Scott Flanders, MD

Sanjay Saint, MD, MPH

SHM’s scott Flanders, MD, of the University of Michigan Health System, and Sanjay Saint, MD, MPH, a hospitalist at the Ann Arbor VA Medical Center and University of Michigan Health System, are spearheading the nation’s first multi-hospital patient safety project to protect hospital patients from errors and oversights. The project, called Hospitalists as Emerging Leaders in Patient Safety, or HELPS, will coordinate the efforts of nine southeast Michigan health systems, allowing hospitalists from around the region to share tips, tools and techniques. It also will help doctors put proven safety ideas into motion at their hospitals and measure how well this pooled effort can prevent such problems as medication errors, hospital-acquired infections and dangerous falls.

The patient safety project was launched in April via an $117,000 grant to the University of Michigan Health System from the Blue Cross Blue Shield of Michigan Foundation. This is the latest of several recent patient safety-related grants awarded to the University of Michigan by the Blue Cross Blue Shield of Michigan Foundation.

“Although patient safety relies on every member of the hospital staff to take appropriate actions and to speak up when something goes wrong, the buck stops with the physician who leads the inpatient team – and increasingly that physician is a hospitalist,” said Dr. Flanders, chief of the hospitalist service at UMHS, associate professor of medicine and member of the SHM board of directors. “Health systems are hiring hospitalists to maximize inpatient care efficiency, coordination and patient satisfaction, while lowering the costs of care,” added Dr. Flanders. “An integral part of these goals should be to improve patient safety by reducing medical errors.”

Dr. Saint, an associate professor who heads the Patient Safety Enhancement Program at the Ann Arbor VA Medical Center and UMHS, credits much of the impetus for HELPS to the Agency for Healthcare Research and Quality and the VA’s Health Services Research and Development Program, both of which have supported previous patient safety work that forms much of the basis of this new project. Dr. Saint and hospitalists at the University of Michigan have already shown that they can reduce urinary tract and bloodstream infections among hospitalized patients by using reminders and automatic orders to prompt doctors, and by standardizing the use of new site disinfectants and novel antibacterial catheters. This effort alone is saving UMHS hospital patients considerable pain and risk, while lowering UMHS costs, despite the fact that the new technology costs more initially. Drs. Flanders and Saint will attempt to repeat this success in hospitals across the southeast region in nine different areas of medicine, including:

• Techniques for performing quality-improvement research, so that doctors can accurately assess the effects of their efforts;
• Preventing device-related infections;
• Eliminating medication errors and creating a culture of safety;
• Improving the use of preventive medications for surgical patients;
• Closing gaps in care between different services in the hospital and gaps that exist as patients are discharged from the hospital;
• Improving intensive-care practices, including pneumonia prevention;
• End-of-life care, including pain and advance directives;
• Safety for older patients, including prevention of falls and delirium; and
• Learning lessons from patient safety efforts.

The nine participating Michigan health systems include:

• University of Michigan Health System
• VA Ann Arbor Healthcare System
• St. Joseph Mercy Healthcare System
• Oakwood Healthcare System
• Beaumont Hospital
• Detroit Medical Center
• Henry Ford Health System
• Chelsea Community Hospital and
• Michigan Hospitalists, who practice throughout the St. John Health System.

In all, the hospitalists in the new consortium care for about 80,000 patients each year.

“Linking these key hospitals, where hospitalists care for so many patients, will make a huge difference in patient safety in southeast Michigan,” said Dr. Saint. “We’ll all now have the advantage of cross-sharing patient safety tactics that work, instead of allowing that knowledge to stay within one hospital or health system. We will also focus on which implementation strategies are likely to work and which ones should be abandoned.”

In addition to its cross-sharing of patient safety information, UMHS will also provide expertise in patient-safety research and statistical analysis that will boost the project’s impact. The hospitalist team hopes to publish its data about safety-enhancing practices that show the most promise―and about how to persuade and remind doctors to use safety-enhancing practices. The team has already begun publishing work related to HELPS. The manuscript describing this unique consortium was recently accepted in the Journal of Patient Safety.

The UMHS hospitalist practice currently cares for nearly half of the adult patients admitted to the internal medicine services of University Hospital. UMHS has also added a team of pediatric hospitalists. In addition to the patient safety project, UMHS hospitalists are pioneering co-management of surgical patients with orthopaedic surgeons.

Drs. Flanders and Saint also anticipate that their nine-hospital consortium will eventually develop into a multicenter collaborative in which clinical studies―both experimental and observational―will be conducted. They expect that hospitalists, working closely with specialist colleagues, will be actively engaged in creating the new knowledge that is increasingly required to care for hospitalized patients. Importantly, this knowledge will come not just from patients admitted to tertiary-care academic medical centers, but also community hospitals, the venue in which the majority of hospitalized patients receive care. Similar to the success of cardiologists and oncologists in establishing regional, national, and international networks of clinical investigators, Drs. Flanders and Saint would be thrilled if HELPS is viewed in a decade as birthing a hospitalist network of clinical research excellence. Given the high level of support that has been provided by the UMHS and the enthusiastic response HELPS has received from each of the participating sites, Saint feels they are well on their way.

Flanders says that more and more, hospitalists will become the linchpins to patient safety improvement. “It would be extremely difficult to coordinate the efforts of the thousands of independent, community-based doctors who spend part of their time caring for inpatients,” he said. “By spearheading this effort through hospitalists, we can change the system from the inside out, and help spread patient safety best practices to other physician specialists, primary care doctors, nurses and every member of the patient care team.”

Scott Flanders, MD

Sanjay Saint, MD, MPH

SHM’s scott Flanders, MD, of the University of Michigan Health System, and Sanjay Saint, MD, MPH, a hospitalist at the Ann Arbor VA Medical Center and University of Michigan Health System, are spearheading the nation’s first multi-hospital patient safety project to protect hospital patients from errors and oversights. The project, called Hospitalists as Emerging Leaders in Patient Safety, or HELPS, will coordinate the efforts of nine southeast Michigan health systems, allowing hospitalists from around the region to share tips, tools and techniques. It also will help doctors put proven safety ideas into motion at their hospitals and measure how well this pooled effort can prevent such problems as medication errors, hospital-acquired infections and dangerous falls.

The patient safety project was launched in April via an $117,000 grant to the University of Michigan Health System from the Blue Cross Blue Shield of Michigan Foundation. This is the latest of several recent patient safety-related grants awarded to the University of Michigan by the Blue Cross Blue Shield of Michigan Foundation.

“Although patient safety relies on every member of the hospital staff to take appropriate actions and to speak up when something goes wrong, the buck stops with the physician who leads the inpatient team – and increasingly that physician is a hospitalist,” said Dr. Flanders, chief of the hospitalist service at UMHS, associate professor of medicine and member of the SHM board of directors. “Health systems are hiring hospitalists to maximize inpatient care efficiency, coordination and patient satisfaction, while lowering the costs of care,” added Dr. Flanders. “An integral part of these goals should be to improve patient safety by reducing medical errors.”

Dr. Saint, an associate professor who heads the Patient Safety Enhancement Program at the Ann Arbor VA Medical Center and UMHS, credits much of the impetus for HELPS to the Agency for Healthcare Research and Quality and the VA’s Health Services Research and Development Program, both of which have supported previous patient safety work that forms much of the basis of this new project. Dr. Saint and hospitalists at the University of Michigan have already shown that they can reduce urinary tract and bloodstream infections among hospitalized patients by using reminders and automatic orders to prompt doctors, and by standardizing the use of new site disinfectants and novel antibacterial catheters. This effort alone is saving UMHS hospital patients considerable pain and risk, while lowering UMHS costs, despite the fact that the new technology costs more initially. Drs. Flanders and Saint will attempt to repeat this success in hospitals across the southeast region in nine different areas of medicine, including:

• Techniques for performing quality-improvement research, so that doctors can accurately assess the effects of their efforts;
• Preventing device-related infections;
• Eliminating medication errors and creating a culture of safety;
• Improving the use of preventive medications for surgical patients;
• Closing gaps in care between different services in the hospital and gaps that exist as patients are discharged from the hospital;
• Improving intensive-care practices, including pneumonia prevention;
• End-of-life care, including pain and advance directives;
• Safety for older patients, including prevention of falls and delirium; and
• Learning lessons from patient safety efforts.

The nine participating Michigan health systems include:

• University of Michigan Health System
• VA Ann Arbor Healthcare System
• St. Joseph Mercy Healthcare System
• Oakwood Healthcare System
• Beaumont Hospital
• Detroit Medical Center
• Henry Ford Health System
• Chelsea Community Hospital and
• Michigan Hospitalists, who practice throughout the St. John Health System.

In all, the hospitalists in the new consortium care for about 80,000 patients each year.

“Linking these key hospitals, where hospitalists care for so many patients, will make a huge difference in patient safety in southeast Michigan,” said Dr. Saint. “We’ll all now have the advantage of cross-sharing patient safety tactics that work, instead of allowing that knowledge to stay within one hospital or health system. We will also focus on which implementation strategies are likely to work and which ones should be abandoned.”

In addition to its cross-sharing of patient safety information, UMHS will also provide expertise in patient-safety research and statistical analysis that will boost the project’s impact. The hospitalist team hopes to publish its data about safety-enhancing practices that show the most promise―and about how to persuade and remind doctors to use safety-enhancing practices. The team has already begun publishing work related to HELPS. The manuscript describing this unique consortium was recently accepted in the Journal of Patient Safety.

The UMHS hospitalist practice currently cares for nearly half of the adult patients admitted to the internal medicine services of University Hospital. UMHS has also added a team of pediatric hospitalists. In addition to the patient safety project, UMHS hospitalists are pioneering co-management of surgical patients with orthopaedic surgeons.

Drs. Flanders and Saint also anticipate that their nine-hospital consortium will eventually develop into a multicenter collaborative in which clinical studies―both experimental and observational―will be conducted. They expect that hospitalists, working closely with specialist colleagues, will be actively engaged in creating the new knowledge that is increasingly required to care for hospitalized patients. Importantly, this knowledge will come not just from patients admitted to tertiary-care academic medical centers, but also community hospitals, the venue in which the majority of hospitalized patients receive care. Similar to the success of cardiologists and oncologists in establishing regional, national, and international networks of clinical investigators, Drs. Flanders and Saint would be thrilled if HELPS is viewed in a decade as birthing a hospitalist network of clinical research excellence. Given the high level of support that has been provided by the UMHS and the enthusiastic response HELPS has received from each of the participating sites, Saint feels they are well on their way.

Flanders says that more and more, hospitalists will become the linchpins to patient safety improvement. “It would be extremely difficult to coordinate the efforts of the thousands of independent, community-based doctors who spend part of their time caring for inpatients,” he said. “By spearheading this effort through hospitalists, we can change the system from the inside out, and help spread patient safety best practices to other physician specialists, primary care doctors, nurses and every member of the patient care team.”

Scott Flanders, MD

Sanjay Saint, MD, MPH

SHM’s scott Flanders, MD, of the University of Michigan Health System, and Sanjay Saint, MD, MPH, a hospitalist at the Ann Arbor VA Medical Center and University of Michigan Health System, are spearheading the nation’s first multi-hospital patient safety project to protect hospital patients from errors and oversights. The project, called Hospitalists as Emerging Leaders in Patient Safety, or HELPS, will coordinate the efforts of nine southeast Michigan health systems, allowing hospitalists from around the region to share tips, tools and techniques. It also will help doctors put proven safety ideas into motion at their hospitals and measure how well this pooled effort can prevent such problems as medication errors, hospital-acquired infections and dangerous falls.

The patient safety project was launched in April via an $117,000 grant to the University of Michigan Health System from the Blue Cross Blue Shield of Michigan Foundation. This is the latest of several recent patient safety-related grants awarded to the University of Michigan by the Blue Cross Blue Shield of Michigan Foundation.

“Although patient safety relies on every member of the hospital staff to take appropriate actions and to speak up when something goes wrong, the buck stops with the physician who leads the inpatient team – and increasingly that physician is a hospitalist,” said Dr. Flanders, chief of the hospitalist service at UMHS, associate professor of medicine and member of the SHM board of directors. “Health systems are hiring hospitalists to maximize inpatient care efficiency, coordination and patient satisfaction, while lowering the costs of care,” added Dr. Flanders. “An integral part of these goals should be to improve patient safety by reducing medical errors.”

Dr. Saint, an associate professor who heads the Patient Safety Enhancement Program at the Ann Arbor VA Medical Center and UMHS, credits much of the impetus for HELPS to the Agency for Healthcare Research and Quality and the VA’s Health Services Research and Development Program, both of which have supported previous patient safety work that forms much of the basis of this new project. Dr. Saint and hospitalists at the University of Michigan have already shown that they can reduce urinary tract and bloodstream infections among hospitalized patients by using reminders and automatic orders to prompt doctors, and by standardizing the use of new site disinfectants and novel antibacterial catheters. This effort alone is saving UMHS hospital patients considerable pain and risk, while lowering UMHS costs, despite the fact that the new technology costs more initially. Drs. Flanders and Saint will attempt to repeat this success in hospitals across the southeast region in nine different areas of medicine, including:

• Techniques for performing quality-improvement research, so that doctors can accurately assess the effects of their efforts;
• Preventing device-related infections;
• Eliminating medication errors and creating a culture of safety;
• Improving the use of preventive medications for surgical patients;
• Closing gaps in care between different services in the hospital and gaps that exist as patients are discharged from the hospital;
• Improving intensive-care practices, including pneumonia prevention;
• End-of-life care, including pain and advance directives;
• Safety for older patients, including prevention of falls and delirium; and
• Learning lessons from patient safety efforts.

The nine participating Michigan health systems include:

• University of Michigan Health System
• VA Ann Arbor Healthcare System
• St. Joseph Mercy Healthcare System
• Oakwood Healthcare System
• Beaumont Hospital
• Detroit Medical Center
• Henry Ford Health System
• Chelsea Community Hospital and
• Michigan Hospitalists, who practice throughout the St. John Health System.

In all, the hospitalists in the new consortium care for about 80,000 patients each year.

“Linking these key hospitals, where hospitalists care for so many patients, will make a huge difference in patient safety in southeast Michigan,” said Dr. Saint. “We’ll all now have the advantage of cross-sharing patient safety tactics that work, instead of allowing that knowledge to stay within one hospital or health system. We will also focus on which implementation strategies are likely to work and which ones should be abandoned.”

In addition to its cross-sharing of patient safety information, UMHS will also provide expertise in patient-safety research and statistical analysis that will boost the project’s impact. The hospitalist team hopes to publish its data about safety-enhancing practices that show the most promise―and about how to persuade and remind doctors to use safety-enhancing practices. The team has already begun publishing work related to HELPS. The manuscript describing this unique consortium was recently accepted in the Journal of Patient Safety.

The UMHS hospitalist practice currently cares for nearly half of the adult patients admitted to the internal medicine services of University Hospital. UMHS has also added a team of pediatric hospitalists. In addition to the patient safety project, UMHS hospitalists are pioneering co-management of surgical patients with orthopaedic surgeons.

Drs. Flanders and Saint also anticipate that their nine-hospital consortium will eventually develop into a multicenter collaborative in which clinical studies―both experimental and observational―will be conducted. They expect that hospitalists, working closely with specialist colleagues, will be actively engaged in creating the new knowledge that is increasingly required to care for hospitalized patients. Importantly, this knowledge will come not just from patients admitted to tertiary-care academic medical centers, but also community hospitals, the venue in which the majority of hospitalized patients receive care. Similar to the success of cardiologists and oncologists in establishing regional, national, and international networks of clinical investigators, Drs. Flanders and Saint would be thrilled if HELPS is viewed in a decade as birthing a hospitalist network of clinical research excellence. Given the high level of support that has been provided by the UMHS and the enthusiastic response HELPS has received from each of the participating sites, Saint feels they are well on their way.

Flanders says that more and more, hospitalists will become the linchpins to patient safety improvement. “It would be extremely difficult to coordinate the efforts of the thousands of independent, community-based doctors who spend part of their time caring for inpatients,” he said. “By spearheading this effort through hospitalists, we can change the system from the inside out, and help spread patient safety best practices to other physician specialists, primary care doctors, nurses and every member of the patient care team.”

Despite more intensive guidelines and advances in resuscitation research, the survival rate for victims of cardiopulmonary arrest remains virtually unchanged from forty years ago when modern cardiopulmonary resuscitation (CPR) was first described (1). Perhaps in part because the guidelines for ACLS set forth by the American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) have become so complex―and continue to increase in breadth and scope into topics well beyond cardiopulmonary arrest with each revision―the critical aspects of resuscitation have become diluted by unnecessarily difficult algorithms. Critical skill sets―such as proper performance of CPR and rapid defibrillation―have become dwarfed by less critical aspects of acute resuscitation. Remarkably common errors usurp the dual fundamental goals of ACLS: neurological preservation and prevention of early death. This review will address the historical context of resuscitation and then will focus on seven of the most essential, evidence-based strategies for improving outcomes in ACLS.

History of Resuscitation

The modern resuscitation era began in 1960 when Kouwenhoven, Jude, and Knickerbocker published a pair of landmark papers on the use of closed chest compressions (CCC) as a means to resuscitate patients in cardiopulmonary arrest (2,3). Interestingly, the culmination of their three and a half decades of work was initially motivated and sponsored by an electric company seeking to reduce the death rate of its linemen from ventricular fibrillation. While innovative, their technique built on millennia of creative, and sometimes bizarre ancient practices geared at reversing death. Given the lack of in-depth knowledge of anatomy and physiology combined with a rich overlap between shamanism and medicine, it is perhaps stunning to realize that the oldest recorded reasonably physiologic approach to resuscitation stems from over 3500 years ago. Egyptian hieroglyphs show the story of the healing goddess, Isis, reviving her husband Osiris using mouth-to-mouth ventilation (4). Still other Egyptian texts advocated hanging drowned victims upside down, compressing and releasing the thorax with the goal to ventilate and revive the patient (5). Hebrew midwives were documented as having performed mouth-to-mouth on deceased newborns as early as 1300 BCE (6). And even the Bible tells of the prophet Elishah’s successful resuscitation of a deceased child through artificial respiration:

...And he went up, and lay upon the child, and put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his hands; and he stretched himself upon the child; and the flesh of the child waxed warm (7).

One of the forefathers of modern medicine, the Greek physician Galen, was the first doctor to use an artificial ventilation strategy in 177, filling dead animals’ lungs with air from a bellows (8).

In 1628, physician William Harvey, the first to accurately describe circulation, used his newfound knowledge to successfully stop ventricular fibrillation in a pigeon using open heart massage (9 ). John Hunter created a bellows that could deliver positive and negative pressure ventilation, which he used to resuscitate dogs in 1755 (10). The Dutch Humane Society immediately tapped Hunter’s knowledge to help reduce the death rate of drowning victims (11). The resultant 1767 publication was the first ever to advocate the use of “artificial respiration”:

…the operator closed the patient’s nostrils, applied his mouth to the patient’s mouth, inflated the lungs and expanded the chest and belly, and produced expiration by compressing the abdomen with his free hand (12).

Despite giving ventilation equal measure with another popular technique at the time called fumigation―the use of tobacco smoke to fill the colon of drowned victims via a rectal tube―scientists rapidly began to use true physiologic practices to advance resuscitation.

Within eight years, Priestly would discover the element oxygen and Squires of London would record the first-ever use of electricity in resuscitation:

…he tried the effects of electricity. Twenty minutes elapsed before he could apply the shock [to the 3 year old child who had fallen out of a 1st story window], which he gave to various parts of the body in vain; but upon transmitting a few shocks through the thorax, he perceived a small pulsation; in a few minutes the child began to breathe….her health was restored (4).

Resuscitation became a legitimate science during the 19th century with literature replete of experimental successes in laboratory animal resuscitations. Techniques included using closed and open heart massage, manual ventilation using specialized medical bellows, and then finally, in 1899, documented cessation of ventricular fibrillation by electricity. Jean Louis Prevost and Frederic Batelli reported that they had defibrillated a dog successfully with the use of two electrodes―one on the head and one in the rectum―with high voltage AC current (13).

As the 20th century dawned, George Washington Crile―the cofounder of the Cleveland Clinic and considered by many as the most innovative researcher in the field of resuscitation―described successful closed chest cardiac massage in man and the first use of saline and epinephrine infusion in cardiac arrest in 1903. after the Russians Gurvich and Yuniev had demonstrated the superiority of DC current to AC current in defibrillation in 1939, Beck (1947) and Zoll (1956) published their successes in humans of open and closed chest defibrillation respectively.13 Even though the advent of the modern defibrillator loomed imminently, the practicality of widespread dissemination of the cumbersome equipment needed to provide these shocks was not yet manifest. Thus, Kouwenhoven and colleagues created a technique of closed chest cardiac massage that could keep patients alive long enough to receive definitive treatment, and modern CPR was born (14).

Epidemiology of Cardiopulmonary Arrest

In the United States an estimated 375,000 to 750,000 hospitalized patients suffer a cardiopulmonary arrest (CA) requiring advanced cardiac life support (ACLS) annually (15). The incidence of CA is estimated to be as high as 1–2% of all patients admitted to academic hospitals with a prevalence of 58 to 71 people per 100,000 nationally (16,17). The demographics of over 14,000 patients resuscitated for a CA are summarized in Table 1; patient comorbidities are listed in Figure 1.18 The typical CA patient is a white male in his seventh decade of life with a history of cardiac, pulmonary, or renal disease suffering from a pre-arrest arrhythmia or respiratory problem. Over 86% of patients are either on continuous cardiac monitoring (telemetry) or have a witnessed CA.

When primary respiratory arrests are excluded (such as from opiate overdose or post-anesthesia), only approximately 1 in 7 patients will survive an in-hospital resuscitation to discharge (1,19). Survivors’ initial rhythms are typically either pulseless ventricular tachycardia (VT) (35%) or ventricular fibrillation (VF) (34%), but fully 20% of survivors have initial “rhythms” of asystole or pulseless electrical activity (PEA)―which comprise virtually two–thirds of all arrests―suggesting a meager benefit to resuscitation of this subgroup of patients. Almost one third of survivors who lived independently pre-arrest are unable to be discharged home and between 14-23% of survivors―whose pre-arrest neurological function was normal―develop moderate to severe cognitive deficits after resuscitation (18,20). Fewer than 2% of survivors suffer coma or a persistent vegetative state. Neither gender nor advanced age appears to be a negative predictor of survival (1,21).

Time is Life Lost

The goals of resuscitation are two-fold: preservation of neurological function and prevention of early death. Expedient resuscitation maximizes the likelihood of positive outcomes, but too often, precious time is life lost spent performing unnecessary diagnostic maneuvers or unimportant interventions that have little impact on prognosis. The overarching target in in-hospital adult resuscitation is minimizing the time it takes for patients to receive defibrillation. All other activities are only a mean to this end. The remainder of this review will focus on seven highly effective strategies for successful resuscitations.

Primary Survey

Guidelines continue to stress the importance of airway, breathing, and circulation as the basic tenets of initial response to a CA. While this approach has merit in out-of-hospital arrests, it is an anathema in hospitalized patients. Valuable time is often lost trying to ascertain the presence or absence of respirations or pulse. Earle et al. designed a very creative way to gauge the operating characteristics of the carotid pulse check. Providers were asked to assess randomized patients who were to undergo open-heart surgery; some of the patients were already on cardiopulmonary bypass (“true negatives” with no spontaneous pulse) and the remainder were not (“true positives” with a pulse). With a median time of over 30 seconds, care providers could only accurately determine pulselessness 65% of the time (90% sensitivity and 55% specificity).22 Given that this study occurred in a very controlled environment without the drama of a real CA, it is likely that these data would even be worse in the chaos of resuscitation.

First Effective Stratagem: If an unresponsive adult inpatient clinically appears to be suffering a cardiopulmonary arrest, treatment (activation of a “code team” and application of CPR) should be initiated immediately without performing a pulse check.

CPR Physiology and Impact

CPR is a critical bridge to defibrillation but is not an end unto itself. The physiology that occurs during CPR is remarkably complex, and our current understanding is incomplete. Kouwenhoven posited that chest compressions result in a functional equivalent to open cardiac massage (2). In this “cardiac pump model,” the physiology is similar to a surgeon’s hands squeezing the non-beating heart: artificial systole from the down stroke of a compression compresses the heart against the spinal column forcing blood from the ventricles and forcing closure of the mitral and tricuspid valves. During artificial diastole, reversing pressure gradients result in closure of the aortic and pulmonic valves resulting in bi-ventricular filling of blood and perfusion of the coronary arteries.

An alternative model, the “thoracic pump model,” looks at the entire thoracic cavity as a pump with functional “valves” at the thoracic inlet preventing back-flow from the intrathoracic veins into the extrathoracic veins (23). The intrathoracic pressure rapidly increases during artificial systole leading to antegrade flow of blood from vessels under relatively higher pressure (the aorta and the pulmonary vasculature) to blood vessels under relatively lower pressure (the carotid arteries). The elevated intrathoracic pressure collapses the comparably weak vena cava, and, combined with tricuspid valve closure, prevents simultaneous retrograde venous flow. With three of the cardiac valves open during artificial systole, the heart is relegated to the role of a passive conduit for blood rather than providing any meaningful pumping action. During artificial diastole, intrathoracic pressure drops to near zero resulting in transient back flow of blood from the carotid arteries toward the heart. This induces aortic valve closure and generates only meager coronary artery perfusion.

Subsequent work by Paradis et al. shows that, in essence, both “pump” models have equal validity, and one or the other physiology dominates in any given patient (24). Regardless of which type of physiology occurs during resuscitation, neither provides physiologically sufficient circulation to maintain organ viability for long. When performed ideally, chest compressions during actual resuscitations in humans yield systolic blood pressures of only 60–80mmHg; and blood flow of less than one third the normal cardiac output, less than 10–15% of normal cerebral blood flow, and less than 1–5% of normal coronary artery blood flow (25).

Such subphysiologic circulation leaves little latitude for improper technique. Yet, care providers rarely perform chest compressions properly, erring towards too shallow a compression depth 62.6% of the time and too slow a compression rate 71.9% of the time on actual resuscitations―errors that increase in frequency the longer it has been since the caregiver was trained (26,27). Observational data on the quality of CPR suggest that these are not just esoteric technical deviations, but that compared with those in whom CPR is correctly performed, 14-day survival was almost 75% lower in those on whom CPR was incorrectly performed (16% vs. 4%)(28).

Furthermore, routine interruptions in chest compressions― such as for positive pressure ventilations in non-intubated patients―likely further hinder survival rather than contribute meaningfully to outcome. For example, medical students performing traditional CPR took an average of 14 seconds to administer two mouth-to-mouth ventilations after each group of 15 compressions. This effectively reduced the number of compressions to a mere 43 per minute, or less than half the guideline-mandated 100 per minute, thus theoretically reducing circulation to the heart and brain by a similar percentage (29). Yu et al demonstrated that swine receiving more than 80 compressions per minute during CPR had a 100% survival at 24 hours compared with a dismal 10% survival in animals that had less than 80 compressions per minute (30). Kern et al found statistically significantly higher coronary artery perfusion pressures and markedly higher neurological normal 24 hour survival in swine receiving continuous chest compressions compared with controls receiving traditional CPR (31).

Increasingly data such as these do raise the question of what―if any―benefit rescue breathing has in adult resuscitation. Human data show that a strategy of continuous chest compressions―without rescue breathing―is equally efficacious to traditional CPR in terms of outcome (32). Two physiologic theories prevail: 1) the mechanics of chest wall compression may be sufficient to provide a limited minute ventilation independent of supplemental ventilation (author’s speculation); and 2) the improved oxygenation that occurs in those receiving artificial ventilation is offset by the deleterious impact on hemodynamics that occur when chest compressions are interrupted for ventilation (34).

Second Effective Stratagem: Until an adult inpatient can be defibrillated, the focus of resuscitation should be on proper continuous chest compression depth and rate, not on ventilation.

Ventilations are Harmful

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Cardiopulmonary collapse has immediate consequences on cellular physiology. Both due to a lack of expiration of carbon dioxide and the development of lactatemia due to the shift to anaerobic metabolism, blood pH drops precipitously. As the pH shifts out of the physiologic range, drugs begin to perform in unexpected ways or fail altogether; ion trapping occurs; and many electrolytes begin to shift in or out of cells affecting their serum concentration. Diminished or absent cardiac output accelerates these derangements in a relentless positive feedback loop. Logic, therefore, dictates that anything that can improve oxygenation and ventilation would be helpful at slowing or reversing this pathophysiology. Surprisingly, however, clinicians’ lack of knowledge of both equipment and technique often promotes, rather than mitigates, the physiologic derangements.

The bag-valve-mask (BVM) is one of the least understood resuscitation devices. For example, clinicians occasionally place a BVM over spontaneously breathing patients who are exceptionally ill with the goal of augmenting patients’ meager ventilations. However, the BVM is constructed only for positive pressure ventilation and thus, unless the clinician squeezes the bag in perfect coordination with the patient’s ventilatory effort, the BVM will paradoxically smother the patient.

The bag portion of the BVM is designed for a one-handed squeeze to deliver a tidal volume that is roughly 750cc; this volume is in keeping with guideline recommendations of positive pressure ventilation volumes of roughly 10cc/kg/ventilation (29). Yet, clinicians commonly use two hands to compress the BVM maximally during resuscitation (theoretically delivering upwards of double the recommended volume).

In addition to excessive volume, clinicians also deliver ventilations too rapidly. Abella et al. showed that during human resuscitations, ventilation rate exceeded the recommended goal of 20 ventilations/minute 60.9% of the time (27). Theoretically, high minute ventilations lead to an increased incidence of gastric insufflation, regurgitation, and post-resuscitation aspiration.

Though no studies have ever been performed to understand why clinicians hyperventilate patients during resuscitation, it is interesting to speculate that clinicians are not only trying to raise blood oxygen levels rapidly, but also to reverse the profound metabolic and respiratory acidosis that occur during CA. While seemingly mechanistically sound, the logic that supraphysiologic minute ventilations will profoundly change blood pH without other physiologic costs is specious at best. Aufderheide et al. Demonstrated that hyperventilation during resuscitation in swine resulted in increased intrathoracic pressures, markedly reduced coronary artery perfusion pressures, and resultant proportional reductions in survival rates as hyperventilation increased (35). Clinically these findings are known as auto-PEEP, a known complication of artificial ventilation that results in systemic arterial hypotension. Thus the paradox: aggressive attempts to overcorrect systemic acidoses via higher minute ventilations leads to worsening systemic blood pressures and thus worsening lactic acidosis. I believe that iatrogenic hypotension is one of the most common problems to complicate an otherwise successful resuscitation and that more research is urgently needed on this issue.

Third Effective Stratagem: Bag-valve-mask ventilations should be performed with precision; when used, the bag should be compressed with only one hand and delivered no faster than one breath every 3–5 seconds.

Fourth Effective Stratagem: In cases of pulseless electrical activity (PEA) or post-resuscitation hypotension, auto-PEEP should be considered foremost as a proximal cause.

Fifth Effective Stratagem: Ventilations in resuscitation should be viewed primarily as a means to oxygenate the patient rather than as a means to compensate from a systemic acidemia.

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Shocking Revelations

Even though patients in ventricular fibrillation (VF) and pulseless ventricular tachycardia (PVT) together only comprise about one–third of all inpatient cardiac arrests, they account for almost 70% of survivors of CA. Survival in these arrhythmias is predicated solely on rapid defibrillation: the simultaneous depolarization of a critical mass of myocytes by an electrical current with resultant resumption of normal cardiac conduction (36). Perhaps the best attestation to the importance of rapid defibrillation actually comes from the survival of patients with cardiac arrest at casinos: security cameras provided exact documentation of time of collapse and defibrillation. Survival to hospital discharge was cut in half when the time-from-collapse-to-defibrillation was greater than 3 minutes (74% vs. 49%)(37).

Sixth Effective Stratagem: Since patients in VF/PVT are the most likely to survive CA―and that rate is directly related to immediacy of defibrillation―all patients should be presumptively treated as if they are in VF/PVT and should be defibrillated within 3 minutes of collapse unless there are data to support another arrhythmia or cause of collapse.

Much of the electrical current delivered during a defibrillation attempt is either dissipated as heat or is conducted around the thorax without penetrating the myocardium; Lerman and Deale have shown that the amount of current reaching the heart may be as little as 4% during a defibrillation attempt (38). From Ohm’s Law, the current that reaches the heart is directly proportional to the voltage across the chest and inversely related to the resistance of the supervening tissues. Interestingly, increasing the voltage of a shock only increases the amount of heat produced without a commensurate increase in current delivered. Therefore, techniques that reduce thoracic resistance yield the highest current delivery: the use of manual defibrillator paddles (as opposed to self adhesive defibrillation pads), the amount of pressure applied to the paddles (>25 pounds), the correct placement (underneath, rather than on top of breast tissue), the use of a conduction material (gel or pads), and the rapid delivery of a stacked shock (resistance transiently decreases after a counter-shock) all improve current delivery and thus may improve defibrillation outcome (36).

Physician leadership during resuscitations is critical for maximizing likelihood of patient survival. Perhaps due to physicians’ lack of familiarity with defibrillators, the mechanics of defibrillation are often deferred unnecessarily to nursing staff. Unfortunately, this may have profoundly negative effects on the resuscitation. Since many hospitals reduce educational expenses by foregoing training nurses in ACLS unless they work in intensive care units, nurses on a code may have even less comfort in using defibrillators than physicians. One study showed nearly a 72.5% decrease in patient survival when the nurse who arrived first at the resuscitation was untrained in ACLS (37.5% vs. 10.3%); a difference that probably is related to delayed defibrillation though the study could not establish direct causality (39).

A separate study showed that 85% of patients on cardiac monitored wards were defibrillated in the target time of 3 minutes from collapse, while only 28% of patients on unmonitored wards were defibrillated within the target time; this led to an adjusted odds ratio for survival-to-discharge in patients on monitored versus non-monitored wards of 1.45 (95% CI, 0.95–2.20)(40). While at first these data seem to indicate faster responses on monitored wards, these data were specific to time-from-collapse-to-defibrillation and therefore should be location-independent once the need for resuscitation was identified. Instead, I interpret these data as showing the lower comfort nurses on non-monitored wards have with rapid defibrillation. Rather than serving as an indictment against nurses, these data in aggregate underscore the vital role physician responders have to ensure rapid defibrillation of patients in cardiac arrest.

Seventh Effective Stratagem: Physicians should aggressively pursue defibrillation as early as possible during resuscitation especially on non-monitored wards where nurses are less likely to be ACLS trained and less likely to be familiar with defibrillator operation.

Conclusions

Resuscitation, the act of bringing back life from imminent death, is one of the most sensationalized practices in medicine and dates almost to the beginning of recorded history. In the past two decades, increasingly evidence-based guidelines have tried to provide a guide to help practitioners treat patients effectively in the minutes after cardiopulmonary collapse. Unfortunately, with each new iteration of the guidelines, it has become increasingly difficult to determine which strategies offer the highest yield or the most import. As ILCOR meets in 2005 to revise the guidelines once again, hopefully the most important strategies will be given their proper highlight, providing clinicians with increased comfort and confidence with cardiopulmonary resuscitation.

Bibliography

1. Brindley PG, Markland DM, Mayers I, Kutsogiannis DJ. Predictors of survival following inhospital adult cardiopulmonary resuscitation. CMAJ. 2002;167:343-8.
2. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed chest cardiac massage. JAMA. 1960;173:1064-7.
3. Jude JR, Kouwenhoven WB, Knickerbocker GG. Cardiac arrest; report of application of external cardiac massage on 118 patients. JAMA. 1961;178:1063-71.
4. Varon J, Sternback GL. Cardiopulmonary resuscitation: lessons from the past. J Emerg Med. 1991;9:5037.
5. Liss HP. A history of resuscitation. Ann Emerg Med.1986;15: 65-72.
6. Thangam S, Weil MH, Rackow EC. Cardiopulmonary resuscitation: a historical review. Acute Care. 1986;12:63-94.
7. Kings II, 4:34-35 (KJV).
8. Baker AB. Artificial respiration: the history of an idea. Med Hist. 1971;15:336-46.
9. Stephenson HE. Cardiac Arrest and Resuscitation. St Louis: CV Mosby; 1969.
10. Lee RV. Cardiopulmonary resuscitation in the eighteenth century: a historical perspective on present practice. J Hist Med. 1972;27:418-33.
11. Varon J, Marik PE, Fromm RE. Cardiopulmonary resuscitation: a review for clinicians. Resuscitation. 1998;36: 133-45.
12. Keith A. Three Hunterian lectures on the various mechanisms underlying the various methods of artificial respiration. Lancet. 1909;1:895-9.
13. DeBard ML. The history of cardiopulmonary resuscitation. Ann Emerg Med. 1980;9:273-5.
14. Acosta P, Varion J, Sternbach GL, BaskeQ P. Resuscitation great. Kouwenhoven, Jude and Knickerbocker: the introduction of defibrillation and external chest compressions into modern resuscitation. Resuscitation. 2005;64:139-43.
15. US Congress, Office of Technology Assessment. Life-sustaining technologies and the elderly. Washington, DC: US Government Printing Office, 1987; 11, Publication OTA-BA-306.
16. DeBard ML. Cardiopulmonary resuscitation: analysis of six years’ experience and review of the literature. Ann Emerg Med. 1981;10:408-11.
17. Cassel CK, et al. Cardiopulmonary resuscitation in the elderly. Office of Technology Assessment, U.S. Congress, Washington, DC, November, 1985.
18. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14 720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003;58297-308.
19. Valentin A, Karnik R, Donath P, Winkler WB, Slany J. Outcome of cardiopulmonary resuscitation in hospitalized patients. Resuscitation. 1995;30:217-21.
20. Robinson GR, Hess D. Postdischarge survival and functional status following in-hospital cardiopulmonary resuscitation. Chest. 1994;105:991-6.
21. Murphy DI, Murray AM, Robinson BE. Outcomes of cardiopulmonary resuscitation in the elderly. Ann Int Med. 1989;111:199-205.
22. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation. 1996;33:107-16.
23. Rudikoff MT, Maughan WL, Effron M, Freund P, Weisfeldt ML. Mechanisms of blood flow during cardiopulmonary resuscitation. Circulation. 1980;61:345-52.
24. Paradis NA, Martin GB, Goetting MG, et al. Simultaneous aortic, jugular bulb, and right atrial pressures during cardiopulmonary resuscitation in humans: insight into mechanisms. Circulation. 1989;80:361-8.
25. Sanders AB, Ogle M, Ewy GA. Coronary perfusion pressure during cardiopulmonary resuscitation. Am J Emerg Med. 1985;3:11-4.
26. Heidenreich JW, Higdon TA, Kern KB, et al. Single-rescuer cardiopulmonary resuscitation: “two quick breaths”―an oxymoron. Resuscitation. 2004;62:283-89.
27. Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA. 2005;293:305-10.
28. Van Hoeyweghen RJ, Bossaert LL, Mullie A, et al. (Belgian Cerebral Resuscitation Study Group.) Quality and efficiency of bystander CPR. Resuscitation. 1993;26:47-52.
29. American Heart Association in collaboration with the International Liaison Committee on Resuscitation (ILCOR). International Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care―a consensus on science. Resuscitation. 2000.46:1-448.
30. Yu T, Weil MH, Tang W, et al. Adverse outcomes of interrupted precordial compression during automated defibrillation. Circulation. 2002;106:368-72.
31. Kern KB, Hilwig RW, Berg RA, Sanders AB, Ewy GA. Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario. Circulation. 2002;105:645-649.
32. Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary resuscitation by chest compression alone or with to-mouth ventilation. N Engl J Med. ;342: 154-653.
33.  
34. Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation. 2001;104:2465-70.
35. Aufderheide TP, Sigurdsson G, Pirallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. 2004;109:1960-5.
36. Dalzell GWN. Determinants of successful defibrillation. Heart. ;80:405-7.
37. Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW,Hardman RG. Outcomes of rapid defibrillation by security ad er cardiac arrest in casinos. N Engl J Med. ;343:120-69.
38. Lerman BB, Deale C. Relation between transcardiac and thransthoracic current during defibrillation in humans. Circ Res. 1990;67:1420-6.
39. Dane FC, RussellLindgren KS, Parish DC, Durham MD, Brown TD. Inhospital resuscitation: association between ACLS training and survival to discharge. Resuscitation. 2000;47:83-7.
40. Herlitz J, Bang A, Aune S, Ekstrom L, Lundstrom G, Holmberg S. Characteristics and outcome among patients suffering inhospital cardiac arrest in monitored and nonmonitored areas. Resuscitation. ;48:125-35.

Despite more intensive guidelines and advances in resuscitation research, the survival rate for victims of cardiopulmonary arrest remains virtually unchanged from forty years ago when modern cardiopulmonary resuscitation (CPR) was first described (1). Perhaps in part because the guidelines for ACLS set forth by the American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) have become so complex―and continue to increase in breadth and scope into topics well beyond cardiopulmonary arrest with each revision―the critical aspects of resuscitation have become diluted by unnecessarily difficult algorithms. Critical skill sets―such as proper performance of CPR and rapid defibrillation―have become dwarfed by less critical aspects of acute resuscitation. Remarkably common errors usurp the dual fundamental goals of ACLS: neurological preservation and prevention of early death. This review will address the historical context of resuscitation and then will focus on seven of the most essential, evidence-based strategies for improving outcomes in ACLS.

History of Resuscitation

The modern resuscitation era began in 1960 when Kouwenhoven, Jude, and Knickerbocker published a pair of landmark papers on the use of closed chest compressions (CCC) as a means to resuscitate patients in cardiopulmonary arrest (2,3). Interestingly, the culmination of their three and a half decades of work was initially motivated and sponsored by an electric company seeking to reduce the death rate of its linemen from ventricular fibrillation. While innovative, their technique built on millennia of creative, and sometimes bizarre ancient practices geared at reversing death. Given the lack of in-depth knowledge of anatomy and physiology combined with a rich overlap between shamanism and medicine, it is perhaps stunning to realize that the oldest recorded reasonably physiologic approach to resuscitation stems from over 3500 years ago. Egyptian hieroglyphs show the story of the healing goddess, Isis, reviving her husband Osiris using mouth-to-mouth ventilation (4). Still other Egyptian texts advocated hanging drowned victims upside down, compressing and releasing the thorax with the goal to ventilate and revive the patient (5). Hebrew midwives were documented as having performed mouth-to-mouth on deceased newborns as early as 1300 BCE (6). And even the Bible tells of the prophet Elishah’s successful resuscitation of a deceased child through artificial respiration:

...And he went up, and lay upon the child, and put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his hands; and he stretched himself upon the child; and the flesh of the child waxed warm (7).

One of the forefathers of modern medicine, the Greek physician Galen, was the first doctor to use an artificial ventilation strategy in 177, filling dead animals’ lungs with air from a bellows (8).

In 1628, physician William Harvey, the first to accurately describe circulation, used his newfound knowledge to successfully stop ventricular fibrillation in a pigeon using open heart massage (9 ). John Hunter created a bellows that could deliver positive and negative pressure ventilation, which he used to resuscitate dogs in 1755 (10). The Dutch Humane Society immediately tapped Hunter’s knowledge to help reduce the death rate of drowning victims (11). The resultant 1767 publication was the first ever to advocate the use of “artificial respiration”:

…the operator closed the patient’s nostrils, applied his mouth to the patient’s mouth, inflated the lungs and expanded the chest and belly, and produced expiration by compressing the abdomen with his free hand (12).

Despite giving ventilation equal measure with another popular technique at the time called fumigation―the use of tobacco smoke to fill the colon of drowned victims via a rectal tube―scientists rapidly began to use true physiologic practices to advance resuscitation.

Within eight years, Priestly would discover the element oxygen and Squires of London would record the first-ever use of electricity in resuscitation:

…he tried the effects of electricity. Twenty minutes elapsed before he could apply the shock [to the 3 year old child who had fallen out of a 1st story window], which he gave to various parts of the body in vain; but upon transmitting a few shocks through the thorax, he perceived a small pulsation; in a few minutes the child began to breathe….her health was restored (4).

Resuscitation became a legitimate science during the 19th century with literature replete of experimental successes in laboratory animal resuscitations. Techniques included using closed and open heart massage, manual ventilation using specialized medical bellows, and then finally, in 1899, documented cessation of ventricular fibrillation by electricity. Jean Louis Prevost and Frederic Batelli reported that they had defibrillated a dog successfully with the use of two electrodes―one on the head and one in the rectum―with high voltage AC current (13).

As the 20th century dawned, George Washington Crile―the cofounder of the Cleveland Clinic and considered by many as the most innovative researcher in the field of resuscitation―described successful closed chest cardiac massage in man and the first use of saline and epinephrine infusion in cardiac arrest in 1903. after the Russians Gurvich and Yuniev had demonstrated the superiority of DC current to AC current in defibrillation in 1939, Beck (1947) and Zoll (1956) published their successes in humans of open and closed chest defibrillation respectively.13 Even though the advent of the modern defibrillator loomed imminently, the practicality of widespread dissemination of the cumbersome equipment needed to provide these shocks was not yet manifest. Thus, Kouwenhoven and colleagues created a technique of closed chest cardiac massage that could keep patients alive long enough to receive definitive treatment, and modern CPR was born (14).

Epidemiology of Cardiopulmonary Arrest

In the United States an estimated 375,000 to 750,000 hospitalized patients suffer a cardiopulmonary arrest (CA) requiring advanced cardiac life support (ACLS) annually (15). The incidence of CA is estimated to be as high as 1–2% of all patients admitted to academic hospitals with a prevalence of 58 to 71 people per 100,000 nationally (16,17). The demographics of over 14,000 patients resuscitated for a CA are summarized in Table 1; patient comorbidities are listed in Figure 1.18 The typical CA patient is a white male in his seventh decade of life with a history of cardiac, pulmonary, or renal disease suffering from a pre-arrest arrhythmia or respiratory problem. Over 86% of patients are either on continuous cardiac monitoring (telemetry) or have a witnessed CA.

When primary respiratory arrests are excluded (such as from opiate overdose or post-anesthesia), only approximately 1 in 7 patients will survive an in-hospital resuscitation to discharge (1,19). Survivors’ initial rhythms are typically either pulseless ventricular tachycardia (VT) (35%) or ventricular fibrillation (VF) (34%), but fully 20% of survivors have initial “rhythms” of asystole or pulseless electrical activity (PEA)―which comprise virtually two–thirds of all arrests―suggesting a meager benefit to resuscitation of this subgroup of patients. Almost one third of survivors who lived independently pre-arrest are unable to be discharged home and between 14-23% of survivors―whose pre-arrest neurological function was normal―develop moderate to severe cognitive deficits after resuscitation (18,20). Fewer than 2% of survivors suffer coma or a persistent vegetative state. Neither gender nor advanced age appears to be a negative predictor of survival (1,21).

Time is Life Lost

The goals of resuscitation are two-fold: preservation of neurological function and prevention of early death. Expedient resuscitation maximizes the likelihood of positive outcomes, but too often, precious time is life lost spent performing unnecessary diagnostic maneuvers or unimportant interventions that have little impact on prognosis. The overarching target in in-hospital adult resuscitation is minimizing the time it takes for patients to receive defibrillation. All other activities are only a mean to this end. The remainder of this review will focus on seven highly effective strategies for successful resuscitations.

Primary Survey

Guidelines continue to stress the importance of airway, breathing, and circulation as the basic tenets of initial response to a CA. While this approach has merit in out-of-hospital arrests, it is an anathema in hospitalized patients. Valuable time is often lost trying to ascertain the presence or absence of respirations or pulse. Earle et al. designed a very creative way to gauge the operating characteristics of the carotid pulse check. Providers were asked to assess randomized patients who were to undergo open-heart surgery; some of the patients were already on cardiopulmonary bypass (“true negatives” with no spontaneous pulse) and the remainder were not (“true positives” with a pulse). With a median time of over 30 seconds, care providers could only accurately determine pulselessness 65% of the time (90% sensitivity and 55% specificity).22 Given that this study occurred in a very controlled environment without the drama of a real CA, it is likely that these data would even be worse in the chaos of resuscitation.

First Effective Stratagem: If an unresponsive adult inpatient clinically appears to be suffering a cardiopulmonary arrest, treatment (activation of a “code team” and application of CPR) should be initiated immediately without performing a pulse check.

CPR Physiology and Impact

CPR is a critical bridge to defibrillation but is not an end unto itself. The physiology that occurs during CPR is remarkably complex, and our current understanding is incomplete. Kouwenhoven posited that chest compressions result in a functional equivalent to open cardiac massage (2). In this “cardiac pump model,” the physiology is similar to a surgeon’s hands squeezing the non-beating heart: artificial systole from the down stroke of a compression compresses the heart against the spinal column forcing blood from the ventricles and forcing closure of the mitral and tricuspid valves. During artificial diastole, reversing pressure gradients result in closure of the aortic and pulmonic valves resulting in bi-ventricular filling of blood and perfusion of the coronary arteries.

An alternative model, the “thoracic pump model,” looks at the entire thoracic cavity as a pump with functional “valves” at the thoracic inlet preventing back-flow from the intrathoracic veins into the extrathoracic veins (23). The intrathoracic pressure rapidly increases during artificial systole leading to antegrade flow of blood from vessels under relatively higher pressure (the aorta and the pulmonary vasculature) to blood vessels under relatively lower pressure (the carotid arteries). The elevated intrathoracic pressure collapses the comparably weak vena cava, and, combined with tricuspid valve closure, prevents simultaneous retrograde venous flow. With three of the cardiac valves open during artificial systole, the heart is relegated to the role of a passive conduit for blood rather than providing any meaningful pumping action. During artificial diastole, intrathoracic pressure drops to near zero resulting in transient back flow of blood from the carotid arteries toward the heart. This induces aortic valve closure and generates only meager coronary artery perfusion.

Subsequent work by Paradis et al. shows that, in essence, both “pump” models have equal validity, and one or the other physiology dominates in any given patient (24). Regardless of which type of physiology occurs during resuscitation, neither provides physiologically sufficient circulation to maintain organ viability for long. When performed ideally, chest compressions during actual resuscitations in humans yield systolic blood pressures of only 60–80mmHg; and blood flow of less than one third the normal cardiac output, less than 10–15% of normal cerebral blood flow, and less than 1–5% of normal coronary artery blood flow (25).

Such subphysiologic circulation leaves little latitude for improper technique. Yet, care providers rarely perform chest compressions properly, erring towards too shallow a compression depth 62.6% of the time and too slow a compression rate 71.9% of the time on actual resuscitations―errors that increase in frequency the longer it has been since the caregiver was trained (26,27). Observational data on the quality of CPR suggest that these are not just esoteric technical deviations, but that compared with those in whom CPR is correctly performed, 14-day survival was almost 75% lower in those on whom CPR was incorrectly performed (16% vs. 4%)(28).

Furthermore, routine interruptions in chest compressions― such as for positive pressure ventilations in non-intubated patients―likely further hinder survival rather than contribute meaningfully to outcome. For example, medical students performing traditional CPR took an average of 14 seconds to administer two mouth-to-mouth ventilations after each group of 15 compressions. This effectively reduced the number of compressions to a mere 43 per minute, or less than half the guideline-mandated 100 per minute, thus theoretically reducing circulation to the heart and brain by a similar percentage (29). Yu et al demonstrated that swine receiving more than 80 compressions per minute during CPR had a 100% survival at 24 hours compared with a dismal 10% survival in animals that had less than 80 compressions per minute (30). Kern et al found statistically significantly higher coronary artery perfusion pressures and markedly higher neurological normal 24 hour survival in swine receiving continuous chest compressions compared with controls receiving traditional CPR (31).

Increasingly data such as these do raise the question of what―if any―benefit rescue breathing has in adult resuscitation. Human data show that a strategy of continuous chest compressions―without rescue breathing―is equally efficacious to traditional CPR in terms of outcome (32). Two physiologic theories prevail: 1) the mechanics of chest wall compression may be sufficient to provide a limited minute ventilation independent of supplemental ventilation (author’s speculation); and 2) the improved oxygenation that occurs in those receiving artificial ventilation is offset by the deleterious impact on hemodynamics that occur when chest compressions are interrupted for ventilation (34).

Second Effective Stratagem: Until an adult inpatient can be defibrillated, the focus of resuscitation should be on proper continuous chest compression depth and rate, not on ventilation.

Ventilations are Harmful

click for large version

Cardiopulmonary collapse has immediate consequences on cellular physiology. Both due to a lack of expiration of carbon dioxide and the development of lactatemia due to the shift to anaerobic metabolism, blood pH drops precipitously. As the pH shifts out of the physiologic range, drugs begin to perform in unexpected ways or fail altogether; ion trapping occurs; and many electrolytes begin to shift in or out of cells affecting their serum concentration. Diminished or absent cardiac output accelerates these derangements in a relentless positive feedback loop. Logic, therefore, dictates that anything that can improve oxygenation and ventilation would be helpful at slowing or reversing this pathophysiology. Surprisingly, however, clinicians’ lack of knowledge of both equipment and technique often promotes, rather than mitigates, the physiologic derangements.

The bag-valve-mask (BVM) is one of the least understood resuscitation devices. For example, clinicians occasionally place a BVM over spontaneously breathing patients who are exceptionally ill with the goal of augmenting patients’ meager ventilations. However, the BVM is constructed only for positive pressure ventilation and thus, unless the clinician squeezes the bag in perfect coordination with the patient’s ventilatory effort, the BVM will paradoxically smother the patient.

The bag portion of the BVM is designed for a one-handed squeeze to deliver a tidal volume that is roughly 750cc; this volume is in keeping with guideline recommendations of positive pressure ventilation volumes of roughly 10cc/kg/ventilation (29). Yet, clinicians commonly use two hands to compress the BVM maximally during resuscitation (theoretically delivering upwards of double the recommended volume).

In addition to excessive volume, clinicians also deliver ventilations too rapidly. Abella et al. showed that during human resuscitations, ventilation rate exceeded the recommended goal of 20 ventilations/minute 60.9% of the time (27). Theoretically, high minute ventilations lead to an increased incidence of gastric insufflation, regurgitation, and post-resuscitation aspiration.

Though no studies have ever been performed to understand why clinicians hyperventilate patients during resuscitation, it is interesting to speculate that clinicians are not only trying to raise blood oxygen levels rapidly, but also to reverse the profound metabolic and respiratory acidosis that occur during CA. While seemingly mechanistically sound, the logic that supraphysiologic minute ventilations will profoundly change blood pH without other physiologic costs is specious at best. Aufderheide et al. Demonstrated that hyperventilation during resuscitation in swine resulted in increased intrathoracic pressures, markedly reduced coronary artery perfusion pressures, and resultant proportional reductions in survival rates as hyperventilation increased (35). Clinically these findings are known as auto-PEEP, a known complication of artificial ventilation that results in systemic arterial hypotension. Thus the paradox: aggressive attempts to overcorrect systemic acidoses via higher minute ventilations leads to worsening systemic blood pressures and thus worsening lactic acidosis. I believe that iatrogenic hypotension is one of the most common problems to complicate an otherwise successful resuscitation and that more research is urgently needed on this issue.

Third Effective Stratagem: Bag-valve-mask ventilations should be performed with precision; when used, the bag should be compressed with only one hand and delivered no faster than one breath every 3–5 seconds.

Fourth Effective Stratagem: In cases of pulseless electrical activity (PEA) or post-resuscitation hypotension, auto-PEEP should be considered foremost as a proximal cause.

Fifth Effective Stratagem: Ventilations in resuscitation should be viewed primarily as a means to oxygenate the patient rather than as a means to compensate from a systemic acidemia.

click for large version

Shocking Revelations

Even though patients in ventricular fibrillation (VF) and pulseless ventricular tachycardia (PVT) together only comprise about one–third of all inpatient cardiac arrests, they account for almost 70% of survivors of CA. Survival in these arrhythmias is predicated solely on rapid defibrillation: the simultaneous depolarization of a critical mass of myocytes by an electrical current with resultant resumption of normal cardiac conduction (36). Perhaps the best attestation to the importance of rapid defibrillation actually comes from the survival of patients with cardiac arrest at casinos: security cameras provided exact documentation of time of collapse and defibrillation. Survival to hospital discharge was cut in half when the time-from-collapse-to-defibrillation was greater than 3 minutes (74% vs. 49%)(37).

Sixth Effective Stratagem: Since patients in VF/PVT are the most likely to survive CA―and that rate is directly related to immediacy of defibrillation―all patients should be presumptively treated as if they are in VF/PVT and should be defibrillated within 3 minutes of collapse unless there are data to support another arrhythmia or cause of collapse.

Much of the electrical current delivered during a defibrillation attempt is either dissipated as heat or is conducted around the thorax without penetrating the myocardium; Lerman and Deale have shown that the amount of current reaching the heart may be as little as 4% during a defibrillation attempt (38). From Ohm’s Law, the current that reaches the heart is directly proportional to the voltage across the chest and inversely related to the resistance of the supervening tissues. Interestingly, increasing the voltage of a shock only increases the amount of heat produced without a commensurate increase in current delivered. Therefore, techniques that reduce thoracic resistance yield the highest current delivery: the use of manual defibrillator paddles (as opposed to self adhesive defibrillation pads), the amount of pressure applied to the paddles (>25 pounds), the correct placement (underneath, rather than on top of breast tissue), the use of a conduction material (gel or pads), and the rapid delivery of a stacked shock (resistance transiently decreases after a counter-shock) all improve current delivery and thus may improve defibrillation outcome (36).

Physician leadership during resuscitations is critical for maximizing likelihood of patient survival. Perhaps due to physicians’ lack of familiarity with defibrillators, the mechanics of defibrillation are often deferred unnecessarily to nursing staff. Unfortunately, this may have profoundly negative effects on the resuscitation. Since many hospitals reduce educational expenses by foregoing training nurses in ACLS unless they work in intensive care units, nurses on a code may have even less comfort in using defibrillators than physicians. One study showed nearly a 72.5% decrease in patient survival when the nurse who arrived first at the resuscitation was untrained in ACLS (37.5% vs. 10.3%); a difference that probably is related to delayed defibrillation though the study could not establish direct causality (39).

A separate study showed that 85% of patients on cardiac monitored wards were defibrillated in the target time of 3 minutes from collapse, while only 28% of patients on unmonitored wards were defibrillated within the target time; this led to an adjusted odds ratio for survival-to-discharge in patients on monitored versus non-monitored wards of 1.45 (95% CI, 0.95–2.20)(40). While at first these data seem to indicate faster responses on monitored wards, these data were specific to time-from-collapse-to-defibrillation and therefore should be location-independent once the need for resuscitation was identified. Instead, I interpret these data as showing the lower comfort nurses on non-monitored wards have with rapid defibrillation. Rather than serving as an indictment against nurses, these data in aggregate underscore the vital role physician responders have to ensure rapid defibrillation of patients in cardiac arrest.

Seventh Effective Stratagem: Physicians should aggressively pursue defibrillation as early as possible during resuscitation especially on non-monitored wards where nurses are less likely to be ACLS trained and less likely to be familiar with defibrillator operation.

Conclusions

Resuscitation, the act of bringing back life from imminent death, is one of the most sensationalized practices in medicine and dates almost to the beginning of recorded history. In the past two decades, increasingly evidence-based guidelines have tried to provide a guide to help practitioners treat patients effectively in the minutes after cardiopulmonary collapse. Unfortunately, with each new iteration of the guidelines, it has become increasingly difficult to determine which strategies offer the highest yield or the most import. As ILCOR meets in 2005 to revise the guidelines once again, hopefully the most important strategies will be given their proper highlight, providing clinicians with increased comfort and confidence with cardiopulmonary resuscitation.

Bibliography

1. Brindley PG, Markland DM, Mayers I, Kutsogiannis DJ. Predictors of survival following inhospital adult cardiopulmonary resuscitation. CMAJ. 2002;167:343-8.
2. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed chest cardiac massage. JAMA. 1960;173:1064-7.
3. Jude JR, Kouwenhoven WB, Knickerbocker GG. Cardiac arrest; report of application of external cardiac massage on 118 patients. JAMA. 1961;178:1063-71.
4. Varon J, Sternback GL. Cardiopulmonary resuscitation: lessons from the past. J Emerg Med. 1991;9:5037.
5. Liss HP. A history of resuscitation. Ann Emerg Med.1986;15: 65-72.
6. Thangam S, Weil MH, Rackow EC. Cardiopulmonary resuscitation: a historical review. Acute Care. 1986;12:63-94.
7. Kings II, 4:34-35 (KJV).
8. Baker AB. Artificial respiration: the history of an idea. Med Hist. 1971;15:336-46.
9. Stephenson HE. Cardiac Arrest and Resuscitation. St Louis: CV Mosby; 1969.
10. Lee RV. Cardiopulmonary resuscitation in the eighteenth century: a historical perspective on present practice. J Hist Med. 1972;27:418-33.
11. Varon J, Marik PE, Fromm RE. Cardiopulmonary resuscitation: a review for clinicians. Resuscitation. 1998;36: 133-45.
12. Keith A. Three Hunterian lectures on the various mechanisms underlying the various methods of artificial respiration. Lancet. 1909;1:895-9.
13. DeBard ML. The history of cardiopulmonary resuscitation. Ann Emerg Med. 1980;9:273-5.
14. Acosta P, Varion J, Sternbach GL, BaskeQ P. Resuscitation great. Kouwenhoven, Jude and Knickerbocker: the introduction of defibrillation and external chest compressions into modern resuscitation. Resuscitation. 2005;64:139-43.
15. US Congress, Office of Technology Assessment. Life-sustaining technologies and the elderly. Washington, DC: US Government Printing Office, 1987; 11, Publication OTA-BA-306.
16. DeBard ML. Cardiopulmonary resuscitation: analysis of six years’ experience and review of the literature. Ann Emerg Med. 1981;10:408-11.
17. Cassel CK, et al. Cardiopulmonary resuscitation in the elderly. Office of Technology Assessment, U.S. Congress, Washington, DC, November, 1985.
18. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14 720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003;58297-308.
19. Valentin A, Karnik R, Donath P, Winkler WB, Slany J. Outcome of cardiopulmonary resuscitation in hospitalized patients. Resuscitation. 1995;30:217-21.
20. Robinson GR, Hess D. Postdischarge survival and functional status following in-hospital cardiopulmonary resuscitation. Chest. 1994;105:991-6.
21. Murphy DI, Murray AM, Robinson BE. Outcomes of cardiopulmonary resuscitation in the elderly. Ann Int Med. 1989;111:199-205.
22. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation. 1996;33:107-16.
23. Rudikoff MT, Maughan WL, Effron M, Freund P, Weisfeldt ML. Mechanisms of blood flow during cardiopulmonary resuscitation. Circulation. 1980;61:345-52.
24. Paradis NA, Martin GB, Goetting MG, et al. Simultaneous aortic, jugular bulb, and right atrial pressures during cardiopulmonary resuscitation in humans: insight into mechanisms. Circulation. 1989;80:361-8.
25. Sanders AB, Ogle M, Ewy GA. Coronary perfusion pressure during cardiopulmonary resuscitation. Am J Emerg Med. 1985;3:11-4.
26. Heidenreich JW, Higdon TA, Kern KB, et al. Single-rescuer cardiopulmonary resuscitation: “two quick breaths”―an oxymoron. Resuscitation. 2004;62:283-89.
27. Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA. 2005;293:305-10.
28. Van Hoeyweghen RJ, Bossaert LL, Mullie A, et al. (Belgian Cerebral Resuscitation Study Group.) Quality and efficiency of bystander CPR. Resuscitation. 1993;26:47-52.
29. American Heart Association in collaboration with the International Liaison Committee on Resuscitation (ILCOR). International Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care―a consensus on science. Resuscitation. 2000.46:1-448.
30. Yu T, Weil MH, Tang W, et al. Adverse outcomes of interrupted precordial compression during automated defibrillation. Circulation. 2002;106:368-72.
31. Kern KB, Hilwig RW, Berg RA, Sanders AB, Ewy GA. Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario. Circulation. 2002;105:645-649.
32. Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary resuscitation by chest compression alone or with to-mouth ventilation. N Engl J Med. ;342: 154-653.
33.  
34. Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation. 2001;104:2465-70.
35. Aufderheide TP, Sigurdsson G, Pirallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. 2004;109:1960-5.
36. Dalzell GWN. Determinants of successful defibrillation. Heart. ;80:405-7.
37. Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW,Hardman RG. Outcomes of rapid defibrillation by security ad er cardiac arrest in casinos. N Engl J Med. ;343:120-69.
38. Lerman BB, Deale C. Relation between transcardiac and thransthoracic current during defibrillation in humans. Circ Res. 1990;67:1420-6.
39. Dane FC, RussellLindgren KS, Parish DC, Durham MD, Brown TD. Inhospital resuscitation: association between ACLS training and survival to discharge. Resuscitation. 2000;47:83-7.
40. Herlitz J, Bang A, Aune S, Ekstrom L, Lundstrom G, Holmberg S. Characteristics and outcome among patients suffering inhospital cardiac arrest in monitored and nonmonitored areas. Resuscitation. ;48:125-35.

Despite more intensive guidelines and advances in resuscitation research, the survival rate for victims of cardiopulmonary arrest remains virtually unchanged from forty years ago when modern cardiopulmonary resuscitation (CPR) was first described (1). Perhaps in part because the guidelines for ACLS set forth by the American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) have become so complex―and continue to increase in breadth and scope into topics well beyond cardiopulmonary arrest with each revision―the critical aspects of resuscitation have become diluted by unnecessarily difficult algorithms. Critical skill sets―such as proper performance of CPR and rapid defibrillation―have become dwarfed by less critical aspects of acute resuscitation. Remarkably common errors usurp the dual fundamental goals of ACLS: neurological preservation and prevention of early death. This review will address the historical context of resuscitation and then will focus on seven of the most essential, evidence-based strategies for improving outcomes in ACLS.

History of Resuscitation

The modern resuscitation era began in 1960 when Kouwenhoven, Jude, and Knickerbocker published a pair of landmark papers on the use of closed chest compressions (CCC) as a means to resuscitate patients in cardiopulmonary arrest (2,3). Interestingly, the culmination of their three and a half decades of work was initially motivated and sponsored by an electric company seeking to reduce the death rate of its linemen from ventricular fibrillation. While innovative, their technique built on millennia of creative, and sometimes bizarre ancient practices geared at reversing death. Given the lack of in-depth knowledge of anatomy and physiology combined with a rich overlap between shamanism and medicine, it is perhaps stunning to realize that the oldest recorded reasonably physiologic approach to resuscitation stems from over 3500 years ago. Egyptian hieroglyphs show the story of the healing goddess, Isis, reviving her husband Osiris using mouth-to-mouth ventilation (4). Still other Egyptian texts advocated hanging drowned victims upside down, compressing and releasing the thorax with the goal to ventilate and revive the patient (5). Hebrew midwives were documented as having performed mouth-to-mouth on deceased newborns as early as 1300 BCE (6). And even the Bible tells of the prophet Elishah’s successful resuscitation of a deceased child through artificial respiration:

...And he went up, and lay upon the child, and put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his hands; and he stretched himself upon the child; and the flesh of the child waxed warm (7).

One of the forefathers of modern medicine, the Greek physician Galen, was the first doctor to use an artificial ventilation strategy in 177, filling dead animals’ lungs with air from a bellows (8).

In 1628, physician William Harvey, the first to accurately describe circulation, used his newfound knowledge to successfully stop ventricular fibrillation in a pigeon using open heart massage (9 ). John Hunter created a bellows that could deliver positive and negative pressure ventilation, which he used to resuscitate dogs in 1755 (10). The Dutch Humane Society immediately tapped Hunter’s knowledge to help reduce the death rate of drowning victims (11). The resultant 1767 publication was the first ever to advocate the use of “artificial respiration”:

…the operator closed the patient’s nostrils, applied his mouth to the patient’s mouth, inflated the lungs and expanded the chest and belly, and produced expiration by compressing the abdomen with his free hand (12).

Despite giving ventilation equal measure with another popular technique at the time called fumigation―the use of tobacco smoke to fill the colon of drowned victims via a rectal tube―scientists rapidly began to use true physiologic practices to advance resuscitation.

Within eight years, Priestly would discover the element oxygen and Squires of London would record the first-ever use of electricity in resuscitation:

…he tried the effects of electricity. Twenty minutes elapsed before he could apply the shock [to the 3 year old child who had fallen out of a 1st story window], which he gave to various parts of the body in vain; but upon transmitting a few shocks through the thorax, he perceived a small pulsation; in a few minutes the child began to breathe….her health was restored (4).

Resuscitation became a legitimate science during the 19th century with literature replete of experimental successes in laboratory animal resuscitations. Techniques included using closed and open heart massage, manual ventilation using specialized medical bellows, and then finally, in 1899, documented cessation of ventricular fibrillation by electricity. Jean Louis Prevost and Frederic Batelli reported that they had defibrillated a dog successfully with the use of two electrodes―one on the head and one in the rectum―with high voltage AC current (13).

As the 20th century dawned, George Washington Crile―the cofounder of the Cleveland Clinic and considered by many as the most innovative researcher in the field of resuscitation―described successful closed chest cardiac massage in man and the first use of saline and epinephrine infusion in cardiac arrest in 1903. after the Russians Gurvich and Yuniev had demonstrated the superiority of DC current to AC current in defibrillation in 1939, Beck (1947) and Zoll (1956) published their successes in humans of open and closed chest defibrillation respectively.13 Even though the advent of the modern defibrillator loomed imminently, the practicality of widespread dissemination of the cumbersome equipment needed to provide these shocks was not yet manifest. Thus, Kouwenhoven and colleagues created a technique of closed chest cardiac massage that could keep patients alive long enough to receive definitive treatment, and modern CPR was born (14).

Epidemiology of Cardiopulmonary Arrest

In the United States an estimated 375,000 to 750,000 hospitalized patients suffer a cardiopulmonary arrest (CA) requiring advanced cardiac life support (ACLS) annually (15). The incidence of CA is estimated to be as high as 1–2% of all patients admitted to academic hospitals with a prevalence of 58 to 71 people per 100,000 nationally (16,17). The demographics of over 14,000 patients resuscitated for a CA are summarized in Table 1; patient comorbidities are listed in Figure 1.18 The typical CA patient is a white male in his seventh decade of life with a history of cardiac, pulmonary, or renal disease suffering from a pre-arrest arrhythmia or respiratory problem. Over 86% of patients are either on continuous cardiac monitoring (telemetry) or have a witnessed CA.

When primary respiratory arrests are excluded (such as from opiate overdose or post-anesthesia), only approximately 1 in 7 patients will survive an in-hospital resuscitation to discharge (1,19). Survivors’ initial rhythms are typically either pulseless ventricular tachycardia (VT) (35%) or ventricular fibrillation (VF) (34%), but fully 20% of survivors have initial “rhythms” of asystole or pulseless electrical activity (PEA)―which comprise virtually two–thirds of all arrests―suggesting a meager benefit to resuscitation of this subgroup of patients. Almost one third of survivors who lived independently pre-arrest are unable to be discharged home and between 14-23% of survivors―whose pre-arrest neurological function was normal―develop moderate to severe cognitive deficits after resuscitation (18,20). Fewer than 2% of survivors suffer coma or a persistent vegetative state. Neither gender nor advanced age appears to be a negative predictor of survival (1,21).

Time is Life Lost

The goals of resuscitation are two-fold: preservation of neurological function and prevention of early death. Expedient resuscitation maximizes the likelihood of positive outcomes, but too often, precious time is life lost spent performing unnecessary diagnostic maneuvers or unimportant interventions that have little impact on prognosis. The overarching target in in-hospital adult resuscitation is minimizing the time it takes for patients to receive defibrillation. All other activities are only a mean to this end. The remainder of this review will focus on seven highly effective strategies for successful resuscitations.

Primary Survey

Guidelines continue to stress the importance of airway, breathing, and circulation as the basic tenets of initial response to a CA. While this approach has merit in out-of-hospital arrests, it is an anathema in hospitalized patients. Valuable time is often lost trying to ascertain the presence or absence of respirations or pulse. Earle et al. designed a very creative way to gauge the operating characteristics of the carotid pulse check. Providers were asked to assess randomized patients who were to undergo open-heart surgery; some of the patients were already on cardiopulmonary bypass (“true negatives” with no spontaneous pulse) and the remainder were not (“true positives” with a pulse). With a median time of over 30 seconds, care providers could only accurately determine pulselessness 65% of the time (90% sensitivity and 55% specificity).22 Given that this study occurred in a very controlled environment without the drama of a real CA, it is likely that these data would even be worse in the chaos of resuscitation.

First Effective Stratagem: If an unresponsive adult inpatient clinically appears to be suffering a cardiopulmonary arrest, treatment (activation of a “code team” and application of CPR) should be initiated immediately without performing a pulse check.

CPR Physiology and Impact

CPR is a critical bridge to defibrillation but is not an end unto itself. The physiology that occurs during CPR is remarkably complex, and our current understanding is incomplete. Kouwenhoven posited that chest compressions result in a functional equivalent to open cardiac massage (2). In this “cardiac pump model,” the physiology is similar to a surgeon’s hands squeezing the non-beating heart: artificial systole from the down stroke of a compression compresses the heart against the spinal column forcing blood from the ventricles and forcing closure of the mitral and tricuspid valves. During artificial diastole, reversing pressure gradients result in closure of the aortic and pulmonic valves resulting in bi-ventricular filling of blood and perfusion of the coronary arteries.

An alternative model, the “thoracic pump model,” looks at the entire thoracic cavity as a pump with functional “valves” at the thoracic inlet preventing back-flow from the intrathoracic veins into the extrathoracic veins (23). The intrathoracic pressure rapidly increases during artificial systole leading to antegrade flow of blood from vessels under relatively higher pressure (the aorta and the pulmonary vasculature) to blood vessels under relatively lower pressure (the carotid arteries). The elevated intrathoracic pressure collapses the comparably weak vena cava, and, combined with tricuspid valve closure, prevents simultaneous retrograde venous flow. With three of the cardiac valves open during artificial systole, the heart is relegated to the role of a passive conduit for blood rather than providing any meaningful pumping action. During artificial diastole, intrathoracic pressure drops to near zero resulting in transient back flow of blood from the carotid arteries toward the heart. This induces aortic valve closure and generates only meager coronary artery perfusion.

Subsequent work by Paradis et al. shows that, in essence, both “pump” models have equal validity, and one or the other physiology dominates in any given patient (24). Regardless of which type of physiology occurs during resuscitation, neither provides physiologically sufficient circulation to maintain organ viability for long. When performed ideally, chest compressions during actual resuscitations in humans yield systolic blood pressures of only 60–80mmHg; and blood flow of less than one third the normal cardiac output, less than 10–15% of normal cerebral blood flow, and less than 1–5% of normal coronary artery blood flow (25).

Such subphysiologic circulation leaves little latitude for improper technique. Yet, care providers rarely perform chest compressions properly, erring towards too shallow a compression depth 62.6% of the time and too slow a compression rate 71.9% of the time on actual resuscitations―errors that increase in frequency the longer it has been since the caregiver was trained (26,27). Observational data on the quality of CPR suggest that these are not just esoteric technical deviations, but that compared with those in whom CPR is correctly performed, 14-day survival was almost 75% lower in those on whom CPR was incorrectly performed (16% vs. 4%)(28).

Furthermore, routine interruptions in chest compressions― such as for positive pressure ventilations in non-intubated patients―likely further hinder survival rather than contribute meaningfully to outcome. For example, medical students performing traditional CPR took an average of 14 seconds to administer two mouth-to-mouth ventilations after each group of 15 compressions. This effectively reduced the number of compressions to a mere 43 per minute, or less than half the guideline-mandated 100 per minute, thus theoretically reducing circulation to the heart and brain by a similar percentage (29). Yu et al demonstrated that swine receiving more than 80 compressions per minute during CPR had a 100% survival at 24 hours compared with a dismal 10% survival in animals that had less than 80 compressions per minute (30). Kern et al found statistically significantly higher coronary artery perfusion pressures and markedly higher neurological normal 24 hour survival in swine receiving continuous chest compressions compared with controls receiving traditional CPR (31).

Increasingly data such as these do raise the question of what―if any―benefit rescue breathing has in adult resuscitation. Human data show that a strategy of continuous chest compressions―without rescue breathing―is equally efficacious to traditional CPR in terms of outcome (32). Two physiologic theories prevail: 1) the mechanics of chest wall compression may be sufficient to provide a limited minute ventilation independent of supplemental ventilation (author’s speculation); and 2) the improved oxygenation that occurs in those receiving artificial ventilation is offset by the deleterious impact on hemodynamics that occur when chest compressions are interrupted for ventilation (34).

Second Effective Stratagem: Until an adult inpatient can be defibrillated, the focus of resuscitation should be on proper continuous chest compression depth and rate, not on ventilation.

Ventilations are Harmful

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Cardiopulmonary collapse has immediate consequences on cellular physiology. Both due to a lack of expiration of carbon dioxide and the development of lactatemia due to the shift to anaerobic metabolism, blood pH drops precipitously. As the pH shifts out of the physiologic range, drugs begin to perform in unexpected ways or fail altogether; ion trapping occurs; and many electrolytes begin to shift in or out of cells affecting their serum concentration. Diminished or absent cardiac output accelerates these derangements in a relentless positive feedback loop. Logic, therefore, dictates that anything that can improve oxygenation and ventilation would be helpful at slowing or reversing this pathophysiology. Surprisingly, however, clinicians’ lack of knowledge of both equipment and technique often promotes, rather than mitigates, the physiologic derangements.

The bag-valve-mask (BVM) is one of the least understood resuscitation devices. For example, clinicians occasionally place a BVM over spontaneously breathing patients who are exceptionally ill with the goal of augmenting patients’ meager ventilations. However, the BVM is constructed only for positive pressure ventilation and thus, unless the clinician squeezes the bag in perfect coordination with the patient’s ventilatory effort, the BVM will paradoxically smother the patient.

The bag portion of the BVM is designed for a one-handed squeeze to deliver a tidal volume that is roughly 750cc; this volume is in keeping with guideline recommendations of positive pressure ventilation volumes of roughly 10cc/kg/ventilation (29). Yet, clinicians commonly use two hands to compress the BVM maximally during resuscitation (theoretically delivering upwards of double the recommended volume).

In addition to excessive volume, clinicians also deliver ventilations too rapidly. Abella et al. showed that during human resuscitations, ventilation rate exceeded the recommended goal of 20 ventilations/minute 60.9% of the time (27). Theoretically, high minute ventilations lead to an increased incidence of gastric insufflation, regurgitation, and post-resuscitation aspiration.

Though no studies have ever been performed to understand why clinicians hyperventilate patients during resuscitation, it is interesting to speculate that clinicians are not only trying to raise blood oxygen levels rapidly, but also to reverse the profound metabolic and respiratory acidosis that occur during CA. While seemingly mechanistically sound, the logic that supraphysiologic minute ventilations will profoundly change blood pH without other physiologic costs is specious at best. Aufderheide et al. Demonstrated that hyperventilation during resuscitation in swine resulted in increased intrathoracic pressures, markedly reduced coronary artery perfusion pressures, and resultant proportional reductions in survival rates as hyperventilation increased (35). Clinically these findings are known as auto-PEEP, a known complication of artificial ventilation that results in systemic arterial hypotension. Thus the paradox: aggressive attempts to overcorrect systemic acidoses via higher minute ventilations leads to worsening systemic blood pressures and thus worsening lactic acidosis. I believe that iatrogenic hypotension is one of the most common problems to complicate an otherwise successful resuscitation and that more research is urgently needed on this issue.

Third Effective Stratagem: Bag-valve-mask ventilations should be performed with precision; when used, the bag should be compressed with only one hand and delivered no faster than one breath every 3–5 seconds.

Fourth Effective Stratagem: In cases of pulseless electrical activity (PEA) or post-resuscitation hypotension, auto-PEEP should be considered foremost as a proximal cause.

Fifth Effective Stratagem: Ventilations in resuscitation should be viewed primarily as a means to oxygenate the patient rather than as a means to compensate from a systemic acidemia.

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Shocking Revelations

Even though patients in ventricular fibrillation (VF) and pulseless ventricular tachycardia (PVT) together only comprise about one–third of all inpatient cardiac arrests, they account for almost 70% of survivors of CA. Survival in these arrhythmias is predicated solely on rapid defibrillation: the simultaneous depolarization of a critical mass of myocytes by an electrical current with resultant resumption of normal cardiac conduction (36). Perhaps the best attestation to the importance of rapid defibrillation actually comes from the survival of patients with cardiac arrest at casinos: security cameras provided exact documentation of time of collapse and defibrillation. Survival to hospital discharge was cut in half when the time-from-collapse-to-defibrillation was greater than 3 minutes (74% vs. 49%)(37).

Sixth Effective Stratagem: Since patients in VF/PVT are the most likely to survive CA―and that rate is directly related to immediacy of defibrillation―all patients should be presumptively treated as if they are in VF/PVT and should be defibrillated within 3 minutes of collapse unless there are data to support another arrhythmia or cause of collapse.

Much of the electrical current delivered during a defibrillation attempt is either dissipated as heat or is conducted around the thorax without penetrating the myocardium; Lerman and Deale have shown that the amount of current reaching the heart may be as little as 4% during a defibrillation attempt (38). From Ohm’s Law, the current that reaches the heart is directly proportional to the voltage across the chest and inversely related to the resistance of the supervening tissues. Interestingly, increasing the voltage of a shock only increases the amount of heat produced without a commensurate increase in current delivered. Therefore, techniques that reduce thoracic resistance yield the highest current delivery: the use of manual defibrillator paddles (as opposed to self adhesive defibrillation pads), the amount of pressure applied to the paddles (>25 pounds), the correct placement (underneath, rather than on top of breast tissue), the use of a conduction material (gel or pads), and the rapid delivery of a stacked shock (resistance transiently decreases after a counter-shock) all improve current delivery and thus may improve defibrillation outcome (36).

Physician leadership during resuscitations is critical for maximizing likelihood of patient survival. Perhaps due to physicians’ lack of familiarity with defibrillators, the mechanics of defibrillation are often deferred unnecessarily to nursing staff. Unfortunately, this may have profoundly negative effects on the resuscitation. Since many hospitals reduce educational expenses by foregoing training nurses in ACLS unless they work in intensive care units, nurses on a code may have even less comfort in using defibrillators than physicians. One study showed nearly a 72.5% decrease in patient survival when the nurse who arrived first at the resuscitation was untrained in ACLS (37.5% vs. 10.3%); a difference that probably is related to delayed defibrillation though the study could not establish direct causality (39).

A separate study showed that 85% of patients on cardiac monitored wards were defibrillated in the target time of 3 minutes from collapse, while only 28% of patients on unmonitored wards were defibrillated within the target time; this led to an adjusted odds ratio for survival-to-discharge in patients on monitored versus non-monitored wards of 1.45 (95% CI, 0.95–2.20)(40). While at first these data seem to indicate faster responses on monitored wards, these data were specific to time-from-collapse-to-defibrillation and therefore should be location-independent once the need for resuscitation was identified. Instead, I interpret these data as showing the lower comfort nurses on non-monitored wards have with rapid defibrillation. Rather than serving as an indictment against nurses, these data in aggregate underscore the vital role physician responders have to ensure rapid defibrillation of patients in cardiac arrest.

Seventh Effective Stratagem: Physicians should aggressively pursue defibrillation as early as possible during resuscitation especially on non-monitored wards where nurses are less likely to be ACLS trained and less likely to be familiar with defibrillator operation.

Conclusions

Resuscitation, the act of bringing back life from imminent death, is one of the most sensationalized practices in medicine and dates almost to the beginning of recorded history. In the past two decades, increasingly evidence-based guidelines have tried to provide a guide to help practitioners treat patients effectively in the minutes after cardiopulmonary collapse. Unfortunately, with each new iteration of the guidelines, it has become increasingly difficult to determine which strategies offer the highest yield or the most import. As ILCOR meets in 2005 to revise the guidelines once again, hopefully the most important strategies will be given their proper highlight, providing clinicians with increased comfort and confidence with cardiopulmonary resuscitation.

Bibliography

1. Brindley PG, Markland DM, Mayers I, Kutsogiannis DJ. Predictors of survival following inhospital adult cardiopulmonary resuscitation. CMAJ. 2002;167:343-8.
2. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed chest cardiac massage. JAMA. 1960;173:1064-7.
3. Jude JR, Kouwenhoven WB, Knickerbocker GG. Cardiac arrest; report of application of external cardiac massage on 118 patients. JAMA. 1961;178:1063-71.
4. Varon J, Sternback GL. Cardiopulmonary resuscitation: lessons from the past. J Emerg Med. 1991;9:5037.
5. Liss HP. A history of resuscitation. Ann Emerg Med.1986;15: 65-72.
6. Thangam S, Weil MH, Rackow EC. Cardiopulmonary resuscitation: a historical review. Acute Care. 1986;12:63-94.
7. Kings II, 4:34-35 (KJV).
8. Baker AB. Artificial respiration: the history of an idea. Med Hist. 1971;15:336-46.
9. Stephenson HE. Cardiac Arrest and Resuscitation. St Louis: CV Mosby; 1969.
10. Lee RV. Cardiopulmonary resuscitation in the eighteenth century: a historical perspective on present practice. J Hist Med. 1972;27:418-33.
11. Varon J, Marik PE, Fromm RE. Cardiopulmonary resuscitation: a review for clinicians. Resuscitation. 1998;36: 133-45.
12. Keith A. Three Hunterian lectures on the various mechanisms underlying the various methods of artificial respiration. Lancet. 1909;1:895-9.
13. DeBard ML. The history of cardiopulmonary resuscitation. Ann Emerg Med. 1980;9:273-5.
14. Acosta P, Varion J, Sternbach GL, BaskeQ P. Resuscitation great. Kouwenhoven, Jude and Knickerbocker: the introduction of defibrillation and external chest compressions into modern resuscitation. Resuscitation. 2005;64:139-43.
15. US Congress, Office of Technology Assessment. Life-sustaining technologies and the elderly. Washington, DC: US Government Printing Office, 1987; 11, Publication OTA-BA-306.
16. DeBard ML. Cardiopulmonary resuscitation: analysis of six years’ experience and review of the literature. Ann Emerg Med. 1981;10:408-11.
17. Cassel CK, et al. Cardiopulmonary resuscitation in the elderly. Office of Technology Assessment, U.S. Congress, Washington, DC, November, 1985.
18. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14 720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003;58297-308.
19. Valentin A, Karnik R, Donath P, Winkler WB, Slany J. Outcome of cardiopulmonary resuscitation in hospitalized patients. Resuscitation. 1995;30:217-21.
20. Robinson GR, Hess D. Postdischarge survival and functional status following in-hospital cardiopulmonary resuscitation. Chest. 1994;105:991-6.
21. Murphy DI, Murray AM, Robinson BE. Outcomes of cardiopulmonary resuscitation in the elderly. Ann Int Med. 1989;111:199-205.
22. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation. 1996;33:107-16.
23. Rudikoff MT, Maughan WL, Effron M, Freund P, Weisfeldt ML. Mechanisms of blood flow during cardiopulmonary resuscitation. Circulation. 1980;61:345-52.
24. Paradis NA, Martin GB, Goetting MG, et al. Simultaneous aortic, jugular bulb, and right atrial pressures during cardiopulmonary resuscitation in humans: insight into mechanisms. Circulation. 1989;80:361-8.
25. Sanders AB, Ogle M, Ewy GA. Coronary perfusion pressure during cardiopulmonary resuscitation. Am J Emerg Med. 1985;3:11-4.
26. Heidenreich JW, Higdon TA, Kern KB, et al. Single-rescuer cardiopulmonary resuscitation: “two quick breaths”―an oxymoron. Resuscitation. 2004;62:283-89.
27. Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA. 2005;293:305-10.
28. Van Hoeyweghen RJ, Bossaert LL, Mullie A, et al. (Belgian Cerebral Resuscitation Study Group.) Quality and efficiency of bystander CPR. Resuscitation. 1993;26:47-52.
29. American Heart Association in collaboration with the International Liaison Committee on Resuscitation (ILCOR). International Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care―a consensus on science. Resuscitation. 2000.46:1-448.
30. Yu T, Weil MH, Tang W, et al. Adverse outcomes of interrupted precordial compression during automated defibrillation. Circulation. 2002;106:368-72.
31. Kern KB, Hilwig RW, Berg RA, Sanders AB, Ewy GA. Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario. Circulation. 2002;105:645-649.
32. Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary resuscitation by chest compression alone or with to-mouth ventilation. N Engl J Med. ;342: 154-653.
33.  
34. Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation. 2001;104:2465-70.
35. Aufderheide TP, Sigurdsson G, Pirallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. 2004;109:1960-5.
36. Dalzell GWN. Determinants of successful defibrillation. Heart. ;80:405-7.
37. Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW,Hardman RG. Outcomes of rapid defibrillation by security ad er cardiac arrest in casinos. N Engl J Med. ;343:120-69.
38. Lerman BB, Deale C. Relation between transcardiac and thransthoracic current during defibrillation in humans. Circ Res. 1990;67:1420-6.
39. Dane FC, RussellLindgren KS, Parish DC, Durham MD, Brown TD. Inhospital resuscitation: association between ACLS training and survival to discharge. Resuscitation. 2000;47:83-7.
40. Herlitz J, Bang A, Aune S, Ekstrom L, Lundstrom G, Holmberg S. Characteristics and outcome among patients suffering inhospital cardiac arrest in monitored and nonmonitored areas. Resuscitation. ;48:125-35.

The interval between hospital discharge and the continuity provider’s first post-hospital patient visit is being increasingly recognized as a hazardous hiatus (1). The patient is vulnerable to a variety of factors that may result in morbidity or hospital readmission, including the recurrence of symptoms that prompted the initial hospitalization, adverse drug events from new medications, new drug-drug interactions, or issues of care coordination, such as followup visits and tests. Inadequate social support can further exacerbate the medical complexity of care transition from the inpatient to the outpatient setting.

Many post-discharge adverse events are preventable or “ameliorable” by careful discharge planning and timely followup (1). However, existing guidelines and standards regarding the discharge process have been disease specific and have not focused on populations, such as the elderly, that may be at especially high risk regardless of their specific medical issues. For example, CMS currently requires that all patients have an assessment of cognition, mobility, and family support before final discharge plans are set. Experienced hospitalists know that these basic elements are only the beginning of a more complex and robust algorithm of discharge planning; including trimming and reconciling medications; planning followup tests; engineering followup appointments; and activating any required community resources, durable medical good needs, or home health care. In fact, many SHM members have already begun to implement local strategies to ease the care transition at the time of discharge.

The SHM Hospital Quality & Patient Safety (HQPS) Committee believes that hospitalists will play an important role in shaping the ideal discharge process. With support from the Hartford foundation, HQPS has formulated a strategy to develop “discharge best practices,” integrating evidence-based care with the experience and expert opinion of hospitalist leaders. To our knowledge, no national society or professional organization has undertaken such an activity to improve the quality of care at discharge and after hospitalization.

click for large version

The process began with a literature review in 2004 that showed no commonly accepted compendium or consolidated list of activities that could form the basis for the ideal discharge. Drawing upon SHM member experience and the literature, HQPS committee members formulated a list of potential best practices, which are presented in Table 1. Although many discharge activities are required and many are done automatically (such as writing a discharge order or prescriptions) the committee chose to focus on important but discretionary activities that may be overlooked by a busy physician. To complement this checklist of activities, the committee is developing a discharge framework with the input of experts in the area of care transitions.

The committee held a consensus-building workshop at the SHM annual meeting entitled “Developing the Ideal Discharge Process.” This session provided a forum to discuss the checklist of best practices and discharge framework with attendees, receive their feedback, and identify hospitalists interested in validating and refining the materials over time. The committee will continue revising the materials in 2005, with the goal of developing a usable and valuable consensus statement addressing the steps involved in the ideal hospital discharge.

References

1. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-7.
2. Guidelines for appropriate use of “Do-Not-Resuscitate” orders. Council on Ethical and Judicial Affairs. American Medical Association. JAMA. 1991;265:1868-71.
3. Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “getup and go” test. Arch Phys Med Rehabil. 1986;67:387-9.
4. Manning DM, Keller AS, Frank DL. Independent Mobility Validation Exam (IMOVE): A tool for periodic reassessment of fallrisk and discharge planning. Abstract and poster presentation at SHM (formerly NAIP) 5th Annual Meeting in Philadelphia, PA, on April 9, 2002.
5. van Walraven C, Mamdani M, Fang J, Austin PC. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004;19:624-31.
6. van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during the post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17:186-92.
7. Whitford K, Huddleston JM. Specific appointments after pneumonia hospitalization reduce readmissions. Abstract and Poster presentation at SHM (formerly NAIP) 5th Annual Meeting in Philadelphia, PA, on April 9, 2002.
8. JCAHO Manual: Information Management (IM) 6.10 and Patient Care (PC) 15.30.
9. Lewis T. Using the NO TEARS tool for medication review. BMJ. 2004;329:434.
10. Whittington J, Cohen H. OSF healthcare’s journey in patient safety. Qual Manag Health Care. 2004;13:53-9.
11. Kucukarslan SN, Peters M, Mlynarek M, Nafziger D. Pharmacists on rounding teams reduce preventable adverse events in hospital general medicine units. Arch Intern Med. 2003;163:2014-18.
12. Dudas V, Bookwalter T, Kerr K, Pantilat SZ. The impact of followup telephone calls to patients after hospitalization. Am J Med. 2001;111(9B):26S-30S.
13. Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004.
14. Manning DM. Toward safer warfarin therapy: does precise daily dosing improve international normalized ratio control? Mayo Clin Proc. 2002;77:873-5.

Resources (including Medline Search: “patient discharge” and/ or “quality indicators” and “quality of care”):

1. Bull MJ, Hansen HE, Gross CR. Predictors of elder and family caregiver satisfaction with discharge planning. J Cardiovasc Nurs. 2000;14:76-87.
2. Charles C, Gauld M, Chambers L, O’Brien B, Haynes RB, Labelle R. How was your hospital stay? Patients’ report about their care in Canadian hospitals. CMAJ. 1994; 150:1813-22.
3. Cleary PD. A hospitalization from hell: a patient’s perspective on quality. Ann Intern Med. 2003:138:33-9.
4. Demlo LK, Campbell PM. Improving hospital discharge data: lessons from the National Hospital Discharge Survey. Med Care. 1981 Oct;19(10):1030-40.
5. Felden JM, scott S, Horne JG. An investigation of patient satisfaction following discharge after total hip replacement surgery. Orthop Nurs. 2003;22:429-36.
6. Frain JP, Frain AE, Carr PH. Experience of medical senior house officers in preparing discharge summaries. BMJ. 1996;312:350.
7. Gombeski WR, Miller PJ, Hahn JH, et al. Patient callback program. J Health Care Mark 1993;13:60-5.
8. Hickey ML, Kleefield SF, Pearson SD, et al. Payer-hospital collaboration to improve patient satisfaction with hospital discharge. Jt Comm J Qual Improv. 1996;22:336-44.
9. Kroenke K, Stump T, Clark DO, Callahan CM, McDonald CJ. Symptoms in hospitalized patients: outcome and satisfaction with care. Am J Med 1999;107: 425-31.
10. Macaulay EM, Cooper GC, Engeset J, Naylor AR. Prospective audit of discharge summary errors. Br J Surg. 1996;83:788-90.
11. Moher D, Weinberg A, Hanlon R, Runnalls K. Effects of a medical team coordinator on length of hospital stay. CMAJ. 1992;146:511-5.
12. Minnick A, Young WB. Comparison between reports of care obtained by post-discharge telephone interview and pre-discharge personal interview. Outcomes Manag Nurs Pract 1999;3:32-7.
13. Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home followup of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-20.
14. Parkes J, Shepperd S. Discharge planning from hospital to home. Cochrane Database Syst Rev. 2004. Review.
15. Reiley P, Pike A, Phipps M, et al. Learning from patients: a discharge planning improvement project. Jt Comm J Qual Improv. 1996;22:31122.
16. van Walraven C, Weinberg AL. Quality assessment of a discharge summary system. CMAJ. 1995;152:1437-42.
17. van Walraven C, Rokosh E. What is necessary for high-quality discharge summaries? Am J Med Qual. 1999;14: 160-9.
18. Zwicker D, Picariello G. Discharge planning for the older adult. In: Mezey M, Fulmer T, Abraaham I, Zwicker D, eds. Geriatric Nursing Protocols for Best Practice. 2nd ed. New York: Springer Publishing 2003;292-316.

The interval between hospital discharge and the continuity provider’s first post-hospital patient visit is being increasingly recognized as a hazardous hiatus (1). The patient is vulnerable to a variety of factors that may result in morbidity or hospital readmission, including the recurrence of symptoms that prompted the initial hospitalization, adverse drug events from new medications, new drug-drug interactions, or issues of care coordination, such as followup visits and tests. Inadequate social support can further exacerbate the medical complexity of care transition from the inpatient to the outpatient setting.

Many post-discharge adverse events are preventable or “ameliorable” by careful discharge planning and timely followup (1). However, existing guidelines and standards regarding the discharge process have been disease specific and have not focused on populations, such as the elderly, that may be at especially high risk regardless of their specific medical issues. For example, CMS currently requires that all patients have an assessment of cognition, mobility, and family support before final discharge plans are set. Experienced hospitalists know that these basic elements are only the beginning of a more complex and robust algorithm of discharge planning; including trimming and reconciling medications; planning followup tests; engineering followup appointments; and activating any required community resources, durable medical good needs, or home health care. In fact, many SHM members have already begun to implement local strategies to ease the care transition at the time of discharge.

The SHM Hospital Quality & Patient Safety (HQPS) Committee believes that hospitalists will play an important role in shaping the ideal discharge process. With support from the Hartford foundation, HQPS has formulated a strategy to develop “discharge best practices,” integrating evidence-based care with the experience and expert opinion of hospitalist leaders. To our knowledge, no national society or professional organization has undertaken such an activity to improve the quality of care at discharge and after hospitalization.

click for large version

The process began with a literature review in 2004 that showed no commonly accepted compendium or consolidated list of activities that could form the basis for the ideal discharge. Drawing upon SHM member experience and the literature, HQPS committee members formulated a list of potential best practices, which are presented in Table 1. Although many discharge activities are required and many are done automatically (such as writing a discharge order or prescriptions) the committee chose to focus on important but discretionary activities that may be overlooked by a busy physician. To complement this checklist of activities, the committee is developing a discharge framework with the input of experts in the area of care transitions.

The committee held a consensus-building workshop at the SHM annual meeting entitled “Developing the Ideal Discharge Process.” This session provided a forum to discuss the checklist of best practices and discharge framework with attendees, receive their feedback, and identify hospitalists interested in validating and refining the materials over time. The committee will continue revising the materials in 2005, with the goal of developing a usable and valuable consensus statement addressing the steps involved in the ideal hospital discharge.

References

1. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-7.
2. Guidelines for appropriate use of “Do-Not-Resuscitate” orders. Council on Ethical and Judicial Affairs. American Medical Association. JAMA. 1991;265:1868-71.
3. Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “getup and go” test. Arch Phys Med Rehabil. 1986;67:387-9.
4. Manning DM, Keller AS, Frank DL. Independent Mobility Validation Exam (IMOVE): A tool for periodic reassessment of fallrisk and discharge planning. Abstract and poster presentation at SHM (formerly NAIP) 5th Annual Meeting in Philadelphia, PA, on April 9, 2002.
5. van Walraven C, Mamdani M, Fang J, Austin PC. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004;19:624-31.
6. van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during the post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17:186-92.
7. Whitford K, Huddleston JM. Specific appointments after pneumonia hospitalization reduce readmissions. Abstract and Poster presentation at SHM (formerly NAIP) 5th Annual Meeting in Philadelphia, PA, on April 9, 2002.
8. JCAHO Manual: Information Management (IM) 6.10 and Patient Care (PC) 15.30.
9. Lewis T. Using the NO TEARS tool for medication review. BMJ. 2004;329:434.
10. Whittington J, Cohen H. OSF healthcare’s journey in patient safety. Qual Manag Health Care. 2004;13:53-9.
11. Kucukarslan SN, Peters M, Mlynarek M, Nafziger D. Pharmacists on rounding teams reduce preventable adverse events in hospital general medicine units. Arch Intern Med. 2003;163:2014-18.
12. Dudas V, Bookwalter T, Kerr K, Pantilat SZ. The impact of followup telephone calls to patients after hospitalization. Am J Med. 2001;111(9B):26S-30S.
13. Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004.
14. Manning DM. Toward safer warfarin therapy: does precise daily dosing improve international normalized ratio control? Mayo Clin Proc. 2002;77:873-5.

Resources (including Medline Search: “patient discharge” and/ or “quality indicators” and “quality of care”):

1. Bull MJ, Hansen HE, Gross CR. Predictors of elder and family caregiver satisfaction with discharge planning. J Cardiovasc Nurs. 2000;14:76-87.
2. Charles C, Gauld M, Chambers L, O’Brien B, Haynes RB, Labelle R. How was your hospital stay? Patients’ report about their care in Canadian hospitals. CMAJ. 1994; 150:1813-22.
3. Cleary PD. A hospitalization from hell: a patient’s perspective on quality. Ann Intern Med. 2003:138:33-9.
4. Demlo LK, Campbell PM. Improving hospital discharge data: lessons from the National Hospital Discharge Survey. Med Care. 1981 Oct;19(10):1030-40.
5. Felden JM, scott S, Horne JG. An investigation of patient satisfaction following discharge after total hip replacement surgery. Orthop Nurs. 2003;22:429-36.
6. Frain JP, Frain AE, Carr PH. Experience of medical senior house officers in preparing discharge summaries. BMJ. 1996;312:350.
7. Gombeski WR, Miller PJ, Hahn JH, et al. Patient callback program. J Health Care Mark 1993;13:60-5.
8. Hickey ML, Kleefield SF, Pearson SD, et al. Payer-hospital collaboration to improve patient satisfaction with hospital discharge. Jt Comm J Qual Improv. 1996;22:336-44.
9. Kroenke K, Stump T, Clark DO, Callahan CM, McDonald CJ. Symptoms in hospitalized patients: outcome and satisfaction with care. Am J Med 1999;107: 425-31.
10. Macaulay EM, Cooper GC, Engeset J, Naylor AR. Prospective audit of discharge summary errors. Br J Surg. 1996;83:788-90.
11. Moher D, Weinberg A, Hanlon R, Runnalls K. Effects of a medical team coordinator on length of hospital stay. CMAJ. 1992;146:511-5.
12. Minnick A, Young WB. Comparison between reports of care obtained by post-discharge telephone interview and pre-discharge personal interview. Outcomes Manag Nurs Pract 1999;3:32-7.
13. Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home followup of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-20.
14. Parkes J, Shepperd S. Discharge planning from hospital to home. Cochrane Database Syst Rev. 2004. Review.
15. Reiley P, Pike A, Phipps M, et al. Learning from patients: a discharge planning improvement project. Jt Comm J Qual Improv. 1996;22:31122.
16. van Walraven C, Weinberg AL. Quality assessment of a discharge summary system. CMAJ. 1995;152:1437-42.
17. van Walraven C, Rokosh E. What is necessary for high-quality discharge summaries? Am J Med Qual. 1999;14: 160-9.
18. Zwicker D, Picariello G. Discharge planning for the older adult. In: Mezey M, Fulmer T, Abraaham I, Zwicker D, eds. Geriatric Nursing Protocols for Best Practice. 2nd ed. New York: Springer Publishing 2003;292-316.

The interval between hospital discharge and the continuity provider’s first post-hospital patient visit is being increasingly recognized as a hazardous hiatus (1). The patient is vulnerable to a variety of factors that may result in morbidity or hospital readmission, including the recurrence of symptoms that prompted the initial hospitalization, adverse drug events from new medications, new drug-drug interactions, or issues of care coordination, such as followup visits and tests. Inadequate social support can further exacerbate the medical complexity of care transition from the inpatient to the outpatient setting.

Many post-discharge adverse events are preventable or “ameliorable” by careful discharge planning and timely followup (1). However, existing guidelines and standards regarding the discharge process have been disease specific and have not focused on populations, such as the elderly, that may be at especially high risk regardless of their specific medical issues. For example, CMS currently requires that all patients have an assessment of cognition, mobility, and family support before final discharge plans are set. Experienced hospitalists know that these basic elements are only the beginning of a more complex and robust algorithm of discharge planning; including trimming and reconciling medications; planning followup tests; engineering followup appointments; and activating any required community resources, durable medical good needs, or home health care. In fact, many SHM members have already begun to implement local strategies to ease the care transition at the time of discharge.

The SHM Hospital Quality & Patient Safety (HQPS) Committee believes that hospitalists will play an important role in shaping the ideal discharge process. With support from the Hartford foundation, HQPS has formulated a strategy to develop “discharge best practices,” integrating evidence-based care with the experience and expert opinion of hospitalist leaders. To our knowledge, no national society or professional organization has undertaken such an activity to improve the quality of care at discharge and after hospitalization.

click for large version

The process began with a literature review in 2004 that showed no commonly accepted compendium or consolidated list of activities that could form the basis for the ideal discharge. Drawing upon SHM member experience and the literature, HQPS committee members formulated a list of potential best practices, which are presented in Table 1. Although many discharge activities are required and many are done automatically (such as writing a discharge order or prescriptions) the committee chose to focus on important but discretionary activities that may be overlooked by a busy physician. To complement this checklist of activities, the committee is developing a discharge framework with the input of experts in the area of care transitions.

The committee held a consensus-building workshop at the SHM annual meeting entitled “Developing the Ideal Discharge Process.” This session provided a forum to discuss the checklist of best practices and discharge framework with attendees, receive their feedback, and identify hospitalists interested in validating and refining the materials over time. The committee will continue revising the materials in 2005, with the goal of developing a usable and valuable consensus statement addressing the steps involved in the ideal hospital discharge.

References

1. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-7.
2. Guidelines for appropriate use of “Do-Not-Resuscitate” orders. Council on Ethical and Judicial Affairs. American Medical Association. JAMA. 1991;265:1868-71.
3. Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “getup and go” test. Arch Phys Med Rehabil. 1986;67:387-9.
4. Manning DM, Keller AS, Frank DL. Independent Mobility Validation Exam (IMOVE): A tool for periodic reassessment of fallrisk and discharge planning. Abstract and poster presentation at SHM (formerly NAIP) 5th Annual Meeting in Philadelphia, PA, on April 9, 2002.
5. van Walraven C, Mamdani M, Fang J, Austin PC. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004;19:624-31.
6. van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during the post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17:186-92.
7. Whitford K, Huddleston JM. Specific appointments after pneumonia hospitalization reduce readmissions. Abstract and Poster presentation at SHM (formerly NAIP) 5th Annual Meeting in Philadelphia, PA, on April 9, 2002.
8. JCAHO Manual: Information Management (IM) 6.10 and Patient Care (PC) 15.30.
9. Lewis T. Using the NO TEARS tool for medication review. BMJ. 2004;329:434.
10. Whittington J, Cohen H. OSF healthcare’s journey in patient safety. Qual Manag Health Care. 2004;13:53-9.
11. Kucukarslan SN, Peters M, Mlynarek M, Nafziger D. Pharmacists on rounding teams reduce preventable adverse events in hospital general medicine units. Arch Intern Med. 2003;163:2014-18.
12. Dudas V, Bookwalter T, Kerr K, Pantilat SZ. The impact of followup telephone calls to patients after hospitalization. Am J Med. 2001;111(9B):26S-30S.
13. Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004.
14. Manning DM. Toward safer warfarin therapy: does precise daily dosing improve international normalized ratio control? Mayo Clin Proc. 2002;77:873-5.

Resources (including Medline Search: “patient discharge” and/ or “quality indicators” and “quality of care”):

1. Bull MJ, Hansen HE, Gross CR. Predictors of elder and family caregiver satisfaction with discharge planning. J Cardiovasc Nurs. 2000;14:76-87.
2. Charles C, Gauld M, Chambers L, O’Brien B, Haynes RB, Labelle R. How was your hospital stay? Patients’ report about their care in Canadian hospitals. CMAJ. 1994; 150:1813-22.
3. Cleary PD. A hospitalization from hell: a patient’s perspective on quality. Ann Intern Med. 2003:138:33-9.
4. Demlo LK, Campbell PM. Improving hospital discharge data: lessons from the National Hospital Discharge Survey. Med Care. 1981 Oct;19(10):1030-40.
5. Felden JM, scott S, Horne JG. An investigation of patient satisfaction following discharge after total hip replacement surgery. Orthop Nurs. 2003;22:429-36.
6. Frain JP, Frain AE, Carr PH. Experience of medical senior house officers in preparing discharge summaries. BMJ. 1996;312:350.
7. Gombeski WR, Miller PJ, Hahn JH, et al. Patient callback program. J Health Care Mark 1993;13:60-5.
8. Hickey ML, Kleefield SF, Pearson SD, et al. Payer-hospital collaboration to improve patient satisfaction with hospital discharge. Jt Comm J Qual Improv. 1996;22:336-44.
9. Kroenke K, Stump T, Clark DO, Callahan CM, McDonald CJ. Symptoms in hospitalized patients: outcome and satisfaction with care. Am J Med 1999;107: 425-31.
10. Macaulay EM, Cooper GC, Engeset J, Naylor AR. Prospective audit of discharge summary errors. Br J Surg. 1996;83:788-90.
11. Moher D, Weinberg A, Hanlon R, Runnalls K. Effects of a medical team coordinator on length of hospital stay. CMAJ. 1992;146:511-5.
12. Minnick A, Young WB. Comparison between reports of care obtained by post-discharge telephone interview and pre-discharge personal interview. Outcomes Manag Nurs Pract 1999;3:32-7.
13. Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home followup of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-20.
14. Parkes J, Shepperd S. Discharge planning from hospital to home. Cochrane Database Syst Rev. 2004. Review.
15. Reiley P, Pike A, Phipps M, et al. Learning from patients: a discharge planning improvement project. Jt Comm J Qual Improv. 1996;22:31122.
16. van Walraven C, Weinberg AL. Quality assessment of a discharge summary system. CMAJ. 1995;152:1437-42.
17. van Walraven C, Rokosh E. What is necessary for high-quality discharge summaries? Am J Med Qual. 1999;14: 160-9.
18. Zwicker D, Picariello G. Discharge planning for the older adult. In: Mezey M, Fulmer T, Abraaham I, Zwicker D, eds. Geriatric Nursing Protocols for Best Practice. 2nd ed. New York: Springer Publishing 2003;292-316.

When we speak of “quality” in health care, we generally think of mortality outcomes or regulatory requirements that are mandated by the JCAHO (Joint Commission for Accreditation of Healthcare Organizations). But how do these relate to and impact our everyday lives as hospitalists? At the 8th Annual Meeting of SHM we presented a workshop on RCA and FMEA, taking a practical approach to illustrate how these two JCAHO required methodologies can improve patient care as well as improve the work environment for hospitalists by addressing the systemic issues that can compromise care.

The workshop starts by stepping into the life of a hospitalist and something we all fear: “Something bad happens. Then what?” Depending on the severity of the event, the options include peer review, notifying the Department Chief, calling the Risk Manager, calling your lawyer, or doing nothing. You’ve probably had many experiences when “something wasn’t quite right,” but often there is no obvious bad outcome or obvious solution, so we shrug our shoulders and say, “Oh well, we got lucky this time; no harm, no foul.” The problem is, there are recurring patterns to these types of events, and the same issues may affect the next patient, who may not be so lucky.

Defining “Something Bad”

These types of cases, which have outcomes ranging from no effect on the patient to death, may be approached several different ways. The terms “near miss” or “close call” refer to an incident where a mistake was made but caught in time, so no harm was done to the patient. An example of this is when a physician makes a mistake on a medication order, but it is caught and corrected by a pharmacist or nurse.

When adverse outcomes do occur, think about and define etiologies so that you identify and address underlying causes. Is the outcome an expected or unexpected complication of therapy? Was there an error involved? In asking these questions, remember that you can have harm without error and error without harm. Error is defined as “failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim; the accumulation of errors results in accidents” (Kohn, et al). This definition points out that usually a chain of events rather than a single individual or event results in a bad outcome. The purpose of defining etiologies is not to assign blame but to identify underlying issues and surrounding circumstances that may have contributed to the adverse outcome.

Significant adverse events are called “sentinel events” and defined as an “unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function” (JCAHO 1998).

How We Approach Error

Unfortunately, as humans we are fallible and make errors quite reliably. Table 1 demonstrates types of errors and expected rates of errors. For example, we make errors of omission 0.01% of the time, but the good news is that with reminders or ticklers, we can reduce this rate to 0.003%. Unfortunately, when humans are under high stress in danger, research from the military indicates error rates of 25% (Salvendy 1997). In a complex ICU setting, researchers have documented an average of 178 activities per patient per day with an error rate of 0.95%. Despite an error rate of less than 1%, the yield of errors during the 4-month period of observation was still over 1000 errors, 29% of which were considered to have severe or potentially severe consequences (Donchin, et al).

click for large versionAdapted from: park K. Human error. In: Salvendy G, ed. Handbook of human factors and ergonomics. New York: John Wiley & Sons; 1997.

The reality is that we err. Having the unrealistic expectations developed in medical training of being perfect in all our actions perpetuates the blame cycle when the inevitable mistake occurs, and it prevents us from implementing solutions that prevent errors from ever occurring or catching them before they cause harm.

RCA and FMEA Help Us Create Solutions That Make a Difference

Briefly, Root Cause Analysis (RCA) is a retrospective investigation that is required by JCAHO after a sentinel event: “Root cause analysis is a process for identifying the basic or causal factor(s) that underlies variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause is that most fundamental reason a problem―a situation where performance does not meet expectations―has occurred” (JCAHO 1998). An RCA looks back in time at an event and asks the question “What

happened?” The utility of this methodology lies in the fact that it not only asks what happened but also asks “Why did this happen” rather than focus on “Who is to blame?” Some hospitals use this methodology for cases that are not sentinel events, because the knowledge gained from these investigations often uncovers system issues previously not known and that negatively impact many departments, not just the departments involved in a particular case.

Failure Modes and Effects Analysis (FMEA) is a prospective investigation aimed at identifying vulnerabilities and preventing failures in the future. It looks forward and asks what could go wrong? Performance of an FMEA is also required yearly by JCAHO and focuses on improving risky processes such as blood transfusions, chemotherapy, and other high risk medications.

Approaching a clinical case clearly demonstrates the differences between RCA and FMEA. Imagine a 72-year-old patient admitted to your hospital with findings of an acute abdomen requiring surgery. The patient is a smoker, with Type 2 diabetes and an admission blood sugar of 465, but no evidence of DKA. She normally takes an oral hypoglycemic to control her diabetes and an ACE inhibitor for high blood pressure but no other medications. She is taken to the OR emergently, where surgery seems to go well, and post-operatively is admitted to the ICU. Subsequently, her blood glucose ranges from 260 to 370 and is “controlled” with sliding scale insulin. Unfortunately, within 18 hours of surgery she suffers an MI and develops a postoperative wound infection 4 days after surgery. She eventually dies from sepsis.

click for large version

An RCA of this case might reveal causal factors such as lack of use of a beta-blocker preoperatively and lack of use of IV insulin to lower her blood sugars to the 80–110 range. While possibly identifying the root cause of this adverse outcome, an RCA is limited by its hindsight bias and the labor-intensive nature of the investigation that may or may not have broad application, since it is an in-depth study of one case. However, RCA’s do have the salutary effects of building teamwork, identifying needed changes, and if carried out impartially without assigning blame can facilitate a culture of patient safety.

FMEA takes a different approach and proactively aims to prevent failure. It is a systematic method of identifying and preventing product and process failures before they occur. It does not require a specific case or adverse event. Rather, a high-risk process is chosen for study, and an interdisciplinary team asks the question “What can go wrong with this process and how can we prevent failures?” Considering the above case, imagine that before it ever occurred you as the hospitalist concerned with patient safety decided to conduct an FMEA on controlling blood sugar in the ICU or administering beta-blockers perioperatively to patients who are appropriate candidates.

For example, using FMEA methodology to study the process of intensive insulin therapy to achieve tight control of glucose in the ICU would identify potential barriers and failures preventing successful implementation. A significant risk encountered in achieving tight glucose control in the range of 80–110 includes hypoglycemia. Common pitfalls of insulin administration include administration and calculation errors that can result in 10-fold differences in doses of insulin. Other details of administration, such as type of IV tubing used and how the IV tubing is primed, can greatly affect the amount of insulin delivered to the patient and thus the glucose levels. If an inadequate amount of solution is flushed through to prime the tubing, the patient may receive saline rather than insulin for a few hours, resulting in higher-than-expected glucose levels and titration of insulin to higher doses. The result would then be an unexpectedly low glucose several hours later. Once failure modes such as these are identified, a fail-safe system can be designed so that failures are less likely to occur.

The advantages of FMEA include its focus on system design rather than on a single incident such as in RCA. By focusing on systems and processes, the learning and changes implemented are likely to impact a larger number of patients.

Summary and Discussion

To summarize, RCA is retrospective and dissects a case, while FMEA is prospective and dissects a process. It is important to remember that given the right set of circumstances, any physician can make a mistake. It makes sense to apply methodologies that probe into surrounding circumstances and contributing factors so that knowledge gained can be used to prevent the same mistakes from happening to different individuals and have broader impact on healthcare systems.

Resources

1. www.patientsafety.gov: VA National Center for Patient Safety. Excellent website with very helpful, practical tools.
2. www.ihi.org: Institute for Healthcare Improvement website. Has a nice FMEA toolkit.
3. www.jcaho.com: The Joint Commission for Accreditation of Healthcare Organizations website. Has information on sentinel events and use of RCA.

Bibliography

1. Kohn LT, Corrigan JM, Eds. To Err is Human. Building a Safer Helath System. Washington, DC: National Academy Press; 1999.
2. Joint Commission on Accreditation of Healthcare Organizations. Sentinel events: evaluating cause and planning improvement. 1998. Library of congress catalog number 97-80531.
3. Salvendy G, ed. Handbook of Human Factors and Ergonomics. New York: John Wiley & Sons;1997:163
4. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23:294-300.
5. McNutt R, Abrams R, Hasler S, et al. Determining medical error: three case reports. Eff Clin Pract. 2002;5:23-8.
6. Senders JW. FMEA and RCA: the mantras of modern risk management. Qual Saf Health Care. 2004;13:249-50.
7. Spath PL. Investigating Sentinel Events: How to Find and Resolve Root Causes. Forest Grove, OR: Brown Spath and Associates; 1997.
8. Wald H, Shojania KG. Root cause analysis. In: Shojania KG, McDonald KM, Wachter RM, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43, AHRQ Publication No. 01-E058; July 2001. Available at http://www.ahrq.gov.
9. Woodhouse S, Burney B, Coste K. To err is human: improving patient safety through failure mode and effect analysis. Clin leadersh Manag Rev. 2004;18:32-6.

When we speak of “quality” in health care, we generally think of mortality outcomes or regulatory requirements that are mandated by the JCAHO (Joint Commission for Accreditation of Healthcare Organizations). But how do these relate to and impact our everyday lives as hospitalists? At the 8th Annual Meeting of SHM we presented a workshop on RCA and FMEA, taking a practical approach to illustrate how these two JCAHO required methodologies can improve patient care as well as improve the work environment for hospitalists by addressing the systemic issues that can compromise care.

The workshop starts by stepping into the life of a hospitalist and something we all fear: “Something bad happens. Then what?” Depending on the severity of the event, the options include peer review, notifying the Department Chief, calling the Risk Manager, calling your lawyer, or doing nothing. You’ve probably had many experiences when “something wasn’t quite right,” but often there is no obvious bad outcome or obvious solution, so we shrug our shoulders and say, “Oh well, we got lucky this time; no harm, no foul.” The problem is, there are recurring patterns to these types of events, and the same issues may affect the next patient, who may not be so lucky.

Defining “Something Bad”

These types of cases, which have outcomes ranging from no effect on the patient to death, may be approached several different ways. The terms “near miss” or “close call” refer to an incident where a mistake was made but caught in time, so no harm was done to the patient. An example of this is when a physician makes a mistake on a medication order, but it is caught and corrected by a pharmacist or nurse.

When adverse outcomes do occur, think about and define etiologies so that you identify and address underlying causes. Is the outcome an expected or unexpected complication of therapy? Was there an error involved? In asking these questions, remember that you can have harm without error and error without harm. Error is defined as “failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim; the accumulation of errors results in accidents” (Kohn, et al). This definition points out that usually a chain of events rather than a single individual or event results in a bad outcome. The purpose of defining etiologies is not to assign blame but to identify underlying issues and surrounding circumstances that may have contributed to the adverse outcome.

Significant adverse events are called “sentinel events” and defined as an “unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function” (JCAHO 1998).

How We Approach Error

Unfortunately, as humans we are fallible and make errors quite reliably. Table 1 demonstrates types of errors and expected rates of errors. For example, we make errors of omission 0.01% of the time, but the good news is that with reminders or ticklers, we can reduce this rate to 0.003%. Unfortunately, when humans are under high stress in danger, research from the military indicates error rates of 25% (Salvendy 1997). In a complex ICU setting, researchers have documented an average of 178 activities per patient per day with an error rate of 0.95%. Despite an error rate of less than 1%, the yield of errors during the 4-month period of observation was still over 1000 errors, 29% of which were considered to have severe or potentially severe consequences (Donchin, et al).

click for large versionAdapted from: park K. Human error. In: Salvendy G, ed. Handbook of human factors and ergonomics. New York: John Wiley & Sons; 1997.

The reality is that we err. Having the unrealistic expectations developed in medical training of being perfect in all our actions perpetuates the blame cycle when the inevitable mistake occurs, and it prevents us from implementing solutions that prevent errors from ever occurring or catching them before they cause harm.

RCA and FMEA Help Us Create Solutions That Make a Difference

Briefly, Root Cause Analysis (RCA) is a retrospective investigation that is required by JCAHO after a sentinel event: “Root cause analysis is a process for identifying the basic or causal factor(s) that underlies variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause is that most fundamental reason a problem―a situation where performance does not meet expectations―has occurred” (JCAHO 1998). An RCA looks back in time at an event and asks the question “What

happened?” The utility of this methodology lies in the fact that it not only asks what happened but also asks “Why did this happen” rather than focus on “Who is to blame?” Some hospitals use this methodology for cases that are not sentinel events, because the knowledge gained from these investigations often uncovers system issues previously not known and that negatively impact many departments, not just the departments involved in a particular case.

Failure Modes and Effects Analysis (FMEA) is a prospective investigation aimed at identifying vulnerabilities and preventing failures in the future. It looks forward and asks what could go wrong? Performance of an FMEA is also required yearly by JCAHO and focuses on improving risky processes such as blood transfusions, chemotherapy, and other high risk medications.

Approaching a clinical case clearly demonstrates the differences between RCA and FMEA. Imagine a 72-year-old patient admitted to your hospital with findings of an acute abdomen requiring surgery. The patient is a smoker, with Type 2 diabetes and an admission blood sugar of 465, but no evidence of DKA. She normally takes an oral hypoglycemic to control her diabetes and an ACE inhibitor for high blood pressure but no other medications. She is taken to the OR emergently, where surgery seems to go well, and post-operatively is admitted to the ICU. Subsequently, her blood glucose ranges from 260 to 370 and is “controlled” with sliding scale insulin. Unfortunately, within 18 hours of surgery she suffers an MI and develops a postoperative wound infection 4 days after surgery. She eventually dies from sepsis.

click for large version

An RCA of this case might reveal causal factors such as lack of use of a beta-blocker preoperatively and lack of use of IV insulin to lower her blood sugars to the 80–110 range. While possibly identifying the root cause of this adverse outcome, an RCA is limited by its hindsight bias and the labor-intensive nature of the investigation that may or may not have broad application, since it is an in-depth study of one case. However, RCA’s do have the salutary effects of building teamwork, identifying needed changes, and if carried out impartially without assigning blame can facilitate a culture of patient safety.

FMEA takes a different approach and proactively aims to prevent failure. It is a systematic method of identifying and preventing product and process failures before they occur. It does not require a specific case or adverse event. Rather, a high-risk process is chosen for study, and an interdisciplinary team asks the question “What can go wrong with this process and how can we prevent failures?” Considering the above case, imagine that before it ever occurred you as the hospitalist concerned with patient safety decided to conduct an FMEA on controlling blood sugar in the ICU or administering beta-blockers perioperatively to patients who are appropriate candidates.

For example, using FMEA methodology to study the process of intensive insulin therapy to achieve tight control of glucose in the ICU would identify potential barriers and failures preventing successful implementation. A significant risk encountered in achieving tight glucose control in the range of 80–110 includes hypoglycemia. Common pitfalls of insulin administration include administration and calculation errors that can result in 10-fold differences in doses of insulin. Other details of administration, such as type of IV tubing used and how the IV tubing is primed, can greatly affect the amount of insulin delivered to the patient and thus the glucose levels. If an inadequate amount of solution is flushed through to prime the tubing, the patient may receive saline rather than insulin for a few hours, resulting in higher-than-expected glucose levels and titration of insulin to higher doses. The result would then be an unexpectedly low glucose several hours later. Once failure modes such as these are identified, a fail-safe system can be designed so that failures are less likely to occur.

The advantages of FMEA include its focus on system design rather than on a single incident such as in RCA. By focusing on systems and processes, the learning and changes implemented are likely to impact a larger number of patients.

Summary and Discussion

To summarize, RCA is retrospective and dissects a case, while FMEA is prospective and dissects a process. It is important to remember that given the right set of circumstances, any physician can make a mistake. It makes sense to apply methodologies that probe into surrounding circumstances and contributing factors so that knowledge gained can be used to prevent the same mistakes from happening to different individuals and have broader impact on healthcare systems.

Resources

1. www.patientsafety.gov: VA National Center for Patient Safety. Excellent website with very helpful, practical tools.
2. www.ihi.org: Institute for Healthcare Improvement website. Has a nice FMEA toolkit.
3. www.jcaho.com: The Joint Commission for Accreditation of Healthcare Organizations website. Has information on sentinel events and use of RCA.

Bibliography

1. Kohn LT, Corrigan JM, Eds. To Err is Human. Building a Safer Helath System. Washington, DC: National Academy Press; 1999.
2. Joint Commission on Accreditation of Healthcare Organizations. Sentinel events: evaluating cause and planning improvement. 1998. Library of congress catalog number 97-80531.
3. Salvendy G, ed. Handbook of Human Factors and Ergonomics. New York: John Wiley & Sons;1997:163
4. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23:294-300.
5. McNutt R, Abrams R, Hasler S, et al. Determining medical error: three case reports. Eff Clin Pract. 2002;5:23-8.
6. Senders JW. FMEA and RCA: the mantras of modern risk management. Qual Saf Health Care. 2004;13:249-50.
7. Spath PL. Investigating Sentinel Events: How to Find and Resolve Root Causes. Forest Grove, OR: Brown Spath and Associates; 1997.
8. Wald H, Shojania KG. Root cause analysis. In: Shojania KG, McDonald KM, Wachter RM, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43, AHRQ Publication No. 01-E058; July 2001. Available at http://www.ahrq.gov.
9. Woodhouse S, Burney B, Coste K. To err is human: improving patient safety through failure mode and effect analysis. Clin leadersh Manag Rev. 2004;18:32-6.

When we speak of “quality” in health care, we generally think of mortality outcomes or regulatory requirements that are mandated by the JCAHO (Joint Commission for Accreditation of Healthcare Organizations). But how do these relate to and impact our everyday lives as hospitalists? At the 8th Annual Meeting of SHM we presented a workshop on RCA and FMEA, taking a practical approach to illustrate how these two JCAHO required methodologies can improve patient care as well as improve the work environment for hospitalists by addressing the systemic issues that can compromise care.

The workshop starts by stepping into the life of a hospitalist and something we all fear: “Something bad happens. Then what?” Depending on the severity of the event, the options include peer review, notifying the Department Chief, calling the Risk Manager, calling your lawyer, or doing nothing. You’ve probably had many experiences when “something wasn’t quite right,” but often there is no obvious bad outcome or obvious solution, so we shrug our shoulders and say, “Oh well, we got lucky this time; no harm, no foul.” The problem is, there are recurring patterns to these types of events, and the same issues may affect the next patient, who may not be so lucky.

Defining “Something Bad”

These types of cases, which have outcomes ranging from no effect on the patient to death, may be approached several different ways. The terms “near miss” or “close call” refer to an incident where a mistake was made but caught in time, so no harm was done to the patient. An example of this is when a physician makes a mistake on a medication order, but it is caught and corrected by a pharmacist or nurse.

When adverse outcomes do occur, think about and define etiologies so that you identify and address underlying causes. Is the outcome an expected or unexpected complication of therapy? Was there an error involved? In asking these questions, remember that you can have harm without error and error without harm. Error is defined as “failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim; the accumulation of errors results in accidents” (Kohn, et al). This definition points out that usually a chain of events rather than a single individual or event results in a bad outcome. The purpose of defining etiologies is not to assign blame but to identify underlying issues and surrounding circumstances that may have contributed to the adverse outcome.

Significant adverse events are called “sentinel events” and defined as an “unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function” (JCAHO 1998).

How We Approach Error

Unfortunately, as humans we are fallible and make errors quite reliably. Table 1 demonstrates types of errors and expected rates of errors. For example, we make errors of omission 0.01% of the time, but the good news is that with reminders or ticklers, we can reduce this rate to 0.003%. Unfortunately, when humans are under high stress in danger, research from the military indicates error rates of 25% (Salvendy 1997). In a complex ICU setting, researchers have documented an average of 178 activities per patient per day with an error rate of 0.95%. Despite an error rate of less than 1%, the yield of errors during the 4-month period of observation was still over 1000 errors, 29% of which were considered to have severe or potentially severe consequences (Donchin, et al).

click for large versionAdapted from: park K. Human error. In: Salvendy G, ed. Handbook of human factors and ergonomics. New York: John Wiley & Sons; 1997.

The reality is that we err. Having the unrealistic expectations developed in medical training of being perfect in all our actions perpetuates the blame cycle when the inevitable mistake occurs, and it prevents us from implementing solutions that prevent errors from ever occurring or catching them before they cause harm.

RCA and FMEA Help Us Create Solutions That Make a Difference

Briefly, Root Cause Analysis (RCA) is a retrospective investigation that is required by JCAHO after a sentinel event: “Root cause analysis is a process for identifying the basic or causal factor(s) that underlies variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause is that most fundamental reason a problem―a situation where performance does not meet expectations―has occurred” (JCAHO 1998). An RCA looks back in time at an event and asks the question “What

happened?” The utility of this methodology lies in the fact that it not only asks what happened but also asks “Why did this happen” rather than focus on “Who is to blame?” Some hospitals use this methodology for cases that are not sentinel events, because the knowledge gained from these investigations often uncovers system issues previously not known and that negatively impact many departments, not just the departments involved in a particular case.

Failure Modes and Effects Analysis (FMEA) is a prospective investigation aimed at identifying vulnerabilities and preventing failures in the future. It looks forward and asks what could go wrong? Performance of an FMEA is also required yearly by JCAHO and focuses on improving risky processes such as blood transfusions, chemotherapy, and other high risk medications.

Approaching a clinical case clearly demonstrates the differences between RCA and FMEA. Imagine a 72-year-old patient admitted to your hospital with findings of an acute abdomen requiring surgery. The patient is a smoker, with Type 2 diabetes and an admission blood sugar of 465, but no evidence of DKA. She normally takes an oral hypoglycemic to control her diabetes and an ACE inhibitor for high blood pressure but no other medications. She is taken to the OR emergently, where surgery seems to go well, and post-operatively is admitted to the ICU. Subsequently, her blood glucose ranges from 260 to 370 and is “controlled” with sliding scale insulin. Unfortunately, within 18 hours of surgery she suffers an MI and develops a postoperative wound infection 4 days after surgery. She eventually dies from sepsis.

click for large version

An RCA of this case might reveal causal factors such as lack of use of a beta-blocker preoperatively and lack of use of IV insulin to lower her blood sugars to the 80–110 range. While possibly identifying the root cause of this adverse outcome, an RCA is limited by its hindsight bias and the labor-intensive nature of the investigation that may or may not have broad application, since it is an in-depth study of one case. However, RCA’s do have the salutary effects of building teamwork, identifying needed changes, and if carried out impartially without assigning blame can facilitate a culture of patient safety.

FMEA takes a different approach and proactively aims to prevent failure. It is a systematic method of identifying and preventing product and process failures before they occur. It does not require a specific case or adverse event. Rather, a high-risk process is chosen for study, and an interdisciplinary team asks the question “What can go wrong with this process and how can we prevent failures?” Considering the above case, imagine that before it ever occurred you as the hospitalist concerned with patient safety decided to conduct an FMEA on controlling blood sugar in the ICU or administering beta-blockers perioperatively to patients who are appropriate candidates.

For example, using FMEA methodology to study the process of intensive insulin therapy to achieve tight control of glucose in the ICU would identify potential barriers and failures preventing successful implementation. A significant risk encountered in achieving tight glucose control in the range of 80–110 includes hypoglycemia. Common pitfalls of insulin administration include administration and calculation errors that can result in 10-fold differences in doses of insulin. Other details of administration, such as type of IV tubing used and how the IV tubing is primed, can greatly affect the amount of insulin delivered to the patient and thus the glucose levels. If an inadequate amount of solution is flushed through to prime the tubing, the patient may receive saline rather than insulin for a few hours, resulting in higher-than-expected glucose levels and titration of insulin to higher doses. The result would then be an unexpectedly low glucose several hours later. Once failure modes such as these are identified, a fail-safe system can be designed so that failures are less likely to occur.

The advantages of FMEA include its focus on system design rather than on a single incident such as in RCA. By focusing on systems and processes, the learning and changes implemented are likely to impact a larger number of patients.

Summary and Discussion

To summarize, RCA is retrospective and dissects a case, while FMEA is prospective and dissects a process. It is important to remember that given the right set of circumstances, any physician can make a mistake. It makes sense to apply methodologies that probe into surrounding circumstances and contributing factors so that knowledge gained can be used to prevent the same mistakes from happening to different individuals and have broader impact on healthcare systems.

Resources

1. www.patientsafety.gov: VA National Center for Patient Safety. Excellent website with very helpful, practical tools.
2. www.ihi.org: Institute for Healthcare Improvement website. Has a nice FMEA toolkit.
3. www.jcaho.com: The Joint Commission for Accreditation of Healthcare Organizations website. Has information on sentinel events and use of RCA.

Bibliography

1. Kohn LT, Corrigan JM, Eds. To Err is Human. Building a Safer Helath System. Washington, DC: National Academy Press; 1999.
2. Joint Commission on Accreditation of Healthcare Organizations. Sentinel events: evaluating cause and planning improvement. 1998. Library of congress catalog number 97-80531.
3. Salvendy G, ed. Handbook of Human Factors and Ergonomics. New York: John Wiley & Sons;1997:163
4. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23:294-300.
5. McNutt R, Abrams R, Hasler S, et al. Determining medical error: three case reports. Eff Clin Pract. 2002;5:23-8.
6. Senders JW. FMEA and RCA: the mantras of modern risk management. Qual Saf Health Care. 2004;13:249-50.
7. Spath PL. Investigating Sentinel Events: How to Find and Resolve Root Causes. Forest Grove, OR: Brown Spath and Associates; 1997.
8. Wald H, Shojania KG. Root cause analysis. In: Shojania KG, McDonald KM, Wachter RM, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43, AHRQ Publication No. 01-E058; July 2001. Available at http://www.ahrq.gov.
9. Woodhouse S, Burney B, Coste K. To err is human: improving patient safety through failure mode and effect analysis. Clin leadersh Manag Rev. 2004;18:32-6.

Richard Wade

If you’re a “boomer”―one of those Americans born between 1946 and 1964―you have witnessed the most dramatic changes in history in the essential community institution called the hospital. From the technology inside to the kinds of people who deliver the medical care and operate the organization, and from the financial structure that supports it to its image in the eyes of the public, today’s hospital has been radically reformed in the past few decades.

Most Americans don’t like to think about hospitals; they enter our minds only when they must. There’s only one time in the life of a family when they want to be in the hospital. All others are moments of fear at best, human crisis at worst.

As a full-fledged boomer, I remember my early impressions of hospitals: big, mysterious places that sometimes didn’t allow children in. The grownups I knew talked about hospitals with a curious mixture of reverence and fear. If someone died in the hospital, the common notion was that the doctors “did all they could, but Uncle Fred didn’t make it.”

If, heaven forbid, a person faced hospitalization, he or she went wherever the doctor directed. In my small hometown, everybody knew somebody who worked at the hospital, so you at least knew that if you had to go there, you’d see people you knew. And if you knew the people, you trusted the hospital to be a good place where good people did their best for you. And that was about all the information most people had about their local hospital.

Today, the public pressure for information about the inner workings of hospitals is coming from every direction― regulators, politicians at every level, the press, organizations claiming to represent “consumers” and distinct groups such as the elderly and uninsured, unions, the business community, and the list keeps growing. The demand is for an unvarnished took at what occurs in every place, from the boardroom to the billing office to the bedside. How do hospitals govern themselves? Whom do they pay how much? What prevents conflicts of interest? What do they charge for their services, and who actually pays what? What are the policies and practices on charity care, billing, and collections? How many errors do the clinicians make? How many people get infections in the hospital? What are the outcomes of the care? Are patients getting the right care at the right time? Do patients get too much care? Too little? What do you do about inept doctors?

It’s a virtual tsunami for transparency. And hospital people are reacting to this tidal wave in multiple ways. Some are running away from reality. Some are standing their ground. And some are adapting and changing to survive and thrive in an environment vastly different than anything their careers have prepared them for so far.

Because hospitalists are a growing presence and are playing an increasingly important role in all aspects of quality and patient safety, they will be critical to the hospital’s ability to adapt successfully to this new era of transparency and accountability.

The public’s attitudes toward medical error reporting and hospital acquired infections and how hospitals are responding to them today are important clues to the future. In 1999, the Institute of Medicine released its now famous report, To Err Is Human. It estimated that between 45,000 and 98,000 Americans die in hospitals each year from preventable medical errors. The report was nuclear. Not only did it open a national debate on patient safety that continues still, but also it compelled thousands of hospitals to talk with their communities for the first time about what they do to prevent errors.

A recent survey found that 55% of Americans are dissatisfied with the quality of hospital care. In the same poll, 34% said they or a family member had experienced a preventable medical error, and 70% of them said they were not told. Ninety-two percent of the respondents said medical error reporting should be mandatory and public.

Hospitals have agreed that errors should be reported. But unless there’s confidentiality, a culture of blame will discourage reporting and drive errors underground. Caregivers won’t come forward to admit mistakes, making it difficult to get to the root cause and to prevent future incidents. While the national debate goes on, 18 states have passed laws requiring hospitals to report errors to some external body. Some of that data will be made public in some form. Will lawmakers and hospitals be able to resist public pressure over time for public reporting of errors by all hospitals? Can we convince the public that confidentiality will actually lead to safer care and a culture of safety in the nation’s hospitals?

In 2002, the Chicago Tribune reported the results of its investigation into hospital acquired infections, estimating that about 75,000 people died in 2000 from infections that could have been prevented. The Centers for Disease Control and Prevention (CDC) has said that 90,000 patients die annually from hospital acquired infections, adding $5 billion to America’s health care costs. If hospital personnel were more observant of simple infection control procedures, such as regular hand washing, the CDC says thousands of lives and billions of dollars could be saved.

Consumers Union, publisher of the powerful magazine, Consumer Reports, has taken on health care in recent years with the same vigor that it used to get information to the public on autos and appliances. Its current national campaign calls for the reporting and publicizing of hospital acquired infection rates by all hospitals. In 30 states, bills have been introduced to mandate reporting of infection rates. Fifteen states are considering laws to control and oversee hospitals’ infection control practices. The concept that the public should know how well hospitals perform at infection control and prevention resonates strongly. Public reporting of hospital quality measures is in its infancy. Earlier this month, the first public private website opened with information that will allow comparison of hospitals’ performance around pneumonia, heart attack, and heart failure. Soon data on patients’ experience with care―how well they think their doctors and nurses did―will be added. Will infection and infection control statistics be far behind?

And the challenges and tensions are not all in the clinical arena. A recent survey by the American College of Physician Executives found 9 out of 10 physicians concerned about dishonesty, financial conflicts, and unethical behavior among their colleagues.

Eighty percent said they were worried about doctors refusing to treat uninsured patients as part of “on call” responsibilities. And 79% pointed to undue Influence on physicians by medical device companies to perform certain procedures. Physicians’ over treatment of patients to boost income were cited by 78% of the doctors. Another major concern: the influence of drug companies on physicians’ prescribing habits.

In early April, the federal government announced that it would begin investigating the upsurge in tests being ordered for Medicare patients. The issues: medical necessity and rapidly increasing costs.

Hospitals are at a crossroads in their relationships with many publics: their patients, employees and medical staff s, their communities, the government, and the media. The issue is building and retaining trust on so many fronts. Hospitals must be proactive when it comes to accountability and transparency. Doing so will create enormous tensions and challenges inside an institution. This will require leadership and motivation. Hospitalists, given their unique role, are positioned to be powerful catalysts for change―change that will result either in a mountain of cumbersome new laws and regulations or a new culture of openness and trust with the people hospitals exist to serve.

Richard Wade

If you’re a “boomer”―one of those Americans born between 1946 and 1964―you have witnessed the most dramatic changes in history in the essential community institution called the hospital. From the technology inside to the kinds of people who deliver the medical care and operate the organization, and from the financial structure that supports it to its image in the eyes of the public, today’s hospital has been radically reformed in the past few decades.

Most Americans don’t like to think about hospitals; they enter our minds only when they must. There’s only one time in the life of a family when they want to be in the hospital. All others are moments of fear at best, human crisis at worst.

As a full-fledged boomer, I remember my early impressions of hospitals: big, mysterious places that sometimes didn’t allow children in. The grownups I knew talked about hospitals with a curious mixture of reverence and fear. If someone died in the hospital, the common notion was that the doctors “did all they could, but Uncle Fred didn’t make it.”

If, heaven forbid, a person faced hospitalization, he or she went wherever the doctor directed. In my small hometown, everybody knew somebody who worked at the hospital, so you at least knew that if you had to go there, you’d see people you knew. And if you knew the people, you trusted the hospital to be a good place where good people did their best for you. And that was about all the information most people had about their local hospital.

Today, the public pressure for information about the inner workings of hospitals is coming from every direction― regulators, politicians at every level, the press, organizations claiming to represent “consumers” and distinct groups such as the elderly and uninsured, unions, the business community, and the list keeps growing. The demand is for an unvarnished took at what occurs in every place, from the boardroom to the billing office to the bedside. How do hospitals govern themselves? Whom do they pay how much? What prevents conflicts of interest? What do they charge for their services, and who actually pays what? What are the policies and practices on charity care, billing, and collections? How many errors do the clinicians make? How many people get infections in the hospital? What are the outcomes of the care? Are patients getting the right care at the right time? Do patients get too much care? Too little? What do you do about inept doctors?

It’s a virtual tsunami for transparency. And hospital people are reacting to this tidal wave in multiple ways. Some are running away from reality. Some are standing their ground. And some are adapting and changing to survive and thrive in an environment vastly different than anything their careers have prepared them for so far.

Because hospitalists are a growing presence and are playing an increasingly important role in all aspects of quality and patient safety, they will be critical to the hospital’s ability to adapt successfully to this new era of transparency and accountability.

The public’s attitudes toward medical error reporting and hospital acquired infections and how hospitals are responding to them today are important clues to the future. In 1999, the Institute of Medicine released its now famous report, To Err Is Human. It estimated that between 45,000 and 98,000 Americans die in hospitals each year from preventable medical errors. The report was nuclear. Not only did it open a national debate on patient safety that continues still, but also it compelled thousands of hospitals to talk with their communities for the first time about what they do to prevent errors.

A recent survey found that 55% of Americans are dissatisfied with the quality of hospital care. In the same poll, 34% said they or a family member had experienced a preventable medical error, and 70% of them said they were not told. Ninety-two percent of the respondents said medical error reporting should be mandatory and public.

Hospitals have agreed that errors should be reported. But unless there’s confidentiality, a culture of blame will discourage reporting and drive errors underground. Caregivers won’t come forward to admit mistakes, making it difficult to get to the root cause and to prevent future incidents. While the national debate goes on, 18 states have passed laws requiring hospitals to report errors to some external body. Some of that data will be made public in some form. Will lawmakers and hospitals be able to resist public pressure over time for public reporting of errors by all hospitals? Can we convince the public that confidentiality will actually lead to safer care and a culture of safety in the nation’s hospitals?

In 2002, the Chicago Tribune reported the results of its investigation into hospital acquired infections, estimating that about 75,000 people died in 2000 from infections that could have been prevented. The Centers for Disease Control and Prevention (CDC) has said that 90,000 patients die annually from hospital acquired infections, adding $5 billion to America’s health care costs. If hospital personnel were more observant of simple infection control procedures, such as regular hand washing, the CDC says thousands of lives and billions of dollars could be saved.

Consumers Union, publisher of the powerful magazine, Consumer Reports, has taken on health care in recent years with the same vigor that it used to get information to the public on autos and appliances. Its current national campaign calls for the reporting and publicizing of hospital acquired infection rates by all hospitals. In 30 states, bills have been introduced to mandate reporting of infection rates. Fifteen states are considering laws to control and oversee hospitals’ infection control practices. The concept that the public should know how well hospitals perform at infection control and prevention resonates strongly. Public reporting of hospital quality measures is in its infancy. Earlier this month, the first public private website opened with information that will allow comparison of hospitals’ performance around pneumonia, heart attack, and heart failure. Soon data on patients’ experience with care―how well they think their doctors and nurses did―will be added. Will infection and infection control statistics be far behind?

And the challenges and tensions are not all in the clinical arena. A recent survey by the American College of Physician Executives found 9 out of 10 physicians concerned about dishonesty, financial conflicts, and unethical behavior among their colleagues.

Eighty percent said they were worried about doctors refusing to treat uninsured patients as part of “on call” responsibilities. And 79% pointed to undue Influence on physicians by medical device companies to perform certain procedures. Physicians’ over treatment of patients to boost income were cited by 78% of the doctors. Another major concern: the influence of drug companies on physicians’ prescribing habits.

In early April, the federal government announced that it would begin investigating the upsurge in tests being ordered for Medicare patients. The issues: medical necessity and rapidly increasing costs.

Hospitals are at a crossroads in their relationships with many publics: their patients, employees and medical staff s, their communities, the government, and the media. The issue is building and retaining trust on so many fronts. Hospitals must be proactive when it comes to accountability and transparency. Doing so will create enormous tensions and challenges inside an institution. This will require leadership and motivation. Hospitalists, given their unique role, are positioned to be powerful catalysts for change―change that will result either in a mountain of cumbersome new laws and regulations or a new culture of openness and trust with the people hospitals exist to serve.

Richard Wade

If you’re a “boomer”―one of those Americans born between 1946 and 1964―you have witnessed the most dramatic changes in history in the essential community institution called the hospital. From the technology inside to the kinds of people who deliver the medical care and operate the organization, and from the financial structure that supports it to its image in the eyes of the public, today’s hospital has been radically reformed in the past few decades.

Most Americans don’t like to think about hospitals; they enter our minds only when they must. There’s only one time in the life of a family when they want to be in the hospital. All others are moments of fear at best, human crisis at worst.

As a full-fledged boomer, I remember my early impressions of hospitals: big, mysterious places that sometimes didn’t allow children in. The grownups I knew talked about hospitals with a curious mixture of reverence and fear. If someone died in the hospital, the common notion was that the doctors “did all they could, but Uncle Fred didn’t make it.”

If, heaven forbid, a person faced hospitalization, he or she went wherever the doctor directed. In my small hometown, everybody knew somebody who worked at the hospital, so you at least knew that if you had to go there, you’d see people you knew. And if you knew the people, you trusted the hospital to be a good place where good people did their best for you. And that was about all the information most people had about their local hospital.

Today, the public pressure for information about the inner workings of hospitals is coming from every direction― regulators, politicians at every level, the press, organizations claiming to represent “consumers” and distinct groups such as the elderly and uninsured, unions, the business community, and the list keeps growing. The demand is for an unvarnished took at what occurs in every place, from the boardroom to the billing office to the bedside. How do hospitals govern themselves? Whom do they pay how much? What prevents conflicts of interest? What do they charge for their services, and who actually pays what? What are the policies and practices on charity care, billing, and collections? How many errors do the clinicians make? How many people get infections in the hospital? What are the outcomes of the care? Are patients getting the right care at the right time? Do patients get too much care? Too little? What do you do about inept doctors?

It’s a virtual tsunami for transparency. And hospital people are reacting to this tidal wave in multiple ways. Some are running away from reality. Some are standing their ground. And some are adapting and changing to survive and thrive in an environment vastly different than anything their careers have prepared them for so far.

Because hospitalists are a growing presence and are playing an increasingly important role in all aspects of quality and patient safety, they will be critical to the hospital’s ability to adapt successfully to this new era of transparency and accountability.

The public’s attitudes toward medical error reporting and hospital acquired infections and how hospitals are responding to them today are important clues to the future. In 1999, the Institute of Medicine released its now famous report, To Err Is Human. It estimated that between 45,000 and 98,000 Americans die in hospitals each year from preventable medical errors. The report was nuclear. Not only did it open a national debate on patient safety that continues still, but also it compelled thousands of hospitals to talk with their communities for the first time about what they do to prevent errors.

A recent survey found that 55% of Americans are dissatisfied with the quality of hospital care. In the same poll, 34% said they or a family member had experienced a preventable medical error, and 70% of them said they were not told. Ninety-two percent of the respondents said medical error reporting should be mandatory and public.

Hospitals have agreed that errors should be reported. But unless there’s confidentiality, a culture of blame will discourage reporting and drive errors underground. Caregivers won’t come forward to admit mistakes, making it difficult to get to the root cause and to prevent future incidents. While the national debate goes on, 18 states have passed laws requiring hospitals to report errors to some external body. Some of that data will be made public in some form. Will lawmakers and hospitals be able to resist public pressure over time for public reporting of errors by all hospitals? Can we convince the public that confidentiality will actually lead to safer care and a culture of safety in the nation’s hospitals?

In 2002, the Chicago Tribune reported the results of its investigation into hospital acquired infections, estimating that about 75,000 people died in 2000 from infections that could have been prevented. The Centers for Disease Control and Prevention (CDC) has said that 90,000 patients die annually from hospital acquired infections, adding $5 billion to America’s health care costs. If hospital personnel were more observant of simple infection control procedures, such as regular hand washing, the CDC says thousands of lives and billions of dollars could be saved.

Consumers Union, publisher of the powerful magazine, Consumer Reports, has taken on health care in recent years with the same vigor that it used to get information to the public on autos and appliances. Its current national campaign calls for the reporting and publicizing of hospital acquired infection rates by all hospitals. In 30 states, bills have been introduced to mandate reporting of infection rates. Fifteen states are considering laws to control and oversee hospitals’ infection control practices. The concept that the public should know how well hospitals perform at infection control and prevention resonates strongly. Public reporting of hospital quality measures is in its infancy. Earlier this month, the first public private website opened with information that will allow comparison of hospitals’ performance around pneumonia, heart attack, and heart failure. Soon data on patients’ experience with care―how well they think their doctors and nurses did―will be added. Will infection and infection control statistics be far behind?

And the challenges and tensions are not all in the clinical arena. A recent survey by the American College of Physician Executives found 9 out of 10 physicians concerned about dishonesty, financial conflicts, and unethical behavior among their colleagues.

Eighty percent said they were worried about doctors refusing to treat uninsured patients as part of “on call” responsibilities. And 79% pointed to undue Influence on physicians by medical device companies to perform certain procedures. Physicians’ over treatment of patients to boost income were cited by 78% of the doctors. Another major concern: the influence of drug companies on physicians’ prescribing habits.

In early April, the federal government announced that it would begin investigating the upsurge in tests being ordered for Medicare patients. The issues: medical necessity and rapidly increasing costs.

Hospitals are at a crossroads in their relationships with many publics: their patients, employees and medical staff s, their communities, the government, and the media. The issue is building and retaining trust on so many fronts. Hospitals must be proactive when it comes to accountability and transparency. Doing so will create enormous tensions and challenges inside an institution. This will require leadership and motivation. Hospitalists, given their unique role, are positioned to be powerful catalysts for change―change that will result either in a mountain of cumbersome new laws and regulations or a new culture of openness and trust with the people hospitals exist to serve.

Bob Wachter, MD, FACP

Robert M. Wachter, MD, professor and chief of the medical service at the University of California, San Francisco (UCSF) Medical Center and director of its hospital medicine group, addressed the audience at the 8th Annual Meeting of the Society of Hospital Medicine (SHM), along with several other noted leaders. Shortly before the meeting, Wachter shared his insight on the initial years of hospital medicine as well as the complexities, challenges, and opportunities the future holds for hospital medicine groups with The Hospitalist.

Well known for having coined the term “hospitalist” in a 1996 New England Journal of Medicine article, Wachter provided a brief outline of the birth of the hospital medicine discipline. He recalled that the initial growth of the field was slow, but it gained momentum as healthcare facilities began to perceive this specialty as an effective way to fulfill a need. During the last 10 years, hospitalists have made clear their value as agents of throughput, systems management, resource utilization, physician practice improvement, round the clock availability, and medical student education, always placing patient safety, satisfaction, and quality at the forefront of the practice. During the next 10 years―and beyond―Wachter envisions an evolution in the critical role hospitalists will play in the continued delivery of quality health care, although he does admit there are some obstacles in the path.

Surgical Co-management

Having established their core role as managers of medical inpatients, hospitalists are setting their sights on other goals. “It’s logical and inevitable that hospitalists will take on roles in surgical co-management,” Wachter says. “Patients who are sick enough to be inpatients for surgery often have multiple medical illnesses. And surgeons are in the OR for much of the day, in some ways like primary care doctors’ being in the office.” Although the data to support this model are limited presently, he believes that good co-management programs will likely lead to an increase in the quality of care, efficiency and patient satisfaction as well as surgeon satisfaction. “This makes … intuitive sense, just as the whole hospitalist idea made sense 10 years ago,” he says.

Wachter admits that the transition will probably be gradual, because of the many clinical, economic, and political complexities. In many cases, surgeons receive a global fee , linked to the expectation that they will administer preoperative and postoperative care. “It will be tricky to try to figure out how to compensate the hospitalist for surgical co-management,” Wachter says. However, he expects the financial aspect of surgical co-management to eventually work itself out. “If there is a more efficient way to manage patients and a way to free up beds, hospitals will be interested in supporting it,” he says. Wachter anticipates a 5- to 10-year evolution before this model becomes widely embraced.

Patient Safety and Quality Improvement

Timing is everything, and for hospitalists the timing could not have been better. “The hospital medicine movement evolved precisely when American medicine began to care about safety and quality,” says Wachter. ”When I first read the Institute of Medicine report on patient safety, ‘To Err is Human,’ in 1999, I knew that we had a tremendous opportunity to make a difference.” Wachter notes that in the past, incentives for high quality performance were lacking. “That is changing rapidly,” he says. With the profusion of Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandates, Centers for Medicare and Medicaid Services (CMS) metrics, Leapfrog initiatives, and other quality measures, patient safety and quality have become top priorities. Since hospital medicine encompasses all the vital aspects of quality improvement and patient safety―from understanding transitions and working collaboratively with other medical specialists to improving systems and more effective oversight―hospitalists are becoming the “goto people,” according to Wachter. This is incredibly healthy for our field, he notes, “but more importantly, it will help save.”

As one measure of how the world has changed in just a few years, Wachter reflects on the experience of editing his textbook, Hospital Medicine, in 2000, and again in 2005 for the second edition. He was particularly struck by the chapter he wrote (in the 2005 edition, with his UCSF colleague Niraj Sehgal) on quality measurement and improvement. “It was staggering how much the area had changed,” he says. In the 2000 edition, there were 2 inpatient quality measures: aspirin and beta blockers for patients with myocardial infarction. In the 2005 edition, “we needed a 2-page table to catalogue all of the hospital quality measures produced by an alphabet soup of agencies and organizations.” In fact, he notes, of the 122 chapters in the book, the chapter that had changed the most in 5 years was the one on quality measurement. “This is a complex science that is still evolving,” Wachter says. “I fully expect that the chapter in the 3rd edition will change even more.”

Wachter has spearheaded several other initiatives designed to improve hospital conditions and care of patients. He leads a team of editors for the website, AHRQ Web M&M: Morbidity and Mortality Rounds on the Web (www.webmm.ahrq.gov), which provides expert analyses on medical errors, as well as a forum and online discussions on patient safety issues. He and his colleagues recently launched a second federally sponsored portal for patient safety, “AHRQ Patient Safety Network” (www.psnet.ahrq.gov), which offers regularly updated tools, new literature, surveys, videos, and links to other useful resources and experts and is customizable according to users’ interests.

Burnout

With all the responsibilities assigned to hospitalists, the issue of burnout might become a concern. Defined as mental and/or physical exhaustion caused by excessive and prolonged stress, burnout can afflict medical professionals who spend long hours caring for complicated patients. Wachter worries about burnout, but not unduly so. “There is nothing fundamental about our field that will cause burnout,” he says. He cites 4 factors that contribute to burnout: doing uninteresting, unimportant work; receiving little or no respect from peers; having little or no time to “catch your breath”; and earning an inadequate and unreasonable income. With the diverse responsibilities and personally and professionally satisfying work in which a hospitalist engages, these risks can be mitigated. “I’ve certainly visited hospital medicine groups that were rife with burned out providers,” he says. “But more often, I’ve seen terrific doctors doing work they love, making a difference in the lives of their patients and their institutions. When that’s the case, you don’t see much burnout.” Wachter believes that the way in which hospital medicine groups are designed influences the potential burnout factor. Considerable thought and planning should precede the creation of a hospital medicine group, he asserts. “Some groups are well constructed,” he says. “They’ve created jobs with reasonable amounts of downtime, an opportunity to earn a good income, and the chance to spend time improving the system and deliver high quality patient care.” On the other hand, groups that care for an unsustainable number of patients with lower recompense might well have burnout; some have even collapsed after the physicians led. “You can be sure,” he notes, “that the second iteration of the hospital medicine programs at these institutions will be structured much more carefully so as not to repeat the same mistakes.”

Using his own UCSF Medical Center as an example, Wachter notes virtually no burnout or attrition among his faculty, even though salaries are on an academic scale, below the prevailing community rate. “We feel supported and have time to catch our breath,” he says. “We are respected by our colleagues and the institution, we have a chance to teach, and we genuinely enjoy each other’s company. And we have a chance to work on other things, not just patient care.” And that makes all the difference.

The Future of Hospital Medicine

Wachter was recently elected to the American Board of Internal Medicine, the only new member and the sole hospitalist to earn this honor. In this role, he will have the opportunity to provide input that will influence the development and expansion of the hospital medicine movement. “The Board is interested in the growth of the hospitalist field and what it means for the future,” he says. “They would like to know how to support the field and how best to attract students to it.” Many members of the Board who were skeptical at first about the hospitalist field have now recognized that “hospitalists have brought back the excitement of being an internist.” Wachter believes that students exposed to hospitalists soon realize that these doctors have fulfilling, diverse careers. “Hospitalists interact with patients, act as leaders to make patient care better, increase quality, and write guidelines,” he says. “This is a rich job description.” At the UCSF Medical Center, students involved in various clerkships have the opportunity to work under the tutelage of hospitalists. These collaborative relationships bring greater understanding of the work a hospitalist does and promotes the future of the field, according to Wachter.

Specialized Certification

As each new specialty evolves, different requirements for certification arise. Since hospital medicine is still a fairly young field, educational and training qualifications have yet to be determined. In his role on the American Board of Internal Medicine, Wachter will probably contribute to the discussion on what certification can and should look like. “This is an area of active investigation,” he says. “Will there be a separate certification for hospitalists? Should it be given at initial certification or when a physician recertifies after having been a practicing hospitalist with demonstrated competency? Right now there is no widespread model for hospitalist training at the residency level,” says Wachter. “I would not be surprised if in 10 or 15 years specialized training evolves for hospitalists. If so, then it would be logical that there be some type of separate certification. It’ll be fascinating working with the Board and SHM to determine the best course in the meantime.”

Bob Wachter, MD, FACP

Robert M. Wachter, MD, professor and chief of the medical service at the University of California, San Francisco (UCSF) Medical Center and director of its hospital medicine group, addressed the audience at the 8th Annual Meeting of the Society of Hospital Medicine (SHM), along with several other noted leaders. Shortly before the meeting, Wachter shared his insight on the initial years of hospital medicine as well as the complexities, challenges, and opportunities the future holds for hospital medicine groups with The Hospitalist.

Well known for having coined the term “hospitalist” in a 1996 New England Journal of Medicine article, Wachter provided a brief outline of the birth of the hospital medicine discipline. He recalled that the initial growth of the field was slow, but it gained momentum as healthcare facilities began to perceive this specialty as an effective way to fulfill a need. During the last 10 years, hospitalists have made clear their value as agents of throughput, systems management, resource utilization, physician practice improvement, round the clock availability, and medical student education, always placing patient safety, satisfaction, and quality at the forefront of the practice. During the next 10 years―and beyond―Wachter envisions an evolution in the critical role hospitalists will play in the continued delivery of quality health care, although he does admit there are some obstacles in the path.

Surgical Co-management

Having established their core role as managers of medical inpatients, hospitalists are setting their sights on other goals. “It’s logical and inevitable that hospitalists will take on roles in surgical co-management,” Wachter says. “Patients who are sick enough to be inpatients for surgery often have multiple medical illnesses. And surgeons are in the OR for much of the day, in some ways like primary care doctors’ being in the office.” Although the data to support this model are limited presently, he believes that good co-management programs will likely lead to an increase in the quality of care, efficiency and patient satisfaction as well as surgeon satisfaction. “This makes … intuitive sense, just as the whole hospitalist idea made sense 10 years ago,” he says.

Wachter admits that the transition will probably be gradual, because of the many clinical, economic, and political complexities. In many cases, surgeons receive a global fee , linked to the expectation that they will administer preoperative and postoperative care. “It will be tricky to try to figure out how to compensate the hospitalist for surgical co-management,” Wachter says. However, he expects the financial aspect of surgical co-management to eventually work itself out. “If there is a more efficient way to manage patients and a way to free up beds, hospitals will be interested in supporting it,” he says. Wachter anticipates a 5- to 10-year evolution before this model becomes widely embraced.

Patient Safety and Quality Improvement

Timing is everything, and for hospitalists the timing could not have been better. “The hospital medicine movement evolved precisely when American medicine began to care about safety and quality,” says Wachter. ”When I first read the Institute of Medicine report on patient safety, ‘To Err is Human,’ in 1999, I knew that we had a tremendous opportunity to make a difference.” Wachter notes that in the past, incentives for high quality performance were lacking. “That is changing rapidly,” he says. With the profusion of Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandates, Centers for Medicare and Medicaid Services (CMS) metrics, Leapfrog initiatives, and other quality measures, patient safety and quality have become top priorities. Since hospital medicine encompasses all the vital aspects of quality improvement and patient safety―from understanding transitions and working collaboratively with other medical specialists to improving systems and more effective oversight―hospitalists are becoming the “goto people,” according to Wachter. This is incredibly healthy for our field, he notes, “but more importantly, it will help save.”

As one measure of how the world has changed in just a few years, Wachter reflects on the experience of editing his textbook, Hospital Medicine, in 2000, and again in 2005 for the second edition. He was particularly struck by the chapter he wrote (in the 2005 edition, with his UCSF colleague Niraj Sehgal) on quality measurement and improvement. “It was staggering how much the area had changed,” he says. In the 2000 edition, there were 2 inpatient quality measures: aspirin and beta blockers for patients with myocardial infarction. In the 2005 edition, “we needed a 2-page table to catalogue all of the hospital quality measures produced by an alphabet soup of agencies and organizations.” In fact, he notes, of the 122 chapters in the book, the chapter that had changed the most in 5 years was the one on quality measurement. “This is a complex science that is still evolving,” Wachter says. “I fully expect that the chapter in the 3rd edition will change even more.”

Wachter has spearheaded several other initiatives designed to improve hospital conditions and care of patients. He leads a team of editors for the website, AHRQ Web M&M: Morbidity and Mortality Rounds on the Web (www.webmm.ahrq.gov), which provides expert analyses on medical errors, as well as a forum and online discussions on patient safety issues. He and his colleagues recently launched a second federally sponsored portal for patient safety, “AHRQ Patient Safety Network” (www.psnet.ahrq.gov), which offers regularly updated tools, new literature, surveys, videos, and links to other useful resources and experts and is customizable according to users’ interests.

Burnout

With all the responsibilities assigned to hospitalists, the issue of burnout might become a concern. Defined as mental and/or physical exhaustion caused by excessive and prolonged stress, burnout can afflict medical professionals who spend long hours caring for complicated patients. Wachter worries about burnout, but not unduly so. “There is nothing fundamental about our field that will cause burnout,” he says. He cites 4 factors that contribute to burnout: doing uninteresting, unimportant work; receiving little or no respect from peers; having little or no time to “catch your breath”; and earning an inadequate and unreasonable income. With the diverse responsibilities and personally and professionally satisfying work in which a hospitalist engages, these risks can be mitigated. “I’ve certainly visited hospital medicine groups that were rife with burned out providers,” he says. “But more often, I’ve seen terrific doctors doing work they love, making a difference in the lives of their patients and their institutions. When that’s the case, you don’t see much burnout.” Wachter believes that the way in which hospital medicine groups are designed influences the potential burnout factor. Considerable thought and planning should precede the creation of a hospital medicine group, he asserts. “Some groups are well constructed,” he says. “They’ve created jobs with reasonable amounts of downtime, an opportunity to earn a good income, and the chance to spend time improving the system and deliver high quality patient care.” On the other hand, groups that care for an unsustainable number of patients with lower recompense might well have burnout; some have even collapsed after the physicians led. “You can be sure,” he notes, “that the second iteration of the hospital medicine programs at these institutions will be structured much more carefully so as not to repeat the same mistakes.”

Using his own UCSF Medical Center as an example, Wachter notes virtually no burnout or attrition among his faculty, even though salaries are on an academic scale, below the prevailing community rate. “We feel supported and have time to catch our breath,” he says. “We are respected by our colleagues and the institution, we have a chance to teach, and we genuinely enjoy each other’s company. And we have a chance to work on other things, not just patient care.” And that makes all the difference.

The Future of Hospital Medicine

Wachter was recently elected to the American Board of Internal Medicine, the only new member and the sole hospitalist to earn this honor. In this role, he will have the opportunity to provide input that will influence the development and expansion of the hospital medicine movement. “The Board is interested in the growth of the hospitalist field and what it means for the future,” he says. “They would like to know how to support the field and how best to attract students to it.” Many members of the Board who were skeptical at first about the hospitalist field have now recognized that “hospitalists have brought back the excitement of being an internist.” Wachter believes that students exposed to hospitalists soon realize that these doctors have fulfilling, diverse careers. “Hospitalists interact with patients, act as leaders to make patient care better, increase quality, and write guidelines,” he says. “This is a rich job description.” At the UCSF Medical Center, students involved in various clerkships have the opportunity to work under the tutelage of hospitalists. These collaborative relationships bring greater understanding of the work a hospitalist does and promotes the future of the field, according to Wachter.

Specialized Certification

As each new specialty evolves, different requirements for certification arise. Since hospital medicine is still a fairly young field, educational and training qualifications have yet to be determined. In his role on the American Board of Internal Medicine, Wachter will probably contribute to the discussion on what certification can and should look like. “This is an area of active investigation,” he says. “Will there be a separate certification for hospitalists? Should it be given at initial certification or when a physician recertifies after having been a practicing hospitalist with demonstrated competency? Right now there is no widespread model for hospitalist training at the residency level,” says Wachter. “I would not be surprised if in 10 or 15 years specialized training evolves for hospitalists. If so, then it would be logical that there be some type of separate certification. It’ll be fascinating working with the Board and SHM to determine the best course in the meantime.”

Bob Wachter, MD, FACP

Robert M. Wachter, MD, professor and chief of the medical service at the University of California, San Francisco (UCSF) Medical Center and director of its hospital medicine group, addressed the audience at the 8th Annual Meeting of the Society of Hospital Medicine (SHM), along with several other noted leaders. Shortly before the meeting, Wachter shared his insight on the initial years of hospital medicine as well as the complexities, challenges, and opportunities the future holds for hospital medicine groups with The Hospitalist.

Well known for having coined the term “hospitalist” in a 1996 New England Journal of Medicine article, Wachter provided a brief outline of the birth of the hospital medicine discipline. He recalled that the initial growth of the field was slow, but it gained momentum as healthcare facilities began to perceive this specialty as an effective way to fulfill a need. During the last 10 years, hospitalists have made clear their value as agents of throughput, systems management, resource utilization, physician practice improvement, round the clock availability, and medical student education, always placing patient safety, satisfaction, and quality at the forefront of the practice. During the next 10 years―and beyond―Wachter envisions an evolution in the critical role hospitalists will play in the continued delivery of quality health care, although he does admit there are some obstacles in the path.

Surgical Co-management

Having established their core role as managers of medical inpatients, hospitalists are setting their sights on other goals. “It’s logical and inevitable that hospitalists will take on roles in surgical co-management,” Wachter says. “Patients who are sick enough to be inpatients for surgery often have multiple medical illnesses. And surgeons are in the OR for much of the day, in some ways like primary care doctors’ being in the office.” Although the data to support this model are limited presently, he believes that good co-management programs will likely lead to an increase in the quality of care, efficiency and patient satisfaction as well as surgeon satisfaction. “This makes … intuitive sense, just as the whole hospitalist idea made sense 10 years ago,” he says.

Wachter admits that the transition will probably be gradual, because of the many clinical, economic, and political complexities. In many cases, surgeons receive a global fee , linked to the expectation that they will administer preoperative and postoperative care. “It will be tricky to try to figure out how to compensate the hospitalist for surgical co-management,” Wachter says. However, he expects the financial aspect of surgical co-management to eventually work itself out. “If there is a more efficient way to manage patients and a way to free up beds, hospitals will be interested in supporting it,” he says. Wachter anticipates a 5- to 10-year evolution before this model becomes widely embraced.

Patient Safety and Quality Improvement

Timing is everything, and for hospitalists the timing could not have been better. “The hospital medicine movement evolved precisely when American medicine began to care about safety and quality,” says Wachter. ”When I first read the Institute of Medicine report on patient safety, ‘To Err is Human,’ in 1999, I knew that we had a tremendous opportunity to make a difference.” Wachter notes that in the past, incentives for high quality performance were lacking. “That is changing rapidly,” he says. With the profusion of Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandates, Centers for Medicare and Medicaid Services (CMS) metrics, Leapfrog initiatives, and other quality measures, patient safety and quality have become top priorities. Since hospital medicine encompasses all the vital aspects of quality improvement and patient safety―from understanding transitions and working collaboratively with other medical specialists to improving systems and more effective oversight―hospitalists are becoming the “goto people,” according to Wachter. This is incredibly healthy for our field, he notes, “but more importantly, it will help save.”

As one measure of how the world has changed in just a few years, Wachter reflects on the experience of editing his textbook, Hospital Medicine, in 2000, and again in 2005 for the second edition. He was particularly struck by the chapter he wrote (in the 2005 edition, with his UCSF colleague Niraj Sehgal) on quality measurement and improvement. “It was staggering how much the area had changed,” he says. In the 2000 edition, there were 2 inpatient quality measures: aspirin and beta blockers for patients with myocardial infarction. In the 2005 edition, “we needed a 2-page table to catalogue all of the hospital quality measures produced by an alphabet soup of agencies and organizations.” In fact, he notes, of the 122 chapters in the book, the chapter that had changed the most in 5 years was the one on quality measurement. “This is a complex science that is still evolving,” Wachter says. “I fully expect that the chapter in the 3rd edition will change even more.”

Wachter has spearheaded several other initiatives designed to improve hospital conditions and care of patients. He leads a team of editors for the website, AHRQ Web M&M: Morbidity and Mortality Rounds on the Web (www.webmm.ahrq.gov), which provides expert analyses on medical errors, as well as a forum and online discussions on patient safety issues. He and his colleagues recently launched a second federally sponsored portal for patient safety, “AHRQ Patient Safety Network” (www.psnet.ahrq.gov), which offers regularly updated tools, new literature, surveys, videos, and links to other useful resources and experts and is customizable according to users’ interests.

Burnout

With all the responsibilities assigned to hospitalists, the issue of burnout might become a concern. Defined as mental and/or physical exhaustion caused by excessive and prolonged stress, burnout can afflict medical professionals who spend long hours caring for complicated patients. Wachter worries about burnout, but not unduly so. “There is nothing fundamental about our field that will cause burnout,” he says. He cites 4 factors that contribute to burnout: doing uninteresting, unimportant work; receiving little or no respect from peers; having little or no time to “catch your breath”; and earning an inadequate and unreasonable income. With the diverse responsibilities and personally and professionally satisfying work in which a hospitalist engages, these risks can be mitigated. “I’ve certainly visited hospital medicine groups that were rife with burned out providers,” he says. “But more often, I’ve seen terrific doctors doing work they love, making a difference in the lives of their patients and their institutions. When that’s the case, you don’t see much burnout.” Wachter believes that the way in which hospital medicine groups are designed influences the potential burnout factor. Considerable thought and planning should precede the creation of a hospital medicine group, he asserts. “Some groups are well constructed,” he says. “They’ve created jobs with reasonable amounts of downtime, an opportunity to earn a good income, and the chance to spend time improving the system and deliver high quality patient care.” On the other hand, groups that care for an unsustainable number of patients with lower recompense might well have burnout; some have even collapsed after the physicians led. “You can be sure,” he notes, “that the second iteration of the hospital medicine programs at these institutions will be structured much more carefully so as not to repeat the same mistakes.”

Using his own UCSF Medical Center as an example, Wachter notes virtually no burnout or attrition among his faculty, even though salaries are on an academic scale, below the prevailing community rate. “We feel supported and have time to catch our breath,” he says. “We are respected by our colleagues and the institution, we have a chance to teach, and we genuinely enjoy each other’s company. And we have a chance to work on other things, not just patient care.” And that makes all the difference.

The Future of Hospital Medicine

Wachter was recently elected to the American Board of Internal Medicine, the only new member and the sole hospitalist to earn this honor. In this role, he will have the opportunity to provide input that will influence the development and expansion of the hospital medicine movement. “The Board is interested in the growth of the hospitalist field and what it means for the future,” he says. “They would like to know how to support the field and how best to attract students to it.” Many members of the Board who were skeptical at first about the hospitalist field have now recognized that “hospitalists have brought back the excitement of being an internist.” Wachter believes that students exposed to hospitalists soon realize that these doctors have fulfilling, diverse careers. “Hospitalists interact with patients, act as leaders to make patient care better, increase quality, and write guidelines,” he says. “This is a rich job description.” At the UCSF Medical Center, students involved in various clerkships have the opportunity to work under the tutelage of hospitalists. These collaborative relationships bring greater understanding of the work a hospitalist does and promotes the future of the field, according to Wachter.

Specialized Certification

As each new specialty evolves, different requirements for certification arise. Since hospital medicine is still a fairly young field, educational and training qualifications have yet to be determined. In his role on the American Board of Internal Medicine, Wachter will probably contribute to the discussion on what certification can and should look like. “This is an area of active investigation,” he says. “Will there be a separate certification for hospitalists? Should it be given at initial certification or when a physician recertifies after having been a practicing hospitalist with demonstrated competency? Right now there is no widespread model for hospitalist training at the residency level,” says Wachter. “I would not be surprised if in 10 or 15 years specialized training evolves for hospitalists. If so, then it would be logical that there be some type of separate certification. It’ll be fascinating working with the Board and SHM to determine the best course in the meantime.”

Editor’s Note:

Having returned from the 8th SHM Annual Meeting at the time of this writing, it is clear that this was not only the biggest but also the best Annual Meeting to date. As Larry Wellikson and Joe Miller describe more fully in this issue, the lectures, workshops and networking activities available far outstripped the ability of attendees to take part in all of them. In fact, it was common to feel that there were 2, 3, or even more “must attend” sessions taking place simultaneously and if this was sometimes frustrating, it also spoke to the fact that the meeting’s quality was strikingly high. With the realization that a collection of articles is unable to fully convey the vibrancy of the meeting, we have assembled in the following section a “Big Picture” from imbedded reporter Joe Miller, overviews of 2 of the plenary lectures, and recaps of several outstanding breakout sessions. A separate monograph that will include other highlights of the Annual Meeting is under development and will be mailed in August.―JP

I was invited to write a short piece for The Hospitalist summarizing SHM’s 8th Annual Meeting on Thursday, April 28 through Saturday, April 30 in Chicago. As I sat on the airplane on my return flight to Boston, I reflected on what would define a “successful” annual meeting for the professional society representing hospitalists. I concluded that three criteria would define success. Specifically that the conference would:

• Demonstrate the strength and resiliency of the hospital medicine movement
• Provide quality content and learning opportunities to a diverse group of attendees
• Demonstrate that SHM is a competent and effective organization meeting the needs of its members.

I believe the meeting measured up extremely well on all three criteria.

With regard to demonstrating the vibrancy of the hospital medicine movement:

• At the conference, there was recognition by three significant stakeholders in the healthcare industry (hospitals, employers, and regulators) of the critical role of hospitalists. In the opening keynote address, Rick Wade, Senior Vice President of the American Hospital Association, described the growing pressure on hospitals to be “transparent,” sharing information with patients and the public on their performance. Mr. Wade’s address was followed by a presentation by Arnold Milstein, MD, Medical Director of the Pacific Business Group on Health and cofounder of the Leapfrog Group. Dr. Milstein used the metaphor of a shark’s jaws to describe the threat of the continued escalation of healthcare costs, and he indicated that the key to addressing this crisis is to “re-engineer” clinical processes to make them more efficient. On Saturday, Dennis O’Leary, CEO of JCAHO, described the challenge of evaluating the performance of hospitals in the era of patient safety. All three speakers indicated that hospitalists will be critical resources to healthcare leaders faced with these challenges. Another measure of the recognition of hospitalists as a force in the healthcare industry was the fact that over 90 exhibitors wanted the opportunity to get the ear of the conference attendees. The exhibit floor was teeming with hospitalists interested in learning about programs, products, and services.
• The growth of the hospital medicine movement was clearly evident to attendees of the conference. This year’s conference had over 1000 attendees,a growth of 15% over the 2004 annual meeting. When Alpesh Amin, MD, co-director of the course, opened the meeting, the attendees responded to a series of questions through the audience response system. For over 50% of the attendees, this was their first SHM Annual Meeting, indicating that the specialty of hospital medicine has a constant influx of “new blood.” And at the President’s Luncheon, the presentation by Larry Wellikson, MD, CEO of SHM, conveyed a broad array of statistics on the status of the hospital medicine movement, including the fact that the 12,000+ hospitalists in the U.S. makes the specialty bigger than gastroenterology and neurology. Approximately 30% of all U.S. Hospitals have hospital medicine programs; for hospitals with over 200 beds, 55% have hospitalists.
• The excellence of the hospital medicine movement was evident through the quality of the 120+ research, innovation, and clinical vignette posters presented on Friday. Furthermore, the accomplishments of the SHM award winners announced at the President’s Luncheon were quite impressive. Joseph Li, MD, won the award for Outstanding Service in Hospital Medicine, Sunil Kripalani, MD, was named the Outstanding Young Investigator, Shaun Frost, MD, won the Clinical Excellence award, and Jeff Wiese, MD, won the award for Excellence in Teaching. Hospitalists are demonstrating their ability to be innovative, high impact physicians.

With regard to providing learning opportunities for a diverse audience:

• The pre-courses on Thursday allowed attendees to gain in-depth knowledge on practice management, perioperative medicine, and critical care medicine.
• There were 35 separate presentations in 7 tracks over the 2 days of the main meeting. The clinical, adult clinical, and pediatric clinical tracks covered a wide array of topics, from maternal fetal medicine to acquired pediatric heart disease to addiction medicine. Tracks on quality and patient safety were very well attended, and the academic track included an important update on the hospitalist core curriculum being developed by SHM.
• There were 10 special interest forums allowing attendees interested in the following subjects to exchange ideas: community based hospitalists, research, education, medical directors, women hospitalists, pediatric hospitalists, family practice hospitalists, geriatric hospitalists, early career hospitalists, and nurse practitioners and physician assistants.
• The plenary sessions on updates in hospital medicine and pediatric hospital medicine provided excellent reviews of recent research relevant to hospitalists. Bob Wachter’s annual presentation, this year entitled “Hospital Medicine: Still Crazy After All These Years” laid out some important challenges for the hospital medicine movement as it moves into adolescence.

Finally, with regard to demonstrating SHM’s competence and its ability to meet the needs of its members:

• At the President’s Luncheon, the depth of SHM leadership was evident. Jeanne Huddleston, MD, reported on the significant accomplishments of the past year and handed the torch to SHM’s new President, Steve Pantilat, MD. Steve described his two goals for the upcoming year, the development ofan SHM Research Foundation and an emphasis on the role of hospitalists in palliative care. And Larry Wellikson, MD, SHM’s CEO, displayed energy and charisma throughout the meeting.
• The power of SHM volunteerism was unmistakable throughout the meeting. Preetha Basaviah, MD, the overall course director, harnessed group of SHM members participating in a planning committee to decide on the topics and choose the speakers for the meeting. A broad cross-section of SHM members participated in over 15 committee meetings in Chicago, as they donated their time to improving the field of hospital medicine.
• The conference was a vehicle to display the public relations capabilities of SHM. Melanie Bloom, wife of NBC newscaster David Bloom who died in Iraq of DVT complications, described the awareness campaign that SHM led. The attendees then viewed a short video of the television appearances by hospitalists in the last year, as hospital medicine has received increasing attention in the media. Larry Wellikson announced that every SHM member will receive a DVD with these video news segments.
• The strength of SHM staff and organization was on display in Chicago. Larry Wellikson reported that the staff has more than doubled and he cited a litany of accomplishments, including a new improved website, electronic registration for meetings, a broad range of educational offerings, and a healthy financial outlook. Furthermore, SHM has continued to experience significant membership growth, as the number of members now exceeds 4700, an increase of more than 40% in the past 12 months.
• Finally, and perhaps most importantly, Wellikson described a wide variety of initiatives that are being pursued to meet the needs of SHM members. These initiatives include a long range plan for the formal certification of hospitalists, strategic partnerships with key organizations, public policy initiatives, and the continued strengthening of historical efforts regarding education, leadership, and surveys.

In summary, the SHM conference was greater than the sum of the parts. It was successfully executed on multiple fronts. However I have not yet discussed perhaps the most important achievement of this meeting. It served as an opportunity for hospitalists to meet new friends and to reconnect with old colleagues. The Annual Meeting in Chicago created a positive energy that will carry SHM members until we have the opportunity to meet again next year in Washington, DC.

Editor’s Note:

Having returned from the 8th SHM Annual Meeting at the time of this writing, it is clear that this was not only the biggest but also the best Annual Meeting to date. As Larry Wellikson and Joe Miller describe more fully in this issue, the lectures, workshops and networking activities available far outstripped the ability of attendees to take part in all of them. In fact, it was common to feel that there were 2, 3, or even more “must attend” sessions taking place simultaneously and if this was sometimes frustrating, it also spoke to the fact that the meeting’s quality was strikingly high. With the realization that a collection of articles is unable to fully convey the vibrancy of the meeting, we have assembled in the following section a “Big Picture” from imbedded reporter Joe Miller, overviews of 2 of the plenary lectures, and recaps of several outstanding breakout sessions. A separate monograph that will include other highlights of the Annual Meeting is under development and will be mailed in August.―JP

I was invited to write a short piece for The Hospitalist summarizing SHM’s 8th Annual Meeting on Thursday, April 28 through Saturday, April 30 in Chicago. As I sat on the airplane on my return flight to Boston, I reflected on what would define a “successful” annual meeting for the professional society representing hospitalists. I concluded that three criteria would define success. Specifically that the conference would:

• Demonstrate the strength and resiliency of the hospital medicine movement
• Provide quality content and learning opportunities to a diverse group of attendees
• Demonstrate that SHM is a competent and effective organization meeting the needs of its members.

I believe the meeting measured up extremely well on all three criteria.

With regard to demonstrating the vibrancy of the hospital medicine movement:

• At the conference, there was recognition by three significant stakeholders in the healthcare industry (hospitals, employers, and regulators) of the critical role of hospitalists. In the opening keynote address, Rick Wade, Senior Vice President of the American Hospital Association, described the growing pressure on hospitals to be “transparent,” sharing information with patients and the public on their performance. Mr. Wade’s address was followed by a presentation by Arnold Milstein, MD, Medical Director of the Pacific Business Group on Health and cofounder of the Leapfrog Group. Dr. Milstein used the metaphor of a shark’s jaws to describe the threat of the continued escalation of healthcare costs, and he indicated that the key to addressing this crisis is to “re-engineer” clinical processes to make them more efficient. On Saturday, Dennis O’Leary, CEO of JCAHO, described the challenge of evaluating the performance of hospitals in the era of patient safety. All three speakers indicated that hospitalists will be critical resources to healthcare leaders faced with these challenges. Another measure of the recognition of hospitalists as a force in the healthcare industry was the fact that over 90 exhibitors wanted the opportunity to get the ear of the conference attendees. The exhibit floor was teeming with hospitalists interested in learning about programs, products, and services.
• The growth of the hospital medicine movement was clearly evident to attendees of the conference. This year’s conference had over 1000 attendees,a growth of 15% over the 2004 annual meeting. When Alpesh Amin, MD, co-director of the course, opened the meeting, the attendees responded to a series of questions through the audience response system. For over 50% of the attendees, this was their first SHM Annual Meeting, indicating that the specialty of hospital medicine has a constant influx of “new blood.” And at the President’s Luncheon, the presentation by Larry Wellikson, MD, CEO of SHM, conveyed a broad array of statistics on the status of the hospital medicine movement, including the fact that the 12,000+ hospitalists in the U.S. makes the specialty bigger than gastroenterology and neurology. Approximately 30% of all U.S. Hospitals have hospital medicine programs; for hospitals with over 200 beds, 55% have hospitalists.
• The excellence of the hospital medicine movement was evident through the quality of the 120+ research, innovation, and clinical vignette posters presented on Friday. Furthermore, the accomplishments of the SHM award winners announced at the President’s Luncheon were quite impressive. Joseph Li, MD, won the award for Outstanding Service in Hospital Medicine, Sunil Kripalani, MD, was named the Outstanding Young Investigator, Shaun Frost, MD, won the Clinical Excellence award, and Jeff Wiese, MD, won the award for Excellence in Teaching. Hospitalists are demonstrating their ability to be innovative, high impact physicians.

With regard to providing learning opportunities for a diverse audience:

• The pre-courses on Thursday allowed attendees to gain in-depth knowledge on practice management, perioperative medicine, and critical care medicine.
• There were 35 separate presentations in 7 tracks over the 2 days of the main meeting. The clinical, adult clinical, and pediatric clinical tracks covered a wide array of topics, from maternal fetal medicine to acquired pediatric heart disease to addiction medicine. Tracks on quality and patient safety were very well attended, and the academic track included an important update on the hospitalist core curriculum being developed by SHM.
• There were 10 special interest forums allowing attendees interested in the following subjects to exchange ideas: community based hospitalists, research, education, medical directors, women hospitalists, pediatric hospitalists, family practice hospitalists, geriatric hospitalists, early career hospitalists, and nurse practitioners and physician assistants.
• The plenary sessions on updates in hospital medicine and pediatric hospital medicine provided excellent reviews of recent research relevant to hospitalists. Bob Wachter’s annual presentation, this year entitled “Hospital Medicine: Still Crazy After All These Years” laid out some important challenges for the hospital medicine movement as it moves into adolescence.

Finally, with regard to demonstrating SHM’s competence and its ability to meet the needs of its members:

• At the President’s Luncheon, the depth of SHM leadership was evident. Jeanne Huddleston, MD, reported on the significant accomplishments of the past year and handed the torch to SHM’s new President, Steve Pantilat, MD. Steve described his two goals for the upcoming year, the development ofan SHM Research Foundation and an emphasis on the role of hospitalists in palliative care. And Larry Wellikson, MD, SHM’s CEO, displayed energy and charisma throughout the meeting.
• The power of SHM volunteerism was unmistakable throughout the meeting. Preetha Basaviah, MD, the overall course director, harnessed group of SHM members participating in a planning committee to decide on the topics and choose the speakers for the meeting. A broad cross-section of SHM members participated in over 15 committee meetings in Chicago, as they donated their time to improving the field of hospital medicine.
• The conference was a vehicle to display the public relations capabilities of SHM. Melanie Bloom, wife of NBC newscaster David Bloom who died in Iraq of DVT complications, described the awareness campaign that SHM led. The attendees then viewed a short video of the television appearances by hospitalists in the last year, as hospital medicine has received increasing attention in the media. Larry Wellikson announced that every SHM member will receive a DVD with these video news segments.
• The strength of SHM staff and organization was on display in Chicago. Larry Wellikson reported that the staff has more than doubled and he cited a litany of accomplishments, including a new improved website, electronic registration for meetings, a broad range of educational offerings, and a healthy financial outlook. Furthermore, SHM has continued to experience significant membership growth, as the number of members now exceeds 4700, an increase of more than 40% in the past 12 months.
• Finally, and perhaps most importantly, Wellikson described a wide variety of initiatives that are being pursued to meet the needs of SHM members. These initiatives include a long range plan for the formal certification of hospitalists, strategic partnerships with key organizations, public policy initiatives, and the continued strengthening of historical efforts regarding education, leadership, and surveys.

In summary, the SHM conference was greater than the sum of the parts. It was successfully executed on multiple fronts. However I have not yet discussed perhaps the most important achievement of this meeting. It served as an opportunity for hospitalists to meet new friends and to reconnect with old colleagues. The Annual Meeting in Chicago created a positive energy that will carry SHM members until we have the opportunity to meet again next year in Washington, DC.

Editor’s Note:

Having returned from the 8th SHM Annual Meeting at the time of this writing, it is clear that this was not only the biggest but also the best Annual Meeting to date. As Larry Wellikson and Joe Miller describe more fully in this issue, the lectures, workshops and networking activities available far outstripped the ability of attendees to take part in all of them. In fact, it was common to feel that there were 2, 3, or even more “must attend” sessions taking place simultaneously and if this was sometimes frustrating, it also spoke to the fact that the meeting’s quality was strikingly high. With the realization that a collection of articles is unable to fully convey the vibrancy of the meeting, we have assembled in the following section a “Big Picture” from imbedded reporter Joe Miller, overviews of 2 of the plenary lectures, and recaps of several outstanding breakout sessions. A separate monograph that will include other highlights of the Annual Meeting is under development and will be mailed in August.―JP

I was invited to write a short piece for The Hospitalist summarizing SHM’s 8th Annual Meeting on Thursday, April 28 through Saturday, April 30 in Chicago. As I sat on the airplane on my return flight to Boston, I reflected on what would define a “successful” annual meeting for the professional society representing hospitalists. I concluded that three criteria would define success. Specifically that the conference would:

• Demonstrate the strength and resiliency of the hospital medicine movement
• Provide quality content and learning opportunities to a diverse group of attendees
• Demonstrate that SHM is a competent and effective organization meeting the needs of its members.

I believe the meeting measured up extremely well on all three criteria.

With regard to demonstrating the vibrancy of the hospital medicine movement:

• At the conference, there was recognition by three significant stakeholders in the healthcare industry (hospitals, employers, and regulators) of the critical role of hospitalists. In the opening keynote address, Rick Wade, Senior Vice President of the American Hospital Association, described the growing pressure on hospitals to be “transparent,” sharing information with patients and the public on their performance. Mr. Wade’s address was followed by a presentation by Arnold Milstein, MD, Medical Director of the Pacific Business Group on Health and cofounder of the Leapfrog Group. Dr. Milstein used the metaphor of a shark’s jaws to describe the threat of the continued escalation of healthcare costs, and he indicated that the key to addressing this crisis is to “re-engineer” clinical processes to make them more efficient. On Saturday, Dennis O’Leary, CEO of JCAHO, described the challenge of evaluating the performance of hospitals in the era of patient safety. All three speakers indicated that hospitalists will be critical resources to healthcare leaders faced with these challenges. Another measure of the recognition of hospitalists as a force in the healthcare industry was the fact that over 90 exhibitors wanted the opportunity to get the ear of the conference attendees. The exhibit floor was teeming with hospitalists interested in learning about programs, products, and services.
• The growth of the hospital medicine movement was clearly evident to attendees of the conference. This year’s conference had over 1000 attendees,a growth of 15% over the 2004 annual meeting. When Alpesh Amin, MD, co-director of the course, opened the meeting, the attendees responded to a series of questions through the audience response system. For over 50% of the attendees, this was their first SHM Annual Meeting, indicating that the specialty of hospital medicine has a constant influx of “new blood.” And at the President’s Luncheon, the presentation by Larry Wellikson, MD, CEO of SHM, conveyed a broad array of statistics on the status of the hospital medicine movement, including the fact that the 12,000+ hospitalists in the U.S. makes the specialty bigger than gastroenterology and neurology. Approximately 30% of all U.S. Hospitals have hospital medicine programs; for hospitals with over 200 beds, 55% have hospitalists.
• The excellence of the hospital medicine movement was evident through the quality of the 120+ research, innovation, and clinical vignette posters presented on Friday. Furthermore, the accomplishments of the SHM award winners announced at the President’s Luncheon were quite impressive. Joseph Li, MD, won the award for Outstanding Service in Hospital Medicine, Sunil Kripalani, MD, was named the Outstanding Young Investigator, Shaun Frost, MD, won the Clinical Excellence award, and Jeff Wiese, MD, won the award for Excellence in Teaching. Hospitalists are demonstrating their ability to be innovative, high impact physicians.

With regard to providing learning opportunities for a diverse audience:

• The pre-courses on Thursday allowed attendees to gain in-depth knowledge on practice management, perioperative medicine, and critical care medicine.
• There were 35 separate presentations in 7 tracks over the 2 days of the main meeting. The clinical, adult clinical, and pediatric clinical tracks covered a wide array of topics, from maternal fetal medicine to acquired pediatric heart disease to addiction medicine. Tracks on quality and patient safety were very well attended, and the academic track included an important update on the hospitalist core curriculum being developed by SHM.
• There were 10 special interest forums allowing attendees interested in the following subjects to exchange ideas: community based hospitalists, research, education, medical directors, women hospitalists, pediatric hospitalists, family practice hospitalists, geriatric hospitalists, early career hospitalists, and nurse practitioners and physician assistants.
• The plenary sessions on updates in hospital medicine and pediatric hospital medicine provided excellent reviews of recent research relevant to hospitalists. Bob Wachter’s annual presentation, this year entitled “Hospital Medicine: Still Crazy After All These Years” laid out some important challenges for the hospital medicine movement as it moves into adolescence.

Finally, with regard to demonstrating SHM’s competence and its ability to meet the needs of its members:

• At the President’s Luncheon, the depth of SHM leadership was evident. Jeanne Huddleston, MD, reported on the significant accomplishments of the past year and handed the torch to SHM’s new President, Steve Pantilat, MD. Steve described his two goals for the upcoming year, the development ofan SHM Research Foundation and an emphasis on the role of hospitalists in palliative care. And Larry Wellikson, MD, SHM’s CEO, displayed energy and charisma throughout the meeting.
• The power of SHM volunteerism was unmistakable throughout the meeting. Preetha Basaviah, MD, the overall course director, harnessed group of SHM members participating in a planning committee to decide on the topics and choose the speakers for the meeting. A broad cross-section of SHM members participated in over 15 committee meetings in Chicago, as they donated their time to improving the field of hospital medicine.
• The conference was a vehicle to display the public relations capabilities of SHM. Melanie Bloom, wife of NBC newscaster David Bloom who died in Iraq of DVT complications, described the awareness campaign that SHM led. The attendees then viewed a short video of the television appearances by hospitalists in the last year, as hospital medicine has received increasing attention in the media. Larry Wellikson announced that every SHM member will receive a DVD with these video news segments.
• The strength of SHM staff and organization was on display in Chicago. Larry Wellikson reported that the staff has more than doubled and he cited a litany of accomplishments, including a new improved website, electronic registration for meetings, a broad range of educational offerings, and a healthy financial outlook. Furthermore, SHM has continued to experience significant membership growth, as the number of members now exceeds 4700, an increase of more than 40% in the past 12 months.
• Finally, and perhaps most importantly, Wellikson described a wide variety of initiatives that are being pursued to meet the needs of SHM members. These initiatives include a long range plan for the formal certification of hospitalists, strategic partnerships with key organizations, public policy initiatives, and the continued strengthening of historical efforts regarding education, leadership, and surveys.

In summary, the SHM conference was greater than the sum of the parts. It was successfully executed on multiple fronts. However I have not yet discussed perhaps the most important achievement of this meeting. It served as an opportunity for hospitalists to meet new friends and to reconnect with old colleagues. The Annual Meeting in Chicago created a positive energy that will carry SHM members until we have the opportunity to meet again next year in Washington, DC.

The bomb. The franchise. Sine qua non. Must see. Must be there. How do you say it when something or someone just seems to be in the middle of everything? That is hospital medicine, and that is SHM.

Nowhere was this more evident than at the largest gathering of hospitalists to date, the SHM Annual Meeting held in Chicago at the end of April. If you have a stake in hospital medicine or in building and improving the hospital of the future, all roads led to Chicago and SHM.

Not only was the CME content cutting edge and geared specifically for hospitalists, but also the sessions were greeted with standing room attendance. Clearly we struck a nerve with our 1-day in-depth pre-courses on Perioperative Care and Critical Care. The Practice Management course continues to attract 250 to 300 people as everyone tries to figure out how to get the most out of their hospital medicine group.

SHM virtually took over the entire Sheraton Hotel in downtown Chicago. Everywhere you looked, all you saw were hospitalists or people who needed to talk to hospitalists. The exhibit hall was sold out, and the networking between all the industries that support and depend on hospitalists continued well beyond the boundaries of the exhibit hall.

The Research Abstract, Clinical Vignette, and Innovation Poster session had almost 200 entries. On display here was the new thinking that is so characteristic of hospital medicine. As much as anything, this gathering displayed the youthful energy and innovation that will continue to propel hospital medicine into the future.

Important people came to be heard and to hear from hospitalists. Dennis O’Leary, the CEO of JCAHO, challenged hospitalists to lead their hospitals into a future with improved measurable quality. Rick Wade, a senior leader at the American Hospital Association, saw hospitalists as key partners with other stakeholders to meet the increasing demands on hospitals to do a better job. Arnie Milstein, the CMO and one of the founders of the Leapfrog Group, placed hospitalists squarely in the center of delivering the effective and efficient health care now demanded by America’s businesses and patients. And our own Bob Wachter challenged hospitalists to continue to lead the patient safety revolution.

But hospitalists did not just come to Chicago to sit and listen. Hospitalists are faced with so many new and difficult challenges that they clearly came to ask questions and give answers. Networking was both informal and formal and almost constant. With hospitalists everywhere you turned it was clear that people were out seeking the next new idea, the solution to a real life problem back home, and maybe even their next job.

The SHM Special Interest Forums were lively and well attended. This is where SHM gets its ideas. This is where hospitalists have their voices heard. This is where the diversity of hospital medicine can be seen up close and personal. The world of the hospital and our specialty looks different if you are a pediatrician or a family practitioner or a woman or an NP or a PA or a group leader or a young hospitalist. The demands, and your needs to meet them, can be different if you are in academics or a community hospital. SHM must hear your perspective and, boy, did we hear from you in Chicago.

For me personally, it was an opportunity to see and talk to over 1000 people connected in some way to the growing hospital medicine movement. Many of the people I spoke with were frontline hospitalists, earnest and dedicated to making hospital medicine their life’s work. They want to work with SHM to create a specialty and a career that is satisfying and fulfilling.

Some were representatives from publishers or pharmaceutical companies or hospitalist staffing and recruitment companies trying to bring their unique take on hospital medicine to SHM’s attention. Some were key leaders of other national healthcare organizations looking to partner with hospital medicine, the fastest growing workforce component of the hospital of the future and a force for change and improvement.

There were so many good ideas flying around that there is enough to keep SHM busy for years to come. And you will be hearing and reading about these in the coming months and years. It is clear that the energy around hospital medicine is not waning any time in the near future. There will be much for us to do. And if the talent and the drive to succeed of those who came to Chicago last month are any indication, SHM and our nation’s hospitalists are up to the challenge. Stay tuned.

The bomb. The franchise. Sine qua non. Must see. Must be there. How do you say it when something or someone just seems to be in the middle of everything? That is hospital medicine, and that is SHM.

Nowhere was this more evident than at the largest gathering of hospitalists to date, the SHM Annual Meeting held in Chicago at the end of April. If you have a stake in hospital medicine or in building and improving the hospital of the future, all roads led to Chicago and SHM.

Not only was the CME content cutting edge and geared specifically for hospitalists, but also the sessions were greeted with standing room attendance. Clearly we struck a nerve with our 1-day in-depth pre-courses on Perioperative Care and Critical Care. The Practice Management course continues to attract 250 to 300 people as everyone tries to figure out how to get the most out of their hospital medicine group.

SHM virtually took over the entire Sheraton Hotel in downtown Chicago. Everywhere you looked, all you saw were hospitalists or people who needed to talk to hospitalists. The exhibit hall was sold out, and the networking between all the industries that support and depend on hospitalists continued well beyond the boundaries of the exhibit hall.

The Research Abstract, Clinical Vignette, and Innovation Poster session had almost 200 entries. On display here was the new thinking that is so characteristic of hospital medicine. As much as anything, this gathering displayed the youthful energy and innovation that will continue to propel hospital medicine into the future.

Important people came to be heard and to hear from hospitalists. Dennis O’Leary, the CEO of JCAHO, challenged hospitalists to lead their hospitals into a future with improved measurable quality. Rick Wade, a senior leader at the American Hospital Association, saw hospitalists as key partners with other stakeholders to meet the increasing demands on hospitals to do a better job. Arnie Milstein, the CMO and one of the founders of the Leapfrog Group, placed hospitalists squarely in the center of delivering the effective and efficient health care now demanded by America’s businesses and patients. And our own Bob Wachter challenged hospitalists to continue to lead the patient safety revolution.

But hospitalists did not just come to Chicago to sit and listen. Hospitalists are faced with so many new and difficult challenges that they clearly came to ask questions and give answers. Networking was both informal and formal and almost constant. With hospitalists everywhere you turned it was clear that people were out seeking the next new idea, the solution to a real life problem back home, and maybe even their next job.

The SHM Special Interest Forums were lively and well attended. This is where SHM gets its ideas. This is where hospitalists have their voices heard. This is where the diversity of hospital medicine can be seen up close and personal. The world of the hospital and our specialty looks different if you are a pediatrician or a family practitioner or a woman or an NP or a PA or a group leader or a young hospitalist. The demands, and your needs to meet them, can be different if you are in academics or a community hospital. SHM must hear your perspective and, boy, did we hear from you in Chicago.

For me personally, it was an opportunity to see and talk to over 1000 people connected in some way to the growing hospital medicine movement. Many of the people I spoke with were frontline hospitalists, earnest and dedicated to making hospital medicine their life’s work. They want to work with SHM to create a specialty and a career that is satisfying and fulfilling.

Some were representatives from publishers or pharmaceutical companies or hospitalist staffing and recruitment companies trying to bring their unique take on hospital medicine to SHM’s attention. Some were key leaders of other national healthcare organizations looking to partner with hospital medicine, the fastest growing workforce component of the hospital of the future and a force for change and improvement.

There were so many good ideas flying around that there is enough to keep SHM busy for years to come. And you will be hearing and reading about these in the coming months and years. It is clear that the energy around hospital medicine is not waning any time in the near future. There will be much for us to do. And if the talent and the drive to succeed of those who came to Chicago last month are any indication, SHM and our nation’s hospitalists are up to the challenge. Stay tuned.

The bomb. The franchise. Sine qua non. Must see. Must be there. How do you say it when something or someone just seems to be in the middle of everything? That is hospital medicine, and that is SHM.

Nowhere was this more evident than at the largest gathering of hospitalists to date, the SHM Annual Meeting held in Chicago at the end of April. If you have a stake in hospital medicine or in building and improving the hospital of the future, all roads led to Chicago and SHM.

Not only was the CME content cutting edge and geared specifically for hospitalists, but also the sessions were greeted with standing room attendance. Clearly we struck a nerve with our 1-day in-depth pre-courses on Perioperative Care and Critical Care. The Practice Management course continues to attract 250 to 300 people as everyone tries to figure out how to get the most out of their hospital medicine group.

SHM virtually took over the entire Sheraton Hotel in downtown Chicago. Everywhere you looked, all you saw were hospitalists or people who needed to talk to hospitalists. The exhibit hall was sold out, and the networking between all the industries that support and depend on hospitalists continued well beyond the boundaries of the exhibit hall.

The Research Abstract, Clinical Vignette, and Innovation Poster session had almost 200 entries. On display here was the new thinking that is so characteristic of hospital medicine. As much as anything, this gathering displayed the youthful energy and innovation that will continue to propel hospital medicine into the future.

Important people came to be heard and to hear from hospitalists. Dennis O’Leary, the CEO of JCAHO, challenged hospitalists to lead their hospitals into a future with improved measurable quality. Rick Wade, a senior leader at the American Hospital Association, saw hospitalists as key partners with other stakeholders to meet the increasing demands on hospitals to do a better job. Arnie Milstein, the CMO and one of the founders of the Leapfrog Group, placed hospitalists squarely in the center of delivering the effective and efficient health care now demanded by America’s businesses and patients. And our own Bob Wachter challenged hospitalists to continue to lead the patient safety revolution.

But hospitalists did not just come to Chicago to sit and listen. Hospitalists are faced with so many new and difficult challenges that they clearly came to ask questions and give answers. Networking was both informal and formal and almost constant. With hospitalists everywhere you turned it was clear that people were out seeking the next new idea, the solution to a real life problem back home, and maybe even their next job.

The SHM Special Interest Forums were lively and well attended. This is where SHM gets its ideas. This is where hospitalists have their voices heard. This is where the diversity of hospital medicine can be seen up close and personal. The world of the hospital and our specialty looks different if you are a pediatrician or a family practitioner or a woman or an NP or a PA or a group leader or a young hospitalist. The demands, and your needs to meet them, can be different if you are in academics or a community hospital. SHM must hear your perspective and, boy, did we hear from you in Chicago.

For me personally, it was an opportunity to see and talk to over 1000 people connected in some way to the growing hospital medicine movement. Many of the people I spoke with were frontline hospitalists, earnest and dedicated to making hospital medicine their life’s work. They want to work with SHM to create a specialty and a career that is satisfying and fulfilling.

Some were representatives from publishers or pharmaceutical companies or hospitalist staffing and recruitment companies trying to bring their unique take on hospital medicine to SHM’s attention. Some were key leaders of other national healthcare organizations looking to partner with hospital medicine, the fastest growing workforce component of the hospital of the future and a force for change and improvement.

There were so many good ideas flying around that there is enough to keep SHM busy for years to come. And you will be hearing and reading about these in the coming months and years. It is clear that the energy around hospital medicine is not waning any time in the near future. There will be much for us to do. And if the talent and the drive to succeed of those who came to Chicago last month are any indication, SHM and our nation’s hospitalists are up to the challenge. Stay tuned.

As I write first column as President of SHM, palliative care has been much in the news. As a hospitalist who spends much of my time caring for people approaching the end of life and teaching about palliative care, these 2 weeks have kept me busy talking about end of life issues with family, friends, patients, colleagues, and the media. At the same time, these events have reaffirmed for me my choice of a career as a hospitalist and the central role that hospitalists play in providing the highest quality care for the sickest patients, in continually improving that care, and in refining the systems to deliver it.

Terri Schiavo died 2 weeks after her feeding tube was removed. Her life and death sparked protests and political debate. Yet in the end, what seems most profound is the great sadness and loss for her family. Soon after Terri Schiavo died, Pope John Paul II became acutely ill. Several days after a feeding tube was placed, the Pope died in his apartment at the Vatican, triggering a global outpouring of love and grief.

In modern American health care, probably Terri Schiavo and the Pope would have received care from a hospitalist. If she were to arrive in a hospital after a cardiac arrest today, Terri Schiavo would likely be cared for by a hospitalist. It is the hospitalist who would have the first discussions with her family about her condition and prognosis. Similarly, most 84-year-old men with Parkinson’s disease, pneumonia, and a urinary tract infection would be cared for by a hospitalist. Hospitalists are serving as de facto ethicists and palliative care physicians, as we care for increasing numbers of people with serious and terminal illness. This shift in care provides an unprecedented opportunity for us to improve the quality of care for the half of all Americans who die in hospitals. Providing state of the art palliative care reinforces our efforts globally to improve the quality of care for all hospitalized patients. Furthermore, these cases highlight the need for research to define the best ways to deliver that care. As I thought about Terri Schiavo and the Pope, and saw the intense media spotlight on them, I kept thinking, “What does this mean for me?”

I have given this question a great deal of thought over the past week. What, if anything, do the deaths of Terri Schiavo and the Pope teach us? As I see it there are at least 3 important lessons for us as individuals and as hospitalists.

The first lesson is that each of us should consider the kind of care we would want if we were to suffer a devastating injury, as did Terri Schiavo, or be stricken with a progressive, debilitating illness, like the Pope. We should discuss our preferences for care with our loved ones and write them down. As hospitalists we should have these discussions routinely with our patients, document the conversations, notify the patient’s primary care physician, and encourage patients to share their thoughts with their loved ones. As a son, husband, brother, nephew, grandson, and father, I realized that one of the most important obligations I owed to my family was to make my wishes known, and to learn about the wishes of my loved ones. As a hospitalist, I realized that I owed it to my patients to help them express their preferences for care. What I learned echoed what we know about advance directives: You cannot predict what someone will say. Not unexpectedly, my mother, grandmother, and aunt told me that they would never want to live like Terri Schiavo. But in a complete surprise my aunt told me that my favorite uncle, who is blessed with a quick wit and brilliant sense of humor, wants to be kept alive as long as possible.

As a hospitalist, I know that my patients care deeply about these issues and are quite eager to discuss them. Talking with patients about these issues is not just a good thing to do, but ultimately improves quality of care by promoting care that is consistent with patient preferences and emphasizes our commitment to respect patients and advocate on their behalf. I still remember early concerns about hospitalists that we would be cowboys more interested in procedures and yelling “Stat!” than in being caring providers who took time to get to know our patients. Yet an early study of hospitalists that I was involved in found just the opposite. Hospitalists recognized the importance of palliative care and good communication with patients. As I made rounds in the hospital in late March, many patients were watching the vigil outside the hospice in Florida and talking about the Pope. Many patients wanted to know my thoughts. Using the communication skills I have honed over the years, and my cultural background of always answering a question with a question, I turned it around and asked them, “What do you think?” I suspect that patients will be using Terri Schiavo as an example of how they do or do not want to live―and die―for a long time. I will do my best to use this shared touchstone as a starting point for understanding their preferences: “Tell me what it is about Terri Schiavo that worries you?” By helping our patients express their preferences and encouraging them to discuss these with their loved ones, we may ease the burden of families who would otherwise have to make a difficult decision without direct knowledge of the patient’s choice.

The second lesson for us to embrace is that palliative care is a core competency for hospitalists. Palliative care is already identified as a core competency in the Core Curriculum under development by SHM. As part of our goal of improving the quality of care for all of our patients, we have the opportunity to dramatically improve end of life care and to identify people who would benefit from palliative care earlier in the course of illness. This opportunity represents a sacred trust and speaks to the most basic role of the physician to “cure sometimes and comfort always.” Ultimately, the deaths of Terri Schiavo and the Pope, although fundamentally different from each other, and unique in many respects, reaffirmed for me the importance of my role as a hospitalist in providing the highest possible quality of care for people facing serious illness and death. With these skills, we will secure our place as leaders in quality care and reap the rich rewards of using our humanity to help patients and families at one of the most important, profound, and intimate times.

The third lesson for us as hospitalists is that more research is needed to define the optimal ways to care for hospitalized patients. While the case of Terri Schiavo raised particularly thorny family issues that might defy the ability of research to clarify, issues of how best to care for patients like Terri Schiavo and the Pope and the millions of people like them with heart failure, deep vein thromboses, aspiration pneumonia, gastrointestinal bleeding, cancer, and myriad other conditions can be, must be, and will be investigated. The only question will be, by whom? As the providers of an increasingly large percentage of hospital care, we are on the front-lines of recognizing the clinical questions that arise and understanding the systems of care in which solutions must be implemented. Therefore we must play a central role in defining the questions and discovering the answers. Further, because we need research not only in how best to treat patients but also in how to ensure that patients receive these treatments, we need to conduct this research in community hospitals, where the majority of patients are cared for, and not just at academic centers.

In my year as President of SHM, I will continue to develop our organization’s founding mission and to serve hospitalists in their goal of providing the best quality of care to their patients and having satisfying, sustainable, and rewarding jobs. SHM will continue to lead and define the field of hospital medicine in education, leadership, quality, patient safety, and teamwork. In addition, I hope to use my unique skills and insights to focus our members on the central role of research in defining our field and the need for SHM to help direct that research. I will also highlight the importance of hospitalists in providing palliative care and in improving the care of patients with serious and terminal illness. I encourage each hospitalist to embrace these critical issues and invite you to join me in implementing this vision to advance research in hospital medicine and to improve palliative care in hospitals. The research committee has already completed a report on the potential role of SHM in research in hospital medicine that the Board of Directors will discuss at our meeting in May, and I am planning an initiative in palliative care. If you would like to participate in either initiative or simply want to share your thoughts and ideas about these or other important issues in hospital medicine, please contact me by email ([email protected]). My closing wish is that Terri Schiavo’s family will find comfort and closure, out of the media spotlight, and that the memory of the Pope is honored by the ongoing lessons of tolerance and peace that he taught.

As I write first column as President of SHM, palliative care has been much in the news. As a hospitalist who spends much of my time caring for people approaching the end of life and teaching about palliative care, these 2 weeks have kept me busy talking about end of life issues with family, friends, patients, colleagues, and the media. At the same time, these events have reaffirmed for me my choice of a career as a hospitalist and the central role that hospitalists play in providing the highest quality care for the sickest patients, in continually improving that care, and in refining the systems to deliver it.

Terri Schiavo died 2 weeks after her feeding tube was removed. Her life and death sparked protests and political debate. Yet in the end, what seems most profound is the great sadness and loss for her family. Soon after Terri Schiavo died, Pope John Paul II became acutely ill. Several days after a feeding tube was placed, the Pope died in his apartment at the Vatican, triggering a global outpouring of love and grief.

In modern American health care, probably Terri Schiavo and the Pope would have received care from a hospitalist. If she were to arrive in a hospital after a cardiac arrest today, Terri Schiavo would likely be cared for by a hospitalist. It is the hospitalist who would have the first discussions with her family about her condition and prognosis. Similarly, most 84-year-old men with Parkinson’s disease, pneumonia, and a urinary tract infection would be cared for by a hospitalist. Hospitalists are serving as de facto ethicists and palliative care physicians, as we care for increasing numbers of people with serious and terminal illness. This shift in care provides an unprecedented opportunity for us to improve the quality of care for the half of all Americans who die in hospitals. Providing state of the art palliative care reinforces our efforts globally to improve the quality of care for all hospitalized patients. Furthermore, these cases highlight the need for research to define the best ways to deliver that care. As I thought about Terri Schiavo and the Pope, and saw the intense media spotlight on them, I kept thinking, “What does this mean for me?”

I have given this question a great deal of thought over the past week. What, if anything, do the deaths of Terri Schiavo and the Pope teach us? As I see it there are at least 3 important lessons for us as individuals and as hospitalists.

The first lesson is that each of us should consider the kind of care we would want if we were to suffer a devastating injury, as did Terri Schiavo, or be stricken with a progressive, debilitating illness, like the Pope. We should discuss our preferences for care with our loved ones and write them down. As hospitalists we should have these discussions routinely with our patients, document the conversations, notify the patient’s primary care physician, and encourage patients to share their thoughts with their loved ones. As a son, husband, brother, nephew, grandson, and father, I realized that one of the most important obligations I owed to my family was to make my wishes known, and to learn about the wishes of my loved ones. As a hospitalist, I realized that I owed it to my patients to help them express their preferences for care. What I learned echoed what we know about advance directives: You cannot predict what someone will say. Not unexpectedly, my mother, grandmother, and aunt told me that they would never want to live like Terri Schiavo. But in a complete surprise my aunt told me that my favorite uncle, who is blessed with a quick wit and brilliant sense of humor, wants to be kept alive as long as possible.

As a hospitalist, I know that my patients care deeply about these issues and are quite eager to discuss them. Talking with patients about these issues is not just a good thing to do, but ultimately improves quality of care by promoting care that is consistent with patient preferences and emphasizes our commitment to respect patients and advocate on their behalf. I still remember early concerns about hospitalists that we would be cowboys more interested in procedures and yelling “Stat!” than in being caring providers who took time to get to know our patients. Yet an early study of hospitalists that I was involved in found just the opposite. Hospitalists recognized the importance of palliative care and good communication with patients. As I made rounds in the hospital in late March, many patients were watching the vigil outside the hospice in Florida and talking about the Pope. Many patients wanted to know my thoughts. Using the communication skills I have honed over the years, and my cultural background of always answering a question with a question, I turned it around and asked them, “What do you think?” I suspect that patients will be using Terri Schiavo as an example of how they do or do not want to live―and die―for a long time. I will do my best to use this shared touchstone as a starting point for understanding their preferences: “Tell me what it is about Terri Schiavo that worries you?” By helping our patients express their preferences and encouraging them to discuss these with their loved ones, we may ease the burden of families who would otherwise have to make a difficult decision without direct knowledge of the patient’s choice.

The second lesson for us to embrace is that palliative care is a core competency for hospitalists. Palliative care is already identified as a core competency in the Core Curriculum under development by SHM. As part of our goal of improving the quality of care for all of our patients, we have the opportunity to dramatically improve end of life care and to identify people who would benefit from palliative care earlier in the course of illness. This opportunity represents a sacred trust and speaks to the most basic role of the physician to “cure sometimes and comfort always.” Ultimately, the deaths of Terri Schiavo and the Pope, although fundamentally different from each other, and unique in many respects, reaffirmed for me the importance of my role as a hospitalist in providing the highest possible quality of care for people facing serious illness and death. With these skills, we will secure our place as leaders in quality care and reap the rich rewards of using our humanity to help patients and families at one of the most important, profound, and intimate times.

The third lesson for us as hospitalists is that more research is needed to define the optimal ways to care for hospitalized patients. While the case of Terri Schiavo raised particularly thorny family issues that might defy the ability of research to clarify, issues of how best to care for patients like Terri Schiavo and the Pope and the millions of people like them with heart failure, deep vein thromboses, aspiration pneumonia, gastrointestinal bleeding, cancer, and myriad other conditions can be, must be, and will be investigated. The only question will be, by whom? As the providers of an increasingly large percentage of hospital care, we are on the front-lines of recognizing the clinical questions that arise and understanding the systems of care in which solutions must be implemented. Therefore we must play a central role in defining the questions and discovering the answers. Further, because we need research not only in how best to treat patients but also in how to ensure that patients receive these treatments, we need to conduct this research in community hospitals, where the majority of patients are cared for, and not just at academic centers.

In my year as President of SHM, I will continue to develop our organization’s founding mission and to serve hospitalists in their goal of providing the best quality of care to their patients and having satisfying, sustainable, and rewarding jobs. SHM will continue to lead and define the field of hospital medicine in education, leadership, quality, patient safety, and teamwork. In addition, I hope to use my unique skills and insights to focus our members on the central role of research in defining our field and the need for SHM to help direct that research. I will also highlight the importance of hospitalists in providing palliative care and in improving the care of patients with serious and terminal illness. I encourage each hospitalist to embrace these critical issues and invite you to join me in implementing this vision to advance research in hospital medicine and to improve palliative care in hospitals. The research committee has already completed a report on the potential role of SHM in research in hospital medicine that the Board of Directors will discuss at our meeting in May, and I am planning an initiative in palliative care. If you would like to participate in either initiative or simply want to share your thoughts and ideas about these or other important issues in hospital medicine, please contact me by email ([email protected]). My closing wish is that Terri Schiavo’s family will find comfort and closure, out of the media spotlight, and that the memory of the Pope is honored by the ongoing lessons of tolerance and peace that he taught.

As I write first column as President of SHM, palliative care has been much in the news. As a hospitalist who spends much of my time caring for people approaching the end of life and teaching about palliative care, these 2 weeks have kept me busy talking about end of life issues with family, friends, patients, colleagues, and the media. At the same time, these events have reaffirmed for me my choice of a career as a hospitalist and the central role that hospitalists play in providing the highest quality care for the sickest patients, in continually improving that care, and in refining the systems to deliver it.

Terri Schiavo died 2 weeks after her feeding tube was removed. Her life and death sparked protests and political debate. Yet in the end, what seems most profound is the great sadness and loss for her family. Soon after Terri Schiavo died, Pope John Paul II became acutely ill. Several days after a feeding tube was placed, the Pope died in his apartment at the Vatican, triggering a global outpouring of love and grief.

In modern American health care, probably Terri Schiavo and the Pope would have received care from a hospitalist. If she were to arrive in a hospital after a cardiac arrest today, Terri Schiavo would likely be cared for by a hospitalist. It is the hospitalist who would have the first discussions with her family about her condition and prognosis. Similarly, most 84-year-old men with Parkinson’s disease, pneumonia, and a urinary tract infection would be cared for by a hospitalist. Hospitalists are serving as de facto ethicists and palliative care physicians, as we care for increasing numbers of people with serious and terminal illness. This shift in care provides an unprecedented opportunity for us to improve the quality of care for the half of all Americans who die in hospitals. Providing state of the art palliative care reinforces our efforts globally to improve the quality of care for all hospitalized patients. Furthermore, these cases highlight the need for research to define the best ways to deliver that care. As I thought about Terri Schiavo and the Pope, and saw the intense media spotlight on them, I kept thinking, “What does this mean for me?”

I have given this question a great deal of thought over the past week. What, if anything, do the deaths of Terri Schiavo and the Pope teach us? As I see it there are at least 3 important lessons for us as individuals and as hospitalists.

The first lesson is that each of us should consider the kind of care we would want if we were to suffer a devastating injury, as did Terri Schiavo, or be stricken with a progressive, debilitating illness, like the Pope. We should discuss our preferences for care with our loved ones and write them down. As hospitalists we should have these discussions routinely with our patients, document the conversations, notify the patient’s primary care physician, and encourage patients to share their thoughts with their loved ones. As a son, husband, brother, nephew, grandson, and father, I realized that one of the most important obligations I owed to my family was to make my wishes known, and to learn about the wishes of my loved ones. As a hospitalist, I realized that I owed it to my patients to help them express their preferences for care. What I learned echoed what we know about advance directives: You cannot predict what someone will say. Not unexpectedly, my mother, grandmother, and aunt told me that they would never want to live like Terri Schiavo. But in a complete surprise my aunt told me that my favorite uncle, who is blessed with a quick wit and brilliant sense of humor, wants to be kept alive as long as possible.

As a hospitalist, I know that my patients care deeply about these issues and are quite eager to discuss them. Talking with patients about these issues is not just a good thing to do, but ultimately improves quality of care by promoting care that is consistent with patient preferences and emphasizes our commitment to respect patients and advocate on their behalf. I still remember early concerns about hospitalists that we would be cowboys more interested in procedures and yelling “Stat!” than in being caring providers who took time to get to know our patients. Yet an early study of hospitalists that I was involved in found just the opposite. Hospitalists recognized the importance of palliative care and good communication with patients. As I made rounds in the hospital in late March, many patients were watching the vigil outside the hospice in Florida and talking about the Pope. Many patients wanted to know my thoughts. Using the communication skills I have honed over the years, and my cultural background of always answering a question with a question, I turned it around and asked them, “What do you think?” I suspect that patients will be using Terri Schiavo as an example of how they do or do not want to live―and die―for a long time. I will do my best to use this shared touchstone as a starting point for understanding their preferences: “Tell me what it is about Terri Schiavo that worries you?” By helping our patients express their preferences and encouraging them to discuss these with their loved ones, we may ease the burden of families who would otherwise have to make a difficult decision without direct knowledge of the patient’s choice.

The second lesson for us to embrace is that palliative care is a core competency for hospitalists. Palliative care is already identified as a core competency in the Core Curriculum under development by SHM. As part of our goal of improving the quality of care for all of our patients, we have the opportunity to dramatically improve end of life care and to identify people who would benefit from palliative care earlier in the course of illness. This opportunity represents a sacred trust and speaks to the most basic role of the physician to “cure sometimes and comfort always.” Ultimately, the deaths of Terri Schiavo and the Pope, although fundamentally different from each other, and unique in many respects, reaffirmed for me the importance of my role as a hospitalist in providing the highest possible quality of care for people facing serious illness and death. With these skills, we will secure our place as leaders in quality care and reap the rich rewards of using our humanity to help patients and families at one of the most important, profound, and intimate times.

The third lesson for us as hospitalists is that more research is needed to define the optimal ways to care for hospitalized patients. While the case of Terri Schiavo raised particularly thorny family issues that might defy the ability of research to clarify, issues of how best to care for patients like Terri Schiavo and the Pope and the millions of people like them with heart failure, deep vein thromboses, aspiration pneumonia, gastrointestinal bleeding, cancer, and myriad other conditions can be, must be, and will be investigated. The only question will be, by whom? As the providers of an increasingly large percentage of hospital care, we are on the front-lines of recognizing the clinical questions that arise and understanding the systems of care in which solutions must be implemented. Therefore we must play a central role in defining the questions and discovering the answers. Further, because we need research not only in how best to treat patients but also in how to ensure that patients receive these treatments, we need to conduct this research in community hospitals, where the majority of patients are cared for, and not just at academic centers.

In my year as President of SHM, I will continue to develop our organization’s founding mission and to serve hospitalists in their goal of providing the best quality of care to their patients and having satisfying, sustainable, and rewarding jobs. SHM will continue to lead and define the field of hospital medicine in education, leadership, quality, patient safety, and teamwork. In addition, I hope to use my unique skills and insights to focus our members on the central role of research in defining our field and the need for SHM to help direct that research. I will also highlight the importance of hospitalists in providing palliative care and in improving the care of patients with serious and terminal illness. I encourage each hospitalist to embrace these critical issues and invite you to join me in implementing this vision to advance research in hospital medicine and to improve palliative care in hospitals. The research committee has already completed a report on the potential role of SHM in research in hospital medicine that the Board of Directors will discuss at our meeting in May, and I am planning an initiative in palliative care. If you would like to participate in either initiative or simply want to share your thoughts and ideas about these or other important issues in hospital medicine, please contact me by email ([email protected]). My closing wish is that Terri Schiavo’s family will find comfort and closure, out of the media spotlight, and that the memory of the Pope is honored by the ongoing lessons of tolerance and peace that he taught.

Supplement Editor:
Gary Falk, MD

Contents

Helicobacter pylori: Why it still matters in 2005
M. Brian Fennerty, MD

How to test for Helicobacter pylori in 2005
Nimish Vakil, MD, and A. Mark Fendrick, MD

Pitfalls, pearls, and practicalities in the diagnosis of Helicobacter pylori infection
Gary Falk, MD; Leonard Ehrlich, MD; A. Mark Fendrick, MD; M. Brian Fennerty, MD; Ben Gold, MD; Nimish Vakil, MD; Derek van Amerongen, MD, MS; and David Wyatt, MD

Supplement Editor:
Gary Falk, MD

Contents

Helicobacter pylori: Why it still matters in 2005
M. Brian Fennerty, MD

How to test for Helicobacter pylori in 2005
Nimish Vakil, MD, and A. Mark Fendrick, MD

Pitfalls, pearls, and practicalities in the diagnosis of Helicobacter pylori infection
Gary Falk, MD; Leonard Ehrlich, MD; A. Mark Fendrick, MD; M. Brian Fennerty, MD; Ben Gold, MD; Nimish Vakil, MD; Derek van Amerongen, MD, MS; and David Wyatt, MD

Supplement Editor:
Gary Falk, MD

Contents

Helicobacter pylori: Why it still matters in 2005
M. Brian Fennerty, MD

How to test for Helicobacter pylori in 2005
Nimish Vakil, MD, and A. Mark Fendrick, MD

Pitfalls, pearls, and practicalities in the diagnosis of Helicobacter pylori infection
Gary Falk, MD; Leonard Ehrlich, MD; A. Mark Fendrick, MD; M. Brian Fennerty, MD; Ben Gold, MD; Nimish Vakil, MD; Derek van Amerongen, MD, MS; and David Wyatt, MD