As a board-certified medical oncologist with certification in hospice medicine and palliative care and 32 years of experience dealing with some thorny issues, I offer to our readers the 10 commandments that each of us should expect when we shift from caregivers to care receivers.

In effect, we are all patients. It is just a matter of time before we are in a bed in a hospital or nursing home rather than standing around the bed providing care. So here it goes.

1. Acknowledge me as a person. I am not simply a “diagnosis,” an ICD code, or a billing rubric. Find out something about me as a person. I am very funny. I have interests and hobbies. Get to know me.
2. Provide me with a medical quarterback, a Marcus Welby to direct my care. Do not bombard me with seven subspecialists each of who use a tiny piece of my anatomy and each of whom has a catheter or a tube to put in some orifice.
3. I understand that I will often be visited by teams of providers. If I am really sick, nauseated, or in pain, let’s minimize the size of the herd around the bedside. It takes energy to confront a team.
4. Treat me as if you would a member of your family. We all know that tests are sometimes done unnecessarily and subspecialty consultations might not always be necessary. Target my management to get the most value from the test.
5. Ask me about my major concerns. What worries me, what torments me may not even be on your radar screen. (One of our patients was a gentleman with far-advanced cancer of the pancreas, unresectable disease, and no one bothered to ask him what his greatest concern was. It was to get out of the hospital, to be with his daughter at her wedding the following month. Once we knew that, every effort was made for aggressive hydration and nutrition so he could make that important date.)
6. Have some understanding of my insurance policy. What is covered, what is not, are there deductibles, are there copays? Why? (One of our head and neck cancer patients was advised to receive an off-label use of a relatively new agent. No one bothered to inquire that the patient did not have great insurance, and he was responsible for a $15,000 a month bill for a medication with a less than 10% chance of working.)
7. If I have a serious illness and my expected survival is less than six months, do not wait to bring up the issue of hospice care. (This is a wonderful program, and what I consistently hear as a clinician from families, “Why didn’t we know about this sooner?”)
8. Whom do I call, whom do I contact if I have a problem outside of the hospital? I will have seen umpteen clinicians, most of whose names I do not remember so what do I do if there is a problem at 2 o’clock in the morning?
9. Please be certain that none of my medications have to be refilled within three days of leaving the hospital. No, I am not kidding. Give me enough medications to get me through acute episodes whether this is an antibiotic, an antiemetic, or a sleeping medication.
10. Equally importantly, please be aware of the healing power of sleep. Most of us are sleep deprived under optimum circumstances and this becomes magnified under the rigors of our modern techno hospitals.

One final thought, have some understanding of my faith/belief system. A century ago, the Mayo brothers clearly recognized the importance of the mind-body connection. To paraphrase Drs. Will and Charlie Mayo, they made the comment that the spiritual dimension of healing cannot be overlooked. They also commented that the Beatitudes and the 23rd Psalm are of great comfort to many individuals.

So, there you have it, my 10 commandments. Honor them, honor me, honor my family, and honor our patients.

Dr. Creagan is the American Cancer Society professor of clinical oncology, John and Roma Rouse Professor of Humanism in Medicine, professor, Mayo Clinic College of Medicine, and past president, Mayo Clinic Staff, Rochester, Minn.

As a board-certified medical oncologist with certification in hospice medicine and palliative care and 32 years of experience dealing with some thorny issues, I offer to our readers the 10 commandments that each of us should expect when we shift from caregivers to care receivers.

In effect, we are all patients. It is just a matter of time before we are in a bed in a hospital or nursing home rather than standing around the bed providing care. So here it goes.

1. Acknowledge me as a person. I am not simply a “diagnosis,” an ICD code, or a billing rubric. Find out something about me as a person. I am very funny. I have interests and hobbies. Get to know me.
2. Provide me with a medical quarterback, a Marcus Welby to direct my care. Do not bombard me with seven subspecialists each of who use a tiny piece of my anatomy and each of whom has a catheter or a tube to put in some orifice.
3. I understand that I will often be visited by teams of providers. If I am really sick, nauseated, or in pain, let’s minimize the size of the herd around the bedside. It takes energy to confront a team.
4. Treat me as if you would a member of your family. We all know that tests are sometimes done unnecessarily and subspecialty consultations might not always be necessary. Target my management to get the most value from the test.
5. Ask me about my major concerns. What worries me, what torments me may not even be on your radar screen. (One of our patients was a gentleman with far-advanced cancer of the pancreas, unresectable disease, and no one bothered to ask him what his greatest concern was. It was to get out of the hospital, to be with his daughter at her wedding the following month. Once we knew that, every effort was made for aggressive hydration and nutrition so he could make that important date.)
6. Have some understanding of my insurance policy. What is covered, what is not, are there deductibles, are there copays? Why? (One of our head and neck cancer patients was advised to receive an off-label use of a relatively new agent. No one bothered to inquire that the patient did not have great insurance, and he was responsible for a $15,000 a month bill for a medication with a less than 10% chance of working.)
7. If I have a serious illness and my expected survival is less than six months, do not wait to bring up the issue of hospice care. (This is a wonderful program, and what I consistently hear as a clinician from families, “Why didn’t we know about this sooner?”)
8. Whom do I call, whom do I contact if I have a problem outside of the hospital? I will have seen umpteen clinicians, most of whose names I do not remember so what do I do if there is a problem at 2 o’clock in the morning?
9. Please be certain that none of my medications have to be refilled within three days of leaving the hospital. No, I am not kidding. Give me enough medications to get me through acute episodes whether this is an antibiotic, an antiemetic, or a sleeping medication.
10. Equally importantly, please be aware of the healing power of sleep. Most of us are sleep deprived under optimum circumstances and this becomes magnified under the rigors of our modern techno hospitals.

One final thought, have some understanding of my faith/belief system. A century ago, the Mayo brothers clearly recognized the importance of the mind-body connection. To paraphrase Drs. Will and Charlie Mayo, they made the comment that the spiritual dimension of healing cannot be overlooked. They also commented that the Beatitudes and the 23rd Psalm are of great comfort to many individuals.

So, there you have it, my 10 commandments. Honor them, honor me, honor my family, and honor our patients.

Dr. Creagan is the American Cancer Society professor of clinical oncology, John and Roma Rouse Professor of Humanism in Medicine, professor, Mayo Clinic College of Medicine, and past president, Mayo Clinic Staff, Rochester, Minn.

As a board-certified medical oncologist with certification in hospice medicine and palliative care and 32 years of experience dealing with some thorny issues, I offer to our readers the 10 commandments that each of us should expect when we shift from caregivers to care receivers.

In effect, we are all patients. It is just a matter of time before we are in a bed in a hospital or nursing home rather than standing around the bed providing care. So here it goes.

1. Acknowledge me as a person. I am not simply a “diagnosis,” an ICD code, or a billing rubric. Find out something about me as a person. I am very funny. I have interests and hobbies. Get to know me.
2. Provide me with a medical quarterback, a Marcus Welby to direct my care. Do not bombard me with seven subspecialists each of who use a tiny piece of my anatomy and each of whom has a catheter or a tube to put in some orifice.
3. I understand that I will often be visited by teams of providers. If I am really sick, nauseated, or in pain, let’s minimize the size of the herd around the bedside. It takes energy to confront a team.
4. Treat me as if you would a member of your family. We all know that tests are sometimes done unnecessarily and subspecialty consultations might not always be necessary. Target my management to get the most value from the test.
5. Ask me about my major concerns. What worries me, what torments me may not even be on your radar screen. (One of our patients was a gentleman with far-advanced cancer of the pancreas, unresectable disease, and no one bothered to ask him what his greatest concern was. It was to get out of the hospital, to be with his daughter at her wedding the following month. Once we knew that, every effort was made for aggressive hydration and nutrition so he could make that important date.)
6. Have some understanding of my insurance policy. What is covered, what is not, are there deductibles, are there copays? Why? (One of our head and neck cancer patients was advised to receive an off-label use of a relatively new agent. No one bothered to inquire that the patient did not have great insurance, and he was responsible for a $15,000 a month bill for a medication with a less than 10% chance of working.)
7. If I have a serious illness and my expected survival is less than six months, do not wait to bring up the issue of hospice care. (This is a wonderful program, and what I consistently hear as a clinician from families, “Why didn’t we know about this sooner?”)
8. Whom do I call, whom do I contact if I have a problem outside of the hospital? I will have seen umpteen clinicians, most of whose names I do not remember so what do I do if there is a problem at 2 o’clock in the morning?
9. Please be certain that none of my medications have to be refilled within three days of leaving the hospital. No, I am not kidding. Give me enough medications to get me through acute episodes whether this is an antibiotic, an antiemetic, or a sleeping medication.
10. Equally importantly, please be aware of the healing power of sleep. Most of us are sleep deprived under optimum circumstances and this becomes magnified under the rigors of our modern techno hospitals.

One final thought, have some understanding of my faith/belief system. A century ago, the Mayo brothers clearly recognized the importance of the mind-body connection. To paraphrase Drs. Will and Charlie Mayo, they made the comment that the spiritual dimension of healing cannot be overlooked. They also commented that the Beatitudes and the 23rd Psalm are of great comfort to many individuals.

So, there you have it, my 10 commandments. Honor them, honor me, honor my family, and honor our patients.

Dr. Creagan is the American Cancer Society professor of clinical oncology, John and Roma Rouse Professor of Humanism in Medicine, professor, Mayo Clinic College of Medicine, and past president, Mayo Clinic Staff, Rochester, Minn.

The forces of our universe are described and measured by a series of laws and equations known collectively as physics. Though we seem far removed from those halcyon (or Halcion) days of college physics, we exist in a universe still ruled by them. In this instance, our world is the hospital.

Strange vectors of force and difficult-to-fathom principles swirl, causing unanticipated changes in our environment. Using the laws of physics we can attempt to understand these forces.

NEWTON’S FIRST LAW: Newton’s first law is a statement about inertia. An object at rest stays at rest; an object in motion stays in motion unless compelled to change its state by the action of an external force. Byzantine bureaucracies maintain a significant amount of inertia. The expression “that’s the way we’ve always done it here” best summarizes this philosophy.

NEWTON’S SECOND LAW: Newton’s second law examines the force necessary to cause the acceleration of an object in relationship to its mass (F=MA). A moderate amount of force applied to a golf ball may send that object 250 yards—hook right, but the same force applied to a dump truck causes no significant motion.

In the hospital, we often see large expenditures of energy resulting in little movement. This is generally an administrative phenomenon.

NEWTON’S THIRD LAW: For every action there is an equal and opposite reaction. This is an important law in the hospital. The most recent example is the change in residents’ work hours. A seemingly simple issue, residents working too many hours leads to a legislative action and mandated hours. This specific alteration has had unintended consequences and affected numerous other systems. In the case of resident work hours the potential advantages in hours worked has led to a potentially adverse effect on such things as continuity and learning—and an increase in demand for hospitalists.

No system changes can occur without consequences, and the trick is to identify those changes before they occur. Luckily most systems have significant inertia, and only the greatest forces cause major change. It takes massive energy expenditure (i.e., government regulation or resident review boards) to solicit the forces adequate to overcome escape velocity and cause change.

Some forces can cause change not by their sheer energy level, but by their strategic placement. A small forceful tap may split a diamond. A call by a resident’s spouse can cause the downfall of a program. An off-hand comment by a colleague can lead to a disastrous malpractice settlement.

CENTRIFUGAL PSEUDOFORCE: A pseudoforce occurs when one moves in a uniform circular motion. Most of us have observed this phenomenon. When you run around in circles like the proverbial decapitated fowl, little is accomplished despite a sensation of energy expended.

A related principle is Brownian motion: Particles in a gas or fluid collide against each other and the walls of the container causing a random motion. At times the hospitalist’s day may feel that way: active movement but much of it nondirectional.

COPERNICAN PRINCIPLE: The idea, suggested by Copernicus was that the sun—not the earth—is the center of this universe. This is an essential point for hospitalists to remember. We spend hours rounding on our patients. We must always remember that the physician is not the center of the universe for the hospitalized patient. As the name suggests, when we “round” we are the satellite.

CAUSALITY PRINCIPLE: Cause must follow effect. This is a dangerous theory exemplified by the classic post-hoc, prompter hoc: Because I did something, something happened.

When applied to patients, the causality principle can mislead. The fever went down when the antibiotic was started. Coincidence or causality? We hired a hospitalist and our length of stay went down. Coincidence or causality?

THE THEORY OF RELATIVITY: Einstein’s famous equation E=mc2 represents his theory of relativity. This equation represents the relationship between an object’s mass and its energy. Mass is represented by the formula M=DV where D is density and V=volume.

In a hospital setting we see this formula used in a corollary to Einstein’s, called the Theory of Relatives. When entering a patient’s room, one is often confronted with a large number of relatives, spouses, siblings, and the dreaded estranged children. These situations almost always require an increased amount of energy expenditure in communication, consensus building, and time.

As the absolute number (or volume) of family members increases, concurrent with any increased density on the individual members’ part, energy expenditure increases dramatically. This follows the mass equation closely. In situations where the density of an individual family member increases beyond measurable levels, one can enter a Black Hole scenario (see illustration).

BLACK HOLES: A black hole is a region of space-time from which nothing can escape—even light.

A black hole is a region of such extreme density that all energy is sucked into its gravitational field. Once exposed to a black hole situation, the observer may note expected phenomena, including absence of light, loss of energy, extreme fatigue and malaise, and a sensation of hopelessness. This effect can be seen in committee rooms or on the wards.

The only known remedies for this condition are avoidance or going off-service.

THE GIBBS FREE ENERGY EQUATION: The Gibbs free energy equation, G=H-(TS), is a thermodynamic formula and a measure of the conservation of energy. Simply put, the energy of a system is related to the enthalpy (H) or positive creative energy input minus the product of time and entropy, the natural tendency of systems to fall apart.

This effect can be seen in the creation of hospitalist programs.

A hospitalist program is sometimes created by an energetic entrepreneur responding to a vacuum or potential space. A great design leads to a functional program (G). The hospitalist (H) must continually put energy into maintaining the system, otherwise over time (T) entropy (S) takes hold and the system deteriorates. A hospitalist program can’t rely on its initial successful design to survive.

PARTICLE WAVE DUALITY: Quanta are bundles of energy. We see these basic units in the hospital on a nonsubatomic level.

Our admissions seem to come in waves. Our daily workload seems to come in waves as well. Yet the essential quantum of hospital medicine is the patient. RVUs may be 1.33, and LOS 3.2 days, and FTEs 0.8, but I have yet to see a patient-and-a-half in a room.

CRITICAL MASS: Critical mass is the smallest amount of fissionable material necessary to maintain a nuclear chain reaction at a constant level. The term is also used to denote an amount or level needed for a specific result or new action to occur. Happily the hospitalist movement in America has reached that self-sustaining critical mass.

CONCLUSION: As Sir Isaac Newton sat under the proverbial tree and watched a ripe Granny Smith drop on his noggin, little did he know how profoundly he would affect the world of hospital medicine. What goes up must come down. The patient admitted must be discharged. And the editorial started must eventually finish. TH

Jamie Newman, MD, FACP, is physician editor of The Hopitalist, and senior associate consultant, Hospital Internal Medicine and associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

The forces of our universe are described and measured by a series of laws and equations known collectively as physics. Though we seem far removed from those halcyon (or Halcion) days of college physics, we exist in a universe still ruled by them. In this instance, our world is the hospital.

Strange vectors of force and difficult-to-fathom principles swirl, causing unanticipated changes in our environment. Using the laws of physics we can attempt to understand these forces.

NEWTON’S FIRST LAW: Newton’s first law is a statement about inertia. An object at rest stays at rest; an object in motion stays in motion unless compelled to change its state by the action of an external force. Byzantine bureaucracies maintain a significant amount of inertia. The expression “that’s the way we’ve always done it here” best summarizes this philosophy.

NEWTON’S SECOND LAW: Newton’s second law examines the force necessary to cause the acceleration of an object in relationship to its mass (F=MA). A moderate amount of force applied to a golf ball may send that object 250 yards—hook right, but the same force applied to a dump truck causes no significant motion.

In the hospital, we often see large expenditures of energy resulting in little movement. This is generally an administrative phenomenon.

NEWTON’S THIRD LAW: For every action there is an equal and opposite reaction. This is an important law in the hospital. The most recent example is the change in residents’ work hours. A seemingly simple issue, residents working too many hours leads to a legislative action and mandated hours. This specific alteration has had unintended consequences and affected numerous other systems. In the case of resident work hours the potential advantages in hours worked has led to a potentially adverse effect on such things as continuity and learning—and an increase in demand for hospitalists.

No system changes can occur without consequences, and the trick is to identify those changes before they occur. Luckily most systems have significant inertia, and only the greatest forces cause major change. It takes massive energy expenditure (i.e., government regulation or resident review boards) to solicit the forces adequate to overcome escape velocity and cause change.

Some forces can cause change not by their sheer energy level, but by their strategic placement. A small forceful tap may split a diamond. A call by a resident’s spouse can cause the downfall of a program. An off-hand comment by a colleague can lead to a disastrous malpractice settlement.

CENTRIFUGAL PSEUDOFORCE: A pseudoforce occurs when one moves in a uniform circular motion. Most of us have observed this phenomenon. When you run around in circles like the proverbial decapitated fowl, little is accomplished despite a sensation of energy expended.

A related principle is Brownian motion: Particles in a gas or fluid collide against each other and the walls of the container causing a random motion. At times the hospitalist’s day may feel that way: active movement but much of it nondirectional.

COPERNICAN PRINCIPLE: The idea, suggested by Copernicus was that the sun—not the earth—is the center of this universe. This is an essential point for hospitalists to remember. We spend hours rounding on our patients. We must always remember that the physician is not the center of the universe for the hospitalized patient. As the name suggests, when we “round” we are the satellite.

CAUSALITY PRINCIPLE: Cause must follow effect. This is a dangerous theory exemplified by the classic post-hoc, prompter hoc: Because I did something, something happened.

When applied to patients, the causality principle can mislead. The fever went down when the antibiotic was started. Coincidence or causality? We hired a hospitalist and our length of stay went down. Coincidence or causality?

THE THEORY OF RELATIVITY: Einstein’s famous equation E=mc2 represents his theory of relativity. This equation represents the relationship between an object’s mass and its energy. Mass is represented by the formula M=DV where D is density and V=volume.

In a hospital setting we see this formula used in a corollary to Einstein’s, called the Theory of Relatives. When entering a patient’s room, one is often confronted with a large number of relatives, spouses, siblings, and the dreaded estranged children. These situations almost always require an increased amount of energy expenditure in communication, consensus building, and time.

As the absolute number (or volume) of family members increases, concurrent with any increased density on the individual members’ part, energy expenditure increases dramatically. This follows the mass equation closely. In situations where the density of an individual family member increases beyond measurable levels, one can enter a Black Hole scenario (see illustration).

BLACK HOLES: A black hole is a region of space-time from which nothing can escape—even light.

A black hole is a region of such extreme density that all energy is sucked into its gravitational field. Once exposed to a black hole situation, the observer may note expected phenomena, including absence of light, loss of energy, extreme fatigue and malaise, and a sensation of hopelessness. This effect can be seen in committee rooms or on the wards.

The only known remedies for this condition are avoidance or going off-service.

THE GIBBS FREE ENERGY EQUATION: The Gibbs free energy equation, G=H-(TS), is a thermodynamic formula and a measure of the conservation of energy. Simply put, the energy of a system is related to the enthalpy (H) or positive creative energy input minus the product of time and entropy, the natural tendency of systems to fall apart.

This effect can be seen in the creation of hospitalist programs.

A hospitalist program is sometimes created by an energetic entrepreneur responding to a vacuum or potential space. A great design leads to a functional program (G). The hospitalist (H) must continually put energy into maintaining the system, otherwise over time (T) entropy (S) takes hold and the system deteriorates. A hospitalist program can’t rely on its initial successful design to survive.

PARTICLE WAVE DUALITY: Quanta are bundles of energy. We see these basic units in the hospital on a nonsubatomic level.

Our admissions seem to come in waves. Our daily workload seems to come in waves as well. Yet the essential quantum of hospital medicine is the patient. RVUs may be 1.33, and LOS 3.2 days, and FTEs 0.8, but I have yet to see a patient-and-a-half in a room.

CRITICAL MASS: Critical mass is the smallest amount of fissionable material necessary to maintain a nuclear chain reaction at a constant level. The term is also used to denote an amount or level needed for a specific result or new action to occur. Happily the hospitalist movement in America has reached that self-sustaining critical mass.

CONCLUSION: As Sir Isaac Newton sat under the proverbial tree and watched a ripe Granny Smith drop on his noggin, little did he know how profoundly he would affect the world of hospital medicine. What goes up must come down. The patient admitted must be discharged. And the editorial started must eventually finish. TH

Jamie Newman, MD, FACP, is physician editor of The Hopitalist, and senior associate consultant, Hospital Internal Medicine and associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

The forces of our universe are described and measured by a series of laws and equations known collectively as physics. Though we seem far removed from those halcyon (or Halcion) days of college physics, we exist in a universe still ruled by them. In this instance, our world is the hospital.

Strange vectors of force and difficult-to-fathom principles swirl, causing unanticipated changes in our environment. Using the laws of physics we can attempt to understand these forces.

NEWTON’S FIRST LAW: Newton’s first law is a statement about inertia. An object at rest stays at rest; an object in motion stays in motion unless compelled to change its state by the action of an external force. Byzantine bureaucracies maintain a significant amount of inertia. The expression “that’s the way we’ve always done it here” best summarizes this philosophy.

NEWTON’S SECOND LAW: Newton’s second law examines the force necessary to cause the acceleration of an object in relationship to its mass (F=MA). A moderate amount of force applied to a golf ball may send that object 250 yards—hook right, but the same force applied to a dump truck causes no significant motion.

In the hospital, we often see large expenditures of energy resulting in little movement. This is generally an administrative phenomenon.

NEWTON’S THIRD LAW: For every action there is an equal and opposite reaction. This is an important law in the hospital. The most recent example is the change in residents’ work hours. A seemingly simple issue, residents working too many hours leads to a legislative action and mandated hours. This specific alteration has had unintended consequences and affected numerous other systems. In the case of resident work hours the potential advantages in hours worked has led to a potentially adverse effect on such things as continuity and learning—and an increase in demand for hospitalists.

No system changes can occur without consequences, and the trick is to identify those changes before they occur. Luckily most systems have significant inertia, and only the greatest forces cause major change. It takes massive energy expenditure (i.e., government regulation or resident review boards) to solicit the forces adequate to overcome escape velocity and cause change.

Some forces can cause change not by their sheer energy level, but by their strategic placement. A small forceful tap may split a diamond. A call by a resident’s spouse can cause the downfall of a program. An off-hand comment by a colleague can lead to a disastrous malpractice settlement.

CENTRIFUGAL PSEUDOFORCE: A pseudoforce occurs when one moves in a uniform circular motion. Most of us have observed this phenomenon. When you run around in circles like the proverbial decapitated fowl, little is accomplished despite a sensation of energy expended.

A related principle is Brownian motion: Particles in a gas or fluid collide against each other and the walls of the container causing a random motion. At times the hospitalist’s day may feel that way: active movement but much of it nondirectional.

COPERNICAN PRINCIPLE: The idea, suggested by Copernicus was that the sun—not the earth—is the center of this universe. This is an essential point for hospitalists to remember. We spend hours rounding on our patients. We must always remember that the physician is not the center of the universe for the hospitalized patient. As the name suggests, when we “round” we are the satellite.

CAUSALITY PRINCIPLE: Cause must follow effect. This is a dangerous theory exemplified by the classic post-hoc, prompter hoc: Because I did something, something happened.

When applied to patients, the causality principle can mislead. The fever went down when the antibiotic was started. Coincidence or causality? We hired a hospitalist and our length of stay went down. Coincidence or causality?

THE THEORY OF RELATIVITY: Einstein’s famous equation E=mc2 represents his theory of relativity. This equation represents the relationship between an object’s mass and its energy. Mass is represented by the formula M=DV where D is density and V=volume.

In a hospital setting we see this formula used in a corollary to Einstein’s, called the Theory of Relatives. When entering a patient’s room, one is often confronted with a large number of relatives, spouses, siblings, and the dreaded estranged children. These situations almost always require an increased amount of energy expenditure in communication, consensus building, and time.

As the absolute number (or volume) of family members increases, concurrent with any increased density on the individual members’ part, energy expenditure increases dramatically. This follows the mass equation closely. In situations where the density of an individual family member increases beyond measurable levels, one can enter a Black Hole scenario (see illustration).

BLACK HOLES: A black hole is a region of space-time from which nothing can escape—even light.

A black hole is a region of such extreme density that all energy is sucked into its gravitational field. Once exposed to a black hole situation, the observer may note expected phenomena, including absence of light, loss of energy, extreme fatigue and malaise, and a sensation of hopelessness. This effect can be seen in committee rooms or on the wards.

The only known remedies for this condition are avoidance or going off-service.

THE GIBBS FREE ENERGY EQUATION: The Gibbs free energy equation, G=H-(TS), is a thermodynamic formula and a measure of the conservation of energy. Simply put, the energy of a system is related to the enthalpy (H) or positive creative energy input minus the product of time and entropy, the natural tendency of systems to fall apart.

This effect can be seen in the creation of hospitalist programs.

A hospitalist program is sometimes created by an energetic entrepreneur responding to a vacuum or potential space. A great design leads to a functional program (G). The hospitalist (H) must continually put energy into maintaining the system, otherwise over time (T) entropy (S) takes hold and the system deteriorates. A hospitalist program can’t rely on its initial successful design to survive.

PARTICLE WAVE DUALITY: Quanta are bundles of energy. We see these basic units in the hospital on a nonsubatomic level.

Our admissions seem to come in waves. Our daily workload seems to come in waves as well. Yet the essential quantum of hospital medicine is the patient. RVUs may be 1.33, and LOS 3.2 days, and FTEs 0.8, but I have yet to see a patient-and-a-half in a room.

CRITICAL MASS: Critical mass is the smallest amount of fissionable material necessary to maintain a nuclear chain reaction at a constant level. The term is also used to denote an amount or level needed for a specific result or new action to occur. Happily the hospitalist movement in America has reached that self-sustaining critical mass.

CONCLUSION: As Sir Isaac Newton sat under the proverbial tree and watched a ripe Granny Smith drop on his noggin, little did he know how profoundly he would affect the world of hospital medicine. What goes up must come down. The patient admitted must be discharged. And the editorial started must eventually finish. TH

Jamie Newman, MD, FACP, is physician editor of The Hopitalist, and senior associate consultant, Hospital Internal Medicine and associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

WORSENING OUTCOMES AND INCREASED RECURRENCE OF CLOSTRIDIUM DIFFICILE AFTER INITIAL TREATMENT WITH METRONIDAZOLE?

Pepin J, Alary ME, Valiquette L, et al. Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. Clin Infect Dis. 2005;40:1591-1597; and Musher DM, Aslam S, Logan N, et al. Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis. 2005;40:1586-1590.

Information on treatment of colitis caused by Clostridium difficile began to appear in the late 1970s and early 1980s. Since that time there have been a paucity of novel therapies. It has been well-established that both metronidazole and vancomycin can effectively treat this entity. Traditionally metronidazole has been the first-line agent for C. difficile-associated diarrhea (CDAD). The reasons for this are three:

1. Randomized controlled trials have shown vancomycin and metronidazole to be equally efficacious;
2. The cost of oral vancomycin is substantially more than oral metronidazole; and
3. Many experts have cautioned that using vancomycin may contribute to the blooming number of bacteria that are resistant to vancomycin.

Indeed recommendations from the Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee as well as the American Society for Health-System Pharmacists have supported using metronidazole as our initial agent of choice for CDAD (oral vancomycin is actually the only agent that is approved by the Food and Drug Administration for CDAD). Most of our earlier data claim initial response rates to be 88% or better and relapse rates to be somewhere between 5% and 12% when metronidazole is used.

Two new studies have been published raising a red flag on our current standard of practice. Musher, et al., designed a prospective, observational study in which they followed more 200 patients with CDAD that were initially treated with metronidazole. The patient pool came from a Veterans Affairs Medical Center. They all had a positive fecal ELISA for C. difficile toxin and were treated for seven or more days using at least 1.5 grams per day of metronidazole.

Records were reviewed six weeks prior to the diagnosis and then patients were followed for three months after cessation of therapy. Patients were assigned to four outcome groups:

1. Complete responders who did not have recurrence over four months;
2. Refractory-to-treatment where signs and symptoms of CDAD were present for 10 or more days;
3. Recurrence after initial clinical response with signs and symptoms of CDAD and a positive toxin; and
4. Clinical recurrence where there was an initial response but a recurrence of signs and symptoms of CDAD without a positive toxin (either the toxin was not present when tested or the test was not done).

Fifty percent were completely cured. Twenty-two percent were refractory to initial therapy. Twenty-eight percent had a recurrence of CDAD within the 90-day period. The mortality was 27%. This was higher among people who had failed to respond to initial therapy (31% versus 21%; p<.05).

Pepin, et al., retrospectively looked at more than 2,000 CDAD cases from one hospital between 1991 and 2004. To be included the patients needed either a positive toxin, endoscopic evidence of pseudomembranous colitis, or histopathologic evidence of pseudomembranous colitis on a biopsy specimen. Patients received at least 1 gram per day of metronidazole for 10 to 14 days. They were considered to have a recurrence if they had diarrhea within two months of the completion of therapy and either a positive toxin at that time or if the attending physician ordered a second course of antibiotics for C. difficile.

Between 1991 and 2002 the frequency of times that either therapy was changed to vancomycin or vancomycin was added to metronidazole was unchanged (9.6%). During 2003-2004 this more than doubled (25.7%). The number of patients experiencing recurrence over a two-month period comparing data from 1991-2002 to 2003- 2004 was staggering (20.8% versus 47.2%; p<.001). The authors noted that as patients aged the probabilities of recurrence increased.

They also found that a subgroup of patients with a white blood cell count over 20,000 cells/mm3 and an elevated creatinine had a high short-term mortality rate.

Why might we be seeing these results? Several theories exist. Patients are both older and sicker than they have been in the past. Our antibiotic choice is changing with an increase in using agents that provide a more broad-spectrum coverage. Immune responses vary with fewer antitoxin antibodies found in those patients with symptoms and/or recurrence. Metronidazole levels in stool decrease as inflammation and diarrhea resolve; this is not the case with vancomycin where fecal concentrations remain high throughout treatment.

A survey of infectious disease physicians found that they believe antibiotic failure is on the rise in this setting. Before we take this as true, consider the following:

1. We have no universally accepted clinical definition of what constitutes diarrhea for CDAD;
2. Previous studies did not look for recurrence as far out from initial treatment as these two did; and
3. These studies do not have the design to support arguments powerful enough to change our paradigm just yet.

The editorial comment acknowledged the Pepin, et al., report that patients with a high white blood cell count and worsening renal function are those that we should be particularly concerned about. The authors write that if the patient’s white blood cell count is increasing while on therapy that he changes his antibiotic choice to vancomycin. In addition, if someone has either ileus or fulminant CDAD he will use multiple antibiotics and consult the surgeons. At this time we have other agents being studied for CDAD, such as tinidazole. We now need a larger randomized prospective trial to better explore treatment outcomes in CDAD.

HYPERTONIC SALINE SOLUTION TO TREAT REFRACTORY CONGESTIVE HEART FAILURE

Paterna S, Di Pasquale P, Parrinello G, et al. Changes in brain natriuretic peptide levels and bioelectrical impedance measurements after treatment with high-dose furosemide and hypertonic saline solution versus high-dose furosemide alone in refractory congestive heart failure. J Am Coll Cardiol. 2005;45:1997–2003.

CHF continues to increase in prevalence and incidence, despite our advances with therapies using ACE inhibitors, beta-blockers, and aldosterone antagonists. Refractory CHF accounts for a considerable portion of admissions to hospitalists’ services. Loop diuretics are part of the standard of arsenal we employ in these patients. Unfortunately, many patients fail to respond to initial diuretic doses. In this situation we might begin a constant infusion of diuretic or recruit diuretics from other classes in hope of synergism. Another typical approach in treating advanced CHF is restriction of sodium intake.

Paterna, et al., previously published four studies using small volume hypertonic saline solution and high-dose furosemide in refractory CHF, in which they demonstrated the safety and tolerability of these measures. They now present the first randomized double-blinded trial using this intervention. Ninety-four patients were included with NYHA functional class IV CHF on standard medical therapy and high doses of diuretics for at least two weeks. They had to have a left ventricular ejection fraction of <35%, serum creatinine <2 mg/dL, reduced urinary volume (<500 mL/24 h), and a low natriuresis (<60 mEq/24 h). They could not be taking NSAIDs.

Patients received either intravenous furosemide (500 to 1000 mg) plus hypertonic saline solution bid or the IV furosemide bid alone. Treatment lasted four to six days. Body weights were followed. Brain natriuretic peptide plasma levels were measured on hospital days one and six, as well as 30 days after discharge.

The group receiving hypertonic saline solution had brow-raising results. They had a significant increase in daily diuresis and natriuresis (p<0.05), a difference in brain natriuretic peptide levels on days six and 30, a reduction in their length of stay, and a decrease in their hospital readmission rate.

This is a provocative study. At this time the mechanism responsible for the results is unclear. Paterna, et al., offer multiple explanations. One possibility is through the osmotic action of hypertonic saline solution. It may hasten the mobilization of extravascular fluid into the intravascular space and then this volume is quickly excreted. Also, hypertonic saline solution may increase renal blood flow and perfusion alternating the handling of sodium and natriuresis while also allowing the concentration of furosemide in the loop of Henle to attain a more desirable level.

Should these results hold true in other investigations and the inclusion criteria loosen (measuring patients urine volume and sodium concentration for 24 hours prior to admission may not be easy or practical) then we might have a very inexpensive new method for treating refractory CHF.

PERIOPERATIVE BETA-BLOCKERS: HELPFUL OR HARMFUL FOR MAJOR NONCARDIAC SURGERY?

Lindenauer P, Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353:349–361.

Among the most common reasons that hospitalists are consulted is the “perioperative evaluation.” This is with good reason because 50,000 patients each year have a perioperative myocardial infarction. A statement by the Agency for Health Care Research and Quality proclaims that we have “clear opportunities for safety improvement” in regard to using beta-blockers for patients with intermediate and high risk for perioperative cardiovascular complications. The American Heart Association and the American College of Cardiology recommend using these medications in patients with either risk factors for or known coronary artery disease when undergoing high-risk surgeries. Despite all of this the efficacy of the class has not been proven by large randomized clinical studies.

Using a large national registry of more than 300 U.S. hospitals, Lindenauer, et al., conducted a large observational study evaluating beta-blockade in the perioperative period in patients undergoing major noncardiac surgery. Looking at more than 700,000 patients, they found that 85% had no recorded contraindication to beta-blockers. Only 18% of eligible patients received beta-blockers (n=122, 338).

Patients were considered to have had a beta-blocker for prophylaxis if it was given within the first 48 hours of their hospitalization, though this may or may not have been the intended use (this information was not provided by the registry data base). Only in-hospital mortality was evaluated as postdischarge information was not available. All patients had a revised cardiac risk index configured. This index places risk on perioperative cardiac events by looking at the nature of the surgery as well as whether or not a history of congestive heart failure, ischemic heart disease, perioperative treatment with insulin, an elevated preoperative creatinine, and cerebrovascular disease are present. An increasing score means that major perioperative complications become more likely (scores range from 0–5).

Considering all patients, there was no risk reduction of in-hospital death for those receiving beta-blockers. If the revised cardiac risk index score was 0 or 1, the patients had an increase in the risk of death (43% and 13%, respectively). However, those patients whose scores were 2, 3, or 4 or higher had a reduction in the risk of death (from 10% to 43% as their score increased).

How are we to account for these results? In the high-risk patients we see benefit in treatment with beta-blockers. We suspect this drug class improves coronary filling time during diastole and/or prevents dangerous arrhythmias. In patients at low and intermediate risk, the results may be surprising. The study group did not have patient charts available. It is possible that these patients were given betablockers not for prophylaxis but in response to a postoperative ischemic event or infarction. If this misclassification took place, then the effectiveness of beta-blockers is underestimated and the suggestion that these drugs are harmful in this situation would be erroneous.

Given the data gleaned from this study and considering previous publications, we are justified—even obligated—in using betablockers in high-risk patients, without contraindications, who undergo major noncardiac surgery. Before using these drugs in patients at low or intermediate risk we need more information. Two large ongoing randomized trials (POISE and DECREASE–IV) should bring clarity to this issue. We expect results from these in the next four years.

A NEW CLINICAL ENTITY: THE HEPATOADRENAL SYNDROME

Marik PE, Gayowski T, Starzl TE, et al. The hepatoadrenal syndrome: a common yet unrecognized clinical condition. Crit Care Med. 2005;33:1254-1259.

It is not uncommon to see the temporary dysfunction of the hypothalamic-pituitary-adrenal axis while someone is critically ill. Many physicians who suspect this condition attempt to make a diagnosis using either a random total cortisol level or perform a cosyntropin stimulation test. End-stage liver disease and sepsis share some elements of their pathophysiology, such as endotoxemia and increased levels of mediators that influence inflammation.

A liver transplant intensive care unit has produced data on what they have coined the “hepatoadrenal syndrome.” Due to emerging evidence that severe liver disease is associated with adrenal insufficiency, this liver transplant intensive care unit began routinely testing all patients admitted to their unit for this condition. They presented their findings for 340 patients. This review will focus only on those patients with chronic liver failure and fulminant hepatic failure because transplant patients are often cared for by a multidisciplinary team. Patients were labeled as having adrenal insufficiency if the random total cortisol level was <20 micrograms (mcg)/dL in patients who were “highly stressed” (i.e., hypotension, respiratory failure). In all other patients a random total cortisol level of <15 mcg/dL or a 30-minute level <20 mcg/dL post-low-dose (1 mcg) cosyntropin established the diagnosis. Lipid profiles were also obtained from each patient. Those receiving glucocorticoids were excluded. It was left to the discretion of the treating physician whether or not to treat patients with steroids.

Eight patients (33%) with fulminant hepatic failure and 97 patients (66%) with chronic liver disease met their criteria for adrenal insufficiency. Of the patients with adrenal insufficiency the mortality rate was 46% for those not treated with glucocorticoids compared with 26% for those receiving glucocorticoid therapy. The HDL level was the only variable predictive of adrenal insufficiency (p<.0001).

The association between HDL levels and cortisol is as follows: The adrenal glands do not store cortisol. Cholesterol is a precursor for the synthesis of steroids—80% of cortisol arises from it. The lipoprotein of choice to use as substrate in steroid production is HDL. Because a major protein component of HDL is synthesized by the liver, those with liver disease have low levels of serum HDL.

Recently our current method of diagnosing adrenal insufficiency during acute illness has been challenged in the literature. Measuring free cortisol rather than total cortisol has been suggested as proteins that bind cortisol decrease in this setting while free cortisol levels actually rise. Similar to the picture we see in sepsis, there are low levels of these same proteins in liver disease.

At this time testing for free cortisol is not widely available nor do we have good information on what an “appropriate” free cortisol level should be during acute illness. Therefore, given the frequency in which Marik, et al., report encountering this condition and the effect that treatment had on mortality it seems as though this is a diagnosis worth consideration.

TREATMENT OPTIONS FOR ATRIAL FIBRILLATION

Wazni OM, Marrouche NF, Martin DO, et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation. JAMA. 2005;293(21):2634-2640.

Atrial fibrillation affects millions of people. This diagnosis has a significant mortality associated with it, causes strokes, and influences quality of life. Therapy has been less than satisfying. Both rate control and rhythm control have multiple potential adverse consequences. Pulmonary vein isolation is performed in the electrophysiology laboratory using an ablation catheter. The goal of this procedure is to completely disconnect the electrical activity between the pulmonary vein antrum and the left atrium. This is a potentially curable procedure for atrial fibrillation.

In a multicenter prospective randomized pilot study Wazni, et al., studied 70 patients with highly symptomatic atrial fibrillation. Patients were between 18 and 75 years old. They could not have undergone ablation in the past, had a history of open-heart surgery, been previously treated with antiarrhythmic drugs, or had a contraindication to long-term anticoagulation. Patients were randomized to antiarrhythmic therapy or pulmonary vein isolation. Those receiving medical treatment were given flecainide, propafenone, or sotalol. Amiodarone was used for patients who had failed at least two or more of these medications. Drugs were titrated to the maximum tolerable doses. The other arm of the group underwent pulmonary vein isolation. This group also received anticoagulation with warfarin beginning the day of the procedure, and this was continued for at least three months. Anticoagulation was extended beyond this time if atrial fibrillation recurred or the pulmonary vein was narrowed by 50% or more (as seen on a three-month post-procedure CT scan). Follow-up was at least one year. A loop event-recorder was worn for one month by all patients and event recorders were used for patients who were symptomatic beyond the first three months of therapy initiation.

After one year, symptomatic atrial fibrillation recurred in 63% of the antiarrhythmic group versus 13% in the pulmonary vein isolation group (p<.001). Fifty-four percent of those medically treated were hospitalized versus 9% of pulmonary vein isolation patients (p<.001). There were no thromboembolic events in either group. Bleeding rates were similar in both groups. For those who underwent pulmonary vein isolation 3% had mild pulmonary vein stenosis and 3% had moderate stenosis (all of which were asymptomatic). Five of the eight measures of quality of life were significantly improved in the pulmonary vein isolation arm versus those receiving antiarrhythmic drugs.

Recently data from multiple trials such as AFFIRM and RACE confirm that rhythm control does not confer significant benefits over rate-control for atrial fibrillation. In fact rate control seems to be a more attractive approach to many patients given the side-effect profile of the antiarrhythmia medications. This study was initiated prior to the release of the information gained from RACE and AFFIRM, thus no rate-control arm was included. This trial also differed from previous studies by using a younger population that was highly symptomatic in comparison with other recent studies using older patients who had recurrent persistent atrial fibrillation.

The biggest concerns about pulmonary vein isolation are the complication rates (death in 0.05% and stroke in 0.28%). We also don’t know if this procedure will translate into long-term cures. Until we have larger studies this should not be a first-line modality for treating all patients. Quite often we find patients where neither rate nor rhythm control is a particularly attractive option, especially in regard to long-term anticoagulation. Pulmonary vein isolation provides us with a new viable option for these people as well as something to consider for carefully selected highly symptomatic patients. TH

WORSENING OUTCOMES AND INCREASED RECURRENCE OF CLOSTRIDIUM DIFFICILE AFTER INITIAL TREATMENT WITH METRONIDAZOLE?

Pepin J, Alary ME, Valiquette L, et al. Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. Clin Infect Dis. 2005;40:1591-1597; and Musher DM, Aslam S, Logan N, et al. Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis. 2005;40:1586-1590.

Information on treatment of colitis caused by Clostridium difficile began to appear in the late 1970s and early 1980s. Since that time there have been a paucity of novel therapies. It has been well-established that both metronidazole and vancomycin can effectively treat this entity. Traditionally metronidazole has been the first-line agent for C. difficile-associated diarrhea (CDAD). The reasons for this are three:

1. Randomized controlled trials have shown vancomycin and metronidazole to be equally efficacious;
2. The cost of oral vancomycin is substantially more than oral metronidazole; and
3. Many experts have cautioned that using vancomycin may contribute to the blooming number of bacteria that are resistant to vancomycin.

Indeed recommendations from the Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee as well as the American Society for Health-System Pharmacists have supported using metronidazole as our initial agent of choice for CDAD (oral vancomycin is actually the only agent that is approved by the Food and Drug Administration for CDAD). Most of our earlier data claim initial response rates to be 88% or better and relapse rates to be somewhere between 5% and 12% when metronidazole is used.

Two new studies have been published raising a red flag on our current standard of practice. Musher, et al., designed a prospective, observational study in which they followed more 200 patients with CDAD that were initially treated with metronidazole. The patient pool came from a Veterans Affairs Medical Center. They all had a positive fecal ELISA for C. difficile toxin and were treated for seven or more days using at least 1.5 grams per day of metronidazole.

Records were reviewed six weeks prior to the diagnosis and then patients were followed for three months after cessation of therapy. Patients were assigned to four outcome groups:

1. Complete responders who did not have recurrence over four months;
2. Refractory-to-treatment where signs and symptoms of CDAD were present for 10 or more days;
3. Recurrence after initial clinical response with signs and symptoms of CDAD and a positive toxin; and
4. Clinical recurrence where there was an initial response but a recurrence of signs and symptoms of CDAD without a positive toxin (either the toxin was not present when tested or the test was not done).

Fifty percent were completely cured. Twenty-two percent were refractory to initial therapy. Twenty-eight percent had a recurrence of CDAD within the 90-day period. The mortality was 27%. This was higher among people who had failed to respond to initial therapy (31% versus 21%; p<.05).

Pepin, et al., retrospectively looked at more than 2,000 CDAD cases from one hospital between 1991 and 2004. To be included the patients needed either a positive toxin, endoscopic evidence of pseudomembranous colitis, or histopathologic evidence of pseudomembranous colitis on a biopsy specimen. Patients received at least 1 gram per day of metronidazole for 10 to 14 days. They were considered to have a recurrence if they had diarrhea within two months of the completion of therapy and either a positive toxin at that time or if the attending physician ordered a second course of antibiotics for C. difficile.

Between 1991 and 2002 the frequency of times that either therapy was changed to vancomycin or vancomycin was added to metronidazole was unchanged (9.6%). During 2003-2004 this more than doubled (25.7%). The number of patients experiencing recurrence over a two-month period comparing data from 1991-2002 to 2003- 2004 was staggering (20.8% versus 47.2%; p<.001). The authors noted that as patients aged the probabilities of recurrence increased.

They also found that a subgroup of patients with a white blood cell count over 20,000 cells/mm3 and an elevated creatinine had a high short-term mortality rate.

Why might we be seeing these results? Several theories exist. Patients are both older and sicker than they have been in the past. Our antibiotic choice is changing with an increase in using agents that provide a more broad-spectrum coverage. Immune responses vary with fewer antitoxin antibodies found in those patients with symptoms and/or recurrence. Metronidazole levels in stool decrease as inflammation and diarrhea resolve; this is not the case with vancomycin where fecal concentrations remain high throughout treatment.

A survey of infectious disease physicians found that they believe antibiotic failure is on the rise in this setting. Before we take this as true, consider the following:

1. We have no universally accepted clinical definition of what constitutes diarrhea for CDAD;
2. Previous studies did not look for recurrence as far out from initial treatment as these two did; and
3. These studies do not have the design to support arguments powerful enough to change our paradigm just yet.

The editorial comment acknowledged the Pepin, et al., report that patients with a high white blood cell count and worsening renal function are those that we should be particularly concerned about. The authors write that if the patient’s white blood cell count is increasing while on therapy that he changes his antibiotic choice to vancomycin. In addition, if someone has either ileus or fulminant CDAD he will use multiple antibiotics and consult the surgeons. At this time we have other agents being studied for CDAD, such as tinidazole. We now need a larger randomized prospective trial to better explore treatment outcomes in CDAD.

HYPERTONIC SALINE SOLUTION TO TREAT REFRACTORY CONGESTIVE HEART FAILURE

Paterna S, Di Pasquale P, Parrinello G, et al. Changes in brain natriuretic peptide levels and bioelectrical impedance measurements after treatment with high-dose furosemide and hypertonic saline solution versus high-dose furosemide alone in refractory congestive heart failure. J Am Coll Cardiol. 2005;45:1997–2003.

CHF continues to increase in prevalence and incidence, despite our advances with therapies using ACE inhibitors, beta-blockers, and aldosterone antagonists. Refractory CHF accounts for a considerable portion of admissions to hospitalists’ services. Loop diuretics are part of the standard of arsenal we employ in these patients. Unfortunately, many patients fail to respond to initial diuretic doses. In this situation we might begin a constant infusion of diuretic or recruit diuretics from other classes in hope of synergism. Another typical approach in treating advanced CHF is restriction of sodium intake.

Paterna, et al., previously published four studies using small volume hypertonic saline solution and high-dose furosemide in refractory CHF, in which they demonstrated the safety and tolerability of these measures. They now present the first randomized double-blinded trial using this intervention. Ninety-four patients were included with NYHA functional class IV CHF on standard medical therapy and high doses of diuretics for at least two weeks. They had to have a left ventricular ejection fraction of <35%, serum creatinine <2 mg/dL, reduced urinary volume (<500 mL/24 h), and a low natriuresis (<60 mEq/24 h). They could not be taking NSAIDs.

Patients received either intravenous furosemide (500 to 1000 mg) plus hypertonic saline solution bid or the IV furosemide bid alone. Treatment lasted four to six days. Body weights were followed. Brain natriuretic peptide plasma levels were measured on hospital days one and six, as well as 30 days after discharge.

The group receiving hypertonic saline solution had brow-raising results. They had a significant increase in daily diuresis and natriuresis (p<0.05), a difference in brain natriuretic peptide levels on days six and 30, a reduction in their length of stay, and a decrease in their hospital readmission rate.

This is a provocative study. At this time the mechanism responsible for the results is unclear. Paterna, et al., offer multiple explanations. One possibility is through the osmotic action of hypertonic saline solution. It may hasten the mobilization of extravascular fluid into the intravascular space and then this volume is quickly excreted. Also, hypertonic saline solution may increase renal blood flow and perfusion alternating the handling of sodium and natriuresis while also allowing the concentration of furosemide in the loop of Henle to attain a more desirable level.

Should these results hold true in other investigations and the inclusion criteria loosen (measuring patients urine volume and sodium concentration for 24 hours prior to admission may not be easy or practical) then we might have a very inexpensive new method for treating refractory CHF.

PERIOPERATIVE BETA-BLOCKERS: HELPFUL OR HARMFUL FOR MAJOR NONCARDIAC SURGERY?

Lindenauer P, Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353:349–361.

Among the most common reasons that hospitalists are consulted is the “perioperative evaluation.” This is with good reason because 50,000 patients each year have a perioperative myocardial infarction. A statement by the Agency for Health Care Research and Quality proclaims that we have “clear opportunities for safety improvement” in regard to using beta-blockers for patients with intermediate and high risk for perioperative cardiovascular complications. The American Heart Association and the American College of Cardiology recommend using these medications in patients with either risk factors for or known coronary artery disease when undergoing high-risk surgeries. Despite all of this the efficacy of the class has not been proven by large randomized clinical studies.

Using a large national registry of more than 300 U.S. hospitals, Lindenauer, et al., conducted a large observational study evaluating beta-blockade in the perioperative period in patients undergoing major noncardiac surgery. Looking at more than 700,000 patients, they found that 85% had no recorded contraindication to beta-blockers. Only 18% of eligible patients received beta-blockers (n=122, 338).

Patients were considered to have had a beta-blocker for prophylaxis if it was given within the first 48 hours of their hospitalization, though this may or may not have been the intended use (this information was not provided by the registry data base). Only in-hospital mortality was evaluated as postdischarge information was not available. All patients had a revised cardiac risk index configured. This index places risk on perioperative cardiac events by looking at the nature of the surgery as well as whether or not a history of congestive heart failure, ischemic heart disease, perioperative treatment with insulin, an elevated preoperative creatinine, and cerebrovascular disease are present. An increasing score means that major perioperative complications become more likely (scores range from 0–5).

Considering all patients, there was no risk reduction of in-hospital death for those receiving beta-blockers. If the revised cardiac risk index score was 0 or 1, the patients had an increase in the risk of death (43% and 13%, respectively). However, those patients whose scores were 2, 3, or 4 or higher had a reduction in the risk of death (from 10% to 43% as their score increased).

How are we to account for these results? In the high-risk patients we see benefit in treatment with beta-blockers. We suspect this drug class improves coronary filling time during diastole and/or prevents dangerous arrhythmias. In patients at low and intermediate risk, the results may be surprising. The study group did not have patient charts available. It is possible that these patients were given betablockers not for prophylaxis but in response to a postoperative ischemic event or infarction. If this misclassification took place, then the effectiveness of beta-blockers is underestimated and the suggestion that these drugs are harmful in this situation would be erroneous.

Given the data gleaned from this study and considering previous publications, we are justified—even obligated—in using betablockers in high-risk patients, without contraindications, who undergo major noncardiac surgery. Before using these drugs in patients at low or intermediate risk we need more information. Two large ongoing randomized trials (POISE and DECREASE–IV) should bring clarity to this issue. We expect results from these in the next four years.

A NEW CLINICAL ENTITY: THE HEPATOADRENAL SYNDROME

Marik PE, Gayowski T, Starzl TE, et al. The hepatoadrenal syndrome: a common yet unrecognized clinical condition. Crit Care Med. 2005;33:1254-1259.

It is not uncommon to see the temporary dysfunction of the hypothalamic-pituitary-adrenal axis while someone is critically ill. Many physicians who suspect this condition attempt to make a diagnosis using either a random total cortisol level or perform a cosyntropin stimulation test. End-stage liver disease and sepsis share some elements of their pathophysiology, such as endotoxemia and increased levels of mediators that influence inflammation.

A liver transplant intensive care unit has produced data on what they have coined the “hepatoadrenal syndrome.” Due to emerging evidence that severe liver disease is associated with adrenal insufficiency, this liver transplant intensive care unit began routinely testing all patients admitted to their unit for this condition. They presented their findings for 340 patients. This review will focus only on those patients with chronic liver failure and fulminant hepatic failure because transplant patients are often cared for by a multidisciplinary team. Patients were labeled as having adrenal insufficiency if the random total cortisol level was <20 micrograms (mcg)/dL in patients who were “highly stressed” (i.e., hypotension, respiratory failure). In all other patients a random total cortisol level of <15 mcg/dL or a 30-minute level <20 mcg/dL post-low-dose (1 mcg) cosyntropin established the diagnosis. Lipid profiles were also obtained from each patient. Those receiving glucocorticoids were excluded. It was left to the discretion of the treating physician whether or not to treat patients with steroids.

Eight patients (33%) with fulminant hepatic failure and 97 patients (66%) with chronic liver disease met their criteria for adrenal insufficiency. Of the patients with adrenal insufficiency the mortality rate was 46% for those not treated with glucocorticoids compared with 26% for those receiving glucocorticoid therapy. The HDL level was the only variable predictive of adrenal insufficiency (p<.0001).

The association between HDL levels and cortisol is as follows: The adrenal glands do not store cortisol. Cholesterol is a precursor for the synthesis of steroids—80% of cortisol arises from it. The lipoprotein of choice to use as substrate in steroid production is HDL. Because a major protein component of HDL is synthesized by the liver, those with liver disease have low levels of serum HDL.

Recently our current method of diagnosing adrenal insufficiency during acute illness has been challenged in the literature. Measuring free cortisol rather than total cortisol has been suggested as proteins that bind cortisol decrease in this setting while free cortisol levels actually rise. Similar to the picture we see in sepsis, there are low levels of these same proteins in liver disease.

At this time testing for free cortisol is not widely available nor do we have good information on what an “appropriate” free cortisol level should be during acute illness. Therefore, given the frequency in which Marik, et al., report encountering this condition and the effect that treatment had on mortality it seems as though this is a diagnosis worth consideration.

TREATMENT OPTIONS FOR ATRIAL FIBRILLATION

Wazni OM, Marrouche NF, Martin DO, et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation. JAMA. 2005;293(21):2634-2640.

Atrial fibrillation affects millions of people. This diagnosis has a significant mortality associated with it, causes strokes, and influences quality of life. Therapy has been less than satisfying. Both rate control and rhythm control have multiple potential adverse consequences. Pulmonary vein isolation is performed in the electrophysiology laboratory using an ablation catheter. The goal of this procedure is to completely disconnect the electrical activity between the pulmonary vein antrum and the left atrium. This is a potentially curable procedure for atrial fibrillation.

In a multicenter prospective randomized pilot study Wazni, et al., studied 70 patients with highly symptomatic atrial fibrillation. Patients were between 18 and 75 years old. They could not have undergone ablation in the past, had a history of open-heart surgery, been previously treated with antiarrhythmic drugs, or had a contraindication to long-term anticoagulation. Patients were randomized to antiarrhythmic therapy or pulmonary vein isolation. Those receiving medical treatment were given flecainide, propafenone, or sotalol. Amiodarone was used for patients who had failed at least two or more of these medications. Drugs were titrated to the maximum tolerable doses. The other arm of the group underwent pulmonary vein isolation. This group also received anticoagulation with warfarin beginning the day of the procedure, and this was continued for at least three months. Anticoagulation was extended beyond this time if atrial fibrillation recurred or the pulmonary vein was narrowed by 50% or more (as seen on a three-month post-procedure CT scan). Follow-up was at least one year. A loop event-recorder was worn for one month by all patients and event recorders were used for patients who were symptomatic beyond the first three months of therapy initiation.

After one year, symptomatic atrial fibrillation recurred in 63% of the antiarrhythmic group versus 13% in the pulmonary vein isolation group (p<.001). Fifty-four percent of those medically treated were hospitalized versus 9% of pulmonary vein isolation patients (p<.001). There were no thromboembolic events in either group. Bleeding rates were similar in both groups. For those who underwent pulmonary vein isolation 3% had mild pulmonary vein stenosis and 3% had moderate stenosis (all of which were asymptomatic). Five of the eight measures of quality of life were significantly improved in the pulmonary vein isolation arm versus those receiving antiarrhythmic drugs.

Recently data from multiple trials such as AFFIRM and RACE confirm that rhythm control does not confer significant benefits over rate-control for atrial fibrillation. In fact rate control seems to be a more attractive approach to many patients given the side-effect profile of the antiarrhythmia medications. This study was initiated prior to the release of the information gained from RACE and AFFIRM, thus no rate-control arm was included. This trial also differed from previous studies by using a younger population that was highly symptomatic in comparison with other recent studies using older patients who had recurrent persistent atrial fibrillation.

The biggest concerns about pulmonary vein isolation are the complication rates (death in 0.05% and stroke in 0.28%). We also don’t know if this procedure will translate into long-term cures. Until we have larger studies this should not be a first-line modality for treating all patients. Quite often we find patients where neither rate nor rhythm control is a particularly attractive option, especially in regard to long-term anticoagulation. Pulmonary vein isolation provides us with a new viable option for these people as well as something to consider for carefully selected highly symptomatic patients. TH

WORSENING OUTCOMES AND INCREASED RECURRENCE OF CLOSTRIDIUM DIFFICILE AFTER INITIAL TREATMENT WITH METRONIDAZOLE?

Pepin J, Alary ME, Valiquette L, et al. Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. Clin Infect Dis. 2005;40:1591-1597; and Musher DM, Aslam S, Logan N, et al. Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis. 2005;40:1586-1590.

Information on treatment of colitis caused by Clostridium difficile began to appear in the late 1970s and early 1980s. Since that time there have been a paucity of novel therapies. It has been well-established that both metronidazole and vancomycin can effectively treat this entity. Traditionally metronidazole has been the first-line agent for C. difficile-associated diarrhea (CDAD). The reasons for this are three:

1. Randomized controlled trials have shown vancomycin and metronidazole to be equally efficacious;
2. The cost of oral vancomycin is substantially more than oral metronidazole; and
3. Many experts have cautioned that using vancomycin may contribute to the blooming number of bacteria that are resistant to vancomycin.

Indeed recommendations from the Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee as well as the American Society for Health-System Pharmacists have supported using metronidazole as our initial agent of choice for CDAD (oral vancomycin is actually the only agent that is approved by the Food and Drug Administration for CDAD). Most of our earlier data claim initial response rates to be 88% or better and relapse rates to be somewhere between 5% and 12% when metronidazole is used.

Two new studies have been published raising a red flag on our current standard of practice. Musher, et al., designed a prospective, observational study in which they followed more 200 patients with CDAD that were initially treated with metronidazole. The patient pool came from a Veterans Affairs Medical Center. They all had a positive fecal ELISA for C. difficile toxin and were treated for seven or more days using at least 1.5 grams per day of metronidazole.

Records were reviewed six weeks prior to the diagnosis and then patients were followed for three months after cessation of therapy. Patients were assigned to four outcome groups:

1. Complete responders who did not have recurrence over four months;
2. Refractory-to-treatment where signs and symptoms of CDAD were present for 10 or more days;
3. Recurrence after initial clinical response with signs and symptoms of CDAD and a positive toxin; and
4. Clinical recurrence where there was an initial response but a recurrence of signs and symptoms of CDAD without a positive toxin (either the toxin was not present when tested or the test was not done).

Fifty percent were completely cured. Twenty-two percent were refractory to initial therapy. Twenty-eight percent had a recurrence of CDAD within the 90-day period. The mortality was 27%. This was higher among people who had failed to respond to initial therapy (31% versus 21%; p<.05).

Pepin, et al., retrospectively looked at more than 2,000 CDAD cases from one hospital between 1991 and 2004. To be included the patients needed either a positive toxin, endoscopic evidence of pseudomembranous colitis, or histopathologic evidence of pseudomembranous colitis on a biopsy specimen. Patients received at least 1 gram per day of metronidazole for 10 to 14 days. They were considered to have a recurrence if they had diarrhea within two months of the completion of therapy and either a positive toxin at that time or if the attending physician ordered a second course of antibiotics for C. difficile.

Between 1991 and 2002 the frequency of times that either therapy was changed to vancomycin or vancomycin was added to metronidazole was unchanged (9.6%). During 2003-2004 this more than doubled (25.7%). The number of patients experiencing recurrence over a two-month period comparing data from 1991-2002 to 2003- 2004 was staggering (20.8% versus 47.2%; p<.001). The authors noted that as patients aged the probabilities of recurrence increased.

They also found that a subgroup of patients with a white blood cell count over 20,000 cells/mm3 and an elevated creatinine had a high short-term mortality rate.

Why might we be seeing these results? Several theories exist. Patients are both older and sicker than they have been in the past. Our antibiotic choice is changing with an increase in using agents that provide a more broad-spectrum coverage. Immune responses vary with fewer antitoxin antibodies found in those patients with symptoms and/or recurrence. Metronidazole levels in stool decrease as inflammation and diarrhea resolve; this is not the case with vancomycin where fecal concentrations remain high throughout treatment.

A survey of infectious disease physicians found that they believe antibiotic failure is on the rise in this setting. Before we take this as true, consider the following:

1. We have no universally accepted clinical definition of what constitutes diarrhea for CDAD;
2. Previous studies did not look for recurrence as far out from initial treatment as these two did; and
3. These studies do not have the design to support arguments powerful enough to change our paradigm just yet.

The editorial comment acknowledged the Pepin, et al., report that patients with a high white blood cell count and worsening renal function are those that we should be particularly concerned about. The authors write that if the patient’s white blood cell count is increasing while on therapy that he changes his antibiotic choice to vancomycin. In addition, if someone has either ileus or fulminant CDAD he will use multiple antibiotics and consult the surgeons. At this time we have other agents being studied for CDAD, such as tinidazole. We now need a larger randomized prospective trial to better explore treatment outcomes in CDAD.

HYPERTONIC SALINE SOLUTION TO TREAT REFRACTORY CONGESTIVE HEART FAILURE

Paterna S, Di Pasquale P, Parrinello G, et al. Changes in brain natriuretic peptide levels and bioelectrical impedance measurements after treatment with high-dose furosemide and hypertonic saline solution versus high-dose furosemide alone in refractory congestive heart failure. J Am Coll Cardiol. 2005;45:1997–2003.

CHF continues to increase in prevalence and incidence, despite our advances with therapies using ACE inhibitors, beta-blockers, and aldosterone antagonists. Refractory CHF accounts for a considerable portion of admissions to hospitalists’ services. Loop diuretics are part of the standard of arsenal we employ in these patients. Unfortunately, many patients fail to respond to initial diuretic doses. In this situation we might begin a constant infusion of diuretic or recruit diuretics from other classes in hope of synergism. Another typical approach in treating advanced CHF is restriction of sodium intake.

Paterna, et al., previously published four studies using small volume hypertonic saline solution and high-dose furosemide in refractory CHF, in which they demonstrated the safety and tolerability of these measures. They now present the first randomized double-blinded trial using this intervention. Ninety-four patients were included with NYHA functional class IV CHF on standard medical therapy and high doses of diuretics for at least two weeks. They had to have a left ventricular ejection fraction of <35%, serum creatinine <2 mg/dL, reduced urinary volume (<500 mL/24 h), and a low natriuresis (<60 mEq/24 h). They could not be taking NSAIDs.

Patients received either intravenous furosemide (500 to 1000 mg) plus hypertonic saline solution bid or the IV furosemide bid alone. Treatment lasted four to six days. Body weights were followed. Brain natriuretic peptide plasma levels were measured on hospital days one and six, as well as 30 days after discharge.

The group receiving hypertonic saline solution had brow-raising results. They had a significant increase in daily diuresis and natriuresis (p<0.05), a difference in brain natriuretic peptide levels on days six and 30, a reduction in their length of stay, and a decrease in their hospital readmission rate.

This is a provocative study. At this time the mechanism responsible for the results is unclear. Paterna, et al., offer multiple explanations. One possibility is through the osmotic action of hypertonic saline solution. It may hasten the mobilization of extravascular fluid into the intravascular space and then this volume is quickly excreted. Also, hypertonic saline solution may increase renal blood flow and perfusion alternating the handling of sodium and natriuresis while also allowing the concentration of furosemide in the loop of Henle to attain a more desirable level.

Should these results hold true in other investigations and the inclusion criteria loosen (measuring patients urine volume and sodium concentration for 24 hours prior to admission may not be easy or practical) then we might have a very inexpensive new method for treating refractory CHF.

PERIOPERATIVE BETA-BLOCKERS: HELPFUL OR HARMFUL FOR MAJOR NONCARDIAC SURGERY?

Lindenauer P, Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353:349–361.

Among the most common reasons that hospitalists are consulted is the “perioperative evaluation.” This is with good reason because 50,000 patients each year have a perioperative myocardial infarction. A statement by the Agency for Health Care Research and Quality proclaims that we have “clear opportunities for safety improvement” in regard to using beta-blockers for patients with intermediate and high risk for perioperative cardiovascular complications. The American Heart Association and the American College of Cardiology recommend using these medications in patients with either risk factors for or known coronary artery disease when undergoing high-risk surgeries. Despite all of this the efficacy of the class has not been proven by large randomized clinical studies.

Using a large national registry of more than 300 U.S. hospitals, Lindenauer, et al., conducted a large observational study evaluating beta-blockade in the perioperative period in patients undergoing major noncardiac surgery. Looking at more than 700,000 patients, they found that 85% had no recorded contraindication to beta-blockers. Only 18% of eligible patients received beta-blockers (n=122, 338).

Patients were considered to have had a beta-blocker for prophylaxis if it was given within the first 48 hours of their hospitalization, though this may or may not have been the intended use (this information was not provided by the registry data base). Only in-hospital mortality was evaluated as postdischarge information was not available. All patients had a revised cardiac risk index configured. This index places risk on perioperative cardiac events by looking at the nature of the surgery as well as whether or not a history of congestive heart failure, ischemic heart disease, perioperative treatment with insulin, an elevated preoperative creatinine, and cerebrovascular disease are present. An increasing score means that major perioperative complications become more likely (scores range from 0–5).

Considering all patients, there was no risk reduction of in-hospital death for those receiving beta-blockers. If the revised cardiac risk index score was 0 or 1, the patients had an increase in the risk of death (43% and 13%, respectively). However, those patients whose scores were 2, 3, or 4 or higher had a reduction in the risk of death (from 10% to 43% as their score increased).

How are we to account for these results? In the high-risk patients we see benefit in treatment with beta-blockers. We suspect this drug class improves coronary filling time during diastole and/or prevents dangerous arrhythmias. In patients at low and intermediate risk, the results may be surprising. The study group did not have patient charts available. It is possible that these patients were given betablockers not for prophylaxis but in response to a postoperative ischemic event or infarction. If this misclassification took place, then the effectiveness of beta-blockers is underestimated and the suggestion that these drugs are harmful in this situation would be erroneous.

Given the data gleaned from this study and considering previous publications, we are justified—even obligated—in using betablockers in high-risk patients, without contraindications, who undergo major noncardiac surgery. Before using these drugs in patients at low or intermediate risk we need more information. Two large ongoing randomized trials (POISE and DECREASE–IV) should bring clarity to this issue. We expect results from these in the next four years.

A NEW CLINICAL ENTITY: THE HEPATOADRENAL SYNDROME

Marik PE, Gayowski T, Starzl TE, et al. The hepatoadrenal syndrome: a common yet unrecognized clinical condition. Crit Care Med. 2005;33:1254-1259.

It is not uncommon to see the temporary dysfunction of the hypothalamic-pituitary-adrenal axis while someone is critically ill. Many physicians who suspect this condition attempt to make a diagnosis using either a random total cortisol level or perform a cosyntropin stimulation test. End-stage liver disease and sepsis share some elements of their pathophysiology, such as endotoxemia and increased levels of mediators that influence inflammation.

A liver transplant intensive care unit has produced data on what they have coined the “hepatoadrenal syndrome.” Due to emerging evidence that severe liver disease is associated with adrenal insufficiency, this liver transplant intensive care unit began routinely testing all patients admitted to their unit for this condition. They presented their findings for 340 patients. This review will focus only on those patients with chronic liver failure and fulminant hepatic failure because transplant patients are often cared for by a multidisciplinary team. Patients were labeled as having adrenal insufficiency if the random total cortisol level was <20 micrograms (mcg)/dL in patients who were “highly stressed” (i.e., hypotension, respiratory failure). In all other patients a random total cortisol level of <15 mcg/dL or a 30-minute level <20 mcg/dL post-low-dose (1 mcg) cosyntropin established the diagnosis. Lipid profiles were also obtained from each patient. Those receiving glucocorticoids were excluded. It was left to the discretion of the treating physician whether or not to treat patients with steroids.

Eight patients (33%) with fulminant hepatic failure and 97 patients (66%) with chronic liver disease met their criteria for adrenal insufficiency. Of the patients with adrenal insufficiency the mortality rate was 46% for those not treated with glucocorticoids compared with 26% for those receiving glucocorticoid therapy. The HDL level was the only variable predictive of adrenal insufficiency (p<.0001).

The association between HDL levels and cortisol is as follows: The adrenal glands do not store cortisol. Cholesterol is a precursor for the synthesis of steroids—80% of cortisol arises from it. The lipoprotein of choice to use as substrate in steroid production is HDL. Because a major protein component of HDL is synthesized by the liver, those with liver disease have low levels of serum HDL.

Recently our current method of diagnosing adrenal insufficiency during acute illness has been challenged in the literature. Measuring free cortisol rather than total cortisol has been suggested as proteins that bind cortisol decrease in this setting while free cortisol levels actually rise. Similar to the picture we see in sepsis, there are low levels of these same proteins in liver disease.

At this time testing for free cortisol is not widely available nor do we have good information on what an “appropriate” free cortisol level should be during acute illness. Therefore, given the frequency in which Marik, et al., report encountering this condition and the effect that treatment had on mortality it seems as though this is a diagnosis worth consideration.

TREATMENT OPTIONS FOR ATRIAL FIBRILLATION

Wazni OM, Marrouche NF, Martin DO, et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation. JAMA. 2005;293(21):2634-2640.

Atrial fibrillation affects millions of people. This diagnosis has a significant mortality associated with it, causes strokes, and influences quality of life. Therapy has been less than satisfying. Both rate control and rhythm control have multiple potential adverse consequences. Pulmonary vein isolation is performed in the electrophysiology laboratory using an ablation catheter. The goal of this procedure is to completely disconnect the electrical activity between the pulmonary vein antrum and the left atrium. This is a potentially curable procedure for atrial fibrillation.

In a multicenter prospective randomized pilot study Wazni, et al., studied 70 patients with highly symptomatic atrial fibrillation. Patients were between 18 and 75 years old. They could not have undergone ablation in the past, had a history of open-heart surgery, been previously treated with antiarrhythmic drugs, or had a contraindication to long-term anticoagulation. Patients were randomized to antiarrhythmic therapy or pulmonary vein isolation. Those receiving medical treatment were given flecainide, propafenone, or sotalol. Amiodarone was used for patients who had failed at least two or more of these medications. Drugs were titrated to the maximum tolerable doses. The other arm of the group underwent pulmonary vein isolation. This group also received anticoagulation with warfarin beginning the day of the procedure, and this was continued for at least three months. Anticoagulation was extended beyond this time if atrial fibrillation recurred or the pulmonary vein was narrowed by 50% or more (as seen on a three-month post-procedure CT scan). Follow-up was at least one year. A loop event-recorder was worn for one month by all patients and event recorders were used for patients who were symptomatic beyond the first three months of therapy initiation.

After one year, symptomatic atrial fibrillation recurred in 63% of the antiarrhythmic group versus 13% in the pulmonary vein isolation group (p<.001). Fifty-four percent of those medically treated were hospitalized versus 9% of pulmonary vein isolation patients (p<.001). There were no thromboembolic events in either group. Bleeding rates were similar in both groups. For those who underwent pulmonary vein isolation 3% had mild pulmonary vein stenosis and 3% had moderate stenosis (all of which were asymptomatic). Five of the eight measures of quality of life were significantly improved in the pulmonary vein isolation arm versus those receiving antiarrhythmic drugs.

Recently data from multiple trials such as AFFIRM and RACE confirm that rhythm control does not confer significant benefits over rate-control for atrial fibrillation. In fact rate control seems to be a more attractive approach to many patients given the side-effect profile of the antiarrhythmia medications. This study was initiated prior to the release of the information gained from RACE and AFFIRM, thus no rate-control arm was included. This trial also differed from previous studies by using a younger population that was highly symptomatic in comparison with other recent studies using older patients who had recurrent persistent atrial fibrillation.

The biggest concerns about pulmonary vein isolation are the complication rates (death in 0.05% and stroke in 0.28%). We also don’t know if this procedure will translate into long-term cures. Until we have larger studies this should not be a first-line modality for treating all patients. Quite often we find patients where neither rate nor rhythm control is a particularly attractive option, especially in regard to long-term anticoagulation. Pulmonary vein isolation provides us with a new viable option for these people as well as something to consider for carefully selected highly symptomatic patients. TH

Denver—The Pediatric Hospital Medicine 2005 conference, held July 28–31, got off to a rousing start with a networking reception that preceded the keynote lecture on Thursday evening, July 28. Dan Rauch, MD, cochair of the Ambulatory Pediatric Association (APA) Special Interest Group in Hospital Medicine, welcomed the 200+ attendees. He described the meeting as the result of tremendous cooperation among the APA, the American Academy of Pediatrics (AAP), and the SHM.

“It’s been a tremendous pleasure to work with all three organizations,” said Dr. Rauch. “We have been truly blessed with leaders who think that growth of the field is more important than individual turf battles. I highly recommend that everybody in the room become members of all three organizations.”

Dr. Rauch later told The Hospitalist that he was surprised by how many attendees actually weren’t members of any of the three organizations.

The mostly young pediatric hospitalists in attendance came from all over the United States and Canada. According to keynote speaker Larry Wellikson, MD, CEO of SHM, the median age of the typical hospitalist is 37, and fewer than 10% are 50 or older. Dr. Rauch said the typical pediatric hospitalist is even younger.

In fact, the pediatric hospitalist profession is still in its infancy, a point underscored by the panel discussion during Friday’s plenary session, “Future Directions.” The conversation centered on whether pediatric hospitalist medicine is truly a new subspecialty or simply a job type within general pediatrics. Most attendees seemed to agree that in practice it is a new subspecialty, but gaining acknowledgement of that fact from the professional organizations, academics, hospital administrators, insurers, general practice pediatricians, and even from some pediatric hospitalists themselves is the continuing challenge.

Professional advancement was a theme every speaker emphasized, beginning with Dr. Wellikson.

You are building and defining the hospital of the future.

—Larry Wellikson, MD, CEO of SHM, explaining that the legacy of this generation of hospitalists will be to define hospital medicine.

CREATING THE HOSPITAL OF THE FUTURE

“My life’s goals were to be dean of a med school when I was 40 and a United States senator at 50,” said Dr. Wellikson during his keynote address. He may not have achieved those particular goals, but, he revealed, “believe it or not, my life has been even better than that.”

Dr. Wellikson, who discussed the current status of hospital medicine, is a sought-after speaker and consultant who helps hospitals and physicians understand the current medical environment and create strategies to succeed in it.

“You are building and defining the hospital of the future,” Dr. Wellikson told participants, explaining that the legacy of this generation of hospitalists will be to define hospital medicine. “[Hospitalists] are going to be the most important part of the hospital of the future.

“Hospitals are changing,” he said, describing the hospital of the future as patient-centered with medical care driven by measurable data and practiced in teams. With emergency departments overcrowded and hospitals and ICUs running at capacity, he predicts that $20 billion per year will be spent on hospital construction over the next 10 years. He foresees primary care pediatricians giving up inpatient care.

“Hospitalist medicine is by far the fastest growing medical specialty in the country,” said Dr. Wellikson. Currently, there are approximately 11,295 hospitalists, and he predicts that there will be 30,000 by the end of the decade. Approximately 9% of hospitalists are pediatricians.

According to Dr. Wellikson, 30% of 4,895 community hospitals today have hospitalists on staff, with about eight hospitalists per hospital. The larger the hospital, the more likely it is to have hospitalists:

• 71% of hospitals with more than 500 beds have hospitalists on staff; and
• 50% of hospitals with more than 100 beds have hospitalists.

“We believe at SHM that in 15 years 25% of the CEOs will be hospitalists and 15% of CMOs will be hospitalists,” said Dr. Wellikson, “ ... and you’re not all going to be able to take time off to go get an MBA. We’re going to be in the business of educating you to be a leader, how to be a manager. ... If you will commit to creating the hospital of the future, [SHM] will commit to giving you the tools to do it.”

VALUE VERSUS COMPENSATION

During the keynote, Dr. Wellikson set the stage for a compensation discussion that continued throughout the conference, both during sessions and in networking conversations.

“One of the things that makes the compensation model so unfair for hospital medicine,” said Dr. Wellikson, “is that the way we pay for medical care in this country is so screwed up. We pay by the unit of the visit and by the unit of the procedure. And so it is much better to do something wrong and do it a lot than it is to sit down and spend an hour talking with a family. And God forbid that you’re asked to sit on a QI committee; that’s really down time. ... And God forbid that instead of earning a living and seeing patients for three days you’re wasting your time here in Denver trying to be a better doctor. Our system doesn’t reward that.”

Several attendees mentioned that their hospitals consider them loss leaders. “Don’t allow yourself to be called a loss leader,” said Linda Snelling, MD, in her Friday session on contract negotiation. “You’re a system sustainer. If you want this profession to be respected, you’ve got to be paid for it.” Dr. Snelling is chief of pediatric critical care and associate professor of pediatrics and surgery (anesthesiology) at Brown University, Providence, R.I.

“Hospitalists need to convince ourselves of the value we bring to our institutions and to our patients,” said Mark Joffe, MD, director of community pediatric medicine for the Children’s Hospital of Philadelphia.

Dr. Wellikson emphasized that hospitalists do add value to hospitals—whether it’s educating, whether it’s throughput, whether it’s 24/7, whether it’s improving the quality. He said that hospital administrators—the CMOs at your hospital—understand that. “The reason that leadership and that hospitalists are important is that hospitals see you as the solution to many hospital issues,” he said. “When anthrax was thought to be a public health problem, every hospital started a bioterrorism committee and put the hospitalist on it.

“Almost every place I go, they want more of you. You’re better for their bottom line,” he continued. “If they’re ever going to be a better hospital, they need more of you, and they need you motivated, and they need you seeing the right number of patients so that you have the time to do a better job.”

According to Dr. Wellikson, the expectations of hospitalists is that they will improve efficiency, save the hospital money, provide measurable quality improvement (creating standards and measuring compliance), collect data, do things no one else will (e.g., provide uncompensated care, serve on committees).

Dr. Snelling agreed. “The benefit of hospitalists is not in what you bill,” she said, “but in systems improvements, patient satisfaction, QI, initiatives to start or change a program, teaching, cost-savings, and value-added services you provide to the hospital. ... Start with value. Figure out what you want. Identify common ground. Bargaining is the last thing you do.”

Hospitalists create a seamless continuity from inpatient to outpatient, from the emergency department to the floor, from the ICU to the floor. They improve efficiency via throughput and early discharge. They help uncrowd the emergency department and open ICU beds. “We make other physicians’ lives better,” said Dr. Wellikson. “We do a lot of things for the generalists so that they can go and have a better life.”

There is a definite bright side to being a hospitalist right now. According to Dr. Wellikson there are many more jobs than hospitalists—a trend that he predicts will continue for at least for the next five years.

“Don’t let the fact that we have a totally screwed up healthcare system get you down,” he said. “You’re not replaceable. The service you provide, someone must provide. Your hospital has more wastage in durable goods than it spends on pediatric hospitalists. They will pay for expertise.”

Dr. Snelling advised, “Be direct and shameless about compensation. No surgeon works for free unless they want to; no hospitalist should work for free unless that’s your selected charity, and my favorite charity is not the hospital I work for.

“Continually self-promote,” she continued. “Make sure [the person determining your compensation] knows what your successes are. If you’re doing something that’s successful—you get praise, you get a grant, you get a nice letter from a parent—pass that on. Document your value. If you save your hospital a million bucks, why shouldn’t you get a hunk of that? The CEO’s job is to pay you as little as possible.”

One attendee interjected, “I feel uncomfortable with the idea that what I’m doing as a hospitalist is worth more than what my private-practice colleagues are doing. I don’t want to be offensive.”

To which Dr. Snelling replied, “We’re not talking about being elitist. ‘Mine’s bigger than yours.’ What you’re talking about is the differences between C care—the minimum standard—and A care—the hospitalist. ... Who in this room wants to go to an average doctor?”

Dr. Snelling’s bottom line: “My message is not to gouge the system; it’s about respect. In an ideal situation, everybody gains.”

SHOULD PEDIATRIC HOSPITAL MEDICINE BE A BOARD-CERTIFIED SPECIALTY?

“This is a specialty,” emphasized Dr. Snelling during the contract negotiation session.

On the other hand, during the “Future Directions” plenary panel Dr. Wellikson said, “It is almost not relevant whether there is board certification or no board certification.” He described board certification as a way to measure quality.

“Clearly we need to find a way to validate what we’re doing for our good as well as for the good of our patients,” said Doug Carlson, MD, director of the Pediatric Hospital Medicine Program at St. Louis Children’s Hospital and associate professor of pediatrics at Washington University, St. Louis.

Stephen Ludwig, MD, associate chair for medical education at the Children’s Hospital of Philadelphia presented the case for becoming a board-certified specialty. Some benefits: recognition, prestige, job security, and professional advancement.

“Is this just a job, or do you want to fit into—become a thread in—the fabric of organized medicine?” asked Dr. Ludwig. Most important, though, would be the impact on child health. “Is [board certification] good for children and their parents? Unless you can demonstrate that, it won’t happen.”

According to Dr. Ludwig, becoming a board-certified specialty requires a defined body of knowledge, scientific basis, a sufficient number of practitioners, viable academic training programs, sufficient number of trainees willing to go into those fellowship programs, a board exam, geographic diversity, creation of new knowledge (or at least the application of existing knowledge in new ways), the support of national societies and organizations, and the consent of other specialties, such as internal medicine and family practice. It also takes time—likely years.

Some questions pediatric hospitalists still need to consider: Can you fill a void? Is there sufficient novel material for creating a certifying exam? Are there enough people who would take this exam? How will physicians view maintenance of certification? Where will the naysayers come from? What will be the response from primary care general pediatricians? What will be the response from academic generalists/pediatricians? What will be the subspecialist response?

Dr. Ludwig expressed one concern succinctly: “You might ultimately decrease the number of practitioners willing to make the commitment.”

Dr. Wellikson concurred. “Those of you who are group leaders are constantly in a recruiting mode,” he said. “You need something to help you determine who is good and who is not, but adding three years may drive those who would have been great pediatric hospitalists to become great pediatric anesthesiologists.”

In the end, the group could not agree on an answer. “You have an amazing amount of excitement,” said Dr. Ludwig. “Temper your excitement with focus. You need to decide whether becoming another subspecialty is what you want.”

SOMETHING FOR EVERYONE

The conference offered a broad range of learning opportunities.

Those interested in research heard about opportunities to collaborate and learned how to share resources and develop research projects.

Educators—and aren’t all hospitalists involved in education at some level?—learned “Seven Simple Secrets to Successful Supervision” from Vinny Chiang, MD, chief of inpatient services at Children’s Hospital, Boston. He says the single most powerful question you can ask as an educator is, “What do you think?”

“The med student may say, ‘I think the kid is sick.’ The intern may say, ‘I think it’s rejection.’ The resident may say, ‘We need to distinguish between infection and rejection,’” said Dr. Chiang. By asking this question, he said, “You make that trainee an active participant.”

Evidence-based medicine and the use of pathways were also on the agenda. The discussions started with the basics, defining terms. According to Dr. Chiang, evidence-based medicine is, “the conscientious, explicit, and judicious use of current best evidence in making a clinical decision.” (See also “Evidence-Based Medicine for the Hospitalist,” p. 22.)

Pathways, developed from that best evidence, are tools that guide clinical care. “It’s the same as with calculators and PDAs,” said Stephen E. Muething, MD, associate director of clinical services at Cincinnati Children’s Hospital. “A pathway is a tool that allows a resident to spend their time identifying the 20% who shouldn’t be on the pathway and figuring out what to do for them.”

“Medicine can be systematized,” said Dr. Wellikson. “You can have best practices.”

Attendees expressed concerns that pathways may not leave room for a hospitalist’s judgment.

“There is no pathway that addresses 100% of patients,” said Dr. Muething. “A pathway should be defined as a guideline not a standard of care. From a medicallegal standpoint, you need to document why you deviated from a pathway. You still need to use clinical judgment. Don’t forget to think.”

One reason to use pathways, according to Dr. Muething, is that you can more rapidly identify what works and what doesn’t. “If everyone is doing it the same way,” he said, “then even if everyone is doing it wrong, you’ll be able to identify the problem and resolve it more quickly, improving outcome.”

Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.

—Erin Stiucky, MD

HOT TOPICS

Clinical topics were also on the agenda. On the final day of the conference, Erin R. Stucky, MD, director of graduate medical education, an associate clinical professor in the University of California at San Diego Department of Pediatrics, and a pediatric hospitalist at the Children’s

Hospital and Health Center San Diego, tackled “The Top Five in ’05,” discussing:

1. Bronchiolitis;
2. Emerging pathogens;
3. Venous thrombosis;
4. Fungal infections; and
5. Kawasaki disease (KD).

In a whirlwind review, she presented the latest research on each of these topics.

Bronchiolitis: Surveys reveal that there’s a lot of variability in how hospitalists currently manage bronchiolitis, beginning with whether or not viral testing is helpful. “Testing, do we care? Does more than RSV matter?” asked Dr. Stucky. Her literature review of studies on bronchiolitis reveals, “Actually knowing the viral type is probably not helpful. Think before you test. Prevention is key.”

She also mentioned the need for additional studies on the use of heliox and CPAP in treating the condition.

Emerging pathogens: Dr. Stucky rapidly reviewed West Nile virus, coronavirus, varicella, influenza, MRSA, and pneumococcus. Discussing West Nile, Dr. Stucky said that diagnosing children with the condition can be tricky, particularly because the “predictive value [of diagnostic tests] isn’t 100%,” making the history and exam crucial. Of particular note for pediatric hospitalists, she said, is that the virus can be transmitted in blood, in utero, and via breast milk.

When speaking about coronavirus, Dr. Stucky said, “Transspecies jump (from civets, raccoons, ferrets, mice) is a great concern.” For diagnostic purposes, “Consider travel and exposure to animals.”

On varicella, Dr. Stucky said, “Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.”

On influenza, the discussion focused upon the reality of the avian strain causing human disease and increasing resistance as farmers use prophylactic doses of antibiotics for their poultry. There is worldwide effect of both human and avian strains. “The hospitalist as leader: public speaking in anxious times and real crises” is critical, said Dr Stucky.

Venous thrombosis: Kids with venous thrombosis typically have at least one known risk factor, with diabetics at increased risk. Thrombolytics can help save a limb or an organ, but “long-term prophylaxis is controversial,” said Dr. Stucky.

Fungal infections: Truly eradicating a fungal infection is difficult, said Dr. Stucky, with recurrence common. There’s currently no empirical evidence to support combination therapy. More research is needed.

KD: “Treat early and often,” said Dr. Stucky. Treatment goals are to stop inflammation, inhibit thrombosis, and avoid stenosis. Because stenotic lesions progress, “long-term therapy and follow-up are needed.” Children with KD should avoid ibuprofen. They should receive the influenza vaccine, but defer measles and varicella vaccines for 11 months after intravenous immunoglobulin.

COMING SOON

The pediatric hospitalists who met in Denver left the conference energized, armed with new leadership skills and clinical knowledge, and asking for more. Organizers are now starting to plan for Pediatric Hospital Medicine 2007. The Hospitalist will keep you posted with information on the next conference as soon as it’s available, and we’ll publish half a dozen additional articles related to pediatric hospital medicine in the coming months.

Keri Losavio is a medical journalist with more than 10 years’ experience writing about healthcare issues.

PEDIATRIC SPECIAL SECTION

In The Literature

Systemic Steroid Use in Pediatric Sepsis Patients

Review by Julia Simmons, MD

Markovitz BP, Goodman DM, Watson RS, et al. A retrospective cohort study of prognostic factors associated with outcome in pediatric severe sepsis: what is the role of steroids? Pediatr Crit Care Med. 2005:6:270-274.

The use of systemic steroids in septic adults with relative adrenal insufficiency has recently been shown to decrease mortality. The use of systemic steroids in the septic pediatric population remains a topic of debate and research focus. The goal of this retrospective cohort study was to determine factors associated with mortality in pediatric patients with severe sepsis treated with systemic steroids.

The authors searched the Pediatric Health Information System for their data. This system is a database for 35 pediatric hospitals within the Child Heath Corporation of America, a children’s hospital consortium. The International Classification Disease Codes for infection were used to search the database for patients from birth through 17 with sepsis during a one-year period.

Severe sepsis was defined as one or more organ dysfunction secondary to an infectious etiology during which the patient required mechanical ventilation and vasoactive medications. The primary outcome variable was mortality. Other variables analyzed included duration of hospitalization, duration of mechanical ventilatory support and vasoactive medications. Predictor variable was the use of parenteral systemic steroids given at least one day during which the patient required artificial ventilation and vasoactive medications.

There were 6,693 participants in the study. Mean days of ventilation was 24.4 +/- 37.3, median 13. Mean number of days hospitalized was 46.8 +/- 51.3 with a median of 30. The mean number of days requiring cardiac supportive medications was 7.8 +/- 9.9 with a median of five. The use of systemic steroids (hydrocortisone, dexamethasone, or methylprednisolone) with increased age, decreased hospital volume, and a history of a hematological/oncological disease were associated with an increased mortality. Even after controlling for the variables, steroids were a strong predictor of mortality. The overall mortality rate in the study was 24%.

In summary, there was an increase in mortality associated with systemic steroid use in the severely septic pediatric patient. As noted by the authors, the study was limited because there was no stratification for disease severity. Further, the rationale for giving the steroids was not known. Overall, larger prospective studies with controlled protocols are necessary in order to make recommendations regarding the use of systemic steroids in septic pediatric patients. TH

Denver—The Pediatric Hospital Medicine 2005 conference, held July 28–31, got off to a rousing start with a networking reception that preceded the keynote lecture on Thursday evening, July 28. Dan Rauch, MD, cochair of the Ambulatory Pediatric Association (APA) Special Interest Group in Hospital Medicine, welcomed the 200+ attendees. He described the meeting as the result of tremendous cooperation among the APA, the American Academy of Pediatrics (AAP), and the SHM.

“It’s been a tremendous pleasure to work with all three organizations,” said Dr. Rauch. “We have been truly blessed with leaders who think that growth of the field is more important than individual turf battles. I highly recommend that everybody in the room become members of all three organizations.”

Dr. Rauch later told The Hospitalist that he was surprised by how many attendees actually weren’t members of any of the three organizations.

The mostly young pediatric hospitalists in attendance came from all over the United States and Canada. According to keynote speaker Larry Wellikson, MD, CEO of SHM, the median age of the typical hospitalist is 37, and fewer than 10% are 50 or older. Dr. Rauch said the typical pediatric hospitalist is even younger.

In fact, the pediatric hospitalist profession is still in its infancy, a point underscored by the panel discussion during Friday’s plenary session, “Future Directions.” The conversation centered on whether pediatric hospitalist medicine is truly a new subspecialty or simply a job type within general pediatrics. Most attendees seemed to agree that in practice it is a new subspecialty, but gaining acknowledgement of that fact from the professional organizations, academics, hospital administrators, insurers, general practice pediatricians, and even from some pediatric hospitalists themselves is the continuing challenge.

Professional advancement was a theme every speaker emphasized, beginning with Dr. Wellikson.

You are building and defining the hospital of the future.

—Larry Wellikson, MD, CEO of SHM, explaining that the legacy of this generation of hospitalists will be to define hospital medicine.

CREATING THE HOSPITAL OF THE FUTURE

“My life’s goals were to be dean of a med school when I was 40 and a United States senator at 50,” said Dr. Wellikson during his keynote address. He may not have achieved those particular goals, but, he revealed, “believe it or not, my life has been even better than that.”

Dr. Wellikson, who discussed the current status of hospital medicine, is a sought-after speaker and consultant who helps hospitals and physicians understand the current medical environment and create strategies to succeed in it.

“You are building and defining the hospital of the future,” Dr. Wellikson told participants, explaining that the legacy of this generation of hospitalists will be to define hospital medicine. “[Hospitalists] are going to be the most important part of the hospital of the future.

“Hospitals are changing,” he said, describing the hospital of the future as patient-centered with medical care driven by measurable data and practiced in teams. With emergency departments overcrowded and hospitals and ICUs running at capacity, he predicts that $20 billion per year will be spent on hospital construction over the next 10 years. He foresees primary care pediatricians giving up inpatient care.

“Hospitalist medicine is by far the fastest growing medical specialty in the country,” said Dr. Wellikson. Currently, there are approximately 11,295 hospitalists, and he predicts that there will be 30,000 by the end of the decade. Approximately 9% of hospitalists are pediatricians.

According to Dr. Wellikson, 30% of 4,895 community hospitals today have hospitalists on staff, with about eight hospitalists per hospital. The larger the hospital, the more likely it is to have hospitalists:

• 71% of hospitals with more than 500 beds have hospitalists on staff; and
• 50% of hospitals with more than 100 beds have hospitalists.

“We believe at SHM that in 15 years 25% of the CEOs will be hospitalists and 15% of CMOs will be hospitalists,” said Dr. Wellikson, “ ... and you’re not all going to be able to take time off to go get an MBA. We’re going to be in the business of educating you to be a leader, how to be a manager. ... If you will commit to creating the hospital of the future, [SHM] will commit to giving you the tools to do it.”

VALUE VERSUS COMPENSATION

During the keynote, Dr. Wellikson set the stage for a compensation discussion that continued throughout the conference, both during sessions and in networking conversations.

“One of the things that makes the compensation model so unfair for hospital medicine,” said Dr. Wellikson, “is that the way we pay for medical care in this country is so screwed up. We pay by the unit of the visit and by the unit of the procedure. And so it is much better to do something wrong and do it a lot than it is to sit down and spend an hour talking with a family. And God forbid that you’re asked to sit on a QI committee; that’s really down time. ... And God forbid that instead of earning a living and seeing patients for three days you’re wasting your time here in Denver trying to be a better doctor. Our system doesn’t reward that.”

Several attendees mentioned that their hospitals consider them loss leaders. “Don’t allow yourself to be called a loss leader,” said Linda Snelling, MD, in her Friday session on contract negotiation. “You’re a system sustainer. If you want this profession to be respected, you’ve got to be paid for it.” Dr. Snelling is chief of pediatric critical care and associate professor of pediatrics and surgery (anesthesiology) at Brown University, Providence, R.I.

“Hospitalists need to convince ourselves of the value we bring to our institutions and to our patients,” said Mark Joffe, MD, director of community pediatric medicine for the Children’s Hospital of Philadelphia.

Dr. Wellikson emphasized that hospitalists do add value to hospitals—whether it’s educating, whether it’s throughput, whether it’s 24/7, whether it’s improving the quality. He said that hospital administrators—the CMOs at your hospital—understand that. “The reason that leadership and that hospitalists are important is that hospitals see you as the solution to many hospital issues,” he said. “When anthrax was thought to be a public health problem, every hospital started a bioterrorism committee and put the hospitalist on it.

“Almost every place I go, they want more of you. You’re better for their bottom line,” he continued. “If they’re ever going to be a better hospital, they need more of you, and they need you motivated, and they need you seeing the right number of patients so that you have the time to do a better job.”

According to Dr. Wellikson, the expectations of hospitalists is that they will improve efficiency, save the hospital money, provide measurable quality improvement (creating standards and measuring compliance), collect data, do things no one else will (e.g., provide uncompensated care, serve on committees).

Dr. Snelling agreed. “The benefit of hospitalists is not in what you bill,” she said, “but in systems improvements, patient satisfaction, QI, initiatives to start or change a program, teaching, cost-savings, and value-added services you provide to the hospital. ... Start with value. Figure out what you want. Identify common ground. Bargaining is the last thing you do.”

Hospitalists create a seamless continuity from inpatient to outpatient, from the emergency department to the floor, from the ICU to the floor. They improve efficiency via throughput and early discharge. They help uncrowd the emergency department and open ICU beds. “We make other physicians’ lives better,” said Dr. Wellikson. “We do a lot of things for the generalists so that they can go and have a better life.”

There is a definite bright side to being a hospitalist right now. According to Dr. Wellikson there are many more jobs than hospitalists—a trend that he predicts will continue for at least for the next five years.

“Don’t let the fact that we have a totally screwed up healthcare system get you down,” he said. “You’re not replaceable. The service you provide, someone must provide. Your hospital has more wastage in durable goods than it spends on pediatric hospitalists. They will pay for expertise.”

Dr. Snelling advised, “Be direct and shameless about compensation. No surgeon works for free unless they want to; no hospitalist should work for free unless that’s your selected charity, and my favorite charity is not the hospital I work for.

“Continually self-promote,” she continued. “Make sure [the person determining your compensation] knows what your successes are. If you’re doing something that’s successful—you get praise, you get a grant, you get a nice letter from a parent—pass that on. Document your value. If you save your hospital a million bucks, why shouldn’t you get a hunk of that? The CEO’s job is to pay you as little as possible.”

One attendee interjected, “I feel uncomfortable with the idea that what I’m doing as a hospitalist is worth more than what my private-practice colleagues are doing. I don’t want to be offensive.”

To which Dr. Snelling replied, “We’re not talking about being elitist. ‘Mine’s bigger than yours.’ What you’re talking about is the differences between C care—the minimum standard—and A care—the hospitalist. ... Who in this room wants to go to an average doctor?”

Dr. Snelling’s bottom line: “My message is not to gouge the system; it’s about respect. In an ideal situation, everybody gains.”

SHOULD PEDIATRIC HOSPITAL MEDICINE BE A BOARD-CERTIFIED SPECIALTY?

“This is a specialty,” emphasized Dr. Snelling during the contract negotiation session.

On the other hand, during the “Future Directions” plenary panel Dr. Wellikson said, “It is almost not relevant whether there is board certification or no board certification.” He described board certification as a way to measure quality.

“Clearly we need to find a way to validate what we’re doing for our good as well as for the good of our patients,” said Doug Carlson, MD, director of the Pediatric Hospital Medicine Program at St. Louis Children’s Hospital and associate professor of pediatrics at Washington University, St. Louis.

Stephen Ludwig, MD, associate chair for medical education at the Children’s Hospital of Philadelphia presented the case for becoming a board-certified specialty. Some benefits: recognition, prestige, job security, and professional advancement.

“Is this just a job, or do you want to fit into—become a thread in—the fabric of organized medicine?” asked Dr. Ludwig. Most important, though, would be the impact on child health. “Is [board certification] good for children and their parents? Unless you can demonstrate that, it won’t happen.”

According to Dr. Ludwig, becoming a board-certified specialty requires a defined body of knowledge, scientific basis, a sufficient number of practitioners, viable academic training programs, sufficient number of trainees willing to go into those fellowship programs, a board exam, geographic diversity, creation of new knowledge (or at least the application of existing knowledge in new ways), the support of national societies and organizations, and the consent of other specialties, such as internal medicine and family practice. It also takes time—likely years.

Some questions pediatric hospitalists still need to consider: Can you fill a void? Is there sufficient novel material for creating a certifying exam? Are there enough people who would take this exam? How will physicians view maintenance of certification? Where will the naysayers come from? What will be the response from primary care general pediatricians? What will be the response from academic generalists/pediatricians? What will be the subspecialist response?

Dr. Ludwig expressed one concern succinctly: “You might ultimately decrease the number of practitioners willing to make the commitment.”

Dr. Wellikson concurred. “Those of you who are group leaders are constantly in a recruiting mode,” he said. “You need something to help you determine who is good and who is not, but adding three years may drive those who would have been great pediatric hospitalists to become great pediatric anesthesiologists.”

In the end, the group could not agree on an answer. “You have an amazing amount of excitement,” said Dr. Ludwig. “Temper your excitement with focus. You need to decide whether becoming another subspecialty is what you want.”

SOMETHING FOR EVERYONE

The conference offered a broad range of learning opportunities.

Those interested in research heard about opportunities to collaborate and learned how to share resources and develop research projects.

Educators—and aren’t all hospitalists involved in education at some level?—learned “Seven Simple Secrets to Successful Supervision” from Vinny Chiang, MD, chief of inpatient services at Children’s Hospital, Boston. He says the single most powerful question you can ask as an educator is, “What do you think?”

“The med student may say, ‘I think the kid is sick.’ The intern may say, ‘I think it’s rejection.’ The resident may say, ‘We need to distinguish between infection and rejection,’” said Dr. Chiang. By asking this question, he said, “You make that trainee an active participant.”

Evidence-based medicine and the use of pathways were also on the agenda. The discussions started with the basics, defining terms. According to Dr. Chiang, evidence-based medicine is, “the conscientious, explicit, and judicious use of current best evidence in making a clinical decision.” (See also “Evidence-Based Medicine for the Hospitalist,” p. 22.)

Pathways, developed from that best evidence, are tools that guide clinical care. “It’s the same as with calculators and PDAs,” said Stephen E. Muething, MD, associate director of clinical services at Cincinnati Children’s Hospital. “A pathway is a tool that allows a resident to spend their time identifying the 20% who shouldn’t be on the pathway and figuring out what to do for them.”

“Medicine can be systematized,” said Dr. Wellikson. “You can have best practices.”

Attendees expressed concerns that pathways may not leave room for a hospitalist’s judgment.

“There is no pathway that addresses 100% of patients,” said Dr. Muething. “A pathway should be defined as a guideline not a standard of care. From a medicallegal standpoint, you need to document why you deviated from a pathway. You still need to use clinical judgment. Don’t forget to think.”

One reason to use pathways, according to Dr. Muething, is that you can more rapidly identify what works and what doesn’t. “If everyone is doing it the same way,” he said, “then even if everyone is doing it wrong, you’ll be able to identify the problem and resolve it more quickly, improving outcome.”

Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.

—Erin Stiucky, MD

HOT TOPICS

Clinical topics were also on the agenda. On the final day of the conference, Erin R. Stucky, MD, director of graduate medical education, an associate clinical professor in the University of California at San Diego Department of Pediatrics, and a pediatric hospitalist at the Children’s

Hospital and Health Center San Diego, tackled “The Top Five in ’05,” discussing:

1. Bronchiolitis;
2. Emerging pathogens;
3. Venous thrombosis;
4. Fungal infections; and
5. Kawasaki disease (KD).

In a whirlwind review, she presented the latest research on each of these topics.

Bronchiolitis: Surveys reveal that there’s a lot of variability in how hospitalists currently manage bronchiolitis, beginning with whether or not viral testing is helpful. “Testing, do we care? Does more than RSV matter?” asked Dr. Stucky. Her literature review of studies on bronchiolitis reveals, “Actually knowing the viral type is probably not helpful. Think before you test. Prevention is key.”

She also mentioned the need for additional studies on the use of heliox and CPAP in treating the condition.

Emerging pathogens: Dr. Stucky rapidly reviewed West Nile virus, coronavirus, varicella, influenza, MRSA, and pneumococcus. Discussing West Nile, Dr. Stucky said that diagnosing children with the condition can be tricky, particularly because the “predictive value [of diagnostic tests] isn’t 100%,” making the history and exam crucial. Of particular note for pediatric hospitalists, she said, is that the virus can be transmitted in blood, in utero, and via breast milk.

When speaking about coronavirus, Dr. Stucky said, “Transspecies jump (from civets, raccoons, ferrets, mice) is a great concern.” For diagnostic purposes, “Consider travel and exposure to animals.”

On varicella, Dr. Stucky said, “Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.”

On influenza, the discussion focused upon the reality of the avian strain causing human disease and increasing resistance as farmers use prophylactic doses of antibiotics for their poultry. There is worldwide effect of both human and avian strains. “The hospitalist as leader: public speaking in anxious times and real crises” is critical, said Dr Stucky.

Venous thrombosis: Kids with venous thrombosis typically have at least one known risk factor, with diabetics at increased risk. Thrombolytics can help save a limb or an organ, but “long-term prophylaxis is controversial,” said Dr. Stucky.

Fungal infections: Truly eradicating a fungal infection is difficult, said Dr. Stucky, with recurrence common. There’s currently no empirical evidence to support combination therapy. More research is needed.

KD: “Treat early and often,” said Dr. Stucky. Treatment goals are to stop inflammation, inhibit thrombosis, and avoid stenosis. Because stenotic lesions progress, “long-term therapy and follow-up are needed.” Children with KD should avoid ibuprofen. They should receive the influenza vaccine, but defer measles and varicella vaccines for 11 months after intravenous immunoglobulin.

COMING SOON

The pediatric hospitalists who met in Denver left the conference energized, armed with new leadership skills and clinical knowledge, and asking for more. Organizers are now starting to plan for Pediatric Hospital Medicine 2007. The Hospitalist will keep you posted with information on the next conference as soon as it’s available, and we’ll publish half a dozen additional articles related to pediatric hospital medicine in the coming months.

Keri Losavio is a medical journalist with more than 10 years’ experience writing about healthcare issues.

PEDIATRIC SPECIAL SECTION

In The Literature

Systemic Steroid Use in Pediatric Sepsis Patients

Review by Julia Simmons, MD

Markovitz BP, Goodman DM, Watson RS, et al. A retrospective cohort study of prognostic factors associated with outcome in pediatric severe sepsis: what is the role of steroids? Pediatr Crit Care Med. 2005:6:270-274.

The use of systemic steroids in septic adults with relative adrenal insufficiency has recently been shown to decrease mortality. The use of systemic steroids in the septic pediatric population remains a topic of debate and research focus. The goal of this retrospective cohort study was to determine factors associated with mortality in pediatric patients with severe sepsis treated with systemic steroids.

The authors searched the Pediatric Health Information System for their data. This system is a database for 35 pediatric hospitals within the Child Heath Corporation of America, a children’s hospital consortium. The International Classification Disease Codes for infection were used to search the database for patients from birth through 17 with sepsis during a one-year period.

Severe sepsis was defined as one or more organ dysfunction secondary to an infectious etiology during which the patient required mechanical ventilation and vasoactive medications. The primary outcome variable was mortality. Other variables analyzed included duration of hospitalization, duration of mechanical ventilatory support and vasoactive medications. Predictor variable was the use of parenteral systemic steroids given at least one day during which the patient required artificial ventilation and vasoactive medications.

There were 6,693 participants in the study. Mean days of ventilation was 24.4 +/- 37.3, median 13. Mean number of days hospitalized was 46.8 +/- 51.3 with a median of 30. The mean number of days requiring cardiac supportive medications was 7.8 +/- 9.9 with a median of five. The use of systemic steroids (hydrocortisone, dexamethasone, or methylprednisolone) with increased age, decreased hospital volume, and a history of a hematological/oncological disease were associated with an increased mortality. Even after controlling for the variables, steroids were a strong predictor of mortality. The overall mortality rate in the study was 24%.

In summary, there was an increase in mortality associated with systemic steroid use in the severely septic pediatric patient. As noted by the authors, the study was limited because there was no stratification for disease severity. Further, the rationale for giving the steroids was not known. Overall, larger prospective studies with controlled protocols are necessary in order to make recommendations regarding the use of systemic steroids in septic pediatric patients. TH

Denver—The Pediatric Hospital Medicine 2005 conference, held July 28–31, got off to a rousing start with a networking reception that preceded the keynote lecture on Thursday evening, July 28. Dan Rauch, MD, cochair of the Ambulatory Pediatric Association (APA) Special Interest Group in Hospital Medicine, welcomed the 200+ attendees. He described the meeting as the result of tremendous cooperation among the APA, the American Academy of Pediatrics (AAP), and the SHM.

“It’s been a tremendous pleasure to work with all three organizations,” said Dr. Rauch. “We have been truly blessed with leaders who think that growth of the field is more important than individual turf battles. I highly recommend that everybody in the room become members of all three organizations.”

Dr. Rauch later told The Hospitalist that he was surprised by how many attendees actually weren’t members of any of the three organizations.

The mostly young pediatric hospitalists in attendance came from all over the United States and Canada. According to keynote speaker Larry Wellikson, MD, CEO of SHM, the median age of the typical hospitalist is 37, and fewer than 10% are 50 or older. Dr. Rauch said the typical pediatric hospitalist is even younger.

In fact, the pediatric hospitalist profession is still in its infancy, a point underscored by the panel discussion during Friday’s plenary session, “Future Directions.” The conversation centered on whether pediatric hospitalist medicine is truly a new subspecialty or simply a job type within general pediatrics. Most attendees seemed to agree that in practice it is a new subspecialty, but gaining acknowledgement of that fact from the professional organizations, academics, hospital administrators, insurers, general practice pediatricians, and even from some pediatric hospitalists themselves is the continuing challenge.

Professional advancement was a theme every speaker emphasized, beginning with Dr. Wellikson.

You are building and defining the hospital of the future.

—Larry Wellikson, MD, CEO of SHM, explaining that the legacy of this generation of hospitalists will be to define hospital medicine.

CREATING THE HOSPITAL OF THE FUTURE

“My life’s goals were to be dean of a med school when I was 40 and a United States senator at 50,” said Dr. Wellikson during his keynote address. He may not have achieved those particular goals, but, he revealed, “believe it or not, my life has been even better than that.”

Dr. Wellikson, who discussed the current status of hospital medicine, is a sought-after speaker and consultant who helps hospitals and physicians understand the current medical environment and create strategies to succeed in it.

“You are building and defining the hospital of the future,” Dr. Wellikson told participants, explaining that the legacy of this generation of hospitalists will be to define hospital medicine. “[Hospitalists] are going to be the most important part of the hospital of the future.

“Hospitals are changing,” he said, describing the hospital of the future as patient-centered with medical care driven by measurable data and practiced in teams. With emergency departments overcrowded and hospitals and ICUs running at capacity, he predicts that $20 billion per year will be spent on hospital construction over the next 10 years. He foresees primary care pediatricians giving up inpatient care.

“Hospitalist medicine is by far the fastest growing medical specialty in the country,” said Dr. Wellikson. Currently, there are approximately 11,295 hospitalists, and he predicts that there will be 30,000 by the end of the decade. Approximately 9% of hospitalists are pediatricians.

According to Dr. Wellikson, 30% of 4,895 community hospitals today have hospitalists on staff, with about eight hospitalists per hospital. The larger the hospital, the more likely it is to have hospitalists:

• 71% of hospitals with more than 500 beds have hospitalists on staff; and
• 50% of hospitals with more than 100 beds have hospitalists.

“We believe at SHM that in 15 years 25% of the CEOs will be hospitalists and 15% of CMOs will be hospitalists,” said Dr. Wellikson, “ ... and you’re not all going to be able to take time off to go get an MBA. We’re going to be in the business of educating you to be a leader, how to be a manager. ... If you will commit to creating the hospital of the future, [SHM] will commit to giving you the tools to do it.”

VALUE VERSUS COMPENSATION

During the keynote, Dr. Wellikson set the stage for a compensation discussion that continued throughout the conference, both during sessions and in networking conversations.

“One of the things that makes the compensation model so unfair for hospital medicine,” said Dr. Wellikson, “is that the way we pay for medical care in this country is so screwed up. We pay by the unit of the visit and by the unit of the procedure. And so it is much better to do something wrong and do it a lot than it is to sit down and spend an hour talking with a family. And God forbid that you’re asked to sit on a QI committee; that’s really down time. ... And God forbid that instead of earning a living and seeing patients for three days you’re wasting your time here in Denver trying to be a better doctor. Our system doesn’t reward that.”

Several attendees mentioned that their hospitals consider them loss leaders. “Don’t allow yourself to be called a loss leader,” said Linda Snelling, MD, in her Friday session on contract negotiation. “You’re a system sustainer. If you want this profession to be respected, you’ve got to be paid for it.” Dr. Snelling is chief of pediatric critical care and associate professor of pediatrics and surgery (anesthesiology) at Brown University, Providence, R.I.

“Hospitalists need to convince ourselves of the value we bring to our institutions and to our patients,” said Mark Joffe, MD, director of community pediatric medicine for the Children’s Hospital of Philadelphia.

Dr. Wellikson emphasized that hospitalists do add value to hospitals—whether it’s educating, whether it’s throughput, whether it’s 24/7, whether it’s improving the quality. He said that hospital administrators—the CMOs at your hospital—understand that. “The reason that leadership and that hospitalists are important is that hospitals see you as the solution to many hospital issues,” he said. “When anthrax was thought to be a public health problem, every hospital started a bioterrorism committee and put the hospitalist on it.

“Almost every place I go, they want more of you. You’re better for their bottom line,” he continued. “If they’re ever going to be a better hospital, they need more of you, and they need you motivated, and they need you seeing the right number of patients so that you have the time to do a better job.”

According to Dr. Wellikson, the expectations of hospitalists is that they will improve efficiency, save the hospital money, provide measurable quality improvement (creating standards and measuring compliance), collect data, do things no one else will (e.g., provide uncompensated care, serve on committees).

Dr. Snelling agreed. “The benefit of hospitalists is not in what you bill,” she said, “but in systems improvements, patient satisfaction, QI, initiatives to start or change a program, teaching, cost-savings, and value-added services you provide to the hospital. ... Start with value. Figure out what you want. Identify common ground. Bargaining is the last thing you do.”

Hospitalists create a seamless continuity from inpatient to outpatient, from the emergency department to the floor, from the ICU to the floor. They improve efficiency via throughput and early discharge. They help uncrowd the emergency department and open ICU beds. “We make other physicians’ lives better,” said Dr. Wellikson. “We do a lot of things for the generalists so that they can go and have a better life.”

There is a definite bright side to being a hospitalist right now. According to Dr. Wellikson there are many more jobs than hospitalists—a trend that he predicts will continue for at least for the next five years.

“Don’t let the fact that we have a totally screwed up healthcare system get you down,” he said. “You’re not replaceable. The service you provide, someone must provide. Your hospital has more wastage in durable goods than it spends on pediatric hospitalists. They will pay for expertise.”

Dr. Snelling advised, “Be direct and shameless about compensation. No surgeon works for free unless they want to; no hospitalist should work for free unless that’s your selected charity, and my favorite charity is not the hospital I work for.

“Continually self-promote,” she continued. “Make sure [the person determining your compensation] knows what your successes are. If you’re doing something that’s successful—you get praise, you get a grant, you get a nice letter from a parent—pass that on. Document your value. If you save your hospital a million bucks, why shouldn’t you get a hunk of that? The CEO’s job is to pay you as little as possible.”

One attendee interjected, “I feel uncomfortable with the idea that what I’m doing as a hospitalist is worth more than what my private-practice colleagues are doing. I don’t want to be offensive.”

To which Dr. Snelling replied, “We’re not talking about being elitist. ‘Mine’s bigger than yours.’ What you’re talking about is the differences between C care—the minimum standard—and A care—the hospitalist. ... Who in this room wants to go to an average doctor?”

Dr. Snelling’s bottom line: “My message is not to gouge the system; it’s about respect. In an ideal situation, everybody gains.”

SHOULD PEDIATRIC HOSPITAL MEDICINE BE A BOARD-CERTIFIED SPECIALTY?

“This is a specialty,” emphasized Dr. Snelling during the contract negotiation session.

On the other hand, during the “Future Directions” plenary panel Dr. Wellikson said, “It is almost not relevant whether there is board certification or no board certification.” He described board certification as a way to measure quality.

“Clearly we need to find a way to validate what we’re doing for our good as well as for the good of our patients,” said Doug Carlson, MD, director of the Pediatric Hospital Medicine Program at St. Louis Children’s Hospital and associate professor of pediatrics at Washington University, St. Louis.

Stephen Ludwig, MD, associate chair for medical education at the Children’s Hospital of Philadelphia presented the case for becoming a board-certified specialty. Some benefits: recognition, prestige, job security, and professional advancement.

“Is this just a job, or do you want to fit into—become a thread in—the fabric of organized medicine?” asked Dr. Ludwig. Most important, though, would be the impact on child health. “Is [board certification] good for children and their parents? Unless you can demonstrate that, it won’t happen.”

According to Dr. Ludwig, becoming a board-certified specialty requires a defined body of knowledge, scientific basis, a sufficient number of practitioners, viable academic training programs, sufficient number of trainees willing to go into those fellowship programs, a board exam, geographic diversity, creation of new knowledge (or at least the application of existing knowledge in new ways), the support of national societies and organizations, and the consent of other specialties, such as internal medicine and family practice. It also takes time—likely years.

Some questions pediatric hospitalists still need to consider: Can you fill a void? Is there sufficient novel material for creating a certifying exam? Are there enough people who would take this exam? How will physicians view maintenance of certification? Where will the naysayers come from? What will be the response from primary care general pediatricians? What will be the response from academic generalists/pediatricians? What will be the subspecialist response?

Dr. Ludwig expressed one concern succinctly: “You might ultimately decrease the number of practitioners willing to make the commitment.”

Dr. Wellikson concurred. “Those of you who are group leaders are constantly in a recruiting mode,” he said. “You need something to help you determine who is good and who is not, but adding three years may drive those who would have been great pediatric hospitalists to become great pediatric anesthesiologists.”

In the end, the group could not agree on an answer. “You have an amazing amount of excitement,” said Dr. Ludwig. “Temper your excitement with focus. You need to decide whether becoming another subspecialty is what you want.”

SOMETHING FOR EVERYONE

The conference offered a broad range of learning opportunities.

Those interested in research heard about opportunities to collaborate and learned how to share resources and develop research projects.

Educators—and aren’t all hospitalists involved in education at some level?—learned “Seven Simple Secrets to Successful Supervision” from Vinny Chiang, MD, chief of inpatient services at Children’s Hospital, Boston. He says the single most powerful question you can ask as an educator is, “What do you think?”

“The med student may say, ‘I think the kid is sick.’ The intern may say, ‘I think it’s rejection.’ The resident may say, ‘We need to distinguish between infection and rejection,’” said Dr. Chiang. By asking this question, he said, “You make that trainee an active participant.”

Evidence-based medicine and the use of pathways were also on the agenda. The discussions started with the basics, defining terms. According to Dr. Chiang, evidence-based medicine is, “the conscientious, explicit, and judicious use of current best evidence in making a clinical decision.” (See also “Evidence-Based Medicine for the Hospitalist,” p. 22.)

Pathways, developed from that best evidence, are tools that guide clinical care. “It’s the same as with calculators and PDAs,” said Stephen E. Muething, MD, associate director of clinical services at Cincinnati Children’s Hospital. “A pathway is a tool that allows a resident to spend their time identifying the 20% who shouldn’t be on the pathway and figuring out what to do for them.”

“Medicine can be systematized,” said Dr. Wellikson. “You can have best practices.”

Attendees expressed concerns that pathways may not leave room for a hospitalist’s judgment.

“There is no pathway that addresses 100% of patients,” said Dr. Muething. “A pathway should be defined as a guideline not a standard of care. From a medicallegal standpoint, you need to document why you deviated from a pathway. You still need to use clinical judgment. Don’t forget to think.”

One reason to use pathways, according to Dr. Muething, is that you can more rapidly identify what works and what doesn’t. “If everyone is doing it the same way,” he said, “then even if everyone is doing it wrong, you’ll be able to identify the problem and resolve it more quickly, improving outcome.”

Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.

—Erin Stiucky, MD

HOT TOPICS

Clinical topics were also on the agenda. On the final day of the conference, Erin R. Stucky, MD, director of graduate medical education, an associate clinical professor in the University of California at San Diego Department of Pediatrics, and a pediatric hospitalist at the Children’s

Hospital and Health Center San Diego, tackled “The Top Five in ’05,” discussing:

1. Bronchiolitis;
2. Emerging pathogens;
3. Venous thrombosis;
4. Fungal infections; and
5. Kawasaki disease (KD).

In a whirlwind review, she presented the latest research on each of these topics.

Bronchiolitis: Surveys reveal that there’s a lot of variability in how hospitalists currently manage bronchiolitis, beginning with whether or not viral testing is helpful. “Testing, do we care? Does more than RSV matter?” asked Dr. Stucky. Her literature review of studies on bronchiolitis reveals, “Actually knowing the viral type is probably not helpful. Think before you test. Prevention is key.”

She also mentioned the need for additional studies on the use of heliox and CPAP in treating the condition.

Emerging pathogens: Dr. Stucky rapidly reviewed West Nile virus, coronavirus, varicella, influenza, MRSA, and pneumococcus. Discussing West Nile, Dr. Stucky said that diagnosing children with the condition can be tricky, particularly because the “predictive value [of diagnostic tests] isn’t 100%,” making the history and exam crucial. Of particular note for pediatric hospitalists, she said, is that the virus can be transmitted in blood, in utero, and via breast milk.

When speaking about coronavirus, Dr. Stucky said, “Transspecies jump (from civets, raccoons, ferrets, mice) is a great concern.” For diagnostic purposes, “Consider travel and exposure to animals.”

On varicella, Dr. Stucky said, “Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.”

On influenza, the discussion focused upon the reality of the avian strain causing human disease and increasing resistance as farmers use prophylactic doses of antibiotics for their poultry. There is worldwide effect of both human and avian strains. “The hospitalist as leader: public speaking in anxious times and real crises” is critical, said Dr Stucky.

Venous thrombosis: Kids with venous thrombosis typically have at least one known risk factor, with diabetics at increased risk. Thrombolytics can help save a limb or an organ, but “long-term prophylaxis is controversial,” said Dr. Stucky.

Fungal infections: Truly eradicating a fungal infection is difficult, said Dr. Stucky, with recurrence common. There’s currently no empirical evidence to support combination therapy. More research is needed.

KD: “Treat early and often,” said Dr. Stucky. Treatment goals are to stop inflammation, inhibit thrombosis, and avoid stenosis. Because stenotic lesions progress, “long-term therapy and follow-up are needed.” Children with KD should avoid ibuprofen. They should receive the influenza vaccine, but defer measles and varicella vaccines for 11 months after intravenous immunoglobulin.

COMING SOON

The pediatric hospitalists who met in Denver left the conference energized, armed with new leadership skills and clinical knowledge, and asking for more. Organizers are now starting to plan for Pediatric Hospital Medicine 2007. The Hospitalist will keep you posted with information on the next conference as soon as it’s available, and we’ll publish half a dozen additional articles related to pediatric hospital medicine in the coming months.

Keri Losavio is a medical journalist with more than 10 years’ experience writing about healthcare issues.

PEDIATRIC SPECIAL SECTION

In The Literature

Systemic Steroid Use in Pediatric Sepsis Patients

Review by Julia Simmons, MD

Markovitz BP, Goodman DM, Watson RS, et al. A retrospective cohort study of prognostic factors associated with outcome in pediatric severe sepsis: what is the role of steroids? Pediatr Crit Care Med. 2005:6:270-274.

The use of systemic steroids in septic adults with relative adrenal insufficiency has recently been shown to decrease mortality. The use of systemic steroids in the septic pediatric population remains a topic of debate and research focus. The goal of this retrospective cohort study was to determine factors associated with mortality in pediatric patients with severe sepsis treated with systemic steroids.

The authors searched the Pediatric Health Information System for their data. This system is a database for 35 pediatric hospitals within the Child Heath Corporation of America, a children’s hospital consortium. The International Classification Disease Codes for infection were used to search the database for patients from birth through 17 with sepsis during a one-year period.

Severe sepsis was defined as one or more organ dysfunction secondary to an infectious etiology during which the patient required mechanical ventilation and vasoactive medications. The primary outcome variable was mortality. Other variables analyzed included duration of hospitalization, duration of mechanical ventilatory support and vasoactive medications. Predictor variable was the use of parenteral systemic steroids given at least one day during which the patient required artificial ventilation and vasoactive medications.

There were 6,693 participants in the study. Mean days of ventilation was 24.4 +/- 37.3, median 13. Mean number of days hospitalized was 46.8 +/- 51.3 with a median of 30. The mean number of days requiring cardiac supportive medications was 7.8 +/- 9.9 with a median of five. The use of systemic steroids (hydrocortisone, dexamethasone, or methylprednisolone) with increased age, decreased hospital volume, and a history of a hematological/oncological disease were associated with an increased mortality. Even after controlling for the variables, steroids were a strong predictor of mortality. The overall mortality rate in the study was 24%.

In summary, there was an increase in mortality associated with systemic steroid use in the severely septic pediatric patient. As noted by the authors, the study was limited because there was no stratification for disease severity. Further, the rationale for giving the steroids was not known. Overall, larger prospective studies with controlled protocols are necessary in order to make recommendations regarding the use of systemic steroids in septic pediatric patients. TH

Although most hospitalists have internal medicine as their medical specialty, a new breed of practitioners is gaining popularity. Hospitalists from obstetrics, pediatrics, psychiatry, dermatology, orthopedic surgery, and other fields bring the knowledge and experience of their specialties to hospital-based positions. In doing so, they gain many benefits they didn’t have as private practitioners. It’s a win-win situation that has the trend toward hospital-based specialists growing and receiving praise from physicians, administrators, and patients alike.

According to SHM CEO Larry Wellikson, MD, the demand for specialist hospitalists “is driven by hospitals’ needs to have these specialists available to them on a regular basis.”

HOSPITAL-BASED CARE DELIVERS FOR OBSTETRICIANS

Addressing a problem in their communities is one reason specialists join hospital teams. “The introduction of a new hospital in our small community, which previously only had one, created a challenge for small OB/GYN groups who didn’t have enough personnel to cover calls at two facilities,” says obstetric hospitalist Duncan Neilson, MD, chief of women’s services for Legacy Health System in Portland, Ore.

The ultimate question, Dr. Neilson says, was how to provide adequate OB/GYN and high-risk services and back up the community without having to hire “a lot” of physicians. “We solved both problems with hospitalists,” he explains.

Keith Marton, MD, FACP, chief medical officer/senior vice president at Legacy, adds that a key driver for the move to obstetric hospitalists was the desire to mitigate the facility’s liability risk.

“We saw hospitalists as providing continuity, more predictable physician presence to work with nurses to improve delivery outcomes,” he explains. Another important driver, Dr. Marton emphasizes, was his facility’s neonatal intensive care unit and the need for the perinatal specialists there to work with obstetricians they know and trust.

“We have seen from other communities that you don’t go out and ask community obstetricians to fill this role,” he says, adding that hospitalists are a better option. “This would improve care, increase our volume and revenues, and decrease costs.”

Being a hospital-based obstetrician has both business and lifestyle advantages. “In a typical OB/GYN practice, physicians often have to be in two places at once,” says Dr. Neilson. “When you’re with a laboring patient, you can’t be with patients in your office. You feel torn.”

There is no such split in hospital-based practice. “You’re free to concentrate on the care of laboring patients,” he says.

This is appealing for practitioners who especially like handling labor and deliveries because that’s the focus of their work. At the same time overhead and malpractice insurance are managed by the hospital, enabling specialty hospitalists to provide the best possible care with the least amount of hassle.

As for lifestyle, “you come to the hospital in the morning, you work your shift, you go home, and you are done,” explains Dr. Neilson.

Patients also benefit from having obstetric hospitalists involved in their care. “Patient safety is improved. A physician is onsite 24 hours a day to address problems,” says Dr. Neilson, who notes that this situation enables patients to stay with their own practitioner while having access to the hospital-based labor expert.

Are there disadvantages to being or hiring a hospital-based obstetrician? “It’s kind of hard to think of any,” admits Dr. Neilson. He suggests that physicians who like the variety of handling obstetrics and gynecology “might not like being a hospital-based specialist.”

PSYCHIATRIC HOSPITALISTS ANALYZE NEW OPPORTUNITIES

Obstetricians aren’t the only specialists enjoying lives as hospitalists. A growing number of psychiatrists are finding new and exciting opportunities as hospital-based practitioners. (See “The Doctor Is In,” p. 30.) For example, Thomas O’Brien, MD, a psychiatric hospitalist at Swedish Medical Center in Seattle, was drawn to hospital-based practice by his love of this setting and for treating acutely ill patients.

“I can intervene earlier,” he says. “And, as a result, patients don’t spin out of control.”

Dr. O’Brien likes the challenge of the complex cases he encounters. But he also likes the flexibility he enjoys. “It’s a good arrangement for me,” he says. “On the nights you’re off, you’re really off.”

As with other specialties, hospitals enjoy the arrangement as well. “Hospitals are much happier having physician employees that they can train and support more fully because they know them better,” observes Dr. O’Brien. “They also like the consistency of a physician who knows the staff and can respond quickly to problems, as well as patient and family questions. The doctor is part of the family, rather than an outsider,” which benefits both the facility and the practitioner.

KIDS TAKE CENTER STAGE

Mary Ottolini, MD, MPH, medical director, Hospitalist Services, at Children’s National Medical Center in Washington, D.C., was a pediatric hospitalist even before the job had a name.

“I was providing inpatient pediatric care, and I really loved it,” she says. “About that time, the hospitalist movement started, and I finally could attach a name to what I was doing.”

Everyone loves the arrangement, says Dr. Ottolini. Attending and referring physicians have the security of knowing that their patients are being cared for by specialists 24 hours a day.

“This removes a lot of stress and burden from them,” she notes. At the same time, parents “feel that there is someone taking ultimate responsibility for their child and looking after the whole child.”

Even when the prognosis is poor, “it is good to be there for families and help them through a difficult time,” continues Dr. Ottolini, who adds that it “is gratifying to work with an excellent team of experts to help a gravely ill child.”

HOSPITAL NEED FOR DERMATOLOGY: MORE THAN SKIN DEEP?

The need for a dermatologic hospitalist seems questionable. “Traditionally, dermatologists came to the hospital so infrequently,” recalls Dr. Wellikson. “There were few dermatologic emergencies.”

Even Rokea el-Azhary, MD, a dermatologic hospitalist at the Mayo Clinic in Rochester, Minn., admits, “There are so many medications to treat dermatologic conditions on an outpatient basis. This has influenced a downward trend in hospital dermatology over the years.”

Nonetheless, Dr. el-Azhary and her colleagues keep busy addressing severe medication-related and other rashes. They’re able to provide fast relief, which is important for patients with painful, uncomfortable conditions.

“If someone comes into the hospital with fever and a rash, aches, pain, neuralgia, and skin that shows vasculitis, we can make a diagnosis quickly and promptly begin treatment,” she explains.

PASSING FAD OR GROWING TREND?

Ask hospital-based specialists or their administrators if they think this trend is here to stay, and they are emphatic that it is.

“I think the hospitalist movement in general is reminiscent of the era when hospitals began hiring emergency room physicians,” suggests Dr. Marton. “These hadn’t existed previously; then overnight they were a common part of the hospital staff.”

Dr. Wellikson agrees. “Traditionally, hospitals have not been in the business of hiring physicians,” he says. “But now they are in the position of assembling a team with physicians as part of that.”

With the growth of hospital medicine overall, the variety of hospitalists will increase as well. The specialties will continue to transition into hospitalist programs and grow. They’re also expected to include such areas as orthopedic surgery. Specifically, Dr. Marton suggests that the next hot specialty for hospitalists can be predicted by identifying fields where there are high volumes of potential shortages. Still, he notes, some specialties, such as plastic surgery and neurosurgery, are unlikely to become hospital-based.

Many experts are not surprised by the rise of hospital-based specialists. Dr. Neilson points out that, in 2003, Louis Weinstein, MD, chair of the department of obstetrics and gynecology, Jefferson Medical College, Philadelphia, said that only about 10 hospitals had obstetric hospitalists, but that he expected this number to increase to several hundred in a few years.

“Weinstein proposed the idea of ‘laborists’ as a solution to the problems many hospitals had getting community obstetricians to handle patients besides their own,” recalls Dr. Neilson (see also, “What is a Laborist?” p. 6). “In fact, he felt it would evolve to a point where these laborists would handle the majority of hospital deliveries.”

RESEARCH SAYS …

Practitioners and administrators state anecdotally that hospital-based specialists make a positive difference in patient care, and research is just beginning to support these claims. For example, one study showed that pediatric hospitalists improve critical care outcomes. The authors concluded that patients treated by pediatric hospitalists were discharged nearly a full day sooner and were almost three times more likely to survive that stay after the pediatric intensive care unit switched after-hours coverage from residents to hospitalists.1

Clearly, more studies are needed regarding the effect of specialist hospitalists on outcomes, patient satisfaction, costs, and other aspects of hospital care. However, such research is likely to become more common as hospital-based specialists continue to gain popularity.

According to physicians who are hospital-based specialists, these studies will show that their services not only improve outcomes, but have a positive effect on practitioner lifestyle, hospital quality improvement efforts, and patient satisfaction.

“I think a few years ago this was a trend,” says Dr. Ottolini. “Now it’s not at all unusual to see specialists working as hospitalists.” TH

Writer Joanne Kaldy, who is based in Maryland, has covered healthcare issues for more than 10 years.

REFERENCE

1. Ottolini M, Pollack M. Pediatric hospitalists improve critical care outcomes. Crit Care Med. 2003;31(3):986-987.

Although most hospitalists have internal medicine as their medical specialty, a new breed of practitioners is gaining popularity. Hospitalists from obstetrics, pediatrics, psychiatry, dermatology, orthopedic surgery, and other fields bring the knowledge and experience of their specialties to hospital-based positions. In doing so, they gain many benefits they didn’t have as private practitioners. It’s a win-win situation that has the trend toward hospital-based specialists growing and receiving praise from physicians, administrators, and patients alike.

According to SHM CEO Larry Wellikson, MD, the demand for specialist hospitalists “is driven by hospitals’ needs to have these specialists available to them on a regular basis.”

HOSPITAL-BASED CARE DELIVERS FOR OBSTETRICIANS

Addressing a problem in their communities is one reason specialists join hospital teams. “The introduction of a new hospital in our small community, which previously only had one, created a challenge for small OB/GYN groups who didn’t have enough personnel to cover calls at two facilities,” says obstetric hospitalist Duncan Neilson, MD, chief of women’s services for Legacy Health System in Portland, Ore.

The ultimate question, Dr. Neilson says, was how to provide adequate OB/GYN and high-risk services and back up the community without having to hire “a lot” of physicians. “We solved both problems with hospitalists,” he explains.

Keith Marton, MD, FACP, chief medical officer/senior vice president at Legacy, adds that a key driver for the move to obstetric hospitalists was the desire to mitigate the facility’s liability risk.

“We saw hospitalists as providing continuity, more predictable physician presence to work with nurses to improve delivery outcomes,” he explains. Another important driver, Dr. Marton emphasizes, was his facility’s neonatal intensive care unit and the need for the perinatal specialists there to work with obstetricians they know and trust.

“We have seen from other communities that you don’t go out and ask community obstetricians to fill this role,” he says, adding that hospitalists are a better option. “This would improve care, increase our volume and revenues, and decrease costs.”

Being a hospital-based obstetrician has both business and lifestyle advantages. “In a typical OB/GYN practice, physicians often have to be in two places at once,” says Dr. Neilson. “When you’re with a laboring patient, you can’t be with patients in your office. You feel torn.”

There is no such split in hospital-based practice. “You’re free to concentrate on the care of laboring patients,” he says.

This is appealing for practitioners who especially like handling labor and deliveries because that’s the focus of their work. At the same time overhead and malpractice insurance are managed by the hospital, enabling specialty hospitalists to provide the best possible care with the least amount of hassle.

As for lifestyle, “you come to the hospital in the morning, you work your shift, you go home, and you are done,” explains Dr. Neilson.

Patients also benefit from having obstetric hospitalists involved in their care. “Patient safety is improved. A physician is onsite 24 hours a day to address problems,” says Dr. Neilson, who notes that this situation enables patients to stay with their own practitioner while having access to the hospital-based labor expert.

Are there disadvantages to being or hiring a hospital-based obstetrician? “It’s kind of hard to think of any,” admits Dr. Neilson. He suggests that physicians who like the variety of handling obstetrics and gynecology “might not like being a hospital-based specialist.”

PSYCHIATRIC HOSPITALISTS ANALYZE NEW OPPORTUNITIES

Obstetricians aren’t the only specialists enjoying lives as hospitalists. A growing number of psychiatrists are finding new and exciting opportunities as hospital-based practitioners. (See “The Doctor Is In,” p. 30.) For example, Thomas O’Brien, MD, a psychiatric hospitalist at Swedish Medical Center in Seattle, was drawn to hospital-based practice by his love of this setting and for treating acutely ill patients.

“I can intervene earlier,” he says. “And, as a result, patients don’t spin out of control.”

Dr. O’Brien likes the challenge of the complex cases he encounters. But he also likes the flexibility he enjoys. “It’s a good arrangement for me,” he says. “On the nights you’re off, you’re really off.”

As with other specialties, hospitals enjoy the arrangement as well. “Hospitals are much happier having physician employees that they can train and support more fully because they know them better,” observes Dr. O’Brien. “They also like the consistency of a physician who knows the staff and can respond quickly to problems, as well as patient and family questions. The doctor is part of the family, rather than an outsider,” which benefits both the facility and the practitioner.

KIDS TAKE CENTER STAGE

Mary Ottolini, MD, MPH, medical director, Hospitalist Services, at Children’s National Medical Center in Washington, D.C., was a pediatric hospitalist even before the job had a name.

“I was providing inpatient pediatric care, and I really loved it,” she says. “About that time, the hospitalist movement started, and I finally could attach a name to what I was doing.”

Everyone loves the arrangement, says Dr. Ottolini. Attending and referring physicians have the security of knowing that their patients are being cared for by specialists 24 hours a day.

“This removes a lot of stress and burden from them,” she notes. At the same time, parents “feel that there is someone taking ultimate responsibility for their child and looking after the whole child.”

Even when the prognosis is poor, “it is good to be there for families and help them through a difficult time,” continues Dr. Ottolini, who adds that it “is gratifying to work with an excellent team of experts to help a gravely ill child.”

HOSPITAL NEED FOR DERMATOLOGY: MORE THAN SKIN DEEP?

The need for a dermatologic hospitalist seems questionable. “Traditionally, dermatologists came to the hospital so infrequently,” recalls Dr. Wellikson. “There were few dermatologic emergencies.”

Even Rokea el-Azhary, MD, a dermatologic hospitalist at the Mayo Clinic in Rochester, Minn., admits, “There are so many medications to treat dermatologic conditions on an outpatient basis. This has influenced a downward trend in hospital dermatology over the years.”

Nonetheless, Dr. el-Azhary and her colleagues keep busy addressing severe medication-related and other rashes. They’re able to provide fast relief, which is important for patients with painful, uncomfortable conditions.

“If someone comes into the hospital with fever and a rash, aches, pain, neuralgia, and skin that shows vasculitis, we can make a diagnosis quickly and promptly begin treatment,” she explains.

PASSING FAD OR GROWING TREND?

Ask hospital-based specialists or their administrators if they think this trend is here to stay, and they are emphatic that it is.

“I think the hospitalist movement in general is reminiscent of the era when hospitals began hiring emergency room physicians,” suggests Dr. Marton. “These hadn’t existed previously; then overnight they were a common part of the hospital staff.”

Dr. Wellikson agrees. “Traditionally, hospitals have not been in the business of hiring physicians,” he says. “But now they are in the position of assembling a team with physicians as part of that.”

With the growth of hospital medicine overall, the variety of hospitalists will increase as well. The specialties will continue to transition into hospitalist programs and grow. They’re also expected to include such areas as orthopedic surgery. Specifically, Dr. Marton suggests that the next hot specialty for hospitalists can be predicted by identifying fields where there are high volumes of potential shortages. Still, he notes, some specialties, such as plastic surgery and neurosurgery, are unlikely to become hospital-based.

Many experts are not surprised by the rise of hospital-based specialists. Dr. Neilson points out that, in 2003, Louis Weinstein, MD, chair of the department of obstetrics and gynecology, Jefferson Medical College, Philadelphia, said that only about 10 hospitals had obstetric hospitalists, but that he expected this number to increase to several hundred in a few years.

“Weinstein proposed the idea of ‘laborists’ as a solution to the problems many hospitals had getting community obstetricians to handle patients besides their own,” recalls Dr. Neilson (see also, “What is a Laborist?” p. 6). “In fact, he felt it would evolve to a point where these laborists would handle the majority of hospital deliveries.”

RESEARCH SAYS …

Practitioners and administrators state anecdotally that hospital-based specialists make a positive difference in patient care, and research is just beginning to support these claims. For example, one study showed that pediatric hospitalists improve critical care outcomes. The authors concluded that patients treated by pediatric hospitalists were discharged nearly a full day sooner and were almost three times more likely to survive that stay after the pediatric intensive care unit switched after-hours coverage from residents to hospitalists.1

Clearly, more studies are needed regarding the effect of specialist hospitalists on outcomes, patient satisfaction, costs, and other aspects of hospital care. However, such research is likely to become more common as hospital-based specialists continue to gain popularity.

According to physicians who are hospital-based specialists, these studies will show that their services not only improve outcomes, but have a positive effect on practitioner lifestyle, hospital quality improvement efforts, and patient satisfaction.

“I think a few years ago this was a trend,” says Dr. Ottolini. “Now it’s not at all unusual to see specialists working as hospitalists.” TH

Writer Joanne Kaldy, who is based in Maryland, has covered healthcare issues for more than 10 years.

REFERENCE

1. Ottolini M, Pollack M. Pediatric hospitalists improve critical care outcomes. Crit Care Med. 2003;31(3):986-987.

Although most hospitalists have internal medicine as their medical specialty, a new breed of practitioners is gaining popularity. Hospitalists from obstetrics, pediatrics, psychiatry, dermatology, orthopedic surgery, and other fields bring the knowledge and experience of their specialties to hospital-based positions. In doing so, they gain many benefits they didn’t have as private practitioners. It’s a win-win situation that has the trend toward hospital-based specialists growing and receiving praise from physicians, administrators, and patients alike.

According to SHM CEO Larry Wellikson, MD, the demand for specialist hospitalists “is driven by hospitals’ needs to have these specialists available to them on a regular basis.”

HOSPITAL-BASED CARE DELIVERS FOR OBSTETRICIANS

Addressing a problem in their communities is one reason specialists join hospital teams. “The introduction of a new hospital in our small community, which previously only had one, created a challenge for small OB/GYN groups who didn’t have enough personnel to cover calls at two facilities,” says obstetric hospitalist Duncan Neilson, MD, chief of women’s services for Legacy Health System in Portland, Ore.

The ultimate question, Dr. Neilson says, was how to provide adequate OB/GYN and high-risk services and back up the community without having to hire “a lot” of physicians. “We solved both problems with hospitalists,” he explains.

Keith Marton, MD, FACP, chief medical officer/senior vice president at Legacy, adds that a key driver for the move to obstetric hospitalists was the desire to mitigate the facility’s liability risk.

“We saw hospitalists as providing continuity, more predictable physician presence to work with nurses to improve delivery outcomes,” he explains. Another important driver, Dr. Marton emphasizes, was his facility’s neonatal intensive care unit and the need for the perinatal specialists there to work with obstetricians they know and trust.

“We have seen from other communities that you don’t go out and ask community obstetricians to fill this role,” he says, adding that hospitalists are a better option. “This would improve care, increase our volume and revenues, and decrease costs.”

Being a hospital-based obstetrician has both business and lifestyle advantages. “In a typical OB/GYN practice, physicians often have to be in two places at once,” says Dr. Neilson. “When you’re with a laboring patient, you can’t be with patients in your office. You feel torn.”

There is no such split in hospital-based practice. “You’re free to concentrate on the care of laboring patients,” he says.

This is appealing for practitioners who especially like handling labor and deliveries because that’s the focus of their work. At the same time overhead and malpractice insurance are managed by the hospital, enabling specialty hospitalists to provide the best possible care with the least amount of hassle.

As for lifestyle, “you come to the hospital in the morning, you work your shift, you go home, and you are done,” explains Dr. Neilson.

Patients also benefit from having obstetric hospitalists involved in their care. “Patient safety is improved. A physician is onsite 24 hours a day to address problems,” says Dr. Neilson, who notes that this situation enables patients to stay with their own practitioner while having access to the hospital-based labor expert.

Are there disadvantages to being or hiring a hospital-based obstetrician? “It’s kind of hard to think of any,” admits Dr. Neilson. He suggests that physicians who like the variety of handling obstetrics and gynecology “might not like being a hospital-based specialist.”

PSYCHIATRIC HOSPITALISTS ANALYZE NEW OPPORTUNITIES

Obstetricians aren’t the only specialists enjoying lives as hospitalists. A growing number of psychiatrists are finding new and exciting opportunities as hospital-based practitioners. (See “The Doctor Is In,” p. 30.) For example, Thomas O’Brien, MD, a psychiatric hospitalist at Swedish Medical Center in Seattle, was drawn to hospital-based practice by his love of this setting and for treating acutely ill patients.

“I can intervene earlier,” he says. “And, as a result, patients don’t spin out of control.”

Dr. O’Brien likes the challenge of the complex cases he encounters. But he also likes the flexibility he enjoys. “It’s a good arrangement for me,” he says. “On the nights you’re off, you’re really off.”

As with other specialties, hospitals enjoy the arrangement as well. “Hospitals are much happier having physician employees that they can train and support more fully because they know them better,” observes Dr. O’Brien. “They also like the consistency of a physician who knows the staff and can respond quickly to problems, as well as patient and family questions. The doctor is part of the family, rather than an outsider,” which benefits both the facility and the practitioner.

KIDS TAKE CENTER STAGE

Mary Ottolini, MD, MPH, medical director, Hospitalist Services, at Children’s National Medical Center in Washington, D.C., was a pediatric hospitalist even before the job had a name.

“I was providing inpatient pediatric care, and I really loved it,” she says. “About that time, the hospitalist movement started, and I finally could attach a name to what I was doing.”

Everyone loves the arrangement, says Dr. Ottolini. Attending and referring physicians have the security of knowing that their patients are being cared for by specialists 24 hours a day.

“This removes a lot of stress and burden from them,” she notes. At the same time, parents “feel that there is someone taking ultimate responsibility for their child and looking after the whole child.”

Even when the prognosis is poor, “it is good to be there for families and help them through a difficult time,” continues Dr. Ottolini, who adds that it “is gratifying to work with an excellent team of experts to help a gravely ill child.”

HOSPITAL NEED FOR DERMATOLOGY: MORE THAN SKIN DEEP?

The need for a dermatologic hospitalist seems questionable. “Traditionally, dermatologists came to the hospital so infrequently,” recalls Dr. Wellikson. “There were few dermatologic emergencies.”

Even Rokea el-Azhary, MD, a dermatologic hospitalist at the Mayo Clinic in Rochester, Minn., admits, “There are so many medications to treat dermatologic conditions on an outpatient basis. This has influenced a downward trend in hospital dermatology over the years.”

Nonetheless, Dr. el-Azhary and her colleagues keep busy addressing severe medication-related and other rashes. They’re able to provide fast relief, which is important for patients with painful, uncomfortable conditions.

“If someone comes into the hospital with fever and a rash, aches, pain, neuralgia, and skin that shows vasculitis, we can make a diagnosis quickly and promptly begin treatment,” she explains.

PASSING FAD OR GROWING TREND?

Ask hospital-based specialists or their administrators if they think this trend is here to stay, and they are emphatic that it is.

“I think the hospitalist movement in general is reminiscent of the era when hospitals began hiring emergency room physicians,” suggests Dr. Marton. “These hadn’t existed previously; then overnight they were a common part of the hospital staff.”

Dr. Wellikson agrees. “Traditionally, hospitals have not been in the business of hiring physicians,” he says. “But now they are in the position of assembling a team with physicians as part of that.”

With the growth of hospital medicine overall, the variety of hospitalists will increase as well. The specialties will continue to transition into hospitalist programs and grow. They’re also expected to include such areas as orthopedic surgery. Specifically, Dr. Marton suggests that the next hot specialty for hospitalists can be predicted by identifying fields where there are high volumes of potential shortages. Still, he notes, some specialties, such as plastic surgery and neurosurgery, are unlikely to become hospital-based.

Many experts are not surprised by the rise of hospital-based specialists. Dr. Neilson points out that, in 2003, Louis Weinstein, MD, chair of the department of obstetrics and gynecology, Jefferson Medical College, Philadelphia, said that only about 10 hospitals had obstetric hospitalists, but that he expected this number to increase to several hundred in a few years.

“Weinstein proposed the idea of ‘laborists’ as a solution to the problems many hospitals had getting community obstetricians to handle patients besides their own,” recalls Dr. Neilson (see also, “What is a Laborist?” p. 6). “In fact, he felt it would evolve to a point where these laborists would handle the majority of hospital deliveries.”

RESEARCH SAYS …

Practitioners and administrators state anecdotally that hospital-based specialists make a positive difference in patient care, and research is just beginning to support these claims. For example, one study showed that pediatric hospitalists improve critical care outcomes. The authors concluded that patients treated by pediatric hospitalists were discharged nearly a full day sooner and were almost three times more likely to survive that stay after the pediatric intensive care unit switched after-hours coverage from residents to hospitalists.1

Clearly, more studies are needed regarding the effect of specialist hospitalists on outcomes, patient satisfaction, costs, and other aspects of hospital care. However, such research is likely to become more common as hospital-based specialists continue to gain popularity.

According to physicians who are hospital-based specialists, these studies will show that their services not only improve outcomes, but have a positive effect on practitioner lifestyle, hospital quality improvement efforts, and patient satisfaction.

“I think a few years ago this was a trend,” says Dr. Ottolini. “Now it’s not at all unusual to see specialists working as hospitalists.” TH

Writer Joanne Kaldy, who is based in Maryland, has covered healthcare issues for more than 10 years.

REFERENCE

1. Ottolini M, Pollack M. Pediatric hospitalists improve critical care outcomes. Crit Care Med. 2003;31(3):986-987.

Magnet certification draws nurses to hospitals by documenting that these facilities are good places for them to work. But does magnet also suggest a positive environment for hospitalists and other physicians?

Ask Kathy Sparger, RN, MSN, chief nursing officer at South Miami Hospital in South Miami, Fla., who says her magnet facility perpetuates teamwork and collaboration in a way that creates a positive professional atmosphere for both nurses and physicians. She’s also emphatic that it enables high-quality care.

South Miami Nurses Kathleen Gori, RN, Melissa Korman, RN, and Zully Darby, RN, show off their magnet pride.

The mother of at least one patient likely agrees. Sparger tells the story of a baby born in the hospital with compromised circulation in his leg.

“When he was born, his leg was black,” she recalls. “We thought we would have to amputate.”

Devastated by the prospect of this decision, the physician-nurse team searched frantically for another solution. Then Sparger remembered an instance from years before when an elderly patient’s compromised circulation was resolved through the use of medicinal leeches. While the team had never heard of this procedure being used for an infant, they trusted Sparger and decided to follow her suggestion.

“We started therapy that night, and the baby went home with his leg intact,” she says, adding that she can recollect “hundreds of such scenarios” where the teamwork between physicians and nurses enabled positive outcomes. This is the essence of magnet, she notes: “Nurses know that their opinions are valued, so there is a better partnership with physicians.”

WHAT IS MAGNET?

Magnet certification is offered by the American Nurses Credentialing Center (ANCC) as a means of identifying hospitals that value nurses and provide optimal environments in which these professionals practice. According to ANCC, magnet designation is an important recognition of nurses’ work, the quality of a facility’s nursing program, and the importance of nurses to the entire organization’s success.

The concept of magnet dates back to the early 1980s. In 1981, the American Academy of Nurses developed the criteria for Magnet certification, which covered three broad areas:

• Administration: Participatory and supportive management style; well-prepared, decentralized organizational structure; “adequate” nurse staffing; deployment of opportunities;
• Professional practice: Professional practice models of care delivery; professional availability of specialist advice; emphasis on teaching staff responsibilities;
• Professional development: Planned staff orientation; emphasized in-service/competency-based clinical ladders; management development.1

A 1983 Magnet Hospital study identified variables found in a “magnet-like” environment, although these evolved over the next decade into 14 key forces used to determine magnet status.2-4 These include quality of nursing leadership, organizational structure, management style, personnel policies and programs, professional models of care, quality of care, autonomy, and quality improvement.

Applying for magnet certification is an elaborate process that involves extensive and detailed documentation, site visits, and interviews. Staff participation includes nurses, administrators, and physicians—among others. The certification process can take a year or more, and facilities must recertify every four years.

Magnet-certified facilities are required to submit quality data for the ANCC to track. However, the agency states on its Web site that “independently sponsored research” has shown that magnet-certified facilities:

• Consistently outperform nonmagnet organizations;
• Deliver better patient outcomes;
• Have shorter lengths of patient stays;
• Enjoy increased nurse retention rates;
• Report higher rates of nursing job satisfaction; and
• Report higher patient satisfaction.5

To date more than 100 U.S. healthcare facilities have earned magnet certification, and the number is growing almost daily. In fact, Allen Kaiser, MD, chief of staff at Vanderbilt

University Hospital in Tennessee, wonders if the point will come where so many facilities are magnet-certified that that status will lose its significance. Or, perhaps, “people will wonder what is wrong if a facility isn’t certified,” he says.

HOSPITALISTS AND MAGNET

An academic hospitalist and Assistant Professor at Chicago’s Rush University Medical Center, Richard Abrams, MD, said that nursing-physician collaboration is key to a positive environment for hospitalist practice.

“To me, the strongest suit of the nurses I work with here is that they are collaborators,” he explains. “Everyone brings something—some unique skill set—to the table. This, along with our proclivity for collaboration and mutual trust—makes our facility successful.”

Magnet certification didn’t cause this collaborative atmosphere, Dr. Abrams is quick to stress. “Our facility was magnet before there was such a thing,” he explains. “Magnet status is nice, but nursing care was always fantastic here. Magnet just put a name to what we are and recognizes it nationally.”

Dr. Abrams encourages his residents to look for this quality at facilities with which they are considering employment. In fact, he even uses Rush’s magnet status as a selling point to attract hospitalists to his program.

“Sometimes they ask what that is and what it means,” he says. “You know the quality of the nursing staff at a magnet hospital. You know that there is a minimal level of quality you can expect.”

Dr. Abrams emphasizes the importance of trust between hospitalists and nurses. “If you can’t trust each other, it makes it so much harder to care for patients,” he says. “Our nurses spend much more time with patients than anyone else. I wouldn’t do anything without input from the nursing staff.

“We have a rule in the hospital. If a nurse thinks a patient needs to be transferred to intensive care, the patient is transferred,” continues Dr. Abrams. “We put this policy in place four to five years ago, and no one has ever questioned or disputed it.”

The biggest plus for nurses is that I’m on the floor eight or more hours a day. We have repeated interactions, and relationships develop more quickly. This probably breaks down some barriers that can exist between physicians and nurses.

—Richard Abrams, MD

PERFECT TOGETHER

Magnet status and hospitalists represent a good match. Just as magnet nursing status provides benefits for hospitalists, the presence of hospitalists helps create a positive environment for nurses.

“The biggest plus for nurses is that I’m on the floor eight or more hours a day. We have repeated interactions, and relationships develop more quickly,” notes Dr. Abrams. “This probably breaks down some barriers that can exist between physicians and nurses.”

When nurses have to whether to call an attending physician at 3 a.m., this often creates additional stress or worries for them. With hospitalists around, they almost always have a physician onsite. Even when the hospitalist isn’t right there, they know who to call and theyare likely to have a trusting relationship with this individual.

“I would feel bad if a nurse didn’t feel that she could pick up the phone and call me about any case,” says Dr. Abrams. “The more you work with people, the more trust you build.”

Magnet status is particularly important for hospitalists, explains Dr. Kaiser. “Because they spend so much time with nursing staff, the quality of nurses is especially important to hospitalists. Therefore, if we want to attract good hospitalists, we have to have good nurses. Because we have magnet status, we not only can say that we have a great nursing program; we can prove it.”

Sparger concurs. “Magnet validates a facility’s quality efforts and teamwork,” she says. “It makes you sit back and look at evidence-based practices for how you do things. You have to have evidence-based practices to write a policy. As hospitalists are more familiar and comfortable with hospital policies and procedures, this makes them the perfect match for magnet hospitals.”

At the same time when facilities put the hospitalist model together with magnet certification, the result is improved quality of life for both physicians and nurses.

While ANCC is still collecting data about magnet status and quality, Sparger and many individuals who work at magnet-certified facilities firmly believe that the characteristics that make they magnet also lead to reduced mortality and infections.

THE WORD SPREADS

If they don’t know about magnet certification already, hospitalists and other physicians likely will hear more about it in the near future.

“Magnet certification is a quality indicator at some level for hospitals,” says Dr. Abrams. “We will see a big push nationally for magnet at many more facilities.”

Nurses already see magnet status as an important sign that a hospital is a good place to work where quality care is high and nurses are respected. Increasingly, Dr. Abrams proposes, physicians will consider magnet status when choosing facilities at which to work. In fact this already is happening.

“I had one physicians say that he came here with confidence because he knew that we had a magnet staff,” says Beverly Hancock, MS, RN, education/quality and magnet project coordinator at Rush University Medical Center. “Also, I recently noticed on our Web site that several departments and programs mention our magnet status in their recruitment announcements.”

In fact, physicians themselves sometimes are the greatest advertisement for magnet hospitals. “If you talk to our physicians, they say that they tell everyone about the great nurses here,” says Hancock. “They say that they heard about it in their interviews and now they’re seeing it in person.”

At the same time, the word is spreading rapidly beyond practitioners. Just this year, U.S. News & World Report added magnet certification to its criteria for determining its annual list of the country’s best hospitals.

“There is no question that patients, insurers, and other healthcare groups will begin to place a lot of emphasis on magnet status as well,” concludes Dr. Abrams. TH

Contributor Joanne Kaldy is based in Maryland.

REFERENCES

1. McClure M, Poulin M, Sovie M, Wandelt M. Magnet Hospitals: Attraction and Retention of Professional Nurses. American Academy of Nursing Task Force and Nursing Practice in Hospitals. Kansas City, MO: American Nurses Association 1983.
2. Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing care, part I. Nursing Management. 1987;18(9):38-42.
3. Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing car, part II. Nursing Management. 1987; 18(10):33-40.
4. Kramer M, Schmalenberg C. Job satisfaction and retention. Insights for the ‘90s, part I. Nursing. 1991;3(3):50-55.
5. American Nurses Credentialing Center Web site. www.nursingworld.org/ancc/magnet/consumer/benefits.html. Benefits of magnet. Last accessed 8/16/05.

Magnet certification draws nurses to hospitals by documenting that these facilities are good places for them to work. But does magnet also suggest a positive environment for hospitalists and other physicians?

Ask Kathy Sparger, RN, MSN, chief nursing officer at South Miami Hospital in South Miami, Fla., who says her magnet facility perpetuates teamwork and collaboration in a way that creates a positive professional atmosphere for both nurses and physicians. She’s also emphatic that it enables high-quality care.

South Miami Nurses Kathleen Gori, RN, Melissa Korman, RN, and Zully Darby, RN, show off their magnet pride.

The mother of at least one patient likely agrees. Sparger tells the story of a baby born in the hospital with compromised circulation in his leg.

“When he was born, his leg was black,” she recalls. “We thought we would have to amputate.”

Devastated by the prospect of this decision, the physician-nurse team searched frantically for another solution. Then Sparger remembered an instance from years before when an elderly patient’s compromised circulation was resolved through the use of medicinal leeches. While the team had never heard of this procedure being used for an infant, they trusted Sparger and decided to follow her suggestion.

“We started therapy that night, and the baby went home with his leg intact,” she says, adding that she can recollect “hundreds of such scenarios” where the teamwork between physicians and nurses enabled positive outcomes. This is the essence of magnet, she notes: “Nurses know that their opinions are valued, so there is a better partnership with physicians.”

WHAT IS MAGNET?

Magnet certification is offered by the American Nurses Credentialing Center (ANCC) as a means of identifying hospitals that value nurses and provide optimal environments in which these professionals practice. According to ANCC, magnet designation is an important recognition of nurses’ work, the quality of a facility’s nursing program, and the importance of nurses to the entire organization’s success.

The concept of magnet dates back to the early 1980s. In 1981, the American Academy of Nurses developed the criteria for Magnet certification, which covered three broad areas:

• Administration: Participatory and supportive management style; well-prepared, decentralized organizational structure; “adequate” nurse staffing; deployment of opportunities;
• Professional practice: Professional practice models of care delivery; professional availability of specialist advice; emphasis on teaching staff responsibilities;
• Professional development: Planned staff orientation; emphasized in-service/competency-based clinical ladders; management development.1

A 1983 Magnet Hospital study identified variables found in a “magnet-like” environment, although these evolved over the next decade into 14 key forces used to determine magnet status.2-4 These include quality of nursing leadership, organizational structure, management style, personnel policies and programs, professional models of care, quality of care, autonomy, and quality improvement.

Applying for magnet certification is an elaborate process that involves extensive and detailed documentation, site visits, and interviews. Staff participation includes nurses, administrators, and physicians—among others. The certification process can take a year or more, and facilities must recertify every four years.

Magnet-certified facilities are required to submit quality data for the ANCC to track. However, the agency states on its Web site that “independently sponsored research” has shown that magnet-certified facilities:

• Consistently outperform nonmagnet organizations;
• Deliver better patient outcomes;
• Have shorter lengths of patient stays;
• Enjoy increased nurse retention rates;
• Report higher rates of nursing job satisfaction; and
• Report higher patient satisfaction.5

To date more than 100 U.S. healthcare facilities have earned magnet certification, and the number is growing almost daily. In fact, Allen Kaiser, MD, chief of staff at Vanderbilt

University Hospital in Tennessee, wonders if the point will come where so many facilities are magnet-certified that that status will lose its significance. Or, perhaps, “people will wonder what is wrong if a facility isn’t certified,” he says.

HOSPITALISTS AND MAGNET

An academic hospitalist and Assistant Professor at Chicago’s Rush University Medical Center, Richard Abrams, MD, said that nursing-physician collaboration is key to a positive environment for hospitalist practice.

“To me, the strongest suit of the nurses I work with here is that they are collaborators,” he explains. “Everyone brings something—some unique skill set—to the table. This, along with our proclivity for collaboration and mutual trust—makes our facility successful.”

Magnet certification didn’t cause this collaborative atmosphere, Dr. Abrams is quick to stress. “Our facility was magnet before there was such a thing,” he explains. “Magnet status is nice, but nursing care was always fantastic here. Magnet just put a name to what we are and recognizes it nationally.”

Dr. Abrams encourages his residents to look for this quality at facilities with which they are considering employment. In fact, he even uses Rush’s magnet status as a selling point to attract hospitalists to his program.

“Sometimes they ask what that is and what it means,” he says. “You know the quality of the nursing staff at a magnet hospital. You know that there is a minimal level of quality you can expect.”

Dr. Abrams emphasizes the importance of trust between hospitalists and nurses. “If you can’t trust each other, it makes it so much harder to care for patients,” he says. “Our nurses spend much more time with patients than anyone else. I wouldn’t do anything without input from the nursing staff.

“We have a rule in the hospital. If a nurse thinks a patient needs to be transferred to intensive care, the patient is transferred,” continues Dr. Abrams. “We put this policy in place four to five years ago, and no one has ever questioned or disputed it.”

The biggest plus for nurses is that I’m on the floor eight or more hours a day. We have repeated interactions, and relationships develop more quickly. This probably breaks down some barriers that can exist between physicians and nurses.

—Richard Abrams, MD

PERFECT TOGETHER

Magnet status and hospitalists represent a good match. Just as magnet nursing status provides benefits for hospitalists, the presence of hospitalists helps create a positive environment for nurses.

“The biggest plus for nurses is that I’m on the floor eight or more hours a day. We have repeated interactions, and relationships develop more quickly,” notes Dr. Abrams. “This probably breaks down some barriers that can exist between physicians and nurses.”

When nurses have to whether to call an attending physician at 3 a.m., this often creates additional stress or worries for them. With hospitalists around, they almost always have a physician onsite. Even when the hospitalist isn’t right there, they know who to call and theyare likely to have a trusting relationship with this individual.

“I would feel bad if a nurse didn’t feel that she could pick up the phone and call me about any case,” says Dr. Abrams. “The more you work with people, the more trust you build.”

Magnet status is particularly important for hospitalists, explains Dr. Kaiser. “Because they spend so much time with nursing staff, the quality of nurses is especially important to hospitalists. Therefore, if we want to attract good hospitalists, we have to have good nurses. Because we have magnet status, we not only can say that we have a great nursing program; we can prove it.”

Sparger concurs. “Magnet validates a facility’s quality efforts and teamwork,” she says. “It makes you sit back and look at evidence-based practices for how you do things. You have to have evidence-based practices to write a policy. As hospitalists are more familiar and comfortable with hospital policies and procedures, this makes them the perfect match for magnet hospitals.”

At the same time when facilities put the hospitalist model together with magnet certification, the result is improved quality of life for both physicians and nurses.

While ANCC is still collecting data about magnet status and quality, Sparger and many individuals who work at magnet-certified facilities firmly believe that the characteristics that make they magnet also lead to reduced mortality and infections.

THE WORD SPREADS

If they don’t know about magnet certification already, hospitalists and other physicians likely will hear more about it in the near future.

“Magnet certification is a quality indicator at some level for hospitals,” says Dr. Abrams. “We will see a big push nationally for magnet at many more facilities.”

Nurses already see magnet status as an important sign that a hospital is a good place to work where quality care is high and nurses are respected. Increasingly, Dr. Abrams proposes, physicians will consider magnet status when choosing facilities at which to work. In fact this already is happening.

“I had one physicians say that he came here with confidence because he knew that we had a magnet staff,” says Beverly Hancock, MS, RN, education/quality and magnet project coordinator at Rush University Medical Center. “Also, I recently noticed on our Web site that several departments and programs mention our magnet status in their recruitment announcements.”

In fact, physicians themselves sometimes are the greatest advertisement for magnet hospitals. “If you talk to our physicians, they say that they tell everyone about the great nurses here,” says Hancock. “They say that they heard about it in their interviews and now they’re seeing it in person.”

At the same time, the word is spreading rapidly beyond practitioners. Just this year, U.S. News & World Report added magnet certification to its criteria for determining its annual list of the country’s best hospitals.

“There is no question that patients, insurers, and other healthcare groups will begin to place a lot of emphasis on magnet status as well,” concludes Dr. Abrams. TH

Contributor Joanne Kaldy is based in Maryland.

REFERENCES

1. McClure M, Poulin M, Sovie M, Wandelt M. Magnet Hospitals: Attraction and Retention of Professional Nurses. American Academy of Nursing Task Force and Nursing Practice in Hospitals. Kansas City, MO: American Nurses Association 1983.
2. Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing care, part I. Nursing Management. 1987;18(9):38-42.
3. Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing car, part II. Nursing Management. 1987; 18(10):33-40.
4. Kramer M, Schmalenberg C. Job satisfaction and retention. Insights for the ‘90s, part I. Nursing. 1991;3(3):50-55.
5. American Nurses Credentialing Center Web site. www.nursingworld.org/ancc/magnet/consumer/benefits.html. Benefits of magnet. Last accessed 8/16/05.

Magnet certification draws nurses to hospitals by documenting that these facilities are good places for them to work. But does magnet also suggest a positive environment for hospitalists and other physicians?

Ask Kathy Sparger, RN, MSN, chief nursing officer at South Miami Hospital in South Miami, Fla., who says her magnet facility perpetuates teamwork and collaboration in a way that creates a positive professional atmosphere for both nurses and physicians. She’s also emphatic that it enables high-quality care.

South Miami Nurses Kathleen Gori, RN, Melissa Korman, RN, and Zully Darby, RN, show off their magnet pride.

The mother of at least one patient likely agrees. Sparger tells the story of a baby born in the hospital with compromised circulation in his leg.

“When he was born, his leg was black,” she recalls. “We thought we would have to amputate.”

Devastated by the prospect of this decision, the physician-nurse team searched frantically for another solution. Then Sparger remembered an instance from years before when an elderly patient’s compromised circulation was resolved through the use of medicinal leeches. While the team had never heard of this procedure being used for an infant, they trusted Sparger and decided to follow her suggestion.

“We started therapy that night, and the baby went home with his leg intact,” she says, adding that she can recollect “hundreds of such scenarios” where the teamwork between physicians and nurses enabled positive outcomes. This is the essence of magnet, she notes: “Nurses know that their opinions are valued, so there is a better partnership with physicians.”

WHAT IS MAGNET?

Magnet certification is offered by the American Nurses Credentialing Center (ANCC) as a means of identifying hospitals that value nurses and provide optimal environments in which these professionals practice. According to ANCC, magnet designation is an important recognition of nurses’ work, the quality of a facility’s nursing program, and the importance of nurses to the entire organization’s success.

The concept of magnet dates back to the early 1980s. In 1981, the American Academy of Nurses developed the criteria for Magnet certification, which covered three broad areas:

• Administration: Participatory and supportive management style; well-prepared, decentralized organizational structure; “adequate” nurse staffing; deployment of opportunities;
• Professional practice: Professional practice models of care delivery; professional availability of specialist advice; emphasis on teaching staff responsibilities;
• Professional development: Planned staff orientation; emphasized in-service/competency-based clinical ladders; management development.1

A 1983 Magnet Hospital study identified variables found in a “magnet-like” environment, although these evolved over the next decade into 14 key forces used to determine magnet status.2-4 These include quality of nursing leadership, organizational structure, management style, personnel policies and programs, professional models of care, quality of care, autonomy, and quality improvement.

Applying for magnet certification is an elaborate process that involves extensive and detailed documentation, site visits, and interviews. Staff participation includes nurses, administrators, and physicians—among others. The certification process can take a year or more, and facilities must recertify every four years.

Magnet-certified facilities are required to submit quality data for the ANCC to track. However, the agency states on its Web site that “independently sponsored research” has shown that magnet-certified facilities:

• Consistently outperform nonmagnet organizations;
• Deliver better patient outcomes;
• Have shorter lengths of patient stays;
• Enjoy increased nurse retention rates;
• Report higher rates of nursing job satisfaction; and
• Report higher patient satisfaction.5

To date more than 100 U.S. healthcare facilities have earned magnet certification, and the number is growing almost daily. In fact, Allen Kaiser, MD, chief of staff at Vanderbilt

University Hospital in Tennessee, wonders if the point will come where so many facilities are magnet-certified that that status will lose its significance. Or, perhaps, “people will wonder what is wrong if a facility isn’t certified,” he says.

HOSPITALISTS AND MAGNET

An academic hospitalist and Assistant Professor at Chicago’s Rush University Medical Center, Richard Abrams, MD, said that nursing-physician collaboration is key to a positive environment for hospitalist practice.

“To me, the strongest suit of the nurses I work with here is that they are collaborators,” he explains. “Everyone brings something—some unique skill set—to the table. This, along with our proclivity for collaboration and mutual trust—makes our facility successful.”

Magnet certification didn’t cause this collaborative atmosphere, Dr. Abrams is quick to stress. “Our facility was magnet before there was such a thing,” he explains. “Magnet status is nice, but nursing care was always fantastic here. Magnet just put a name to what we are and recognizes it nationally.”

Dr. Abrams encourages his residents to look for this quality at facilities with which they are considering employment. In fact, he even uses Rush’s magnet status as a selling point to attract hospitalists to his program.

“Sometimes they ask what that is and what it means,” he says. “You know the quality of the nursing staff at a magnet hospital. You know that there is a minimal level of quality you can expect.”

Dr. Abrams emphasizes the importance of trust between hospitalists and nurses. “If you can’t trust each other, it makes it so much harder to care for patients,” he says. “Our nurses spend much more time with patients than anyone else. I wouldn’t do anything without input from the nursing staff.

“We have a rule in the hospital. If a nurse thinks a patient needs to be transferred to intensive care, the patient is transferred,” continues Dr. Abrams. “We put this policy in place four to five years ago, and no one has ever questioned or disputed it.”

The biggest plus for nurses is that I’m on the floor eight or more hours a day. We have repeated interactions, and relationships develop more quickly. This probably breaks down some barriers that can exist between physicians and nurses.

—Richard Abrams, MD

PERFECT TOGETHER

Magnet status and hospitalists represent a good match. Just as magnet nursing status provides benefits for hospitalists, the presence of hospitalists helps create a positive environment for nurses.

“The biggest plus for nurses is that I’m on the floor eight or more hours a day. We have repeated interactions, and relationships develop more quickly,” notes Dr. Abrams. “This probably breaks down some barriers that can exist between physicians and nurses.”

When nurses have to whether to call an attending physician at 3 a.m., this often creates additional stress or worries for them. With hospitalists around, they almost always have a physician onsite. Even when the hospitalist isn’t right there, they know who to call and theyare likely to have a trusting relationship with this individual.

“I would feel bad if a nurse didn’t feel that she could pick up the phone and call me about any case,” says Dr. Abrams. “The more you work with people, the more trust you build.”

Magnet status is particularly important for hospitalists, explains Dr. Kaiser. “Because they spend so much time with nursing staff, the quality of nurses is especially important to hospitalists. Therefore, if we want to attract good hospitalists, we have to have good nurses. Because we have magnet status, we not only can say that we have a great nursing program; we can prove it.”

Sparger concurs. “Magnet validates a facility’s quality efforts and teamwork,” she says. “It makes you sit back and look at evidence-based practices for how you do things. You have to have evidence-based practices to write a policy. As hospitalists are more familiar and comfortable with hospital policies and procedures, this makes them the perfect match for magnet hospitals.”

At the same time when facilities put the hospitalist model together with magnet certification, the result is improved quality of life for both physicians and nurses.

While ANCC is still collecting data about magnet status and quality, Sparger and many individuals who work at magnet-certified facilities firmly believe that the characteristics that make they magnet also lead to reduced mortality and infections.

THE WORD SPREADS

If they don’t know about magnet certification already, hospitalists and other physicians likely will hear more about it in the near future.

“Magnet certification is a quality indicator at some level for hospitals,” says Dr. Abrams. “We will see a big push nationally for magnet at many more facilities.”

Nurses already see magnet status as an important sign that a hospital is a good place to work where quality care is high and nurses are respected. Increasingly, Dr. Abrams proposes, physicians will consider magnet status when choosing facilities at which to work. In fact this already is happening.

“I had one physicians say that he came here with confidence because he knew that we had a magnet staff,” says Beverly Hancock, MS, RN, education/quality and magnet project coordinator at Rush University Medical Center. “Also, I recently noticed on our Web site that several departments and programs mention our magnet status in their recruitment announcements.”

In fact, physicians themselves sometimes are the greatest advertisement for magnet hospitals. “If you talk to our physicians, they say that they tell everyone about the great nurses here,” says Hancock. “They say that they heard about it in their interviews and now they’re seeing it in person.”

At the same time, the word is spreading rapidly beyond practitioners. Just this year, U.S. News & World Report added magnet certification to its criteria for determining its annual list of the country’s best hospitals.

“There is no question that patients, insurers, and other healthcare groups will begin to place a lot of emphasis on magnet status as well,” concludes Dr. Abrams. TH

Contributor Joanne Kaldy is based in Maryland.

REFERENCES

1. McClure M, Poulin M, Sovie M, Wandelt M. Magnet Hospitals: Attraction and Retention of Professional Nurses. American Academy of Nursing Task Force and Nursing Practice in Hospitals. Kansas City, MO: American Nurses Association 1983.
2. Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing care, part I. Nursing Management. 1987;18(9):38-42.
3. Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing car, part II. Nursing Management. 1987; 18(10):33-40.
4. Kramer M, Schmalenberg C. Job satisfaction and retention. Insights for the ‘90s, part I. Nursing. 1991;3(3):50-55.
5. American Nurses Credentialing Center Web site. www.nursingworld.org/ancc/magnet/consumer/benefits.html. Benefits of magnet. Last accessed 8/16/05.

While the idea of applying current knowledge to patient care dates back as far as medicine itself, the modern concept of evidence-based medicine (EBM) has developed in response to the ever-increasing need for clinicians to make patient care decisions in a reasoned and rational manner. It is the application of evidence gleaned from careful research, merged with clinical experience, patient values, and the unique features of every individual case, for the purpose of making the most effective patient care decisions.

It must be noted that the search for and use of the best evidence does not by itself constitute the appropriate practice of EBM: Patient care requires a more global balance of many factors, and true EBM attempts to address this. While there are general themes to an EBM approach to clinical problems, it would be a mistake to view EBM as a search for a “script” to follow in deciding how to handle a clinical presentation. EBM is not meant to exclude the individualized approach to medicine, but rather to enhance and refine it.

Perhaps the best way to think of EBM comes from McMaster University (Hamilton, Ontario, Canada), where in the 1970s the scholarly pursuit of EBM began to flourish. Researchers at McMaster describe EBM as the development of an attitude of enlightened skepticism toward the evidence behind daily clinical decisions. Clinical evidence should be viewed through the lens of epidemiologic principles, and rather than accepting all that we are told, we should require a careful evaluation of the evidence. Our patients demand the best possible care, and we owe it to ourselves, our patients, and our profession to determine the best possible care for each individual.

HOW IS EBM RELEVANT TO THE HOSPITALIST?

To make effective patient care decisions, hospitalists are no different than other clinicians. In fact, every practicing hospitalist asks and answers dozens of clinical questions each day, and many of these decisions immediately affect the well-being of patients.

For example, should an otherwise healthy 60-year-old patient receive perioperative beta-blocker therapy prior to laparoscopic cholecystectomy? What is the best way to evaluate this diabetic woman’s nonhealing leg ulcer for osteomyelitis? What is the prognosis for this young man newly diagnosed with glioblastoma multiforme?

Each of these is an example of a clinical question many of us may have already asked ourselves today. Hospital medicine moves quickly, and it is important to find the best answers to these questions as rapidly as possible. EBM provides a framework to help get to these answers and ultimately it helps us manage patients most effectively.

EBM is not meant to exclude the individualized approach to medicine, but rather to enhance and refine it.

An additional aspect of hospitalist practice that is somewhat unique is the central role the hospitalist plays in the complete care of patients. The hospitalist is often called upon to bring specialists together for a patient’s care, and EBM can be important in ensuring that these specialists make the best decisions for the patient.

For example, a careful review of the literature suggests that low molecular weight heparin is preferable to aspirin for postoperative deep vein thrombosis prophylaxis for most hip replacement patients. If an orthopedic service nevertheless writes orders for aspirin in such a patient, the informed hospitalist would want to clarify the rationale behind this choice and if appropriate recommend the use of low molecular weight heparin instead. Thus, hospitalists may need to anticipate not only their own clinical questions but also any clinical question relevant to the care of any of their patients.

THE ELEMENTS OF EBM?

At its essence, EBM means applying the best evidence available for the benefit of patients. In this series, we will review the basic elements of EBM:

• Constructing an answerable clinical question;
• Searching for the best evidence for the question at hand;
• Critically appraising the evidence for its validity, importance, and relevance to your patient; and
• Applying the best evidence to your clinical practice.

Each of these deserves a brief comment. To find the information most relevant to a clinical question, it is helpful to have a well-defined query of appropriately narrow scope. If we

want information on perioperative beta-blockade in the scenario outlined above, it may not be helpful to apply evidence derived from vascular surgery patients over age 65 with known coronary artery disease. If information were available on outcomes in younger patients undergoing lower-risk procedures, this might be more relevant to our question. Thus, an approach to constructing effective clinical questions is a critical skill for EBM.

The best clinical question cannot help us if we don’t know how to find the evidence relating to that question, however. Therefore, EBM requires some understanding of the relative benefits of sources such as Ovid MEDLINE (www.medscape.com) or UpToDate (www.uptodate.com), in addition to how to navigate through these sources to get to the evidence. Thankfully, these databases are becoming more powerful all the time, while also working to remain user-friendly. An approach to effective searches is clearly an important skill for EBM.

Once we have found the evidence for our question, we need to know how to evaluate the quality of the evidence. There are many guides available for individual types of clinical questions, but there are consistent themes across all types of questions, including assessment for potential bias, proper interpretation of study results, and deciding whether the results can be applied to your patient. Understanding these themes and then taking the evidence back to the bedside is the culmination of the EBM process for our patients.

SUMMARY

EBM is an approach to making patient care decisions incorporating the highest quality available evidence. This is of great relevance to hospitalists, especially given the central role hospitalists play in the care of patients across multiple disciplines. This series will serve as an introduction to the many facets of EBM, focused to a practicing hospitalist audience. TH

Dr. West practices in the Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn.

While the idea of applying current knowledge to patient care dates back as far as medicine itself, the modern concept of evidence-based medicine (EBM) has developed in response to the ever-increasing need for clinicians to make patient care decisions in a reasoned and rational manner. It is the application of evidence gleaned from careful research, merged with clinical experience, patient values, and the unique features of every individual case, for the purpose of making the most effective patient care decisions.

It must be noted that the search for and use of the best evidence does not by itself constitute the appropriate practice of EBM: Patient care requires a more global balance of many factors, and true EBM attempts to address this. While there are general themes to an EBM approach to clinical problems, it would be a mistake to view EBM as a search for a “script” to follow in deciding how to handle a clinical presentation. EBM is not meant to exclude the individualized approach to medicine, but rather to enhance and refine it.

Perhaps the best way to think of EBM comes from McMaster University (Hamilton, Ontario, Canada), where in the 1970s the scholarly pursuit of EBM began to flourish. Researchers at McMaster describe EBM as the development of an attitude of enlightened skepticism toward the evidence behind daily clinical decisions. Clinical evidence should be viewed through the lens of epidemiologic principles, and rather than accepting all that we are told, we should require a careful evaluation of the evidence. Our patients demand the best possible care, and we owe it to ourselves, our patients, and our profession to determine the best possible care for each individual.

HOW IS EBM RELEVANT TO THE HOSPITALIST?

To make effective patient care decisions, hospitalists are no different than other clinicians. In fact, every practicing hospitalist asks and answers dozens of clinical questions each day, and many of these decisions immediately affect the well-being of patients.

For example, should an otherwise healthy 60-year-old patient receive perioperative beta-blocker therapy prior to laparoscopic cholecystectomy? What is the best way to evaluate this diabetic woman’s nonhealing leg ulcer for osteomyelitis? What is the prognosis for this young man newly diagnosed with glioblastoma multiforme?

Each of these is an example of a clinical question many of us may have already asked ourselves today. Hospital medicine moves quickly, and it is important to find the best answers to these questions as rapidly as possible. EBM provides a framework to help get to these answers and ultimately it helps us manage patients most effectively.

EBM is not meant to exclude the individualized approach to medicine, but rather to enhance and refine it.

An additional aspect of hospitalist practice that is somewhat unique is the central role the hospitalist plays in the complete care of patients. The hospitalist is often called upon to bring specialists together for a patient’s care, and EBM can be important in ensuring that these specialists make the best decisions for the patient.

For example, a careful review of the literature suggests that low molecular weight heparin is preferable to aspirin for postoperative deep vein thrombosis prophylaxis for most hip replacement patients. If an orthopedic service nevertheless writes orders for aspirin in such a patient, the informed hospitalist would want to clarify the rationale behind this choice and if appropriate recommend the use of low molecular weight heparin instead. Thus, hospitalists may need to anticipate not only their own clinical questions but also any clinical question relevant to the care of any of their patients.

THE ELEMENTS OF EBM?

At its essence, EBM means applying the best evidence available for the benefit of patients. In this series, we will review the basic elements of EBM:

• Constructing an answerable clinical question;
• Searching for the best evidence for the question at hand;
• Critically appraising the evidence for its validity, importance, and relevance to your patient; and
• Applying the best evidence to your clinical practice.

Each of these deserves a brief comment. To find the information most relevant to a clinical question, it is helpful to have a well-defined query of appropriately narrow scope. If we

want information on perioperative beta-blockade in the scenario outlined above, it may not be helpful to apply evidence derived from vascular surgery patients over age 65 with known coronary artery disease. If information were available on outcomes in younger patients undergoing lower-risk procedures, this might be more relevant to our question. Thus, an approach to constructing effective clinical questions is a critical skill for EBM.

The best clinical question cannot help us if we don’t know how to find the evidence relating to that question, however. Therefore, EBM requires some understanding of the relative benefits of sources such as Ovid MEDLINE (www.medscape.com) or UpToDate (www.uptodate.com), in addition to how to navigate through these sources to get to the evidence. Thankfully, these databases are becoming more powerful all the time, while also working to remain user-friendly. An approach to effective searches is clearly an important skill for EBM.

Once we have found the evidence for our question, we need to know how to evaluate the quality of the evidence. There are many guides available for individual types of clinical questions, but there are consistent themes across all types of questions, including assessment for potential bias, proper interpretation of study results, and deciding whether the results can be applied to your patient. Understanding these themes and then taking the evidence back to the bedside is the culmination of the EBM process for our patients.

SUMMARY

EBM is an approach to making patient care decisions incorporating the highest quality available evidence. This is of great relevance to hospitalists, especially given the central role hospitalists play in the care of patients across multiple disciplines. This series will serve as an introduction to the many facets of EBM, focused to a practicing hospitalist audience. TH

Dr. West practices in the Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn.

While the idea of applying current knowledge to patient care dates back as far as medicine itself, the modern concept of evidence-based medicine (EBM) has developed in response to the ever-increasing need for clinicians to make patient care decisions in a reasoned and rational manner. It is the application of evidence gleaned from careful research, merged with clinical experience, patient values, and the unique features of every individual case, for the purpose of making the most effective patient care decisions.

It must be noted that the search for and use of the best evidence does not by itself constitute the appropriate practice of EBM: Patient care requires a more global balance of many factors, and true EBM attempts to address this. While there are general themes to an EBM approach to clinical problems, it would be a mistake to view EBM as a search for a “script” to follow in deciding how to handle a clinical presentation. EBM is not meant to exclude the individualized approach to medicine, but rather to enhance and refine it.

Perhaps the best way to think of EBM comes from McMaster University (Hamilton, Ontario, Canada), where in the 1970s the scholarly pursuit of EBM began to flourish. Researchers at McMaster describe EBM as the development of an attitude of enlightened skepticism toward the evidence behind daily clinical decisions. Clinical evidence should be viewed through the lens of epidemiologic principles, and rather than accepting all that we are told, we should require a careful evaluation of the evidence. Our patients demand the best possible care, and we owe it to ourselves, our patients, and our profession to determine the best possible care for each individual.

HOW IS EBM RELEVANT TO THE HOSPITALIST?

To make effective patient care decisions, hospitalists are no different than other clinicians. In fact, every practicing hospitalist asks and answers dozens of clinical questions each day, and many of these decisions immediately affect the well-being of patients.

For example, should an otherwise healthy 60-year-old patient receive perioperative beta-blocker therapy prior to laparoscopic cholecystectomy? What is the best way to evaluate this diabetic woman’s nonhealing leg ulcer for osteomyelitis? What is the prognosis for this young man newly diagnosed with glioblastoma multiforme?

Each of these is an example of a clinical question many of us may have already asked ourselves today. Hospital medicine moves quickly, and it is important to find the best answers to these questions as rapidly as possible. EBM provides a framework to help get to these answers and ultimately it helps us manage patients most effectively.

EBM is not meant to exclude the individualized approach to medicine, but rather to enhance and refine it.

An additional aspect of hospitalist practice that is somewhat unique is the central role the hospitalist plays in the complete care of patients. The hospitalist is often called upon to bring specialists together for a patient’s care, and EBM can be important in ensuring that these specialists make the best decisions for the patient.

For example, a careful review of the literature suggests that low molecular weight heparin is preferable to aspirin for postoperative deep vein thrombosis prophylaxis for most hip replacement patients. If an orthopedic service nevertheless writes orders for aspirin in such a patient, the informed hospitalist would want to clarify the rationale behind this choice and if appropriate recommend the use of low molecular weight heparin instead. Thus, hospitalists may need to anticipate not only their own clinical questions but also any clinical question relevant to the care of any of their patients.

THE ELEMENTS OF EBM?

At its essence, EBM means applying the best evidence available for the benefit of patients. In this series, we will review the basic elements of EBM:

• Constructing an answerable clinical question;
• Searching for the best evidence for the question at hand;
• Critically appraising the evidence for its validity, importance, and relevance to your patient; and
• Applying the best evidence to your clinical practice.

Each of these deserves a brief comment. To find the information most relevant to a clinical question, it is helpful to have a well-defined query of appropriately narrow scope. If we

want information on perioperative beta-blockade in the scenario outlined above, it may not be helpful to apply evidence derived from vascular surgery patients over age 65 with known coronary artery disease. If information were available on outcomes in younger patients undergoing lower-risk procedures, this might be more relevant to our question. Thus, an approach to constructing effective clinical questions is a critical skill for EBM.

The best clinical question cannot help us if we don’t know how to find the evidence relating to that question, however. Therefore, EBM requires some understanding of the relative benefits of sources such as Ovid MEDLINE (www.medscape.com) or UpToDate (www.uptodate.com), in addition to how to navigate through these sources to get to the evidence. Thankfully, these databases are becoming more powerful all the time, while also working to remain user-friendly. An approach to effective searches is clearly an important skill for EBM.

Once we have found the evidence for our question, we need to know how to evaluate the quality of the evidence. There are many guides available for individual types of clinical questions, but there are consistent themes across all types of questions, including assessment for potential bias, proper interpretation of study results, and deciding whether the results can be applied to your patient. Understanding these themes and then taking the evidence back to the bedside is the culmination of the EBM process for our patients.

SUMMARY

EBM is an approach to making patient care decisions incorporating the highest quality available evidence. This is of great relevance to hospitalists, especially given the central role hospitalists play in the care of patients across multiple disciplines. This series will serve as an introduction to the many facets of EBM, focused to a practicing hospitalist audience. TH

Dr. West practices in the Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn.

This article is the second in a series on the hospital of the future, designed to get our readers thinking and planning ahead for their own facilities.

Hospitals across the country wrestle with improving their discharge process, whether the goal is gaining a more time- and cost-effective outcome for the facility, or improving quality measures for patients upon departure, or both.

“A lot of people are attacking discharge problems from a lot of different angles,” says Vineet Arora, MD, academic hospitalist and researcher, University of Chicago Pritzker School of Medicine.

What will hospital discharge look like in the future? Based on current research, trials, and trends, it seems there are few surprises down the road in this area. The changes will come in the form of fine-tuning critical areas in the process rather than implementing new technology to radically change the way we release patients. Positive changes seem to be people-based rather than computer-based.

“Everybody’s on the technology bandwagon, but we have to understand the processes first,” says Lakshmi Halasyamani, MD, associate chair for the Department of Internal Medicine, St. Joseph Mercy Hospital, Ann Arbor, Mich. “Better technology won’t make care safer or more efficient. We have to examine how we organize care delivery, then look at technology. Otherwise it replicates the inefficiencies we have now.”

Here are some predictions for how the discharge process will be improved in the hospital of the future.

THE DISCHARGE PROCESS WILL BE SMOOTHER AND SAFER

Most hospital-based professionals agree that discharge is an area of care that needs more attention.

“Every day that you’re [in the hospital], we spend a little less time with you,” says Dr. Halasyamani. “We undervalue the risk of discharging patients; we need to focus on [the patients] more. The nurse calls us, and we get the discharge done as quickly as possible.”

In the hospital of the future, the discharge process will be driven by specific structured guidelines that ensure patients safety when they leave the hospital. Every discharge will involve a multidisciplinary team, with members signing off that the patient is not only ready to leave the hospital, but informed about their condition and any next steps, and has necessary medications or prescriptions in hand.

As for improving efficiency, minor changes can make a big difference. Chad Whelan, MD, assistant professor of medicine, University of Chicago Hospitals, is part of a task force working on how to move hospital discharges earlier in the day.

“An earlier discharge is better for everyone, including the patient—especially if they’re being transferred to another facility,” he points out. “One thing we’re looking at is the way diagnostic tests are categorized. Everything falls into two categories now: emergency diagnostics and everything else.”

Dr. Whelan and the taskforce have asked departments, including radiology and other labs, to create a third category: for patients waiting for a test before they can be discharged. All it takes is one question on the part of the service provider: “Is this patient waiting for these results before she can go home?” to move that patient to the front of the line.

Another recommendation Dr. Whelan’s task force will make involves staffing up. “Like we ramp nursing staff up and down depending on the census, we are looking at doing that with case managers and ward clerks to handle heavy discharge times,” he says.

David J. Rosenman, MD, senior associate consultant, Hospital Internal Medicine, Mayo Clinic in Rochester, Minn., suggests that paperwork might also be changed. “The discharge summary of the future will be more visual,” he predicts. “There are ways of displaying information that are more sophisticated and probably more helpful than static lists and linear prose alone.”

EMPOWERED PATIENTS

One change we are likely to see is patients taking on the responsibility of their own medical information. Ideally, the patients themselves will make caring for—and discharging—them easier and more efficient by sharing complete information on their current medications and other healthcare details that are often forgotten or overlooked by a provider or caregiver.

“The future of discharge lies with our ability to arm patients with their own information,” says Dr. Arora. “The more empowered the patient is, the better the outcome.” Personal health records (PHRs) are one solution. MyPHR is one online product, offered free by the American Health Information Management Association (AHIMA). Roughly 30 companies currently offer paid subscription PHR services to consumers. Peoplechart Corporation (San Francisco) is one of them and provides a single source of information controlled by the patient.

“We’re a pioneer of the PHR idea,” says Megan Mok, president and founder, Peoplechart Corporation. “There are not that many out there.”

Healthcare consumers can subscribe to a variety of Peoplechart tools and services (including initial collection of their records) that allow them to gain access to their comprehensive medical records via the Internet—or phone, if they choose—and to grant any given healthcare provider access to part or all of their records.

“Everything is patient-initiated and patient-controlled,” explains Mok. “There’s a big difference from systems controlled by providers, which may allow patients access, but not ownership.”

PHRs typically offer a comprehensive, integrated overview of an individual’s health data, including information that individuals add themselves on their symptoms and prescriptions, along with information such as diagnoses and lab results. Once a discharged patient updates her PHR, she can share her complete hospital records with her primary care physician, physical therapist, rehab facility, or whatever caregiver requires the information. This will save time and effort for all healthcare providers, and, more importantly, ensures that essential information is available.

Regardless of whether a patient has a PHR, physicians and other staff must ensure that the individual leaves the hospital with complete information on their care and medications.

“Discharge is a quality measure,” says Dr. Arora. “We need a multidisciplinary approach to address what each patient needs to go home.”

DEMYSTIFIED MEDICATIONS

In the very near future, the 2006 JCAHO standard for medication reconciliation will eliminate many problems with medications after discharge.

“This standard is extremely important,” says Dr. Rosenman. “Almost half of medication errors occur at transition points in a patient’s care. Reconciling medication lists—especially at these points—is critical to ensuring patient safety.”

The medication reconciliation form could conceivably morph into something broader in the future. “It would be nice for the medical record to be a living document that evolved with each encounter over the course of a patient’s life,” says Dr. Rosenman. “People may someday carry replaceable, updatable, credit-card-like medical cards or chips. In the meantime, we need to do our very best to keep medication lists and related data accurate and complete.”

While the patient will own his or her medical information, “the burden for ensuring the med list is accurate falls entirely on the healthcare organization,” insists Dr. Halasyamani. “This is a ripe opportunity to partner with the patients themselves. They and their families own the information. We have to help patients be stakeholders and give them the tools to manage their ever-changing medications and their healthcare.”

Many paper-based and computerized tools exist now, but there is no obvious standout product or method physicians can provide to patients that will ensure they take their prescriptions correctly on an ongoing basis.

“Health systems will have to develop a standard” for helping patients manage their medications, says Dr. Halasyamani. “Strategies must be low-tech but get the job done. They must resonate with things that patients already do, like paying bills.”

COMMUNICATION STILL CRITICAL

One step in the discharge process that ensures a smooth transition for inpatient to outpatient is communication with the professionals, facilities, or caregivers who will take over the patient’s care.

“The gap in care after discharge puts patients at risk for adverse events,” warns Dr. Arora. “One reason for this vulnerable gap is the flow of information between settings and teams of providers.” In the future, hospitals will better manage this essential transfer of information.

Typically, the patient’s primary care physician wants information from the hospital at admission and at discharge, and, if the primary care physician wishes, in between.

“We need to improve communications with primary care physicians in a way that respects their wishes for communication,” says Dr. Arora. The UCSF Hospitalist Group is already working on this.

“Until recently, we provided fax copies of our notes to primary care physicians. Now we have a new dictation system,” says Steven Pantilat, MD, FACP, SHM president. “We did a survey that found that most physicians want telephone contact at admission and at discharge, plus any major occurrences in between. The ability to exchange information in real time is important—and e-mail is not realtime.”

How does a hospitalist keep track of everyone’s communication preferences? “The hospitalist simply has to figure out what each primary care physician wants,” stresses Dr. Pantilat. “My sense is that in any hospital, there is a limited number of doctors or practices to deal with. How do you keep them all straight? Well, the same way a hospitalist keeps all the various nurses straight—you just do. It’s your business.”

PLANNED FOLLOW-UP

In the future, nearly every discharged patient will be contacted within two or three days by the hospitalist or another hospital medical staff. This may come in the form of a phone call to the patient to check on their overall health, symptoms, and medications. Or it may be a more hands-on approach.

The UCSF Medical Center has established a follow-up service to provide care to patients during the transition period immediately following discharge.

“This service was designed for patients who couldn’t otherwise be followed up on or those who would benefit from seeing the doctor who treated them in the hospital,” explains Dr. Pantilat, who initiated the idea for the service. “For example, if a patient with DVT was discharged, is the swelling smaller? The primary care physician can’t say—he didn’t see it.”

Out of more than 2,600 discharges during 1997-1998, the first year that the follow-up service existed, only 47 patients were prescribed with follow-up visits. “It was never meant to be a highly utilized service,” says Dr. Pantilat, “but to be a highly expandable, flexible service that addresses the needs of specific patients.” Of those 47 patients, four were readmitted to the hospital—one directly from the follow-up visit—compared with a national readmission average of 14%.

“We see these patients in the ED,” says Dr. Pantilat. “It’s the only department that’s open 24/7, and the ED has some extra bed capacity.”

When the hospitalist feels a follow-up is necessary, he or she schedules a visit with the patient before discharge for midmorning one or two days after discharge. (Midmorning is typically a slow time in the emergency department.) He then faxes the appointment information to the emergency department, so that when the patient shows up, she is preregistered. The emergency department telephones the hospitalist when the patient arrives, and that doctor then comes down to see the patient. The emergency department physicians have nothing to do with these follow-ups, though the nursing staff might be asked to help. Also, follow-up visits are considered an outpatient service and charged as such. “The follow-up service was established and run at virtually no cost,” says Dr. Pantilat.

Even if every hospital doesn’t arrange in-person follow-ups, there will be some form of contact after discharge. “Hospitals providing care in transition will expand a lot,” he explains, “whether it’s phone calls from a nurse or other healthcare professional or some other contact during that gap until a patient can re-establish with their primary care physician. Not every patient needs this, but a lot would benefit.”

THE HOSPITALIST ROLE IN DISCHARGE

As we move toward creating a better discharge process, hospitalists will be at the center of that change and the process itself.

“The hospitalist is the keeper of information,” says Dr. Arora. “They know why certain care decisions were made. This movement depends on the flow of information to help design systems to help implement communication.”

There are some barriers to a smooth discharge process that only hospitalists can eliminate. “The increased use of hospitalists means that patients are not familiar with their doctor” in the hospital, says Dr. Arora. “When they leave the hospital, some information stays behind. They don’t know who to call for that follow-up lab work prescribed in the hospital. … The hospitalist needs to do a better job of telling patients who they are and how to reach them after discharge. A systems-based solution, or solutions, is needed.”

It is up to hospitalists to ensure that their discharge system works, that each patient leaves with an understanding of next steps in their care and knows who to call for which specific follow-up step, and with contact information if they (or their primary care physician) need to reach their hospitalist.

Dr. Halasyamani believes that hospitalists are well positioned to implement change in general within their systems. “The hospitalist is in the trenches, in a position to see what changes have to take place,” she says. “It’s their role to inform their management of better processes.

Each of us needs to be a waver of the banner for new standards—it’s not good enough to just scribble prescriptions”

CONCLUSION

The future is coming fast, for improved hospital discharge as well as other everyday processes. “We’re learning that discharge should be a more structured, formal process,” says Dr. Whelan. “We’d like to move to a safer, more complete and more efficient way of handling it.”

Consider what your own facility is doing regarding discharging patients. If there is room for improvement, can you envision a way to bring that process into the future? TH

Jane Jerrard will continue writing the “Hospital of the Future” series this fall.

Flashback:

Colonial Hospitalists

250 years of admissions and discharge

The hospital-based physician must deal with many arcane and Byzantine criteria for admission, care, and discharge of patients. There are regulations for record-keeping and concerns about length of stay. Becoming a staff member may involve physician credentialing, and practitioners from other states or countries have to meet more rigorous standards.

This previous paragraph was not written about modern-day America. These issues are lifted from the “Rules and Regulations of the Pennsylvania Hospital” approved by the Board of Managers in 1752.1 The Pennsylvania Hospital was founded that year under the guidance of Benjamin Franklin. The facility was dedicated to care for the sick and poor. Among the biggest obstacles to its creation was fundraising. Franklin’s accounts of the early years of this institution included a final page with a useful form for donating money.

Hospitalists today face many of the same issues, including admission and discharge criteria, concerns about funding, and practice regulation, as their peers in 1752.

ADMISSION AND DISCHARGE CRITERIA

In 1752 there were 15 rules for admission and discharge of patients, as well as regulations for patients’ behavior while hospitalized. Among the most interesting:

1. No patients can be admitted if deemed incurable, lunaticks [sic] excepted, nor any case not requiring special services of a hospital.
2. No admits for smallpox, itch, or other infectious distempers unless proper apartments [isolation] available. Admits found to have the above will be discharged.
3. No admits of women with small children. Hospital will not maintain childcare facilities.
4. Persons admitted as above must provide funds for their own burial in case of their own demise.
5. 5. One bed to be held for a trauma case.
6. Patients will be discharged when cured or judged incurable
7. All cured patients must sign a release stating their cure and the benefit received from the hospital for use by the hospital managers.
8. No patient may leave the facility without a physician release. They may not swear or curse, get drunk, behave rudely or indecently, on pain of expulsion at first admonition.
9. No patient may gamble or beg.
10. Patients will aide in nursing other patients when able. This will include washing and ironing the linen and cleaning the rooms.

The Hospital Management Board was responsible for choosing a staff of six practitioners to manage these patients. There were guidelines for who could fill this job.

RULES FOR CHOICE OF PHYSICIANS AND SURGEONS

There were the rules in place in 1752 for choosing physicians and surgeons who could work in the hospital; the most interesting was that applying practitioners must be 27 years old, have served an apprenticeship in Philadelphia, have studied “physick” or surgery for seven years or more, and have undergone an exam by six hospital practitioners. Visiting practitioners had to reside in the city for three years before applying and then had to qualify under the same criteria.

LENGTH OF STAY

There was a significant interest in abstracting the admit diagnosis, length of stay, and outcome. The disposition of patients admitted during the first two years of the hospital’s existence, ending in April 1754 was presented in a modern format.

There were 117 admissions, with 60 cures. Eleven patients were relieved, though not cured. Seven were deemed incurable, 10 were taken away by friends, and 10 died. Three were discharged for irregular behavior, and 16 remained hospitalized.

The most common admission diagnosis was ulcers, representing almost a third of all admits, followed by lunacy. Other frequent diagnoses were dropsy (congestive heart disease), scrophulous and scorbutic diseases (extrapulmonary tuberculosis and scurvy) and rheumatism.

The highest mortality was for consumption, at 100%. The two patients admitted with flux (diarrhea) and prolapsus ani also died. Dropsy carried a 33% mortality rate, without the benefit of the latest medical innovation, foxglove (digitalis), which would be described a few decades later.2 Also notable is death from scurvy, the cure for which was described in 1753 by James Lind.3

The managers were pleased with the performance of the facility. They believed that their efforts had resulted in “good” for the 60 persons afflicted with “various distempers” who were cured and that many had received considerable relief. This was accomplished despite the limited amount of funds available, thanks to careful attendance afforded to the sick and poor, as well as proper diet and availability of medicines. Based on these favorable reports, the Board of Managers requested further funding.

Two hundred and fifty years later, physicians face many of the same issues, including admission and discharge criteria, concerns about funding, and practice regulation. Their actions continue to be monitored, and it is likely that the same will be true in the future. Hospital administrators remain frugal, and we are admonished, in the words of Benjamin Franklin, writing in Poor Richard’s Almanac, “A penny saved is a penny earned.”

—Jamie Newman, MD, FACP

REFERENCES

1. Franklin B. Some Account of the Pennsylvania Hospital 1754. (Facsimile Edition.) Baltimore: The Johns Hopkins Press; 1954.
2. Withering W. An Account of the Foxglove and Some of Its Medical Uses. Birmingham, England: M. Swinney; 1785.
3. Lind J. A Treatise of the Scurvy. Edinburgh, Scotland: Sands, Murray and Cochran; 1753.

This article is the second in a series on the hospital of the future, designed to get our readers thinking and planning ahead for their own facilities.

Hospitals across the country wrestle with improving their discharge process, whether the goal is gaining a more time- and cost-effective outcome for the facility, or improving quality measures for patients upon departure, or both.

“A lot of people are attacking discharge problems from a lot of different angles,” says Vineet Arora, MD, academic hospitalist and researcher, University of Chicago Pritzker School of Medicine.

What will hospital discharge look like in the future? Based on current research, trials, and trends, it seems there are few surprises down the road in this area. The changes will come in the form of fine-tuning critical areas in the process rather than implementing new technology to radically change the way we release patients. Positive changes seem to be people-based rather than computer-based.

“Everybody’s on the technology bandwagon, but we have to understand the processes first,” says Lakshmi Halasyamani, MD, associate chair for the Department of Internal Medicine, St. Joseph Mercy Hospital, Ann Arbor, Mich. “Better technology won’t make care safer or more efficient. We have to examine how we organize care delivery, then look at technology. Otherwise it replicates the inefficiencies we have now.”

Here are some predictions for how the discharge process will be improved in the hospital of the future.

THE DISCHARGE PROCESS WILL BE SMOOTHER AND SAFER

Most hospital-based professionals agree that discharge is an area of care that needs more attention.

“Every day that you’re [in the hospital], we spend a little less time with you,” says Dr. Halasyamani. “We undervalue the risk of discharging patients; we need to focus on [the patients] more. The nurse calls us, and we get the discharge done as quickly as possible.”

In the hospital of the future, the discharge process will be driven by specific structured guidelines that ensure patients safety when they leave the hospital. Every discharge will involve a multidisciplinary team, with members signing off that the patient is not only ready to leave the hospital, but informed about their condition and any next steps, and has necessary medications or prescriptions in hand.

As for improving efficiency, minor changes can make a big difference. Chad Whelan, MD, assistant professor of medicine, University of Chicago Hospitals, is part of a task force working on how to move hospital discharges earlier in the day.

“An earlier discharge is better for everyone, including the patient—especially if they’re being transferred to another facility,” he points out. “One thing we’re looking at is the way diagnostic tests are categorized. Everything falls into two categories now: emergency diagnostics and everything else.”

Dr. Whelan and the taskforce have asked departments, including radiology and other labs, to create a third category: for patients waiting for a test before they can be discharged. All it takes is one question on the part of the service provider: “Is this patient waiting for these results before she can go home?” to move that patient to the front of the line.

Another recommendation Dr. Whelan’s task force will make involves staffing up. “Like we ramp nursing staff up and down depending on the census, we are looking at doing that with case managers and ward clerks to handle heavy discharge times,” he says.

David J. Rosenman, MD, senior associate consultant, Hospital Internal Medicine, Mayo Clinic in Rochester, Minn., suggests that paperwork might also be changed. “The discharge summary of the future will be more visual,” he predicts. “There are ways of displaying information that are more sophisticated and probably more helpful than static lists and linear prose alone.”

EMPOWERED PATIENTS

One change we are likely to see is patients taking on the responsibility of their own medical information. Ideally, the patients themselves will make caring for—and discharging—them easier and more efficient by sharing complete information on their current medications and other healthcare details that are often forgotten or overlooked by a provider or caregiver.

“The future of discharge lies with our ability to arm patients with their own information,” says Dr. Arora. “The more empowered the patient is, the better the outcome.” Personal health records (PHRs) are one solution. MyPHR is one online product, offered free by the American Health Information Management Association (AHIMA). Roughly 30 companies currently offer paid subscription PHR services to consumers. Peoplechart Corporation (San Francisco) is one of them and provides a single source of information controlled by the patient.

“We’re a pioneer of the PHR idea,” says Megan Mok, president and founder, Peoplechart Corporation. “There are not that many out there.”

Healthcare consumers can subscribe to a variety of Peoplechart tools and services (including initial collection of their records) that allow them to gain access to their comprehensive medical records via the Internet—or phone, if they choose—and to grant any given healthcare provider access to part or all of their records.

“Everything is patient-initiated and patient-controlled,” explains Mok. “There’s a big difference from systems controlled by providers, which may allow patients access, but not ownership.”

PHRs typically offer a comprehensive, integrated overview of an individual’s health data, including information that individuals add themselves on their symptoms and prescriptions, along with information such as diagnoses and lab results. Once a discharged patient updates her PHR, she can share her complete hospital records with her primary care physician, physical therapist, rehab facility, or whatever caregiver requires the information. This will save time and effort for all healthcare providers, and, more importantly, ensures that essential information is available.

Regardless of whether a patient has a PHR, physicians and other staff must ensure that the individual leaves the hospital with complete information on their care and medications.

“Discharge is a quality measure,” says Dr. Arora. “We need a multidisciplinary approach to address what each patient needs to go home.”

DEMYSTIFIED MEDICATIONS

In the very near future, the 2006 JCAHO standard for medication reconciliation will eliminate many problems with medications after discharge.

“This standard is extremely important,” says Dr. Rosenman. “Almost half of medication errors occur at transition points in a patient’s care. Reconciling medication lists—especially at these points—is critical to ensuring patient safety.”

The medication reconciliation form could conceivably morph into something broader in the future. “It would be nice for the medical record to be a living document that evolved with each encounter over the course of a patient’s life,” says Dr. Rosenman. “People may someday carry replaceable, updatable, credit-card-like medical cards or chips. In the meantime, we need to do our very best to keep medication lists and related data accurate and complete.”

While the patient will own his or her medical information, “the burden for ensuring the med list is accurate falls entirely on the healthcare organization,” insists Dr. Halasyamani. “This is a ripe opportunity to partner with the patients themselves. They and their families own the information. We have to help patients be stakeholders and give them the tools to manage their ever-changing medications and their healthcare.”

Many paper-based and computerized tools exist now, but there is no obvious standout product or method physicians can provide to patients that will ensure they take their prescriptions correctly on an ongoing basis.

“Health systems will have to develop a standard” for helping patients manage their medications, says Dr. Halasyamani. “Strategies must be low-tech but get the job done. They must resonate with things that patients already do, like paying bills.”

COMMUNICATION STILL CRITICAL

One step in the discharge process that ensures a smooth transition for inpatient to outpatient is communication with the professionals, facilities, or caregivers who will take over the patient’s care.

“The gap in care after discharge puts patients at risk for adverse events,” warns Dr. Arora. “One reason for this vulnerable gap is the flow of information between settings and teams of providers.” In the future, hospitals will better manage this essential transfer of information.

Typically, the patient’s primary care physician wants information from the hospital at admission and at discharge, and, if the primary care physician wishes, in between.

“We need to improve communications with primary care physicians in a way that respects their wishes for communication,” says Dr. Arora. The UCSF Hospitalist Group is already working on this.

“Until recently, we provided fax copies of our notes to primary care physicians. Now we have a new dictation system,” says Steven Pantilat, MD, FACP, SHM president. “We did a survey that found that most physicians want telephone contact at admission and at discharge, plus any major occurrences in between. The ability to exchange information in real time is important—and e-mail is not realtime.”

How does a hospitalist keep track of everyone’s communication preferences? “The hospitalist simply has to figure out what each primary care physician wants,” stresses Dr. Pantilat. “My sense is that in any hospital, there is a limited number of doctors or practices to deal with. How do you keep them all straight? Well, the same way a hospitalist keeps all the various nurses straight—you just do. It’s your business.”

PLANNED FOLLOW-UP

In the future, nearly every discharged patient will be contacted within two or three days by the hospitalist or another hospital medical staff. This may come in the form of a phone call to the patient to check on their overall health, symptoms, and medications. Or it may be a more hands-on approach.

The UCSF Medical Center has established a follow-up service to provide care to patients during the transition period immediately following discharge.

“This service was designed for patients who couldn’t otherwise be followed up on or those who would benefit from seeing the doctor who treated them in the hospital,” explains Dr. Pantilat, who initiated the idea for the service. “For example, if a patient with DVT was discharged, is the swelling smaller? The primary care physician can’t say—he didn’t see it.”

Out of more than 2,600 discharges during 1997-1998, the first year that the follow-up service existed, only 47 patients were prescribed with follow-up visits. “It was never meant to be a highly utilized service,” says Dr. Pantilat, “but to be a highly expandable, flexible service that addresses the needs of specific patients.” Of those 47 patients, four were readmitted to the hospital—one directly from the follow-up visit—compared with a national readmission average of 14%.

“We see these patients in the ED,” says Dr. Pantilat. “It’s the only department that’s open 24/7, and the ED has some extra bed capacity.”

When the hospitalist feels a follow-up is necessary, he or she schedules a visit with the patient before discharge for midmorning one or two days after discharge. (Midmorning is typically a slow time in the emergency department.) He then faxes the appointment information to the emergency department, so that when the patient shows up, she is preregistered. The emergency department telephones the hospitalist when the patient arrives, and that doctor then comes down to see the patient. The emergency department physicians have nothing to do with these follow-ups, though the nursing staff might be asked to help. Also, follow-up visits are considered an outpatient service and charged as such. “The follow-up service was established and run at virtually no cost,” says Dr. Pantilat.

Even if every hospital doesn’t arrange in-person follow-ups, there will be some form of contact after discharge. “Hospitals providing care in transition will expand a lot,” he explains, “whether it’s phone calls from a nurse or other healthcare professional or some other contact during that gap until a patient can re-establish with their primary care physician. Not every patient needs this, but a lot would benefit.”

THE HOSPITALIST ROLE IN DISCHARGE

As we move toward creating a better discharge process, hospitalists will be at the center of that change and the process itself.

“The hospitalist is the keeper of information,” says Dr. Arora. “They know why certain care decisions were made. This movement depends on the flow of information to help design systems to help implement communication.”

There are some barriers to a smooth discharge process that only hospitalists can eliminate. “The increased use of hospitalists means that patients are not familiar with their doctor” in the hospital, says Dr. Arora. “When they leave the hospital, some information stays behind. They don’t know who to call for that follow-up lab work prescribed in the hospital. … The hospitalist needs to do a better job of telling patients who they are and how to reach them after discharge. A systems-based solution, or solutions, is needed.”

It is up to hospitalists to ensure that their discharge system works, that each patient leaves with an understanding of next steps in their care and knows who to call for which specific follow-up step, and with contact information if they (or their primary care physician) need to reach their hospitalist.

Dr. Halasyamani believes that hospitalists are well positioned to implement change in general within their systems. “The hospitalist is in the trenches, in a position to see what changes have to take place,” she says. “It’s their role to inform their management of better processes.

Each of us needs to be a waver of the banner for new standards—it’s not good enough to just scribble prescriptions”

CONCLUSION

The future is coming fast, for improved hospital discharge as well as other everyday processes. “We’re learning that discharge should be a more structured, formal process,” says Dr. Whelan. “We’d like to move to a safer, more complete and more efficient way of handling it.”

Consider what your own facility is doing regarding discharging patients. If there is room for improvement, can you envision a way to bring that process into the future? TH

Jane Jerrard will continue writing the “Hospital of the Future” series this fall.

Flashback:

Colonial Hospitalists

250 years of admissions and discharge

The hospital-based physician must deal with many arcane and Byzantine criteria for admission, care, and discharge of patients. There are regulations for record-keeping and concerns about length of stay. Becoming a staff member may involve physician credentialing, and practitioners from other states or countries have to meet more rigorous standards.

This previous paragraph was not written about modern-day America. These issues are lifted from the “Rules and Regulations of the Pennsylvania Hospital” approved by the Board of Managers in 1752.1 The Pennsylvania Hospital was founded that year under the guidance of Benjamin Franklin. The facility was dedicated to care for the sick and poor. Among the biggest obstacles to its creation was fundraising. Franklin’s accounts of the early years of this institution included a final page with a useful form for donating money.

Hospitalists today face many of the same issues, including admission and discharge criteria, concerns about funding, and practice regulation, as their peers in 1752.

ADMISSION AND DISCHARGE CRITERIA

In 1752 there were 15 rules for admission and discharge of patients, as well as regulations for patients’ behavior while hospitalized. Among the most interesting:

1. No patients can be admitted if deemed incurable, lunaticks [sic] excepted, nor any case not requiring special services of a hospital.
2. No admits for smallpox, itch, or other infectious distempers unless proper apartments [isolation] available. Admits found to have the above will be discharged.
3. No admits of women with small children. Hospital will not maintain childcare facilities.
4. Persons admitted as above must provide funds for their own burial in case of their own demise.
5. 5. One bed to be held for a trauma case.
6. Patients will be discharged when cured or judged incurable
7. All cured patients must sign a release stating their cure and the benefit received from the hospital for use by the hospital managers.
8. No patient may leave the facility without a physician release. They may not swear or curse, get drunk, behave rudely or indecently, on pain of expulsion at first admonition.
9. No patient may gamble or beg.
10. Patients will aide in nursing other patients when able. This will include washing and ironing the linen and cleaning the rooms.

The Hospital Management Board was responsible for choosing a staff of six practitioners to manage these patients. There were guidelines for who could fill this job.

RULES FOR CHOICE OF PHYSICIANS AND SURGEONS

There were the rules in place in 1752 for choosing physicians and surgeons who could work in the hospital; the most interesting was that applying practitioners must be 27 years old, have served an apprenticeship in Philadelphia, have studied “physick” or surgery for seven years or more, and have undergone an exam by six hospital practitioners. Visiting practitioners had to reside in the city for three years before applying and then had to qualify under the same criteria.

LENGTH OF STAY

There was a significant interest in abstracting the admit diagnosis, length of stay, and outcome. The disposition of patients admitted during the first two years of the hospital’s existence, ending in April 1754 was presented in a modern format.

There were 117 admissions, with 60 cures. Eleven patients were relieved, though not cured. Seven were deemed incurable, 10 were taken away by friends, and 10 died. Three were discharged for irregular behavior, and 16 remained hospitalized.

The most common admission diagnosis was ulcers, representing almost a third of all admits, followed by lunacy. Other frequent diagnoses were dropsy (congestive heart disease), scrophulous and scorbutic diseases (extrapulmonary tuberculosis and scurvy) and rheumatism.

The highest mortality was for consumption, at 100%. The two patients admitted with flux (diarrhea) and prolapsus ani also died. Dropsy carried a 33% mortality rate, without the benefit of the latest medical innovation, foxglove (digitalis), which would be described a few decades later.2 Also notable is death from scurvy, the cure for which was described in 1753 by James Lind.3

The managers were pleased with the performance of the facility. They believed that their efforts had resulted in “good” for the 60 persons afflicted with “various distempers” who were cured and that many had received considerable relief. This was accomplished despite the limited amount of funds available, thanks to careful attendance afforded to the sick and poor, as well as proper diet and availability of medicines. Based on these favorable reports, the Board of Managers requested further funding.

Two hundred and fifty years later, physicians face many of the same issues, including admission and discharge criteria, concerns about funding, and practice regulation. Their actions continue to be monitored, and it is likely that the same will be true in the future. Hospital administrators remain frugal, and we are admonished, in the words of Benjamin Franklin, writing in Poor Richard’s Almanac, “A penny saved is a penny earned.”

—Jamie Newman, MD, FACP

REFERENCES

1. Franklin B. Some Account of the Pennsylvania Hospital 1754. (Facsimile Edition.) Baltimore: The Johns Hopkins Press; 1954.
2. Withering W. An Account of the Foxglove and Some of Its Medical Uses. Birmingham, England: M. Swinney; 1785.
3. Lind J. A Treatise of the Scurvy. Edinburgh, Scotland: Sands, Murray and Cochran; 1753.

This article is the second in a series on the hospital of the future, designed to get our readers thinking and planning ahead for their own facilities.

Hospitals across the country wrestle with improving their discharge process, whether the goal is gaining a more time- and cost-effective outcome for the facility, or improving quality measures for patients upon departure, or both.

“A lot of people are attacking discharge problems from a lot of different angles,” says Vineet Arora, MD, academic hospitalist and researcher, University of Chicago Pritzker School of Medicine.

What will hospital discharge look like in the future? Based on current research, trials, and trends, it seems there are few surprises down the road in this area. The changes will come in the form of fine-tuning critical areas in the process rather than implementing new technology to radically change the way we release patients. Positive changes seem to be people-based rather than computer-based.

“Everybody’s on the technology bandwagon, but we have to understand the processes first,” says Lakshmi Halasyamani, MD, associate chair for the Department of Internal Medicine, St. Joseph Mercy Hospital, Ann Arbor, Mich. “Better technology won’t make care safer or more efficient. We have to examine how we organize care delivery, then look at technology. Otherwise it replicates the inefficiencies we have now.”

Here are some predictions for how the discharge process will be improved in the hospital of the future.

THE DISCHARGE PROCESS WILL BE SMOOTHER AND SAFER

Most hospital-based professionals agree that discharge is an area of care that needs more attention.

“Every day that you’re [in the hospital], we spend a little less time with you,” says Dr. Halasyamani. “We undervalue the risk of discharging patients; we need to focus on [the patients] more. The nurse calls us, and we get the discharge done as quickly as possible.”

In the hospital of the future, the discharge process will be driven by specific structured guidelines that ensure patients safety when they leave the hospital. Every discharge will involve a multidisciplinary team, with members signing off that the patient is not only ready to leave the hospital, but informed about their condition and any next steps, and has necessary medications or prescriptions in hand.

As for improving efficiency, minor changes can make a big difference. Chad Whelan, MD, assistant professor of medicine, University of Chicago Hospitals, is part of a task force working on how to move hospital discharges earlier in the day.

“An earlier discharge is better for everyone, including the patient—especially if they’re being transferred to another facility,” he points out. “One thing we’re looking at is the way diagnostic tests are categorized. Everything falls into two categories now: emergency diagnostics and everything else.”

Dr. Whelan and the taskforce have asked departments, including radiology and other labs, to create a third category: for patients waiting for a test before they can be discharged. All it takes is one question on the part of the service provider: “Is this patient waiting for these results before she can go home?” to move that patient to the front of the line.

Another recommendation Dr. Whelan’s task force will make involves staffing up. “Like we ramp nursing staff up and down depending on the census, we are looking at doing that with case managers and ward clerks to handle heavy discharge times,” he says.

David J. Rosenman, MD, senior associate consultant, Hospital Internal Medicine, Mayo Clinic in Rochester, Minn., suggests that paperwork might also be changed. “The discharge summary of the future will be more visual,” he predicts. “There are ways of displaying information that are more sophisticated and probably more helpful than static lists and linear prose alone.”

EMPOWERED PATIENTS

One change we are likely to see is patients taking on the responsibility of their own medical information. Ideally, the patients themselves will make caring for—and discharging—them easier and more efficient by sharing complete information on their current medications and other healthcare details that are often forgotten or overlooked by a provider or caregiver.

“The future of discharge lies with our ability to arm patients with their own information,” says Dr. Arora. “The more empowered the patient is, the better the outcome.” Personal health records (PHRs) are one solution. MyPHR is one online product, offered free by the American Health Information Management Association (AHIMA). Roughly 30 companies currently offer paid subscription PHR services to consumers. Peoplechart Corporation (San Francisco) is one of them and provides a single source of information controlled by the patient.

“We’re a pioneer of the PHR idea,” says Megan Mok, president and founder, Peoplechart Corporation. “There are not that many out there.”

Healthcare consumers can subscribe to a variety of Peoplechart tools and services (including initial collection of their records) that allow them to gain access to their comprehensive medical records via the Internet—or phone, if they choose—and to grant any given healthcare provider access to part or all of their records.

“Everything is patient-initiated and patient-controlled,” explains Mok. “There’s a big difference from systems controlled by providers, which may allow patients access, but not ownership.”

PHRs typically offer a comprehensive, integrated overview of an individual’s health data, including information that individuals add themselves on their symptoms and prescriptions, along with information such as diagnoses and lab results. Once a discharged patient updates her PHR, she can share her complete hospital records with her primary care physician, physical therapist, rehab facility, or whatever caregiver requires the information. This will save time and effort for all healthcare providers, and, more importantly, ensures that essential information is available.

Regardless of whether a patient has a PHR, physicians and other staff must ensure that the individual leaves the hospital with complete information on their care and medications.

“Discharge is a quality measure,” says Dr. Arora. “We need a multidisciplinary approach to address what each patient needs to go home.”

DEMYSTIFIED MEDICATIONS

In the very near future, the 2006 JCAHO standard for medication reconciliation will eliminate many problems with medications after discharge.

“This standard is extremely important,” says Dr. Rosenman. “Almost half of medication errors occur at transition points in a patient’s care. Reconciling medication lists—especially at these points—is critical to ensuring patient safety.”

The medication reconciliation form could conceivably morph into something broader in the future. “It would be nice for the medical record to be a living document that evolved with each encounter over the course of a patient’s life,” says Dr. Rosenman. “People may someday carry replaceable, updatable, credit-card-like medical cards or chips. In the meantime, we need to do our very best to keep medication lists and related data accurate and complete.”

While the patient will own his or her medical information, “the burden for ensuring the med list is accurate falls entirely on the healthcare organization,” insists Dr. Halasyamani. “This is a ripe opportunity to partner with the patients themselves. They and their families own the information. We have to help patients be stakeholders and give them the tools to manage their ever-changing medications and their healthcare.”

Many paper-based and computerized tools exist now, but there is no obvious standout product or method physicians can provide to patients that will ensure they take their prescriptions correctly on an ongoing basis.

“Health systems will have to develop a standard” for helping patients manage their medications, says Dr. Halasyamani. “Strategies must be low-tech but get the job done. They must resonate with things that patients already do, like paying bills.”

COMMUNICATION STILL CRITICAL

One step in the discharge process that ensures a smooth transition for inpatient to outpatient is communication with the professionals, facilities, or caregivers who will take over the patient’s care.

“The gap in care after discharge puts patients at risk for adverse events,” warns Dr. Arora. “One reason for this vulnerable gap is the flow of information between settings and teams of providers.” In the future, hospitals will better manage this essential transfer of information.

Typically, the patient’s primary care physician wants information from the hospital at admission and at discharge, and, if the primary care physician wishes, in between.

“We need to improve communications with primary care physicians in a way that respects their wishes for communication,” says Dr. Arora. The UCSF Hospitalist Group is already working on this.

“Until recently, we provided fax copies of our notes to primary care physicians. Now we have a new dictation system,” says Steven Pantilat, MD, FACP, SHM president. “We did a survey that found that most physicians want telephone contact at admission and at discharge, plus any major occurrences in between. The ability to exchange information in real time is important—and e-mail is not realtime.”

How does a hospitalist keep track of everyone’s communication preferences? “The hospitalist simply has to figure out what each primary care physician wants,” stresses Dr. Pantilat. “My sense is that in any hospital, there is a limited number of doctors or practices to deal with. How do you keep them all straight? Well, the same way a hospitalist keeps all the various nurses straight—you just do. It’s your business.”

PLANNED FOLLOW-UP

In the future, nearly every discharged patient will be contacted within two or three days by the hospitalist or another hospital medical staff. This may come in the form of a phone call to the patient to check on their overall health, symptoms, and medications. Or it may be a more hands-on approach.

The UCSF Medical Center has established a follow-up service to provide care to patients during the transition period immediately following discharge.

“This service was designed for patients who couldn’t otherwise be followed up on or those who would benefit from seeing the doctor who treated them in the hospital,” explains Dr. Pantilat, who initiated the idea for the service. “For example, if a patient with DVT was discharged, is the swelling smaller? The primary care physician can’t say—he didn’t see it.”

Out of more than 2,600 discharges during 1997-1998, the first year that the follow-up service existed, only 47 patients were prescribed with follow-up visits. “It was never meant to be a highly utilized service,” says Dr. Pantilat, “but to be a highly expandable, flexible service that addresses the needs of specific patients.” Of those 47 patients, four were readmitted to the hospital—one directly from the follow-up visit—compared with a national readmission average of 14%.

“We see these patients in the ED,” says Dr. Pantilat. “It’s the only department that’s open 24/7, and the ED has some extra bed capacity.”

When the hospitalist feels a follow-up is necessary, he or she schedules a visit with the patient before discharge for midmorning one or two days after discharge. (Midmorning is typically a slow time in the emergency department.) He then faxes the appointment information to the emergency department, so that when the patient shows up, she is preregistered. The emergency department telephones the hospitalist when the patient arrives, and that doctor then comes down to see the patient. The emergency department physicians have nothing to do with these follow-ups, though the nursing staff might be asked to help. Also, follow-up visits are considered an outpatient service and charged as such. “The follow-up service was established and run at virtually no cost,” says Dr. Pantilat.

Even if every hospital doesn’t arrange in-person follow-ups, there will be some form of contact after discharge. “Hospitals providing care in transition will expand a lot,” he explains, “whether it’s phone calls from a nurse or other healthcare professional or some other contact during that gap until a patient can re-establish with their primary care physician. Not every patient needs this, but a lot would benefit.”

THE HOSPITALIST ROLE IN DISCHARGE

As we move toward creating a better discharge process, hospitalists will be at the center of that change and the process itself.

“The hospitalist is the keeper of information,” says Dr. Arora. “They know why certain care decisions were made. This movement depends on the flow of information to help design systems to help implement communication.”

There are some barriers to a smooth discharge process that only hospitalists can eliminate. “The increased use of hospitalists means that patients are not familiar with their doctor” in the hospital, says Dr. Arora. “When they leave the hospital, some information stays behind. They don’t know who to call for that follow-up lab work prescribed in the hospital. … The hospitalist needs to do a better job of telling patients who they are and how to reach them after discharge. A systems-based solution, or solutions, is needed.”

It is up to hospitalists to ensure that their discharge system works, that each patient leaves with an understanding of next steps in their care and knows who to call for which specific follow-up step, and with contact information if they (or their primary care physician) need to reach their hospitalist.

Dr. Halasyamani believes that hospitalists are well positioned to implement change in general within their systems. “The hospitalist is in the trenches, in a position to see what changes have to take place,” she says. “It’s their role to inform their management of better processes.

Each of us needs to be a waver of the banner for new standards—it’s not good enough to just scribble prescriptions”

CONCLUSION

The future is coming fast, for improved hospital discharge as well as other everyday processes. “We’re learning that discharge should be a more structured, formal process,” says Dr. Whelan. “We’d like to move to a safer, more complete and more efficient way of handling it.”

Consider what your own facility is doing regarding discharging patients. If there is room for improvement, can you envision a way to bring that process into the future? TH

Jane Jerrard will continue writing the “Hospital of the Future” series this fall.

Flashback:

Colonial Hospitalists

250 years of admissions and discharge

The hospital-based physician must deal with many arcane and Byzantine criteria for admission, care, and discharge of patients. There are regulations for record-keeping and concerns about length of stay. Becoming a staff member may involve physician credentialing, and practitioners from other states or countries have to meet more rigorous standards.

This previous paragraph was not written about modern-day America. These issues are lifted from the “Rules and Regulations of the Pennsylvania Hospital” approved by the Board of Managers in 1752.1 The Pennsylvania Hospital was founded that year under the guidance of Benjamin Franklin. The facility was dedicated to care for the sick and poor. Among the biggest obstacles to its creation was fundraising. Franklin’s accounts of the early years of this institution included a final page with a useful form for donating money.

Hospitalists today face many of the same issues, including admission and discharge criteria, concerns about funding, and practice regulation, as their peers in 1752.

ADMISSION AND DISCHARGE CRITERIA

In 1752 there were 15 rules for admission and discharge of patients, as well as regulations for patients’ behavior while hospitalized. Among the most interesting:

1. No patients can be admitted if deemed incurable, lunaticks [sic] excepted, nor any case not requiring special services of a hospital.
2. No admits for smallpox, itch, or other infectious distempers unless proper apartments [isolation] available. Admits found to have the above will be discharged.
3. No admits of women with small children. Hospital will not maintain childcare facilities.
4. Persons admitted as above must provide funds for their own burial in case of their own demise.
5. 5. One bed to be held for a trauma case.
6. Patients will be discharged when cured or judged incurable
7. All cured patients must sign a release stating their cure and the benefit received from the hospital for use by the hospital managers.
8. No patient may leave the facility without a physician release. They may not swear or curse, get drunk, behave rudely or indecently, on pain of expulsion at first admonition.
9. No patient may gamble or beg.
10. Patients will aide in nursing other patients when able. This will include washing and ironing the linen and cleaning the rooms.

The Hospital Management Board was responsible for choosing a staff of six practitioners to manage these patients. There were guidelines for who could fill this job.

RULES FOR CHOICE OF PHYSICIANS AND SURGEONS

There were the rules in place in 1752 for choosing physicians and surgeons who could work in the hospital; the most interesting was that applying practitioners must be 27 years old, have served an apprenticeship in Philadelphia, have studied “physick” or surgery for seven years or more, and have undergone an exam by six hospital practitioners. Visiting practitioners had to reside in the city for three years before applying and then had to qualify under the same criteria.

LENGTH OF STAY

There was a significant interest in abstracting the admit diagnosis, length of stay, and outcome. The disposition of patients admitted during the first two years of the hospital’s existence, ending in April 1754 was presented in a modern format.

There were 117 admissions, with 60 cures. Eleven patients were relieved, though not cured. Seven were deemed incurable, 10 were taken away by friends, and 10 died. Three were discharged for irregular behavior, and 16 remained hospitalized.

The most common admission diagnosis was ulcers, representing almost a third of all admits, followed by lunacy. Other frequent diagnoses were dropsy (congestive heart disease), scrophulous and scorbutic diseases (extrapulmonary tuberculosis and scurvy) and rheumatism.

The highest mortality was for consumption, at 100%. The two patients admitted with flux (diarrhea) and prolapsus ani also died. Dropsy carried a 33% mortality rate, without the benefit of the latest medical innovation, foxglove (digitalis), which would be described a few decades later.2 Also notable is death from scurvy, the cure for which was described in 1753 by James Lind.3

The managers were pleased with the performance of the facility. They believed that their efforts had resulted in “good” for the 60 persons afflicted with “various distempers” who were cured and that many had received considerable relief. This was accomplished despite the limited amount of funds available, thanks to careful attendance afforded to the sick and poor, as well as proper diet and availability of medicines. Based on these favorable reports, the Board of Managers requested further funding.

Two hundred and fifty years later, physicians face many of the same issues, including admission and discharge criteria, concerns about funding, and practice regulation. Their actions continue to be monitored, and it is likely that the same will be true in the future. Hospital administrators remain frugal, and we are admonished, in the words of Benjamin Franklin, writing in Poor Richard’s Almanac, “A penny saved is a penny earned.”

—Jamie Newman, MD, FACP

REFERENCES

1. Franklin B. Some Account of the Pennsylvania Hospital 1754. (Facsimile Edition.) Baltimore: The Johns Hopkins Press; 1954.
2. Withering W. An Account of the Foxglove and Some of Its Medical Uses. Birmingham, England: M. Swinney; 1785.
3. Lind J. A Treatise of the Scurvy. Edinburgh, Scotland: Sands, Murray and Cochran; 1753.

SHM has established an aggressive goal of getting 400 respondents for its biannual Productivity and Compensation Survey. This would mean a 33% increase over the 300 respondents to the 2003 survey. SHM is tracking the number of respondents on its Web site homepage (www.hospitalmedicine.org). All surveys must be completed and returned by Nov. 25.

By now hospital medicine group leaders should have received a copy of the survey with instructions. SHM prefers that you complete the survey online. The response process for the online survey is simplified with built-in edits and a streamlined flow. In addition, you can stop in the middle of the questionnaire and return to complete it later.

WHY SHOULD YOU PARTICIPATE?

• Information: The survey questions represent the metrics most critical in benchmarking your hospital medicine program. You’ll be able to compare the characteristics and performance of your group with other hospital medicine programs across the country.
• Financial Incentive: There is a financial incentive to participate. Only survey respondents will receive the full survey report and analysis on a CD at no additional charge. Nonrespondents will pay as much as $495 for the results. The results will be available at the SHM Annual Meeting in Washington D.C., May 3-5, 2006.
• Potential Awards: Participants will be eligible to participate in a drawing to receive complimentary registrations to an upcoming Leadership Academy (valued at $1,500) or to the 2006 SHM Annual Meeting (valued at $525). If your group submits its completed questionnaires by Oct. 25 it will have two entries in the drawing. After that date, you’ll receive only one entry.
• Confidentiality: Survey responses will be completely confidential and data will be reported only in the aggregate. International Communications Research, an experienced survey research firm, is conducting the survey. SHM is not involved in collecting or processing the data.

SURVEY CONTENT

This year’s survey builds on the success of the 2003 survey, which is viewed by SHM members as the most accurate and useful source of hospitalist benchmark information. The 2005 survey features the following improvements: better definitions and instructions, and additional questions covering such topics as night coverage, hospitalist services, and the use of nurse practitioners and physician assistants.

The group questionnaire poses questions intended to characterize your hospital medicine program at the group and hospital level. To answer these questions you will need specific information about your hospital (e.g., number of beds, teaching status), the number of fulltime employees (including nonclinical staff), staff turnover, additional revenue received from the hospital or other sources, and the program’s average length-of-stay and case-mix index.

The individual questionnaire poses questions at individual hospitalist level. To answer these you will need information about demographics (age, gender, fulltime employees, specialty, years as a hospitalist, years with group), billing information (encounters, relative value units, charges, collections), hours and shifts worked, and compensation/ benefits for each hospitalist in the group.

CALL TO ACTION

If your hospital medicine group has not received a survey and you would like to participate, e-mail the following information to Marie Francois at [email protected]: the name of your group, leader’s name, mailing address, e-mail, and telephone number. If you are completing the survey and you need clarification about any of the questions, contact SHM Customer Service at [email protected] or call (800) 843-3360.

As hospital medicine continues to grow and emerge, SHM seeks to provide vital data characterizing the specialty to hospitalists, hospital and healthcare leaders, and policymakers. The 2005 Productivity and Compensation Survey is the key vehicle for providing that data. Help us achieve our goal of 400 hospital medicine group respondents.

Joe Miller is senior vice president for SHM.

NPs and PAs Help Shape SHM Initiatives

By Kevin Whitford, MD

The Nonphysician-Provider Task Force met at SHM’s Annual Meeting in Chicago in April. The meeting marked a significant transition as Mitchell Wilson, MD, concluded his term as chair of the committee. Dr. Wilson’s excellent leadership and organization greatly benefited the task force during its inaugural year. The task force is fortunate to have Dr. Wilson remain as a member.

During the April meeting, the group reviewed the SHM charge to the task force: the responsibility to develop initiatives and programs to promote and define the role of nurse practitioners, physician assistants, and other hospitalist nonphysician providers in hospital medicine. The task force must recommend an SHM nonphysicianprovider agenda to the SHM Board. The task force is looking for opportunities to encourage nonphysician providers to become active SHM members.

The group prepared a document, “Top Five Roles/Functions for Nonphysician Providers” to present to the SHM Board as a framework for the future.

At the annual meeting the task force pursued strategic planning for 2005 and 2006. The Web-based “Resource Center” development was at the top of the list. The task force has collected job descriptions that include acute care nurse practitioner, hospitalist physician assistant, clinical care coordinator, clinical nurse manager, hospitalist case manager, hospitalist program manager, and medical director.

Competency forms are also posted on the SHM Web site; the forms may be used as models to evaluate hospitalist clinical coordinator, hospitalist physician assistant, hospitalist program manager, and advanced nurse practitioner in hospital medicine. The task force plans to expand this resource area to include staffing models, billing and documentation, frequently asked questions, and a document on the value added by nonphysician providers.

The Nonphysician-Provider Task Force also has a “Hub and Spoke” initiative to broaden the input for nonphysician providers by linking members to the task force with hospitalist nonphysician providers across a broad representation of practices.

Other covered areas include plans for publishing articles in The Hospitalist, membership initiatives, and promoting the development of external relationships with national organizations such as the American Academy of Physician Assistants and American Association of Nurse Practitioners.

Task force members helped lead the forum on nonphysician providers at the SHM Annual Meeting. Participants’ questions ranged from specifics regarding the roles of nonphysician providers to filling in documentation issues and included a broad spectrum of practice types from small private to large academic medical centers. The Nonphysician-Provider Task Force is making plans for the program for the 2006 Annual Meeting.

We’ve also sought involvement across the spectrum of task forces and committees in the SHM to increase the representation and raise the awareness of nonphysician providers.

The SHM Board approved the list of top five roles for nonphysician providers in SHM. These include:

1. To foster hospital medicine nonphysician-provider educational and professional development;
2. To network with other nonphysician providers to share ideas concerning the integration of nonphysician providers in hospital medicine;
3. To provide input to SHM and SHM committees/task forces related to the role of the nonphysician provider on the hospital medicine team;
4. To serve as “ambassadors” for SHM recruitment of nonphysician-provider members; and
5. To share varied expertise in the educational offerings pertinent to nonphysician providers on the hospitalist team.

In the coming year, the task force will further refine this list and present a revised charge to the SHM Board. The original charge specifically mentions only nurse practitioners and physician assistants. We’ve been fortunate to have a clinical care coordinator and a health systems pharmacist join the task force. This broader perspective will benefit the task force and recognizes the broad range of professionals working with the hospitalist team.

If you’re interested in the issues being addressed by the Nonphysician-Provider Task Force, you have several avenues available to pursue those interests. The SHM listserv is an active forum for discussing issues and sharing solutions. If you’re interested in working with the Nonphysician Task Force directly, contact Jeanette Kalupa at [email protected] or Scarlett Blue at [email protected] to be added to the Hub and Spoke initiative. You can also visit the resource center on the SHM Web site to view the nonphysician-provider resources, or you can submit documents for the task force to review for posting to the resource area.

Dr. Whitford is chair of SHM’s Nonphysician-Provider Task Force. Contact him at [email protected].

10 Tips for a Successful Compensation Negotiation

Here are some strategies that Linda Snelling, MD, presented at the Pediatric Hospital Medicine conference in Denver in July regarding how to best negotiate your compensation. These strategies apply to all hospitalists.

1. Start with value: describe what you’re doing, who benefits from your work.
2. Review your own billing and collections.
3. Evaluate your program costs.
4. Apply for grants (finding money allows your program to grow).
5. Determine synergy: Are you fulfilling your role in the institution/department? Are there other opportunities to explore?
6. Start from a position of strength. Determining how much the opponent is willing to pay or increase support based on your current success and the anticipated benefit from your continued efforts is the starting point from which you have to negotiate up. A better position is to determine the amount by which you want your support adjusted so you are at the starting point from which the opponent negotiates down.
7. Remember, you’re not going in there for a handout. You’re going in there with a promise of what you’ll deliver.
8. Think long term.
9. Leave room to negotiate. Never put all your cards on the table. You’ll have to make concessions; get something for that concession. “If you can’t do 8%, what can you do? 5%. OK, so what about 5% this year and 5% next year?”
10. Remain positive.

SHM’s Advocacy Efforts

Pay-for-performance legislation gains momentum on Capitol Hill

By Eric Siegal, MD

Washington policymakers are embracing a new approach to reforming the Medicare payment system: giving physicians and other providers financial incentives to meet certain quality standards. The so-called “pay-for-performance” or “value-based purchasing” model contained in various bills moving through Congress builds on recommendations made earlier this year by the Medicare Payment Advisory Commission (MedPAC) and mirrors initiatives that have proliferated in the private sector. In its March 2005 report to Congress, MedPAC officially recommended that Congress establish a pay-for-performance system for Medicare providers.

The Center for Medicare and Medicaid Services (CMS) is also developing and implementing a set of pay-for-performance initiatives to support quality improvement in the care of Medicare beneficiaries. CMS Administrator Mark McClellan, MD, an internist, has been a big proponent of this effort.

The basic thrust of pay-for-performance is to use Medicare’s purchasing power to reward and promote quality. This effort is also tied to legislation to accelerate the development of electronic medical records and to expand the use of information technology in the healthcare delivery system. The Public Policy Committee is examining the pay-for-performance bills introduced in Congress and their implications for hospital medicine.

SENATE LEGISLATION

In late June, Senate Finance Committee Chair Charles Grassley (R-IA) and Ranking Member Max Baucus (D-MT) introduced the Medicare Value Purchasing Act of 2005, S. 1356. This legislation would apply to physicians, acute care hospitals, Medicare Advantage plans, end-stage renal disease providers, home health agencies, and (to some extent) skilled nursing facilities.

In the first phase of implementation, Medicare reimbursement rates would be tied directly to reporting data on quality measures, while the second phase ties a portion of payment to provider performance. The Senate bill doesn’t makes changes to the sustainable growth rate formula that determines Medicare payments to physicians. That will likely be handled in separate legislation.

S. 1356 directs the Secretary of Health and Human Services to select quality measures through a multistakeholder, consensus-building process. Those quality measures already developed and accepted by the healthcare community would be taken into account. Under the legislation, the Secretary has the ability to vary measures used within types of providers. For example, the Secretary could differentiate hospital measures by the hospital’s size and scope of services. Or, the Secretary could vary physician measures based on physician specialty, type of practitioner, or the volume of services delivered. The legislation also specifies criteria for the selection of quality measures. For example, the measures should be evidence-based, reliable, and valid; relevant to rural areas; and relevant to the frail elderly and those with chronic conditions. They should include measures of over- and under use and measures of health information technology infrastructure.

HOUSE ACTION

House Ways and Means Health Subcommittee Chair Nancy Johnson (R-CT) was expected to introduce legislation before the August Congressional recess that would add pay-for-performance programs for physicians under Medicare and repeal the sustainable growth rate formula.

On July 12, Ways and Means Committee Chairman William M. Thomas (R-CA) and Johnson asked McClellan to make regulatory changes that could avert a 4.3% cut in the Medicare physician update in 2006. In particular, the lawmakers said that CMS should remove prescription drug expenditures from the sustainable growth rate, which are used to calculate yearly changes in reimbursements. Legislation to permanently fix the sustainable growth rate “would be prohibitively expensive given current interpretations of the formula,” they said.

In testimony before the Ways and Means Committee July 21, McClellan said eliminating the sustainable growth rate system in favor of an update that is similar to the current Medicare Economic Index, which measures the weighted average price change for various inputs involved with producing physicians’ services, would cost $183 billion over 10 years. CMS is currently reviewing the legal arguments regarding whether it can remove prescription drugs from the services included in the sustainable growth rate under existing authorities, he told the subcommittee.

The notion of linking a portion of Medicare payments to valid measures of quality, or paying for performance, is clearly here to stay. The concept has broad support from the Administration, Congress, CMS, and several specialty societies, even though many questions about its implementation must still be answered. The Public Policy Committee will work to position SHM to influence this important debate.

In the first phase of the Medicare Value Purchasing Act of 2005 implementation, Medicare reimbursement rates would be tied directly to reporting data on quality measures, while the second phase ties a portion of payment to provider performance.

SHM Partners with Patient Safety Leadership Fellowship Program

Focus on interdisciplinary leadership and patient safety proves invaluable

By Jeanne M. Huddleston, MD, FACP

SHM is now a partner in the Patient Safety Leadership Fellowship (PSLF) program, an intensive learning experience that develops leadership competencies and advances patient safety in healthcare through a dynamic, highly participatory, structured learning community.

The Health Forum-American Hospital Association and the National Patient Safety Foundation created the fellowship and now has several program partners. SHM has joined the list as a program partner in this PSLF with the Health Research and Education Trust (HRET), the American Organization of Nurse Executives (AONE), and the American Society for Healthcare Risk Management (ASHRM).

The ultimate objective of the PSLF is to provide multidisciplinary teams and individual providers with the opportunity to develop the leadership competencies necessary to make meaningful changes in healthcare safety. Through a combination of expert leadership and patient safety faculty, a specially designed curriculum, and field-based projects, PSLF Health Forum Fellowships offer an intensive educational opportunity.

Each fellowship experience is highly participatory and interdisciplinary. Participants from past fellowship classes include physicians, pharmacists, nurses, lawyers, risk managers, educators, administrators, and patients. This environment encourages the creation of new knowledge to advance the patient safety science and enhances interpersonal and professional effectiveness. Each fellowship is a yearlong journey that blends face-to-face leadership retreats, self-study educational curriculum, online computer conferencing, and site visits.

The heart of the fellowship program is an Action Learning Project (ALP) that fellows design and implement in their own organization/community/region. This allows for direct application of each participant’s knowledge and experience gained through the other curricular venues to be immediately applied with the added benefit of being able to draw on the experience of the fellowship faculty and staff to advance the participant’s progress. Fellows are required to provide a midyear and final report to their respective executives and/or boards, in addition to their learning community of fellows during the face-to-face leadership retreats. Examples of ALPs can be found at www.healthforumfellowships.com/healthforumfellowships/html/project.htm.

Through the course of the one-year learning experience, fellows are exposed to the following curricular components:

1. Knowledge of what creates safe healthcare systems;
2. Leadership, collaboration, and complexity;
3. The path to a culture of safety;
4. Lessons from inside and outside healthcare;
5. Disclosure, reporting, and transparency; and
6. The business case for creating a culture of safety.

Given the alignment of interests in quality, patient safety, and leadership between this fellowship and the developing core curriculum in hospital medicine, SHM became a program partner in mid2004. During 2005, SHM will become more involved by serving on the Fellowship’s Advisory and Curriculum Committees to help with oversight of the program concept and curricular development. In addition, SHM will provide one day of educational content drawing from the vast experience of hospitalists in the fields of leadership and patient safety.

I participated in the 2002-2003 PSLF inaugural class. The interdisciplinary nature of the education experience was rewarding and, I believe, was one of the core reasons the curricula benefited my effectiveness specifically in participating in quality and patient safety initiatives. My fellow alumni continue to serve as a community of quality and patient safety champions and assist each other by being a sounding board and advisory group to ongoing local activities. TH

Dr. Huddleston can be contacted via e-mail at [email protected].

SHM has established an aggressive goal of getting 400 respondents for its biannual Productivity and Compensation Survey. This would mean a 33% increase over the 300 respondents to the 2003 survey. SHM is tracking the number of respondents on its Web site homepage (www.hospitalmedicine.org). All surveys must be completed and returned by Nov. 25.

By now hospital medicine group leaders should have received a copy of the survey with instructions. SHM prefers that you complete the survey online. The response process for the online survey is simplified with built-in edits and a streamlined flow. In addition, you can stop in the middle of the questionnaire and return to complete it later.

WHY SHOULD YOU PARTICIPATE?

• Information: The survey questions represent the metrics most critical in benchmarking your hospital medicine program. You’ll be able to compare the characteristics and performance of your group with other hospital medicine programs across the country.
• Financial Incentive: There is a financial incentive to participate. Only survey respondents will receive the full survey report and analysis on a CD at no additional charge. Nonrespondents will pay as much as $495 for the results. The results will be available at the SHM Annual Meeting in Washington D.C., May 3-5, 2006.
• Potential Awards: Participants will be eligible to participate in a drawing to receive complimentary registrations to an upcoming Leadership Academy (valued at $1,500) or to the 2006 SHM Annual Meeting (valued at $525). If your group submits its completed questionnaires by Oct. 25 it will have two entries in the drawing. After that date, you’ll receive only one entry.
• Confidentiality: Survey responses will be completely confidential and data will be reported only in the aggregate. International Communications Research, an experienced survey research firm, is conducting the survey. SHM is not involved in collecting or processing the data.

SURVEY CONTENT

This year’s survey builds on the success of the 2003 survey, which is viewed by SHM members as the most accurate and useful source of hospitalist benchmark information. The 2005 survey features the following improvements: better definitions and instructions, and additional questions covering such topics as night coverage, hospitalist services, and the use of nurse practitioners and physician assistants.

The group questionnaire poses questions intended to characterize your hospital medicine program at the group and hospital level. To answer these questions you will need specific information about your hospital (e.g., number of beds, teaching status), the number of fulltime employees (including nonclinical staff), staff turnover, additional revenue received from the hospital or other sources, and the program’s average length-of-stay and case-mix index.

The individual questionnaire poses questions at individual hospitalist level. To answer these you will need information about demographics (age, gender, fulltime employees, specialty, years as a hospitalist, years with group), billing information (encounters, relative value units, charges, collections), hours and shifts worked, and compensation/ benefits for each hospitalist in the group.

CALL TO ACTION

If your hospital medicine group has not received a survey and you would like to participate, e-mail the following information to Marie Francois at [email protected]: the name of your group, leader’s name, mailing address, e-mail, and telephone number. If you are completing the survey and you need clarification about any of the questions, contact SHM Customer Service at [email protected] or call (800) 843-3360.

As hospital medicine continues to grow and emerge, SHM seeks to provide vital data characterizing the specialty to hospitalists, hospital and healthcare leaders, and policymakers. The 2005 Productivity and Compensation Survey is the key vehicle for providing that data. Help us achieve our goal of 400 hospital medicine group respondents.

Joe Miller is senior vice president for SHM.

NPs and PAs Help Shape SHM Initiatives

By Kevin Whitford, MD

The Nonphysician-Provider Task Force met at SHM’s Annual Meeting in Chicago in April. The meeting marked a significant transition as Mitchell Wilson, MD, concluded his term as chair of the committee. Dr. Wilson’s excellent leadership and organization greatly benefited the task force during its inaugural year. The task force is fortunate to have Dr. Wilson remain as a member.

During the April meeting, the group reviewed the SHM charge to the task force: the responsibility to develop initiatives and programs to promote and define the role of nurse practitioners, physician assistants, and other hospitalist nonphysician providers in hospital medicine. The task force must recommend an SHM nonphysicianprovider agenda to the SHM Board. The task force is looking for opportunities to encourage nonphysician providers to become active SHM members.

The group prepared a document, “Top Five Roles/Functions for Nonphysician Providers” to present to the SHM Board as a framework for the future.

At the annual meeting the task force pursued strategic planning for 2005 and 2006. The Web-based “Resource Center” development was at the top of the list. The task force has collected job descriptions that include acute care nurse practitioner, hospitalist physician assistant, clinical care coordinator, clinical nurse manager, hospitalist case manager, hospitalist program manager, and medical director.

Competency forms are also posted on the SHM Web site; the forms may be used as models to evaluate hospitalist clinical coordinator, hospitalist physician assistant, hospitalist program manager, and advanced nurse practitioner in hospital medicine. The task force plans to expand this resource area to include staffing models, billing and documentation, frequently asked questions, and a document on the value added by nonphysician providers.

The Nonphysician-Provider Task Force also has a “Hub and Spoke” initiative to broaden the input for nonphysician providers by linking members to the task force with hospitalist nonphysician providers across a broad representation of practices.

Other covered areas include plans for publishing articles in The Hospitalist, membership initiatives, and promoting the development of external relationships with national organizations such as the American Academy of Physician Assistants and American Association of Nurse Practitioners.

Task force members helped lead the forum on nonphysician providers at the SHM Annual Meeting. Participants’ questions ranged from specifics regarding the roles of nonphysician providers to filling in documentation issues and included a broad spectrum of practice types from small private to large academic medical centers. The Nonphysician-Provider Task Force is making plans for the program for the 2006 Annual Meeting.

We’ve also sought involvement across the spectrum of task forces and committees in the SHM to increase the representation and raise the awareness of nonphysician providers.

The SHM Board approved the list of top five roles for nonphysician providers in SHM. These include:

1. To foster hospital medicine nonphysician-provider educational and professional development;
2. To network with other nonphysician providers to share ideas concerning the integration of nonphysician providers in hospital medicine;
3. To provide input to SHM and SHM committees/task forces related to the role of the nonphysician provider on the hospital medicine team;
4. To serve as “ambassadors” for SHM recruitment of nonphysician-provider members; and
5. To share varied expertise in the educational offerings pertinent to nonphysician providers on the hospitalist team.

In the coming year, the task force will further refine this list and present a revised charge to the SHM Board. The original charge specifically mentions only nurse practitioners and physician assistants. We’ve been fortunate to have a clinical care coordinator and a health systems pharmacist join the task force. This broader perspective will benefit the task force and recognizes the broad range of professionals working with the hospitalist team.

If you’re interested in the issues being addressed by the Nonphysician-Provider Task Force, you have several avenues available to pursue those interests. The SHM listserv is an active forum for discussing issues and sharing solutions. If you’re interested in working with the Nonphysician Task Force directly, contact Jeanette Kalupa at [email protected] or Scarlett Blue at [email protected] to be added to the Hub and Spoke initiative. You can also visit the resource center on the SHM Web site to view the nonphysician-provider resources, or you can submit documents for the task force to review for posting to the resource area.

Dr. Whitford is chair of SHM’s Nonphysician-Provider Task Force. Contact him at [email protected].

10 Tips for a Successful Compensation Negotiation

Here are some strategies that Linda Snelling, MD, presented at the Pediatric Hospital Medicine conference in Denver in July regarding how to best negotiate your compensation. These strategies apply to all hospitalists.

1. Start with value: describe what you’re doing, who benefits from your work.
2. Review your own billing and collections.
3. Evaluate your program costs.
4. Apply for grants (finding money allows your program to grow).
5. Determine synergy: Are you fulfilling your role in the institution/department? Are there other opportunities to explore?
6. Start from a position of strength. Determining how much the opponent is willing to pay or increase support based on your current success and the anticipated benefit from your continued efforts is the starting point from which you have to negotiate up. A better position is to determine the amount by which you want your support adjusted so you are at the starting point from which the opponent negotiates down.
7. Remember, you’re not going in there for a handout. You’re going in there with a promise of what you’ll deliver.
8. Think long term.
9. Leave room to negotiate. Never put all your cards on the table. You’ll have to make concessions; get something for that concession. “If you can’t do 8%, what can you do? 5%. OK, so what about 5% this year and 5% next year?”
10. Remain positive.

SHM’s Advocacy Efforts

Pay-for-performance legislation gains momentum on Capitol Hill

By Eric Siegal, MD

Washington policymakers are embracing a new approach to reforming the Medicare payment system: giving physicians and other providers financial incentives to meet certain quality standards. The so-called “pay-for-performance” or “value-based purchasing” model contained in various bills moving through Congress builds on recommendations made earlier this year by the Medicare Payment Advisory Commission (MedPAC) and mirrors initiatives that have proliferated in the private sector. In its March 2005 report to Congress, MedPAC officially recommended that Congress establish a pay-for-performance system for Medicare providers.

The Center for Medicare and Medicaid Services (CMS) is also developing and implementing a set of pay-for-performance initiatives to support quality improvement in the care of Medicare beneficiaries. CMS Administrator Mark McClellan, MD, an internist, has been a big proponent of this effort.

The basic thrust of pay-for-performance is to use Medicare’s purchasing power to reward and promote quality. This effort is also tied to legislation to accelerate the development of electronic medical records and to expand the use of information technology in the healthcare delivery system. The Public Policy Committee is examining the pay-for-performance bills introduced in Congress and their implications for hospital medicine.

SENATE LEGISLATION

In late June, Senate Finance Committee Chair Charles Grassley (R-IA) and Ranking Member Max Baucus (D-MT) introduced the Medicare Value Purchasing Act of 2005, S. 1356. This legislation would apply to physicians, acute care hospitals, Medicare Advantage plans, end-stage renal disease providers, home health agencies, and (to some extent) skilled nursing facilities.

In the first phase of implementation, Medicare reimbursement rates would be tied directly to reporting data on quality measures, while the second phase ties a portion of payment to provider performance. The Senate bill doesn’t makes changes to the sustainable growth rate formula that determines Medicare payments to physicians. That will likely be handled in separate legislation.

S. 1356 directs the Secretary of Health and Human Services to select quality measures through a multistakeholder, consensus-building process. Those quality measures already developed and accepted by the healthcare community would be taken into account. Under the legislation, the Secretary has the ability to vary measures used within types of providers. For example, the Secretary could differentiate hospital measures by the hospital’s size and scope of services. Or, the Secretary could vary physician measures based on physician specialty, type of practitioner, or the volume of services delivered. The legislation also specifies criteria for the selection of quality measures. For example, the measures should be evidence-based, reliable, and valid; relevant to rural areas; and relevant to the frail elderly and those with chronic conditions. They should include measures of over- and under use and measures of health information technology infrastructure.

HOUSE ACTION

House Ways and Means Health Subcommittee Chair Nancy Johnson (R-CT) was expected to introduce legislation before the August Congressional recess that would add pay-for-performance programs for physicians under Medicare and repeal the sustainable growth rate formula.

On July 12, Ways and Means Committee Chairman William M. Thomas (R-CA) and Johnson asked McClellan to make regulatory changes that could avert a 4.3% cut in the Medicare physician update in 2006. In particular, the lawmakers said that CMS should remove prescription drug expenditures from the sustainable growth rate, which are used to calculate yearly changes in reimbursements. Legislation to permanently fix the sustainable growth rate “would be prohibitively expensive given current interpretations of the formula,” they said.

In testimony before the Ways and Means Committee July 21, McClellan said eliminating the sustainable growth rate system in favor of an update that is similar to the current Medicare Economic Index, which measures the weighted average price change for various inputs involved with producing physicians’ services, would cost $183 billion over 10 years. CMS is currently reviewing the legal arguments regarding whether it can remove prescription drugs from the services included in the sustainable growth rate under existing authorities, he told the subcommittee.

The notion of linking a portion of Medicare payments to valid measures of quality, or paying for performance, is clearly here to stay. The concept has broad support from the Administration, Congress, CMS, and several specialty societies, even though many questions about its implementation must still be answered. The Public Policy Committee will work to position SHM to influence this important debate.

In the first phase of the Medicare Value Purchasing Act of 2005 implementation, Medicare reimbursement rates would be tied directly to reporting data on quality measures, while the second phase ties a portion of payment to provider performance.

SHM Partners with Patient Safety Leadership Fellowship Program

Focus on interdisciplinary leadership and patient safety proves invaluable

By Jeanne M. Huddleston, MD, FACP

SHM is now a partner in the Patient Safety Leadership Fellowship (PSLF) program, an intensive learning experience that develops leadership competencies and advances patient safety in healthcare through a dynamic, highly participatory, structured learning community.

The Health Forum-American Hospital Association and the National Patient Safety Foundation created the fellowship and now has several program partners. SHM has joined the list as a program partner in this PSLF with the Health Research and Education Trust (HRET), the American Organization of Nurse Executives (AONE), and the American Society for Healthcare Risk Management (ASHRM).

The ultimate objective of the PSLF is to provide multidisciplinary teams and individual providers with the opportunity to develop the leadership competencies necessary to make meaningful changes in healthcare safety. Through a combination of expert leadership and patient safety faculty, a specially designed curriculum, and field-based projects, PSLF Health Forum Fellowships offer an intensive educational opportunity.

Each fellowship experience is highly participatory and interdisciplinary. Participants from past fellowship classes include physicians, pharmacists, nurses, lawyers, risk managers, educators, administrators, and patients. This environment encourages the creation of new knowledge to advance the patient safety science and enhances interpersonal and professional effectiveness. Each fellowship is a yearlong journey that blends face-to-face leadership retreats, self-study educational curriculum, online computer conferencing, and site visits.

The heart of the fellowship program is an Action Learning Project (ALP) that fellows design and implement in their own organization/community/region. This allows for direct application of each participant’s knowledge and experience gained through the other curricular venues to be immediately applied with the added benefit of being able to draw on the experience of the fellowship faculty and staff to advance the participant’s progress. Fellows are required to provide a midyear and final report to their respective executives and/or boards, in addition to their learning community of fellows during the face-to-face leadership retreats. Examples of ALPs can be found at www.healthforumfellowships.com/healthforumfellowships/html/project.htm.

Through the course of the one-year learning experience, fellows are exposed to the following curricular components:

1. Knowledge of what creates safe healthcare systems;
2. Leadership, collaboration, and complexity;
3. The path to a culture of safety;
4. Lessons from inside and outside healthcare;
5. Disclosure, reporting, and transparency; and
6. The business case for creating a culture of safety.

Given the alignment of interests in quality, patient safety, and leadership between this fellowship and the developing core curriculum in hospital medicine, SHM became a program partner in mid2004. During 2005, SHM will become more involved by serving on the Fellowship’s Advisory and Curriculum Committees to help with oversight of the program concept and curricular development. In addition, SHM will provide one day of educational content drawing from the vast experience of hospitalists in the fields of leadership and patient safety.

I participated in the 2002-2003 PSLF inaugural class. The interdisciplinary nature of the education experience was rewarding and, I believe, was one of the core reasons the curricula benefited my effectiveness specifically in participating in quality and patient safety initiatives. My fellow alumni continue to serve as a community of quality and patient safety champions and assist each other by being a sounding board and advisory group to ongoing local activities. TH

Dr. Huddleston can be contacted via e-mail at [email protected].

SHM has established an aggressive goal of getting 400 respondents for its biannual Productivity and Compensation Survey. This would mean a 33% increase over the 300 respondents to the 2003 survey. SHM is tracking the number of respondents on its Web site homepage (www.hospitalmedicine.org). All surveys must be completed and returned by Nov. 25.

By now hospital medicine group leaders should have received a copy of the survey with instructions. SHM prefers that you complete the survey online. The response process for the online survey is simplified with built-in edits and a streamlined flow. In addition, you can stop in the middle of the questionnaire and return to complete it later.

WHY SHOULD YOU PARTICIPATE?

• Information: The survey questions represent the metrics most critical in benchmarking your hospital medicine program. You’ll be able to compare the characteristics and performance of your group with other hospital medicine programs across the country.
• Financial Incentive: There is a financial incentive to participate. Only survey respondents will receive the full survey report and analysis on a CD at no additional charge. Nonrespondents will pay as much as $495 for the results. The results will be available at the SHM Annual Meeting in Washington D.C., May 3-5, 2006.
• Potential Awards: Participants will be eligible to participate in a drawing to receive complimentary registrations to an upcoming Leadership Academy (valued at $1,500) or to the 2006 SHM Annual Meeting (valued at $525). If your group submits its completed questionnaires by Oct. 25 it will have two entries in the drawing. After that date, you’ll receive only one entry.
• Confidentiality: Survey responses will be completely confidential and data will be reported only in the aggregate. International Communications Research, an experienced survey research firm, is conducting the survey. SHM is not involved in collecting or processing the data.

SURVEY CONTENT

This year’s survey builds on the success of the 2003 survey, which is viewed by SHM members as the most accurate and useful source of hospitalist benchmark information. The 2005 survey features the following improvements: better definitions and instructions, and additional questions covering such topics as night coverage, hospitalist services, and the use of nurse practitioners and physician assistants.

The group questionnaire poses questions intended to characterize your hospital medicine program at the group and hospital level. To answer these questions you will need specific information about your hospital (e.g., number of beds, teaching status), the number of fulltime employees (including nonclinical staff), staff turnover, additional revenue received from the hospital or other sources, and the program’s average length-of-stay and case-mix index.

The individual questionnaire poses questions at individual hospitalist level. To answer these you will need information about demographics (age, gender, fulltime employees, specialty, years as a hospitalist, years with group), billing information (encounters, relative value units, charges, collections), hours and shifts worked, and compensation/ benefits for each hospitalist in the group.

CALL TO ACTION

If your hospital medicine group has not received a survey and you would like to participate, e-mail the following information to Marie Francois at [email protected]: the name of your group, leader’s name, mailing address, e-mail, and telephone number. If you are completing the survey and you need clarification about any of the questions, contact SHM Customer Service at [email protected] or call (800) 843-3360.

As hospital medicine continues to grow and emerge, SHM seeks to provide vital data characterizing the specialty to hospitalists, hospital and healthcare leaders, and policymakers. The 2005 Productivity and Compensation Survey is the key vehicle for providing that data. Help us achieve our goal of 400 hospital medicine group respondents.

Joe Miller is senior vice president for SHM.

NPs and PAs Help Shape SHM Initiatives

By Kevin Whitford, MD

The Nonphysician-Provider Task Force met at SHM’s Annual Meeting in Chicago in April. The meeting marked a significant transition as Mitchell Wilson, MD, concluded his term as chair of the committee. Dr. Wilson’s excellent leadership and organization greatly benefited the task force during its inaugural year. The task force is fortunate to have Dr. Wilson remain as a member.

During the April meeting, the group reviewed the SHM charge to the task force: the responsibility to develop initiatives and programs to promote and define the role of nurse practitioners, physician assistants, and other hospitalist nonphysician providers in hospital medicine. The task force must recommend an SHM nonphysicianprovider agenda to the SHM Board. The task force is looking for opportunities to encourage nonphysician providers to become active SHM members.

The group prepared a document, “Top Five Roles/Functions for Nonphysician Providers” to present to the SHM Board as a framework for the future.

At the annual meeting the task force pursued strategic planning for 2005 and 2006. The Web-based “Resource Center” development was at the top of the list. The task force has collected job descriptions that include acute care nurse practitioner, hospitalist physician assistant, clinical care coordinator, clinical nurse manager, hospitalist case manager, hospitalist program manager, and medical director.

Competency forms are also posted on the SHM Web site; the forms may be used as models to evaluate hospitalist clinical coordinator, hospitalist physician assistant, hospitalist program manager, and advanced nurse practitioner in hospital medicine. The task force plans to expand this resource area to include staffing models, billing and documentation, frequently asked questions, and a document on the value added by nonphysician providers.

The Nonphysician-Provider Task Force also has a “Hub and Spoke” initiative to broaden the input for nonphysician providers by linking members to the task force with hospitalist nonphysician providers across a broad representation of practices.

Other covered areas include plans for publishing articles in The Hospitalist, membership initiatives, and promoting the development of external relationships with national organizations such as the American Academy of Physician Assistants and American Association of Nurse Practitioners.

Task force members helped lead the forum on nonphysician providers at the SHM Annual Meeting. Participants’ questions ranged from specifics regarding the roles of nonphysician providers to filling in documentation issues and included a broad spectrum of practice types from small private to large academic medical centers. The Nonphysician-Provider Task Force is making plans for the program for the 2006 Annual Meeting.

We’ve also sought involvement across the spectrum of task forces and committees in the SHM to increase the representation and raise the awareness of nonphysician providers.

The SHM Board approved the list of top five roles for nonphysician providers in SHM. These include:

1. To foster hospital medicine nonphysician-provider educational and professional development;
2. To network with other nonphysician providers to share ideas concerning the integration of nonphysician providers in hospital medicine;
3. To provide input to SHM and SHM committees/task forces related to the role of the nonphysician provider on the hospital medicine team;
4. To serve as “ambassadors” for SHM recruitment of nonphysician-provider members; and
5. To share varied expertise in the educational offerings pertinent to nonphysician providers on the hospitalist team.

In the coming year, the task force will further refine this list and present a revised charge to the SHM Board. The original charge specifically mentions only nurse practitioners and physician assistants. We’ve been fortunate to have a clinical care coordinator and a health systems pharmacist join the task force. This broader perspective will benefit the task force and recognizes the broad range of professionals working with the hospitalist team.

If you’re interested in the issues being addressed by the Nonphysician-Provider Task Force, you have several avenues available to pursue those interests. The SHM listserv is an active forum for discussing issues and sharing solutions. If you’re interested in working with the Nonphysician Task Force directly, contact Jeanette Kalupa at [email protected] or Scarlett Blue at [email protected] to be added to the Hub and Spoke initiative. You can also visit the resource center on the SHM Web site to view the nonphysician-provider resources, or you can submit documents for the task force to review for posting to the resource area.

Dr. Whitford is chair of SHM’s Nonphysician-Provider Task Force. Contact him at [email protected].

10 Tips for a Successful Compensation Negotiation

Here are some strategies that Linda Snelling, MD, presented at the Pediatric Hospital Medicine conference in Denver in July regarding how to best negotiate your compensation. These strategies apply to all hospitalists.

1. Start with value: describe what you’re doing, who benefits from your work.
2. Review your own billing and collections.
3. Evaluate your program costs.
4. Apply for grants (finding money allows your program to grow).
5. Determine synergy: Are you fulfilling your role in the institution/department? Are there other opportunities to explore?
6. Start from a position of strength. Determining how much the opponent is willing to pay or increase support based on your current success and the anticipated benefit from your continued efforts is the starting point from which you have to negotiate up. A better position is to determine the amount by which you want your support adjusted so you are at the starting point from which the opponent negotiates down.
7. Remember, you’re not going in there for a handout. You’re going in there with a promise of what you’ll deliver.
8. Think long term.
9. Leave room to negotiate. Never put all your cards on the table. You’ll have to make concessions; get something for that concession. “If you can’t do 8%, what can you do? 5%. OK, so what about 5% this year and 5% next year?”
10. Remain positive.

SHM’s Advocacy Efforts

Pay-for-performance legislation gains momentum on Capitol Hill

By Eric Siegal, MD

Washington policymakers are embracing a new approach to reforming the Medicare payment system: giving physicians and other providers financial incentives to meet certain quality standards. The so-called “pay-for-performance” or “value-based purchasing” model contained in various bills moving through Congress builds on recommendations made earlier this year by the Medicare Payment Advisory Commission (MedPAC) and mirrors initiatives that have proliferated in the private sector. In its March 2005 report to Congress, MedPAC officially recommended that Congress establish a pay-for-performance system for Medicare providers.

The Center for Medicare and Medicaid Services (CMS) is also developing and implementing a set of pay-for-performance initiatives to support quality improvement in the care of Medicare beneficiaries. CMS Administrator Mark McClellan, MD, an internist, has been a big proponent of this effort.

The basic thrust of pay-for-performance is to use Medicare’s purchasing power to reward and promote quality. This effort is also tied to legislation to accelerate the development of electronic medical records and to expand the use of information technology in the healthcare delivery system. The Public Policy Committee is examining the pay-for-performance bills introduced in Congress and their implications for hospital medicine.

SENATE LEGISLATION

In late June, Senate Finance Committee Chair Charles Grassley (R-IA) and Ranking Member Max Baucus (D-MT) introduced the Medicare Value Purchasing Act of 2005, S. 1356. This legislation would apply to physicians, acute care hospitals, Medicare Advantage plans, end-stage renal disease providers, home health agencies, and (to some extent) skilled nursing facilities.

In the first phase of implementation, Medicare reimbursement rates would be tied directly to reporting data on quality measures, while the second phase ties a portion of payment to provider performance. The Senate bill doesn’t makes changes to the sustainable growth rate formula that determines Medicare payments to physicians. That will likely be handled in separate legislation.

S. 1356 directs the Secretary of Health and Human Services to select quality measures through a multistakeholder, consensus-building process. Those quality measures already developed and accepted by the healthcare community would be taken into account. Under the legislation, the Secretary has the ability to vary measures used within types of providers. For example, the Secretary could differentiate hospital measures by the hospital’s size and scope of services. Or, the Secretary could vary physician measures based on physician specialty, type of practitioner, or the volume of services delivered. The legislation also specifies criteria for the selection of quality measures. For example, the measures should be evidence-based, reliable, and valid; relevant to rural areas; and relevant to the frail elderly and those with chronic conditions. They should include measures of over- and under use and measures of health information technology infrastructure.

HOUSE ACTION

House Ways and Means Health Subcommittee Chair Nancy Johnson (R-CT) was expected to introduce legislation before the August Congressional recess that would add pay-for-performance programs for physicians under Medicare and repeal the sustainable growth rate formula.

On July 12, Ways and Means Committee Chairman William M. Thomas (R-CA) and Johnson asked McClellan to make regulatory changes that could avert a 4.3% cut in the Medicare physician update in 2006. In particular, the lawmakers said that CMS should remove prescription drug expenditures from the sustainable growth rate, which are used to calculate yearly changes in reimbursements. Legislation to permanently fix the sustainable growth rate “would be prohibitively expensive given current interpretations of the formula,” they said.

In testimony before the Ways and Means Committee July 21, McClellan said eliminating the sustainable growth rate system in favor of an update that is similar to the current Medicare Economic Index, which measures the weighted average price change for various inputs involved with producing physicians’ services, would cost $183 billion over 10 years. CMS is currently reviewing the legal arguments regarding whether it can remove prescription drugs from the services included in the sustainable growth rate under existing authorities, he told the subcommittee.

The notion of linking a portion of Medicare payments to valid measures of quality, or paying for performance, is clearly here to stay. The concept has broad support from the Administration, Congress, CMS, and several specialty societies, even though many questions about its implementation must still be answered. The Public Policy Committee will work to position SHM to influence this important debate.

In the first phase of the Medicare Value Purchasing Act of 2005 implementation, Medicare reimbursement rates would be tied directly to reporting data on quality measures, while the second phase ties a portion of payment to provider performance.

SHM Partners with Patient Safety Leadership Fellowship Program

Focus on interdisciplinary leadership and patient safety proves invaluable

By Jeanne M. Huddleston, MD, FACP

SHM is now a partner in the Patient Safety Leadership Fellowship (PSLF) program, an intensive learning experience that develops leadership competencies and advances patient safety in healthcare through a dynamic, highly participatory, structured learning community.

The Health Forum-American Hospital Association and the National Patient Safety Foundation created the fellowship and now has several program partners. SHM has joined the list as a program partner in this PSLF with the Health Research and Education Trust (HRET), the American Organization of Nurse Executives (AONE), and the American Society for Healthcare Risk Management (ASHRM).

The ultimate objective of the PSLF is to provide multidisciplinary teams and individual providers with the opportunity to develop the leadership competencies necessary to make meaningful changes in healthcare safety. Through a combination of expert leadership and patient safety faculty, a specially designed curriculum, and field-based projects, PSLF Health Forum Fellowships offer an intensive educational opportunity.

Each fellowship experience is highly participatory and interdisciplinary. Participants from past fellowship classes include physicians, pharmacists, nurses, lawyers, risk managers, educators, administrators, and patients. This environment encourages the creation of new knowledge to advance the patient safety science and enhances interpersonal and professional effectiveness. Each fellowship is a yearlong journey that blends face-to-face leadership retreats, self-study educational curriculum, online computer conferencing, and site visits.

The heart of the fellowship program is an Action Learning Project (ALP) that fellows design and implement in their own organization/community/region. This allows for direct application of each participant’s knowledge and experience gained through the other curricular venues to be immediately applied with the added benefit of being able to draw on the experience of the fellowship faculty and staff to advance the participant’s progress. Fellows are required to provide a midyear and final report to their respective executives and/or boards, in addition to their learning community of fellows during the face-to-face leadership retreats. Examples of ALPs can be found at www.healthforumfellowships.com/healthforumfellowships/html/project.htm.

Through the course of the one-year learning experience, fellows are exposed to the following curricular components:

1. Knowledge of what creates safe healthcare systems;
2. Leadership, collaboration, and complexity;
3. The path to a culture of safety;
4. Lessons from inside and outside healthcare;
5. Disclosure, reporting, and transparency; and
6. The business case for creating a culture of safety.

Given the alignment of interests in quality, patient safety, and leadership between this fellowship and the developing core curriculum in hospital medicine, SHM became a program partner in mid2004. During 2005, SHM will become more involved by serving on the Fellowship’s Advisory and Curriculum Committees to help with oversight of the program concept and curricular development. In addition, SHM will provide one day of educational content drawing from the vast experience of hospitalists in the fields of leadership and patient safety.

I participated in the 2002-2003 PSLF inaugural class. The interdisciplinary nature of the education experience was rewarding and, I believe, was one of the core reasons the curricula benefited my effectiveness specifically in participating in quality and patient safety initiatives. My fellow alumni continue to serve as a community of quality and patient safety champions and assist each other by being a sounding board and advisory group to ongoing local activities. TH

Dr. Huddleston can be contacted via e-mail at [email protected].

An 84-year-old woman with history of coronary artery disease, hypertension, and hyperlipidemia presented with six months of anorexia, nausea, a five-pound weight loss, weakness, and nonbloody diarrhea. Over the past one to two weeks, she noticed decreased urine output despite her use of furosemide.

She was found to have a serum creatinine of 3.5 mg/dL on admission, increased from 1.5 mg/dL five days previously. She had no rash, dyspnea, cough, or abdominal pain. Urinalysis revealed >100 red blood cells (RBC), >100 white blood cells (WBC), occasional hyaline casts, and many gramnegative bacilli. Ciprofloxacin was started for her urinary tract infection. A renal biopsy was performed. The images shown are photomicrographs of light microscopy and immunofluorescence of the renal biopsy specimen. TH

Kidney biopsy: Immunofluorescence

Which of the following would be the most appropriate initial therapy for this condition?

1. Increase dose of furosemide;
2. Start fish oil;
3. Initiate Low-dose dopamine;
4. Discontinue ACE inhibitor; or
5. Begin emergent plasmapheresis.

Discussion

The correct answer is e: plasmapheresis. The renal biopsy, as shown in the image at left, reveals crescents involving glomeruli on light microscopy and linear IgG staining on immunofluorescence. This patient has antiglomerular basement membrane (anti-GBM) glomerulonephritis (GN), which accounts for 10% to 20% of crescentic glomerulonephritides. It is characterized by circulating antibodies to the glomerular basement membrane with deposition of IgG or, rarely, IgA along the GBM.

The pulmonary-renal vasculitic syndrome is called Goodpasture’s syndrome, in which pulmonary hemorrhage occurs concurrently with GN. Anti-GBM disease has a bimodal distribution, with peaks in the second to third decades and the sixth to seventh decades of life.

Kidney biopsy: Immunofluorescence

Etiology is usually idiopathic, but hydrocarbon exposure has also been associated with the disease. Clinical presentation of renal anti-GBM disease is characterized by an acute onset of GN with severe oliguria or anuria. Urinalysis typically shows hematuria, dysmorphic red blood cells, and red blood cell casts. The diagnostic laboratory finding is circulating antibodies to GBM, specifically to the alpha-3 chain of type IV collagen; these are detected by radioimmunoassay or enzyme immunoassay in approximately 90% of patients.

The standard treatment for anti-GBM disease includes intensive plasmapheresis combined with corticosteroids and cyclophosphamide or azathioprine. Plasmapheresis consists of removal of two to four liters of plasma and replacement with fresh frozen plasma or a 5% albumin solution on a daily basis until circulating antibody levels become undetectable (usually two to three weeks). Steroids should be administered initially as pulse methylprednisolone (30 mg/kg or 1,000 mg intravenously over 20 minutes) for three doses (daily or every other day) followed by daily oral prednisone (1 mg/kg per day) for at least the first month, followed by a gradual taper. The initial cyclophosphamide dose is 2 mg/kg per day either orally or intravenously (0.5 g/m2 body surface area).

Selecting patients for treatment is based primarily on severity at presentation. Based on a large retrospective review of 71 patients treated with plasma exchange, prednisolone, and cyclophosphamide, those who presented with plasma creatinine (Cr) concentration of less than 5.7 mg/dL or those who had Cr greater than 5.7 mg/dL but did not require immediate dialysis had a favorable long-term patient and renal survival (approximately 70% to 80% at 90 months). Patients who required immediate dialysis had poor survival (approximately 35% at 90 months). Patients who had crescents in all glomeruli on renal biopsy required long-term maintenance dialysis. Therefore, plasma exchange, prednisone, and cyclophosphamide should be administered in the following settings:

1. Pulmonary hemorrhage;
2. Renal failure (Cr above 5-7 mg/dL) but not requiring immediate renal replacement therapy; and
3. Less severe disease on renal biopsy (less than 30% to 50% crescents). Therapy is unlikely to be effective in patients who present with dialysisdependent renal failure without hemoptysis or if 100% of glomeruli have crescents on renal biopsy. In these settings, the risk of therapy may exceed the likelihood of benefit.

Fish oil is a potential therapy for IgA nephropathy, not anti-GBM disease. ACE inhibition may be useful in patients with nephrotic syndrome. IV hydration would be likely to cause volume overload and precipitate the need for acute dialysis. Low-dose dopamine has not proven effective in reversing acute renal failure. TH

REFERENCES

1. Clarkson MR, Brenner BM. Pocket Companion to Brenner & Rector’s The Kidney, 7th ed. Philadelphia, Pa: Elsevier Inc; 2005:198-199.
2. Rose BD, Kaplan AA, Appel GB. Treatment of anti-GBM antibody disease (Goodpasture’s syndrome). UpToDate Online. Available at: www.uptodate.com/physicians/pulmonology_toclist.asp. Last accessed August 18, 2005.
3. Levy JB, Turner AN, Rees AJ, et al. Long-term outcome of anti-glomerular basement membrane antibody disease treated with plasma exchange and immunosuppression. Ann Intern Med. 2001;134:1033.
4. Bolton WK. Goodpasture’s syndrome. Kidney Int. 1996;50:1753.
5. Jennette JC. Rapidly progressive crescentic glomerulonephritis. Kidney Int. 2003;63:1164.

An 84-year-old woman with history of coronary artery disease, hypertension, and hyperlipidemia presented with six months of anorexia, nausea, a five-pound weight loss, weakness, and nonbloody diarrhea. Over the past one to two weeks, she noticed decreased urine output despite her use of furosemide.

She was found to have a serum creatinine of 3.5 mg/dL on admission, increased from 1.5 mg/dL five days previously. She had no rash, dyspnea, cough, or abdominal pain. Urinalysis revealed >100 red blood cells (RBC), >100 white blood cells (WBC), occasional hyaline casts, and many gramnegative bacilli. Ciprofloxacin was started for her urinary tract infection. A renal biopsy was performed. The images shown are photomicrographs of light microscopy and immunofluorescence of the renal biopsy specimen. TH

Kidney biopsy: Immunofluorescence

Which of the following would be the most appropriate initial therapy for this condition?

1. Increase dose of furosemide;
2. Start fish oil;
3. Initiate Low-dose dopamine;
4. Discontinue ACE inhibitor; or
5. Begin emergent plasmapheresis.

Discussion

The correct answer is e: plasmapheresis. The renal biopsy, as shown in the image at left, reveals crescents involving glomeruli on light microscopy and linear IgG staining on immunofluorescence. This patient has antiglomerular basement membrane (anti-GBM) glomerulonephritis (GN), which accounts for 10% to 20% of crescentic glomerulonephritides. It is characterized by circulating antibodies to the glomerular basement membrane with deposition of IgG or, rarely, IgA along the GBM.

The pulmonary-renal vasculitic syndrome is called Goodpasture’s syndrome, in which pulmonary hemorrhage occurs concurrently with GN. Anti-GBM disease has a bimodal distribution, with peaks in the second to third decades and the sixth to seventh decades of life.

Kidney biopsy: Immunofluorescence

Etiology is usually idiopathic, but hydrocarbon exposure has also been associated with the disease. Clinical presentation of renal anti-GBM disease is characterized by an acute onset of GN with severe oliguria or anuria. Urinalysis typically shows hematuria, dysmorphic red blood cells, and red blood cell casts. The diagnostic laboratory finding is circulating antibodies to GBM, specifically to the alpha-3 chain of type IV collagen; these are detected by radioimmunoassay or enzyme immunoassay in approximately 90% of patients.

The standard treatment for anti-GBM disease includes intensive plasmapheresis combined with corticosteroids and cyclophosphamide or azathioprine. Plasmapheresis consists of removal of two to four liters of plasma and replacement with fresh frozen plasma or a 5% albumin solution on a daily basis until circulating antibody levels become undetectable (usually two to three weeks). Steroids should be administered initially as pulse methylprednisolone (30 mg/kg or 1,000 mg intravenously over 20 minutes) for three doses (daily or every other day) followed by daily oral prednisone (1 mg/kg per day) for at least the first month, followed by a gradual taper. The initial cyclophosphamide dose is 2 mg/kg per day either orally or intravenously (0.5 g/m2 body surface area).

Selecting patients for treatment is based primarily on severity at presentation. Based on a large retrospective review of 71 patients treated with plasma exchange, prednisolone, and cyclophosphamide, those who presented with plasma creatinine (Cr) concentration of less than 5.7 mg/dL or those who had Cr greater than 5.7 mg/dL but did not require immediate dialysis had a favorable long-term patient and renal survival (approximately 70% to 80% at 90 months). Patients who required immediate dialysis had poor survival (approximately 35% at 90 months). Patients who had crescents in all glomeruli on renal biopsy required long-term maintenance dialysis. Therefore, plasma exchange, prednisone, and cyclophosphamide should be administered in the following settings:

1. Pulmonary hemorrhage;
2. Renal failure (Cr above 5-7 mg/dL) but not requiring immediate renal replacement therapy; and
3. Less severe disease on renal biopsy (less than 30% to 50% crescents). Therapy is unlikely to be effective in patients who present with dialysisdependent renal failure without hemoptysis or if 100% of glomeruli have crescents on renal biopsy. In these settings, the risk of therapy may exceed the likelihood of benefit.

Fish oil is a potential therapy for IgA nephropathy, not anti-GBM disease. ACE inhibition may be useful in patients with nephrotic syndrome. IV hydration would be likely to cause volume overload and precipitate the need for acute dialysis. Low-dose dopamine has not proven effective in reversing acute renal failure. TH

REFERENCES

1. Clarkson MR, Brenner BM. Pocket Companion to Brenner & Rector’s The Kidney, 7th ed. Philadelphia, Pa: Elsevier Inc; 2005:198-199.
2. Rose BD, Kaplan AA, Appel GB. Treatment of anti-GBM antibody disease (Goodpasture’s syndrome). UpToDate Online. Available at: www.uptodate.com/physicians/pulmonology_toclist.asp. Last accessed August 18, 2005.
3. Levy JB, Turner AN, Rees AJ, et al. Long-term outcome of anti-glomerular basement membrane antibody disease treated with plasma exchange and immunosuppression. Ann Intern Med. 2001;134:1033.
4. Bolton WK. Goodpasture’s syndrome. Kidney Int. 1996;50:1753.
5. Jennette JC. Rapidly progressive crescentic glomerulonephritis. Kidney Int. 2003;63:1164.

An 84-year-old woman with history of coronary artery disease, hypertension, and hyperlipidemia presented with six months of anorexia, nausea, a five-pound weight loss, weakness, and nonbloody diarrhea. Over the past one to two weeks, she noticed decreased urine output despite her use of furosemide.

She was found to have a serum creatinine of 3.5 mg/dL on admission, increased from 1.5 mg/dL five days previously. She had no rash, dyspnea, cough, or abdominal pain. Urinalysis revealed >100 red blood cells (RBC), >100 white blood cells (WBC), occasional hyaline casts, and many gramnegative bacilli. Ciprofloxacin was started for her urinary tract infection. A renal biopsy was performed. The images shown are photomicrographs of light microscopy and immunofluorescence of the renal biopsy specimen. TH

Kidney biopsy: Immunofluorescence

Which of the following would be the most appropriate initial therapy for this condition?

1. Increase dose of furosemide;
2. Start fish oil;
3. Initiate Low-dose dopamine;
4. Discontinue ACE inhibitor; or
5. Begin emergent plasmapheresis.

Discussion

The correct answer is e: plasmapheresis. The renal biopsy, as shown in the image at left, reveals crescents involving glomeruli on light microscopy and linear IgG staining on immunofluorescence. This patient has antiglomerular basement membrane (anti-GBM) glomerulonephritis (GN), which accounts for 10% to 20% of crescentic glomerulonephritides. It is characterized by circulating antibodies to the glomerular basement membrane with deposition of IgG or, rarely, IgA along the GBM.

The pulmonary-renal vasculitic syndrome is called Goodpasture’s syndrome, in which pulmonary hemorrhage occurs concurrently with GN. Anti-GBM disease has a bimodal distribution, with peaks in the second to third decades and the sixth to seventh decades of life.

Kidney biopsy: Immunofluorescence

Etiology is usually idiopathic, but hydrocarbon exposure has also been associated with the disease. Clinical presentation of renal anti-GBM disease is characterized by an acute onset of GN with severe oliguria or anuria. Urinalysis typically shows hematuria, dysmorphic red blood cells, and red blood cell casts. The diagnostic laboratory finding is circulating antibodies to GBM, specifically to the alpha-3 chain of type IV collagen; these are detected by radioimmunoassay or enzyme immunoassay in approximately 90% of patients.

The standard treatment for anti-GBM disease includes intensive plasmapheresis combined with corticosteroids and cyclophosphamide or azathioprine. Plasmapheresis consists of removal of two to four liters of plasma and replacement with fresh frozen plasma or a 5% albumin solution on a daily basis until circulating antibody levels become undetectable (usually two to three weeks). Steroids should be administered initially as pulse methylprednisolone (30 mg/kg or 1,000 mg intravenously over 20 minutes) for three doses (daily or every other day) followed by daily oral prednisone (1 mg/kg per day) for at least the first month, followed by a gradual taper. The initial cyclophosphamide dose is 2 mg/kg per day either orally or intravenously (0.5 g/m2 body surface area).

Selecting patients for treatment is based primarily on severity at presentation. Based on a large retrospective review of 71 patients treated with plasma exchange, prednisolone, and cyclophosphamide, those who presented with plasma creatinine (Cr) concentration of less than 5.7 mg/dL or those who had Cr greater than 5.7 mg/dL but did not require immediate dialysis had a favorable long-term patient and renal survival (approximately 70% to 80% at 90 months). Patients who required immediate dialysis had poor survival (approximately 35% at 90 months). Patients who had crescents in all glomeruli on renal biopsy required long-term maintenance dialysis. Therefore, plasma exchange, prednisone, and cyclophosphamide should be administered in the following settings:

1. Pulmonary hemorrhage;
2. Renal failure (Cr above 5-7 mg/dL) but not requiring immediate renal replacement therapy; and
3. Less severe disease on renal biopsy (less than 30% to 50% crescents). Therapy is unlikely to be effective in patients who present with dialysisdependent renal failure without hemoptysis or if 100% of glomeruli have crescents on renal biopsy. In these settings, the risk of therapy may exceed the likelihood of benefit.

Fish oil is a potential therapy for IgA nephropathy, not anti-GBM disease. ACE inhibition may be useful in patients with nephrotic syndrome. IV hydration would be likely to cause volume overload and precipitate the need for acute dialysis. Low-dose dopamine has not proven effective in reversing acute renal failure. TH

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