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Student Hospitalist Scholars: Strengthening research skills
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
I’m always surprised by how much I can learn in a few short weeks. I am now up to full speed with my project studying the utility of bone biopsies in the management of osteomyelitis.
This is a retrospective study, which means I’ll be collecting historical data from patient charts to be used for our analysis. My mentor – Ernie Esquivel, MD – has played an invaluable role in helping me get this project off the ground. He has worked with me on everything from project planning to successfully navigating the ever-confusing institutional review board (IRB) process. He has also provided advice in areas I thought I might actually have more experience, such as data collection and analysis methods.
This form has streamlined the data collection process and will save me a significant amount of time down the road when we have to code the data for statistical analysis programs. After putting in the hard work gathering all of this information, I look forward to beginning the process of analyzing and interpreting our results.
Dr. Esquivel has also helped me improve the value and credibility of this research by encouraging me to present our ideas in front of several groups of people from different departments and specialties. The feedback from these meetings has helped refine our study design and methods while also providing me with the opportunity to improve my communication and presentation skills.
I think such diverse input has helped shape this project into something that will be accessible to a broader audience, and has strengthened my understanding of why our work is important to both clinicians and patients.
Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
I’m always surprised by how much I can learn in a few short weeks. I am now up to full speed with my project studying the utility of bone biopsies in the management of osteomyelitis.
This is a retrospective study, which means I’ll be collecting historical data from patient charts to be used for our analysis. My mentor – Ernie Esquivel, MD – has played an invaluable role in helping me get this project off the ground. He has worked with me on everything from project planning to successfully navigating the ever-confusing institutional review board (IRB) process. He has also provided advice in areas I thought I might actually have more experience, such as data collection and analysis methods.
This form has streamlined the data collection process and will save me a significant amount of time down the road when we have to code the data for statistical analysis programs. After putting in the hard work gathering all of this information, I look forward to beginning the process of analyzing and interpreting our results.
Dr. Esquivel has also helped me improve the value and credibility of this research by encouraging me to present our ideas in front of several groups of people from different departments and specialties. The feedback from these meetings has helped refine our study design and methods while also providing me with the opportunity to improve my communication and presentation skills.
I think such diverse input has helped shape this project into something that will be accessible to a broader audience, and has strengthened my understanding of why our work is important to both clinicians and patients.
Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
I’m always surprised by how much I can learn in a few short weeks. I am now up to full speed with my project studying the utility of bone biopsies in the management of osteomyelitis.
This is a retrospective study, which means I’ll be collecting historical data from patient charts to be used for our analysis. My mentor – Ernie Esquivel, MD – has played an invaluable role in helping me get this project off the ground. He has worked with me on everything from project planning to successfully navigating the ever-confusing institutional review board (IRB) process. He has also provided advice in areas I thought I might actually have more experience, such as data collection and analysis methods.
This form has streamlined the data collection process and will save me a significant amount of time down the road when we have to code the data for statistical analysis programs. After putting in the hard work gathering all of this information, I look forward to beginning the process of analyzing and interpreting our results.
Dr. Esquivel has also helped me improve the value and credibility of this research by encouraging me to present our ideas in front of several groups of people from different departments and specialties. The feedback from these meetings has helped refine our study design and methods while also providing me with the opportunity to improve my communication and presentation skills.
I think such diverse input has helped shape this project into something that will be accessible to a broader audience, and has strengthened my understanding of why our work is important to both clinicians and patients.
Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.
Even short-term steroids can be problematic
Clinical Question: What is the frequency of short-term corticosteroid prescriptions and adverse events associated with their use?
Background: Long-term corticosteroid use is usually avoided given risks of complications. Less is known about the risk and frequency of short-term corticosteroid use.
Study Design: Retrospective cohort study and self-controlled case series.
Setting: National U.S. dataset of private insurance claims.
Synopsis: Data from 1,548,945 adults (aged 18-64 years) showed that 21.1% of adults received a prescription for short-term corticosteroids. Within 30 days of filling corticosteroids, incident rate ratios (IRR) were increased for sepsis (5.3; 95% confidence interval, 3.8-7.4), venous thromboembolism (3.3; 95% CI, 2.78-3.99), and fracture (1.87; 95% CI, 1.69-2.07).
Short-term corticosteroids were frequently prescribed for indications with little evidence of benefit, such as upper respiratory conditions, spinal conditions, and allergies. For these conditions, patients should be educated about the risks of short-term corticosteroid use and alternative treatments should be considered. This study only evaluated for these three adverse reactions and excluded the elderly, so these findings likely underestimate the adverse effects of short-term corticosteroids.
Bottom Line: Corticosteroids are frequently prescribed for short courses and were associated with increased rates of sepsis, venous thromboembolism, and fracture.
Citation: Waljee AK, Rogers MA, Lin P, et al. Short term use of oral corticosteroids and related harms among adults in the United States: Population based cohort study. BMJ. 2017;357:j1415.
Dr. Gray is assistant professor in the University of Kentucky division of hospital medicine and the Lexington VA Medical Center.
Clinical Question: What is the frequency of short-term corticosteroid prescriptions and adverse events associated with their use?
Background: Long-term corticosteroid use is usually avoided given risks of complications. Less is known about the risk and frequency of short-term corticosteroid use.
Study Design: Retrospective cohort study and self-controlled case series.
Setting: National U.S. dataset of private insurance claims.
Synopsis: Data from 1,548,945 adults (aged 18-64 years) showed that 21.1% of adults received a prescription for short-term corticosteroids. Within 30 days of filling corticosteroids, incident rate ratios (IRR) were increased for sepsis (5.3; 95% confidence interval, 3.8-7.4), venous thromboembolism (3.3; 95% CI, 2.78-3.99), and fracture (1.87; 95% CI, 1.69-2.07).
Short-term corticosteroids were frequently prescribed for indications with little evidence of benefit, such as upper respiratory conditions, spinal conditions, and allergies. For these conditions, patients should be educated about the risks of short-term corticosteroid use and alternative treatments should be considered. This study only evaluated for these three adverse reactions and excluded the elderly, so these findings likely underestimate the adverse effects of short-term corticosteroids.
Bottom Line: Corticosteroids are frequently prescribed for short courses and were associated with increased rates of sepsis, venous thromboembolism, and fracture.
Citation: Waljee AK, Rogers MA, Lin P, et al. Short term use of oral corticosteroids and related harms among adults in the United States: Population based cohort study. BMJ. 2017;357:j1415.
Dr. Gray is assistant professor in the University of Kentucky division of hospital medicine and the Lexington VA Medical Center.
Clinical Question: What is the frequency of short-term corticosteroid prescriptions and adverse events associated with their use?
Background: Long-term corticosteroid use is usually avoided given risks of complications. Less is known about the risk and frequency of short-term corticosteroid use.
Study Design: Retrospective cohort study and self-controlled case series.
Setting: National U.S. dataset of private insurance claims.
Synopsis: Data from 1,548,945 adults (aged 18-64 years) showed that 21.1% of adults received a prescription for short-term corticosteroids. Within 30 days of filling corticosteroids, incident rate ratios (IRR) were increased for sepsis (5.3; 95% confidence interval, 3.8-7.4), venous thromboembolism (3.3; 95% CI, 2.78-3.99), and fracture (1.87; 95% CI, 1.69-2.07).
Short-term corticosteroids were frequently prescribed for indications with little evidence of benefit, such as upper respiratory conditions, spinal conditions, and allergies. For these conditions, patients should be educated about the risks of short-term corticosteroid use and alternative treatments should be considered. This study only evaluated for these three adverse reactions and excluded the elderly, so these findings likely underestimate the adverse effects of short-term corticosteroids.
Bottom Line: Corticosteroids are frequently prescribed for short courses and were associated with increased rates of sepsis, venous thromboembolism, and fracture.
Citation: Waljee AK, Rogers MA, Lin P, et al. Short term use of oral corticosteroids and related harms among adults in the United States: Population based cohort study. BMJ. 2017;357:j1415.
Dr. Gray is assistant professor in the University of Kentucky division of hospital medicine and the Lexington VA Medical Center.
Axillary thermometry is the best choice for newborns
NASHVILLE, TENN. – Axillary thermometry outperformed both rectal and temporal artery thermometry in 205 newborns aged 12-72 hours in a study performed at the University of North Carolina at Chapel Hill.
The infants had two temperatures taken by each method over a period of 15 minutes, for a total of six readings per child and 1,230 measurements overall. Axillary thermometry proved both accurate and reliable. Rectal thermometry was accurate but less reliable, and temporal thermometry was reliable but less accurate.
Lead investigator Ketan Nadkarni, MD, a 3rd-year pediatrics resident, and his colleagues wanted to compare the three methods head-to-head to make sure axillary thermometers were okay to use in the nursery, and to see if it really was necessary to tell parents to use rectal thermometers; many are reluctant to use them. Plus, “there’s been a lot of controversy” in pediatrics “over the best way to measure temperature,” Dr. Nadkarni said at the Pediatric Hospital Medicine annual meeting.
“With our data, we think axillary is what we should continue to use in the newborn nursery,” he said. Some attending physicians still are hesitant to recommend axillary thermometers to new parents, but “all of the nurses are aware of” the study findings “and a lot of the residents are, too, so I think we are starting to move” in that direction.
The study had some unexpected findings as well: “The biggest surprise was how wide the distribution of rectal temperatures was. The distribution” around the mean “was way larger than we had thought, so [rectal thermometry was] not very reliable at all. Our study surprisingly exhibited suboptimal performance in terms of reliability,” for rectal thermometry, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Specifically, the average distance of any given rectal measurement from the mean rectal temperature of 98.3º F was 0.45º F. The second rectal temperature in the study sometimes varied a half a degree or more from the first taken shortly before, in the same infant.
The average distance of an axillary temperature from the axillary mean of 98.32º F was 0.32º F; for temporal thermometry it was 0.34º F from a mean of 98.55º F.
Another surprise was that temporal thermometry overestimated temperature by an average of about a quarter of a degree, compared with rectal readings. Even small overestimates could lead to unnecessary sepsis work-ups; “the last thing we want is to hospitalize these kids when they don’t need to be,” Dr. Nadkarni said.
The mean axillary and rectal temperatures, meanwhile, were only 0.02º F apart, which was not statistically significant. “Axillary was absolutely interchangeable with rectal in terms of accuracy,” he said.
The children were born at 37 weeks’ gestation or later, and were excluded if they had a temperature of 100.4º F or higher by any method. Rectal and axillary temperatures were taken with a Welch Allyn SureTemp Plus 690. Temple temperatures were taken with an Exergen TAT-2000c.
The investigators plan to run a similar trial in the ED with children up to 3 months old.
There was no external funding for the work, and Dr. Nadkarni had no relevant financial disclosures.
NASHVILLE, TENN. – Axillary thermometry outperformed both rectal and temporal artery thermometry in 205 newborns aged 12-72 hours in a study performed at the University of North Carolina at Chapel Hill.
The infants had two temperatures taken by each method over a period of 15 minutes, for a total of six readings per child and 1,230 measurements overall. Axillary thermometry proved both accurate and reliable. Rectal thermometry was accurate but less reliable, and temporal thermometry was reliable but less accurate.
Lead investigator Ketan Nadkarni, MD, a 3rd-year pediatrics resident, and his colleagues wanted to compare the three methods head-to-head to make sure axillary thermometers were okay to use in the nursery, and to see if it really was necessary to tell parents to use rectal thermometers; many are reluctant to use them. Plus, “there’s been a lot of controversy” in pediatrics “over the best way to measure temperature,” Dr. Nadkarni said at the Pediatric Hospital Medicine annual meeting.
“With our data, we think axillary is what we should continue to use in the newborn nursery,” he said. Some attending physicians still are hesitant to recommend axillary thermometers to new parents, but “all of the nurses are aware of” the study findings “and a lot of the residents are, too, so I think we are starting to move” in that direction.
The study had some unexpected findings as well: “The biggest surprise was how wide the distribution of rectal temperatures was. The distribution” around the mean “was way larger than we had thought, so [rectal thermometry was] not very reliable at all. Our study surprisingly exhibited suboptimal performance in terms of reliability,” for rectal thermometry, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Specifically, the average distance of any given rectal measurement from the mean rectal temperature of 98.3º F was 0.45º F. The second rectal temperature in the study sometimes varied a half a degree or more from the first taken shortly before, in the same infant.
The average distance of an axillary temperature from the axillary mean of 98.32º F was 0.32º F; for temporal thermometry it was 0.34º F from a mean of 98.55º F.
Another surprise was that temporal thermometry overestimated temperature by an average of about a quarter of a degree, compared with rectal readings. Even small overestimates could lead to unnecessary sepsis work-ups; “the last thing we want is to hospitalize these kids when they don’t need to be,” Dr. Nadkarni said.
The mean axillary and rectal temperatures, meanwhile, were only 0.02º F apart, which was not statistically significant. “Axillary was absolutely interchangeable with rectal in terms of accuracy,” he said.
The children were born at 37 weeks’ gestation or later, and were excluded if they had a temperature of 100.4º F or higher by any method. Rectal and axillary temperatures were taken with a Welch Allyn SureTemp Plus 690. Temple temperatures were taken with an Exergen TAT-2000c.
The investigators plan to run a similar trial in the ED with children up to 3 months old.
There was no external funding for the work, and Dr. Nadkarni had no relevant financial disclosures.
NASHVILLE, TENN. – Axillary thermometry outperformed both rectal and temporal artery thermometry in 205 newborns aged 12-72 hours in a study performed at the University of North Carolina at Chapel Hill.
The infants had two temperatures taken by each method over a period of 15 minutes, for a total of six readings per child and 1,230 measurements overall. Axillary thermometry proved both accurate and reliable. Rectal thermometry was accurate but less reliable, and temporal thermometry was reliable but less accurate.
Lead investigator Ketan Nadkarni, MD, a 3rd-year pediatrics resident, and his colleagues wanted to compare the three methods head-to-head to make sure axillary thermometers were okay to use in the nursery, and to see if it really was necessary to tell parents to use rectal thermometers; many are reluctant to use them. Plus, “there’s been a lot of controversy” in pediatrics “over the best way to measure temperature,” Dr. Nadkarni said at the Pediatric Hospital Medicine annual meeting.
“With our data, we think axillary is what we should continue to use in the newborn nursery,” he said. Some attending physicians still are hesitant to recommend axillary thermometers to new parents, but “all of the nurses are aware of” the study findings “and a lot of the residents are, too, so I think we are starting to move” in that direction.
The study had some unexpected findings as well: “The biggest surprise was how wide the distribution of rectal temperatures was. The distribution” around the mean “was way larger than we had thought, so [rectal thermometry was] not very reliable at all. Our study surprisingly exhibited suboptimal performance in terms of reliability,” for rectal thermometry, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Specifically, the average distance of any given rectal measurement from the mean rectal temperature of 98.3º F was 0.45º F. The second rectal temperature in the study sometimes varied a half a degree or more from the first taken shortly before, in the same infant.
The average distance of an axillary temperature from the axillary mean of 98.32º F was 0.32º F; for temporal thermometry it was 0.34º F from a mean of 98.55º F.
Another surprise was that temporal thermometry overestimated temperature by an average of about a quarter of a degree, compared with rectal readings. Even small overestimates could lead to unnecessary sepsis work-ups; “the last thing we want is to hospitalize these kids when they don’t need to be,” Dr. Nadkarni said.
The mean axillary and rectal temperatures, meanwhile, were only 0.02º F apart, which was not statistically significant. “Axillary was absolutely interchangeable with rectal in terms of accuracy,” he said.
The children were born at 37 weeks’ gestation or later, and were excluded if they had a temperature of 100.4º F or higher by any method. Rectal and axillary temperatures were taken with a Welch Allyn SureTemp Plus 690. Temple temperatures were taken with an Exergen TAT-2000c.
The investigators plan to run a similar trial in the ED with children up to 3 months old.
There was no external funding for the work, and Dr. Nadkarni had no relevant financial disclosures.
AT PHM 2017
Key clinical point:
Major finding: The average distance of an axillary temperature from the axillary mean of 98.32º F was only 0.32º F, while the average distance of any given rectal measurement from the mean rectal temperature of 98.3º F was 0.45º F, and for temporal thermometry it was 0.34º F from a mean of 98.55º F.
Data source: Head-to-head thermometry study in more than 200 infants aged 12-72 hours.
Disclosures: There was no outside funding, and Dr. Nadkarni had no relevant financial disclosures.
Communication tools improve patient experience and satisfaction
How hospitalists and other clinicians communicate with patients impacts a patient’s overall experience and satisfaction. But according to the authors of “Communication the Cleveland Way,”1 a book about how the clinic created and applied communication skills training, “in a culture prioritizing clinical outcomes above all, there can be a tendency to lose sight of one of the most critical aspects of providing effective care: the communication skills that build and foster physician-patient relationships.”
“Studies2,3 have shown that good communication between doctors and patients and among all caregivers who interface with patients directly results in better clinical outcomes, reduced costs, greater patient satisfaction, and lower rates of physician burnout,” the authors wrote.
“It places a special focus on empathy in relationships, and in our case, the provider-patient relationship rather than patient-centered care. The former acknowledges that the thoughts and feelings in both sides of a relationship are important. We know that clinicians, too, can suffer as a result of the care they provide,” Dr. Velez wrote in “Communication the Cleveland Way.”1
“Healthy relationships are based on balance and mutual respect,” Dr Velez said. “Courses made a strong point to practice empathy in order to teach empathy. Clinician participants were gifted with a safe space, an opportunity to share their own skills and expertise, and a chance to be appreciated for what they already do effectively. Most of all, activities were designed to be fun and engaging.” For example, CEHC encouraged and fostered an attitude of exploration, experimentation, and adventure. Various warm-up activities effectively helped the participants enter a more playful space and get into character portrayal.
Dr. Velez credits the CEHC model’s sustainability and success to the early realization that an appreciative approach is effective. In a study3 about the strategy, hospital-employed attending physicians participated in the 8-hour experiential communication skills training course on REDE. The study compared approximately 1,500 “intervention” physicians who attended and 1,900 “nonintervention” physicians who did not attend.
Following the course, scores for physician communication and respect were higher for intervention physicians. Furthermore, physicians showed significant improvement in self-perceptions of empathy and burnout. Some of these gains were sustained for at least 3 months. “This is especially important because in the current health care climate, physicians experience increased burnout,” Dr. Velez notes.
How it works
Because a provider’s connection with a patient occurs when a relationship is established, the REDE course focuses on the beginning of the conversation. “It’s important for clinicians to exhibit value and respect through words and actions when welcoming patients,” Dr. Velez said. “Further, instead of guiding the medical interview with a series of close-ended questions like an interrogator would, we invite the use of open-ended questions and setting an agenda for the visit early on, by asking the patient what they wish to discuss.”
Another key component is empathy, which plays a huge role in patient satisfaction. “Learning how to express empathy is very important,” Dr. Velez said. “A patient may not remember all of the medical details discussed, but human interactions, rapport, expressions of care, support, validation, and acknowledgment of emotions tend to be more indelible.”
Dr. Velez notes that decades of literature regarding effective communication have demonstrated improved outcomes. “If trust in a therapeutic relationship is strong, a patient is more likely to follow instructions and have better engagement with their care plan,” he said. “If a clinician ensures that the patient understands the diagnosis and recommendations, then compliance will increase, especially if the plan is tailored to the patient’s goals and perspective.”
One surprising effect of the REDE course was how it improved relationships among professionals. “Many participants have shared that having a day out of one’s normal schedule, not only to learn, but also to share their own experiences, is quite therapeutic,” Dr. Velez said. “We can extend the same communication strategies to team building, interprofessional interactions, and challenging encounters.”
Study focuses on comportment and communication
In an effort to define optimal care in hospital medicine, a team from Johns Hopkins Health System set out to establish a metric that would comprehensively assess hospitalists’ comportment (which includes behavior as well as general demeanor) and communication to establish norms and expectations when they saw patients at the bedside.
To perform the study,4 chiefs of hospital medicine divisions at five independent hospitals located in Baltimore and Washington identified their most clinically excellent hospitalists. Then, an investigator observed each hospitalist during a routine clinical shift and recorded behaviors believed to be associated with excellent behavior and communication using the hospital medicine comportment and communication observation tool (HMCCOT), said Susrutha Kotwal, MD, assistant professor of medicine at Johns Hopkins University School of Medicine, Baltimore, and lead author. The investigators collected basic demographic information while observing hospitalists for an average of 280 minutes; 26 physicians were observed for 181 separate clinical encounters. Each provider’s mean HMCCOT score was compared with patient satisfaction surveys such as Press Ganey (PG) scores.
Noteworthy is the fact that the distribution of HMCCOT scores were similar when analyzed by age, gender, race, amount of clinical experience, the hospitalist’s clinical workload, hospital, or time spent observing the hospitalist. But the distribution of HMCCOT scores was quite different in new patient encounters, compared with follow-ups (68.1% versus 39.7%). Encounters with patients that generated HMCCOT scores above versus below the mean were longer (13 minutes versus 8.7 minutes). The physicians’ HMCCOT scores were also associated with their PG scores. These findings suggest that improved bedside communication and comportment with patients might also translate into enhanced patient satisfaction.
As a result of the study, a comportment and communication tool was established and validated by following clinically excellent hospitalists at the bedside. “Even among clinically respected hospitalists, the results reveal that there is wide variability in behaviors and communication practices at the bedside,” Dr. Kotwal said.
Employing the tool
Hospitalists can choose whether to perform behaviors in the HMCCOT themselves, while others may wish to watch other hospitalists to give them feedback tied to specific behaviors. “These simple behaviors are intimately linked to excellent communication and comportment, which can serve as the foundation for delivering patient-centered care,” Dr. Kotwal said.
A positive correlation was found between spending more time with patients and higher HMCCOT scores. “Patients’ complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that they did not convey information in a clear manner,” Dr. Kotwal said. “When successfully achieved, patient-centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self-management of chronic disease. Many of the components of the HMCCOT described in our study are at the heart of patient-centered care.”
Dr. Kotwal believes HMCCOT is a better strategy to improve patient satisfaction than patient satisfaction surveys because patients can’t always recall which specific provider saw them. In addition, patients’ recall about the provider may be poor because surveys are sent to patients days after they return home. In addition, patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Therefore, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.5
The study authors conclude that, “Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies are then needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital. Because hospitalists spend only a small proportion of their clinical time in direct patient care, it is imperative that excellent comportment and communication be established as a goal for every encounter.”
The effectiveness of care team rounds at the bedside
Investigators at the UMass Memorial Medical Center, in Worcester, Mass., studied the effectiveness of assembling the entire care team (i.e., physicians, including residents and attendings, nursing, and clinical pharmacy) to round at the patient’s bedside each morning – in lieu of its traditionally separate rounding strategies – on one unit of its academic hospitalist service for an internal quality program, said Patricia Seymour, MD, FAAFP, assistant professor and family medicine hospitalist education director.
Additionally, academic presentations and discussions were all done in front of patients and their families (with a few exceptions) rather than traditional hallway rounds or sit rounds. Over the course of the project, the hospital also offered residents training around physician behaviors that improve patient satisfaction; provided incentives for nurses and residents to work as a team; and created a welcome visit template for the nursing manager and instruments for patients to enhance engagement. Through all of these cycles, the collaborative rounding strategy continued.
Because Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores yielded low response rates for the singular test unit and service, the investigators used a validated patient satisfaction instrument and surveyed patients from the intervention group and patients on the same unit who did not experience this collaborative rounding on their day of discharge. The intervention group had higher satisfaction scores at most of the time points. The unit-based HCAHPS scores (not just study patients) improved during this time period.
“We think the strategy of collaborative rounding yielded positive results for obvious reasons – the entire team was on the same page and the information given to the patient was consistent,” said Dr. Seymour, who notes that the study’s findings weren’t published and the project was completed for an internal quality program. “Doctors had an increased understanding about nursing concerns and the nursing staff expressed improved understanding of patients’ care plans.”
Certainly, face time with the patient was extended because much of the academic discussion occurred at the bedside instead of at another physical location without patient awareness, Dr. Seymour said. She believes the strategy boosted patient satisfaction because it was patient centered. “While this rounding strategy is not the most convenient rounding strategy for nurses or doctors, it consolidates the discussion about the patient’s clinical condition and the plan for the day. The patient experiences a strong sense of being cared for by a unified team and receives consistent messaging,” she said.
Also noteworthy is that job satisfaction for residents and nurses improved on the unit over the study time period because of the expected collaboration that was built into the work flow.
Although the facility is no longer using this communication strategy to the same degree, teaching attendings have seen the value of true bedside rounding and continue to teach this skill to learners. “We have had some challenges with geographic cohorting at our institution, which is essential for this type of team-based strategy,” Dr. Seymour said. “Sustainability requires constant encouragement, oversight, and auditing from team leaders which is also challenging and fluctuates with competing demands.”
The results of this study, and others, show that employing tools to improve communication can also result in improved patient satisfaction and experience.
Karen Appold is a medical writer in Pennsylvania.
References
1. Boissy A, Gilligan T. “Communication the Cleveland Clinic Way: How to drive a relationship-centered strategy for superior patient experience.” New York: McGraw-Hill Education. 2016.
2. Weng HC, Hung CM, Liu YT, et al. Associations between emotional intelligence and doctor burnout, job satisfaction and patient satisfaction. Med Educ. 2011;45:835-42.
3. Boissy A, Windover AK, Bokar D, et al. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med. 2016 Jul;31(7):755-761. doi: 10.1007/s11606-016-3597-2. Epub 2016 Feb 26.
4. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine. J Hosp Med. 2016 Dec;11(12):853-858. doi: 10.1002/jhm.2647. Epub 2016 Aug 13.
5. Fong Ha J, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010 Spring; 10(1):38-43.
6. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient requires care of the provider. Ann Fam Med. 2014 Nov;12(6): 573-6. doi: 10.1370/afm.1713.
Bonus Content
Clinicians wary of course's worthiness
Before clinicians took Cleveland Clinic’s Relationship Establishment, Development, and Engagement (REDE) course, only 20% strongly agreed that the course would be valuable, whereas afterward 58% strongly agreed that it was indeed valuable. Less than 1% said it wasn’t valuable.4 “Most likely clinicians had a preconceived notion about how communication courses go, but they were probably surprised at how much these sessions were equally about them as providers as they were about caring for patients,” said Vicente J. Velez, MD, FACP, FHM, a hospitalist who serves as the director of faculty enrichment for the leadership team of CEHC. “This is the power of relationship-centered care, and also why I think the model has been sustainable.”
Physicians also reported that before taking the course, they had moderate levels of burnout and low levels of empathy. After taking it, burnout metrics (i.e., emotional exhaustion, depersonalization, and personal achievement) and empathy improved significantly. “I observed that most are surprised to find out that empathy is a discreet set of skills that can be learned, practiced, observed, measured, and improved upon,” Dr. Velez said. “If taught in a safe and validating environment and if principles of adult learning are followed, improvement can be optimized and sustained.”
Since the REDE course rolled out in 2012, all attending physicians and medical staff members have been trained in it.
Why empathy is preferred over patient-centered care
The Cleveland Clinic intentionally puts a focus on relationship-centered care.
“When there’s an emphasis on patient-centered care, some physicians have a hard time figuring out what to do when the patient wants something that the physician doesn’t feel is appropriate,” said Katie Neuendorf, MD, director for the Center for Excellence in Healthcare Communication. “Patient-centered implies that the patient is always right and that their opinion should win out over the physician’s opinion. In that same scenario, relationship-centered care implies that the relationship should be prioritized, even when there’s disagreement in the plan of care. I can tell my patients that I hear what they are saying, that I empathize with their struggles, that I care about the way the illness is affecting their lives, and that I am here to support them. I can do all of that and still not prescribe a treatment that I feel is inappropriate just because it happens to be what the patient wants.”
The Cleveland Clinic’s Relationship Establishment, Development and Engagement (REDE) course helps clinicians to see the individual that exists beyond a diagnosis. “Having empathy, or putting yourself in the other person’s shoes, is a key step in that process,” Dr. Neuendorf said. “Once a physician understands the patient’s perspective, the treatment for the diagnosis is more meaningful to both the patient and physician. Finding meaning in their work addresses the Quadruple Aim.”
How hospitalists and other clinicians communicate with patients impacts a patient’s overall experience and satisfaction. But according to the authors of “Communication the Cleveland Way,”1 a book about how the clinic created and applied communication skills training, “in a culture prioritizing clinical outcomes above all, there can be a tendency to lose sight of one of the most critical aspects of providing effective care: the communication skills that build and foster physician-patient relationships.”
“Studies2,3 have shown that good communication between doctors and patients and among all caregivers who interface with patients directly results in better clinical outcomes, reduced costs, greater patient satisfaction, and lower rates of physician burnout,” the authors wrote.
“It places a special focus on empathy in relationships, and in our case, the provider-patient relationship rather than patient-centered care. The former acknowledges that the thoughts and feelings in both sides of a relationship are important. We know that clinicians, too, can suffer as a result of the care they provide,” Dr. Velez wrote in “Communication the Cleveland Way.”1
“Healthy relationships are based on balance and mutual respect,” Dr Velez said. “Courses made a strong point to practice empathy in order to teach empathy. Clinician participants were gifted with a safe space, an opportunity to share their own skills and expertise, and a chance to be appreciated for what they already do effectively. Most of all, activities were designed to be fun and engaging.” For example, CEHC encouraged and fostered an attitude of exploration, experimentation, and adventure. Various warm-up activities effectively helped the participants enter a more playful space and get into character portrayal.
Dr. Velez credits the CEHC model’s sustainability and success to the early realization that an appreciative approach is effective. In a study3 about the strategy, hospital-employed attending physicians participated in the 8-hour experiential communication skills training course on REDE. The study compared approximately 1,500 “intervention” physicians who attended and 1,900 “nonintervention” physicians who did not attend.
Following the course, scores for physician communication and respect were higher for intervention physicians. Furthermore, physicians showed significant improvement in self-perceptions of empathy and burnout. Some of these gains were sustained for at least 3 months. “This is especially important because in the current health care climate, physicians experience increased burnout,” Dr. Velez notes.
How it works
Because a provider’s connection with a patient occurs when a relationship is established, the REDE course focuses on the beginning of the conversation. “It’s important for clinicians to exhibit value and respect through words and actions when welcoming patients,” Dr. Velez said. “Further, instead of guiding the medical interview with a series of close-ended questions like an interrogator would, we invite the use of open-ended questions and setting an agenda for the visit early on, by asking the patient what they wish to discuss.”
Another key component is empathy, which plays a huge role in patient satisfaction. “Learning how to express empathy is very important,” Dr. Velez said. “A patient may not remember all of the medical details discussed, but human interactions, rapport, expressions of care, support, validation, and acknowledgment of emotions tend to be more indelible.”
Dr. Velez notes that decades of literature regarding effective communication have demonstrated improved outcomes. “If trust in a therapeutic relationship is strong, a patient is more likely to follow instructions and have better engagement with their care plan,” he said. “If a clinician ensures that the patient understands the diagnosis and recommendations, then compliance will increase, especially if the plan is tailored to the patient’s goals and perspective.”
One surprising effect of the REDE course was how it improved relationships among professionals. “Many participants have shared that having a day out of one’s normal schedule, not only to learn, but also to share their own experiences, is quite therapeutic,” Dr. Velez said. “We can extend the same communication strategies to team building, interprofessional interactions, and challenging encounters.”
Study focuses on comportment and communication
In an effort to define optimal care in hospital medicine, a team from Johns Hopkins Health System set out to establish a metric that would comprehensively assess hospitalists’ comportment (which includes behavior as well as general demeanor) and communication to establish norms and expectations when they saw patients at the bedside.
To perform the study,4 chiefs of hospital medicine divisions at five independent hospitals located in Baltimore and Washington identified their most clinically excellent hospitalists. Then, an investigator observed each hospitalist during a routine clinical shift and recorded behaviors believed to be associated with excellent behavior and communication using the hospital medicine comportment and communication observation tool (HMCCOT), said Susrutha Kotwal, MD, assistant professor of medicine at Johns Hopkins University School of Medicine, Baltimore, and lead author. The investigators collected basic demographic information while observing hospitalists for an average of 280 minutes; 26 physicians were observed for 181 separate clinical encounters. Each provider’s mean HMCCOT score was compared with patient satisfaction surveys such as Press Ganey (PG) scores.
Noteworthy is the fact that the distribution of HMCCOT scores were similar when analyzed by age, gender, race, amount of clinical experience, the hospitalist’s clinical workload, hospital, or time spent observing the hospitalist. But the distribution of HMCCOT scores was quite different in new patient encounters, compared with follow-ups (68.1% versus 39.7%). Encounters with patients that generated HMCCOT scores above versus below the mean were longer (13 minutes versus 8.7 minutes). The physicians’ HMCCOT scores were also associated with their PG scores. These findings suggest that improved bedside communication and comportment with patients might also translate into enhanced patient satisfaction.
As a result of the study, a comportment and communication tool was established and validated by following clinically excellent hospitalists at the bedside. “Even among clinically respected hospitalists, the results reveal that there is wide variability in behaviors and communication practices at the bedside,” Dr. Kotwal said.
Employing the tool
Hospitalists can choose whether to perform behaviors in the HMCCOT themselves, while others may wish to watch other hospitalists to give them feedback tied to specific behaviors. “These simple behaviors are intimately linked to excellent communication and comportment, which can serve as the foundation for delivering patient-centered care,” Dr. Kotwal said.
A positive correlation was found between spending more time with patients and higher HMCCOT scores. “Patients’ complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that they did not convey information in a clear manner,” Dr. Kotwal said. “When successfully achieved, patient-centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self-management of chronic disease. Many of the components of the HMCCOT described in our study are at the heart of patient-centered care.”
Dr. Kotwal believes HMCCOT is a better strategy to improve patient satisfaction than patient satisfaction surveys because patients can’t always recall which specific provider saw them. In addition, patients’ recall about the provider may be poor because surveys are sent to patients days after they return home. In addition, patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Therefore, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.5
The study authors conclude that, “Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies are then needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital. Because hospitalists spend only a small proportion of their clinical time in direct patient care, it is imperative that excellent comportment and communication be established as a goal for every encounter.”
The effectiveness of care team rounds at the bedside
Investigators at the UMass Memorial Medical Center, in Worcester, Mass., studied the effectiveness of assembling the entire care team (i.e., physicians, including residents and attendings, nursing, and clinical pharmacy) to round at the patient’s bedside each morning – in lieu of its traditionally separate rounding strategies – on one unit of its academic hospitalist service for an internal quality program, said Patricia Seymour, MD, FAAFP, assistant professor and family medicine hospitalist education director.
Additionally, academic presentations and discussions were all done in front of patients and their families (with a few exceptions) rather than traditional hallway rounds or sit rounds. Over the course of the project, the hospital also offered residents training around physician behaviors that improve patient satisfaction; provided incentives for nurses and residents to work as a team; and created a welcome visit template for the nursing manager and instruments for patients to enhance engagement. Through all of these cycles, the collaborative rounding strategy continued.
Because Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores yielded low response rates for the singular test unit and service, the investigators used a validated patient satisfaction instrument and surveyed patients from the intervention group and patients on the same unit who did not experience this collaborative rounding on their day of discharge. The intervention group had higher satisfaction scores at most of the time points. The unit-based HCAHPS scores (not just study patients) improved during this time period.
“We think the strategy of collaborative rounding yielded positive results for obvious reasons – the entire team was on the same page and the information given to the patient was consistent,” said Dr. Seymour, who notes that the study’s findings weren’t published and the project was completed for an internal quality program. “Doctors had an increased understanding about nursing concerns and the nursing staff expressed improved understanding of patients’ care plans.”
Certainly, face time with the patient was extended because much of the academic discussion occurred at the bedside instead of at another physical location without patient awareness, Dr. Seymour said. She believes the strategy boosted patient satisfaction because it was patient centered. “While this rounding strategy is not the most convenient rounding strategy for nurses or doctors, it consolidates the discussion about the patient’s clinical condition and the plan for the day. The patient experiences a strong sense of being cared for by a unified team and receives consistent messaging,” she said.
Also noteworthy is that job satisfaction for residents and nurses improved on the unit over the study time period because of the expected collaboration that was built into the work flow.
Although the facility is no longer using this communication strategy to the same degree, teaching attendings have seen the value of true bedside rounding and continue to teach this skill to learners. “We have had some challenges with geographic cohorting at our institution, which is essential for this type of team-based strategy,” Dr. Seymour said. “Sustainability requires constant encouragement, oversight, and auditing from team leaders which is also challenging and fluctuates with competing demands.”
The results of this study, and others, show that employing tools to improve communication can also result in improved patient satisfaction and experience.
Karen Appold is a medical writer in Pennsylvania.
References
1. Boissy A, Gilligan T. “Communication the Cleveland Clinic Way: How to drive a relationship-centered strategy for superior patient experience.” New York: McGraw-Hill Education. 2016.
2. Weng HC, Hung CM, Liu YT, et al. Associations between emotional intelligence and doctor burnout, job satisfaction and patient satisfaction. Med Educ. 2011;45:835-42.
3. Boissy A, Windover AK, Bokar D, et al. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med. 2016 Jul;31(7):755-761. doi: 10.1007/s11606-016-3597-2. Epub 2016 Feb 26.
4. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine. J Hosp Med. 2016 Dec;11(12):853-858. doi: 10.1002/jhm.2647. Epub 2016 Aug 13.
5. Fong Ha J, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010 Spring; 10(1):38-43.
6. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient requires care of the provider. Ann Fam Med. 2014 Nov;12(6): 573-6. doi: 10.1370/afm.1713.
Bonus Content
Clinicians wary of course's worthiness
Before clinicians took Cleveland Clinic’s Relationship Establishment, Development, and Engagement (REDE) course, only 20% strongly agreed that the course would be valuable, whereas afterward 58% strongly agreed that it was indeed valuable. Less than 1% said it wasn’t valuable.4 “Most likely clinicians had a preconceived notion about how communication courses go, but they were probably surprised at how much these sessions were equally about them as providers as they were about caring for patients,” said Vicente J. Velez, MD, FACP, FHM, a hospitalist who serves as the director of faculty enrichment for the leadership team of CEHC. “This is the power of relationship-centered care, and also why I think the model has been sustainable.”
Physicians also reported that before taking the course, they had moderate levels of burnout and low levels of empathy. After taking it, burnout metrics (i.e., emotional exhaustion, depersonalization, and personal achievement) and empathy improved significantly. “I observed that most are surprised to find out that empathy is a discreet set of skills that can be learned, practiced, observed, measured, and improved upon,” Dr. Velez said. “If taught in a safe and validating environment and if principles of adult learning are followed, improvement can be optimized and sustained.”
Since the REDE course rolled out in 2012, all attending physicians and medical staff members have been trained in it.
Why empathy is preferred over patient-centered care
The Cleveland Clinic intentionally puts a focus on relationship-centered care.
“When there’s an emphasis on patient-centered care, some physicians have a hard time figuring out what to do when the patient wants something that the physician doesn’t feel is appropriate,” said Katie Neuendorf, MD, director for the Center for Excellence in Healthcare Communication. “Patient-centered implies that the patient is always right and that their opinion should win out over the physician’s opinion. In that same scenario, relationship-centered care implies that the relationship should be prioritized, even when there’s disagreement in the plan of care. I can tell my patients that I hear what they are saying, that I empathize with their struggles, that I care about the way the illness is affecting their lives, and that I am here to support them. I can do all of that and still not prescribe a treatment that I feel is inappropriate just because it happens to be what the patient wants.”
The Cleveland Clinic’s Relationship Establishment, Development and Engagement (REDE) course helps clinicians to see the individual that exists beyond a diagnosis. “Having empathy, or putting yourself in the other person’s shoes, is a key step in that process,” Dr. Neuendorf said. “Once a physician understands the patient’s perspective, the treatment for the diagnosis is more meaningful to both the patient and physician. Finding meaning in their work addresses the Quadruple Aim.”
How hospitalists and other clinicians communicate with patients impacts a patient’s overall experience and satisfaction. But according to the authors of “Communication the Cleveland Way,”1 a book about how the clinic created and applied communication skills training, “in a culture prioritizing clinical outcomes above all, there can be a tendency to lose sight of one of the most critical aspects of providing effective care: the communication skills that build and foster physician-patient relationships.”
“Studies2,3 have shown that good communication between doctors and patients and among all caregivers who interface with patients directly results in better clinical outcomes, reduced costs, greater patient satisfaction, and lower rates of physician burnout,” the authors wrote.
“It places a special focus on empathy in relationships, and in our case, the provider-patient relationship rather than patient-centered care. The former acknowledges that the thoughts and feelings in both sides of a relationship are important. We know that clinicians, too, can suffer as a result of the care they provide,” Dr. Velez wrote in “Communication the Cleveland Way.”1
“Healthy relationships are based on balance and mutual respect,” Dr Velez said. “Courses made a strong point to practice empathy in order to teach empathy. Clinician participants were gifted with a safe space, an opportunity to share their own skills and expertise, and a chance to be appreciated for what they already do effectively. Most of all, activities were designed to be fun and engaging.” For example, CEHC encouraged and fostered an attitude of exploration, experimentation, and adventure. Various warm-up activities effectively helped the participants enter a more playful space and get into character portrayal.
Dr. Velez credits the CEHC model’s sustainability and success to the early realization that an appreciative approach is effective. In a study3 about the strategy, hospital-employed attending physicians participated in the 8-hour experiential communication skills training course on REDE. The study compared approximately 1,500 “intervention” physicians who attended and 1,900 “nonintervention” physicians who did not attend.
Following the course, scores for physician communication and respect were higher for intervention physicians. Furthermore, physicians showed significant improvement in self-perceptions of empathy and burnout. Some of these gains were sustained for at least 3 months. “This is especially important because in the current health care climate, physicians experience increased burnout,” Dr. Velez notes.
How it works
Because a provider’s connection with a patient occurs when a relationship is established, the REDE course focuses on the beginning of the conversation. “It’s important for clinicians to exhibit value and respect through words and actions when welcoming patients,” Dr. Velez said. “Further, instead of guiding the medical interview with a series of close-ended questions like an interrogator would, we invite the use of open-ended questions and setting an agenda for the visit early on, by asking the patient what they wish to discuss.”
Another key component is empathy, which plays a huge role in patient satisfaction. “Learning how to express empathy is very important,” Dr. Velez said. “A patient may not remember all of the medical details discussed, but human interactions, rapport, expressions of care, support, validation, and acknowledgment of emotions tend to be more indelible.”
Dr. Velez notes that decades of literature regarding effective communication have demonstrated improved outcomes. “If trust in a therapeutic relationship is strong, a patient is more likely to follow instructions and have better engagement with their care plan,” he said. “If a clinician ensures that the patient understands the diagnosis and recommendations, then compliance will increase, especially if the plan is tailored to the patient’s goals and perspective.”
One surprising effect of the REDE course was how it improved relationships among professionals. “Many participants have shared that having a day out of one’s normal schedule, not only to learn, but also to share their own experiences, is quite therapeutic,” Dr. Velez said. “We can extend the same communication strategies to team building, interprofessional interactions, and challenging encounters.”
Study focuses on comportment and communication
In an effort to define optimal care in hospital medicine, a team from Johns Hopkins Health System set out to establish a metric that would comprehensively assess hospitalists’ comportment (which includes behavior as well as general demeanor) and communication to establish norms and expectations when they saw patients at the bedside.
To perform the study,4 chiefs of hospital medicine divisions at five independent hospitals located in Baltimore and Washington identified their most clinically excellent hospitalists. Then, an investigator observed each hospitalist during a routine clinical shift and recorded behaviors believed to be associated with excellent behavior and communication using the hospital medicine comportment and communication observation tool (HMCCOT), said Susrutha Kotwal, MD, assistant professor of medicine at Johns Hopkins University School of Medicine, Baltimore, and lead author. The investigators collected basic demographic information while observing hospitalists for an average of 280 minutes; 26 physicians were observed for 181 separate clinical encounters. Each provider’s mean HMCCOT score was compared with patient satisfaction surveys such as Press Ganey (PG) scores.
Noteworthy is the fact that the distribution of HMCCOT scores were similar when analyzed by age, gender, race, amount of clinical experience, the hospitalist’s clinical workload, hospital, or time spent observing the hospitalist. But the distribution of HMCCOT scores was quite different in new patient encounters, compared with follow-ups (68.1% versus 39.7%). Encounters with patients that generated HMCCOT scores above versus below the mean were longer (13 minutes versus 8.7 minutes). The physicians’ HMCCOT scores were also associated with their PG scores. These findings suggest that improved bedside communication and comportment with patients might also translate into enhanced patient satisfaction.
As a result of the study, a comportment and communication tool was established and validated by following clinically excellent hospitalists at the bedside. “Even among clinically respected hospitalists, the results reveal that there is wide variability in behaviors and communication practices at the bedside,” Dr. Kotwal said.
Employing the tool
Hospitalists can choose whether to perform behaviors in the HMCCOT themselves, while others may wish to watch other hospitalists to give them feedback tied to specific behaviors. “These simple behaviors are intimately linked to excellent communication and comportment, which can serve as the foundation for delivering patient-centered care,” Dr. Kotwal said.
A positive correlation was found between spending more time with patients and higher HMCCOT scores. “Patients’ complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that they did not convey information in a clear manner,” Dr. Kotwal said. “When successfully achieved, patient-centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self-management of chronic disease. Many of the components of the HMCCOT described in our study are at the heart of patient-centered care.”
Dr. Kotwal believes HMCCOT is a better strategy to improve patient satisfaction than patient satisfaction surveys because patients can’t always recall which specific provider saw them. In addition, patients’ recall about the provider may be poor because surveys are sent to patients days after they return home. In addition, patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Therefore, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.5
The study authors conclude that, “Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies are then needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital. Because hospitalists spend only a small proportion of their clinical time in direct patient care, it is imperative that excellent comportment and communication be established as a goal for every encounter.”
The effectiveness of care team rounds at the bedside
Investigators at the UMass Memorial Medical Center, in Worcester, Mass., studied the effectiveness of assembling the entire care team (i.e., physicians, including residents and attendings, nursing, and clinical pharmacy) to round at the patient’s bedside each morning – in lieu of its traditionally separate rounding strategies – on one unit of its academic hospitalist service for an internal quality program, said Patricia Seymour, MD, FAAFP, assistant professor and family medicine hospitalist education director.
Additionally, academic presentations and discussions were all done in front of patients and their families (with a few exceptions) rather than traditional hallway rounds or sit rounds. Over the course of the project, the hospital also offered residents training around physician behaviors that improve patient satisfaction; provided incentives for nurses and residents to work as a team; and created a welcome visit template for the nursing manager and instruments for patients to enhance engagement. Through all of these cycles, the collaborative rounding strategy continued.
Because Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores yielded low response rates for the singular test unit and service, the investigators used a validated patient satisfaction instrument and surveyed patients from the intervention group and patients on the same unit who did not experience this collaborative rounding on their day of discharge. The intervention group had higher satisfaction scores at most of the time points. The unit-based HCAHPS scores (not just study patients) improved during this time period.
“We think the strategy of collaborative rounding yielded positive results for obvious reasons – the entire team was on the same page and the information given to the patient was consistent,” said Dr. Seymour, who notes that the study’s findings weren’t published and the project was completed for an internal quality program. “Doctors had an increased understanding about nursing concerns and the nursing staff expressed improved understanding of patients’ care plans.”
Certainly, face time with the patient was extended because much of the academic discussion occurred at the bedside instead of at another physical location without patient awareness, Dr. Seymour said. She believes the strategy boosted patient satisfaction because it was patient centered. “While this rounding strategy is not the most convenient rounding strategy for nurses or doctors, it consolidates the discussion about the patient’s clinical condition and the plan for the day. The patient experiences a strong sense of being cared for by a unified team and receives consistent messaging,” she said.
Also noteworthy is that job satisfaction for residents and nurses improved on the unit over the study time period because of the expected collaboration that was built into the work flow.
Although the facility is no longer using this communication strategy to the same degree, teaching attendings have seen the value of true bedside rounding and continue to teach this skill to learners. “We have had some challenges with geographic cohorting at our institution, which is essential for this type of team-based strategy,” Dr. Seymour said. “Sustainability requires constant encouragement, oversight, and auditing from team leaders which is also challenging and fluctuates with competing demands.”
The results of this study, and others, show that employing tools to improve communication can also result in improved patient satisfaction and experience.
Karen Appold is a medical writer in Pennsylvania.
References
1. Boissy A, Gilligan T. “Communication the Cleveland Clinic Way: How to drive a relationship-centered strategy for superior patient experience.” New York: McGraw-Hill Education. 2016.
2. Weng HC, Hung CM, Liu YT, et al. Associations between emotional intelligence and doctor burnout, job satisfaction and patient satisfaction. Med Educ. 2011;45:835-42.
3. Boissy A, Windover AK, Bokar D, et al. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med. 2016 Jul;31(7):755-761. doi: 10.1007/s11606-016-3597-2. Epub 2016 Feb 26.
4. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine. J Hosp Med. 2016 Dec;11(12):853-858. doi: 10.1002/jhm.2647. Epub 2016 Aug 13.
5. Fong Ha J, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010 Spring; 10(1):38-43.
6. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient requires care of the provider. Ann Fam Med. 2014 Nov;12(6): 573-6. doi: 10.1370/afm.1713.
Bonus Content
Clinicians wary of course's worthiness
Before clinicians took Cleveland Clinic’s Relationship Establishment, Development, and Engagement (REDE) course, only 20% strongly agreed that the course would be valuable, whereas afterward 58% strongly agreed that it was indeed valuable. Less than 1% said it wasn’t valuable.4 “Most likely clinicians had a preconceived notion about how communication courses go, but they were probably surprised at how much these sessions were equally about them as providers as they were about caring for patients,” said Vicente J. Velez, MD, FACP, FHM, a hospitalist who serves as the director of faculty enrichment for the leadership team of CEHC. “This is the power of relationship-centered care, and also why I think the model has been sustainable.”
Physicians also reported that before taking the course, they had moderate levels of burnout and low levels of empathy. After taking it, burnout metrics (i.e., emotional exhaustion, depersonalization, and personal achievement) and empathy improved significantly. “I observed that most are surprised to find out that empathy is a discreet set of skills that can be learned, practiced, observed, measured, and improved upon,” Dr. Velez said. “If taught in a safe and validating environment and if principles of adult learning are followed, improvement can be optimized and sustained.”
Since the REDE course rolled out in 2012, all attending physicians and medical staff members have been trained in it.
Why empathy is preferred over patient-centered care
The Cleveland Clinic intentionally puts a focus on relationship-centered care.
“When there’s an emphasis on patient-centered care, some physicians have a hard time figuring out what to do when the patient wants something that the physician doesn’t feel is appropriate,” said Katie Neuendorf, MD, director for the Center for Excellence in Healthcare Communication. “Patient-centered implies that the patient is always right and that their opinion should win out over the physician’s opinion. In that same scenario, relationship-centered care implies that the relationship should be prioritized, even when there’s disagreement in the plan of care. I can tell my patients that I hear what they are saying, that I empathize with their struggles, that I care about the way the illness is affecting their lives, and that I am here to support them. I can do all of that and still not prescribe a treatment that I feel is inappropriate just because it happens to be what the patient wants.”
The Cleveland Clinic’s Relationship Establishment, Development and Engagement (REDE) course helps clinicians to see the individual that exists beyond a diagnosis. “Having empathy, or putting yourself in the other person’s shoes, is a key step in that process,” Dr. Neuendorf said. “Once a physician understands the patient’s perspective, the treatment for the diagnosis is more meaningful to both the patient and physician. Finding meaning in their work addresses the Quadruple Aim.”
Despite global decline, rheumatic heart disease persists in poorest regions
Global mortality due to rheumatic heart disease fell by about 48% during a recent 25-year-period, but some of the poorest areas of the world were left behind, according to a report in the New England Journal of Medicine.
Those regions included Oceania, South Asia, and central sub-Saharan Africa, where rheumatic heart disease remains endemic, wrote David A. Watkins, MD, MPH, of the University of Washington, Seattle, and his coinvestigators. “We estimate that 10 persons per 1,000 population living in South Asia and central sub-Saharan Africa and 15 persons per 1,000 population in Oceania were living with rheumatic heart disease in the year 2015,” they wrote. “Improvements in the measurement of the burden of rheumatic heart disease will assist in planning for its control and will help identify countries where further investments are needed.”
To better define the problem, Dr. Watkins and his associates analyzed epidemiologic studies of rheumatic heart disease from 1990 through 2015. They used the Cause of Death Ensemble model, which estimates mortality more reliably than older methods, and DisMod-MR (version 2.1), which sums epidemiologic data from multiple sources and corrects for gaps and inconsistencies (N Engl J Med. 2017;377:713-22).
Worldwide, about 319,400 individuals died of rheumatic heart disease in 2015, the researchers reported. Age-adjusted death rates fell by about 48% (95% confidence interval, 45%-51%), from 9.2 deaths per 100,000 population in 1990 to 4.8 deaths per 100,000 population in 2015. But this global trend masked striking regional disparities. In 1990, 77% of deaths from rheumatic heart disease occurred in endemic areas of Africa, South Asia, Oceania, and the Caribbean; by 2015, 82% of deaths occurred in endemic regions. Oceania, South Asia, and central sub-Saharan Africa had the highest death rates and were the only regions where the 95% confidence intervals for 1990 and 2015 overlapped, the investigators noted.
In 2015, age-standardized death rates exceeded 10 deaths per 100,000 population in the Solomon Islands, Pakistan, Papua New Guinea, Kiribati, Vanuatu, Fiji, India, Federated States of Micronesia, Marshall Islands, Central African Republic, and Lesotho, they reported. Estimated fatalities were highest in India (119,100 deaths), China (72,600), and Pakistan (18,900). They estimated that in 2015, there were 33.2 million cases of rheumatic heart disease and 10.5 million associated disability-adjusted life-years globally.
The study excluded “borderline” or subclinical rheumatic heart disease, which is detected by echocardiography and whose management remains unclear. “Better data for low-income and middle-income countries are needed to guide policies for the control of rheumatic heart disease,” the investigators wrote. They recommended studying death certificate misclassifications, disease prevalence among adults, and longitudinal trends in nonfatal outcomes and excess mortality.
Funders of the study included the Bill and Melinda Gates Foundation and the Medtronic Foundation. Dr. Watkins disclosed grants from the Medtronic Foundation during the conduct of the study and grants from the Bill and Melinda Gates Foundation outside the submitted work.
Rheumatic heart disease ranks as one of the most serious cardiovascular scourges of the past century. As a result of improvements in living conditions and the introduction of penicillin, the disease was almost eradicated in the developed world by the 1980s. However, it remains a force to be reckoned with in the developing world, as demonstrated by an assessment from the 2015 Global Burden of Disease study (GBD 2015), painstakingly performed by Dr. Watkins and his colleagues.
Several key messages emerge from this important study. It confirms the marked global heterogeneity of the burden of rheumatic heart disease, with near-zero prevalence in developed countries sharply contrasting with substantial prevalence and mortality in developing areas. In addition, however, the study documents the scarcity of accurately measured data in many locations, especially in areas with the highest prevalence (such as sub-Saharan Africa).
Although the “headline news” of a global decline in the prevalence of rheumatic heart disease described by Watkins et al. may give cause for optimism, the burden remains great for those parts of the world least able to afford it. Without sustained re-engagement of clinicians, researchers, funders, and public health bodies, the menace of rheumatic heart disease is unlikely to be eliminated in the near future. Rheumatic heart disease remains a problematic iceberg, yet undissolved, in warm tropical waters.
Eloi Marijon, MD, PhD, and Xavier Jouven, MD, PhD, are at European Georges Pompidou Hospital, Paris. David S. Celermajer, PhD, is at Sydney (Australia) Medical School. They reported having no conflicts of interest. Their editorial accompanied the report by Dr. Watkins and his colleagues (N Engl J Med. 2017;377:780-1).
Rheumatic heart disease ranks as one of the most serious cardiovascular scourges of the past century. As a result of improvements in living conditions and the introduction of penicillin, the disease was almost eradicated in the developed world by the 1980s. However, it remains a force to be reckoned with in the developing world, as demonstrated by an assessment from the 2015 Global Burden of Disease study (GBD 2015), painstakingly performed by Dr. Watkins and his colleagues.
Several key messages emerge from this important study. It confirms the marked global heterogeneity of the burden of rheumatic heart disease, with near-zero prevalence in developed countries sharply contrasting with substantial prevalence and mortality in developing areas. In addition, however, the study documents the scarcity of accurately measured data in many locations, especially in areas with the highest prevalence (such as sub-Saharan Africa).
Although the “headline news” of a global decline in the prevalence of rheumatic heart disease described by Watkins et al. may give cause for optimism, the burden remains great for those parts of the world least able to afford it. Without sustained re-engagement of clinicians, researchers, funders, and public health bodies, the menace of rheumatic heart disease is unlikely to be eliminated in the near future. Rheumatic heart disease remains a problematic iceberg, yet undissolved, in warm tropical waters.
Eloi Marijon, MD, PhD, and Xavier Jouven, MD, PhD, are at European Georges Pompidou Hospital, Paris. David S. Celermajer, PhD, is at Sydney (Australia) Medical School. They reported having no conflicts of interest. Their editorial accompanied the report by Dr. Watkins and his colleagues (N Engl J Med. 2017;377:780-1).
Rheumatic heart disease ranks as one of the most serious cardiovascular scourges of the past century. As a result of improvements in living conditions and the introduction of penicillin, the disease was almost eradicated in the developed world by the 1980s. However, it remains a force to be reckoned with in the developing world, as demonstrated by an assessment from the 2015 Global Burden of Disease study (GBD 2015), painstakingly performed by Dr. Watkins and his colleagues.
Several key messages emerge from this important study. It confirms the marked global heterogeneity of the burden of rheumatic heart disease, with near-zero prevalence in developed countries sharply contrasting with substantial prevalence and mortality in developing areas. In addition, however, the study documents the scarcity of accurately measured data in many locations, especially in areas with the highest prevalence (such as sub-Saharan Africa).
Although the “headline news” of a global decline in the prevalence of rheumatic heart disease described by Watkins et al. may give cause for optimism, the burden remains great for those parts of the world least able to afford it. Without sustained re-engagement of clinicians, researchers, funders, and public health bodies, the menace of rheumatic heart disease is unlikely to be eliminated in the near future. Rheumatic heart disease remains a problematic iceberg, yet undissolved, in warm tropical waters.
Eloi Marijon, MD, PhD, and Xavier Jouven, MD, PhD, are at European Georges Pompidou Hospital, Paris. David S. Celermajer, PhD, is at Sydney (Australia) Medical School. They reported having no conflicts of interest. Their editorial accompanied the report by Dr. Watkins and his colleagues (N Engl J Med. 2017;377:780-1).
Global mortality due to rheumatic heart disease fell by about 48% during a recent 25-year-period, but some of the poorest areas of the world were left behind, according to a report in the New England Journal of Medicine.
Those regions included Oceania, South Asia, and central sub-Saharan Africa, where rheumatic heart disease remains endemic, wrote David A. Watkins, MD, MPH, of the University of Washington, Seattle, and his coinvestigators. “We estimate that 10 persons per 1,000 population living in South Asia and central sub-Saharan Africa and 15 persons per 1,000 population in Oceania were living with rheumatic heart disease in the year 2015,” they wrote. “Improvements in the measurement of the burden of rheumatic heart disease will assist in planning for its control and will help identify countries where further investments are needed.”
To better define the problem, Dr. Watkins and his associates analyzed epidemiologic studies of rheumatic heart disease from 1990 through 2015. They used the Cause of Death Ensemble model, which estimates mortality more reliably than older methods, and DisMod-MR (version 2.1), which sums epidemiologic data from multiple sources and corrects for gaps and inconsistencies (N Engl J Med. 2017;377:713-22).
Worldwide, about 319,400 individuals died of rheumatic heart disease in 2015, the researchers reported. Age-adjusted death rates fell by about 48% (95% confidence interval, 45%-51%), from 9.2 deaths per 100,000 population in 1990 to 4.8 deaths per 100,000 population in 2015. But this global trend masked striking regional disparities. In 1990, 77% of deaths from rheumatic heart disease occurred in endemic areas of Africa, South Asia, Oceania, and the Caribbean; by 2015, 82% of deaths occurred in endemic regions. Oceania, South Asia, and central sub-Saharan Africa had the highest death rates and were the only regions where the 95% confidence intervals for 1990 and 2015 overlapped, the investigators noted.
In 2015, age-standardized death rates exceeded 10 deaths per 100,000 population in the Solomon Islands, Pakistan, Papua New Guinea, Kiribati, Vanuatu, Fiji, India, Federated States of Micronesia, Marshall Islands, Central African Republic, and Lesotho, they reported. Estimated fatalities were highest in India (119,100 deaths), China (72,600), and Pakistan (18,900). They estimated that in 2015, there were 33.2 million cases of rheumatic heart disease and 10.5 million associated disability-adjusted life-years globally.
The study excluded “borderline” or subclinical rheumatic heart disease, which is detected by echocardiography and whose management remains unclear. “Better data for low-income and middle-income countries are needed to guide policies for the control of rheumatic heart disease,” the investigators wrote. They recommended studying death certificate misclassifications, disease prevalence among adults, and longitudinal trends in nonfatal outcomes and excess mortality.
Funders of the study included the Bill and Melinda Gates Foundation and the Medtronic Foundation. Dr. Watkins disclosed grants from the Medtronic Foundation during the conduct of the study and grants from the Bill and Melinda Gates Foundation outside the submitted work.
Global mortality due to rheumatic heart disease fell by about 48% during a recent 25-year-period, but some of the poorest areas of the world were left behind, according to a report in the New England Journal of Medicine.
Those regions included Oceania, South Asia, and central sub-Saharan Africa, where rheumatic heart disease remains endemic, wrote David A. Watkins, MD, MPH, of the University of Washington, Seattle, and his coinvestigators. “We estimate that 10 persons per 1,000 population living in South Asia and central sub-Saharan Africa and 15 persons per 1,000 population in Oceania were living with rheumatic heart disease in the year 2015,” they wrote. “Improvements in the measurement of the burden of rheumatic heart disease will assist in planning for its control and will help identify countries where further investments are needed.”
To better define the problem, Dr. Watkins and his associates analyzed epidemiologic studies of rheumatic heart disease from 1990 through 2015. They used the Cause of Death Ensemble model, which estimates mortality more reliably than older methods, and DisMod-MR (version 2.1), which sums epidemiologic data from multiple sources and corrects for gaps and inconsistencies (N Engl J Med. 2017;377:713-22).
Worldwide, about 319,400 individuals died of rheumatic heart disease in 2015, the researchers reported. Age-adjusted death rates fell by about 48% (95% confidence interval, 45%-51%), from 9.2 deaths per 100,000 population in 1990 to 4.8 deaths per 100,000 population in 2015. But this global trend masked striking regional disparities. In 1990, 77% of deaths from rheumatic heart disease occurred in endemic areas of Africa, South Asia, Oceania, and the Caribbean; by 2015, 82% of deaths occurred in endemic regions. Oceania, South Asia, and central sub-Saharan Africa had the highest death rates and were the only regions where the 95% confidence intervals for 1990 and 2015 overlapped, the investigators noted.
In 2015, age-standardized death rates exceeded 10 deaths per 100,000 population in the Solomon Islands, Pakistan, Papua New Guinea, Kiribati, Vanuatu, Fiji, India, Federated States of Micronesia, Marshall Islands, Central African Republic, and Lesotho, they reported. Estimated fatalities were highest in India (119,100 deaths), China (72,600), and Pakistan (18,900). They estimated that in 2015, there were 33.2 million cases of rheumatic heart disease and 10.5 million associated disability-adjusted life-years globally.
The study excluded “borderline” or subclinical rheumatic heart disease, which is detected by echocardiography and whose management remains unclear. “Better data for low-income and middle-income countries are needed to guide policies for the control of rheumatic heart disease,” the investigators wrote. They recommended studying death certificate misclassifications, disease prevalence among adults, and longitudinal trends in nonfatal outcomes and excess mortality.
Funders of the study included the Bill and Melinda Gates Foundation and the Medtronic Foundation. Dr. Watkins disclosed grants from the Medtronic Foundation during the conduct of the study and grants from the Bill and Melinda Gates Foundation outside the submitted work.
FROM NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point:
Major finding: Globally, age-adjusted death rates fell by about 48% between 1990 and 2015. Oceania, South Asia, and central sub-Saharan Africa had the highest death rates in 2015, and were the only regions where the 95% confidence intervals overlapped with those for 1990.
Data source: A systematic review and analysis of morbidity and mortality data from 1990 through 2015.
Disclosures: Funders included the Bill and Melinda Gates Foundation and the Medtronic Foundation. Dr. Watkins disclosed grants from the Medtronic Foundation during the conduct of the study and grants from the Bill and Melinda Gates Foundation outside the submitted work.
Epidemiology of meningitis and encephalitis in the United States
Clinical Question: What is the epidemiology of meningitis and encephalitis in adults in the United States?
Background: Previous epidemiologic studies have been smaller with less clinical information available and without steroid usage rates.
Study Design: A retrospective database review.
Setting: The Premier HealthCare Database, including hospitals of all types and sizes.
Synopsis: Of patients aged 18 or older, 26,429 were included with a primary or secondary discharge diagnosis of meningitis or encephalitis from 2011-2014. Enterovirus was the most common infectious cause (51%), followed by unknown etiology (19%), bacterial (14%), herpetic (8%), fungal (3%), and arboviruses (1%). Of patients, 4.2% had HIV.
Steroids were given on the first day of antibiotics in 25.9%. The only statistical mortality benefit was found with steroid use in pneumococcal meningitis (6.7% vs. 12.5%; P = .0245), with a trend toward increased mortality for steroids in fungal meningitis.
Of patients, 87.2% were admitted through the ED, though 22.5% of lumbar punctures were done after admission and 77.4% were discharged home.
Bottom Line: Enterovirus was the most common cause of adult meningoencephalitis, and patients with pneumococcal meningitis who received steroids had decreased mortality.
Citation: Hasbun R, Ning R, Balada-Llasat JM, Chung J, Duff S, Bozzette S, et al. Meningitis and encephalitis in the United States from 2011-2014. Published online, Apr 17, 2017. Clin Infect Dis. 2017. doi: 10.1093/cid/cix319.
Dr. Hall is an assistant professor in the University of Kentucky division of hospital medicine and pediatrics.
Clinical Question: What is the epidemiology of meningitis and encephalitis in adults in the United States?
Background: Previous epidemiologic studies have been smaller with less clinical information available and without steroid usage rates.
Study Design: A retrospective database review.
Setting: The Premier HealthCare Database, including hospitals of all types and sizes.
Synopsis: Of patients aged 18 or older, 26,429 were included with a primary or secondary discharge diagnosis of meningitis or encephalitis from 2011-2014. Enterovirus was the most common infectious cause (51%), followed by unknown etiology (19%), bacterial (14%), herpetic (8%), fungal (3%), and arboviruses (1%). Of patients, 4.2% had HIV.
Steroids were given on the first day of antibiotics in 25.9%. The only statistical mortality benefit was found with steroid use in pneumococcal meningitis (6.7% vs. 12.5%; P = .0245), with a trend toward increased mortality for steroids in fungal meningitis.
Of patients, 87.2% were admitted through the ED, though 22.5% of lumbar punctures were done after admission and 77.4% were discharged home.
Bottom Line: Enterovirus was the most common cause of adult meningoencephalitis, and patients with pneumococcal meningitis who received steroids had decreased mortality.
Citation: Hasbun R, Ning R, Balada-Llasat JM, Chung J, Duff S, Bozzette S, et al. Meningitis and encephalitis in the United States from 2011-2014. Published online, Apr 17, 2017. Clin Infect Dis. 2017. doi: 10.1093/cid/cix319.
Dr. Hall is an assistant professor in the University of Kentucky division of hospital medicine and pediatrics.
Clinical Question: What is the epidemiology of meningitis and encephalitis in adults in the United States?
Background: Previous epidemiologic studies have been smaller with less clinical information available and without steroid usage rates.
Study Design: A retrospective database review.
Setting: The Premier HealthCare Database, including hospitals of all types and sizes.
Synopsis: Of patients aged 18 or older, 26,429 were included with a primary or secondary discharge diagnosis of meningitis or encephalitis from 2011-2014. Enterovirus was the most common infectious cause (51%), followed by unknown etiology (19%), bacterial (14%), herpetic (8%), fungal (3%), and arboviruses (1%). Of patients, 4.2% had HIV.
Steroids were given on the first day of antibiotics in 25.9%. The only statistical mortality benefit was found with steroid use in pneumococcal meningitis (6.7% vs. 12.5%; P = .0245), with a trend toward increased mortality for steroids in fungal meningitis.
Of patients, 87.2% were admitted through the ED, though 22.5% of lumbar punctures were done after admission and 77.4% were discharged home.
Bottom Line: Enterovirus was the most common cause of adult meningoencephalitis, and patients with pneumococcal meningitis who received steroids had decreased mortality.
Citation: Hasbun R, Ning R, Balada-Llasat JM, Chung J, Duff S, Bozzette S, et al. Meningitis and encephalitis in the United States from 2011-2014. Published online, Apr 17, 2017. Clin Infect Dis. 2017. doi: 10.1093/cid/cix319.
Dr. Hall is an assistant professor in the University of Kentucky division of hospital medicine and pediatrics.
Sneak Peek: Journal of Hospital Medicine – August 2017
BACKGROUND: There is increasing recognition that patients have critical insights into care experiences, including about breakdowns in care. Harnessing patient perspectives for hospital improvement requires an in-depth understanding of the types of breakdowns patients identify and the impact of these events.
RESULTS: Of 979 interviewees, 386 (39.4%) believed they had experienced at least one breakdown in care. The most common reported breakdowns involved information exchange (n = 158; 16.1%), medications (n = 120; 12.3%), delays in admission (n = 90; 9.2%), team communication (n = 65; 6.6%), providers’ manner (n = 62; 6.3%), and discharge (n = 56; 5.7%). Of the 386 interviewees who reported a breakdown, 140 (36.3%) perceived associated harm. Patient-perceived harms included physical (e.g., pain), emotional (e.g., distress, worry), damage to relationship with providers, need for additional care or prolonged hospital stay, and life disruption. We found higher rates of reporting breakdowns among younger (less than 60 years old) patients (45.4% vs. 34.5%; P less than .001), those with at least some college education (46.8% vs 32.7%; P less than .001), and those with another person (family or friend) present during the interview or interviewed in lieu of the patient (53.4% vs 37.8%; P = .002).
CONCLUSIONS: When asked directly, almost 4 out of 10 hospitalized patients reported a breakdown in their care. Patient-perceived breakdowns in care are frequently associated with perceived harm, illustrating the importance of detecting and addressing these events.
Also in JHM
Excess readmission vs. excess penalties: Maximum readmission penalties as a function of socioeconomics and geography
AUTHORS: Chris M. Caracciolo, MPH, Devin M. Parker, MS, Emily Marshall, MS, Jeremiah R. Brown, PhD, MS
Impact of a safety huddle-based intervention on monitor alarm rates in low-acuity pediatric intensive care unit patientsAUTHORS: Maya Dewan, MD, MPH, Heather Wolfe, MD, MSHP, Richard Lin, MD, Eileen Ware, RN, Michelle Weiss, RN, Lihai Song, MS, Matthew MacMurchy, BA, Daniela Davis, MD, MSCE, Christopher P. Bonafide MD MSCE
Perspectives of clinicians at skilled nursing facilities on 30-day hospital readmissions: A qualitative studyAUTHORS: Bennett W. Clark, MD, Katelyn Baron, MSIOP, Kathleen Tynan-McKiernan, RN, MSN, Meredith Campbell Britton, LMSW, Karl E. Minges, PhD, Sarwat I. Chaudhry, MD
Use of postacute facility care in children hospitalized with acute respiratory illnessAUTHORS: Jay G. Berry, MD, MPH, Karen M. Wilson, MD, MPH, FAAP, Helene Dumas, PT, MS, Edwin Simpser, MD, Jane O’Brien, MD, Kathleen Whitford, PNP, Rachna May, MD, Vineeta Mittal, MD, Nancy Murphy, MD, David Steinhorn, MD, Rishi Agrawal, MD, MPH, Kris Rehm, MD, Michelle Marks, DO, FAAP, SFHM, Christine Traul, MD, Michael Dribbon, PhD, Christopher J. Haines, DO, MBA, FAAP, FACEP, Matt Hall, PhD
A contemporary assessment of mechanical complication rates and trainee perceptions of central venous catheter insertionAUTHORS: Lauren Heidemann, MD, Niket Nathani, MD, Rommel Sagana, MD, Vineet Chopra, MD, MSc, Michael Heung, MD, MS
For more articles and subscription information, visit www.journalofhospitalmedicine.com.
BACKGROUND: There is increasing recognition that patients have critical insights into care experiences, including about breakdowns in care. Harnessing patient perspectives for hospital improvement requires an in-depth understanding of the types of breakdowns patients identify and the impact of these events.
RESULTS: Of 979 interviewees, 386 (39.4%) believed they had experienced at least one breakdown in care. The most common reported breakdowns involved information exchange (n = 158; 16.1%), medications (n = 120; 12.3%), delays in admission (n = 90; 9.2%), team communication (n = 65; 6.6%), providers’ manner (n = 62; 6.3%), and discharge (n = 56; 5.7%). Of the 386 interviewees who reported a breakdown, 140 (36.3%) perceived associated harm. Patient-perceived harms included physical (e.g., pain), emotional (e.g., distress, worry), damage to relationship with providers, need for additional care or prolonged hospital stay, and life disruption. We found higher rates of reporting breakdowns among younger (less than 60 years old) patients (45.4% vs. 34.5%; P less than .001), those with at least some college education (46.8% vs 32.7%; P less than .001), and those with another person (family or friend) present during the interview or interviewed in lieu of the patient (53.4% vs 37.8%; P = .002).
CONCLUSIONS: When asked directly, almost 4 out of 10 hospitalized patients reported a breakdown in their care. Patient-perceived breakdowns in care are frequently associated with perceived harm, illustrating the importance of detecting and addressing these events.
Also in JHM
Excess readmission vs. excess penalties: Maximum readmission penalties as a function of socioeconomics and geography
AUTHORS: Chris M. Caracciolo, MPH, Devin M. Parker, MS, Emily Marshall, MS, Jeremiah R. Brown, PhD, MS
Impact of a safety huddle-based intervention on monitor alarm rates in low-acuity pediatric intensive care unit patientsAUTHORS: Maya Dewan, MD, MPH, Heather Wolfe, MD, MSHP, Richard Lin, MD, Eileen Ware, RN, Michelle Weiss, RN, Lihai Song, MS, Matthew MacMurchy, BA, Daniela Davis, MD, MSCE, Christopher P. Bonafide MD MSCE
Perspectives of clinicians at skilled nursing facilities on 30-day hospital readmissions: A qualitative studyAUTHORS: Bennett W. Clark, MD, Katelyn Baron, MSIOP, Kathleen Tynan-McKiernan, RN, MSN, Meredith Campbell Britton, LMSW, Karl E. Minges, PhD, Sarwat I. Chaudhry, MD
Use of postacute facility care in children hospitalized with acute respiratory illnessAUTHORS: Jay G. Berry, MD, MPH, Karen M. Wilson, MD, MPH, FAAP, Helene Dumas, PT, MS, Edwin Simpser, MD, Jane O’Brien, MD, Kathleen Whitford, PNP, Rachna May, MD, Vineeta Mittal, MD, Nancy Murphy, MD, David Steinhorn, MD, Rishi Agrawal, MD, MPH, Kris Rehm, MD, Michelle Marks, DO, FAAP, SFHM, Christine Traul, MD, Michael Dribbon, PhD, Christopher J. Haines, DO, MBA, FAAP, FACEP, Matt Hall, PhD
A contemporary assessment of mechanical complication rates and trainee perceptions of central venous catheter insertionAUTHORS: Lauren Heidemann, MD, Niket Nathani, MD, Rommel Sagana, MD, Vineet Chopra, MD, MSc, Michael Heung, MD, MS
For more articles and subscription information, visit www.journalofhospitalmedicine.com.
BACKGROUND: There is increasing recognition that patients have critical insights into care experiences, including about breakdowns in care. Harnessing patient perspectives for hospital improvement requires an in-depth understanding of the types of breakdowns patients identify and the impact of these events.
RESULTS: Of 979 interviewees, 386 (39.4%) believed they had experienced at least one breakdown in care. The most common reported breakdowns involved information exchange (n = 158; 16.1%), medications (n = 120; 12.3%), delays in admission (n = 90; 9.2%), team communication (n = 65; 6.6%), providers’ manner (n = 62; 6.3%), and discharge (n = 56; 5.7%). Of the 386 interviewees who reported a breakdown, 140 (36.3%) perceived associated harm. Patient-perceived harms included physical (e.g., pain), emotional (e.g., distress, worry), damage to relationship with providers, need for additional care or prolonged hospital stay, and life disruption. We found higher rates of reporting breakdowns among younger (less than 60 years old) patients (45.4% vs. 34.5%; P less than .001), those with at least some college education (46.8% vs 32.7%; P less than .001), and those with another person (family or friend) present during the interview or interviewed in lieu of the patient (53.4% vs 37.8%; P = .002).
CONCLUSIONS: When asked directly, almost 4 out of 10 hospitalized patients reported a breakdown in their care. Patient-perceived breakdowns in care are frequently associated with perceived harm, illustrating the importance of detecting and addressing these events.
Also in JHM
Excess readmission vs. excess penalties: Maximum readmission penalties as a function of socioeconomics and geography
AUTHORS: Chris M. Caracciolo, MPH, Devin M. Parker, MS, Emily Marshall, MS, Jeremiah R. Brown, PhD, MS
Impact of a safety huddle-based intervention on monitor alarm rates in low-acuity pediatric intensive care unit patientsAUTHORS: Maya Dewan, MD, MPH, Heather Wolfe, MD, MSHP, Richard Lin, MD, Eileen Ware, RN, Michelle Weiss, RN, Lihai Song, MS, Matthew MacMurchy, BA, Daniela Davis, MD, MSCE, Christopher P. Bonafide MD MSCE
Perspectives of clinicians at skilled nursing facilities on 30-day hospital readmissions: A qualitative studyAUTHORS: Bennett W. Clark, MD, Katelyn Baron, MSIOP, Kathleen Tynan-McKiernan, RN, MSN, Meredith Campbell Britton, LMSW, Karl E. Minges, PhD, Sarwat I. Chaudhry, MD
Use of postacute facility care in children hospitalized with acute respiratory illnessAUTHORS: Jay G. Berry, MD, MPH, Karen M. Wilson, MD, MPH, FAAP, Helene Dumas, PT, MS, Edwin Simpser, MD, Jane O’Brien, MD, Kathleen Whitford, PNP, Rachna May, MD, Vineeta Mittal, MD, Nancy Murphy, MD, David Steinhorn, MD, Rishi Agrawal, MD, MPH, Kris Rehm, MD, Michelle Marks, DO, FAAP, SFHM, Christine Traul, MD, Michael Dribbon, PhD, Christopher J. Haines, DO, MBA, FAAP, FACEP, Matt Hall, PhD
A contemporary assessment of mechanical complication rates and trainee perceptions of central venous catheter insertionAUTHORS: Lauren Heidemann, MD, Niket Nathani, MD, Rommel Sagana, MD, Vineet Chopra, MD, MSc, Michael Heung, MD, MS
For more articles and subscription information, visit www.journalofhospitalmedicine.com.
Managing hospital- and ventilator-associated pneumonia
Background
Hospital-acquired pneumonia (HAP) is defined as pneumonia that develops 48 hours or more after admission that was not present on admission; and ventilator-associated pneumonia (VAP) is pneumonia that develops 48 hours or more after endotracheal intubation.
HAP and VAP are common afflictions in hospitalized patients, accounting for nearly one-quarter of all hospital-acquired infections. They confer mortality rates of 24%-50%, increasing to nearly 75% if caused by resistant organisms.1,2 Given the high prevalence and significant mortality associated with these types of pneumonia, diagnosis and treatment are essential. Treatment must be balanced against potential unintended consequences of antibiotic use including Clostridium difficile infections and the promotion of resistant bacteria caused by poor antibiotic stewardship.
Given the frequency with which HAP and VAP occur, and the need for equipoise with antibiotic use, it is essential that all practicing clinicians have an evidence-based construct for the diagnosis and treatment of HAP and VAP.
Guideline updates
In 2016, the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) reconvened after 11 years to update their recommendations for the treatment of HAP and VAP.2 The decision to update their recommendations was based on the availability of new evidence regarding the diagnosis and treatment of these conditions.
Included in this review are guideline updates on methods for diagnosis, initial antibiotic choice, pathogen-specific therapy, and duration of therapy. The guidelines also have recommendations for the role of inhaled antibiotics and pharmacokinetic optimization of antibiotic dosing, which will not be reviewed here.
Methods for Diagnosis: The use of semi-quantitative, noninvasive sampling of respiratory cultures is preferred for HAP and VAP, rather than empiric treatment or quantitative cultures (i.e., bronchoalveolar lavage, protected-specimen brush and blind bronchial sampling).
Initial antibiotic choice: For HAP and VAP, clinicians should include therapy targeting S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli. Therapy for methicillin-resistant S. aureus should be included if patients are at high risk for death (i.e., septic shock or ventilated patients) or if local drug-resistant prevalence is greater than 10%-20%. Similarly, two antipseudomonal antibiotics should be used only with empiric therapy if the patient is at high risk for mortality or local drug-resistant prevalence is greater than 10%.
Duration of therapy: HAP and VAP should be treated for 7 days with regimens that are tailored to culture data when available, assuming there has been appropriate clinical response. Procalcitonin may be paired with clinical judgment when considering antibiotic discontinuation.
Guideline analysis
There are several notable differences between the 2016 IDSA/ATS guidelines and the 2005 guidelines.3 The earlier guidelines recommended strong consideration of invasive respiratory cultures such as bronchoalveolar lavage or protected-specimen brush sampling for HAP/VAP. It is now recommended that only noninvasive cultures be performed in most clinical scenarios.
Last, the updated guidelines recommend dual therapy for potential or documented Pseudomonas infection only for patients at high risk for mortality or in hospitals with a high prevalence of antibiotic resistance; previously, dual antipseudomonal therapy was recommended for all cases of HAP and VAP, based upon the risk of developing resistant strains with monotherapy.3
Since 2005, several organizations have released guidelines addressing the management of HAP and VAP.1,4,5,6 These are largely in keeping with the current version released by the IDSA/ATS. Across all guidelines, there is a focus on the importance of local antibiograms for appropriate and effective treatment, and the use of noninvasive culture data to guide therapy. Also, all groups recommend a short-course (7-8 days) of antibiotics for both HAP and VAP, assuming there has been an appropriate clinical response. The recent Canadian guidelines have one unique recommendation, which is to avoid the use of ceftazidime for suspected Pseudomonas pneumonia, based upon inferior outcomes when compared to alternative regimens.5
Takeaways
When considering the diagnosis of HAP and VAP, clinicians should be aware that the category of HCAP has been removed from current guidelines, and methods for microbiological diagnosis have been simplified.7 In addition, initial antibiotic selection should rely on institution-specific antibiograms and local resistance patterns when available. Recommended duration of therapy has been shortened, and should not include aminoglycosides.
Finally, antibiotic stewardship is the responsibility of each clinician and de-escalation of therapy for HAP and VAP should be guided by available respiratory cultures.
Dr. Hippensteel is a pulmonologist in Aurora, Colo. Dr. Sippel is visiting associate professor of clinical practice, medicine-pulmonary sciences & critical care at the University of Colorado School of Medicine.
References
1. Masterton R, Galloway A, French G, Street M, Armstrong J, Brown E, Cleverley J, Dilworth P, Fry C, Gascoigne A. Guidelines for the management of hospital-acquired pneumonia in the UK: report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother. 2008;62(1):5-34.
2. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O’grady NP, Bartlett JG, Carratalà J. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016:ciw353.
3. Society AT, America IDSo. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416.
4. Dalhoff K, Abele-Horn M, Andreas S, Bauer T, von Baum H, Deja M, Ewig S, Gastmeier P, Gatermann S, Gerlach H. Epidemiology, diagnosis, and treatment of adult patients with nosocomial pneumonia. S-3 Guideline of the German Society for Anaesthesiology and Intensive Care Medicine, the German Society for Infectious Diseases, the German Society for Hygiene and Microbiology, the German Respiratory Society and the Paul-Ehrlich-Society for Chemotherapy. Pneumologie (Stuttgart, Germany). 2012;66(12):707-65.
5. Rotstein C, Evans G, Born A, Grossman R, Light RB, Magder S, McTaggart B, Weiss K, Zhanel GG. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Canadian Journal of Infectious Diseases and Medical Microbiology. 2008;19(1):19-53.
6. Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Dubberke ER, Fraser V. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(S1):S31-S40.
7. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing healthcare-associated pneumonia, 2003. MMWR. 2004;53(RR-3):1-36.
Background
Hospital-acquired pneumonia (HAP) is defined as pneumonia that develops 48 hours or more after admission that was not present on admission; and ventilator-associated pneumonia (VAP) is pneumonia that develops 48 hours or more after endotracheal intubation.
HAP and VAP are common afflictions in hospitalized patients, accounting for nearly one-quarter of all hospital-acquired infections. They confer mortality rates of 24%-50%, increasing to nearly 75% if caused by resistant organisms.1,2 Given the high prevalence and significant mortality associated with these types of pneumonia, diagnosis and treatment are essential. Treatment must be balanced against potential unintended consequences of antibiotic use including Clostridium difficile infections and the promotion of resistant bacteria caused by poor antibiotic stewardship.
Given the frequency with which HAP and VAP occur, and the need for equipoise with antibiotic use, it is essential that all practicing clinicians have an evidence-based construct for the diagnosis and treatment of HAP and VAP.
Guideline updates
In 2016, the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) reconvened after 11 years to update their recommendations for the treatment of HAP and VAP.2 The decision to update their recommendations was based on the availability of new evidence regarding the diagnosis and treatment of these conditions.
Included in this review are guideline updates on methods for diagnosis, initial antibiotic choice, pathogen-specific therapy, and duration of therapy. The guidelines also have recommendations for the role of inhaled antibiotics and pharmacokinetic optimization of antibiotic dosing, which will not be reviewed here.
Methods for Diagnosis: The use of semi-quantitative, noninvasive sampling of respiratory cultures is preferred for HAP and VAP, rather than empiric treatment or quantitative cultures (i.e., bronchoalveolar lavage, protected-specimen brush and blind bronchial sampling).
Initial antibiotic choice: For HAP and VAP, clinicians should include therapy targeting S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli. Therapy for methicillin-resistant S. aureus should be included if patients are at high risk for death (i.e., septic shock or ventilated patients) or if local drug-resistant prevalence is greater than 10%-20%. Similarly, two antipseudomonal antibiotics should be used only with empiric therapy if the patient is at high risk for mortality or local drug-resistant prevalence is greater than 10%.
Duration of therapy: HAP and VAP should be treated for 7 days with regimens that are tailored to culture data when available, assuming there has been appropriate clinical response. Procalcitonin may be paired with clinical judgment when considering antibiotic discontinuation.
Guideline analysis
There are several notable differences between the 2016 IDSA/ATS guidelines and the 2005 guidelines.3 The earlier guidelines recommended strong consideration of invasive respiratory cultures such as bronchoalveolar lavage or protected-specimen brush sampling for HAP/VAP. It is now recommended that only noninvasive cultures be performed in most clinical scenarios.
Last, the updated guidelines recommend dual therapy for potential or documented Pseudomonas infection only for patients at high risk for mortality or in hospitals with a high prevalence of antibiotic resistance; previously, dual antipseudomonal therapy was recommended for all cases of HAP and VAP, based upon the risk of developing resistant strains with monotherapy.3
Since 2005, several organizations have released guidelines addressing the management of HAP and VAP.1,4,5,6 These are largely in keeping with the current version released by the IDSA/ATS. Across all guidelines, there is a focus on the importance of local antibiograms for appropriate and effective treatment, and the use of noninvasive culture data to guide therapy. Also, all groups recommend a short-course (7-8 days) of antibiotics for both HAP and VAP, assuming there has been an appropriate clinical response. The recent Canadian guidelines have one unique recommendation, which is to avoid the use of ceftazidime for suspected Pseudomonas pneumonia, based upon inferior outcomes when compared to alternative regimens.5
Takeaways
When considering the diagnosis of HAP and VAP, clinicians should be aware that the category of HCAP has been removed from current guidelines, and methods for microbiological diagnosis have been simplified.7 In addition, initial antibiotic selection should rely on institution-specific antibiograms and local resistance patterns when available. Recommended duration of therapy has been shortened, and should not include aminoglycosides.
Finally, antibiotic stewardship is the responsibility of each clinician and de-escalation of therapy for HAP and VAP should be guided by available respiratory cultures.
Dr. Hippensteel is a pulmonologist in Aurora, Colo. Dr. Sippel is visiting associate professor of clinical practice, medicine-pulmonary sciences & critical care at the University of Colorado School of Medicine.
References
1. Masterton R, Galloway A, French G, Street M, Armstrong J, Brown E, Cleverley J, Dilworth P, Fry C, Gascoigne A. Guidelines for the management of hospital-acquired pneumonia in the UK: report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother. 2008;62(1):5-34.
2. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O’grady NP, Bartlett JG, Carratalà J. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016:ciw353.
3. Society AT, America IDSo. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416.
4. Dalhoff K, Abele-Horn M, Andreas S, Bauer T, von Baum H, Deja M, Ewig S, Gastmeier P, Gatermann S, Gerlach H. Epidemiology, diagnosis, and treatment of adult patients with nosocomial pneumonia. S-3 Guideline of the German Society for Anaesthesiology and Intensive Care Medicine, the German Society for Infectious Diseases, the German Society for Hygiene and Microbiology, the German Respiratory Society and the Paul-Ehrlich-Society for Chemotherapy. Pneumologie (Stuttgart, Germany). 2012;66(12):707-65.
5. Rotstein C, Evans G, Born A, Grossman R, Light RB, Magder S, McTaggart B, Weiss K, Zhanel GG. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Canadian Journal of Infectious Diseases and Medical Microbiology. 2008;19(1):19-53.
6. Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Dubberke ER, Fraser V. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(S1):S31-S40.
7. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing healthcare-associated pneumonia, 2003. MMWR. 2004;53(RR-3):1-36.
Background
Hospital-acquired pneumonia (HAP) is defined as pneumonia that develops 48 hours or more after admission that was not present on admission; and ventilator-associated pneumonia (VAP) is pneumonia that develops 48 hours or more after endotracheal intubation.
HAP and VAP are common afflictions in hospitalized patients, accounting for nearly one-quarter of all hospital-acquired infections. They confer mortality rates of 24%-50%, increasing to nearly 75% if caused by resistant organisms.1,2 Given the high prevalence and significant mortality associated with these types of pneumonia, diagnosis and treatment are essential. Treatment must be balanced against potential unintended consequences of antibiotic use including Clostridium difficile infections and the promotion of resistant bacteria caused by poor antibiotic stewardship.
Given the frequency with which HAP and VAP occur, and the need for equipoise with antibiotic use, it is essential that all practicing clinicians have an evidence-based construct for the diagnosis and treatment of HAP and VAP.
Guideline updates
In 2016, the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) reconvened after 11 years to update their recommendations for the treatment of HAP and VAP.2 The decision to update their recommendations was based on the availability of new evidence regarding the diagnosis and treatment of these conditions.
Included in this review are guideline updates on methods for diagnosis, initial antibiotic choice, pathogen-specific therapy, and duration of therapy. The guidelines also have recommendations for the role of inhaled antibiotics and pharmacokinetic optimization of antibiotic dosing, which will not be reviewed here.
Methods for Diagnosis: The use of semi-quantitative, noninvasive sampling of respiratory cultures is preferred for HAP and VAP, rather than empiric treatment or quantitative cultures (i.e., bronchoalveolar lavage, protected-specimen brush and blind bronchial sampling).
Initial antibiotic choice: For HAP and VAP, clinicians should include therapy targeting S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli. Therapy for methicillin-resistant S. aureus should be included if patients are at high risk for death (i.e., septic shock or ventilated patients) or if local drug-resistant prevalence is greater than 10%-20%. Similarly, two antipseudomonal antibiotics should be used only with empiric therapy if the patient is at high risk for mortality or local drug-resistant prevalence is greater than 10%.
Duration of therapy: HAP and VAP should be treated for 7 days with regimens that are tailored to culture data when available, assuming there has been appropriate clinical response. Procalcitonin may be paired with clinical judgment when considering antibiotic discontinuation.
Guideline analysis
There are several notable differences between the 2016 IDSA/ATS guidelines and the 2005 guidelines.3 The earlier guidelines recommended strong consideration of invasive respiratory cultures such as bronchoalveolar lavage or protected-specimen brush sampling for HAP/VAP. It is now recommended that only noninvasive cultures be performed in most clinical scenarios.
Last, the updated guidelines recommend dual therapy for potential or documented Pseudomonas infection only for patients at high risk for mortality or in hospitals with a high prevalence of antibiotic resistance; previously, dual antipseudomonal therapy was recommended for all cases of HAP and VAP, based upon the risk of developing resistant strains with monotherapy.3
Since 2005, several organizations have released guidelines addressing the management of HAP and VAP.1,4,5,6 These are largely in keeping with the current version released by the IDSA/ATS. Across all guidelines, there is a focus on the importance of local antibiograms for appropriate and effective treatment, and the use of noninvasive culture data to guide therapy. Also, all groups recommend a short-course (7-8 days) of antibiotics for both HAP and VAP, assuming there has been an appropriate clinical response. The recent Canadian guidelines have one unique recommendation, which is to avoid the use of ceftazidime for suspected Pseudomonas pneumonia, based upon inferior outcomes when compared to alternative regimens.5
Takeaways
When considering the diagnosis of HAP and VAP, clinicians should be aware that the category of HCAP has been removed from current guidelines, and methods for microbiological diagnosis have been simplified.7 In addition, initial antibiotic selection should rely on institution-specific antibiograms and local resistance patterns when available. Recommended duration of therapy has been shortened, and should not include aminoglycosides.
Finally, antibiotic stewardship is the responsibility of each clinician and de-escalation of therapy for HAP and VAP should be guided by available respiratory cultures.
Dr. Hippensteel is a pulmonologist in Aurora, Colo. Dr. Sippel is visiting associate professor of clinical practice, medicine-pulmonary sciences & critical care at the University of Colorado School of Medicine.
References
1. Masterton R, Galloway A, French G, Street M, Armstrong J, Brown E, Cleverley J, Dilworth P, Fry C, Gascoigne A. Guidelines for the management of hospital-acquired pneumonia in the UK: report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother. 2008;62(1):5-34.
2. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O’grady NP, Bartlett JG, Carratalà J. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016:ciw353.
3. Society AT, America IDSo. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416.
4. Dalhoff K, Abele-Horn M, Andreas S, Bauer T, von Baum H, Deja M, Ewig S, Gastmeier P, Gatermann S, Gerlach H. Epidemiology, diagnosis, and treatment of adult patients with nosocomial pneumonia. S-3 Guideline of the German Society for Anaesthesiology and Intensive Care Medicine, the German Society for Infectious Diseases, the German Society for Hygiene and Microbiology, the German Respiratory Society and the Paul-Ehrlich-Society for Chemotherapy. Pneumologie (Stuttgart, Germany). 2012;66(12):707-65.
5. Rotstein C, Evans G, Born A, Grossman R, Light RB, Magder S, McTaggart B, Weiss K, Zhanel GG. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Canadian Journal of Infectious Diseases and Medical Microbiology. 2008;19(1):19-53.
6. Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Dubberke ER, Fraser V. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(S1):S31-S40.
7. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing healthcare-associated pneumonia, 2003. MMWR. 2004;53(RR-3):1-36.
PVC phlebitis rates varied widely, depending on assessment tool
Rates of phlebitis associated with peripheral venous catheters (PVC) ranged from less than 1% to 34% depending on which assessment tool researchers used in a large cross-sectional study.
Rates also varied within individual instruments because they included several possible case definitions, Katarina Göransson, PhD, and her associates reported in Lancet Haematology. “We find it concerning that our study shows variation of the proportion of PVCs causing phlebitis both within and across the instruments investigated,” they wrote. “How to best measure phlebitis outcomes is still unclear, since no universally accepted instrument exists that has had rigorous testing. From a work environment and patient safety perspective, clinical staff engaged in PVC management should be aware of the absence of adequately validated instruments for phlebitis assessment.”
There are many tools to measure PVC-related phlebitis, but no consensus on which to use, and past studies have reported rates of anywhere from 2% to 62%. Hypothesizing that instrument variability contributed to this discrepancy, the researchers tested 17 instruments in 1,032 patients who had 1,175 PVCs placed at 12 inpatient units in Sweden. Eight tools used clinical definitions, seven used severity rating systems, and two used scoring systems (Lancet Haematol. 2017 doi: 10.1016/S2352-3026[17]30122-9).
Rates of PVC-induced phlebitis reached 12% (137 cases) when the researchers used case definition tools, up to 31% when they used scoring systems (P less than .0001), and up to 34% when they used severity rating systems (P less than .0001, compared with the 12% rate). “The proportion within instruments ranged from less than 1% to 28%,” they added. “We [also] identified face validity issues, such as use of indistinct or complex measurements and inconsistent measurements or definitions.”
The investigators did not perform a systematic review to identify these instruments, and they did not necessarily use the most recent versions, they noted. Nevertheless, the findings have direct implications for hospital quality control measures, which require using a single validated instrument over time to generate meaningful results, they said. Hence, the investigators recommended developing a joint research program to develop reliable measures of PVC-related adverse events and better support clinicians who are trying to decide whether to remove PVCs.
The investigators reported having no funding sources and no competing interests.
Rates of phlebitis associated with peripheral venous catheters (PVC) ranged from less than 1% to 34% depending on which assessment tool researchers used in a large cross-sectional study.
Rates also varied within individual instruments because they included several possible case definitions, Katarina Göransson, PhD, and her associates reported in Lancet Haematology. “We find it concerning that our study shows variation of the proportion of PVCs causing phlebitis both within and across the instruments investigated,” they wrote. “How to best measure phlebitis outcomes is still unclear, since no universally accepted instrument exists that has had rigorous testing. From a work environment and patient safety perspective, clinical staff engaged in PVC management should be aware of the absence of adequately validated instruments for phlebitis assessment.”
There are many tools to measure PVC-related phlebitis, but no consensus on which to use, and past studies have reported rates of anywhere from 2% to 62%. Hypothesizing that instrument variability contributed to this discrepancy, the researchers tested 17 instruments in 1,032 patients who had 1,175 PVCs placed at 12 inpatient units in Sweden. Eight tools used clinical definitions, seven used severity rating systems, and two used scoring systems (Lancet Haematol. 2017 doi: 10.1016/S2352-3026[17]30122-9).
Rates of PVC-induced phlebitis reached 12% (137 cases) when the researchers used case definition tools, up to 31% when they used scoring systems (P less than .0001), and up to 34% when they used severity rating systems (P less than .0001, compared with the 12% rate). “The proportion within instruments ranged from less than 1% to 28%,” they added. “We [also] identified face validity issues, such as use of indistinct or complex measurements and inconsistent measurements or definitions.”
The investigators did not perform a systematic review to identify these instruments, and they did not necessarily use the most recent versions, they noted. Nevertheless, the findings have direct implications for hospital quality control measures, which require using a single validated instrument over time to generate meaningful results, they said. Hence, the investigators recommended developing a joint research program to develop reliable measures of PVC-related adverse events and better support clinicians who are trying to decide whether to remove PVCs.
The investigators reported having no funding sources and no competing interests.
Rates of phlebitis associated with peripheral venous catheters (PVC) ranged from less than 1% to 34% depending on which assessment tool researchers used in a large cross-sectional study.
Rates also varied within individual instruments because they included several possible case definitions, Katarina Göransson, PhD, and her associates reported in Lancet Haematology. “We find it concerning that our study shows variation of the proportion of PVCs causing phlebitis both within and across the instruments investigated,” they wrote. “How to best measure phlebitis outcomes is still unclear, since no universally accepted instrument exists that has had rigorous testing. From a work environment and patient safety perspective, clinical staff engaged in PVC management should be aware of the absence of adequately validated instruments for phlebitis assessment.”
There are many tools to measure PVC-related phlebitis, but no consensus on which to use, and past studies have reported rates of anywhere from 2% to 62%. Hypothesizing that instrument variability contributed to this discrepancy, the researchers tested 17 instruments in 1,032 patients who had 1,175 PVCs placed at 12 inpatient units in Sweden. Eight tools used clinical definitions, seven used severity rating systems, and two used scoring systems (Lancet Haematol. 2017 doi: 10.1016/S2352-3026[17]30122-9).
Rates of PVC-induced phlebitis reached 12% (137 cases) when the researchers used case definition tools, up to 31% when they used scoring systems (P less than .0001), and up to 34% when they used severity rating systems (P less than .0001, compared with the 12% rate). “The proportion within instruments ranged from less than 1% to 28%,” they added. “We [also] identified face validity issues, such as use of indistinct or complex measurements and inconsistent measurements or definitions.”
The investigators did not perform a systematic review to identify these instruments, and they did not necessarily use the most recent versions, they noted. Nevertheless, the findings have direct implications for hospital quality control measures, which require using a single validated instrument over time to generate meaningful results, they said. Hence, the investigators recommended developing a joint research program to develop reliable measures of PVC-related adverse events and better support clinicians who are trying to decide whether to remove PVCs.
The investigators reported having no funding sources and no competing interests.
FROM LANCET HAEMATOLOGY
Key clinical point: Rates of PVC-induced phlebitis varied widely within and between assessment instruments.
Major finding: Rates were as high as 12% (137 cases) based on the case definition tools, up to 31% based on the scoring systems (P less than .0001), and up to 34% based on the severity rating systems (P less than .0001, compared with the case definition rate).
Data source: A cross-sectional study of 17 instruments used to identify phlebitis associated with peripheral venous catheters.
Disclosures: The investigators reported having no funding sources and no competing interests.
Standardized infection ratio for CLABSI almost halved since 2009
The standardized infection ratio (SIR) for central line–associated bloodstream infections dropped 42% from 2009 to 2014, according to the Agency for Healthcare Research and Quality.
For acute care hospitalizations, the SIR for central line–associated bloodstream infections (CLABSIs) fell from 0.854 in 2009 to 0.495 in 2014. Over that same time period, the SIR for surgical site infections involving Surgical Care Improvement Project procedures decreased from 0.981 to 0.827 – almost 16%, the AHRQ said in its annual National Healthcare Quality and Disparities Report.
From 2010 to 2014, the SIR for catheter-associated urinary tract infections increased 6.7% from 0.937 to 1.000, but that change was not significant. For laboratory-identified hospital-onset Clostridium difficile infection, the SIR dropped from 0.963 to 0.924 – about 4% – from 2012 to 2014, the AHRQ reported using data from the National Center for Emerging and Zoonotic Infectious Diseases and the National Healthcare Safety Network.
The standardized infection ratio (SIR) for central line–associated bloodstream infections dropped 42% from 2009 to 2014, according to the Agency for Healthcare Research and Quality.
For acute care hospitalizations, the SIR for central line–associated bloodstream infections (CLABSIs) fell from 0.854 in 2009 to 0.495 in 2014. Over that same time period, the SIR for surgical site infections involving Surgical Care Improvement Project procedures decreased from 0.981 to 0.827 – almost 16%, the AHRQ said in its annual National Healthcare Quality and Disparities Report.
From 2010 to 2014, the SIR for catheter-associated urinary tract infections increased 6.7% from 0.937 to 1.000, but that change was not significant. For laboratory-identified hospital-onset Clostridium difficile infection, the SIR dropped from 0.963 to 0.924 – about 4% – from 2012 to 2014, the AHRQ reported using data from the National Center for Emerging and Zoonotic Infectious Diseases and the National Healthcare Safety Network.
The standardized infection ratio (SIR) for central line–associated bloodstream infections dropped 42% from 2009 to 2014, according to the Agency for Healthcare Research and Quality.
For acute care hospitalizations, the SIR for central line–associated bloodstream infections (CLABSIs) fell from 0.854 in 2009 to 0.495 in 2014. Over that same time period, the SIR for surgical site infections involving Surgical Care Improvement Project procedures decreased from 0.981 to 0.827 – almost 16%, the AHRQ said in its annual National Healthcare Quality and Disparities Report.
From 2010 to 2014, the SIR for catheter-associated urinary tract infections increased 6.7% from 0.937 to 1.000, but that change was not significant. For laboratory-identified hospital-onset Clostridium difficile infection, the SIR dropped from 0.963 to 0.924 – about 4% – from 2012 to 2014, the AHRQ reported using data from the National Center for Emerging and Zoonotic Infectious Diseases and the National Healthcare Safety Network.