Chad Whelan, MD

A 33‐year‐old Caucasian woman presented to an outside hospital with a 10‐day history of fever, cough, and progressive dyspnea on exertion. Ten days prior to the onset of symptoms, she had traveled to Calgary, Alberta, Canada. Her niece and nephew had recently suffered upper respiratory symptoms. Additional review of systems was negative for joint pain, rash, diarrhea, or bloody stools. She had a history of ulcerative colitis, primary sclerosing cholangitis, and juvenile rheumatoid arthritis. Her outpatient medications included prednisone 10 mg daily, methotrexate 7.5 mg weekly, and ursodiol 200 mg 3 times daily. She was employed at a local hospital and her annual purified protein derivative (PPD) test had been negative. Computed tomography angiography demonstrated bilateral patchy consolidation. Vancomycin, levofloxacin, piperacillin/tazobactam, and fluconazole were initiated and she was transferred to our hospital for further evaluation.

On arrival, her vital signs were within normal limits. She was breathing comfortably but on auscultation had crackles at the right‐mid lung field. A complete blood cell count demonstrated a white blood cell count of 7000/L with left shift, hemoglobin 10.7 g/dL, and platelet count 156,000/L. Liver function tests showed albumin 2.6 g/dL, total bilirubin 9.0 mg/dL with conjugated fraction 6.6 mg/dL, alkaline phosphatase 586 U/L, aspartate aminotransferase 104 U/L, and alanine aminotransferase 72 U/L; these were all near her baseline. The basic metabolic panel was within normal limits. A chest X‐ray showed dense areas of consolidation in the lingula and left upper lobe. All antibiotics from the outside hospital were discontinued and empiric moxifloxacin was initiated.

On hospital day 1, she underwent bronchoscopy, which yielded cloudy fluid from the bronchoalveolar lavage (BAL). Initial BAL gram stain showed moderate white blood cells but no organisms; fungal smears and stains for acid fast bacilli were negative. Blood cultures and Legionella and Streptococcus urinary antigen tests were negative. The remainder of her hospital course was uneventful. Her shortness of breath improved and she remained afebrile. She was discharged home on a 10‐day course of moxifloxacin with close follow‐up. Six days after the BAL specimen was collected, the culture grew Legionella micdadei. Repeat chest film 2 weeks later demonstrated resolution of the original findings.

DISCUSSION

Legionella is responsible for 8000 to 18,000 hospitalizations for pneumonia annually.1 It is associated with community‐acquired, hospital‐acquired, and travel‐associated pneumonia. Twenty‐five Legionella species have been identified and 8 species are associated with pneumonia in humans.2 Community‐acquired and travel‐acquired Legionella pneumonia is most commonly caused by Legionella pneumophila; the second most common cause is L. micdadei.2, 3 It was initially identified in 1977 at the University of Pittsburgh in renal transplant patients with acute pneumonitis and is known as the Pittsburgh pneumonia agent. Similar cases were identified in a group of immunocompromised patients in Virginia, all of whom were receiving steroids and cytotoxic chemotherapy. It is unclear why L. micdadei predominates in this population, but is likely related to its decreased virulence compared to L. pneumophila. The definitive mode of transmission of L. micdadei is not known; it may be from contaminated water supplies but infections from inhalation of respiratory secretions have also been documented.2 While L. micdadei is not commonly seen in travel‐associated Legionella pneumonia, the patient's immunocompromised status secondary to the treatment of her underlying medical conditions made her particularly vulnerable. Given the temporal association with her trip, she was most likely exposed during her travels but her hospital employment should also be considered.

Legionella pneumonia is underdiagnosed because of difficulty distinguishing it from other types of pneumonia, failure to order diagnostic tests, and variable sensitivity of available diagnostic tests.4 Culture is considered the gold standard and is ideally performed from lower respiratory secretions, but variable sensitivity due to interlaboratory variation (range, 10%‐80%) limits its use.3, 4 Direct immunofluorescence assay (DFA) testing of respiratory secretions is available but also limited by poor sensitivity. Both culture and DFA have specificities approaching 100%. A newer test, the Legionella urinary antigen test, is an immunochromatographic assay. It is less technically difficult and results are available in less than 1 hour. The assay can detect the antigen in the urine starting 1 day after the onset of symptoms, and can remain positive for days or weeks following treatment.4

With the introduction and wide availability of the Legionella urinary antigen test, it is important to consider its limitations. While the test carries a high specificity, it detects only the soluble antigen of Legionella pneumophila serogroup 1. Thus, as in this case, the urinary test can be negative when infection is caused by other species such as L. micdadei. In the literature, the urine assay's sensitivity is variously reported at 45% to 100% with lower sensitivities in circumstances such as hospital‐acquired disease, where the association with other species is higher than in the community setting.3, 4 For instance, in nosocomial infections, the reported sensitivity is 45%.3 False‐positive results have also been seen in patients with serum sickness.4

The Legionella urinary antigen test has improved detection of Legionella pneumonia. Given its limitations, it is likely to be most accurate in community‐acquired and travel‐acquired cases.3 The Centers for Disease Control and Prevention recommend testing for Legionella in pneumonia patients requiring admission to the intensive care unit (ICU), immunocompromised patients, patients who traveled within 2 weeks of presentation, and those who have failed treatment with beta‐lactams or cephalosporins. A negative test does not rule out Legionella infection and additional testing with bronchoscopy may be indicated, especially in immunocompromised hosts.4

A 33‐year‐old Caucasian woman presented to an outside hospital with a 10‐day history of fever, cough, and progressive dyspnea on exertion. Ten days prior to the onset of symptoms, she had traveled to Calgary, Alberta, Canada. Her niece and nephew had recently suffered upper respiratory symptoms. Additional review of systems was negative for joint pain, rash, diarrhea, or bloody stools. She had a history of ulcerative colitis, primary sclerosing cholangitis, and juvenile rheumatoid arthritis. Her outpatient medications included prednisone 10 mg daily, methotrexate 7.5 mg weekly, and ursodiol 200 mg 3 times daily. She was employed at a local hospital and her annual purified protein derivative (PPD) test had been negative. Computed tomography angiography demonstrated bilateral patchy consolidation. Vancomycin, levofloxacin, piperacillin/tazobactam, and fluconazole were initiated and she was transferred to our hospital for further evaluation.

On arrival, her vital signs were within normal limits. She was breathing comfortably but on auscultation had crackles at the right‐mid lung field. A complete blood cell count demonstrated a white blood cell count of 7000/L with left shift, hemoglobin 10.7 g/dL, and platelet count 156,000/L. Liver function tests showed albumin 2.6 g/dL, total bilirubin 9.0 mg/dL with conjugated fraction 6.6 mg/dL, alkaline phosphatase 586 U/L, aspartate aminotransferase 104 U/L, and alanine aminotransferase 72 U/L; these were all near her baseline. The basic metabolic panel was within normal limits. A chest X‐ray showed dense areas of consolidation in the lingula and left upper lobe. All antibiotics from the outside hospital were discontinued and empiric moxifloxacin was initiated.

On hospital day 1, she underwent bronchoscopy, which yielded cloudy fluid from the bronchoalveolar lavage (BAL). Initial BAL gram stain showed moderate white blood cells but no organisms; fungal smears and stains for acid fast bacilli were negative. Blood cultures and Legionella and Streptococcus urinary antigen tests were negative. The remainder of her hospital course was uneventful. Her shortness of breath improved and she remained afebrile. She was discharged home on a 10‐day course of moxifloxacin with close follow‐up. Six days after the BAL specimen was collected, the culture grew Legionella micdadei. Repeat chest film 2 weeks later demonstrated resolution of the original findings.

DISCUSSION

Legionella is responsible for 8000 to 18,000 hospitalizations for pneumonia annually.1 It is associated with community‐acquired, hospital‐acquired, and travel‐associated pneumonia. Twenty‐five Legionella species have been identified and 8 species are associated with pneumonia in humans.2 Community‐acquired and travel‐acquired Legionella pneumonia is most commonly caused by Legionella pneumophila; the second most common cause is L. micdadei.2, 3 It was initially identified in 1977 at the University of Pittsburgh in renal transplant patients with acute pneumonitis and is known as the Pittsburgh pneumonia agent. Similar cases were identified in a group of immunocompromised patients in Virginia, all of whom were receiving steroids and cytotoxic chemotherapy. It is unclear why L. micdadei predominates in this population, but is likely related to its decreased virulence compared to L. pneumophila. The definitive mode of transmission of L. micdadei is not known; it may be from contaminated water supplies but infections from inhalation of respiratory secretions have also been documented.2 While L. micdadei is not commonly seen in travel‐associated Legionella pneumonia, the patient's immunocompromised status secondary to the treatment of her underlying medical conditions made her particularly vulnerable. Given the temporal association with her trip, she was most likely exposed during her travels but her hospital employment should also be considered.

Legionella pneumonia is underdiagnosed because of difficulty distinguishing it from other types of pneumonia, failure to order diagnostic tests, and variable sensitivity of available diagnostic tests.4 Culture is considered the gold standard and is ideally performed from lower respiratory secretions, but variable sensitivity due to interlaboratory variation (range, 10%‐80%) limits its use.3, 4 Direct immunofluorescence assay (DFA) testing of respiratory secretions is available but also limited by poor sensitivity. Both culture and DFA have specificities approaching 100%. A newer test, the Legionella urinary antigen test, is an immunochromatographic assay. It is less technically difficult and results are available in less than 1 hour. The assay can detect the antigen in the urine starting 1 day after the onset of symptoms, and can remain positive for days or weeks following treatment.4

With the introduction and wide availability of the Legionella urinary antigen test, it is important to consider its limitations. While the test carries a high specificity, it detects only the soluble antigen of Legionella pneumophila serogroup 1. Thus, as in this case, the urinary test can be negative when infection is caused by other species such as L. micdadei. In the literature, the urine assay's sensitivity is variously reported at 45% to 100% with lower sensitivities in circumstances such as hospital‐acquired disease, where the association with other species is higher than in the community setting.3, 4 For instance, in nosocomial infections, the reported sensitivity is 45%.3 False‐positive results have also been seen in patients with serum sickness.4

The Legionella urinary antigen test has improved detection of Legionella pneumonia. Given its limitations, it is likely to be most accurate in community‐acquired and travel‐acquired cases.3 The Centers for Disease Control and Prevention recommend testing for Legionella in pneumonia patients requiring admission to the intensive care unit (ICU), immunocompromised patients, patients who traveled within 2 weeks of presentation, and those who have failed treatment with beta‐lactams or cephalosporins. A negative test does not rule out Legionella infection and additional testing with bronchoscopy may be indicated, especially in immunocompromised hosts.4

A 33‐year‐old Caucasian woman presented to an outside hospital with a 10‐day history of fever, cough, and progressive dyspnea on exertion. Ten days prior to the onset of symptoms, she had traveled to Calgary, Alberta, Canada. Her niece and nephew had recently suffered upper respiratory symptoms. Additional review of systems was negative for joint pain, rash, diarrhea, or bloody stools. She had a history of ulcerative colitis, primary sclerosing cholangitis, and juvenile rheumatoid arthritis. Her outpatient medications included prednisone 10 mg daily, methotrexate 7.5 mg weekly, and ursodiol 200 mg 3 times daily. She was employed at a local hospital and her annual purified protein derivative (PPD) test had been negative. Computed tomography angiography demonstrated bilateral patchy consolidation. Vancomycin, levofloxacin, piperacillin/tazobactam, and fluconazole were initiated and she was transferred to our hospital for further evaluation.

On arrival, her vital signs were within normal limits. She was breathing comfortably but on auscultation had crackles at the right‐mid lung field. A complete blood cell count demonstrated a white blood cell count of 7000/L with left shift, hemoglobin 10.7 g/dL, and platelet count 156,000/L. Liver function tests showed albumin 2.6 g/dL, total bilirubin 9.0 mg/dL with conjugated fraction 6.6 mg/dL, alkaline phosphatase 586 U/L, aspartate aminotransferase 104 U/L, and alanine aminotransferase 72 U/L; these were all near her baseline. The basic metabolic panel was within normal limits. A chest X‐ray showed dense areas of consolidation in the lingula and left upper lobe. All antibiotics from the outside hospital were discontinued and empiric moxifloxacin was initiated.

On hospital day 1, she underwent bronchoscopy, which yielded cloudy fluid from the bronchoalveolar lavage (BAL). Initial BAL gram stain showed moderate white blood cells but no organisms; fungal smears and stains for acid fast bacilli were negative. Blood cultures and Legionella and Streptococcus urinary antigen tests were negative. The remainder of her hospital course was uneventful. Her shortness of breath improved and she remained afebrile. She was discharged home on a 10‐day course of moxifloxacin with close follow‐up. Six days after the BAL specimen was collected, the culture grew Legionella micdadei. Repeat chest film 2 weeks later demonstrated resolution of the original findings.

DISCUSSION

Legionella is responsible for 8000 to 18,000 hospitalizations for pneumonia annually.1 It is associated with community‐acquired, hospital‐acquired, and travel‐associated pneumonia. Twenty‐five Legionella species have been identified and 8 species are associated with pneumonia in humans.2 Community‐acquired and travel‐acquired Legionella pneumonia is most commonly caused by Legionella pneumophila; the second most common cause is L. micdadei.2, 3 It was initially identified in 1977 at the University of Pittsburgh in renal transplant patients with acute pneumonitis and is known as the Pittsburgh pneumonia agent. Similar cases were identified in a group of immunocompromised patients in Virginia, all of whom were receiving steroids and cytotoxic chemotherapy. It is unclear why L. micdadei predominates in this population, but is likely related to its decreased virulence compared to L. pneumophila. The definitive mode of transmission of L. micdadei is not known; it may be from contaminated water supplies but infections from inhalation of respiratory secretions have also been documented.2 While L. micdadei is not commonly seen in travel‐associated Legionella pneumonia, the patient's immunocompromised status secondary to the treatment of her underlying medical conditions made her particularly vulnerable. Given the temporal association with her trip, she was most likely exposed during her travels but her hospital employment should also be considered.

Legionella pneumonia is underdiagnosed because of difficulty distinguishing it from other types of pneumonia, failure to order diagnostic tests, and variable sensitivity of available diagnostic tests.4 Culture is considered the gold standard and is ideally performed from lower respiratory secretions, but variable sensitivity due to interlaboratory variation (range, 10%‐80%) limits its use.3, 4 Direct immunofluorescence assay (DFA) testing of respiratory secretions is available but also limited by poor sensitivity. Both culture and DFA have specificities approaching 100%. A newer test, the Legionella urinary antigen test, is an immunochromatographic assay. It is less technically difficult and results are available in less than 1 hour. The assay can detect the antigen in the urine starting 1 day after the onset of symptoms, and can remain positive for days or weeks following treatment.4

With the introduction and wide availability of the Legionella urinary antigen test, it is important to consider its limitations. While the test carries a high specificity, it detects only the soluble antigen of Legionella pneumophila serogroup 1. Thus, as in this case, the urinary test can be negative when infection is caused by other species such as L. micdadei. In the literature, the urine assay's sensitivity is variously reported at 45% to 100% with lower sensitivities in circumstances such as hospital‐acquired disease, where the association with other species is higher than in the community setting.3, 4 For instance, in nosocomial infections, the reported sensitivity is 45%.3 False‐positive results have also been seen in patients with serum sickness.4

The Legionella urinary antigen test has improved detection of Legionella pneumonia. Given its limitations, it is likely to be most accurate in community‐acquired and travel‐acquired cases.3 The Centers for Disease Control and Prevention recommend testing for Legionella in pneumonia patients requiring admission to the intensive care unit (ICU), immunocompromised patients, patients who traveled within 2 weeks of presentation, and those who have failed treatment with beta‐lactams or cephalosporins. A negative test does not rule out Legionella infection and additional testing with bronchoscopy may be indicated, especially in immunocompromised hosts.4

A crucial arena of innovative educational programs for the care of the elderly must include the hospital setting, a place of great cost, morbidity, and mortality for a population currently occupying approximately half of US hospital beds.1 With a marked acceleration in the number of persons living to an advanced age, there is a clear imperative to address the health‐care needs of the elderly, particularly the complex and frail.24 An educational grounding that steps beyond the traditional organ‐based models of disease to a much broader patient‐centered framework of care is necessary to aid physicians in advanced clinical decision‐making in the care of older patients. Organizing the medical care of the older patient within existing systems of care and a team care management network must also be improved.

Curricular materials and methods are widely available for teaching geriatric medicine,57 but most are geared toward outpatient care and management, with few addressing the care of the hospitalized, older medical patient.810 There is even less published on curricular materials, methods, and tools for such teaching outside of specialized hospital‐based geriatric units by nongeriatrics‐trained faculty.1113 Furthermore, the evaluation of geriatrics educational programs in the hospital setting has not been done with the ultimate assessment, the linking of educational programs to demonstrated changes in clinical practice and patient care outcomes.

To address these needs, we designed and implemented the Curriculum for the Hospitalized Aging Medical Patient (CHAMP) Faculty Development Program (FDP). CHAMP was funded by a grant from the Donald W. Reynolds Foundation Aging and Quality of Life Program with a matching commitment from the University of Chicago Department of Medicine. At the core of CHAMP are principles of care for the older patient in the hospital setting, with an emphasis on identifying and providing care for the complex and frail elderly with nongeriatrician inpatient medicine faculty as the primary teachers of these materials. The overall educational goals of the CHAMP FDP are the following: (1) to train hospitalists and general internists to recognize opportunities to teach geriatric medicine topics specific to the care of the hospitalized older patient; (2) to create teaching materials, tools, and methods that can be used in the busy medical inpatient setting at the bedside; (3) to create materials and tools that facilitate teaching the Accreditation Council for Graduate Medical Education (ACGME) core competencies14 during ward rounds; and (4) to increase the frequency and effectiveness with which this geriatrics content is taught in the hospital setting. This article describes the development and refinement of the CHAMP FDP and evaluation results to date.

METHODS

The CHAMP FDP was developed by a core group of geriatricians, hospitalists, general medicine faculty, and PhD educators from the Office of the Dean at the University of Chicago Pritzker School of Medicine. The core group piloted the FDP for themselves in spring 2004, and the FDP was offered to target learners annually from 2004 to 2006.

RESULTS

We pilot‐tested the format, materials, methods, and evaluation components of the CHAMP FDP with the CHAMP core faculty in the spring of 2004. The revised CHAMP FDP was given in the fall of 2004 to the first group of 8 faculty learners. Similar annual CHAMP FDPs have occurred since 2004, with a total of 29 Faculty Scholars by 2006. This includes approximately half of the University of Chicago general medicine faculty and the majority of the hospitalist faculty. Geriatrics fellows, a medicine chief resident, and other internal medicine subspecialists have also taken the CHAMP FDP. The average evaluations of all CHAMP sessions by all participants are shown in Table 3.

Faculty Scholars rated the FDP highly regarding preparation for teaching and incorporation of the material into their teaching and practice. Likewise, qualitative comments by the Faculty Scholars were strongly supportive of CHAMP:

• Significantly more aware and confident in teaching around typical geriatric issues present in our patients.

• Provided concrete, structured ideas about curriculum, learning goals, content materials and how to implement them.

• The online teaching resources were something I used on an almost daily basis.

• Wish we had this for outpatient.

CHAMP had a favorable impact on the Faculty Scholars across the domains of knowledge, attitudes, and perceived behavior change (Table 4). Significant differences on paired‐sample t tests found significant improvement on all but one measure (importance of teaching). After the CHAMP program, Faculty Scholars were more knowledgeable about geriatrics content (P = 0.023), had more positive attitudes to older patients (P = 0.049), and had greater confidence in their ability to care for older patients (P < 0.001) and teach geriatric medicine skills (P < 0.001) and Teaching on Today's Wards content (P < 0.001). There was a significant increase in the perceived importance of practicing the learned skills (P = 0.008) and Teaching on Today's Wards (P = 0.001). The increased importance of teaching geriatrics skills was marginally significant (P = 0.064).

DISCUSSION

Central to CHAMP's design are (1) the creation of teaching materials and teaching resources that specifically address the challenges of teaching the care of the hospitalized older patient in busy hospital settings, (2) the provision of methods to reinforce the newly learned geriatrics teaching skills, and (3) a multidimensional evaluation scheme. The enthusiastic response to the CHAMP FDP and the evaluation results to date support the relevance and importance of CHAMP's focus, materials, and educational methods. The ideal outcome for our CHAMP FDP graduates is more informed, confident, and frequent teaching of geriatrics topics keyed to quality improvement and systems of care through a more streamlined but personalized bedside teaching process.13, 46 The CHAMP Faculty Scholar graduates' self‐report surveys of their performance and teaching of CHAMP course geriatrics skills did reveal a significant shift in clinical behavior, teaching, and confidence. Although the strongest indicator of perceived behavior change was in the enhanced self‐confidence in practicing and teaching, the significant changes in knowledge and attitude reinforce our observations of a shift in the mindset about teaching and caring for hospitalized elderly patients. This provides strong evidence for the efficacy of the CHAMP course in positively influencing participants.

Our biggest challenge with the CHAMP FDP was providing enough ongoing support to reinforce learning with an eye on the greater goal of changing teaching behaviors and clinical outcomes. After pilot testing, we added multiple types of support and follow‐up to the FDP: observed structured teaching exercises to practice CHAMP geriatrics content and teaching skills; modification of Teaching on Today's Wards through the addition of practice‐oriented exercises, games, and tutorials; frequent contact with our Faculty Scholar graduates post‐CHAMP FDP through CTC contracts; annual Faculty Scholars reunions; and continued access for the scholars to CHAMP materials on our Web site. Maintaining face‐to‐face contact between CHAMP core faculty and Faculty Scholars once the latter have finished the FDP has been challenging, largely because of clinical and teaching obligations over geographically separate sites. To overcome this, we are working to integrate CHAMP core faculty into hospitalist and general medicine section lecture series, increasing the frequency of CHAMP reunions, renewing CTC contracts with the Faculty Scholar graduates annually, and considering the concept of CHAMP core faculty guests attending during Faculty Scholars inpatient ward rounds.47

The CHAMP FDP and our evaluations to date have several limitations. First, FDP Scholars were volunteer participants who may have been more motivated to improve their geriatric care and teaching than nonparticipants. However, FDP Scholars had only moderate levels of geriatrics knowledge, attitudes, and confidence in their teaching on baseline testing and showed marked improvements in these domains after the FDP. In addition, Scholars' FDP participation was made possible by a reduction of other clinical obligations through direct reimbursement to their sections with CHAMP funds. Other incentives for CHAMP participation could include its focus on generalizable bedside teaching skills and provision of specific techniques for teaching the ACGME core competencies and quality improvement while using geriatrics content. Although the CHAMP FDP in its 48‐hour format is not sustainable or generalizable, the FDP modules and CHAMP materials were specifically designed to be usable in small pieces that could be incorporated into existing teaching structures, grand rounds, section meetings, teacher conferences, and continuing medical education workshops. CHAMP core group members have already presented and taught CHAMP components in many venues (see Dissemination on the CHAMP Web site). The excitement generated by CHAMP at national and specialty meetings, including multiple requests for materials, speaks to widespread interest in our CHAMP model. We are pursuing the creation of a mini‐CHAMP, an abbreviated FDP with an online component. These activities as well as feedback from users of CHAMP materials from the CHAMP Web site and the Portal of Geriatric Online Education will provide important opportunities for examining the use and acceptance of CHAMP outside our institution.

Another limitation of the CHAMP FDP is reliance on FDP Scholar self‐assessment in several of the evaluation components. Some studies have shown poor concordance between physicians' self‐assessment and external assessment over a range of domains.48 However, others have noted that despite these limitations, self‐assessment remains an essential tool for enabling physicians to discover the motivational discomfort of a performance gap, which may lead to changing concepts and mental models or changing work‐flow processes.49 Teaching on Today's Wards sessions in CHAMP emphasize self‐audit processes (such as process mapping and census audits) that can augment self‐assessment. We used such self‐audit processes in 1 small pilot study to date, providing summative and qualitative feedback to a group of FDP Scholars on their use of census audits.

However, the evaluation of the CHAMP FDP is enhanced by a yearly survey of all medical residents and medical students and by the linking of the teaching reported by residents and medical students to specific attendings. We have begun the analysis of resident perceptions of being taught CHAMP geriatrics topics by CHAMP faculty versus non‐CHAMP faculty. In addition, we are gathering data on patient‐level process of care and outcomes tied to the CHAMP FDP course session objectives by linking to the ongoing University of Chicago Hospitalist Project, a large clinical research project that enrolls general medicine inpatients in a study examining the quality of care and resource allocation for these patients.50 Because the ultimate goal of CHAMP is to improve the quality of care and outcomes for elderly hospitalized patients, the University of Chicago Hospitalist Project infrastructure was modified by the incorporation of the Vulnerable Elder Survey‐1351 and a process‐of‐care chart audit specifically based on the Assessing Care of the Vulnerable Elders Hospital Quality Indicators.52 Preliminary work included testing and validating these measures.53 Further evaluation of these clinical outcomes and CHAMP's efficacy and durability at the University of Chicago is ongoing and will be presented in future reports.

CONCLUSIONS

Through a collaboration of geriatricians, hospitalists, and general internists, the CHAMP FDP provides educational materials and methods keyed to bedside teaching in the fast‐paced world of the hospital. CHAMP improves faculty knowledge and attitudes and the frequency of teaching geriatrics topics and skills necessary to deliver quality care to the elderly hospitalized medical patient. Although the CHAMP FDP was developed and refined for use at a specific institution, the multitiered CHAMP FDP materials and methods have the potential for widespread use by multiple types of inpatient attendings for teaching the care of the older hospitalized medicine patient. Hospitalists in particular will require this expertise as both clinicians and teachers as their role, leadership, and influence continue to expand nationally.

A crucial arena of innovative educational programs for the care of the elderly must include the hospital setting, a place of great cost, morbidity, and mortality for a population currently occupying approximately half of US hospital beds.1 With a marked acceleration in the number of persons living to an advanced age, there is a clear imperative to address the health‐care needs of the elderly, particularly the complex and frail.24 An educational grounding that steps beyond the traditional organ‐based models of disease to a much broader patient‐centered framework of care is necessary to aid physicians in advanced clinical decision‐making in the care of older patients. Organizing the medical care of the older patient within existing systems of care and a team care management network must also be improved.

Curricular materials and methods are widely available for teaching geriatric medicine,57 but most are geared toward outpatient care and management, with few addressing the care of the hospitalized, older medical patient.810 There is even less published on curricular materials, methods, and tools for such teaching outside of specialized hospital‐based geriatric units by nongeriatrics‐trained faculty.1113 Furthermore, the evaluation of geriatrics educational programs in the hospital setting has not been done with the ultimate assessment, the linking of educational programs to demonstrated changes in clinical practice and patient care outcomes.

To address these needs, we designed and implemented the Curriculum for the Hospitalized Aging Medical Patient (CHAMP) Faculty Development Program (FDP). CHAMP was funded by a grant from the Donald W. Reynolds Foundation Aging and Quality of Life Program with a matching commitment from the University of Chicago Department of Medicine. At the core of CHAMP are principles of care for the older patient in the hospital setting, with an emphasis on identifying and providing care for the complex and frail elderly with nongeriatrician inpatient medicine faculty as the primary teachers of these materials. The overall educational goals of the CHAMP FDP are the following: (1) to train hospitalists and general internists to recognize opportunities to teach geriatric medicine topics specific to the care of the hospitalized older patient; (2) to create teaching materials, tools, and methods that can be used in the busy medical inpatient setting at the bedside; (3) to create materials and tools that facilitate teaching the Accreditation Council for Graduate Medical Education (ACGME) core competencies14 during ward rounds; and (4) to increase the frequency and effectiveness with which this geriatrics content is taught in the hospital setting. This article describes the development and refinement of the CHAMP FDP and evaluation results to date.

METHODS

The CHAMP FDP was developed by a core group of geriatricians, hospitalists, general medicine faculty, and PhD educators from the Office of the Dean at the University of Chicago Pritzker School of Medicine. The core group piloted the FDP for themselves in spring 2004, and the FDP was offered to target learners annually from 2004 to 2006.

RESULTS

We pilot‐tested the format, materials, methods, and evaluation components of the CHAMP FDP with the CHAMP core faculty in the spring of 2004. The revised CHAMP FDP was given in the fall of 2004 to the first group of 8 faculty learners. Similar annual CHAMP FDPs have occurred since 2004, with a total of 29 Faculty Scholars by 2006. This includes approximately half of the University of Chicago general medicine faculty and the majority of the hospitalist faculty. Geriatrics fellows, a medicine chief resident, and other internal medicine subspecialists have also taken the CHAMP FDP. The average evaluations of all CHAMP sessions by all participants are shown in Table 3.

Faculty Scholars rated the FDP highly regarding preparation for teaching and incorporation of the material into their teaching and practice. Likewise, qualitative comments by the Faculty Scholars were strongly supportive of CHAMP:

• Significantly more aware and confident in teaching around typical geriatric issues present in our patients.

• Provided concrete, structured ideas about curriculum, learning goals, content materials and how to implement them.

• The online teaching resources were something I used on an almost daily basis.

• Wish we had this for outpatient.

CHAMP had a favorable impact on the Faculty Scholars across the domains of knowledge, attitudes, and perceived behavior change (Table 4). Significant differences on paired‐sample t tests found significant improvement on all but one measure (importance of teaching). After the CHAMP program, Faculty Scholars were more knowledgeable about geriatrics content (P = 0.023), had more positive attitudes to older patients (P = 0.049), and had greater confidence in their ability to care for older patients (P < 0.001) and teach geriatric medicine skills (P < 0.001) and Teaching on Today's Wards content (P < 0.001). There was a significant increase in the perceived importance of practicing the learned skills (P = 0.008) and Teaching on Today's Wards (P = 0.001). The increased importance of teaching geriatrics skills was marginally significant (P = 0.064).

DISCUSSION

Central to CHAMP's design are (1) the creation of teaching materials and teaching resources that specifically address the challenges of teaching the care of the hospitalized older patient in busy hospital settings, (2) the provision of methods to reinforce the newly learned geriatrics teaching skills, and (3) a multidimensional evaluation scheme. The enthusiastic response to the CHAMP FDP and the evaluation results to date support the relevance and importance of CHAMP's focus, materials, and educational methods. The ideal outcome for our CHAMP FDP graduates is more informed, confident, and frequent teaching of geriatrics topics keyed to quality improvement and systems of care through a more streamlined but personalized bedside teaching process.13, 46 The CHAMP Faculty Scholar graduates' self‐report surveys of their performance and teaching of CHAMP course geriatrics skills did reveal a significant shift in clinical behavior, teaching, and confidence. Although the strongest indicator of perceived behavior change was in the enhanced self‐confidence in practicing and teaching, the significant changes in knowledge and attitude reinforce our observations of a shift in the mindset about teaching and caring for hospitalized elderly patients. This provides strong evidence for the efficacy of the CHAMP course in positively influencing participants.

Our biggest challenge with the CHAMP FDP was providing enough ongoing support to reinforce learning with an eye on the greater goal of changing teaching behaviors and clinical outcomes. After pilot testing, we added multiple types of support and follow‐up to the FDP: observed structured teaching exercises to practice CHAMP geriatrics content and teaching skills; modification of Teaching on Today's Wards through the addition of practice‐oriented exercises, games, and tutorials; frequent contact with our Faculty Scholar graduates post‐CHAMP FDP through CTC contracts; annual Faculty Scholars reunions; and continued access for the scholars to CHAMP materials on our Web site. Maintaining face‐to‐face contact between CHAMP core faculty and Faculty Scholars once the latter have finished the FDP has been challenging, largely because of clinical and teaching obligations over geographically separate sites. To overcome this, we are working to integrate CHAMP core faculty into hospitalist and general medicine section lecture series, increasing the frequency of CHAMP reunions, renewing CTC contracts with the Faculty Scholar graduates annually, and considering the concept of CHAMP core faculty guests attending during Faculty Scholars inpatient ward rounds.47

The CHAMP FDP and our evaluations to date have several limitations. First, FDP Scholars were volunteer participants who may have been more motivated to improve their geriatric care and teaching than nonparticipants. However, FDP Scholars had only moderate levels of geriatrics knowledge, attitudes, and confidence in their teaching on baseline testing and showed marked improvements in these domains after the FDP. In addition, Scholars' FDP participation was made possible by a reduction of other clinical obligations through direct reimbursement to their sections with CHAMP funds. Other incentives for CHAMP participation could include its focus on generalizable bedside teaching skills and provision of specific techniques for teaching the ACGME core competencies and quality improvement while using geriatrics content. Although the CHAMP FDP in its 48‐hour format is not sustainable or generalizable, the FDP modules and CHAMP materials were specifically designed to be usable in small pieces that could be incorporated into existing teaching structures, grand rounds, section meetings, teacher conferences, and continuing medical education workshops. CHAMP core group members have already presented and taught CHAMP components in many venues (see Dissemination on the CHAMP Web site). The excitement generated by CHAMP at national and specialty meetings, including multiple requests for materials, speaks to widespread interest in our CHAMP model. We are pursuing the creation of a mini‐CHAMP, an abbreviated FDP with an online component. These activities as well as feedback from users of CHAMP materials from the CHAMP Web site and the Portal of Geriatric Online Education will provide important opportunities for examining the use and acceptance of CHAMP outside our institution.

Another limitation of the CHAMP FDP is reliance on FDP Scholar self‐assessment in several of the evaluation components. Some studies have shown poor concordance between physicians' self‐assessment and external assessment over a range of domains.48 However, others have noted that despite these limitations, self‐assessment remains an essential tool for enabling physicians to discover the motivational discomfort of a performance gap, which may lead to changing concepts and mental models or changing work‐flow processes.49 Teaching on Today's Wards sessions in CHAMP emphasize self‐audit processes (such as process mapping and census audits) that can augment self‐assessment. We used such self‐audit processes in 1 small pilot study to date, providing summative and qualitative feedback to a group of FDP Scholars on their use of census audits.

However, the evaluation of the CHAMP FDP is enhanced by a yearly survey of all medical residents and medical students and by the linking of the teaching reported by residents and medical students to specific attendings. We have begun the analysis of resident perceptions of being taught CHAMP geriatrics topics by CHAMP faculty versus non‐CHAMP faculty. In addition, we are gathering data on patient‐level process of care and outcomes tied to the CHAMP FDP course session objectives by linking to the ongoing University of Chicago Hospitalist Project, a large clinical research project that enrolls general medicine inpatients in a study examining the quality of care and resource allocation for these patients.50 Because the ultimate goal of CHAMP is to improve the quality of care and outcomes for elderly hospitalized patients, the University of Chicago Hospitalist Project infrastructure was modified by the incorporation of the Vulnerable Elder Survey‐1351 and a process‐of‐care chart audit specifically based on the Assessing Care of the Vulnerable Elders Hospital Quality Indicators.52 Preliminary work included testing and validating these measures.53 Further evaluation of these clinical outcomes and CHAMP's efficacy and durability at the University of Chicago is ongoing and will be presented in future reports.

CONCLUSIONS

Through a collaboration of geriatricians, hospitalists, and general internists, the CHAMP FDP provides educational materials and methods keyed to bedside teaching in the fast‐paced world of the hospital. CHAMP improves faculty knowledge and attitudes and the frequency of teaching geriatrics topics and skills necessary to deliver quality care to the elderly hospitalized medical patient. Although the CHAMP FDP was developed and refined for use at a specific institution, the multitiered CHAMP FDP materials and methods have the potential for widespread use by multiple types of inpatient attendings for teaching the care of the older hospitalized medicine patient. Hospitalists in particular will require this expertise as both clinicians and teachers as their role, leadership, and influence continue to expand nationally.

A crucial arena of innovative educational programs for the care of the elderly must include the hospital setting, a place of great cost, morbidity, and mortality for a population currently occupying approximately half of US hospital beds.1 With a marked acceleration in the number of persons living to an advanced age, there is a clear imperative to address the health‐care needs of the elderly, particularly the complex and frail.24 An educational grounding that steps beyond the traditional organ‐based models of disease to a much broader patient‐centered framework of care is necessary to aid physicians in advanced clinical decision‐making in the care of older patients. Organizing the medical care of the older patient within existing systems of care and a team care management network must also be improved.

Curricular materials and methods are widely available for teaching geriatric medicine,57 but most are geared toward outpatient care and management, with few addressing the care of the hospitalized, older medical patient.810 There is even less published on curricular materials, methods, and tools for such teaching outside of specialized hospital‐based geriatric units by nongeriatrics‐trained faculty.1113 Furthermore, the evaluation of geriatrics educational programs in the hospital setting has not been done with the ultimate assessment, the linking of educational programs to demonstrated changes in clinical practice and patient care outcomes.

To address these needs, we designed and implemented the Curriculum for the Hospitalized Aging Medical Patient (CHAMP) Faculty Development Program (FDP). CHAMP was funded by a grant from the Donald W. Reynolds Foundation Aging and Quality of Life Program with a matching commitment from the University of Chicago Department of Medicine. At the core of CHAMP are principles of care for the older patient in the hospital setting, with an emphasis on identifying and providing care for the complex and frail elderly with nongeriatrician inpatient medicine faculty as the primary teachers of these materials. The overall educational goals of the CHAMP FDP are the following: (1) to train hospitalists and general internists to recognize opportunities to teach geriatric medicine topics specific to the care of the hospitalized older patient; (2) to create teaching materials, tools, and methods that can be used in the busy medical inpatient setting at the bedside; (3) to create materials and tools that facilitate teaching the Accreditation Council for Graduate Medical Education (ACGME) core competencies14 during ward rounds; and (4) to increase the frequency and effectiveness with which this geriatrics content is taught in the hospital setting. This article describes the development and refinement of the CHAMP FDP and evaluation results to date.

METHODS

The CHAMP FDP was developed by a core group of geriatricians, hospitalists, general medicine faculty, and PhD educators from the Office of the Dean at the University of Chicago Pritzker School of Medicine. The core group piloted the FDP for themselves in spring 2004, and the FDP was offered to target learners annually from 2004 to 2006.

RESULTS

We pilot‐tested the format, materials, methods, and evaluation components of the CHAMP FDP with the CHAMP core faculty in the spring of 2004. The revised CHAMP FDP was given in the fall of 2004 to the first group of 8 faculty learners. Similar annual CHAMP FDPs have occurred since 2004, with a total of 29 Faculty Scholars by 2006. This includes approximately half of the University of Chicago general medicine faculty and the majority of the hospitalist faculty. Geriatrics fellows, a medicine chief resident, and other internal medicine subspecialists have also taken the CHAMP FDP. The average evaluations of all CHAMP sessions by all participants are shown in Table 3.

Faculty Scholars rated the FDP highly regarding preparation for teaching and incorporation of the material into their teaching and practice. Likewise, qualitative comments by the Faculty Scholars were strongly supportive of CHAMP:

• Significantly more aware and confident in teaching around typical geriatric issues present in our patients.

• Provided concrete, structured ideas about curriculum, learning goals, content materials and how to implement them.

• The online teaching resources were something I used on an almost daily basis.

• Wish we had this for outpatient.

CHAMP had a favorable impact on the Faculty Scholars across the domains of knowledge, attitudes, and perceived behavior change (Table 4). Significant differences on paired‐sample t tests found significant improvement on all but one measure (importance of teaching). After the CHAMP program, Faculty Scholars were more knowledgeable about geriatrics content (P = 0.023), had more positive attitudes to older patients (P = 0.049), and had greater confidence in their ability to care for older patients (P < 0.001) and teach geriatric medicine skills (P < 0.001) and Teaching on Today's Wards content (P < 0.001). There was a significant increase in the perceived importance of practicing the learned skills (P = 0.008) and Teaching on Today's Wards (P = 0.001). The increased importance of teaching geriatrics skills was marginally significant (P = 0.064).

DISCUSSION

Central to CHAMP's design are (1) the creation of teaching materials and teaching resources that specifically address the challenges of teaching the care of the hospitalized older patient in busy hospital settings, (2) the provision of methods to reinforce the newly learned geriatrics teaching skills, and (3) a multidimensional evaluation scheme. The enthusiastic response to the CHAMP FDP and the evaluation results to date support the relevance and importance of CHAMP's focus, materials, and educational methods. The ideal outcome for our CHAMP FDP graduates is more informed, confident, and frequent teaching of geriatrics topics keyed to quality improvement and systems of care through a more streamlined but personalized bedside teaching process.13, 46 The CHAMP Faculty Scholar graduates' self‐report surveys of their performance and teaching of CHAMP course geriatrics skills did reveal a significant shift in clinical behavior, teaching, and confidence. Although the strongest indicator of perceived behavior change was in the enhanced self‐confidence in practicing and teaching, the significant changes in knowledge and attitude reinforce our observations of a shift in the mindset about teaching and caring for hospitalized elderly patients. This provides strong evidence for the efficacy of the CHAMP course in positively influencing participants.

Our biggest challenge with the CHAMP FDP was providing enough ongoing support to reinforce learning with an eye on the greater goal of changing teaching behaviors and clinical outcomes. After pilot testing, we added multiple types of support and follow‐up to the FDP: observed structured teaching exercises to practice CHAMP geriatrics content and teaching skills; modification of Teaching on Today's Wards through the addition of practice‐oriented exercises, games, and tutorials; frequent contact with our Faculty Scholar graduates post‐CHAMP FDP through CTC contracts; annual Faculty Scholars reunions; and continued access for the scholars to CHAMP materials on our Web site. Maintaining face‐to‐face contact between CHAMP core faculty and Faculty Scholars once the latter have finished the FDP has been challenging, largely because of clinical and teaching obligations over geographically separate sites. To overcome this, we are working to integrate CHAMP core faculty into hospitalist and general medicine section lecture series, increasing the frequency of CHAMP reunions, renewing CTC contracts with the Faculty Scholar graduates annually, and considering the concept of CHAMP core faculty guests attending during Faculty Scholars inpatient ward rounds.47

The CHAMP FDP and our evaluations to date have several limitations. First, FDP Scholars were volunteer participants who may have been more motivated to improve their geriatric care and teaching than nonparticipants. However, FDP Scholars had only moderate levels of geriatrics knowledge, attitudes, and confidence in their teaching on baseline testing and showed marked improvements in these domains after the FDP. In addition, Scholars' FDP participation was made possible by a reduction of other clinical obligations through direct reimbursement to their sections with CHAMP funds. Other incentives for CHAMP participation could include its focus on generalizable bedside teaching skills and provision of specific techniques for teaching the ACGME core competencies and quality improvement while using geriatrics content. Although the CHAMP FDP in its 48‐hour format is not sustainable or generalizable, the FDP modules and CHAMP materials were specifically designed to be usable in small pieces that could be incorporated into existing teaching structures, grand rounds, section meetings, teacher conferences, and continuing medical education workshops. CHAMP core group members have already presented and taught CHAMP components in many venues (see Dissemination on the CHAMP Web site). The excitement generated by CHAMP at national and specialty meetings, including multiple requests for materials, speaks to widespread interest in our CHAMP model. We are pursuing the creation of a mini‐CHAMP, an abbreviated FDP with an online component. These activities as well as feedback from users of CHAMP materials from the CHAMP Web site and the Portal of Geriatric Online Education will provide important opportunities for examining the use and acceptance of CHAMP outside our institution.

Another limitation of the CHAMP FDP is reliance on FDP Scholar self‐assessment in several of the evaluation components. Some studies have shown poor concordance between physicians' self‐assessment and external assessment over a range of domains.48 However, others have noted that despite these limitations, self‐assessment remains an essential tool for enabling physicians to discover the motivational discomfort of a performance gap, which may lead to changing concepts and mental models or changing work‐flow processes.49 Teaching on Today's Wards sessions in CHAMP emphasize self‐audit processes (such as process mapping and census audits) that can augment self‐assessment. We used such self‐audit processes in 1 small pilot study to date, providing summative and qualitative feedback to a group of FDP Scholars on their use of census audits.

However, the evaluation of the CHAMP FDP is enhanced by a yearly survey of all medical residents and medical students and by the linking of the teaching reported by residents and medical students to specific attendings. We have begun the analysis of resident perceptions of being taught CHAMP geriatrics topics by CHAMP faculty versus non‐CHAMP faculty. In addition, we are gathering data on patient‐level process of care and outcomes tied to the CHAMP FDP course session objectives by linking to the ongoing University of Chicago Hospitalist Project, a large clinical research project that enrolls general medicine inpatients in a study examining the quality of care and resource allocation for these patients.50 Because the ultimate goal of CHAMP is to improve the quality of care and outcomes for elderly hospitalized patients, the University of Chicago Hospitalist Project infrastructure was modified by the incorporation of the Vulnerable Elder Survey‐1351 and a process‐of‐care chart audit specifically based on the Assessing Care of the Vulnerable Elders Hospital Quality Indicators.52 Preliminary work included testing and validating these measures.53 Further evaluation of these clinical outcomes and CHAMP's efficacy and durability at the University of Chicago is ongoing and will be presented in future reports.

CONCLUSIONS

Through a collaboration of geriatricians, hospitalists, and general internists, the CHAMP FDP provides educational materials and methods keyed to bedside teaching in the fast‐paced world of the hospital. CHAMP improves faculty knowledge and attitudes and the frequency of teaching geriatrics topics and skills necessary to deliver quality care to the elderly hospitalized medical patient. Although the CHAMP FDP was developed and refined for use at a specific institution, the multitiered CHAMP FDP materials and methods have the potential for widespread use by multiple types of inpatient attendings for teaching the care of the older hospitalized medicine patient. Hospitalists in particular will require this expertise as both clinicians and teachers as their role, leadership, and influence continue to expand nationally.