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Revolutionizing Quality Improvement in Hospital Medicine
As the senior physician advisor to SHM’s Center for Hospital Innovation and Improvement, Eric Howell, MD, SFHM, bridges the gap between clinical expertise and project support and development. The Hospitalist recently had a conversation with Dr. Howell, a past president of SHM, to learn more about his role and how the Center for Hospital Innovation and Improvement is revolutionizing quality improvement (QI) in hospital medicine.
Question: What is your role as the senior physician advisor to The Center for Hospital Innovation and Improvement?
Answer: I see my role as the intersection of a Venn diagram; one circle involves my clinical know-how, and the other includes the proposals brought to the Center for Hospital Innovation and Improvement by hospitalists and healthcare professionals. Where those two circles intersect is where I am able to use my experience from the front line of patient care to validate potential projects.
In addition to project assessment, I monitor the pulse of healthcare professionals and hospital leadership to ensure we are meeting their needs, including our efforts of convening a recent summit, where hospitalist clinicians … weighed in on how our team could help them improve. I plan to share this feedback in an upcoming feature, centered on emerging topics in hospital medicine, including care transitions, high-risk medications, advance care planning, and others.
Q: Given your clinical experience and involvement with SHM, how would you say hospitalists are positioned to improve quality, safety, and patient outcomes?
appropriate prescribing practices, which will aid in slowing the emergence of antibiotic-resistant bacteria and prevent the spread of resistant infections.
—Dr. Howell
A: We possess the necessary ingredients to develop a recipe for success in QI from both a clinical and an operational perspective. Hospital medicine is still a young, innovative field that is extremely open to change. Anyone who knows QI knows that it is all about effectively managing and responding to change. Hospitalists also are aware of how to operate in a highly matrixed environment and to collaborate as part of an interdisciplinary team, which are invaluable assets to implementing QI initiatives successfully and proactively monitoring their impact.
Q: What are the biggest assets the Center for Hospital Innovation and Improvement can offer hospitalists in their mission to improve patient care?
A: Our team has resources to help hospitalists improve their skills at whatever stage they are in their careers. If you are just beginning or trying to learn new things independently, you can explore the web-based materials and resource rooms. They are publicly accessible resources that can assist in informing quality improvement efforts in the hospital. For those looking to expand their skills in a more hands-on way, we offer a mentored implementation program, where hospitalists can receive guidance from expert mentors in a number of different clinical areas.
Q: How can the Center for Hospital Innovation and Improvement help hospitalists address emerging challenges in hospital medicine?
A: You cannot talk about the Center for Hospital Innovation and Improvement without mentioning signature mentored implementation programs like Project BOOST, focused on effective care transitions, and glycemic control—they are juggernauts for SHM’s portfolio because of their proven track records and sustainable frameworks for driving positive change. These two alone have already been implemented at over 400 facilities, with more inquiries each day.
With support from The Milbank Foundation, The Hastings Center and SHM have joined forces and will create new skills-based training resources and a QI framework to improve end-of-life care in the hospital. Our goal is to equip hospital clinicians with the requisite tools to provide adequate palliative care, especially given the policy landscape related to advance care planning discussions.
As antibiotic resistance emerges as a global issue, antibiotic stewardship has continued to be a high priority for hospitalists. After attending the related White House forum earlier this year, SHM committed to cultivating initiatives that emphasize appropriate prescribing practices, which will aid in slowing the emergence of antibiotic-resistant bacteria and prevent the spread of resistant infections. SHM looks forward to making noteworthy contributions to this initiative, promoting awareness and behavior change through the “Fight the Resistance” campaign.
Q: What is one major takeaway about The Center for Hospital Innovation and Improvement hospitalists should know?
A: The Center for Hospital Innovation and Improvement is not an exclusive club—rather, it is like an open farmers’ market. Anyone with any amount of expertise can get resources through collaboration and partnership. Whether it is residents trying to improve the house staff or professors at major academic centers looking for research partners, The Center for Hospital Innovation and Improvement will welcome you to collaborate and link you to valuable resources.
Brett Radler is SHM’s communications coordinator.
As the senior physician advisor to SHM’s Center for Hospital Innovation and Improvement, Eric Howell, MD, SFHM, bridges the gap between clinical expertise and project support and development. The Hospitalist recently had a conversation with Dr. Howell, a past president of SHM, to learn more about his role and how the Center for Hospital Innovation and Improvement is revolutionizing quality improvement (QI) in hospital medicine.
Question: What is your role as the senior physician advisor to The Center for Hospital Innovation and Improvement?
Answer: I see my role as the intersection of a Venn diagram; one circle involves my clinical know-how, and the other includes the proposals brought to the Center for Hospital Innovation and Improvement by hospitalists and healthcare professionals. Where those two circles intersect is where I am able to use my experience from the front line of patient care to validate potential projects.
In addition to project assessment, I monitor the pulse of healthcare professionals and hospital leadership to ensure we are meeting their needs, including our efforts of convening a recent summit, where hospitalist clinicians … weighed in on how our team could help them improve. I plan to share this feedback in an upcoming feature, centered on emerging topics in hospital medicine, including care transitions, high-risk medications, advance care planning, and others.
Q: Given your clinical experience and involvement with SHM, how would you say hospitalists are positioned to improve quality, safety, and patient outcomes?
appropriate prescribing practices, which will aid in slowing the emergence of antibiotic-resistant bacteria and prevent the spread of resistant infections.
—Dr. Howell
A: We possess the necessary ingredients to develop a recipe for success in QI from both a clinical and an operational perspective. Hospital medicine is still a young, innovative field that is extremely open to change. Anyone who knows QI knows that it is all about effectively managing and responding to change. Hospitalists also are aware of how to operate in a highly matrixed environment and to collaborate as part of an interdisciplinary team, which are invaluable assets to implementing QI initiatives successfully and proactively monitoring their impact.
Q: What are the biggest assets the Center for Hospital Innovation and Improvement can offer hospitalists in their mission to improve patient care?
A: Our team has resources to help hospitalists improve their skills at whatever stage they are in their careers. If you are just beginning or trying to learn new things independently, you can explore the web-based materials and resource rooms. They are publicly accessible resources that can assist in informing quality improvement efforts in the hospital. For those looking to expand their skills in a more hands-on way, we offer a mentored implementation program, where hospitalists can receive guidance from expert mentors in a number of different clinical areas.
Q: How can the Center for Hospital Innovation and Improvement help hospitalists address emerging challenges in hospital medicine?
A: You cannot talk about the Center for Hospital Innovation and Improvement without mentioning signature mentored implementation programs like Project BOOST, focused on effective care transitions, and glycemic control—they are juggernauts for SHM’s portfolio because of their proven track records and sustainable frameworks for driving positive change. These two alone have already been implemented at over 400 facilities, with more inquiries each day.
With support from The Milbank Foundation, The Hastings Center and SHM have joined forces and will create new skills-based training resources and a QI framework to improve end-of-life care in the hospital. Our goal is to equip hospital clinicians with the requisite tools to provide adequate palliative care, especially given the policy landscape related to advance care planning discussions.
As antibiotic resistance emerges as a global issue, antibiotic stewardship has continued to be a high priority for hospitalists. After attending the related White House forum earlier this year, SHM committed to cultivating initiatives that emphasize appropriate prescribing practices, which will aid in slowing the emergence of antibiotic-resistant bacteria and prevent the spread of resistant infections. SHM looks forward to making noteworthy contributions to this initiative, promoting awareness and behavior change through the “Fight the Resistance” campaign.
Q: What is one major takeaway about The Center for Hospital Innovation and Improvement hospitalists should know?
A: The Center for Hospital Innovation and Improvement is not an exclusive club—rather, it is like an open farmers’ market. Anyone with any amount of expertise can get resources through collaboration and partnership. Whether it is residents trying to improve the house staff or professors at major academic centers looking for research partners, The Center for Hospital Innovation and Improvement will welcome you to collaborate and link you to valuable resources.
Brett Radler is SHM’s communications coordinator.
As the senior physician advisor to SHM’s Center for Hospital Innovation and Improvement, Eric Howell, MD, SFHM, bridges the gap between clinical expertise and project support and development. The Hospitalist recently had a conversation with Dr. Howell, a past president of SHM, to learn more about his role and how the Center for Hospital Innovation and Improvement is revolutionizing quality improvement (QI) in hospital medicine.
Question: What is your role as the senior physician advisor to The Center for Hospital Innovation and Improvement?
Answer: I see my role as the intersection of a Venn diagram; one circle involves my clinical know-how, and the other includes the proposals brought to the Center for Hospital Innovation and Improvement by hospitalists and healthcare professionals. Where those two circles intersect is where I am able to use my experience from the front line of patient care to validate potential projects.
In addition to project assessment, I monitor the pulse of healthcare professionals and hospital leadership to ensure we are meeting their needs, including our efforts of convening a recent summit, where hospitalist clinicians … weighed in on how our team could help them improve. I plan to share this feedback in an upcoming feature, centered on emerging topics in hospital medicine, including care transitions, high-risk medications, advance care planning, and others.
Q: Given your clinical experience and involvement with SHM, how would you say hospitalists are positioned to improve quality, safety, and patient outcomes?
appropriate prescribing practices, which will aid in slowing the emergence of antibiotic-resistant bacteria and prevent the spread of resistant infections.
—Dr. Howell
A: We possess the necessary ingredients to develop a recipe for success in QI from both a clinical and an operational perspective. Hospital medicine is still a young, innovative field that is extremely open to change. Anyone who knows QI knows that it is all about effectively managing and responding to change. Hospitalists also are aware of how to operate in a highly matrixed environment and to collaborate as part of an interdisciplinary team, which are invaluable assets to implementing QI initiatives successfully and proactively monitoring their impact.
Q: What are the biggest assets the Center for Hospital Innovation and Improvement can offer hospitalists in their mission to improve patient care?
A: Our team has resources to help hospitalists improve their skills at whatever stage they are in their careers. If you are just beginning or trying to learn new things independently, you can explore the web-based materials and resource rooms. They are publicly accessible resources that can assist in informing quality improvement efforts in the hospital. For those looking to expand their skills in a more hands-on way, we offer a mentored implementation program, where hospitalists can receive guidance from expert mentors in a number of different clinical areas.
Q: How can the Center for Hospital Innovation and Improvement help hospitalists address emerging challenges in hospital medicine?
A: You cannot talk about the Center for Hospital Innovation and Improvement without mentioning signature mentored implementation programs like Project BOOST, focused on effective care transitions, and glycemic control—they are juggernauts for SHM’s portfolio because of their proven track records and sustainable frameworks for driving positive change. These two alone have already been implemented at over 400 facilities, with more inquiries each day.
With support from The Milbank Foundation, The Hastings Center and SHM have joined forces and will create new skills-based training resources and a QI framework to improve end-of-life care in the hospital. Our goal is to equip hospital clinicians with the requisite tools to provide adequate palliative care, especially given the policy landscape related to advance care planning discussions.
As antibiotic resistance emerges as a global issue, antibiotic stewardship has continued to be a high priority for hospitalists. After attending the related White House forum earlier this year, SHM committed to cultivating initiatives that emphasize appropriate prescribing practices, which will aid in slowing the emergence of antibiotic-resistant bacteria and prevent the spread of resistant infections. SHM looks forward to making noteworthy contributions to this initiative, promoting awareness and behavior change through the “Fight the Resistance” campaign.
Q: What is one major takeaway about The Center for Hospital Innovation and Improvement hospitalists should know?
A: The Center for Hospital Innovation and Improvement is not an exclusive club—rather, it is like an open farmers’ market. Anyone with any amount of expertise can get resources through collaboration and partnership. Whether it is residents trying to improve the house staff or professors at major academic centers looking for research partners, The Center for Hospital Innovation and Improvement will welcome you to collaborate and link you to valuable resources.
Brett Radler is SHM’s communications coordinator.
Antimicrobial Stewardship Resources Often Lacking in Hospitalists' Routines
The best antibiotic stewardship programs weave improvements into the routines of hospitalists. But at the end of the day, developing and overseeing these important programs does require some level of time and money. And setting aside that time and money has been the exception rather than the rule.
According to early results from an SHM survey, nine of 123 hospitalists said that they are compensated for work on antimicrobial stewardship programs at their hospitals. That’s a mere 7%. Only 10 out of 122 respondents said they have “protected time” for work on an antimicrobial stewardship program. That’s about 8%. And it’s possible that the survey results are actually skewed somewhat, receiving responses from more proactive centers. One hundred fifteen out of 178 respondents, or 65%, said that they have an antimicrobial stewardship program at their centers.
Arjun Srinivasan, the CDC’s associate director for healthcare-associated infection prevention programs, says he has found that typically about half of U.S. hospitals have such programs. Eric Howell, MD, SFHM, director of the collaborative inpatient medicine service at Johns Hopkins Bayview Medical Center in Baltimore, says change can be a slow process, but he expects initiatives like SHM’s new antibiotic stewardship campaign to help tip the scales toward more resources and more change. It’s a matter of “making the case that, No. 1, this is a problem and, No. 2, there are solutions out there and, No. 3, these solutions are cost effective, as well as improving quality.” Demonstrating the effects on cost and outcomes, he says, is “likely the tipping point [where] we will see real change.”
“If we don’t change, we’re going to run out of antibiotics,” says Dr. Howell, who is also senior physician advisor to SHM’s Center for Hospital Innovation and Improvement. “People are sort of really panic-stricken. And that fear is helping to motivate them to drive change, too.”
Jonathan Zenilman, MD, chief of the division of infectious diseases at Bayview, says that his team worked with a non-Hopkins hospital in Delaware and found they saved about $80,000 a year just by eliminating the use of ertapenem for pre-operative prophylaxis for abdominal surgery. Numbers like that, he says, show that the case for savings can be made to hospital administration. Then again, it’s often easier to make the case before a program is started—and harder to keep it going after that first year.
“Between the second and the third year, you’re not going to generate much savings, if anything,” he says. If a new administrator is in place, it can be a challenge to get them to realize that costs will go back up once a program is dismantled.
“They look at this as an additional business model,” Dr. Zenilman explains. “They’ll say, ‘Where does my revenue offset the costs?’ And sometimes they just don’t get the value proposition…It needs to be pitched as a value proposition and not as a revenue proposition.”
The culture change toward value in the U.S. is helping, though, he says. “Now the business case is easier,” he says, “because there’s clearly this regulatory push towards doing it.” TH
The best antibiotic stewardship programs weave improvements into the routines of hospitalists. But at the end of the day, developing and overseeing these important programs does require some level of time and money. And setting aside that time and money has been the exception rather than the rule.
According to early results from an SHM survey, nine of 123 hospitalists said that they are compensated for work on antimicrobial stewardship programs at their hospitals. That’s a mere 7%. Only 10 out of 122 respondents said they have “protected time” for work on an antimicrobial stewardship program. That’s about 8%. And it’s possible that the survey results are actually skewed somewhat, receiving responses from more proactive centers. One hundred fifteen out of 178 respondents, or 65%, said that they have an antimicrobial stewardship program at their centers.
Arjun Srinivasan, the CDC’s associate director for healthcare-associated infection prevention programs, says he has found that typically about half of U.S. hospitals have such programs. Eric Howell, MD, SFHM, director of the collaborative inpatient medicine service at Johns Hopkins Bayview Medical Center in Baltimore, says change can be a slow process, but he expects initiatives like SHM’s new antibiotic stewardship campaign to help tip the scales toward more resources and more change. It’s a matter of “making the case that, No. 1, this is a problem and, No. 2, there are solutions out there and, No. 3, these solutions are cost effective, as well as improving quality.” Demonstrating the effects on cost and outcomes, he says, is “likely the tipping point [where] we will see real change.”
“If we don’t change, we’re going to run out of antibiotics,” says Dr. Howell, who is also senior physician advisor to SHM’s Center for Hospital Innovation and Improvement. “People are sort of really panic-stricken. And that fear is helping to motivate them to drive change, too.”
Jonathan Zenilman, MD, chief of the division of infectious diseases at Bayview, says that his team worked with a non-Hopkins hospital in Delaware and found they saved about $80,000 a year just by eliminating the use of ertapenem for pre-operative prophylaxis for abdominal surgery. Numbers like that, he says, show that the case for savings can be made to hospital administration. Then again, it’s often easier to make the case before a program is started—and harder to keep it going after that first year.
“Between the second and the third year, you’re not going to generate much savings, if anything,” he says. If a new administrator is in place, it can be a challenge to get them to realize that costs will go back up once a program is dismantled.
“They look at this as an additional business model,” Dr. Zenilman explains. “They’ll say, ‘Where does my revenue offset the costs?’ And sometimes they just don’t get the value proposition…It needs to be pitched as a value proposition and not as a revenue proposition.”
The culture change toward value in the U.S. is helping, though, he says. “Now the business case is easier,” he says, “because there’s clearly this regulatory push towards doing it.” TH
The best antibiotic stewardship programs weave improvements into the routines of hospitalists. But at the end of the day, developing and overseeing these important programs does require some level of time and money. And setting aside that time and money has been the exception rather than the rule.
According to early results from an SHM survey, nine of 123 hospitalists said that they are compensated for work on antimicrobial stewardship programs at their hospitals. That’s a mere 7%. Only 10 out of 122 respondents said they have “protected time” for work on an antimicrobial stewardship program. That’s about 8%. And it’s possible that the survey results are actually skewed somewhat, receiving responses from more proactive centers. One hundred fifteen out of 178 respondents, or 65%, said that they have an antimicrobial stewardship program at their centers.
Arjun Srinivasan, the CDC’s associate director for healthcare-associated infection prevention programs, says he has found that typically about half of U.S. hospitals have such programs. Eric Howell, MD, SFHM, director of the collaborative inpatient medicine service at Johns Hopkins Bayview Medical Center in Baltimore, says change can be a slow process, but he expects initiatives like SHM’s new antibiotic stewardship campaign to help tip the scales toward more resources and more change. It’s a matter of “making the case that, No. 1, this is a problem and, No. 2, there are solutions out there and, No. 3, these solutions are cost effective, as well as improving quality.” Demonstrating the effects on cost and outcomes, he says, is “likely the tipping point [where] we will see real change.”
“If we don’t change, we’re going to run out of antibiotics,” says Dr. Howell, who is also senior physician advisor to SHM’s Center for Hospital Innovation and Improvement. “People are sort of really panic-stricken. And that fear is helping to motivate them to drive change, too.”
Jonathan Zenilman, MD, chief of the division of infectious diseases at Bayview, says that his team worked with a non-Hopkins hospital in Delaware and found they saved about $80,000 a year just by eliminating the use of ertapenem for pre-operative prophylaxis for abdominal surgery. Numbers like that, he says, show that the case for savings can be made to hospital administration. Then again, it’s often easier to make the case before a program is started—and harder to keep it going after that first year.
“Between the second and the third year, you’re not going to generate much savings, if anything,” he says. If a new administrator is in place, it can be a challenge to get them to realize that costs will go back up once a program is dismantled.
“They look at this as an additional business model,” Dr. Zenilman explains. “They’ll say, ‘Where does my revenue offset the costs?’ And sometimes they just don’t get the value proposition…It needs to be pitched as a value proposition and not as a revenue proposition.”
The culture change toward value in the U.S. is helping, though, he says. “Now the business case is easier,” he says, “because there’s clearly this regulatory push towards doing it.” TH
Thrombosis Management Demands Delicate, Balanced Approach
The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications while minimizing bleed risks was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient Conference.
“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs the Anticoagulation and Thrombosis Service at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and she said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.
“There is interest on both sides of that question,” Dr. Minichiello said, adding the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—over-diagnosis and over-treatment—where we’re also trying to avoid, for example, overuse of CT scans.”
Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk, but with an increased risk for bleeding.
“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.
Literature increasingly recommends hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, she noted.
“[Hospitalists] must be mindful of the risks and benefits,” she said.
Physicians should also think twice about concomitant antiplatelet therapy like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”
Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Quebec, attended Dr. Minichiello’s breakout session on challenging cases.
“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,” Dr. Bouchard said. She also explained a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries when possible to offer the oral anticoagulants.
Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around procedures, anticoagulant choices, and when to restart treatments.
“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s anticoagulation service website, or the American Society of Health System Pharmacists’ anticoagulation resource center. TH
The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications while minimizing bleed risks was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient Conference.
“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs the Anticoagulation and Thrombosis Service at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and she said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.
“There is interest on both sides of that question,” Dr. Minichiello said, adding the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—over-diagnosis and over-treatment—where we’re also trying to avoid, for example, overuse of CT scans.”
Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk, but with an increased risk for bleeding.
“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.
Literature increasingly recommends hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, she noted.
“[Hospitalists] must be mindful of the risks and benefits,” she said.
Physicians should also think twice about concomitant antiplatelet therapy like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”
Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Quebec, attended Dr. Minichiello’s breakout session on challenging cases.
“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,” Dr. Bouchard said. She also explained a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries when possible to offer the oral anticoagulants.
Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around procedures, anticoagulant choices, and when to restart treatments.
“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s anticoagulation service website, or the American Society of Health System Pharmacists’ anticoagulation resource center. TH
The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications while minimizing bleed risks was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient Conference.
“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs the Anticoagulation and Thrombosis Service at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and she said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.
“There is interest on both sides of that question,” Dr. Minichiello said, adding the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—over-diagnosis and over-treatment—where we’re also trying to avoid, for example, overuse of CT scans.”
Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk, but with an increased risk for bleeding.
“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.
Literature increasingly recommends hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, she noted.
“[Hospitalists] must be mindful of the risks and benefits,” she said.
Physicians should also think twice about concomitant antiplatelet therapy like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”
Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Quebec, attended Dr. Minichiello’s breakout session on challenging cases.
“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,” Dr. Bouchard said. She also explained a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries when possible to offer the oral anticoagulants.
Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around procedures, anticoagulant choices, and when to restart treatments.
“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s anticoagulation service website, or the American Society of Health System Pharmacists’ anticoagulation resource center. TH
"Wish List" Outlines Patients' Expectations for Hospital Stays, and Some Easy Fixes
So, how does this apply to hospitalists? Many of the items on the list are an easy fix and don't cost a thing. Here are a few areas hospitalist can impact:
- I want to sleep. For example: are there standing overnight test orders that could be provided during the day?
- Reduce noise outside my room, particularly at night. How can hospitalists contribute to reducing hallway and nursing station noise?
- Knock before entering. It's a sign of respect to knock before entering the patient's room. Sitting down while talking to the patient and introducing yourself are also key.
- Keep me (and my family) updated. Are you always updating the patient and family about the plan of care and if things change?
- I want to be a part of my care. Do you always use language patients (and families) can easily understand? How do you ensure patients (and families) understand the plan of care?
- Be professional, always. No matter where you are in the hospital, patients and families are watching you closely. Ask yourself, "How I perceive you is often how I perceive the hospital and care that I am receiving."
What else can you do to improve the patient's experience in your hospital? TH
So, how does this apply to hospitalists? Many of the items on the list are an easy fix and don't cost a thing. Here are a few areas hospitalist can impact:
- I want to sleep. For example: are there standing overnight test orders that could be provided during the day?
- Reduce noise outside my room, particularly at night. How can hospitalists contribute to reducing hallway and nursing station noise?
- Knock before entering. It's a sign of respect to knock before entering the patient's room. Sitting down while talking to the patient and introducing yourself are also key.
- Keep me (and my family) updated. Are you always updating the patient and family about the plan of care and if things change?
- I want to be a part of my care. Do you always use language patients (and families) can easily understand? How do you ensure patients (and families) understand the plan of care?
- Be professional, always. No matter where you are in the hospital, patients and families are watching you closely. Ask yourself, "How I perceive you is often how I perceive the hospital and care that I am receiving."
What else can you do to improve the patient's experience in your hospital? TH
So, how does this apply to hospitalists? Many of the items on the list are an easy fix and don't cost a thing. Here are a few areas hospitalist can impact:
- I want to sleep. For example: are there standing overnight test orders that could be provided during the day?
- Reduce noise outside my room, particularly at night. How can hospitalists contribute to reducing hallway and nursing station noise?
- Knock before entering. It's a sign of respect to knock before entering the patient's room. Sitting down while talking to the patient and introducing yourself are also key.
- Keep me (and my family) updated. Are you always updating the patient and family about the plan of care and if things change?
- I want to be a part of my care. Do you always use language patients (and families) can easily understand? How do you ensure patients (and families) understand the plan of care?
- Be professional, always. No matter where you are in the hospital, patients and families are watching you closely. Ask yourself, "How I perceive you is often how I perceive the hospital and care that I am receiving."
What else can you do to improve the patient's experience in your hospital? TH
Hospitals Save Estimated $67 Million by Tracking Energy Consumption
Estimated savings in energy costs posted by hospitals participating in the American Hospital Association’s affiliated American Society for Healthcare Engineering (ASHE) Energy to Care Program. Twenty participating hospitals received Energy to Care awards from ASHE in July for reducing their energy consumption by 10% or more. ASHE’s free program includes a benchmarking dashboard hospitals can use to track their own energy consumption, thereby saving energy and reducing costs.
Larry Beresford is a freelance writer in Alameda, Calif.
Estimated savings in energy costs posted by hospitals participating in the American Hospital Association’s affiliated American Society for Healthcare Engineering (ASHE) Energy to Care Program. Twenty participating hospitals received Energy to Care awards from ASHE in July for reducing their energy consumption by 10% or more. ASHE’s free program includes a benchmarking dashboard hospitals can use to track their own energy consumption, thereby saving energy and reducing costs.
Larry Beresford is a freelance writer in Alameda, Calif.
Estimated savings in energy costs posted by hospitals participating in the American Hospital Association’s affiliated American Society for Healthcare Engineering (ASHE) Energy to Care Program. Twenty participating hospitals received Energy to Care awards from ASHE in July for reducing their energy consumption by 10% or more. ASHE’s free program includes a benchmarking dashboard hospitals can use to track their own energy consumption, thereby saving energy and reducing costs.
Larry Beresford is a freelance writer in Alameda, Calif.
How to Develop a Comprehensive Pediatric Palliative Care Program
For Ami Doshi, MD, FAAP, a hospitalist at Rady Children’s Hospital San Diego, the path to establishing a comprehensive pediatric palliative care program began with her realization during medical training that doctors didn’t always adequately address the suffering of young patients with advanced disease and their families. Then, in a hospice rotation, she saw that the palliative approach could offer a better way.
During a pediatric hospital medicine fellowship at the University of California at San Diego, Dr. Doshi conducted an educational needs assessment and then created a palliative care curriculum for residents. Rady administrators supported her attending the Palliative Care Leadership Center training at UC San Francisco, with a team from Rady and Harvard Medical School’s program in Palliative Care Education and Practice.
After five years of development, the program Dr. Doshi helped to launch at Rady has grown into a division of palliative medicine, with a medical director, an inpatient consultation service, a palliative home care program coordinated by a health navigator, and a variety of models in the outpatient clinics.
“The goal is to be seamless and to treat patients across the continuum of care,” says Dr. Doshi, who is now board certified in hospice and palliative. Although she is based in the division of hospital medicine, she leads sit-down rounds with the full palliative care team and bioethics consultants every other week.
“Finding time for this work is always a challenge,” she says, adding that administrative support for physicians’ protected time is growing and that the program is ramping up its data collection to document outcomes resulting from palliative care.
For more information on the program, email her at [email protected].
Larry Beresford is a freelance writer in Alameda, Calif.
For Ami Doshi, MD, FAAP, a hospitalist at Rady Children’s Hospital San Diego, the path to establishing a comprehensive pediatric palliative care program began with her realization during medical training that doctors didn’t always adequately address the suffering of young patients with advanced disease and their families. Then, in a hospice rotation, she saw that the palliative approach could offer a better way.
During a pediatric hospital medicine fellowship at the University of California at San Diego, Dr. Doshi conducted an educational needs assessment and then created a palliative care curriculum for residents. Rady administrators supported her attending the Palliative Care Leadership Center training at UC San Francisco, with a team from Rady and Harvard Medical School’s program in Palliative Care Education and Practice.
After five years of development, the program Dr. Doshi helped to launch at Rady has grown into a division of palliative medicine, with a medical director, an inpatient consultation service, a palliative home care program coordinated by a health navigator, and a variety of models in the outpatient clinics.
“The goal is to be seamless and to treat patients across the continuum of care,” says Dr. Doshi, who is now board certified in hospice and palliative. Although she is based in the division of hospital medicine, she leads sit-down rounds with the full palliative care team and bioethics consultants every other week.
“Finding time for this work is always a challenge,” she says, adding that administrative support for physicians’ protected time is growing and that the program is ramping up its data collection to document outcomes resulting from palliative care.
For more information on the program, email her at [email protected].
Larry Beresford is a freelance writer in Alameda, Calif.
For Ami Doshi, MD, FAAP, a hospitalist at Rady Children’s Hospital San Diego, the path to establishing a comprehensive pediatric palliative care program began with her realization during medical training that doctors didn’t always adequately address the suffering of young patients with advanced disease and their families. Then, in a hospice rotation, she saw that the palliative approach could offer a better way.
During a pediatric hospital medicine fellowship at the University of California at San Diego, Dr. Doshi conducted an educational needs assessment and then created a palliative care curriculum for residents. Rady administrators supported her attending the Palliative Care Leadership Center training at UC San Francisco, with a team from Rady and Harvard Medical School’s program in Palliative Care Education and Practice.
After five years of development, the program Dr. Doshi helped to launch at Rady has grown into a division of palliative medicine, with a medical director, an inpatient consultation service, a palliative home care program coordinated by a health navigator, and a variety of models in the outpatient clinics.
“The goal is to be seamless and to treat patients across the continuum of care,” says Dr. Doshi, who is now board certified in hospice and palliative. Although she is based in the division of hospital medicine, she leads sit-down rounds with the full palliative care team and bioethics consultants every other week.
“Finding time for this work is always a challenge,” she says, adding that administrative support for physicians’ protected time is growing and that the program is ramping up its data collection to document outcomes resulting from palliative care.
For more information on the program, email her at [email protected].
Larry Beresford is a freelance writer in Alameda, Calif.
Consumer Reports Rates Hospitals on Infection Control, Prevention
Consumer Reports included for the first time in its national hospital quality ratings a ranking of how well 3,000 hospitals are controlling common deadly infections such as methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile.
The How Your Hospital Can Make You Sick report is based on information provided to the CDC between October 2013 and September 2014. The CDC found that 105 hospitals distinguished themselves by earning high ratings against both infections. Nine hospitals received top ratings for having no infections from MRSA, C. diff, or other measured infections, although none of the country’s highest-profile hospitals are on that list. Only 6% of hospitals scored well against both infections in the new ratings. The CDC estimates that 648,000 people develop infections during their hospital stay, with 75,000 dying from them; many of the deaths can be traced back to widespread, inappropriate use of antibiotics.
“High rates for MRSA and C. diff can be a red flag that a hospital isn’t following the best practices in preventing infections and prescribing antibiotics,” notes Doris Peter, PhD, director of Consumer Reports’ Health Ratings Center, in a prepared statement. “The data show that it is possible to keep infection rates down and in some cases avoid them altogether.”
Among Consumer Reports’ recommendations for hospitals:
- Consistently follow established protocols for managing superbug infections;
- Accurately track how many infections patients get; and
- Promptly report outbreaks to patients and health authorities.
Reference
- Consumer Reports. America’s antibiotic crisis: how your hospital can make you sick. July 29, 2015. Accessed September 12, 2015.
Consumer Reports included for the first time in its national hospital quality ratings a ranking of how well 3,000 hospitals are controlling common deadly infections such as methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile.
The How Your Hospital Can Make You Sick report is based on information provided to the CDC between October 2013 and September 2014. The CDC found that 105 hospitals distinguished themselves by earning high ratings against both infections. Nine hospitals received top ratings for having no infections from MRSA, C. diff, or other measured infections, although none of the country’s highest-profile hospitals are on that list. Only 6% of hospitals scored well against both infections in the new ratings. The CDC estimates that 648,000 people develop infections during their hospital stay, with 75,000 dying from them; many of the deaths can be traced back to widespread, inappropriate use of antibiotics.
“High rates for MRSA and C. diff can be a red flag that a hospital isn’t following the best practices in preventing infections and prescribing antibiotics,” notes Doris Peter, PhD, director of Consumer Reports’ Health Ratings Center, in a prepared statement. “The data show that it is possible to keep infection rates down and in some cases avoid them altogether.”
Among Consumer Reports’ recommendations for hospitals:
- Consistently follow established protocols for managing superbug infections;
- Accurately track how many infections patients get; and
- Promptly report outbreaks to patients and health authorities.
Reference
- Consumer Reports. America’s antibiotic crisis: how your hospital can make you sick. July 29, 2015. Accessed September 12, 2015.
Consumer Reports included for the first time in its national hospital quality ratings a ranking of how well 3,000 hospitals are controlling common deadly infections such as methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile.
The How Your Hospital Can Make You Sick report is based on information provided to the CDC between October 2013 and September 2014. The CDC found that 105 hospitals distinguished themselves by earning high ratings against both infections. Nine hospitals received top ratings for having no infections from MRSA, C. diff, or other measured infections, although none of the country’s highest-profile hospitals are on that list. Only 6% of hospitals scored well against both infections in the new ratings. The CDC estimates that 648,000 people develop infections during their hospital stay, with 75,000 dying from them; many of the deaths can be traced back to widespread, inappropriate use of antibiotics.
“High rates for MRSA and C. diff can be a red flag that a hospital isn’t following the best practices in preventing infections and prescribing antibiotics,” notes Doris Peter, PhD, director of Consumer Reports’ Health Ratings Center, in a prepared statement. “The data show that it is possible to keep infection rates down and in some cases avoid them altogether.”
Among Consumer Reports’ recommendations for hospitals:
- Consistently follow established protocols for managing superbug infections;
- Accurately track how many infections patients get; and
- Promptly report outbreaks to patients and health authorities.
Reference
- Consumer Reports. America’s antibiotic crisis: how your hospital can make you sick. July 29, 2015. Accessed September 12, 2015.
Joint Commission Offers Resource to Prevent Hospital Falls
The Joint Commission’s Center for Transforming Healthcare has released its Targeted Solutions Tool for preventing hospital inpatient falls and falls with injuries. This step-by-step, online resource helps hospitals measure their fall rates and identify barriers to fall prevention and the specific contributing factors that lead to falls. A systematic approach enables the organization to assess each patient’s risk for falling and then implement specific targeted solutions to address the contributing factors, which will vary from one organization to the next.
Hospital falls total between 700,000 and one million per year, according to the Agency for Healthcare Research and Quality; since 2008, the Centers for Medicare and Medicaid Services has not paid hospitals for the costs of extra care related to falls.
The Joint Commission calculates, based on average baseline and improvement figures from its Preventing Falls with Injury Project, that a typical 200-bed hospital could reduce its number of patients injured by falls annually from 117 to 45. Key elements of a program achieving that kind of success include consistent messaging focused on operational and cultural change, staff engagement, and an “all hands on deck” approach that involves hospitalists and other physicians in helping to prevent falls by hospitalized patients.
The Joint Commission’s Center for Transforming Healthcare has released its Targeted Solutions Tool for preventing hospital inpatient falls and falls with injuries. This step-by-step, online resource helps hospitals measure their fall rates and identify barriers to fall prevention and the specific contributing factors that lead to falls. A systematic approach enables the organization to assess each patient’s risk for falling and then implement specific targeted solutions to address the contributing factors, which will vary from one organization to the next.
Hospital falls total between 700,000 and one million per year, according to the Agency for Healthcare Research and Quality; since 2008, the Centers for Medicare and Medicaid Services has not paid hospitals for the costs of extra care related to falls.
The Joint Commission calculates, based on average baseline and improvement figures from its Preventing Falls with Injury Project, that a typical 200-bed hospital could reduce its number of patients injured by falls annually from 117 to 45. Key elements of a program achieving that kind of success include consistent messaging focused on operational and cultural change, staff engagement, and an “all hands on deck” approach that involves hospitalists and other physicians in helping to prevent falls by hospitalized patients.
The Joint Commission’s Center for Transforming Healthcare has released its Targeted Solutions Tool for preventing hospital inpatient falls and falls with injuries. This step-by-step, online resource helps hospitals measure their fall rates and identify barriers to fall prevention and the specific contributing factors that lead to falls. A systematic approach enables the organization to assess each patient’s risk for falling and then implement specific targeted solutions to address the contributing factors, which will vary from one organization to the next.
Hospital falls total between 700,000 and one million per year, according to the Agency for Healthcare Research and Quality; since 2008, the Centers for Medicare and Medicaid Services has not paid hospitals for the costs of extra care related to falls.
The Joint Commission calculates, based on average baseline and improvement figures from its Preventing Falls with Injury Project, that a typical 200-bed hospital could reduce its number of patients injured by falls annually from 117 to 45. Key elements of a program achieving that kind of success include consistent messaging focused on operational and cultural change, staff engagement, and an “all hands on deck” approach that involves hospitalists and other physicians in helping to prevent falls by hospitalized patients.
Hospitalists’ Research Analyzes Links between Hyperglycemia, Sleep Deprivation
An RIV poster presented at HM15 highlights a common problem hospitalists face: morning hyperglycemia in hospitalized patients, including patients not previously diagnosed with diabetes.1 Lead author Regina Heyl DePietro, BA, now a medical student at Stony Brook (N.Y.) School of Medicine, working with colleagues including David O. Meltzer, MD, PhD, MHM, and Vineet Arora, MD, MAPP, FHM, at the University of Chicago, gathered data to analyze the connections among sleep deprivation, diabetes, and hyperglycemia of hospitalization.
Prior epidemiologic and laboratory research has shown a correlation between hyperglycemia and impaired sleep, DePietro says, but she is not aware of any inpatient cohort study done on this subject. Although diabetic patients have worse morning fasting glucose measures, the correlation between poor quality and quantity of sleep and higher blood glucose levels is also present in patients not previously diagnosed with diabetes.
In her study, participating patients reported their sleep quality prior to hospitalization, while wrist actigraphy measured the duration and efficiency of their sleep in the hospital. Every hour of inpatient sleep loss raised the odds of elevated subsequent morning blood glucose rates by 17%.
by 17%.
“Sleep helps healing,” DePietro says. “Sleep deprivation is a preventable patient quality metric that we have shown affects a health measure.”
Based on additional research, hospitals could take behavioral and/or design measures to help ameliorate this problem.
Reference
- DePietro RH, Spampinato LM, Knutson KL, Cauter EV, Meltzer DO, Arora VM. Hyperglycemia of hospitalization: side effect of sleep deprivation? [abstract] Society of Hospital Medicine Annual Meeting 2015. Accessed September 12, 2015.
An RIV poster presented at HM15 highlights a common problem hospitalists face: morning hyperglycemia in hospitalized patients, including patients not previously diagnosed with diabetes.1 Lead author Regina Heyl DePietro, BA, now a medical student at Stony Brook (N.Y.) School of Medicine, working with colleagues including David O. Meltzer, MD, PhD, MHM, and Vineet Arora, MD, MAPP, FHM, at the University of Chicago, gathered data to analyze the connections among sleep deprivation, diabetes, and hyperglycemia of hospitalization.
Prior epidemiologic and laboratory research has shown a correlation between hyperglycemia and impaired sleep, DePietro says, but she is not aware of any inpatient cohort study done on this subject. Although diabetic patients have worse morning fasting glucose measures, the correlation between poor quality and quantity of sleep and higher blood glucose levels is also present in patients not previously diagnosed with diabetes.
In her study, participating patients reported their sleep quality prior to hospitalization, while wrist actigraphy measured the duration and efficiency of their sleep in the hospital. Every hour of inpatient sleep loss raised the odds of elevated subsequent morning blood glucose rates by 17%.
by 17%.
“Sleep helps healing,” DePietro says. “Sleep deprivation is a preventable patient quality metric that we have shown affects a health measure.”
Based on additional research, hospitals could take behavioral and/or design measures to help ameliorate this problem.
Reference
- DePietro RH, Spampinato LM, Knutson KL, Cauter EV, Meltzer DO, Arora VM. Hyperglycemia of hospitalization: side effect of sleep deprivation? [abstract] Society of Hospital Medicine Annual Meeting 2015. Accessed September 12, 2015.
An RIV poster presented at HM15 highlights a common problem hospitalists face: morning hyperglycemia in hospitalized patients, including patients not previously diagnosed with diabetes.1 Lead author Regina Heyl DePietro, BA, now a medical student at Stony Brook (N.Y.) School of Medicine, working with colleagues including David O. Meltzer, MD, PhD, MHM, and Vineet Arora, MD, MAPP, FHM, at the University of Chicago, gathered data to analyze the connections among sleep deprivation, diabetes, and hyperglycemia of hospitalization.
Prior epidemiologic and laboratory research has shown a correlation between hyperglycemia and impaired sleep, DePietro says, but she is not aware of any inpatient cohort study done on this subject. Although diabetic patients have worse morning fasting glucose measures, the correlation between poor quality and quantity of sleep and higher blood glucose levels is also present in patients not previously diagnosed with diabetes.
In her study, participating patients reported their sleep quality prior to hospitalization, while wrist actigraphy measured the duration and efficiency of their sleep in the hospital. Every hour of inpatient sleep loss raised the odds of elevated subsequent morning blood glucose rates by 17%.
by 17%.
“Sleep helps healing,” DePietro says. “Sleep deprivation is a preventable patient quality metric that we have shown affects a health measure.”
Based on additional research, hospitals could take behavioral and/or design measures to help ameliorate this problem.
Reference
- DePietro RH, Spampinato LM, Knutson KL, Cauter EV, Meltzer DO, Arora VM. Hyperglycemia of hospitalization: side effect of sleep deprivation? [abstract] Society of Hospital Medicine Annual Meeting 2015. Accessed September 12, 2015.
LISTEN NOW: Pediatric Hospital Medicine and the “Right Care” Movement
Three pediatric hospitalists – Dr. Ricardo Quiñonez of San Antonio Children’s Hospital, Dr. Shawn Ralston of Dartmouth-Hitchcock, and Dr. Alan Schroeder of Santa Clara Valley Medical Center – talk about the concept of “right care” in hospital medicine, and their participation in the Lown Institute’s Right Care movement.
Three pediatric hospitalists – Dr. Ricardo Quiñonez of San Antonio Children’s Hospital, Dr. Shawn Ralston of Dartmouth-Hitchcock, and Dr. Alan Schroeder of Santa Clara Valley Medical Center – talk about the concept of “right care” in hospital medicine, and their participation in the Lown Institute’s Right Care movement.
Three pediatric hospitalists – Dr. Ricardo Quiñonez of San Antonio Children’s Hospital, Dr. Shawn Ralston of Dartmouth-Hitchcock, and Dr. Alan Schroeder of Santa Clara Valley Medical Center – talk about the concept of “right care” in hospital medicine, and their participation in the Lown Institute’s Right Care movement.