But See the Patient First
A 55-year-old man with acute myeloid leukemia presented to the emergency department (ED) with a chief complaint of fever. Five days previously, he had recently completed his third cycle of consolidation chemotherapy (high dose cytarabine). He reported no focal symptoms. His temperature was 38.8°C and his pulse rate was 110 beats per minute. Physical examination did not reveal a focal site of infection. He was found to have neutropenia (absolute neutrophil count, 120/microliter, reference 1,500-8,000) and thrombocytopenia (platelet count 22,000/microliter, reference 150,000-400,000). The patient was admitted, blood and urine cultures were obtained, and intravenous cefepime was initiated for neutropenic fever. He reported subjective improvement over the next 24 hours.
Overnight on hospital day 2, the patient’s temperature was 38.7°C on a routine vital sign check, with no significant change to other vital signs. The cross-covering physician was paged and, following sign-out instructions from the primary team, requested repeat blood cultures. The cross-covering physician did not evaluate the patient in person but confirmed that the blood cultures obtained at admission still showed no growth.
On rounds the following morning, the patient reported new oral pain which had started early the previous day. On physical exam, he had grade 2 mucositis, as per the Common Terminology Criteria for Adverse Events (CTCAE) in cancer therapy from the National Cancer Institute (i.e., painful erythema, edema, or ulcers but eating or swallowing possible). Given his clinical stability and negative cultures, antibiotics were not escalated. Mucositis was managed with supportive care, including salt and sodium bicarbonate mouthwash, lidocaine mouthwash for pain, and dietary modification. Both sets of blood cultures remained negative and the patient was discharged on hospital day five with clinical improvement and neutrophil count recovery.
By Voltaire R Sinigayan, MD
Providing cross-coverage care is considered a core responsibility of inpatient providers. It is also often seen as a rite of passage for most physicians during their formative years of training due to the multiple and daunting responsibilities involved. With the increased number of patient encounters many inpatient providers are expected to maintain, along with the increased number of people involved in patient care, interruptions to a provider’s workflow which are punctuated by pages, texts, and calls have vastly increased and are more frequent than ever before. Tasks which often require periods of full attention, such as bedside assessments, can unfortunately be seen as burdensome or, even worse, a waste of one’s time. During cross-cover, when a sole provider is pulled in many different directions with competing responsibilities – answering multiple pages, admitting patients in the ED, following up on tasks that were handed off – performing a bedside assessment may provide little added information and be viewed as an inefficient use of one’s time.
In this Case, the clinical stability of the patient may have prompted the cross-covering provider to be comfortable with not conducting an in-person bedside assessment. The ultimate clinical outcome was unchanged, possibly reinforcing the provider’s clinical reasoning that a bedside assessment had not been warranted. However, health professionals need to build safer systems and encourage providers to evaluate patients in-person when appropriate, versus reflexively “panculturing.” Currently, there are no best practices guidelines on cross-coverage care.
In this Case, the patient experienced fevers and the cross-covering provider was given sign-out instructions on what to do in the case of fevers. Fevers are a common occurrence among inpatients, and often encountered by overnight providers who may be cross-covering. Because of extremely diverse etiology and clinical backgrounds, there is no standardized guideline for the appropriate work-up for fever in a hospitalized patient.1 Ideally, the work-up should take careful consideration of specific populations such as those who are immunocompromised and receiving chemotherapy, since prompt evaluation and management for those patients is critical. Appropriate evaluation of patients with neutropenic fever should include a history and examination with emphasis on skin, oral mucosa, sinuses, lungs, abdomen, perianal, and catheter-insertion sites. Two sets of blood cultures should be obtained, symptoms-guided imaging should be considered, and empiric antimicrobial therapy with an antipseudomonal agent (piperacillin-tazobactam, or cefepime) should be initiated.2,3 The presence of hemodynamic instability, suspected catheter infection, skin and soft tissue infection, pneumonia, or severe mucositis can indicate the addition of vancomycin alongside appropriate further work-up. Sinus signs and symptoms can prompt imaging for sinusitis, which can be fungal in nature, warranting the addition of antifungal agents.2,3 A rectal exam should never be performed in a patient with neutropenia, but non-invasive inspection of the peri-anal region is indicated. Low-grade oral mucositis can easily be diagnosed upon physical exam and managed with careful dental care, including salt and sodium bicarbonate mouthwash and pain control.4 A timely diagnosis of oral mucositis will lead to appropriate therapy and improvement of the patient’s overall condition, and avoid unnecessary testing.
The patient in this Case was appropriately managed for neutropenic fever initially. However, overnight, a repeat fever prompted ‘’culturing the patient’’ without an in-person bedside assessment. This situation, in which inpatient providers obtain blood cultures for patients with any fever, is actually a very common, almost daily (and nightly) occurrence. Unfortunately, published guidelines do not provide clear indications for use of blood cultures.4 As a result, the sign-out instructions of “culture if spike” is the most common anticipatory guidance communicated between inpatient providers, occurring in up to 75% of written sign-out instructions according to Horwtiz et al.5 Unfortunately, blood cultures are low in yield6 and a false positive can often lead to more blood cultures, unnecessary antibiotics, and increased hospital costs and length of stay.7,8 Yet, due to the high mortality associated with blood stream infections and with the ease of electronic ordering, along with the added false sense of security of “doing something,” physicians are likely to continue to order blood cultures frequently.
For the patient in this Case, an in-person beside assessment might have detected developing oral mucositis. Symptoms in patients with neutropenia may be more subtle due to lack of florid inflammation. While mucositis was luckily not severe in this patient, in severe mucositis, empiric vancomycin is indicated. Often, especially while busy on cross-cover, inpatient providers do not conduct in-person evaluation of patients with neutropenic fever, relying only on sign-out instructions instead, which heavily influences behavior. In a prospective study of 253 episodes of fever at a US academic medical center, residents evaluated the patient in-person in just 29 (11%) of the cases.1 Guidelines published by the American College of Critical Care Medicine and the Infectious Disease Society of America that state that a new fever in a patient in the ICU “should trigger a careful clinical assessment rather than automatic orders for laboratory or radiologic tests.”9 The reflexive ordering of tests without a proper in-person bedside assessment may lead not only to frequent unnecessary tests but also to administering inappropriate antibiotics and other potentially harmful interventions (such as frequent needlesticks). The recommendations of O’Grady et al.9 should also be considered for inpatients beyond the ICU.
Unfortunately, we may continue to see this trend of forgoing bedside assessment for years to come. According to Kakarala and Jain,10 an unintended consequence of work-hour restrictions is that a new “cross-cover mindset” has taken root. This new mindset consists of a lack of ownership, a focus on self-preservation, and an emphasis on expediency. Despite having the good intention of providing a balanced and more reasonable workload, work-hour restrictions may be contributing, inadvertently, to training future providers to adopt this new mindset, which may further perpetuate our reluctance towards conducting bedside assessments.
Approach to Improving Safety & Achieving Systems Change
It has been noted that reduced work hours often lead to more patient handoffs.11 Frequent and poor handoffs can lead to more cross-cover questions, calls, and uncertainty, to more handoff short-cuts and, unfortunately, to more medical errors.12 One approach to improving handoffs that has shown great potential has been utilization of I-PASS – a structured handoff-improvement tool. I-PASS is a pneumonic abbreviation for Illness severity, Patient summary, Action list, Situation awareness and contingency plans, and Synthesis by receiver. According to Starmer et al.,13 the multicenter implementation of I-PASS was associated with a reduction in medical errors and in preventable adverse events. These researchers also observed improvement in communication without a negative effect on workflow.13 Increased inclusion of important written and oral handoff elements was most notably associated with illness severity, to-do lists, contingency plans, and receiver readback of the situation. Apparently, use of this handoff-improvement tool resulted in better instructions and possibly a better understanding of the need for and the importance of an in-person assessment. As a counter to the “cross-cover mindset,” implementation of a handoff tool like I-PASS can bring ownership and accountability back to patient care.
Cross-cover care is a core activity for all inpatient providers and there are clinical competencies that are very unique to this role. Unfortunately, there are not many resources that provide any best practices for cross-cover care nor has cross-cover care been extensively studied. Heidemann et al.14 sought to provide a best practices framework by using a consensus method to address gaps in our understanding of core cross-coverage activities and expectations around handling them. They identified 28 activities for which high levels of consensus on that activity being necessary for safe and efficient cross-coverage care were reached; in-person bedside assessments were among the activities for which the greatest consensus was reached. Additionally, agreement that a bedside assessment was appropriate was 90% or greater for each of the following: 1) at the request of a nurse, 2) activation of a code or rapid response, 3) a significant change in clinical status, 4) a patient fall, and 5) a new instability in a vital sign.14
With the patient in this Case, it’s safe to say that there would be agreement among providers that the patient’s fever warranted a bedside assessment. And most providers would agree that being at the bedside is a best practice. However, the realities of cross-cover care – multiple competing responsibilities such as new admissions and cross-coverage of multiple patients – can, of necessity, limit the performance of bedside assessments; providers often have to triage and decide which responsibility takes precedence.
One approach that can help an individual provider deal with competing responsibilities is knowing they can depend on a multidisciplinary team. Extending a team-based approach to cross-cover care has the potential to foster better collaboration and shared decision-making that may improve overall care. However, only a handful of studies have evaluated the effectiveness that training care teams may have on patient outcomes and, unfortunately, the available literature on this subject is mixed.
Auerbach et al.15 and the TOPS (Triad for Optimal Patient Safety) project team examined how teamwork and communication interventions impact clinical outcomes. Theirs was a three-phase intervention that implemented a team training program, unit-based safety teams, and focused engagement with patients in communication efforts. Despite the fact that physicians and nurses reported an increased perception of a culture of safety as a result of the interventions, and patients expressed improved perception of team functions, patients actually became more aware of gaps in care.15 One can argue that patients were empowered by the perception of an improved culture of safety and participated in actual quality improvement. However, improvements in clinical outcomes, such as length of stay (LOS) and readmissions, were not not observed in this study. Yet, there is still hope that creating a better culture of safety will hopefully encourage more teamwork and lead to better patient care.
An ongoing study called RESET (REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients), being conducted by O’Leary and colleagues,16 holds promise. The goal of the RESET study is to implement a set of complementary and mutually reinforcing interventions across a range of clinical microsystems caring for patients, identify factors and strategies associated with successful implementation, and evaluate the impact(s) the interventions have on quality. Hopefully, the results of this study will be useful to hospital systems trying to gain perspective on redesigning and improving team-based care.
There are, of course, system-level issues that limit in-person bedside evaluations by cross-covering providers (as mentioned above). And cross-covering care providers, in recognition of the limited time they have to manage multiple competing issues overnight, often make contingency plans that minimize the need to intervene until necessary, plans that could be considered “rescue care.” As a result, unfortunately, it is not uncommon on the wards to see a written or oral handoff, which are known to influence behavior, like “culture if spike.” While appropriate in some cases, the content of such handoffs is often inappropriate.
The hope is that with utilization of structured handoff tools like I-PASS, development of best practices for cross-cover care, and more emphasis on team-based approaches to care, we can minimize the “cross-cover mindset” and further promote a culture of safety. In short, implementing these kinds of interventions holds promise for encouraging care providers to see the patient first.
- Most healthcare providers agree that an in-person bedside assessment during cross-cover care is a best practice.
- Utilizing structured and validated handoff tools, developing cross-cover care best practices, and implementing a multidisciplinary team-based approach to cross-cover care are all likely essential to improving care for hospitalized patients.
- Health systems may need to redesign the continuum of care for hospitalized patients to promote a culture of safety and patient-centered care.
- But first, see the patient.
Voltaire R Sinigayan, MD, FACP
Associate Clinical Professor, Department of Internal Medicine
Vice Chief, Division of Hospital Medicine
UC Davis Health
- Howard-Anderson J, Schwab K, Quinn R, Graber CJ. Choosing Wisely Overnight? Residents' Approach to Fever. Open Forum Infect Dis. 2017;4(2):ofx080. Published 2017 Apr 19. doi:10.1093/ofid/ofx080
- Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2011;52(4):e56-e93. doi:10.1093/cid/cir073
- Pizzo PA. Management of Patients With Fever and Neutropenia Through the Arc of Time: A Narrative Review. Ann Intern Med. 2019;170(6):389-397. doi:10.7326/M18-3192
- Uberoi AS, Brown TJ, Gupta A. Magic Mouthwash for Oral Mucositis: A Teachable Moment. JAMA Intern Med. 2019;179(1):104-105. doi:10.1001/jamainternmed.2018.6223
- Baron EJ, Miller JM, Weinstein MP, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)(a). Clin Infect Dis. 2013;57(4):e22-e121. doi:10.1093/cid/cit278
- Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248-255. doi:10.1136/qshc.2008.028654
- Bates DW, Cook EF, Goldman L, Lee TH. Predicting bacteremia in hospitalized patients. A prospectively validated model. Ann Intern Med. 1990;113(7):495-500. doi:10.7326/0003-4819-113-7-495
- Bates DW, Goldman L, Lee TH. Contaminant blood cultures and resource utilization. The true consequences of false-positive results. JAMA. 1991;265(3):365-369.
- O'Grady NP, Barie PS, Bartlett JG, et al. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America [published correction appears in Crit Care Med. 2008 Jun;36(6):1992]. Crit Care Med. 2008;36(4):1330-1349. doi:10.1097/CCM.0b013e318169eda9
- Kakarala K, Jain SH. The "cross-cover" mindset. J Patient Saf. 2012;8(1):1-2. doi:10.1097/PTS.0b013e318242ad70
- Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial. JAMA Intern Med. 2013;173(8):649-655. doi:10.1001/jamainternmed.2013.2973
- Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34(10):563-570. doi:10.1016/s1553-7250(08)34071-9
- Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):1803-1812. doi:10.1056/NEJMsa1405556
- Heidemann LA, Fitzgerald JT, Hughes DT, Hartley S. Inpatient Cross-Cover Consensus Recommendations for Medical and Surgical Residents: A Delphi Analysis. J Grad Med Educ. 2019;11(3):277-283. doi:10.4300/JGME-D-18-00707.1
- Auerbach AD, Sehgal NL, Blegen MA, et al. Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad for Optimal Patient Safety (TOPS) project. BMJ Qual Saf. 2012;21(2):118-126. doi:10.1136/bmjqs-2011-000311
- O'Leary KJ, Johnson JK, Manojlovich M, Goldstein JD, Lee J, Williams MV. Redesigning systems to improve teamwork and quality for hospitalized patients (RESET): study protocol evaluating the effect of mentored implementation to redesign clinical microsystems. BMC Health Serv Res. 2019;19(1):293. Published 2019 May 8. doi:10.1186/s12913-019-4116-z