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Abstracts for the Society of Hospital Medicine Meeting May 2011

Abstracts for the Society of Hospital Medicine Meeting May 2011

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    Hospital medicine shm 2011 abstracts Hospital medicine shm 2011 abstracts Document Transcript

    • 2011 Abstracts Research, Innovations,Clinical Vignettes Competition Hospital Medicine 2011 May10–13, 2011Gaylord Texan Resort and Convention Center Á Grapevine, TX
    • Contents 135. ICU BEDSIDE ASSESSMENTS OF DELIRIUM: SUSTAINABILITY AND RELIABILITY. Eduard.............................. . . .Page Vasilevskis, MD, Tennessee Valley VA.Research Abstracts . . . . . . . . . . . . . . . ..... 1 139. A SIMPLIFIED FRAILTY INDEX TO PREDICTResearch Abstracts: Plenary and Oral PERIOPERATIVE RISK IN THE ORTHOPEDIC Presentations, only . . . . . . . . . . . . . . . . . . 93 POPULATION. Peter Watson, MD, Henry Ford Hospital.Other Research Abstracts. . . . . . . . . . . . . . . 96 Research, Oral Presentations OnlyInnovations Abstracts . . . . . . . . . . . . . . . . . . 97 CLINICAL OUTCOMES AMONG NON–MECHANICALLYInnovations Abstracts: Plenary and Oral VENTILATED PATIENTS WITH ACUTE LUNG INJURY. Presentations, only . . . . . . . . . . . . . . . . . .142 Kirsten Kangelaris, MD, MAS, University of California.Clinical Vignettes Abstracts. . . . . . . . . . . . . .143 THE DERIVATION OF THE LUNG INJURY SEVERITYOther Clinical Vignettes Abstracts . . . . . . . . .273 SCORE (LISS): A PROGNOSTIC INDEX FOR IN-HOSPITAL MORTALITY IN ACUTE LUNG INJURY. Kirsten Kangelaris, MD, MAS, University of California.Best of Research, Innovations, and Clinical Vignettes EVALUATION OF AN ELECTRONIC DISCHARGEin 2011 Presentations SUMMARY FOR TIMELINESS AND QUALITY COMPARED TO DICTATION. Michelle Mourad, MD,Research University of California.100. COMPLIANCE WITH NEW ACGME DUTY-HOUR UNDERSTANDING UNSUCCESSFUL PROCEDURES ONREQUIREMENTS CAN IMPROVE PATIENT CARE A HOSPITALIST PROCEDURE SERVICE. MichelleMEASURES. Glenn Rosenbluth, MD, University of Mourad, MD, University of California.California. Innovations, Oral and Poster PresentationsFINANCIAL IMPACT OF PRESENTING LAB COST DATATO PROVIDERS AT THE TIME OF ORDER ENTRY: A 158. RESIDENT CASE REVIEW AT THERANDOMIZED CONTROLLED CLINICAL TRIAL. Leonard DEPARTMENTAL LEVEL: A WIN–WIN SCENARIO.Feldman, MD, Johns Hopkins University Medical Center. Alexander Carbo, MD, Beth Israel Deaconess Medical Center.Innovations 164. DESIGN AND IMPLEMENTATION OF AN AUTO-USING TOYOTA PRODUCTION SYSTEM TOOLS TO MATED E-MAIL NOTIFICATION SYSTEM FOR RESULTSREENGINEER AN ACADEMIC MEDICAL SERVICE. OF TESTS PENDING AT DISCHARGE. Anuj Dalal, MD,Diana Mancini, MD, Denver Health Hospital Authority. Brigham and Women’s Hospital. 197. ASSESSING PERCEPTION OF A NEWLY IMPLEMENTED HOSPITALIST FEEDBACK MODEL.Oral Presentations Dahlia Rizk, DO, Beth Israel Medical Center.Research, Oral and Poster Presentations Innovations, Oral Presentations Only84. PHARMACIST GLYCEMIC CONTROL TEAM IMPROVEMENT IN EMERGENCY DEPARTMENTIMPROVES GLYCEMIC CONTROL AND REDUCES TREATMENT CAPACITY:HOSPITAL READMISSIONS IN NON–CRITICALLY ILL A HEALTH SYSTEM INTEGRATION APPROACH. DiegoSURGICAL PATIENTS. Karen Mularski, MD, Northwest Martinez-Vasquez, MD, MPH, Maryland General Hospital,Permanente. Baltimore, MD, Michael Winters, MD, University Of85. USE OF ELECTROCARDIOGRAPHIC TELEMETRY Maryland Medical Center.MONITORING ON A MEDICINE SERVICE. A NOVEL APPROACH TO THE ADULT PEDIATRICNader Najafi, MD, University of California. PATIENT. Nathan O’Dorisio, MD, Ohio State University.
    • Since the inception of the Society of Hospital Medicine Annual Meeting, the Research, Innovations, and Clinical Vignettes (RIV)Competition has been an integral part of the program. The number of abstract entries has grown to 675 for Hospital Medicine2011, and quality and creativity have grown with quantity. Topics spanned many clinical areas and ranged from scientificresearch to innovations in hospital medicine practice to diagnostic dilemmas in clinical medicine.For the sixth year, SHM is proud to devote a Supplement of the Journal of Hospital Medicine to the publication of the acceptedabstracts.SHM gratefully acknowledges the contributions of the cochairs and abstract reviewers of the RIV Competition.Annual Meeting Course Director Reviewers Francis Mc Bee Orzulak, MD Daniel Dressler, MD, MSc, SFHM, Chadi Alraies, MD David Meltzer, MD, PhD, FHM Emory University School of Vineet Arora, MD, FHM Geraldine Menard, MD Medicine Moises Auron, MD, FAAP, FACP Joshua Metlay, MD, PhDRIV Chair Rubin Bahuva, MD Susanne Mierendorf, MD, MS, FHM Bradley Sharpe, MD, SFHM, FACP, Jeff Barsuk, MD, FHM Satyen Nichani, MD University of California, Adrienne Bennett, MD Heather Nye, MD, PhD San Francisco Aaron Berg, MD Kevin O’Leary, MD, MSResearch Cochairs Pouya Bina, MD Rita Pappas, MD Daniel Brotman, MD, FHM, Shane Borkowsky, MD Mital Patel, MD, MBBS Johns Hopkins University School of Alex Carbo, MD, SFHM Rehan Qayyum, MD, MBBS Medicine Dominique Cosco, MD Anitha Rajamanickam, MD Dana Edelson, MD, MS, Erik DeLue, MD, MBA, SFHM Daniel Ries, MD University of Chicago Margaret Fang, MD, FHM Greg Ruhnke, MD Medical Center Leonard Feldman, MD, FAAP, FACP Adam Schaffer, MDInnovations Cochairs Rachel George, MD, MBA, CPE, Danielle Scheurer, MD, SFHM Luci Leykum, MD, MBA, MSc, FHM, FHM Jeffrey Schnipper, MD, MPH, FHM University of Texas Health Science Sarah Hartley, MD Zishan Siddiqui, MD Center Carrie Herzke, MD William Southern, MD Andrew Modest, MD, Susan Hunt, MD Audrey Tio, MD Harvard Vanguard Medical Saurabh Kandpal, MD Associates Haruka Torok MD, MS Sunil Kripalani, MD, MSc, SFHM Robert Trowbridge, MDClinical Vignettes Cochairs David Lovinger, MD, FHM Ed Vasilevskis, MD Paul Grant, MD, Sudhir Manda, MD Sridhar Venkatachalam, MD University of Michigan Michelle Marks, DO, FAAP Christopher Whinney, MD Tarek Hamieh, MD, Scott Marsal, MD Health Partners Medical Group
    • regarding HIV testing have shifted. Further evaluation ofRESEARCH physician attitudes and increased education regarding the1 CDC recommendations and changes in state law are neces-EVALUATION OF HIV SCREENING UTILITY AND sary to increase HIV screening rates.PRACTICABILITY IN AN INPATIENT MEDICINE Disclosures:WARD SETTING A. K. Abramson - none; E. Machtinger - noneAnna Abramson, MD, Edward Machtinger, MD; University ofCalifornia, San Francisco, San Francisco, CABackground: The Centers for Disease Control and Preven- 2tion recommended in 2006 to test all patients for HIV with- SAFETY OF ARTHROCENTESIS IN PATIENTS ONout requiring counseling or written consent. The CDC CHRONIC WARFARIN THERAPY WITHsuggested ‘‘opt-out’’ testing to increase adoption. In 2007, THERAPEUTIC INRCalifornia removed the legal requirement for written con- Imdad Ahmed, MD, Elie Gertner, MD, FRCP(C), FACP; Regionssent. However, the volume of HIV tests in the University of Hospital, St. Paul, MNCalifornia, San Francisco infectious disease laboratory didnot increase after either the CDC statement or the change Background: Patients often need arthrocentesis for diagnos-in law. The objective of this study was to determine the tic and therapeutic reasons while on chronic warfarin ther-prevalence of undiagnosed HIV and the practicality of apy. Often the procedure is delayed or avoided because ofimplementing universal opt-out HIV screening for all medi- concern about bleeding. The aim of this retrospective studycine service inpatients ages 18–65. Methods: This was a was to determine the safety of arthrocentesis in patients onsingle-center prospective pilot program run for 1 year on a chronic oral warfarin therapy with INR ! 2.0. Methods:nonteaching academic medicine service to evaluate 3 out- We reviewed the records at Regions Hospital and Health-come measures: (1) number of patients with newly identi- Partners Medical Group of 514 consecutive patients onfied HIV infections; (2) identify barriers to physician- chronic warfarin therapy who underwent 640 joint aspira-administered HIV screening; (3) translatability of the pilot to tion procedures from January 2001 to November 2008. Aa larger academic medical center setting. All providers total of 456 procedures were performed with INR ! 2.0admitting patients to the medicine service were informed of (group A), and 184 procedures were performed with INRthe opt-out HIV screening program by an educational meet- < 2.0 (group B). The end points were: (1) clinically signifi-ing or e-mail memo. A prompt for HIV screening informa- cant bleeding; (2) infection of the joint; and (3) pain in thetion was added to the electronic admission note. When joint needing emergency room, urgent care, or physicianeligible patients were not screened on admission, practi- visits. The end points were both early (within 24 hours post-tioners were contacted via e-mail to encourage next-day procedure) and late (within 30 days). Indications for arthro-screening. Data were collected by a single analyst and centesis were usually pain/effusion in patients withdocumented in a secure hospital intranet repository. All diseases such as rheumatoid arthritis, osteoarthritis, andidentifiers were stripped prior to data analysis. Results: Dur- gout. Results: There were no significant differences in age,ing the initial 6 months of the study, 203 patients between sex, body mass index, and concurrent use of antiplateletages 18 and 65 were admitted to the medicine ward agents between the 2 groups. Groups were also compara-involved in this pilot. Of these, 12 (5.9%) were known HIV- ble among all medical comorbidities examined (diabetespositive persons, and 69 (34%) were not tested. Of the mellitus, hypercoagulability, hypertension, liver failure, re-newly tested patients, 1 (0.82%) tested HIV positive, and 1 nal failure, and smoking status). Mean INR at the time of(0.82%) tested inconclusive. Of the 69 untested persons, the procedure for group A was higher than that for group Bthe most common reasons were physician omission (32 (2.7 Æ 0.03 vs. 1.6 Æ 0.02). Table 1 shows the early andpatients, 46%), patient report of recent negative (15 late complications in both groups. There was no statisticallypatients, 22%), patient refusal (14 patients, 20%), practi- significant difference in the overall complication ratetioner preference due to terminal diagnosis (7 patients, between patients with INR ! 2.0 (group A) and patients10%), and patient inability to consent due to cognitive dis- with INR < 2.0 (group B); P 5 0.708. Receiver operatingturbance (5 patients, 7%). Conclusions: This study shows characteristic (Fig. 1) analysis showed that INR offeredthat a universal opt-out HIV screening program in an inpati- modest value as a predictive instrument, with a c-statistic ofent setting yields a similar percentage of newly detected 0.615. Conclusions: Arthrocentesis in patients on chronicHIV infections as previous emergency department studies. warfarin therapy with therapeutic INR appears to be safeThis study used real-time personal interaction betweenresearcher and clinician to explore physicians’ barriers to without an increased risk of bleeding complications. Thisordering an HIV test. These barriers included forgetting, approach simplifies the periprocedural management ofmisunderstanding the state law, screening only perceived anticoagulation and could lead to improved outcomes andat-risk persons, and discomfort raising this topic with an ill reduced health care costs.patient. Considering the relatively low number of patients to Disclosures:refuse screening, this study suggests that patient attitudes I. Ahmed - none; E. Gertner - noneª 2011 Society of Hospital Medicine S1DOI 10.1002/jhm.920View this article online at wileyonlinelibrary.com.
    • 3 4INCIDENCE OF VENOUS THROMBOEMBOLISM IN ASSESSMENT OF PAIN IN PATIENTSA HOMEBOUND POPULATION: A RETROSPECTIVE UNDERGOING BONE MARROW BIOPSYCOHORT STUDY AT A COMMUNITY TEACHING HOSPITAL: AJamal Ahmed, BA, Katherine Ornstein, MPH, Andrew Dunn, MULTIDISCIPLINARY PRACTICEMD, Peter Gliatto, MD; Mount Sinai School of Medicine, New IMPROVEMENT PROJECTYork, NY Mohammed Ahmed, MD, George Vinales, MD, Emily Leigh,Background: Venous thromboembolism (VTE) is a source of RN, Jenni Steinbrunner, BS, Susan Partusch, MSN, RN,morbidity and mortality for high-risk populations. The risk of Thomas Imhoff, PharmD, Muhammad Afzal, MD, UmasankarVTE in homebound patients is unknown, and therefore it is Kakumanu, MD; Good Samaritan Hospital, Cincinnati, OHunclear whether they should be offered VTE prophylaxis Background: Bone marrow examination is useful in the diag-when feasible. The purpose of this retrospective cohort nosis and staging of hematologic disease, as well as in thestudy was to estimate the incidence of venous thromboem- assessment of overall bone marrow cellularity. The procedurebolism (VTE) in homebound patients. Methods: The study can be a difficult experience for the patient. Pain and anxietysample included all patients active in a home-based pri- may play a role in the experience. The purpose of the studymary care program, the Mount Sinai Visiting Doctors Pro- was to assess practices for pain control in patients under-gram; VDP), over a 4-year period. Outpatient medical going bone marrow biopsy at a private community hospitalrecords and relevant inpatient admissions or clinical testing and to determine if pain medication before bone marrow bi-were retrospectively reviewed. Data were extracted to opsy impacts pain during and after the procedure. Methods:determine whether the patient experienced a VTE and if the Patients undergoing bone marrow biopsy at a 588-bed com-event occurred in a home setting while the patient was en- munity teaching hospital during a 1-year period wererolled in the VDP. Baseline functional assessment scores included in a prospective cohort study. Patients were askedwere abstracted when available. Incident VTE in a home to rate their level of pain and anxiety before the procedure,setting was defined as the diagnosis of a symptomatic deep their highest level of pain during the procedure, and theirvein thrombosis or pulmonary embolism that did not occur level of pain after the procedure. The visual analog scale wasduring a hospitalization, within 4 weeks of a medical hospi- used for pain scores and the distress thermometer was usedtalization, or within 12 weeks of a surgical hospitalization. for anxiety scores. Patients who received some type of painDefinite VTE was defined as events substantiated by clinical medication before the procedure were compared withtesting (Doppler ultrasound, CT angiography, ventila- patients who did not receive any type of medication beforetion–perfusion scan, and/or pulmonary angiography.) Prob- the procedure. Results: Eighty-five patients were included inable VTE was defined as events not substantiated by the study. The majority of patients (72%) received some typeclinical testing but that resulted in a decision to anticoagu- of pain medication before the procedure. Administration oflate. Incident VTE was calculated as the number of patients pain medication throughout the various hospital sites waswith probable and or definite VTE over person time. Statisti- inconsistent. All patients receiving their bone marrow biopsycal analysis was done using the Student t test. Results: A through the radiology department and the majority oftotal of 1913 patients were enrolled in the VDP during the patients (77%) undergoing bone marrow biopsy at inpatientstudy period. The database queries yielded 196 patients bedside received pain medication before the procedure.with possible home-based VTE for full chart review. Fromthese patients, there were 33 VTE events (28 definite and 5 However, only 30% of patients receiving their bone marrowprobable) that occurred in a home setting, yielding an inci- biopsy at the outpatient cancer center received pain medica-dence rate of 0.68 symptomatic VTE events per 100 person tion before the procedure. Furthermore, patients whoyears (95% CI, 0.448–0.912). There was no difference in received pain medication before the procedure experiencedbaseline functional assessment scores for patients with or significantly lower pain during and after the procedure whenwithout incident VTE. Conclusions: The estimated incidence compared with patients who received no pain medication.of VTE in a chronically homebound population is low and The average difference in the pain rating from before the pro-does not correlate with baseline functional status. There is cedure to the most pain experienced during the procedureinsufficient evidence to recommend VTE prophylaxis for this was 2.9 for patients who received pain medication and 6.2patient population. for patients who did not receive pain medication (P <Disclosures: 0.001). In addition, the average difference in the pain ratingJ. Ahmed - none; K. Ornstein, none; A. Dunn - none; P. Gliatto - none from before to after the procedure was 0.6 for patients who received pain medication and 2.2 for patients who did not receive pain medication (P 5 0.01). Conclusions: Currently, there is not a standard way of managing pain for patients undergoing bone marrow biopsies. Pain medication has a significant impact on pain experienced by the patient during and after the bone marrow biopsy. Increasing awareness byS2 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • implementing a standardized protocol will likely improve needed to determine if these data have clinical significancepatient care. and if prophylactic doses should be adjusted for body weightDisclosures: Disclosures:M. Ahmed - none L. Rojas - none; A. Aizman, none; D. Ernst, none; M. Paz Acuna, none; ˜ P. Moya, none; R. Mellado, none; F. Garrido, none; J. Cerda - none5 6ANTIFACTOR Xa ACTIVITY AFTER PROPHYLACTIC STREAMLINING DISCHARGE PROCESS UTILIZINGDOSE OF ENOXAPARIN (40 MILLIGRAMS) IN LEAN METHODOLOGY—EXPERIENCE OF AHOSPITALIZED PATIENTS WITH LESS THAN 55 NURSING UNITKILOGRAMS OF WEIGHT Val Akopov, MD, Willie Smith, MD, Sandra Thomason, RN,Andres Aizman, Instructor1, Luis Rojas, Instructor1, Daniel Ernst, Kimberly Graham, RN, Pam Graham, RN, Sandra Mullings,Resident1, Maria Paz Acuna, Resident1, Pablo Moya, Intern2, Rose- ˜ LCSW, Karen O’Donald, CPA; Emory Healthcare, Atlanta, GAmarie Mellado, Porfessor2, Felipe Garrido, Instructor2, Jaime Background: The cohesiveness of the discharge process isCerda, Professor1; 1Faculty of Medicine, Pontificia Universidad critical for ensuring the safety and quality of transition ofCatolica de Chile, Santiago, Chile, 2Faculty of Pharmacy, Pontifi- ´ patient care from the inpatient setting to the next level of ´lica de Chile, Santiago, Chile,cia Universidad Cato care. The discharge process is often viewed as chaotic by theBackground: Low-molecular-weight heparins are the most health care team as well as patients and families. A few rea-commonly used for thromboembolic disease prophylaxis, sons why the discharge process is being viewed as complexprobably because of their security profile and once-daily and at times disjointed include the declining presence of pri-administration. Contrary to therapeutic doses, prophylactic mary care physicians in hospitals and emergence of hospital-recommended doses are fixed (40 mg once a day for enoxa- ists; lack of consistency in information flow between hospitalparin). Dosing in extreme body weights has little evidence, team and the next level of care team; and patients feelingespecially in patients with low weight. The aim of the study unprepared for discharge. Certain peridischarge interven-was to establish if the recommended dose of enoxaparin (40 tions have demonstrated improved primary care physicianmg once a day) in patients who weighed less than 55 kg pro- satisfaction, patient satisfaction, and readmission rates.duces antifactor Xa activity over desired ranges for throm- Methods: This study was conducted on a 50-bed generalboembolic prophylaxis. Methods: This was a transversal medical telemetry nursing unit that served as the test site forstudy with prospective recruitment. Sample size was esti- inpatient discharge process improvement from January 2008mated in 53 patients. Inclusion criteria were: patients older to December 2008. A multidisciplinary team of physicians,than 18 years, body weight 55 kg, hospitalized in medical frontline nursing staff, social workers, hospital administration, ´or surgical services in the Hospital Clınico Pontificia Universi- unit leadership, and personnel from the office of quality who ´dad Catolica de Chile, and with indication of thromboem- were trained in the Lean methodology were assembled forbolic prophylaxis with enoxaparin 40 mg once a day by the this initiative. First, the team created a detailed process map,treating physician. Exclusion criteria were: renal failure (cre- called a Value Stream. This map allowed for the visualizationatinine clearance < 30 mL/min estimated with Cockroft- of the entire process flow from admission to treatment to dis-Gault formula), amyloidosis, and concomitant use of oral charge. Second, the team identified 5 areas of delay withinanticoagulants. Antifactor Xa activity was measured 3–4 the discharge flow. These identified areas became targets forhours after the second or third dose of enoxaparin. We esti- intervention or rapid improvement events (RIEs). RIEs aremated the proportion of patients with antifactor Xa activity weeklong activities that are a part of the Lean tool kit and pro-over 0.5 unit/mL and the average of antifactor Xa activity. vide a mechanism for making radical changes to current pro-Results: The average age of patients was 65.4 Æ 20.3 years, cesses and activities within very short timescales. Over thethe average weight was 47.7 kg (26–54.8 kg), and 86.7% course of 1 year the team participated in 7 RIE initiatives: (1)of patients were female. The average antifactor Xa activity visual notification of discharge readiness, (2) patient dis-was 0.54 Æ 0.18 units/mL, and the proportion of patients charge education, (3) standardization of the MD dischargewith values over 0.5 units/mL was 60%. Weight and antifac- process, (4) demographic and insurance quality, (5) stand-tor Xa activity had an inverse correlation, with a Pearson ardization of the RN discharge process, (6) standardizationcoefficient of 20.497. In subgroup analysis, patients < 50 of SW discharge—disposition home, and (7) standardizationkg of weight had antifactor Xa activity of 0.61 Æ 0.18 units/ of SW discharge—disposition skilled nursing facility. The fol-mL, whereas those who weighed > 50 kg had an antifactor lowing outcomes were measured: (1) length of stay indexXa activity of 0.47 Æ 0.16 unit/mL (P 5 0.019). Conclusions: (LOS index), defined as a ratio of observed to expectedAntifactor Xa activity rises significantly when body weight length of stay, (2) physician and RN satisfaction with dis-decreases. Patients with low weight had antifactor Xa activity charge process before and after the study, and (3) proportionover the desired range for thromboembolic prophylaxis, of discharges before 2 PM. Results: As a result of the interven-especially in those under 50 kg. Further investigation is tion, the LOS index had steadily declined from 1.16 to con- Hospital Medicine 2011 Abstracts S3
    • sistently below 1.0 (organizational target is LOS index < was a disagreement, a third reviewer determined appropriate-1.0); physician and nursing satisfaction with discharge pro- ness. Bayesian statistics were used to determine the diagnosticcess significantly improved from the pre- to the postinterven- accuracy of emergency medicine providers, and chi-squaredtion state; the proportion of patients discharged before 2 PM testing was used to compare accuracy pre- and postinterven-increased from 24% to 36% Conclusions: Lean methodology tion. Results: Neither the overall admission rate nor the inap-is an excellent tool for improving the quality and efficiency of propriate admission rate changed from pre- to postinterventionthe discharge process and should be widely utilized in the (Table). The positive predictive values and negative predictivehealth care setting values of the ED decision to admit were >98% and 99%,Disclosures: respectively, and did not change postintervention. In the postin-V. Akopov - none; W. Smith, Jr. - none; S. Thomason - none; K. Graham - none; tervention period, 82.5% of triage changes (n 5 141) wereP. Graham - none; C. Mims - none; S. Mullings - none; K. O’Donald - none classified as escalations in care setting. The most common diagnoses were chest pain (n 5 78, 46%), pneumonia (n 5 11, 6.4%), alcohol withdrawal (n 5 8, 4.7%), and sepsis (n 57 8, 4.7%). Of triage changes, 17.5% (n 5 30) were classifiedHOSPITALIST SCREENING OF EMERGENCY as de-escalations of care setting. The most common diagnosesMEDICINE TRIAGE DECISIONS DOES NOT for these patients were chest pain (n 5 18, 60%) and deepIMPROVE TRIAGE ACCURACY vein thrombosis (n 5 3, 10%). Conclusions: Our study suggestsRebecca Allyn, MD, Jeremy Long, MD, Lee Shockley, MD, that the screening of admissions from the ED by hospital medi-Angela Keniston, MSPH, Barbara Cleary, MD, Eugene Chu, cine attending physicians is not an efficient allocation ofMD; Denver Health Medical Center, Denver, CO resources. At our institution, inappropriate admissions are rela-Background: Hospital care accounts for more than 30% of tively rare events. Attempts to further reduce inappropriatehealth care expenditures in the United States. In an effort to admissions may increase inappropriate discharges.reduce inappropriate admissions, we implemented hospital Disclosures:medicine attending screening of non–intensive care unit (ICU) R. Allyn - none; J. Long - none; L. Shockley - none; B. Cleary - none; A. Keniston - none; E. S. Chu - nonemedicine admissions. Methods: We conducted a before andafter study at our urban, academic safety-net hospital. FromJanuary to June 2008, all patients admitted to the medicine 8wards or to the chest pain observation unit were screened by a RELATIONSHIP BETWEEN 25-HYDROXYVITAMIN Dhospital medicine attending physician, who, in collaborationwith referring providers, could change the initially recom- AND ALL-CAUSE AND CARDIOVASCULARmended disposition. Patients who were admitted to inpatient MORTALITY: RESULTS FROM THE NATIONALmedicine and discharged or transferred to the ICU within 24 HEALTH AND NUTRITIONAL EXAMINATIONhours or admitted to medicine after having been discharged SURVEY LINKED MORTALITY FILES, 2001–2004within 7 days from the Emergency Department (ED) from Janu- Muhammad Amer, MD1, Muhammad Bakht, MBBS2, Rehanary to June 2008 were identified and compared with a histori- Qayyum, MD, MHS1; 1Johns Hopkins School of Medicine, Bal-cal control from the same months 1 year prior. Two physicians timore, MD, 2 University of Medicine and Dentistry of New Jer-reviewed each chart for appropriateness of disposition. If there sey School of Public Health, Piscataway, NJ Background: Observational studies have reported significant protective associations between 25-hydroxyvitamin DAccuracy of Triage Decisions [25(OH) D] and all-cause and cardiovascular (CV) mortality. Prehospitalist Screening Posthospitalist Screening We believe that these associations have nonlinear relation- ships and 25(OH) D probably offers greater protection at Appropriate Appropriate Appropriate Appropriate lower serum levels. To study this hypothesis, we examined the Admission: Admission: Admission: Admission: relationship between 25(OH) D and all-cause and CV mortal- Yes No Total Yes No Total ity in a healthy adult U.S. population. Methods: We usedAdmitted: yes 2812 38 2850 3865 76 3941 data from the continuous National Health and Nutrition Ex-Admitted: no 6 5712 5718 4 6623 6627 amination Survey (NHANES), a probability sample of nonin-Total 2818 5750 8568 3869 6699 10,568 stitutionalized civilians for the years 2001–2004 (baseline).Prevalence of 1.3%y 1.9%y Data on mortality status were obtained from NHANES linked inappropriate admissions (National Death Index) mortality files, with follow-up informa-Sensitivity 99.8 (99.5–99.9)y 99.9 (99.7–100.0)y tion from date of survey participation to December 2006. percent (95% CI) Analysis was limited to individuals older than 18 years. IfSpecificity 99.3 (99.1–99.5)y 98.9 (98.6–99.1)y needed, variables were log-transformed to meet assumptions percent (95% CI) of residual normality. To examine the nonlinear relationshipy of 25(OH) D with all-cause and CV mortality, we used a P 5 NS. spline, with single knot at median serum levels (21 ng/mL) ofS4 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • 25(OH) D. The effect of 25(OH) D was calculated for every between all-cause mortality and 25(OH) D below (HR, 0.59;10-unit increase below and above spline. Cox proportional 95% CI, 0.45–0.77) but not above its median serum levelsregression models were used to estimate the hazard ratio (HR, 0.83; 95% CI, 0.65–1.06). In the multivariable model,(HR) and 95% confidence interval (CI) for all-cause and CV the association between all-cause mortality and 25(OH) Dmortality. Results: There were 509 all-cause and 184 CV- below its median remained significant (HR, 0.55; 95% CI,related deaths during the median (range) follow-up of 4 years 0.4–0.82). Similarly, in univariate regression, we observed a(3–5 years). Of the 10,170 participants, 52% were female, significant association between CV mortality and 25(OH) D51% were white, 16.4% were current smokers, and 37% below (HR 0.56, 95% CI 0.4-0.8) but not above its medianhad hypertension. Mean (SD) age and 25(OH) D levels were (HR, 0.91; 95% CI, 0.56–1.5). In the multivariable-adjusted46.6 (20.5) and 22 (9.2), respectively. In the univariate model, 25(OH) D retained its significant association with CVregression, we found a statistically significant association mortality below its median (HR, 0.53; 95% CI, 0.3–.93), whereas it conferred no protection for CV mortality above its median serum levels (HR, 0.89; 95% CI, 0.52–1.53). Con-TABLE Population Characteristics of Participants Aged 18 and Above; clusions: The protective relationships between 25(OH) D andNHANES 2001–2004 all-cause and CV mortality are nonlinear. In addition, we found that serum 25(OH) D levels above 21 ng/mL appear Vitamin D(ng/mL) to offer no protection against all-cause and CV mortality in both simple and multivariable-adjusted models in a healthyCovariates £ 21 (N 5 5237) > 21 (N 5 4933) p-values adult U.S. population.Age (years), Mean (SD) 45.75 (20.6) 47,56 (20,4) <0.0001 Disclosures:Females n (%) 2795 (53) 2470 (50) 0.001 M. Amer - none; M. Bakht - none; R. Qayyum - noneRare, n (%) Mexican American 1358 (26) 852 (17) <0,001 Non Hispanic Black 1686 (32.2) 334 (7) <0.001 9 Other Hispanic 133 (4) 175 (3.5) 0.7 DURATION OF RISK OF VENOUS Other Rare 258 (5) 127 (2.6) <0.001 THROMBOEMBOLISM IN REAL-WORLD U.S. Caucasians (Ref) 1742 (33.3) 3 445 (70) <0.001HTN, n(%) 2054 (39) 1740 (35.3) <0.001 PATIENTS HOSPITALIZED FOR MEDICAL ILLNESSCurrent Smoker, n (%) 896 (20) 771 (17) 0.01 Alpesh Amin, MD, MBA, FACP1, Helen Varker, BS2, Jay Lin,GFRml/mtn/m2, Mean(SD) 103.8 (32.34) 95.52 (32.33) <0.0001 PhD3, Stephen Thompson, MS4, Stephen Johnston, MA2; 1SchoolCholesterol (mg/dL), Mean (SD) 137 (45.05) 202.4 (43.51) <0.0001 of Medicine, University of California, Irvine, Irvine, CA;All cause mortality, n (%) 297 (6) 216 (4.4) 0.003 2 Thomson Reuters, Washington, DC; 3 Bruce Wong & AssociatesCardiovascular mortality, n (%) 109 (2.1) 77(1.6) 0.05 Inc., Radnor, PA; 4 Sanofi-aventis, Bridgewater, NJHTN; hypertension; defined as average systolic BP > 140 or average diastolic BP > 90 mm Hg or Background: Patients hospitalized for medical illness are atindividuals ever told to have HTN, or if participants we re taking an antihypertensive. Current an increased risk of developing venous thromboembolismsmoker, individuals smoke daily. GFR, Glomerular Filtration Rate measured using Modification of (VTE). The present study retrospectively assessed the inci-Diet in Renal Disease (MDRD) equation. dence and time course of symptomatic VTE events following hospitalization in a large, real-world patient population. Methods: Administrative claims data derived from the Thom- son Reuters MarketScan1 Inpatient Drug Link File were used to identify patients hospitalized for severe infectious disease, congestive heart failure, cancer, or chronic ob- structive pulmonary disease. Included patients had been admitted to the hospital between January 1, 2005, and De- cember 31, 2008, and had been continuously enrolled ! 12 months prior to admission (patient history) and ! 180 days after admission. The cumulative risk and hazard of VTE—measured as the number of VTE events per 1000 per- son-days—were established across an evaluation period of 180 days. Results: The study cohort consisted of 11,139 medical patients, with a mean (standard deviation [SD]) age of 67.6 (13.9) years, and 51.6% were female. The mean (SD) length of stay in the hospital was 5.3 (5.3) days, during which 46.7% of patients (ranging from 30.7% of cancer patients to 64.1% of heart failure patients) received any VTE prophylaxis for a mean (SD) duration of FIGURE . Kaplan–Meier survival curves for cardiovascular mortality. 5.0 (4.7) days. Enoxaparin was the most common prophy- Hospital Medicine 2011 Abstracts S5
    • lactic method (26.8%), 12.2% of patients received mechan-ical prophylaxis, and 8.8% of patients received anticoagu-lation therapy within the period extending from discharge Outcome HN Cohort Non-HN Cohort Difference P Valueto 35 days after discharge, most commonly with warfarin Mortality (%) 1.57 1.45 0.12 <0.001(7.7%). Appropriateness of prophylaxis was not deter- ICU admission (%) 23.13 22.10 1.03 <0.001mined. During the 180-day evaluation period, 366 sympto- LOS (days) 8.78 7.65 1.13 <0.001matic VTE events occurred (3.3%), comprising 241 deep ICU LOS (days) 5.51 4.85 0.66 <0.001vein thrombosis (DVT)–only events, 98 PE-only events, and ICU cost ($) 8525 7597 928 <0.00127 events with evidence of both DVT and PE. Of the events, Total hospital cost ($) $15,281 $13,439 $1842 <0.00143% (97 DVT only, 44 PE only, and 18 both DVT and PE)occurred during the index hospitalization. The highest num- spective analysis used the Premier’s Perspective1 databaseber of VTE events occurred during the first 9 days (97 to select hospitalizations with HN (serum sodium 135events, 88% in-hospital; proportion of 180-day cumulativerisk, $20%) and during days 10-–9 (82 events, 71% in-hos- mmol/L as defined by primary or secondary ICD-9 276.1)pital; proportion of 180-day cumulative risk, $45%) follow- for the January 2007 to June 2009 time frame. Patientsing index admission. VTE hazard peaked at approximately transferred to/from another acute care facility and who left1.05 per 1000 person-days on the eighth day following against medical advice, and labor/delivery patients wereadmission, and 50% had been incurred by the 23rd day. excluded from this analysis. HN patients (n 5 564,723)VTE frequency gradually declined thereafter, fluctuating at were matched to a non-HN control by age, sex, providera background level of 4–7 events during each 10-day inter- region, and 3MTM APR-DRG assignment. Matching wasval from 130 to 139 days up to 170–180 days. Conclu- refined using propensity scores on other patient and hospi-sions: Among the cohort of 11,139 medical patients at risk tal characteristics and patient comorbidities. Matchedof VTE, 3.3% experienced a symptomatic VTE event during patients were assigned to HN and non-HN groups for com-the 180-day evaluation period following index hospitaliza- parisons of total hospital cost, intensive care unit (ICU) cost,tion, and more than half of these events (57%) occurred length of stay, ICU length of stay, rate of ICU admission,postdischarge. Although the risk of VTE was highest within and inpatient mortality rate. Results: Hospital demographicsthe first 19 days after the index admission, results from this were similarly distributed across both cohorts. Approxi-study indicate that a considerable risk of VTE extends into mately 57% of the patients came from hospitals located inthe period after discharge. the South Atlantic, Middle Atlantic, and Pacific regions. Sixty percent of hospitals were nonteaching. Patient demo-Disclosures: graphics included: 57% female, mean age of approxi-A. Amin - sanofi-aventis U.S., Inc., research honorarium, speakers bureau; H.Varker - sanofi-aventis U.S., Inc., employee at Thomson Reuters, which mately 68 years, and 41% hypervolemic with comorbiditiesreceived funding to carry out this work from sanofi-aventis U.S., Inc.; J. Lin - of heart failure and/or cirrhosis in approximately 48% ofsanofi-aventis U.S., Inc., employee at Bruce Wong & Associates Inc., which both cohorts. A hospitalist attended to 43% of all patients.received funding to carry out this work from sanofi-aventis U.S., Inc.;S. Thompson - sanofi-aventis U.S., Inc., employment; S. Johnston - sanofi- HN contributed to an increased LOS, increased total andaventis U.S., Inc., employee at Thomson Reuters, which received funding to ICU hospitalization costs, increased percentage of patientscarry out this work from sanofi-aventis U.S., Inc requiring an ICU admission, increased ICU LOS, and increased inpatient mortality. Conclusions: In a hospitalized population, HN was associated with a statistically signifi-10 cant negative impact on inpatient mortality, ICU admission,IMPACT OF HYPONATREMIA ON PATIENT and total/ICU LOS. HN was also associated with signifi-OUTCOMES AND HEALTH CARE RESOURCE cantly increased total hospital and ICU costs.UTILIZATION IN HOSPITALIZED PATIENTS Disclosures:Alpesh Amin, MD1, Steven Deitelzweig, MD1, Jay Lin, PhD2, A. Amin - Otsuka, research funding, speakers bureau; S. Deitelzweig - Otsuka,Kathy Belk, BA3, Dorothy Baumer, MS3; 1Ochsner Health Sys- research funding, speakers bureau; J. Lin - Otsuka, consultant; K. Belk - Otsuka,tem, New Orleans, LA; 2Novosys Health, Flemington, NJ; 3Pre- consultant; D. Baumer - Otsuka, consultantmier, Charlotte, NCBackground: Hyponatremia (HN) is the leading electrolyte 11abnormality among hospitalized patients. In the absence of PROTON PUMP INHIBITOR USE IN HOSPITALIZEDsymptoms, HN is often overlooked as a condition that war- MEDICAL PATIENTSrants aggressive intervention. However, a careful history of-ten reveals symptoms associated with HN. Although HN is Mary Anderson, MD1, Amy Go, PharmD2, Dimitriy Levin,common, little is known regarding the influence of HN on MD1; 1University of Colorado Denver, Aurora, CO; 2Universitypatient outcomes and health care resource utilization. The of Colorado Hospital, Aurora, COpresent study was designed to identify the impact of HN on Background: Acid suppressive medications, including hista-length of stay (LOS), inpatient mortality, and cost variables mine2-receptor antagonists (H2RAs) and proton pump inhibi-in a hospitalized patient population. Methods: This retro- tors (PPIs), are widely used to treat conditions associatedS6 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • with the overproduction of acid. Accepted indications 12include upper gastrointestinal bleeding, erosive esophagitis PARTICIPATION IN UNPROFESSIONAL BEHAVIORSor gastritis, gastroesophageal reflux disease, ulcers, Helico- AMONG HOSPITALISTS: A MULTISITE STUDYbacter pylori eradication, Zollinger–Ellison syndrome, stress Vineet Arora, MD, MAPP1, James Iwaz, BS1, Kevin O’Leary,ulcer prophylaxis (SUP) in high-risk patients, dyspepsia MD2, Aashish Didwani, MD2, Andy Anderson, MD3, Hollyassociated with nonsteroidal anti-inflammatory drugs in Humphrey, MD1, Jeanne Farnan, MD, MHPE1, Diane Wayne,high-risk patients, and severe dyspepsia unresponsive to MD2, Shalini Reddy, MD1; 1University of Chicago, Chicago,adequate trials of symptomatic drugs. Although PPIs are IL; 2Northwestern University, Chicago, IL; 3NorthShore Univer-effective and well tolerated, there is growing concern about sity HealthSystem, Chicago, IL,the overuse of PPIs in hospitalized patients. PPIs mayincrease the risk of nosocomial Clostridium difficile infec- Background: Unprofessional behaviors can undermine thetions and hospital-acquired pneumonia. The literature also hospital learning environment and patient care. To date, nosuggests that patients frequently receive PPIs without a clear study has examined unprofessional behaviors in hospital-indication and that PPIs are often inadvertently continued ists. Methods: A 35-item survey of unprofessional behaviorson discharge. The purpose of this quality improvement pro- adapted from prior studies was administered to hospitalistsject was to evaluate current prescribing practices for PPIs in from 3 academic programs at 7 Chicago hospitals. The sur-hospitalized medical patients. Methods: This was a pro- vey included behaviors related to interactions with othersspective observational study of adults admitted to general (i.e., making fun of residents), patient care scenarios (i.e.,medicine (non-ICU) services at a tertiary-care medical cen- blocking an admission), and interactions with trainees (i.e.,ter between February and May 2010. Patients were identi- asking a student to perform a procedure beyond his or herfied based on pharmacy order entry for esomeprazole, the skill). Participants reported whether they participated andPPI on formulary. The frequency of PPI use, indications, rated their perception of this behavior on a Likert-type scaleappropriateness of use, and discharge PPI orders were ranging from 1 (unprofessional) to 5 (professional). Routineexamined. Results: The overall frequency of PPI use was demographics including job type (clinical, teaching,45% in this study. Of 100 patients randomly selected for research, administrative, night work, etc.) were alsoanalysis, 69% were taking a PPI prior to hospitalization, assessed. Data were merged with a deidentified code forwhereas 31% were started on a PPI as an inpatient. Major site. Factor analysis was performed to extract the principalindications for a new PPI during hospitalization included components of unprofessional behavior. A scree plot deter-gastrointestinal bleeding (26%), followed by dyspepsia mined the number of factors to retain. Item loadings were(23%) and SUP (23%). The new PPI was appropriate in used to name factors. Site-adjusted multivariate regression52% and inappropriate in 36% of patients; inappropriate models were used to examine the association between de-indications included SUP in low-risk patients and dyspepsia mographic and job characteristics and factors of unprofes-without a prior trial of calcium carbonate or H2RA. Overall, sional behavior. Results: Seventy-eight percent of83% of patients were continued on a PPI at discharge, hospitalists (79 of 101) responded. Participation in egre-including 52% (17 of 31) of those started on a PPI in the gious behaviors (i.e., falsifying medical records, mistreat-hospital. Of those patients discharged with a new PPI, the ment of students) was very low (<5%), and most behaviorsmedication was likely unnecessary in 42% of cases. Con- were recognized as unprofessional (rated < 3 on theclusions: PPI use in hospitalized medical patients is com- Likert). The most common unprofessional behaviors reportedmon, with a high rate of inappropriate use both during were having personal conversations in patient corridorshospitalization and at discharge. This increases the likeli- (66%), ordering a routine test as ‘‘urgent’’ to expedite carehood of adverse medication events as well as the cost of (62%), texting or using smartphones during educationalhealth care. Patients started on a new PPI during hospitali- conferences (40%), and disparaging the emergency roomzation represent the first target group for intervention. (ER) or primary care physician for findings later discoveredAdhering to approved indications for PPI use, discontinuing on the floor (40%). Factor analysis revealed 3 major factorsPPIs when no longer indicated, and considering alternative that accounted for half of survey variance: (1) disrespecttherapies such as H2RAs are areas for improvement. Strate- (e.g., making fun of residents, disparaging the ER), (2)gies to improve prescribing practices may include imple- patient safety (e.g., failing to report an error), and (3) work-menting automatic stop orders on PPIs, reevaluating use of load reduction (e.g., blocking admissions). In site-adjustedPPIs on standardized order sets, and integrating decision- multivariate regression models, hospitalists with less clinicalmaking prompts into the electronic medical record. time were more likely to participate in disrespectful beha-Disclosures: viors (b 5 0.75, P 5 0.014), but less likely to disregard safety (b 5 20.69, P 5 0.034). In addition, hospitalistsM. Anderson - none; A. Go - none; D. Levin - none with any night work were more likely to disregard safety (b 5 0.57, P 5 0.044). Younger hospitalists (b 5 0.94, P 5 0.029) and those with administrative time (b 5 0.56, P 5 0.38) were more likely to participate in behaviors to actively reduce workload. Site differences were only noted Hospital Medicine 2011 Abstracts S7
    • for workload reduction. Conclusions: Although participation (starting shift) were significantly less likely to provide super-in egregious unprofessional behaviors was low, job type ior (top quartile) ratings in 3 areas (overall, organization,(clinical, administrative, and night work), age, and institu- setting) than were receivers (ending shift). Observer ratingstional culture seem to be associated with certain behaviors. did not show this disparity. Evaluator satisfaction with theFuture work to address professionalism among hospitalists tool was high (mean, 6.80; IQR, 6–8) and was also asso-should take these findings into account. ciated with overall hand-off quality (b 5 0.60, P < 0.001).Disclosures: Conclusions: Real-time assessment of hand-off quality byV. Arora - ABIM Foundation, NIA, AHRQ, ACGME, research funding; J. Iwaz - clinicians using the Handoff CEX is feasible and reliable.NIA, research funding; K. O’Leary - ABIM Foundation, research funding; A. Arriving late to hand-offs can dramatically affect ratings ofDidwania - ABIM Foundation, research funding; A. Anderson - ABIMFoundation, research funding; H. Humphrey - ABIM Foundation, research hand-off quality. Other characteristics, such as day of weekfunding; J. Farnan - ABIM Foundation, research funding; D. Wayne - ABIM and sender/receiver roles, are also related to hand-off rat-Foundation, research funding; S. Reddy - ABIM Foundation, research funding ings. It may be easier to critically evaluate senders, who bear the burden of communication, than receivers. Alternatively, receivers may be more critical because of the stress of receiv-13 ing work, or senders may overestimate receiver performanceREAL-TIME RATINGS OF HAND-OFF QUALITY BY because of the excitement of ending their shift. Further workHOSPITALIST CLINICIANS to explore the mechanism of these findings is under way. Disclosures:Vineet Arora, MD, MAPP1, Paul Staisiunas, BA1, Stacy Bane-rjee, MD1, Elizabeth Greenstein, BA1, Leora Horwitz, MD, V. Arora - AHRQ, NIA, ABIM, ACGME, research funding; P. Staisiunas - AHRQ, research funding; S. Banerjee - none; E. Greenstein - NIA, researchMHS2, Jeanne Farnan, MD, MHPE1; 1University of Chicago, funding; L. Horwitz - NIA, AHRQ, research funding; J. Farnan - AHRQ,Chicago, IL, 2Yale University, New Haven, CT research fundingBackground: Hand-offs are a core competency of hospital-ists. Although the Society of Hospital Medicine and othersrecommend improving hand-offs, monitoring and improving 14hand-off quality are limited by lack of reliable tools to mea- THORACENTESIS BLEEDING RISK FACTORS:sure hand-off quality. This study aimed to assess the feasibil- THEY’RE NOT WHAT YOU THINKity and reliability of using a paper-based tool, ‘‘HandoffCEX (Clinical Evaluation Exercise),’’ to evaluate real patient Mark Ault, MD, FACEP, Bradley Rosen, MD, MBA, FHM;hand-offs between hospitalist clinicians. Methods: The Cedars–Sinai Medical Center, Los Angeles, CAHandoff CEX, developed based on literature review and Background: Postprocedural bleeding is a significant adverseexpert consensus, includes ratings of overall performance outcome. Clinicians routinely assess bleeding risk by orderingand its components (organization, communication skills, coagulation labs (INR, PTT, platelets) and administer blood pro-clinical judgment, setting, patient-focused) on a 0–9 scale. ducts to correct any discovered coagulopathies. CertainFor 3 hand-offs a week (Monday/Tuesday/Friday), clini- ‘‘bleeding risk’’ medications are also held. Although the effi-cian senders and receivers were evaluated by a trained cacy of these steps seems intuitive, coagulation labs were notthird-party nonmedical observer using the Handoff CEX. designed to assess bleeding risk, and the need to ‘‘correct’’Senders and receivers also evaluated each other using the abnormal coagulation lab values or stop certain medicationsinstrument. Interrater reliability between clinician and ob- has never actually been demonstrated. Further, this practiceserver was calculated using Spearman’s rho. Descriptive comes at the expense of valuable time, limited blood bankand comparative statistics were used to examine mean per- resources, and increased cost. The Procedure Center atformance and ‘‘superior’’ performance, defined as the top Cedars–Sinai Medical Center performs approximately 1200quartile. Results: From March to December 2010, all 38 thoracenteses annually, and historically has relied on patients’(100%) hospitalist clinicians (nurse practitioners, hospital- bleeding history to determine preprocedural risk rather thanists) consented to participate. Senders, receivers, and a routine lab screening or the presence of certain medications.trained observer rated 78 hand-offs, resulting in 156 partic- To evaluate the safety of this practice, we undertook an assess-ipant and 153 observer evaluations. Domain means were ment of procedural outcomes for thoracenteses relative tobetween 6 and 7, with full use of the 0–9 scale noted. Inter- patients’ coagulation parameters and/or the presence ofnal consistency was high (Cronbach’s alpha 5 0.90). blood-thinning or antiplatelet medications. Methods: PatientsSpearman’s rho between participating clinicians and for whom a thoracentesis was order were evaluated consecu-trained observer was calculated as 0.52 (P < 0.001), indi- tively. A chart review was performed to capture coagulationcating moderate interrater reliability. Although tardiness parameters (INR, PTT, platelets), and the presence of blood-thin-was noted in only 9% of hand-offs, nearly all ratings were ning or antiplatelet medications. The decision to perform thelower if a clinician arrived late (overall, 7.26 not tardy vs. procedure was not affected by the findings of the preprocedure5.85 tardy, P < 0.001). Setting was rated significantly chart review, and the proceduralist generally was not aware ofhigher on Monday than on other days (7.50 Monday vs. the findings. All procedures were performed according to6.75 Tuesday/Friday, P < 0.001). Clinician senders established Procedure Center protocol. Patients were assessedS8 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • TABLE 1 Postprocedure Complications in Relation to Coagulopathies or after 24 hours for complications (bleeding related or other),‘‘Bleeding Risk’’ Medications and complications were categorized as ‘‘major’’ or ‘‘minor.’’ Results: A thousand consecutive thoracenteses were performed Minor from February 2010 to October 2010. Figure 1 depicts (a) the Major Complications frequency of abnormal preprocedure coagulation labs and (b) Cases Complications from Nonbleeding the prevalence of ‘‘bleeding risk’’ medications. Table 1 sum- (n) from Bleeding Bleeding Complications marizes the incidence of complications for each of those cate-All coag labs unknown 132 0 0 19 (3 major, gories. Patients with abnormal coagulation parameters or who 16 minor) were on certain medications did not suffer higher rates of com-!1 Coag lab known, normal 224 0 4 (3.5%) 0 plications than other patients. Conclusions: The overall compli-!1 Coag known, abnormal 644 0 1 (0.2%) 0 cation rate in this series of thoracenteses was very low (2.4%).No ’’bleeding risk’’ 485 0 3 (0.6%) 19 (3 major, The presence of abnormal coagulation labs and/or blood-thin- medications present 16 minor) ning medications did not increase the incidence of complica-1 ’’Bleeding risk’’ 405 0 2 (0.5%) 0 tions. These findings suggest that routinely checking medication present coagulation labs, transfusing blood products to correct abnor->1 ’’Bleeding risk’’ 110 0 0 0 mal lab values, and/or stopping certain medications prior to medication present performing thoracenteses may be unnecessary.Note: Each complication is listed twice—once in the ‘‘coag labs’’ section (top half of table) and once Disclosures:in the ‘‘bleeding risk meds’’ section (bottom half of table). M. Ault - none; B. Rosen - none 15 EXENATIDE, A GLUCAGON-LIKE PEPTIDE-1 MIMETIC, IMPROVES LEFT VENTRICULAR EJECTION FRACTION IN PATIENTS WITH STABLE ISCHEMIC CARDIOMYOPATHY AND LEFT VENTRICULAR EJECTION FRACTION £ 40% Wamiq Banday, MBBS, MD, Aravind Herle, MD, Banjamin Rueda, MD, Howard Lippes, MD; FACP; University of Buffalo, Sisters of Charity Hospital, Buffalo, NY Background: Glucagon-like peptide-1 (GLP-1) receptors are present in human cardiac myocytes. Myocardial cells demonstrate insulin resistance in the setting of left ventricu- lar dysfunction. Exenatide is a synthetic GLP-1 mimetic mol- ecule with insulinotropic and insulinomimetic properties. It has a favorable pharmacokinetic profile over GLP-1. Insulin and GLP-1 increase glucose utilization by cardiac myocytes and improve cardiac contractility. We hypothesized that a single subcutaneous dose of exenatide would improve the left ventricular ejection fraction (LVEF) of patients with stable CHF and an LVEF 40%. Methods: We investigated the short-term efficacy and safety of a single dose of exenatide in patients with an LVEF 40%. A single 5-lg subcuta- neous dose of exenatide was given to 7 patients who were previously on standard heart failure medication for at least 6 weeks. These patients acted as their own controls. The primary end point was change in LVEF, and secondary end points were end-systolic volume index (ESVI), end-diastolic volume index (EDVI), peripheral blood sugar, and hemody- namic response (systolic blood pressure, diastolic blood pressure, heart rate, and mean arterial pressure). Base line LVEF assessment was done with a MUGA scan with stand- ard radioactive isotope dose and technique, and a repeat MUGA scan was done 1 hour after the administration of 5FIGURE (a) Coagulation laboratory abnormalities preprocedure. (b) lg of subcutaneous exenatide. This study was HIPAA com-Prevalence of ‘‘bleeding risk’’ medications. pliant. The hospital institutional review board approved Hospital Medicine 2011 Abstracts S9
    • Short-Term Effect of Exenatide (GLP-1 Mimetic) on LVEF 16 EFFECTIVENESS OF RAPID RESPONSE CALL 60 Minutes After CRITERIA: A SYSTEMATIC REVIEW AND Before Exenatide Exenatide (Mean 6 SEM), (Mean 6 SEM), P Value META-ANALYSIS n57 n 5 7. (2-Tailed)* Srinivas Bapoje, MD, MPH1, Philip Mehler, MD1, Richard Albert, MD1, Allison Sabel, MD, MPH, PhD1, Rinaldo Bellomo,LVEF (%) 33.86 Æ 3.1 35.86 Æ 2.9 0.013 MD2, Sumithra Chandrasekaran, MD3, Eugene Chu, MD,EDVI (mL/m2)a 63.2 Æ 4.7 70.4 Æ 3.5 0.212 FHM1; 1Denver Health Medical Center, Denver, CO; 2Univer-ESVI (mL/m2)b 41 Æ 3.9 44.2 Æ 3.85 0.381 sity of Colorado Denver School of Medicine, Denver, CO;Blood sugar (mg/dL) 121.29 Æ 10.6 82.43 Æ 7.5 0.021 3 Portland Medical Center, Portland, ORHeart rate (beats/min) 71.86 Æ 5.4 71.29 Æ 3.4 0.888SBP (mm Hg) 124.86 Æ 4.3 128.57 Æ 2.8 0.528 Background: In-hospital adverse events such as unplannedDBP (mm Hg) 73.43 Æ 4.3 76.71 Æ 2.0 0.276 intensive care unit transfers (UICUTs), cardiopulmonaryMAP (mm Hg) 88.2 Æ 4.2 93.014 Æ 2.7 0.207 arrests (CAs), and unanticipated mortality are frequently preceded by clinical instabilities. Rapid response systemsa EDVI was measured in only 6 of 7 patients; b ESVI was measured in only 6 of 7 patients. (RRSs) have been advocated to detect and intervene on * P values were calculated with the paired t test. LVEF, left ventricular ejection fraction; EDVI, end- these instabilities with the goal of preventing seriousdiastolic volume index; ESVI, end-systolic volume index; SBP, systolic blood pressure; DBP, diastolic adverse events. Although call criteria have been establishedblood pressure; MAP, mean arterial pressure. based on retrospective analyses of patients’ clinical courses preceding in-hospital adverse events, how well these crite- ria operate in practice is not known. Methods: We per-conducting this pilot, nonrandomized single-center study. formed a search of major scientific databases andSeven of 10 patients were able to complete the study. Data conference proceedings including Pubmed (MEDLINE),were analyzed using the paired t test and the independent t EMBASE, CINAHL, Cochrane Database, and Web oftest and are presented as mean Æ SEM. The P value was 2- Knowledge through March 1, 2010, for studies using keytailed, and a value < 0.05 was considered statistically sig- words for RRSs. The quality of all studies was judged usingnificant. Statistical analysis was done using SPSS software. prespecified criteria. Two independent reviewers using aResults: Single-dose exenatide in immediate follow-up standardized data extraction form extracted call criteria asincreased the LVEF (from 33.86 Æ 3.051 to 35.86 Æ 2.915, well as event and call rates for each adverse outcome. InP 5 0.013) and decreased peripheral blood sugar (from the initial stages of data analysis, we pooled the individual121.29 Æ 10.58 to 82.43 Æ 7.521, P 5 0.021). There event and call rates from each study and used Bayesian sta-was no significant change in EDVI (from 63.2 Æ 4.7 to 70.4 tistics to determine the overall accuracy of call criteria byÆ 3.5, P 5 0.212), ESVI (from 41 Æ 3.9 to 44.2 Æ 3.85, adverse outcome. Results: We retrieved 2197 citationsP 5 0.381), heart rate (from 71.86 Æ 5.378 to 71.29 Æ based on a key word search. Of these, 13 studies repre-3.414, P 5 0.888), and mean arterial pressure (from 88.2 senting 416,797 patients matched our screening criteriaÆ 4.182 to 93.014 Æ 2.71, P 5 0.207). One patient had and were included. All 13 studies reported data for CAnausea, and 1 patient experienced hypoglycemia. There and unanticipated mortality. Only 7 of 13 studies reportedwere no adverse cardiovascular events. All 7 patients com- data in UICUT. RRS calling criteria demonstrated significantpleted the study. Conclusions: There was significant improve- heterogeneity. For example, respiratory rate criteria rangedment in LVEF 1 hour after administration of subcutaneous from highs of 30–36/minute to lows of 5–8/minute. Prelim-exenatide in patients with an LVEF 40% who were onstandard heart failure medications for at least 6-weeks. Nolarger prospective human clinical trial has been conducted so TABLE 1 Pooled Event and Call Rate by Adverse Outcomefar to elucidate the long-term effects of GLP-1 or exenatide onthe stable heart failure population. Exenatide has provided CAy (1) Event (2) Event Totalpromising results in our study, and it can be studied prospec- (1) Call 782 4496 5278tively in a larger population, which is technically feasible. (2) Call 3302 408,217 411,519 Total 4084 412,713 416,797Disclosures: Mortality (1) Event (2) Event TotalW. Y. Banday - none; B.G. Rueda - none; A. Herle - none; H. Lippes - Amylin (1) Call 294 6195 6489Pharmaeuticals; Eli Lilly Co; Novo Nordisk - speakers bureau (2) Call 422 405,759 406,181 Total 716 411,954 412,670 UICUT{ (1) Event (2) Event Total (1) Call 1027 25,429 26,456 (2) Call 469 197,959 198,428 Total 1496 223,388 224,884 y Cardiopulmonary arrest; {unplanned intensive care unit transfer.S10 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • TABLE 2 Rapid Response Criteria Operating Characteristics TABLE Demographics and LOS Sensitivity Specificity PPV* NPV** Prevalence Pre (n 5 557) Post (n 5 230)Event (%) (%) (%) (%) (%) Age* 49 (14) 51 (14)**CAy 41 98 4 100 2 Maley 369 (66) 152 (66)**Mortality 19 99 15 99 2 Hispanicy 178 (32) 91 (40)**UICUT{ 67 89 4 100 7 Blacky 92 (17) 37 (16)** Whitey 251 (45) 93 (40)**y Cardiopulmonary arrest; { unplanned intensive care unit transfer; * positive predictive value; Case Mix Index* 2.40 (2.47) 2.44 (1.86)**** negative predictive value. LOS, median (95% CI) 8.5 (7.9, 9.0) 6.9 (6.7, 8.2){ * Mean (SD); y n (%); ** P ! 0.05; { P < 0.05.inary results of pooled events and call rates are shown inTable 1. Operating characteristics of call criteria are shownin Table 2. Conclusions: Only 41% of CA and 19% of by HMPs between May 2009 and October 2010. Exclu-unexpected deaths are detected by rapid response screen- sion criteria included patients receiving triple-lumen CVCs,ing criteria. Anywhere from 6.8 (mortality) to 25.6 (UICUT) CVCs placed while in the intensive care unit, and multiplecalls are needed to prevent 1 adverse in-hospital event placements of CVCs. We recorded demographics, thebecause of a low positive predictive value (PPV). The low Diagnostic Related Group–based Case Mix Index, medianPPV of calling criteria may help explain why nurses often length of stay (LOS) and complications, including centraldo not activate RRSs. Although attempts to improve the PPV line–associated bloodstream infection, pneumothorax, andby increasing the specificity of criteria would be limited by major bleeding (need for blood transfusion). Data from thethe concomitant decrease in sensitivity, screening a higher- 2 groups were compared using the Wilcoxon rank sumrisk subset of inpatients would improve the overall perform- test. A P < 0.05 was considered significant. All analysesance of the call criteria. The poor real-world operating were performed using SAS Enterprise Guide 4.1. Results:characteristics of RRS calling criteria highlight the uncertain Two hundred and thirty single-lumen LT-CVCs were placedvalue of implementing RRSs to improve hospital outcomes. by HMPs in the 18-month intervention period (13/month)Disclosures:S. R. Bapoje - none; P. S. Mehler - none; R. K. compared with 557 by IR over the 2 years prior (23/Albert - none; A. Sabel - none; R. Bellomo - none; S. Chan- month). Patients in the 2 groups were well matched (seedrasekaran - none; E. S. Chu - none Table 1). Median LOS was reduced by 1.6 days. In the 230 line placements, accounting for 1863 line-days, no17 major complications (central line–associated bloodstreamHOSPITAL MEDICINE PROCEDURALISTS INSERTING infection, pneumothorax, and major bleeding) were observed. Conclusions: Hospital medicine physicians canLONG-TERM CENTRAL VENOUS CATHETERS be trained to safely and efficiently place LT-CVCs. WhenIMPROVES THROUGHPUT access to interventional radiology services is limited, LT-Srinivas Bapoje, MD, MPH, Rebecca Allyn, MD, Marshall CVC placement by hospital medicine proceduralistsMiller, MD, Sarah Stella, MD, Diana Mancini, MD, Angela improves throughput.Keniston, MSPH, Robert Allen, MD, Richard Albert, MD, Disclosures:Eugene Chu, MD, FHM; Denver Health Medical Center, Den- S. R. Bapoje - none; R. Allyn - none; M. Miller - none; S. Stella - none; D. Mancini -ver, CO none; K. Angela - none; R. Allen - none; R. K. Albert - none; E. S. Chu - noneBackground: Limited access to interventional radiology (IR)services may delay placement of long-term central venous 18catheters (LT-CVCs). This can impair hospital throughput IMPROVING PATIENT SAFETY DURING BEDSIDEand escalate costs by increasing length of stay. We devel- PROCEDURES: SUCCESSFULLY IMPLEMENTING THEoped and implemented a hospital medicine procedure ser- UNIVERSAL PROTOCOLvice to decrease delays in LT-CVC placements. Methods:We performed a pre–post study at our university-affiliated Jeffrey Barsuk, MD1, Helga Brake, PharmD2, Timothy Caprio,public safety net hospital. In spring 2009, a group of 6 MD1, Cynthia Barnard, MBA2, Denise Anderson, BSN2, Mark Wil-hospital medicine proceduralists (HMPs) underwent a pe- liams, MD1; 1Northwestern University Feinberg School of Medi-riod of formal training by IR attendings in the insertion of cine, Chicago, IL; 2Northwestern Memorial Hospital, Chicago, ILLT-CVCs (Hohn1) using the micropuncture technique and Background: The Universal Protocol was created by thedirected ultrasound guidance. HMPs started inserting LT- Joint Commission to eliminate the occurrence of wrong-site,CVCs in May 2009. We compared data from patients wrong-procedure, and wrong-person surgery. This studybetween 18 and 89 years of age who had single-lumen LT- evaluated the effects of an innovative reengineered processCVCs placed by IR between May 2007 and April 2009, for bedside procedures with an aim of improving compli-with those from patients in whom the LT-CVCs were placed ance with the Universal Protocol (specifically, time-out) and Hospital Medicine 2011 Abstracts S11
    • increasing nursing and physician communication duringbedside procedures. Methods: This pre-/postinterventionstudy of implementation of the Universal Protocol for bed-side procedures at a large tertiary-care academic medicalcenter was undertaken from July 2008 to May 2010.Administrative data identified patients who underwent lum-bar puncture, paracentesis, or thoracentesis on inpatientmedicine units. Compliance with time-out was comparedfrom baseline (10 months before) to postintervention (9months after). Pre- and postintervention surveys were sent toclinicians addressing their experience, bedside procedureparticipation, and time-out compliance. The postinterventionsurvey also evaluated physician–nurse communication,patient safety, and utilization of the new process. The pri-mary outcome measure was the rate of documented time- FIGURE 1. Overview of Code Assignments by Documentout compliance before and after implementation of the inter-vention. Secondary outcomes were clinician perceptions ofcompliance and safety before and after the intervention. significant interobserver differences. In a recent unpublishedResults: A total of 265 procedures performed at the bed- study, 1 of the investigators (T.E.B.) utilized mock inpatientside on medical floors qualified for study inclusion. Preinter- documents to assess resident understanding of the CMS E/Mvention, 16% of procedures had a documented time-out guidelines. We found variability in the responses from certifiedcompared with 94% of postintervention procedures (OR, coders who were asked to assign a ‘‘correct’’ code to the docu-83.5; 95% CI, 31.8–219.5). Survey results indicated that ments in question. Based on our observations, we believe thatpreintervention, only 59% of the nursing staff who partici- the E/M guidelines may be subject to significant variability inpated in a bedside procedure (23 of 39) assisted in a pre- interpretation, which in turn could lead to variability in reimbur-procedure time-out compared with 96% (56 of 58; OR, sement rates for similar work and documentation. Methods:19.5; 95% CI, 4.1–91.6) postintervention. Physicians We delivered a demographic survey and series of 3 mockreported 33% (19 of 57) compliance preintervention and inpatient admission documents and 3 mock inpatient subse-87% (33 of 38) postintervention (OR, 13.2; 95% CI, quent encounter documents to approximately 250 physicians4.4–39.3). In the postintervention survey 78% of nurses (62 and coding specialists. Subjects were asked to review the 6of 80) felt the intervention improved their involvement in documents and determine which CMS E/M code most accu-patient care, 67% (54 of 81) felt it improved nur- rately described the amount, complexity, and appropriatenessse–physician communication, and 74% (61 of 82) felt it of work documented. Results: Forty-one completed surveys (15improved patient safety. Physicians did not agree with physicians and 26 coding specialists) were returned (16%).nurses that the intervention improved communication (47%; Coding assignments by participants are shown in Figure 1.34 of 72; P 5 0.016) or patient safety (38%; 27 of 71; P Concordance of code assignment was evaluated using Ran-< 0.001). Conclusions: A hospital-based intervention using dolph’s free-margin multirater kappa, where a result of ‘‘0’’ isa well-engineered process integrated with the electronic similar to random chance and ‘‘0.6’’ or higher is consideredmedical record enhances patient safety by increasing com- substantial agreement (Landis and Koch, 1977). Overallpliance with the Universal Protocol. kappa for agreement among all respondents was 0.016 forDisclosures: admission documents and 0.18 for subsequent encounters.J. H. Barsuk - none; H. Brake - none; T. Caprio - none; C. Barnard - none; D. Results of concordance among all respondents, coding specia-Anderson - none; M. Williams - none lists, and physicians per document are noted in Table 1. For most documents, there was little agreement in code assign-19 ments. Conclusions: In this small study, there was significant var-A PROSPECTIVE EVALUATION OF E/M CODINGVARIABILITY TABLE 1 Kappa Coefficient for Measure of Concordance Among Raters: from 1 5 Perfect Agreement to ‡0.6 5 Substantial AgreementTodd Bell, MD, Jenna Aldinger, BS, Harvey Richey, MD; TexasTech University Health Science Center, Amarillo, Amarillo, TX Document All Respondents Physicians Coding SpecialistsBackground: Consistent and accurate documentation withproper coding for physician services is the fiscal foundation of A 0.07 0.00 0.13a successful medical practice. There may be, however, signifi- B 0.00 0.08 20.03cant variability in interpretation of the Centers for Medicare C 20.02 0.19 0.06and Medicaid Evaluation and Management (CMS E/M) guide- D 0.24 0.34 0.22 E 0.21 0.13 0.32lines as they apply to clinical practice. In 2000, Zuber et al. F 0.10 0.19 0.15reviewed 1069 patient charts from physician offices and foundS12 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • iability in code assignments by participants. The lack of con- regression modeling, TIMP-2 was still an independent predictorcordance among both physicians and coding specialists sug- of LOS-HF. Conclusions: Serum levels of TIMP-2 were signifi-gests consistency may not be correctable by education, but cantly and independently associated with length of stay duringrather a more fundamental problem with the code assignment HF hospitalization in this cohort of stable outpatients with pri-system. If our results can be extrapolated to real-world practice, marily systolic HF.some of the hundreds of billions of dollars spent on physician Disclosures:services nationally may be dispensed inconsistently. V. Bhalla - none; V. V. Georgiopoulou - none; A. P. Kalogeropoulos - none; L.Disclosures: Fike - none; G. Giamouzis - none; C. P. Norton - none; S. R. Laskar - none; A. L. Smith - none; J. Butler - noneT. Bell - none; J. Aldinger - none; H. Richey - none 2120 SERUM MATRIX METALLOPROTEINASES (MMPS)SERUM MATRIX METALLOPROTEINASES (MMPS), AND THEIR TISSUE INHIBITOR (TIMP) LEVELS ANDTHEIR TISSUE INHIBITOR (TIMP) LEVELS, AND OUTCOMES IN HEART FAILURELENGTH OF STAY IN HOSPITALIZED PATIENTS Vikas Bhalla, MD, Vasiliki Georgiopoulou, MD, Andreas Kalo-WITH HEART FAILURE geropoulos, MD, Lucy Fike, MPH, Grigorios Giamouzis, MD,Vikas Bhalla, MD, Vasiliki Georgiopoulou, MD, Andreas Kalo- Catherine Norton, MD, Sonjoy Laskar, MD, Andrew Smith,geropoulos, MD, Lucy Fike, MPH, Grigorios Giamouzis, MD, MD, Javed Butler, MD; Emory University, Atlanta, GA, EmoryCatherine Norton, MD, Sonjoy Laskar, MD, Andrew Smith, University, Atlanta, GAMD, Javed Butler, MD; Emory University, Atlanta, GA Background: Matrix metalloproteinases (MMPs) and their tis-Background: Matrix metalloproteinases (MMPs) and their tis- sue inhibitors (TIMPs) are involved in cardiac remodelingsue inhibitors (TIMPs) are involved in cardiac remodeling through regulation of extracellular matrix. Reports on theirthrough regulation of extracellular matrix and eventually devel- association with heart failure (HF) outcomes have been con-opment of heart failure. We explored their association with flicting. Methods: We prospectively examined the associationheart failure (HF)–related hospital length of stay (LOS-HF). of baseline serum levels of MMP-1, -2, and -9 and TIMP-1, -2,Methods: We prospectively examined the association of base- -3, and -4 with outcomes (death, cardiac transplantation, leftline serum levels of MMP -1, -2, and -9 and TIMP-1, -2, -3, and - ventricular assist device implantation, or HF hospitalization)4 with outcomes (death, cardiac transplantation, left ventricular in 147 stable outpatients with HF from January 2008 to Julyassist device implantation, or HF hospitalization) and their 2009. Levels of MMPs and TIMPs were measured by Fluoro-length of stay in the hospital related to those in 147 stable out- kine MAP Human MMP and TIMP kits. Results: Mean age ofpatients with HF from January 2008 to July 2009. Levels of patients was 56.5 Æ 12 years, 66.7% were male, 57.8%MMPs and TIMPs were measured by fluorokine MAP, human were white, and 36.7% were black. Mean left ventricularMMP, and TIMP kits. Results: Mean age of patients was 56.5 ejection fraction was 24.6% Æ 11%. During a mean follow-Æ 12 years, 66.7% were male, 57.8% were white, and up of 23.4 Æ 6.7 months, 49 patients (33%) experienced an36.7% were black. Mean left ventricular ejection fraction was outcome event. MMP-2 (239 Æ 76 vs. 286 Æ 78 ng/mL, P 524.6% Æ 11%. During a mean follow-up of 23.4 Æ 6.7 0.01) and TIMP-2 (119 Æ 20 vs. 133 Æ 22 ng/mL, P 5months, 49 patients (33%) experienced an outcome event; of 0.01) were significantly higher in patients with events. MMP-these, 42 patients were hospitalized and had a mean LOS-HF 2 and TIMP-2 had an area under the curve of 0.68 Æ 0.05of 6.6 Æ 17.3 days. MMP-2, TIMP-2, and TIMP-4 positively and 0.71 Æ 0.05 for predicting outcomes. TIMP-2 positivelycorrelated with length of stay during HF hospitalization (LOS- correlated with MMP-2 (r 5 0.77, P < 0.01) and B-type natri-HF; r 5 0.193, P < 0.02; r 5 0.235, P < 0.01; r 5 0.225, uretic peptide (r 5 0.19, P < 0.03) and negatively with ejec-P < 0.01, respectively). Also LOS-HF correlated positively with tion fraction (r 5 0.26, P < 0.01) and the 6-minute walk testcreatinine and negatively with EF and the 6-minute walk test (r 5 0.19, P < 0.03). In Cox models controlling for age, sex,but did not correlate with brain natriuretic peptide (BNP); see ejection fraction, creatinine, and therapy, only TIMP-2 levelTable 1. In multivariate analysis among significantly correlated was associated with risk of adverse outcomes (OR, 1.018;MMPs and TIMPs, TIMP-2 and TIMP-4 were significant predic- 95% CI, 1.005–1.031, per ng/m; P 5 0.005). Conclusions:tors of HF-LOS. Even after adjusting for EF, BNP level, creati- Elevated serum levels of TIMP-2 were strongly and independ-nine level, 6-minute walk test, TIMP-4, and age, using linear ently associated with adverse outcomes in this cohort of stable outpatients with primarily systolic HF.TABLE 1 Correlates of Length of Stay in the Hospital During Heart Failure Disclosures:Hospitalization V. Bhalla - none; V. V. Georgiopoulou - none; A. P. Kalogeropoulos - none; L. Fike - none; G. Giamouzis - none; C. P. Norton - none; S. R. Laskar - none; A. L. Smith - none; J. Butler - noneTotal HF LOS TIMP-2 EF BNP Creatinine 6-Minute Walk TestCorrelation 0.235 20.246 0.139 0.208 20.199P value 0.005 0.003 0.143 0.015 0.022 Hospital Medicine 2011 Abstracts S13
    • 22DEEP VEIN THROMBOSIS AS A PREDICTOR OFMORTALITY IN PATIENTS HOSPITALIZED WITHCONGESTIVE HEART FAILURE: RESULTS FROM THENATIONWIDE INPATIENT SAMPLE (1998–2007)OF HEALTHCARE COST AND UTILIZATIONPROJECTOluwaseyi Bolorunduro, MD, MPH1, Muhammad Bakht,MBBS2, Ediri Brume, MD3, Muhammad Amer, MD4; 1Maimo-nides Medical Center, Brooklyn, NY; 2University of Medicineand Dentistry New Jersey, Piscataway, NJ; 3Saint Joseph Hos-pital, Chicago, IL; 4Johns Hopkins School of Medicine, Balti-more, MDBackground: The prevalence of congestive heart failure FIGURE . Graph representing odds ratio of developing DVT with(CHF) in the United States has been on the rise over the last increasing length of hospital stay (in days).decade. This is likely because of the standardized manage-ment of hospitalized patients with CHF decompensation, ure (odds ratio, 0.81; P < 0.01). Other predictors of DVTallowing patients with CHF to live longer. These patients included comorbidities and longer length of stay (3 daysare known to posses increased risk of developing deep and above). Conclusions: Deep vein thrombosis is an inde-vein thrombosis (DVT). We analyzed data from the Nation- pendent predictor of mortality among patients hospitalizedwide Inpatient Sample (NIS) to examine the impact of DVT with CHF. Increasing LOS in this population was associatedon mortality in patients hospitalized with CHF. Methods: with a significantly higher incidence of DVT. These findingsWe conducted a retrospective analysis using the NIS, a from the nationally representative sample highlight the needdatabase developed as part of the Healthcare Cost and Uti- for early mobilization and ambulation to prevent DVT inlization Project sponsored by the federal Agency for Health- patients hospitalized with CHF.care Research and Quality (AHRQ) from 1998 to 2007. Disclosures:NIS is the largest all-payer inpatient care database in the O. Bolorunduro - none; M. Bakht - none; E. Brume - none; M. Amer - noneUnited States, which contains data from approximately 8million hospital stays per year. Adult patients (>18 years)with CHF during the 10-year period were identified using 23ICD-9 codes. The prevalence of DVT in this population was A MULTIDISCIPLINARY APPROACH TO REDUCINGcalculated. Characteristics of patients with and without DVT HEART FAILURE READMISSIONSwere compared, utilizing data over a 10-year period start- David Boyte, MD, Lalit Verma, MD, Marilyn Wightman, MSN,ing with the index admission. Chi-square, median, and Stu- MBA; Duke University, Durham Regional Hospital, Durham,dent t tests were used as appropriate. Multivariate NCregression for overall mortality and length of stay (LOS) Background: Patients hospitalized with congestive heart fail-was conducted using logistic and linear models, respec- ure are more likely to be readmitted than any other group.tively. The analysis was controlled for sex, insurance status, We found our hospital’s 30-day readmission rate for heartand comorbidities using the Charlson comorbidity index. failure patients to be 22% for any cause and 8.5% for theResults: A total of 7.8 million patients were hospitalized for same diagnosis. Heart failure was the top readmission di-CHF management from 1998 to 2007. The overall mortal- agnosis, and the readmission rate had been steadilyity during the index hospital admission was 6.9%. We increasing. Other organizations have employed care transi-observed a significant decline in index-hospitalization mor- tion models, posthospitalization teaching, and self-manage-tality over the 10-year period (7.9%–5.7%, P < 0.01). The ment strategies for reducing heart failure readmissions.prevalence of documented DVT during the index admission Besides medical management, it is unclear what specificwas 0.43%. Using bivariate analysis, patients with DVT interventions during a hospitalization may contribute mostwere more likely female (55%), were slightly older (75 vs. to decreasing readmission rates for heart failure patients.74 years, P < 0.01), had a longer LOS (median, 5 days; Methods: Using the Transforming Care at the Bedside tool,IQR, 3–8 days; vs. median, 8 days; IQR, 5–13 days; P < we flowcharted our discharge process and noted gaps in0.01} and had a higher mortality rate (9.3% vs. 6.9%, P < preparing our heart failure patients for discharge. To iden-0.01). In multivariate regression we observed that patients tify primary contributors to readmission in our patient popu-with DVT were more likely to die than those without DVT af- lation, we used the Six Sigma Voice of the Customerter controlling for comorbidities (odds ratio, 1.38; P < process to survey patients readmitted with heart failure. Dis-0.01). In addition, patients with systolic heart failure were coveries included 51% reporting not receiving educationalless likely to have DVT than patients with diastolic heart fail- materials during their previous hospitalization, 75% notS14 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • weighing themselves daily, and 39% not understanding the and responded via an electronic survey. Respondents wereneed to track their weight. Furthermore, 31% of those sur- queried about the frequency of various behaviors. Responsesveyed had not followed up with an outpatient physician were assessed with a 5 point Likert-type scale that rangedprior to their readmission. After employing a collaborative from ‘‘never’’ to ‘‘always.’’ Data were analyzed using de-process to identify heart failure patients, we created a multi- scriptive statistics. Results: Twenty-seven hospitalists com-disciplinary protocol to provide focused education and care pleted the questionnaire (100% response rate). Fifty-twocoordination during their hospitalization. We developed a percent of respondents were female, and 74% had beenchecklist of 10 items to be addressed with each patient, working within this hospitalist group > 1 year. Thirty percentand it required interventions from nurses, physicians, nutri- had at least some experience working in ambulatory settingstionists, unit managers, unit clerks, and performance after residency. Hospitalists infrequently employed teach-backimprovement personnel. Patients received calendars with methods with their patients at the time of discharge (55.6%educational messages. They learned the importance of responded ‘‘never’’ or ‘‘rarely’’), contacted the patient’s pri-weighing themselves and when to call their provider. If they mary care provider after discharge (41% responded ‘‘never’’did not have scales at home, they were given digital scales. or ‘‘rarely’’), or called their patient after discharge (93%Follow-up appointments were made for the patients prior to responded ‘‘never’’ or ‘‘rarely’’). In contrast, respondentsdischarge. The protocol was piloted for 3 months in the car- reported more concern with timeliness of discharge summa-diac nursing unit, where the majority of our hospital’s heart ries (74% reported ‘‘usually’’ or ‘‘always’’ completing dis-failure patients receive care. Costs were minimal and lim- charge summaries within 24 hours of discharge) andited to printing calendars and purchasing scales. We used personally ensuring that patients had a scheduled follow-upexisting resources otherwise. Limitations included our using appointment (56% responded ‘‘usually’’ or ‘‘always’’).a convenience sample of patients for the survey and not Respondents also personally spoke with patients or their care-comparing readmission rates for patients with a secondary givers about significant test results (96% responded ‘‘usually’’diagnosis of heart failure. Results: The 30-day all-cause or ‘‘always’’), red flags (78% responded ‘‘usually’’ orreadmission rate for the pilot group was 10.7%, signifi- ‘‘always’’), and discharge medications (89% respondedcantly less than our previous rate (27.6% for the same nur- ‘‘usually’’ or ‘‘always’’). Relatively fewer respondents (52%)sing unit and 22.4% for the entire hospital). Conclusions: reported that they ‘‘usually’’ or ‘‘always’’ spoke with aEven though hospitals are not directly involved in primary patient’s nurse about the postdischarge care plan, and onlycare after discharge, a well-managed protocol of multidisci- 7.4% ‘‘usually’’ or ‘‘always’’ contacted the primary careplinary efforts during a hospitalization directed toward provider after a patient was discharged. Conclusions: Inidentifying and addressing postdischarge needs can reduce general, hospitalists most reliably convey important infor-30-day readmissions for heart failure patients. mation to the patients themselves prior to discharge.Disclosures: However, only a minority employ the ‘‘teach-back’’D. Boyte - none; L. Verma - none; M. S. Wightman - none method when doing so. Many hospitalists also do not communicate with other providers who play key roles during hospital discharge and in the post–acute care set-24 ting. Standardizing discharge processes among providersHOSPITALISTS’ COMMUNICATION BEHAVIORS may positively influence hospitalist behaviors around theAROUND THE TIME OF HOSPITAL DISCHARGE time of discharge. Further work is needed to understand the effects of these communication patterns.Jennifer Bracey, MD1, Scott Wright, MD2, Romsai Boonyasai, Disclosures:MD3; 1Johns Hopkins Bayview Medical Center. CollaborativeInpatient Medicine Service (CIMS), Baltimore, MD; 2Johns Hop- J. Bracey - none; R. Boonyasai - none; S. Wright - nonekins Bayview Medical Center. Division of General InternalMedicine, Baltimore, MD; 3Johns Hopkins Hospital. Division ofGeneral Internal Medicine--hospitalist program, Baltimore, MD 25 READMISSIONS: A MISSED LEARNINGBackground: The quality of provider–provider and patient- OPPORTUNITY FOR HOSPITALISTSprovider communication at discharge is associated withpatient satisfaction, adherence to treatment plans, and clini- Jennifer Bracey, MD1, Romsai Boonyasai, MD2, Scott Wright,cal outcomes. However, the ways in which providers commu- MD3; 1Johns Hopkins Bayview Medical Center. Collaborativenicate with each other and with patients at discharge is Inpatient Medicine Service, Baltimore, MD; 2Johns Hopkinsunknown. Therefore, we queried hospitalists about their inter- Hospital. Division of General Internal Medicine—hospitalistactions with patients and other providers at the time of hospi- program, Baltimore, MD; 3Johns Hopkins Bayview Medicaltal discharge. Methods: As part of an ongoing institutional Center. Division of General Internal Medicine, Baltimore, MDreview board–approved intervention focused on medical pro- Background: Hospitalists are often not aware when afessionalism, we conducted a cross-sectional survey of 27 patient whom they have cared for is readmitted to the hos-hospitalists at a 350-bed university-affiliated community pital. However, there may be much to learn from readmis-teaching hospital. Respondents were contacted by e-mail sions, both in terms of clinical care and systems Hospital Medicine 2011 Abstracts S15
    • improvement. To this end, we asked hospitalists how they 26learn when a patient has been readmitted, what they do HOW CAN WE DECREASE THE READMISSIONwhen they hear of these cases, and to what extent they RATES OF PATIENTS WITH CONGESTIVE HEARTview readmissions as opportunities for professional growth. FAILURE?Methods: As part of an ongoing institution review Beril Cakir, MD, FHM, Gary Gammon, MD, FHM, Judithboard–approved intervention focused on medical profes- Abernathy, RN, Christina Huitt, RN, Suzanne Howell, RN;sionalism, we conducted a cross-sectional survey of 27 hos- Gaston Memorial Hospital, Gastonia, NCpitalists. Respondents were contacted by e-mail andresponded via an electronic survey. Respondents were quer- Background: Heart failure is one of the most frequentied about their attitudes regarding learning and profession- causes of hospitalizations and readmissions in the Unitedalism opportunities from readmissions. Attitude responses States. Several peridischarge interventions were reported towere assessed with a 5-point Likert-type scale that ranged decrease the readmission rates. The objective was to assessfrom ‘‘strongly disagree’’ to ‘‘strongly agree.’’ In addition, the feasibility and effectiveness of a discharge planningrespondents were queried about how they learned of a intervention to decrease all-cause readmission rates withinpatient’s readmission and about behaviors they demon- 30 days among patients with congestive heart failurestrated once this knowledge was obtained. Behavior (CHF). Methods: We conducted a pilot study as a qualityresponses were assessed using a 5-point Likert-type scale improvement project at a 450-bed community hospital onthat ranged from ‘‘always’’ to ‘‘never.’’ Data were ana- patients with a principle diagnosis of CHF. The study waslyzed using descriptive statistics. Results are reported as the designed as a prospective cohort, using intervention andpercentage of respondents who chose ‘‘agree’’ or ‘‘strongly control groups. The discharge planning interventionagree’’ for attitude responses versus ‘‘usually’’ or ‘‘always’’ included patient teaching, medication reconciliation withfor behavior responses. Results: Twenty-seven hospitalists com- detailed discharge instructions, peridischarge planningpleted the questionnaire (100% response rate). Forty-eight involving arrangement of home health care, early follow-uppercent were male, and 74% had worked within the hospital- appointments, and follow-up phone calls. Main study out-ist group > 1 year. Ninety percent of respondents agreed comes were readmission rates and mortality within 30 daysthat learning of readmissions could help them become ‘‘more of discharge. Baseline characteristics and outcomes wereskilled and effective physicians.’’ Ninety percent of respon- compared between intervention and control groups todents agreed that learning why patients are readmitted ‘‘is demonstrate the effect of the intervention. Results: Baselinean act of professionalism for hospitalists.’’ Respondents characteristics of the intervention and control groups werelearned of readmissions multiple ways: 89% learned of the similar with respect to age, sex, race, type of attendingevent accidentally (e.g., noticing the patient’s name on a (hospitalist, cardiologist, or other), cardiologist care, ejec-door), 48% from the readmitting provider, 7% from the tion fraction, Charlson comorbidity index, and length ofpatient/patient’s family, and 30% through ‘‘other’’ channels stay. We did not detect a statistically significant difference(e.g., ‘‘the case manager informs me’’). Once a provider in 30-day readmission rates (27.6% vs. 24.1%, P 5 0.67)learned of a patient readmission, 41% communicated with between the intervention (n 5 58) and control (n 5 54)the patient’s current provider, and 41% visited the readmitted groups. Mortality rates within 30 days were also similar.patient. Conclusions: Hospitalists recognize that commit- Although there was no statistically significant difference, theting the time and effort to learn why a patient has been intervention appeared to be relatively protective againstreadmitted is both an act of professionalism and an op- readmission in patients < 65 years old, those having ambu-portunity for clinical learning through deliberate practice. latory dysfunction, and those discharged home or to anWhen they do learn that their patients have been read- assisted-living facility. Time to readmission was also slightlymitted, a sizable minority communicate directly with the longer in the intervention group (15.5 vs. 9 days, P 5current providers or with the patients—steps that enhance 0.07). Conclusions: Our discharge planning interventionindividual learning and improve patient care. Unfortu- did not demonstrate a significant decrease in 30-day read-nately, this is often a missed opportunity, as hospitalists mission or mortality rates among CHF patients. However,are frequently unaware that a patient has been read- our study confirmed that low-cost, low-resource intense inter-mitted. Establishing formal processes to inform hospital- ventions are feasible in community hospitals. Extending theists of patient readmissions may contribute to improved study for a longer period may provide statistically signifi-clinical skill and inpatient care. cant results, demonstrating the success of the intervention.Disclosures: Disclosures:J. Bracey - none; R. Boonyasai - none; S. Wright - none B. Cakir - none; G. Gammon - none; J. Abernathy - none; C. Huitt - none; S. Howell - noneS16 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • 27 28A DIRTY BUSINESS: IMPLEMENTATION OF CICLE: CREATING INCENTIVES AND CONTINUITYCONTACT PRECAUTIONS AT A UNIVERSITY LEADING TO EFFICIENCYTEACHING HOSPITAL Shalini Chandra, MD, MS, Eric Howell, MD, Scott Wright,Amit Chadha, MD1, Francesca Torriani, MD2, Brian Clay, MD; Johns Hopkins Bayview Medical Center, Baltimore, MDMD2, Gregory Seymann, MD2; 1Santa Clara Valley Medical Background: The Joint Commission and Institute of MedicineCenter, San Jose, CA; 2University of California, San Diego, have stressed that provider discontinuity of inpatient careSan Diego, CA poses many hazards to patient care. This fragmentation isBackground: The incidence of health care–associated infec- thought to threaten patient safety and may influence lengthtions is a significant cause of morbidity and a driver of of stay (LOS), health care costs, and patient satisfaction.excess costs in U.S. hospitals. Compliance with contact pre- The impact of improved continuity of inpatient care is notcautions is important in reducing transmission of multidrug- known. Our objective was to determine the impact of a hos-resistant organisms (MDRO) such as methicillin-resistant pitalist-developed continuity-centered staffing model onStaphylococcus aureus, vancomycin-resistant Enterococcus, hand-offs, efficiency, and resource utilization. We hypothe-Clostridium difficile, and gram-negative organisms produ- sized that the Creating Incentives and Continuity Leading tocing extended-spectrum b-lactamases. In 2009, our institu- Efficiency (CICLE) model would result in desired outcomes.tion added a new function to all computer-based admission Methods: Using a pre–post study design, we comparedorder sets, which prompted clinicians to assess each patient-level data from the 6 months after the first month ofpatient’s history of MDRO and to order appropriate precau- implementation of the CICLE staffing model (Septembertions. Although this new system improved early identifica- 2009–February 2010) to that from those same months intion of patients at risk of transmitting MDRO, it was unclear the prior year. Our study took place at a 335-bed universityhow reliably the precautions were being implemented. affiliated medical center in Baltimore. All faculty hospitalistsMethods: Unannounced audits of all rooms at both sites of and midlevel providers participated in the study. Outcomesan urban university medical center with an active order for were measured using a population-based convenience sam-‘‘contact precautions’’ were performed by a single investi- ple of 1743 and 1642 admissions during the pre- and postgator at random times on 11 days between November periods, respectively. Admissions that involved house staff2009 and March 2010. Adherence to the various compo- were excluded. The number of unique hospitalists whonents of the hospital’s contact precautions policy (as billed a professional fee during hospitalization were useddefined below) was recorded. Compliance was defined as as a measure of continuity of care. Charges per admissionfollows: (1) gloves in all sizes available in front of or inside and LOS assessed resource utilization, whereas readmis-the room, (2) gowns available within 3 doors in either sion rates and payer-denied days were reviewed to charac-direction of the room, (3) an unobstructed sink, (4) a func- terize quality. Results: Unique providers per admissiontioning hand gel dispenser, (5) a dedicated stethoscope declined by 13% under the CICLE model, from 2.09 toinside the patient room, and (5) a dedicated flashlight 1.81 (P < 0.0001). The LOS decreased by 16%, frominside the patient room. Results: A total of 279 observations 4.31 to 3.60 days (P < 0.0001). Mean total hospitalwere recorded during the study period (24% from the inten- charge per admission fell approximately 20%, fromsive care unit). Compliance with the individual components $9967.54 to $7999.27 (P < 0.0001), with significant sav-of contact precautions was >90% except for the presence ings in medications, laboratory charges, and radiologyof dedicated stethoscopes (76%) and flashlights (61%). charges (all P < 0.001). All-cause readmission rates at 7,Stethoscopes and flashlights were available significantly 15, and 30 days and payer-denied days were not affectedmore often in the intensive care unit (ICU) than on the (all P > 0.05). Conclusions: The CICLE staffing modelwards (93% vs. 70% and 91% vs. 51%, respectively, P < directly addresses the continuity problem in inpatient care.0.0001). Outside the ICU, compliance with stethoscopes Furthermore, the CICLE model represents a viable cost-sav-and flashlights varied significantly between units. The range ing and efficient model that is beneficial to all stakeholdersof compliance was 0%– 93% for stethoscopes and in health care delivery.0%–100% for flashlights. Conclusions: Despite an aggres- Disclosures:sive program to optimize physician ordering of contact pre- S. Chandra - none; E. E. Howell - none; S. M. Wright - Miller-Coulson Familycautions, provision of dedicated equipment was highly through the Johns Hopkins Center for Innovative Medicine, scholar/researchvariable outside the ICU. However, some units, such as the supportbone marrow transplant unit, demonstrated high compli-ance with dedicated equipment standards, suggesting thepresence of a remediable performance gap. Future direc-tions will be to study and disseminate best practices fromthe high-performing units throughout the hospital.Disclosures:A. Chadha - none; F. Torriani - none; B. Clay - none; G. Seymann - none Hospital Medicine 2011 Abstracts S17
    • 29 TABLE 2 Pre and Post Survey Results (Percent answering Agree of StronglySTANDARDIZED PATIENTS TO IMPROVE WORK Agree)*ROUNDS AND DISCHARGE ENCOUNTERS Group A Group ADennis Chang, MD, Micah Mann, MD, Erica Friedman, MD,Terry Sommer, BFA, Robert Faller, MS, Kristofer Smith, MD, Pre Post Pre PostMPP, Mount Sinai Medical Center, New York, NY (n5136) (n5122) p (n589) (n590) p valueyBackground: Discussions with patients during work rounds Work Rounds Caseand at the time of hospital discharge are encounters that Right now, I feel confident about 88% 92% 0.342 87% 99% 0.012require substantial skill. High-quality execution of these my ability to conduct a highinteractions can improve satisfaction and quality of care. quality work roundsStandardized patients (SPs) provide an opportunity to iden- discussion with a potenttify skills gaps and to train house staff on high-quality work hospitalized for smallrounds and discharge interactions. Methods: Two SP bowel obstruction.encounters were created. The first encounter, ‘‘work Right now. I feel confident 96% 96% 0.901 96% 100% 0.059rounds,’’ involved a patient with a partial small bowel about my ability toobstruction (SBO) awaiting imaging. The second encounter, conduct a high quality‘‘discharge,’’ involved a patient discharge after a conges- general work roundstive heart failure exacerbation. As a teaching tool, a 10-mi- discussion with a patient.nute ideal discussion video was created for each case. Discharge DiscussionEach house staff completed pre- and postencounter surveys Right now, I feel confident 89% 95% 0.073 89% 99% 0.005investigating behavior change resulting from the encounter. about my ability to conductHalf the participants experienced the SP encounters without a high quality work rounds discussion with a potentthe teaching video (group A), whereas the other half hospitalized forreviewed the teaching video at the completion of the SP en- heart failure.counter (group B). Change in self-reported confidence was Right now, I can decrease a 88% 95% 0.049 78% 97% <.0001assessed using the chi-square test for proportions with 95% heart failure patient’s riskconfidence interval. Demographics of the house staff were of rehospitalization throughprovided by the Graduate Medical Education office, and my discharge discussion.prior exposure to SPs was assessed on the day of participa- Right now, I feel confident about 97% 97% 1.000 92% 99% 0.034tion. Results: Two hundred and twenty-six members of the my ability to conduct a highhouse staff from 22 programs have completed the encoun- quality general dischargeters to date (Table 1). Examining change in behavior, a discussion with a patient.number of findings emerge (Table 2). For the ‘‘work Right now, I can decrease a 91% 97% 0.065 88% 99% 0.002rounds’’ case, house staff generally showed improved rat- general rehospitalizationings of self-efficacy, but these changes only reached statisti- through my dischargecal significance for group B participants when asked about discussion.their ability to conduct high-quality work rounds for an SBO * Modified Like Scurv. 15Strongly Disagree; 25Disagree; 3-Agree; 4-Strongly Agreepatient (P 5 0.012). For the ‘‘discharge’’ case, group A y Calculated using chi-square test for proportionsreported improvement on only 1 question, ability to impactTABLE 1 Demographics for Group A and B a heart failure patient’s risk of rehospitalization (P 5 0.049). Members of group B, however, reported broad Group A (n5136) Group B (n589) p improvement in their ability to conduct a high-quality dis- charge discussion for heart failure (P 5 0.005) and in gen-Gender (% Male) 45% 51% .402 eral (P 5 0.034) and in their ability to decreasePGY1 92% 75% .001Foreign Medical School Graduate 71% 56% .020 rehospitalization for heart failure (P < 0.0001) and in gen-Previous SP experience:> 5 73% 77% .683 eral (P 5 0.002). These results remained even when base-Previous SP experience: none 27% 23% line demographic differences were controlled for.Current residency:* Conclusions: SP encounters can lead to improved self-confi-Internal Medicine 59% 58% dence for house staff in work rounds and discharge discus-Family Practice 0% 7% .003 sions. Greater improvement comes from a combination ofPediatrics 9% 12% .392 an SP encounter and a postencounter teaching video. AObstetrics/Gynecology 4% 8% teaching video combined with a standardized patient expe-Prelim/Calcgorical/Transitional 18% 15% rience may be a novel way to improve quality of care.Sugery 10% 4% .202 Disclosures: D. Chang - none; M. Mann - none; E. Friedman - none; T. Sommer - none; R.* Statistical testing conducted comparing each residency type versus all others combined. Faller - none; K. Smith - noneS18 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • 30 70 (20%); Escherichia coli, 41 (11.7%); coagulase-positiveEPIDEMIOLOGY OF HOSPITAL-ACQUIRED URINARY Staphylococcus, 36 (10.3%); and Pseudomonas sp., 31TRACT–RELATED BLOODSTREAM INFECTION: (9%); see Figure 1. Enterococcus sp. were more frequent2000–2008 among cases with histories of malignancy (P 5 0.021), neutropenia (P < 0.001), transplant (P 5 0.01), immuno-Robert Chang, MD1, Carol Chenoweth, MD1, Mary Rogers, suppressant therapy (P 5 0.008), antiviral therapy (P <PhD1, Latoya Kuhn, MPH2, Todd Greene, PhD, MPH1, Emily 0.001), and antifungal therapy (P < 0.001). Candida sp.Shuman, MD1, Sanjay Saint, MD, MPH1; 1University of Michi- were more frequent among cases with histories of liver dis-gan Medical School, Ann Arbor, MI; 2Veterans Affairs Health ease (P 5 0.003), renal disease (P 5 0.002), transplant (PServices Research and Development Center of Excellence, Ann 5 0.03), and previous antibacterial use (P < 0.001). Con-Arbor, MI clusions: Enterococcus sp. and Candida sp. were the mostBackground: Urinary tract infection (UTI) is the most fre- frequent pathogens isolated from the bloodstream inquent hospital-acquired infection in the United States. patients with hospital-acquired bacteriuria. Enterococcus sp.Bloodstream infection (BSI) secondary to UTI occurs less fre- infections were associated with malignancy, neutropenia,quently but is associated with significant morbidity and mor- and transplantation. Candida sp. infections were asso-tality. Despite renewed interest in hospital-acquired UTI, ciated with renal disease and liver disease. The potentiallittle is known about the epidemiology of nosocomial uri- influence of Enterococcus sp. and Candida sp. should benary tract–related BSI. Methods: We reviewed patients considered in the context of patient comorbidities for appro-using administrative electronic records coupled with manual priate presumptive antimicrobial therapy for nosocomial uri-chart review in a Midwestern academic medical center nary tract–related bloodstream infection.with more than 800 beds (99 of them intensive care units). Disclosures:The case definition was any hospitalized adult patient with S. Saint - none; L. Kuhn - none; E. Shuman - none; C. Chenoweth - none; T.a positive urine culture obtained >48 hours after admission Greene - none; R. Chang - noneand a blood culture obtained within 14 days of the urineculture that grew the same organism. A urine culture wasdefined as positive if it grew >103 CFU/mL of a single or- 31ganism. Chi-square analyses and t tests were used to assess PUBLIC REPORTING FOR PERCUTANEOUSunadjusted bivariate comparisons, and all analyses were CORONARY INTERVENTIONS IN NEW YORKperformed using Stata/SE 11.0 Results: During the study STATEperiod, 350 patients met the case definition, with meanage of 58 years (range, 21–92 years), and 192 were Lena Chen, MD, MS1, Arnold Epstein, MD, MA2; 1Ann Arbormale (54.9%). A majority of cases were admitted through Veterans Affairs Medical Center, Ann Arbor, MI; 2University ofthe emergency department, 136 (38.9%), or from home, Michigan, Ann Arbor, MI83 (23.7%). Comorbid conditions included: renal disease, Background: Prior studies of public reporting on risk-176 (50.3%); heart disease, 170 (48.6%); malignancy, adjusted mortality for coronary artery bypass grafting139 (39.7%); diabetes, 86 (24.6%); neutropenia, 72 (CABG) have found that public reports have strong predic-(20.6%); and transplant, 67 (19.1%). Predominant organ- tive validity and likely encourage poor-quality surgeons toisms included: Enterococcus sp., 97 (27.7%); Candida sp., leave practice. However, except for CABG surgery, there are few data on the predictive accuracy of public reports or their impact on providers’ practice. We used data from New York State on percutaneous coronary interventions (PCIs) to address 3 questions. (1) What is the predictive ac- curacy of public reports for PCIs? (2) What is their impact on market share? (3) Is report performance associated with decisions to leave practice? Methods: We examined quality performance by hospitals (and cardiologists), as measured by publicly reported risk-adjusted mortality rates (RAMRs) for nonemergent PCIs performed in New York State between 1998 and 2007. For hospitals (and cardiologists) in each performance quartile, we estimated: (1) the aver- age risk-adjusted mortality rate after report publication, (2) the change in market share from prerelease to postrelease year, and (3) the proportion of physicians leaving practice in the postrelease year. Results: Between 1998 and 2007, the New York State public reports included data on 351FIGURE 1. Temporal trends of nosocomial urinary tract–related cardiologists who performed nonemergent PCIs at 49 hospi-bloodstream infection from 350 cases, 2000–2008. tals. Patients who picked a hospital in the highest quartile Hospital Medicine 2011 Abstracts S19
    • of performance in the most recent report did not have a 716,023 unique patients were admitted to 121 VA hospi-lower chance of dying than those who picked a hospital in tals. Of these patients, 68,389 (9.6%) were initiallythe lower 3 quartiles (RAMRs of 0.61, 0.59, 0.58, 0.71; P admitted to the ICU, and 647,634 (90.4%) were admitted> 0.05). Results were similar for cardiologists (RAMRs from elsewhere. Direct admissions to the ICU had a higher pre-top to bottom performance quartile: 0.57, 0.59, 0.57, dicted mortality (ICUS, 0.084; 30-day mortality, 7.7%)0.74; P > 0.05). Performance ranking was not associated than admissions to a non-ICU ward (ISS score, 0.042; 30-with a change in market share for hospitals or for physi- day mortality, 3.5%). Transfers to the ICU from a non-ICUcians (all P > 0.05). There was no association between ward had the highest predicted mortality (ICUS, 0.194; 30-report performance, and decisions to stop practicing in day mortality, 19.9%). The proportion of patients that hos-New York after report publication (4% in top and bottom pitals triaged to the ICU increased with mortality riskquartiles; P > 0.05). Conclusions: Public reporting on percu- (patient-level quintiles of predicted mortality: <0.6%,taneous interventions in New York State provides informa- 0.6%–1.1%, 1.1%–2.2%, 2.2%–5.3%, 5.3% to 1.0; corre-tion that, even if used, would not significantly help patients sponding mean proportion admitted to the ICU: 5%, 8%,decrease their risk of dying after a nonemergent percutane- 11%, 15%, and 21%). For a given mortality risk, the pro-ous coronary intervention. Public reporting appears to have portion of patients sent to the ICU varied among hospitalshad no effect on hospital or physician market share, or phy- (range by quintile of predicted mortality: 0%–33%,sicians’ decisions to leave practice. The utility of public 0%–35%, 8%–41%, 8%–47%, and 5%–53%). Results werereporting may differ substantially for different procedures. comparable when we restricted our sample to the 51 levelDisclosures: 1 hospitals with similar ICU capabilities (mean proportionL. Chen - none; A. Epstein - none admitted to the ICU, by severity quintile: 0%–16%, 0%–31%, 2%–39%, 3%–47%, and 10%–51%). Conclu- sions: Hospitals vary widely in their propensity to send32 patients with the same predicted mortality to the ICU.VARIATION IN TRIAGE PRACTICES AMONG Access to critical care services may depend in part on theVETERANS AFFAIRS HOSPITALS hospital where a patient seeks his or her care. Disclosures:Lena Chen, MD, MS1, Marta Render, MD2, Anne Sales, MSN,PhD, RN2, Edward Kennedy, MS1, Wyndy Wiitala, PhD1, Tim- L. Chen - none; M. Render - none; A. Sales - none; E. Kennedy - none; W. Wiitala - none; T. Hofer - noneothy Hofer, MD, MSc1; 1Ann Arbor VA Heathcare System,Ann Arbor, MI; 2VA Inpatient Evaluation Center, Cincinnati,OH 33Background: Regional variation in critical care use has TEMPORARY CENTRAL VENOUS CATHETERbeen described, but the reason for this variation remains UTILIZATION PATTERNS IN A LARGE TERTIARY-unclear. Multiple factors contribute to the decision to admit CARE CENTER: TRACKING THE ‘‘IDLE’’ CENTRALpatients to the intensive care unit (ICU), including local ex- VENOUS CATHETERpertise, bed availability, and the perceived need for ICUcare. We used retrospective data from a national sample Sheri Chernetsky Tejedor, MD, Christina Payne, MD, Jasonof Veterans Affairs (VA) acute care hospitals, to better Stein, MD, Daniel Dressler, MD, David Tong, MD; Emory Uni-understand hospital variation in triage practices on admis- versity School of Medicine, Atlanta, GAsion. Methods: We constructed a longitudinal cohort of Background: Although central line (CVC) dwell time is aadult admissions to any VA acute care hospital from April major risk factor for central line–associated bloodstream2007 to June 2010, using data from the VA Inpatient Eva- infections (CLABSIs), there is little information about how of-luation Center. We included the first admission for all non- ten CVCs are retained when not needed (‘‘idle’’). Wesurgical patients who were admitted from the emergency describe the use patterns of CVCs on medical wards. Meth-department or outpatient clinic. We excluded VA hospitals ods: A retrospective chart review focused on daily CVC jus-with fewer than 10 ICU admissions. For each admission, tification was obtained on a random sample of patientswe estimated predicted mortality using either the inpatient with a temporary CVC, including peripherally inserted cen-severity score (ISS), for those admitted to a non-ICU ward, tral catheters (PICCs). An idle day was defined as a dayor the VA-ICU score (ICUS), for those admitted directly to with a CVC that did not meet the justification criteria in Fig-the ICU. Both scores are based on clinical, laboratory, and ure 1. Each ward day, an eligible CVC was in place anddemographic variables collected in the 24 hours surround- was scrutinized for CVC necessity. Results: We analyzeding admission. We measured the proportion of patients that 89 patients, 151 CVCs (80% were PICCs), and 1433each hospital admitted directly to the ICU, stratified by ward line days. Three hundred and sixty-one CVC daysascending quintiles of mortality risk (as measured by the (25%) were idle. Patients had a mean of 4.06 (SD 6.6)ICUS, if admitted directly to the ICU, or the ISS, if admitted idle days if IV antimicrobials were considered a justificationdirectly to a non-ICU ward). Each quintile contained equal for the CVC, and 10.83 (SD 10.87) days if they were not.numbers of patients. Results: During the study period, At least 1 and !2 idle days were seen in 63% and 48% ofS20 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • PICCs lines were often retained until the day of discharge. The combination of the above factors may adversely affect CLABSI rates. Disclosures: S. Chernetsky Tejedor - Baxter Healthcare, research grant; C. Payne - none; J. Stein - none; D. Dressler - none; D. Tong - none 34 PROGNOSTIC SIGNIFICANCE OF ABNORMAL LIVER FUNCTION TESTS IN ACUTE DECOMPENSATED HEART FAILURE JayaKrishna Chintanaboina, MD1, Matthew Haner, PhD2, Arjinder Sethi, MD1, Nimesh Patel, MD1, Walid Tanyous, MD1, Alexander Lalos, MD1; 1Wright Center for Graduate Medical Education, Scranton, PA; 2Mansfield University, Mans- field, PA Background: Hepatic congestion leading to abnormal liver function tests (LFTs) is a common finding in patients withpatients, respectively. Patients had an average of 7.37 (SD acute decompensated heart failure. The aim of this study(8.3) days (median, 5 days) on the ward with a peripheral was to determine the prognostic significance, if any, ofIV (PIV) and a mean of 3.43 days with both a CVC and abnormal LFTs in acute decompensated heart failure, as thisPIV. Eighty-one percent of patients had at least 1 day with has not been extensively studied so far. Methods: A retro-a PIV. Compared to those without a PICC, PICC patients spective chart review of all adult patients (>18 years old)had 1.61 times longer CVC dwell times (95% CI, who were admitted to a community hospital with a diagno-1.37–1.89; P < 0.0001) adjusting for ward days and sis of acute decompensated heart failure during the period1.47 times more idle days (95% CI, 1.19–1.82; P 5 from January 1, 2008, to June 30, 2010, was performed.0.0004) adjusting for ward CVC days. Patients without a Of the 187 patients identified, 170 patients were includedPICC had 1.84 times more PIV days than the PICC group in the study. Exclusion criteria included insufficient labora-(95% CI, 1.54–2.19; P < 0.0001) adjusting for ward tory data, acute/chronic kidney injury (serum creatinine >days. However, most patients (77%) in the PICC group had 2 mg/dL), acute myocardial infarction, hepatitis (drug-at least 1 day with a PIV, and PICC patients had a mean of induced/infectious), malignancy, and death from any cause6.88 days with a PIV and 3.5 days with both a CVC and a other than heart failure. Primary end points of the studyPIV. Patients with a PICC often retained their CVC until the were readmission or death secondary to heart failure. Theday of discharge. PICC patients who did not go home with Cox proportional hazard model was used for statisticaltheir CVC were 3.11 times more likely to have their CVC analysis of the data. P 0.05 was considered statisticallyremoved on the day of discharge than non-PICC patients significant. Results: The mean age of the patients was 78.5(95% CI, 0.97–9.97; P 5 0.0526); see Table 1. Conclu- years. Forty-two percent of the patients were men. One hun-sions: A quarter of ward CVC days were idle among medi- dred and twenty-two patients were readmitted secondary tocal-floor patients. PIVs were possible for most patients, even heart failure during the study period. Serum total bilirubinthose with PICCs. PICC use was associated with longer (P < 0.01), serum B-natriuretic peptide (P < 0.05), ejectionCVC dwell time, more idle days, and less PIV use, and fraction (P < 0.05), and heart rate (P < 0.05) were found to be significant predictors of hospital readmission second- ary to acute decompensated heart failure. Multivariate analy- sis showed that high serum total bilirubin (>1.3 mg/dL) on Non PICC CVC PICC Group admission was an independent predictor (P 5 0.05) of hospital Group (n522) (n567) P value readmission secondary to heart failure. Blood pressure (sys- tolic/diastolic), serum creatinine, serum sodium, serum alkalineMean Ward CVC days 8 13.76 0.008 phosphatase, serum alanine transaminase, and serum aspar-Mean Idle* days adjusted for 63 929 0.004 tate transaminase levels on admission were not significant pre- ward CVC days ("antibiotics dictors of readmission secondary to heart failure. An analysis did not justify CVC) by stratification showed that patients with serum total bilirubinCVC removed on day of 9/21 (43%) 2130 (70%) 0.0526 >1.3 mg/dL on admission had a readmission rate that was discharge 78% Æ 20% higher (P < 0.01) at any given time than thoseMean PIV days adjusted 9.97 5.43 <0.001 with serum total bilirubin 1.3 mg/dL. Patients with either se- for ward days rum total bilirubin > 1.3 mg/dL on admission or an ejection Hospital Medicine 2011 Abstracts S21
    • fraction < 35% collectively had a readmission rate that was Effect of Staggered Interventions on CAUTI Rate87% Æ 20% higher (P < 0.05) than those without these crite-ria. Conclusions: In patients with acute decompensated heart Time Interval Implementation of Interventions CAUTI Ratefailure, elevated serum total bilirubin on admission with or with- October 1–December 30, 2008 Baseline (before any 5.6out low ejection fraction (<35%) predicts worse prognosis and interventions implemented)early future readmission secondary to heart failure. January 1-–February 28, 2009 Interventions 1, 2, 7.3Disclosures: and 3 implementedJ. Chintanaboina - none; M. Haner - none; A. Sethi - none; N. Patel - none; W. March 1–September 30, 2009 3.0Tanyous - none; A. Lalos - none October 1, 2009–April 30, 2010 Intervention 1.9 4 implemented on October 1, 200935REDUCTION OF CATHETER-ASSOCIATED URINARY lower than the rate for January 1–February 28, 2009 (P 5TRACT INFECTIONS THROUGH A BUNDLED 0.03). Conclusions: A bundle of 4 evidence-based interventions reduced the incidence of CAUTIs by two thirds in a communityINTERVENTION IN A COMMUNITY HOSPITAL hospital. These relatively simple interventions should be easilyKaren Clarke, MD, MS, MPH1, Bonnie Norrick, CLS, EdM, sustainable and could be readily transferable to other hospitals.CIC2, Kirk Easley, MS1, Yi Pan, MS1, David Tong, MD, MPH1, Disclosures:Alan Wang, MD1, Penny Hill, RN2, Jason Stein, MD1; 1Emory K. Clarke - none; B. Norrick - none; J. Stein - none; D. Tong - none; A. Wang -University, Atlanta, GA; 2West Georgia Health, LaGrange, GA none; K. Easley - none; Y. Pan - none; P. Hill - none; D. Williams - noneBackground: Urinary tract infections (UTIs) are the most com-mon type of hospital-acquired infection, and 80% are asso- 36ciated with indwelling urinary catheters. The relatively high POTENTIAL IMPACT OF AN AUTOMATED E-MAILfrequency of catheter-associated UTIs (CAUTIs) leads to signifi- NOTIFICATION SYSTEM FOR RESULTS OF TESTScant clinical and financial concerns for both patients and hos- PENDING AT DISCHARGEpitals. Because Medicare no longer covers the costs oftreating CAUTIs, the development of cost-effective strategies Anuj Dalal, MD, Christopher Roy, MD, Catherine Liang, MPH,to reduce their incidence has received increased attention. Jonas Budris, BA, Deborah Williams, MHA, Jeffrey Schnipper,Methods: We retrospectively examined the effect of a bundle MD, MPH, Brigham and Women’s Hospital, Boston, MAof 4 evidence-based interventions, introduced in staggered Background: Physician awareness of tests pending at dis-fashion, on the incidence of CAUTIs in a 276-bed community charge (TPADs) is poor ($40%). We designed and imple-hospital. Rates of CAUTIs per 1000 catheter-days were esti- mented an automated e-mail notification system to ‘‘push’’mated and compared using exact methods based on the Pois- the finalized results of selected TPADs to responsible inpati-son distribution. The first intervention was the exclusive use of ent physicians. The aim of this study was to evaluate thesilver alloy catheters in the acute care areas of the hospital, impact of our automated e-mail notification system on inpati-the use of which had been sporadic in the hospital over the ent physician awareness of the finalized results of TPADs.previous 3 years. The second intervention was a new secur- Methods: We randomly assigned discharging inpatienting device to limit movement of the indwelling catheter after attending physicians to receive automated e-mail notificationinsertion. The third intervention consisted of repositioning the of the finalized results of pending chemistry and hematologycatheter tubing if it was found to be touching the floor. A 2- tests for patients discharged from general medicine and cardi-month run-in period began when the first intervention was ology services at Brigham and Women’s Hospital from Sep-started, in January 2009, and ended when the routine use of tember 1, 2010, to date. For each discharged patient withthe second and third interventions was introduced the follow- TPADs, we surveyed physicians with regard to (1) awarenessing month. The fourth intervention, which was implemented in of any of the finalized test results and (2) whether theyOctober 2009, was the removal of indwelling urinary cathe- thought at least 1 result was actionable. Surveys were sent byters on postoperative day 1 or 2 for most surgical patients. e-mail approximately 72 hours after the last pending testResults: For the 3-month baseline (October 1–December 31, result was finalized. We assessed satisfaction with their cur-2008) before the run-in period, the mean rate of CAUTIs per rent system and with e-mail notification on a 5-point Likert1000 catheter-days was 5.6 and that for January 1–February scale. We performed Fisher’s exact test to compare out-28, 2009, was 7.3. For the 7 months after full implementation comes. Results: We sent a total of 62 surveys to 49 inpatientof the first 3 interventions (March 1-September 30, 2009), the physicians (25 intervention, 24 control). We received 43mean rate of CAUTIs per 1000 catheter-days was 3.0 and responses (69% response rate) from 31 physicians (14 inter-showed a significant reduction compared with January vention, 17 control). Fifty-eight percent of physician respon-1–February 28, 2009 (P 5 0.04). For the 7 months after the dents assigned to automated e-mail notification (10 of 17)implementation of the fourth intervention (October 1, were aware of any finalized result, compared with 38% (102009–April 30, 2010), the mean rate of CAUTIs per 1000 of 26) assigned to the control (unadjusted P 5 0.23). Eight-catheter-days decreased further to 1.9, which was significantly een percent of intervention physicians thought at least 1 testS22 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • result was actionable compared with 19% of control physi- of $13 million. On average, they utilized outpatient visitscians (unadjusted P > 0.99). Overall, 32% of inpatient physi- 10 times in 6 months. The most common comorbiditiescian respondents stated that they were satisfied with their were renal disease (39%), diabetes mellitus (34%), chroniccurrent system of managing TPADs. Fifty-six percent of inter- pulmonary disease (30%), coronary artery disease (28%),vention physicians (9 of 17) stated that they were satisfied malignancy (28%), congestive heart failure (23%), immuno-with the new e-mail notification system. Conclusions: This in- suppression (20%), and cerebrovascular accident/transientterim analysis demonstrates a nonsignificant trend toward ischemic attack (16%). Even more common than medicalincreased awareness of the finalized results of TPADs among comorbidities were coexisting mental health disordersphysicians receiving automated e-mail notifications. Inpatient (63%) and chronic pain/narcotic dependence (61%). Asidephysicians are not satisfied with their current system of mana- from the most frequent reason for hospitalization (atypicalging TPADs, but those receiving the intervention were only chest pain), reasons for hospitalization were quite varied.modestly satisfied with the new e-mail notification system. Thirty-four percent of patients died within 1 year of theAutomated e-mail notification is a potentially promising strat- study period. Conclusions: Frequently hospitalized patientsegy to manage the results of TPADs. Understanding how to who utilize an enormous amount of hospital resources haveimprove the intervention to maximize user satisfaction will beimportant in future versions. a wide variety of comorbidities and reasons for hospitaliza- tion. All patients were insured, and the majority of patientsDisclosures:A. Dalal - none; C. Roy - none; C. Liang - none; J. Budris - none; D. Williams - maintained outpatient follow-up visits in the interim betweennone; J. Schnipper - none hospitalizations, indicating better than average access to medical care. There was a strong association between fre- quently hospitalized patients and underlying mental health disorders as well as chronic pain. Frequent hospitalizations37 were a predictor of 1-year mortality.EPIDEMIOLOGIC AND COST ANALYSIS OF Disclosures:FREQUENTLY HOSPITALIZED PATIENTS AT A LARGE J. G. Dastidar - none; M. Jiang - none; S. J. Bernstein - noneACADEMIC MEDICAL CENTERJoyeeta Dastidar, MD, Min Jiang, MD, Steven Bernstein, MD,MPH; University of Michigan, Ann Arbor, MI 38Background: Although many studies have described THE CMS POLICY ON VENOUSpatients who frequently utilize emergency department and THROMBOEMBOLISM AS A HOSPITAL ACQUIREDpsychiatry services, little is known of the population fre- CONDITION: PROJECTED REVENUE AND COSTquently admitted to inpatient medicine services. This study IMPACT OF POTENTIAL EXPANSION TO INCLUDEcharacterized the frequently hospitalized group in terms of MEDICAL AND SURGICAL PATIENTSdemographics, length of stay, costs, comorbidities, 1-year Steven Deitelzweig, MD1, Stephen Thompson, MS2, Jay Lin,mortality, and reason for hospitalization. Methods: During PhD, MBA3, Donna McMorrow4, Barbara Johnson, MBA5; 1a 6-month period (January 21, 2009, through July 20, Ochsner Clinic Foundation, New Orleans, LA; 2sanofi-aventis2009), we selected all adult patients who had >4 admis- U.S., Inc., Bridgewater, NJ; 3Bruce Wong & Associates, Rad-sions to inpatient medicine services at a large academic nor, PA; 4Thomson Reuters, Cambridge, MA; 5Thomson Reu-hospital. Scheduled admissions (largely for chemotherapy) ters, Washington, DCwere excluded. We identified a total of 64 such patients. Background: The Centers for Medicare and Medicaid Ser-Data were collected on sex, age, race, marital status, insur- vices (CMS) executed a policy denying reimbursement forance status, utilization of outpatient resources, comorbid- hospital-acquired conditions (HACs)—‘‘never events.’’ Ve-ities from the Charlson comorbidity index, coexistence of nous thromboembolism (VTE) was identified as a HAC inmental health disorders, chronic pain syndromes/narcotic patients undergoing total hip/knee replacement, partial hipdependence, reason for hospitalization, length of stay, and replacement, or hip resurfacing as part of this policy in fis-cost (the latter 2 both for index hospitalization and cumula- cal year 2009. This study estimated the projected financialtive for 6 months). Descriptive statistics were used to deter- impact of potential expansion of this policy, to include othermine characteristics and trends within the group. Results: surgical procedures and medical conditions associated withThe population was 78% white, 17% black, and 36% mar- VTE risk, on U.S. hospitals in terms of increased costs andried. All patients were insured; 61% had Medicaid/Medi- loss of revenue. Methods: Discharge data were extractedcare. On average, patients were admitted 6 times for 29 from the Thomson Reuters MarketScan1 Hospital Drugdays total (5 days/hospitalization) at a cost of $203,000 Database for patients at risk of VTE undergoing ‘‘CMS-($28,900 per hospitalization) over the 6-month period. Dur- defined’’ and ‘‘other’’ major hip/knee surgery, small/largeing this time frame, these 64 patients utilized a total of 405 bowel surgery, or hospitalized with chronic obstructive pul-hospitalizations and 1850 hospital days at a cost in excess monary disease, acute myocardial infarction, congestive Hospital Medicine 2011 Abstracts S23
    • heart failure, cancer or severe infectious disease. Inclusion TABLE Rehospitalization Rates for HN and non-HN Cohorts 30 and 180criteria included admission/discharge between October Days Postdischarge2007 and September 2008, age ! 18 years, Medicare Rehospitalization HN Cohort Non-HN Cohort Difference P Valueprimary payer, valid CMS hospital ID, and no evidence ofVTE on admission. Frequency of CMS-defined VTE was All-cause inpatient at 30 days 17.47% 16.36% 1.11% < 0.001assessed, and the projected economic impact of potential All primary Dx HN at 30 days 1.03% 0.20% 0.83% < 0.001expansion of the CMS policy estimated. The projected an- All-cause inpatient at 180 days 34.89% 34.87% 0.02% < 0.001nual revenue loss per hospital was calculated using the All primary Dx HN at 180 days 1.81% 0.35% 1.46% < 0.001existing CMS reimbursement rules and potential inclusion ofother surgical procedures and medical conditions. Theincremental cost impact—the additional hospital cost due to Background: Readmission rates are becoming an importanta VTE—was also analyzed. Results: Most of the 109 study quality and reimbursement metric in our health care system.hospitals (51.4%) were medium to large and nonteaching Hospitalists are held accountable for patients who requirein urban areas. A total of 147,071 discharges were eligi- premature readmission. Little is known about the impact ofble for inclusion, 17.8% for ‘‘CMS-defined’’ hip/knee pro- hyponatremia (HN) on inpatient readmission rates, evencedures, 7.4% for other surgical procedures, and 74.8% though HN is the leading electrolyte abnormality amongfor medical conditions. Under the current CMS policy, hospitalized patients. This study was designed to evaluatesymptomatic VTE occurred in 1.1% of discharges, with a the impact of HN on readmission rates among hospitalizedmean annual revenue loss per hospital of $8453. Potential patients. Methods: This retrospective analysis examinedexpansion of the current policy led to a projected revenue inpatient readmissions among HN patients discharged fromloss of $42,889 for inclusion of other surgical procedures more than 450 hospitals using the Premier Perspective1and $52,676 for medical conditions. Mean incremental database. The population for this analysis included inpati- ents with HN as a primary or secondary diagnosis whocost per hospital for a discharge with VTE was $6581 for were discharged between January 2007 and June 2009.hip/knee procedures under the current CMS policy, Patients transferred to/from another acute care facility,$13,990 for potential expansion to other surgical proce- patients who left against medical advice, and labor/deliv-dures, and $6359 for medical conditions. Annually, these ery patients were excluded from this analysis. HN patientscosts were projected to be $31,609, $104,492, and (n 5 564,723) were matched to a non-HN control using$137,460, respectively. Conclusions: The current CMS pol- exact matching on age, sex, provider region, and 3MTMicy for VTE as a HAC in certain hip/knee procedures is APR-DRG assignment. Matching was further refined usingassociated with hospital revenue loss and increased hospi- propensity scores on other patient and hospital characteris-tal costs, which are projected to become substantially tics and patient comorbidities. Statistical analyses were con-higher with potential expansion to other surgical proce- ducted using chi square or Fisher’s exact probability.dures and medical conditions associated with VTE risk. If Results: Hospital demographics were similarly distributedCMS were to expand its current policy in a similar manner across both cohorts. Sixty-seven percent of patients wereto our hypothetical assumptions, these significant costs white, with 75% admitted through the emergency room,would no longer be reimbursed. Therefore, it is important and 49.8% discharged home. Approximately 56% had athat hospitals reduce VTE rates through appropriate prophy- primary payer of traditional Medicare, whereas nearlylaxis of at-risk patients. 48% fell into the major severity of illness category. PatientsDisclosures: with HN had a significantly higher readmission rate, bothS. Deitelzweig - sanofi-aventis US Inc., Bristol-Myers Squibb, Scios, honoraria, short term and long term, than patients who did not haveresearch funding, and speakers bureau; Pfizer, speakers bureau; S. Thompson - HN. Conclusions: HN has a significant impact on the ratesanofi-aventis U.S. Inc., employment; J. Lin - sanofi-aventis U.S. Inc., employment of all-cause and all primary diagnosis HN-related inpatientand research funding; D. McMorrow - sanofi-aventis U.S. Inc., research funding;B. Johnson - sanofi-aventis U.S. Inc., research funding; all authors - sanofi-aventis rehospitalization rates 30 and 180 days postdischarge.U.S. Inc. This study was funded by sanofi-aventis U.S., Inc. The authors received The primary or secondary diagnosis of HN is a risk factoreditorial/writing support in the preparation of this abstract provided byKatherine Roberts, PhD, of Excerpta Medica, funded by sanofi-aventis U.S., Inc for readmission of hospitalized patients. By identifying that HN patients are being readmitted frequently, an organiza- tion may have an opportunity to reduce this rate and39 improve outcomes by improving discharge planning andIMPACT OF HYPONATREMIA ON THE patient education and increasing the availability of outpati-READMISSION RATES OF HOSPITALIZED PATIENTS ent/home health services.Steven Deitelzweig, MD1, Alpesh Amin, MD2, Jay Lin, PhD3, Disclosures:Dorothy Baumer, MS4, Kathy Belk, BA4; 1Ochsner Clinic Foun- S. Deitelzweig - Otsuka, research funding, speakers bureau; A. Amin - Otsuka,dation, New Orleans, LA; 2University of California, Irvine, Or- research funding, speakers bureau; J. Lin - Otsuka, consultant; D. Baumer - Otsuka, Consultant; K. Belk - Otsuka, consultantange, CA; 3Novosys Health, Flemington, NJ; 4Premier,Charlotte, NCS24 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • 40 41DESPERATE HEROICS VERSUS 2010 MEDICINE: HISTORY REVISITED: 50 YEARS LATER ARE WE STILLINTENSIVE RESOURCE UTILIZATION REVIVING HEARTS TOO YOUNG TO DIE?POST–CARDIAC ARREST Shaker Eid, MD, Umashankar Lakshmanados, MD, DevonShaker Eid, MD, Janet McIntyre, BSN, Skon Nazarian, BSc, Dobrosielski, PhD, Joel Palachuvatil, MSc, Scott Carey, BSc,Nisha Chandra-Strobos, MD; Johns Hopkins University School Kerry Stewart, EdD, Nisha Chandra-Strobos, MD; Johns Hop-of Medicine, Baltimore, MD kins University School of Medicine, Baltimore, MDBackground: In an effort to standardize health care delivery Background: The landmark article on ‘‘application of exter-and improve outcomes, agencies such as the AHA and nal cardiac massage’’ published in 1961 reported survivalILCOR have developed guidelines for the initial care of the to discharge in 24% of patients sustaining cardiac arrest.out-of-hospital cardiac arrest patient. These guidelines are Cardiopulmonary resuscitation (CPR) emerged as a strategylimited in directing subsequent patient care. In the United of care for ‘‘hearts too young to die,’’ with the goal beingStates, such patients are always admitted to the ICU, an neurologic viability. Given the changes in prehospital care,environment where multiple ‘‘high-cost resources’’ (HCRs) improved outcomes, and mortality in patients with cardio-are easily accessible and commonly utilized. However, vascular diseases and other diseases, balanced with thevery little has been published about resource utilization pat- dissemination of advanced directives, this study exploredterns or the associated expenditure in post–cardiac arrest the profile of patients commonly being resuscitated 50patients. Methods: We studied 167 patients admitted to our years later to examine whether we were actually limitingacademic medical center between January 2005 and De- CPR to hearts ‘‘too young to die.’’ Methods: Over a periodcember 2009. Standard ICU care involved daily compre- of 24 months, we evaluated 45 consecutive survivors ofhensive blood tests, ECG, and chest x-ray. A high-cost nontraumatic out-of-hospital cardiac arrest. Data were col-resource, as defined in this study, included any CT/MRI lected according to a standardized protocol following theimaging study, 2-D echocardiography, venous Doppler Utstein guidelines. The subgroup with ‘‘hearts too young toultrasound, electroencephalography, and sensory evoked die’’ (group A) was defined as having age < 75 years,potentials. Charges for the entire hospitalization (exclusive ventricular fibrillation/ventricular tachycardia as the initial arrest rhythm, and an interval of collapse–return of sponta-of physician charges) were obtained from the hospital data- neous circulation < 20 minutes. Group B constituted thebase. We assigned a score of 1 unit each time any HCR rest of the cohort. Results: Overall survival to discharge inwas used. Data are means Æ standard deviation. Results: this study was 42.22% (19 of 45); however, selectingCharges were essentially stable over the study period patients with ‘‘hearts too young to die’’ increased the sur-(2005–2009) and were driven primarily by the cost of vival rate to 100% (group A) versus 31.58% (group B); P <extensive testing rather than the length of hospital stay (see 0.01 (see Table 1). Conclusions: These data suggest thatTable 1). Conclusions: We concluded that postarrestpatients in the United States undergo extensive and expen- TABLE 1sive evaluations irrespective of whether they eventually sur-vive to discharge or die in the hospital. Published CPR Characteristics Group A (n 5 7) Group B (n 5 38) P valuesurvival rates in the United States are not better than those Mean age, years 66.28 Æ 7.16 63.78 Æ 15.59 0.68reported in countries where the access to and utilization of Sex, n (%)such resources is limited. In-depth comparisons of clinical Men 4 (57.14) 23 (60.53) 0.59outcomes and resource utilization in varied health care sys- Women 3 (42.86) 15 (39.47) 0.87tems are essential not only to minimize costs but also to bet- Interval of collapse to ROSC, minutes* 9.43 Æ 5.26 45.00 Æ 7.14 0.04ter identify those resources that are critical to optimizing Initial rhythm VT/VF, n (%) 7 (100.00) 7 (18.42) 0.01care delivery. Therapeutic hypothermia, n (%) 3 (42.86) 12 (31.58) 0.29Disclosures: Total length of stay, days 14.71 Æ 2.83 5.72 Æ 1.21 0.01S. M. Eid - none; J. McIntyre - none; S. M. Nazarian - none; N. Chandra- Comorbidities, n (%)Strobos - none Hypertension 29 (76.32) 0.06 Diabetes mellitus 1 (14.29) 17 (44.74) 0.11 Coronary artery disease 6 (85.71) 15 (39.47) 0.08TABLE 1 Congestive heart failure 3 (42.86) 17 (44.74) 0.93 Renal insufficiency 1 (14.29) 4 (10.53) 0.78Variable Alive (n 5 39) Dead (n 5 128) P Value Alive on discharge, n (%) 7 (100.00) 12 (31.58) 0.01 CPC score on discharge, n (%)**Length of stay LOS (days) 10.76 Æ 5.11 4.12 Æ 1.23 P < 0.01 Good (1 or 2) 7 (100.00) 5 (13.16) 0.01Total high-cost resource 5.42 Æ 2.34 3.73 Æ 0.73 P < 0.01 Bad (3, 4, or 5) 0 (0.00) 33 (86.84) 0.01 units/patientTotal charges per $38,605 Æ $18,561.38 $20,071 Æ $5164.44 P < 0.01 * ROSC, return of spontaneous circulation; ** CPC, Glasgow–Pittsburgh Cerebral Performance Cate- patient (US$) gory. Hospital Medicine 2011 Abstracts S25
    • patients with ‘‘hearts too young to die’’ are in a conspicu- Fifty-five percent of our patients had good to strong docu-ous minority but continue to be effectively resuscitated with mentation to support the diagnosis of CHF, whereas inexcellent neurological outcomes. However, CPR is most of- 39% an alternative diagnosis was more likely. (2) BNP wasten performed in patients who do not have viable heart obtained in 93%. It was used in part to make a diagnosis,rhythms, and although they may survive to discharge, they but commonly without supporting findings/documentation.are often severely impaired. We concluded that the original It is unclear if some of these patients had CHF but withpremise of CPR has been abandoned, with no obvious evi- inadequate documentation, whereas for others the diagno-dence of benefit to the extended population. sis may be based only on an elevated BNP. We are con-Disclosures: cerned that the use of BNP may have resulted in prematureS. M. Eid - none; U. Lakshmanados - none; D. Dobrosielski - none; J. M. closure, leading to misdiagnosis/misclassification. WePalachuvatil - none; S. M. Carey - none; K. J. Stewart - none; N. Chandra- believe our findings are not unique to our hospital, andStrobos - none with CHF a high-stakes diagnosis, monitored by the Centers for Medicare/Medicaid Services for hospital statistics. The42 magnitude of this problem warrants the development of aCONGESTIVE HEART FAILURE IN A COMMUNITY guideline-based rating systems for the diagnosis of CHF toHOSPITAL: DO WE DOCUMENT THE PERTINENT improve our documentation to support this diagnosis.FINDINGS AND INTERPRET THE DATA CORRECTLY? Disclosures:WILL IMPROVED DOCUMENTATION OR J. Escandon - none; J. Hanley - none; C. Mild - noneINTERPRETATION LEAD TO IMPROVEDCLASSIFICATION?Jose Escandon, MD, James Hanley, MD, Charles Mild, MD; 43University of Texas Health Science Center–Lower Rio Grande EXPERIENCE SAMPLING MEASUREMENT OFValley Regional Academic Health Center, Harlingen, TX INPATIENT PAIN AND PAIN MANAGMENTBackground: Congestive heart failure (CHF) can be a diffi- Toritseju Eshedagho, BS, David Meltzer, MD, PhD, Hyo Jungcult diagnosis, requiring the physician to integrate a symp- Tak, PhD, Andrew Schram, BA, Ainoa Mayo, MA; Universitytom complex with physical and x-ray findings. The of Chicago, Chicago, ILintroduction of brain natriuretic peptide (BNP) when used Background: Timely treatment of pain is a key measure ofcorrectly has improved our ability to differentiate patients quality of pain control for hospitalized patients. However,with dyspnea, but when used incorrectly may lead to mis- this is usually measured by retrospective patient reports thatclassification. We tested the following hypotheses: (1) for may be inaccurate. The experience sampling method (ESM)some patients admitted with a diagnosis of CHF, there is provides real-time assessments of experience at randomlyinadequate documentation to support the diagnosis; (2) for selected times. ESM may provide more accurate data tosome patients admitted with CHF, an alternative diagnosis understand the relationship between waiting time for painmay be more likely; (3) an elevated BNP will make CHF a medication and patient satisfaction, which could helpdefault diagnosis without supporting evidence. Methods: improve the quality of pain control for hospitalized patients.Retrospective chart review was performed on 100 charts, Methods: We investigated the relationship of waiting timewith CHF as a primary diagnosis. The charts were reviewed for pain medication to patient satisfaction with physicianfor predetermined signs, symptoms, BNP, and radiological and nurse efforts to control pain and overall satisfactionfinding to support the diagnosis of CHF. Patients were strati- with pain control. Two data sources were collected fromfied based on a modified version of the Framingham crite- each patient: (1) ESM data collected during 5 randomria (FC) for CHF. We reviewed the charts’ documentation, times throughout the day concerning current pain, waitingfindings, or treatment supporting an alternative diagnosis to time for pain medications, and satisfaction with pain con-CHF. Results: Seventy-one percent of our patients were His- trol; and (2) follow-up data on satisfaction with pain controlpanic, with a median age of 73 years. We found docu- from a phone interview 30 days postdischarge. Becausementation of an S3 in 6%, paroxysmal nocturnal dyspnea repeated responses are nested within each level, ESM datain 10%, jugular venous distention in 19%, dyspnea on were estimated with a multilevel mixed-effects model. An or-exertion in 79%, weight gain in 15%, crackles in 53%, dered logit model was used for the patient level follow-upand pitting edema in 55%. Based on this documentation data. Results: We collected 1906 ESM survey responsesand the FC, CHF could be classified as high/definite in from 469 patients. Twenty percent of patients waited more33%, probable in 22%, and unlikely in 6%. CHF was mis- than 30 minutes to receive their pain medication in theclassified in 39%: as chronic kidney disease volume over- ESM data; 28% reported waiting at least 30 minutes forload in 9%, as pneumonia in 7%, as chronic obstructive pain medication at some point in their hospitalization. ESMpulmonary disease in 3%, and as other in 20%. Seventy- data demonstrated that patients became dissatisfied whennine percent of the patients had an elevated BNP, but only they waited 20 minutes or longer for pain medication.33% had sufficient supporting documentation for CHF; 7% Patients were more likely to be dissatisfied with nursesof patients did not have a BNP drawn. Conclusions: (1) rather than physicians as waiting time increased. EstimationS26 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • with the follow-up data indicated that the longest waiting TABLE 2 Perforation Rates per 1000 Patient Admissions with AP Aged 1–17time per hospital stay increased patient dissatisfaction up to5.25 times for overall pain management (P 5 0.001), Standard P Value P Value Relative3.58 times for pain management by the nurse (P 5 0.032), Year Estimate Error Relative to 1994 to Previous Yearand 4.87 times for pain management by the physician (P Adjusted Ratesa5 0.005). Conclusions: ESM and retrospective data indi- 2000 303.4 4.2 0.68 0.01*cate that patients’ satisfaction with pain control decreases 2001 304.9 4.3 0.87 0.80with greater waiting time for pain medication, especially af- 2002 303.3 4.7 0.69 0.80ter 20 minutes. ESM measures of satisfaction with pain con- 2003 311.8 4.5 0.37 0.19trol are strongly associated with maximum wait times. 2004 308.9 4.7 0.66 0.66Disclosures: 2005 308.8 4.7 0.67 0.99T. Eshedagho - none; D. Meltzer - none; H. Tak - none; A. Schram - none; A. 2006 298.0 4.3 0.21 0.09Mayo - none 2007 302.0 4.9 0.55 0.53 Healthcare Cost and Utilization Project, AHRQ. a Rates are adjusted by age and sex.44 * Not significant compared with 1994.ACUTE APPENDICITIS IN CHILDREN: THE PAINFULTRUTHNora Esteban-Cruciani, MD, MS, Katherine O’Connor, MD, was associated with a high perforation rate (0.65), and thisGabriella Azzarone, MD; Children’s Hospital at Montefiore, rate has remained unchanged since 1997 (Table 1). Simi-Albert Einstein College of Medicine, Bronx, NY larly, overall rates of perforation adjusted for age and sexBackground: Acute appendicitis (AP) is the most common stayed the same when compared with 1994 between 1997surgical emergency in childhood. Despite the disproportion- and 2006 and year-to-year (2000–2007); see Table 2.ate morbidity and length of stay of children with perforated Male/female rate remained 0.59–0.60 across conditionsAP, there have been no longitudinal national studies to date over time. Resource utilization showed significant increasesfocusing on rates of perforation in children. Methods: The in ED admissions, 67%–76%; admissions to children’s hos-objective was to improve institutional outcomes and pitals, 21%–31%; number of admissions/year,resource utilization in the care of hospitalized children with 67,733–81,169 (P < 0.01). Mean hospital chargesAP. We examined national trends of perforated versus non- increased significantly from $9,172 to $21,002, whereasperforated AP in children aged 1–17 years, using nation- LOS decreased by 18% only for nonruptured AP (P <wide inpatient databases. The study population of 303,428 0.01). Perforated AP accounted for 45% of aggregatechildren aged 1–17 years was extracted from the Nation- charges in 2006, with a ‘‘national bill’’ of $1.7 billion.wide Inpatient Sample 1997-2007 (NIS), the Kids’ Inpatient Conclusions: This is the first study to report longitudinal nor-Database 1997–2006 (KID), and the AHRQ Quality Indica- mative data in children with ruptured AP in the United Statestors (1994 vs. 2000–2007), HCUP, AHRQ, by selecting and should assist physicians involved in their care. Age-de-discharge ICD-9 CM codes for acute nonperforated AP and pendent and overall rates of perforation remainedperforated AP. No children were excluded. The outcome unchanged from 1994 to 2007 despite changes in practicevariables were: (1) AP perforation rates by age over time; and resource utilization, suggesting intrinsic rather than ex-(2) overall trends of perforated AP since 1994 (the first trinsic factors. These provocative epidemiological findingsavailable AHRQ pediatric data set) and year-to-year com- warrant further investigation.parison between 1997 and 2007; and (3) resource utiliza- Disclosures:tion and changes in practice. Results: Age < 4 years old N. Esteban-Cruciani - none; K. O’Connor - none; G. Azzarone - noneTABLE 1 National Trends in Age-Related Perforation Rates and LOS 45 IMPACT OF A PEDIATRIC HOSPITAL MEDICINE 1997 2006 PROGRAM ON RESOURCE UTILIZATION FOR CHILDREN WITH RESPIRATORY DISORDERS LOS LOS LOS LOSAge Non-Perf-AP, Perf-AP, Perf-AP Non-Perf-AP, Non-Perf-AP, Perf-AP Nora Esteban-Cruciani, MD, MS, Jazmin Montejo, HS, Gab-(years) mean (n) mean (n) (rate) mean (n) mean (n) (rate) riella Azzarone, MD, Lindsey Douglas, MD, Sheila Liewehr, MD, Joanne Nazif, MD, Katherine O’Connor, MD, Hai Jung1–4 2.9 (1117) 6.9 (2070) 0.65 2.5 (1544) 6.4 (2936) 0.66 Rhim, MD, MPH, Alyssa Silver, MD, Nathan Litman, MD;5–9 2.3 (10,548) 5.9 (6878) 0.39 1.9 (14,001) 5.6 (7729) 0.36 Children s Hospital at Montefiore, Albert Einstein College of10–14 2.1 (20,607) 5.8 (8931) 0.30 1.8 (23,215) 5.7 (9758) 0.30 Medicine, Bronx, NY15–17 2.1 (13,342) 5.3 (4214) 0.24 1.7 (16,907) 4.9 (5046) 0.23Total 2.2 (45,631) 5.8 (22,102) 0.33 1.8 (55,681) 5.5 (25,488) 0.31 Background: Asthma and bronchiolitis are the most frequent causes of hospital admissions among children in the United Hospital Medicine 2011 Abstracts S27
    • States. Pediatric hospitalists focusing on process improve- Future studies should assess the specific organizationalment are well positioned to optimize resource utilization for characteristics of evolving PHM models that may influencecommon respiratory disorders. Methods: The objectives patient outcomes and resource utilization.were: (1) to compare length of stay (LOS) and 30-day Disclosures:emergency department (ED) return visits, readmission, and N. Esteban-Cruciani - none; J. Montejo - none; G. Azzarone - none; L. Douglasmortality rates among children hospitalized for asthma and - none; S. Liewehr - none; J. Nazif - none; K. O’Connor - none; H. Rhim - none; A. Silver - none; N. Litman - nonebronchiolitis before and after the implementation of a pedi-atric hospital medicine (PHM) program; (2) to contrast ourresults with weighted national estimates; (3) to estimate thepotential impact of PHM programs on hospital charges at 46the local and national levels. The setting was a 120-bed, HOSPITALISTS AND HOUSE STAFF SUPERVISION: Ainner-city academic medical center, the Children’s Hospital MARRIAGE OF CONVENIENCE?at Montefiore (CHAM), Bronx, New York. Data wereextracted by selecting all ICD-9-CM admission codes for Jeanne Farnan, MD, MHPE1, Luci Leykum, MD2, Alfred Burger,asthma and bronchiolitis (<18 and <4 years old, respec- MD3, Rebecca Harrison, MD4, Julie Machulsky, BA5, Vikastively), using unidentified electronic health record data by Parekh, MD6, Brad Sharpe, MD7, Anneliese Schleyer, MD,means of the Clinical Looking GlassTM (an interactive analy- MHA8, Romsai Boonyasai, MD, MPH9, Vineet Arora, MD,tic tool to access clinical and administrative hospital data) MPP1; 1University of Chicago, Chicago, IL; 2University ofand a national database: the Kids’ Inpatient Database Texas, San Antonio, TX; 3Beth Israel Medical Center, New(KID) 2006, Healthcare Cost and Utilization Project, York, NY, 4OHSU, Portland, OR; 5SGIM, Washington, DC; 6AHRQ. No children were excluded. The retrospective University of Michigan, Ann Arbor, MI; 7University of California,before-and-after QI project was a 2-group comparison. San Francisco, San Francisco, CA; 8University of Washington,Group 1 was 12-month historical control before July 1, Seattle, WA; 9Johns Hopkins University, Baltimore2007: traditional resident-attending team. Group 2 was the Background: In 2010, the Accreditation Council for Gradu-40-month period after the implementation of a PHM pro- ate Medical Education (ACGME) announced recommenda-gram: the resident–PA–hospitalist team. The cross-sectional tions that focus on enhancing on-site house staffstudy used a national database, KID 2006, with data from supervision. To meet these standards, many residency pro-both children’s and all hospitals in the United States. De- grams have looked to hospitalists to fill that need. We aimscriptive statistics, percentile and cumulative percent curve, to describe academic hospitalists’ current overnightand 2-group comparisons were used to test for difference in supervision of house staff and perceptions of the impacteach group’s curve (log-rank Mantel-Haenszel). Results: of ACGME policies on trainee–hospitalist interactions.LOS for asthma and bronchiolitis decreased significantly Methods: The Housestaff Oversight Committee, a workingduring the 40-month PHM program implementation period group of members of the Society of General Internal Medi-(Table 1). There were no significant differences in 30-day cine Academic Hospitalist Taskforce and the Society of Hos-ED return-visits, readmission, or mortality rates. Estimated pital Medicine, created a survey to assess the current statushospital-bed days saved at CHAM were 378/year (esti- of trainee supervision performed by hospitalists. Hospitalistmated savings/year 5 $943,866). National database programs were chosen based on location and practice in abenchmarking—PHM resource utilization compared favor- hospital participating in the National Resident Matchingably against national data. Conclusions: The introduction of Program for Internal Medicine. Program leaders were iden-a PHM program focusing on process improvement was tified using program Web sites and querying departmentalassociated with decreased LOS for asthma and bronchiolitis leadership. Respondents were contacted by e-mail for parti-without significant adverse outcomes. To our knowledge, cipation. The 19-item SurveyMonkey instrument includedthis is the first study to demonstrate such an effect in an questions about hospitalists’ role in trainees’ education andinner-city academic setting. Given the frequency of these evaluation. A Likert-type scale assessed perceptions regard-conditions, a 12%–15% reduction in LOS can potentially ing the impact of on-site supervision on trainee autonomyimpact resource utilization nationwide and decrease the and hospitalist workload. Descriptive statistics were per-yearly ‘‘national bill’’ by approximately $350 million. formed. Results: Thirty-five of 47 hospitalist program leadersTABLE 1 LOS Before and After PHM Versus National Estimates (KID 2006)Groups 1 and 2 Before PHM After PHM P Value KID-2006 Children’s Hospitals KID-2006 All Hospitals Aggregate Charges ‘‘National Bill’’Bronchiolitis n 5 192 n 5 626 — n 5 44,477 n 5 134,301 $1,394,447,283 LOS (median) 2.45 2.07 0.03 3.3 3.0 —Asthma n 5 842 n 5 2814 — n 5 52,092 n 5 137,729 $1,251,956,610 LOS (median) 2.20 1.94 < 0.0001 2.3 2.2 —S28 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • responded (74%). Five nonprogram leaders were removed disease associated with indwelling catheterization.from analyses, yielding a 64% response rate. Respondents Although successful patient safety initiatives must involveaveraged 12 years in practice postresidency, and 73% key medical personnel, the extent to which hospitalists canwere male. Respondents’ programs averaged 18 faculty. be leveraged to help prevent CAUTI remains unknown.All reported that faculty are expected to participate in Methods: We conducted a mixed-methods study to assesshouse staff teaching or other educational roles. Twenty-one barriers and facilitators to implementing practices to preventprograms (70%) described having a hospitalist present CAUTI. We surveyed infection preventionists at all Michi-overnight to provide cross-coverage or admit new patients, gan hospitals in 2009 and asked about the Bladder Bundlebut only 8 of 21 (38%) described a formal supervisory role and the use of CAUTI preventive practices in their hospital.for hospitalists requiring house staff to present new admis- In 2010, we subsequently surveyed infection preventionistssions or contact regarding patient management questions. at the 102 Michigan hospitals that responded to the 2009Although 63% of programs have a formal house staff super- survey to learn more about the potential role for hospitalistsvision policy in place, only 43% stated that their hospitalists in the Bladder Bundle, clinician engagement, and team lea-receive formal faculty development on trainee supervision. dership. In addition to the survey, we conducted semistruc-Eighty-five percent of respondents agreed that formal over- tured interviews with 38 individuals, including chiefnight supervision by a hospitalist would improve patient medical officers, chief nurses, infection preventionists, front-safety, and 62% agreed formal overnight supervision would line physicians, and nurses. All interviews were transcribedimprove trainee-hospitalist relationships. However, 44% dis- and analyzed using qualitative techniques. Results: Theagreed and believed increased on-site hospitalist supervi- response rate for the 2010 survey was 75% (76 of 102).sion would hamper resident autonomy, and 82% agreed a Infection preventionists were most often chosen as theformal supervisory role would increase hospitalist workload. ‘‘ideal’’ team leader for Bladder Bundle implementation (nConclusions: Hospitalists frequently provide overnight cover-age in academic centers. However, formal supervision of 5 18, 24%), followed by nurse managers (n 5 15, 20%),trainees is not uniform, and few receive formal training on bedside nurses (n 5 14, 18%), and hospitalists (n 5 7,providing supervision. Program leaders expressed concern 9%). However, most respondents (92%) believed that hospi-that creating overnight supervisory roles might add to an al- talists had a key role in the implementation of the Bladderready burdened overnight hospitalist. Staffing for and for- Bundle. According to infection preventionists, the best waymalizing this role, including explicit definitions and faculty to engage both frontline clinicians and hospital leadershiptraining on trainee supervision, are needed. is to focus on CAUTI prevention rather than preventing non-Disclosures: infectious complications of urinary catheter use (e.g.,J. M. Farnan - none; L. Leykum - none; A. Burger - none; R. Harrison - none; J. improving ambulation). Interviews demonstrated: (1) a per-Machulsky - none; V. Parekh - none; B. Sharpe - none; A. Schleyer - none; R. ception of improved nurse–physician communication andBoonyasai - none; V. M. Arora - none increased continuity of care with hospitalists and (2) a clear role for hospitalists in CAUTI prevention activities. Conclu- sions: Our results suggest that although hospitalists may not47 be selected as team leaders for implementation effortsTHE POTENTIAL ROLE OF HOSPITALISTS IN focused on preventing CAUTI, they could have a key rolePREVENTING CATHETER-ASSOCIATED URINARY in implementing the Bladder Bundle. National initiatives designed to prevent HAIs—CAUTI, in particular—shouldTRACT INFECTION: RESULTS OF A STATEWIDE ideally engage hospitalists to facilitate the uptake of bestINITIATIVE practices.Scott Flanders, MD1, Sarah Krein, PhD, RN,2 Christine Disclosures:Kowalski, MPH, BS,2 Latoya Kuhn, MPH,2 Sanjay Saint, MD, S. Flanders - IHI/CDC Foundation/BCBS of Michigan, honorarium/researchMPH,3; 1University of Michigan, Ann Arbor, MI; 2VA Ann support; S. Krein - none; C. Kowalski - none; L. Kuhn - none; S. Saint - IHI/MHA,Arbor HSR&D Center of Excellence, Ann Arbor, MI; 3Ann honorarium for speakingArbor VA Medical Center, Ann Arbor, MIBackground: Catheter-associated urinary tract infection 48(CAUTI) is the most common health care–associated infec- NEW MODELS FOR HOSPITAL-BASED STROKEtion (HAI), accounting for more than 40% of all HAIs. CARE: LEVERAGING HOSPITALISTS ANDApproximately 15% of patients admitted to acute care hos- TELEMEDICINE TO BUILD A JOINT COMMISSIONpitals in the United States receive an indwelling urinary CERTIFIED PRIMARY STROKE CENTERcatheter during their hospital stay, many without anaccepted indication. The Michigan Health and Hospital Karim Godamunne, MD, MBA; Morehouse School of Medi-Association (MHA) Keystone Center for Patient Safety & cine, Atlanta, GAQuality has begun a statewide initiative that focuses on pre- Background: Stroke is a leading cause of mortality andventing CAUTI by implementing evidence-based best prac- morbidity. Only 10% of the hospitals in the United Statestices (the ‘‘Bladder Bundle’’) to reduce the burden of have stroke centers certified by the Joint Commission. Many Hospital Medicine 2011 Abstracts S29
    • measures, mortality, and LOS from SFMC were not statisti- cally different than that at other stroke centers. Seventy per- cent of stroke admits were by hospitalists. Ninety-eight percent were nonhemorrhagic strokes. Conclusions: This study supports that a primary stroke center can be built with a telemedicine/hospitalist/neurologist model. This includes the immediate benefit of thrombolytics and the secondary preventive benefits of meeting stroke center guidelines. Mechanisms must address hemorrhagic strokes that require neurosurgical intervention. Disclosures: K. Godamunne - Eagle Hospital Physicians, employee SFMC PSC core measures. 49other hospitals lack the ability to give thrombolytics (tPA). A INTERRUPTIONS AND SIDE CONVERSATIONS INmajor barrier is the shortage of stroke specialists. This study HOSPITALIST HAND-OFFS: AN OBSERVATIONALreports on the first-year experience with the Joint Commis-sion Certified (JC) Stroke Center at South Fulton Medical STUDYCenter (SFMC), East Point, Georgia. The Stroke Center at Elizabeth Greenstein, BA1, Vineet Arora, MD, MAPP2, PaulSFMC addressed the shortage of neurologists by combining Staisiunas, BA2, Jeanne Farnan, MD, MHPE2; 1University ofa 24/7 telemedicine-based stroke consult service with a Chicago Pritzker School of Medicine, Chicago, IL; 2Universityhospitalist team and a hospitalist serving as the Stroke Med- of Chicago Medical Center, Chicago, ILical Director. At SFMC there is limited part-time in-house Background: The Society of Hospital Medicine (SHM) hasneurology coverage (coverage varying from weekdays only made hand-offs one of the core competencies of hospitalto 2 days a week in-house coverage). By combining teleme- medicine and released recommendations for hospitalistdicine, hospitalists, and neurologists, the number of hospi- hand-offs. To date, most hand-off studies have focused ontals that can build stroke centers may be increased, the sender. A recent study suggested that despite optimalimproving patient access to the stroke standard of care. conditions for senders, significant information is still lost,Methods: For this retrospective cohort study, the records for highlighting the need to examine the role of the receiver.stroke patients from the Primary Stroke Center (PSC) at We aimed to observe and characterize the behaviors ofSFMC were reviewed from October 15, 2009, through Oc- hand-off receivers on an academic hospitalist service. Meth-tober 14, 2010, for the PSC core measures, length of stay ods: Hospitalist hand-offs were directly observed by a(LOS), type of stroke, in-house mortality, and demo- trained third-party observer at a single academic medicalgraphics. Data were collected on the number of stroke dis- center using the paper-based listening checklist. The listen-charges from SFMC for the prior 2-year periods, for ing checklist was developed following a review of relevantpercentage of stroke patients admitted by hospitalists, and listening literature, including prior hand-off, organizational,total number of admits to the SFMC Stroke Center. The PSC psychological, cognitive science, and medical literature,core measures, LOS, and mortality from SFMC were com- and expert review. The checklist has 3 domains: (1) dis-pared with the aggregate of all other JC stroke centers over plays of understanding, which quantifies passive listeningthe period of the study. Statistical analysis was performed behaviors such as nodding and affirmatory statements; (2)using the chi-square and unpaired t tests dependent on vari- processing information, which focuses on active listeningables. PSC core measures were deep vein thrombosis pro- behaviors such as note taking and questioning; and (3)phylaxis by end of day 2 of admission, antithrombotic interruptions/distractions. The checklist was piloted on thetherapy at discharge for ischemic strokes, anticoagulation hospitalist service from June to November 2010. Descrip-therapy form ischemic stroke patients at discharge, tPA for tive statistics were performed and, where appropriate, 2-patients with ischemic stroke within 3 hours of last-known sided t tests, to compare passive and active listening beha-well, antithrombotic therapy for ischemic stroke by end of viors. Results: Forty-eight hand-offs were observed andday 2 of admission, statin medicine for LDL ! 100 for is- assessed utilizing the listening checklist. Receivers displayedchemic stroke patients, stroke education for patients and active listening behaviors significantly less frequently thancaregivers, and assessment of stroke patients for rehabilita- passive listening behaviors (0.89 vs. 1.65, on a 0–3 scale,tion. Results: About 250 patients were admitted to the per hand-off; P < 0.001). Read-back occurred 8 timesSFMC Stroke Center. One hundred and sixty-four patients (16.7%), and in 11 hand-offs (23%), receivers took notes.were discharged with a stroke diagnosis. Eleven patients The mean number of questions asked per hand-off was 2.1,received tPA; no stroke patients prior to launch of the stroke with 67% directly related to hand-off content and 33%center received tPA. The number of stroke admits to SFMC related to systems/other issues (mean, 1.42 vs. 0.69 perincreased by 90% compared with prior years. The PSC hand-off, P 5 0.003). Almost all hand-offs observed (98%)S30 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • had at least 1 interruption, and the median number of inter- less individuals were enrolled in the study: 78 were maleruptions per hand-off was 3, ranging from 0 to 12 interrup- (80%), and reported race/ethnicity was 42% black, 41%tions per hand-off. The most frequent interruptions noted white, and 16% Hispanic. Average age was 44 years, andwere: side conversations (42%), clinicians arriving for average reported length of homelessness was 2.8 years.hand-off (15%), and pagers going off (19%). Side conver- Fifty-one participants (52%) reported their housing statussations occurred at least once in nearly three fourths of was assessed by any hospital staff during their acute carehand-offs (72%), and the number of side conversations per episode. Of these, only 19 (37%) reported a physicianhand-off ranged from 0 to 5. Side conversations ranged in assessed their housing status. The percentages of patientscontent from personal to job-related topics. The number of reporting components of high-quality discharge included:interruptions was also directly related to patients discussed. medication reconciliation, 75%; advice on how to pay for(r 5 0.56, P 5 0.0025) Conclusions: Direct observation of medications, 54%; arrangement for follow-up care with pri-hospitalist hand-offs revealed that receivers rarely use active mary care, 53%; arrangement for follow-up care with men-listening behaviors, like note taking and read-back, which tal health provider, 36%; explanation of safe patientare recommended to enhance memory. Furthermore, hand- activity level, 50%; and transportation assistance for follow-offs, especially with more patients, were characterized by up visits, 20%. In the multivariable logistic regression wefrequent interruptions, the most common of which were side found significant associations between assessment of hous-conversations and clinicians arriving for the hand-off, both ing status and advice on how to pay for medications (OR,of which are potentially modifiable targets for improvement. 4.4; 95% CI, 1.1–17.6) but not medication reconciliation;Disclosures: follow-up arrangements with mental health provider (OR,E. Greenstein - research funding, AHRQ R03 grant 1R03HS018278-01; NIA 10.5; 95% CI, 1.2–96.1) but not primary care provider;T35 grant 5T35AG029795-02; V. Arora - research funding, AHRQ R03 grant and both explanation of postdischarge patient activity1R03HS018278-01; NIA T35 grant 5T35AG029795-02; P. Staisiunas -research funding, AHRQ R03 grant 1R03HS018278-01; NIA T35 grant level (OR, 5.3; 95% CI, 1.6–18.4) and transportation assis-5T35AG029795-02; J. Farnan - research funding, AHRQ R03 grant tance for follow-up visits (OR, 10.1; 95% CI, 1.8–58.0).1R03HS018278-01; NIA T35 grant 5T35AG029795-02 Conclusions: Homeless patients report variable levels of satis- faction with key discharge components during the transition50 from an acute care setting. Assessment of homelessness byIMPROVING DISCHARGE CARE FOR THE hospital staff correlates with higher performance on some butHOMELESS PATIENT: PERSPECTIVES FROM THE not all of these measures. Greater attention to addressing theSHELTER housing status of acute care patients may aid hospital-levelS. Ryan Greysen, MD, MA1, Marjorie Rosenthal, MD, MPH1, efforts to improve transitions in care for homeless patients.Rebecca Allen, MSW2, Georgina Lucas, MSW1, Emily Wang, Disclosures:MD, MAS1; 1Yale School of Medicine, New Haven, CT; ; S. R. Greysen - none; M. S. Rosenthal - none; G. I. Lucas - none; E. Wang -2 none Columbus House Shelter, New Haven, CTBackground: Acute care transitions are particularly difficultfor patients experiencing homelessness, yet there are lim- 51ited data from the perspective of this high-risk population to RESIDENTS’ PERCEPTIONS OF FACTORS LIMITINGguide hospital-based interventions to improve the quality of THE QUALITY OF HOSPITAL DISCHARGEdischarge care specifically. Methods: To better understand S. Ryan Greysen, MD, MA1, Danise Schiliro, MD2, Leora Hor-the experience of discharge care among homeless patients, witz, MD, MHS51, Leslie Curry, PhD, MPH51, Martha Radford,we formed a strategic partnership with an area shelter, and MD, MA1, Elizabeth Bradley, PhD1; 1Yale School of Medicine,together we recruited participants who reported an episode New Haven, CT; 2New York University School of Medicine,of acute care in the preceding 12 months. We performed New York, NYstructured interviews, with questions about sociodemo- Background: Hospital discharge is a critical transition ingraphics and components of discharge care, including care, yet recent data show much room for improvement: 1medication reconciliation and arrangement of follow-up in 5 patients experiences an adverse event or readmissioncare. We performed multivariable logistic regression of sur- within 30 days of discharge. Presently, metrics for the qual-vey data to determine whether housing assessment by any ity of discharge care are limited, and little is known abouthospital staff predicted higher performance on any of these factors affecting the quality of hospital discharge from thedischarge components while adjusting for patient demo- perspective of physicians. Residents’ perceptions are parti-graphics (age, race, sex, and reported length of homeless- cularly important given their unique viewpoint of the dis-ness) and inpatient care versus emergency department–only charge process as trainees and their role as primary carecare. We hypothesized that patients would report a higher- givers at teaching hospitals, which collectively provide 20%quality discharge plan if they reported their providers of all hospital care in the United States. Methods: Weinquired about housing status. Results: Ninety-eight home- employed qualitative methods to describe the discharge Hospital Medicine 2011 Abstracts S31
    • process from the resident’s perspective and generate teamwork in health care centered on communication tools.hypotheses about quality-limiting factors and key strategies We implemented an integrated multidisciplinary Team-for improvement through in-depth in-person interviews. We STEPPS curriculum to improve teamwork and communica-developed a purposeful sample of participants with atten- tion in code blue and rapid response activations. Methods:tion to postgraduate year and experience in different hospi- Members of our hospital’s rapid response and code bluetal settings. Our study design included 2 internal medicine teams executed a survey designed to elicit impressions oftraining programs—Yale and New York University (NYU)— teamwork effectiveness during rapid responses and codeto ensure a wide breadth of experiences. To date, we have blue activations. Teammates surveyed included internalcompleted 17 interviews with Yale residents and have medicine residents, critical care nurses, medical/surgicalbegun enrollment at NYU. Interviews were professionally ward nurses, and respiratory therapists. Participants thentranscribed and independently coded by 2 investigators, selected 1 of 6 training sessions. Each session included aand discrepancies were resolved by consensus. Thematic mix of physicians, nurses, and respiratory therapistanalysis was performed by a diverse research team using designed to reproduce the true composition of our hospi-the constant comparative method. Results: We have ana- tal’s rapid response and code blue teams. Each traininglyzed interviews with 17 Yale residents to date: 10 (59%) session included a TeamSTEPPS didactic period followedwere seniors (PGY-2 or PGY-3), 7 were interns (41%), and by coached practice of TeamSTEPPS tools during simulated10 were female (59%). Based on these interviews, we have rapid response and code blue scenarios at our simulationidentified 5 unifying themes representing factors perceived center. Three months after all sessions were completed, par-to limit the quality of discharge care: (1) competing priori- ticipants were again surveyed to assess their impressions ofties of timely versus thorough discharge, (2) lack of commu- teamwork in code blue and rapid response activations.nication between discharge team members, (3) uncertainty Results: A total of 79 teammates participated in the trainingabout provider roles and patient readiness for discharge, sessions: 39 nurses, 6 respiratory therapists, and 34 inter-(4) lack of standardization in discharge procedures, and nal medicine residents. Survey data revealed improved(5) poor patient communication and postdischarge feed- teamwork and communication from an average of 46.8%back. Representative excerpts from interview transcripts will positive responses prior to training to an average of 72.9%be presented to illustrate conceptual variations of these positive responses after training. The most significantquality-limiting factors as well as to support the overall con- improvements from before the intervention to after the inter-sistency and robustness of each theme above. Conclusions: vention were: ‘‘I feel comfortable expressing my ideas dur-Quality-limiting factors identified by residents may generate ing rapid response and code blue activations’’ (56.9%hypotheses to develop novel quantitative measures of qual- affirmative responses before, 97.2% affirmative responsesity that are grounded in the experiences of physicians pro- after), ‘‘Information is consistently conveyed in SBAR for-viding discharge care. Residents’ insights on this topic may mat’’ (14% affirmative responses before, 54% affirmativealso help shape training and practice to improve the quality responses after), and ‘‘Team members repeat orders andof discharge care at teaching hospitals. requests to the team leader’’ (37% affirmative responsesDisclosures: before, 66% affirmative responses after). Data obtained af-S. R. Greysen - none; D. Schiliro - none; L. I. Horwitz - none; L. A. Curry - none; M. ter actual patient code blue and rapid responses are cur-Radford - none; E. H. Bradley - none rently being collected. Conclusions: Integrated multidisciplinary training and coached practice of Team- STEPPS concepts in hospital providers improves reporting of52 teamwork and communication in code blue and rapidINTEGRATED MULTIDISCIPLINARY TRAINING AND response activations.PRACTICED COACHING OF TEAMSTEPPS Disclosures:IMPROVES REPORTING OF TEAMWORK IN CODE M. Guidry - none; W. Rothwell - none; B. Conkerton - noneBLUE AND RAPID RESPONSE PERFORMANCEMichelle Guidry, MD, William Rothwell, MD, Brian Conkerton,RN; Tulane University School of Medicine, New Orleans, LA 53 OVERUTILIZATION OF CARDIAC MONITORING INBackground: Practiced teamwork with good communication THE NONINTENSIVE CARE SETTINGis a necessary component of safe, quality health care. Com-munication failures are the leading root cause of harm in Ayyoub Haddad, DO, David Paje, MD, William Bisset, DO,hospitalized patients; poor teamwork is associated with Yoo Joo Hwang, DO, Heidi Gunderson, DO; Henry Fordworse health care outcomes. The Institute of Medicine and Macomb Hospital, Warren, MIthe Joint Commission have made communication and inter- Background: Cardiac monitoring has become increasinglydisciplinary team training national patient safety goals. available in noncritical beds. Most clinicians assume thatDesigned by the Department of Defense in collaboration this practice enhances patient care and improves outcomes,with the Agency for Healthcare Research and Quality, but such benefits have not been systematically proven. InTeamSTEPPS is an evidenced-based curriculum to improve 2004, the American Heart Association (AHA) publishedS32 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • TABLE Distribution of Patients Admitted to the Telemetry Unit 54 MEDICATION ADJUSTMENT IN RENAL Developed Significant No New Cardiac IMPAIRMENT: INSIGHT INTO THE RESIDENT MINDClass 1 Indications Cardiac Event Event Totals Kathrin Harrington, MD, Dimitriy Levin, MD, Kelly Schoeppler,Present 7 104 111 PharmD, Katherine Lundin, PharmD, Larry Golightly, PharmD,Absent 0 47 47 BCPS; University of Colorado Denver, Aurora, COTotals 7 151 158 Background: Chronic kidney disease (CKD) affects 13% of adults in the United States, and acute renal failure (ARF) ispractice standards that included expert opinions regarding present in up to 7% of hospitalized patients. Individualsindications for electrocardiographic monitoring in hospital with CKD are at an elevated risk for cardiovascular compli-settings. However, there is still variable understanding of cations and anemia and have increased mortality. Mortalityhow to optimally use this often limited resource. The objec- in ARF can be as high as 50%. Appropriate dosing of med-tive of this study was to determine the proportion of patients ications is important to avoid adverse drug events includingadmitted to the telemetry unit who have class 1 indications further renal injury. Studies have shown that physicians arebased on the AHA recommendations and to determine the often nonadherent with renal dosing of medications. Thisrate of significant cardiac events during the monitoring pe- may be because of unawareness as well as lack of skill inriod. Methods: The electronic medical records of all admis- recognizing and executing renal adjustment. Because thesions to the telemetry unit of a community hospital for the house staff prescribes a large proportion of medications atmonth of January 2009 were reviewed. The indications for academic medical centers, we set out to better understandadmission were classified based on the AHA practice how residents approach renal dosing of medications. Meth-standards. Class 1 includes clinical conditions in which car- ods: First-, second-, and third-year internal medicine resi-diac monitoring is indicated in most, if not all, patients in dents at 1 academic medical center were invited tothe group; class 2 is when cardiac monitoring may be of participate in a 10-question online survey to evaluate atti-benefit for some patients but is not considered essential for tudes, knowledge, and skills in renal dosing of medications.all patients; and class 3 is when cardiac monitoring is not The survey contained 5-point Likert scales and multiple-indicated because a patient’s risk of a serious event is so choice questions with the ability to write in additionallow that monitoring has no therapeutic benefit. The occur- answers. Results: Eighty-nine of 151 internal medicine resi-rences of new significant cardiac events during the period dents completed the survey (response rate, 59%). Renalof monitoring were recorded, such as acute coronary syn- dosing was considered important or very important bydrome, symptomatic or malignant arrhythmias, QT prolon- 100% of responders. Residents reported adjusting medica-gation, and sudden cardiac death. Results: Of the 158 tions for renal clearance often or always 76% of the time.admissions to the telemetry unit that were reviewed, 111 There was a significant increase in frequency of adjustment(70%) met class 1 indications based on AHA recommenda- between PGY-1 and PGY-2 years (P 5 0.007). Seventy-fivetions, and 47 (30%) did not. Seven of the 111 (6.3%) percent of residents endorsed feeling comfortable or verydeveloped a significant cardiac event during the telemetry comfortable adjusting medications for decreased renal func-stay; including 3 patients who were diagnosed with acute tion, with a significant increase in comfort between themyocardial infarction (AMI) after presenting in the emer- PGY-1 and PGY-2 years (P < 0.005). Residents reportedgency department with chest pain and 2 patients who died being able to recognize medications that require renal dos-from sudden cardiac death after being admitted for an AMI ing often or always 48% of the time, with a significantand for acute heart failure. Nobody in the group who did improvement from the PGY-1 to PGY-2 year (P < 0.005).not meet class 1 indications developed a significant cardiac Eighty percent of responders reported writing an order withevent. Conclusions: Physicians overestimate the role of te- the expectation that a pharmacist would adjust the dose,lemetry in guiding patient management in the non–intensive with no significant difference between PGY years. Everycare setting. The AHA practice standards appear to provide resident reported having orders adjusted by a pharmacist.safe and effective guidance on selecting patients for car- There was a significant reduction in frequency of adjust-diac monitoring in the hospital. Larger prospective studies ment between the PGY-2 and PGY-3 years (P 5 0.029).are needed to further strengthen this decision-support tool. Conclusions: Internal medicine residents understand the im-Disclosures: portance of renal adjustment of medications in hospitalizedA. Haddad - none; D. Paje - none; W. Bisset - none; Y. Hwang - none; H. patients but lack the knowledge and skills to do so consis-Gunderson - none tently and correctly. An intervention such as incorporation of pharmacists into daily rounds would provide oversight and education about renal dosing. In addition, an electro- nic medical order system with alerts for patients with reduced creatinine clearance or medications that require re- nal adjustment may improve recognition and execution of renal dosing. Hospital Medicine 2011 Abstracts S33
    • Disclosures: 45% were on antibiotics within 48 hours prior to urine col-K. Harrington - University of Colorado Denver, resident; D. Levin - University of lection. More than 10% of culture-negative patients wereColorado Denver, employment; K. Schoepple - University of Colorado Denver, started on antibiotics for UTI within 72 hours after culture.resident; K. Lundin - University of Colorado Denver, resident; L. Golightly -University of Colorado Denver, employment The kappa statistic on indications for culture was 0.89, indi- cating excellent interrater agreement. Conclusions: In more than half of hospitalized patients, urine cultures are obtained outside of accepted criteria, often being sent for55 reasons other than urinary symptoms. In these scenarios,INAPPROPRIATE TESTING FOR URINARY TRACT complicating factors included insufficient supporting dataINFECTION IN HOSPITALIZED PATIENTS: AN (orthopedic procedures) or nonspecific symptoms (alteredOPPORTUNITY FOR IMPROVEMENT mental status), which might include UTI in the differential di-Sarah Hartley, MD1, Staci Valley, MD1, Latoya Kuhn, MPH2, agnosis. Urine cultures infrequently generated new antibi-Laraine Washer, MD1, Tejal Gandhi, MD1, Anurag Malani, MD1, otic use, perhaps because of high rates of preexistingCarol Chenoweth, MD1, Sanjay Saint, MD, MPH1, Scott Flanders, antimicrobial use. Guidelines relevant to the hospitalizedMD1; 1University of Michigan, Ann Arbor, MI; 2Ann Arbor patient are urgently needed.VAMC, Ann Arbor, MI; 3St. Joseph Hospital, Ann Arbor, MI Disclosures:Background: Urinary tract infection (UTI) is the second most S. Hartley - none; S. Valley - none; L. Kuhn - none; A. Malani - none; L. Washercommon bacterial infection leading to hospitalization, - none; T. Gandhi - none; C. Chenoweth - none; S. Saint - Institute for Healthcare Improvement, Michigan Health and Hospital Association, numer-accounting for 40% of nosocomial infections. Despite the ous hospitals and nonprofit health care organizations and medical societies,high prevalence of UTI, variability in diagnostic testing and honoraria for speaking; S. Flanders - Centers for Disease Control and Prevention, Institute for Healthcare Improvement, research funding, Antimicro-treatment of UTI among hospitalized patients is common bial Stewardship Facultyand can lead to inappropriate antibiotic use and subse-quent antibiotic resistance. We therefore sought to deter-mine the appropriateness of urine culture for UTI and itsimpact on antimicrobial prescribing. Methods: We ran-domly selected patients admitted to a large academic cen- 56ter between February 2008 and February 2009 who had FACTORS ASSOCIATED WITH INAPPROPRIATEurine cultures obtained during the hospital stay. Patients DEFINITIVE ANTIMICROBIAL THERAPY FORwere excluded if they were admitted to intensive care, had BLOODSTREAM INFECTION FROM METHICILLIN-a major urinary procedure (e.g., renal transplant, diversion, RESISTANT STAPHYLOCOCCUS AUREUSor stents), were actively being treated for a UTI at the time Carrie Herzke, MD1, Luke Chen, MSSB2, Daniel Brotman,of admission, were on empiric treatment > 48 hours prior MD1, Deverick Anderson, MD, MPH2, Yong Choi, MSN2,to urine collection while hospitalized, or were obstetrics Daniel Sexton, MD2, Keith Kaye, MD, MPH3; 1Johns Hopkins,patients. Retrospective chart review was independently per- Baltimore, MD; 2Duke University, Durham, NC; Johns Hopkins,formed by 2 physicians to determine the presence of signs Baltimore, MD; 3Wayne State, Detroit, MIor symptoms of a UTI, presence of a urinary catheter, anti- Background: Approximately three quarters of all invasivebiotic administration, and urine culture results. Determina- methicillin-resistant Staphylococcus aureus (MRSA) infec-tion of the appropriateness for sending urine cultures was tions in the United States are bloodstream infections (BSIs).compiled from national and professional society guidelines(i.e., from the Centers of Disease Control and Prevention Many patients with MRSA BSIs are not treated with effectiveand the Infectious Disease Society of America). Results: Of definitive therapy even when antibiotic susceptibility resultsthe 210 patients included, 97 patients (46%) had an are known. Inappropriate antibiotic selection for MRSAappropriate reason documented to obtain a urine culture. BSIs results in poor clinical outcomes. Methods: We per-The majority of these (72%) had fever. Urinary symptoms formed a retrospective case–cohort study of consecutivewere infrequent, occurring in 22%. In 113 patients patients with MRSA BSIs from 10 hospitals (1 tertiary-care(53.8%), no guideline-accepted criterion for obtaining a and 9 community medical centers) from 1999 to 2003.urine culture was found. Of these 113 patients, 46 (41%) Patients were included if they were alive and remained at ahad no documented indication for culture, whereas 67 study hospital on day 3 following a positive MRSA bloodpatients (59%) had documented reasons that were not con- culture. Data were extracted by chart review. The primarysistent with guidelines, including orthopedic procedures end point was the administration of effective definitive ther-(21%) and altered mental status without a urinary catheter apy within the first 3 days following the first positive MRSA(14%). Of all 210 patients, 84% had negative urine cul- blood culture. Effective definitive therapy was defined astures. Culture negativity was similar regardless of the pre- receipt of 1 or more of the following antimicrobial agents:sence or absence of indications supported by the daptomycin, linezolid, quinupristin/dalfopristin, or vanco-guidelines (84% vs. 84%). Of the culture-negative patients, mycin. Multivariable logistic regression was used to deter-S34 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • mine variables associated with receipt of effective definitivetherapy. Results: Five hundred and sixty-two patients werestudied. Of these, 482 were alive and hospitalized on day3. The mean age of the cohort was 63 years, and 50%were male. Three hundred and seventy-four patients(77.6%) had received appropriate definitive therapyagainst MRSA by day 3. In multivariable analysis, patientswere more likely to receive effective therapy if they were ata tertiary-care center (OR, 1.96; 95% CI, 1.16–3.40), hada McCabe score of 1 (indicating an expected survival < 2weeks; OR, 1.97; 95% CI, 1.11–3.71), or a central ve-nous catheter at the time of admission (OR, 1.96; 95% CI,1.14–3.739). Patients with a primary BSI at the time ofadmission (OR, 0.326; 95% CI, 0.183–0.56) were lesslikely to receive effective definitive therapy. Conclusions: Inour study, 108 patients with MRSA BSIs (22.4%) did notreceive effective definitive therapy for MRSA by day 3 fol- standardizing the skin preparatory process, educationlowing the first positive blood culture. The presence of a pri- regarding how to avoid contamination of the sterilized site,mary BSI was associated with inappropriate definitive and proper preparation of blood culture bottle tops. A sec-therapy for MRSA BSI, suggesting that providers underre- ondary intervention was also deployed as a blood culturecognized the infection risk of catheters placed after admis- bundle that included all necessary supplies as well as educa-sion to the hospital. Treatment at a tertiary-care center, high tional reminder cards/prompts to ensure the above primaryacuity of illness, and the presence of a central venous intervention was followed. Results: A run chart was createdcatheter at admission predicted higher rates of appropriate to include the original, preintervention data (mean contami-definitive therapy. Further studies to clarify the factors that nation rate, 4%), as well as our postintervention data (6.3%contribute to inappropriate definitive therapy and evalua- initially). These initial results were alarming and forced us totion of contemporary prescribing practices for patients with re examine unexpected trends and revisit our process analy-MRSA BSI are needed. In addition, our results suggest the sis. We unveiled a change in process; specifically, a changeneed for provider notification, both when the blood culture in the intravenous (IV) catheter that was being used, whichis positive and when sensitivities are resulted. required a ‘‘2-handed threading technique’’ versus ‘‘1-Disclosures: handed technique.’’ This system change occurred in the 2-C. Herzke - none; L. Chen - none; D. Brotman - none; D. Anderson - none; Y.Choi - none; K. Kaye - none month window between collected data points, prior to our interventions, and made the increase in contamination rate explainable (mean contamination rate with new catheter57 without intervention, 9.3%). We have since reinstated the ori-REDUCING THE CHILDREN’S ED BLOOD CULTURE ginal, preferred IV catheter and are now measuring the com-CONTAMINATION RATE BY 50% bined effects of both our interventions and improvedVanessa Hill, MD, Michelle Arandes-Matthews, MD; University of equipment. Following both catheter change and interven- tional strategies, we did reach ‘‘0.’’ Conclusions: In the feb-Texas Health Science Center at San Antonio, San Antonio, TX rile, young child, obtaining blood cultures in the ED setting isBackground: Blood cultures are frequently obtained by provi- a frequent practice. Standardizing technique and continuedders in the emergency department (ED) to evaluate pediatric education can be used to reduce the contamination rate,patients presenting with fever. In pediatrics, nurses and labo- yielding improved care and resource allocation. Unintendedratory personnel often obtain blood cultures at the time of pla- positive outcomes and observations can result from qualitycement of an intravenous catheter. Because of this collection improvement measures.technique, blood culture contaminants present myriad scenar- Disclosures:ios leading to unnecessary and costly interventions for the V. Hill - none; M. Arandes - nonepatient and the system. Published benchmark rates for con-tamination are 2%–3%. At our children’s ED, we had a rateof 4% during the period from September 2008 through Octo- 58ber 2009. The aim of our quality improvement project was to PREMEDICAL STUDENT EXPOSURE TOreduce the blood culture contamination rate by 50% in the INTERACTION WITH THE PHARMACEUTICALchildren’s emergency department by May 1, 2010. Meth- INDUSTRYods: The number of contaminated blood cultures wasexpressed as a rate. Data were reported from the laboratory Laura Hodges, BFA, Vineet Arora, MD, MAPP, Holly Humphrey,in 2-week intervals following our interventions. Multidisciplin- MD, Shalini Reddy, MD; University of Chicago, Chicago, ILary brainstorming sessions were held to identify potential tar- Background: Physician interaction with the pharmaceuticalgets for intervention. Our initial intervention included industry begins early in medical education. Several studies Hospital Medicine 2011 Abstracts S35
    • demonstrate that exposure to the pharmaceutical industry 59occurs throughout the medical training process, from the first READMISSION CASE REVIEWS WITH INTERNS ONyears of medical school on through residency. Practicing physi- A QUALITY IMPROVEMENT ROTATIONcians’ interactions with pharmaceutical industry representatives Saraswati Iobst, MD, Sumant Ranji, MD; University of Califor-have been shown to have effects on physician prescribing nia, San Francisco, San Francisco, CAbehavior and requests to hospital drug formularies. Starting as Background: The Institute for Healthcare Improvementearly as medical school, exposure to drug promotional items recommends that unplanned readmissions within 30 daysshifts student attitudes in favor of promoted drugs. Efforts aimed of discharge prompt a formal case review to identify system-at addressing conflict-of-interest issues are currently directed to- atic flaws in discharge processes. As frontline providers, resi-ward trainees in medical school and residency. However, dents may have insights that can help assess readmissionopportunities for pharmaceutical industry interaction exist even preventability and identify underlying system flaws that lead tobefore students enter into medical school. Methods: An anony- readmissions. We therefore developed a readmission casemous survey was distributed to all incoming first-years at the review system with medical interns on a quality improvementUniversity of Chicago Pritzker School of Medicine between (QI) rotation in order to understand the epidemiology and pre-2007 and 2010. Questions were asked about observations of, ventability of our unplanned readmissions. Methods: Beginningparticipation in, and opinions toward the following profes- in June 2010, all unplanned readmissions within 30 days ofsional behaviors: ‘‘Attending a ‘drug rep’ (pharma-sponsored) discharge were reviewed in real time by interns during a 2-dinner or social event’’ and ‘‘Accepting a pen from a pharma- week QI rotation. Interns used a standardized form to analyzeceutical representative.’’ Results: Of respondents (n 5 279) in cases via chart review, discussions with the discharging andthe incoming classes of 2007–2010, 41.0% of students readmitting physicians, and patient interviews. Interns werereported that, as premedical students, they participated in the asked to describe the reasons for readmission including preven-acceptance of a pen from a pharmaceutical representative. As table factors related to the discharge process (see Table 1).well, 59.4% of students reported that they observed the accep- Patients could have multiple reasons for readmission. Threetance of a pen from a pharmaceutical representative by others. attending hospitalists independently reviewed 30 cases thatAlso, 2.3% of students found this behavior to be unprofes- had been completed by the interns. Results: Interns reviewedsional, 9.0% found it to be somewhat unprofessional, 65.8% 111 consecutive cases. Reason for readmission was often multi-found it to be neutral, 10.9% found it to be somewhat profes- factorial: 10% of patients had 3 and 36% had 2 identifiablesional, whereas 12.0% found it to be a professional behavior. factors that contributed to their readmission. Interns consideredIn addition, 21.7% of students also reported that, as premedi- most readmissions to be nonpreventable (see Table 1). How-cal students, they participated in attending a dinner or social ever, 35% of patients had a preventable reason for readmis-event sponsored by a pharmaceutical representative. 33.3% of sion (see Table 2), with medication-related events being most frequent. Thirty percent of patients had both preventable andstudents similarly reported having observed the attendance at a nonpreventable reasons for readmission, for example, worsen-dinner or social event by others. In regard to this behavior, ing of underlying disease and inadequate family support. The7.6% of students found it to be unprofessional, 21.7% found it attending faculty agreed with the intern assessments of prevent-to be somewhat unprofessional, 50.2% found it to be neutral, ability 80% of the time; when they disagreed, they thought an12.6% found it to be somewhat professional, and 8.0% found additional preventable factor contributed to the readmission.it to be a professional behavior. Conclusions: The exposure of Interns had difficulty identifying broader, systems-based pro-premedical students to the pharmaceutical industry demon- blems. For example, they attributed uncontrolled pain in a met-strates a continued need for intervention in medical school curri- astatic cancer patient to worsening of underlying disease,cula. Our data indicate that these interactions start at an earlier whereas attendings thought the admission could have beenstage of training than previously documented. Efforts to address prevented if palliative care was consulted on the index admis-physician interactions with the pharmaceutical industry need to sion. Also, nearly half the ‘‘new diagnoses’’ at readmissionstart at an earlier stage of medical training in order to account were hospital-acquired infections, which are often preventable.for premedical student exposure to this industry. The impact of Conclusions: Our case series highlights that reasons for readmis-conflict of interest policy changes at many academic medical sion are often multifactorial, and a significant proportion ofcenters also needs to be investigated, as tighter restrictions may patients have both preventable and nonpreventable reasons forlead to fewer opportunities for premedical students to interactwith the pharmaceutical industry over time.Disclosures:L. Hodges - none; H. Humphrey - none; V. Arora - none; S. Reddy - none TABLE 1 Nonpreventable Reasons for Readmission Reason for Readmission Number of Patients (%) Worsening of underlying disease 81 (73) New diagnosis 20 (18)S36 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • TABLE 2 Preventable Reasons for Readmission overnight hand-offs. Thirty-nine percent of providers reported themselves as ‘‘very satisfied,’’ versus 21% pre-Reason for Readmission Number of Patients (%) change. Physicians did not report greater satisfaction with hand-offs during the day shift, during which physiciansMedication-related (adverse effect of a new 14 (13) were mandated to give a verbal sign-out but did not have a medication, unable to fill prescriptions)Inappropriate discharge location (home 5 (5) specified time to do so. Comments suggested that this may instead of skilled nursing facility) have been because of too many work flow interruptions.Inadequate family/caregiver support 7 (6) The LOS index was 0.968 before the intervention andInadequate communication between inpatient 3 (3) 0.905 after (P < 0.01). Conclusions: Mandating verbal and outpatient providers handovers and dedicating time for sign-out was associatedUnable to obtain timely follow-up 4 (4) with estimates of fewer medical errors, greater physician satis-Incorrect diagnosis 4 (4) faction with handovers, and lower LOS index. Mandating verbal handovers without dedicating time to do so was asso-readmission. We also found that compared with faculty assess- ciated with lower physician satisfaction, presumably becausement, interns underestimate the preventability of readmissions. of interruptions in work flow. These findings suggest that dedi-Disclosures: cated time for verbal handovers may have positive effects onS. Iobst - none; S. Ranji - none the quality and efficiency of hospital practice. Disclosures: J. Bonsall - none; W. Smith Jr. - none; K. Qatsha - none; A. Webb - none; Z.60 Wiley - none; N. Maleque - none; V. Akopov - noneMANDATORY AND DEDICATED TIME FOR VERBALHANDOVERS MAY REDUCE ERRORS, IMPROVEPHYSICIAN SATISFACTION, AND DECREASE 61LENGTH OF STAY MANAGEMENT OF BRONCHIOLITIS IN THEBonsall Joanna, MD, PhD, Willie Smith, MD, Kelly Qatsha, MD, EMERGENCY DEPARTMENT FROM 2001 TO 2008:Anthony Webb, MD, Zanthia Wiley, MD, Noble Maleque, MD, INFLUENCE OF EVIDENCE-BASED GUIDELINES?FHM, Val Akopov, MD, SFHM; Emory University, Atlanta, GA Lara Johnson, MD, MHS, Janie Robles, PharmD, Shea Madrid,Background: Transitions of care occur any time a patient MD, Amanda Hudgins, MD, Devona Martin, MD, Amy Thomp-moves from 1 care setting to another or from 1 provider to son, MD; Texas Tech University Health Sciences Center Schoolanother. A higher frequency of errors has been described of Medicine, Lubbock, TXduring these vulnerable periods, and a Society of Hospital Background: Bronchiolitis is one of the most common condi-Medicine Task Force has issued recommendations for best tions for which infants and young children are evaluated in thepractices in handovers among hospital-based physicians. emergency department (ED). Recent practice guidelines fromWe describe an effort at 1 institution to improve handover the American Academy of Pediatrics recommend limiting thepractice. Methods: Twenty hospital medicine physicians use of bronchodilators, steroids, and diagnostic testing forwere surveyed to assess satisfaction with current handover patients with bronchiolitis. We sought to determine the associa-practice and perceived errors. Using survey results, an insti- tion of the publication of national guidelines with bronchiolitistutional task force identified barriers to safe handovers and care and practices in the ED. Methods: We analyzed datarecommend the 2 changes in practice: (1) mandatory from the National Hospital Ambulatory Medical Survey emer-verbal handover of all new patients by the admitting physi- gency department component, a nationally representative 4-cian to the accepting team and (2) extension of the nightshift by 1 hour to establish daily overlap for face-to-face stage probability sample of ED visits. For all patients withinteraction with day shift. Three months after these changes bronchiolitis, we generated descriptive statistics regardingwere implemented, physicians were resurveyed. End points medication and imaging utilization and bivariate analyses towere estimated medical error rates, provider satisfaction, compare utilization for patient visits before and after the intro-and length of stay (LOS) index, a standardized LOS duction of the guidelines. We used logistic regression to deter-adjusted for diagnosis. Results: The surveys had a 100% mine the independent association of the availability of theresponse rate. Initially, 30% of providers reported that guidelines aspects of care. All analyses were completed usingminor medical errors, errors not resulting in patient harm, SUDAAN. Results: There were approximately 220 million EDoccurred ‘‘somewhat often’’; after the changes, only 4% of visits by pediatric patients during the 8-year study. Approxi-providers reported ‘‘somewhat often’’ (P < 0.05). Providers mately 1.9 million patients under 2 years of age were diag-also reported fewer major medical errors; 56% of physi- nosed with bronchiolitis, representing about 0.90% of the totalcians reported 1 or more events in the 3 months prior to ED visits by pediatric patients and 3.6% of ED visits for patientsthe first survey. Only 24% reported major errors in the sub- younger than 2 years. Bronchodilators were prescribed insequent 3 months. Although not statistically significant, 52.7% of patient visits, with no differences noted after the intro-there was also a trend toward improved satisfaction with duction of the guidelines (53.0% vs. 51.7%, P 5 0.85). Sys- Hospital Medicine 2011 Abstracts S37
    • temic steroids were used in 20.0% of patient visits with no dif- to object to a student being present and would object if a stu-ferences noted after the introduction of the guidelines (21.9% dent examined the patient. White patients were more likelyvs. 14.7%, P 5 0.12). Chest x-rays were utilized significantly to react to a student’s nationality and/or culture comparedless frequently after the introduction of the guidelines (65.3% with the other racial and ethnic groups. More women thanvs. 51.9%, P 5 0.04). After adjusting for patient and hospital men expressed discomfort with examination of their genitalia,characteristics, patients seen after the introduction of the guide- whereas more men than women had more difficulty discuss-lines had significantly reduced odds of having radiographs ing topics identified as personal. The respondents felt theyobtained (adjusted odds ratio, 0.45; 95% CI, 0.28–0.73). would cooperate with the student, but they also wished toConclusions: For patients with bronchiolitis seen in the ED, utili- retain the right to refuse participation if they so wished and tozation of medications remains similar to rates seen in the previ- be informed in advance of a student’s presence. Conclusions:ous decade, although utilization of radiographs has decreased Efforts under way to expand training in primary care may leadover the study period. Publication of evidence-based guidelines to physician involvement in venues not accustomed to teachinghas not had a significant impact on ED management of bronch- and supervising medical students. The results of this single-cen-iolitis in this nationally representative sample. ter study suggest that patient views on who they feel comforta-Disclosures: ble with interacting in their clinical care should be consideredL. Johnson - none; J. Robles - none; A. Hudgins - none; S. Madrid - none; D. in designing clinical experiences for medical students.Martin - none; A. Thompson - none Disclosures: A. Kalra - none; R. Tandon - none; J. S. Reis - none; J. A. Jokela - none; R. W. Kirby - none62MEDICAL STUDENTS IN THE CLINIC: THEPATIENTS’ PERSPECTIVE 63Amandeep Kalra, MD, Rudhir Tandon, MD, Janet Reis, PhD, MAGNESIUM DEFICIENCY AND REPLACEMENTJanet Jokela, MD, MPH, FACP, Robert Kirby, MD, FACP; Uni- AMONG HOSPITALIZED PATIENTSversity of Illinois at Urbana-Champaign, Internal Medicine, Col- Ariel Katz, MD, MPH, Shweta Punj, MD, Naykky Singh, MD,lege of Medicine, Urbana, IL Ayokunle Abegunde, MBBS, Dayra Avila, MD, Elena Xintavelo-Background: Current health care reform calls for an increase nis, MD, Marwan Qattan, MD, Brian Lucas, MD, MS, FHM;of 46,000 full-time equivalent primary care providers by John H. Stroger Hospital of Cook County, Chicago, IL2025, requiring a significant expansion of teaching and Background: Hypomagnesemia is often neither adequatelytraining venues. Questions arise as to whether there are suffi- replaced nor appropriately followed in hospitalized patients. Incient physician faculty to teach medical students. Willingness particular, because the average magnesium deficiency in hypo-of physicians to teach depends in part on the patients’ atti- magnesemia is 50–100 mEq, a single parenteral dose of 2 gtudes toward medical students. This study explores patients’ of magnesium sulfate is woefully inadequate, not only becauseattitudes toward medical students involved in clinical care in it contains just 16.2 mEq of magnesium, but also because halfthe outpatient setting Methods: A mailed survey drawing on of it will typically be lost in the urine. Moreover, because serumprimary care records maintained by a 300-physician group magnesium requires 3–4 days to reach tissue equilibration,in a Midwest university community of 150,000 was used to ‘‘normal’’ magnesium levels in the midst of active repletion doassess patients’ attitudes toward medical students. The origi- not accurately reflect magnesium stores and should generallynal 12-item instrument was rephrased to use a 5-point Likert be ignored. Suspecting that these principles of magnesiumscale (from 1 5 strongly disagree to 5 5 strongly agree) management are not followed, we sought to describe the ade-along with 8 background sociodemographic questions. The quacy of replacement and the appropriateness of follow-up test-chi-square analysis examined the associations between the ing among general medicine inpatients. Methods: Our studyattitude questions and the sociodemographic variables. sample was drawn from 13,191 hospitalizations to the generalResults: There were statistically significant associations (P < medicine service of a public teaching hospital from May 2009,0.05) between individual questions and 7 sociodemographic to July 2010. The inclusion criterion was an initial serum mag-variables. The pattern of associations between sociodemo- nesium level < 1.8 mg/dL, and the exclusion criterion was agraphic characteristics and individual questions illustrates dif- glomerular filtration rate (GFR) < 30 mL/min using the Modifi-ferent preferences according to subgroups of patients. Older cation of Diet in Renal Disease formula. We calculated the totalpatients reported that they would react to a student’s country inpatient magnesium dose from published data for each formu-of origin and examination of genitalia more often than did lation. The magnesium replacement dose was deemed ade-younger patients. Younger patients disproportionately wanted quate if the total dose was >50 mEq, a low-end estimate for athe right to refuse student participation but were less likely to 50-kg hypomagnesemic patient. We used the Wilcoxon rankfeel embarrassed by questions about alcohol intake or sexual sum test to test for differences in redosing durations becauseactivities. Patients with more education wished to be informed these data were nonparametric. Results: Of 13,191 hospitali-in advance about the presence of a medical student, whereas zations to the general medicine service during the study period,patients with a high school education or less were more likely at least 1 serum magnesium level was drawn in 6173. AmongS38 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • these 6173 hospitalizations, 1851 met the inclusion criterionfor hypomagnesemia, but 331 were excluded due to reducedGFRs. Thus, the primary study cohort was 1520 patients. Nomagnesium supplements were given to 45% (690 of 1520),and only 21% (321 of 1520) received adequate replacementthroughout their hospitalizations. Among 34 patients withsevere hypomagnesemia (initial serum magnesium level < 1.2mg/dL), 64% (22 of 34) received adequate replacement.Repeat magnesium levels were performed during hospitaliza-tion after a median of 24 hours (IQR, 18–40 hours) after initialmagnesium doses. Patients whose serum magnesium valuesreturned to normal were redosed a median of 20 hours laterthan patients whose values remained decreased (P < 0.0001),suggesting that prescribing physicians delayed treatmentbecause of deceptively normal serum magnesium levels. Con-clusions: Magnesium replacement doses were inadequate in79% of patients. Repeat magnesium testing occurred too soonafter initial replacement doses and may have inappropriatelydelayed further treatment. To address these problems, we plan in 1997 and 2006, the percentage of admissions from trans-quality improvement initiatives that incorporate physician edu- fers to CHs has risen over time. This was true whether the totalcation on the principles of hypomagnesemia replacement. number of discharges rose or fell. Conclusions: From 1997 toDisclosures: 2006, transfers to CHs have risen. The KID does not provideA. Katz - none; S. Punj - none; N. Singh - none; A. Abegunde - none; D. Avila - acuity, so it may be that hospitalized children have becomenone; A. Xintavelonis - none; B. Ninan - none; M. Qattan - none; B. Lucas - sicker over the study period and the percentage of childrennone requiring more specialized care has risen. It may also reflect a declining capacity to care for sick children in the non-CH set-64 ting, possibly from lack of bed space. Continuation of this trendTRENDS IN TRANSFERS TO CHILDREN’S HOSPITALS will require an increase in CH beds. Disclosures:Caryn Kerman, MD, Daniel Rauch, MD; Elmhurst Hospital Cen- D. Rauch - Baxter, consultantter/Mount Sinai School of MedicineBackground: Access to care is a critical issue for child health.Although most of the focus on access is availability of primary 65care, the availability of hospital care for children is an underap- RISK FACTORS FOR ACQUISITION OFpreciated issue. Data from various sources indicate that the CARBAPENEM-RESISTANT KLEBSIELLAnational pediatric bed census is falling, with losses in particular PNEUMONIAE: A CASE–CONTROL STUDYfrom general hospitals. HCUP Kids’ Inpatient Database (KID)shows a national increase in discharges and length of stay Ketino Kobaidze, MD, PhD, Jesse Jacob, MD, James Steinberg,from 1997 to 2006, creating an increased need for beds. This MD, Eileen Burd, PhD, Bruce Ribner, MD, Dana Flanders, MD,trend coincides with efforts to regionalize or centralize pediat- Dsc; Emory University School of Medicine, Atlanta, GAric care at children’s hospitals (CHs). A marker of the increased Background: Carbapenem-resistant Klebsiella pneumoniaepressure for pediatric beds may be the incidence of transfers as (KPC-KP) has become a major nosocomial pathogen over thea source of admission to CHs. Our objective was to utilize KID past decade. The first KPC-KP was isolated in an Emory Univer-to examine trends in transfers as a source of admission to CHs sity–affiliated hospital in 2006, and since then the number offrom 1997 to 2006. Methods: We examined the KID, a isolates has increased annually, including 36 isolates in 2009.national data set available through the Agency for Healthcare The treatment of this multidrug-resistant infection is challenging,Research and Quality from 1997 to 2006 via HCUPnet. KID given that KPC-KP confers resistant to virtually all commonlydata are triennial. We looked at total discharges and specifi- using antibiotics. Determination of risk factors for infection/cally the top 25 ICD-9 codes in 2006, excluding newborn colonization remains critical in order to develop effective meas-diagnoses, for discharge volume and source of admission as a ures to prevent spread. Methods: To detect risk factors for ac-total number and percentage of discharges for trends over quisition of KPC-KP, we conducted a retrospective case–controltime. Results: From 1997 to 2006, the total percentage of all study across the 2 Emory University–affiliated teaching hospi-pediatric discharges from CHs remained stable, at about 24%, tals. A total of 30 KPC-KP isolates were identified by the Emorybut the percentage of transfers to CHs rose from 6.19% to University laboratory registry from 2006 through 2008. All8.90%. Transfer volume and percentage were higher for ages patients with KPC-KP-positive cultures (defined as cases) were0–4 than for older children, even without NICU transfers. For randomly matched with controls (1:4) by initial culture date,14 of 15 of the 2006 top-volume ICD-9 codes that were similar sex, and age. The exact conditional logistic regression method Hospital Medicine 2011 Abstracts S39
    • was used for statistical analysis. Pulsed-field gel electrophoresis(PFGE) was used for molecular subtyping for detection of Care Withdrawn Care Withdrawn Care Notgenetic relatedness among the isolates. Results: Charts were < 72 Hours > 72 Hours Withdrawnreviewed from 30 cases and 120 controls. Statistically signifi- (n 5 14) (n 5 6) (n 5 20) P Valuecant risk factors for acquisition of KPC-KP included prehospital Initial rhythm VT/VF 1 (7%) 1 (17%) 2 (10%) 0.52antibiotic use (P < 0.005), in-hospital use of 2 or more antibio- Collapse to ROSC (minutes) 58 Æ 18 30 Æ 17 27 Æ 19 0.09tics (P < 0.005), poor performance status defined by the Kar- Bystander CPR—yes 3 (21%) 2 (33.3%) 5 (20%) 0.66nofsky performance scale index (P < 0.002), multiple Age, years 66 Æ 13 59 Æ 18 64 Æ 16 0.66comorbidities calculated using the Charlson comorbidity index Female 6 (43%) 4 (66.6%) 7 (35%) 0.38score (P < 0.02), malnutrition (P < 0.03), and nursing home Coronary artery disease 6 (42%) 1 (17%) 11 (55%) 0.22residence (P < 0.017), which significantly increase risk for this Diabetes mellitus 6 (42%) 3 (50%) 8 (32%) 0.91infection. ICU exposure prior to KPC-KP isolation (P < 0.03), Hypertension 12 (84%) 4 (66.6%) 17 (85%) 0.58prolonged hospitalization (P < 0.04), and multiple surgical Congestive heart failure 8 (57%) 2 (33%) 9 (45%) 0.58procedures (P < 0.03) also increased the risk for KPC-KP acqui- Hypothermia therapy 2 (14%) 3 (50%) 10 (50%) 0.06 BSR score on day 3 0.3 Æ 0.8 1.8 Æ 1.4 3.7 Æ 1.3 < 0.001sition. Molecular epidemiology investigation conducted by Poor EEG findings at 48 hours 6 (42%) 3 (50%) 3 (15%) 0.10PFGE revealed that more than 90% of KPC-KP isolates shared CPC score on day 1 4 4 3.6 Æ 1 0.53similar PFGE patterns (>85% band similarity) and suggested CPC score on day 2 4 4 3.2 Æ 0.2 0.21interhospital transmission. Conclusions: The results of our study CPC score on day 3 4 4 3 0.10suggest that prolonged hospitalization and prior antibiotic use Advance directives—yes 5 (36%) 3 (50%) 5 (20%) 0.5increases the risk of acquisition of KPC-KP. The patients most Outcome alive at discharge 1 (7%) 2 (33%) 12 (60%) 0.003vulnerable to KPC-KP include those with multiple comorbiditiesand functional impairment. Because interhospital transmissions ROSC, return of spontaneous circulation; CPC, cerebral performance category; CPR, cardiopulmo-occur, implementation of infection control practices are neces- nary resuscitation; BSR, brain stem reflex.sary to prevent spread among hospitalized patients.Disclosures:K. Kobaidze - none; J. Jacob - none; B. Ribner - none; J. Steinberg - none; E. of the care was withdrawn within 72 hours. Patients withBurd - none; D. W. Flanders - none early care withdrawal have longer collapse to ROSC time (58 Æ 18 vs. 30 Æ 17 minutes) and lower brain stem reflex score on day 3 (0.3 Æ 0.8 vs. 1.8 Æ 1.4). Conclusions: Fewer than one third of patients have advanced directives. In66 approximately 50% of survivors of sudden cardiac arrest,EARLY WITHDRAWAL OF CARE FOLLOWING care is withdrawn; in many (70%), this decision is madeSUDDEN CARDIAC ARREST: DEFINING PATIENT before the recommended time for assessment of neurologicalPROFILES recovery. Patients with early care withdrawal differ from others only in that they have a longer time to return of sponta-Umashankar Lakshmanadoss, MD, Shaker Eid, MD, Devon neous circulation and a worse brain stem reflex score. How-Dobrosielski, PhD, Joe Palachuvattil, PhD, Karey Stewart, MD, ever, their CPC score is no different on day 3 than that ofScott Carey, MD, Nisha Chandra-Strobos, MD; Johns Hopkins those in whom care is not withdrawn, many of who survive toBayview Medical Center, Baltimore, MD discharge. These observations are concerning and prompt anBackground: Severe neurological impairment is a tragic out- in-depth evaluation of such a decision process.come in survivors of sudden cardiac arrest (SCA). Standard Disclosures:practice to assess neurological recovery requires clinical U. Lakshmanadoss - none; S. Eid - none; D. Dobrosielski - none; J. Palachuvattiland diagnostic evaluation 3–4 days after SCA. It is unclear - none; K. Stewart - none; S. Carey - none; N. Chandra-Strobos - nonewhether this standard of practice is implemented or whetherphysicians advise or families choose to withdraw care at 67earlier intervals. We examined the pattern of care withdra- PATIENTS’ PERSPECTIVES ON MAINTAINING THEIRwal in patients surviving SCA. Methods: All SCA patients PERSONAL MEDICATION INFORMATION TOadmitted in 2 consecutive years (n 5 45) were studied. IMPROVE PATIENT—PROVIDER COMMUNICATIONFive had incomplete data. We evaluated when life-sustain- AND FACILITATE SHARED DECISION MAKING:ing therapies were withdrawn. Patients were divided into 3 A SURVEYgroups. Profiles of patients with early care withdrawal (<72hours) versus withdrawal > 72 hours versus no withdrawal of Kirby Lee, PharmD, MA, MAS, Caroline Hartridge-Beam, BS,care are as noted below. Neurological status was assessed Jennifer Nguyen, BS, Arjang Ahmadpour, BS, Ashley Diaz,by daily Glasgow–Pittsburgh cerebral performance category BS, Andrew Auerbach, MD, MPH; University of California,(CPC) scores and by evaluating EEG and brain stem reflex San Francisco, San Francisco, CAscores on day 3 (higher 5 better neurological function). Background: Transfer of accurate medication informationResults: Care was withdrawn in 20 patients. Of these, 70% across patient care settings is crucial to preventing medica-S40 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • tion errors and promoting patient safety. Patient participa- stopped, changed, or added is clear to caregivers andtion is a key factor in obtaining complete and accurate patients alike. Clinically meaningful medication reconcilia-medication information as patients frequently self-medicate tion requires changes in work flow, organizational manage-or alter adherence to prescribed therapy. Encouraging and ment, and substantial resources and has been difficult toempowering patients to manage their medication informa- achieve across health care settings, particularly in emer-tion and engage them in shared decision making is an im- gency departments, because of time constraints and over-portant step toward optimizing drug therapy and crowding. Methods: This was a qualitative study based onpreventing medication errors. Methods: A survey and struc- semistructured interviews with emergency department clini-tured interviews were conducted among a consecutive sam- cians, administrators, and staff at 3 hospitals (urban privateple of patients attending the preoperative clinic for elective academic teaching hospital, urban county hospital, subur-surgery at theUniversity of California, San Francisco, Sep- ban HMO hospital) from September 2009 to Septembertember 2009–March 2010. Survey data were analyzed 2010. Results: We have interviewed approximately 33 pro-using descriptive statistics, and qualitative data were ana- viders across all 3 sites (15 physicians, 15 nurses, 3 phar-lyzed to identify common themes for maintaining or not macists). Providers expressed concern about spending amaintaining a medication list. Results: Of 192 eligible great deal of time interviewing patients to obtain and verifypatients, 140 patients completed the survey (73% response the accuracy of medications a patient is taking that mayrate). Patients averaged 61 years of age (range, 22–89 produce some overall benefit but a significant consequenceyears), 51% were male, and were predominantly white in trade-off costs to effectively manage other patients in the(77%) and had completed some level of college education time-sensitive setting of the emergency department. They(78%). Most patients brought medication lists to their clinic commented on the need to design and develop more effi-visits (79%) after receiving telephone reminders and written cient, standardized systems and processes for obtaininginstructions from clinic staff; however, few reported that a medication histories using electronic medical records andhealth care provider recommended they maintain a medica- other health information technology platforms, as their cur-tion list and discuss it at every health care visit (36%). rent systems were less than ideal (e.g., difficult or slowAmong the 111 patients with a list, 87% reported improved access to medical records, concerns about accuracy ofcommunication with their doctor. Common reasons for data in medical records, minimal interoperability, newmaintaining a list included improved self-management of patient encounters). Empowering the patient to provide atheir medications and convenience. Common themes current medication list in the emergency department (ED)among patients without a list included lack of importance was discussed as a highly desirable process to helpor need (e.g., could remember their medications) and improve assessment and evaluation by providers, althoughexpectations that providers and hospitals would maintain there were concerns about verifying the accuracy of theaccurate medication information within their health records. patient-generated medication list. Conclusions: Providers inConclusions: Personal medication lists maintained by the ED face a number of challenges and barriers to effec-patients provide an opportunity to improve communication tively conducting medication reconciliation. A number ofand facilitate shared decision making between patients and solutions involve defining standard procedures and roles,health care providers. Interventions that encourage and having improved computer systems and interoperability,empower patients to maintain a medication list and make it and engaging the patient to improve communication.accessible for review are needed. Disclosures:Disclosures: K. Lee - none; D. Dohan - none; D. Ballard - none; J. Stein - none; J. Hsu - noneK. Lee - none; C. Hartridge-Beam - none; J. Nguyen - none; A. Ahmadpour -none; A. Diaz - none; A. Auerbach - none 69 IMPACT OF A STANDARDIZED CURRICULUM ON68 REDUCING THORACENTESIS-INDUCEDUNDERSTANDING BARRIERS AND SOLUTIONS TO PNEUMOTHORAXIMPLEMENTING MEDICATION RECONCILIATION Joshua Lenchus, DO, Alice Gallo de Moraes, MD, MeghaIN EMERGENCY DEPARTMENTS: A QUALITATIVE Garg, MPH, Venkat Kalidindi, MD, Andres Soto, MD, AldoSTUDY Pavon, MD; University of Miami Miller School of Medicine,Kirby Lee, PharmD, MA, MAS1, Daniel Dohan, PhD1, Dustin Miami, FLBallard, MD2, John Stein, MD, MAS1, John Hsu, MD1; 1Univer- Background: Pneumothorax is a known potential complica-sity of California, San Francisco, San Francisco, CA; 2Kaiser tion of thoracentesis, with an estimated incidence rate ofPermanente, San Rafael, CA; 3Harvard, Boston, MA 6.0% according to a recent meta-analysis. Several interven-Background: Medication reconciliation is a process tions can reduce this accidental iatrogenic complication. Atwhereby medication lists are crosschecked and verified at Jackson Memorial Hospital (JMH), in Miami, Florida, wesignificant points of contact with the health care system, so created and implemented a simulation-based curriculum inthat a record of which medications are appropriately procedural instruction in July 2007. It encompasses standar- Hospital Medicine 2011 Abstracts S41
    • dized training, a validated checklist, bedside use of ultraso- 70nography, a dedicated team-based resident rotation for HOSPITALISTS IN MEDICAL EDUCATION: RESULTSexperiential learning, and direct attending supervision. We FROM A NATIONAL SURVEYhypothesized that these novel changes would result in a Beth Liston, MD, PhD1, Nathan O’Dorisio, MD1, Dario Torre,lower postthoracentesis pneumothorax rate and compared MD2, Klara Papp, PhD3; 1Ohio State University, Columbus,those done by the procedure team with those that were not. OH; 2University of Pittsburgh, Pittsburgh, PA; 3Case WesternMethods: We prospectively collected standardized patient Reserve University, Cleveland, OHdata on all thoracenteses performed by the procedure teambetween July 2, 2007, and June 30, 2010. Similar data of Background: Hospital medicine is growing rapidly across thethose done throughout the hospital during the first year (July nation, with more than 10,000 hospitalists in practice today.2, 2007, through June 30, 2008) were also collected Although initially focused in the community sector, hospitaliststhrough a retrospective chart review. The data was then an- have had an increasing presence within academic centers. Thealyzed to determine the rate of pneumothorax and subse- University Hospital Consortium 2007 survey found that prior toquent chest tube requirement in both groups. This project instituting work-hour restrictions, 57% of university hospitalswas approved by our institutional review board. Results: had hospitalists, whereas afterward, hospitalists were practi-From July 2, 2007, to June 30, 2008, a total of 378 thora- cing in 82% of these centers. This changing inpatient workforcecenteses were performed at JMH, with 18 resulting pneu- has had consequences on medical education, with an increas-mothoraces, an overall postprocedure rate of 4.76%. Of ing hospitalist presence in both resident and student training.those, 89 were done by the procedure team, with a single The full effects of this have not yet been completely elucidated.ensuing pneumothorax (1.12%), whereas the remaining Initially met by educators with apprehension, there is a growing289 were done by other operators, with 17 subsequent body of literature to suggest that hospitalists are perceived bypneumothoraces (5.88%). Although all these latter proce- students to be more effective clinical teachers than are nonhos-dures were supervised by attending physicians, none were pitalists. However, the extent to which hospitalists are involvedperformed subsequent to their operators undergoing stan- in teaching internal medicine (IM) to medical students is notdardized simulation-based training or using a checklist; known. Methods: To determine the role of hospitalists in medi-ultrasound use was variable. The difference in complication cal student education within the United States and Canada, werates was significantly better (P < 0.05), favoring those per- queried clerkship directors in internal medicine as part of theformed by the procedure team. This low complication rate 2010 annual Clerkship Directors in Internal Medicine (CDIM)has held over time. Over the 3-year period, July 2007 survey. In June 2010, CDIM surveyed its North American insti-through June 2010, 314 thoracenteses were performed by tutional members, which represent 110 of 143 Departments ofthe procedure team, with an overall pneumothorax rate of Medicine in the United States and Canada. The section on hos-1.91%. A chest tube was required in 2 pneumothorax pital medicine comprised 6 multiple-choice and 2 free-responsecases (33%), which is consistent with published data. Con- questions. Descriptive statistics were used to analyze the data.clusions: The procedure team at JMH incorporates a num- Results: Eight-two of 110 programs responded to the surveyber of elements aimed at increasing patient safety: a (75%). Seventy-five respondents (91%) indicated that hospital-standardized, simulation-based curriculum in procedural ists serve as teaching attendings at their teaching hospital. Atinstruction, the use of a validated checklist and ultrasono- 22 IM programs (27%), 75%–100% of students rotate with agraphic imaging, and a team-based experience in the con- hospitalist during their IM clerkships. The majority of clerkshiptext of direct faculty supervision. This comprehensive directors (51%) report that only 1%–25% of formal didacticsapproach to the performance of a thoracentesis demon- are being conducted by hospitalists. Students at 7 respondentstrated a lower postprocedure pneumothorax rate when institutions (8.5%) rotate with hospitalists on non-resident-cov-compared with other operators at our institution as well as ered services. Thirty-three institutions (42%) reported that stu-that of the average reported in a recently published meta- dents are directly supervised by in-house hospitalists duringanalysis. The widespread adoption of these elements can their nighttime call requirements. Sixty-six schools (80.5%) indi-have a significant impact on patient safety, ultimately lead- cated that hospitalists hold administrative positions within theiring to decreased morbidity, mortality, and health care institution. Conclusions: Hospitalists are involved in medical stu-expenditures related to procedural complications. dent education in the large majority of Departments of InternalDisclosures: Medicine throughout the United States and Canada. Their edu- cational role appears to be in clinical settings rather than in for-J. Lenchus - Sanofi-Aventis, Pfizer, speakers bureau, advisory board; A. Gallode Moraes - none; M. Garg - none; V. Kalidindi - none; A. Soto - none; A. mal didactics. In some cases, students are supervised directlyPavon - none by hospitalists in the absence of residents. Many educational administration positions are held by hospitalists, reflecting the growth of hospital medicine nationally. Disclosures: B. W. Liston - none; N. O’Dorisio - none; D. Torre - none; K. Papp - noneS42 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • 71EFFECTS OF HAND-CARRIED ULTRASOUNDECHOCARDIOGRAPHY BY HOSPITALISTS AMONGINPATIENTS REFERRED FOR STANDARDECHOCARDIOGRAPHY: A RANDOMIZED TRIALBrian Lucas, MD, MS, FHM1, Carolina Candotti, MD2, BoskoMargeta, MD1, Benjamin Mba, MBBS, MRCP1, Rudolf Kumap-ley, MBCHB1, Abdo Asmar, MD1, Ricardo Franco-Sadud, MD1,Joshua Baru, MD1, Christine Acob, MD1, Shane Borkowsky,MD1, Arthur Evans, MD, MPH3; 1Stroger Hospital of CookCounty and Rush Medical College, Chicago, IL; 2Milton S. Her-shey Medical Center, Hershey, PA; 3New York Presbyterian Hos-pital and Weill Cornell Medical College, New York, NYBackground: The projected role of hand-carried ultrasoundechocardiography (HCUE) is not to replace state-of-the-art FIGURE 1. Effect of HCUE on length of stay in relation to partici-standard echocardiography (SE) but instead to precede pants’ location, day of randomization, and indication for echocar-and, in some cases, obviate it with simple and routine diography. The overall treatment effect of HCUE-guided careassessments by frontline physicians. This seems possible compared with usual care is shown by the square at the top of thebecause in the hands of noncardiologists who have under-gone brief training programs, HCUE is accurate for the figure and the vertical solid line. For each subgroup, the square ismost common indications for SE referral. Yet beyond diag- proportional to the number of patients and represents the pointnostic accuracy studies, patient outcome data are sparse. In estimate of the treatment effect. The left and right edges of the hor-fact, although HCUE has become more widespread, there izontal lines represent the borders of the 95% CI for each pointare no randomized trials of noncardiologists applying estimate.HCUE-guided care to general medicine inpatients. Meth-ods: We performed an unblinded, parallel-group rando- HCUE and SE, hospitalists changed management due tomized trial between July 2008 and March 2009 at 1 HCUE in 37%. Despite the favorable diagnostic accuracyteaching hospital. We randomly assigned adult general of HCUE, most changes to the timing of hospital dischargemedicine inpatients referred for standard echocardiography occurred after SE. Conclusions: HCUE-guided care by hos-(SE) with HCUE-investigatable indications to usual care or pitalists for unselected general medicine patients does notcare guided by early HCUE for 6 cardiac abnormalities. meaningfully affect length of stay. Whether or not it affectsThe main outcome measure was length of stay on the refer- care quality remains unstudied.ring hospitalist’s service. Secondary outcomes included a Disclosures:before–after analysis of reported changes in management B. P. Lucas - none; C. Candotti - none; B. Margeta - none; B. Mba - none; R.due to HCUE and the diagnostic accuracy of HCUE. Even Kumapley - none; A. Asmar - none; R. Franco-Sadud - none; J. Baru - none; C.though participants were randomized as individuals, cluster- Acob - none; S. Borkowsky - noneing by hospitalists could affect our conclusions. Thus, forour primary outcome and subgroup analyses we con-structed post hoc multilevel models with random effects to 72adjust for heterogeneity between hospitalists. Results: Figure EMOTIONAL EXHAUSTION, LIFE STRESS, AND1 depicts the effect of HCUE on length of stay in relation to PERCEIVED CONTROL AMONG MEDICINE WARDparticipants’ location, day of randomization, and indication ATTENDING PHYSICIANS: A RANDOMIZED TRIALfor echocardiography. The difference in length of stay OF 2- VERSUS 4-WEEK WARD ROTATIONSbetween 227 participants randomized to HCUE-guided Brian Lucas, MD, MS, FHM1, William Trick, MD1, Arthurcare (geometric mean, 46.1 hours; IQR, 29.0–70.9 hours) Evans, MD, MPH2, Robert Weinstein, MD1, Anita Varkey,and 226 participants randomized to usual care (46.9 MD3, Jennifer Smith, MD1, Benjamin Mba, MBBS, MRCP1,hours; IQR, 34.1–68.3 hours) corresponded to a 1.7% Krishna Das, MD1, Peter Clarke, MD1, Suja Mathew, MD1; 1reduction in length of stay that was not statistically signifi- Cook County Hospital, Chicago, IL; 2New York Presbyteriancant (95% CI, 212.1% to 9.8%). In post hoc subgroup Hospital, New York, NY; ; 3Loyola University Medical Center,analyses, HCUE-guided care reduced length of stay in parti- Chicago, ILcipants referred for heart failure (P 5 0.0008). Multilevel Background: The duration of rotations for medicine wardmodeling to adjust for clustering by hospitalist did not affect attending physicians has declined. Whereas monthlongany conclusions from the primary outcome, including sub- ward rotations had been common, 2-week rotations aregroup effects. Among participants who underwent both now the norm. One driver for this change is the percep- Hospital Medicine 2011 Abstracts S43
    • TABLE 1 Effect of 2- Versus 4-Week Rotation Duration on Domains of Work- paired differences by attending and tested the signifi-Life Balance in Relation to Ward Attending Physician Type cance of these differences with the nonparametric Wil- coxon signed rank test. We used random-interceptWard Attending Emotional Life Perceived Control multilevel models to test for the heterogeneity of the effectPhysician Type Measure Exhaustion Stress in the Workplace of rotation duration between physician subgroups whileHospitalist (n 5 18) Overall summary score, 11.8 4.6 21.5 accounting for correlations within physician. Results: median Among 80 ward attending physicians from the Depart- Paired difference 20.3 0.6 20.2 ment of Medicine who staffed a general medicine ward (4-week - 2-week service during the duration of the study period, 62 physi- rotation), median cians staffed the service in both 2- and 4-week rotations P value for paired 0.7 0.1 0.8 and were therefore available for this paired analysis. differences Among them, 18 (29%) were hospitalists, and 44 (71%)Nonhospitalist (n 5 44) Overall summary score, 24.8 6.8 18.0 median were nonhospitalists. Data in Table 1 suggest that among Paired difference 6.8 1.0 21.5 all physicians emotional exhaustion and life stress were (4-week -2-week lower, whereas perceived control was higher after 2- rotation), median week rotations. These differences were more pronounced P value for paired 0.0001 0.0006 0.002 among nonhospitalists, but the heterogeneity of these dif- differences ferences by physician subgroups (the interaction term)All (n 5 62) Overall summary score, 22.0 6.0 19.0 reached statistical significance only for perceived control. median Conclusions: Shorter inpatient ward rotations improved Paired difference 4.5 0.8 20.6 (4-week - 2-week measures of work-life balance among attending physi- rotation), median cians. These effects were more pronounced among non- P value for paired 0.0001 0.0002 0.01 hospitalists. differences Disclosures:P value for interaction 0.2 0.5 0.006 B. P. Lucas - none; W. Trick - none; A. T. Evans - none; R. Weinstein - none; B. term hospitalist 3 Mba - none; J. Smith - none; A. Varkey - none; K. Das - none; P. Clarke - none; 4-week rotation S. Mathew - noneP values for paired differences are from nonparametric the Wilcoxon sign rank test. P values for 73interaction terms are from random-intercept multilevel models with summary scores as the depend- THE ECONOMIC IMPACT OF A BEDSIDEent variable and 4-week rotation (yes/no), hospitalist (yes/no), and the interaction term 4-week rota-tion 3 hospitalist as the independent variables. PROCEDURE TEAM FROM THE PERSPECTIVE OF A HOSPITALIST GROUP LEADER Brian Lucas, MD, MS, FHM1, Tricia Johnson, PhD2, Ricardotion that shorter rotations improve ward attending physi- Franco-Sadud, MD1, Stephen Shaw, MD3; 1Cook County Hos-cians’ work-life balance. Yet the psychological impact of pital, Chicago, IL; 2Rush University, Chicago, IL; 3Case Wes-the duration of inpatient rotations is unknown. Nor is it tern Reserve University, Cleveland, OHknown whether rotation duration has a different effect on Background: Despite fewer general internists performinghospitalists and nonhospitalists. Methods: We conductedthis randomized crossover trial on the general medicine central venous catheter (CVC) insertion, lumbar puncture,inpatient teaching service of a 450-bed public hospital paracentesis, and thoracentesis, the demand for these pro-during the 2009 academic year. We divided the inpati- cedures has not dropped. Because hospitalists are chargedent service of each attending physician who was sched- with the responsibility of coordinating inpatient care, theyuled for at least 6 weeks in a random sequence of 2- may be best equipped to ensure timely access to these pro-and 4-week rotations. On the last day of each 2- or 4- cedures, particularly because roughly half of bedside proce-week rotation, attending physicians completed a confiden- dures performed on general medicine inpatients aretial, self-administered questionnaire. We measured 3 needed off-hours. Yet little is known about the costs of adomains: life stress using 4 items from the Cohen Per- hospitalist-run bedside procedure team or the volumes ofceived Stress Scale, emotional exhaustion using 9 items procedures needed to support one. The objective of thisfrom the Human Services Survey of the Maslach Burnout study was to evaluate the cost of a hospitalist-run bedsideInventory, and perceived control in the workplace using procedure team compared with the cost without the bedside8 items from the Clinic Provider Survey of the Physician procedure team. Costs were compared for different combi-Worklife Study II. We generated summary scores for nations of procedures, different productivity thresholds, andeach domain by adding all items within each domain; various staffing models. Methods: We conducted a break-high scores reflected more emotional exhaustion, life even analysis to compare the revenue generated from astress, and perceived control. We then subtracted 2-week bedside procedure service with (1) the costs of hiring ansummary scores from 4-week summary scores to generate additional hospitalist to cover the incremental work asso-S44 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • 74 USE OF CLINICAL PREDICTORS INCREASE THE YIELD OF TELEMETRY MONITORING IN UNEXPLAINED SYNCOPE Mary Maher, MD, Richard Albert, MD, Angela Keniston, MSPH; Denver Health Medical Center, Denver, CO Background: Syncope accounts for 1%–2% of ED visits. His- tory, physical exam, and ECG establish the etiology of syn- cope about 50% of the time, but many patients are admitted for observation and telemetry monitoring seeking evidence of arrhythmias. The objectives of this study were to determine (1) the diagnostic yield of telemetry monitoring in unexplained syncope and (2) if the diagnostic yield canFIGURE 1. Break-even analysis for proceduralist versus hospitalist be increased by clinical predictors. Methods: We retrospec-productivity benchmarks, total relative value units (RVUs), and tively assessed 220 consecutive patients older than age 18number of procedures per day. Benchmarks are from the who were admitted to a university-affiliated, public safety-2007–2008 Society of Hospital Medicine Biannual Survey. Combi- net hospital with unexplained syncope. Patients with seizurenation procedure service includes 25% thoracentesis, 25% para- activity or neurologic events, those who were found downcentesis, 20% lumbar puncture, and 30% central venous catheter or had suffered mechanical falls, and those with near-syn-(CVC) insertions. cope were excluded, as were incarcerated patients and those with incomplete records. Patient data were collected from the electronic medical information database. Allciated with the bedside procedure service and (2) the reve- patients were monitored on telemetry from admission to dis-nue generated by a hospitalist who does not perform proce- charge. Telemetry was considered positive if it revealeddures. We specifically examined 4 bedside procedures: ventricular fibrillation, ventricular tachycardia, atrial fibrilla-CVC insertion, paracentesis, thoracentesis, and lumbar tion, atrial flutter, paroxysmal supraventricular tachycardia,puncture (LP). Productivity benchmarks from the Society of atrioventricular block, sinus pause, or symptomatic brady-Hospital Medicine were used to assess hospitalist productiv- cardia that resulted in a clinical intervention. Potential clini-ity. Results: The highest revenue-producing bedside proce- cal predictors were determined by using ICD-9 codes ofdure service would perform only CVC insertions, whereas discharge diagnoses. Ejection fraction (EF) was determinedthe lowest revenue-producing procedure service would per- from reviewing echocardiograms for all patients with anform only LPs, with other combinations of the 4 procedures ICD-9 code for congestive heart failure. Results: Only 8 offalling between these 2 extremes (Fig. 1). A local hospitalist 220 patients had clinically significant arrhythmias detectedgroup would need to perform 7 CVCs or 16 LPs per day to on telemetry monitoring (diagnostic yield, 3.6%). Thesebreak even, whereas an academic hospitalist group would included atrial tachyarrhythmias (n 5 3), ventricular tachy-need to perform 4 CVCs or 9 LPs per day. Including a medi- arrhythmias (n 5 3), and bradyarrhythmias (n 5 2). Multi-cal assistant in the procedure team would increase the variate analysis determined that age (OR, 2.3; P < 0.003)break-even number of procedures by 11%–19%, whereas and EF < 35% (OR, 21.9; P < 0.005) predicted telemetryincluding a registered nurse in the procedure team would events. The presence of either of these predictors increasedincrease the break-even number of procedures by the diagnostic yield to 10.8%. All 8 patients with arrhyth-24%–38%. Conclusions: The number of procedures needed mias detected by telemetry monitoring were older than 64to support a bedside procedure service depends on the years, and 3 had an EF < 35% (Table 1). The presence oftypes of procedures that the procedure service would per- coronary disease, diabetes mellitus, and hypertension wereform and the mix of procedures required by the patientpopulation. Because CVCs are the highest revenue-generat- TABLE 1 Clinical Predictors of Telemetry Events in Unexplained Syncopeing procedures, hospitalist groups should consider perform-ing these procedures at the bedside first. Employed and Negative Positiveacademic hospitalist groups could support a bedside proce- Predictive Predictive Sensitivity Specificity Value Valuedure service with approximately 1 procedure per hour if acombination of the 4 procedures is performed. EF < 35% 37.5% 97.7% 97.7% 37.5%Disclosures: (8.5%, 75.5%) (94.8%, 99.3%) (94.8%, 99.2%) (8.5%, 75.5%)B. P. Lucas - none; T. J. Johnson - none; R. Franco-Sadud - none; S. T. Shaw - Age > 64 100% 67.6% 100% 10.1%none years (63.1%, 100%) (60.9%, 73.7%) (97.5%, 100%) (4.5%, 18.9%) (95% confidence interval). Hospital Medicine 2011 Abstracts S45
    • not significant predictors. Prior arrhythmia and valvular dis- Good history, physical exam, vital signs, fluid status, andease occurred too infrequently to evaluate. Two patients urine analysis remain key in the diagnosis of cause of AKI,had life-threatening arrhythmias that resulted in death, and but FENa and FEUA may assist in early diagnosis. FEUAboth had an EF < 35% and were older than 64 years. may be a better tool that FENa in certain cases, and furtherConclusions: The yield of telemetry monitoring in unex- prospective studies need to be designed to validate this ret-plained syncope was low but could be markedly increased rospective analysis.by using simple clinical predictors. Disclosures:Disclosures: K. Malhotra - none; A. Bland - none; G. S. Nace - noneM. Maher - none; R. Albert - none; A. Keniston - none 7675 DEEP VEIN THROMBOSIS AND PULMONARYRETROSPECTIVE STUDY OF FRACTIONAL EMBOLISM: AWARENESS AND PROPHYLAXISEXCRETION OF URIC ACID IN ACUTE KIDNEY PRACTICES REPORTED BY RECENTLY HOSPITALIZEDINJURY PATIENTSKunal Malhotra, MD, Andrew Bland, MD, Gary Nace, MD; Greg Maynard, MD, MSc, SFHM1, Jack Ansell, MD2, Eliza-University of Illinois College of Medicine at Peoria, Peoria, IL beth Varga, MS, CGC3, Alan Brownstein, MPH4, RichardBackground: Acute kidney injury (AKI) is a common present- Friedman, MD, FRCSC5; 1UC San Diego, San Diego, CA; 2ing problem accounting for 1% hospital admission and also Lenox Hill Hospital, New York, NY; 3Columbus Children’sa major complication developing during in-hospital stay for Research Institute, Columbus, OH; 4National Blood Clot Alli-other reasons. Rapid identification and treatment of reversi- ance, Tarrytown, NY; 5Medical University of South Carolina,ble causes of renal failure may improve patient outcome, Charleston, SCreducing hospital and ICU stays and preventing progres- Background: Deep vein thrombosis (DVT) and pulmonarysion to established renal failure. Traditionally fractional embolism (PE) impose a major public health burden in theexcretion of sodium (FENa) is used to discriminate acute tu- United States, affecting an estimated 350,000–600,000bular necrosis (ATN) from prerenal causes, but there are individuals and accounting for approximately 100,000certain situations that render the FENa unreliable. In these deaths in the United States each year. Hospitalization is acircumstances, including diuretic use, a fractional excretion major risk factor for DVT/PE, with a 10-fold increased riskof uric acid (FEUA) can be measured, as it has been postu- for venous thromboembolism (VTE) among hospitalizedlated to be unaffected by diuretics. Currently, there is a patients with acute medical illness and about 1 in 10 hospi-paucity of data addressing the validity of using the FEUA in tal deaths related to PE. The goals of this study were toAKI. Methods: To further examine this question, we measure DVT/PE awareness among patients hospitalized >designed a retrospective chart review. After institutional 3 days and to identify barriers and gaps in evidence-basedreview board approval, charts were obtained from medical prophylaxis practices as reported by these patients. Meth-records of patients who had FEUA ordered. The study popu- ods: A survey was conducted among 500 adults, screenedlations were all adult patients of all races hospitalized at from an online research panel, who had been admitted toOSF St. Francis Medical Center who had AKI. Patients with a hospital for more than 3 days within 12 months of sam-postrenal causes and acute interstitial nephritis were pling. Results: Of the 500 patients surveyed, mean age wasexcluded. A total of 154 patients were grouped into prere- 52.5 yars (range, 20–801 years), and 64% were female.nal AKI and ATN based on final diagnosis. Final diagnosis Length of hospital stay totaled 3–4 days for 51%, 5–10 dayswas based on improvement in renal function within a week for 37%, and >10 days for 12%, with admissions for sur-or clinical documentation of recovery. The values of FEUA gery, 43%; major illness, 32%; accident/trauma, 11%; child-were then compared between the 2 groups. We also col- birth, 6% other, 21%. Among all respondents surveyed, 72%lected data on FENa when it was done. SPSS was used to (360) and 85% (425) had not heard of a condition calledrun independent-samples t tests to analyze the data. Results: DVT or PE, respectively, when these specific terms were used,Our lab reports FEUA < 12 as prerenal, 12–20 as indeter- even though 15% reported a personal history of a blood clotminate, and > 20 as ATN. An independent-samples t test in the leg or lung, and 43% said they had a family memberwas conducted to compare prerenal AKI and ATN cases, who previously had a blood clot in the leg or lung. Amongand there was a significant difference in scores for prerenal the 172 respondents who said they could name DVT risk fac-(mean, 7.7; SD, 5.4) and ATN (mean, 21.9; SD, 13.2); tors, 45% cited sitting for a long time, and 9% cited surgery.t12 5 23.8, P 5 0.002. These results show that FEUA is a Among the 109 respondents who could name DVT signs/good test to distinguish between prerenal AKI and ATN. symptoms, 42% cited swelling in the legs, 38% pain in theBecause it was a retrospective study, it did rely on the accu- legs, 23% skin redness/discoloration, and 22% skin beingracy of written records, and there was a lack of blinding. hot over the area. Of 103 respondents who said they couldWe double-checked the final diagnosis with improvement name PE signs/symptoms, 64% cited breathing difficulties,of renal function within days versus weeks. Conclusions: 36% chest pain/tightness, and 10% coughing up blood.S46 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • Among all respondents surveyed, 83% said that they knew 20 years screened from an online panel and admitted to awhat a ‘‘blood clot’’ was, and 99% recognized that blood hospital for more than 3 days within 12 months of sampling.clots can be life threatening. About half of all respondents The oncology group included 500 adults > 20 years(46%) reported that their doctor or health care professional screened from an online research panel and on active cancerdid not discuss the risk of DVT or blood clots related to hospi- treatment or with a cancer diagnosis or recurrence within 12talization. Fewer than one third of all respondents report DVT months of sampling. Results: Awareness of DVT/PE amongprophylaxis with either an anticoagulant pill or anticoagulant hospitalized and oncology groups was similar to awarenessinjection. DVT prophylaxis reported by respondents included: levels seen among the general public or national sample:63%, ambulation; 39%, compression stockings; 37%, me- 28% of hospitalized patients and 24% of oncology patientschanical compression; 37%, aspirin; 29%, anticoagulant said they had heard of a medical condition called DVT usinginjection; 28%, anticoagulant pill. Conclusions: Despite a sig- this specific term, compared with 21% of the national sample;nificantly increased risk of DVT/PE and a high reported per- 15% of both the hospitalized and oncology groups said theysonal and family history of blood clots, awareness of the had heard of a medical condition called PE using this specificspecific terms DVT and PE and familiarity with DVT/PE risk term, compared with 16% of the national sample. Amongfactors is low, but awareness of the term blood clot is high. national respondents aware of what a deep vein thrombosisInterventions in the hospital setting are needed to improve is (n 5 206), more than half (53%) said they could namepatient understanding and awareness to optimize DVT pro- DVT risk factors. In comparison, among hospitalized (n 5phylaxis and to reduce the related incidence of morbidity 269) and oncology patients (n 5 254) aware of what aand mortality associated with DVT/PE among hospitalized deep vein thrombosis is, more than 6 in 10 said they couldpatients. name DVT risk factors. Fewer than half of hospitalizedDisclosures: patients who could name DVT risk factors (45%) cited ‘‘sittingG. Maynard - none; E. Varga - none; J. Ansell - Bayer, Ortho McNeil, Bristol for a long time’’ as a risk factor, and 9% cited surgery. OfMyers Squibb, Pfizer, Boehringer Ingelheim, Portola, Daiichi, ITC, Hemo- oncology patients who could name DVT risk factors, 8% citedSense, Roche, Instrumentation Laboratories, consultant; Sanofi-Aventis, speak-ers bureau; A. Brownstein - Ortho-McNeil, Bristol-Myers Squibb, Eisai, surgery, and 1% cited some cancer treatment as a risk factor.GlaxoSmithKlline, Talacris Biotherapeutics, Lundbeck, Boehringer Ingelheim, Among hospitalized and oncology patients able to nameHemoSense, QAS, Roche, Alexion Pharmaceuticals, Compression Manage- DVT risk factors, 63% in each group said they could namement Services, ITC, Sanofi Aventis, research support; R. Friedman - Johnsonand Johnson, DJO Surgical, Pfizer, Boehringer Ingelheim, consultant; Astellas DVT signs/symptoms, which is significantly fewer than theUS, Boehringer Ingelheim, research support 79% of national respondents able to name DVT risk factors after indicating they could name DVT signs/symptoms. About 1 in 3 of all respondents who said they knew what PE stands77 for or what a PE is said they could name PE signs/symptoms.DVT/PE AWARENESS AMONG AT-RISK HOSPITAL Conclusions: Despite increased risks, hospitalized and oncol-PATIENTS AND AT-RISK ONCOLOGY PATIENTS ogy patients do not demonstrate significantly greater aware-COMPARED WITH DVT/PE AWARENESS AMONG ness of DVT/PE than the general public. DVT/PETHE GENERAL PUBLIC information/awareness interventions should target the general public, with special emphasis on at-risk patients.Greg Maynard, MD, MSc, SFHM1, Jack Ansell, MD2, Eliza- Disclosures:beth Varga, MS, CGC3, Alan Brownstein, MPH4, RichardFriedman, MD, FRCSC5; 1UC San Diego, San Diego, CA; G. Maynard - none; E. Varga - none; J. Ansell - Bayer, Ortho McNeil, Bristol2 Myers Squibb, Pfizer, Boehringer Ingelheim, Portola, Daiichi, ITC, Hemo- Lenox Hill Hospital, New York, NY; 3Columbus Children’s Sense, Roche, Instrumentation Laboratories, consultant; Sanofi Aventis,Research Institute, Columbus, OH; 4National Blood Clot Alli- speakers bureau; A. Brownstein - Ortho-McNeil, Bristol-Myers Squibb, Eisai, GlaxoSmithKlline, Talacris Biotherapeutics, Lundbeck, Boehringer Ingelheim,ance, Tarrytown, NY; 5Medical University of South Carolina, HemoSense, QAS, Roche, Alexion Pharmaceuticals, Compression Manage-Charleston, SC ment Services, ITC, Sanofi Aventis, research support; R. Friedman - Johnson and Johnson, DJO Surgical, Pfizer, Boehringer Ingelheim, Consultant; AstellasBackground: Deep vein thrombosis (DVT) and pulmonary em- US, Boehringer Ingelheim, research supportbolism (PE) impose a major public health burden, affectingup to 600,000 individuals and accounting for approximately100,000 deaths in the United States each year. There is a 7810-fold increased risk for DVT/PE among hospitalized A SURVEY OF DEMOGRAPHICS, EMPLOYMENTpatients and up to a 6-fold increased risk for DVT/PE among SETTINGS, AND SCOPE OF PRACTICE OFoncology patients. The goal of this study was to compare HOSPITALISTS TRAINED IN FAMILY MEDICINEDVT/PE awareness between the general public and at-riskhospitalized and oncology patients. Methods: A national Shauna McElrath, DO, Claudia Geyer, MD, FHM, John Dick-DVT/PE awareness survey was conducted among a represen- ens, MD, MPH, SFHM; Central Maine Medical Center, Lewis-tative cross-section of 500 adults > 20 years old participating ton, ME; Central Maine Medical Center, Lewiston, ME; Centralin online research panels. For comparison, the same survey Maine Medical Center, Lewiston, MEwas conducted among hospitalized patients and oncology Background: Physicians trained in family medicine repre-patients. The hospital patient sample included 500 adults > sent a growing population of hospitalists in the United Hospital Medicine 2011 Abstracts S47
    • States. Based on the 2007–2008 Society of Hospital Medi- TABLE 2 Scope of Practice of Hospitalists Trained in Family Medicine Ques-cine (SHM) annual survey, hospitalists trained in family tionnaire Respondentsmedicine made up 3.7% of U.S. hospitalists. However,2010 SHM membership data report 6.9% of SHM physi- Inpatient Medicine No. (%)cians are trained in family medicine. Despite this rapid rate Adult 79 (97.5)of growth, there is a lack of information currently available Pediatric 17 (21)regarding characteristics and practice patterns of these phy- Adult and Pediatric 17 (21)sicians. Methods: Family medicine physicians registered Obstetrics 6(7.4)with the Society of Hospital Medicine were e-mailed an Inpatient Medicine Dutieselectronic questionnaire through Zoomerang Online Survey Average daily census (patients/hospitalist) 15.7Software. Results: Eighty-one of the 263 physicians con- Admissions, rounding, discharges 80 (98.7)tacted completed the survey, for a return rate of 31%. The Consultative Services 71 (07.7)majority of respondents (51%) had completed their resi- Emergency Department Shift Coverage 10 (12.3)dency training in excess of 10 years ago, although the lar- Provide critical care in the ICU 66 (01)gest single group of respondents (37%) fell in the category Pressor management 63 (77.8) Ventilator Management 39 (59)of 6–10 years since residency completion (Table 1). The Use of Pulmonary Artery Catheter 9 (11.1) Procedures Lumbar puncture 58 (71.6)TABLE 1 Characteristics of Hospitalists Trained in Family Medicine Question- Central line placement 48 (59.3)naire Respondents Para centesis 46 (56.7) Arthro centesis 43 (53.1)Demographics No.(%) Thoracentesis 37 (45.7) Outpatient Medicine Family Medicine Trained 81 (100) Any Outpatient 23 (28.4) Male 64 (09) Adult Outpatient 18 (22.2) Average Age (yrs.) 45.7 Pediatrics Outpatient 14 (17.3) MD Degree 70 (06) Obstetrics Outpatient 4 (4.9) Full Time Employment 78 (96) Administrative and Leadership Roles Additional Training, Certificates, Fellowships 22 (27) Lead hospital or SHM committees 32 (40)Years Since Residency Participate in hospital or SHM committees 57 (70) 1–5 yrs 10 (12.3) Family Medicine Residency Faculty 20 (25) 6–10 yrs 30 (37.0) Residency Director 2(2.5) 11–15 yrs 12 (14.8) Non-faculty teaching role 40 (49.4) 16–20 yrs 16 (19.8) Administrator (Group Director, medical 41 (51) 20 1yrs 13 (16.1) staff president or department chief)Years as a hospitalist 1–5 yrs 35 (43.2) 6–10 yrs 35 (43.2) 11–15 yrs 7(8.6) 16–20 yrs 2(2.5) majority of these physicians are hospital employees who 20 1yrs 2 (2.5) practice full-time, with an average daily census of 15.7Region patients. In addition to the 97.5% of respondents who pro- NorthEast 12 (14.8) vide adult inpatient medical care, 66% provide critical care South 23 (28.4) in the intensive care unit. Twenty-one percent of doctors MidWest 16 (19.8) also provide inpatient pediatric care, and 28% provide out- West 27 (33.3) patient care. Seventy percent of respondents are involved Canada 3(3.7) in SHM or hospital committees,, and 40% serve as leadersEmployment Model in these roles. Finally, 25% of respondents are residency Academic Institution 18 (22) faculty, including 2 residency directors, and a total of 77% Hospital employed 27 (33) Private Practice Group 15 (19) of all respondents are involved in some aspect of medical Hospitalist Management Company 7(9) education (Table 2). Conclusions: The hospitalists who Multi-specialty group 9(11) responded to this survey are an experienced group of phy- Other 5(B) sicians who practice in a variety of hospital settings acrossHospital bed capacity the country. The majority perform primary and consultative <50 5(6.2) inpatient medicine including critical care. Uniquely, a sig- 50–100 8 (9.9) nificant number also offer pediatric and outpatient services. 101–200 18 (22.2) In addition to their clinical roles, these physicians partici- 201–400 29 (35.8) pate in committee work and have leadership positions. 4001 21 (25.9) Finally, with a remarkable number of respondents involvedS48 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • in medical education, these hospitalists are playing a vital TABLErole in the training of future physicians.Disclosures: GV N Mean SD Mean CV LOS Readmit BG < 70 BG > 300 DiabetesS. McElrath - none; C. Geyer - none; J. Dickens - none High 8 79.95 2.4 6.5 37.5% 50% 63% 100% Moderate 10 53.79 3.4 6.7 20% 10% 30% 80% Low 23 33.78 5.4 6.6 35% 9% 17% 61%79HIGH GLYCEMIC VARIABILITY ANDHYPOGLYCEMIA IN PATIENTS WITH DIABETESAND SEPSIS IN A NON–CRITICAL CARE SETTING: sample size, this study shows increased GV (high SD and CVCAN WE PREDICT HYPOGLYCEMIC EVENTS? < 3) to be associated with increased hypoglycemia. Hospital-Renee Meadows, MD, Nicole Fabre-LaCoste, PharmD, Anita ists should consider glycemic variability a risk factor for, andKoshy, PharmD, Samuel Andrews, MD; Ochsner Health Sys- potentially predictive of, hypoglycemia in patients with diabe-tem, New Orleans, LA tes and sepsis admitted to general medical units. Disclosures:Background: Believed related to oxidative stress, the long-term R. Y Meadows - none; N. Fabre-LaCoste - none; A. Koshy - none; S. S.effects of glycemic variability (GV) are associated with progres- Andrews - nonesion of microvascular complications in diabetics. Short-termeffects on increased mortality have been shown in nondiabetic,critically ill patients. The severity of sepsis correlates with hyper- 80glycemia and severe hypoglycemia. Hypoglycemia is more CYSTATIN C LEVELS AND AGE MAY PREDICTcommon in diabetics with increased GV, suggesting a role for SUCCESSFUL ATTENUATION OF HORMONALGV in the prediction of severe hypoglycemia. Continuous glu- ACTIVATION IN HEART FAILURE PATIENTScose measurement for the mean amplitude of glycemic excur- Henry Michtalik, MD, MPH, Hsin-Chieh Yeh, PhD, Catherinesion is not practical for the majority of hospitalized patients. Campbell, MD, Nowreen Haq, MD, MPH, Haeseong Park,This study characterized the effects of GV on morbidity and MD, MPH, William Clarke, PhD, MBA, Daniel Brotman, MD;mortality in patients with sepsis for the purpose of predicting Johns Hopkins University School of Medicine, Baltimore, MDhypoglycemia via routine blood glucose (BG) monitoring.Methods: This was a retrospective cohort study in an academic Background: Initial treatment of heart failure is empiric andtertiary-care hospital. Subjects were selected from 470 adults requires frequent monitoring and medication adjustment.consecutively admitted to non–critical care units during 2009 Predicting which patients require more intensive treatmentwith a primary diagnosis of septicemia and secondary diagno- may improve outcomes and decrease hospital length ofsis of hyperglycemia. Exclusion criteria were length of stay stay. Cystatin C, a novel marker for renal function, has(LOS) < 72 hours or > 14 days; treatment with insulin infusion been studied for its prognostic value in heart failure but notor corticosteroids diagnosis of diabetic ketoacidosis, hyperos- in predicting treatment response. Our study examinecmolar state, end-stage liver disease, or pregnancy; creatinine whether the level of cystatin C at hospital admission and> 3 mg/dL or CrCl < 30 mL/min; and lack of SIRS criteria on age are associated with successful attenuation of N-terminaladmission. Forty-one patients, with a mean age of 65 years pro-B-type natriuretic peptide (NT-proBNP), a biomarker of(range, 36–91 years), met inclusion criteria. GV was measured ventricular distention and overload. Methods: Data wereby averaging the first 10 BG measurements taken routinely by analyzed from a cohort of 165 consecutive patients ! 25point-of-care testing during the first 48 hours of hospitalization, years with a baseline creatinine 1.5 mg/dL who werethus capturing fasting and interprandial glucose excursions. admitted to an urban tertiary-care hospital from June 2006The standard deviation (SD) and coefficient of variation (CV) of to April 2007 with a primary diagnosis of heart failure andthe BG values were obtained for each subject. CV (SD cor- received intravenous furosemide. Creatinine, cystatin C,rected for BG mean) was used as the marker for increased indi- and NT-proBNP levels were measured at admission. NT-vidual GV. Outcomes measured were mortality, hyperglycemia proBNP was also measured at discharge. Demographic in-(BG > 300), hypoglycemia (BG < 70), severe hypoglycemia formation was collected. We prospectively defined the pri-(BG < 40), LOS, transfer to ICU, and 30- and 60-day readmis- mary outcome as odds of successful attenuation of NT-sions. Results: Results were grouped into statistically significant proBNP levels, defined by a decline ! 50% from admis-GV ranges (P 5 0.0001) for analysis representing high, mod- sion. We have previously shown that improvement in NT-erate, and low GV (see Table). None of the 41 patients died, proBNP of <50% during an acute hospitalization is asso-were transferred to the ICU, or suffered severe hypoglycemia. ciated with an increased hazard of readmission/death.Readmission rates and LOS were higher than those for other Logistic regression adjusted for potential confounders, andmedicine patients but did not significantly differ among groups. log-likelihood ratio testing examined interactions betweenHypoglycemia occurred over 5 times more frequently in cystatin C and the other covariates. Results: After excludingpatients with high GV. Patients with the greatest GV were pre- patients with incomplete medical records (n 5 5), our studyviously diagnosed with diabetes. Conclusions: Limited by small sample was 44% male and 69% nonwhite, with a mean Hospital Medicine 2011 Abstracts S49
    • age Æ SD of 63 Æ 15 years, median admission creatinine impact of average census on process and outcome meas-of 1.1 mg/dL (IQR, 0.9, 1.3 mg/L), median admission ures using a Likert scale ranging from 1 5 never/definitelycystatin C of 1.08 mg/L (0.82, 1.38 mg/L), median admis- not to 5 5 very often/definitely. Results: Of the 890 physi-sion NT-proBNP of 4270 pg/mL (1140, 8180 pg/mL), cians contacted, 506 (57%) responded. Five (1%) wereand median discharge NT-proBNP of 1626 pg/mL (498, excluded for not completing the survey. Physicians had an5221 pg/mL). Seventy-two patients (45%) and 88 patients average age of 38.3 Æ 8.4 years and were in practice for(55%) had a decline ! 50% or < 50% in NT-proBNP, a median of 6 years (IQR, 3, 10 years). The majority identi-respectively. After adjustment for age, sex, race, and fied their primary practice area as adult (77.8%), pediatricadmission creatinine level, the odds of successful attenua- (1.2%), or combined medical/pediatrics (1.6%) hospitaltion of NT-proBNP decreased by 55% for each 1 mg/L medicine. Physicians practiced in urban (46.4%), suburbanincrease in admission cystatin C (OR, 0.45; 95% CI, (42.5%), and rural (11.1%) settings and primarily as part0.20–1.00; P 5 0.05). For patients ! 50 years, odds of of a community hospital (54%), academic teaching hospitalsuccessful attenuation decreased by 4% per additional year (27.9%), or private group (11.7%). Forty percent of physi-of age, independent of sex, race, creatinine, and cystatin cians reported that their typical inpatient census exceededC (OR, 0.96; 95% CI, 0.93–0.99; P 5 0.01). Race, sex, safe levels at least monthly and 36.1% of these reported aadmission creatinine, and age < 50 years were not signifi- frequency greater than once per week. When the averagecantly associated with odds of attenuation. No significant actual workload was compared to the perceived safe work-interaction between cystatin C and age, race, sex, or creat- load, 40.1% of physicians exceeded their own reportedinine level was found. Conclusions: In heart failure patients safe level. Physicians reported that their patient load oftenwith normal admission creatinine, increasing admission (!4/5) led to incomplete patient/family discussionscystatin C and advanced age are associated with a (24.6%), ordering potentially unnecessary tests or proce-decrease in attenuation of NT-proBNP. Admission cystatin dures (22%), delaying admitting or discharging patientsC level may be an independent predictor for successful until the next shift or day (21.5%), cross-covering (20.3%)attenuation of hormonal activation and useful in identifying or caring (16.5%) for too many patients, worsened patientheart failure patients requiring more intensive treatment, satisfaction (19.3%), poorer hand-offs (17.9%), increasedmonitoring, and follow-up. 30-day readmission (14%), worsened overall quality ofDisclosures: care (12.4%), failure to promptly act on critical findingsH. Michtalik - none; H. Yeh - none; C. Campbell - none; N. Haq - none; H. Park (9.8%), and treatment errors (6.5%). With respect to- none; W. Clarke - none; D. Brotman - Siemens Healthcare Diagnostics, adverse events, physicians reported that workload hasresearch funding likely (!4/5) caused transfers to higher levels of care (9.8%), morbidity/complications (6.9%), mortality (0.6%), and incident reports (5.7%). Conclusions: Forty percent of hospitalists reported an unsafe workload at least monthly.81 More than 20% of hospitalists reported the workload hasIMPACT OF WORKLOAD ON PATIENT SAFETY often caused incomplete patient discussions, unnecessaryAND QUALITY OF CARE: A SURVEY OF AN tests and procedures, admission/discharge delays, and ex-ONLINE COMMUNITY OF HOSPITALISTS cessive cross-coverage. Hospitalist workload may beHenry Michtalik, MD, MPH1, Peter Pronovost, MD, PhD1, Brian adversely affecting patient safety and quality of care andDriscoll, BA2, Michael Paskavitz, BA2, Daniel Brotman, MD1; should be further explored.1 Johns Hopkins University School of Medicine, Baltimore, MD; Disclosures:2 Quantia Communications, Waltham, MA H. Michtalik - none; P. Pronovost - none; B. Driscoll - Quantia Communications, managing editor; M. Paskavitz - Quantia Communications, editor-in-chief; D.Background: Studies of the impact of provider workload on Brotman - Quantia Communications, consultantpatient safety and quality of care have primarily focused onnurses and resident physicians, but not hospitalists. Weexamined the relationship between workload and patient 82safety and quality via a survey of an online community of DECREASING BARRIERS IN PREVENTION OFhospitalists. Methods: We electronically surveyed 890 self- HOSPITAL-ACQUIRED Clostridium difficile COLITISidentified hospitalists enrolled in QuantiaMD.com, anonline physician community that provides continuing medi- Susanne Mierendorf, MD, MS, FHM, Michele Rushton, MD;cal education and a national discussion forum. Participants Kaiser Permanente Medical Center, Santa Clara, CAreceived a secure e-mail link to the online survey and were Background: Nearly all hospital-acquired infections are pre-awarded $10 at completion. The survey queried physician ventable. There has been at least a twofold increase in hos-and practice characteristics, workload, frequency of an pital-acquired Clostridium difficile–associated diarrhea (HA-unsafe census, and what a ‘‘safe’’ workload would be in CDAD) across the country. Hospitalized patients withhis/her setting. ‘‘Safe’’ was defined as ‘‘with minimal CDAD can have 3 times the length of stay and 4.5 timespotential for error or harm.’’ Physicians also rated the the death rate. CDAD is an enteric pathogen often seen inS50 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • and water, and bleach. Early detection or suspicion of the possibility of HA-CDAD helped prevent the spread by early isolation. Also readily available was disposable personal equipment. This decreased the chances of spread to other patients by fomites. The nursing education to visitors was also helpful. Previous antimicrobial therapy is a well-estab- lished risk factor for HA-CDAD and was not addressed in this study. Other challenges include human complacency. Our study highlights the extreme importance of education in getting all hospital health care workers on board with proper infection control to potentially significantly affect the incidence and spread of hospital-acquired infections. Disclosures: S. Mierendorf - none; M. Rushton - none 83 POSTDISCHARGE ISSUES AND NURSING INTERVENTIONS: A CASE SERIES OF FOLLOW-UP PHONE CALLS AFTER HOSPITAL DISCHARGE Michelle Mourad, MD, Ellen Kynoch, RN, Sumana Kesh, MD,patients shortly after a course of antibiotics or in hospita- Stephanie Rennke, MD; University of California, San Francisco,lized patients. Spores can survive up to 70 days and be San Francisco, CAcarried to another hospitalized patient. In our institution, Background: Posthospitalization phone calls have been pro-we noticed multiple impedances to improving this situation posed as a means to reduce postdischarge adverse events,such as confusing signage, unavailability of personal pro- increase patient satisfaction, and reduce costly return visitstective equipment (PPE), and ignorance regarding the to the hospital. Some programs have utilized hospital-basedinadequacies of alcohol gels. Methods: Several measures nurses to provide follow-up calls, but the outcomes of thesewere undertaken to decrease the rate of this infection, most interventions have not been well described. Methods: Afterimportantly, an electronic educational module for all health a 3-month pilot on a single unit, 4 bedside nurses begancare workers who have patient contact. This reiterated con- calling all patients discharged home from the medicine ser-tact precautions with gown and gloves, soap and water for vice at a large academic medical center. All patientshand washing, and bleach for disinfecting. Any patient received 2 phone call attempts within 72 hours of leavingwith possible infectious diarrhea had their own room with the hospital. Nurses followed a standard script to addressdisposable stethoscope, pulse oximetry, and blood pressure patient questions and concerns and worked to troubleshootcuff. There was a designated place in the room for PPE. issues arising after hospital discharge. Their findings wereThere was nursing education to patient, family, and visitors. documented in a templated note in the electronic medicalThe precaution signage was changed to ‘‘CONTACT record. If an intervention was required, nurses performedPLUS’’ precautions with simple pictorial instructions. Results: and documented a second follow-up call to assess the suc-We measured the absolute number of new cases and num- cess of their intervention. Notes were audited for areas ofber of cases/10,000 patient-days before and after our nursing intervention including discharge or medicationinterventions in 2 quarters of 2008 and compared them instructions, discharge prescriptions, follow-up appoint-with postintervention corresponding quarters in 2009. The ments, and home care (services and supplies). Results: Dur-first 2 quarters were 13.8 and 13.3 in 2008, which went ing the 5-month audit, the nurses made 933 phone callsdown to 9.18 and 8.00 in 2009 (postintervention), which and reached 699 patients and caregivers (70%). Anwas statistically significant (see Fig. 1). Conclusions: Con- instructional message with follow-up appointments and con-sistent and simplified standardized precautions significantly tact instructions was left for an additional 142 patientsdecreased the rate of HA-CDAD infection in our institution. (15%). In total the nurses intervened on 454 issues on 316This study was able to decrease the incidence of HA-CDAD patients (45%). Of the 158 patients (23%) with questionsin the face of a rapid, national increase. Probably the most regarding discharge instructions, nurses clarified generalimportant intervention was the brief educational module discharge instructions for 26 patients (16%) and medicationthat was mandatory for all hospital employees with patient instructions for 90 (57%), contacting a physician or phar-contact. Housekeeping learned that daily environmental macist in the remaining 42 cases (27%). In 87 patientscleaning with bleach was necessary. The previous confus- (12%) with new or ongoing symptoms, nurses were able toing precaution signage was changed to a consistent color independently triage 59 patients (67%) to home health pro-and was pictorial for easy reminders of gown, gloves, soap viders, appointments with outpatient physicians and Hospital Medicine 2011 Abstracts S51
    • TABLE 1 Areas of Nursing Intervention in Postdischarge Phone Calls pharmacists oversaw dosing and arranged nutrition consults and patient education when needed. Methods: We evalu-Patients not aware of any follow-up appointments 167 (24%) ated the intervention by selecting patients admitted to theNurses informed patients of existing appointments 47 (28%) PACU who had 2 or more daily glucose point-of-care testsNurses called clinics and obtained expedited appointments 28 (17%) (POCTs) perioperatively during a 12-month preimplementa-Nurses confirmed that appropriate clinics had received the referral 84 (50%) tion and a 12-month postimplementation period beginningNurses told patient to call PMD as needed 8 (5%)Patients with issues filling prescriptions 49 (7%) after a 6-month ramp-up period. Our population excludedNurses reinforced the importance of taking the prescription to pharmacy 20 (41%) cardiac surgery patients and critically ill postoperativeNurses contacted a pharmacist for insurance authorization 21 (43%) patients who are directly admitted to our intensive careNurses contacted physicians to correct prescription errors/lost prescriptions 8 (16%) units. Using this pre–post observational study design, wePatients with issues obtaining home care or equipment* 21 (12%) extracted electronic medical record data to assess processNurses called case management or agency to confirm service 17 (77%) measures of glycemic control and hypoglycemia and out-Patient declined home services or equipment 5 (33%) come measures of utilization. We used multivariate model- ing to assess the efficacy of the GCT intervention adjusting* Percentage only applies to the 175 patients receiving home care. for age, sex, race, economic status, Charlson comorbidity, length of stay (LOS), surgery type, and prior 12-monthurgent/emergency care, contacting hospitalists for only 28 health care utilization. Results: Defining good glycemic con-patients (32%). Other issues were resolved as described in trol as having capillary blood glucose between 70 andTable 1. Conclusions: The majority of issues surrounded fol- 180 mg/dL (allowing 1 value to fall outside range daily),low-up appointments, discharge and medication instruc- we demonstrated significant improvements in patient care,tions, and symptom management. Nurses intervened as exemplified in the run chart demonstrating postoperativefrequently, independently managing the majority post- day 1 glycemic control. Overall, the percentage of patientsdischarge issues, with low rates of physician and pharma- with good glycemic control on postoperative days 1–3cist contact. Contrary to previous published reports, the increased from 75.7% pre (n 5 1371 patients) to 86.8%need for more specialized providers was low. Nursing suc- post (n 5 5253), P < 0.0001, and hypoglycemia (definedcess at independently managing the majority of issues sug- as any POCT < 70) was reduced from 9.1% to 4.5%, P <gests that well-resourced nurses can provide a wide range 0.0001. Utilization measures improved including reducedof postdischarge interventions and may be a cost-effective all-cause 90-day hospital readmission from 14.9% toalternative to more specialized providers. 11.1%, P 5 0.0006, and 90-day emergency departmentDisclosures: (ED) visits from 25.1% to 18.1%, P < 0.0001. AdjustedM. Mourad - none; S. Rennke - none; S. Kesh - none; E. Kynoch - none odds ratio from multivariate modeling demonstrate sus- tained significant improvements for the glycemic measures and utilization outcome measures as shown in Table 1.84PHARMACIST GLYCEMIC CONTROL TEAMIMPROVES GLYCEMIC CONTROL AND REDUCES TABLE 1 Multivariate Logistic Regression Analysis of Pre- and PostglycemicHOSPITAL READMISSIONS IN NON–CRITICALLY ILL Control Team ImplementationSURGICAL PATIENTS Postimplementation GCT Vs.Karen Mularski, MD1, Richard Mularski, MD, MSHS, MCR2, PreimplementationCynthia Yeh, PharmD2, Jaspreet Bains, PharmD2, Ariel Hill, Outcome Measure Odds Ratio (95% CI) P valueMS2, David Mosen, PhD, MPH2; 1Northwest Permanente, Port-land, OR; 2Kaiser Permanente Northwest, Portland, OR Glycemic control measuresBackground: Perioperative hyperglycemia is a risk factor Good glycemic control, day 1 (n 5 6514) 3.89 (2.630, 3.629) <0.0001for increased morbidity and mortality. Improved glycemic Good glycemic control, day 2 (n 5 3004) 1.711 (1.397, 2.095) <0.0001 Good glycemic control, day 3 (n 5 2116) 1.213 (0.965,1.526) 0.0980control has been demonstrated to reduce surgical site infec- Hypoglycemia (any POCT < 70), 0.601 (0.481, 0.751) <0.0001tions and reduce perioperative morbidity and length of days 1–3 (n 5 2063)stay. However, safe and effective glycemic control in transi- Utilization outcome measurestion from the postanesthesia care unit (PACU) can be lim- Wound-infection-related readmission, 0.586 (0.357, 0.963) 0.0348ited by expert clinician availability. We implemented and 90 days postdischarge (n 5 6566)evaluated a protocol-driven and pharmacist-staffed glycemic All-cause hospital readmissions, 0.636 (0.525, 0.770) <0.0001control team (GCT) at the main hospital within a large inte- 90 days postdischarge (n 5 6566)grated health maintenance organization. All surgical All-cause ED visits, 90 days 0.668 (0.572, 0.780) <0.0001patients with dysglycemia were eligible, but the team only postdischarge (n 5 6566)intervened on a consultation basis. The protocol targeted Mortality outcome measure All-cause mortality, 90-days 0.890 (0.610, 1.297) 0.5436optimizing glycemic control using intravenous or subcuta- postdischarge (n 5 6566)neous basal-bolus dosing of insulin as appropriate. TheS52 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • tracked. The surveys recorded admitting diagnoses, code sta- tus, reasoning behind the use of telemetry, cardiac history, recalled telemetry events, and management changes in response to events. Results: Sixty patients were tracked dur- ing the study period. Fifty-eight percent had no cardiac his- tory and 22% were DNR/DNI. The most often cited reason for telemetry monitoring was early detection of clinical dete- rioration. The top 3 new arrhythmias detected on telemetry were: nonsustained VT or PVCs, sinus bradycardia, and sinus tachycardia. One patient developed new atrial flutter. One patient became dyspneic while on monitoring and was found to have developed rapid atrial fibrillation and sustained ven- tricular tachycardia. This patient was transferred to the ICU. The most common management change in response to telemetry monitoring was the administration of IV fluids. Conclusions: Our results suggest that telemetry monitoring usually detects non-life-threatening arrhythmias and that moreThe glycemic control team ramp-up period was January–June 2009, serious arrhythmias may be detected just as often usingwith full implementation occurring in July 2009. prompting from symptoms and vital signs alone. Thus, EKG telemetry monitoring may be of less value in medicineConclusions: Implementation of a pharmacist team available patients than current practice suggests.to manage glycemic control in hospitalized postoperative Disclosures:patients led to safer and better quality of care, as measured N. Najafi - none; A. Auerbach - noneby improved glycemic control and less hypoglycemia. Wefurther demonstrated reductions in all-cause hospital read-missions, ED visits, and readmissions for wound infection. 86Disclosures: UTILITY OF ANION GAP AS A PREDICTOR OFK. Mularski - none; D. Mosen - none; C. Yeh - none; R. Mularski - none; A. Hill - LACTIC ACIDOSIS IN PATIENTS IN THEnone; J. Bains - none EMERGENCY DEPARTMENT Susie Namo, MD, Karen Olarte-Merida, MD, Waqas Qureshi, MD, Niki Hector, MD, Gregory Buran, MD; Henry Ford Health85 Systems, Detroit, MIUSE OF ELECTROCARDIOGRAPHIC TELEMETRY Background: Lactic acid is a marker of life-threatening ill-MONITORING ON A MEDICINE SERVICE ness, and any delay between recognizing an increasedNader Najafi, MD, Andrew Auerbach, MD, MPH; University level and initiating treatment may be dangerous. The pre-of California, San Francisco, San Francisco, CA sence or absence of an anion gap (AG) has classicallyBackground: Guidelines for the use of EKG telemetry moni- been used as a screening tool for lactic acidosis. Priortoring for inpatients with cardiac diagnoses, such as myocar- studies of the reliability of AG as a screening tool in thedial infarction, are provided by the American Heart emergency department (ED) setting have produced con-Association. However, no guidelines exist for its use specifi- flicting results. We sought to determine the value of thecally in patients with medical diagnoses, such as renal failure AG for detecting the presence of lactic acidosis in adultsor pulmonary embolism. This is in large part due to the pau- presenting to the ED. Methods: The authors conducted acity of data on the use of telemetry in this population. This ex- retrospective cohort study over a 24-month period on sub-pensive and resource-consuming technology is currently used jects 18 years or older presenting to the ED. The AGon a medicine service without a clear understanding of its was calculated from initial basic chemistry panel with lac-benefit. Methods: Over the course of 3 weeks in July 2010 at tate levels drawn within 1 hour of the electrolytes. Re-the University of California, San Francisco Medical Center, ceiver operating characteristic (ROC) curves were createdall new admissions to the medicine service with EKG teleme- using AG versus lactate level with abnormal lactate var-try monitoring were logged. Each day the telemetry techni- iously defined as 2.5 and 4.0 mmol/L. The area undercian was asked for the names of the patients who were the curve (AUC) was calculated, and Youden’s index wasadmitted or discharged from telemetry as well as the past 24 used to determine the optimal AG cut point for detectionhours of telemetry events for all patients in the log. Surveys of an abnormal lactate level. Finally, 2 3 2 tables usingwere then administered to house staff on the day of admis- the optimal AG were used to calculate sensitivity, speci-sion and day of discharge for all patients that were being ficity, positive predictive value (PPV), and negative predic- Hospital Medicine 2011 Abstracts S53
    • tive value (NPV) for 2 levels of abnormal lactate. Results: TABLE 1 DemographicsA total of 13,456 patients were included in the study.AUC was 0.82 for a lactate cutoff of 2.5 mmol/L and All Patients, CSAy (%), FNS{ (%),0.90 for a lactate cutoff of 4.0 mmol/L. The optimal cut n 5 766 n 5 61 (8) n 5 45 (6)point for AG appeared to be 12 for both definitions of Age 55 Æ 15 55 Æ 14 57 Æ 12abnormal lactate. Using an AG > 12, the sensitivity for Sex (% male) 444 (58) 37 (61) 28 (62)detecting lactic acid > 2.5 mg/dL was 66% (64%–67%), Race (% white) 308 (40) 21 (34) 18 (40)specificity 85% (85%–86%), PPV 53% (52%–54%), and InsuranceNPV 91% (90%–91%). Similarly, for a lactate > 4.0 Medicare 39 (5) 15 (25) 14 (32)mmol/L, the sensitivity was 86% (84%–88%), specificity Medicaid 176 (23) 21 (35) 16 (36)81% (81%–81%), PPV 28% (27%–28%), and NPV 99% Commercial Medically 153 (20) 4 (7) 3 (7) Indigent 281 (37) 11 (18) 6 (14)(98%–99%). Conclusions: We found high sensitivity and Self-pay 8 (1) 7 (12) 3 (7)very high NPV for abnormal lactate with an AG cut point Other/Unknown 94 (13) 2 (3) 2 (5)of 12. The AG can be rapidly calculated from a screen- Top 5 primary discharge diagnosesing electrolyte profile done shortly after ED presentation. Alcohol- or drug-induced mental disorder 56 (7) 1 (2) 0Perhaps the greatest utility of the AG in the ED is in Occlusion of cerebral arteries 41 (5) 16 (26) 14 (31)excluding hyperlactemia from consideration. Patients with Syncope and collapse 36 (5) 0 0an anion gap 12 are unlikely to have clinically signifi- Pneumonia, organism unspecified 20 (3) 0 0cant lactic acidosis. Urinary tract infection, site not specified 19 (2) 0 0 Medicine service 581 (76) 26 (43) 18 (40)Disclosures: Nonmedicine service 185 (24) 35 (57) 27 (60)S. Namo - none; K. Olarte-Meridia - none; W. Oureshi - none; N. Hector - Emergent neurosurgical intervention 6 (0.8) 6 (10) 6 (13)none; G. Buran - none Any neurosurgical intervention 11 (1) 11 (18) 9 (20) y CSA, clinically significant abnormalities; { FNS, focal neurological signs.87ABSENCE OF FOCAL NEUROLOGICAL SIGNSACCURATELY EXCLUDES NEED FOR EMERGENT these findings. Results: In the study period, 766 patientsNEUROSURGERY AMONG PATIENTS WITH met the inclusion criteria. As shown in Table 1, CCTNONTRAUMA NEUROLOGICAL COMPLAINTS revealed clinically significant abnormalities in 61 of 766Vignesh Narayanan, MD, Angela Keniston, MSPH, Richard cases (8%), 45 of whom had focal neurological findingsAlbert, MD; Denver Health and Hospital Authority, Denver, CO (6%). Focal neurological signs were also present in 38Background: A large majority of emergency cranial com- patients without CCT abnormalities (false positives). Elevenputed tomography (CCT) scans performed in the evaluation of 766 patients (1%) underwent a neurosurgical interven-of nontrauma neurological complaints neither reveal clini- tion, only 6 (0.8%) of which were emergency procedures,cally significant abnormalities nor result in emergent inter- all of whom had focal neurological signs (100%). The neg-ventions. Over-utilization of imaging modalities results in ative predictive value (NPV) of focal neurological signs isradiation exposure, undue reliance on imaging, delayedemergency department (ED) throughput, and increased TABLE 2 Comparison of the Diagnostic Yield of CCT to Focal Neurologicalcosts. To reduce unwanted imaging, we studied the utility Signsof focal neurological signs in identifying patients with clini-cally significant abnormalities on CCT who require clini- Emergent Anycally pertinent interventions such as emergency Neurosurgical Neurosurgicalneurosurgery. Methods: We retrospectively audited charts Intervention Interventionof all patients between ages 18 and 89 who underwent aCCT in the ED before admission to the hospital from Janu- CCTy FNS{ CCTy FNS{ary 1 to December 31, 2007. We excluded patients who Sensitivity 1.00 1.00 1.00 0.82had any evidence of trauma, CCT at an outside hospital (95% CI) (0.54, 1.00) (0.54,1.00) (0.72, 1.00) (0.48, 0.98)prior to arrival at our ED, cranial surgery, or clinically sig- Specificity 0.93 0.95 0.93 0.95nificant abnormality in the preceding 6 weeks and if they (95% CI) (0.91, 0.95) (0.93, 0.96) (0.91, 0.95) (0.93, 0.97)had a lumbar puncture in the ED. Demographics, chief com- Positive predictive 0.10 0.13 0.18 0.20plaint, neurological exam, results of CCT, neurosurgical value (95% CI) (0.04, 0.20) (0.05, 0.27) (0.09, 0.30) (0.10, 0.35)interventions, and discharge diagnoses were recorded. The Negative predictive 1.00 1.00 1.00 1.00following were considered clinically significant abnormal- value (95% CI) (0.99, 1.00) (0.99, 1.00) (0.99, 1.00) (0.99, 1.00)ities: ischemic stroke, intracranial hemorrhage, mass, infec- y CCT, cranial computed tomography; { FNS, focal neurological signs.tion, cerebral edema, hydrocephalus, or a combination ofS54 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • 100% for clinically significant abnormalities that require sive medicine, including 96% reporting assurance andemergent neurosurgical interventions (Table 2). The sensitiv- 43% reporting avoidance behavior. Overall, 40% of medi-ity and NPV of focal neurological signs in predicting the cal students and 47% of residents reported being explicitlyneed for any neurosurgery is also high. Conclusions: taught to take malpractice concerns into account when mak-Among nontrauma cases, the prevalence of clinically signif- ing clinical decisions. Among medical students who hadicant abnormalities and emergency neurosurgery are both witnessed a medical error resulting in harm, 30% reported a failure to disclose, and 63% of those reporting a failurelow. If we restricted CCT ordering only to those patients to disclose indicated that malpractice liability concernwith focal neurological signs, 643 such scans could have played a role in the decision. Among residents who hadbeen avoided without missing any patient who would have witnessed a medical error resulting in harm, 27% reportedrequired emergent neurosurgery. In the absence of focal a failure to disclose, and 86% of these respondents indi-neurological findings, emergency CCT may be entirely cated that malpractice liability played a role in the deci-avoided or safely delayed based on clinical course. sion. Conclusions: The majority of trainees experiencedDisclosures: defensive medicine practices, and many reported being ex-V. Narayanan - none; A. Keniston - none; R. K. Albert - none plicitly taught to take malpractice liability into account when making clinical decisions. Moreover, more than a quarter of trainees reported failure to disclose a medical88 error resulting in harm, and concern over medical liabilityMEDICAL STUDENT AND RESIDENT CLINICAL AND was cited as a common contributing factor to this decision.EDUCATIONAL EXPERIENCE WITH DEFENSIVE Our findings have broad implications for how the informalMEDICINE curriculum influences trainees’ developing practice patternsKevin O’Leary, MD1, Jennifer Choi, BS2, Katie Watson, JD2, Mark and disclosure of medical error.V. Williams, MD1; 1Northwestern University, Chicago, IL; 2North- Disclosures:western University Feinberg School of Medicine, Chicago, IL K. O’Leary - none; J. Choi - none; K. Watson - none; M. Williams - noneBackground: Defensive medicine is defined as a deviationfrom sound medical practice induced primarily by a threatof liability and is categorized as assurance or avoidance 89 IMPROVING GLYCEMIC CONTROL WITH THE USEbehaviors. Assurance behaviors include the provision ofadditional services of minimal value with the goal of redu- OF A NURSE-DRIVEN PROTOCOL FOR THEcing adverse outcomes. Avoidance behaviors include efforts TRANSITION FROM INTRAVENOUS TOto avoid providing services or caring for certain patients SUBCUTANEOUS INSULIN THERAPYperceived as high risk. Research shows that defensive medi- Cheryl O’Malley, MD, Jacqueline Keuth, RN, MS, CCNS, CCRN,cine is common among practicing physicians, but little is Krishna Schiller, PharmD, Richard Gerkin, MD, Dale Bikin,known about trainees’ experience with defensive medicine. PharmD; Banner Good Samaritan Medical Center, Phoenix, AZMethods: We conducted a cross-sectional survey of all Background: Optimal conversion to a subcutaneous insulinfourth-year medical students and third-year residents in med- regimen following an insulin infusion requires knowledge ofical and surgical specialties at the Northwestern University patients’ current clinical status, medical history, and mostFeinberg School of Medicine. Respondents were asked to recent intravenous (IV) insulin drip requirements. This up-to-rate how often concerns about malpractice liability caused date information is most available to a bedside nurse. Wetheir teams to engage in 4 types of assurance and 2 types proposed that implementation of a nurse-driven transitionof avoidance behaviors using a 4-point scale (never, rarely, protocol would result in improved glycemic control whensometimes, often). Respondents similarly rated how often compared with the prior physician initiated process. Meth-their attending physicians explicitly recommended that mal- ods: The institution’s existing insulin infusion orders werepractice liability be taken into account during clinical deci- modified to include orders for transition. Patients off vasoac-sions. We collapsed ‘‘sometimes’’ and ‘‘often’’ responses tive medications and eating meals (or on goal tube feeds)during our analysis as indicative of an affirmative response. or those with orders to transfer out of the intensive care unitWe also asked respondents whether their teams had ever met criteria for transition. Patients with an average infusionchosen not to disclose a medical error resulting in harm rate ! 1.5 units/h, an HgbA1C > 6.5, or known diabetesand, if so, whether concern about medical liability played were transitioned using the following steps. The bedsidea role in the decision. Results: Overall, 126 of 194 eligible ICU nurse entered the infusion rates for the last 7 hours intomedical students (65%) and 76 of 141 residents (54%) an electronic form, embedded calculations averaged thecompleted the survey. Among medical students, 94% had lowest 5 rates, and multiplied by 20 to determine the totalexperienced 1 or more defensive medical practices, includ- daily dose of insulin (TDD). This was divided into 50% glar-ing 92% reporting assurance and 34% reporting avoidance gine and 50% rapid-acting nutritional. The calculated dosespractices. Among residents, 96% had experienced defen- then appeared within the electronic form. A retrospective Hospital Medicine 2011 Abstracts S55
    • TABLE 1 Day Weighted Mean (mg/dL) Following Transition from IV to SC In- Recent reports reveal that readmissions are costly andsulin Therapy potentially preventable in many cases. Limited research is available on what factors place a patient a risk and if tar-Day Pre Post geted interventions can reduce the observed readmission rate. Our objectives were to determine if there are patient1 149.7 149.2 factors that correlate to 30-day readmission rates, and if a2* 155.1 137.23* 150.5 133 cumulative set of factors correlates to increased observed4* 147.0 132.6 rates. Methods: We performed a retrospective, observa-5* 143.8 128.5 tional cohort study. Patients were eligible if they were dis-6* 144.7 135.8 charged from general medicine services at a single7* 139.3 132.1 academic medical center between April 1, 2010, and June 30, 2010. Exclusion criteria were death during hos-* Denotes P 0.05. pitalization, leaving AMA, and encounters within 30 days of index hospitalization. As a participant in Project BOOST, much emphasis was placed on the target screen-review of all patients undergoing cardiovascular surgery ing tool criteria. Patient records were evaluated for: ageduring the 4 months before (n 5 65) and after (n 5 108) > 65; problem diagnosis based on coded diagnoses of acute or chronic CHF, acute or chronic obstructive pulmo-implementation of the transition protocol was completed. nary disease, acute pneumonia, acute stroke, active can-Glucose values from the time of discontinuation of IV insulin cer, and acute or chronic diabetes mellitus; problemuntil hospital discharge were analyzed. The primary endpoints were the mean glucose, day weighted mean, thepercentage of patients with hypoglycemia (<70 mg/dL)and severe hypoglycemia (<40 mg/dL), and the percent-age of values between 70 and 180 mg/dL. Secondary endpoints included hospital length of stay (LOS), 30-day mortal-ity and readmission, and sternal wound infection. Results:Improvements were seen in mean glucose (145.8 vs.135.1 mg/dL; P < 0.001), percentage of glucose valuesbetween 70 and 180 mg/dL (77.3% vs. 81.7%; P <0.001), and day weighted mean (Table 1). There was nodifference in the percentage of patients with hypoglycemia(24.6% vs. 29.6%; P 5 0.55) or rates of severe hypoglyce-mia (1.5% vs. 1.9%; P 5 0.65). In multiple linear regres-sion, transition group was a significant predictor of surgicalLOS, with adjusted LOS 1.27 days less in the group follow-ing implementation of the transition orders. There was nodifference in 30-day mortality (none in either group), read-mission, or sternal wound infections. Conclusions: A nurse-driven protocol for the transition from IV to subcutaneous in-sulin resulted in significant improvements in glycemic con-trol for cardiovascular surgery patients without increasinghypoglycemia.Disclosures:C. O’Malley - none; J. Keuth - none; K. Schiller - none; R. Gerkin - none; D.Bikin - none90RISK FACTORS FOR 30-DAY READMISSIONSAroop Pal, MD, Mohammad Taha, MD, Adam Merando, BS,Megan McDonald, BA, Chris Wesselman, BA; University ofKansas Medical Center, Kansas City, KSBackground: Hospital readmission within 30 days of dis-charge is an area of emphasis of health care reform.S56 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • medications (anticoagulants, insulin, aspirin and clopido- TABLEgrel, digoxin, or scheduled narcotics); polypharmacy(defined as !10 medications on the discharge orders); HAPS normal (122) HAPS abnormal (181) P valueprior hospitalization at our institution within 6 months; and ICU admission or death 8 44 < 0.0002coded diagnosis of depression. We identified readmis- Length of stay 4.3 Æ 3.8 days 6.2 Æ 7.0 days 0.002sions from administrative data and confirmed by chart Age 49.2 Æ 15.2 years 48.8 Æ 14.6 years 0.81review. Charts were scored for 6 primary risk factors, andan overall score was calculated. Chi-square analysis wasperformed. We also assessed the value of cutoff scores of guarding or rebound tenderness, serum creatinine level,0, 1–3, and 4–6. Results: Eight hundred and fifty-eight and hematocrit level on presentation. A normal HAPScases met study criteria. The observed 30-day readmission meant the patient had no guarding or rebound tendernessrate was 15.96%. Table 1 shows the prevalence of the 6 on presentation, a serum creatinine < 2 mg/dL and a nor-factors studied, including observed 30-day readmission mal hematocrit (below 43% in men and below 39.6% inrate, calculated odds ratios, and P values. Table 2 shows women). Patients with severe pancreatitis were as definedthe correlation of a range of scores and observed read- as those requiring ICU stay or who died during the hospital-mission rates. Problem diagnosis, problem medication, ization. Results: Of the 303 patients in the study, 122polypharmacy, and prior admission within 6 months were patients had normal HAPS. There were a total of 52significant individual risk factors correlating with observed patients who developed severe pancreatitis. A normal30-day readmissions in our study. A score of 1–3 and >4 HAPS was highly correlated with a nonsevere course of thefactors were indicative of a significantly higher risk for 30- disease (P < 0.0002). The score correctly identified aday readmission than a score of 0. Conclusions: Select harmless course in 114 of 122 patients. Using the HAPS,patient factors and a screening score obtainable near the overall specificity for predicting mild disease was 84.6%,time of discharge can be used to identify patients at higher risk with a positive predictive value of 93.4%. The averagefor 30-day readmission. These findings may be useful to deter- length of stay in the hospital was 4.3 days with a normalmine targeted use of interventions to reduce readmission risk. HAPS versus 6.2 days for an abnormal HAPS (P 5 0.002).Disclosures: Age, race, and sex did not affect the accuracy of theA. Pal - none; M. Taha - none; A. Merando - none; M. McDonald - none; C. HAPS. Conclusions: We validated the HAPS in a Midwes-Wesselman - none tern tertiary-care hospital as a predictor for nonsevere dis- ease. It proved to be highly accurate in identifying patients who would not require intensive care management. The91 score is simple and easy to calculate. Use of the HAPSHARMLESS ACUTE PANCREATITIS SCORE (HAPS) could help physicians more effectively triage patients pre-AS AN INITIAL PREDICTOR OF NONSEVERE senting with acute pancreatitis and may identify patientsDISEASE IN ACUTE PANCREATITIS requiring supportive care rather than full admission. Thus, itRavish Parekh, MD, Ashish Zalawadia, MD, Aalok Dave, MD, could positively impact the hospital by lowering its costs.Nikhil Ambulgekar, MD, Gregory Buran, MD; Henry Ford Hos- Disclosures:pital, Detroit, MI R. Parekh - none; A. Zalawadia - none; N. Ambulgekar - none; A. Dave - none;Background: Acute pancreatitis may manifest as mild to G. Buran - nonesevere disease. Severe acute pancreatitis requires manage-ment in an intensive care unit, whereas mild acute pancrea-titis may only need brief supportive care. Because it is 92difficult to predict the course of pancreatitis on presentation, DEHYDRATION SECONDARY TO DIURETICS MAYvarious algorithms have been devised to predict the severity CONTRIBUTE TO FALLS IN THE ELDERLYof disease. The Harmless Acute Pancreatitis Score (HAPS) Gauravkumar Patel, MD, Michael Cratty, MD; Allegheny Gen-has been proposed as an early predictor of severity of ill- eral Hospital, Pittsburgh, PAness among the patients presenting with acute pancreatitis. Background: Falls are the leading cause of accidentalIt allows rapid identification of patients with acute pancrea- death in the elderly older than 65 years of age in thetitis who will have a milder course and will not require in- United States. Many factors lead to falls in the elderly,tensive care unit (ICU) admission. The aim of this study was with a common etiology being medications Diuretics haveto validate the HAPS in patients in the United States Meth- shown a weak association with an increased risk of falls.ods: Consecutive adults admitted with acute pancreatitis The goal of this study was to determine if elderly patientsbetween January 2007 and June 2010 to a tertiary-care admitted to the hospital with falls had a tendency to behospital were identified from computerized medical hypovolemic. Blood urea nitrogen (BUN)/creatinine (Cr)records. The HAPS was calculated based on presence of ratio > 20 is often used as a marker of intravascular Hospital Medicine 2011 Abstracts S57
    • dehydration. It was hypothesized that diuretics may becontributing to elderly patients’ fall risk secondary to hy- Research Type 2006 Abstracts, Proportion 2010 Abstracts, Proportion P Valuepovolemia. Methods: A retrospective chart review wasdone at our tertiary-care center. All patients were older B 0.00 0.00 — C 0.12 0.24 0.02than 65 years of age and were admitted from January E 0.17 0.10 0.102007 to June 2007. The BUN/Cr ratios were compared H 0.18 0.13 0.26in 2 groups of patients. The first group was elderly Q 0.49 0.45 0.51patients admitted to the trauma service with falls whowere on diuretic(s). Group 2 was a comparison group ofelderly patients admitted to the hospitalist service whowere on diuretics but were admitted to the hospital for a reviewed all abstracts selected for presentation in the researchreason other than a fall. Three groups of patients were and innovations categories at the 2006 and 2010 SHM meet-examined based on stage of chronic kidney disease ings. Using predetermined criteria, reviewers assigned(CKD), stages 1 and 2, stage 3, and stage 4 and 5. abstracts to 1 of 5 types: basic science (B), clinical care (C),Patients with end-stage renal disease on hemodialysis education (E), hospitalist medicine as a specialty (H), and qual-were excluded from the study. Results: The results of the ity improvement/patient safety (Q). When an abstractstudy demonstrated that patients with mild to moderate re- addressed more than 1 type, reviewers were asked to makenal impairment with falls on diuretics generally had a assignment on the 1 main type addressed by the study. Propor-higher overall BUN/Cr ratio than patients without falls on tions and interobserver variations were determined for 2006diuretics. In patients with stages 1 and 2 CKD, patients and 2010 abstracts. Proportions were determined when atwith falls on diuretics had a BUN/Cr ratio of 28.5 Æ least 2 reviewers agreed on an abstract’s type. Results: Eighty-1.2 (n 5 78) versus 22.0 Æ 0.9 (n 5 71) in patients nine abstracts were presented in 2006 and 203 in 2010.without falls on diuretics. In stage 3 CKD, the results Reviewers assigned 290 (99%) of these 292 abstracts to 1 ofwere similar, with patients with falls on diuretics having a the 5 types. Two observers agreed on type for 272 of 290BUN/Cr ratio of 23.5 Æ 1.1 (n 5 46) versus 19.2 Æ 1 abstracts (94%), and all 3 observers agreed on type for 155 of(n 5 59) in patients without falls on diuretics. In stages 290 abstracts (53%). Kappa for overall agreement among the4 and 5 CKD, the BUN/Cr ratio did not differ between 3 reviewers was 0.52 (2006 abstracts) and 0.52 (2010the groups. Conclusions: Patients treated with diuretics abstracts). Overall proportion of research by type for bothadmitted to the hospital with falls appear to more intravas- years combined was quality improvement/patient safety, 0.47cularly depleted than patients on diuretics admitted to the (135 of 290); clinical care, 0.21 (60 of 290); hospitalist medi-hospital with diagnoses other than a fall. A significant state cine as a specialty, 0.14) 42 of 290); education, 0.12 (35 ofof intravascular volume depletion in patients on diuretics 290), and basic science, 0.00 (0 of 290). Proportions by typemay be contributing to falls in the elderly. The results of for each year are shown in the table. There was no significantour study suggest that patients with falls on diuretics had a difference (a 5 0.05) in proportions of types between 2006higher BUN/Cr ratio than patients on diuretics without falls. and 2010 except for clinical care. Conclusions: On the basis ofIt is speculated that the elevated BUN/Cr ratio reflects a abstracts presented at SHM meetings, nearly half of researchhypovolemic state in the elderly that may be contributing to by hospitalists concerns quality improvement or patient safety,their falls. Elderly patients on diuretics should be monitored and one fifth concerns the clinical care of hospitalized patients.very closely for hypovolemia when treated with diuretics. It Compared with 2006, type of research by hospitalists in 2010may be necessary to reduce diuretic medication doses or was similar, except that there was more research in the area ofchange medication if an elderly patients BUN/Cr ratio clinical care of hospitalized patients.reaches a high level to reduce the risk of falls. Disclosures:Disclosures: J. Pierce - none; H. Kang - none; L. Noronha - none; D. Rao - noneM. Cratty - none; G. Patel - none 9493 PLATELET DISTRIBUTION WIDTH IS ANHAVE THE TYPES OF RESEARCH DONE BY INDEPENDENT PREDICTOR OF ALL-CAUSE ANDHOSPITALISTS CHANGED OVER THE PAST 5 YEARS? CARDIOVASCULAR MORTALITY AMONG HEALTHYJohn Pierce, MD, MPH, Huining Kang, PhD, Leonard Noronha, U.S. ADULTSMD, Deepti Rao, MD; University of New Mexico School of Rehan Qayyum, MD1, MHS, Jurga Adomaityte, MD2, Muznay Kha-Medicine, Albuquerque, NM waja, MBBS1, Anis Rehman, MBBS1, Sidra Shakeel, MBBS1,Background: Little is known about the type of research done Muhammad Amer, MD1; Johns Hopkins School of Medicine, Balti-by hospitalists. The Society of Hospital Medicine (SHM) has more, MD; 2Sinai Hospital of Baltimore, MDselected abstracts for presentation at its annual meeting since Background: Platelet distribution width (PDW) is a quantita-2006. Methods: Three academic hospitalists independently tive measure of variability in platelet size. It has beenS58 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • 95 THE INVERSE RELATIONSHIP BETWEEN LOW BODY IRON STORES AND PLATELET COUNT IS MODIFIED BY AGE Rehan Qayyum, MD, MHS, Jurga Adomaityte, MD, Anis Rehman, MBBS, Sidra Shakeel, MBBS, Muznay Khawaja, MBBS, Muhammad Amer, MD; Johns Hopkins School of Medicine, Baltimore, MD; Sinai Hospital of Baltimore, Balti-Kaplan-Meier survival curves of participants in the lowest (first) more, MDand uppermost (fourth) quartiles of platelet distribution width. Background: Elevated platelet count is frequently reported to be associated with iron deficiency. However, the causes underlying iron deficiency vary with age and mayhypothesized that increased PDW may be a predictor of have differential effect on platelet count. Therefore, wemortality. However, this hypothesis has not been examined hypothesized that the effect of body iron stores (BIS) onin a community-based population. Methods: We used the platelet count varies between younger and older indivi-Third National Health and Nutrition Examination Survey to duals. Methods: Participants (N 5 14,440) in the Thirdexamine association between PDW and all-cause mortality National Health and Nutrition Examination Surveyand cardiovascular (CV) mortality. We used the Cox pro- (1988–94) older than 20 years were divided into youngerportional hazards model to calculate hazards ratios (HRs) ( 35 years, n 5 5085) and older (>35 years, n 5and 95% confidence intervals (CIs) in 14,876 participants 9355) cohorts. As there is no single perfect measure ofwho were older than 20 years and were free of clinical CV BIS, we ran 3 sets of analyses, each using 1 of the 3disease at baseline. Results: There were 3377 all-cause measures of BIS [serum iron (SI), transferrin saturationdeaths and 1397 CV deaths during the follow-up (median (TS), and serum ferritin (SF)]. In addition, to examine a dif-follow-up, 16.4 years; range, 0–18 years). The mean (SD) ferential role of lower versus higher BIS on platelet count,age of the participants was 47 (19) years, 54% were we used a spline separating low from high BIS measuresfemale, 40% were white, 26% were current smokers, and (spline knots at 50 lg/dL for SI, 25 ng/mL for SF, and25% had a history of hypertension. Mean (SD) PDW was 20% for TS). Multivariable analyses adjusting for BIS, age16.4% (0.5). Univariate analyses found a significant asso- cohort, smoking status, C-reactive protein (CRP), whiteciation between PDW and all-cause and CV mortality (HR, blood cell count (WBC), glomerular filtration rate, race,1.48 per unit increase in PDW; 95% CI, 1.31–1.67; and sex, and serum folate were performed with and withoutHR, 1.51 per unit increase in PDW; 95% CI, 1.31–1.75, an interaction between age cohort and a measure of BIS.respectively). This association remained statistically signifi- WBC, CRP, serum folate, and SF were log-transformed tocant in multivariable analyses after adjusting for age, sex, meet the assumption of normality. Results: Of the studyrace, C-reactive protein, diabetes, hypertension, smoking participants, 54% were women, 27% were African Ameri-status, glomerular filtration rate, and total cholesterol (HR cans, and 26% were smokers. Mean (SD) platelet countfor all-cause mortality, 1.30; 95% CI, 1.19–1.42; HR for was 274,000 (71,000)/lL, hemoglobin 13.9 (2.3) g/dL,CV mortality, 1.27; 95% CI, 1.12–1.43). Moreover, com- SI 87 (37) lg/dL, TS 25% (11%), and SF 133 (148) ng/pared with participants who were in the lowest quartile of mL. Consistent with the previously reported findings, with-PDW (mean, 15.8%), those in the upper quartile of PDW out an interaction term, all measures of BIS in the lower(mean,17.2%) had 47% (HR, 1.47; 95% CI, 1.19–1.83) range were inversely and significantly associated with pla-and 34% (HR, 1.34; 95% CI, 1.04–1.72) greater hazards telet count, but this association was not present at higherof all-cause death and CV death, respectively. Conclusions: ranges of BIS. On the other hand, when the interactionPDW is an independent predictor of all-cause and CV mor- term was include in the model, the inverse associationtality and may identify high-risk individuals. We propose between lower-range BIS and platelet count was presentthat this test should be routinely reported with other hemato- only in the older cohort and was absent in the youngerlogical parameters in complete blood count reports. cohort. There was a positive association between BIS inDisclosures: the higher range and platelet count in the younger cohort,R. Qayyum - none; J. Adomaityte - none; M. Khawaja - none; A. Rehman -none; S. Shakeel - none; M. Amer - none although it reached statistical significance for SI only. In contrast, there was an inverse association between BIS in the higher range and platelet count in the older cohort, although it was significant for only ST (Table 1). Conclu- sions: Low iron levels are inversely associated with platelet counts only in individuals >35 years, not in individuals 35 years. This differential inverse association between low iron levels and platelet count could be a result of differ- Hospital Medicine 2011 Abstracts S59
    • TABLE 1 Relationship Between Platelet Count and Body Iron Stores with Effect Modification by Age Models without Models with interaction term interaction termChange in platelet count (1000/lL) per 10 ng/mL increase in serum ferritin (95% CI)Ferritin 25 ng/mL 223.75 (242.4 to 25.1) Age 35 years 25.07 (229.4 to 19.3) Age > 35 years 239.17 (260.2 to 218.2)Ferritin > 25 ng/mL 21.88 (27.7 to 3.9) Age 35 years 5.40 (23.7 to 14.5) Age > 35 years 23.84 (210.5 to 2.9)Change in platelet count (1000/lL) per 10 lg/dL increase in serum iron (95% CI)Serum iron 50 lg/dL 210.46 (214.7 to 26.2) Age 35 years 23.31 (211.1 to 4.5) Age > 35 years 214.14 (218.1 to 210.1)Serum iron > 50 lg/dL 0.24 (20.2 to 0.7) Age 35 years 0.84 (0.1 to 1.5) Age > 35 years 20.41 (21.0 to 0.2Change in platelet count (103/lL) per 10% increase in transferrin saturation (95% CI)Transferrin saturation 20% 213.48 (219.8 to 27.2) Age 35 years 22.67 (213.2 to 7.9) Age > 35 years 219.30 (225.9 to 212.8)Transferrin saturation > 20% 0.07 (21.8 to 2.0) Age 35 years 2.40 (20.4 to 5.2) Age > 35 years 22.32 (24.5 to 20.1)ent causes of iron deficiency in the 2 age groups. Hospi- was obtained from the patient, using a translator if needed,talists should be aware of the differential effect of age and verified by their pharmacy. This list was then com-while evaluating the cause of thrombocytosis in the pre- pared to the standard physician-obtained medication list insence of iron deficiency. the electronic medical record. Medication discrepanciesDisclosures: between the 2 lists were then identified and noted asR. Qayyum - none; J. Adomaityte - none; M. Khawaja - none; A. Rehman - none; errors. Data were dichotomized for age (<65 or >65S. Shakeel - none; M. Amer - none years), language (English speaking vs. non–English speak- ing) and polypharmacy (>5 medications or < 5 medica- tions used). The rates of medication history errors between96 electronic and hand-written medication history were com-AN EVALUATION OF THE EFFECT OF pared using logistic regression with a 95% confidenceELECTRONIC MEDICATION RECONCILIATION interval. Results: One hundred and twelve patients wereON THE RATE OF MEDICATION ERRORS interviewed. The average number of medication errors perAT THE TIME OF HOSPITAL ADMISSION patient was 3.5, and 82% of patients had at least 1 medi-Jennifer Quartarolo, MD, Elaine Tsang, BS, Katherine Hollen- cation error. Logistic regression analysis revealed a 4.3-bach, PhD; University of California, San Diego, School of Med- fold increased risk of errors among polypharmacy patientsicine, San Diego, CA after adjusting for the competing effects of age and lan-Background: The eighth National Patient Safety Goal, guage (95% CI, 1.5–12.4). Electronic medication reconcili-developed by the Joint Commission in 2009, emphasizes ation had a protective effect against medication historythe significance of reconciliation of medications during the errors. After adjusting for the confounding effect of poly-entire period of hospitalization. Inaccuracies in the home pharmacy, data collected using the electronic medicationmedication list may lead to medication errors and possible history resulted in significantly lower error occurrence thanadverse drug events which often persist across transitions in traditional handwritten medication history (OR, 0.43; 95%care. Prior study at our institution found that 92% of CI, 0.20–0.95). One limitation of the study was compli-patients on the general medicine service had at least 1 ance with electronic medication reconciliation, as 30.3%error on written physician-obtained medication history, with of patients’ medication reconciliations were incomplete.an average of 3.8 errors per patient. Since then, our cen- Conclusions: Multiple medication history errors per patientter has implemented use of electronic medication reconcilia- were identified following implementation of electronic medi-tion. The objective of the study was to investigate whether cation reconciliation. Electronic medication reconciliationelectronic medication reconciliation decreased the rate of resulted in a significant reduction in the rate of medicationadmission medication errors compared with the prior hand- history errors compared with handwritten medication his-written process. Methods: Consenting patients aged 18 tory, but physicians’ compliance needs to be improved inyears or older who were admitted to the general medicine order to fully benefit from this implementation.service at an urban academic medical center were inter- Disclosures:viewed by a trained pharmacy student. Medication history J. Quartarolo - none; E. Tsang - none; K. Hollenbach - noneS60 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • 97 98PREVALENCE AND IMPACT OF ANEMIA IN READMISSION RATES ON A SICKLE CELL SERVICEHOSPITALIZED PATIENTS: AN EPIDEMIOLOGICAL RUN BY HOSPITALISTS AND SICKLE CELLSTUDY OF 10 YEARS OF INPATIENT ADMISSIONS SPECIALISTS: A QUALITY IMPROVEMENT PILOTJean-Sebastien Rachoin, MD, Elizabeth Cerceo, MD, Barry Mil- PROJECTcarek, PhD, Krystal Hunter, MBA, Gandhi Snehal, MD, Eric Padmini Ranasinghe, MD, MPH, Carlton Haywood, PhD, MA,Kupersmith, MD, David Gerber, DO; Cooper University Hospi- Sophie Lanzkron, MD, MHS, Daniel Brotman, MD, FHM,tal, Camden, NJ FACP; Johns Hopkins Hospital, Baltimore, MDBackground: Prevalence of anemia is increasing in the gen- Background: Sickle cell disease (SCD) patients are overre-eral population along with other comorbidities. Anemia is presented in emergency department and inpatient settings,associated with higher morbidity and mortality in a variety requiring more than $2 billion annually for hospitalization.of settings. Most studies have analyzed elderly patients or Average length of stay (LOS) is 5.3 days, whereas 14-dayspecific comorbidities, and the independent impact of ane- readmission rates can be as high as 30%. We describe amia on outcomes in general hospitalized patients (including new service aimed at improving SCD patient outcomes inyounger patients) has not been clearly defined. We aimed the hospital. Methods: A 4-bed specialized sickle cell ser-to evaluate the prevalence and associated factors for ane- vice (SCS) was created in March 2010 to promote bettermia in hospitalized patients over a 10-year period and comanagement for the hospitalist team and sickle cell teamassess the independent impact of anemia on mortality in (SCT). The service consists of a hospitalist attending and ayounger patients (<65 years). We hypothesized that ane- provider from the SCT, with no residents. SCS members seemia was becoming more common and associated with all SCD patients in the hospital but write orders only forhigher mortality over the period under investigation. Meth- patients on the SCS, which at any given time includes aods: We performed a retrospective analysis of administra- subset medicine in patients with SCD. Patients not admittedtive data of all consecutive discharges (age ! 18) from to this service serve as concurrent controls. We collectedCooper University Hospital from January 1, 1999, through data on all SCD-related hospital discharges from January toDecember 31, 2008. We recorded the presence/absence November 2010. Here we describe characteristics andof discharge ICD-9 codes for anemia, chronic kidney dis- comparison data on LOS, total charges, and hospital read-ease (CKD), congestive heart failure (CHF), chronic obstruc- mission rates, comparing the new SCS and the generaltive lung disease (COPD), hypertension (HTN), diabetes medical services (usual care). Patient-level analyses were(DM), coronary artery disease (CAD), and hyperlipidemia conducted using t tests. Discharge-level analyses were con-(HPL) and demographic data (age, sex, race) and mortality. ducted using generalized estimating equations to accountWe used chi-square analysis, the continuous data t test, for multiple observations on individual patients. Results: Inand multivariable logistic regression. Results: A total of total, 188 individuals with SCD were admitted to the hospi-179,516 admissions were included, of which 18,589 had tal during the study period, accounting for 405 total admis-anemia (10.4%). The prevalence of anemia increased sig- sions, 79 of these on the SCS (24%). Average age wasnificantly from 8.7% (1999) to 12.8% (2008); P < 0.001. 34.4 years, and 38% were male. The difference in LOSAnemic patients were significantly older and had more was not statistically different for those admitted to the SCScomorbidities (P < 0.001). Over time anemic patients had [6.6 days (5.5, 7.6 days)] versus general medical servicesdecreasing rates of CHF, DM, COPD, and CAD and more [5.9 days (5.1, 6.8 days)]; average charges per admissionHTN, CKD, and HPL, but overall significantly more comor- were not significantly different. Twenty-three percent of thebidities (P < 0.001). Five thousand two hundred and sixty- 188 patients (n 5 43) had at least 1 readmission within 30two patients died, and anemia was significantly associated days of discharge. On average, patients with at least onewith mortality (6.5% vs. 2.5%; P < 0.001; OR, 2.68) and 30-day readmission spent significantly more days in theremained significant after adjusting for demographical vari- hospital during the time period than those without a 30-dayables and comorbidities. There were 123,586 patients < readmission [34.1 days (25.2, 42.9 days) vs. 7.4 days65 years. Both the unadjusted (2.9 vs. 1.8) and adjusted (5.86, 9.0 days)]. We found that the odds of experiencing(2.4 vs. 1.65) ORs for mortality were significantly higher in a readmission within 14 days were 65% lower for patientsthis subset of patients. Conclusions: The prevalence of ane- discharged from the sickle cell service than those dis-mia increased from 1999 to 2008. The number of asso- charged from the general medical services (adjusted OR,ciated comorbid conditions increased as well during that 0.35; 95% CI, 0.13–0.92; P 5 0.032). There was no sta-time. Nevertheless, anemia remained independently asso- tistically significant difference in 30-day readmission rateciated with mortality. This association was stronger in between services (adjusted OR, 0.83; 95% CI, 0.39–1.8;younger patients. To further elucidate these findings, further P 5 0.63). Conclusions: In this pilot study, we found thatstudies should be performed. patients cared for by a SCS were significantly less likely toDisclosures: be readmitted within 14 days of discharge; other metricsJ.-S. Rachoin - none; E. Cerceo - none; B. Milcarek - none; K. Hunter - none; were not significantly affected. We intend to continue andS. Gandhi - none; E. Kupersmith - Merck, speaker; D. R. Gerber - none refine this clinical care model. Hospital Medicine 2011 Abstracts S61
    • Disclosures: gories and text exemplars are shown in Table 1. AcrossP. Ranasinghe - Johns Hopkins School of Medicine, employment; C. Haywood, and within these categories, hospitalists’ descriptions ofJr. - Johns Hopkins School of Medicine, employment; S. Lanzkron - Johns their involvement in patient care varied widely. For exam-Hopkins School of Medicine, employment ple, some described their primary responsibility as checking labs, whereas others described coordinating all the99 patient’s inpatient and follow-up care. Hospitalists nego-‘‘I’M ONE OF THE HOSPITALISTS’’: HOSPITALISTS’ tiated with patients about patients’ expectations of theirCOMMUNICATION ABOUT THEIR ROLE IN role, such as when the patient was seen by providers, whoPATIENT CARE IN ADMISSION ENCOUNTERS would coordinate aspects of care, and who would provide information. Conclusions: In admission encounters, hospital-Faye Reiff-Pasarew, BA, Jenica Cimino, BA, Wendy Anderson, ists frequently described their role in patient care. AlthoughMD MS; University of California, San Francisco, San Fran- all participating physicians shared the same position andcisco, CA responsibilities, how they described their role to patientsBackground: Although concerns have been raised about varied widely. How hospitalists describe themselves maythe effect of the hospitalist model on the doctor–patient rela- have a significant impact on how patients understand thetionship, hospitalists now care for many hospitalized hospitalist’s role as well as their trust in the hospitalist.patients. How hospitalists explain their role may influence Future research should explore patient perceptions of hospi-patients’ perception of the hospitalist. Methods: To charac- talists’ descriptions and develop clear and consistent lan-terize how hospitalists describe their role to patients, we guage for hospitalists to describe their role.performed a qualitative analysis of audio-recorded admis- Disclosures:sion encounters between attending hospitalists and their F. Reiff-Pasarew - none; J. E. W. Cimino - none; W. G. Anderson, nonepatients at 2 hospitals within a university system. First, acodebook was developed using an iterative process to iden-tify passages in which hospitalists described, directly or 100indirectly, their and other providers’ involvement in patient COMPLIANCE WITH NEW ACGME DUTY-HOURcare. To test the reliability of the codebook, 2 coders used REQUIREMENTS CAN IMPROVE PATIENT CAREit to independently code a 20% subset of encounters; MEASURESkappa was 0.77, indicating substantial agreement. A sin-gle coder coded the remaining transcripts. We then per- Glenn Rosenbluth, MD, Darren Fiore, MD, Stephen Wilson,formed a secondary analysis of all identified passages and MD, Judith Maselli, MSPH, Andrew Auerbach, MD, MPH; Uni-the patients’ responses to them to identify descriptive cate- versity of California, San Francisco, San Francisco, CAgories and overarching themes. Results: Audio-recordings Background: New ACGME duty-hour requirements limitingof 80 patients’ encounters with 27 hospitalists were ana- intern shifts to fewer than 16 continuous hours go into effectlyzed. All encounters contained some description by the July 1, 2011. Little is known about how this work-hourhospitalist of his/her role in the patient’s care. Five cate- reduction might affect patient outcomes. Our objective wasgories were identified within the descriptions; these cate- to test the hypothesis that length of stay and cost of hospital-TABLE 1 Categories of Hospitalist Descriptions of Their Role in Patient Care and Text ExemplarsCategory Text ExemplarsRelationship to other providers—how the attending hospitalist works ‘‘I’m the boss. Dr. [Resident] is the resident on the team, and Dr. [Medical Student] is the medical student with other providers, including trainees, consulting services, who’s taking care of you.’’ ‘‘So we will—I’ll talk with your primary care doctor.’’ ‘‘I’ll go talk with your nurses, ancillary services, and outpatient providers nurse about the idea of getting up for a walk.’’Information about the patient—information the hospitalist had ‘‘So we talked about your case throughout the morning and what’s been going on with you, and I just or did not have about the patient prior to the encounter and wanted to come by, say hello, take a look at you, see how you were feeling.’’ ‘‘Um, I’ll tell you what I how this history was obtained learned from the emergency department, and then you can correct me if I’m wrong. How’s that?’’Medical tasks and responsibilities—the tasks or activities the ‘‘The thing that I am primarily concerned about is ensuring that nothing is wrong that leads to your hospitalist undertakes in caring for the patient weakness such as your labs are out of whack, you know, your sodium is high or low, your potassium is high or low.’’ ‘‘We’ll decide the exact treatment and also what you’re going to go home on, what kind of medications.’’Medical expertise and recommendations—descriptions of ‘‘From my understanding of the literature, [enoxaparin] actually is overall a better drug to use in terms expertise and how it was used to form treatment of getting your blood thinned fast enough and getting your blood clot under control.’’ ‘‘You bring up recommendations Limitations of training and expertise a very important thing, and that is the conversation about prognosis. It’s difficult for me to have a conversation about it with you, because I’m not an oncologist.’’Determination of level of care inpatient/outpatient/other (e.g., ‘‘Sometimes if we’re waiting for pathology, it can take a week, and we don’t necessarily keep patients in nursing home)—assessment of medical stability Financial/ the hospital while we wait for that.’’ ‘‘Well, the plan was for you to go home, but then we just got insurance considerations these new glucose values back, and I think it would be unsafe for you to do that at this point.’’S62 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • ization would decrease for general pediatrics patients on a ing patterns and risk of myocardial infarction (MI) usinghospitalist service after transitioning to a trainee staffing both standard risk-adjustment and instrumental variable (IV)model compliant with planned ACGME standards. Meth- methods. Methods: Patients continuously enrolled in Market-ods: We compared patient outcomes before and after Scan claims data from 2005 to 2007 residing in 1 of 15changes in resident call schedules on a hospitalist service study metropolitan statistical areas (MSAs) were included.in an academic children’s hospital. In the preintervention American Medical Association Master File physician supplyschedule, general pediatrics patients were covered by data and Census Bureau data were used to determine theinterns who took call every sixth night (duty-hour periods up cardiologist density in these MSAs (range, 5–21 perto 30 hours), with cross-coverage of patients on multiple 100,000 population). Patients newly diagnosed with CADteams. Senior residents took call every fifth night and super- by a general internist or family physician between Januaryvised interns for multiple teams. In the postintervention 1, 2006, and June 30, 2006, were categorized based onschedule, all trainees worked day- and night shifts (primar- whether they saw a cardiologist (C1) within 6 months of di-ily 12-hour shifts), with increased night staffing to eliminate agnosis. Claims 1 year prior to the CAD diagnosis wereintern-level cross-coverage of multiple teams. Attending cov- used to determine comorbidities, which were mapped intoerage and PICU coverage were unchanged throughout the binary indicator variables using Elixhauser Comorbiditystudy period. Using multivariable models accounting for Software. Outpatient and inpatient claims were analyzed inpatient factors and severity of illness, we compared length the year subsequent to diagnosis. The number of each testof stay (LOS) and total cost (TC) for inpatients with our 10 [electrocardiogram (EKG), stress test (ST), echocardiogrammost common general pediatrics diagnoses during the year (EC)] was the dependent variable in separate linear regres-before and after the schedule change. Results: We ana- sions. Cardiac catheterization (CC) and MI were dichoto-lyzed data for 334 patients preintervention and 330 postin- mized (!1/0) and analyzed using logistic regression. Thetervention. In this sample, we saw significant reductions in cardiologist density in each patient’s MSA was used as anLOS (rate ratio, 0.86; 95% CI, 0.77–0.96) but not in TC IV, which predicted the chance of seeing a cardiologist (F(rate ratio, 0.91; 95% CI, 0.83–1.00). When the analysis 5 25, P < 0.0001). Results: Of 46,605 patients newlywas limited to the subset of patients who did not receive diagnosed with CAD, 57% saw a cardiologist (mean age,ICU care (n 5 280 preintervention and n 5 274 postinter- 55.4 vs. 53.2 years) within 6 months. Comorbidities werevention), both measures were statistically significant. LOS more common among C1 patients, a higher proportion ofdecreased by 18% (rate ratio, 0.82; 95% CI, 0.73–0.93), whom had !2 EKGs (43% vs. 28%), !2 STs (20% vs.and TC decreased by 10% (rate ratio, 0.90; 95% CI, 14%), !3 ECs (32% vs. 19%), and !1 CC (18% vs. 9%).0.81–0.99). We did not detect a differential impact of the Regression, adjusting for age, sex, and comorbidities,schedule change on individual patient diagnosis groups. showed that C1 was associated with having more EKGs (PConclusions: A trainee staffing model that complied with < 0.001), STs (P < 0.001), ECs (P < 0.001), CC (OR,new ACGME duty-hour requirements was associated with 2.20; CI, 2.16–2.24), and MI (OR, 1.67; CI, 1.53–1.81).reduced length of stay and total costs. Although changes in Using the predicted probability of C1, IV regression resultscare models needed to adapt to ACGME requirements may were consistent with those of the standard risk-adjustmentincur incremental costs, our findings suggest these costs analysis, except that a higher cardiologist density was asso-may be partially offset by improved care efficiency. ciated with fewer EKGs (P < 0.01) and reduced chance of MI (OR, 0.83; CI, 0.70–0.96). Conclusions: Standard risk-Disclosures: adjustment methods revealed a higher rate of all tests andG. Rosenbluth - none; D. Fiore - none; S. Wilson - none; J. Maselli - none; A.Auerbach - none MI among CAD patients seen by a cardiologist, suggesting a higher-intensity practice style. IV analysis suggests that these findings are accurate, except that the higher rate of101 EKGs and MI may be a result of unmeasured factors. Spe-THE IMPACT OF SPECIALTY CARE ON INTENSITY cialty care is higher intensity but may improve outcomes.OF UTILIZATION AND OUTCOMES: A Disclosures:COMPARISON OF ANALYTIC METHODS G. Ruhnke - noneGregory Ruhnke, MD; University of Chicago, Chicago, ILBackground: The literature argues that regions with greater 102availability of health care services have high-intensity pat- FINANCIAL RESPONSIBILITY OF HOSPITALIZEDterns of care that raise costs but do not improve outcomes. PATIENTS WHO LEFT AGAINST MEDICAL ADVICE:It has been proposed that limiting the supply of medical ser- MEDICAL URBAN LEGEND?vices may improve efficiency by reducing unnecessary anddiscretionary care. However, other research suggests that Gabrielle Schaefer, BA, John Schumann, MD, Heidi Matus,specialized services improve health. Meanwhile, physician MD, Keith Sauter, David Meltzer, MD, PhD, Vineet Arora, MD;supply is being actively increased. This analysis selected University of Chicago, Chicago, ILpatients newly diagnosed with coronary artery disease Background: Every year, 1%–2% of hospitalized patients(CAD) to assess the impact of seeing a cardiologist on test- leave the hospital against medical advice (AMA), placing Hospital Medicine 2011 Abstracts S63
    • them at risk for increased readmission and 30-day mortal- 103ity. Although 1 prior emergency department study sug- COMPARISON OF POSTDISCHARGE ANDgested clinicians often counsel patients leaving AMA that EXPERIENCE SAMPLING METHOD MEASUREMENTinsurance will not pay for their care despite the contrary, it OF PAIN IN HOSPITALIZED PATIENTSis unclear if this occurs for hospitalized patients. This study Andrew Schram, BA, Ainoa Mayo, MA, Hyo Jung Tak, PhD,aimed to assess whether insurance does not pay when hos- Toritseju Eshedagho, BS, David Meltzer, MD, PhD; Universitypitalized patients leave AMA and whether hospital physi- of Chicago, Chicago, ILcians discuss this with their AMA patients. Methods: Weanalyzed billing and chart data from a large ongoing study Background: Postdischarge assessments of pain and painof hospitalized medicine patients to identify AMA patients. control among recently hospitalized patients are an estab-Demographic and disease characteristics of AMA patients lished element of hospital quality measurement. However,were compared with non-AMA patients. For all patients retrospective assessments may not accurately measure painwho left AMA between July 2001 and November 2009, in- because patient experience varies over time and recall cansurance claims data were reviewed to ascertain if payment be poor. The experience sampling method (ESM) provideswas denied and the reason why. Residents and attendings real-time assessment of patients’ experiences by capturingwere surveyed to determine their perceptions of financial momentary experiences at randomly selected times through-responsibility and how they counsel patients when they out the day. This study compares data obtained from tradi-leave AMA. Results: From 2001 to 2009, 526 hospitalized tional postdischarge assessments with 2 ESMpatients (2%) left AMA. Like prior work, AMA patients were methodologies: the gold standard—in-person ESM—and amore often male (54% vs. 39%, P < 0.001), African Ameri- less expensive, but perhaps less representative, phone-can (87% vs. 73%, P < 0.001), and admitted with sickle based approach. Methods: This study employed 2 phasescell disease, HIV, or tobacco or substance abuse. Of the of data collection, a phone phase (n 5 399 participants,453 AMA patients with insurance (86%), payment was June 23, 2008–January 25, 2009) and an in-person phasedenied in only 18 cases (4%). Reasons for denial were unti- (n 5 204 participants, November 3, 2009–June 15,mely bill submission, incorrect name or date of birth, and 2010). After patient consent and collection of demographicadmission classified as ambulatory or within 72 hours of information, study staff either called (phone phase) or vis-prior hospitalization. Payment was never denied because a ited (in-person phase) the patient at 5 randomly assignedpatient left AMA. Seventy-four percent of residents (51 of times throughout the day (9 AM–5 PM) to administer the ESM69) and 56% of attendings (41 of 73) responded. Many survey. The questionnaire asked about whether any painresidents (68%) and attendings (45%) believed that insur- had been experienced, present pain and its severity, painance companies do not pay for hospital care if a patient medication, and satisfaction with pain control. Thirty daysleaves AMA. Also, most residents (71%) and attendings after discharge, a questionnaire was administered asking(51%) reported often or always informing patients leaving about pain and its severity throughout the hospital stay andAMA that they may be held financially responsible. Attend- perceptions of pain management and the quality of careings who believed insurance will not pay were more likely received. Relationships between ESM survey questions wereto inform patients they will be held financially responsible compared across all 3 methodologies using multivariate(Likert mean, 4.2 believe vs. 1.7 don’t believe; P < 0.001). hierarchical regression. Results: Sex was the only statisti-Similar results were noted for residents. Most physicians cally significant demographic predictor of satisfaction withreported ‘‘learning’’ insurance may not pay if patients leaveAMA from residents (61% residents, 24% attendings) andcase managers (35% residents, 36% attendings). Althoughthis may reflect a single institution ‘‘myth,’’ a recent anony-mous poll of more than 100 residents from nearby institu-tions document otherwise (44% believe insurance does notpay; 47% counsel patients they may be financially responsi-ble). Conclusions: Despite evidence to the contrary, manyhospital physicians believe and incorrectly counsel patientsthat insurance does not pay if they leave AMA. Although alarger study is needed, hospitals need to ensure that doc-tors, including hospitalists, and case managers are edu-cated appropriately to prevent misinforming patients.Disclosures:G. Schaefer - none; J. Schumann - none; H. Matus - none; K. Sauter - none;D. Meltzer - none; V. Arora - none FIGURE 1. Comparison of Phone Experience Sampling Method (ESM) and Post-Discharge Questionnaires for Measuring Satisfac- tion with Pain Management by GenderS64 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • Proportion of Patients Assessed for PTP Prior to CTA Unlikely D-Dimer PTP Performed PTP Correct Wells score Performed Inpatients 1 8 of 112 4 of 112 88 of 112 28 of 88 outpatients (7.1%) (3.6%) (78.6%) (31.8%) Outpatients 8 of 74 4 of 74 61 of 74 22 of 61 (10.8%) (5.4%) (82.4%) (36.1%) ods: A cohort of all patients who received and were billed for a CTA during November 2009 for the purpose of diag- nosing PE at UNC Hospitals was examined. A chart reviewFIGURE 2. Comparison of Phone and In-Person Experience Sam- was performed to evaluate the use of PTP calculation andpling Method (ESM) for Measuring Satisfaction with Pain Manage- D-dimer prior to CTA. At the same time, an attempt wasment by Gender made to estimate the Wells score from retrospective chart review. Information regarding performing service and clini- cal setting was also obtained. Results: Physicians who or-pain management measured either with postdischarge sur- dered CT scans for the purpose of ‘‘ruling out’’ pulmonaryveys or ESM. However, phone ESM suggested greater satis- embolism mentioned a clinical pretest probability in 8 offaction among men, whereas postdischarge surveys 112 cases. Physicians were correct in their clinical assess-suggested greater satisfaction among women (Fig. 1). To ment in only 4 of 112 cases. In patients with a low PTPfurther assess this difference, we compared a larger sample (Wells score < 2), D-dimer was checked in 24 of 58. Inof phone ESM participants to an independent sample sur- patients with an ‘‘unlikely’’ PTP (Wells score 4), D-dimerveyed with in-person ESM (Fig. 2). These results confirmed was checked in only 28 of 88. In outpatients 61 of 74the result of phone ESM. Conclusions: Postdischarge surveys patients had an ‘‘unlikely’’ Wells score. Only 22 of 61 ofand ESM do not always identify the same predictors of these patients had D-dimers measured. Incidence of PE insatisfaction with pain control. The similarity of results across this cohort was 11.6%. Conclusions: Risk stratification inESM methods in independent samples suggests that ESM diagnosing PE is proven with the use of routine pretestmay provide a more robust approach to measuring patient probability assessment. Coupled with a simple blood test, itsatisfaction than postdischarge surveys and that phone ESM means patients believed to be unlikely to have a PE clini-may be practical alternative to in-person ESM. cally can safely avoid further evaluation. Our study demon-Disclosures: strates that the majority of clinicians forego PTP tools and D-A. Schram - none; A. Mayo - none; H. Tak - none; T. Eshedagho - none; D. dimer testing in favor of radiologic studies. However, theMeltzer - none performance of CTA decreases if used injudiciously in a population of patients who have not been appropriately104 assessed for their PTP of PE. By extrapolating from pub-LACK OF CLINICAL RISK STRATIFICATION FOR lished data CTA could have been avoided in favor of lessPULMONARY EMBOLISM AND OVERUSE OF CT invasive, costly, and inconvenient studies in 40 of 112 patients (36%). The incidence of PE seen during this periodANGIOGRAPHY at UNC hospitals was much lower than the typicalKristine Scruggs, MD1, Edmund Liles, MD2; 1WakeMed Faculty 20%–30% incidence seen in trials evaluating CTA perform-Physicians, Raleigh, NC; 2University of North Carolina School ance when algorithms using PTP and D-dimers are used. Aof Medicine, Chapel Hill, NC project is currently being performed to examine the impactBackground: Current recommendations for diagnosing pul- of an algorithm requiring a calculated PTP, and D-dimer formonary embolism (PE) include using a clinical pretest prob- those scoring ‘‘unlikely,’’ prior to obtaining CTA. Becauseability (PTP) assessment as the initial screening tool. of the retrospective nature of the study and the selectionHowever, research has shown that physicians do not con- methodology for the cohort, patients in whom a diagnosissistently use clinical assessment tools, such as the Wells cri- of PE was entertained but ruled out without the use of cross-teria, to determine PTP before ordering CT angiography. sectional imaging were excluded.Radiation and IV contrast exposure leads to future health Disclosures:concerns, such as kidney damage and radiation-induced K. Scruggs - none; E. A. Liles, Jr. - nonemalignancy. Incomplete assessment of PTP can alter the ac-curacy of CTA. The use of a clinical assessment tool in com-bination with D-dimer measurement has been shown tosafely exclude the diagnosis of pulmonary embolism. Meth- Hospital Medicine 2011 Abstracts S65
    • 105 106PREDICTORS OF LENGTH OF STAY IN PATIENTS SURVIVAL OF ELDERLY PATIENTS WITH DEMENTIAUNDERGOING TOTAL KNEE REPLACEMENT AFTER PERCUTANEOUS FEEDING TUBE PLACEMENTSURGERY Arunabh Sekhri, MD, Gregory Buran, MD, Jose Velasco, MD,Vishal Sehgal, MD, Praveen Reddy, MD, Jeremiah Eagan, MD, Gordon Jacobsen, MS, Leslie Bricker, MD, David Debono,Pardeep Bansal, MD; Mercy Hospital, Scranton, PA MD; Henry Ford Hospital, Detroit, MIBackground: Very few studies have focused on patient char- Background: Dementia is a progressive neurodegenerativeacteristics that influence length of stay (LOS) after total knee syndrome. The percutaneous endoscopic gastrostomy/jeju-arthroplasty (TKR). The primary goal of this retrospective nostomy (PEGJ) tube was first introduced in clinical practicestudy was to identify patient characteristics associated with in 1980 as a means to provide nutrition to children. PEGJsLOS in TKR surgeries Methods: Between January 2008 and are often placed in elderly patients with advanced demen-December 2009, 659 patients (442 female) with a mean tia who cannot swallow but have intact gut function forage of 67.1 years (39–99 years) underwent knee replace- long-term nutritional support. Data are lacking on survivalment surgery at the Mercy Hospital Knee and Hip Institute. of this population following PEGJ placement. We report theRetrospective chart review was done to identify patient survival after PEGJ placement in elderly patients sufferingcharacteristics associated with LOS, postoperative blood from dementia at a large Midwestern hospital. Methods:loss, and AKI after TKR. Linear regression analysis was Medical records were reviewed of consecutive patients !used to identify significant parameters influencing LOS and 65 years undergoing initial PEGJ insertion with a history ofpostoperative blood loss. Logistic regression was used to dementia during the period 2000 through 2007. Collectedevaluate AKI. The significance level was set at P < 0.05 data included albumin level, hemoglobin, white blood cellResults: Mean LOS after TKR was 3.27 days. AKI was the count (WBC), sex, race and age of the patient. The Charle-only factor associated with increased LOS. Compared with son comorbidity index (CCI) was calculated for eachpatients without AKI and controlling for age, sex, and an- patient as a measure of chronic disease burden. Date ofgiotensin converting enzyme inhibitors/angiotensive recep- death was determined using medical records and thetor blocker (ACEI/ARB) use, LOS among patients with AKI Social Security Death Index. Results: Five hundred andwas 0.23 days longer (P 5 0.03). Diabetes was not asso- twelve cases were available for study, and 376 cases hadciated with longer LOS. Mean postoperative hemoglobin complete information for multivariate analysis. Average ageloss was 2.6%. Increasing age was associated with increas- of the patients was 81.6 years (range, 65–103 years),ing blood loss (P 5 0.01), and diabetics has significantly men compromised 46% and African Americans 76% of theless blood loss that nondiabetic patients (P 5 0.04). AKI population. The average albumin was 2.7 g/dL, hemoglo-occurred in 20.8% of patients. AKI risk decreased between bin 10.4 g/dL, and WBC 9.6 3 103/lL. Approximately2008 and 2009 (odds ratio, 0.55; 95% CI, 0.37–0.82) 25% of patients died within 1 month, 50% died within 3but increased with age (P < 0.001), Diabetes and ACEI months, and 73% died within 12 months. Multivariate anal-use (OR, 1.6; 95% CI, 1.0–2.5; OR, 1.5; 95% CI, ysis using Cox proportional hazards regression found the1.0–2.3, respectively.) However, the effects of diabetes following factors predictive of early death: age (P <and ACEI use were not independent; when both were 0.0001), high WBC (P 5 0.009), low albumin (P 5included in the regression model, neither was statistically 0.014), CCI score (P 5 0.017), and male sex (P 5significant, and both odds ratios were smaller Conclusions: 0.040). Hemoglobin level and race were not independentlyIn these data, age was associated with increased blood associated with mortality in these patients. There was someloss and risk of AKI. When examined separately, both dia- evidence of improved survival over the duration of the studybetes and preoperative ACEI use increased the risk of AKI. period (P 5 0.05). Conclusions: Patients with diagnosis ofHowever these factors were correlated and were not inde- dementia have limited life expectancy even after PEGJ pla-pendent predictors of significantly increased risk. AKI was cement. Our cohort had decreased survival after PEGJ tubethe only factor associated with a prolonged LOS. insertion compared with previous small studies. We foundDisclosures: that older male patients with elevated WBC, low albumin, and multiple comorbidities in this population do particularlyV. Sehgal - Mercy Hospital, employer; V. Kresse - Mercy Hospital, student; P.Reddy - Mercy Hospital, student; V. Sharma - Mercy Hospital, student; Slesko - poorly. Careful assessment of coexisting conditions and clini-Mercy Hospital, faculty; J. Eagan - Mercy Hospital, faculty cal status of the patient should be done before considering placing PEGJ tubes in patients with advanced dementia. Disclosures: A. Sekhri - Henry Ford Health System, employment, none; G. Buran - Henry Ford Health System, employment, none; J. Velasco - Henry Ford Health System, employment, none; G. Jacobsen - Henry Ford Health System, employment, none; L. J. Bricker - Henry Ford Health System, employment, none; D. Debono - Henry Ford Health System, employment, noneS66 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • 107 propriate. Postintervention, 8% of all PRBC transfusionSUSTAINED REDUCTIONS IN INAPPROPRIATE orders were deemed inappropriate (P < 0.01); see the sta-PACKED RED BLOOD CELL UTILIZATION THROUGH tistical process control chart in Figure 1. Results continue toMANDATORY TRANSFUSION ORDER SET AND be sustained for 13 months. Conclusions: A mandatoryCOMPLEMENTARY EDUCATIONAL CAMPAIGN transfusion order set reduced inappropriate PRBC transfu- sions by more than half at a community teaching hospital.Hasan Shabbir, MD1, Sasikala Ponnambalam, MD1, Mariana Important cofactors included staff education and consensusBotha, RN2, Jason Stein, MD1; 1Emory University, Atlanta, building among local opinion leaders regarding HTs andGA; 2Emory Johns Creek Hospital, Johns Creek, GA PRBC use.Background: Five million patients receive packed red blood Disclosures:cell (PRBC) transfusions annually in the United States and H. Shabbir - none; S. Ponnamballum - none; M. Botha - none; J. Stein - noneCanada, and 43,000 units of PRBCs are transfused daily.Although PRBCs augment oxygen delivery, they alsoincrease the risk of infectious and ischemic morbidity and 108mortality, prolong length of stay, and increase hospital A MULTILAYERED STRATEGY TO IMPROVE VENOUScosts. Despite substantial evidence to support restrictive THROMBOEMBOLISM EVENTS AT AN ACADEMICtransfusion practices, providers retaining liberal hemoglobin MEDICAL CENTERtriggers (HTs) create preventable patient risk while inflating Hiren Shah, MD, MBA, FHM1, Jennifer Van Dyke, MA2, Amycosts and overutilization of a scare resource. We hypothe- Halverson, MD1, Charles Watts, MD1, Scott Greene, MD1;sized that a mandatory order set containing clear indica- 1 Northwestern University, Chicago, IL; 2Northwestern Memo-tions for PRBC transfusion could reduce the proportion of rial Hospital, Chicago, ILinappropriate PRBC transfusions in a community teachinghospital. Methods: A consensus-building phase preceded Background: Venous thromboembolism (VTE) is an AHRQthe intervention with physician representatives from hematol- safety measure. VTE rates at our academic medical centerogy, hospital medicine, and general surgery collaborating were higher than other University HealthSystem Consortiumwith blood bank personnel and nursing staff to create a list peers. Relative to best practices at leading hospitals, weof approved transfusion indications and suggested HTs. identified numerous improvement opportunities to ensureAppropriateness of PRBC transfusions for hospitalized appropriate VTE prophylaxis. There were many gaps in ourpatients was determined for a 7-month baseline and 13- processes including a lack of uniformity in admission ordermonth postintervention period through chart review by 2 or protocols across disciplines that led to no standardizationmore physicians for every patient receiving a PRBC transfu- of dosing and timing of prophylaxis drugs. Contraindica-sion. A mandatory paper-based transfusion order set, incor- tions to prophylaxis used by physicians were often not evi-porating the approved indications and HTs, was launched dence based. When prophylaxis was appropriately startedas the only way to order PRBCs. Nurses, blood bank staff, on admission, it was often stopped when contraindicationsand physicians were informed and educated about the new arose but never restarted if the contraindication was tempo-program. Results: During the 7-month baseline period, 21% rary. In addition, mechanical prophylaxis usage was subop-of all inpatient PRBC transfusion orders were deemed inap- timal, and compliance, when ordered, was poor. There was no system in place to obtain real-time feedback on pro- phylaxis usage by providers. Methods: A multilayered strat- egy was developed to improve VTE rates and was implemented over a 2-year period. A multidisciplinary team developed a single VTE prophylaxis order set that standar- dized dosage and timing and was embedded in all admis- sion and postoperative order sets. This also allowed documentation of contraindications, if any. A standard, evi- denced-based list of contraindications was developed by our VTE team. For patients with contraindications to phar- macoprophylaxis, an EMR alert was developed that prompted the ordering of mechanical prophylaxis. A new process involving pharmacists was developed to monitor VTE prophylaxis compliance to ensure pharmacoprophy- laxis was ordered or contraindications were documented. For patients who may have temporary contraindications, an EMR alert was developed to remind physicians to reevalu- ate patients for pharmacoprophylaxis every 24 hours. AFIGURE 1. Statistical process control chart showing percent of blood nursing awareness campaign emphasizing the importancetransfusion orders deemed inappropriate. of mechanical devices, and its usage for a minimum of Hospital Medicine 2011 Abstracts S67
    • FIGURE 1. FIGURE 1.18–20 hours was conducted and monthly room audits per-formed to monitor compliance. A real-time prophylaxis but do not address situations when a contraindication onreport was developed and available in the EMR that admission may no longer be valid later in the hospital stay.allowed providers to see if pharmacoprophylaxis was or- In addition, once prophylaxis is discontinued for proceduresdered on their patients. A targeted effort with orthopedics or subsequent bleeding risks, it is often not restarted onceand neurosurgery, which accounted for 45% of the post- the contraindication is no longer present. To address this, aoperative rate, was launched. Results: The overall VTE rate process was developed that reminded physicians 6 hoursof surgical patients went from 23.5 per 1000 discharges to after admission and every subsequent 24 hours to start or10.1, the rate in medical patients went from 3.8 per 1000 resume VTE prophylaxis. This allowed contraindications todischarges to 2.4, and the overall rate in both surgical and prophylaxis to be reevaluated throughout the entire inpati-medical patients went from 17.2 per 1000 discharges to ent stay. Methods: The hospital developed a VTE prophy-11.1, representing a decrease of 57%, 37%, and 35%, laxis reminder in the electronic medical record. If there wasrespectively (Fig. 1). Conclusions: A multilayered approach no pharmacoprophylaxis ordered on admission, an alertto decrease overall VTE rates may be much more effective triggered within 6 hours of admission and then every subse-than individual strategies to improve VTE prophylaxis aimed quent 24 hours, notifying the physician that the patient wasat specific gaps in processes. at risk for VTE and pharmacoprophylaxis should be consid-Disclosures: ered. The alert provided 3 ordering options: an order forH. Shah - none; J. Van Dyke - none; A. Halverson - none; C. Watts - none; S. prophylactic low-molecular-weight heparin, prophylacticGreene - none unfractionated heparin, and an order that documented that pharmacoprophylaxis is contraindicated. Also, if the order for pharmacoprophylaxis is contraindicated was selected,109 then an additional alert would appear recommending thatUSE OF 24-HOUR ELECTRONIC ALERTS TO pneumatic compression devices be ordered. In addition,INCREASE VENOUS THROMBOEMBOLISM (VTE) the pharmacoprophylaxis is contraindicated order automati-PROPHYLAXIS USAGE IN MEDICINE PATIENTS cally expired after 24 hours. Once this order expired, theHiren Shah, MD, MBA, FHM1, Jennifer Van Dyke, MA2, David same alert would trigger every 24 hours prompting the phy-Liebovitz, MD1, Anne Bobb, RPh2, Elizabeth Standardi, BS2, sician to reevaluate the prophylaxis decision. Results: TheCharles Watts, MD1, Scott Greene, MD1; 1Northwestern Uni- alerts were implemented at the end of April 2010. The start-versity, Chicago, IL; 2Northwestern Memorial Hospital, Chi- ing of prophylaxis within 24 hours of admission was usedcago, IL as a proxy for appropriate prophylaxis throughout the inpa-Background: Deep vein thrombosis (DVT)–related pulmo- tient stay since these alerts triggered within 6 hours ofnary embolism (PE) is the most common cause of preventa- admission and then daily. Before the alerts, 90% of medi-ble death in hospitalized patients. A large tertiary-care cine patients received VTE prophylaxis within 24 hours ofacademic medical center focused on increasing venous admission or had a documented contraindication. After thethromboembolism (VTE) prophylaxis for all medicine inpati- alerts, this rate increased to 97% for all medical patientsents to reduce the risk of developing a DVT or PE. Admis- (Fig. 1). Conclusions: System alerts are an effective tool tosion order sets that prompt physicians to start VTE remind physicians to start VTE prophylaxis and reevaluateprophylaxis or to document a contraindication are effective contraindications to pharmacoprophylaxis throughout theS68 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • patient’s stay. Because many contraindications are tempo-rary, these reminders can ensure that VTE prophylaxis ismaintained daily.Disclosures:H. Shah - none; J. Van Dyke - none; D. Liebovitz - none; A. Bobb - none; E.Standardi - none; C. Watts - none; S. Greene - none110THE USE OF PHARMACISTS AS AN EFFECTIVESTRATEGY TO IMPROVE VENOUS FIGURE 1.THROMBOEMBOLISM PROPHYLAXISHiren Shah, MD, MBA, FHM1, Jennifer Van Dyke, MA2, Desi riod and ranged from 93 to 152 patients starting prophy-Kotis, PharmD2, Jean Patel, PharmD2, Anne Bobb, RPh2, laxis monthly due to this new process (Fig. 1). Conclusions:Noelle Chapman, PharmD2, Scott Greene, MD1; 1Northwes- Pharmacist interventions including chart review, evaluationtern University, Chicago, IL; 2Northwestern Memorial Hospital, of appropriate contraindications, and subsequent discussionChicago, IL with ordering physicians led to initiation of pharmacologic prophylaxis on 905 patients at our academic medical cen-Background: Venous thromboembolism (VTE) represents sig- ter over 8 months. Leveraging the use of clinical pharma-nificant morbidity and mortality challenges for hospitals. De- cists of inpatient units represents an added opportunity tospite the implementation of risk stratification methodologies improving pharmacologic prophylaxis compliance.and admission order sets to ensure VTE prophylaxis at most Disclosures:hospitals, studies indicate that a significant proportion ofmedicine inpatients are not receiving VTE pharmacoprophy- H. Shah - none; J. Van Dyke - none; D. Kotis - none; J. Patel - none; A. Bobb - none; N. Chapman - none; S. Greene - nonelaxis. Most current strategies for improving prophylaxishave focused on education and process improvementchanges aimed at house staff and admitting physicians. 111Our academic medical center leveraged the involvement of UP IN SMOKE! TREATING TOBACCO ADDICTIONour clinical pharmacists on inpatient floors in improving IN THE HOSPITAL AND POLICY IMPLICATIONSprophylaxis for VTE through chart review, documentation ina pharmacy database, and physician notification. Methods: Lisa Shah, MD, MAPP1, Valerie Press, MD, MPP2, Jerry Krish-Inpatient clinical pharmacists evaluated all medicine charts nan, MD, PhD2, Kalpana Suresh, BA2, Vineet Arora, MD,daily for the presence of a VTE pharmacoprophylaxis order MAPP2, David Meltzer, MD, PhD2; 1Avalere Health, Washing-or a documented contraindication to prophylaxis. If either ton, DC; 2University of Chicago, Chicago, ILwas lacking, house staff and/or attending hospitalists were Background: Hospital-based tobacco cessation counseling iscontacted to start prophylaxis or document a contraindica- critical, especially among African Americans, who suffer ation. Appropriate contraindications to pharmacologic pro- disproportionate burden of tobacco-related disease. Recentlyphylaxis were standardized across disciplines by the VTE updated cessation guidelines are available, and qualityleadership team. Once prophylaxis information was measures for counseling are tied to physician reimbursement.obtained, it was entered daily into a pharmacy-based clini- Yet previous research showed only 10% of patients withcal decision support system. Based on chart review and dis- tobacco-related disease quit smoking postdischarge. Thiscussion with physicians, 1 of the following was entered into study aimed to understand barriers to providing guideline-the pharmacy database: on prophylaxis, prophylaxis con- based care for inpatient smokers. Methods: Current smokingtraindicated long term, prophylaxis temporarily contraindi- inpatients were identified and interviewed at admissioncated with follow-up needed, or prophylaxis refused by about smoking behaviors and cessation barriers. In addition,physician. If pharmacologic prophylaxis was temporarily providers were surveyed regarding barriers to followingcontraindicated, this was noted, and physicians were con- guidelines for tobacco cessation. At discharge, interns, resi-tacted again the next day, if needed. If pharmacologic pro- dents, and nurses caring for enrolled smokers were inter-phylaxis was refused by the physician without a valid viewed regarding their awareness of tobacco cessationcontraindication, an escalation procedure was developed guidelines, any tobacco cessation guideline-based care theythat included notifying VTE project team leadership, who offered to the patient, and their assessments of individualthen contacted individual physicians to ensure compliance patient readiness to quit. Results: From September 2008 towith prophylaxis. Results: Pharmacists reviewed all charts July 2009, 225 of 289 hospitalized smokers (78%) partici-daily, which totaled more than 12,000 patients in an 8- pated in the study. Of the 225 patients, 193 (86%) were Afri-month period. Pharmacist notifications to physicians can American, and 77 (34%) had a discharge diagnosis ofresulted in the initiation of pharmacologic prophylaxis on a tobacco-related illness. A total of 196 provider surveysan average of 113 patients per month over an 8-month pe- were completed; these included 102 surveys of interns and Hospital Medicine 2011 Abstracts S69
    • residents rotating on the general medicine service and 94 patients waiting in the ED for team assignments, perpetuatingsurveys of medicine ward nurses caring for enrolled smokers the crisis of overcrowding. To decrease holdovers and pro-at discharge. Of the 102 house staff surveys, physicians vide more timely care, a ‘‘hospitalist of the day’’ (HOD) wasreported being aware that the patient was a smoker 77% of established to triage all calls for admits on non–critical carethe time and offering tobacco cessation advice to these smo- medicine patients. Methods: In October 2009, 2.4 FTEskers 60% of the time. This advice consisted of at least 10 min- were dedicated for HOD shifts Monday–Friday from 6 AM toutes of counseling only 18% of the time. House staff reported midnight. The HOD answered all calls for IM admits from thereferring known smokers to an onsite tobacco cessation pro- ED and clinics and triaged them to appropriate IM servicesgram only 10% of the time. Similarly, nurses were aware a (diabetes, hematology–oncology, teaching IM wards, trans-patient was a smoker 77% of the time. In these cases, nurses plant, or hospitalist); evaluated and assisted with dischargingreported they gave advice to quit 59% of the time and spent patients who were deemed to not require admission; wroteat least 10 minutes counseling patients on quitting only 13% consult/preoperative notes for patients better served on a sur-of the time. They referred patients to an onsite tobacco cessa- gical service; assigned unstable patients to critical caretion clinic in only 13% of cases. All providers cited multiple teams; arranged elective admits for nonemergent patients onreasons for lack of counseling and lack of referral to a post- alternate days based on bed capacity; performed diagnosticdischarge clinic including time constraints, a lack of prioriti- or therapeutic bedside interventions (e.g., large-volume para-zation, a belief that individual patients were not ready to centesis) on patients whose sole indication for admission wasquit, and a lack of awareness of tobacco cessation guide- the procedure. A prospective cohort of 88 HOD shifts waslines or postdischarge options. Conclusions: Hospitalization analyzed from July to October 2010 and compared with ais a missed opportunity to counsel on tobacco cessation, with historical control of 81 shifts over the same 4 months infew patients quitting postdischarge and few providers deli- 2009. Results: The HOD was contacted an average of 42.9vering evidence-based care. Despite quality measures for times/day over the 4-month study period. Of these, the HODassessing tobacco use and advising patients to quit, health discharged an average of 2.3 patients/day (5.3%), triagedcare providers face many challenges to implementing guide- 2.2 patients/day (5.1%) to nonmedicine services (e.g., EDline-based tobacco cessation care in the hospital. Quality observation, neurology, surgery), and triaged 2.2 patients/measures may need to be expanded to further promote the day (5.0%) to non–general internal medicine teaching/hos-use of evidence-based methods. Health care providers may pitalist services (e.g., cardiology, hematology). Overall, thebenefit from training and support in promoting tobacco ces- HOD altered the disposition of 6.7 patients per day, whichsation at all stages of the care continuum. accounted for 15.4% fewer admissions that would haveDisclosures: otherwise been admitted to the teaching IM ward/hospitalistL. M. Shah - none; V. Press - none; J. Krishnan - none; K. Suresh - none; V. services. In addition, there was a 47.6% decrease in theArora - none; D. Meltzer - none number of holdovers after implementation of the HOD (81.7% vs. 34.1%, P < 0.0001; RR, 0;42; CI, 0.31–0.57). Conclusions: A program of having a hospitalist triage all pro-112 posed IM admissions from the clinic and ED on weekdaysROBODOC: IMPACT OF A HOSPITALIST TRIAGE from 6 AM to midnight resulted in a more rationale allocation ofCOP ON MEDICINE ADMISSIONS AND ED patients to the inpatient service best fitted to their clinical needs,OVERCROWDING reduced the number of inappropriate admits, and decreased holdovers and overcrowding in the ED. Because of this, weMonal Shah, MD1, Amanda Stream, MD1, Kristin Alvarez, have been asked to expand the HOD shift from 18 to 24 hoursPharmD2, Kassidy James, MHS, PA-C2, Gary Reed, MD1, on weekdays and begin a 10-hour shift on Saturdays.Reeni Abraham, MD1, Stephen Harder, MD1, Phuong Tran, Disclosures:MD1, Dwain Thiele, MD1, Brent Treichler, MD1, EllenO’Connell, MD1, Ethan Halm, MD1; 1University of Texas South- M. Shah - none; A. Stream - none; K. Alvarez - none; K. James - none; G. Reed - none; R. Abraham - none; S. Harder - none; P. Tran - none; B. Treichler - none;western Medical Center, Dallas, TX; 2Parkland Health & Hospi- E. Halm - nonetal System, Dallas, TXBackground: Similar to national trends, the emergency 113department (ED) at our 960-bed institution faced increasing ASSESSING LEVEL OF AGREEMENT BETWEEN 3volume and overcrowding, resulting in delays in treatment, RISK STRATIFICATION MODELS TO PREVENTlower patient satisfaction, and concerns about quality. VENOUS THROMBOEMBOLISM IN HOSPITALIZEDBetween January 2009 and June 2009, the number of MEDICAL PATIENTSpatients treated in the ED rose by 24.5% compared with2008, causing an increase in internal medicine (IM) admits. Sunay Shah, MD, Shital Patel, MD, Jatin Rana, MD, HanishThe high volume of admissions combined with ACGME rules Singh, MD, Eiad Sabia, MD, David Paje, MD, Scott Kaatz,in the setting of limited inpatient providers resulted in a MD; Henry Ford Hospital, Detroit, MIpatient cap on the teaching IM ward and non–house staff Background: Venous thromboembolism (VTE) is a commonhospitalist services by July 2009. This led to a bottleneck of preventable cause of inpatient mortality. PharmacologicS70 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • TABLE 1 Distribution of Patients Based on Risk Assessment Method Disclosures: S. Shah - none; S. Patel - none; J. Rana - none; H. Singh - none; E. Sabia - none; Risk Assessment Model D. Paje - none; S. Kaatz - noneRisk Category Caprini Kucher Maynard 114Low 20 (16%) 97 (76%) 9 (7%)Moderate 57 (44%) 15 (12%) 116 (91%) A UNIT-LOCALIZED HOSPITALIST SYSTEM AND ITSHigh 51 (40%) 16 (12%) 3 (2%) IMPACT ON PATIENTS REQUIRING COMPLEX 128 128 128 DISCHARGE PLANNING Matthew Shaines, MD, William Southern, MD; Montefiore Medi- cal Center/Albert Einstein College of Medicine, Bronx, NYmethods are the preferred mode of prophylaxis accordingto guidelines. Various risk-assessment tools are available to Background: A unit-localized hospitalist physician is oftenassist physicians in identifying patients who should receive utilized to improve the overall efficiency of patient care.VTE prophylaxis when hospitalized. The objective of this The effect of this type of system specifically on dischargestudy was to determine the level of agreement between 3 time of day and length of stay (LOS) in patients with vary-published VTE risk stratification models. Methods: Adult ing discharge needs is unknown. Methods: We examinedpatients newly admitted to the general medical service electronic data on all discharges from a hospitalist servicewere assessed and were categorized as low, moderate, or in a large urban teaching hospital during 2 periods: (1)high risk for VTE based on the Caprini, Kucher, and May- when all care was offered by a unit-localized hospitalistnard risk stratification models. The level of agreement physician (July 2005–June 2007) and (2) when all carebetween the 3 models was determined using the weighted was offered by the same hospitalist physicians who werekappa statistic. Results: One hundred and eighty-four not unit-localized (July 2007–June 2008). All patients werepatients were assessed, and data were analyzed on 128 directly cared for by physician assistants, without housepatients. Those who were admitted with deep vein thrombo- staff involvement. A unit-localized hospitalist was defined assis or pulmonary embolism (11 patients) were excluded. An a physician who was responsible for patients exclusively onadditional 45 patients (24%) had to be excluded because 1 medicine ward. A nonlocalized hospitalist was responsi-of missing clinical data that prevented calculation of 1 or ble for patients on up to 5 geographically separate wards.more of the scores or assignment to a risk category. There The main outcome measures were time of day of dischargewas poor agreement between the Caprini and Kucher (j 5 and inpatient LOS. For each discharge, demographic, labo-0.205), Caprini and Maynard (j 5 0.165), and Kucher ratory, and diagnosis data were extracted from our clinicaland Maynard risk assignments (j 5 0.051). The Maynard information system. The Charlson comorbidity score wasscale identified most patients (91%) as moderate risk, calculated for each discharge. Discharges cared for bywhereas the Kucher scale scored 76% of patients as low unit-localized versus nonlocalized hospitalists were com-risk. The Caprini scale never classified a patient at a lower pared with respect to time of day of discharge and LOSrisk when compared with the Kucher scale. The rates of using t tests and Wilcoxon rank sum tests as appropriate.pharmacologic prophylaxis and of any prophylaxis did not Because varying discharge dispositions will require increas-correlate with the level of VTE risk as determined by the 3 ingly complex discharge planning, we further explored thescales. Conclusions: We found poor agreement between 3 differences between the subsets of patients dischargedpublished risk assessment models for VTE. The rates of pro- home, home with services, and to skilled nursing facilities.phylaxis in all risk categories were generally high in our Multiple linear and Poisson regression models were con-institution, where we follow an ‘‘opt-out’’ policy, and did structed to assess the independent associations betweennot correlate with the level of risk as determined by the 3 unit-localized care and time of day of discharge and LOS,models. Future studies are needed to validate the most use- after adjustment for demographic and clinical characteris-ful tool in clinical practice. tics and comorbidities. Results: One thousand one hundred and thirty-six discharges by unit-localized hospitalists wereTABLE 2 Proportion of Patients in Each Risk Category Receiving Prophylaxis compared with 531 discharges by nonlocalized hospital- ists. Overall and within the home discharge disposition sub- Caprini Kucher Maynard groups, there was no significant difference in the length ofRisk Category Pharmacologic Any Pharmacologic Any Pharmacologic Any stay or time of discharge between the 2 systems. In the sub- set of patients discharged to a skilled nursing facility, thereLow 85% 95% 85% 94% 100% 100% was a significant decrease in length of stay in the patientsModerate 88% 93% 93% 100% 85% 94% cared for by a unit-localized hospitalist when comparedHigh 84% 96% 88% 94% 67% 100% with a nonlocalized structure (7.46 vs. 10.94 days; P < 0.05), with no significant difference in the time of dis-Any, pharmacologic or nonpharmacologic methods of VTE prophylaxis, that is, sequential compres- charge (5:46 PM vs. 5:16 PM; P 5 0.17). Conclusions: Asion devices. unit-localized hospitalist system had no overall effect on a Hospital Medicine 2011 Abstracts S71
    • patient’s discharge efficiency but did significantly impact the discharge process must include effective verbal commu-LOS of those patients with the most complex discharge nication with the patient about discharge care plans andplanning. should include information about healthy lifestyle changes.Disclosures: Disclosures:M. Shaines - none; W. Southern - none M. Shoeb - none; S. Merel - none; M. Jackson - none; A. Himmel - none; S. Martinez - none; B. Anawalt - none115PATIENTS VALUE VERBAL COMMUNICATION 116ABOUT DISCHARGE CARE PLANS OUTCOMES OF LOCALIZING HOSPITALIST-Marwa Shoeb, MD, Susan Merel, MD, Molly Jackson, MD, PHYSICIAN ASSISTANT TEAMS TO A NURSINGAllison Himmel, MD, Shay Martinez, MD, Bradley Anawalt, UNITMD; University of Washington, Seattle, WA Siddhartha Singh, MD, MS1, Sergey Tarima, PhD1, MaryBackground: Studies show that hospitalized patients do not Conti, BSN, RN2, Vipul Rana, MD1, David Marks, MD, MBA1; 1understand their postdischarge care plan. Increased patient Medical College of Wisconsin, Milwaukee, WI; 2Froedtertinvolvement in care has been found to improve outcomes; Hospital And the Medical College of Wisconsin, Milwaukee,understanding the care plan is the first step in engaging WIpatients. Several groups, including the Institute for Health- Background: Localization of medical teams to a hospitalcare Improvement and the Agency for Healthcare Research unit has been shown to improve nurse–provider communica-and Quality, provide resources such as Project BOOST tion, but its affect on patient outcomes is unknown. Meth-(Better Outcomes for Older Adults through Safe Transitions) ods: Between April 1, 2010, and July 10, 2010, weto optimize the hospital discharge process. The resources conducted a trial of localizing patients assigned to 2 hospi-include printed ‘‘care plans’’ that have reminders of key talist–physician assistant (HPA) teams to 1 nursing unit. Weaspects of postdischarge care. There are few studies about concurrently compared their outcomes with the outcomes ofwhat patients’ preferences are regarding the content of patients assigned to 2 similar HPA teams with patients dis-these care plans. We sought to identify what patients view persed throughout the hospital to more than 10 units (theas some of the essential elements of a posthospitalization usual practice). Patients with a principal diagnosis of sickleplan. Methods: We surveyed English-speaking adult inpati- cell disease (SSD) were excluded from the analysis, as theyents ! 18 years or their proxies with an anonymous written were preferentially assigned only to the nonlocalizedsurvey on the second day of admission to internal medicine teams. A faculty admitting medical officer (AMO) assignedwards at an academic hospital and a county hospital in patients to each team and did not use any clinical criteriaSeattle, Washington. Results: We enrolled 240 patients or (other than diagnosis of SSD) to make this assignment. Theproxies, and 200 completed the survey; 10.4% were ineli- AMO was asked to assign at least 5 admissions to eachgible and 6.3% refused. Of patients, 92.5% completed the nonlocalized team every day. Nonlocalized teams did notsurveys. The majority were 18–59 years (80%), male take new patients beyond a maximum census of 16 patients(62.5%), and had at least a 4-year-college education each. The AMO assigned new patients to the localized(45%). One hundred percent of patients valued the follow- teams to keep the nursing unit patient census (32) full.ing items as essential: ‘‘when you need to follow-up with Beyond these guidelines, the AMO was asked to considerPCP,’’ ‘‘warning signs to call PCP,’’ and ‘‘medicines to con- the team’s perceived workload and use judgment in decid-tinue posthospitalization.’’ One hundred percent of patients ing assignment. We used linear mixed models for compar-wanted ‘‘a lot of information about my condition’’ and ‘‘test ing log-transformed length of stay and charges andresults,’’ but only 39% wanted ‘‘a lot of information about generalized linear mixed models for comparing 30-day riskmy medications’’ (P < 0.0001). When asked to choose the of readmission. We controlled for age, race, sex, payermost important piece of information, 67.5% of patients status, weekend admission/discharge, comorbidities, princi-chose ‘‘lifestyle changes.’’ The majority of patients (64.5%) pal diagnosis and the effect of repeat admissions of thesurveyed wanted verbal discharge instructions, with only same patient. This study was reviewed by the institutional10.5% requesting written discharge instructions (P < review board and granted an exemption as a quality assur-0.0001). One hundred percent of patents thought that per- ance project. Results: Six hundred and fifty-five admissionssonal communication between the inpatient provider and were assigned to the localized teams, and 541 (non–sicklethe outpatient primary care provider was ‘‘extremely impor- cell) admissions were assigned to the nonlocalized teams.tant’’ or ‘‘essential.’’ Conclusions: Patients uniformly place These admissions were similar except that patients on loca-high value on (1) verbal (more than written) communication lized teams were older. Compared with patients cared forabout discharge care plans; (2) personal communication by nonlocalized teams, patients cared for by localizedbetween inpatient and outpatient providers; and (3) infor- teams had a 11% longer adjusted length of stay (P 5mation about lifestyle changes (more than medications) for 0.022) but similar charges and similar 30-day risk of read-improved health. To engage patients in postdischarge care, mission (see Table 1). Conclusions: Our study revealed aS72 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • TABLE 1 Outcomes of Patients Assigned to Localized Hospitalist–Physician patients each. The AMO assigned new patients to the loca-Assistant (HPA) Teams Versus Nonlocalized HPA Teams lized teams to keep the nursing unit patient census (32) full. Beyond these guidelines the AMO was asked to consider Nonlocalized the team’s perceived workload and use judgment in decid- Localized HPA Teams HPA teams P Value ing assignment. We collected billing information to deter- mine total encounters for providers on these teams as aAdmissions 655 541Patients 616 518 measure of clinical workload. We determined number ofUnadjusted analysis pages to each provider during work hours (from 7 AM to 6 Length of stay, 2.58 (1.37–4.90) 2.28 0.017 PM) through our telecommunication records. For the final 15 median (IQR) (1.30–4.27) days of the intervention period, we asked the physician as- Charges, median (IQR) 11,732 11,621 0.540 sistant (PA) on each team to wear a pedometer and record (7386–20,749) (7284–19,740) steps taken during her or his workday as a measure of non- 30-Day readmission 98 (15.31%) 82 (15.33%) 0.994 value-added work. We used generalized estimating equa- rate, n (%) tions to determine the effect of localization on the numberAdjusted analysis of patient encounters per day by the HPA team, number of Length of stay, % change (CI) 11.8% (2.15–22.5) ref 0.022 pages during work hours to the HPA team, and number of Charges, % change (CI) 0.2% (28.1% to 9.3%) ref 0.961 30-Day readmission rate, 0.97% 0.68%–1.38%) ref 0.857 steps taken by the PAs while accounting for repeated meas- OR (CI) ures per provider. This study was reviewed by the institu- tional review board and granted an exemption as a qualityIQR, interquartile range; n, number; CI, confidence interval; OR, odds ratio; ref, referent assurance project. Results: Nonlocalized teams performed an average of 11 billable patient encounters and received 28 pages between 7 AM and 6 PM, and the nonlocalizedcounterintuitive finding of higher length of stay when we PAs took 5554 steps during the workday. In comparison,localized HPA teams—an intervention designed to promote localized HPA teams averaged 0.99 more billable patientefficiency. This finding needs to be further explored within encounters a day (CI, 0.41–1.58; P 5 0.001) anda wider context of other measures of quality of care such as received 11.93 fewer pages every day (CI, 10.95–12.91;patient satisfaction, failure to rescue rates, and process meas- P < 0.001). PAs on localized teams walked 1182 fewerures. In addition, as new patients could be assigned to the steps during the workday (CI, 2215 to 2580; P 5 0.097).localized teams only when the nursing unit had open beds Conclusions: Our study shows that localizing HPA teams todue to discharges, there may have been a perverse incentive 1 nursing unit allowed them to perform more clinical workpromoting longer length of stay to keep the unit census high. while decreasing the number of interruptions from pages.Disclosures: Fewer pages may also mean that localized HPA teamsS. Singh - none; S. Tarima - none; M. Conti - none; V. Rana - none; D. Marks - communicated more with nurses directly—a safer andnone richer mode of communication than phone communication or orders. In addition, the pedometer data suggest that non-117 value-added work represented by number of steps walkedTALK THE WALK TO DO MORE: LOCALIZING per day may have been lower on localized teams. In sum-HOSPITALIST PHYSICIAN ASSISTANT TEAMS TO A mary, localizing HPA teams to 1 nursing unit has a dramati-SINGLE UNIT IMPROVES WORK FLOW cally positive impact on their work flow. Disclosures:Siddhartha Singh, MD, MS1, Vipul Rana, MD1, Cheryl Jenks,BSN, RN2, Kathleen Idstein, PA-C1, David Marks, MD, MBA1; S. Singh - none; V. Rana - none; C. Jenks - none; K. Idstein - none; D. Marks -1 none Medical College of Wisconsin, Milwaukee, WI; 2FroedtertHospital, Milwaukee, WIBackground: Localization of medical teams to a hospital 118unit is an attractive way to organize hospitalist services but DECREASED RATE OF COMPLICATIONS WITHits operational impact on work flow has not been exam- PROPOFOL SEDATIONS BY A HOSPITALIST GROUPined. Methods: Between April 1, 2010, and July 10, THROUGH IDENTIFICATION AND REDUCTION OF2010, we localized patients assigned to 2 hospitalist–physi- RISK FACTORScian assistant (HPA) teams on 1 nursing unit. We concur-rently compared the operational outcomes of these Mythili Srinivasan, MD, PhD, Leanne Depalma, MD, Michaellocalized teams with 2 similar HPA teams with patients dis- Turmelle, MD, Jingnan Mao, MS, Douglas Carlson, MD;persed throughout the hospital to more than 10 units (the Washington University School of Medicine, St. Louis, MOusual practice). A hospitalist faculty admitting medical offi- Background: Propofol is widely used to sedate children forcer (AMO) was asked to assign at least 5 admissions to radiological procedures. Because propofol is an anesthetic,each nonlocalized team every day. Nonlocalized teams its use in the past was restricted to anesthesiologists. Thedid not take new patients beyond a maximum census of 16 hospitalist group at St. Louis Children’s Hospital (SLCH) suc- Hospital Medicine 2011 Abstracts S73
    • cessfully performed more than 1600 propofol sedations 119between 2005 and 2009. A chart review of patients EVALUATION OF THE ACCURACY OFsedated with propofol over that period showed that the rate INFORMATION IN QUALITY IMPROVEMENTof adverse events such as apnea, obstruction, desaturation, SEDATION FORMS IN COMPARISON WITHand need for airway interventions was 9.8%. However, MEDICAL CHARTSthat rate dropped from 11% in 2005 to 2.3% in 2009. Mythili Srinivasan, MD, PhD, Kim Hamlin, MD, YasmeenOur goal was to identify risk factors and patient characteris- Daud, MD, Douglas Carlson, MD; Washington Universitytics that changed between 2005 and 2009 and that con- School of Medicine, St. Louis, MOtributed to the decreased rate of events. Methods: The CPTcode for deep sedation was used to identify all patients (n Background: Ongoing evaluation of sedation programs5 1649) sedated by hospitalists from January 2005 and individual physician performance are important ele-through September 2009 at SLCH. Charts were reviewed ments in a successful sedation program. In our institution,to determine factors associated with an increased likelihood quality improvement (QI) forms are used to track adverseof adverse events. Odds ratios (ORs) with 95% confidence events occurring during procedural sedation. Despite wide-intervals were calculated by comparing the likelihood of spread use of similar forms, there are little available data toevents in a given group to that of the entire patient popula- support the accuracy of such systems in reflecting actualtion. Results: Several factors contributed to a decreased events that occur during sedations. Our objective was tolikelihood of adverse events in the period from 2005 to assess the accuracy of QI forms in reporting adverse events2009. The percentage of patients in American Society of associated with propofol sedations. Methods: Since JanuaryAnesthesiology (ASA) category 3 decreased from 10% to 2007, sedation providers in our hospital have filled out a2%, whereas those in ASA category 1 increased from 25% paper QI form after the completion of sedation, and theto 50%. ASA 3 patients had an increased likelihood of data are subsequently entered into a computerized data-events, with an OR of 1.6 (0.96–2.6), whereas ASA 1 base. We had previously reviewed 1649 charts of patientspatients had a lower likelihood, with an OR of 0.66 sedated with propofol from 2005 to 2009. Based on this(0.45–0.99). Premedication with oral Versed was signifi- chart review, we identified 67 patients who experiencedcantly associated with events, with an OR of 1.6 (1.2–2.3); adverse events during propofol sedation between Januaryits use decreased from 41% to 3.3% of patients between 2007 and September 2009. The QI database was queried2005 and 2009. Likewise, patients given Robinul to control about these 67 patients to determine the concordancesecretions had a higher likelihood of events, with an OR of between the QI forms and medical charts. Results: Only 408.0 (2.7–24); its use decreased from 5.6% to 3.2% of of the 67 patients (60%) were identified as having adversepatients. Occurrence of events was significantly higher in events in the QI database. We were able to recover infor-patients > 12 years: OR, 3.9 (2.4–6.3). The fraction of this mation for 56 of the 67 patients from the QI database. Thepatient population dropped 2-fold from 8.0% to 3.8% over information in 29 of the 56 QI sheets (50%) matched thethat period. Additional risk factors for events were identi- events as recorded in the chart. In the 27 QI sheets that didfied, but they did not change in frequency over that period: not match the medical charts, the majority were casesa history of snoring, with an OR of 2.5 (1.8–3.5), and where events such as insertion of oral airway (11), adminis-coughing during the procedure, with an OR of 50 tration of continuous positive airway pressure (3), or(22–116). Conclusions: The safety of propofol sedations increased oxygen requirement (3) were not recorded in thecan be improved by identification and reduction of risk fac- QI form. There was 1 emergent anesthesia consult and 3tors. Patient characteristics associated with adverse events procedures that were aborted because of complicationsare ASA 3 and age > 12 years, whereas ASA 1 patients that were not recorded in the QI sheet. For the remaininghave fewer events. Procedurally, premedication with oral 7, an adverse event was recorded in the QI database butVersed and the use of Robinul to control secretions predis- not in the medical chart. We also found that premedicationpose to adverse events. Appropriate patient selection and with midazolam during propofol sedations increase the like-cautious use of adjuvant medications significantly improves lihood of adverse events in our initial propofol study. Of thepatient safety during propofol sedation performed by a hos- 67 charts identified with events, 18 patients were premedi-pitalist group. cated with Versed, but this was recorded in the QI form inDisclosures: only 9 cases (50%). Conclusions: Reporting adverse eventsM. Srinivasan - none; L. Depalma - none; M. Turmelle - none; J. Mao - none; D. on paper-based QI forms appears to be inaccurate in ourCarlson - none institution. There are likely multiple reasons for underreporting adverse events. Sedation providers enter the information at the conclusion of the sedation rather than concurrently. At the end of a successful sedation, minor interventions are often not believed to be significant and are not recorded. The structure of the QI forms may also have posed a barrier for capturing all events. As our institution moves forward to electronic seda-S74 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • tion forms in the near future, there may be opportunities tocreate a program in which the QI form is automatically gener-ated from the actual sedation forms.Disclosures:M. Srinivasan - none; K. Hamlin - none; Y. Daud - none; D. Carlson - none120COMBINED EFFECT OF MULTIDISCIPLINARYBEDSIDE ROUNDING AND REAL-TIMEVISUALIZATION OF PROPHYLAXIS STATUS ONHOSPITAL-ACQUIRED VENOUSTHROMBOEMBOLISM IN A SURGICAL INTENSIVECARE UNITJason Stein, MD1, Melissa Chesson, PharmD2, Alley Killian,PharmD2, Mary Still, RN2, Justin Rykowski, BS2, Traci Leong,PhD3, David Tong, MD, MPH1; 1Emory University School ofMedicine, Atlanta, GA; 2Emory Healthcare, Atlanta, GA; ary rounding teams may represent an important mechanism to3 Rollins School of Public Health, Atlanta, GA improve hospital outcomes.Background: Hospital-acquired venous thromboembolism Disclosures:(HA-VTE) is a predictable complication that increases mor- J. Stein - Emory, entitled to royalty payments from Emory patent licensed commercially; M. Chesson - none; A. Killian - none; J. Rykowski - none; T.bidity and mortality. Despite overwhelming evidence sup- Leong - none; D. Tong - noneporting the effectiveness of VTE prophylaxis, safe, effective,and cost-efficient methods to prevent VTE remain underuti-lized. In the high-risk patient population of a surgical inten- 121sive care unit (ICU), we examined the effect on HA-VTE COLLABORATION OF PHARMACISTS ANDwhen a unit-based multidisciplinary team conducted bed- HOSPITALISTS TO INCREASE USE OF ADA-side rounds using a dynamic dashboard designed to RECOMMENDED INSULIN REGIMENS IN INTERNALenable real-time visualization of VTE prophylaxis status. MEDICINE PATIENTS: IMPLEMENTATION OF AMethods: A retrospective, observational analysis was con- PILOT PROGRAMducted of all patients cared for in a single 20-bed SICU forthe 12 months before and after introduction of the dynamic Sanjeev Suri, MD, MBA, Jeff Ketz, PharmD, Jun-Yen Yeh, PhD;dashboard (2008 vs. 2009). A total of 154 patients met Cleveland Clinic, Cleveland, OHinclusion criteria, having both a SICU stay and a diagnosis Background: American Diabetes Association (ADA) goalscode for VTE. A total of 101 patients met exclusion criteria: for hospitalized patients include: premeal blood glucose53 patients had VTE diagnosed prior to admission or within (BG) < 140 mg/dL, random BG < 180 mg/dL, and avoid48 hours of admission, and 48 patients had no radio- hypoglycemia (BG < 70 mg/mL). To achieve these goals,graphic evidence to confirm the diagnosis of VTE despite the ADA recommends use of basal-mealtime-supplementalthe diagnosis code for VTE. The primary outcome was the (BMS) insulin regimens, avoidance of sliding-scale insulinrate of HA-VTE per 1000 patient-days. Secondary outcomes monotherapy (SSIM), and adjustment of insulin based onwere the rates of lower-extremity deep vein thrombosis (DVT), BG. We evaluated a collaborative model involving hospi-upper-extremity DVT, pulmonary embolism, and potentially tal-based pharmacist and hospitalist physicians for its effec-preventable HA-VTE per 1000 patient-days, which was tiveness in increasing the implementation of ADA-defined as development of a HA-VTE in the absence of VTE recommended regimens and on attainment of ADA glyce-prophylaxis. Results: In 2008, 35 patients developed an HA- mia targets in hospitalized patients. Methods: This was aVTE, compared with 18 in 2009. The rate of HA-VTE per prospective, randomized, open-label, parallel-group trial in1000 patient-days decreased from 5.84 to 3.10 (RR, 1.89; diabetic inpatients prescribed insulin. Hospitalist physi-CI, 1.04–3.53; P 5 0.036). The rate of potentially preventa- cian–led medical teams were randomized to study interven-ble HA-VTE per 1000 patient-days decreased from 2.00 to tion (INV) or usual care (UC). In the INV group, to meet the0.52 (RR, 3.87; CI, 1.05–21.39; P 5 0.041). Other second- ADA glycemia targets, hospital pharmacists evaluated BGary outcomes were reduced but did not achieve statistical sig- control daily along with the nutritional intake of hospita-nificance. Conclusions: The addition of real-time visualization lized patients. They made recommendations, as needed,of VTE prophylaxis status to multidisciplinary bedside rounds for adjustment of the insulin regimen to the medical teamcoincided with decreased rates of HA-VTE in a SICU. Combin- using a weight-based insulin dosing algorithm and ADAing real-time, actionable performance data with the structure guidelines. Physicians in the UC group prescribed insulinand accountability afforded by daily unit-based multidisciplin- according to their usual practice. Results were also com- Hospital Medicine 2011 Abstracts S75
    • pared with a historical cohort (HC). Results: One hundred ing an in-hospital stroke during the study period. At theand eighty-eight UC and 181 INV subjects were enrolled time of this interim analysis, data had been entered on 32over 29 weeks. Ninety-six patients were studied in the HC. of those patients. Mean age was 74 years, 53% wereMean daily blood glucose was 194 mg/dL in the HC, 176 women, and 88% were white. Five of the patients (15%)mg/dL in the UC group, and 179 mg/dL in the INV group died in the hospital, 7 (22%) were dead by 30 days, and(P < 0.001 HC–INV). More insulin adjustments were per- 9 (28%) by 90 days. In 28 patients, we were able to deter-formed in the INV group: 423 in the INV group, 184 in the mine the time of onset of symptoms and calculate the timeUC group, and 94 in the HC group (P < 0.001 UC–INV). from onset to completion of the CT scan. Only 19 patientsHypoglycemic event days—10.8% in the HC group, 10% had witnessed onset of symptoms. Of these, 1 had a seri-in the UC group, and 8.7% in the INV group—occurred ous risk for bleeding, 1 had experienced serious sideless often in the INV group (P 5 NS). The INV group used effects from tPA, and 5 were terminally ill. This left 12basal insulin 60.3% of days versus 52% in the UC group (P patients (42%) eligible for treatment with tPA. None of< 0.001). BMS regimens were utilized 23.3% of the days them received tPA. Fewer than 5% of eligible patientsin the INV group versus 18.5% in the UC group (P 5 received dysphagia screening or DVT prophylaxis. Conclu-0.004). Use of SSIM was 46.2% in the UC group and sions: This study identified several opportunities for improving39.1% of days in the INV group (P < 0.001). Conclusions: the management of IHS patients at SJMH including timelyHospitalist–-pharmacist collaboration increased the use of availability of diagnostics and use of thrombolytic therapies.basal insulin and BMS regimens and decreased the use of Disclosures:SSIM without increased risk of hypoglycemia. A nonscienti- L. Swaminathan - none; S. Hickenbottom - nonefic survey of the hospitalists showed that they valued theinput of the hospital pharmacists in managing the insulin 123regimen of their patients. RETROSPECTIVE REVIEW OF PATIENTS ADMITTEDDisclosures: WITH SELF-MUTILATION INJURIES IN AS. Suri - none; J. Ketz - none; J. Yeh - none NONUNIVERSITY TEACHING HOSPITAL122 Lakshmi Swaminathan, MD1, Rebecca Daniel, MD2; 1Oak-IN-HOSPITAL STROKES IN A NONUNIVERSITY wood Hospital, Dearborn, MI; 2St. Joseph Mercy Hospital,TEACHING HOSPITAL Ypsilanti, MILakshmi Swaminathan, MD1, Susan Hickenbottom, MD2; 1Oak- Background: Self-mutilation has been defined as the deliber-wood Hospital, Dearborn, MI; 2St. Joseph Mercy Health Sys- ate commission of recurrent socially unacceptable directtem, Ann Arbor, MI physical harm to one’s own body without conscious suicidal motivation. There is evidence that self-mutilation hasBackground: In-hospital stroke (IHS) represents 5%–15% of become more prevalent in the recent years. Self-mutilatingall hospitalized acute stroke cases and is associated with patients are often hospitalized for further evaluation andpoor outcomes. These patients may be excellent candidates management and evoke strong emotional responses fromfor rapid assessment and potential thrombolytic therapies. health care providers. The goal of our descriptive studyThis project aimed to study the magnitude of IHS in patients was to assess the prevalence and trends of self-mutilationadmitted to St. Joseph Mercy Hospital (SJMH), Ann Arbor,Michigan, and to compare the performance of IHS patientswith patients admitted with stroke on key Joint Commissionstroke quality indicators. Methods: This was a retrospectiveobservational study of IHS patients discharged from SJMHfrom January 2008 to December 2008. Cases includedpatients discharged with a secondary diagnosis of stroke(ICD-9 codes 430.0–436.0) during the study period.Patients with a medical history of stroke were excludedbased on the documentation of the new CMS modifier‘‘present on admission.’’ The hospital’s quality databasewas used to retrieve information on demographics, comor-bidities, length of stay, discharge disposition, and mortality.Data on quality of care and treatments were obtained bychart review by trained staff. Demographic, clinical, andoutcome variables were summarized using means, med-ians, and percentages, as appropriate. Wilcoxon rank sumtests for continuous variables, Z tests for proportions, andlogistic regression analysis for outcome variables were per- Incidence of self-mutilation relative to all self-inflicted injuryformed. Results: Forty-three patients were identified as hav- 2001–2008.S76 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • 124 SCORING HOSPITALIST ETIQUETTE Sean Tackett, MD, Darlene Tad-y, MD, Scott Wright, MD; Johns Hopkins Bayview Medical Center, Baltimore, MD Background: As physicians are forced to spend more time in ‘‘indirect’’ patient care activities, particularly on docu- mentation, it has become difficult to establish meaningful physician–patient relationships. Dr. Michael Kahn proposed a checklist of 6 etiquette-based behaviors as a strategy to improve physician rapport with patients. We hypothesized that the creation of a score for ‘‘etiquette-based medicine’’ (EtBM) score could allow for the grading of physician eti- quette. Methods: Eight hospitalists were randomly selected at each of 3 hospitals in the greater Baltimore area and were shadowed by a single observer during a nonadmitting shift between May and June 2009. Hospitalists knew only Cost of self-mutilation-related hospitalizations 2001–2008. that the observer was conducting a time–motion analysis. Each time the hospitalist entered a patient’s room, the ob-admissions at Saint Joseph Mercy Health System’s (SJMHS) server recorded whether ‘‘etiquette-based medicine’’ beha-Ann Arbor, Saline, and Livingston hospitals over the past 9 viors were performed: (1) knocking or asking to enter theyears and to understand the demographic and clinical char- patient’s room, (2) introducing oneself, (3) shaking theacteristics and cost burden associated with these patients. patient’s hand, (4) sitting down in the patient’s room, (5)Methods: This was a retrospective observational study of explaining one’s role in the patient’s care, and (6) askingpatients hospitalized with self-mutilation injuries at SJMHS about the patient’s feelings regarding the hospitalization orfrom January 2001 to December 2008. Self-mutilation his or her illness. The EtBM score for each physician wascases included all patients discharged from SJMHS with an characterized as percentages derived by dividing the num-intentional self-inflicted injury ICD-9 code E 956.0–E959.9. ber of times EtBM behaviors were performed by the numberThe SJMHS Quality Institute database was used to obtain of opportunities to carry them out. Physician activities weredemographic information, information on comorbidities, recorded at 30-second intervals and categorized as direct patient care (e.g., time spent with patients or their families),length of stay, readmission rate, and mortality and to esti- indirect patient care (e.g., documentation, coordinatingmate the cost burden. Demographic, clinical, and outcome care, writing orders), other activities (e.g., walking, admin-variables were summarized using means, medians, and istrative meetings, scholarly work), and personal activitiespercentages, as appropriate. We tested for increase in the (e.g., meals, restroom breaks, personal calls). Linear regres-overall admissions for self-mutilation and the proportion of sion was used to assess whether EtBM scores were asso-self-mutilation of all self-inflicted injuries using Cochrane- ciated with physician characteristics. Results: The 24Armitage tests of trend. We tested for cost trends using gen- observed hospitalists collectively saw 226 unique patientseral linear models. Results: There were 4606 cases of self- and had 389 patient encounters. The average shift lengthinflicted injury, 1113 of which (25%) were for self-mutila- was 9.9 hours (SD, 1.9 hours), and the average length oftion. Self-mutilators were young, male, and more likely to each patient encounter was 12 minutes (SD, 9 minutes).be incarcerated at the time of admission. These patients Overall, 18% of hospitalists’ time was spent in directhad psychiatric and substance abuse comorbidities, had patient care, 60% in indirect patient care, 13% in othermultiple admissions, and underwent recurrent foreign-body activities, and 9% in personal activities. EtBM scores for theremoval procedures. The trend of self-mutilation admissions providers ranged from a low of 3% to a high of 44%as a proportion of self-inflicted injuries over the 7 years of (mean, 19%). Physician age, sex, and experience were notobservation increased from 23% in 2001 to 36% in 2008 associated with EtBM scores. Physicians in the top quartileand was statistically significant (P < 0.0001). There was for EtBM score spent more time with each of their patientsalso an increase seen in self-mutilation admissions and than those in the bottom quartile (14 vs. 12 minutes) andassociated costs relative to all admissions to the hospital (P spent a greater proportion of their day in direct patient< 0.0001). Conclusions: There appears to be an increase care (21% vs. 16%); both P < 0.05. Conclusions: Higherin self-mutilation encounters over the past few years. Given EtBM scores were more common among physicians spend-their central role in caring for hospitalized patients, it is impor- ing more time with patients and may represent a marker oftant for hospitalists to be aware of this growing trend. Further patient-centered care. However, EtBM behaviors were infre-investigation into the causes and possible treatments including quently practiced by every hospitalist in the sample, thuspreemptive educational interventions are also warranted. indicating significant room for improvement.Disclosures: Disclosures:L. Swaminathan - none; A. R. Daniel - none; B. Singal - none S. Tackett - none; D. Tad-y - none; S. Wright - none Hospital Medicine 2011 Abstracts S77
    • 125 trative topics. Conclusions: Hospitalists spend only a smallCOMMUNICATION BETWEEN HOSPITALISTS AND proportion of their day discussing patient care with nurses.NURSES: A TIME–MOTION STUDY Because hospitalists and nurses work so closely together in patient care, studying the communication between these 2Darlene Tad-y, MD1, Flora Kisuule, MD2, Laura Rosenthal, MSN, groups could provide further insight in improving qualityACNP1, Scott Wright, MD2; 1University of Colorado Denver and efficiency of care, as well as patient outcomes.School of Medicine, Aurora, CO; 2Johns Hopkins School of Disclosures:Medicine, Baltimore, MD D. Tad-y - none; L. Rosenthal - none; F. Kisuule - none; S. Wright - noneBackground: Communication between nurses and physi-cians has been studied in settings of intensive care units, in- 126ternal medicine wards, operating rooms, and labor and DETERMINING THE MOST APPROPRIATEdelivery. These studies have shown that this communication RESOURCE FOR MAKING TELEPHONE FOLLOW-UPcan affect nursing retention and satisfaction, patient satis- AFTER HOSPITALIZATIONfaction, and patient safety. The interaction between hospi- Mohammad Taha, MD, Aroop Pal, MD; Kansas Universitytalists and nurses in caring for inpatients has not been wellstudied. Methods: The study was a cross-sectional observa- Medical Center, Kansas City, KStional study using time–motion techniques at 3 urban hospi- Background: Patients frequently encounter questions or pro-tals. Two institutions were academic centers, and 1 was a blems shortly after discharge. Telephone follow-up hascommunity hospital. The study was conducted over 3 become an essential part of transitions of care interventionsmonths during the spring of 2009. Eight hospitalists from to address postdischarge problems, increase patient satis-each hospital were chosen randomly to be observed during faction, and decrease readmission rate. There is no consen-a nonadmitting clinical day shift. During the observed sin- sus on who should make telephone follow-up calls. Thegle daytime shift, all activities, including direct and indirect objective of this study was to describe the frequency andpatient care, and nonclinical activities were timed and types of problems encountered by discharged patients andrecorded. Interactions and communication between each to use this data to determine which health care profes-hospitalist and nurses throughout the day were recorded sionals (nurse case manager, pharmacist, or physician) areunder indirect patient care. Summary and descriptive statis- best suited for making telephone follow-up calls. Methods:tics characterized the observed findings. Results: Twenty- Patients discharged by hospitalists were surveyed within 96four hospitalists were observed caring for 230 patients in hours of discharge using a standard phone script. The script389 follow-up patient encounters for a total of 14,421 min- included questions about patient understanding of admis-utes (approximately 600 minutes for each doctor). Of the sion diagnosis, follow-up plan, medication changes, and iftotal minutes, 506.7, or 3.5% of the total number of min- they had any new or worsening symptoms. Patient satisfac-utess, were spent interacting with nurses. On average, tion with telephone follow-up was also recorded on a scaleeach hospitalist spent 20.3 minutes in conversation with from 1 to 5. Questions and problems encountered bynurses (SD, 11.84 minutes). Of the time spent conversing patients were categorized into 4 groups: social issues, med-with nurses, hospitalists discussed 3 major topics with ication questions, follow-up questions, and new or worsen-nurses: patient plan of care (33% of time spent conversing ing symptoms. The appropriate resource to make the phonewith nurses), patient updates or progress (32%), and call (nurse case manager, physician, or pharmacist) waschanges to patient care (29%), with other topics including determined by based on the type and complexity of ques-nonmedical conversation, nursing questions, and adminis- tions. Results: Twenty-four percent of patients had questions or problems within 96 hours of discharge (questions from 21 of 90 patients surveyed). Thirty-three percent of ques- tions were related to social issues, 29% to medication, 25% to follow-up plan, and only 13% to new or worsening symptoms. Eighty-eight percent of questions could be addressed without the expertise of a physician either by nurse case manager or a pharmacist. Eighty-seven percent of patients indicated the telephone follow-up was ei- ther useful or very useful (4 or 5 on a scale from 1 to 5). Conclusions: Postdischarge questions are common, and they can be addressed through a telephone follow-up call made by a nurse case manager or a pharmacist. Disclosures: M. Taha - KU, none; A. Pal - KU, noneS78 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • 127 TABLE Reflective Writing ThemesA COST EFFECTIVE PANEL OF SENIORS SHAPESATTITUDES OF MEDICAL STUDENTS DURING EARLY N (% of students)CLINICAL EDUCATION Positive Experience with Elderly Pre Panel 17(71)Rudhir Tandon, MD, Amandeep Kalra, MD, Janet Jokela, MD, Examples of Student Statements:MPH, Robert Kirby, MD, Janet Reis, PhD; University of Illinois She told me many stories and illuminated for me theCollege of Medicine at Urbana-Champaign, Urbana, IL perspective of being a patient dependent on the care and attention of nurses.Background: Today’s medical students frequently lack positive He (patient with CHF) was very friendly about mc examiningopportunities for interaction with elderly people because of him and told me that he would be pleased to contributerestructuring and distribution of families according to age. How- to my medical education and that I should feel free toever, the elderly patient will be disproportionately represented come back to his room anytime I wanted.in many clinicians’ practices, with people 65 years and older Elderly patients are like any other patient capable of: makingconstituting about 38% of hospitals’ inpatient census nationwide their own decisions and play an important role in their awn health outcomes. Negative Experience with Elderly Pre Panel 4(17)TABLE 1 Pre-/Postresponses on Geriatric Attitudinal Scale Examples of Student Statements: I have had very few superbly positive experiences with the Pre-Test Post-Test elderly. They have all been demanding in lime and Mean and Mean and resources. I haven’t done internal medicine yet so that Standard Standard feeling may change, but I doubt it.Item Deviation Deviation P He almost seemed to accept that his current state of health would not improve.Most old people are pleasant to be with 3.83 4.08 NS Positive Experience with Provider/System Pre Panel 2(8) 0.70 1.10 Examples of Student Statements:It is a society’s responsibility to provide 4.00 3.75 NS The techniques used by my instructor were not used very care for its elderly persons 0.78 0.99 commonly in regular practice because of reliance on X-Elderly patients tend to be more 3.91 3.87 NS rays and CT scans but proved useful for identifying an appreciative of the medical care 1 0.67 0.87 undiagnosed tumor in a patient that would have been provide than are younger patients missed otherwise.It is interesting listening to old people’s 4.44 4.48 NS I suppose the thing that stands out most for me was the accounts of their past experiences 0.66 0.66 peace of mind each of them had knowing that theirI tend to pay more attention and have 3.00 3.26 0.05* medical care was not going to he a financial burden for more sympathy towards my elderly 0.74 0.69 their kids. patients than my younger patients Negative Experience with Provider/System Pre Panel 5(21)The Federal government should 2.54 2.25 NS Examples of Student Statements: reallocate money from Medicare to 1.10 I’ve seen several instances when a physician is telling some research on AIDS or pediatric bad or uncomfortable news to the patient but the patient diseases is treated as a third party in the discussion.If I have the choice, I would rather sec 3.33 2.79 0.025** She (mother-m-law) was also pushed aside and forgotten younger patients than elderly ones 1.2? 1.21 about and needed someoneMedical care for old people uses up 3.35 2.71 0.025** too much human and material 1.03 1.04 resources and 12.4% of the total population. Given these realities, it is im-As people grow older, they become less 2.88 2.58 0.09* portant to identify cost-effective ways to introduce medical stu- organized and more confused 0.80 0.97 dents to the needs of elderly patients. This study presents theTaking a medical history from elderly 3.22 3.00 NS results of a 90-minute interaction between medical students in patients is frequently m ordeal 1.09 1.00 their beginning clinical year and a panel of elders. Methods: AOld people in general do not 1.57 1.57 NS* mixed-method pretest–posttest intervention group design was contribute much to society 0.84 0.66 used for a 90-minute ‘‘White Coats Meet Gray Power’’ sessionTreatment of chronically ill old patients 2.17 2.04 0.09 with 25 students with varied clinical clerkship. The senior panel is hopeless 0.98 0.98 members included 3 men and 3 women older than 65 years.Old persons don’t contribute their fair 2.13 2.00 NS share towards paying for their health 1.06 0.90 Students completed a 14-item Geriatric Attitude Scale with a 5- care point Likert scale before and after the elderly panel, and stu-In general, old people act too slow for 2.17 2.09 NS dents and wrote pre- and postintervention narratives reflecting modern society 1.03 0.90 on ‘‘the most memorable experience they have had with an older adult who taught something important about medicine* one tailed p value and/or health care.’’ Paired t tests were used to compare the** two tailed p value student’s attitudes before and after the panel. Students’ reflec-N524 tions identified 3 major themes coded for positive and negative Hospital Medicine 2011 Abstracts S79
    • element,s with analysis of any changes in attitudes after inter- 128vention. Results: Several positive changes in attitudes toward THE IMPACT OF DRUG AND ALCOHOL DISORDERSthe elderly were seen at the conclusion of the panel. Students, in IN A UNIVERSITY-AFFILIATED PUBLIC HOSPITAL—Atheir written reflections, reported either no shift in their earlier CALL TO ACTIONpositive attitudes toward the elderly or a change in perception Julie Taub, MD, Angela Keniston, MPH, Richard Albert, MD;toward being more positive. Forty percent of those students with Denver Health & Hospital Authority, Denver, COno change in attitude had expressed positive experiences withthe elderly prior to the panel, and 30% in this same category of Background: The National Epidemiologic Survey on Alco-assessment of no change had written about some negative hol and Related Conditions indicates that American adultsexperiences. For those students determined to have developed a have a 30% lifetime prevalence of any alcohol disorderpositive attitude by the conclusion of the panel, 34% had com- and a 10% lifetime prevalence of any drug disorder. Themented on some previous negative experience. Conclusions: An purpose of this study was to determine the prevalence ofopportunity for a semistructured interaction between medical stu- alcohol and drug disorders in a university-affiliated publicdents in the beginning of their clinical training and a panel of hospital. Methods: This was a retrospective review of allelders provided a cost-effective method for introducing the stu- adult inpatient admissions to Denver Health for alcohol ordents to the perspectives and experiences of an older person. The drug abuse and addiction from 2005 to 2009. Patients <students were generally positive about the experience, suggesting 18 years old, pregnant women, prisoners, and patients onthat placing such a brief intervention in the context of medical stu- physical medicine and rehabilitation were excluded.dents’ clinical training may help to further expand students’ under- Encounters with 1 of the following admission or dischargestanding and appreciation of the needs of the older person. diagnoses were included: alcohol-induced mental disordersDisclosures: (291.0–291.9); alcohol dependence syndrome (303.0–303.9);R. Tandon - none; A. Kalra - none; J. Jokela - none; R. Kirby - none; J. Reis - none alcoholic polyneuropathy (357.5); alcoholic cardiomyopathy (425.5); alcoholic gastritis (535.3); alcoholic fatty liver (571.0); acute alcoholic hepatitis (571.1); alcoholic cirrhosis of liver (571.2); alcoholic liver damage, unspecified (571.3); excessive blood level of alcohol (790.3); accidental poisoning by alcohol, not elsewhere classified (E860.0); drug dependenceTABLE 1 Alcohol Only (n 5 9210) Drugs Only (n 5 4773) Alcohol and Drugs (n 5 2809) Total Encounters (n 5 16,792)Age* 48 Æ 12 42 Æ 12 42 Æ 11 45 Æ 12Sex (% male) 78% 66% 73% 74%Racey Hispanic/Latino/Spanish 2762 (30%) 1200 (25%) 770 (27%) 4732 (28%) African American 933 (10%) 1172 (25%) 606 (22%) 2711 (16%) White 4946 (54%) 2279 (48%) 1315 (47%) 8540 (51%) Other/unknown 564 (6%) 118 (2%) 117 (4%) 799 (5%)Payery Medicare 1520 (17%) 882 (18%) 434 (15%) 2836 (17%) Medicaid 2197 (24%) 1337 (28%) 732 (26%) 4266 (25%) Commercial 772 (8%) 231 (5%) 165 (6%) 1168 (7%) Self-pay 1459 (16%) 698 (15%) 492 (18%) 2649 (16%) Medically indigent 3152 (34%) 1559 (33%) 952 (34%) 5663 (34%) Other/unknown 110 (1%) 66 (1%) 34 (1%) 210 (1%)Homelessy 2421 (26%) 1303 (27%) 796 (28%) 4520 (27%)MICU daysy 2162 (23%) 732 (15%) 520 (19%) 3414 (20%)MICU length of stay (days){ 2.1 (2.0, 2.2) 1.8 (1.8, 2.0) 1.9 (1.8, 2.1) 2.00 (1.96, 2.08)SICU daysy 1012 (11%) 199 (4%) 189 (7%) 1400 (8%)SICU length of stay (days){ 1.9 (1.8, 2.0) 1.8 (1.5, 2.2) 1.9 (1.5, 2.3) 1.9 (1.79, 2.04)Any ICU (MICU/SICU) daysy 3052 (33%) 907 (19%) 691 (25%) 4650 (28%)Hospital length of stay (days){ 3.4 (3.3, 3.5) 3.5 (3.3, 3.6) 3.9 (3.8, 4.2) 3.54 (3.46, 3.58)Total charges{ $15,796 ($15,422–$16,090) $12,254 ($11,926–$12,500) $13,190 ($12,607–$13,662) $14,104 ($13,894–$14,291)Readmitted within 30 daysy 1108 (12%) 552 (12%) 357 (13%) 2017 (12%)* Mean Æ SD;y n (%);{ median (95% CI).S80 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • (304.0–304.9); and nondependent abuse of alcohol or drugs of repeated observations on each patient. The dependent(305.0, 305.2–305.9). Patients with multiple admissions were variable was IVC diameter, and the independent variablesconsidered separate encounters. Results: Alcohol and drug disor- were dummy variables for time 2 (yes/no) and time 3 (yes/ders accounted for 16,792 of 62,103 of all encounters (27%) no). Results: A convenience sample of 70 patients made upduring the 5-year review (see Table 1). Conclusions: At this hos- the primary study cohort. Most patients were obese (meanpital, alcohol and drug disorders are one of the most common weight, 236 pounds) and 60% had left ventricular systolicreasons for admission. They frequently require ICU-level care, dysfunction. Within 1 hour before furosemide, median IVCare associated with a high rate of 30-day readmission, and diameter was 2.25 cm (IQR, 1.88–2.55 cm), suggestingrepresent a significant cost to the health care system. Accord- that most patients had elevated right atrium pressures atingly, treatment standards should be developed and implemen- baseline (values > 1.8 cm suggest pressure elevation).ted similar to what exists for other common diagnoses that Between 1 and 2 hours after furosemide, IVC diameterwould facilitate evidence-based improvement in the care for decreased by 0.20 cm (95% CI, 0.13–0.27 cm). Then 2–4these important problems. hours after furosemide, it began to return to baseline butDisclosures: remained significantly below it by 0.12 cm (95% CI,J. Taub - none; A. Keniston - none; R. Albert - none 0.05–0.20 cm). Conclusions: In adult patients with heart failure exacerbation, the IVC diameter changes measurably in relation to the timing of intravenous furosemide. Interpre-129 tations of measurements of the IVC, therefore, should incorpo-INFERIOR VENA CAVA DIAMETER BEFORE AND rate the time since intravenous furosemide. Iterative assessmentsAFTER INTRAVENOUS FUROSEMIDE IN PATIENTS of IVC diameter in acute heart failure patients should be consis-ADMITTED WITH ACUTE HEART FAILURE tently scheduled in relation to intravenous furosemide.EXACERBATION Disclosures:Stefan Tchernodrinski, MD, Brian Lucas, MD, MS, FHM, Ambarish S. Tchernodrinski - none; B. Lucas - none; A. Athavale - none; C. Candotti - none; B. Margeta - none; A. Katz - none; R. Kumapley - noneAthavale, MD, Carolina Candotti, MD, Bosko Margeta, MD, ArielKatz, MD, Rudolf Kumapley, MD; John H. Stroger Hospital ofCook County, Chicago, IL 130Background: Sonographic measurement of the inferior vena PREVALENCE OF COMMUNITY-ACQUIREDcava (IVC) diameter is straightforward and reliably per- METHICILLIN-RESISTANT STAPHYLOCOCCUSformed by noncardiologists using hand-carried ultrasound AMONG CHILDREN WITH SKIN AND SOFT-TISSUE(HCU) at patients’ bedsides. It provides a noninvasive esti- INFECTIONSmate of the right atrium pressure and might be a moreaccurate marker for fluid overload in acute heart failure Carlos Teran, MD, Cynthia Donkor, MD, Thant Lin, MD, Sunitapatients when compared with the traditional bedside clini- Sura, MD, Mohamed Tarek, MD, Marsha Medows, MD; Newcal evaluation. Yet it is not known whether IVC measure- York University, New York, NYments vary in relation to the timing of intravenous Background: The prevalence of community-acquired methi-furosemide. This is an important consideration because the cillin-resistant Staphylococcus aureus (CA-MRSA) infectionseffectiveness of intravenous furosemide is known to peak among the pediatric population has been gradually increas-rapidly, within hours of administration. We sought to deter- ing over the years. Similarly, the resistance to other familiesmine whether there is a noticeable difference in the IVC di- of antibiotics has also developed rapidly in communityameter before and after intravenous furosemide strains, leading to a large burden on the health system.administration. Methods: We performed an observational Methods: The aim of the study was to determine the preva-study in a large, public teaching hospital. Potential eligible lence of CA-MRSA among skin and soft-tissue infections inpatients were identified from a list of daily admissions to children from a large community in north Brooklyn, Newthe general medicine inpatient service. We enrolled adult York. Secondary goals were to know the prevalence of re-patients with a diagnosis of acute heart failure exacerba- sistance to cotrimoxazole, erythromycin, and clindamycintion who were prescribed intravenous furosemide. Exclusion in accordance with the D-test. We also describe and ana-criterion was a serum albumin < 3 mg/dL. Ultrasonogra- lyzed the most common diagnoses, days of hospitalization,phy of the IVC was performed by a hospitalist attending and chosen antibiotics associated with CA-MRSA. We ret-physician and a second-year internal medicine resident rospectively reviewed medical records of patients < 18who underwent a 6-hour training program. HCU was used years seen in the hospital with a diagnosis of skin, bone, orto capture 2-dimensional grayscale images of the IVC soft-tissue infections from January 2008 to August 2010. Allthrough the subcostal window. Measurements were those patients with cultures positive for MRSA wereobtained at 3 times: (1) within 1 hour before furosemide, included and analyzed. Results: A total of 603 patients(2) between 1 and 2 hours after furosemide, and (3) with skin and soft-tissue infections were reviewed. In 181 ofbetween 3 and 4 hours after furosemide. We used a ran- them, a culture was obtained. One hundred and twenty-sixdom-intercept multilevel model to account for the clustering of the cultures were positive for Staphylococcus aureus, of Hospital Medicine 2011 Abstracts S81
    • which 76 (60.3%) were CA-MRSA. Of the isolates, 97.3% pate, 65 responded (response rate, 56%). Sixty-four percentwere sensitive to cotrimoxazole, 88.1% to clindamycin, of respondents were female, and 56% were between 26 andand only 7.8% to erythromycin. The D-test was negative in 35 years old. The mean number of years working as a PAall those strains resistant to erythromycin and sensitive to was 8 years, with 4.3 years working as a hospitalist PA.clindamycin, confirming the susceptibility to this antibiotic. About half (48%) became hospitalists immediately after grad-The main diagnosis associated with CA-MRSA was gluteal uating from PA school. Of 19 core competence clinical condi-abscess (34.2%), followed by leg cellulitis and abscess tions, prior to starting their hospitalist careers, they had the(11.8%). Of those with CA-MRSA, 57.8% required hospital- most clinical experience taking care of patients with diabetesization (mean, 3.3 Æ 2.5 days). Clindamycin was the pre- mellitus (4.5), urinary tract infection (4.5), and asthma (4.3)ferred drug in hospitalized patients (65.1%). Cephalexin and the least amount of experience taking care of patients(40.2%) followed by clindamycin (28.5%) were the favor- with hospital-acquired pneumonia (3.2), sepsis syndromeites initial drugs prescribed for outpatient cases. Conclu- (3.3), and alcohol and drug withdrawal (3.4). Conclusions:sions: The prevalence of CA-MRSA is high (41.9%) among PAs who are choosing hospitalist careers are young, andskin and soft-tissue infections in children in our community. they have limited prior clinical experience in the hospital. TheThe sensitivity of CA-MRSA to cotrimoxazole and clindamy- noted variations in clinical experience level with specific clini-cin is still favorably high, and the presence of clindamycin- cal conditions mandates that hospitalist programs be learnerinducible macrolide-lincosamide-streptogramin B resistance centered so as to provide tailored guidance and oversight toamong the strains is very low in our community. newly hired hospitalist PAs.Disclosures: Disclosures:C. Teran - none; C. Donkor - none; T. Lin - none; S. Sura - none; M. Tarek - H. Torok - none; C. Lackner - none; R. Landis - none; S. Wright - nonenone; M. Medows - none 132131 A CROSS-SECTIONAL STATEWISE STUDY OFHOW CLINICALLY EXPERIENCED ARE THE PREVENTABLE HOSPITALIZATION RATES AMONGPHYSICIAN ASSISTANTS WHO ARE JOINING THE MEDICAID RECIPIENTSHOSPITALIST WORKFORCE? Srilaxmi Tumuluri, MD, Gavin Hougham, PhD, David Meltzer,Haruka Torok, MD, Christina Lackner, PA, Regina Landis, BS, MD/PhD; University of Chicago, Chicago, ILScott Wright, MD; Johns Hopkins Bayview Medical Center, Background: States in the United States have wide latitudeBaltimore, MD in administering Medicaid, thus creating an opportunity toBackground: Hospital medicine is the fastest-growing medical study interstate differences in quality and outcomes amongfield in the United States. Given a pressing shortage of hospi- Medicaid recipients. Studying statewise variations in pre-talist physicians and restrictions on resident duty hours, the ventable hospitalization (PH) rates for ambulatory-sensitivenumber of physician assistants (PAs) in hospital medicine is conditions (ASC) can provide insights into the quality andonly expected to increase. In 2006, the Society of Hospital access to health care services in this patient population.Medicine (SHM) identified 51 core competencies in hospital Methods: We evaluated state variations in PH rates amongmedicine. Limited general medicine inpatient experience dur- Medicaid recipients using hospital discharge data from theing PA school necessitates substantial on-the-job training to re- AHRQ’s National Inpatient Sample (NIS) database foralize proficiencies related to these competencies. We 2003. The NIS contains data from 8 million hospital stays,conducted a survey study to understand the clinical experi- or about 90% of all hospital discharges in the Unitedence level of hospitalist PAs on starting their hospitalist States. We used hospital discharge data from the NIS tocareers. Methods: After obtaining institutional review board obtain a cross-sectional sample of hospitalizations for eachapproval, an Internet-based survey was distributed to 116 available state. Hospitalizations with a primary diagnosisPAs identified in the Facebook group ‘‘PAs in Hospital Medi- that was either ambulatory sensitive or a marker (ambula-cine.’’ Subjects were eligible to participate if they were PAs tory insensitive) were included. Ambulatory-sensitive, or pre-with experience working in hospital medicine settings taking ventable, hospitalizations are those that can be potentiallycare of adult internal medicine inpatients. The survey content avoided by access to timely primary care. In contrast,was guided based on the clinical topics within SHM’s core marker conditions are relatively insensitive to primary carecompetencies, and participants were asked to rate their expe- access. Because Medicaid enrollment varies throughout therience level in each of the 19 clinical conditions prior to start- year, the number of marker hospitalizations, which occur ating their hospitalist careers using a 5-point Likert scale relatively constant rates in populations, was used in the de-ranging from 1 5 ‘‘knew nothing about the condition’’ to 5 nominator. We calculated the ratio of preventable to5 ‘‘had experience taking care of many (>5) patients.’’ marker conditions for 37 U.S. states. Results: We calcu-Once the survey was completed, the results were analyzed lated ratios of preventable to marker hospitalizationsusing Stata. Descriptive statistics were used to identify their among Medicaid recipients for each state in 2003. Nation-clinical experience level. Results: Of the 116 invited to partici- ally, there was 6.6 times as many preventable hospitaliza-S82 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • tions as marker hospitalizations, but this ratio varied across tion logic models for all stakeholders. Barriers to vaccinestates from 3.04 to 11.74. The data were distributed nor- administration were placed on a fishbone diagram. Themally, but there was significant regional clustering. States percentage of patients screened for vaccination on admis-in the Southeast and Southwest had significantly higher PH sion, percentage of patients receiving the vaccination, andrates compared with the rest of the country (P < 0.01). All percentage core measures compliance were identified asthe Southeastern states had rates that were above the U.S. key process measures and used to determine the effect ofmean, whereas those in the Pacific Northwest had rates the interventions. The interventions identified and agreed onbelow the U.S. mean. Among states with large Medicaid by the interdisciplinary team were: an educational interven-populations, New York, New Jersey, Texas, and Florida tion targeting nurses, a redesign of the vaccine screeninghad higher rates, whereas Illinois and California had lower tool incorporating qualitative feedback, employment of arates of preventable hospitalizations. Conclusions: States real-time nursing dashboard on each hospital unit thathave varying rates of Medicaid population hospitalization noted which patients needed screening and vaccination,for ambulatory-sensitive conditions. There is nearly a four- modification of vaccine administration from the day of dis-fold difference between states with the highest and lowest charge to 900 AM the second day of admission, and use ofPH rates, with states in the Southeast having the highest a social work consult to trigger vaccine screening in the in-rates. Several factors could explain this varying propensity tensive care unit. Results: Before introduction of the interven-for hospitalization. Patient factors, such as demographic tions, the vaccine administration compliance rates wascharacteristics, health status, and care preferences, as well 40%. Introduction of an educational intervention did notas physician supply and practice style could help explain result in an increase in vaccination rates. Rapid implemen-PH variation. Differing Medicaid eligibility, coverage, and tation of a user-friendly vaccine screening tool, a real-timephysician reimbursement rates could also affect statewise nursing dashboard, and modification of the time of vaccinePH variation. Future research to identify the causes of this administration were key initiatives that resulted in the per-variation will be useful to policymakers as they craft Medic- centage of patients who received ‘‘perfect vaccine care’’ toaid policy that aims to reduce hospitalization costs. increase to 95.4% for the entire system. Conclusions: TheDisclosures: use of a multidisciplinary team and appropriate quality improvement tools to identify interventions resulted in aS. Tumuluri - none; G. Hougham - none; D. Meltzer - none marked improvement in vaccination rates. Disclosures:133 D. S. VanderEnde - none; N. Spell - none; K. Graham - none; T. Wilds - none;A SYSTEMATIC APPROACH TO INCREASING B. McKee-Waddle - none; L. Hurt - none; J. Gibbons - none; D. Bowen - none; C. Batchelder - none; R. Gitomer - nonePNEUMOCOCCAL AND INFLUENZAVACCINATION RATES AMONG HOSPITALIZEDPATIENTS 134Daniel VanderEnde, MD, DTM&H, Nathan Spell, MD, Kim- THE TRANSFUSION PRACTICES OF HOSPITALISTSberly Graham, RN, Tracey Wilds, RN, Becky McKee-Waddle, AT A SINGLE TERTIARY-CARE CENTER AND THEIRRN, Laura Hurt, RN, Juanita Gibbons, RN, Dawnette Bowen, RESPONSE TO AN EDUCATIONAL INTERVENTIONRN, Carol Batchelder, RN, Demetrice Askew, RN, Marilyn Daniel VanderEnde, MD, DTM&H, Katarina Topchan, MD;Margolis, RN, Pam Sapp, RN, Cheryl Wheeler, RN, Leslie Emory University, Atlanta, GACaesar, RN, Courtenay Wannamaker, RN, Rosalynn Comer, Background: Blood transfusion raises many questions ofRN, Bridgett Stroud, RN, Richard Gitomer, MD; Emory Univer- safety and economics. We examined blood usage and itssity, Atlanta, GA characteristics in patients taken care of by hospitalists, aBackground: Inadequate vaccination of eligible inpatients group of physicians for whom there is a scarcity of publishedagainst influenza and pneumococcal infections is a gap in data. We also sought to determine if an educational interven-quality care that contributes to the spread of disease in the tion changed hospitalist transfusion practice patterns. Meth-community. Rates of vaccination at Emory University hospi- ods: Hospitalist transfusion practices at a 550-bed inner-citytals were noted to be 40% with a desired rate > 90%. The community teaching hospital were assessed from Novemberobjective of this study was to evaluate the reasons for the 1, 2006, to January 31, 2007, with a retrospective chartfailure to vaccinate all eligible inpatients in the hospital sys- review of the first transfusion performed on each patienttem against influenza and pneumococcal infections and to cared for by a hospitalist. Following a 2-month educationaldevelop interventions to improve vaccination rates. Meth- intervention, hospitalist transfusion practices were reassessedods: An interdisciplinary team including administration, nur- from April 1, 2007, to June 30, 2007, and compared withsing staff, physicians, pharmacists, information the preeducation period. Patients who were on dialysis ortechnologists, and secretarial staff performed a qualitative were admitted from a clinic for transfusion were excluded.and quantitative review of the vaccine process. Quality Data collected included age, sex, pretransfusion hemoglobinimprovement tools used included a conceptual model, a level, primary cause of anemia, primary reason for admis-process flow diagram, and behavior determinate interven- sion, and whether cardiac disease was present. Pre- and post- Hospital Medicine 2011 Abstracts S83
    • education populations were compared using age, sex, and bedside nurse assessment frequency was calculated as theICD-9 codes extracted from the hospital billing database and mean number of assessments for each patient-day. Forsubjected to statistical analysis. Results: Enrollment criteria for each research nurse CAM-ICU and RASS assessment, wethe study were met by 248 patients. The most common rea- selected the closest bedside nurse assessment that was nosons for transfusion in the pre- and posteducation periods more than 4 hours apart. We assessed agreement withwere anemia of chronic disease, followed by acute blood weighted kappa statistics. To describe the nature of dis-loss, chronic blood loss, hemolytic anemia, and B12 or folate agreement, we calculated sensitivity and specificity of bed-deficiency. Sixty-one percent of patients were admitted for side nurse assessments of delirium compared with thereasons other than anemia or active bleeding. Following the research nurse assessments. Results: Five hundred and teneducational intervention there was a 65.7% drop in the total patients were assessed. Their median age was 58 (IQR,number of transfusions (P < 0.0001). Decreased use 47–67), 12% had cognitive impairment prior to admission,occurred in all causes of anemia but only reached statistical and the median APACHE II score at enrollment was 27,significance in patients with hemolytic anemia (P 5 0.006) indicating a high severity of illness. Bedside nursesand anemia of chronic disease (P < 0.0001). Although there assessed delirium (CAM-ICU) and sedation (RASS) an aver-was a trend toward a lower mean pretransfusion hemoglobin age of 7.4 (SD, 2.9) and 7.8 (SD, 3) times per patient-day,after the educational intervention, it did not reach statistical respectively. There were 7156 CAM-ICU and RASS pairedsignificance by unpaired t tests comparing groups, even after assessments within 4 hours; 98% of these occurred 2a stepwise analysis was performed to eliminate outlying hours apart. Across the entire population, there was sub-values. Conclusions: The decrease in the number of transfu- stantial agreement between bedside and research nursessions performed after the educational intervention suggests (CAM-ICU weighted kappa, 0.67; 95% CI, 0.66–0.70;that mistransfusions occur frequently in many types of anemia, RASS weighted kappa, 0.66; 95% CI, 0.64–0.68). Agree-and education may be an effective way to promote the appro- ment was stable regardless of severity of illness, preexistingpriate use of red blood cells. Further studies are needed to vali- cognitive impairment, and study year. The sensitivity anddate our observations and corroborate their significance. specificity of delirium nurse assessments was 0.81 (95% CI,Disclosures: 0.78–0.83) and 0.81 (95% CI, 0.78–0.85), respectively,D. VanderEnde - none; K. Topchan - none corresponding to a positive and negative likelihood ratio of 4.3 (95% CI, 3.6–5.2) and 0.2 (95% CI, 0.2–0.3), respec- tively. Conclusions: We have demonstrated that delirium135 and sedation measurements performed by bedside nursesICU BEDSIDE ASSESSMENTS OF DELIRIUM: are sustainable and a reliable source of information. TheseSUSTAINABILITY AND RELIABILITY measures can be used for clinical decision making, quality improvement, and quality measurement activities.Eduard Vasilevskis, MD1, Alessandro Morandi, MD2, Leanne Disclosures:Boehm, MSN, RN, ACNS-BC2, Pratik Pandharipande, MD,MSCI1, Timothy Girard, MD, MSCI2, James Jackson, PsyD2, E. Vasilevskis - none; A. Morandi - none; L. Boehm - Hospira Inc., honoraria; P. Pandharipande - Hospira Inc. and GlaxoSmithKline, honoraria; T. Girard -Jennifer Thompson, MPH2, Ayumi Shintani, PhD, MPH2, Hospira Inc., honoraria; J. Jackson - none; J. Thompson - none; A. Shintani -Brenda Pun, RN, MSN, ACNP2, E. Ely, MD, MPH2, Sharon none; B. Pun - Hospira Inc., honoraria; E. Ely - Eli LIlly, Pfizer, Hospira Inc., Aspect Medical Systems, GlaxoSmithKline, grant support and honorariaGordon, PsyD1; 1Tennessee Valley VA, Nashville, TN; 2Van-derbilt University, Nashville, TNBackground: Delirium affects 50% of intensive care unit 136(ICU) patients and is associated with increased mortality USE AND APPROPRIATENESS OF FRESH FROZENand long-term cognitive impairment. Instruments can accu- PLASMA TRANSFUSIONS AMONG ADULTrately measure delirium; however, the sustainability and INPATIENTSreliability of delirium measurement tools are unknown inusual practice. We therefore examined delirium assess- Larissa Verda, MD, PhD, Emilio Araujo Mino, MD, Aarti Man-ments by ICU bedside nurses during routine clinical care chanda, MD, Sumedha Dhar, MD, Saurabh Gupta, MD, Nasercompared with concurrent measurements made by research Yamani, MD, Ariel Katz, MD, Brian Lucas, MD, MS, FHM;personnel. Methods: This prospective cohort study included John H. Stroger Jr. Hospital of Cook County, Chicago, ILpatients admitted to medical or surgical ICUs between Background: Inappropriate fresh frozen plasma (FFP) prescrip-2007 and 2010 at a tertiary-care teaching hospital. We tions may account for at least some of the dramatic increaseexcluded patients with states preventing delirium assessment seen in FFP transfusions. In particular, FFP prescribed for bleed-(e.g., severe baseline cognitive impairment, inability to ing prophylaxis prior to invasive procedures may be largelyunderstand English). Delirium was independently measured unwarranted. FFP should only be transfused when indicated,by bedside nurses and reference-rater research nurses using because like any medical therapy, it can cause harm. FFP canthe Confusion Assessment Method for the Intensive Care lead to fluid overload, febrile and allergic reactions, transfusion-Unit (CAM-ICU) and the Richmond Agitation-Sedation Scale related acute lung injury, alloimmunization, and infection. The(RASS), a component of the CAM-ICU. CAM-ICU and RASS aim of this study was to assess the appropriateness of FFP trans-S84 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • fusions at 1 hospital. Methods: We reviewed the blood bank TABLE 1 Patient Characteristicsrecords from our 450-bed public teaching hospital to identifypatients older than 18 years who received at least 1 FFP transfu- MICU cases CICU casession between January 1, 2008, and December 31, 2009. n % n % P ValueAmong these patients, we randomly selected 500 FFP ordersand reviewed the electronic medical records. We adapted Total number of patients 100 NA 41 NArecommendations from the College of American Pathologists to Average age (years) 67 NA 72 NA 0.105classify FFP transfusions as appropriate or not. Appropriate clini- Female 57 57% 27 65.9% 0.331cal indications were (1) treatment of active bleeding in a coagu- Chronic Organ deficiency 59 59% 22 53.7% 0.56lopathic patient; (2) bleeding prophylaxis prior to an invasive Severe sepsis (as documented by 88 88% 21 51.2% < 0.001procedure in a coagulopathic patient; (3) blood transfusion organ dysfunction,large enough to replace a full blood volume with subsequent hypoperfusion, and hypotension)evidence of coagulopathy; (4) reversal of warfarin to stop active Mechanical ventilation 43 43% 14 34.1% 0.331bleeding or to conduct an emergent, invasive procedure; and Primary site of Infection(5) plasma exchange for thrombotic thrombocytopenic purpura. a) Lung 60 60% 20 48.8% 0.222 b) Bloodstream 15 15% 6 14.6% 0.956Coagulopathy was defined as a prothrombin time or an acti- c) Abdomen 1 1% 1 2.4% 0.512vated partial thromboplastin time > 1.5 times the midpoint of d) Urine 25 25% 11 26.8% 0.821the normal range. In patients whose coagulation parameters e) Other 7 7% 4 9.76% 0.579did not meet the criteria for coagulopathy, we used additional Sepsis processeslaboratory values to classify FFP orders as probably appropri- Received antibiotics within 60 minutes 46 75.4% 12 66.7% 0.461ate. These laboratory values included hemoglobin < 8.0 g/dL, Central venous oxygen saturation checked 39 54.9% 13 56.5% 0.894platelet count < 50 k/lL, and serum creatinine level > 3.0 Lactate checked in patients with 58 95.1% 18 100% 0.337mg/dL. Results: During the 2-year study period, 1029 adult sepsis and hypotensioninpatients received 1781 orders for FFP, with an average of ICU processes5.6 units transfused per order. After random selection of 500 DVT prophylaxis on day 1 74 74% 20 48.8% 0.004 GI prophylaxis on day 1 68 68% 18 43.9% 0.012FFP orders, we excluded 54 because of missing laboratorydata. Using our definitions of appropriateness, the remaining464 FFP transfusions were classified as appropriate in 43%(95% CI, 38%–47%), inappropriate in 40% (95% CI, MICU. Methods: All patients admitted with a possible diag-36%–45%), and possibly appropriate in 17% (95% CI, 13 nosis of sepsis between July 2009 and January 2010 to ei-%–20%). One third of FFP transfusions (149 of 446) were given ther the MICU or the overflow cardiac intensive care unitfor bleeding prophylaxis prior to invasive procedures, and 40% (CICU) were identified by querying hospital databases usingof these were inappropriate. Conclusions: These early data sug- key words that included pneumonia, sepsis, hypotension,gest that 2 of every 5 FFP transfusion orders are inappropriate. high lactate, hypoxia, UTI/urosepsis, SIRS, hypothermia,Quality improvement initiatives aimed at changing current FFP and respiratory failure. The electronic medical record (EMR)transfusion practices are warranted. and patient charts were reviewed, and patients with sepsis were identified using published objective criteria. A standar-Disclosures: dized data extraction instrument was used to characterizeL. Verda - none; E. Araujo Mino - none; A. Manchanda - none; S. Dhar - none;S. Gupta - none; N. Yamani - none; A. R. Katz - none; B. P. Lucas - none the process-of-care interventions via a systematic review of the patient charts and EMR. The chi-square test was used to compare the patient care interventions in the MICU and the137 CICU. Results: A total of 197 patients were identified fromPROCESS-OF-CARE OUTCOMES FOR PATIENTS WITH the electronic databases, and 141 patients were identifiedSEPSIS: MEDICAL ICU VERSUS OVERFLOW ICU to have sepsis based on objective criteria. One hundredKittane Vishnupriya, MBBS1, Scott Wright, MD1, Olufunmilayo patients were admitted to the MICU, and 41 patients wereFalade, MD2, Addisu Workneh, MD2, Satish Chandolu, admitted to the CICU in the study period. Age and sex dis-MBBS2, Regina Landis2, Kaweesa Elizabeth2, Jonathan Sev- tributions were comparable in the 2 groups (both P >ransky, MD1; 1Johns Hopkins University, Baltimore, MD; 2Johns 0.05). The MICU patients had a higher proportion ofHopkins Bayview Medical Center, Baltimore, MD patients (88% vs. 51%; P < 0.001) with severe sepsisBackground: Sepsis is a major cause of death in hospitalized (sepsis patients with documented organ dysfunction, hypo-patients. The preferred setting to care for patients with sepsis perfusion, or hypotension). There were no significant differ-is the medical intensive care unit (MICU). However if the ences between the groups in percentage of patients withMICU is full, patients are admitted to overflow units. Protocols mechanical ventilation, chronic organ deficiency, and pri-for management of sepsis patients that include specific pro- mary site of infection. There were no significant differencescess-of-care interventions are associated with better out- in process-of-care interventions in the categories of percentcomes. We hypothesized that process-of-care interventions of patients receiving antibiotics within 60 minutes (75.45%are more strictly adhered to when sepsis patients are in the vs. 66.7%), percentage with central venous oxygen satura- Hospital Medicine 2011 Abstracts S85
    • tion checked (54.9% vs. 56.5%), and percentage with lac- more infections (13.3%) than ORAL patients (9.5%) andtate level checked (95.1% vs. 100%). The MICU had a NoDM patients (6.9%). The overall mortality rate was 1.7%.significantly higher proportion of patients who received The rate was 3.2% in diabetics, far higher in IRDM patients,DVT prophylaxis on day 1 (74% vs. 48.8%; P 5 0.004) at 4.4%, compared with 1.7% in ORAL patients and 1.5% inand gastrointestinal (GI) prophylaxis on day 1 (68% vs. NoDM patients. Examining the inpatient subset of the popula-43.9%; P 5 0.012). Conclusions: In the study period, the tion revealed similar results. A total of 377,594 patients wereMICU had a higher proportion of patients with severe sep- analyzed, of whom 17.6% were diabetic and 7.5% weresis. There were no significant differences in the measured IRDM patients. Diabetics again displayed higher mortalityprocess-of-care interventions in the MICU versus CICU (OR, 1.73) and postoperative complications (OR, 1.52), withexcept in the categories of DVT and GI prophylaxes on IRDM patients typically showing an even higher likelihood ofday 1, which were better adhered to in the MICU. mortality (OR, 2.20) and complications (OR, 1.83). Conclu-Disclosures: sions: Diabetes is predicted to affect half of all Americans byK. Vishnupriya - none; S. Wright - none; O. Falade - none; A. Workneh - none; 2020. Even gross classification of this common disease canS. Chandolu - none; R. Landis - none; E. Kaweesa - none; J. Sevransky - none result in significant predictive value and aid in the process of assessing operative risk and counseling patients. Further work138 is warranted to develop simplified but broader risk models toDIABETES AND PERIOPERATIVE RISK EVALUATION predict and modify perioperative risk in these patients.IN MEDICAL PRACTICE Disclosures:Peter Watson, MD, Maria Farooq, MD, Ilan Rubinfeld, MD, M. Farooq - none; P. Watson - none; I. Rubinfeld - noneMBA; Henry Ford Hospital, Detroit, MIBackground: Assessing perioperative risk is a common chal- 139lenge in daily internal medicine practice. Risk models are A SIMPLIFIED FRAILTY INDEX TO PREDICTsparse and focus primarily on cardiac and pulmonary risk. Lit- PERIOPERATIVE RISK IN THE ORTHOPEDICtle has been established regarding the implications of more POPULATIONcommon diagnoses. Affecting 23.5 million Americans, diabe-tes mellitus has long been associated with poor wound heal- Peter Watson, MD, Heath Antoine, Andrew Swartz, Vic Vela-ing. In the American College of Surgeon’s National Surgical novich, MD, Ilan Rubinfeld, MD, MBA; Henry Ford Hospital,Quality Improvement project (ACS-NSQIP) a simplified data Detroit, MIpoint regarding diabetes is gathered, splitting diabetics into 3 Background: There are limited tools to aid in stratifying peri-categories: none, oral diabetic treatment, and insulin. We operative risk in orthopedic surgical patients. Frailty has beenhypothesized that diabetes would represent an important di- associated with poor clinical outcomes yet is difficult to mea-agnosis in stratifying risk. Methods: We utilized the ACS- sure. We sought to better understand the implications ofNSQIP public use files (PUF) from 2005 to 2008. This was frailty measures for perioperative risk stratification. Wedone under their data use agreement and under the supervi- hypothesized that a simplified modification of the Canadiansion of our institutional review board. Patient with diabetes Study of Health and Aging frailty index (FI) could be con-were compared with those without including demographics structed from standard demographic variables. Furthermore,and outcomes. Data were evaluated using chi-square analysis we hypothesized that this index would serve as a robustin SPSS. Unless otherwise specified, significance of all predictor of postoperative morbidity and mortality. Methods:reported proportions and odds ratios was P < 0.001. Results: Under the Data Use Agreement of the American College ofOf 635,265 patients in the data set, 85.5% did not have dia- Surgeons, and with institutional review board approval, thebetes (NoDM), 8.7% took oral medication (ORAL), and National Surgical Quality Improvement Program (NSQIP) Par-another 5.8% required insulin (IRDM). African Americans ticipant Utilization File was accessed for the yearscomprised 9.8% of the study population. Among African 2005–2008 for inpatient orthopedic patients. PreoperativeAmericans in the data set, DM was more prevalent (OR, 1.7) clinical NSQIP variables were matched to 1 of the 71 FI vari-and there was a far greater rate of IRDM (OR, 2.15) than in ables. There were 11 matches (changes in daily activities,the remaining population. Patients older than 60 years had malignant disease, gastrointestinal problems, respiratory pro-higher rates of diabetes (OR, 2.31) and IRDM (1.89) than blems, clouding or delirium, hypertension, lung problems, car-those younger than 60. Men had higher rates of IRDM diac problems, congestive heart failure, and other medical(6.5%) than women (5.2%). DM patients were more likely to problems). A modified perioperative FI was determined byexperience postoperative complications (OR, 1.88) and mor- the number of NSQIP variables above in which an abnormal-tality (OR, 2.15) than NoDM patients. In addition, the subset ity was present divided by the number of items consideredof IRDM patients experienced significantly higher rates of (11), with an increase in the FI implying increased frailty. Thecomplications (OR, 2.37) and mortality (OR, 2.87). IRDM outcomes assessed were 30-day wound occurrence, infection,patients experienced more wound occurrence (9.9%), fol- any occurrence, and mortality. Statistical analysis was donelowed by ORAL patients (6.7%) and then NoDM patients using chi-square analysis and stepwise logistic regression.(4.9%); P < 0.001. Patients with IRDM also experienced Results: There were 67,308 patients with 3913 wound occur-S86 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • group) and 3 employee-type practices (14.9% multispecialty practice, 43.3% hospital, and 12.0% university or medical school). Significant differences across the practice models were seen in the number of work shifts per month, number of billable encounters per shift, hours of nonclinical work, and compensa- tion. No differences in job or specialty satisfaction were detected in hospitalists across the practice models. A majority of hospitalists perform nonreimbursable activities such as coor- dination of patient transfers (92.0%) and quality improvementrences, 6691 infections, 12,847 occurrences of all kinds, (84.7%). Compared with nonleaders, group leaders workedand 2800 deaths in the database. Table 1 summarizes the significantly more hours on nonclinical tasks per month (48.0proportion of patients experiencing each occurrence based vs. 25.2, P < 0.001) but receive greater compensation. Com-on the FI. As the FI increased, postoperative mortality pared with men, women earned a smaller income (P < 0.001)increased (P < 0.001). Stepwise logistic regression using the but worked fewer hours per month (153.0 vs. 164.3, P 5FI, with NSQIP variables of age, work RVU, ASA class, 0.006) and saw fewer patients per shift (14.2 vs. 15.3, P 5wound classification, emergency status, and functional status, 0.017). Conclusions: Similar levels of satisfaction are reportedwas significant (P < 0.001), with the FI having the highest by hospitalists across practice models despite significant differ-odds ratio (OR) for each occurrence: wound occurrence (OR, ences in practice patterns and compensation. The hospital med-9.8), infection (OR, 5.4), any minor/major occurrence (OR, icine specialty offers opportunities to group leaders and5.1), and death (OR 3.1); P < 0.001 for all occurrences women who appear more satisfied with the specialty than theirreported. Conclusions: A frailty index based on simple, preop- respective counterparts.eratively identifiable patient clinical information can accu- Disclosures:rately assess the risk of postoperative morbidity and mortality. K. Hinami - Northwestern University, employee; C. T. Whelan - LoyolaThe use of such an index may be an easy method to improve University, employee; R. J. Wolosin - Press Ganey Associates, employee; J. A. Miller - Society of Hospital Medicine, employee; T. B. Wetterneck - Universityperioperative risk stratification in high-risk elderly populations. of Wisconsin, employeeDisclosures:P. Watson - none; V. Velanovich - none; I. Rubinfeld - none; H. Antoine - none 141 WORK LIFE AND SATISFACTION OF HOSPITALISTS140 Tosha Wetterneck, MD, MS1, Keiki Hinami, MD, MS2, RobertSATISFACTION AND VARIABILITY IN HOSPITALIST Wolosin, PhD3, Joseph Miller, MS4, Chad Whelan, MD,5;PRACTICE MODELS 1 University of Wisconsin School of Medicine and PublicTosha Wetterneck, MD, MS1, Keiki Hinami, MD, MS2, Chad Health, Madison, WI; 2Northwestern University FeinbergWhelan, MD3, Robert Wolosin, PhD4, Joseph Miller, MS,5; School of Medicine, Chicago, IL; 3Press Ganey Associates,1 University of Wisconsin School of Medicine and Public South Bend, IN; 4Society of Hospital Medicine, Philadelphia,Health, Madison, WI; 2Northwestern University Feinberg PA; 5Loyola University Stritch School of Medicine, Chicago, ILSchool of Medicine, Chicago, IL; 3Loyola University Stritch Background: The number of hospitalists in the United StatesSchool of Medicine, Chicago, IL; 4Press Ganey Associates, continues to grow rapidly, yet little is known about the workChicago, IN; 5Society of Hospital Medicine, Philadelphia, PA life of hospitalists to inform whether hospital medicine is aBackground: Nearly two thirds of U.S. hospitals are served by viable long-term career for physicians. Methods: A nationalhospitalists who work under a variety of practice models. Differ- random stratified sample of 3105 potential hospitalists plusences in hospitalist practice patterns and satisfaction of indivi- 662 hospitalist employees of 3 multistate hospitalist compa-dual hospitalists across these models are unknown. Methods: nies were administered the Hospital Medicine PhysicianWe surveyed a randomized stratified sample of 3105 potential Worklife Survey. The survey assessed demographic informa-hospitalists augmented by 662 hospitalist members of 3 multi- tion, 2 global dimensions of satisfaction (job and specialty),state hospitalist companies. Details about respondents’ demo- and 10 satisfaction domains: workload, compensation, caregraphics and current practice model were assessed focusing quality, organizational fairness, autonomy, availability of per-on hospital and organizational characteristics, intensity and sonal time, and relationships with colleagues, staff, patients,distribution of work, patient load, types of responsibilities, and and leader. Differences in satisfaction by sex, specialty, age,compensation. Job and specialty satisfaction were measured and experience were sought using bivariate and multivariateusing validated instruments. Pediatrician hospitalists were ana- regression analyses. The relationships between the 2 globallyzed separately, and subanalyses comparing group leaders satisfaction measures and their satisfaction domains wereversus nonleaders and women versus men were performed. examined. The prevalence of burnout symptoms and theirResults: We achieved an adjusted response rate of 25.6% relationship with longevity were explored. Results: Afterfrom the sample. Hospitalists were distributed across 2 group- excluding ineligible surveyees, 776 hospitalist responses fromtype practices (12.4% local groups and 15.0% multistate the sample (adjusted response rate, 25.6%) were analyzed Hospital Medicine 2011 Abstracts S87
    • together with 40 hospitalist responses from the sponsoring which included the variables white, time, and their interac-organizations. Thirty-four percent of respondents were tion. The white 3 time interaction was assessed using thewomen, and 7.1% were pediatricians. Among the satisfac- likelihood ratio test (LRT). Also, after the interaction wastion domains, hospitalists rated care quality and relationships found not significant, the LRT test was performed to test forwith staff and colleagues highest, whereas compensation, trends over time. Results: Most measures had improved per-organizational climate, autonomy, and availability of perso- formance in both white and nonwhite institutions. Beforenal time were rated relatively low. In adjusted analysis, care public reporting, white institutions performed better thanquality was most highly correlated with job satisfaction (R 5 nonwhite institutions on 9 of 11 measures. After controlling0.302), whereas personal time was most highly correlated for hospital correlations over time, white hospitals outper-with specialty satisfaction (R 5 0.295). Satisfaction with com- formed nonwhite hospitals on 5 of 11 measures. The great-pensation was correlated the least with both job and specialty est difference was seen in door-to-balloon time (whitesatisfaction. Women and pediatricians were more satisfied hospitals’ performance rate ratio, 1.35; 95% CI,with the specialty than their counterparts. Job burnout symp- 1.13–1.61; relative to nonwhite hospitals). After publictoms were reported by 29.9% of respondents, who were reporting, the disparity gap disappeared in 4 of 5 of thesemore likely to leave and reduce work effort. Conclusions: The measures. In door-to-balloon time, the rate ratio was 1.00majority of hospitalists appear to be engaged in sustainable after public reporting. In no instance was there a worseningcareers, but domains that appear to drive job and specialty of the disparity gap. Conclusions: Significant racial dispari-satisfaction warrant institutional attention to minimize burnout ties exist at baseline in process-of-care measures for 2 com-and attrition of hospitalists. mon cardiac conditions. Among UHC institutions,Disclosures: post–public reporting performance was higher than preper-K. Hinami - Northwestern University Feinberg School of Medicine, employee; formance. This improved overall improvement led to eitherC. T. Whelan - Loyola University Stritch School of Medicine, employee; R. J. no significant change in, a reduction in, or elimination ofWolosin - Press Ganey Associates, employee; J. A. Miller - Society of HospitalMedicine, employee; T. B. Wetterneck - University of Wisconsin School of the baseline disparity gap. This study suggests that publicMedicine and Public Health, employee reporting tied to financial incentives may lead to improved overall care while lowering the racial disparity gap through local quality improvement efforts.142 Disclosures:PUBLIC REPORTING AND RACIAL DISPARITIES: C. T. Whelan - none; R. A. Durazo-Arvizu - none; G. Steinhardt - none; R. S.DOES IT AFFECT THE DISPARITY GAP? Cooper - noneChad Whelan, MD1, Ramon Durazo-Arvizu, PhD1, GeorgeSteinhardt, MS2, Richard Cooper, MD1; 1Loyola University Chi- 143cago, Maywood, IL; 2Boston University, Boston, MA BOOST: IMPACT OF A QUALITY IMPROVEMENT PROJECT TO REDUCE REHOSPITALIZATIONSBackground: Racial disparities in the quality of health careare well recognized in the United States. Multiple factors Mark V. Williams, MD1, Luke Hansen, MD1, Jeffrey Green-drive this disparity gap in quality, but few strategies have wald, MD2, Eric Howell, MD3, Lakshmi Halasyamani, MD4,proven successful in decreasing the gap. Quality improve- Daniel Dressler, MD, MS5, Arpana Vidyarthi, MD6, Janetment has been heralded as a solution to these disparities. If Nagamine, MD7, Greg Maynard, MD6, Tina Budnitz, MPH,8; 1everybody gets high-quality care through global quality Northwestern University Feinberg School of Medicine, Chi-improvement, then racial disparities should decrease. There cago, IL; 2Massachusetts General Hospital, Boston, MA; 3Johnsare concerns that if only the ‘‘haves’’ in health care are Hopkins Medical Center, Baltimore, MD; 4St. Joseph Mercyable to improve through quality improvement, the ‘‘have Medical Center, Ann Arbor, MI; 5Emory University Hospital,nots’’ will be left behind, and the disparity gap may Atlanta, GA; 6University of California San Francisco, San Fran-increase. We examined the effects of HospitalCompare cisco, CA; 7Kaiser Permanente/Safe and Reliable Healthcare,public reporting on the disparity gap among UHC partici- Santa Clara, CA; 8Society of Hospital Medicine, Philadelphia, PApating institutions at the institution level. Methods: UHC par- Background: The hospital discharge transition can be dan-ticipating institutions were defined as white if >60% white gerous for patients with a high risk of failed follow-up andpatients or nonwhite if <60% white patients. Racial assign- adverse events. Moreover, about 20% of hospitalized Med-ment used UHC administrative data. Institutional perform- icare patients are readmitted within 30 days of discharge.ance on meeting 11 quality measures for myocardial Although studies have documented reduced rates of read-infarction and congestive heart failure were assessed missions from interventions at individual hospitals, dissemi-before and after public reporting using data from Hospital- nation to larger cohorts is lacking, and the role ofCompare. Performance was estimated per year for each of hospitalists is unclear. Project BOOST (Better Outcomes forthe condition–measure combinations. Naive rate ratios Older Adults through Safe Transitions) was developed towere estimated with 95% confidence intervals (ignoring help hospitals improve their discharge processes andwithin-hospital correlations over time). Final analyses were reduce 30-day readmission rates. Methods: Development ofcarried out using random intercept Poisson regression, a Web-based tool kit was overseen by an advisory boardS88 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • of nationally recognized experts in transitions of care. The Coverdell National Acute Stroke Registry suggest manytool kit focuses on key aspects of the hospital discharge acute stroke patients do not receive treatment according totransition including: (1) ensuring high-risk patients are iden- established guidelines. Stroke units have been shown totified and specific interventions are offered to mitigate the save lives, reduce dependency, and increase the chance ofrisk of adverse events, (2) improving patient and family returning home. Our aim was to establish if stroke carepreparation for discharge including medication reconcilia- improved through the institution of a standardized care pro-tion, (3) optimizing the flow of information between hospi- gram via a hospitalist-led multidisciplinary stroke team withtal and outpatient physicians, and (4) ensuring appropriate mandatory neurology and PM&R consultation. With the im-follow-up. Six pilot hospitals initiated implementation of this petus to reduce errors, improve communication, and pro-tool kit in 2008, each guided by a hospitalist mentor knowl- vide appropriate care, hospitalists face immense challengesedgeable in quality improvement and care transitions. An to give the best care at maximum efficiency and safety.additional 24 hospitals enrolled in 2009. Both cohorts Multidisciplinary teams that exclusively manage strokebegan with a 2-day conference orienting the participating patients in a dedicated ward may positively affect and stan-hospital teams and connecting them with their mentor. Men-tors subsequently communicated regularly with their sites dardize care. We sought to improve communication,via conference calls using a standardized approach with patient care, and patient satisfaction through team roundingdocumentation via Web-based forms and often made site with nursing, case managers, and mandatory consultationvisits. Enrolled hospitals participated in an online commu- with neurology and PM&R. Methods: Prior to implementa-nity consisting of a participant listserv, teleconferences, and tion of the team, administrative data were collected prein-webinars. To better understand the effectiveness of this tervention as baseline. Patients were comanaged on anational quality improvement project, we collected same- dedicated stroke unit with a stroke coordinator responsiblehospital 30-day readmission data for a BOOST intervention for cohorting patients and data collection. Guidelines wereunit and a non-BOOST control unit. Results: Of the 30 enrolled established for quick turnaround of consults and investiga-hospitals, 21 hospitals contributed data to the BOOST data- tions. Data review was performed at monthly stroke per-base to date. Data collection for 1-year outcomes of Project formance improvement meetings cochaired by a hospitalistBOOST is expected to close in March 2011. Presently, the and a neurologist. Any core measure misses were analyzeddatabase contains 730 unit-months of data for BOOST units. and discussed, with action plans implemented. Results:At sites that have submitted data describing both the 6-month Data pre- and postimplementation of the multidisciplinaryperiod prior to BOOST implementation and the 6-month period team with mandatory consultation were collected for allfollowing BOOST implementation (n 5 6), readmission rates stroke patients and are reported here for the periodfell from an average of 14.2% 6 months prior to implementa- 2007–2009. The average length of stay was 5.68 daystion to 11.2% 6 months after implementation. Comparative prestudy compared with 5.43 days poststudy. The coredata between BOOST units and site-matched control units are measures before and after were: use of a lipid loweringanticipated for March 2011. Conclusions: Preliminary data indi- agent increased from 68% to 75%, antiplatelet agent usecate that hospitalist-mentored implementation of Project BOOST increased from 92% to 96%, and lipid profile evaluationwas associated with reductions in 30-day readmissions. Furtherspread will require an understanding of barriers that prevent its increased from 68% to 72%, respectively. Utilization wasimplementation at some hospitals. also assessed; the number of CT scans ordered didDisclosures: increase, from 94% pre to 98% after, as did the number of MRIs ordered, from 74% to 77% of cases poststudy. Dis-M. V. Williams - Society of Hospital Medicine, funding support for ProjectBOOST; L. Hansen - Society of Hospital Medicine, funding support for Project charge home with self-care increased from 32% to 42% inBOOST; J. L. Greenwald - Society of Hospital Medicine, funding support for the first year but then dropped to 34%. The average totalProject BOOST; E. Howell - Society of Hospital Medicine, funding support forProject BOOST; L. Halasyamani - none; D. Dressler - Society of Hospital cost per case decreased from $9396 prestudy to $9028Medicine, funding support for Project BOOST; A. Vidyarthi - Society of poststudy at the end of year 2. Mortality and readmissionsHospital Medicine, funding support for Project BOOST; J. Nagamine - Society did not change. Conclusions: Our data show a multidisci-of Hospital Medicine, funding support for Project BOOST; T. Budnitz - Societyof Hospital Medicine, funding support for Project BOOST plinary team approach to be effective. We saw a reduction in length of stay, with an overall decrease in cost per case. Coordinated care improved compliance of core measures,144 but ongoing analysis and interventions are needed to main-IMPACT OF A HOSPITALIST-LED MULTIDISCIPLINARY tain this. Mandatory use of specialists, as expected,STROKE CARE TEAM increased utilization; however, it did not negatively affect cost. With emphasis on accountable care organizations inSurinder Yadav, MD, Jan Fitzgerald, RN, Barbara Niemiec, the near future, refining coordinated disease specific careBS, RN, Robert Hayden, BS, Fayla Leaming, RN, Barry Rod- is critical to providing cost-effective care.stein, MD, Roy Sittig, MD, Carmel Armon, MD, Evan Benja-min, MD; Baystate Medical Center, Springfield, MA Disclosures: S. Yadav - none; J. Fitzgerald - none; B. Niemiciec - none; R. Hayden - none;Background: Each year approximately 795,000 persons in F. Leming - none; R. Sittig - none; C. Armon - none; B. Rodstein - none;the United States experience a stroke. Data from the Paul E. Benjamin - none Hospital Medicine 2011 Abstracts S89
    • 145 of a chainsaw. For patients exposed to the loudest tercileASSOCIATION BETWEEN HOSPITAL NOISE LEVELS of sound levels, noise could account for almost 2 hours ofAND INPATIENT SLEEP AMONG MIDDLE-AGED sleep loss every night hospitalized. Given the magnitudeAND OLDER ADULTS: FAR FROM A QUIET NIGHT of this association and the known adverse health effects of sleep loss, interventions to reduce hospital noise levels areJordan Yoder, BSE, Arshiya Fazal, Paul Staisiunas, BA, David needed.Meltzer, MD, PhD, Kristen Knutson, PhD, Eve Van Cauter, PhD, Disclosures:Vineet Arora, MD, MA; University of Chicago, Chicago, IL J. Yoder - University of Chicago, Pritzker School of Medicine, student; A. FazalBackground: Sleep disturbances are prevalent among hos- - University of Chicago, Biological Sciences Division, student; P. Staisiunas -pitalized seniors and often neglected by clinicians, despite University of Chicago, Department of Medicine, employment; D. Meltzer - University of Chicago, Department of Medicine, employment; Agency fortheir potential for negative health outcomes. One of the pri- Healthcare Research and Quality, research funding (5U18HS016967-04);mary reported causes of sleep loss in hospitals is environ- National Institute on Aging, research funding (5K24AG031326-03); K.mental noise, a new publicly reported hospital quality Knutson - University of Chicago, Department of Medicine, employment; E. Van Cauter - University of Chicago, Department of Medicine, employment; V.measure for Medicare patients. Using objective methods, Arora - University of Chicago, Department of Medicine, employment; Nationalwe characterized noise levels in patient rooms and its asso- Institute on Aging, research funding (1K23AG033763-01A1)ciation with sleep among older inpatients. Methods: FromApril to August of 2010, we conducted a prospective 146cohort study of community-dwelling inpatients 50 years and BURNOUT, SENSE OF CALLING, AND CAREERolder hospitalized on the University of Chicago general RESILIENCE AMONG HOSPITALISTS AND PRIMARYmedicine services. Noise levels in patient rooms were meas- CARE PHYSICIANS: A NATIONAL SURVEYured nightly by continuous sound level monitoring to deter- John Yoon, MD, Annikea Miller, BA, Kenneth Rasinski, PhD,mine average and percentile noise measures. Objective Farr Curlin, MD; University of Chicago, Chicago, ILsleep data were obtained using wristwatch actigraphy andanalyzed to determine sleep duration and sleep efficiency. Background: Physicians’ levels of burnout shape the trajec-Patients reported in-hospital sleep quality and disruptions as tory of their professional development, ultimately affectingwell as baseline sleep hygiene using standard question- their career resilience. Burnout poses a challenge to long-naires. Descriptive statistics were used to characterize noise term career resilience by preventing physicians from responding to their intrinsic motivations. However, having alevels and sleep measures. Random-effects multivariate lin- sense of calling in one’s practice may sustain one’s career,ear regression models, clustered by subject, were used to even in the face of obstacles like burnout. Methods: Intest the association between noise levels and inpatient sleep 2009–2010, we used the AMA Masterfile to survey acharacteristics, controlling for patient demographics and nationally representative sample of 1504 U.S. physiciansbaseline sleep hygiene. Results: Of 37 consented patients, reporting only a primary board specialty of internal medi-23 (62%) completed at least 1 night of actigraphy, noise cine, family medicine, or general practice and no second-monitoring, and surveys for a total of 36 nights. Patient ary specialty. Primary dependent variables includedroom noise levels universally exceeded the World Health physicians’ levels of career satisfaction, job morale, as wellOrganization (WHO) recommendations for hospitals as intentions to reduce time spent in direct patient care or(mean, 56.3 dB; 95% CI, 54.4–58.3 dB; vs. WHO, 30 leave the practice of medicine in the next 3 years. Inde-dB; P < 0.001). Maximum noise levels were louder than a pendent variables included physicians’ level of burnout andchain saw at 15 m (mean, 87.9 dB; 95% CI, 83.5–92.2 sense of calling as assessed by single-item measures uti-dB), and the top fifth percentile noise level (L5) was similar lized in previous national studies. For example, burned-outto dogs barking (mean, 60.6 dB; 95% CI, 59.1–62.0 dB). physicians marked statements such as ‘‘I have one or moreInpatients slept an average of 283 minutes (95% CI, symptoms of burnout, such as physical or emotional exhaus-239–326 minutes), which was significantly less than their tion.’’ Physicians with a sense of calling agreed with theself-reported baseline sleep (mean, 379 minutes; 95% CI, statement ‘‘For me, the practice of medicine is a calling.’’329–428 minutes; P 5 0.008). In multivariate analyses, We also included other demographic and work-related vari-patients with higher recorded sound levels (loudest tercile of ables in our multivariate logistic regression models. Results:L5) had significantly lower sleep duration (D 5 2112 min- Eight hundred and ninety-six of 1427 eligible physiciansutes, 95% CI, 2218 to 26 minutes; P 5 0.039) and sleep responded (63%). Sixteen percent of our respondent poolefficiency (D 5 218.5%; 95% CI, 229.5% to 27.6%; P 5 identified themselves as hospitalists (n 5 142). The majority0.001). Roughly half of patients (53%) complained of noise of hospitalists were somewhat satisfied (49%) or very satis-on surveys, and these complaints were associated with sig- fied (36%) with their overall career in medicine. Twenty-nificantly higher maximum noise levels (92.9 vs. 82.0 dB, four percent of hospitalists regretted choosing medicine asP 5 0.006). Surveys also revealed that the most commonly a career, 38% wanted a different clinical specialty, 36%reported source of noise was staff conversation (41% of intended to reduce time spent in patient care, whereaspatients reported). Conclusions: Hospital noise levels are far 14% of hospitalists intended to leave the practice of medi-from acceptable, with maximums exceeding the noise level cine within 3 years. Compared with primary care physi-S90 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • cians who work >20 hours/week, hospitalists were less TABLE Baseline characteristics, CPR quality and outcomes by sexlikely to report burnout [18% vs. 27% of primary care provi-ders (PCPs), P 5 0.01] and less likely to report intentions to Female [n5247] Male [n5226] P-valuereduce time spent in direct patient care (36% vs. 48% ofPCPs, P 5 0.005). Burned-out physicians were more likely Baseline Characteristics Age 61 Æ 16 59 Æ 15 0.17to report regretting choosing medicine as a career [multi- Body Mass Index 29 Æ 8 28 Æ 8 0.29variate OR, 2.3 (1.6–3.7)]. Even among burned-out physi- Race 0.04cians, those with a sense of calling were less likely to Black 147 (60%) 115(51%)regret choosing medicine as a career [multivariate OR, 0.3 White 62 (25%) 79 (35%)(0.1–0.6)]. Conclusions: Hospitalists and primary care phy- Other/Unknown 38(15%) 32(14%)sicians who report burnout are more likely to regret choos- Arrest Location 0.64ing medicine as a career, want a different clinical ICU 164 (66%) 158 (70%)specialty, intend to see fewer patients, and intend to leave Ward 73 (30%) 58 (26%)the practice of medicine within 3 years. Having a sense of Other 10 (4%) 10 (4%)calling in one’s practice may promote career resilience in Initial Pulseless Rhythm 0.91 PEA 161 (55%) 140 (52%)medicine, even among those who experience symptoms of VF/VT 56 (23%) 56 (25%)burnout. Asystole 22 (9%) 22(10%)Disclosures: CPR QualityJ. Yoon - none; A. Miller - none; K. Rasinski - none; F. Curlin - none Compression Depth, mm 48 Æ9 46 1 9 0 005 Compression Rate, /min 105 1 11 106 1 9 025 No-Flow Fraction 0.09 Æ 0.09 0.09 Æ 0.09 0.38147 Duty Cycle Fraction 0.38 Æ 0.05 0.37 Æ 0.05 0.01SEX DISPARITIES IN CARDIOPULMONARY Leaning Fraction 0.08 Æ 0.13 0.09 Æ 0.12 0.35RESUSCITATION QUALITY AND OUTCOMES IN Outcomes ROSC 145 (59%) 121 (54%) 0.26THE HOSPITAL Survival to Discharge 28 (11%) 27(12%)0.84Trevor Yuen, BA, Jefferson Cua, BA, Elizabeth Retzer, MD,Dana Edelson, MD, MS; University of Chicago, Chicago, IL All results are shown as mean Æ standard deviation, or n (%). Abbreviations: ICU, Intensive Care Unit; PEA, Pulseless Electrical Activity; VF, Ventricular Fibrillation;Background: Several previous studies have documented VT, Ventricular Tachycardia; ROSC Return of Spontaneous Circulationlower initial survival in men than women following cardiacarrest, primarily in the out-of-hospital setting. However, theetiology of this discrepancy and its translation into the in- Women received deeper chest compressions (48 Æ 9 vs.hospital environment is unknown. One possibility, which is 46 Æ 9 mm; P 5 0.005) and had higher duty cycles thannot well studied, is that there are discrepancies in cardio- their male counterparts (0.38 Æ 0.05 vs. 0.37 Æ 0.05; Ppulmonary resuscitation (CPR) quality between men and 5 0.04). There were no significant differences between thewomen. Women have been documented to have softer 2 sexes in other CPR process variables, including compres-chests, requiring less elastic force in order to reach the sion rate, leaning, and no-flow fraction. The results are sum-same compression depth. We hypothesized that this would marized in the table. Conclusions: In this in-hospital study oftranslate into deeper chest compressions in women during cardiac arrest, we found a trend toward improved short-in-hospital cardiac arrest. Methods: We conducted a pro- term outcomes in female patients but no difference in long-spective study of consecutive, adult in-hospital cardiac term outcomes. This difference may be partially explainedarrests at an academic medical center between April 2006 by the deeper chest compressions that women receivedand February 2010. CPR quality was recorded using an ac- compared with those received by men. Rescuers performingcelerometer-based, CPR-recording defibrillator (MRX/QCPR, CPR in the hospital should be cognizant of sex difference inPhilips Healthcare). Patient and arrest characteristics were chest stiffness, which may require more force in maleabstracted by chart review. Only the first arrest for each patients to achieve the same depth of chest compressions.patient was included if a patient suffered multiple events. Disclosures:Cases were excluded if CPR process data were not avail- D. P. Edelson - National Heart Lung Blood Institute, research funding; Philips Healthcare, Andover, MA, research funding; Program for Resuscitationable. Results: Of the 473 in-hospital cardiac arrests that Education and Patient Safety, Mount Sinai Hospital, Toronto, ON, honoraria;met inclusion criteria, 52% were female. There was a trend Sotera Wireless, San Diego, CA, consultant/advisory board; Sudden Cardiactoward improved return of spontaneous circulation in Arrest Foundation, CONSULTANT/ADVISORY BOARD; T. C. Yuen - none; J. L. Cua - nonewomen (59% vs. 54%, P 5 0.26) but no difference in sur-vival to discharge (11% vs. 12%, P 5 0.84). Femalepatients were more likely to be black (60% vs. 51%, P 50.04) but were otherwise similar to male patients in termsof baseline characteristics, including mean age, body massindex, arrest location, and initial pulseless cardiac rhythm. Hospital Medicine 2011 Abstracts S91
    • 148 149VALIDATION OF CLAIMS DATA FOR COMPARISON OF THE GLASGOW BLATCHFORDDETERMINATION OF IN-HOSPITAL CARDIAC AND CLINICAL ROCKALL SCORING SYSTEM TOARREST INCIDENCE PREDICT NEED FOR CLINICAL INTERVENTION FORTrevor Yuen, BA, Donald Saner, MS, Dana Edelson, MD, MS; PATIENTS WITH NONVARICEAL UPPERUniversity of Chicago, Chicago, IL GASTROINTESTINAL TRACT BLEEDINGBackground: The incidence of in-hospital cardiac arrest Ashish Zalawadia, MD, Ravish Parekh, MD, Bassam Yagh-(IHCA) in the United States is unknown but has been esti- mour, MD, George Yaghmour, MD, Gregory Buran, MD;mated using administrative data from large nationally repre- Henry Ford Hospital, Detroit, MIsentative samples such the Medicare and Nationwide Background: Upper gastrointestinal bleeding is a commonInpatient Sample databases. However, the use of claims indication for admission to the hospital. Several risk scoredata has not been validated for this purpose. We aimed to systems are designed for triage patients with acute nonvari-measure the accuracy of inpatient claims data in determin- ceal upper gastrointestinal bleeding (UGIB). Glasgowing IHCA incidence. Methods: A prospective observational Blatchford score (GBS) and clinical or preendoscopic Rock-study of adult IHCAs was conducted between January all score (CRS) use simple clinical factors such as age, evi-2006 and July 2009 at a university teaching hospital. Dur- dence of shock, hemoglobin, plasma urea, presence ofing that time, investigators tracked every activation of the comorbidity, and presentation with melena or syncope ascardiac arrest response team, excluding events in the oper- predictors of outcome. The aim of our study was to com-ating or emergency rooms (where the team is not routinely pare the GBS and the CRS to predict the need for clinicalactivated). Administrative records were downloaded for ev- intervention for patients with nonvariceal upper gastrointes-ery hospital admission over the same period and searched tinal tract bleeding. Methods: Consecutive adults admittedfor ICD-9 diagnostic code 427.5, procedural codes 99.60 between December 2006 and June 2010 with UGIB to aand 99.63, and a pharmacy crash cart restocking fee. tertiary-care hospital were identified from computerizedThese were compared against our prospective gold stand- medical records. Patients with variceal bleeding wereard for index arrests only. Results: There were 73,111 excluded. GBS and CRS were calculated for each patient.admissions and 704 index IHCAs, yielding an incidence A high-risk score was defined as a GBS > 0 and a CRS >rate of 9.6 IHCAs per 1000 admissions. The 2 procedure 0. Patients were defined as needing clinical intervention ifcodes were not utilized during this period, but 466 admis- they had a blood transfusion or any operative or endo-sions were billed for ICD-9 427.50, of which 300 were scopic intervention to control their bleeding. Results: A totalconfirmed prospectively (see Table 1). However, the of 388 adults with UGIB were available for study. The GBSrestocking charge was utilized in 544 instances, of which identified 369 (95.1%) of the 388 patients as high risk for406 were true instances. Table 1 shows the sensitivity, clinical intervention. The CRS identified 356 (91.8%) of thespecificity, positive predictive value, and negative predic- 388 patients as high risk. The yield of identifying high-risktive value for each of the measures, individually and com- cases with the GBS was significantly greater than that withbined. Using the ICD-9 code alone would have yielded a the CRS (P < 0.0001). Of the total of 388 patients, 266calculated incidence of 6.3. Conclusions: Standard adminis- patients (68.6%) required clinical intervention. The GBStrative data likely underestimate the true incidence of identified 265 (99.6%) of 266 patients as high risk (sensi-IHCAs. Incidence rates based on these data should be inter- tivity, 99.6%; specificity, 14.8%; positive predictive value,preted with this understanding. 71.8%; negative predictive value, 94.7%). The singleDisclosures: patient not identified via GBS as high risk required endo-D. P. Edelson - National Heart Lung Blood Institute, research funding; Philips scopic intervention to stop bleeding but did not have recur-Healthcare, research funding; Program for Resuscitation Education and PatientSafety, honoraria; Sotera Wireless, consultant/advisory board; Sudden rent bleeding or receive blood transfusion. The CRSCardiac Arrest Foundation, consultant/advisory board; T. C. Yuen - none identified 249 (93.6%) of 266 patients as high risk (sensi- tivity, 93.6%; specificity, 12.3%; positive predictive value, 69.9%; negative predictive value, 46.9%). SeventeenTABLE 1 Sensitivity and Specificity of Billing Data patients who required clinical intervention were not recog- nized via CRS. Of these patients, 4 needed endoscopicMeasure Sensitivity Specificity PPV NPV intervention to stop bleeding, 17 needed blood transfusion,ICD-9 code 427.50 42.6% 99.8% 64.4% 99.4% and none developed recurrent bleeding. Conclusions: ThePharmacy charge to restock the crash cart 57.7% 99.8% 74.6% 99.6% Glasgow Blatchford score, which is based on clinical andICD-9 427.50 and pharmacy charge 26.8% 100% 87.5% 99.3% laboratory variables, may be a useful risk-stratification toolICD-9 427.5 or pharmacy charge 73.4% 99.6% 65.1% 99.7% in detecting which patients need clinical intervention in patients with acute nonvariceal UGIB. It does not needPPV, positive predictive value; NPV, negative predictive value. urgent endoscopy for scoring and has higher sensitivityS92 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • than the preendoscopic Rockall score in identifying high- or palliative medicines such as morphine. Conclusions:risk patients. Most patients with advanced cancer have decisional capa-Disclosures: city at the time of a terminal hospitalization. In theseA. Zalawadia - none; R. Parekh - none; B. Yaghmour - none; G. Yaghmour - patients, a discussion about end-of-life care is associatednone; G. Buran - none with decreased use of invasive life-sustaining treatments. Our results suggest that it is important to seize the opportu-150 nity to involve hospitalized terminal cancer patients in dis-OPPORTUNITY LOST: END-OF-LIFE DISCUSSIONS cussions about end-of-life care, as such discussions areIN CANCER PATIENTS WHO DIE IN THE HOSPITAL associated with lower use of invasive treatment. Disclosures:Mark Zaros, MD1, J. Randall Curtis, MD, MPH1, Maria Sil-veira, MD, MPH2, Joann Elmore, MD, MPH1; 1University of M. Zaros - noneWashington, Seattle, WA; 2University of Michigan, AnnArbor, MI RESEARCH ABSTRACTS: PLENARY AND ORALBackground: The majority of patients with serious illness die PRESENTATIONS ONLYin an acute care hospital. The dying process is often filled Plenarywith clinically and ethically challenging decisions. Fre- FINANCIAL IMPACT OF PRESENTING LAB COSTquently, patient care at the end of life is focused on life-sus- DATA TO PROVIDERS AT THE TIME OF ORDERtaining treatments, whereas patient comfort, dignity, and ENTRY: A RANDOMIZED CONTROLLED CLINICALsuffering are not a primary focus. End-of-life discussions TRIALmay clarify treatment options and shift the emphasis fromcure to palliation. Among cancer patients, end-of-life discus- Leonard Feldman, MD, David Thiemann, MD, Daniel Brotman,sions can reduce the use of life-sustaining treatments, CPR, MD; Johns Hopkins, Baltimore, MDand ICU admission while enhancing quality of life at the Background: Hospital care consumes a large percentage ofend of life. We examined patients with advanced cancer U.S. health care costs, yet providers practicing in the hospitalwho died in the hospital. Our questions were: (1) What are often unaware of the actual costs of the diagnostic testsproportion of these patients had decisional capacity at the they order. We hypothesized that displaying the actual costtime of a terminal hospital admission? (2) Among those of the diagnostic test at the time of order entry wouldwith decisional capacity on admission, was medical record enhance provider awareness that their orders consumedocumentation of a discussion about end-of-life care asso- resources. This might lead them to order fewer tests, decreas-ciated with life-sustaining and palliative treatments ing the total expenses incurred. Methods: Using data from fis-received? Methods: This was a retrospective chart review of cal year 2007 at our hospital, we compiled a list of the 35consecutive patients with the following criteria: (1) age ! laboratory tests that were most frequently ordered throughout18 years at time of cancer diagnosis, (2) estimated 5-year the hospital and the 35 that were most expensive. To besurvival < 20% at time of cancer diagnosis, (3) entirety of included, the most expensive tests needed to be ordered atcancer treatment conducted at the university hospital, and least 50 times. We randomly assigned each diagnostic test(4) died during the target hospitalization. We also identi- to be an ‘‘active’’ test or a control test. For all tests, we deter-fied patients who had intact decisional capacity on admis- mined the cost, utilizing FY 2008 Medicare allowable costsion. We examined all eligible patients hospitalized from rather than the inflated hospital charge. During a 6-monthJanuary 1, 2004, to December 31, 2007. Charts were baseline period, November 10 2008–May 9, 2009, we didreviewed by an internist using a 47-item chart abstraction not display any cost data. During a 6-month intervention pe-tool. Outcomes included life-sustaining and palliative treat- riod, November 10,, 2009–May 9, 2010, we displayedments received. Results: A total of 145 patients met inclu- only the cost of the ‘‘active’’ tests to ordering providers viasion criteria, and 103 of these patients (71%) had the computerized provider order entry system. Our main out-decisional capacity at the time of admission. The leading come measure was the change in total cost (intervention pe-cancer diagnoses were lung (n 5 42), acute myelogenous riod minus control period) at the test level (e.g., the cost of allleukemia (n 5 29), esophagus (n 5 9), and pancreas (n 5 Heme-8s ordered). The Student t test was used to assess statis-6). Of the patients with decisional capacity on admission, tical significance. The institutional review board waived the57 (55.3%) participated and 46 (44.7%) did not partici- requirement for informed consent, and providers were notpate in a discussion about end-of-life care with their provi- routinely informed why the price data were displayed.ders, as documented in the medical record. Patients who Results: For the 33 active tests, the mean decrease in costsdid not participate in these conversations were more likely over the 6 month intervention period was $15,647 per testto receive invasive mechanical ventilation (56.5% vs. ($516,336 total for all 33 active tests combined) relative to22.8%, P < 0.01) and to receive chemotherapy (39.1% vs. the control period, a 10.5% cost reduction from baseline. For5.3%, P < 0.01) compared with those patients who did the 33 control tests, the mean decrease in total costs wasparticipate in a discussion. There was no statistically signifi- $242 per test ($7991 total for all 33 control tests combined),cant difference between groups in the use of comfort care a 0.2% cost reduction from baseline. This difference was sta- Hospital Medicine 2011 Abstracts S93
    • TABLE 1 Odds of In-Hospital Death According to Mechanical Ventilation Status Adjusted by Age, Adjusted by APACHE II, Age-Adjusted Age, APACHE II ALI Risk OR (95% CI) OR (95% CI) Factor* OR (95% CI) Baseline non–mechanically 1.0 1.0 1.0 ventilated, no MV days 0-3 Baseline non–mechanically 5.2 (2.3–3.3) 5.2 (2.2–12.1) 5.0 (2.1–11.7) ventilated, requiring MV days 1-3 Baseline mechanically ventilated 1.8 (1.0–3.3) 1.1 (0.6–2.0) 1.3 (0.7–2.4) * ALI risk factor: sepsis, pneumonia, trauma, aspiration, other; MV, mechanical ventilation.tistically significant (P 5 0.035). Conclusions: This rando-mized controlled trial suggests that simply showing providers Nonventilated patients had lower baseline morbidity andthe cost of some diagnostic tests at the time of order entry severity of illness compared with mechanically ventilatedcan affect behavior. Although this finding may be a function patients (Acute Physiology and Chronic Health Evaluationof culture, display format, and provider incentives, that there (APACHE) II mean, 22 Æ 7 versus 29 Æ 8); however, in-were no direct financial incentives (at the provider level) at hospital mortality was similar between the groups (26% inour institution for containing costs suggests that physicians nonventilated vs. 23% in mechanically ventilated patients, Pmay be receptive to cost-containment initiatives even when 5 0.59). We found that 39 (28%) of initially nonventilatedthere is no direct incentive. It is not clear if ordering behavior patients required MV within the subsequent 3 days of fol-will change permanently, and the overall effect of displaying low-up, and although this subgroup did not differ accordingthe costs of all laboratory tests, rather than a select few, to age, sex, baseline morbidity, or severity of illness com-remains unknown. pared with the 98 other baseline nonventilated patients,Disclosures: they had significantly increased in-hospital mortality (49%)L. Feldman - none; D. Brotman - none; D. Thiemann - none compared with both the group requiring no mechanical ventilation within the first 3 days of hospitalization (16%) and the group that was ventilated on the day of ALI diagno-Oral sis (33%), P < 0.001. Severity of illness (APACHE II)CLINICAL OUTCOMES AMONG accounted for the difference in mortality observed betweenNON–MECHANICALLY VENTILATED PATIENTS the baseline mechanically ventilated group and those notWITH ACUTE LUNG INJURY requiring MV days 0-3 (Table 1). However, the subgroup of patients nonventilated at baseline who went on toKirsten Kangelaris, MD, MAS1, Lorraine Ware, MD2, Hanjing require MV in the subsequent 3 days had a fivefoldZhuo, MD, MPH1, Michael Matthay, MD1, Carolyn Calfee, increased adjusted odds of death compared with those notMD, MAS1; 1University of California, San Francisco, San Fran- requiring MV days 0–3 (Table 1). Conclusions: In a large,cisco, CA; 2Vanderbilt University, Nashville, TN multi-ICU cohort of patients with ALI, 20% of patients meet-Background: Acute lung injury (ALI) is a common cause of ing ALI criteria are not mechanically ventilated on diagno-respiratory failure among hospitalized patients. Large stu- sis. Although this group has a baseline lower morbidity anddies have been limited to patients requiring mechanical severity of illness, in-hospital mortality does not differ.ventilation, and little is known about non–mechanically ven- Furthermore, a subgroup of initially non–mechanically venti-tilated adults with ALI. We sought to compare the clinical lated patients with similar morbidity and severity of illnessoutcomes of non–mechanically ventilated patients with go on to require mechanical ventilation within the first 3those of those requiring mechanical ventilation (MV) on day days of ALI diagnosis, and this subgroup has a significantlyof ALI diagnosis. Methods: We evaluated all patients with increased risk of in-hospital death. This finding raises theALI/acute respiratory distress syndrome (ARDS) enrolled in question of how to identify these high-risk patients earlierthe Validation of Biomarkers in Acute Lung Injury Diagnosis and whether earlier mechanical ventilation would affect the(VALID) study, a large, multi–intensive care cohort. Mechan- clinical outcomes of these patients.ical ventilation status, s defined as the absence of MV on Disclosures:the day of diagnosis of ALI (day 0), was the predictor vari- K. N. Kangelaris - Society of Hospital Medicine Junior Investigator Award,able. We also evaluated requirement for MV within the first research funding; C. S. Calfee - K23 (NIH HL090833) and Flight Attendant3 days (days 1–3) of ALI diagnosis. Our outcome variable Medical Research Institute, research funding; H. Zhuo - none; M. A. Matthay - NIH R37HL51856, research funding; L. B. Ware - NIH HL081332 andwas in-hospital mortality. Results: Of 685 patients with ALI, HL103836 and American Heart Association Established Investigator Award,137 (20%) did not require MV on the day of diagnosis. research fundingS94 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • THE DERIVATION OF THE LUNG INJURY SEVERITYSCORE (LISS): A PROGNOSTIC INDEX FOR IN-HOSPITAL MORTALITY IN ACUTE LUNG INJURYKirsten Kangelaris, MD, MAS1, Carolyn Calfee, MD, MAS1,Hanjing Zhuo, MD, MPH1, Michael Matthay, MD1, LorraineWare, MD2; 1University of California, San Francisco, SanFrancisco, CA; 2Vanderbilt University, Nashville, TNBackground: Acute lung injury (ALI) is a frequently fatal causeof respiratory failure among hospitalized patients, and a practi-cal and easily obtainable prognostic index at the time of ALI di-agnosis is needed for risk prediction. The utility of currentprognostic indexes is limited, as they cannot be generated onpresentation, and they contain components not routinely avail-able in clinical practice. We developed a prognostic index forin-hospital mortality using clinical data that is readily availablein both mechanically ventilated and non–mechanically venti-lated patients on the day of diagnosis of ALI. Methods: Usingthe Validation of Biomarkers in Acute Lung Injury Diagnosis(VALID) study, a large, multi–intensive care unit cohort, we FIGURE 1. Receiver operator curves and area under the curve (C-developed a prognostic index from all adults meeting consen- statistic) for the LISS compared with other mortality risk indexessus criteria for ALI/acute respiratory distress syndrome (ARDS). among 629 patients with ALI [APACHE II, Acute Physiology andWe identified 16 clinical variables available in at least 90% of Chronic Health Evaluation II; SAPS II, Simplified Acute Physiologypatients on the day of ALI/ARDS diagnosis that were independ- Score II; LIS, lung injury score (Murray).ently associated with in-hospital mortality and used backwardelimination (P < 0.10) to determine which variables remainedindependent predictors of mortality. Leave-one-out cross-valida- EVALUATION OF AN ELECTRONIC DISCHARGEtion was used for internal validation, and coefficients were SUMMARY FOR TIMELINESS AND QUALITYweighted to create a risk index. The test characteristics of the COMPARED WITH DICTATIONderived risk index, called ‘‘lung injury severity score’’ (LISS), Michelle Mourad, MD, Russell Cucina, MD, Sumant Ranji, MD;were compared to conventional prognostic indices. Quartiles University of California, San Francisco, San Francisco, CAof the LISS were then generated to predict mortality risk at eachlevel. Results: Of 629 patients with ALI/ARDS, 24% died dur- Background: The Center for Medicaid and Medicare Servicesing hospitalization. Seven independent predictors of mortality requires that a discharge summary be completed only withinwere identified on the day of diagnosis of ALI/ARDS, including 30 days of discharge. This rule is inadequate to ensure safeage, respiratory rate, systolic blood pressure, pulse oximetric care transitions, as outpatient physicians must receive moresaturation (SpO2)/fraction of inspired oxygen (FiO2) ratio, se- timely information regarding a patient’s hospital course. Werum bilirubin, serum creatinine, and platelet count (Table 1). describe the implementation of an electronic discharge sum-Scores on the risk index were strongly associated with in-hospi- mary (EDCS) and report preliminary data on discharge sum-tal mortality for a maximum possible score of 16 points (Table mary quality and timeliness compared with standard dictated1). For each 1-point increase in LISS, odds of death increased summaries. Methods: The EDCS, a note template completedby 40% (OR, 1.4; 95% CI, 1.3–1.5). The LISS risk index through the use of checkboxes and imported data balancedshowed improved discrimination compared with conventional with free text, was introduced to all medicine teams in Octo-prognostic indexes (Fig. 1). The C-statistic of 0.76 was margin- ber 2010. To promote efficiency, the note was designed toally reduced to 0.74 on cross-validation. Conclusions: The LISS serve both as the discharge summary and as the last day’sprognostic index, incorporating readily available clinical vari- progress note and appeared instantly in the electronic medi-ables on the day of ALI/ARDS diagnosis, accurately predicts cal record. Residents were incentivized to complete the EDCSmortality in acute lung injury in a broad ALI sample. The test on the day of discharge, and attendings were instructed tocharacteristics in this derivation cohort are superior to conven- finalize it within 48 hours of discharge. Time of dischargetional risk indexes. External validation of this score is required summary completion and finalization were analyzed for a 3-prior to implementation in clinical practice. month period prior to implementation of EDCS and for 2Disclosures: months after. Eighty randomly selected discharge summariesK. N. Kangelaris - Society of Hospital Medicine Young Investigator Award, completed before and after the intervention were manuallyresearch funding; C. S. Calfee - K23 NIH HL090833 and Flight Attendant audited for quality, defined as completion of recommendedMedical Research Institute, research funding; H. Zhuo - none; M. A. Matthay - fields (reason for admission, hospital course, significant find-NIH R37HL51856, research funding; L. B. Ware - NIH HL081332 andHL103836 and American Heart Association Established Investigator Award, ings, discharge instructions, discharge diet and activity, dis-research funding charge medications, pending tests, follow-up plans, and Hospital Medicine 2011 Abstracts S95
    • discharge diagnosis). Results: Five hundred and sixty-three dis- All unsuccessful paracenteses occurred in the presence of ancharge summaries were completed during a 3-month period abdominal wall > 5 cm in thickness, and all had ascitic fluidprior to EDCS implementation compared wth 509 in the 2 on formal US. Patients with a high suspicion for SBP (3, 75%)months after. Adoption of EDCS use was high, with 490 were treated empirically. Of the 16 patients who had an unsuc-(96%) of 509 discharge summaries using the EDCS instead of cessful thoracentesis, 2 procedures obtained fluid, but the pro-dictation. The average time from discharge to resident com- cedure was aborted because of the bloody nature of the fluid.pletion fell from 4 to 0.53 days (P < 0.001), and the time to Eight patients (50%) demonstrated loculated fluid on ultrasoundattending finalization fell from 9 to 1.48 days (P < 0.001). or CT chest. Interventional radiology (IR) attempted a thoracent-Prior to the initiation of EDCS, residents completed 38% of esis in 9 patients and was successful in 6 (66.7%), using CTdischarge summaries on the day of discharge, compared with guidance for 3 procedures and placing a chest tube in 2. Of77% after the intervention, and attendings finalized 15% of the 56 failed lumbar punctures, 24 (43%) had resolution of ordischarge summaries within 48 hours of discharge, compared an alternative explanation of their symptoms that initiallywith 81% after (P < 0.001 for both). Of the 80 discharge prompted the lumbar puncture, and further attempts were notsummaries audited for quality in the pre- and postimplementa- pursued. Of the lumbar punctures eventually performed, 28tion periods, completion of recommended elements increased (50%) were performed by neuro IR, and 6 (11%) were laterfrom 46 to 76 (58% vs. 95%, P < 0.001). Seventy-two EDCS performed by other providers. Of those done by neuro IR, 8compared with 8 dictated summaries (90% vs. 10%, P < (14%) required CT guidance. The most commonly cited rea-0.001) included detailed information about medications sons for difficulty were body habitus 16 (28.6%) and challen-stopped, new medications started, and old medications con- ging spinal anatomy 13 (28.2%). Twenty patients (36%) withtinued, and 78 EDCS (98%) mentioned both pending tests unsuccessful lumbar punctures had a BMI > 30, and 15 (28%)and follow-up plans, compared with 26 summaries (33%) dic- had abnormal lumbar anatomy on imaging. Conclusions: Ourtated previously (P < 0.001 for both). Conclusions: By inte- data provide new benchmarking for procedures performed bygrating discharge summary creation into existing resident andattending work flow, we were able to decrease time to dis- hospitalists with bedside ultrasound. Better understanding ofcharge summary completion while improving quality. unsuccessful procedures attempted by a bedside procedure ser- vice provides an opportunity to both improve practice whereDisclosures: possible and refer procedures directly to interventional radiol-M. Mourad - none; R. Cucina - none; S. Ranji - none ogy to improve procedure efficiency. Disclosures: M. Mourad - none; D. Sliwka - noneUNDERSTANDING UNSUCCESSFUL PROCEDURESON A HOSPITALIST PROCEDURE SERVICE OTHER RESEARCH ABSTRACTSMichelle Mourad, MD, Diane Sliwka, MD; University of Cali-fornia, San Francisco, San Francisco, CA FAILURE OF A HOSPITAL-WIDE CHLORHEXIDINEBackground: Ultrasonography (US) has improved the yield of BATH ADMISSION PROTOCOL IN PREVENTINGbedside invasive procedures over the last decade; however, HOSPITAL-ACQUIRED METHICILLIN-RESISTANTunsuccessful procedures still occur. As benchmarks for the yield Staphylococcus Aureus INFECTIONof procedures using US are limited, we aimed to quantify andreview unsuccessful procedures done by the hospitalist proce- Jonathan Cohen, MD, Adwait Silwal, MD, Riddish Shah, MD, Tim-dure service (HPS) at the University of California, San Fran- othy Lane, MD; Moses Cone Health System, Greensboro, NCcisco, in its first 2 years. Methods: The HPS began offering Background: Hospital-acquired methicillin-resistant Staphylo-procedure services for paracentesis, thoracentesis, lumbar coccus aureus (HA-MRSA) infections annually affect almostpuncture, and arthrocentesis in November 2008. Interns per- 21,000 patients nationwide. Randomized controlled trialsform nearly all procedures during a 2-week rotation supervised have demonstrated the efficacy of chlorhexidine gluconateby an attending hospitalist with additional US and procedural (CHG) in preventing HA-MRSA infections associated with inva-training. All paracenteses and thoracenteses are performed sive procedures. Several small studies involving CHG baths inunder US guidance, and US is used for lumbar puncture as the intensive care unit (ICU) have demonstrated a reduction inneeded. Unsuccessful procedures were defined as those that HA-MRSA colonization and bacteremia. However, the efficacywere deemed to be safe by examination, imaging, and ultra- of CHG bathing on all inpatients, including those outside thesound, but where no fluid was obtained. We queried our data- ICU, in preventing clinically significant HA-MRSA infectionsbase for attempted procedures in which little to no fluid was remains unproven. The objective of this study was to evaluateremoved to screen for unsuccessful procedures and then per- the effectiveness of a CHG bath protocol on admission in redu-formed a detailed chart analysis to determine the reasons for cing the incidence of HA-MRSA infection in all adult hospita-failure and patient outcomes. Results: Of the 1005 procedures lized patients. Methods: A retrospective cohort analysis of HA-performed by the service in the first 2 years, 76 (7.6%) were MRSA infections in adult inpatients was performed in a commu-unsuccessful [4 of 409 paracenteses (1%), 16 of 278 thora- nity hospital before and after initiating a protocol in which allcenteses (5.8%), and 56 of 290 lumbar punctures (19.3%)]. patients were to receive a full body CHG bath on admission.S96 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • HA-MRSA infection was defined by CDC criteria and positive TABLE Health Literacy Assessment Resultspertinent cultures. Comparisons were made between a preinter-vention control group, June through November 2008, and a Reading Grade Level Number of Words Correcty n (60 Total) %postintervention group, June through November 2009. Statisti-cal comparisons of categorical variables were performed using < Third grade 0 12 20.0% Fourth–sixth grades 1–3 10 16.7%the chi-square or Fisher’s exact test, as appropriate. The proto- Seventh–eighth grades 4–6 18 30.0%col was initiated in December 2008, but similar calendar > Ninth grade 7 20 33.3%months were compared in our study to account for seasonal Numeracy Results Number Correct{ n (60 Total) %variation. The study was powered to detect a 50% reduction inHA-MRSA infection with 95% sensitivity. Results: Forty-eight 0 35 58.3%patients (0.21%) of 23,194 admissions developed HA-MRSA 1 18 30.0%infections during the study period. In the preimplementation 2 5 8.3%control group, 20 patients (0.18%) of 11,373 admissions 3 2 3.3%developed HA-MRSA infection; this compares to 26 (0.22%) of y11,821 after protocol implementation (P < 0.67). Of the HA- REALM-SF: fat (not tested), flu (not tested), behavior, exercise, menopause, rectal, antibiotics, ane-MRSA infections, there was a statistically significant increase in mia, jaundice. {the incidence of HA-MRSA pneumonia (P < 0.021) in the post- Numeracy questions: (1) Imagine we flip a fair coin 1000 times. What is your best guess about how many times the coin would come up heads in 1000 flips? (2) In the Big Bucks Lottery, the chance ofintervention group; but no statistically significant change in the winning a $10 prize is 1%. What is your best guess about how many people would win a $10 prize ifincidence of sepsis, surgical/wound infections, or urinary tract 1000 people each buy a single ticket to Big Bucks? (3) In ACME Publishing Sweepstakes, the chanceinfections. The CHG bath protocol was discontinued for lack of of winning a car is 1 in 1000. What percent of tickets to ACME Publishing Sweepstakes win a car?efficacy and potential for harm. Conclusions: Our intention-to-treat analysis suggests that a hospital-wide protocol to adminis-ter full body CHG baths on admission does not reduce the inci- patients with inadequate health literacy was determined baseddence of HA-MRSA infections. Furthermore, the increase in HA- on the results of these 2 assessments and extrapolated toMRSA pneumonia in the postintervention group—with a plausi- include patients hospital-wide. Results: The 60 eligible patientsble relationship to the initiation of the CHG protocol—is espe- completed literacy testing in less than 1 minute. Based on thecially concerning. Variables possibly contributing to the REALM-SF, 36.7% of the study population had a reading gradeincreasing trend in HA-MRSA pneumonia include an increase level sixth grade. Approximately 90% of the study popula-in MRSA surveillance and/or the development of CHG resist- tion was unable to answer more than 1 of the numeracy ques-ance. This is the first study to our knowledge examining the effi- tions correctly. Extrapolating the mean counseling time percacy of a hospital-wide CHG bath protocol on the incidence of patient of 46 minutes, as determined in a previous pilot study,HA-MRSA infections. Before implementing similar hospital-wide a pharmacist would need approximately 4.7 hours per day toCHG bath protocols, further studies are warranted. counsel all inpatients treated with either insulin or warfarin whoDisclosures: have less than a seventh-grade reading level. Conclusions:J. Cohen - none; A. Silwal - none; R. Shah - none; T. Lane - none Given limited pharmacy resources, the REALM-SF is an efficient method to identify a subset of patients with a sixth-grade read- ing level or less who may benefit from pharmacist-deliveredEVALUATION OF HEALTH LITERACY AS A counseling. A numeracy evaluation was not useful in stratifyingMECHANISM FOR IDENTIFYING PATIENTS FOR the study population.PHARMACIST-PROVIDED COUNSELING ON Disclosures:HIGH-RISK MEDICATIONS L. Feldman - none; V. Brown - none; Y. LeBlanc - none; L. Efird - none; T. Nesbit - none; J. Wellman - noneLeonard Feldman, MD, Yvonne LeBlanc, PharmD, MBA, LeighEfird, PharmD, BCPS, Todd Nesbit, PharmD, MBA, JessicaWellman, PharmD, MBA, BCPS, Victoria Brown, PharmD; INNOVATIONSJohns Hopkins Hospital, Baltimore, MD 151Background: Many hospitals lack adequate resources to pro- BALANCING HOSPITALIST PRODUCTIVITY ANDvide pharmacist-delivered discharge counseling for all inpati- SATISFACTION WITH PATIENT CARE CONTINUITYents. We hypothesized that health literacy testing could identify UTILIZING SOFTWARE-BASED SCHEDULINGa manageable subset of high-risk diabetic and anticoagulationpatients in need of additional discharge counseling. Methods: Troy Ahlstrom, MD1, Suvas Vajracharya, PhD2, NirmalPatients admitted to a general medicine unit who were pre- Govind, PhD2; 1Hospitalist of Norther Michigan, Traverse City,scribed warfarin, insulin glargine, or insulin NPH during the MI; 2Lightning Bolt Solutions, Burlingame, CAhospital admission completed a 2-minute health literacy assess- Background: Many hospitalist groups recognize the impor-ment. The health literacy assessment was a combination of the tance of ensuring that the individual preferences, strengths,Rapid Estimate of Adult Literacy in Medicine–Short Form and practice styles of their providers are taken into account(REALM-SF) and 3 numeracy questions. The percentage of while determining the work schedule for the practice. Rigid Hospital Medicine 2011 Abstracts S97
    • schedules with longer scheduled periods per provider can Background: The number of attending-only services in tradi-minimize care transitions for patients, whereas flexible sche- tional teaching hospitals has increased. This trend is largelydules allow hospitalists to seek a balance between variable a result of decreased patient coverage by residents inpatient census or acuity-based staffing versus vacation and response to ACGME duty-hour restrictions, as well asdowntime requirements. In essence, ‘‘Seven On–Seven planned growth within institutions. Medical student enroll-Off’’ rarely represents reality. Variability in practitioner pre- ment has not decreased, leading to medical student partici-ferences, such as daily patient load, acuity, shift and care pation on attending-only teams. An attending-only servicesite preference along with the constantly changing practice can offer some unique benefits for medical students, includ-requirements, make this scheduling problem challenging. ing increased direct contact with attendings and enhancedPurpose: To achieve goals in patient care quality while opportunities for direct observation and feedback. Chal-meeting varying individual physician downtime requests lenges to medical student education on attending-only ser-and practice styles by using a software-based tool that opti- vices may include the attending’s competing patient caremizes physician schedules. Description: Organizations turn obligations, rapid turnover of attending assignments, and ato optimizing the scheduling of available physicians so that more complex case mix. A standardized curriculum forboth individual and institutional needs are met. As the number medical students on an attending-only service can take advantage of these benefits, address the potential chal-of practitioners and requirements increase, managing a sched- lenges, and provide a comprehensive general pediatricsule becomes a daily time-consuming headache that leads to inpatient experience. Purpose: To create a curriculum speci-simplification of the schedule back to a rigid system. The only fic to medical students who do their core pediatrics clerk-realistic alternative is group and individual practitioner schedul- ship on an attending-only hospitalist service. Description: Aing via artificial intelligence algorithms capable of handling the curriculum was developed for students completing the inpa-complexity. Our sophisticated scheduling system allows practi- tient portion of their pediatric core clerkship on our attend-tioners to easily specify work patterns and preferences, which ing-only hospitalist team. Using the general pediatricsare used to generate a schedule that can be accessed via the clerkship learning objectives as a reference, a list of coreInternet. The scalable algorithms used are similar to algorithms pediatric topics and corresponding teaching materials waswe have implemented in computer chip manufacturing fabs to created. A ‘‘teaching checklist’’ was developed, whichschedule expensive machines. This is a highly combinatorial includes these core topics, as well as specific educationalproblem involving millions of constraints and variables, not activities for attendings to carry out with the students. Exam-unlike the physician scheduling problem. Our approach trans- ples include direct observation of histories, physical exami-forms the requirements into a set of mathematical equations nations, or interactions with patients and families, provisionthat are then solved simultaneously to produce a schedule that of feedback on written and verbal presentations, and dem-meets all requirements. Conclusions: Embracing innovative onstration or role modeling of particular behaviors or skills.technology to handle changing scheduling requirements allows The checklist also lists patients of different ages (infant, tod-us to meet any number of scheduling problems head on. The dler, preschooler, school-aged child, and adolescent) toWeb-based system provides the our hospitalists more flexibility ensure the student is exposed to a variety of developmentaland the ability to work according to their preferred pattern. The stages and pathologies. The students’ daily scheduleuse of the system also allows hospitalists to increase their includes structured rounds in the mornings and dedicatedincome by working more shifts while still scheduling off-time, learning time in the afternoons. We added teaching ses-vacation, and medical education blocks within their established sions on the 2 afternoons per week when the students didrules, as they wish. The system improves overall provider utiliza- not already have scheduled didactic sessions, and thetion, which also increases income for the practice. It leads to teaching checklist was used for planning and tracking thesefairer schedules, reduces conflicts, and supports an important sessions. For times when the patient care responsibilities ofpractice goal of limiting provider turnover, which improves the the service attendings interfered with their ability to teach,group’s overall satisfaction, efficiency, and bottom line. a ‘‘teaching float’’ system was developed utilizing the off-Disclosures: service hospitalist attendings. Conclusions: We developed aT. Ahlstrom - Lightning Bolt Solutions, client structured curriculum for third-year medical students, taking advantage of the unique qualities of an attending-only ser- vice while optimizing the students’ learning experience in a152 fast-paced patient-care environment. The curriculum hasDEVELOPING A CURRICULUM FOR MEDICAL been well-received by students, attendings, and the clerk-STUDENTS COMPLETING THEIR CORE PEDIATRICS ship director.CLERKSHIP ON AN ATTENDING-ONLY Disclosures:HOSPITALIST SERVICE J. Alegria - none; K. Lamphier - none; V. Lee - none; C. Russell - none; J. Maniscalco - noneJamilet Alegria, MD, Kyle Lamphier, MD, Vivian Lee, MD,Christopher Russell, MD, Jennifer Maniscalco, MD; Children’sHospital Los Angeles, Los Angeles, CAS98 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • 153 ward CLABSI rates prior to our program, data from theHOSPITAL MEDICINE PROCEDURALISTS AND A National Healthcare Safety Network indicate that the rate ofCOMPREHENSIVE PROGRAM TO ELIMINATE non–intensive care unit CLABSIs is 1.5 per 1000 line-days. ThisCENTRAL LINE–ASSOCIATED BLOODSTREAM places our CLABSI prevention program in the top 25% of thisINFECTIONS national data set. To reach a P < 0.05, when comparing our CLABSI rates with national rates, a total of 3422 line-days with-Rebecca Allyn, MD, Srinivas Bapoje, MD, Connie Price, MD, out a CLABSI are needed. Data collection continues. Conclu-Bryan Knepper, MSc, MPH, Shailendra Sharma, MD, Amit sions: Hospital medicine physicians specializing in centralBahia, MD, Vignesh Narayanan, MD, Robert Allen, MD, venous access as part of a comprehensive program includingEugene Chu, MD; Denver Health Medical Center, Denver, CO formal training, Web-based education, an evidence-basedBackground: Central line–associated bloodstream infections checklist, and a dedicated procedure room may decrease or(CLABSIs) increase length of stay, add an additional even eliminate CLABSIs.$10,000 in costs per event, and increase mortality. Educa- Disclosures:tion, procedure carts, and checklists to improve compliance R. Allyn - none; S. Bapoje - none; C. Price - none; B. Knepper - none; A. Bahia -with evidence-based, sterile procedures have been shown none; S. Sharma - none; V. Narayanan - none; R. Allen - none; E. S. Chu - noneto decrease CLABSI rates in intensive care units. High-vol-ume, specialized operators have been shown to improveoutcomes for high-risk procedures. Purpose: To develop and 154implement a comprehensive program with a subgroup of IMPLEMENTATION OF A PULMONARY ARTERIALspecially trained hospitalists to insert central venous cathe- HYPERTENSION (PAH) PREOPERATIVE ALGORITHMters (CVC) in an effort to decrease or eliminate CLABSI on FOR NONCARDIAC SURGERYthe medical wards. Description: In spring 2009, we devel- Moises Auron, MD, FAAP, FACP1, Ajay Kumar, MD, FACP1,oped and implemented a multifactorial program with the goal Marina Duran-Castillo, MD2, Gustavo Heresi-Davila, MD1, Clau-of eliminating CLABSIs at our urban, academic safety-net hospi- dene Vlah, MD1, Raed Dweik, MD1; 1Cleveland Clinic, Cleve-tal. In an effort to standardize line insertion, decrease proce- land, OH; 2MetroHealth Medical Center, Cleveland, OHdure duration, and optimize insertion techniques, a subgroupof 6 hospitalists was trained by interventional radiology attend- Background: Noncardiac surgery in patients with pulmo-ings in the micropuncture technique of CVC insertion using nary arterial hypertension (PAH) is associated with a mor-direct ultrasound guidance. The 6 hospital medicine procedur- bidity of 42% and a mortality of 7%. The most importantalists also received Web-based education about ideal insertion pathophysiologic consideration is the effect of increasedpractices. Checklists utilizing evidence-based safety practices pulmonary vascular resistance (PVR) on the right ventricularto perform the insertions were implemented, and a semisterile function. PAH has a progressive nature; initially it is causedprocedure room was dedicated to central venous access. Start- by a vasoconstrictor process that reverses easily with vaso-ing in May 2009, hospital medicine proceduralists inserted dilator therapy, but then it progresses toward significantCVCs for general medical floor patients. Preliminary data col- vascular fibrosis with irreversible changes with limited or nolected from May 2009 through October 2010 revealed 243 effect of vasodilator therapy. The main predictors of morbid-CVCs placed by proceduralists. After 2770 line-days, the ity and mortality in these patients include: history of pulmo-CLABSI rate was zero. The average case-mix index for these nary embolism, NYHA class II, intermediate- to high-riskpatients was 3.04. Although our institution did not monitor surgery, surgery duration > 3 hours, right axis deviation, right ventricular hypertrophy, right ventricle systolic pressure (RVSP) > than SBP, and intraoperative vasopressor use.Patient Demographics Purpose: To implement a preoperative algorithm to identify patients with PAH undergoing noncardiac surgery forUnique Patients 243 appropriate stratification and optimization and minimizeTotal number of line-days 2770 perioperative morbidity and mortality. Description: A com-Average number of line-days per patient 8.15Central line–associated bloodstream infections 0 plete history and physical examination is performed withCase-Mix Index 3.04 special attention to signs and symptoms of right ventricularSex: male 68% dysfunction: dyspnea on exertion (DOE), chest pain, exer-Race tional desaturation, right heart failure (large jugular V White 42% wave, peripheral edema, and hepatomegaly), syncope, Hispanic 39% loud P2, and systolic murmur LLSB. The initial preoperative Black 14% tests include: EKG, chest roentgenogram, and echocardiog- Other 5% raphy. The patient is referred to the pulmonary vascularAge consult service if she or he has: (1) an established diagno- 18–44 33% sis of PAH; (2) RVSP > 50 mm Hg on echocardiogram; (3) 45-74 64% 75 and older 3% RVSP 40–50 with DOE, right ventricular dilatation, or dys- function (see table). The patient is streamlined to surgery if Hospital Medicine 2011 Abstracts S99
    • tion techniques are based on Buckman’s 6-step protocol for breaking bad news. The lecture was followed by a role- play session. Two cases were created for the course. One involves an expected death; the other involves an unex- pected death. Each session consists of 15 interns and is facilitated by a chief medical resident and a palliative care attending physician. The hospital’s death packet was re- vised to minimize the paperwork required for physicians, nurses, and ward clerks. The packet was reviewed by key stakeholders including the leadership of critical care units, trauma units, nursing, admitting, and the morgue. A list of communication tips for care providers and a bereavement packet for next of kin were created to accompany this packet. All items were posted on the hospital’s intranet forRVSP < 50, is asymptomatic, and has normal RV function. ease of access. A template for the death note was createdIn the immediate perioperative period chronic PAH therapy in the electronic medical record. The template includesshould be continued. Patients on parenteral prostacyclines prompts for each of the key tasks in the death pronounce-may be maintained on their baseline infusion, although ment procedure described in the didactic session. Afterthey may be switched to intravenous prostacycline perioper- piloting in the medical intensive care unit (ICU), revisionsatively (e.g., epoprostenol). All patients on chronic anticoa- were made and finalized. The new procedures weregulation should be bridged to intravenous heparin. announced at monthly orientation sessions for pediatric,Conclusions: This algorithm will permit the preoperative general medicine, and medical ICU ward rotations. Theyidentification and optimization of patients with PAH at were also presented to the heads of nursing and admis-higher risk of postoperative morbid and mortality. sions. Conclusions: Hospitalists who work with trainees are responsible for teaching residents the skills required to man-Disclosures: age inpatient deaths. By reinforcing the impact of learningM. Auron - none; A. Kumar - none; M. Y. Duran-Castillo - none; G. Heresi-Davila - none; C. Vlah - none; R. Dweik - none sessions with prompts built into the procedure, this interven- tion has the potential to enhance physician performance and improve patient satisfaction.155 Disclosures:TEACHING DEATH PRONOUNCEMENT: J. Baru - none; C. Deamant - noneREINFORCING DIDACTICS WITH SYSTEMS-BASEDIMPROVEMENTS 156Joshua Baru, MD, Catherine Deamant, MD; Cook County Hos- THE WARD ATTENDING SCHOLARS PROGRAMpital, Chicago, IL (WASP): A MULTIMODAL, COLLABORATIVEBackground: Handling deaths is a stressful but unfortunately FACULTY DEVELOPMENT PROGRAM FORcommon event for hospital-based trainees. This experience TEACHING ATTENDINGSis a key component of the practice of palliative care. Train-ing in palliative care is a responsibility and a requirement Joshua Baru, MD, Benjamin Mba, MD, MRCP(UK), Brianof postgraduate medical education programs. Systems- Lucas, MD, MS, Jennifer Smith, MD, Darryl Woods, MD,based improvements have the capacity to reinforce learned Susan Rogers, MD, Lou Rohr, MD, Isaac Paintsil, MD, MPH;behaviors. Purpose: (1) To teach trainees key aspects of the Cook County Hospital, Chicago, ILprocess of declaring death, including communication tech- Background: Clinician-educators are responsible for moreniques and (2) to create systems-based improvements to information and sicker patients than in the past. Yet theyensure sensitive and proper handling of inpatient deaths. face greater time pressures. Faculty development programsDescription: The program consists of 4 parts, 2 educational ought to teach clinician-educators to handle these conflict-interventions and 2 system improvements. An hourlong di- ing responsibilities while retaining excellence in medicaldactic session is given to interns in the beginning of their education. Purpose: To improve the inpatient attending ex-residency as part of a course on hospital emergencies. The perience by teaching skills for leadership, time manage-content focuses on procedural and communication issues. ment, bedside teaching, and intrateam communication.Procedural issues include documenting the physical exam, Description: A committee of leaders from the divisions ofcompletion of the death certificate, discussion of autopsy, hospital and general internal medicine devised the wardand notification of the medical examiner and the organ attending scholars program (WASP) curriculum after a liter-procurement organization. Communication issues include ature review and needs assessment survey of all physiciansdiscussions with families of patients after expected deaths, who attend on the general medicine wards. The WASP cur-unexpected deaths, and over the telephone. Communica- riculum consists of 5 components. (1) A half-day seminarS100 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • involves didactic presentations ranging from 15 to 45 min- admitting diagnosis, and correct status (observation vs.utes in duration. Content included setting expectations, time inpatient). A patient placement manager (PPM) thenmanagement, intrateam communication, conflict manage- received this information electronically and found a bed.ment, delivering feedback, and interfacing with key clinical We hypothesized that by involving the PPM earlier, weservices in our hospital. (2) Peer coaching sessions pair fac- would improve getting patients to the right bed the firstulty who have demonstrated excellence in teaching with time. In our pilot, we had the ER doctor page the PPM withnew or struggling ward attendings. In the month prior to the patient name, medical record number, and admitting di-their first attending experience of the year, faculty trainees agnosis. The PPM then took a look at the patient’s record toobserve preceptors during 1 postcall and 1 non-postcall see if he or she had issues that affected the placement. Forrounds. The curriculum committee created a checklist to act example a patient with pneumonia but also on peritonealas a guide for key observable teaching and leadership dialysis should be booked to the renal floor with nursestechniques. The preceptor and trainee use this checklist as trained to handle peritoneal dialysis and not placed baseda tool for a debriefing session after the rounds. This process on the diagnosis of pneumonia. After this initial triage, theis repeated with the trainee as the attending and the pre- PPM paged the hospitalist with the same information, withceptor as the observer. (3) Monthly debriefing sessions are an expected call-back time of 15 minutes. Then the ER doc-led by an experienced clinician in hospital medicine. The tor, the PPM, and the hospitalist had a 3-way conversationgoal of these sessions is to provide attending physicians on about patient presentation, working diagnosis, and inpati-the wards an opportunity to share obstacles encountered ent versus observation status. Conclusions: For the 3 weeksduring the month and techniques that they used to over- prior to and the 3 weeks of the pilot, the PPMs tracked howcome them. (4) A handbook based on the content of the often they had to change a patient’s bed assignment. Thelectures in the half-day seminar was created and distributed daily rate of incorrect placement fell from 8 (9.4%) beforeto faculty. It contains specific recommendations about strate- the pilot to 2 (3.1%) during the pilot (P < 0.001). A con-gies for setting expectations, time management, bedside servative estimate of the expense for housekeeping, PPM,teaching, and navigating key services in the hospital. It is and nursing time as well as supplies totaled $106 wastedposted on the Internet. (5) A bibliography was created as a for every error. Thus, if the pilot were implemented and suc-supplement to the information presented in the seminar. cess rate stayed the same, the annualized institutional sav-Content includes seminal articles on bedside teaching, lead- ings would be $232,140. Including physician time,ing ward rounds, providing feedback, and communication. pharmacy time, and messenger and other ancillary staffThis bibliography is posted on the Internet. All phases of time would make the savings even greater. Lastly, althoughthe program are evaluated. Participants are surveyed after we did not measure the effects on patient safety and satis-the seminar and peer coaching sessions. Monthly debrief- faction, these were likely to have improved as well. Weing sessions are recorded, transcribed, and evaluated for encountered a number of barriers. Technology problemscommon themes requiring intervention. Conclusions: The such as pagers and computer systems going down wereWASP is a unique collaboration between hospitalists and experienced. PPMs were variably familiar with admissiongeneral internists. It uses multiple tools to improve faculty criteria in regard to inpatient and observation status, lead-performance and, potentially, the experience for faculty ing to incorrect status designation and placement. Subopti-and trainees on the inpatient medical wards. mal staffing of PPMs and large volumes of calls at once toDisclosures: the hospitalist led to delays in call-backs to the ER doctors.J. S. Baru - none; B. P. Lucas - none; J. Smith - none; B. Mba - none; D. Woods - The ER doctors perceived this as adding delays to patientnone; S. Rogers - none; I. Paintsil - none; L. Rohr - none; S. Vargas - none care and ER flow, and a waste of ER doctor time may have been a hidden cost as well. The next steps include a future157 pilot with increased PPM staffing.RIGHT PATIENT, RIGHT BED Disclosures:Christine Bryson, DO; Baystate Medical Center, Springfield, C. Bryson - noneMABackground: Our program admits approximately 15,000 158patients a year. Bed assignment depends on availability RESIDENT CASE REVIEW AT THE DEPARTMENTALand level of care required. Incorrect placement occurs fre- LEVEL: A WIN–WIN SCENARIOquently, leading to delays in patient care and causing adrain on nursing, physician, and housekeeping resources. Alexander Carbo, MD1, Elaine Besancon, BS2, Cheryle Totte,Purpose: In spring 2010, our hospital contacted a consul- MS, RN1, Mark Aronson, MD1, Anjala Tess, MD1; 1Beth Israeltant group to examine its efficiency and throughput. Our Deaconess Medical Center, Boston, MA; 2Harvard Medicalgroup was charged with improving bed assignment prac- School, Boston, MAtice. Description: We examined the admission process. The Background: In 2001 our residency program developed aER attending would decide on admission and page the quality improvement elective. Our goals were to provideadmitting hospitalist. They discussed patient presentation, residents with hands-on experience in peer review root Hospital Medicine 2011 Abstracts S101
    • cause analysis (RCA) and performance improvement, which 159would also satisfy the ACGME systems-based practice com- READMISSIONS—THE SAME OLD THING?petency. In 2006 the rotation became mandatory for all Robert Chang, MD, Satyen Nichani, MD, Christopher Kim,residents. As residents took on a larger role within the for- MD; University of Michigan Medical School, Ann Arbor, MImal departmental process for peer review, we implementeda more structured approach to case review. Purpose: To de- Background: Hospitalized patients are frequently readmittedvelop a standardized approach to training residents in within 30 days of their discharge. It is believed that manyadverse event review and incorporate resident work into patients are readmitted because of a recurrence or worsen-the peer review structure of the Department of Medicine. ing of the same condition for which they were originallyDescription: Cases for review are gathered via the usual hospitalized. Such readmissions might be preventable ifdepartmental process; each resident is assigned a case dur- related to inadequate treatment or poor care transitions.ing his or her 3-week elective. Cases with emphasis on pro- However, the degree to which patient readmissions occurcess are selected for residents to broaden their perspective on for the same reason remains uncertain, as most studies thussystems-based thinking. Prior to their review, residents partici- far have relied on administrative data. Purpose: To deter-pate in a faculty-led didactic session on RCA and complete mine (1) the accuracy of billing data compared with clinicalonline modules on systems theory. They meet with the patient chart review in determining the reason for readmissionssafety coordinator to review the process, to strategize around and (2) whether patients were readmitted for the same rea-issues of hierarchy when reviewing cases involving faculty son as the original admission based on clinical assessment.members, and to learn to minimize the negative impact on Description: All patients who were readmitted in November‘‘second victims.’’ We provide a scripted e-mail to use in 2009 within 30 days of their discharge from the inpatient gen- eral medicine service were included. Sixty-seven uniqueapproaching providers for interview. Residents complete a patients were identified. Administrative data regarding patientchart review, interview providers, and complete an online identification, reason for initial and subsequent admissions, de-database that walks them through an RCA. This structured mographic data, and length of stay were obtained. Only theapproach fosters independent assessment and analysis by the first readmission was evaluated if more than 1 readmissionresident, with faculty supervision. Residents present their find- occurred. Data elements in the chart review of the electronicings and make suggestions for improvement at the depart- medical record included discharge summaries, laboratorymental peer review committee. They also close the loop by data, radiographic imaging, and inpatient progress notes fromproviding feedback to the providers in the case. To ensure the primary and consulting services. Two reviewers evaluatedthat residents can present their findings, the department has the data independently looking at (1) the primary reasons (uprescheduled the peer review committee meeting to match the to 4) for initial admission, (2) primary reasons for readmission,resident schedule, now meeting every 3 weeks instead of ev- (3) whether these reasons matched the primary billing diagno-ery 4. Residents have been responsible for 167 (60%) of sis-related group (DRG) code listed for admission and readmis-277 departmental case reviews since 2006. They presented sion, and (4) categorizing the readmission into 1 of 4 nominal132 (79%) of 167 cases at the departmental peer review categories: same–planned, same–unplanned, different–-committee, accounting for 48% of all presentations over this planned, and different–unplanned. Cohen’s kappa coefficienttime. Only 11 (7%) were procedure-related events. Of the was used to calculate the degree of interrater agreement. The137 cases for which follow-up data are available, 18 (13%) reasons for both admission and readmission in the administra-were reported to state and federal agencies. Forty-five (33%) tive billing record matched the findings of the clinical reviewerswere referred for presentation at morbidity and mortality con- in only 34 cases (51%). Only 8 readmissions (12%) wereferences, and 89 (65%) were referred to additional depart- planned. Of the unplanned readmissions, 31 patients (46%)mental and extradepartmental meetings. Conclusions: were readmitted for the same reasons and 28 (42%) for differ-Although reports exist of residents participating in adverse ent reasons from their index hospitalization. The K coefficientevent review at the residency program or divisional level, our was 0.63 between observers. Conclusions: The majority ofstructured approach is the first example of resident involve- patients in this sample were readmitted in an unplanned fash-ment in hands-on case review with full integration into the ion. Of these, only half were for reasons similar to their indexDepartment of Medicine peer review process. Participation hospitalization. Moreover, discrepancies in the reason forprovides residents with key knowledge and skills in this arena admission between billing DRG and clinical chart review wereand allows them to provide insights into processes of care at found in a substantial number of patients, highlighting the lim-the departmental level. ited accuracy of using administrative databases for this pur-Disclosures: pose. These results are limited by sample size, single-centerA. Carbo - none; E. Besancon - none; C. Totte - none; M. Aronson - none; A. experience, and the retrospective nature of the study.Tess - none Disclosures: R. Chang - none; S. Nichani - none; C. Kim - noneS102 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
    • 160ELECTRONIC DOCUMENTATION OF CENTRALLINE-DAYS; VALIDATION IS ESSENTIALSheri Chernetsky Tejedor, MD, FHM1, Jason Stein, MD,SFHM1, Gina Garrett, RN, BSN, CRNI2, Jesse Jacob, MD1,Laura Phillips, BS2, Ellen Meyer, MSN, RN2, Mary Dent Reyes,MPH1, Chad Robichaux, MS2, James Steinberg, MD1; 1EmoryUniversity School of Medicine, Atlanta, GA; 2Emory Health-care, Atlanta, GABackground: Beginning in January 2011, hospitals willreport central line–associated bloodstream infections(CLABSIs) to the National Healthcare Safety Network(NHSN) per Center for Medicare and Medicaid Services(CMS) payment rules. The NHSN definition of CLABSI usescentral line–days as the denominator. Manual collection ofline-days is resource intensive, and NHSN allows for use ofelectronic data sources if line-days are within 5% of themanual count. However, NHSN has no validation compo-nent at the facility level. Purpose: We sought to design andvalidate an accurate process to electronically ‘‘count’’ line-days outside the ICU at 2 university hospitals with a total of1000 beds and assess the impact of this intervention onCLABSI rates. Description: An electronic query was createdto capture patient and line information along with a processfor tracking, reporting, and correcting errors in documenta-tion to improve the validity of the electronic data. The inter-ventions included: an electronic error tracking tool,reeducation of 98% of the nursing staff, redesign of the FIGURE 1. The validity of the electronic central line day countdocumentation interface, audit and feedback of errors inreal time, and a dedicated line champion. After the initial depended on the quality of central line documentation. The docu-manual validation, an electronic documentation error track- mentation error rate improved with each system-wide intervention.ing tool was developed to flag common errors leading toincorrect line-day counts, used daily by a trained nurse cov-ering 2 hospitals. Ongoing education focused on wards denominator line-day data. Our pilot comparing CLABSIwith a high error rate, and errors were corrected in real rates on 2 wards had discordant results depending ontime. After validation of electronic data capture, CLABSI choice of denominator.rates were calculated using both patient-days and electronic Disclosures:line-days for 2 selected wards over 8 months. Baseline, S. Chernetsky Tejedor - Baxter Healthcare, research grant; J. Stein - none; G.there were 3454 errors/month in 5576 line-days, for an Garrett - none; J. Jacob - Baxter Healthcare, research grant; L. Phillips - none;error rate of 0.6 /line-days. Postintervention, there were E. Meyer - none; M. Dent Reyes - Baxter Healthcare, research grant; C. Robichaux - none; J. P. Steinberg - Baxter Healthcare, research grant343 errors/month in 5061 line-days, for an overall rate of0.07/line-days, now stable 19 months postintervention(Fig. 1). Baseline, a mean of 121 patients/day had !1 161errors (81% involved a missing line type or insertion date), READMISSIONS, FACEBOOK AND INFORMATIONwhich decreased to 12 patients/day 13 months postinter- SHARING: LESSONS LEARNED FOR FUTURE PATHSvention. There were 7 CLABSIs on ward A and 6 on wardB in the study period. Using the patient-days denominator, Vineet Chopra, MD, FACP, FHM, Laurence McMahon, MD;ward A had a higher CLABSI rate than ward B (1.4 vs. University of Michigan Health System, Ann Arbor, MI1.2/1000 patient-days). However, using line-days as the Background: The hospitalist model of care may adverselydenominator, ward A had a lower rate than ward B (3.2 affect the transition to or from the hospital by interruptingvs. 4.8/1000 line-days). Conclusions: Without intensive val- the flow of information between providers. The resulting in-idation efforts, electronic line-day coun