal medicine is evolving there have to be connections between inpatient and outpatient doctors,” says Dr. Oxenhandler. As the hospitalist leader he mentors young doctors, knows how to distribute the workload, and loves to share clinical insights.

Other Paths

For a doctor who finished residency at nearly 40, “mid-career change” takes on new meaning. Ron Jacobs, MD, internist, chief medical officer, and co-founder of PrimeDoc Management Services of Asheville, N.C., was a businessman in his 20s, then studied medicine and started an office practice in 1997. That practice—with four internists, a pulmonologist, and a cardiologist—was thriving. But Dr. Jacobs was bored. He missed the hospital’s intensity, was used to visiting six or eight hospitalized patients daily, and decided that seeing 16 or 18 patients without the office practice would suit him. So he co-founded PrimeDoc, which now has 100 hospitalists practicing in 15 programs throughout the Southeast and Mid-Atlantic.

The 49-year-old doctor eases the transition for other mid-lifers, recognizing that avoiding burnout as a hospitalist requires mental and physical preparation.

“The sheer volume of rounding, whether for an [average daily census] of 18 or 13 consults a day is tough,” says Dr. Jacobs. “They’ve got to be solid internists with strong ICU skills. I like diverse teams of older and younger docs. They work well because a team of hospitalists all just out of residency can easily burn out. They need the experience and mentoring of older docs to augment their up-to-date clinical skills.”

Academia is also fertile ground for mid-career changes. A doctor with an office practice and a faculty appointment may someday close the office and return to the hospital he or she loves. (See the profile of Joseph Snitzer, MD: “Sibling Rivalry,” in The Hospitalist, Sept. 2005.) Scott Wilson, MD, of The University of Iowa Hospitals and Clinic, Rapid City, left to start a hospitalist program in 2000 for the 880-bed University Hospital and its 250-bed Veterans Affairs Hospital after many years of teaching in the medical school. Dr. Wilson was tapped to start the hospitalist program because of improvements he had made in educating physicians.

I like diverse teams of older and younger docs. They work well because a team of hospitalists all just out of residency can easily burn out. They need the experience and mentoring of older docs to augment their up-to-date clinical skills.

—Ron Jacobs, MD

“Our program has some unique features, particularly our interaction with residents, improving the med school curriculum, and building research into our practice,” says Dr. Wilson.

In 2004 that included a study showing that patients managed by hospitalists had shorter length of stay (LOS) and lower costs than patients managed by non-hospitalists, but had higher costs per day. (Kaboli PJ, Barnett MJ, Rosenthal GE. Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004 Aug;10 (8):561-568). The schedule’s tough for a non-20-something: call every fourth night, three-week blocks for six months, then six months of research.

Dr. Wilson enjoys the challenge and the $1 million hospital support the program garnered in 2005. “We meet their needs to reduce LOS and improve quality, and we keep growing our program through new tasks such as surgical co-management of orthopedics,” he says.

Recruiting Them

Hospital administrators who want to recruit mid-career physicians as hospitalists need look no further than their own backyards. The internist or family practice doctor who relishes hospital rounds but has to rush back to the office, such as Dr. Oxenhandler, is a prime candidate for hospitalist recruitment. Areas where medical groups have trouble recruiting new doctors because reimbursements are flat (e.g., San Pablo) are also fertile ground for recruiting. Entrepreneurial physicians like Drs. Brannon and Jacobs, who had already dabbled in other medical careers before becoming hospitalists, are another choice.

Doctors in each of these categories are still brimming with energy and enthusiasm for medicine and are a looking for ways to make things better for patients and themselves. They might be your next hospitalist recruit. TH

Look at hospitalists and you’ll find more gray hair, crow’s feet, and accumulated wisdom than you might expect. While many hospitalists are physicians fresh from residency, the average age of a hospitalist is actually 40—in part because some hospitalist are docs who have left office practices in favor of hospital work.

These docs, who we’ll call “mid-career hospitalists,” take diverse paths to this change. Some miss the adrenaline rush of acute care. Others have become weary of the flat reimbursements and high patient volumes needed to maintain office practices today. Whatever their paths, they’re an interesting lot.

The most common scenario by which mid-career hospitalists make a transition is when hospital administrators recruit their own. That’s how Robert Brannon, MD, an Ob/Gyn in private practice since 1968, became a hospitalist at Presbyterian Hospital of Dallas in July 2005. Shrinking reimbursements, the costs of running an office, having to cover night call, and a national request for proposal (RFP) by the hospital precipitated Dr. Brannon’s career move.

He and nine other Ob/Gyns submitted a proposal in response to the RFP; hospital administrators awarded the group, OB on Call, LLP, a contract to start a hospitalist service for a largely indigent population in a hospital with more than 7,000 births annually.

I had already started to phase out the office practice and was working in a Medicaid clinic and an osteoporosis clinic when the hospital decided it had to do better with its indigent patients, particularly the 80 to 90 each month who came in with no prenatal care,” says Dr. Brannon. “The medical staff knew that resident work rules precluded their work off hours, so patient needs indicated that full-time hospitalists were in order.”

Now Dr. Brannon has the camaraderie of working with other hospitalists and neonatologists, delivering many babies, but still eliminating on-call obligations when he’s off duty.

“I’m doing more significant obstetrics work, re-honing my skills, and doing high-risk deliveries,” he says. “I’m doing what I love without the administrative hassles of a private practice.”

Jeffrey Frank, MD, had an even bigger nut to crack when he switched from an office-based practice to start a hospitalist medicine service at Doctors Medical Center (DMC) in San Pablo, Calif. The 45-year-old internist graduated from medical school in 1987 and worked in a four-person medical group in the area he describes as “very industrial, with oil refineries all around and the home base of the Hells Angels.”

Helping to cover hospitalized patients for five HMOs precipitated his career change. “That was a mini-hospitalist assignment, and I felt I could adapt to full-time,” says Dr. Frank.

On DMC’s medical staff for years, Dr. Frank saw the hospital go from first in market share to a distant second after entrepreneurial doctors built a newer hospital north of town. Dr. Frank’s patients were aging and the prospects for improving the office practice were poor. Then there was Dr. Frank’s 800-pound gorilla: Kaiser-Permanente, a giant with 45% market share, with plans geared to younger patients, and physician salaries that his group couldn’t match. DMC continued slowly downhill, with closure a real risk.

In 2004, with his family’s acceptance of the long hours that launching a hospitalist program would take, Dr. Frank initiated discussions with hospital administrators to become its first chief hospitalist. Rather than leaving the office practice and launching a hospitalist service simultaneously, Dr. Frank approached established vendors for help. He chose IPC for its technology infrastructure and electronic medical records, competitive salaries, and the hope of attracting more physicians, whom Dr. Frank eventually recruited locally.

He built the hospitalist patient base by admitting all patients of the two largest medical groups. His entrepreneurial spirit intrigued both IPC and the hospital’s chief financial officer by reducing the average length of stay from 5.3 to 4.0 days, which improved the bottom line. Dr. Frank’s salary then increased by 30%. He says he loves doing acute care again and sees many of his former patients because the medical group has transferred hospital work to the hospitalists.

I was worried about being at the hospital all the time. I’m 45 years old, but energetic because there’s lots of work. I can keep up with three of the hospitalists just out of residency. Seeing my old patients also connects me to my old practice.

—Jeffrey Frank, MD

“I was worried about being at the hospital all the time,” says Dr. Frank. “I’m 45 years old, but energetic because there’s lots of work. I can keep up with three of the hospitalists just out of residency. Seeing my old patients also connects me to my old practice.”

Across the country in Hollywood, Fla., Scott Oxenhandler, MD, a geriatrician, couldn’t be happier with his mid-career change from office-based doctor to hospitalist. He left a thriving practice of eight physicians he helped start in 1987 to be chief hospitalist at Hollywood Memorial Regional Hospital (Fla.). Seeing five to eight hospitalized patients every day as their primary physician, he knew the hospital’s inner workings and how to start a hospitalist program—largely for unassigned patients.

“I wanted a free hand practicing acute care medicine, good compensation and benefits, lack of paperwork hassles, and a great schedule,” says Dr. Oxenhandler.

When he started in July 2004 Dr. Oxenhandler had no problem structuring a hospital medicine service that attracted physicians with competitive salaries and schedules to accommodate individual needs. He now has 21 full- and part-time hospitalists. They mostly work 8 a.m. to 5 p.m. with an average daily census of 12 to 15 and several consults. A nocturnist admits patients from 8 p.m. to 8 a.m., and 10 doctors handle 5 p.m. to 8 p.m. short call four times per month.

Overall, the transition for the 48-year-old veteran was surprisingly easy. “I was in the hospital all the time anyway, and the way internal medicine is evolving there have to be connections between inpatient and outpatient doctors,” says Dr. Oxenhandler. As the hospitalist leader he mentors young doctors, knows how to distribute the workload, and loves to share clinical insights.

Other Paths

For a doctor who finished residency at nearly 40, “mid-career change” takes on new meaning. Ron Jacobs, MD, internist, chief medical officer, and co-founder of PrimeDoc Management Services of Asheville, N.C., was a businessman in his 20s, then studied medicine and started an office practice in 1997. That practice—with four internists, a pulmonologist, and a cardiologist—was thriving. But Dr. Jacobs was bored. He missed the hospital’s intensity, was used to visiting six or eight hospitalized patients daily, and decided that seeing 16 or 18 patients without the office practice would suit him. So he co-founded PrimeDoc, which now has 100 hospitalists practicing in 15 programs throughout the Southeast and Mid-Atlantic.

The 49-year-old doctor eases the transition for other mid-lifers, recognizing that avoiding burnout as a hospitalist requires mental and physical preparation.

“The sheer volume of rounding, whether for an [average daily census] of 18 or 13 consults a day is tough,” says Dr. Jacobs. “They’ve got to be solid internists with strong ICU skills. I like diverse teams of older and younger docs. They work well because a team of hospitalists all just out of residency can easily burn out. They need the experience and mentoring of older docs to augment their up-to-date clinical skills.”

Academia is also fertile ground for mid-career changes. A doctor with an office practice and a faculty appointment may someday close the office and return to the hospital he or she loves. (See the profile of Joseph Snitzer, MD: “Sibling Rivalry,” in The Hospitalist, Sept. 2005.) Scott Wilson, MD, of The University of Iowa Hospitals and Clinic, Rapid City, left to start a hospitalist program in 2000 for the 880-bed University Hospital and its 250-bed Veterans Affairs Hospital after many years of teaching in the medical school. Dr. Wilson was tapped to start the hospitalist program because of improvements he had made in educating physicians.

I like diverse teams of older and younger docs. They work well because a team of hospitalists all just out of residency can easily burn out. They need the experience and mentoring of older docs to augment their up-to-date clinical skills.

—Ron Jacobs, MD

“Our program has some unique features, particularly our interaction with residents, improving the med school curriculum, and building research into our practice,” says Dr. Wilson.

In 2004 that included a study showing that patients managed by hospitalists had shorter length of stay (LOS) and lower costs than patients managed by non-hospitalists, but had higher costs per day. (Kaboli PJ, Barnett MJ, Rosenthal GE. Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004 Aug;10 (8):561-568). The schedule’s tough for a non-20-something: call every fourth night, three-week blocks for six months, then six months of research.

Dr. Wilson enjoys the challenge and the $1 million hospital support the program garnered in 2005. “We meet their needs to reduce LOS and improve quality, and we keep growing our program through new tasks such as surgical co-management of orthopedics,” he says.

Recruiting Them

Hospital administrators who want to recruit mid-career physicians as hospitalists need look no further than their own backyards. The internist or family practice doctor who relishes hospital rounds but has to rush back to the office, such as Dr. Oxenhandler, is a prime candidate for hospitalist recruitment. Areas where medical groups have trouble recruiting new doctors because reimbursements are flat (e.g., San Pablo) are also fertile ground for recruiting. Entrepreneurial physicians like Drs. Brannon and Jacobs, who had already dabbled in other medical careers before becoming hospitalists, are another choice.

Doctors in each of these categories are still brimming with energy and enthusiasm for medicine and are a looking for ways to make things better for patients and themselves. They might be your next hospitalist recruit. TH

Look at hospitalists and you’ll find more gray hair, crow’s feet, and accumulated wisdom than you might expect. While many hospitalists are physicians fresh from residency, the average age of a hospitalist is actually 40—in part because some hospitalist are docs who have left office practices in favor of hospital work.

These docs, who we’ll call “mid-career hospitalists,” take diverse paths to this change. Some miss the adrenaline rush of acute care. Others have become weary of the flat reimbursements and high patient volumes needed to maintain office practices today. Whatever their paths, they’re an interesting lot.

The most common scenario by which mid-career hospitalists make a transition is when hospital administrators recruit their own. That’s how Robert Brannon, MD, an Ob/Gyn in private practice since 1968, became a hospitalist at Presbyterian Hospital of Dallas in July 2005. Shrinking reimbursements, the costs of running an office, having to cover night call, and a national request for proposal (RFP) by the hospital precipitated Dr. Brannon’s career move.

He and nine other Ob/Gyns submitted a proposal in response to the RFP; hospital administrators awarded the group, OB on Call, LLP, a contract to start a hospitalist service for a largely indigent population in a hospital with more than 7,000 births annually.

I had already started to phase out the office practice and was working in a Medicaid clinic and an osteoporosis clinic when the hospital decided it had to do better with its indigent patients, particularly the 80 to 90 each month who came in with no prenatal care,” says Dr. Brannon. “The medical staff knew that resident work rules precluded their work off hours, so patient needs indicated that full-time hospitalists were in order.”

Now Dr. Brannon has the camaraderie of working with other hospitalists and neonatologists, delivering many babies, but still eliminating on-call obligations when he’s off duty.

“I’m doing more significant obstetrics work, re-honing my skills, and doing high-risk deliveries,” he says. “I’m doing what I love without the administrative hassles of a private practice.”

Jeffrey Frank, MD, had an even bigger nut to crack when he switched from an office-based practice to start a hospitalist medicine service at Doctors Medical Center (DMC) in San Pablo, Calif. The 45-year-old internist graduated from medical school in 1987 and worked in a four-person medical group in the area he describes as “very industrial, with oil refineries all around and the home base of the Hells Angels.”

Helping to cover hospitalized patients for five HMOs precipitated his career change. “That was a mini-hospitalist assignment, and I felt I could adapt to full-time,” says Dr. Frank.

On DMC’s medical staff for years, Dr. Frank saw the hospital go from first in market share to a distant second after entrepreneurial doctors built a newer hospital north of town. Dr. Frank’s patients were aging and the prospects for improving the office practice were poor. Then there was Dr. Frank’s 800-pound gorilla: Kaiser-Permanente, a giant with 45% market share, with plans geared to younger patients, and physician salaries that his group couldn’t match. DMC continued slowly downhill, with closure a real risk.

In 2004, with his family’s acceptance of the long hours that launching a hospitalist program would take, Dr. Frank initiated discussions with hospital administrators to become its first chief hospitalist. Rather than leaving the office practice and launching a hospitalist service simultaneously, Dr. Frank approached established vendors for help. He chose IPC for its technology infrastructure and electronic medical records, competitive salaries, and the hope of attracting more physicians, whom Dr. Frank eventually recruited locally.

He built the hospitalist patient base by admitting all patients of the two largest medical groups. His entrepreneurial spirit intrigued both IPC and the hospital’s chief financial officer by reducing the average length of stay from 5.3 to 4.0 days, which improved the bottom line. Dr. Frank’s salary then increased by 30%. He says he loves doing acute care again and sees many of his former patients because the medical group has transferred hospital work to the hospitalists.

I was worried about being at the hospital all the time. I’m 45 years old, but energetic because there’s lots of work. I can keep up with three of the hospitalists just out of residency. Seeing my old patients also connects me to my old practice.

—Jeffrey Frank, MD

“I was worried about being at the hospital all the time,” says Dr. Frank. “I’m 45 years old, but energetic because there’s lots of work. I can keep up with three of the hospitalists just out of residency. Seeing my old patients also connects me to my old practice.”

Across the country in Hollywood, Fla., Scott Oxenhandler, MD, a geriatrician, couldn’t be happier with his mid-career change from office-based doctor to hospitalist. He left a thriving practice of eight physicians he helped start in 1987 to be chief hospitalist at Hollywood Memorial Regional Hospital (Fla.). Seeing five to eight hospitalized patients every day as their primary physician, he knew the hospital’s inner workings and how to start a hospitalist program—largely for unassigned patients.

“I wanted a free hand practicing acute care medicine, good compensation and benefits, lack of paperwork hassles, and a great schedule,” says Dr. Oxenhandler.

When he started in July 2004 Dr. Oxenhandler had no problem structuring a hospital medicine service that attracted physicians with competitive salaries and schedules to accommodate individual needs. He now has 21 full- and part-time hospitalists. They mostly work 8 a.m. to 5 p.m. with an average daily census of 12 to 15 and several consults. A nocturnist admits patients from 8 p.m. to 8 a.m., and 10 doctors handle 5 p.m. to 8 p.m. short call four times per month.

Overall, the transition for the 48-year-old veteran was surprisingly easy. “I was in the hospital all the time anyway, and the way internal medicine is evolving there have to be connections between inpatient and outpatient doctors,” says Dr. Oxenhandler. As the hospitalist leader he mentors young doctors, knows how to distribute the workload, and loves to share clinical insights.

Other Paths

For a doctor who finished residency at nearly 40, “mid-career change” takes on new meaning. Ron Jacobs, MD, internist, chief medical officer, and co-founder of PrimeDoc Management Services of Asheville, N.C., was a businessman in his 20s, then studied medicine and started an office practice in 1997. That practice—with four internists, a pulmonologist, and a cardiologist—was thriving. But Dr. Jacobs was bored. He missed the hospital’s intensity, was used to visiting six or eight hospitalized patients daily, and decided that seeing 16 or 18 patients without the office practice would suit him. So he co-founded PrimeDoc, which now has 100 hospitalists practicing in 15 programs throughout the Southeast and Mid-Atlantic.

The 49-year-old doctor eases the transition for other mid-lifers, recognizing that avoiding burnout as a hospitalist requires mental and physical preparation.

“The sheer volume of rounding, whether for an [average daily census] of 18 or 13 consults a day is tough,” says Dr. Jacobs. “They’ve got to be solid internists with strong ICU skills. I like diverse teams of older and younger docs. They work well because a team of hospitalists all just out of residency can easily burn out. They need the experience and mentoring of older docs to augment their up-to-date clinical skills.”

Academia is also fertile ground for mid-career changes. A doctor with an office practice and a faculty appointment may someday close the office and return to the hospital he or she loves. (See the profile of Joseph Snitzer, MD: “Sibling Rivalry,” in The Hospitalist, Sept. 2005.) Scott Wilson, MD, of The University of Iowa Hospitals and Clinic, Rapid City, left to start a hospitalist program in 2000 for the 880-bed University Hospital and its 250-bed Veterans Affairs Hospital after many years of teaching in the medical school. Dr. Wilson was tapped to start the hospitalist program because of improvements he had made in educating physicians.

I like diverse teams of older and younger docs. They work well because a team of hospitalists all just out of residency can easily burn out. They need the experience and mentoring of older docs to augment their up-to-date clinical skills.

—Ron Jacobs, MD

“Our program has some unique features, particularly our interaction with residents, improving the med school curriculum, and building research into our practice,” says Dr. Wilson.

In 2004 that included a study showing that patients managed by hospitalists had shorter length of stay (LOS) and lower costs than patients managed by non-hospitalists, but had higher costs per day. (Kaboli PJ, Barnett MJ, Rosenthal GE. Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004 Aug;10 (8):561-568). The schedule’s tough for a non-20-something: call every fourth night, three-week blocks for six months, then six months of research.

Dr. Wilson enjoys the challenge and the $1 million hospital support the program garnered in 2005. “We meet their needs to reduce LOS and improve quality, and we keep growing our program through new tasks such as surgical co-management of orthopedics,” he says.

Recruiting Them

Hospital administrators who want to recruit mid-career physicians as hospitalists need look no further than their own backyards. The internist or family practice doctor who relishes hospital rounds but has to rush back to the office, such as Dr. Oxenhandler, is a prime candidate for hospitalist recruitment. Areas where medical groups have trouble recruiting new doctors because reimbursements are flat (e.g., San Pablo) are also fertile ground for recruiting. Entrepreneurial physicians like Drs. Brannon and Jacobs, who had already dabbled in other medical careers before becoming hospitalists, are another choice.

Doctors in each of these categories are still brimming with energy and enthusiasm for medicine and are a looking for ways to make things better for patients and themselves. They might be your next hospitalist recruit. TH

Something didn’t seem quite right. The person in the hooded sweatshirt standing near the entrance looked suspicious to respiratory therapist Betty Collins as she entered the newborn nursery on the evening of Jan. 12, 2006, during her shift at Ouachita County Medical Center in Camden, Ark. Perhaps this is why she shielded her fingers as she punched in the combination to the lock on the nursery door before entering to check on a baby inside.

Leaving minutes later, her work done, Collins’ suspicions were confirmed when Nikenya Washington, 18, shoved her way into the nursery yelling, “Move out my way, I’ll shoot you b----!”

Collins and the other nurse in the unit bravely wrestled with the would-be abductor. A Code Pink was called.

It is notable that January’s Ouachita Hospital case is unique as the first reported case of physical violence during an in-hospital abduction.

This frightening episode is one example of the phenomenon of infant abduction, and according to Cathy Nahirny of the National Center for Missing and Exploited Children (NCMEC) it is the first reported case in 2006.

Infant abduction is defined as the act of kidnapping an infant less than six months of age by a non-family member. Code Pink is the almost universally adopted code word signaling that an abduction is taking place. Though infrequent by comparison to other types of kidnapping or exploitation of children, infant abduction—like many pediatric situations—is quite dramatic.

This crime is of particular concern to pediatric hospitalists because about half of these events occur within the hospital setting. It plays on the fears of expectant parents and communities, and a successful abduction can be catastrophic for a hospital’s image and reputation. Preventing infant abduction and maintaining preparedness for Code Pink situations represents an ongoing challenge for the approximately 3,500 hospitals where about 4 million American babies are born each year.

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Small Number, Large Impact

According to Daniel Broughton, MD, infant abduction is a small subset of a much larger problem. As the director of the Child Abuse Program at the Mayo Clinic in Rochester, Minn., and co-author of the American Academy of Pediatrics’ Clinical Report on the pediatrician’s role in the prevention of missing children, he is an expert on the subject.

There are an estimated 1-2 million runaways and as many as 200,000 abductions by family members in the United States each year. By contrast, since 1983 when the NCMEC began to collect information on reports of infant abduction, there have been a total of 235 recorded infant kidnappings by non-family members. Nevertheless, “from the standpoint of impact both on families and the hospitals, it is huge,” says Dr. Broughton of infant abduction.

Bob Chicarello, the interim head of security at the Brigham and Women’s Hospital in Boston, agrees.

“You want to do everything possible to prevent [an infant abduction] because it could really shake an institution to its knees,” he says.

In addition, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) considers infant abduction such a safety priority that it was made a reportable “Sentinel Event” in 1998. Of the reported 235 reported cases 117 abductions—or 50%—have occurred in the hospital setting. Most children taken from the hospital—57%—are taken from their mother’s room. Roughly 15% each are taken from the newborn nursery, other pediatric wards, or from other parts of the hospital grounds.

Among abductions occurring outside the healthcare setting, 38% of the total occurred from private homes, and the final 13% of the total in other public venues.

A Unique Crime

Infant abduction seems to be distinct from other types of kidnapping in several ways. The first unique characteristic of infant abduction is the profile of the stereotypical perpetrator. Examination of case reports shows that the vast majority of abductors are females of childbearing age. Most live in or near the city where the abduction takes place. Many are overweight, and they may have a history of depression or lying, manipulative behavior.

Additionally, the motives of these women are notably different than those of other kidnappers who are interested in sexual exploitation, money, or revenge. Instead, these women most often desire to have a child of their own. This may be to replace a child or pregnancy that was lost, or to appease a significant other who they perceive may leave them if they cannot produce a child. Notably, many of the kidnappers, later caught, have been observed to provide adequate care for the infants.

Though the timing of an infant abduction can be impulsive, many kidnappers show evidence of elaborate planning beforehand. Several women have staged fictitious pregnancies on one or more occasions. Some kidnappers have even bought baby items or furnished nurseries in anticipation of having a child. Many offenders visit the hospitals or other facilities they later target on several occasions prior to an attempted abduction. They will try to become familiar with hospital personnel often by asking probing questions about security and procedure. A common ploy is for the kidnappers to impersonate nurses, lab technicians, or other hospital personnel in an attempt to gain access to the children. Some even acquire hospital uniforms or other disguises.

They may pose as family members of other patients in order to befriend the parents of their victims. This was the case of Nikenya Washington, who actually entered the room of the would-be victim’s mother early in the evening on the night of the crime. She stated that she had walked into the wrong room and tried to strike up a conversation before leaving.

Prevention is Key

Preventing infant abduction is key, and this process starts by putting proper procedures and hardware in place at healthcare facilities.

“We use a multilayered approach,” says Chicarello. This includes prior planning, physical barriers, electronic aides, and ongoing training and education of staff and parents alike. At Brigham and Women’s, security starts in the lobby where admittance to the maternity ward is gained only after signing in and using a specific elevator. Hospital personnel wear specific nursery badges, and they obtain access to the ward by key card.

The hospital also uses various forms of technology including closed circuit TV monitors, silent “panic” buttons at the nurse’s stations, and electronic wrist/ankle bracelets for the babies.

Chicarello stresses the importance of both initial training for new personnel as well as ongoing education throughout the hospital. This includes hospital-wide awareness drives and an annual Code Pink Fair. Education for parents is incorporated into a pre-natal curriculum. A big part of ongoing training is the use of monthly unscheduled Code Pink drills.

“We try to vary the scenarios to keep the staff on their toes and to expose any weaknesses,” he says. Such scenarios might include having people pose as lab personnel or pulling the fire alarm to create a diversion. “My favorite was once when we had a pizza delivered to the nurses station.” Fortunately, this didn’t work.

Dr. Broughton echoes the notion that a multifaceted approach is important. In addition to well-defined procedures in the birthing suite, the Mayo Clinic’s plan for preventing infant abduction extends to the larger children’s hospital and even to the clinic. Having a well-defined abduction plan has other positive effects as well, notes Dr. Broughton. Such programs are useful in preventing other types of theft, in aiding infection control efforts, and in locating ambulatory children who might wander or get lost.

The process requires input from several disciplines including nursing, security, and physicians. “I think pediatricians should be completely supportive of programs that provide a safety net,” says Dr. Broughton. “[Physicians] should be the leaders in the hospital setting.” One problem he has seen is that physicians sometimes don’t want to be bothered by little details like wearing a proper ID or leaving doors properly locked. Getting physicians to say, “this is important” is an essential first step.

A Disturbing Trend

Though changes in the landscape of infant abduction are difficult to discern, a few trends are notable. Encouragingly, in-hospital abductions are a smaller fraction of the total incidence, perhaps in response to better deterrence by medical facilities. As evidence of this, there was a recent 20-month period without a single abduction from a hospital setting. More disturbingly, though, the incidence of out-of-hospital abductions and the use of violence in abductions seem on the rise. Among these about 29% have involved violence to the parents or family of the infant including eight cases of homicide.

Obviously, preventing abductions outside the hospital presents its own challenges. Nahirny cautions strongly against the publication of birth information on the local press or on Web sites. “These shouldn’t include any specifically identifying information,” she states, such as full names of parents or a home address.

Second, parents must understand the potential danger of posting signs or balloons outside the home after a birth, as these might alert a potential abductor to the presence of an infant. Finally, parents should be careful with unknown, unexpected, or recently acquainted visitors shortly after coming home from the hospital. There are several cases of abductors posing as home-health nurses, social workers, or other official personnel.

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Conclusion

Even though she was able to grab the child and make it out of the room, Nikenya Washington did not make if off the hospital ward before being subdued by a security guard and other hospital personnel. Thankfully, the healthy 8-pound, 1-once baby girl was safely returned to her mother. In fact, hospital personnel in conjunction with local law enforcement and media safely recover most abducted infants thanks to orderly responses. However, the best option for all parties involved is a well-planned strategy of prevention. This includes physical barriers, electronic aides, and education of personnel and parents, as well as constant vigilance.

For those who want to get involved in preventing infant abduction, several resources are available. The NCMEC has quite a bit of information on its Web site (www.missingkids.com). There is also an excellent educational video produced by Mead Johnson Nutritionals called “Safeguard Their Tomorrows” available for viewing.

The most definitive resource for clinicians is a book entitled Guidelines for the Prevention of and Response to Infant Abduction. Currently in its eighth edition by John Rabun of the NCEMC, the book discusses the problem of infant abduction and defines its scope. There are various practical recommendations on the general, proactive, and physical measures to prevent abductions and on how to respond once an incident has occurred. There are also sections on how to advise parents and how to assess level of preparedness.

Dr. Axon is an instructor, Departments of Medicine and Pediatrics, Medical University of South Carolina Medical Center, Charleston.

Bibliography

• Ankrom LG, Lent CJ. Cradle robbers: A study of the infant abductor. The FBI Law Enforcement Bulletin. 1995;64(9):112-118.
• Hillen M. Teen held in attempt to abduct newborn. Arkansas Democrat Gazette. 16 January, 2006.
• Rabun J. For Healthcare Professionals: Guidelines for the Prevention of and Response to Infant Abduction. 8th ed. Alexandria, Virginia: National Center for Missing and Exploited Children; 2005.

Pediatric Special Section

In the Literature

By G. Ronald Nicholis, MD, Children’s Mercy Hospital, Kansas City, Mo., Gina Weddle, RN, CPNP, Section of Pediatric Hospitalists, Department of Pediatrics, Children’s Mercy Hospitals and Clinics (Kansas City, Mo.), and J. Christopher Day, MD, Section of Pediatric Hospitalists, Department of Pediatrics, Children’s Mercy Hospitals and Clinics (Kansas City, Mo.)

Computerized Physician Order Entry—Not a Finished Product

Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116(6):1506-1512.

Over the past several years attention has been increasingly focused on the inadequacy of patient safety in our practices. In response, hospitals, insurers, and practices have examined many potential changes to current systems in an effort to improve safety.

The Institute of Medicine (IOM) and the Leapfrog Group have championed computerized physician order entry (CPOE) as necessary for improving patient safety, citing the inadequacy of paper and pen for the ordering process. Research documenting that CPOE systems used in the hospital setting can decrease adverse drug events has fostered the promise and potential for CPOE to make the hospital a safer place for our patients, particularly when enhanced with decision support. Decision support can allow the physician to be alerted to errors in dose, drug-drug interaction, drug-food interaction, allergies, and the need for dosage corrections based on laboratory values at the time of ordering. Contrary to the research demonstrating improved safety, some studies have shown an increase in unique errors after implementation of CPOE.

The current study from the Departments of Critical Care Medicine and Pediatrics at Children’s Hospital of Pittsburgh calls our attention to significant issues with implementation of CPOE that have potential to inhibit the goal of improving patient safety. Citing a study by Upperman, et al. from their own institution, which noted significant improvement in adverse drug events after implementation of CPOE, the authors of the current study state, “Children’s Hospital of Pittsburgh implemented … Cerner’s commercial CPOE system in October 2002 in an effort to become one of the first children’s hospitals in the U.S. to attain 100% CPOE status.”

The study was designed to measure the effect of CPOE implementation on mortality rate for patients transferred into this pediatric tertiary care facility who required “immediate processing … and stabilization orders.” This retrospective study examined an 18-month period of mortality data: Thirteen months before the implementation of CPOE and five months after.

They discovered an unexpected increase in unadjusted mortality rate after the implementation of CPOE from 2.8% to 6.57%, (P<0.001). Mortality odds ratios were calculated, and observed mortality before CPOE implementation was consistently better than after CPOE implementation. Regression analysis with and without Pediatric Risk of Mortality comparisons were performed and CPOE, in addition to other factors, was associated with increased mortality in both analyses. How should this be interpreted?

The authors note several factors having impact on the validity of the study, specifically mentioning that “study design precludes any statements regarding cause and effect,” “[researchers] examined a unique patient population admitted through interfacility transport … (thus) findings may not be generalizable to the hospital experience as a whole,” and “[the] observation period after CPOE implementation was brief.”

Seasonal variability was also a potential confounding factor because CPOE implementation was in October and the observation period post-CPOE extended only five months—to March of the next year. However, a statistical comparison between matched five-month periods supported the association between implementation of CPOE and increased mortality in this population.

In addition, the authors discuss how their institution’s chosen implementation process for CPOE affected the work processes and pattern of care provided to these critically ill patients. Issues such as being unable to enter orders on a patient in preparation of their arrival because they were not yet enrolled in the electronic system hampered the availability of important medications at the time of arrival. Forcing all of the orders to go through their designed CPOE process in an effort to use the error prevention capabilities of the system caused potentially significant delays in the administration of life-saving medications.

The lack of functional order sets further delayed the physician’s ability to efficiently enter orders electronically. These variables may have impacted mortality rates. Further delays were evident due to the fact that a nurse had to activate orders placed by the physician, bypassing some of the efficiency of an electronic system. Similarly, the pharmacy reviewed and processed the order before the medication was available to the nurse for delivery to the patient.

These checks and balances have the potential to prevent errors in medication ordering, but if inefficient, they may not be appropriate for an intensive care setting in every circumstance. Researchers stated the new workflow took the physicians and nurses away from the patient’s bedside, potentially decreasing observation benefits for the patient. The capacity of the system to compute at times seemed “frozen” causing further delays—not necessarily an uncommon occurrence with any electronic system.

The practice of medicine is complex and work processes do not easily translate to the electronic models currently available. It is crucial that hospitalists, other specialists, all ancillary services, as well as administration be involved in the building and implementation of the systems to be used in our individual facilities. The systems and technology for effective CPOE in hospital settings—especially in pediatric settings—have yet to be developed. The implementation of CPOE for improved patient safety requires exploration given the exposed inadequacies of our current methods of practice.

Like any best practice this exploration will be continuous and require evaluation and improvement. While we must involve ourselves with the development and implementation of CPOE, we must not let the inadequacies of new systems negatively affect patient care. The dichotomy may be omnipresent: Use the system to gain protections from errors and bypass the system when its design or function interferes with good patient practice. This will require us to possess the wisdom to determine the correct path to follow in any instance.

Every day in our practice we make efforts to compensate for failures in our methods to prevent errors from affecting our patient’s care. Electronic systems do not excuse us from continued vigilance, communication, and action to protect our patients from medical errors. The authors appropriately state that “accurate evaluation of CPOE will require systems-based troubleshooting with well-funded, well-designed, multicenter studies that can adequately address these questions.”

Unfortunately, because of the proven inadequacies of the current system, CPOE, like other methodologies we use in the advancement of patient care, cannot wait for proof of perfection before being used to enhance the outcomes of our patients. Thus we need to be vigorous in our participation of the development and implementation of CPOE for our individual institutions and alert to the prevention of harm in all we do. Software companies cannot accomplish improvement in our practices without our involvement, and we cannot meet our demands for quality without good software companies.

The Link between Age and Orchiectomy Due to Testicular Torsion

Mansbach J, Forbes P, Peters C. Testicular torsion and risk factors for orchiectomy. Arch Pediatr Adolesc Med. 2005;159(12):1167-1171.

Testicular torsion is a urologic emergency that requires a four- to eight-hour window from presentation of symptoms until intervention in order to increase the potential for a viable testis. Steps to ensure a viable testis include timely presentation, rapid diagnosis, and curative intervention.

Chart review was done from a national database consisting of 984 hospitals in 22 states. The review included 436 patients ranging from one to 25 years. The incidence of torsion was 4.5 cases/100,000 male subjects with a peak at 10-19 years of age. Of the 436 subjects, 34% required orchiectomy. After all factors (race, insurance status, income, region, and hospital location) were evaluated, increased age at presentation was the only statistically significant factor associated orchiectomy. Male subjects were hesitant to seek medical attention for conditions associated with the genitals. Healthcare providers need to provide anticipatory guidance when educating males about testicular disorders. Testicular exam should be incorporated as part of every physical exam, especially if an abdominal complaint exists.

Heliox Aids Peds with Moderate to Severe Asthma

Kim K, Phrampus E, Venkataraman S, et al. Helium/oxygen-driven albuterol nebulization in the treatment of children with moderate to severe asthma exacerbations: A randomized controlled trial. Pediatrics. 2005;116(5):1127-1133.

Heliox is a 70%/30% helium/oxygen mixture. Heliox mixtures have a lower gas density than oxygen and, therefore, can increase pulmonary gas delivery. This study compared heliox versus oxygen delivery of continuous albuterol nebulization for patients with asthma treated in the emergency department.

Investigators enrolled 30 subjects between ages two and 18 with moderate to severe asthma. Severity of asthma was determined by a pulmonary index (PI) of >8. PI scores are based on respiratory rate, wheezing, accessory muscle use, inspiratory/expiratory ratio, and pulse oximetry. All children were given one 5mg albuterol treatment using traditional oxygen delivery along with oral steroids dosed at 2mg/kg. After the initial treatment and steroids if the PI score was >8 they were randomly assigned to receive continuous albuterol by heliox or traditional oxygen delivery.

The study showed that continuous albuterol delivered by heliox mixture lowered PI scores from baseline to 240 minutes into the study (P<0.001). Results also demonstrated a trend towards improved rate of discharge from the emergency department and hospital, but the study was not powered to adequately evaluate these outcomes Limitations of the study include lack of complete blinding and a small sample size. TH

Something didn’t seem quite right. The person in the hooded sweatshirt standing near the entrance looked suspicious to respiratory therapist Betty Collins as she entered the newborn nursery on the evening of Jan. 12, 2006, during her shift at Ouachita County Medical Center in Camden, Ark. Perhaps this is why she shielded her fingers as she punched in the combination to the lock on the nursery door before entering to check on a baby inside.

Leaving minutes later, her work done, Collins’ suspicions were confirmed when Nikenya Washington, 18, shoved her way into the nursery yelling, “Move out my way, I’ll shoot you b----!”

Collins and the other nurse in the unit bravely wrestled with the would-be abductor. A Code Pink was called.

It is notable that January’s Ouachita Hospital case is unique as the first reported case of physical violence during an in-hospital abduction.

This frightening episode is one example of the phenomenon of infant abduction, and according to Cathy Nahirny of the National Center for Missing and Exploited Children (NCMEC) it is the first reported case in 2006.

Infant abduction is defined as the act of kidnapping an infant less than six months of age by a non-family member. Code Pink is the almost universally adopted code word signaling that an abduction is taking place. Though infrequent by comparison to other types of kidnapping or exploitation of children, infant abduction—like many pediatric situations—is quite dramatic.

This crime is of particular concern to pediatric hospitalists because about half of these events occur within the hospital setting. It plays on the fears of expectant parents and communities, and a successful abduction can be catastrophic for a hospital’s image and reputation. Preventing infant abduction and maintaining preparedness for Code Pink situations represents an ongoing challenge for the approximately 3,500 hospitals where about 4 million American babies are born each year.

click for large version

Small Number, Large Impact

According to Daniel Broughton, MD, infant abduction is a small subset of a much larger problem. As the director of the Child Abuse Program at the Mayo Clinic in Rochester, Minn., and co-author of the American Academy of Pediatrics’ Clinical Report on the pediatrician’s role in the prevention of missing children, he is an expert on the subject.

There are an estimated 1-2 million runaways and as many as 200,000 abductions by family members in the United States each year. By contrast, since 1983 when the NCMEC began to collect information on reports of infant abduction, there have been a total of 235 recorded infant kidnappings by non-family members. Nevertheless, “from the standpoint of impact both on families and the hospitals, it is huge,” says Dr. Broughton of infant abduction.

Bob Chicarello, the interim head of security at the Brigham and Women’s Hospital in Boston, agrees.

“You want to do everything possible to prevent [an infant abduction] because it could really shake an institution to its knees,” he says.

In addition, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) considers infant abduction such a safety priority that it was made a reportable “Sentinel Event” in 1998. Of the reported 235 reported cases 117 abductions—or 50%—have occurred in the hospital setting. Most children taken from the hospital—57%—are taken from their mother’s room. Roughly 15% each are taken from the newborn nursery, other pediatric wards, or from other parts of the hospital grounds.

Among abductions occurring outside the healthcare setting, 38% of the total occurred from private homes, and the final 13% of the total in other public venues.

A Unique Crime

Infant abduction seems to be distinct from other types of kidnapping in several ways. The first unique characteristic of infant abduction is the profile of the stereotypical perpetrator. Examination of case reports shows that the vast majority of abductors are females of childbearing age. Most live in or near the city where the abduction takes place. Many are overweight, and they may have a history of depression or lying, manipulative behavior.

Additionally, the motives of these women are notably different than those of other kidnappers who are interested in sexual exploitation, money, or revenge. Instead, these women most often desire to have a child of their own. This may be to replace a child or pregnancy that was lost, or to appease a significant other who they perceive may leave them if they cannot produce a child. Notably, many of the kidnappers, later caught, have been observed to provide adequate care for the infants.

Though the timing of an infant abduction can be impulsive, many kidnappers show evidence of elaborate planning beforehand. Several women have staged fictitious pregnancies on one or more occasions. Some kidnappers have even bought baby items or furnished nurseries in anticipation of having a child. Many offenders visit the hospitals or other facilities they later target on several occasions prior to an attempted abduction. They will try to become familiar with hospital personnel often by asking probing questions about security and procedure. A common ploy is for the kidnappers to impersonate nurses, lab technicians, or other hospital personnel in an attempt to gain access to the children. Some even acquire hospital uniforms or other disguises.

They may pose as family members of other patients in order to befriend the parents of their victims. This was the case of Nikenya Washington, who actually entered the room of the would-be victim’s mother early in the evening on the night of the crime. She stated that she had walked into the wrong room and tried to strike up a conversation before leaving.

Prevention is Key

Preventing infant abduction is key, and this process starts by putting proper procedures and hardware in place at healthcare facilities.

“We use a multilayered approach,” says Chicarello. This includes prior planning, physical barriers, electronic aides, and ongoing training and education of staff and parents alike. At Brigham and Women’s, security starts in the lobby where admittance to the maternity ward is gained only after signing in and using a specific elevator. Hospital personnel wear specific nursery badges, and they obtain access to the ward by key card.

The hospital also uses various forms of technology including closed circuit TV monitors, silent “panic” buttons at the nurse’s stations, and electronic wrist/ankle bracelets for the babies.

Chicarello stresses the importance of both initial training for new personnel as well as ongoing education throughout the hospital. This includes hospital-wide awareness drives and an annual Code Pink Fair. Education for parents is incorporated into a pre-natal curriculum. A big part of ongoing training is the use of monthly unscheduled Code Pink drills.

“We try to vary the scenarios to keep the staff on their toes and to expose any weaknesses,” he says. Such scenarios might include having people pose as lab personnel or pulling the fire alarm to create a diversion. “My favorite was once when we had a pizza delivered to the nurses station.” Fortunately, this didn’t work.

Dr. Broughton echoes the notion that a multifaceted approach is important. In addition to well-defined procedures in the birthing suite, the Mayo Clinic’s plan for preventing infant abduction extends to the larger children’s hospital and even to the clinic. Having a well-defined abduction plan has other positive effects as well, notes Dr. Broughton. Such programs are useful in preventing other types of theft, in aiding infection control efforts, and in locating ambulatory children who might wander or get lost.

The process requires input from several disciplines including nursing, security, and physicians. “I think pediatricians should be completely supportive of programs that provide a safety net,” says Dr. Broughton. “[Physicians] should be the leaders in the hospital setting.” One problem he has seen is that physicians sometimes don’t want to be bothered by little details like wearing a proper ID or leaving doors properly locked. Getting physicians to say, “this is important” is an essential first step.

A Disturbing Trend

Though changes in the landscape of infant abduction are difficult to discern, a few trends are notable. Encouragingly, in-hospital abductions are a smaller fraction of the total incidence, perhaps in response to better deterrence by medical facilities. As evidence of this, there was a recent 20-month period without a single abduction from a hospital setting. More disturbingly, though, the incidence of out-of-hospital abductions and the use of violence in abductions seem on the rise. Among these about 29% have involved violence to the parents or family of the infant including eight cases of homicide.

Obviously, preventing abductions outside the hospital presents its own challenges. Nahirny cautions strongly against the publication of birth information on the local press or on Web sites. “These shouldn’t include any specifically identifying information,” she states, such as full names of parents or a home address.

Second, parents must understand the potential danger of posting signs or balloons outside the home after a birth, as these might alert a potential abductor to the presence of an infant. Finally, parents should be careful with unknown, unexpected, or recently acquainted visitors shortly after coming home from the hospital. There are several cases of abductors posing as home-health nurses, social workers, or other official personnel.

click for large version

Conclusion

Even though she was able to grab the child and make it out of the room, Nikenya Washington did not make if off the hospital ward before being subdued by a security guard and other hospital personnel. Thankfully, the healthy 8-pound, 1-once baby girl was safely returned to her mother. In fact, hospital personnel in conjunction with local law enforcement and media safely recover most abducted infants thanks to orderly responses. However, the best option for all parties involved is a well-planned strategy of prevention. This includes physical barriers, electronic aides, and education of personnel and parents, as well as constant vigilance.

For those who want to get involved in preventing infant abduction, several resources are available. The NCMEC has quite a bit of information on its Web site (www.missingkids.com). There is also an excellent educational video produced by Mead Johnson Nutritionals called “Safeguard Their Tomorrows” available for viewing.

The most definitive resource for clinicians is a book entitled Guidelines for the Prevention of and Response to Infant Abduction. Currently in its eighth edition by John Rabun of the NCEMC, the book discusses the problem of infant abduction and defines its scope. There are various practical recommendations on the general, proactive, and physical measures to prevent abductions and on how to respond once an incident has occurred. There are also sections on how to advise parents and how to assess level of preparedness.

Dr. Axon is an instructor, Departments of Medicine and Pediatrics, Medical University of South Carolina Medical Center, Charleston.

Bibliography

• Ankrom LG, Lent CJ. Cradle robbers: A study of the infant abductor. The FBI Law Enforcement Bulletin. 1995;64(9):112-118.
• Hillen M. Teen held in attempt to abduct newborn. Arkansas Democrat Gazette. 16 January, 2006.
• Rabun J. For Healthcare Professionals: Guidelines for the Prevention of and Response to Infant Abduction. 8th ed. Alexandria, Virginia: National Center for Missing and Exploited Children; 2005.

Pediatric Special Section

In the Literature

By G. Ronald Nicholis, MD, Children’s Mercy Hospital, Kansas City, Mo., Gina Weddle, RN, CPNP, Section of Pediatric Hospitalists, Department of Pediatrics, Children’s Mercy Hospitals and Clinics (Kansas City, Mo.), and J. Christopher Day, MD, Section of Pediatric Hospitalists, Department of Pediatrics, Children’s Mercy Hospitals and Clinics (Kansas City, Mo.)

Computerized Physician Order Entry—Not a Finished Product

Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116(6):1506-1512.

Over the past several years attention has been increasingly focused on the inadequacy of patient safety in our practices. In response, hospitals, insurers, and practices have examined many potential changes to current systems in an effort to improve safety.

The Institute of Medicine (IOM) and the Leapfrog Group have championed computerized physician order entry (CPOE) as necessary for improving patient safety, citing the inadequacy of paper and pen for the ordering process. Research documenting that CPOE systems used in the hospital setting can decrease adverse drug events has fostered the promise and potential for CPOE to make the hospital a safer place for our patients, particularly when enhanced with decision support. Decision support can allow the physician to be alerted to errors in dose, drug-drug interaction, drug-food interaction, allergies, and the need for dosage corrections based on laboratory values at the time of ordering. Contrary to the research demonstrating improved safety, some studies have shown an increase in unique errors after implementation of CPOE.

The current study from the Departments of Critical Care Medicine and Pediatrics at Children’s Hospital of Pittsburgh calls our attention to significant issues with implementation of CPOE that have potential to inhibit the goal of improving patient safety. Citing a study by Upperman, et al. from their own institution, which noted significant improvement in adverse drug events after implementation of CPOE, the authors of the current study state, “Children’s Hospital of Pittsburgh implemented … Cerner’s commercial CPOE system in October 2002 in an effort to become one of the first children’s hospitals in the U.S. to attain 100% CPOE status.”

The study was designed to measure the effect of CPOE implementation on mortality rate for patients transferred into this pediatric tertiary care facility who required “immediate processing … and stabilization orders.” This retrospective study examined an 18-month period of mortality data: Thirteen months before the implementation of CPOE and five months after.

They discovered an unexpected increase in unadjusted mortality rate after the implementation of CPOE from 2.8% to 6.57%, (P<0.001). Mortality odds ratios were calculated, and observed mortality before CPOE implementation was consistently better than after CPOE implementation. Regression analysis with and without Pediatric Risk of Mortality comparisons were performed and CPOE, in addition to other factors, was associated with increased mortality in both analyses. How should this be interpreted?

The authors note several factors having impact on the validity of the study, specifically mentioning that “study design precludes any statements regarding cause and effect,” “[researchers] examined a unique patient population admitted through interfacility transport … (thus) findings may not be generalizable to the hospital experience as a whole,” and “[the] observation period after CPOE implementation was brief.”

Seasonal variability was also a potential confounding factor because CPOE implementation was in October and the observation period post-CPOE extended only five months—to March of the next year. However, a statistical comparison between matched five-month periods supported the association between implementation of CPOE and increased mortality in this population.

In addition, the authors discuss how their institution’s chosen implementation process for CPOE affected the work processes and pattern of care provided to these critically ill patients. Issues such as being unable to enter orders on a patient in preparation of their arrival because they were not yet enrolled in the electronic system hampered the availability of important medications at the time of arrival. Forcing all of the orders to go through their designed CPOE process in an effort to use the error prevention capabilities of the system caused potentially significant delays in the administration of life-saving medications.

The lack of functional order sets further delayed the physician’s ability to efficiently enter orders electronically. These variables may have impacted mortality rates. Further delays were evident due to the fact that a nurse had to activate orders placed by the physician, bypassing some of the efficiency of an electronic system. Similarly, the pharmacy reviewed and processed the order before the medication was available to the nurse for delivery to the patient.

These checks and balances have the potential to prevent errors in medication ordering, but if inefficient, they may not be appropriate for an intensive care setting in every circumstance. Researchers stated the new workflow took the physicians and nurses away from the patient’s bedside, potentially decreasing observation benefits for the patient. The capacity of the system to compute at times seemed “frozen” causing further delays—not necessarily an uncommon occurrence with any electronic system.

The practice of medicine is complex and work processes do not easily translate to the electronic models currently available. It is crucial that hospitalists, other specialists, all ancillary services, as well as administration be involved in the building and implementation of the systems to be used in our individual facilities. The systems and technology for effective CPOE in hospital settings—especially in pediatric settings—have yet to be developed. The implementation of CPOE for improved patient safety requires exploration given the exposed inadequacies of our current methods of practice.

Like any best practice this exploration will be continuous and require evaluation and improvement. While we must involve ourselves with the development and implementation of CPOE, we must not let the inadequacies of new systems negatively affect patient care. The dichotomy may be omnipresent: Use the system to gain protections from errors and bypass the system when its design or function interferes with good patient practice. This will require us to possess the wisdom to determine the correct path to follow in any instance.

Every day in our practice we make efforts to compensate for failures in our methods to prevent errors from affecting our patient’s care. Electronic systems do not excuse us from continued vigilance, communication, and action to protect our patients from medical errors. The authors appropriately state that “accurate evaluation of CPOE will require systems-based troubleshooting with well-funded, well-designed, multicenter studies that can adequately address these questions.”

Unfortunately, because of the proven inadequacies of the current system, CPOE, like other methodologies we use in the advancement of patient care, cannot wait for proof of perfection before being used to enhance the outcomes of our patients. Thus we need to be vigorous in our participation of the development and implementation of CPOE for our individual institutions and alert to the prevention of harm in all we do. Software companies cannot accomplish improvement in our practices without our involvement, and we cannot meet our demands for quality without good software companies.

The Link between Age and Orchiectomy Due to Testicular Torsion

Mansbach J, Forbes P, Peters C. Testicular torsion and risk factors for orchiectomy. Arch Pediatr Adolesc Med. 2005;159(12):1167-1171.

Testicular torsion is a urologic emergency that requires a four- to eight-hour window from presentation of symptoms until intervention in order to increase the potential for a viable testis. Steps to ensure a viable testis include timely presentation, rapid diagnosis, and curative intervention.

Chart review was done from a national database consisting of 984 hospitals in 22 states. The review included 436 patients ranging from one to 25 years. The incidence of torsion was 4.5 cases/100,000 male subjects with a peak at 10-19 years of age. Of the 436 subjects, 34% required orchiectomy. After all factors (race, insurance status, income, region, and hospital location) were evaluated, increased age at presentation was the only statistically significant factor associated orchiectomy. Male subjects were hesitant to seek medical attention for conditions associated with the genitals. Healthcare providers need to provide anticipatory guidance when educating males about testicular disorders. Testicular exam should be incorporated as part of every physical exam, especially if an abdominal complaint exists.

Heliox Aids Peds with Moderate to Severe Asthma

Kim K, Phrampus E, Venkataraman S, et al. Helium/oxygen-driven albuterol nebulization in the treatment of children with moderate to severe asthma exacerbations: A randomized controlled trial. Pediatrics. 2005;116(5):1127-1133.

Heliox is a 70%/30% helium/oxygen mixture. Heliox mixtures have a lower gas density than oxygen and, therefore, can increase pulmonary gas delivery. This study compared heliox versus oxygen delivery of continuous albuterol nebulization for patients with asthma treated in the emergency department.

Investigators enrolled 30 subjects between ages two and 18 with moderate to severe asthma. Severity of asthma was determined by a pulmonary index (PI) of >8. PI scores are based on respiratory rate, wheezing, accessory muscle use, inspiratory/expiratory ratio, and pulse oximetry. All children were given one 5mg albuterol treatment using traditional oxygen delivery along with oral steroids dosed at 2mg/kg. After the initial treatment and steroids if the PI score was >8 they were randomly assigned to receive continuous albuterol by heliox or traditional oxygen delivery.

The study showed that continuous albuterol delivered by heliox mixture lowered PI scores from baseline to 240 minutes into the study (P<0.001). Results also demonstrated a trend towards improved rate of discharge from the emergency department and hospital, but the study was not powered to adequately evaluate these outcomes Limitations of the study include lack of complete blinding and a small sample size. TH

Something didn’t seem quite right. The person in the hooded sweatshirt standing near the entrance looked suspicious to respiratory therapist Betty Collins as she entered the newborn nursery on the evening of Jan. 12, 2006, during her shift at Ouachita County Medical Center in Camden, Ark. Perhaps this is why she shielded her fingers as she punched in the combination to the lock on the nursery door before entering to check on a baby inside.

Leaving minutes later, her work done, Collins’ suspicions were confirmed when Nikenya Washington, 18, shoved her way into the nursery yelling, “Move out my way, I’ll shoot you b----!”

Collins and the other nurse in the unit bravely wrestled with the would-be abductor. A Code Pink was called.

It is notable that January’s Ouachita Hospital case is unique as the first reported case of physical violence during an in-hospital abduction.

This frightening episode is one example of the phenomenon of infant abduction, and according to Cathy Nahirny of the National Center for Missing and Exploited Children (NCMEC) it is the first reported case in 2006.

Infant abduction is defined as the act of kidnapping an infant less than six months of age by a non-family member. Code Pink is the almost universally adopted code word signaling that an abduction is taking place. Though infrequent by comparison to other types of kidnapping or exploitation of children, infant abduction—like many pediatric situations—is quite dramatic.

This crime is of particular concern to pediatric hospitalists because about half of these events occur within the hospital setting. It plays on the fears of expectant parents and communities, and a successful abduction can be catastrophic for a hospital’s image and reputation. Preventing infant abduction and maintaining preparedness for Code Pink situations represents an ongoing challenge for the approximately 3,500 hospitals where about 4 million American babies are born each year.

click for large version

Small Number, Large Impact

According to Daniel Broughton, MD, infant abduction is a small subset of a much larger problem. As the director of the Child Abuse Program at the Mayo Clinic in Rochester, Minn., and co-author of the American Academy of Pediatrics’ Clinical Report on the pediatrician’s role in the prevention of missing children, he is an expert on the subject.

There are an estimated 1-2 million runaways and as many as 200,000 abductions by family members in the United States each year. By contrast, since 1983 when the NCMEC began to collect information on reports of infant abduction, there have been a total of 235 recorded infant kidnappings by non-family members. Nevertheless, “from the standpoint of impact both on families and the hospitals, it is huge,” says Dr. Broughton of infant abduction.

Bob Chicarello, the interim head of security at the Brigham and Women’s Hospital in Boston, agrees.

“You want to do everything possible to prevent [an infant abduction] because it could really shake an institution to its knees,” he says.

In addition, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) considers infant abduction such a safety priority that it was made a reportable “Sentinel Event” in 1998. Of the reported 235 reported cases 117 abductions—or 50%—have occurred in the hospital setting. Most children taken from the hospital—57%—are taken from their mother’s room. Roughly 15% each are taken from the newborn nursery, other pediatric wards, or from other parts of the hospital grounds.

Among abductions occurring outside the healthcare setting, 38% of the total occurred from private homes, and the final 13% of the total in other public venues.

A Unique Crime

Infant abduction seems to be distinct from other types of kidnapping in several ways. The first unique characteristic of infant abduction is the profile of the stereotypical perpetrator. Examination of case reports shows that the vast majority of abductors are females of childbearing age. Most live in or near the city where the abduction takes place. Many are overweight, and they may have a history of depression or lying, manipulative behavior.

Additionally, the motives of these women are notably different than those of other kidnappers who are interested in sexual exploitation, money, or revenge. Instead, these women most often desire to have a child of their own. This may be to replace a child or pregnancy that was lost, or to appease a significant other who they perceive may leave them if they cannot produce a child. Notably, many of the kidnappers, later caught, have been observed to provide adequate care for the infants.

Though the timing of an infant abduction can be impulsive, many kidnappers show evidence of elaborate planning beforehand. Several women have staged fictitious pregnancies on one or more occasions. Some kidnappers have even bought baby items or furnished nurseries in anticipation of having a child. Many offenders visit the hospitals or other facilities they later target on several occasions prior to an attempted abduction. They will try to become familiar with hospital personnel often by asking probing questions about security and procedure. A common ploy is for the kidnappers to impersonate nurses, lab technicians, or other hospital personnel in an attempt to gain access to the children. Some even acquire hospital uniforms or other disguises.

They may pose as family members of other patients in order to befriend the parents of their victims. This was the case of Nikenya Washington, who actually entered the room of the would-be victim’s mother early in the evening on the night of the crime. She stated that she had walked into the wrong room and tried to strike up a conversation before leaving.

Prevention is Key

Preventing infant abduction is key, and this process starts by putting proper procedures and hardware in place at healthcare facilities.

“We use a multilayered approach,” says Chicarello. This includes prior planning, physical barriers, electronic aides, and ongoing training and education of staff and parents alike. At Brigham and Women’s, security starts in the lobby where admittance to the maternity ward is gained only after signing in and using a specific elevator. Hospital personnel wear specific nursery badges, and they obtain access to the ward by key card.

The hospital also uses various forms of technology including closed circuit TV monitors, silent “panic” buttons at the nurse’s stations, and electronic wrist/ankle bracelets for the babies.

Chicarello stresses the importance of both initial training for new personnel as well as ongoing education throughout the hospital. This includes hospital-wide awareness drives and an annual Code Pink Fair. Education for parents is incorporated into a pre-natal curriculum. A big part of ongoing training is the use of monthly unscheduled Code Pink drills.

“We try to vary the scenarios to keep the staff on their toes and to expose any weaknesses,” he says. Such scenarios might include having people pose as lab personnel or pulling the fire alarm to create a diversion. “My favorite was once when we had a pizza delivered to the nurses station.” Fortunately, this didn’t work.

Dr. Broughton echoes the notion that a multifaceted approach is important. In addition to well-defined procedures in the birthing suite, the Mayo Clinic’s plan for preventing infant abduction extends to the larger children’s hospital and even to the clinic. Having a well-defined abduction plan has other positive effects as well, notes Dr. Broughton. Such programs are useful in preventing other types of theft, in aiding infection control efforts, and in locating ambulatory children who might wander or get lost.

The process requires input from several disciplines including nursing, security, and physicians. “I think pediatricians should be completely supportive of programs that provide a safety net,” says Dr. Broughton. “[Physicians] should be the leaders in the hospital setting.” One problem he has seen is that physicians sometimes don’t want to be bothered by little details like wearing a proper ID or leaving doors properly locked. Getting physicians to say, “this is important” is an essential first step.

A Disturbing Trend

Though changes in the landscape of infant abduction are difficult to discern, a few trends are notable. Encouragingly, in-hospital abductions are a smaller fraction of the total incidence, perhaps in response to better deterrence by medical facilities. As evidence of this, there was a recent 20-month period without a single abduction from a hospital setting. More disturbingly, though, the incidence of out-of-hospital abductions and the use of violence in abductions seem on the rise. Among these about 29% have involved violence to the parents or family of the infant including eight cases of homicide.

Obviously, preventing abductions outside the hospital presents its own challenges. Nahirny cautions strongly against the publication of birth information on the local press or on Web sites. “These shouldn’t include any specifically identifying information,” she states, such as full names of parents or a home address.

Second, parents must understand the potential danger of posting signs or balloons outside the home after a birth, as these might alert a potential abductor to the presence of an infant. Finally, parents should be careful with unknown, unexpected, or recently acquainted visitors shortly after coming home from the hospital. There are several cases of abductors posing as home-health nurses, social workers, or other official personnel.

click for large version

Conclusion

Even though she was able to grab the child and make it out of the room, Nikenya Washington did not make if off the hospital ward before being subdued by a security guard and other hospital personnel. Thankfully, the healthy 8-pound, 1-once baby girl was safely returned to her mother. In fact, hospital personnel in conjunction with local law enforcement and media safely recover most abducted infants thanks to orderly responses. However, the best option for all parties involved is a well-planned strategy of prevention. This includes physical barriers, electronic aides, and education of personnel and parents, as well as constant vigilance.

For those who want to get involved in preventing infant abduction, several resources are available. The NCMEC has quite a bit of information on its Web site (www.missingkids.com). There is also an excellent educational video produced by Mead Johnson Nutritionals called “Safeguard Their Tomorrows” available for viewing.

The most definitive resource for clinicians is a book entitled Guidelines for the Prevention of and Response to Infant Abduction. Currently in its eighth edition by John Rabun of the NCEMC, the book discusses the problem of infant abduction and defines its scope. There are various practical recommendations on the general, proactive, and physical measures to prevent abductions and on how to respond once an incident has occurred. There are also sections on how to advise parents and how to assess level of preparedness.

Dr. Axon is an instructor, Departments of Medicine and Pediatrics, Medical University of South Carolina Medical Center, Charleston.

Bibliography

• Ankrom LG, Lent CJ. Cradle robbers: A study of the infant abductor. The FBI Law Enforcement Bulletin. 1995;64(9):112-118.
• Hillen M. Teen held in attempt to abduct newborn. Arkansas Democrat Gazette. 16 January, 2006.
• Rabun J. For Healthcare Professionals: Guidelines for the Prevention of and Response to Infant Abduction. 8th ed. Alexandria, Virginia: National Center for Missing and Exploited Children; 2005.

Pediatric Special Section

In the Literature

By G. Ronald Nicholis, MD, Children’s Mercy Hospital, Kansas City, Mo., Gina Weddle, RN, CPNP, Section of Pediatric Hospitalists, Department of Pediatrics, Children’s Mercy Hospitals and Clinics (Kansas City, Mo.), and J. Christopher Day, MD, Section of Pediatric Hospitalists, Department of Pediatrics, Children’s Mercy Hospitals and Clinics (Kansas City, Mo.)

Computerized Physician Order Entry—Not a Finished Product

Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116(6):1506-1512.

Over the past several years attention has been increasingly focused on the inadequacy of patient safety in our practices. In response, hospitals, insurers, and practices have examined many potential changes to current systems in an effort to improve safety.

The Institute of Medicine (IOM) and the Leapfrog Group have championed computerized physician order entry (CPOE) as necessary for improving patient safety, citing the inadequacy of paper and pen for the ordering process. Research documenting that CPOE systems used in the hospital setting can decrease adverse drug events has fostered the promise and potential for CPOE to make the hospital a safer place for our patients, particularly when enhanced with decision support. Decision support can allow the physician to be alerted to errors in dose, drug-drug interaction, drug-food interaction, allergies, and the need for dosage corrections based on laboratory values at the time of ordering. Contrary to the research demonstrating improved safety, some studies have shown an increase in unique errors after implementation of CPOE.

The current study from the Departments of Critical Care Medicine and Pediatrics at Children’s Hospital of Pittsburgh calls our attention to significant issues with implementation of CPOE that have potential to inhibit the goal of improving patient safety. Citing a study by Upperman, et al. from their own institution, which noted significant improvement in adverse drug events after implementation of CPOE, the authors of the current study state, “Children’s Hospital of Pittsburgh implemented … Cerner’s commercial CPOE system in October 2002 in an effort to become one of the first children’s hospitals in the U.S. to attain 100% CPOE status.”

The study was designed to measure the effect of CPOE implementation on mortality rate for patients transferred into this pediatric tertiary care facility who required “immediate processing … and stabilization orders.” This retrospective study examined an 18-month period of mortality data: Thirteen months before the implementation of CPOE and five months after.

They discovered an unexpected increase in unadjusted mortality rate after the implementation of CPOE from 2.8% to 6.57%, (P<0.001). Mortality odds ratios were calculated, and observed mortality before CPOE implementation was consistently better than after CPOE implementation. Regression analysis with and without Pediatric Risk of Mortality comparisons were performed and CPOE, in addition to other factors, was associated with increased mortality in both analyses. How should this be interpreted?

The authors note several factors having impact on the validity of the study, specifically mentioning that “study design precludes any statements regarding cause and effect,” “[researchers] examined a unique patient population admitted through interfacility transport … (thus) findings may not be generalizable to the hospital experience as a whole,” and “[the] observation period after CPOE implementation was brief.”

Seasonal variability was also a potential confounding factor because CPOE implementation was in October and the observation period post-CPOE extended only five months—to March of the next year. However, a statistical comparison between matched five-month periods supported the association between implementation of CPOE and increased mortality in this population.

In addition, the authors discuss how their institution’s chosen implementation process for CPOE affected the work processes and pattern of care provided to these critically ill patients. Issues such as being unable to enter orders on a patient in preparation of their arrival because they were not yet enrolled in the electronic system hampered the availability of important medications at the time of arrival. Forcing all of the orders to go through their designed CPOE process in an effort to use the error prevention capabilities of the system caused potentially significant delays in the administration of life-saving medications.

The lack of functional order sets further delayed the physician’s ability to efficiently enter orders electronically. These variables may have impacted mortality rates. Further delays were evident due to the fact that a nurse had to activate orders placed by the physician, bypassing some of the efficiency of an electronic system. Similarly, the pharmacy reviewed and processed the order before the medication was available to the nurse for delivery to the patient.

These checks and balances have the potential to prevent errors in medication ordering, but if inefficient, they may not be appropriate for an intensive care setting in every circumstance. Researchers stated the new workflow took the physicians and nurses away from the patient’s bedside, potentially decreasing observation benefits for the patient. The capacity of the system to compute at times seemed “frozen” causing further delays—not necessarily an uncommon occurrence with any electronic system.

The practice of medicine is complex and work processes do not easily translate to the electronic models currently available. It is crucial that hospitalists, other specialists, all ancillary services, as well as administration be involved in the building and implementation of the systems to be used in our individual facilities. The systems and technology for effective CPOE in hospital settings—especially in pediatric settings—have yet to be developed. The implementation of CPOE for improved patient safety requires exploration given the exposed inadequacies of our current methods of practice.

Like any best practice this exploration will be continuous and require evaluation and improvement. While we must involve ourselves with the development and implementation of CPOE, we must not let the inadequacies of new systems negatively affect patient care. The dichotomy may be omnipresent: Use the system to gain protections from errors and bypass the system when its design or function interferes with good patient practice. This will require us to possess the wisdom to determine the correct path to follow in any instance.

Every day in our practice we make efforts to compensate for failures in our methods to prevent errors from affecting our patient’s care. Electronic systems do not excuse us from continued vigilance, communication, and action to protect our patients from medical errors. The authors appropriately state that “accurate evaluation of CPOE will require systems-based troubleshooting with well-funded, well-designed, multicenter studies that can adequately address these questions.”

Unfortunately, because of the proven inadequacies of the current system, CPOE, like other methodologies we use in the advancement of patient care, cannot wait for proof of perfection before being used to enhance the outcomes of our patients. Thus we need to be vigorous in our participation of the development and implementation of CPOE for our individual institutions and alert to the prevention of harm in all we do. Software companies cannot accomplish improvement in our practices without our involvement, and we cannot meet our demands for quality without good software companies.

The Link between Age and Orchiectomy Due to Testicular Torsion

Mansbach J, Forbes P, Peters C. Testicular torsion and risk factors for orchiectomy. Arch Pediatr Adolesc Med. 2005;159(12):1167-1171.

Testicular torsion is a urologic emergency that requires a four- to eight-hour window from presentation of symptoms until intervention in order to increase the potential for a viable testis. Steps to ensure a viable testis include timely presentation, rapid diagnosis, and curative intervention.

Chart review was done from a national database consisting of 984 hospitals in 22 states. The review included 436 patients ranging from one to 25 years. The incidence of torsion was 4.5 cases/100,000 male subjects with a peak at 10-19 years of age. Of the 436 subjects, 34% required orchiectomy. After all factors (race, insurance status, income, region, and hospital location) were evaluated, increased age at presentation was the only statistically significant factor associated orchiectomy. Male subjects were hesitant to seek medical attention for conditions associated with the genitals. Healthcare providers need to provide anticipatory guidance when educating males about testicular disorders. Testicular exam should be incorporated as part of every physical exam, especially if an abdominal complaint exists.

Heliox Aids Peds with Moderate to Severe Asthma

Kim K, Phrampus E, Venkataraman S, et al. Helium/oxygen-driven albuterol nebulization in the treatment of children with moderate to severe asthma exacerbations: A randomized controlled trial. Pediatrics. 2005;116(5):1127-1133.

Heliox is a 70%/30% helium/oxygen mixture. Heliox mixtures have a lower gas density than oxygen and, therefore, can increase pulmonary gas delivery. This study compared heliox versus oxygen delivery of continuous albuterol nebulization for patients with asthma treated in the emergency department.

Investigators enrolled 30 subjects between ages two and 18 with moderate to severe asthma. Severity of asthma was determined by a pulmonary index (PI) of >8. PI scores are based on respiratory rate, wheezing, accessory muscle use, inspiratory/expiratory ratio, and pulse oximetry. All children were given one 5mg albuterol treatment using traditional oxygen delivery along with oral steroids dosed at 2mg/kg. After the initial treatment and steroids if the PI score was >8 they were randomly assigned to receive continuous albuterol by heliox or traditional oxygen delivery.

The study showed that continuous albuterol delivered by heliox mixture lowered PI scores from baseline to 240 minutes into the study (P<0.001). Results also demonstrated a trend towards improved rate of discharge from the emergency department and hospital, but the study was not powered to adequately evaluate these outcomes Limitations of the study include lack of complete blinding and a small sample size. TH

Insanity in colonial America was not pretty: emotional torment, social isolation, physical pain—and these were just the treatments! In the late 1700s facilities and treatments were often crude and barbaric; however, this doesn’t mean that those who applied them were fueled by cruelty. There were often dedicated and intelligent individuals behind the torturers’ masks. How can this be? Prevailing thoughts on the etiology of mental illness and political forces played large roles in how patients were treated. An excellent example of this is the story of North America’s first public mental health hospital: the Public Hospital for Persons of Insane and Disordered Minds in Williamsburg, Va.

Prior to the opening of the mental health hospital in 1773, the prevailing goal was to minimize the trouble caused to the community by the mentally ill. The quietly insane were simply left to their own devices in the countryside. Those who committed crimes, caused a nuisance or posed a potential threat of either, though, were subject to imprisonment in the local jail.

Virginia’s Acting-Royal Governor and Chief Administrative Officer Francis Fauquier (1758-1768) struggled with the legality of imprisoning the innocent, as well as the lack of treatment for them. Publicly run hospitals specifically for the insane had been in practice for a century in France and England. Fauquier proposed a similar idea to be implemented on American soil.

The hospital was born of unruly times. In 1766, pre-Revolutionary-War America experienced growing anti-British grumblings and political unrest. Just one year prior, a 1765 British Stamp Tax had been imposed on the colonies. Mass riots and pillage ensued. Eventually the tax was repealed. Fauquier gave a speech calling for citizens’ gratitude and obedience to the British Parliament for this concession.

He also proposed the mental health hospital in this speech. Given the juxtaposition, it has been suggested that the governor was likening the violent protests against the Stamp Tax to unreasoned acts of the mentally ill. He described the insane as “persons who are so unhappy as to be deprived of their reason,” a phrase that could equally describe unruly dissenters. Taking this further, one might wonder if Fauquier hoped these protesters would be similarly contained.

What qualified as mental illness? A list of “supposed or assumed causes of insanity” for the hospital’s 754 patients in 1879 identifies 46 such causes. Many, such as excessive study, seduction, matrimony, or the fall of the confederacy, are unlikely to make the modern DSM. But some are familiar (e.g., loss of property, disappointment in love, intemperance, excessive fatigue, and ill health).

It seems the more things change, the more they stay the same: In those predisposed to depression, mania, or psychosis, psychosocial stressors often precipitated acute psychiatric decompensation. In addition, physiological factors such as substance abuse, insomnia, and delirium often played a large role as well.

The treatments of the time seem like torture today. During the hospital’s first 60 years prevailing treatments included solitary confinement, conditioned fear of doctors, powerful but minimally effective drugs, bleeding, shackles, and plunge baths. It was thought that the patients had chosen a life of insanity and needed to decide to change their ways.

Eventually, thought changed. In 1790s post-revolution France, the beginnings of the “moral management” movement took place. This was based on the idea that mental illness was rooted in emotions and that harsh treatment simply confirmed the patients’ fears, thus being ineffective and detrimental.

By the 1840s, these ideas finally spread to Williamsburg. John Minson Galt II took over the hospital in 1841 and dedicated himself to maximizing the use of respect and kindness in shaping the behavior of the mentally ill. He instituted treatments such as good nutrition and sleep, socialization, and recreational therapy. The hospital census swelled, stretching resources thin. As the Civil War brewed, support shifted to the war effort, and the hospital was forced to release many patients into the countryside.

Thus, things had come full circle. Due to the political upheaval, mental healthcare had returned to pre-Revolutionary War conditions. Despite continued interest in the “moral management” methods of treatment, the political times could not provide the support.

As is so common today, the struggle between idealism and practicality was clearly reflected in the patients’ treatments and lives. Though the pendulum did swing back, bringing better treatment for the mentally ill, we continue to seek this fine balance. TH

Reference

Zwelling SS. Quest for a cure: The public hospital in Williamsburg, Virginia, 1773-1885. Williamsburg, Va; Colonial Williamsburg Foundation: 1986.

Insanity in colonial America was not pretty: emotional torment, social isolation, physical pain—and these were just the treatments! In the late 1700s facilities and treatments were often crude and barbaric; however, this doesn’t mean that those who applied them were fueled by cruelty. There were often dedicated and intelligent individuals behind the torturers’ masks. How can this be? Prevailing thoughts on the etiology of mental illness and political forces played large roles in how patients were treated. An excellent example of this is the story of North America’s first public mental health hospital: the Public Hospital for Persons of Insane and Disordered Minds in Williamsburg, Va.

Prior to the opening of the mental health hospital in 1773, the prevailing goal was to minimize the trouble caused to the community by the mentally ill. The quietly insane were simply left to their own devices in the countryside. Those who committed crimes, caused a nuisance or posed a potential threat of either, though, were subject to imprisonment in the local jail.

Virginia’s Acting-Royal Governor and Chief Administrative Officer Francis Fauquier (1758-1768) struggled with the legality of imprisoning the innocent, as well as the lack of treatment for them. Publicly run hospitals specifically for the insane had been in practice for a century in France and England. Fauquier proposed a similar idea to be implemented on American soil.

The hospital was born of unruly times. In 1766, pre-Revolutionary-War America experienced growing anti-British grumblings and political unrest. Just one year prior, a 1765 British Stamp Tax had been imposed on the colonies. Mass riots and pillage ensued. Eventually the tax was repealed. Fauquier gave a speech calling for citizens’ gratitude and obedience to the British Parliament for this concession.

He also proposed the mental health hospital in this speech. Given the juxtaposition, it has been suggested that the governor was likening the violent protests against the Stamp Tax to unreasoned acts of the mentally ill. He described the insane as “persons who are so unhappy as to be deprived of their reason,” a phrase that could equally describe unruly dissenters. Taking this further, one might wonder if Fauquier hoped these protesters would be similarly contained.

What qualified as mental illness? A list of “supposed or assumed causes of insanity” for the hospital’s 754 patients in 1879 identifies 46 such causes. Many, such as excessive study, seduction, matrimony, or the fall of the confederacy, are unlikely to make the modern DSM. But some are familiar (e.g., loss of property, disappointment in love, intemperance, excessive fatigue, and ill health).

It seems the more things change, the more they stay the same: In those predisposed to depression, mania, or psychosis, psychosocial stressors often precipitated acute psychiatric decompensation. In addition, physiological factors such as substance abuse, insomnia, and delirium often played a large role as well.

The treatments of the time seem like torture today. During the hospital’s first 60 years prevailing treatments included solitary confinement, conditioned fear of doctors, powerful but minimally effective drugs, bleeding, shackles, and plunge baths. It was thought that the patients had chosen a life of insanity and needed to decide to change their ways.

Eventually, thought changed. In 1790s post-revolution France, the beginnings of the “moral management” movement took place. This was based on the idea that mental illness was rooted in emotions and that harsh treatment simply confirmed the patients’ fears, thus being ineffective and detrimental.

By the 1840s, these ideas finally spread to Williamsburg. John Minson Galt II took over the hospital in 1841 and dedicated himself to maximizing the use of respect and kindness in shaping the behavior of the mentally ill. He instituted treatments such as good nutrition and sleep, socialization, and recreational therapy. The hospital census swelled, stretching resources thin. As the Civil War brewed, support shifted to the war effort, and the hospital was forced to release many patients into the countryside.

Thus, things had come full circle. Due to the political upheaval, mental healthcare had returned to pre-Revolutionary War conditions. Despite continued interest in the “moral management” methods of treatment, the political times could not provide the support.

As is so common today, the struggle between idealism and practicality was clearly reflected in the patients’ treatments and lives. Though the pendulum did swing back, bringing better treatment for the mentally ill, we continue to seek this fine balance. TH

Reference

Zwelling SS. Quest for a cure: The public hospital in Williamsburg, Virginia, 1773-1885. Williamsburg, Va; Colonial Williamsburg Foundation: 1986.

Insanity in colonial America was not pretty: emotional torment, social isolation, physical pain—and these were just the treatments! In the late 1700s facilities and treatments were often crude and barbaric; however, this doesn’t mean that those who applied them were fueled by cruelty. There were often dedicated and intelligent individuals behind the torturers’ masks. How can this be? Prevailing thoughts on the etiology of mental illness and political forces played large roles in how patients were treated. An excellent example of this is the story of North America’s first public mental health hospital: the Public Hospital for Persons of Insane and Disordered Minds in Williamsburg, Va.

Prior to the opening of the mental health hospital in 1773, the prevailing goal was to minimize the trouble caused to the community by the mentally ill. The quietly insane were simply left to their own devices in the countryside. Those who committed crimes, caused a nuisance or posed a potential threat of either, though, were subject to imprisonment in the local jail.

Virginia’s Acting-Royal Governor and Chief Administrative Officer Francis Fauquier (1758-1768) struggled with the legality of imprisoning the innocent, as well as the lack of treatment for them. Publicly run hospitals specifically for the insane had been in practice for a century in France and England. Fauquier proposed a similar idea to be implemented on American soil.

The hospital was born of unruly times. In 1766, pre-Revolutionary-War America experienced growing anti-British grumblings and political unrest. Just one year prior, a 1765 British Stamp Tax had been imposed on the colonies. Mass riots and pillage ensued. Eventually the tax was repealed. Fauquier gave a speech calling for citizens’ gratitude and obedience to the British Parliament for this concession.

He also proposed the mental health hospital in this speech. Given the juxtaposition, it has been suggested that the governor was likening the violent protests against the Stamp Tax to unreasoned acts of the mentally ill. He described the insane as “persons who are so unhappy as to be deprived of their reason,” a phrase that could equally describe unruly dissenters. Taking this further, one might wonder if Fauquier hoped these protesters would be similarly contained.

What qualified as mental illness? A list of “supposed or assumed causes of insanity” for the hospital’s 754 patients in 1879 identifies 46 such causes. Many, such as excessive study, seduction, matrimony, or the fall of the confederacy, are unlikely to make the modern DSM. But some are familiar (e.g., loss of property, disappointment in love, intemperance, excessive fatigue, and ill health).

It seems the more things change, the more they stay the same: In those predisposed to depression, mania, or psychosis, psychosocial stressors often precipitated acute psychiatric decompensation. In addition, physiological factors such as substance abuse, insomnia, and delirium often played a large role as well.

The treatments of the time seem like torture today. During the hospital’s first 60 years prevailing treatments included solitary confinement, conditioned fear of doctors, powerful but minimally effective drugs, bleeding, shackles, and plunge baths. It was thought that the patients had chosen a life of insanity and needed to decide to change their ways.

Eventually, thought changed. In 1790s post-revolution France, the beginnings of the “moral management” movement took place. This was based on the idea that mental illness was rooted in emotions and that harsh treatment simply confirmed the patients’ fears, thus being ineffective and detrimental.

By the 1840s, these ideas finally spread to Williamsburg. John Minson Galt II took over the hospital in 1841 and dedicated himself to maximizing the use of respect and kindness in shaping the behavior of the mentally ill. He instituted treatments such as good nutrition and sleep, socialization, and recreational therapy. The hospital census swelled, stretching resources thin. As the Civil War brewed, support shifted to the war effort, and the hospital was forced to release many patients into the countryside.

Thus, things had come full circle. Due to the political upheaval, mental healthcare had returned to pre-Revolutionary War conditions. Despite continued interest in the “moral management” methods of treatment, the political times could not provide the support.

As is so common today, the struggle between idealism and practicality was clearly reflected in the patients’ treatments and lives. Though the pendulum did swing back, bringing better treatment for the mentally ill, we continue to seek this fine balance. TH

Reference

Zwelling SS. Quest for a cure: The public hospital in Williamsburg, Virginia, 1773-1885. Williamsburg, Va; Colonial Williamsburg Foundation: 1986.

Every facility has their own twist for what an occupational therapist might do,” says Marla Quinney, OTR/L, assistant director of Adult Inpatient Therapy Services at the University of Chicago (UC) Medical Center. Occupational therapists look at “how patients spend their days and ask, ‘What do they engage in and what do they not engage in because of the current condition?’”

The occupational therapist then helps to rehabilitate patients to baseline. “In an acute care facility,” says Quinney, “a lot of what we do is evaluation and then getting patients to the correct discharge disposition and follow-up care.”

Depending on the institution, occupational therapy offerings may involve management for range of motion, strength, coordination, and sensation; they also include therapy for activities of daily living (ADLs), such as self-care, home management, and community involvement, including vision retraining and cognitive and/or perceptual retraining as they relate to ADLs. Occupational therapists might also include management using assistive devices, and the provision of adaptive equipment. In some institutions, occupational therapy involves aspects of home evaluations, and feeding and swallowing therapy.

Working with Hospitalists: Challenges and Highlights for Occupational Therapists

Marla Quinney

Occupational therapists cite a few areas where hospitalists could provide more help to their fellow professionals in occupational therapy.

Distinction between occupational and physical therapists: To expedite care, hospitalists need to know whether to refer patients to occupational therapy or physical therapy.

“In general, a physical therapist would look at gross motor functions, which affect the patient’s ability to be mobilized from one place to another,” says Quinney. “This also includes whether or not they need assistance to do that safely, and then there’s a myriad of things they look at, including wound care, generalized weakness, and—with a general medicine patient—deconditioning, to make sure that they’re safe in their mobility. An occupational therapist looks more at ADLs, and what patients need to do in order to function in their daily lives and the safety associated with that.”

Timeliness of referrals: Quinney concedes that in the case of a patient who is deconditioned, it might be difficult to discern whether a patient requires occupational therapy or physical therapy. That is one reason why the timeliness of referral is important. If an occupational therapist receives a referral on the day the patient is scheduled for discharge, it may be too late to help them.

But referrals can also be made too soon, says Quinney, “because when the patient is in the ER being admitted, what’s needed may be something as simple as getting their fluids corrected, and once that’s done, then [occupational] therapy is no longer indicated.”

Another example of inappropriate referral timing, she says, might be in the case of a diabetic “whose blood sugars are too high or too low, and clearly, they’re not functioning at their premorbid level. But given the right intervention by the medical team, they’ll bounce back to their baseline.”

Other inappropriate referrals: A patient might also be assessed as having too high or too low a functional status to benefit from occupational therapy. For instance, “a patient might be at too low a level if they came from a nursing home for a UTI or some other complication,” says Quinney, “but their functional status is not something that a therapist would be able to impact in a short hospital stay once that medical problem is corrected.”

From what his occupational therapists tell him, Vijay Rajput, MD, FACP, senior hospitalist at Cooper University Hospital in Camden, N.J., concurs. “If the patient has been in a nursing home for 10 years and is completely custodial and bed-bound, when that patient comes to the hospital and a hospitalist has ordered an occupational therapy consult … , the occupational therapist then has to assess it, and there are no [achievable] goals of care in terms of occupational therapy, then the therapists think that is a [poor use of their] time.”

Vijay Rajput, MD, FACP

In that case, however, the family may benefit from a home visit that will provide maintenance or training.

When Quinney receives what she believes is an inappropriate referral from a hospitalist or other provider, she encourages her therapists to say that back to the hospitalist in a direct, to-the-point communication. Therapists are encouraged to say, “This is what I saw with patient X. I’m not seeing any skilled therapy needs. Is there something else I’m missing?”

“We always give [the provider] the benefit of the doubt of having done an assessment in their mind,” explains Quinney.

How consults are written: Quinney’s team has discussed whether to ask hospitalists to be specific about what they are referring for, so “we as therapists are able to affect the whole person. Because if they only give a referral for a specific task, then it makes it more limiting,” she explains. “If they write a referral for ‘functional ability’ or [one] that says ‘concerned with balance,’ that [allows us] to do some problem-solving.”

Tiffani Morales, LOTR, the occupational therapy team leader at Our Lady of Lourdes Regional Medical Center in Lafayette, La., agrees. “We’ve only had hospitalists for about a year, and the three that we have are really doing a good job, [including the way in which] they’re writing their consults,” says Morales. “They’re leaving it open and trusting us to make recommendations, and they’re going along with them.”

Because hospitalists write the chart note as “Consult,” occupational therapy “gives us leeway to make any equipment recommendations or, actually, any of the treatments that may be warranted versus having to call them back, which takes time to keep giving an order over the phone,” explains Morales.

Geography of patient assignments: The system or structure by which patients are assigned will usually differ between occupational therapists and hospitalists. For instance, at Cooper University Hospital, a 520-bed academic, tertiary hospital in Camden, N.J., where Dr. Rajput began the hospitalist program, the six occupational therapists are assigned patients on a geographical basis, according to floor in a 10-story building. But the group of 25 hospitalists, which has grown from four since 1999, is not assigned that way.

“If I am on service,” says Dr. Rajput, “my patients are assigned [perhaps as] one on the 10th floor, one on the ninth floor, [and] one on the eighth floor.”

His occupational therapists told him that if the hospitalists could be assigned to patients the way they are, it would certainly improve the communication between the two groups.

“It is much better to have a verbal communication with the hospitalist than [simply] reviewing the chart,” says Dr. Rajput.

Some hospitalist groups are looking at returning to this geographically based system. “To restructure the whole system would be very complex,” says Dr. Rajput, who is also the program director for the Internal Medicine Residency Program at UMNDNJ—Robert Wood Johnson Medical School in Camden, “but… it still makes sense [from a communication perspective], for instance, the way it does in the ICU.”

Given the difficulties and drawbacks of making that system a widespread reality, however, Plan B would be to increase and encourage contact between occupational therapists and hospitalists. At the UC Hospital, which employs 12 occupational therapists who work with the patient population that hospitalists are responsible for, “the volume of [patients in] the general medicine unit is too high for OTs to meet with hospitalists daily” explains Quinney, who has been with the UC hospitals for six years.

To breach what might be a communication gap, however, she says, “all OTs have pagers, and whenever they write their note in the chart they will leave their pager number. There is always a way for someone to get in touch with them.”

That, of course, can also be said of hospitalists. And because hospitalists respond quickly when occupational therapists page or call them, says Morales, it can help with patient satisfaction.

“The hospitalists round more quickly or at certain times; they have a routine down,” she says. “And that’s a big thing because when patients are ready to be discharged, they want it now. They don’t want to wait.” And when they can be discharged expediently, “we all look better.”

Throughput and quality care: At the UC Medical Center, as at most institutions, hospitalists are encouraged to move patients from admitting through discharge in the most timely and efficient way possible.

“Hospitalists know that [occupational] therapy is part of that important closure of getting them from one site to another,” says Quinney. But sometimes she hears a [hospitalist or resident] say, “I was just told I need to refer them to you in order to get my patient out of the hospital.”

That’s important, Quinney emphasizes, because occupational therapists want to be part of discharge planning. “But we want to be referred to appropriately so that the people who need us most can utilize us, versus going after patients that aren’t appropriate and are using our resources,” she says. “It’s not that we aren’t happy to see those patients, we truly are; it’s a matter of getting people in a timely manner so that we can really make a difference.”

Great Working Relationships

Morales thinks hospitalists have a good understanding of the services that are available from occupational therapists “because whenever we see them about a patient, if they’re not sure about something, they ask questions such as, ‘Is there anything else you can offer?’” she says. “I think they’re right on target [with us].”

Morales’ team thinks hospitalists are involved, friendly, and open. “It’s just a great work relationship,” she says, “because they’re actually seeing the patients in therapy and asking for our input; it’s very refreshing.” Most of all, she appreciates how they show respect for what the occupational therapists do. “They are listening to what we are saying and that makes a difference.”

Tiffani Morales

Educational Opportunities

Because hospitalists look at the bigger picture of what is going on with patients, they generally consult occupational therapy early enough so that therapists can educate hospitalists, patients, and families at Morales’ institution. This also helps prevent patients’ further deconditioning, and helps them to arrive at a discharge disposition earlier.

Dr. Rajput, who is an associate professor of medicine at the University of Medicine and Dentistry, (Brunswick) New Jersey–Robert Wood Johnson Medical School, thinks it would benefit those involved in medical education and hospital medicine “to see that there is sufficient formal training for the residency level or hospitalist level to understand the component [of occupational therapy] and the indication for occupational therapy, and occupational therapy versus physical therapy, as practice.”

Conclusion

Hospitalists can help their occupational therapist colleagues by recognizing the distinction between occupational therapy and physical therapy, making timely and appropriate referrals, writing consults in an open-ended manner to allow occupational therapists to do “whole-person” assessments, and making sure to educate themselves and their hospitalist colleagues on the services and needs of occupational therapists. TH

Andrea Sattinger regularly writes the “Alliances” department.

Every facility has their own twist for what an occupational therapist might do,” says Marla Quinney, OTR/L, assistant director of Adult Inpatient Therapy Services at the University of Chicago (UC) Medical Center. Occupational therapists look at “how patients spend their days and ask, ‘What do they engage in and what do they not engage in because of the current condition?’”

The occupational therapist then helps to rehabilitate patients to baseline. “In an acute care facility,” says Quinney, “a lot of what we do is evaluation and then getting patients to the correct discharge disposition and follow-up care.”

Depending on the institution, occupational therapy offerings may involve management for range of motion, strength, coordination, and sensation; they also include therapy for activities of daily living (ADLs), such as self-care, home management, and community involvement, including vision retraining and cognitive and/or perceptual retraining as they relate to ADLs. Occupational therapists might also include management using assistive devices, and the provision of adaptive equipment. In some institutions, occupational therapy involves aspects of home evaluations, and feeding and swallowing therapy.

Working with Hospitalists: Challenges and Highlights for Occupational Therapists

Marla Quinney

Occupational therapists cite a few areas where hospitalists could provide more help to their fellow professionals in occupational therapy.

Distinction between occupational and physical therapists: To expedite care, hospitalists need to know whether to refer patients to occupational therapy or physical therapy.

“In general, a physical therapist would look at gross motor functions, which affect the patient’s ability to be mobilized from one place to another,” says Quinney. “This also includes whether or not they need assistance to do that safely, and then there’s a myriad of things they look at, including wound care, generalized weakness, and—with a general medicine patient—deconditioning, to make sure that they’re safe in their mobility. An occupational therapist looks more at ADLs, and what patients need to do in order to function in their daily lives and the safety associated with that.”

Timeliness of referrals: Quinney concedes that in the case of a patient who is deconditioned, it might be difficult to discern whether a patient requires occupational therapy or physical therapy. That is one reason why the timeliness of referral is important. If an occupational therapist receives a referral on the day the patient is scheduled for discharge, it may be too late to help them.

But referrals can also be made too soon, says Quinney, “because when the patient is in the ER being admitted, what’s needed may be something as simple as getting their fluids corrected, and once that’s done, then [occupational] therapy is no longer indicated.”

Another example of inappropriate referral timing, she says, might be in the case of a diabetic “whose blood sugars are too high or too low, and clearly, they’re not functioning at their premorbid level. But given the right intervention by the medical team, they’ll bounce back to their baseline.”

Other inappropriate referrals: A patient might also be assessed as having too high or too low a functional status to benefit from occupational therapy. For instance, “a patient might be at too low a level if they came from a nursing home for a UTI or some other complication,” says Quinney, “but their functional status is not something that a therapist would be able to impact in a short hospital stay once that medical problem is corrected.”

From what his occupational therapists tell him, Vijay Rajput, MD, FACP, senior hospitalist at Cooper University Hospital in Camden, N.J., concurs. “If the patient has been in a nursing home for 10 years and is completely custodial and bed-bound, when that patient comes to the hospital and a hospitalist has ordered an occupational therapy consult … , the occupational therapist then has to assess it, and there are no [achievable] goals of care in terms of occupational therapy, then the therapists think that is a [poor use of their] time.”

Vijay Rajput, MD, FACP

In that case, however, the family may benefit from a home visit that will provide maintenance or training.

When Quinney receives what she believes is an inappropriate referral from a hospitalist or other provider, she encourages her therapists to say that back to the hospitalist in a direct, to-the-point communication. Therapists are encouraged to say, “This is what I saw with patient X. I’m not seeing any skilled therapy needs. Is there something else I’m missing?”

“We always give [the provider] the benefit of the doubt of having done an assessment in their mind,” explains Quinney.

How consults are written: Quinney’s team has discussed whether to ask hospitalists to be specific about what they are referring for, so “we as therapists are able to affect the whole person. Because if they only give a referral for a specific task, then it makes it more limiting,” she explains. “If they write a referral for ‘functional ability’ or [one] that says ‘concerned with balance,’ that [allows us] to do some problem-solving.”

Tiffani Morales, LOTR, the occupational therapy team leader at Our Lady of Lourdes Regional Medical Center in Lafayette, La., agrees. “We’ve only had hospitalists for about a year, and the three that we have are really doing a good job, [including the way in which] they’re writing their consults,” says Morales. “They’re leaving it open and trusting us to make recommendations, and they’re going along with them.”

Because hospitalists write the chart note as “Consult,” occupational therapy “gives us leeway to make any equipment recommendations or, actually, any of the treatments that may be warranted versus having to call them back, which takes time to keep giving an order over the phone,” explains Morales.

Geography of patient assignments: The system or structure by which patients are assigned will usually differ between occupational therapists and hospitalists. For instance, at Cooper University Hospital, a 520-bed academic, tertiary hospital in Camden, N.J., where Dr. Rajput began the hospitalist program, the six occupational therapists are assigned patients on a geographical basis, according to floor in a 10-story building. But the group of 25 hospitalists, which has grown from four since 1999, is not assigned that way.

“If I am on service,” says Dr. Rajput, “my patients are assigned [perhaps as] one on the 10th floor, one on the ninth floor, [and] one on the eighth floor.”

His occupational therapists told him that if the hospitalists could be assigned to patients the way they are, it would certainly improve the communication between the two groups.

“It is much better to have a verbal communication with the hospitalist than [simply] reviewing the chart,” says Dr. Rajput.

Some hospitalist groups are looking at returning to this geographically based system. “To restructure the whole system would be very complex,” says Dr. Rajput, who is also the program director for the Internal Medicine Residency Program at UMNDNJ—Robert Wood Johnson Medical School in Camden, “but… it still makes sense [from a communication perspective], for instance, the way it does in the ICU.”

Given the difficulties and drawbacks of making that system a widespread reality, however, Plan B would be to increase and encourage contact between occupational therapists and hospitalists. At the UC Hospital, which employs 12 occupational therapists who work with the patient population that hospitalists are responsible for, “the volume of [patients in] the general medicine unit is too high for OTs to meet with hospitalists daily” explains Quinney, who has been with the UC hospitals for six years.

To breach what might be a communication gap, however, she says, “all OTs have pagers, and whenever they write their note in the chart they will leave their pager number. There is always a way for someone to get in touch with them.”

That, of course, can also be said of hospitalists. And because hospitalists respond quickly when occupational therapists page or call them, says Morales, it can help with patient satisfaction.

“The hospitalists round more quickly or at certain times; they have a routine down,” she says. “And that’s a big thing because when patients are ready to be discharged, they want it now. They don’t want to wait.” And when they can be discharged expediently, “we all look better.”

Throughput and quality care: At the UC Medical Center, as at most institutions, hospitalists are encouraged to move patients from admitting through discharge in the most timely and efficient way possible.

“Hospitalists know that [occupational] therapy is part of that important closure of getting them from one site to another,” says Quinney. But sometimes she hears a [hospitalist or resident] say, “I was just told I need to refer them to you in order to get my patient out of the hospital.”

That’s important, Quinney emphasizes, because occupational therapists want to be part of discharge planning. “But we want to be referred to appropriately so that the people who need us most can utilize us, versus going after patients that aren’t appropriate and are using our resources,” she says. “It’s not that we aren’t happy to see those patients, we truly are; it’s a matter of getting people in a timely manner so that we can really make a difference.”

Great Working Relationships

Morales thinks hospitalists have a good understanding of the services that are available from occupational therapists “because whenever we see them about a patient, if they’re not sure about something, they ask questions such as, ‘Is there anything else you can offer?’” she says. “I think they’re right on target [with us].”

Morales’ team thinks hospitalists are involved, friendly, and open. “It’s just a great work relationship,” she says, “because they’re actually seeing the patients in therapy and asking for our input; it’s very refreshing.” Most of all, she appreciates how they show respect for what the occupational therapists do. “They are listening to what we are saying and that makes a difference.”

Tiffani Morales

Educational Opportunities

Because hospitalists look at the bigger picture of what is going on with patients, they generally consult occupational therapy early enough so that therapists can educate hospitalists, patients, and families at Morales’ institution. This also helps prevent patients’ further deconditioning, and helps them to arrive at a discharge disposition earlier.

Dr. Rajput, who is an associate professor of medicine at the University of Medicine and Dentistry, (Brunswick) New Jersey–Robert Wood Johnson Medical School, thinks it would benefit those involved in medical education and hospital medicine “to see that there is sufficient formal training for the residency level or hospitalist level to understand the component [of occupational therapy] and the indication for occupational therapy, and occupational therapy versus physical therapy, as practice.”

Conclusion

Hospitalists can help their occupational therapist colleagues by recognizing the distinction between occupational therapy and physical therapy, making timely and appropriate referrals, writing consults in an open-ended manner to allow occupational therapists to do “whole-person” assessments, and making sure to educate themselves and their hospitalist colleagues on the services and needs of occupational therapists. TH

Andrea Sattinger regularly writes the “Alliances” department.

Every facility has their own twist for what an occupational therapist might do,” says Marla Quinney, OTR/L, assistant director of Adult Inpatient Therapy Services at the University of Chicago (UC) Medical Center. Occupational therapists look at “how patients spend their days and ask, ‘What do they engage in and what do they not engage in because of the current condition?’”

The occupational therapist then helps to rehabilitate patients to baseline. “In an acute care facility,” says Quinney, “a lot of what we do is evaluation and then getting patients to the correct discharge disposition and follow-up care.”

Depending on the institution, occupational therapy offerings may involve management for range of motion, strength, coordination, and sensation; they also include therapy for activities of daily living (ADLs), such as self-care, home management, and community involvement, including vision retraining and cognitive and/or perceptual retraining as they relate to ADLs. Occupational therapists might also include management using assistive devices, and the provision of adaptive equipment. In some institutions, occupational therapy involves aspects of home evaluations, and feeding and swallowing therapy.

Working with Hospitalists: Challenges and Highlights for Occupational Therapists

Marla Quinney

Occupational therapists cite a few areas where hospitalists could provide more help to their fellow professionals in occupational therapy.

Distinction between occupational and physical therapists: To expedite care, hospitalists need to know whether to refer patients to occupational therapy or physical therapy.

“In general, a physical therapist would look at gross motor functions, which affect the patient’s ability to be mobilized from one place to another,” says Quinney. “This also includes whether or not they need assistance to do that safely, and then there’s a myriad of things they look at, including wound care, generalized weakness, and—with a general medicine patient—deconditioning, to make sure that they’re safe in their mobility. An occupational therapist looks more at ADLs, and what patients need to do in order to function in their daily lives and the safety associated with that.”

Timeliness of referrals: Quinney concedes that in the case of a patient who is deconditioned, it might be difficult to discern whether a patient requires occupational therapy or physical therapy. That is one reason why the timeliness of referral is important. If an occupational therapist receives a referral on the day the patient is scheduled for discharge, it may be too late to help them.

But referrals can also be made too soon, says Quinney, “because when the patient is in the ER being admitted, what’s needed may be something as simple as getting their fluids corrected, and once that’s done, then [occupational] therapy is no longer indicated.”

Another example of inappropriate referral timing, she says, might be in the case of a diabetic “whose blood sugars are too high or too low, and clearly, they’re not functioning at their premorbid level. But given the right intervention by the medical team, they’ll bounce back to their baseline.”

Other inappropriate referrals: A patient might also be assessed as having too high or too low a functional status to benefit from occupational therapy. For instance, “a patient might be at too low a level if they came from a nursing home for a UTI or some other complication,” says Quinney, “but their functional status is not something that a therapist would be able to impact in a short hospital stay once that medical problem is corrected.”

From what his occupational therapists tell him, Vijay Rajput, MD, FACP, senior hospitalist at Cooper University Hospital in Camden, N.J., concurs. “If the patient has been in a nursing home for 10 years and is completely custodial and bed-bound, when that patient comes to the hospital and a hospitalist has ordered an occupational therapy consult … , the occupational therapist then has to assess it, and there are no [achievable] goals of care in terms of occupational therapy, then the therapists think that is a [poor use of their] time.”

Vijay Rajput, MD, FACP

In that case, however, the family may benefit from a home visit that will provide maintenance or training.

When Quinney receives what she believes is an inappropriate referral from a hospitalist or other provider, she encourages her therapists to say that back to the hospitalist in a direct, to-the-point communication. Therapists are encouraged to say, “This is what I saw with patient X. I’m not seeing any skilled therapy needs. Is there something else I’m missing?”

“We always give [the provider] the benefit of the doubt of having done an assessment in their mind,” explains Quinney.

How consults are written: Quinney’s team has discussed whether to ask hospitalists to be specific about what they are referring for, so “we as therapists are able to affect the whole person. Because if they only give a referral for a specific task, then it makes it more limiting,” she explains. “If they write a referral for ‘functional ability’ or [one] that says ‘concerned with balance,’ that [allows us] to do some problem-solving.”

Tiffani Morales, LOTR, the occupational therapy team leader at Our Lady of Lourdes Regional Medical Center in Lafayette, La., agrees. “We’ve only had hospitalists for about a year, and the three that we have are really doing a good job, [including the way in which] they’re writing their consults,” says Morales. “They’re leaving it open and trusting us to make recommendations, and they’re going along with them.”

Because hospitalists write the chart note as “Consult,” occupational therapy “gives us leeway to make any equipment recommendations or, actually, any of the treatments that may be warranted versus having to call them back, which takes time to keep giving an order over the phone,” explains Morales.

Geography of patient assignments: The system or structure by which patients are assigned will usually differ between occupational therapists and hospitalists. For instance, at Cooper University Hospital, a 520-bed academic, tertiary hospital in Camden, N.J., where Dr. Rajput began the hospitalist program, the six occupational therapists are assigned patients on a geographical basis, according to floor in a 10-story building. But the group of 25 hospitalists, which has grown from four since 1999, is not assigned that way.

“If I am on service,” says Dr. Rajput, “my patients are assigned [perhaps as] one on the 10th floor, one on the ninth floor, [and] one on the eighth floor.”

His occupational therapists told him that if the hospitalists could be assigned to patients the way they are, it would certainly improve the communication between the two groups.

“It is much better to have a verbal communication with the hospitalist than [simply] reviewing the chart,” says Dr. Rajput.

Some hospitalist groups are looking at returning to this geographically based system. “To restructure the whole system would be very complex,” says Dr. Rajput, who is also the program director for the Internal Medicine Residency Program at UMNDNJ—Robert Wood Johnson Medical School in Camden, “but… it still makes sense [from a communication perspective], for instance, the way it does in the ICU.”

Given the difficulties and drawbacks of making that system a widespread reality, however, Plan B would be to increase and encourage contact between occupational therapists and hospitalists. At the UC Hospital, which employs 12 occupational therapists who work with the patient population that hospitalists are responsible for, “the volume of [patients in] the general medicine unit is too high for OTs to meet with hospitalists daily” explains Quinney, who has been with the UC hospitals for six years.

To breach what might be a communication gap, however, she says, “all OTs have pagers, and whenever they write their note in the chart they will leave their pager number. There is always a way for someone to get in touch with them.”

That, of course, can also be said of hospitalists. And because hospitalists respond quickly when occupational therapists page or call them, says Morales, it can help with patient satisfaction.

“The hospitalists round more quickly or at certain times; they have a routine down,” she says. “And that’s a big thing because when patients are ready to be discharged, they want it now. They don’t want to wait.” And when they can be discharged expediently, “we all look better.”

Throughput and quality care: At the UC Medical Center, as at most institutions, hospitalists are encouraged to move patients from admitting through discharge in the most timely and efficient way possible.

“Hospitalists know that [occupational] therapy is part of that important closure of getting them from one site to another,” says Quinney. But sometimes she hears a [hospitalist or resident] say, “I was just told I need to refer them to you in order to get my patient out of the hospital.”

That’s important, Quinney emphasizes, because occupational therapists want to be part of discharge planning. “But we want to be referred to appropriately so that the people who need us most can utilize us, versus going after patients that aren’t appropriate and are using our resources,” she says. “It’s not that we aren’t happy to see those patients, we truly are; it’s a matter of getting people in a timely manner so that we can really make a difference.”

Great Working Relationships

Morales thinks hospitalists have a good understanding of the services that are available from occupational therapists “because whenever we see them about a patient, if they’re not sure about something, they ask questions such as, ‘Is there anything else you can offer?’” she says. “I think they’re right on target [with us].”

Morales’ team thinks hospitalists are involved, friendly, and open. “It’s just a great work relationship,” she says, “because they’re actually seeing the patients in therapy and asking for our input; it’s very refreshing.” Most of all, she appreciates how they show respect for what the occupational therapists do. “They are listening to what we are saying and that makes a difference.”

Tiffani Morales

Educational Opportunities

Because hospitalists look at the bigger picture of what is going on with patients, they generally consult occupational therapy early enough so that therapists can educate hospitalists, patients, and families at Morales’ institution. This also helps prevent patients’ further deconditioning, and helps them to arrive at a discharge disposition earlier.

Dr. Rajput, who is an associate professor of medicine at the University of Medicine and Dentistry, (Brunswick) New Jersey–Robert Wood Johnson Medical School, thinks it would benefit those involved in medical education and hospital medicine “to see that there is sufficient formal training for the residency level or hospitalist level to understand the component [of occupational therapy] and the indication for occupational therapy, and occupational therapy versus physical therapy, as practice.”

Conclusion

Hospitalists can help their occupational therapist colleagues by recognizing the distinction between occupational therapy and physical therapy, making timely and appropriate referrals, writing consults in an open-ended manner to allow occupational therapists to do “whole-person” assessments, and making sure to educate themselves and their hospitalist colleagues on the services and needs of occupational therapists. TH

Andrea Sattinger regularly writes the “Alliances” department.

The medical literature pertaining to patient safety is voluminous, especially since the publication of the 1999 Institute of Medicine (IOM) report estimating that between 44,000 and 98,000 Americans die from medical errors each year.1 When focusing on hospitalists and the matter of near misses, however, where the outcome of the error has been intercepted before harm can occur, the volume of published information is far more limited.2

“There are few good data about the role that hospitalists play in preventing adverse events,” says Saul Weingart, MD, PhD, vice president for patient safety at the Dana-Farber Cancer Institute, Boston, “so most accounts are anecdotal. My own sense is that hospital medicine plays a critical role in preventing and mitigating errors in the acute care setting.”

One study, conducted by two hospitalists in a 200-bed academic hospital and published in 2003 in the Journal of General Internal Medicine, distinguished near misses from adverse events.3 The investigators set out to determine the frequency, types, and consequences of errors that can be detected by hospitalists during routine clinical care, and to compare the types of errors first discovered by hospitalists to those discovered by other providers.

Sarwat Chaudhry, MD, a former hospitalist who is now a health services researcher and assistant professor of medicine at the Yale School of Medicine in New Haven, Conn., was the lead investigator in that study. “Oftentimes the errors that are ‘sexier’ and more exciting for people to talk about are the adverse events,” she says. “But I think what are perhaps more common and more informative are the near misses.”

Definitions

For purposes of Chaudhry, et al.’s study, “adverse events” were defined as adverse outcomes that resulted from errors.3 Errors that did not result in patient harm, but could have, were categorized as near misses. The umbrella definition of error fit that which was used in the IOM report; that is, “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”1 Cases in which a bad outcome occurred (such as death or disability) without a preventable cause were not considered errors and, therefore, were not included in the data.

A more practical understanding of a near miss is apparent in the following illustration: “If pharmacy came to me and said, ‘Oh, Dr. Chaudhry, one of the physicians on your team wrote for drug X but the patient is also on drug Y and that’s a known contraindication so we don’t think this should be administered, do you agree?’ I’d say, ‘Yes, I agree.’ So the drug was never given, but it was a near miss for the way it was written if it hadn’t been picked up on.”

In fact there are two kinds of near misses. “One is where the error is intercepted by [a] pharmacy or somebody else before harm is done,” says Dr. Weingart. “The other kind is where the error reaches the patient—for instance, where he or she receives the antibiotic to which they are allergic—but no reaction takes place.”

An important element in the study was that both types of errors were identified during the course of routine, clinical care by Dr. Chaudhry and her colleague, Kolawole Olofinboba, MD. Errors first detected by other healthcare workers were also recorded. Of the 528 patients included in the study, 10.4% experienced at least one error: 6.2% a near miss and 4.2% an adverse event. Interestingly, most of the errors first detected by house staff, nurses, and laboratory technicians were adverse events, whereas most of the errors first detected by the attending hospitalists, pharmacists, and consultants were near misses. Drug errors were the most common type of error overall.

Although differences did not achieve statistical significance, Dr. Chaudhry says the data were illuminating and the hospital administration was anxious to clarify the processes of care that could be modified to make the workflow more efficient and the different pieces of each patient’s critical data more integrated.

“For instance,” she says, “at our hospital there was a lot of separation of data. … The vitals were right outside the patient’s room. The list of medications was kept in a central pharmacy location, and the medical chart with everyone’s notes was in a third location.”

After the study’s completion, the integration of data was facilitated by the adoption of an electronic medical record (EMR) and there is ongoing research at that institution concerning whether that has affected error rates.

Hospitalists are ideally poised to take a lead in promoting patient safety by becoming more involved and developing the systems for error reporting.

—Sarwat Chaudhry, MD

Lessons Learned

“This was one of the first and, still I think, only studies of attending physicians reporting their own errors,” says Dr. Chaudhry, “as well as reporting the scope, type, and frequency of the errors.”

There were several lessons learned. The first is that near misses are very common—at least as common as adverse events and perhaps more frequent. The second is that the nature of near misses is similar enough to that of adverse events that they can still be informative in preventing harm to patients. The third lesson arises from the investigators’ review of the kinds of errors that were reported by the different providers. “Different types of providers are going to pick up on different kinds of errors,” says Dr. Chaudhry. “Pharmacy, of course, is going to be detecting drug errors. But nurses are going to be detecting a different kind of error than residents, and residents are detecting a different kind of error than attending physicians.”

Dr. Weingart, who was trained as an internist, says his sense is that “we often pick up errors that occur just upstream in the process of care. For instance, pharmacy finds doctor prescribing errors and nursing finds pharmacy dispensing errors.”

Drs. Chaudhry and Olofinboba discovered 17/47 (36%) of the errors on their own, and pharmacists, resident physicians, consulting physicians, nurses, and ancillary staff discovered the remaining 30/47 (64%). The hospitalists were more likely to detect therapeutic errors; house staff physicians were more likely to detect drug errors. House staff also detected procedural errors at a higher rate than did the hospitalists. Consequently, Dr. Chaudhry emphasizes, another highlight of these data shows that “engaging as many different kinds of healthcare providers in error reporting is very important to understand what’s going on.”

Documenting Errors

The two hospitalists in Dr. Chaudhry’s study underwent no formal training in error detection, and all errors identified were documented. This in itself is a remarkable aspect of this study for hospitalists to note.

“In most hospitals, the risk management department feels like breaking out a bottle of champagne to celebrate every time a physician submits an incident report,” says Dr. Weingart, “because in most hospitals physicians don’t view incident reporting as part of their responsibility. On the other hand, physicians constantly talk about the errors, near misses, and adverse events they encounter day-to-day. Unfortunately, formal incident reporting isn’t an activity that most physicians see as a part of their duty to deliver excellent care at the bedside.” By virtue of this, he says, “critical information is often lost to the system. Error experience is transmitted person-to-person but isn’t captured and analyzed.”

The good news here, however, is that by simply launching a study of this nature and capturing the data it is reasonable to expect that any hospitalist group could take it on and any hospital’s quality of care would be improved.

“There is a spectrum of practice review that is conducted by a variety of people,” says Dr. Chaudhry. “On one end of the spectrum, you have the uninvolved reviewer coming in and doing formal chart reviews … and our process was at other end of spectrum, where we were going about our daily business, the routine clinical care of patients.”

By maintaining the potential for errors at the forefront of their thinking, she says, it became the background against which they performed the constant daily review of patient data. “When I would go to the bedside in the morning,” she says, “to see the patient, talk to the patient, review the chart, look at notes, look at vitals, look at meds—that was my process for picking up on errors.”

Barriers and Opportunities

There are two major barriers to performing this kind of research in other institutions where hospitalists practice, but they are easily resolved. The first is the importance of standardizing definitions.

“We came to consensus before the study began of what things should count and what things shouldn’t count,” says Dr. Chaudhry. “Because there is a degree of subjectivity and especially when a patient experiences harm, it’s a bit easier to attribute that to an error—though not always. For instance, with a patient with asthma who ends up with fluid overload and gets intubated. Well, was that an error? … Or was that just the patient’s own asthma getting worse? How much did the fluid contribute to that?”

There is still a degree of judgment, even there, she says, “but as much as possible we wanted to come to consensus at least about our definitions, our terminology, and our categorization.”

The second barrier to performing this research is the real or perceived risk of litigation. There was a lot of concern at the beginning of her study, says Dr. Chaudhry (and again at the time of publication), regarding the aftermath of disclosing errors.

“As much as the Institute of Medicine and other accreditation and safety organizations talk about how error reporting is so important and that physicians have to be willing to come forward with their errors, there are really no formal, legal, protective mechanisms in place,” she says, adding that this was true three years ago, and she does not believe much has changed.

Consequently, when constructing the study, she reached out to the authors of other error studies and asked them how they had handled the risk of potential litigation. Most of them told her they did not think there was much risk of being sued, but disclosing errors in the literature is certainly not something an institution or individuals would be clamoring to do. If a multi-center study of this nature might be undertaken, she says, these barriers could be traversed and it would be worth it. “Because if we let that opportunity slip through our fingers, it will be taken on by nonphysicians,” she cautions, “by the external reviewers, by the accreditation organizations, by professional quality control people.”

Dr. Chaudhry’s overall recommendation to hospitalists involves the position they hold at this time. “Hospitalists are ideally poised to take a lead in promoting patient safety by becoming more involved and developing the systems for error reporting,” she says.

Dr. Weingart tells hospitalist audiences that the most important areas for detecting errors in their practice include safe prescription writing and error-proofing high-risk activities (such as hand-offs and sign-outs, and follow-up of test results). He also recommends that hospitalists play the role of responsible citizens in their institutions and be open to ways your patients can contribute by helping you detect errors in their care.4 These issues will be addressed in more detail in future articles in The Hospitalist.

Although Dr. Chaudhry is no longer practicing as a hospitalist, she believes that hospital teams working closely together in patient care have a strong advantage to identify any errors.

“As physicians, with hospital medicine expanding,” she says, “this is the opportune time to take on a leadership role, and this needs to be part of the hospitalist mission. Not everyone has to come out and report their adverse events, especially since the legal risks are still unclear. But a safe way and equally informative way to work on preventing harm is to focus on those near misses.”

Conclusion

Hospitalists who search for near misses, volunteer this information, and enroll their colleagues in doing the same contribute to reforming systems and processes that will ultimately reduce the potential for all errors. Those who pay close attention to standardized rules for prescription-writing, error-proofing high-risk activities, and their roles for institutional citizenship and encouraging patient contribution in regard to possible errors, are doing the best possible job to prevent harm to patients and the institution as a whole. TH

Andrea Sattinger will write about apology in medicine in the June issue.

References

1. Kohn LT, Corrigan JM, Donaldson MS, Institute of Medicine Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
2. Bleich S. Medical Errors: Five Years After the IOM Report. New York: Commonwealth Fund; July 2005: Available at: www.mihealthandsafety.org/pdfs/pub-4-commonwealth.pdf. Last accessed March 22, 2006.
3. Chaudhry SI, Olofinboba KA, Krumholz HM. Detection of errors by attending physicians on a general medicine service. J Gen Intern Med. 2003 Aug;18(8):595-600.
4. Weingart SN, Pagovich O, Sands DZ, et al. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. J Gen Intern Med. 2005 Sep;20(9):830-836.

The medical literature pertaining to patient safety is voluminous, especially since the publication of the 1999 Institute of Medicine (IOM) report estimating that between 44,000 and 98,000 Americans die from medical errors each year.1 When focusing on hospitalists and the matter of near misses, however, where the outcome of the error has been intercepted before harm can occur, the volume of published information is far more limited.2

“There are few good data about the role that hospitalists play in preventing adverse events,” says Saul Weingart, MD, PhD, vice president for patient safety at the Dana-Farber Cancer Institute, Boston, “so most accounts are anecdotal. My own sense is that hospital medicine plays a critical role in preventing and mitigating errors in the acute care setting.”

One study, conducted by two hospitalists in a 200-bed academic hospital and published in 2003 in the Journal of General Internal Medicine, distinguished near misses from adverse events.3 The investigators set out to determine the frequency, types, and consequences of errors that can be detected by hospitalists during routine clinical care, and to compare the types of errors first discovered by hospitalists to those discovered by other providers.

Sarwat Chaudhry, MD, a former hospitalist who is now a health services researcher and assistant professor of medicine at the Yale School of Medicine in New Haven, Conn., was the lead investigator in that study. “Oftentimes the errors that are ‘sexier’ and more exciting for people to talk about are the adverse events,” she says. “But I think what are perhaps more common and more informative are the near misses.”

Definitions

For purposes of Chaudhry, et al.’s study, “adverse events” were defined as adverse outcomes that resulted from errors.3 Errors that did not result in patient harm, but could have, were categorized as near misses. The umbrella definition of error fit that which was used in the IOM report; that is, “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”1 Cases in which a bad outcome occurred (such as death or disability) without a preventable cause were not considered errors and, therefore, were not included in the data.

A more practical understanding of a near miss is apparent in the following illustration: “If pharmacy came to me and said, ‘Oh, Dr. Chaudhry, one of the physicians on your team wrote for drug X but the patient is also on drug Y and that’s a known contraindication so we don’t think this should be administered, do you agree?’ I’d say, ‘Yes, I agree.’ So the drug was never given, but it was a near miss for the way it was written if it hadn’t been picked up on.”

In fact there are two kinds of near misses. “One is where the error is intercepted by [a] pharmacy or somebody else before harm is done,” says Dr. Weingart. “The other kind is where the error reaches the patient—for instance, where he or she receives the antibiotic to which they are allergic—but no reaction takes place.”

An important element in the study was that both types of errors were identified during the course of routine, clinical care by Dr. Chaudhry and her colleague, Kolawole Olofinboba, MD. Errors first detected by other healthcare workers were also recorded. Of the 528 patients included in the study, 10.4% experienced at least one error: 6.2% a near miss and 4.2% an adverse event. Interestingly, most of the errors first detected by house staff, nurses, and laboratory technicians were adverse events, whereas most of the errors first detected by the attending hospitalists, pharmacists, and consultants were near misses. Drug errors were the most common type of error overall.

Although differences did not achieve statistical significance, Dr. Chaudhry says the data were illuminating and the hospital administration was anxious to clarify the processes of care that could be modified to make the workflow more efficient and the different pieces of each patient’s critical data more integrated.

“For instance,” she says, “at our hospital there was a lot of separation of data. … The vitals were right outside the patient’s room. The list of medications was kept in a central pharmacy location, and the medical chart with everyone’s notes was in a third location.”

After the study’s completion, the integration of data was facilitated by the adoption of an electronic medical record (EMR) and there is ongoing research at that institution concerning whether that has affected error rates.

Hospitalists are ideally poised to take a lead in promoting patient safety by becoming more involved and developing the systems for error reporting.

—Sarwat Chaudhry, MD

Lessons Learned

“This was one of the first and, still I think, only studies of attending physicians reporting their own errors,” says Dr. Chaudhry, “as well as reporting the scope, type, and frequency of the errors.”

There were several lessons learned. The first is that near misses are very common—at least as common as adverse events and perhaps more frequent. The second is that the nature of near misses is similar enough to that of adverse events that they can still be informative in preventing harm to patients. The third lesson arises from the investigators’ review of the kinds of errors that were reported by the different providers. “Different types of providers are going to pick up on different kinds of errors,” says Dr. Chaudhry. “Pharmacy, of course, is going to be detecting drug errors. But nurses are going to be detecting a different kind of error than residents, and residents are detecting a different kind of error than attending physicians.”

Dr. Weingart, who was trained as an internist, says his sense is that “we often pick up errors that occur just upstream in the process of care. For instance, pharmacy finds doctor prescribing errors and nursing finds pharmacy dispensing errors.”

Drs. Chaudhry and Olofinboba discovered 17/47 (36%) of the errors on their own, and pharmacists, resident physicians, consulting physicians, nurses, and ancillary staff discovered the remaining 30/47 (64%). The hospitalists were more likely to detect therapeutic errors; house staff physicians were more likely to detect drug errors. House staff also detected procedural errors at a higher rate than did the hospitalists. Consequently, Dr. Chaudhry emphasizes, another highlight of these data shows that “engaging as many different kinds of healthcare providers in error reporting is very important to understand what’s going on.”

Documenting Errors

The two hospitalists in Dr. Chaudhry’s study underwent no formal training in error detection, and all errors identified were documented. This in itself is a remarkable aspect of this study for hospitalists to note.

“In most hospitals, the risk management department feels like breaking out a bottle of champagne to celebrate every time a physician submits an incident report,” says Dr. Weingart, “because in most hospitals physicians don’t view incident reporting as part of their responsibility. On the other hand, physicians constantly talk about the errors, near misses, and adverse events they encounter day-to-day. Unfortunately, formal incident reporting isn’t an activity that most physicians see as a part of their duty to deliver excellent care at the bedside.” By virtue of this, he says, “critical information is often lost to the system. Error experience is transmitted person-to-person but isn’t captured and analyzed.”

The good news here, however, is that by simply launching a study of this nature and capturing the data it is reasonable to expect that any hospitalist group could take it on and any hospital’s quality of care would be improved.

“There is a spectrum of practice review that is conducted by a variety of people,” says Dr. Chaudhry. “On one end of the spectrum, you have the uninvolved reviewer coming in and doing formal chart reviews … and our process was at other end of spectrum, where we were going about our daily business, the routine clinical care of patients.”

By maintaining the potential for errors at the forefront of their thinking, she says, it became the background against which they performed the constant daily review of patient data. “When I would go to the bedside in the morning,” she says, “to see the patient, talk to the patient, review the chart, look at notes, look at vitals, look at meds—that was my process for picking up on errors.”

Barriers and Opportunities

There are two major barriers to performing this kind of research in other institutions where hospitalists practice, but they are easily resolved. The first is the importance of standardizing definitions.

“We came to consensus before the study began of what things should count and what things shouldn’t count,” says Dr. Chaudhry. “Because there is a degree of subjectivity and especially when a patient experiences harm, it’s a bit easier to attribute that to an error—though not always. For instance, with a patient with asthma who ends up with fluid overload and gets intubated. Well, was that an error? … Or was that just the patient’s own asthma getting worse? How much did the fluid contribute to that?”

There is still a degree of judgment, even there, she says, “but as much as possible we wanted to come to consensus at least about our definitions, our terminology, and our categorization.”

The second barrier to performing this research is the real or perceived risk of litigation. There was a lot of concern at the beginning of her study, says Dr. Chaudhry (and again at the time of publication), regarding the aftermath of disclosing errors.

“As much as the Institute of Medicine and other accreditation and safety organizations talk about how error reporting is so important and that physicians have to be willing to come forward with their errors, there are really no formal, legal, protective mechanisms in place,” she says, adding that this was true three years ago, and she does not believe much has changed.

Consequently, when constructing the study, she reached out to the authors of other error studies and asked them how they had handled the risk of potential litigation. Most of them told her they did not think there was much risk of being sued, but disclosing errors in the literature is certainly not something an institution or individuals would be clamoring to do. If a multi-center study of this nature might be undertaken, she says, these barriers could be traversed and it would be worth it. “Because if we let that opportunity slip through our fingers, it will be taken on by nonphysicians,” she cautions, “by the external reviewers, by the accreditation organizations, by professional quality control people.”

Dr. Chaudhry’s overall recommendation to hospitalists involves the position they hold at this time. “Hospitalists are ideally poised to take a lead in promoting patient safety by becoming more involved and developing the systems for error reporting,” she says.

Dr. Weingart tells hospitalist audiences that the most important areas for detecting errors in their practice include safe prescription writing and error-proofing high-risk activities (such as hand-offs and sign-outs, and follow-up of test results). He also recommends that hospitalists play the role of responsible citizens in their institutions and be open to ways your patients can contribute by helping you detect errors in their care.4 These issues will be addressed in more detail in future articles in The Hospitalist.

Although Dr. Chaudhry is no longer practicing as a hospitalist, she believes that hospital teams working closely together in patient care have a strong advantage to identify any errors.

“As physicians, with hospital medicine expanding,” she says, “this is the opportune time to take on a leadership role, and this needs to be part of the hospitalist mission. Not everyone has to come out and report their adverse events, especially since the legal risks are still unclear. But a safe way and equally informative way to work on preventing harm is to focus on those near misses.”

Conclusion

Hospitalists who search for near misses, volunteer this information, and enroll their colleagues in doing the same contribute to reforming systems and processes that will ultimately reduce the potential for all errors. Those who pay close attention to standardized rules for prescription-writing, error-proofing high-risk activities, and their roles for institutional citizenship and encouraging patient contribution in regard to possible errors, are doing the best possible job to prevent harm to patients and the institution as a whole. TH

Andrea Sattinger will write about apology in medicine in the June issue.

References

1. Kohn LT, Corrigan JM, Donaldson MS, Institute of Medicine Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
2. Bleich S. Medical Errors: Five Years After the IOM Report. New York: Commonwealth Fund; July 2005: Available at: www.mihealthandsafety.org/pdfs/pub-4-commonwealth.pdf. Last accessed March 22, 2006.
3. Chaudhry SI, Olofinboba KA, Krumholz HM. Detection of errors by attending physicians on a general medicine service. J Gen Intern Med. 2003 Aug;18(8):595-600.
4. Weingart SN, Pagovich O, Sands DZ, et al. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. J Gen Intern Med. 2005 Sep;20(9):830-836.

The medical literature pertaining to patient safety is voluminous, especially since the publication of the 1999 Institute of Medicine (IOM) report estimating that between 44,000 and 98,000 Americans die from medical errors each year.1 When focusing on hospitalists and the matter of near misses, however, where the outcome of the error has been intercepted before harm can occur, the volume of published information is far more limited.2

“There are few good data about the role that hospitalists play in preventing adverse events,” says Saul Weingart, MD, PhD, vice president for patient safety at the Dana-Farber Cancer Institute, Boston, “so most accounts are anecdotal. My own sense is that hospital medicine plays a critical role in preventing and mitigating errors in the acute care setting.”

One study, conducted by two hospitalists in a 200-bed academic hospital and published in 2003 in the Journal of General Internal Medicine, distinguished near misses from adverse events.3 The investigators set out to determine the frequency, types, and consequences of errors that can be detected by hospitalists during routine clinical care, and to compare the types of errors first discovered by hospitalists to those discovered by other providers.

Sarwat Chaudhry, MD, a former hospitalist who is now a health services researcher and assistant professor of medicine at the Yale School of Medicine in New Haven, Conn., was the lead investigator in that study. “Oftentimes the errors that are ‘sexier’ and more exciting for people to talk about are the adverse events,” she says. “But I think what are perhaps more common and more informative are the near misses.”

Definitions

For purposes of Chaudhry, et al.’s study, “adverse events” were defined as adverse outcomes that resulted from errors.3 Errors that did not result in patient harm, but could have, were categorized as near misses. The umbrella definition of error fit that which was used in the IOM report; that is, “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”1 Cases in which a bad outcome occurred (such as death or disability) without a preventable cause were not considered errors and, therefore, were not included in the data.

A more practical understanding of a near miss is apparent in the following illustration: “If pharmacy came to me and said, ‘Oh, Dr. Chaudhry, one of the physicians on your team wrote for drug X but the patient is also on drug Y and that’s a known contraindication so we don’t think this should be administered, do you agree?’ I’d say, ‘Yes, I agree.’ So the drug was never given, but it was a near miss for the way it was written if it hadn’t been picked up on.”

In fact there are two kinds of near misses. “One is where the error is intercepted by [a] pharmacy or somebody else before harm is done,” says Dr. Weingart. “The other kind is where the error reaches the patient—for instance, where he or she receives the antibiotic to which they are allergic—but no reaction takes place.”

An important element in the study was that both types of errors were identified during the course of routine, clinical care by Dr. Chaudhry and her colleague, Kolawole Olofinboba, MD. Errors first detected by other healthcare workers were also recorded. Of the 528 patients included in the study, 10.4% experienced at least one error: 6.2% a near miss and 4.2% an adverse event. Interestingly, most of the errors first detected by house staff, nurses, and laboratory technicians were adverse events, whereas most of the errors first detected by the attending hospitalists, pharmacists, and consultants were near misses. Drug errors were the most common type of error overall.

Although differences did not achieve statistical significance, Dr. Chaudhry says the data were illuminating and the hospital administration was anxious to clarify the processes of care that could be modified to make the workflow more efficient and the different pieces of each patient’s critical data more integrated.

“For instance,” she says, “at our hospital there was a lot of separation of data. … The vitals were right outside the patient’s room. The list of medications was kept in a central pharmacy location, and the medical chart with everyone’s notes was in a third location.”

After the study’s completion, the integration of data was facilitated by the adoption of an electronic medical record (EMR) and there is ongoing research at that institution concerning whether that has affected error rates.

Hospitalists are ideally poised to take a lead in promoting patient safety by becoming more involved and developing the systems for error reporting.

—Sarwat Chaudhry, MD

Lessons Learned

“This was one of the first and, still I think, only studies of attending physicians reporting their own errors,” says Dr. Chaudhry, “as well as reporting the scope, type, and frequency of the errors.”

There were several lessons learned. The first is that near misses are very common—at least as common as adverse events and perhaps more frequent. The second is that the nature of near misses is similar enough to that of adverse events that they can still be informative in preventing harm to patients. The third lesson arises from the investigators’ review of the kinds of errors that were reported by the different providers. “Different types of providers are going to pick up on different kinds of errors,” says Dr. Chaudhry. “Pharmacy, of course, is going to be detecting drug errors. But nurses are going to be detecting a different kind of error than residents, and residents are detecting a different kind of error than attending physicians.”

Dr. Weingart, who was trained as an internist, says his sense is that “we often pick up errors that occur just upstream in the process of care. For instance, pharmacy finds doctor prescribing errors and nursing finds pharmacy dispensing errors.”

Drs. Chaudhry and Olofinboba discovered 17/47 (36%) of the errors on their own, and pharmacists, resident physicians, consulting physicians, nurses, and ancillary staff discovered the remaining 30/47 (64%). The hospitalists were more likely to detect therapeutic errors; house staff physicians were more likely to detect drug errors. House staff also detected procedural errors at a higher rate than did the hospitalists. Consequently, Dr. Chaudhry emphasizes, another highlight of these data shows that “engaging as many different kinds of healthcare providers in error reporting is very important to understand what’s going on.”

Documenting Errors

The two hospitalists in Dr. Chaudhry’s study underwent no formal training in error detection, and all errors identified were documented. This in itself is a remarkable aspect of this study for hospitalists to note.

“In most hospitals, the risk management department feels like breaking out a bottle of champagne to celebrate every time a physician submits an incident report,” says Dr. Weingart, “because in most hospitals physicians don’t view incident reporting as part of their responsibility. On the other hand, physicians constantly talk about the errors, near misses, and adverse events they encounter day-to-day. Unfortunately, formal incident reporting isn’t an activity that most physicians see as a part of their duty to deliver excellent care at the bedside.” By virtue of this, he says, “critical information is often lost to the system. Error experience is transmitted person-to-person but isn’t captured and analyzed.”

The good news here, however, is that by simply launching a study of this nature and capturing the data it is reasonable to expect that any hospitalist group could take it on and any hospital’s quality of care would be improved.

“There is a spectrum of practice review that is conducted by a variety of people,” says Dr. Chaudhry. “On one end of the spectrum, you have the uninvolved reviewer coming in and doing formal chart reviews … and our process was at other end of spectrum, where we were going about our daily business, the routine clinical care of patients.”

By maintaining the potential for errors at the forefront of their thinking, she says, it became the background against which they performed the constant daily review of patient data. “When I would go to the bedside in the morning,” she says, “to see the patient, talk to the patient, review the chart, look at notes, look at vitals, look at meds—that was my process for picking up on errors.”

Barriers and Opportunities

There are two major barriers to performing this kind of research in other institutions where hospitalists practice, but they are easily resolved. The first is the importance of standardizing definitions.

“We came to consensus before the study began of what things should count and what things shouldn’t count,” says Dr. Chaudhry. “Because there is a degree of subjectivity and especially when a patient experiences harm, it’s a bit easier to attribute that to an error—though not always. For instance, with a patient with asthma who ends up with fluid overload and gets intubated. Well, was that an error? … Or was that just the patient’s own asthma getting worse? How much did the fluid contribute to that?”

There is still a degree of judgment, even there, she says, “but as much as possible we wanted to come to consensus at least about our definitions, our terminology, and our categorization.”

The second barrier to performing this research is the real or perceived risk of litigation. There was a lot of concern at the beginning of her study, says Dr. Chaudhry (and again at the time of publication), regarding the aftermath of disclosing errors.

“As much as the Institute of Medicine and other accreditation and safety organizations talk about how error reporting is so important and that physicians have to be willing to come forward with their errors, there are really no formal, legal, protective mechanisms in place,” she says, adding that this was true three years ago, and she does not believe much has changed.

Consequently, when constructing the study, she reached out to the authors of other error studies and asked them how they had handled the risk of potential litigation. Most of them told her they did not think there was much risk of being sued, but disclosing errors in the literature is certainly not something an institution or individuals would be clamoring to do. If a multi-center study of this nature might be undertaken, she says, these barriers could be traversed and it would be worth it. “Because if we let that opportunity slip through our fingers, it will be taken on by nonphysicians,” she cautions, “by the external reviewers, by the accreditation organizations, by professional quality control people.”

Dr. Chaudhry’s overall recommendation to hospitalists involves the position they hold at this time. “Hospitalists are ideally poised to take a lead in promoting patient safety by becoming more involved and developing the systems for error reporting,” she says.

Dr. Weingart tells hospitalist audiences that the most important areas for detecting errors in their practice include safe prescription writing and error-proofing high-risk activities (such as hand-offs and sign-outs, and follow-up of test results). He also recommends that hospitalists play the role of responsible citizens in their institutions and be open to ways your patients can contribute by helping you detect errors in their care.4 These issues will be addressed in more detail in future articles in The Hospitalist.

Although Dr. Chaudhry is no longer practicing as a hospitalist, she believes that hospital teams working closely together in patient care have a strong advantage to identify any errors.

“As physicians, with hospital medicine expanding,” she says, “this is the opportune time to take on a leadership role, and this needs to be part of the hospitalist mission. Not everyone has to come out and report their adverse events, especially since the legal risks are still unclear. But a safe way and equally informative way to work on preventing harm is to focus on those near misses.”

Conclusion

Hospitalists who search for near misses, volunteer this information, and enroll their colleagues in doing the same contribute to reforming systems and processes that will ultimately reduce the potential for all errors. Those who pay close attention to standardized rules for prescription-writing, error-proofing high-risk activities, and their roles for institutional citizenship and encouraging patient contribution in regard to possible errors, are doing the best possible job to prevent harm to patients and the institution as a whole. TH

Andrea Sattinger will write about apology in medicine in the June issue.

References

1. Kohn LT, Corrigan JM, Donaldson MS, Institute of Medicine Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
2. Bleich S. Medical Errors: Five Years After the IOM Report. New York: Commonwealth Fund; July 2005: Available at: www.mihealthandsafety.org/pdfs/pub-4-commonwealth.pdf. Last accessed March 22, 2006.
3. Chaudhry SI, Olofinboba KA, Krumholz HM. Detection of errors by attending physicians on a general medicine service. J Gen Intern Med. 2003 Aug;18(8):595-600.
4. Weingart SN, Pagovich O, Sands DZ, et al. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. J Gen Intern Med. 2005 Sep;20(9):830-836.

Editors’ note: We originally conceived this article with the authors just before Hurricanes Katrina and Rita devastated the Gulf Coast last year. Once the hurricanes hit, we decided to “bump” this article in favor of running coverage of the hurricanes and their effects on hospitals in the Gulf Coast area.

The Ochsner Clinic Foundation rests on the eastern bank of an acute flexure in the Mississippi river similar to its twin just downstream, which lurches around a crescent forming the historic and infamous French Vieux Carré, or Old Quarter. From a perch on the hospital’s 11th floor I often start my evening by taking in the full scope of the river’s powerful swirling eddies and copious flotsam churning past in the westerly sun. The view has become a familiar sight to me over the past several years as our hospital’s primary night shift internist.

Though my comrades jokingly refer to me as Ochsner’s “nocturnist,” an assignment surprisingly relished by few, the position has proven mutually beneficial in serving a vital role for the hospital and our group, while accommodating my own crepuscular nature and lifestyle.

Our night position—officially known as IHC (or in-house call)—was conceived from several requisites desired by both administration and physicians. Ochsner Clinic Foundation is steeped in academic history, and the nights have traditionally been dominated by semi-autonomously operating residents. During the past five years, practice changes in the local area afforded Ochsner unprecedented growth, requiring constant accommodation and development of our hospitalist group. Many of these changes were accelerated by the devastation wrought by Hurricane Katrina. With a nod to quality over quantity, we decided against expanding the teaching program in favor of developing several non-resident-based hospital services.

These unique and burgeoning parallel systems of care quickly presented many challenges for those staff clinicians stationed at home when problems arose during the evening. The original expectation was that the residents would have no direct involvement in the care of this subset of patients to avoid overburdening a system already operating near capacity. Subsequent intradepartmental disputation ensued over how to provide our patients with personal on-site care through the wee hours while arresting the surge of hectoring beeps that inevitably start after midnight. The exigency of solving this problem grew as our physicians’ slumber waned and patient admissions soared over the following months.

Our group’s consensus that a full-time night staff physician was needed soon emerged as the best potential remedy for our predicament. As no person wanted to be commandeered for the job, volunteers were sought for a trial run with the very reasonable hours of 4 p.m. to midnight, Monday through Friday. Hardly ever retiring to bed before the witching hour, I accepted the first week of our nascent, early evening shift.

The Rise of the Nocturnist

The expectations were simple. I was to independently admit “bounce-backs:” observation level patients, hip fracture service patients, and overflow admissions from a frequently dropsical emergency department. This specious solution proved very successful but ultimately served to highlight the overall need for a hospitalist to remain in-house for the duration of the evening and early morning hours.

The subsequent creation of a newly expanded, more permanent role for our IHC was proffered for consideration. This vision of moving to 24-hour staff coverage on site met with universal acceptance from the physicians, nursing staff, residents, and administration. The lone problem remained of finding physicians willing to dedicate themselves to working primarily at night.

Rather than rotating doctors weekly, we hoped to maintain some consistency by having certain physicians dedicated to staffing nights. From this graveyard shift arose true nocturnists, as in my case, working evenings nearly 75% of the time. Implementation of a weekend nocturnist to cover Saturday and Sunday is being developed as the need for coverage increases and the success of the current system continues.

Rapid Growth

These expanded changes to the system soon proved fortuitous. Within one year after the inception of IHC, admissions to the medicine services had consistently swollen to between 20 and 30 patients each night—a record for even the busiest periods in the history of the institution. The surge of patients being admitted through our emergency department to medicine proved to be an enduring change, which progressed unabated until Katrina struck. By necessity, the number of “unresidented” services quickly grew to accommodate our patients’ needs and concerns.

In addition, residency-review guidelines governing capitation of resident admissions were also carefully maintained to provide a consistent teaching environment for the house staff. Though stalling momentarily after Katrina struck, medical admissions have continued to climb seemingly without limit. The capacity of our six inpatient medical services with residents is now matched by an equal number of services managed privately by attending physicians alone.

Post-Katrina, the responsibilities of our three primary “nocturnists” have grown in tandem with the increasing number of patients on the wards to now cover the sub-acute nursing facility patients, geriatric nursing home patients, and acute preoperative clearances throughout the night. The lion’s share of time is still spent assisting and facilitating the admissions process for our patients through the emergency department.

In the past several years the role of the night hospitalist has become an integral part of our emergency department. In effect, most of the night is now spent in the emergency department providing consults, triage help, and early assistance with the care of patients ultimately bound for medicine admission. Besides the pragmatic benefits of expedited care, new interpersonal bonds of understanding and empathy have been forged between the two departments. I now count most of the emergency department staff, from physicians to nurses and secretaries, as personal friends and colleagues. The beleaguered admitting process has gradually transformed into a more cooperative, harmonious transfer of patient care between trusting teams.

Tracking Patients

With so many patients now spilling over the next day to various teams, one of the most vital functions of the IHC staff is to provide complete and accurate information about each patient assigned to the accepting teams the following day. This has required cooperation from both emergency staff in writing temporary floor orders, proper information flow between the on-call resident, night float resident and IHC staff, and proper notification of direct admissions arriving on the floor of patients accepted from the on call medicine staff during the day.

Currently each patient is simultaneously tracked by name, clinic number, and diagnosis by both the IHC staff and the overnight resident. The lists are frequently compared for accuracy, and in the morning an individual e-mail notification is sent to every physician on service for the day of every admission, distribution, and diagnosis by the IHC staff. As a second line of defense against error, the resident places an individual phone call to each physician receiving an overnight admission to reiterate any clinical problems.

As a department we have crafted fixed schedules of admission for the following morning so each day a physician knows whether to expect patients on the service or not. These numbers are forwarded to admissions for that day in order to keep each of the services as numerically equitable as possible. These careful tracking mechanisms, expectations of good communication between our physicians, and months of trial and error have proven invaluable during the months of highest volume when essentially every patient admitted overnight must be redistributed to various teams in the morning.

In addition to securing safe transition of the patient between teams and ensuring proper medical care, each patient is greeted in his or her room in the emergency department by the IHC staff, who take a moment to explain the admission process, the future plan of care, and who will assume the patient’s case in the morning. This has continuously provided an early opportunity to establish bonds of trust with each patient and assuage any lingering questions the patient may have after evaluation by the resident physician. Many of our patients are now displaced, frightened, and homeless. The value of providing face-to-face, 24-hour attending level care for our patients cannot be overstated.

Conclusion

Auguring the future of medical practice in New Orleans since hurricanes Katrina and Rita ravaged the city has proved difficult if not impossible. The degree of change during the past six months has shown that flexibility and adaptability are mainstays of the ability to practice good medicine. Without doubt, New Orleans will return more lively, more resilient, and wiser for all of our losses over the past year. TH

Dr. Blalock is based at the Department of Hospital-Based Internal Medicine, Ochsner Clinic Foundation, New Orleans. Special thanks to Steven B. Deitelzweig, MD, Doris Lin, MD, and Srinivas Vuppala, MD, for their assistance with this article.

Editors’ note: We originally conceived this article with the authors just before Hurricanes Katrina and Rita devastated the Gulf Coast last year. Once the hurricanes hit, we decided to “bump” this article in favor of running coverage of the hurricanes and their effects on hospitals in the Gulf Coast area.

The Ochsner Clinic Foundation rests on the eastern bank of an acute flexure in the Mississippi river similar to its twin just downstream, which lurches around a crescent forming the historic and infamous French Vieux Carré, or Old Quarter. From a perch on the hospital’s 11th floor I often start my evening by taking in the full scope of the river’s powerful swirling eddies and copious flotsam churning past in the westerly sun. The view has become a familiar sight to me over the past several years as our hospital’s primary night shift internist.

Though my comrades jokingly refer to me as Ochsner’s “nocturnist,” an assignment surprisingly relished by few, the position has proven mutually beneficial in serving a vital role for the hospital and our group, while accommodating my own crepuscular nature and lifestyle.

Our night position—officially known as IHC (or in-house call)—was conceived from several requisites desired by both administration and physicians. Ochsner Clinic Foundation is steeped in academic history, and the nights have traditionally been dominated by semi-autonomously operating residents. During the past five years, practice changes in the local area afforded Ochsner unprecedented growth, requiring constant accommodation and development of our hospitalist group. Many of these changes were accelerated by the devastation wrought by Hurricane Katrina. With a nod to quality over quantity, we decided against expanding the teaching program in favor of developing several non-resident-based hospital services.

These unique and burgeoning parallel systems of care quickly presented many challenges for those staff clinicians stationed at home when problems arose during the evening. The original expectation was that the residents would have no direct involvement in the care of this subset of patients to avoid overburdening a system already operating near capacity. Subsequent intradepartmental disputation ensued over how to provide our patients with personal on-site care through the wee hours while arresting the surge of hectoring beeps that inevitably start after midnight. The exigency of solving this problem grew as our physicians’ slumber waned and patient admissions soared over the following months.

Our group’s consensus that a full-time night staff physician was needed soon emerged as the best potential remedy for our predicament. As no person wanted to be commandeered for the job, volunteers were sought for a trial run with the very reasonable hours of 4 p.m. to midnight, Monday through Friday. Hardly ever retiring to bed before the witching hour, I accepted the first week of our nascent, early evening shift.

The Rise of the Nocturnist

The expectations were simple. I was to independently admit “bounce-backs:” observation level patients, hip fracture service patients, and overflow admissions from a frequently dropsical emergency department. This specious solution proved very successful but ultimately served to highlight the overall need for a hospitalist to remain in-house for the duration of the evening and early morning hours.

The subsequent creation of a newly expanded, more permanent role for our IHC was proffered for consideration. This vision of moving to 24-hour staff coverage on site met with universal acceptance from the physicians, nursing staff, residents, and administration. The lone problem remained of finding physicians willing to dedicate themselves to working primarily at night.

Rather than rotating doctors weekly, we hoped to maintain some consistency by having certain physicians dedicated to staffing nights. From this graveyard shift arose true nocturnists, as in my case, working evenings nearly 75% of the time. Implementation of a weekend nocturnist to cover Saturday and Sunday is being developed as the need for coverage increases and the success of the current system continues.

Rapid Growth

These expanded changes to the system soon proved fortuitous. Within one year after the inception of IHC, admissions to the medicine services had consistently swollen to between 20 and 30 patients each night—a record for even the busiest periods in the history of the institution. The surge of patients being admitted through our emergency department to medicine proved to be an enduring change, which progressed unabated until Katrina struck. By necessity, the number of “unresidented” services quickly grew to accommodate our patients’ needs and concerns.

In addition, residency-review guidelines governing capitation of resident admissions were also carefully maintained to provide a consistent teaching environment for the house staff. Though stalling momentarily after Katrina struck, medical admissions have continued to climb seemingly without limit. The capacity of our six inpatient medical services with residents is now matched by an equal number of services managed privately by attending physicians alone.

Post-Katrina, the responsibilities of our three primary “nocturnists” have grown in tandem with the increasing number of patients on the wards to now cover the sub-acute nursing facility patients, geriatric nursing home patients, and acute preoperative clearances throughout the night. The lion’s share of time is still spent assisting and facilitating the admissions process for our patients through the emergency department.

In the past several years the role of the night hospitalist has become an integral part of our emergency department. In effect, most of the night is now spent in the emergency department providing consults, triage help, and early assistance with the care of patients ultimately bound for medicine admission. Besides the pragmatic benefits of expedited care, new interpersonal bonds of understanding and empathy have been forged between the two departments. I now count most of the emergency department staff, from physicians to nurses and secretaries, as personal friends and colleagues. The beleaguered admitting process has gradually transformed into a more cooperative, harmonious transfer of patient care between trusting teams.

Tracking Patients

With so many patients now spilling over the next day to various teams, one of the most vital functions of the IHC staff is to provide complete and accurate information about each patient assigned to the accepting teams the following day. This has required cooperation from both emergency staff in writing temporary floor orders, proper information flow between the on-call resident, night float resident and IHC staff, and proper notification of direct admissions arriving on the floor of patients accepted from the on call medicine staff during the day.

Currently each patient is simultaneously tracked by name, clinic number, and diagnosis by both the IHC staff and the overnight resident. The lists are frequently compared for accuracy, and in the morning an individual e-mail notification is sent to every physician on service for the day of every admission, distribution, and diagnosis by the IHC staff. As a second line of defense against error, the resident places an individual phone call to each physician receiving an overnight admission to reiterate any clinical problems.

As a department we have crafted fixed schedules of admission for the following morning so each day a physician knows whether to expect patients on the service or not. These numbers are forwarded to admissions for that day in order to keep each of the services as numerically equitable as possible. These careful tracking mechanisms, expectations of good communication between our physicians, and months of trial and error have proven invaluable during the months of highest volume when essentially every patient admitted overnight must be redistributed to various teams in the morning.

In addition to securing safe transition of the patient between teams and ensuring proper medical care, each patient is greeted in his or her room in the emergency department by the IHC staff, who take a moment to explain the admission process, the future plan of care, and who will assume the patient’s case in the morning. This has continuously provided an early opportunity to establish bonds of trust with each patient and assuage any lingering questions the patient may have after evaluation by the resident physician. Many of our patients are now displaced, frightened, and homeless. The value of providing face-to-face, 24-hour attending level care for our patients cannot be overstated.

Conclusion

Auguring the future of medical practice in New Orleans since hurricanes Katrina and Rita ravaged the city has proved difficult if not impossible. The degree of change during the past six months has shown that flexibility and adaptability are mainstays of the ability to practice good medicine. Without doubt, New Orleans will return more lively, more resilient, and wiser for all of our losses over the past year. TH

Dr. Blalock is based at the Department of Hospital-Based Internal Medicine, Ochsner Clinic Foundation, New Orleans. Special thanks to Steven B. Deitelzweig, MD, Doris Lin, MD, and Srinivas Vuppala, MD, for their assistance with this article.

Editors’ note: We originally conceived this article with the authors just before Hurricanes Katrina and Rita devastated the Gulf Coast last year. Once the hurricanes hit, we decided to “bump” this article in favor of running coverage of the hurricanes and their effects on hospitals in the Gulf Coast area.

The Ochsner Clinic Foundation rests on the eastern bank of an acute flexure in the Mississippi river similar to its twin just downstream, which lurches around a crescent forming the historic and infamous French Vieux Carré, or Old Quarter. From a perch on the hospital’s 11th floor I often start my evening by taking in the full scope of the river’s powerful swirling eddies and copious flotsam churning past in the westerly sun. The view has become a familiar sight to me over the past several years as our hospital’s primary night shift internist.

Though my comrades jokingly refer to me as Ochsner’s “nocturnist,” an assignment surprisingly relished by few, the position has proven mutually beneficial in serving a vital role for the hospital and our group, while accommodating my own crepuscular nature and lifestyle.

Our night position—officially known as IHC (or in-house call)—was conceived from several requisites desired by both administration and physicians. Ochsner Clinic Foundation is steeped in academic history, and the nights have traditionally been dominated by semi-autonomously operating residents. During the past five years, practice changes in the local area afforded Ochsner unprecedented growth, requiring constant accommodation and development of our hospitalist group. Many of these changes were accelerated by the devastation wrought by Hurricane Katrina. With a nod to quality over quantity, we decided against expanding the teaching program in favor of developing several non-resident-based hospital services.

These unique and burgeoning parallel systems of care quickly presented many challenges for those staff clinicians stationed at home when problems arose during the evening. The original expectation was that the residents would have no direct involvement in the care of this subset of patients to avoid overburdening a system already operating near capacity. Subsequent intradepartmental disputation ensued over how to provide our patients with personal on-site care through the wee hours while arresting the surge of hectoring beeps that inevitably start after midnight. The exigency of solving this problem grew as our physicians’ slumber waned and patient admissions soared over the following months.

Our group’s consensus that a full-time night staff physician was needed soon emerged as the best potential remedy for our predicament. As no person wanted to be commandeered for the job, volunteers were sought for a trial run with the very reasonable hours of 4 p.m. to midnight, Monday through Friday. Hardly ever retiring to bed before the witching hour, I accepted the first week of our nascent, early evening shift.

The Rise of the Nocturnist

The expectations were simple. I was to independently admit “bounce-backs:” observation level patients, hip fracture service patients, and overflow admissions from a frequently dropsical emergency department. This specious solution proved very successful but ultimately served to highlight the overall need for a hospitalist to remain in-house for the duration of the evening and early morning hours.

The subsequent creation of a newly expanded, more permanent role for our IHC was proffered for consideration. This vision of moving to 24-hour staff coverage on site met with universal acceptance from the physicians, nursing staff, residents, and administration. The lone problem remained of finding physicians willing to dedicate themselves to working primarily at night.

Rather than rotating doctors weekly, we hoped to maintain some consistency by having certain physicians dedicated to staffing nights. From this graveyard shift arose true nocturnists, as in my case, working evenings nearly 75% of the time. Implementation of a weekend nocturnist to cover Saturday and Sunday is being developed as the need for coverage increases and the success of the current system continues.

Rapid Growth

These expanded changes to the system soon proved fortuitous. Within one year after the inception of IHC, admissions to the medicine services had consistently swollen to between 20 and 30 patients each night—a record for even the busiest periods in the history of the institution. The surge of patients being admitted through our emergency department to medicine proved to be an enduring change, which progressed unabated until Katrina struck. By necessity, the number of “unresidented” services quickly grew to accommodate our patients’ needs and concerns.

In addition, residency-review guidelines governing capitation of resident admissions were also carefully maintained to provide a consistent teaching environment for the house staff. Though stalling momentarily after Katrina struck, medical admissions have continued to climb seemingly without limit. The capacity of our six inpatient medical services with residents is now matched by an equal number of services managed privately by attending physicians alone.

Post-Katrina, the responsibilities of our three primary “nocturnists” have grown in tandem with the increasing number of patients on the wards to now cover the sub-acute nursing facility patients, geriatric nursing home patients, and acute preoperative clearances throughout the night. The lion’s share of time is still spent assisting and facilitating the admissions process for our patients through the emergency department.

In the past several years the role of the night hospitalist has become an integral part of our emergency department. In effect, most of the night is now spent in the emergency department providing consults, triage help, and early assistance with the care of patients ultimately bound for medicine admission. Besides the pragmatic benefits of expedited care, new interpersonal bonds of understanding and empathy have been forged between the two departments. I now count most of the emergency department staff, from physicians to nurses and secretaries, as personal friends and colleagues. The beleaguered admitting process has gradually transformed into a more cooperative, harmonious transfer of patient care between trusting teams.

Tracking Patients

With so many patients now spilling over the next day to various teams, one of the most vital functions of the IHC staff is to provide complete and accurate information about each patient assigned to the accepting teams the following day. This has required cooperation from both emergency staff in writing temporary floor orders, proper information flow between the on-call resident, night float resident and IHC staff, and proper notification of direct admissions arriving on the floor of patients accepted from the on call medicine staff during the day.

Currently each patient is simultaneously tracked by name, clinic number, and diagnosis by both the IHC staff and the overnight resident. The lists are frequently compared for accuracy, and in the morning an individual e-mail notification is sent to every physician on service for the day of every admission, distribution, and diagnosis by the IHC staff. As a second line of defense against error, the resident places an individual phone call to each physician receiving an overnight admission to reiterate any clinical problems.

As a department we have crafted fixed schedules of admission for the following morning so each day a physician knows whether to expect patients on the service or not. These numbers are forwarded to admissions for that day in order to keep each of the services as numerically equitable as possible. These careful tracking mechanisms, expectations of good communication between our physicians, and months of trial and error have proven invaluable during the months of highest volume when essentially every patient admitted overnight must be redistributed to various teams in the morning.

In addition to securing safe transition of the patient between teams and ensuring proper medical care, each patient is greeted in his or her room in the emergency department by the IHC staff, who take a moment to explain the admission process, the future plan of care, and who will assume the patient’s case in the morning. This has continuously provided an early opportunity to establish bonds of trust with each patient and assuage any lingering questions the patient may have after evaluation by the resident physician. Many of our patients are now displaced, frightened, and homeless. The value of providing face-to-face, 24-hour attending level care for our patients cannot be overstated.

Conclusion

Auguring the future of medical practice in New Orleans since hurricanes Katrina and Rita ravaged the city has proved difficult if not impossible. The degree of change during the past six months has shown that flexibility and adaptability are mainstays of the ability to practice good medicine. Without doubt, New Orleans will return more lively, more resilient, and wiser for all of our losses over the past year. TH

Dr. Blalock is based at the Department of Hospital-Based Internal Medicine, Ochsner Clinic Foundation, New Orleans. Special thanks to Steven B. Deitelzweig, MD, Doris Lin, MD, and Srinivas Vuppala, MD, for their assistance with this article.

A75-year-old previously healthy woman presented with one-month history of extensive necrotic coalescing erythematous weeping vesicles and bullae. A skin biopsy was performed. (See right and right bottom for images.)

Based on the skin biopsy and clinical presentation, the most likely diagnosis is:

1. Pemphigoid;
2. Pemphigus vulgaris;
3. Staphylococcus scalded skin syndrome;
4. Porphyria cutanea tarda; or
5. Darier’s disease.

Discussion

The correct answer is B: pemphigus vulgaris. The skin biopsy demonstrates an intra-epidermal split along the basal layer of keratinocytes. The basal cells along the basement membrane zone demonstrate tombstoning consistent with pemphigus vulgaris. Clinically, she has erythematous superficial erosions with slight re-epithelialization.

Pemphigoid is another blistering disorder that often affects the elderly and classically presents with tense bulla that demonstrate an infra-basilar split on histology. Staphylococcus scalded skin syndrome may present similarly, but histology shows acantholysis in the superficial epidermis. Porphyria cutanea tarda often is on the hands, arms, and other sun-exposed areas, and biopsy reveals dermal papillae protruding up toward the bulla (festooning). Darier’s disease is autosomal dominant and presents with greasy hyperkeratotic papules that show acantholysis and dyskeratosis on histology, with occasional suprabasal clefting.

Pemphigus vulgaris is an autoimmune process that often affects those in middle age. It usually first involves the mucous membranes and then progresses to the skin, where intraepidermal bullae form. These bullae are flaccid and easily rupture, often easily extending beyond their original dimensions with only slight perturbation. Because of their fragility patients may not present with any intact bullae and instead only have painful erosions, as in this case.

The disease is mediated by circulating immunoglobulin G (IgG), which binds to the cell surface of keratinocytes, breaking up intercellular connections and resulting in acantholysis and bulla formation. The process is diagnosed with the shown histology and with direct in vivo immunofluorescence, which demonstrates a “chicken-wire” pattern around keratinocytes. Paraneoplastic pemphigus and pemphigus foliaceous are the other two types of pemphigus, and a work up for underlying malignancy is indicated to rule out the former. Opportunistic infections are common and can lead to exacerbation of the disease, so culture and antimicrobial therapy often play an important role in recovery.

Pemphigus can often be controlled with adequate immunosuppression. High-dose systemic steroids are the first-line treatment. Other immunosuppressive medications, such as dapsone, azathioprine, and mycophenolate mofetil, are used for maintenance therapy during and after the patient has recovered from a flare-up. Intravenous immunoglobulin (IVIG) and plasmapheresis therapy has also showed promising results.1,2

This case was complicated by superinfection with both methicillin-resistant staphylococcus aureus (MRSA) and herpes simplex virus. One course of IVIG produced no benefit. The patient then underwent intensive inpatient wet-dressing therapy with topical steroids and antimicrobial treatment. She was placed on high-dose prednisone and began to recover, without new lesion development and with re-epithelialization. First mycophenolate mofetil followed by azathioprine were started, to which the patient responded well. TH

References

1. Bystryn JC, Rudolph JL. IVIG treatment of pemphigus: how it works and how to use it. J Investig Dermatol. 2005 Dec;125(6):1093-1098.
2. Stanley JR. Therapy of pemphigus vulgaris. Arch Dermatol. 1999 Jan;135(1):76-78.

A75-year-old previously healthy woman presented with one-month history of extensive necrotic coalescing erythematous weeping vesicles and bullae. A skin biopsy was performed. (See right and right bottom for images.)

Based on the skin biopsy and clinical presentation, the most likely diagnosis is:

1. Pemphigoid;
2. Pemphigus vulgaris;
3. Staphylococcus scalded skin syndrome;
4. Porphyria cutanea tarda; or
5. Darier’s disease.

Discussion

The correct answer is B: pemphigus vulgaris. The skin biopsy demonstrates an intra-epidermal split along the basal layer of keratinocytes. The basal cells along the basement membrane zone demonstrate tombstoning consistent with pemphigus vulgaris. Clinically, she has erythematous superficial erosions with slight re-epithelialization.

Pemphigoid is another blistering disorder that often affects the elderly and classically presents with tense bulla that demonstrate an infra-basilar split on histology. Staphylococcus scalded skin syndrome may present similarly, but histology shows acantholysis in the superficial epidermis. Porphyria cutanea tarda often is on the hands, arms, and other sun-exposed areas, and biopsy reveals dermal papillae protruding up toward the bulla (festooning). Darier’s disease is autosomal dominant and presents with greasy hyperkeratotic papules that show acantholysis and dyskeratosis on histology, with occasional suprabasal clefting.

Pemphigus vulgaris is an autoimmune process that often affects those in middle age. It usually first involves the mucous membranes and then progresses to the skin, where intraepidermal bullae form. These bullae are flaccid and easily rupture, often easily extending beyond their original dimensions with only slight perturbation. Because of their fragility patients may not present with any intact bullae and instead only have painful erosions, as in this case.

The disease is mediated by circulating immunoglobulin G (IgG), which binds to the cell surface of keratinocytes, breaking up intercellular connections and resulting in acantholysis and bulla formation. The process is diagnosed with the shown histology and with direct in vivo immunofluorescence, which demonstrates a “chicken-wire” pattern around keratinocytes. Paraneoplastic pemphigus and pemphigus foliaceous are the other two types of pemphigus, and a work up for underlying malignancy is indicated to rule out the former. Opportunistic infections are common and can lead to exacerbation of the disease, so culture and antimicrobial therapy often play an important role in recovery.

Pemphigus can often be controlled with adequate immunosuppression. High-dose systemic steroids are the first-line treatment. Other immunosuppressive medications, such as dapsone, azathioprine, and mycophenolate mofetil, are used for maintenance therapy during and after the patient has recovered from a flare-up. Intravenous immunoglobulin (IVIG) and plasmapheresis therapy has also showed promising results.1,2

This case was complicated by superinfection with both methicillin-resistant staphylococcus aureus (MRSA) and herpes simplex virus. One course of IVIG produced no benefit. The patient then underwent intensive inpatient wet-dressing therapy with topical steroids and antimicrobial treatment. She was placed on high-dose prednisone and began to recover, without new lesion development and with re-epithelialization. First mycophenolate mofetil followed by azathioprine were started, to which the patient responded well. TH

References

1. Bystryn JC, Rudolph JL. IVIG treatment of pemphigus: how it works and how to use it. J Investig Dermatol. 2005 Dec;125(6):1093-1098.
2. Stanley JR. Therapy of pemphigus vulgaris. Arch Dermatol. 1999 Jan;135(1):76-78.

A75-year-old previously healthy woman presented with one-month history of extensive necrotic coalescing erythematous weeping vesicles and bullae. A skin biopsy was performed. (See right and right bottom for images.)

Based on the skin biopsy and clinical presentation, the most likely diagnosis is:

1. Pemphigoid;
2. Pemphigus vulgaris;
3. Staphylococcus scalded skin syndrome;
4. Porphyria cutanea tarda; or
5. Darier’s disease.

Discussion

The correct answer is B: pemphigus vulgaris. The skin biopsy demonstrates an intra-epidermal split along the basal layer of keratinocytes. The basal cells along the basement membrane zone demonstrate tombstoning consistent with pemphigus vulgaris. Clinically, she has erythematous superficial erosions with slight re-epithelialization.

Pemphigoid is another blistering disorder that often affects the elderly and classically presents with tense bulla that demonstrate an infra-basilar split on histology. Staphylococcus scalded skin syndrome may present similarly, but histology shows acantholysis in the superficial epidermis. Porphyria cutanea tarda often is on the hands, arms, and other sun-exposed areas, and biopsy reveals dermal papillae protruding up toward the bulla (festooning). Darier’s disease is autosomal dominant and presents with greasy hyperkeratotic papules that show acantholysis and dyskeratosis on histology, with occasional suprabasal clefting.

Pemphigus vulgaris is an autoimmune process that often affects those in middle age. It usually first involves the mucous membranes and then progresses to the skin, where intraepidermal bullae form. These bullae are flaccid and easily rupture, often easily extending beyond their original dimensions with only slight perturbation. Because of their fragility patients may not present with any intact bullae and instead only have painful erosions, as in this case.

The disease is mediated by circulating immunoglobulin G (IgG), which binds to the cell surface of keratinocytes, breaking up intercellular connections and resulting in acantholysis and bulla formation. The process is diagnosed with the shown histology and with direct in vivo immunofluorescence, which demonstrates a “chicken-wire” pattern around keratinocytes. Paraneoplastic pemphigus and pemphigus foliaceous are the other two types of pemphigus, and a work up for underlying malignancy is indicated to rule out the former. Opportunistic infections are common and can lead to exacerbation of the disease, so culture and antimicrobial therapy often play an important role in recovery.

Pemphigus can often be controlled with adequate immunosuppression. High-dose systemic steroids are the first-line treatment. Other immunosuppressive medications, such as dapsone, azathioprine, and mycophenolate mofetil, are used for maintenance therapy during and after the patient has recovered from a flare-up. Intravenous immunoglobulin (IVIG) and plasmapheresis therapy has also showed promising results.1,2

This case was complicated by superinfection with both methicillin-resistant staphylococcus aureus (MRSA) and herpes simplex virus. One course of IVIG produced no benefit. The patient then underwent intensive inpatient wet-dressing therapy with topical steroids and antimicrobial treatment. She was placed on high-dose prednisone and began to recover, without new lesion development and with re-epithelialization. First mycophenolate mofetil followed by azathioprine were started, to which the patient responded well. TH

References

1. Bystryn JC, Rudolph JL. IVIG treatment of pemphigus: how it works and how to use it. J Investig Dermatol. 2005 Dec;125(6):1093-1098.
2. Stanley JR. Therapy of pemphigus vulgaris. Arch Dermatol. 1999 Jan;135(1):76-78.

Kempainen RR, Migeon MB, Wolf FM. Understanding our mistakes: a primer on errors in clinical reasoning. Med Teach. Mar;2003:25(2);177-181.

Many hospitalists are involved in processes to reduce errors in the hospital. Given the dozens of clinical decisions hospitalists make each day, errors in clinical reasoning are worth exploring. However, few physicians are familiar with the terminology and classes of clinical reasoning errors as described in the literature.

This article outlines two models of clinical reasoning and explains common biases that distort clinical reasoning. Although the examples used to illustrate these errors draw from primary care internal medicine, they are easily recognizable.

Biases are defined as inaccurate beliefs that affect decision-making.

When generating a differential diagnosis, the bias of availability (aka recall bias) involves a clinician being influenced by what is easily recalled, creating a false sense of prevalence. This is especially common with less experienced clinicians, residents, and medical students.

The bias of representativeness (aka judging by similarity) involves the physician choosing a diagnosis based solely on signs and symptoms, while neglecting the prevalence of competing diagnoses.

The bias of confirmation involves the clinician using additional testing to confirm a suspected diagnosis, but failing to test competing hypotheses.

The bias of anchoring and adjustment involves the clinician inadequately adjusting the differential in light of new data.

The bias of bounded rationality (aka search satisfying) involves the clinician stopping the search for additional diagnoses after the anticipated diagnosis has been made.

Outcome bias involves judging a clinical decision retrospectively based on the outcome, rather than on logic and evidence supporting the original decision.

Omission bias involves placing undue emphasis on avoiding the adverse effect of a therapy, leading to under-utilization of a beneficial treatment.

Most of the work in clinical reasoning errors is published in the cognitive psychology and education literature, which most hospitalists do not regularly read. By becoming familiar with the concepts and terminology, hospitalists can more readily engage in discussions of clinical reasoning errors and how to avoid them. TH

Kempainen RR, Migeon MB, Wolf FM. Understanding our mistakes: a primer on errors in clinical reasoning. Med Teach. Mar;2003:25(2);177-181.

Many hospitalists are involved in processes to reduce errors in the hospital. Given the dozens of clinical decisions hospitalists make each day, errors in clinical reasoning are worth exploring. However, few physicians are familiar with the terminology and classes of clinical reasoning errors as described in the literature.

This article outlines two models of clinical reasoning and explains common biases that distort clinical reasoning. Although the examples used to illustrate these errors draw from primary care internal medicine, they are easily recognizable.

Biases are defined as inaccurate beliefs that affect decision-making.

When generating a differential diagnosis, the bias of availability (aka recall bias) involves a clinician being influenced by what is easily recalled, creating a false sense of prevalence. This is especially common with less experienced clinicians, residents, and medical students.

The bias of representativeness (aka judging by similarity) involves the physician choosing a diagnosis based solely on signs and symptoms, while neglecting the prevalence of competing diagnoses.

The bias of confirmation involves the clinician using additional testing to confirm a suspected diagnosis, but failing to test competing hypotheses.

The bias of anchoring and adjustment involves the clinician inadequately adjusting the differential in light of new data.

The bias of bounded rationality (aka search satisfying) involves the clinician stopping the search for additional diagnoses after the anticipated diagnosis has been made.

Outcome bias involves judging a clinical decision retrospectively based on the outcome, rather than on logic and evidence supporting the original decision.

Omission bias involves placing undue emphasis on avoiding the adverse effect of a therapy, leading to under-utilization of a beneficial treatment.

Most of the work in clinical reasoning errors is published in the cognitive psychology and education literature, which most hospitalists do not regularly read. By becoming familiar with the concepts and terminology, hospitalists can more readily engage in discussions of clinical reasoning errors and how to avoid them. TH

Kempainen RR, Migeon MB, Wolf FM. Understanding our mistakes: a primer on errors in clinical reasoning. Med Teach. Mar;2003:25(2);177-181.

Many hospitalists are involved in processes to reduce errors in the hospital. Given the dozens of clinical decisions hospitalists make each day, errors in clinical reasoning are worth exploring. However, few physicians are familiar with the terminology and classes of clinical reasoning errors as described in the literature.

This article outlines two models of clinical reasoning and explains common biases that distort clinical reasoning. Although the examples used to illustrate these errors draw from primary care internal medicine, they are easily recognizable.

Biases are defined as inaccurate beliefs that affect decision-making.

When generating a differential diagnosis, the bias of availability (aka recall bias) involves a clinician being influenced by what is easily recalled, creating a false sense of prevalence. This is especially common with less experienced clinicians, residents, and medical students.

The bias of representativeness (aka judging by similarity) involves the physician choosing a diagnosis based solely on signs and symptoms, while neglecting the prevalence of competing diagnoses.

The bias of confirmation involves the clinician using additional testing to confirm a suspected diagnosis, but failing to test competing hypotheses.

The bias of anchoring and adjustment involves the clinician inadequately adjusting the differential in light of new data.

The bias of bounded rationality (aka search satisfying) involves the clinician stopping the search for additional diagnoses after the anticipated diagnosis has been made.

Outcome bias involves judging a clinical decision retrospectively based on the outcome, rather than on logic and evidence supporting the original decision.

Omission bias involves placing undue emphasis on avoiding the adverse effect of a therapy, leading to under-utilization of a beneficial treatment.

Most of the work in clinical reasoning errors is published in the cognitive psychology and education literature, which most hospitalists do not regularly read. By becoming familiar with the concepts and terminology, hospitalists can more readily engage in discussions of clinical reasoning errors and how to avoid them. TH