Transforming Healthcare

Delivery of insulin via continuous subcutaneous insulin infusion (CSII), or insulin pump, has gained wide acceptance. It is estimated that 400,000 patients with type 1 diabetes mellitus (T1DM) are using insulin pumps.[1] A registry for T1DM in the United States indicated that 50% of the 25,833 participants were using an insulin pump.[2] Use of CSII in type 2 DM (T2DM) is also increasing.[3]

Patients with DM are 3 as likely to be hospitalized than patients without DM.[4] Twenty percent to 30% of adult hospitalized patients have a known diagnosis of DM.[5] It is therefore to be expected that patients on CSII will be seen with increased frequency in the hospital setting. This leads to potential difficultiesinpatient healthcare providers may not be familiar with insulin pumps, and patients may not be aware of complexities associated with pump usage in the hospital.

This article will review CSII usage in the hospital, offering strategies for management in partnership with the patient based on our experiences and processes developed in our institution.

SHOULD CONTINUOUS SUBCUTANEOUS INSULIN INFUSION BE CONTINUED IN THE HOSPITAL?

The American Diabetes Association advocates (1) allowing patients who are physically and mentally able to continue CSII when hospitalized, (2) having a hospital policy for CSII use, and (3) having hospital personnel with expertise on pump management.[6] The American Association of Clinical Endocrinologists echoes much of the same and suggests contacting the specialist responsible for the pump in the ambulatory setting for decisions on adjustments in the hospitalized patient,[7] which at times may not be feasible.

The logic and benefits of basal‐bolus insulin dosing (ie, giving basal insulin to account for fasting requirements, plus bolus insulin to cover nutritional and correctional needs) have been well‐described.[8, 9, 10] In randomized clinical trials on patients admitted to general medical and surgical floors, basal‐bolus insulin (long‐acting basal insulin plus mealtime fast‐acting insulin injections) resulted in better glycemic control and reduced infection rates compared with sliding‐scale therapy (waiting for high blood glucoses before giving insulin, instead of giving it proactively to prevent hyperglycemia).[9, 10] At present, insulin delivery via the insulin pump is the best commercially available method to deliver insulin in a basal‐bolus manner in ambulatory patients. It thus makes sense to continue CSII in the hospital if patients are able to manage their pumps, though there are no randomized trials answering this question as of yet.

Studies on insulin pumps in the hospital are sparse. In one group's latest retrospective study of 136 patients over a 6‐year period, CSII was continued during the entire hospital stay in 65% of the hospitalizations, was used intermittently in 20%, and was discontinued with alternative insulin regimens given in 15%.[11] Mean glucose was 178 47 mg/dL (mean standard deviation), with no significant difference between groups. There were fewer episodes of severe hyperglycemia among those who continued on the pump compared with the other groups, and fewer episodes of hypoglycemia in those who continued on vs those taken off the pump. There was 1 episode of an infusion catheter kinking, resulting in nonfatal hyperglycemia, but no reported pump‐site infections, mechanical pump failure, or diabetic ketoacidosis (DKA) among patients remaining on CSII.

CLINICAL VIGNETTES

The following cases illustrate potential challenges with CSII use that we have encountered in the hospital.

The Patient Needing Transition to Multiple Daily Insulin Injections

A 29‐year‐old male with T1DM, on CSII, was admitted for fever and chills. His latest glycated hemoglobin (HbA_1c) level was 6.8%. His glucose levels started rising, and he wished to be taken off the insulin pump. He was started by the primary team on multiple daily insulin injections (MDII) with insulin glargine and insulin lispro. His glucose levels continued to rise, so an intravenous (IV) insulin infusion was started. Endocrinology was then consulted. The patient's condition was concerning for the potential development of DKA, so he was kept on IV insulin. When he was ready for transitioning to subcutaneous insulin, the pump had been taken home by a family member, and the patient could not recall his CSII basal rates but knew his total basal insulin dose, carbohydrate ratio, and sensitivity factor. Endocrinology assisted in transitioning him from the insulin infusion to MDII based on these recalled doses. When the insulin pump was available, the pump settings were interrogated, and he was transitioned back to it.

Key points:

• Having key hospital personnel trained on CSII, including interrogating the pump's settings, facilitates the transitioning of these patients from one hospital unit, or level of care, to another.
• Accessing the pump's settings involves pushing several buttons on the insulin pump. Because key hospital personnel will encounter patients on different insulin pumps, it may be helpful to keep menu maps handy as a quick reference. A menu map will show at a glance where certain information can be found, such as the basal insulin rate or the sensitivity factor (see examples in Figures 1 and 2).[12, 13]
• Knowing the HbA_1c will help determine if pump use has been effective.

Figure 1

Figure 2

STEPS IN TAKING CARE OF PATIENTS ON CONTINUOUS SUBCUTANEOUS INSULIN INFUSION

INTERRUPTION OF CONTINUOUS SUBCUTANEOUS INSULIN INFUSION FOR SHORT AND PROLONGED PERIODS

Patients with T1DM should not be left without basal insulin. However, pump interruption for 30 minutes to an hour often does not lead to problems. Beyond an hour and certainly closer to 2 to 3 hours off the pump, the patient should be given a subcutaneous insulin injection if the patient is left without easy access to the insulin pump.

The subcutaneous insulin dose for temporary pump suspension can be roughly calculated as hourly basal rate multiplier, where the multiplier is the number of hours that the patient is expected to be disconnected from the pump (for example, hourly basal rate of 0.85 unit/hour 3 hours = 2.55 units, which can be rounded off to 2 or 3 units depending on the patient's general glucose control).

When it has been determined that the patient should come off the pump for substantial periods of time, then subcutaneous insulin injections should be given. This is imperative for the prevention of DKA in patients with T1DM, and highly recommended for maintenance of good glycemic control for patients with T2DM.

SUMMARY

As patients on an insulin pump are increasingly seen in the hospital, inpatient providers have to be able to adapt to these patients' needs. Inpatient providers need to have a working knowledge of the insulin pump. Alternative methods of insulin delivery will have to be discussed with the patient to assure continued safety in the hospital.

Delivery of insulin via continuous subcutaneous insulin infusion (CSII), or insulin pump, has gained wide acceptance. It is estimated that 400,000 patients with type 1 diabetes mellitus (T1DM) are using insulin pumps.[1] A registry for T1DM in the United States indicated that 50% of the 25,833 participants were using an insulin pump.[2] Use of CSII in type 2 DM (T2DM) is also increasing.[3]

Patients with DM are 3 as likely to be hospitalized than patients without DM.[4] Twenty percent to 30% of adult hospitalized patients have a known diagnosis of DM.[5] It is therefore to be expected that patients on CSII will be seen with increased frequency in the hospital setting. This leads to potential difficultiesinpatient healthcare providers may not be familiar with insulin pumps, and patients may not be aware of complexities associated with pump usage in the hospital.

This article will review CSII usage in the hospital, offering strategies for management in partnership with the patient based on our experiences and processes developed in our institution.

SHOULD CONTINUOUS SUBCUTANEOUS INSULIN INFUSION BE CONTINUED IN THE HOSPITAL?

The American Diabetes Association advocates (1) allowing patients who are physically and mentally able to continue CSII when hospitalized, (2) having a hospital policy for CSII use, and (3) having hospital personnel with expertise on pump management.[6] The American Association of Clinical Endocrinologists echoes much of the same and suggests contacting the specialist responsible for the pump in the ambulatory setting for decisions on adjustments in the hospitalized patient,[7] which at times may not be feasible.

The logic and benefits of basal‐bolus insulin dosing (ie, giving basal insulin to account for fasting requirements, plus bolus insulin to cover nutritional and correctional needs) have been well‐described.[8, 9, 10] In randomized clinical trials on patients admitted to general medical and surgical floors, basal‐bolus insulin (long‐acting basal insulin plus mealtime fast‐acting insulin injections) resulted in better glycemic control and reduced infection rates compared with sliding‐scale therapy (waiting for high blood glucoses before giving insulin, instead of giving it proactively to prevent hyperglycemia).[9, 10] At present, insulin delivery via the insulin pump is the best commercially available method to deliver insulin in a basal‐bolus manner in ambulatory patients. It thus makes sense to continue CSII in the hospital if patients are able to manage their pumps, though there are no randomized trials answering this question as of yet.

Studies on insulin pumps in the hospital are sparse. In one group's latest retrospective study of 136 patients over a 6‐year period, CSII was continued during the entire hospital stay in 65% of the hospitalizations, was used intermittently in 20%, and was discontinued with alternative insulin regimens given in 15%.[11] Mean glucose was 178 47 mg/dL (mean standard deviation), with no significant difference between groups. There were fewer episodes of severe hyperglycemia among those who continued on the pump compared with the other groups, and fewer episodes of hypoglycemia in those who continued on vs those taken off the pump. There was 1 episode of an infusion catheter kinking, resulting in nonfatal hyperglycemia, but no reported pump‐site infections, mechanical pump failure, or diabetic ketoacidosis (DKA) among patients remaining on CSII.

CLINICAL VIGNETTES

The following cases illustrate potential challenges with CSII use that we have encountered in the hospital.

The Patient Needing Transition to Multiple Daily Insulin Injections

A 29‐year‐old male with T1DM, on CSII, was admitted for fever and chills. His latest glycated hemoglobin (HbA_1c) level was 6.8%. His glucose levels started rising, and he wished to be taken off the insulin pump. He was started by the primary team on multiple daily insulin injections (MDII) with insulin glargine and insulin lispro. His glucose levels continued to rise, so an intravenous (IV) insulin infusion was started. Endocrinology was then consulted. The patient's condition was concerning for the potential development of DKA, so he was kept on IV insulin. When he was ready for transitioning to subcutaneous insulin, the pump had been taken home by a family member, and the patient could not recall his CSII basal rates but knew his total basal insulin dose, carbohydrate ratio, and sensitivity factor. Endocrinology assisted in transitioning him from the insulin infusion to MDII based on these recalled doses. When the insulin pump was available, the pump settings were interrogated, and he was transitioned back to it.

Key points:

• Having key hospital personnel trained on CSII, including interrogating the pump's settings, facilitates the transitioning of these patients from one hospital unit, or level of care, to another.
• Accessing the pump's settings involves pushing several buttons on the insulin pump. Because key hospital personnel will encounter patients on different insulin pumps, it may be helpful to keep menu maps handy as a quick reference. A menu map will show at a glance where certain information can be found, such as the basal insulin rate or the sensitivity factor (see examples in Figures 1 and 2).[12, 13]
• Knowing the HbA_1c will help determine if pump use has been effective.

Figure 1

Figure 2

STEPS IN TAKING CARE OF PATIENTS ON CONTINUOUS SUBCUTANEOUS INSULIN INFUSION

INTERRUPTION OF CONTINUOUS SUBCUTANEOUS INSULIN INFUSION FOR SHORT AND PROLONGED PERIODS

Patients with T1DM should not be left without basal insulin. However, pump interruption for 30 minutes to an hour often does not lead to problems. Beyond an hour and certainly closer to 2 to 3 hours off the pump, the patient should be given a subcutaneous insulin injection if the patient is left without easy access to the insulin pump.

The subcutaneous insulin dose for temporary pump suspension can be roughly calculated as hourly basal rate multiplier, where the multiplier is the number of hours that the patient is expected to be disconnected from the pump (for example, hourly basal rate of 0.85 unit/hour 3 hours = 2.55 units, which can be rounded off to 2 or 3 units depending on the patient's general glucose control).

When it has been determined that the patient should come off the pump for substantial periods of time, then subcutaneous insulin injections should be given. This is imperative for the prevention of DKA in patients with T1DM, and highly recommended for maintenance of good glycemic control for patients with T2DM.

SUMMARY

As patients on an insulin pump are increasingly seen in the hospital, inpatient providers have to be able to adapt to these patients' needs. Inpatient providers need to have a working knowledge of the insulin pump. Alternative methods of insulin delivery will have to be discussed with the patient to assure continued safety in the hospital.

Delivery of insulin via continuous subcutaneous insulin infusion (CSII), or insulin pump, has gained wide acceptance. It is estimated that 400,000 patients with type 1 diabetes mellitus (T1DM) are using insulin pumps.[1] A registry for T1DM in the United States indicated that 50% of the 25,833 participants were using an insulin pump.[2] Use of CSII in type 2 DM (T2DM) is also increasing.[3]

Patients with DM are 3 as likely to be hospitalized than patients without DM.[4] Twenty percent to 30% of adult hospitalized patients have a known diagnosis of DM.[5] It is therefore to be expected that patients on CSII will be seen with increased frequency in the hospital setting. This leads to potential difficultiesinpatient healthcare providers may not be familiar with insulin pumps, and patients may not be aware of complexities associated with pump usage in the hospital.

This article will review CSII usage in the hospital, offering strategies for management in partnership with the patient based on our experiences and processes developed in our institution.

SHOULD CONTINUOUS SUBCUTANEOUS INSULIN INFUSION BE CONTINUED IN THE HOSPITAL?

The American Diabetes Association advocates (1) allowing patients who are physically and mentally able to continue CSII when hospitalized, (2) having a hospital policy for CSII use, and (3) having hospital personnel with expertise on pump management.[6] The American Association of Clinical Endocrinologists echoes much of the same and suggests contacting the specialist responsible for the pump in the ambulatory setting for decisions on adjustments in the hospitalized patient,[7] which at times may not be feasible.

The logic and benefits of basal‐bolus insulin dosing (ie, giving basal insulin to account for fasting requirements, plus bolus insulin to cover nutritional and correctional needs) have been well‐described.[8, 9, 10] In randomized clinical trials on patients admitted to general medical and surgical floors, basal‐bolus insulin (long‐acting basal insulin plus mealtime fast‐acting insulin injections) resulted in better glycemic control and reduced infection rates compared with sliding‐scale therapy (waiting for high blood glucoses before giving insulin, instead of giving it proactively to prevent hyperglycemia).[9, 10] At present, insulin delivery via the insulin pump is the best commercially available method to deliver insulin in a basal‐bolus manner in ambulatory patients. It thus makes sense to continue CSII in the hospital if patients are able to manage their pumps, though there are no randomized trials answering this question as of yet.

Studies on insulin pumps in the hospital are sparse. In one group's latest retrospective study of 136 patients over a 6‐year period, CSII was continued during the entire hospital stay in 65% of the hospitalizations, was used intermittently in 20%, and was discontinued with alternative insulin regimens given in 15%.[11] Mean glucose was 178 47 mg/dL (mean standard deviation), with no significant difference between groups. There were fewer episodes of severe hyperglycemia among those who continued on the pump compared with the other groups, and fewer episodes of hypoglycemia in those who continued on vs those taken off the pump. There was 1 episode of an infusion catheter kinking, resulting in nonfatal hyperglycemia, but no reported pump‐site infections, mechanical pump failure, or diabetic ketoacidosis (DKA) among patients remaining on CSII.

CLINICAL VIGNETTES

The following cases illustrate potential challenges with CSII use that we have encountered in the hospital.

The Patient Needing Transition to Multiple Daily Insulin Injections

A 29‐year‐old male with T1DM, on CSII, was admitted for fever and chills. His latest glycated hemoglobin (HbA_1c) level was 6.8%. His glucose levels started rising, and he wished to be taken off the insulin pump. He was started by the primary team on multiple daily insulin injections (MDII) with insulin glargine and insulin lispro. His glucose levels continued to rise, so an intravenous (IV) insulin infusion was started. Endocrinology was then consulted. The patient's condition was concerning for the potential development of DKA, so he was kept on IV insulin. When he was ready for transitioning to subcutaneous insulin, the pump had been taken home by a family member, and the patient could not recall his CSII basal rates but knew his total basal insulin dose, carbohydrate ratio, and sensitivity factor. Endocrinology assisted in transitioning him from the insulin infusion to MDII based on these recalled doses. When the insulin pump was available, the pump settings were interrogated, and he was transitioned back to it.

Key points:

• Having key hospital personnel trained on CSII, including interrogating the pump's settings, facilitates the transitioning of these patients from one hospital unit, or level of care, to another.
• Accessing the pump's settings involves pushing several buttons on the insulin pump. Because key hospital personnel will encounter patients on different insulin pumps, it may be helpful to keep menu maps handy as a quick reference. A menu map will show at a glance where certain information can be found, such as the basal insulin rate or the sensitivity factor (see examples in Figures 1 and 2).[12, 13]
• Knowing the HbA_1c will help determine if pump use has been effective.

Figure 1

Figure 2

STEPS IN TAKING CARE OF PATIENTS ON CONTINUOUS SUBCUTANEOUS INSULIN INFUSION

INTERRUPTION OF CONTINUOUS SUBCUTANEOUS INSULIN INFUSION FOR SHORT AND PROLONGED PERIODS

Patients with T1DM should not be left without basal insulin. However, pump interruption for 30 minutes to an hour often does not lead to problems. Beyond an hour and certainly closer to 2 to 3 hours off the pump, the patient should be given a subcutaneous insulin injection if the patient is left without easy access to the insulin pump.

The subcutaneous insulin dose for temporary pump suspension can be roughly calculated as hourly basal rate multiplier, where the multiplier is the number of hours that the patient is expected to be disconnected from the pump (for example, hourly basal rate of 0.85 unit/hour 3 hours = 2.55 units, which can be rounded off to 2 or 3 units depending on the patient's general glucose control).

When it has been determined that the patient should come off the pump for substantial periods of time, then subcutaneous insulin injections should be given. This is imperative for the prevention of DKA in patients with T1DM, and highly recommended for maintenance of good glycemic control for patients with T2DM.

SUMMARY

As patients on an insulin pump are increasingly seen in the hospital, inpatient providers have to be able to adapt to these patients' needs. Inpatient providers need to have a working knowledge of the insulin pump. Alternative methods of insulin delivery will have to be discussed with the patient to assure continued safety in the hospital.

Across the country, hospitals are rolling out programs to reduce readmissions. These range from patient education around their disease process and medications, improvements in discharge planning, medication reconciliation, outpatient appointments scheduled prior to discharge, and follow‐up phone calls, among others.[1, 2] Several collaboratives such as Project Better Outcomes by Optimizing Safe Transitions[3] and Hospital Medicine Reengineering Network[4] have formed to test, study, and share lessons learned from these inpatient‐based interventions. Because financial penalties thus far have focused on decreases in inpatient reimbursement by the Centers for Medicare and Medicaid Services (CMS), most of the interventions to reduce hospital readmissions have been concentrated in the inpatient domain. It is unclear whether new payment arrangements with CMS or commercial insurers, such as bundled payments and accountable care organizations (ACOs), will pressure primary care physicians (PCPs) to further develop outpatient‐based interventions.

In this article, I provide a PCP's perspective of how inpatient and outpatient providers can partner to create the ideal care transition from hospital to home. Although others have conducted systematic reviews or surveys of interventions to reduce hospital readmissions,[2, 5, 6, 7] I will start from a vision of an ideal transition, and then evaluate evidence supporting each step. I will also highlight areas where new reimbursement codes can help support an idealized transitions‐of‐care program.

ON HOSPITAL ADMISSION

Many PCPs consider the beginning of the care continuum to rest in the primary care practice and relationship. Over time, PCPs develop relationships with their patients, understanding the patients' values toward health and healthcare, learning their social support system and home environment, and documenting a clinical course of chronic diseases, including which therapies have and have not worked well. From a PCP perspective, it seems natural to be involved in care at the point of hospital admission. Some emergency departments (EDs) and hospital admissions offices have automated systems to email or fax PCPs admission notifications. Others rely on providers to make this connection.

Ideally, PCP communication would occur early in the hospitalization, especially for medically or socially complex patients, for 3 main reasons: (1) The PCP can offer insights on goals of care or therapies attempted in the past that may reduce unnecessary procedures, decrease length of stay, and improve patient satisfaction; (2) Reconciling medications that the patient should be taking and the list the patient reports may highlight noncompliance and trigger education around medication compliance prior to discharge; (3) Early PCP involvement may improve discharge planning efficiency, whereby the inpatient and outpatient teams agree on medical and social issues to be addressed for a safe discharge. Although there are no published studies that show communication early in the hospitalization impacts clinical outcomes, a national survey of hospitalists highlighted concerns about poor information exchange, particularly around medical history and outpatient medications, at the time of admission.[8]

As new financial models push healthcare providers to manage a population of patients under a global budget, inpatient and outpatient providers will need to communicate and collaborate at a level that is new for most institutions and providers.[9] Because early markers of success are based on financial savings, this means further reducing length of stay and transferring more care to the outpatient arena, tapping into community and home care resources. Involving PCPs early in the admission may help inpatient providers meet these goals.

DURING HOSPITALIZATION

Several publications from hospitalists have evaluated inpatient‐based interventions to reduce readmissions and improve care transitions.[10, 11, 12] Table 1 summarizes 6 steps that can improve communication and collaboration.

AFTER HOSPITAL DISCHARGE

Immediately after hospital discharge, there are 7 steps that PCPs and their clinic staff can follow to support a safe transition from hospital to home. The literature supports several individual steps, but not the full package. I am proposing that primary care clinics adopt all 7 steps in an ideal transitions‐of‐care program.

IMPLICATIONS

In this vision of the ideal care transition, I am suggesting a shift in culture from a predominantly hospital‐based program to a program that spans the care continuum and requires active participation and ownership from the PCP's team. It will require inpatient and outpatient providers to communicate early and frequently during the hospitalization, sharing patient information efficiently and working collaboratively as part of a larger team to meet the medical and psychosocial needs of the patient. This concept is not new, but has not been supported financially from payors.[1, 9, 40] Most PCPs operate on margins that cannot support additional PCP time to coordinate care for patients or staff to assist (although many PCPs believe this is the role of the primary care medical home).[33] Some payors agree that stipends to support infrastructure change are needed to improve patient outcomes.[17, 38, 39]

Even though every envisioned step does not require additional funding, new payment arrangements under ACOs and bundled payments may offer opportunities for PCPs to assume a larger role in care transitions and secure funding to pay for interventions. However, primary care practices must be positioned to negotiate favorable global payment agreements, be willing to assume risks associated with global payments, and prioritize management of medically and socially complex patients who are at risk for preventable ED visits and hospitalizations. PCPs who are not participating in ACOs or bundled payments, or those who are risk adverse, may be able to finance pieces of this vision with the new care coordination CPT codes supported by Medicare (and possibly commercial payors in the future). They may also partner with community groups participating in CCTP for additional support. Others focus on the long‐term benefits of ACO‐like structures rather than the short‐term investments needed.[41]

Are all 14 steps proposed above essential? Without doubt, this vision will be difficult to fully operationalize and requires coordination and support from many distinct groups. Should all patients be offered a basic package of interventions, reserving the full package for those who are identified as highest risk for poor outcomes after hospital discharge? There is already some support around specialized interventions for patients at high risk for readmissions,[32, 41] and risk prediction models have been introduced to identify these individuals.[42] Or should we approach this as a menu of interventions from which to choose, tailoring interventions to individual patient needs? These questions should be tested, as our experience in coordinating care across the continuum matures. With over 100 ACOs formed in Medicare alone[43] and many more with commercial insurers, our understanding in this area will grow in the next 5 years.

CONCLUSIONS

As cost containment measures in healthcare target preventable readmissions, hospitals and primary care physicians are increasingly encouraged to improve transitions along the care continuum. In this article, I offer 1 PCP's vision of the ideal transitions‐of‐care program from hospital to home. This article focuses on steps that can be taken by PCPs and their clinic staff; it does not address the role of outpatient specialists, home care agencies, or community support groups in care transitions. Operationalizing this vision requires commitment from the hospital and clinic leadership, as well as buy‐in from front‐line providers. More research is required to understand the marginal impact of each component of this vision, as well as the comprehensive package of interventions proposed, on patient outcomes. New financial models with payors and hospitals may make it easier for primary care clinics to test this vision. Current financial incentives are likely still inadequate to fully align care along the continuum, but they offer some support for more PCPs to take an active role. The time has come to shift our traditional view of transitions of care from a hospital‐centric set of interventions toward one that spans the entire care continuum and includes primary care physicians and their clinic staff as key partners.

Across the country, hospitals are rolling out programs to reduce readmissions. These range from patient education around their disease process and medications, improvements in discharge planning, medication reconciliation, outpatient appointments scheduled prior to discharge, and follow‐up phone calls, among others.[1, 2] Several collaboratives such as Project Better Outcomes by Optimizing Safe Transitions[3] and Hospital Medicine Reengineering Network[4] have formed to test, study, and share lessons learned from these inpatient‐based interventions. Because financial penalties thus far have focused on decreases in inpatient reimbursement by the Centers for Medicare and Medicaid Services (CMS), most of the interventions to reduce hospital readmissions have been concentrated in the inpatient domain. It is unclear whether new payment arrangements with CMS or commercial insurers, such as bundled payments and accountable care organizations (ACOs), will pressure primary care physicians (PCPs) to further develop outpatient‐based interventions.

In this article, I provide a PCP's perspective of how inpatient and outpatient providers can partner to create the ideal care transition from hospital to home. Although others have conducted systematic reviews or surveys of interventions to reduce hospital readmissions,[2, 5, 6, 7] I will start from a vision of an ideal transition, and then evaluate evidence supporting each step. I will also highlight areas where new reimbursement codes can help support an idealized transitions‐of‐care program.

ON HOSPITAL ADMISSION

Many PCPs consider the beginning of the care continuum to rest in the primary care practice and relationship. Over time, PCPs develop relationships with their patients, understanding the patients' values toward health and healthcare, learning their social support system and home environment, and documenting a clinical course of chronic diseases, including which therapies have and have not worked well. From a PCP perspective, it seems natural to be involved in care at the point of hospital admission. Some emergency departments (EDs) and hospital admissions offices have automated systems to email or fax PCPs admission notifications. Others rely on providers to make this connection.

Ideally, PCP communication would occur early in the hospitalization, especially for medically or socially complex patients, for 3 main reasons: (1) The PCP can offer insights on goals of care or therapies attempted in the past that may reduce unnecessary procedures, decrease length of stay, and improve patient satisfaction; (2) Reconciling medications that the patient should be taking and the list the patient reports may highlight noncompliance and trigger education around medication compliance prior to discharge; (3) Early PCP involvement may improve discharge planning efficiency, whereby the inpatient and outpatient teams agree on medical and social issues to be addressed for a safe discharge. Although there are no published studies that show communication early in the hospitalization impacts clinical outcomes, a national survey of hospitalists highlighted concerns about poor information exchange, particularly around medical history and outpatient medications, at the time of admission.[8]

As new financial models push healthcare providers to manage a population of patients under a global budget, inpatient and outpatient providers will need to communicate and collaborate at a level that is new for most institutions and providers.[9] Because early markers of success are based on financial savings, this means further reducing length of stay and transferring more care to the outpatient arena, tapping into community and home care resources. Involving PCPs early in the admission may help inpatient providers meet these goals.

DURING HOSPITALIZATION

Several publications from hospitalists have evaluated inpatient‐based interventions to reduce readmissions and improve care transitions.[10, 11, 12] Table 1 summarizes 6 steps that can improve communication and collaboration.

AFTER HOSPITAL DISCHARGE

Immediately after hospital discharge, there are 7 steps that PCPs and their clinic staff can follow to support a safe transition from hospital to home. The literature supports several individual steps, but not the full package. I am proposing that primary care clinics adopt all 7 steps in an ideal transitions‐of‐care program.

IMPLICATIONS

In this vision of the ideal care transition, I am suggesting a shift in culture from a predominantly hospital‐based program to a program that spans the care continuum and requires active participation and ownership from the PCP's team. It will require inpatient and outpatient providers to communicate early and frequently during the hospitalization, sharing patient information efficiently and working collaboratively as part of a larger team to meet the medical and psychosocial needs of the patient. This concept is not new, but has not been supported financially from payors.[1, 9, 40] Most PCPs operate on margins that cannot support additional PCP time to coordinate care for patients or staff to assist (although many PCPs believe this is the role of the primary care medical home).[33] Some payors agree that stipends to support infrastructure change are needed to improve patient outcomes.[17, 38, 39]

Even though every envisioned step does not require additional funding, new payment arrangements under ACOs and bundled payments may offer opportunities for PCPs to assume a larger role in care transitions and secure funding to pay for interventions. However, primary care practices must be positioned to negotiate favorable global payment agreements, be willing to assume risks associated with global payments, and prioritize management of medically and socially complex patients who are at risk for preventable ED visits and hospitalizations. PCPs who are not participating in ACOs or bundled payments, or those who are risk adverse, may be able to finance pieces of this vision with the new care coordination CPT codes supported by Medicare (and possibly commercial payors in the future). They may also partner with community groups participating in CCTP for additional support. Others focus on the long‐term benefits of ACO‐like structures rather than the short‐term investments needed.[41]

Are all 14 steps proposed above essential? Without doubt, this vision will be difficult to fully operationalize and requires coordination and support from many distinct groups. Should all patients be offered a basic package of interventions, reserving the full package for those who are identified as highest risk for poor outcomes after hospital discharge? There is already some support around specialized interventions for patients at high risk for readmissions,[32, 41] and risk prediction models have been introduced to identify these individuals.[42] Or should we approach this as a menu of interventions from which to choose, tailoring interventions to individual patient needs? These questions should be tested, as our experience in coordinating care across the continuum matures. With over 100 ACOs formed in Medicare alone[43] and many more with commercial insurers, our understanding in this area will grow in the next 5 years.

CONCLUSIONS

As cost containment measures in healthcare target preventable readmissions, hospitals and primary care physicians are increasingly encouraged to improve transitions along the care continuum. In this article, I offer 1 PCP's vision of the ideal transitions‐of‐care program from hospital to home. This article focuses on steps that can be taken by PCPs and their clinic staff; it does not address the role of outpatient specialists, home care agencies, or community support groups in care transitions. Operationalizing this vision requires commitment from the hospital and clinic leadership, as well as buy‐in from front‐line providers. More research is required to understand the marginal impact of each component of this vision, as well as the comprehensive package of interventions proposed, on patient outcomes. New financial models with payors and hospitals may make it easier for primary care clinics to test this vision. Current financial incentives are likely still inadequate to fully align care along the continuum, but they offer some support for more PCPs to take an active role. The time has come to shift our traditional view of transitions of care from a hospital‐centric set of interventions toward one that spans the entire care continuum and includes primary care physicians and their clinic staff as key partners.

Across the country, hospitals are rolling out programs to reduce readmissions. These range from patient education around their disease process and medications, improvements in discharge planning, medication reconciliation, outpatient appointments scheduled prior to discharge, and follow‐up phone calls, among others.[1, 2] Several collaboratives such as Project Better Outcomes by Optimizing Safe Transitions[3] and Hospital Medicine Reengineering Network[4] have formed to test, study, and share lessons learned from these inpatient‐based interventions. Because financial penalties thus far have focused on decreases in inpatient reimbursement by the Centers for Medicare and Medicaid Services (CMS), most of the interventions to reduce hospital readmissions have been concentrated in the inpatient domain. It is unclear whether new payment arrangements with CMS or commercial insurers, such as bundled payments and accountable care organizations (ACOs), will pressure primary care physicians (PCPs) to further develop outpatient‐based interventions.

In this article, I provide a PCP's perspective of how inpatient and outpatient providers can partner to create the ideal care transition from hospital to home. Although others have conducted systematic reviews or surveys of interventions to reduce hospital readmissions,[2, 5, 6, 7] I will start from a vision of an ideal transition, and then evaluate evidence supporting each step. I will also highlight areas where new reimbursement codes can help support an idealized transitions‐of‐care program.

ON HOSPITAL ADMISSION

Many PCPs consider the beginning of the care continuum to rest in the primary care practice and relationship. Over time, PCPs develop relationships with their patients, understanding the patients' values toward health and healthcare, learning their social support system and home environment, and documenting a clinical course of chronic diseases, including which therapies have and have not worked well. From a PCP perspective, it seems natural to be involved in care at the point of hospital admission. Some emergency departments (EDs) and hospital admissions offices have automated systems to email or fax PCPs admission notifications. Others rely on providers to make this connection.

Ideally, PCP communication would occur early in the hospitalization, especially for medically or socially complex patients, for 3 main reasons: (1) The PCP can offer insights on goals of care or therapies attempted in the past that may reduce unnecessary procedures, decrease length of stay, and improve patient satisfaction; (2) Reconciling medications that the patient should be taking and the list the patient reports may highlight noncompliance and trigger education around medication compliance prior to discharge; (3) Early PCP involvement may improve discharge planning efficiency, whereby the inpatient and outpatient teams agree on medical and social issues to be addressed for a safe discharge. Although there are no published studies that show communication early in the hospitalization impacts clinical outcomes, a national survey of hospitalists highlighted concerns about poor information exchange, particularly around medical history and outpatient medications, at the time of admission.[8]

As new financial models push healthcare providers to manage a population of patients under a global budget, inpatient and outpatient providers will need to communicate and collaborate at a level that is new for most institutions and providers.[9] Because early markers of success are based on financial savings, this means further reducing length of stay and transferring more care to the outpatient arena, tapping into community and home care resources. Involving PCPs early in the admission may help inpatient providers meet these goals.

DURING HOSPITALIZATION

Several publications from hospitalists have evaluated inpatient‐based interventions to reduce readmissions and improve care transitions.[10, 11, 12] Table 1 summarizes 6 steps that can improve communication and collaboration.

AFTER HOSPITAL DISCHARGE

Immediately after hospital discharge, there are 7 steps that PCPs and their clinic staff can follow to support a safe transition from hospital to home. The literature supports several individual steps, but not the full package. I am proposing that primary care clinics adopt all 7 steps in an ideal transitions‐of‐care program.

IMPLICATIONS

In this vision of the ideal care transition, I am suggesting a shift in culture from a predominantly hospital‐based program to a program that spans the care continuum and requires active participation and ownership from the PCP's team. It will require inpatient and outpatient providers to communicate early and frequently during the hospitalization, sharing patient information efficiently and working collaboratively as part of a larger team to meet the medical and psychosocial needs of the patient. This concept is not new, but has not been supported financially from payors.[1, 9, 40] Most PCPs operate on margins that cannot support additional PCP time to coordinate care for patients or staff to assist (although many PCPs believe this is the role of the primary care medical home).[33] Some payors agree that stipends to support infrastructure change are needed to improve patient outcomes.[17, 38, 39]

Even though every envisioned step does not require additional funding, new payment arrangements under ACOs and bundled payments may offer opportunities for PCPs to assume a larger role in care transitions and secure funding to pay for interventions. However, primary care practices must be positioned to negotiate favorable global payment agreements, be willing to assume risks associated with global payments, and prioritize management of medically and socially complex patients who are at risk for preventable ED visits and hospitalizations. PCPs who are not participating in ACOs or bundled payments, or those who are risk adverse, may be able to finance pieces of this vision with the new care coordination CPT codes supported by Medicare (and possibly commercial payors in the future). They may also partner with community groups participating in CCTP for additional support. Others focus on the long‐term benefits of ACO‐like structures rather than the short‐term investments needed.[41]

Are all 14 steps proposed above essential? Without doubt, this vision will be difficult to fully operationalize and requires coordination and support from many distinct groups. Should all patients be offered a basic package of interventions, reserving the full package for those who are identified as highest risk for poor outcomes after hospital discharge? There is already some support around specialized interventions for patients at high risk for readmissions,[32, 41] and risk prediction models have been introduced to identify these individuals.[42] Or should we approach this as a menu of interventions from which to choose, tailoring interventions to individual patient needs? These questions should be tested, as our experience in coordinating care across the continuum matures. With over 100 ACOs formed in Medicare alone[43] and many more with commercial insurers, our understanding in this area will grow in the next 5 years.

CONCLUSIONS

As cost containment measures in healthcare target preventable readmissions, hospitals and primary care physicians are increasingly encouraged to improve transitions along the care continuum. In this article, I offer 1 PCP's vision of the ideal transitions‐of‐care program from hospital to home. This article focuses on steps that can be taken by PCPs and their clinic staff; it does not address the role of outpatient specialists, home care agencies, or community support groups in care transitions. Operationalizing this vision requires commitment from the hospital and clinic leadership, as well as buy‐in from front‐line providers. More research is required to understand the marginal impact of each component of this vision, as well as the comprehensive package of interventions proposed, on patient outcomes. New financial models with payors and hospitals may make it easier for primary care clinics to test this vision. Current financial incentives are likely still inadequate to fully align care along the continuum, but they offer some support for more PCPs to take an active role. The time has come to shift our traditional view of transitions of care from a hospital‐centric set of interventions toward one that spans the entire care continuum and includes primary care physicians and their clinic staff as key partners.

The practice of bloodletting, performed using sticks, thorns, bones, or anything sharp, probably began in Egypt about 3,000 years ago.[1] The practice continued in Greece, where Hippocrates recommended bloodletting to balance the body's four humorsblood, phlegm, yellow bile, and black bileand continued during Roman times under the influence of Galen. In the United States, perhaps the most infamous use of bloodletting was when doctors reportedly bled as much as 5 U of blood from George Washington before he died from what was probably either acute epiglottitis or streptococcal pharyngitis.[2, 3] Although many infectious organisms, especially malaria parasites, require iron to proliferateand therefore may be less virulent in iron‐deficient people[4]acute near‐exsanguination undoubtedly did more harm than good in the elderly ex‐president.

But the practice of bloodletting continued and even flourished. In 1833 alone, France reportedly imported more than 40 million leeches to assist in bloodletting,[5] which oftentimes was thought to be sufficiently aggressive only when the patient actually fainted. Enthusiasm for bloodletting declined in the second half of the 19th century, influenced in part by a nonrandomized study that compared mortality rates among patients who were bled early in their illness with those who were bled later.[6] Nevertheless, Sir William Osler still recommended small amounts of bloodletting for pneumonia in his last edition of his famous textbook, The Principles and Practice of Medicine, published in 1920.[7] By 1927, however, the first edition of the Cecil's A Textbook of Medicine thankfully no longer recommended venesection except to treat conditions such as pulmonary edema.[8]

Why would I start this essay with a history of bloodletting? Surely, one might argue, nothing could be less relevant to a modern discussion of the quality of in‐hospital medical care. The substantial literature on quality improvement emphasizes the practical implementation of strategies to increase the appropriate adherence to processes that are known to improve outcomes. A number of common quality measures quickly come to mind: the use of aspirin, ‐blockers, angiotensin‐converting enzyme inhibitors, and statins in post‐myocardial infarction patients without contraindications,[9, 10] the rapid initiation of appropriate antibiotics to patients with community‐acquired pneumonia,[11] and early endoscopy for patients with acute upper gastrointestinal hemorrhage.[12] I could go on and on, listing in‐hospital interventions supported by class 1 evidence from more than one definitive randomized trial. In essentially all of these situations, the creation of quality metrics, often accompanied by measurement and feedback, have improved adherence and undoubtedly saved lives. But although adherence has improved, the explosion in evidence‐based medicine means that even the best hospitals may be in perpetual catch‐up mode as they try to ensure adherence with the next wave of improvement interventions.

Unfortunately, every now and then a lot of attention is paid to meeting a quality metric that turns out to be misguided. Perhaps the best recent in‐hospital example was the metric of prophylactic ‐blocker use before major noncardiac surgery. Although this recommendation initially appeared to be based on reasonable data,[13] the large Perioperative Ischemic Evaluation Study (POISE) trial showed that reductions in rates of myocardial infarction were more than offset by an increased risk of stroke and other complications; therefore, average‐risk patients actually did worse, not better, with the ‐blocker regimen used in the trial. Although some have questioned whether these results were a function of the precise ‐blocker regimen that was used, the results of POISE are actually remarkably consistent with prior data on the risk of myocardial infarction and stroke.[14, 15] What was really different was the relative importance of these and other end points in patients whose risk of cardiac death was lower than those of higher risk patients in prior studies. But more recently, an even more disturbing reality has emerged: a number of key reports on which the guidelines were based came from an investigator whose publications included data that could not be confirmed when his studies were reviewed by his home institution.[16] Regardless of the precise reasons, we no longer routinely recommend an intervention that at one time was a key quality indicator.

The ‐blocker fiasco brings me back to bloodletting. In the early 19th century, a hypothetical visionary physician interested in quality improvement would likely have looked for ways to improve the efficiency and reduce the cost of bloodletting. Perhaps the leeches could be bigger, hungrier, or applied in a more effective fashion? Or perhaps vacuum tubes would have been invented sooner?

Of course, I am overemphasizing to prove a point. I truly believe that more and more of what we recommend is based on solid evidence to document, at least for now, that we are doing the right thing. If we do it more often and in more people, net benefit will be realized.

What does all this mean for the future of hospital medicine and its emerging research endeavors? For me at least, the message is pretty clear. First, we must be careful not to over extrapolate from limited studies in high risk patients, or we will jump to more conclusions like we did with ‐blockers. Second, most advances in medicine require new and better data.

How can new clinical data be generated most quickly and efficiently? One‐off studies at individual institutions are logistically and financially challenging, whereas an enduring research infrastructure is a treasure that can study a series of questions as they arise. The Thrombolysis in Myocardial Infarction Study Group has published scores of papers looking at a series of interventions in patients with acute myocardial infarction and the acute coronary syndrome.[17, 18] The Acute Respiratory Distress Syndrome Network has demonstrated the value of lower tidal volumes and less aggressive fluid strategies in patients with respiratory failure.[19, 20]

The success of these large, multicenter research networks should become the paradigm for the study of common hospital problems, ranging from the conditions that result in admission on the medical service to the problems that have engendered surgical comanagement services. New data can be gleaned by studying the medical care system, by studying routinely gathered administrative and clinical data, or even better yet, by gathering prospective data on patients and their diseases. For hospitalized patients, a variety of unanswered questions remain regarding the epidemiology of common diseases, the value of diagnostic tests, the impact of various therapies and treatment protocols, and the incremental value of new technologies, ranging from self‐monitoring to handheld ultrasound. High‐quality research may address the genetic epidemiology of why one person is admitted with pneumococcal pneumonia, whereas family members seem perfectly healthy; which patients with a particular diagnosis might be managed for different lengths of time in different settings; what physical findings or diagnostic tests best stratify prognosis; what new technologies are truly worth their cost; and especially, what therapies really work.

I do not dispute that hospital medicine researchers should try to improve the current use of interventions that are deemed to be valuable right now. But if that is all the field does, it will be a huge disappointment. Hospitalists should not be relegated to being adherence police who spend their collective research energy finding ways to force themselves to follow recommendations based on data gathered by others.

Hospital medicine researchers are uniquely positioned to discover new information that will change what should be done and help create the quality metrics for the future. Unless both of these two goalsimproving the implementation of today's knowledge and generating new and better knowledgeare part of the research agenda, we run the risk that some of the best minds in internal medicine may, when all is said and done, have spent an inordinate number of IQ hours on what, a century from now, will be reminiscent of improving the quality of bloodletting.

The practice of bloodletting, performed using sticks, thorns, bones, or anything sharp, probably began in Egypt about 3,000 years ago.[1] The practice continued in Greece, where Hippocrates recommended bloodletting to balance the body's four humorsblood, phlegm, yellow bile, and black bileand continued during Roman times under the influence of Galen. In the United States, perhaps the most infamous use of bloodletting was when doctors reportedly bled as much as 5 U of blood from George Washington before he died from what was probably either acute epiglottitis or streptococcal pharyngitis.[2, 3] Although many infectious organisms, especially malaria parasites, require iron to proliferateand therefore may be less virulent in iron‐deficient people[4]acute near‐exsanguination undoubtedly did more harm than good in the elderly ex‐president.

But the practice of bloodletting continued and even flourished. In 1833 alone, France reportedly imported more than 40 million leeches to assist in bloodletting,[5] which oftentimes was thought to be sufficiently aggressive only when the patient actually fainted. Enthusiasm for bloodletting declined in the second half of the 19th century, influenced in part by a nonrandomized study that compared mortality rates among patients who were bled early in their illness with those who were bled later.[6] Nevertheless, Sir William Osler still recommended small amounts of bloodletting for pneumonia in his last edition of his famous textbook, The Principles and Practice of Medicine, published in 1920.[7] By 1927, however, the first edition of the Cecil's A Textbook of Medicine thankfully no longer recommended venesection except to treat conditions such as pulmonary edema.[8]

Why would I start this essay with a history of bloodletting? Surely, one might argue, nothing could be less relevant to a modern discussion of the quality of in‐hospital medical care. The substantial literature on quality improvement emphasizes the practical implementation of strategies to increase the appropriate adherence to processes that are known to improve outcomes. A number of common quality measures quickly come to mind: the use of aspirin, ‐blockers, angiotensin‐converting enzyme inhibitors, and statins in post‐myocardial infarction patients without contraindications,[9, 10] the rapid initiation of appropriate antibiotics to patients with community‐acquired pneumonia,[11] and early endoscopy for patients with acute upper gastrointestinal hemorrhage.[12] I could go on and on, listing in‐hospital interventions supported by class 1 evidence from more than one definitive randomized trial. In essentially all of these situations, the creation of quality metrics, often accompanied by measurement and feedback, have improved adherence and undoubtedly saved lives. But although adherence has improved, the explosion in evidence‐based medicine means that even the best hospitals may be in perpetual catch‐up mode as they try to ensure adherence with the next wave of improvement interventions.

Unfortunately, every now and then a lot of attention is paid to meeting a quality metric that turns out to be misguided. Perhaps the best recent in‐hospital example was the metric of prophylactic ‐blocker use before major noncardiac surgery. Although this recommendation initially appeared to be based on reasonable data,[13] the large Perioperative Ischemic Evaluation Study (POISE) trial showed that reductions in rates of myocardial infarction were more than offset by an increased risk of stroke and other complications; therefore, average‐risk patients actually did worse, not better, with the ‐blocker regimen used in the trial. Although some have questioned whether these results were a function of the precise ‐blocker regimen that was used, the results of POISE are actually remarkably consistent with prior data on the risk of myocardial infarction and stroke.[14, 15] What was really different was the relative importance of these and other end points in patients whose risk of cardiac death was lower than those of higher risk patients in prior studies. But more recently, an even more disturbing reality has emerged: a number of key reports on which the guidelines were based came from an investigator whose publications included data that could not be confirmed when his studies were reviewed by his home institution.[16] Regardless of the precise reasons, we no longer routinely recommend an intervention that at one time was a key quality indicator.

The ‐blocker fiasco brings me back to bloodletting. In the early 19th century, a hypothetical visionary physician interested in quality improvement would likely have looked for ways to improve the efficiency and reduce the cost of bloodletting. Perhaps the leeches could be bigger, hungrier, or applied in a more effective fashion? Or perhaps vacuum tubes would have been invented sooner?

Of course, I am overemphasizing to prove a point. I truly believe that more and more of what we recommend is based on solid evidence to document, at least for now, that we are doing the right thing. If we do it more often and in more people, net benefit will be realized.

What does all this mean for the future of hospital medicine and its emerging research endeavors? For me at least, the message is pretty clear. First, we must be careful not to over extrapolate from limited studies in high risk patients, or we will jump to more conclusions like we did with ‐blockers. Second, most advances in medicine require new and better data.

How can new clinical data be generated most quickly and efficiently? One‐off studies at individual institutions are logistically and financially challenging, whereas an enduring research infrastructure is a treasure that can study a series of questions as they arise. The Thrombolysis in Myocardial Infarction Study Group has published scores of papers looking at a series of interventions in patients with acute myocardial infarction and the acute coronary syndrome.[17, 18] The Acute Respiratory Distress Syndrome Network has demonstrated the value of lower tidal volumes and less aggressive fluid strategies in patients with respiratory failure.[19, 20]

The success of these large, multicenter research networks should become the paradigm for the study of common hospital problems, ranging from the conditions that result in admission on the medical service to the problems that have engendered surgical comanagement services. New data can be gleaned by studying the medical care system, by studying routinely gathered administrative and clinical data, or even better yet, by gathering prospective data on patients and their diseases. For hospitalized patients, a variety of unanswered questions remain regarding the epidemiology of common diseases, the value of diagnostic tests, the impact of various therapies and treatment protocols, and the incremental value of new technologies, ranging from self‐monitoring to handheld ultrasound. High‐quality research may address the genetic epidemiology of why one person is admitted with pneumococcal pneumonia, whereas family members seem perfectly healthy; which patients with a particular diagnosis might be managed for different lengths of time in different settings; what physical findings or diagnostic tests best stratify prognosis; what new technologies are truly worth their cost; and especially, what therapies really work.

I do not dispute that hospital medicine researchers should try to improve the current use of interventions that are deemed to be valuable right now. But if that is all the field does, it will be a huge disappointment. Hospitalists should not be relegated to being adherence police who spend their collective research energy finding ways to force themselves to follow recommendations based on data gathered by others.

Hospital medicine researchers are uniquely positioned to discover new information that will change what should be done and help create the quality metrics for the future. Unless both of these two goalsimproving the implementation of today's knowledge and generating new and better knowledgeare part of the research agenda, we run the risk that some of the best minds in internal medicine may, when all is said and done, have spent an inordinate number of IQ hours on what, a century from now, will be reminiscent of improving the quality of bloodletting.

The practice of bloodletting, performed using sticks, thorns, bones, or anything sharp, probably began in Egypt about 3,000 years ago.[1] The practice continued in Greece, where Hippocrates recommended bloodletting to balance the body's four humorsblood, phlegm, yellow bile, and black bileand continued during Roman times under the influence of Galen. In the United States, perhaps the most infamous use of bloodletting was when doctors reportedly bled as much as 5 U of blood from George Washington before he died from what was probably either acute epiglottitis or streptococcal pharyngitis.[2, 3] Although many infectious organisms, especially malaria parasites, require iron to proliferateand therefore may be less virulent in iron‐deficient people[4]acute near‐exsanguination undoubtedly did more harm than good in the elderly ex‐president.

But the practice of bloodletting continued and even flourished. In 1833 alone, France reportedly imported more than 40 million leeches to assist in bloodletting,[5] which oftentimes was thought to be sufficiently aggressive only when the patient actually fainted. Enthusiasm for bloodletting declined in the second half of the 19th century, influenced in part by a nonrandomized study that compared mortality rates among patients who were bled early in their illness with those who were bled later.[6] Nevertheless, Sir William Osler still recommended small amounts of bloodletting for pneumonia in his last edition of his famous textbook, The Principles and Practice of Medicine, published in 1920.[7] By 1927, however, the first edition of the Cecil's A Textbook of Medicine thankfully no longer recommended venesection except to treat conditions such as pulmonary edema.[8]

Why would I start this essay with a history of bloodletting? Surely, one might argue, nothing could be less relevant to a modern discussion of the quality of in‐hospital medical care. The substantial literature on quality improvement emphasizes the practical implementation of strategies to increase the appropriate adherence to processes that are known to improve outcomes. A number of common quality measures quickly come to mind: the use of aspirin, ‐blockers, angiotensin‐converting enzyme inhibitors, and statins in post‐myocardial infarction patients without contraindications,[9, 10] the rapid initiation of appropriate antibiotics to patients with community‐acquired pneumonia,[11] and early endoscopy for patients with acute upper gastrointestinal hemorrhage.[12] I could go on and on, listing in‐hospital interventions supported by class 1 evidence from more than one definitive randomized trial. In essentially all of these situations, the creation of quality metrics, often accompanied by measurement and feedback, have improved adherence and undoubtedly saved lives. But although adherence has improved, the explosion in evidence‐based medicine means that even the best hospitals may be in perpetual catch‐up mode as they try to ensure adherence with the next wave of improvement interventions.

Unfortunately, every now and then a lot of attention is paid to meeting a quality metric that turns out to be misguided. Perhaps the best recent in‐hospital example was the metric of prophylactic ‐blocker use before major noncardiac surgery. Although this recommendation initially appeared to be based on reasonable data,[13] the large Perioperative Ischemic Evaluation Study (POISE) trial showed that reductions in rates of myocardial infarction were more than offset by an increased risk of stroke and other complications; therefore, average‐risk patients actually did worse, not better, with the ‐blocker regimen used in the trial. Although some have questioned whether these results were a function of the precise ‐blocker regimen that was used, the results of POISE are actually remarkably consistent with prior data on the risk of myocardial infarction and stroke.[14, 15] What was really different was the relative importance of these and other end points in patients whose risk of cardiac death was lower than those of higher risk patients in prior studies. But more recently, an even more disturbing reality has emerged: a number of key reports on which the guidelines were based came from an investigator whose publications included data that could not be confirmed when his studies were reviewed by his home institution.[16] Regardless of the precise reasons, we no longer routinely recommend an intervention that at one time was a key quality indicator.

The ‐blocker fiasco brings me back to bloodletting. In the early 19th century, a hypothetical visionary physician interested in quality improvement would likely have looked for ways to improve the efficiency and reduce the cost of bloodletting. Perhaps the leeches could be bigger, hungrier, or applied in a more effective fashion? Or perhaps vacuum tubes would have been invented sooner?

Of course, I am overemphasizing to prove a point. I truly believe that more and more of what we recommend is based on solid evidence to document, at least for now, that we are doing the right thing. If we do it more often and in more people, net benefit will be realized.

What does all this mean for the future of hospital medicine and its emerging research endeavors? For me at least, the message is pretty clear. First, we must be careful not to over extrapolate from limited studies in high risk patients, or we will jump to more conclusions like we did with ‐blockers. Second, most advances in medicine require new and better data.

How can new clinical data be generated most quickly and efficiently? One‐off studies at individual institutions are logistically and financially challenging, whereas an enduring research infrastructure is a treasure that can study a series of questions as they arise. The Thrombolysis in Myocardial Infarction Study Group has published scores of papers looking at a series of interventions in patients with acute myocardial infarction and the acute coronary syndrome.[17, 18] The Acute Respiratory Distress Syndrome Network has demonstrated the value of lower tidal volumes and less aggressive fluid strategies in patients with respiratory failure.[19, 20]

The success of these large, multicenter research networks should become the paradigm for the study of common hospital problems, ranging from the conditions that result in admission on the medical service to the problems that have engendered surgical comanagement services. New data can be gleaned by studying the medical care system, by studying routinely gathered administrative and clinical data, or even better yet, by gathering prospective data on patients and their diseases. For hospitalized patients, a variety of unanswered questions remain regarding the epidemiology of common diseases, the value of diagnostic tests, the impact of various therapies and treatment protocols, and the incremental value of new technologies, ranging from self‐monitoring to handheld ultrasound. High‐quality research may address the genetic epidemiology of why one person is admitted with pneumococcal pneumonia, whereas family members seem perfectly healthy; which patients with a particular diagnosis might be managed for different lengths of time in different settings; what physical findings or diagnostic tests best stratify prognosis; what new technologies are truly worth their cost; and especially, what therapies really work.

I do not dispute that hospital medicine researchers should try to improve the current use of interventions that are deemed to be valuable right now. But if that is all the field does, it will be a huge disappointment. Hospitalists should not be relegated to being adherence police who spend their collective research energy finding ways to force themselves to follow recommendations based on data gathered by others.

Hospital medicine researchers are uniquely positioned to discover new information that will change what should be done and help create the quality metrics for the future. Unless both of these two goalsimproving the implementation of today's knowledge and generating new and better knowledgeare part of the research agenda, we run the risk that some of the best minds in internal medicine may, when all is said and done, have spent an inordinate number of IQ hours on what, a century from now, will be reminiscent of improving the quality of bloodletting.

The field of hospital medicine, now the fastest growing specialty in medical history,[1] was born out of pressure to improve the efficiency and quality of clinical care in US hospitals.[2] Delivering safe and high‐value clinical care is a central goal of the field and has been an essential component of its growth and success.

The clinical demands on academic hospitalists have grown recently, fueled by the need to staff services previously covered by housestaff, whose hours are now restricted. Despite these new demands, expectations have grown in other arenas as well. Academic hospitalist groups (AHGs) are often expected to make significant contributions in quality improvement, patient safety, education, research, and administration. With broad expectations beyond clinical care, AHGs face unique challenges. Groups that focus mainly on providing coverage and improving clinical performance may find that they are unable to fully contribute in these other domains. To be successful, AHGs must develop strategies that balance their energies, resources, and performance.

The balanced scorecard (BSC) was introduced by Kaplan and Norton in 1992 to allow corporations to view their performance broadly, rather than narrowly focusing on financial measures. The BSC requires organizations to develop a balanced portfolio of performance metrics across 4 key perspectives: financial, customers, internal processes, and learning and growth. Metrics within these perspectives should help answer fundamental questions about the organization (Table 1).[3] Over time, the BSC evolved from a performance measurement tool to a strategic management system.[4] Successful organizations translate their mission and vision to specific strategic objectives in each of the 4 perspectives, delineate how these objectives will help the organization reach its vision with a strategy map,[5] and then utilize the BSC to track and monitor performance to ensure that the vision is achieved.[6]

Although originally conceived for businesses, the BSC has found its way into the healthcare industry, with reports of successful implementation in organizations ranging from individual departments to research collaboratives[7] to national healthcare systems.[8] However, there are few reports of BSC implementation in academic health centers.[9, 10] Because most academic centers are not‐for‐profit, Zelman suggests that the 4 BSC perspectives be modified to better fit their unique characteristics (Table 1).[11] To the best of our knowledge, there is no literature describing the development of a BSC in an academic hospitalist group. In this article, we describe the development of, and early experiences with, an academic hospital medicine BSC developed as part of a strategic planning initiative.

METHODS

The University of California, San Francisco (UCSF) Division of Hospital Medicine (DHM) was established in 2005. Currently, there are more than 50 faculty members, having doubled in the last 4 years. In addition to staffing several housestaff and nonhousestaff clinical services, faculty are involved in a wide variety of nonclinical endeavors at local and national levels. They participate and lead initiatives in education, faculty development, patient safety, care efficiency, quality improvement, information technology, and global health. There is an active research enterprise that generates nearly $5 million in grant funding annually.

RESULTS

There were 41 initial metrics considered by the division BSC task force (Table 3). Of these, 16 were chosen for the initial BSC through the modified Delphi method. Over the past 2 years, these initial metrics have been modified to reflect current strategic goals and objectives. Figure 1 illustrates the BSC for fiscal year (FY) 2012. An online version of this, complete with graphical representations of the data and metric definitions, can be found at http://hospitalmedicine.ucsf.edu/bsc/fy2012.html. Our strategy map (Figure 2) demonstrates how these metrics are interconnected across the 4 BSC perspectives and how they fit into our overall strategic plan.

Figure 1

Figure 2

DISCUSSION

Like many hospitalist groups, our division has experienced tremendous growth, both in our numbers and the breadth of roles that we fill. With this growth has come increasing expectations in multiple domains, competing priorities, and limited resources. We successfully developed a BSC as a tool to help our division reach its vision: balancing high quality clinical care, education, academics, and faculty development while maintaining a strong sense of community. We have found that the BSC has helped us meet several key goals.

The first goal was to allow for a broad view of our performance. This is the BSC's most basic function, and we saw immediate and tangible benefits. The scorecard provided a broad snapshot of our performance in a single place. For example, in the clinical domain, we saw that our direct cost per case was increasing despite our adjusted average length of stay remaining stable from FY2010‐FY2011. In academics and research, we saw that the number of abstracts accepted at national meetings increased by almost 30% in FY2011 (Figure 1).

The second goal was to create transparency and accountability. By measuring performance and displaying it on the division Web site, the BSC has promoted transparency. If performance does not meet our targets, the division as a whole becomes accountable. Leadership must understand why performance fell short and initiate changes to improve it. For instance, the rising direct cost per case has spurred the development of a high‐value care committee tasked with finding ways of reducing cost while providing high‐quality care.[12]

The third goal was to communicate goals and engage our faculty. As our division has grown, ensuring a shared vision among our entire faculty became an increasing challenge. The BSC functions as a communication platform between leadership and faculty, and yielded multiple benefits. As the metrics were born out of our mission and vision, the BSC has become a tangible representation of our core values. Moreover, individual faculty can see that they are part of a greater, high‐performing organization and realize they can impact the group's performance through their individual effort. For example, this has helped promote receptivity to carefully disseminated individual performance measures for billing and documentation, and patient satisfaction, in conjunction with faculty development in these areas.

The fourth goal was to ensure that we use data to guide strategic decisions. We felt that strategic decisions needed to be based on objective, rather than perceived or anecdotal, information. This meant translating our vision into measurable objectives that would drive performance improvement. For example, before the BSC, we were committed to the dissemination of our research and innovations. Yet, we quickly realized that we did not have a system to collect even basic data on academic performancea deficit we filled by leveraging information gathered from online databases and faculty curricula vitae. These data allowed us, for the first time, to objectively reflect on this as a strategic goal and to have an ongoing mechanism to monitor academic productivity.

Disclosure

Nothing to report.

The field of hospital medicine, now the fastest growing specialty in medical history,[1] was born out of pressure to improve the efficiency and quality of clinical care in US hospitals.[2] Delivering safe and high‐value clinical care is a central goal of the field and has been an essential component of its growth and success.

The clinical demands on academic hospitalists have grown recently, fueled by the need to staff services previously covered by housestaff, whose hours are now restricted. Despite these new demands, expectations have grown in other arenas as well. Academic hospitalist groups (AHGs) are often expected to make significant contributions in quality improvement, patient safety, education, research, and administration. With broad expectations beyond clinical care, AHGs face unique challenges. Groups that focus mainly on providing coverage and improving clinical performance may find that they are unable to fully contribute in these other domains. To be successful, AHGs must develop strategies that balance their energies, resources, and performance.

The balanced scorecard (BSC) was introduced by Kaplan and Norton in 1992 to allow corporations to view their performance broadly, rather than narrowly focusing on financial measures. The BSC requires organizations to develop a balanced portfolio of performance metrics across 4 key perspectives: financial, customers, internal processes, and learning and growth. Metrics within these perspectives should help answer fundamental questions about the organization (Table 1).[3] Over time, the BSC evolved from a performance measurement tool to a strategic management system.[4] Successful organizations translate their mission and vision to specific strategic objectives in each of the 4 perspectives, delineate how these objectives will help the organization reach its vision with a strategy map,[5] and then utilize the BSC to track and monitor performance to ensure that the vision is achieved.[6]

Although originally conceived for businesses, the BSC has found its way into the healthcare industry, with reports of successful implementation in organizations ranging from individual departments to research collaboratives[7] to national healthcare systems.[8] However, there are few reports of BSC implementation in academic health centers.[9, 10] Because most academic centers are not‐for‐profit, Zelman suggests that the 4 BSC perspectives be modified to better fit their unique characteristics (Table 1).[11] To the best of our knowledge, there is no literature describing the development of a BSC in an academic hospitalist group. In this article, we describe the development of, and early experiences with, an academic hospital medicine BSC developed as part of a strategic planning initiative.

METHODS

The University of California, San Francisco (UCSF) Division of Hospital Medicine (DHM) was established in 2005. Currently, there are more than 50 faculty members, having doubled in the last 4 years. In addition to staffing several housestaff and nonhousestaff clinical services, faculty are involved in a wide variety of nonclinical endeavors at local and national levels. They participate and lead initiatives in education, faculty development, patient safety, care efficiency, quality improvement, information technology, and global health. There is an active research enterprise that generates nearly $5 million in grant funding annually.

RESULTS

There were 41 initial metrics considered by the division BSC task force (Table 3). Of these, 16 were chosen for the initial BSC through the modified Delphi method. Over the past 2 years, these initial metrics have been modified to reflect current strategic goals and objectives. Figure 1 illustrates the BSC for fiscal year (FY) 2012. An online version of this, complete with graphical representations of the data and metric definitions, can be found at http://hospitalmedicine.ucsf.edu/bsc/fy2012.html. Our strategy map (Figure 2) demonstrates how these metrics are interconnected across the 4 BSC perspectives and how they fit into our overall strategic plan.

Figure 1

Figure 2

DISCUSSION

Like many hospitalist groups, our division has experienced tremendous growth, both in our numbers and the breadth of roles that we fill. With this growth has come increasing expectations in multiple domains, competing priorities, and limited resources. We successfully developed a BSC as a tool to help our division reach its vision: balancing high quality clinical care, education, academics, and faculty development while maintaining a strong sense of community. We have found that the BSC has helped us meet several key goals.

The first goal was to allow for a broad view of our performance. This is the BSC's most basic function, and we saw immediate and tangible benefits. The scorecard provided a broad snapshot of our performance in a single place. For example, in the clinical domain, we saw that our direct cost per case was increasing despite our adjusted average length of stay remaining stable from FY2010‐FY2011. In academics and research, we saw that the number of abstracts accepted at national meetings increased by almost 30% in FY2011 (Figure 1).

The second goal was to create transparency and accountability. By measuring performance and displaying it on the division Web site, the BSC has promoted transparency. If performance does not meet our targets, the division as a whole becomes accountable. Leadership must understand why performance fell short and initiate changes to improve it. For instance, the rising direct cost per case has spurred the development of a high‐value care committee tasked with finding ways of reducing cost while providing high‐quality care.[12]

The third goal was to communicate goals and engage our faculty. As our division has grown, ensuring a shared vision among our entire faculty became an increasing challenge. The BSC functions as a communication platform between leadership and faculty, and yielded multiple benefits. As the metrics were born out of our mission and vision, the BSC has become a tangible representation of our core values. Moreover, individual faculty can see that they are part of a greater, high‐performing organization and realize they can impact the group's performance through their individual effort. For example, this has helped promote receptivity to carefully disseminated individual performance measures for billing and documentation, and patient satisfaction, in conjunction with faculty development in these areas.

The fourth goal was to ensure that we use data to guide strategic decisions. We felt that strategic decisions needed to be based on objective, rather than perceived or anecdotal, information. This meant translating our vision into measurable objectives that would drive performance improvement. For example, before the BSC, we were committed to the dissemination of our research and innovations. Yet, we quickly realized that we did not have a system to collect even basic data on academic performancea deficit we filled by leveraging information gathered from online databases and faculty curricula vitae. These data allowed us, for the first time, to objectively reflect on this as a strategic goal and to have an ongoing mechanism to monitor academic productivity.

Disclosure

Nothing to report.

The field of hospital medicine, now the fastest growing specialty in medical history,[1] was born out of pressure to improve the efficiency and quality of clinical care in US hospitals.[2] Delivering safe and high‐value clinical care is a central goal of the field and has been an essential component of its growth and success.

The clinical demands on academic hospitalists have grown recently, fueled by the need to staff services previously covered by housestaff, whose hours are now restricted. Despite these new demands, expectations have grown in other arenas as well. Academic hospitalist groups (AHGs) are often expected to make significant contributions in quality improvement, patient safety, education, research, and administration. With broad expectations beyond clinical care, AHGs face unique challenges. Groups that focus mainly on providing coverage and improving clinical performance may find that they are unable to fully contribute in these other domains. To be successful, AHGs must develop strategies that balance their energies, resources, and performance.

The balanced scorecard (BSC) was introduced by Kaplan and Norton in 1992 to allow corporations to view their performance broadly, rather than narrowly focusing on financial measures. The BSC requires organizations to develop a balanced portfolio of performance metrics across 4 key perspectives: financial, customers, internal processes, and learning and growth. Metrics within these perspectives should help answer fundamental questions about the organization (Table 1).[3] Over time, the BSC evolved from a performance measurement tool to a strategic management system.[4] Successful organizations translate their mission and vision to specific strategic objectives in each of the 4 perspectives, delineate how these objectives will help the organization reach its vision with a strategy map,[5] and then utilize the BSC to track and monitor performance to ensure that the vision is achieved.[6]

Although originally conceived for businesses, the BSC has found its way into the healthcare industry, with reports of successful implementation in organizations ranging from individual departments to research collaboratives[7] to national healthcare systems.[8] However, there are few reports of BSC implementation in academic health centers.[9, 10] Because most academic centers are not‐for‐profit, Zelman suggests that the 4 BSC perspectives be modified to better fit their unique characteristics (Table 1).[11] To the best of our knowledge, there is no literature describing the development of a BSC in an academic hospitalist group. In this article, we describe the development of, and early experiences with, an academic hospital medicine BSC developed as part of a strategic planning initiative.

METHODS

The University of California, San Francisco (UCSF) Division of Hospital Medicine (DHM) was established in 2005. Currently, there are more than 50 faculty members, having doubled in the last 4 years. In addition to staffing several housestaff and nonhousestaff clinical services, faculty are involved in a wide variety of nonclinical endeavors at local and national levels. They participate and lead initiatives in education, faculty development, patient safety, care efficiency, quality improvement, information technology, and global health. There is an active research enterprise that generates nearly $5 million in grant funding annually.

RESULTS

There were 41 initial metrics considered by the division BSC task force (Table 3). Of these, 16 were chosen for the initial BSC through the modified Delphi method. Over the past 2 years, these initial metrics have been modified to reflect current strategic goals and objectives. Figure 1 illustrates the BSC for fiscal year (FY) 2012. An online version of this, complete with graphical representations of the data and metric definitions, can be found at http://hospitalmedicine.ucsf.edu/bsc/fy2012.html. Our strategy map (Figure 2) demonstrates how these metrics are interconnected across the 4 BSC perspectives and how they fit into our overall strategic plan.

Figure 1

Figure 2

DISCUSSION

Like many hospitalist groups, our division has experienced tremendous growth, both in our numbers and the breadth of roles that we fill. With this growth has come increasing expectations in multiple domains, competing priorities, and limited resources. We successfully developed a BSC as a tool to help our division reach its vision: balancing high quality clinical care, education, academics, and faculty development while maintaining a strong sense of community. We have found that the BSC has helped us meet several key goals.

The first goal was to allow for a broad view of our performance. This is the BSC's most basic function, and we saw immediate and tangible benefits. The scorecard provided a broad snapshot of our performance in a single place. For example, in the clinical domain, we saw that our direct cost per case was increasing despite our adjusted average length of stay remaining stable from FY2010‐FY2011. In academics and research, we saw that the number of abstracts accepted at national meetings increased by almost 30% in FY2011 (Figure 1).

The second goal was to create transparency and accountability. By measuring performance and displaying it on the division Web site, the BSC has promoted transparency. If performance does not meet our targets, the division as a whole becomes accountable. Leadership must understand why performance fell short and initiate changes to improve it. For instance, the rising direct cost per case has spurred the development of a high‐value care committee tasked with finding ways of reducing cost while providing high‐quality care.[12]

The third goal was to communicate goals and engage our faculty. As our division has grown, ensuring a shared vision among our entire faculty became an increasing challenge. The BSC functions as a communication platform between leadership and faculty, and yielded multiple benefits. As the metrics were born out of our mission and vision, the BSC has become a tangible representation of our core values. Moreover, individual faculty can see that they are part of a greater, high‐performing organization and realize they can impact the group's performance through their individual effort. For example, this has helped promote receptivity to carefully disseminated individual performance measures for billing and documentation, and patient satisfaction, in conjunction with faculty development in these areas.

The fourth goal was to ensure that we use data to guide strategic decisions. We felt that strategic decisions needed to be based on objective, rather than perceived or anecdotal, information. This meant translating our vision into measurable objectives that would drive performance improvement. For example, before the BSC, we were committed to the dissemination of our research and innovations. Yet, we quickly realized that we did not have a system to collect even basic data on academic performancea deficit we filled by leveraging information gathered from online databases and faculty curricula vitae. These data allowed us, for the first time, to objectively reflect on this as a strategic goal and to have an ongoing mechanism to monitor academic productivity.

Disclosure

Nothing to report.

DEVELOPMENT OF THE POSITION PAPER

In June of 2011, the executive leadership of the Society of Critical Care Medicine (SCCM) and the Society of Hospital Medicine (SHM) convened a daylong summit to discuss intensive care unit (ICU) workforce issues as they affect intensivists and hospitalists. Attendees included the executive leadership of both societies and invited participants with cross‐disciplinary expertise in hospital medicine and critical care medicine.0

The summit was convened to address the following issues:

• Defining hospitalists' roles in providing ICU coverage in the presence or absence of intensivists.

• Developing standardized and universally recognized supplementary training pathways for hospitalists who practice in the ICU.

• Identifying clinical, logistical, and political barriers that might impair or preclude such training.

At the close of the summit, the executive leadership of both societies agreed that they had sufficient consensus on the aforementioned issues to delegate a subgroup of participants to formulate a position paper. The authors of the position paper were selected based upon their diverse professional experience, senior leadership in both SHM and SCCM, and their cross‐disciplinary expertise in hospital medicine and critical care medicine. Four of the 5 authors (E.M.S., J.R.D., M.J.G., P.A.L.) are board‐certified intensivists. Three (E.M.S., J.R.D., M.J.G.) are members of both SCCM and SHM, 2 (M.J.G., J.R.D.) are Past‐Presidents of SHM, and 1 (P.A.L.) is Immediate Past‐President of SCCM. E.M.S. and D.D.D. are current members of the SHM Board of Directors.

After the summit, the authors held several conference calls to review the structure and content of the position paper. The boards of directors of both societies independently approved a draft of the paper and the executive leadership of both societies approved subsequent revisions. The position paper was submitted for joint publication in the Journal of Hospital Medicine and Critical Care Medicine and underwent formal peer‐review by reviewers representing both societies.

INTRODUCTION

The growing shortage of intensivists and its implications for hospitalized Americans is well documented and remains an ongoing concern for hospitals, clinicians, payers, and the federal government.17 Despite numerous recommendations that intensivists manage critically ill adults,8, 9 most American hospitals cannot and will not meet this proposed standard.10, 11 When surveyed, only 20% of Michigan hospitals participating in the Keystone Project responded that they staffed their ICUs exclusively with board‐certified intensivists, and 75% maintained open ICU staffing models.12 The mismatch between intensivist supply and demand is expected to worsen as inpatient volume and acuity grow in concert with an aging and increasingly comorbid American population, yet with the exception of a 2010 agreement between the American Board of Internal Medicine (ABIM) and American Board of Emergency Medicine (ABEM) to cosponsor a medical critical care fellowship pathway for emergency medicine (EM) physicians, little has changed to expand the intensivist trainee pipeline. Although the addition of a sanctioned EM critical care pathway is a positive development, it is unlikely to significantly impact the intensivist shortage in the near term. Between 2000 and 2007, 43 emergency medicine physicians entered non‐board sanctioned American critical care fellowships,13 while in the 20112012 academic year, 1957 trainees are enrolled in adult critical care medicine fellowships (surgery, anesthesia, medical critical care, and pulmonary/critical care).14 It remains to be seen if the availability of a formal critical care pathway will significantly increase the numbers of emergency medicine physicians who pursue critical care training.

The growing intensivist shortage has coincided with the appearance of hospitalists, physicians who focus on the care of hospitalized medical patients, on the healthcare landscape.15 Increasing from 2000 to 34,000 practitioners in 15 years, hospital medicine is the fastest growing specialty in organized medicine, with an estimated plateau of as many as 50,000 practitioners.16 As of 2009, hospitalists were present in 89% of hospitals with over 200 beds, largely replacing primary care physicians as the managers of ICU patients in non‐tertiary hospital settings.16 In surveys performed by the Society of Hospital Medicine, 75% of hospitalists reported that they practice in the ICU, often shouldering much of the responsibility for managing critically ill patients.17 In 37.5% of Michigan Keystone Project hospitals, hospitalists served as attending physicians of record in the ICU.10 Although legitimate concerns have been raised about whether hospitalists are uniformly qualified to practice in the ICU, this issue has become moot at many hospitals where intensivists are either in short supply or entirely absent.1821 As previously noted by Heisler,22 the issue is no longer whether hospitalists should practice in the ICU, but rather to ensure that they do so safely, effectively, and seamlessly in collaboration with intensivists, or independently when intensivists are unavailable.

POTENTIAL VALUE OF HOSPITALISTS IN THE ICU

Hospital medicine and critical care medicine share similar competencies and values. Eighty‐five percent of practicing hospitalists are internists, who have historically been well trained to manage acutely ill hospitalized patients. Categorical internal medicine (IM) training emphasizes acute inpatient medicine, with residents spending approximately two‐thirds of their training time in the hospital. Many of the cognitive skills required for practicing critical care medicine are encompassed in categorical IM training, as well as in the Core Competencies in Hospital Medicine.23, 24 Furthermore, hospitalist staffing models are specifically adapted to meet the needs of acutely ill patients. With their consistent presence in the hospital (many programs provide 24:7 in‐house coverage), hospitalists see patients several times a day if necessary and can respond to their acute needs in real time. In many institutions, hospitalists are tasked as first responders to in‐house emergencies, often covering ICUs when intensivists are unavailable.

Most importantly, hospital medicine and critical care medicine are philosophically aligned. Both disciplines are defined by their location of practice rather than by an organ system or constellation of diseases. Both specialties embrace hospital‐based process improvement, lead multidisciplinary teams, and champion quality and safety initiatives.23, 25 Hospitalists and intensivists routinely collaborate to improve hospital care through shared protocol implementation, patient throughput management, and quality improvement initiatives. The ideology and mechanics of high‐performing hospitalist and intensivist programs are extremely similar.

LIMITATIONS OF HOSPITALISTS IN ICUs

Although the majority of hospitalists are general internists, individual hospitalists' skills may be heterogeneous, reflecting differences in training and clinical practice experience prior to becoming hospitalists. A hospitalist entering practice directly from a rigorous categorical IM training program will likely have different skills and knowledge than an ambulatory‐based general internist who makes a mid‐career switch to hospital medicine. Furthermore, increasingly stringent restrictions on housestaff work hours and patient loads, coupled with increasing emphasis on ambulatory medicine, have substantially decreased IM residents' cumulative exposure to acutely ill inpatients and inpatient procedures, raising concerns that the current generation of IM residents are less well‐prepared to manage ICU patients than their predecessors. The growing prevalence of family practitioners in the adult hospitalist workforce (currently estimated at 6%8%), who generally are not as rigorously or comprehensively trained in critical care medicine as internists, further complicates efforts to broadly categorize adult hospitalists' ICU skills.26, 27

Once hospitalists enter the workforce, they have few formal opportunities to significantly advance their critical care knowledge and skills. Existing critical care educational offerings are generally limited to 1‐ or 2‐day critical care refresher courses or narrowly focused ICU skills courses, such as acute airway management or critical care ultrasonography. These courses, while valuable, are often insufficient for hospitalists who need to broaden their general critical care knowledge base or obtain skills that they did not acquire in residency training. The result is a hospitalist workforce that practices in the ICU but has limited opportunity to enhance the skills and knowledge necessary to do so safely and competently.

ENHANCING HOSPITALISTS' SKILLS TO PROVIDE CRITICAL CARE SERVICES

In the absence of a systemic solution to the intensivist shortage, the healthcare marketplace is independently developing alternative critical care delivery solutions, such as deploying telemedicine systems and expanding the roles of nurse practitioners and physician assistants in the ICU. To a lesser extent, there have been calls for hospitalists to fill similar intensivist extender roles in the ICU, and Heisler and others have suggested developing limited, competency‐based critical care training to allow hospitalists to manage a subset of ICU patients, either independently or collaboratively with intensivists.22 Several healthcare systems are in various stages of developing such critical care training programs for their hospitalists, many of whom already practice in the ICU. These programs will likely blend fellowship‐level training with supervised attending duties in the ICU, with the expectation that graduates will be able to independently manage a portion of an ICU population (Timothy G. Buchman, MD, PhD, Department of Surgery, Emory University School of Medicine, personal communication, May 11, 2011).

Although informal hospitalist training programs could make an important contribution to ICU staffing, they raise new concerns as well. In the absence of uniform, formal training and evaluation standards, the quality and consistency of these homegrown programs could vary widely, with participants developing critical care skills and competencies that might not conform to requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME). Even if training could be standardized, the practical implementation of a 2‐tier intensivist model would create extreme political and operational challenges for hospitals, which would be required to differentially credential and privilege providers with similar training and overlapping patient responsibilities. In light of these complexities and uncertainties, hospitalists might be unwilling to risk investing in lengthy training offering uncertain recognition and delineation of what they can and cannot do in the ICU.

A more durable long‐term solution is to create an ACGME‐sanctioned and accredited critical care certification pathway for IM hospitalists, with the express goal of expanding the intensivist workforce by attracting practicing hospitalists to critical care fellowship training. Hospitalists who complete such training would be full‐fledged intensivists, subject to the same privileges and expectations as any other intensivist.

We believe that many hospitalists could acquire the competencies necessary to become board‐eligible intensivists in less than the 2 years currently required for general internists to complete critical care medicine training. The existence of 6 unique pathways for critical care training and board certification in the United States, all maintaining unique training criteria and durations of training, strongly suggests that competent intensivists can be trained through disparate pathways to achieve equivalent outcomes (Table 1). For example, both surgical and anesthesia critical care programs require only a single added year of training following their respective residency training programs.28, 29 Of the 24 months that comprise a medical critical care fellowship, only 12 months of clinical duties are required, with the remainder allocated to electives, quality‐improvement initiatives, research, and other academic pursuits.30 The ACGME and ABIM have tacitly acknowledged that medical critical care training is achievable in less than 2 years, by allowing those who enter or complete accredited 2‐year fellowships in other medical specialties to obtain critical care certification with a single additional year of critical care training.30 If infectious disease and nephrology fellows can become competent intensivists with a single year of critical care training, it is reasonable to believe that experienced IM hospitalists can do so as well.

Offering a 1‐year critical care fellowship training track for experienced IM hospitalists will require careful consideration of which components of existing 2‐year critical care fellowship can be removed or condensed without materially compromising the quality of training. Hospitalists participating in a condensed 1‐year training program would need the maturity and experience to hit the ground running, mandating a robust entry bar predicated upon relevant prior clinical practice experience. We believe that 3 sequential years of prior hospitalist practice experience is a reasonable prerequisite for participation. Additionally, eligible hospitalists would need to participate in the (currently voluntary) ABIM Focused Practice in Hospital Medicine Maintenance of Certification (MOC) process,31 which mandates completion of hospital‐based education and practice improvement modules. Prior training and participation in quality improvement (QI) processes could supplant some of the scholarly activity that is currently expected during the nonclinical portion of a traditional 2‐year medical critical care fellowship, and candidates would be required to have completed at least one meaningful hospital‐based QI initiative while still in practice.

Although new curricular standards would need to be developed, 1‐year medical intensivist fellowships could coexist alongside 2‐year fellowships within a single critical care training program, as is the case when internal medicine fellows in other specialties complete an added year of critical care fellowship. However, to meaningfully impact the intensivist shortage, the number and capacity of medical critical care fellowships, which currently train approximately 10% of the critical care workforce, would need to significantly expand.13

Importantly, the impact that critical care‐trained hospitalists will have on the quality and safety of patient care in the ICU will require evaluation and study. We presume that inserting this new cohort of intensivists into previously unmanaged or undermanaged ICUs will improve care, but this, like many other uncertainties regarding optimal models of ICU staffing, should be subject to rigorous and objective examination through additional clinical research.10, 3236

Offering a 1‐year critical care training track will raise new challenges. Skepticism about the rigor and content of 1‐year programs may foster the perception that graduates are inadequately trained or skilled to function at the level of other board‐certified intensivists. It is also possible that a 1‐year hospitalistcritical care fellowship could divert trainees from traditional critical care programs, offsetting net gains in the number of intensivists. However, we suspect that a 1‐year fellowship program will attract primarily practicing hospitalists, while 2‐year tracks will continue to attract IM residents. We conceptualize participation in a 1‐year hospitalistcritical care fellowship program as a (minimum) 4‐year post‐residency commitment, consisting of at least 3 years of clinical practice as a hospitalist, followed by 1 year of critical care fellowship training. Internal medicine residents would find a shorter pathway to intensivist practice by enrolling in traditional 2‐year critical care or even 3‐year pulmonary/critical care training programs. The compensation advantage afforded to intensivists relative to hospitalists (approximately $100,000 per year) would offset any financial advantage gained by shaving a year off of critical care fellowship training.37, 38 We also suspect that those seeking careers in academic medicine would almost exclusively opt for a traditional 2‐year training pathway.

Finally, while Europe and Australia offer a single common pathway to critical care certification, the United States maintains multiple, independent, specialty‐specific training pathways, each with unique durations, requirements, and certification processes. Although consideration of this important issue is beyond the scope of this paper, we believe that developing a hospitalist‐intensivist workforce should be part of a broader initiative to reform critical care training to better meet the demand for intensivists across the spectrum of American ICUs. Adopting a global intensivist training strategy that is specialty‐independent and specific to critical care medicine may result in a more consistent, collaborative, and interoperable critical care workforce.

CONCLUSION

American critical care training programs have failed to produce enough intensivists to meet demand, and this mismatch between supply and demand will substantially worsen over upcoming decades. Hospitals and healthcare systems, faced with the mandate to provide care for their ICU populations, have already innovated to offset this shortage through the use of telemedicine and the extension of nonphysician providers into ICUs. As the gap between intensivist supply and demand widens, healthcare systems will be increasingly likely to pursue more radical solutions, up to and including independently training their own critical care workforces. We believe that there are better alternatives.

Hospitalists have rapidly proliferated to become the dominant provider of inpatient medical care in American hospitals and are already providing a substantial amount of critical care. As such, they remain a largely untapped and potentially significant source of new intensivists. The skills, competencies, and values embodied in hospital medicine are already highly congruent with those of critical care. By virtue of their numbers and penetrance into the vast majority of large American hospitals, hospitalists are well situated to make a substantial impact on the intensivist shortage. If only 5% of the projected hospitalist workforce were to receive the critical care training that we propose, 2500 new intensivists would enter the critical care workforce, substantially decreasing the impact of the national intensivist shortage.12

Internal medicine hospitalists who obtain additional training as intensivists would also bring new capabilities and flexibility to hospitals seeking to implement intensivist programs. In smaller hospitals that cannot support freestanding intensivist programs, hospitalist‐intensivists might divide their time between ICU and ward duties. In larger hospitals, these clinicians might function exclusively as intensivists alongside their traditionally trained peers. Whether they affiliate as hospitalists, intensivists, or something else entirely will largely depend upon the roles that they fulfill, the governance of their institutions, and the departments that most effectively meet their clinical and organizational needs.

Bringing qualified hospitalists into the critical care workforce through rigorous sanctioned and accredited 1‐year training programs, will open a new intensivist training pipeline and potentially offer more critically ill patients the benefit of providers who are unequivocally qualified to care for them. Similarly, unification of critical care training and certification across disciplines will better focus efforts to expand the intensivist workforce, more efficiently leverage limited training resources, and facilitate standardization of critical care skills, policies, and procedures across the nation's ICUs. Although moving this agenda forward may be logistically challenging and politically daunting, we believe that the results will be worth the effort.

DEVELOPMENT OF THE POSITION PAPER

In June of 2011, the executive leadership of the Society of Critical Care Medicine (SCCM) and the Society of Hospital Medicine (SHM) convened a daylong summit to discuss intensive care unit (ICU) workforce issues as they affect intensivists and hospitalists. Attendees included the executive leadership of both societies and invited participants with cross‐disciplinary expertise in hospital medicine and critical care medicine.0

The summit was convened to address the following issues:

• Defining hospitalists' roles in providing ICU coverage in the presence or absence of intensivists.

• Developing standardized and universally recognized supplementary training pathways for hospitalists who practice in the ICU.

• Identifying clinical, logistical, and political barriers that might impair or preclude such training.

At the close of the summit, the executive leadership of both societies agreed that they had sufficient consensus on the aforementioned issues to delegate a subgroup of participants to formulate a position paper. The authors of the position paper were selected based upon their diverse professional experience, senior leadership in both SHM and SCCM, and their cross‐disciplinary expertise in hospital medicine and critical care medicine. Four of the 5 authors (E.M.S., J.R.D., M.J.G., P.A.L.) are board‐certified intensivists. Three (E.M.S., J.R.D., M.J.G.) are members of both SCCM and SHM, 2 (M.J.G., J.R.D.) are Past‐Presidents of SHM, and 1 (P.A.L.) is Immediate Past‐President of SCCM. E.M.S. and D.D.D. are current members of the SHM Board of Directors.

After the summit, the authors held several conference calls to review the structure and content of the position paper. The boards of directors of both societies independently approved a draft of the paper and the executive leadership of both societies approved subsequent revisions. The position paper was submitted for joint publication in the Journal of Hospital Medicine and Critical Care Medicine and underwent formal peer‐review by reviewers representing both societies.

INTRODUCTION

The growing shortage of intensivists and its implications for hospitalized Americans is well documented and remains an ongoing concern for hospitals, clinicians, payers, and the federal government.17 Despite numerous recommendations that intensivists manage critically ill adults,8, 9 most American hospitals cannot and will not meet this proposed standard.10, 11 When surveyed, only 20% of Michigan hospitals participating in the Keystone Project responded that they staffed their ICUs exclusively with board‐certified intensivists, and 75% maintained open ICU staffing models.12 The mismatch between intensivist supply and demand is expected to worsen as inpatient volume and acuity grow in concert with an aging and increasingly comorbid American population, yet with the exception of a 2010 agreement between the American Board of Internal Medicine (ABIM) and American Board of Emergency Medicine (ABEM) to cosponsor a medical critical care fellowship pathway for emergency medicine (EM) physicians, little has changed to expand the intensivist trainee pipeline. Although the addition of a sanctioned EM critical care pathway is a positive development, it is unlikely to significantly impact the intensivist shortage in the near term. Between 2000 and 2007, 43 emergency medicine physicians entered non‐board sanctioned American critical care fellowships,13 while in the 20112012 academic year, 1957 trainees are enrolled in adult critical care medicine fellowships (surgery, anesthesia, medical critical care, and pulmonary/critical care).14 It remains to be seen if the availability of a formal critical care pathway will significantly increase the numbers of emergency medicine physicians who pursue critical care training.

The growing intensivist shortage has coincided with the appearance of hospitalists, physicians who focus on the care of hospitalized medical patients, on the healthcare landscape.15 Increasing from 2000 to 34,000 practitioners in 15 years, hospital medicine is the fastest growing specialty in organized medicine, with an estimated plateau of as many as 50,000 practitioners.16 As of 2009, hospitalists were present in 89% of hospitals with over 200 beds, largely replacing primary care physicians as the managers of ICU patients in non‐tertiary hospital settings.16 In surveys performed by the Society of Hospital Medicine, 75% of hospitalists reported that they practice in the ICU, often shouldering much of the responsibility for managing critically ill patients.17 In 37.5% of Michigan Keystone Project hospitals, hospitalists served as attending physicians of record in the ICU.10 Although legitimate concerns have been raised about whether hospitalists are uniformly qualified to practice in the ICU, this issue has become moot at many hospitals where intensivists are either in short supply or entirely absent.1821 As previously noted by Heisler,22 the issue is no longer whether hospitalists should practice in the ICU, but rather to ensure that they do so safely, effectively, and seamlessly in collaboration with intensivists, or independently when intensivists are unavailable.

POTENTIAL VALUE OF HOSPITALISTS IN THE ICU

Hospital medicine and critical care medicine share similar competencies and values. Eighty‐five percent of practicing hospitalists are internists, who have historically been well trained to manage acutely ill hospitalized patients. Categorical internal medicine (IM) training emphasizes acute inpatient medicine, with residents spending approximately two‐thirds of their training time in the hospital. Many of the cognitive skills required for practicing critical care medicine are encompassed in categorical IM training, as well as in the Core Competencies in Hospital Medicine.23, 24 Furthermore, hospitalist staffing models are specifically adapted to meet the needs of acutely ill patients. With their consistent presence in the hospital (many programs provide 24:7 in‐house coverage), hospitalists see patients several times a day if necessary and can respond to their acute needs in real time. In many institutions, hospitalists are tasked as first responders to in‐house emergencies, often covering ICUs when intensivists are unavailable.

Most importantly, hospital medicine and critical care medicine are philosophically aligned. Both disciplines are defined by their location of practice rather than by an organ system or constellation of diseases. Both specialties embrace hospital‐based process improvement, lead multidisciplinary teams, and champion quality and safety initiatives.23, 25 Hospitalists and intensivists routinely collaborate to improve hospital care through shared protocol implementation, patient throughput management, and quality improvement initiatives. The ideology and mechanics of high‐performing hospitalist and intensivist programs are extremely similar.

LIMITATIONS OF HOSPITALISTS IN ICUs

Although the majority of hospitalists are general internists, individual hospitalists' skills may be heterogeneous, reflecting differences in training and clinical practice experience prior to becoming hospitalists. A hospitalist entering practice directly from a rigorous categorical IM training program will likely have different skills and knowledge than an ambulatory‐based general internist who makes a mid‐career switch to hospital medicine. Furthermore, increasingly stringent restrictions on housestaff work hours and patient loads, coupled with increasing emphasis on ambulatory medicine, have substantially decreased IM residents' cumulative exposure to acutely ill inpatients and inpatient procedures, raising concerns that the current generation of IM residents are less well‐prepared to manage ICU patients than their predecessors. The growing prevalence of family practitioners in the adult hospitalist workforce (currently estimated at 6%8%), who generally are not as rigorously or comprehensively trained in critical care medicine as internists, further complicates efforts to broadly categorize adult hospitalists' ICU skills.26, 27

Once hospitalists enter the workforce, they have few formal opportunities to significantly advance their critical care knowledge and skills. Existing critical care educational offerings are generally limited to 1‐ or 2‐day critical care refresher courses or narrowly focused ICU skills courses, such as acute airway management or critical care ultrasonography. These courses, while valuable, are often insufficient for hospitalists who need to broaden their general critical care knowledge base or obtain skills that they did not acquire in residency training. The result is a hospitalist workforce that practices in the ICU but has limited opportunity to enhance the skills and knowledge necessary to do so safely and competently.

ENHANCING HOSPITALISTS' SKILLS TO PROVIDE CRITICAL CARE SERVICES

In the absence of a systemic solution to the intensivist shortage, the healthcare marketplace is independently developing alternative critical care delivery solutions, such as deploying telemedicine systems and expanding the roles of nurse practitioners and physician assistants in the ICU. To a lesser extent, there have been calls for hospitalists to fill similar intensivist extender roles in the ICU, and Heisler and others have suggested developing limited, competency‐based critical care training to allow hospitalists to manage a subset of ICU patients, either independently or collaboratively with intensivists.22 Several healthcare systems are in various stages of developing such critical care training programs for their hospitalists, many of whom already practice in the ICU. These programs will likely blend fellowship‐level training with supervised attending duties in the ICU, with the expectation that graduates will be able to independently manage a portion of an ICU population (Timothy G. Buchman, MD, PhD, Department of Surgery, Emory University School of Medicine, personal communication, May 11, 2011).

Although informal hospitalist training programs could make an important contribution to ICU staffing, they raise new concerns as well. In the absence of uniform, formal training and evaluation standards, the quality and consistency of these homegrown programs could vary widely, with participants developing critical care skills and competencies that might not conform to requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME). Even if training could be standardized, the practical implementation of a 2‐tier intensivist model would create extreme political and operational challenges for hospitals, which would be required to differentially credential and privilege providers with similar training and overlapping patient responsibilities. In light of these complexities and uncertainties, hospitalists might be unwilling to risk investing in lengthy training offering uncertain recognition and delineation of what they can and cannot do in the ICU.

A more durable long‐term solution is to create an ACGME‐sanctioned and accredited critical care certification pathway for IM hospitalists, with the express goal of expanding the intensivist workforce by attracting practicing hospitalists to critical care fellowship training. Hospitalists who complete such training would be full‐fledged intensivists, subject to the same privileges and expectations as any other intensivist.

We believe that many hospitalists could acquire the competencies necessary to become board‐eligible intensivists in less than the 2 years currently required for general internists to complete critical care medicine training. The existence of 6 unique pathways for critical care training and board certification in the United States, all maintaining unique training criteria and durations of training, strongly suggests that competent intensivists can be trained through disparate pathways to achieve equivalent outcomes (Table 1). For example, both surgical and anesthesia critical care programs require only a single added year of training following their respective residency training programs.28, 29 Of the 24 months that comprise a medical critical care fellowship, only 12 months of clinical duties are required, with the remainder allocated to electives, quality‐improvement initiatives, research, and other academic pursuits.30 The ACGME and ABIM have tacitly acknowledged that medical critical care training is achievable in less than 2 years, by allowing those who enter or complete accredited 2‐year fellowships in other medical specialties to obtain critical care certification with a single additional year of critical care training.30 If infectious disease and nephrology fellows can become competent intensivists with a single year of critical care training, it is reasonable to believe that experienced IM hospitalists can do so as well.

Offering a 1‐year critical care fellowship training track for experienced IM hospitalists will require careful consideration of which components of existing 2‐year critical care fellowship can be removed or condensed without materially compromising the quality of training. Hospitalists participating in a condensed 1‐year training program would need the maturity and experience to hit the ground running, mandating a robust entry bar predicated upon relevant prior clinical practice experience. We believe that 3 sequential years of prior hospitalist practice experience is a reasonable prerequisite for participation. Additionally, eligible hospitalists would need to participate in the (currently voluntary) ABIM Focused Practice in Hospital Medicine Maintenance of Certification (MOC) process,31 which mandates completion of hospital‐based education and practice improvement modules. Prior training and participation in quality improvement (QI) processes could supplant some of the scholarly activity that is currently expected during the nonclinical portion of a traditional 2‐year medical critical care fellowship, and candidates would be required to have completed at least one meaningful hospital‐based QI initiative while still in practice.

Although new curricular standards would need to be developed, 1‐year medical intensivist fellowships could coexist alongside 2‐year fellowships within a single critical care training program, as is the case when internal medicine fellows in other specialties complete an added year of critical care fellowship. However, to meaningfully impact the intensivist shortage, the number and capacity of medical critical care fellowships, which currently train approximately 10% of the critical care workforce, would need to significantly expand.13

Importantly, the impact that critical care‐trained hospitalists will have on the quality and safety of patient care in the ICU will require evaluation and study. We presume that inserting this new cohort of intensivists into previously unmanaged or undermanaged ICUs will improve care, but this, like many other uncertainties regarding optimal models of ICU staffing, should be subject to rigorous and objective examination through additional clinical research.10, 3236

Offering a 1‐year critical care training track will raise new challenges. Skepticism about the rigor and content of 1‐year programs may foster the perception that graduates are inadequately trained or skilled to function at the level of other board‐certified intensivists. It is also possible that a 1‐year hospitalistcritical care fellowship could divert trainees from traditional critical care programs, offsetting net gains in the number of intensivists. However, we suspect that a 1‐year fellowship program will attract primarily practicing hospitalists, while 2‐year tracks will continue to attract IM residents. We conceptualize participation in a 1‐year hospitalistcritical care fellowship program as a (minimum) 4‐year post‐residency commitment, consisting of at least 3 years of clinical practice as a hospitalist, followed by 1 year of critical care fellowship training. Internal medicine residents would find a shorter pathway to intensivist practice by enrolling in traditional 2‐year critical care or even 3‐year pulmonary/critical care training programs. The compensation advantage afforded to intensivists relative to hospitalists (approximately $100,000 per year) would offset any financial advantage gained by shaving a year off of critical care fellowship training.37, 38 We also suspect that those seeking careers in academic medicine would almost exclusively opt for a traditional 2‐year training pathway.

Finally, while Europe and Australia offer a single common pathway to critical care certification, the United States maintains multiple, independent, specialty‐specific training pathways, each with unique durations, requirements, and certification processes. Although consideration of this important issue is beyond the scope of this paper, we believe that developing a hospitalist‐intensivist workforce should be part of a broader initiative to reform critical care training to better meet the demand for intensivists across the spectrum of American ICUs. Adopting a global intensivist training strategy that is specialty‐independent and specific to critical care medicine may result in a more consistent, collaborative, and interoperable critical care workforce.

CONCLUSION

American critical care training programs have failed to produce enough intensivists to meet demand, and this mismatch between supply and demand will substantially worsen over upcoming decades. Hospitals and healthcare systems, faced with the mandate to provide care for their ICU populations, have already innovated to offset this shortage through the use of telemedicine and the extension of nonphysician providers into ICUs. As the gap between intensivist supply and demand widens, healthcare systems will be increasingly likely to pursue more radical solutions, up to and including independently training their own critical care workforces. We believe that there are better alternatives.

Hospitalists have rapidly proliferated to become the dominant provider of inpatient medical care in American hospitals and are already providing a substantial amount of critical care. As such, they remain a largely untapped and potentially significant source of new intensivists. The skills, competencies, and values embodied in hospital medicine are already highly congruent with those of critical care. By virtue of their numbers and penetrance into the vast majority of large American hospitals, hospitalists are well situated to make a substantial impact on the intensivist shortage. If only 5% of the projected hospitalist workforce were to receive the critical care training that we propose, 2500 new intensivists would enter the critical care workforce, substantially decreasing the impact of the national intensivist shortage.12

Internal medicine hospitalists who obtain additional training as intensivists would also bring new capabilities and flexibility to hospitals seeking to implement intensivist programs. In smaller hospitals that cannot support freestanding intensivist programs, hospitalist‐intensivists might divide their time between ICU and ward duties. In larger hospitals, these clinicians might function exclusively as intensivists alongside their traditionally trained peers. Whether they affiliate as hospitalists, intensivists, or something else entirely will largely depend upon the roles that they fulfill, the governance of their institutions, and the departments that most effectively meet their clinical and organizational needs.

Bringing qualified hospitalists into the critical care workforce through rigorous sanctioned and accredited 1‐year training programs, will open a new intensivist training pipeline and potentially offer more critically ill patients the benefit of providers who are unequivocally qualified to care for them. Similarly, unification of critical care training and certification across disciplines will better focus efforts to expand the intensivist workforce, more efficiently leverage limited training resources, and facilitate standardization of critical care skills, policies, and procedures across the nation's ICUs. Although moving this agenda forward may be logistically challenging and politically daunting, we believe that the results will be worth the effort.

DEVELOPMENT OF THE POSITION PAPER

In June of 2011, the executive leadership of the Society of Critical Care Medicine (SCCM) and the Society of Hospital Medicine (SHM) convened a daylong summit to discuss intensive care unit (ICU) workforce issues as they affect intensivists and hospitalists. Attendees included the executive leadership of both societies and invited participants with cross‐disciplinary expertise in hospital medicine and critical care medicine.0

The summit was convened to address the following issues:

• Defining hospitalists' roles in providing ICU coverage in the presence or absence of intensivists.

• Developing standardized and universally recognized supplementary training pathways for hospitalists who practice in the ICU.

• Identifying clinical, logistical, and political barriers that might impair or preclude such training.

At the close of the summit, the executive leadership of both societies agreed that they had sufficient consensus on the aforementioned issues to delegate a subgroup of participants to formulate a position paper. The authors of the position paper were selected based upon their diverse professional experience, senior leadership in both SHM and SCCM, and their cross‐disciplinary expertise in hospital medicine and critical care medicine. Four of the 5 authors (E.M.S., J.R.D., M.J.G., P.A.L.) are board‐certified intensivists. Three (E.M.S., J.R.D., M.J.G.) are members of both SCCM and SHM, 2 (M.J.G., J.R.D.) are Past‐Presidents of SHM, and 1 (P.A.L.) is Immediate Past‐President of SCCM. E.M.S. and D.D.D. are current members of the SHM Board of Directors.

After the summit, the authors held several conference calls to review the structure and content of the position paper. The boards of directors of both societies independently approved a draft of the paper and the executive leadership of both societies approved subsequent revisions. The position paper was submitted for joint publication in the Journal of Hospital Medicine and Critical Care Medicine and underwent formal peer‐review by reviewers representing both societies.

INTRODUCTION

The growing shortage of intensivists and its implications for hospitalized Americans is well documented and remains an ongoing concern for hospitals, clinicians, payers, and the federal government.17 Despite numerous recommendations that intensivists manage critically ill adults,8, 9 most American hospitals cannot and will not meet this proposed standard.10, 11 When surveyed, only 20% of Michigan hospitals participating in the Keystone Project responded that they staffed their ICUs exclusively with board‐certified intensivists, and 75% maintained open ICU staffing models.12 The mismatch between intensivist supply and demand is expected to worsen as inpatient volume and acuity grow in concert with an aging and increasingly comorbid American population, yet with the exception of a 2010 agreement between the American Board of Internal Medicine (ABIM) and American Board of Emergency Medicine (ABEM) to cosponsor a medical critical care fellowship pathway for emergency medicine (EM) physicians, little has changed to expand the intensivist trainee pipeline. Although the addition of a sanctioned EM critical care pathway is a positive development, it is unlikely to significantly impact the intensivist shortage in the near term. Between 2000 and 2007, 43 emergency medicine physicians entered non‐board sanctioned American critical care fellowships,13 while in the 20112012 academic year, 1957 trainees are enrolled in adult critical care medicine fellowships (surgery, anesthesia, medical critical care, and pulmonary/critical care).14 It remains to be seen if the availability of a formal critical care pathway will significantly increase the numbers of emergency medicine physicians who pursue critical care training.

The growing intensivist shortage has coincided with the appearance of hospitalists, physicians who focus on the care of hospitalized medical patients, on the healthcare landscape.15 Increasing from 2000 to 34,000 practitioners in 15 years, hospital medicine is the fastest growing specialty in organized medicine, with an estimated plateau of as many as 50,000 practitioners.16 As of 2009, hospitalists were present in 89% of hospitals with over 200 beds, largely replacing primary care physicians as the managers of ICU patients in non‐tertiary hospital settings.16 In surveys performed by the Society of Hospital Medicine, 75% of hospitalists reported that they practice in the ICU, often shouldering much of the responsibility for managing critically ill patients.17 In 37.5% of Michigan Keystone Project hospitals, hospitalists served as attending physicians of record in the ICU.10 Although legitimate concerns have been raised about whether hospitalists are uniformly qualified to practice in the ICU, this issue has become moot at many hospitals where intensivists are either in short supply or entirely absent.1821 As previously noted by Heisler,22 the issue is no longer whether hospitalists should practice in the ICU, but rather to ensure that they do so safely, effectively, and seamlessly in collaboration with intensivists, or independently when intensivists are unavailable.

POTENTIAL VALUE OF HOSPITALISTS IN THE ICU

Hospital medicine and critical care medicine share similar competencies and values. Eighty‐five percent of practicing hospitalists are internists, who have historically been well trained to manage acutely ill hospitalized patients. Categorical internal medicine (IM) training emphasizes acute inpatient medicine, with residents spending approximately two‐thirds of their training time in the hospital. Many of the cognitive skills required for practicing critical care medicine are encompassed in categorical IM training, as well as in the Core Competencies in Hospital Medicine.23, 24 Furthermore, hospitalist staffing models are specifically adapted to meet the needs of acutely ill patients. With their consistent presence in the hospital (many programs provide 24:7 in‐house coverage), hospitalists see patients several times a day if necessary and can respond to their acute needs in real time. In many institutions, hospitalists are tasked as first responders to in‐house emergencies, often covering ICUs when intensivists are unavailable.

Most importantly, hospital medicine and critical care medicine are philosophically aligned. Both disciplines are defined by their location of practice rather than by an organ system or constellation of diseases. Both specialties embrace hospital‐based process improvement, lead multidisciplinary teams, and champion quality and safety initiatives.23, 25 Hospitalists and intensivists routinely collaborate to improve hospital care through shared protocol implementation, patient throughput management, and quality improvement initiatives. The ideology and mechanics of high‐performing hospitalist and intensivist programs are extremely similar.

LIMITATIONS OF HOSPITALISTS IN ICUs

Although the majority of hospitalists are general internists, individual hospitalists' skills may be heterogeneous, reflecting differences in training and clinical practice experience prior to becoming hospitalists. A hospitalist entering practice directly from a rigorous categorical IM training program will likely have different skills and knowledge than an ambulatory‐based general internist who makes a mid‐career switch to hospital medicine. Furthermore, increasingly stringent restrictions on housestaff work hours and patient loads, coupled with increasing emphasis on ambulatory medicine, have substantially decreased IM residents' cumulative exposure to acutely ill inpatients and inpatient procedures, raising concerns that the current generation of IM residents are less well‐prepared to manage ICU patients than their predecessors. The growing prevalence of family practitioners in the adult hospitalist workforce (currently estimated at 6%8%), who generally are not as rigorously or comprehensively trained in critical care medicine as internists, further complicates efforts to broadly categorize adult hospitalists' ICU skills.26, 27

Once hospitalists enter the workforce, they have few formal opportunities to significantly advance their critical care knowledge and skills. Existing critical care educational offerings are generally limited to 1‐ or 2‐day critical care refresher courses or narrowly focused ICU skills courses, such as acute airway management or critical care ultrasonography. These courses, while valuable, are often insufficient for hospitalists who need to broaden their general critical care knowledge base or obtain skills that they did not acquire in residency training. The result is a hospitalist workforce that practices in the ICU but has limited opportunity to enhance the skills and knowledge necessary to do so safely and competently.

ENHANCING HOSPITALISTS' SKILLS TO PROVIDE CRITICAL CARE SERVICES

In the absence of a systemic solution to the intensivist shortage, the healthcare marketplace is independently developing alternative critical care delivery solutions, such as deploying telemedicine systems and expanding the roles of nurse practitioners and physician assistants in the ICU. To a lesser extent, there have been calls for hospitalists to fill similar intensivist extender roles in the ICU, and Heisler and others have suggested developing limited, competency‐based critical care training to allow hospitalists to manage a subset of ICU patients, either independently or collaboratively with intensivists.22 Several healthcare systems are in various stages of developing such critical care training programs for their hospitalists, many of whom already practice in the ICU. These programs will likely blend fellowship‐level training with supervised attending duties in the ICU, with the expectation that graduates will be able to independently manage a portion of an ICU population (Timothy G. Buchman, MD, PhD, Department of Surgery, Emory University School of Medicine, personal communication, May 11, 2011).

Although informal hospitalist training programs could make an important contribution to ICU staffing, they raise new concerns as well. In the absence of uniform, formal training and evaluation standards, the quality and consistency of these homegrown programs could vary widely, with participants developing critical care skills and competencies that might not conform to requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME). Even if training could be standardized, the practical implementation of a 2‐tier intensivist model would create extreme political and operational challenges for hospitals, which would be required to differentially credential and privilege providers with similar training and overlapping patient responsibilities. In light of these complexities and uncertainties, hospitalists might be unwilling to risk investing in lengthy training offering uncertain recognition and delineation of what they can and cannot do in the ICU.

A more durable long‐term solution is to create an ACGME‐sanctioned and accredited critical care certification pathway for IM hospitalists, with the express goal of expanding the intensivist workforce by attracting practicing hospitalists to critical care fellowship training. Hospitalists who complete such training would be full‐fledged intensivists, subject to the same privileges and expectations as any other intensivist.

We believe that many hospitalists could acquire the competencies necessary to become board‐eligible intensivists in less than the 2 years currently required for general internists to complete critical care medicine training. The existence of 6 unique pathways for critical care training and board certification in the United States, all maintaining unique training criteria and durations of training, strongly suggests that competent intensivists can be trained through disparate pathways to achieve equivalent outcomes (Table 1). For example, both surgical and anesthesia critical care programs require only a single added year of training following their respective residency training programs.28, 29 Of the 24 months that comprise a medical critical care fellowship, only 12 months of clinical duties are required, with the remainder allocated to electives, quality‐improvement initiatives, research, and other academic pursuits.30 The ACGME and ABIM have tacitly acknowledged that medical critical care training is achievable in less than 2 years, by allowing those who enter or complete accredited 2‐year fellowships in other medical specialties to obtain critical care certification with a single additional year of critical care training.30 If infectious disease and nephrology fellows can become competent intensivists with a single year of critical care training, it is reasonable to believe that experienced IM hospitalists can do so as well.

Offering a 1‐year critical care fellowship training track for experienced IM hospitalists will require careful consideration of which components of existing 2‐year critical care fellowship can be removed or condensed without materially compromising the quality of training. Hospitalists participating in a condensed 1‐year training program would need the maturity and experience to hit the ground running, mandating a robust entry bar predicated upon relevant prior clinical practice experience. We believe that 3 sequential years of prior hospitalist practice experience is a reasonable prerequisite for participation. Additionally, eligible hospitalists would need to participate in the (currently voluntary) ABIM Focused Practice in Hospital Medicine Maintenance of Certification (MOC) process,31 which mandates completion of hospital‐based education and practice improvement modules. Prior training and participation in quality improvement (QI) processes could supplant some of the scholarly activity that is currently expected during the nonclinical portion of a traditional 2‐year medical critical care fellowship, and candidates would be required to have completed at least one meaningful hospital‐based QI initiative while still in practice.

Although new curricular standards would need to be developed, 1‐year medical intensivist fellowships could coexist alongside 2‐year fellowships within a single critical care training program, as is the case when internal medicine fellows in other specialties complete an added year of critical care fellowship. However, to meaningfully impact the intensivist shortage, the number and capacity of medical critical care fellowships, which currently train approximately 10% of the critical care workforce, would need to significantly expand.13

Importantly, the impact that critical care‐trained hospitalists will have on the quality and safety of patient care in the ICU will require evaluation and study. We presume that inserting this new cohort of intensivists into previously unmanaged or undermanaged ICUs will improve care, but this, like many other uncertainties regarding optimal models of ICU staffing, should be subject to rigorous and objective examination through additional clinical research.10, 3236

Offering a 1‐year critical care training track will raise new challenges. Skepticism about the rigor and content of 1‐year programs may foster the perception that graduates are inadequately trained or skilled to function at the level of other board‐certified intensivists. It is also possible that a 1‐year hospitalistcritical care fellowship could divert trainees from traditional critical care programs, offsetting net gains in the number of intensivists. However, we suspect that a 1‐year fellowship program will attract primarily practicing hospitalists, while 2‐year tracks will continue to attract IM residents. We conceptualize participation in a 1‐year hospitalistcritical care fellowship program as a (minimum) 4‐year post‐residency commitment, consisting of at least 3 years of clinical practice as a hospitalist, followed by 1 year of critical care fellowship training. Internal medicine residents would find a shorter pathway to intensivist practice by enrolling in traditional 2‐year critical care or even 3‐year pulmonary/critical care training programs. The compensation advantage afforded to intensivists relative to hospitalists (approximately $100,000 per year) would offset any financial advantage gained by shaving a year off of critical care fellowship training.37, 38 We also suspect that those seeking careers in academic medicine would almost exclusively opt for a traditional 2‐year training pathway.

Finally, while Europe and Australia offer a single common pathway to critical care certification, the United States maintains multiple, independent, specialty‐specific training pathways, each with unique durations, requirements, and certification processes. Although consideration of this important issue is beyond the scope of this paper, we believe that developing a hospitalist‐intensivist workforce should be part of a broader initiative to reform critical care training to better meet the demand for intensivists across the spectrum of American ICUs. Adopting a global intensivist training strategy that is specialty‐independent and specific to critical care medicine may result in a more consistent, collaborative, and interoperable critical care workforce.

CONCLUSION

American critical care training programs have failed to produce enough intensivists to meet demand, and this mismatch between supply and demand will substantially worsen over upcoming decades. Hospitals and healthcare systems, faced with the mandate to provide care for their ICU populations, have already innovated to offset this shortage through the use of telemedicine and the extension of nonphysician providers into ICUs. As the gap between intensivist supply and demand widens, healthcare systems will be increasingly likely to pursue more radical solutions, up to and including independently training their own critical care workforces. We believe that there are better alternatives.

Hospitalists have rapidly proliferated to become the dominant provider of inpatient medical care in American hospitals and are already providing a substantial amount of critical care. As such, they remain a largely untapped and potentially significant source of new intensivists. The skills, competencies, and values embodied in hospital medicine are already highly congruent with those of critical care. By virtue of their numbers and penetrance into the vast majority of large American hospitals, hospitalists are well situated to make a substantial impact on the intensivist shortage. If only 5% of the projected hospitalist workforce were to receive the critical care training that we propose, 2500 new intensivists would enter the critical care workforce, substantially decreasing the impact of the national intensivist shortage.12

Internal medicine hospitalists who obtain additional training as intensivists would also bring new capabilities and flexibility to hospitals seeking to implement intensivist programs. In smaller hospitals that cannot support freestanding intensivist programs, hospitalist‐intensivists might divide their time between ICU and ward duties. In larger hospitals, these clinicians might function exclusively as intensivists alongside their traditionally trained peers. Whether they affiliate as hospitalists, intensivists, or something else entirely will largely depend upon the roles that they fulfill, the governance of their institutions, and the departments that most effectively meet their clinical and organizational needs.

Bringing qualified hospitalists into the critical care workforce through rigorous sanctioned and accredited 1‐year training programs, will open a new intensivist training pipeline and potentially offer more critically ill patients the benefit of providers who are unequivocally qualified to care for them. Similarly, unification of critical care training and certification across disciplines will better focus efforts to expand the intensivist workforce, more efficiently leverage limited training resources, and facilitate standardization of critical care skills, policies, and procedures across the nation's ICUs. Although moving this agenda forward may be logistically challenging and politically daunting, we believe that the results will be worth the effort.