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Win Whitcomb: Spotlight on Medical Necessity
EDITOR’S NOTE: An incorrect version of Win Whitcomb’s “On the Horizon” column was published in the July issue of The Hospitalist. We deeply regret the error. The correct version of Dr. Whitcomb’s column appears this month, with proper attribution given to hospitalist Brad Flansbaum, DO, SFHM, who contributed to the column.
Assigning the appropriate status to patients (“inpatient” or “observation”) has emerged as a front-and-center issue for hospitalists. Also known as “medical necessity,” many HM groups have been called upon to help solve the “status” problem for their institutions. With nearly 1 in 5 hospitalized patients on observation status in U.S. hospitals, appropriately assigning status is now a dominant, system-level challenge for hospitalists.
This month, we asked two experts to shed light on the nature of this beast, with a focus on the impact on the patient. Brad Flansbaum, DO, SFHM, hospitalist at Lenox Hill Hospital in New York City, and Patrick Conway, MD, FAAP, MSC, SFHM, chief medical officer at the Centers for Medicare & Medicaid Services (CMS), were kind enough to participate in the interview. We start with Dr. Flansbaum.
Dr. Whitcomb: It appears that patients are caught in the middle of the observation status challenge, at least as it relates to footing the bill. Explain the patient perspective of being unwittingly placed on observation status.
Dr. Flansbaum: Recall your last credit card statement. On it is the hotel charge from your last out-of-town CME excursion. Below the total charge, which you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that, because you used the hotel gym and pool—accessed with your room key, they levied the fee. No signs, alerts, or postings denoted the policy, so you expected inclusive use of the facilities as a price of your visit. Capture the emotion of the moment, when you see that bill, feel your heart race, and think to yourself, “Get me the manager!”
WW: Why has assigning appropriate status captured the attention of hospitals?
BF: Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing patients under observation, rather than inpatient, status to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change, and much in the same way of our hotel charge, our patients experience sticker shock when they receive their bill. It is leading to confusion among providers and consternation within the Medicare recipient community.
WW: Why is there so much confusion around appropriate patient status?
BF: The dilemma stems from Medicare payment, and the key distinction between inpatient coverage (Part A) and outpatient coverage, including pharmaceuticals (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation, sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit, beneficiary charges are different. This could result in discrete—and sometimes jolting—enrollee copayments and deductibles for drugs and services.
WW: I’ve heard observation status is having a big, adverse impact on patients who go to skilled nursing facilities. Why?
BF: If a patient requires a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because the patient never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and consequently, tempers are rising. The rules for Medicare Advantage enrollees (Part C—commercial payers receive a fixed sum from CMS, and oversee parts A, B, and D for an individual beneficiary), which comprise 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional, fee-for-service in their policies and, consequently, no exemplar of success in this realm exits.
WW: Why is the number of patients on observation status growing?
BF: Hospitals have significantly increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists often are navigating without a compass. Again, fear of fraud and penalty places hospitals and, indirectly, hospitalists—who often make judgments on admission grade—in a precarious position.
The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which may change in real time during the stay, and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices, as well as the beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after the stay. Hospitalists, of course, want direction on coding, along with an understanding of the impact their decisions will have on patients and subspecialty colleagues.
Let’s now bring in Dr. Conway, a pediatric hospitalist. I thank Dr. Flansbaum, who formulated the following questions.
BF/WW: Is it tenable to keep the current system in place? Would it help to require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet to-be-determined manner?
Dr. Conway: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for beneficiary coverage post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask,” to educate beneficiaries on this issue. (Download a PDF of the pamphlet at www.medicare.gov/Publications/Pubs/pdf/11435.pdf.)
BF/WW: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?
PC: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary-care, emergency medicine, and/or HM clinician.
BF/WW: Before the U.S. healthcare system matures to a more full-out, integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?
PC: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.
With growing attention to observation status coming from patients and provider groups (the AMA is requesting that CMS revise its coverage rules), we will no doubt be hearing more about this going forward.
Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].
EDITOR’S NOTE: An incorrect version of Win Whitcomb’s “On the Horizon” column was published in the July issue of The Hospitalist. We deeply regret the error. The correct version of Dr. Whitcomb’s column appears this month, with proper attribution given to hospitalist Brad Flansbaum, DO, SFHM, who contributed to the column.
Assigning the appropriate status to patients (“inpatient” or “observation”) has emerged as a front-and-center issue for hospitalists. Also known as “medical necessity,” many HM groups have been called upon to help solve the “status” problem for their institutions. With nearly 1 in 5 hospitalized patients on observation status in U.S. hospitals, appropriately assigning status is now a dominant, system-level challenge for hospitalists.
This month, we asked two experts to shed light on the nature of this beast, with a focus on the impact on the patient. Brad Flansbaum, DO, SFHM, hospitalist at Lenox Hill Hospital in New York City, and Patrick Conway, MD, FAAP, MSC, SFHM, chief medical officer at the Centers for Medicare & Medicaid Services (CMS), were kind enough to participate in the interview. We start with Dr. Flansbaum.
Dr. Whitcomb: It appears that patients are caught in the middle of the observation status challenge, at least as it relates to footing the bill. Explain the patient perspective of being unwittingly placed on observation status.
Dr. Flansbaum: Recall your last credit card statement. On it is the hotel charge from your last out-of-town CME excursion. Below the total charge, which you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that, because you used the hotel gym and pool—accessed with your room key, they levied the fee. No signs, alerts, or postings denoted the policy, so you expected inclusive use of the facilities as a price of your visit. Capture the emotion of the moment, when you see that bill, feel your heart race, and think to yourself, “Get me the manager!”
WW: Why has assigning appropriate status captured the attention of hospitals?
BF: Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing patients under observation, rather than inpatient, status to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change, and much in the same way of our hotel charge, our patients experience sticker shock when they receive their bill. It is leading to confusion among providers and consternation within the Medicare recipient community.
WW: Why is there so much confusion around appropriate patient status?
BF: The dilemma stems from Medicare payment, and the key distinction between inpatient coverage (Part A) and outpatient coverage, including pharmaceuticals (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation, sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit, beneficiary charges are different. This could result in discrete—and sometimes jolting—enrollee copayments and deductibles for drugs and services.
WW: I’ve heard observation status is having a big, adverse impact on patients who go to skilled nursing facilities. Why?
BF: If a patient requires a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because the patient never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and consequently, tempers are rising. The rules for Medicare Advantage enrollees (Part C—commercial payers receive a fixed sum from CMS, and oversee parts A, B, and D for an individual beneficiary), which comprise 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional, fee-for-service in their policies and, consequently, no exemplar of success in this realm exits.
WW: Why is the number of patients on observation status growing?
BF: Hospitals have significantly increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists often are navigating without a compass. Again, fear of fraud and penalty places hospitals and, indirectly, hospitalists—who often make judgments on admission grade—in a precarious position.
The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which may change in real time during the stay, and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices, as well as the beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after the stay. Hospitalists, of course, want direction on coding, along with an understanding of the impact their decisions will have on patients and subspecialty colleagues.
Let’s now bring in Dr. Conway, a pediatric hospitalist. I thank Dr. Flansbaum, who formulated the following questions.
BF/WW: Is it tenable to keep the current system in place? Would it help to require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet to-be-determined manner?
Dr. Conway: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for beneficiary coverage post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask,” to educate beneficiaries on this issue. (Download a PDF of the pamphlet at www.medicare.gov/Publications/Pubs/pdf/11435.pdf.)
BF/WW: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?
PC: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary-care, emergency medicine, and/or HM clinician.
BF/WW: Before the U.S. healthcare system matures to a more full-out, integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?
PC: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.
With growing attention to observation status coming from patients and provider groups (the AMA is requesting that CMS revise its coverage rules), we will no doubt be hearing more about this going forward.
Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].
EDITOR’S NOTE: An incorrect version of Win Whitcomb’s “On the Horizon” column was published in the July issue of The Hospitalist. We deeply regret the error. The correct version of Dr. Whitcomb’s column appears this month, with proper attribution given to hospitalist Brad Flansbaum, DO, SFHM, who contributed to the column.
Assigning the appropriate status to patients (“inpatient” or “observation”) has emerged as a front-and-center issue for hospitalists. Also known as “medical necessity,” many HM groups have been called upon to help solve the “status” problem for their institutions. With nearly 1 in 5 hospitalized patients on observation status in U.S. hospitals, appropriately assigning status is now a dominant, system-level challenge for hospitalists.
This month, we asked two experts to shed light on the nature of this beast, with a focus on the impact on the patient. Brad Flansbaum, DO, SFHM, hospitalist at Lenox Hill Hospital in New York City, and Patrick Conway, MD, FAAP, MSC, SFHM, chief medical officer at the Centers for Medicare & Medicaid Services (CMS), were kind enough to participate in the interview. We start with Dr. Flansbaum.
Dr. Whitcomb: It appears that patients are caught in the middle of the observation status challenge, at least as it relates to footing the bill. Explain the patient perspective of being unwittingly placed on observation status.
Dr. Flansbaum: Recall your last credit card statement. On it is the hotel charge from your last out-of-town CME excursion. Below the total charge, which you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that, because you used the hotel gym and pool—accessed with your room key, they levied the fee. No signs, alerts, or postings denoted the policy, so you expected inclusive use of the facilities as a price of your visit. Capture the emotion of the moment, when you see that bill, feel your heart race, and think to yourself, “Get me the manager!”
WW: Why has assigning appropriate status captured the attention of hospitals?
BF: Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing patients under observation, rather than inpatient, status to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change, and much in the same way of our hotel charge, our patients experience sticker shock when they receive their bill. It is leading to confusion among providers and consternation within the Medicare recipient community.
WW: Why is there so much confusion around appropriate patient status?
BF: The dilemma stems from Medicare payment, and the key distinction between inpatient coverage (Part A) and outpatient coverage, including pharmaceuticals (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation, sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit, beneficiary charges are different. This could result in discrete—and sometimes jolting—enrollee copayments and deductibles for drugs and services.
WW: I’ve heard observation status is having a big, adverse impact on patients who go to skilled nursing facilities. Why?
BF: If a patient requires a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because the patient never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and consequently, tempers are rising. The rules for Medicare Advantage enrollees (Part C—commercial payers receive a fixed sum from CMS, and oversee parts A, B, and D for an individual beneficiary), which comprise 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional, fee-for-service in their policies and, consequently, no exemplar of success in this realm exits.
WW: Why is the number of patients on observation status growing?
BF: Hospitals have significantly increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists often are navigating without a compass. Again, fear of fraud and penalty places hospitals and, indirectly, hospitalists—who often make judgments on admission grade—in a precarious position.
The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which may change in real time during the stay, and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices, as well as the beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after the stay. Hospitalists, of course, want direction on coding, along with an understanding of the impact their decisions will have on patients and subspecialty colleagues.
Let’s now bring in Dr. Conway, a pediatric hospitalist. I thank Dr. Flansbaum, who formulated the following questions.
BF/WW: Is it tenable to keep the current system in place? Would it help to require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet to-be-determined manner?
Dr. Conway: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for beneficiary coverage post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask,” to educate beneficiaries on this issue. (Download a PDF of the pamphlet at www.medicare.gov/Publications/Pubs/pdf/11435.pdf.)
BF/WW: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?
PC: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary-care, emergency medicine, and/or HM clinician.
BF/WW: Before the U.S. healthcare system matures to a more full-out, integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?
PC: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.
With growing attention to observation status coming from patients and provider groups (the AMA is requesting that CMS revise its coverage rules), we will no doubt be hearing more about this going forward.
Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].
Estimating End-of-Life for Hospitalized Patients
Quotes from the Field
We cannot rely solely on a tool to make decisions. The tool is a decision aid.
Alvin H. Moss, MD, FAAHPM
Professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown
Predictions really apply to groups of people, not individuals.
J. Randall Curtis, MD, MPH
Professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle
if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing.
JoAnn Wood, MD, MSEd, MHA
Hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock
Patients feel that you’re almost abandoning them, that there’s something you’re withholding.
Ann Sheehy
Director of the hospitalist service at University of Wisconsin Medical Center in Madison
Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking.
David Casarett, MD, MA
Associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia
End-of-life conversations are common in hospital medicine, and Caitlin Foxley, MD, FHM, is no stranger to their nuance. She offers patients and loved ones as much factual information as she can. And regardless of their preference—aggressive treatment, comfort care, something in between—it’s ultimately their choice, not hers. But no matter what, she will ensure the patient’s pain remains under control.
“The way I practice is to allow my patients to make the end-of-life decision that is in accordance with their wishes, and not simply push the least expensive one on them,” says Dr. Foxley, medical director of IMI Hospitalists and hospital service chief of internal medicine at Nebraska Medical Center in Omaha. However, she adds, “most people, given accurate information in a compassionate manner, would choose to die at home, and not in an ICU on a ventilator, with chemo and pressers going through a central line.”
Although hospitalists differ in their approaches to end-of-life discussions, most agree that the majority of critically ill patients want to know their prognosis. Tested end-of-life prediction tools can help physicians provide realistic ranges for patients and families (see “Helpful End-of-Life Prediction Tools,” p. 39). Armed with this insight, they can hope to deliver better and more cost-effective end-of-life care.
Nonetheless, “we cannot rely solely on a tool to make decisions,” says Alvin H. Moss, MD, FAAHPM, professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown. “The tool is a decision aid.”
Clinicians still need to help patients and families identify their treatment goals while determining which life-sustaining options they would or wouldn’t want to pursue, Dr. Moss says. That conversation would include an estimated prognosis of survival.
“If you try to prognosticate a specific length of time, you will be wrong,” says Steven Z. Pantilat, MD, FACP, SFHM, professor of clinical medicine and director of the palliative care program at the University of California San Francisco Medical Center. “You can give patients a lot of useful information by speaking in ranges.”
But it’s important to also convey the inherent uncertainty of any prognosis, considering that a very sick patient might suffer a sudden decline. For this reason, even the best prognostic indicators aren’t exact, Dr. Pantilat cautions. A prediction tool could forecast a 20% chance of six-month survival on the day before a patient’s death in the ICU.
“Predictions really apply to groups of people, not individuals,” says J. Randall Curtis, MD, MPH, professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle. Physicians can’t possibly know whether someone will fall into the 95% of patients who die or the 5% of patients who beat the odds.
“It’s never certain that a patient is not going to survive,” says Dr. Curtis, who is director of the Harborview/University of Washington End-of-Life Care Research Program. While patients are less likely to request aggressive care in light of a poor prognosis, some will elect intensive treatment in hopes of defying even the grimmest statistics.
More Medical Tests and Procedures
In the U.S., it’s much more common for patients to receive life-saving treatments than in other countries. The expectation is that expensive medical technology can always prolong life.1
“A lot of patients have that mentality,” says Ann Sheehy, MD, MS, director of the hospitalist service at University of Wisconsin Medical Center in Madison. “That makes it harder to have the discussion with patients that there isn’t something else we can do.” Patients feel “that you’re almost abandoning them, that there’s something you’re withholding.”
The widespread assumption that more medical tests and procedures lead to better outcomes goes hand in hand with the misperception that sufficiently controlling pain and other symptoms draws death closer. As a result, many patients end up dying with distressing symptoms in the hospital instead of peacefully at home.1
As physicians, Dr. Sheehy points out, “We don’t do a good job of saying, ‘This care probably is not going to help you or that it will leave you with a very bad quality of life in the end.’” But projections are far from perfect.
“Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking. Nor is it enough to justify withholding treatment,” says David Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia.
What prognostic information can do is play an important part in guiding appropriate screening and preventive health measures. For example, if a male patient has a 50% chance of dying within four years, it doesn’t make sense to screen for prostate cancer, a slow-growing malignancy that often takes years to develop. This protocol may also apply to cancer screenings, as well as treatments for diabetes, high blood pressure, or high cholesterol, Dr. Casarett says.
End-of-Life Conversations
By not taking a patient’s prognosis into account, many clinical decisions are not fully informed. In physicians’ clinical practice and training, there tends to be less emphasis on estimating prognosis than on diagnosing and treating illness. This is particularly significant in older adults with competing chronic conditions and diminished life expectancy.2
“Many physicians have not been trained in how to have these conversations, which is something we’re trying to change,” says Dr. Curtis, the pulmonary and critical care specialist at the University of Washington. “This is very emotionally difficult for patients and families, and therefore, it can also be emotionally difficult for physicians.”
Starting this summer, medical residents at Cooper University Hospital in Camden, N.J., will have mandated exposure to palliative care. The rotation, lasting from two to four weeks, will occur in their second year of training, says Mark Angelo, MD, FACP, director of palliative medicine.
Residents will accompany the palliative-care team for an intensive period of time to learn about different techniques for symptom control and to observe end-of-life conversations, which often elicit patients’ angst, depression, and physiologic and spiritual unrest.
“We already have residents rotating with us now in the palliative-care program, and everybody is very struck by how honest patients want you to be,” Dr. Angelo says. “It certainly is devastating, and we understand that. But it does give patients the opportunity to reorganize their lives and to prioritize a number of issues, including medical treatment.”
Some patients opt to spend more time with their grandchildren rather than stay in the hospital. Others prefer to eat and drink whatever they want. Many terminally ill Hispanic patients in the Camden area travel to Latin America, where they were born, or they invite relatives to visit them here, Dr. Angelo says.
While it’s difficult to accept finality, “there’s a certain amount of freedom that comes with that,” he says. “If someone has a prognosis of two months, they may make very different decisions than someone who has a prognosis of two years.”
Physicians tend to be overly optimistic, notes JoAnn Wood, MD, MSEd, MHA, a hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock. “The data suggest that, if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing,” particularly with cancer patients, Dr. Wood says. “Physicians don’t choose this line of work to facilitate people’s dying.”
When Doing Less Is More
End-of-life prediction tools enable clinicians to keep their expectations of a patient’s survival grounded in reality. And in many hospitals, palliative-care providers are available to lend their expertise. “The field of palliative medicine has taken a lot of strides,” Dr. Wood says, “in helping us to seeing that dying is something that can be done well, just like living can be done well.”
In fact, growing evidence indicates that treating a patient’s discomfort is linked to improvement in physical status and might even increase survival.3 What this means is that, at the end of life, sometimes doing less is actually more. And if patients request less medical care, physicians should honor those desires.4,5
Dr. Pantilat, the UCSF palliative-care expert, suggests asking open-ended questions to get at the heart of a patient’s wishes. For instance: “‘When you look to the future, what do you hope will happen?’ Or ‘When you think of life ahead, what worries you the most?’” The responses guide physicians in devising a plan of care that is consistent with a patient’s values. Having these discussions sooner rather than later is best for everyone involved, Dr. Pantilat says. Unfortunately, that’s not what usually happens.
About half of the more than 40% of Americans who die annually under hospice care do so within two weeks after being admitted. In such a short timeframe, even the most skilled experts are limited in what they can do, according to the National Hospice and Palliative Care Organization. To reverse this trend, Dr. Pantilat recommends that physicians consider making referrals to palliative care much earlier, whenever they sense that a patient may have a year or less to live.
Providing palliative care can be done in conjunction with life-prolonging therapies or as the central focus. The goal is to prevent and relieve suffering and to ensure the best possible quality of life for patients and their families, regardless of disease stage or the need for other treatments. Such care is suitable for patients with cancer, heart conditions, liver or renal failure, Alzheimer’s disease, spinal cord injuries, and a number of other illnesses, according to the National Consensus Project for Quality Palliative Care.
—Caitlin Foxley, MD, FHM, medical director, IMI Hospitalists, hospital service chief of internal medicine, Nebraska Medical Center, Omaha
Planning Ahead
In Arkansas, Dr. Wood typically turns to the hospital’s palliative-care team in end-of-life situations, asking its members to join in a conference with the patient and family. The team typically consists of a nurse, social worker and chaplain who can address various concerns. An employee from the medical billing department participates if necessary.
“Physicians should never assume that they understand the healthcare system, because it’s incredibly complicated,” Dr. Wood says, adding that she doesn’t pretend to be an expert in Medicare, Medicaid, or private insurance reimbursement issues.
Helping patients with advanced care planning can minimize difficulties later. Most patients who die in hospitals are admitted with end-stage disease, and most spend time in the ICU with mechanical ventilation. Physicians often are unaware of patients’ preferences, and this could lead to misunderstandings, especially in the ICU setting, where prognoses can shift quickly. One study showed that, in order for some of these patients to die, clinicians and families generally had to decide explicitly to strive toward less-than-completely-aggressive care.1
“We’re trying to make sure that patients and families have an opportunity to do advanced-care planning,” Dr. Curtis says. Talking with them about their values and goals is essential for clinicians to understand their preferences.
Part of this involves crafting advanced-care directives. One such directive would be a power of attorney for healthcare, in which a patient states who is authorized to make decisions if he or she becomes unable to do so. This is particularly important for patients who select someone other than whom their state’s law would normally designate.
Another document—the living will—allows patients to specify their own preferences for end-of-life care. Yet “it’s often very difficult to know exactly what decisions will need to be made,” Dr. Curtis says. “Those documents are rarely determinative.” Even when a patient stipulates his or her wishes against “extraordinary life-sustaining measures, it still leaves a lot for interpretation.”
Some patients may spell out more clearly whether they wouldn’t want tube-feeding, CPR, or ventilation. This can be prescribed in written and signed Physician Orders for Life-Sustaining Treatment (POLST).
—Steven Z. Pantilat, MD, FACP, professor of clinical medicine, director of the palliative-care program, University of California San Francisco Medical Center
Educating the Public
End-of-life discussions also pose a threat of litigation. “It takes a significant amount of time, often during a very busy day, to sit down with a patient and family members to bring up an issue that will undoubtedly raise many questions, some of which are impossible to answer,” says Dr. Foxley, the hospitalist service chief in Omaha. “I’m sure many physicians are uncomfortable with the tears that are shed.”
When Dr. Foxley recently advised a patient’s family that aggressive care would be futile, they directed their anger toward her. Their loved one died, despite the intensive treatment. It’s just one example of many in which Dr. Foxley has witnessed how high-tech medical treatments can incur astronomical hospital bills after just a few days while doing little—if anything—helpful for the patient.
“We have a lot of work to do to educate the public about the dying process,” she says, adding that the entire burden shouldn’t fall on physicians, and that patients should inform family members of their end-of-life wishes. “We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.”
Susan Kreimer is a freelance medical writer based in New York.
Helpful End-of-Life Prediction Tools
APACHE II (Acute Physiology and Chronic Health Evaluation II)
A severity-of-disease classification system and one of several ICU scoring systems, it is applied within 24 hours of patient admission. An integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death. http://clincalc.com/IcuMortality/APACHEII.aspx
SOFA (Sequential Organ Failure Assessment)
SOFA tracks a patient’s status during an ICU stay. This scoring system determines the extent of a person’s organ function or rate of failure. The overall score is based on scores of the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. http://www.sfar.org/scores2/sofa2.html
The Karnofsky Performance Scale Index
This tool allows patients to be classified by functional impairment. It compares effectiveness of different therapies and assesses the prognosis in individual patients. The lower the Karnofsky score, the worse the survival outlook for most serious illnesses. http://www.hospicepatients.org/karnofsky.html
PPS (Palliative Performance Scale)
First introduced in 1996 as a tool for performance status in palliative care, the PPS uses five observer-rated domains correlated to the Karnofsky index (100-0). PPS is used in many countries and is translated into many languages. http://supportforhome.wordpress.com/2011/06/15/palliative-performance-scale/
The BODE Index
BODE helps predict mortality from chronic obstructive pulmonary disease (COPD) after diagnosis. Presumably, a higher BODE score correlates with an increased risk of death. http://copd.about.com/od/copdbasics/a/BODEIndex.htm
The Charlson Comorbidity Index
This index predicts the 10-year mortality for a patient who might have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score, depending on the risk of dying associated with the condition. http://www.medal.org/OnlineCalculators/ch1/ch1.13/ch1.13.01.php
Hemodialysis Mortality Predictor
This online calculator estimates prognosis in end-stage renal disease patients using an integrated model that incorporates the patient age, serum albumin, comorbidities, and clinician assessment of the patient’s likelihood of being dead within a year. http://touchcalc.com/calculators/sq
—Susan Kreimer
References
- Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.
- Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.
- Grudzen C, Grady D. Improving care at the end of life. Arch Intern Med. 2011;171(13):1202.
- Grudzen C. At the end of life, sometimes less is more. Arch Intern Med. 2011;171(13):1201.
- Bale PW. Honoring patients’ wishes for less health care. Arch Intern Med. 2011;171(13):1200.
Quotes from the Field
We cannot rely solely on a tool to make decisions. The tool is a decision aid.
Alvin H. Moss, MD, FAAHPM
Professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown
Predictions really apply to groups of people, not individuals.
J. Randall Curtis, MD, MPH
Professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle
if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing.
JoAnn Wood, MD, MSEd, MHA
Hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock
Patients feel that you’re almost abandoning them, that there’s something you’re withholding.
Ann Sheehy
Director of the hospitalist service at University of Wisconsin Medical Center in Madison
Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking.
David Casarett, MD, MA
Associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia
End-of-life conversations are common in hospital medicine, and Caitlin Foxley, MD, FHM, is no stranger to their nuance. She offers patients and loved ones as much factual information as she can. And regardless of their preference—aggressive treatment, comfort care, something in between—it’s ultimately their choice, not hers. But no matter what, she will ensure the patient’s pain remains under control.
“The way I practice is to allow my patients to make the end-of-life decision that is in accordance with their wishes, and not simply push the least expensive one on them,” says Dr. Foxley, medical director of IMI Hospitalists and hospital service chief of internal medicine at Nebraska Medical Center in Omaha. However, she adds, “most people, given accurate information in a compassionate manner, would choose to die at home, and not in an ICU on a ventilator, with chemo and pressers going through a central line.”
Although hospitalists differ in their approaches to end-of-life discussions, most agree that the majority of critically ill patients want to know their prognosis. Tested end-of-life prediction tools can help physicians provide realistic ranges for patients and families (see “Helpful End-of-Life Prediction Tools,” p. 39). Armed with this insight, they can hope to deliver better and more cost-effective end-of-life care.
Nonetheless, “we cannot rely solely on a tool to make decisions,” says Alvin H. Moss, MD, FAAHPM, professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown. “The tool is a decision aid.”
Clinicians still need to help patients and families identify their treatment goals while determining which life-sustaining options they would or wouldn’t want to pursue, Dr. Moss says. That conversation would include an estimated prognosis of survival.
“If you try to prognosticate a specific length of time, you will be wrong,” says Steven Z. Pantilat, MD, FACP, SFHM, professor of clinical medicine and director of the palliative care program at the University of California San Francisco Medical Center. “You can give patients a lot of useful information by speaking in ranges.”
But it’s important to also convey the inherent uncertainty of any prognosis, considering that a very sick patient might suffer a sudden decline. For this reason, even the best prognostic indicators aren’t exact, Dr. Pantilat cautions. A prediction tool could forecast a 20% chance of six-month survival on the day before a patient’s death in the ICU.
“Predictions really apply to groups of people, not individuals,” says J. Randall Curtis, MD, MPH, professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle. Physicians can’t possibly know whether someone will fall into the 95% of patients who die or the 5% of patients who beat the odds.
“It’s never certain that a patient is not going to survive,” says Dr. Curtis, who is director of the Harborview/University of Washington End-of-Life Care Research Program. While patients are less likely to request aggressive care in light of a poor prognosis, some will elect intensive treatment in hopes of defying even the grimmest statistics.
More Medical Tests and Procedures
In the U.S., it’s much more common for patients to receive life-saving treatments than in other countries. The expectation is that expensive medical technology can always prolong life.1
“A lot of patients have that mentality,” says Ann Sheehy, MD, MS, director of the hospitalist service at University of Wisconsin Medical Center in Madison. “That makes it harder to have the discussion with patients that there isn’t something else we can do.” Patients feel “that you’re almost abandoning them, that there’s something you’re withholding.”
The widespread assumption that more medical tests and procedures lead to better outcomes goes hand in hand with the misperception that sufficiently controlling pain and other symptoms draws death closer. As a result, many patients end up dying with distressing symptoms in the hospital instead of peacefully at home.1
As physicians, Dr. Sheehy points out, “We don’t do a good job of saying, ‘This care probably is not going to help you or that it will leave you with a very bad quality of life in the end.’” But projections are far from perfect.
“Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking. Nor is it enough to justify withholding treatment,” says David Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia.
What prognostic information can do is play an important part in guiding appropriate screening and preventive health measures. For example, if a male patient has a 50% chance of dying within four years, it doesn’t make sense to screen for prostate cancer, a slow-growing malignancy that often takes years to develop. This protocol may also apply to cancer screenings, as well as treatments for diabetes, high blood pressure, or high cholesterol, Dr. Casarett says.
End-of-Life Conversations
By not taking a patient’s prognosis into account, many clinical decisions are not fully informed. In physicians’ clinical practice and training, there tends to be less emphasis on estimating prognosis than on diagnosing and treating illness. This is particularly significant in older adults with competing chronic conditions and diminished life expectancy.2
“Many physicians have not been trained in how to have these conversations, which is something we’re trying to change,” says Dr. Curtis, the pulmonary and critical care specialist at the University of Washington. “This is very emotionally difficult for patients and families, and therefore, it can also be emotionally difficult for physicians.”
Starting this summer, medical residents at Cooper University Hospital in Camden, N.J., will have mandated exposure to palliative care. The rotation, lasting from two to four weeks, will occur in their second year of training, says Mark Angelo, MD, FACP, director of palliative medicine.
Residents will accompany the palliative-care team for an intensive period of time to learn about different techniques for symptom control and to observe end-of-life conversations, which often elicit patients’ angst, depression, and physiologic and spiritual unrest.
“We already have residents rotating with us now in the palliative-care program, and everybody is very struck by how honest patients want you to be,” Dr. Angelo says. “It certainly is devastating, and we understand that. But it does give patients the opportunity to reorganize their lives and to prioritize a number of issues, including medical treatment.”
Some patients opt to spend more time with their grandchildren rather than stay in the hospital. Others prefer to eat and drink whatever they want. Many terminally ill Hispanic patients in the Camden area travel to Latin America, where they were born, or they invite relatives to visit them here, Dr. Angelo says.
While it’s difficult to accept finality, “there’s a certain amount of freedom that comes with that,” he says. “If someone has a prognosis of two months, they may make very different decisions than someone who has a prognosis of two years.”
Physicians tend to be overly optimistic, notes JoAnn Wood, MD, MSEd, MHA, a hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock. “The data suggest that, if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing,” particularly with cancer patients, Dr. Wood says. “Physicians don’t choose this line of work to facilitate people’s dying.”
When Doing Less Is More
End-of-life prediction tools enable clinicians to keep their expectations of a patient’s survival grounded in reality. And in many hospitals, palliative-care providers are available to lend their expertise. “The field of palliative medicine has taken a lot of strides,” Dr. Wood says, “in helping us to seeing that dying is something that can be done well, just like living can be done well.”
In fact, growing evidence indicates that treating a patient’s discomfort is linked to improvement in physical status and might even increase survival.3 What this means is that, at the end of life, sometimes doing less is actually more. And if patients request less medical care, physicians should honor those desires.4,5
Dr. Pantilat, the UCSF palliative-care expert, suggests asking open-ended questions to get at the heart of a patient’s wishes. For instance: “‘When you look to the future, what do you hope will happen?’ Or ‘When you think of life ahead, what worries you the most?’” The responses guide physicians in devising a plan of care that is consistent with a patient’s values. Having these discussions sooner rather than later is best for everyone involved, Dr. Pantilat says. Unfortunately, that’s not what usually happens.
About half of the more than 40% of Americans who die annually under hospice care do so within two weeks after being admitted. In such a short timeframe, even the most skilled experts are limited in what they can do, according to the National Hospice and Palliative Care Organization. To reverse this trend, Dr. Pantilat recommends that physicians consider making referrals to palliative care much earlier, whenever they sense that a patient may have a year or less to live.
Providing palliative care can be done in conjunction with life-prolonging therapies or as the central focus. The goal is to prevent and relieve suffering and to ensure the best possible quality of life for patients and their families, regardless of disease stage or the need for other treatments. Such care is suitable for patients with cancer, heart conditions, liver or renal failure, Alzheimer’s disease, spinal cord injuries, and a number of other illnesses, according to the National Consensus Project for Quality Palliative Care.
—Caitlin Foxley, MD, FHM, medical director, IMI Hospitalists, hospital service chief of internal medicine, Nebraska Medical Center, Omaha
Planning Ahead
In Arkansas, Dr. Wood typically turns to the hospital’s palliative-care team in end-of-life situations, asking its members to join in a conference with the patient and family. The team typically consists of a nurse, social worker and chaplain who can address various concerns. An employee from the medical billing department participates if necessary.
“Physicians should never assume that they understand the healthcare system, because it’s incredibly complicated,” Dr. Wood says, adding that she doesn’t pretend to be an expert in Medicare, Medicaid, or private insurance reimbursement issues.
Helping patients with advanced care planning can minimize difficulties later. Most patients who die in hospitals are admitted with end-stage disease, and most spend time in the ICU with mechanical ventilation. Physicians often are unaware of patients’ preferences, and this could lead to misunderstandings, especially in the ICU setting, where prognoses can shift quickly. One study showed that, in order for some of these patients to die, clinicians and families generally had to decide explicitly to strive toward less-than-completely-aggressive care.1
“We’re trying to make sure that patients and families have an opportunity to do advanced-care planning,” Dr. Curtis says. Talking with them about their values and goals is essential for clinicians to understand their preferences.
Part of this involves crafting advanced-care directives. One such directive would be a power of attorney for healthcare, in which a patient states who is authorized to make decisions if he or she becomes unable to do so. This is particularly important for patients who select someone other than whom their state’s law would normally designate.
Another document—the living will—allows patients to specify their own preferences for end-of-life care. Yet “it’s often very difficult to know exactly what decisions will need to be made,” Dr. Curtis says. “Those documents are rarely determinative.” Even when a patient stipulates his or her wishes against “extraordinary life-sustaining measures, it still leaves a lot for interpretation.”
Some patients may spell out more clearly whether they wouldn’t want tube-feeding, CPR, or ventilation. This can be prescribed in written and signed Physician Orders for Life-Sustaining Treatment (POLST).
—Steven Z. Pantilat, MD, FACP, professor of clinical medicine, director of the palliative-care program, University of California San Francisco Medical Center
Educating the Public
End-of-life discussions also pose a threat of litigation. “It takes a significant amount of time, often during a very busy day, to sit down with a patient and family members to bring up an issue that will undoubtedly raise many questions, some of which are impossible to answer,” says Dr. Foxley, the hospitalist service chief in Omaha. “I’m sure many physicians are uncomfortable with the tears that are shed.”
When Dr. Foxley recently advised a patient’s family that aggressive care would be futile, they directed their anger toward her. Their loved one died, despite the intensive treatment. It’s just one example of many in which Dr. Foxley has witnessed how high-tech medical treatments can incur astronomical hospital bills after just a few days while doing little—if anything—helpful for the patient.
“We have a lot of work to do to educate the public about the dying process,” she says, adding that the entire burden shouldn’t fall on physicians, and that patients should inform family members of their end-of-life wishes. “We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.”
Susan Kreimer is a freelance medical writer based in New York.
Helpful End-of-Life Prediction Tools
APACHE II (Acute Physiology and Chronic Health Evaluation II)
A severity-of-disease classification system and one of several ICU scoring systems, it is applied within 24 hours of patient admission. An integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death. http://clincalc.com/IcuMortality/APACHEII.aspx
SOFA (Sequential Organ Failure Assessment)
SOFA tracks a patient’s status during an ICU stay. This scoring system determines the extent of a person’s organ function or rate of failure. The overall score is based on scores of the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. http://www.sfar.org/scores2/sofa2.html
The Karnofsky Performance Scale Index
This tool allows patients to be classified by functional impairment. It compares effectiveness of different therapies and assesses the prognosis in individual patients. The lower the Karnofsky score, the worse the survival outlook for most serious illnesses. http://www.hospicepatients.org/karnofsky.html
PPS (Palliative Performance Scale)
First introduced in 1996 as a tool for performance status in palliative care, the PPS uses five observer-rated domains correlated to the Karnofsky index (100-0). PPS is used in many countries and is translated into many languages. http://supportforhome.wordpress.com/2011/06/15/palliative-performance-scale/
The BODE Index
BODE helps predict mortality from chronic obstructive pulmonary disease (COPD) after diagnosis. Presumably, a higher BODE score correlates with an increased risk of death. http://copd.about.com/od/copdbasics/a/BODEIndex.htm
The Charlson Comorbidity Index
This index predicts the 10-year mortality for a patient who might have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score, depending on the risk of dying associated with the condition. http://www.medal.org/OnlineCalculators/ch1/ch1.13/ch1.13.01.php
Hemodialysis Mortality Predictor
This online calculator estimates prognosis in end-stage renal disease patients using an integrated model that incorporates the patient age, serum albumin, comorbidities, and clinician assessment of the patient’s likelihood of being dead within a year. http://touchcalc.com/calculators/sq
—Susan Kreimer
References
- Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.
- Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.
- Grudzen C, Grady D. Improving care at the end of life. Arch Intern Med. 2011;171(13):1202.
- Grudzen C. At the end of life, sometimes less is more. Arch Intern Med. 2011;171(13):1201.
- Bale PW. Honoring patients’ wishes for less health care. Arch Intern Med. 2011;171(13):1200.
Quotes from the Field
We cannot rely solely on a tool to make decisions. The tool is a decision aid.
Alvin H. Moss, MD, FAAHPM
Professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown
Predictions really apply to groups of people, not individuals.
J. Randall Curtis, MD, MPH
Professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle
if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing.
JoAnn Wood, MD, MSEd, MHA
Hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock
Patients feel that you’re almost abandoning them, that there’s something you’re withholding.
Ann Sheehy
Director of the hospitalist service at University of Wisconsin Medical Center in Madison
Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking.
David Casarett, MD, MA
Associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia
End-of-life conversations are common in hospital medicine, and Caitlin Foxley, MD, FHM, is no stranger to their nuance. She offers patients and loved ones as much factual information as she can. And regardless of their preference—aggressive treatment, comfort care, something in between—it’s ultimately their choice, not hers. But no matter what, she will ensure the patient’s pain remains under control.
“The way I practice is to allow my patients to make the end-of-life decision that is in accordance with their wishes, and not simply push the least expensive one on them,” says Dr. Foxley, medical director of IMI Hospitalists and hospital service chief of internal medicine at Nebraska Medical Center in Omaha. However, she adds, “most people, given accurate information in a compassionate manner, would choose to die at home, and not in an ICU on a ventilator, with chemo and pressers going through a central line.”
Although hospitalists differ in their approaches to end-of-life discussions, most agree that the majority of critically ill patients want to know their prognosis. Tested end-of-life prediction tools can help physicians provide realistic ranges for patients and families (see “Helpful End-of-Life Prediction Tools,” p. 39). Armed with this insight, they can hope to deliver better and more cost-effective end-of-life care.
Nonetheless, “we cannot rely solely on a tool to make decisions,” says Alvin H. Moss, MD, FAAHPM, professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown. “The tool is a decision aid.”
Clinicians still need to help patients and families identify their treatment goals while determining which life-sustaining options they would or wouldn’t want to pursue, Dr. Moss says. That conversation would include an estimated prognosis of survival.
“If you try to prognosticate a specific length of time, you will be wrong,” says Steven Z. Pantilat, MD, FACP, SFHM, professor of clinical medicine and director of the palliative care program at the University of California San Francisco Medical Center. “You can give patients a lot of useful information by speaking in ranges.”
But it’s important to also convey the inherent uncertainty of any prognosis, considering that a very sick patient might suffer a sudden decline. For this reason, even the best prognostic indicators aren’t exact, Dr. Pantilat cautions. A prediction tool could forecast a 20% chance of six-month survival on the day before a patient’s death in the ICU.
“Predictions really apply to groups of people, not individuals,” says J. Randall Curtis, MD, MPH, professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle. Physicians can’t possibly know whether someone will fall into the 95% of patients who die or the 5% of patients who beat the odds.
“It’s never certain that a patient is not going to survive,” says Dr. Curtis, who is director of the Harborview/University of Washington End-of-Life Care Research Program. While patients are less likely to request aggressive care in light of a poor prognosis, some will elect intensive treatment in hopes of defying even the grimmest statistics.
More Medical Tests and Procedures
In the U.S., it’s much more common for patients to receive life-saving treatments than in other countries. The expectation is that expensive medical technology can always prolong life.1
“A lot of patients have that mentality,” says Ann Sheehy, MD, MS, director of the hospitalist service at University of Wisconsin Medical Center in Madison. “That makes it harder to have the discussion with patients that there isn’t something else we can do.” Patients feel “that you’re almost abandoning them, that there’s something you’re withholding.”
The widespread assumption that more medical tests and procedures lead to better outcomes goes hand in hand with the misperception that sufficiently controlling pain and other symptoms draws death closer. As a result, many patients end up dying with distressing symptoms in the hospital instead of peacefully at home.1
As physicians, Dr. Sheehy points out, “We don’t do a good job of saying, ‘This care probably is not going to help you or that it will leave you with a very bad quality of life in the end.’” But projections are far from perfect.
“Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking. Nor is it enough to justify withholding treatment,” says David Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia.
What prognostic information can do is play an important part in guiding appropriate screening and preventive health measures. For example, if a male patient has a 50% chance of dying within four years, it doesn’t make sense to screen for prostate cancer, a slow-growing malignancy that often takes years to develop. This protocol may also apply to cancer screenings, as well as treatments for diabetes, high blood pressure, or high cholesterol, Dr. Casarett says.
End-of-Life Conversations
By not taking a patient’s prognosis into account, many clinical decisions are not fully informed. In physicians’ clinical practice and training, there tends to be less emphasis on estimating prognosis than on diagnosing and treating illness. This is particularly significant in older adults with competing chronic conditions and diminished life expectancy.2
“Many physicians have not been trained in how to have these conversations, which is something we’re trying to change,” says Dr. Curtis, the pulmonary and critical care specialist at the University of Washington. “This is very emotionally difficult for patients and families, and therefore, it can also be emotionally difficult for physicians.”
Starting this summer, medical residents at Cooper University Hospital in Camden, N.J., will have mandated exposure to palliative care. The rotation, lasting from two to four weeks, will occur in their second year of training, says Mark Angelo, MD, FACP, director of palliative medicine.
Residents will accompany the palliative-care team for an intensive period of time to learn about different techniques for symptom control and to observe end-of-life conversations, which often elicit patients’ angst, depression, and physiologic and spiritual unrest.
“We already have residents rotating with us now in the palliative-care program, and everybody is very struck by how honest patients want you to be,” Dr. Angelo says. “It certainly is devastating, and we understand that. But it does give patients the opportunity to reorganize their lives and to prioritize a number of issues, including medical treatment.”
Some patients opt to spend more time with their grandchildren rather than stay in the hospital. Others prefer to eat and drink whatever they want. Many terminally ill Hispanic patients in the Camden area travel to Latin America, where they were born, or they invite relatives to visit them here, Dr. Angelo says.
While it’s difficult to accept finality, “there’s a certain amount of freedom that comes with that,” he says. “If someone has a prognosis of two months, they may make very different decisions than someone who has a prognosis of two years.”
Physicians tend to be overly optimistic, notes JoAnn Wood, MD, MSEd, MHA, a hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock. “The data suggest that, if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing,” particularly with cancer patients, Dr. Wood says. “Physicians don’t choose this line of work to facilitate people’s dying.”
When Doing Less Is More
End-of-life prediction tools enable clinicians to keep their expectations of a patient’s survival grounded in reality. And in many hospitals, palliative-care providers are available to lend their expertise. “The field of palliative medicine has taken a lot of strides,” Dr. Wood says, “in helping us to seeing that dying is something that can be done well, just like living can be done well.”
In fact, growing evidence indicates that treating a patient’s discomfort is linked to improvement in physical status and might even increase survival.3 What this means is that, at the end of life, sometimes doing less is actually more. And if patients request less medical care, physicians should honor those desires.4,5
Dr. Pantilat, the UCSF palliative-care expert, suggests asking open-ended questions to get at the heart of a patient’s wishes. For instance: “‘When you look to the future, what do you hope will happen?’ Or ‘When you think of life ahead, what worries you the most?’” The responses guide physicians in devising a plan of care that is consistent with a patient’s values. Having these discussions sooner rather than later is best for everyone involved, Dr. Pantilat says. Unfortunately, that’s not what usually happens.
About half of the more than 40% of Americans who die annually under hospice care do so within two weeks after being admitted. In such a short timeframe, even the most skilled experts are limited in what they can do, according to the National Hospice and Palliative Care Organization. To reverse this trend, Dr. Pantilat recommends that physicians consider making referrals to palliative care much earlier, whenever they sense that a patient may have a year or less to live.
Providing palliative care can be done in conjunction with life-prolonging therapies or as the central focus. The goal is to prevent and relieve suffering and to ensure the best possible quality of life for patients and their families, regardless of disease stage or the need for other treatments. Such care is suitable for patients with cancer, heart conditions, liver or renal failure, Alzheimer’s disease, spinal cord injuries, and a number of other illnesses, according to the National Consensus Project for Quality Palliative Care.
—Caitlin Foxley, MD, FHM, medical director, IMI Hospitalists, hospital service chief of internal medicine, Nebraska Medical Center, Omaha
Planning Ahead
In Arkansas, Dr. Wood typically turns to the hospital’s palliative-care team in end-of-life situations, asking its members to join in a conference with the patient and family. The team typically consists of a nurse, social worker and chaplain who can address various concerns. An employee from the medical billing department participates if necessary.
“Physicians should never assume that they understand the healthcare system, because it’s incredibly complicated,” Dr. Wood says, adding that she doesn’t pretend to be an expert in Medicare, Medicaid, or private insurance reimbursement issues.
Helping patients with advanced care planning can minimize difficulties later. Most patients who die in hospitals are admitted with end-stage disease, and most spend time in the ICU with mechanical ventilation. Physicians often are unaware of patients’ preferences, and this could lead to misunderstandings, especially in the ICU setting, where prognoses can shift quickly. One study showed that, in order for some of these patients to die, clinicians and families generally had to decide explicitly to strive toward less-than-completely-aggressive care.1
“We’re trying to make sure that patients and families have an opportunity to do advanced-care planning,” Dr. Curtis says. Talking with them about their values and goals is essential for clinicians to understand their preferences.
Part of this involves crafting advanced-care directives. One such directive would be a power of attorney for healthcare, in which a patient states who is authorized to make decisions if he or she becomes unable to do so. This is particularly important for patients who select someone other than whom their state’s law would normally designate.
Another document—the living will—allows patients to specify their own preferences for end-of-life care. Yet “it’s often very difficult to know exactly what decisions will need to be made,” Dr. Curtis says. “Those documents are rarely determinative.” Even when a patient stipulates his or her wishes against “extraordinary life-sustaining measures, it still leaves a lot for interpretation.”
Some patients may spell out more clearly whether they wouldn’t want tube-feeding, CPR, or ventilation. This can be prescribed in written and signed Physician Orders for Life-Sustaining Treatment (POLST).
—Steven Z. Pantilat, MD, FACP, professor of clinical medicine, director of the palliative-care program, University of California San Francisco Medical Center
Educating the Public
End-of-life discussions also pose a threat of litigation. “It takes a significant amount of time, often during a very busy day, to sit down with a patient and family members to bring up an issue that will undoubtedly raise many questions, some of which are impossible to answer,” says Dr. Foxley, the hospitalist service chief in Omaha. “I’m sure many physicians are uncomfortable with the tears that are shed.”
When Dr. Foxley recently advised a patient’s family that aggressive care would be futile, they directed their anger toward her. Their loved one died, despite the intensive treatment. It’s just one example of many in which Dr. Foxley has witnessed how high-tech medical treatments can incur astronomical hospital bills after just a few days while doing little—if anything—helpful for the patient.
“We have a lot of work to do to educate the public about the dying process,” she says, adding that the entire burden shouldn’t fall on physicians, and that patients should inform family members of their end-of-life wishes. “We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.”
Susan Kreimer is a freelance medical writer based in New York.
Helpful End-of-Life Prediction Tools
APACHE II (Acute Physiology and Chronic Health Evaluation II)
A severity-of-disease classification system and one of several ICU scoring systems, it is applied within 24 hours of patient admission. An integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death. http://clincalc.com/IcuMortality/APACHEII.aspx
SOFA (Sequential Organ Failure Assessment)
SOFA tracks a patient’s status during an ICU stay. This scoring system determines the extent of a person’s organ function or rate of failure. The overall score is based on scores of the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. http://www.sfar.org/scores2/sofa2.html
The Karnofsky Performance Scale Index
This tool allows patients to be classified by functional impairment. It compares effectiveness of different therapies and assesses the prognosis in individual patients. The lower the Karnofsky score, the worse the survival outlook for most serious illnesses. http://www.hospicepatients.org/karnofsky.html
PPS (Palliative Performance Scale)
First introduced in 1996 as a tool for performance status in palliative care, the PPS uses five observer-rated domains correlated to the Karnofsky index (100-0). PPS is used in many countries and is translated into many languages. http://supportforhome.wordpress.com/2011/06/15/palliative-performance-scale/
The BODE Index
BODE helps predict mortality from chronic obstructive pulmonary disease (COPD) after diagnosis. Presumably, a higher BODE score correlates with an increased risk of death. http://copd.about.com/od/copdbasics/a/BODEIndex.htm
The Charlson Comorbidity Index
This index predicts the 10-year mortality for a patient who might have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score, depending on the risk of dying associated with the condition. http://www.medal.org/OnlineCalculators/ch1/ch1.13/ch1.13.01.php
Hemodialysis Mortality Predictor
This online calculator estimates prognosis in end-stage renal disease patients using an integrated model that incorporates the patient age, serum albumin, comorbidities, and clinician assessment of the patient’s likelihood of being dead within a year. http://touchcalc.com/calculators/sq
—Susan Kreimer
References
- Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.
- Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.
- Grudzen C, Grady D. Improving care at the end of life. Arch Intern Med. 2011;171(13):1202.
- Grudzen C. At the end of life, sometimes less is more. Arch Intern Med. 2011;171(13):1201.
- Bale PW. Honoring patients’ wishes for less health care. Arch Intern Med. 2011;171(13):1200.
John Nelson: Admit Resolution
Editor’s note: Second in a two-part series.
I used last month’s column to frame the issue of disagreement between doctors over who should admit a particular patient, as well as discuss the value of good social connections to reduce the chance that divergent opinions lead to outright conflict. This month, I’ll review another worthwhile strategy—one that could be a definitive solution to these disagreements but often falls short of that goal in practice.
Service Agreements, or “Compacts,” between Physician Groups
If, at your hospital, there are reasonably frequent cases of divergent opinions regarding whether an ED admission or transfer from elsewhere should be admitted by a hospitalist or doctor in another specialty, why not meet in advance to decide this? Many hospitalist groups have held meetings with doctors in other specialties and now have a collection of agreements outlining scenarios, such as:
- ESRD patients: Hospitalist admits for non-dialysis issues (pneumonia, diabetic issues, etc.); nephrologist admits for urgent dialysis issues (K+>6.3, pH<7.3, etc.).
- Cardiology: Hospitalist admits CHF and non-ST elevation chest pain; cardiologist admits STEMI.
- General surgery: Hospitalist admits ileus, pseudo obstruction, and SBO due to adhesions; general surgery admits bowel obstruction in “virgin abdomen,” volvulus, and any obstruction thought to require urgent surgery.
To be clear, I’m not suggesting the above guidelines are evidence-based or are the right ones for your institution. I just made these up, so yours might differ significantly. I just want to provide a sense of the kinds of issues these agreements typically cover. The comanagement section of the SHM website has several documents regarding hospitalist-orthopedic service agreements.
The Negotiation Process
It’s tempting for the lead hospitalist to just have a hallway chat with a spokesperson from the other specialty, then email a draft agreement, exchange a few messages until both parties are satisfied, then email a copy of the final document to all the doctors in both groups. This might work for some simple service agreements, but for any area with significant ambiguity or disagreements (or potential for disagreements), one or more in-person meetings are usually necessary. Ideally, several doctors in both groups will attend these meetings.
Much work could be done in advance of the first meeting, including surveying other practices to see how they decide which group admits the same kinds of patents, gathering any relevant published research, and possibly drafting a “straw man” proposed agreement. When meeting in person, the doctors will have a chance to explain their points of view, needs, and concerns, and gain a greater appreciation of the way “the other guy” sees things. An important purpose of the in-person meeting is to “look the other guy in the eye” to know if he or she really is committed to following through.
Remember that written agreements like these might become an issue in malpractice suits, so you might want to have them reviewed first by risk managers. You might also write them as guidelines rather than rigid protocols that don’t allow variations.
Maximize Effectiveness
Ideally, every doctor involved in the agreement should document their approval with a signature and date. My experience is that this doesn’t happen at most places, but if there is concern about whether everyone will comply, signing the document will probably help at least a little.
The completed agreements should be provided to all doctors in both groups, the ED, affected hospital nursing units, and others. Any new doctor should get a copy of all such agreements that might be relevant. And, most important, it should be made available electronically so that it is easy to find at any time. Some agreements cover uncommon events, and the doctors on duty might not remember what the agreement said and will need ready access to it.
Most service agreements should be reviewed and updated every two or three years or as needed. If there is confusion or controversy around a particular agreement, or if disagreements about which doctor does the admission are common despite the agreement, then an in-person meeting between the physician groups should be scheduled to revise or update it.
Keep Your Fingers Crossed
If it sounds like a lot of work to develop and maintain these agreements, it is. But they’re worth every bit of that work if they reduce confusion or discord. Sadly, for several reasons, they rarely prove so effective.
One doctor might think the agreement applies, but the other doctor says this patient is an exception and the agreement doesn’t apply. It is impossible to write an agreement that addresses all possible scenarios, so a doctor can argue that any particular patient falls outside the agreement because of things like comorbidities, which service admitted the patient last time (many agreements will have defined “bounce back” intervals), which primary-care physician (PCP) the patient sees, etc.
Even if there is no dispute about whether the agreement covers a particular patient, many doctors simply don’t feel obligated to uphold the agreement. Such a doctor might tell the ED doctor: “Yep, I signed the agreement, but only as a way to get the meeting over with. I was never in favor of it and just can’t admit the patient. Call the other guy to admit.” So in spite of all the work done to create a reasonable agreement, some doctors might feel entitled to ignore it when it suits them.
Compliance Is Critical
Sadly, my take is that despite the tremendous hoped-for benefits that service agreements might provide, poor compliance means they rarely achieve their potential. Even so, they are usually worth the time and effort to create them if it leads doctors in the two specialties to schedule time away from patient care to listen to the other group’s point of view and discuss how best to handle particular types of patients. In some cases, it will be the first time the two groups of doctors have set aside time to talk about the work they do together; that alone can have significant value.
Tom Lorence, MD, a Kaiser hospitalist in Portland, Ore., who is chief of hospital medicine for Northwest Permanente, developed more than 20 service agreements with many different specialties at his institution. He has found that they are worth the effort, and that they helped allay hospitalists’ feeling of being “dumped on.”
He also told me a rule that probably applies to all such agreements in any setting: The tie goes to the hospitalist—that is, when there is reasonable uncertainty or disagreement about which group should admit a patient, it is nearly always the hospitalist who will do so.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course.
Editor’s note: Second in a two-part series.
I used last month’s column to frame the issue of disagreement between doctors over who should admit a particular patient, as well as discuss the value of good social connections to reduce the chance that divergent opinions lead to outright conflict. This month, I’ll review another worthwhile strategy—one that could be a definitive solution to these disagreements but often falls short of that goal in practice.
Service Agreements, or “Compacts,” between Physician Groups
If, at your hospital, there are reasonably frequent cases of divergent opinions regarding whether an ED admission or transfer from elsewhere should be admitted by a hospitalist or doctor in another specialty, why not meet in advance to decide this? Many hospitalist groups have held meetings with doctors in other specialties and now have a collection of agreements outlining scenarios, such as:
- ESRD patients: Hospitalist admits for non-dialysis issues (pneumonia, diabetic issues, etc.); nephrologist admits for urgent dialysis issues (K+>6.3, pH<7.3, etc.).
- Cardiology: Hospitalist admits CHF and non-ST elevation chest pain; cardiologist admits STEMI.
- General surgery: Hospitalist admits ileus, pseudo obstruction, and SBO due to adhesions; general surgery admits bowel obstruction in “virgin abdomen,” volvulus, and any obstruction thought to require urgent surgery.
To be clear, I’m not suggesting the above guidelines are evidence-based or are the right ones for your institution. I just made these up, so yours might differ significantly. I just want to provide a sense of the kinds of issues these agreements typically cover. The comanagement section of the SHM website has several documents regarding hospitalist-orthopedic service agreements.
The Negotiation Process
It’s tempting for the lead hospitalist to just have a hallway chat with a spokesperson from the other specialty, then email a draft agreement, exchange a few messages until both parties are satisfied, then email a copy of the final document to all the doctors in both groups. This might work for some simple service agreements, but for any area with significant ambiguity or disagreements (or potential for disagreements), one or more in-person meetings are usually necessary. Ideally, several doctors in both groups will attend these meetings.
Much work could be done in advance of the first meeting, including surveying other practices to see how they decide which group admits the same kinds of patents, gathering any relevant published research, and possibly drafting a “straw man” proposed agreement. When meeting in person, the doctors will have a chance to explain their points of view, needs, and concerns, and gain a greater appreciation of the way “the other guy” sees things. An important purpose of the in-person meeting is to “look the other guy in the eye” to know if he or she really is committed to following through.
Remember that written agreements like these might become an issue in malpractice suits, so you might want to have them reviewed first by risk managers. You might also write them as guidelines rather than rigid protocols that don’t allow variations.
Maximize Effectiveness
Ideally, every doctor involved in the agreement should document their approval with a signature and date. My experience is that this doesn’t happen at most places, but if there is concern about whether everyone will comply, signing the document will probably help at least a little.
The completed agreements should be provided to all doctors in both groups, the ED, affected hospital nursing units, and others. Any new doctor should get a copy of all such agreements that might be relevant. And, most important, it should be made available electronically so that it is easy to find at any time. Some agreements cover uncommon events, and the doctors on duty might not remember what the agreement said and will need ready access to it.
Most service agreements should be reviewed and updated every two or three years or as needed. If there is confusion or controversy around a particular agreement, or if disagreements about which doctor does the admission are common despite the agreement, then an in-person meeting between the physician groups should be scheduled to revise or update it.
Keep Your Fingers Crossed
If it sounds like a lot of work to develop and maintain these agreements, it is. But they’re worth every bit of that work if they reduce confusion or discord. Sadly, for several reasons, they rarely prove so effective.
One doctor might think the agreement applies, but the other doctor says this patient is an exception and the agreement doesn’t apply. It is impossible to write an agreement that addresses all possible scenarios, so a doctor can argue that any particular patient falls outside the agreement because of things like comorbidities, which service admitted the patient last time (many agreements will have defined “bounce back” intervals), which primary-care physician (PCP) the patient sees, etc.
Even if there is no dispute about whether the agreement covers a particular patient, many doctors simply don’t feel obligated to uphold the agreement. Such a doctor might tell the ED doctor: “Yep, I signed the agreement, but only as a way to get the meeting over with. I was never in favor of it and just can’t admit the patient. Call the other guy to admit.” So in spite of all the work done to create a reasonable agreement, some doctors might feel entitled to ignore it when it suits them.
Compliance Is Critical
Sadly, my take is that despite the tremendous hoped-for benefits that service agreements might provide, poor compliance means they rarely achieve their potential. Even so, they are usually worth the time and effort to create them if it leads doctors in the two specialties to schedule time away from patient care to listen to the other group’s point of view and discuss how best to handle particular types of patients. In some cases, it will be the first time the two groups of doctors have set aside time to talk about the work they do together; that alone can have significant value.
Tom Lorence, MD, a Kaiser hospitalist in Portland, Ore., who is chief of hospital medicine for Northwest Permanente, developed more than 20 service agreements with many different specialties at his institution. He has found that they are worth the effort, and that they helped allay hospitalists’ feeling of being “dumped on.”
He also told me a rule that probably applies to all such agreements in any setting: The tie goes to the hospitalist—that is, when there is reasonable uncertainty or disagreement about which group should admit a patient, it is nearly always the hospitalist who will do so.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course.
Editor’s note: Second in a two-part series.
I used last month’s column to frame the issue of disagreement between doctors over who should admit a particular patient, as well as discuss the value of good social connections to reduce the chance that divergent opinions lead to outright conflict. This month, I’ll review another worthwhile strategy—one that could be a definitive solution to these disagreements but often falls short of that goal in practice.
Service Agreements, or “Compacts,” between Physician Groups
If, at your hospital, there are reasonably frequent cases of divergent opinions regarding whether an ED admission or transfer from elsewhere should be admitted by a hospitalist or doctor in another specialty, why not meet in advance to decide this? Many hospitalist groups have held meetings with doctors in other specialties and now have a collection of agreements outlining scenarios, such as:
- ESRD patients: Hospitalist admits for non-dialysis issues (pneumonia, diabetic issues, etc.); nephrologist admits for urgent dialysis issues (K+>6.3, pH<7.3, etc.).
- Cardiology: Hospitalist admits CHF and non-ST elevation chest pain; cardiologist admits STEMI.
- General surgery: Hospitalist admits ileus, pseudo obstruction, and SBO due to adhesions; general surgery admits bowel obstruction in “virgin abdomen,” volvulus, and any obstruction thought to require urgent surgery.
To be clear, I’m not suggesting the above guidelines are evidence-based or are the right ones for your institution. I just made these up, so yours might differ significantly. I just want to provide a sense of the kinds of issues these agreements typically cover. The comanagement section of the SHM website has several documents regarding hospitalist-orthopedic service agreements.
The Negotiation Process
It’s tempting for the lead hospitalist to just have a hallway chat with a spokesperson from the other specialty, then email a draft agreement, exchange a few messages until both parties are satisfied, then email a copy of the final document to all the doctors in both groups. This might work for some simple service agreements, but for any area with significant ambiguity or disagreements (or potential for disagreements), one or more in-person meetings are usually necessary. Ideally, several doctors in both groups will attend these meetings.
Much work could be done in advance of the first meeting, including surveying other practices to see how they decide which group admits the same kinds of patents, gathering any relevant published research, and possibly drafting a “straw man” proposed agreement. When meeting in person, the doctors will have a chance to explain their points of view, needs, and concerns, and gain a greater appreciation of the way “the other guy” sees things. An important purpose of the in-person meeting is to “look the other guy in the eye” to know if he or she really is committed to following through.
Remember that written agreements like these might become an issue in malpractice suits, so you might want to have them reviewed first by risk managers. You might also write them as guidelines rather than rigid protocols that don’t allow variations.
Maximize Effectiveness
Ideally, every doctor involved in the agreement should document their approval with a signature and date. My experience is that this doesn’t happen at most places, but if there is concern about whether everyone will comply, signing the document will probably help at least a little.
The completed agreements should be provided to all doctors in both groups, the ED, affected hospital nursing units, and others. Any new doctor should get a copy of all such agreements that might be relevant. And, most important, it should be made available electronically so that it is easy to find at any time. Some agreements cover uncommon events, and the doctors on duty might not remember what the agreement said and will need ready access to it.
Most service agreements should be reviewed and updated every two or three years or as needed. If there is confusion or controversy around a particular agreement, or if disagreements about which doctor does the admission are common despite the agreement, then an in-person meeting between the physician groups should be scheduled to revise or update it.
Keep Your Fingers Crossed
If it sounds like a lot of work to develop and maintain these agreements, it is. But they’re worth every bit of that work if they reduce confusion or discord. Sadly, for several reasons, they rarely prove so effective.
One doctor might think the agreement applies, but the other doctor says this patient is an exception and the agreement doesn’t apply. It is impossible to write an agreement that addresses all possible scenarios, so a doctor can argue that any particular patient falls outside the agreement because of things like comorbidities, which service admitted the patient last time (many agreements will have defined “bounce back” intervals), which primary-care physician (PCP) the patient sees, etc.
Even if there is no dispute about whether the agreement covers a particular patient, many doctors simply don’t feel obligated to uphold the agreement. Such a doctor might tell the ED doctor: “Yep, I signed the agreement, but only as a way to get the meeting over with. I was never in favor of it and just can’t admit the patient. Call the other guy to admit.” So in spite of all the work done to create a reasonable agreement, some doctors might feel entitled to ignore it when it suits them.
Compliance Is Critical
Sadly, my take is that despite the tremendous hoped-for benefits that service agreements might provide, poor compliance means they rarely achieve their potential. Even so, they are usually worth the time and effort to create them if it leads doctors in the two specialties to schedule time away from patient care to listen to the other group’s point of view and discuss how best to handle particular types of patients. In some cases, it will be the first time the two groups of doctors have set aside time to talk about the work they do together; that alone can have significant value.
Tom Lorence, MD, a Kaiser hospitalist in Portland, Ore., who is chief of hospital medicine for Northwest Permanente, developed more than 20 service agreements with many different specialties at his institution. He has found that they are worth the effort, and that they helped allay hospitalists’ feeling of being “dumped on.”
He also told me a rule that probably applies to all such agreements in any setting: The tie goes to the hospitalist—that is, when there is reasonable uncertainty or disagreement about which group should admit a patient, it is nearly always the hospitalist who will do so.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course.
ONLINE EXCLUSIVE: L.A. Care Health Plan's Z. Joseph Wanski discusses efforts to prevent 30-day readmissions
Click here to listen to Dr. Wanski
Click here to listen to Dr. Wanski
Click here to listen to Dr. Wanski
Report: Wrong-Patient Orders Occur Frequently with CPOE Systems
Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.
Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.
CPOE systems have "certainly prevented errors," he says, "but they've unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."
The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.
Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.
The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.
"I think the goal is to try to get perfection," Dr. Adelman says. "I don't know if you could ever get totally there ... but you try."
Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.
Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.
CPOE systems have "certainly prevented errors," he says, "but they've unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."
The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.
Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.
The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.
"I think the goal is to try to get perfection," Dr. Adelman says. "I don't know if you could ever get totally there ... but you try."
Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.
Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.
CPOE systems have "certainly prevented errors," he says, "but they've unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."
The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.
Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.
The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.
"I think the goal is to try to get perfection," Dr. Adelman says. "I don't know if you could ever get totally there ... but you try."
Guidelines Urge Transfer of Subarachnoid Hemorrhage Patients
The new “Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage,” published online May 3 in Stroke, call for hospitals treating fewer than 10 aneurysmal subarachnoid hemorrhage (aSAH) cases per year to consider their immediate transfer to facilities that handle at least 35 such cases annually.1 The recommendation is based on research suggesting that 30-day death rates were significantly higher in low-volume facilities (39%) vs. facilities treating more than 35 cases per year (27%), reflecting the latter’s greater access to cerebrovascular surgeons, endovascular specialists, and neuro-intensive-care services.
This type of hemorrhage accounts for 5% of all strokes and affects more than 30,000 Americans annually.
Reference
The new “Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage,” published online May 3 in Stroke, call for hospitals treating fewer than 10 aneurysmal subarachnoid hemorrhage (aSAH) cases per year to consider their immediate transfer to facilities that handle at least 35 such cases annually.1 The recommendation is based on research suggesting that 30-day death rates were significantly higher in low-volume facilities (39%) vs. facilities treating more than 35 cases per year (27%), reflecting the latter’s greater access to cerebrovascular surgeons, endovascular specialists, and neuro-intensive-care services.
This type of hemorrhage accounts for 5% of all strokes and affects more than 30,000 Americans annually.
Reference
The new “Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage,” published online May 3 in Stroke, call for hospitals treating fewer than 10 aneurysmal subarachnoid hemorrhage (aSAH) cases per year to consider their immediate transfer to facilities that handle at least 35 such cases annually.1 The recommendation is based on research suggesting that 30-day death rates were significantly higher in low-volume facilities (39%) vs. facilities treating more than 35 cases per year (27%), reflecting the latter’s greater access to cerebrovascular surgeons, endovascular specialists, and neuro-intensive-care services.
This type of hemorrhage accounts for 5% of all strokes and affects more than 30,000 Americans annually.
Reference
Report Highlights Strategies for Reducing AMI Mortality Rates
A new report on acute myocardial infarction (AMI) suggests that implementing a handful of relatively easy strategies can improve mortality rates.
The research, "Hospital Strategies for Reducing Risk-Standardized Mortality Rates in Acute Myocardial Infarction," highlights several techniques for lowering risk-standardized mortality rates (RSMR) in this patient population:
• Holding monthly meetings to review AMI cases (lowered RSMR by 0.7%);
• Fostering an environment that encourages clinicians to solve problems creatively (lowered RSMR by 0.84%);
• Having 24-hour coverage by cardiologists (lowered RSMR by 0.54%);
• Having both a nurse and physician champion for quality in AMI (lowered RSMR by 0.88%); and
• Avoiding cross-training nurses from ICUs for cardiac catheterization laboratories (lowered RSMR by 0.44%).
Fewer than 10% of the 537 hospitals in the cross-sectional survey reported using at least four of the five strategies. Lead author Elizabeth H. Bradley, PhD, faculty director of the Global Health Leadership Institute and professor of public health at Yale University, says the challenge in implementing the strategies lies in changing the often-obstinate culture of healthcare institutions.
"The root of this is the culture," she says, adding if nothing else, "begin with the problems, begin with an analytical mind when errors occur." Dr. Bradley adds that culture of teamwork works only when it has buy-in from in-the-trenches physicians, such as hospitalists and C-suite executives.
"It has to come from the front line and from the top," she says. "In all of our studies over the last decade, [physicians and administrators] need to be supportive of an environment in which problem solving can happen."
A new report on acute myocardial infarction (AMI) suggests that implementing a handful of relatively easy strategies can improve mortality rates.
The research, "Hospital Strategies for Reducing Risk-Standardized Mortality Rates in Acute Myocardial Infarction," highlights several techniques for lowering risk-standardized mortality rates (RSMR) in this patient population:
• Holding monthly meetings to review AMI cases (lowered RSMR by 0.7%);
• Fostering an environment that encourages clinicians to solve problems creatively (lowered RSMR by 0.84%);
• Having 24-hour coverage by cardiologists (lowered RSMR by 0.54%);
• Having both a nurse and physician champion for quality in AMI (lowered RSMR by 0.88%); and
• Avoiding cross-training nurses from ICUs for cardiac catheterization laboratories (lowered RSMR by 0.44%).
Fewer than 10% of the 537 hospitals in the cross-sectional survey reported using at least four of the five strategies. Lead author Elizabeth H. Bradley, PhD, faculty director of the Global Health Leadership Institute and professor of public health at Yale University, says the challenge in implementing the strategies lies in changing the often-obstinate culture of healthcare institutions.
"The root of this is the culture," she says, adding if nothing else, "begin with the problems, begin with an analytical mind when errors occur." Dr. Bradley adds that culture of teamwork works only when it has buy-in from in-the-trenches physicians, such as hospitalists and C-suite executives.
"It has to come from the front line and from the top," she says. "In all of our studies over the last decade, [physicians and administrators] need to be supportive of an environment in which problem solving can happen."
A new report on acute myocardial infarction (AMI) suggests that implementing a handful of relatively easy strategies can improve mortality rates.
The research, "Hospital Strategies for Reducing Risk-Standardized Mortality Rates in Acute Myocardial Infarction," highlights several techniques for lowering risk-standardized mortality rates (RSMR) in this patient population:
• Holding monthly meetings to review AMI cases (lowered RSMR by 0.7%);
• Fostering an environment that encourages clinicians to solve problems creatively (lowered RSMR by 0.84%);
• Having 24-hour coverage by cardiologists (lowered RSMR by 0.54%);
• Having both a nurse and physician champion for quality in AMI (lowered RSMR by 0.88%); and
• Avoiding cross-training nurses from ICUs for cardiac catheterization laboratories (lowered RSMR by 0.44%).
Fewer than 10% of the 537 hospitals in the cross-sectional survey reported using at least four of the five strategies. Lead author Elizabeth H. Bradley, PhD, faculty director of the Global Health Leadership Institute and professor of public health at Yale University, says the challenge in implementing the strategies lies in changing the often-obstinate culture of healthcare institutions.
"The root of this is the culture," she says, adding if nothing else, "begin with the problems, begin with an analytical mind when errors occur." Dr. Bradley adds that culture of teamwork works only when it has buy-in from in-the-trenches physicians, such as hospitalists and C-suite executives.
"It has to come from the front line and from the top," she says. "In all of our studies over the last decade, [physicians and administrators] need to be supportive of an environment in which problem solving can happen."
Banner Good Samaritan Battles VTE in Real Time
Banner Good Samaritan Medical Center in Phoenix is combating hospital-acquired VTE with a quality initiative that uses risk-assessment tools and order sets embedded in the electronic health record (EHR) and real-time interventions with physicians.
Cases of hospital-acquired VTE are identified as they occur and assessed for whether they were preventable, says Lori Porter, DO, academic hospitalist and team leader for Banner Good Samaritan's VTE Committee. "If we think the VTE was preventable, we will call the provider and say, 'Can you tell me why you think this happened?'" she says. (Check out more information about Banner Good Samaritan’s VTE program at the Institute for Healthcare Improvement website.)
The program emphasizes risk re-assessment, appropriate use of extended prophylaxis, and involvement of Banner's house staff. All four hospitalist services at Banner Good Samaritan have been receptive to using the order sets.
Banner Good Samaritan's results include a drop in preventable hospital-acquired VTEs to 25% in 2011 from 45% in 2009, along with a 29% relative risk reduction in DVT and 18% in pulmonary embolism.
The hospital belongs to SHM's VTE Prevention Collaborative, and works with mentor Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM's Center for Healthcare Improvement and Innovation. It uses what Dr. Porter calls "a simple, three-bucket system" for assessing and classifying risk level, derived from the 2008 antithrombotic therapy guidelines from the American College of Chest Physicians (ACCP). However, in February, ACCP issued a new edition of the guidelines, which Dr. Porter has not been eager to embrace.
"They've gone back to a conservative point-scoring system for risk assessment, which seems cumbersome in clinical practice. If a simpler approach has proven to be effective for us, then why commit to making a complicated change?" says Dr. Porter.
Dr. Maynard agrees that the new antithrombotic guidelines have sparked differences of opinion. Dr. Porter's teams, for example, "use the simpler three-bucket model with good results: better prophylaxis, decrease in VTE, and no discernible increase in bleeding," he says. "Improvement teams that want to mimic these results should look at this model, in addition to the models outlined in the ninth edition, and see which models their doctors and nurses would actually use reliably."
Banner Good Samaritan Medical Center in Phoenix is combating hospital-acquired VTE with a quality initiative that uses risk-assessment tools and order sets embedded in the electronic health record (EHR) and real-time interventions with physicians.
Cases of hospital-acquired VTE are identified as they occur and assessed for whether they were preventable, says Lori Porter, DO, academic hospitalist and team leader for Banner Good Samaritan's VTE Committee. "If we think the VTE was preventable, we will call the provider and say, 'Can you tell me why you think this happened?'" she says. (Check out more information about Banner Good Samaritan’s VTE program at the Institute for Healthcare Improvement website.)
The program emphasizes risk re-assessment, appropriate use of extended prophylaxis, and involvement of Banner's house staff. All four hospitalist services at Banner Good Samaritan have been receptive to using the order sets.
Banner Good Samaritan's results include a drop in preventable hospital-acquired VTEs to 25% in 2011 from 45% in 2009, along with a 29% relative risk reduction in DVT and 18% in pulmonary embolism.
The hospital belongs to SHM's VTE Prevention Collaborative, and works with mentor Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM's Center for Healthcare Improvement and Innovation. It uses what Dr. Porter calls "a simple, three-bucket system" for assessing and classifying risk level, derived from the 2008 antithrombotic therapy guidelines from the American College of Chest Physicians (ACCP). However, in February, ACCP issued a new edition of the guidelines, which Dr. Porter has not been eager to embrace.
"They've gone back to a conservative point-scoring system for risk assessment, which seems cumbersome in clinical practice. If a simpler approach has proven to be effective for us, then why commit to making a complicated change?" says Dr. Porter.
Dr. Maynard agrees that the new antithrombotic guidelines have sparked differences of opinion. Dr. Porter's teams, for example, "use the simpler three-bucket model with good results: better prophylaxis, decrease in VTE, and no discernible increase in bleeding," he says. "Improvement teams that want to mimic these results should look at this model, in addition to the models outlined in the ninth edition, and see which models their doctors and nurses would actually use reliably."
Banner Good Samaritan Medical Center in Phoenix is combating hospital-acquired VTE with a quality initiative that uses risk-assessment tools and order sets embedded in the electronic health record (EHR) and real-time interventions with physicians.
Cases of hospital-acquired VTE are identified as they occur and assessed for whether they were preventable, says Lori Porter, DO, academic hospitalist and team leader for Banner Good Samaritan's VTE Committee. "If we think the VTE was preventable, we will call the provider and say, 'Can you tell me why you think this happened?'" she says. (Check out more information about Banner Good Samaritan’s VTE program at the Institute for Healthcare Improvement website.)
The program emphasizes risk re-assessment, appropriate use of extended prophylaxis, and involvement of Banner's house staff. All four hospitalist services at Banner Good Samaritan have been receptive to using the order sets.
Banner Good Samaritan's results include a drop in preventable hospital-acquired VTEs to 25% in 2011 from 45% in 2009, along with a 29% relative risk reduction in DVT and 18% in pulmonary embolism.
The hospital belongs to SHM's VTE Prevention Collaborative, and works with mentor Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM's Center for Healthcare Improvement and Innovation. It uses what Dr. Porter calls "a simple, three-bucket system" for assessing and classifying risk level, derived from the 2008 antithrombotic therapy guidelines from the American College of Chest Physicians (ACCP). However, in February, ACCP issued a new edition of the guidelines, which Dr. Porter has not been eager to embrace.
"They've gone back to a conservative point-scoring system for risk assessment, which seems cumbersome in clinical practice. If a simpler approach has proven to be effective for us, then why commit to making a complicated change?" says Dr. Porter.
Dr. Maynard agrees that the new antithrombotic guidelines have sparked differences of opinion. Dr. Porter's teams, for example, "use the simpler three-bucket model with good results: better prophylaxis, decrease in VTE, and no discernible increase in bleeding," he says. "Improvement teams that want to mimic these results should look at this model, in addition to the models outlined in the ninth edition, and see which models their doctors and nurses would actually use reliably."
Training, Leadership, Commitment Integral to HM Improving Stroke Care
Stroke specialists like to say that “time is brain.” With an emphatic focus on those first few critical hours, however, it’s sometimes easy to overlook the vital role that hospitalists play in the days, weeks, and months that follow.
A recent study in The Neurohospitalist suggests that compared to community-based neurologists, practitioners of neurohospital medicine can reduce the length of stay for patients with ischemic stroke.1 A separate study, however, suggests that similar success might have come at a price for their less-specialized hospitalist counterparts.2 Among stroke patients, the latter study found that while the HM model is also associated with a reduced length of stay, it is associated with increased discharges to inpatient rehabilitation centers instead of to home, and higher readmission rates.
In sum, the evidence raises questions about whether rank-and-file hospitalists are adequately equipped to deal with a disease that is a core competency for the profession and ranks among the top sources of adult disability in the United States, at an estimated cost of $34.3 billion in 2008.3
“I think there’s been a mismatch between the training of the average hospitalist and then the expectations for the amount of neurological care they end up delivering once in practice,” says David Likosky, MD, SFHM, director of the stroke program at Evergreen Hospital Medical Center in Kirkland, Wash. “When surveyed, it’s been shown that hospitalists feel that care of stroke is one of the areas with which they’re least comfortable once they get out into practice.” Over the past decade, several studies have reinforced the notion of a training deficit.4,5
Demographic trends suggest that getting up to speed will be imperative, however. “One alarming thing we’re seeing is strokes among individuals that are not in the elderly group, and that group seems to be increasing at an alarming rate,” says Daniel T. Lackland, PhD, professor of epidemiology and neurosciences at the Medical University of South Carolina in Charleston. Hospitals are seeing more ischemic stroke patients in their 40s and 50s, likely a reflection of risk factors such as hypertension, diabetes, and hyperlipidemia that are occurring earlier in life. And because those patients are younger, the aftermath of a stroke could linger for decades.
Although the stroke mortality rate is declining in the U.S., statistics find that about 14% of all patients diagnosed with an initial stroke will have a second one within a year, placing continued strain on a healthcare system already stretched thin.6 Hospitalists, Dr. Lackland says, have an “ideal” opportunity to help build up and improve that system, potentially yielding significant cost savings along with the dramatic improvement in quality of life. Making the most of that opportunity, though, will require a solid understanding of multiple trends that are quickly transforming stroke care delivery.
Time Is of the Essence
Kevin Barrett, MD, MSc, assistant professor of neurology and stroke telemedicine director at the Mayo Clinic in Jacksonville, Fla., says hospitals are focusing more and more on a metric known as “door-to-needle time.” The goal is to treat at least half of incoming ischemic stroke patients with intravenous tissue-type plasminogen activator (IV tPA) within the first 60 minutes after onset of symptoms.
The American Heart Association/American Stroke Association has reinforced the message with its Get With the Guidelines Stroke Program. A recent analysis suggested the program has led to more timely tPA administration and, in turn, better patient outcomes (the program is funded in part through the Bristol-Myers Squib/Sanofi Pharmaceutical Partnership).7
At the same time, clinical research has widened the window for IV tPA delivery from three hours to 4.5 hours for certain patients after the onset of symptoms. Dr. Barrett says “strong evidence” from the European Cooperative Acute Stroke Study III has convinced most clinicians, and the FDA is expected to follow suit in officially approving the extension.8 As more stroke centers become certified, the use of IV tPA has increased accordingly.
Patients who have missed the time window or are not good candidates for IV tPA can still be aided by interarterial tPA at the site of the clot up to six hours after the onset of symptoms. Dr. Likosky says the treatment option should be of particular interest to hospitalists, given that strokes can occur post-operatively and in other patients who cannot receive IV tPA because of bleeding risk.
—Karim Godamunne, MD, MBA, SFHM, medical director, Eagle Hospital Physicians, Roswell, Ga.
For up to eight hours after the onset of symptoms, mechanical clot removal techniques have shown continued efficacy at revascularizing affected areas, with some newer options also offering greater promise of improving patient outcomes. Even with the prospects of declining complication rates, however, “evaluating and initiating treatment in a timely fashion is still going to be one of the most important predictors of outcome,” Dr. Barrett says.
After the initial intervention, hospitalists often are the go-to providers for anticipating and preventing common post-stroke complications, such as aspiration pneumonia, VTE from immobilization, and other infections. The proper use of anti-platelet agents and high-dose statins, also falling solidly within the HM realm, can pay big dividends if used consistently.
Meanwhile, newer studies and clinical observations are widening the scope of considerations that should be on every hospitalist’s radar. Here are a few cited by stroke experts:
Permissive hypertension. After an ischemic stroke, the benefit of permissive hypertension is still widely misunderstood. Perhaps counterintuitively, high blood pressure after a stroke can help protect the area of the brain that is damaged but not yet dead, sometimes called the penumbra. “I highlight this because I think it’s a common mistake, that internists are very used to high blood pressure being a bad thing,” says Andrew Josephson, MD, associate professor of clinical neurology and director of the neurohospitalist program at the University of California at San Francisco (UCSF) Medical Center. “And in general, it is; it’s a cause of stroke. But once somebody has a stroke, in the acute period, it’s important to allow the blood pressure to be high.”
Atrial fibrillation. The accepted role of atrial fibrillation in stroke is evolving. Research suggests that the common but often preventable arrhythmia is an important cause of stroke in about 15% to 20% of cases.9 By the time of hospital discharge, however, Dr. Josephson says physicians haven’t established a cause in about 1 in 4 cases. For these “cryptogenic strokes,” he says, doctors have long suspected that atrial fibrillation not picked up during the initial EKG or by the monitoring with cardiac telemetry could be a major cause.
Recent observations suggest that a longer monitoring period of up to 30 days may uncover atrial fibrillation in a sizable fraction of those patients, highlighting the importance of keeping a close eye on stroke patients both in the hospital and beyond. “It’s very important to identify, because atrial fibrillation changes what we do for folks to prevent a second stroke,” Dr. Josephson explains. Instead of anti-platelet medicine like aspirin, patients with atrial fibrillation often receive anticoagulants like warfarin, or the more recently approved dabigatran and rivaroxaban.
Transient ischemic attack. Improvements in imaging techniques like MRI have likewise begun to shift how stroke patients are treated. For example, Dr. Likosky says, medicine is moving away from a time-based definition of transient ischemic attack (TIA), in which symptoms resolve within 24 hours, to a tissue-based definition. Recent MRI imaging has uncovered evidence of a new infarction in more than half of patients initially diagnosed with TIA.10
“If they do have an infarction on their scan, even if they had symptoms that only lasted for five minutes, that’s a stroke,” Dr. Josephson says. And even a true TIA, he says, represents “a kind of stroke where you got really lucky and you’re not left with deficits, but the risk is still very high.” Accordingly, more patients with TIA are being admitted to the hospital to receive a full workup and preventive treatment. “We think that by evaluating these people urgently, we can reduce the risk of having a stroke by maybe 75% over a three-month time period,” Dr. Josephson says.
Hemorrhagic stroke. To date, the vast majority of patients with hemorrhagic stroke (which accounts for only 13% of all stroke cases) have been managed by neurosurgeons and neurologists. But here, too, Dr. Likosky says the picture could be changing. Recent findings that surgical treatment of intracranial hemorrhaging might not benefit many patients could shift the care paradigm toward a medical management strategy that involves more hospitalists.
Innovations Aplenty
The increasing complexity of stroke care and uneven distribution of resources and expertise have helped fuel several important innovations in delivery, most notably telestroke and neurohospital medicine. Both are being driven, in part, by an increased awareness of time-sensitive interventions and a frequent lack of on-site neurologists at smaller and more rural facilities. If telestroke programs are expanding the reach of neurologists, neurohospitalists are helping to fill the gaps in inpatient stroke care.
Amid the changes, one element is proving a necessary constant: a team approach that relies heavily on the HM emphasis on quality metrics, intensive monitoring, and careful coordination. Who better to lead the charge than hospitalists, says Mary E. Jensen, MD, professor of radiology and neurosurgery at the University of Virginia in Charlottesville. “They’re the ones who are in the hospital, and when these patients go bad, they go bad fast,” she says.
More broadly, Dr. Jensen says, hospitalists should get in on the ground floor when their facility seeks certification as a primary or a comprehensive stroke center. “And they need to make sure that the hospital isn’t just trying to get the sexy elements—the guy with the cath or the gal with the cath who can pull the clot out—but that they have a complete program that involves the care of the patient after they’ve had the procedure done,” she says.
As healthcare reform efforts are making clear, the responsibility doesn’t end after discharge, either. The Affordable Care Act includes a hospital readmission reduction program that will kick in this October, with penalties for hospitals posting unacceptably high 30-day readmission rates. Amy Kind, MD, PhD, assistant professor of medicine in the Division of Geriatrics at the University of Wisconsin School of Medicine and Public Health in Madison, is convinced that a key contributor to high rehospitalization rates among stroke patients may be the woefully incomplete nature of discharge communication.
—Mary E. Jensen, MD, professor of radiology and neurosurgery, University of Virginia, Charlottesville
Dr. Kind, for example, has found a disturbing pattern in communication regarding issues like dysphagia, a common complication among stroke patients and an important risk factor for pneumonia. Countering the risk usually requires such measures as putting patients on a special diet or elevating the head of their bed. “We looked at the quality of the communication of that information in discharge summaries, and it’s just abysmal. It’s absolutely abysmal,” she says. Without clear directives to providers in the next setting of care, such as a skilled-nursing facility, patients could be erroneously put back on a regular diet and aspirate, sending them right back to the hospital.
As one potential solution, Dr. Kind’s team is developing a multidisciplinary stroke discharge summary tool that automatically imports elements like speech-language pathology and dietary recommendations. Although most discharge communication may focus on more visible issues and interventions, Dr. Kind argues that some of the “bread and butter” concerns might ultimately prove just as important for long-term patient outcomes.
Karim Godamunne, MD, MBA, SFHM, vice president of clinical systems integration and medical director of Eagle Hospital Physicians in Atlanta, sees telemedicine as another potential tool to help reach patients after discharge, especially those who haven’t received follow-up care from a primary-care physician (PCP). “We need to be the champions at our hospitals for improving care processes, and we need to work in partnership with the nurses and the other professionals,” Dr. Godamunne says. “As a group, we can really make a difference, and stroke is one of those areas in which we can truly contribute.”
Bryn Nelson is a freelance medical writer in Seattle.
References
- Freeman WD, Dawson SB, Raper C, Thiemann K, et al. Neurohospitalists reduce length of stay for patients with ischemic stroke. The Neurohospitalist. 2011;1(2): 67-70.
- Howrey BT, Kuo Y-F, Goodwin JS. Association of care by hospitalists on discharge destination and 30-day outcomes after acute ischemic stroke. Medical Care. 2011;49(8): 701-707.
- Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2-e220.
- Glasheen JJ, Epstein KR, Siegal E, Kutner JS, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
- Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001; 111(3):247-254.
- Dickerson LM, Carek PJ, Quattlebaum RG. Prevention of recurrent ischemic stroke. Am Fam Physician. 2007; 76(3):382-388.
- Fonarow GC, Smith EE, Saver JL, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation. 2011;123(7):750-758.
- Hacke W, Kaste M, Bluhmki E, Brozman M, et al. Thrombolysis with Alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317-1329.
- Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010;121:e91.
- Albers GW, Caplan LR, Easton JD, et al. Transient ischemic attack—proposal for a new definition. N Engl J Med. 2002;347(21):1713-1716.
- Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med. 2011;365:993-1003.
Stroke specialists like to say that “time is brain.” With an emphatic focus on those first few critical hours, however, it’s sometimes easy to overlook the vital role that hospitalists play in the days, weeks, and months that follow.
A recent study in The Neurohospitalist suggests that compared to community-based neurologists, practitioners of neurohospital medicine can reduce the length of stay for patients with ischemic stroke.1 A separate study, however, suggests that similar success might have come at a price for their less-specialized hospitalist counterparts.2 Among stroke patients, the latter study found that while the HM model is also associated with a reduced length of stay, it is associated with increased discharges to inpatient rehabilitation centers instead of to home, and higher readmission rates.
In sum, the evidence raises questions about whether rank-and-file hospitalists are adequately equipped to deal with a disease that is a core competency for the profession and ranks among the top sources of adult disability in the United States, at an estimated cost of $34.3 billion in 2008.3
“I think there’s been a mismatch between the training of the average hospitalist and then the expectations for the amount of neurological care they end up delivering once in practice,” says David Likosky, MD, SFHM, director of the stroke program at Evergreen Hospital Medical Center in Kirkland, Wash. “When surveyed, it’s been shown that hospitalists feel that care of stroke is one of the areas with which they’re least comfortable once they get out into practice.” Over the past decade, several studies have reinforced the notion of a training deficit.4,5
Demographic trends suggest that getting up to speed will be imperative, however. “One alarming thing we’re seeing is strokes among individuals that are not in the elderly group, and that group seems to be increasing at an alarming rate,” says Daniel T. Lackland, PhD, professor of epidemiology and neurosciences at the Medical University of South Carolina in Charleston. Hospitals are seeing more ischemic stroke patients in their 40s and 50s, likely a reflection of risk factors such as hypertension, diabetes, and hyperlipidemia that are occurring earlier in life. And because those patients are younger, the aftermath of a stroke could linger for decades.
Although the stroke mortality rate is declining in the U.S., statistics find that about 14% of all patients diagnosed with an initial stroke will have a second one within a year, placing continued strain on a healthcare system already stretched thin.6 Hospitalists, Dr. Lackland says, have an “ideal” opportunity to help build up and improve that system, potentially yielding significant cost savings along with the dramatic improvement in quality of life. Making the most of that opportunity, though, will require a solid understanding of multiple trends that are quickly transforming stroke care delivery.
Time Is of the Essence
Kevin Barrett, MD, MSc, assistant professor of neurology and stroke telemedicine director at the Mayo Clinic in Jacksonville, Fla., says hospitals are focusing more and more on a metric known as “door-to-needle time.” The goal is to treat at least half of incoming ischemic stroke patients with intravenous tissue-type plasminogen activator (IV tPA) within the first 60 minutes after onset of symptoms.
The American Heart Association/American Stroke Association has reinforced the message with its Get With the Guidelines Stroke Program. A recent analysis suggested the program has led to more timely tPA administration and, in turn, better patient outcomes (the program is funded in part through the Bristol-Myers Squib/Sanofi Pharmaceutical Partnership).7
At the same time, clinical research has widened the window for IV tPA delivery from three hours to 4.5 hours for certain patients after the onset of symptoms. Dr. Barrett says “strong evidence” from the European Cooperative Acute Stroke Study III has convinced most clinicians, and the FDA is expected to follow suit in officially approving the extension.8 As more stroke centers become certified, the use of IV tPA has increased accordingly.
Patients who have missed the time window or are not good candidates for IV tPA can still be aided by interarterial tPA at the site of the clot up to six hours after the onset of symptoms. Dr. Likosky says the treatment option should be of particular interest to hospitalists, given that strokes can occur post-operatively and in other patients who cannot receive IV tPA because of bleeding risk.
—Karim Godamunne, MD, MBA, SFHM, medical director, Eagle Hospital Physicians, Roswell, Ga.
For up to eight hours after the onset of symptoms, mechanical clot removal techniques have shown continued efficacy at revascularizing affected areas, with some newer options also offering greater promise of improving patient outcomes. Even with the prospects of declining complication rates, however, “evaluating and initiating treatment in a timely fashion is still going to be one of the most important predictors of outcome,” Dr. Barrett says.
After the initial intervention, hospitalists often are the go-to providers for anticipating and preventing common post-stroke complications, such as aspiration pneumonia, VTE from immobilization, and other infections. The proper use of anti-platelet agents and high-dose statins, also falling solidly within the HM realm, can pay big dividends if used consistently.
Meanwhile, newer studies and clinical observations are widening the scope of considerations that should be on every hospitalist’s radar. Here are a few cited by stroke experts:
Permissive hypertension. After an ischemic stroke, the benefit of permissive hypertension is still widely misunderstood. Perhaps counterintuitively, high blood pressure after a stroke can help protect the area of the brain that is damaged but not yet dead, sometimes called the penumbra. “I highlight this because I think it’s a common mistake, that internists are very used to high blood pressure being a bad thing,” says Andrew Josephson, MD, associate professor of clinical neurology and director of the neurohospitalist program at the University of California at San Francisco (UCSF) Medical Center. “And in general, it is; it’s a cause of stroke. But once somebody has a stroke, in the acute period, it’s important to allow the blood pressure to be high.”
Atrial fibrillation. The accepted role of atrial fibrillation in stroke is evolving. Research suggests that the common but often preventable arrhythmia is an important cause of stroke in about 15% to 20% of cases.9 By the time of hospital discharge, however, Dr. Josephson says physicians haven’t established a cause in about 1 in 4 cases. For these “cryptogenic strokes,” he says, doctors have long suspected that atrial fibrillation not picked up during the initial EKG or by the monitoring with cardiac telemetry could be a major cause.
Recent observations suggest that a longer monitoring period of up to 30 days may uncover atrial fibrillation in a sizable fraction of those patients, highlighting the importance of keeping a close eye on stroke patients both in the hospital and beyond. “It’s very important to identify, because atrial fibrillation changes what we do for folks to prevent a second stroke,” Dr. Josephson explains. Instead of anti-platelet medicine like aspirin, patients with atrial fibrillation often receive anticoagulants like warfarin, or the more recently approved dabigatran and rivaroxaban.
Transient ischemic attack. Improvements in imaging techniques like MRI have likewise begun to shift how stroke patients are treated. For example, Dr. Likosky says, medicine is moving away from a time-based definition of transient ischemic attack (TIA), in which symptoms resolve within 24 hours, to a tissue-based definition. Recent MRI imaging has uncovered evidence of a new infarction in more than half of patients initially diagnosed with TIA.10
“If they do have an infarction on their scan, even if they had symptoms that only lasted for five minutes, that’s a stroke,” Dr. Josephson says. And even a true TIA, he says, represents “a kind of stroke where you got really lucky and you’re not left with deficits, but the risk is still very high.” Accordingly, more patients with TIA are being admitted to the hospital to receive a full workup and preventive treatment. “We think that by evaluating these people urgently, we can reduce the risk of having a stroke by maybe 75% over a three-month time period,” Dr. Josephson says.
Hemorrhagic stroke. To date, the vast majority of patients with hemorrhagic stroke (which accounts for only 13% of all stroke cases) have been managed by neurosurgeons and neurologists. But here, too, Dr. Likosky says the picture could be changing. Recent findings that surgical treatment of intracranial hemorrhaging might not benefit many patients could shift the care paradigm toward a medical management strategy that involves more hospitalists.
Innovations Aplenty
The increasing complexity of stroke care and uneven distribution of resources and expertise have helped fuel several important innovations in delivery, most notably telestroke and neurohospital medicine. Both are being driven, in part, by an increased awareness of time-sensitive interventions and a frequent lack of on-site neurologists at smaller and more rural facilities. If telestroke programs are expanding the reach of neurologists, neurohospitalists are helping to fill the gaps in inpatient stroke care.
Amid the changes, one element is proving a necessary constant: a team approach that relies heavily on the HM emphasis on quality metrics, intensive monitoring, and careful coordination. Who better to lead the charge than hospitalists, says Mary E. Jensen, MD, professor of radiology and neurosurgery at the University of Virginia in Charlottesville. “They’re the ones who are in the hospital, and when these patients go bad, they go bad fast,” she says.
More broadly, Dr. Jensen says, hospitalists should get in on the ground floor when their facility seeks certification as a primary or a comprehensive stroke center. “And they need to make sure that the hospital isn’t just trying to get the sexy elements—the guy with the cath or the gal with the cath who can pull the clot out—but that they have a complete program that involves the care of the patient after they’ve had the procedure done,” she says.
As healthcare reform efforts are making clear, the responsibility doesn’t end after discharge, either. The Affordable Care Act includes a hospital readmission reduction program that will kick in this October, with penalties for hospitals posting unacceptably high 30-day readmission rates. Amy Kind, MD, PhD, assistant professor of medicine in the Division of Geriatrics at the University of Wisconsin School of Medicine and Public Health in Madison, is convinced that a key contributor to high rehospitalization rates among stroke patients may be the woefully incomplete nature of discharge communication.
—Mary E. Jensen, MD, professor of radiology and neurosurgery, University of Virginia, Charlottesville
Dr. Kind, for example, has found a disturbing pattern in communication regarding issues like dysphagia, a common complication among stroke patients and an important risk factor for pneumonia. Countering the risk usually requires such measures as putting patients on a special diet or elevating the head of their bed. “We looked at the quality of the communication of that information in discharge summaries, and it’s just abysmal. It’s absolutely abysmal,” she says. Without clear directives to providers in the next setting of care, such as a skilled-nursing facility, patients could be erroneously put back on a regular diet and aspirate, sending them right back to the hospital.
As one potential solution, Dr. Kind’s team is developing a multidisciplinary stroke discharge summary tool that automatically imports elements like speech-language pathology and dietary recommendations. Although most discharge communication may focus on more visible issues and interventions, Dr. Kind argues that some of the “bread and butter” concerns might ultimately prove just as important for long-term patient outcomes.
Karim Godamunne, MD, MBA, SFHM, vice president of clinical systems integration and medical director of Eagle Hospital Physicians in Atlanta, sees telemedicine as another potential tool to help reach patients after discharge, especially those who haven’t received follow-up care from a primary-care physician (PCP). “We need to be the champions at our hospitals for improving care processes, and we need to work in partnership with the nurses and the other professionals,” Dr. Godamunne says. “As a group, we can really make a difference, and stroke is one of those areas in which we can truly contribute.”
Bryn Nelson is a freelance medical writer in Seattle.
References
- Freeman WD, Dawson SB, Raper C, Thiemann K, et al. Neurohospitalists reduce length of stay for patients with ischemic stroke. The Neurohospitalist. 2011;1(2): 67-70.
- Howrey BT, Kuo Y-F, Goodwin JS. Association of care by hospitalists on discharge destination and 30-day outcomes after acute ischemic stroke. Medical Care. 2011;49(8): 701-707.
- Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2-e220.
- Glasheen JJ, Epstein KR, Siegal E, Kutner JS, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
- Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001; 111(3):247-254.
- Dickerson LM, Carek PJ, Quattlebaum RG. Prevention of recurrent ischemic stroke. Am Fam Physician. 2007; 76(3):382-388.
- Fonarow GC, Smith EE, Saver JL, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation. 2011;123(7):750-758.
- Hacke W, Kaste M, Bluhmki E, Brozman M, et al. Thrombolysis with Alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317-1329.
- Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010;121:e91.
- Albers GW, Caplan LR, Easton JD, et al. Transient ischemic attack—proposal for a new definition. N Engl J Med. 2002;347(21):1713-1716.
- Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med. 2011;365:993-1003.
Stroke specialists like to say that “time is brain.” With an emphatic focus on those first few critical hours, however, it’s sometimes easy to overlook the vital role that hospitalists play in the days, weeks, and months that follow.
A recent study in The Neurohospitalist suggests that compared to community-based neurologists, practitioners of neurohospital medicine can reduce the length of stay for patients with ischemic stroke.1 A separate study, however, suggests that similar success might have come at a price for their less-specialized hospitalist counterparts.2 Among stroke patients, the latter study found that while the HM model is also associated with a reduced length of stay, it is associated with increased discharges to inpatient rehabilitation centers instead of to home, and higher readmission rates.
In sum, the evidence raises questions about whether rank-and-file hospitalists are adequately equipped to deal with a disease that is a core competency for the profession and ranks among the top sources of adult disability in the United States, at an estimated cost of $34.3 billion in 2008.3
“I think there’s been a mismatch between the training of the average hospitalist and then the expectations for the amount of neurological care they end up delivering once in practice,” says David Likosky, MD, SFHM, director of the stroke program at Evergreen Hospital Medical Center in Kirkland, Wash. “When surveyed, it’s been shown that hospitalists feel that care of stroke is one of the areas with which they’re least comfortable once they get out into practice.” Over the past decade, several studies have reinforced the notion of a training deficit.4,5
Demographic trends suggest that getting up to speed will be imperative, however. “One alarming thing we’re seeing is strokes among individuals that are not in the elderly group, and that group seems to be increasing at an alarming rate,” says Daniel T. Lackland, PhD, professor of epidemiology and neurosciences at the Medical University of South Carolina in Charleston. Hospitals are seeing more ischemic stroke patients in their 40s and 50s, likely a reflection of risk factors such as hypertension, diabetes, and hyperlipidemia that are occurring earlier in life. And because those patients are younger, the aftermath of a stroke could linger for decades.
Although the stroke mortality rate is declining in the U.S., statistics find that about 14% of all patients diagnosed with an initial stroke will have a second one within a year, placing continued strain on a healthcare system already stretched thin.6 Hospitalists, Dr. Lackland says, have an “ideal” opportunity to help build up and improve that system, potentially yielding significant cost savings along with the dramatic improvement in quality of life. Making the most of that opportunity, though, will require a solid understanding of multiple trends that are quickly transforming stroke care delivery.
Time Is of the Essence
Kevin Barrett, MD, MSc, assistant professor of neurology and stroke telemedicine director at the Mayo Clinic in Jacksonville, Fla., says hospitals are focusing more and more on a metric known as “door-to-needle time.” The goal is to treat at least half of incoming ischemic stroke patients with intravenous tissue-type plasminogen activator (IV tPA) within the first 60 minutes after onset of symptoms.
The American Heart Association/American Stroke Association has reinforced the message with its Get With the Guidelines Stroke Program. A recent analysis suggested the program has led to more timely tPA administration and, in turn, better patient outcomes (the program is funded in part through the Bristol-Myers Squib/Sanofi Pharmaceutical Partnership).7
At the same time, clinical research has widened the window for IV tPA delivery from three hours to 4.5 hours for certain patients after the onset of symptoms. Dr. Barrett says “strong evidence” from the European Cooperative Acute Stroke Study III has convinced most clinicians, and the FDA is expected to follow suit in officially approving the extension.8 As more stroke centers become certified, the use of IV tPA has increased accordingly.
Patients who have missed the time window or are not good candidates for IV tPA can still be aided by interarterial tPA at the site of the clot up to six hours after the onset of symptoms. Dr. Likosky says the treatment option should be of particular interest to hospitalists, given that strokes can occur post-operatively and in other patients who cannot receive IV tPA because of bleeding risk.
—Karim Godamunne, MD, MBA, SFHM, medical director, Eagle Hospital Physicians, Roswell, Ga.
For up to eight hours after the onset of symptoms, mechanical clot removal techniques have shown continued efficacy at revascularizing affected areas, with some newer options also offering greater promise of improving patient outcomes. Even with the prospects of declining complication rates, however, “evaluating and initiating treatment in a timely fashion is still going to be one of the most important predictors of outcome,” Dr. Barrett says.
After the initial intervention, hospitalists often are the go-to providers for anticipating and preventing common post-stroke complications, such as aspiration pneumonia, VTE from immobilization, and other infections. The proper use of anti-platelet agents and high-dose statins, also falling solidly within the HM realm, can pay big dividends if used consistently.
Meanwhile, newer studies and clinical observations are widening the scope of considerations that should be on every hospitalist’s radar. Here are a few cited by stroke experts:
Permissive hypertension. After an ischemic stroke, the benefit of permissive hypertension is still widely misunderstood. Perhaps counterintuitively, high blood pressure after a stroke can help protect the area of the brain that is damaged but not yet dead, sometimes called the penumbra. “I highlight this because I think it’s a common mistake, that internists are very used to high blood pressure being a bad thing,” says Andrew Josephson, MD, associate professor of clinical neurology and director of the neurohospitalist program at the University of California at San Francisco (UCSF) Medical Center. “And in general, it is; it’s a cause of stroke. But once somebody has a stroke, in the acute period, it’s important to allow the blood pressure to be high.”
Atrial fibrillation. The accepted role of atrial fibrillation in stroke is evolving. Research suggests that the common but often preventable arrhythmia is an important cause of stroke in about 15% to 20% of cases.9 By the time of hospital discharge, however, Dr. Josephson says physicians haven’t established a cause in about 1 in 4 cases. For these “cryptogenic strokes,” he says, doctors have long suspected that atrial fibrillation not picked up during the initial EKG or by the monitoring with cardiac telemetry could be a major cause.
Recent observations suggest that a longer monitoring period of up to 30 days may uncover atrial fibrillation in a sizable fraction of those patients, highlighting the importance of keeping a close eye on stroke patients both in the hospital and beyond. “It’s very important to identify, because atrial fibrillation changes what we do for folks to prevent a second stroke,” Dr. Josephson explains. Instead of anti-platelet medicine like aspirin, patients with atrial fibrillation often receive anticoagulants like warfarin, or the more recently approved dabigatran and rivaroxaban.
Transient ischemic attack. Improvements in imaging techniques like MRI have likewise begun to shift how stroke patients are treated. For example, Dr. Likosky says, medicine is moving away from a time-based definition of transient ischemic attack (TIA), in which symptoms resolve within 24 hours, to a tissue-based definition. Recent MRI imaging has uncovered evidence of a new infarction in more than half of patients initially diagnosed with TIA.10
“If they do have an infarction on their scan, even if they had symptoms that only lasted for five minutes, that’s a stroke,” Dr. Josephson says. And even a true TIA, he says, represents “a kind of stroke where you got really lucky and you’re not left with deficits, but the risk is still very high.” Accordingly, more patients with TIA are being admitted to the hospital to receive a full workup and preventive treatment. “We think that by evaluating these people urgently, we can reduce the risk of having a stroke by maybe 75% over a three-month time period,” Dr. Josephson says.
Hemorrhagic stroke. To date, the vast majority of patients with hemorrhagic stroke (which accounts for only 13% of all stroke cases) have been managed by neurosurgeons and neurologists. But here, too, Dr. Likosky says the picture could be changing. Recent findings that surgical treatment of intracranial hemorrhaging might not benefit many patients could shift the care paradigm toward a medical management strategy that involves more hospitalists.
Innovations Aplenty
The increasing complexity of stroke care and uneven distribution of resources and expertise have helped fuel several important innovations in delivery, most notably telestroke and neurohospital medicine. Both are being driven, in part, by an increased awareness of time-sensitive interventions and a frequent lack of on-site neurologists at smaller and more rural facilities. If telestroke programs are expanding the reach of neurologists, neurohospitalists are helping to fill the gaps in inpatient stroke care.
Amid the changes, one element is proving a necessary constant: a team approach that relies heavily on the HM emphasis on quality metrics, intensive monitoring, and careful coordination. Who better to lead the charge than hospitalists, says Mary E. Jensen, MD, professor of radiology and neurosurgery at the University of Virginia in Charlottesville. “They’re the ones who are in the hospital, and when these patients go bad, they go bad fast,” she says.
More broadly, Dr. Jensen says, hospitalists should get in on the ground floor when their facility seeks certification as a primary or a comprehensive stroke center. “And they need to make sure that the hospital isn’t just trying to get the sexy elements—the guy with the cath or the gal with the cath who can pull the clot out—but that they have a complete program that involves the care of the patient after they’ve had the procedure done,” she says.
As healthcare reform efforts are making clear, the responsibility doesn’t end after discharge, either. The Affordable Care Act includes a hospital readmission reduction program that will kick in this October, with penalties for hospitals posting unacceptably high 30-day readmission rates. Amy Kind, MD, PhD, assistant professor of medicine in the Division of Geriatrics at the University of Wisconsin School of Medicine and Public Health in Madison, is convinced that a key contributor to high rehospitalization rates among stroke patients may be the woefully incomplete nature of discharge communication.
—Mary E. Jensen, MD, professor of radiology and neurosurgery, University of Virginia, Charlottesville
Dr. Kind, for example, has found a disturbing pattern in communication regarding issues like dysphagia, a common complication among stroke patients and an important risk factor for pneumonia. Countering the risk usually requires such measures as putting patients on a special diet or elevating the head of their bed. “We looked at the quality of the communication of that information in discharge summaries, and it’s just abysmal. It’s absolutely abysmal,” she says. Without clear directives to providers in the next setting of care, such as a skilled-nursing facility, patients could be erroneously put back on a regular diet and aspirate, sending them right back to the hospital.
As one potential solution, Dr. Kind’s team is developing a multidisciplinary stroke discharge summary tool that automatically imports elements like speech-language pathology and dietary recommendations. Although most discharge communication may focus on more visible issues and interventions, Dr. Kind argues that some of the “bread and butter” concerns might ultimately prove just as important for long-term patient outcomes.
Karim Godamunne, MD, MBA, SFHM, vice president of clinical systems integration and medical director of Eagle Hospital Physicians in Atlanta, sees telemedicine as another potential tool to help reach patients after discharge, especially those who haven’t received follow-up care from a primary-care physician (PCP). “We need to be the champions at our hospitals for improving care processes, and we need to work in partnership with the nurses and the other professionals,” Dr. Godamunne says. “As a group, we can really make a difference, and stroke is one of those areas in which we can truly contribute.”
Bryn Nelson is a freelance medical writer in Seattle.
References
- Freeman WD, Dawson SB, Raper C, Thiemann K, et al. Neurohospitalists reduce length of stay for patients with ischemic stroke. The Neurohospitalist. 2011;1(2): 67-70.
- Howrey BT, Kuo Y-F, Goodwin JS. Association of care by hospitalists on discharge destination and 30-day outcomes after acute ischemic stroke. Medical Care. 2011;49(8): 701-707.
- Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2-e220.
- Glasheen JJ, Epstein KR, Siegal E, Kutner JS, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
- Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001; 111(3):247-254.
- Dickerson LM, Carek PJ, Quattlebaum RG. Prevention of recurrent ischemic stroke. Am Fam Physician. 2007; 76(3):382-388.
- Fonarow GC, Smith EE, Saver JL, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation. 2011;123(7):750-758.
- Hacke W, Kaste M, Bluhmki E, Brozman M, et al. Thrombolysis with Alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317-1329.
- Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010;121:e91.
- Albers GW, Caplan LR, Easton JD, et al. Transient ischemic attack—proposal for a new definition. N Engl J Med. 2002;347(21):1713-1716.
- Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med. 2011;365:993-1003.
Is Hospitalist Proficiency in Bedside Procedures in Decline?
It’s 3:30 p.m. You’ve seen your old patients, holdovers, and an admission, but you haven’t finished your notes yet. Lunch was an afterthought between emails about schedule changes for the upcoming year. Two pages ring happily from your belt, the first from you-know-who in the ED, and the next from a nurse: “THORA SUPPLIES AT BEDSIDE SINCE THIS AM—WHEN WILL THIS HAPPEN?” The phone number on the wall for the on-call radiologist beckons...
An all-too-familiar situation for hospitalists across the country, this awkward moment raises a series of difficult questions:
Should I set aside time from my day to perform a procedure that could be time-consuming?
- Do I feel confident I can perform this procedure safely?
- Am I really the best physician to provide this service?
- As hospitalists are tasked with an ever-increasing array of responsibilities, answering the call of duty for bedside procedures is becoming more difficult for some.
A Core Competency
“The Core Competencies in Hospital Medicine,” authored by a group of HM thought leaders, was published as a supplement to the January/February 2006 issue of the Journal of Hospital Medicine. The core competencies include such bedside procedures as arthrocentesis, paracentesis, thoracentesis, lumbar puncture, and vascular (arterial and central venous) access (see “Core Competencies in Hospital Medicine: Procedures,” below). Although the authors stressed that the core competencies are to be viewed as a resource rather than as a set of requirements, the inclusion of bedside procedures emphasized the importance of procedural skills for future hospitalists.
“[Hospitalists] are in a perfect spot to continue to perform procedures in a structured manner,” says Joshua Lenchus, DO, RPh, FACP, FHM, associate director of the University of Miami-Jackson Memorial Hospital (UM-JMH) Center for Patient Safety. “As agents of quality and safety, hospitalists should continue to perform this clinically necessary service.”
Jeffrey Barsuk, MD, FHM, associate professor of medicine at Northwestern Feinberg School of Medicine in Chicago and an academic hospitalist at Northwestern Memorial Hospital (NMH), not only agrees that bedside procedures should be a core competency, but he also says hospitalists are the most appropriate providers of these services.
“I think this is part of hospital medicine. We’re in the hospital, [and] that’s what we do,” Dr. Barsuk says. Other providers, such as interventional radiologists, “really don’t understand why I’m doing [a procedure]. They understand it’s safe to do it, but they might not understand all the indications for it, and they certainly don’t understand the interpretation of the tests they’re sending.”
Despite the goals set forth by the core competencies and authorities in procedural safety, the reality of who actually performs bedside procedures is somewhat murky and varies greatly by institution. Many point to HM program setting (urban vs. rural) or structure (academic vs. community) to explain variance, but often it is other factors that determine whether hospitalists are actually preforming bedside procedures regularly.
Where Does HM Perform Procedures?
Community hospitalists, with strong support from interventional radiologists and subspecialists, often find it more efficient—even necessary, considering their patient volumes—to leave procedures to others. Community hospitalists with ICU admitting privileges, intensivists, and other HM subgroups say that being able to perform procedures should be a prerequisite for employment. Hospitalists in rural communities say they are doing procedures because they are “the only game in town.”
“Sometimes you are the only one available, and you are called upon to stretch your abilities,” says Beatrice Szantyr, MD, FAAP, a community hospitalist and pediatrician in Lincoln, Maine, who has practiced most of her career in rural settings.
Academic hospitalists in large, research-based HM programs can, paradoxically, find themselves performing fewer procedures as residents often take the lead on the majority of such cases. Conversely, academic hospitalists in large, nonteaching programs often find themselves called on to perform more bedside procedures.
No matter the setting, the simplicity of being the physician to recognize the need for a procedure, perform it, and interpret the results is undeniably efficient and “clean,” according to authorities on inpatient bedside procedures. Having to consult other physicians, optimize the patient’s lab values to their standards (a common issue with interventional radiologists), and adhere to their work schedules can often delay procedures unnecessarily.
—Joshua Lenchus, DO, RPh, FACP, FHM, associate director, University of Miami-Jackson Memorial Hospital (UM-JMH) Center for Patient Safety
“Hospitalists care for floor and ICU patients in many hospitals, and the inability to perform bedside procedures delays patient care,” says Dr. Nilam Soni, an academic hospitalist at the University of Chicago and a recognized expert on procedural safety.
Dr. Soni notes that when it comes to current techniques, many hospitalists suffer from a knowledge deficit. “The introduction of ultrasound for guidance of bedside procedures has been shown to improve the success and safety of certain procedures,” he says, “but the majority of practicing hospitalists did not learn how to use ultrasound for procedure guidance during residency.”
Heterogeneity of Training, Experience, and Skill
While all hospitalists draw upon different bases of training and experience, the heterogeneity of training, confidence, and inherent skill is greatest when it comes to bedside procedures. Mirroring the heterogeneity at the individual level, hospitalist programs vary greatly on the requirements placed on their staffs in regards to procedural skill and privileging.
Such research-driven programs as Brigham and Women’s Hospital (BWH) in Boston often find requiring maintenance of privileges in bedside procedures to be difficult, says Sally Wang, MD, FHM, director of procedural education at BWH. In fact, a new procedure service being created there will be staffed mainly with ED physicians. On the flipside, most community hospitalist programs leave the task of procedural “policing” to the hospital’s medical staff affairs office.
At the University of California at San Diego (UCSD) Medical Center, the HM group is instituting a division standard in which hospitalists maintain privileging and proficiency in a core group of bedside procedures. Other large hospitalist groups have created “proceduralist” subgroups that shoulder the burden of trainee education, as well as provide a resource for less skilled or less experienced inpatient providers.
“If you have a big group, you could have a dedicated procedure service and have a core group of hospitalists who are experts in procedure,” Dr. Barsuk says. “But it needs to be self-sustaining.” Once started, Dr. Barsuk says, proceduralist groups would continue to provide hospitals with ongoing return-on-investment (ROI) benefit.
Variability in procedure volume and payor mix, however, can make it hard for HM groups to demonstrate to hospital leadership a satisfactory ROI for a proceduralist program. Financial backing from grant support or a high-volume procedure—such as paracentesis in hospitals with large hepatology programs—can nurture starting proceduralist programs until all procedural revenues can justify the costs. Lower ROI can also be justified by showing improvement in quality indices—such as CLABSI rates—reduced time to procedures, and reduced costs compared to other subspecialists offering similar services.
“I’m of the firm belief that we can reduce costs by doing the procedures at the bedside rather than referring them to departments such as interventional radiology (IR),” Dr. Barsuk says. “What you would have to do is show the institution that it costs more money to have IR do [bedside procedures].”
National Response
—Jeffrey Barsuk, MD, MS, FHM, associate professor of medicine, Northwestern Feinberg School of Medicine, academic hospitalist, Northwestern Memorial Hospital, Chicago
Filling in the procedural training gaps found on the local level, such national organizations as SHM have stepped in to provide education and support for hospitalists yearning for training. Since its inception, an SHM annual meeting pre-course that focuses on hand-held ultrasound and invasive procedures has consistently been one of the first to sell out. Other national organizations, such as ACP and its annual meeting, have seen similar interest in their courses on ultrasound-guided procedures.
The popularity of this continuing education bears out a worrisome trend: Hospitalists feel they are losing their procedural skills. An online survey conducted by The Hospitalist in May 2011 found that a majority of respondents (62%) had experienced deterioration of their procedural skills in the past five years; only 25% said they experienced improvement over the same period.
Historically, general internists have claimed bedside procedures as their domain. As stated dispassionately in the 1978 book The House of God, “There is no body cavity that cannot be reached with a #14G needle and a good strong arm.”1 Yet much has changed since Samuel Shem’s apocryphal description of medical residency training.
Most notably, the Accreditation Council of Graduate Medical Education (ACGME) has not only progressively restricted inpatient hours and patient loads for residents, but also increased the requirements for outpatient training. Some feel the balance of inpatient and outpatient training has tipped too far toward the latter in medicine residency programs, especially in light of the growing popularity of the hospitalist career path amongst new residency program graduates. This stands in contrast to ED training programs, which have embraced focused procedures training more readily.
“Adult care appears to be diverging into two career tacks as a result of external forces, of which we have limited control over, “ says Michael Beck, MD, a pediatric and adult hospitalist at Milton S. Hershey Medical Center in Hershey, Pa. “With new career choices emerging for graduates, the same square-peg, round-hole residency training should not exist.”
Dr. Beck advocates continuing an ongoing trend of “track” creation in residency programs, which allow trainees to focus training on their planned career path. Hospitalist tracks already exist in many medicine programs, including those at Cleveland Clinic and Northwestern. But many other factors limit the opportunity for trainees to obtain experience with bedside procedures, including competition with nurse practitioners and physician assistants. Even the increasing availability of ancillary phlebotomy and IV-start teams can increase a resident’s anxiety about procedures.
“By the time my residency was over [in 1993] and the work restrictions were beginning, hospital employees were doing all these tasks, making the residents less comfortable with hurting a patient when it was therapeutically necessary,” says Katharine Deiss, MD, assistant clinical professor of medicine at the University of Rochester Medical Center in New York. Interns who came from medical schools without extensive ancillary services in their teaching hospitals, she adds, were more comfortable with invasive procedures.
ACGME has sent a subtle message by decreasing emphasis on procedural skills by eradicating the requirement of showing manual proficiency in most bedside procedures as a requirement for certification. The omission has left individual residency programs and hospitalist groups to determine training and proficiency requirements for more invasive bedside procedures without a national standard.
In an editorial in the March 2007 issue of the Annals of Internal Medicine, F. Daniel Duffy, MD, and Eric Holmboe, MD, wrote that the American Board of Internal Medicine (ABIM) could only give a “qualified ‘yes’” to the question of whether residents should be trained in procedures they may not perform in practice. Although the authors asserted that the relaxed ABIM policy was “an important but small step toward revamping procedure skill training during residency,” others say it portrays an image of the ABIM de-emphasizing the importance of procedural training.
In addition, the recently established Focused Practice in Hospital Medicine (FPHM) pathway to ABIM Maintenance of Certification (MOC) has no requirement to show proficiency in bedside procedures.
“The absence of the procedural requirement in no way constitutes a statement that procedural skills are not important,” says Jeff Wiese, MD, FACP, SFHM, associate professor of medicine and residency program director at Tulane University Health Sciences Center in New Orleans, chair of the ABIM Hospital Medicine MOC Question Writing Committee, and former SHM president. “Rather, it is merely a practical issue with respect to making the MOC process applicable to all physicians engaged in hospital medicine (i.e. many hospitalists do not do procedures) while still making the MOC focused on the skill sets that are common for physicians doing hospital medicine.”
Once released into the world, even if trained well in residency, hospitalists can find it difficult to maintain their skills. In community and nonteaching settings, the pressure to admit and discharge in a timely manner can make procedures seem like the easiest corner to cut. Before long, it has been months since they have laid eyes on a needle of any sort. Many begin to develop performance anxiety.
In teaching hospitals, academic hospitalists often are called upon to participate in quality improvement (QI) and research efforts, which take time away from clinical rotations. Once there, it can be easy for a ward attending to rely upon a well-trained resident to supervise interns doing procedures. The lack of first-hand or even supervisory experience can lead to many academic hospitalists losing facility with procedures, with potentially disastrous results.
“In order to supervise a group of residents, the attending needs to be technically proficient and able to salvage a botched, or failed, procedure,” UM-JMH’s Dr. Lenchus says. “To this end, we strictly limit who can attend on the service.”
So what’s a residency or HM program director to do in the face of wavering support nationally, and sometimes locally, for maintaining procedural skills for hospitalists and trainees? Many hospitalists in teaching hospitals say it’s critical for clinicians to “get their own house in order,” to maintain procedural standards of proficiency with ongoing training, education, and verification.
“The profession now needs to redesign procedural training across the continuum of education and a lifetime of practice,” Drs. Duffy and Holmboe editorialized in the March 2007 Annals paper. “This approach would recognize the varied settings of internal-medicine practice and offer manual skills training to those whose practice settings require such skills.” Hospitalists can partner with medicine residency program leaders to provide procedural education and training to residents, either as a standalone elective or as a more general resource.
Hospitalists in such teaching hospitals as UCSD, Brigham and Women’s, UM-JMH, and Northwestern are leading efforts to provide procedural education to medical students, residents, and attendings. Training takes many forms, including formal procedural electives, required procedure rotations, or even brief one- or two-day courses in procedural skills at a simulation center.
Utilizing simulation training has been shown in many studies to be helpful in establishing procedural skills in learners of all training levels. Dr. Barsuk and his colleagues at Northwestern published studies in the Journal of Hospital Medicine in 2008 and 2009 showing that simulation training of residents was effective in improving skills in thoracentesis and central venous catheterization, respectively.3,4
In the community hospital setting, requirements for procedural skills can vary greatly based on the institution. For those community programs requiring procedural skills of their hospitalists, the clear definition of procedural training and requirements at the time of hiring is critical. Even after vetting a hospitalist’s procedural skills at hire, however, community programs should consider monitoring procedural skills and provide ongoing time and money for CME focused on procedural skills.
Currently, most hospitals depend on the honesty of individual physicians during the privileging process for bedside procedures. Even when the skills of physicians begin to wane, most are reluctant to voluntarily give up their procedure privileges.
“I think it would be pretty unusual for a hospitalist to relinquish their privileges,” Dr. Barsuk admits. But ideally, physicians who relinquish their privileges due to lack of experience could get retrained in simulation centers, then reproctored in order to regain their privileges. Northwestern established the Center for Simulation Technology and Immersive Learning as a resource for simulation training both locally and nationally.
Establishing an environment that supports hospitalists performing bedside procedures is critical. This includes the need to limit hospitalist workload to ensure adequate time to meet the procedural needs of patients. Providing easy access to the tools necessary to perform bedside procedures (e.g. portable ultrasound and pre-packaged procedure trays) helps avoid additional hurdles.
Academic hospitalist programs can serve as a regional resource by developing ongoing procedure mastery programs for hospitalists in their communities, as many smaller institutions do not have the resources to provide ongoing training in bedside procedures. This process can be tedious, but it should not be humiliating.
If the popularity of the SHM pre-course in bedside ultrasound and procedures is any indication, when given the opportunity to receive protected time for procedure training, most hospitalists will likely jump at the chance.
Dr. Chang is an associate clinical professor of medicine in the division of hospital medicine at Diego Medical Center. He is also a member of Team Hospitalist.
References
- Shem S. The House of God. New York: Dell Publishing; 1978.
- Duffy FD, Holmboe ES. What procedures should internists do? Ann Intern Med. 2007;146(5):392-393.
- Wayne DB, Barsuk JH, O’Leary KJ, Fudala MJ, McGaghie WC. Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. J Hosp Med. 2008;3(1):48-54.
- Barsuk JH, McGaghie WC, Cohen ER, Balachandran JS, Wayne DB. Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. J Hosp Med. 2009;4(7):397–403.
It’s 3:30 p.m. You’ve seen your old patients, holdovers, and an admission, but you haven’t finished your notes yet. Lunch was an afterthought between emails about schedule changes for the upcoming year. Two pages ring happily from your belt, the first from you-know-who in the ED, and the next from a nurse: “THORA SUPPLIES AT BEDSIDE SINCE THIS AM—WHEN WILL THIS HAPPEN?” The phone number on the wall for the on-call radiologist beckons...
An all-too-familiar situation for hospitalists across the country, this awkward moment raises a series of difficult questions:
Should I set aside time from my day to perform a procedure that could be time-consuming?
- Do I feel confident I can perform this procedure safely?
- Am I really the best physician to provide this service?
- As hospitalists are tasked with an ever-increasing array of responsibilities, answering the call of duty for bedside procedures is becoming more difficult for some.
A Core Competency
“The Core Competencies in Hospital Medicine,” authored by a group of HM thought leaders, was published as a supplement to the January/February 2006 issue of the Journal of Hospital Medicine. The core competencies include such bedside procedures as arthrocentesis, paracentesis, thoracentesis, lumbar puncture, and vascular (arterial and central venous) access (see “Core Competencies in Hospital Medicine: Procedures,” below). Although the authors stressed that the core competencies are to be viewed as a resource rather than as a set of requirements, the inclusion of bedside procedures emphasized the importance of procedural skills for future hospitalists.
“[Hospitalists] are in a perfect spot to continue to perform procedures in a structured manner,” says Joshua Lenchus, DO, RPh, FACP, FHM, associate director of the University of Miami-Jackson Memorial Hospital (UM-JMH) Center for Patient Safety. “As agents of quality and safety, hospitalists should continue to perform this clinically necessary service.”
Jeffrey Barsuk, MD, FHM, associate professor of medicine at Northwestern Feinberg School of Medicine in Chicago and an academic hospitalist at Northwestern Memorial Hospital (NMH), not only agrees that bedside procedures should be a core competency, but he also says hospitalists are the most appropriate providers of these services.
“I think this is part of hospital medicine. We’re in the hospital, [and] that’s what we do,” Dr. Barsuk says. Other providers, such as interventional radiologists, “really don’t understand why I’m doing [a procedure]. They understand it’s safe to do it, but they might not understand all the indications for it, and they certainly don’t understand the interpretation of the tests they’re sending.”
Despite the goals set forth by the core competencies and authorities in procedural safety, the reality of who actually performs bedside procedures is somewhat murky and varies greatly by institution. Many point to HM program setting (urban vs. rural) or structure (academic vs. community) to explain variance, but often it is other factors that determine whether hospitalists are actually preforming bedside procedures regularly.
Where Does HM Perform Procedures?
Community hospitalists, with strong support from interventional radiologists and subspecialists, often find it more efficient—even necessary, considering their patient volumes—to leave procedures to others. Community hospitalists with ICU admitting privileges, intensivists, and other HM subgroups say that being able to perform procedures should be a prerequisite for employment. Hospitalists in rural communities say they are doing procedures because they are “the only game in town.”
“Sometimes you are the only one available, and you are called upon to stretch your abilities,” says Beatrice Szantyr, MD, FAAP, a community hospitalist and pediatrician in Lincoln, Maine, who has practiced most of her career in rural settings.
Academic hospitalists in large, research-based HM programs can, paradoxically, find themselves performing fewer procedures as residents often take the lead on the majority of such cases. Conversely, academic hospitalists in large, nonteaching programs often find themselves called on to perform more bedside procedures.
No matter the setting, the simplicity of being the physician to recognize the need for a procedure, perform it, and interpret the results is undeniably efficient and “clean,” according to authorities on inpatient bedside procedures. Having to consult other physicians, optimize the patient’s lab values to their standards (a common issue with interventional radiologists), and adhere to their work schedules can often delay procedures unnecessarily.
—Joshua Lenchus, DO, RPh, FACP, FHM, associate director, University of Miami-Jackson Memorial Hospital (UM-JMH) Center for Patient Safety
“Hospitalists care for floor and ICU patients in many hospitals, and the inability to perform bedside procedures delays patient care,” says Dr. Nilam Soni, an academic hospitalist at the University of Chicago and a recognized expert on procedural safety.
Dr. Soni notes that when it comes to current techniques, many hospitalists suffer from a knowledge deficit. “The introduction of ultrasound for guidance of bedside procedures has been shown to improve the success and safety of certain procedures,” he says, “but the majority of practicing hospitalists did not learn how to use ultrasound for procedure guidance during residency.”
Heterogeneity of Training, Experience, and Skill
While all hospitalists draw upon different bases of training and experience, the heterogeneity of training, confidence, and inherent skill is greatest when it comes to bedside procedures. Mirroring the heterogeneity at the individual level, hospitalist programs vary greatly on the requirements placed on their staffs in regards to procedural skill and privileging.
Such research-driven programs as Brigham and Women’s Hospital (BWH) in Boston often find requiring maintenance of privileges in bedside procedures to be difficult, says Sally Wang, MD, FHM, director of procedural education at BWH. In fact, a new procedure service being created there will be staffed mainly with ED physicians. On the flipside, most community hospitalist programs leave the task of procedural “policing” to the hospital’s medical staff affairs office.
At the University of California at San Diego (UCSD) Medical Center, the HM group is instituting a division standard in which hospitalists maintain privileging and proficiency in a core group of bedside procedures. Other large hospitalist groups have created “proceduralist” subgroups that shoulder the burden of trainee education, as well as provide a resource for less skilled or less experienced inpatient providers.
“If you have a big group, you could have a dedicated procedure service and have a core group of hospitalists who are experts in procedure,” Dr. Barsuk says. “But it needs to be self-sustaining.” Once started, Dr. Barsuk says, proceduralist groups would continue to provide hospitals with ongoing return-on-investment (ROI) benefit.
Variability in procedure volume and payor mix, however, can make it hard for HM groups to demonstrate to hospital leadership a satisfactory ROI for a proceduralist program. Financial backing from grant support or a high-volume procedure—such as paracentesis in hospitals with large hepatology programs—can nurture starting proceduralist programs until all procedural revenues can justify the costs. Lower ROI can also be justified by showing improvement in quality indices—such as CLABSI rates—reduced time to procedures, and reduced costs compared to other subspecialists offering similar services.
“I’m of the firm belief that we can reduce costs by doing the procedures at the bedside rather than referring them to departments such as interventional radiology (IR),” Dr. Barsuk says. “What you would have to do is show the institution that it costs more money to have IR do [bedside procedures].”
National Response
—Jeffrey Barsuk, MD, MS, FHM, associate professor of medicine, Northwestern Feinberg School of Medicine, academic hospitalist, Northwestern Memorial Hospital, Chicago
Filling in the procedural training gaps found on the local level, such national organizations as SHM have stepped in to provide education and support for hospitalists yearning for training. Since its inception, an SHM annual meeting pre-course that focuses on hand-held ultrasound and invasive procedures has consistently been one of the first to sell out. Other national organizations, such as ACP and its annual meeting, have seen similar interest in their courses on ultrasound-guided procedures.
The popularity of this continuing education bears out a worrisome trend: Hospitalists feel they are losing their procedural skills. An online survey conducted by The Hospitalist in May 2011 found that a majority of respondents (62%) had experienced deterioration of their procedural skills in the past five years; only 25% said they experienced improvement over the same period.
Historically, general internists have claimed bedside procedures as their domain. As stated dispassionately in the 1978 book The House of God, “There is no body cavity that cannot be reached with a #14G needle and a good strong arm.”1 Yet much has changed since Samuel Shem’s apocryphal description of medical residency training.
Most notably, the Accreditation Council of Graduate Medical Education (ACGME) has not only progressively restricted inpatient hours and patient loads for residents, but also increased the requirements for outpatient training. Some feel the balance of inpatient and outpatient training has tipped too far toward the latter in medicine residency programs, especially in light of the growing popularity of the hospitalist career path amongst new residency program graduates. This stands in contrast to ED training programs, which have embraced focused procedures training more readily.
“Adult care appears to be diverging into two career tacks as a result of external forces, of which we have limited control over, “ says Michael Beck, MD, a pediatric and adult hospitalist at Milton S. Hershey Medical Center in Hershey, Pa. “With new career choices emerging for graduates, the same square-peg, round-hole residency training should not exist.”
Dr. Beck advocates continuing an ongoing trend of “track” creation in residency programs, which allow trainees to focus training on their planned career path. Hospitalist tracks already exist in many medicine programs, including those at Cleveland Clinic and Northwestern. But many other factors limit the opportunity for trainees to obtain experience with bedside procedures, including competition with nurse practitioners and physician assistants. Even the increasing availability of ancillary phlebotomy and IV-start teams can increase a resident’s anxiety about procedures.
“By the time my residency was over [in 1993] and the work restrictions were beginning, hospital employees were doing all these tasks, making the residents less comfortable with hurting a patient when it was therapeutically necessary,” says Katharine Deiss, MD, assistant clinical professor of medicine at the University of Rochester Medical Center in New York. Interns who came from medical schools without extensive ancillary services in their teaching hospitals, she adds, were more comfortable with invasive procedures.
ACGME has sent a subtle message by decreasing emphasis on procedural skills by eradicating the requirement of showing manual proficiency in most bedside procedures as a requirement for certification. The omission has left individual residency programs and hospitalist groups to determine training and proficiency requirements for more invasive bedside procedures without a national standard.
In an editorial in the March 2007 issue of the Annals of Internal Medicine, F. Daniel Duffy, MD, and Eric Holmboe, MD, wrote that the American Board of Internal Medicine (ABIM) could only give a “qualified ‘yes’” to the question of whether residents should be trained in procedures they may not perform in practice. Although the authors asserted that the relaxed ABIM policy was “an important but small step toward revamping procedure skill training during residency,” others say it portrays an image of the ABIM de-emphasizing the importance of procedural training.
In addition, the recently established Focused Practice in Hospital Medicine (FPHM) pathway to ABIM Maintenance of Certification (MOC) has no requirement to show proficiency in bedside procedures.
“The absence of the procedural requirement in no way constitutes a statement that procedural skills are not important,” says Jeff Wiese, MD, FACP, SFHM, associate professor of medicine and residency program director at Tulane University Health Sciences Center in New Orleans, chair of the ABIM Hospital Medicine MOC Question Writing Committee, and former SHM president. “Rather, it is merely a practical issue with respect to making the MOC process applicable to all physicians engaged in hospital medicine (i.e. many hospitalists do not do procedures) while still making the MOC focused on the skill sets that are common for physicians doing hospital medicine.”
Once released into the world, even if trained well in residency, hospitalists can find it difficult to maintain their skills. In community and nonteaching settings, the pressure to admit and discharge in a timely manner can make procedures seem like the easiest corner to cut. Before long, it has been months since they have laid eyes on a needle of any sort. Many begin to develop performance anxiety.
In teaching hospitals, academic hospitalists often are called upon to participate in quality improvement (QI) and research efforts, which take time away from clinical rotations. Once there, it can be easy for a ward attending to rely upon a well-trained resident to supervise interns doing procedures. The lack of first-hand or even supervisory experience can lead to many academic hospitalists losing facility with procedures, with potentially disastrous results.
“In order to supervise a group of residents, the attending needs to be technically proficient and able to salvage a botched, or failed, procedure,” UM-JMH’s Dr. Lenchus says. “To this end, we strictly limit who can attend on the service.”
So what’s a residency or HM program director to do in the face of wavering support nationally, and sometimes locally, for maintaining procedural skills for hospitalists and trainees? Many hospitalists in teaching hospitals say it’s critical for clinicians to “get their own house in order,” to maintain procedural standards of proficiency with ongoing training, education, and verification.
“The profession now needs to redesign procedural training across the continuum of education and a lifetime of practice,” Drs. Duffy and Holmboe editorialized in the March 2007 Annals paper. “This approach would recognize the varied settings of internal-medicine practice and offer manual skills training to those whose practice settings require such skills.” Hospitalists can partner with medicine residency program leaders to provide procedural education and training to residents, either as a standalone elective or as a more general resource.
Hospitalists in such teaching hospitals as UCSD, Brigham and Women’s, UM-JMH, and Northwestern are leading efforts to provide procedural education to medical students, residents, and attendings. Training takes many forms, including formal procedural electives, required procedure rotations, or even brief one- or two-day courses in procedural skills at a simulation center.
Utilizing simulation training has been shown in many studies to be helpful in establishing procedural skills in learners of all training levels. Dr. Barsuk and his colleagues at Northwestern published studies in the Journal of Hospital Medicine in 2008 and 2009 showing that simulation training of residents was effective in improving skills in thoracentesis and central venous catheterization, respectively.3,4
In the community hospital setting, requirements for procedural skills can vary greatly based on the institution. For those community programs requiring procedural skills of their hospitalists, the clear definition of procedural training and requirements at the time of hiring is critical. Even after vetting a hospitalist’s procedural skills at hire, however, community programs should consider monitoring procedural skills and provide ongoing time and money for CME focused on procedural skills.
Currently, most hospitals depend on the honesty of individual physicians during the privileging process for bedside procedures. Even when the skills of physicians begin to wane, most are reluctant to voluntarily give up their procedure privileges.
“I think it would be pretty unusual for a hospitalist to relinquish their privileges,” Dr. Barsuk admits. But ideally, physicians who relinquish their privileges due to lack of experience could get retrained in simulation centers, then reproctored in order to regain their privileges. Northwestern established the Center for Simulation Technology and Immersive Learning as a resource for simulation training both locally and nationally.
Establishing an environment that supports hospitalists performing bedside procedures is critical. This includes the need to limit hospitalist workload to ensure adequate time to meet the procedural needs of patients. Providing easy access to the tools necessary to perform bedside procedures (e.g. portable ultrasound and pre-packaged procedure trays) helps avoid additional hurdles.
Academic hospitalist programs can serve as a regional resource by developing ongoing procedure mastery programs for hospitalists in their communities, as many smaller institutions do not have the resources to provide ongoing training in bedside procedures. This process can be tedious, but it should not be humiliating.
If the popularity of the SHM pre-course in bedside ultrasound and procedures is any indication, when given the opportunity to receive protected time for procedure training, most hospitalists will likely jump at the chance.
Dr. Chang is an associate clinical professor of medicine in the division of hospital medicine at Diego Medical Center. He is also a member of Team Hospitalist.
References
- Shem S. The House of God. New York: Dell Publishing; 1978.
- Duffy FD, Holmboe ES. What procedures should internists do? Ann Intern Med. 2007;146(5):392-393.
- Wayne DB, Barsuk JH, O’Leary KJ, Fudala MJ, McGaghie WC. Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. J Hosp Med. 2008;3(1):48-54.
- Barsuk JH, McGaghie WC, Cohen ER, Balachandran JS, Wayne DB. Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. J Hosp Med. 2009;4(7):397–403.
It’s 3:30 p.m. You’ve seen your old patients, holdovers, and an admission, but you haven’t finished your notes yet. Lunch was an afterthought between emails about schedule changes for the upcoming year. Two pages ring happily from your belt, the first from you-know-who in the ED, and the next from a nurse: “THORA SUPPLIES AT BEDSIDE SINCE THIS AM—WHEN WILL THIS HAPPEN?” The phone number on the wall for the on-call radiologist beckons...
An all-too-familiar situation for hospitalists across the country, this awkward moment raises a series of difficult questions:
Should I set aside time from my day to perform a procedure that could be time-consuming?
- Do I feel confident I can perform this procedure safely?
- Am I really the best physician to provide this service?
- As hospitalists are tasked with an ever-increasing array of responsibilities, answering the call of duty for bedside procedures is becoming more difficult for some.
A Core Competency
“The Core Competencies in Hospital Medicine,” authored by a group of HM thought leaders, was published as a supplement to the January/February 2006 issue of the Journal of Hospital Medicine. The core competencies include such bedside procedures as arthrocentesis, paracentesis, thoracentesis, lumbar puncture, and vascular (arterial and central venous) access (see “Core Competencies in Hospital Medicine: Procedures,” below). Although the authors stressed that the core competencies are to be viewed as a resource rather than as a set of requirements, the inclusion of bedside procedures emphasized the importance of procedural skills for future hospitalists.
“[Hospitalists] are in a perfect spot to continue to perform procedures in a structured manner,” says Joshua Lenchus, DO, RPh, FACP, FHM, associate director of the University of Miami-Jackson Memorial Hospital (UM-JMH) Center for Patient Safety. “As agents of quality and safety, hospitalists should continue to perform this clinically necessary service.”
Jeffrey Barsuk, MD, FHM, associate professor of medicine at Northwestern Feinberg School of Medicine in Chicago and an academic hospitalist at Northwestern Memorial Hospital (NMH), not only agrees that bedside procedures should be a core competency, but he also says hospitalists are the most appropriate providers of these services.
“I think this is part of hospital medicine. We’re in the hospital, [and] that’s what we do,” Dr. Barsuk says. Other providers, such as interventional radiologists, “really don’t understand why I’m doing [a procedure]. They understand it’s safe to do it, but they might not understand all the indications for it, and they certainly don’t understand the interpretation of the tests they’re sending.”
Despite the goals set forth by the core competencies and authorities in procedural safety, the reality of who actually performs bedside procedures is somewhat murky and varies greatly by institution. Many point to HM program setting (urban vs. rural) or structure (academic vs. community) to explain variance, but often it is other factors that determine whether hospitalists are actually preforming bedside procedures regularly.
Where Does HM Perform Procedures?
Community hospitalists, with strong support from interventional radiologists and subspecialists, often find it more efficient—even necessary, considering their patient volumes—to leave procedures to others. Community hospitalists with ICU admitting privileges, intensivists, and other HM subgroups say that being able to perform procedures should be a prerequisite for employment. Hospitalists in rural communities say they are doing procedures because they are “the only game in town.”
“Sometimes you are the only one available, and you are called upon to stretch your abilities,” says Beatrice Szantyr, MD, FAAP, a community hospitalist and pediatrician in Lincoln, Maine, who has practiced most of her career in rural settings.
Academic hospitalists in large, research-based HM programs can, paradoxically, find themselves performing fewer procedures as residents often take the lead on the majority of such cases. Conversely, academic hospitalists in large, nonteaching programs often find themselves called on to perform more bedside procedures.
No matter the setting, the simplicity of being the physician to recognize the need for a procedure, perform it, and interpret the results is undeniably efficient and “clean,” according to authorities on inpatient bedside procedures. Having to consult other physicians, optimize the patient’s lab values to their standards (a common issue with interventional radiologists), and adhere to their work schedules can often delay procedures unnecessarily.
—Joshua Lenchus, DO, RPh, FACP, FHM, associate director, University of Miami-Jackson Memorial Hospital (UM-JMH) Center for Patient Safety
“Hospitalists care for floor and ICU patients in many hospitals, and the inability to perform bedside procedures delays patient care,” says Dr. Nilam Soni, an academic hospitalist at the University of Chicago and a recognized expert on procedural safety.
Dr. Soni notes that when it comes to current techniques, many hospitalists suffer from a knowledge deficit. “The introduction of ultrasound for guidance of bedside procedures has been shown to improve the success and safety of certain procedures,” he says, “but the majority of practicing hospitalists did not learn how to use ultrasound for procedure guidance during residency.”
Heterogeneity of Training, Experience, and Skill
While all hospitalists draw upon different bases of training and experience, the heterogeneity of training, confidence, and inherent skill is greatest when it comes to bedside procedures. Mirroring the heterogeneity at the individual level, hospitalist programs vary greatly on the requirements placed on their staffs in regards to procedural skill and privileging.
Such research-driven programs as Brigham and Women’s Hospital (BWH) in Boston often find requiring maintenance of privileges in bedside procedures to be difficult, says Sally Wang, MD, FHM, director of procedural education at BWH. In fact, a new procedure service being created there will be staffed mainly with ED physicians. On the flipside, most community hospitalist programs leave the task of procedural “policing” to the hospital’s medical staff affairs office.
At the University of California at San Diego (UCSD) Medical Center, the HM group is instituting a division standard in which hospitalists maintain privileging and proficiency in a core group of bedside procedures. Other large hospitalist groups have created “proceduralist” subgroups that shoulder the burden of trainee education, as well as provide a resource for less skilled or less experienced inpatient providers.
“If you have a big group, you could have a dedicated procedure service and have a core group of hospitalists who are experts in procedure,” Dr. Barsuk says. “But it needs to be self-sustaining.” Once started, Dr. Barsuk says, proceduralist groups would continue to provide hospitals with ongoing return-on-investment (ROI) benefit.
Variability in procedure volume and payor mix, however, can make it hard for HM groups to demonstrate to hospital leadership a satisfactory ROI for a proceduralist program. Financial backing from grant support or a high-volume procedure—such as paracentesis in hospitals with large hepatology programs—can nurture starting proceduralist programs until all procedural revenues can justify the costs. Lower ROI can also be justified by showing improvement in quality indices—such as CLABSI rates—reduced time to procedures, and reduced costs compared to other subspecialists offering similar services.
“I’m of the firm belief that we can reduce costs by doing the procedures at the bedside rather than referring them to departments such as interventional radiology (IR),” Dr. Barsuk says. “What you would have to do is show the institution that it costs more money to have IR do [bedside procedures].”
National Response
—Jeffrey Barsuk, MD, MS, FHM, associate professor of medicine, Northwestern Feinberg School of Medicine, academic hospitalist, Northwestern Memorial Hospital, Chicago
Filling in the procedural training gaps found on the local level, such national organizations as SHM have stepped in to provide education and support for hospitalists yearning for training. Since its inception, an SHM annual meeting pre-course that focuses on hand-held ultrasound and invasive procedures has consistently been one of the first to sell out. Other national organizations, such as ACP and its annual meeting, have seen similar interest in their courses on ultrasound-guided procedures.
The popularity of this continuing education bears out a worrisome trend: Hospitalists feel they are losing their procedural skills. An online survey conducted by The Hospitalist in May 2011 found that a majority of respondents (62%) had experienced deterioration of their procedural skills in the past five years; only 25% said they experienced improvement over the same period.
Historically, general internists have claimed bedside procedures as their domain. As stated dispassionately in the 1978 book The House of God, “There is no body cavity that cannot be reached with a #14G needle and a good strong arm.”1 Yet much has changed since Samuel Shem’s apocryphal description of medical residency training.
Most notably, the Accreditation Council of Graduate Medical Education (ACGME) has not only progressively restricted inpatient hours and patient loads for residents, but also increased the requirements for outpatient training. Some feel the balance of inpatient and outpatient training has tipped too far toward the latter in medicine residency programs, especially in light of the growing popularity of the hospitalist career path amongst new residency program graduates. This stands in contrast to ED training programs, which have embraced focused procedures training more readily.
“Adult care appears to be diverging into two career tacks as a result of external forces, of which we have limited control over, “ says Michael Beck, MD, a pediatric and adult hospitalist at Milton S. Hershey Medical Center in Hershey, Pa. “With new career choices emerging for graduates, the same square-peg, round-hole residency training should not exist.”
Dr. Beck advocates continuing an ongoing trend of “track” creation in residency programs, which allow trainees to focus training on their planned career path. Hospitalist tracks already exist in many medicine programs, including those at Cleveland Clinic and Northwestern. But many other factors limit the opportunity for trainees to obtain experience with bedside procedures, including competition with nurse practitioners and physician assistants. Even the increasing availability of ancillary phlebotomy and IV-start teams can increase a resident’s anxiety about procedures.
“By the time my residency was over [in 1993] and the work restrictions were beginning, hospital employees were doing all these tasks, making the residents less comfortable with hurting a patient when it was therapeutically necessary,” says Katharine Deiss, MD, assistant clinical professor of medicine at the University of Rochester Medical Center in New York. Interns who came from medical schools without extensive ancillary services in their teaching hospitals, she adds, were more comfortable with invasive procedures.
ACGME has sent a subtle message by decreasing emphasis on procedural skills by eradicating the requirement of showing manual proficiency in most bedside procedures as a requirement for certification. The omission has left individual residency programs and hospitalist groups to determine training and proficiency requirements for more invasive bedside procedures without a national standard.
In an editorial in the March 2007 issue of the Annals of Internal Medicine, F. Daniel Duffy, MD, and Eric Holmboe, MD, wrote that the American Board of Internal Medicine (ABIM) could only give a “qualified ‘yes’” to the question of whether residents should be trained in procedures they may not perform in practice. Although the authors asserted that the relaxed ABIM policy was “an important but small step toward revamping procedure skill training during residency,” others say it portrays an image of the ABIM de-emphasizing the importance of procedural training.
In addition, the recently established Focused Practice in Hospital Medicine (FPHM) pathway to ABIM Maintenance of Certification (MOC) has no requirement to show proficiency in bedside procedures.
“The absence of the procedural requirement in no way constitutes a statement that procedural skills are not important,” says Jeff Wiese, MD, FACP, SFHM, associate professor of medicine and residency program director at Tulane University Health Sciences Center in New Orleans, chair of the ABIM Hospital Medicine MOC Question Writing Committee, and former SHM president. “Rather, it is merely a practical issue with respect to making the MOC process applicable to all physicians engaged in hospital medicine (i.e. many hospitalists do not do procedures) while still making the MOC focused on the skill sets that are common for physicians doing hospital medicine.”
Once released into the world, even if trained well in residency, hospitalists can find it difficult to maintain their skills. In community and nonteaching settings, the pressure to admit and discharge in a timely manner can make procedures seem like the easiest corner to cut. Before long, it has been months since they have laid eyes on a needle of any sort. Many begin to develop performance anxiety.
In teaching hospitals, academic hospitalists often are called upon to participate in quality improvement (QI) and research efforts, which take time away from clinical rotations. Once there, it can be easy for a ward attending to rely upon a well-trained resident to supervise interns doing procedures. The lack of first-hand or even supervisory experience can lead to many academic hospitalists losing facility with procedures, with potentially disastrous results.
“In order to supervise a group of residents, the attending needs to be technically proficient and able to salvage a botched, or failed, procedure,” UM-JMH’s Dr. Lenchus says. “To this end, we strictly limit who can attend on the service.”
So what’s a residency or HM program director to do in the face of wavering support nationally, and sometimes locally, for maintaining procedural skills for hospitalists and trainees? Many hospitalists in teaching hospitals say it’s critical for clinicians to “get their own house in order,” to maintain procedural standards of proficiency with ongoing training, education, and verification.
“The profession now needs to redesign procedural training across the continuum of education and a lifetime of practice,” Drs. Duffy and Holmboe editorialized in the March 2007 Annals paper. “This approach would recognize the varied settings of internal-medicine practice and offer manual skills training to those whose practice settings require such skills.” Hospitalists can partner with medicine residency program leaders to provide procedural education and training to residents, either as a standalone elective or as a more general resource.
Hospitalists in such teaching hospitals as UCSD, Brigham and Women’s, UM-JMH, and Northwestern are leading efforts to provide procedural education to medical students, residents, and attendings. Training takes many forms, including formal procedural electives, required procedure rotations, or even brief one- or two-day courses in procedural skills at a simulation center.
Utilizing simulation training has been shown in many studies to be helpful in establishing procedural skills in learners of all training levels. Dr. Barsuk and his colleagues at Northwestern published studies in the Journal of Hospital Medicine in 2008 and 2009 showing that simulation training of residents was effective in improving skills in thoracentesis and central venous catheterization, respectively.3,4
In the community hospital setting, requirements for procedural skills can vary greatly based on the institution. For those community programs requiring procedural skills of their hospitalists, the clear definition of procedural training and requirements at the time of hiring is critical. Even after vetting a hospitalist’s procedural skills at hire, however, community programs should consider monitoring procedural skills and provide ongoing time and money for CME focused on procedural skills.
Currently, most hospitals depend on the honesty of individual physicians during the privileging process for bedside procedures. Even when the skills of physicians begin to wane, most are reluctant to voluntarily give up their procedure privileges.
“I think it would be pretty unusual for a hospitalist to relinquish their privileges,” Dr. Barsuk admits. But ideally, physicians who relinquish their privileges due to lack of experience could get retrained in simulation centers, then reproctored in order to regain their privileges. Northwestern established the Center for Simulation Technology and Immersive Learning as a resource for simulation training both locally and nationally.
Establishing an environment that supports hospitalists performing bedside procedures is critical. This includes the need to limit hospitalist workload to ensure adequate time to meet the procedural needs of patients. Providing easy access to the tools necessary to perform bedside procedures (e.g. portable ultrasound and pre-packaged procedure trays) helps avoid additional hurdles.
Academic hospitalist programs can serve as a regional resource by developing ongoing procedure mastery programs for hospitalists in their communities, as many smaller institutions do not have the resources to provide ongoing training in bedside procedures. This process can be tedious, but it should not be humiliating.
If the popularity of the SHM pre-course in bedside ultrasound and procedures is any indication, when given the opportunity to receive protected time for procedure training, most hospitalists will likely jump at the chance.
Dr. Chang is an associate clinical professor of medicine in the division of hospital medicine at Diego Medical Center. He is also a member of Team Hospitalist.
References
- Shem S. The House of God. New York: Dell Publishing; 1978.
- Duffy FD, Holmboe ES. What procedures should internists do? Ann Intern Med. 2007;146(5):392-393.
- Wayne DB, Barsuk JH, O’Leary KJ, Fudala MJ, McGaghie WC. Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. J Hosp Med. 2008;3(1):48-54.
- Barsuk JH, McGaghie WC, Cohen ER, Balachandran JS, Wayne DB. Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. J Hosp Med. 2009;4(7):397–403.