Transitions of Care

Background: Efforts to reduce and monitor high-risk opioid prescribing have largely focused on outpatient prescribing with less empiric evaluation of inpatient administration. Little is known about the association of inpatient opioid administration and postdischarge opioid use.

This observational study is prone to potential unmeasured confounders negating any clear causation. Rather, hospitalists should be aware of the increasing focus on inpatient opioid administration as it relates to outpatient opioid use, especially in the setting of the current opioid crisis.

Bottom line: Inpatient opioid administration and administration patterns are associated with 90-day postdischarge opioid use in opioid-­naive patients.

Citation: Donohue JM et al. Patterns of opioid administration among opioid-naive inpatients and associations with postdischarge opioid use. Ann Intern Med. 2019 Jun 18:171(2):81-90.

Dr. Ledford is a hospitalist at Vanderbilt University Medical Center, Nashville, Tenn.

Background: Efforts to reduce and monitor high-risk opioid prescribing have largely focused on outpatient prescribing with less empiric evaluation of inpatient administration. Little is known about the association of inpatient opioid administration and postdischarge opioid use.

This observational study is prone to potential unmeasured confounders negating any clear causation. Rather, hospitalists should be aware of the increasing focus on inpatient opioid administration as it relates to outpatient opioid use, especially in the setting of the current opioid crisis.

Bottom line: Inpatient opioid administration and administration patterns are associated with 90-day postdischarge opioid use in opioid-­naive patients.

Citation: Donohue JM et al. Patterns of opioid administration among opioid-naive inpatients and associations with postdischarge opioid use. Ann Intern Med. 2019 Jun 18:171(2):81-90.

Dr. Ledford is a hospitalist at Vanderbilt University Medical Center, Nashville, Tenn.

Background: Efforts to reduce and monitor high-risk opioid prescribing have largely focused on outpatient prescribing with less empiric evaluation of inpatient administration. Little is known about the association of inpatient opioid administration and postdischarge opioid use.

This observational study is prone to potential unmeasured confounders negating any clear causation. Rather, hospitalists should be aware of the increasing focus on inpatient opioid administration as it relates to outpatient opioid use, especially in the setting of the current opioid crisis.

Bottom line: Inpatient opioid administration and administration patterns are associated with 90-day postdischarge opioid use in opioid-­naive patients.

Citation: Donohue JM et al. Patterns of opioid administration among opioid-naive inpatients and associations with postdischarge opioid use. Ann Intern Med. 2019 Jun 18:171(2):81-90.

Dr. Ledford is a hospitalist at Vanderbilt University Medical Center, Nashville, Tenn.

The COVID-19 pandemic continues to disrupt all aspects of hospital care, and has altered nearly all fundamental practices, including discharge protocols. A session presented at the Society of Hospitalist Medicine’s 2020 Virtual Annual Conference will focus on discharge issues in the COVID-19 era.

“Discharge planning is an integral part of a hospitalist’s clinical care. On a daily basis, we think carefully about how to help our patients safely transition back into life outside of the hospital,” said Maralyssa Bann, MD, of the University of Washington, Seattle, a copresenter at the session.

“Patients need up-to-date information about how to keep themselves and those around them safe,” she said. “They need resources and supports to help them recover from illness.”

These supports include access to appropriate follow-up with primary care doctors or other specialists and being discharged to the right location, such as home or a skilled nursing facility, Dr. Bann noted.

In response to COVID-19, “within an exceptionally short time frame, hospitals have had to rapidly adapt their discharge planning protocols and have had to continue to adapt as new information comes out,” Dr. Bann said.

“In many ways, the COVID-19 pandemic has highlighted the importance of discharge planning for patient care and has added a new element of public health in that we have to take all possible precautions to ensure that patients are not spreading the virus after they leave the hospital,” said Ryan Greysen, MD, of the University of Pennsylvania, Philadelphia, and Dr. Bann’s copresenter.

Dan Burke Photography

Many elements go into creating a good discharge plan, but there are often many unknowns, Dr. Greysen said. “I think there is an opportunity to improve the process by improving follow-up as well.”

“For example, one program at our hospital focused on vulnerable older adults includes an in-home visit by a visiting nurse on the day of discharge to verify the patient has everything they need when they arrive home,” However, now with more telemedicine and social distancing, there should be creative approaches to tying up loose ends and monitoring for things that can go wrong in order to give additional guidance, he said.

“In a previous study of 12 U.S. academic medical centers, my colleagues and I interviewed over 1,000 patients who were discharged and then readmitted to ask them what they thought went wrong,” said Dr. Greysen. “Overwhelmingly, patients indicated that they understood their discharge instructions and the plan of care at the time they left the hospital, but then when there were breakdowns or unanticipated challenges in the plan, they were uncertain what to do.”

In the HM20 Virtual session, Dr. Greysen and Dr. Bann will present additional data from the same network that Dr. Greysen used in his study, the Hospital Medicine Reengineering Network or HOMERuN, but expanded to include 22 sites.

The specific areas will include clinical and nonclinical criteria for patients to be discharged home, how criteria differed for discharge destinations other than home, discharge logistics, discharge instructions for patients and caregivers, and postdischarge follow-up.

“Developing a discharge protocol during a pandemic is a major challenge. There are new barriers and challenges to finding the right discharge location, as information about illness course and outcome is incomplete or evolving,” Dr. Bann said. “The safety of patients and their loved ones, health care workers and staff, as well as the public at large is always top of mind. Decisions have to be made in a timely way and communicated clearly. This is a huge task in addition to all of the other competing work in the midst of a pandemic, which is why learning from each other and collectively creating our shared best practices is tremendously helpful. If I can take example approaches from other hospitals and update them for use at my site, this saves a lot of time and effort.”

“There is great urgency to understand when it is safe to discharge these patients from the hospital,” Dr. Greysen said. “Many COVID patients can have worsening of their symptoms after a period of initial improvement so sending them home too soon is a major concern. On the other hand, we can’t keep COVID patients in the hospital until they have fully recovered; we would increase their risk of iatrogenic events and we could risk using up capacity of the health care system to care for other patients, both COVID and non-COVID.”

Unfortunately, no evidence base yet exists to guide the creation of discharge guidelines for COVID patients, said Dr. Greysen. “Therefore, we conducted a survey of HOMERuN sites to synthesize practices across sites and provide some guidance for hospitals based on themes or concordance between these sites.

“One area of clear concordance among sites in our study was around the use of [Centers for Disease Control and Prevention] guidelines to address patient isolation procedures as well as strategies to mitigate transmission, such as providing patients with protective gear like masks or requiring the driver who picks up the patient wear a mask for transportation,” Dr. Greysen said. “We also found that many sites used certain clinical criteria – for example, temperature, oxygen saturation or supplementation, and improvement of presenting symptoms – but there was wide variation in the details for these criteria.”

In addition, “some sites required that a patient be afebrile for a certain period of time before discharge whereas others only required that patients be afebrile at the time of discharge. There was also relatively strong consensus around assessing the level of social support and ability to perform activities of daily living prior to discharge,” since social support and ability to function are often interrelated and can be difficult to assess without visiting the home, he said.

“Further development the evidence around which discharge criteria are associated with adverse outcomes such as readmission or death is urgently needed. At this moment, we really don’t know which clinical criteria such as oxygen supplementation or nonclinical criteria are associated with better outcomes in COVID patients,” Dr. Greysen said, but he and his team plan to study this using EMR data in HOMERuN.

Dr. Bann said that clinical criteria for discharge will likely provoke lively discussions during the interactive part of the virtual session. “Also, I have heard a lot of discussion and interest in learning about how different sites are handling postdischarge monitoring and follow-up, such as how we ensure that patients are recovering well after discharge, and whether there are new or different needs for this patient population,” she added.

“Attendees should come away from this session with an understanding of how hospitals across the country have augmented their discharge planning responses during the COVID-19 pandemic,” Dr. Bann said. “This session is all about learning from each other and creating shared best practices,” she said.

“I hope that those who attend our session are able to see some areas of consensus in our study that could be applied to their discharge criteria,” Dr. Greysen added.

Dr. Bann and Dr. Greysen had no relevant financial conflicts to disclose.



Discharge Planning for COVID-19: Collected Practices from Across the U.S.

The COVID-19 pandemic continues to disrupt all aspects of hospital care, and has altered nearly all fundamental practices, including discharge protocols. A session presented at the Society of Hospitalist Medicine’s 2020 Virtual Annual Conference will focus on discharge issues in the COVID-19 era.

“Discharge planning is an integral part of a hospitalist’s clinical care. On a daily basis, we think carefully about how to help our patients safely transition back into life outside of the hospital,” said Maralyssa Bann, MD, of the University of Washington, Seattle, a copresenter at the session.

“Patients need up-to-date information about how to keep themselves and those around them safe,” she said. “They need resources and supports to help them recover from illness.”

These supports include access to appropriate follow-up with primary care doctors or other specialists and being discharged to the right location, such as home or a skilled nursing facility, Dr. Bann noted.

In response to COVID-19, “within an exceptionally short time frame, hospitals have had to rapidly adapt their discharge planning protocols and have had to continue to adapt as new information comes out,” Dr. Bann said.

“In many ways, the COVID-19 pandemic has highlighted the importance of discharge planning for patient care and has added a new element of public health in that we have to take all possible precautions to ensure that patients are not spreading the virus after they leave the hospital,” said Ryan Greysen, MD, of the University of Pennsylvania, Philadelphia, and Dr. Bann’s copresenter.

Dan Burke Photography

Many elements go into creating a good discharge plan, but there are often many unknowns, Dr. Greysen said. “I think there is an opportunity to improve the process by improving follow-up as well.”

“For example, one program at our hospital focused on vulnerable older adults includes an in-home visit by a visiting nurse on the day of discharge to verify the patient has everything they need when they arrive home,” However, now with more telemedicine and social distancing, there should be creative approaches to tying up loose ends and monitoring for things that can go wrong in order to give additional guidance, he said.

“In a previous study of 12 U.S. academic medical centers, my colleagues and I interviewed over 1,000 patients who were discharged and then readmitted to ask them what they thought went wrong,” said Dr. Greysen. “Overwhelmingly, patients indicated that they understood their discharge instructions and the plan of care at the time they left the hospital, but then when there were breakdowns or unanticipated challenges in the plan, they were uncertain what to do.”

In the HM20 Virtual session, Dr. Greysen and Dr. Bann will present additional data from the same network that Dr. Greysen used in his study, the Hospital Medicine Reengineering Network or HOMERuN, but expanded to include 22 sites.

The specific areas will include clinical and nonclinical criteria for patients to be discharged home, how criteria differed for discharge destinations other than home, discharge logistics, discharge instructions for patients and caregivers, and postdischarge follow-up.

“Developing a discharge protocol during a pandemic is a major challenge. There are new barriers and challenges to finding the right discharge location, as information about illness course and outcome is incomplete or evolving,” Dr. Bann said. “The safety of patients and their loved ones, health care workers and staff, as well as the public at large is always top of mind. Decisions have to be made in a timely way and communicated clearly. This is a huge task in addition to all of the other competing work in the midst of a pandemic, which is why learning from each other and collectively creating our shared best practices is tremendously helpful. If I can take example approaches from other hospitals and update them for use at my site, this saves a lot of time and effort.”

“There is great urgency to understand when it is safe to discharge these patients from the hospital,” Dr. Greysen said. “Many COVID patients can have worsening of their symptoms after a period of initial improvement so sending them home too soon is a major concern. On the other hand, we can’t keep COVID patients in the hospital until they have fully recovered; we would increase their risk of iatrogenic events and we could risk using up capacity of the health care system to care for other patients, both COVID and non-COVID.”

Unfortunately, no evidence base yet exists to guide the creation of discharge guidelines for COVID patients, said Dr. Greysen. “Therefore, we conducted a survey of HOMERuN sites to synthesize practices across sites and provide some guidance for hospitals based on themes or concordance between these sites.

“One area of clear concordance among sites in our study was around the use of [Centers for Disease Control and Prevention] guidelines to address patient isolation procedures as well as strategies to mitigate transmission, such as providing patients with protective gear like masks or requiring the driver who picks up the patient wear a mask for transportation,” Dr. Greysen said. “We also found that many sites used certain clinical criteria – for example, temperature, oxygen saturation or supplementation, and improvement of presenting symptoms – but there was wide variation in the details for these criteria.”

In addition, “some sites required that a patient be afebrile for a certain period of time before discharge whereas others only required that patients be afebrile at the time of discharge. There was also relatively strong consensus around assessing the level of social support and ability to perform activities of daily living prior to discharge,” since social support and ability to function are often interrelated and can be difficult to assess without visiting the home, he said.

“Further development the evidence around which discharge criteria are associated with adverse outcomes such as readmission or death is urgently needed. At this moment, we really don’t know which clinical criteria such as oxygen supplementation or nonclinical criteria are associated with better outcomes in COVID patients,” Dr. Greysen said, but he and his team plan to study this using EMR data in HOMERuN.

Dr. Bann said that clinical criteria for discharge will likely provoke lively discussions during the interactive part of the virtual session. “Also, I have heard a lot of discussion and interest in learning about how different sites are handling postdischarge monitoring and follow-up, such as how we ensure that patients are recovering well after discharge, and whether there are new or different needs for this patient population,” she added.

“Attendees should come away from this session with an understanding of how hospitals across the country have augmented their discharge planning responses during the COVID-19 pandemic,” Dr. Bann said. “This session is all about learning from each other and creating shared best practices,” she said.

“I hope that those who attend our session are able to see some areas of consensus in our study that could be applied to their discharge criteria,” Dr. Greysen added.

Dr. Bann and Dr. Greysen had no relevant financial conflicts to disclose.



Discharge Planning for COVID-19: Collected Practices from Across the U.S.

The COVID-19 pandemic continues to disrupt all aspects of hospital care, and has altered nearly all fundamental practices, including discharge protocols. A session presented at the Society of Hospitalist Medicine’s 2020 Virtual Annual Conference will focus on discharge issues in the COVID-19 era.

“Discharge planning is an integral part of a hospitalist’s clinical care. On a daily basis, we think carefully about how to help our patients safely transition back into life outside of the hospital,” said Maralyssa Bann, MD, of the University of Washington, Seattle, a copresenter at the session.

“Patients need up-to-date information about how to keep themselves and those around them safe,” she said. “They need resources and supports to help them recover from illness.”

These supports include access to appropriate follow-up with primary care doctors or other specialists and being discharged to the right location, such as home or a skilled nursing facility, Dr. Bann noted.

In response to COVID-19, “within an exceptionally short time frame, hospitals have had to rapidly adapt their discharge planning protocols and have had to continue to adapt as new information comes out,” Dr. Bann said.

“In many ways, the COVID-19 pandemic has highlighted the importance of discharge planning for patient care and has added a new element of public health in that we have to take all possible precautions to ensure that patients are not spreading the virus after they leave the hospital,” said Ryan Greysen, MD, of the University of Pennsylvania, Philadelphia, and Dr. Bann’s copresenter.

Dan Burke Photography

Many elements go into creating a good discharge plan, but there are often many unknowns, Dr. Greysen said. “I think there is an opportunity to improve the process by improving follow-up as well.”

“For example, one program at our hospital focused on vulnerable older adults includes an in-home visit by a visiting nurse on the day of discharge to verify the patient has everything they need when they arrive home,” However, now with more telemedicine and social distancing, there should be creative approaches to tying up loose ends and monitoring for things that can go wrong in order to give additional guidance, he said.

“In a previous study of 12 U.S. academic medical centers, my colleagues and I interviewed over 1,000 patients who were discharged and then readmitted to ask them what they thought went wrong,” said Dr. Greysen. “Overwhelmingly, patients indicated that they understood their discharge instructions and the plan of care at the time they left the hospital, but then when there were breakdowns or unanticipated challenges in the plan, they were uncertain what to do.”

In the HM20 Virtual session, Dr. Greysen and Dr. Bann will present additional data from the same network that Dr. Greysen used in his study, the Hospital Medicine Reengineering Network or HOMERuN, but expanded to include 22 sites.

The specific areas will include clinical and nonclinical criteria for patients to be discharged home, how criteria differed for discharge destinations other than home, discharge logistics, discharge instructions for patients and caregivers, and postdischarge follow-up.

“Developing a discharge protocol during a pandemic is a major challenge. There are new barriers and challenges to finding the right discharge location, as information about illness course and outcome is incomplete or evolving,” Dr. Bann said. “The safety of patients and their loved ones, health care workers and staff, as well as the public at large is always top of mind. Decisions have to be made in a timely way and communicated clearly. This is a huge task in addition to all of the other competing work in the midst of a pandemic, which is why learning from each other and collectively creating our shared best practices is tremendously helpful. If I can take example approaches from other hospitals and update them for use at my site, this saves a lot of time and effort.”

“There is great urgency to understand when it is safe to discharge these patients from the hospital,” Dr. Greysen said. “Many COVID patients can have worsening of their symptoms after a period of initial improvement so sending them home too soon is a major concern. On the other hand, we can’t keep COVID patients in the hospital until they have fully recovered; we would increase their risk of iatrogenic events and we could risk using up capacity of the health care system to care for other patients, both COVID and non-COVID.”

Unfortunately, no evidence base yet exists to guide the creation of discharge guidelines for COVID patients, said Dr. Greysen. “Therefore, we conducted a survey of HOMERuN sites to synthesize practices across sites and provide some guidance for hospitals based on themes or concordance between these sites.

“One area of clear concordance among sites in our study was around the use of [Centers for Disease Control and Prevention] guidelines to address patient isolation procedures as well as strategies to mitigate transmission, such as providing patients with protective gear like masks or requiring the driver who picks up the patient wear a mask for transportation,” Dr. Greysen said. “We also found that many sites used certain clinical criteria – for example, temperature, oxygen saturation or supplementation, and improvement of presenting symptoms – but there was wide variation in the details for these criteria.”

In addition, “some sites required that a patient be afebrile for a certain period of time before discharge whereas others only required that patients be afebrile at the time of discharge. There was also relatively strong consensus around assessing the level of social support and ability to perform activities of daily living prior to discharge,” since social support and ability to function are often interrelated and can be difficult to assess without visiting the home, he said.

“Further development the evidence around which discharge criteria are associated with adverse outcomes such as readmission or death is urgently needed. At this moment, we really don’t know which clinical criteria such as oxygen supplementation or nonclinical criteria are associated with better outcomes in COVID patients,” Dr. Greysen said, but he and his team plan to study this using EMR data in HOMERuN.

Dr. Bann said that clinical criteria for discharge will likely provoke lively discussions during the interactive part of the virtual session. “Also, I have heard a lot of discussion and interest in learning about how different sites are handling postdischarge monitoring and follow-up, such as how we ensure that patients are recovering well after discharge, and whether there are new or different needs for this patient population,” she added.

“Attendees should come away from this session with an understanding of how hospitals across the country have augmented their discharge planning responses during the COVID-19 pandemic,” Dr. Bann said. “This session is all about learning from each other and creating shared best practices,” she said.

“I hope that those who attend our session are able to see some areas of consensus in our study that could be applied to their discharge criteria,” Dr. Greysen added.

Dr. Bann and Dr. Greysen had no relevant financial conflicts to disclose.



Discharge Planning for COVID-19: Collected Practices from Across the U.S.

Background: In the United States, there are over 1 million visits to EDs for syncope with a greater than 50% hospitalization rate for older adult patients. There remains uncertainty around which patients without an identified cause for the syncope could be discharged from the ED and managed as an outpatient.

These results show no clinical benefit in hospitalization for older adults with unexplained syncope after ED evaluation suggesting that it would be reasonable to proceed with outpatient management and evaluation of these patients.

Bottom line: Consider discharging older patients home from the ED who do not have high risk factors and no identified cause of their syncope.

Citation: Probst MA et al. Clinical benefit of hospitalization for older adults with unexplained syncope: A propensity-matched analysis. Ann Emerg Med. 2019 Aug;74(2):260-9.

Dr. Field is a hospitalist at Ochsner Health System, New Orleans.

Background: In the United States, there are over 1 million visits to EDs for syncope with a greater than 50% hospitalization rate for older adult patients. There remains uncertainty around which patients without an identified cause for the syncope could be discharged from the ED and managed as an outpatient.

These results show no clinical benefit in hospitalization for older adults with unexplained syncope after ED evaluation suggesting that it would be reasonable to proceed with outpatient management and evaluation of these patients.

Bottom line: Consider discharging older patients home from the ED who do not have high risk factors and no identified cause of their syncope.

Citation: Probst MA et al. Clinical benefit of hospitalization for older adults with unexplained syncope: A propensity-matched analysis. Ann Emerg Med. 2019 Aug;74(2):260-9.

Dr. Field is a hospitalist at Ochsner Health System, New Orleans.

Background: In the United States, there are over 1 million visits to EDs for syncope with a greater than 50% hospitalization rate for older adult patients. There remains uncertainty around which patients without an identified cause for the syncope could be discharged from the ED and managed as an outpatient.

These results show no clinical benefit in hospitalization for older adults with unexplained syncope after ED evaluation suggesting that it would be reasonable to proceed with outpatient management and evaluation of these patients.

Bottom line: Consider discharging older patients home from the ED who do not have high risk factors and no identified cause of their syncope.

Citation: Probst MA et al. Clinical benefit of hospitalization for older adults with unexplained syncope: A propensity-matched analysis. Ann Emerg Med. 2019 Aug;74(2):260-9.

Dr. Field is a hospitalist at Ochsner Health System, New Orleans.

Although there are many benefits to the hospital medicine model of inpatient care, there is perhaps no greater Achilles heel than the discontinuity inherent to the care model. The trust and familiarity garnered from longitudinal patient-provider relationships is sacrificed for the benefits of focused practice, efficiency, and enhanced availability.

Any system involves competing priorities, and some degree of discontinuity is inevitable. Would it make sense for a hospitalist to stay on service until every panel patient is discharged? For obvious economic, lifestyle, and other reasons, of course not. Our charge then is not to make the perfect the enemy of the good, but to ensure thoughtful and consistent continuity for the good of the patient, the provider, and the hospital. The following tips should help your team achieve the best possible balance.
 

Avoid orphan rounding shifts

An “orphan” rounding shift refers to a single shift untethered to a stretch. For admitting or administrative duties, this generally poses no problem, but for a rounding shift it is undesirable. No matter how talented or industrious the provider, it is very difficult for them to effectively provide seamless care for a single day; such care is often disconcerting for patients, families, case managers, and consultants. In situations such as significant census spikes, this may be a necessary evil, but avoid this if you can.

Orphan shift duties

If you can’t avoid an orphan rounding shift, be creative regarding which patients get assigned. Can that provider cover observation or simple short stay patients who may be discharged, or consult follow ups that may be signed off? Can they see stable long-stay patients where the plan isn’t changing and the patient isn’t going anywhere? (Think guardianships, chronic ventilated patients awaiting a facility, stable patients with a history of intravenous drug abuse who may not be safely discharged with a line, etc.) Can they do lab, culture, or path report follow-up calls? Getting creative in responsibilities for an orphan shift can benefit all involved.

Rounding shifts following admitting shifts

Dedicated admitting and rounding shifts are the norm these days. But rather than a pure stretch of one or the other, consider a few days admitting followed by the rest of the stretch rounding. Particularly in a small- to mid-sized hospital, multiple admits done over a few days (and especially if also cross-covering floor calls) will mean many familiar cases when rounding thereafter.

Standard sign-out that travels with patients

The hospital is a dynamic environment. Patients, providers and staff move around a lot. Given this reality, the importance of a complete standardized and accessible sign-out is paramount.

Imagine a rounder starting their last day with 15 patients. By the end of the shift, some have been discharged, transferred to telemetry or the ICU, or left against medical advice, leaving seven patients to sign out. By the next day, there are eight new faces, including fresh admits or consults from the prior day, swing, and night providers as well as existing patients transferred from telemetry/ICU to the general medical ward. A practical solution incorporates an asynchronous sign-out that travels with the patient regardless of geographic location or which provider(s) are following them. Billing software or census reports can typically achieve this. Of course, allow for additional verbal communication as necessary and appropriate.
 

Geographic rounds, with exceptions

Geographic rounds make a lot of sense most of the time. Less transit time and phone tag and more frequent interactions with the care team make for a more efficient day. But sometimes it’s best to bend this rule.

A patient that you’ve seen for 5 days and was transferred off your telemetry floor to go home tomorrow might best be served by you trekking up a flight of stairs to do the discharge. Similarly, complicated medical, psychosocial, or other circumstances may argue for keeping the patient on your list despite a change in location.

The above rules are foundational elements for good continuity. Two bonus considerations include:
 

Wind up, wind down

It’s difficult to walk into a full panel of patients especially when many have been in house for a while. Consider overlapping providers coming onto and going off a shared service.

In a buddy arrangement the oncoming provider starting would take new patients from the outgoing provider finishing. The provider finishing discharges patients with long length of stays and continues to round on more-complicated patients with whom they are familiar. Opportunities for face-to-face verbal handover, and even bedside introduction to the provider starting, can improve care coordination and safety and enhance the patient experience.
 

Reconsider split rounding and admitting

Most physicians would attest that the second time seeing a patient is much easier than the first, the third easier than the second, and so on. This holds true even more so when the first encounter is the history and physical, and the provider subsequently rounds on the patient for the duration of the hospitalization.

You know what the plan is because you made it; you are confident that the patient’s leg with cellulitis looks better or the patient with congested lungs sounds clearer because the baseline against which you’re comparing is your own. It can be a challenge to interrupt a busy day of clinical rounds, discharges, and interdisciplinary meetings to admit a patient. But the upstream investment pays rich downstream dividends and is well worth consideration.

Hospital medicine outcomes as measured by cost, quality, and patient and provider experience are often hampered by suboptimal continuity of care. With recognition of the problem and some simple operational adjustments as outlined above, your team can minimize negative impacts.

Dr. Krisa is a former regional medical director for a national hospitalist group and currently serves as a physician advisor for St. Peter’s Health Partners, a large integrated health system in Albany, N.Y. You can contact him at [email protected].

Although there are many benefits to the hospital medicine model of inpatient care, there is perhaps no greater Achilles heel than the discontinuity inherent to the care model. The trust and familiarity garnered from longitudinal patient-provider relationships is sacrificed for the benefits of focused practice, efficiency, and enhanced availability.

Any system involves competing priorities, and some degree of discontinuity is inevitable. Would it make sense for a hospitalist to stay on service until every panel patient is discharged? For obvious economic, lifestyle, and other reasons, of course not. Our charge then is not to make the perfect the enemy of the good, but to ensure thoughtful and consistent continuity for the good of the patient, the provider, and the hospital. The following tips should help your team achieve the best possible balance.
 

Avoid orphan rounding shifts

An “orphan” rounding shift refers to a single shift untethered to a stretch. For admitting or administrative duties, this generally poses no problem, but for a rounding shift it is undesirable. No matter how talented or industrious the provider, it is very difficult for them to effectively provide seamless care for a single day; such care is often disconcerting for patients, families, case managers, and consultants. In situations such as significant census spikes, this may be a necessary evil, but avoid this if you can.

Orphan shift duties

If you can’t avoid an orphan rounding shift, be creative regarding which patients get assigned. Can that provider cover observation or simple short stay patients who may be discharged, or consult follow ups that may be signed off? Can they see stable long-stay patients where the plan isn’t changing and the patient isn’t going anywhere? (Think guardianships, chronic ventilated patients awaiting a facility, stable patients with a history of intravenous drug abuse who may not be safely discharged with a line, etc.) Can they do lab, culture, or path report follow-up calls? Getting creative in responsibilities for an orphan shift can benefit all involved.

Rounding shifts following admitting shifts

Dedicated admitting and rounding shifts are the norm these days. But rather than a pure stretch of one or the other, consider a few days admitting followed by the rest of the stretch rounding. Particularly in a small- to mid-sized hospital, multiple admits done over a few days (and especially if also cross-covering floor calls) will mean many familiar cases when rounding thereafter.

Standard sign-out that travels with patients

The hospital is a dynamic environment. Patients, providers and staff move around a lot. Given this reality, the importance of a complete standardized and accessible sign-out is paramount.

Imagine a rounder starting their last day with 15 patients. By the end of the shift, some have been discharged, transferred to telemetry or the ICU, or left against medical advice, leaving seven patients to sign out. By the next day, there are eight new faces, including fresh admits or consults from the prior day, swing, and night providers as well as existing patients transferred from telemetry/ICU to the general medical ward. A practical solution incorporates an asynchronous sign-out that travels with the patient regardless of geographic location or which provider(s) are following them. Billing software or census reports can typically achieve this. Of course, allow for additional verbal communication as necessary and appropriate.
 

Geographic rounds, with exceptions

Geographic rounds make a lot of sense most of the time. Less transit time and phone tag and more frequent interactions with the care team make for a more efficient day. But sometimes it’s best to bend this rule.

A patient that you’ve seen for 5 days and was transferred off your telemetry floor to go home tomorrow might best be served by you trekking up a flight of stairs to do the discharge. Similarly, complicated medical, psychosocial, or other circumstances may argue for keeping the patient on your list despite a change in location.

The above rules are foundational elements for good continuity. Two bonus considerations include:
 

Wind up, wind down

It’s difficult to walk into a full panel of patients especially when many have been in house for a while. Consider overlapping providers coming onto and going off a shared service.

In a buddy arrangement the oncoming provider starting would take new patients from the outgoing provider finishing. The provider finishing discharges patients with long length of stays and continues to round on more-complicated patients with whom they are familiar. Opportunities for face-to-face verbal handover, and even bedside introduction to the provider starting, can improve care coordination and safety and enhance the patient experience.
 

Reconsider split rounding and admitting

Most physicians would attest that the second time seeing a patient is much easier than the first, the third easier than the second, and so on. This holds true even more so when the first encounter is the history and physical, and the provider subsequently rounds on the patient for the duration of the hospitalization.

You know what the plan is because you made it; you are confident that the patient’s leg with cellulitis looks better or the patient with congested lungs sounds clearer because the baseline against which you’re comparing is your own. It can be a challenge to interrupt a busy day of clinical rounds, discharges, and interdisciplinary meetings to admit a patient. But the upstream investment pays rich downstream dividends and is well worth consideration.

Hospital medicine outcomes as measured by cost, quality, and patient and provider experience are often hampered by suboptimal continuity of care. With recognition of the problem and some simple operational adjustments as outlined above, your team can minimize negative impacts.

Dr. Krisa is a former regional medical director for a national hospitalist group and currently serves as a physician advisor for St. Peter’s Health Partners, a large integrated health system in Albany, N.Y. You can contact him at [email protected].

Although there are many benefits to the hospital medicine model of inpatient care, there is perhaps no greater Achilles heel than the discontinuity inherent to the care model. The trust and familiarity garnered from longitudinal patient-provider relationships is sacrificed for the benefits of focused practice, efficiency, and enhanced availability.

Any system involves competing priorities, and some degree of discontinuity is inevitable. Would it make sense for a hospitalist to stay on service until every panel patient is discharged? For obvious economic, lifestyle, and other reasons, of course not. Our charge then is not to make the perfect the enemy of the good, but to ensure thoughtful and consistent continuity for the good of the patient, the provider, and the hospital. The following tips should help your team achieve the best possible balance.
 

Avoid orphan rounding shifts

An “orphan” rounding shift refers to a single shift untethered to a stretch. For admitting or administrative duties, this generally poses no problem, but for a rounding shift it is undesirable. No matter how talented or industrious the provider, it is very difficult for them to effectively provide seamless care for a single day; such care is often disconcerting for patients, families, case managers, and consultants. In situations such as significant census spikes, this may be a necessary evil, but avoid this if you can.

Orphan shift duties

If you can’t avoid an orphan rounding shift, be creative regarding which patients get assigned. Can that provider cover observation or simple short stay patients who may be discharged, or consult follow ups that may be signed off? Can they see stable long-stay patients where the plan isn’t changing and the patient isn’t going anywhere? (Think guardianships, chronic ventilated patients awaiting a facility, stable patients with a history of intravenous drug abuse who may not be safely discharged with a line, etc.) Can they do lab, culture, or path report follow-up calls? Getting creative in responsibilities for an orphan shift can benefit all involved.

Rounding shifts following admitting shifts

Dedicated admitting and rounding shifts are the norm these days. But rather than a pure stretch of one or the other, consider a few days admitting followed by the rest of the stretch rounding. Particularly in a small- to mid-sized hospital, multiple admits done over a few days (and especially if also cross-covering floor calls) will mean many familiar cases when rounding thereafter.

Standard sign-out that travels with patients

The hospital is a dynamic environment. Patients, providers and staff move around a lot. Given this reality, the importance of a complete standardized and accessible sign-out is paramount.

Imagine a rounder starting their last day with 15 patients. By the end of the shift, some have been discharged, transferred to telemetry or the ICU, or left against medical advice, leaving seven patients to sign out. By the next day, there are eight new faces, including fresh admits or consults from the prior day, swing, and night providers as well as existing patients transferred from telemetry/ICU to the general medical ward. A practical solution incorporates an asynchronous sign-out that travels with the patient regardless of geographic location or which provider(s) are following them. Billing software or census reports can typically achieve this. Of course, allow for additional verbal communication as necessary and appropriate.
 

Geographic rounds, with exceptions

Geographic rounds make a lot of sense most of the time. Less transit time and phone tag and more frequent interactions with the care team make for a more efficient day. But sometimes it’s best to bend this rule.

A patient that you’ve seen for 5 days and was transferred off your telemetry floor to go home tomorrow might best be served by you trekking up a flight of stairs to do the discharge. Similarly, complicated medical, psychosocial, or other circumstances may argue for keeping the patient on your list despite a change in location.

The above rules are foundational elements for good continuity. Two bonus considerations include:
 

Wind up, wind down

It’s difficult to walk into a full panel of patients especially when many have been in house for a while. Consider overlapping providers coming onto and going off a shared service.

In a buddy arrangement the oncoming provider starting would take new patients from the outgoing provider finishing. The provider finishing discharges patients with long length of stays and continues to round on more-complicated patients with whom they are familiar. Opportunities for face-to-face verbal handover, and even bedside introduction to the provider starting, can improve care coordination and safety and enhance the patient experience.
 

Reconsider split rounding and admitting

Most physicians would attest that the second time seeing a patient is much easier than the first, the third easier than the second, and so on. This holds true even more so when the first encounter is the history and physical, and the provider subsequently rounds on the patient for the duration of the hospitalization.

You know what the plan is because you made it; you are confident that the patient’s leg with cellulitis looks better or the patient with congested lungs sounds clearer because the baseline against which you’re comparing is your own. It can be a challenge to interrupt a busy day of clinical rounds, discharges, and interdisciplinary meetings to admit a patient. But the upstream investment pays rich downstream dividends and is well worth consideration.

Hospital medicine outcomes as measured by cost, quality, and patient and provider experience are often hampered by suboptimal continuity of care. With recognition of the problem and some simple operational adjustments as outlined above, your team can minimize negative impacts.

Dr. Krisa is a former regional medical director for a national hospitalist group and currently serves as a physician advisor for St. Peter’s Health Partners, a large integrated health system in Albany, N.Y. You can contact him at [email protected].

ORLANDO – Medicare beneficiaries are receiving a low number of rehabilitation visits in the early posthospitalization period after critical illness, an analysis of hospital and home health claims data suggests.

The beneficiaries, all discharged directly to home health after an intensive care unit stay, received an average of less than one visit per week in the ensuing month, while a full third received no visits at all, according to authors of the analysis, presented at the Critical Care Congress sponsored by the Society of Critical Care Medicine.

Living alone and living in a rural area were associated with significantly fewer home health rehabilitation visits, according to investigator Jason Raymond Falvey, PT, DPT, PhD, of Yale University, New Haven, Conn.

“We identified that these patients are receiving low doses of rehabilitation in home health care settings, and perhaps doses low enough to not be physiologically adequate to overcome the deconditioning and aerobic capacity concerns that these patients have,” Dr. Falvey said.

These findings reflect an “underrecognition” of the importance of rehabilitation both outside and inside the hospital setting, according to Patricia J. Posa, RN, of Saint Joseph Mercy Hospital, Northville, Mich.

“We even struggle to provide sufficient rehabilitation while they’re in the hospital,” Ms. Posa said in an interview. “So I think that we still have a major gap in providing rehab services across the continuum, and part of that is recognizing the deficits that patients, especially our elderly patients, might be leaving the hospital with.”

Medicare beneficiaries who survive a critical illness are often discharged with referrals for physical, occupational, or speech therapy, yet there are not much data on the delivery of that care or how many visits actually take place, according to Dr. Falvey.

SOURCE: Falvey J et al. Crit Care Med. 2020 Jan;48(1):28.

ORLANDO – Medicare beneficiaries are receiving a low number of rehabilitation visits in the early posthospitalization period after critical illness, an analysis of hospital and home health claims data suggests.

The beneficiaries, all discharged directly to home health after an intensive care unit stay, received an average of less than one visit per week in the ensuing month, while a full third received no visits at all, according to authors of the analysis, presented at the Critical Care Congress sponsored by the Society of Critical Care Medicine.

Living alone and living in a rural area were associated with significantly fewer home health rehabilitation visits, according to investigator Jason Raymond Falvey, PT, DPT, PhD, of Yale University, New Haven, Conn.

“We identified that these patients are receiving low doses of rehabilitation in home health care settings, and perhaps doses low enough to not be physiologically adequate to overcome the deconditioning and aerobic capacity concerns that these patients have,” Dr. Falvey said.

These findings reflect an “underrecognition” of the importance of rehabilitation both outside and inside the hospital setting, according to Patricia J. Posa, RN, of Saint Joseph Mercy Hospital, Northville, Mich.

“We even struggle to provide sufficient rehabilitation while they’re in the hospital,” Ms. Posa said in an interview. “So I think that we still have a major gap in providing rehab services across the continuum, and part of that is recognizing the deficits that patients, especially our elderly patients, might be leaving the hospital with.”

Medicare beneficiaries who survive a critical illness are often discharged with referrals for physical, occupational, or speech therapy, yet there are not much data on the delivery of that care or how many visits actually take place, according to Dr. Falvey.

SOURCE: Falvey J et al. Crit Care Med. 2020 Jan;48(1):28.

ORLANDO – Medicare beneficiaries are receiving a low number of rehabilitation visits in the early posthospitalization period after critical illness, an analysis of hospital and home health claims data suggests.

The beneficiaries, all discharged directly to home health after an intensive care unit stay, received an average of less than one visit per week in the ensuing month, while a full third received no visits at all, according to authors of the analysis, presented at the Critical Care Congress sponsored by the Society of Critical Care Medicine.

Living alone and living in a rural area were associated with significantly fewer home health rehabilitation visits, according to investigator Jason Raymond Falvey, PT, DPT, PhD, of Yale University, New Haven, Conn.

“We identified that these patients are receiving low doses of rehabilitation in home health care settings, and perhaps doses low enough to not be physiologically adequate to overcome the deconditioning and aerobic capacity concerns that these patients have,” Dr. Falvey said.

These findings reflect an “underrecognition” of the importance of rehabilitation both outside and inside the hospital setting, according to Patricia J. Posa, RN, of Saint Joseph Mercy Hospital, Northville, Mich.

“We even struggle to provide sufficient rehabilitation while they’re in the hospital,” Ms. Posa said in an interview. “So I think that we still have a major gap in providing rehab services across the continuum, and part of that is recognizing the deficits that patients, especially our elderly patients, might be leaving the hospital with.”

Medicare beneficiaries who survive a critical illness are often discharged with referrals for physical, occupational, or speech therapy, yet there are not much data on the delivery of that care or how many visits actually take place, according to Dr. Falvey.

SOURCE: Falvey J et al. Crit Care Med. 2020 Jan;48(1):28.

Among Medicare beneficiaries admitted to the hospital between 2008 and 2016, there was an increase in postdischarge 30-day mortality for patients with heart failure, but not for those with acute myocardial infarction or pneumonia.

The finding comes from an effort to evaluate the use of services soon after discharge for conditions targeted in the U.S. Hospital Readmissions Reduction Program (HRRP), and patients’ outcomes.

“The announcement and implementation of the HRRP were associated with a reduction in readmissions within 30 days of discharge for heart failure, acute myocardial infarction, and pneumonia, as shown by a decrease in the overall national rate of readmissions,” first author Rohan Khera, MD, and colleagues wrote in a study published online Jan. 15, 2020, in the British Medical Journal (doi:10.1136/bmj.l6831).

“Concerns existed that pressures to reduce readmissions had led to the evolution of care patterns that may have adverse consequences through reducing access to care in appropriate settings. Therefore, determining whether patients who are seen in acute care settings, but not admitted to hospital, experience an increased risk of mortality is essential.”

Dr. Khera, a cardiologist at the University of Texas Southwestern Medical Center, Dallas, and colleagues limited the analysis to Medicare claims data from patients who were admitted to the hospital with heart failure, acute myocardial infarction (MI), or pneumonia between 2008 and 2016. Key outcomes of interest were: (1) postdischarge 30-day mortality; and (2) acute care utilization in inpatient units, observation units, and the ED during the postdischarge period.

During the study period there were 3,772,924 hospital admissions for heart failure, 1,570,113 for acute MI, and 3,131,162 for pneumonia. The greatest number of readmissions within 30 days of discharge was for heart failure patients (22.5%), followed by acute MI (17.5%), and pneumonia (17.2%).

The overall rates of observation stays were 1.7% for heart failure, 2.6% for acute MI, and 1.4% for pneumonia, while the overall rates of emergency department visits were 6.4% for heart failure, 6.8% for acute MI, and 6.3% for pneumonia. Cumulatively, about one-third of all admissions – 30.7% for heart failure, 26.9% for acute MI, and 24.8% for pneumonia – received postdischarge care in any acute care setting.

Dr. Khera and colleagues found that overall postdischarge 30-day mortality was 8.7% for heart failure, 7.3% for acute MI, and 8.4% for pneumonia. At the same time, postdischarge 30-day mortality was higher in patients with readmissions (13.2% for heart failure, 12.7% for acute MI, and 15.3% for pneumonia), compared with those who had observation stays (4.5% for heart failure, 2.7% for acute MI, and 4.6% for pneumonia), emergency department visits (9.7% for heart failure, 8.8% for acute MI, and 7.8% for pneumonia), or no postdischarge acute care (7.2% for heart failure, 6.0% for acute MI, and 6.9% for pneumonia). Risk adjusted mortality increased annually by 0.05% only for heart failure, while it decreased by 0.06% for acute MI, and did not significantly change for pneumonia.

“The study strongly suggests that the HRRP did not lead to harm through inappropriate triage of patients at high risk to observation units and the emergency department, and therefore provides evidence against calls to curtail the program owing to this theoretical concern (see JAMA 2018;320:2539-41),” the researchers concluded.

They acknowledged certain limitations of the study, including the fact that they were “unable to identify patterns of acute care during the index hospital admission that would be associated with a higher rate of postdischarge acute care in observation units and emergency departments and whether these visits represented avenues for planned postdischarge follow-up care. Moreover, the proportion of these care encounters that were preventable remains poorly understood.”

Dr. Khera disclosed that he is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health. His coauthors reported having numerous disclosures.

[email protected]

SOURCE: Khera et al. BMJ 2020;368:l6831.

Among Medicare beneficiaries admitted to the hospital between 2008 and 2016, there was an increase in postdischarge 30-day mortality for patients with heart failure, but not for those with acute myocardial infarction or pneumonia.

The finding comes from an effort to evaluate the use of services soon after discharge for conditions targeted in the U.S. Hospital Readmissions Reduction Program (HRRP), and patients’ outcomes.

“The announcement and implementation of the HRRP were associated with a reduction in readmissions within 30 days of discharge for heart failure, acute myocardial infarction, and pneumonia, as shown by a decrease in the overall national rate of readmissions,” first author Rohan Khera, MD, and colleagues wrote in a study published online Jan. 15, 2020, in the British Medical Journal (doi:10.1136/bmj.l6831).

“Concerns existed that pressures to reduce readmissions had led to the evolution of care patterns that may have adverse consequences through reducing access to care in appropriate settings. Therefore, determining whether patients who are seen in acute care settings, but not admitted to hospital, experience an increased risk of mortality is essential.”

Dr. Khera, a cardiologist at the University of Texas Southwestern Medical Center, Dallas, and colleagues limited the analysis to Medicare claims data from patients who were admitted to the hospital with heart failure, acute myocardial infarction (MI), or pneumonia between 2008 and 2016. Key outcomes of interest were: (1) postdischarge 30-day mortality; and (2) acute care utilization in inpatient units, observation units, and the ED during the postdischarge period.

During the study period there were 3,772,924 hospital admissions for heart failure, 1,570,113 for acute MI, and 3,131,162 for pneumonia. The greatest number of readmissions within 30 days of discharge was for heart failure patients (22.5%), followed by acute MI (17.5%), and pneumonia (17.2%).

The overall rates of observation stays were 1.7% for heart failure, 2.6% for acute MI, and 1.4% for pneumonia, while the overall rates of emergency department visits were 6.4% for heart failure, 6.8% for acute MI, and 6.3% for pneumonia. Cumulatively, about one-third of all admissions – 30.7% for heart failure, 26.9% for acute MI, and 24.8% for pneumonia – received postdischarge care in any acute care setting.

Dr. Khera and colleagues found that overall postdischarge 30-day mortality was 8.7% for heart failure, 7.3% for acute MI, and 8.4% for pneumonia. At the same time, postdischarge 30-day mortality was higher in patients with readmissions (13.2% for heart failure, 12.7% for acute MI, and 15.3% for pneumonia), compared with those who had observation stays (4.5% for heart failure, 2.7% for acute MI, and 4.6% for pneumonia), emergency department visits (9.7% for heart failure, 8.8% for acute MI, and 7.8% for pneumonia), or no postdischarge acute care (7.2% for heart failure, 6.0% for acute MI, and 6.9% for pneumonia). Risk adjusted mortality increased annually by 0.05% only for heart failure, while it decreased by 0.06% for acute MI, and did not significantly change for pneumonia.

“The study strongly suggests that the HRRP did not lead to harm through inappropriate triage of patients at high risk to observation units and the emergency department, and therefore provides evidence against calls to curtail the program owing to this theoretical concern (see JAMA 2018;320:2539-41),” the researchers concluded.

They acknowledged certain limitations of the study, including the fact that they were “unable to identify patterns of acute care during the index hospital admission that would be associated with a higher rate of postdischarge acute care in observation units and emergency departments and whether these visits represented avenues for planned postdischarge follow-up care. Moreover, the proportion of these care encounters that were preventable remains poorly understood.”

Dr. Khera disclosed that he is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health. His coauthors reported having numerous disclosures.

[email protected]

SOURCE: Khera et al. BMJ 2020;368:l6831.

Among Medicare beneficiaries admitted to the hospital between 2008 and 2016, there was an increase in postdischarge 30-day mortality for patients with heart failure, but not for those with acute myocardial infarction or pneumonia.

The finding comes from an effort to evaluate the use of services soon after discharge for conditions targeted in the U.S. Hospital Readmissions Reduction Program (HRRP), and patients’ outcomes.

“The announcement and implementation of the HRRP were associated with a reduction in readmissions within 30 days of discharge for heart failure, acute myocardial infarction, and pneumonia, as shown by a decrease in the overall national rate of readmissions,” first author Rohan Khera, MD, and colleagues wrote in a study published online Jan. 15, 2020, in the British Medical Journal (doi:10.1136/bmj.l6831).

“Concerns existed that pressures to reduce readmissions had led to the evolution of care patterns that may have adverse consequences through reducing access to care in appropriate settings. Therefore, determining whether patients who are seen in acute care settings, but not admitted to hospital, experience an increased risk of mortality is essential.”

Dr. Khera, a cardiologist at the University of Texas Southwestern Medical Center, Dallas, and colleagues limited the analysis to Medicare claims data from patients who were admitted to the hospital with heart failure, acute myocardial infarction (MI), or pneumonia between 2008 and 2016. Key outcomes of interest were: (1) postdischarge 30-day mortality; and (2) acute care utilization in inpatient units, observation units, and the ED during the postdischarge period.

During the study period there were 3,772,924 hospital admissions for heart failure, 1,570,113 for acute MI, and 3,131,162 for pneumonia. The greatest number of readmissions within 30 days of discharge was for heart failure patients (22.5%), followed by acute MI (17.5%), and pneumonia (17.2%).

The overall rates of observation stays were 1.7% for heart failure, 2.6% for acute MI, and 1.4% for pneumonia, while the overall rates of emergency department visits were 6.4% for heart failure, 6.8% for acute MI, and 6.3% for pneumonia. Cumulatively, about one-third of all admissions – 30.7% for heart failure, 26.9% for acute MI, and 24.8% for pneumonia – received postdischarge care in any acute care setting.

Dr. Khera and colleagues found that overall postdischarge 30-day mortality was 8.7% for heart failure, 7.3% for acute MI, and 8.4% for pneumonia. At the same time, postdischarge 30-day mortality was higher in patients with readmissions (13.2% for heart failure, 12.7% for acute MI, and 15.3% for pneumonia), compared with those who had observation stays (4.5% for heart failure, 2.7% for acute MI, and 4.6% for pneumonia), emergency department visits (9.7% for heart failure, 8.8% for acute MI, and 7.8% for pneumonia), or no postdischarge acute care (7.2% for heart failure, 6.0% for acute MI, and 6.9% for pneumonia). Risk adjusted mortality increased annually by 0.05% only for heart failure, while it decreased by 0.06% for acute MI, and did not significantly change for pneumonia.

“The study strongly suggests that the HRRP did not lead to harm through inappropriate triage of patients at high risk to observation units and the emergency department, and therefore provides evidence against calls to curtail the program owing to this theoretical concern (see JAMA 2018;320:2539-41),” the researchers concluded.

They acknowledged certain limitations of the study, including the fact that they were “unable to identify patterns of acute care during the index hospital admission that would be associated with a higher rate of postdischarge acute care in observation units and emergency departments and whether these visits represented avenues for planned postdischarge follow-up care. Moreover, the proportion of these care encounters that were preventable remains poorly understood.”

Dr. Khera disclosed that he is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health. His coauthors reported having numerous disclosures.

[email protected]

SOURCE: Khera et al. BMJ 2020;368:l6831.

PHILADELPHIA – A clinical trial of a program that transitions heart failure patients after they’re discharged from the hospital didn’t result in any appreciable improvement in all-cause death, readmissions or emergency department visits after 6 months overall, but it did show that women responded more favorably than men.

Harriette G.C. Van Spall, MD, MPH, reported 6-month results of the Patient-Centered Transitional Care Services in Heart Failure (PACT-HF) trial of 2,494 HF patients at 10 hospitals in Ontario during February 2015 to March 2016. They were randomized to the care-transition program or usual care. The findings, she said at the American Heart Association scientific sessions, “highlight the gap between efficacy that’s often demonstrated in mechanistic clinical trials and effectiveness when we aim to implement these results in real-world settings.” Three-month PACT-HF results were reported previously (JAMA. 2019 Feb 26;321:753-61).

The transitional-care model consisted of a comprehensive needs assessment by a nurse who also provided self-care education, a patient-centered discharge summary, and follow-up with a family physician within 7 days of discharge, which Dr. Van Spall noted “is not current practice in our health care system.”

Patients deemed high risk for readmission or death also received nurse home visits and scheduled visits to a multidisciplinary heart function clinic within 2-4 weeks of discharge and continuing as long as clinically suitable, said Dr. Van Spall, a principal investigator at the Population Health Research Institute, Hamilton, Ont., and assistant professor in cardiology at McMaster University in Hamilton.

The trial found no difference between the intervention and usual-care groups in the two composite endpoints at 6 months, Dr. Van Spall said: all-cause death, readmissions, or ED visits (63.1% and 64.5%, respectively; P = .50); or all-cause readmissions or ED visits (60.8% and 62.4%; P = .36).

“Despite the mutual overall clinical outcomes, we noted specific differences in response to treatment,” she said. With regard to the composite endpoint that included all-cause death, “Men had an attenuated response to the treatment with a hazard ratio of 1.05 (95% confidence interval, 0.87-1.26), whereas women had a hazard ratio of 0.85 (95% CI, 0.71-1.03), demonstrating that women have more of a treatment response to this health care service,” she said.

In men, rates for the first primary composite outcome were 66.3% and 64.1% in the intervention and usual-care groups, whereas in women those rates were 59.9% and 64.8% (P = .04 for sex interaction).

In the second composite endpoint, all-cause readmission or ED visit, “again, men had an attenuated response” with a HR of 1.03, whereas women had a HR of 0.83. Results were similar to those for the first primary composite outcome: 63.4% and 61.7% for intervention and usual care in men and 57.7% and 63% in women (P = .03 for sex interaction).

In putting the findings into context, Dr. Van Spall said tailoring services to risk in HF patients may be fraught with pitfalls. “We delivered intensive services to those patients at high risk of readmission or death, but it is quite possible they are the least likely to derive benefit by virtue of their advanced heart failure,” she said. “It may be that more benefit would have been derived had we chosen low- or moderate-risk patients to receive the intervention.”

She also said the sex-specific outcomes must be interpreted with caution. “But they do give us pause to consider that services could be titrated more effectively if delivered to patients who are more likely to derive benefit,” Dr. Van Spall said. The finding that women derived more of a benefit is in line with other prospective and observational studies that have found that women have a higher sense of self-care, self-efficacy, and confidence in managing their own health care needs than men.

Dr. Van Spall has no financial relationships to disclose.

PHILADELPHIA – A clinical trial of a program that transitions heart failure patients after they’re discharged from the hospital didn’t result in any appreciable improvement in all-cause death, readmissions or emergency department visits after 6 months overall, but it did show that women responded more favorably than men.

Harriette G.C. Van Spall, MD, MPH, reported 6-month results of the Patient-Centered Transitional Care Services in Heart Failure (PACT-HF) trial of 2,494 HF patients at 10 hospitals in Ontario during February 2015 to March 2016. They were randomized to the care-transition program or usual care. The findings, she said at the American Heart Association scientific sessions, “highlight the gap between efficacy that’s often demonstrated in mechanistic clinical trials and effectiveness when we aim to implement these results in real-world settings.” Three-month PACT-HF results were reported previously (JAMA. 2019 Feb 26;321:753-61).

The transitional-care model consisted of a comprehensive needs assessment by a nurse who also provided self-care education, a patient-centered discharge summary, and follow-up with a family physician within 7 days of discharge, which Dr. Van Spall noted “is not current practice in our health care system.”

Patients deemed high risk for readmission or death also received nurse home visits and scheduled visits to a multidisciplinary heart function clinic within 2-4 weeks of discharge and continuing as long as clinically suitable, said Dr. Van Spall, a principal investigator at the Population Health Research Institute, Hamilton, Ont., and assistant professor in cardiology at McMaster University in Hamilton.

The trial found no difference between the intervention and usual-care groups in the two composite endpoints at 6 months, Dr. Van Spall said: all-cause death, readmissions, or ED visits (63.1% and 64.5%, respectively; P = .50); or all-cause readmissions or ED visits (60.8% and 62.4%; P = .36).

“Despite the mutual overall clinical outcomes, we noted specific differences in response to treatment,” she said. With regard to the composite endpoint that included all-cause death, “Men had an attenuated response to the treatment with a hazard ratio of 1.05 (95% confidence interval, 0.87-1.26), whereas women had a hazard ratio of 0.85 (95% CI, 0.71-1.03), demonstrating that women have more of a treatment response to this health care service,” she said.

In men, rates for the first primary composite outcome were 66.3% and 64.1% in the intervention and usual-care groups, whereas in women those rates were 59.9% and 64.8% (P = .04 for sex interaction).

In the second composite endpoint, all-cause readmission or ED visit, “again, men had an attenuated response” with a HR of 1.03, whereas women had a HR of 0.83. Results were similar to those for the first primary composite outcome: 63.4% and 61.7% for intervention and usual care in men and 57.7% and 63% in women (P = .03 for sex interaction).

In putting the findings into context, Dr. Van Spall said tailoring services to risk in HF patients may be fraught with pitfalls. “We delivered intensive services to those patients at high risk of readmission or death, but it is quite possible they are the least likely to derive benefit by virtue of their advanced heart failure,” she said. “It may be that more benefit would have been derived had we chosen low- or moderate-risk patients to receive the intervention.”

She also said the sex-specific outcomes must be interpreted with caution. “But they do give us pause to consider that services could be titrated more effectively if delivered to patients who are more likely to derive benefit,” Dr. Van Spall said. The finding that women derived more of a benefit is in line with other prospective and observational studies that have found that women have a higher sense of self-care, self-efficacy, and confidence in managing their own health care needs than men.

Dr. Van Spall has no financial relationships to disclose.

PHILADELPHIA – A clinical trial of a program that transitions heart failure patients after they’re discharged from the hospital didn’t result in any appreciable improvement in all-cause death, readmissions or emergency department visits after 6 months overall, but it did show that women responded more favorably than men.

Harriette G.C. Van Spall, MD, MPH, reported 6-month results of the Patient-Centered Transitional Care Services in Heart Failure (PACT-HF) trial of 2,494 HF patients at 10 hospitals in Ontario during February 2015 to March 2016. They were randomized to the care-transition program or usual care. The findings, she said at the American Heart Association scientific sessions, “highlight the gap between efficacy that’s often demonstrated in mechanistic clinical trials and effectiveness when we aim to implement these results in real-world settings.” Three-month PACT-HF results were reported previously (JAMA. 2019 Feb 26;321:753-61).

The transitional-care model consisted of a comprehensive needs assessment by a nurse who also provided self-care education, a patient-centered discharge summary, and follow-up with a family physician within 7 days of discharge, which Dr. Van Spall noted “is not current practice in our health care system.”

Patients deemed high risk for readmission or death also received nurse home visits and scheduled visits to a multidisciplinary heart function clinic within 2-4 weeks of discharge and continuing as long as clinically suitable, said Dr. Van Spall, a principal investigator at the Population Health Research Institute, Hamilton, Ont., and assistant professor in cardiology at McMaster University in Hamilton.

The trial found no difference between the intervention and usual-care groups in the two composite endpoints at 6 months, Dr. Van Spall said: all-cause death, readmissions, or ED visits (63.1% and 64.5%, respectively; P = .50); or all-cause readmissions or ED visits (60.8% and 62.4%; P = .36).

“Despite the mutual overall clinical outcomes, we noted specific differences in response to treatment,” she said. With regard to the composite endpoint that included all-cause death, “Men had an attenuated response to the treatment with a hazard ratio of 1.05 (95% confidence interval, 0.87-1.26), whereas women had a hazard ratio of 0.85 (95% CI, 0.71-1.03), demonstrating that women have more of a treatment response to this health care service,” she said.

In men, rates for the first primary composite outcome were 66.3% and 64.1% in the intervention and usual-care groups, whereas in women those rates were 59.9% and 64.8% (P = .04 for sex interaction).

In the second composite endpoint, all-cause readmission or ED visit, “again, men had an attenuated response” with a HR of 1.03, whereas women had a HR of 0.83. Results were similar to those for the first primary composite outcome: 63.4% and 61.7% for intervention and usual care in men and 57.7% and 63% in women (P = .03 for sex interaction).

In putting the findings into context, Dr. Van Spall said tailoring services to risk in HF patients may be fraught with pitfalls. “We delivered intensive services to those patients at high risk of readmission or death, but it is quite possible they are the least likely to derive benefit by virtue of their advanced heart failure,” she said. “It may be that more benefit would have been derived had we chosen low- or moderate-risk patients to receive the intervention.”

She also said the sex-specific outcomes must be interpreted with caution. “But they do give us pause to consider that services could be titrated more effectively if delivered to patients who are more likely to derive benefit,” Dr. Van Spall said. The finding that women derived more of a benefit is in line with other prospective and observational studies that have found that women have a higher sense of self-care, self-efficacy, and confidence in managing their own health care needs than men.

Dr. Van Spall has no financial relationships to disclose.

In the fall of 2016, Hyma Polimera, MD, a hospitalist at Penn State Health in Hershey, Pa., approached the bedside of a patient with dementia and several other chronic conditions, and introduced herself to him and his family.

The patient’s daughter, who had power of attorney, took one look at Dr. Polimera and told her, “I’d like to see an American doctor.” Dr. Polimera is originally from India, but moved to Europe in 2005 and did her residency in Pennsylvania. She stayed calm and confident – she understood that she had done nothing wrong – but didn’t really know what to do next. All of the other hospitalists on the ward at the time were nonwhite and were also rejected by the patient’s daughter.

“I was wondering what was going to happen and who would provide care to this patient?” she said.

Dr. Polimera is far from alone. Nonwhite physicians, nurses, and other health care providers say they increasingly encounter patients who demand that only “white” health professionals take care of them. The number of these reassignment requests has ticked upward in the last few years, they say, coinciding with the 2016 U.S. presidential campaign and the subsequent election of Donald Trump.

The requests often come at medical centers with no policy in place for how to deal with them. And the unpleasant encounters find providers unprepared for how to respond, not knowing whether or how to resolve the situation with patients and their families. Clinicians sometimes wonder whether they are allowed to care for a patient even if they are willing to do so, and how to go about reassigning a patient to another clinician if that is the choice that the family makes.

To many hospitalists working in the field, it seems obvious that such situations are encouraged by a political environment in which discriminatory beliefs – once considered shameful to express publicly – are now deemed acceptable, even in health care encounters. Indeed, the health care encounter is perhaps the only time some patients will find themselves in intimate interactions with people of other ethnicities.
 

Responding to discrimination

A workshop at the 2019 Society of Hospital Medicine Annual Conference offered hospitalists an opportunity to discuss encounters with patients who expressed discriminatory attitudes. One physician, of South Asian descent, said that she had encountered no reassignment requests rooted in racial intolerance over more than a decade of work, but has encountered several in the last year or two.

Sabrina Chaklos, MD, a hospitalist at Burlington, Mass.–based Lahey Hospital & Medical Center and clinical assistant professor at Tufts University, said she has had a similar experience.

“It was blatantly bad behavior for 2018,” she said. Dr. Chaklos said she and other clinicians of color have been told, “I want an American doctor,” and that some patients see her darker complexion and conclude, “You must not be an American.”

Given the charged political environment since 2016, some medical facilities have been adapting how they respond to these comments and requests.

“The policy of the organization prior to 2016 was to give patients a new doctor,” Dr. Chaklos said. “Within the past year or so, they’re finally allowing people to say, ‘Look, you cannot just pick and choose your doctor,’ based on arbitrary reasons that are discriminatory in nature.”

Emily Whitgob, MD, MEd, a developmental-behavioral pediatrician at Santa Clara Valley Medical Center in San Jose, Calif., said that, several years ago, a scenario unfolded that led her to study the issue. An intern she was overseeing told her that the father of a pediatric patient had scrutinized the intern’s name tag and said, “Is that a Jewish last name? I don’t want a Jewish doctor.”

“I didn’t know what to do,” Dr. Whitgob said. Later, she brought up the situation at a meeting of 30 staff members. It led to an outpouring of sharing about similar incidents that other clinicians had experienced but had never talked about with colleagues.

“Half the room, by the end, was in tears talking about their experiences,” Dr. Whitgob said.

Since then, she has led research into how physicians typically handle such situations, performing semistructured interviews to survey pediatricians about their experiences with patients who discriminate on racial and ethnic grounds.

One important step, she said, is assessing the acuity of the illness involved to help determine whether the transfer of a patient from one provider to another should even be considered. In a dire situation, or when the physician involved is the foremost expert on a given condition, it might not be realistic.

Dr. Whitgob said some clinicians advocated cultivating a kind of alliance with the parents of pediatric patients, informing them that they’re part of a team that interacts with many types of providers, and redirecting them to focus on their child’s care.

“This takes time, and in a busy setting, that might not happen,” she acknowledged.

Physicians surveyed also said they try to depersonalize the uncomfortable encounter, remembering that discrimination is often motivated by a patient’s fears and a lack of control.

An important consideration, researchers found, was ensuring a safe learning environment for trainees, telling patients they would trust the physician with the care of their own children, escalating a complaint to hospital administration when appropriate, and empowering trainees to choose the next step in a situation.

Dr. Whitgob said that handling a reassignment request based on discriminatory sentiments is not as easy as “calling out ‘Code Bigotry.’ ”

“It’s not that simple,” Dr. Whitgob said. “There’s not going to be a one-size-fits-all or even a one-size-fits-most solution. Each case is an individual case.”
 

Taking action

Penn State Health is based in Hershey, Pa., a city that tends to vote Democratic in local and national elections but is encircled by Republican-leaning counties. Dr. Polimera’s encounter with her patient’s daughter led to changes in the way the health system handles encounters like hers.

When Dr. Polimera explained the situation to physician leadership, she was asked whether she was still comfortable taking care of the patient, and she said yes. The physician leaders informed the family that they could not change providers simply because of ethnicity. But that was just the first step.

Ultimately, the health system undertook a survey of all its health care providers, to determine whether others had similar experiences with patients or families, and had to deal with rude comments or were rejected as caregivers based on their race, gender, or religion.

“The feedback we received was massive and detailed,” Dr. Polimera said.

Brian McGillen, MD, section chief of hospital medicine and associate professor in the department of medicine at Penn State Health, said physician leaders took the survey results to the dean’s executive council, a who’s-who of medical leadership at the health system.

“I read aloud to the executive council what our folks were facing out on the floors,” Dr. McGillen said. “And I was halfway through my third story when the dean threw his hands up in the air and said, ‘We have to do something.’ ”

As a result, the health system’s policy on patient responsibility was changed to protect all health care providers from threats, violence, disrespectful communication, or harassment by patients, families, and other visitors. Before the change, the policy covered only discriminatory acts by patients themselves.

Penn State Health is now embarking on a training program for faculty, residents, and students that uses simulations of common hospital encounters. The health system also is engaging its patient relations staff to help mediate patient reassignment requests, and is trying to increase real-time debriefing of these events to further improve awareness and training.

Dr. McGillen noted that researchers at the University of North Texas, using data from the Anti-Defamation League, found that counties in which President Trump held campaign rallies – such as Dauphin County, Pa., where Hershey is located – had a 226% increase in hate crimes in the months after the rallies.

“This isn’t to say that every county and every person in these counties that voted for Mr. Trump is racist, but we surely know that his campaign unlocked an undercurrent of political incorrectness that has existed for ages,” he said. “We had to do something as an organization.”
 

Adapting to change

While some health systems are acting to limit the harm caused by discrimination, there is still much awareness to be raised and work to be done on this issue nationally. Some hospitalists at the 2019 SHM Annual Conference said they suspect that discriminatory incidents involving patients are still so underreported that the C-suite leaders at their hospitals do not recognize how serious a problem it is. Attendees at the HM19 workshop said discriminatory behavior by patients could affect hospitalist turnover and lead to burnout.

Multiple hospitalists at the workshop said that if a transfer of a patient is going to take place – if the patient requests a “white” doctor and there is not one available where the patient is admitted – they are unsure whether it is their responsibility to make the necessary phone calls. Some hospitalists say that if that job does fall to them, it interrupts work flow.

Susan Hakes, MHA, director of hospital administration at the Guthrie Clinic in Ithaca, N.Y., said that when a patient recently asked for a “white” doctor and there was not one available at the time of the request, the patient changed her mind when costs were considered.

“I was willing to have this patient transferred to another one of our hospitals that did have a white doctor, but it would have been at her expense since insurance wouldn’t cover the ambulance ride,” Ms. Hakes said. “She had second thoughts after learning that.”

Ms. Hakes said that the broader community in her region – which is predominantly white – needs to adapt to a changing health care scene.

“We’re recruiting international nurses now, due to the nursing shortage,” she said. “It will serve our community well to be receptive and welcome this additional resource.”

Kunal P. Bhagat, MD, chief of hospital medicine at Christiana Care Health System in Newark, Del., said that medical centers should set parameters for action when a patient discriminates, but that clinicians should not expect to fundamentally change a patient’s mindset.

In the fall of 2016, Hyma Polimera, MD, a hospitalist at Penn State Health in Hershey, Pa., approached the bedside of a patient with dementia and several other chronic conditions, and introduced herself to him and his family.

The patient’s daughter, who had power of attorney, took one look at Dr. Polimera and told her, “I’d like to see an American doctor.” Dr. Polimera is originally from India, but moved to Europe in 2005 and did her residency in Pennsylvania. She stayed calm and confident – she understood that she had done nothing wrong – but didn’t really know what to do next. All of the other hospitalists on the ward at the time were nonwhite and were also rejected by the patient’s daughter.

“I was wondering what was going to happen and who would provide care to this patient?” she said.

Dr. Polimera is far from alone. Nonwhite physicians, nurses, and other health care providers say they increasingly encounter patients who demand that only “white” health professionals take care of them. The number of these reassignment requests has ticked upward in the last few years, they say, coinciding with the 2016 U.S. presidential campaign and the subsequent election of Donald Trump.

The requests often come at medical centers with no policy in place for how to deal with them. And the unpleasant encounters find providers unprepared for how to respond, not knowing whether or how to resolve the situation with patients and their families. Clinicians sometimes wonder whether they are allowed to care for a patient even if they are willing to do so, and how to go about reassigning a patient to another clinician if that is the choice that the family makes.

To many hospitalists working in the field, it seems obvious that such situations are encouraged by a political environment in which discriminatory beliefs – once considered shameful to express publicly – are now deemed acceptable, even in health care encounters. Indeed, the health care encounter is perhaps the only time some patients will find themselves in intimate interactions with people of other ethnicities.
 

Responding to discrimination

A workshop at the 2019 Society of Hospital Medicine Annual Conference offered hospitalists an opportunity to discuss encounters with patients who expressed discriminatory attitudes. One physician, of South Asian descent, said that she had encountered no reassignment requests rooted in racial intolerance over more than a decade of work, but has encountered several in the last year or two.

Sabrina Chaklos, MD, a hospitalist at Burlington, Mass.–based Lahey Hospital & Medical Center and clinical assistant professor at Tufts University, said she has had a similar experience.

“It was blatantly bad behavior for 2018,” she said. Dr. Chaklos said she and other clinicians of color have been told, “I want an American doctor,” and that some patients see her darker complexion and conclude, “You must not be an American.”

Given the charged political environment since 2016, some medical facilities have been adapting how they respond to these comments and requests.

“The policy of the organization prior to 2016 was to give patients a new doctor,” Dr. Chaklos said. “Within the past year or so, they’re finally allowing people to say, ‘Look, you cannot just pick and choose your doctor,’ based on arbitrary reasons that are discriminatory in nature.”

Emily Whitgob, MD, MEd, a developmental-behavioral pediatrician at Santa Clara Valley Medical Center in San Jose, Calif., said that, several years ago, a scenario unfolded that led her to study the issue. An intern she was overseeing told her that the father of a pediatric patient had scrutinized the intern’s name tag and said, “Is that a Jewish last name? I don’t want a Jewish doctor.”

“I didn’t know what to do,” Dr. Whitgob said. Later, she brought up the situation at a meeting of 30 staff members. It led to an outpouring of sharing about similar incidents that other clinicians had experienced but had never talked about with colleagues.

“Half the room, by the end, was in tears talking about their experiences,” Dr. Whitgob said.

Since then, she has led research into how physicians typically handle such situations, performing semistructured interviews to survey pediatricians about their experiences with patients who discriminate on racial and ethnic grounds.

One important step, she said, is assessing the acuity of the illness involved to help determine whether the transfer of a patient from one provider to another should even be considered. In a dire situation, or when the physician involved is the foremost expert on a given condition, it might not be realistic.

Dr. Whitgob said some clinicians advocated cultivating a kind of alliance with the parents of pediatric patients, informing them that they’re part of a team that interacts with many types of providers, and redirecting them to focus on their child’s care.

“This takes time, and in a busy setting, that might not happen,” she acknowledged.

Physicians surveyed also said they try to depersonalize the uncomfortable encounter, remembering that discrimination is often motivated by a patient’s fears and a lack of control.

An important consideration, researchers found, was ensuring a safe learning environment for trainees, telling patients they would trust the physician with the care of their own children, escalating a complaint to hospital administration when appropriate, and empowering trainees to choose the next step in a situation.

Dr. Whitgob said that handling a reassignment request based on discriminatory sentiments is not as easy as “calling out ‘Code Bigotry.’ ”

“It’s not that simple,” Dr. Whitgob said. “There’s not going to be a one-size-fits-all or even a one-size-fits-most solution. Each case is an individual case.”
 

Taking action

Penn State Health is based in Hershey, Pa., a city that tends to vote Democratic in local and national elections but is encircled by Republican-leaning counties. Dr. Polimera’s encounter with her patient’s daughter led to changes in the way the health system handles encounters like hers.

When Dr. Polimera explained the situation to physician leadership, she was asked whether she was still comfortable taking care of the patient, and she said yes. The physician leaders informed the family that they could not change providers simply because of ethnicity. But that was just the first step.

Ultimately, the health system undertook a survey of all its health care providers, to determine whether others had similar experiences with patients or families, and had to deal with rude comments or were rejected as caregivers based on their race, gender, or religion.

“The feedback we received was massive and detailed,” Dr. Polimera said.

Brian McGillen, MD, section chief of hospital medicine and associate professor in the department of medicine at Penn State Health, said physician leaders took the survey results to the dean’s executive council, a who’s-who of medical leadership at the health system.

“I read aloud to the executive council what our folks were facing out on the floors,” Dr. McGillen said. “And I was halfway through my third story when the dean threw his hands up in the air and said, ‘We have to do something.’ ”

As a result, the health system’s policy on patient responsibility was changed to protect all health care providers from threats, violence, disrespectful communication, or harassment by patients, families, and other visitors. Before the change, the policy covered only discriminatory acts by patients themselves.

Penn State Health is now embarking on a training program for faculty, residents, and students that uses simulations of common hospital encounters. The health system also is engaging its patient relations staff to help mediate patient reassignment requests, and is trying to increase real-time debriefing of these events to further improve awareness and training.

Dr. McGillen noted that researchers at the University of North Texas, using data from the Anti-Defamation League, found that counties in which President Trump held campaign rallies – such as Dauphin County, Pa., where Hershey is located – had a 226% increase in hate crimes in the months after the rallies.

“This isn’t to say that every county and every person in these counties that voted for Mr. Trump is racist, but we surely know that his campaign unlocked an undercurrent of political incorrectness that has existed for ages,” he said. “We had to do something as an organization.”
 

Adapting to change

While some health systems are acting to limit the harm caused by discrimination, there is still much awareness to be raised and work to be done on this issue nationally. Some hospitalists at the 2019 SHM Annual Conference said they suspect that discriminatory incidents involving patients are still so underreported that the C-suite leaders at their hospitals do not recognize how serious a problem it is. Attendees at the HM19 workshop said discriminatory behavior by patients could affect hospitalist turnover and lead to burnout.

Multiple hospitalists at the workshop said that if a transfer of a patient is going to take place – if the patient requests a “white” doctor and there is not one available where the patient is admitted – they are unsure whether it is their responsibility to make the necessary phone calls. Some hospitalists say that if that job does fall to them, it interrupts work flow.

Susan Hakes, MHA, director of hospital administration at the Guthrie Clinic in Ithaca, N.Y., said that when a patient recently asked for a “white” doctor and there was not one available at the time of the request, the patient changed her mind when costs were considered.

“I was willing to have this patient transferred to another one of our hospitals that did have a white doctor, but it would have been at her expense since insurance wouldn’t cover the ambulance ride,” Ms. Hakes said. “She had second thoughts after learning that.”

Ms. Hakes said that the broader community in her region – which is predominantly white – needs to adapt to a changing health care scene.

“We’re recruiting international nurses now, due to the nursing shortage,” she said. “It will serve our community well to be receptive and welcome this additional resource.”

Kunal P. Bhagat, MD, chief of hospital medicine at Christiana Care Health System in Newark, Del., said that medical centers should set parameters for action when a patient discriminates, but that clinicians should not expect to fundamentally change a patient’s mindset.

In the fall of 2016, Hyma Polimera, MD, a hospitalist at Penn State Health in Hershey, Pa., approached the bedside of a patient with dementia and several other chronic conditions, and introduced herself to him and his family.

The patient’s daughter, who had power of attorney, took one look at Dr. Polimera and told her, “I’d like to see an American doctor.” Dr. Polimera is originally from India, but moved to Europe in 2005 and did her residency in Pennsylvania. She stayed calm and confident – she understood that she had done nothing wrong – but didn’t really know what to do next. All of the other hospitalists on the ward at the time were nonwhite and were also rejected by the patient’s daughter.

“I was wondering what was going to happen and who would provide care to this patient?” she said.

Dr. Polimera is far from alone. Nonwhite physicians, nurses, and other health care providers say they increasingly encounter patients who demand that only “white” health professionals take care of them. The number of these reassignment requests has ticked upward in the last few years, they say, coinciding with the 2016 U.S. presidential campaign and the subsequent election of Donald Trump.

The requests often come at medical centers with no policy in place for how to deal with them. And the unpleasant encounters find providers unprepared for how to respond, not knowing whether or how to resolve the situation with patients and their families. Clinicians sometimes wonder whether they are allowed to care for a patient even if they are willing to do so, and how to go about reassigning a patient to another clinician if that is the choice that the family makes.

To many hospitalists working in the field, it seems obvious that such situations are encouraged by a political environment in which discriminatory beliefs – once considered shameful to express publicly – are now deemed acceptable, even in health care encounters. Indeed, the health care encounter is perhaps the only time some patients will find themselves in intimate interactions with people of other ethnicities.
 

Responding to discrimination

A workshop at the 2019 Society of Hospital Medicine Annual Conference offered hospitalists an opportunity to discuss encounters with patients who expressed discriminatory attitudes. One physician, of South Asian descent, said that she had encountered no reassignment requests rooted in racial intolerance over more than a decade of work, but has encountered several in the last year or two.

Sabrina Chaklos, MD, a hospitalist at Burlington, Mass.–based Lahey Hospital & Medical Center and clinical assistant professor at Tufts University, said she has had a similar experience.

“It was blatantly bad behavior for 2018,” she said. Dr. Chaklos said she and other clinicians of color have been told, “I want an American doctor,” and that some patients see her darker complexion and conclude, “You must not be an American.”

Given the charged political environment since 2016, some medical facilities have been adapting how they respond to these comments and requests.

“The policy of the organization prior to 2016 was to give patients a new doctor,” Dr. Chaklos said. “Within the past year or so, they’re finally allowing people to say, ‘Look, you cannot just pick and choose your doctor,’ based on arbitrary reasons that are discriminatory in nature.”

Emily Whitgob, MD, MEd, a developmental-behavioral pediatrician at Santa Clara Valley Medical Center in San Jose, Calif., said that, several years ago, a scenario unfolded that led her to study the issue. An intern she was overseeing told her that the father of a pediatric patient had scrutinized the intern’s name tag and said, “Is that a Jewish last name? I don’t want a Jewish doctor.”

“I didn’t know what to do,” Dr. Whitgob said. Later, she brought up the situation at a meeting of 30 staff members. It led to an outpouring of sharing about similar incidents that other clinicians had experienced but had never talked about with colleagues.

“Half the room, by the end, was in tears talking about their experiences,” Dr. Whitgob said.

Since then, she has led research into how physicians typically handle such situations, performing semistructured interviews to survey pediatricians about their experiences with patients who discriminate on racial and ethnic grounds.

One important step, she said, is assessing the acuity of the illness involved to help determine whether the transfer of a patient from one provider to another should even be considered. In a dire situation, or when the physician involved is the foremost expert on a given condition, it might not be realistic.

Dr. Whitgob said some clinicians advocated cultivating a kind of alliance with the parents of pediatric patients, informing them that they’re part of a team that interacts with many types of providers, and redirecting them to focus on their child’s care.

“This takes time, and in a busy setting, that might not happen,” she acknowledged.

Physicians surveyed also said they try to depersonalize the uncomfortable encounter, remembering that discrimination is often motivated by a patient’s fears and a lack of control.

An important consideration, researchers found, was ensuring a safe learning environment for trainees, telling patients they would trust the physician with the care of their own children, escalating a complaint to hospital administration when appropriate, and empowering trainees to choose the next step in a situation.

Dr. Whitgob said that handling a reassignment request based on discriminatory sentiments is not as easy as “calling out ‘Code Bigotry.’ ”

“It’s not that simple,” Dr. Whitgob said. “There’s not going to be a one-size-fits-all or even a one-size-fits-most solution. Each case is an individual case.”
 

Taking action

Penn State Health is based in Hershey, Pa., a city that tends to vote Democratic in local and national elections but is encircled by Republican-leaning counties. Dr. Polimera’s encounter with her patient’s daughter led to changes in the way the health system handles encounters like hers.

When Dr. Polimera explained the situation to physician leadership, she was asked whether she was still comfortable taking care of the patient, and she said yes. The physician leaders informed the family that they could not change providers simply because of ethnicity. But that was just the first step.

Ultimately, the health system undertook a survey of all its health care providers, to determine whether others had similar experiences with patients or families, and had to deal with rude comments or were rejected as caregivers based on their race, gender, or religion.

“The feedback we received was massive and detailed,” Dr. Polimera said.

Brian McGillen, MD, section chief of hospital medicine and associate professor in the department of medicine at Penn State Health, said physician leaders took the survey results to the dean’s executive council, a who’s-who of medical leadership at the health system.

“I read aloud to the executive council what our folks were facing out on the floors,” Dr. McGillen said. “And I was halfway through my third story when the dean threw his hands up in the air and said, ‘We have to do something.’ ”

As a result, the health system’s policy on patient responsibility was changed to protect all health care providers from threats, violence, disrespectful communication, or harassment by patients, families, and other visitors. Before the change, the policy covered only discriminatory acts by patients themselves.

Penn State Health is now embarking on a training program for faculty, residents, and students that uses simulations of common hospital encounters. The health system also is engaging its patient relations staff to help mediate patient reassignment requests, and is trying to increase real-time debriefing of these events to further improve awareness and training.

Dr. McGillen noted that researchers at the University of North Texas, using data from the Anti-Defamation League, found that counties in which President Trump held campaign rallies – such as Dauphin County, Pa., where Hershey is located – had a 226% increase in hate crimes in the months after the rallies.

“This isn’t to say that every county and every person in these counties that voted for Mr. Trump is racist, but we surely know that his campaign unlocked an undercurrent of political incorrectness that has existed for ages,” he said. “We had to do something as an organization.”
 

Adapting to change

While some health systems are acting to limit the harm caused by discrimination, there is still much awareness to be raised and work to be done on this issue nationally. Some hospitalists at the 2019 SHM Annual Conference said they suspect that discriminatory incidents involving patients are still so underreported that the C-suite leaders at their hospitals do not recognize how serious a problem it is. Attendees at the HM19 workshop said discriminatory behavior by patients could affect hospitalist turnover and lead to burnout.

Multiple hospitalists at the workshop said that if a transfer of a patient is going to take place – if the patient requests a “white” doctor and there is not one available where the patient is admitted – they are unsure whether it is their responsibility to make the necessary phone calls. Some hospitalists say that if that job does fall to them, it interrupts work flow.

Susan Hakes, MHA, director of hospital administration at the Guthrie Clinic in Ithaca, N.Y., said that when a patient recently asked for a “white” doctor and there was not one available at the time of the request, the patient changed her mind when costs were considered.

“I was willing to have this patient transferred to another one of our hospitals that did have a white doctor, but it would have been at her expense since insurance wouldn’t cover the ambulance ride,” Ms. Hakes said. “She had second thoughts after learning that.”

Ms. Hakes said that the broader community in her region – which is predominantly white – needs to adapt to a changing health care scene.

“We’re recruiting international nurses now, due to the nursing shortage,” she said. “It will serve our community well to be receptive and welcome this additional resource.”

Kunal P. Bhagat, MD, chief of hospital medicine at Christiana Care Health System in Newark, Del., said that medical centers should set parameters for action when a patient discriminates, but that clinicians should not expect to fundamentally change a patient’s mindset.

Emergency department overcrowding is common, and it can result in both increased costs and poor clinical outcomes.

EyeMark/thinkstockphotos.com

“We sought to evaluate the impact and safety of hospitalist-directed transfers on patients boarding in the ER as a means to alleviate overcrowding,” said Yihan Chen, MD, MPH, of the University of California, Los Angeles. “High inpatient census has been shown to impair ER throughput by increasing the number of ER ‘boarders,’ which creates a suboptimal care environment for practicing hospitalists. For example, some studies have shown associations with delays in medical decision making when admitted patients remain and receive care in the emergency department.”

Dr. Chen was the lead author of an abstract describing a chart review on 1,016 admissions to the hospitalist service. About half remained at the reference hospital and half were transferred to a nearby affiliate hospital.

In analyzing the data, the researchers’ top takeaway was the many benefits for the transferred patients. “Hospitalist-directed transfer and direct admission of stable ER patients to an affiliate facility with greater bed availability is associated with shorter ER lengths of stay, fewer adverse events, and lower rates of readmission within 30 days of hospitalization,” Dr. Chen said. “Having a system in place to transfer patients to an affiliate hospital with lower census is a way to improve flow.”

Hospitalists have a unique opportunity to take on a triage role in the ED to safely and effectively decrease ED overcrowding and throughput, improve resource utilization at the hospital level, and allow for other hospitalists at their institution to optimize patient care on the inpatient ward rather than in the ED, Dr. Chen said.

“Health systems privileged to have more than one facility should consider an intra–health system transfer process lead by triage hospitalists to identify stable patients who can be directly admitted to the off-site, affiliate hospital,” she said. “By improving patient throughput, hospitalists would play a critical role in relieving institutional stressors, impacting cost and quality of care, and enhancing clinical outcomes.”

Reference

1. Chen Y et al. Hospitalist-Directed Transfers Improve Emergency Room Length of Stay. Hospital Medicine 2018, Abstract 12. Accessed April 3, 2019.

Emergency department overcrowding is common, and it can result in both increased costs and poor clinical outcomes.

EyeMark/thinkstockphotos.com

“We sought to evaluate the impact and safety of hospitalist-directed transfers on patients boarding in the ER as a means to alleviate overcrowding,” said Yihan Chen, MD, MPH, of the University of California, Los Angeles. “High inpatient census has been shown to impair ER throughput by increasing the number of ER ‘boarders,’ which creates a suboptimal care environment for practicing hospitalists. For example, some studies have shown associations with delays in medical decision making when admitted patients remain and receive care in the emergency department.”

Dr. Chen was the lead author of an abstract describing a chart review on 1,016 admissions to the hospitalist service. About half remained at the reference hospital and half were transferred to a nearby affiliate hospital.

In analyzing the data, the researchers’ top takeaway was the many benefits for the transferred patients. “Hospitalist-directed transfer and direct admission of stable ER patients to an affiliate facility with greater bed availability is associated with shorter ER lengths of stay, fewer adverse events, and lower rates of readmission within 30 days of hospitalization,” Dr. Chen said. “Having a system in place to transfer patients to an affiliate hospital with lower census is a way to improve flow.”

Hospitalists have a unique opportunity to take on a triage role in the ED to safely and effectively decrease ED overcrowding and throughput, improve resource utilization at the hospital level, and allow for other hospitalists at their institution to optimize patient care on the inpatient ward rather than in the ED, Dr. Chen said.

“Health systems privileged to have more than one facility should consider an intra–health system transfer process lead by triage hospitalists to identify stable patients who can be directly admitted to the off-site, affiliate hospital,” she said. “By improving patient throughput, hospitalists would play a critical role in relieving institutional stressors, impacting cost and quality of care, and enhancing clinical outcomes.”

Reference

1. Chen Y et al. Hospitalist-Directed Transfers Improve Emergency Room Length of Stay. Hospital Medicine 2018, Abstract 12. Accessed April 3, 2019.

Emergency department overcrowding is common, and it can result in both increased costs and poor clinical outcomes.

EyeMark/thinkstockphotos.com

“We sought to evaluate the impact and safety of hospitalist-directed transfers on patients boarding in the ER as a means to alleviate overcrowding,” said Yihan Chen, MD, MPH, of the University of California, Los Angeles. “High inpatient census has been shown to impair ER throughput by increasing the number of ER ‘boarders,’ which creates a suboptimal care environment for practicing hospitalists. For example, some studies have shown associations with delays in medical decision making when admitted patients remain and receive care in the emergency department.”

Dr. Chen was the lead author of an abstract describing a chart review on 1,016 admissions to the hospitalist service. About half remained at the reference hospital and half were transferred to a nearby affiliate hospital.

In analyzing the data, the researchers’ top takeaway was the many benefits for the transferred patients. “Hospitalist-directed transfer and direct admission of stable ER patients to an affiliate facility with greater bed availability is associated with shorter ER lengths of stay, fewer adverse events, and lower rates of readmission within 30 days of hospitalization,” Dr. Chen said. “Having a system in place to transfer patients to an affiliate hospital with lower census is a way to improve flow.”

Hospitalists have a unique opportunity to take on a triage role in the ED to safely and effectively decrease ED overcrowding and throughput, improve resource utilization at the hospital level, and allow for other hospitalists at their institution to optimize patient care on the inpatient ward rather than in the ED, Dr. Chen said.

“Health systems privileged to have more than one facility should consider an intra–health system transfer process lead by triage hospitalists to identify stable patients who can be directly admitted to the off-site, affiliate hospital,” she said. “By improving patient throughput, hospitalists would play a critical role in relieving institutional stressors, impacting cost and quality of care, and enhancing clinical outcomes.”

Reference

1. Chen Y et al. Hospitalist-Directed Transfers Improve Emergency Room Length of Stay. Hospital Medicine 2018, Abstract 12. Accessed April 3, 2019.

Background: There is increasing concern that the patient experience in the hospital may be associated with post-hospital adverse outcomes, including new or recurrent illnesses after discharge or unplanned return to the hospital or readmission.

Because this is an observational study, causal inferences were not possible; however, hospitalists should keep in mind the possible association of the patient experience and the link to clinical outcomes.

Bottom line: Trauma of hospitalization is common and may be associated with an increased 30-day risk of readmission or ED visit.

Citation: Rawal J et al. Association of the trauma of hospitalization with 30-day readmission or emergency department visit. JAMA Intern Med. 2019;179(1):38-45.

Dr. Wang is an associate professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.

Background: There is increasing concern that the patient experience in the hospital may be associated with post-hospital adverse outcomes, including new or recurrent illnesses after discharge or unplanned return to the hospital or readmission.

Because this is an observational study, causal inferences were not possible; however, hospitalists should keep in mind the possible association of the patient experience and the link to clinical outcomes.

Bottom line: Trauma of hospitalization is common and may be associated with an increased 30-day risk of readmission or ED visit.

Citation: Rawal J et al. Association of the trauma of hospitalization with 30-day readmission or emergency department visit. JAMA Intern Med. 2019;179(1):38-45.

Dr. Wang is an associate professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.

Background: There is increasing concern that the patient experience in the hospital may be associated with post-hospital adverse outcomes, including new or recurrent illnesses after discharge or unplanned return to the hospital or readmission.

Because this is an observational study, causal inferences were not possible; however, hospitalists should keep in mind the possible association of the patient experience and the link to clinical outcomes.

Bottom line: Trauma of hospitalization is common and may be associated with an increased 30-day risk of readmission or ED visit.

Citation: Rawal J et al. Association of the trauma of hospitalization with 30-day readmission or emergency department visit. JAMA Intern Med. 2019;179(1):38-45.

Dr. Wang is an associate professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.