Category: Inpatient Practice

Supplemental oxygen is one of the most commonly prescribed treatments in the hospital. Patients with acute or chronic lung disease depend on supplemental oxygen to stay alive. As a natural and necessary substance, oxygen would seem like a safe thing to prescribe for patients that need it. But sometimes too much of a necessary thing can be harmful. So, when is too much oxygen bad for patients? We can take a lesson from vitamins.

The supplemental vitamin industry is based on the tenet that if our bodies need a small amount of a vitamin to live, then it must follow that by supplementing larger and larger amounts of that vitamin, our bodies will function better and better. Americans love this concept and we spend $30 billion every year on supplements. But frequently, too much of a good thing turns out to be a bad thing. Take Vitamin A – it is necessary for normal health and without vitamin A, we can lose night vision and become immunocompromised. A small amount of vitamin A in our diet keeps our bodies functioning normally. But if a person ingests too much vitamin A from supplements or from a dietary source that is high in it (such as polar bear liver), death can result from vitamin A toxicity. The same is true for water: drinking too little and a person dies of dehydration but drink too much and a person dies of hyponatremia. For decades, we thought oxygen was somehow different and that it was always better to err on the side of prescribing too much oxygen than risk prescribing too little. It turns out that we were wrong.

There are a lot of different oxygen delivery options: home concentrators, portable concentrators, compressed oxygen gas tanks, liquid oxygen, etc. In the hospital, oxygen is usually delivered through a medical gas panel that will have outlets for medical grade oxygen, regular air, and wall suction. The oxygen that comes out of these outlets is generally at a maximum pressure of 55 PSI. Conventional oxygen delivery devices (nasal cannulas and simple face masks) in the hospital usually are capped at a maximum flow rate of 15 liters per minute. Heated high flow nasal cannulas can deliver very high oxygen flow rates of up to 60 liters per minute. Mechanical ventilators can blend pure oxygen with room air to achieve anywhere from 21% to 100% inhaled oxygen concentrations (FiO2). As a result, physicians can adjust the amount of supplemental oxygen that a patient receives from a very small amount to a very large amount.

In the past, when EMS personnel would bring a patient with shortness of breath to the emergency department, they would put a mask on that patient and turn the oxygen up to a 15-liter flow rate to achieve close to 100% inhaled oxygen. In the hospitals, doctors would prescribe a high flow of oxygen and then not decrease that flow rate until a patient’s condition was improving and it was time to wean the oxygen down. In our emergency departments, ICUs, operating rooms, and hospital wards, we would give the patient as much oxygen as it took to raise their blood oxygen saturation to 100% and leave the oxygen at that flow rate for hours or days. But it turns out that we were probably harming patients by doing so.

In the past several years, there have been studies showing that prescribing excessively high oxygen flow rates can worsen patient outcomes in adults with lung disease. A study published in this week’s JAMA extended those findings to children. This study looked at 1,567 children, ages 1 – 4 years old, at 14 hospitals in Australia and New Zealand who had respiratory failure. The children were randomly assigned to receive either standard oxygen therapy or high-flow oxygen therapy. The high-flow group received as high as 40 liters per minute, depending on body weight. The standard-flow group received up to 2 liters per minute that was titrated to keep the blood oxygen saturation above 92%. The children receiving high-flow oxygen had a significantly longer length of hospital stay (1.77 vs. 1.50 days), longer duration of time on oxygen (1.07 vs 0.75 days), and higher rate of admission to the ICU (12.5% vs 6.9%).

Other studies have shown that excessive supplemental oxygen can be harmful in adults. A study of 429 patients given supplemental oxygen after resuscitation for cardiac arrest found that 40.7% of those receiving a conservative oxygen flow rate died but 50% of those receiving a liberal (i.e., higher) oxygen flow rate died. A meta-analysis study of 16,037 critically ill patients treated with conservative vs. liberal oxygen therapy found that those treated with liberal oxygen therapy (higher flow rates) had a higher mortality than those treated with conservative oxygen therapy (lower flow rates). A 2022 study of inpatients receiving supplemental oxygen during COPD exacerbations found that those who had arterial oxygen saturations of 88 – 92% had the lowest mortality rate and those patients given greater amounts of supplemental oxygen to maintain arterial oxygen saturation > 92% had significantly higher mortality rates.

For patients having out-of-hospital cardiac arrest, the conservative oxygen approach may be risky, however, A 2022 study from Australia found that cardiac arrest patients treated by EMS personnel with a conservative oxygen strategy (targeting a blood oxygen saturation of 90 – 94%) had a higher mortality rate than those patients treated with a liberal oxygen strategy (targeting a blood oxygen saturation of 98 – 100%). Because there was a tendency to frequently undershoot the oxygen saturation in conservative oxygen therapy group, it is possible that even brief periods of low oxygen saturations can be harmful in patients immediately after a cardiac arrest which may have resulted in the higher mortality rate.

Adverse effects of too much oxygen

So, if oxygen is so necessary for us, how can it harm us? There are several effects of excessive oxygen that can result in harm:

• Oxygen toxicity. High oxygen concentrations can damage lung cells by oxidant injury resulting from the production of substances such as superoxide anion, hydroxyl radical, and hydrogen peroxide. We sometimes see this in the intensive care unit in respiratory failure patients who require 100% oxygen concentrations for long periods of time who get into a vicious cycle of pneumonia requiring supplemental oxygen and then the high oxygen concentrations cause further lung damage resulting in the patients needing even higher oxygen concentrations in order to get enough oxygen into the blood stream to keep the body’s organs alive. These patients can end up with permanent lung scarring and never get off of the mechanical ventilator. Lung damage depends on how long a person is exposed to high concentrations of oxygen – brief periods are less harmful than breathing very high concentrations of oxygen for longer periods of time. This mainly applies to those patients in the ICU left on 60% – 100% inhaled oxygen for several days.
• Drug-induced lung disease. Many drugs can cause damage to the lung resulting in inflammation and scar in the lungs (interstitial lung disease). Certain drugs are particularly likely to do this when combined with high concentrations of inhaled oxygen. The two biggest offenders are bleomycin (used in cancer chemotherapy) and amiodarone (used in heart rhythm disorders). When a patient is breathing room air, these drugs are usually safe but when breathing high concentrations of oxygen, these drugs can become very toxic. Bleomycin is particularly notable because the risk of pulmonary toxicity from breathing high oxygen concentrations can persist for many years after the patient was given bleomycin.
• Radiation-induced lung disease. Excessively high amounts of radiation to the chest can cause interstitial lung disease but moderate amounts can be used safely to treat lung cancer. However, when a patient is using high oxygen concentrations, those moderate amounts of radiation can cause interstitial lung disease. Thus, like amiodarone and bleomycin, oxygen therapy can increase the risk of radiation-induced pulmonary fibrosis.
• Adsorptive atelectasis. Room air contains about 21% oxygen and 78% nitrogen. Oxygen readily passes from the alveoli of the lungs (air sacks) into the blood stream but nitrogen does not cross as easily. Because of this, nitrogen in the air helps keep the alveoli of the lungs propped open, similar to using PEEP (positive end-expiratory pressure) on a mechanical ventilator, thus preventing atelectasis. When a person breathes very high concentrations of oxygen, the nitrogen in the alveoli gets “washed out” and as a result, the lungs are more prone to developing atelectasis that can in turn worsen oxygenation. Once again, the patient can get into a vicious cycle of worsened blood oxygen levels leading to the doctor increasing the supplemental oxygen concentration leading to worsened atelectasis leading back to worsened blood oxygen levels.
• Carbon dioxide retention. Our breathing rate is determined by the blood oxygen level (PO2) and carbon dioxide level (PCO2). Patients with COPD are sometimes less sensitive to rising carbon dioxide levels and more dependent on the blood oxygen level to determine respiratory rates. In this setting, by giving too much supplemental oxygen, the patient can lose their respiratory drive and begin to hypoventilate, resulting in a high blood carbon dioxide level. Although this effect on PCO2 levels is usually small, it can be important when combined with other things that can suppress the respiratory drive centers, such as sedatives and opioids.
• Longer oxygen weaning times. When a patient with acute respiratory failure in the hospital begins to improve, the doctor will generally order the respiratory therapist to wean the oxygen off (or back down to the patient’s normal home supplemental oxygen flow rate). The respiratory therapist will then reduce the oxygen flow rate by 1-2 liters per minute, wait a couple of hours, recheck the blood oxygen saturation, reduce the flow rate by another 1-2 liters, etc. It takes less time to wean oxygen off if a patient is on less oxygen to begin with than if they are receiving higher flow rates of oxygen. The doctors generally wait until the oxygen is completely off (or down to the normal flow rate the patient uses at home) before the patient is allowed to be discharged. As a result, longer oxygen weaning times can sometimes lengthen the patient’s hospital stay.

So, what is the right amount of supplemental oxygen?

Our bodies require oxygen to live. If we don’t get enough oxygen, our tissues become damaged. On the other hand, too much oxygen is also bad for our bodies. Here is what we can do in our hospitals to draw the right balance between not enough and too much:

1. In emergencies, it is better to give too much than to give too little. In settings such as cardiac arrest, myocardial infarction, and stroke, brief periods of low blood oxygen levels can worsen clinical outcomes. If too much emphasis is placed on using the least amount of supplemental oxygen, there is a greater risk of undershooting the oxygen flow rate and causing low blood oxygen levels for seconds or minutes. Situations where this applies include during transport of cardiac arrest or stroke patients by emergency squads, during CPR for cardiopulmonary arrest, and during the first hours of a myocardial infarction or stroke.
2. Target a blood oxygen saturation of 88 – 92%. After the initial resuscitation, titrate the supplemental oxygen flow rate (or the FiO2 on the mechanical ventilator) to the least amount necessary to keep the oxygen saturation between 88 – 92%. For years, physicians have written orders to “Wean supplemental oxygen to maintain oxygen saturation > 92%”. This is probably too high and our default oxygen weaning orders in our electronic medical records need to be revised.
3. In the ICU, use other measures to improve oxygenation when patients need more than 60% FiO2. This could include increasing the PEEP on the ventilator, using prone ventilation, giving sedatives, controlling fever, or using neuromuscular blockade.
4. Avoid unnecessary use of 100% FiO2 during surgery. In the past, anesthesiologists would sometimes leave patients on 100% FiO2 throughout surgical operations so that there would be no risk of the patient desaturating during surgery. Not only can this increase the risk of post-operative absorptive atelectasis, but it can be particularly harmful if patients have previously received sensitizing drugs or radiation. One of my colleagues was a physician who had been treated with bleomycin years previously for lymphoma. He underwent an elective gall bladder surgery and was left on 100% FiO2 during the procedure. He developed acute lung injury post-operatively and died from bleomycin-induced acute oxygen toxicity.
5. We need pharmacologic 2,3-DPG. 2,3-Disphosphoglycerate (2,3-DPG) is a chemical in red blood cells that helps hemoglobin molecules release oxygen. Physiologically, this can result in a  shift in the oxy-hemoglobin dissociation curve to the right. This means that oxygen can pop off of hemoglobin easier, allowing the red blood cells to release more of their oxygen to tissues that need it. In other words, 2,3-DPG allows the tissues to get by when there is less oxygen in the blood. Normally, red blood cells release about 30% of their oxygen when they pass through tissues; 2,3-DPG allows them to release more than 30%. What is important to our bodies is not the amount of oxygen in the blood but rather the amount of oxygen that our tissues get. 2,3-DPG allows our tissues to function normally when the blood oxygen saturation is lower. If we could increase red blood cell 2,3-DPG levels pharmacologically, we could use lower amounts of supplemental oxygen in patients with acute respiratory failure.
6. Not everyone with a low oxygen saturation needs supplemental oxygen. Insurance will not pay for supplemental oxygen unless a patient has an oxygen saturation of < 89%, either at rest, during exercise, or during sleep. But that does not mean that every patient with brief oxygen saturations < 89% needs supplemental oxygen. The LOTT study showed that COPD patients with oxygen saturations 89 – 92% at rest that desaturated to 80 – 90% with exercise had no benefit from supplemental oxygen, including death rates, hospitalization rates, COPD exacerbations, and quality of life. In my own clinical practice, I have also been hesitant to prescribe oxygen in hyperemic patients who are at fire risk, including those who smoke, have smokers in the home, or use gas cooking stoves. These patients are often more likely to be injured or die from fire caused by supplemental oxygen than they are to die from hypoxemia without supplemental oxygen.

It’s time for auto-titrating oxygen delivery devices

Auto-titrating oxygen devices adjust the oxygen flow rate based on a patient’s oxygen saturation. A 2019 meta-analysis showed that compared to manual oxygen titration, these devices shortened hospital length of stay by shortening oxygen weaning times. A 2020 study of outpatients found that by using auto-titrating oxygen devices, patients had improved 6-minute walk distances and improved dyspnea. It is not surprising that these devices are effective in the hospital – a respiratory therapist cannot be in a patient’s hospital room 24 hours a day to constantly adjust the supplement oxygen flow rate but the auto-titrating oxygen delivery device can. Not only can these devices reduce excessive supplemental oxygen flow rates in hospitalized patients, but they can also reduce excessive oxygen flow rates in outpatients.

The cost to hospitals to buy and implement auto-titrating oxygen delivery devices would be considerable. However, these costs could potentially be off-set by shortened hospital length of stays and by reduction in utilization of respiratory therapists. These devices would also take some of the guesswork out of ordering oxygen flow rates for hospitalized patients resulting in a more standardized and consistent use of supplemental oxygen by hospitalists and intensivists. In addition, there is a potential for a reduction in hospital mortality rates by avoiding excessively high amounts of supplemental oxygen.

There is both an art of medicine and a science of medicine. It is time to harness science to guide the use of supplemental oxygen.

January 26, 2023

“Observation status” was originally conceived of as a way to watch patients presenting to the emergency department for a few hours in order to determine whether or not they needed to be admitted to the hospital. The purpose was to reduce unnecessary inpatient hospitalizations and thus reduce overall healthcare costs. But there has been a creep in the use of observation status as well as the healthcare bureaucracy to administrate it. The result is that observation status has now increased overall healthcare costs. It is time to consider eliminating observation status in the United States.

How did we get here?

Prior to 1960, emergency departments were staffed by residents and general practitioners. The doctor who saw you in the ER was generally the same doctor who took care of you in the hospital. Emergency medicine became a specialty in 1968 with the creation of the American College of Emergency Medicine. The first emergency medicine resident began training in 1970 and the first board examination in emergency medicine was offered in 1980. The result was that the doctor that took care of a patient in the ER was no longer the same doctor who took care of them once they were admitted to the hospital. In 1983, DRGs were first used to determine the amount of money that Medicare would pay hospitals for inpatient admissions for any given diagnosis. After the introduction of DRGs, it became immediately clear that there needed to be some way of determining which patients were sick enough to warrant admission to the hospital from the emergency room, otherwise, the hospitals would be incentivized to admit as many people as possible, even if they were not very sick.

Initially, that determination was left to the emergency room physician. But that ER doctor needed to find an inpatient physician who would agree to admit the patient. During my residency, we had a designated “medical admitting resident” each day who would make the decision about which patients were sick enough to require admission. Some residents got the reputation of being “sieves”, meaning that they would admit everyone that the ER physician called them about whereas other residents got the reputation of being “walls”, meaning that they would block admissions from the ER unless the patients were at death’s door. You always wanted to be on-call at night with a resident who was a “wall” because that meant you would have to do fewer history and physical exams, your inpatient service census would be lower, and you might actually get a few hours of sleep that night.

In order to provide some rules for which patients warranted inpatient admission, Medicare directed that patients who could be sent home within 24 hours should be observed in the ER rather than admitted to the hospital. However, keeping a lot of patients in ER beds for 24 hours was impractical so hospitals started putting those observation patients in regular hospital beds to avoid congestion in the emergency department. The unintended consequence was that this simply led to keeping patients in the hospital for longer than 24 hours, just so they could be classified as inpatients. This was especially a problem with outpatient procedures when many hospitals kept patients overnight for procedural recovery and then billed Medicare for both the outpatient procedure plus an inpatient hospital admission. Medicare countered in 2002 by agreeing to pay hospitals specifically for observation stays in order to provide an alternative to inpatient admission for those patients who were only mildly ill or who needed extra time to recover from an outpatient procedure. Initially, the only diagnoses that could be billed as observation stays were heart failure, chest pain, and asthma. In 2008, Medicare began paying for observation stays for all diagnoses.

In parallel with the development of reimbursement policies for observation stays, Medicare began policing hospital admissions by using the RAC (recovery audit contractors). RAC auditors would review the charts of patients who had been admitted to the hospital and if the auditor determined that there was not sufficient documentation in the chart to justify inpatient admission, Medicare would collect penalties from the hospital for overpayment. By 2014, the RAC program had collected $2.3 billion from hospital overpayments. One of the most common reasons by RAC auditors when denying an inpatient admission was that “…the patient could have safely and effectively been treated as an outpatient.” The auditors were often incentivized to deny admissions since more denials often led to bigger bonuses for the auditors. As a result, the denials were frequently capricious and arbitrary. 25 years ago, a coder for a commercial insurance company confided in me that her supervisors told her to randomly deny every 10th hospital admission because hospitals usually found that it was too expensive to contest denials. Fear of RAC audits resulted in physicians and hospitals increasing the use of observation status in order to avoid the risk of being penalized for an unnecessary inpatient admission.

A second strategy employed by Medicare was to create a list of surgical procedures that were classified as “Medicare Inpatient-Only Procedures”, meaning that those operations required an inpatient admission. Any surgical procedure not on the list was to be classified as an outpatient procedure unless there were extenuating circumstances that uniquely required a patient to be admitted to the hospital. Medicare pays much more if a surgery is performed as an inpatient (Medicare Part A) than if it is performed as an outpatient (Medicare Part B). Over time, the Medicare Inpatient-Only list shrank as more and more surgical procedures were reclassified as being appropriately done as outpatient and not requiring of hospital admission. Thus, knee and hip replacement surgeries were initially considered to require inpatient admission  but are now considered to be outpatient procedures.

Medicare also changed its definition of observation stays to be any condition that requires the patient to be in the hospital for “less than 2 midnights”. Although it could be argued that this gave hospitals longer than 24 hours to treat an observation status patient and send them home, the 2-midnight definition was somewhat arbitrary. For example, a patient presenting to the emergency department at 11:00 PM would spend 25 hours in the hospital before crossing 2 midnights but a patient presenting at 1:00 AM would spend 47 hours in the hospital before meeting the 2-midnight definition. However it is not how many midnights a patient actually spent in the hospital that Medicare auditors used when deciding whether to deny a hospital admission. Instead, it is whether the auditor believed that had the patient been managed appropriately, that patient could have been sent home before 2 midnights have elapsed. For example, if a patient came to the emergency department on Saturday evening with chest pain but the hospital could not do a cardiac stress test until Monday morning (2 midnights later), the auditor would still deny an inpatient admission since if the hospital offered 7-day a week stress tests, they could have sent the patient home on Sunday (after 1 midnight).

The observation vs. inpatient status bureaucracy

In order to avoid losing money from admission denials, hospitals started to go to great lengths to insure that the medical record contained sufficient documentation to justify every hospital admission. This was greatly facilitated by the development of electronic medical records that permitted realtime review of each patient’s hospital stay to ensure that the patient’s chart had appropriate documentation to meet Medicare’s requirements to bill that hospital stay as an inpatient admission. Some of the measures that hospitals now take in order to oversee their hospital admission practices include:

1. Physician training. When a patient is admitted to the hospital from the emergency room, the admitting physician has to enter an order directing that the patient is an “inpatient” or “observation” admission. This means that the physician has to estimate how long the patient will need to be in the hospital at the very beginning of the hospital stay and that estimated length of time dictates whether a patient will be inpatient or observation status. We now train residents in how to correctly estimate length of stay. For example, patients admitted for chest pain, syncope, and dehydration are generally observation status unless there are extenuating circumstances.
2. Nurse admission reviwers. Hospitals will generally hire a group of nurses or other healthcare workers to review every patient’s chart on a daily basis to determine if the medical record documentation justifies inpatient admission. These nurses get special training in the Medicare inpatient admission requirements. If the patient’s chart does not contain the proper documentation, the nurse’s first step is usually to contact the physician since frequently, all that is needed is an extra sentence or two in the medical record describing how sick the patient actually is. If that does not resolve the issue, the next step is to contact a physician admission advisor.
3. Physician admission advisors. Many times, the admitting physician is uncertain whether or not a patient’s illness justifies an inpatient admission order. Or the nurse reviewer’s determination is different from the physician’s admitting order for observation vs. inpatient status. For this reason, hospitals employ physicians whose main job is to arbitrate inpatient and observation orders. Often, this will be a private physician review company where the physician reviewers can access patient charts on a daily basis. Larger hospitals usually do this internally by hiring some of its own emergency medicine physicians or hospitalists to dedicate a certain number of hours per day reviewing admissions.
4. Hospital medical directors. When another layer of physician review of how to classify a patient’s admission is required, it then goes to the hospital medical director. Even for a small hospital, this is usually several charts to review every week. It takes about 15-20 minutes to do one of these reviews and then contact the admitting physicians to try to talk them into changing an admission order from inpatient to observation or vice-versa. Frequently, it requires the medical director to either enter an administrative note in the electronic medical record or to send the hospital utilization review office a letter so that the hospital has a documentation  paper trail in the event of a Medicare denial. More often, the medical director is sent charts for patients who had an inpatient admission order but were discharged before 2 midnights had elapsed. This is a red flag for Medicare auditors. We then have to provide written documentation for why the patient should be billed as an inpatient. Sometimes, this is easy, for example, when a patient dies from their condition in the hospital before 2 midnights elapse. But more frequently, it is because the admitting physician legitimately believed that the patient would need to be in the hospital for at least 2 midnights when that patient first arrived at the hospital. Several years ago, I attended a Medicare seminar and one of the medical administrators from Medicare told us that when this happens, we should use the phrase “The patient had an unexpectedly rapid recovery and was able to be discharged after less than 2 midnights”. Pretty much every time a patient in inpatient status was discharged before 2 midnights, one of our hospital medical directors would review that chart and send the billing office a letter using that phrase.
5. Pre-admission testing consultation. Patients who are planned to undergo a surgical procedure will frequently be sent for pre-operative medical consultation by an internist, family physician, or specially trained advance practice provider. Although designed to identify medical co-morbidities that could increase the risk of complications during surgery, these consultations are increasingly being used to determine whether or not a given patient’s surgery should be classified as an inpatient or an outpatient surgery. And most importantly, these consultations ensure that there is sufficient documentation in the electronic medical record to justify an inpatient procedure. For example, most knee replacement surgeries are now considered outpatient procedures. But if the chart documents that the patient has sleep apnea requiring CPAP, brittle diabetes, COPD requiring supplemental oxygen, and a history of vomiting after anesthesia, then that patient’s knee replacement can be done as an inpatient and the hospital gets paid considerably more. Surgeons are trained to be experts in surgery but are not trained in the nuances of co-morbid medical illnesses that they do not normally manage. Consequently, the surgeon’s outpatient notes often do not contain documentation of the significance of those medical co-morbidities and whether they are severe enough to warrant an inpatient admission for the surgery. That is why the pre-op medical consultation is so highly valued. If the surgeon admits the patient as an inpatient to do the surgery and then discharges that patient before 2 midnights pass, the chart once again gets sent to the medical director so that a letter containing the phrase “The patient had an unexpectedly rapid recovery and was able to be discharged after less than 2 midnights” is sent to the utilization review and billing offices for a documentation paper trail in the event of an admission denial by Medicare.
6. Utilization review staff. Every hospital employs a large number of personnel devoted solely to coding, billing, and utilization review. Before a bill goes out to Medicare or a commercial insurance company, these staff will do a final review to ensure that all of the proper documentation justifying an inpatient admission is present in the chart, including physician admission advisor notes and hospital medical director correspondence.There will also usually be personnel whose only job is to work denials when Medicare or an insurance company denies an inpatient admission. These personnel will then prepare and submit documentation contesting that denial in hopes of overturning the denial and getting paid for the hospital stay.
7. Attorneys and peer reviewers. When Medicare or an insurance company refuses to overturn an admission denial after the billing staff contest the denial, the next step is to turn to the legal system. This usually starts by paying an independent physician reviewer to opine whether the patient’s hospital stay should be classified as inpatient or observation. Next, hospital attorneys get involved by contacting Medicare attorneys about the denial. Sometimes, contested denials require adjudication, requiring more attorney time.
8. Medicare staff. On the other side of the bill, Medicare and commercial insurance companies employ large numbers of staff to review charts to decide whether they think that hospitalizations should be inpatient or outpatient.

So, for any given patient’s hospitalization, there is an army of Medicare nurse reviewers, physician reviewers, utilization review staff, and attorneys that face off against an army of the hospital’s  nurse reviewers, physician reviewers, utilization review staff, and attorneys. In the end, more money is sometimes spent battling an admission denial than is actually paid to the hospital for the admission. Hospitals are willing to occasionally spend the excessive cost to contest a denial since it sends Medicare or the insurance company a signal that the hospital will not go down easily for future admission denials. It is kind of like a basketball coach throwing a tantrum about a penalty call in order to try to dissuade the referee from calling future penalties.

The net result of all of this is that the United States has created an enormous bureaucracy devoted to preventing and contesting hospital admission denials.  So, why don’t hospitals just classify more patients as being in observation status and avoid all of the expense of justifying inpatient status? The reason is money.

The finances of inpatient vs. observation status

The genesis of observation status was to reduce Medicare costs by eliminating unnecessary hospital admissions. For any given diagnosis, hospitals get paid much less if a patient is designated to be in observation status than if that same patient is designated to be in inpatient status. Overall, the reimbursement is about 1/3 less for observation stays. In other words, Medicare can reduce overall Medicare costs by pressuring hospitals to put more patients in observation status. The same holds for commercial insurance companies.

Until several years ago, Medicare also paid doctors less if patients were in observation status. However, it became clear to Medicare that this was incentivizing doctors to preferentially use inpatient status rather than observation status. And since doctors are the ones who write the admission orders, Medicare realized that it could reduce inpatient admissions by removing the physician financial incentive to put patients in inpatient status. Because the physician professional fees are much, much less than the hospital fees, by paying physicians the same whether a patient was in observation or inpatient status, Medicare would pay a little more to the doctors but would pay a whole lot less to the hospitals.

But the biggest savings to Medicare in observation status is that it transfers much of the cost of the hospital stay from Medicare to individual patients. This is because Medicare considers observation stays as outpatient visits. Outpatient services are billed to Medicare Part B but inpatient services are billed to Medicare Part A. This is hugely important to patients because patients have much higher co-pays and deductibles for their Part B charges than their Part A charges.

• Medicare Part A covers inpatient admissions including a semi-private room, nursing care, medications, meals, and tests done during inpatient admissions. Part A also covers skilled nursing facility care, home health care, and hospice care. Medicare Part A is free to Americans over age 65 who have previously worked at least 10 years (or have a spouse who worked 10 years). There are no monthly premiums and no annual deductible. The amount that Medicare covers depends on the length of stay of the hospital admission:
  • $1,600 deductible per admission
  • Days 1-60: Part A covers in full
  • Days 61-90: patients are responsible for $400 per day co-pay, either by co-insurance or out of pocket if the patient lacks co-insurance
  • Days 91-lifetime reserve limit days: patients are responsible for $800 per day co-pay, either by co-insurance or out of pocket if the patient lacks co-insurance
  • After lifetime reserve limit days (total of 60 over the entire lifetime): Part A pays nothing and patients (or their co-insurance) are responsible for the entire costs
• Medicare Part B covers hospital outpatient charges and physician professional charges. Unlike Part A, there is a monthly premium for Part B of $165/month with higher premiums for those with higher incomes. There is an annual deductible amount of $226. Patients also have additional deductibles and co-pays that are either paid by secondary insurance or out of pocket if there is either no secondary insurance or the insurance policy has limited benefits:
  • 20% co-pay for all physician charges
  • 20% co-pay for hospital outpatient charges (hospital room, nursing care, meals)
  • 20% co-pay for x-rays and procedures
  • Part B does not cover medications so the patient (or their Part D insurance) is responsible for medication charges during observation stays

The net result of these differences is that the patient will have greater out of pocket expenses for an observation stay than for an inpatient admission. This is especially true for the 7.5% of Americans over age 65 who are enrolled in Medicare Part A only and do not enroll in Medicare Part B – these patients pay the entire cost of their observation stay out of pocket.

Another financial implication of observation vs. inpatient stays is in skilled nursing facility (SNF) coverage. Medicare Part A pays for 100% of SNF charges for up to 20 days (there is a $200/day co-pay for days 21-100). However, Medicare will only pay for SNF care if a person first has an inpatient hospital stay of at least 3 days. Medicare will not pay for SNF care after an observation stay. If a patient is in observation status (or has an inpatient stay of < 3 days) and gets transferred to a SNF, the patient is responsible for all of the SNF charges.

Why observation status is really, really dumb

CMS absolutely loves observation status. It reduces Medicare costs by paying the hospitals less for any given diagnosis and it also reduces Medicare costs by transferring much of the costs directly to the patient. This allows CMS officials to report to Congress that they are reducing federal spending on healthcare. Congressional representatives can then report to voters that they are reducing government spending. But there is no such thing as free healthcare… the cost of healthcare does not go away, it just gets transferred to the patient. The individual American ends up with more out of pocket costs for co-pays, medication charges, and SNF costs that would have otherwise been covered by Medicare Part A had their hospital stay been inpatient status as opposed to observation status. So, in the long run, the average American does not save any money by being in observation status.

Nationwide, 16% of all hospital stays are observation stays and 84% are inpatient stays. But this percentage can vary widely from hospital to hospital. A tertiary care referral hospital will usually have a lower percentage of observation stays since its patients tend to be sicker with more complex medical problems. On the other hand, a community hospital, especially one that cares for underserved patients, will have a higher percentage of observation stays, typically 25% or more. About the best a hospital can hope for is to break even on observation patients – most hospitals actually lose money on observation stays.

It’s bad enough that observation status does not really save money by transferring the cost of care to the individual patient rather than Medicare. The worst part about observation status is that it actually increases U.S. healthcare expenses. Not only do hospitals have to spend an enormous amount of money justifying inpatient admissions and working inpatient denials, but Medicare spends an enormous amount of money paying staff who police admissions in order to deny inpatient admission charges.

The net result is that observation status represents the epitome of U.S. healthcare dysfunction. It has led to an enormous bureaucracy devoted entirely to deciding whether Medicare or individual patients should pay for hospital care. And that bureaucracy is enormously expensive.

How can we fix this?

Americans pay way more for healthcare than people in any other country. In 2021, the average per capita healthcare cost in the U.S. was $12,914. It will undoubtedly be much higher in 2023. One of the contributors to this is too much of the healthcare costs go into trying to decide whether Medicare or the individual American will be responsible for paying for healthcare. Getting rid of the observation status designation can reduce U.S. per capita healthcare costs. Here is how to do it:

1. Create low-acuity DRGs. For conditions that are currently commonly managed by observation status (chest pain, syncope, dehydration, etc.), CMS can create inpatient DRGs that pay the hospital less, thus simulating the amount that CMS would have paid for an observation stay.
2. Require a modest Part A co-pay for hospitalization. The biggest argument against eliminating observation status is that Medicare costs would go up since co-pay costs currently paid by patients would go back to Medicare. The solution to this would be to require a small co-pay for hospitalization days 1-60. The amount to keep Medicare’s annual budget neutral could be as little as $10 or $20 per day.
3. Outpatient should mean outpatient. How in the world we ever got to the point that we define outpatient care as needing to be in the hospital for more than 2 midnights is baffling. Either a patient needs to be in the hospital or they don’t. I once had a admission denial for a patient in respiratory failure admitted from the ER to our ICU on a mechanical ventilator. The Medicare reviewer said that in his opinion, I should have been able to correct the respiratory failure, extubate the patient, and discharge her before 2 midnights passed. Really?
4. Eliminate the SNF 3-day rule. The whole idea behind the 3-day rule was that Medicare wanted to see if a patient really needed SNF care before it would pay for it. But the unintended consequence is that if one of our patients needs to go to a SNF, we have to figure out a way to admit them to the hospital for at least 3 days first. This means that we have to wait until they fall at home and break their hip or wait until they get septic from an infected decubitus ulcer if they are unable to get out of bed. For patients undergoing surgery, such as a knee replacement, we have to keep them in the hospital for 3 days after their surgery before they can go to a SNF for rehabilitation, even if they live alone and cannot walk after their operation.
5. Eliminate the observation industry. By eliminating observation status, hospitals would no longer have to spend money on nurse admission reviewers, physician admission advisors, and medical directors who laboriously review charts for inpatient justification. Hospitals could reduce their utilization management staff and Medicare could reduce its admission reviewer staff. Hospitals, patients, and Medicare would have less need for attorneys to contest admission denials. Yes, a lot of people would lose their jobs but the overall U.S. healthcare costs would drop.

Elimination of the observation status designation would make everyone happy. Patients would not be surprised by unexpectedly high hospital bills. Doctors would not have to spend time entering unnecessary documentation in their hospital notes to justify why a patient warrants an inpatient admission. Hospitals would not have to pay as much for staff to oversee admission determination. A fundamental concept of industrial engineering is that the more complex a process is, the more energy it takes to keep that process working. Observation status has created a terribly complex process. It is time to simplify the U.S. admission process.

January 22, 2023

Every year, the Centers for Medicare & Medicaid Services (CMS) penalizes hospitals with excessively high readmission rates. The monetary penalty for every U.S. hospital in 2023 was recently released by CMS. In theory, a higher penalty should indicate lower quality and vice-versa. However, the methodology used in calculating the penalties is complex and nuanced with the result that the readmission penalty may not be entirely reflective of a hospital’s overall quality of care.

Background

One of the provisions of the Affordable Care Act of 2010 (aka “Obamacare”) was to direct CMS to penalize hospitals with high rates of patients requiring readmission to a hospital within 30 days of an inpatient hospital stay. The first penalties were assessed in 2013; this is the 11th year of the penalty program. The calculations are only made for a few specific diagnoses and are based on data during 3 previous years. CMS calculates the amount of every hospital’s penalty in October or November each year and then that penalty is applied to the following year’s Medicare payments. The maximum penalty is 3%, meaning that for a hospital receiving the maximum penalty, CMS will reduce the amount that it pays that hospital for all of the Medicare services the hospital charges by 3% the next calendar year. Because many hospitals operate on razor-thin margins, even a relatively small reduction in what it gets paid by Medicare can be financially devastating. This is especially true for hospitals that operate on a July to June fiscal year, such as most academic medical centers, that can find themselves with an reduction in Medicare payments in the middle of the fiscal year. This can make it very difficult for these hospitals to accurately forecast their annual budgets since they do not know what they will get paid from Medicare services during the second half of their fiscal year.

You can look up every U.S. hospital’s readmission penalty for 2023 here. CMS uses a 4-step process to determine the amount of each hospital’s penalty.

The actual equation that CMS uses to calculate each hospital’s penalty is complex with the result that even most hospital administrators do not fully understand it:

Lurking behind the equation are a lot of subtleties that affect how the public should interpret the readmission penalty.

COVID affected the calculations

Normally, CMS looks at historical readmission data from between 2 and 5 years in the past. Thus, normally, CMS would base the 2023 readmission penalty on data from July 2018 to June 2021. This has always been a source of criticism since the penalty is based on what a hospital did 5 years ago rather than what it has done more recently in the past 2 years. Consequently, a hospital with poor readmission performance 5 years ago could have a large readmission penalty even if its readmission performance was stellar during the past 2 years.

The first 6 months of the COVID pandemic was a trying time for most hospitals. Many exceeded their maximum inpatient capacity. To care for inpatients, many had to recruit doctors and nurses who did not normally provide inpatient care. Because of this, CMS excluded all data from January 2020 to July 2020. As a result, rather than being based on 3 years of historical readmission data, this year’s penalty is based on 2.5 year of data.

A second effect of COVID was on the diagnoses used for penalty determination. Normally, CMS looks at readmission rates only for patients with one of six diagnoses: acute myocardial infarction, heart failure, pneumonia, COPD, coronary artery bypass surgery, and hip & knee replacement surgery. COVID disproportionately affected patients coded with pneumonia. As a result, CMS dropped pneumonia as one of the diagnoses used for readmission calculations. Therefore, the penalties were based on 5 diagnoses this year rather than 6.

A third effect of COVID on the readmission penalty calculation was that any patient with COVID as a primary or secondary admission diagnosis was eliminated from the hospital’s readmission calculation. Thus, a patient admitted with an acute myocardial infarction who was found to also have COVID on admission was excluded from the hospital’s data.

A fourth effect of COVID was on comorbidity determination. CMS adjusts every individual patient for that particular patient’s medical co-morbidities. So, for example, a patient with an admission for COPD who requires mechanical ventilation is expected to have a higher readmission rate than a COPD patient who does not require mechanical ventilation. Similarly, a patient undergoing knee replacement who is over age 65 and has diabetes is expected to have a higher readmission rate than a knee replacement patient who is younger than age 65 and not diabetic. This year, CMS added history of COVID within the past year as one of the co-morbidities used in the readmission calculation for all five of the readmission diagnoses. Thus, a patient admitted with COPD who had a COVID infection 8 months previously would be expected to have a higher 30-day readmission rate than a COPD patient who had never had COVID in the past.

Not all hospitals are included

CMS excludes about 40% of U.S. hospitals from the readmission penalty program. These include pediatric hospitals, Veterans Administration hospitals, psychiatric hospitals, rehabilitation hospitals, long-term acute care hospitals, and critical access hospitals. In addition, a hospital must have had more than 25 eligible patients for each of the 5 diagnoses. Thus, a hospital that only performed 24 coronary artery bypass surgeries during the 2.5 year period would not be subject for readmission penalties for CABG surgeries. CMS also excludes all hospitals in Maryland from readmission penalties because of an agreement between CMS and Maryland.

It is impossible for hospitals to monitor their readmission rates

Every autumn, hospitals await the CMS report on their readmission data with no advance knowledge of what the hospital’s readmission rate will be. These are sent to the hospital as a “Hospital Specific Report”. For most other quality metrics, hospitals can continuously monitor their performance internally. For example, any hospital should be able to determine on any given day what their mortality rate, C. difficile incidence, and emergency department wait times are. But readmission rates are unique. Medicare looks at admission to any hospital within 30 days of an inpatient discharge, not just the the hospital that the patient was originally admitted to. The original hospital will know if a patient gets admitted again to that hospital but has no way of knowing if a patient gets admitted to some other hospital. For example, if a patient is discharged from the Ohio State University Medical Center, OSU can track any readmissions to an OSU hospital. However, if that patient gets admitted to a non-OSU hospital in Cincinnati, OSU will not know about it. On the other hand, Medicare gets billed by every hospital that a patient is admitted to so Medicare will know whenever a patient is admitted to any hospital in the United States. This phenomenon has little impact on small, rural or community hospitals since a patient admitted to that hospital will likely return to that same hospital given that it is the only hospital in the region. But for tertiary care or referral hospitals, patients often live hundreds of miles away and readmissions are more likely to occur at their local community hospital rather than at the tertiary care hospital. Thus a tertiary care hospital will have no idea what its readmission rate performance is until CMS sends out the Hospital Specific Reports.

Hospitals normally institute a continuous quality improvement process for quality metrics. This requires real-time monitoring of that quality metric so that the hospital can continuously change its procedures and policies to make their quality outcomes better. This turns out to be difficult for reducing 30-day readmissions because the readmission data that Medicare gets is 2-5 years old. To make an analogy, imagine how difficult it would be for a coach to improve his or her basketball team if the coach did not know the outcome of each game until 5 years after it was played.

All hospitals are not treated the same

One of the main criticisms of the initial formula that CMS used in the first years of the readmission penalty was that hospitals that cared for a large number of poor people were disproportionately penalized compared to hospitals caring for a largely affluent patient population. Poor individuals are less likely to have insurance, less likely to be able to afford medications, less likely to have transportation for doctor office visits, and less likely to have a primary care physician. All of these factors contribute to higher hospital readmission rates but these are factors that are largely not under the hospital’s control. In response to this criticism, several years ago, CMS changed the methodology used in readmission calculation to adjust for the percentage of poor and underserved patients that each hospital cares for. The current methodology uses the percentage of “dual-proportion” patients. This is based on the percentage of Medicare patients that also have full Medicaid benefits. Medicaid is used as a marker for low-income patients. CMS divides U.S. hospitals into one of five quintiles based on the percentage of a hospital’s dual proportion patients. Quintile #1 includes hospitals with fewer than 14% of its Medicare patients having dual coverage with Medicaid. Quintile #5 includes hospitals with more than 31% of its Medicare patients having dual coverage with Medicaid.  The breakdown of hospitals based on their percentage of dual proportion is seen in the graph below:

All hospital stays are not treated the same

Medicare classifies each patient’s hospital stay as either an “inpatient” stay or an “observation” stay. The rules for how to classify any given patient are complicated but in general, a patient who is expected at the time of arrival to the hospital to be in the hospital for less than 2 midnights is considered to be in observation status. Overall in the U.S., about 84% of hospital stays are designated as inpatient and about 16% are designated as observation. The financial difference in the two types of hospital stays is very significant, both for the hospital and for the patient. An observation stay is considered an outpatient visit and is thus subject to Medicare Part B billing rather than Medicare Part A billing. This means that the patient in observation status is responsible for all medication charges and is responsible for a 20% co-pay of the cost of the hospital stay. CMS pays the hospital much less for an observation stay than for a regular inpatient stay. Observation stays are less expensive for Medicare because much of the healthcare costs are passed on to the patient.

Because observation stays are considered outpatient visits from a Medicare perspective, these hospital stays are not included in the hospital readmission calculation. For a readmission to count, both the initial hospital stay must be an inpatient stay and the second hospital stay within 30 days must also be an inpatient stay. This is also the same when CMS calculates a hospital’s mortality rate – only inpatient stays are included and deaths occurring when a patient is in observation status do not count against the hospital’s mortality rate.

Hospitals can “game the system” by putting certain patients in observation status in order to improve their readmission data and their mortality data. For example, take a patient who is admitted for a COPD exacerbation on February 1st. That patient then comes back to the hospital on February 20th after having a cardiopulmonary arrest following a drug overdose. The patient is intubated, receives mechanical ventilation, and placed in the ICU but it is clear that the patient has had severe brain and heart damage and is not expected to live beyond 24 hours. The person overseeing the hospital’s quality data will advise the ICU physician to admit the patient as an observation stay so that the hospital stay does not count as a readmission and so that the death does not count as an inpatient mortality. On the other hand, the person overseeing the hospital’s finances will advise the ICU physician to admit the patient as an inpatient stay so that the hospital gets paid more from Medicare. Whichever of the two hospital administrators is most persuasive (or most vocal) will usually win out. The result is that hospitals that more liberally designate patients as being in observation status can lower their CMS readmission penalty. The goal of Medicare auditors is to pay hospitals as little as possible so they will penalize hospitals who put patients in inpatient status who should really be in observation status. However, those auditors do not care if a hospital puts patients in observation status who should really be in inpatient status since it saves Medicare money.

This can also be an effective strategy for hospitals that have a low volume of patients with one of the five diagnoses used in the readmission calculation. For example, if a hospital has 24 heart failure inpatient admissions over a 3-year period, then putting the next heart failure patient in observation status ensures that the hospital will not have any heart failure readmission penalty since there would still be fewer than 25 heart failure inpatient admissions during that 3-year period. The cost to the hospital is that they might get paid $4,000 less by putting that patient in observation status rather in inpatient status. But by avoiding a 0.2% readmission penalty for all medicare charges for the next year, that hospital might avoid a total $80,000 penalty. That is a $76,000 net return on investment for putting that one patient in observation status rather than inpatient status!

For some hospitals, it is cheaper to pay the penalty

In the United States, the average hospital has 19.8% of revenue from Medicare, 13.1% from Medicaid, and 68.4% from private commercial insurance. The hospital with the highest annual net patient revenue in the U.S. is New York Presbyterian Hospital at $5.7 billion. However, the average U.S. hospital’s total annual patient revenue is much lower at about $200 million. Thus, the average hospital has annual Medicare revenue of about $40 million ($200 million x 19.8%). A maximum Medicare readmission penalty of 3% would therefore be about $1.2 million for that average hospital. Only 17 hospitals were fined the full 3% for 2023 and only 231 hospitals will pay more than 1% penalty. 25% of hospitals will pay no penalty at all. The average hospital penalty is 0.43%.

Given that the average hospital has $40 million in annual Medicare revenue and that the average hospital has a 0.43% Medicare penalty in 2023, that average hospital will have a $172,000 penalty. Implementing a readmission reduction program in a hospital can be very costly. It requires hiring data analysts to monitor readmissions, instituting costly discharge transition clinics, and increasing the percentage of patients in observation status. For many hospitals, the total cost to reduce readmissions sufficiently to avoid a CMS penalty can be considerably more than the expense of the penalty. In general, the larger the hospital and the higher the percentage of Medicare patients in a hospital’s payer mix, the more likely it will make financial sense for a hospital to devote a lot of money into a readmission reduction program. Furthermore, because the readmission penalty is based on the hospital’s performance between 2-5 years previously, it will take 5 years before money spent today on a readmission reduction program will fully affect the annual CMS penalty. And it is likely that CMS will continue to revise the readmission penalty formula so that the formula will look considerably different over the next 5 years.

How can the process be improved?

Medical care in the United States is more expensive than anywhere else in the world and it is essential for our economy that we reign in healthcare costs. Because hospitalizations are expensive, reducing unnecessary hospital admissions is central to controlling those healthcare costs. Readmissions to the hospital within 30 days of hospital discharge are frequently avoidable if processes are in place to ensure that patients get appropriate outpatient care. This includes filling medication prescriptions, keeping office appointments with medical providers after discharge, access to outpatient physical & occupational therapy, etc. Penalizing hospitals for excessive readmissions is one way to reduce costs by incentivizing hospitals to institute processes that reduce hospital readmissions. However, after eleven years of the CMS Hospital Readmissions Reduction Program, it is clear that the program can do better. Some specific improvements include:

1. Provide hospitals with real-time readmission data. This is probably the single most important change that CMS can make and it really should not be terribly difficult. Ideally, hospitals should know what their current readmission rates are every month so that the hospital can employ continuous improvement processes to reduce those readmissions. The current model of basing the penalty on a hospital’s readmission rates from 2-5 years in the past makes improving readmissions very difficult. Ideally, CMS should provide every hospital with its current rolling 3-year average readmission rate and this should be updated monthly.
2. Eliminate observation status hospital stays. Currently, hospitals spend an enormous amount of money to determine whether any given patient should be in observation status or inpatient status. Medicare loves observation status because CMS does not have to pay as much to hospitals for patients in observation status as opposed to inpatient status. Instead, those additional costs are passed on to the individual patient. So, the net overall cost to the country as a whole is the same, regardless of whether a patient is in observation or inpatient status. When the overhead expense of monitoring and policing observation stays is included, the overall cost of having observation status actually increases the country’s overall healthcare costs. When it comes to readmission rates, some hospitals game the system by preferentially putting readmitted patients in observation status instead of inpatient status. It is time to eliminate observation status and simply pay hospitals for patient stays, regardless of whether or not the patient’s hospital stay crosses two midnights.
3. Base the penalty on the overall readmission rate rather readmission rates for only 6 diagnoses. Every hospital is different. Not all hospitals perform coronary artery bypass graft surgery and not all hospitals perform knee & hip replacement surgery. Currently, hospitals focus their readmission rate reduction strategies on just the 6 conditions that CMS penalizes them on. Savvy hospitalists know that they can readmit patients who have had a stroke, diverticulitis, or a drug overdose every week without having to worry about any penalty. By using overall readmission rates (for all diagnoses), the quality process will be simpler for hospitals and will benefit all patients and not just those patients who have one of the 6 conditions that CMS currently uses in readmission penalty determination. However, CMS would need to determine a different method of risk-adjustment for comorbidity since the current method is by using specific comorbidities for each of the 6 eligible diagnoses.
4. Eliminate hospital exceptions. Currently, about 40% of U.S. hospitals are not subject to readmission penalties. This is understandable for pediatric hospitals (few, if any, Medicare patients) and Veterans Administration hospitals (funded by the VA and not by CMS). Psychiatric hospitals are excluded because they do not normally admit patients with the 6 conditions that CMS bases the readmission penalty on. Long-term acute care hospitals, rehabilitation hospitals, and critical access hospitals are also excluded. Ideally, CMS should use data for both Medicare and Medicaid patients since it can track readmissions for both groups. By focusing on total readmission rates rather than the 6 currently used diagnoses, many of the currently exempted hospitals can be included in the readmission reduction program. However, there may need to be different readmission rate benchmarks for psychiatric hospitals, long-term acute care hospitals, etc.

January 4, 2023

A reader recently emailed me to ask: “How do you define a hospitalist FTE?” It turns out that it is a great question with a very nuanced answer. Twenty years ago, an FTE was whatever a physician wanted it to be. Physician earnings were directly tied to physician billing and so a physician would work as much as they wanted in order to generate the income that they wanted. But over the past 2 decades, revenue from physician professional services has not changed appreciably – in 2002, Medicare reimbursed physicians at $36.20 per RVU; in 2022, an RVU was worth $34.61.

To put that in perspective, $1.00 in 2002 is worth $1.66 in 2022 whereas an RVU is now worth $1.59 less than it was in 2002! In order to keep physician incomes constant, hospitals have had to increasingly subsidize physicians. As a result, most physicians are now hospital-employed, rather than independent practitioners. This is especially true for hospitalists who rarely, if ever, are able to support their full salary on billings alone. In the past, the physicians defined what working full-time constitutes but today, it is the hospitals that define what working full-time means for a hospitalist.

Hospitals typically subsidize hospitalist groups based on the number of FTEs (full-time equivalents) that are required in order to cover the hospital’s inpatients. But defining exactly what an FTE is can be complicated and often a source of disagreement between the hospital and the hospitalist group. There are a number of equally valid ways of defining “full-time” and no one definition works best in every hospital. There are several steps to determine the best model in your hospital.

Step 1: Determine the number of patients per hospitalist per day

The number of patients each hospitalist should see per day will vary considerably from hospital to hospital and from nursing unit to nursing unit. There are 19 factors to consider when determining this number as outlined in a previous post:

• • • Case mix index
    • Residents versus no residents
    • Admitting service versus consultative service
    • Presence or absence of advance practice providers
    • ICU versus general ward patients
    • Day shift versus night shift
    • Observation status versus regular inpatient status
    • Ease of documentation
    • Shared electronic medical record with primary care physicians
    • Non-clinical duties
    • Shift duration (hours)
    • Hospitalist experience
    • Patient geographical location within the hospital
    • Average length of stay
    • Inpatient census variability
    • RVU productivity
    • Quality of case management
    • Local hospitalist employment market
    • Patient demographics

There has to be flexibility, however, and rigid adherence to a given number of patients is a recipe for dissatisfaction on both the part of the hospital and the part of the hospitalist. If the hospital inpatient census falls, then the hospital will be unhappy that each on-duty hospitalist is not seeing enough patients. On the other hand, if the inpatient census surges, then the hospitalists will be unhappy since they have to see more patients than they agreed on in their contracts. Many hospitals will have a “risk-call” hospitalist each day who is on standby to come in to work if needed when the inpatient census is higher than normal.

Step 2: Determine how the hospitalists will be scheduled

Early in the hospitalist era, scheduling was simple: a shift was 12 hours long and there were two shifts – a day shift and a night shift. Hospitalist schedules have gotten a lot more complex in recent years as outlined in a previous post. Now, hospitalists often have 8-hour short day shifts and evening swing shifts to cover ER admissions in the early evenings. As a result, scheduling hospitalists has become much more complex. Here are some of the scheduling models:

The 12-hour shift model. This was the original hospitalist scheduling model and typically will have two 12-hour shifts per day, a day shift and a night shift. The day shift is typically 6:00 AM to 6:00 PM or 7:00 AM to 7:00 PM. The night shift starts when the day shift is over. Day shifts and night shifts are treated equally but since night shifts are considered less desirable by most hospitalists, there needs to be a “shift differential” to provide extra payment for covering night shifts. Many hospitals will also provide additional pay for hospitalists who work on holidays. Because most patient care (work rounds, interdisciplinary rounds, daily charting, discharges, family meetings, etc.) occurs during the day shift, hospitals will typically have 1 night shift hospitalist for every 3 -4 day shift hospitalists. High acuity patient care areas, such as the intensive care unit, may require 1 night shift hospitalist for every 1 day shift hospitalist.

The long-shift, short-shift model. In this model, one or more hospitalists works the entire 12-hour day shift but other hospitalists leave earlier in the day, after their work is done. The short-shift hospitalists check out to one of the long-shift hospitalists when leaving. The long-shift hospitalist is then responsible for any admissions that come in later in the day. Some hospitalist groups will have the short-shift hospitalists continue to take phone calls from nurses, the lab, and consultants after they leave the hospital; other hospitalist groups will have the long-shift hospitalists cover calls. Some hospitals will have a specific check-out time for the short-shift hospitalists, for example, 3:00 PM. Other hospitals will have the short-shift hospitalists check out whenever their work is completed, whether that be 1:00 PM or 5:00 PM. An advantage of this model is that it avoids having a lot of hospitalists sitting around doing nothing in the late afternoon, after all of their work is done. In addition, this model is very attractive to hospitalists with children, since they can be home when the kids get out of school.

The swing-shift model. In most hospitals, the peak in admissions from the emergency department occurs between 3:00 PM and midnight. After midnight, the admissions slow down, the inpatients go to sleep, and the hospitalist workload drops. To optimize patient care coverage, some hospitals will create a “swing-shift” to cover the surge in admissions during the evening. Every hospital’s pattern of ER admission is different so swing-shifts could be from 3:00 to midnight, 5:00 to 10:00, etc.

The comprehensive services model. In many hospitals, the hospitalists do more than just serve as the attending physician for inpatients. For example, they may perform medical pre-operative consultation in an outpatient pre-admission testing clinic. They may provide medical consultation for surgical inpatients. They may have a designated “triage attending” to serve as a liaison between the hospitalist services and the emergency department or the outside referring hospitals. Or they may provide on-site supervision of infusion centers. In these situations (except for triage attending), the duration of a shift is determined by whenever the work is done, rather than by a specific time of day or number of hours. In general, these other services require fewer than 12 hours per day. These types of services are often attractive to hospitalists with young children since they are generally able to get home earlier than they would with a traditional 12-hour inpatient hospitalist shift.

Step 3: Determine how a 100% FTE will be defined

Once the hospital has determined how many inpatients a rounding hospitalist should cover and how the hospitalists are to be scheduled, the next step is to determine what will constitute a 100% FTE hospitalist. There are several ways of defining an FTE.

The shifts per month model. This works best when all of the hospitalists work 12-hour shifts. A full-time hospitalist is typically defined as 15 or 16 shifts per month (180 – 192 shifts per year). It generally takes about a half hour to check out at the end of every shift with the result that a 12-hour shift is really a 12.5-hour shift. This works out to about 43 – 46 hours per week on average. Some hospitals will grant additional time off for vacations and CME with the result that full-time may be fewer shifts per year, for example, 170 shifts.

The hours per month model. This model works when there there are different hospitalist shifts of varying durations. In this model, a hospitalist may be scheduled for shifts of a variety of durations up to some pre-agreed upon number of total hours per month. This results in a great deal of scheduling complexity and often requires considerable effort by the scheduler to ensure equity among the hospitalists. Many jobs define an FTE as 40 hours per week, however, most physicians work more than that. Although physician time surveys vary, most find that physicians average closer to 50 hours per week. If we extrapolate from the 15 – 16 twelve hour shifts per month model that results in 43 – 46 hours per week, then this would equate to 2,236 – 2,392 hours per year. Rigid adherence to a specific number of hours per year is difficult. Unlike other hospital employees, hospitalists do not punch in and out on a time clock. There are always some days when a hospitalist needs to stay in the hospital past the end of their shift to finish charting, complete the H&P on a late admission, or provide care for a critically ill patient. In addition, some hospitalists may check-out early to one of their peers once they complete their daily work.

The number of billed wRVUs model. If you look in the annual MGMA physician salary survey, you can find the mean, median, 25th percentile, 75th percentile, and 90th percentile of work RVUs  produced by physicians in every specialty. Using wRVUs as a general guide of FTE productivity can be useful for many specialties but as discussed in a previous post, it is inadvisable to pay individual hospitalists by the wRVU. Nor is it advisable to use wRVU targets to define an FTE. If wRUVs are used to benchmark hospitalist productivity, the RVU targets need to be for the entire hospitalist group and not for individual hospitalists. There is too much variation in RVU production intrinsic to different types of hospitalist shifts – fewer RVUs with night shifts, more with ICU shifts, and none for triage attending shifts. In other words, rather than requiring each of your 10 hospitalists to produce 4,300 wRVUs per year, instead require the entire group of hospitalists to produce 43,000 wRVUs per year.

The traditional workweek model. Most outpatient physicians define full-time as traditional office hours, working Monday through Friday, 8:00 – 5:00. With physician offices often closed on weekends, evenings, and holidays, this works fairly well for outpatient medicine. This model is harder to apply to hospitalists because illnesses requiring inpatient care are just as likely to occur on weekends and holidays as they are on weekdays. Therefore, hospitalists need to cover every day of the year. Nevertheless, some hospitals will have a core group of hospitalists who cover Monday through Friday day shifts. Part-time hospitalists or moonlighters cover weekends. And nights are either covered by home call, by inpatient advance practice providers, or by nocturnists. This model can sometimes work in smaller hospitals that care for lower acuity patients but is impractical in larger hospitals. The weekday hospitalists typically take care of their daily rounds and any admissions. They then leave the hospital in the afternoon, after their work is done. A typical full-time hospitalist in this model might work 46 weeks with 4 weeks of vacation, a week of CME, and a week for holidays. This equates to 230 working days per year.

The academic hospitalist model. In many teaching hospitals, the attending physicians on medical inpatient services are hospitalists who oversee care provided by internal medicine, family medicine, or pediatric residents. In this situation, the residents typically cover a given inpatient service for 4-week blocks. The attending hospitalist typically covers the teaching service daily for 2 weeks, although at some hospitals, the hospitalist covers the service for shorter (1 week) or longer (4 week) blocks. Because residents are in the hospital to perform H&Ps and care for any acute medical problems, the hospitalist can often leave the hospital after rounding with the resident and completing charting. This results in the hospitalist typically being in the hospital for 5 – 8 hours per day. The attending hospitalists generally provide back-up coverage to the residents at night by home call, either individually for their particular inpatient service or on a group rotational night call basis. Unlike the traditional workweek model, the academic hospitalist model generally requires both weekday and weekend coverage in order to ensure continuity of patient care and continuity of resident education. Thus, full time is considered less than 46 weeks and may be anywhere from 6 months (182 days per year) to 8 months (243 days per year) of service time.

Step 4: Determine how a part-time FTE will be defined

Once there is agreement between the hospital and the hospitalists on what will constitute a full-time FTE, it then becomes easier to assign a percent effort to part-time physicians and to determine how those part-time hospitalists will be paid.

For compensation of hospitalists who work less than 100% FTE, the easy answer is to make their base pay the same percent as their FTE. However, that can pose more cost to the employer since there are certain employer-paid expenses that are fixed, regardless of whether a hospitalist is 100% or 70% FTE. For example, the employer’s portion of health insurance premiums and life insurance premiums is the same for part-time employees as it is for full-time employees. Similarly, the employer’s cost of recruitment and credentialing is the same whether the hospitalist is 100% or 70%. In other words, it costs the employer more to have 2 hospitalists who each work 50% FTE than to have 1 hospitalist who works 100% FTE. Most hospitals are willing to cover those higher costs in order to keep high-performing hospitalists who wants to work part-time, particularly if there is a reasonable chance that the hospitalist will eventually return to 100% FTE in the future. For example, an experienced hospitalist who is a parent who wants to cut back to 70% for a few years until his/her child is older.

One size does not fit all

From the above discussion, it is clear that no one single model is best for all hospitals. Each hospital (and each hospitalist group) must examine its own unique inpatient service coverage needs in order to select the definition of “full-time” that fits best. From the hospital standpoint, it is important to be flexible and work with the hospitalists to be sure that they are happy with the model. From the hospitalist standpoint, it is important to ensure that a model that optimizes their work-life balance does not interfere with optimal patient care.

Because hospital censuses ebb and flow from year to year and because new hospitalists are hired from year to year, it is important that every hospital re-examines how full-time is defined periodically to ensure that the agreed upon model best fits the dynamic nature of inpatient medicine.

December 10, 2022

It has now been 3 years since the SARS-CoV-2 virus first infected humans in Wuhong, China in December 2019. By now, most Americans have either had a COVID-19 infection or have been vaccinated against COVID. So, what type of mask should we be wearing in the hospital and in public places?

Our two most powerful weapons against COVID are vaccination and mask-wearing but mandates for both have been been unpopular in the United States. Since the peak of the pandemic, most mask mandates in public areas have been relaxed. However, mask mandates are still in place in many hospitals. Furthermore, as of the writing of this post, there are 25,380 patients with COVID infection currently admitted in U.S. hospitals. Consequently, healthcare workers continue to have regular exposure to infected persons. So, what kind of mask should our healthcare workers wear?

Mask-wearing is not new. Surgeons and other operating room personnel have worn masks during surgeries for more than a century. However, the purpose of wearing masks in the OR is to prevent the surgeon’s respiratory secretions from infecting the patient’s incision and not to prevent the patient’s incision from infecting the surgeon. A simple surgical mask is very effective in catching respiratory droplets if the surgeon sneezes, coughs, or talks during an operation.

Before COVID, there were situations when healthcare workers did wear masks to prevent getting infected by patients, for example, when caring for patients infected with influenza (where transmission is usually by respiratory secretion droplets). A regular surgical mask is effective in preventing infection from respiratory secretion droplets but for smaller particles, an N95 mask is necessary. For 35 years, I wore N95 masks whenever I was caring for patients infected with tuberculosis or when doing bronchoscopy on patients suspected of having TB. It only takes inhaling  one tuberculosis bacteria to become infected with TB. A respiratory secretion droplet is about 5-10 μm in size whereas a tuberculosis bacteria is about 2 μm in size. A regular surgical mask will usually stop the droplets but will not stop a TB bacteria, whereas an N95 mask will.

For an N95 mask to be effective, it must have a tight seal to the face so that air cannot get between the edges of the mask and the skin. Everyone’s face is shaped a little differently and not all brands of N95 masks fit all faces equally well. Healthcare workers are normally required to be “fit-tested” to determine which N95 mask provides an acceptable seal against the face. Passing the fit test meant that all of the inhaled air went through the mask material and did not leak between the mask and the skin. At our hospital, we required healthcare workers who worked with patients with suspected tuberculosis to be fit tested every year. A number of years ago, the Occupational Safety and Health Administration (OSHA) put out a requirement stating “The employer shall not permit respirators with tight-fitting facepieces to be worn by employees who have facial hair that comes between the sealing surface of the facepiece and the face…“. In other words, men with beards were not supposed to use N95 masks.

Like influenza, the COVID virus is usually transmitted by respiratory secretion droplets. So, in theory, a surgical mask should be sufficient. However, there are certain situations when an infected patient’s respiratory secretion droplets can be broken down into smaller particles, in which case, a surgical mask could be insufficient and an N95 mask may be more effective. Such situations include performing endotracheal intubation and bronchoscopy. Having had a beard for 40 years, I had repeatedly passed my annual N95 fit tests despite having a beard but when COVID hit, I shaved it in order to be in compliance.

We now have several studies performed over the past 3 years of the pandemic to give us better guidance of what type of mask is most effective in preventing healthcare workers from becoming infected. Unfortunately, each of these studies have potential limitations and the studies have given mixed results.

A word about KN95 masks. An N95 mask is a NIOSH-approved mask that filters out at least 95% of particles that are 0.3 micons in size. In reality, a well-fitting N95 mask actually filters out 99.8% of particles that are 0.1 micons in size, which is also the size of a COVID virus particle. A KN95 mask is a mask approved by the Chinese government (and not NIOSH). A study of KN95 masks found that 70% of them did not meet the NIOSH standard for effectiveness. For hospital purposes, a KN95 mask can be considered as effective as a surgical mask but not as effective as an N95 mask

One of the earliest studies comparing surgical to N95 masks was published in JAMA in 2009 and randomized 446 nurses caring for patients with acute febrile respiratory illnesses to wear either surgical masks or N95 masks during patient care. An equal percentage of the nurses were diagnosed with influenza during the study and the conclusion was that the type of mask worn did not make a difference. Another study published 10 years later in JAMA in 2019 also found that among 1,993 healthcare workers randomized to wearing surgical or N95 masks, there was no difference in the incidence of influenza or other respiratory infections.

There have been several studies comparing masks to prevent COVID infection. A 2021 study examining the effectiveness of N95 versus surgical masks based on analysis of droplet size characteristics concluded that a surgical mask was theoretically sufficient to prevent COVID infection in low-virus environments but N95 masks would be theoretically more effective in virus-rich environments. A 2021 study comparing the fit of cloth, surgical, KN95, and N95 masks found that N95 masks had better fit factor scores than the other masks and that KN95 masks had similar fit factor scores as surgical masks. The study also concluded that fit is critical to the level of protection offered by masks. A 2021 meta-analysis of 8 studies involving N95 versus surgical masks found that N95 masks were more effective than surgical masks in preventing healthcare workers from becoming infected with a variety of respiratory viruses, including COVID. A 2022 study of 3,259 healthcare workers who were randomly assigned to use filtering facepiece class 2 masks (analogous to N95 masks) versus surgical masks found no overall effect on the incidence of COVID infection; however, those healthcare workers with > 20 contacts with COVID patients did have fewer COVID infections if they were wearing the filtering face piece class 2 masks. A 2022 MMWR report involved a retrospective review of 1,528 COVID-infected persons and 1,511 case controls and found that people who reported wearing N95 masks in public were less likely to become infected than those who wore surgical masks in public places. However, a major limitation of this study is presumably those wearing N95 masks were also more likely to take other precautions to avoid COVID than those who chose to wear a regular surgical mask.

The most recent study was published this week in Annals of Internal Medicine. 1,009 healthcare workers in Canada, Israel, Egypt, and Pakistan were randomized to use N95 or surgical masks during patient care for 10 weeks. Overall, there was no difference in the incidence of COVID infection between the two groups but it is notable that most of the subjects (71%) were in Pakistan or Egypt with only 29% in Canada or Israel. In Pakistan and Egypt, 82% of subjects had previously been infected by COVID before the study whereas in Canada and Israel, only 3% of subjects had a previous COVID infection. There was a trend for N95 masks to be more effective than surgical masks in Canada and Israel; however, because of the low number of subjects in those countries, the results did not reach statistical significance. Because past COVID infection confers some immunity to reinfection, it is possible that the failure of N95 masks to have superior protection over surgical masks was due to the very high percentage of healthcare workers with immunity from previous infection in Pakistan and Egypt.

The bottom line: What mask should you wear?

Medicine is a very dynamic science and recommendations change as new clinical studies are published. As a result, today’s medical dogma is tomorrow’s medical malpractice. Based on the available information a few general recommendations can be made:

1. In hospital areas where the prevalence of COVID infection is low, wearing regular surgical masks is sufficient to prevent healthcare workers from becoming infected. This means parts of the hospital that provide care for non-COVID patients, such as general medical and surgical floors, cafeterias, public areas, and offices.
2. In hospital areas where there is likely to be a high number of viral particles in the air breathed by a healthcare worker, N95 masks are preferable. This would include areas where the viruses are likely to be aerosolized, such as during intubation or bronchoscopy, particularly in rooms with stagnant airflow, such as those lacking sufficient number of air exchanges per hour. In locations where the virus is in respiratory droplets (as opposed to being aerosolized), surgical masks may be sufficient. Because several studies have shown that the viral loads are similar among symptomatic versus asymptomatic patients with COVID infection, the decision of whether to wear an N95 mask should not be based on the severity of the patient’s infection.
3. Wearing surgical masks by healthcare workers is sufficient to prevent workers with asymptomatic COVID infection from infecting patients. This has been a concern for the care of patients at high risk of severe COVID infection, such as those patients who are immunocompromised, obese, diabetic, or elderly. These patient are at particular risk if in contact with a maskless infected healthcare worker. Because daily testing of all healthcare workers caring for these patients is impractical, preventative mask-wearing is prudent.
4. Because viral loads are just as high in asymptomatic patients as in symptomatic patients, hospital visitors should wear surgical masks inside of the hospital as long as the prevalence of COVID infection in the community remains substantial or high. What constitutes “high” is a matter of opinion but the CDC defines “low” as up to 10 cases/100,000 population, “moderate” as between 10-50/100,000, “substantial” as 50-100/100,000 population, and “high” as greater than 100/100,000 population. Currently, the U.S. as a whole has a case rate of 91/100,000 population. However, hospitals are not like the country as a whole – currently 5.6% of all Ohio inpatients have COVID infections for an inpatient rate of 5,600/100,000. Because inpatients with COVID infection are more likely to have family and friends who are also infected (from home and workplace transmission), the probability of encountering a hospital visitor with a COVID infection is a lot higher than encountering a waiter in a restaurant with a COVID infection.
5. Healthcare workers who prefer to wear an N95 mask (but are not required) should be permitted to do so. Because of non-statistically significant trends in some studies suggesting a slight benefit of N95 over surgical masks, those healthcare workers who perceive greater safety with the N95 masks should be allowed to wear them if desired and if supplies permit.
6. Healthcare workers who are required to wear N95 masks should be fit-tested annually. Because ill-fitting N95 masks lose most of their protective benefit, there needs to be assurance that the N95 mask that the worker wears actually does what it has the potential to do. It is reasonable for hospitals to also require fit-testing for those employees who want to wear an N95 mask but are not required to wear an N95 mask, especially if the hospital is paying for the masks.
7. KN95 masks are an acceptable alternative to wearing a surgical mask but should not be used in clinical situations when N95 masks are required. Given the reduced effectiveness of KN95 masks compared to N95 masks, a KN95 mask cannot be viewed as equivalent to an N95 mask. It may, however, be better than a surgical mask.

What about outside of the hospital? At the grocery store or airport, I generally see only 5-10% of people wearing masks. At athletic events, that percentage is even lower. The risk of becoming infected in a public place is dependent on how likely you are to come in contact with someone’s exhaled viruses. That in turn depends on the prevalence of COVID infection in the community, the number of people in an enclosed space, the size of the enclosed space, the duration of time that you are in that space, the amount of singing or shouting in the space, and the ventilation of the space. Based on viral load studies, it does not matter whether an infected person in the space is symptomatic or asymptomatic. In situations when those variables indicate a higher risk of COVID, wearing a surgical mask is prudent. Those people who feel more secure wearing a KN95 mask or an N95 mask should do so.

As for me, N95 masks kept me from getting TB despite caring for patients with tuberculosis for decades. They also kept me from getting COVID infection despite intubating and performing bronchoscopy on COVID patients in our intensive care unit. My fit-tested N95 mask is sort of like a security blanket for me. So, I think I’ll keep wearing it in public areas for now. When the case rate gets below 50/100,000 population, I’ll reconsider. And when the case rate gets below 10/100,000, I’ll feel safe without any kind of mask in public.

December 2, 2022

A few years ago, one of our physicians was threatened by a patient who said he was “…going to come after you with my gun” because she refused to prescribe opioid pain medications for him. She was very distraught and came to me looking for measures to keep her safe in the workplace. In the past week, there have been several homicides at American healthcare facilities that have caused me to think back to that doctor.

Doctors and nurses facing the wrath of angry patients and their families is nothing new. Thirty-five years ago, when I was a fellow in training, a woman sent our division a letter saying that she was going to come to the hospital to kill all of the pulmonary and critical care doctors with her automatic rifle because her husband had died in our ICU. I had never even met her or her husband. What is different today compared to 35 years ago is that weapons are much more easily available and America has increasingly developed a culture of gun violence.

In the latter half of the last century, the United States was embracing greater degrees of gun control. In 1967, then governor Ronald Reagan signed the California Mulford Act that prohibited the public carrying of loaded firearms without a permit; violations were subject to a felony. At the time of signing, Reagan famously said that there was “…no reason why on the street today a citizen should be carrying loaded weapons”. The Mulford Act was notably supported by the NRA, which at the time was an organization primarily focused on the recreational use of guns and on gun safety. In 1993, the Brady Bill required mandatory criminal background checks on anyone purchasing firearms. In 1994, the Violent Crime Control and Law Enforcement Act banned the sale of assault rifles in the U.S.; the law had a 10-year limitation and expired in 2004. However, over the last 15 years, due largely to lobbying by special interest groups that promote gun availability, weapon laws have been rolled back. Coincident with this has been an increase in gun deaths, mass shootings, and healthcare shootings. Prior to the 1994 assault rifle ban, there were an average of 7.2 mass shooting deaths per year in the U.S. During the ban, that number dropped to 5.3 per year. After the ban expired in 2005, the average number of mass shooting deaths rose to 25 per year.

Shootings at healthcare settings

An FBI report found that there were 13,927 U.S. homicides in 2019. Firearms were by far the most commonly used weapons, accounting for 73% of the homicides.

Semi-automatic rifles (such as the AR-15 rifle) loom large in the public perception of homicides, largely due to their use in high-profile mass shootings. However, handguns are by far the most commonly used weapons in American homicides and account for 91% of firearm-related homicides. Firearms are also the method of choice for suicide in the United States and account for 53% of deaths by suicide per CDC data.

The CDC reports that in 2020, the firearm-related homicide rate was the highest that it has been in more than 25 years with a 35% increase compared to 2019. Overall, 45,222 Americans died from firearms in 2020. There have been a total of 18,882 gun-related deaths so far this year in the U.S. which puts us on a pace to exceed the 2020 number – and we have not even reached the busy summer homicide season. There have been 247 mass shootings so far this year and last Wednesday, there were fatal shootings at hospitals in Tulsa, OK and in Dayton, OH. Last Saturday, a physician and 2 nurses were stabbed in an emergency department in California. Our hospitals are becoming increasingly dangerous – The International Association for Healthcare Security and Safety reports that there was a 47% increase in hospital violent crimes in 2021 compared to 2020.

Violence against healthcare workers is incredibly common. According to the Bureau of Labor Statistics, healthcare providers account for 73% of all workplace injuries due to violence.  A hospital is one of the most dangerous places to work in the United States.

In a 2017 study of 346,343 emergency department visits, weapons were found in 3% of all ER visits with a total of 10,691 weapons confiscated at screening. Weapons were most likely to be found at hospitals that provide trauma and behavioral health services. Knives were the most common weapons found.

Hospital shootings are relatively rare but are usually widely publicized resulting in a greater awareness of shootings compared to other violent acts at hospitals. A 2012 study found that there were 154 shootings at healthcare facilities between 2000 and 2011 (12.8 per year). A more recent study found that there were 88 hospital shootings at healthcare facilities between 2012-2016 (17.6 per year). These data indicate that the annual number of hospital shootings is increasing.

What can we do to keep our healthcare workers safe?

There is no single best answer to this question because each healthcare setting is unique. Measures that are effective in an emergency department may not be practical nor effective in a free-standing medical office. Here are some of the steps that we took to improve healthcare worker safety in our own hospital and clinic building.

1. Listen. When a doctor or nurse says that a patient has threatened them, take them seriously. Even if you believe that the threat is minimal, the person who has been threatened feels vulnerable and experiences trepidation. Take every patient threat seriously.
2. Encourage reporting. Far too many violent incidents and threats in our nation’s hospitals go unreported. The most common reasons are (1) fear of retaliation, (2) lack of a clear reporting method, and (3) belief that nothing will be done. Reporting should be simple and easy. Ideally, there should be multiple options for reporting – by phone, email, on-line, in-person, etc.
3. Engage hospital security. Keeping patients and employees safe is what they are trained to do. The security staff will have ideas about threat assessment and threat mitigation that you have not even thought about. For smaller, private medical practices that are not affiliated with a hospital, having on-site security personnel is not feasible. However, a healthcare security consulting company may be able to at least advise options for reducing the risk of staff being harmed.
4. Video surveillance. Cameras can relatively easily be installed in parking areas, entryways, lobbies, and main corridors. Because the emergency department is the location of frequent violence against healthcare workers, extra cameras in the ER are generally warranted. In large hospitals, it is often optimal to have a member of the security staff continuously monitoring video feeds. Constant monitoring by a staff member may not be practical in a smaller outpatient office but video recordings can be very useful to substantiate threats if police become involved and signage announcing video surveillance can serve as a deterrent in some cases.
5. Weapon-free zones. We have signs in our hospital and clinic building entrances stating that guns and other weapons are not permitted on premises. These signs are useful to make the hospital staff and general public feel safe but do very little to prevent a person from bringing a weapon inside. I was taught to recognize concealed guns carried by visitors to our ICU and have frequently identified people walking in with a handgun. In my outpatient pulmonary practice, I have unexpectedly encountered many holstered handguns during my auscultation of patients’ lungs from their backs. In Ohio, anyone can now carry a concealed handgun with no training or permit required and so I anticipate that even more people will ignore ‘No Guns Allowed’ signs.
6. Limit door access. When our outpatient doctor was threatened after refusing to prescribe opioids, we put ID badge-access locks on the doors leading from the lobbies to the patient care areas. This required any patient or visitor to be escorted by an office staff member with badge access. We periodically receive threats from family members of ICU patients and so we have installed similar badge-access door locks to the ICU as well as other vulnerable locations such as the operating room and the emergency department. Creating this type of entrance barrier to an angry person with a weapon is one of the most effective preventive measures that we can take.
7. Interior design. No only should staff have easy access to exits, but staff also need to know where all possible exits are. Mirrors and strategic positioning of reception desks can improve line-of-sight in corridors and lobbies. Interior spaces and parking areas should have adequate lighting. Enclosing reception desks can create a barrier to accessing adjacent patient care areas.
8. Metal detectors. These are not practical at every hospital or outpatient office entrance. However, we do use metal detectors at our emergency department public entrance and the number of weapons that are found is astounding. This requires a security staff member to be stationed at the metal detector. It is not possible to use a metal detector at ambulance entrances to the emergency department so patients brought by ambulance must be manually searched or checked with a hand-held metal detector on arrival – this is particularly necessary for trauma and psychiatric patients arriving by ambulance since these patients are more likely to have weapons.
9. Panic buttons. These are devices that can be placed in a physicians office or can be carried by the physician (or nurse) that send a signal directly to the security staff if the physician (or other healthcare worker) is confronted by a threatening person. We have frequently provided these to doctors who have received threats from patients, patient family members, or former employees. The won’t stop the first bullet from a gun but they might prevent the second bullet from being fired.
10. Phone call code phrases. This is a simple measure that every hospital should utilize. Staff are taught that if there is person making a threat in their area, the staff call the security office and state the code words. In order to protect the safety of our own hospital’s staff, I won’t say what our code phrase is. But choose something that won’t be obvious to the general public such as “Please page Dr. G”. The code phrase then triggers security staff to immediately go to the location of the phone call.
11. Run, Hide, Fight. Active shooter training should be available to every healthcare worker. The Ohio State University uses the Run, Hide, Fight procedure for students, faculty, and staff. We require Run, Hide, Fight training for some of our hospital employees and make the training optional for others, depending on the hospital location where they work. For an example of what the training involves, watch this short video created by the FBI.
12. Safety training. In situations less emergent than active shooter situations, other tactics should be used. All staff should be trained to identify warning signs and escalating behaviors that can precede a violent assault. Training should also include de-escalation techniques, available alarms, behavior control methods, and location of safe areas. Free self-defense training is often seen as a valuable fringe benefit by healthcare workers.
13. Involve the police. When a doctor receives a credible threat, contact the police. Be sure to save any evidence such as letters, emails, voicemails, or video recordings. Encourage staff to press criminal charges when appropriate. This may require financial support for legal assistance as well as paid time off for legal proceedings.
14. First name ID badges. This is usually impractical for physicians who by necessity need ID badges stating their last names. But patients and visitors generally do not need to know the last names of nurses and other hospital employees. Instead of their ID badge reading “Carol Smith, RN”, consider having the ID badge simply read “Carol RN”. Identity concealment can be an important deterrent to a vindictive patient.
15. Parking lot escorts. Any hospital employee who feels unsafe should have the option of being escorted by security staff from their car to the building and from the building to their car. Parking lots and parking garages are second only to the emergency department in numbers of violent assaults in hospitals.
16. Provide counseling. A violent assault or the threat of violence is extraordinarily stressful for hospital staff. Unaddressed, this emotional stress can result in reduced employee performance, absenteeism, and employee resignation. Counseling should be available to staff through free employee assistance programs. Hospitals and large medical practices may be able to use internal resources such as social workers and mental health providers. Small medical practices may need to establish a relationship with private counselors.

People with weapons kill people

Gun control advocates often say “Guns kill people”. Gun rights advocates counter by saying “Guns don’t kill people, people kill people”. I think they are both wrong: people with weapons kill people. Guns just happen to be America’s weapon of choice. The United States has, by far, the highest gun-related homicide rate of all high-income countries. Our healthcare facilities are not immune to homicide and other forms of violence. Doctors will always be blamed by some people for their pain, for the outcome of their illness, or for the death of a family member. Our job as hospital leaders is to create a safe workplace so that our doctors can improve people’s lives without having to worry about losing their own.

June 8, 2022

No two hospitals have exactly the same approach to scheduling hospitalists. Early in the era of hospitalists, a 7-day on, 7-day off work schedule was most common, with hospitalists working a total of about 15 shifts per month, each of which was 12-hours. Schedulers liked this because it was simple. But the 7-on, 7-off work schedule can lead to physician burnout. So, what is the ideal schedule?

The best schedule is the one that results in optimal patient outcomes plus optimal physician job satisfaction, tempered with fiscal responsibility.

Optimizing patient outcomes

Although many hospitalist variables can affect patient outcomes, two of the most important are inpatient continuity and inpatient workload. Inpatient continuity refers to how consistently a single physician manages a patient during that patient’s hospital stay. This generally equates to how many days a hospitalist works in a row. Inpatient workload refers to the number of patients a hospitalist manages per shift.

Inpatient Continuity 

In a 2020 study from JAMA Internal Medicine, the clinical outcomes of 114,777 patients were studied from 229 hospitals in Texas. 25% of the patients had low hospitalist continuity during their hospitalization, defined as hospitalists working 0 – 30% of their total working days with shifts of ≥ 7 days in a row. 25% of the patients had high hospitalist continuity during their hospitalization, defined as hospitalists working 67 – 100% of their total working days with shifts of ≥ 7 days in a row. The high continuity cohort had a lower average 30-day mortality rate, lower readmission rate, higher rate of discharge to home, and lower 30-day post-discharge costs. The authors’ overall conclusion was that “…patients receiving care from hospitalists who usually work several days in a row experience better outcomes and lower costs…”.

In many ways, these results are not surprising. Patient hand-offs are frequently sources inadequate communication. For hospitalists, there are 2 kinds of handoffs: (1) those that occur between the day shifts and night shift hospitalists and (2) those that occur between two sequential day shifts. The information impacting continuity of care is primarily in the second type of handoff whereas day-night shift handoffs are limited to new problems occurring with a patient during the night shift and with new nighttime admissions. The Joint Commission has identified hand-offs as major source of medical errors. More consecutive days on-duty equates to fewer handoffs.

I have only rarely worked shifts as a hospitalist. However, I have attended innumerable times on our hospital’s general internal medicine resident teaching services and on our medical intensive care unit service. On the first day of service, I would spend the bulk of my time just getting to know the patients’ histories and active medical problems. I never knew the patients who I picked up as well as those that I admitted and performed the initial history and physical exam myself. And I often kept those picked-up patients in the hospital longer so I could be sure that I had addressed all of their medical issues. Moreover, I would generally work longer hours on those first days of service because for me, every patient on the service was a new patient that required more time to become familiar with.

Patient satisfaction can also improve if inpatients see the same doctor every day. All too often, inpatients do not even know who their attending physician is. If the hospitalist caring for a patient changes every one or two days, then there is no opportunity to build a doctor-patient relationship and inpatient satisfaction scores will suffer.

Inpatient Workload 

When a hospitalist has to take care of too many patients, bad things happen. But what constitutes too many patients? There is not a single number because workload involves both the number of patients encounters per day and the complexity of the patient encounters. Taking care of 18 inpatients per day at one hospital may be easier than taking care of 12 inpatients per day at another hospital.

In a previous post, I discussed 19 variables that impact the ideal number of patients that a hospitalist should see per day. Those include:

• • • Case mix index
    • Residents versus no residents
    • Admitting service versus consultative service
    • Presence or absence of advance practice providers
    • ICU versus general ward patients
    • Day shift versus night shift
    • Observation status versus regular inpatient status
    • Ease of documentation
    • Shared electronic medical record with primary care physicians
    • Non-clinical duties
    • Shift duration (hours)
    • Hospitalist experience
    • Patient geographical location within the hospital
    • Average length of stay
    • Inpatient census variability
    • RVU productivity
    • Quality of case management
    • Local hospitalist employment market
    • Patient demographics

A good rule of thumb is to start with a target inpatient census of 15 patients per hospitalist and then work up or down depending on your hospital’s unique mix of these 19 variables. So, if you have a very robust case management department, increase the number to 17 per day. Or if your hospitalists are mostly new residency program graduates, then drop the number down to 13.

Optimizing hospitalist job satisfaction

Physician burnout is real and when it comes to burnout, nothing is more combustable than an unhappy doctor. But a schedule that makes one hospitalist happy may make another hospitalist unhappy. At the risk of over-generalization, the age of the hospitalists can affect their schedule preferences:

• The 30-year old hospitalists. Young hospitalists are fresh out of residency where they had been working 60-80 hours per week with 1-month service blocks and 4 days off per month. They are used to working long hours and working many days in a row. For these hospitalists, a 7-day on, 7-day off schedule with 12-hour shifts can seem like career heaven. From their vantage point, they have a vacation every other week. They have been doing night block rotations for the past 3 years and still owe a lot on their medical school loans so they do not object to doing night shifts, as long as they get paid a shift differential. They will likely need maternity and paternity leave.
• The 40-year old hospitalists. They now have 10 years of hospitalist experience and with that experience, they have become very efficient. They can take care of more patients per day and still finish their daily work sooner than the 30-year old hospitalist. They begin feeling resentful when they are sitting around in the physician lounge at 4:00 pm reading the newspaper and waiting for their shift to end while their kids are playing in a little league game that they are missing. They want to be able to schedule their shifts around their family’s calendar.
• The 50-year old hospitalists. With 20 years of hospital medicine behind them, they are highly efficient. They began working as hospitalists in the very beginning of the hospitalist movement and now are valuable as mentors for younger hospitalists. They feel that they have put in their time and do not want to do overnight shifts. They are taking on administrative roles in exchange for doing fewer shifts. Working 7 days in a row is increasingly tedious. They would often prefer to do more shifts per year in exchange for the shifts being shorter.
• The 60-year old hospitalists. There are very few of these now but as the current hospitalists continue to age, they will be increasingly common in the future. They are close to retirement and are less interested in making major career changes at this point in their lives. Their children are now grown so as empty-nesters, they do not have the priority of getting home early or having weekends free. But they prefer lower acuity patients.

The main point is that different hospitalists have different priorities. Some hospitalist groups will develop their own work schedule culture and then hire new hospitalists who share those same priorities. These groups can have a fairly standardized schedule and keep everyone happy. Other hospitalist groups will have a more heterogenous set of hospitalist priorities and forcing hospitalists into shift schedules that do not match their priorities will result in unhappy hospitalists and a high turn-over rate. The bottom line is that it is essential that you know what your own hospitalists’ priorities are.

Fiscal responsibility

Hospitalists are expensive. The average hospitalist total compensation varies considerably by region and by who is doing the salary survey but the national average is about $290,000 for salary, bonuses, and incentives. If you add in other benefits (malpractice insurance, retirement, disability insurance, health insurance) as well as the cost of recruiting a new hospitalist (at least $30,000 in direct costs alone), the number rises considerably. It is virtually impossible for hospitalists to cover their entire costs from professional revenue alone and almost all hospitalists require hospital subsidization. This subsidy will vary from hospital to hospital but $200,000 per hospitalist is typical.

Because of the magnitude of this expense, hospital CEOs want value from their hospitalists. That means hitting the sweet spot of the hospitalists seeing as many patients per day while at the same time keeping the per-patient costs as low as possible and at the same time keeping the patient outcomes has high as possible and at the same time keeping hospitalist turnover as low as possible.

The relationship between these variables is complex. For example, the amount of subsidy that the hospital has to pay per hospitalist compared to the number of patients seen per day by the hospitalist is fairly linear (red line above). The more patients a hospitalist sees per day, the more professional revenue the hospitalist generates and therefore the less subsidy the hospital has to provide. On the other hand, the relationship between hospitalist case load and patient outcomes is exponential instead of linear (blue line above). Once a critical number of patients per day is exceeded, patient outcomes worsen and per patient hospital expenses increase. Having a hospitalist take care of one patient per day would result in the best outcomes but would be prohibitively expensive. On the other hand, having a hospitalist take care of 25 patients per day would cost the hospital very little in hospitalist subsidy but would result in devastatingly poor patient outcomes, longer length of stay, and frequent hospitalist turnover.

So, what is the best schedule?

By now, it should be clear that there is no one single best hospitalist schedule. The best schedule at any given hospital will depend on the unique needs of that hospital and the priorities of the individual hospitalists. But the underlying theme of scheduling success is flexibility. To understand how to incorporate flexibility into your hospitalists’ schedule, it is first necessary to understand the circadian rhythm of the hospitalist’s workday. A typical day would look something like this:

7 AM to 8 AM – chart review

8 AM to 10 AM – morning work rounds

10 AM to 11 AM – interdisciplinary rounds

11 AM to 1 PM – discharges

1 PM to 3 PM – write daily notes

3 PM to 6 PM – new admission work-ups

6 PM to 7 PM – chart review

7 PM to 12 midnight – evening admissions

12 midnight to 7 AM – emergency calls

In terms of the amount of work, hospitalists are generally busy from early morning to mid afternoon, have a lull until early evening when admissions start to increase, then have a bigger lull after midnight. Each hospital will have slightly different hospitalist needs by time of the day so it is important that you track your admissions by time of the day in order to optimize hospitalist schedules. A typical hospital’s requirements are as seen below:

There are several tactics that you can take to achieve the goals of optimizing hospitalist satisfaction and optimizing patient outcomes while being fiscally prudent:

1. Know what your hospitalists want. Knowing what is valued by each party is the key to any successful negotiation. Survey your hospitalists to find out what their scheduling priorities are. Because those priorities will change as a hospitalist gets older and as their family life changes, get in the habit of re-assessing their individual priorities annually.
2. Know your hospital’s hourly hospitalist needs. This  will require you to learn how long it takes the hospitalists to do work rounds, interdisciplinary rounds, and daily charting. You will need to know what time of day your patients are typically discharged and what your average admissions are by hour of the day.
3. Incentivize continuity. Because it takes a hospitalist less time to care for a group of patients the more continuous days that hospitalist works, use that to your mutual advantages. For example, when working a 7-on and 7-off schedule, consider making the first 3 days of the 7-day block 12-hour shifts, the next 3 days of the block 10-hour shifts, and the last day of the block an 8-hour shift. Let the hospitalists take home calls from the nurses until the night shift hospitalist arrives.
4. But you don’t need continuity at night. The night shift hospitalists are there for new admissions and patient care emergencies. They are not necessary for the regular continuity of care and it is not essential that they do consecutive days on-duty.
5. Consider an observation unit. By definition, observation patients spend less than 2 midnights in the hospital. Their care is often more protocoled and with their short hospital stays, it is less necessary for daily continuity. Hospitalists covering observation units do not need to adhere to a consecutive 7-day on schedule to ensure optimal outcomes.
6. Align shift duration with workload. If you find that the hospitalists are often done with their work at 3:00 PM, then create an option for them to leave the hospital at 3:00 but to carry their pager for nursing calls and do their evening chart review later from home. This may require designating one or more hospitalists to have the “long shift” to cover admissions and patient emergencies until the night shift hospitalist arrives.
7. Use resident teaching services strategically. Residents learn the most when they do their own admissions and then follow those patients that they admitted. So, consider having the teaching services take the bulk of new admissions in the mornings and early afternoons. That frees up the hospitalists to get their daily rounds completed and get their discharges out earlier in the day so that they can then take admissions in the evening and night.
8. Flexibility, flexibility, flexibility. If you ask hospitalists what the one thing is that they would like in their schedule, it is flexibility. Maybe they want a particular day off for their spouse’s birthday. Maybe they want to be able to get home in time to pick up their kids from school. Maybe they are planning a 2-week international vacation and want to do a 14-day work block to accrue 14 consecutive days off. A schedule that is too rigid will lead to dissatisfaction. Preserve the ability of the hospitalists to switch shifts for days off on short notice. Create a short shift/long shift schedule so the 40-year old hospitalists can pick-up their children from grade school. This may require some scheduling creativity, for example, requiring a hospitalist to do one long shift for every short shift, requiring an extra shift per month for every 2 short shifts, or paying less for a short shift than for a long shift.
9. Be woman-friendly. Do not penalize maternity leave by requiring new mothers to make up the shifts that they were off during maternity leave. Once you know that one of your hospitalists will be out on maternity leave, if you won’t be able to cover her shifts internally then start looking for a locum tenens hospitalist for those months. New mothers may prefer doing more shorter shifts instead of fewer 12-hour shifts. Or they may want to come back part-time. Breast feeding hospitalists need extra time during the day to pump so be sure that there is backup coverage and/or give them fewer patients per shift. The majority of medical students are now women; in order to be competitive for the best hospitalists in the future, your hospital must be accommodating for pregnancy and new mothers.
10. Consider a swing shift. In most hospitals, the majority of hospitalist admissions come from the emergency department. The number of ER admissions tends to be low in the early morning hours, shortly after midnight. The number of admissions starts to rise in late morning and then peaks in the evening. Having an extra hospitalist or advance practice provider to help with admissions between 5:00 PM and 11:00 PM can improve patient throughput. Alternatively, have the swing shift start at 3:00 PM to cover both admissions and emergency calls on short-shift hospitalist’s inpatients.
11. Schedule holidays intelligently. Be equitable when assigning holidays. A policy of assigning the youngest hospitalists all of the major holidays can breed disgruntlement if those are the only hospitalists with young children at home. Don’t assign your Jewish hospitalist to be on-duty during Rosh Hashanah and Yom Kippur.  Don’t assign your Muslim hospitalist to be on-duty during Eid al-Fitr and Eid al-Adha. Don’t assign your Christian hospitalist to be on-duty on Christmas and Easter. Different people prioritize New Year’s Day, MLK Day, Memorial Day, and Thanksgiving differently so create a preference list each year allowing hospitalists to choose which of those holidays they want to be off-duty.
12. Consider an advance practice provider. If your hospitalists strongly prefer fewer consecutive days on-duty, then an APP can bridge the continuity gap. A nurse practitioner or physician assistant who works on the same nursing unit Monday through Friday every week can allow for the improved outcomes that continuity brings. The APP results in the supervising hospitalist being able to cover more inpatients by freeing the hospitalist up from time-consuming data collection, note writing, and paperwork. Having a consistent APP permits the hospitalists to do fewer consecutive work days.
13. Align incentives. The hospital is going to have to subsidize the hospitalists so use the subsidization as an opportunity to align what the hospital wants (optimal patient outcomes and low inpatient costs) with hospitalist bonuses and incentives. With respect to the hospitalist schedule, an example could be bonusing based on the number of times the day shift hospitalists do 7 consecutive days on-duty each year.
14. Be willing to change. Just because you had a 7-on, 7-off schedule last year does not mean that you must have a 7-on, 7-off schedule next year. Don’t be committed to one schedule simply because that is the way that you have always done things. If 7 consecutive days on is too much, try 6. If 7 consecutive days off is too little, try 8. If your hospitalists are consistently done with their work at 4:00 PM, then change to 8-hour day shifts with a reduced staff 4-hour evening shift before the 12-hour night shift.

For many years, our hospital had two hospitalist groups – a private group that did mostly 7 days on, 7 days off with shifts that were 12 hours each and an academic group that did more shifts per year per hospitalist but many of the shifts were shorter than 12 hours. The two groups attracted different types of physicians with different priorities. The physicians in both groups were equally happy and the patient outcomes were similar. The lesson was that you do not have to do the same thing for everybody in order to achieve the same level of success.

May 19, 2022

An important mission of the hospital is the relief of suffering and that includes relief of pain. Pain management programs are central to fulfilling this mission. The past decade has taught us that you cannot effectively manage pain with an opioid prescription alone. The combination of opioid addiction plus the COVID-19 pandemic has proven to be lethal for many Americans. Last year, there were 100,306 drug overdose deaths in the United States, up by 28.5% from the 78,056 overdose deaths in the previous year. The vast majority of these deaths were caused by natural or synthetic opioids and for many of these people, their addiction started with a pain medication initially prescribed by a doctor.

In the 1990’s, “Pain as the 5th vital sign” was the mantra of pain management services with the implication that physicians were not prescribing enough opioids and that it was our moral duty to prescribe more. The consequence of this campaign was that many of our patients became opioid-dependent. When we realized this, the pendulum swung the other way, with state medical boards restricting the amount and duration of opioid prescriptions that doctors could order. As a result, the supply of prescription opioids fell dramatically and the opioid-dependent population turned to illegal opioids. Coincident with this, inexpensive synthetic fentanyl became readily available on our streets and many Americans died of unintentional overdose due to the unpredictable concentrations of fentanyl in purchased quantities of street drugs.

The good news, is that we have a number of great alternatives to opioid pain medications for both acute and chronic pain management. However, a high-functioning hospital needs to have  more than just one of these pain management services.

What is pain, anyhow?

Pain exists when our peripheral nerves let us know that a part of the body is being injured. This is a great defense mechanism to avoid bodily harm, for example, pain is how we know to pull our hand away when we touch a hot stove. But pain can become pathologic when those pain nerves keep firing even though there is no avoidable injury – for example, the patient with bone metastases from cancer, the patient hospitalized after multiple trauma, the patient with chronic arthritis, or the patient recovering from a knee replacement surgery. In those situations, the pain nerves just keep firing away and there is nothing that the person can do by themself to make those nerves stop.

But there is a lot more to the perception of pain than just signal from a peripheral nerve. There are pain amplifiers that can turn the volume of pain up. The most important of these are fear, anxiety, and depression. Often, the presence of one of these modifiers can convert tolerable pain into intolerable pain.

What pain management services does the hospital need?

Comprehensive pain management does not boil down to having a single pain management service. Hospitals need to have a spectrum of options for treating pain in order to do the most good for the most people. All too often, the physicians or advance practice providers who are proficient with one type of pain management option are not proficient with other options.

1. Acute pain services. These are inpatient providers, frequently anesthesiologists, nurse anesthetists, pharmacists, and/or nurse practitioners. These providers are very good at managing temporary pain, particularly post-operative pain and trauma-related pain. They will have experience in managing pain pumps and in selecting opioid and non-opioid pain medications that are meant to be used for limited numbers of hours or days. A larger hospital can afford to maintain an acute pain service but the low patient volume at a smaller hospital may make an acute pain management service cost-prohibitive. In order to serve our smaller, urban hospital, we created an acute pain telemedicine consultation service with providers located at our larger, tertiary care hospital located on the other side of town.
2. Pain and palliative care services. These are providers who may work in either inpatient or outpatient areas and typically focus more on chronic pain management. They are usually physicians who have completed a palliative medicine fellowship who lead a team that may include nurse practitioners, physician assistants, pharmacists, and social workers. Cancer-related pain and sickle cell anemia-related pain are examples of their clinical focus. Although chronic opioid prescription may be a part of their practice, they will also typically address pain modifiers, such as fear and depression.
3. Interventional pain services. These are physicians who have done fellowship training in interventional pain management and most commonly draw from anesthesiology, physical medicine & rehabilitation, and neurology. Their practice is generally outpatient and many include steroid injections, radiofrequency ablation, intrathecal pumps, sympathetic blocks, peripheral nerve stimulators, and spinal stimulators. They will often interface with outpatient therapies such as physical therapy, aqua therapy, and psychology. The procedures that they perform often require use of the operating room or an imaging area such as a cath lab or interventional radiology lab. Many of their procedures are done using moderate sedation but some may require general anesthesia.
4. Sports medicine. These are family physicians, internists, or pediatricians who have done fellowship training in sports-related injuries and over-use injuries. Despite the name, sports medicine physicians treat many patients who are not athletes. They will often interface with physical therapists, athletic trainers, and orthopedic surgeons when directing specific treatments for injuries accompanied by pain.
5. Complementary and alternative medicine. This includes a wide variety of services such as acupuncture, massage therapy, chiropractic treatments, yoga, and traditional Chinese medicine. Although physicians may be involved in alternative medicine, many of these providers are non-physicians. Many hospital medical directors take a jaded view of alternative medicine. However, these services can often de-amplify pain by reducing anxiety and fear. They can also provide a sense of control to patients with chronic pain that can make pain much more manageable. Regardless of what the hospital medical director may think, if the patient believes that these services work, then they can be beneficial.
6. Inpatient physicians. Hospitalists, surgeons, and anesthesiologists are the first-line of pain management for most inpatients. However, the formal training that they get in pain management is highly variable. Clinical practice guidelines and treatment protocols can be very useful to ensure a hospital-wide standard of practice. Periodic continuing medical education events are also valuable. One of the most important roles of these physicians is to manage pain expectations. If patients are told that they are going to have post-operative pain before they actually have their surgery and they are told that their pain will be manageable with non-steroidal anti-inflammatory drugs and physical therapy, then those patients are less likely to require opioids post-operatively compared to patients who go into surgery unprepared to experience any pain after surgery.
7. Outpatient physicians. Primary care physicians, surgeons, and emergency medicine physicians are the front-line of pain management for most outpatients. Once again, their formal training in pain management can be highly variable and so just as for inpatient physicians, clinical practice guidelines, treatment protocols, and periodic continuing medical education are usually necessary. Most state medical boards have state-specific rules and regulations regarding chronic opioid prescription and  it can be very difficult for the primary care physician to ensure that all of the monitoring and documentation requirements are met. A robust electronic medical record can help with this. But if there is a critical mass of patients receiving chronic opioid medications, an advanced practice provider dedicated to chronic, stable-dose opioid management can be cost-effective.

In addition to pain services that manage a spectrum of conditions, there are also disease-specific specialists needed to manage certain conditions. Migraine (often managed by neurologists) and fibromyalgia (often managed by rheumatologists) are two examples. Having a physician on the hospital medical staff who specializes in these conditions can help avoid primary care physicians ordering opioids out of frustration.

Match the patient with the pain service

Although there is frequently a lot of overlap between different types of pain services, to optimally meet the needs of the most patients, all seven of the above pain services need to be available – if not in each hospital, then at least somewhere in the community. No two patients are exactly alike when it comes to pain tolerance and pain perception. Treating fibromyalgia with chronic opioids just doesn’t work. Nor does bone metastasis pain with physical therapy. We should strive to match the patient’s type of pain with the right type of pain service.

Our natural tendency as humans is to use whatever tool we are familiar with to fix whatever problem we face (“When all you have is a hammer, everything looks like a nail”). When it comes to pain management, be sure that your hospital has a full toolbox.

February 19, 2022