This month SHM presents its 2006 national awards of excellence to five hospitalists whose work and research have contributed significantly to hospital medicine and to the betterment of patient care and hospital quality improvement across America. The award winners will be recognized at SHM’s 2006 annual meeting in Washington, D.C., on May 5 from 11:35 a.m. to 1:35 p.m. They include:
- Howard Epstein, MD—Award for Clinical Excellence
- Christopher P. Landrigan, MD, MPH—Excellence in Research Award
- Sylvia McKean, MD, FACP—Excellence in Teaching Award
- Erin Ragan Stucky, MD—Award for Outstanding Service in Hospital Medicine
- Thomas J. Yacovella, MD—Excellence in Teaching Award
“SHM is very pleased each year to recognize the hospitalist leaders among us who consistently go above and beyond to champion hospital medicine, to expand the role of hospitalists in areas of patient care and hospital leadership, and to enhance the quality of care, communication, and service we provide,” says Larry Wellikson, CEO of SHM. “These individuals are a true inspiration to us and we congratulate them all for their many accomplishments.”
Dr. Epstein is a recognized leader in the development of clinical excellence and standardization of care in hospital medicine in Minnesota and nationally, and has championed the role of the hospitalist as part of an interdisciplinary team. He currently works with HealthPartners Medical Group at Regions Hospital in St. Paul, Minn., where he is a hospitalist and medical director of the Care Management and Palliative Care Departments. He also is an assistant clinical professor of medicine at the University of Minnesota.
As one of HealthPartners’ first hospitalists, he introduced “Implementation of MCAP Guidelines,” which produced significant improvements in resource utilization. As Regions Hospital’s first medical director for Care Management, he has been instrumental in expanding the role of the Medical Management Steering Committee to routinely incorporate data collection, analysis, and implementation of quality improvement strategies across the care continuum, thus elevating the value of Care Management and enhancing patient care.
Best known for his clinical focus on palliative care, Dr. Esptein established Regions’ Palliative Care Team, the first inpatient program in St. Paul. There he developed a model for palliative care that has improved patient quality of life, eased family suffering, and lessened the use of unnecessary resources at the end of life.
A member of the Institute for Clinical Systems Improvement, a collaborative organization of 57 healthcare organizations and nearly 80% of the physicians in Minnesota, Dr. Epstein has provided leadership in the development of clinical practice guidelines, order sets, healthcare protocols and technology assessments, and the production of standardized, evidence-based hospital order sets used across the state.
A tireless proponent of Hospital Medicine, Dr. Epstein founded the Minnesota Hospitalist Association (now a chapter of SHM) and is a frequent speaker on hospitalists and inpatient palliative care. He currently serves on SHM’s Ethics Committee and Palliative Care Task Force, and will lecture on “The Basic Why and and How to Develop a Hospital-Based Palliative Care Program” on May 5 from 1:35 to 3:05 p.m. at the SHM 2006 Annual Meeting.
Dr. Epstein earned his undergraduate degree and medical degree from Washington University in St. Louis. He completed his residency in internal medicine at the University of Minnesota (Minneapolis) in 1994 and joined the teaching faculty at St. Paul-Ramsey Medical Center (now Regions Hospital) that same year.
Dr. Landrigan has rapidly established himself as one of the nation’s leading investigators in hospital medicine and patient safety, and is a pioneer in academic pediatric hospital medicine. In only a few short years, he has participated in landmark investigative projects, including the establishment of the Pediatric Research in the Inpatient Setting (PRIS) network and the creation of a second textbook for pediatric hospital medicine. The PRIS network is modeled after the American Academy of Pediatrics’ (AAP) successful Pediatric Research in the Outpatient Setting (PROS) network.
Dr. Landrigan was the first physician in the United States to complete a fellowship in pediatric hospital medicine, and he focused his research on the future of the field and on evaluating efficiency, quality of care, patient experience, and education in pediatric hospitalist systems. His first published papers helped to define the direction of pediatric hospital medicine.
Dr. Landrigan currently is a pediatric hospitalist at Children’s Hospital Boston, where he is also research director of the Children’s Hospital Inpatient Pediatric Service (CHIPS), and is a pediatric hospitalist fellowship director. At CHIPS, he co-authored one of the first papers to examine medication errors and adverse drug events in the pediatric population, which was published in JAMA (Kaushal R, Bates DW, Landrigan C, et al. Medication Errors and Adverse Drug Events in Pediatric Inpatients. JAMA. 2001 Apr(285):2114-2120).
Dr. Landrigan also is director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital, Boston, and is an assistant professor at Harvard Medical School (Boston). His interest in the role of sleep deprivation in patient safety spurred him to work with a team at Harvard on a project assessing the effects of physician/staff sleep deprivation on patient safety.
As project director of the Harvard Work Hours, Health, and Safety Study, he was lead investigator on an October 2005 New England Journal of Medicine study that demonstrated that interns working industry-sanctioned work schedules with recurrent 30-hour shifts made 36% more serious medical errors, and more than five times as many serious diagnostic errors than interns whose scheduled work was limited to 16 consecutive hours (Pennel NA, Liu JF, Mazzini MJ, et al. Interns’ work hours. N Engl J Med. 2005;352:726-728). This study led to other related studies evaluating the effect of industry-sanctioned work schedules, and sleep deprivation and patient safety, resulting in improvements to the standards.
Dr. Landrigan joined SHM in 1998 as a charter member and has served on the Pediatric Committee since 2002. From 2003-2004 he was also a member of the Research Abstract Committee.
Dr. Landrigan earned his undergraduate degree in 1991 and went on to earn his MD from Mount Sinai Medical School, New York City, and his MPH from Harvard School of Public Health, Boston. He completed his residency in pediatrics at Children’s Hospital Boston and his fellowship in general pediatrics there. He joined the Harvard faculty as instructor in 2000, and was promoted to assistant professor in 2004.
Dr. Stucky is recognized as an innovator in pediatrics and has been one of the nation’s most influential pediatric hospitalists. She has participated in landmark projects advancing pediatric medicine, including the establishment of the PRIS network and the development of the nation’s first pediatric hospital medicine core curriculum program to help define the skills and knowledge base needed for the practice of pediatric hospital medicine.
Dr. Stucky is a pediatric hospitalist at San Diego Children’s Hospital-University of California, where she is also director of the Hospital’s Graduate Medical Education. Dr. Stucky also directs the inpatient teaching service for four area-wide pediatric residency programs, oversees a core lecture series for trainees, and serves on multiple UCSD pediatric residency, intern, and education committees. In conjunction with UCSD, Dr. Stucky also participates in a national collaborative research project with the U.S. Department of Veterans Affairs. As site director for the project, she is finalizing data on medication errors and stress management in hospitalists and residents over a one-year period.
In the public policy arena, Dr. Stucky has distinguished herself as an author and a co-author of a number of policy statements. She was the lead author of the AAP’s policy statement “Prevention of Medication Errors in the Pediatric Inpatient Setting,” which outlines the importance of creating an environment of medication safety. On behalf of the AAP, Dr. Stucky challenged the Joint Council on the Accreditation of Healthcare Organizations (JCAHO) on one of its 2004 national patient safety goals requiring that hospitals caring for neonatal and pediatric patients rapidly eliminate the long-standing “rule of 6” method for administering drug dosages in favor of standardized drip concentrations.
Dr. Stucky led a diverse group that convinced JCAHO to develop an alternative proposal. As a result of her persistence, hospitals now have the appropriate time to comply with the new rules.
Because of Dr. Stucky’s clinical credibility and personal collaborative style, she has been successful in co-authoring and completing many controversial policies requiring negotiation and resolution of different interests. She is widely sought after as a reviewer of policies, offering opinions to the Centers for Disease Control and Prevention, Institute of Medicine, and others.
A long-standing member of SHM’s Pediatric Committee, Dr. Stucky has presented an “Update in Pediatric Hospital Medicine” at SHM’s annual meeting for the past three years, and was a plenary speaker at the 2005 tri-sponsored (AAP, the Ambulatory Pediatric Association, and SHM) pediatric hospital medicine conference in Denver—the largest-ever gathering of pediatric hospitalists.
Throughout her career, Dr. Stucky has been the recipient of numerous regional and national awards, including: Best Doctors in America Award (2005); San Diego Magazine’s Best Doctors (2003, 2002); American Academy of Family Physicians “Active Teacher in Family Medicine” Award from the Camp Pendleton Family Practice Program (2002); and the Physician Leadership Award Children’s Hospital (2000).
Dr. Stucky earned her bachelor of science degree in biology from Stanford University and received her MD from the University of California at San Francisco in 1988. She performed her residency at UCSD before becoming chief resident there from 1991-1992.
Dr. McKean is an associate physician in the Division of General Internal Medicine at Brigham and Women’s Hospital, Boston, and is medical director of the Brigham and Women’s and Faulkner Hospitals Hospitalist Service. She also is assistant professor of medicine at Harvard Medical School in Boston. In each of these roles she teaches and mentors hospital residents and medical students, fostering their careers in academia for both research and education.
Through the years, Dr. McKean has received more than a dozen awards for leadership, excellence, and teaching, including the prestigious George W. Thorn Award (1997-1998) from Brigham and Women’s Hospital for outstanding contributions to clinical education. In 2002 she was appointed “scholar” as a charter member of the Harvard Medical School Academy, in recognition of excellence and commitment to improvement and innovation in medical education. Most recently, she was nominated for Harvard Medical School’s 2005 Faculty Prize for Excellence in Teaching.
Dr. McKean’s future vision for hospital medicine education includes the training of hospitalists as leaders and change agents within the hospital system. She emphasizes evidence-based practice, use of multi-disciplinary teams, attention to care transitions, and the importance of doctor-patient communications.
Within SHM, she has fostered many teaching efforts that will advance the knowledge of future hospitalists. As a member of the SHM Core Competencies Task Force, she was a lead author on the nation’s first book outlining core competencies for hospitalists, The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, published in February 2006. This publication is the basis of SHM educational initiatives in the future and provides a roadmap for cultivation of the specialty of hospital medicine, including accreditation.
Dr. McKean also helped SHM develop a series of Web-based quality improvement (QI) resource rooms that feature educational toolkits designed to guide hospitalists step-by-step through the process of implementing a QI program at their institutions. As a clinical expert in venous thromboembolism, she became medical editor of the “Venous Thromboembolism Resource Room” on the SHM Web site and today facilitates the online “VTE Ask the Expert” resource. Dr. McKean also serves as medical editor for SHM’s Web-based, case study CME module titled, “Risk Stratifying for the Development of VTE in the Hospital Setting.”
Dr. McKean received her bachelor of arts from Yale University (New Haven, Conn.), completed post baccalaureate science courses at Stanford University, and earned an MD from Dartmouth Medical School (Hanover, N.H.) in 1977. She completed her residency and chief residency training at The New York Hospital and Memorial Sloan Kettering (Cornell Medical Center) in New York City and completed a fellowship in nephrology at The Rogosin Kidney Center, The New York Hospital, New York City.
Dr. Yacovella is assistant professor of medicine at the University of Minnesota Hospitals and Clinic in Minneapolis; section head, Department of Internal Medicine, Regions Hospital in St. Paul; and a practicing hospitalist with HealthPartners Medical Group in St. Paul.
Dr. Yacovella has been recognized throughout his career for his expansive medical knowledge and ability to convey complex medical concepts to his students. He has received more than seven prior distinguished teaching awards from the University of Minnesota Hospital and Clinics in Minneapolis, where he is currently an assistant professor of medicine.
He discovered his love of teaching early in his career as chief resident at St. Paul Ramsey Medical Center (now Regions Hospital) from 1996-1997. He was one of the first hospitalists hired there for what is now a well established, hospitalist program. Many credit the success of the program to Dr. Yacovella.
Dr. Yacovella received his BA in Psychology from the State University of New York at Buffalo in 1989, where he also obtained his MD in 1993. He began his residency program at the University of Minnesota Hospitals and Clinics and was made chief resident at St. Paul Ramsey Medical Center in 1996.
A Preview of the Pediatric Core Curriculum
By Jack Percelay, MD, and David Zipes, MD
Pediatric activity and visibility within SHM has increased over the past several months with increased membership, a focus on the Pediatric Core Competencies, and plans for SHM to sponsor the Pediatric Hospital Medicine Meeting in the summer of 2008.
Approximately 20% of SHM’s new members are pediatricians. Historically, pediatricians number roughly 10% of SHM membership and 10% of hospitalists overall. This increase in pediatric membership is most likely due to a combination of highlighting the value of SHM membership by word of mouth, word of the Listserv, and word of Larry Wellikson as the keynote speaker at the 2005 Pediatric Hospital Medicine Meeting in Denver.
Pediatricians also took advantage of the 2005 productivity survey to generate current benchmarks for pediatric hospitalists. Roughly 15% of returned surveys came from pediatric hospital medicine groups. Initial results will be revealed at this month’s SHM Annual Meeting, and will be available as a benefit to current SHM members through the SHM Web site.
Pediatrics hospitalists were nominated in all four categories of the SHM 2006 Hospital Medicine Awards in 2006. The nominees illustrated the depth and breadth of pediatric hospital medicine programs. Pediatricians Christopher Landrigan, MD, MPH, and Erin Stucky, MD, have been honored as award winners. (See “2006 National Awards of Excellence,” p. 6.)
Pediatric topics continue to appear regularly in The Hospitalist, but as yet there has been no original research published in The Journal of Hospital Medicine. Your contributions are encouraged. Information about submitting topics for either SHM publication is available on the Web site and in the publications themselves.
The current focus of pediatrics within SHM is development of the Pediatric Core Competencies under the leadership of pediatricians Tim Cornell, MD, and Dan Rauch, MD, and SHM Board Member Alpesh Amin, MD, who helped lead the development of the adult core competencies. The core competencies currently include the following proposed clinical, procedural, and systems topics:
- Acute abdomen;
- Apparent life-threatening event;
- Bone and joint infection
- Failure to thrive;
- Febrile infant;
- Kawasaki syndrome;
- Lower respiratory infection;
- Toxic ingestion;
- Meningitis and encephalitis;
- Non-accidental trauma and neglect;
- Pain management;
- Sickle cell disease complications;
- Soft tissue infection;
- Special technology needs patients;
- Upper respiratory infection; and
- Urinary tract infections.
The style and content of the Pediatric Core Competencies will undergo internal revision and editing before being distributed to external reviewers. Target completion date is the first half of 2007. At this point, we plan to identify appropriate individuals and organizations for the external review process. It would be particularly helpful to identify individuals in lead positions of important organizations (e.g., American Board of Pediatrics), program and clerkship directors, sub-specialty organizations, and so on who have some familiarity with pediatric hospital medicine programs and would be willing to offer a thoughtful critique. The importance of this project cannot be overemphasized. It is the prerequisite for any meaningful discussions for pediatric hospital medicine as a sub-specialty.
SHM Hospital Quality and Patient Safety Committee Update
By Lakshmi Halasyamani, MD
The Health Quality and Patient Safety Committee (HQPSC) is working to represent members at quality improvement forums and create innovate tools and resources to support members in their local QI efforts.
Member Education and Resources
At this year’s SHM Annual Meeting, HQPSC will deliver the pre-course, “High Impact Quality Improvement: How to Ensure a Successful Project,” on May 3 from 8 a.m.-5:30 p.m. The morning session of the pre-course provides in-depth instruction on quality improvement principles and theory. The entire afternoon is devoted to hands-on application of these principles to design and plan local QI programs in one of three areas selected by each participant: glycemic control, VTE prevention, or improving ACE inhibitor/angiotensin receptor blocker (ACEI/ARB) use for heart failure.
The Heart Failure Resource Room recently launched in time for Heart Failure Awareness Week. Visit this Web resource to download a workbook that will guide and support your heart failure-directed QI effort. Learn from an improvement report submitted by Saint Joseph Mercy Hospital in Ann Arbor, Mich., or read or post questions to a panel of heart failure improvement experts.
HQPSC at Large
SHM selected Andrew Auerbach, MD, and Greg Maynard, MD, to attend the Assessing the Care of Vulnerable Elders meeting in March. The panel will discuss quality indicators for hospital care, peri-operative care, diabetes, COPD, osteoarthritis, osteoporosis, pressure ulcers, and benign prostatic hyperplasia as they relate to elder care.
The Pay for Performance (P4P) Task Force was recently created to respond to regulatory and legislative initiatives related to P4P. The task force is charged with:
- Educating SHM members on federal P4P initiatives and how they affect hospital medicine, and
- Responding to and formulating SHM position statements and input on P4P programs and legislation.
In the future the HQPSC will review quality indicators proposed by major quality organizations in terms of how relevant they are to hospitalists and hospital medicine. We are working with the SHM Public Policy Committee to ensure that SHM has a representative in the national P4P and quality indicator selection discussion.
JHM Up Close
Barriers and opportunities in caring for the elderly
By Norra MacReady
In 2002 people age 65 years and older accounted for 12% of the population and a whopping 50% of all hospitalizations unrelated to childbirth. The ranks of senior citizens are increasing by 1 million per year in the U.S. and are expected swell to 21% of the population by 2030.
Surprisingly, hospitalists know little about how best to care for the elderly, writes C. Seth Landefeld, MD, in the January/February issue of the Journal of Hospital Medicine. “Hospitalists are good at taking care of acute illnesses like GI bleeding or cardiovascular problems, but they often don’t receive extensive training in problems that occur with aging, like delirium, cognitive impairment, or limitations in mobility,” Dr. Landefeld tells The Hospitalist.
For his article, Dr. Landefeld reviewed the medical literature published since 1980 that covers the course of these patients during and after hospitalization, and he identified gaps in knowledge and treatment strategies.
Clinical trials often include few if any seniors, yet conventional treatments for such common conditions as acute myocardial infarction and delirium may become less effective with age, suggesting that many drugs should be tested in this population.
What’s more, a hospitalized older person is likely to have several comorbidities, as well as cognitive impairment or dementia. As many as one-third of elderly patients have not recovered their baseline function by the time of hospital discharge and can no longer live at home.
—C. Seth Landefeld, MD
There are effective, evidence-based ways to prevent functional disability and delirium—two syndromes common in hospitalized elderly people, writes Dr. Landefeld, who is professor of medicine and chief of the Division of Geriatrics at the University of California, San Francisco. Comprehensive assessment, targeted treatment, and environmental modifications that promote independence and safety can reduce the incidence of both.
All of this could be accomplished with no increase in hospital costs, but several barriers stand in the way, including lack of knowledge about the needs of elderly patients and systems of care that emphasize mechanisms and efficiency over disease management and structured clinical care. Hospitalists trained to maximize outcomes and send patients home as soon as possible may be unaware of the complexity of the issues involved in caring for the very old.
“The overall treatment goal is to get the patient back to their original functional level, or at least as well as possible,” says Dr. Landefeld. “When you look at things through that lens, the goal becomes less focused on finding the best antibiotic or anti-thrombolytic, and more on the broader picture of getting the person home.”
Hospitalists and geriatricians should join forces, he adds. At the University of California, San Francisco, they worked together to create the Acute Care for Elders (ACE) units, wards designed for patients who are at least 75. Importantly, nurses play a prominent role in addressing these patient challenges because they are often familiar with the problems these patients have performing simple tasks, such as walking and eating.
UCSF also has established post-discharge clinics—another joint hospitalist-geriatrician venture—where elderly patients can be followed after they leave the hospital. And geriatricians can help hospitalists ensure there are programs in place to let patients make the transition from hospital to home or assisted living as smoothly as possible. TH