David Likosky

Inpatient falls: defining the problem and identifying possible solutions. Part I: an evidence-based review.

In this 2 part series, analysis of the risk stratification tools that are available, definition for the scope of the problem, and potential solutions through a review of the literature are presented. A systematic review was used to identify articles for risk stratification and interventions. Three risk stratification systems are discussed, St Thomas’s Risk Assessment Tool in Falling Elderly Inpatients, Morse Fall Scale, and the Hendrich Fall Risk Model. Of these scoring systems, the Hendrich Fall Risk Model is the easiest to use and score. Predominantly, multifactorial interventions are used to prevent patient falls. Education and rehabilitation are common themes in studies with statistically significant results. The second article presents a guide to implementing a quality improvement project around hospital falls. A 10-step approach to Plan-Do-Study-Act (PDSA) cycles is described. Specific examples of problems and analysis are easily applicable to any institution. Furthermore, the sustainability of interventions and targeting new areas for improvement is discussed. Although specific to falls in the hospitalized patient, the goal is to present a stepwise approach which is broadly applicable to other areas requiring quality improvement.

Survey of neurohospitalists: subspecialty definition and practice characteristics.

Neurohospitalists represent an emerging neurological subspecialty focusing on inpatient neurological disease. Little data exists regarding neurohospitalist practice information and clinical activity. A survey among neurohospitalists was performed to help define the subspecialty, yield demographic information, practice characteristics, and understand clinical and non-clinical activities. During the formation the Neurohospitalist Section of the American Academy of Neurology September 2008, an online survey (29 questions mixed categorical, numerical, and free text) of 93 neurohospitalists was performed. The survey closed on October 13, 2008. The survey achieved a 54% response rate. Eighty-two percent of respondents were male, mean age 42 (range, 34–68), median practice duration 6 years, with broad distribution of practices across the US. Seventy-five percent of respondents reported having general neurology residency plus additional fellowship training (54% vascular neurology fellowship, 13% neurocritical care, and 33% other no response). Fifty-one percent of neurohospitalists were hired by non-academic (private) institutions, whereas academic institutions hired 49%. There was a wide array of responses for call frequency, duration, number of practice partners, and annual income. A uniform definition of the neurohospitalist subspecialty emerged as one who cares for inpatients, focusing primarily on in-hospital responsibilities. Neurohospitalists defined themselves as inpatient neurological subspecialists. Neurohospitalists have a broad US geographic distribution (and possibly international), in both academic and private practice (or hybrid) forms, and typically provide inpatient and Emergency Department (ED) call coverage for hospitals or outpatient neurologic practices. Most neurohospitalists were involved in administrative aspects of stroke or inpatient quality initiatives.

Inpatient Falls: Defining the Problem and Identifying Possible Solutions. Part II: Application of Quality Improvement Principles to Hospital Falls.

In this 2 part series, analysis of the risk stratification tools that are available and definition of the scope of the problem and potential solutions through a review of the literature is presented. A systematic review was used to identify articles for risk stratification and interventions. Three risk stratification systems are discussed, STRATIFY, Morse Fall Scale, and the Hendrich Fall Risk Model (HFRM). Of these scoring systems, the HFRM is the easiest to use and score. Predominantly, multifactorial interventions are used to prevent patient falls. Education and rehabilitation are common themes in studies with statistically significant results. The second article presents a guide to implementing a quality improvement project around hospital falls. A 10-step approach to Plan-Do-Study-Act (PDSA) cycles is described. Specific examples of problems and analysis are easily applicable to any institution. Furthermore, the sustainability of interventions and targeting new areas for improvement are discussed. Although specific to falls in the hospitalized patient, the goal is to present a stepwise approach that is broadly applicable to other areas requiring quality improvement.

Who Will Care for Our Hospitalized Patients

To the Editor: Much debate has recently focused on who is best qualified to care for stroke patients.1,2 Arguments have been made for the certification of a neurology subspecialist—the “strokologist.”3 Care for the stroke patient is complicated now and only becoming more so. However, in an era when subspecialty coverage for emergency and inpatient care is scarce, the more appropriate question seems not who should care for these patients but rather, who will shoulder this responsibility. Neurologists have been accused of being …

IS IT TIME FOR NEUROHOSPITALISTS

We read the invited article by Freeman et al.1 regarding the advantages of neurohospitalists, which represents an emerging field of neurology serving cost-effective, high-quality medical care to the inpatient population. The authors postulated potential advantages of improved logistical efficiency leading to improved patient outcome but how this is achieved was not explained. In our 400-bed academic medical center at the University of California, Irvine (UCI), the Hospitalist Program consists of 16 board-certified hospitalists physicians from nine medical specialties: internal medicine, family medicine, pediatrics, neurology, geriatrics, palliative care, adult infectious disease, pediatric infectious disease, and critical care. One of us (G.Y.C.) joined …

Survey of current neurohospitalist practice

Summary Neurohospitalists represent a new approach to inpatient neurologic care. In order to characterize this practice, we surveyed both a general neurology sample as well as a sample of pertinent American Academy of Neurology sections. Of the section sample, 42% defined themselves as neurohospitalists, compared to 16% of the general sample. The majority of neurohospitalists are in an academic setting and share call responsibilities with non-neurohospitalists. Many are concerned about the possibility of burnout in their current practice setting. This representative sample of neurohospitalists reveals a diverse group facing a number of unanswered questions and challenges, including concerns for burnout, ideal practice setting, and defining the core curriculum for a neurohospitalist.

In-hospital falls: evaluation and response.

Purpose of Review: In-hospital falls are a significant source of morbidity in the inpatient setting and a common reason for neurologic consultation. Patients with neurologic disease are at increased risk for these falls. Neurologists should attempt to identify those who are at risk and mitigate risk using individualized and systemwide approaches. Recent Findings: Organizations such as the Centers for Medicare & Medicaid Services and the Joint Commission have brought increased scrutiny on this serious issue. Care for in-hospital falls resulting in serious injury is no longer reimbursed by Medicare, and in-hospital falls represent sentinel events requiring investigation according to the Joint Commission. Even the best-performing fall risk stratification tools have limitations in both sensitivity and specificity. However, recent randomized trial data demonstrated the efficacy of targeted intervention to modifiable risk factors in reducing falls in the hospital. Summary: The combination of acute illness, patient vulnerability, and environmental factors in the hospital plays a critical role in determining fall likelihood. A systematic approach to identification of modifiable risk factors and application of measures designed to remove or compensate for them has the potential to reduce the burden of falls and their consequences. Careful evaluation of the patient who has fallen is important given the likelihood of harm in vulnerable patients as well as the potential for subtle presentations of serious injuries. It is incumbent on the practicing neurologist to be aware of the scope of the issue, the potential underlying risks in each patient, strategies to mitigate those risks, and how best to approach the patient who has fallen.

The Role of Hospitalists in the Acute Care of Stroke Patients

Opinion statementStroke care has become progressively more complicated with advances in therapies necessitating timely intervention. There are multiple potential providers of stroke care, which traditionally has been the province of general neurologists and primary care physicians. These new players, be they vascular neurologists, neurohospitalists, internal medicine hospitalists, or neurocritical care physicians, at the bedside or at a distance, are poised to make a significant impact on our care of stroke patients. The collaborative model of care may be or become the most prevalent as physicians apply their distinct skill sets to the complex care of inpatients with cerebrovascular disease.

If Not Neurohospitalists, Who? If Not Now, When?

There has been a national exodus of specialists leaving the hospital.1 The reasons for this are varied, but typically include factors such as declining reimbursement, perceived increased medicolegal risk, subspecialization away from inpatient work, increased expenses such as office overhead, and adverse effects on lifestyle. Neurology has been no different. It is no longer the case that medical staff privileges are seen as core to a practice and are not a necessity for referrals or malpractice insurance. The practice of inpatient medicine in general and neurology in particular has changed. The timelines are shorter, acuity is higher and the demands on the individual physician are greater. As a result, many neurologists have stopped participating in hospital care.2 Unfortunately, however, there remain patients with acute neurological issues who need a neurologist to care for them. Neurologists are not alone in their reticence or increasing difficulty in caring for inpatients. Emergency physicians have faced progressive shortages in many specialties, including plastic surgery, ophthalmology, otolaryngology, and neurosurgery. There has been a move toward marked subspecialization and many of the surgical specialists can now perform their procedures at their own facilities without the encumbrance of call which may have both a real financial as well as lifestyle cost.3 In addition, this subspecialization may make the physician feel uncomfortable or unqualified to take general emergency department call in their general specialty. This trend has resulted in a slowly burgeoning group of hospitalists, including obstetricians, acute care surgeons, gastroenterologists, and, most prominently, internal medicine hospitalists.4

Management of ischemic stroke: Part 2. The inpatient stay.

BACKGROUND Acute ischemic stroke is commonly encountered by the hospitalist. There have been dramatic changes in our ability to care for these patients both acutely and in secondary prevention. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) primary stroke center certification has become progressively more important to institutions nationally and emphasizes many elements of the inpatient stay and discharge process. PURPOSE After admission, the focus changes to avoidance of complications and the appropriate initiation of allied therapies and secondary prevention. DATA SOURCES Primary trials, current guidelines. CONCLUSIONS The hospitalist is well-positioned to play a major role in the treatment of stroke patients as well as the systems work that aids in the management of this population.