Research Project: Peer Editing Paper

High mortality results from infection within healthcare institutions whether community or hospital acquired. Hospitalists provide inpatient care with increasing frequency due to the overwhelming workload upon primary care physicians. However, hospitalists are generalists and are minimally prepared to attend patients with serious infections which may rapidly overwhelm particularly in vulnerable populations. Duplication of diagnostic testing, prolonged length of stay drives up costs for institutions and patients. Erroneous or inadequate prescription of antibiotics costs lives, Infectious disease specialists are inadequately utilized despite statistical evidence that such specialty care improves outcomes. Education, collaboration between providers, and prescribing guidelines are recommended to address these needs.

Providers Challenge for Treating Infectious Disease

Technology has become increasingly advanced and the ability to diagnose, treat, and manage patients is ever evolving. Although advancements in imaging, surgical procedures and medication therapies make possible a better quality of life, they are often required to self-manage very serious disease and infection. Insurance companies and healthcare regulations often guide the path providers must take to care for patients. The length of stay in hospitals are decreasing and patients are being treated on an outpatient basis. Patients often receive care in outpatient rehabs, infusion centers, and home health agencies with medications supplied by specialty pharmacies. Drug resistant organisms are becoming more common and the risks associated with treating these organisms can often be challenging to manage. Treatment is often received for an extended amount of time and many primary care providers no longer see patients on an inpatient basis. This means that hospitalists assume care when they are admitted into the hospital but are unable to follow the patient for the remainder of treatment when they are discharged. When complications arise for these patients, they have limited ways of seeking help. There is fragmented care and lack of continuity. In the case of patients diagnosed with infection, questions about when hospitalists should consult specialists such as infectious disease physicians often occur. Mortality and morbidity for patients as well as hospital stays and readmission are decreased when an Infectious Disease physician is consulted early (CDC, 2013). Research is focused on the education of these two types of physicians, why some providers decide not to pursue a specialty, as well as success rates of patients treated by both. Factors affecting the care of patients, unnecessary testing and treatments, the need for stewardship programs in hospitals, and other associated issues are also discussed. Research Project: Peer Editing Paper

Impact of Infection

Infection is often the diagnosis for admission into the hospital for many patients. However, infections can also be acquired or developed in the hospital. “Some common infections include clostridium difficile, bacteremia, central line associated bloodstream infections (CLABSI), bacterial endocarditis, HIV/opportunistic infections, meningitis, osteomyelitis, prosthetic joint infections, septic arthritis, septic shock and vascular device infections” (Schmitt, 2013, para 3). Whether infection develops in or out of the hospital, many causative organisms become resistant to treatment. When this occurs, successful treatment becomes much more challenging. “Infections are among the top leadings causes of death in the United States” (Schmitt, 2013, para 1). Additional testing including specific blood analyses, cultures of the infected sites, stool samples, aspirate of infected area, biopsy, or imaging are often ordered to determine causative organism(s) and to what antibiotic it is sensitive. After results have been obtained from diagnostic testing and bloodwork, then assessment of the patient’s health status, medication profile, and allergies must be considered. Once treatment decisions are determined, insurance coverage and approval also must be obtained; and the physician must order what they deem as necessary and best practice. The question then becomes not only what treatment is necessary, but what provider and what setting is best suited to optimize care for the patient. Resource utilization is key. Research Project: Peer Editing Paper

Hospitalist Care

Workload increase is experienced by physicians as they struggle to meet the demands of facilities where they practice. “Hospital administration and financial officers demand increased productivity by physicians to compensate for decreased revenue from insurance companies” (Elliott et al., 2014, p.786). Consequently, primary care providers often admit patients under the care of hospitalists. “Hospitalists are not required to have additional years of subspecialty training and often are paid higher wages than a board-certified infectious diseases physician, work in shifts with extended periods of time off, and have no outpatient overhead or responsibilities” (Chandrasekar et al., 2014, p.1594). While this lifestyle is attractive to physicians, it often negatively impacts continuity of care in the outpatient setting. Patients who are discharged from the hospital must follow up with their primary care provider or specialists if needed as there is no outpatient practice for the hospitalists who cared for them while hospitalized. Patients who do not have primary care providers must seek follow up care in a resource clinic, mission clinic, or emergency room if complications arise.

This increase in the workload, revealed in a recent survey of hospitalists, that more than 40% feel that they are exceeding what they perceived as a safe workload at least monthly and that increased workload led to delays in care, poor communication between physicians and patients, delivery of unnecessary care, medication errors, and complications of care, including death (Elliott et al., 2013, p.786).

These statistics are concerning as many patients whom the hospitalists care for often have difficult infections to treat. The question of when to consult an infectious disease physician to care for a patient is often a controversial issue among hospitalists.

Infectious Disease Specialist

The infectious disease (ID) physician is a resource who often is not effectively utilized in the hospital setting. ID have a specialized knowledge of drug resistant organism(s), new emerging pathogens, and geographical locations where infection occur. “Their education includes an emphasis on infection control, quality improvement, and antibiotic stewardship. Numerous hours are spent on presentations, meetings, and researching topic that deal with infectious disease and diagnostic microbiology” (Chandresekar et al., 2014). The lack of consultation for ID is often due to patients initially being admitted under hospitalist care. Hospitalists must understand the extent of the knowledge base of an ID physician, therefore see the need to consult them early for the best patient outcome. The incentive to study this career path is often not as attractive as the ever-growing hospitalist path. Recruiters of applicants for the infectious disease specialty have surveyed some reasons for possible shortages. Program directors of medical schools are offering some solutions to target graduates to apply for the infectious disease specialty.

It is time to review, update, and expand the syllabi for infectious diseases in medical school curricula. . . . Increasing knowledge and experience among medical students in areas of global health, HIV infection, antibiotic stewardship, and diagnostic microbiology would hopefully increase the pool of future applicants. The infectious diseases faculty (practitioners) need to work toward a mandatory rotation in infectious diseases for all internal medicine residents, (Chandrasekar et al., 2013, p. 1596).

Promotion of infectious disease topics with global attention and involvement is important as well for ID physicians. Although this field is very specialized, these physicians must also be afforded opportunities to participate with other sub-specialties regarding research and patient care. Interdisciplinary meetings with those who are involved more specifically in tropical medicine, or third world countries where the development of epidemics occur can also prove beneficial in the education of ID providers.

Educating Hospitalists and Improving Antibiotic Utilization

Inappropriate use of antibiotics and hospital acquired infections are both major concerns for the general public. Hospitalists are among the top physicians who admit patients with infection into the hospital, and the need to educate them to coordinate patient care with other healthcare providers is important. Patients with serious infections under the care of hospitalists only experience longer length of stay and higher mortality and morbidity rates (Kisuule, 2008). “More than 70% of hospital acquired infections are resistant to at least one commonly used drug” (Kisuule et al., 2008, p. 64). Five categories involving inappropriate use of antibiotics include: 1) antibiotics given for illnesses for which they are not indicated; 2) broad spectrum antibiotics overuse in the empiric treatment of common infections; 3) intravenous antibiotics prescribed for infection when oral agents would be similar; 4) inappropriate antibiotic dosage, schedule, and/or duration of treatment when the correct antibiotic choice is made; and 5) mismatch when susceptibility studies indicate that the drug being used is ineffective or only marginally effective i.e. “bug-drug” error (Kisuule, 2008). Formulating a model to guide antibiotic prescribing, developed with participation of providers including hospitalists is an important step in educating frontline providers and enhancing patient safety.

Antimicrobial Stewardship Programs

In the acute care setting, many facilities are adopting antimicrobial stewardship programs (ASP). The focus of these programs is to offer guidelines for physicians treating community or hospital acquired infections and facilitates. As hospitalists are often generalists, ASP allows them to feel comfortable prescribing antibiotic therapies in collaboration with or in the absence of ID physicians. It is important for patients to trust that the goal of the hospitalist is to achieve the best patient outcome while increasing knowledge base and promoting communication between providers. This helps to enhance patient experience, improve population health, reduce cost, and improve the work life of healthcare providers (Bodenheimer and Sinsky, 2014). “Reducing the use of antimicrobials where they are not indicated will slow down the emergence of antimicrobial resistance while ensuring antimicrobials remain an effective treatment, improving clinical outcomes, conserving resources” (NICE, 2015). The antimicrobial stewardship team should have core members such as an antimicrobial pharmacist and a medical microbiologist and contract other members depending on setting and resources (NICE, 2015). In order to be an affective change agent education and feedback are required for the healthcare providers. Data collection is an important part of this process to not only educate the importance of this change but also encourage prescribers to reflect on their personal practice. Implementing checks and balances such as an audit system and including objectives with a review in annual evaluations of the providers (NICE, 2015). “Commissioners could support a change in prescribing practice by using contracts to ensure that prescribers have the training and skills for antimicrobial stewardship” (NICE, 2015, p. 5). Information systems are critical for trending for feedback on prescribing, resistance, and patient use of prescriptions (NICE, 2015).

Conclusion

The world of infection continues to pose new challenges for treating patients with infection in both the inpatient and outpatient setting. The development and identification of new pathogens, advancements in diagnostic technology, and new antimicrobial therapies, the medical profession will undoubtedly continue to change and fine tune how they treat infectious diseases. Although hospitalists are considered a specialty, they have many aspects of a patient’s health to oversee including infection. Their knowledge base is vast and broad while infectious disease physicians have numerous hours dealing specifically with infection. They are faced with limited length of stays, an increased workload in the hospital, and their job is considered complete when the patient is discharged from the hospital. Infectious disease will further investigate the cause and the extended treatment of infection and possibly discuss prevention of reoccurrence and readmission for the same diagnoses. Hospitalists and infectious disease physicians are challenged to collaborate, communicate, and educate in an environment of transparency to strengthen antimicrobial stewardship programs for the delivery of high -quality care

Annotated Bibliography

Research topic will be benefits and risks of having the care of a specialist such as infectious disease, compared to hospitalist care in the inpatient care setting.

Gupta, S., Bansal, A., Newman, E. & Martin, S. (2017). Opportunities in the Acute Care Setting for Infectious Diseases/Hospitalist Patient Co-Management. Open Forum Infectious Diseases, 4(1), S328–S329. doi.org/10.1093/ofid/ofx163.777

This article speaks to the importance of consulting with an Infectious Diseases physician from the time of admission all the way to discharge and follow up care for patients. It also discusses the model of primary care physicians being the one to consult Infectious Disease leading to missed opportunities in care, testing, and use of antimicrobial, antifungal, or antiviral medication use. Lower mortality rates and readmissions being the benefit of patients seeing the specialist while they are inpatient is also discussed. The peril of not having the specialist to see the patients initially and how that can have long term effects on the patient’s care and overall outcome will be useful in my paper for comparing some pros and cons on hospitalist or primary care versus the specialist or Infectious Disease physician.

Elliott, D. J., Young, R. S., Brice, J., Aguiar, R., & Kolm, P. (2014). Effect of Hospitalist Workload on the Quality and Efficiency of Care. JAMA Internal Medicine, 174(5), 786. doi: 10.1001/jamainternmed.2014.300

This article discusses some of the issues that hospitalists face when they have an increased work load in the hospital and how that can affect patient’s outcome in a negative way. This supports my research that it is best to consult a specialist when it comes to infection diagnosis, care, and management. It also supports the idea that although hospitalists are trained physicians and can manage many conditions, that certain areas require more time and assessment of patients than others. In these situations, hospitalists may be overwhelmed with the number of patients to be seen and are not able to spend this needed time on patients.

Chandrasekar, P., Havlichek, D., & Johnson, L. B. (2014). Infectious Diseases Subspecialty: Declining Demand Challenges and Opportunities. Clinical Infectious Diseases, 59(11), 1593–1598. doi: 10.1093/cid/ciu656

This article discusses the shortage of applicants in medical school who apply to the infectious disease specialty. Awareness of the lack of support for these physicians while they are residents as well as when they are practicing is investigated. The need to revamp medical programs to include more opportunities for providers to spend time in their specialty. Strong mentorship and fellowship with other sub specialties for those who are pursuing infectious disease is suggested. The benefits of a hospitalist lifestyle and some perks to choosing that path are explored. Discussion about how the health care reform and other factors affect the desires of new physicians is also covered.

Pulcini, C., Botelho-Nevers, E., Dyar, O., & Harbarth, S. (2014). The impact of infectious disease specialists on antibiotic prescribing in hospitals. Clinical Microbiology and Infection, 20(10), 963–972. doi: 10.1111/1469-0691.12751

This article discusses how the use of Infectious Disease physicians influence the quantity and quality of antibiotic use in the hospital setting and discuss factors that could limit the efficacy of antibiotics. Appropriate antimicrobial therapy and ways to identify when oral versus intravenous therapies should be prescribed are explored. Discussion on how interventions from the Infectious Disease physicians resulted in an increased appropriateness of antibiotic prescribing compared to prescriptions ordered without the influence of an Infectious Disease physicians. This also describes the antimicrobial stewardship program in hospitals.

Kisuule, F., Wright, S., Barreto, J., & Zenilman, J. (2008). Improving antibiotic utilization among hospitalists: A pilot academic detailing project with a public health approach. Journal of Hospital Medicine, 3(1), 64–70. doi: 10.1002/jhm.278

Hospital setting where hospitalist practitioners discuss antibiotic prescribing patterns. Motives for chosen prescriptions are analyzed. Assessing the inappropriate use of antibiotics as a clinical health problem and public health concern. Actions taken before, during, and after details given of an intervention and how this can result in behavior change for the hospitalists or practitioners in this health setting is researched. Practice based learning components and improved antibiotic prescribing practices are found to be successful among hospitalists when there is the influence of an infectious disease specialist. Infectious disease specialists are able to collaborate with other providers and discuss their rationale for prescribing antimicrobial therapies to inpatients and follow up care upon discharge.

Nathan, C., & Cars, O. (2014). Antibiotic Resistance — Problems, Progress, and Prospects. New England Journal of Medicine, 371(19), 1761–1763. doi: 10.1056/nejmp1408040

This article discusses the recognition of antibiotic resistance, partnerships for antibiotic discoveries of new drugs, retreat if antimicrobial research, prevention of the lack of effectiveness, the need for global collaboration and leadership regarding antimicrobial therapies, and access to life saving antibiotics. It also details tailoring antimicrobial therapies to only susceptible pathogens, and controlled access of drugs. The global action plan is delivered on antimicrobial therapies. The proposition of antimicrobial stewardships in health care facilities, communities as well as collaboration nation- wide is addressed. An increase in the monitoring of antibiotic effectiveness, renewed interest and promotion of vaccinations, and attention to sanitation is discussed.

Redwood, R., Knobloch, M. J., Pellegrini, D. C., Ziegler, M. J., Pulia, M., & Safdar, N. (2018). Reducing unnecessary culturing: a systems approach to evaluating urine culture ordering and collection practices among nurses in two acute care settings. Antimicrobial Resistance & Infection Control, 7(1). doi: 10.1186/s13756-017-0278-9

Inappropriate ordering of culturing and samples of various types continue to be an issue in the field of healthcare. Treating antimicrobial resistant organisms continues to climb as well. Investigations of ordering urine cultures and collection practices among nurses is researched to identify issues and human factors that may result in unnecessary antimicrobial therapy. Focus study is in emergency department and intensive care unit nurses. This would detail how human factors and foundation of nurses working with patients can affect what physicians order and what antimicrobial therapies patient may take and become resistant to. These patients would then benefit from Infectious Disease physicians per other articles.

Fair, R. J., & Tor, Y. (2014). Antibiotics and Bacterial Resistance in the 21st Century. Perspectives in Medicinal Chemistry, 6. doi: 10.4137/pmc.s14459459

This article discusses the rise of antibiotic resistance, the decrease in pharmaceutical investment, the over prescription of antibiotics and public misconceptions. Misuse of antibiotics by the food industry, and human independent resistance, emergent bacterial threats, and various resistant organisms are also identified and detailed. Hospital acquired and community acquired infections along with searches for new antibacterial agents are discussed as well. This information helps to emphasize the quantity of these types of infections and the importance of appropriately prescribing these medications and not misusing them. Increased education for patients with information and brochures to ensure knowledge about antibiotics is encouraged. The use of antimicrobial stewardship programs to monitor the use of antimicrobial therapies is explored.

Llor, C., & Bjerrum, L. (2014). Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Therapeutic Advances in Drug Safety, 5(6), 229–241. doi: 10.1177/2042098614554919

This article describes antibiotic resistance as one of the greatest threats to humans. The tradition of this being only a clinical problem in the hospital and the trend of these types of patients existing in the community and now being treated by primary care physicians in an outpatient setting instead of specialists for inpatients. Increased complications in mortality rates, complications of disease, and more frequent admissions to the hospital are also a regular occurrence. Higher mortality and morbidity rates, longer length of stay and readmissions are also stated. Some interventions to assist with decreasing these numbers are discussed and suggest for practitioners and all forms of healthcare providers.

Morley, G. L., & Wacogne, I. D. (2017). UK recommendations for combating antimicrobial resistance: a review of ‘antimicrobial stewardship: systems and processes for effective antimicrobial medicine use’ (NICE guideline NG15, 2015) and related guidance. Archives of Disease in Childhood – Education & Practice Edition, 103(1), 46–49. doi: 10.1136/archdischild-2016-311557

This reference supports antimicrobial stewardship programs including but not limited to implementation, guidelines for initiation evaluation and ongoing support thereof. The need for providers to be educated and given feedback regarding their treatment plan, and their rationale and motive for antimicrobial therapies ordered. Support staff and stakeholders are discussed as well as those individuals that would be contracted out to make these programs successful. Resources and financial information guidelines are presented as well as tools to assist administration in evaluating physicians. Benefits and challenges of having an antimicrobial stewardship program in a healthcare facility for all parties involved is detailed. The success for treating infection that is attained when there is the use of an ASP is discussed as well.

Research Project: Peer Editing Paper