The use of microfocused ultrasound (MFUS) emerged in dermatology in 2009 as a minimally invasive approach to treating mild to moderate facial and neck laxity. Microfocused ultrasound with visualization (MFU-V), as represented by the device Ultherapy, adds high-resolution ultrasound imaging so that the user can see the targets for MFUS energy. Visualization also allows the user to choose the appropriate treatment depth and transducer.¹ Since its introduction, Ultherapy has been investigated for efficacy and safety in tightening, lifting, and wrinkle reduction beyond the face and neck, specifically including the décolletage, abdomen, arms/elbows, knees, medial thighs, and buttocks.^1-8 This column will focus on using cosmeceuticals to improve the skin-tightening outcomes of microfocused ultrasound.

scisettialfio/Thinkstock

Two weeks before the procedure

Ingredients that should be used prior to MFU-V include retinoids, such as tretinoin and retinol. Various studies have demonstrated that pretreatment with tretinoin increases collagen production and speeds wound healing.^12-14 Kligman et al. assessed wound healing after punch biopsy and found that arm wounds pretreated with tretinoin cream 0.05%-0.1% were significantly smaller by 35%-37% on days 1 and 4 and by 47%-50% on days 6, 8, and 11 than were wounds on the untreated arms.¹⁵ The majority of studies on the subject recommend a 2- to 4-week tretinoin pretreatment regimen because peak epidermal hypertrophy occurs after 7 days of tretinoin application and normalizes after 14 days of continued treatment.^16,17 This time frame allows for the skin to recover from any retinoid dermatitis prior to the procedure. Adapalene should be started 5-6 weeks prior to procedures because it has a longer half-life and requires an earlier initiation period.¹⁸ Although studies have not been performed evaluating the efficacy of topical ascorbic acid and hydroxy acids, pretreating skin with them also may accelerate collagen production after procedures such as MFU-V.^19,20

ezp/Thinkstock

Postprocedure skin care

Because no incision or ablation occurs with MFUS, the use of ascorbic acid, hydroxy acids, and retinoids can and should be continued after the procedure in addition to before the procedure. The combination of topical Arnica montana and Rhododendron tomentosum in a gel pad has been shown to mitigate postoperative ecchymosis and edema after oculofacial surgery.²⁴ Topical curcumin has been shown to facilitate wound healing in animals, but its smell and color make it difficult to use topically. I recommend adding turmeric to food pre- and postprocedure.²⁵

Adverse events

Late in 2017, Friedmann et al. offered a report on the nature of the rare complications from MFUS, which have included mild and fleeting ecchymosis, edema, erythema, and nerve paralysis. In this retrospective multicenter case series of five patients seen in the authors’ practice who experienced serious adverse reactions to Ultherapy, the authors reported that single sessions of MFUS yielded blistering, erosion/ulceration, or cutaneous or subcutaneous tissue edema with resulting atrophy and/or cutaneous necrosis. The authors concluded that while serious adverse events following MFUS are rare, such reactions might be underreported and should be prepared for with early management to diminish inflammation.²⁶ Other adverse events, which are transient and rare, may include discomfort and mild bruising.

Educating patients on pre- and postprocedure instructions can help minimize adverse events. Avoiding foods that decrease platelet function, like ginger, green tea, alcohol (red wine), salmon, and flax seeds, can reduce the risk of bruising. Use of topical and oral antioxidants before and after treatments also may help reduce inflammation and edema.
 

Conclusion

Please email me at [email protected] if you have any comments, suggestions, or anecdotal reports to share on using cosmeceuticals and nutraceuticals before and after procedures. I will share your responses on my LinkedIn account.
 

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems.

References

1. Clin Cosmet Investig Dermatol. 2017 Oct 30;10:423-9.

2. J Am Acad Dermatol. 2013 Dec;69(6):965-71.

3. Dermatol Surg. 2015 Mar;41(3):327-35.

4. J Cosmet Dermatol Sci Appl. 2012;2(2A):108-16.

5. Dermatol Surg. 2015 Jul;41(7):821-6.

6. J Cosmet Laser Ther. 2014 Oct;16(5):225-9.

7. Dermatol Surg. 2012 May;38(5):754-9.

8. Dermatol Surg. 2014 Oct;40(10):1113-7.

9. Clin Cosmet Investig Dermatol. 2015; 8: 47-52.

10. Dermatol Surg. 2017 Sep 8. doi: 10.1097/DSS.0000000000001216. [Epub ahead of print]

11. Arch Dermatol. 2004 Feb;140(2):204-9.

12. Aesthetic Plast Surg. 1995 May-Jun;19(3):243-6.

13. Plast Reconstr Surg. 2011 Mar;127(3):1343-5.

14. J Am Acad Dermatol. 1998 Aug;39(2 Pt 3):S79-81.

15. Popp C et al. Br J Dermatol. 1995 Jan;132(1):46-53.

16. J Am Acad Dermatol. 2004 Dec;51(6):940-6.

17. J Korean Med Sci. 1996 Aug;11(4):335-41.

18. Eur J Dermatol. 2002 Mar-Apr;12(2):145-8.

19. Proc Natl Acad Sci U S A. 1981 May; 78(5): 2879-82.

20. Exp Dermatol. 2003;12 Suppl 2:57-63.

21. Dermatol Surg. 2001 Feb;27(2):137-42.

22. Br J Dermatol. 1992 Sep;127(3):247-53.

23. J Invest Dermatol. 1991;96:587.

24. Ophthal Plast Reconstr Surg. 2017 Jan/Feb;33(1):47-52.

25. Wound Repair Regen. 1998 Mar-Apr;6(2):167-77.

26. Lasers Surg Med. 2018 Jan;50(1):13-9.
 

The use of microfocused ultrasound (MFUS) emerged in dermatology in 2009 as a minimally invasive approach to treating mild to moderate facial and neck laxity. Microfocused ultrasound with visualization (MFU-V), as represented by the device Ultherapy, adds high-resolution ultrasound imaging so that the user can see the targets for MFUS energy. Visualization also allows the user to choose the appropriate treatment depth and transducer.¹ Since its introduction, Ultherapy has been investigated for efficacy and safety in tightening, lifting, and wrinkle reduction beyond the face and neck, specifically including the décolletage, abdomen, arms/elbows, knees, medial thighs, and buttocks.^1-8 This column will focus on using cosmeceuticals to improve the skin-tightening outcomes of microfocused ultrasound.

scisettialfio/Thinkstock

Two weeks before the procedure

Ingredients that should be used prior to MFU-V include retinoids, such as tretinoin and retinol. Various studies have demonstrated that pretreatment with tretinoin increases collagen production and speeds wound healing.^12-14 Kligman et al. assessed wound healing after punch biopsy and found that arm wounds pretreated with tretinoin cream 0.05%-0.1% were significantly smaller by 35%-37% on days 1 and 4 and by 47%-50% on days 6, 8, and 11 than were wounds on the untreated arms.¹⁵ The majority of studies on the subject recommend a 2- to 4-week tretinoin pretreatment regimen because peak epidermal hypertrophy occurs after 7 days of tretinoin application and normalizes after 14 days of continued treatment.^16,17 This time frame allows for the skin to recover from any retinoid dermatitis prior to the procedure. Adapalene should be started 5-6 weeks prior to procedures because it has a longer half-life and requires an earlier initiation period.¹⁸ Although studies have not been performed evaluating the efficacy of topical ascorbic acid and hydroxy acids, pretreating skin with them also may accelerate collagen production after procedures such as MFU-V.^19,20

ezp/Thinkstock

Postprocedure skin care

Because no incision or ablation occurs with MFUS, the use of ascorbic acid, hydroxy acids, and retinoids can and should be continued after the procedure in addition to before the procedure. The combination of topical Arnica montana and Rhododendron tomentosum in a gel pad has been shown to mitigate postoperative ecchymosis and edema after oculofacial surgery.²⁴ Topical curcumin has been shown to facilitate wound healing in animals, but its smell and color make it difficult to use topically. I recommend adding turmeric to food pre- and postprocedure.²⁵

Adverse events

Late in 2017, Friedmann et al. offered a report on the nature of the rare complications from MFUS, which have included mild and fleeting ecchymosis, edema, erythema, and nerve paralysis. In this retrospective multicenter case series of five patients seen in the authors’ practice who experienced serious adverse reactions to Ultherapy, the authors reported that single sessions of MFUS yielded blistering, erosion/ulceration, or cutaneous or subcutaneous tissue edema with resulting atrophy and/or cutaneous necrosis. The authors concluded that while serious adverse events following MFUS are rare, such reactions might be underreported and should be prepared for with early management to diminish inflammation.²⁶ Other adverse events, which are transient and rare, may include discomfort and mild bruising.

Educating patients on pre- and postprocedure instructions can help minimize adverse events. Avoiding foods that decrease platelet function, like ginger, green tea, alcohol (red wine), salmon, and flax seeds, can reduce the risk of bruising. Use of topical and oral antioxidants before and after treatments also may help reduce inflammation and edema.
 

Conclusion

Please email me at [email protected] if you have any comments, suggestions, or anecdotal reports to share on using cosmeceuticals and nutraceuticals before and after procedures. I will share your responses on my LinkedIn account.
 

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems.

References

1. Clin Cosmet Investig Dermatol. 2017 Oct 30;10:423-9.

2. J Am Acad Dermatol. 2013 Dec;69(6):965-71.

3. Dermatol Surg. 2015 Mar;41(3):327-35.

4. J Cosmet Dermatol Sci Appl. 2012;2(2A):108-16.

5. Dermatol Surg. 2015 Jul;41(7):821-6.

6. J Cosmet Laser Ther. 2014 Oct;16(5):225-9.

7. Dermatol Surg. 2012 May;38(5):754-9.

8. Dermatol Surg. 2014 Oct;40(10):1113-7.

9. Clin Cosmet Investig Dermatol. 2015; 8: 47-52.

10. Dermatol Surg. 2017 Sep 8. doi: 10.1097/DSS.0000000000001216. [Epub ahead of print]

11. Arch Dermatol. 2004 Feb;140(2):204-9.

12. Aesthetic Plast Surg. 1995 May-Jun;19(3):243-6.

13. Plast Reconstr Surg. 2011 Mar;127(3):1343-5.

14. J Am Acad Dermatol. 1998 Aug;39(2 Pt 3):S79-81.

15. Popp C et al. Br J Dermatol. 1995 Jan;132(1):46-53.

16. J Am Acad Dermatol. 2004 Dec;51(6):940-6.

17. J Korean Med Sci. 1996 Aug;11(4):335-41.

18. Eur J Dermatol. 2002 Mar-Apr;12(2):145-8.

19. Proc Natl Acad Sci U S A. 1981 May; 78(5): 2879-82.

20. Exp Dermatol. 2003;12 Suppl 2:57-63.

21. Dermatol Surg. 2001 Feb;27(2):137-42.

22. Br J Dermatol. 1992 Sep;127(3):247-53.

23. J Invest Dermatol. 1991;96:587.

24. Ophthal Plast Reconstr Surg. 2017 Jan/Feb;33(1):47-52.

25. Wound Repair Regen. 1998 Mar-Apr;6(2):167-77.

26. Lasers Surg Med. 2018 Jan;50(1):13-9.
 

The use of microfocused ultrasound (MFUS) emerged in dermatology in 2009 as a minimally invasive approach to treating mild to moderate facial and neck laxity. Microfocused ultrasound with visualization (MFU-V), as represented by the device Ultherapy, adds high-resolution ultrasound imaging so that the user can see the targets for MFUS energy. Visualization also allows the user to choose the appropriate treatment depth and transducer.¹ Since its introduction, Ultherapy has been investigated for efficacy and safety in tightening, lifting, and wrinkle reduction beyond the face and neck, specifically including the décolletage, abdomen, arms/elbows, knees, medial thighs, and buttocks.^1-8 This column will focus on using cosmeceuticals to improve the skin-tightening outcomes of microfocused ultrasound.

scisettialfio/Thinkstock

Two weeks before the procedure

Ingredients that should be used prior to MFU-V include retinoids, such as tretinoin and retinol. Various studies have demonstrated that pretreatment with tretinoin increases collagen production and speeds wound healing.^12-14 Kligman et al. assessed wound healing after punch biopsy and found that arm wounds pretreated with tretinoin cream 0.05%-0.1% were significantly smaller by 35%-37% on days 1 and 4 and by 47%-50% on days 6, 8, and 11 than were wounds on the untreated arms.¹⁵ The majority of studies on the subject recommend a 2- to 4-week tretinoin pretreatment regimen because peak epidermal hypertrophy occurs after 7 days of tretinoin application and normalizes after 14 days of continued treatment.^16,17 This time frame allows for the skin to recover from any retinoid dermatitis prior to the procedure. Adapalene should be started 5-6 weeks prior to procedures because it has a longer half-life and requires an earlier initiation period.¹⁸ Although studies have not been performed evaluating the efficacy of topical ascorbic acid and hydroxy acids, pretreating skin with them also may accelerate collagen production after procedures such as MFU-V.^19,20

ezp/Thinkstock

Postprocedure skin care

Because no incision or ablation occurs with MFUS, the use of ascorbic acid, hydroxy acids, and retinoids can and should be continued after the procedure in addition to before the procedure. The combination of topical Arnica montana and Rhododendron tomentosum in a gel pad has been shown to mitigate postoperative ecchymosis and edema after oculofacial surgery.²⁴ Topical curcumin has been shown to facilitate wound healing in animals, but its smell and color make it difficult to use topically. I recommend adding turmeric to food pre- and postprocedure.²⁵

Adverse events

Late in 2017, Friedmann et al. offered a report on the nature of the rare complications from MFUS, which have included mild and fleeting ecchymosis, edema, erythema, and nerve paralysis. In this retrospective multicenter case series of five patients seen in the authors’ practice who experienced serious adverse reactions to Ultherapy, the authors reported that single sessions of MFUS yielded blistering, erosion/ulceration, or cutaneous or subcutaneous tissue edema with resulting atrophy and/or cutaneous necrosis. The authors concluded that while serious adverse events following MFUS are rare, such reactions might be underreported and should be prepared for with early management to diminish inflammation.²⁶ Other adverse events, which are transient and rare, may include discomfort and mild bruising.

Educating patients on pre- and postprocedure instructions can help minimize adverse events. Avoiding foods that decrease platelet function, like ginger, green tea, alcohol (red wine), salmon, and flax seeds, can reduce the risk of bruising. Use of topical and oral antioxidants before and after treatments also may help reduce inflammation and edema.
 

Conclusion

Please email me at [email protected] if you have any comments, suggestions, or anecdotal reports to share on using cosmeceuticals and nutraceuticals before and after procedures. I will share your responses on my LinkedIn account.
 

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems.

References

1. Clin Cosmet Investig Dermatol. 2017 Oct 30;10:423-9.

2. J Am Acad Dermatol. 2013 Dec;69(6):965-71.

3. Dermatol Surg. 2015 Mar;41(3):327-35.

4. J Cosmet Dermatol Sci Appl. 2012;2(2A):108-16.

5. Dermatol Surg. 2015 Jul;41(7):821-6.

6. J Cosmet Laser Ther. 2014 Oct;16(5):225-9.

7. Dermatol Surg. 2012 May;38(5):754-9.

8. Dermatol Surg. 2014 Oct;40(10):1113-7.

9. Clin Cosmet Investig Dermatol. 2015; 8: 47-52.

10. Dermatol Surg. 2017 Sep 8. doi: 10.1097/DSS.0000000000001216. [Epub ahead of print]

11. Arch Dermatol. 2004 Feb;140(2):204-9.

12. Aesthetic Plast Surg. 1995 May-Jun;19(3):243-6.

13. Plast Reconstr Surg. 2011 Mar;127(3):1343-5.

14. J Am Acad Dermatol. 1998 Aug;39(2 Pt 3):S79-81.

15. Popp C et al. Br J Dermatol. 1995 Jan;132(1):46-53.

16. J Am Acad Dermatol. 2004 Dec;51(6):940-6.

17. J Korean Med Sci. 1996 Aug;11(4):335-41.

18. Eur J Dermatol. 2002 Mar-Apr;12(2):145-8.

19. Proc Natl Acad Sci U S A. 1981 May; 78(5): 2879-82.

20. Exp Dermatol. 2003;12 Suppl 2:57-63.

21. Dermatol Surg. 2001 Feb;27(2):137-42.

22. Br J Dermatol. 1992 Sep;127(3):247-53.

23. J Invest Dermatol. 1991;96:587.

24. Ophthal Plast Reconstr Surg. 2017 Jan/Feb;33(1):47-52.

25. Wound Repair Regen. 1998 Mar-Apr;6(2):167-77.

26. Lasers Surg Med. 2018 Jan;50(1):13-9.
 

If prior SHM annual meetings are any guide, a highlight of the upcoming HM18 conference will be the Scientific Abstract and Poster Competition. This event, also known as the Research, Innovations, and Clinical Vignettes (RIV), has become one of the annual meeting’s most popular events. Crowds of attendees cluster around posters to read abstracts summarizing some of the most exciting, cutting-edge research in hospital medicine.

Networking in that crowd is a major factor in the RIV’s popularity, says the HM18 Innovations chair, Benji K. Mathews, MD, FACP, SFHM, CLHM, section head of hospital medicine at Regions Hospital, St. Paul, Minn., which is part of HealthPartners, the largest consumer-governed, non-profit health care organization in the U.S.

“From my standpoint, the power of this Innovations RIV competition is the opportunity to network,” said Dr. Mathews, who is also assistant professor of medicine at the University of Minnesota, Minneapolis. “In addition to primary authors, often these posters have several different people involved, and then there’s the foot traffic: We’re expecting thousands of people to walk through. The hope is to create the opportunity to network, to collaborate intergenerationally and also cross-institutionally.”

The RIV competition features some 1,000 posters this year, Dr. Mathews said. Plenary and oral sessions are chosen from the pool of abstracts prior to the meeting, and their authors are invited to present on-site at HM18.

But in spirit, the RIV is not really a competition, said RIV chair Ethan Cumbler, MD, FACP, FHM, professor of medicine at the University of Colorado.

What’s new in 2018

The more than 1,000 posters and oral presentations at HM18 is a new record, and it demonstrates the growth of hospital medicine as a scientific field, Dr. Cumbler said.

“We received a huge number of submissions,” he revealed. “We see that trend rise, year over year, and the quality has been going up as well.”

New this year is a Trainee Award category for resident and student authors. Another difference in 2018: The top 15 advances in Research and Innovations have been given a special track on day 2 of the conference, with oral presentations by the authors sharing their work.

The Vignettes are being featured in a new way as well. “We have so many incredible cases that we’re going to have a clinical vignette luncheon on two different days of the conference,” Dr. Cumbler said. “These are cases that we want to highlight, so that the experience of a hospitalist in one part of the country could help a hospitalist provide the right diagnosis for a patient on the other side of the country. There are lessons to be learned in clinical medicine, and our clinical vignettes is a fantastic way of sharing them.”

In making their selections in the different categories, the judges aimed to highlight some negative studies this year, Dr. Mathews said, which is a slight departure from previous years. “Sometimes you try something and it didn’t work, and it’s important to share that so we don’t just try the same thing over and over.”

This year, Research and Innovations abstracts will be grouped by theme, making it easier for attendees to navigate the posters. “If you’ve got a particular interest in a topic like transitions or communication, you’ll be able to find that portion of the poster session and talk to some of the people who are doing groundbreaking work in that topic,” Dr. Cumbler said. 

He also noted that he expects to see a strong expression of RIV content on social media from HM18, as judges encounter some of the best and most interesting work at RIV. Dr. Mathews is similarly enthusiastic about that amplification of the work.

“I love that the conversation continues into social media platforms such as Twitter,” he said. “People are engaging back and forth, saying, ‘Hey, take a look at this poster.’ Being in a room with countless people interested in research innovations for a field that’s still relatively young – I love that there’s movement toward that.”
 

Exciting research

By definition, the research on display at the RIV is the best of the best. “It’s difficult to get your work accepted at a national meeting, and it’s a high honor to be selected as a finalist. The poster abstracts or oral presentations that win are always remarkable pieces of work,” Dr. Cumbler said.

Some of this year’s most exciting projects examine prediction models and scoring systems for patients with infections such as sepsis or influenza, he said. “One of the most fascinating abstracts looked at deep learning, or machine learning, to create algorithms to predict sepsis and decompensation in ways that simplistic models might not. Many of our current prediction rules are designed around simple acronyms, because they’re easy to remember: the ABCD score, the CURB-65 score. But if you looked at the source code of the Google search algorithm – not that they’d let you – you’d discover that it doesn’t translate to a simple four-variable prediction model. It’s incredibly complex; it looks at interactions between variables.”

This research attempts to move medical prediction models in that direction, Dr. Cumbler said. “Examining deep learning models, or neural networks, to help clinicians make more accurate predictions and take better care of patients – we are getting a taste of the future of clinical medicine at HM18.”

Several research projects highlighted at RIV this year examine ways to make better use of the data in the electronic health record.

“One of the pieces of research I’m particularly excited to hear more about looks at how the vast data that exists within electronic health records is actually used,” Dr. Cumbler said. “With electronic health records, we have all of the information in a patient’s record at our fingertips, yet this creates incredible new challenges for the hospitalist needing to make decisions in real time, with the limitations of our organic neural networks.” Dr. Cumbler revealed that one of the research teams sharing their work at HM18 explored how hospitalists interact with the volume of information that exists within the health record at the time of admission. “The results are pretty amazing,” he said.

Another project Dr. Cumbler found fascinating examines the impact of delivery of real-time performance data to hospitalists on their phones, and how it affected practice across a number of different performance metrics.

“We will see a project using game theory to teach quality improvement and another sharing important quality improvement work occurring at the intersection of evidence-based medicine and patient experience – like looking at how to keep patients NPO for less unnecessary time,” he said. “It makes perfect sense that we don’t want to keep people hungry in the hospital longer than we need to. It’s really interesting seeing how one team worked to make that happen and what they found.”
 

The importance of the RIV

The influence of the RIV program extends far beyond the conference itself; there are implications for the field of hospital medicine today and into the future.

“The RIV competition allows the field in hospital medicine to mature and evolve, so we remain cutting edge,” Dr. Mathews said. “That’s the beauty of the innovation field: Research is built off of it.”

Dr. Cumbler said that the growth and evolution of the RIV is reflective of the maturation of hospital medicine as a specialty. “It’s transitioning from a different way to organize patient care to learning more, in a scientific way, about how care can and should be delivered.”

At its heart, the RIV is really about community, he added. “The community of hospitalists is sharing knowledge, graciously and unselfishly, so that we can all improve the quality of care that we’re providing and give patients safer care, a better experience, and improved outcomes.”

Finally, RIV offers a way for hospitalists to be engaged in lifelong learning. “The presenters are teaching from their experience, and the hospitalists who come to the RIV get to leave better clinicians, researchers, and leaders as a result,” Dr. Cumbler said. “These things, to me, are about our evolution as a profession.”

If prior SHM annual meetings are any guide, a highlight of the upcoming HM18 conference will be the Scientific Abstract and Poster Competition. This event, also known as the Research, Innovations, and Clinical Vignettes (RIV), has become one of the annual meeting’s most popular events. Crowds of attendees cluster around posters to read abstracts summarizing some of the most exciting, cutting-edge research in hospital medicine.

Networking in that crowd is a major factor in the RIV’s popularity, says the HM18 Innovations chair, Benji K. Mathews, MD, FACP, SFHM, CLHM, section head of hospital medicine at Regions Hospital, St. Paul, Minn., which is part of HealthPartners, the largest consumer-governed, non-profit health care organization in the U.S.

“From my standpoint, the power of this Innovations RIV competition is the opportunity to network,” said Dr. Mathews, who is also assistant professor of medicine at the University of Minnesota, Minneapolis. “In addition to primary authors, often these posters have several different people involved, and then there’s the foot traffic: We’re expecting thousands of people to walk through. The hope is to create the opportunity to network, to collaborate intergenerationally and also cross-institutionally.”

The RIV competition features some 1,000 posters this year, Dr. Mathews said. Plenary and oral sessions are chosen from the pool of abstracts prior to the meeting, and their authors are invited to present on-site at HM18.

But in spirit, the RIV is not really a competition, said RIV chair Ethan Cumbler, MD, FACP, FHM, professor of medicine at the University of Colorado.

What’s new in 2018

The more than 1,000 posters and oral presentations at HM18 is a new record, and it demonstrates the growth of hospital medicine as a scientific field, Dr. Cumbler said.

“We received a huge number of submissions,” he revealed. “We see that trend rise, year over year, and the quality has been going up as well.”

New this year is a Trainee Award category for resident and student authors. Another difference in 2018: The top 15 advances in Research and Innovations have been given a special track on day 2 of the conference, with oral presentations by the authors sharing their work.

The Vignettes are being featured in a new way as well. “We have so many incredible cases that we’re going to have a clinical vignette luncheon on two different days of the conference,” Dr. Cumbler said. “These are cases that we want to highlight, so that the experience of a hospitalist in one part of the country could help a hospitalist provide the right diagnosis for a patient on the other side of the country. There are lessons to be learned in clinical medicine, and our clinical vignettes is a fantastic way of sharing them.”

In making their selections in the different categories, the judges aimed to highlight some negative studies this year, Dr. Mathews said, which is a slight departure from previous years. “Sometimes you try something and it didn’t work, and it’s important to share that so we don’t just try the same thing over and over.”

This year, Research and Innovations abstracts will be grouped by theme, making it easier for attendees to navigate the posters. “If you’ve got a particular interest in a topic like transitions or communication, you’ll be able to find that portion of the poster session and talk to some of the people who are doing groundbreaking work in that topic,” Dr. Cumbler said. 

He also noted that he expects to see a strong expression of RIV content on social media from HM18, as judges encounter some of the best and most interesting work at RIV. Dr. Mathews is similarly enthusiastic about that amplification of the work.

“I love that the conversation continues into social media platforms such as Twitter,” he said. “People are engaging back and forth, saying, ‘Hey, take a look at this poster.’ Being in a room with countless people interested in research innovations for a field that’s still relatively young – I love that there’s movement toward that.”
 

Exciting research

By definition, the research on display at the RIV is the best of the best. “It’s difficult to get your work accepted at a national meeting, and it’s a high honor to be selected as a finalist. The poster abstracts or oral presentations that win are always remarkable pieces of work,” Dr. Cumbler said.

Some of this year’s most exciting projects examine prediction models and scoring systems for patients with infections such as sepsis or influenza, he said. “One of the most fascinating abstracts looked at deep learning, or machine learning, to create algorithms to predict sepsis and decompensation in ways that simplistic models might not. Many of our current prediction rules are designed around simple acronyms, because they’re easy to remember: the ABCD score, the CURB-65 score. But if you looked at the source code of the Google search algorithm – not that they’d let you – you’d discover that it doesn’t translate to a simple four-variable prediction model. It’s incredibly complex; it looks at interactions between variables.”

This research attempts to move medical prediction models in that direction, Dr. Cumbler said. “Examining deep learning models, or neural networks, to help clinicians make more accurate predictions and take better care of patients – we are getting a taste of the future of clinical medicine at HM18.”

Several research projects highlighted at RIV this year examine ways to make better use of the data in the electronic health record.

“One of the pieces of research I’m particularly excited to hear more about looks at how the vast data that exists within electronic health records is actually used,” Dr. Cumbler said. “With electronic health records, we have all of the information in a patient’s record at our fingertips, yet this creates incredible new challenges for the hospitalist needing to make decisions in real time, with the limitations of our organic neural networks.” Dr. Cumbler revealed that one of the research teams sharing their work at HM18 explored how hospitalists interact with the volume of information that exists within the health record at the time of admission. “The results are pretty amazing,” he said.

Another project Dr. Cumbler found fascinating examines the impact of delivery of real-time performance data to hospitalists on their phones, and how it affected practice across a number of different performance metrics.

“We will see a project using game theory to teach quality improvement and another sharing important quality improvement work occurring at the intersection of evidence-based medicine and patient experience – like looking at how to keep patients NPO for less unnecessary time,” he said. “It makes perfect sense that we don’t want to keep people hungry in the hospital longer than we need to. It’s really interesting seeing how one team worked to make that happen and what they found.”
 

The importance of the RIV

The influence of the RIV program extends far beyond the conference itself; there are implications for the field of hospital medicine today and into the future.

“The RIV competition allows the field in hospital medicine to mature and evolve, so we remain cutting edge,” Dr. Mathews said. “That’s the beauty of the innovation field: Research is built off of it.”

Dr. Cumbler said that the growth and evolution of the RIV is reflective of the maturation of hospital medicine as a specialty. “It’s transitioning from a different way to organize patient care to learning more, in a scientific way, about how care can and should be delivered.”

At its heart, the RIV is really about community, he added. “The community of hospitalists is sharing knowledge, graciously and unselfishly, so that we can all improve the quality of care that we’re providing and give patients safer care, a better experience, and improved outcomes.”

Finally, RIV offers a way for hospitalists to be engaged in lifelong learning. “The presenters are teaching from their experience, and the hospitalists who come to the RIV get to leave better clinicians, researchers, and leaders as a result,” Dr. Cumbler said. “These things, to me, are about our evolution as a profession.”

If prior SHM annual meetings are any guide, a highlight of the upcoming HM18 conference will be the Scientific Abstract and Poster Competition. This event, also known as the Research, Innovations, and Clinical Vignettes (RIV), has become one of the annual meeting’s most popular events. Crowds of attendees cluster around posters to read abstracts summarizing some of the most exciting, cutting-edge research in hospital medicine.

Networking in that crowd is a major factor in the RIV’s popularity, says the HM18 Innovations chair, Benji K. Mathews, MD, FACP, SFHM, CLHM, section head of hospital medicine at Regions Hospital, St. Paul, Minn., which is part of HealthPartners, the largest consumer-governed, non-profit health care organization in the U.S.

“From my standpoint, the power of this Innovations RIV competition is the opportunity to network,” said Dr. Mathews, who is also assistant professor of medicine at the University of Minnesota, Minneapolis. “In addition to primary authors, often these posters have several different people involved, and then there’s the foot traffic: We’re expecting thousands of people to walk through. The hope is to create the opportunity to network, to collaborate intergenerationally and also cross-institutionally.”

The RIV competition features some 1,000 posters this year, Dr. Mathews said. Plenary and oral sessions are chosen from the pool of abstracts prior to the meeting, and their authors are invited to present on-site at HM18.

But in spirit, the RIV is not really a competition, said RIV chair Ethan Cumbler, MD, FACP, FHM, professor of medicine at the University of Colorado.

What’s new in 2018

The more than 1,000 posters and oral presentations at HM18 is a new record, and it demonstrates the growth of hospital medicine as a scientific field, Dr. Cumbler said.

“We received a huge number of submissions,” he revealed. “We see that trend rise, year over year, and the quality has been going up as well.”

New this year is a Trainee Award category for resident and student authors. Another difference in 2018: The top 15 advances in Research and Innovations have been given a special track on day 2 of the conference, with oral presentations by the authors sharing their work.

The Vignettes are being featured in a new way as well. “We have so many incredible cases that we’re going to have a clinical vignette luncheon on two different days of the conference,” Dr. Cumbler said. “These are cases that we want to highlight, so that the experience of a hospitalist in one part of the country could help a hospitalist provide the right diagnosis for a patient on the other side of the country. There are lessons to be learned in clinical medicine, and our clinical vignettes is a fantastic way of sharing them.”

In making their selections in the different categories, the judges aimed to highlight some negative studies this year, Dr. Mathews said, which is a slight departure from previous years. “Sometimes you try something and it didn’t work, and it’s important to share that so we don’t just try the same thing over and over.”

This year, Research and Innovations abstracts will be grouped by theme, making it easier for attendees to navigate the posters. “If you’ve got a particular interest in a topic like transitions or communication, you’ll be able to find that portion of the poster session and talk to some of the people who are doing groundbreaking work in that topic,” Dr. Cumbler said. 

He also noted that he expects to see a strong expression of RIV content on social media from HM18, as judges encounter some of the best and most interesting work at RIV. Dr. Mathews is similarly enthusiastic about that amplification of the work.

“I love that the conversation continues into social media platforms such as Twitter,” he said. “People are engaging back and forth, saying, ‘Hey, take a look at this poster.’ Being in a room with countless people interested in research innovations for a field that’s still relatively young – I love that there’s movement toward that.”
 

Exciting research

By definition, the research on display at the RIV is the best of the best. “It’s difficult to get your work accepted at a national meeting, and it’s a high honor to be selected as a finalist. The poster abstracts or oral presentations that win are always remarkable pieces of work,” Dr. Cumbler said.

Some of this year’s most exciting projects examine prediction models and scoring systems for patients with infections such as sepsis or influenza, he said. “One of the most fascinating abstracts looked at deep learning, or machine learning, to create algorithms to predict sepsis and decompensation in ways that simplistic models might not. Many of our current prediction rules are designed around simple acronyms, because they’re easy to remember: the ABCD score, the CURB-65 score. But if you looked at the source code of the Google search algorithm – not that they’d let you – you’d discover that it doesn’t translate to a simple four-variable prediction model. It’s incredibly complex; it looks at interactions between variables.”

This research attempts to move medical prediction models in that direction, Dr. Cumbler said. “Examining deep learning models, or neural networks, to help clinicians make more accurate predictions and take better care of patients – we are getting a taste of the future of clinical medicine at HM18.”

Several research projects highlighted at RIV this year examine ways to make better use of the data in the electronic health record.

“One of the pieces of research I’m particularly excited to hear more about looks at how the vast data that exists within electronic health records is actually used,” Dr. Cumbler said. “With electronic health records, we have all of the information in a patient’s record at our fingertips, yet this creates incredible new challenges for the hospitalist needing to make decisions in real time, with the limitations of our organic neural networks.” Dr. Cumbler revealed that one of the research teams sharing their work at HM18 explored how hospitalists interact with the volume of information that exists within the health record at the time of admission. “The results are pretty amazing,” he said.

Another project Dr. Cumbler found fascinating examines the impact of delivery of real-time performance data to hospitalists on their phones, and how it affected practice across a number of different performance metrics.

“We will see a project using game theory to teach quality improvement and another sharing important quality improvement work occurring at the intersection of evidence-based medicine and patient experience – like looking at how to keep patients NPO for less unnecessary time,” he said. “It makes perfect sense that we don’t want to keep people hungry in the hospital longer than we need to. It’s really interesting seeing how one team worked to make that happen and what they found.”
 

The importance of the RIV

The influence of the RIV program extends far beyond the conference itself; there are implications for the field of hospital medicine today and into the future.

“The RIV competition allows the field in hospital medicine to mature and evolve, so we remain cutting edge,” Dr. Mathews said. “That’s the beauty of the innovation field: Research is built off of it.”

Dr. Cumbler said that the growth and evolution of the RIV is reflective of the maturation of hospital medicine as a specialty. “It’s transitioning from a different way to organize patient care to learning more, in a scientific way, about how care can and should be delivered.”

At its heart, the RIV is really about community, he added. “The community of hospitalists is sharing knowledge, graciously and unselfishly, so that we can all improve the quality of care that we’re providing and give patients safer care, a better experience, and improved outcomes.”

Finally, RIV offers a way for hospitalists to be engaged in lifelong learning. “The presenters are teaching from their experience, and the hospitalists who come to the RIV get to leave better clinicians, researchers, and leaders as a result,” Dr. Cumbler said. “These things, to me, are about our evolution as a profession.”

Welcome to Hospital Medicine 2018, the second-happiest place in Orlando – at least for hospitalists who want to be in the know.

The 2018 education program is a ride through the diverse world of hospital medicine, with sessions ranging from clinical updates to cutting-edge techniques, communication tools, building a satisfying career, and finding your way through tangles of red tape and policy.

Two tracks new for 2018 hone in on managing alternative providers and palliative care.

The half-day NP/PA track (beginning April 11 at 7:30 a.m.) recognizes these practitioners for their crucial roles in hospital medicine care delivery. Among the discussions aimed at hospitalists: Best practices in provider utilization and collaboration; supervision vs. collaboration; and challenging situations when working with mid-level providers.

The palliative care track (also a half day, starting April 11 at 10 a.m.) recognizes the crucial role hospitalists play in optimizing end-of-life care. Sessions will help hospitalists understand that role, and guide them in managing pain and other symptoms commonly encountered during this transitional time.

As for the rest of the meeting, picking favorites is as tough as picking between Disney’s Big Thunder Railroad and Splash Mountain, said HM18 course director Dustin Smith, MD, SFHM, of Emory University, Atlanta. “We feel strongly that all offerings at the conference are ‘must-sees,’ and it’s why we offer repeat sessions of what we predict will be the most popular talks overall. Since there are so many good sessions competing for attendees at the same time, we wanted to make sure we offered these repeat sessions of common, high-yield clinical topics.”

The Repeated Sessions track is set for April 10, and runs a full day. The track includes these dynamic sessions:

• Updates in congestive heart failure: Pablo Quintero, MD; 11-11:40 a.m.
• He-who-shall-not-be-named: Updates in sepsis and critical care: Patricia Kritek, MD, EdM; 11:50 a.m.-12:30 p.m.
• Not true love’s kiss? Updates in infectious disease: John Sanders, MD, MPHTM; 2:50-3:30 p.m.
• Updates in acute coronary syndrome: Jeff Trost, MD; 3:40-4:20 p.m.
• Waiting in line for ‘It’s a Small World’ and other things we do for no reason: Tony Breu, MD, FHM; 4:30-5:10 p.m.
• “The Mad Hatter”: Updates in delirium: Ethan Cumbler, MD, FHM; 5:20-6:00 p.m.

In addition to the sepsis update in the Repeated Sessions track, Dr. Smith noted that sepsis will also be the topic of a pre-course offering (April 8, 8:15 a.m.-4:50 p.m.). “The topic of sepsis remains a hot item in hospital medicine,” he said.

“I’d also like to highlight a new pre-course offering this year – ‘Keep your finger on the pulse: Cardiology update for the hospitalist’ (April 8, 8:30 a.m.-4:50 p.m.),” he said. “Many of our pre-course offerings are carry-overs from previous years due to ongoing great success with the individual pre-courses themselves. Although we have had a cardiology pre-course in our lineup of offerings in the past, we chose to offer a freshly redesigned pre-course in cardiology this year to round out the lineup of pre-course offerings and to keep things fresh.”

The “Stump the attentive (not absent-minded) professor” sessions on clinical unknowns in the Diagnostics Reasoning track are also must-sees, Dr. Smith said. So much so, that SHM is offering two of them this year (April 9, 2:00-2:40 p.m.; 3:45-4:25 p.m.).

Dr. Smith’s codirector Kathleen Finn, MD, MPhil, SFHM, also has a few personal favorites on the education program.

“I know the talks in the ‘Seasoning your career track’ will be great,” said Dr. Finn, a hospitalist at Massachusetts General Hospital, Boston. “This new track provides mid-career hospitalists (and new hospitalists) ideas in how to continue to make their career enjoyable and stimulating. It includes talks on how to advance in a leadership position, use emotional intelligence to achieve success, prevent burnout or design your groups schedule so it doesn’t rule your life.”
 

The board weighs in

The 2018 HM18 line-up garnered an enthusiastic thumbs-up from The Hospitalist’s editorial advisory board. We polled these experts for their 2018 “must-see” sessions, and they responded with a selection that spans the meeting’s wide-ranging offerings.



1. Leadership essentials for success in hospital medicine (April 9, 10:35 a.m.-12:05 p.m.)

Amit Vashist, MD, MBA, FHM, system chair, hospitalist division, Mountain State Health Alliance, Virginia/Tennessee, is especially excited about this session, intended to help hospitalists assume leadership roles.

“Given the ever-expanding footprint of hospitalists inside the hospitals and beyond, and the way they are being called upon to be the drivers of an increasingly value-based care, I believe it is imperative for every hospitalist provider – regardless of being in a leadership role or not – to have a fundamental understanding of the leadership nuances pertaining specifically to hospital medicine in order to optimally leverage their skill set to drive transformational changes in the health care arena,” he said. “This primer on leadership essentials should pique the interest of the hospitalists further towards developing a deeper appreciation of some of the leadership dimensions must-haves in the realm of hospital medicine.”

No need for an academic meeting to be boring, said Weijen Chang, MD, SFHM, chief of pediatric hospital medicine at Baystate Children’s Hospital, Springfield, Mass.

4. Can we just stick to the “Bare Necessities”? – Things we do for no reason (April 9, 10:35-11:35 a.m.)

5. “Mirror, Mirror on the Wall”: Which articles are the fairest of them all? Top pediatric updates (April 10, 5:45-6:45 p.m.)

“I’d say Dr. Lenny Feldman’s [SFHM] ‘Things we do for no reason’ is a must-see. Lenny is a master at simplifying complex issues and communicating them in an easily understood manner, and he’s quite entertaining,” Dr. Chang said. “And of course, another must-see is Top Pediatric Updates. It is entertaining, educational, and we almost got thrown out last year for bringing beer!”

Sarah Stella, MD, FHM, a hospitalist at Denver Health, had a hard time choosing between the many interesting offerings. “There are quite a few great sessions this year that I’m interested in, but these are my top picks:”

6. Convert your everyday work into scholarship (and get it funded) (April 9, 1:35-2:35 p.m.)

“By virtue of their daily clinical and quality improvement/committee work, many hospitalists are well on their way to generating scholarship and funding, but are unsure how to make this conversion,” she said. “This workshop is a must for academic hospitalists working toward promotion who want a framework and tangible steps on how to get credit for what they are already doing.”

7. “Heigh ho, heigh ho,” it’s off to changing roles mid-career we go (April 11, 8:20-9:00 a.m.)

“Part of what attracts many of us to hospital medicine in the first place is the versatility of what we do and the ability to diversify based on our interests. I think this is a must-see for mid-career hospitalists like myself, or really any hospitalist dreaming of reinventing oneself.”

8. Winning hearts and minds at the bedside: Battling unconscious bias through cultural humility (April 11, 9:10-9:50 a.m.)

“Recognizing and confronting our implicit biases and how they affect patient-physician interactions is hard but incredibly important work,” Dr. Stella said. “I’ll definitely be attending this session by Aziz Ansari, DO, SFHM, to learn how to improve my relationship (and hence outcomes) with my patients.”

Harry (Hyung) Cho, MD, FHM, assistant professor of medicine and director of quality, safety, and value, division of hospital medicine, Mount Sinai Hospital, New York, had some diverse choices.

9. Being female in hospital medicine: Overcoming individual and institutional barriers in the workplace (April 9, 12:40-2:15 p.m.)

“This is a very timely, very important topic in the news and I think it will draw a lot of people,” he said.

10. Every patient tells a story and the art of diagnosis (April 9, 2:55-3:35 p.m.)

“The presenter is Dr. Lisa Sanders, who writes the ‘Diagnosis’ column for the New York Times and is a Yale University faculty member. She’s a great speaker and, incidentally, was a consultant on the TV show, ‘House, MD.’ ”

Raman Palabindala, MD, FHM, a hospitalist at the University of Mississippi Medical Center, Jackson, thinks the most important session at HM18 is the annual update.

11. Update in hospital medicine (April 10, 1:40-2:40 p.m.)“Almost every year, this is the most high energy presentation, and I don’t think I ever missed this session, no matter who is the presenter is,” he said. “As physicians, I think we need this update every year, and this is the best single hour where we can learn a lot as a hospitalist related to hospital medicine. This is the most concentrated extract of the entire meeting. What I learned about the behind scenes efforts up to 50-100 hours of work – why not we take advantage of this session.”

Lonika Sood, MD, FHM of the department of hospital medicine, Aurora BayCare Medical Center, Green Bay, Wis., has a passion for both leadership and scholarship, and her choices reflect that interest.

12. How to write a winning abstract (April 11, 7:30-8:30 a.m.)

13. Leadership positions in medical education: How to break into the field (April 11, 11:40 a.m.-12:20 p.m.)

14. Serious illness communication: A skills-based workshop (April 11, 8:00-9:30 a.m.)

“I would recommend all of those, especially for early-career hospitalists. And, having enjoyed and learned a lot from the workshops at HM17, I would highly recommend checking out a few that will help polish your communications – a much-needed skill in hospital medicine,” she said.

Finally, don’t just pick up another embroidered mouse ear hat on your way out. The best HM18 souvenir is taking back the knowledge you gained and – as Dr. Sood said – there’s a session for that.

15. How to bring the things you learn at SHM back to your institution: Advocating for high value care on hospital committees (April 11, 8:00-9:30 a.m.).

For more information on the HM18 education sessions, check the latest version of the conference schedule at http://shmannualconference.org/conference-schedule.


 

Welcome to Hospital Medicine 2018, the second-happiest place in Orlando – at least for hospitalists who want to be in the know.

The 2018 education program is a ride through the diverse world of hospital medicine, with sessions ranging from clinical updates to cutting-edge techniques, communication tools, building a satisfying career, and finding your way through tangles of red tape and policy.

Two tracks new for 2018 hone in on managing alternative providers and palliative care.

The half-day NP/PA track (beginning April 11 at 7:30 a.m.) recognizes these practitioners for their crucial roles in hospital medicine care delivery. Among the discussions aimed at hospitalists: Best practices in provider utilization and collaboration; supervision vs. collaboration; and challenging situations when working with mid-level providers.

The palliative care track (also a half day, starting April 11 at 10 a.m.) recognizes the crucial role hospitalists play in optimizing end-of-life care. Sessions will help hospitalists understand that role, and guide them in managing pain and other symptoms commonly encountered during this transitional time.

As for the rest of the meeting, picking favorites is as tough as picking between Disney’s Big Thunder Railroad and Splash Mountain, said HM18 course director Dustin Smith, MD, SFHM, of Emory University, Atlanta. “We feel strongly that all offerings at the conference are ‘must-sees,’ and it’s why we offer repeat sessions of what we predict will be the most popular talks overall. Since there are so many good sessions competing for attendees at the same time, we wanted to make sure we offered these repeat sessions of common, high-yield clinical topics.”

The Repeated Sessions track is set for April 10, and runs a full day. The track includes these dynamic sessions:

• Updates in congestive heart failure: Pablo Quintero, MD; 11-11:40 a.m.
• He-who-shall-not-be-named: Updates in sepsis and critical care: Patricia Kritek, MD, EdM; 11:50 a.m.-12:30 p.m.
• Not true love’s kiss? Updates in infectious disease: John Sanders, MD, MPHTM; 2:50-3:30 p.m.
• Updates in acute coronary syndrome: Jeff Trost, MD; 3:40-4:20 p.m.
• Waiting in line for ‘It’s a Small World’ and other things we do for no reason: Tony Breu, MD, FHM; 4:30-5:10 p.m.
• “The Mad Hatter”: Updates in delirium: Ethan Cumbler, MD, FHM; 5:20-6:00 p.m.

In addition to the sepsis update in the Repeated Sessions track, Dr. Smith noted that sepsis will also be the topic of a pre-course offering (April 8, 8:15 a.m.-4:50 p.m.). “The topic of sepsis remains a hot item in hospital medicine,” he said.

“I’d also like to highlight a new pre-course offering this year – ‘Keep your finger on the pulse: Cardiology update for the hospitalist’ (April 8, 8:30 a.m.-4:50 p.m.),” he said. “Many of our pre-course offerings are carry-overs from previous years due to ongoing great success with the individual pre-courses themselves. Although we have had a cardiology pre-course in our lineup of offerings in the past, we chose to offer a freshly redesigned pre-course in cardiology this year to round out the lineup of pre-course offerings and to keep things fresh.”

The “Stump the attentive (not absent-minded) professor” sessions on clinical unknowns in the Diagnostics Reasoning track are also must-sees, Dr. Smith said. So much so, that SHM is offering two of them this year (April 9, 2:00-2:40 p.m.; 3:45-4:25 p.m.).

Dr. Smith’s codirector Kathleen Finn, MD, MPhil, SFHM, also has a few personal favorites on the education program.

“I know the talks in the ‘Seasoning your career track’ will be great,” said Dr. Finn, a hospitalist at Massachusetts General Hospital, Boston. “This new track provides mid-career hospitalists (and new hospitalists) ideas in how to continue to make their career enjoyable and stimulating. It includes talks on how to advance in a leadership position, use emotional intelligence to achieve success, prevent burnout or design your groups schedule so it doesn’t rule your life.”
 

The board weighs in

The 2018 HM18 line-up garnered an enthusiastic thumbs-up from The Hospitalist’s editorial advisory board. We polled these experts for their 2018 “must-see” sessions, and they responded with a selection that spans the meeting’s wide-ranging offerings.



1. Leadership essentials for success in hospital medicine (April 9, 10:35 a.m.-12:05 p.m.)

Amit Vashist, MD, MBA, FHM, system chair, hospitalist division, Mountain State Health Alliance, Virginia/Tennessee, is especially excited about this session, intended to help hospitalists assume leadership roles.

“Given the ever-expanding footprint of hospitalists inside the hospitals and beyond, and the way they are being called upon to be the drivers of an increasingly value-based care, I believe it is imperative for every hospitalist provider – regardless of being in a leadership role or not – to have a fundamental understanding of the leadership nuances pertaining specifically to hospital medicine in order to optimally leverage their skill set to drive transformational changes in the health care arena,” he said. “This primer on leadership essentials should pique the interest of the hospitalists further towards developing a deeper appreciation of some of the leadership dimensions must-haves in the realm of hospital medicine.”

No need for an academic meeting to be boring, said Weijen Chang, MD, SFHM, chief of pediatric hospital medicine at Baystate Children’s Hospital, Springfield, Mass.

4. Can we just stick to the “Bare Necessities”? – Things we do for no reason (April 9, 10:35-11:35 a.m.)

5. “Mirror, Mirror on the Wall”: Which articles are the fairest of them all? Top pediatric updates (April 10, 5:45-6:45 p.m.)

“I’d say Dr. Lenny Feldman’s [SFHM] ‘Things we do for no reason’ is a must-see. Lenny is a master at simplifying complex issues and communicating them in an easily understood manner, and he’s quite entertaining,” Dr. Chang said. “And of course, another must-see is Top Pediatric Updates. It is entertaining, educational, and we almost got thrown out last year for bringing beer!”

Sarah Stella, MD, FHM, a hospitalist at Denver Health, had a hard time choosing between the many interesting offerings. “There are quite a few great sessions this year that I’m interested in, but these are my top picks:”

6. Convert your everyday work into scholarship (and get it funded) (April 9, 1:35-2:35 p.m.)

“By virtue of their daily clinical and quality improvement/committee work, many hospitalists are well on their way to generating scholarship and funding, but are unsure how to make this conversion,” she said. “This workshop is a must for academic hospitalists working toward promotion who want a framework and tangible steps on how to get credit for what they are already doing.”

7. “Heigh ho, heigh ho,” it’s off to changing roles mid-career we go (April 11, 8:20-9:00 a.m.)

“Part of what attracts many of us to hospital medicine in the first place is the versatility of what we do and the ability to diversify based on our interests. I think this is a must-see for mid-career hospitalists like myself, or really any hospitalist dreaming of reinventing oneself.”

8. Winning hearts and minds at the bedside: Battling unconscious bias through cultural humility (April 11, 9:10-9:50 a.m.)

“Recognizing and confronting our implicit biases and how they affect patient-physician interactions is hard but incredibly important work,” Dr. Stella said. “I’ll definitely be attending this session by Aziz Ansari, DO, SFHM, to learn how to improve my relationship (and hence outcomes) with my patients.”

Harry (Hyung) Cho, MD, FHM, assistant professor of medicine and director of quality, safety, and value, division of hospital medicine, Mount Sinai Hospital, New York, had some diverse choices.

9. Being female in hospital medicine: Overcoming individual and institutional barriers in the workplace (April 9, 12:40-2:15 p.m.)

“This is a very timely, very important topic in the news and I think it will draw a lot of people,” he said.

10. Every patient tells a story and the art of diagnosis (April 9, 2:55-3:35 p.m.)

“The presenter is Dr. Lisa Sanders, who writes the ‘Diagnosis’ column for the New York Times and is a Yale University faculty member. She’s a great speaker and, incidentally, was a consultant on the TV show, ‘House, MD.’ ”

Raman Palabindala, MD, FHM, a hospitalist at the University of Mississippi Medical Center, Jackson, thinks the most important session at HM18 is the annual update.

11. Update in hospital medicine (April 10, 1:40-2:40 p.m.)“Almost every year, this is the most high energy presentation, and I don’t think I ever missed this session, no matter who is the presenter is,” he said. “As physicians, I think we need this update every year, and this is the best single hour where we can learn a lot as a hospitalist related to hospital medicine. This is the most concentrated extract of the entire meeting. What I learned about the behind scenes efforts up to 50-100 hours of work – why not we take advantage of this session.”

Lonika Sood, MD, FHM of the department of hospital medicine, Aurora BayCare Medical Center, Green Bay, Wis., has a passion for both leadership and scholarship, and her choices reflect that interest.

12. How to write a winning abstract (April 11, 7:30-8:30 a.m.)

13. Leadership positions in medical education: How to break into the field (April 11, 11:40 a.m.-12:20 p.m.)

14. Serious illness communication: A skills-based workshop (April 11, 8:00-9:30 a.m.)

“I would recommend all of those, especially for early-career hospitalists. And, having enjoyed and learned a lot from the workshops at HM17, I would highly recommend checking out a few that will help polish your communications – a much-needed skill in hospital medicine,” she said.

Finally, don’t just pick up another embroidered mouse ear hat on your way out. The best HM18 souvenir is taking back the knowledge you gained and – as Dr. Sood said – there’s a session for that.

15. How to bring the things you learn at SHM back to your institution: Advocating for high value care on hospital committees (April 11, 8:00-9:30 a.m.).

For more information on the HM18 education sessions, check the latest version of the conference schedule at http://shmannualconference.org/conference-schedule.


 

Welcome to Hospital Medicine 2018, the second-happiest place in Orlando – at least for hospitalists who want to be in the know.

The 2018 education program is a ride through the diverse world of hospital medicine, with sessions ranging from clinical updates to cutting-edge techniques, communication tools, building a satisfying career, and finding your way through tangles of red tape and policy.

Two tracks new for 2018 hone in on managing alternative providers and palliative care.

The half-day NP/PA track (beginning April 11 at 7:30 a.m.) recognizes these practitioners for their crucial roles in hospital medicine care delivery. Among the discussions aimed at hospitalists: Best practices in provider utilization and collaboration; supervision vs. collaboration; and challenging situations when working with mid-level providers.

The palliative care track (also a half day, starting April 11 at 10 a.m.) recognizes the crucial role hospitalists play in optimizing end-of-life care. Sessions will help hospitalists understand that role, and guide them in managing pain and other symptoms commonly encountered during this transitional time.

As for the rest of the meeting, picking favorites is as tough as picking between Disney’s Big Thunder Railroad and Splash Mountain, said HM18 course director Dustin Smith, MD, SFHM, of Emory University, Atlanta. “We feel strongly that all offerings at the conference are ‘must-sees,’ and it’s why we offer repeat sessions of what we predict will be the most popular talks overall. Since there are so many good sessions competing for attendees at the same time, we wanted to make sure we offered these repeat sessions of common, high-yield clinical topics.”

The Repeated Sessions track is set for April 10, and runs a full day. The track includes these dynamic sessions:

• Updates in congestive heart failure: Pablo Quintero, MD; 11-11:40 a.m.
• He-who-shall-not-be-named: Updates in sepsis and critical care: Patricia Kritek, MD, EdM; 11:50 a.m.-12:30 p.m.
• Not true love’s kiss? Updates in infectious disease: John Sanders, MD, MPHTM; 2:50-3:30 p.m.
• Updates in acute coronary syndrome: Jeff Trost, MD; 3:40-4:20 p.m.
• Waiting in line for ‘It’s a Small World’ and other things we do for no reason: Tony Breu, MD, FHM; 4:30-5:10 p.m.
• “The Mad Hatter”: Updates in delirium: Ethan Cumbler, MD, FHM; 5:20-6:00 p.m.

In addition to the sepsis update in the Repeated Sessions track, Dr. Smith noted that sepsis will also be the topic of a pre-course offering (April 8, 8:15 a.m.-4:50 p.m.). “The topic of sepsis remains a hot item in hospital medicine,” he said.

“I’d also like to highlight a new pre-course offering this year – ‘Keep your finger on the pulse: Cardiology update for the hospitalist’ (April 8, 8:30 a.m.-4:50 p.m.),” he said. “Many of our pre-course offerings are carry-overs from previous years due to ongoing great success with the individual pre-courses themselves. Although we have had a cardiology pre-course in our lineup of offerings in the past, we chose to offer a freshly redesigned pre-course in cardiology this year to round out the lineup of pre-course offerings and to keep things fresh.”

The “Stump the attentive (not absent-minded) professor” sessions on clinical unknowns in the Diagnostics Reasoning track are also must-sees, Dr. Smith said. So much so, that SHM is offering two of them this year (April 9, 2:00-2:40 p.m.; 3:45-4:25 p.m.).

Dr. Smith’s codirector Kathleen Finn, MD, MPhil, SFHM, also has a few personal favorites on the education program.

“I know the talks in the ‘Seasoning your career track’ will be great,” said Dr. Finn, a hospitalist at Massachusetts General Hospital, Boston. “This new track provides mid-career hospitalists (and new hospitalists) ideas in how to continue to make their career enjoyable and stimulating. It includes talks on how to advance in a leadership position, use emotional intelligence to achieve success, prevent burnout or design your groups schedule so it doesn’t rule your life.”
 

The board weighs in

The 2018 HM18 line-up garnered an enthusiastic thumbs-up from The Hospitalist’s editorial advisory board. We polled these experts for their 2018 “must-see” sessions, and they responded with a selection that spans the meeting’s wide-ranging offerings.



1. Leadership essentials for success in hospital medicine (April 9, 10:35 a.m.-12:05 p.m.)

Amit Vashist, MD, MBA, FHM, system chair, hospitalist division, Mountain State Health Alliance, Virginia/Tennessee, is especially excited about this session, intended to help hospitalists assume leadership roles.

“Given the ever-expanding footprint of hospitalists inside the hospitals and beyond, and the way they are being called upon to be the drivers of an increasingly value-based care, I believe it is imperative for every hospitalist provider – regardless of being in a leadership role or not – to have a fundamental understanding of the leadership nuances pertaining specifically to hospital medicine in order to optimally leverage their skill set to drive transformational changes in the health care arena,” he said. “This primer on leadership essentials should pique the interest of the hospitalists further towards developing a deeper appreciation of some of the leadership dimensions must-haves in the realm of hospital medicine.”

No need for an academic meeting to be boring, said Weijen Chang, MD, SFHM, chief of pediatric hospital medicine at Baystate Children’s Hospital, Springfield, Mass.

4. Can we just stick to the “Bare Necessities”? – Things we do for no reason (April 9, 10:35-11:35 a.m.)

5. “Mirror, Mirror on the Wall”: Which articles are the fairest of them all? Top pediatric updates (April 10, 5:45-6:45 p.m.)

“I’d say Dr. Lenny Feldman’s [SFHM] ‘Things we do for no reason’ is a must-see. Lenny is a master at simplifying complex issues and communicating them in an easily understood manner, and he’s quite entertaining,” Dr. Chang said. “And of course, another must-see is Top Pediatric Updates. It is entertaining, educational, and we almost got thrown out last year for bringing beer!”

Sarah Stella, MD, FHM, a hospitalist at Denver Health, had a hard time choosing between the many interesting offerings. “There are quite a few great sessions this year that I’m interested in, but these are my top picks:”

6. Convert your everyday work into scholarship (and get it funded) (April 9, 1:35-2:35 p.m.)

“By virtue of their daily clinical and quality improvement/committee work, many hospitalists are well on their way to generating scholarship and funding, but are unsure how to make this conversion,” she said. “This workshop is a must for academic hospitalists working toward promotion who want a framework and tangible steps on how to get credit for what they are already doing.”

7. “Heigh ho, heigh ho,” it’s off to changing roles mid-career we go (April 11, 8:20-9:00 a.m.)

“Part of what attracts many of us to hospital medicine in the first place is the versatility of what we do and the ability to diversify based on our interests. I think this is a must-see for mid-career hospitalists like myself, or really any hospitalist dreaming of reinventing oneself.”

8. Winning hearts and minds at the bedside: Battling unconscious bias through cultural humility (April 11, 9:10-9:50 a.m.)

“Recognizing and confronting our implicit biases and how they affect patient-physician interactions is hard but incredibly important work,” Dr. Stella said. “I’ll definitely be attending this session by Aziz Ansari, DO, SFHM, to learn how to improve my relationship (and hence outcomes) with my patients.”

Harry (Hyung) Cho, MD, FHM, assistant professor of medicine and director of quality, safety, and value, division of hospital medicine, Mount Sinai Hospital, New York, had some diverse choices.

9. Being female in hospital medicine: Overcoming individual and institutional barriers in the workplace (April 9, 12:40-2:15 p.m.)

“This is a very timely, very important topic in the news and I think it will draw a lot of people,” he said.

10. Every patient tells a story and the art of diagnosis (April 9, 2:55-3:35 p.m.)

“The presenter is Dr. Lisa Sanders, who writes the ‘Diagnosis’ column for the New York Times and is a Yale University faculty member. She’s a great speaker and, incidentally, was a consultant on the TV show, ‘House, MD.’ ”

Raman Palabindala, MD, FHM, a hospitalist at the University of Mississippi Medical Center, Jackson, thinks the most important session at HM18 is the annual update.

11. Update in hospital medicine (April 10, 1:40-2:40 p.m.)“Almost every year, this is the most high energy presentation, and I don’t think I ever missed this session, no matter who is the presenter is,” he said. “As physicians, I think we need this update every year, and this is the best single hour where we can learn a lot as a hospitalist related to hospital medicine. This is the most concentrated extract of the entire meeting. What I learned about the behind scenes efforts up to 50-100 hours of work – why not we take advantage of this session.”

Lonika Sood, MD, FHM of the department of hospital medicine, Aurora BayCare Medical Center, Green Bay, Wis., has a passion for both leadership and scholarship, and her choices reflect that interest.

12. How to write a winning abstract (April 11, 7:30-8:30 a.m.)

13. Leadership positions in medical education: How to break into the field (April 11, 11:40 a.m.-12:20 p.m.)

14. Serious illness communication: A skills-based workshop (April 11, 8:00-9:30 a.m.)

“I would recommend all of those, especially for early-career hospitalists. And, having enjoyed and learned a lot from the workshops at HM17, I would highly recommend checking out a few that will help polish your communications – a much-needed skill in hospital medicine,” she said.

Finally, don’t just pick up another embroidered mouse ear hat on your way out. The best HM18 souvenir is taking back the knowledge you gained and – as Dr. Sood said – there’s a session for that.

15. How to bring the things you learn at SHM back to your institution: Advocating for high value care on hospital committees (April 11, 8:00-9:30 a.m.).

For more information on the HM18 education sessions, check the latest version of the conference schedule at http://shmannualconference.org/conference-schedule.


 

Point-of-care ultrasound (POCUS) is proving to be an increasing useful diagnostic tool for clinicians at the bedside, and many hospitalists have expressed interest in learning best practices in the use of the technology.

To that end, the Society of Hospital Medicine (SHM) is offering a half-day POCUS pre-course at Hospital Medicine 2018 this April in Orlando, with the intent of helping hospitalists learn how best to use POCUS in clinical settings.

“The agenda is really designed to teach people the basics of point-of-care ultrasound,” said Nilam J. Soni, MD, MSc, of the University of Texas at San Antonio and South Texas Veterans Health Care System, also in San Antonio, and a coinstructor of the POCUS pre-course. “It’s designed for the novice learner who has no prior experience in using ultrasound.”

Dr. Soni and his coinstructor, Ricardo Antonio Franco-Sadud, MD, of the Medical College of Wisconsin, Milwaukee, will lead attendees through the basics of “Point-of-Care Ultrasound for the Hospitalist” at HM18. Dr. Soni has taught a version of this course for almost a decade and is the assistant director of POCUS training programs with Veterans Affairs’ Simulation Learning Education and Research Network (SimLEARN). The pre-course is a 4.5-hour, multimodal class that involves hands-on training to teach the fundamentals of how to evaluate patients using POCUS.

With this course, Dr. Soni said, SHM is addressing training needs from “above and below.”

“Medical students, residents, fellows – basically doctors in training, whether they are student residents or getting ultrasound instruction in their basic training – when these kids graduate, they are pretty good,” he said. “But what about all the doctors who graduated long ago? They didn’t get any POCUS training. That’s where SHM, CHEST, and some of the other societies come in to play. We can offer these courses for training.”

Ultrasound training and credentialing has become a focus for SHM as interest has grown among clinicians. The Journal of Hospital Medicine recently released a consensus statement, “Credentialing of Hospitalists in Ultrasound-Guided Bedside Procedures,” which offers recommendations for credentialing hospitalists in ultrasound guidance and proposes initial and ongoing pathways to improve how hospitalists perform these procedures. The statement emphasizes how ultrasound guidance is increasingly essential to six bedside procedures that are core competencies of hospitalists: abdominal paracentesis, arterial catheter placement, arthrocentesis, central venous catheter placement, lumbar puncture, and thoracentesis.

According to Brian P. Lucas, MD, of Rush Medical College, Chicago, and lead author of the position statement, SHM’s Education Committee convened a POCUS Task Force to take on the project as American Board of Internal Medicine (ABIM) diplomates are no longer expected as part of their residency training to manually perform certain bedside procedures, with or without ultrasound guidance. SHM’s Board of Directors gave final approval on the statement in September 2017.

“There is much variation in the training and experience of both bedside procedures and point-of-care ultrasound. Many practicing hospitalists, for example, have no experience using ultrasound guidance for central lines,” Dr. Lucas said. “How then should hospitals initially, and then biennially, vet hospitalists’ competence in the performance of ultrasound-guided bedside procedures? This nationwide collaborative of experts, educators and front-line providers puts forth some recommendations to this very thorny problem.”

SHM also offers, in collaboration with the American College of Chest Physicians, a Point-of-Care Ultrasound Certificate of Completion for clinicians. The program is designed primarily to educate hospitalists and other providers caring for acutely ill patients, and requires attendance at a series of training programs within the course of 3 years, at the end of which a clinician must complete a comprehensive skills and knowledge assessment to obtain the certificate.
 

Focus on POCUS

Although medical societies recognize the growing demand, and are offering more ultrasound training, many hospitalists may not be familiar with POCUS specifically and the benefits of utilizing a bedside ultrasound exam, Dr. Soni noted.

“When we talk about point-of-care ultrasound, how is it different from what everyone else thinks about ultrasound? Specifically, it’s a point-of-care bedside exam” Dr. Soni explained. “So, the same provider – whether it’s a physician, nurse practitioner, or PA – who is taking care of a patient, can use ultrasound at the bedside to evaluate specific things in the patient’s body and answer very focused questions.”

The ability to have a hospitalist immediately use an imaging technique at a patient’s bedside can be invaluable, because it allows the clinician to provide a fairly accurate diagnosis in conjunction with patient input. This is much more effective than the traditional process of ultrasound imaging, Dr. Soni said.

“If you go to your primary care doctor [who orders] an ultrasound, you go to the radiology department and the technician captures the images,” he said. “Then the radiologist, who never even sees the patient, reads the ultrasound images with little to no clinical data.” The compartmentalization of the treating clinician, patient, and radiologist leaves the latter without critical information when reading an ultrasound. POCUS can potentially overcome this problematic situation, Dr. Soni suggested.

The HM18 POCUS pre-course has four objectives:

1. Recognize the fundamentals of ultrasound and the basic operation of an ultrasound machine (“knobology”).

2. Differentiate between the different types of ultrasound transducers and determine which is most appropriate for different POCUS applications.

3. Exhibit proper techniques on focused cardiac and lung ultrasound exams and be able to recognize thoracic pathologies from abnormal ultrasound results.

4. Identify and understand normal sonographic appearance of solid abdominal organs and vasculature of the neck and lower extremities and the ability to interpret abnormal ultrasounds to identify pathologies.

While all attendees can expect to learn a new skill that will improve their practice, POCUS training will specifically benefit hospitalists and the institutions in which they work, Dr. Soni said.

“Hospitalists, by nature, work for the hospital. In most cases, hospitalists are subsidized by the hospital. Because of that, the bigger gain from using ultrasound is not in the billing,” he said. “You can bill for focused ultrasound exams of the lungs, heart, abdomen, etc., and you might get a professional fee of $30-$40. But the bigger win in all of this, financially, is giving people more efficient health care. If we can prevent one complication from a bedside procedure or expedite a patient’s care and get them better sooner, we can save the hospital and the system money.”

The SHM is accredited to provide continuing medical education for physicians by the Accreditation Council for Continuing Medical Education. This live activity course will count for a maximum of 4.75 AMA PRA Category 1 Credits.

Point-of-Care Ultrasound for the Hospitalist ​
Sunday, April 8, 7:30 a.m.–12:15 p.m.

Point-of-care ultrasound (POCUS) is proving to be an increasing useful diagnostic tool for clinicians at the bedside, and many hospitalists have expressed interest in learning best practices in the use of the technology.

To that end, the Society of Hospital Medicine (SHM) is offering a half-day POCUS pre-course at Hospital Medicine 2018 this April in Orlando, with the intent of helping hospitalists learn how best to use POCUS in clinical settings.

“The agenda is really designed to teach people the basics of point-of-care ultrasound,” said Nilam J. Soni, MD, MSc, of the University of Texas at San Antonio and South Texas Veterans Health Care System, also in San Antonio, and a coinstructor of the POCUS pre-course. “It’s designed for the novice learner who has no prior experience in using ultrasound.”

Dr. Soni and his coinstructor, Ricardo Antonio Franco-Sadud, MD, of the Medical College of Wisconsin, Milwaukee, will lead attendees through the basics of “Point-of-Care Ultrasound for the Hospitalist” at HM18. Dr. Soni has taught a version of this course for almost a decade and is the assistant director of POCUS training programs with Veterans Affairs’ Simulation Learning Education and Research Network (SimLEARN). The pre-course is a 4.5-hour, multimodal class that involves hands-on training to teach the fundamentals of how to evaluate patients using POCUS.

With this course, Dr. Soni said, SHM is addressing training needs from “above and below.”

“Medical students, residents, fellows – basically doctors in training, whether they are student residents or getting ultrasound instruction in their basic training – when these kids graduate, they are pretty good,” he said. “But what about all the doctors who graduated long ago? They didn’t get any POCUS training. That’s where SHM, CHEST, and some of the other societies come in to play. We can offer these courses for training.”

Ultrasound training and credentialing has become a focus for SHM as interest has grown among clinicians. The Journal of Hospital Medicine recently released a consensus statement, “Credentialing of Hospitalists in Ultrasound-Guided Bedside Procedures,” which offers recommendations for credentialing hospitalists in ultrasound guidance and proposes initial and ongoing pathways to improve how hospitalists perform these procedures. The statement emphasizes how ultrasound guidance is increasingly essential to six bedside procedures that are core competencies of hospitalists: abdominal paracentesis, arterial catheter placement, arthrocentesis, central venous catheter placement, lumbar puncture, and thoracentesis.

According to Brian P. Lucas, MD, of Rush Medical College, Chicago, and lead author of the position statement, SHM’s Education Committee convened a POCUS Task Force to take on the project as American Board of Internal Medicine (ABIM) diplomates are no longer expected as part of their residency training to manually perform certain bedside procedures, with or without ultrasound guidance. SHM’s Board of Directors gave final approval on the statement in September 2017.

“There is much variation in the training and experience of both bedside procedures and point-of-care ultrasound. Many practicing hospitalists, for example, have no experience using ultrasound guidance for central lines,” Dr. Lucas said. “How then should hospitals initially, and then biennially, vet hospitalists’ competence in the performance of ultrasound-guided bedside procedures? This nationwide collaborative of experts, educators and front-line providers puts forth some recommendations to this very thorny problem.”

SHM also offers, in collaboration with the American College of Chest Physicians, a Point-of-Care Ultrasound Certificate of Completion for clinicians. The program is designed primarily to educate hospitalists and other providers caring for acutely ill patients, and requires attendance at a series of training programs within the course of 3 years, at the end of which a clinician must complete a comprehensive skills and knowledge assessment to obtain the certificate.
 

Focus on POCUS

Although medical societies recognize the growing demand, and are offering more ultrasound training, many hospitalists may not be familiar with POCUS specifically and the benefits of utilizing a bedside ultrasound exam, Dr. Soni noted.

“When we talk about point-of-care ultrasound, how is it different from what everyone else thinks about ultrasound? Specifically, it’s a point-of-care bedside exam” Dr. Soni explained. “So, the same provider – whether it’s a physician, nurse practitioner, or PA – who is taking care of a patient, can use ultrasound at the bedside to evaluate specific things in the patient’s body and answer very focused questions.”

The ability to have a hospitalist immediately use an imaging technique at a patient’s bedside can be invaluable, because it allows the clinician to provide a fairly accurate diagnosis in conjunction with patient input. This is much more effective than the traditional process of ultrasound imaging, Dr. Soni said.

“If you go to your primary care doctor [who orders] an ultrasound, you go to the radiology department and the technician captures the images,” he said. “Then the radiologist, who never even sees the patient, reads the ultrasound images with little to no clinical data.” The compartmentalization of the treating clinician, patient, and radiologist leaves the latter without critical information when reading an ultrasound. POCUS can potentially overcome this problematic situation, Dr. Soni suggested.

The HM18 POCUS pre-course has four objectives:

1. Recognize the fundamentals of ultrasound and the basic operation of an ultrasound machine (“knobology”).

2. Differentiate between the different types of ultrasound transducers and determine which is most appropriate for different POCUS applications.

3. Exhibit proper techniques on focused cardiac and lung ultrasound exams and be able to recognize thoracic pathologies from abnormal ultrasound results.

4. Identify and understand normal sonographic appearance of solid abdominal organs and vasculature of the neck and lower extremities and the ability to interpret abnormal ultrasounds to identify pathologies.

While all attendees can expect to learn a new skill that will improve their practice, POCUS training will specifically benefit hospitalists and the institutions in which they work, Dr. Soni said.

“Hospitalists, by nature, work for the hospital. In most cases, hospitalists are subsidized by the hospital. Because of that, the bigger gain from using ultrasound is not in the billing,” he said. “You can bill for focused ultrasound exams of the lungs, heart, abdomen, etc., and you might get a professional fee of $30-$40. But the bigger win in all of this, financially, is giving people more efficient health care. If we can prevent one complication from a bedside procedure or expedite a patient’s care and get them better sooner, we can save the hospital and the system money.”

The SHM is accredited to provide continuing medical education for physicians by the Accreditation Council for Continuing Medical Education. This live activity course will count for a maximum of 4.75 AMA PRA Category 1 Credits.

Point-of-Care Ultrasound for the Hospitalist ​
Sunday, April 8, 7:30 a.m.–12:15 p.m.

Point-of-care ultrasound (POCUS) is proving to be an increasing useful diagnostic tool for clinicians at the bedside, and many hospitalists have expressed interest in learning best practices in the use of the technology.

To that end, the Society of Hospital Medicine (SHM) is offering a half-day POCUS pre-course at Hospital Medicine 2018 this April in Orlando, with the intent of helping hospitalists learn how best to use POCUS in clinical settings.

“The agenda is really designed to teach people the basics of point-of-care ultrasound,” said Nilam J. Soni, MD, MSc, of the University of Texas at San Antonio and South Texas Veterans Health Care System, also in San Antonio, and a coinstructor of the POCUS pre-course. “It’s designed for the novice learner who has no prior experience in using ultrasound.”

Dr. Soni and his coinstructor, Ricardo Antonio Franco-Sadud, MD, of the Medical College of Wisconsin, Milwaukee, will lead attendees through the basics of “Point-of-Care Ultrasound for the Hospitalist” at HM18. Dr. Soni has taught a version of this course for almost a decade and is the assistant director of POCUS training programs with Veterans Affairs’ Simulation Learning Education and Research Network (SimLEARN). The pre-course is a 4.5-hour, multimodal class that involves hands-on training to teach the fundamentals of how to evaluate patients using POCUS.

With this course, Dr. Soni said, SHM is addressing training needs from “above and below.”

“Medical students, residents, fellows – basically doctors in training, whether they are student residents or getting ultrasound instruction in their basic training – when these kids graduate, they are pretty good,” he said. “But what about all the doctors who graduated long ago? They didn’t get any POCUS training. That’s where SHM, CHEST, and some of the other societies come in to play. We can offer these courses for training.”

Ultrasound training and credentialing has become a focus for SHM as interest has grown among clinicians. The Journal of Hospital Medicine recently released a consensus statement, “Credentialing of Hospitalists in Ultrasound-Guided Bedside Procedures,” which offers recommendations for credentialing hospitalists in ultrasound guidance and proposes initial and ongoing pathways to improve how hospitalists perform these procedures. The statement emphasizes how ultrasound guidance is increasingly essential to six bedside procedures that are core competencies of hospitalists: abdominal paracentesis, arterial catheter placement, arthrocentesis, central venous catheter placement, lumbar puncture, and thoracentesis.

According to Brian P. Lucas, MD, of Rush Medical College, Chicago, and lead author of the position statement, SHM’s Education Committee convened a POCUS Task Force to take on the project as American Board of Internal Medicine (ABIM) diplomates are no longer expected as part of their residency training to manually perform certain bedside procedures, with or without ultrasound guidance. SHM’s Board of Directors gave final approval on the statement in September 2017.

“There is much variation in the training and experience of both bedside procedures and point-of-care ultrasound. Many practicing hospitalists, for example, have no experience using ultrasound guidance for central lines,” Dr. Lucas said. “How then should hospitals initially, and then biennially, vet hospitalists’ competence in the performance of ultrasound-guided bedside procedures? This nationwide collaborative of experts, educators and front-line providers puts forth some recommendations to this very thorny problem.”

SHM also offers, in collaboration with the American College of Chest Physicians, a Point-of-Care Ultrasound Certificate of Completion for clinicians. The program is designed primarily to educate hospitalists and other providers caring for acutely ill patients, and requires attendance at a series of training programs within the course of 3 years, at the end of which a clinician must complete a comprehensive skills and knowledge assessment to obtain the certificate.
 

Focus on POCUS

Although medical societies recognize the growing demand, and are offering more ultrasound training, many hospitalists may not be familiar with POCUS specifically and the benefits of utilizing a bedside ultrasound exam, Dr. Soni noted.

“When we talk about point-of-care ultrasound, how is it different from what everyone else thinks about ultrasound? Specifically, it’s a point-of-care bedside exam” Dr. Soni explained. “So, the same provider – whether it’s a physician, nurse practitioner, or PA – who is taking care of a patient, can use ultrasound at the bedside to evaluate specific things in the patient’s body and answer very focused questions.”

The ability to have a hospitalist immediately use an imaging technique at a patient’s bedside can be invaluable, because it allows the clinician to provide a fairly accurate diagnosis in conjunction with patient input. This is much more effective than the traditional process of ultrasound imaging, Dr. Soni said.

“If you go to your primary care doctor [who orders] an ultrasound, you go to the radiology department and the technician captures the images,” he said. “Then the radiologist, who never even sees the patient, reads the ultrasound images with little to no clinical data.” The compartmentalization of the treating clinician, patient, and radiologist leaves the latter without critical information when reading an ultrasound. POCUS can potentially overcome this problematic situation, Dr. Soni suggested.

The HM18 POCUS pre-course has four objectives:

1. Recognize the fundamentals of ultrasound and the basic operation of an ultrasound machine (“knobology”).

2. Differentiate between the different types of ultrasound transducers and determine which is most appropriate for different POCUS applications.

3. Exhibit proper techniques on focused cardiac and lung ultrasound exams and be able to recognize thoracic pathologies from abnormal ultrasound results.

4. Identify and understand normal sonographic appearance of solid abdominal organs and vasculature of the neck and lower extremities and the ability to interpret abnormal ultrasounds to identify pathologies.

While all attendees can expect to learn a new skill that will improve their practice, POCUS training will specifically benefit hospitalists and the institutions in which they work, Dr. Soni said.

“Hospitalists, by nature, work for the hospital. In most cases, hospitalists are subsidized by the hospital. Because of that, the bigger gain from using ultrasound is not in the billing,” he said. “You can bill for focused ultrasound exams of the lungs, heart, abdomen, etc., and you might get a professional fee of $30-$40. But the bigger win in all of this, financially, is giving people more efficient health care. If we can prevent one complication from a bedside procedure or expedite a patient’s care and get them better sooner, we can save the hospital and the system money.”

The SHM is accredited to provide continuing medical education for physicians by the Accreditation Council for Continuing Medical Education. This live activity course will count for a maximum of 4.75 AMA PRA Category 1 Credits.

Point-of-Care Ultrasound for the Hospitalist ​
Sunday, April 8, 7:30 a.m.–12:15 p.m.

At the 2018 annual meeting of the Society of Hospital Medicine – running from April 8 to 11 in Orlando – the theme could well be “in with the new, and in with the new.”

Planners for Hospital Medicine 2018 (HM18) have managed to pack the conference with five new tracks: Great Debate, Nurse Practitioner/Physician’s Assistant (NP/PA), Palliative Care, Seasoning Your Career, and a new Career Development workshop track. And they did this while eliminating only one track that was on the schedule last year – technology – and without adding any extra days to the meeting.

Great debate

The annual meeting has traditionally had a “Great Debate” on perioperative medicine, but the format – with carefully chosen speakers who are dynamic and entertaining – will be used to cover pulmonary medicine and infectious diseases this year as well.

“It’s a hugely successful talk,” Dr. Finn said. “We can tell by our numbers that lots of people go, and it’s always funny, and it’s a very clever way of discussing the latest literature – by having two very dynamic speakers present a case and then debate the two options of the case and then use the literature to support the answer,” she said.

The hope is that the format will be more than just entertaining but will be an effective teaching tool, too.

“We think the high level of engagement and format of the talk leads to better overall education for those who attend,” Dr. Smith said.
 

NP/PA

This track includes topics chosen by the committee for advanced practice professionals.

“There are many hospitalist programs that include NP/PAs – this is what came through in all the feedback – and everybody is struggling with how do you best incorporate NPs and PAs into the group practice and have everybody work at the top of their license and work well together,” Dr. Finn said.

“The idea, too, is to be very inclusive of all providers and offering a track that focuses on NP/PAs but also includes physicians, physician leaders, and physician administrators,” Dr. Smith said. “It’s not designed for one type of practicing professional; it should be a good educational track for all.”
 

Palliative care

This was a topic that had been sprinkled throughout programs in previous years, but Dr. Finn and Dr. Smith said it was considered too important not to have its own track this year.

“I think hospitalists are often the doctors caring for patients at the end of their lives since many Americans die in the hospital,” Dr. Finn said. “So as a result, this is a skill set that as hospitalists we need to be very good at.”
 

Seasoning your career

This is a track geared toward one of this year’s themes: With “hospital medicine” now a concept that’s more than two decades old, how do hospitalists keep up the momentum in their careers, how do they take stock, how do they make the important decisions they face as they move ahead in their jobs?

“Hospital medicine is now over 20 years old – many hospitalists are now mid-career,” Dr. Finn said. “We picked an entire track on ‘seasoning your career’ to offer people ideas and skills to reflect on and rethink their career. Do you want to expand what you’re doing? Do you want to change it? How do you make this a lifelong career?”
 

Career development

There have always been workshops with a ‘career development’ focus, but this year six of them were chosen to be placed under the heading of an official “career development” workshop track.

“When you review the Day-at-a-Glance schedule, it really demarcates it,” Dr. Smith said. “This really helps attendees be able to quickly look through and find where they want to be for their next session.”

“Are there other skills you want to take on for the second half of your career?” Dr. Finn said. “Do you want to take on leadership? Do you want to learn how to better give your peers feedback? Do you want to promote women in your group? Do you want to prevent burnout or use emotional intelligence to improve your career? We cohorted these topics together.”



Aside from the new tracks, the course directors also drew attention to other new elements of the HM18 program.

For instance there are new topics in the Rapid Fire sessions. In the “Managing the patient on your service: Appendicitis, Bowel and biliary obstruction” session, a general surgeon will talk about how to manage these surgical issues when the patient is on a medical service. In “Interventional radiology: What every hospitalist needs to know,” an interventional radiologist will discuss when hospitalists may want to call in an interventional radiologist or refer to a hospital that has an interventional radiologist. And “Vulnerable populations and hospitalists” will continue with the theme of social determinants of health that was highlighted at last year’s meeting by keynote speaker Karen DeSalvo, MD, the national coordinator for health information technology.

Dr. Smith said that the program committee directors work with the Rapid Fire presenters so that the three or four questions discussed in the sessions are what attendees will want to learn most.

“We take an additional step: Once we recruit the speaker and have identified the topic, we have members of our committee work with the speakers,” he said.

“We don’t want them to come and give us an esoteric talk in an area that interests them. We want them to answer the clinical questions that hospitalists have,” Dr. Finn added.

Dr. Finn and Dr. Smith also highlighted sessions with a twist. For example, “Stupefy: EKGs for fun” is a session about EKGs that encourages hospitalists to “just go have fun reading them,” Dr. Finn said, while “Voldemort is on the plane: Airplane emergencies,” is scheduled for the final day of the conference, just before everyone flies back home.

As for catchy Disney-influenced titles, such as “The Mad Hatter: Updates in delirium” and “Waiting in line for ‘It’s a Small World’ and other things we do for no reason,” part of the credit can go to Dr. Finn’s niece. She said she “hired” her to come up with a list of Disney, Pixar, and Harry Potter movies and catchphrases. Then the committee worked them into the session titles.

Dr. Smith joked that part of his role was to veto some titles that were “a bit too cringe-worthy.”

“The theme of Orlando is making people happy,” Dr. Finn said. “One of the goals – the hopes – for me for at this meeting is that people bring their inner child and get curious again and explore new ideas and new topics and new career possibilities.”

At the 2018 annual meeting of the Society of Hospital Medicine – running from April 8 to 11 in Orlando – the theme could well be “in with the new, and in with the new.”

Planners for Hospital Medicine 2018 (HM18) have managed to pack the conference with five new tracks: Great Debate, Nurse Practitioner/Physician’s Assistant (NP/PA), Palliative Care, Seasoning Your Career, and a new Career Development workshop track. And they did this while eliminating only one track that was on the schedule last year – technology – and without adding any extra days to the meeting.

Great debate

The annual meeting has traditionally had a “Great Debate” on perioperative medicine, but the format – with carefully chosen speakers who are dynamic and entertaining – will be used to cover pulmonary medicine and infectious diseases this year as well.

“It’s a hugely successful talk,” Dr. Finn said. “We can tell by our numbers that lots of people go, and it’s always funny, and it’s a very clever way of discussing the latest literature – by having two very dynamic speakers present a case and then debate the two options of the case and then use the literature to support the answer,” she said.

The hope is that the format will be more than just entertaining but will be an effective teaching tool, too.

“We think the high level of engagement and format of the talk leads to better overall education for those who attend,” Dr. Smith said.
 

NP/PA

This track includes topics chosen by the committee for advanced practice professionals.

“There are many hospitalist programs that include NP/PAs – this is what came through in all the feedback – and everybody is struggling with how do you best incorporate NPs and PAs into the group practice and have everybody work at the top of their license and work well together,” Dr. Finn said.

“The idea, too, is to be very inclusive of all providers and offering a track that focuses on NP/PAs but also includes physicians, physician leaders, and physician administrators,” Dr. Smith said. “It’s not designed for one type of practicing professional; it should be a good educational track for all.”
 

Palliative care

This was a topic that had been sprinkled throughout programs in previous years, but Dr. Finn and Dr. Smith said it was considered too important not to have its own track this year.

“I think hospitalists are often the doctors caring for patients at the end of their lives since many Americans die in the hospital,” Dr. Finn said. “So as a result, this is a skill set that as hospitalists we need to be very good at.”
 

Seasoning your career

This is a track geared toward one of this year’s themes: With “hospital medicine” now a concept that’s more than two decades old, how do hospitalists keep up the momentum in their careers, how do they take stock, how do they make the important decisions they face as they move ahead in their jobs?

“Hospital medicine is now over 20 years old – many hospitalists are now mid-career,” Dr. Finn said. “We picked an entire track on ‘seasoning your career’ to offer people ideas and skills to reflect on and rethink their career. Do you want to expand what you’re doing? Do you want to change it? How do you make this a lifelong career?”
 

Career development

There have always been workshops with a ‘career development’ focus, but this year six of them were chosen to be placed under the heading of an official “career development” workshop track.

“When you review the Day-at-a-Glance schedule, it really demarcates it,” Dr. Smith said. “This really helps attendees be able to quickly look through and find where they want to be for their next session.”

“Are there other skills you want to take on for the second half of your career?” Dr. Finn said. “Do you want to take on leadership? Do you want to learn how to better give your peers feedback? Do you want to promote women in your group? Do you want to prevent burnout or use emotional intelligence to improve your career? We cohorted these topics together.”



Aside from the new tracks, the course directors also drew attention to other new elements of the HM18 program.

For instance there are new topics in the Rapid Fire sessions. In the “Managing the patient on your service: Appendicitis, Bowel and biliary obstruction” session, a general surgeon will talk about how to manage these surgical issues when the patient is on a medical service. In “Interventional radiology: What every hospitalist needs to know,” an interventional radiologist will discuss when hospitalists may want to call in an interventional radiologist or refer to a hospital that has an interventional radiologist. And “Vulnerable populations and hospitalists” will continue with the theme of social determinants of health that was highlighted at last year’s meeting by keynote speaker Karen DeSalvo, MD, the national coordinator for health information technology.

Dr. Smith said that the program committee directors work with the Rapid Fire presenters so that the three or four questions discussed in the sessions are what attendees will want to learn most.

“We take an additional step: Once we recruit the speaker and have identified the topic, we have members of our committee work with the speakers,” he said.

“We don’t want them to come and give us an esoteric talk in an area that interests them. We want them to answer the clinical questions that hospitalists have,” Dr. Finn added.

Dr. Finn and Dr. Smith also highlighted sessions with a twist. For example, “Stupefy: EKGs for fun” is a session about EKGs that encourages hospitalists to “just go have fun reading them,” Dr. Finn said, while “Voldemort is on the plane: Airplane emergencies,” is scheduled for the final day of the conference, just before everyone flies back home.

As for catchy Disney-influenced titles, such as “The Mad Hatter: Updates in delirium” and “Waiting in line for ‘It’s a Small World’ and other things we do for no reason,” part of the credit can go to Dr. Finn’s niece. She said she “hired” her to come up with a list of Disney, Pixar, and Harry Potter movies and catchphrases. Then the committee worked them into the session titles.

Dr. Smith joked that part of his role was to veto some titles that were “a bit too cringe-worthy.”

“The theme of Orlando is making people happy,” Dr. Finn said. “One of the goals – the hopes – for me for at this meeting is that people bring their inner child and get curious again and explore new ideas and new topics and new career possibilities.”

At the 2018 annual meeting of the Society of Hospital Medicine – running from April 8 to 11 in Orlando – the theme could well be “in with the new, and in with the new.”

Planners for Hospital Medicine 2018 (HM18) have managed to pack the conference with five new tracks: Great Debate, Nurse Practitioner/Physician’s Assistant (NP/PA), Palliative Care, Seasoning Your Career, and a new Career Development workshop track. And they did this while eliminating only one track that was on the schedule last year – technology – and without adding any extra days to the meeting.

Great debate

The annual meeting has traditionally had a “Great Debate” on perioperative medicine, but the format – with carefully chosen speakers who are dynamic and entertaining – will be used to cover pulmonary medicine and infectious diseases this year as well.

“It’s a hugely successful talk,” Dr. Finn said. “We can tell by our numbers that lots of people go, and it’s always funny, and it’s a very clever way of discussing the latest literature – by having two very dynamic speakers present a case and then debate the two options of the case and then use the literature to support the answer,” she said.

The hope is that the format will be more than just entertaining but will be an effective teaching tool, too.

“We think the high level of engagement and format of the talk leads to better overall education for those who attend,” Dr. Smith said.
 

NP/PA

This track includes topics chosen by the committee for advanced practice professionals.

“There are many hospitalist programs that include NP/PAs – this is what came through in all the feedback – and everybody is struggling with how do you best incorporate NPs and PAs into the group practice and have everybody work at the top of their license and work well together,” Dr. Finn said.

“The idea, too, is to be very inclusive of all providers and offering a track that focuses on NP/PAs but also includes physicians, physician leaders, and physician administrators,” Dr. Smith said. “It’s not designed for one type of practicing professional; it should be a good educational track for all.”
 

Palliative care

This was a topic that had been sprinkled throughout programs in previous years, but Dr. Finn and Dr. Smith said it was considered too important not to have its own track this year.

“I think hospitalists are often the doctors caring for patients at the end of their lives since many Americans die in the hospital,” Dr. Finn said. “So as a result, this is a skill set that as hospitalists we need to be very good at.”
 

Seasoning your career

This is a track geared toward one of this year’s themes: With “hospital medicine” now a concept that’s more than two decades old, how do hospitalists keep up the momentum in their careers, how do they take stock, how do they make the important decisions they face as they move ahead in their jobs?

“Hospital medicine is now over 20 years old – many hospitalists are now mid-career,” Dr. Finn said. “We picked an entire track on ‘seasoning your career’ to offer people ideas and skills to reflect on and rethink their career. Do you want to expand what you’re doing? Do you want to change it? How do you make this a lifelong career?”
 

Career development

There have always been workshops with a ‘career development’ focus, but this year six of them were chosen to be placed under the heading of an official “career development” workshop track.

“When you review the Day-at-a-Glance schedule, it really demarcates it,” Dr. Smith said. “This really helps attendees be able to quickly look through and find where they want to be for their next session.”

“Are there other skills you want to take on for the second half of your career?” Dr. Finn said. “Do you want to take on leadership? Do you want to learn how to better give your peers feedback? Do you want to promote women in your group? Do you want to prevent burnout or use emotional intelligence to improve your career? We cohorted these topics together.”



Aside from the new tracks, the course directors also drew attention to other new elements of the HM18 program.

For instance there are new topics in the Rapid Fire sessions. In the “Managing the patient on your service: Appendicitis, Bowel and biliary obstruction” session, a general surgeon will talk about how to manage these surgical issues when the patient is on a medical service. In “Interventional radiology: What every hospitalist needs to know,” an interventional radiologist will discuss when hospitalists may want to call in an interventional radiologist or refer to a hospital that has an interventional radiologist. And “Vulnerable populations and hospitalists” will continue with the theme of social determinants of health that was highlighted at last year’s meeting by keynote speaker Karen DeSalvo, MD, the national coordinator for health information technology.

Dr. Smith said that the program committee directors work with the Rapid Fire presenters so that the three or four questions discussed in the sessions are what attendees will want to learn most.

“We take an additional step: Once we recruit the speaker and have identified the topic, we have members of our committee work with the speakers,” he said.

“We don’t want them to come and give us an esoteric talk in an area that interests them. We want them to answer the clinical questions that hospitalists have,” Dr. Finn added.

Dr. Finn and Dr. Smith also highlighted sessions with a twist. For example, “Stupefy: EKGs for fun” is a session about EKGs that encourages hospitalists to “just go have fun reading them,” Dr. Finn said, while “Voldemort is on the plane: Airplane emergencies,” is scheduled for the final day of the conference, just before everyone flies back home.

As for catchy Disney-influenced titles, such as “The Mad Hatter: Updates in delirium” and “Waiting in line for ‘It’s a Small World’ and other things we do for no reason,” part of the credit can go to Dr. Finn’s niece. She said she “hired” her to come up with a list of Disney, Pixar, and Harry Potter movies and catchphrases. Then the committee worked them into the session titles.

Dr. Smith joked that part of his role was to veto some titles that were “a bit too cringe-worthy.”

“The theme of Orlando is making people happy,” Dr. Finn said. “One of the goals – the hopes – for me for at this meeting is that people bring their inner child and get curious again and explore new ideas and new topics and new career possibilities.”

Barbara Slawski, MD, MS, SFHM, and Cynthia Cooper, MD, hadn’t met in person until early 2018. But that doesn’t mean they haven’t spent a lot of time together.

Once a month, usually on a Friday afternoon, the two hospitalists checked in with one another through relaxed, wide-ranging phone calls. Together they have combed the medical literature and conferred over the past year, making long lists of candidate studies for the “top 20” journal articles of 2018 for practicing hospitalists.

The two physicians are preparing for the “Update in Hospital Medicine” session they will comoderate at HM18 – historically one of the most popular at SHM annual meetings – where the research findings of these “Top 20” articles are summarized for conference attendees. Their hope, they said, is to present research that each attendee can bring home to improve patient outcomes on a daily basis, while making for a smoother and more efficient practice of hospital medicine.

“We hope that our unique approaches lend more breadth to the session,” said Dr. Slawski. “We want to make sure we have a good representation of SHM’s constituency, and that we present high-impact studies.”

In addition to her work at Mass General, Dr. Cooper also holds an appointment at Harvard Medical School. She said that the challenge over the past year has been to find the studies that are not focused just on primary care, but that really touch on the unique practice demands and skill set of physicians who practice hospital-based medicine.

Dr. Slawski said that cardiology is one of the areas that’s had relevant, practice-changing findings this past year: She expects to put at least one practice-changing cardiology article on the “Top 20” list. “How do we address patients with suspected acute coronary syndromes? Well, we have some new direction this year,” she said.

To hit the mark of articles that are relevant for all, Dr. Cooper said she wants to make sure to include a focus on research that touches on the practicalities of hospital-based practice – possible topics include prediction scores, hepatic encephalopathy, and the management of sepsis.

Dr. Slawski said that in addition to relevance, she and Dr. Cooper looked for methodological rigor in the studies they’ll be presenting; they agreed that having an adequate sample size for statistical power was a must.

The two presenters said they’re working hard to put together a session that’s as enjoyable as it is relevant. “I hope we’ll be able to inject some humor into the presentation, too,” Dr. Cooper said. Dr. Slawski agreed, noting that the bar has been set high at SHM. “It feels like a community,” she said. “There are always great speakers with a sense of humor.”

Dr. Slawski stressed that even though they’ll have their list ready to go for HM18, they will still be scouring journals until the week of the meeting so they can update their presentation with any late-breaking news of significance.

Neither Dr. Slawski nor Dr. Cooper reported any relevant conflicts of interest.

[email protected]

Barbara Slawski, MD, MS, SFHM, and Cynthia Cooper, MD, hadn’t met in person until early 2018. But that doesn’t mean they haven’t spent a lot of time together.

Once a month, usually on a Friday afternoon, the two hospitalists checked in with one another through relaxed, wide-ranging phone calls. Together they have combed the medical literature and conferred over the past year, making long lists of candidate studies for the “top 20” journal articles of 2018 for practicing hospitalists.

The two physicians are preparing for the “Update in Hospital Medicine” session they will comoderate at HM18 – historically one of the most popular at SHM annual meetings – where the research findings of these “Top 20” articles are summarized for conference attendees. Their hope, they said, is to present research that each attendee can bring home to improve patient outcomes on a daily basis, while making for a smoother and more efficient practice of hospital medicine.

“We hope that our unique approaches lend more breadth to the session,” said Dr. Slawski. “We want to make sure we have a good representation of SHM’s constituency, and that we present high-impact studies.”

In addition to her work at Mass General, Dr. Cooper also holds an appointment at Harvard Medical School. She said that the challenge over the past year has been to find the studies that are not focused just on primary care, but that really touch on the unique practice demands and skill set of physicians who practice hospital-based medicine.

Dr. Slawski said that cardiology is one of the areas that’s had relevant, practice-changing findings this past year: She expects to put at least one practice-changing cardiology article on the “Top 20” list. “How do we address patients with suspected acute coronary syndromes? Well, we have some new direction this year,” she said.

To hit the mark of articles that are relevant for all, Dr. Cooper said she wants to make sure to include a focus on research that touches on the practicalities of hospital-based practice – possible topics include prediction scores, hepatic encephalopathy, and the management of sepsis.

Dr. Slawski said that in addition to relevance, she and Dr. Cooper looked for methodological rigor in the studies they’ll be presenting; they agreed that having an adequate sample size for statistical power was a must.

The two presenters said they’re working hard to put together a session that’s as enjoyable as it is relevant. “I hope we’ll be able to inject some humor into the presentation, too,” Dr. Cooper said. Dr. Slawski agreed, noting that the bar has been set high at SHM. “It feels like a community,” she said. “There are always great speakers with a sense of humor.”

Dr. Slawski stressed that even though they’ll have their list ready to go for HM18, they will still be scouring journals until the week of the meeting so they can update their presentation with any late-breaking news of significance.

Neither Dr. Slawski nor Dr. Cooper reported any relevant conflicts of interest.

[email protected]

Barbara Slawski, MD, MS, SFHM, and Cynthia Cooper, MD, hadn’t met in person until early 2018. But that doesn’t mean they haven’t spent a lot of time together.

Once a month, usually on a Friday afternoon, the two hospitalists checked in with one another through relaxed, wide-ranging phone calls. Together they have combed the medical literature and conferred over the past year, making long lists of candidate studies for the “top 20” journal articles of 2018 for practicing hospitalists.

The two physicians are preparing for the “Update in Hospital Medicine” session they will comoderate at HM18 – historically one of the most popular at SHM annual meetings – where the research findings of these “Top 20” articles are summarized for conference attendees. Their hope, they said, is to present research that each attendee can bring home to improve patient outcomes on a daily basis, while making for a smoother and more efficient practice of hospital medicine.

“We hope that our unique approaches lend more breadth to the session,” said Dr. Slawski. “We want to make sure we have a good representation of SHM’s constituency, and that we present high-impact studies.”

In addition to her work at Mass General, Dr. Cooper also holds an appointment at Harvard Medical School. She said that the challenge over the past year has been to find the studies that are not focused just on primary care, but that really touch on the unique practice demands and skill set of physicians who practice hospital-based medicine.

Dr. Slawski said that cardiology is one of the areas that’s had relevant, practice-changing findings this past year: She expects to put at least one practice-changing cardiology article on the “Top 20” list. “How do we address patients with suspected acute coronary syndromes? Well, we have some new direction this year,” she said.

To hit the mark of articles that are relevant for all, Dr. Cooper said she wants to make sure to include a focus on research that touches on the practicalities of hospital-based practice – possible topics include prediction scores, hepatic encephalopathy, and the management of sepsis.

Dr. Slawski said that in addition to relevance, she and Dr. Cooper looked for methodological rigor in the studies they’ll be presenting; they agreed that having an adequate sample size for statistical power was a must.

The two presenters said they’re working hard to put together a session that’s as enjoyable as it is relevant. “I hope we’ll be able to inject some humor into the presentation, too,” Dr. Cooper said. Dr. Slawski agreed, noting that the bar has been set high at SHM. “It feels like a community,” she said. “There are always great speakers with a sense of humor.”

Dr. Slawski stressed that even though they’ll have their list ready to go for HM18, they will still be scouring journals until the week of the meeting so they can update their presentation with any late-breaking news of significance.

Neither Dr. Slawski nor Dr. Cooper reported any relevant conflicts of interest.

[email protected]

Amandeep Godara, MD

SALT LAKE CITY—Results of a large, retrospective analysis support the notion that patients who receive cord blood (CB) transplants have a higher risk of infection than other hematopoietic stem cell transplant (HSCT) recipients.

Investigators found that CB recipients had a significantly higher risk of bacterial, viral, and fungal infections in the early post-transplant period than patients who received peripheral blood (PB) or bone marrow (BM) transplants.

In addition, CB recipients had longer hospital stays, higher inpatient costs, and greater inpatient mortality than PB and BM recipients.

Amandeep Godara, MD, of Tufts Medical Center in Boston, Massachusetts, presented these results at the 2018 BMT Tandem Meetings (abstract 30*).

“Infections are considered more common in cord blood transplant recipients based on some prior retrospective analyses,” Dr Godara noted. “But there is limited data comparing these infectious complications between cord blood transplant and peripheral blood/bone marrow stem cell transplants during the inpatient stay for the stem cell transplant.”

With this in mind, Dr Godara and his colleagues analyzed data from the Healthcare Cost and Utilization Project National Inpatient Sample. This database covers 46 US states and contains data from more than 7 million hospital stays each year.

The investigators searched the database for hospital admissions for HSCT from 2002 to 2014. They identified 2979 CB transplants and 56,845 PB or BM transplants.

The CB recipients had a median age of 48, and 55% were male. Fifty-nine percent were white, 18% Hispanic, 13% black, 5% Asian, and 5% “other.” Sixty-six percent of patients had acute leukemia, 18% non-Hodgkin lymphoma, 5% Hodgkin lymphoma, and 11% “other” diseases.

The PB/BM recipients had a median age of 45, and 58% were male. Seventy-nine percent were white, 8% Hispanic, 6% black, 3% Asian, and 4% “other.” Sixty-one percent of patients had acute leukemia, 16% non-Hodgkin lymphoma, 4% Hodgkin lymphoma, and 19% “other” diseases.

Results

Dr Godara and his colleagues compared the rates and types of infection from the time of HSCT to hospital discharge in CB and PB/BM recipients. The team also compared early inpatient mortality, the cost of hospitalization, and the length of hospital stay.

“[W]e observed a higher risk for infections in cord blood transplant patients compared to peripheral blood and bone marrow stem cell transplant patients, and this risk for infection extended through a wide spectrum of pathogens,” Dr Godara said.

“We also observed a higher all-cause inpatient mortality in cord blood transplant compared to peripheral blood and bone marrow transplant, especially in patients who had bacterial sepsis or invasive fungal infection.”

The rate of bacterial sepsis was 34.87% in CB recipients and 20.20% in PB/BM recipients (P<0.0001). Rates of viral infection were 20.05% and 8.19%, respectively (P<0.0001). And rates of invasive fungal infection were 12.87% and 7.89% (P<0.0001).

There was a similar distribution of bacterial infections in CB and PB/BM recipients. The most common was pneumonia (47% and 41%, respectively), followed by abdominal infections (29% and 31%, respectively), urinary tract infections (17% and 21%, respectively), central line-associated bloodstream infections (4% and 6%, respectively), and acute sinusitis (3% and 1%, respectively).

The rate of Clostridium difficile infection was significantly higher in CB recipients than PB/BM recipients—11.75% and 8.90%, respectively (P=0.02). However, there was no significant difference in mortality related to C. difficile—14% and 10%, respectively (P=0.3).

On the other hand, all-cause inpatient mortality was significantly higher in CB recipients than PB/BM recipients—16% and 7%, respectively (P<0.0001).

Inpatient mortality rates were significantly higher for CB recipients with bacterial sepsis (33% vs 23%, P=0.001) and invasive fungal infections (29% vs 16%, P=0.0045) but not viral infections (19% vs 17%, P=0.5).

The median length of hospital stay was 36 days for CB recipients and 25 days for PB/BM recipients. The mean inpatient charges were $448,892 and $250,437 respectively.

*Data in the abstract differ from the presentation.

Amandeep Godara, MD

SALT LAKE CITY—Results of a large, retrospective analysis support the notion that patients who receive cord blood (CB) transplants have a higher risk of infection than other hematopoietic stem cell transplant (HSCT) recipients.

Investigators found that CB recipients had a significantly higher risk of bacterial, viral, and fungal infections in the early post-transplant period than patients who received peripheral blood (PB) or bone marrow (BM) transplants.

In addition, CB recipients had longer hospital stays, higher inpatient costs, and greater inpatient mortality than PB and BM recipients.

Amandeep Godara, MD, of Tufts Medical Center in Boston, Massachusetts, presented these results at the 2018 BMT Tandem Meetings (abstract 30*).

“Infections are considered more common in cord blood transplant recipients based on some prior retrospective analyses,” Dr Godara noted. “But there is limited data comparing these infectious complications between cord blood transplant and peripheral blood/bone marrow stem cell transplants during the inpatient stay for the stem cell transplant.”

With this in mind, Dr Godara and his colleagues analyzed data from the Healthcare Cost and Utilization Project National Inpatient Sample. This database covers 46 US states and contains data from more than 7 million hospital stays each year.

The investigators searched the database for hospital admissions for HSCT from 2002 to 2014. They identified 2979 CB transplants and 56,845 PB or BM transplants.

The CB recipients had a median age of 48, and 55% were male. Fifty-nine percent were white, 18% Hispanic, 13% black, 5% Asian, and 5% “other.” Sixty-six percent of patients had acute leukemia, 18% non-Hodgkin lymphoma, 5% Hodgkin lymphoma, and 11% “other” diseases.

The PB/BM recipients had a median age of 45, and 58% were male. Seventy-nine percent were white, 8% Hispanic, 6% black, 3% Asian, and 4% “other.” Sixty-one percent of patients had acute leukemia, 16% non-Hodgkin lymphoma, 4% Hodgkin lymphoma, and 19% “other” diseases.

Results

Dr Godara and his colleagues compared the rates and types of infection from the time of HSCT to hospital discharge in CB and PB/BM recipients. The team also compared early inpatient mortality, the cost of hospitalization, and the length of hospital stay.

“[W]e observed a higher risk for infections in cord blood transplant patients compared to peripheral blood and bone marrow stem cell transplant patients, and this risk for infection extended through a wide spectrum of pathogens,” Dr Godara said.

“We also observed a higher all-cause inpatient mortality in cord blood transplant compared to peripheral blood and bone marrow transplant, especially in patients who had bacterial sepsis or invasive fungal infection.”

The rate of bacterial sepsis was 34.87% in CB recipients and 20.20% in PB/BM recipients (P<0.0001). Rates of viral infection were 20.05% and 8.19%, respectively (P<0.0001). And rates of invasive fungal infection were 12.87% and 7.89% (P<0.0001).

There was a similar distribution of bacterial infections in CB and PB/BM recipients. The most common was pneumonia (47% and 41%, respectively), followed by abdominal infections (29% and 31%, respectively), urinary tract infections (17% and 21%, respectively), central line-associated bloodstream infections (4% and 6%, respectively), and acute sinusitis (3% and 1%, respectively).

The rate of Clostridium difficile infection was significantly higher in CB recipients than PB/BM recipients—11.75% and 8.90%, respectively (P=0.02). However, there was no significant difference in mortality related to C. difficile—14% and 10%, respectively (P=0.3).

On the other hand, all-cause inpatient mortality was significantly higher in CB recipients than PB/BM recipients—16% and 7%, respectively (P<0.0001).

Inpatient mortality rates were significantly higher for CB recipients with bacterial sepsis (33% vs 23%, P=0.001) and invasive fungal infections (29% vs 16%, P=0.0045) but not viral infections (19% vs 17%, P=0.5).

The median length of hospital stay was 36 days for CB recipients and 25 days for PB/BM recipients. The mean inpatient charges were $448,892 and $250,437 respectively.

*Data in the abstract differ from the presentation.

Amandeep Godara, MD

SALT LAKE CITY—Results of a large, retrospective analysis support the notion that patients who receive cord blood (CB) transplants have a higher risk of infection than other hematopoietic stem cell transplant (HSCT) recipients.

Investigators found that CB recipients had a significantly higher risk of bacterial, viral, and fungal infections in the early post-transplant period than patients who received peripheral blood (PB) or bone marrow (BM) transplants.

In addition, CB recipients had longer hospital stays, higher inpatient costs, and greater inpatient mortality than PB and BM recipients.

Amandeep Godara, MD, of Tufts Medical Center in Boston, Massachusetts, presented these results at the 2018 BMT Tandem Meetings (abstract 30*).

“Infections are considered more common in cord blood transplant recipients based on some prior retrospective analyses,” Dr Godara noted. “But there is limited data comparing these infectious complications between cord blood transplant and peripheral blood/bone marrow stem cell transplants during the inpatient stay for the stem cell transplant.”

With this in mind, Dr Godara and his colleagues analyzed data from the Healthcare Cost and Utilization Project National Inpatient Sample. This database covers 46 US states and contains data from more than 7 million hospital stays each year.

The investigators searched the database for hospital admissions for HSCT from 2002 to 2014. They identified 2979 CB transplants and 56,845 PB or BM transplants.

The CB recipients had a median age of 48, and 55% were male. Fifty-nine percent were white, 18% Hispanic, 13% black, 5% Asian, and 5% “other.” Sixty-six percent of patients had acute leukemia, 18% non-Hodgkin lymphoma, 5% Hodgkin lymphoma, and 11% “other” diseases.

The PB/BM recipients had a median age of 45, and 58% were male. Seventy-nine percent were white, 8% Hispanic, 6% black, 3% Asian, and 4% “other.” Sixty-one percent of patients had acute leukemia, 16% non-Hodgkin lymphoma, 4% Hodgkin lymphoma, and 19% “other” diseases.

Results

Dr Godara and his colleagues compared the rates and types of infection from the time of HSCT to hospital discharge in CB and PB/BM recipients. The team also compared early inpatient mortality, the cost of hospitalization, and the length of hospital stay.

“[W]e observed a higher risk for infections in cord blood transplant patients compared to peripheral blood and bone marrow stem cell transplant patients, and this risk for infection extended through a wide spectrum of pathogens,” Dr Godara said.

“We also observed a higher all-cause inpatient mortality in cord blood transplant compared to peripheral blood and bone marrow transplant, especially in patients who had bacterial sepsis or invasive fungal infection.”

The rate of bacterial sepsis was 34.87% in CB recipients and 20.20% in PB/BM recipients (P<0.0001). Rates of viral infection were 20.05% and 8.19%, respectively (P<0.0001). And rates of invasive fungal infection were 12.87% and 7.89% (P<0.0001).

There was a similar distribution of bacterial infections in CB and PB/BM recipients. The most common was pneumonia (47% and 41%, respectively), followed by abdominal infections (29% and 31%, respectively), urinary tract infections (17% and 21%, respectively), central line-associated bloodstream infections (4% and 6%, respectively), and acute sinusitis (3% and 1%, respectively).

The rate of Clostridium difficile infection was significantly higher in CB recipients than PB/BM recipients—11.75% and 8.90%, respectively (P=0.02). However, there was no significant difference in mortality related to C. difficile—14% and 10%, respectively (P=0.3).

On the other hand, all-cause inpatient mortality was significantly higher in CB recipients than PB/BM recipients—16% and 7%, respectively (P<0.0001).

Inpatient mortality rates were significantly higher for CB recipients with bacterial sepsis (33% vs 23%, P=0.001) and invasive fungal infections (29% vs 16%, P=0.0045) but not viral infections (19% vs 17%, P=0.5).

The median length of hospital stay was 36 days for CB recipients and 25 days for PB/BM recipients. The mean inpatient charges were $448,892 and $250,437 respectively.

*Data in the abstract differ from the presentation.

AML cells

The European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) has recommended marketing authorization for gemtuzumab ozogamicin (GO, Mylotarg™).

The recommendation is for GO to be used in combination with daunorubicin and cytarabine to treat patients age 15 years and older with previously untreated, de novo, CD33-positive acute myeloid leukemia (AML) but not acute promyelocytic leukemia.

The CHMP’s opinion on GO will be reviewed by the European Commission (EC).

If the EC agrees with the CHMP, the commission will grant a centralized marketing authorization that will be valid in the European Union. Norway, Iceland, and Liechtenstein will make corresponding decisions on the basis of the EC’s decision.

The EC typically makes a decision within 67 days of the CHMP’s recommendation.

Previous rejection

The CHMP previously issued a negative opinion of GO (first in 2007, confirmed in 2008), saying the drug should not receive marketing authorization.

The proposed indication for GO at that time was as re-induction treatment in adults with CD33-positive AML in first relapse who were not candidates for other intensive re-induction chemotherapy regimens and were either older than 60 or had a duration of first remission lasting less than 12 months.

The CHMP said there was insufficient evidence to establish the effectiveness of GO in AML, and the drug’s benefits did not outweigh its risks.

Phase 3 trial

The current marketing authorization application for GO is supported by data from an investigator-led, phase 3, randomized trial known as ALFA-0701. Updated results from this trial are available in the US prescribing information for GO.

Patients and treatment

ALFA-0701 included 271 patients with newly diagnosed, de novo AML who were 50 to 70 years of age.

Patients were randomized (1:1) to receive induction consisting of daunorubicin (60 mg/m² on days 1 to 3) and cytarabine (200 mg/m² on days 1 to 7) with (n=135) or without (n=136) GO at 3 mg/m² (up to maximum of 1 vial) on days 1, 4, and 7. Patients who did not achieve a response after first induction could receive a second induction with daunorubicin and cytarabine alone.

Patients with a response received consolidation therapy with 2 courses of treatment including daunorubicin (60 mg/m² on day 1 of first consolidation course; 60 mg/m² on days 1 and 2 of second consolidation course) and cytarabine (1 g/m² every 12 hours on days 1 to 4) with or without GO at 3 mg/m² (up to a maximum of 1 vial) on day 1 according to their initial randomization.

Patients who achieved remission were also eligible for allogeneic transplant. An interval of at least 2 months between the last dose of GO and transplant was recommended.

Baseline characteristics were largely well balanced between the treatment arms, but there was a higher percentage of males in the GO arm than the control arm—55% and 44%, respectively.

Results

The study’s primary endpoint was event-free survival. The median event-free survival was 17.3 months in the GO arm and 9.5 months in the control arm (hazard ratio=0.56; 95% CI: 0.42-0.76; P<0.001).

There was no significant difference in overall survival between the treatment arms. (Updated overall survival data have not been provided).

All patients in this trial developed severe neutropenia, thrombocytopenia, and anemia. However, the incidence of prolonged, grade 3–4 thrombocytopenia in the absence of active leukemia was higher in the GO arm.

Treatment-emergent adverse events (AEs) considered most important for understanding the safety profile of GO were hemorrhage, veno-occlusive liver disease (VOD), and severe infections.

Treatment discontinuation due to any AE occurred in 31% of patients in the GO arm and 7% of those in the control arm. The most frequent AEs leading to discontinuation for patients on GO were thrombocytopenia (15%), VOD (3%), and septic shock (2%).

Fatal AEs occurred in 8 patients (6%) in the GO arm and 3 (2%) in the control arm. In the GO arm, 3 patients died of VOD, 4 died of hemorrhage-related events, and 1 died of a suspected cardiac cause. All 3 fatal AEs in the control arm were sepsis.

AML cells

The European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) has recommended marketing authorization for gemtuzumab ozogamicin (GO, Mylotarg™).

The recommendation is for GO to be used in combination with daunorubicin and cytarabine to treat patients age 15 years and older with previously untreated, de novo, CD33-positive acute myeloid leukemia (AML) but not acute promyelocytic leukemia.

The CHMP’s opinion on GO will be reviewed by the European Commission (EC).

If the EC agrees with the CHMP, the commission will grant a centralized marketing authorization that will be valid in the European Union. Norway, Iceland, and Liechtenstein will make corresponding decisions on the basis of the EC’s decision.

The EC typically makes a decision within 67 days of the CHMP’s recommendation.

Previous rejection

The CHMP previously issued a negative opinion of GO (first in 2007, confirmed in 2008), saying the drug should not receive marketing authorization.

The proposed indication for GO at that time was as re-induction treatment in adults with CD33-positive AML in first relapse who were not candidates for other intensive re-induction chemotherapy regimens and were either older than 60 or had a duration of first remission lasting less than 12 months.

The CHMP said there was insufficient evidence to establish the effectiveness of GO in AML, and the drug’s benefits did not outweigh its risks.

Phase 3 trial

The current marketing authorization application for GO is supported by data from an investigator-led, phase 3, randomized trial known as ALFA-0701. Updated results from this trial are available in the US prescribing information for GO.

Patients and treatment

ALFA-0701 included 271 patients with newly diagnosed, de novo AML who were 50 to 70 years of age.

Patients were randomized (1:1) to receive induction consisting of daunorubicin (60 mg/m² on days 1 to 3) and cytarabine (200 mg/m² on days 1 to 7) with (n=135) or without (n=136) GO at 3 mg/m² (up to maximum of 1 vial) on days 1, 4, and 7. Patients who did not achieve a response after first induction could receive a second induction with daunorubicin and cytarabine alone.

Patients with a response received consolidation therapy with 2 courses of treatment including daunorubicin (60 mg/m² on day 1 of first consolidation course; 60 mg/m² on days 1 and 2 of second consolidation course) and cytarabine (1 g/m² every 12 hours on days 1 to 4) with or without GO at 3 mg/m² (up to a maximum of 1 vial) on day 1 according to their initial randomization.

Patients who achieved remission were also eligible for allogeneic transplant. An interval of at least 2 months between the last dose of GO and transplant was recommended.

Baseline characteristics were largely well balanced between the treatment arms, but there was a higher percentage of males in the GO arm than the control arm—55% and 44%, respectively.

Results

The study’s primary endpoint was event-free survival. The median event-free survival was 17.3 months in the GO arm and 9.5 months in the control arm (hazard ratio=0.56; 95% CI: 0.42-0.76; P<0.001).

There was no significant difference in overall survival between the treatment arms. (Updated overall survival data have not been provided).

All patients in this trial developed severe neutropenia, thrombocytopenia, and anemia. However, the incidence of prolonged, grade 3–4 thrombocytopenia in the absence of active leukemia was higher in the GO arm.

Treatment-emergent adverse events (AEs) considered most important for understanding the safety profile of GO were hemorrhage, veno-occlusive liver disease (VOD), and severe infections.

Treatment discontinuation due to any AE occurred in 31% of patients in the GO arm and 7% of those in the control arm. The most frequent AEs leading to discontinuation for patients on GO were thrombocytopenia (15%), VOD (3%), and septic shock (2%).

Fatal AEs occurred in 8 patients (6%) in the GO arm and 3 (2%) in the control arm. In the GO arm, 3 patients died of VOD, 4 died of hemorrhage-related events, and 1 died of a suspected cardiac cause. All 3 fatal AEs in the control arm were sepsis.

AML cells

The European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) has recommended marketing authorization for gemtuzumab ozogamicin (GO, Mylotarg™).

The recommendation is for GO to be used in combination with daunorubicin and cytarabine to treat patients age 15 years and older with previously untreated, de novo, CD33-positive acute myeloid leukemia (AML) but not acute promyelocytic leukemia.

The CHMP’s opinion on GO will be reviewed by the European Commission (EC).

If the EC agrees with the CHMP, the commission will grant a centralized marketing authorization that will be valid in the European Union. Norway, Iceland, and Liechtenstein will make corresponding decisions on the basis of the EC’s decision.

The EC typically makes a decision within 67 days of the CHMP’s recommendation.

Previous rejection

The CHMP previously issued a negative opinion of GO (first in 2007, confirmed in 2008), saying the drug should not receive marketing authorization.

The proposed indication for GO at that time was as re-induction treatment in adults with CD33-positive AML in first relapse who were not candidates for other intensive re-induction chemotherapy regimens and were either older than 60 or had a duration of first remission lasting less than 12 months.

The CHMP said there was insufficient evidence to establish the effectiveness of GO in AML, and the drug’s benefits did not outweigh its risks.

Phase 3 trial

The current marketing authorization application for GO is supported by data from an investigator-led, phase 3, randomized trial known as ALFA-0701. Updated results from this trial are available in the US prescribing information for GO.

Patients and treatment

ALFA-0701 included 271 patients with newly diagnosed, de novo AML who were 50 to 70 years of age.

Patients were randomized (1:1) to receive induction consisting of daunorubicin (60 mg/m² on days 1 to 3) and cytarabine (200 mg/m² on days 1 to 7) with (n=135) or without (n=136) GO at 3 mg/m² (up to maximum of 1 vial) on days 1, 4, and 7. Patients who did not achieve a response after first induction could receive a second induction with daunorubicin and cytarabine alone.

Patients with a response received consolidation therapy with 2 courses of treatment including daunorubicin (60 mg/m² on day 1 of first consolidation course; 60 mg/m² on days 1 and 2 of second consolidation course) and cytarabine (1 g/m² every 12 hours on days 1 to 4) with or without GO at 3 mg/m² (up to a maximum of 1 vial) on day 1 according to their initial randomization.

Patients who achieved remission were also eligible for allogeneic transplant. An interval of at least 2 months between the last dose of GO and transplant was recommended.

Baseline characteristics were largely well balanced between the treatment arms, but there was a higher percentage of males in the GO arm than the control arm—55% and 44%, respectively.

Results

The study’s primary endpoint was event-free survival. The median event-free survival was 17.3 months in the GO arm and 9.5 months in the control arm (hazard ratio=0.56; 95% CI: 0.42-0.76; P<0.001).

There was no significant difference in overall survival between the treatment arms. (Updated overall survival data have not been provided).

All patients in this trial developed severe neutropenia, thrombocytopenia, and anemia. However, the incidence of prolonged, grade 3–4 thrombocytopenia in the absence of active leukemia was higher in the GO arm.

Treatment-emergent adverse events (AEs) considered most important for understanding the safety profile of GO were hemorrhage, veno-occlusive liver disease (VOD), and severe infections.

Treatment discontinuation due to any AE occurred in 31% of patients in the GO arm and 7% of those in the control arm. The most frequent AEs leading to discontinuation for patients on GO were thrombocytopenia (15%), VOD (3%), and septic shock (2%).

Fatal AEs occurred in 8 patients (6%) in the GO arm and 3 (2%) in the control arm. In the GO arm, 3 patients died of VOD, 4 died of hemorrhage-related events, and 1 died of a suspected cardiac cause. All 3 fatal AEs in the control arm were sepsis.

Gilead Sciences, Inc.

Gilead Sciences International Ltd. recently withdrew its application for European approval of idelalisib (Zydelig) in combination with rituximab and bendamustine for the treatment of relapsed/refractory chronic lymphocytic leukemia (CLL).

Idelalisib is currently approved in the European Union for use in combination with an anti-CD20 monoclonal antibody (rituximab or ofatumumab) to treat adults with CLL who have received at least 1 prior therapy or as first-line treatment of CLL in the presence of 17p deletion or TP53 mutation in patients who are not eligible for any other therapies.

Idelalisib is also approved as monotherapy for adults with follicular lymphoma that is refractory to 2 prior lines of treatment.

In seeking expanded approval for idelalisib, Gilead submitted data from a study (NCT01569295) comparing idelalisib plus bendamustine and rituximab to placebo plus bendamustine and rituximab.

Interim results from this study were published in The Lancet Oncology in March 2017.

Gilead withdrew the application for idelalisib after the European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) had evaluated documentation provided by the company and formulated lists of questions.

Gilead had not responded to the last round of questions at the time of the withdrawal.

At that point, the CHMP was of the provisional opinion that idelalisib should not be approved for use in combination with rituximab and bendamustine in patients with relapsed/refractory CLL.

The CHMP said additional, longer-term data are needed to show the benefits of idelalisib plus rituximab and bendamustine outweigh the risks.

Gilead said its withdrawal of the application was based on the CHMP’s opinion that there was insufficient evidence of a favorable benefit-risk profile.

The company also said the withdrawal does not impact ongoing trials of idelalisib.

Gilead Sciences, Inc.

Gilead Sciences International Ltd. recently withdrew its application for European approval of idelalisib (Zydelig) in combination with rituximab and bendamustine for the treatment of relapsed/refractory chronic lymphocytic leukemia (CLL).

Idelalisib is currently approved in the European Union for use in combination with an anti-CD20 monoclonal antibody (rituximab or ofatumumab) to treat adults with CLL who have received at least 1 prior therapy or as first-line treatment of CLL in the presence of 17p deletion or TP53 mutation in patients who are not eligible for any other therapies.

Idelalisib is also approved as monotherapy for adults with follicular lymphoma that is refractory to 2 prior lines of treatment.

In seeking expanded approval for idelalisib, Gilead submitted data from a study (NCT01569295) comparing idelalisib plus bendamustine and rituximab to placebo plus bendamustine and rituximab.

Interim results from this study were published in The Lancet Oncology in March 2017.

Gilead withdrew the application for idelalisib after the European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) had evaluated documentation provided by the company and formulated lists of questions.

Gilead had not responded to the last round of questions at the time of the withdrawal.

At that point, the CHMP was of the provisional opinion that idelalisib should not be approved for use in combination with rituximab and bendamustine in patients with relapsed/refractory CLL.

The CHMP said additional, longer-term data are needed to show the benefits of idelalisib plus rituximab and bendamustine outweigh the risks.

Gilead said its withdrawal of the application was based on the CHMP’s opinion that there was insufficient evidence of a favorable benefit-risk profile.

The company also said the withdrawal does not impact ongoing trials of idelalisib.

Gilead Sciences, Inc.

Gilead Sciences International Ltd. recently withdrew its application for European approval of idelalisib (Zydelig) in combination with rituximab and bendamustine for the treatment of relapsed/refractory chronic lymphocytic leukemia (CLL).

Idelalisib is currently approved in the European Union for use in combination with an anti-CD20 monoclonal antibody (rituximab or ofatumumab) to treat adults with CLL who have received at least 1 prior therapy or as first-line treatment of CLL in the presence of 17p deletion or TP53 mutation in patients who are not eligible for any other therapies.

Idelalisib is also approved as monotherapy for adults with follicular lymphoma that is refractory to 2 prior lines of treatment.

In seeking expanded approval for idelalisib, Gilead submitted data from a study (NCT01569295) comparing idelalisib plus bendamustine and rituximab to placebo plus bendamustine and rituximab.

Interim results from this study were published in The Lancet Oncology in March 2017.

Gilead withdrew the application for idelalisib after the European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) had evaluated documentation provided by the company and formulated lists of questions.

Gilead had not responded to the last round of questions at the time of the withdrawal.

At that point, the CHMP was of the provisional opinion that idelalisib should not be approved for use in combination with rituximab and bendamustine in patients with relapsed/refractory CLL.

The CHMP said additional, longer-term data are needed to show the benefits of idelalisib plus rituximab and bendamustine outweigh the risks.

Gilead said its withdrawal of the application was based on the CHMP’s opinion that there was insufficient evidence of a favorable benefit-risk profile.

The company also said the withdrawal does not impact ongoing trials of idelalisib.

CASE A 40-year-old man came to our office slightly agitated. He had an acute illness that was minor in nature. However, he was not interested in answering my questions or undergoing a physical exam. The more I tried to proceed with the visit, the more agitated he became—pacing the room, muttering, avoiding eye contact. I was uncomfortable and knew that the situation could quickly escalate if it was not brought under control.

What steps would you take if this were your patient?

The scene described above occurred several years ago, but more recently, one of the institutions in my (TIM) area was affected by a shooter in the workplace. The apprehension felt by all of us who were on the periphery paled in comparison to what was experienced by those at the scene. The outcome was horrific. Communicating with those directly involved during, and immediately after, the event was heart-wrenching. The trauma that they continue to relive is unimaginable, and some are not yet able to return to work.

Situations involving agitated patients are not uncommon in health care settings, although ones that escalate to the level of a shooting are. And no matter where on the spectrum an incident involving an agitated patient falls, it can leave those involved with various levels of physical, emotional, and psychological harm. It can also leave everyone asking themselves: “How can I better prepare for such occurrences?”

This article offers some answers by providing tips and guidelines for handling agitated and/or violent patients in various settings.

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Defining the problem, assessing its severity

Between 2011 and 2013, workplace assaults ranged from 23,540 and 25,630 annually, with 70% to 74% occurring in health care and social service settings.^1,2

Agitation is defined as a state that may include inattention, disinhibition, emotional lability, impulsivity, motor restlessness, and aggression.^3,4 Violence in a clinical setting may be seen as an extreme expression of agitation sufficient enough to cause harm to an individual or damage to an object.^5,6

The causes of agitation can be grouped into categories: those due to a general medical condition, those due to a psychiatric condition, and those due to drug intoxication and/or withdrawal.⁷ We have chosen to add a fourth category—iatrogenic (see TABLE 1^3,4,7-9). They are not distinct categories, as there is sometimes overlap among areas.

Determining the level of agitation. Various scales and approaches can help determine the level of agitation in a patient (eg, the Agitated Behavior Scale [ABS; FIGURE];⁵ the Behavioral Activity Rating Scale [BARS]¹⁰) and the risk for violence (eg, the ABC violence risk assessment, TABLE 2⁸).

Scales like the ABS should be employed as soon as a patient shows signs of agitation sufficient to warrant intervention. The idea is for the family physician (FP) to be familiar enough with the tool to be able to mentally check it off, fill it out when time permits, and keep it in the patient’s chart. The first version of the form serves as a baseline so that if care is handed off to another provider, that provider can monitor whether signs and symptoms are improving or worsening.

Setting often drives the solution

Much of the evidence-based research on managing patient agitation and violence stems from inpatient psychiatric and emergency department (ED) settings. To make other health care providers aware of the experience gained in those settings, the American Association for Emergency Psychiatry created Project BETA (Best Practices in Evaluation and Treatment of Agitation). This project is designed to help promote consistency across health care settings and specialties in the way clinicians respond to agitated patients and to emphasize for all health care providers the availability of more than just pharmacologic approaches.⁷

De-escalating the situation. General tenets of de-escalation apply across practice settings. Among them:

• Stay calm. Avoid aggressive postures and prolonged eye contact.
• Be nonconfrontational. Acknowledge the patient’s frustration/perceptions and ask open-ended questions.
• Assess available resources such as clinical team members, family members, and silent alarms.
• Manage the situation and the patient’s underlying issues/diagnoses. This includes mobilizing other patients to avoid collateral damage and exploring solutions with the patient.

For more on de-escalation tools, see (TABLE 3^4,6,9,11).

Your setting matters. It’s worth noting that the settings in which clinicians practice greatly influence the resources available to de-escalate a situation and ensure the safety of the patient and others.⁷ The review that follows provides some issues—and tips—that are unique to different practice settings.

Ambulatory settings

Sim and colleagues⁹ noted that aggressive behavior in the general practice setting may stem not only from factors related to the patient’s own physical or psychological discomfort, but from patients feeling that they are being treated unfairly, whether it be because of wait times, uncomfortable waiting conditions, or something else. A number of international studies have shown high rates of abuse toward FPs.^9,12 Of 831 primary care physicians surveyed in a German study, close to three-quarters indicated that within the last year, they had experienced aggression (ranging from verbal abuse and threats to physical violence and property damage) from a patient.¹² This statistic increased to 91% when it included the length of their career.

Between 2011 and 2013, 7 out of 10 workplace assaults occurred in health care and social service settings.

Bell¹³ suggests that physicians be aware that transference and countertransference issues are often at play when dealing with hostile or potentially violent patients. Suggestions to prevent aggression include some practice-level approaches (eg, providing waiting room distractions, making patients aware of potential delays), as well as being aware of nonverbal cues suggesting increased agitation (eg, clenched fists, crossed arms, chin thrusts, finger pointing).⁹

Group practice

An FP who practices with other health care providers and clinical staff has a built-in team that can assist with de-escalation. When meeting with a patient who has a history of violence or agitation in an exam room or office, try to ensure that you can get to an exit quickly if necessary. Also, alert staff to any concerns, and have a system for at least one staff member to check in periodically during the visit.

It is also helpful to develop an evacuation plan and create a “panic room” or “safe zone” for emergencies.^14,15 Such a space may be nothing more than an area or room for staff to gather. It should have access to the police or other emergency services via a land and/or cell phone line.

Solo practice

If you practice alone, institute safeguards whereby a colleague (at a different practice, building, or location) can be alerted if concerns arise. In addition, consider the following precautions: locking the door when alone after hours, screening potential patients, having a way to call for help (keep the number for the local police station and ED readily available), prohibiting potential weapons (as some states allow them to be carried), and learning some form of self-defense.¹⁵

Ensure that agitated patients are not positioned between you and the exit so that you can quickly escape if necessary.

Resources exist that offer guidelines for developing policies and procedures, checklists, and sample incident forms (eg, the International Association for Healthcare Security and Safety; iahss.org). Other organizations that can help with the development of a preparedness plan include the Occupational Safety and Health Administration (https://www.osha.gov/SLTC/workplaceviolence/evaluation.html), the Department of Homeland Security (https://www.dhs.gov/sites/default/files/publications/ISC%20Violence%20in%20%20the%20Federal%20Workplace%20Guide%20April%202013.pdf), and The Joint Commission (https://www.jointcommission.org/workplace_violence.aspx).

In long-term care settings, such as nursing homes, and shorter-term care settings, such as rehabilitation facilities, agitation may stem from causes related to a head injury or dementia or from living in an unfamiliar environment. Assessment can be accomplished using a formal scale (eg, the ABS), as well as by identifying potential underlying health-related factors that can lead to agitation, such as pain, an infection, bowel and bladder issues, seizures, wounds, endocrine anomalies, cardiac or pulmonary problems, gastrointestinal dysfunction, and metabolic abnormalities.³

Modify the environment. For this population, a primary approach involves modifying the environment to decrease the likelihood of agitation. This may involve decreasing noise or light or ensuring adequate levels of stimulation. Preventing disorientation can be addressed through verbal and visual reminders of the date, schedule, etc. If a particular situation or activity is identified as a source of agitation, attempts at modifications are called for.³

For patients with dementia, the American Psychiatric Association recommends using the lowest effective dose of an antipsychotic in conjunction with environmental and behavioral measures.¹⁶ A benzodiazepine (lorazepam, oxazepam) may be used for infrequent agitation. Trazodone or a selective serotonin reuptake inhibitor are alternatives for those without psychosis or who are intolerant to antipsychotics.¹⁶

For individuals in a rehabilitation setting, agitation can impede participation in therapy and has been associated with poorer functioning at the time of discharge.³ Agitation can also be disruptive and lead to distress for family members and caregivers, as well as for fellow patients. And because this environment has a greater likelihood of visitors unrelated to the patient being exposed to the aberrant behavior, it is especially important to have established policies and procedures for de-escalation in place.

Home care

More and more FPs and residents are conducting home visits. That’s because the Accreditation Council for Graduate Medical Education Program Requirements for Graduate Medical Education in Family Medicine now include integrating a patient’s care across settings—including the home.¹⁷ Those who do provide home care may find themselves in circumstances similar to those of domestic disputes.

The German study mentioned earlier of more than 800 primary care physicians found that while the vast majority of physicians felt safe in their offices, 66% of female doctors and 34% of male doctors did not feel safe making home visits.¹²

Know the neighborhood. There’s no doubt that working in the home health sector makes one vulnerable. More than 61% of home care workers report workplace violence annually.^18,19 An action plan, as well as established policies and procedures, are essential when making home visits. Prior to the visit, be aware of the community and the location of the nearest police department and hospital.

Unwin and Tatum²⁰ suggest not wearing a white coat or carrying a doctor’s bag so as not to stand out as a physician in neighborhoods where personal safety is an issue. Make sure that your cell phone is fully charged and that there is a GPS mechanism activated that allows others to locate you.²¹ Note the available exits in a patient’s home, and position yourself near them, if possible. Have someone call or text you at predetermined times so that the absence of a response from you will alert someone to send help.

In such situations, it is imperative to remain calm and to use the same verbal de-escalation techniques (TABLE 3^4,6,9,11) that would be used in any other health care setting. It is prudent to set expectations for the patient and family members prior to the home visit regarding the tools and services that will be provided in the home setting and the limitations in terms of scope of practice.

Emergency department

The ED is one of the most common settings for patient agitation and violence within the health care continuum.²² Providers must quickly determine the cause of the agitation while de-escalating the situation and ensuring that they do not miss a pertinent medical finding related to a time-sensitive issue, such as an intracerebral bleed or poisoning.⁷ In addition, the ED is usually heavily populated, providing an opportunity for tremendous collateral human damage should the violence escalate or weapons be deployed. The upside is that many EDs are now staffed with security personnel and, depending on the community, police officers may be on the premises or in the vicinity.²²

Avoid wearing a white coat or carrying a doctor's bag when doing a home visit so as not to stand out as a physician in neighborhoods where personal safety is an issue.

Etiologies for agitation in the ED can range from ingestion of unknown or unidentified substances to psychiatric or medical conditions. Knowledge of etiology is necessary prior to initiation of treatment.⁴

As in other settings, the safety of the patient and others present is of utmost importance. Key recommendations for managing agitated patients in the ED include: ⁴

1. Have an established plan for the management of agitated patients.
2. Identify signs of agitation early, and complete an agitation rating scale.
3. Attempt verbal de-escalation before using medication whenever possible.
4. Employ a “show of concern” rather than “a show of force” in response to escalating agitation/violence. Doing so can strengthen the perception that interventions are coming from a place of caring.
5. Use physical restraint as a last resort. When used, it should be with the intention of protecting the patient and those present, rather than as punishment.

Inpatient units

Unlike the ED, patients on units generally have a working diagnosis, and the provider has some background information with which to work, such as laboratory test results and radiology reports, facilitating more expedient and accurate situational assessment. However, the recommendations for assessment and early identification, as described for the ED, still apply.

If a provider finds him- or herself in an escalating situation, the call bells located in the rooms are of use. An alternative is to call out for help from someone in the hallway. One needs to be aware of the current policies and procedures for de-escalation, as some facilities have a specific “code” that is called for such occasions.¹⁹

Postop delirium is a common cause of agitation in the inpatient setting. Ng and colleagues¹¹ recommend a cognitive assessment before surgery to establish a baseline in order to determine the risk for delirium after surgery. Additionally, the FP must remain aware of preexisting conditions that may surface during a hospital stay, such as dehydration or unrecognized alcohol or medication withdrawal.

A "show of concern" rather than a "show of force" can strengthen the perception that interventions are coming from a place of caring.

Medication choice should be based on the type of delirium. Hyperactive delirium (restlessness, emotional lability, hallucinations) and mixed delirium (a combination of signs of hyperactive and hypoactive dementia) both hold the potential for agitation and even violence. The approach to hyperactive delirium includes consideration of an antipsychotic medication, although the efficacy of antipsychotics is considered controversial. In the case of mixed delirium, behavioral and environmental modifications are useful (eg, reducing noise and early ambulation).¹¹

No medications are registered with the US Food and Drug Administration for the management of delirium, and it is suggested that antipsychotics be considered only when other, less invasive, strategies have been attempted.²³

Regardless of the setting in which FPs work, witnessing or being directly involved in a traumatic event puts one at risk for symptoms—or a full diagnosis—of posttraumatic stress disorder (PTSD), acute stress disorder, or anxiety or mood disorders.^24,25 Although findings vary, studies have found that as many as 12% of ED personnel meet the criteria for PTSD^26,27 and 12% to 15% report having been threatened physically.^28,29 More than half of physicians in another study had witnessed a physical attack.³⁰

Physicians and other health care personnel who have experienced a traumatic incident, or offered help to another during an incident, may attempt to cope through avoidance, cutting down on work hours, leaving the work setting in which the event took place, or leaving the profession altogether.^29,31,32

There is a paucity of methodologically sound research with regard to prevention and treatment of PTSD symptoms in this population.²⁴ According to a 2002 Cochrane review, the effectiveness of individual, single-session debriefing does not have solid research support,³³ and there are concerns about potential harms due to reliving the traumatic event when sessions are led by poorly trained debriefing staff.^34-36

Critical incident stress debriefing (CISD), however, holds promise in terms of facilitating a return to pretrauma functioning based on studies of first responders.^34,35 This may be because CISD follows a specific protocol and that group sessions may capitalize on the social support/camaraderie within a group that has undergone a traumatic event.^34,35 It is important that those providing debriefing and support be well-trained.³⁵

Debriefing, however, is not always sufficient, and those who appear to be affected on an ongoing basis may require individual treatment for PTSD symptoms. Evidence-based treatments for PTSD, such as trauma-focused psychotherapy and/or pharmacotherapy, may be considered³⁷ (TABLE 4^24,34,38).

Ongoing support in the workplace. The Cleveland Clinic has developed a “Code Lavender” to combat stress in the workplace. Like a Code Blue for medical emergencies, a Code Lavender is called when a health care worker is in need of emotional or spiritual support.³⁸ A provider who initiates the call is met by a team of holistic nurses within 30 minutes. The team provides Reiki and massage, healthy snacks and water, and lavender arm bands to remind the individual to relax for the rest of the day. Further opportunities for spiritual support, mindfulness training, counseling, and yoga may also be made available.

CASE  Sensing that the situation with my patient might escalate, I lowered my voice, relaxed my shoulders, leaned casually against the desk, and asked him to tell me how I could best help him. As he spoke, I offered him a seat (by gesturing to the chair). I did this for 2 reasons: to move him away from blocking my exit from the room, and to put him at a lower level than me so that he was entirely in my view. I didn’t interrupt him as he spoke. I just nodded or tilted my head to show I was listening. In my mind, I played out the various scenarios that could ensue.

Like a Code Blue for medical emergencies, a Code Lavender is called when a health care worker is in need of emotional or spiritual support.

Fortunately, I was able to get him to relax enough for an assessment, which involved a more relevant history and the exam, which he agreed to once an aide had come into the room. He did not exhibit the concerning signs of flushed skin, dilated pupils, shallow rapid respirations, or perspiration. He did have a comorbid behavioral health issue, which we were able to address. His earlier behavioral indicators of agitation were controlled with verbal and physical cues on my part. Our conversation didn't reveal an intent to harm himself or others. In this case, physical restraints were not required. Throughout the encounter the door was left open, and the patient was reminded that we were there to help.

Once he left, I made the relevant notes in the chart regarding his agitated state at the start of the visit and his final state at the end of the visit so as to assist any other providers. We (TIM, MG) also held a quick debrief after the encounter with the office staff and decided that we needed to create a policy and protocol regarding how to handle such situations in the future.

CORRESPONDENCE
Tochi Iroku-Malize, MD, MPH, MBA, Family Medicine Department, Southside Hospital, 301 East Main Street, Bay Shore, NY 11706; [email protected].

CASE A 40-year-old man came to our office slightly agitated. He had an acute illness that was minor in nature. However, he was not interested in answering my questions or undergoing a physical exam. The more I tried to proceed with the visit, the more agitated he became—pacing the room, muttering, avoiding eye contact. I was uncomfortable and knew that the situation could quickly escalate if it was not brought under control.

What steps would you take if this were your patient?

The scene described above occurred several years ago, but more recently, one of the institutions in my (TIM) area was affected by a shooter in the workplace. The apprehension felt by all of us who were on the periphery paled in comparison to what was experienced by those at the scene. The outcome was horrific. Communicating with those directly involved during, and immediately after, the event was heart-wrenching. The trauma that they continue to relive is unimaginable, and some are not yet able to return to work.

Situations involving agitated patients are not uncommon in health care settings, although ones that escalate to the level of a shooting are. And no matter where on the spectrum an incident involving an agitated patient falls, it can leave those involved with various levels of physical, emotional, and psychological harm. It can also leave everyone asking themselves: “How can I better prepare for such occurrences?”

This article offers some answers by providing tips and guidelines for handling agitated and/or violent patients in various settings.

[polldaddy:9948472]

Defining the problem, assessing its severity

Between 2011 and 2013, workplace assaults ranged from 23,540 and 25,630 annually, with 70% to 74% occurring in health care and social service settings.^1,2

Agitation is defined as a state that may include inattention, disinhibition, emotional lability, impulsivity, motor restlessness, and aggression.^3,4 Violence in a clinical setting may be seen as an extreme expression of agitation sufficient enough to cause harm to an individual or damage to an object.^5,6

The causes of agitation can be grouped into categories: those due to a general medical condition, those due to a psychiatric condition, and those due to drug intoxication and/or withdrawal.⁷ We have chosen to add a fourth category—iatrogenic (see TABLE 1^3,4,7-9). They are not distinct categories, as there is sometimes overlap among areas.

Determining the level of agitation. Various scales and approaches can help determine the level of agitation in a patient (eg, the Agitated Behavior Scale [ABS; FIGURE];⁵ the Behavioral Activity Rating Scale [BARS]¹⁰) and the risk for violence (eg, the ABC violence risk assessment, TABLE 2⁸).

Scales like the ABS should be employed as soon as a patient shows signs of agitation sufficient to warrant intervention. The idea is for the family physician (FP) to be familiar enough with the tool to be able to mentally check it off, fill it out when time permits, and keep it in the patient’s chart. The first version of the form serves as a baseline so that if care is handed off to another provider, that provider can monitor whether signs and symptoms are improving or worsening.

Setting often drives the solution

Much of the evidence-based research on managing patient agitation and violence stems from inpatient psychiatric and emergency department (ED) settings. To make other health care providers aware of the experience gained in those settings, the American Association for Emergency Psychiatry created Project BETA (Best Practices in Evaluation and Treatment of Agitation). This project is designed to help promote consistency across health care settings and specialties in the way clinicians respond to agitated patients and to emphasize for all health care providers the availability of more than just pharmacologic approaches.⁷

De-escalating the situation. General tenets of de-escalation apply across practice settings. Among them:

• Stay calm. Avoid aggressive postures and prolonged eye contact.
• Be nonconfrontational. Acknowledge the patient’s frustration/perceptions and ask open-ended questions.
• Assess available resources such as clinical team members, family members, and silent alarms.
• Manage the situation and the patient’s underlying issues/diagnoses. This includes mobilizing other patients to avoid collateral damage and exploring solutions with the patient.

For more on de-escalation tools, see (TABLE 3^4,6,9,11).

Your setting matters. It’s worth noting that the settings in which clinicians practice greatly influence the resources available to de-escalate a situation and ensure the safety of the patient and others.⁷ The review that follows provides some issues—and tips—that are unique to different practice settings.

Ambulatory settings

Sim and colleagues⁹ noted that aggressive behavior in the general practice setting may stem not only from factors related to the patient’s own physical or psychological discomfort, but from patients feeling that they are being treated unfairly, whether it be because of wait times, uncomfortable waiting conditions, or something else. A number of international studies have shown high rates of abuse toward FPs.^9,12 Of 831 primary care physicians surveyed in a German study, close to three-quarters indicated that within the last year, they had experienced aggression (ranging from verbal abuse and threats to physical violence and property damage) from a patient.¹² This statistic increased to 91% when it included the length of their career.

Between 2011 and 2013, 7 out of 10 workplace assaults occurred in health care and social service settings.

Bell¹³ suggests that physicians be aware that transference and countertransference issues are often at play when dealing with hostile or potentially violent patients. Suggestions to prevent aggression include some practice-level approaches (eg, providing waiting room distractions, making patients aware of potential delays), as well as being aware of nonverbal cues suggesting increased agitation (eg, clenched fists, crossed arms, chin thrusts, finger pointing).⁹

Group practice

An FP who practices with other health care providers and clinical staff has a built-in team that can assist with de-escalation. When meeting with a patient who has a history of violence or agitation in an exam room or office, try to ensure that you can get to an exit quickly if necessary. Also, alert staff to any concerns, and have a system for at least one staff member to check in periodically during the visit.

It is also helpful to develop an evacuation plan and create a “panic room” or “safe zone” for emergencies.^14,15 Such a space may be nothing more than an area or room for staff to gather. It should have access to the police or other emergency services via a land and/or cell phone line.

Solo practice

If you practice alone, institute safeguards whereby a colleague (at a different practice, building, or location) can be alerted if concerns arise. In addition, consider the following precautions: locking the door when alone after hours, screening potential patients, having a way to call for help (keep the number for the local police station and ED readily available), prohibiting potential weapons (as some states allow them to be carried), and learning some form of self-defense.¹⁵

Ensure that agitated patients are not positioned between you and the exit so that you can quickly escape if necessary.

Resources exist that offer guidelines for developing policies and procedures, checklists, and sample incident forms (eg, the International Association for Healthcare Security and Safety; iahss.org). Other organizations that can help with the development of a preparedness plan include the Occupational Safety and Health Administration (https://www.osha.gov/SLTC/workplaceviolence/evaluation.html), the Department of Homeland Security (https://www.dhs.gov/sites/default/files/publications/ISC%20Violence%20in%20%20the%20Federal%20Workplace%20Guide%20April%202013.pdf), and The Joint Commission (https://www.jointcommission.org/workplace_violence.aspx).

In long-term care settings, such as nursing homes, and shorter-term care settings, such as rehabilitation facilities, agitation may stem from causes related to a head injury or dementia or from living in an unfamiliar environment. Assessment can be accomplished using a formal scale (eg, the ABS), as well as by identifying potential underlying health-related factors that can lead to agitation, such as pain, an infection, bowel and bladder issues, seizures, wounds, endocrine anomalies, cardiac or pulmonary problems, gastrointestinal dysfunction, and metabolic abnormalities.³

Modify the environment. For this population, a primary approach involves modifying the environment to decrease the likelihood of agitation. This may involve decreasing noise or light or ensuring adequate levels of stimulation. Preventing disorientation can be addressed through verbal and visual reminders of the date, schedule, etc. If a particular situation or activity is identified as a source of agitation, attempts at modifications are called for.³

For patients with dementia, the American Psychiatric Association recommends using the lowest effective dose of an antipsychotic in conjunction with environmental and behavioral measures.¹⁶ A benzodiazepine (lorazepam, oxazepam) may be used for infrequent agitation. Trazodone or a selective serotonin reuptake inhibitor are alternatives for those without psychosis or who are intolerant to antipsychotics.¹⁶

For individuals in a rehabilitation setting, agitation can impede participation in therapy and has been associated with poorer functioning at the time of discharge.³ Agitation can also be disruptive and lead to distress for family members and caregivers, as well as for fellow patients. And because this environment has a greater likelihood of visitors unrelated to the patient being exposed to the aberrant behavior, it is especially important to have established policies and procedures for de-escalation in place.

Home care

More and more FPs and residents are conducting home visits. That’s because the Accreditation Council for Graduate Medical Education Program Requirements for Graduate Medical Education in Family Medicine now include integrating a patient’s care across settings—including the home.¹⁷ Those who do provide home care may find themselves in circumstances similar to those of domestic disputes.

The German study mentioned earlier of more than 800 primary care physicians found that while the vast majority of physicians felt safe in their offices, 66% of female doctors and 34% of male doctors did not feel safe making home visits.¹²

Know the neighborhood. There’s no doubt that working in the home health sector makes one vulnerable. More than 61% of home care workers report workplace violence annually.^18,19 An action plan, as well as established policies and procedures, are essential when making home visits. Prior to the visit, be aware of the community and the location of the nearest police department and hospital.

Unwin and Tatum²⁰ suggest not wearing a white coat or carrying a doctor’s bag so as not to stand out as a physician in neighborhoods where personal safety is an issue. Make sure that your cell phone is fully charged and that there is a GPS mechanism activated that allows others to locate you.²¹ Note the available exits in a patient’s home, and position yourself near them, if possible. Have someone call or text you at predetermined times so that the absence of a response from you will alert someone to send help.

In such situations, it is imperative to remain calm and to use the same verbal de-escalation techniques (TABLE 3^4,6,9,11) that would be used in any other health care setting. It is prudent to set expectations for the patient and family members prior to the home visit regarding the tools and services that will be provided in the home setting and the limitations in terms of scope of practice.

Emergency department

The ED is one of the most common settings for patient agitation and violence within the health care continuum.²² Providers must quickly determine the cause of the agitation while de-escalating the situation and ensuring that they do not miss a pertinent medical finding related to a time-sensitive issue, such as an intracerebral bleed or poisoning.⁷ In addition, the ED is usually heavily populated, providing an opportunity for tremendous collateral human damage should the violence escalate or weapons be deployed. The upside is that many EDs are now staffed with security personnel and, depending on the community, police officers may be on the premises or in the vicinity.²²

Avoid wearing a white coat or carrying a doctor's bag when doing a home visit so as not to stand out as a physician in neighborhoods where personal safety is an issue.

Etiologies for agitation in the ED can range from ingestion of unknown or unidentified substances to psychiatric or medical conditions. Knowledge of etiology is necessary prior to initiation of treatment.⁴

As in other settings, the safety of the patient and others present is of utmost importance. Key recommendations for managing agitated patients in the ED include: ⁴

1. Have an established plan for the management of agitated patients.
2. Identify signs of agitation early, and complete an agitation rating scale.
3. Attempt verbal de-escalation before using medication whenever possible.
4. Employ a “show of concern” rather than “a show of force” in response to escalating agitation/violence. Doing so can strengthen the perception that interventions are coming from a place of caring.
5. Use physical restraint as a last resort. When used, it should be with the intention of protecting the patient and those present, rather than as punishment.

Inpatient units

Unlike the ED, patients on units generally have a working diagnosis, and the provider has some background information with which to work, such as laboratory test results and radiology reports, facilitating more expedient and accurate situational assessment. However, the recommendations for assessment and early identification, as described for the ED, still apply.

If a provider finds him- or herself in an escalating situation, the call bells located in the rooms are of use. An alternative is to call out for help from someone in the hallway. One needs to be aware of the current policies and procedures for de-escalation, as some facilities have a specific “code” that is called for such occasions.¹⁹

Postop delirium is a common cause of agitation in the inpatient setting. Ng and colleagues¹¹ recommend a cognitive assessment before surgery to establish a baseline in order to determine the risk for delirium after surgery. Additionally, the FP must remain aware of preexisting conditions that may surface during a hospital stay, such as dehydration or unrecognized alcohol or medication withdrawal.

A "show of concern" rather than a "show of force" can strengthen the perception that interventions are coming from a place of caring.

Medication choice should be based on the type of delirium. Hyperactive delirium (restlessness, emotional lability, hallucinations) and mixed delirium (a combination of signs of hyperactive and hypoactive dementia) both hold the potential for agitation and even violence. The approach to hyperactive delirium includes consideration of an antipsychotic medication, although the efficacy of antipsychotics is considered controversial. In the case of mixed delirium, behavioral and environmental modifications are useful (eg, reducing noise and early ambulation).¹¹

No medications are registered with the US Food and Drug Administration for the management of delirium, and it is suggested that antipsychotics be considered only when other, less invasive, strategies have been attempted.²³

Regardless of the setting in which FPs work, witnessing or being directly involved in a traumatic event puts one at risk for symptoms—or a full diagnosis—of posttraumatic stress disorder (PTSD), acute stress disorder, or anxiety or mood disorders.^24,25 Although findings vary, studies have found that as many as 12% of ED personnel meet the criteria for PTSD^26,27 and 12% to 15% report having been threatened physically.^28,29 More than half of physicians in another study had witnessed a physical attack.³⁰

Physicians and other health care personnel who have experienced a traumatic incident, or offered help to another during an incident, may attempt to cope through avoidance, cutting down on work hours, leaving the work setting in which the event took place, or leaving the profession altogether.^29,31,32

There is a paucity of methodologically sound research with regard to prevention and treatment of PTSD symptoms in this population.²⁴ According to a 2002 Cochrane review, the effectiveness of individual, single-session debriefing does not have solid research support,³³ and there are concerns about potential harms due to reliving the traumatic event when sessions are led by poorly trained debriefing staff.^34-36

Critical incident stress debriefing (CISD), however, holds promise in terms of facilitating a return to pretrauma functioning based on studies of first responders.^34,35 This may be because CISD follows a specific protocol and that group sessions may capitalize on the social support/camaraderie within a group that has undergone a traumatic event.^34,35 It is important that those providing debriefing and support be well-trained.³⁵

Debriefing, however, is not always sufficient, and those who appear to be affected on an ongoing basis may require individual treatment for PTSD symptoms. Evidence-based treatments for PTSD, such as trauma-focused psychotherapy and/or pharmacotherapy, may be considered³⁷ (TABLE 4^24,34,38).

Ongoing support in the workplace. The Cleveland Clinic has developed a “Code Lavender” to combat stress in the workplace. Like a Code Blue for medical emergencies, a Code Lavender is called when a health care worker is in need of emotional or spiritual support.³⁸ A provider who initiates the call is met by a team of holistic nurses within 30 minutes. The team provides Reiki and massage, healthy snacks and water, and lavender arm bands to remind the individual to relax for the rest of the day. Further opportunities for spiritual support, mindfulness training, counseling, and yoga may also be made available.

CASE  Sensing that the situation with my patient might escalate, I lowered my voice, relaxed my shoulders, leaned casually against the desk, and asked him to tell me how I could best help him. As he spoke, I offered him a seat (by gesturing to the chair). I did this for 2 reasons: to move him away from blocking my exit from the room, and to put him at a lower level than me so that he was entirely in my view. I didn’t interrupt him as he spoke. I just nodded or tilted my head to show I was listening. In my mind, I played out the various scenarios that could ensue.

Like a Code Blue for medical emergencies, a Code Lavender is called when a health care worker is in need of emotional or spiritual support.

Fortunately, I was able to get him to relax enough for an assessment, which involved a more relevant history and the exam, which he agreed to once an aide had come into the room. He did not exhibit the concerning signs of flushed skin, dilated pupils, shallow rapid respirations, or perspiration. He did have a comorbid behavioral health issue, which we were able to address. His earlier behavioral indicators of agitation were controlled with verbal and physical cues on my part. Our conversation didn't reveal an intent to harm himself or others. In this case, physical restraints were not required. Throughout the encounter the door was left open, and the patient was reminded that we were there to help.

Once he left, I made the relevant notes in the chart regarding his agitated state at the start of the visit and his final state at the end of the visit so as to assist any other providers. We (TIM, MG) also held a quick debrief after the encounter with the office staff and decided that we needed to create a policy and protocol regarding how to handle such situations in the future.

CORRESPONDENCE
Tochi Iroku-Malize, MD, MPH, MBA, Family Medicine Department, Southside Hospital, 301 East Main Street, Bay Shore, NY 11706; [email protected].

CASE A 40-year-old man came to our office slightly agitated. He had an acute illness that was minor in nature. However, he was not interested in answering my questions or undergoing a physical exam. The more I tried to proceed with the visit, the more agitated he became—pacing the room, muttering, avoiding eye contact. I was uncomfortable and knew that the situation could quickly escalate if it was not brought under control.

What steps would you take if this were your patient?

The scene described above occurred several years ago, but more recently, one of the institutions in my (TIM) area was affected by a shooter in the workplace. The apprehension felt by all of us who were on the periphery paled in comparison to what was experienced by those at the scene. The outcome was horrific. Communicating with those directly involved during, and immediately after, the event was heart-wrenching. The trauma that they continue to relive is unimaginable, and some are not yet able to return to work.

Situations involving agitated patients are not uncommon in health care settings, although ones that escalate to the level of a shooting are. And no matter where on the spectrum an incident involving an agitated patient falls, it can leave those involved with various levels of physical, emotional, and psychological harm. It can also leave everyone asking themselves: “How can I better prepare for such occurrences?”

This article offers some answers by providing tips and guidelines for handling agitated and/or violent patients in various settings.

[polldaddy:9948472]

Defining the problem, assessing its severity

Between 2011 and 2013, workplace assaults ranged from 23,540 and 25,630 annually, with 70% to 74% occurring in health care and social service settings.^1,2

Agitation is defined as a state that may include inattention, disinhibition, emotional lability, impulsivity, motor restlessness, and aggression.^3,4 Violence in a clinical setting may be seen as an extreme expression of agitation sufficient enough to cause harm to an individual or damage to an object.^5,6

The causes of agitation can be grouped into categories: those due to a general medical condition, those due to a psychiatric condition, and those due to drug intoxication and/or withdrawal.⁷ We have chosen to add a fourth category—iatrogenic (see TABLE 1^3,4,7-9). They are not distinct categories, as there is sometimes overlap among areas.

Determining the level of agitation. Various scales and approaches can help determine the level of agitation in a patient (eg, the Agitated Behavior Scale [ABS; FIGURE];⁵ the Behavioral Activity Rating Scale [BARS]¹⁰) and the risk for violence (eg, the ABC violence risk assessment, TABLE 2⁸).

Scales like the ABS should be employed as soon as a patient shows signs of agitation sufficient to warrant intervention. The idea is for the family physician (FP) to be familiar enough with the tool to be able to mentally check it off, fill it out when time permits, and keep it in the patient’s chart. The first version of the form serves as a baseline so that if care is handed off to another provider, that provider can monitor whether signs and symptoms are improving or worsening.

Setting often drives the solution

Much of the evidence-based research on managing patient agitation and violence stems from inpatient psychiatric and emergency department (ED) settings. To make other health care providers aware of the experience gained in those settings, the American Association for Emergency Psychiatry created Project BETA (Best Practices in Evaluation and Treatment of Agitation). This project is designed to help promote consistency across health care settings and specialties in the way clinicians respond to agitated patients and to emphasize for all health care providers the availability of more than just pharmacologic approaches.⁷

De-escalating the situation. General tenets of de-escalation apply across practice settings. Among them:

• Stay calm. Avoid aggressive postures and prolonged eye contact.
• Be nonconfrontational. Acknowledge the patient’s frustration/perceptions and ask open-ended questions.
• Assess available resources such as clinical team members, family members, and silent alarms.
• Manage the situation and the patient’s underlying issues/diagnoses. This includes mobilizing other patients to avoid collateral damage and exploring solutions with the patient.

For more on de-escalation tools, see (TABLE 3^4,6,9,11).

Your setting matters. It’s worth noting that the settings in which clinicians practice greatly influence the resources available to de-escalate a situation and ensure the safety of the patient and others.⁷ The review that follows provides some issues—and tips—that are unique to different practice settings.

Ambulatory settings

Sim and colleagues⁹ noted that aggressive behavior in the general practice setting may stem not only from factors related to the patient’s own physical or psychological discomfort, but from patients feeling that they are being treated unfairly, whether it be because of wait times, uncomfortable waiting conditions, or something else. A number of international studies have shown high rates of abuse toward FPs.^9,12 Of 831 primary care physicians surveyed in a German study, close to three-quarters indicated that within the last year, they had experienced aggression (ranging from verbal abuse and threats to physical violence and property damage) from a patient.¹² This statistic increased to 91% when it included the length of their career.

Between 2011 and 2013, 7 out of 10 workplace assaults occurred in health care and social service settings.

Bell¹³ suggests that physicians be aware that transference and countertransference issues are often at play when dealing with hostile or potentially violent patients. Suggestions to prevent aggression include some practice-level approaches (eg, providing waiting room distractions, making patients aware of potential delays), as well as being aware of nonverbal cues suggesting increased agitation (eg, clenched fists, crossed arms, chin thrusts, finger pointing).⁹

Group practice

An FP who practices with other health care providers and clinical staff has a built-in team that can assist with de-escalation. When meeting with a patient who has a history of violence or agitation in an exam room or office, try to ensure that you can get to an exit quickly if necessary. Also, alert staff to any concerns, and have a system for at least one staff member to check in periodically during the visit.

It is also helpful to develop an evacuation plan and create a “panic room” or “safe zone” for emergencies.^14,15 Such a space may be nothing more than an area or room for staff to gather. It should have access to the police or other emergency services via a land and/or cell phone line.

Solo practice

If you practice alone, institute safeguards whereby a colleague (at a different practice, building, or location) can be alerted if concerns arise. In addition, consider the following precautions: locking the door when alone after hours, screening potential patients, having a way to call for help (keep the number for the local police station and ED readily available), prohibiting potential weapons (as some states allow them to be carried), and learning some form of self-defense.¹⁵

Ensure that agitated patients are not positioned between you and the exit so that you can quickly escape if necessary.

Resources exist that offer guidelines for developing policies and procedures, checklists, and sample incident forms (eg, the International Association for Healthcare Security and Safety; iahss.org). Other organizations that can help with the development of a preparedness plan include the Occupational Safety and Health Administration (https://www.osha.gov/SLTC/workplaceviolence/evaluation.html), the Department of Homeland Security (https://www.dhs.gov/sites/default/files/publications/ISC%20Violence%20in%20%20the%20Federal%20Workplace%20Guide%20April%202013.pdf), and The Joint Commission (https://www.jointcommission.org/workplace_violence.aspx).

In long-term care settings, such as nursing homes, and shorter-term care settings, such as rehabilitation facilities, agitation may stem from causes related to a head injury or dementia or from living in an unfamiliar environment. Assessment can be accomplished using a formal scale (eg, the ABS), as well as by identifying potential underlying health-related factors that can lead to agitation, such as pain, an infection, bowel and bladder issues, seizures, wounds, endocrine anomalies, cardiac or pulmonary problems, gastrointestinal dysfunction, and metabolic abnormalities.³

Modify the environment. For this population, a primary approach involves modifying the environment to decrease the likelihood of agitation. This may involve decreasing noise or light or ensuring adequate levels of stimulation. Preventing disorientation can be addressed through verbal and visual reminders of the date, schedule, etc. If a particular situation or activity is identified as a source of agitation, attempts at modifications are called for.³

For patients with dementia, the American Psychiatric Association recommends using the lowest effective dose of an antipsychotic in conjunction with environmental and behavioral measures.¹⁶ A benzodiazepine (lorazepam, oxazepam) may be used for infrequent agitation. Trazodone or a selective serotonin reuptake inhibitor are alternatives for those without psychosis or who are intolerant to antipsychotics.¹⁶

For individuals in a rehabilitation setting, agitation can impede participation in therapy and has been associated with poorer functioning at the time of discharge.³ Agitation can also be disruptive and lead to distress for family members and caregivers, as well as for fellow patients. And because this environment has a greater likelihood of visitors unrelated to the patient being exposed to the aberrant behavior, it is especially important to have established policies and procedures for de-escalation in place.

Home care

More and more FPs and residents are conducting home visits. That’s because the Accreditation Council for Graduate Medical Education Program Requirements for Graduate Medical Education in Family Medicine now include integrating a patient’s care across settings—including the home.¹⁷ Those who do provide home care may find themselves in circumstances similar to those of domestic disputes.

The German study mentioned earlier of more than 800 primary care physicians found that while the vast majority of physicians felt safe in their offices, 66% of female doctors and 34% of male doctors did not feel safe making home visits.¹²

Know the neighborhood. There’s no doubt that working in the home health sector makes one vulnerable. More than 61% of home care workers report workplace violence annually.^18,19 An action plan, as well as established policies and procedures, are essential when making home visits. Prior to the visit, be aware of the community and the location of the nearest police department and hospital.

Unwin and Tatum²⁰ suggest not wearing a white coat or carrying a doctor’s bag so as not to stand out as a physician in neighborhoods where personal safety is an issue. Make sure that your cell phone is fully charged and that there is a GPS mechanism activated that allows others to locate you.²¹ Note the available exits in a patient’s home, and position yourself near them, if possible. Have someone call or text you at predetermined times so that the absence of a response from you will alert someone to send help.

In such situations, it is imperative to remain calm and to use the same verbal de-escalation techniques (TABLE 3^4,6,9,11) that would be used in any other health care setting. It is prudent to set expectations for the patient and family members prior to the home visit regarding the tools and services that will be provided in the home setting and the limitations in terms of scope of practice.

Emergency department

The ED is one of the most common settings for patient agitation and violence within the health care continuum.²² Providers must quickly determine the cause of the agitation while de-escalating the situation and ensuring that they do not miss a pertinent medical finding related to a time-sensitive issue, such as an intracerebral bleed or poisoning.⁷ In addition, the ED is usually heavily populated, providing an opportunity for tremendous collateral human damage should the violence escalate or weapons be deployed. The upside is that many EDs are now staffed with security personnel and, depending on the community, police officers may be on the premises or in the vicinity.²²

Avoid wearing a white coat or carrying a doctor's bag when doing a home visit so as not to stand out as a physician in neighborhoods where personal safety is an issue.

Etiologies for agitation in the ED can range from ingestion of unknown or unidentified substances to psychiatric or medical conditions. Knowledge of etiology is necessary prior to initiation of treatment.⁴

As in other settings, the safety of the patient and others present is of utmost importance. Key recommendations for managing agitated patients in the ED include: ⁴

1. Have an established plan for the management of agitated patients.
2. Identify signs of agitation early, and complete an agitation rating scale.
3. Attempt verbal de-escalation before using medication whenever possible.
4. Employ a “show of concern” rather than “a show of force” in response to escalating agitation/violence. Doing so can strengthen the perception that interventions are coming from a place of caring.
5. Use physical restraint as a last resort. When used, it should be with the intention of protecting the patient and those present, rather than as punishment.

Inpatient units

Unlike the ED, patients on units generally have a working diagnosis, and the provider has some background information with which to work, such as laboratory test results and radiology reports, facilitating more expedient and accurate situational assessment. However, the recommendations for assessment and early identification, as described for the ED, still apply.

If a provider finds him- or herself in an escalating situation, the call bells located in the rooms are of use. An alternative is to call out for help from someone in the hallway. One needs to be aware of the current policies and procedures for de-escalation, as some facilities have a specific “code” that is called for such occasions.¹⁹

Postop delirium is a common cause of agitation in the inpatient setting. Ng and colleagues¹¹ recommend a cognitive assessment before surgery to establish a baseline in order to determine the risk for delirium after surgery. Additionally, the FP must remain aware of preexisting conditions that may surface during a hospital stay, such as dehydration or unrecognized alcohol or medication withdrawal.

A "show of concern" rather than a "show of force" can strengthen the perception that interventions are coming from a place of caring.

Medication choice should be based on the type of delirium. Hyperactive delirium (restlessness, emotional lability, hallucinations) and mixed delirium (a combination of signs of hyperactive and hypoactive dementia) both hold the potential for agitation and even violence. The approach to hyperactive delirium includes consideration of an antipsychotic medication, although the efficacy of antipsychotics is considered controversial. In the case of mixed delirium, behavioral and environmental modifications are useful (eg, reducing noise and early ambulation).¹¹

No medications are registered with the US Food and Drug Administration for the management of delirium, and it is suggested that antipsychotics be considered only when other, less invasive, strategies have been attempted.²³

Regardless of the setting in which FPs work, witnessing or being directly involved in a traumatic event puts one at risk for symptoms—or a full diagnosis—of posttraumatic stress disorder (PTSD), acute stress disorder, or anxiety or mood disorders.^24,25 Although findings vary, studies have found that as many as 12% of ED personnel meet the criteria for PTSD^26,27 and 12% to 15% report having been threatened physically.^28,29 More than half of physicians in another study had witnessed a physical attack.³⁰

Physicians and other health care personnel who have experienced a traumatic incident, or offered help to another during an incident, may attempt to cope through avoidance, cutting down on work hours, leaving the work setting in which the event took place, or leaving the profession altogether.^29,31,32

There is a paucity of methodologically sound research with regard to prevention and treatment of PTSD symptoms in this population.²⁴ According to a 2002 Cochrane review, the effectiveness of individual, single-session debriefing does not have solid research support,³³ and there are concerns about potential harms due to reliving the traumatic event when sessions are led by poorly trained debriefing staff.^34-36

Critical incident stress debriefing (CISD), however, holds promise in terms of facilitating a return to pretrauma functioning based on studies of first responders.^34,35 This may be because CISD follows a specific protocol and that group sessions may capitalize on the social support/camaraderie within a group that has undergone a traumatic event.^34,35 It is important that those providing debriefing and support be well-trained.³⁵

Debriefing, however, is not always sufficient, and those who appear to be affected on an ongoing basis may require individual treatment for PTSD symptoms. Evidence-based treatments for PTSD, such as trauma-focused psychotherapy and/or pharmacotherapy, may be considered³⁷ (TABLE 4^24,34,38).

Ongoing support in the workplace. The Cleveland Clinic has developed a “Code Lavender” to combat stress in the workplace. Like a Code Blue for medical emergencies, a Code Lavender is called when a health care worker is in need of emotional or spiritual support.³⁸ A provider who initiates the call is met by a team of holistic nurses within 30 minutes. The team provides Reiki and massage, healthy snacks and water, and lavender arm bands to remind the individual to relax for the rest of the day. Further opportunities for spiritual support, mindfulness training, counseling, and yoga may also be made available.

CASE  Sensing that the situation with my patient might escalate, I lowered my voice, relaxed my shoulders, leaned casually against the desk, and asked him to tell me how I could best help him. As he spoke, I offered him a seat (by gesturing to the chair). I did this for 2 reasons: to move him away from blocking my exit from the room, and to put him at a lower level than me so that he was entirely in my view. I didn’t interrupt him as he spoke. I just nodded or tilted my head to show I was listening. In my mind, I played out the various scenarios that could ensue.

Like a Code Blue for medical emergencies, a Code Lavender is called when a health care worker is in need of emotional or spiritual support.

Fortunately, I was able to get him to relax enough for an assessment, which involved a more relevant history and the exam, which he agreed to once an aide had come into the room. He did not exhibit the concerning signs of flushed skin, dilated pupils, shallow rapid respirations, or perspiration. He did have a comorbid behavioral health issue, which we were able to address. His earlier behavioral indicators of agitation were controlled with verbal and physical cues on my part. Our conversation didn't reveal an intent to harm himself or others. In this case, physical restraints were not required. Throughout the encounter the door was left open, and the patient was reminded that we were there to help.

Once he left, I made the relevant notes in the chart regarding his agitated state at the start of the visit and his final state at the end of the visit so as to assist any other providers. We (TIM, MG) also held a quick debrief after the encounter with the office staff and decided that we needed to create a policy and protocol regarding how to handle such situations in the future.

CORRESPONDENCE
Tochi Iroku-Malize, MD, MPH, MBA, Family Medicine Department, Southside Hospital, 301 East Main Street, Bay Shore, NY 11706; [email protected].