Sleep and circadian misalignment for the hospitalist: A review

Shift work is necessary for hospitalists to provide on-site 24-hour patient care. Like all shift workers, hospitalists working beyond daylight hours are subject to a misalignment between work obligations and the endogenous circadian system, which regulates sleep and alertness patterns. With chronic misalignment, sleep loss accumulates and can lead to shift work disorder or other chronic medical conditions. Hospitalists suffering from sleep deprivation also risk increased rates of medical errors. By realigning work and circadian schedules, a process called circadian adaptation, hospitalists can limit fatigue and potentially improve safety. Adaptation strategies include improving sleep hygiene before work, caffeine use at the start of the night shift, bright light exposure and planned naps during the shift, and short-term use of a mild hypnotic after night work. If these attempts fail and chronic fatigue persists, then a diagnosis of shift work disorder should be considered, which can be treated with stronger pharmacotherapy. Night float scheduling strategies may also help to limit chronic sleep loss. More research is urgently needed regarding the sleep patterns and job performance of hospitalists working at night to improve scheduling decisions and patient safety. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine

Acute medicine in the United Kingdom: First-hand perspectives on a parallel evolution of inpatient medical care

Macrolide therapy and outcomes in a multicenter cohort of children hospitalized with Mycoplasma pneumoniae pneumonia

BACKGROUND:Mycoplasma pneumoniae is a common cause of community-acquired pneumonia in childhood. Few studies have addressed the association of antimicrobial treatment and outcomes.OBJECTIVE:To determine whether macrolide therapy is associated with improved outcomes among children hospitalized with M. pneumoniae pneumonia.DESIGN:Multicenter retrospective cohort study.SETTING:Thirty-six children's hospitals which contribute data to the Pediatric Health Information System.PATIENTS:Children 6-18 years of age discharged with a diagnosis of M. pneumoniae pneumonia.MAIN EXPOSURE:Initial macrolide therapy.MAIN OUTCOME MEASURES:Length of stay (LOS), all-cause readmissions, and asthma-related hospitalizations.RESULTS:Empiric macrolide therapy was administered to 405 (58.7%) of 690 patients. The median LOS was 3 days (interquartile range, 2-6 days). Eight (1.2 %) patients were readmitted within 28 days, and 160 (23.2%) were readmitted within 15 months of index discharge. Ninety-five (13.7%) patients were hospitalized for asthma within 15 months of index discharge. Empiric macrolide therapy was associated with a 32% shorter overall LOS (adjusted beta-coefficient, −0.38; 95% confidence interval [CI]: −0.59 to −0.17). Macrolide therapy was not associated with all-cause readmission at 28 days (adjusted odds ratio, 1.12; 95% CI: 0.22-5.78) or 15 months (adjusted odds ratio, 1.00; 95% CI: 0.59-1.70) or with asthma-related hospitalizations at 15 months (adjusted odds ratio, 0.85; 95% CI: 0.36-1.97).CONCLUSION:In this large multicenter study of children hospitalized with M. pneumoniae pneumonia, empiric macrolide therapy was associated with a shorter hospital LOS. Macrolide therapy was not associated with 28-day or 15-month hospital readmission. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine

Questions about the role of oral baclofen in acute ethanol withdrawal

Job characteristics, satisfaction, and burnout across hospitalist practice models

BACKGROUND:Nearly two-thirds of hospitals in the United States are served by hospitalist physicians. How hospitalist work patterns and job satisfaction vary across various practice models is unknown.METHODS:We administered the Hospitalist Worklife Survey to a randomized stratified sample of 3105 potential hospitalists and 662 hospitalist members of 3 multistate hospitalist companies. Details about respondents' hospitalist group characteristics, their work patterns, and satisfaction with 2 global and 11 domain measures were assessed. Factors influencing job satisfaction were also solicited. These factors, job characteristics, job satisfaction, and burnout were compared across predefined practice models.RESULTS:The adjusted response rate was 25.6%. Among the respondents, 44% were employed by a hospital, 15% by a multispecialty physician group, 14% by a multistate hospitalist group, 14% by a university or medical school, 12% by a local hospitalist group, and 2% by other. Hospitalists of local groups reported more clinical shifts per month, and hospitalists of local and multistate groups reported more billable encounters per shift compared to other practice models. Academic hospitalists reported fewer night shifts, fewer billable encounters per shift, more nonclinical work hours, and lower earnings compared to other practice models. Differences in clinical and nonclinical responsibilities, and differences in factors most important to job satisfaction, were noted across the 5 models. Despite these differences, levels of global job satisfaction and burnout were similar across the practice models.CONCLUSIONS:Work patterns, compensation, and hospitalists' priorities varied significantly across practice models. Overall job satisfaction and burnout were similar across models, despite these differences. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine

Baclofen in the management of alcohol withdrawal syndrome

ACUTE center for eating disorders

BACKGROUND:While patients with anorexia nervosa have a high mortality rate, more are living into adulthood. Patients with severe malnutrition secondary to anorexia nervosa often require hospitalization for medical stabilization prior to treatment in eating disorders programs.METHODS:We developed the ACUTE Center at Denver Health Medical Center to medically stabilize adults with the medical complications of severe malnutrition due to an eating disorder. The first 2 years of patient characteristics and outcomes are reported.RESULTS:From October 2008 through December 2010, the ACUTE unit had 76 admissions of which 62 were for medical stabilization, comprising 54 patients. Eighty-nine percent of patients were female. The mean age was 27 years old (range 17–65). The mean body mass index on admission was 12.9 kg/m2 (standard deviation [SD] 2.0). At admission, patients were hyponatremic, anemic, and leukopenic, with low bone density, but had normal albumin levels. The mean body mass index on discharge was 13.1 ± 1.9 kg/m2. Median length of stay was 16 days (interquartile range [IQR] 9–29 days). Eighteen percent were discharged to home and eighty-two percent were discharged to inpatient psychiatric eating disorder units. Inpatient mortality was zero.DISCUSSION:Patients with this degree of severe malnutrition due to eating disorders are medically complex and relatively uncommon. Regionalized subspecialty centers of excellence, in which a multidisciplinary team is led by practitioners of hospital medicine who have developed expertise in a rare condition, may improve clinical outcomes, optimize healthcare resources, and provide unique professional and academic opportunities for the clinicians involved. Journal of Hospital Medicine 2012;. © 2012 Society of Hospital Medicine

Results of a retrospective observational study of intermediate care staffed by hospitalists: Impact on mortality, co-management, and teaching

BACKGROUND:Hospitalized patients are complex and institutions have to face the high cost of critical care and the limited resources of the ward. Intermediate care appears as an attractive strategy to provide rational care according to patient needs. It is an interesting scenario to expand co-management and teaching.STUDY DESIGN:Retrospective observational study.SETTING:Intermediate care unit (ImCU) of a single academic hospital.PATIENTS AND METHODS:456 patients admitted from April 2006 to April 2010 were included in the study. Demographics, admission physiologic parameters and in-hospital mortality were recorded. We used the Simplified Acute Physiology Score II (SAPS II) as prognostic score system. Co-management with medical and surgical teams, and the number of training residents were evaluated.RESULTS:In-hospital mortality was 20.6%, whereas the expected mortality was 23.2% based on SAPS II score. The correlation between SAPS II predicted and observed death rates was accurate and statistically significant (Rho = 1.0, p < 0.001). Co-management was performed with several medical and surgical teams, with an increase in perioperative comanagement of 22.7% (p = 0.014). The number of training residents in ImCU increased from 4.3% to 30.4% (p = 0.002)CONCLUSIONS:An ImCU led by hospitalists showed encouraging results regarding patient survival and SAPS II is an useful tool for prognostic evaluation in this population. Intermediate care serves as an expansion of role for hospitalists; and clinicians, trainees and patients may benefit from co-management and teaching opportunities at this unique level of care. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine

“They're going to unplug grandma”: Advance directive discussions and documentation do not decrease survival in patients at baseline lower risk of death

OBJECTIVE:To determine the effect of having advance directive (AD) discussions or having an AD in the medical record on patient survival.DESIGN:Prospective observational cohort study.SETTING:Three Colorado area hospitals: a large academic tertiary referral center, a Veteran's Affairs medical center, and an urban safety net hospital.PARTICIPANTS:Four hundred fifty-eight adults admitted to the general internal medicine service interviewed about AD discussions. A concurrent chart review documented the presence of an AD in the medical record. Participants were stratified into low, medium, and high risk of death within 1 year based on validated prognostic criteria.MEASURES:Kaplan-Meier survival plots were estimated for those at low and medium risk of death.RESULTS:No significant differences in survival for participants at low and medium risk of death who reported having had an AD discussion and those who had not (Wilcoxon low risk, P = 0.97; medium risk, P = 0.28; and log-rank low risk, P = 0.82; medium risk, P = 0.45), and for those who had an AD in the medical record vs those who did not (Wilcoxon low risk, P = 0.84; medium risk, P = 0.78; and log-rank low risk, P = 0.86; medium risk, P = 0.69).CONCLUSIONS:There is no evidence that AD discussions or documentation result in increased mortality. In regards to the current national debate about the merits of advance care planning, this study suggests that honoring patients' wishes to engage in AD discussions and documentation does not lead to harm. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine

Broad-range bacterial polymerase chain reaction in the microbiologic diagnosis of complicated pneumonia

BACKGROUND:A bacterial cause is not frequently identified in children with pneumonia complicated by parapneumonic effusion (ie, complicated pneumonia).OBJECTIVES:To determine the frequency of positive blood and pleural fluid cultures in children with complicated pneumonia and to determine whether broad-range 16S rRNA polymerase chain reaction (PCR) improves identification of a microbiologic cause.METHODS:This prospective cohort study included children 1–18 years of age hospitalized with complicated pneumonia.RESULTS:Pleural fluid drainage was performed in 64 (51.6%) of 124 children with complicated pneumonia. A microbiologic cause was identified in 11 of 64 patients (17.2%; 95% confidence interval [CI]: 8.9%–28.7%). Bacteria were isolated from pleural fluid culture in 6 of 64 patients (9.4 %; 95% CI: 3.5%–19.3%) undergoing pleural drainage; the causative bacteria were Staphylococcus aureus (n = 5) and Streptococcus pneumoniae (n = 1). Blood culture identified a bacterial cause in 3 of 44 cases (6.8%; 95% CI: 1.4%–18.7%) undergoing pleural fluid drainage; S. pneumoniae (n = 1), Haemophilus influenzae (n = 1), and S. aureus (n = 1) were isolated. Only 3 of the 19 pleural fluid samples (15.8%; 95% CI: 3.4%–39.6%) analyzed with 16S rRNA PCR were positive. S. pneumoniae was the only organism detected in all three samples; two of these three had negative pleural fluid cultures and absence of bacteria on Gram stain. S. aureus was isolated from pleural fluid culture in one patient with a negative 16S rRNA PCR test.CONCLUSIONS:Causative bacteria were infrequently identified in children with complicated pneumonia. Broad-range 16S rRNA PCR only modestly improved the microbiologic yield over conventional culture methods. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine

Comparing the pulmonary embolism severity index and the prognosis in pulmonary embolism scores as risk stratification tools

BACKGROUND:Multiple risk stratification scoring systems exist to forecast outcomes in patients with acute pulmonary embolism (PE).OBJECTIVE:We evaluated the comparative validity of the PE severity index (PESI) and the prognosis in pulmonary embolism (PREP) scores to predict mortality in acute PE.DESIGN:Retrospective observational cohort study.SETTING:Washington Hospital Center, Washington, DC.PATIENTS:Consecutive adults (aged >18 years) diagnosed with acute PE.INTERVENTION:The PESI and PREP scores were calculated.MEASUREMENTS:Raw PESI scores were segregated into risk class (I-V) and then dichotomized into low (I-II) versus high (III-V) risk groups; the raw PREP scores were divided into low (0-7) versus high (>7) risk groups. The primary endpoint was 30-day and 90-day mortality. We determined the negative predictive value and computed the area under the receiver operating characteristics (AUROC) curves to compare the ability of these scoring tools.RESULTS:The cohort consisted of 302 subjects. Thirty-day mortality was 3.0%, and 4.0% died within 90 days. The PESI and the PREP performed similarly (PESI AUROC: 0.858 [95% confidence interval (CI), 0.773-0.943] vs 0.719 [95% CI, 0.563-0.875] for PREP). Segregating these scores into risk categories did not affect their discriminatory power (AUROC: 0.684 [95% CI, 0.559-0.810] for PESI and 0.790 [95% CI, 0.679-0.903] for PREP). The negative predictive value for death of being classified as low risk by the PESI or PREP was 100% and 99%, respectively.CONCLUSIONS:The PREP score performed comparably to the PESI score for identifying PE patients at low risk for short-term and intermediate-term mortality. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine

JHM 2.0: The Journal of Hospital Medicine at its first transition

Barriers and potential solutions toward optimal prophylaxis against deep vein thrombosis for hospitalized medical patients: A survey of healthcare professionals

OBJECTIVE:Deep vein thrombosis (DVT) prophylaxis remains underused in hospitalized medical patients despite strong recommendations that at-risk patients should receive prophylaxis. To understand this gap between knowledge and practice, we surveyed clinicians' perceptions about the importance of DVT prophylaxis, barriers to guideline implementation, and interventions to optimize prophylaxis.METHODS:Paper- and electronic mail-based surveys were sent to 1553 internists, nurses, pharmacists, and physiotherapists in Ontario, Canada. Responses were scored on 7-point Likert scales. An important barrier to optimal DVT prophylaxis was 1 with a mean score ≥5, and interventions with high potential success or feasibility were those with mean scores ≥5.RESULTS:DVT prophylaxis was perceived as important by all clinician groups but this did not appear to translate into knowledge about underutilization of current DVT prophylaxis strategies. Physicians and pharmacists recognized the underuse of DVT prophylaxis in medical patients, while nurses and physiotherapists tended to perceive prophylaxis strategies as appropriate. Lack of clear indications and contraindications for prophylaxis and concerns about bleeding risks were perceived as important barriers. Preprinted orders were considered the most potentially successful and feasible way to optimize prophylaxis.CONCLUSIONS:A considerable barrier to optimal DVT prophylaxis utilization may be that those healthcare providers best able to conduct a daily assessment of patients' need for prophylaxis underrecognize the problem that prophylaxis is underutilized in this population. Interventions to bridge the gap between knowledge and practice should consider preprinted orders outlining DVT risk factors, and educating front-line care providers prior to implementation of a top-down approach. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine

Use of a virtual classroom in training fourth-year medical students on care transitions

BACKGROUND:Transferring complex patients between settings can be fraught with poor communication and adverse outcomes, yet few medical students nationwide are trained in specific skills to improve care transitions.OBJECTIVE:To give medical students the fund of knowledge and skills to develop and implement a safe discharge plan.DESIGN:A new care transitions curriculum imparted to all fourth-year medical students from August 2009 to April 2010 during their internal medicine sub-internship.SETTING:Emory University School of Medicine.INTERVENTION:Activities included: 1) discussion of an online case highlighting care transitions issues; 2) preparation of a discharge summary based on online templates; and 3) a postdischarge phone call to one of their patients.MEASUREMENTS:We evaluated the curriculum using questionnaires measuring changes in pretest to posttest confidence in performing discharge tasks, attitudes toward the care transitions process, and performance on a knowledge quiz. We also assessed course satisfaction and the quality of students' discharge summaries and postdischarge call reports performed during the module.RESULTS:Students' confidence in their ability to perform discharge tasks improved from 16.5 to 20.8 on a 25-point scale (P < 0.001). Knowledge quiz scores improved from 68 to 82 out of 100 (P < 0.001); 90.1% (109/121) of discharge summaries and 90.1% (109/121) of postdischarge call reports met all quality criteria.CONCLUSIONS:This curriculum showed that students could acquire the needed skills to prepare quality discharge summaries and communicate well with patients at discharge, as well as improve their overall knowledge surrounding care transitions. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine

Implementation of a continuous admission model reduces the length of stay of patients on an internal medicine clinical teaching unit

BACKGROUND:Optimizing hospital operations is a critical issue facing healthcare systems. Reducing unnecessary variation in patient flow is likely to improve efficiency and optimize capacity for hospital inpatients. The objective of this study was to determine whether changing admissions, from a “bolus” system to a “drip” system, would result in a smoothed daily discharge rate, and reduce the length of stay of patients on a General Internal Medicine clinical teaching unit over a period of 1 year.METHODS:We conducted a retrospective analysis of the General Internal Medicine inpatient service at Toronto General Hospital for the 6-month periods from March to August during 2 consecutive years. Length of stay distributions and daily discharge rate variations were compared between the 2 study periods.RESULTS:There were a total of 2734 discharges, 1446 occurring in the pre-change period, and 1288 in the post-change period. There was overall smoothing of the daily discharge rates, and a reduction of 0.3 days in median length of stay in the post-change period (P = 0.0065).CONCLUSIONS:Restructuring the admission system to achieve constant daily admissions to each care team resulted in a smoothing of daily discharge rates and improved operational efficiency with shorter lengths of stay. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

Pocket card and dedicated feedback session to improve feedback to ward residents: A randomized trial

BACKGROUND:Residents are often dissatisfied with feedback received on the wards, and hospital attendings are often uncomfortable and unskilled at giving feedback.OBJECTIVE:Determine the impact of a pocket card and feedback session on Internal Medicine (IM) residents' perceptions of feedback and attendings' comfort giving feedback.DESIGN:Prospective randomized trial using chi-square analysis.SETTING:Inpatient wards at 1 academic medical center.PARTICIPANTS:One hundred eleven IM residents and 36 attendings.INTERVENTION:We introduced a pocket feedback card, structured around the Accreditation Council for Graduate Medical Education competencies, and a feedback session to guide mid-rotation feedback. Control group attendings received the usual reminder to provide feedback.MEASUREMENTS:Attendings' and residents' survey responses, after the inpatient month, assessing attitudes towards feedback and qualitative interviews with intervention attendings.RESULTS:Intervention residents were more likely than controls to report sufficient and useful feedback from attendings. They reported more feedback regarding skills needing improvement and how to improve their skills (51.3% vs 25.5%, P = 0.02), and felt their clinical (61.5% vs 27.8%, P = 0.001) and professionalism/communication (51.3% vs 29.1%, P = 0.03) skills improved based on this feedback. Intervention attendings, as compared to controls, agreed that residents improved their professionalism/communication skills (76.9% vs 31.1%, P = 0.02) based on feedback. Most intervention attendings found the card and session acceptable and would use both in the future.CONCLUSIONS:A pocket feedback card and dedicated feedback session improved the quantity and quality of feedback delivered to IM residents by their attendings on the inpatient wards. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine

Quick diagnosis units versus hospitalization for the diagnosis of potentially severe diseases in Spain

OBJECTIVES:We describe the functioning of a quick diagnosis unit (QDU) in a Spanish public university hospital to ascertain the utility and cost of the model compared to conventional hospitalization.DESIGN:Observational study with a prospective and retrospective cohort.SETTING:Spanish tertiary public university hospital.PATIENTS:Two thousand consecutive patients evaluated between December 2007 and July 2010 with potentially severe diseases normally requiring hospitalization for diagnosis. For comparative purposes, we analyzed a randomized, retrospective cohort of 1454 hospitalized patients.MEASUREMENTS:Variables measured included source of referral, reason for consultation, time to diagnosis and length-of-stay, hospitalizations avoided, Charlson comorbidity index, costs, and patient satisfaction using a telephone survey.RESULTS:Suspected anemia, cachexia-anorexia syndrome, febrile syndrome, adenopathies and/or palpable masses, abdominal pain, diarrhea, and lung abnormalities accounted for 88% of QDU patients. The most-frequent diagnoses were cancer (26.3%) and iron-deficiency anemia. QDU patients with anemia were significantly younger than hospitalized patients with the same diagnosis (P < 0.0001). Other parameters were similar between QDU and hospitalized patients. The mean cost of treatment was 3153.87 Euros for hospitalization and 702.33 Euros for the QDU. Patients expressed a high degree of satisfaction with QDU care.CONCLUSIONS:QDUs can manage the diagnosis of patients with potentially severe diseases equally as well as traditional hospitalization, and saves costs. QDU patients expressed a high degree of satisfaction, with most preferring this model to hospitalization. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine

Can healthcare go from good to great?

Healthcare's improvement efforts have focused on the point of care, targeting specific processes such as preventing central line infections, while paying relatively less attention to the larger issues of organizational structure and leadership. Interestingly, the business community has long recognized that poor management and structure can thwart improvement efforts. Perhaps the corporate world's best-known study of these issues is found in the book Good to Great, which identifies top-performing corporations, compares them to carefully selected organizations that failed to achieve similar levels of performance, and gleans lessons from these analyses. In this article, we analyze the feasibility of carefully applying Good to Great's methods for analyzing organizational structure and leadership to healthcare. While a few studies in healthcare have come close to emulating Good to Great's methodology, none have matched its rigor. These shortcomings highlight key information and measurement gaps that must be addressed to facilitate unbiased, rigorous studies of the organizational and leadership predictors of institutional excellence in healthcare. Journal of Hospital Medicine 2011; © 2011 Society of Hospital Medicine.

Interdisciplinary teamwork in hospitals: A review and practical recommendations for improvement

Recognizing the importance of teamwork in hospitals, senior leadership from the American College of Physician Executives (ACPE), the American Hospital Association (AHA), the American Organization of Nurse Executives (AONE), and the Society of Hospital Medicine (SHM) established the High Performance Teams and the Hospital of the Future project. This collaborative learning effort aims to redesign care delivery to provide optimal value to hospitalized patients. With input from members of this initiative, we prepared this report which reviews the literature related to teamwork in hospitals. Teamwork is critically important to provide safe and effective hospital care. Hospitals with high teamwork ratings experience higher patient satisfaction, higher nurse retention, and lower hospital costs. Elements of effective teamwork have been defined and provide a framework for assessment and improvement efforts in hospitals. Measurement of teamwork is essential to understand baseline performance, and to demonstrate the utility of resources invested to enhance it and the subsequent impact on patient care. Interventions designed to improve teamwork in hospitals include localization of physicians, daily goals of care forms and checklists, teamwork training, and interdisciplinary rounds. Though additional research is needed to evaluate the impact on patient outcomes, these interventions consistently result in improved teamwork knowledge, ratings of teamwork climate, and better understanding of patients' plans of care. The optimal approach is implementation of a combination of interventions, with adaptations to fit unique clinical settings and local culture. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine

Duration of venous thromboembolism risk across a continuum in medically ill hospitalized patients

BACKGROUND:Patients hospitalized for medical illness are at increased risk of venous thromboembolism (VTE), but the duration of risk is not well understood.OBJECTIVE:To assess incidence and time course of symptomatic VTE following hospitalization for medical illness in a large, real-world patient population.DESIGN:Data were extracted from the Thomson Reuters MarketScan® Inpatient Drug Link File.PATIENTS:Those hospitalized with cancer, heart failure, severe lung disease, or infectious disease from 2005 to 2008.MEASUREMENTS:The cumulative VTE risk over 180 days after admission was calculated using Kaplan-Meier analysis. VTE hazard was calculated on a daily basis and smoothed through LOESS regression.RESULTS:The analysis included 11,139 medically ill patients, 46.7% and 8.8% of whom received pharmacological thromboprophylaxis during hospitalization and after discharge, respectively. The mean duration of prophylaxis during hospitalization was 5.0 days. Of the 11,139 patients, 366 (3.3%) experienced a symptomatic VTE event. VTE events were most frequent during days 0-9 (97 events), followed by days 10-19 (82 events). The mean length of hospital stay was 5.3 days, and 56.6% of all VTE events occurred after discharge. VTE hazard peaked at day 8, with 1.05 events per 1000 person-days.CONCLUSIONS:The time course of VTE in medical patients shows that risk of symptomatic VTE is highest during the first 19 days after hospital admission, and extends into the period after discharge. Future research is warranted to investigate risks and benefits of reducing the incidence of VTE after discharge, including the role of improving thromboprophylaxis practices in the inpatient setting and extending thromboprophylaxis after hospitalization. Journal of Hospital Medicine 2012;. © 2011 Society of Hospital Medicine

Why surgeons can say “No”: Exploring “Unilateral Withholding”

OBJECTIVE:To explore why it is permissible for surgeons to “unilaterally withhold” surgery, whereas it is not commonplace (in the United States) to unilaterally withhold cardiopulmonary resuscitation (CPR) for clinical situations with similar degrees of uncertainty and prognosis.DATA SOURCES:The medical literature was sampled using PubMed and Google search engines, employing a variety of search strategies to capture articles relating to medical/surgical decision-making, risk aversion, acute care surgery, and withholding life-saving therapies. These topics are used to highlight interprovider variability that affects all practitioners—not just surgeons—and to consider why we deem it permissible for surgeons to withhold surgery, whereas—in the United States, at least—it is not routinely permissible for clinicians to unilaterally withhold mechanical ventilation and CPR for cases with similar prognoses.CONCLUSIONS:While there are no published research studies that deal directly with this topic, knowledge, heuristics, experience, variable aversion to risk, and other features inherent in medical-surgical education likely impact decisions to offer or withhold potentially life-saving therapies of all kinds. Both surgeons and clinicians, who request surgical consultation for hospitalized patients, should consider these issues and politely pursue second opinions when there is any doubt whether forgoing surgery is in the patient's best interests. Similarly, while unilateral withholding of CPR is not commonly employed in some medical cultures, including the United States, beneficence can be facilitated through robust informed consent. Journal of Hospital Medicine 2012; © 2011 Society of Hospital Medicine

Inappropriate prescribing of proton pump inhibitors in hospitalized patients

BACKGROUND:Proton pump inhibitors have numerous important side effects, yet they are prescribed for outpatients who do not have recognized indications. Less is known with respect to prescribing for inpatients.OBJECTIVE:To determine the rate of inappropriate prescribing of protein pump inhibitors and to assess reasons why they are prescribed.DESIGN AND PARTICIPANTS:The study was a retrospective review of administrative data for adult hospital patients discharged from the Medicine service of Denver Health (DH) and from the University HealthSystem Consortium (UHC) between January 1, 2008 and December 31, 2009.MEASUREMENTS:Valid indications for proton pump inhibitors were sought from discharge diagnoses, prescription records, and, in a randomly selected group of patients from DH, from direct review of records.RESULTS:Inclusion criteria were met by 9875 DH patients and 6,592,100 UHC patients; of patients receiving a proton pump inhibitor, 61% and 73%, respectively, did not have a valid indication. Increased rates of Clostridium difficile infection were found in both groups of patients receiving proton pump inhibitors. Chart reviews found valid indications for proton pump inhibitors in 19% of patients who did not have a valid indication on the basis of the administrative data, and “prophylaxis” was the justification for inappropriate prescribing in 56%.CONCLUSION:Proton pump inhibitors are frequently inappropriately prescribed to Medicine inpatients who do not have a valid indication and this practice is associated with an increase in C. difficile infection. Interventions are needed to curtail this inappropriate prescribing practice. Journal of Hospital Medicine 2012; © 2011 Society of Hospital Medicine

Nominal group technique: A brainstorming tool for identifying areas to improve pain management in hospitalized patients

BACKGROUND:Pain management in hospitalized patients remains a priority area for improvement; effective strategies for consensus development are needed to prioritize interventions.OBJECTIVE:To identify challenges, barriers, and perspectives of healthcare providers in managing pain among hospitalized patients.DESIGN:Qualitative and quantitative group consensus using a brainstorming technique for quality improvement—the nominal group technique (NGT).SETTING:One medical, 1 medical-surgical, and 1 surgical hospital unit at a large academic medical center.PARTICIPANTS:Nurses, resident physicians, patient care technicians, and unit clerks.MEASUREMENTS:Responses and ranking to the NGT question: “What causes uncontrolled pain in your unit?”RESULTS:Twenty-seven health workers generated a total of 94 ideas. The ideas perceived contributing to a suboptimal pain control were grouped as system factors (timeliness, n = 18 ideas; communication, n = 11; pain assessment, n = 8), human factors (knowledge and experience, n = 16; provider bias, n = 8; patient factors, n = 19), and interface of system and human factors (standardization, n = 14). Knowledge, timeliness, provider bias, and patient factors were the top ranked themes.CONCLUSIONS:Knowledge and timeliness are considered main priorities to improve pain control. NGT is an efficient tool for identifying general and context-specific priority areas for quality improvement; teams of healthcare providers should consider using NGT to address their own challenges and barriers. Journal of Hospital Medicine 2012; © 2011 Society of Hospital Medicine

Learning needs of physician assistants working in hospital medicine

BACKGROUND:Hospital Medicine is growing rapidly, and the number of physician assistants (PAs) in this field is expected to grow. However, there is no available data related to the learning needs of PA hospitalists.OBJECTIVE:To conduct a needs assessment for PA hospitalists who may be embarking on a hospitalist career.DESIGN:Cross-sectional survey based on the Core Competencies in Hospital Medicine.SETTING/PARTICIPANTS:A sample of hospitalist PAs working in the United States.MEASUREMENTS:Amount of experience with core diagnoses and procedures, preferences for additional training that would have prepared them to function as hospitalist PAs.RESULTS:Sixty-nine PAs responded (response rate, 67%). Among the core clinical conditions, respondents had the most experience in managing diabetes and urinary tract infections and were least experienced with health care–associated pneumonias and sepsis syndrome. Over 90% rarely performed core competency procedures other than electrocardiogram and chest X-ray interpretations. The top 3 content areas that PA hospitalists believed would have helped to better prepare them to care for inpatients were palliative care (percent of PAs who agreed or strongly agreed: 85%), nutrition for hospitalized patients (84%), and consultations (64%). Almost all (91%) indicated that they would have been interested in formal postgraduate hospital medicine training even if it meant having a lower stipend during the first year on the job.CONCLUSIONS:This is the first national data on self-perceived learning needs of PA hospitalists. The results may prove helpful for both PAs entering hospitalist careers and for the physician groups looking to hire them. Journal of Hospital Medicine 2012;. © 2012 Society of Hospital Medicine

Serial administration of a modified richmond agitation and sedation scale for delirium screening

OBJECTIVES:Because delirium is a common yet frequently unrecognized condition, this study sought to design a brief screening tool for a core feature of mental status and to validate the instrument as a serial assessment for delirium.DESIGN:Prospective cohort study.SETTING:Tertiary VA Hospital in New England.PARTICIPANTS:A total of 95 veterans admitted to the medical service.METHODS:A consensus panel developed a modified version of the Richmond Agitation and Sedation Scale (RASS) to capture alterations in consciousness. Upon admission, and daily thereafter, patients were screened with a modified RASS (mRASS) and independently underwent a comprehensive mental status interview by a geriatric expert, who determined whether the criteria for delirium were met. The sensitivity, specificity, and positive likelihood ratio (LR) of the mRASS for delirium are reported.RESULTS:As a single assessment, the mRASS had a sensitivity of 64% and a specificity of 93% for delirium (LR, 9.4). When used to detect change, serial mRASS assessments had a sensitivity of 74% and a specificity of 92% (LR, 8.9) in both prevalent and incident delirium. When prevalent cases were excluded, any change in the mRASS had a sensitivity of 85% and a specificity of 92% for incident delirium (LR, 10.2)CONCLUSION:When administered daily, the mRASS has good sensitivity and specificity for incident delirium. Given the brevity of the instrument (<30 seconds), consideration should be given to incorporating the modified RASS as a daily screening measure for consciousness and delirium. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine

Nonmedical factors associated with prolonged hospital length of stay in an urban homebound population

BACKGROUND:Prolonged length of stay (LOS) is a major concern for hospitalized populations at risk for adverse events. Homebound patients are at particular risk for long stays and may have unique discharge needs because of their commitment to be cared for at home despite poor functional status.OBJECTIVE:The goal of this study was to describe factors contributing to long hospitalizations in the homebound population.DESIGN:This retrospective observational pilot study included all 2007 discharges that occurred for patients at The Mount Sinai Hospital enrolled in the Mount Sinai Visiting Doctors Program.MEASURES:Long-stay patients were defined as those having an LOS 2 standard deviations above the mean. Hospitalization days were defined as “nonmedical” when patients medically ready for discharge remained in the hospital. Patients discharged immediately after determination of medical readiness were characterized as “medical stay” cases. The University HealthSystems Consortium Database was used to calculate expected LOS and the LOS ratio. Chart reviews were performed to describe long-stay cases as nonmedical or medical.RESULTS:The average LOS for 479 discharges was 7.84 days, with a mean LOS Ratio of 1.23. Seventeen cases were determined to be long stays. Eight of these cases (47%) were defined as nonmedical stays. These accounted for 136 days of hospitalization and 32% of total long-stay days. The most common reason for a nonmedical stay was nursing facility placement delay.CONCLUSIONS:Nonmedical factors accounted for nearly one-third of all long-stay days in the hospitalized homebound population. Increased interdisciplinary collaboration may help address homebound patient LOS. Journal of Hospital Medicine 2011; © 2011 Society of Hospital Medicine.

Appropriate diuretic dosing: Closed loop communication

Dabigatran etexilate: What do hospitalists need to know?

Dabigatran etexilate (dabigatran) is a novel, oral, reversible, direct thrombin inhibitor that exhibits several advantages over warfarin for therapeutic anticoagulation. The predictable pharmacokinetic profile and minimal food and drug interactions of dabigatran allow for a fixed-dosing regimen and obviate the need for routine laboratory monitoring. Dabigatran has been approved in the United States for prevention of stroke in patients with nonvalvular atrial fibrillation and in the European Union and other countries for primary prevention of thromboembolic events after total knee or hip replacement. More indications for the use of dabigatran are under review by regulatory authorities and are undergoing active clinical investigation. Due to its rapid onset of action, dabigatran may omit the need for a parenteral anticoagulant for acute treatment of thromboembolic conditions. Because wide-scale use of dabigatran is expected in the near future, hospitalists need to familiarize themselves with this agent. The lack of a standardized reliable laboratory method to monitor the anticoagulant effects of dabigatran complicates verifying compliance, measuring the effects of drug interactions, evaluating cases of dabigatran toxicity, and conducting preoperative evaluations. The lack of an antidote to dabigatran complicates the management of toxicity and makes it largely supportive. The elimination of dabigatran is dependent on renal function, with the potential for drug accumulation and toxicity with renal impairment. The noninferiority design of the clinical trials that evaluated dabigatran and the absence of long-term safety and efficacy data and issues related to the cost effectiveness of dabigatran should all be considered when prescribing this agent. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.

Management of severe hypertriglyceridemia in the hospital: A review

For hospitalists, hypertriglyceridemia (HTG) is more than cardiovascular risk. Severe HTG occurs when serum triglycerides rise above 1000 mg/dL, and it carries a risk of abdominal pain and pancreatitis. The etiology of severe HTG is usually a combination of genetic and secondary factors. A detailed history with attention to family history, medications, and alcohol consumption can often lead to the cause. Physical examination findings may stretch across multiple organ systems. Patients with severe HTG should be admitted to the hospital for aggressive medical therapy if they develop symptoms such as abdominal pain or pancreatitis. Asymptomatic patients with severe HTG who have significant short-term risk for developing symptoms require urgent consultation that may lead to a brief hospitalization to address exacerbating factors. Treatment of severe HTG includes a combination of pharmacologic agents and a restriction on dietary triglyceride intake. If oral medications fail to adequately lower triglyceride levels, intravenous insulin and in rare cases therapeutic plasma exchange may be required. To prevent recurrent severe HTG, the patient should be counseled about adherence to long-term medications and lifestyle changes. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine

Continuous infusion versus intermittent bolus furosemide in ADHF: An updated meta-analysis of randomized control trials

OBJECTIVE:Administering intermittent boluses of furosemide to patients with acute decompensated heart failure (ADHF) often leads to unfavorable hemodynamic changes. Continuous infusion may induce similar or greater diuresis without adverse hemodynamic consequences. We conducted a systemic review and meta-analysis of randomized clinical trials that compared the effects of continuous infusion and intermittent bolus of furosemide in patients hospitalized with ADHF.METHODS:We searched PubMed, EMBASE, and The Cochrane Central Register of Controlled Trials databases from their inception until March 2011. Two investigators independently abstracted data on study characteristics, quality, and selected outcomes. Differences between investigators were resolved by mutual consensus. Comparisons were reported as the weighted mean difference (WMDs).RESULTS:Ten trials involving a total of 564 patients were included. When administered as a continuous infusion, furosemide resulted in greater diuresis (WMD, −240.54 mL/24 hours/100 mg furosemide; 95% confidence interval [CI], −462.42 to −18.66) and reduction in total body weight (WMD, −0.78 kg; 95% CI, −1.54 to −0.03), than when administered in intermittent boluses. Urinary sodium excretion (WMD, −20.26 mmol/24 hours; 95% CI, −60.48 to 19.96) and duration of hospital stay (WMD, 0.99 days; 95% CI, −2.08 to 4.06) were not different between the 2 groups.CONCLUSION:This meta-analysis showed statistical support for administering furosemide as a continuous infusion for greater diuresis and reduction in total body weight in patients hospitalized with ADHF. With the exception of greater diuresis, available data are homogenous for the reported outcomes but lack information on clinical endpoints. Larger studies are needed to provide robust recommendations for clinical practice. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.

Patients' diverse beliefs about what happens at the time of death

BACKGROUND:Beliefs about what happens at the time of death surely affect a patient's whole dying experience and could help guide end-of-life care. Yet virtually no research describes those beliefs. This exploratory study begins the descriptive process.METHODS:Assuming culture is key, we interviewed 26 Mexican-American (MA), 18 Euro-American (EA), and 14 African-American (AA) inpatients about their beliefs concerning what happens at the time of death.RESULTS:One belief, that death separates the dead from the living, was widespread. Majorities of all 3 ethnic group samples and of 5 of the 6 gender subsamples expressed this belief, saying the dead “go” or “leave” from this life. Other beliefs differed by ethnic group or gender. For example, more EAs (50%) than others said death is a momentary event, and more MAs (35%) than others said death involves “being taken” by an external force (always God or Jesus). Furthermore, considerably more EA women (45%) than others said some senses persist after death. In contrast, the physiologic signs that participants cited as defining the exact time of death varied from individual to individual with no ethnic or gender pattern, and no one sign predominated.CONCLUSIONS:A few beliefs about what happens at the time of death may characterize Americans in general; many other beliefs may characterize only certain ethnic groups, genders, or individuals. To identify such beliefs and to use them to guide end-of-life care, hospitalists and other health professionals may have to elicit them directly from patients or survivors. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine

Transition of care: What Is the pediatric hospitalist's role? An exploratory survey of current attitudes

OBJECTIVE:Survey of current attitudes of pediatric hospitalists related to transition of care.METHODS:We developed and piloted a survey that was validated by an expert on transition. It was introduced it to the AAP/Pediatric Hospital Medicine Listserv using Survey MonkeyTM. Any participant who agreed to the informed consent was included in the survey.RESULTS:Patients aged 16–17 with chronic medical conditions were taken care of by pediatric hospitalists 70% of the time. Patients aged 18–20 were cared for by pediatric hospitalists 36.8% of the time. Advantages of hospitalist participation in healthcare transition include improved continuity of care and quality of care. The biggest impediments might be lack of time and resources. Most surveyed would be interested in a web based educational module to develop their understanding of healthcare transition.CONCLUSION:The survey provides a snapshot of current attitudes of pediatric hospitalist involvement in transition of care. Pediatric hospitalists are interested in participating in healthcare transition. Although more research is needed to compare current models of transition services and a hospitalist model, the perception for inpatients is that better quality of care can be expected. Targeted educational modules might provide a foundation for pediatric hospitalists to build their scope of practice to include transition services. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine

Direct observation of bed utilization in the pediatric intensive care unit

BACKGROUND:The pediatric intensive care unit (PICU), with limited number of beds and resource-intensive services, is a key component of patient flow. Because the PICU is a crossroads for many patients, transfer or discharge delays can negatively impact a patient's clinical status and efficiency.OBJECTIVE:The objective of this study was to describe, using direct observation, PICU bed utilization.METHODS:We conducted a real-time, prospective observational study in a convenience sample of days in the PICU of an urban, tertiary-care children's hospital.RESULTS:Among 824 observed hours, 19,887 bed-hours were recorded, with 82% being for critical care services and 18% for non–critical care services. Fourteen activities accounted for 95% of bed-hours. Among 200 hours when the PICU was at full capacity, 75% of the time included at least 1 bed that was used for non–critical care services; 37% of the time at least 2 beds. The mean waiting time for a floor bed assignment was 9 hours (median, 5.5 hours) and accounted for 4.62% of all bed-hours observed.CONCLUSIONS:The PICU delivered critical care services most of the time, but periods of non–critical care services represented a significant amount of time. In particular, periods with no bed available for new patients were associated with at least 1 or more PICU beds being used for non–critical care activities. The method should be reproducible in other settings to learn more about the structure and processes of care and patient flow and to make improvements. Journal of Hospital Medicine 2011; © 2011 Society of Hospital Medicine

Toxin assay is more reliable than ICD-9 data and less time-consuming than chart review for public reporting of Clostridium difficile hospital case rates

OBJECTIVE:Clostridium difficile–associated disease (CDAD) is common and has a 6.1% mortality. Governmental agencies have recommended surveillance, but reporting increases health care costs. We sought to identify a reliable method of reporting CDAD that will not significantly increase health care costs.METHODS:Patients were identified via database query for International Statistical Classification of Diseases and Related Health Problems, 9th Edition (ICD-9) codes and C. difficile toxin positivity. All identified patients underwent a chart review, which was used to determine the accuracy of the database query methods. Methods of determining whether CDAD was acquired at the reporting institution were studied, and time required to perform each method was measured.RESULTS:The toxin assay reported 96.1% (369/384) of cases and had a positive predictive value of 100%. No difference was found in comparison of the toxin assay case rate of 15.7 per 1000 discharged patients to the rate of 16.3 identified by chart review (P = 0.440; 95% confidence interval [CI], 14.1–17.4), whereas the ICD-9 method was found to be significantly different by reporting 116.1% (446/384) of cases for a case rate of 19.0 per 1000 discharges (P = 0.001; 95% CI, 17.3–20.8). The time for data extraction via the toxin assay method required only 842 minutes, while the chart review method consumed 21,899 minutes.CONCLUSION:A positive C. difficile toxin assay accurately reports the institutional incidence of disease and is more reliable than ICD-9 query. This process can be instituted at a fraction of the cost of the standard chart review, and enables governmental agencies to inexpensively add CDAD to their list of reportable diseases. Journal of Hospital Medicine 2011; © 2011 Society of Hospital Medicine.

Improving stroke alert response time: Applying quality improvement methodology to the inpatient neurologic emergency

BACKGROUND:Stroke often leaves its victims with devastating disabilities if not treated promptly. Guidelines recommend that brain imaging be obtained within 25 minutes, yet this benchmark is rarely achieved for the in-hospital stroke.PURPOSE:To reduce time to evaluation for strokes occurring in patients already hospitalized, through systematic analysis of current processes and application of standardized quality improvement methodology.METHODS:Improving the quality of care for in-hospital stroke patients involved 4 key steps: (1) creation of a detailed process map to identify inefficiencies in the current process for identifying and treating hospitalized stroke patients, (2) development of an optimized care pathway, (3) implementation of a checklist of optimal practices for the acute stroke response team and nursing staff, and (4) real-time feedback. Time from stroke alert to initiation of computed tomography (CT) scan was prospectively tracked for the 6-month period prior to intervention. After a 3-month interval for intervention roll-out, the response times for the pre-intervention period were compared to a 6-month post-intervention evaluation period.RESULTS:Pre-intervention median inpatient stroke alert-to-CT time was 69.0 minutes, with 19% meeting the goal of 25 minutes from alert to CT time. Post-intervention median inpatient stroke alert-to-CT time was reduced to 29.5 minutes, with 32% at goal (P < 0.0001).CONCLUSIONS:This inpatient stroke alert quality improvement initiative decreased median inpatient alert-to-CT time by 57%, and demonstrated that speed of in-hospital stroke evaluation can be improved through systematic application of quality improvement principles. Journal of Hospital Medicine 2011; © 2011 Society of Hospital Medicine

Development of a score to predict clinical deterioration in hospitalized children

BACKGROUND:Identification of the characteristics that put hospitalized children at high risk of deterioration may help to target patients whose physiologic status should be intensively monitored for signs of deterioration, and reduce unnecessary monitoring in patients at very low risk. Previous studies have evaluated vital sign-based early warning scores to detect deterioration that has already begun.OBJECTIVE:To develop a predictive score for deterioration using non-vital sign patient characteristics in order to risk-stratify hospitalized children before signs of deterioration are detectable.DESIGN:Case-control study.SETTING:A 460-bed children's hospital.PATIENTS:Cases (n = 141) were children who deteriorated while receiving care on non-intensive care unit (non-ICU) inpatient units. Controls (n = 423) were randomly selected.MEASUREMENTS:The exposures were complex chronic conditions, other patient characteristics, and laboratory studies. The outcome was clinical deterioration, defined as cardiopulmonary arrest, acute respiratory compromise, or urgent ICU transfer.RESULTS:The 7-item score included age <1 year, epilepsy, congenital/genetic conditions, history of transplant, enteral tube, hemoglobin <10 g/dL, and blood culture drawn in the preceding 72 hours. We grouped the patients into risk strata based on their scores. The very low-risk group's probability of deterioration was less than half of baseline risk. The high-risk group's probability of deterioration was more than 80-fold higher than the baseline risk.CONCLUSIONS:We identified a set of characteristics associated with clinical deterioration in children. Used in combination as a score, these characteristics may be useful in triaging the intensity of monitoring and surveillance for deterioration that children receive while hospitalized on non-ICU units. Journal of Hospital Medicine 2011;

Use of UpToDate and outcomes in US hospitals

BACKGROUND:Computerized clinical knowledge mana-gement systems hold enormous potential for improving quality and efficiency. However, their impact on clinical practice is not well known.OBJECTIVE:To examine the impact of UpToDate on outcomes of care.DESIGN:Retrospective study.SETTING:National sample of US inpatient hospitals.PATIENTS:Fee-for-service Medicare beneficiaries.INTERVENTION:Adoption of UpToDate in US hospitals.MEASUREMENT:Risk-adjusted lengths of stay, mortality rates, and quality performance.RESULTS:We found that patients admitted to hospitals using UpToDate had shorter lengths of stay than patients admitted to non-UpToDate hospitals overall (5.6 days vs 5.7 days; P < 0.001) and among 6 prespecified conditions (range, −0.1 to −0.3 days; P < 0.001 for each). Further, patients admitted to UpToDate hospitals had lower risk-adjusted mortality rate for 3 of the 6 conditions (range, −0.1% to −0.6% mortality reduction; P < 0.05). Finally, hospitals with UpToDate had better quality performance for every condition on the Hospital Quality Alliance metrics. In subgroup analyses, we found that it was the smaller hospitals and the non-teaching hospitals where the benefits of the UpToDate seemed most pronounced, compared to the larger, teaching institutions where the benefits of UpToDate seemed small or nonexistent.CONCLUSIONS:We found a very small but consistent association between use of UpToDate and reduced length of stay, lower risk-adjusted mortality rates, and better quality performance, at least in the smaller, non-teaching institutions. These findings may suggest that computerized tools such as UpToDate could be helpful in improving care. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.

Post-discharge intervention in vulnerable, chronically ill patients

BACKGROUND:Studies suggest that the inpatient to outpatient transition of care is a vulnerable period for patients, and socioeconomically disadvantaged populations may be particularly susceptible.OBJECTIVE:In this prospective cohort study, clustered by hospital, we sought to determine the feasibility and utility of a simple, post-discharge intervention in reducing hospital readmissions.METHODS:Chronically ill Medicaid managed care members were consecutively identified from the discharge records of 10 area hospitals. For patients from the 7 intervention hospitals, trained medical assistants performed a brief telephone needs assessment, within 1 week of discharge, in which issues requiring near-term resolution were identified and addressed. Patients with more complicated care needs were identified according to a 4-domain care needs framework and enrolled in more intensive care management. Patients discharged from the 3 control hospitals received usual care. We used a generalized estimating equation model, which adjusts for clustering by hospital, to evaluate the primary outcome of hospital readmission within 60 days.RESULTS:There were 97 intervention and 130 control patients. Intervention patients were slightly younger and had higher adjusted clinical group (ACG) scores. In unadjusted analysis, the intervention group had lower, but statistically similar, 60-day rehospitalization rates (23.7% vs 29.2%, P = 0.35). This difference became significant after controlling for ACG score, prior inpatient utilization, and age: adjusted odds ratio (OR) [95% confidence interval (CI)] 0.49 [0.24-1.00].CONCLUSIONS:A simple post-discharge intervention and needs assessment may be associated with reduced recurrent hospitalization rates in a cohort of chronically ill Medicaid managed care patients with diverse care needs. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine

Residents contributing to inpatient quality: Blending learning and improvement

BACKGROUND:Quality improvement (QI) initiatives reduce medical errors and are an important aspect of resident physician training. Many institutions have limited funding and few QI experts, making it essential to develop effective programs that require only modest resources. We describe a resident-led, hospitalist-facilitated limited root cause analysis (RCA) QI program developed to meet training needs and institutional constraints.METHODS:We initiated a monthly quality improvement conference (QIC) at the Mount Sinai Hospital in New York City, New York. Before each conference, a third-year resident investigated a patient care issue and completed a limited RCA. At the QIC, the findings were presented to the Internal Medicine residents, followed by a chief resident and hospitalist-facilitated group discussion. All proposed interventions were recorded, and selected interventions were later implemented. The success of these interventions in achieving permanent system-wide change or resident behavior change was tracked. Residents' views on the conferences were solicited via an anonymous questionnaire.RESULTS:Twenty conferences were held over the first 22 months of the program. Twenty-five (54%) of the 46 suggested interventions were initiated. Eighteen (72%) attempted interventions resulted in system-wide change or resident behavior change. Fifty-three residents evaluated the quality of the conferences. The majority believed the conferences were high quality (98%) and led to patient care improvements (96%).CONCLUSIONS:Resident-led modified RCAs are an effective method of integrating QI efforts into resident training. As front line providers, residents are uniquely positioned to identify and implement system changes that benefit patients. Conferences were implemented without overburdening facilitators or participants. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine

Elevated vancomycin trough is not associated with nephrotoxicity among inpatient veterans

BACKGROUND:Vancomycin troughs of 15-20 mg/L are recommended in the treatment of invasive staphylococcal disease, higher levels than previously recommended.OBJECTIVE/SETTING:We sought to determine if there was an association between vancomycin trough and nephrotoxicity, defined as 0.5 mg/L or 50% increase in serum creatinine, at a large Veterans Affairs medical center.PATIENTS AND METHODS:We reviewed records of 348 inpatients at our institution who received ≥5 days of vancomycin during 2 time periods when vancomycin dosing protocols differed (May 2005-April 2006 and January 2007-December 2007). Potential risk factors for nephrotoxicity were collected prior to nephrotoxicity onset, and all patients with nephrotoxicity events occurring within 5 days of starting vancomycin were excluded.RESULTS:Overall incidence of nephrotoxicity was 31/348 patients (8.9%). A similar percentage of patients experienced nephrotoxicity in 2005-2006 versus 2007 (16/201 vs 15/147, respectively; P = 0.57), despite a rise in mean (9.7 mg/L in 2005-2006 vs 13.2 mg/L in 2007; P < 0.0001) and highest (11.8 mg/L in 2005-2006 vs 15.7 mg/L in 2007; P < 0.0001) vancomycin trough levels achieved. In a multivariate logistic regression model, only receipt of intravenous contrast dye was significantly associated with nephrotoxicity (OR 4.01, P < 0.001), though there was a trend toward an association between maximum vancomycin trough ≥15 mg/L and nephrotoxicity (OR 2.05, P = 0.082). Overall reversibility of nephrotoxicity either prior to or within 72 hours of vancomycin discontinuation was 77.8%.CONCLUSIONS:We conclude that nephrotoxicity, with higher trough levels occurring at ≥5 days of vancomycin therapy, was uncommon at our institution and typically reversible. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine

Incidence of hypoglycemia following insulin-based acute stabilization of hyperkalemia treatment

PURPOSE:The aim of this study was to assess the incidence of hypoglycemia in hospitalized patients following acute treatment of hyperkalemia with insulin. A characterization of the affected patients and the administered insulin/dextrose regimens was also performed.METHODS:A retrospective search of the electronic records of a large university-based tertiary care hospital was conducted, from June 1, 2009 to December 1, 2009, to identify patients who developed hypoglycemia following acute stabilization of hyperkalemia treatment with regular insulin.RESULTS:Of 219 hyperkalemic patients who met the criteria of the study, 19 patients (8.7%) were identified as hypoglycemic (blood glucose <70 mg/dl), and 5 of these patients (2.3% of study patients) were classified as severely hypoglycemic (blood glucose <40 mg/dl). Fifteen (79%) of the hypoglycemic patients had acute kidney injury or were end-stage renal disease patients on hemodialysis at the time of treatment. Fifty-eight percent of the hypoglycemic events occurred following the commonly employed 10 units of regular insulin and 25 gm of dextrose 50% treatment regimen.CONCLUSION:Iatrogenic hypoglycemia, as a result of treatment for hyperkalemia, is a common occurrence. Hyperkalemia occurs disproportionately in patients with acute kidney injury or end-stage renal disease, and these patients are predisposed to an increased risk of hypoglycemia. The risk of severe hypoglycemia escalates in patients with lower body weight and creatinine clearance. Hypoglycemia risk can be minimized by providing sufficient dextrose in the treatment regimen, however, patient variability in treatment response dictates careful blood glucose monitoring before and after treatment. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

What every hospitalist should know about the post-bariatric surgery patient

Obesity is a growing worldwide epidemic, increasingly addressed through surgical options for weight loss. Benefits of these operations, such as weight loss and improvement or reversal of obesity-related comorbidities, are well established; however, postoperative complications do occur. This article will evaluate common causes for hospital admissions in the post-bariatric surgery population as they relate to the hospitalist who is often responsible for their care. Here we provide an overview of the most common bariatric procedures currently performed, early postoperative complications, late medical complications (ie, abdominal complaints, weight fluctuations, nutritional deficiencies, and metabolic bone disease), and late surgical complications that often affect these patients and result in hospital admissions. Special attention will be paid to radiologic pearls that can assist in the initial evaluation and diagnosis of these patients. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine

Hospice eligibility in patients who died in a tertiary care center

BACKGROUND:Hospice is a service that patients, families, and physicians find beneficial, yet a majority of patients die without receiving hospice care. Little is known about how many hospitalized patients are hospice eligible at the time of hospitalization.METHODS:Retrospective chart review was used to examine all adult deaths (n = 688) at a tertiary care center during 2009. Charts were selected for full review if the death was nontraumatic and the patient had a hospital admission within 12 months of the terminal admission. The charts were examined for hospice eligibility based on medical criteria, evidence of a hospice discussion, and hospice enrollment.RESULTS:Two hundred nine patients had an admission in the year preceding the terminal admission and a nontraumatic death. Sixty percent were hospice eligible during the penultimate admission. Hospice discussions were documented in 14% of the hospice-eligible patients. Patients who were hospice eligible had more subspecialty consults on the penultimate admission compared to those not hospice eligible (P = 0.016), as well as more overall hospitalizations in the 12 months preceding their terminal admission (P = 0.0003), and fewer days between their penultimate admission and death (P = 0.001).CONCLUSION:The majority of terminally ill inpatients did not have a documented discussion of hospice with their care provider. Educating physicians to recognize the stepwise decline of most illnesses and hospice admission criteria will facilitate a more informed decision-making process for patients and their families. A consistent commitment to offer hospice earlier than the terminal admission would increase access to community or home-based care, potentially increasing quality of life. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

A grumpy old man

Vancomycin-resistant Enterococcus bacteremia: An evaluation of treatment with linezolid or daptomycin

BACKGROUND:Due to high rates of resistance and a limited number of efficacious antimicrobials for vancomycin-resistant Enterococcus (VRE), appropriate antibiotic selection is vital to treatment success. The purpose of this study was to assess clinical and microbiologic outcomes associated with the use of linezolid or daptomycin in the treatment of VRE bacteremia.METHODS:A retrospective analysis of adult patients with VRE bacteremia between January 2004 and July 2009 was conducted at a tertiary care hospital in the United States. Clinical and microbiologic outcomes for both therapies were evaluated using multiple criteria.RESULTS:Of the 361 patients with VRE bacteremia identified, 201 were included in the study (linezolid group, n = 138; daptomycin group, n = 63). More patients in the daptomycin group had hematologic malignancies (33% vs 14%) or received liver transplants (13% vs 4%). There was no difference in clinical or microbiologic cure between the linezolid and daptomycin groups (74% vs 75% and 94% vs 94%, respectively). Recurrence was documented in 3% of linezolid patients vs 12% of daptomycin patients (P = 0.0321). Reinfection was noted in 1% of patients in the linezolid group vs 6% of patients in the daptomycin group (P not significant). The average length of stay (LOS) was 37 days for the linezolid group vs 40 days for the daptomycin group (P not significant). Overall mortality was 20%, occurring in 25/138 linezolid patients vs 15/63 daptomycin patients (P not significant).CONCLUSIONS:No differences in clinical or microbiologic cure rates, LOS, or mortality were identified between the groups. Various factors may have contributed to the significantly higher recurrence of VRE bacteremia in daptomycin patients. This study suggests that linezolid and daptomycin appear equally efficacious in the treatment of VRE bacteremia. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

Hospitalists and intensivists in the medical ICU: A prospective observational study comparing mortality and length of stay between two staffing models

BACKGROUND:A shortage of critical care specialists or intensivists, coupled with expanding United States critical care needs, mandates identification of alternate qualified physicians for intensive care unit (ICU) staffing.OBJECTIVE:To compare mortality and length of stay (LOS) of medical ICU patients cared for by a hospitalist or an intensivist-led team.DESIGN:Prospective observational study.SETTING:Urban academic community hospital affiliated with a major regional academic university.PATIENTS:Consecutive medical patients admitted to a hospitalist ICU team (n = 828) with selective intensivist consultation or an intensivist-led ICU teaching team (n = 528).MEASUREMENTS:Endpoints were ICU and in-hospital mortality and LOS, adjusted for patient differences with logistic and linear regression models and propensity scores.RESULTS:The odds ratio adjusted for disease severity for in-hospital mortality was 0.8 (95% confidence interval [CI]: 0.49, 1.18; P = 0.23) and ICU mortality was 0.8 (95% CI: 0.51, 1.32; P = 0.41), referent to the hospitalist team. The adjusted LOS was similar between teams (hospital LOS difference 0.9 days, P = 0.98; ICU LOS difference 0.3 days, P = 0.32). Mechanically ventilated patients with intermediate illness severity had lower hospital LOS (10.6 vs 17.8 days, P < 0.001) and ICU LOS (7.2 vs 10.6 days, P = 0.02), and a trend towards decreased in-hospital mortality (15.6% vs 27.5%, P = 0.10) in the intensivist-led group.CONCLUSIONS:The adjusted mortality and LOS demonstrated no statistically significant difference between hospitalist and intensivist-led ICU models. Mechanically ventilated patients with intermediate illness severity showed improved LOS and a trend towards improved mortality when cared for by an intensivist-led ICU teaching team. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine

Economic impact of enoxaparin versus unfractionated heparin for venous thromboembolism prophylaxis in patients with acute ischemic stroke: A hospital perspective of the PREVAIL trial

BACKGROUND:The PREVAIL (Prevention of VTE [venous thromboembolism] after acute ischemic stroke with LMWH [low-molecular-weight heparin] and UFH [unfractionated heparin]) study demonstrated a 43% VTE risk reduction with enoxaparin versus UFH in patients with acute ischemic stroke (AIS). A 1% rate of symptomatic intracranial and major extracranial hemorrhage was observed in both groups.OBJECTIVE:To determine the economic impact, from a hospital perspective, of enoxaparin versus UFH for VTE prophylaxis after AIS.DESIGN:A decision-analytic model was constructed and hospital-based costs analyzed using clinical information from PREVAIL. Total hospital costs were calculated based on mean costs in the Premier™ database and from wholesalers acquisition data. Costs were also compared in patients with severe stroke (National Institutes of Health Stroke Scale [NIHSS] score ≥14) and less severe stroke (NIHSS score <14).RESULTS:The average cost per patient due to VTE or bleeding events was lower with enoxaparin versus UFH ($422 vs $662, respectively; net savings $240). The average anticoagulant cost, including drug-administration cost per patient, was lower with UFH versus enoxaparin ($259 vs $360, respectively; net savings $101). However, when both clinical events and drug-acquisition costs were considered, the total hospital cost was lower with enoxaparin versus UFH ($782 vs $922, respectively; savings $140). Hospital cost-savings were greatest ($287) in patients with NIHSS scores ≥14.CONCLUSIONS:The higher drug cost of enoxaparin was offset by the reduction in clinical events as compared to the use of UFH for VTE prophylaxis after an AIS, particularly in patients with severe stroke. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

Risk factors of workplace violence at hospitals in Japan

BACKGROUND:Patients and their relatives exposed to mental stress caused by hospitalization or illness might use violence against healthcare staff and interfere with quality healthcare.OBJECTIVE:The aim of this study was to investigate incidences of workplace violence and the attributes of healthcare staff who are at high risk.DESIGN:A questionnaire-based, anonymous, and self-administered cross-sectional survey.SETTING:Healthcare staff (n = 11,095) of 19 hospitals in Japan.MEASUREMENTS:Incidence rates and adjusted odd ratios of workplace violence were calculated to examine the effect of attributes of healthcare staff to workplace violence by using logistic regression analysis.RESULTS:The response rate for survey completion was 79.1% (8711/11,095). Among the respondents, 36.4% experienced workplace violence by patients or their relatives in the past year; 15.9% experienced physical aggression, 29.8% experienced verbal abuse, and 9.9% experienced sexual harassment. Adjusted odds ratios of physical aggression were significantly high in psychiatric wards, critical care centers/intensive care units (ICU)/cardiac care units (CCU), long-term care wards, for nurses, nursing aides/care workers, and for longer working hours. Adjusted odds ratios of verbal abuse were significantly high in psychiatric wards, long-term care wards, outpatient departments, dialysis departments, and for longer years of work experience, and for longer working hours. Adjusted odds ratios of sexual harassment were significantly high in dialysis departments, for nurses, nursing aides/care workers, technicians, therapists and females. The general ward and direct interaction with patients were common risk factors for each type of workplace violence.CONCLUSIONS:The mechanisms and the countermeasures for each type of workplace violence at those high-risk areas should be investigated. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

Development of a pediatric hospitalist sedation service: Training and implementation

OBJECTIVE:There is growing demand for safe and effective procedural sedation in pediatric facilities nationally. Currently, these needs are being met by a variety of providers and sedation techniques, including anesthesiologists, pediatric intensivists, emergency medicine physicians, and pediatric hospitalists. There is currently no consensus regarding the training required by non-anesthesiologists to provide safe sedation. We will outline the training method developed at St. Louis Children's Hospital.METHODS:In 2003, the Division of Pediatric Anesthesia at St. Louis Children's Hospital approached the Division of Pediatric Hospitalist Medicine as a resource to provide pediatric sedation outside of the operating room. Over the last seven years, Pediatric Hospitalist Sedation services have evolved into a three-tiered system of sedation providers. The first tier provides sedation services in the emergency unit (EU) and the Center for After Hours Referral for Emergency Services (CARES). The second tier provides sedation throughout the hospital including the EU, CARES, inpatient units, Ambulatory Procedure Center (APC), and Pediatric Acute Wound Service (PAWS); it also provides night/weekend sedation call for urgent needs. The third tier provides sedation in all of the second-tier locations, as well as utilizing propofol in the APC.RESULTS:This training program has resulted in a successful pediatric hospitalist sedation service. Based on fiscal year 2009 billing data, the division performed 2,471 sedations. We currently have 43 hospitalists providing Tier-One sedation, 18 Tier-Two providers, and six Tier-Three providers.CONCLUSIONS:A pediatric hospitalist sedation service with proper training and oversight can successfully augment sedation provided by anesthesiologists. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine

Contarini's syndrome: Bilateral pleural effusion, each side from different causes

Bilateral pleural effusions usually have a single causative factor, such as heart failure or malignancy. Contarini's syndrome refers to the occurrence of bilateral pleural fluid accumulation which can be explained by a different cause for each side. Literature search finds, along with 5 new descriptions from our center, totaled 12 cases. A frequent combination is that of a parapneumonic effusion that triggers heart failure, which in turn produces a contralateral transudate. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine

Patient satisfaction with hospital care provided by hospitalists and primary care physicians

BACKGROUND:Compared to hospital care provided by primary care physicians (PCPs), the hospitalist model provides equal-to-superior efficiency and outcomes; however, little is known about how the model affects patient satisfaction.METHODS:Random patient satisfaction telephone interviews were conducted on discharged adult medicine inpatients at 3 Massachusetts hospitals between 2003 and 2009. Questionnaires included variables assessing patient satisfaction with various physician care domains. Patient age, gender, admission year, education level, language, illness severity, emergency room admission status, institution, and attending physician type were extracted from billing records. We used adjusted multivariable models to compare patient satisfaction with hospitalists and PCPs for domains of: physician care quality, physician behavior, pain management, communication.RESULTS:Inpatients completed discharge surveys for 8295 encounters (3597 hospitalist, 4698 PCP). Multivariate-adjusted satisfaction scores for physician care quality were slightly higher for PCPs than hospitalists (4.24 vs 4.20, P = 0.04); there was no statistical difference at any individual hospital, and no difference among different hospitalist groups. Patient ratings of hospitalists and PCPs for behavior, pain control, and communication were equivalent (all P values >0.23). In multivariable models, hospitalists and PCPs had similar adjusted proportions in the highest satisfaction category (79.2% vs 80.5%, respectively, P = 0.17) and lowest category (5.1% vs 4.5%, respectively, P = 0.19). Quality ratings of both groups improved equivalently (P slope interaction = 0.47) but significantly over time (PCP 4.21 (2003) to 4.36 (2009), hospitalist 4.11 to 4.33, P Δ <0.001).CONCLUSIONS:Patients appear similarly satisfied with inpatient care provided by several hospitalist models and by primary care physicians. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

Predicting antibiotic resistance to community-acquired pneumonia antibiotics in culture-positive patients with healthcare-associated pneumonia

OBJECTIVE:To develop and validate a model to predict resistance to community-acquired pneumonia antibiotics (CAP-resistance) among patients with healthcare-associated pneumonia (HCAP), and to compare the model's predictive performance to a model including only guideline-defined criteria for HCAP.DESIGN:Retrospective cohort study.SETTING:Six Veterans Affairs Medical Centers in the northwestern United States.PATIENTS:Culture-positive inpatients with HCAP.MEASUREMENTS:Patients were identified based upon guideline-defined criteria for HCAP. Relevant cultures obtained within 48 hours of admission were assessed to determine bacteriology and antibiotic susceptibility. Medical records for the year preceding admission were assessed to develop predictive models of CAP-resistance with logistic regression. The predictive performance of cohort-developed and guideline-defined models was compared.RESULTS:CAP-resistant organisms were identified in 118 of 375 culture-positive patients. Of guideline-defined criteria, CAP-resistance was associated (odds ratio (OR) [95% confidence interval (CI)]) with: admission from nursing home (2.6 [1.6-4.4]); recent antibiotic exposure (1.7 [1.0-2.8]); and prior hospitalization (1.6 [1.0-2.6]). In the cohort-developed model, CAP-resistance was associated with: admission from nursing home or recent nursing home discharge (2.3 [1.4-3.8]); positive methicillin-resistant Staphylococcus aureus (MRSA) history within 90 days of admission (6.4 [2.6-17.8]) or 91-365 days (2.3 [0.9-5.9]); cephalosporin exposure (1.8 [1.1-2.9]); recent infusion therapy (1.9 [1.0-3.5]); diabetes (1.7 [1.0-2.8]); and intensive care unit (ICU) admission (1.6 [1.0-2.6]). Area under the receiver operating characteristic curve (aROC [95% CI]) for the cohort-developed model (0.71 [0.65-0.77]) was significantly higher than for the guideline-defined model (0.63 [0.57-0.69]) (P = 0.01).CONCLUSIONS:Select guideline-defined criteria predicted CAP-resistance. A cohort-developed model based primarily on prior MRSA history, nursing home residence, and specific antibiotic exposures provided improved prediction of CAP-resistant organisms in HCAP. Journal of Hospital Medicine 2011; © 2011 Society of Hospital Medicine.

Inpatient staffing within pediatric residency programs: Work hour restrictions and the evolving role of the pediatric hospitalist

OBJECTIVE:In October 2010, the Accreditation Council for Graduate Medical Education (ACGME) mandated new standards that will further restrict resident work hours. There is growing concern surrounding the impact these restrictions will have on the staffing of inpatient services. The objective of this study was to survey the landscape of pediatric resident coverage of noncritical care inpatient teaching services prior to the implementation of these guidelines. In addition, we sought to explore how changes in work hour restrictions might affect the role of pediatric hospitalists in training programs.METHODS:In January 2010, an institutional review board (IRB)-approved electronic survey was sent to 196 US residency training programs via the Association of Pediatric Program Directors (APPD) listserve.RESULTS:One hundred twenty responses were received representing 5201 pediatric residents. Of the programs that responded, 84% have hospitalists. At programs with hospitalists (n = 97), 24% have pediatric hospitalist attendings in-house at night. Nearly a quarter of responding programs (22%) reported having no attending physicians in-house at night. At the time of our survey, 31% of programs anticipated the addition of 24-hour in-house hospitalist coverage within the next 5 years. When the additional work hour restrictions are implemented, 70% of programs anticipated the need to add additional hospitalist coverage at night.CONCLUSIONS:Significant variation exists in how pediatric teaching services provide overnight coverage. While hospitalists are prevalent in pediatric training programs (84% overall, 67% day only), their role in direct patient care during the overnight hours has been limited thus far. New work hour restrictions will promote the need for more hospitalists. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

Adverse outcomes associated with delayed intensive care unit transfers in an integrated healthcare system

BACKGROUND:Patients with intensive care unit (ICU) transfers from hospital wards have higher mortality than those directly admitted from the emergency department.OBJECTIVE:To describe the association between the timing of unplanned ICU transfers and hospital outcomes.DESIGN, SETTING, PATIENTS:Evaluation of 6369 early (within 24 hours of hospital admission) unplanned ICU transfer cases and matched directly admitted ICU controls from an integrated healthcare system. Cohorts were matched by predicted mortality, age, gender, diagnosis, and admission characteristics. Hospital mortality of cases and controls were compared based on elapsed time and diagnosis.RESULTS:More than 5% of patients admitted through the emergency department experienced an unplanned ICU transfer; the incidence and rates of transfers were highest within the first 24 hours of hospitalization. Multivariable matching produced 5839 (92%) case-control pairs. Median length of stay was higher among cases (5.0 days) than controls (4.1 days, P < 0.01); mortality was also higher among cases (11.6%) than controls (8.5%, P < 0.01). Patients with early unplanned transfers were at an increased risk of death (odds ratio, 1.44; 95% confidence interval, 1.26-1.64; P < 0.01); an increased risk of death was observed even among patients transferred within 8 hours of hospitalization. Hospital mortality differed based on admitting diagnosis categories. While it was higher among cases admitted for respiratory infections and gastrointestinal bleeding, it was not different for those with acute myocardial infarction, sepsis, and stroke.CONCLUSIONS:Early unplanned ICU transfers—even within 8 hours of hospitalization—are associated with increased mortality; outcomes vary by elapsed time to transfer and admitting diagnosis. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

Severe acute hypertension among inpatients admitted from the emergency department

BACKGROUND:Hospitalists often treat patients with severe acute hypertension (AH) presenting to the hospital. Little is known about the epidemiology of this syndrome.OBJECTIVE:To examine the prevalence of severe AH in patients admitted through the emergency department (ED) and its associated outcomes.DESIGN:A cohort study using retrospectively collected vital signs and other clinical data.PATIENTS:A total of 1,290,804 adults admitted between 2005 and 2007.SETTING:One hundred fourteen acute-care hospitals.MEASUREMENTS:Severe AH was defined as at least 1 systolic blood pressure (SBP) >180 mmHg. We used multivariable regression to estimate AH-attributable in-hospital mortality, need for mechanical ventilation (MV), and length of stay (LOS).RESULTS:Severe AH occurred in 178,131 (13.8%) patients. Disease categories with the highest prevalence were nervous (29.0%), circulatory (16.0%), endocrine (14.7%), and kidney/urinary (13.5%). The overall in-hospital mortality was 3.6%. The relationship between severe AH strata and mortality was graded for nervous system diseases; mortality rates for each 10 mmHg increase in SBP from 180 to >220 mmHg were 6.5%, 8.1%, 9.9%, 12.0%, and 19.7%, respectively (P < 0.0001). The relationship between severe AH strata and need for MV was graded in the most pronounced way in respiratory and circulatory conditions (P < 0.0001). The relationship between severe AH strata and LOS was graded in most disease categories (P < 0.0001).CONCLUSIONS:Severe AH appears common and its prevalence varies by underlying clinical condition. Severe AH is associated with excess in-hospital mortality for patients with nervous system diseases and, for most disease categories, prolongs hospitalization. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine

Differences in designations of observation care in US freestanding children's hospitals: Are they virtual or real?

OBJECTIVE:To characterize practices related to observation care and to examine the current models of pediatric observation medicine in US children's hospitals.DESIGN:We utilized 2 web-based surveys to examine observation care in the 42 hospitals participating in the Pediatric Health Information System database. We obtained information regarding the designation of observation status, including the criteria used to admit patients into observation. From hospitals reporting the use of observation status, we requested specific details relating to the structures of observation care and the processes of care for observation patients following emergency department treatment.RESULTS:A total of 37 hospitals responded to Survey 1, and 20 hospitals responded to Survey 2. Designated observation units were present in only 12 of 31 (39%) hospitals that report observation patient data to the Pediatric Health Information System. Observation status was variably defined in terms of duration of treatment and prespecified criteria. Observation periods were limited to <48 hours in 24 of 31 (77%) hospitals. Hospitals reported that various standards were used by different payers to determine observation status reimbursement. Observation care was delivered in a variety of settings. Most hospitals indicated that there were no differences in the clinical care delivered to virtual observation status patients when compared with other inpatients.CONCLUSIONS:Observation is a variably applied patient status, defined differently by individual hospitals. Consistency in the designation of patients under observation status among hospitals and payers may be necessary to compare quality outcomes and costs, as well as optimize models of pediatric observation care.Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

Short-term mortality among older persons hospitalized for pneumonia: Influence of baseline patient characteristics beyond severity of illness

BACKGROUND:Although severity of illness indices such as pneumonia severity index (PSI) are good predictors of short-term mortality for community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP), other patient factors may have added prognostic value.OBJECTIVE:To identify patient factors beyond the PSI which explain 30-day mortality among older persons hospitalized with CAP and HCAP.DESIGN:Retrospective cohort study.SETTING:Three acute care hospitals in Singapore in 2007.PATIENTS:Hospitalized adults aged 65 years or older who have primary International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes 480 to 486 with clinical and radiological features of pneumonia.INTERVENTIONS:None.MEASUREMENTS:Thirty-day mortality, PSI class, demographic and clinical features, comorbid conditions, functional status, selected laboratory tests, and chest radiographic findings.RESULTS:Among 1607 patients included, 890 (55.4%) had CAP and 717 (44.6%) had HCAP. After adjustment for PSI class in logistic regression analyses, pre-morbid ambulation impairment (odds ratio [OR] 2.61, 95% confidence interval [CI] 1.98 to 3.45), hospitalization in the prior 30 days (OR 1.93, 95% CI 1.38 to 2.71), and absence of cough and purulent sputum (OR 1.47, 95% CI 1.14 to 1.90) were all significantly associated with 30-day mortality. These associations remained constant when CAP and HCAP were analyzed separately.CONCLUSIONS:Recent hospitalization, pre-morbid ambulation impairment, and atypical presentation were independently associated with higher 30-day mortality among older persons hospitalized for pneumonia, after adjusting for severity of illness. These factors could be considered in addition to PSI when performing risk stratification and adjustment in this setting. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

Variability in the interpretation of chest radiographs for the diagnosis of pneumonia in children

BACKGROUND:Although chest radiography is commonly used to establish the diagnosis of pneumonia in children, the reliability of radiographic findings among radiologists is not well described.OBJECTIVE:We sought to evaluate the inter-rater and intra-rater reliability of radiographic features commonly described by radiologists in childhood pneumonia.METHODS:Prospective case-based study. One hundred and ten radiographs of children evaluated in a pediatric emergency department for suspicion of pneumonia were interpreted by six radiologists at two academic children's hospitals. Radiologists were blinded to the clinical history. Reliability of standardized radiographic features was evaluated using the kappa statistic.RESULTS:The radiographic finding of an alveolar infiltrate demonstrated substantial reliability among radiologists (κ = 0.69). The presence of ‘any infiltrate’ and pleural effusion demonstrated moderate reliability (κ = 0.47 and k=0.45, respectively). Other radiographic features were less reliable: air bronchograms (κ = 0.32), hilar adenopathy (κ = 0.21), and interstitial infiltrate (κ = 0.14). Similarly, the finding of alveolar infiltrate demonstrated substantial intra-rater reliability upon review of ten duplicate radiographs, whereas interstitial infiltrate was less reliable.CONCLUSION:The radiographic finding of an alveolar infiltrate is very reliable among pediatric radiologists, whereas the finding of an interstitial infiltrate is less reliable. Journal of Hospital Medicine 2011; © 2011 Society of Hospital Medicine.

Four years' experience with a hospitalist-led medical emergency team: An interrupted time series

BACKGROUND:The effect of Medical Emergency Teams (METs) on cardiopulmonary arrests (codes) and fatal codes remains unclear and widely debated.OBJECTIVE:To describe the implementation of a hospitalist-led MET and compare the number of code calls and code deaths before and after implementation.DESIGN:Interrupted time series.SETTING:Tertiary care academic medical center.PATIENTS:All hospitalized patients.INTERVENTION:Implementation of an MET, consisting of a critical care nurse, respiratory therapist, intravenous therapist, and the patient's physician.MEASUREMENTS:Number of MET calls, code calls, cardiac arrests and other medical crises, and code deaths per 1000 admissions, stratified by location (inside vs outside critical care).RESULTS:From implementation in March 2006 through December 2009, the MET logged 2717 calls, most commonly for respiratory distress (33%), cardiovascular instability (25%), and neurological abnormality (20%). Overall code calls declined significantly between pre-implementation and post-implementation of the MET from 7.30 (95% confidence interval [CI] 5.81, 9.16) to 4.21 (95% CI 3.42, 5.18) code calls per 1000 admissions. Outside of critical care, code calls declined from 4.70 (95% CI 3.92, 5.63) before the MET was implemented to 3.11 (95% CI 2.44, 3.97) afterwards, primarily due to a decrease in medical crises, which averaged 3.29 events per 1000 admissions (95% CI 2.70, 4.02) before implementation and decreased to 1.72 (95% CI 1.28, 2.31) afterwards. Code calls within critical care also declined. The rate of fatal codes was not affected.CONCLUSIONS:A hospitalist-led MET decreased code call rates but did not affect mortality rates. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine

Creating a web-based incident analysis and communication system

BACKGROUND:Hospitals perform root cause analyses (RCA) and implement action plans for sentinel events (SE) to prevent similar adverse events. Dissemination of RCA action plans between hospitals has been limited by an absence of universal definitions of terms and classification frameworks, which have been recently proposed by the World Health Organization's International Classification for Patient Safety (ICPS). Tools do not exist, however, to assist hospitals in performing SE reviews aligned with the ICPS framework.METHODS:We developed an intranet-based decision support tool that aligns SE reviews with the ICPS framework, and captures SEs and action plans into a searchable database for aggregate reporting. Its structural elements include: 1) encrypted database on a secure server; 2) decision support resources that align SE analyses with the ICPS classification; 3) drop-down lists and help tools to standardize input; 4) standardized individual and aggregate SE reports that vary depending on recipients; 5) real-time access to Web-based RCA resources; 6) fishbone diagramming; and 7) query functions for database searches.RESULTS:Entry of 15 SE reports into the database framework identified gaps in our previous reviews. Safety personnel and health system leadership have expressed positive assessments of the database and approved funding for evaluation of system-wide implementation.DISCUSSION:Expansion of our database to all safety incidents beyond SEs provides a resource for communicating safety opportunities between hospitals. We demonstrate how the ICPS classifications can be migrated into a decision support tool that has potential for standardizing root cause analyses, disseminating action plans, and improving patient safety. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

Contribution of body mass index to postoperative outcome in minority patients

OBJECTIVE:The purpose of this investigation was to examine the association of body mass index (BMI) category with short-term outcomes in minority surgical patients—a relationship that previously has not been well characterized.METHODS:Data from the National Surgical Quality Improvement Program were used to calculate the BMI of minority patients undergoing surgery from 2005 to 2008. Patients were stratified into 5 BMI classes. Stepwise logistic regression was used to calculate odds ratios for mortality after controlling for known clinically relevant covariates.MAIN OUTCOME MEASURES:Morbidity and mortality at 30 days, across all 5 BMI classes.RESULTS:Among 119,619 minority patients studied, 50% were African American, 36% Hispanic, 10% Asian and Pacific Islanders, and 4% American Indian and Alaskan natives. Seventy percent were overweight or obese. Women were more likely to be obese or severely obese. The overall mortality rate was 1.5%, and this varied significantly by BMI class. Distribution of 30-day mortality demonstrated a progressive decrease, with the highest risk of death in the underweight class, and the lowest risk of death in the severely obese class. This relationship was maintained, even in patients with at least 1 major postoperative complication.CONCLUSION:The prevalence of being overweight or obese was high in this nationally representative cohort of minority surgical patients. Although BMI class is a significant predictor of 30-day mortality, the effect appeared paradoxical. The poorest outcomes were in the underweight and normal BMI patients. Severely obese patients had the lowest risk of mortality, even after experiencing a major postoperative complication. Journal of Hospital Medicine 2011; © 2011 Society of Hospital Medicine.

Pediatric hospitalists' influences on education and career plans

BACKGROUND:Pediatric hospitalist (PH) presence is rapidly increasing, yet little is known about pediatric resident exposure to hospitalists, or how this affects resident education/career decisions.OBJECTIVES:To determine resident exposure to pediatric hospitalists; examine resident opinions regarding hospitalists' roles; examine resident opinion of hospital medicine career training needs; explore how resident exposure to hospitalists affects career choices.METHODS:Survey of random sample of 300 residents from the American Academy of Pediatrics Section on Residents database.RESULTS:Two-hundred seventy-nine pediatric residents surveyed; 120(43%) responded with variance by question; 90% work with hospitalists during residency. Of this national sample, 82% cite hospitalists as enhancing education. A majority (64%) believe pediatric hospitalists are better than primary care physicians at caring for complex inpatients; 28% felt PH provided better care for routine admissions. Over one-third surveyed are considering a career in Pediatric Hospital Medicine (PHM); 7% plan to enter the field upon graduation. Residents cited opportunities to participate in education, flexible hours, and better salaries as the top 3 reasons to become a hospitalist. Ten percent felt there was no difference between resident and hospitalist positions; 21% see PHM as a short-term job without long-term potential. Of residents entering Primary Care, a majority (59%) stated that the availability of hospitalists would positively influence their choice of a practice position; 7% said they were “less likely to choose to practice Primary Care Pediatrics because of hospitalists.”CONCLUSIONS:PH have a role in physician training. While PHM has become a career consideration for trainees, more work needs to be done to improve the perception of PHM as a viable long-term career. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine

Subcutaneous methylnaltrexone for treatment of acute opioid-induced constipation: Phase 2 study in rehabilitation after orthopedic surgery

BACKGROUND:Methylnaltrexone has been shown to be effective for treating opioid-induced constipation (OIC) in chronic settings, but its effects on acute OIC have not been studied.OBJECTIVE:To assess safety and efficacy of subcutaneous methylnaltrexone in patients with acute OIC after orthopedic procedures.DESIGN:Double-blind, randomized, parallel-group, placebo-controlled, hypothesis-generating phase 2 study.SETTING:Sixteen US hospitals and rehabilitation facilities.PATIENTS:Adult patients with acute OIC after orthopedic surgical procedure, expected to require opioids for at least 7 days postrandomization.INTERVENTIONS:Patients received once-daily subcutaneous methylnaltrexone 12 mg or placebo for up to 4 or 7 days.MEASUREMENTS:All endpoints were exploratory and included the percentage of patients achieving laxation within 2 and 4 hours of first dose and time to laxation.RESULTS:Thirty-three patients received at least 1 dose of study drug (methylnaltrexone, n = 18; placebo, n = 15). Within 2 and 4 hours, significantly more patients receiving methylnaltrexone achieved laxation (2 hours: 33.3% vs 0%, P = 0.021; 4 hours: 38.9% vs 6.7%, P = 0.046) compared with placebo. Time to laxation was significantly shorter with methylnaltrexone (median = 15.8 hours) versus placebo (median = 50.9 hours), P = 0.0197. The most common adverse events related to the gastrointestinal tract. Pain scores remained stable and were similar to those of placebo, and signs and symptoms of opioid withdrawal did not emerge in patients receiving methylnaltrexone.CONCLUSIONS:Methylnaltrexone was generally well tolerated and was active in inducing laxation in this study of patients experiencing acute OIC following orthopedic surgery. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.

Pediatric hospital medicine: A strategic planning roundtable to chart the future

Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association sponsored a roundtable to discuss the future of the field. Twenty-one leaders were invited plus a facilitator utilizing established health care strategic planning methods. A “vision statement” was developed. Specific initiatives in 4 domains (clinical practice, quality of care, research, and workforce) were identified that would advance PHM with a plan to complete each initiative. Review of the current issues demonstrated gaps between the current state of affairs and the full vision of the potential impact of PHM. Clinical initiatives were to develop an educational plan supporting the PHM Core Competencies and a clinical practice monitoring dashboard template. Quality initiatives included an environmental assessment of PHM participation on key committees, societies, and agencies to ensure appropriate PHM representation. Three QI collaboratives are underway. A Research Leadership Task Force was created and the Pediatric Research in Inpatient Settings (PRIS) network was refocused, defining a strategic framework for PRIS, and developing a funding strategy. Workforce initiatives were to develop a descriptive statement that can be used by any PHM physician, a communications tool describing “value added” of PHM; and a tool to assess career satisfaction among PHM physicians. We believe the Roundtable was successful in describing the current state of PHM and laying a course for the near future. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine

Cost-related medication underuse: Prevalence among hospitalized managed care patients

BACKGROUND:The affordability of prescription medications continues to be a major public health issue in the United States. Estimates of cost-related medication underuse come largely from surveys of ambulatory patients. Hospitalized patients may be vulnerable to cost-related underuse and its consequences, but have been subject to little investigation.OBJECTIVE:To determine impact of medication costs in a cohort of hospitalized managed care beneficiaries.METHODS:We surveyed consecutive patients admitted to medical services at an academic medical center. Questions about cost-related underuse were based on validated measures; predictors were assessed with multivariable models. Participants were asked about strategies to improve medication affordability, and were contacted after discharge to determine if they had filled newly prescribed medications.RESULTS:One-hundred thirty (41%) of 316 potentially eligible patients participated; 93 (75%) of these completed postdischarge surveys. Thirty patients (23%) reported cost-related underuse in the year prior to admission. In adjusted analyses, patients of black race were 3.39 times (95% confidence interval [CI], 1.05 to 11.02) more likely to report cost-related underuse than non-Hispanic white patients. Virtually all respondents (n = 123; 95%) endorsed at least 1 strategy to make medications more affordable. Few (16%) patients, prescribed medications at discharge, knew how much they would pay at the pharmacy. Almost none had spoken to their inpatient (4%) or outpatient (2%) providers about the cost of newly prescribed drugs.CONCLUSIONS:Cost-related underuse is common among hospitalized patients. Individuals of black race appear to be particularly at risk. Strategies should be developed to address this issue around the time of hospital discharge. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine

Pediatric hospitalist systems versus traditional models of care: Effect on quality and cost outcomes

BACKGROUND:Pediatric hospitalist systems are increasing in popularity, but data regarding the effects of hospitalist systems on the quality of care has been sparse, in part because rigorous metrics for analysis have not yet been established. We conducted a literature review of studies comparing the performance of pediatric hospitalists and traditional attendings.OBJECTIVE:To determine the effect of pediatric hospitalists on quality and outcome metrics such as length of stay, cost, patient satisfaction, mortality, readmission rates, and use of evidence-based medicine during care.RESULTS:A Medline literature search identified 11 studies that met criteria for inclusion. Five previously reviewed studies reported lengths of stay between 6% and 14% shorter for hospitalists. Five of the new studies evaluated lengths of stay, with 1 showing significantly lower length of stay and cost for a faculty model, 1 showing lower length of stay for hospitalists for all conditions, 1 for certain conditions only, and 2 showing no statistical difference. Six studies reported on readmission rate, with 4 showing no difference, 1 showing decreased readmissions for hospitalists, and 1 showing decreased readmissions for a traditional faculty service. Hospitalists self-report higher use of evidence-based guidelines. Few differences in patient satisfaction were reported. Mortality on the pediatrics wards is rare, and no studies were adequately powered to evaluate mortality rate.CONCLUSION:Hospitalists can improve the quality and efficiency of inpatient care in the pediatric population, but the effect is not universal, and mechanisms underlying demonstrated improvements are poorly understood. We propose 4 components to improve quality and value in hospital medicine systems: investment in comparative effectiveness research involving delivery system interventions, development and implementation of pediatric quality measures, better understanding of improvement mechanisms for hospital medicine systems, and increased focus on quality and value delivered by hospital medicine groups and individuals. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine

Health insurance and length of stay for children hospitalized with community-acquired pneumonia

BACKGROUND:Disparities in patterns of care and outcomes for ambulatory-care sensitive childhood conditions such as community-acquired pneumonia (CAP) persist. However, the influence of insurance status on length of stay (LOS) for children hospitalized with CAP remains unexplored.METHODS:Secondary analysis of children (<18 years) hospitalized with CAP sampled in the Kids' Inpatient Database (KID) for years 1997, 2000, 2003, and 2006. Insurance status (private, public, uninsured) was based on claims data. Hospital LOS was calculated in days. Taking into account the complex sampling design, negative binomial regression models produced adjusted estimates of incidence rate ratios (IRR) for hospital LOS for children by insurance status.RESULTS:There was little variation in the categories of insurance status of children hospitalized with CAP between 1997 and 2006, with at least 40% privately insured, at least 40% publicly insured, and at least 5% uninsured in each sampled year. In all years, publicly insured children had a significantly longer hospital stay than privately insured children, and uninsured children had a significantly shorter hospital stay than privately insured children. These observed differences persisted after multivariate adjustment.CONCLUSIONS:Differences in LOS between uninsured, publicly insured, and privately insured children with CAP raise concerns about potential differences in hospital discharge practices related to insurance status and type. As healthcare reform is implemented, policy makers should strengthen efforts to reduce these disparities in order to achieve health for the population. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.