Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors

Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293:1197-1203.

Computerized Physician Order Entry (CPOE) has been touted as an effective means to reduce medical errors, especially medication errors. There have been preliminary studies that showed both potential and actual error reductions with CPOE. More recent data suggested that there may be potential for facilitating errors as well.

Koppel et al. aimed to study CPOE system-related factors that may actually increase risk of medication errors. The authors conducted structured interviews with end users (housestaff, pharmacists, nurses, nurse managers, and attending physicians), real-time observations of end users interfacing with the system, entering orders, charting medications, and reviewing orders, and focus groups with housestaff. These qualitative data were used to help generate a 71-question structured survey subsequently given to the housestaff. These questions pertain to working conditions, sources of stress, and errors. There were 261 responses representing an 88% response rate.

Twenty-two previously unexplored potential medication error sources abstracted from the survey were grouped into the 2 categories: 1) information errors, and 2) human-machine interface flaws. The first category refers to fragmented data and the disparate information systems within hospitals. The latter category includes rigid machine programming that does not correspond to or facilitate workflow. Only 10 survey elements with sufficiently robust results were reported. About 40% of respondents used CPOE to determine dosage of infrequently prescribed medications at least once a week or more. Incorrect doses may be ordered if users follow the dosage information in the system that is based on drug inventory rather than clinical recommendations. Twenty-two percent of respondents noted that more than once a week duplicate or conflicting medications were ordered and not detected for several hours. Disorganized display of patient medications was believed to be partly responsible. More than 80% of respondents noted unintended delay in renewing antibiotics at least once. Such gaps were possible partially because the reminder system occurred in the paper chart while order entry was done with the computer. With respect to the human-machine interface, 55% reported difficulty identifying the correct patient because of poor or fragmented displays, and 23% reported this occurring more than a few times per week. System downtime leading to delay in order entry was reported by 47% to occur more than once a week. System inflexibility also led to difficulties in specifying medications and ordering nonformulary medications. This was reported by 31% to occur at least several times a week, and 24% reported this daily or more frequently.

This was a survey of end users of a CPOE system in a single institution, and the survey elements were mainly estimates of error risks. Nevertheless, it appropriately draws attention to the importance of the unique culture of each institution, efficient workflow, and coherent human-machine interface. The anticipated error reductions may not materialize if these issues are neglected. Hospitalists can serve a critical role in implementation and customization of CPOE systems that allow clinicians to do the right thing more timely and efficiently.

Risk Stratification for In-hospital Mortality in Acutely Decompensated Heart Failure: Classification and Regression Tree Analysis

Fonarow GC, Adams KF, Abraham WT, Yancy CW, Boscardin WJ; ADHERE Scientific Advisory Committee, Study Group, and Investigators. Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis. JAMA. 2005;293:572-80.

Heart failure is an important and growing cause of hospitalization in this country, and it is one of the most common clinical entities encountered by hospitalists. While there are some risk assessment tools available for outpatients with heart failure, there has not been a risk stratification tool published for inpatients. In this study by Fonarow et al. in JAMA, the authors describe a simple risk-stratification formula for in-hospital mortality in patients with acutely decompensated heart failure. Data from the ADHERE registry (Acute Decompensated Heart Failure National Registry, which is industry sponsored, as was this study) were used to model the risk of in-hospital death using a classification and regression tree (CART) analysis. This was done in a 2-stage process. First, investigators established a derivation cohort of approximately 33,000 patients (sequential hospital admissions from October 2001 to February 2003) from the ADHERE registry, and used the CART method to analyze 39 clinical variables to determine which were the best predictors of in-hospital mortality. This analysis was used to derive a risk tree to partition patients into low-, intermediate-, and high-risk groups. Second, the validity of this method was tested by applying the prediction tool to a cohort of the subsequent 32,229 patients hospitalized in the ADHERE registry, from March 2003 to July 2003. The results were striking. Baseline characteristics and clinical outcomes between the derivation and validation cohorts were similar across the wide range of parameters examined. The difference in mortality between the low-, intermediate-, and high-risk groups was 23.6% in the highest-risk category and 1.8% in the low-risk category, while the intermediate group was stratified into 3 levels, with 20.0%, 5.0%, and 5.1% mortality risk in intermediate group levels 1, 2, and 3, respectively. Aside from the more than 10-fold range in mortality risk across the various groups, the outstanding feature of the authors’ findings was that 3 simple parameters were the most significant predictors of in-hospital mortality risk: BUN, SBP, and serum creatinine. Specifically, combinations of a serum BUN of 43 or greater, a serum creatinine of 2.75 or greater, and a systolic blood pressure of less than 115 were associated with higher mortality. They note that adding other predictors did not meaningfully increase the model’s accuracy. The authors comment that unlike other predictive models based on multivariate analyses (which are often complex, and therefore difficult to employ at bedside), this simple tool is easy to use. An additional advantage is that the data needed are typically available at time of admission and can therefore be used to make a timely clinical decision in terms of triage into an appropriate level of care. Similar risk assessment tools exist for the risk stratification of patients with the acute coronary syndrome, and given the frequency with which patients are admitted with acutely decompensated heart failure, this new tool should prove a welcome addition to the clinical decision-making abilities of hospitalists.

Risk of Endocarditis among Patients with Prosthetic Valves and Staphylococcus Aureus Bacteremia

El-Ahdab F, Benjamin DK, Wang A, , et al. Risk of endocarditis among patients with prosthetic valves and Staphylococcus aureus bacteremia. Am J Med. 2005;118:225-9.

The risk of developing endocarditis in patients with Staphylococcus aureus bacteremia and prosthetic valves increases as more than 600,000 prosthetic valves are implanted annually in the United States. A prospective study at Duke University identified 51 patients with prosthetic valves or mitral ring who developed S. aureus bacteremia. The modified Duke criteria were used for the diagnosis of endocarditis. The onset and sources of bacteremia, locations of acquiring bacteremia, as well as clinical outcome were analyzed. The overall incidence of definite prosthetic valve endocarditis was as high as 51%, with the remaining 49% patients meeting Duke criteria for possible endocarditis. The results showed that endocarditis occurred more frequently in mitral (62%) and aortic positions (48%), and with mitral ring the rate of endocarditis was slightly lower (33%). Among prostheses, mechanical and bioprosthetic valves had endocarditis rates of 62% and 44%, respectively. About 63% of patients had early onset of bacteremia (<1 year after valve placement), and 37% had late onset of bacteremia (>1 year after valve placement). Overall, the most common source of bacteremia was from infected surgical wound sites (33%). Early bacteremia was more likely to result from infected surgical wound sites (59%), while late bacteremia was more likely to have an unidentified source (48%). The majority of episodes of bacteremia (47%) were hospital-acquired (i.e., a positive blood culture occurred >72 hours after admission). The frequency of healthcare-associated bacteremia and community-acquired bacteremia was about 26%–27%.

In terms of mortality, there was no difference for a patient with early and late S. aureus bacteremia, bioprosthetic and mechanical valves, and infection due to methicillin-resistant or methicillin-susceptible S. aureus. However, mortality was higher among patients with definite endocarditis (62%) vs. possible endocarditis (28%). Patients with endocarditis who underwent valve surgery had lower mortality than those who did not undergo valve surgery due to inoperable comorbid conditions, such as stroke, multiorgan system failure, and mediastinitis. Persistent fever (≥ 38°C after 72 hours of adequate parenteral antibiotics) and persistent bacteremia (positive blood culture within 2–4 days of the initial positive blood culture) were independently associated with definite endocarditis with odds ratio of 4.4 and 11.7, respectively. Overall, 96% of patients underwent echocardiography (55% with both transesophageal and transthoracic echo, 14% with only transesophageal echo, 27% with only transthoracic echo). However, 10% patients with definite endocarditis had no diagnostic finding on either transthoracic or transesophageal echocardiography.

S. aureus bacteremia is a common phenomenon in inpatient settings. This study demonstrated an approximately 50% rate of definite prosthetic valve endocarditis in patients with S. aureus bacteremia. The risks of endocarditis were independent of valve type, location, and duration of implantation. This study highlights the need for aggressive treatment and evaluation of S. aureus bacteremia in patients with prosthetic valves. Clinically, persistent fever and bacteremia were independently associated with definite endocarditis in this study population. Clinicians cannot over-rely on transesophageal echocardiogram to identify occult endocarditis in high-risk patients.

Optimizing the Prediction of Perioperative Mortality in Vascular Surgery by Using a Customized Probability Model

Kertai MD, Boersma E, Klein J, van Urk H, Poldermans D. Optimizing the prediction of perioperative mortality in vascular surgery by using a customized probability model. Arch Intern Med. 2005;165:898-904.

Traditional perioperative risk-assessment models and indexes have focused primarily on cardiac outcomes and involved mainly clinical risk factors. The model proposed in this paper focused instead on overall mortality and incorporated not only clinical risk factors but also more precise surgery-specific risks and the use of beta-blocker and statin agents.

click for large version

Investigators in the Netherlands targeted only vascular surgery patients identified from a computerized hospital information system. From a system, 2,310 patients who underwent 2,758 noncardiac vascular surgeries during a 10-year period in the 1990s were selected. Clinical risk factors, data on noninvasive stress testing, and long-term medication use, including statin agents, beta-blockers, calcium channel blockers, diuretics, insulin, nitrate, and aspirin, were abstracted. Outcome measures were all-cause mortality before discharge or within 30 days after surgery. The proposed model (see Figure) was based on modifications of the original Goldman Index, with the addition of more precise surgery risk stratification and statin and beta-blocker use. The specific types of vascular surgeries: carotid endarterectomy, infrainguinal bypass, abdominal aortic surgery, thoracoabdominal surgery, and acute abdominal aortic aneurysm rupture repair, carried systematically increased risk in expected fashion. Upon univariate analysis in the derivation cohort (n = 1,537), most of the clinical predictors from the Goldman Index were associated with increased perioperative mortality. Similar conclusions persisted in multivariate logistic regression analysis. Risk of surgical procedures, cardiovascular morbidity (ischemic heart disease, congestive heart failure, history of cerebrovascular event, and hypertension), renal dysfunction, and chronic pulmonary disease are independent predictors of increased all-cause perioperative mortality. In contrast, use of beta-blockers and statins were associated with reduced incidence of perioperative mortality. The final model included a scoring system with points assigned according to risk estimates of individual predictors. Beta-blocker and statin use in this model are assigned negative scores as their use lowers risk. For example, a patient with ischemic heart disease and hypertension undergoing abdominal aortic surgery would have a score of 46, corresponding to a 14% probability of mortality. That risk would be reduced to about 4% (score of 31) by use of beta-blockers (−15). In the same database, with 773 patients as the validation cohort, this prediction model performed nearly as well as the derivation model. Hypertension was not found to be an independent predictor in this validation cohort.

This tool appears provide robust risk assessment for vascular surgery patients. The inclusion of estimated benefit-of-statin and beta-blocker use may allow a more accurate “net” risk assessment. Those patients who are already on these 2 agents but still deemed at higher risk can be informed and may benefit from close monitoring. Additional preoperative interventions may include revascularization, if these high-risk patients have a decompensated cardiac status.

Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors

Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293:1197-1203.

Computerized Physician Order Entry (CPOE) has been touted as an effective means to reduce medical errors, especially medication errors. There have been preliminary studies that showed both potential and actual error reductions with CPOE. More recent data suggested that there may be potential for facilitating errors as well.

Koppel et al. aimed to study CPOE system-related factors that may actually increase risk of medication errors. The authors conducted structured interviews with end users (housestaff, pharmacists, nurses, nurse managers, and attending physicians), real-time observations of end users interfacing with the system, entering orders, charting medications, and reviewing orders, and focus groups with housestaff. These qualitative data were used to help generate a 71-question structured survey subsequently given to the housestaff. These questions pertain to working conditions, sources of stress, and errors. There were 261 responses representing an 88% response rate.

Twenty-two previously unexplored potential medication error sources abstracted from the survey were grouped into the 2 categories: 1) information errors, and 2) human-machine interface flaws. The first category refers to fragmented data and the disparate information systems within hospitals. The latter category includes rigid machine programming that does not correspond to or facilitate workflow. Only 10 survey elements with sufficiently robust results were reported. About 40% of respondents used CPOE to determine dosage of infrequently prescribed medications at least once a week or more. Incorrect doses may be ordered if users follow the dosage information in the system that is based on drug inventory rather than clinical recommendations. Twenty-two percent of respondents noted that more than once a week duplicate or conflicting medications were ordered and not detected for several hours. Disorganized display of patient medications was believed to be partly responsible. More than 80% of respondents noted unintended delay in renewing antibiotics at least once. Such gaps were possible partially because the reminder system occurred in the paper chart while order entry was done with the computer. With respect to the human-machine interface, 55% reported difficulty identifying the correct patient because of poor or fragmented displays, and 23% reported this occurring more than a few times per week. System downtime leading to delay in order entry was reported by 47% to occur more than once a week. System inflexibility also led to difficulties in specifying medications and ordering nonformulary medications. This was reported by 31% to occur at least several times a week, and 24% reported this daily or more frequently.

This was a survey of end users of a CPOE system in a single institution, and the survey elements were mainly estimates of error risks. Nevertheless, it appropriately draws attention to the importance of the unique culture of each institution, efficient workflow, and coherent human-machine interface. The anticipated error reductions may not materialize if these issues are neglected. Hospitalists can serve a critical role in implementation and customization of CPOE systems that allow clinicians to do the right thing more timely and efficiently.

Risk Stratification for In-hospital Mortality in Acutely Decompensated Heart Failure: Classification and Regression Tree Analysis

Fonarow GC, Adams KF, Abraham WT, Yancy CW, Boscardin WJ; ADHERE Scientific Advisory Committee, Study Group, and Investigators. Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis. JAMA. 2005;293:572-80.

Heart failure is an important and growing cause of hospitalization in this country, and it is one of the most common clinical entities encountered by hospitalists. While there are some risk assessment tools available for outpatients with heart failure, there has not been a risk stratification tool published for inpatients. In this study by Fonarow et al. in JAMA, the authors describe a simple risk-stratification formula for in-hospital mortality in patients with acutely decompensated heart failure. Data from the ADHERE registry (Acute Decompensated Heart Failure National Registry, which is industry sponsored, as was this study) were used to model the risk of in-hospital death using a classification and regression tree (CART) analysis. This was done in a 2-stage process. First, investigators established a derivation cohort of approximately 33,000 patients (sequential hospital admissions from October 2001 to February 2003) from the ADHERE registry, and used the CART method to analyze 39 clinical variables to determine which were the best predictors of in-hospital mortality. This analysis was used to derive a risk tree to partition patients into low-, intermediate-, and high-risk groups. Second, the validity of this method was tested by applying the prediction tool to a cohort of the subsequent 32,229 patients hospitalized in the ADHERE registry, from March 2003 to July 2003. The results were striking. Baseline characteristics and clinical outcomes between the derivation and validation cohorts were similar across the wide range of parameters examined. The difference in mortality between the low-, intermediate-, and high-risk groups was 23.6% in the highest-risk category and 1.8% in the low-risk category, while the intermediate group was stratified into 3 levels, with 20.0%, 5.0%, and 5.1% mortality risk in intermediate group levels 1, 2, and 3, respectively. Aside from the more than 10-fold range in mortality risk across the various groups, the outstanding feature of the authors’ findings was that 3 simple parameters were the most significant predictors of in-hospital mortality risk: BUN, SBP, and serum creatinine. Specifically, combinations of a serum BUN of 43 or greater, a serum creatinine of 2.75 or greater, and a systolic blood pressure of less than 115 were associated with higher mortality. They note that adding other predictors did not meaningfully increase the model’s accuracy. The authors comment that unlike other predictive models based on multivariate analyses (which are often complex, and therefore difficult to employ at bedside), this simple tool is easy to use. An additional advantage is that the data needed are typically available at time of admission and can therefore be used to make a timely clinical decision in terms of triage into an appropriate level of care. Similar risk assessment tools exist for the risk stratification of patients with the acute coronary syndrome, and given the frequency with which patients are admitted with acutely decompensated heart failure, this new tool should prove a welcome addition to the clinical decision-making abilities of hospitalists.

Risk of Endocarditis among Patients with Prosthetic Valves and Staphylococcus Aureus Bacteremia

El-Ahdab F, Benjamin DK, Wang A, , et al. Risk of endocarditis among patients with prosthetic valves and Staphylococcus aureus bacteremia. Am J Med. 2005;118:225-9.

The risk of developing endocarditis in patients with Staphylococcus aureus bacteremia and prosthetic valves increases as more than 600,000 prosthetic valves are implanted annually in the United States. A prospective study at Duke University identified 51 patients with prosthetic valves or mitral ring who developed S. aureus bacteremia. The modified Duke criteria were used for the diagnosis of endocarditis. The onset and sources of bacteremia, locations of acquiring bacteremia, as well as clinical outcome were analyzed. The overall incidence of definite prosthetic valve endocarditis was as high as 51%, with the remaining 49% patients meeting Duke criteria for possible endocarditis. The results showed that endocarditis occurred more frequently in mitral (62%) and aortic positions (48%), and with mitral ring the rate of endocarditis was slightly lower (33%). Among prostheses, mechanical and bioprosthetic valves had endocarditis rates of 62% and 44%, respectively. About 63% of patients had early onset of bacteremia (<1 year after valve placement), and 37% had late onset of bacteremia (>1 year after valve placement). Overall, the most common source of bacteremia was from infected surgical wound sites (33%). Early bacteremia was more likely to result from infected surgical wound sites (59%), while late bacteremia was more likely to have an unidentified source (48%). The majority of episodes of bacteremia (47%) were hospital-acquired (i.e., a positive blood culture occurred >72 hours after admission). The frequency of healthcare-associated bacteremia and community-acquired bacteremia was about 26%–27%.

In terms of mortality, there was no difference for a patient with early and late S. aureus bacteremia, bioprosthetic and mechanical valves, and infection due to methicillin-resistant or methicillin-susceptible S. aureus. However, mortality was higher among patients with definite endocarditis (62%) vs. possible endocarditis (28%). Patients with endocarditis who underwent valve surgery had lower mortality than those who did not undergo valve surgery due to inoperable comorbid conditions, such as stroke, multiorgan system failure, and mediastinitis. Persistent fever (≥ 38°C after 72 hours of adequate parenteral antibiotics) and persistent bacteremia (positive blood culture within 2–4 days of the initial positive blood culture) were independently associated with definite endocarditis with odds ratio of 4.4 and 11.7, respectively. Overall, 96% of patients underwent echocardiography (55% with both transesophageal and transthoracic echo, 14% with only transesophageal echo, 27% with only transthoracic echo). However, 10% patients with definite endocarditis had no diagnostic finding on either transthoracic or transesophageal echocardiography.

S. aureus bacteremia is a common phenomenon in inpatient settings. This study demonstrated an approximately 50% rate of definite prosthetic valve endocarditis in patients with S. aureus bacteremia. The risks of endocarditis were independent of valve type, location, and duration of implantation. This study highlights the need for aggressive treatment and evaluation of S. aureus bacteremia in patients with prosthetic valves. Clinically, persistent fever and bacteremia were independently associated with definite endocarditis in this study population. Clinicians cannot over-rely on transesophageal echocardiogram to identify occult endocarditis in high-risk patients.

Optimizing the Prediction of Perioperative Mortality in Vascular Surgery by Using a Customized Probability Model

Kertai MD, Boersma E, Klein J, van Urk H, Poldermans D. Optimizing the prediction of perioperative mortality in vascular surgery by using a customized probability model. Arch Intern Med. 2005;165:898-904.

Traditional perioperative risk-assessment models and indexes have focused primarily on cardiac outcomes and involved mainly clinical risk factors. The model proposed in this paper focused instead on overall mortality and incorporated not only clinical risk factors but also more precise surgery-specific risks and the use of beta-blocker and statin agents.

click for large version

Investigators in the Netherlands targeted only vascular surgery patients identified from a computerized hospital information system. From a system, 2,310 patients who underwent 2,758 noncardiac vascular surgeries during a 10-year period in the 1990s were selected. Clinical risk factors, data on noninvasive stress testing, and long-term medication use, including statin agents, beta-blockers, calcium channel blockers, diuretics, insulin, nitrate, and aspirin, were abstracted. Outcome measures were all-cause mortality before discharge or within 30 days after surgery. The proposed model (see Figure) was based on modifications of the original Goldman Index, with the addition of more precise surgery risk stratification and statin and beta-blocker use. The specific types of vascular surgeries: carotid endarterectomy, infrainguinal bypass, abdominal aortic surgery, thoracoabdominal surgery, and acute abdominal aortic aneurysm rupture repair, carried systematically increased risk in expected fashion. Upon univariate analysis in the derivation cohort (n = 1,537), most of the clinical predictors from the Goldman Index were associated with increased perioperative mortality. Similar conclusions persisted in multivariate logistic regression analysis. Risk of surgical procedures, cardiovascular morbidity (ischemic heart disease, congestive heart failure, history of cerebrovascular event, and hypertension), renal dysfunction, and chronic pulmonary disease are independent predictors of increased all-cause perioperative mortality. In contrast, use of beta-blockers and statins were associated with reduced incidence of perioperative mortality. The final model included a scoring system with points assigned according to risk estimates of individual predictors. Beta-blocker and statin use in this model are assigned negative scores as their use lowers risk. For example, a patient with ischemic heart disease and hypertension undergoing abdominal aortic surgery would have a score of 46, corresponding to a 14% probability of mortality. That risk would be reduced to about 4% (score of 31) by use of beta-blockers (−15). In the same database, with 773 patients as the validation cohort, this prediction model performed nearly as well as the derivation model. Hypertension was not found to be an independent predictor in this validation cohort.

This tool appears provide robust risk assessment for vascular surgery patients. The inclusion of estimated benefit-of-statin and beta-blocker use may allow a more accurate “net” risk assessment. Those patients who are already on these 2 agents but still deemed at higher risk can be informed and may benefit from close monitoring. Additional preoperative interventions may include revascularization, if these high-risk patients have a decompensated cardiac status.

Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors

Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293:1197-1203.

Computerized Physician Order Entry (CPOE) has been touted as an effective means to reduce medical errors, especially medication errors. There have been preliminary studies that showed both potential and actual error reductions with CPOE. More recent data suggested that there may be potential for facilitating errors as well.

Koppel et al. aimed to study CPOE system-related factors that may actually increase risk of medication errors. The authors conducted structured interviews with end users (housestaff, pharmacists, nurses, nurse managers, and attending physicians), real-time observations of end users interfacing with the system, entering orders, charting medications, and reviewing orders, and focus groups with housestaff. These qualitative data were used to help generate a 71-question structured survey subsequently given to the housestaff. These questions pertain to working conditions, sources of stress, and errors. There were 261 responses representing an 88% response rate.

Twenty-two previously unexplored potential medication error sources abstracted from the survey were grouped into the 2 categories: 1) information errors, and 2) human-machine interface flaws. The first category refers to fragmented data and the disparate information systems within hospitals. The latter category includes rigid machine programming that does not correspond to or facilitate workflow. Only 10 survey elements with sufficiently robust results were reported. About 40% of respondents used CPOE to determine dosage of infrequently prescribed medications at least once a week or more. Incorrect doses may be ordered if users follow the dosage information in the system that is based on drug inventory rather than clinical recommendations. Twenty-two percent of respondents noted that more than once a week duplicate or conflicting medications were ordered and not detected for several hours. Disorganized display of patient medications was believed to be partly responsible. More than 80% of respondents noted unintended delay in renewing antibiotics at least once. Such gaps were possible partially because the reminder system occurred in the paper chart while order entry was done with the computer. With respect to the human-machine interface, 55% reported difficulty identifying the correct patient because of poor or fragmented displays, and 23% reported this occurring more than a few times per week. System downtime leading to delay in order entry was reported by 47% to occur more than once a week. System inflexibility also led to difficulties in specifying medications and ordering nonformulary medications. This was reported by 31% to occur at least several times a week, and 24% reported this daily or more frequently.

This was a survey of end users of a CPOE system in a single institution, and the survey elements were mainly estimates of error risks. Nevertheless, it appropriately draws attention to the importance of the unique culture of each institution, efficient workflow, and coherent human-machine interface. The anticipated error reductions may not materialize if these issues are neglected. Hospitalists can serve a critical role in implementation and customization of CPOE systems that allow clinicians to do the right thing more timely and efficiently.

Risk Stratification for In-hospital Mortality in Acutely Decompensated Heart Failure: Classification and Regression Tree Analysis

Fonarow GC, Adams KF, Abraham WT, Yancy CW, Boscardin WJ; ADHERE Scientific Advisory Committee, Study Group, and Investigators. Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis. JAMA. 2005;293:572-80.

Heart failure is an important and growing cause of hospitalization in this country, and it is one of the most common clinical entities encountered by hospitalists. While there are some risk assessment tools available for outpatients with heart failure, there has not been a risk stratification tool published for inpatients. In this study by Fonarow et al. in JAMA, the authors describe a simple risk-stratification formula for in-hospital mortality in patients with acutely decompensated heart failure. Data from the ADHERE registry (Acute Decompensated Heart Failure National Registry, which is industry sponsored, as was this study) were used to model the risk of in-hospital death using a classification and regression tree (CART) analysis. This was done in a 2-stage process. First, investigators established a derivation cohort of approximately 33,000 patients (sequential hospital admissions from October 2001 to February 2003) from the ADHERE registry, and used the CART method to analyze 39 clinical variables to determine which were the best predictors of in-hospital mortality. This analysis was used to derive a risk tree to partition patients into low-, intermediate-, and high-risk groups. Second, the validity of this method was tested by applying the prediction tool to a cohort of the subsequent 32,229 patients hospitalized in the ADHERE registry, from March 2003 to July 2003. The results were striking. Baseline characteristics and clinical outcomes between the derivation and validation cohorts were similar across the wide range of parameters examined. The difference in mortality between the low-, intermediate-, and high-risk groups was 23.6% in the highest-risk category and 1.8% in the low-risk category, while the intermediate group was stratified into 3 levels, with 20.0%, 5.0%, and 5.1% mortality risk in intermediate group levels 1, 2, and 3, respectively. Aside from the more than 10-fold range in mortality risk across the various groups, the outstanding feature of the authors’ findings was that 3 simple parameters were the most significant predictors of in-hospital mortality risk: BUN, SBP, and serum creatinine. Specifically, combinations of a serum BUN of 43 or greater, a serum creatinine of 2.75 or greater, and a systolic blood pressure of less than 115 were associated with higher mortality. They note that adding other predictors did not meaningfully increase the model’s accuracy. The authors comment that unlike other predictive models based on multivariate analyses (which are often complex, and therefore difficult to employ at bedside), this simple tool is easy to use. An additional advantage is that the data needed are typically available at time of admission and can therefore be used to make a timely clinical decision in terms of triage into an appropriate level of care. Similar risk assessment tools exist for the risk stratification of patients with the acute coronary syndrome, and given the frequency with which patients are admitted with acutely decompensated heart failure, this new tool should prove a welcome addition to the clinical decision-making abilities of hospitalists.

Risk of Endocarditis among Patients with Prosthetic Valves and Staphylococcus Aureus Bacteremia

El-Ahdab F, Benjamin DK, Wang A, , et al. Risk of endocarditis among patients with prosthetic valves and Staphylococcus aureus bacteremia. Am J Med. 2005;118:225-9.

The risk of developing endocarditis in patients with Staphylococcus aureus bacteremia and prosthetic valves increases as more than 600,000 prosthetic valves are implanted annually in the United States. A prospective study at Duke University identified 51 patients with prosthetic valves or mitral ring who developed S. aureus bacteremia. The modified Duke criteria were used for the diagnosis of endocarditis. The onset and sources of bacteremia, locations of acquiring bacteremia, as well as clinical outcome were analyzed. The overall incidence of definite prosthetic valve endocarditis was as high as 51%, with the remaining 49% patients meeting Duke criteria for possible endocarditis. The results showed that endocarditis occurred more frequently in mitral (62%) and aortic positions (48%), and with mitral ring the rate of endocarditis was slightly lower (33%). Among prostheses, mechanical and bioprosthetic valves had endocarditis rates of 62% and 44%, respectively. About 63% of patients had early onset of bacteremia (<1 year after valve placement), and 37% had late onset of bacteremia (>1 year after valve placement). Overall, the most common source of bacteremia was from infected surgical wound sites (33%). Early bacteremia was more likely to result from infected surgical wound sites (59%), while late bacteremia was more likely to have an unidentified source (48%). The majority of episodes of bacteremia (47%) were hospital-acquired (i.e., a positive blood culture occurred >72 hours after admission). The frequency of healthcare-associated bacteremia and community-acquired bacteremia was about 26%–27%.

In terms of mortality, there was no difference for a patient with early and late S. aureus bacteremia, bioprosthetic and mechanical valves, and infection due to methicillin-resistant or methicillin-susceptible S. aureus. However, mortality was higher among patients with definite endocarditis (62%) vs. possible endocarditis (28%). Patients with endocarditis who underwent valve surgery had lower mortality than those who did not undergo valve surgery due to inoperable comorbid conditions, such as stroke, multiorgan system failure, and mediastinitis. Persistent fever (≥ 38°C after 72 hours of adequate parenteral antibiotics) and persistent bacteremia (positive blood culture within 2–4 days of the initial positive blood culture) were independently associated with definite endocarditis with odds ratio of 4.4 and 11.7, respectively. Overall, 96% of patients underwent echocardiography (55% with both transesophageal and transthoracic echo, 14% with only transesophageal echo, 27% with only transthoracic echo). However, 10% patients with definite endocarditis had no diagnostic finding on either transthoracic or transesophageal echocardiography.

S. aureus bacteremia is a common phenomenon in inpatient settings. This study demonstrated an approximately 50% rate of definite prosthetic valve endocarditis in patients with S. aureus bacteremia. The risks of endocarditis were independent of valve type, location, and duration of implantation. This study highlights the need for aggressive treatment and evaluation of S. aureus bacteremia in patients with prosthetic valves. Clinically, persistent fever and bacteremia were independently associated with definite endocarditis in this study population. Clinicians cannot over-rely on transesophageal echocardiogram to identify occult endocarditis in high-risk patients.

Optimizing the Prediction of Perioperative Mortality in Vascular Surgery by Using a Customized Probability Model

Kertai MD, Boersma E, Klein J, van Urk H, Poldermans D. Optimizing the prediction of perioperative mortality in vascular surgery by using a customized probability model. Arch Intern Med. 2005;165:898-904.

Traditional perioperative risk-assessment models and indexes have focused primarily on cardiac outcomes and involved mainly clinical risk factors. The model proposed in this paper focused instead on overall mortality and incorporated not only clinical risk factors but also more precise surgery-specific risks and the use of beta-blocker and statin agents.

click for large version

Investigators in the Netherlands targeted only vascular surgery patients identified from a computerized hospital information system. From a system, 2,310 patients who underwent 2,758 noncardiac vascular surgeries during a 10-year period in the 1990s were selected. Clinical risk factors, data on noninvasive stress testing, and long-term medication use, including statin agents, beta-blockers, calcium channel blockers, diuretics, insulin, nitrate, and aspirin, were abstracted. Outcome measures were all-cause mortality before discharge or within 30 days after surgery. The proposed model (see Figure) was based on modifications of the original Goldman Index, with the addition of more precise surgery risk stratification and statin and beta-blocker use. The specific types of vascular surgeries: carotid endarterectomy, infrainguinal bypass, abdominal aortic surgery, thoracoabdominal surgery, and acute abdominal aortic aneurysm rupture repair, carried systematically increased risk in expected fashion. Upon univariate analysis in the derivation cohort (n = 1,537), most of the clinical predictors from the Goldman Index were associated with increased perioperative mortality. Similar conclusions persisted in multivariate logistic regression analysis. Risk of surgical procedures, cardiovascular morbidity (ischemic heart disease, congestive heart failure, history of cerebrovascular event, and hypertension), renal dysfunction, and chronic pulmonary disease are independent predictors of increased all-cause perioperative mortality. In contrast, use of beta-blockers and statins were associated with reduced incidence of perioperative mortality. The final model included a scoring system with points assigned according to risk estimates of individual predictors. Beta-blocker and statin use in this model are assigned negative scores as their use lowers risk. For example, a patient with ischemic heart disease and hypertension undergoing abdominal aortic surgery would have a score of 46, corresponding to a 14% probability of mortality. That risk would be reduced to about 4% (score of 31) by use of beta-blockers (−15). In the same database, with 773 patients as the validation cohort, this prediction model performed nearly as well as the derivation model. Hypertension was not found to be an independent predictor in this validation cohort.

This tool appears provide robust risk assessment for vascular surgery patients. The inclusion of estimated benefit-of-statin and beta-blocker use may allow a more accurate “net” risk assessment. Those patients who are already on these 2 agents but still deemed at higher risk can be informed and may benefit from close monitoring. Additional preoperative interventions may include revascularization, if these high-risk patients have a decompensated cardiac status.

Documentation in the form of the daily progress note is an important and cumbersome detail in the life of a hospitalist. Recognizing this, we saw an opportunity for improvement in this process and began a creative endeavor to rework the progress note. Our goal was to decrease the length of time that we spent on documenting redundant information such as writing out “lungs are clear to auscultation” on every patient, in order for us to focus our documentation time on more individualized information and discussion of the patients. We also wanted to simultaneously include quality improvement measures on indicators such as deep vein thrombosis (DVT) prophylaxis, urinary catheter existence, ambulation status, and nutrition. In January 2004, we instituted a template progress note for our hospital medicine service at Lee Memorial Health Systems in Lee County, FL, that has changed how we document increased DVT prophylaxis and increased our efficiency.

click for large version

After some literature review, we found that evidence existed to support our initiative. Findings of several studies suggest that strategies focused on the prevention of errors of omission have utility in improving guideline compliance (1,2,3). We also found that reminders for prevention at the point of care (the progress note in our situation) were important for compliance (2–5). Furthermore, the findings of one study suggested that it was the facilitation of documentation and ordering of recommended procedures that improved guideline compliance in a small sample of resident physicians (3).

The creation of the template progress note had just begun. We knew that it would require several revisions. Therefore, we wanted to have the control of the template without needing hospital approval. To do this, we decided to use the hospital’s standard blank progress note and print the template onto the progress note using a word processing document and a laser printer. We solicited input from various members of the group for the design and required information on the template, and we reviewed previous template notes that had been utilized (although these were created for outpatient environments). We learned that having a 1-page template was important for the group. We also discovered that the hospitalists needed ample room for free writing subjective data as well as the assessment and discussion. We finally arrived at the hospitalist template progress note.

Each hospitalist was sent a copy of the template via electronic mail that could easily be printed at each nursing station. A supply of preprinted template progress notes was placed at each nursing station and maintained by our support staff. The hospitalists could also have the progress note on their personal digital assistant (PDA) and print out to the infrared enabled laser printers found throughout our institution. This option was not exercised routinely by our hospitalists.

It took a few months for the hospitalists to adapt to using the template progress notes. The initial hurdles were documentation habits and the availability of the notes at the nursing station. The documentation habits quickly changed to using the templates once the hospitalists were able to appreciate the time they saved. After 1 year of implementation, we have 100% utilization among the hospitalists at Lee Memorial Hospital (the flagship hospital of the health system). Utilization at the smaller hospitals in the system remains disappointing, likely a result of lack of template availability at the nursing stations.

click for large version

An early supporter of the template progress note was Director of Case Management at Lee Memorial Health Systems Karen Harris Wise. She said, “The template progress notes are great from a case management standpoint. We can easily identify the physician, and it gives us the necessary information for our job.” Case management soon came to ask us to incorporate the estimated date of discharge at the bottom of the progress note. Once we incorporated the estimated date of discharge, the hospitalists felt they received fewer calls from case management, and the case managers were soon requesting hospitalists not using the template progress note to do so, thus improving utilization compliance.

Once implemented, the accolades and success stories for the template progress notes began flowing. Other non-hospitalist physicians at the hospital liked the idea so much that they created their own. A local pulmonologist said, “The progress note template is a great idea. It cuts out the time you waste documenting routine items and gives you more time and highlights the thoughts that you document in the discussion section.” His group later created and implemented their own template progress note specifically for ICU patients, based upon our template.

The progress note decreased the time to document each patient by approximately 42 seconds. This may not seem substantial, but multiplied by 18 patients per day (our average), this equated to over 12 minutes each day, over an hour each week, and over 60 hours a year per hospitalist.

After about 6 months of experience and success with the progress note templates, the hospital approached us to make a standardized progress note that could be used by the entire staff (Figure 1). They also wanted to incorporate Joint Commission on Accreditation of Healthcare Organizations (JCAHO) quality indicators such as smoking cessation documentation and vaccination status. We submitted our form with some modifications, and the hospital approved and published it as an official progress note template. When the hospital was inspected by JCAHO in March of 2005, it received accolades for this quality improvement tool.

This template was created with the input of our group as an initiative to have a system-wide progress note for Internal Medicine based on the success our hospitalist group had with the template progress note. (Reproduced with permission from LMHS.)

Implementing documentation of DVT prophylaxis (if applicable) was one of our original motivations for the progress note. With a check box at the top of the template note, hospitalists were faced with this documentation on every patient. We also reinforced the DVT prophylaxis with quarterly educational sessions. A DVT prophylaxis order set (Figure 2) with DVT prophylaxis indications and recommendations was also encouraged and utilized during this period of time. DVT prophylaxis compliance in our group went from less than 50% to nearly 100% during the first year of implementing the hospital progress note.

Another potential benefit may be coding compliance. Prior to implementation, we had a substantial failure rate on Medicare audits. We suspect that this number will be substantially reduced with detailed physical examination documentation built into the template, although corroborating data are not available.

Based upon our experience, a hospitalist progress note template is a promising tool with regard to time efficiency, coding compliance, and quality improvement. The electronic medical record will likely soon become the standard of inpatient documentation. The template progress note may serve as an efficient tool in the meantime and may even serve as a basis for the hospitalist electronic templates, as electronic medical records are often template based.

References

1. McDonald CJ. Protocol-based reminders, the quality of care, and the non-perfectibility of man. N Engl J Med. 1976;295: 1351-5.
2. Overhage JM, Tierney WM, Zhou X, McDonald CJ. A randomized trial of “corollary orders” to prevent errors of omission. J Am Med Inform Assoc. 1997;4: 364-71.
3. Nilasena DS, Lincoln MJ. A computer-based reminder system improved physician compliance with diabetes preventive care guidelines. Proc 19th Annu Symp Comput Appl Med Care. 1995:640-5.
4. Lobach DF, Hammond WE. Development and evaluation of a computer-assisted management protocol (CAMP): improved compliance with care guidelines for diabetes mellitus. Proc 18th Annu Symp Comput Appl Med Care. 1994:787-91.
5. Tierney WM, Hui SL, McDonald CJ. Delayed feedback of physician performance versus immediate reminders to perform preventive care. Effects on physician compliance. Med Care. 1986;24:659-66.

Robert Hasty, DO, is assistant professor of internal medicine and a hospitalist at Nova Southeastern University College of Osteopathic Medicine in Fort Lauderdale, FL. Prior to his academic career, he was an associate lead hospitalist for Cogent Healthcare, Inc., at Lee Memorial Health Systems in Lee County, FL. Dr. Hasty can be contacted at [email protected] or 954-262-1473.

Documentation in the form of the daily progress note is an important and cumbersome detail in the life of a hospitalist. Recognizing this, we saw an opportunity for improvement in this process and began a creative endeavor to rework the progress note. Our goal was to decrease the length of time that we spent on documenting redundant information such as writing out “lungs are clear to auscultation” on every patient, in order for us to focus our documentation time on more individualized information and discussion of the patients. We also wanted to simultaneously include quality improvement measures on indicators such as deep vein thrombosis (DVT) prophylaxis, urinary catheter existence, ambulation status, and nutrition. In January 2004, we instituted a template progress note for our hospital medicine service at Lee Memorial Health Systems in Lee County, FL, that has changed how we document increased DVT prophylaxis and increased our efficiency.

click for large version

After some literature review, we found that evidence existed to support our initiative. Findings of several studies suggest that strategies focused on the prevention of errors of omission have utility in improving guideline compliance (1,2,3). We also found that reminders for prevention at the point of care (the progress note in our situation) were important for compliance (2–5). Furthermore, the findings of one study suggested that it was the facilitation of documentation and ordering of recommended procedures that improved guideline compliance in a small sample of resident physicians (3).

The creation of the template progress note had just begun. We knew that it would require several revisions. Therefore, we wanted to have the control of the template without needing hospital approval. To do this, we decided to use the hospital’s standard blank progress note and print the template onto the progress note using a word processing document and a laser printer. We solicited input from various members of the group for the design and required information on the template, and we reviewed previous template notes that had been utilized (although these were created for outpatient environments). We learned that having a 1-page template was important for the group. We also discovered that the hospitalists needed ample room for free writing subjective data as well as the assessment and discussion. We finally arrived at the hospitalist template progress note.

Each hospitalist was sent a copy of the template via electronic mail that could easily be printed at each nursing station. A supply of preprinted template progress notes was placed at each nursing station and maintained by our support staff. The hospitalists could also have the progress note on their personal digital assistant (PDA) and print out to the infrared enabled laser printers found throughout our institution. This option was not exercised routinely by our hospitalists.

It took a few months for the hospitalists to adapt to using the template progress notes. The initial hurdles were documentation habits and the availability of the notes at the nursing station. The documentation habits quickly changed to using the templates once the hospitalists were able to appreciate the time they saved. After 1 year of implementation, we have 100% utilization among the hospitalists at Lee Memorial Hospital (the flagship hospital of the health system). Utilization at the smaller hospitals in the system remains disappointing, likely a result of lack of template availability at the nursing stations.

click for large version

An early supporter of the template progress note was Director of Case Management at Lee Memorial Health Systems Karen Harris Wise. She said, “The template progress notes are great from a case management standpoint. We can easily identify the physician, and it gives us the necessary information for our job.” Case management soon came to ask us to incorporate the estimated date of discharge at the bottom of the progress note. Once we incorporated the estimated date of discharge, the hospitalists felt they received fewer calls from case management, and the case managers were soon requesting hospitalists not using the template progress note to do so, thus improving utilization compliance.

Once implemented, the accolades and success stories for the template progress notes began flowing. Other non-hospitalist physicians at the hospital liked the idea so much that they created their own. A local pulmonologist said, “The progress note template is a great idea. It cuts out the time you waste documenting routine items and gives you more time and highlights the thoughts that you document in the discussion section.” His group later created and implemented their own template progress note specifically for ICU patients, based upon our template.

The progress note decreased the time to document each patient by approximately 42 seconds. This may not seem substantial, but multiplied by 18 patients per day (our average), this equated to over 12 minutes each day, over an hour each week, and over 60 hours a year per hospitalist.

After about 6 months of experience and success with the progress note templates, the hospital approached us to make a standardized progress note that could be used by the entire staff (Figure 1). They also wanted to incorporate Joint Commission on Accreditation of Healthcare Organizations (JCAHO) quality indicators such as smoking cessation documentation and vaccination status. We submitted our form with some modifications, and the hospital approved and published it as an official progress note template. When the hospital was inspected by JCAHO in March of 2005, it received accolades for this quality improvement tool.

This template was created with the input of our group as an initiative to have a system-wide progress note for Internal Medicine based on the success our hospitalist group had with the template progress note. (Reproduced with permission from LMHS.)

Implementing documentation of DVT prophylaxis (if applicable) was one of our original motivations for the progress note. With a check box at the top of the template note, hospitalists were faced with this documentation on every patient. We also reinforced the DVT prophylaxis with quarterly educational sessions. A DVT prophylaxis order set (Figure 2) with DVT prophylaxis indications and recommendations was also encouraged and utilized during this period of time. DVT prophylaxis compliance in our group went from less than 50% to nearly 100% during the first year of implementing the hospital progress note.

Another potential benefit may be coding compliance. Prior to implementation, we had a substantial failure rate on Medicare audits. We suspect that this number will be substantially reduced with detailed physical examination documentation built into the template, although corroborating data are not available.

Based upon our experience, a hospitalist progress note template is a promising tool with regard to time efficiency, coding compliance, and quality improvement. The electronic medical record will likely soon become the standard of inpatient documentation. The template progress note may serve as an efficient tool in the meantime and may even serve as a basis for the hospitalist electronic templates, as electronic medical records are often template based.

References

1. McDonald CJ. Protocol-based reminders, the quality of care, and the non-perfectibility of man. N Engl J Med. 1976;295: 1351-5.
2. Overhage JM, Tierney WM, Zhou X, McDonald CJ. A randomized trial of “corollary orders” to prevent errors of omission. J Am Med Inform Assoc. 1997;4: 364-71.
3. Nilasena DS, Lincoln MJ. A computer-based reminder system improved physician compliance with diabetes preventive care guidelines. Proc 19th Annu Symp Comput Appl Med Care. 1995:640-5.
4. Lobach DF, Hammond WE. Development and evaluation of a computer-assisted management protocol (CAMP): improved compliance with care guidelines for diabetes mellitus. Proc 18th Annu Symp Comput Appl Med Care. 1994:787-91.
5. Tierney WM, Hui SL, McDonald CJ. Delayed feedback of physician performance versus immediate reminders to perform preventive care. Effects on physician compliance. Med Care. 1986;24:659-66.

Robert Hasty, DO, is assistant professor of internal medicine and a hospitalist at Nova Southeastern University College of Osteopathic Medicine in Fort Lauderdale, FL. Prior to his academic career, he was an associate lead hospitalist for Cogent Healthcare, Inc., at Lee Memorial Health Systems in Lee County, FL. Dr. Hasty can be contacted at [email protected] or 954-262-1473.

Documentation in the form of the daily progress note is an important and cumbersome detail in the life of a hospitalist. Recognizing this, we saw an opportunity for improvement in this process and began a creative endeavor to rework the progress note. Our goal was to decrease the length of time that we spent on documenting redundant information such as writing out “lungs are clear to auscultation” on every patient, in order for us to focus our documentation time on more individualized information and discussion of the patients. We also wanted to simultaneously include quality improvement measures on indicators such as deep vein thrombosis (DVT) prophylaxis, urinary catheter existence, ambulation status, and nutrition. In January 2004, we instituted a template progress note for our hospital medicine service at Lee Memorial Health Systems in Lee County, FL, that has changed how we document increased DVT prophylaxis and increased our efficiency.

click for large version

After some literature review, we found that evidence existed to support our initiative. Findings of several studies suggest that strategies focused on the prevention of errors of omission have utility in improving guideline compliance (1,2,3). We also found that reminders for prevention at the point of care (the progress note in our situation) were important for compliance (2–5). Furthermore, the findings of one study suggested that it was the facilitation of documentation and ordering of recommended procedures that improved guideline compliance in a small sample of resident physicians (3).

The creation of the template progress note had just begun. We knew that it would require several revisions. Therefore, we wanted to have the control of the template without needing hospital approval. To do this, we decided to use the hospital’s standard blank progress note and print the template onto the progress note using a word processing document and a laser printer. We solicited input from various members of the group for the design and required information on the template, and we reviewed previous template notes that had been utilized (although these were created for outpatient environments). We learned that having a 1-page template was important for the group. We also discovered that the hospitalists needed ample room for free writing subjective data as well as the assessment and discussion. We finally arrived at the hospitalist template progress note.

Each hospitalist was sent a copy of the template via electronic mail that could easily be printed at each nursing station. A supply of preprinted template progress notes was placed at each nursing station and maintained by our support staff. The hospitalists could also have the progress note on their personal digital assistant (PDA) and print out to the infrared enabled laser printers found throughout our institution. This option was not exercised routinely by our hospitalists.

It took a few months for the hospitalists to adapt to using the template progress notes. The initial hurdles were documentation habits and the availability of the notes at the nursing station. The documentation habits quickly changed to using the templates once the hospitalists were able to appreciate the time they saved. After 1 year of implementation, we have 100% utilization among the hospitalists at Lee Memorial Hospital (the flagship hospital of the health system). Utilization at the smaller hospitals in the system remains disappointing, likely a result of lack of template availability at the nursing stations.

click for large version

An early supporter of the template progress note was Director of Case Management at Lee Memorial Health Systems Karen Harris Wise. She said, “The template progress notes are great from a case management standpoint. We can easily identify the physician, and it gives us the necessary information for our job.” Case management soon came to ask us to incorporate the estimated date of discharge at the bottom of the progress note. Once we incorporated the estimated date of discharge, the hospitalists felt they received fewer calls from case management, and the case managers were soon requesting hospitalists not using the template progress note to do so, thus improving utilization compliance.

Once implemented, the accolades and success stories for the template progress notes began flowing. Other non-hospitalist physicians at the hospital liked the idea so much that they created their own. A local pulmonologist said, “The progress note template is a great idea. It cuts out the time you waste documenting routine items and gives you more time and highlights the thoughts that you document in the discussion section.” His group later created and implemented their own template progress note specifically for ICU patients, based upon our template.

The progress note decreased the time to document each patient by approximately 42 seconds. This may not seem substantial, but multiplied by 18 patients per day (our average), this equated to over 12 minutes each day, over an hour each week, and over 60 hours a year per hospitalist.

After about 6 months of experience and success with the progress note templates, the hospital approached us to make a standardized progress note that could be used by the entire staff (Figure 1). They also wanted to incorporate Joint Commission on Accreditation of Healthcare Organizations (JCAHO) quality indicators such as smoking cessation documentation and vaccination status. We submitted our form with some modifications, and the hospital approved and published it as an official progress note template. When the hospital was inspected by JCAHO in March of 2005, it received accolades for this quality improvement tool.

This template was created with the input of our group as an initiative to have a system-wide progress note for Internal Medicine based on the success our hospitalist group had with the template progress note. (Reproduced with permission from LMHS.)

Implementing documentation of DVT prophylaxis (if applicable) was one of our original motivations for the progress note. With a check box at the top of the template note, hospitalists were faced with this documentation on every patient. We also reinforced the DVT prophylaxis with quarterly educational sessions. A DVT prophylaxis order set (Figure 2) with DVT prophylaxis indications and recommendations was also encouraged and utilized during this period of time. DVT prophylaxis compliance in our group went from less than 50% to nearly 100% during the first year of implementing the hospital progress note.

Another potential benefit may be coding compliance. Prior to implementation, we had a substantial failure rate on Medicare audits. We suspect that this number will be substantially reduced with detailed physical examination documentation built into the template, although corroborating data are not available.

Based upon our experience, a hospitalist progress note template is a promising tool with regard to time efficiency, coding compliance, and quality improvement. The electronic medical record will likely soon become the standard of inpatient documentation. The template progress note may serve as an efficient tool in the meantime and may even serve as a basis for the hospitalist electronic templates, as electronic medical records are often template based.

References

1. McDonald CJ. Protocol-based reminders, the quality of care, and the non-perfectibility of man. N Engl J Med. 1976;295: 1351-5.
2. Overhage JM, Tierney WM, Zhou X, McDonald CJ. A randomized trial of “corollary orders” to prevent errors of omission. J Am Med Inform Assoc. 1997;4: 364-71.
3. Nilasena DS, Lincoln MJ. A computer-based reminder system improved physician compliance with diabetes preventive care guidelines. Proc 19th Annu Symp Comput Appl Med Care. 1995:640-5.
4. Lobach DF, Hammond WE. Development and evaluation of a computer-assisted management protocol (CAMP): improved compliance with care guidelines for diabetes mellitus. Proc 18th Annu Symp Comput Appl Med Care. 1994:787-91.
5. Tierney WM, Hui SL, McDonald CJ. Delayed feedback of physician performance versus immediate reminders to perform preventive care. Effects on physician compliance. Med Care. 1986;24:659-66.

Robert Hasty, DO, is assistant professor of internal medicine and a hospitalist at Nova Southeastern University College of Osteopathic Medicine in Fort Lauderdale, FL. Prior to his academic career, he was an associate lead hospitalist for Cogent Healthcare, Inc., at Lee Memorial Health Systems in Lee County, FL. Dr. Hasty can be contacted at [email protected] or 954-262-1473.

“Culture trumps strategy every time”

As hospitalists attempt to improve hospital care delivery, they strive to develop strategies for successful implementation of new guidelines, order sets, and alteration of utilization patterns. Key to this success will be collaboration with staff also caring for patients in the hospital. How best to make these changes is unclear, but Kurt Swartout, a hospitalist at Kaiser Permanente’s Roseville Medical Center in California, is involved in a unique project to figure this out. Roseville is one of 13 hospitals (Figure 1) participating in the Institute for Healthcare Improvement (IHI) Transforming Care at the Bedside (TCAB) initiative.

click for large version

“In July 2003, The Robert Wood Johnson Foundation awarded IHI a grant to study and develop one or more models of care at the bedside on medical and surgical units that would result in improved quality of patient care and service, more effective care teams, improved staff satisfaction and retention, and greater efficiency. Utilizing an innovative approach, IHI and select pilot organizations have been piloting new ideas based on the six Institute of Medicine dimensions of quality (safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity), plus the added dimension of vitality” (www.ihi.org).

Since joining the project in October 2003, many changes have occurred on a couple of the hospital floors at Roseville Medical Center. Dr. Swartout raves about this initiative: “TCAB significantly helped set the stage for effective communication and has helped improve the quality of care at the hospital in which I work. It is the most exciting project in which I have been involved and has done more to improve the quality of patient care than anything else I have seen as a hospitalist.”

Dr. Swartout’s hospital was selected as 1 of 3 test hospitals along with the University of Pittsburgh Medical Center at Shady Side and Seton Hospital in Austin, TX. The first phase at Kaiser Roseville started with a meeting of all employees who worked on medical floor Two South. This included the nurses, the unit assistant, respiratory and physical therapists, pharmacists, administrators, and physicians working on the unit. They had 9 areas from which to choose to study and as a group selected 3:

1. Increasing patient safety;
2. Improving communication among different health care providers; and
3. Making care more patient oriented (patient-centered care).

Utilizing rapid-cycle testing and small tests of change, they then moved forward to improve performance with the above aims. To generate ideas, a “safe” environment was created in which no ideas were considered “bad” and everyone was encouraged to exchange suggestions freely. Administrative support was and continues to be critical to the success of TCAB, because everyone involved was given permission and in fact was empowered to develop creative testing solutions to common problems. Interventions were implemented using rapid-cycle tests and evaluated on 1 patient for 1 shift. Depending upon the outcome, these interventions were either adopted for expansion, or they were modified for further testing or abandoned if unsuccessful. This rapid-cycle testing using small tests of change appealed to everyone, generating a level of energy and enthusiasm among the entire team that had not been present among hospital staff prior to TCAB. Unique to the philosophy of the TCAB initiative, whenever an idea was being tested, the rank-and-file staff had the opportunity to stop it, no matter how enthusiastic the management staff believed in it.

During phase I, Two South rapid-cycle tested over 250 staff-generated ideas. Of note, brainstorming by the staff mainly yielded low-cost and easy-to-implement ideas. Many interventions were simple but allowed the caregiver to focus on the patient, experimenting with ideas that had previously gone unsolicited by management. For example, the staff evaluated placing white boards at the patient’s bedside on which the daily goals were outlined in collaboration with the patient, family, and caregivers. Additionally, they tried alternating midnight rounds between the hospitalist and charge nurse to proactively address issues that might otherwise result in an early, 4 a.m. phone call to the physician. These trials were successful and became permanent efforts.

Perhaps the biggest impact was on the culture of the unit. Because identified issues had become opportunities for improvement instead of problems, a new sense of optimism prevailed. Care on one patient typified this evolving approach induced by the TCAB initiative. An 81-year-old demented man was admitted for behavioral problems because the family could no longer handle him; he appeared destined to languish in the hospital. We have all taken care of patients like this, and difficulties in their management combined with no obvious disposition usually result in prolonged hospitalizations. The staff immediately saw this patient as an opportunity to work closely with the family. Making arrangements for the wife to spend time with the patient in the hospital and aggressively devising a care plan that involved the family resulted in the patient’s return home after just 4 days. The patient’s family was delighted with the care, and everybody on the unit shared a real sense of accomplishment.

A concrete example of using the white board for communication resulted in optimization of care for another gentleman who was admitted after a complicated bowel resection with a projected length of stay of 8–10 days according to the surgeon. The Two South staff worked closely with the surgeon and placed daily goals on the white board for all to see. Additionally, the nurses and patient were actively involved in the decision-making process, particularly with regard to increasing ambulation and decreasing narcotic use. This resulted in more rapid achievement of goals and recovery by the patient, with discharge from the unit occurring after just 4 days.

With the success of phase I at Kaiser Roseville, the staff anxiously set forth to participate in Phase II. Phase II increased the number of hospital sites to 13 and increased the rapid-cycle testing module. Ten areas of focused improvement were selected, including attempts to reduce unplanned transfers to the ICU and decreasing adverse events for hospitalized patients. During Phase II, Roseville developed its own Rapid Medical Response Team (RMRT). The RMRT is composed of the charge nurse for the ICU, a respiratory therapist, and a house supervisor. This team responds emergently at the request of any Medical-Surgical nurse to evaluate any patient about whom the nurse has concerns. These patients usually have a quickly evolving medical crisis such as respiratory distress, hypotension, or an altered level of consciousness. The primary goal of the RMRT is to quickly evaluate the patient, obtain physician support if needed, and stabilize the patient promptly on the floor or transfer them in a controlled fashion to the ICU. A secondary goal pertains to another TCAB aim, staff vitality, in that the medical-surgical nurse is now placed in a safe environment where he or she interacts with peers from the RMRT and gain additional critical thinking and physical assessment skills through that interaction. It is still early, as we just started the RMRT in September 2004, but the early data suggest we have significantly decreased transfers to the ICU, Code Blues outside the ICU, and unplanned mortality on the Medical-Surgical floors.

In an effort to minimize patient falls, Roseville instituted hourly safety rounds in which a direct care provider (RN, LVN, or NA) quickly looks at all the patients and their current status and implements a fall prevention protocol as needed. Another intervention they have adopted is the use of portable bed alarms, which alerts staff that a patient is attempting to get out of bed. The net result of this has been a dramatic reduction in the fall rate on the floor from a California average of 3.1 falls/thousand patient days to 0.8 falls/ thousand patient days on Two North, demonstrating expansion of the TCAB initiative to other floors in the hospital.

When the TCAB initiative was initiated at Roseville 18 months ago with the Robert Wood Johnson Foundation and the IHI, the Roseville staff had no idea of how much could be achieved—from enhancing patient care to improving both physician and nursing satisfaction to decreasing patient mortality. Although the TCAB initiative is viewed as an ongoing journey, the staff is eagerly anticipating the remainder of the voyage.

An example of an initiative at other hospitals among the 13 includes “peace and quiet time” at Long Island Jewish/North Shore. These nursing “magnet” hospitals discovered when they surveyed their patients that noise preventing patients from resting and recuperating was a major problem. Beginning with 30 minutes of enforced quiet time in the afternoon and then expanding to an hour, patients have reportedly been delighted with this. Snacks were passed out to the patients so they would buy into the initiative and believe they were not being ignored—a floor staff suggestion!

Another hospital modified the usual “multidisciplinary rounds” into highly functional, true patient rounds. At this hospital they originally were called “discharge rounds,” with a focus on discharging the patient. Recognizing that the patient had not been involved because these occurred in a conference room, they were renamed “patient care rounds” and moved out of the conference room to round in the patients’ rooms. Following the dictum of “nothing about the patient without the patient,” these rounds include a pharmacist, a social worker, the charge nurse, a nutritionist, a case manager, and the patient in the patients’ room. This team rounds on all the patients on the unit, seeing up to 37 patients in 1 hour! After initial difficulties involving the residents, they now have “firm directors,” so a physician is now involved. Based on this experience, they proclaim that their culture has changed from “no, it won’t work” to “why not try it?”

Hospitals and staff participating in TCAB are discovering just how successful they can be in achieving enhanced communication, implementing novel interventions to improve care, and optimizing the overall hospital experience for patients.

“Culture trumps strategy every time”

As hospitalists attempt to improve hospital care delivery, they strive to develop strategies for successful implementation of new guidelines, order sets, and alteration of utilization patterns. Key to this success will be collaboration with staff also caring for patients in the hospital. How best to make these changes is unclear, but Kurt Swartout, a hospitalist at Kaiser Permanente’s Roseville Medical Center in California, is involved in a unique project to figure this out. Roseville is one of 13 hospitals (Figure 1) participating in the Institute for Healthcare Improvement (IHI) Transforming Care at the Bedside (TCAB) initiative.

click for large version

“In July 2003, The Robert Wood Johnson Foundation awarded IHI a grant to study and develop one or more models of care at the bedside on medical and surgical units that would result in improved quality of patient care and service, more effective care teams, improved staff satisfaction and retention, and greater efficiency. Utilizing an innovative approach, IHI and select pilot organizations have been piloting new ideas based on the six Institute of Medicine dimensions of quality (safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity), plus the added dimension of vitality” (www.ihi.org).

Since joining the project in October 2003, many changes have occurred on a couple of the hospital floors at Roseville Medical Center. Dr. Swartout raves about this initiative: “TCAB significantly helped set the stage for effective communication and has helped improve the quality of care at the hospital in which I work. It is the most exciting project in which I have been involved and has done more to improve the quality of patient care than anything else I have seen as a hospitalist.”

Dr. Swartout’s hospital was selected as 1 of 3 test hospitals along with the University of Pittsburgh Medical Center at Shady Side and Seton Hospital in Austin, TX. The first phase at Kaiser Roseville started with a meeting of all employees who worked on medical floor Two South. This included the nurses, the unit assistant, respiratory and physical therapists, pharmacists, administrators, and physicians working on the unit. They had 9 areas from which to choose to study and as a group selected 3:

1. Increasing patient safety;
2. Improving communication among different health care providers; and
3. Making care more patient oriented (patient-centered care).

Utilizing rapid-cycle testing and small tests of change, they then moved forward to improve performance with the above aims. To generate ideas, a “safe” environment was created in which no ideas were considered “bad” and everyone was encouraged to exchange suggestions freely. Administrative support was and continues to be critical to the success of TCAB, because everyone involved was given permission and in fact was empowered to develop creative testing solutions to common problems. Interventions were implemented using rapid-cycle tests and evaluated on 1 patient for 1 shift. Depending upon the outcome, these interventions were either adopted for expansion, or they were modified for further testing or abandoned if unsuccessful. This rapid-cycle testing using small tests of change appealed to everyone, generating a level of energy and enthusiasm among the entire team that had not been present among hospital staff prior to TCAB. Unique to the philosophy of the TCAB initiative, whenever an idea was being tested, the rank-and-file staff had the opportunity to stop it, no matter how enthusiastic the management staff believed in it.

During phase I, Two South rapid-cycle tested over 250 staff-generated ideas. Of note, brainstorming by the staff mainly yielded low-cost and easy-to-implement ideas. Many interventions were simple but allowed the caregiver to focus on the patient, experimenting with ideas that had previously gone unsolicited by management. For example, the staff evaluated placing white boards at the patient’s bedside on which the daily goals were outlined in collaboration with the patient, family, and caregivers. Additionally, they tried alternating midnight rounds between the hospitalist and charge nurse to proactively address issues that might otherwise result in an early, 4 a.m. phone call to the physician. These trials were successful and became permanent efforts.

Perhaps the biggest impact was on the culture of the unit. Because identified issues had become opportunities for improvement instead of problems, a new sense of optimism prevailed. Care on one patient typified this evolving approach induced by the TCAB initiative. An 81-year-old demented man was admitted for behavioral problems because the family could no longer handle him; he appeared destined to languish in the hospital. We have all taken care of patients like this, and difficulties in their management combined with no obvious disposition usually result in prolonged hospitalizations. The staff immediately saw this patient as an opportunity to work closely with the family. Making arrangements for the wife to spend time with the patient in the hospital and aggressively devising a care plan that involved the family resulted in the patient’s return home after just 4 days. The patient’s family was delighted with the care, and everybody on the unit shared a real sense of accomplishment.

A concrete example of using the white board for communication resulted in optimization of care for another gentleman who was admitted after a complicated bowel resection with a projected length of stay of 8–10 days according to the surgeon. The Two South staff worked closely with the surgeon and placed daily goals on the white board for all to see. Additionally, the nurses and patient were actively involved in the decision-making process, particularly with regard to increasing ambulation and decreasing narcotic use. This resulted in more rapid achievement of goals and recovery by the patient, with discharge from the unit occurring after just 4 days.

With the success of phase I at Kaiser Roseville, the staff anxiously set forth to participate in Phase II. Phase II increased the number of hospital sites to 13 and increased the rapid-cycle testing module. Ten areas of focused improvement were selected, including attempts to reduce unplanned transfers to the ICU and decreasing adverse events for hospitalized patients. During Phase II, Roseville developed its own Rapid Medical Response Team (RMRT). The RMRT is composed of the charge nurse for the ICU, a respiratory therapist, and a house supervisor. This team responds emergently at the request of any Medical-Surgical nurse to evaluate any patient about whom the nurse has concerns. These patients usually have a quickly evolving medical crisis such as respiratory distress, hypotension, or an altered level of consciousness. The primary goal of the RMRT is to quickly evaluate the patient, obtain physician support if needed, and stabilize the patient promptly on the floor or transfer them in a controlled fashion to the ICU. A secondary goal pertains to another TCAB aim, staff vitality, in that the medical-surgical nurse is now placed in a safe environment where he or she interacts with peers from the RMRT and gain additional critical thinking and physical assessment skills through that interaction. It is still early, as we just started the RMRT in September 2004, but the early data suggest we have significantly decreased transfers to the ICU, Code Blues outside the ICU, and unplanned mortality on the Medical-Surgical floors.

In an effort to minimize patient falls, Roseville instituted hourly safety rounds in which a direct care provider (RN, LVN, or NA) quickly looks at all the patients and their current status and implements a fall prevention protocol as needed. Another intervention they have adopted is the use of portable bed alarms, which alerts staff that a patient is attempting to get out of bed. The net result of this has been a dramatic reduction in the fall rate on the floor from a California average of 3.1 falls/thousand patient days to 0.8 falls/ thousand patient days on Two North, demonstrating expansion of the TCAB initiative to other floors in the hospital.

When the TCAB initiative was initiated at Roseville 18 months ago with the Robert Wood Johnson Foundation and the IHI, the Roseville staff had no idea of how much could be achieved—from enhancing patient care to improving both physician and nursing satisfaction to decreasing patient mortality. Although the TCAB initiative is viewed as an ongoing journey, the staff is eagerly anticipating the remainder of the voyage.

An example of an initiative at other hospitals among the 13 includes “peace and quiet time” at Long Island Jewish/North Shore. These nursing “magnet” hospitals discovered when they surveyed their patients that noise preventing patients from resting and recuperating was a major problem. Beginning with 30 minutes of enforced quiet time in the afternoon and then expanding to an hour, patients have reportedly been delighted with this. Snacks were passed out to the patients so they would buy into the initiative and believe they were not being ignored—a floor staff suggestion!

Another hospital modified the usual “multidisciplinary rounds” into highly functional, true patient rounds. At this hospital they originally were called “discharge rounds,” with a focus on discharging the patient. Recognizing that the patient had not been involved because these occurred in a conference room, they were renamed “patient care rounds” and moved out of the conference room to round in the patients’ rooms. Following the dictum of “nothing about the patient without the patient,” these rounds include a pharmacist, a social worker, the charge nurse, a nutritionist, a case manager, and the patient in the patients’ room. This team rounds on all the patients on the unit, seeing up to 37 patients in 1 hour! After initial difficulties involving the residents, they now have “firm directors,” so a physician is now involved. Based on this experience, they proclaim that their culture has changed from “no, it won’t work” to “why not try it?”

Hospitals and staff participating in TCAB are discovering just how successful they can be in achieving enhanced communication, implementing novel interventions to improve care, and optimizing the overall hospital experience for patients.

“Culture trumps strategy every time”

As hospitalists attempt to improve hospital care delivery, they strive to develop strategies for successful implementation of new guidelines, order sets, and alteration of utilization patterns. Key to this success will be collaboration with staff also caring for patients in the hospital. How best to make these changes is unclear, but Kurt Swartout, a hospitalist at Kaiser Permanente’s Roseville Medical Center in California, is involved in a unique project to figure this out. Roseville is one of 13 hospitals (Figure 1) participating in the Institute for Healthcare Improvement (IHI) Transforming Care at the Bedside (TCAB) initiative.

click for large version

“In July 2003, The Robert Wood Johnson Foundation awarded IHI a grant to study and develop one or more models of care at the bedside on medical and surgical units that would result in improved quality of patient care and service, more effective care teams, improved staff satisfaction and retention, and greater efficiency. Utilizing an innovative approach, IHI and select pilot organizations have been piloting new ideas based on the six Institute of Medicine dimensions of quality (safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity), plus the added dimension of vitality” (www.ihi.org).

Since joining the project in October 2003, many changes have occurred on a couple of the hospital floors at Roseville Medical Center. Dr. Swartout raves about this initiative: “TCAB significantly helped set the stage for effective communication and has helped improve the quality of care at the hospital in which I work. It is the most exciting project in which I have been involved and has done more to improve the quality of patient care than anything else I have seen as a hospitalist.”

Dr. Swartout’s hospital was selected as 1 of 3 test hospitals along with the University of Pittsburgh Medical Center at Shady Side and Seton Hospital in Austin, TX. The first phase at Kaiser Roseville started with a meeting of all employees who worked on medical floor Two South. This included the nurses, the unit assistant, respiratory and physical therapists, pharmacists, administrators, and physicians working on the unit. They had 9 areas from which to choose to study and as a group selected 3:

1. Increasing patient safety;
2. Improving communication among different health care providers; and
3. Making care more patient oriented (patient-centered care).

Utilizing rapid-cycle testing and small tests of change, they then moved forward to improve performance with the above aims. To generate ideas, a “safe” environment was created in which no ideas were considered “bad” and everyone was encouraged to exchange suggestions freely. Administrative support was and continues to be critical to the success of TCAB, because everyone involved was given permission and in fact was empowered to develop creative testing solutions to common problems. Interventions were implemented using rapid-cycle tests and evaluated on 1 patient for 1 shift. Depending upon the outcome, these interventions were either adopted for expansion, or they were modified for further testing or abandoned if unsuccessful. This rapid-cycle testing using small tests of change appealed to everyone, generating a level of energy and enthusiasm among the entire team that had not been present among hospital staff prior to TCAB. Unique to the philosophy of the TCAB initiative, whenever an idea was being tested, the rank-and-file staff had the opportunity to stop it, no matter how enthusiastic the management staff believed in it.

During phase I, Two South rapid-cycle tested over 250 staff-generated ideas. Of note, brainstorming by the staff mainly yielded low-cost and easy-to-implement ideas. Many interventions were simple but allowed the caregiver to focus on the patient, experimenting with ideas that had previously gone unsolicited by management. For example, the staff evaluated placing white boards at the patient’s bedside on which the daily goals were outlined in collaboration with the patient, family, and caregivers. Additionally, they tried alternating midnight rounds between the hospitalist and charge nurse to proactively address issues that might otherwise result in an early, 4 a.m. phone call to the physician. These trials were successful and became permanent efforts.

Perhaps the biggest impact was on the culture of the unit. Because identified issues had become opportunities for improvement instead of problems, a new sense of optimism prevailed. Care on one patient typified this evolving approach induced by the TCAB initiative. An 81-year-old demented man was admitted for behavioral problems because the family could no longer handle him; he appeared destined to languish in the hospital. We have all taken care of patients like this, and difficulties in their management combined with no obvious disposition usually result in prolonged hospitalizations. The staff immediately saw this patient as an opportunity to work closely with the family. Making arrangements for the wife to spend time with the patient in the hospital and aggressively devising a care plan that involved the family resulted in the patient’s return home after just 4 days. The patient’s family was delighted with the care, and everybody on the unit shared a real sense of accomplishment.

A concrete example of using the white board for communication resulted in optimization of care for another gentleman who was admitted after a complicated bowel resection with a projected length of stay of 8–10 days according to the surgeon. The Two South staff worked closely with the surgeon and placed daily goals on the white board for all to see. Additionally, the nurses and patient were actively involved in the decision-making process, particularly with regard to increasing ambulation and decreasing narcotic use. This resulted in more rapid achievement of goals and recovery by the patient, with discharge from the unit occurring after just 4 days.

With the success of phase I at Kaiser Roseville, the staff anxiously set forth to participate in Phase II. Phase II increased the number of hospital sites to 13 and increased the rapid-cycle testing module. Ten areas of focused improvement were selected, including attempts to reduce unplanned transfers to the ICU and decreasing adverse events for hospitalized patients. During Phase II, Roseville developed its own Rapid Medical Response Team (RMRT). The RMRT is composed of the charge nurse for the ICU, a respiratory therapist, and a house supervisor. This team responds emergently at the request of any Medical-Surgical nurse to evaluate any patient about whom the nurse has concerns. These patients usually have a quickly evolving medical crisis such as respiratory distress, hypotension, or an altered level of consciousness. The primary goal of the RMRT is to quickly evaluate the patient, obtain physician support if needed, and stabilize the patient promptly on the floor or transfer them in a controlled fashion to the ICU. A secondary goal pertains to another TCAB aim, staff vitality, in that the medical-surgical nurse is now placed in a safe environment where he or she interacts with peers from the RMRT and gain additional critical thinking and physical assessment skills through that interaction. It is still early, as we just started the RMRT in September 2004, but the early data suggest we have significantly decreased transfers to the ICU, Code Blues outside the ICU, and unplanned mortality on the Medical-Surgical floors.

In an effort to minimize patient falls, Roseville instituted hourly safety rounds in which a direct care provider (RN, LVN, or NA) quickly looks at all the patients and their current status and implements a fall prevention protocol as needed. Another intervention they have adopted is the use of portable bed alarms, which alerts staff that a patient is attempting to get out of bed. The net result of this has been a dramatic reduction in the fall rate on the floor from a California average of 3.1 falls/thousand patient days to 0.8 falls/ thousand patient days on Two North, demonstrating expansion of the TCAB initiative to other floors in the hospital.

When the TCAB initiative was initiated at Roseville 18 months ago with the Robert Wood Johnson Foundation and the IHI, the Roseville staff had no idea of how much could be achieved—from enhancing patient care to improving both physician and nursing satisfaction to decreasing patient mortality. Although the TCAB initiative is viewed as an ongoing journey, the staff is eagerly anticipating the remainder of the voyage.

An example of an initiative at other hospitals among the 13 includes “peace and quiet time” at Long Island Jewish/North Shore. These nursing “magnet” hospitals discovered when they surveyed their patients that noise preventing patients from resting and recuperating was a major problem. Beginning with 30 minutes of enforced quiet time in the afternoon and then expanding to an hour, patients have reportedly been delighted with this. Snacks were passed out to the patients so they would buy into the initiative and believe they were not being ignored—a floor staff suggestion!

Another hospital modified the usual “multidisciplinary rounds” into highly functional, true patient rounds. At this hospital they originally were called “discharge rounds,” with a focus on discharging the patient. Recognizing that the patient had not been involved because these occurred in a conference room, they were renamed “patient care rounds” and moved out of the conference room to round in the patients’ rooms. Following the dictum of “nothing about the patient without the patient,” these rounds include a pharmacist, a social worker, the charge nurse, a nutritionist, a case manager, and the patient in the patients’ room. This team rounds on all the patients on the unit, seeing up to 37 patients in 1 hour! After initial difficulties involving the residents, they now have “firm directors,” so a physician is now involved. Based on this experience, they proclaim that their culture has changed from “no, it won’t work” to “why not try it?”

Hospitals and staff participating in TCAB are discovering just how successful they can be in achieving enhanced communication, implementing novel interventions to improve care, and optimizing the overall hospital experience for patients.

Hospital medicine groups are becoming an integral part of healthcare delivery in the US. Since the term hospitalist was coined in 1996 by Robert Wachter, the U.S. has witnessed an amazing growth and development of inpatient programs. Physicians going into inpatient medicine experience impressive fluctuations in patient volume when new programs begin and when existing programs expand their primary referral base or comanage patients with subspecialists and surgeons.

Ideal patient volume numbers vary from group to group but range, on average, from 15 to 18 patients per hospitalist. Layered on the management of patients in the hospital is a myriad of duties the hospitalist must perform to effectively care for patients. Depending on program layout, hospitalists will also be involved in committee work, end-of-life discussions, protocol development, and measurement of data that links improvement of care when hospitalists are involved in caring for patients.

A good reason to talk about inpatient time management is that without it physicians can become overstressed. Physician burnout, job dissatisfaction, and high turnover with hospital medicine groups are major concerns, due in part to the increased demands placed on hospitalists. Small programs, especially, can experience great fluctuations in volume as they define their patient referral base, and deficient physician time management skills can be the main reason a program does not gain momentum.

Early in my training, I wondered if there was a better way to see patients and not feel stressed when new patients were admitted to my service. But it wasn’t until I started work with a healthcare organization in Wisconsin that I noticed there was a way to gain control of my busy day. I was introduced to time management principles by physicians who exercised this important skill everyday. These physicians did not seem stressed when the day seemed to be getting “out of control.” Their time management skills allowed them to stay efficient. After a few busy days, it didn’t take long for me to seek out information on time management and begin my own journey of self-assessment. At its core, that’s what time management is: an honest assessment of yourself. After learning about time management, I created a plan to assist me in getting through my day. Now, time management is automatic, an integral part of my ability to function on a busy inpatient floor. Time management is important for anyone who wants to achieve more control of his or her day, improve on work efficiency, set personal and professional goals, and, in my opinion, extend himself or herself in ways that don’t seem possible.

Some important terms to review include “goal,” “objective,” and “priority.” Goals are long-range and provide overall direction for an individual or a group. A good goal for a hospital medicine group is to be the premiere group in their state or their region. A good goal for a hospitalist is to implement an inpatient time management strategy. An objective is a clear-cut description of how to achieve a goal, and priorities are the ranked items in a goal or objective list. Priorities must be assigned to time management objectives. An exact order will ensure nothing is missed when working on a given objective.

The best way to tackle inpatient time management is to see how the day is laid out by keeping a time log and by performing an internal review of how a typical day marches out. When I performed my internal review I realized I looked at my day chopped into sections that were spent rounding, teaching, and discharging. I never discharged a patient in the morning. I saved all my discharges until the afternoon. I knew discharges required more time, and I felt better seeing patients first and then going back and doing discharges. I wasn’t being efficient with this method, because I always felt tired in the afternoon.

There were different categories of patients: new admits from the previous night, discharges, routine patients, and critical patients. Critical patients received my highest priority, and discharges received the least priority. I was looking at critical patients differently than my discharges. Processing the ICU patients meant more thinking, diagnosing, and reviewing, whereas discharging meant dictating, writing prescriptions, educating patients, and making PCP call-backs. I wasn’t looking at each process in terms of time; rather, I was looking at discharges as a final step and the ICU as a place where all my energy had to be placed. I wasn’t making the connection with time and how I was comparing patients being discharged with patients in the ICU.

Energy level and task demands, in relationship to productive time, can be graphed (Figure 1). Energy level is highest in the morning, and tasks march out throughout the day. At the intersection, the time is usually noon for hospitalists. Energy level begins to dip after this time. The most productive time is in the early morning with a plateau around noon. This is why I felt tired in the afternoon, having important discharges to finish.

click for large versionFrom Mackenzie A. The Time Trap: The Classic Book on Time Management. New York, NY: AMACOM; 1997.

Once I made the connection that discharges take time and ICU patients take time, I knew I had to revamp how I saw patients. The most time-consuming patients need to be seen first when my energy level is high.

My new routine was to see the ICU patients first, new admissions second, and discharges third, all before noon. This new plan allowed me to begin seeing routine patients earlier. For my routine patients, I review the chart, look at lab and imaging tests ordered, and then go into the room and examine the patient. The difference with these patients is that I wait to write my final impression and discussion section until after I’ve seen all the routine patients. Then I go back and write my final notes. The rest of the day is concentrated on finishing notes, PCP call-backs, billing, family conferences, new admissions, and emergencies.

A good way to look at inpatient work is in sets of blocks. (Figure 2) Within each block are the duties of the hospitalist. Blocks are prioritized in order of importance. Within the prioritized blocks are the “absolute” duties that a hospitalist must perform each day. They include patient care (new and existing), billing capture, and multidisciplinary care conferences. After the absolutes come duties that are routinely performed, including patient and nonpatient functions such as PCP call-backs, family conferencing, resident teaching, and time interrupters. Inpatient blocks can be stacked, with the first layer containing the absolutes and the subsequent layers containing the regular duties or tasks.

click for large version

Interrupters are time delays that take a busy hospitalist away from absolute and regular work tasks. They are polygonal and can be placed anywhere along the blocks. Interrupters may be new patients, an established patient with an emergency, an outside physician trying to contact the service, a spouse, the medical records department, a funeral home inquiring about a death certificate, a home health agency trying to get certification for a patient’s wheelchair or a subspecialist, for example.

An ideal day shows the blocks in perfect formation, pyramid style. A day with interruptions will result in the blocks appearing disorganized. The ability to recognize time interrupters and to have a plan to deal with them is the key to managing a busy inpatient service. Any plan developed must use patient care as the focus. Everything the hospitalist does is centered on this block, and priorities can be developed to keep it focused.

Interruptions are a part of any busy inpatient service. Interrupters need to be prioritized, and a system needs to be in place for handling them with any good time management plan. Code Blue response, emergency patient need, and new patients on the floor rank high in priority for interrupters. Phone interruptions and nursing questions are ranked based on urgency and patient impact. One of the best ways to avoid too many phone interruptions is to have a coordinator or secretary assist with filtering incoming calls. This person will have specific instructions on how calls are to be handled. Emergency calls and incoming calls from physicians are given priority. A call from a drug representative or friend can be postponed.

A good rule to have when seeing new patients on the floor is to visualize each new patient coming onto the service. ER physicians visualize each patient coming into the ED arena. By direct visualization of incoming patients, ER physicians determine what their level of involvement will be. A patient who appears ill will get a quicker evaluation than a patient who appears stable. Principles that underlie patient triage include meeting the patient and identifying oneself as the responsible physician, visualization of the patient even while interviewing others, and communication and delegation of work.

Talking to an ED physician about a patient or to a PCP at an outreach facility is helpful, but the direct visualization of the patient by the hospitalist when he or she arrives on the ward is key to managing floor time. This method allows for patients to be prioritized based on acuity. Direct visualization can also be performed before resident contact is initiated. A quick look at the patient and his or her vitals provides reassurance that nothing immediate needs to be performed. A brief hospitalist introduction gives comfort to the patient and family. Patients are impressed when you meet them in their room when they arrive.

Critical patients require more attention, and care can be started with a primary survey. Trauma services have modes of triage care and initial evaluations of trauma patients that can be modified by hospitalists.

The objectives of initial trauma care include 1) stabilization, 2) identification of life-threatening injuries and initiation of adequate supportive therapy, and 3) efficient and rapid organization of either definitive therapy or transfer to a facility that provides definite therapy. Within this set of objectives is a triage objective to prioritize patients with a high likelihood of early deterioration.

click for large version

Direct hospitalist visualization of every patient coming onto the service accomplishes the objectives of initial care and triage. Of course, the hospitalist isn’t prioritizing a gunshot wound patient, but the principles are the same: visualizing the patient, determining a level of involvement, and initiating a primary survey for critical patients. This approach to patients can be adopted in the hospitalist patient-care repertoire.

As an example, I was asked to consult on a patient with a subarachnoid bleed to manage hypertension. The patient was already admitted into the ICU by the neurosurgeon. Subarachnoid bleed and hypertension are 2 urgent needs, and this was a new patient on my service. I went to visualize the patient. I finished my brief survey and was writing down some orders when the nurse came over to me and told me the patient was not responding to her the way he had earlier. The patient’s admitting blood pressure was 180/100 and when the nurse reported the change to me, the blood pressure was 230/106. The patient was obtunded and unable to protect his airway. In addition to intubating the patient and hyperventilating him, I contacted the neurosurgeon to notify him of the change in status, started intravenous mannitol, established large bore venous access, and started nitroprusside. The surgeon returned to the ICU and took the patient for corrective surgery.

When the nurse alerted me to the change in status with the patient, I performed actions based on my survey, stabilized the patient, identified a threat, provided supportive care, and contacted the person who would be able to provide definitive treatment. I was able to do this because of the discipline provided to me with time management and by prioritizing an interrupter.

Developing a system to flexibly see new patients and provide quick surveys should be a focus for any hospitalist. By doing this, the hospitalist is providing the plan for how the day will flow, regardless of interruptions. The plan, the objectives, and the priorities are there to ensure a day happens the way the physician wants it to happen.

Time management courses and books usually recommend that people complete a daily log of how and what they do in the course of their day. (Figure 3) The daily log is an honest portrayal of the day as it unfolds and how one responds to events as they happen. Logs include phone calls to friends, stockbrokers, and spouses. Each hospitalist’s log notes when a patient or family conference occurred, when interruptions occurred, and how they were handled. Taking coffee breaks, reading a paper, and talking to a partner are all fair game in the log. Everything needs to be put in the log. Keeping a log for 1 or 2 days is a great exercise with endless ways of showing people where their time and energy is going. I encourage physicians who ask me what some of my secrets are to getting done early to read a book on time management or attend a course.

When I took my first time management course in 1998, I became an instant student of my time and an observer of how others mange their time. I didn’t realize how incredible a force time management was, because I thought it was mainly for business people. A course may range from the implementation of a few basic strategies to a complete revamp of how the day is structured, but any hospitalist can benefit from time management techniques.

Dr. Houser can be contacted at [email protected].

Reading List

1. Mackenzie A. The Time Trap: The Classic Book on Time Management. New York, NY: AMACOM; 1997.
2. Lane, B and Rierdan, R. Managing People-A Practical Guide. Oasis Press. 2001.
3. Wachter R. The emerging role of “hospitalists” in the American health care system, N Engl J Me. 1996;335:514-7.
4. Dries DJ. Initial evaluation of the trauma patient. www.eMedicine.com, 2004.

Hospital medicine groups are becoming an integral part of healthcare delivery in the US. Since the term hospitalist was coined in 1996 by Robert Wachter, the U.S. has witnessed an amazing growth and development of inpatient programs. Physicians going into inpatient medicine experience impressive fluctuations in patient volume when new programs begin and when existing programs expand their primary referral base or comanage patients with subspecialists and surgeons.

Ideal patient volume numbers vary from group to group but range, on average, from 15 to 18 patients per hospitalist. Layered on the management of patients in the hospital is a myriad of duties the hospitalist must perform to effectively care for patients. Depending on program layout, hospitalists will also be involved in committee work, end-of-life discussions, protocol development, and measurement of data that links improvement of care when hospitalists are involved in caring for patients.

A good reason to talk about inpatient time management is that without it physicians can become overstressed. Physician burnout, job dissatisfaction, and high turnover with hospital medicine groups are major concerns, due in part to the increased demands placed on hospitalists. Small programs, especially, can experience great fluctuations in volume as they define their patient referral base, and deficient physician time management skills can be the main reason a program does not gain momentum.

Early in my training, I wondered if there was a better way to see patients and not feel stressed when new patients were admitted to my service. But it wasn’t until I started work with a healthcare organization in Wisconsin that I noticed there was a way to gain control of my busy day. I was introduced to time management principles by physicians who exercised this important skill everyday. These physicians did not seem stressed when the day seemed to be getting “out of control.” Their time management skills allowed them to stay efficient. After a few busy days, it didn’t take long for me to seek out information on time management and begin my own journey of self-assessment. At its core, that’s what time management is: an honest assessment of yourself. After learning about time management, I created a plan to assist me in getting through my day. Now, time management is automatic, an integral part of my ability to function on a busy inpatient floor. Time management is important for anyone who wants to achieve more control of his or her day, improve on work efficiency, set personal and professional goals, and, in my opinion, extend himself or herself in ways that don’t seem possible.

Some important terms to review include “goal,” “objective,” and “priority.” Goals are long-range and provide overall direction for an individual or a group. A good goal for a hospital medicine group is to be the premiere group in their state or their region. A good goal for a hospitalist is to implement an inpatient time management strategy. An objective is a clear-cut description of how to achieve a goal, and priorities are the ranked items in a goal or objective list. Priorities must be assigned to time management objectives. An exact order will ensure nothing is missed when working on a given objective.

The best way to tackle inpatient time management is to see how the day is laid out by keeping a time log and by performing an internal review of how a typical day marches out. When I performed my internal review I realized I looked at my day chopped into sections that were spent rounding, teaching, and discharging. I never discharged a patient in the morning. I saved all my discharges until the afternoon. I knew discharges required more time, and I felt better seeing patients first and then going back and doing discharges. I wasn’t being efficient with this method, because I always felt tired in the afternoon.

There were different categories of patients: new admits from the previous night, discharges, routine patients, and critical patients. Critical patients received my highest priority, and discharges received the least priority. I was looking at critical patients differently than my discharges. Processing the ICU patients meant more thinking, diagnosing, and reviewing, whereas discharging meant dictating, writing prescriptions, educating patients, and making PCP call-backs. I wasn’t looking at each process in terms of time; rather, I was looking at discharges as a final step and the ICU as a place where all my energy had to be placed. I wasn’t making the connection with time and how I was comparing patients being discharged with patients in the ICU.

Energy level and task demands, in relationship to productive time, can be graphed (Figure 1). Energy level is highest in the morning, and tasks march out throughout the day. At the intersection, the time is usually noon for hospitalists. Energy level begins to dip after this time. The most productive time is in the early morning with a plateau around noon. This is why I felt tired in the afternoon, having important discharges to finish.

click for large versionFrom Mackenzie A. The Time Trap: The Classic Book on Time Management. New York, NY: AMACOM; 1997.

Once I made the connection that discharges take time and ICU patients take time, I knew I had to revamp how I saw patients. The most time-consuming patients need to be seen first when my energy level is high.

My new routine was to see the ICU patients first, new admissions second, and discharges third, all before noon. This new plan allowed me to begin seeing routine patients earlier. For my routine patients, I review the chart, look at lab and imaging tests ordered, and then go into the room and examine the patient. The difference with these patients is that I wait to write my final impression and discussion section until after I’ve seen all the routine patients. Then I go back and write my final notes. The rest of the day is concentrated on finishing notes, PCP call-backs, billing, family conferences, new admissions, and emergencies.

A good way to look at inpatient work is in sets of blocks. (Figure 2) Within each block are the duties of the hospitalist. Blocks are prioritized in order of importance. Within the prioritized blocks are the “absolute” duties that a hospitalist must perform each day. They include patient care (new and existing), billing capture, and multidisciplinary care conferences. After the absolutes come duties that are routinely performed, including patient and nonpatient functions such as PCP call-backs, family conferencing, resident teaching, and time interrupters. Inpatient blocks can be stacked, with the first layer containing the absolutes and the subsequent layers containing the regular duties or tasks.

click for large version

Interrupters are time delays that take a busy hospitalist away from absolute and regular work tasks. They are polygonal and can be placed anywhere along the blocks. Interrupters may be new patients, an established patient with an emergency, an outside physician trying to contact the service, a spouse, the medical records department, a funeral home inquiring about a death certificate, a home health agency trying to get certification for a patient’s wheelchair or a subspecialist, for example.

An ideal day shows the blocks in perfect formation, pyramid style. A day with interruptions will result in the blocks appearing disorganized. The ability to recognize time interrupters and to have a plan to deal with them is the key to managing a busy inpatient service. Any plan developed must use patient care as the focus. Everything the hospitalist does is centered on this block, and priorities can be developed to keep it focused.

Interruptions are a part of any busy inpatient service. Interrupters need to be prioritized, and a system needs to be in place for handling them with any good time management plan. Code Blue response, emergency patient need, and new patients on the floor rank high in priority for interrupters. Phone interruptions and nursing questions are ranked based on urgency and patient impact. One of the best ways to avoid too many phone interruptions is to have a coordinator or secretary assist with filtering incoming calls. This person will have specific instructions on how calls are to be handled. Emergency calls and incoming calls from physicians are given priority. A call from a drug representative or friend can be postponed.

A good rule to have when seeing new patients on the floor is to visualize each new patient coming onto the service. ER physicians visualize each patient coming into the ED arena. By direct visualization of incoming patients, ER physicians determine what their level of involvement will be. A patient who appears ill will get a quicker evaluation than a patient who appears stable. Principles that underlie patient triage include meeting the patient and identifying oneself as the responsible physician, visualization of the patient even while interviewing others, and communication and delegation of work.

Talking to an ED physician about a patient or to a PCP at an outreach facility is helpful, but the direct visualization of the patient by the hospitalist when he or she arrives on the ward is key to managing floor time. This method allows for patients to be prioritized based on acuity. Direct visualization can also be performed before resident contact is initiated. A quick look at the patient and his or her vitals provides reassurance that nothing immediate needs to be performed. A brief hospitalist introduction gives comfort to the patient and family. Patients are impressed when you meet them in their room when they arrive.

Critical patients require more attention, and care can be started with a primary survey. Trauma services have modes of triage care and initial evaluations of trauma patients that can be modified by hospitalists.

The objectives of initial trauma care include 1) stabilization, 2) identification of life-threatening injuries and initiation of adequate supportive therapy, and 3) efficient and rapid organization of either definitive therapy or transfer to a facility that provides definite therapy. Within this set of objectives is a triage objective to prioritize patients with a high likelihood of early deterioration.

click for large version

Direct hospitalist visualization of every patient coming onto the service accomplishes the objectives of initial care and triage. Of course, the hospitalist isn’t prioritizing a gunshot wound patient, but the principles are the same: visualizing the patient, determining a level of involvement, and initiating a primary survey for critical patients. This approach to patients can be adopted in the hospitalist patient-care repertoire.

As an example, I was asked to consult on a patient with a subarachnoid bleed to manage hypertension. The patient was already admitted into the ICU by the neurosurgeon. Subarachnoid bleed and hypertension are 2 urgent needs, and this was a new patient on my service. I went to visualize the patient. I finished my brief survey and was writing down some orders when the nurse came over to me and told me the patient was not responding to her the way he had earlier. The patient’s admitting blood pressure was 180/100 and when the nurse reported the change to me, the blood pressure was 230/106. The patient was obtunded and unable to protect his airway. In addition to intubating the patient and hyperventilating him, I contacted the neurosurgeon to notify him of the change in status, started intravenous mannitol, established large bore venous access, and started nitroprusside. The surgeon returned to the ICU and took the patient for corrective surgery.

When the nurse alerted me to the change in status with the patient, I performed actions based on my survey, stabilized the patient, identified a threat, provided supportive care, and contacted the person who would be able to provide definitive treatment. I was able to do this because of the discipline provided to me with time management and by prioritizing an interrupter.

Developing a system to flexibly see new patients and provide quick surveys should be a focus for any hospitalist. By doing this, the hospitalist is providing the plan for how the day will flow, regardless of interruptions. The plan, the objectives, and the priorities are there to ensure a day happens the way the physician wants it to happen.

Time management courses and books usually recommend that people complete a daily log of how and what they do in the course of their day. (Figure 3) The daily log is an honest portrayal of the day as it unfolds and how one responds to events as they happen. Logs include phone calls to friends, stockbrokers, and spouses. Each hospitalist’s log notes when a patient or family conference occurred, when interruptions occurred, and how they were handled. Taking coffee breaks, reading a paper, and talking to a partner are all fair game in the log. Everything needs to be put in the log. Keeping a log for 1 or 2 days is a great exercise with endless ways of showing people where their time and energy is going. I encourage physicians who ask me what some of my secrets are to getting done early to read a book on time management or attend a course.

When I took my first time management course in 1998, I became an instant student of my time and an observer of how others mange their time. I didn’t realize how incredible a force time management was, because I thought it was mainly for business people. A course may range from the implementation of a few basic strategies to a complete revamp of how the day is structured, but any hospitalist can benefit from time management techniques.

Dr. Houser can be contacted at [email protected].

Reading List

1. Mackenzie A. The Time Trap: The Classic Book on Time Management. New York, NY: AMACOM; 1997.
2. Lane, B and Rierdan, R. Managing People-A Practical Guide. Oasis Press. 2001.
3. Wachter R. The emerging role of “hospitalists” in the American health care system, N Engl J Me. 1996;335:514-7.
4. Dries DJ. Initial evaluation of the trauma patient. www.eMedicine.com, 2004.

Hospital medicine groups are becoming an integral part of healthcare delivery in the US. Since the term hospitalist was coined in 1996 by Robert Wachter, the U.S. has witnessed an amazing growth and development of inpatient programs. Physicians going into inpatient medicine experience impressive fluctuations in patient volume when new programs begin and when existing programs expand their primary referral base or comanage patients with subspecialists and surgeons.

Ideal patient volume numbers vary from group to group but range, on average, from 15 to 18 patients per hospitalist. Layered on the management of patients in the hospital is a myriad of duties the hospitalist must perform to effectively care for patients. Depending on program layout, hospitalists will also be involved in committee work, end-of-life discussions, protocol development, and measurement of data that links improvement of care when hospitalists are involved in caring for patients.

A good reason to talk about inpatient time management is that without it physicians can become overstressed. Physician burnout, job dissatisfaction, and high turnover with hospital medicine groups are major concerns, due in part to the increased demands placed on hospitalists. Small programs, especially, can experience great fluctuations in volume as they define their patient referral base, and deficient physician time management skills can be the main reason a program does not gain momentum.

Early in my training, I wondered if there was a better way to see patients and not feel stressed when new patients were admitted to my service. But it wasn’t until I started work with a healthcare organization in Wisconsin that I noticed there was a way to gain control of my busy day. I was introduced to time management principles by physicians who exercised this important skill everyday. These physicians did not seem stressed when the day seemed to be getting “out of control.” Their time management skills allowed them to stay efficient. After a few busy days, it didn’t take long for me to seek out information on time management and begin my own journey of self-assessment. At its core, that’s what time management is: an honest assessment of yourself. After learning about time management, I created a plan to assist me in getting through my day. Now, time management is automatic, an integral part of my ability to function on a busy inpatient floor. Time management is important for anyone who wants to achieve more control of his or her day, improve on work efficiency, set personal and professional goals, and, in my opinion, extend himself or herself in ways that don’t seem possible.

Some important terms to review include “goal,” “objective,” and “priority.” Goals are long-range and provide overall direction for an individual or a group. A good goal for a hospital medicine group is to be the premiere group in their state or their region. A good goal for a hospitalist is to implement an inpatient time management strategy. An objective is a clear-cut description of how to achieve a goal, and priorities are the ranked items in a goal or objective list. Priorities must be assigned to time management objectives. An exact order will ensure nothing is missed when working on a given objective.

The best way to tackle inpatient time management is to see how the day is laid out by keeping a time log and by performing an internal review of how a typical day marches out. When I performed my internal review I realized I looked at my day chopped into sections that were spent rounding, teaching, and discharging. I never discharged a patient in the morning. I saved all my discharges until the afternoon. I knew discharges required more time, and I felt better seeing patients first and then going back and doing discharges. I wasn’t being efficient with this method, because I always felt tired in the afternoon.

There were different categories of patients: new admits from the previous night, discharges, routine patients, and critical patients. Critical patients received my highest priority, and discharges received the least priority. I was looking at critical patients differently than my discharges. Processing the ICU patients meant more thinking, diagnosing, and reviewing, whereas discharging meant dictating, writing prescriptions, educating patients, and making PCP call-backs. I wasn’t looking at each process in terms of time; rather, I was looking at discharges as a final step and the ICU as a place where all my energy had to be placed. I wasn’t making the connection with time and how I was comparing patients being discharged with patients in the ICU.

Energy level and task demands, in relationship to productive time, can be graphed (Figure 1). Energy level is highest in the morning, and tasks march out throughout the day. At the intersection, the time is usually noon for hospitalists. Energy level begins to dip after this time. The most productive time is in the early morning with a plateau around noon. This is why I felt tired in the afternoon, having important discharges to finish.

click for large versionFrom Mackenzie A. The Time Trap: The Classic Book on Time Management. New York, NY: AMACOM; 1997.

Once I made the connection that discharges take time and ICU patients take time, I knew I had to revamp how I saw patients. The most time-consuming patients need to be seen first when my energy level is high.

My new routine was to see the ICU patients first, new admissions second, and discharges third, all before noon. This new plan allowed me to begin seeing routine patients earlier. For my routine patients, I review the chart, look at lab and imaging tests ordered, and then go into the room and examine the patient. The difference with these patients is that I wait to write my final impression and discussion section until after I’ve seen all the routine patients. Then I go back and write my final notes. The rest of the day is concentrated on finishing notes, PCP call-backs, billing, family conferences, new admissions, and emergencies.

A good way to look at inpatient work is in sets of blocks. (Figure 2) Within each block are the duties of the hospitalist. Blocks are prioritized in order of importance. Within the prioritized blocks are the “absolute” duties that a hospitalist must perform each day. They include patient care (new and existing), billing capture, and multidisciplinary care conferences. After the absolutes come duties that are routinely performed, including patient and nonpatient functions such as PCP call-backs, family conferencing, resident teaching, and time interrupters. Inpatient blocks can be stacked, with the first layer containing the absolutes and the subsequent layers containing the regular duties or tasks.

click for large version

Interrupters are time delays that take a busy hospitalist away from absolute and regular work tasks. They are polygonal and can be placed anywhere along the blocks. Interrupters may be new patients, an established patient with an emergency, an outside physician trying to contact the service, a spouse, the medical records department, a funeral home inquiring about a death certificate, a home health agency trying to get certification for a patient’s wheelchair or a subspecialist, for example.

An ideal day shows the blocks in perfect formation, pyramid style. A day with interruptions will result in the blocks appearing disorganized. The ability to recognize time interrupters and to have a plan to deal with them is the key to managing a busy inpatient service. Any plan developed must use patient care as the focus. Everything the hospitalist does is centered on this block, and priorities can be developed to keep it focused.

Interruptions are a part of any busy inpatient service. Interrupters need to be prioritized, and a system needs to be in place for handling them with any good time management plan. Code Blue response, emergency patient need, and new patients on the floor rank high in priority for interrupters. Phone interruptions and nursing questions are ranked based on urgency and patient impact. One of the best ways to avoid too many phone interruptions is to have a coordinator or secretary assist with filtering incoming calls. This person will have specific instructions on how calls are to be handled. Emergency calls and incoming calls from physicians are given priority. A call from a drug representative or friend can be postponed.

A good rule to have when seeing new patients on the floor is to visualize each new patient coming onto the service. ER physicians visualize each patient coming into the ED arena. By direct visualization of incoming patients, ER physicians determine what their level of involvement will be. A patient who appears ill will get a quicker evaluation than a patient who appears stable. Principles that underlie patient triage include meeting the patient and identifying oneself as the responsible physician, visualization of the patient even while interviewing others, and communication and delegation of work.

Talking to an ED physician about a patient or to a PCP at an outreach facility is helpful, but the direct visualization of the patient by the hospitalist when he or she arrives on the ward is key to managing floor time. This method allows for patients to be prioritized based on acuity. Direct visualization can also be performed before resident contact is initiated. A quick look at the patient and his or her vitals provides reassurance that nothing immediate needs to be performed. A brief hospitalist introduction gives comfort to the patient and family. Patients are impressed when you meet them in their room when they arrive.

Critical patients require more attention, and care can be started with a primary survey. Trauma services have modes of triage care and initial evaluations of trauma patients that can be modified by hospitalists.

The objectives of initial trauma care include 1) stabilization, 2) identification of life-threatening injuries and initiation of adequate supportive therapy, and 3) efficient and rapid organization of either definitive therapy or transfer to a facility that provides definite therapy. Within this set of objectives is a triage objective to prioritize patients with a high likelihood of early deterioration.

click for large version

Direct hospitalist visualization of every patient coming onto the service accomplishes the objectives of initial care and triage. Of course, the hospitalist isn’t prioritizing a gunshot wound patient, but the principles are the same: visualizing the patient, determining a level of involvement, and initiating a primary survey for critical patients. This approach to patients can be adopted in the hospitalist patient-care repertoire.

As an example, I was asked to consult on a patient with a subarachnoid bleed to manage hypertension. The patient was already admitted into the ICU by the neurosurgeon. Subarachnoid bleed and hypertension are 2 urgent needs, and this was a new patient on my service. I went to visualize the patient. I finished my brief survey and was writing down some orders when the nurse came over to me and told me the patient was not responding to her the way he had earlier. The patient’s admitting blood pressure was 180/100 and when the nurse reported the change to me, the blood pressure was 230/106. The patient was obtunded and unable to protect his airway. In addition to intubating the patient and hyperventilating him, I contacted the neurosurgeon to notify him of the change in status, started intravenous mannitol, established large bore venous access, and started nitroprusside. The surgeon returned to the ICU and took the patient for corrective surgery.

When the nurse alerted me to the change in status with the patient, I performed actions based on my survey, stabilized the patient, identified a threat, provided supportive care, and contacted the person who would be able to provide definitive treatment. I was able to do this because of the discipline provided to me with time management and by prioritizing an interrupter.

Developing a system to flexibly see new patients and provide quick surveys should be a focus for any hospitalist. By doing this, the hospitalist is providing the plan for how the day will flow, regardless of interruptions. The plan, the objectives, and the priorities are there to ensure a day happens the way the physician wants it to happen.

Time management courses and books usually recommend that people complete a daily log of how and what they do in the course of their day. (Figure 3) The daily log is an honest portrayal of the day as it unfolds and how one responds to events as they happen. Logs include phone calls to friends, stockbrokers, and spouses. Each hospitalist’s log notes when a patient or family conference occurred, when interruptions occurred, and how they were handled. Taking coffee breaks, reading a paper, and talking to a partner are all fair game in the log. Everything needs to be put in the log. Keeping a log for 1 or 2 days is a great exercise with endless ways of showing people where their time and energy is going. I encourage physicians who ask me what some of my secrets are to getting done early to read a book on time management or attend a course.

When I took my first time management course in 1998, I became an instant student of my time and an observer of how others mange their time. I didn’t realize how incredible a force time management was, because I thought it was mainly for business people. A course may range from the implementation of a few basic strategies to a complete revamp of how the day is structured, but any hospitalist can benefit from time management techniques.

Dr. Houser can be contacted at [email protected].

Reading List

1. Mackenzie A. The Time Trap: The Classic Book on Time Management. New York, NY: AMACOM; 1997.
2. Lane, B and Rierdan, R. Managing People-A Practical Guide. Oasis Press. 2001.
3. Wachter R. The emerging role of “hospitalists” in the American health care system, N Engl J Me. 1996;335:514-7.
4. Dries DJ. Initial evaluation of the trauma patient. www.eMedicine.com, 2004.

Introduction

Patient satisfaction is a highly desirable outcome of clinical care in the hospital and may even be an element of health status itself (1). A patient’s expression of satisfaction or dissatisfaction is a judgment on the quality of hospital care in all of its aspects. Whatever its strengths and limitations, patient satisfaction is an indicator that should be indispensable to the assessment of the quality of care in hospitals.

The word “hospital” comes from the Latin for both “guest” and “host,” and the true spirit of hospitality is at the core of the hospital experience (2). The original mission of hospitals was to serve as houses of mercy, refuge, and dying for pilgrims returning from the Holy Land at the time of the late Christian antiquity (3). The striving to please patients is in harmony with the service calling of medicine and is certainly the right thing to do.

Current Reality

From the patient’s perspective, hospitals can be scary and unfriendly places. The American Hospital Association’s Reality Check (4) evaluated the public’s perceptions of hospitals and hospital care using a time-honored technique of asking focus group participants to imagine that the hospital was an animal and a car. Two out of 3 respondents chose animals that would be seen as aggressive, scary, or lumbering to suggest traits such as arrogance, uncontrolled power, and sluggishness. For cars, no respondent chose the Toyota Camry or any other model that would likely make the Consumer Reports list of best values. Instead, the cars chosen were representatives of unreasonable overpricing, waste, and outdated engineering.

“Imagine that the hospital is …”

A Car

“Volkswagen bus...Old, very noisy, just not a real great car.”

“A Rolls Royce, because of the expense.”

“A Pinto, because it was run down.”

“Ford Escort, just barely passing the test.”

“A Cadillac…big and expensive.”

An Animal

“A bear…a grizzly…horrible.”

“Elephant…large…cumbersome.”

“A leech.…I’m sure all hospitals aren’t that lowly.”

“A snake, kind of slithery and sneaky, because of what hospitals charge.”

The same AHA survey showed that patients felt that insurance companies and not physicians were in charge of their care in the hospital. A follow-up question revealed that patients clearly want to be in charge of their own hospital care. Additionally, patients do not see hospitals as part of a planned or consumer-focused health care system. In fact, they see quite the opposite: a confusing, expensive, unreliable, and often impersonal disassembly of medical professionals and institutions. If they see any system at all, it is one devoted to maximizing profits by blocking access, reducing quality, and limiting spending, all at the expense of the patient.

The American Customer Satisfaction Index (5) gave hospitals an overall 67% satisfaction rating, ranking 27th out of 31 industries. This ranking placed hospitals 10 percentage points below the tobacco industry and just above the Internal Revenue Service. A National Coalition on Health Care survey (6) found that 80% of respondents believe hospitals cut corners to save money, and 77% believe that these cuts have endangered patients. Quality of care and patient safety have become significant public concerns recently. “To Err is Human,” the 1999 report from the Institute of Medicine, highlighted the potential for serious injury and death in U.S. hospitals (7). Estimates are that 44,000 to 98,000 Americans die each year in hospitals as a result of medical errors and unsafe practices.

Patient Satisfaction Is Important

Patient satisfaction is the health care recipient’s reaction to aspects of his or her service experience (8). Patient satisfaction belongs to the service dimension as opposed to the technical dimension of quality of care. Most patients report few problems related to technical quality of care in hospitals and moreover do not feel qualified to judge technical quality and therefore assume technical competence (9).

From 1986 to 1992, the Health Care Financing Administration publicly reported hospital mortality rates as an effort to aid consumers in selecting hospitals (10). Hospitals with over twice the expected mortality rate saw very little change in volume during that time. Patients do not seem to be affected by morbidity and mortality statistics but more by personal stories of care. Patient perception of quality is assessed through dimensions of what is personally valued, and often they do not distinguish between the provider of the service and the service received.

Being treated with respect and dignity and involvement in treatment decisions are intangible issues of patient satisfaction that are paramount issues for patients (11).

As many as one quarter of 13,000 patients discharged from 51 Massachusetts hospitals reported problems with patient satisfaction issues such as the involvement of families in their care, communication and coordination of care, and the transition from hospital to home (12). Patients who had been admitted to academic health centers and teaching hospitals generally reported more problems than those cared for in community hospitals. As it turns out, service outcomes such as patient satisfaction drive market share and profitability for hospitals (13). With the average medical/surgery hospital charge amounting to $12,083, hospitals cannot afford to lose patients and, therefore, revenue due to issues of patient dissatisfaction (14). Recruiting new patients as customers is 5 times more costly than retaining an existing customer base (15).

There is compelling evidence from well-developed lines of research demonstrating that increasing patient satisfaction improves clinical outcomes, such as functional status and physiologic measures of health (16,17). Finally, it is important for clinicians to know that it has been clearly demonstrated that satisfied patients improve physician satisfaction (18,19).

Psychology of Satisfaction

To create a culture of customer service excellence in hospitals and achieve outstanding patient satisfaction, it is necessary to understand the intangible aspects of perception and expectation that contribute to patient satisfaction. The “First Law of Service” provides a useful, simple mathematical model of satisfaction (20). The formula for this model is Satisfaction = Perception – Expectation. If a patient’s perception of their hospital experience meets or exceeds the expectation, there will be a corresponding degree of satisfaction. However, if the perception does not meet the expectation, there will be resulting dissatisfaction. Thus, patient satisfaction results from meeting or exceeding patients’ expectations. Patient perceptions of care can be measured directly from patient satisfaction surveys, focus groups, and telephone surveys. A hospital’s reputation and market share are indirect measurements of patient perceptions. There are 2 main directions in which patient satisfaction can be influenced: by working on what the patient perceives and on what the patient expects.

Expectations are integral to the experience of being a customer. There has been confusion and controversy in health care as to whether patients are in fact customers. This confusion may be at the root of the overall service failing of hospitals (21). “The more horizontal they are, the more they are a patient. The more vertical they are, the more they are a customer” (22). Using a technical definition, a customer is anyone who has expectations about process operations or outputs (23). Therefore, all patients are customers, but not all customers are patients (21). Hospitals have a whole list of primary and secondary customers, each of whom has his or her own set of expectations. Patients and their families can be seen as primary customers, and referring physicians, third-party payers, external overseers, communities, shareholders, and employees are all secondary customers of hospitals.

Expectations are psychological phenomena that can be defined as beliefs created and sustained by cognitive processes (24). Expectations of patients as hospital customers rise from past experiences of their own or of others, as well as from current needs and unique internal preferences that form the basis of a value system. Expectations cannot be mandated, because they are based in self-gratification. However, expectations may change over time, and, very importantly, they can be measured and perhaps modified through education. For most people, illness and hospitalization is a rare event. Patients will know something is wrong and that treatment is needed, but most won’t know the nature of their disease, the diagnostic and therapeutic options, and the likely outcomes. Therefore, patients seek out health care professionals who have the opportunity to inform them on what to expect as a way to begin the process of managing expectations.

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The Kano Model

The Kano Model provides a useful tool for studying different levels of patient expectations (23).

This model is useful to examine the voice of the customer in the relationship between satisfaction and quality, and it is relevant for hospital encounters. According to the model, patients will have a basic set of subconscious expectations about their care that will be taken for granted. These expectations are so routine and expected that patients don’t recognize them as comparative quality factors, but they will be shocked if they are absent. For example, patients assume that physicians are basically competent, and that hospitals are capable of providing safe, courteous, lifesaving medical care (25). Although these expectations are in the patient’s subconscious, if they are not met, the patient will be dissatisfied. Providing this level of basic quality isn’t necessarily enough to create satisfied patients.

There is a normal level of service that patients consciously consider, they have to do with the anticipated issues of hospital care related to access, wait times, scheduling, and billing. The model shows that satisfaction increases as more of these expectations are met and that patients will be dissatisfied if these quality expectations are not met. Patients use comparisons of these expectations to recognize differences among competitors and to make choices.

The latent quality curve lies entirely in the satisfaction region and represents supraconscious, unexpected quality items that patients didn’t know they wanted and result in a delightful surprise when present. In this experience, patients receive more than they had expected, often as the result of innovation that can raise patient expectations and provide a significant competitive advantage. The data from hospitals show that this is achieved primarily through the patient’s perception of personalized, customized service, provided by caring and concerned clinicians (26).

There is a tremendous opportunity in hospital care to modify patient expectations through education and to create high levels of patient satisfaction. Hospitals that are successful in this endeavor will have a significant competitive advantage. Hospital patients have a whole list of issues about which they have expectations: the smoothness of the admission and discharge process, accuracy and clarity of billing statements, courtesy of hospital employees, response time for calls and requests, the level of technology available in the hospital, nurse competency, taste and temperature of the food, and price. Most of these issues are not directly related to clinical care and certainly not under the control or influence of the hospitalist. What are the expectations that patients have for their clinical care by hospitalists, and how can we give it to them?

The Hospitalist as a Caring and Concerned Clinician

A useful model to define the hospitalist’s role in patient satisfaction is that of a caring and concerned clinician. This caring and concern for patients is exemplified by attentiveness, dignity and respect, effective information transfer, and shared decision making (23).

The outcome service chain for hospitals begins with the patient’s perception of caring and concerned clinicians who demonstrate these attributes of attentiveness, dignity and respect, effective information transfer, and shared decision making. This leads to the degree of patient satisfaction and loyalty that results in patients who will return to the hospital, seek related business, and refer additional business. This drives market share and financial success for hospitals (9).

The characteristics of the caring and concerned clinician begin with attentiveness. This is the practice of establishing a person-to-person connection with patients and involves attending to them as unique individuals and not just in their role as patients. The constant interruptions that occur in physician/patient encounters, control issues, discontinuity of care, and the often overwhelming complexity of a patient’s illness can be obstacles to the perception of attentiveness that result in patients feeling connected with the clinician. Some effective tools for attentiveness are demonstrating curiosity about the patient as a person, using open-ended questions to gather clinical data, orienting patients to the process of care, and actively eliciting a patient’s agenda for their care and then summarizing their concerns.

The demonstration of dignity and respect results in a patient’s feeling understood and accepted as a person. This is the practice of empathy, which is often confused with sympathy (27). Sympathy is an expression of one’s own feelings (“I’m sorry”). Empathy is the demonstration of an understanding of the patient’s feelings (“You must be very sad”). The confusion of medical terminology as well as the time constraints of modern hospital-care encounters can be obstacles to achieving the type of dignity and respect that results in a high degree of patient satisfaction. A number of effective tools are available to facilitate this important result. Sitting down during patient encounters greatly enhances the perception of time and caring of hospitalists on the part of patients. Eye contact and appropriate touch are demonstrations of dignity and respect, as is seeing patients fully clothed. It is important to pay attention to nonverbal communication issues with patients. An important element of how hospitalists are perceived by patients has to do with nonverbal issues such as demeanor, body posture, and verbal tone. Using a patient’s own words and addressing underlying feelings facilitates the practice of dignity and respect (28). Patients perceive statements of assured understanding as confirmation that they have been listened to. Remember the words of Sir William Osler: “Listening is unspoken caring.”

The effective transfer of information is at the core of physician/patient communication (29). Patients have the need to provide complete information to physicians to facilitate an accurate diagnosis. The physician’s role is to provide information that addresses the cognitive, behavioral, and affective needs of patients and their families concerning their illness. The discrepancy of language, time constraints, and the ability of patients to remember are all barriers to the effective transfer of information. Some useful techniques for effective information transfer include assessing a patient’s current level of understanding and asking about their self-diagnosis. Timeliness in providing results of diagnostic tests is an important issue to patients who are often waiting expectantly. Studies have shown that the majority of patients have questions about the so-called “mysteries of medicine,” related to the diagnosis, etiology, and prognosis of their illness (30).

Patients may not specifically ask these questions; however, they are present, and patient satisfaction will increase if these questions are answered. Patients have decisively indicated their desire for shared decision making regarding their health care and for patient and family control of all-important choices (26). The process of shared decision making can be facilitated by collaboration between patients and the hospitalist around goals ands plans for treatment in the hospital (31). A barrier to shared decision making is a patient/physician relationship based on a model of paternalism (“I’m the doctor, and I know best”). A more productive model for the therapeutic relationship is that of a partnership between the hospitalist and the patient, particularly in the present era of web-educated, sophisticated consumer patients.

An important tool to achieving this type of collaboration involves the approach of presenting patients and families with treatment options and then actively soliciting patient preferences. A question is whether patients will actively participate in treatment decisions and then adhere to treatment plans. This is in large part determined by the interpersonal relationship skills of the clinician and can be further facilitated with simplified regimens that have been agreed upon by the patient and the hospitalist (32).

A complete model of the hospital-care encounter provided by hospitalists has an opening and a closing. In between there is a series of moments of truth that can potentially be imbued with attentiveness, dignity and respect, effective information transfer, and shared decision making. The opening is a brief moment that will set the stage for the remainder of the encounter. Greeting patients by name and maintaining eye contact will help in establishing the early perception of being a caring and concerned clinician. It is important to close hospital encounters with a sense of hope and optimism, making sure that all of the patient’s issues have been addressed, as well as planning for the next steps.

The development and growth of hospital medicine is the latest site-specific evolution of practice specialization and focuses on the complex care of hospitalized patients. Hospitalists spend most of their professional time in the hospital providing care for general medical patients and are well positioned and uniquely committed to improving the care of hospitalized patients. Exceptional patient satisfaction is a key outcome that should result from the care provided by hospitalists.

References

1. Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260:1743-8.
2. Zaleski P. Knights Hospitaller: the rise and fall of a chivalric order of Christian caregiving. Parabola. 1990;15:55-62.
3. Risse GB. Mending Bodies, Saving Souls. New York, NY: Oxford University Press; 1999.
4. Reality Check: Public Perceptions of Health Care and Hospitals. The American Hospital Association. 1996.
5. Now are you satisfied? Fortune. February 1998:166.
6. National Coalition on Health Care. How Americans perceive the health care system. www.nchc.org/perceive.html. Accessed August 2004.
7. To Err Is Human: Building a Safer Health Care System. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 1998.
8. Pascoe GC. Patient satisfaction in primary health care: a literature review and analysis. Eval Prog Plann. 1983;6:185-210.
9. Kenagy JW, Berwick DM, Shore MF. Service quality in heath care. JAMA. 1999;281:661-5.
10. Mennemeyer ST, Morrisey MA, Howard LZ. Death and reputation: how consumers acted upon HCFA mortality information. Inquiry. 1997;34:117-28.
11. Cleary PD, Edgman-Levitan S. Health care quality. Incorporating consumer perspectives. JAMA. 1997;278:1608-12.
12. Rogers G, Smith DP. Reporting comparative results from hospital surveys. Int J Qual Health Care. 1999;11:251-9.
13. Schlesinger LA, Heskett JL. The service-driven service company. Harvard Business Review. 1991;Sept-Oct:1-19.
14. Modern Health care. 2000;May:70.
15. Mittal B, Lassar W. Why do customers switch? The dynamics of satisfaction versus loyalty. Journal of Services Marketing. 1998;12:177-191.
16. Greenfield S, Kaplan S, Ware WE Jr. Expanding patient involvement in care: Effects on patient outcomes. Ann Intern Med. 1985;102:520-8.
17. Sobel DS. Rethinking medicine: improving health outcomes with cost-effective psychosocial interventions. Psychosom Med. 1995;57:234-44.
18. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997;278:502-9.
19. Suchman AL, Roter D, Green M, Lipkin M Jr. Physician satisfaction with primary care office visits. Collaborative Study Group of the American Academy on Physician and Patient. Med Care. 1993;31:1083-92.
20. Maister DH. The Psychology of Waiting Lines. Case No. 9-684-064. Boston, Mass: Harvard Business School Publishing; 1984.
21. Fottler MD, Ford RC, Heaton CP. Achieving Service Excellence. Chicago, Ill.: Health Administration Press; 2002.
22. Mayer T, Cates RJ. Service excellence in health care. JAMA. 1999;282:1281-83.
23. James BC. Curing vs. Caring: The Art of Service Quality. Institute for Health Care Delivery Research. Intermountain Health Care. Salt Lake City, Utah; 2003.
24. Thompson AG, Sunol R. Expectations as determinants of patient satisfaction: concepts, theory and evidence. Int J Qual Health Care. 1995;7:127-41.
25. Larson CO, Nelson EC, Gustafson D, Batalden PB. The relationship between meeting patient’s information needs and their satisfaction with hospital care and general health status outcomes. Int J Qual Health Care. 1996;8:447-56.
26. Gerteis M, Edgman-Levitan S, Daley J, Deblanco T, eds. Through the Patient’s Eyes. San Francisco, Calif.: Jossey-Bass; 1993.
27. Spiro H, Peschel E, Curnen MG, St. James D, eds. Empathy and the Practice of Medicine: Beyond Pills and the Scalpel. New Haven, Conn.: Yale University Press; 1993.
28. Branch WT, Malik TK. Using ‘windows of opportunities’ in brief interviews to understand patients’ concerns. JAMA. 1993;269:1667-68.
29. Worthlin Group. Communication and the physician/patient relationship: A physician and communication survey. Bayer Institute for Health Care Communication. New Haven, CT; 1995.
30. Clinician Patient Communication to Enhance Health Outcomes. Bayer Institute for Health Care Communication Workshop. Bayer Institute, New Haven, Conn.; 1999.
31. Donovan J, Blake R. Patient non-compliance: deviance or reasoned decision-making? Soc Sci Med. 1992;34:507-13.
32. DiMatteo MR, Reiter RC, Gambone JC. Enhancing medication adherence through communication and informed collaborative choice. Health Commun. 1994;6:253-65.

Introduction

Patient satisfaction is a highly desirable outcome of clinical care in the hospital and may even be an element of health status itself (1). A patient’s expression of satisfaction or dissatisfaction is a judgment on the quality of hospital care in all of its aspects. Whatever its strengths and limitations, patient satisfaction is an indicator that should be indispensable to the assessment of the quality of care in hospitals.

The word “hospital” comes from the Latin for both “guest” and “host,” and the true spirit of hospitality is at the core of the hospital experience (2). The original mission of hospitals was to serve as houses of mercy, refuge, and dying for pilgrims returning from the Holy Land at the time of the late Christian antiquity (3). The striving to please patients is in harmony with the service calling of medicine and is certainly the right thing to do.

Current Reality

From the patient’s perspective, hospitals can be scary and unfriendly places. The American Hospital Association’s Reality Check (4) evaluated the public’s perceptions of hospitals and hospital care using a time-honored technique of asking focus group participants to imagine that the hospital was an animal and a car. Two out of 3 respondents chose animals that would be seen as aggressive, scary, or lumbering to suggest traits such as arrogance, uncontrolled power, and sluggishness. For cars, no respondent chose the Toyota Camry or any other model that would likely make the Consumer Reports list of best values. Instead, the cars chosen were representatives of unreasonable overpricing, waste, and outdated engineering.

“Imagine that the hospital is …”

A Car

“Volkswagen bus...Old, very noisy, just not a real great car.”

“A Rolls Royce, because of the expense.”

“A Pinto, because it was run down.”

“Ford Escort, just barely passing the test.”

“A Cadillac…big and expensive.”

An Animal

“A bear…a grizzly…horrible.”

“Elephant…large…cumbersome.”

“A leech.…I’m sure all hospitals aren’t that lowly.”

“A snake, kind of slithery and sneaky, because of what hospitals charge.”

The same AHA survey showed that patients felt that insurance companies and not physicians were in charge of their care in the hospital. A follow-up question revealed that patients clearly want to be in charge of their own hospital care. Additionally, patients do not see hospitals as part of a planned or consumer-focused health care system. In fact, they see quite the opposite: a confusing, expensive, unreliable, and often impersonal disassembly of medical professionals and institutions. If they see any system at all, it is one devoted to maximizing profits by blocking access, reducing quality, and limiting spending, all at the expense of the patient.

The American Customer Satisfaction Index (5) gave hospitals an overall 67% satisfaction rating, ranking 27th out of 31 industries. This ranking placed hospitals 10 percentage points below the tobacco industry and just above the Internal Revenue Service. A National Coalition on Health Care survey (6) found that 80% of respondents believe hospitals cut corners to save money, and 77% believe that these cuts have endangered patients. Quality of care and patient safety have become significant public concerns recently. “To Err is Human,” the 1999 report from the Institute of Medicine, highlighted the potential for serious injury and death in U.S. hospitals (7). Estimates are that 44,000 to 98,000 Americans die each year in hospitals as a result of medical errors and unsafe practices.

Patient Satisfaction Is Important

Patient satisfaction is the health care recipient’s reaction to aspects of his or her service experience (8). Patient satisfaction belongs to the service dimension as opposed to the technical dimension of quality of care. Most patients report few problems related to technical quality of care in hospitals and moreover do not feel qualified to judge technical quality and therefore assume technical competence (9).

From 1986 to 1992, the Health Care Financing Administration publicly reported hospital mortality rates as an effort to aid consumers in selecting hospitals (10). Hospitals with over twice the expected mortality rate saw very little change in volume during that time. Patients do not seem to be affected by morbidity and mortality statistics but more by personal stories of care. Patient perception of quality is assessed through dimensions of what is personally valued, and often they do not distinguish between the provider of the service and the service received.

Being treated with respect and dignity and involvement in treatment decisions are intangible issues of patient satisfaction that are paramount issues for patients (11).

As many as one quarter of 13,000 patients discharged from 51 Massachusetts hospitals reported problems with patient satisfaction issues such as the involvement of families in their care, communication and coordination of care, and the transition from hospital to home (12). Patients who had been admitted to academic health centers and teaching hospitals generally reported more problems than those cared for in community hospitals. As it turns out, service outcomes such as patient satisfaction drive market share and profitability for hospitals (13). With the average medical/surgery hospital charge amounting to $12,083, hospitals cannot afford to lose patients and, therefore, revenue due to issues of patient dissatisfaction (14). Recruiting new patients as customers is 5 times more costly than retaining an existing customer base (15).

There is compelling evidence from well-developed lines of research demonstrating that increasing patient satisfaction improves clinical outcomes, such as functional status and physiologic measures of health (16,17). Finally, it is important for clinicians to know that it has been clearly demonstrated that satisfied patients improve physician satisfaction (18,19).

Psychology of Satisfaction

To create a culture of customer service excellence in hospitals and achieve outstanding patient satisfaction, it is necessary to understand the intangible aspects of perception and expectation that contribute to patient satisfaction. The “First Law of Service” provides a useful, simple mathematical model of satisfaction (20). The formula for this model is Satisfaction = Perception – Expectation. If a patient’s perception of their hospital experience meets or exceeds the expectation, there will be a corresponding degree of satisfaction. However, if the perception does not meet the expectation, there will be resulting dissatisfaction. Thus, patient satisfaction results from meeting or exceeding patients’ expectations. Patient perceptions of care can be measured directly from patient satisfaction surveys, focus groups, and telephone surveys. A hospital’s reputation and market share are indirect measurements of patient perceptions. There are 2 main directions in which patient satisfaction can be influenced: by working on what the patient perceives and on what the patient expects.

Expectations are integral to the experience of being a customer. There has been confusion and controversy in health care as to whether patients are in fact customers. This confusion may be at the root of the overall service failing of hospitals (21). “The more horizontal they are, the more they are a patient. The more vertical they are, the more they are a customer” (22). Using a technical definition, a customer is anyone who has expectations about process operations or outputs (23). Therefore, all patients are customers, but not all customers are patients (21). Hospitals have a whole list of primary and secondary customers, each of whom has his or her own set of expectations. Patients and their families can be seen as primary customers, and referring physicians, third-party payers, external overseers, communities, shareholders, and employees are all secondary customers of hospitals.

Expectations are psychological phenomena that can be defined as beliefs created and sustained by cognitive processes (24). Expectations of patients as hospital customers rise from past experiences of their own or of others, as well as from current needs and unique internal preferences that form the basis of a value system. Expectations cannot be mandated, because they are based in self-gratification. However, expectations may change over time, and, very importantly, they can be measured and perhaps modified through education. For most people, illness and hospitalization is a rare event. Patients will know something is wrong and that treatment is needed, but most won’t know the nature of their disease, the diagnostic and therapeutic options, and the likely outcomes. Therefore, patients seek out health care professionals who have the opportunity to inform them on what to expect as a way to begin the process of managing expectations.

click for large version

The Kano Model

The Kano Model provides a useful tool for studying different levels of patient expectations (23).

This model is useful to examine the voice of the customer in the relationship between satisfaction and quality, and it is relevant for hospital encounters. According to the model, patients will have a basic set of subconscious expectations about their care that will be taken for granted. These expectations are so routine and expected that patients don’t recognize them as comparative quality factors, but they will be shocked if they are absent. For example, patients assume that physicians are basically competent, and that hospitals are capable of providing safe, courteous, lifesaving medical care (25). Although these expectations are in the patient’s subconscious, if they are not met, the patient will be dissatisfied. Providing this level of basic quality isn’t necessarily enough to create satisfied patients.

There is a normal level of service that patients consciously consider, they have to do with the anticipated issues of hospital care related to access, wait times, scheduling, and billing. The model shows that satisfaction increases as more of these expectations are met and that patients will be dissatisfied if these quality expectations are not met. Patients use comparisons of these expectations to recognize differences among competitors and to make choices.

The latent quality curve lies entirely in the satisfaction region and represents supraconscious, unexpected quality items that patients didn’t know they wanted and result in a delightful surprise when present. In this experience, patients receive more than they had expected, often as the result of innovation that can raise patient expectations and provide a significant competitive advantage. The data from hospitals show that this is achieved primarily through the patient’s perception of personalized, customized service, provided by caring and concerned clinicians (26).

There is a tremendous opportunity in hospital care to modify patient expectations through education and to create high levels of patient satisfaction. Hospitals that are successful in this endeavor will have a significant competitive advantage. Hospital patients have a whole list of issues about which they have expectations: the smoothness of the admission and discharge process, accuracy and clarity of billing statements, courtesy of hospital employees, response time for calls and requests, the level of technology available in the hospital, nurse competency, taste and temperature of the food, and price. Most of these issues are not directly related to clinical care and certainly not under the control or influence of the hospitalist. What are the expectations that patients have for their clinical care by hospitalists, and how can we give it to them?

The Hospitalist as a Caring and Concerned Clinician

A useful model to define the hospitalist’s role in patient satisfaction is that of a caring and concerned clinician. This caring and concern for patients is exemplified by attentiveness, dignity and respect, effective information transfer, and shared decision making (23).

The outcome service chain for hospitals begins with the patient’s perception of caring and concerned clinicians who demonstrate these attributes of attentiveness, dignity and respect, effective information transfer, and shared decision making. This leads to the degree of patient satisfaction and loyalty that results in patients who will return to the hospital, seek related business, and refer additional business. This drives market share and financial success for hospitals (9).

The characteristics of the caring and concerned clinician begin with attentiveness. This is the practice of establishing a person-to-person connection with patients and involves attending to them as unique individuals and not just in their role as patients. The constant interruptions that occur in physician/patient encounters, control issues, discontinuity of care, and the often overwhelming complexity of a patient’s illness can be obstacles to the perception of attentiveness that result in patients feeling connected with the clinician. Some effective tools for attentiveness are demonstrating curiosity about the patient as a person, using open-ended questions to gather clinical data, orienting patients to the process of care, and actively eliciting a patient’s agenda for their care and then summarizing their concerns.

The demonstration of dignity and respect results in a patient’s feeling understood and accepted as a person. This is the practice of empathy, which is often confused with sympathy (27). Sympathy is an expression of one’s own feelings (“I’m sorry”). Empathy is the demonstration of an understanding of the patient’s feelings (“You must be very sad”). The confusion of medical terminology as well as the time constraints of modern hospital-care encounters can be obstacles to achieving the type of dignity and respect that results in a high degree of patient satisfaction. A number of effective tools are available to facilitate this important result. Sitting down during patient encounters greatly enhances the perception of time and caring of hospitalists on the part of patients. Eye contact and appropriate touch are demonstrations of dignity and respect, as is seeing patients fully clothed. It is important to pay attention to nonverbal communication issues with patients. An important element of how hospitalists are perceived by patients has to do with nonverbal issues such as demeanor, body posture, and verbal tone. Using a patient’s own words and addressing underlying feelings facilitates the practice of dignity and respect (28). Patients perceive statements of assured understanding as confirmation that they have been listened to. Remember the words of Sir William Osler: “Listening is unspoken caring.”

The effective transfer of information is at the core of physician/patient communication (29). Patients have the need to provide complete information to physicians to facilitate an accurate diagnosis. The physician’s role is to provide information that addresses the cognitive, behavioral, and affective needs of patients and their families concerning their illness. The discrepancy of language, time constraints, and the ability of patients to remember are all barriers to the effective transfer of information. Some useful techniques for effective information transfer include assessing a patient’s current level of understanding and asking about their self-diagnosis. Timeliness in providing results of diagnostic tests is an important issue to patients who are often waiting expectantly. Studies have shown that the majority of patients have questions about the so-called “mysteries of medicine,” related to the diagnosis, etiology, and prognosis of their illness (30).

Patients may not specifically ask these questions; however, they are present, and patient satisfaction will increase if these questions are answered. Patients have decisively indicated their desire for shared decision making regarding their health care and for patient and family control of all-important choices (26). The process of shared decision making can be facilitated by collaboration between patients and the hospitalist around goals ands plans for treatment in the hospital (31). A barrier to shared decision making is a patient/physician relationship based on a model of paternalism (“I’m the doctor, and I know best”). A more productive model for the therapeutic relationship is that of a partnership between the hospitalist and the patient, particularly in the present era of web-educated, sophisticated consumer patients.

An important tool to achieving this type of collaboration involves the approach of presenting patients and families with treatment options and then actively soliciting patient preferences. A question is whether patients will actively participate in treatment decisions and then adhere to treatment plans. This is in large part determined by the interpersonal relationship skills of the clinician and can be further facilitated with simplified regimens that have been agreed upon by the patient and the hospitalist (32).

A complete model of the hospital-care encounter provided by hospitalists has an opening and a closing. In between there is a series of moments of truth that can potentially be imbued with attentiveness, dignity and respect, effective information transfer, and shared decision making. The opening is a brief moment that will set the stage for the remainder of the encounter. Greeting patients by name and maintaining eye contact will help in establishing the early perception of being a caring and concerned clinician. It is important to close hospital encounters with a sense of hope and optimism, making sure that all of the patient’s issues have been addressed, as well as planning for the next steps.

The development and growth of hospital medicine is the latest site-specific evolution of practice specialization and focuses on the complex care of hospitalized patients. Hospitalists spend most of their professional time in the hospital providing care for general medical patients and are well positioned and uniquely committed to improving the care of hospitalized patients. Exceptional patient satisfaction is a key outcome that should result from the care provided by hospitalists.

References

1. Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260:1743-8.
2. Zaleski P. Knights Hospitaller: the rise and fall of a chivalric order of Christian caregiving. Parabola. 1990;15:55-62.
3. Risse GB. Mending Bodies, Saving Souls. New York, NY: Oxford University Press; 1999.
4. Reality Check: Public Perceptions of Health Care and Hospitals. The American Hospital Association. 1996.
5. Now are you satisfied? Fortune. February 1998:166.
6. National Coalition on Health Care. How Americans perceive the health care system. www.nchc.org/perceive.html. Accessed August 2004.
7. To Err Is Human: Building a Safer Health Care System. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 1998.
8. Pascoe GC. Patient satisfaction in primary health care: a literature review and analysis. Eval Prog Plann. 1983;6:185-210.
9. Kenagy JW, Berwick DM, Shore MF. Service quality in heath care. JAMA. 1999;281:661-5.
10. Mennemeyer ST, Morrisey MA, Howard LZ. Death and reputation: how consumers acted upon HCFA mortality information. Inquiry. 1997;34:117-28.
11. Cleary PD, Edgman-Levitan S. Health care quality. Incorporating consumer perspectives. JAMA. 1997;278:1608-12.
12. Rogers G, Smith DP. Reporting comparative results from hospital surveys. Int J Qual Health Care. 1999;11:251-9.
13. Schlesinger LA, Heskett JL. The service-driven service company. Harvard Business Review. 1991;Sept-Oct:1-19.
14. Modern Health care. 2000;May:70.
15. Mittal B, Lassar W. Why do customers switch? The dynamics of satisfaction versus loyalty. Journal of Services Marketing. 1998;12:177-191.
16. Greenfield S, Kaplan S, Ware WE Jr. Expanding patient involvement in care: Effects on patient outcomes. Ann Intern Med. 1985;102:520-8.
17. Sobel DS. Rethinking medicine: improving health outcomes with cost-effective psychosocial interventions. Psychosom Med. 1995;57:234-44.
18. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997;278:502-9.
19. Suchman AL, Roter D, Green M, Lipkin M Jr. Physician satisfaction with primary care office visits. Collaborative Study Group of the American Academy on Physician and Patient. Med Care. 1993;31:1083-92.
20. Maister DH. The Psychology of Waiting Lines. Case No. 9-684-064. Boston, Mass: Harvard Business School Publishing; 1984.
21. Fottler MD, Ford RC, Heaton CP. Achieving Service Excellence. Chicago, Ill.: Health Administration Press; 2002.
22. Mayer T, Cates RJ. Service excellence in health care. JAMA. 1999;282:1281-83.
23. James BC. Curing vs. Caring: The Art of Service Quality. Institute for Health Care Delivery Research. Intermountain Health Care. Salt Lake City, Utah; 2003.
24. Thompson AG, Sunol R. Expectations as determinants of patient satisfaction: concepts, theory and evidence. Int J Qual Health Care. 1995;7:127-41.
25. Larson CO, Nelson EC, Gustafson D, Batalden PB. The relationship between meeting patient’s information needs and their satisfaction with hospital care and general health status outcomes. Int J Qual Health Care. 1996;8:447-56.
26. Gerteis M, Edgman-Levitan S, Daley J, Deblanco T, eds. Through the Patient’s Eyes. San Francisco, Calif.: Jossey-Bass; 1993.
27. Spiro H, Peschel E, Curnen MG, St. James D, eds. Empathy and the Practice of Medicine: Beyond Pills and the Scalpel. New Haven, Conn.: Yale University Press; 1993.
28. Branch WT, Malik TK. Using ‘windows of opportunities’ in brief interviews to understand patients’ concerns. JAMA. 1993;269:1667-68.
29. Worthlin Group. Communication and the physician/patient relationship: A physician and communication survey. Bayer Institute for Health Care Communication. New Haven, CT; 1995.
30. Clinician Patient Communication to Enhance Health Outcomes. Bayer Institute for Health Care Communication Workshop. Bayer Institute, New Haven, Conn.; 1999.
31. Donovan J, Blake R. Patient non-compliance: deviance or reasoned decision-making? Soc Sci Med. 1992;34:507-13.
32. DiMatteo MR, Reiter RC, Gambone JC. Enhancing medication adherence through communication and informed collaborative choice. Health Commun. 1994;6:253-65.

Introduction

Patient satisfaction is a highly desirable outcome of clinical care in the hospital and may even be an element of health status itself (1). A patient’s expression of satisfaction or dissatisfaction is a judgment on the quality of hospital care in all of its aspects. Whatever its strengths and limitations, patient satisfaction is an indicator that should be indispensable to the assessment of the quality of care in hospitals.

The word “hospital” comes from the Latin for both “guest” and “host,” and the true spirit of hospitality is at the core of the hospital experience (2). The original mission of hospitals was to serve as houses of mercy, refuge, and dying for pilgrims returning from the Holy Land at the time of the late Christian antiquity (3). The striving to please patients is in harmony with the service calling of medicine and is certainly the right thing to do.

Current Reality

From the patient’s perspective, hospitals can be scary and unfriendly places. The American Hospital Association’s Reality Check (4) evaluated the public’s perceptions of hospitals and hospital care using a time-honored technique of asking focus group participants to imagine that the hospital was an animal and a car. Two out of 3 respondents chose animals that would be seen as aggressive, scary, or lumbering to suggest traits such as arrogance, uncontrolled power, and sluggishness. For cars, no respondent chose the Toyota Camry or any other model that would likely make the Consumer Reports list of best values. Instead, the cars chosen were representatives of unreasonable overpricing, waste, and outdated engineering.

“Imagine that the hospital is …”

A Car

“Volkswagen bus...Old, very noisy, just not a real great car.”

“A Rolls Royce, because of the expense.”

“A Pinto, because it was run down.”

“Ford Escort, just barely passing the test.”

“A Cadillac…big and expensive.”

An Animal

“A bear…a grizzly…horrible.”

“Elephant…large…cumbersome.”

“A leech.…I’m sure all hospitals aren’t that lowly.”

“A snake, kind of slithery and sneaky, because of what hospitals charge.”

The same AHA survey showed that patients felt that insurance companies and not physicians were in charge of their care in the hospital. A follow-up question revealed that patients clearly want to be in charge of their own hospital care. Additionally, patients do not see hospitals as part of a planned or consumer-focused health care system. In fact, they see quite the opposite: a confusing, expensive, unreliable, and often impersonal disassembly of medical professionals and institutions. If they see any system at all, it is one devoted to maximizing profits by blocking access, reducing quality, and limiting spending, all at the expense of the patient.

The American Customer Satisfaction Index (5) gave hospitals an overall 67% satisfaction rating, ranking 27th out of 31 industries. This ranking placed hospitals 10 percentage points below the tobacco industry and just above the Internal Revenue Service. A National Coalition on Health Care survey (6) found that 80% of respondents believe hospitals cut corners to save money, and 77% believe that these cuts have endangered patients. Quality of care and patient safety have become significant public concerns recently. “To Err is Human,” the 1999 report from the Institute of Medicine, highlighted the potential for serious injury and death in U.S. hospitals (7). Estimates are that 44,000 to 98,000 Americans die each year in hospitals as a result of medical errors and unsafe practices.

Patient Satisfaction Is Important

Patient satisfaction is the health care recipient’s reaction to aspects of his or her service experience (8). Patient satisfaction belongs to the service dimension as opposed to the technical dimension of quality of care. Most patients report few problems related to technical quality of care in hospitals and moreover do not feel qualified to judge technical quality and therefore assume technical competence (9).

From 1986 to 1992, the Health Care Financing Administration publicly reported hospital mortality rates as an effort to aid consumers in selecting hospitals (10). Hospitals with over twice the expected mortality rate saw very little change in volume during that time. Patients do not seem to be affected by morbidity and mortality statistics but more by personal stories of care. Patient perception of quality is assessed through dimensions of what is personally valued, and often they do not distinguish between the provider of the service and the service received.

Being treated with respect and dignity and involvement in treatment decisions are intangible issues of patient satisfaction that are paramount issues for patients (11).

As many as one quarter of 13,000 patients discharged from 51 Massachusetts hospitals reported problems with patient satisfaction issues such as the involvement of families in their care, communication and coordination of care, and the transition from hospital to home (12). Patients who had been admitted to academic health centers and teaching hospitals generally reported more problems than those cared for in community hospitals. As it turns out, service outcomes such as patient satisfaction drive market share and profitability for hospitals (13). With the average medical/surgery hospital charge amounting to $12,083, hospitals cannot afford to lose patients and, therefore, revenue due to issues of patient dissatisfaction (14). Recruiting new patients as customers is 5 times more costly than retaining an existing customer base (15).

There is compelling evidence from well-developed lines of research demonstrating that increasing patient satisfaction improves clinical outcomes, such as functional status and physiologic measures of health (16,17). Finally, it is important for clinicians to know that it has been clearly demonstrated that satisfied patients improve physician satisfaction (18,19).

Psychology of Satisfaction

To create a culture of customer service excellence in hospitals and achieve outstanding patient satisfaction, it is necessary to understand the intangible aspects of perception and expectation that contribute to patient satisfaction. The “First Law of Service” provides a useful, simple mathematical model of satisfaction (20). The formula for this model is Satisfaction = Perception – Expectation. If a patient’s perception of their hospital experience meets or exceeds the expectation, there will be a corresponding degree of satisfaction. However, if the perception does not meet the expectation, there will be resulting dissatisfaction. Thus, patient satisfaction results from meeting or exceeding patients’ expectations. Patient perceptions of care can be measured directly from patient satisfaction surveys, focus groups, and telephone surveys. A hospital’s reputation and market share are indirect measurements of patient perceptions. There are 2 main directions in which patient satisfaction can be influenced: by working on what the patient perceives and on what the patient expects.

Expectations are integral to the experience of being a customer. There has been confusion and controversy in health care as to whether patients are in fact customers. This confusion may be at the root of the overall service failing of hospitals (21). “The more horizontal they are, the more they are a patient. The more vertical they are, the more they are a customer” (22). Using a technical definition, a customer is anyone who has expectations about process operations or outputs (23). Therefore, all patients are customers, but not all customers are patients (21). Hospitals have a whole list of primary and secondary customers, each of whom has his or her own set of expectations. Patients and their families can be seen as primary customers, and referring physicians, third-party payers, external overseers, communities, shareholders, and employees are all secondary customers of hospitals.

Expectations are psychological phenomena that can be defined as beliefs created and sustained by cognitive processes (24). Expectations of patients as hospital customers rise from past experiences of their own or of others, as well as from current needs and unique internal preferences that form the basis of a value system. Expectations cannot be mandated, because they are based in self-gratification. However, expectations may change over time, and, very importantly, they can be measured and perhaps modified through education. For most people, illness and hospitalization is a rare event. Patients will know something is wrong and that treatment is needed, but most won’t know the nature of their disease, the diagnostic and therapeutic options, and the likely outcomes. Therefore, patients seek out health care professionals who have the opportunity to inform them on what to expect as a way to begin the process of managing expectations.

click for large version

The Kano Model

The Kano Model provides a useful tool for studying different levels of patient expectations (23).

This model is useful to examine the voice of the customer in the relationship between satisfaction and quality, and it is relevant for hospital encounters. According to the model, patients will have a basic set of subconscious expectations about their care that will be taken for granted. These expectations are so routine and expected that patients don’t recognize them as comparative quality factors, but they will be shocked if they are absent. For example, patients assume that physicians are basically competent, and that hospitals are capable of providing safe, courteous, lifesaving medical care (25). Although these expectations are in the patient’s subconscious, if they are not met, the patient will be dissatisfied. Providing this level of basic quality isn’t necessarily enough to create satisfied patients.

There is a normal level of service that patients consciously consider, they have to do with the anticipated issues of hospital care related to access, wait times, scheduling, and billing. The model shows that satisfaction increases as more of these expectations are met and that patients will be dissatisfied if these quality expectations are not met. Patients use comparisons of these expectations to recognize differences among competitors and to make choices.

The latent quality curve lies entirely in the satisfaction region and represents supraconscious, unexpected quality items that patients didn’t know they wanted and result in a delightful surprise when present. In this experience, patients receive more than they had expected, often as the result of innovation that can raise patient expectations and provide a significant competitive advantage. The data from hospitals show that this is achieved primarily through the patient’s perception of personalized, customized service, provided by caring and concerned clinicians (26).

There is a tremendous opportunity in hospital care to modify patient expectations through education and to create high levels of patient satisfaction. Hospitals that are successful in this endeavor will have a significant competitive advantage. Hospital patients have a whole list of issues about which they have expectations: the smoothness of the admission and discharge process, accuracy and clarity of billing statements, courtesy of hospital employees, response time for calls and requests, the level of technology available in the hospital, nurse competency, taste and temperature of the food, and price. Most of these issues are not directly related to clinical care and certainly not under the control or influence of the hospitalist. What are the expectations that patients have for their clinical care by hospitalists, and how can we give it to them?

The Hospitalist as a Caring and Concerned Clinician

A useful model to define the hospitalist’s role in patient satisfaction is that of a caring and concerned clinician. This caring and concern for patients is exemplified by attentiveness, dignity and respect, effective information transfer, and shared decision making (23).

The outcome service chain for hospitals begins with the patient’s perception of caring and concerned clinicians who demonstrate these attributes of attentiveness, dignity and respect, effective information transfer, and shared decision making. This leads to the degree of patient satisfaction and loyalty that results in patients who will return to the hospital, seek related business, and refer additional business. This drives market share and financial success for hospitals (9).

The characteristics of the caring and concerned clinician begin with attentiveness. This is the practice of establishing a person-to-person connection with patients and involves attending to them as unique individuals and not just in their role as patients. The constant interruptions that occur in physician/patient encounters, control issues, discontinuity of care, and the often overwhelming complexity of a patient’s illness can be obstacles to the perception of attentiveness that result in patients feeling connected with the clinician. Some effective tools for attentiveness are demonstrating curiosity about the patient as a person, using open-ended questions to gather clinical data, orienting patients to the process of care, and actively eliciting a patient’s agenda for their care and then summarizing their concerns.

The demonstration of dignity and respect results in a patient’s feeling understood and accepted as a person. This is the practice of empathy, which is often confused with sympathy (27). Sympathy is an expression of one’s own feelings (“I’m sorry”). Empathy is the demonstration of an understanding of the patient’s feelings (“You must be very sad”). The confusion of medical terminology as well as the time constraints of modern hospital-care encounters can be obstacles to achieving the type of dignity and respect that results in a high degree of patient satisfaction. A number of effective tools are available to facilitate this important result. Sitting down during patient encounters greatly enhances the perception of time and caring of hospitalists on the part of patients. Eye contact and appropriate touch are demonstrations of dignity and respect, as is seeing patients fully clothed. It is important to pay attention to nonverbal communication issues with patients. An important element of how hospitalists are perceived by patients has to do with nonverbal issues such as demeanor, body posture, and verbal tone. Using a patient’s own words and addressing underlying feelings facilitates the practice of dignity and respect (28). Patients perceive statements of assured understanding as confirmation that they have been listened to. Remember the words of Sir William Osler: “Listening is unspoken caring.”

The effective transfer of information is at the core of physician/patient communication (29). Patients have the need to provide complete information to physicians to facilitate an accurate diagnosis. The physician’s role is to provide information that addresses the cognitive, behavioral, and affective needs of patients and their families concerning their illness. The discrepancy of language, time constraints, and the ability of patients to remember are all barriers to the effective transfer of information. Some useful techniques for effective information transfer include assessing a patient’s current level of understanding and asking about their self-diagnosis. Timeliness in providing results of diagnostic tests is an important issue to patients who are often waiting expectantly. Studies have shown that the majority of patients have questions about the so-called “mysteries of medicine,” related to the diagnosis, etiology, and prognosis of their illness (30).

Patients may not specifically ask these questions; however, they are present, and patient satisfaction will increase if these questions are answered. Patients have decisively indicated their desire for shared decision making regarding their health care and for patient and family control of all-important choices (26). The process of shared decision making can be facilitated by collaboration between patients and the hospitalist around goals ands plans for treatment in the hospital (31). A barrier to shared decision making is a patient/physician relationship based on a model of paternalism (“I’m the doctor, and I know best”). A more productive model for the therapeutic relationship is that of a partnership between the hospitalist and the patient, particularly in the present era of web-educated, sophisticated consumer patients.

An important tool to achieving this type of collaboration involves the approach of presenting patients and families with treatment options and then actively soliciting patient preferences. A question is whether patients will actively participate in treatment decisions and then adhere to treatment plans. This is in large part determined by the interpersonal relationship skills of the clinician and can be further facilitated with simplified regimens that have been agreed upon by the patient and the hospitalist (32).

A complete model of the hospital-care encounter provided by hospitalists has an opening and a closing. In between there is a series of moments of truth that can potentially be imbued with attentiveness, dignity and respect, effective information transfer, and shared decision making. The opening is a brief moment that will set the stage for the remainder of the encounter. Greeting patients by name and maintaining eye contact will help in establishing the early perception of being a caring and concerned clinician. It is important to close hospital encounters with a sense of hope and optimism, making sure that all of the patient’s issues have been addressed, as well as planning for the next steps.

The development and growth of hospital medicine is the latest site-specific evolution of practice specialization and focuses on the complex care of hospitalized patients. Hospitalists spend most of their professional time in the hospital providing care for general medical patients and are well positioned and uniquely committed to improving the care of hospitalized patients. Exceptional patient satisfaction is a key outcome that should result from the care provided by hospitalists.

References

1. Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260:1743-8.
2. Zaleski P. Knights Hospitaller: the rise and fall of a chivalric order of Christian caregiving. Parabola. 1990;15:55-62.
3. Risse GB. Mending Bodies, Saving Souls. New York, NY: Oxford University Press; 1999.
4. Reality Check: Public Perceptions of Health Care and Hospitals. The American Hospital Association. 1996.
5. Now are you satisfied? Fortune. February 1998:166.
6. National Coalition on Health Care. How Americans perceive the health care system. www.nchc.org/perceive.html. Accessed August 2004.
7. To Err Is Human: Building a Safer Health Care System. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 1998.
8. Pascoe GC. Patient satisfaction in primary health care: a literature review and analysis. Eval Prog Plann. 1983;6:185-210.
9. Kenagy JW, Berwick DM, Shore MF. Service quality in heath care. JAMA. 1999;281:661-5.
10. Mennemeyer ST, Morrisey MA, Howard LZ. Death and reputation: how consumers acted upon HCFA mortality information. Inquiry. 1997;34:117-28.
11. Cleary PD, Edgman-Levitan S. Health care quality. Incorporating consumer perspectives. JAMA. 1997;278:1608-12.
12. Rogers G, Smith DP. Reporting comparative results from hospital surveys. Int J Qual Health Care. 1999;11:251-9.
13. Schlesinger LA, Heskett JL. The service-driven service company. Harvard Business Review. 1991;Sept-Oct:1-19.
14. Modern Health care. 2000;May:70.
15. Mittal B, Lassar W. Why do customers switch? The dynamics of satisfaction versus loyalty. Journal of Services Marketing. 1998;12:177-191.
16. Greenfield S, Kaplan S, Ware WE Jr. Expanding patient involvement in care: Effects on patient outcomes. Ann Intern Med. 1985;102:520-8.
17. Sobel DS. Rethinking medicine: improving health outcomes with cost-effective psychosocial interventions. Psychosom Med. 1995;57:234-44.
18. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997;278:502-9.
19. Suchman AL, Roter D, Green M, Lipkin M Jr. Physician satisfaction with primary care office visits. Collaborative Study Group of the American Academy on Physician and Patient. Med Care. 1993;31:1083-92.
20. Maister DH. The Psychology of Waiting Lines. Case No. 9-684-064. Boston, Mass: Harvard Business School Publishing; 1984.
21. Fottler MD, Ford RC, Heaton CP. Achieving Service Excellence. Chicago, Ill.: Health Administration Press; 2002.
22. Mayer T, Cates RJ. Service excellence in health care. JAMA. 1999;282:1281-83.
23. James BC. Curing vs. Caring: The Art of Service Quality. Institute for Health Care Delivery Research. Intermountain Health Care. Salt Lake City, Utah; 2003.
24. Thompson AG, Sunol R. Expectations as determinants of patient satisfaction: concepts, theory and evidence. Int J Qual Health Care. 1995;7:127-41.
25. Larson CO, Nelson EC, Gustafson D, Batalden PB. The relationship between meeting patient’s information needs and their satisfaction with hospital care and general health status outcomes. Int J Qual Health Care. 1996;8:447-56.
26. Gerteis M, Edgman-Levitan S, Daley J, Deblanco T, eds. Through the Patient’s Eyes. San Francisco, Calif.: Jossey-Bass; 1993.
27. Spiro H, Peschel E, Curnen MG, St. James D, eds. Empathy and the Practice of Medicine: Beyond Pills and the Scalpel. New Haven, Conn.: Yale University Press; 1993.
28. Branch WT, Malik TK. Using ‘windows of opportunities’ in brief interviews to understand patients’ concerns. JAMA. 1993;269:1667-68.
29. Worthlin Group. Communication and the physician/patient relationship: A physician and communication survey. Bayer Institute for Health Care Communication. New Haven, CT; 1995.
30. Clinician Patient Communication to Enhance Health Outcomes. Bayer Institute for Health Care Communication Workshop. Bayer Institute, New Haven, Conn.; 1999.
31. Donovan J, Blake R. Patient non-compliance: deviance or reasoned decision-making? Soc Sci Med. 1992;34:507-13.
32. DiMatteo MR, Reiter RC, Gambone JC. Enhancing medication adherence through communication and informed collaborative choice. Health Commun. 1994;6:253-65.

Case Presentation

A 68-year-old man presented to a university hospital with a 4-day history of sudden, progressive finger ischemia. His past medical history was significant for type II diabetes mellitus and hyperlipidemia. He also suffered from severe vascular disease. Four years prior to admission, he underwent several surgeries, including right carotid endarterectomy, coronary artery bypass, and right-lower-extremity revascularization. One year prior, he also required a left below-the-knee amputation due to vascular insufficiency. Additional history revealed long-standing asthma, hearing loss due to chronic bilateral otitis media, and multiple sinus surgeries in attempts to relieve recurrent infections. He also had lower-extremity peripheral neuropathy, attributed to diabetes and frequent steroid use for asthma control.

On admission, vital signs were stable. Physical exam demonstrated mild cyanosis of digits 2 through 5 on both hands. There were also scattered splinter hemorrhages and petechiae on the involved fingers. Rales were noted in the left lung base with diffuse wheezes. Cardiac and vascular exams were unremarkable. Chronic ulceration of the right toes was also noted. Laboratory studies were significant for a white blood cell count of 26,700 cells/mL with 52% eosinophils and a positive perinuclear antineutrophil cytoplasmic antibody (p-ANCA).

A chest radiograph revealed hazy, bilateral perihilar and left lower lobe infiltrates (Figure 1). Computed tomography of the chest was then performed and showed bronchiectasis of the left lung (Figure 2). This prompted a transbronchial biopsy that yielded tissue consistent with chronic inflammation.

What Is the Diagnosis?

Churg-Strauss Syndrome

Discussion

Churg-Strauss syndrome (CSS) is an allergic and granulomatous vasculitic illness affecting multiple organ systems. It typically follows 3 phases of progression. The first occurs in the second or third decade of life and includes the development of asthma in addition to chronic ear, nose, and sinus inflammation or infection. This is followed by eosinophilic infiltration of the lungs, skin, and other organs. The third phase commonly occurs 10 to 20 years after initial presentation, and it is heralded by small- and medium-vessel vasculitis.

In 1990, the American College of Rheumatology developed 6 diagnostic criteria for CSS and showed that having at least 4 of the 6 predicted the presence of CSS with a sensitivity of 85% and a specificity of 99.7%. They include:

• Asthma;
• Eosinophilia of >10% on a peripheral white blood cell count;
• Paranasal sinus disease;
• Mononeuropathy or polyneuropathy;
• Migratory or transient pulmonary opacities seen radiographically; and
• A blood vessel showing the accumulation of eosinophils in extravascular areas, as revealed by a biopsy.

Other helpful, but nonspecific diagnostic tests include a significantly elevated sedimentation rate, a positive p-ANCA with low titers of rheumatoid factor, high circulating IgE levels, and normocytic, normochromic anemia. CSS typically responds quite well to immunosuppressive therapy. The usual regimen consists of corticosteroids, and cyclophosphamide is frequently added. Before the advent of such therapies, CSS was consistently fatal, often within 3 months of the onset of vasculitis. Currently, 5-year survival rates exceed 70%.

In this patient, a diagnosis of CSS was based on history, clinical presentation, and laboratory results. Highdose methylprednisolone was initiated, and complete resolution of finger cyanosis and pain occurred in 48 hours. Oral cyclophosphamide was added the following day, and the patient was discharged home to complete 6 months of aggressive immunosuppressive therapy.

This presentation of CSS was rather unusual. Digital ischemia is uncommon in CSS, although it is consistent with the small-vessel vasculitis seen in this syndrome. Similarly, the late onset of the patient’s vasculitis is also unusual. The intermittent use of prednisone for asthma perhaps delayed the declaration of systemic symptoms.

Suggested Reading

1. Noth I, Strek ME, Leff AR. Churg-Strauss syndrome. Lancet. 2003;361:587-94.
2. Abril A, Calamia KT, Cohen MD. The Churg-Strauss syndrome (allergic granulomatous angiitis): review and update. Semin Arthritis Rheum. 2003; 33:106-14.
3. Gross WL. Churg-Strauss syndrome: update on recent developments. Curr Opin Rheumatol. 2002;14:11-4.
4. Masi AT, Hunder GG, Lie JT, et al. The American College of Rheumatology 1990 Criteria for the classification of Churg-Strauss syndrome (allergic granulomatosis and angiitis). Arthritis Rheum. 1990;33:1094-100.

Case Presentation

A 68-year-old man presented to a university hospital with a 4-day history of sudden, progressive finger ischemia. His past medical history was significant for type II diabetes mellitus and hyperlipidemia. He also suffered from severe vascular disease. Four years prior to admission, he underwent several surgeries, including right carotid endarterectomy, coronary artery bypass, and right-lower-extremity revascularization. One year prior, he also required a left below-the-knee amputation due to vascular insufficiency. Additional history revealed long-standing asthma, hearing loss due to chronic bilateral otitis media, and multiple sinus surgeries in attempts to relieve recurrent infections. He also had lower-extremity peripheral neuropathy, attributed to diabetes and frequent steroid use for asthma control.

On admission, vital signs were stable. Physical exam demonstrated mild cyanosis of digits 2 through 5 on both hands. There were also scattered splinter hemorrhages and petechiae on the involved fingers. Rales were noted in the left lung base with diffuse wheezes. Cardiac and vascular exams were unremarkable. Chronic ulceration of the right toes was also noted. Laboratory studies were significant for a white blood cell count of 26,700 cells/mL with 52% eosinophils and a positive perinuclear antineutrophil cytoplasmic antibody (p-ANCA).

A chest radiograph revealed hazy, bilateral perihilar and left lower lobe infiltrates (Figure 1). Computed tomography of the chest was then performed and showed bronchiectasis of the left lung (Figure 2). This prompted a transbronchial biopsy that yielded tissue consistent with chronic inflammation.

What Is the Diagnosis?

Churg-Strauss Syndrome

Discussion

Churg-Strauss syndrome (CSS) is an allergic and granulomatous vasculitic illness affecting multiple organ systems. It typically follows 3 phases of progression. The first occurs in the second or third decade of life and includes the development of asthma in addition to chronic ear, nose, and sinus inflammation or infection. This is followed by eosinophilic infiltration of the lungs, skin, and other organs. The third phase commonly occurs 10 to 20 years after initial presentation, and it is heralded by small- and medium-vessel vasculitis.

In 1990, the American College of Rheumatology developed 6 diagnostic criteria for CSS and showed that having at least 4 of the 6 predicted the presence of CSS with a sensitivity of 85% and a specificity of 99.7%. They include:

• Asthma;
• Eosinophilia of >10% on a peripheral white blood cell count;
• Paranasal sinus disease;
• Mononeuropathy or polyneuropathy;
• Migratory or transient pulmonary opacities seen radiographically; and
• A blood vessel showing the accumulation of eosinophils in extravascular areas, as revealed by a biopsy.

Other helpful, but nonspecific diagnostic tests include a significantly elevated sedimentation rate, a positive p-ANCA with low titers of rheumatoid factor, high circulating IgE levels, and normocytic, normochromic anemia. CSS typically responds quite well to immunosuppressive therapy. The usual regimen consists of corticosteroids, and cyclophosphamide is frequently added. Before the advent of such therapies, CSS was consistently fatal, often within 3 months of the onset of vasculitis. Currently, 5-year survival rates exceed 70%.

In this patient, a diagnosis of CSS was based on history, clinical presentation, and laboratory results. Highdose methylprednisolone was initiated, and complete resolution of finger cyanosis and pain occurred in 48 hours. Oral cyclophosphamide was added the following day, and the patient was discharged home to complete 6 months of aggressive immunosuppressive therapy.

This presentation of CSS was rather unusual. Digital ischemia is uncommon in CSS, although it is consistent with the small-vessel vasculitis seen in this syndrome. Similarly, the late onset of the patient’s vasculitis is also unusual. The intermittent use of prednisone for asthma perhaps delayed the declaration of systemic symptoms.

Suggested Reading

1. Noth I, Strek ME, Leff AR. Churg-Strauss syndrome. Lancet. 2003;361:587-94.
2. Abril A, Calamia KT, Cohen MD. The Churg-Strauss syndrome (allergic granulomatous angiitis): review and update. Semin Arthritis Rheum. 2003; 33:106-14.
3. Gross WL. Churg-Strauss syndrome: update on recent developments. Curr Opin Rheumatol. 2002;14:11-4.
4. Masi AT, Hunder GG, Lie JT, et al. The American College of Rheumatology 1990 Criteria for the classification of Churg-Strauss syndrome (allergic granulomatosis and angiitis). Arthritis Rheum. 1990;33:1094-100.

Case Presentation

A 68-year-old man presented to a university hospital with a 4-day history of sudden, progressive finger ischemia. His past medical history was significant for type II diabetes mellitus and hyperlipidemia. He also suffered from severe vascular disease. Four years prior to admission, he underwent several surgeries, including right carotid endarterectomy, coronary artery bypass, and right-lower-extremity revascularization. One year prior, he also required a left below-the-knee amputation due to vascular insufficiency. Additional history revealed long-standing asthma, hearing loss due to chronic bilateral otitis media, and multiple sinus surgeries in attempts to relieve recurrent infections. He also had lower-extremity peripheral neuropathy, attributed to diabetes and frequent steroid use for asthma control.

On admission, vital signs were stable. Physical exam demonstrated mild cyanosis of digits 2 through 5 on both hands. There were also scattered splinter hemorrhages and petechiae on the involved fingers. Rales were noted in the left lung base with diffuse wheezes. Cardiac and vascular exams were unremarkable. Chronic ulceration of the right toes was also noted. Laboratory studies were significant for a white blood cell count of 26,700 cells/mL with 52% eosinophils and a positive perinuclear antineutrophil cytoplasmic antibody (p-ANCA).

A chest radiograph revealed hazy, bilateral perihilar and left lower lobe infiltrates (Figure 1). Computed tomography of the chest was then performed and showed bronchiectasis of the left lung (Figure 2). This prompted a transbronchial biopsy that yielded tissue consistent with chronic inflammation.

What Is the Diagnosis?

Churg-Strauss Syndrome

Discussion

Churg-Strauss syndrome (CSS) is an allergic and granulomatous vasculitic illness affecting multiple organ systems. It typically follows 3 phases of progression. The first occurs in the second or third decade of life and includes the development of asthma in addition to chronic ear, nose, and sinus inflammation or infection. This is followed by eosinophilic infiltration of the lungs, skin, and other organs. The third phase commonly occurs 10 to 20 years after initial presentation, and it is heralded by small- and medium-vessel vasculitis.

In 1990, the American College of Rheumatology developed 6 diagnostic criteria for CSS and showed that having at least 4 of the 6 predicted the presence of CSS with a sensitivity of 85% and a specificity of 99.7%. They include:

• Asthma;
• Eosinophilia of >10% on a peripheral white blood cell count;
• Paranasal sinus disease;
• Mononeuropathy or polyneuropathy;
• Migratory or transient pulmonary opacities seen radiographically; and
• A blood vessel showing the accumulation of eosinophils in extravascular areas, as revealed by a biopsy.

Other helpful, but nonspecific diagnostic tests include a significantly elevated sedimentation rate, a positive p-ANCA with low titers of rheumatoid factor, high circulating IgE levels, and normocytic, normochromic anemia. CSS typically responds quite well to immunosuppressive therapy. The usual regimen consists of corticosteroids, and cyclophosphamide is frequently added. Before the advent of such therapies, CSS was consistently fatal, often within 3 months of the onset of vasculitis. Currently, 5-year survival rates exceed 70%.

In this patient, a diagnosis of CSS was based on history, clinical presentation, and laboratory results. Highdose methylprednisolone was initiated, and complete resolution of finger cyanosis and pain occurred in 48 hours. Oral cyclophosphamide was added the following day, and the patient was discharged home to complete 6 months of aggressive immunosuppressive therapy.

This presentation of CSS was rather unusual. Digital ischemia is uncommon in CSS, although it is consistent with the small-vessel vasculitis seen in this syndrome. Similarly, the late onset of the patient’s vasculitis is also unusual. The intermittent use of prednisone for asthma perhaps delayed the declaration of systemic symptoms.

Suggested Reading

1. Noth I, Strek ME, Leff AR. Churg-Strauss syndrome. Lancet. 2003;361:587-94.
2. Abril A, Calamia KT, Cohen MD. The Churg-Strauss syndrome (allergic granulomatous angiitis): review and update. Semin Arthritis Rheum. 2003; 33:106-14.
3. Gross WL. Churg-Strauss syndrome: update on recent developments. Curr Opin Rheumatol. 2002;14:11-4.
4. Masi AT, Hunder GG, Lie JT, et al. The American College of Rheumatology 1990 Criteria for the classification of Churg-Strauss syndrome (allergic granulomatosis and angiitis). Arthritis Rheum. 1990;33:1094-100.

Background: Several studies suggest that hospitalists can improve costs or outcomes in academic medical centers, but almost all of these studies have nonrandom assignment of patients to hospitalists, and no multi-center studies exist. We studied patients assigned to hospitalist or non-hospitalist physicians based only on day of admission to determine the effects of hospitalists on outcomes and costs in 6 academic medical centers.

Methods: From July 2001 to June 2003, 31,891 general medicine inpatients were assigned to hospitalist or non-hospitalist physicians according to a predetermined daily call schedule. Patient interviews at admission and 1 month after discharge and administrative data were used to study effects on outcomes and costs.

Results: Twelve thousand and one patients were cared for by hospitalists and 19,890 by non-hospitalists. There were no statistically significant differences in age, race, gender, Charlson Index, or distribution of primary diagnosis between the 2 groups. There were no statistically significant differences in in-hospital mortality, 30-day readmission and emergency room use, 30-day self-reported health status, or patient satisfaction. Mortality data up to 1 year after admission are pending. Average length of stay was 0.05 days shorter for hospitalist patients but this difference was not statistically significant. Costs were also similar between the groups. Individual center analyses had large confidence intervals on outcomes and costs and failed to show statistically significant effects on any measure of outcomes or costs except for 1 of the larger centers, which had lower length of stay and costs for hospitalists.

Conclusions: Hospitalists had small effects on selected outcome measures available to date, but did not produce the large resource savings that had been suggested by some earlier studies. The effectiveness of hospitalists appeared to vary by site, but was difficult to assess due to limited statistical power for site-specific analyses. Understanding the factors, such as physician experience, that may influence the effectiveness of hospitalists is important for maximizing the efficacy of hospitalist programs, because effects on outcomes may be small, vary by site, and be difficult to distinguish from chance in a specific clinical setting.

Background: Several studies suggest that hospitalists can improve costs or outcomes in academic medical centers, but almost all of these studies have nonrandom assignment of patients to hospitalists, and no multi-center studies exist. We studied patients assigned to hospitalist or non-hospitalist physicians based only on day of admission to determine the effects of hospitalists on outcomes and costs in 6 academic medical centers.

Methods: From July 2001 to June 2003, 31,891 general medicine inpatients were assigned to hospitalist or non-hospitalist physicians according to a predetermined daily call schedule. Patient interviews at admission and 1 month after discharge and administrative data were used to study effects on outcomes and costs.

Results: Twelve thousand and one patients were cared for by hospitalists and 19,890 by non-hospitalists. There were no statistically significant differences in age, race, gender, Charlson Index, or distribution of primary diagnosis between the 2 groups. There were no statistically significant differences in in-hospital mortality, 30-day readmission and emergency room use, 30-day self-reported health status, or patient satisfaction. Mortality data up to 1 year after admission are pending. Average length of stay was 0.05 days shorter for hospitalist patients but this difference was not statistically significant. Costs were also similar between the groups. Individual center analyses had large confidence intervals on outcomes and costs and failed to show statistically significant effects on any measure of outcomes or costs except for 1 of the larger centers, which had lower length of stay and costs for hospitalists.

Conclusions: Hospitalists had small effects on selected outcome measures available to date, but did not produce the large resource savings that had been suggested by some earlier studies. The effectiveness of hospitalists appeared to vary by site, but was difficult to assess due to limited statistical power for site-specific analyses. Understanding the factors, such as physician experience, that may influence the effectiveness of hospitalists is important for maximizing the efficacy of hospitalist programs, because effects on outcomes may be small, vary by site, and be difficult to distinguish from chance in a specific clinical setting.

Background: Several studies suggest that hospitalists can improve costs or outcomes in academic medical centers, but almost all of these studies have nonrandom assignment of patients to hospitalists, and no multi-center studies exist. We studied patients assigned to hospitalist or non-hospitalist physicians based only on day of admission to determine the effects of hospitalists on outcomes and costs in 6 academic medical centers.

Methods: From July 2001 to June 2003, 31,891 general medicine inpatients were assigned to hospitalist or non-hospitalist physicians according to a predetermined daily call schedule. Patient interviews at admission and 1 month after discharge and administrative data were used to study effects on outcomes and costs.

Results: Twelve thousand and one patients were cared for by hospitalists and 19,890 by non-hospitalists. There were no statistically significant differences in age, race, gender, Charlson Index, or distribution of primary diagnosis between the 2 groups. There were no statistically significant differences in in-hospital mortality, 30-day readmission and emergency room use, 30-day self-reported health status, or patient satisfaction. Mortality data up to 1 year after admission are pending. Average length of stay was 0.05 days shorter for hospitalist patients but this difference was not statistically significant. Costs were also similar between the groups. Individual center analyses had large confidence intervals on outcomes and costs and failed to show statistically significant effects on any measure of outcomes or costs except for 1 of the larger centers, which had lower length of stay and costs for hospitalists.

Conclusions: Hospitalists had small effects on selected outcome measures available to date, but did not produce the large resource savings that had been suggested by some earlier studies. The effectiveness of hospitalists appeared to vary by site, but was difficult to assess due to limited statistical power for site-specific analyses. Understanding the factors, such as physician experience, that may influence the effectiveness of hospitalists is important for maximizing the efficacy of hospitalist programs, because effects on outcomes may be small, vary by site, and be difficult to distinguish from chance in a specific clinical setting.

1. When should the observation code be used? Do the provider and facility need to use the same codes in order to be reimbursed for observation? What are the restrictions, if any, on what diagnoses may be used to bill for observation?

Observation status is an “outpatient status” even if the patient is located in an inpatient bed. The purpose of observation is to allow the physician time to make a decision about whether the patient should be admitted, and then rapidly move the patient to the most appropriate setting—i.e., the patient should either be admitted as an inpatient or sent home.

Therefore, only the physician who writes the order that places the patient in “observation status” and is responsible for the patient during his or her stay should use the observation codes. Always date and time the “admitting order,” because this information is needed to meet the minimum 8-hours rule if the patient is admitted and discharged on the same calendar date.

If a patient is both admitted and discharged on the same calendar date, the code range of 99234-99236 are used; however, the following criteria must be met:

1. The patient must be in observation for a minimum of 8 hours.
2. The billing physician must be present and show active involvement by charting condition updates, orders, etc.
3. Both the admission and discharge notes are written by the billing physician (or may be billed by 2 physicians within the same group practice).

The specific CPT observation codes (99218-99220 and 99234-99236) do not have to match those used by the facility, because the physician codes are based on the physician E&M criteria (i.e., extent of history, exam, and decision making). The facility’s use of these codes is based on facility-specific criteria that measure the resources used by the facility’s employees and does not relate to the physician’s evaluation.

There are diagnosis/condition restrictions for separate payment to facilities for observation under the Outpatient Prospective Payment System (OPPS) reimbursement program (i.e., payment is based on Ambulatory Patient Classification [APC]). Even though separate payments for observation charges are made only for chest pain, asthma, and congestive heart failure, the facilities still code and report charges for all patients admitted to observation status. Note, however, that there are no such restrictions for the physician professional services billed. Only hospital facilities are subject to the diagnosis restrictions because of APC payment rules.

2. How should a change in status from observation to full admission affect coding (i.e., when this occurs, what should the appropriate coding be for the initial hospital day or for the second hospital day)?

The best way to answer this question is with some scenarios.

Scenario #1:

The patient is admitted to observation status after being evaluated in the ED. The attending physician writes an order “admit to observation status;” writes an admit note, which includes the intent of observation; and writes orders to help determine if the patient is to be admitted or sent home. After test results return, the physician decides to admit the patient on the same calendar date:

Code: Initial Hospital Care code (99221-99223) that incorporates all services (observation and admission note) provided and documented that day.

Scenario #2:

The patient is admitted in the evening (Day 1) to observation status, tests are performed, and results are pending. The following morning (Day 2), based on the results of tests, the physician evaluates the patient and decides to admit (writes admit order). On Day 3 the patient is evaluated and discharged home.

Code:

Day 1: Initial Observation Care (99218-99220)

Day 2: Initial Hospital Care (99221-99223)

Day 3: Discharge Management (99238 or 99239)

3. Is it acceptable to bill for a d/c day if the patient is not examined that day, but activities such as d/c planning and dictation occur?

Discharge management codes do require the face-to-face evaluation/examination of the patient. Also included is the time spent on instructions to the patient/family, coordination of care with other providers, preparation of discharge records, prescriptions, referrals and/or certification forms, etc. The dictation of discharge summary is not typically included in this definition, because it is usually considered a hospital requirement as opposed to something needed for the patient’s care.

4. How frequently should discharge code 99239 be used? What elements of the d/c process can/should actually be used toward the “greater than 30 minutes” definition? (e.g., do filling out the d/c paperwork, dictating d/c summary, phone time arranging f/u, etc., count?)

There is not a specific “frequency” for any code, although most payers will compare utilization of codes to “peers” of the same specialty. While this helps them identify outliers, it does not necessarily mean someone is coding incorrectly. It does mean that high utilization by a physician will probably result in some sort of “audit” or request for supporting documentation. For instance, if a physician has a high volume of patients who go to nursing homes requiring a lot of coordination of care, referral forms, etc., it may be expected that the physician may have a higher frequency of 99239 discharge management codes. For patients who are going home with great family support and are relatively healthy, it may not seem as “reasonable and necessary” to have greater than 30 minutes of discharge management, especially if every chart is documented with the same “35 minutes.” Therefore, try to keep track of the time devoted to these services as accurately as you can, and document the actual time and sufficient information to support the use of 99239.

Dr. Pfeiffer can be contacted at [email protected].

1. When should the observation code be used? Do the provider and facility need to use the same codes in order to be reimbursed for observation? What are the restrictions, if any, on what diagnoses may be used to bill for observation?

Observation status is an “outpatient status” even if the patient is located in an inpatient bed. The purpose of observation is to allow the physician time to make a decision about whether the patient should be admitted, and then rapidly move the patient to the most appropriate setting—i.e., the patient should either be admitted as an inpatient or sent home.

Therefore, only the physician who writes the order that places the patient in “observation status” and is responsible for the patient during his or her stay should use the observation codes. Always date and time the “admitting order,” because this information is needed to meet the minimum 8-hours rule if the patient is admitted and discharged on the same calendar date.

If a patient is both admitted and discharged on the same calendar date, the code range of 99234-99236 are used; however, the following criteria must be met:

1. The patient must be in observation for a minimum of 8 hours.
2. The billing physician must be present and show active involvement by charting condition updates, orders, etc.
3. Both the admission and discharge notes are written by the billing physician (or may be billed by 2 physicians within the same group practice).

The specific CPT observation codes (99218-99220 and 99234-99236) do not have to match those used by the facility, because the physician codes are based on the physician E&M criteria (i.e., extent of history, exam, and decision making). The facility’s use of these codes is based on facility-specific criteria that measure the resources used by the facility’s employees and does not relate to the physician’s evaluation.

There are diagnosis/condition restrictions for separate payment to facilities for observation under the Outpatient Prospective Payment System (OPPS) reimbursement program (i.e., payment is based on Ambulatory Patient Classification [APC]). Even though separate payments for observation charges are made only for chest pain, asthma, and congestive heart failure, the facilities still code and report charges for all patients admitted to observation status. Note, however, that there are no such restrictions for the physician professional services billed. Only hospital facilities are subject to the diagnosis restrictions because of APC payment rules.

2. How should a change in status from observation to full admission affect coding (i.e., when this occurs, what should the appropriate coding be for the initial hospital day or for the second hospital day)?

The best way to answer this question is with some scenarios.

Scenario #1:

The patient is admitted to observation status after being evaluated in the ED. The attending physician writes an order “admit to observation status;” writes an admit note, which includes the intent of observation; and writes orders to help determine if the patient is to be admitted or sent home. After test results return, the physician decides to admit the patient on the same calendar date:

Code: Initial Hospital Care code (99221-99223) that incorporates all services (observation and admission note) provided and documented that day.

Scenario #2:

The patient is admitted in the evening (Day 1) to observation status, tests are performed, and results are pending. The following morning (Day 2), based on the results of tests, the physician evaluates the patient and decides to admit (writes admit order). On Day 3 the patient is evaluated and discharged home.

Code:

Day 1: Initial Observation Care (99218-99220)

Day 2: Initial Hospital Care (99221-99223)

Day 3: Discharge Management (99238 or 99239)

3. Is it acceptable to bill for a d/c day if the patient is not examined that day, but activities such as d/c planning and dictation occur?

Discharge management codes do require the face-to-face evaluation/examination of the patient. Also included is the time spent on instructions to the patient/family, coordination of care with other providers, preparation of discharge records, prescriptions, referrals and/or certification forms, etc. The dictation of discharge summary is not typically included in this definition, because it is usually considered a hospital requirement as opposed to something needed for the patient’s care.

4. How frequently should discharge code 99239 be used? What elements of the d/c process can/should actually be used toward the “greater than 30 minutes” definition? (e.g., do filling out the d/c paperwork, dictating d/c summary, phone time arranging f/u, etc., count?)

There is not a specific “frequency” for any code, although most payers will compare utilization of codes to “peers” of the same specialty. While this helps them identify outliers, it does not necessarily mean someone is coding incorrectly. It does mean that high utilization by a physician will probably result in some sort of “audit” or request for supporting documentation. For instance, if a physician has a high volume of patients who go to nursing homes requiring a lot of coordination of care, referral forms, etc., it may be expected that the physician may have a higher frequency of 99239 discharge management codes. For patients who are going home with great family support and are relatively healthy, it may not seem as “reasonable and necessary” to have greater than 30 minutes of discharge management, especially if every chart is documented with the same “35 minutes.” Therefore, try to keep track of the time devoted to these services as accurately as you can, and document the actual time and sufficient information to support the use of 99239.

Dr. Pfeiffer can be contacted at [email protected].

1. When should the observation code be used? Do the provider and facility need to use the same codes in order to be reimbursed for observation? What are the restrictions, if any, on what diagnoses may be used to bill for observation?

Observation status is an “outpatient status” even if the patient is located in an inpatient bed. The purpose of observation is to allow the physician time to make a decision about whether the patient should be admitted, and then rapidly move the patient to the most appropriate setting—i.e., the patient should either be admitted as an inpatient or sent home.

Therefore, only the physician who writes the order that places the patient in “observation status” and is responsible for the patient during his or her stay should use the observation codes. Always date and time the “admitting order,” because this information is needed to meet the minimum 8-hours rule if the patient is admitted and discharged on the same calendar date.

If a patient is both admitted and discharged on the same calendar date, the code range of 99234-99236 are used; however, the following criteria must be met:

1. The patient must be in observation for a minimum of 8 hours.
2. The billing physician must be present and show active involvement by charting condition updates, orders, etc.
3. Both the admission and discharge notes are written by the billing physician (or may be billed by 2 physicians within the same group practice).

The specific CPT observation codes (99218-99220 and 99234-99236) do not have to match those used by the facility, because the physician codes are based on the physician E&M criteria (i.e., extent of history, exam, and decision making). The facility’s use of these codes is based on facility-specific criteria that measure the resources used by the facility’s employees and does not relate to the physician’s evaluation.

There are diagnosis/condition restrictions for separate payment to facilities for observation under the Outpatient Prospective Payment System (OPPS) reimbursement program (i.e., payment is based on Ambulatory Patient Classification [APC]). Even though separate payments for observation charges are made only for chest pain, asthma, and congestive heart failure, the facilities still code and report charges for all patients admitted to observation status. Note, however, that there are no such restrictions for the physician professional services billed. Only hospital facilities are subject to the diagnosis restrictions because of APC payment rules.

2. How should a change in status from observation to full admission affect coding (i.e., when this occurs, what should the appropriate coding be for the initial hospital day or for the second hospital day)?

The best way to answer this question is with some scenarios.

Scenario #1:

The patient is admitted to observation status after being evaluated in the ED. The attending physician writes an order “admit to observation status;” writes an admit note, which includes the intent of observation; and writes orders to help determine if the patient is to be admitted or sent home. After test results return, the physician decides to admit the patient on the same calendar date:

Code: Initial Hospital Care code (99221-99223) that incorporates all services (observation and admission note) provided and documented that day.

Scenario #2:

The patient is admitted in the evening (Day 1) to observation status, tests are performed, and results are pending. The following morning (Day 2), based on the results of tests, the physician evaluates the patient and decides to admit (writes admit order). On Day 3 the patient is evaluated and discharged home.

Code:

Day 1: Initial Observation Care (99218-99220)

Day 2: Initial Hospital Care (99221-99223)

Day 3: Discharge Management (99238 or 99239)

3. Is it acceptable to bill for a d/c day if the patient is not examined that day, but activities such as d/c planning and dictation occur?

Discharge management codes do require the face-to-face evaluation/examination of the patient. Also included is the time spent on instructions to the patient/family, coordination of care with other providers, preparation of discharge records, prescriptions, referrals and/or certification forms, etc. The dictation of discharge summary is not typically included in this definition, because it is usually considered a hospital requirement as opposed to something needed for the patient’s care.

4. How frequently should discharge code 99239 be used? What elements of the d/c process can/should actually be used toward the “greater than 30 minutes” definition? (e.g., do filling out the d/c paperwork, dictating d/c summary, phone time arranging f/u, etc., count?)

There is not a specific “frequency” for any code, although most payers will compare utilization of codes to “peers” of the same specialty. While this helps them identify outliers, it does not necessarily mean someone is coding incorrectly. It does mean that high utilization by a physician will probably result in some sort of “audit” or request for supporting documentation. For instance, if a physician has a high volume of patients who go to nursing homes requiring a lot of coordination of care, referral forms, etc., it may be expected that the physician may have a higher frequency of 99239 discharge management codes. For patients who are going home with great family support and are relatively healthy, it may not seem as “reasonable and necessary” to have greater than 30 minutes of discharge management, especially if every chart is documented with the same “35 minutes.” Therefore, try to keep track of the time devoted to these services as accurately as you can, and document the actual time and sufficient information to support the use of 99239.

Dr. Pfeiffer can be contacted at [email protected].

Teresa Marie Schiavo died on March 31, 2005, 15 years after sustaining a cardiac arrest and entering a persistent vegetative state (PVS). Her saga ignited national debates over the rights of the incapacitated, the outcomes of patients in persistent vegetative states, the basic requirements for human life, the distinction between nutrition and other medical treatments, and the involvement of the courts and politicians in our most private affairs. Sadly, Terri’s plight is not unique, and such a tragic predicament poses special challenges for hospitalists. The goals of this article are to review the definition and prognosis of PVS, and to outline the ethical argument for deciding to withdraw or withhold treatment from patients in PVS.

Clinical Features of the Persistent Vegetative State

Comatose patients may experience one of three general outcomes: recovery (partial or complete), death, or a prolonged or irreversible period of unconsciousness. As life support measures improved throughout the 1960s, this latter group represented an increasingly large yet ill-defined subgroup. In an attempt to characterize this population of severely brain-damaged patients who progress from coma to a state of wakefulness without awareness, Jennett and Plum coined the term “vegetative state” in 1972 (1). An estimated 10,000 to 25,000 adults in the United States exist in this manner for at least 1 month and are said to be in a persistent vegetative state.

In 1991, the Multi-Society Task Force on PVS was established and identified several key components of the condition (Table 1) (2). Hospitalists encounter patients who transition into PVS after an acute injury due to head trauma, or following nontraumatic diffuse bilateral cortical insult from prolonged hypoxic-ischemic periods. Less commonly, PVS is diagnosed in the hospital as an end-stage manifestation of a neurodegenerative illness. The cornerstone of PVS is diffuse cortical damage with relative preservation of brainstem and hypothalamic functions. Lacking cortical function, patients in PVS remain unaware of themselves or their environment, and are not thought to suffer. Many autonomic functions remain intact, however. PVS patients exhibit sleep-wake patterns, thermoregulate, maintain stable hemodynamics, respond with reflexive movements, and often live independent of a ventilator.

Several conditions have been confused with PVS (2). Coma is often applied inappropriately to patients in PVS. A lack of self-awareness characterizes both conditions; however, comatose patients (eyes closed, unresponsive) do not have recognizable sleep-wake cycles, whereas PVS patients exhibit wakefulness with open eyes. Key points of distinction between PVS, coma, brain death, and the locked-in syndrome are listed in Table 2.

Physical movements have traditionally been a source of confusion in PVS, and Terri Schiavo’s case was no exception. Politicians with medical backgrounds pointed to publicized video footage as evidence of her potential for recovery, or as an indication that a diagnosis of PVS had been made erroneously. In fact, PVS patients frequently exhibit truncal and limb movement, and they may smile, grimace, grunt, moan, or even cry on occasion. Some demonstrate a startle myoclonus and have preserved gag and cough reflexes. However, PVS patients do not exhibit sustained visual pursuit, visual fixation, or reproducible responses to threatening gestures. Because their ability to coordinate swallowing is impaired, most rely on alternative means to oral feeding and hydration for sustenance.

Prognosis in PVS

After 1 month has elapsed and a diagnosis of PVS is firmly established, attention focuses on prognosis. The Multi-Society Task Force reviewed the outcomes of 603 adults in PVS from traumatic and nontraumatic causes. Although PVS following trauma has a better prognosis than PVS following nontraumatic injury, the outcomes of both are poor (Table 3). Irreversibility is implied the longer a person remains in a vegetative state (3).

When does PVS become permanent?

In their comprehensive review, the Task Force defined durations of PVS after which meaningful recovery is near impossible: 12 months following trauma and 3 months after nontraumatic injury (Figure) (3).

Twenty-four percent of patients who entered PVS following trauma improved to a point of moderate disability. However, once the duration of PVS exceeded 12 months, only 7 of 434 patients recovered. In all 7 cases, recovery was noted between 23 and 36 months after traumatic injury, but the patients’ functional status remained quite poor: 5 remained severely disabled, 1 was moderately disabled, and the status of the 7th could not be determined.

PVS following acute nontraumatic injury portends an even worse prognosis. Among 169 PVS patients in this category, 15% regained consciousness, and only 1 patient experienced a good recovery. After 3 months, the probability of recovery was less than 1%.

Based on the dismal outcomes after several months, how do we account for the occasional media reports of recovery after many years in vegetative states? The Task Force reviewed all such accounts and identified 5 patients with verified recovery after prolonged PVS, ranging in age from 18 to 61; all but 1 remained severely disabled. Following nontraumatic anoxic injury, the longest duration of PVS prior to regaining consciousness was 22 months (3). Given the prevalence of PVS, late recovery after PVS appears to be exceptionally rare. Following her anoxic injury, Terri Schiavo remained in PVS for 15 years—well beyond the 3-month cut-off for potential reversibility.

click for large version

The Ethical Basis for Withdrawing Support in Patients with PVS

Life-sustaining treatment (LST) is most commonly withdrawn or withheld when this is known to be the patient’s preference either because of advance directives or through a surrogate representing the best interests of the patient. Conflicts arise when physicians recommend withdrawal of LST over the objections of surrogates. Faced with this dilemma, physicians caring for patients in PVS may cede to the wishes of the family. Alternatively, they may pursue withdrawal of LST based on 1 of the following 3 arguments:

1. The perceived futility of ongoing LST;
2. The presumption that patients in PVS have very poor quality of life and would opt for withdrawal if they could communicate their wishes; and
3. The belief that patients in PVS no longer possess the minimal requirements for human existence and therefore have no interests to advance.

Is life-sustaining treatment futile for patients in PVS?

In its narrowest sense, futility implies the inability to achieve a particular physiologic goal because the treatment has no pathophysiologic basis, because the treatment has already been tried and failed in a patient, or because maximal therapy is failing (4). Invoking futility as a reason to withhold or withdraw care unilaterally in PVS is problematic. Because patients in PVS can remain alive for months to years with supportive measures, interventions (such as antibiotics or nutrition) are not futile, because the goal of prolonging life can be achieved, though at a markedly diminished level of quality.

click for large version

Does PVS imply a presumption to withdraw LST?

Because futility cannot be invoked, some experts argue that PVS represents such a dismal quality of life that LST cannot be consistent with a patient’s best interests. While society generally errs on the side of prolonging the lives of incapacitated patients whose preferences are unknown, some ethicists argue that it should be presumed patients in PVS would not desire LST unless they have expressly stated preferences to the contrary. Public opinion polls support this notion, because the majority of people surveyed would not want LST if they were in PVS (5). This flexible position respects the divergent beliefs of the minority, permitting previously competent patients to continue LST when they choose.

Physicians who invoke this line of reasoning to override a surrogate’s decision explore relatively uncharted legal terrain. In the 1991 case of Helga Wanglie, an 87-year-old woman in a vegetative state, her husband wished to continue LST. Objecting to ongoing LST, her treating physicians attempted to remove the husband as legal guardian, but were rebuked (6). Without addressing the presumed desires of adults in PVS, the courts uphold the legal standing of surrogate decision-makers as long as they are acting in the patient’s best interests. On the other hand, a Massachusetts jury found that physicians were not guilty of malpractice when they entered a do-not-resuscitate order for a 71-year-old comatose woman without surrogate permission (5).

Do patients in PVS meet the minimal criteria for human existence?

A third ethical argument for withdrawing and withholding treatment in vegetative patients is unique to PVS. This line of reasoning challenges our assumptions about “patient interests” and resurrects the philosophical debate over the essence of human life. By virtue of being in PVS without hope for recovery, these patients have lost the minimal requirements of being human and have no hope of regaining them. In this view, prolonging mere biologic life is pointless because essential human qualities cannot be restored. This applies to patients in PVS for such duration that the probability of regaining consciousness is exceptionally rare (i.e., 12 months after trauma, or 3 months after nontraumatic injury). In such cases because no patient interests can be served and no medical goals are obtainable, no duty exists to provide life-sustaining treatment (7).

Physicians who choose to invoke this last argument should be aware of its uncertain legal and moral acceptance. Legally, the ethical argument that patients in PVS have no interests to advance has not been challenged directly in the courts. Groups rejecting the notion that patients in PVS lack minimal requirements for human life were galvanized by Terri Schiavo’s plight. Although public opinion polls determined that a clear majority would want their guardian to remove the feeding tube if they were in Terri’s predicament, a vocal minority was opposed (5). Politicians such as Congressman Tom DeLay entered the fray, declaring the removal of Terri’s feeding tube an “act of medical terrorism.” This right-to-life movement found an ally in the Roman Catholic Church when Pope John Paul II avowed that patients in PVS do, in fact, meet minimal criteria for human life and as such deserve nutrition and hydration (8). His opinion has yet to be adopted as doctrine, and political and moral consensus have not been achieved.

click for large version

Conclusions

PVS is diagnosed 1 month after a patient enters a state of wakefulness without awareness. Movements are common in these patients, but they are not purposeful or reproducible in response to stimuli. Once PVS has exceeded durations of 3 months following nontraumatic injury or 12 months following trauma, the probability of meaningful recovery is exceptionally rare.

Armed with the above knowledge, what practical recourse exists to hospitalists caring for patients in PVS whose hope for regaining consciousness is exceedingly remote? First, inquire about advance directives that may direct care in such circumstances. If advance directives are not present, identify the surrogate decision maker, keeping in mind the state-to-state legal variations in the surrogate hierarchy. If the appropriate surrogate wishes to continue care and the treating physician objects, attempt to achieve a consensus. Time to adjust to the devastating plight and repeated nonjudgmental discussions focusing on the patient’s wishes often lead surrogates to accept withdrawal, or at least to establish limits on care (e.g., do-not-resuscitate order, withholding antibiotics and nutrition). Involvement of hospital ethics committees, primary care physicians, social workers, and religious or cultural ombudsmen may facilitate this process. Barring a mutually acceptable solution or progress in this direction, physicians may decide to cede to the wishes of the surrogates or, as a last recourse, involve the judicial system to achieve resolution.

References

1. Jennett B. Plum F. Persistent vegetative state after brain damage: a syndrome in search of a name. Lancet. 1972; 1:734-7.
2. The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state—first of two parts. NEJM. 1994; 330:1499-1508.
3. The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state—second of two parts. NEJM. 1994; 330: 1572-9.
4. Lo B. Resolving Ethical Dilemmas. A Guide for Clinicians. 2nd ed. Philadelphia, Pa: Lippincott Williams and Wilkins; p. 73.
5. Eisenberg D. Lessons of the Schiavo battle. Time. April 4, 2005. pp. 26-27.
6. Cantor NL. Can health care providers obtain judicial intervention against surrogates who demand “medically inappropriate” life support for incompetent patients? Crit Care Med. 1996; 24:883-87.
7. Jonsen AR, Siegler M, and Winslade WJ. Clinical Ethics. A practical approach to ethical decisions in clinical practice. 5th ed. McGraw-Hill; p. 129.
8. Address of Pope John Paul II to the participants in the international congress on “life-sustaining treatments and vegetative state: scientific advances and ethical dilemmas.” 20 March, 2004 available at: www.vatican.va/holy_father/john_paul_ii/speeches/2004/march/documents/hf_jp-ii_spe_20040320_congress-fiamc_en.html, Last accessed on May 11, 2005.
9. Doble JE, Haig AJ, Anderson C, Katz R. Impairment, activity, participation, life satisfaction and survival in persons with locked-in syndrome for over a decade. J Head Trauma Rehabil. 2003;18:435-44.
10. Booth CM, Boone RH, Tomlinson J, and Detsky AS. Is this patient dead, vegetative or severely impaired? Assessing outcome for comatose survivors of cardiac arrest. JAMA. 2004; 291:870-9.
11. Levy DE, Caronna JJ, et al. Predicting coma from hypoxic-schemic coma. JAMA. 1985; 253:1420-6.
12. Zandbergen EG, de Haan RJ, et al. Systematic review of early prediction of poor outcome in anoxic-ischaemic coma. Lancet. 1998; 352:1808-12.

Teresa Marie Schiavo died on March 31, 2005, 15 years after sustaining a cardiac arrest and entering a persistent vegetative state (PVS). Her saga ignited national debates over the rights of the incapacitated, the outcomes of patients in persistent vegetative states, the basic requirements for human life, the distinction between nutrition and other medical treatments, and the involvement of the courts and politicians in our most private affairs. Sadly, Terri’s plight is not unique, and such a tragic predicament poses special challenges for hospitalists. The goals of this article are to review the definition and prognosis of PVS, and to outline the ethical argument for deciding to withdraw or withhold treatment from patients in PVS.

Clinical Features of the Persistent Vegetative State

Comatose patients may experience one of three general outcomes: recovery (partial or complete), death, or a prolonged or irreversible period of unconsciousness. As life support measures improved throughout the 1960s, this latter group represented an increasingly large yet ill-defined subgroup. In an attempt to characterize this population of severely brain-damaged patients who progress from coma to a state of wakefulness without awareness, Jennett and Plum coined the term “vegetative state” in 1972 (1). An estimated 10,000 to 25,000 adults in the United States exist in this manner for at least 1 month and are said to be in a persistent vegetative state.

In 1991, the Multi-Society Task Force on PVS was established and identified several key components of the condition (Table 1) (2). Hospitalists encounter patients who transition into PVS after an acute injury due to head trauma, or following nontraumatic diffuse bilateral cortical insult from prolonged hypoxic-ischemic periods. Less commonly, PVS is diagnosed in the hospital as an end-stage manifestation of a neurodegenerative illness. The cornerstone of PVS is diffuse cortical damage with relative preservation of brainstem and hypothalamic functions. Lacking cortical function, patients in PVS remain unaware of themselves or their environment, and are not thought to suffer. Many autonomic functions remain intact, however. PVS patients exhibit sleep-wake patterns, thermoregulate, maintain stable hemodynamics, respond with reflexive movements, and often live independent of a ventilator.

Several conditions have been confused with PVS (2). Coma is often applied inappropriately to patients in PVS. A lack of self-awareness characterizes both conditions; however, comatose patients (eyes closed, unresponsive) do not have recognizable sleep-wake cycles, whereas PVS patients exhibit wakefulness with open eyes. Key points of distinction between PVS, coma, brain death, and the locked-in syndrome are listed in Table 2.

Physical movements have traditionally been a source of confusion in PVS, and Terri Schiavo’s case was no exception. Politicians with medical backgrounds pointed to publicized video footage as evidence of her potential for recovery, or as an indication that a diagnosis of PVS had been made erroneously. In fact, PVS patients frequently exhibit truncal and limb movement, and they may smile, grimace, grunt, moan, or even cry on occasion. Some demonstrate a startle myoclonus and have preserved gag and cough reflexes. However, PVS patients do not exhibit sustained visual pursuit, visual fixation, or reproducible responses to threatening gestures. Because their ability to coordinate swallowing is impaired, most rely on alternative means to oral feeding and hydration for sustenance.

Prognosis in PVS

After 1 month has elapsed and a diagnosis of PVS is firmly established, attention focuses on prognosis. The Multi-Society Task Force reviewed the outcomes of 603 adults in PVS from traumatic and nontraumatic causes. Although PVS following trauma has a better prognosis than PVS following nontraumatic injury, the outcomes of both are poor (Table 3). Irreversibility is implied the longer a person remains in a vegetative state (3).

When does PVS become permanent?

In their comprehensive review, the Task Force defined durations of PVS after which meaningful recovery is near impossible: 12 months following trauma and 3 months after nontraumatic injury (Figure) (3).

Twenty-four percent of patients who entered PVS following trauma improved to a point of moderate disability. However, once the duration of PVS exceeded 12 months, only 7 of 434 patients recovered. In all 7 cases, recovery was noted between 23 and 36 months after traumatic injury, but the patients’ functional status remained quite poor: 5 remained severely disabled, 1 was moderately disabled, and the status of the 7th could not be determined.

PVS following acute nontraumatic injury portends an even worse prognosis. Among 169 PVS patients in this category, 15% regained consciousness, and only 1 patient experienced a good recovery. After 3 months, the probability of recovery was less than 1%.

Based on the dismal outcomes after several months, how do we account for the occasional media reports of recovery after many years in vegetative states? The Task Force reviewed all such accounts and identified 5 patients with verified recovery after prolonged PVS, ranging in age from 18 to 61; all but 1 remained severely disabled. Following nontraumatic anoxic injury, the longest duration of PVS prior to regaining consciousness was 22 months (3). Given the prevalence of PVS, late recovery after PVS appears to be exceptionally rare. Following her anoxic injury, Terri Schiavo remained in PVS for 15 years—well beyond the 3-month cut-off for potential reversibility.

click for large version

The Ethical Basis for Withdrawing Support in Patients with PVS

Life-sustaining treatment (LST) is most commonly withdrawn or withheld when this is known to be the patient’s preference either because of advance directives or through a surrogate representing the best interests of the patient. Conflicts arise when physicians recommend withdrawal of LST over the objections of surrogates. Faced with this dilemma, physicians caring for patients in PVS may cede to the wishes of the family. Alternatively, they may pursue withdrawal of LST based on 1 of the following 3 arguments:

1. The perceived futility of ongoing LST;
2. The presumption that patients in PVS have very poor quality of life and would opt for withdrawal if they could communicate their wishes; and
3. The belief that patients in PVS no longer possess the minimal requirements for human existence and therefore have no interests to advance.

Is life-sustaining treatment futile for patients in PVS?

In its narrowest sense, futility implies the inability to achieve a particular physiologic goal because the treatment has no pathophysiologic basis, because the treatment has already been tried and failed in a patient, or because maximal therapy is failing (4). Invoking futility as a reason to withhold or withdraw care unilaterally in PVS is problematic. Because patients in PVS can remain alive for months to years with supportive measures, interventions (such as antibiotics or nutrition) are not futile, because the goal of prolonging life can be achieved, though at a markedly diminished level of quality.

click for large version

Does PVS imply a presumption to withdraw LST?

Because futility cannot be invoked, some experts argue that PVS represents such a dismal quality of life that LST cannot be consistent with a patient’s best interests. While society generally errs on the side of prolonging the lives of incapacitated patients whose preferences are unknown, some ethicists argue that it should be presumed patients in PVS would not desire LST unless they have expressly stated preferences to the contrary. Public opinion polls support this notion, because the majority of people surveyed would not want LST if they were in PVS (5). This flexible position respects the divergent beliefs of the minority, permitting previously competent patients to continue LST when they choose.

Physicians who invoke this line of reasoning to override a surrogate’s decision explore relatively uncharted legal terrain. In the 1991 case of Helga Wanglie, an 87-year-old woman in a vegetative state, her husband wished to continue LST. Objecting to ongoing LST, her treating physicians attempted to remove the husband as legal guardian, but were rebuked (6). Without addressing the presumed desires of adults in PVS, the courts uphold the legal standing of surrogate decision-makers as long as they are acting in the patient’s best interests. On the other hand, a Massachusetts jury found that physicians were not guilty of malpractice when they entered a do-not-resuscitate order for a 71-year-old comatose woman without surrogate permission (5).

Do patients in PVS meet the minimal criteria for human existence?

A third ethical argument for withdrawing and withholding treatment in vegetative patients is unique to PVS. This line of reasoning challenges our assumptions about “patient interests” and resurrects the philosophical debate over the essence of human life. By virtue of being in PVS without hope for recovery, these patients have lost the minimal requirements of being human and have no hope of regaining them. In this view, prolonging mere biologic life is pointless because essential human qualities cannot be restored. This applies to patients in PVS for such duration that the probability of regaining consciousness is exceptionally rare (i.e., 12 months after trauma, or 3 months after nontraumatic injury). In such cases because no patient interests can be served and no medical goals are obtainable, no duty exists to provide life-sustaining treatment (7).

Physicians who choose to invoke this last argument should be aware of its uncertain legal and moral acceptance. Legally, the ethical argument that patients in PVS have no interests to advance has not been challenged directly in the courts. Groups rejecting the notion that patients in PVS lack minimal requirements for human life were galvanized by Terri Schiavo’s plight. Although public opinion polls determined that a clear majority would want their guardian to remove the feeding tube if they were in Terri’s predicament, a vocal minority was opposed (5). Politicians such as Congressman Tom DeLay entered the fray, declaring the removal of Terri’s feeding tube an “act of medical terrorism.” This right-to-life movement found an ally in the Roman Catholic Church when Pope John Paul II avowed that patients in PVS do, in fact, meet minimal criteria for human life and as such deserve nutrition and hydration (8). His opinion has yet to be adopted as doctrine, and political and moral consensus have not been achieved.

click for large version

Conclusions

PVS is diagnosed 1 month after a patient enters a state of wakefulness without awareness. Movements are common in these patients, but they are not purposeful or reproducible in response to stimuli. Once PVS has exceeded durations of 3 months following nontraumatic injury or 12 months following trauma, the probability of meaningful recovery is exceptionally rare.

Armed with the above knowledge, what practical recourse exists to hospitalists caring for patients in PVS whose hope for regaining consciousness is exceedingly remote? First, inquire about advance directives that may direct care in such circumstances. If advance directives are not present, identify the surrogate decision maker, keeping in mind the state-to-state legal variations in the surrogate hierarchy. If the appropriate surrogate wishes to continue care and the treating physician objects, attempt to achieve a consensus. Time to adjust to the devastating plight and repeated nonjudgmental discussions focusing on the patient’s wishes often lead surrogates to accept withdrawal, or at least to establish limits on care (e.g., do-not-resuscitate order, withholding antibiotics and nutrition). Involvement of hospital ethics committees, primary care physicians, social workers, and religious or cultural ombudsmen may facilitate this process. Barring a mutually acceptable solution or progress in this direction, physicians may decide to cede to the wishes of the surrogates or, as a last recourse, involve the judicial system to achieve resolution.

References

1. Jennett B. Plum F. Persistent vegetative state after brain damage: a syndrome in search of a name. Lancet. 1972; 1:734-7.
2. The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state—first of two parts. NEJM. 1994; 330:1499-1508.
3. The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state—second of two parts. NEJM. 1994; 330: 1572-9.
4. Lo B. Resolving Ethical Dilemmas. A Guide for Clinicians. 2nd ed. Philadelphia, Pa: Lippincott Williams and Wilkins; p. 73.
5. Eisenberg D. Lessons of the Schiavo battle. Time. April 4, 2005. pp. 26-27.
6. Cantor NL. Can health care providers obtain judicial intervention against surrogates who demand “medically inappropriate” life support for incompetent patients? Crit Care Med. 1996; 24:883-87.
7. Jonsen AR, Siegler M, and Winslade WJ. Clinical Ethics. A practical approach to ethical decisions in clinical practice. 5th ed. McGraw-Hill; p. 129.
8. Address of Pope John Paul II to the participants in the international congress on “life-sustaining treatments and vegetative state: scientific advances and ethical dilemmas.” 20 March, 2004 available at: www.vatican.va/holy_father/john_paul_ii/speeches/2004/march/documents/hf_jp-ii_spe_20040320_congress-fiamc_en.html, Last accessed on May 11, 2005.
9. Doble JE, Haig AJ, Anderson C, Katz R. Impairment, activity, participation, life satisfaction and survival in persons with locked-in syndrome for over a decade. J Head Trauma Rehabil. 2003;18:435-44.
10. Booth CM, Boone RH, Tomlinson J, and Detsky AS. Is this patient dead, vegetative or severely impaired? Assessing outcome for comatose survivors of cardiac arrest. JAMA. 2004; 291:870-9.
11. Levy DE, Caronna JJ, et al. Predicting coma from hypoxic-schemic coma. JAMA. 1985; 253:1420-6.
12. Zandbergen EG, de Haan RJ, et al. Systematic review of early prediction of poor outcome in anoxic-ischaemic coma. Lancet. 1998; 352:1808-12.

Teresa Marie Schiavo died on March 31, 2005, 15 years after sustaining a cardiac arrest and entering a persistent vegetative state (PVS). Her saga ignited national debates over the rights of the incapacitated, the outcomes of patients in persistent vegetative states, the basic requirements for human life, the distinction between nutrition and other medical treatments, and the involvement of the courts and politicians in our most private affairs. Sadly, Terri’s plight is not unique, and such a tragic predicament poses special challenges for hospitalists. The goals of this article are to review the definition and prognosis of PVS, and to outline the ethical argument for deciding to withdraw or withhold treatment from patients in PVS.

Clinical Features of the Persistent Vegetative State

Comatose patients may experience one of three general outcomes: recovery (partial or complete), death, or a prolonged or irreversible period of unconsciousness. As life support measures improved throughout the 1960s, this latter group represented an increasingly large yet ill-defined subgroup. In an attempt to characterize this population of severely brain-damaged patients who progress from coma to a state of wakefulness without awareness, Jennett and Plum coined the term “vegetative state” in 1972 (1). An estimated 10,000 to 25,000 adults in the United States exist in this manner for at least 1 month and are said to be in a persistent vegetative state.

In 1991, the Multi-Society Task Force on PVS was established and identified several key components of the condition (Table 1) (2). Hospitalists encounter patients who transition into PVS after an acute injury due to head trauma, or following nontraumatic diffuse bilateral cortical insult from prolonged hypoxic-ischemic periods. Less commonly, PVS is diagnosed in the hospital as an end-stage manifestation of a neurodegenerative illness. The cornerstone of PVS is diffuse cortical damage with relative preservation of brainstem and hypothalamic functions. Lacking cortical function, patients in PVS remain unaware of themselves or their environment, and are not thought to suffer. Many autonomic functions remain intact, however. PVS patients exhibit sleep-wake patterns, thermoregulate, maintain stable hemodynamics, respond with reflexive movements, and often live independent of a ventilator.

Several conditions have been confused with PVS (2). Coma is often applied inappropriately to patients in PVS. A lack of self-awareness characterizes both conditions; however, comatose patients (eyes closed, unresponsive) do not have recognizable sleep-wake cycles, whereas PVS patients exhibit wakefulness with open eyes. Key points of distinction between PVS, coma, brain death, and the locked-in syndrome are listed in Table 2.

Physical movements have traditionally been a source of confusion in PVS, and Terri Schiavo’s case was no exception. Politicians with medical backgrounds pointed to publicized video footage as evidence of her potential for recovery, or as an indication that a diagnosis of PVS had been made erroneously. In fact, PVS patients frequently exhibit truncal and limb movement, and they may smile, grimace, grunt, moan, or even cry on occasion. Some demonstrate a startle myoclonus and have preserved gag and cough reflexes. However, PVS patients do not exhibit sustained visual pursuit, visual fixation, or reproducible responses to threatening gestures. Because their ability to coordinate swallowing is impaired, most rely on alternative means to oral feeding and hydration for sustenance.

Prognosis in PVS

After 1 month has elapsed and a diagnosis of PVS is firmly established, attention focuses on prognosis. The Multi-Society Task Force reviewed the outcomes of 603 adults in PVS from traumatic and nontraumatic causes. Although PVS following trauma has a better prognosis than PVS following nontraumatic injury, the outcomes of both are poor (Table 3). Irreversibility is implied the longer a person remains in a vegetative state (3).

When does PVS become permanent?

In their comprehensive review, the Task Force defined durations of PVS after which meaningful recovery is near impossible: 12 months following trauma and 3 months after nontraumatic injury (Figure) (3).

Twenty-four percent of patients who entered PVS following trauma improved to a point of moderate disability. However, once the duration of PVS exceeded 12 months, only 7 of 434 patients recovered. In all 7 cases, recovery was noted between 23 and 36 months after traumatic injury, but the patients’ functional status remained quite poor: 5 remained severely disabled, 1 was moderately disabled, and the status of the 7th could not be determined.

PVS following acute nontraumatic injury portends an even worse prognosis. Among 169 PVS patients in this category, 15% regained consciousness, and only 1 patient experienced a good recovery. After 3 months, the probability of recovery was less than 1%.

Based on the dismal outcomes after several months, how do we account for the occasional media reports of recovery after many years in vegetative states? The Task Force reviewed all such accounts and identified 5 patients with verified recovery after prolonged PVS, ranging in age from 18 to 61; all but 1 remained severely disabled. Following nontraumatic anoxic injury, the longest duration of PVS prior to regaining consciousness was 22 months (3). Given the prevalence of PVS, late recovery after PVS appears to be exceptionally rare. Following her anoxic injury, Terri Schiavo remained in PVS for 15 years—well beyond the 3-month cut-off for potential reversibility.

click for large version

The Ethical Basis for Withdrawing Support in Patients with PVS

Life-sustaining treatment (LST) is most commonly withdrawn or withheld when this is known to be the patient’s preference either because of advance directives or through a surrogate representing the best interests of the patient. Conflicts arise when physicians recommend withdrawal of LST over the objections of surrogates. Faced with this dilemma, physicians caring for patients in PVS may cede to the wishes of the family. Alternatively, they may pursue withdrawal of LST based on 1 of the following 3 arguments:

1. The perceived futility of ongoing LST;
2. The presumption that patients in PVS have very poor quality of life and would opt for withdrawal if they could communicate their wishes; and
3. The belief that patients in PVS no longer possess the minimal requirements for human existence and therefore have no interests to advance.

Is life-sustaining treatment futile for patients in PVS?

In its narrowest sense, futility implies the inability to achieve a particular physiologic goal because the treatment has no pathophysiologic basis, because the treatment has already been tried and failed in a patient, or because maximal therapy is failing (4). Invoking futility as a reason to withhold or withdraw care unilaterally in PVS is problematic. Because patients in PVS can remain alive for months to years with supportive measures, interventions (such as antibiotics or nutrition) are not futile, because the goal of prolonging life can be achieved, though at a markedly diminished level of quality.

click for large version

Does PVS imply a presumption to withdraw LST?

Because futility cannot be invoked, some experts argue that PVS represents such a dismal quality of life that LST cannot be consistent with a patient’s best interests. While society generally errs on the side of prolonging the lives of incapacitated patients whose preferences are unknown, some ethicists argue that it should be presumed patients in PVS would not desire LST unless they have expressly stated preferences to the contrary. Public opinion polls support this notion, because the majority of people surveyed would not want LST if they were in PVS (5). This flexible position respects the divergent beliefs of the minority, permitting previously competent patients to continue LST when they choose.

Physicians who invoke this line of reasoning to override a surrogate’s decision explore relatively uncharted legal terrain. In the 1991 case of Helga Wanglie, an 87-year-old woman in a vegetative state, her husband wished to continue LST. Objecting to ongoing LST, her treating physicians attempted to remove the husband as legal guardian, but were rebuked (6). Without addressing the presumed desires of adults in PVS, the courts uphold the legal standing of surrogate decision-makers as long as they are acting in the patient’s best interests. On the other hand, a Massachusetts jury found that physicians were not guilty of malpractice when they entered a do-not-resuscitate order for a 71-year-old comatose woman without surrogate permission (5).

Do patients in PVS meet the minimal criteria for human existence?

A third ethical argument for withdrawing and withholding treatment in vegetative patients is unique to PVS. This line of reasoning challenges our assumptions about “patient interests” and resurrects the philosophical debate over the essence of human life. By virtue of being in PVS without hope for recovery, these patients have lost the minimal requirements of being human and have no hope of regaining them. In this view, prolonging mere biologic life is pointless because essential human qualities cannot be restored. This applies to patients in PVS for such duration that the probability of regaining consciousness is exceptionally rare (i.e., 12 months after trauma, or 3 months after nontraumatic injury). In such cases because no patient interests can be served and no medical goals are obtainable, no duty exists to provide life-sustaining treatment (7).

Physicians who choose to invoke this last argument should be aware of its uncertain legal and moral acceptance. Legally, the ethical argument that patients in PVS have no interests to advance has not been challenged directly in the courts. Groups rejecting the notion that patients in PVS lack minimal requirements for human life were galvanized by Terri Schiavo’s plight. Although public opinion polls determined that a clear majority would want their guardian to remove the feeding tube if they were in Terri’s predicament, a vocal minority was opposed (5). Politicians such as Congressman Tom DeLay entered the fray, declaring the removal of Terri’s feeding tube an “act of medical terrorism.” This right-to-life movement found an ally in the Roman Catholic Church when Pope John Paul II avowed that patients in PVS do, in fact, meet minimal criteria for human life and as such deserve nutrition and hydration (8). His opinion has yet to be adopted as doctrine, and political and moral consensus have not been achieved.

click for large version

Conclusions

PVS is diagnosed 1 month after a patient enters a state of wakefulness without awareness. Movements are common in these patients, but they are not purposeful or reproducible in response to stimuli. Once PVS has exceeded durations of 3 months following nontraumatic injury or 12 months following trauma, the probability of meaningful recovery is exceptionally rare.

Armed with the above knowledge, what practical recourse exists to hospitalists caring for patients in PVS whose hope for regaining consciousness is exceedingly remote? First, inquire about advance directives that may direct care in such circumstances. If advance directives are not present, identify the surrogate decision maker, keeping in mind the state-to-state legal variations in the surrogate hierarchy. If the appropriate surrogate wishes to continue care and the treating physician objects, attempt to achieve a consensus. Time to adjust to the devastating plight and repeated nonjudgmental discussions focusing on the patient’s wishes often lead surrogates to accept withdrawal, or at least to establish limits on care (e.g., do-not-resuscitate order, withholding antibiotics and nutrition). Involvement of hospital ethics committees, primary care physicians, social workers, and religious or cultural ombudsmen may facilitate this process. Barring a mutually acceptable solution or progress in this direction, physicians may decide to cede to the wishes of the surrogates or, as a last recourse, involve the judicial system to achieve resolution.

References

1. Jennett B. Plum F. Persistent vegetative state after brain damage: a syndrome in search of a name. Lancet. 1972; 1:734-7.
2. The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state—first of two parts. NEJM. 1994; 330:1499-1508.
3. The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state—second of two parts. NEJM. 1994; 330: 1572-9.
4. Lo B. Resolving Ethical Dilemmas. A Guide for Clinicians. 2nd ed. Philadelphia, Pa: Lippincott Williams and Wilkins; p. 73.
5. Eisenberg D. Lessons of the Schiavo battle. Time. April 4, 2005. pp. 26-27.
6. Cantor NL. Can health care providers obtain judicial intervention against surrogates who demand “medically inappropriate” life support for incompetent patients? Crit Care Med. 1996; 24:883-87.
7. Jonsen AR, Siegler M, and Winslade WJ. Clinical Ethics. A practical approach to ethical decisions in clinical practice. 5th ed. McGraw-Hill; p. 129.
8. Address of Pope John Paul II to the participants in the international congress on “life-sustaining treatments and vegetative state: scientific advances and ethical dilemmas.” 20 March, 2004 available at: www.vatican.va/holy_father/john_paul_ii/speeches/2004/march/documents/hf_jp-ii_spe_20040320_congress-fiamc_en.html, Last accessed on May 11, 2005.
9. Doble JE, Haig AJ, Anderson C, Katz R. Impairment, activity, participation, life satisfaction and survival in persons with locked-in syndrome for over a decade. J Head Trauma Rehabil. 2003;18:435-44.
10. Booth CM, Boone RH, Tomlinson J, and Detsky AS. Is this patient dead, vegetative or severely impaired? Assessing outcome for comatose survivors of cardiac arrest. JAMA. 2004; 291:870-9.
11. Levy DE, Caronna JJ, et al. Predicting coma from hypoxic-schemic coma. JAMA. 1985; 253:1420-6.
12. Zandbergen EG, de Haan RJ, et al. Systematic review of early prediction of poor outcome in anoxic-ischaemic coma. Lancet. 1998; 352:1808-12.

In January 2004, the Mercy Inpatient Medicine Service embarked on a quality-based incentive program, or “pay-for-performance.” This was spurred on by Blue Cross of Massachusetts, which contracted with all hospitals in the state to receive a substantial financial bonus for agreed-upon quality indicators.

Prior to the start date, representatives from Mercy Medical Center negotiated with Blue Cross, arriving at the following quality indicators and targets for all hospital patients for the period of January to December 2004:

• For pneumonia patients, 45% rate of pneumococcal vaccine screening and administration;
• For heart failure patients, 85% rate of documentation of ejection fraction; and
• For heart failure patients with ejection fraction <40%, prescription of an ACE-inhibitor (or documentation of a contraindication) upon discharge.

The Mercy Inpatient Medicine Service, which consisted of 10 full-time hospitalists in 2004, cared for approximately 75% of all medical inpatients at the hospital. We created a quality-based incentive program for this hospital medicine group that mirrored the incentives mentioned above for the entire hospital. We postulated that superior performance by the hospitalists would “raise the bar” for the remainder of the patients, some of whom were cared for by a separate hospital medicine group and some by traditional PCPs.

Mechanics of the Pay for Performance Program

The quality-based bonus was structured so that it would be paid out at 6-month intervals in equal parts to all full-time hospitalists. The magnitude of the bonus was set in excess of 7.5% of the hospitalists’ base salary, an amount that we felt would be large enough to influence behavior change.

From the outset of the bonus period (2004), as medical director of the group, I convened a weekly meeting with hospitalists and representatives from the Quality Improvement department, nursing, and case management. The meeting was being held amid the backdrop of a renewed institutional emphasis on all the JCAHO Core Measures and other quality/patient safety initiatives. The purpose of the meeting was to review hospital performance on all JCAHO Core Measures.

click for large version(Mercy Inpatient Medicine Service) Introduced January 1, 2004

click for large version(Mercy Inpatient Medicine Service) Introduced January 1, 2004

click for large version(Mercy Inpatient Medicine Service) Introduced January 1, 2004

A nurse from the Quality Improvement department reviewed all charts of pneumonia and heart failure patients. For cases where pneumovax was not screened/administered, ejection fraction not assessed, and ACE-I not given, a hospitalist would review the chart and provide feedback to the physician-of-record regarding the nature of the problem. Further, I provided regular feedback to the hospital medicine group regarding their performance on the 3 indicators.

Results

The results in Figures 1–3 are for the hospitalist group, with results for the hospital as a whole slightly lower, but still in excess of the targets agreed upon with Blue Cross.

Summary

Mercy’s experience in 2004 is among the first hospitalist pay-for-performance programs reported. This quality-based incentive resulted in marked improvement in 3 quality indicators, resulting in the hospital’s attainment of the bonus paid by Blue Cross. The hospitalists were satisfied with the incentive program, because they felt appropriately rewarded for high-quality care. It is interesting to note that less-aggressive measures had been undertaken in the past to improve these indicators, but with little success. In 2004, with financial rewards at stake, more robust processes—such as a weekly meeting, ongoing chart review, and direct feedback to physicians—were put in place to ensure quality improvement.

Win Whitcomb, MD, cofounded the Society of Hospital Medicine with John Nelson, MD, in 1996. He is director of Performance Improvement at Mercy Medical Center, Springfield, MA, and can be reached at [email protected].

In January 2004, the Mercy Inpatient Medicine Service embarked on a quality-based incentive program, or “pay-for-performance.” This was spurred on by Blue Cross of Massachusetts, which contracted with all hospitals in the state to receive a substantial financial bonus for agreed-upon quality indicators.

Prior to the start date, representatives from Mercy Medical Center negotiated with Blue Cross, arriving at the following quality indicators and targets for all hospital patients for the period of January to December 2004:

• For pneumonia patients, 45% rate of pneumococcal vaccine screening and administration;
• For heart failure patients, 85% rate of documentation of ejection fraction; and
• For heart failure patients with ejection fraction <40%, prescription of an ACE-inhibitor (or documentation of a contraindication) upon discharge.

The Mercy Inpatient Medicine Service, which consisted of 10 full-time hospitalists in 2004, cared for approximately 75% of all medical inpatients at the hospital. We created a quality-based incentive program for this hospital medicine group that mirrored the incentives mentioned above for the entire hospital. We postulated that superior performance by the hospitalists would “raise the bar” for the remainder of the patients, some of whom were cared for by a separate hospital medicine group and some by traditional PCPs.

Mechanics of the Pay for Performance Program

The quality-based bonus was structured so that it would be paid out at 6-month intervals in equal parts to all full-time hospitalists. The magnitude of the bonus was set in excess of 7.5% of the hospitalists’ base salary, an amount that we felt would be large enough to influence behavior change.

From the outset of the bonus period (2004), as medical director of the group, I convened a weekly meeting with hospitalists and representatives from the Quality Improvement department, nursing, and case management. The meeting was being held amid the backdrop of a renewed institutional emphasis on all the JCAHO Core Measures and other quality/patient safety initiatives. The purpose of the meeting was to review hospital performance on all JCAHO Core Measures.

click for large version(Mercy Inpatient Medicine Service) Introduced January 1, 2004

click for large version(Mercy Inpatient Medicine Service) Introduced January 1, 2004

click for large version(Mercy Inpatient Medicine Service) Introduced January 1, 2004

A nurse from the Quality Improvement department reviewed all charts of pneumonia and heart failure patients. For cases where pneumovax was not screened/administered, ejection fraction not assessed, and ACE-I not given, a hospitalist would review the chart and provide feedback to the physician-of-record regarding the nature of the problem. Further, I provided regular feedback to the hospital medicine group regarding their performance on the 3 indicators.

Results

The results in Figures 1–3 are for the hospitalist group, with results for the hospital as a whole slightly lower, but still in excess of the targets agreed upon with Blue Cross.

Summary

Mercy’s experience in 2004 is among the first hospitalist pay-for-performance programs reported. This quality-based incentive resulted in marked improvement in 3 quality indicators, resulting in the hospital’s attainment of the bonus paid by Blue Cross. The hospitalists were satisfied with the incentive program, because they felt appropriately rewarded for high-quality care. It is interesting to note that less-aggressive measures had been undertaken in the past to improve these indicators, but with little success. In 2004, with financial rewards at stake, more robust processes—such as a weekly meeting, ongoing chart review, and direct feedback to physicians—were put in place to ensure quality improvement.

Win Whitcomb, MD, cofounded the Society of Hospital Medicine with John Nelson, MD, in 1996. He is director of Performance Improvement at Mercy Medical Center, Springfield, MA, and can be reached at [email protected].

In January 2004, the Mercy Inpatient Medicine Service embarked on a quality-based incentive program, or “pay-for-performance.” This was spurred on by Blue Cross of Massachusetts, which contracted with all hospitals in the state to receive a substantial financial bonus for agreed-upon quality indicators.

Prior to the start date, representatives from Mercy Medical Center negotiated with Blue Cross, arriving at the following quality indicators and targets for all hospital patients for the period of January to December 2004:

• For pneumonia patients, 45% rate of pneumococcal vaccine screening and administration;
• For heart failure patients, 85% rate of documentation of ejection fraction; and
• For heart failure patients with ejection fraction <40%, prescription of an ACE-inhibitor (or documentation of a contraindication) upon discharge.

The Mercy Inpatient Medicine Service, which consisted of 10 full-time hospitalists in 2004, cared for approximately 75% of all medical inpatients at the hospital. We created a quality-based incentive program for this hospital medicine group that mirrored the incentives mentioned above for the entire hospital. We postulated that superior performance by the hospitalists would “raise the bar” for the remainder of the patients, some of whom were cared for by a separate hospital medicine group and some by traditional PCPs.

Mechanics of the Pay for Performance Program

The quality-based bonus was structured so that it would be paid out at 6-month intervals in equal parts to all full-time hospitalists. The magnitude of the bonus was set in excess of 7.5% of the hospitalists’ base salary, an amount that we felt would be large enough to influence behavior change.

From the outset of the bonus period (2004), as medical director of the group, I convened a weekly meeting with hospitalists and representatives from the Quality Improvement department, nursing, and case management. The meeting was being held amid the backdrop of a renewed institutional emphasis on all the JCAHO Core Measures and other quality/patient safety initiatives. The purpose of the meeting was to review hospital performance on all JCAHO Core Measures.

click for large version(Mercy Inpatient Medicine Service) Introduced January 1, 2004

click for large version(Mercy Inpatient Medicine Service) Introduced January 1, 2004

click for large version(Mercy Inpatient Medicine Service) Introduced January 1, 2004

A nurse from the Quality Improvement department reviewed all charts of pneumonia and heart failure patients. For cases where pneumovax was not screened/administered, ejection fraction not assessed, and ACE-I not given, a hospitalist would review the chart and provide feedback to the physician-of-record regarding the nature of the problem. Further, I provided regular feedback to the hospital medicine group regarding their performance on the 3 indicators.

Results

The results in Figures 1–3 are for the hospitalist group, with results for the hospital as a whole slightly lower, but still in excess of the targets agreed upon with Blue Cross.

Summary

Mercy’s experience in 2004 is among the first hospitalist pay-for-performance programs reported. This quality-based incentive resulted in marked improvement in 3 quality indicators, resulting in the hospital’s attainment of the bonus paid by Blue Cross. The hospitalists were satisfied with the incentive program, because they felt appropriately rewarded for high-quality care. It is interesting to note that less-aggressive measures had been undertaken in the past to improve these indicators, but with little success. In 2004, with financial rewards at stake, more robust processes—such as a weekly meeting, ongoing chart review, and direct feedback to physicians—were put in place to ensure quality improvement.

Win Whitcomb, MD, cofounded the Society of Hospital Medicine with John Nelson, MD, in 1996. He is director of Performance Improvement at Mercy Medical Center, Springfield, MA, and can be reached at [email protected].