Editorial

The past 20 years has seen an explosion of approaches to improve the recognition of children who deteriorate in the hospital. Early Warning Scores, Rapid Response Teams, Situational Awareness, and Parent-Triggered Activation systems are a few of the safety initiatives implemented worldwide. Many have an inherent face validity; for example, it would appear to be intuitive that highlighting the changes in physiology via a Pediatric Early Warning Score (PEWS) would enable staff to recognize a change in disease process and intervene accordingly. However, although mortality trends have been shown to diminish over time,¹ the evidence base supporting their impact has often been quite heterogeneous.^2,3 In particular, a recent international randomized control trial of a PEWS approach was found not to improve overall mortality.⁴

A major challenge with the evaluation of these patient safety systems is the reliance on mortality as an outcome measure. This is relatively rare, even in large tertiary institutions with complex patients and finding other proxy measures of quality of care are important. Hussain et al. have created a relatively easy to measure metric, an emergency transfer (ET). The benefit of the ET is its simplicity and transferability, which is described as follows:

“Emergency Transfer (ET) is defined as any patient transferred to the ICU where the patient received intubation, inotropes, or three or more fluid boluses in the first hour after arrival or before transfer.”⁵

All these components are easily extractable from written or electronic records and are representative of meaningful deterioration. Pressure on bed states, challenges with staff skill mix, and increasing parental expectation may all impact on decisions to transfer patients. The ET metric is relatively immune to these biases as its tight time definition separates it from the previous Bonafide et al.⁶ measure (similar interventions but within a 12-hour window) as being centered on an abrupt critical change, rather than a potential drift toward deterioration. This makes the measure useful not only to an individual institution to measure the impact of an intervention but also internationally, as a comparison between institutions will not be influenced by health system differences.

The ET metric is important as Hussain et al. have demonstrated that it is associated with a worse outcome for the child both as a concrete outcome (increased mortality when it does occur) and as an experience (a longer stay in hospital). “You can’t improve what you can’t measure” is an old improvement maxim, and only by broadening our use of alternative metrics of care will we be able to understand which interventions will make a difference to patients. Certainly, evidence suggests that cultures, hierarchies, and leadership may well be as important as other more concrete or tangible tools,⁷ but these have seldom been evaluated as part of studies on improving the response to deterioration. The pediatric early warning system utilization and mortality avoidance (PUMA) study, a research program funded by the National Institute for Health Research (United Kingdom), is exploring these tools and will likely report later in 2019.⁸

Two immediate practical implications of this work emerge, which should be of relevance to clinical leaders in children’s hospitals. The first is that it is highly likely that there will be some events you cannot anticipate. A bronchiolitic infant is always likely to suddenly plug off, and invasive group A streptococcus is a mastery of mimicry and deceit. The authors noted that even with a mature, long-standing Rapid Response System process, ETs were still associated with adverse outcomes. Therefore, it may well be that the ET metric measured over time delineates a locally defined acceptable level of unplanned intensive care admission. If your hospital is significantly above this, they must seriously look at how they can improve their performance. It should be noted here that there were only 45 ETs identified in 4.5 years in Cincinnati and 50% of these were from specialist units within the hospital. It is possible that perhaps the ETs will in the future become as rare as mortality is today, and as hospitals improve, new frames of reference will be needed.

These new references are likely to come from high-performing child health institutions such as those in Philadelphia and Cincinnati, and this leads to a second important principle that hospitals should acknowledge. One of the reasons for patient safety success is the relentless pursuit of excellence. The very act of consistently, and transparently, auditing and analyzing performance is vital to change outcomes. We should digest, evaluate, adopt, and improve the research that groups such as these are undertaking as, although sometimes imperfect, they should also inspire us to ensure that children in our own institutions are as safe as they possibly can be.

Disclosure

Dr. Roland reports that he is currently the cochief investigator of a National Institute for Health Research (NIHR) grant investigating pediatric early warning systems (the PUMA study)

The past 20 years has seen an explosion of approaches to improve the recognition of children who deteriorate in the hospital. Early Warning Scores, Rapid Response Teams, Situational Awareness, and Parent-Triggered Activation systems are a few of the safety initiatives implemented worldwide. Many have an inherent face validity; for example, it would appear to be intuitive that highlighting the changes in physiology via a Pediatric Early Warning Score (PEWS) would enable staff to recognize a change in disease process and intervene accordingly. However, although mortality trends have been shown to diminish over time,¹ the evidence base supporting their impact has often been quite heterogeneous.^2,3 In particular, a recent international randomized control trial of a PEWS approach was found not to improve overall mortality.⁴

A major challenge with the evaluation of these patient safety systems is the reliance on mortality as an outcome measure. This is relatively rare, even in large tertiary institutions with complex patients and finding other proxy measures of quality of care are important. Hussain et al. have created a relatively easy to measure metric, an emergency transfer (ET). The benefit of the ET is its simplicity and transferability, which is described as follows:

“Emergency Transfer (ET) is defined as any patient transferred to the ICU where the patient received intubation, inotropes, or three or more fluid boluses in the first hour after arrival or before transfer.”⁵

All these components are easily extractable from written or electronic records and are representative of meaningful deterioration. Pressure on bed states, challenges with staff skill mix, and increasing parental expectation may all impact on decisions to transfer patients. The ET metric is relatively immune to these biases as its tight time definition separates it from the previous Bonafide et al.⁶ measure (similar interventions but within a 12-hour window) as being centered on an abrupt critical change, rather than a potential drift toward deterioration. This makes the measure useful not only to an individual institution to measure the impact of an intervention but also internationally, as a comparison between institutions will not be influenced by health system differences.

The ET metric is important as Hussain et al. have demonstrated that it is associated with a worse outcome for the child both as a concrete outcome (increased mortality when it does occur) and as an experience (a longer stay in hospital). “You can’t improve what you can’t measure” is an old improvement maxim, and only by broadening our use of alternative metrics of care will we be able to understand which interventions will make a difference to patients. Certainly, evidence suggests that cultures, hierarchies, and leadership may well be as important as other more concrete or tangible tools,⁷ but these have seldom been evaluated as part of studies on improving the response to deterioration. The pediatric early warning system utilization and mortality avoidance (PUMA) study, a research program funded by the National Institute for Health Research (United Kingdom), is exploring these tools and will likely report later in 2019.⁸

Two immediate practical implications of this work emerge, which should be of relevance to clinical leaders in children’s hospitals. The first is that it is highly likely that there will be some events you cannot anticipate. A bronchiolitic infant is always likely to suddenly plug off, and invasive group A streptococcus is a mastery of mimicry and deceit. The authors noted that even with a mature, long-standing Rapid Response System process, ETs were still associated with adverse outcomes. Therefore, it may well be that the ET metric measured over time delineates a locally defined acceptable level of unplanned intensive care admission. If your hospital is significantly above this, they must seriously look at how they can improve their performance. It should be noted here that there were only 45 ETs identified in 4.5 years in Cincinnati and 50% of these were from specialist units within the hospital. It is possible that perhaps the ETs will in the future become as rare as mortality is today, and as hospitals improve, new frames of reference will be needed.

These new references are likely to come from high-performing child health institutions such as those in Philadelphia and Cincinnati, and this leads to a second important principle that hospitals should acknowledge. One of the reasons for patient safety success is the relentless pursuit of excellence. The very act of consistently, and transparently, auditing and analyzing performance is vital to change outcomes. We should digest, evaluate, adopt, and improve the research that groups such as these are undertaking as, although sometimes imperfect, they should also inspire us to ensure that children in our own institutions are as safe as they possibly can be.

Disclosure

Dr. Roland reports that he is currently the cochief investigator of a National Institute for Health Research (NIHR) grant investigating pediatric early warning systems (the PUMA study)

The past 20 years has seen an explosion of approaches to improve the recognition of children who deteriorate in the hospital. Early Warning Scores, Rapid Response Teams, Situational Awareness, and Parent-Triggered Activation systems are a few of the safety initiatives implemented worldwide. Many have an inherent face validity; for example, it would appear to be intuitive that highlighting the changes in physiology via a Pediatric Early Warning Score (PEWS) would enable staff to recognize a change in disease process and intervene accordingly. However, although mortality trends have been shown to diminish over time,¹ the evidence base supporting their impact has often been quite heterogeneous.^2,3 In particular, a recent international randomized control trial of a PEWS approach was found not to improve overall mortality.⁴

A major challenge with the evaluation of these patient safety systems is the reliance on mortality as an outcome measure. This is relatively rare, even in large tertiary institutions with complex patients and finding other proxy measures of quality of care are important. Hussain et al. have created a relatively easy to measure metric, an emergency transfer (ET). The benefit of the ET is its simplicity and transferability, which is described as follows:

“Emergency Transfer (ET) is defined as any patient transferred to the ICU where the patient received intubation, inotropes, or three or more fluid boluses in the first hour after arrival or before transfer.”⁵

All these components are easily extractable from written or electronic records and are representative of meaningful deterioration. Pressure on bed states, challenges with staff skill mix, and increasing parental expectation may all impact on decisions to transfer patients. The ET metric is relatively immune to these biases as its tight time definition separates it from the previous Bonafide et al.⁶ measure (similar interventions but within a 12-hour window) as being centered on an abrupt critical change, rather than a potential drift toward deterioration. This makes the measure useful not only to an individual institution to measure the impact of an intervention but also internationally, as a comparison between institutions will not be influenced by health system differences.

The ET metric is important as Hussain et al. have demonstrated that it is associated with a worse outcome for the child both as a concrete outcome (increased mortality when it does occur) and as an experience (a longer stay in hospital). “You can’t improve what you can’t measure” is an old improvement maxim, and only by broadening our use of alternative metrics of care will we be able to understand which interventions will make a difference to patients. Certainly, evidence suggests that cultures, hierarchies, and leadership may well be as important as other more concrete or tangible tools,⁷ but these have seldom been evaluated as part of studies on improving the response to deterioration. The pediatric early warning system utilization and mortality avoidance (PUMA) study, a research program funded by the National Institute for Health Research (United Kingdom), is exploring these tools and will likely report later in 2019.⁸

Two immediate practical implications of this work emerge, which should be of relevance to clinical leaders in children’s hospitals. The first is that it is highly likely that there will be some events you cannot anticipate. A bronchiolitic infant is always likely to suddenly plug off, and invasive group A streptococcus is a mastery of mimicry and deceit. The authors noted that even with a mature, long-standing Rapid Response System process, ETs were still associated with adverse outcomes. Therefore, it may well be that the ET metric measured over time delineates a locally defined acceptable level of unplanned intensive care admission. If your hospital is significantly above this, they must seriously look at how they can improve their performance. It should be noted here that there were only 45 ETs identified in 4.5 years in Cincinnati and 50% of these were from specialist units within the hospital. It is possible that perhaps the ETs will in the future become as rare as mortality is today, and as hospitals improve, new frames of reference will be needed.

These new references are likely to come from high-performing child health institutions such as those in Philadelphia and Cincinnati, and this leads to a second important principle that hospitals should acknowledge. One of the reasons for patient safety success is the relentless pursuit of excellence. The very act of consistently, and transparently, auditing and analyzing performance is vital to change outcomes. We should digest, evaluate, adopt, and improve the research that groups such as these are undertaking as, although sometimes imperfect, they should also inspire us to ensure that children in our own institutions are as safe as they possibly can be.

Disclosure

Dr. Roland reports that he is currently the cochief investigator of a National Institute for Health Research (NIHR) grant investigating pediatric early warning systems (the PUMA study)

With advancement in imaging techniques, incidental pulmonary nodules (IPNs) are routinely found on imaging studies. Depending on the size, an IPN has diagnostic uncertainty. Is it a benign finding? Will it progress to cancer? These questions have the potential to create anxiety for our patients. Between 2012 and 2014, 19,739 patients were discharged from hospitals in the United States with a diagnosis of a solitary pulmonary nodule.¹ Roughly 7,500 were discharged after an inpatient stay; the remainder from the emergency room. Aggregate costs for these visits totaled $49 million. The exact number of nodules receiving follow-up is unknown.

The Fleischner guidelines, updated in 2017, outline management for IPNs.² Depending on nodule size and patient risk factors, repeat imaging is either not indicated or one to two follow-up scans could be recommended. In this issue of the Journal of Hospital Medicine^®, two reports assess provider awareness of the Fleischner guidelines and examine the proportion of patients receiving follow-up.

Umscheid et al. surveyed hospitalists to understand their approach IPN management. Of 174 respondents, 42% were unfamiliar with the Fleischner guidelines.3 The authors proposed methods for improving provider awareness, including better communication between hospitalists and primary care providers, better documentation, and in the case of their institution, the development of an IPN consult team. The IPN consult team is composed of a nurse practitioner and pulmonologist. They inform primary care providers of patient findings and need for follow-up. If no follow-up is made, the team will see the patients in an IPN ambulatory clinic to ensure follow-up imaging is obtained.

Kwan et al. found that fewer than 50% of patients with high-risk new pulmonary nodules received follow-up.4 Although a single-site study, the study is consistent with prior work on tests pending at discharge, which essentially show that there are poor follow-up rates.^5,6 Follow-up was more likely when the IPN was mentioned in the discharge summary. This conclusion builds on previous work showing that IPNs are more likely to be included in a discharge summary if the nodule is noted in the report heading, the radiologist recommends further imaging, and the patient is discharged from a medicine service as opposed to a surgical service.7 IPN follow-up is less likely if results are mentioned in the findings section alone.⁵

IPN follow-up is a piece of a larger issue of how best to ensure appropriate follow-up of any tests pending after discharge. A systematic review of discharge interventions found improvement in follow-up when discharge summaries are combined with e-mail alerts.⁶ A study of the effects of integrated electronic health records (EHR) web modules with discharge specific instructions showed an increase in follow-up from 18% to 27%.8 Studies also consider provider-to-patient communication. One intervention uses the patient portal to remind patients to pick up their medications,9 finding a decrease in nonadherence from 65.5% to 22.2%. Engaging patients by way of patient portals and reminders are an effective way to hold both the physician and the patient accountable for follow-up. Mobile technologies studied in the emergency department show patient preferences toward texting to receive medication and appointment reminders.10 Given wide-spread adoption of mobile technologies,11 notification systems could leverage applications or texting modalities to keep patients informed of discharge appointments and follow-up imaging studies. Similar interventions could be designed for IPNs using the Fleischner guidelines, generating alerts when patients have not received follow-up imaging.

The number of IPNs identified in the hospital will likely remain in the tens of thousands. From the hospitalist perspective, the findings presented in this month’s Journal of Hospital Medicine suggest that patients be educated about their findings and recommended follow-up, that follow-up be arranged before discharge, and that findings are clearly documented for patients and primary care providers to review. More study into how to implement these enhancements is needed to guide how we focus educational, systems, and technological interventions. Further study is also needed to help understand the complexities of communication channels between hospitalists and primary care physicians. As hospitalist workflow is more integrated with the EHR and mobile technology, future interventions can facilitate follow-up, keeping all providers and, most importantly, the patient aware of the next steps in care.

Acknowledgments

Author support is provided by the South Texas Veterans Health Care System. The views expressed are those of the authors and do not reflect the position or policy of the Department of Veterans Affairs.

Disclosures

The authors report no financial conflicts of interest.

With advancement in imaging techniques, incidental pulmonary nodules (IPNs) are routinely found on imaging studies. Depending on the size, an IPN has diagnostic uncertainty. Is it a benign finding? Will it progress to cancer? These questions have the potential to create anxiety for our patients. Between 2012 and 2014, 19,739 patients were discharged from hospitals in the United States with a diagnosis of a solitary pulmonary nodule.¹ Roughly 7,500 were discharged after an inpatient stay; the remainder from the emergency room. Aggregate costs for these visits totaled $49 million. The exact number of nodules receiving follow-up is unknown.

The Fleischner guidelines, updated in 2017, outline management for IPNs.² Depending on nodule size and patient risk factors, repeat imaging is either not indicated or one to two follow-up scans could be recommended. In this issue of the Journal of Hospital Medicine^®, two reports assess provider awareness of the Fleischner guidelines and examine the proportion of patients receiving follow-up.

Umscheid et al. surveyed hospitalists to understand their approach IPN management. Of 174 respondents, 42% were unfamiliar with the Fleischner guidelines.3 The authors proposed methods for improving provider awareness, including better communication between hospitalists and primary care providers, better documentation, and in the case of their institution, the development of an IPN consult team. The IPN consult team is composed of a nurse practitioner and pulmonologist. They inform primary care providers of patient findings and need for follow-up. If no follow-up is made, the team will see the patients in an IPN ambulatory clinic to ensure follow-up imaging is obtained.

Kwan et al. found that fewer than 50% of patients with high-risk new pulmonary nodules received follow-up.4 Although a single-site study, the study is consistent with prior work on tests pending at discharge, which essentially show that there are poor follow-up rates.^5,6 Follow-up was more likely when the IPN was mentioned in the discharge summary. This conclusion builds on previous work showing that IPNs are more likely to be included in a discharge summary if the nodule is noted in the report heading, the radiologist recommends further imaging, and the patient is discharged from a medicine service as opposed to a surgical service.7 IPN follow-up is less likely if results are mentioned in the findings section alone.⁵

IPN follow-up is a piece of a larger issue of how best to ensure appropriate follow-up of any tests pending after discharge. A systematic review of discharge interventions found improvement in follow-up when discharge summaries are combined with e-mail alerts.⁶ A study of the effects of integrated electronic health records (EHR) web modules with discharge specific instructions showed an increase in follow-up from 18% to 27%.8 Studies also consider provider-to-patient communication. One intervention uses the patient portal to remind patients to pick up their medications,9 finding a decrease in nonadherence from 65.5% to 22.2%. Engaging patients by way of patient portals and reminders are an effective way to hold both the physician and the patient accountable for follow-up. Mobile technologies studied in the emergency department show patient preferences toward texting to receive medication and appointment reminders.10 Given wide-spread adoption of mobile technologies,11 notification systems could leverage applications or texting modalities to keep patients informed of discharge appointments and follow-up imaging studies. Similar interventions could be designed for IPNs using the Fleischner guidelines, generating alerts when patients have not received follow-up imaging.

The number of IPNs identified in the hospital will likely remain in the tens of thousands. From the hospitalist perspective, the findings presented in this month’s Journal of Hospital Medicine suggest that patients be educated about their findings and recommended follow-up, that follow-up be arranged before discharge, and that findings are clearly documented for patients and primary care providers to review. More study into how to implement these enhancements is needed to guide how we focus educational, systems, and technological interventions. Further study is also needed to help understand the complexities of communication channels between hospitalists and primary care physicians. As hospitalist workflow is more integrated with the EHR and mobile technology, future interventions can facilitate follow-up, keeping all providers and, most importantly, the patient aware of the next steps in care.

Acknowledgments

Author support is provided by the South Texas Veterans Health Care System. The views expressed are those of the authors and do not reflect the position or policy of the Department of Veterans Affairs.

Disclosures

The authors report no financial conflicts of interest.

With advancement in imaging techniques, incidental pulmonary nodules (IPNs) are routinely found on imaging studies. Depending on the size, an IPN has diagnostic uncertainty. Is it a benign finding? Will it progress to cancer? These questions have the potential to create anxiety for our patients. Between 2012 and 2014, 19,739 patients were discharged from hospitals in the United States with a diagnosis of a solitary pulmonary nodule.¹ Roughly 7,500 were discharged after an inpatient stay; the remainder from the emergency room. Aggregate costs for these visits totaled $49 million. The exact number of nodules receiving follow-up is unknown.

The Fleischner guidelines, updated in 2017, outline management for IPNs.² Depending on nodule size and patient risk factors, repeat imaging is either not indicated or one to two follow-up scans could be recommended. In this issue of the Journal of Hospital Medicine^®, two reports assess provider awareness of the Fleischner guidelines and examine the proportion of patients receiving follow-up.

Umscheid et al. surveyed hospitalists to understand their approach IPN management. Of 174 respondents, 42% were unfamiliar with the Fleischner guidelines.3 The authors proposed methods for improving provider awareness, including better communication between hospitalists and primary care providers, better documentation, and in the case of their institution, the development of an IPN consult team. The IPN consult team is composed of a nurse practitioner and pulmonologist. They inform primary care providers of patient findings and need for follow-up. If no follow-up is made, the team will see the patients in an IPN ambulatory clinic to ensure follow-up imaging is obtained.

Kwan et al. found that fewer than 50% of patients with high-risk new pulmonary nodules received follow-up.4 Although a single-site study, the study is consistent with prior work on tests pending at discharge, which essentially show that there are poor follow-up rates.^5,6 Follow-up was more likely when the IPN was mentioned in the discharge summary. This conclusion builds on previous work showing that IPNs are more likely to be included in a discharge summary if the nodule is noted in the report heading, the radiologist recommends further imaging, and the patient is discharged from a medicine service as opposed to a surgical service.7 IPN follow-up is less likely if results are mentioned in the findings section alone.⁵

IPN follow-up is a piece of a larger issue of how best to ensure appropriate follow-up of any tests pending after discharge. A systematic review of discharge interventions found improvement in follow-up when discharge summaries are combined with e-mail alerts.⁶ A study of the effects of integrated electronic health records (EHR) web modules with discharge specific instructions showed an increase in follow-up from 18% to 27%.8 Studies also consider provider-to-patient communication. One intervention uses the patient portal to remind patients to pick up their medications,9 finding a decrease in nonadherence from 65.5% to 22.2%. Engaging patients by way of patient portals and reminders are an effective way to hold both the physician and the patient accountable for follow-up. Mobile technologies studied in the emergency department show patient preferences toward texting to receive medication and appointment reminders.10 Given wide-spread adoption of mobile technologies,11 notification systems could leverage applications or texting modalities to keep patients informed of discharge appointments and follow-up imaging studies. Similar interventions could be designed for IPNs using the Fleischner guidelines, generating alerts when patients have not received follow-up imaging.

The number of IPNs identified in the hospital will likely remain in the tens of thousands. From the hospitalist perspective, the findings presented in this month’s Journal of Hospital Medicine suggest that patients be educated about their findings and recommended follow-up, that follow-up be arranged before discharge, and that findings are clearly documented for patients and primary care providers to review. More study into how to implement these enhancements is needed to guide how we focus educational, systems, and technological interventions. Further study is also needed to help understand the complexities of communication channels between hospitalists and primary care physicians. As hospitalist workflow is more integrated with the EHR and mobile technology, future interventions can facilitate follow-up, keeping all providers and, most importantly, the patient aware of the next steps in care.

Acknowledgments

Author support is provided by the South Texas Veterans Health Care System. The views expressed are those of the authors and do not reflect the position or policy of the Department of Veterans Affairs.

Disclosures

The authors report no financial conflicts of interest.

In this issue of the Journal of Hospital Medicine^®, Drs. Arora and Moriates highlight an important deficiency in quality improvement efforts designed to reduce overuse of tests and treatments: the potential for trainees—and by extension, more seasoned clinicians—to rationalize minimizing under the guise of high-value care.¹ This insightful perspective from the Co-Directors of Costs of Care should serve as a catalyst for further robust and effective care redesign efforts to optimize the use of all medical resources, including tests, treatments, procedures, consultations, emergency department (ED) visits, and hospital admissions. The formula to root out minimizers is not straightforward and requires an evaluation of wasteful practices in a nuanced and holistic manner that considers not only the frequency that the overused test (or treatment) is ordered but also the collateral impact of not ordering it. This principle has implications for measuring, paying for, and studying high-value care.

Overuse of tests and treatments increases costs and carries a risk of harm, from unnecessary use of creatine kinase–myocardial band (CK-MB) in suspected acute coronary syndrome² to unwarranted administration of antibiotics for asymptomatic bacteriuria³ to over-administration of blood transfusions.⁴ However, decreasing the use of a commonly ordered test is not always clinically appropriate. To illustrate this point, we consider the evidence-based algorithm to deliver best practice in the work-up of pulmonary embolism (PE) by Raja et al; which integrates pretest probability, PERC assessment, and appropriate use of D-dimer and pulmonary CT angiography (CTA).⁵ Avoiding D-dimer testing is appropriate in patients with very low pretest probability who pass a pulmonary embolism rule-out criteria (PERC) clinical assessment and is also appropriate in patients who have sufficiently high clinical probability for PE to justify CTA regardless of a D-dimer result. On the other hand, avoiding D-dimer testing by attributing a patient’s symptoms to anxiety (as a minimizer might do) would increase patient risk, and could potentially increase cost if that patient ends up in intensive care after delayed diagnosis. Following diagnostic algorithms that include physician decision-making and evidence-based guidelines can prevent overuse and underuse, thereby maximizing efficiency and effectiveness. Engaging trainees in the development of such algorithms and decision support tools will serve to ingrain these principles into their practice.

Arora and Moriates highlight the importance of caring for a patient along a continuum rather than simply optimizing practice with respect to a single management decision or an isolated care episode. This approach is fundamental to the quality of care we provide, the public trust our profession still commands, and the total cost of care (TCOC). The two largest contributors to debilitating patient healthcare debt are not overuse of tests and treatments, but ED visits and hospitalizations.⁶ Thus, high-value quality improvement needs to anticipate future healthcare needs, including those that may result from delayed or missed diagnoses. Furthermore, excessive focus on the minutiae of high-value care (fewer daily basic metabolic panels) can lead to change fatigue and divert attention from higher impact utilization. We endorse a holistic approach in which the lens is shifted from the test—and even from the encounter or episode of care—to the entire continuum of care so that we can safeguard against inappropriate minimization. This approach has started to gain traction with policymakers. For example, the state of Maryland has implemented a TCOC hospital payment model predicted to save $1 billion by 2023.⁷ The TCOC model includes a Care Redesign Program whereby hospitals and nonhospital healthcare providers collaborate to improve the quality of care while reducing spending, and cost savings can be used for incentive payments to the nonhospital providers (gainsharing) while simultaneously monitoring quality measures to guard against rationing.⁷ In keeping with the authors’ call to prioritize overall health, this new reimbursement model and others similar to it aim to incentivize the delivery of high-value care across a continuum.

Research is needed to guide best practice from this global perspective; as such, value improvement projects aimed at optimizing use of tests and treatments should include rigorous methodology, measures of downstream outcomes and costs, and balancing safety measures.⁸ For example, the ROMICAT II randomized trial evaluated two diagnostic approaches in emergency department patients with suspected acute coronary syndrome: early coronary computed tomography angiogram (CCTA) and standard ED evaluation.⁹ In addition to outcomes related to the ED visit itself, downstream testing and outcomes for 28 days after the episode were studied. In the acute setting, CCTA decreased time to diagnosis, reduced mean hospital length of stay by 7.6 hours, and resulted in 47% of patients being discharged within 8.6 hours as opposed to only 12% of the standard evaluation cohort. No cases of ACS were missed, and the CCTA cohort has slightly fewer cardiovascular adverse events (P = .18). However, the CCTA patients received significantly more diagnostic and functional testing and higher radiation exposure than the standard evaluation cohort, and underwent modestly higher rates of coronary angiography and percutaneous coronary intervention. The TCOC over the 28-day period was similar at $4,289 for CCTA versus $4,060 for standard care (P = .65).⁹

Reducing the TCOC is imperative to protect patients from the burden of healthcare debt, but concerns have been raised about the ethics of high-value care if decision-making is driven by cost considerations.¹⁰ A recent viewpoint proposed a framework where high-value care recommendations are categorized as obligatory (protecting patients from harm), permissible (call for shared decision-making), or suspect (entirely cost-driven). By reframing care redesign as thoughtful, responsible care delivery, we can better incentivize physicians to exercise professionalism and maintain medical practice as a public trust.

High-value champions have a great deal of work ahead to redesign care to improve health, reduce TCOC, and investigate outcomes of care redesign. We applaud Drs. Arora and Moriates for once again leading the charge in preparing medical students and residents to deliver higher-value healthcare by emphasizing that effective patient care is not measured by a single episode or clinical decision, but is defined through a lifelong partnership between the patient and the healthcare system. As the country moves toward improved holistic models of care and financing, physician leadership in care redesign is essential to ensure that quality, safety, and patient well-being are not sacrificed at the altar of cost savings.

Disclosures

Dr. Johnson is a Consultant and Advisory Board Member at Oliver Wyman, receives salary support from an AHRQ grant, and has pending potential royalties from licensure of evidence-based appropriate use guidelines/criteria to AgilMD (Agile is a clinical decision support company). The other authors have no relevant disclosures. Dr. Johnson and Dr. Pahwa are Co-directors, High Value Practice Academic Alliance, www.hvpaa.org

In this issue of the Journal of Hospital Medicine^®, Drs. Arora and Moriates highlight an important deficiency in quality improvement efforts designed to reduce overuse of tests and treatments: the potential for trainees—and by extension, more seasoned clinicians—to rationalize minimizing under the guise of high-value care.¹ This insightful perspective from the Co-Directors of Costs of Care should serve as a catalyst for further robust and effective care redesign efforts to optimize the use of all medical resources, including tests, treatments, procedures, consultations, emergency department (ED) visits, and hospital admissions. The formula to root out minimizers is not straightforward and requires an evaluation of wasteful practices in a nuanced and holistic manner that considers not only the frequency that the overused test (or treatment) is ordered but also the collateral impact of not ordering it. This principle has implications for measuring, paying for, and studying high-value care.

Overuse of tests and treatments increases costs and carries a risk of harm, from unnecessary use of creatine kinase–myocardial band (CK-MB) in suspected acute coronary syndrome² to unwarranted administration of antibiotics for asymptomatic bacteriuria³ to over-administration of blood transfusions.⁴ However, decreasing the use of a commonly ordered test is not always clinically appropriate. To illustrate this point, we consider the evidence-based algorithm to deliver best practice in the work-up of pulmonary embolism (PE) by Raja et al; which integrates pretest probability, PERC assessment, and appropriate use of D-dimer and pulmonary CT angiography (CTA).⁵ Avoiding D-dimer testing is appropriate in patients with very low pretest probability who pass a pulmonary embolism rule-out criteria (PERC) clinical assessment and is also appropriate in patients who have sufficiently high clinical probability for PE to justify CTA regardless of a D-dimer result. On the other hand, avoiding D-dimer testing by attributing a patient’s symptoms to anxiety (as a minimizer might do) would increase patient risk, and could potentially increase cost if that patient ends up in intensive care after delayed diagnosis. Following diagnostic algorithms that include physician decision-making and evidence-based guidelines can prevent overuse and underuse, thereby maximizing efficiency and effectiveness. Engaging trainees in the development of such algorithms and decision support tools will serve to ingrain these principles into their practice.

Arora and Moriates highlight the importance of caring for a patient along a continuum rather than simply optimizing practice with respect to a single management decision or an isolated care episode. This approach is fundamental to the quality of care we provide, the public trust our profession still commands, and the total cost of care (TCOC). The two largest contributors to debilitating patient healthcare debt are not overuse of tests and treatments, but ED visits and hospitalizations.⁶ Thus, high-value quality improvement needs to anticipate future healthcare needs, including those that may result from delayed or missed diagnoses. Furthermore, excessive focus on the minutiae of high-value care (fewer daily basic metabolic panels) can lead to change fatigue and divert attention from higher impact utilization. We endorse a holistic approach in which the lens is shifted from the test—and even from the encounter or episode of care—to the entire continuum of care so that we can safeguard against inappropriate minimization. This approach has started to gain traction with policymakers. For example, the state of Maryland has implemented a TCOC hospital payment model predicted to save $1 billion by 2023.⁷ The TCOC model includes a Care Redesign Program whereby hospitals and nonhospital healthcare providers collaborate to improve the quality of care while reducing spending, and cost savings can be used for incentive payments to the nonhospital providers (gainsharing) while simultaneously monitoring quality measures to guard against rationing.⁷ In keeping with the authors’ call to prioritize overall health, this new reimbursement model and others similar to it aim to incentivize the delivery of high-value care across a continuum.

Research is needed to guide best practice from this global perspective; as such, value improvement projects aimed at optimizing use of tests and treatments should include rigorous methodology, measures of downstream outcomes and costs, and balancing safety measures.⁸ For example, the ROMICAT II randomized trial evaluated two diagnostic approaches in emergency department patients with suspected acute coronary syndrome: early coronary computed tomography angiogram (CCTA) and standard ED evaluation.⁹ In addition to outcomes related to the ED visit itself, downstream testing and outcomes for 28 days after the episode were studied. In the acute setting, CCTA decreased time to diagnosis, reduced mean hospital length of stay by 7.6 hours, and resulted in 47% of patients being discharged within 8.6 hours as opposed to only 12% of the standard evaluation cohort. No cases of ACS were missed, and the CCTA cohort has slightly fewer cardiovascular adverse events (P = .18). However, the CCTA patients received significantly more diagnostic and functional testing and higher radiation exposure than the standard evaluation cohort, and underwent modestly higher rates of coronary angiography and percutaneous coronary intervention. The TCOC over the 28-day period was similar at $4,289 for CCTA versus $4,060 for standard care (P = .65).⁹

Reducing the TCOC is imperative to protect patients from the burden of healthcare debt, but concerns have been raised about the ethics of high-value care if decision-making is driven by cost considerations.¹⁰ A recent viewpoint proposed a framework where high-value care recommendations are categorized as obligatory (protecting patients from harm), permissible (call for shared decision-making), or suspect (entirely cost-driven). By reframing care redesign as thoughtful, responsible care delivery, we can better incentivize physicians to exercise professionalism and maintain medical practice as a public trust.

High-value champions have a great deal of work ahead to redesign care to improve health, reduce TCOC, and investigate outcomes of care redesign. We applaud Drs. Arora and Moriates for once again leading the charge in preparing medical students and residents to deliver higher-value healthcare by emphasizing that effective patient care is not measured by a single episode or clinical decision, but is defined through a lifelong partnership between the patient and the healthcare system. As the country moves toward improved holistic models of care and financing, physician leadership in care redesign is essential to ensure that quality, safety, and patient well-being are not sacrificed at the altar of cost savings.

Disclosures

Dr. Johnson is a Consultant and Advisory Board Member at Oliver Wyman, receives salary support from an AHRQ grant, and has pending potential royalties from licensure of evidence-based appropriate use guidelines/criteria to AgilMD (Agile is a clinical decision support company). The other authors have no relevant disclosures. Dr. Johnson and Dr. Pahwa are Co-directors, High Value Practice Academic Alliance, www.hvpaa.org

In this issue of the Journal of Hospital Medicine^®, Drs. Arora and Moriates highlight an important deficiency in quality improvement efforts designed to reduce overuse of tests and treatments: the potential for trainees—and by extension, more seasoned clinicians—to rationalize minimizing under the guise of high-value care.¹ This insightful perspective from the Co-Directors of Costs of Care should serve as a catalyst for further robust and effective care redesign efforts to optimize the use of all medical resources, including tests, treatments, procedures, consultations, emergency department (ED) visits, and hospital admissions. The formula to root out minimizers is not straightforward and requires an evaluation of wasteful practices in a nuanced and holistic manner that considers not only the frequency that the overused test (or treatment) is ordered but also the collateral impact of not ordering it. This principle has implications for measuring, paying for, and studying high-value care.

Overuse of tests and treatments increases costs and carries a risk of harm, from unnecessary use of creatine kinase–myocardial band (CK-MB) in suspected acute coronary syndrome² to unwarranted administration of antibiotics for asymptomatic bacteriuria³ to over-administration of blood transfusions.⁴ However, decreasing the use of a commonly ordered test is not always clinically appropriate. To illustrate this point, we consider the evidence-based algorithm to deliver best practice in the work-up of pulmonary embolism (PE) by Raja et al; which integrates pretest probability, PERC assessment, and appropriate use of D-dimer and pulmonary CT angiography (CTA).⁵ Avoiding D-dimer testing is appropriate in patients with very low pretest probability who pass a pulmonary embolism rule-out criteria (PERC) clinical assessment and is also appropriate in patients who have sufficiently high clinical probability for PE to justify CTA regardless of a D-dimer result. On the other hand, avoiding D-dimer testing by attributing a patient’s symptoms to anxiety (as a minimizer might do) would increase patient risk, and could potentially increase cost if that patient ends up in intensive care after delayed diagnosis. Following diagnostic algorithms that include physician decision-making and evidence-based guidelines can prevent overuse and underuse, thereby maximizing efficiency and effectiveness. Engaging trainees in the development of such algorithms and decision support tools will serve to ingrain these principles into their practice.

Arora and Moriates highlight the importance of caring for a patient along a continuum rather than simply optimizing practice with respect to a single management decision or an isolated care episode. This approach is fundamental to the quality of care we provide, the public trust our profession still commands, and the total cost of care (TCOC). The two largest contributors to debilitating patient healthcare debt are not overuse of tests and treatments, but ED visits and hospitalizations.⁶ Thus, high-value quality improvement needs to anticipate future healthcare needs, including those that may result from delayed or missed diagnoses. Furthermore, excessive focus on the minutiae of high-value care (fewer daily basic metabolic panels) can lead to change fatigue and divert attention from higher impact utilization. We endorse a holistic approach in which the lens is shifted from the test—and even from the encounter or episode of care—to the entire continuum of care so that we can safeguard against inappropriate minimization. This approach has started to gain traction with policymakers. For example, the state of Maryland has implemented a TCOC hospital payment model predicted to save $1 billion by 2023.⁷ The TCOC model includes a Care Redesign Program whereby hospitals and nonhospital healthcare providers collaborate to improve the quality of care while reducing spending, and cost savings can be used for incentive payments to the nonhospital providers (gainsharing) while simultaneously monitoring quality measures to guard against rationing.⁷ In keeping with the authors’ call to prioritize overall health, this new reimbursement model and others similar to it aim to incentivize the delivery of high-value care across a continuum.

Research is needed to guide best practice from this global perspective; as such, value improvement projects aimed at optimizing use of tests and treatments should include rigorous methodology, measures of downstream outcomes and costs, and balancing safety measures.⁸ For example, the ROMICAT II randomized trial evaluated two diagnostic approaches in emergency department patients with suspected acute coronary syndrome: early coronary computed tomography angiogram (CCTA) and standard ED evaluation.⁹ In addition to outcomes related to the ED visit itself, downstream testing and outcomes for 28 days after the episode were studied. In the acute setting, CCTA decreased time to diagnosis, reduced mean hospital length of stay by 7.6 hours, and resulted in 47% of patients being discharged within 8.6 hours as opposed to only 12% of the standard evaluation cohort. No cases of ACS were missed, and the CCTA cohort has slightly fewer cardiovascular adverse events (P = .18). However, the CCTA patients received significantly more diagnostic and functional testing and higher radiation exposure than the standard evaluation cohort, and underwent modestly higher rates of coronary angiography and percutaneous coronary intervention. The TCOC over the 28-day period was similar at $4,289 for CCTA versus $4,060 for standard care (P = .65).⁹

Reducing the TCOC is imperative to protect patients from the burden of healthcare debt, but concerns have been raised about the ethics of high-value care if decision-making is driven by cost considerations.¹⁰ A recent viewpoint proposed a framework where high-value care recommendations are categorized as obligatory (protecting patients from harm), permissible (call for shared decision-making), or suspect (entirely cost-driven). By reframing care redesign as thoughtful, responsible care delivery, we can better incentivize physicians to exercise professionalism and maintain medical practice as a public trust.

High-value champions have a great deal of work ahead to redesign care to improve health, reduce TCOC, and investigate outcomes of care redesign. We applaud Drs. Arora and Moriates for once again leading the charge in preparing medical students and residents to deliver higher-value healthcare by emphasizing that effective patient care is not measured by a single episode or clinical decision, but is defined through a lifelong partnership between the patient and the healthcare system. As the country moves toward improved holistic models of care and financing, physician leadership in care redesign is essential to ensure that quality, safety, and patient well-being are not sacrificed at the altar of cost savings.

Disclosures

Dr. Johnson is a Consultant and Advisory Board Member at Oliver Wyman, receives salary support from an AHRQ grant, and has pending potential royalties from licensure of evidence-based appropriate use guidelines/criteria to AgilMD (Agile is a clinical decision support company). The other authors have no relevant disclosures. Dr. Johnson and Dr. Pahwa are Co-directors, High Value Practice Academic Alliance, www.hvpaa.org

Graduate medical education (GME) is heavily reliant on experiential learning. Most of a resident’s time is spent in progressively independent delivery of patient care, which is associated with decreasing supervision. Attainment and demonstration of competence in patient care is the goal and responsibility of GME training programs. What happens, then, if the medicine resident never has the experience necessary to enable experiential learning? What if she never “sees one,” let alone “does one”?

In this month’s Journal of Hospital Medicine, Sclafani et al¹ examine how exposure to urgent clinical situations impacts residents’ confidence in managing these ward emergencies. They astutely reveal the idiosyncratic nature of residency training and consequent gaps created when an educational delivery model predicated on experience lacks certain experiences. How can a resident without certain key experiences be ready for independent practice?

The ACGME’s Next Accreditation System is intended to ensure that residents are prepared for independent practice. The educational outcomes that learners must attain are comprised of six core competencies, with milestones intended to operationalize the measurement and reporting of learner progression toward competence.^2,3 It is challenging to apply general competencies to assessment of day to day clinical activities. This challenge led to the development of 16 Entrustable Professional Activities (EPAs). These allow the direct observation of concrete clinical activities that could then infer the attainment (or not) of multiple competencies. Ideally, EPAs are paired with and mapped to curricular milestones which describe a learner’s trajectory within the framework of competencies and determine if a resident is prepared for independent practice.^4,5

In Sclafani et al.¹ the authors characterize resident exposure to, and confidence in, 50 urgent clinical situations. Both level of training and exposure were associated with increased confidence. However, the most important finding of this paper is the wide variation of resident exposures and confidence with respect to specific urgent clinical events. At least 15% of graduating residents had never seen 16% of the 50 emergency events, and a majority of graduating residents did not feel confident managing 20% of the 50 events, highlighting the idiosyncratic nature of GME training.¹ Of course, while certain entities on the list of clinical emergencies were not identified as final diagnoses, it is possible they were still considered in the process of caring for patients in different situations.

Several factors account for the idiosyncratic nature of medical training, including the rarity of certain clinical events, seasonal variation in conditions, and other variables (ie, learner elective choices). In addition, the scheduling of most residency programs is based on patient care needs instead of individual trainees’ educational needs. Other areas of medicine have attempted to standardize experience and ensure specific exposure and/or competence using strategies such as surgical case logs and case-based certifying examinations. There are very important recently described projects in undergraduate medical education aimed at using longitudinal assessment of EPAs in multiple contexts to make entrustment decisions.⁶ However, Internal Medicine residencies do not routinely employ these strategies.

It must be noted that Sclafani et al. surveyed residents from only one site, and examined only self-reported exposure and confidence, not competence. The relationship between confidence and competence is notoriously problematic⁷ and there is a risk of familiarity creating an illusion of knowledge and/or competence. Ultimately, a competency-based medical system is intended to be dynamic, adaptive, and contextual. Despite the extensive competency-based framework in place to track the development of physicians, data about the contexts in which competency is demonstrated are lacking. There is no reason to think that the key gaps identified in Sclafani et al are unique to their institution.

Given the ultimate goal of developing curricula that prepare residents for independent practice coupled with robust systems of assessment that ensure they are ready to do so, educators must implement strategies to identify and alleviate the idiosyncrasy of the resident experience. The survey tool in the present work could be used as a needs assessment and would require minimal resources, but is limited by recall bias, illusion of knowledge, and lack of data regarding actual competence. Other potential strategies include case logs or e-folios, although these tools are also limited by the understanding that familiarity and exposure do not necessarily engender competence.

One potential strategy suggested by Warm et al. is the addition of the “Observable Practice Activities” (OPA), “a collection of learning objectives/activities that must be observed in daily practice in order to form entrustment decisions.”⁸ The intention is to more granularly define what residents actually do and then map these activities to the established competency-based framework. Using these observable activities as an assessment unit may allow for identification of individual experience gaps, thereby improving the dynamicity and adaptiveness of GME training. Certainly, there are very real concerns about further complicating an already complex and abstract system and using a reductionist approach to define the activities of a profession. However, the findings of Sclafani et al with respect to the wide range of resident experience elucidates the need for continued study and innovation regarding the manner in which the medical education community determines our trainees are prepared for independent practice.

Disclosures

The authors have nothing to disclose.

Graduate medical education (GME) is heavily reliant on experiential learning. Most of a resident’s time is spent in progressively independent delivery of patient care, which is associated with decreasing supervision. Attainment and demonstration of competence in patient care is the goal and responsibility of GME training programs. What happens, then, if the medicine resident never has the experience necessary to enable experiential learning? What if she never “sees one,” let alone “does one”?

In this month’s Journal of Hospital Medicine, Sclafani et al¹ examine how exposure to urgent clinical situations impacts residents’ confidence in managing these ward emergencies. They astutely reveal the idiosyncratic nature of residency training and consequent gaps created when an educational delivery model predicated on experience lacks certain experiences. How can a resident without certain key experiences be ready for independent practice?

The ACGME’s Next Accreditation System is intended to ensure that residents are prepared for independent practice. The educational outcomes that learners must attain are comprised of six core competencies, with milestones intended to operationalize the measurement and reporting of learner progression toward competence.^2,3 It is challenging to apply general competencies to assessment of day to day clinical activities. This challenge led to the development of 16 Entrustable Professional Activities (EPAs). These allow the direct observation of concrete clinical activities that could then infer the attainment (or not) of multiple competencies. Ideally, EPAs are paired with and mapped to curricular milestones which describe a learner’s trajectory within the framework of competencies and determine if a resident is prepared for independent practice.^4,5

In Sclafani et al.¹ the authors characterize resident exposure to, and confidence in, 50 urgent clinical situations. Both level of training and exposure were associated with increased confidence. However, the most important finding of this paper is the wide variation of resident exposures and confidence with respect to specific urgent clinical events. At least 15% of graduating residents had never seen 16% of the 50 emergency events, and a majority of graduating residents did not feel confident managing 20% of the 50 events, highlighting the idiosyncratic nature of GME training.¹ Of course, while certain entities on the list of clinical emergencies were not identified as final diagnoses, it is possible they were still considered in the process of caring for patients in different situations.

Several factors account for the idiosyncratic nature of medical training, including the rarity of certain clinical events, seasonal variation in conditions, and other variables (ie, learner elective choices). In addition, the scheduling of most residency programs is based on patient care needs instead of individual trainees’ educational needs. Other areas of medicine have attempted to standardize experience and ensure specific exposure and/or competence using strategies such as surgical case logs and case-based certifying examinations. There are very important recently described projects in undergraduate medical education aimed at using longitudinal assessment of EPAs in multiple contexts to make entrustment decisions.⁶ However, Internal Medicine residencies do not routinely employ these strategies.

It must be noted that Sclafani et al. surveyed residents from only one site, and examined only self-reported exposure and confidence, not competence. The relationship between confidence and competence is notoriously problematic⁷ and there is a risk of familiarity creating an illusion of knowledge and/or competence. Ultimately, a competency-based medical system is intended to be dynamic, adaptive, and contextual. Despite the extensive competency-based framework in place to track the development of physicians, data about the contexts in which competency is demonstrated are lacking. There is no reason to think that the key gaps identified in Sclafani et al are unique to their institution.

Given the ultimate goal of developing curricula that prepare residents for independent practice coupled with robust systems of assessment that ensure they are ready to do so, educators must implement strategies to identify and alleviate the idiosyncrasy of the resident experience. The survey tool in the present work could be used as a needs assessment and would require minimal resources, but is limited by recall bias, illusion of knowledge, and lack of data regarding actual competence. Other potential strategies include case logs or e-folios, although these tools are also limited by the understanding that familiarity and exposure do not necessarily engender competence.

One potential strategy suggested by Warm et al. is the addition of the “Observable Practice Activities” (OPA), “a collection of learning objectives/activities that must be observed in daily practice in order to form entrustment decisions.”⁸ The intention is to more granularly define what residents actually do and then map these activities to the established competency-based framework. Using these observable activities as an assessment unit may allow for identification of individual experience gaps, thereby improving the dynamicity and adaptiveness of GME training. Certainly, there are very real concerns about further complicating an already complex and abstract system and using a reductionist approach to define the activities of a profession. However, the findings of Sclafani et al with respect to the wide range of resident experience elucidates the need for continued study and innovation regarding the manner in which the medical education community determines our trainees are prepared for independent practice.

Disclosures

The authors have nothing to disclose.

Graduate medical education (GME) is heavily reliant on experiential learning. Most of a resident’s time is spent in progressively independent delivery of patient care, which is associated with decreasing supervision. Attainment and demonstration of competence in patient care is the goal and responsibility of GME training programs. What happens, then, if the medicine resident never has the experience necessary to enable experiential learning? What if she never “sees one,” let alone “does one”?

In this month’s Journal of Hospital Medicine, Sclafani et al¹ examine how exposure to urgent clinical situations impacts residents’ confidence in managing these ward emergencies. They astutely reveal the idiosyncratic nature of residency training and consequent gaps created when an educational delivery model predicated on experience lacks certain experiences. How can a resident without certain key experiences be ready for independent practice?

The ACGME’s Next Accreditation System is intended to ensure that residents are prepared for independent practice. The educational outcomes that learners must attain are comprised of six core competencies, with milestones intended to operationalize the measurement and reporting of learner progression toward competence.^2,3 It is challenging to apply general competencies to assessment of day to day clinical activities. This challenge led to the development of 16 Entrustable Professional Activities (EPAs). These allow the direct observation of concrete clinical activities that could then infer the attainment (or not) of multiple competencies. Ideally, EPAs are paired with and mapped to curricular milestones which describe a learner’s trajectory within the framework of competencies and determine if a resident is prepared for independent practice.^4,5

In Sclafani et al.¹ the authors characterize resident exposure to, and confidence in, 50 urgent clinical situations. Both level of training and exposure were associated with increased confidence. However, the most important finding of this paper is the wide variation of resident exposures and confidence with respect to specific urgent clinical events. At least 15% of graduating residents had never seen 16% of the 50 emergency events, and a majority of graduating residents did not feel confident managing 20% of the 50 events, highlighting the idiosyncratic nature of GME training.¹ Of course, while certain entities on the list of clinical emergencies were not identified as final diagnoses, it is possible they were still considered in the process of caring for patients in different situations.

Several factors account for the idiosyncratic nature of medical training, including the rarity of certain clinical events, seasonal variation in conditions, and other variables (ie, learner elective choices). In addition, the scheduling of most residency programs is based on patient care needs instead of individual trainees’ educational needs. Other areas of medicine have attempted to standardize experience and ensure specific exposure and/or competence using strategies such as surgical case logs and case-based certifying examinations. There are very important recently described projects in undergraduate medical education aimed at using longitudinal assessment of EPAs in multiple contexts to make entrustment decisions.⁶ However, Internal Medicine residencies do not routinely employ these strategies.

It must be noted that Sclafani et al. surveyed residents from only one site, and examined only self-reported exposure and confidence, not competence. The relationship between confidence and competence is notoriously problematic⁷ and there is a risk of familiarity creating an illusion of knowledge and/or competence. Ultimately, a competency-based medical system is intended to be dynamic, adaptive, and contextual. Despite the extensive competency-based framework in place to track the development of physicians, data about the contexts in which competency is demonstrated are lacking. There is no reason to think that the key gaps identified in Sclafani et al are unique to their institution.

Given the ultimate goal of developing curricula that prepare residents for independent practice coupled with robust systems of assessment that ensure they are ready to do so, educators must implement strategies to identify and alleviate the idiosyncrasy of the resident experience. The survey tool in the present work could be used as a needs assessment and would require minimal resources, but is limited by recall bias, illusion of knowledge, and lack of data regarding actual competence. Other potential strategies include case logs or e-folios, although these tools are also limited by the understanding that familiarity and exposure do not necessarily engender competence.

One potential strategy suggested by Warm et al. is the addition of the “Observable Practice Activities” (OPA), “a collection of learning objectives/activities that must be observed in daily practice in order to form entrustment decisions.”⁸ The intention is to more granularly define what residents actually do and then map these activities to the established competency-based framework. Using these observable activities as an assessment unit may allow for identification of individual experience gaps, thereby improving the dynamicity and adaptiveness of GME training. Certainly, there are very real concerns about further complicating an already complex and abstract system and using a reductionist approach to define the activities of a profession. However, the findings of Sclafani et al with respect to the wide range of resident experience elucidates the need for continued study and innovation regarding the manner in which the medical education community determines our trainees are prepared for independent practice.

Disclosures

The authors have nothing to disclose.

Lacy and colleagues identify an important “Thing We Do For No Reason”—prealbumin testing to diagnose malnutrition in hospitalized patients.¹ They highlight the frequency and costs of ordering prealbumin tests although prealbumin is neither specific nor sensitive as a “marker of nutritional status,” shows no response to nutritional interventions, and has not been shown to correlate with clinical outcomes. We strongly support their analysis. A core problem in the process of nutrition assessment underlies this meaningless and costly practice. The term “malnutrition” is perfectly ambiguous. In one common usage, the term means that “markers of nutritional status” are abnormal. This usage allows a circular reasoning process where prealbumin is defined as a marker of nutritional status, and people with low prealbumin are then diagnosed as malnourished.

The term is also used to mean a condition where evidence shows better patient outcomes when improved nutrition is provided. Distinguishing between these two meanings is essential, as numerous patients with inflammatory illness will present abnormal “markers” when good evidence shows that they cannot benefit from nutritional support.

For example, a patient with advanced untreated human immunodeficiency virus (HIV) is likely to be considered malnourished because all of her “markers of nutritional status” are abnormal. She barely eats, has lost weight, and has low anthropometric, immunologic, and serologic measures, poor functional status, extreme vulnerability, and very poor prognosis. In this way she resembles a person in a famine situation. However, the patient is not malnourished in the sense that improved nutrient intake will lead to better patient outcomes. A Cochrane review of “nutritional interventions for reducing morbidity and mortality in people with HIV” found “no evidence that such supplementation translates into reductions in disease progression or HIV‐related complications, such as opportunistic infections or death.”² The patient is dying of an inflammatory, cachectic illness. The same is true in managing patients with advanced cancer or several other serious illnesses.

Low prealbumin measures are associated with poor outcomes, which are then attributed to “malnutrition.” However, as Lacy and colleagues argue, prealbumin is a negative acute phase reactant and is thus a marker of the inflammatory effects of sickness/injury; it also responds variably to nutritional support. Citing Koretz, they note that “even when changes in nutritional markers are seen with nutritional support, the ‘changes in nutritional markers do not predict clinical outcomes.’”^1,3 We know of no evidence from randomized controlled trials that prealbumin measurements help identify patients who can benefit from nutrition support.

By contrast, we and our colleagues have shown that in people who barely eat but show no inflammatory disease, eg, prison hunger-strikers and patients with anorexia nervosa, prealbumin level remains normal down to a body mass index below 13. The same is generally true for albumin.⁴ These measures fail to identify “malnutrition” in people who are starving.

Despite the complete lack of clinical trial evidence of benefit, prealbumin is widely used as an indicator of malnutrition. The National Institutes of Health’s Medline Plus website for the general public lists low prealbumin levels as a possible sign of malnutrition, for example, and advises that the prealbumin test may be used to “find out if you are getting enough nutrients, especially protein, in your diet” and to “check to see if you are getting enough nutrition if you are in the hospital.”⁵ Unjustified assertions such as these contribute to the dramatic overuse of nutritional interventions.

However, as a rule, things do occur for a reason. Using the term “prealbumin” conjures a certain relationship, perhaps as a precursor, to albumin, a venerable (but valueless) “marker of nutrition status.” In fact, the term refers only to a difference in electrophoretic mobility (prealbumin migrates faster). If prealbumin were called it by its proper name, transthyretin, it would probably have languished in obscurity among serum proteins until, in recent years, drug suppression of transthyretin synthesis has been shown to benefit patients with hereditary transthyretin amyloidosis.⁶ Using a name that references albumin, this protein has found the limelight as a marker of nutritional status.

The close similarity in appearance between starvation and wasting illness enables the strong, largely evidence-free⁷ emphasis on nutrition support. Many families and individuals suffer when a loved one loses weight. As a prominent reminder of serious illness, this wasted appearance can be painful to bear. Several caregivers may fear that they will be judged as neglectful by outside observers. Other individuals also wish to maintain their body weight for social reasons (as weight loss may be interpreted as a sign of illness, especially HIV). Nutrition maintains a special status in various contexts during the care of sick patients, and the drive to provide food to individuals who appear undernourished seems fundamental in humans.

A third reason for the frivolous, widespread overdiagnosis of “malnutrition” is that it leads directly to favorable consequences for the multibillion-dollar nutritional support industry. A consistent rational approach to the use of nutritional support products for sick people would lead to multibillion-dollar harm for that industry. For now, however, no self-respecting clinician could fail to provide nutritional support to a patient diagnosed as “malnourished” regardless of evidence.

The consistent rational approach in caring for patients is to search for good evidence of benefit before initiating a treatment course. Although sending blood tests for “nutritional markers” to diagnose nutritional needs may be easier and more popular, we caution against such over-simplification. Using prealbumin as a marker for malnutrition could lead to overlooking potentially treatable inflammatory or infectious illness. On the other hand, the use of prealbumin could also lead to unnecessary and potentially dangerous treatments, such as feeding tube placement and/or total parental nutrition. Thus, with one small amendment, we fully support Lacy and colleagues’ conclusion that prealbumin testing to identify malnutrition in hospitalized patients is a “Thing We Do For No (good) Reason.”

Disclosures

Drs. Lee and Finucane declare no financial conflicts of interest. Dr. Finucane discloses that he serves the pharmacy committee of an insurance company.

Lacy and colleagues identify an important “Thing We Do For No Reason”—prealbumin testing to diagnose malnutrition in hospitalized patients.¹ They highlight the frequency and costs of ordering prealbumin tests although prealbumin is neither specific nor sensitive as a “marker of nutritional status,” shows no response to nutritional interventions, and has not been shown to correlate with clinical outcomes. We strongly support their analysis. A core problem in the process of nutrition assessment underlies this meaningless and costly practice. The term “malnutrition” is perfectly ambiguous. In one common usage, the term means that “markers of nutritional status” are abnormal. This usage allows a circular reasoning process where prealbumin is defined as a marker of nutritional status, and people with low prealbumin are then diagnosed as malnourished.

The term is also used to mean a condition where evidence shows better patient outcomes when improved nutrition is provided. Distinguishing between these two meanings is essential, as numerous patients with inflammatory illness will present abnormal “markers” when good evidence shows that they cannot benefit from nutritional support.

For example, a patient with advanced untreated human immunodeficiency virus (HIV) is likely to be considered malnourished because all of her “markers of nutritional status” are abnormal. She barely eats, has lost weight, and has low anthropometric, immunologic, and serologic measures, poor functional status, extreme vulnerability, and very poor prognosis. In this way she resembles a person in a famine situation. However, the patient is not malnourished in the sense that improved nutrient intake will lead to better patient outcomes. A Cochrane review of “nutritional interventions for reducing morbidity and mortality in people with HIV” found “no evidence that such supplementation translates into reductions in disease progression or HIV‐related complications, such as opportunistic infections or death.”² The patient is dying of an inflammatory, cachectic illness. The same is true in managing patients with advanced cancer or several other serious illnesses.

Low prealbumin measures are associated with poor outcomes, which are then attributed to “malnutrition.” However, as Lacy and colleagues argue, prealbumin is a negative acute phase reactant and is thus a marker of the inflammatory effects of sickness/injury; it also responds variably to nutritional support. Citing Koretz, they note that “even when changes in nutritional markers are seen with nutritional support, the ‘changes in nutritional markers do not predict clinical outcomes.’”^1,3 We know of no evidence from randomized controlled trials that prealbumin measurements help identify patients who can benefit from nutrition support.

By contrast, we and our colleagues have shown that in people who barely eat but show no inflammatory disease, eg, prison hunger-strikers and patients with anorexia nervosa, prealbumin level remains normal down to a body mass index below 13. The same is generally true for albumin.⁴ These measures fail to identify “malnutrition” in people who are starving.

Despite the complete lack of clinical trial evidence of benefit, prealbumin is widely used as an indicator of malnutrition. The National Institutes of Health’s Medline Plus website for the general public lists low prealbumin levels as a possible sign of malnutrition, for example, and advises that the prealbumin test may be used to “find out if you are getting enough nutrients, especially protein, in your diet” and to “check to see if you are getting enough nutrition if you are in the hospital.”⁵ Unjustified assertions such as these contribute to the dramatic overuse of nutritional interventions.

However, as a rule, things do occur for a reason. Using the term “prealbumin” conjures a certain relationship, perhaps as a precursor, to albumin, a venerable (but valueless) “marker of nutrition status.” In fact, the term refers only to a difference in electrophoretic mobility (prealbumin migrates faster). If prealbumin were called it by its proper name, transthyretin, it would probably have languished in obscurity among serum proteins until, in recent years, drug suppression of transthyretin synthesis has been shown to benefit patients with hereditary transthyretin amyloidosis.⁶ Using a name that references albumin, this protein has found the limelight as a marker of nutritional status.

The close similarity in appearance between starvation and wasting illness enables the strong, largely evidence-free⁷ emphasis on nutrition support. Many families and individuals suffer when a loved one loses weight. As a prominent reminder of serious illness, this wasted appearance can be painful to bear. Several caregivers may fear that they will be judged as neglectful by outside observers. Other individuals also wish to maintain their body weight for social reasons (as weight loss may be interpreted as a sign of illness, especially HIV). Nutrition maintains a special status in various contexts during the care of sick patients, and the drive to provide food to individuals who appear undernourished seems fundamental in humans.

A third reason for the frivolous, widespread overdiagnosis of “malnutrition” is that it leads directly to favorable consequences for the multibillion-dollar nutritional support industry. A consistent rational approach to the use of nutritional support products for sick people would lead to multibillion-dollar harm for that industry. For now, however, no self-respecting clinician could fail to provide nutritional support to a patient diagnosed as “malnourished” regardless of evidence.

The consistent rational approach in caring for patients is to search for good evidence of benefit before initiating a treatment course. Although sending blood tests for “nutritional markers” to diagnose nutritional needs may be easier and more popular, we caution against such over-simplification. Using prealbumin as a marker for malnutrition could lead to overlooking potentially treatable inflammatory or infectious illness. On the other hand, the use of prealbumin could also lead to unnecessary and potentially dangerous treatments, such as feeding tube placement and/or total parental nutrition. Thus, with one small amendment, we fully support Lacy and colleagues’ conclusion that prealbumin testing to identify malnutrition in hospitalized patients is a “Thing We Do For No (good) Reason.”

Disclosures

Drs. Lee and Finucane declare no financial conflicts of interest. Dr. Finucane discloses that he serves the pharmacy committee of an insurance company.

Lacy and colleagues identify an important “Thing We Do For No Reason”—prealbumin testing to diagnose malnutrition in hospitalized patients.¹ They highlight the frequency and costs of ordering prealbumin tests although prealbumin is neither specific nor sensitive as a “marker of nutritional status,” shows no response to nutritional interventions, and has not been shown to correlate with clinical outcomes. We strongly support their analysis. A core problem in the process of nutrition assessment underlies this meaningless and costly practice. The term “malnutrition” is perfectly ambiguous. In one common usage, the term means that “markers of nutritional status” are abnormal. This usage allows a circular reasoning process where prealbumin is defined as a marker of nutritional status, and people with low prealbumin are then diagnosed as malnourished.

The term is also used to mean a condition where evidence shows better patient outcomes when improved nutrition is provided. Distinguishing between these two meanings is essential, as numerous patients with inflammatory illness will present abnormal “markers” when good evidence shows that they cannot benefit from nutritional support.

For example, a patient with advanced untreated human immunodeficiency virus (HIV) is likely to be considered malnourished because all of her “markers of nutritional status” are abnormal. She barely eats, has lost weight, and has low anthropometric, immunologic, and serologic measures, poor functional status, extreme vulnerability, and very poor prognosis. In this way she resembles a person in a famine situation. However, the patient is not malnourished in the sense that improved nutrient intake will lead to better patient outcomes. A Cochrane review of “nutritional interventions for reducing morbidity and mortality in people with HIV” found “no evidence that such supplementation translates into reductions in disease progression or HIV‐related complications, such as opportunistic infections or death.”² The patient is dying of an inflammatory, cachectic illness. The same is true in managing patients with advanced cancer or several other serious illnesses.

Low prealbumin measures are associated with poor outcomes, which are then attributed to “malnutrition.” However, as Lacy and colleagues argue, prealbumin is a negative acute phase reactant and is thus a marker of the inflammatory effects of sickness/injury; it also responds variably to nutritional support. Citing Koretz, they note that “even when changes in nutritional markers are seen with nutritional support, the ‘changes in nutritional markers do not predict clinical outcomes.’”^1,3 We know of no evidence from randomized controlled trials that prealbumin measurements help identify patients who can benefit from nutrition support.

By contrast, we and our colleagues have shown that in people who barely eat but show no inflammatory disease, eg, prison hunger-strikers and patients with anorexia nervosa, prealbumin level remains normal down to a body mass index below 13. The same is generally true for albumin.⁴ These measures fail to identify “malnutrition” in people who are starving.

Despite the complete lack of clinical trial evidence of benefit, prealbumin is widely used as an indicator of malnutrition. The National Institutes of Health’s Medline Plus website for the general public lists low prealbumin levels as a possible sign of malnutrition, for example, and advises that the prealbumin test may be used to “find out if you are getting enough nutrients, especially protein, in your diet” and to “check to see if you are getting enough nutrition if you are in the hospital.”⁵ Unjustified assertions such as these contribute to the dramatic overuse of nutritional interventions.

However, as a rule, things do occur for a reason. Using the term “prealbumin” conjures a certain relationship, perhaps as a precursor, to albumin, a venerable (but valueless) “marker of nutrition status.” In fact, the term refers only to a difference in electrophoretic mobility (prealbumin migrates faster). If prealbumin were called it by its proper name, transthyretin, it would probably have languished in obscurity among serum proteins until, in recent years, drug suppression of transthyretin synthesis has been shown to benefit patients with hereditary transthyretin amyloidosis.⁶ Using a name that references albumin, this protein has found the limelight as a marker of nutritional status.

The close similarity in appearance between starvation and wasting illness enables the strong, largely evidence-free⁷ emphasis on nutrition support. Many families and individuals suffer when a loved one loses weight. As a prominent reminder of serious illness, this wasted appearance can be painful to bear. Several caregivers may fear that they will be judged as neglectful by outside observers. Other individuals also wish to maintain their body weight for social reasons (as weight loss may be interpreted as a sign of illness, especially HIV). Nutrition maintains a special status in various contexts during the care of sick patients, and the drive to provide food to individuals who appear undernourished seems fundamental in humans.

A third reason for the frivolous, widespread overdiagnosis of “malnutrition” is that it leads directly to favorable consequences for the multibillion-dollar nutritional support industry. A consistent rational approach to the use of nutritional support products for sick people would lead to multibillion-dollar harm for that industry. For now, however, no self-respecting clinician could fail to provide nutritional support to a patient diagnosed as “malnourished” regardless of evidence.

The consistent rational approach in caring for patients is to search for good evidence of benefit before initiating a treatment course. Although sending blood tests for “nutritional markers” to diagnose nutritional needs may be easier and more popular, we caution against such over-simplification. Using prealbumin as a marker for malnutrition could lead to overlooking potentially treatable inflammatory or infectious illness. On the other hand, the use of prealbumin could also lead to unnecessary and potentially dangerous treatments, such as feeding tube placement and/or total parental nutrition. Thus, with one small amendment, we fully support Lacy and colleagues’ conclusion that prealbumin testing to identify malnutrition in hospitalized patients is a “Thing We Do For No (good) Reason.”

Disclosures

Drs. Lee and Finucane declare no financial conflicts of interest. Dr. Finucane discloses that he serves the pharmacy committee of an insurance company.

Contact precautions (CP), the use of gowns and gloves as personal protective equipment when caring for patients who are colonized or infected with one or more multidrug-resistant organisms (MDROs), is an important infection prevention intervention utilized to prevent pathogens from being transmitted among patients in healthcare settings. Recently, certain healthcare facilities have taken steps to limit the use of CP for patients colonized or infected with MDROs that are considered to be endemic, namely methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE). In this issue of the Journal of Hospital Medicine, authors Young et al. argue that CP for MRSA and VRE is an intervention that should be eliminated as part of the Choosing Wisely^® campaign because it is a “thing we do for no reason.”¹ We respectfully disagree with this characterization of CP for MRSA and VRE, and we assert instead that CP are a necessary practice that should be continued.

Young et al. refer to published studies and a recent meta-analysis that did not conclusively show a benefit of CP for MRSA and VRE.² The quasi-experimental studies cited have major methodological flaws that limit their ability to demonstrate the effect of CP. Most importantly, these studies fail to account for the fact that among patients who develop an infection following hospital-acquired MRSA colonization, approximately 70% of the infections are identified after discharge.³ When such studies do not restrict their outcome measure to include only those infections occurring among patients with hospital-acquired colonization, and do not take steps to accurately identify postdischarge infections that occur in such patients, their results are biased toward the null and difficult to interpret. Due to several serious challenges to study feasibility, including the need for an extremely large sample size, a very long period of follow-up, and the need to control for a variety of other concurrent infection prevention measures, there may never be a study that conclusively proves that CP, apart from other infection prevention interventions, has a significant impact. However, despite these limitations, one of the recent multicenter randomized controlled trials, cited by the authors as evidence against the use of CP, was able to demonstrate a significant reduction in MRSA transmission using universal gowns and gloves for all intensive care unit patients, even in sites that utilized other effective strategies, including chlorhexidine bathing.^4,5

In this issue of the Journal of Hospital Medicine^®, Young et al. acknowledge that CP are generally utilized as part of a comprehensive package of infection prevention approaches that also includes hand hygiene, environmental cleaning, antimicrobial stewardship, and evidence-based interventions to prevent device- and procedure-related infections. This multifaceted approach makes it more difficult to determine the attributable effect of CP alone. However, there is a strong rationale for using CP to prevent transmission, and there are numerous examples where the use of bundled approaches that include CP was associated with success. In the Netherlands, CP were part of an aggressive “search and destroy” approach to MRSA associated with almost total elimination of MRSA from hospitals in that country. The United Kingdom achieved an 80% decrease in MRSA bacteremia following a series of aggressive intervention policies designed to prevent MRSA transmission, including use of screening and CP.⁶ In the United States, the Veterans Affairs system utilizes this type of approach and reported a 62% decrease in MRSA rates. Subsequent analysis showed that the downward trend of hospital-onset MRSA infections was observed only among patients who were not carrying MRSA at the time of admission, suggesting that preventing transmission was an important contributor to the overall trends.^7,8 More broadly, healthcare-associated MRSA rates in the United States have decreased dramatically over the past decade,^9,10 a period during which more than 81% of hospitals reported using CP for patients colonized or infected with MRSA as part of the bundle of infection prevention approaches.¹¹ Given these decreases, and the potential role that CP played in achieving these results, we, along with others,¹² urge caution about the dangers of abandoning CP prematurely and without data to indicate that it is safe to stop.

Although some studies report adverse events associated with CP, including a reduced number of visits from healthcare personnel and increased anxiety and depression, these studies rarely control for important confounding variables such as the severity of illness or the presence of anxiety and depression at the time of hospital admission.^13-15 The highest-quality evidence in studies that control for severity of illness and the presence of depression at the time of admission suggests that CP are not associated with an increased incidence of adverse events.^16,17

Interestingly, Young et al. acknowledge that CP are important and should be continued for patients infected or colonized with certain MDROs, including carbapenem-resistant Enterobacteriaceae, multidrug-resistant Pseudomonas aeruginosa, and Candida auris. They even suggest continuing CP for patients with certain types of antimicrobial-resistant Staphylococcus aureus isolates that are resistant or intermediate to vancomycin (Vancomycin-resistant Staphylococcus aureus [VRSA] or Vancomycin-intermediate Staphylococcus aureus [VISA]) and for which transmission has rarely been documented in the United States. It is unclear why they believe that CP are indicated and useful to prevent transmission of these multidrug-resistant pathogens while advocating that CP are not useful or indicated to prevent transmission of MRSA and VRE. One must consider whether it makes sense to use such a selective approach to using CP for patients with some, but not all, MDROs.

The authors state that CP should be employed to help interrupt outbreaks and for patients with high-risk situations such as open wounds, uncontained secretions, or incontinent diarrhea. We agree that there is appeal to a risk-based approach in which CP are applied based on the likelihood that an individual patient may be carrying and shedding an MDRO. However, to our knowledge, there are no validated algorithms available for this purpose, and it appears likely that using such algorithms would result in an increase in the proportion of patients cared for using CP, rather than a decrease.

The use of CP when caring for patients colonized or infected with an MDRO is considered to be a standard of care. Based on experimental, clinical, and epidemiologic studies and a strong theoretical rationale, the use of CP is currently recommended by the United States Centers for Disease Control and Prevention (CDC), the Healthcare Infection Control Practices Advisory Committee (HICPAC),¹⁸ the Society for Healthcare Epidemiology of America (SHEA),¹⁹ and the Infectious Diseases Society of America.²⁰ Many healthcare facilities continue to employ CP for patients with a wide array of MDROs, including MRSA and VRE, and many infection prevention experts continue to support and utilize this approach. In response to the growing movement to discontinue CP, the CDC recently reaffirmed its support and recommendation for the use of CP when caring for patients colonized or infected with MRSA.²¹

In summary, a bundled, multifaceted approach to infection prevention and transmission of MDROs is extremely important, and we caution against stopping CP for MRSA and VRE before data are available on the potential harm of that approach. Study limitations make it difficult to demonstrate the individual contribution of CP, but CP are an important component of a comprehensive infection prevention MDRO bundle that has successfully reduced healthcare-associated MRSA. Well-designed studies that control for confounders such as the severity of illness at the time of admission suggest that CP are not associated with an increased incidence of adverse events. Currently available data do not support a selective approach to utilizing CP for some MDROs while not using CP for others. Current guidelines call for the use of CP for preventing MDRO transmission, including MRSA and VRE. Healthcare facilities need to focus on how to implement CP in a patient-centered manner, rather than abandoning CP for some MDROs.

Disclosures

Dr. Maragakis is a member of the Healthcare Infection Control Practices Advisory Committee for the Centers for Disease Control and Prevention. Dr. Jernigan is an employee of the Centers for Disease Control and Prevention.

Disclaimer

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Contact precautions (CP), the use of gowns and gloves as personal protective equipment when caring for patients who are colonized or infected with one or more multidrug-resistant organisms (MDROs), is an important infection prevention intervention utilized to prevent pathogens from being transmitted among patients in healthcare settings. Recently, certain healthcare facilities have taken steps to limit the use of CP for patients colonized or infected with MDROs that are considered to be endemic, namely methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE). In this issue of the Journal of Hospital Medicine, authors Young et al. argue that CP for MRSA and VRE is an intervention that should be eliminated as part of the Choosing Wisely^® campaign because it is a “thing we do for no reason.”¹ We respectfully disagree with this characterization of CP for MRSA and VRE, and we assert instead that CP are a necessary practice that should be continued.

Young et al. refer to published studies and a recent meta-analysis that did not conclusively show a benefit of CP for MRSA and VRE.² The quasi-experimental studies cited have major methodological flaws that limit their ability to demonstrate the effect of CP. Most importantly, these studies fail to account for the fact that among patients who develop an infection following hospital-acquired MRSA colonization, approximately 70% of the infections are identified after discharge.³ When such studies do not restrict their outcome measure to include only those infections occurring among patients with hospital-acquired colonization, and do not take steps to accurately identify postdischarge infections that occur in such patients, their results are biased toward the null and difficult to interpret. Due to several serious challenges to study feasibility, including the need for an extremely large sample size, a very long period of follow-up, and the need to control for a variety of other concurrent infection prevention measures, there may never be a study that conclusively proves that CP, apart from other infection prevention interventions, has a significant impact. However, despite these limitations, one of the recent multicenter randomized controlled trials, cited by the authors as evidence against the use of CP, was able to demonstrate a significant reduction in MRSA transmission using universal gowns and gloves for all intensive care unit patients, even in sites that utilized other effective strategies, including chlorhexidine bathing.^4,5

In this issue of the Journal of Hospital Medicine^®, Young et al. acknowledge that CP are generally utilized as part of a comprehensive package of infection prevention approaches that also includes hand hygiene, environmental cleaning, antimicrobial stewardship, and evidence-based interventions to prevent device- and procedure-related infections. This multifaceted approach makes it more difficult to determine the attributable effect of CP alone. However, there is a strong rationale for using CP to prevent transmission, and there are numerous examples where the use of bundled approaches that include CP was associated with success. In the Netherlands, CP were part of an aggressive “search and destroy” approach to MRSA associated with almost total elimination of MRSA from hospitals in that country. The United Kingdom achieved an 80% decrease in MRSA bacteremia following a series of aggressive intervention policies designed to prevent MRSA transmission, including use of screening and CP.⁶ In the United States, the Veterans Affairs system utilizes this type of approach and reported a 62% decrease in MRSA rates. Subsequent analysis showed that the downward trend of hospital-onset MRSA infections was observed only among patients who were not carrying MRSA at the time of admission, suggesting that preventing transmission was an important contributor to the overall trends.^7,8 More broadly, healthcare-associated MRSA rates in the United States have decreased dramatically over the past decade,^9,10 a period during which more than 81% of hospitals reported using CP for patients colonized or infected with MRSA as part of the bundle of infection prevention approaches.¹¹ Given these decreases, and the potential role that CP played in achieving these results, we, along with others,¹² urge caution about the dangers of abandoning CP prematurely and without data to indicate that it is safe to stop.

Although some studies report adverse events associated with CP, including a reduced number of visits from healthcare personnel and increased anxiety and depression, these studies rarely control for important confounding variables such as the severity of illness or the presence of anxiety and depression at the time of hospital admission.^13-15 The highest-quality evidence in studies that control for severity of illness and the presence of depression at the time of admission suggests that CP are not associated with an increased incidence of adverse events.^16,17

Interestingly, Young et al. acknowledge that CP are important and should be continued for patients infected or colonized with certain MDROs, including carbapenem-resistant Enterobacteriaceae, multidrug-resistant Pseudomonas aeruginosa, and Candida auris. They even suggest continuing CP for patients with certain types of antimicrobial-resistant Staphylococcus aureus isolates that are resistant or intermediate to vancomycin (Vancomycin-resistant Staphylococcus aureus [VRSA] or Vancomycin-intermediate Staphylococcus aureus [VISA]) and for which transmission has rarely been documented in the United States. It is unclear why they believe that CP are indicated and useful to prevent transmission of these multidrug-resistant pathogens while advocating that CP are not useful or indicated to prevent transmission of MRSA and VRE. One must consider whether it makes sense to use such a selective approach to using CP for patients with some, but not all, MDROs.

The authors state that CP should be employed to help interrupt outbreaks and for patients with high-risk situations such as open wounds, uncontained secretions, or incontinent diarrhea. We agree that there is appeal to a risk-based approach in which CP are applied based on the likelihood that an individual patient may be carrying and shedding an MDRO. However, to our knowledge, there are no validated algorithms available for this purpose, and it appears likely that using such algorithms would result in an increase in the proportion of patients cared for using CP, rather than a decrease.

The use of CP when caring for patients colonized or infected with an MDRO is considered to be a standard of care. Based on experimental, clinical, and epidemiologic studies and a strong theoretical rationale, the use of CP is currently recommended by the United States Centers for Disease Control and Prevention (CDC), the Healthcare Infection Control Practices Advisory Committee (HICPAC),¹⁸ the Society for Healthcare Epidemiology of America (SHEA),¹⁹ and the Infectious Diseases Society of America.²⁰ Many healthcare facilities continue to employ CP for patients with a wide array of MDROs, including MRSA and VRE, and many infection prevention experts continue to support and utilize this approach. In response to the growing movement to discontinue CP, the CDC recently reaffirmed its support and recommendation for the use of CP when caring for patients colonized or infected with MRSA.²¹

In summary, a bundled, multifaceted approach to infection prevention and transmission of MDROs is extremely important, and we caution against stopping CP for MRSA and VRE before data are available on the potential harm of that approach. Study limitations make it difficult to demonstrate the individual contribution of CP, but CP are an important component of a comprehensive infection prevention MDRO bundle that has successfully reduced healthcare-associated MRSA. Well-designed studies that control for confounders such as the severity of illness at the time of admission suggest that CP are not associated with an increased incidence of adverse events. Currently available data do not support a selective approach to utilizing CP for some MDROs while not using CP for others. Current guidelines call for the use of CP for preventing MDRO transmission, including MRSA and VRE. Healthcare facilities need to focus on how to implement CP in a patient-centered manner, rather than abandoning CP for some MDROs.

Disclosures

Dr. Maragakis is a member of the Healthcare Infection Control Practices Advisory Committee for the Centers for Disease Control and Prevention. Dr. Jernigan is an employee of the Centers for Disease Control and Prevention.

Disclaimer

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Contact precautions (CP), the use of gowns and gloves as personal protective equipment when caring for patients who are colonized or infected with one or more multidrug-resistant organisms (MDROs), is an important infection prevention intervention utilized to prevent pathogens from being transmitted among patients in healthcare settings. Recently, certain healthcare facilities have taken steps to limit the use of CP for patients colonized or infected with MDROs that are considered to be endemic, namely methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE). In this issue of the Journal of Hospital Medicine, authors Young et al. argue that CP for MRSA and VRE is an intervention that should be eliminated as part of the Choosing Wisely^® campaign because it is a “thing we do for no reason.”¹ We respectfully disagree with this characterization of CP for MRSA and VRE, and we assert instead that CP are a necessary practice that should be continued.

Young et al. refer to published studies and a recent meta-analysis that did not conclusively show a benefit of CP for MRSA and VRE.² The quasi-experimental studies cited have major methodological flaws that limit their ability to demonstrate the effect of CP. Most importantly, these studies fail to account for the fact that among patients who develop an infection following hospital-acquired MRSA colonization, approximately 70% of the infections are identified after discharge.³ When such studies do not restrict their outcome measure to include only those infections occurring among patients with hospital-acquired colonization, and do not take steps to accurately identify postdischarge infections that occur in such patients, their results are biased toward the null and difficult to interpret. Due to several serious challenges to study feasibility, including the need for an extremely large sample size, a very long period of follow-up, and the need to control for a variety of other concurrent infection prevention measures, there may never be a study that conclusively proves that CP, apart from other infection prevention interventions, has a significant impact. However, despite these limitations, one of the recent multicenter randomized controlled trials, cited by the authors as evidence against the use of CP, was able to demonstrate a significant reduction in MRSA transmission using universal gowns and gloves for all intensive care unit patients, even in sites that utilized other effective strategies, including chlorhexidine bathing.^4,5

In this issue of the Journal of Hospital Medicine^®, Young et al. acknowledge that CP are generally utilized as part of a comprehensive package of infection prevention approaches that also includes hand hygiene, environmental cleaning, antimicrobial stewardship, and evidence-based interventions to prevent device- and procedure-related infections. This multifaceted approach makes it more difficult to determine the attributable effect of CP alone. However, there is a strong rationale for using CP to prevent transmission, and there are numerous examples where the use of bundled approaches that include CP was associated with success. In the Netherlands, CP were part of an aggressive “search and destroy” approach to MRSA associated with almost total elimination of MRSA from hospitals in that country. The United Kingdom achieved an 80% decrease in MRSA bacteremia following a series of aggressive intervention policies designed to prevent MRSA transmission, including use of screening and CP.⁶ In the United States, the Veterans Affairs system utilizes this type of approach and reported a 62% decrease in MRSA rates. Subsequent analysis showed that the downward trend of hospital-onset MRSA infections was observed only among patients who were not carrying MRSA at the time of admission, suggesting that preventing transmission was an important contributor to the overall trends.^7,8 More broadly, healthcare-associated MRSA rates in the United States have decreased dramatically over the past decade,^9,10 a period during which more than 81% of hospitals reported using CP for patients colonized or infected with MRSA as part of the bundle of infection prevention approaches.¹¹ Given these decreases, and the potential role that CP played in achieving these results, we, along with others,¹² urge caution about the dangers of abandoning CP prematurely and without data to indicate that it is safe to stop.

Although some studies report adverse events associated with CP, including a reduced number of visits from healthcare personnel and increased anxiety and depression, these studies rarely control for important confounding variables such as the severity of illness or the presence of anxiety and depression at the time of hospital admission.^13-15 The highest-quality evidence in studies that control for severity of illness and the presence of depression at the time of admission suggests that CP are not associated with an increased incidence of adverse events.^16,17

Interestingly, Young et al. acknowledge that CP are important and should be continued for patients infected or colonized with certain MDROs, including carbapenem-resistant Enterobacteriaceae, multidrug-resistant Pseudomonas aeruginosa, and Candida auris. They even suggest continuing CP for patients with certain types of antimicrobial-resistant Staphylococcus aureus isolates that are resistant or intermediate to vancomycin (Vancomycin-resistant Staphylococcus aureus [VRSA] or Vancomycin-intermediate Staphylococcus aureus [VISA]) and for which transmission has rarely been documented in the United States. It is unclear why they believe that CP are indicated and useful to prevent transmission of these multidrug-resistant pathogens while advocating that CP are not useful or indicated to prevent transmission of MRSA and VRE. One must consider whether it makes sense to use such a selective approach to using CP for patients with some, but not all, MDROs.

The authors state that CP should be employed to help interrupt outbreaks and for patients with high-risk situations such as open wounds, uncontained secretions, or incontinent diarrhea. We agree that there is appeal to a risk-based approach in which CP are applied based on the likelihood that an individual patient may be carrying and shedding an MDRO. However, to our knowledge, there are no validated algorithms available for this purpose, and it appears likely that using such algorithms would result in an increase in the proportion of patients cared for using CP, rather than a decrease.

The use of CP when caring for patients colonized or infected with an MDRO is considered to be a standard of care. Based on experimental, clinical, and epidemiologic studies and a strong theoretical rationale, the use of CP is currently recommended by the United States Centers for Disease Control and Prevention (CDC), the Healthcare Infection Control Practices Advisory Committee (HICPAC),¹⁸ the Society for Healthcare Epidemiology of America (SHEA),¹⁹ and the Infectious Diseases Society of America.²⁰ Many healthcare facilities continue to employ CP for patients with a wide array of MDROs, including MRSA and VRE, and many infection prevention experts continue to support and utilize this approach. In response to the growing movement to discontinue CP, the CDC recently reaffirmed its support and recommendation for the use of CP when caring for patients colonized or infected with MRSA.²¹

In summary, a bundled, multifaceted approach to infection prevention and transmission of MDROs is extremely important, and we caution against stopping CP for MRSA and VRE before data are available on the potential harm of that approach. Study limitations make it difficult to demonstrate the individual contribution of CP, but CP are an important component of a comprehensive infection prevention MDRO bundle that has successfully reduced healthcare-associated MRSA. Well-designed studies that control for confounders such as the severity of illness at the time of admission suggest that CP are not associated with an increased incidence of adverse events. Currently available data do not support a selective approach to utilizing CP for some MDROs while not using CP for others. Current guidelines call for the use of CP for preventing MDRO transmission, including MRSA and VRE. Healthcare facilities need to focus on how to implement CP in a patient-centered manner, rather than abandoning CP for some MDROs.

Disclosures

Dr. Maragakis is a member of the Healthcare Infection Control Practices Advisory Committee for the Centers for Disease Control and Prevention. Dr. Jernigan is an employee of the Centers for Disease Control and Prevention.

Disclaimer

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

In 2015, the Centers for Medicare and Medicaid Services (CMS) tied 42% of Medicare payments to a value-based model of care.¹ Many of these models are designed to expand the scope of hospitals’ accountability to include care provided to patients postdischarge (eg, readmission penalties, bundled payments, accountable care organizations). With such a significant change in organizational incentives, one would expect to see activity as it relates to hospital-skilled nursing facility (SNF) integration, potentially including shared risk among providers.^2,3

Hospitals can choose from several different strategies when contemplating SNF integration, such as vertical integration with SNFs, which would involve acquiring and owning SNFs. However, despite the high level of incentive alignment and financial integration achieved through SNF acquisition, this strategy has not been widely adopted. Perhaps this is because hospitals can often attain a shorter length of stay and lower readmission rates without taking on the additional risk of owning a facility, except under particular market conditions.⁴ Hospitals can alternatively pursue virtual integration by developing preferred provider networks through contractual relationships or other formal processes, attempting to direct patients to SNF providers that have met predefined criteria, as described by Conway and colleagues in this issue of the Journal of Hospital Medicine^®.⁵ While hospitals have adopted this form of integration more widely than vertical integration, only those with additional financial motivations, such as those employing bundled payments, engaged in accountable care organizations (ACOs) or forward-thinking organizations preparing for looming global models of payment, have implemented such action. Finally, hospitals can focus on relational coordination through informal person-to-person communication and transition management. Given the high number of patients discharged to SNFs, the strategies above are not mutually exclusive, and enhanced relational coordination is most likely going to occur regardless of the type of—and perhaps even without—organizational-level integration.

For those hospitals choosing not to pursue integration with SNFs, there are several reasons to maintain the status quo. First, hospitals have different interpretations of provider choice (“beneficiary freedom to choose”), whereby many do not believe they can provide information to patients outside of facility names and addresses. As such, they will refrain from developing a SNF network due to their interpretation of hazy federal rules.⁶ Second, it is possible that the incremental benefit of establishing a network is viewed by many hospitals as not worth the cost, measured by the time and effort required and the potential risk of not adhering to choice requirements. This could be especially true for hospitals without additional financial motivations, such as participation in an ACO or bundled payment program.

As the landscape continues to evolve, more successful systems will embrace a more concordant partnership with local and regional SNF providers, and several market factors will support the trend. First, the Medicare Payment Advisory Commission (MedPAC) is discussing the idea of choice in the context of postacute discharge, potentially leading to hospitals relaxing their strict interpretations of choice and the level of information provided to patients.⁷ Second, the evidence supports better patient outcomes when hospitals develop SNF networks.^8,9 Finally, continued penetration of value-based payment models combined with CMS decisions regarding choice will continue to provide the additional motivation hospitals may need to change the cost-benefit calculation in favor of developing a network.

IMPLICATIONS FOR HOSPITALISTS

Traditionally, primary care physicians followed their patients through the acute- and postacute care continuum, but a variety of changes led to the growth of hospital medicine as fewer primary care physicians saw patients in the hospital.^10,11 This shift has challenged efforts to ensure continuity of care across settings, especially since most hospitalists have ceded control of postdischarge placement to case managers and therapists. Further, there has been little incentive to connect hospitalists to any other component or provider along the range of care, and compensation models rarely, if at all, consider any accountability for patient outcomes outside the hospital. Several factors can change this reality for hospitalists.

First, as more providers adopt team-based care approaches and as alternative payment models expand the scope of accountability, hospitalists will become an even more central component of the risk evaluation process for hospitalized patients as it relates to their discharge profile. This could mean that hospitalists are more involved in the postdischarge follow-up of patients sent home, to make sure patients adhere to discharge instructions. Alternatively, hospitalists may need to increase the level of physician-to-physician communication with SNF medical directors for patients discharged to SNF. This, in turn, could result in an increasing number of hospitalist groups recruiting SNFists to join their group or potentially assigning existing hospitalists or physician assistants to round on patients in the SNF. The 2018 Society of Hospital Medicine report showed an increase in activity among hospital medicine groups performing services in postacute-care facilities outside the hospital from 13% in 2016 to 25% in 2018.¹² Similarly, a 2017 study in JAMA Internal Medicine reported a 48.2% increase in the number of physicians classified as SNFists from 2007 to 2014.¹³

Second, hospitalists will be more involved in the discharge planning process through internal interdisciplinary team communications. Whereas case managers and therapists owned the discharge planning process historically, new teams will include hospitalists, case managers, physical therapists, and pharmacists. System leaders will task them with identifying the appropriate discharge destination (eg, SNF, home health), finalizing the medication reconciliation, scheduling follow-up appointments, and completing a warm handoff.

Finally, as the field matures and hospitalists learn more about postacute-care connections, they will continue to be held more accountable for patient outcomes postdischarge. Many hospitalists have already connected to community providers through checklists and use evidence-based discharge programs like ProjectRed or Project BOOST.^14,15 Organizations will need a similar strategy for SNFs, developing process measures, with the input of hospitalists, around those noteworthy areas that hospitalists can control. This will require greater alignment among constituents around overall organizational goals and, more importantly, entail the hospitalist to be attuned to overall patient goals beyond the care provided in the hospital setting.

As payment and care models continue to evolve, the status quo cannot be sustained. We anticipate that hospitalists will become more integrated into the patient discharge process, especially as it relates to discharge to SNFs before patients reconnect to their community physicians. Hospital systems will accelerate integration through the development of preferred SNF networks, and hospitalists stand to play a critical role in the success of these arrangements by enriching the benefits they create through these outward relationships.

For organizations engaged in embedded networks, they can realize gains via incentive alignment, trust, information transfer, mutual support, and coordination through virtual integration, without requiring vertical ownership.^3,16Thus, the opportunity exists for hospitalists to be critical drivers of network success, serving as intermediaries from which information, collaboration, and shared problem-solving flow between hospitals, SNFs, patients, and the entire care team. Opportunities to rebuild our system are long past; however, like all changing sectors in healthcare, the disaggregate acute and postacute settings must move in lockstep. Hospitals and postacute care facilities must find ways to alter their thinking to eradicate the obstructive and injurious invisible wall.

Disclosures

The authors have nothing to disclose.

In 2015, the Centers for Medicare and Medicaid Services (CMS) tied 42% of Medicare payments to a value-based model of care.¹ Many of these models are designed to expand the scope of hospitals’ accountability to include care provided to patients postdischarge (eg, readmission penalties, bundled payments, accountable care organizations). With such a significant change in organizational incentives, one would expect to see activity as it relates to hospital-skilled nursing facility (SNF) integration, potentially including shared risk among providers.^2,3

Hospitals can choose from several different strategies when contemplating SNF integration, such as vertical integration with SNFs, which would involve acquiring and owning SNFs. However, despite the high level of incentive alignment and financial integration achieved through SNF acquisition, this strategy has not been widely adopted. Perhaps this is because hospitals can often attain a shorter length of stay and lower readmission rates without taking on the additional risk of owning a facility, except under particular market conditions.⁴ Hospitals can alternatively pursue virtual integration by developing preferred provider networks through contractual relationships or other formal processes, attempting to direct patients to SNF providers that have met predefined criteria, as described by Conway and colleagues in this issue of the Journal of Hospital Medicine^®.⁵ While hospitals have adopted this form of integration more widely than vertical integration, only those with additional financial motivations, such as those employing bundled payments, engaged in accountable care organizations (ACOs) or forward-thinking organizations preparing for looming global models of payment, have implemented such action. Finally, hospitals can focus on relational coordination through informal person-to-person communication and transition management. Given the high number of patients discharged to SNFs, the strategies above are not mutually exclusive, and enhanced relational coordination is most likely going to occur regardless of the type of—and perhaps even without—organizational-level integration.

For those hospitals choosing not to pursue integration with SNFs, there are several reasons to maintain the status quo. First, hospitals have different interpretations of provider choice (“beneficiary freedom to choose”), whereby many do not believe they can provide information to patients outside of facility names and addresses. As such, they will refrain from developing a SNF network due to their interpretation of hazy federal rules.⁶ Second, it is possible that the incremental benefit of establishing a network is viewed by many hospitals as not worth the cost, measured by the time and effort required and the potential risk of not adhering to choice requirements. This could be especially true for hospitals without additional financial motivations, such as participation in an ACO or bundled payment program.

As the landscape continues to evolve, more successful systems will embrace a more concordant partnership with local and regional SNF providers, and several market factors will support the trend. First, the Medicare Payment Advisory Commission (MedPAC) is discussing the idea of choice in the context of postacute discharge, potentially leading to hospitals relaxing their strict interpretations of choice and the level of information provided to patients.⁷ Second, the evidence supports better patient outcomes when hospitals develop SNF networks.^8,9 Finally, continued penetration of value-based payment models combined with CMS decisions regarding choice will continue to provide the additional motivation hospitals may need to change the cost-benefit calculation in favor of developing a network.

IMPLICATIONS FOR HOSPITALISTS

Traditionally, primary care physicians followed their patients through the acute- and postacute care continuum, but a variety of changes led to the growth of hospital medicine as fewer primary care physicians saw patients in the hospital.^10,11 This shift has challenged efforts to ensure continuity of care across settings, especially since most hospitalists have ceded control of postdischarge placement to case managers and therapists. Further, there has been little incentive to connect hospitalists to any other component or provider along the range of care, and compensation models rarely, if at all, consider any accountability for patient outcomes outside the hospital. Several factors can change this reality for hospitalists.

First, as more providers adopt team-based care approaches and as alternative payment models expand the scope of accountability, hospitalists will become an even more central component of the risk evaluation process for hospitalized patients as it relates to their discharge profile. This could mean that hospitalists are more involved in the postdischarge follow-up of patients sent home, to make sure patients adhere to discharge instructions. Alternatively, hospitalists may need to increase the level of physician-to-physician communication with SNF medical directors for patients discharged to SNF. This, in turn, could result in an increasing number of hospitalist groups recruiting SNFists to join their group or potentially assigning existing hospitalists or physician assistants to round on patients in the SNF. The 2018 Society of Hospital Medicine report showed an increase in activity among hospital medicine groups performing services in postacute-care facilities outside the hospital from 13% in 2016 to 25% in 2018.¹² Similarly, a 2017 study in JAMA Internal Medicine reported a 48.2% increase in the number of physicians classified as SNFists from 2007 to 2014.¹³

Second, hospitalists will be more involved in the discharge planning process through internal interdisciplinary team communications. Whereas case managers and therapists owned the discharge planning process historically, new teams will include hospitalists, case managers, physical therapists, and pharmacists. System leaders will task them with identifying the appropriate discharge destination (eg, SNF, home health), finalizing the medication reconciliation, scheduling follow-up appointments, and completing a warm handoff.

Finally, as the field matures and hospitalists learn more about postacute-care connections, they will continue to be held more accountable for patient outcomes postdischarge. Many hospitalists have already connected to community providers through checklists and use evidence-based discharge programs like ProjectRed or Project BOOST.^14,15 Organizations will need a similar strategy for SNFs, developing process measures, with the input of hospitalists, around those noteworthy areas that hospitalists can control. This will require greater alignment among constituents around overall organizational goals and, more importantly, entail the hospitalist to be attuned to overall patient goals beyond the care provided in the hospital setting.

As payment and care models continue to evolve, the status quo cannot be sustained. We anticipate that hospitalists will become more integrated into the patient discharge process, especially as it relates to discharge to SNFs before patients reconnect to their community physicians. Hospital systems will accelerate integration through the development of preferred SNF networks, and hospitalists stand to play a critical role in the success of these arrangements by enriching the benefits they create through these outward relationships.

For organizations engaged in embedded networks, they can realize gains via incentive alignment, trust, information transfer, mutual support, and coordination through virtual integration, without requiring vertical ownership.^3,16Thus, the opportunity exists for hospitalists to be critical drivers of network success, serving as intermediaries from which information, collaboration, and shared problem-solving flow between hospitals, SNFs, patients, and the entire care team. Opportunities to rebuild our system are long past; however, like all changing sectors in healthcare, the disaggregate acute and postacute settings must move in lockstep. Hospitals and postacute care facilities must find ways to alter their thinking to eradicate the obstructive and injurious invisible wall.

Disclosures

The authors have nothing to disclose.

In 2015, the Centers for Medicare and Medicaid Services (CMS) tied 42% of Medicare payments to a value-based model of care.¹ Many of these models are designed to expand the scope of hospitals’ accountability to include care provided to patients postdischarge (eg, readmission penalties, bundled payments, accountable care organizations). With such a significant change in organizational incentives, one would expect to see activity as it relates to hospital-skilled nursing facility (SNF) integration, potentially including shared risk among providers.^2,3

Hospitals can choose from several different strategies when contemplating SNF integration, such as vertical integration with SNFs, which would involve acquiring and owning SNFs. However, despite the high level of incentive alignment and financial integration achieved through SNF acquisition, this strategy has not been widely adopted. Perhaps this is because hospitals can often attain a shorter length of stay and lower readmission rates without taking on the additional risk of owning a facility, except under particular market conditions.⁴ Hospitals can alternatively pursue virtual integration by developing preferred provider networks through contractual relationships or other formal processes, attempting to direct patients to SNF providers that have met predefined criteria, as described by Conway and colleagues in this issue of the Journal of Hospital Medicine^®.⁵ While hospitals have adopted this form of integration more widely than vertical integration, only those with additional financial motivations, such as those employing bundled payments, engaged in accountable care organizations (ACOs) or forward-thinking organizations preparing for looming global models of payment, have implemented such action. Finally, hospitals can focus on relational coordination through informal person-to-person communication and transition management. Given the high number of patients discharged to SNFs, the strategies above are not mutually exclusive, and enhanced relational coordination is most likely going to occur regardless of the type of—and perhaps even without—organizational-level integration.

For those hospitals choosing not to pursue integration with SNFs, there are several reasons to maintain the status quo. First, hospitals have different interpretations of provider choice (“beneficiary freedom to choose”), whereby many do not believe they can provide information to patients outside of facility names and addresses. As such, they will refrain from developing a SNF network due to their interpretation of hazy federal rules.⁶ Second, it is possible that the incremental benefit of establishing a network is viewed by many hospitals as not worth the cost, measured by the time and effort required and the potential risk of not adhering to choice requirements. This could be especially true for hospitals without additional financial motivations, such as participation in an ACO or bundled payment program.

As the landscape continues to evolve, more successful systems will embrace a more concordant partnership with local and regional SNF providers, and several market factors will support the trend. First, the Medicare Payment Advisory Commission (MedPAC) is discussing the idea of choice in the context of postacute discharge, potentially leading to hospitals relaxing their strict interpretations of choice and the level of information provided to patients.⁷ Second, the evidence supports better patient outcomes when hospitals develop SNF networks.^8,9 Finally, continued penetration of value-based payment models combined with CMS decisions regarding choice will continue to provide the additional motivation hospitals may need to change the cost-benefit calculation in favor of developing a network.

IMPLICATIONS FOR HOSPITALISTS

Traditionally, primary care physicians followed their patients through the acute- and postacute care continuum, but a variety of changes led to the growth of hospital medicine as fewer primary care physicians saw patients in the hospital.^10,11 This shift has challenged efforts to ensure continuity of care across settings, especially since most hospitalists have ceded control of postdischarge placement to case managers and therapists. Further, there has been little incentive to connect hospitalists to any other component or provider along the range of care, and compensation models rarely, if at all, consider any accountability for patient outcomes outside the hospital. Several factors can change this reality for hospitalists.

First, as more providers adopt team-based care approaches and as alternative payment models expand the scope of accountability, hospitalists will become an even more central component of the risk evaluation process for hospitalized patients as it relates to their discharge profile. This could mean that hospitalists are more involved in the postdischarge follow-up of patients sent home, to make sure patients adhere to discharge instructions. Alternatively, hospitalists may need to increase the level of physician-to-physician communication with SNF medical directors for patients discharged to SNF. This, in turn, could result in an increasing number of hospitalist groups recruiting SNFists to join their group or potentially assigning existing hospitalists or physician assistants to round on patients in the SNF. The 2018 Society of Hospital Medicine report showed an increase in activity among hospital medicine groups performing services in postacute-care facilities outside the hospital from 13% in 2016 to 25% in 2018.¹² Similarly, a 2017 study in JAMA Internal Medicine reported a 48.2% increase in the number of physicians classified as SNFists from 2007 to 2014.¹³

Second, hospitalists will be more involved in the discharge planning process through internal interdisciplinary team communications. Whereas case managers and therapists owned the discharge planning process historically, new teams will include hospitalists, case managers, physical therapists, and pharmacists. System leaders will task them with identifying the appropriate discharge destination (eg, SNF, home health), finalizing the medication reconciliation, scheduling follow-up appointments, and completing a warm handoff.

Finally, as the field matures and hospitalists learn more about postacute-care connections, they will continue to be held more accountable for patient outcomes postdischarge. Many hospitalists have already connected to community providers through checklists and use evidence-based discharge programs like ProjectRed or Project BOOST.^14,15 Organizations will need a similar strategy for SNFs, developing process measures, with the input of hospitalists, around those noteworthy areas that hospitalists can control. This will require greater alignment among constituents around overall organizational goals and, more importantly, entail the hospitalist to be attuned to overall patient goals beyond the care provided in the hospital setting.

As payment and care models continue to evolve, the status quo cannot be sustained. We anticipate that hospitalists will become more integrated into the patient discharge process, especially as it relates to discharge to SNFs before patients reconnect to their community physicians. Hospital systems will accelerate integration through the development of preferred SNF networks, and hospitalists stand to play a critical role in the success of these arrangements by enriching the benefits they create through these outward relationships.

For organizations engaged in embedded networks, they can realize gains via incentive alignment, trust, information transfer, mutual support, and coordination through virtual integration, without requiring vertical ownership.^3,16Thus, the opportunity exists for hospitalists to be critical drivers of network success, serving as intermediaries from which information, collaboration, and shared problem-solving flow between hospitals, SNFs, patients, and the entire care team. Opportunities to rebuild our system are long past; however, like all changing sectors in healthcare, the disaggregate acute and postacute settings must move in lockstep. Hospitals and postacute care facilities must find ways to alter their thinking to eradicate the obstructive and injurious invisible wall.

Disclosures

The authors have nothing to disclose.

Your pager beeps. Your patient, Mrs. Jones, who was admitted with cellulitis and is improving, now has a blood pressure of 188/103 on routine vitals. Her nurse reports that she is comfortable and asymptomatic, but she met the “call parameters.” You review her chart and find that since admission her systolic blood pressure (SBP) has ranged from 149 to 157 mm Hg and her diastolic blood pressure (DBP) from 84 to 96 mm Hg. Her nurse asks how you would like to treat her.

While over half of inpatients have at least one hypertensive episode during their stay, evidence suggests that nearly all such episodes—estimates are between 98% and 99%^1,2—should be treated over several days with oral antihypertensives, not acutely with intravenous medications.^3-6 Current guidelines recommend that intravenous medications should be reserved for severe hypertensive episodes (SBP > 180, DBP > 120) with acute end-organ damage,^7,8 but such “hypertensive emergencies” are rare on the general medicine wards. Still, hospitalists regularly face the dilemma posed by Mrs. Jones, and evidence shows they often prescribe intravenous antihypertensives.^1,4,5 This unnecessary use can lead to unreliable drops in blood pressure and exposes our patients to potential harm.^5,6

In this issue of the Journal of Hospital Medicine, two papers describe the frequency of inappropriate intravenous antihypertensive use in their hospitals and the subsequent quality improvement efforts implemented to reduce this practice. The first, by Jacobs et al., found that over a 10-month period, 11% of patients who experienced “asymptomatic hypertension” on an urban academic hospital medicine service were treated inappropriately with intravenous antihypertensives,⁹ with 14% of those experiencing an adverse event. The second paper, by Pasik et al., found that in their urban academic medical center there were 8.3 inappropriate intravenous antihypertensive orders placed per 1,000 patient days,¹⁰ with nearly half of those treated experiencing an adverse event. Based on these findings, each group then led interventions to reduce the use of intravenous antihypertensives.

While both groups engaged physicians and nurses as primary stakeholders, Pasik et al.¹⁰ worked to further expand nursing staff roles by empowering them to assess for underlying causes of hypertension, such as pain or anxiety, as well as end-organ damage via specific guided algorithms prior to contacting physicians. In doing so, they reduced intravenous antihypertensive use by 60% during the postintervention period, with a proportional reduction in adverse events. In addition to their educational initiative, Jacobs et al. aimed to limit calls by liberalizing the “ceiling” on standard nursing call parameters for blood pressure from 160/80 to 180/90. Following their intervention, intravenous antihypertensive orders were reduced by 40%, with the mean orders per patient with asymptomatic hypertension decreasing from 11% to 7% .

While these results are admirable, some caution in their interpretation is needed. For example, Jacobs et al. used electronic health record data to retrospectively identify hypertension as “symptomatic” or “asymptomatic” using laboratory, electrocardiogram, and imaging diagnostics as surrogate markers for “provider concern for end-organ damage.” Although it appropriately focused on concern for end-organ damage as justification for intravenous antihypertensives, this approach potentially underappreciated true hypertensive emergencies, thereby overestimating the amount of inappropriate use of intravenous antihypertensives. Pasik et al. utilized chart review of patients prescribed intravenous antihypertensives and therefore did not explore how often symptomatic hypertension occurred in patients who did not receive intravenous antihypertensives. Subsequently, this limited their ability to evaluate unintended harms of their initiative. To address this limitation, the authors followed a group of 111 patients who had elevated hypertension but did not receive intravenous antihypertensives and found no adverse outcomes.¹⁰ Because both studies were retrospective in nature, they were subject to biases from providers choosing intravenous antihypertensives for reasons that were neither captured by their datasets nor adjusted for. Additionally, neither study reported downstream impacts such as an increase in symptomatic hypertensive episodes or more rare events such as kidney injury, stroke, or myocardial infarction.

Given that guidelines discourage using intravenous antihypertensives, why were the efforts of Jacobs et al.⁹ and Pasik et al.¹⁰ needed in the first place? In a recent installment of Choosing Wisely: Things We Do For No Reason, Breu et al.¹¹ cite two primary reasons: first, providers have unfounded fears that asymptomatic hypertension will quickly progress to cause organ damage; second, providers lack understanding of the potential harms from overtreatment. It is fitting, therefore, that both groups of authors focused on these topics in their education initiatives for physicians and nurses. Yet, as good quality improvement requires steps beyond education, it was promising to see that both authors additionally focused on intervening to change the systems and culture that existed around physician and nursing communication.

In the age of electronic health records, there has been a sustained focus on creating standardized order sets. While the value of these order sets has been widely demonstrated, there are downsides. For example, nursing call parameters in admission order sets are rarely patient-specific but account for a significant portion of nursing and physician communication. These one-size-fits-all orders limit nurses from using their clinical training and create unnecessary tensions as nurses are obligated to call covering hospitalists to address “abnormal” but clinically insignificant findings. Regular monitoring of vital signs is an integral part of caring for acutely ill inpatients but for most inpatients, the importance of vitals is to detect clinically meaningful changes, not to treat risk factors like hypertension that should be treated safely over the long term.

When inpatients become febrile, tachycardic, or hypoxic, hospitalists use critical thinking to diagnose the underlying causes. Unfortunately, high blood pressure is a vital sign that is treated differently. Many hospitalists see it as a number to fix, not a potential sign of a new underlying problem such as uncontrolled pain, anxiety, or medication side effects.⁸ Both groups of authors took the important first step of educating physicians to think critically when called about high blood pressure. Even more importantly, they took steps to change the system and culture in which providers make these decisions in the first place. Future work in this area would be wise to follow in these footsteps, by encouraging collaboration between hospitalist and nurses to create more logical and patient-specific call parameters that could potentially improve nursing-physician communication, and subsequently, patient care.

Changing the culture to limit the use of intravenous antihypertensives will not be easy, but it is necessary. We encourage readers to investigate intravenous antihypertensives in their own hospitals and consider how better communication between nurses and physicians could change their practice. Recalling Mrs. Jones above, the provider should engage her nurse to help confirm that her hypertension is “asymptomatic” and then consider underlying causes such as pain, anxiety, or withholding her home medications as reasons for her elevated blood pressure. After all, if nothing else, it seems clear that a call about inpatient hypertension is not a call to act, but to think.

Disclosures

The authors declare that they have no competing interests.

Funding

Dr. Lucas is supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Dartmouth SYNERGY, National Institutes of Health, National Center for Translational Science (UL1TR001086).

Your pager beeps. Your patient, Mrs. Jones, who was admitted with cellulitis and is improving, now has a blood pressure of 188/103 on routine vitals. Her nurse reports that she is comfortable and asymptomatic, but she met the “call parameters.” You review her chart and find that since admission her systolic blood pressure (SBP) has ranged from 149 to 157 mm Hg and her diastolic blood pressure (DBP) from 84 to 96 mm Hg. Her nurse asks how you would like to treat her.

While over half of inpatients have at least one hypertensive episode during their stay, evidence suggests that nearly all such episodes—estimates are between 98% and 99%^1,2—should be treated over several days with oral antihypertensives, not acutely with intravenous medications.^3-6 Current guidelines recommend that intravenous medications should be reserved for severe hypertensive episodes (SBP > 180, DBP > 120) with acute end-organ damage,^7,8 but such “hypertensive emergencies” are rare on the general medicine wards. Still, hospitalists regularly face the dilemma posed by Mrs. Jones, and evidence shows they often prescribe intravenous antihypertensives.^1,4,5 This unnecessary use can lead to unreliable drops in blood pressure and exposes our patients to potential harm.^5,6

In this issue of the Journal of Hospital Medicine, two papers describe the frequency of inappropriate intravenous antihypertensive use in their hospitals and the subsequent quality improvement efforts implemented to reduce this practice. The first, by Jacobs et al., found that over a 10-month period, 11% of patients who experienced “asymptomatic hypertension” on an urban academic hospital medicine service were treated inappropriately with intravenous antihypertensives,⁹ with 14% of those experiencing an adverse event. The second paper, by Pasik et al., found that in their urban academic medical center there were 8.3 inappropriate intravenous antihypertensive orders placed per 1,000 patient days,¹⁰ with nearly half of those treated experiencing an adverse event. Based on these findings, each group then led interventions to reduce the use of intravenous antihypertensives.

While both groups engaged physicians and nurses as primary stakeholders, Pasik et al.¹⁰ worked to further expand nursing staff roles by empowering them to assess for underlying causes of hypertension, such as pain or anxiety, as well as end-organ damage via specific guided algorithms prior to contacting physicians. In doing so, they reduced intravenous antihypertensive use by 60% during the postintervention period, with a proportional reduction in adverse events. In addition to their educational initiative, Jacobs et al. aimed to limit calls by liberalizing the “ceiling” on standard nursing call parameters for blood pressure from 160/80 to 180/90. Following their intervention, intravenous antihypertensive orders were reduced by 40%, with the mean orders per patient with asymptomatic hypertension decreasing from 11% to 7% .

While these results are admirable, some caution in their interpretation is needed. For example, Jacobs et al. used electronic health record data to retrospectively identify hypertension as “symptomatic” or “asymptomatic” using laboratory, electrocardiogram, and imaging diagnostics as surrogate markers for “provider concern for end-organ damage.” Although it appropriately focused on concern for end-organ damage as justification for intravenous antihypertensives, this approach potentially underappreciated true hypertensive emergencies, thereby overestimating the amount of inappropriate use of intravenous antihypertensives. Pasik et al. utilized chart review of patients prescribed intravenous antihypertensives and therefore did not explore how often symptomatic hypertension occurred in patients who did not receive intravenous antihypertensives. Subsequently, this limited their ability to evaluate unintended harms of their initiative. To address this limitation, the authors followed a group of 111 patients who had elevated hypertension but did not receive intravenous antihypertensives and found no adverse outcomes.¹⁰ Because both studies were retrospective in nature, they were subject to biases from providers choosing intravenous antihypertensives for reasons that were neither captured by their datasets nor adjusted for. Additionally, neither study reported downstream impacts such as an increase in symptomatic hypertensive episodes or more rare events such as kidney injury, stroke, or myocardial infarction.

Given that guidelines discourage using intravenous antihypertensives, why were the efforts of Jacobs et al.⁹ and Pasik et al.¹⁰ needed in the first place? In a recent installment of Choosing Wisely: Things We Do For No Reason, Breu et al.¹¹ cite two primary reasons: first, providers have unfounded fears that asymptomatic hypertension will quickly progress to cause organ damage; second, providers lack understanding of the potential harms from overtreatment. It is fitting, therefore, that both groups of authors focused on these topics in their education initiatives for physicians and nurses. Yet, as good quality improvement requires steps beyond education, it was promising to see that both authors additionally focused on intervening to change the systems and culture that existed around physician and nursing communication.

In the age of electronic health records, there has been a sustained focus on creating standardized order sets. While the value of these order sets has been widely demonstrated, there are downsides. For example, nursing call parameters in admission order sets are rarely patient-specific but account for a significant portion of nursing and physician communication. These one-size-fits-all orders limit nurses from using their clinical training and create unnecessary tensions as nurses are obligated to call covering hospitalists to address “abnormal” but clinically insignificant findings. Regular monitoring of vital signs is an integral part of caring for acutely ill inpatients but for most inpatients, the importance of vitals is to detect clinically meaningful changes, not to treat risk factors like hypertension that should be treated safely over the long term.

When inpatients become febrile, tachycardic, or hypoxic, hospitalists use critical thinking to diagnose the underlying causes. Unfortunately, high blood pressure is a vital sign that is treated differently. Many hospitalists see it as a number to fix, not a potential sign of a new underlying problem such as uncontrolled pain, anxiety, or medication side effects.⁸ Both groups of authors took the important first step of educating physicians to think critically when called about high blood pressure. Even more importantly, they took steps to change the system and culture in which providers make these decisions in the first place. Future work in this area would be wise to follow in these footsteps, by encouraging collaboration between hospitalist and nurses to create more logical and patient-specific call parameters that could potentially improve nursing-physician communication, and subsequently, patient care.

Changing the culture to limit the use of intravenous antihypertensives will not be easy, but it is necessary. We encourage readers to investigate intravenous antihypertensives in their own hospitals and consider how better communication between nurses and physicians could change their practice. Recalling Mrs. Jones above, the provider should engage her nurse to help confirm that her hypertension is “asymptomatic” and then consider underlying causes such as pain, anxiety, or withholding her home medications as reasons for her elevated blood pressure. After all, if nothing else, it seems clear that a call about inpatient hypertension is not a call to act, but to think.

Disclosures

The authors declare that they have no competing interests.

Funding

Dr. Lucas is supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Dartmouth SYNERGY, National Institutes of Health, National Center for Translational Science (UL1TR001086).

Your pager beeps. Your patient, Mrs. Jones, who was admitted with cellulitis and is improving, now has a blood pressure of 188/103 on routine vitals. Her nurse reports that she is comfortable and asymptomatic, but she met the “call parameters.” You review her chart and find that since admission her systolic blood pressure (SBP) has ranged from 149 to 157 mm Hg and her diastolic blood pressure (DBP) from 84 to 96 mm Hg. Her nurse asks how you would like to treat her.

While over half of inpatients have at least one hypertensive episode during their stay, evidence suggests that nearly all such episodes—estimates are between 98% and 99%^1,2—should be treated over several days with oral antihypertensives, not acutely with intravenous medications.^3-6 Current guidelines recommend that intravenous medications should be reserved for severe hypertensive episodes (SBP > 180, DBP > 120) with acute end-organ damage,^7,8 but such “hypertensive emergencies” are rare on the general medicine wards. Still, hospitalists regularly face the dilemma posed by Mrs. Jones, and evidence shows they often prescribe intravenous antihypertensives.^1,4,5 This unnecessary use can lead to unreliable drops in blood pressure and exposes our patients to potential harm.^5,6

In this issue of the Journal of Hospital Medicine, two papers describe the frequency of inappropriate intravenous antihypertensive use in their hospitals and the subsequent quality improvement efforts implemented to reduce this practice. The first, by Jacobs et al., found that over a 10-month period, 11% of patients who experienced “asymptomatic hypertension” on an urban academic hospital medicine service were treated inappropriately with intravenous antihypertensives,⁹ with 14% of those experiencing an adverse event. The second paper, by Pasik et al., found that in their urban academic medical center there were 8.3 inappropriate intravenous antihypertensive orders placed per 1,000 patient days,¹⁰ with nearly half of those treated experiencing an adverse event. Based on these findings, each group then led interventions to reduce the use of intravenous antihypertensives.

While both groups engaged physicians and nurses as primary stakeholders, Pasik et al.¹⁰ worked to further expand nursing staff roles by empowering them to assess for underlying causes of hypertension, such as pain or anxiety, as well as end-organ damage via specific guided algorithms prior to contacting physicians. In doing so, they reduced intravenous antihypertensive use by 60% during the postintervention period, with a proportional reduction in adverse events. In addition to their educational initiative, Jacobs et al. aimed to limit calls by liberalizing the “ceiling” on standard nursing call parameters for blood pressure from 160/80 to 180/90. Following their intervention, intravenous antihypertensive orders were reduced by 40%, with the mean orders per patient with asymptomatic hypertension decreasing from 11% to 7% .

While these results are admirable, some caution in their interpretation is needed. For example, Jacobs et al. used electronic health record data to retrospectively identify hypertension as “symptomatic” or “asymptomatic” using laboratory, electrocardiogram, and imaging diagnostics as surrogate markers for “provider concern for end-organ damage.” Although it appropriately focused on concern for end-organ damage as justification for intravenous antihypertensives, this approach potentially underappreciated true hypertensive emergencies, thereby overestimating the amount of inappropriate use of intravenous antihypertensives. Pasik et al. utilized chart review of patients prescribed intravenous antihypertensives and therefore did not explore how often symptomatic hypertension occurred in patients who did not receive intravenous antihypertensives. Subsequently, this limited their ability to evaluate unintended harms of their initiative. To address this limitation, the authors followed a group of 111 patients who had elevated hypertension but did not receive intravenous antihypertensives and found no adverse outcomes.¹⁰ Because both studies were retrospective in nature, they were subject to biases from providers choosing intravenous antihypertensives for reasons that were neither captured by their datasets nor adjusted for. Additionally, neither study reported downstream impacts such as an increase in symptomatic hypertensive episodes or more rare events such as kidney injury, stroke, or myocardial infarction.

Given that guidelines discourage using intravenous antihypertensives, why were the efforts of Jacobs et al.⁹ and Pasik et al.¹⁰ needed in the first place? In a recent installment of Choosing Wisely: Things We Do For No Reason, Breu et al.¹¹ cite two primary reasons: first, providers have unfounded fears that asymptomatic hypertension will quickly progress to cause organ damage; second, providers lack understanding of the potential harms from overtreatment. It is fitting, therefore, that both groups of authors focused on these topics in their education initiatives for physicians and nurses. Yet, as good quality improvement requires steps beyond education, it was promising to see that both authors additionally focused on intervening to change the systems and culture that existed around physician and nursing communication.

In the age of electronic health records, there has been a sustained focus on creating standardized order sets. While the value of these order sets has been widely demonstrated, there are downsides. For example, nursing call parameters in admission order sets are rarely patient-specific but account for a significant portion of nursing and physician communication. These one-size-fits-all orders limit nurses from using their clinical training and create unnecessary tensions as nurses are obligated to call covering hospitalists to address “abnormal” but clinically insignificant findings. Regular monitoring of vital signs is an integral part of caring for acutely ill inpatients but for most inpatients, the importance of vitals is to detect clinically meaningful changes, not to treat risk factors like hypertension that should be treated safely over the long term.

When inpatients become febrile, tachycardic, or hypoxic, hospitalists use critical thinking to diagnose the underlying causes. Unfortunately, high blood pressure is a vital sign that is treated differently. Many hospitalists see it as a number to fix, not a potential sign of a new underlying problem such as uncontrolled pain, anxiety, or medication side effects.⁸ Both groups of authors took the important first step of educating physicians to think critically when called about high blood pressure. Even more importantly, they took steps to change the system and culture in which providers make these decisions in the first place. Future work in this area would be wise to follow in these footsteps, by encouraging collaboration between hospitalist and nurses to create more logical and patient-specific call parameters that could potentially improve nursing-physician communication, and subsequently, patient care.

Changing the culture to limit the use of intravenous antihypertensives will not be easy, but it is necessary. We encourage readers to investigate intravenous antihypertensives in their own hospitals and consider how better communication between nurses and physicians could change their practice. Recalling Mrs. Jones above, the provider should engage her nurse to help confirm that her hypertension is “asymptomatic” and then consider underlying causes such as pain, anxiety, or withholding her home medications as reasons for her elevated blood pressure. After all, if nothing else, it seems clear that a call about inpatient hypertension is not a call to act, but to think.

Disclosures

The authors declare that they have no competing interests.

Funding

Dr. Lucas is supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Dartmouth SYNERGY, National Institutes of Health, National Center for Translational Science (UL1TR001086).