Editorial

In their study of goals of care (GOC) discussions and documentation, Wong et al. add to already robust evidence that communication, in this case from physicians caring for hospitalized patients back to long‐term care facilities, has room for improvement. They highlight that 37.5% of patients had documented discussions, and for cases in which these discussions resulted in changes to a patient's advance directive, only 1 in 4 were relayed in the discharge summary.[1]

As physicians caring for hospitalized patients and concerned with improving care quality and efficiency, many of us are familiar with potential systems solutions to augmenting communication: reminders in the electronic health record, checklists, multidisciplinary teams, scripts, and posthospitalization follow‐up phone calls. However, important as they are, these solutions often elide the underlying cognitive elements related to how we, as physicians, think about and engage in the diversity of cases presented to us, and to how we prioritize communication work.

Wong et al. looked at patient characteristics associated with performance of GOC discussions to understand when and why physicians might engage in GOC conversations in the hospital and to generate insights into potential targets for improvement. They found that characteristics of patients prior to hospital admission were not associated with GOC discussions; signs of acuity of illness were.[1] In other words, physicians in the hospital are pretty good at recognizing patients in extremis, and prioritize GOC discussions with these patients. What we are not good at, or might not be considering, is assessing the broader context of a patient's health.

Whether we interpret these results as appropriate prioritization, or as a sign that we are waiting too long to broach the subject of care goals, depends on how we conceptualize the hospital stay in the context of a patient's health story, and, by extension, the role of the hospitalist in this story. For some patients, an acute illness requiring hospitalization is unexpected and readily treated, and the patient rapidly returns to a prior level of health and function. The need for hospitalization represents an outlier state.

For other patients, often older, more debilitated, or with multiple and chronic medical conditions, minor changes in health or declines in mental, social, or physical function precipitate the need for hospitalization. Likewise, iatrogenic harms of hospitalizationsleeplessness, fasting, delirium, immobilitycan contribute to enduring decline.[2, 3] For these patients, the need for hospitalization is not so far from, or may be, their norm.[4]

I suspect that Wong et al.'s findings reflect a collective response to the uncertainties of prognostication, and the resultant discomfort in raising questions that are difficult to answer. How do we know it is time to start talking about the right amount of care? Some might answer, I think rightly, that it is rarely if ever too early, yet robust discussions are challenging if we are not sure of the relevance or the immediate goal. In the case of the patient who is ill, declining, yet not in extremis, many of us might conclude that raising the question would not produce actionable information; it would not change immediate in‐hospital management.

This common conclusion leads to a significant missed opportunity, both on an individual level for physicians and patients, and for hospital medicine as a specialty. Health, and the losses that come with declining health, are wrapped up with fundamental aspects of our identities, and take time and consideration to change and evolve. Decisions about our healthcare are statements about who we have been, who we are, and who we will no longer be. Especially for the second group of patients described above, each hospital stay affords a chance to assess, counsel, educate, support, and empower patients to move in the direction of their values, and to ready them for that eventuality when they or their loved ones are faced with decisions about how, and where, they will die. As specialists in hospital‐based healthcare, hospitalists have the privilege and professional duty to facilitate this journey.

However, as hospitalists, we are often meeting patients for the first time; how do we assimilate an understanding of that point in time within the context of a patient's life with enough confidence to engage discussions? As Wong et al. show, it appears that in regard to very ill patients, respiratory rate and Glasgow Coma Scale inform action.[1] What signs or observations help inform action earlier in the trajectory of decline, to allow for anticipatory guidance and discussion? Increasingly, we see evidence that measures of frailty and functional status, applied in the hospital, are associated with hospital outcomes including readmission and death.[5, 6, 7] Future work might explore if training physicians to systematically assess frailty and functional status leads to greater frequency of, and comfort with, initiating GOC discussions during hospitalization.

Moreover, an emphasis on evaluating frailty and function, and explicitly including this assessment in our clinical decision‐making might help shift our thinking toward valuing each hospitalization as an opportunity to both intervene to improve function[8, 9] and to support, educate, and prepare patients under our care for the journey aheadin other words, to fully engage with our role as specialists in the comprehensive and coordinated treatment of patients who require hospitalization.

In their study of goals of care (GOC) discussions and documentation, Wong et al. add to already robust evidence that communication, in this case from physicians caring for hospitalized patients back to long‐term care facilities, has room for improvement. They highlight that 37.5% of patients had documented discussions, and for cases in which these discussions resulted in changes to a patient's advance directive, only 1 in 4 were relayed in the discharge summary.[1]

As physicians caring for hospitalized patients and concerned with improving care quality and efficiency, many of us are familiar with potential systems solutions to augmenting communication: reminders in the electronic health record, checklists, multidisciplinary teams, scripts, and posthospitalization follow‐up phone calls. However, important as they are, these solutions often elide the underlying cognitive elements related to how we, as physicians, think about and engage in the diversity of cases presented to us, and to how we prioritize communication work.

Wong et al. looked at patient characteristics associated with performance of GOC discussions to understand when and why physicians might engage in GOC conversations in the hospital and to generate insights into potential targets for improvement. They found that characteristics of patients prior to hospital admission were not associated with GOC discussions; signs of acuity of illness were.[1] In other words, physicians in the hospital are pretty good at recognizing patients in extremis, and prioritize GOC discussions with these patients. What we are not good at, or might not be considering, is assessing the broader context of a patient's health.

Whether we interpret these results as appropriate prioritization, or as a sign that we are waiting too long to broach the subject of care goals, depends on how we conceptualize the hospital stay in the context of a patient's health story, and, by extension, the role of the hospitalist in this story. For some patients, an acute illness requiring hospitalization is unexpected and readily treated, and the patient rapidly returns to a prior level of health and function. The need for hospitalization represents an outlier state.

For other patients, often older, more debilitated, or with multiple and chronic medical conditions, minor changes in health or declines in mental, social, or physical function precipitate the need for hospitalization. Likewise, iatrogenic harms of hospitalizationsleeplessness, fasting, delirium, immobilitycan contribute to enduring decline.[2, 3] For these patients, the need for hospitalization is not so far from, or may be, their norm.[4]

I suspect that Wong et al.'s findings reflect a collective response to the uncertainties of prognostication, and the resultant discomfort in raising questions that are difficult to answer. How do we know it is time to start talking about the right amount of care? Some might answer, I think rightly, that it is rarely if ever too early, yet robust discussions are challenging if we are not sure of the relevance or the immediate goal. In the case of the patient who is ill, declining, yet not in extremis, many of us might conclude that raising the question would not produce actionable information; it would not change immediate in‐hospital management.

This common conclusion leads to a significant missed opportunity, both on an individual level for physicians and patients, and for hospital medicine as a specialty. Health, and the losses that come with declining health, are wrapped up with fundamental aspects of our identities, and take time and consideration to change and evolve. Decisions about our healthcare are statements about who we have been, who we are, and who we will no longer be. Especially for the second group of patients described above, each hospital stay affords a chance to assess, counsel, educate, support, and empower patients to move in the direction of their values, and to ready them for that eventuality when they or their loved ones are faced with decisions about how, and where, they will die. As specialists in hospital‐based healthcare, hospitalists have the privilege and professional duty to facilitate this journey.

However, as hospitalists, we are often meeting patients for the first time; how do we assimilate an understanding of that point in time within the context of a patient's life with enough confidence to engage discussions? As Wong et al. show, it appears that in regard to very ill patients, respiratory rate and Glasgow Coma Scale inform action.[1] What signs or observations help inform action earlier in the trajectory of decline, to allow for anticipatory guidance and discussion? Increasingly, we see evidence that measures of frailty and functional status, applied in the hospital, are associated with hospital outcomes including readmission and death.[5, 6, 7] Future work might explore if training physicians to systematically assess frailty and functional status leads to greater frequency of, and comfort with, initiating GOC discussions during hospitalization.

Moreover, an emphasis on evaluating frailty and function, and explicitly including this assessment in our clinical decision‐making might help shift our thinking toward valuing each hospitalization as an opportunity to both intervene to improve function[8, 9] and to support, educate, and prepare patients under our care for the journey aheadin other words, to fully engage with our role as specialists in the comprehensive and coordinated treatment of patients who require hospitalization.

In their study of goals of care (GOC) discussions and documentation, Wong et al. add to already robust evidence that communication, in this case from physicians caring for hospitalized patients back to long‐term care facilities, has room for improvement. They highlight that 37.5% of patients had documented discussions, and for cases in which these discussions resulted in changes to a patient's advance directive, only 1 in 4 were relayed in the discharge summary.[1]

As physicians caring for hospitalized patients and concerned with improving care quality and efficiency, many of us are familiar with potential systems solutions to augmenting communication: reminders in the electronic health record, checklists, multidisciplinary teams, scripts, and posthospitalization follow‐up phone calls. However, important as they are, these solutions often elide the underlying cognitive elements related to how we, as physicians, think about and engage in the diversity of cases presented to us, and to how we prioritize communication work.

Wong et al. looked at patient characteristics associated with performance of GOC discussions to understand when and why physicians might engage in GOC conversations in the hospital and to generate insights into potential targets for improvement. They found that characteristics of patients prior to hospital admission were not associated with GOC discussions; signs of acuity of illness were.[1] In other words, physicians in the hospital are pretty good at recognizing patients in extremis, and prioritize GOC discussions with these patients. What we are not good at, or might not be considering, is assessing the broader context of a patient's health.

Whether we interpret these results as appropriate prioritization, or as a sign that we are waiting too long to broach the subject of care goals, depends on how we conceptualize the hospital stay in the context of a patient's health story, and, by extension, the role of the hospitalist in this story. For some patients, an acute illness requiring hospitalization is unexpected and readily treated, and the patient rapidly returns to a prior level of health and function. The need for hospitalization represents an outlier state.

For other patients, often older, more debilitated, or with multiple and chronic medical conditions, minor changes in health or declines in mental, social, or physical function precipitate the need for hospitalization. Likewise, iatrogenic harms of hospitalizationsleeplessness, fasting, delirium, immobilitycan contribute to enduring decline.[2, 3] For these patients, the need for hospitalization is not so far from, or may be, their norm.[4]

I suspect that Wong et al.'s findings reflect a collective response to the uncertainties of prognostication, and the resultant discomfort in raising questions that are difficult to answer. How do we know it is time to start talking about the right amount of care? Some might answer, I think rightly, that it is rarely if ever too early, yet robust discussions are challenging if we are not sure of the relevance or the immediate goal. In the case of the patient who is ill, declining, yet not in extremis, many of us might conclude that raising the question would not produce actionable information; it would not change immediate in‐hospital management.

This common conclusion leads to a significant missed opportunity, both on an individual level for physicians and patients, and for hospital medicine as a specialty. Health, and the losses that come with declining health, are wrapped up with fundamental aspects of our identities, and take time and consideration to change and evolve. Decisions about our healthcare are statements about who we have been, who we are, and who we will no longer be. Especially for the second group of patients described above, each hospital stay affords a chance to assess, counsel, educate, support, and empower patients to move in the direction of their values, and to ready them for that eventuality when they or their loved ones are faced with decisions about how, and where, they will die. As specialists in hospital‐based healthcare, hospitalists have the privilege and professional duty to facilitate this journey.

However, as hospitalists, we are often meeting patients for the first time; how do we assimilate an understanding of that point in time within the context of a patient's life with enough confidence to engage discussions? As Wong et al. show, it appears that in regard to very ill patients, respiratory rate and Glasgow Coma Scale inform action.[1] What signs or observations help inform action earlier in the trajectory of decline, to allow for anticipatory guidance and discussion? Increasingly, we see evidence that measures of frailty and functional status, applied in the hospital, are associated with hospital outcomes including readmission and death.[5, 6, 7] Future work might explore if training physicians to systematically assess frailty and functional status leads to greater frequency of, and comfort with, initiating GOC discussions during hospitalization.

Moreover, an emphasis on evaluating frailty and function, and explicitly including this assessment in our clinical decision‐making might help shift our thinking toward valuing each hospitalization as an opportunity to both intervene to improve function[8, 9] and to support, educate, and prepare patients under our care for the journey aheadin other words, to fully engage with our role as specialists in the comprehensive and coordinated treatment of patients who require hospitalization.

Deciding when a hospitalized child's vital signs are acceptably within range and when they should generate alerts, alarms, and escalations of care is critically important yet surprisingly complicated. Many patients in the hospital who are recovering appropriately exhibit vital signs that fall outside normal ranges for well children. In a technology‐focused hospital environment, these out‐of‐range vital signs often generate alerts in the electronic health record (EHR) and alarms on physiologic monitors that can disrupt patients' sleep, generate concern in parents, lead to unnecessary testing and treatment by physicians, interrupt nurses during important patient care tasks, and lead to alarm fatigue. It is this last area, the problem of alarm fatigue, that Goel and colleagues[1] have used to frame the rationale and results of their study reported in this issue of the Journal of Hospital Medicine.

Goel and colleagues correctly point out that physiologic monitor alarm rates are high in children's hospitals, and alarms warranting intervention or action are rare.[2, 3, 4, 5, 6] Few studies have rigorously examined interventions to reduce unnecessary hospital physiologic monitor alarms, especially in pediatric settings. Of all the potential interventions, widening parameters has the most face validity: if you set wide enough alarm parameters, fewer alarms will be triggered. However, it comes with a potential safety tradeoff of missed actionable alarms.

Before EHR data became widely available for research, normal (or perhaps more appropriate for the hospital setting, expected) vital sign ranges were defined using expert opinion. The first publication describing the distribution of EHR‐documented vital signs in hospitalized children was published in 2013.[7] Goel and colleagues have built upon this prior work in their article, in which they present percentiles of EHR‐documented heart rate (HR) and respiratory rate (RR) developed using data from more than 7000 children hospitalized at an academic children's hospital. In a separate validation dataset, they then compared the performance of their proposed physiologic monitor alarm parametersthe 5th and 95th percentiles for HR and RR from this studyto the 2004 National Institutes of Health (NIH) vital sign reference ranges[8] that were the basis of default alarm parameters at their hospital. They also compared their percentiles to the 2013 study.[7]

The 2 main findings of Goel and colleagues' study were: (1) using their separate validation dataset, 55.6% fewer HR and RR observations were out of range based on their newly developed percentiles as compared to the NIH vital sign reference ranges; and (2) the HR and RR percentiles they developed were very similar to those reported in the 2013 study,[7] which used data from 2 other institutions, externally validating their findings.

The team then pushed the data a step further in a safety analysis and evaluated the sensitivity of the 5th and 95th percentiles for HR and RR from this study for detecting deterioration in 148 patients in the 12 hours before either a rapid response team activation or a cardiorespiratory arrest. The overall sensitivity for having either a HR or RR value out of range was 93% for Goel and colleagues' percentiles and 97% for the NIH ranges. Goel and colleagues concluded that using the 5th and 95th HR and RR percentiles provides a potentially safe means by which to modify physiologic bedside monitor alarm limits.

There are 2 important limitations to this work. The first is that the study uses EHR‐documented data to estimate the performance of new physiologic monitor settings. Although there are few published reports of differences between nurse‐charted vital signs and monitor data, those that do exist suggest that nurse charting favors more stable vital signs,[9, 10] even when charting oxygen saturation in patients with true, prolonged desaturation.[9] We agree with the authors of 1 report, who speculated that nurses recognize that temporary changes in vital signs are untypical for that patient and might choose to ignore them and either await a period of stability or make an educated estimate for that hour.[9] When using Goel and colleagues' 5th and 95th percentiles as alarm parameters, the expected scenario is that monitors will generate alarms for 10% of HR values and 10% of RR values. Because of the differences between nurse‐charted vital signs and monitor data, the monitors will probably generate many more alarms.

The second limitation is the approach Goel and colleagues took in performing a safety analysis using chart review. Unfortunately, it is nearly impossible for a retrospective chart review to form the basis of a convincing scientific argument for the safety of different alarm parameters. It requires balancing the complex and sometimes competing nurse‐level, patient‐level, and alarm‐level factors that determine nurse response time to alarms. It is possible to do prospectively, and we hope Goel's team will follow up this article with a description of the implementation and safety of these parameters in clinical practice.

In addition, the clinical implications of HR and RR at the 95th percentile might be considered less immediately life threatening than HR and RR at the 5th percentile, even though statistically they are equally abnormal. When choosing percentile‐based alarm parameters, statistical symmetry might be less important than the potential immediate consequences of missing bradycardia or bradypnea. It would be reasonable to consider setting high HR and RR at the 99th percentile or higher, because elevated HR or RR alone is rarely immediately actionable, and set the low HR and RR at the 5th or 10th percentile.

Despite these caveats, should the percentiles proposed by Goel and colleagues be used to inform pediatric vital sign clinical decision support throughout the world? When faced with the alternative of using vital sign parameters that are not based on data from hospitalized children, these percentiles offer a clear advantage, especially for hospitals similar to Goel's. The most obvious immediate use for these percentiles is to improve noninterruptive[11] vital sign clinical decision support in the EHR, the actual source of the data in this study.

The question of whether to implement Goel's 5th and 95th percentiles as physiologic monitor alarm parameters is more complex. In contrast to EHR decision support, there are much clearer downstream consequences of sounding unnecessary alarms as well as failing to sound important alarms for a child in extremis. Because their percentiles are not based on monitor data, the projected number of alarms generated at different percentile thresholds cannot be accurately estimated, although using their 5th and 95th percentiles should result in fewer alarms than the NIH parameters.

In conclusion, the work by Goel and colleagues represents an important contribution to knowledge about the ranges of expected vital signs in hospitalized children. Their findings can be immediately used to guide EHR decision support. Their percentiles are also relevant to physiologic monitor alarm parameters, although the performance and safety of using the 5th and 95th percentiles remain in question. Hospitals aiming to implement these data‐driven parameters should first evaluate the performance of different percentiles from this article using data obtained from their own monitor system and, if proceeding with clinical implementation, pilot the parameters to accurately gauge alarm rates and assess safety before spreading hospital wide.

Deciding when a hospitalized child's vital signs are acceptably within range and when they should generate alerts, alarms, and escalations of care is critically important yet surprisingly complicated. Many patients in the hospital who are recovering appropriately exhibit vital signs that fall outside normal ranges for well children. In a technology‐focused hospital environment, these out‐of‐range vital signs often generate alerts in the electronic health record (EHR) and alarms on physiologic monitors that can disrupt patients' sleep, generate concern in parents, lead to unnecessary testing and treatment by physicians, interrupt nurses during important patient care tasks, and lead to alarm fatigue. It is this last area, the problem of alarm fatigue, that Goel and colleagues[1] have used to frame the rationale and results of their study reported in this issue of the Journal of Hospital Medicine.

Goel and colleagues correctly point out that physiologic monitor alarm rates are high in children's hospitals, and alarms warranting intervention or action are rare.[2, 3, 4, 5, 6] Few studies have rigorously examined interventions to reduce unnecessary hospital physiologic monitor alarms, especially in pediatric settings. Of all the potential interventions, widening parameters has the most face validity: if you set wide enough alarm parameters, fewer alarms will be triggered. However, it comes with a potential safety tradeoff of missed actionable alarms.

Before EHR data became widely available for research, normal (or perhaps more appropriate for the hospital setting, expected) vital sign ranges were defined using expert opinion. The first publication describing the distribution of EHR‐documented vital signs in hospitalized children was published in 2013.[7] Goel and colleagues have built upon this prior work in their article, in which they present percentiles of EHR‐documented heart rate (HR) and respiratory rate (RR) developed using data from more than 7000 children hospitalized at an academic children's hospital. In a separate validation dataset, they then compared the performance of their proposed physiologic monitor alarm parametersthe 5th and 95th percentiles for HR and RR from this studyto the 2004 National Institutes of Health (NIH) vital sign reference ranges[8] that were the basis of default alarm parameters at their hospital. They also compared their percentiles to the 2013 study.[7]

The 2 main findings of Goel and colleagues' study were: (1) using their separate validation dataset, 55.6% fewer HR and RR observations were out of range based on their newly developed percentiles as compared to the NIH vital sign reference ranges; and (2) the HR and RR percentiles they developed were very similar to those reported in the 2013 study,[7] which used data from 2 other institutions, externally validating their findings.

The team then pushed the data a step further in a safety analysis and evaluated the sensitivity of the 5th and 95th percentiles for HR and RR from this study for detecting deterioration in 148 patients in the 12 hours before either a rapid response team activation or a cardiorespiratory arrest. The overall sensitivity for having either a HR or RR value out of range was 93% for Goel and colleagues' percentiles and 97% for the NIH ranges. Goel and colleagues concluded that using the 5th and 95th HR and RR percentiles provides a potentially safe means by which to modify physiologic bedside monitor alarm limits.

There are 2 important limitations to this work. The first is that the study uses EHR‐documented data to estimate the performance of new physiologic monitor settings. Although there are few published reports of differences between nurse‐charted vital signs and monitor data, those that do exist suggest that nurse charting favors more stable vital signs,[9, 10] even when charting oxygen saturation in patients with true, prolonged desaturation.[9] We agree with the authors of 1 report, who speculated that nurses recognize that temporary changes in vital signs are untypical for that patient and might choose to ignore them and either await a period of stability or make an educated estimate for that hour.[9] When using Goel and colleagues' 5th and 95th percentiles as alarm parameters, the expected scenario is that monitors will generate alarms for 10% of HR values and 10% of RR values. Because of the differences between nurse‐charted vital signs and monitor data, the monitors will probably generate many more alarms.

The second limitation is the approach Goel and colleagues took in performing a safety analysis using chart review. Unfortunately, it is nearly impossible for a retrospective chart review to form the basis of a convincing scientific argument for the safety of different alarm parameters. It requires balancing the complex and sometimes competing nurse‐level, patient‐level, and alarm‐level factors that determine nurse response time to alarms. It is possible to do prospectively, and we hope Goel's team will follow up this article with a description of the implementation and safety of these parameters in clinical practice.

In addition, the clinical implications of HR and RR at the 95th percentile might be considered less immediately life threatening than HR and RR at the 5th percentile, even though statistically they are equally abnormal. When choosing percentile‐based alarm parameters, statistical symmetry might be less important than the potential immediate consequences of missing bradycardia or bradypnea. It would be reasonable to consider setting high HR and RR at the 99th percentile or higher, because elevated HR or RR alone is rarely immediately actionable, and set the low HR and RR at the 5th or 10th percentile.

Despite these caveats, should the percentiles proposed by Goel and colleagues be used to inform pediatric vital sign clinical decision support throughout the world? When faced with the alternative of using vital sign parameters that are not based on data from hospitalized children, these percentiles offer a clear advantage, especially for hospitals similar to Goel's. The most obvious immediate use for these percentiles is to improve noninterruptive[11] vital sign clinical decision support in the EHR, the actual source of the data in this study.

The question of whether to implement Goel's 5th and 95th percentiles as physiologic monitor alarm parameters is more complex. In contrast to EHR decision support, there are much clearer downstream consequences of sounding unnecessary alarms as well as failing to sound important alarms for a child in extremis. Because their percentiles are not based on monitor data, the projected number of alarms generated at different percentile thresholds cannot be accurately estimated, although using their 5th and 95th percentiles should result in fewer alarms than the NIH parameters.

In conclusion, the work by Goel and colleagues represents an important contribution to knowledge about the ranges of expected vital signs in hospitalized children. Their findings can be immediately used to guide EHR decision support. Their percentiles are also relevant to physiologic monitor alarm parameters, although the performance and safety of using the 5th and 95th percentiles remain in question. Hospitals aiming to implement these data‐driven parameters should first evaluate the performance of different percentiles from this article using data obtained from their own monitor system and, if proceeding with clinical implementation, pilot the parameters to accurately gauge alarm rates and assess safety before spreading hospital wide.

Deciding when a hospitalized child's vital signs are acceptably within range and when they should generate alerts, alarms, and escalations of care is critically important yet surprisingly complicated. Many patients in the hospital who are recovering appropriately exhibit vital signs that fall outside normal ranges for well children. In a technology‐focused hospital environment, these out‐of‐range vital signs often generate alerts in the electronic health record (EHR) and alarms on physiologic monitors that can disrupt patients' sleep, generate concern in parents, lead to unnecessary testing and treatment by physicians, interrupt nurses during important patient care tasks, and lead to alarm fatigue. It is this last area, the problem of alarm fatigue, that Goel and colleagues[1] have used to frame the rationale and results of their study reported in this issue of the Journal of Hospital Medicine.

Goel and colleagues correctly point out that physiologic monitor alarm rates are high in children's hospitals, and alarms warranting intervention or action are rare.[2, 3, 4, 5, 6] Few studies have rigorously examined interventions to reduce unnecessary hospital physiologic monitor alarms, especially in pediatric settings. Of all the potential interventions, widening parameters has the most face validity: if you set wide enough alarm parameters, fewer alarms will be triggered. However, it comes with a potential safety tradeoff of missed actionable alarms.

Before EHR data became widely available for research, normal (or perhaps more appropriate for the hospital setting, expected) vital sign ranges were defined using expert opinion. The first publication describing the distribution of EHR‐documented vital signs in hospitalized children was published in 2013.[7] Goel and colleagues have built upon this prior work in their article, in which they present percentiles of EHR‐documented heart rate (HR) and respiratory rate (RR) developed using data from more than 7000 children hospitalized at an academic children's hospital. In a separate validation dataset, they then compared the performance of their proposed physiologic monitor alarm parametersthe 5th and 95th percentiles for HR and RR from this studyto the 2004 National Institutes of Health (NIH) vital sign reference ranges[8] that were the basis of default alarm parameters at their hospital. They also compared their percentiles to the 2013 study.[7]

The 2 main findings of Goel and colleagues' study were: (1) using their separate validation dataset, 55.6% fewer HR and RR observations were out of range based on their newly developed percentiles as compared to the NIH vital sign reference ranges; and (2) the HR and RR percentiles they developed were very similar to those reported in the 2013 study,[7] which used data from 2 other institutions, externally validating their findings.

The team then pushed the data a step further in a safety analysis and evaluated the sensitivity of the 5th and 95th percentiles for HR and RR from this study for detecting deterioration in 148 patients in the 12 hours before either a rapid response team activation or a cardiorespiratory arrest. The overall sensitivity for having either a HR or RR value out of range was 93% for Goel and colleagues' percentiles and 97% for the NIH ranges. Goel and colleagues concluded that using the 5th and 95th HR and RR percentiles provides a potentially safe means by which to modify physiologic bedside monitor alarm limits.

There are 2 important limitations to this work. The first is that the study uses EHR‐documented data to estimate the performance of new physiologic monitor settings. Although there are few published reports of differences between nurse‐charted vital signs and monitor data, those that do exist suggest that nurse charting favors more stable vital signs,[9, 10] even when charting oxygen saturation in patients with true, prolonged desaturation.[9] We agree with the authors of 1 report, who speculated that nurses recognize that temporary changes in vital signs are untypical for that patient and might choose to ignore them and either await a period of stability or make an educated estimate for that hour.[9] When using Goel and colleagues' 5th and 95th percentiles as alarm parameters, the expected scenario is that monitors will generate alarms for 10% of HR values and 10% of RR values. Because of the differences between nurse‐charted vital signs and monitor data, the monitors will probably generate many more alarms.

The second limitation is the approach Goel and colleagues took in performing a safety analysis using chart review. Unfortunately, it is nearly impossible for a retrospective chart review to form the basis of a convincing scientific argument for the safety of different alarm parameters. It requires balancing the complex and sometimes competing nurse‐level, patient‐level, and alarm‐level factors that determine nurse response time to alarms. It is possible to do prospectively, and we hope Goel's team will follow up this article with a description of the implementation and safety of these parameters in clinical practice.

In addition, the clinical implications of HR and RR at the 95th percentile might be considered less immediately life threatening than HR and RR at the 5th percentile, even though statistically they are equally abnormal. When choosing percentile‐based alarm parameters, statistical symmetry might be less important than the potential immediate consequences of missing bradycardia or bradypnea. It would be reasonable to consider setting high HR and RR at the 99th percentile or higher, because elevated HR or RR alone is rarely immediately actionable, and set the low HR and RR at the 5th or 10th percentile.

Despite these caveats, should the percentiles proposed by Goel and colleagues be used to inform pediatric vital sign clinical decision support throughout the world? When faced with the alternative of using vital sign parameters that are not based on data from hospitalized children, these percentiles offer a clear advantage, especially for hospitals similar to Goel's. The most obvious immediate use for these percentiles is to improve noninterruptive[11] vital sign clinical decision support in the EHR, the actual source of the data in this study.

The question of whether to implement Goel's 5th and 95th percentiles as physiologic monitor alarm parameters is more complex. In contrast to EHR decision support, there are much clearer downstream consequences of sounding unnecessary alarms as well as failing to sound important alarms for a child in extremis. Because their percentiles are not based on monitor data, the projected number of alarms generated at different percentile thresholds cannot be accurately estimated, although using their 5th and 95th percentiles should result in fewer alarms than the NIH parameters.

In conclusion, the work by Goel and colleagues represents an important contribution to knowledge about the ranges of expected vital signs in hospitalized children. Their findings can be immediately used to guide EHR decision support. Their percentiles are also relevant to physiologic monitor alarm parameters, although the performance and safety of using the 5th and 95th percentiles remain in question. Hospitals aiming to implement these data‐driven parameters should first evaluate the performance of different percentiles from this article using data obtained from their own monitor system and, if proceeding with clinical implementation, pilot the parameters to accurately gauge alarm rates and assess safety before spreading hospital wide.

In 1995 I took my first job as a hospitalist at a community teaching hospital where hospitalists, though then known as medical directors, had been in place for 20 years. Soon afterward, our field gained a name, and my old job no longer was mistaken for a utilization review functionary or lead of a medical unit.

I have been lucky enough to have seen the field of hospital medicine grow rapidly in scope and importance. The growth of our specialty in mere numbers alone is a testament to the value we in hospital medicine (MDs, DOs, PAs, NPs) bring to the care of acutely ill patients. We are the front line caring for the elderly and vulnerable, the glue holding transdisciplinary care teams together, and lead hospitals, health systems, and governmental organizations. Hospitalists touch the lives of our patients, and shape the health systems' practices and health policy on a national and international scale. These are remarkable achievements for a field which, just a few years ago, was concerned about becoming a job equivalent to perpetual residency training (or worse) and gained only grudging acceptance.[1] There is no doubt that the roles of hospitalists will continue to evolve, and whereas hospitalists will be able to shape the debates and development of new programs solving the problems of our health systems, we must take time to foster the mind, heart, and soul of our field.

When I speak of the mind of hospital medicine, I am thinking of our field's contribution to the evidence for how to care for patients' illnesses, a different body of knowledge than our field's focus to date on hospitals and health systems. Hospital medicine has been growing research capacity at a rate that is slower than the field overall, a problem in part due to limitations in National Institutes of Health funding for fellowships and early‐career awards, which in turn has restricted the pipeline of young and innovative researchers. Slow growth may also be a result of an emphasis on health systems rather than diseases.[2] I and others have written about the need to create mentoring support for junior research faculty as a way to promote success and avoid burnout,[3, 4, 5, 6, 7] and while at least 1 hospital medicine research network exists,[8] there is room for many more. However, at its core, our specialty needs to devote more time and focus to becoming a full scientific partner with our colleagues in cardiology, pulmonary medicine, and critical care, among others. To develop the mind of hospital medicine we will also need to think about our contributions to useful clinical guidelines for care of diseases and patients. Developing trustworthy clinical guidelines can be time consuming[9] but is a key part of ensuring patients and families understand the rationale for changes in clinical care. Hospital medicine as a field has been a leader in programs that develop approaches to implementing evidence and stands in an excellent position toperhaps in collaboration with other specialtiescreate the next‐generation guidelines that are practically minded, evidence based, and end up being used.

The heart I speak of is how we can make sure that the field of hospital medicine is one that is attractive and sustainable as a career. Electronic health records' impact on day‐to‐day work is substantial and a large part of the problem, though a more fundamental problem we face is in how to create sustainable jobs at a time where we are going to need to deliver higher‐value care to more patients with the same number (or fewer) providers. This is an issue that means we need to settle many important aspects of our workpay, relationships with our peers, control over our work on a day‐to‐day basis, hospitalists' work schedules (such as the 7 days on/7 days off model)while we also grapple with how to work within a population‐health framework. I am not prescient enough to see all the solutions to burnout, but there are at least 2 opportunities hospitalists are perhaps best suited to develop and lead. The first is how we arrange our teams in the hospital and afterward. Recent articles have talked about how medicine needs to be open to Uber‐like disruptive models,[10] where labor is deployed in fundamentally different ways. Tools such as e‐consults, the application of population health tools to inpatient care, telemedicine, or some forms of predictive analytics may be examples of these tools, which are routes to allowing more care to be delivered more effectively and more efficiently. Another opportunity lies in how we adapt our electronic health records to our work (and vice versa). The perils of sloppy and paste documentation are indicative of the burden of busywork, the pressures of needing to focus on revenue rather than clinical utility, and exhaustion; hospitalists are well positioned to think about howas payment reform continues to evolvedocumentation can be less busywork and more clinically useful, patient oriented, and shareable across sites and phases of care.

Now to the soul of our field. Hospital medicine has rightly been considered a key partner in developing the solutions hospitals and health systems need to address gaps in quality, safety, value, and clinical outcomes. However, this self‐image of hospital medicine has the downside of being viewed as doctors for hospitals, rather than doctors for patients and families who are in hospitals. As we think about burnout and jobs that are fulfilling and meaningful over the long term, I increasingly return to the factors that motivated me and many others to become physicians: meaningful relationships with patients, being an excellent clinician, and making a lasting contribution to my community through my patient care, support of my colleagues, and teaching younger physicians. It is easy for the pressures of the hospital and need to fix problems rapidly to obscure these larger motivators, but our field will need to ensure that these elements remain how we prioritize and shape our field going forward. Hospital medicine is comprised of physicians who do clinical care and who in most cases entered the field for that reason alone. Using the true north of improving and innovating care in ways that impact patient livesnot just the needs of our hospitalsin meaningful ways will need to be the soul of our field, and will allow the mind and heart of hospitalists and hospital medicine to thrive.

In 1995 I took my first job as a hospitalist at a community teaching hospital where hospitalists, though then known as medical directors, had been in place for 20 years. Soon afterward, our field gained a name, and my old job no longer was mistaken for a utilization review functionary or lead of a medical unit.

I have been lucky enough to have seen the field of hospital medicine grow rapidly in scope and importance. The growth of our specialty in mere numbers alone is a testament to the value we in hospital medicine (MDs, DOs, PAs, NPs) bring to the care of acutely ill patients. We are the front line caring for the elderly and vulnerable, the glue holding transdisciplinary care teams together, and lead hospitals, health systems, and governmental organizations. Hospitalists touch the lives of our patients, and shape the health systems' practices and health policy on a national and international scale. These are remarkable achievements for a field which, just a few years ago, was concerned about becoming a job equivalent to perpetual residency training (or worse) and gained only grudging acceptance.[1] There is no doubt that the roles of hospitalists will continue to evolve, and whereas hospitalists will be able to shape the debates and development of new programs solving the problems of our health systems, we must take time to foster the mind, heart, and soul of our field.

When I speak of the mind of hospital medicine, I am thinking of our field's contribution to the evidence for how to care for patients' illnesses, a different body of knowledge than our field's focus to date on hospitals and health systems. Hospital medicine has been growing research capacity at a rate that is slower than the field overall, a problem in part due to limitations in National Institutes of Health funding for fellowships and early‐career awards, which in turn has restricted the pipeline of young and innovative researchers. Slow growth may also be a result of an emphasis on health systems rather than diseases.[2] I and others have written about the need to create mentoring support for junior research faculty as a way to promote success and avoid burnout,[3, 4, 5, 6, 7] and while at least 1 hospital medicine research network exists,[8] there is room for many more. However, at its core, our specialty needs to devote more time and focus to becoming a full scientific partner with our colleagues in cardiology, pulmonary medicine, and critical care, among others. To develop the mind of hospital medicine we will also need to think about our contributions to useful clinical guidelines for care of diseases and patients. Developing trustworthy clinical guidelines can be time consuming[9] but is a key part of ensuring patients and families understand the rationale for changes in clinical care. Hospital medicine as a field has been a leader in programs that develop approaches to implementing evidence and stands in an excellent position toperhaps in collaboration with other specialtiescreate the next‐generation guidelines that are practically minded, evidence based, and end up being used.

The heart I speak of is how we can make sure that the field of hospital medicine is one that is attractive and sustainable as a career. Electronic health records' impact on day‐to‐day work is substantial and a large part of the problem, though a more fundamental problem we face is in how to create sustainable jobs at a time where we are going to need to deliver higher‐value care to more patients with the same number (or fewer) providers. This is an issue that means we need to settle many important aspects of our workpay, relationships with our peers, control over our work on a day‐to‐day basis, hospitalists' work schedules (such as the 7 days on/7 days off model)while we also grapple with how to work within a population‐health framework. I am not prescient enough to see all the solutions to burnout, but there are at least 2 opportunities hospitalists are perhaps best suited to develop and lead. The first is how we arrange our teams in the hospital and afterward. Recent articles have talked about how medicine needs to be open to Uber‐like disruptive models,[10] where labor is deployed in fundamentally different ways. Tools such as e‐consults, the application of population health tools to inpatient care, telemedicine, or some forms of predictive analytics may be examples of these tools, which are routes to allowing more care to be delivered more effectively and more efficiently. Another opportunity lies in how we adapt our electronic health records to our work (and vice versa). The perils of sloppy and paste documentation are indicative of the burden of busywork, the pressures of needing to focus on revenue rather than clinical utility, and exhaustion; hospitalists are well positioned to think about howas payment reform continues to evolvedocumentation can be less busywork and more clinically useful, patient oriented, and shareable across sites and phases of care.

Now to the soul of our field. Hospital medicine has rightly been considered a key partner in developing the solutions hospitals and health systems need to address gaps in quality, safety, value, and clinical outcomes. However, this self‐image of hospital medicine has the downside of being viewed as doctors for hospitals, rather than doctors for patients and families who are in hospitals. As we think about burnout and jobs that are fulfilling and meaningful over the long term, I increasingly return to the factors that motivated me and many others to become physicians: meaningful relationships with patients, being an excellent clinician, and making a lasting contribution to my community through my patient care, support of my colleagues, and teaching younger physicians. It is easy for the pressures of the hospital and need to fix problems rapidly to obscure these larger motivators, but our field will need to ensure that these elements remain how we prioritize and shape our field going forward. Hospital medicine is comprised of physicians who do clinical care and who in most cases entered the field for that reason alone. Using the true north of improving and innovating care in ways that impact patient livesnot just the needs of our hospitalsin meaningful ways will need to be the soul of our field, and will allow the mind and heart of hospitalists and hospital medicine to thrive.

In 1995 I took my first job as a hospitalist at a community teaching hospital where hospitalists, though then known as medical directors, had been in place for 20 years. Soon afterward, our field gained a name, and my old job no longer was mistaken for a utilization review functionary or lead of a medical unit.

I have been lucky enough to have seen the field of hospital medicine grow rapidly in scope and importance. The growth of our specialty in mere numbers alone is a testament to the value we in hospital medicine (MDs, DOs, PAs, NPs) bring to the care of acutely ill patients. We are the front line caring for the elderly and vulnerable, the glue holding transdisciplinary care teams together, and lead hospitals, health systems, and governmental organizations. Hospitalists touch the lives of our patients, and shape the health systems' practices and health policy on a national and international scale. These are remarkable achievements for a field which, just a few years ago, was concerned about becoming a job equivalent to perpetual residency training (or worse) and gained only grudging acceptance.[1] There is no doubt that the roles of hospitalists will continue to evolve, and whereas hospitalists will be able to shape the debates and development of new programs solving the problems of our health systems, we must take time to foster the mind, heart, and soul of our field.

When I speak of the mind of hospital medicine, I am thinking of our field's contribution to the evidence for how to care for patients' illnesses, a different body of knowledge than our field's focus to date on hospitals and health systems. Hospital medicine has been growing research capacity at a rate that is slower than the field overall, a problem in part due to limitations in National Institutes of Health funding for fellowships and early‐career awards, which in turn has restricted the pipeline of young and innovative researchers. Slow growth may also be a result of an emphasis on health systems rather than diseases.[2] I and others have written about the need to create mentoring support for junior research faculty as a way to promote success and avoid burnout,[3, 4, 5, 6, 7] and while at least 1 hospital medicine research network exists,[8] there is room for many more. However, at its core, our specialty needs to devote more time and focus to becoming a full scientific partner with our colleagues in cardiology, pulmonary medicine, and critical care, among others. To develop the mind of hospital medicine we will also need to think about our contributions to useful clinical guidelines for care of diseases and patients. Developing trustworthy clinical guidelines can be time consuming[9] but is a key part of ensuring patients and families understand the rationale for changes in clinical care. Hospital medicine as a field has been a leader in programs that develop approaches to implementing evidence and stands in an excellent position toperhaps in collaboration with other specialtiescreate the next‐generation guidelines that are practically minded, evidence based, and end up being used.

The heart I speak of is how we can make sure that the field of hospital medicine is one that is attractive and sustainable as a career. Electronic health records' impact on day‐to‐day work is substantial and a large part of the problem, though a more fundamental problem we face is in how to create sustainable jobs at a time where we are going to need to deliver higher‐value care to more patients with the same number (or fewer) providers. This is an issue that means we need to settle many important aspects of our workpay, relationships with our peers, control over our work on a day‐to‐day basis, hospitalists' work schedules (such as the 7 days on/7 days off model)while we also grapple with how to work within a population‐health framework. I am not prescient enough to see all the solutions to burnout, but there are at least 2 opportunities hospitalists are perhaps best suited to develop and lead. The first is how we arrange our teams in the hospital and afterward. Recent articles have talked about how medicine needs to be open to Uber‐like disruptive models,[10] where labor is deployed in fundamentally different ways. Tools such as e‐consults, the application of population health tools to inpatient care, telemedicine, or some forms of predictive analytics may be examples of these tools, which are routes to allowing more care to be delivered more effectively and more efficiently. Another opportunity lies in how we adapt our electronic health records to our work (and vice versa). The perils of sloppy and paste documentation are indicative of the burden of busywork, the pressures of needing to focus on revenue rather than clinical utility, and exhaustion; hospitalists are well positioned to think about howas payment reform continues to evolvedocumentation can be less busywork and more clinically useful, patient oriented, and shareable across sites and phases of care.

Now to the soul of our field. Hospital medicine has rightly been considered a key partner in developing the solutions hospitals and health systems need to address gaps in quality, safety, value, and clinical outcomes. However, this self‐image of hospital medicine has the downside of being viewed as doctors for hospitals, rather than doctors for patients and families who are in hospitals. As we think about burnout and jobs that are fulfilling and meaningful over the long term, I increasingly return to the factors that motivated me and many others to become physicians: meaningful relationships with patients, being an excellent clinician, and making a lasting contribution to my community through my patient care, support of my colleagues, and teaching younger physicians. It is easy for the pressures of the hospital and need to fix problems rapidly to obscure these larger motivators, but our field will need to ensure that these elements remain how we prioritize and shape our field going forward. Hospital medicine is comprised of physicians who do clinical care and who in most cases entered the field for that reason alone. Using the true north of improving and innovating care in ways that impact patient livesnot just the needs of our hospitalsin meaningful ways will need to be the soul of our field, and will allow the mind and heart of hospitalists and hospital medicine to thrive.

When I was a resident, one common warning delivered to us by our putatively omniscient attendings was, Well you know, most children are not hospitalized at children's hospitals. This caution was likely meant to warn us future pediatricians that the supports and access to pediatric subspecialists we took for granted in a children's hospital would be different once we graduated and left for community settings. However, it is doubtful that any resident ever challenged the validity of that statement. Are most children hospitalized at general hospitals and is the availability of subspecialty services different between general and children's hospitals?

In this issue of the Journal of Hospital Medicine, Leyenaar et al.[1] set out to test that warning and to quantify where children in the United States are hospitalized. They investigated differences in the pediatric hospitalizations at general and freestanding children's hospitals. In doing so, their findings began to implicitly explore what is meant by the term children's hospital. The authors utilized the Agency for Healthcare Quality and Research's (AHQR) 2012 Kids Inpatient Database (KID), which after excluding in‐hospital births and pregnancy‐related admissions, captured nearly 4000 hospitals and 1.4 million acute care pediatric admissions across the United States.

Leyenaar et al. found that our attendings were correct, confirming a prior study on the subject[2]; close to three‐quarters of discharges were from general hospitals. However, although the most frequent reasons for hospitalization were similar between the 2 types of hospitals, that is where the similarities ended. They found that although the median annual number of discharges at the 50 freestanding children's hospitals was 12,000, it was only 56 at the nearly 4000 general hospitals. Approximately 80% of general hospitals (the equivalent of nearly 3000 hospitals) accounted for only 11% of all discharges and had less than 375 annual pediatric discharges, essentially 1 discharge per day or fewer. In addition, over one‐third of discharges at freestanding children's hospitals were for children with medical complexity, compared to 1 in 5 at general hospitals. Furthermore, one‐quarter of discharges at freestanding children's hospitals were of high or highest severity, compared with half that amount at general hospitals.

Although it is not possible to determine the quality of care from the KID, the authors insightfully discuss the implications these differences have on quality improvement and quality measurement. General hospitals with low volumes of pediatric inpatients may have difficulty providing condition‐specific quality metrics or implementing condition‐specific quality improvement processes. How can you compare quality across hospitals averaging only 56 pediatric admissions a year? If existing quality metrics are not meaningful for those hospitals, but the majority of children are admitted to them, the development of new, more useful, quality metrics is needed.

Perhaps the most interesting finding resulted from a new and unfortunate limitation in the KID database. Beginning in 2012, the AHQR began deidentifying all hospitals contributing data to the KID, leaving researchers reliant on KID's categorization of hospitals as either freestanding children's hospitals or general hospitals. The authors attempted to work around these limitations to identify those children's hospitals that were not freestanding but were located within general hospitals. They found that 36 general hospitals had patient volumes equivalent to freestanding children's hospitals, whereas 20 freestanding children's hospitals had very infrequent admissions for the most common discharge diagnoses. The authors are almost certainly correct in deeming the latter 20 hospitals to be subspecialty children's hospitals, such as those focused solely on orthopedic or oncologic conditions. Among the 36 high‐volume general hospitals, the authors found that patient complexity and severity was more similar to freestanding children's hospitals than to the low‐volume general hospitals. Length of stay (and therefore presumably costs as well) for high‐volume general hospitals was positioned between freestanding children's hospitals and low‐volume general hospitals.

Who are those high‐volume hospitals that appear to be general in name only? Because of KID's deidentification of hospitals, we do not know. It is possible that those hospitals self‐identify as being children's hospitals, but are not freestanding, meaning that they are located within a general hospital (hospitals within a hospital). If they are children's hospitals within general hospitals, it would provide a different perspective to the study's overall finding that 71% of hospitalizations, 64% of hospital days, and 50% of costs occur at general hospitals. As the authors allude to, some institutions may not call themselves freestanding children's hospitals but function that way; other institutions call themselves freestanding children's hospitals but offer very focused specialty services. Through this limitation in the KID database, the authors began the process of identifying hospitals that look like freestanding children's hospitals but are not called that. In other words, they began creating a more robust functional definition of which institutions are truly children's hospitals. Volume does not, of course, always equate into specialization, and much work needs to be done measuring the availability of subspecialty and critical care services before any functional definition of children's hospital can be made; the potential, however, is intriguing.

Does it matter which hospitals are deemed children's hospitals? Although a hospitalist may not place importance on the name over the hospital's entrance, the Centers for Medicare and Medicaid Services (CMS) and state insurance regulators may find the difference extremely important. CMS and state insurance regulators are increasingly focusing their attention on the adequacy of pediatric insurance networks.[3, 4, 5, 6] They are seeking to create rules that ensure health insurance plans have a broad range of pediatric subspecialists in close proximity to the great majority of children insured by the plan. For adult insurance, the adequacy of a plan's network is typically defined by the time and distance from a patient's home to a specialist. However, unlike in adult medicine, pediatric subspecialty care is becoming increasingly regionalized at academic medical centers, especially children's hospitals. Furthermore, unlike adult care, a wide range of pediatric subspecialists is unlikely to be found at the hospital closest to a patient's home. Therefore, time and distance rules for ensuring network adequacy may fail within pediatric care. Instead, inclusion of a hospital designatedby functional or other criteriaas a children's hospital may be the best way to ensure the adequate provision of pediatric specialty care within a network.

How policymakers define pediatric network adequacy will have important implications for ensuring that pediatric inpatient medicine achieves the goal of the right patient, the right place, the right time. Therefore, the attending from our residency may have been correct that most children are not hospitalized at children's hospitals. However, depending on how pediatric network adequacy rules are developed, that may not have to mean that these children (and their pediatricians) will be out there alone.

When I was a resident, one common warning delivered to us by our putatively omniscient attendings was, Well you know, most children are not hospitalized at children's hospitals. This caution was likely meant to warn us future pediatricians that the supports and access to pediatric subspecialists we took for granted in a children's hospital would be different once we graduated and left for community settings. However, it is doubtful that any resident ever challenged the validity of that statement. Are most children hospitalized at general hospitals and is the availability of subspecialty services different between general and children's hospitals?

In this issue of the Journal of Hospital Medicine, Leyenaar et al.[1] set out to test that warning and to quantify where children in the United States are hospitalized. They investigated differences in the pediatric hospitalizations at general and freestanding children's hospitals. In doing so, their findings began to implicitly explore what is meant by the term children's hospital. The authors utilized the Agency for Healthcare Quality and Research's (AHQR) 2012 Kids Inpatient Database (KID), which after excluding in‐hospital births and pregnancy‐related admissions, captured nearly 4000 hospitals and 1.4 million acute care pediatric admissions across the United States.

Leyenaar et al. found that our attendings were correct, confirming a prior study on the subject[2]; close to three‐quarters of discharges were from general hospitals. However, although the most frequent reasons for hospitalization were similar between the 2 types of hospitals, that is where the similarities ended. They found that although the median annual number of discharges at the 50 freestanding children's hospitals was 12,000, it was only 56 at the nearly 4000 general hospitals. Approximately 80% of general hospitals (the equivalent of nearly 3000 hospitals) accounted for only 11% of all discharges and had less than 375 annual pediatric discharges, essentially 1 discharge per day or fewer. In addition, over one‐third of discharges at freestanding children's hospitals were for children with medical complexity, compared to 1 in 5 at general hospitals. Furthermore, one‐quarter of discharges at freestanding children's hospitals were of high or highest severity, compared with half that amount at general hospitals.

Although it is not possible to determine the quality of care from the KID, the authors insightfully discuss the implications these differences have on quality improvement and quality measurement. General hospitals with low volumes of pediatric inpatients may have difficulty providing condition‐specific quality metrics or implementing condition‐specific quality improvement processes. How can you compare quality across hospitals averaging only 56 pediatric admissions a year? If existing quality metrics are not meaningful for those hospitals, but the majority of children are admitted to them, the development of new, more useful, quality metrics is needed.

Perhaps the most interesting finding resulted from a new and unfortunate limitation in the KID database. Beginning in 2012, the AHQR began deidentifying all hospitals contributing data to the KID, leaving researchers reliant on KID's categorization of hospitals as either freestanding children's hospitals or general hospitals. The authors attempted to work around these limitations to identify those children's hospitals that were not freestanding but were located within general hospitals. They found that 36 general hospitals had patient volumes equivalent to freestanding children's hospitals, whereas 20 freestanding children's hospitals had very infrequent admissions for the most common discharge diagnoses. The authors are almost certainly correct in deeming the latter 20 hospitals to be subspecialty children's hospitals, such as those focused solely on orthopedic or oncologic conditions. Among the 36 high‐volume general hospitals, the authors found that patient complexity and severity was more similar to freestanding children's hospitals than to the low‐volume general hospitals. Length of stay (and therefore presumably costs as well) for high‐volume general hospitals was positioned between freestanding children's hospitals and low‐volume general hospitals.

Who are those high‐volume hospitals that appear to be general in name only? Because of KID's deidentification of hospitals, we do not know. It is possible that those hospitals self‐identify as being children's hospitals, but are not freestanding, meaning that they are located within a general hospital (hospitals within a hospital). If they are children's hospitals within general hospitals, it would provide a different perspective to the study's overall finding that 71% of hospitalizations, 64% of hospital days, and 50% of costs occur at general hospitals. As the authors allude to, some institutions may not call themselves freestanding children's hospitals but function that way; other institutions call themselves freestanding children's hospitals but offer very focused specialty services. Through this limitation in the KID database, the authors began the process of identifying hospitals that look like freestanding children's hospitals but are not called that. In other words, they began creating a more robust functional definition of which institutions are truly children's hospitals. Volume does not, of course, always equate into specialization, and much work needs to be done measuring the availability of subspecialty and critical care services before any functional definition of children's hospital can be made; the potential, however, is intriguing.

Does it matter which hospitals are deemed children's hospitals? Although a hospitalist may not place importance on the name over the hospital's entrance, the Centers for Medicare and Medicaid Services (CMS) and state insurance regulators may find the difference extremely important. CMS and state insurance regulators are increasingly focusing their attention on the adequacy of pediatric insurance networks.[3, 4, 5, 6] They are seeking to create rules that ensure health insurance plans have a broad range of pediatric subspecialists in close proximity to the great majority of children insured by the plan. For adult insurance, the adequacy of a plan's network is typically defined by the time and distance from a patient's home to a specialist. However, unlike in adult medicine, pediatric subspecialty care is becoming increasingly regionalized at academic medical centers, especially children's hospitals. Furthermore, unlike adult care, a wide range of pediatric subspecialists is unlikely to be found at the hospital closest to a patient's home. Therefore, time and distance rules for ensuring network adequacy may fail within pediatric care. Instead, inclusion of a hospital designatedby functional or other criteriaas a children's hospital may be the best way to ensure the adequate provision of pediatric specialty care within a network.

How policymakers define pediatric network adequacy will have important implications for ensuring that pediatric inpatient medicine achieves the goal of the right patient, the right place, the right time. Therefore, the attending from our residency may have been correct that most children are not hospitalized at children's hospitals. However, depending on how pediatric network adequacy rules are developed, that may not have to mean that these children (and their pediatricians) will be out there alone.

When I was a resident, one common warning delivered to us by our putatively omniscient attendings was, Well you know, most children are not hospitalized at children's hospitals. This caution was likely meant to warn us future pediatricians that the supports and access to pediatric subspecialists we took for granted in a children's hospital would be different once we graduated and left for community settings. However, it is doubtful that any resident ever challenged the validity of that statement. Are most children hospitalized at general hospitals and is the availability of subspecialty services different between general and children's hospitals?

In this issue of the Journal of Hospital Medicine, Leyenaar et al.[1] set out to test that warning and to quantify where children in the United States are hospitalized. They investigated differences in the pediatric hospitalizations at general and freestanding children's hospitals. In doing so, their findings began to implicitly explore what is meant by the term children's hospital. The authors utilized the Agency for Healthcare Quality and Research's (AHQR) 2012 Kids Inpatient Database (KID), which after excluding in‐hospital births and pregnancy‐related admissions, captured nearly 4000 hospitals and 1.4 million acute care pediatric admissions across the United States.

Leyenaar et al. found that our attendings were correct, confirming a prior study on the subject[2]; close to three‐quarters of discharges were from general hospitals. However, although the most frequent reasons for hospitalization were similar between the 2 types of hospitals, that is where the similarities ended. They found that although the median annual number of discharges at the 50 freestanding children's hospitals was 12,000, it was only 56 at the nearly 4000 general hospitals. Approximately 80% of general hospitals (the equivalent of nearly 3000 hospitals) accounted for only 11% of all discharges and had less than 375 annual pediatric discharges, essentially 1 discharge per day or fewer. In addition, over one‐third of discharges at freestanding children's hospitals were for children with medical complexity, compared to 1 in 5 at general hospitals. Furthermore, one‐quarter of discharges at freestanding children's hospitals were of high or highest severity, compared with half that amount at general hospitals.

Although it is not possible to determine the quality of care from the KID, the authors insightfully discuss the implications these differences have on quality improvement and quality measurement. General hospitals with low volumes of pediatric inpatients may have difficulty providing condition‐specific quality metrics or implementing condition‐specific quality improvement processes. How can you compare quality across hospitals averaging only 56 pediatric admissions a year? If existing quality metrics are not meaningful for those hospitals, but the majority of children are admitted to them, the development of new, more useful, quality metrics is needed.

Perhaps the most interesting finding resulted from a new and unfortunate limitation in the KID database. Beginning in 2012, the AHQR began deidentifying all hospitals contributing data to the KID, leaving researchers reliant on KID's categorization of hospitals as either freestanding children's hospitals or general hospitals. The authors attempted to work around these limitations to identify those children's hospitals that were not freestanding but were located within general hospitals. They found that 36 general hospitals had patient volumes equivalent to freestanding children's hospitals, whereas 20 freestanding children's hospitals had very infrequent admissions for the most common discharge diagnoses. The authors are almost certainly correct in deeming the latter 20 hospitals to be subspecialty children's hospitals, such as those focused solely on orthopedic or oncologic conditions. Among the 36 high‐volume general hospitals, the authors found that patient complexity and severity was more similar to freestanding children's hospitals than to the low‐volume general hospitals. Length of stay (and therefore presumably costs as well) for high‐volume general hospitals was positioned between freestanding children's hospitals and low‐volume general hospitals.

Who are those high‐volume hospitals that appear to be general in name only? Because of KID's deidentification of hospitals, we do not know. It is possible that those hospitals self‐identify as being children's hospitals, but are not freestanding, meaning that they are located within a general hospital (hospitals within a hospital). If they are children's hospitals within general hospitals, it would provide a different perspective to the study's overall finding that 71% of hospitalizations, 64% of hospital days, and 50% of costs occur at general hospitals. As the authors allude to, some institutions may not call themselves freestanding children's hospitals but function that way; other institutions call themselves freestanding children's hospitals but offer very focused specialty services. Through this limitation in the KID database, the authors began the process of identifying hospitals that look like freestanding children's hospitals but are not called that. In other words, they began creating a more robust functional definition of which institutions are truly children's hospitals. Volume does not, of course, always equate into specialization, and much work needs to be done measuring the availability of subspecialty and critical care services before any functional definition of children's hospital can be made; the potential, however, is intriguing.

Does it matter which hospitals are deemed children's hospitals? Although a hospitalist may not place importance on the name over the hospital's entrance, the Centers for Medicare and Medicaid Services (CMS) and state insurance regulators may find the difference extremely important. CMS and state insurance regulators are increasingly focusing their attention on the adequacy of pediatric insurance networks.[3, 4, 5, 6] They are seeking to create rules that ensure health insurance plans have a broad range of pediatric subspecialists in close proximity to the great majority of children insured by the plan. For adult insurance, the adequacy of a plan's network is typically defined by the time and distance from a patient's home to a specialist. However, unlike in adult medicine, pediatric subspecialty care is becoming increasingly regionalized at academic medical centers, especially children's hospitals. Furthermore, unlike adult care, a wide range of pediatric subspecialists is unlikely to be found at the hospital closest to a patient's home. Therefore, time and distance rules for ensuring network adequacy may fail within pediatric care. Instead, inclusion of a hospital designatedby functional or other criteriaas a children's hospital may be the best way to ensure the adequate provision of pediatric specialty care within a network.

How policymakers define pediatric network adequacy will have important implications for ensuring that pediatric inpatient medicine achieves the goal of the right patient, the right place, the right time. Therefore, the attending from our residency may have been correct that most children are not hospitalized at children's hospitals. However, depending on how pediatric network adequacy rules are developed, that may not have to mean that these children (and their pediatricians) will be out there alone.

Now in its 20th year, hospital medicine hasfrom many perspectivesreached full bloom. Hospitalists populate settings as diverse as academic hospitals, community hospitals, and long‐term care facilities. Many traditional academic medical centers have taken notice of hospitalists, not just for their clinical role in an era of restricted duty hours, but also for the value they provide in advancing the academic and teaching mission of the institution.[1, 2]

As a result, hospital medicine has expanded rapidly, from 10,000 hospitalists in the United States in 2004 to 48,000 hospitalists in 2014.[3] Unfortunately, such growth has led to a profession that is bottom heavy, with leaders that spearheaded the movement occupying the upper echelon followed by a conglomeration of junior faculty at the base. For many at the bottom of this pyramid, the path to promotion remains challenging. Core academic metrics such as peer‐reviewed publications, quality improvement activities, superb teaching evaluations, and a national reputation are challenging to achieve for faculty who remain highly clinically occupied.[4] Mentorship has been cited as a key contributor for academic success and career satisfaction, but not enough senior hospitalists exist with the experience, skills, and bandwidth to adequately groom protgs.[5, 6]

The brief article in this month's edition of the Journal of Hospital Medicine is important and timely. Cumbler and colleagues describe the creation of a visiting professor program specifically aimed at cross‐pollinating junior faculty on the precipice of promotion with senior members from other institutions.[7] Using a model of reciprocity, the visiting professor innovation provided a mechanism by which midcareer faculty could travel to another site, exchange ideas, mentor or be mentored, and find partners and like‐minded faculty to grow their work. Starting with just 2 sites, the program quickly expanded to 5, with exchanges of 7 visiting professors. Initial metrics of success appear promising: early career faculty that interacted with the visiting professor provided positive feedback in key domains including mentor‐mentee relationships and advancement of academic careers. We applaud the authors not only for introducing this novel idea, but also for building in evaluative components such as publications and letters for promotion that allow for assessment of success.

Programs such as these help fill key gaps. First, they provide important mechanisms for expanding the network of available mentors for junior faculty. Second, they provide a venue to promote cross‐institutional collaborations, receive feedback, and grow the circle of stakeholders around innovative projects. Third, they help junior faculty establish a national reputation, propelling them toward promotion. Finally, the program does what few others can; it provides a means by which clinically busy junior faculty can get much‐needed validation for their academic efforts.

How may this innovation be expanded to a national scale? As chairs of the Society of Hospital Medicines Academic and Research Committee, we think this a worthy mission. Following a lively discussion at the national meeting, both committees have established a workgroup to support a visiting professor program. The Visiting Professorship in Hospital Medicine Program will follow the model introduced by Cumbler and colleagues by cross‐linking facilities represented within our committees into the existing network of visiting professor sites. New sites will be asked to name a site lead who will be responsible for identifying appropriate faculty members and areas of expertise that would benefit from interinstitutional exchange. The Society of Hospital Medicine's Chapters Committee has joined the dialogue and will help by developing a database of faculty, domains of expertise, and geographic locations to create a veritable match.com for junior faculty.

We are a field that began with innovation. Developing and diffusing a junior faculty program to grow future academic leaders is just an extension of this type of thinking and demonstrates how we continuously remodel our specialty to meet our unique needs. Ultimately, we envision the program to be a national model adopted by the Society of Hospital Medicine to help grow not only academic, but also community‐hospitalist superstars who also have great ideas and innovations. Faced with the constant peril of clinical workload, academic burnout, and career success, our field must begin to invest in infrastructure that nurtures our young and provides them with the opportunities needed to shine. The innovation proposed by Cumbler et al. is a superb example of this type of initiative, one we are proud to help diffuse on a national level. Onward!

Now in its 20th year, hospital medicine hasfrom many perspectivesreached full bloom. Hospitalists populate settings as diverse as academic hospitals, community hospitals, and long‐term care facilities. Many traditional academic medical centers have taken notice of hospitalists, not just for their clinical role in an era of restricted duty hours, but also for the value they provide in advancing the academic and teaching mission of the institution.[1, 2]

As a result, hospital medicine has expanded rapidly, from 10,000 hospitalists in the United States in 2004 to 48,000 hospitalists in 2014.[3] Unfortunately, such growth has led to a profession that is bottom heavy, with leaders that spearheaded the movement occupying the upper echelon followed by a conglomeration of junior faculty at the base. For many at the bottom of this pyramid, the path to promotion remains challenging. Core academic metrics such as peer‐reviewed publications, quality improvement activities, superb teaching evaluations, and a national reputation are challenging to achieve for faculty who remain highly clinically occupied.[4] Mentorship has been cited as a key contributor for academic success and career satisfaction, but not enough senior hospitalists exist with the experience, skills, and bandwidth to adequately groom protgs.[5, 6]

The brief article in this month's edition of the Journal of Hospital Medicine is important and timely. Cumbler and colleagues describe the creation of a visiting professor program specifically aimed at cross‐pollinating junior faculty on the precipice of promotion with senior members from other institutions.[7] Using a model of reciprocity, the visiting professor innovation provided a mechanism by which midcareer faculty could travel to another site, exchange ideas, mentor or be mentored, and find partners and like‐minded faculty to grow their work. Starting with just 2 sites, the program quickly expanded to 5, with exchanges of 7 visiting professors. Initial metrics of success appear promising: early career faculty that interacted with the visiting professor provided positive feedback in key domains including mentor‐mentee relationships and advancement of academic careers. We applaud the authors not only for introducing this novel idea, but also for building in evaluative components such as publications and letters for promotion that allow for assessment of success.

Programs such as these help fill key gaps. First, they provide important mechanisms for expanding the network of available mentors for junior faculty. Second, they provide a venue to promote cross‐institutional collaborations, receive feedback, and grow the circle of stakeholders around innovative projects. Third, they help junior faculty establish a national reputation, propelling them toward promotion. Finally, the program does what few others can; it provides a means by which clinically busy junior faculty can get much‐needed validation for their academic efforts.

How may this innovation be expanded to a national scale? As chairs of the Society of Hospital Medicines Academic and Research Committee, we think this a worthy mission. Following a lively discussion at the national meeting, both committees have established a workgroup to support a visiting professor program. The Visiting Professorship in Hospital Medicine Program will follow the model introduced by Cumbler and colleagues by cross‐linking facilities represented within our committees into the existing network of visiting professor sites. New sites will be asked to name a site lead who will be responsible for identifying appropriate faculty members and areas of expertise that would benefit from interinstitutional exchange. The Society of Hospital Medicine's Chapters Committee has joined the dialogue and will help by developing a database of faculty, domains of expertise, and geographic locations to create a veritable match.com for junior faculty.

We are a field that began with innovation. Developing and diffusing a junior faculty program to grow future academic leaders is just an extension of this type of thinking and demonstrates how we continuously remodel our specialty to meet our unique needs. Ultimately, we envision the program to be a national model adopted by the Society of Hospital Medicine to help grow not only academic, but also community‐hospitalist superstars who also have great ideas and innovations. Faced with the constant peril of clinical workload, academic burnout, and career success, our field must begin to invest in infrastructure that nurtures our young and provides them with the opportunities needed to shine. The innovation proposed by Cumbler et al. is a superb example of this type of initiative, one we are proud to help diffuse on a national level. Onward!

Now in its 20th year, hospital medicine hasfrom many perspectivesreached full bloom. Hospitalists populate settings as diverse as academic hospitals, community hospitals, and long‐term care facilities. Many traditional academic medical centers have taken notice of hospitalists, not just for their clinical role in an era of restricted duty hours, but also for the value they provide in advancing the academic and teaching mission of the institution.[1, 2]

As a result, hospital medicine has expanded rapidly, from 10,000 hospitalists in the United States in 2004 to 48,000 hospitalists in 2014.[3] Unfortunately, such growth has led to a profession that is bottom heavy, with leaders that spearheaded the movement occupying the upper echelon followed by a conglomeration of junior faculty at the base. For many at the bottom of this pyramid, the path to promotion remains challenging. Core academic metrics such as peer‐reviewed publications, quality improvement activities, superb teaching evaluations, and a national reputation are challenging to achieve for faculty who remain highly clinically occupied.[4] Mentorship has been cited as a key contributor for academic success and career satisfaction, but not enough senior hospitalists exist with the experience, skills, and bandwidth to adequately groom protgs.[5, 6]

The brief article in this month's edition of the Journal of Hospital Medicine is important and timely. Cumbler and colleagues describe the creation of a visiting professor program specifically aimed at cross‐pollinating junior faculty on the precipice of promotion with senior members from other institutions.[7] Using a model of reciprocity, the visiting professor innovation provided a mechanism by which midcareer faculty could travel to another site, exchange ideas, mentor or be mentored, and find partners and like‐minded faculty to grow their work. Starting with just 2 sites, the program quickly expanded to 5, with exchanges of 7 visiting professors. Initial metrics of success appear promising: early career faculty that interacted with the visiting professor provided positive feedback in key domains including mentor‐mentee relationships and advancement of academic careers. We applaud the authors not only for introducing this novel idea, but also for building in evaluative components such as publications and letters for promotion that allow for assessment of success.

Programs such as these help fill key gaps. First, they provide important mechanisms for expanding the network of available mentors for junior faculty. Second, they provide a venue to promote cross‐institutional collaborations, receive feedback, and grow the circle of stakeholders around innovative projects. Third, they help junior faculty establish a national reputation, propelling them toward promotion. Finally, the program does what few others can; it provides a means by which clinically busy junior faculty can get much‐needed validation for their academic efforts.

How may this innovation be expanded to a national scale? As chairs of the Society of Hospital Medicines Academic and Research Committee, we think this a worthy mission. Following a lively discussion at the national meeting, both committees have established a workgroup to support a visiting professor program. The Visiting Professorship in Hospital Medicine Program will follow the model introduced by Cumbler and colleagues by cross‐linking facilities represented within our committees into the existing network of visiting professor sites. New sites will be asked to name a site lead who will be responsible for identifying appropriate faculty members and areas of expertise that would benefit from interinstitutional exchange. The Society of Hospital Medicine's Chapters Committee has joined the dialogue and will help by developing a database of faculty, domains of expertise, and geographic locations to create a veritable match.com for junior faculty.

We are a field that began with innovation. Developing and diffusing a junior faculty program to grow future academic leaders is just an extension of this type of thinking and demonstrates how we continuously remodel our specialty to meet our unique needs. Ultimately, we envision the program to be a national model adopted by the Society of Hospital Medicine to help grow not only academic, but also community‐hospitalist superstars who also have great ideas and innovations. Faced with the constant peril of clinical workload, academic burnout, and career success, our field must begin to invest in infrastructure that nurtures our young and provides them with the opportunities needed to shine. The innovation proposed by Cumbler et al. is a superb example of this type of initiative, one we are proud to help diffuse on a national level. Onward!

Serious illnesses challenge patients, their families, clinicians, and the health systems that care for them. In this issue of the Journal of Hospital Medicine, Cowen and coauthors shed light on the experience of inpatients on medical and surgical services with a high risk of mortality on admission, as measured by Hospital Consumer Assessment of Healthcare Providers and Systems Surveys (HCAHPS).[1] In their study population, even after adjustment for some confounders, these patients tended to rate responsiveness of hospital staff and communication by doctors lower than patients with a low risk of mortality on admission.

A more generalizable frame than admission risk of mortality is to consider the patients they identified as high risk to be patients with serious illness. Using this frame will be helpful in understanding the implications of their results, but it is important to acknowledge that for several reasons, the data in this study may not represent the entire population of seriously ill patients. First, there may be patients at lower risk of mortality who would qualify as having a serious illness. Second, the study's data were from only a few hospitals in 1 healthcare system. Third, 93% of patients at high risk of mortality on admission did not return surveys. Despite these significant limitations, there are still important insights to be gleaned from their work.

Before exploring what they found, it is also important to note that it can be challenging to know what to make of HCAHPS scores. For instance, patients with higher HCAHPS scores have been found to have higher costs of care and higher mortality.[2] Satisfied patients are not clearly better off. However, what if, for purposes of learning, the scores serve as a window into the seriously ill patient's experience, helping inform an understanding of the challenges and opportunities for improvement?

One of the key findings of this study was that seriously ill patients rated responsiveness by hospital staff worse than those who were not as ill. Patients were asked 2 questions as part of the composite measure: During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?

It is not difficult to imagine how seriously ill patients might have more intense care needs that would result in more requests for help, nor is it difficult to imagine how some proportion of those requests might not be handled in a timely fashion. Objective research shows higher rates of call button requests have been associated with slower response times, and it appears there is a complex relationship with staffing levels and the intensity of work on the floor.[3] Certainly there may be times that patients want a quick response after pressing a call button, but do not need one, and a lot of time could be spent discussing these quandaries. However, there are also times when a patient describes having called for help, really needing it, yet no one came. At least some of the time, responsiveness is a matter of respect, especially considering the vulnerability of seriously ill patients and the issue of dignity around toileting.

Another key finding was about communication by doctors, and the questions patients answered were: During this hospital stay, how often did doctors treat you with courtesy and respect? During this hospital stay, how often did doctors listen carefully to you? During this hospital stay, how often did doctors explain things in a way you could understand?

There is a growing and important body of literature about communication with seriously ill patients.[4] Consider some of the data about patients with advanced cancer. Evidence suggests the majority of such patients want to know their prognosis, and that when it is discussed it does not worsen the patient‐physician relationship, sadness, or anxiety.[5] Despite this, among physicians who have formulated a prognosis for patients with advanced cancer, even if they were asked directly by those patients about their prognosis, 23% of the time they would communicate no prognosis. Forty percent of the time they would communicate a different prognosis than what they had formulated, with 70% of those being optimistically discrepant.[6] Although data are more limited, there is evidence that hospitalists are similarly wary to acknowledge when patients are at risk of dying.[7]

Although certainly other aspects of communication by doctors with seriously ill patients contributed to this study's findings, this issue of acknowledging and discussing the serious illness itself is important to highlight. Healthcare professionals have an ethical obligation to respect patients' autonomy by helping them make informed decisions about their care. Having these conversations can be challenging, but training programs and conversation guides are showing promise.[8] If health professionals do not try to ensure that seriously ill patients understand their diagnosis, prognosis, and full range of treatment options in patient‐centered ways, then by definition patients cannot be making informed decisions. It is a matter of respect.

This study's most important contribution is how it focuses attention on the domains of responsiveness by hospital staff and communication by doctors, encouraging a deeper dive to consider what else is known about these topics. Allowing that the lower scores from seriously ill patients might reflect more than just poor satisfaction reveals that at least some proportion of the time, these patients are experiencing disrespect. The work then becomes clear: What are the ways in which health professionals should reliably be demonstrating respect toward patients, especially those who are seriously ill? It is there, in the process of developing a reliable practice of respect, that consensus about how to improve the patient experience is most likely to be found.

Serious illnesses challenge patients, their families, clinicians, and the health systems that care for them. In this issue of the Journal of Hospital Medicine, Cowen and coauthors shed light on the experience of inpatients on medical and surgical services with a high risk of mortality on admission, as measured by Hospital Consumer Assessment of Healthcare Providers and Systems Surveys (HCAHPS).[1] In their study population, even after adjustment for some confounders, these patients tended to rate responsiveness of hospital staff and communication by doctors lower than patients with a low risk of mortality on admission.

A more generalizable frame than admission risk of mortality is to consider the patients they identified as high risk to be patients with serious illness. Using this frame will be helpful in understanding the implications of their results, but it is important to acknowledge that for several reasons, the data in this study may not represent the entire population of seriously ill patients. First, there may be patients at lower risk of mortality who would qualify as having a serious illness. Second, the study's data were from only a few hospitals in 1 healthcare system. Third, 93% of patients at high risk of mortality on admission did not return surveys. Despite these significant limitations, there are still important insights to be gleaned from their work.

Before exploring what they found, it is also important to note that it can be challenging to know what to make of HCAHPS scores. For instance, patients with higher HCAHPS scores have been found to have higher costs of care and higher mortality.[2] Satisfied patients are not clearly better off. However, what if, for purposes of learning, the scores serve as a window into the seriously ill patient's experience, helping inform an understanding of the challenges and opportunities for improvement?

One of the key findings of this study was that seriously ill patients rated responsiveness by hospital staff worse than those who were not as ill. Patients were asked 2 questions as part of the composite measure: During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?

It is not difficult to imagine how seriously ill patients might have more intense care needs that would result in more requests for help, nor is it difficult to imagine how some proportion of those requests might not be handled in a timely fashion. Objective research shows higher rates of call button requests have been associated with slower response times, and it appears there is a complex relationship with staffing levels and the intensity of work on the floor.[3] Certainly there may be times that patients want a quick response after pressing a call button, but do not need one, and a lot of time could be spent discussing these quandaries. However, there are also times when a patient describes having called for help, really needing it, yet no one came. At least some of the time, responsiveness is a matter of respect, especially considering the vulnerability of seriously ill patients and the issue of dignity around toileting.

Another key finding was about communication by doctors, and the questions patients answered were: During this hospital stay, how often did doctors treat you with courtesy and respect? During this hospital stay, how often did doctors listen carefully to you? During this hospital stay, how often did doctors explain things in a way you could understand?

There is a growing and important body of literature about communication with seriously ill patients.[4] Consider some of the data about patients with advanced cancer. Evidence suggests the majority of such patients want to know their prognosis, and that when it is discussed it does not worsen the patient‐physician relationship, sadness, or anxiety.[5] Despite this, among physicians who have formulated a prognosis for patients with advanced cancer, even if they were asked directly by those patients about their prognosis, 23% of the time they would communicate no prognosis. Forty percent of the time they would communicate a different prognosis than what they had formulated, with 70% of those being optimistically discrepant.[6] Although data are more limited, there is evidence that hospitalists are similarly wary to acknowledge when patients are at risk of dying.[7]

Although certainly other aspects of communication by doctors with seriously ill patients contributed to this study's findings, this issue of acknowledging and discussing the serious illness itself is important to highlight. Healthcare professionals have an ethical obligation to respect patients' autonomy by helping them make informed decisions about their care. Having these conversations can be challenging, but training programs and conversation guides are showing promise.[8] If health professionals do not try to ensure that seriously ill patients understand their diagnosis, prognosis, and full range of treatment options in patient‐centered ways, then by definition patients cannot be making informed decisions. It is a matter of respect.

This study's most important contribution is how it focuses attention on the domains of responsiveness by hospital staff and communication by doctors, encouraging a deeper dive to consider what else is known about these topics. Allowing that the lower scores from seriously ill patients might reflect more than just poor satisfaction reveals that at least some proportion of the time, these patients are experiencing disrespect. The work then becomes clear: What are the ways in which health professionals should reliably be demonstrating respect toward patients, especially those who are seriously ill? It is there, in the process of developing a reliable practice of respect, that consensus about how to improve the patient experience is most likely to be found.

Serious illnesses challenge patients, their families, clinicians, and the health systems that care for them. In this issue of the Journal of Hospital Medicine, Cowen and coauthors shed light on the experience of inpatients on medical and surgical services with a high risk of mortality on admission, as measured by Hospital Consumer Assessment of Healthcare Providers and Systems Surveys (HCAHPS).[1] In their study population, even after adjustment for some confounders, these patients tended to rate responsiveness of hospital staff and communication by doctors lower than patients with a low risk of mortality on admission.

A more generalizable frame than admission risk of mortality is to consider the patients they identified as high risk to be patients with serious illness. Using this frame will be helpful in understanding the implications of their results, but it is important to acknowledge that for several reasons, the data in this study may not represent the entire population of seriously ill patients. First, there may be patients at lower risk of mortality who would qualify as having a serious illness. Second, the study's data were from only a few hospitals in 1 healthcare system. Third, 93% of patients at high risk of mortality on admission did not return surveys. Despite these significant limitations, there are still important insights to be gleaned from their work.

Before exploring what they found, it is also important to note that it can be challenging to know what to make of HCAHPS scores. For instance, patients with higher HCAHPS scores have been found to have higher costs of care and higher mortality.[2] Satisfied patients are not clearly better off. However, what if, for purposes of learning, the scores serve as a window into the seriously ill patient's experience, helping inform an understanding of the challenges and opportunities for improvement?

One of the key findings of this study was that seriously ill patients rated responsiveness by hospital staff worse than those who were not as ill. Patients were asked 2 questions as part of the composite measure: During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?

It is not difficult to imagine how seriously ill patients might have more intense care needs that would result in more requests for help, nor is it difficult to imagine how some proportion of those requests might not be handled in a timely fashion. Objective research shows higher rates of call button requests have been associated with slower response times, and it appears there is a complex relationship with staffing levels and the intensity of work on the floor.[3] Certainly there may be times that patients want a quick response after pressing a call button, but do not need one, and a lot of time could be spent discussing these quandaries. However, there are also times when a patient describes having called for help, really needing it, yet no one came. At least some of the time, responsiveness is a matter of respect, especially considering the vulnerability of seriously ill patients and the issue of dignity around toileting.

Another key finding was about communication by doctors, and the questions patients answered were: During this hospital stay, how often did doctors treat you with courtesy and respect? During this hospital stay, how often did doctors listen carefully to you? During this hospital stay, how often did doctors explain things in a way you could understand?

There is a growing and important body of literature about communication with seriously ill patients.[4] Consider some of the data about patients with advanced cancer. Evidence suggests the majority of such patients want to know their prognosis, and that when it is discussed it does not worsen the patient‐physician relationship, sadness, or anxiety.[5] Despite this, among physicians who have formulated a prognosis for patients with advanced cancer, even if they were asked directly by those patients about their prognosis, 23% of the time they would communicate no prognosis. Forty percent of the time they would communicate a different prognosis than what they had formulated, with 70% of those being optimistically discrepant.[6] Although data are more limited, there is evidence that hospitalists are similarly wary to acknowledge when patients are at risk of dying.[7]

Although certainly other aspects of communication by doctors with seriously ill patients contributed to this study's findings, this issue of acknowledging and discussing the serious illness itself is important to highlight. Healthcare professionals have an ethical obligation to respect patients' autonomy by helping them make informed decisions about their care. Having these conversations can be challenging, but training programs and conversation guides are showing promise.[8] If health professionals do not try to ensure that seriously ill patients understand their diagnosis, prognosis, and full range of treatment options in patient‐centered ways, then by definition patients cannot be making informed decisions. It is a matter of respect.

This study's most important contribution is how it focuses attention on the domains of responsiveness by hospital staff and communication by doctors, encouraging a deeper dive to consider what else is known about these topics. Allowing that the lower scores from seriously ill patients might reflect more than just poor satisfaction reveals that at least some proportion of the time, these patients are experiencing disrespect. The work then becomes clear: What are the ways in which health professionals should reliably be demonstrating respect toward patients, especially those who are seriously ill? It is there, in the process of developing a reliable practice of respect, that consensus about how to improve the patient experience is most likely to be found.

Since initial reports describing an emerging opioid epidemic in the early 2000s,[1] we have seen a flurry of studies characterizing the scope and impact of the problem and calling for actions to stem the rising tide.[2] However, most of these studies, even the recently issued Centers for Disease Control and Prevention (CDC) guidelines, have focused on the outpatient setting,[3] rendering the inpatient setting somewhat of an opioid prescribing black box.

Recently, however, several studies have highlighted both the scope and downstream impact of opioid prescribing in the inpatient setting. We now know that more than half of hospitalized patients in the United States are exposed to opioid medications during their hospitalization,[4] the majority of which are new initiations in patients without opioid receipt in the year preceding their hospitalization.[5] Among opioid nave patients admitted to the hospital, one‐quarter go on to receive a script for an opioid in the 72 hours after hospital discharge, and 4% have ongoing use 1 year after discharge.[5] Although this may seem like a relatively small percentage, when you consider that there are about 40 million discharges from US medical centers each year, the majority of which are opioid nave prior to hospitalization, this becomes a large absolute number. Taken together, these studies suggest that inpatient prescribing contributes substantially to more chronic opioid use. Accordingly, reigning in inpatient prescribing may be a crucial step in curbing the opioid epidemic as a whole.

In this issue of the Journal of Hospital Medicine, Calcaterra et al.,[6] in a qualitative analysis of hospitalist perceptions of opioid prescribing, draw attention to the bidirectional pull exerted on physicians by the need to adequately treat pain as mandated by the Joint Commission,[7] while minimizing exposure to medications fraught with a wide array of adverse effects, ranging from constipation to addiction to death. What often ensues is a haphazardly choreographed negotiation between 2 parties, 1 of which, in the setting of addiction, may not know what is best for him/herself, and the other of which is caught between the desire to relieve suffering and the desire to do no harm.

At the center of all this is the fact that pain itself is a nebulous concept, defined and experienced in a multitude of different ways by different people and cultures. For some, there is no distinction between psychological and physical pain. Without sufficient objective measures of pain, we must rely on the patient to convey their degree of suffering, and then use our clinical judgment to decide whether pain is severe enough and risks are low enough to use medications with physiological effects that are identical to heroin.

This study adds important information to the opioid prescribing equation, in that understanding the drivers of physician decision making in this realm is an important prelude to developing strategies that effectively promote more standardized and appropriate opioid prescribing. This is the first study to specifically investigate perceptions of hospitalists. Although their study involved only 25 hospitalists, raising questions of validity and generalizability, as a practicing hospitalist, I anticipate that their findings will resonate widely with other hospitalists across the country. First, although the hospitalists in their study were generally comfortable using opioids for acute pain, they found managing acute pain exacerbations in patients with chronic pain more challenging. Second, negative prior experiences related to opioid prescribing strongly inform future prescribing. Third, opioids are often used as a tool to facilitate discharges and prevent readmissions.

There are several important implications arising from each of these 3 identified emergent themes.

First, although hospitalists felt generally comfortable in prescribing opioids for acute pain in patients not on chronic opioids, in reality, prescribing opioids for acute pain, even in opioid nave patients, is neither straightforward nor done safely. It is important we recognize that our prescribing practices as hospitalists, even for acute pain in opioid nave patients, contribute to adverse events, and promote and propagate addiction. We can do better. Akin to the recent CDC guidelines,[3] prescribing guidelines specifically directed at the hospital setting are necessary. An effective set of guidelines would both promote more standardized and safer prescribing practices, as well as provide support for physician decision making in this realm. Such guidelines would help provide ground rules and a framework from which physicians could draw during those challenging discussions with patients suffering from chronic pain.

Second, many of the negative prior experiences described by the hospitalists in this study as shaping future behavior could have been avoided with enhanced, system‐wide safety measures directed at each of the steps in the medication use continuum, from prescribing to administration. For example, mandatory use of electronic prescribing of controlled substances can prevent patients from tampering with prescriptions.[8] Monitored ingestion can prevent misuse and diversion. Additional safety measures that should be widely adopted in the inpatient setting include integration and mandatory review of the State Prescription Drug Monitoring Program when prescribing opioids on admission and discharge, and clinical decision support to promote safe prescribing decisions related to dose, route, and monitoring practices. Incorporation of these and other safety measures in a systematic way will ultimately improve the experience and outcomes for both patients and physicians.

Finally, opioids are used as a tool to facilitate discharge, in part because it is much harder to discuss a decision not to prescribe opioids with a patient expressing suffering than it is to just provide a limited supply and get them back to their longitudinal provider. Physicians often lack the vocabulary necessary to effectively navigate such discussions. We need to make these discussions easier, through physician education and training regarding how to speak to patients about pain management. A shared, standard vocabulary specific to the inpatient setting should be developed and disseminated for discussing with patients (1) expectations related to pain management, (2) potential benefits and risks of opioids, (3) concerns over addiction, and (4) discontinuing/tapering opioids.

In conclusion, if we are to effectively curb the opioid epidemic, the inpatient setting cannot remain a black box. Standardizing opioid prescribing in the hospital will require a concerted effort by hospitalists and other physicians, nurses, pharmacists, and regulatory bodies, with important input from patients as well as longitudinal providers in the outpatient setting, to assure appropriate navigation during transitions of care. Together, we can turn haphazard negotiation into coordinated comanagement, ultimately promoting individual and public health.

Disclosures: Dr. Herzig was funded by grant number K23AG042459 from the National Institute on Aging. The article contents are solely the responsibility of the author and do not necessarily represent the views of the funding organization. Dr. Herzig has no conflicts to disclose.

Since initial reports describing an emerging opioid epidemic in the early 2000s,[1] we have seen a flurry of studies characterizing the scope and impact of the problem and calling for actions to stem the rising tide.[2] However, most of these studies, even the recently issued Centers for Disease Control and Prevention (CDC) guidelines, have focused on the outpatient setting,[3] rendering the inpatient setting somewhat of an opioid prescribing black box.

Recently, however, several studies have highlighted both the scope and downstream impact of opioid prescribing in the inpatient setting. We now know that more than half of hospitalized patients in the United States are exposed to opioid medications during their hospitalization,[4] the majority of which are new initiations in patients without opioid receipt in the year preceding their hospitalization.[5] Among opioid nave patients admitted to the hospital, one‐quarter go on to receive a script for an opioid in the 72 hours after hospital discharge, and 4% have ongoing use 1 year after discharge.[5] Although this may seem like a relatively small percentage, when you consider that there are about 40 million discharges from US medical centers each year, the majority of which are opioid nave prior to hospitalization, this becomes a large absolute number. Taken together, these studies suggest that inpatient prescribing contributes substantially to more chronic opioid use. Accordingly, reigning in inpatient prescribing may be a crucial step in curbing the opioid epidemic as a whole.

In this issue of the Journal of Hospital Medicine, Calcaterra et al.,[6] in a qualitative analysis of hospitalist perceptions of opioid prescribing, draw attention to the bidirectional pull exerted on physicians by the need to adequately treat pain as mandated by the Joint Commission,[7] while minimizing exposure to medications fraught with a wide array of adverse effects, ranging from constipation to addiction to death. What often ensues is a haphazardly choreographed negotiation between 2 parties, 1 of which, in the setting of addiction, may not know what is best for him/herself, and the other of which is caught between the desire to relieve suffering and the desire to do no harm.

At the center of all this is the fact that pain itself is a nebulous concept, defined and experienced in a multitude of different ways by different people and cultures. For some, there is no distinction between psychological and physical pain. Without sufficient objective measures of pain, we must rely on the patient to convey their degree of suffering, and then use our clinical judgment to decide whether pain is severe enough and risks are low enough to use medications with physiological effects that are identical to heroin.

This study adds important information to the opioid prescribing equation, in that understanding the drivers of physician decision making in this realm is an important prelude to developing strategies that effectively promote more standardized and appropriate opioid prescribing. This is the first study to specifically investigate perceptions of hospitalists. Although their study involved only 25 hospitalists, raising questions of validity and generalizability, as a practicing hospitalist, I anticipate that their findings will resonate widely with other hospitalists across the country. First, although the hospitalists in their study were generally comfortable using opioids for acute pain, they found managing acute pain exacerbations in patients with chronic pain more challenging. Second, negative prior experiences related to opioid prescribing strongly inform future prescribing. Third, opioids are often used as a tool to facilitate discharges and prevent readmissions.

There are several important implications arising from each of these 3 identified emergent themes.

First, although hospitalists felt generally comfortable in prescribing opioids for acute pain in patients not on chronic opioids, in reality, prescribing opioids for acute pain, even in opioid nave patients, is neither straightforward nor done safely. It is important we recognize that our prescribing practices as hospitalists, even for acute pain in opioid nave patients, contribute to adverse events, and promote and propagate addiction. We can do better. Akin to the recent CDC guidelines,[3] prescribing guidelines specifically directed at the hospital setting are necessary. An effective set of guidelines would both promote more standardized and safer prescribing practices, as well as provide support for physician decision making in this realm. Such guidelines would help provide ground rules and a framework from which physicians could draw during those challenging discussions with patients suffering from chronic pain.

Second, many of the negative prior experiences described by the hospitalists in this study as shaping future behavior could have been avoided with enhanced, system‐wide safety measures directed at each of the steps in the medication use continuum, from prescribing to administration. For example, mandatory use of electronic prescribing of controlled substances can prevent patients from tampering with prescriptions.[8] Monitored ingestion can prevent misuse and diversion. Additional safety measures that should be widely adopted in the inpatient setting include integration and mandatory review of the State Prescription Drug Monitoring Program when prescribing opioids on admission and discharge, and clinical decision support to promote safe prescribing decisions related to dose, route, and monitoring practices. Incorporation of these and other safety measures in a systematic way will ultimately improve the experience and outcomes for both patients and physicians.

Finally, opioids are used as a tool to facilitate discharge, in part because it is much harder to discuss a decision not to prescribe opioids with a patient expressing suffering than it is to just provide a limited supply and get them back to their longitudinal provider. Physicians often lack the vocabulary necessary to effectively navigate such discussions. We need to make these discussions easier, through physician education and training regarding how to speak to patients about pain management. A shared, standard vocabulary specific to the inpatient setting should be developed and disseminated for discussing with patients (1) expectations related to pain management, (2) potential benefits and risks of opioids, (3) concerns over addiction, and (4) discontinuing/tapering opioids.

In conclusion, if we are to effectively curb the opioid epidemic, the inpatient setting cannot remain a black box. Standardizing opioid prescribing in the hospital will require a concerted effort by hospitalists and other physicians, nurses, pharmacists, and regulatory bodies, with important input from patients as well as longitudinal providers in the outpatient setting, to assure appropriate navigation during transitions of care. Together, we can turn haphazard negotiation into coordinated comanagement, ultimately promoting individual and public health.

Disclosures: Dr. Herzig was funded by grant number K23AG042459 from the National Institute on Aging. The article contents are solely the responsibility of the author and do not necessarily represent the views of the funding organization. Dr. Herzig has no conflicts to disclose.

Since initial reports describing an emerging opioid epidemic in the early 2000s,[1] we have seen a flurry of studies characterizing the scope and impact of the problem and calling for actions to stem the rising tide.[2] However, most of these studies, even the recently issued Centers for Disease Control and Prevention (CDC) guidelines, have focused on the outpatient setting,[3] rendering the inpatient setting somewhat of an opioid prescribing black box.

Recently, however, several studies have highlighted both the scope and downstream impact of opioid prescribing in the inpatient setting. We now know that more than half of hospitalized patients in the United States are exposed to opioid medications during their hospitalization,[4] the majority of which are new initiations in patients without opioid receipt in the year preceding their hospitalization.[5] Among opioid nave patients admitted to the hospital, one‐quarter go on to receive a script for an opioid in the 72 hours after hospital discharge, and 4% have ongoing use 1 year after discharge.[5] Although this may seem like a relatively small percentage, when you consider that there are about 40 million discharges from US medical centers each year, the majority of which are opioid nave prior to hospitalization, this becomes a large absolute number. Taken together, these studies suggest that inpatient prescribing contributes substantially to more chronic opioid use. Accordingly, reigning in inpatient prescribing may be a crucial step in curbing the opioid epidemic as a whole.

In this issue of the Journal of Hospital Medicine, Calcaterra et al.,[6] in a qualitative analysis of hospitalist perceptions of opioid prescribing, draw attention to the bidirectional pull exerted on physicians by the need to adequately treat pain as mandated by the Joint Commission,[7] while minimizing exposure to medications fraught with a wide array of adverse effects, ranging from constipation to addiction to death. What often ensues is a haphazardly choreographed negotiation between 2 parties, 1 of which, in the setting of addiction, may not know what is best for him/herself, and the other of which is caught between the desire to relieve suffering and the desire to do no harm.

At the center of all this is the fact that pain itself is a nebulous concept, defined and experienced in a multitude of different ways by different people and cultures. For some, there is no distinction between psychological and physical pain. Without sufficient objective measures of pain, we must rely on the patient to convey their degree of suffering, and then use our clinical judgment to decide whether pain is severe enough and risks are low enough to use medications with physiological effects that are identical to heroin.

This study adds important information to the opioid prescribing equation, in that understanding the drivers of physician decision making in this realm is an important prelude to developing strategies that effectively promote more standardized and appropriate opioid prescribing. This is the first study to specifically investigate perceptions of hospitalists. Although their study involved only 25 hospitalists, raising questions of validity and generalizability, as a practicing hospitalist, I anticipate that their findings will resonate widely with other hospitalists across the country. First, although the hospitalists in their study were generally comfortable using opioids for acute pain, they found managing acute pain exacerbations in patients with chronic pain more challenging. Second, negative prior experiences related to opioid prescribing strongly inform future prescribing. Third, opioids are often used as a tool to facilitate discharges and prevent readmissions.

There are several important implications arising from each of these 3 identified emergent themes.

First, although hospitalists felt generally comfortable in prescribing opioids for acute pain in patients not on chronic opioids, in reality, prescribing opioids for acute pain, even in opioid nave patients, is neither straightforward nor done safely. It is important we recognize that our prescribing practices as hospitalists, even for acute pain in opioid nave patients, contribute to adverse events, and promote and propagate addiction. We can do better. Akin to the recent CDC guidelines,[3] prescribing guidelines specifically directed at the hospital setting are necessary. An effective set of guidelines would both promote more standardized and safer prescribing practices, as well as provide support for physician decision making in this realm. Such guidelines would help provide ground rules and a framework from which physicians could draw during those challenging discussions with patients suffering from chronic pain.

Second, many of the negative prior experiences described by the hospitalists in this study as shaping future behavior could have been avoided with enhanced, system‐wide safety measures directed at each of the steps in the medication use continuum, from prescribing to administration. For example, mandatory use of electronic prescribing of controlled substances can prevent patients from tampering with prescriptions.[8] Monitored ingestion can prevent misuse and diversion. Additional safety measures that should be widely adopted in the inpatient setting include integration and mandatory review of the State Prescription Drug Monitoring Program when prescribing opioids on admission and discharge, and clinical decision support to promote safe prescribing decisions related to dose, route, and monitoring practices. Incorporation of these and other safety measures in a systematic way will ultimately improve the experience and outcomes for both patients and physicians.

Finally, opioids are used as a tool to facilitate discharge, in part because it is much harder to discuss a decision not to prescribe opioids with a patient expressing suffering than it is to just provide a limited supply and get them back to their longitudinal provider. Physicians often lack the vocabulary necessary to effectively navigate such discussions. We need to make these discussions easier, through physician education and training regarding how to speak to patients about pain management. A shared, standard vocabulary specific to the inpatient setting should be developed and disseminated for discussing with patients (1) expectations related to pain management, (2) potential benefits and risks of opioids, (3) concerns over addiction, and (4) discontinuing/tapering opioids.

In conclusion, if we are to effectively curb the opioid epidemic, the inpatient setting cannot remain a black box. Standardizing opioid prescribing in the hospital will require a concerted effort by hospitalists and other physicians, nurses, pharmacists, and regulatory bodies, with important input from patients as well as longitudinal providers in the outpatient setting, to assure appropriate navigation during transitions of care. Together, we can turn haphazard negotiation into coordinated comanagement, ultimately promoting individual and public health.

Disclosures: Dr. Herzig was funded by grant number K23AG042459 from the National Institute on Aging. The article contents are solely the responsibility of the author and do not necessarily represent the views of the funding organization. Dr. Herzig has no conflicts to disclose.

Care of hospitalized patients requires effective teamwork within groups composed of physicians (eg, residents, hospitalists, specialists), advanced practice providers, nurses, patient‐care technicians, pharmacists, social workers, and therapists. Sadly, hospital‐based team members often fail to communicate. For example, 2 studies found that nurses and physicians communicated with one another on only 50% to 60% of their patients' hospital days, resulting in a lack of a mutual understanding of the plan of care.[1, 2]

Failure to communicate effectively may be because the hospital setting poses important challenges to teamwork, including the use of large teams with membership that changes frequently because of the need to provide care around the clock. Furthermore, individual team members often have high workloads, care for multiple patients simultaneously, and are seldom in the same place at the same time.

Interdisciplinary rounds (IDR) are a microsystem‐level solution with the goal to share information, achieve mutual understanding, and collaboratively revise the plan of care within care teams. Though common, IDR look very different across hospitals, making studies that evaluate novel strategies to improve IDR and measure their impact of great interest to hospital medicine.

In this issue of the Journal of Hospital Medicine, Bhamidipati and colleagues present a systematic review of published studies evaluating the effect of IDR on patient outcomes.[3] The systematic review included 22 studies, including 12 experimental/quasiexperimental and 10 observational studies. Overall, 13 studies were of low to medium quality, and 9 were high quality. Importantly, relatively few studies reported the degree to which IDR were implemented as planned. The investigators found evidence that IDR had a positive effect on length of stay (LOS) and staff satisfaction, but little evidence to support an effect on patient safety or satisfaction. Furthermore, the investigators found significant variability in IDR design and team composition. Some of this variation is to be expected, as IDR, like other interventions to improve quality and safety of patient care in complex settings, should be implemented with an expectation that the team may need to make adaptations based on local contextual factors such as workload (eg, daily census), environment (eg, open vs closed intensive care unit), local politics (eg, uniquely strong support for/against the intervention), and prior experience (eg, prior failed, similar interventions).[4, 5] Moreover, objectives for IDR may differ across settings. Some hospitals may have room (and a need) to improve LOS, whereas others may prioritize improving patient safety or patient experience metrics.

Bhamidipati and colleagues explain that their review did not reveal a causal pathway between IDR design and outcomes. We believe this lack of association is because most of the included studies did not propose a causal pathway between the IDR components implemented and the outcomes assessed. That is, few studies referred to conceptual models that explain how components of the IDR intervention might influence downstream patient outcomes.

IDR have the potential to influence a number of patient outcomes, including those reflecting efficiency (eg, length of stay), patient safety (eg, adverse events), and patient centeredness (eg, patient satisfaction). However, these outcomes are influenced by many factors, including patient characteristics and other efforts to improve care. As explained by the investigators, the results of many of the included studies may have been confounded due to relatively weak study designs and statistical analyses. Importantly, few of the studies included in this review report the more proximal measure of teamwork. If we hypothesize that IDR improve patient outcomes, they do so by improving teamwork. After all, the purpose of IDR is to assemble team members so they can communicate about and coordinate care. Measuring teamwork behaviors is difficult, especially on medical services. Measuring teamwork climate, the measurable aspects of team culture, is relatively easy. A recent systematic review of teamwork climate assessments in internal medicine identified the Safety Attitudes Questionnaire and the Team Climate Inventory as having substantial validity evidence and association with improved patient outcomes.[6]

Bhamidipati and colleagues proposed a definition for IDR and taxonomy for IDR design and reporting based on their systematic review. Although very useful, the IDR definition may be too limiting as evidenced by the fact that very few studies would be included in a systematic review using this definition as the inclusion criteria. Their proposed taxonomy should serve as a useful framework for future research efforts and appropriately recommends reporting of site characteristics, components of IDR design, and outcomes.

The systematic review by Bhamidipati et al. must also be interpreted in conjunction with another recently published systematic review by Pannick and colleagues assessing the effect of interdisciplinary team care interventions on general medical wards.[7] Contrary to the findings of the Bhamidipati et al. study, Pannick and colleagues found that most interdisciplinary team care interventions had no effect on LOS, but that half of the studies found an improvement in complications of care. Importantly, Pannick and colleagues included only experimental and quasiexperimental studies in their systematic review (ie, no observational studies).

There is clearly more work to be done in researching IDR and other interventions to improve teamwork in general medical settings. Larger studies are needed to provide sufficient power to detect improvement in outcomes. Future studies need to report the degree to which interventions are implemented as planned and need to use stronger study designs (eg, cluster randomized control or interrupted time series) to avoid the influence of confounders. Qualitative methods should be used to assess the influence of contextual factors on the success of interventions.[4] Most importantly, future studies should be based on conceptual models that explain how components of the intervention influence proximal measures of teamwork and downstream patient outcomes.

In the meantime, what is a hospital leader to do? We believe efforts to improve IDR are warranted, but that IDR program leaders need to first specify their primary objective(s). For example, in some hospitals, there may be little room to further reduce LOS, so another goalreducing preventable readmissions or reducing adverse eventsmight be specified as the key performance indicator. This crucial first step of creating a shared goal informs the design, implementation, and evaluation of IDR. We also believe that geographic localization of physicians to specific units is foundational to improving IDR. Physicians cannot feasibly attend IDR if their patients are spread across multiple units (or buildings). Finally, hospital leaders also need to view IDR as part of a larger set of interventions to improve teamwork. Leaders need to assess the adequacy of staffing levels, workflow, and team composition.[8] Unit‐based interdisciplinary leadership models should be used to help link efforts at various levels within a larger system.[9] These models designate a unit medical director and nurse manager who are jointly responsible for unit performance.

In conclusion, IDR play an important role in improving patient outcomes, but only do so by improving teamwork. In redesigning IDR, leaders need to be thoughtful about what outcomes IDR can affect, how IDR affect them, and how IDR fit into larger‐scale efforts to improve performance.

Care of hospitalized patients requires effective teamwork within groups composed of physicians (eg, residents, hospitalists, specialists), advanced practice providers, nurses, patient‐care technicians, pharmacists, social workers, and therapists. Sadly, hospital‐based team members often fail to communicate. For example, 2 studies found that nurses and physicians communicated with one another on only 50% to 60% of their patients' hospital days, resulting in a lack of a mutual understanding of the plan of care.[1, 2]

Failure to communicate effectively may be because the hospital setting poses important challenges to teamwork, including the use of large teams with membership that changes frequently because of the need to provide care around the clock. Furthermore, individual team members often have high workloads, care for multiple patients simultaneously, and are seldom in the same place at the same time.

Interdisciplinary rounds (IDR) are a microsystem‐level solution with the goal to share information, achieve mutual understanding, and collaboratively revise the plan of care within care teams. Though common, IDR look very different across hospitals, making studies that evaluate novel strategies to improve IDR and measure their impact of great interest to hospital medicine.

In this issue of the Journal of Hospital Medicine, Bhamidipati and colleagues present a systematic review of published studies evaluating the effect of IDR on patient outcomes.[3] The systematic review included 22 studies, including 12 experimental/quasiexperimental and 10 observational studies. Overall, 13 studies were of low to medium quality, and 9 were high quality. Importantly, relatively few studies reported the degree to which IDR were implemented as planned. The investigators found evidence that IDR had a positive effect on length of stay (LOS) and staff satisfaction, but little evidence to support an effect on patient safety or satisfaction. Furthermore, the investigators found significant variability in IDR design and team composition. Some of this variation is to be expected, as IDR, like other interventions to improve quality and safety of patient care in complex settings, should be implemented with an expectation that the team may need to make adaptations based on local contextual factors such as workload (eg, daily census), environment (eg, open vs closed intensive care unit), local politics (eg, uniquely strong support for/against the intervention), and prior experience (eg, prior failed, similar interventions).[4, 5] Moreover, objectives for IDR may differ across settings. Some hospitals may have room (and a need) to improve LOS, whereas others may prioritize improving patient safety or patient experience metrics.

Bhamidipati and colleagues explain that their review did not reveal a causal pathway between IDR design and outcomes. We believe this lack of association is because most of the included studies did not propose a causal pathway between the IDR components implemented and the outcomes assessed. That is, few studies referred to conceptual models that explain how components of the IDR intervention might influence downstream patient outcomes.

IDR have the potential to influence a number of patient outcomes, including those reflecting efficiency (eg, length of stay), patient safety (eg, adverse events), and patient centeredness (eg, patient satisfaction). However, these outcomes are influenced by many factors, including patient characteristics and other efforts to improve care. As explained by the investigators, the results of many of the included studies may have been confounded due to relatively weak study designs and statistical analyses. Importantly, few of the studies included in this review report the more proximal measure of teamwork. If we hypothesize that IDR improve patient outcomes, they do so by improving teamwork. After all, the purpose of IDR is to assemble team members so they can communicate about and coordinate care. Measuring teamwork behaviors is difficult, especially on medical services. Measuring teamwork climate, the measurable aspects of team culture, is relatively easy. A recent systematic review of teamwork climate assessments in internal medicine identified the Safety Attitudes Questionnaire and the Team Climate Inventory as having substantial validity evidence and association with improved patient outcomes.[6]

Bhamidipati and colleagues proposed a definition for IDR and taxonomy for IDR design and reporting based on their systematic review. Although very useful, the IDR definition may be too limiting as evidenced by the fact that very few studies would be included in a systematic review using this definition as the inclusion criteria. Their proposed taxonomy should serve as a useful framework for future research efforts and appropriately recommends reporting of site characteristics, components of IDR design, and outcomes.

The systematic review by Bhamidipati et al. must also be interpreted in conjunction with another recently published systematic review by Pannick and colleagues assessing the effect of interdisciplinary team care interventions on general medical wards.[7] Contrary to the findings of the Bhamidipati et al. study, Pannick and colleagues found that most interdisciplinary team care interventions had no effect on LOS, but that half of the studies found an improvement in complications of care. Importantly, Pannick and colleagues included only experimental and quasiexperimental studies in their systematic review (ie, no observational studies).

There is clearly more work to be done in researching IDR and other interventions to improve teamwork in general medical settings. Larger studies are needed to provide sufficient power to detect improvement in outcomes. Future studies need to report the degree to which interventions are implemented as planned and need to use stronger study designs (eg, cluster randomized control or interrupted time series) to avoid the influence of confounders. Qualitative methods should be used to assess the influence of contextual factors on the success of interventions.[4] Most importantly, future studies should be based on conceptual models that explain how components of the intervention influence proximal measures of teamwork and downstream patient outcomes.

In the meantime, what is a hospital leader to do? We believe efforts to improve IDR are warranted, but that IDR program leaders need to first specify their primary objective(s). For example, in some hospitals, there may be little room to further reduce LOS, so another goalreducing preventable readmissions or reducing adverse eventsmight be specified as the key performance indicator. This crucial first step of creating a shared goal informs the design, implementation, and evaluation of IDR. We also believe that geographic localization of physicians to specific units is foundational to improving IDR. Physicians cannot feasibly attend IDR if their patients are spread across multiple units (or buildings). Finally, hospital leaders also need to view IDR as part of a larger set of interventions to improve teamwork. Leaders need to assess the adequacy of staffing levels, workflow, and team composition.[8] Unit‐based interdisciplinary leadership models should be used to help link efforts at various levels within a larger system.[9] These models designate a unit medical director and nurse manager who are jointly responsible for unit performance.

In conclusion, IDR play an important role in improving patient outcomes, but only do so by improving teamwork. In redesigning IDR, leaders need to be thoughtful about what outcomes IDR can affect, how IDR affect them, and how IDR fit into larger‐scale efforts to improve performance.

Care of hospitalized patients requires effective teamwork within groups composed of physicians (eg, residents, hospitalists, specialists), advanced practice providers, nurses, patient‐care technicians, pharmacists, social workers, and therapists. Sadly, hospital‐based team members often fail to communicate. For example, 2 studies found that nurses and physicians communicated with one another on only 50% to 60% of their patients' hospital days, resulting in a lack of a mutual understanding of the plan of care.[1, 2]

Failure to communicate effectively may be because the hospital setting poses important challenges to teamwork, including the use of large teams with membership that changes frequently because of the need to provide care around the clock. Furthermore, individual team members often have high workloads, care for multiple patients simultaneously, and are seldom in the same place at the same time.

Interdisciplinary rounds (IDR) are a microsystem‐level solution with the goal to share information, achieve mutual understanding, and collaboratively revise the plan of care within care teams. Though common, IDR look very different across hospitals, making studies that evaluate novel strategies to improve IDR and measure their impact of great interest to hospital medicine.

In this issue of the Journal of Hospital Medicine, Bhamidipati and colleagues present a systematic review of published studies evaluating the effect of IDR on patient outcomes.[3] The systematic review included 22 studies, including 12 experimental/quasiexperimental and 10 observational studies. Overall, 13 studies were of low to medium quality, and 9 were high quality. Importantly, relatively few studies reported the degree to which IDR were implemented as planned. The investigators found evidence that IDR had a positive effect on length of stay (LOS) and staff satisfaction, but little evidence to support an effect on patient safety or satisfaction. Furthermore, the investigators found significant variability in IDR design and team composition. Some of this variation is to be expected, as IDR, like other interventions to improve quality and safety of patient care in complex settings, should be implemented with an expectation that the team may need to make adaptations based on local contextual factors such as workload (eg, daily census), environment (eg, open vs closed intensive care unit), local politics (eg, uniquely strong support for/against the intervention), and prior experience (eg, prior failed, similar interventions).[4, 5] Moreover, objectives for IDR may differ across settings. Some hospitals may have room (and a need) to improve LOS, whereas others may prioritize improving patient safety or patient experience metrics.

Bhamidipati and colleagues explain that their review did not reveal a causal pathway between IDR design and outcomes. We believe this lack of association is because most of the included studies did not propose a causal pathway between the IDR components implemented and the outcomes assessed. That is, few studies referred to conceptual models that explain how components of the IDR intervention might influence downstream patient outcomes.

IDR have the potential to influence a number of patient outcomes, including those reflecting efficiency (eg, length of stay), patient safety (eg, adverse events), and patient centeredness (eg, patient satisfaction). However, these outcomes are influenced by many factors, including patient characteristics and other efforts to improve care. As explained by the investigators, the results of many of the included studies may have been confounded due to relatively weak study designs and statistical analyses. Importantly, few of the studies included in this review report the more proximal measure of teamwork. If we hypothesize that IDR improve patient outcomes, they do so by improving teamwork. After all, the purpose of IDR is to assemble team members so they can communicate about and coordinate care. Measuring teamwork behaviors is difficult, especially on medical services. Measuring teamwork climate, the measurable aspects of team culture, is relatively easy. A recent systematic review of teamwork climate assessments in internal medicine identified the Safety Attitudes Questionnaire and the Team Climate Inventory as having substantial validity evidence and association with improved patient outcomes.[6]

Bhamidipati and colleagues proposed a definition for IDR and taxonomy for IDR design and reporting based on their systematic review. Although very useful, the IDR definition may be too limiting as evidenced by the fact that very few studies would be included in a systematic review using this definition as the inclusion criteria. Their proposed taxonomy should serve as a useful framework for future research efforts and appropriately recommends reporting of site characteristics, components of IDR design, and outcomes.

The systematic review by Bhamidipati et al. must also be interpreted in conjunction with another recently published systematic review by Pannick and colleagues assessing the effect of interdisciplinary team care interventions on general medical wards.[7] Contrary to the findings of the Bhamidipati et al. study, Pannick and colleagues found that most interdisciplinary team care interventions had no effect on LOS, but that half of the studies found an improvement in complications of care. Importantly, Pannick and colleagues included only experimental and quasiexperimental studies in their systematic review (ie, no observational studies).

There is clearly more work to be done in researching IDR and other interventions to improve teamwork in general medical settings. Larger studies are needed to provide sufficient power to detect improvement in outcomes. Future studies need to report the degree to which interventions are implemented as planned and need to use stronger study designs (eg, cluster randomized control or interrupted time series) to avoid the influence of confounders. Qualitative methods should be used to assess the influence of contextual factors on the success of interventions.[4] Most importantly, future studies should be based on conceptual models that explain how components of the intervention influence proximal measures of teamwork and downstream patient outcomes.

In the meantime, what is a hospital leader to do? We believe efforts to improve IDR are warranted, but that IDR program leaders need to first specify their primary objective(s). For example, in some hospitals, there may be little room to further reduce LOS, so another goalreducing preventable readmissions or reducing adverse eventsmight be specified as the key performance indicator. This crucial first step of creating a shared goal informs the design, implementation, and evaluation of IDR. We also believe that geographic localization of physicians to specific units is foundational to improving IDR. Physicians cannot feasibly attend IDR if their patients are spread across multiple units (or buildings). Finally, hospital leaders also need to view IDR as part of a larger set of interventions to improve teamwork. Leaders need to assess the adequacy of staffing levels, workflow, and team composition.[8] Unit‐based interdisciplinary leadership models should be used to help link efforts at various levels within a larger system.[9] These models designate a unit medical director and nurse manager who are jointly responsible for unit performance.

In conclusion, IDR play an important role in improving patient outcomes, but only do so by improving teamwork. In redesigning IDR, leaders need to be thoughtful about what outcomes IDR can affect, how IDR affect them, and how IDR fit into larger‐scale efforts to improve performance.

In the United States, there are an estimated 744,000 individuals who have engaged in recent injection drug use (IDU) and 6.6 million individuals who have ever injected a drug.[1] The practice of IDU predisposes individuals to serious bacterial and fungal infections that often require long‐term intravenous antibiotics. In individuals without IDU, these serious infections are often treated with outpatient parenteral antibiotic therapy (OPAT). However, a different standard exists for many persons who inject drugs (PWID)the mandated completion of antibiotics in an inpatient setting.

Though mandating inpatient antibiotic therapy for PWID is a widely adopted standard, this practice is not evidence based and may increase overall costs to the healthcare system. In 2012, in a quality‐improvement initiative, UKHealthCare established a protocol for treating appropriate PWID with OPAT.[2] They found very few inpatient providers willing to discharge PWID on OPAT, even with an established protocol.

To better understand the reasons for the low adoption of this protocol, Fanucchi and colleagues developed a survey designed to assess attitudes, practices, and mediating factors impacting the decision making about discharging PWID on OPAT.[2] The results of this survey are reported in this issue of the Journal of Hospital Medicine.

The study found that 95% of inpatient providers use OPAT for patients without IDU, but only 29% would even consider OPAT in PWID. The most common barriers to discharging a patient with IDU on OPAT were socioeconomic factors, willingness of infectious diseases physicians to follow as an outpatient, and concerns for misuse of peripherally inserted central catheters and adherence with antibiotic treatment.

At first glance, these reservations seem very reasonable. The presence of socioeconomic factors such as homelessness or lack of infectious diseases specialist follow‐up would make the risks of discharge on OPAT significant. The concerns for misuse of peripherally inserted central catheters and adherence to antibiotic treatment suggest that inpatient providers have an overall goal of reducing drug misuse and improving treatment outcomes.

Unfortunately, there are no data to suggest that completion of antibiotics in an inpatient setting reduces drug misuse or improves adherence to antibiotic treatments. Studies have found that at least 16% of PWID will misuse drugs during their hospitalization,[3] and 25% to 30% will be discharged against medical advice.[3, 4] This may be in large part due to the fact that inpatient providers are historically poor at addressing substance use disorders, even in patients with serious infections associated with IDU.[5] Yet the provision of methadone during hospitalization has been associated with a significant reduction in discharges against medical advice.[4] Rather than focusing on placing restrictions on individuals with risky behaviors, patients may benefit more from minimizing these risks through prompt recognition and management of substance use disorder.

Although limited, there is also evidence to support the feasibility of safe and effective OPAT in some PWID. A study by Ho et al. used OPAT to treat 29 PWID hospitalized with serious infections.[6] The study population had adequate housing, a reliable guardian, and signed a contract agreeing to abstain from drug misuse. In addition, all patients received substance use counseling and novel tamper‐proof security seals to prevent misuse of peripherally inserted central catheters, and antibiotics were delivered daily at an infusion center. They found no evidence of line tampering, excess readmissions, or excess line infections. Of note, the study population included 2 patients who were discharged against medical advice but successfully completed OPAT without issue. Although we do not believe that all individuals are appropriate for OPAT, this study suggests that OPAT can be considered in select PWID.

The study by Fanucchi et al. also reinforces the importance of making individualized risk assessments of persons with a history of IDU rather than assuming uniformity among the population. Of particular note is the lack of agreed‐upon definition of remote history of IDU (range, 2120 months; median, 12 months). The idea that individuals with a decade of sobriety could be subject to the same restrictions as a patient injecting multiple times a day speaks to providers' discomfort with assessing the individual risk of a person who has suffered from substance use disorder. Further, the fact that so few providers felt substance use disorder treatment was a critical component of a decision to allow OPAT raises concerns that providers are not aware of effective means to treat addiction. In particular, it is crucial for providers to understand that medication‐assisted treatment, such as methadone or buprenorphine for opioid use disorder, has significant evidence to support efficacy in decreasing drug misuse and improving outcomes.

This study suggests more work will need to be done before inpatient providers will be comfortable discharging any PWID with OPAT. This includes improved outpatient services (enhanced case management and home health services, and better access to outpatient physicians including infectious diseases specialists), the development of tamper‐evident devices to deter misuse of peripherally inserted central catheters, and defined legal protection for providers.

In addition, more research needs to be done on this population to objectively stratify risk for PWID and assess outcomes for PWID treated with OPAT versus the current standard of care. This research should have a particular focus on the long‐term financial and societal costs associated with PWID leaving against medical advice or receiving potentially unnecessary inpatient services. Minimizing the length of stay may defray inpatient costs and afford investment into more robust, effective outpatient services. It is essential that we develop a system to provide antibiotics in a way that optimizes outcomes and is cost‐effective.

Regardless of the decision to mandate antibiotic treatment in an inpatient setting or to discharge with OPAT, it is clear that more needs to be done to address addiction in hospitalized patients. All hospitalized PWID should receive safe injection education and a referral to a substance use disorder specialist. In addition, individuals with opioid‐misuse or opioid use disorder should receive opioid overdose education and naloxone distribution. Hospitalizations serve as important opportunities to engage individuals in the treatment of their addiction. It is essential that hospitalists begin utilizing these opportunities.

Disclosures: Nothing to report.

In the United States, there are an estimated 744,000 individuals who have engaged in recent injection drug use (IDU) and 6.6 million individuals who have ever injected a drug.[1] The practice of IDU predisposes individuals to serious bacterial and fungal infections that often require long‐term intravenous antibiotics. In individuals without IDU, these serious infections are often treated with outpatient parenteral antibiotic therapy (OPAT). However, a different standard exists for many persons who inject drugs (PWID)the mandated completion of antibiotics in an inpatient setting.

Though mandating inpatient antibiotic therapy for PWID is a widely adopted standard, this practice is not evidence based and may increase overall costs to the healthcare system. In 2012, in a quality‐improvement initiative, UKHealthCare established a protocol for treating appropriate PWID with OPAT.[2] They found very few inpatient providers willing to discharge PWID on OPAT, even with an established protocol.

To better understand the reasons for the low adoption of this protocol, Fanucchi and colleagues developed a survey designed to assess attitudes, practices, and mediating factors impacting the decision making about discharging PWID on OPAT.[2] The results of this survey are reported in this issue of the Journal of Hospital Medicine.

The study found that 95% of inpatient providers use OPAT for patients without IDU, but only 29% would even consider OPAT in PWID. The most common barriers to discharging a patient with IDU on OPAT were socioeconomic factors, willingness of infectious diseases physicians to follow as an outpatient, and concerns for misuse of peripherally inserted central catheters and adherence with antibiotic treatment.

At first glance, these reservations seem very reasonable. The presence of socioeconomic factors such as homelessness or lack of infectious diseases specialist follow‐up would make the risks of discharge on OPAT significant. The concerns for misuse of peripherally inserted central catheters and adherence to antibiotic treatment suggest that inpatient providers have an overall goal of reducing drug misuse and improving treatment outcomes.

Unfortunately, there are no data to suggest that completion of antibiotics in an inpatient setting reduces drug misuse or improves adherence to antibiotic treatments. Studies have found that at least 16% of PWID will misuse drugs during their hospitalization,[3] and 25% to 30% will be discharged against medical advice.[3, 4] This may be in large part due to the fact that inpatient providers are historically poor at addressing substance use disorders, even in patients with serious infections associated with IDU.[5] Yet the provision of methadone during hospitalization has been associated with a significant reduction in discharges against medical advice.[4] Rather than focusing on placing restrictions on individuals with risky behaviors, patients may benefit more from minimizing these risks through prompt recognition and management of substance use disorder.

Although limited, there is also evidence to support the feasibility of safe and effective OPAT in some PWID. A study by Ho et al. used OPAT to treat 29 PWID hospitalized with serious infections.[6] The study population had adequate housing, a reliable guardian, and signed a contract agreeing to abstain from drug misuse. In addition, all patients received substance use counseling and novel tamper‐proof security seals to prevent misuse of peripherally inserted central catheters, and antibiotics were delivered daily at an infusion center. They found no evidence of line tampering, excess readmissions, or excess line infections. Of note, the study population included 2 patients who were discharged against medical advice but successfully completed OPAT without issue. Although we do not believe that all individuals are appropriate for OPAT, this study suggests that OPAT can be considered in select PWID.

The study by Fanucchi et al. also reinforces the importance of making individualized risk assessments of persons with a history of IDU rather than assuming uniformity among the population. Of particular note is the lack of agreed‐upon definition of remote history of IDU (range, 2120 months; median, 12 months). The idea that individuals with a decade of sobriety could be subject to the same restrictions as a patient injecting multiple times a day speaks to providers' discomfort with assessing the individual risk of a person who has suffered from substance use disorder. Further, the fact that so few providers felt substance use disorder treatment was a critical component of a decision to allow OPAT raises concerns that providers are not aware of effective means to treat addiction. In particular, it is crucial for providers to understand that medication‐assisted treatment, such as methadone or buprenorphine for opioid use disorder, has significant evidence to support efficacy in decreasing drug misuse and improving outcomes.

This study suggests more work will need to be done before inpatient providers will be comfortable discharging any PWID with OPAT. This includes improved outpatient services (enhanced case management and home health services, and better access to outpatient physicians including infectious diseases specialists), the development of tamper‐evident devices to deter misuse of peripherally inserted central catheters, and defined legal protection for providers.

In addition, more research needs to be done on this population to objectively stratify risk for PWID and assess outcomes for PWID treated with OPAT versus the current standard of care. This research should have a particular focus on the long‐term financial and societal costs associated with PWID leaving against medical advice or receiving potentially unnecessary inpatient services. Minimizing the length of stay may defray inpatient costs and afford investment into more robust, effective outpatient services. It is essential that we develop a system to provide antibiotics in a way that optimizes outcomes and is cost‐effective.

Regardless of the decision to mandate antibiotic treatment in an inpatient setting or to discharge with OPAT, it is clear that more needs to be done to address addiction in hospitalized patients. All hospitalized PWID should receive safe injection education and a referral to a substance use disorder specialist. In addition, individuals with opioid‐misuse or opioid use disorder should receive opioid overdose education and naloxone distribution. Hospitalizations serve as important opportunities to engage individuals in the treatment of their addiction. It is essential that hospitalists begin utilizing these opportunities.

Disclosures: Nothing to report.

In the United States, there are an estimated 744,000 individuals who have engaged in recent injection drug use (IDU) and 6.6 million individuals who have ever injected a drug.[1] The practice of IDU predisposes individuals to serious bacterial and fungal infections that often require long‐term intravenous antibiotics. In individuals without IDU, these serious infections are often treated with outpatient parenteral antibiotic therapy (OPAT). However, a different standard exists for many persons who inject drugs (PWID)the mandated completion of antibiotics in an inpatient setting.

Though mandating inpatient antibiotic therapy for PWID is a widely adopted standard, this practice is not evidence based and may increase overall costs to the healthcare system. In 2012, in a quality‐improvement initiative, UKHealthCare established a protocol for treating appropriate PWID with OPAT.[2] They found very few inpatient providers willing to discharge PWID on OPAT, even with an established protocol.

To better understand the reasons for the low adoption of this protocol, Fanucchi and colleagues developed a survey designed to assess attitudes, practices, and mediating factors impacting the decision making about discharging PWID on OPAT.[2] The results of this survey are reported in this issue of the Journal of Hospital Medicine.

The study found that 95% of inpatient providers use OPAT for patients without IDU, but only 29% would even consider OPAT in PWID. The most common barriers to discharging a patient with IDU on OPAT were socioeconomic factors, willingness of infectious diseases physicians to follow as an outpatient, and concerns for misuse of peripherally inserted central catheters and adherence with antibiotic treatment.

At first glance, these reservations seem very reasonable. The presence of socioeconomic factors such as homelessness or lack of infectious diseases specialist follow‐up would make the risks of discharge on OPAT significant. The concerns for misuse of peripherally inserted central catheters and adherence to antibiotic treatment suggest that inpatient providers have an overall goal of reducing drug misuse and improving treatment outcomes.

Unfortunately, there are no data to suggest that completion of antibiotics in an inpatient setting reduces drug misuse or improves adherence to antibiotic treatments. Studies have found that at least 16% of PWID will misuse drugs during their hospitalization,[3] and 25% to 30% will be discharged against medical advice.[3, 4] This may be in large part due to the fact that inpatient providers are historically poor at addressing substance use disorders, even in patients with serious infections associated with IDU.[5] Yet the provision of methadone during hospitalization has been associated with a significant reduction in discharges against medical advice.[4] Rather than focusing on placing restrictions on individuals with risky behaviors, patients may benefit more from minimizing these risks through prompt recognition and management of substance use disorder.

Although limited, there is also evidence to support the feasibility of safe and effective OPAT in some PWID. A study by Ho et al. used OPAT to treat 29 PWID hospitalized with serious infections.[6] The study population had adequate housing, a reliable guardian, and signed a contract agreeing to abstain from drug misuse. In addition, all patients received substance use counseling and novel tamper‐proof security seals to prevent misuse of peripherally inserted central catheters, and antibiotics were delivered daily at an infusion center. They found no evidence of line tampering, excess readmissions, or excess line infections. Of note, the study population included 2 patients who were discharged against medical advice but successfully completed OPAT without issue. Although we do not believe that all individuals are appropriate for OPAT, this study suggests that OPAT can be considered in select PWID.

The study by Fanucchi et al. also reinforces the importance of making individualized risk assessments of persons with a history of IDU rather than assuming uniformity among the population. Of particular note is the lack of agreed‐upon definition of remote history of IDU (range, 2120 months; median, 12 months). The idea that individuals with a decade of sobriety could be subject to the same restrictions as a patient injecting multiple times a day speaks to providers' discomfort with assessing the individual risk of a person who has suffered from substance use disorder. Further, the fact that so few providers felt substance use disorder treatment was a critical component of a decision to allow OPAT raises concerns that providers are not aware of effective means to treat addiction. In particular, it is crucial for providers to understand that medication‐assisted treatment, such as methadone or buprenorphine for opioid use disorder, has significant evidence to support efficacy in decreasing drug misuse and improving outcomes.

This study suggests more work will need to be done before inpatient providers will be comfortable discharging any PWID with OPAT. This includes improved outpatient services (enhanced case management and home health services, and better access to outpatient physicians including infectious diseases specialists), the development of tamper‐evident devices to deter misuse of peripherally inserted central catheters, and defined legal protection for providers.

In addition, more research needs to be done on this population to objectively stratify risk for PWID and assess outcomes for PWID treated with OPAT versus the current standard of care. This research should have a particular focus on the long‐term financial and societal costs associated with PWID leaving against medical advice or receiving potentially unnecessary inpatient services. Minimizing the length of stay may defray inpatient costs and afford investment into more robust, effective outpatient services. It is essential that we develop a system to provide antibiotics in a way that optimizes outcomes and is cost‐effective.

Regardless of the decision to mandate antibiotic treatment in an inpatient setting or to discharge with OPAT, it is clear that more needs to be done to address addiction in hospitalized patients. All hospitalized PWID should receive safe injection education and a referral to a substance use disorder specialist. In addition, individuals with opioid‐misuse or opioid use disorder should receive opioid overdose education and naloxone distribution. Hospitalizations serve as important opportunities to engage individuals in the treatment of their addiction. It is essential that hospitalists begin utilizing these opportunities.

Disclosures: Nothing to report.