1. Flat, distinct, discolored area usually less than 1 cm wide without change in skin texture or thickness.

Diagnosis: Macule

For more information on this case, see “Could Lesion Become a Pain in the Neck?” Clin Rev. 2015;25(7):W1

For the next photograph, proceed to the next page >>

2. Solid or cystic raised area less than 1 cm wide.

Diagnosis: Papule

For more information on this case, see “Irritated and Downright Painful.” Clin Rev. 2014;24(11):W3.

For the next photograph, proceed to the next page >>

3. Collection of pus in any part of the body typically accompanied by swelling and inflammation.

Diagnosis: Skin abscesses/Boils

For more information on this case, see “What Actually Qualifies as a ‘Boil’?” Clin Rev. 2013;23(8):W4.

For the next photograph, proceed to the next page >>

4. Resulting from chronic irritation from conditions like eczema or from continuous rubbing or scratching, the skin becomes thickened and leathery.

Diagnosis: Lichenification

For more information on Figure 4a, see “Leg Lesion Represents a Vicious Cycle.” Clin Rev. 2012;22(12):W5. 

1. Flat, distinct, discolored area usually less than 1 cm wide without change in skin texture or thickness.

Diagnosis: Macule

For more information on this case, see “Could Lesion Become a Pain in the Neck?” Clin Rev. 2015;25(7):W1

For the next photograph, proceed to the next page >>

2. Solid or cystic raised area less than 1 cm wide.

Diagnosis: Papule

For more information on this case, see “Irritated and Downright Painful.” Clin Rev. 2014;24(11):W3.

For the next photograph, proceed to the next page >>

3. Collection of pus in any part of the body typically accompanied by swelling and inflammation.

Diagnosis: Skin abscesses/Boils

For more information on this case, see “What Actually Qualifies as a ‘Boil’?” Clin Rev. 2013;23(8):W4.

For the next photograph, proceed to the next page >>

4. Resulting from chronic irritation from conditions like eczema or from continuous rubbing or scratching, the skin becomes thickened and leathery.

Diagnosis: Lichenification

For more information on Figure 4a, see “Leg Lesion Represents a Vicious Cycle.” Clin Rev. 2012;22(12):W5. 

1. Flat, distinct, discolored area usually less than 1 cm wide without change in skin texture or thickness.

Diagnosis: Macule

For more information on this case, see “Could Lesion Become a Pain in the Neck?” Clin Rev. 2015;25(7):W1

For the next photograph, proceed to the next page >>

2. Solid or cystic raised area less than 1 cm wide.

Diagnosis: Papule

For more information on this case, see “Irritated and Downright Painful.” Clin Rev. 2014;24(11):W3.

For the next photograph, proceed to the next page >>

3. Collection of pus in any part of the body typically accompanied by swelling and inflammation.

Diagnosis: Skin abscesses/Boils

For more information on this case, see “What Actually Qualifies as a ‘Boil’?” Clin Rev. 2013;23(8):W4.

For the next photograph, proceed to the next page >>

4. Resulting from chronic irritation from conditions like eczema or from continuous rubbing or scratching, the skin becomes thickened and leathery.

Diagnosis: Lichenification

For more information on Figure 4a, see “Leg Lesion Represents a Vicious Cycle.” Clin Rev. 2012;22(12):W5. 

SAN FRANCISCO – Hold off on surgery in patients with presumed septic arthritis if they’re not otherwise too sick and their cultures don’t grow out a pathogenic organism within 48 hours.

The reason is because those patients are likely to have synovial fluid that was contaminated during collection, not a true joint infection.

The advice comes from investigators at Beth Israel Deaconess Medical Center, Boston, who compared 425 monoarticular septic arthritis cases with 25 cases that turned out to be false positives due to synovial fluid contamination; most of the false positives got antibiotics, and three (12%) had joint operations that they did not need.

“Rushing off to the operating room isn’t” always warranted. “You can suspect contamination if patients have milder disease manifestations and cultures grow late,” said investigator Dr. Robert H. Shmerling, clinical chief of Beth Israel’s division of rheumatology.

The findings help determine when – and when not – to be aggressive with patients who present with what looks to be septic arthritis. “No one’s ever really looked at this before,” he said at the annual meeting of the American College of Rheumatology.

“These are very different sorts of patients. Look at the full range of clinical characteristics and lab values, not just the synovial fluid tap. If contamination is suspected, you can wait until the cultures come back or possibly do serial taps before going to the operating room,” said coinvestigator Clara Zhu, a medical student at Boston University.

Patients with true joint infections had higher mean peripheral polymorphonuclear neutrophil percentages (78% vs. 68% in false positives) and synovial fluid polymorphonuclear cell percentages (88% vs. 74% in false positives). True cases also had substantially higher mean synovial fluid white blood cell counts (88,000 vs. 29,000).

Unlike true cases, contaminated synovial fluid took about 4 days to grow out a positive culture, and the most common organisms by far were coagulase-negative staphylococci, typically normal skin bacteria.

Patients with contaminated fluid also tended to be older (71 vs. 59 years), with fewer prior admissions. They were far less likely to have had recent joint procedures and histories of septic arthritis but were more likely to have synovial fluid crystals, as in gout. False positives also left the hospital sooner (7 vs. 11 days) and were less likely to be readmitted within 2 months. They were also less likely to present with fever (19% vs. 37%) but not significantly so.

This “study suggests that contaminated synovial fluid is found in up to 6% of patients with suspected septic arthritis and positive synovial fluid or synovial biopsy cultures. We recommend a conservative approach for patients with ... mild disease manifestations and no growth of pathogenic organisms within the first 48 hours,” the investigators concluded.

The authors have no disclosures, and there was no outside funding for the work.

[email protected]

SAN FRANCISCO – Hold off on surgery in patients with presumed septic arthritis if they’re not otherwise too sick and their cultures don’t grow out a pathogenic organism within 48 hours.

The reason is because those patients are likely to have synovial fluid that was contaminated during collection, not a true joint infection.

The advice comes from investigators at Beth Israel Deaconess Medical Center, Boston, who compared 425 monoarticular septic arthritis cases with 25 cases that turned out to be false positives due to synovial fluid contamination; most of the false positives got antibiotics, and three (12%) had joint operations that they did not need.

“Rushing off to the operating room isn’t” always warranted. “You can suspect contamination if patients have milder disease manifestations and cultures grow late,” said investigator Dr. Robert H. Shmerling, clinical chief of Beth Israel’s division of rheumatology.

The findings help determine when – and when not – to be aggressive with patients who present with what looks to be septic arthritis. “No one’s ever really looked at this before,” he said at the annual meeting of the American College of Rheumatology.

“These are very different sorts of patients. Look at the full range of clinical characteristics and lab values, not just the synovial fluid tap. If contamination is suspected, you can wait until the cultures come back or possibly do serial taps before going to the operating room,” said coinvestigator Clara Zhu, a medical student at Boston University.

Patients with true joint infections had higher mean peripheral polymorphonuclear neutrophil percentages (78% vs. 68% in false positives) and synovial fluid polymorphonuclear cell percentages (88% vs. 74% in false positives). True cases also had substantially higher mean synovial fluid white blood cell counts (88,000 vs. 29,000).

Unlike true cases, contaminated synovial fluid took about 4 days to grow out a positive culture, and the most common organisms by far were coagulase-negative staphylococci, typically normal skin bacteria.

Patients with contaminated fluid also tended to be older (71 vs. 59 years), with fewer prior admissions. They were far less likely to have had recent joint procedures and histories of septic arthritis but were more likely to have synovial fluid crystals, as in gout. False positives also left the hospital sooner (7 vs. 11 days) and were less likely to be readmitted within 2 months. They were also less likely to present with fever (19% vs. 37%) but not significantly so.

This “study suggests that contaminated synovial fluid is found in up to 6% of patients with suspected septic arthritis and positive synovial fluid or synovial biopsy cultures. We recommend a conservative approach for patients with ... mild disease manifestations and no growth of pathogenic organisms within the first 48 hours,” the investigators concluded.

The authors have no disclosures, and there was no outside funding for the work.

[email protected]

SAN FRANCISCO – Hold off on surgery in patients with presumed septic arthritis if they’re not otherwise too sick and their cultures don’t grow out a pathogenic organism within 48 hours.

The reason is because those patients are likely to have synovial fluid that was contaminated during collection, not a true joint infection.

The advice comes from investigators at Beth Israel Deaconess Medical Center, Boston, who compared 425 monoarticular septic arthritis cases with 25 cases that turned out to be false positives due to synovial fluid contamination; most of the false positives got antibiotics, and three (12%) had joint operations that they did not need.

“Rushing off to the operating room isn’t” always warranted. “You can suspect contamination if patients have milder disease manifestations and cultures grow late,” said investigator Dr. Robert H. Shmerling, clinical chief of Beth Israel’s division of rheumatology.

The findings help determine when – and when not – to be aggressive with patients who present with what looks to be septic arthritis. “No one’s ever really looked at this before,” he said at the annual meeting of the American College of Rheumatology.

“These are very different sorts of patients. Look at the full range of clinical characteristics and lab values, not just the synovial fluid tap. If contamination is suspected, you can wait until the cultures come back or possibly do serial taps before going to the operating room,” said coinvestigator Clara Zhu, a medical student at Boston University.

Patients with true joint infections had higher mean peripheral polymorphonuclear neutrophil percentages (78% vs. 68% in false positives) and synovial fluid polymorphonuclear cell percentages (88% vs. 74% in false positives). True cases also had substantially higher mean synovial fluid white blood cell counts (88,000 vs. 29,000).

Unlike true cases, contaminated synovial fluid took about 4 days to grow out a positive culture, and the most common organisms by far were coagulase-negative staphylococci, typically normal skin bacteria.

Patients with contaminated fluid also tended to be older (71 vs. 59 years), with fewer prior admissions. They were far less likely to have had recent joint procedures and histories of septic arthritis but were more likely to have synovial fluid crystals, as in gout. False positives also left the hospital sooner (7 vs. 11 days) and were less likely to be readmitted within 2 months. They were also less likely to present with fever (19% vs. 37%) but not significantly so.

This “study suggests that contaminated synovial fluid is found in up to 6% of patients with suspected septic arthritis and positive synovial fluid or synovial biopsy cultures. We recommend a conservative approach for patients with ... mild disease manifestations and no growth of pathogenic organisms within the first 48 hours,” the investigators concluded.

The authors have no disclosures, and there was no outside funding for the work.

[email protected]

Mechanical removal of a thrombus in addition to usual care is associated with significantly better functional outcomes than usual care in patients who have experienced an acute ischemic stroke, according to a meta-analysis published online Nov. 30 in Journal of the American College of Cardiology.

The analysis of nine trials of usual care with or without mechanical thrombectomy in 2,410 patients showed that those undergoing mechanical thrombectomy had a 45% greater likelihood of achieving a good functional outcome and a 67% greater chance of excellent functional outcome, defined respectively as a modified Rankin scale score of 0-2 or 0-1.

©purestock/thinkstockphotos.com

Researchers observed a nonsignificant trend toward lower all-cause mortality in the mechanical thrombectomy patients, which was also linked with improved recanalization, compared with usual care alone (risk ratio, 1.57; 95% confidence interval, 1.11-2.23; P = .01).

Mechanical thrombectomy did show a nonsignificant increase in the risk of recurrent stroke at 90 days, but this was largely driven by one study, and when that was excluded, the risk was similar between mechanical thrombectomy and no mechanical thrombectomy (J Am Coll Cardiol. 2015;66:2498-505).

“Although mechanical thrombectomy is beneficial, this procedure requires specialized centers of excellence; therefore, the widespread application of this therapy for acute ischemic stroke patients will likely remain limited for the foreseeable future,” wrote Dr. Islam Y. Elgendy of the University of Florida, Gainesville, and coauthors.

One author declared advisory board membership and research funding from private industry, but there were no other conflicts of interest declared.

Mechanical removal of a thrombus in addition to usual care is associated with significantly better functional outcomes than usual care in patients who have experienced an acute ischemic stroke, according to a meta-analysis published online Nov. 30 in Journal of the American College of Cardiology.

The analysis of nine trials of usual care with or without mechanical thrombectomy in 2,410 patients showed that those undergoing mechanical thrombectomy had a 45% greater likelihood of achieving a good functional outcome and a 67% greater chance of excellent functional outcome, defined respectively as a modified Rankin scale score of 0-2 or 0-1.

©purestock/thinkstockphotos.com

Researchers observed a nonsignificant trend toward lower all-cause mortality in the mechanical thrombectomy patients, which was also linked with improved recanalization, compared with usual care alone (risk ratio, 1.57; 95% confidence interval, 1.11-2.23; P = .01).

Mechanical thrombectomy did show a nonsignificant increase in the risk of recurrent stroke at 90 days, but this was largely driven by one study, and when that was excluded, the risk was similar between mechanical thrombectomy and no mechanical thrombectomy (J Am Coll Cardiol. 2015;66:2498-505).

“Although mechanical thrombectomy is beneficial, this procedure requires specialized centers of excellence; therefore, the widespread application of this therapy for acute ischemic stroke patients will likely remain limited for the foreseeable future,” wrote Dr. Islam Y. Elgendy of the University of Florida, Gainesville, and coauthors.

One author declared advisory board membership and research funding from private industry, but there were no other conflicts of interest declared.

Mechanical removal of a thrombus in addition to usual care is associated with significantly better functional outcomes than usual care in patients who have experienced an acute ischemic stroke, according to a meta-analysis published online Nov. 30 in Journal of the American College of Cardiology.

The analysis of nine trials of usual care with or without mechanical thrombectomy in 2,410 patients showed that those undergoing mechanical thrombectomy had a 45% greater likelihood of achieving a good functional outcome and a 67% greater chance of excellent functional outcome, defined respectively as a modified Rankin scale score of 0-2 or 0-1.

©purestock/thinkstockphotos.com

Researchers observed a nonsignificant trend toward lower all-cause mortality in the mechanical thrombectomy patients, which was also linked with improved recanalization, compared with usual care alone (risk ratio, 1.57; 95% confidence interval, 1.11-2.23; P = .01).

Mechanical thrombectomy did show a nonsignificant increase in the risk of recurrent stroke at 90 days, but this was largely driven by one study, and when that was excluded, the risk was similar between mechanical thrombectomy and no mechanical thrombectomy (J Am Coll Cardiol. 2015;66:2498-505).

“Although mechanical thrombectomy is beneficial, this procedure requires specialized centers of excellence; therefore, the widespread application of this therapy for acute ischemic stroke patients will likely remain limited for the foreseeable future,” wrote Dr. Islam Y. Elgendy of the University of Florida, Gainesville, and coauthors.

One author declared advisory board membership and research funding from private industry, but there were no other conflicts of interest declared.

The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) is a new resource designed to help clinicians select the safest and most appropriate peripherally inserted central catheter (PICC) for individual patients.

“How do you decide which catheter is best for your patient? Until now there wasn’t a guide bringing together all of the best available evidence,” says the guide’s lead author Vineet Chopra, MD, MSc, FHM, a hospitalist and assistant professor of medicine at the University of Michigan in Ann Arbor.

“These are among the most commonly performed procedures on any hospitalized patient, and yet, the least studied,” he adds. “We as hospitalists are the physicians who order most of these devices, especially PICCs.”

The guide includes algorithms and color-coded pocket cards to help physicians determine which PICC to choose. The cards can be freely downloaded and printed from the Improve PICC website at the University of Michigan.

The project to develop the guide brought together 15 leading international experts on catheters and their infections and complications, including the authors of existing guidelines, to brainstorm more than 600 clinical scenarios and best evidence-based practice for catheter use using the Rand/UCLA Appropriateness Method. “We also had a patient on the panel, which was important to the clinicians because this patient had actually used many of the devices being discussed,” Dr. Chopra explains.

The guidelines “have the potential to change the game for hospitalists,” Dr. Chopra adds. “There has never before been guidance on using IV devices in hospitalized medical patients, despite the fact that we use these devices every day. Now, for the first time, we not only have guidance but also a tool to benchmark the quality of care provided by doctors when it comes to venous access.”

The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) is a new resource designed to help clinicians select the safest and most appropriate peripherally inserted central catheter (PICC) for individual patients.

“How do you decide which catheter is best for your patient? Until now there wasn’t a guide bringing together all of the best available evidence,” says the guide’s lead author Vineet Chopra, MD, MSc, FHM, a hospitalist and assistant professor of medicine at the University of Michigan in Ann Arbor.

“These are among the most commonly performed procedures on any hospitalized patient, and yet, the least studied,” he adds. “We as hospitalists are the physicians who order most of these devices, especially PICCs.”

The guide includes algorithms and color-coded pocket cards to help physicians determine which PICC to choose. The cards can be freely downloaded and printed from the Improve PICC website at the University of Michigan.

The project to develop the guide brought together 15 leading international experts on catheters and their infections and complications, including the authors of existing guidelines, to brainstorm more than 600 clinical scenarios and best evidence-based practice for catheter use using the Rand/UCLA Appropriateness Method. “We also had a patient on the panel, which was important to the clinicians because this patient had actually used many of the devices being discussed,” Dr. Chopra explains.

The guidelines “have the potential to change the game for hospitalists,” Dr. Chopra adds. “There has never before been guidance on using IV devices in hospitalized medical patients, despite the fact that we use these devices every day. Now, for the first time, we not only have guidance but also a tool to benchmark the quality of care provided by doctors when it comes to venous access.”

The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) is a new resource designed to help clinicians select the safest and most appropriate peripherally inserted central catheter (PICC) for individual patients.

“How do you decide which catheter is best for your patient? Until now there wasn’t a guide bringing together all of the best available evidence,” says the guide’s lead author Vineet Chopra, MD, MSc, FHM, a hospitalist and assistant professor of medicine at the University of Michigan in Ann Arbor.

“These are among the most commonly performed procedures on any hospitalized patient, and yet, the least studied,” he adds. “We as hospitalists are the physicians who order most of these devices, especially PICCs.”

The guide includes algorithms and color-coded pocket cards to help physicians determine which PICC to choose. The cards can be freely downloaded and printed from the Improve PICC website at the University of Michigan.

The project to develop the guide brought together 15 leading international experts on catheters and their infections and complications, including the authors of existing guidelines, to brainstorm more than 600 clinical scenarios and best evidence-based practice for catheter use using the Rand/UCLA Appropriateness Method. “We also had a patient on the panel, which was important to the clinicians because this patient had actually used many of the devices being discussed,” Dr. Chopra explains.

The guidelines “have the potential to change the game for hospitalists,” Dr. Chopra adds. “There has never before been guidance on using IV devices in hospitalized medical patients, despite the fact that we use these devices every day. Now, for the first time, we not only have guidance but also a tool to benchmark the quality of care provided by doctors when it comes to venous access.”

Authors of the IOM’s “Improving Diagnosis in Health Care” report cite problems in communication and limitations in electronic health records behind inaccurate and delayed diagnoses, concluding that the problem of diagnostic errors generally has not been adequately studied.¹

“This problem is significant and serious. Yet we don’t know for sure how often it occurs, how serious it is, or how much it costs,” said the IOM committee’s chair, John Ball, MD, of the American College of Physicians, in a prepared statement. The report concludes there is no easy fix for the problem of diagnostic errors, which are a leading cause of adverse events in hospitals and of malpractice lawsuits for hospitalists, but calls for a major reassessment of the diagnostic process.²

Hospitalist Mangla Gulati, MD, FACP, SFHM, assistant chief medical officer at the University of Maryland Medical Center in Baltimore, says hospitalists would be remiss if they failed to take a closer look at the IOM report. “Diagnostic error is something we haven’t much talked about in medicine,” Dr. Gulati says. “Part of the goal of this report is to actually include the patient in those conversations.” Patients who are rehospitalized, she says, may have been given an incorrect initial diagnosis that was never rectified, or there may have been a failure to communicate important information.

“How many tests do we order where results come back after a patient leaves the hospital?” asks Kedar Mate, MD, senior vice president at the Institute for Healthcare Improvement and a hospitalist at Weill Cornell Medicine in New York City. “How many in-hospital diagnoses are made without all of the available information from outside providers?”

One simple intervention hospitalists could do immediately, he says, is to start tracking all important tests ordered for patients on a board in the medical team’s meeting room, only removing them from the board when results have been checked and communicated to the patient and outpatient provider.

References

1. National Academies of Sciences, Engineering, and Medicine. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. 2015.
2. Saber Tehrani AS, Lee HW, Mathews SC, et al. 25-year summary of U.S. malpractice claims for diagnostic errors 1986–2010: An analysis from the National Practitioner Data Bank. BMJ Qual Saf. 2013 Aug; 22(8):672–680.

Authors of the IOM’s “Improving Diagnosis in Health Care” report cite problems in communication and limitations in electronic health records behind inaccurate and delayed diagnoses, concluding that the problem of diagnostic errors generally has not been adequately studied.¹

“This problem is significant and serious. Yet we don’t know for sure how often it occurs, how serious it is, or how much it costs,” said the IOM committee’s chair, John Ball, MD, of the American College of Physicians, in a prepared statement. The report concludes there is no easy fix for the problem of diagnostic errors, which are a leading cause of adverse events in hospitals and of malpractice lawsuits for hospitalists, but calls for a major reassessment of the diagnostic process.²

Hospitalist Mangla Gulati, MD, FACP, SFHM, assistant chief medical officer at the University of Maryland Medical Center in Baltimore, says hospitalists would be remiss if they failed to take a closer look at the IOM report. “Diagnostic error is something we haven’t much talked about in medicine,” Dr. Gulati says. “Part of the goal of this report is to actually include the patient in those conversations.” Patients who are rehospitalized, she says, may have been given an incorrect initial diagnosis that was never rectified, or there may have been a failure to communicate important information.

“How many tests do we order where results come back after a patient leaves the hospital?” asks Kedar Mate, MD, senior vice president at the Institute for Healthcare Improvement and a hospitalist at Weill Cornell Medicine in New York City. “How many in-hospital diagnoses are made without all of the available information from outside providers?”

One simple intervention hospitalists could do immediately, he says, is to start tracking all important tests ordered for patients on a board in the medical team’s meeting room, only removing them from the board when results have been checked and communicated to the patient and outpatient provider.

References

1. National Academies of Sciences, Engineering, and Medicine. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. 2015.
2. Saber Tehrani AS, Lee HW, Mathews SC, et al. 25-year summary of U.S. malpractice claims for diagnostic errors 1986–2010: An analysis from the National Practitioner Data Bank. BMJ Qual Saf. 2013 Aug; 22(8):672–680.

Authors of the IOM’s “Improving Diagnosis in Health Care” report cite problems in communication and limitations in electronic health records behind inaccurate and delayed diagnoses, concluding that the problem of diagnostic errors generally has not been adequately studied.¹

“This problem is significant and serious. Yet we don’t know for sure how often it occurs, how serious it is, or how much it costs,” said the IOM committee’s chair, John Ball, MD, of the American College of Physicians, in a prepared statement. The report concludes there is no easy fix for the problem of diagnostic errors, which are a leading cause of adverse events in hospitals and of malpractice lawsuits for hospitalists, but calls for a major reassessment of the diagnostic process.²

Hospitalist Mangla Gulati, MD, FACP, SFHM, assistant chief medical officer at the University of Maryland Medical Center in Baltimore, says hospitalists would be remiss if they failed to take a closer look at the IOM report. “Diagnostic error is something we haven’t much talked about in medicine,” Dr. Gulati says. “Part of the goal of this report is to actually include the patient in those conversations.” Patients who are rehospitalized, she says, may have been given an incorrect initial diagnosis that was never rectified, or there may have been a failure to communicate important information.

“How many tests do we order where results come back after a patient leaves the hospital?” asks Kedar Mate, MD, senior vice president at the Institute for Healthcare Improvement and a hospitalist at Weill Cornell Medicine in New York City. “How many in-hospital diagnoses are made without all of the available information from outside providers?”

One simple intervention hospitalists could do immediately, he says, is to start tracking all important tests ordered for patients on a board in the medical team’s meeting room, only removing them from the board when results have been checked and communicated to the patient and outpatient provider.

References

1. National Academies of Sciences, Engineering, and Medicine. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. 2015.
2. Saber Tehrani AS, Lee HW, Mathews SC, et al. 25-year summary of U.S. malpractice claims for diagnostic errors 1986–2010: An analysis from the National Practitioner Data Bank. BMJ Qual Saf. 2013 Aug; 22(8):672–680.

A quality improvement (QI) initiative at University Hospital in Salt Lake City aims to save lives and cut hospital costs by reducing inpatient sepsis mortality.

Program co-leaders, hospitalists Devin Horton, MD, and Kencee Graves, MD, of University Hospital, launched the initiative as a pilot program last October. They began by surveying hospital house staff and nurses on their ability to recognize and define six different sepsis syndromes from clinical vignettes. A total of 136 surveyed residents recognized the correct condition only 56% of the time, and 280 surveyed nurses only did so 17% of the time. The hospitalists determined that better education about sepsis was crucial.

“We developed a robust teaching program for nurses and residents using Septris, an online educational game from Stanford University,” Dr. Horton says. The team also developed technology that can recognize worsening vital signs in a patient and automatically trigger an alert to a charge nurse or rapid response team.

The team’s Modified Early Warning System (MEWS) for recognizing sepsis is similar to the Early Warning and Response System (EWRS) system used at the University of Pennsylvania Health System and the University of California San Diego, and draws on other hospitals’ sepsis systems. Dr. Horton says one difference in their system is the involvement of nursing aides who take vital signs, enter them real-time into electronic health records (EHR), and receive prompts from abnormal vital signs to retake all vitals and confirm abnormal results. It also incorporates EHR decision support tools, including links to pre-populated medical order panels, such as for the ordering of tests for lactate and blood cultures.

“Severe sepsis is often quoted as the number one cause of mortality among hospitalized patients, with a rate up to 10 times that of acute myocardial infarction,” Dr. Horton explains. “The one treatment that consistently decreases mortality is timely administration of antibiotics. But, in order for a patient to be given timely antibiotics, the nurse or resident must first recognize that the patient has sepsis.”

“This is one of the biggest and most far-reaching improvement initiatives that has been done at our institution,” says Robert Pendleton, MD, chief quality officer at University Hospital. Dr. Horton says he predicts the program will “save 50 lives and $1 million per year.”

For more information, contact him at: [email protected].

A quality improvement (QI) initiative at University Hospital in Salt Lake City aims to save lives and cut hospital costs by reducing inpatient sepsis mortality.

Program co-leaders, hospitalists Devin Horton, MD, and Kencee Graves, MD, of University Hospital, launched the initiative as a pilot program last October. They began by surveying hospital house staff and nurses on their ability to recognize and define six different sepsis syndromes from clinical vignettes. A total of 136 surveyed residents recognized the correct condition only 56% of the time, and 280 surveyed nurses only did so 17% of the time. The hospitalists determined that better education about sepsis was crucial.

“We developed a robust teaching program for nurses and residents using Septris, an online educational game from Stanford University,” Dr. Horton says. The team also developed technology that can recognize worsening vital signs in a patient and automatically trigger an alert to a charge nurse or rapid response team.

The team’s Modified Early Warning System (MEWS) for recognizing sepsis is similar to the Early Warning and Response System (EWRS) system used at the University of Pennsylvania Health System and the University of California San Diego, and draws on other hospitals’ sepsis systems. Dr. Horton says one difference in their system is the involvement of nursing aides who take vital signs, enter them real-time into electronic health records (EHR), and receive prompts from abnormal vital signs to retake all vitals and confirm abnormal results. It also incorporates EHR decision support tools, including links to pre-populated medical order panels, such as for the ordering of tests for lactate and blood cultures.

“Severe sepsis is often quoted as the number one cause of mortality among hospitalized patients, with a rate up to 10 times that of acute myocardial infarction,” Dr. Horton explains. “The one treatment that consistently decreases mortality is timely administration of antibiotics. But, in order for a patient to be given timely antibiotics, the nurse or resident must first recognize that the patient has sepsis.”

“This is one of the biggest and most far-reaching improvement initiatives that has been done at our institution,” says Robert Pendleton, MD, chief quality officer at University Hospital. Dr. Horton says he predicts the program will “save 50 lives and $1 million per year.”

For more information, contact him at: [email protected].

A quality improvement (QI) initiative at University Hospital in Salt Lake City aims to save lives and cut hospital costs by reducing inpatient sepsis mortality.

Program co-leaders, hospitalists Devin Horton, MD, and Kencee Graves, MD, of University Hospital, launched the initiative as a pilot program last October. They began by surveying hospital house staff and nurses on their ability to recognize and define six different sepsis syndromes from clinical vignettes. A total of 136 surveyed residents recognized the correct condition only 56% of the time, and 280 surveyed nurses only did so 17% of the time. The hospitalists determined that better education about sepsis was crucial.

“We developed a robust teaching program for nurses and residents using Septris, an online educational game from Stanford University,” Dr. Horton says. The team also developed technology that can recognize worsening vital signs in a patient and automatically trigger an alert to a charge nurse or rapid response team.

The team’s Modified Early Warning System (MEWS) for recognizing sepsis is similar to the Early Warning and Response System (EWRS) system used at the University of Pennsylvania Health System and the University of California San Diego, and draws on other hospitals’ sepsis systems. Dr. Horton says one difference in their system is the involvement of nursing aides who take vital signs, enter them real-time into electronic health records (EHR), and receive prompts from abnormal vital signs to retake all vitals and confirm abnormal results. It also incorporates EHR decision support tools, including links to pre-populated medical order panels, such as for the ordering of tests for lactate and blood cultures.

“Severe sepsis is often quoted as the number one cause of mortality among hospitalized patients, with a rate up to 10 times that of acute myocardial infarction,” Dr. Horton explains. “The one treatment that consistently decreases mortality is timely administration of antibiotics. But, in order for a patient to be given timely antibiotics, the nurse or resident must first recognize that the patient has sepsis.”

“This is one of the biggest and most far-reaching improvement initiatives that has been done at our institution,” says Robert Pendleton, MD, chief quality officer at University Hospital. Dr. Horton says he predicts the program will “save 50 lives and $1 million per year.”

For more information, contact him at: [email protected].

“I didn’t get out of bed for 10 days”

—Anonymous patient admitted to a skilled nursing facility post-hospitalization for a COPD exacerbation

Readmission penalties, “Medicare spending per beneficiary” under value-based purchasing, and the move to accountable care are propelling hospitalists to do more to ensure our patients recover well in the least restrictive setting, without returning to the hospital. As we build systems to support patient recovery, we are focused on a medical model, paying attention to managing diseases and reconciling medications. At the same time, there is a growing awareness that functional status and mobility are critical pieces of patient care during and post-hospitalization.

Regardless of principal diagnosis and comorbidities, patients’ functional mobility ultimately determines their trajectory during recovery. To illustrate the importance of functional status and outcomes, one study showed that models predicting readmission based on functional measures outperformed those based on comorbidities.¹

The negative effects of hospitalization on patient mobility, and in turn, on recovery, have been recognized for a long time. Immobility is associated with functional decline, which contributes to falls, increased length of stay, delirium, loss of ability to perform activities of daily living, and loss of ambulatory independence. A number of studies have reported successful early mobility programs in critical care and surgical patients.² Fewer have been reported in general medical patients.³ Taken together, they suggest that a program for mobilizing patients, using a team approach, is an important part of recovery during and after hospitalization.

The purpose of this column is to report the components of one healthcare system’s mobility program for general medical-surgical patients.

Early Mobility: A Case Study

St Luke’s University Health Network (SLUHN) in northeastern Pennsylvania has implemented an early mobility program as part of its broader strategy to reduce readmissions and discharge as many patients home as possible. Although the SLUHN early mobility program depends on nursing, nursing assistants, and the judicious use of therapists, physician leadership during implementation and maintenance of the program has been essential. Moreover, because the program represents a culture shift, especially for nursing, leadership and change management are crucial ingredients for success. Below are the key steps in the SLUHN early mobility program.

Establish baseline functional status. Recording baseline function is an essential first step. For patients admitted through the ED, nurses collect ambulatory status, patient needs for assistance, ambulatory aids/special equipment, and history of falls. They populate an SBAR (situation, background, assessment, recommendation) form with this information and, as part of the handoff, ensure that it is transmitted to the inpatient nurse receiving the patient.

Obtain and document Barthel Index score. SLUHN uses the Barthel Index (see Figure 1) to establish a patient’s degree of independence and need for supervision. The index is scored on a 0-100 scale, with a higher score corresponding to a greater degree of independence. SLUHN created three categories: 0-59, stage 1; 60-84, stage 2; 85-100, stage 3.

Patient mobility plan. Based on the Barthel-derived stage, a patient is assigned a mobility plan.

The role of nursing. The patient’s registered nurse is responsible for implementing the “patient mobility plan.” The nurse initiates an “interdisciplinary plan of care,” in which the mobility stage is written on the SBAR handoff report tool. The report is discussed at change of shift and at multidisciplinary rounds. Nursing also communicates the mobility plan to the nursing assistants and assigns responsibilities for the mobility plan (activities of daily living, out of bed, ambulation, and so on), including verifying documentation of daily activities and assessing the patient’s response to the activity level of the assigned stage.

Further, nursing maintains and revises the mobility status on the SBAR, updates progress toward outcomes on the care plan, consults with the physician and team regarding the discharge plan, and discusses progress with the patient and family.

The role of the nursing/patient care assistant. The nursing assistant is responsible for implementing elements of the plan, such as activities of daily living, getting out of bed, and ambulation, under the guidance of the nurse. The nursing assistant reports patient responses to activity level and reflects mobility goals back to the patient verbally and through white board messaging.

Patient progress in mobility. When a patient sustains progress at one stage for 24 hours, the nurse aims to move the patient to the next stage by reevaluating the Barthel Index and going through the same steps as those followed during the initial scoring. The process moves the patient to higher activity levels, unless there are intervening problems affecting mobility.

In such cases, according to the Barthel Index, the patient may remain at the same—or be moved to a lower—activity level. In practice, patients are assessed each shift, and those with higher function (stage 3) are progressed to unsupervised ambulation.

The role of physical and occupational therapy. Although the role of physical and occupational therapists in the SLUHN mobility program is well codified, it is reserved for patients with complex rehabilitation needs due to the number of patients requiring rehabilitation.

In sum, this patient mobility program–for non-ICU hospitalized patients–relies on:

• Documentation of baseline function;
• Independent scoring using the Barthel Index;
• Creation of clear roles for nursing, nursing assistants, and therapists; and
• Reevaluation of patients at regular intervals based on the Barthel Index, so that they may progress to greater activity levels (or to lower levels in the case of a setback).

A key subsequent step, an evaluation of the program’s performance in terms of readmissions, transfer rates to a skilled nursing facility, and skilled facility length of stay, has shown positive results in all three domains.

References

1. Shi SL, Girrard P, Goldstein R, et al. Functional status outperforms comorbidities in predicting acute care readmissions in medically complex patients. J Gen Intern Med. 2015;30(11):1688-1695.
2. Dammeyer JA, Baldwin N, Packard D, et al. Mobilizing outcomes: implementation of a nurse-led multidisciplinary mobility program. Crit Care Nurs Q. 2013;36(1):109-119.
3. Wood W, Tschannen D, Trotsky A, et al. A mobility program for an inpatient acute care medical unit. Am J Nurs. 2014;114(10):34-40.
4. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:61-65.

“I didn’t get out of bed for 10 days”

—Anonymous patient admitted to a skilled nursing facility post-hospitalization for a COPD exacerbation

Readmission penalties, “Medicare spending per beneficiary” under value-based purchasing, and the move to accountable care are propelling hospitalists to do more to ensure our patients recover well in the least restrictive setting, without returning to the hospital. As we build systems to support patient recovery, we are focused on a medical model, paying attention to managing diseases and reconciling medications. At the same time, there is a growing awareness that functional status and mobility are critical pieces of patient care during and post-hospitalization.

Regardless of principal diagnosis and comorbidities, patients’ functional mobility ultimately determines their trajectory during recovery. To illustrate the importance of functional status and outcomes, one study showed that models predicting readmission based on functional measures outperformed those based on comorbidities.¹

The negative effects of hospitalization on patient mobility, and in turn, on recovery, have been recognized for a long time. Immobility is associated with functional decline, which contributes to falls, increased length of stay, delirium, loss of ability to perform activities of daily living, and loss of ambulatory independence. A number of studies have reported successful early mobility programs in critical care and surgical patients.² Fewer have been reported in general medical patients.³ Taken together, they suggest that a program for mobilizing patients, using a team approach, is an important part of recovery during and after hospitalization.

The purpose of this column is to report the components of one healthcare system’s mobility program for general medical-surgical patients.

Early Mobility: A Case Study

St Luke’s University Health Network (SLUHN) in northeastern Pennsylvania has implemented an early mobility program as part of its broader strategy to reduce readmissions and discharge as many patients home as possible. Although the SLUHN early mobility program depends on nursing, nursing assistants, and the judicious use of therapists, physician leadership during implementation and maintenance of the program has been essential. Moreover, because the program represents a culture shift, especially for nursing, leadership and change management are crucial ingredients for success. Below are the key steps in the SLUHN early mobility program.

Establish baseline functional status. Recording baseline function is an essential first step. For patients admitted through the ED, nurses collect ambulatory status, patient needs for assistance, ambulatory aids/special equipment, and history of falls. They populate an SBAR (situation, background, assessment, recommendation) form with this information and, as part of the handoff, ensure that it is transmitted to the inpatient nurse receiving the patient.

Obtain and document Barthel Index score. SLUHN uses the Barthel Index (see Figure 1) to establish a patient’s degree of independence and need for supervision. The index is scored on a 0-100 scale, with a higher score corresponding to a greater degree of independence. SLUHN created three categories: 0-59, stage 1; 60-84, stage 2; 85-100, stage 3.

Patient mobility plan. Based on the Barthel-derived stage, a patient is assigned a mobility plan.

The role of nursing. The patient’s registered nurse is responsible for implementing the “patient mobility plan.” The nurse initiates an “interdisciplinary plan of care,” in which the mobility stage is written on the SBAR handoff report tool. The report is discussed at change of shift and at multidisciplinary rounds. Nursing also communicates the mobility plan to the nursing assistants and assigns responsibilities for the mobility plan (activities of daily living, out of bed, ambulation, and so on), including verifying documentation of daily activities and assessing the patient’s response to the activity level of the assigned stage.

Further, nursing maintains and revises the mobility status on the SBAR, updates progress toward outcomes on the care plan, consults with the physician and team regarding the discharge plan, and discusses progress with the patient and family.

The role of the nursing/patient care assistant. The nursing assistant is responsible for implementing elements of the plan, such as activities of daily living, getting out of bed, and ambulation, under the guidance of the nurse. The nursing assistant reports patient responses to activity level and reflects mobility goals back to the patient verbally and through white board messaging.

Patient progress in mobility. When a patient sustains progress at one stage for 24 hours, the nurse aims to move the patient to the next stage by reevaluating the Barthel Index and going through the same steps as those followed during the initial scoring. The process moves the patient to higher activity levels, unless there are intervening problems affecting mobility.

In such cases, according to the Barthel Index, the patient may remain at the same—or be moved to a lower—activity level. In practice, patients are assessed each shift, and those with higher function (stage 3) are progressed to unsupervised ambulation.

The role of physical and occupational therapy. Although the role of physical and occupational therapists in the SLUHN mobility program is well codified, it is reserved for patients with complex rehabilitation needs due to the number of patients requiring rehabilitation.

In sum, this patient mobility program–for non-ICU hospitalized patients–relies on:

• Documentation of baseline function;
• Independent scoring using the Barthel Index;
• Creation of clear roles for nursing, nursing assistants, and therapists; and
• Reevaluation of patients at regular intervals based on the Barthel Index, so that they may progress to greater activity levels (or to lower levels in the case of a setback).

A key subsequent step, an evaluation of the program’s performance in terms of readmissions, transfer rates to a skilled nursing facility, and skilled facility length of stay, has shown positive results in all three domains.

References

1. Shi SL, Girrard P, Goldstein R, et al. Functional status outperforms comorbidities in predicting acute care readmissions in medically complex patients. J Gen Intern Med. 2015;30(11):1688-1695.
2. Dammeyer JA, Baldwin N, Packard D, et al. Mobilizing outcomes: implementation of a nurse-led multidisciplinary mobility program. Crit Care Nurs Q. 2013;36(1):109-119.
3. Wood W, Tschannen D, Trotsky A, et al. A mobility program for an inpatient acute care medical unit. Am J Nurs. 2014;114(10):34-40.
4. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:61-65.

“I didn’t get out of bed for 10 days”

—Anonymous patient admitted to a skilled nursing facility post-hospitalization for a COPD exacerbation

Readmission penalties, “Medicare spending per beneficiary” under value-based purchasing, and the move to accountable care are propelling hospitalists to do more to ensure our patients recover well in the least restrictive setting, without returning to the hospital. As we build systems to support patient recovery, we are focused on a medical model, paying attention to managing diseases and reconciling medications. At the same time, there is a growing awareness that functional status and mobility are critical pieces of patient care during and post-hospitalization.

Regardless of principal diagnosis and comorbidities, patients’ functional mobility ultimately determines their trajectory during recovery. To illustrate the importance of functional status and outcomes, one study showed that models predicting readmission based on functional measures outperformed those based on comorbidities.¹

The negative effects of hospitalization on patient mobility, and in turn, on recovery, have been recognized for a long time. Immobility is associated with functional decline, which contributes to falls, increased length of stay, delirium, loss of ability to perform activities of daily living, and loss of ambulatory independence. A number of studies have reported successful early mobility programs in critical care and surgical patients.² Fewer have been reported in general medical patients.³ Taken together, they suggest that a program for mobilizing patients, using a team approach, is an important part of recovery during and after hospitalization.

The purpose of this column is to report the components of one healthcare system’s mobility program for general medical-surgical patients.

Early Mobility: A Case Study

St Luke’s University Health Network (SLUHN) in northeastern Pennsylvania has implemented an early mobility program as part of its broader strategy to reduce readmissions and discharge as many patients home as possible. Although the SLUHN early mobility program depends on nursing, nursing assistants, and the judicious use of therapists, physician leadership during implementation and maintenance of the program has been essential. Moreover, because the program represents a culture shift, especially for nursing, leadership and change management are crucial ingredients for success. Below are the key steps in the SLUHN early mobility program.

Establish baseline functional status. Recording baseline function is an essential first step. For patients admitted through the ED, nurses collect ambulatory status, patient needs for assistance, ambulatory aids/special equipment, and history of falls. They populate an SBAR (situation, background, assessment, recommendation) form with this information and, as part of the handoff, ensure that it is transmitted to the inpatient nurse receiving the patient.

Obtain and document Barthel Index score. SLUHN uses the Barthel Index (see Figure 1) to establish a patient’s degree of independence and need for supervision. The index is scored on a 0-100 scale, with a higher score corresponding to a greater degree of independence. SLUHN created three categories: 0-59, stage 1; 60-84, stage 2; 85-100, stage 3.

Patient mobility plan. Based on the Barthel-derived stage, a patient is assigned a mobility plan.

The role of nursing. The patient’s registered nurse is responsible for implementing the “patient mobility plan.” The nurse initiates an “interdisciplinary plan of care,” in which the mobility stage is written on the SBAR handoff report tool. The report is discussed at change of shift and at multidisciplinary rounds. Nursing also communicates the mobility plan to the nursing assistants and assigns responsibilities for the mobility plan (activities of daily living, out of bed, ambulation, and so on), including verifying documentation of daily activities and assessing the patient’s response to the activity level of the assigned stage.

Further, nursing maintains and revises the mobility status on the SBAR, updates progress toward outcomes on the care plan, consults with the physician and team regarding the discharge plan, and discusses progress with the patient and family.

The role of the nursing/patient care assistant. The nursing assistant is responsible for implementing elements of the plan, such as activities of daily living, getting out of bed, and ambulation, under the guidance of the nurse. The nursing assistant reports patient responses to activity level and reflects mobility goals back to the patient verbally and through white board messaging.

Patient progress in mobility. When a patient sustains progress at one stage for 24 hours, the nurse aims to move the patient to the next stage by reevaluating the Barthel Index and going through the same steps as those followed during the initial scoring. The process moves the patient to higher activity levels, unless there are intervening problems affecting mobility.

In such cases, according to the Barthel Index, the patient may remain at the same—or be moved to a lower—activity level. In practice, patients are assessed each shift, and those with higher function (stage 3) are progressed to unsupervised ambulation.

The role of physical and occupational therapy. Although the role of physical and occupational therapists in the SLUHN mobility program is well codified, it is reserved for patients with complex rehabilitation needs due to the number of patients requiring rehabilitation.

In sum, this patient mobility program–for non-ICU hospitalized patients–relies on:

• Documentation of baseline function;
• Independent scoring using the Barthel Index;
• Creation of clear roles for nursing, nursing assistants, and therapists; and
• Reevaluation of patients at regular intervals based on the Barthel Index, so that they may progress to greater activity levels (or to lower levels in the case of a setback).

A key subsequent step, an evaluation of the program’s performance in terms of readmissions, transfer rates to a skilled nursing facility, and skilled facility length of stay, has shown positive results in all three domains.

References

1. Shi SL, Girrard P, Goldstein R, et al. Functional status outperforms comorbidities in predicting acute care readmissions in medically complex patients. J Gen Intern Med. 2015;30(11):1688-1695.
2. Dammeyer JA, Baldwin N, Packard D, et al. Mobilizing outcomes: implementation of a nurse-led multidisciplinary mobility program. Crit Care Nurs Q. 2013;36(1):109-119.
3. Wood W, Tschannen D, Trotsky A, et al. A mobility program for an inpatient acute care medical unit. Am J Nurs. 2014;114(10):34-40.
4. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:61-65.

The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications, while minimizing bleed risks, was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient conference.

“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs Anticoagulation and Thrombosis Services at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and Dr. Minichiello said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.

“There is interest on both sides of that question,” Dr. Minichiello said, adding that the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion

of the other side of the issue—overdiagnosis and overtreatment—where we’re also trying to avoid, for example, overuse of CT scans.”

“We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—overdiagnosis and overtreatment—where we’re also trying to avoid, for example, overuse of CT scans.” —Tracy Minichiello, MD

Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk but comes with an increased risk for bleeding.

“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.

Literature increasingly recommends that hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, Dr. Minichiello noted. “[Hospitalists] must be mindful of the risks and benefits,” she said. Physicians should also think twice about concomitant antiplatelet therapy, like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”

Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Québec, attended Dr. Minichiello’s breakout session on challenging cases.

“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,”

Dr. Bouchard said. She also explained that a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries to offer the oral anticoagulants whenever possible.

Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around performing procedures, choosing anticoagulants, and determining when to restart treatments.

“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested that hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s Anticoagulation Services website, or the American Society of Health System Pharmacists’ Anticoagulation Resource Center.

The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications, while minimizing bleed risks, was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient conference.

“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs Anticoagulation and Thrombosis Services at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and Dr. Minichiello said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.

“There is interest on both sides of that question,” Dr. Minichiello said, adding that the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion

of the other side of the issue—overdiagnosis and overtreatment—where we’re also trying to avoid, for example, overuse of CT scans.”

“We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—overdiagnosis and overtreatment—where we’re also trying to avoid, for example, overuse of CT scans.” —Tracy Minichiello, MD

Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk but comes with an increased risk for bleeding.

“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.

Literature increasingly recommends that hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, Dr. Minichiello noted. “[Hospitalists] must be mindful of the risks and benefits,” she said. Physicians should also think twice about concomitant antiplatelet therapy, like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”

Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Québec, attended Dr. Minichiello’s breakout session on challenging cases.

“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,”

Dr. Bouchard said. She also explained that a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries to offer the oral anticoagulants whenever possible.

Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around performing procedures, choosing anticoagulants, and determining when to restart treatments.

“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested that hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s Anticoagulation Services website, or the American Society of Health System Pharmacists’ Anticoagulation Resource Center.

The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications, while minimizing bleed risks, was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient conference.

“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs Anticoagulation and Thrombosis Services at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and Dr. Minichiello said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.

“There is interest on both sides of that question,” Dr. Minichiello said, adding that the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion

of the other side of the issue—overdiagnosis and overtreatment—where we’re also trying to avoid, for example, overuse of CT scans.”

“We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—overdiagnosis and overtreatment—where we’re also trying to avoid, for example, overuse of CT scans.” —Tracy Minichiello, MD

Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk but comes with an increased risk for bleeding.

“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.

Literature increasingly recommends that hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, Dr. Minichiello noted. “[Hospitalists] must be mindful of the risks and benefits,” she said. Physicians should also think twice about concomitant antiplatelet therapy, like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”

Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Québec, attended Dr. Minichiello’s breakout session on challenging cases.

“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,”

Dr. Bouchard said. She also explained that a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries to offer the oral anticoagulants whenever possible.

Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around performing procedures, choosing anticoagulants, and determining when to restart treatments.

“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested that hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s Anticoagulation Services website, or the American Society of Health System Pharmacists’ Anticoagulation Resource Center.

WASHINGTON, DC—Limiting the amount of full-contact tackling that occurs in high school football practice reduces the rate of sports-related concussions among the athletes, according to a prospective study.

“Something as simple as saying they can’t tackle all the time, limiting the amount of minutes each month, reduced the incidence,” said Timothy A. McGuine, PhD, Senior Scientist at the University of Wisconsin, Madison, at the American Academy of Pediatrics Annual Meeting.

“The majority of sports-related concussions sustained in high school football practice occurred during full-contact activities,” he said. “The rate of sports-related concussions sustained in high school football practice was more than twice as high in the two seasons prior to a rule change limiting the amount and duration of full-contact activities.”

Testing a Tackle-Limiting Rule

In their study, Dr. McGuine and his associates tested the effects of a tackle-limiting rule implemented in 2014 in a state interscholastic athletic association for all players in grades 9 through 12. The rule prohibited full-contact play during the first practice week, and full contact was defined as “drills or game situations that occur at game speed when full tackles are made at a competitive pace and players are taken to the ground.” The players engaged in full-contact play for as long as 75 minutes total during the second week of practice and for a maximum of 60 min/week for all subsequent weeks in the practice season. The rule did not apply to games.

For data on the two years before the rule change, 2,081 athletes with a mean age of 16 reported their concussion history in the 2012 season, which included 36 schools, and the 2013 season, which included 18 schools. In 2014, licensed athletic trainers recorded the incidence and severity of each sports-related concussion for the 945 players at 26 schools. During all three seasons, almost half the concussions (46%) occurred during tackling. Although the overall rate of concussions dropped from 1.57 per 1,000 athletic exposures in the combined 2012 and 2013 seasons to 1.28 per 1,000 athletic exposures in the 2014 season, the difference was not significant. During the 2012 and 2013 seasons combined, 206 players (9%) sustained 211 concussions, compared with 67 players (7%) with 70 concussions in 2014.

The difference in concussions occurring during practice, however, did differ significantly before and after the rule change. The rate of concussions during practice in 2014 was 0.33 concussions per 1,000 athletic exposures, compared with 0.76 concussions per 1,000 exposures in the 2012 and 2013 seasons. Twelve of 15 concussions in 2014 practices occurred during full-contact practices, a rate of 0.57 per 1,000 exposures, and 82 of 86 concussions in the 2012 and 2013 seasons occurred during full contact practices, a rate of 0.87 per 1,000 exposures.

The investigators observed no difference in concussion rate during the games following the rule change. The 2014 rate of concussions during games was 5.74 per 1,000 exposures, compared with 5.81 per 1,000 exposures in the combined 2012 and 2013 seasons. The severity of concussions sustained before and after the rule change also did not differ, and athletes’ years of football-playing experience had no effect on the concussion incidence in 2014.

To Tackle or Not to Tackle?

Despite the relationship between full-contact play and concussions, Dr. McGuine said that he would not support banning tackling from football.

“I think the benefits of the sport far outweigh the risks,” Dr. McGuine said. “Concussions particularly have transcended a sports issue and become a public health issue and have become political, and I’m very much against legislators, policy makers, [and] associations making blanket rules without the evidence to back those,” he said. “There are lingering long-term effects from all orthopedic injuries, but we’re focusing on concussions.”

Equipment modification is unlikely to make much difference in concussion rates either, said Dr. McGuine, whose previous study on football helmets found that the brand and model did not influence concussion risk. “Concussions are multifactorial,” he said. “We can’t just limit the amount of force transmitted to the brain and say we’re going to stop these injuries from occurring.”

One important strategy for reducing concussions is increasing parents’ and athletes’ awareness about multiple injuries and about ways to reduce the risk, Dr. McGuine said.

“Concussions are like any other injury [such as] ankle sprains, knee injuries and surgeries, [and] shoulder dislocations,” he said. “If you have one, you’re more susceptible to having another one, as opposed to somebody who never had that injury, so the problems are repeat injuries and lingering injuries.” Any of these injuries can have a lasting effect on a young athlete’s quality of life, Dr. McGuine added.

Another way to decrease the incidence of concussions is to enforce rules against leading, or lowering, athletes’ heads during tackling.

“A big issue now is penalizing players for leading with their head and face, but I think we need to be consistent there, too,” Dr. McGuine said. “We can’t penalize defensive players for lowering their helmet if we’re not going to penalize running backs and wide receivers.”

—Tara Haelle

WASHINGTON, DC—Limiting the amount of full-contact tackling that occurs in high school football practice reduces the rate of sports-related concussions among the athletes, according to a prospective study.

“Something as simple as saying they can’t tackle all the time, limiting the amount of minutes each month, reduced the incidence,” said Timothy A. McGuine, PhD, Senior Scientist at the University of Wisconsin, Madison, at the American Academy of Pediatrics Annual Meeting.

“The majority of sports-related concussions sustained in high school football practice occurred during full-contact activities,” he said. “The rate of sports-related concussions sustained in high school football practice was more than twice as high in the two seasons prior to a rule change limiting the amount and duration of full-contact activities.”

Testing a Tackle-Limiting Rule

In their study, Dr. McGuine and his associates tested the effects of a tackle-limiting rule implemented in 2014 in a state interscholastic athletic association for all players in grades 9 through 12. The rule prohibited full-contact play during the first practice week, and full contact was defined as “drills or game situations that occur at game speed when full tackles are made at a competitive pace and players are taken to the ground.” The players engaged in full-contact play for as long as 75 minutes total during the second week of practice and for a maximum of 60 min/week for all subsequent weeks in the practice season. The rule did not apply to games.

For data on the two years before the rule change, 2,081 athletes with a mean age of 16 reported their concussion history in the 2012 season, which included 36 schools, and the 2013 season, which included 18 schools. In 2014, licensed athletic trainers recorded the incidence and severity of each sports-related concussion for the 945 players at 26 schools. During all three seasons, almost half the concussions (46%) occurred during tackling. Although the overall rate of concussions dropped from 1.57 per 1,000 athletic exposures in the combined 2012 and 2013 seasons to 1.28 per 1,000 athletic exposures in the 2014 season, the difference was not significant. During the 2012 and 2013 seasons combined, 206 players (9%) sustained 211 concussions, compared with 67 players (7%) with 70 concussions in 2014.

The difference in concussions occurring during practice, however, did differ significantly before and after the rule change. The rate of concussions during practice in 2014 was 0.33 concussions per 1,000 athletic exposures, compared with 0.76 concussions per 1,000 exposures in the 2012 and 2013 seasons. Twelve of 15 concussions in 2014 practices occurred during full-contact practices, a rate of 0.57 per 1,000 exposures, and 82 of 86 concussions in the 2012 and 2013 seasons occurred during full contact practices, a rate of 0.87 per 1,000 exposures.

The investigators observed no difference in concussion rate during the games following the rule change. The 2014 rate of concussions during games was 5.74 per 1,000 exposures, compared with 5.81 per 1,000 exposures in the combined 2012 and 2013 seasons. The severity of concussions sustained before and after the rule change also did not differ, and athletes’ years of football-playing experience had no effect on the concussion incidence in 2014.

To Tackle or Not to Tackle?

Despite the relationship between full-contact play and concussions, Dr. McGuine said that he would not support banning tackling from football.

“I think the benefits of the sport far outweigh the risks,” Dr. McGuine said. “Concussions particularly have transcended a sports issue and become a public health issue and have become political, and I’m very much against legislators, policy makers, [and] associations making blanket rules without the evidence to back those,” he said. “There are lingering long-term effects from all orthopedic injuries, but we’re focusing on concussions.”

Equipment modification is unlikely to make much difference in concussion rates either, said Dr. McGuine, whose previous study on football helmets found that the brand and model did not influence concussion risk. “Concussions are multifactorial,” he said. “We can’t just limit the amount of force transmitted to the brain and say we’re going to stop these injuries from occurring.”

One important strategy for reducing concussions is increasing parents’ and athletes’ awareness about multiple injuries and about ways to reduce the risk, Dr. McGuine said.

“Concussions are like any other injury [such as] ankle sprains, knee injuries and surgeries, [and] shoulder dislocations,” he said. “If you have one, you’re more susceptible to having another one, as opposed to somebody who never had that injury, so the problems are repeat injuries and lingering injuries.” Any of these injuries can have a lasting effect on a young athlete’s quality of life, Dr. McGuine added.

Another way to decrease the incidence of concussions is to enforce rules against leading, or lowering, athletes’ heads during tackling.

“A big issue now is penalizing players for leading with their head and face, but I think we need to be consistent there, too,” Dr. McGuine said. “We can’t penalize defensive players for lowering their helmet if we’re not going to penalize running backs and wide receivers.”

—Tara Haelle

WASHINGTON, DC—Limiting the amount of full-contact tackling that occurs in high school football practice reduces the rate of sports-related concussions among the athletes, according to a prospective study.

“Something as simple as saying they can’t tackle all the time, limiting the amount of minutes each month, reduced the incidence,” said Timothy A. McGuine, PhD, Senior Scientist at the University of Wisconsin, Madison, at the American Academy of Pediatrics Annual Meeting.

“The majority of sports-related concussions sustained in high school football practice occurred during full-contact activities,” he said. “The rate of sports-related concussions sustained in high school football practice was more than twice as high in the two seasons prior to a rule change limiting the amount and duration of full-contact activities.”

Testing a Tackle-Limiting Rule

In their study, Dr. McGuine and his associates tested the effects of a tackle-limiting rule implemented in 2014 in a state interscholastic athletic association for all players in grades 9 through 12. The rule prohibited full-contact play during the first practice week, and full contact was defined as “drills or game situations that occur at game speed when full tackles are made at a competitive pace and players are taken to the ground.” The players engaged in full-contact play for as long as 75 minutes total during the second week of practice and for a maximum of 60 min/week for all subsequent weeks in the practice season. The rule did not apply to games.

For data on the two years before the rule change, 2,081 athletes with a mean age of 16 reported their concussion history in the 2012 season, which included 36 schools, and the 2013 season, which included 18 schools. In 2014, licensed athletic trainers recorded the incidence and severity of each sports-related concussion for the 945 players at 26 schools. During all three seasons, almost half the concussions (46%) occurred during tackling. Although the overall rate of concussions dropped from 1.57 per 1,000 athletic exposures in the combined 2012 and 2013 seasons to 1.28 per 1,000 athletic exposures in the 2014 season, the difference was not significant. During the 2012 and 2013 seasons combined, 206 players (9%) sustained 211 concussions, compared with 67 players (7%) with 70 concussions in 2014.

The difference in concussions occurring during practice, however, did differ significantly before and after the rule change. The rate of concussions during practice in 2014 was 0.33 concussions per 1,000 athletic exposures, compared with 0.76 concussions per 1,000 exposures in the 2012 and 2013 seasons. Twelve of 15 concussions in 2014 practices occurred during full-contact practices, a rate of 0.57 per 1,000 exposures, and 82 of 86 concussions in the 2012 and 2013 seasons occurred during full contact practices, a rate of 0.87 per 1,000 exposures.

The investigators observed no difference in concussion rate during the games following the rule change. The 2014 rate of concussions during games was 5.74 per 1,000 exposures, compared with 5.81 per 1,000 exposures in the combined 2012 and 2013 seasons. The severity of concussions sustained before and after the rule change also did not differ, and athletes’ years of football-playing experience had no effect on the concussion incidence in 2014.

To Tackle or Not to Tackle?

Despite the relationship between full-contact play and concussions, Dr. McGuine said that he would not support banning tackling from football.

“I think the benefits of the sport far outweigh the risks,” Dr. McGuine said. “Concussions particularly have transcended a sports issue and become a public health issue and have become political, and I’m very much against legislators, policy makers, [and] associations making blanket rules without the evidence to back those,” he said. “There are lingering long-term effects from all orthopedic injuries, but we’re focusing on concussions.”

Equipment modification is unlikely to make much difference in concussion rates either, said Dr. McGuine, whose previous study on football helmets found that the brand and model did not influence concussion risk. “Concussions are multifactorial,” he said. “We can’t just limit the amount of force transmitted to the brain and say we’re going to stop these injuries from occurring.”

One important strategy for reducing concussions is increasing parents’ and athletes’ awareness about multiple injuries and about ways to reduce the risk, Dr. McGuine said.

“Concussions are like any other injury [such as] ankle sprains, knee injuries and surgeries, [and] shoulder dislocations,” he said. “If you have one, you’re more susceptible to having another one, as opposed to somebody who never had that injury, so the problems are repeat injuries and lingering injuries.” Any of these injuries can have a lasting effect on a young athlete’s quality of life, Dr. McGuine added.

Another way to decrease the incidence of concussions is to enforce rules against leading, or lowering, athletes’ heads during tackling.

“A big issue now is penalizing players for leading with their head and face, but I think we need to be consistent there, too,” Dr. McGuine said. “We can’t penalize defensive players for lowering their helmet if we’re not going to penalize running backs and wide receivers.”

—Tara Haelle

Bilal Hameed, MD, assistant professor of medicine in the division of gastroenterology at the University of California San Francisco, reviewed a wide range of serious and life-threatening medical complications resulting from cirrhosis during the annual UCSF Management of the Hospitalized Patient conference.

Recurring complications of cirrhosis can include ascites, acute variceal and portal hypertensive bleeds, hepatic encephalopathy, bacterial peritonitis, acute renal failure, sepsis, and a host of other infections. In many cases, options for treatment are limited, because the patient develops decompensated cirrhosis.

Poor prognosis makes it important to urge these patients to get on a liver transplantation list, sooner rather than later, Dr. Hameed told hospitalists attending his small group session.

“Liver transplantation has changed this field,” he said. “Call us to see if your patient might be a candidate.”

Unlike transplant lists for kidneys and some other organs, on which patients must wait for their turn, liver transplants are assigned based on need, as reflected in the patient’s Model for End-Stage Liver Disease (MELD) score, an objective clinical scale derived from blood values.

“Patients do really well on transplants, with 60% survival at 10 years,” he said. He also noted that patients with advanced, decompensated disease who do not find a place on the transplant list might instead be candidates for palliative care or hospice referral.

Many conditions, such as infections, can still be managed with timely treatment, returning the patient back to baseline.

“The risk of infection is very high. Starting antibiotics early can help,” Dr. Hameed said.

And for conditions where fluid volume is an issue, including spontaneous bacterial peritonitis, hypernatremia, or intrinsic renal disease, albumin is recommended as the evidence-based treatment of choice. “Please don’t overtransfuse these patients,” he said.

Jeannie Yip, MD, a nocturnist at Kaiser Foundation Hospital in Oakland, Calif., said that she frequently admits these kinds of patients to her hospital. For her, Dr. Hameed’s albumin recommendation was the most important lesson.

“I was still using IV fluids in patients coming in with volume depletion, to rule out acute renal failure. It’s always a dilemma if you have a hypotensive patient with low sodium and low blood pressure who tells you, ‘I haven’t eaten for a week,’” she explained. “It’s been hard for me not to give them fluids. But after listening to this talk, I see that I should give albumin instead.”

Bilal Hameed, MD, assistant professor of medicine in the division of gastroenterology at the University of California San Francisco, reviewed a wide range of serious and life-threatening medical complications resulting from cirrhosis during the annual UCSF Management of the Hospitalized Patient conference.

Recurring complications of cirrhosis can include ascites, acute variceal and portal hypertensive bleeds, hepatic encephalopathy, bacterial peritonitis, acute renal failure, sepsis, and a host of other infections. In many cases, options for treatment are limited, because the patient develops decompensated cirrhosis.

Poor prognosis makes it important to urge these patients to get on a liver transplantation list, sooner rather than later, Dr. Hameed told hospitalists attending his small group session.

“Liver transplantation has changed this field,” he said. “Call us to see if your patient might be a candidate.”

Unlike transplant lists for kidneys and some other organs, on which patients must wait for their turn, liver transplants are assigned based on need, as reflected in the patient’s Model for End-Stage Liver Disease (MELD) score, an objective clinical scale derived from blood values.

“Patients do really well on transplants, with 60% survival at 10 years,” he said. He also noted that patients with advanced, decompensated disease who do not find a place on the transplant list might instead be candidates for palliative care or hospice referral.

Many conditions, such as infections, can still be managed with timely treatment, returning the patient back to baseline.

“The risk of infection is very high. Starting antibiotics early can help,” Dr. Hameed said.

And for conditions where fluid volume is an issue, including spontaneous bacterial peritonitis, hypernatremia, or intrinsic renal disease, albumin is recommended as the evidence-based treatment of choice. “Please don’t overtransfuse these patients,” he said.

Jeannie Yip, MD, a nocturnist at Kaiser Foundation Hospital in Oakland, Calif., said that she frequently admits these kinds of patients to her hospital. For her, Dr. Hameed’s albumin recommendation was the most important lesson.

“I was still using IV fluids in patients coming in with volume depletion, to rule out acute renal failure. It’s always a dilemma if you have a hypotensive patient with low sodium and low blood pressure who tells you, ‘I haven’t eaten for a week,’” she explained. “It’s been hard for me not to give them fluids. But after listening to this talk, I see that I should give albumin instead.”

Bilal Hameed, MD, assistant professor of medicine in the division of gastroenterology at the University of California San Francisco, reviewed a wide range of serious and life-threatening medical complications resulting from cirrhosis during the annual UCSF Management of the Hospitalized Patient conference.

Recurring complications of cirrhosis can include ascites, acute variceal and portal hypertensive bleeds, hepatic encephalopathy, bacterial peritonitis, acute renal failure, sepsis, and a host of other infections. In many cases, options for treatment are limited, because the patient develops decompensated cirrhosis.

Poor prognosis makes it important to urge these patients to get on a liver transplantation list, sooner rather than later, Dr. Hameed told hospitalists attending his small group session.

“Liver transplantation has changed this field,” he said. “Call us to see if your patient might be a candidate.”

Unlike transplant lists for kidneys and some other organs, on which patients must wait for their turn, liver transplants are assigned based on need, as reflected in the patient’s Model for End-Stage Liver Disease (MELD) score, an objective clinical scale derived from blood values.

“Patients do really well on transplants, with 60% survival at 10 years,” he said. He also noted that patients with advanced, decompensated disease who do not find a place on the transplant list might instead be candidates for palliative care or hospice referral.

Many conditions, such as infections, can still be managed with timely treatment, returning the patient back to baseline.

“The risk of infection is very high. Starting antibiotics early can help,” Dr. Hameed said.

And for conditions where fluid volume is an issue, including spontaneous bacterial peritonitis, hypernatremia, or intrinsic renal disease, albumin is recommended as the evidence-based treatment of choice. “Please don’t overtransfuse these patients,” he said.

Jeannie Yip, MD, a nocturnist at Kaiser Foundation Hospital in Oakland, Calif., said that she frequently admits these kinds of patients to her hospital. For her, Dr. Hameed’s albumin recommendation was the most important lesson.

“I was still using IV fluids in patients coming in with volume depletion, to rule out acute renal failure. It’s always a dilemma if you have a hypotensive patient with low sodium and low blood pressure who tells you, ‘I haven’t eaten for a week,’” she explained. “It’s been hard for me not to give them fluids. But after listening to this talk, I see that I should give albumin instead.”