After the wild ride of 2010, public-policy watchers could be forgiven for fervently hoping that 2011 offers a calmer year on the healthcare front.

Fat chance.

The turbulence could begin immediately, with the seating of the 112th Congress on Jan. 3. “I think the first question that’s on everybody’s mind is, ‘What will the Republican majority in the House do to Obama’s healthcare reform initiative?’ ” says Eric Siegal, MD, SFHM, a member of SHM’s Public Policy Committee (PPC) and a clinical assistant professor of medicine at the University of Wisconsin School of Medicine and Public Health.

For most issues of direct concern to hospitalists, he says, especially those centered on healthcare delivery, “the wheels were in motion” long before the reform bill became law. Dr. Siegal also says most healthcare experts support the substance of accountable care organizations (ACOs), pay for performance, and reforming Medicare in ways that reward quality instead of quantity. “I think that ship is out of the harbor,” he says.

Throughout the year, the PPC will focus on three priorities identified in the Affordable Care Act: hospital value-based purchasing, bundled payments including ACOs, and hospital readmissions and transitions of care.

Debate, Delay, Defund?

There are several ways that Congress can delay or thwart the launch of specific reform initiatives. The first is to hold hearings about reform measures, Dr. Siegal says, “with the hope that they can somehow undermine it by raising questions about either the finances of it or about the implications for average Americans in terms of what kind of healthcare they’re going to get.” Such tactics carry significant risk, however, because highlighting specific aspects of the reform law could actually increase overall public support. “It has the potential to backfire on them,” he says.

“Repeal won’t happen anytime soon,” predicts Pat Conway, MD, chair of the PPC and director of hospital medicine at Cincinnati Children’s Hospital. “However, Congress could gut or significantly reduce funding to multiple programs within the bill, and then if you significantly reduce the funding, this may make it nearly impossible for those programs to be successful.”

Rough estimates suggest that some $150 billion worth of programs over the 10-year life of the healthcare reform act remain unfunded and are at risk. As an example, Dr. Conway cites wording in the bill that authorizes a program to help ease patient transitions in and out of the hospital. “If you reduce that funding to near zero, hospitals and hospitalists may still be successful, but you’ve essentially removed the program to learn how to be successful,” he says.

Bill Vaughan, a senior policy analyst in healthcare with the Washington, D.C.-based organization Consumers Union, says targeted riders could be added to appropriations bills. For instance, one rider could prohibit the Centers for Medicare & Medicaid Services (CMS) from spending any money to help develop government-supported insurance exchanges. Another could prevent the IRS from collecting money to be channeled into the trust fund for the Patient-Centered Outcomes Research Institute and its focus on comparative-effectiveness research. “There’s no end to mischief,” Vaughan says. “There are as many opportunities as the day is long.”

A major confrontation could arrive in March or April, when the U.S. runs into its debt ceiling. A continuing resolution would then be required to continue the appropriations process (and increase the U.S. debt ceiling past its current limit of $14.3 trillion). At that point or soon thereafter, Vaughan says, an opportunity could arise for legislators to say they won’t vote for a critical appropriations bill unless it includes certain spending reductions cited by one of several commissions tasked with recommending ways to reduce the deficit. “That could include hospital cuts, more doctor cuts, significant cost shifting to beneficiaries, higher copays,” he says.

Amid a “firestorm of ideas” on how to further cut Medicare and Medicaid spending, ideas once deemed radical could gain more traction. Some legislators have tossed around the idea of shutting down the government, if need be. “There’s nothing on the radar scope but static and fuzz,” Vaughan says. “It is totally unclear what is going to happen.”

Dearth of Drugs

Another trend generating both uncertainty and headaches in the nation’s hospitals is an unprecedented prescription drug shortage that could last well into the New Year, based on the number of medicines now in scarce supply across the country. In mid-November, for example, the American Society of Clinical Oncology announced “severe and worsening shortages of many critical therapies,” including doxorubicin, leucovorin, etoposide, nitrogen mustard, vincristine, propofol, and morphine.

Valerie Jensen, associate director of the FDA’s drug shortage program, told the Associated Press that her agency was seeing a record number of drug shortfalls in 2010. In mid-November, the FDA’s Current Drug Shortages list (www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm) included multiple formulations of 50 different medicines. Why so many? Jensen blamed the scarcity, in part, on the fact that many older drugs are not as profitable as newer ones. Manufacturing issues or delays and increased demand were the two biggest official reasons, though the FDA reported that at least eight formulations had been pulled or held from the market.

Vaughan says he’s heard plenty of buzz about the problem showing up quickly and unexpectedly in hospitals. Drug companies are supposed to give the FDA six months’ notice if they stop producing a drug, he says, but there’s no penalty if they don’t. “It’s amazing the number of people who are starting to worry about it,” he says. TH

Bryn Nelson is a freelance medical writer based in Seattle.

After the wild ride of 2010, public-policy watchers could be forgiven for fervently hoping that 2011 offers a calmer year on the healthcare front.

Fat chance.

The turbulence could begin immediately, with the seating of the 112th Congress on Jan. 3. “I think the first question that’s on everybody’s mind is, ‘What will the Republican majority in the House do to Obama’s healthcare reform initiative?’ ” says Eric Siegal, MD, SFHM, a member of SHM’s Public Policy Committee (PPC) and a clinical assistant professor of medicine at the University of Wisconsin School of Medicine and Public Health.

For most issues of direct concern to hospitalists, he says, especially those centered on healthcare delivery, “the wheels were in motion” long before the reform bill became law. Dr. Siegal also says most healthcare experts support the substance of accountable care organizations (ACOs), pay for performance, and reforming Medicare in ways that reward quality instead of quantity. “I think that ship is out of the harbor,” he says.

Throughout the year, the PPC will focus on three priorities identified in the Affordable Care Act: hospital value-based purchasing, bundled payments including ACOs, and hospital readmissions and transitions of care.

Debate, Delay, Defund?

There are several ways that Congress can delay or thwart the launch of specific reform initiatives. The first is to hold hearings about reform measures, Dr. Siegal says, “with the hope that they can somehow undermine it by raising questions about either the finances of it or about the implications for average Americans in terms of what kind of healthcare they’re going to get.” Such tactics carry significant risk, however, because highlighting specific aspects of the reform law could actually increase overall public support. “It has the potential to backfire on them,” he says.

“Repeal won’t happen anytime soon,” predicts Pat Conway, MD, chair of the PPC and director of hospital medicine at Cincinnati Children’s Hospital. “However, Congress could gut or significantly reduce funding to multiple programs within the bill, and then if you significantly reduce the funding, this may make it nearly impossible for those programs to be successful.”

Rough estimates suggest that some $150 billion worth of programs over the 10-year life of the healthcare reform act remain unfunded and are at risk. As an example, Dr. Conway cites wording in the bill that authorizes a program to help ease patient transitions in and out of the hospital. “If you reduce that funding to near zero, hospitals and hospitalists may still be successful, but you’ve essentially removed the program to learn how to be successful,” he says.

Bill Vaughan, a senior policy analyst in healthcare with the Washington, D.C.-based organization Consumers Union, says targeted riders could be added to appropriations bills. For instance, one rider could prohibit the Centers for Medicare & Medicaid Services (CMS) from spending any money to help develop government-supported insurance exchanges. Another could prevent the IRS from collecting money to be channeled into the trust fund for the Patient-Centered Outcomes Research Institute and its focus on comparative-effectiveness research. “There’s no end to mischief,” Vaughan says. “There are as many opportunities as the day is long.”

A major confrontation could arrive in March or April, when the U.S. runs into its debt ceiling. A continuing resolution would then be required to continue the appropriations process (and increase the U.S. debt ceiling past its current limit of $14.3 trillion). At that point or soon thereafter, Vaughan says, an opportunity could arise for legislators to say they won’t vote for a critical appropriations bill unless it includes certain spending reductions cited by one of several commissions tasked with recommending ways to reduce the deficit. “That could include hospital cuts, more doctor cuts, significant cost shifting to beneficiaries, higher copays,” he says.

Amid a “firestorm of ideas” on how to further cut Medicare and Medicaid spending, ideas once deemed radical could gain more traction. Some legislators have tossed around the idea of shutting down the government, if need be. “There’s nothing on the radar scope but static and fuzz,” Vaughan says. “It is totally unclear what is going to happen.”

Dearth of Drugs

Another trend generating both uncertainty and headaches in the nation’s hospitals is an unprecedented prescription drug shortage that could last well into the New Year, based on the number of medicines now in scarce supply across the country. In mid-November, for example, the American Society of Clinical Oncology announced “severe and worsening shortages of many critical therapies,” including doxorubicin, leucovorin, etoposide, nitrogen mustard, vincristine, propofol, and morphine.

Valerie Jensen, associate director of the FDA’s drug shortage program, told the Associated Press that her agency was seeing a record number of drug shortfalls in 2010. In mid-November, the FDA’s Current Drug Shortages list (www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm) included multiple formulations of 50 different medicines. Why so many? Jensen blamed the scarcity, in part, on the fact that many older drugs are not as profitable as newer ones. Manufacturing issues or delays and increased demand were the two biggest official reasons, though the FDA reported that at least eight formulations had been pulled or held from the market.

Vaughan says he’s heard plenty of buzz about the problem showing up quickly and unexpectedly in hospitals. Drug companies are supposed to give the FDA six months’ notice if they stop producing a drug, he says, but there’s no penalty if they don’t. “It’s amazing the number of people who are starting to worry about it,” he says. TH

Bryn Nelson is a freelance medical writer based in Seattle.

After the wild ride of 2010, public-policy watchers could be forgiven for fervently hoping that 2011 offers a calmer year on the healthcare front.

Fat chance.

The turbulence could begin immediately, with the seating of the 112th Congress on Jan. 3. “I think the first question that’s on everybody’s mind is, ‘What will the Republican majority in the House do to Obama’s healthcare reform initiative?’ ” says Eric Siegal, MD, SFHM, a member of SHM’s Public Policy Committee (PPC) and a clinical assistant professor of medicine at the University of Wisconsin School of Medicine and Public Health.

For most issues of direct concern to hospitalists, he says, especially those centered on healthcare delivery, “the wheels were in motion” long before the reform bill became law. Dr. Siegal also says most healthcare experts support the substance of accountable care organizations (ACOs), pay for performance, and reforming Medicare in ways that reward quality instead of quantity. “I think that ship is out of the harbor,” he says.

Throughout the year, the PPC will focus on three priorities identified in the Affordable Care Act: hospital value-based purchasing, bundled payments including ACOs, and hospital readmissions and transitions of care.

Debate, Delay, Defund?

There are several ways that Congress can delay or thwart the launch of specific reform initiatives. The first is to hold hearings about reform measures, Dr. Siegal says, “with the hope that they can somehow undermine it by raising questions about either the finances of it or about the implications for average Americans in terms of what kind of healthcare they’re going to get.” Such tactics carry significant risk, however, because highlighting specific aspects of the reform law could actually increase overall public support. “It has the potential to backfire on them,” he says.

“Repeal won’t happen anytime soon,” predicts Pat Conway, MD, chair of the PPC and director of hospital medicine at Cincinnati Children’s Hospital. “However, Congress could gut or significantly reduce funding to multiple programs within the bill, and then if you significantly reduce the funding, this may make it nearly impossible for those programs to be successful.”

Rough estimates suggest that some $150 billion worth of programs over the 10-year life of the healthcare reform act remain unfunded and are at risk. As an example, Dr. Conway cites wording in the bill that authorizes a program to help ease patient transitions in and out of the hospital. “If you reduce that funding to near zero, hospitals and hospitalists may still be successful, but you’ve essentially removed the program to learn how to be successful,” he says.

Bill Vaughan, a senior policy analyst in healthcare with the Washington, D.C.-based organization Consumers Union, says targeted riders could be added to appropriations bills. For instance, one rider could prohibit the Centers for Medicare & Medicaid Services (CMS) from spending any money to help develop government-supported insurance exchanges. Another could prevent the IRS from collecting money to be channeled into the trust fund for the Patient-Centered Outcomes Research Institute and its focus on comparative-effectiveness research. “There’s no end to mischief,” Vaughan says. “There are as many opportunities as the day is long.”

A major confrontation could arrive in March or April, when the U.S. runs into its debt ceiling. A continuing resolution would then be required to continue the appropriations process (and increase the U.S. debt ceiling past its current limit of $14.3 trillion). At that point or soon thereafter, Vaughan says, an opportunity could arise for legislators to say they won’t vote for a critical appropriations bill unless it includes certain spending reductions cited by one of several commissions tasked with recommending ways to reduce the deficit. “That could include hospital cuts, more doctor cuts, significant cost shifting to beneficiaries, higher copays,” he says.

Amid a “firestorm of ideas” on how to further cut Medicare and Medicaid spending, ideas once deemed radical could gain more traction. Some legislators have tossed around the idea of shutting down the government, if need be. “There’s nothing on the radar scope but static and fuzz,” Vaughan says. “It is totally unclear what is going to happen.”

Dearth of Drugs

Another trend generating both uncertainty and headaches in the nation’s hospitals is an unprecedented prescription drug shortage that could last well into the New Year, based on the number of medicines now in scarce supply across the country. In mid-November, for example, the American Society of Clinical Oncology announced “severe and worsening shortages of many critical therapies,” including doxorubicin, leucovorin, etoposide, nitrogen mustard, vincristine, propofol, and morphine.

Valerie Jensen, associate director of the FDA’s drug shortage program, told the Associated Press that her agency was seeing a record number of drug shortfalls in 2010. In mid-November, the FDA’s Current Drug Shortages list (www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm) included multiple formulations of 50 different medicines. Why so many? Jensen blamed the scarcity, in part, on the fact that many older drugs are not as profitable as newer ones. Manufacturing issues or delays and increased demand were the two biggest official reasons, though the FDA reported that at least eight formulations had been pulled or held from the market.

Vaughan says he’s heard plenty of buzz about the problem showing up quickly and unexpectedly in hospitals. Drug companies are supposed to give the FDA six months’ notice if they stop producing a drug, he says, but there’s no penalty if they don’t. “It’s amazing the number of people who are starting to worry about it,” he says. TH

Bryn Nelson is a freelance medical writer based in Seattle.

In This Edition

Literature at a Glance

A guide to this month’s studies

• Characteristics of CA-MRSA
• Association of gurgling with morbidity and mortality
• Antibiotics for active ulcerative colitis
• TIPS for cirrhosis-induced variceal bleeding
• Steroid dose, route in COPD exacerbations
• Effect of reminders and stop orders on urinary catheter use
• Outcomes of chest-compression-only CPR
• Albumin levels and risk of surgical-site infections

Characteristics of Community-Acquired methicillin-resistant Staphylococcus aureus Pneumonia in an Academic Medical Center

Clinical question: What are the clinical features and epidemiology of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) pneumonia?

Background: CA-MRSA is an emerging cause of pneumonia. The genetic makeup of most CA-MRSA strains is different than that of nosocomial MRSA. Typically, CA-MRSA is resistant to methicillin, beta-lactams, and erythromycin, but it retains susceptibility to trimethoprim-sulfamethoxazole (TMP/sulfa) and clindamycin.

In addition, the most common strain of CA-MRSA carries the Panton-Valentine leukocidin (PVL) toxin, which is associated with necrotizing pneumonia and high mortality rates.

Study design: Retrospective case series.

Setting: A 1,100-bed teaching hospital in Chicago.

Synopsis: Of the 5,955 discharges with a diagnosis-related group (DRG) code of pneumonia, 15 met criteria for CA-MRSA, or <1% of all inpatient community-acquired pneumonia cases. All 15 CA-MRSA strains were positive for PVL.

Seven of the 15 patients never were admitted to the ICU, while seven patients required mechanical ventilation. Seven patients were immunocompromised; one patient presented with preceding influenza; seven patients presented with hemoptysis; and eight patients demonstrated findings of lung necrosis on CT scan. Two patients died; both were immunocompromised.

Although the initial antibiotic regimen varied considerably, 14 patients ultimately received either clindamycin or linezolid.

Bottom line: CA-MRSA pneumonia is an uncommon subset of community-acquired pneumonia admissions. Approximately half the patients admitted with CA-MRSA presented with features of severe pneumonia. Nearly all were treated with antibiotics that inhibit exotoxin production, and the associated mortality rate of 13% was lower than previously reported.

Citation: Lobo JL, Reed KD, Wunderink RG. Expanded clinical presentation of community-acquired methicillin-resistant Staphylococcus aureus pneumonia. Chest. 2010;138(1):130-136.

Gurgling Breath Sounds in Hospitalized Patients Might Predict Subsequent Pneumonia Development

Clinical question: Can gurgling sounds over the glottis during speech or quiet breathing predict hospital-acquired pneumonia (HAP)?

Background: HAP is a relatively frequent complication of hospitalization. HAP usually portends an increase in morbidity and mortality. Patients in the hospital might have disease states that inhibit the reflexes that normally eliminate secretions from above or below their glottis, increasing the risk of pneumonia.

Study design: Prospective cohort.

Setting: A 350-bed community teaching hospital in Bridgeport, Conn.

Synopsis: All patients admitted to a respiratory-care unit and general medical ward from December 2008 to April 2009 underwent auscultation over their glottis by study personnel. Patients with gurgles heard during speech or quiet breathing on auscultation and patients without gurgles were entered into the study in a 1:3 fashion, until 20 patients with gurgles and 60 patients without gurgles had been enrolled. Patients were followed for the development of clinical and radiographic evidence of HAP, ICU transfer, and in-hospital death.

Both dementia and treatment with opiates were independent predictors of gurgle in multivariate analysis. HAP occurred in 55% of the patients with gurgle versus 1.7% of patients without gurgle. In addition, 50% of the patients with gurgle required transfer to the ICU, compared with only 3.3% of patients without gurgle. In-hospital mortality was 30% among patients with gurgle versus 11.7% among patients without gurgle.

Bottom line: In patients admitted to the medical service of a community teaching hospital, gurgling sounds heard over the glottis during speech or quiet inspiration are independently associated with the development of HAP, ICU transfer, and in-hospital mortality.

Citation: Vazquez R, Gheorghe C, Ramos F, Dadu R, Amoateng-Adjepong Y, Manthous CA. Gurgling breath sounds may predict hospital-acquired pneumonia. Chest. 2010;138(2):284-288.

Treatment of Active Ulcerative Colitis with Triple Antibiotic Therapy Provides Better Response than Placebo

Clinical question: Does combination antibiotic therapy induce and/or maintain remission of active ulcerative colitis (UC)?

Background: Mouse models and other experimental evidence have suggested a pathogenic role for microbes in the development and/or exacerbation of ulcerative colitis, although antibiotic human trials have produced conflicting results. Recently, Fusobacterium varium was shown to be present in the gastrointestinal (GI) tract of most UC patients, and a pilot study using targeted antibacterials demonstrated efficacy in treating active UC.

Study design: Randomized, double-blind, placebo-controlled, multicenter trial.

Setting: Eleven hospitals in Japan.

Synopsis: Patients with mild to severe chronic relapsing UC were randomly assigned to either combination antibiotic therapy or placebo. All previous UC treatment regimens were continued in study patients, with the exception of steroids, which were tapered slowly if possible. Patients in the antibiotic group received a two-week combination therapy of amoxicillin, tetracycline, and metronidazole. Patients were followed weekly or monthly and underwent periodic exams and colonoscopies to assess clinical and endoscopic improvement for 12 months.

One hundred five patients were enrolled in each group. The clinical response rate at one year in patients treated with antibiotics was 44.8% versus 22.8% in the placebo group. Remission at one year was achieved in 26.7% of patients treated with antibiotics versus 14.9% of placebo patients. Endoscopic response rates and steroid discontinuation rates were higher in the antibiotic-treated groups. Effects were most pronounced in the group of patients with active disease.

Bottom line: Triple antibiotic therapy with amoxicillin, tetracycline, and metronidazole, when compared with placebo, was associated with improvement in clinical symptoms, endoscopic findings, remission rates, and steroid withdrawal in patients with active ulcerative colitis.

Citation: Ohkusa T, Kato K, Terao S, et al. Newly developed antibiotic combination therapy for ulcerative colitis: a double-blind placebo-controlled multicenter trial. Am J Gastroenterol. 2010;105(8):1820-1829.

Early TIPS Outperformed Optimal Medical Therapy in Patients with Advanced Cirrhosis and Variceal Bleeding

Clinical question: Does early treatment with a transjugular intrahepatic portosystemic shunt (TIPS) improve outcomes in patients with advanced cirrhosis and variceal bleeding?

Background: Current management guidelines for variceal bleeding include treatment with vasoactive drugs and serial endoscopy, yet treatment failure occurs in 10% to 15% of patients. TIPS is highly effective in controlling bleeding in such patients, but it historically has been reserved for patients who repeatedly fail preventive strategies.

Study design: Randomized controlled trial.

Setting: Nine European centers.

Synopsis: Sixty-three patients with advanced cirrhosis and acute esophageal variceal bleeding treated with optimal medical therapy were randomized within 24 hours of admission to either 1) early TIPS (polytetrafluoroethylene-covered stents) within 72 hours of randomization, or 2) ongoing optimal medical therapy with vasoactive drugs, treatment with a nonselective beta-blocker, and endoscopic band ligation.

During the median 16-month follow-up, rebleeding or failure to control bleeding occurred in 45% of patients in the optimal medical therapy group versus 3% of patients in the early TIPS group. One-year actuarial survival was 61% in the optimal medical therapy group versus 86% in the early-TIPS group. Remarkably, encephalopathy was less common in the early-TIPS group, and adverse events as a whole were similar in both groups.

Bottom line: Early use of TIPS was superior to optimal medical therapy for patients with advanced cirrhosis hospitalized for acute variceal bleeding at high risk for treatment failure.

Citation: García-Pagán JC, Caca K, Bureau C, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362(25):2370-2379.

Low-Dose Oral Corticosteroids As Effective As High-Dose Intravenous Therapy in COPD Exacerbations

Clinical question: In patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD), what are the outcomes of those initially treated with low doses of steroids administered orally compared with those initially treated with higher doses intravenously?

Background: COPD affects 6% of adults in the U.S., and acute exacerbation of COPD is one of the leading causes of hospitalization nationwide. Systemic corticosteroids are beneficial for patients hospitalized with acute exacerbation of COPD; however, optimal dose and route of administration are uncertain.

Study design: Retrospective cohort.

Setting: Four hundred fourteen U.S. acute-care hospitals; most were small to midsize nonteaching facilities serving urban patient populations.

Synopsis: Almost 80,000 patients admitted to a non-ICU setting with a diagnosis of acute exacerbation of COPD from 2006 to 2007, and who received systemic corticosteroids during the first two hospital days, were included in the study. In contrast to clinical guidelines recommending the use of low-dose oral corticosteroids, 92% of study participants were treated initially with intravenous steroids, whereas 8% received oral treatment. The primary composite outcome measure—need for mechanical ventilation after the second hospital day, inpatient mortality, or readmission for COPD within 30 days—was no worse in patients treated with oral steroids. Risk of treatment failure, length of stay, and cost were significantly lower among orally treated patients.

Bottom line: High-dose intravenous steroids appear to be no more effective than low-dose oral steroids for acute exacerbation of COPD. The authors recommend a randomized controlled trial be conducted to compare these two management strategies.

Citation: Lindenauer PK, Pekow PS, Lahti MC, Lee Y, Benjamin EM, Rothberg MB. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA. 2010;303(23):2359-2367.

Reminders and Stop Orders Reduce Catheter-Associated Urinary Tract Infections

Clinical question: Do interventions that remind clinicians of the presence of urinary catheters and prompt timely removal decrease the rate of catheter-associated urinary tract infections (CA-UTI)?

Background: CA-UTI is a common yet preventable hospital-acquired infection. Many catheters are placed unnecessarily, remain in use without physician awareness, and are not removed promptly when no longer needed.

Study design: Systematic review and meta-analysis of 13 preintervention and postintervention quasi-experimental trials and one randomized controlled trial.

Setting: Studies conducted in the U.S., Canada, Europe, and Asia.

Synopsis: This literature search revealed 14 articles that used a reminder or stop-order intervention to prompt removal of urinary catheters and reported pre- and postintervention outcomes for CA-UTI rates, duration of urinary catheter use, and recatheterization need. Five studies used stop orders and nine studies used reminder interventions.

Use of a stop order or reminder reduced the rate of CA-UTI (episodes per 1,000 catheter days) by 52%. Mean duration of catheterization decreased by 37%, which resulted in 2.61 fewer days of catheterization per patient in the intervention versus control groups. Recatheterization rates were similar in the control and intervention groups.

Bottom line: Urinary catheter reminders and stop orders are low-cost strategies that appear to reduce the rate of CA-UTI.

Citation: Meddings J, Rogers MA, Macy M, Saint S. Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis. 2010;51(5):550-560.

Chest-Compression-Only Bystander CPR Increases Survival

Clinical question: Is bystander cardiopulmonary resuscitation (CPR) with chest compressions alone or chest compressions with rescue breathing superior in out-of-hospital adult cardiac arrest?

Background: Out-of-hospital cardiac arrest claims hundreds of thousands of lives each year. Early initiation of CPR by a layperson can increase a patient’s chances of surviving and having a favorable long-term neurologic recovery. Although traditional CPR consists of chest compression with rescue breathing, chest compression alone might be more acceptable to many laypersons and has the potential advantage of fewer compression interruptions.

Study design: Multicenter randomized trial.

Setting: Two EMSs in Washington state and one in London.

Synopsis: Patients were initially eligible for this study if a dispatcher determined that the patient was unconscious and not breathing, and that bystander CPR was not yet under way. If the caller was willing to undertake CPR with the dispatcher’s assistance, a randomization envelope containing CPR instructions was opened. Patients with arrest due to trauma, drowning, or asphyxiation were excluded, as were those under 18 years of age.

No significant difference was observed between the two groups in the percentage of patients who survived to hospital discharge or who survived with a favorable neurologic outcome. However, subgroup analyses showed a trend toward a higher percentage of patients surviving to hospital discharge with chest compressions alone, as compared with chest compressions with rescue breathing for patients with a cardiac cause of arrest and for those with shockable rhythms.

Bottom line: Dispatcher CPR instruction consisting of chest compression alone was noninferior to conventional CPR with rescue breathing, and it showed a trend toward better outcomes in cardiac cause of arrest.

Citation: Rea TD, Fahrenbruch C, Culley L, et al. CPR with chest compression alone or with rescue breathing. N Engl J Med. 2010;363(5):423-433.

Low Albumin Is Associated with Postoperative Wound Infections

Clinical question: What is the relationship between preoperative serum albumin levels and postoperative surgical-site infections (SSI)?

Background: Poor nutritional status is associated with adverse surgical outcomes. Serum albumin can both reflect nutritional status and function as a negative acute phase reactant, i.e., decreases in the setting of inflammation. It is uncertain whether low preoperative albumin levels are associated with postoperative SSI risk.

Study design: Retrospective cohort with multivariate analysis.

Setting: Four centers in Ireland.

Synopsis: Patients undergoing GI surgery (n=524) were prospectively followed as part of an SSI database. Demographic data, American Society of Anesthesia class, serum albumin levels, and presence and severity of SSI data were collected on all patients. Follow-up extended to 30 days.

SSI developed in 20% of patients. Patients who developed a SSI had lower serum albumin levels (mean 3.0 g/dL versus 3.6 g/dL). A serum albumin level less than 3.0 g/dL was associated with greater risk of SSI (relative risk 5.68), deeper SSI, and prolonged length of stay.

Bottom line: After controlling for other variables, serum albumin lower than 3.0 g/dL is independently associated with SSI frequency and severity.

Citation: Hennessey DB, Burke JP, Ni-Dhonochu T, Shields C, Winter DC, Mealy K. Preoperative hypoalbuminemia is an independent risk factor for the development of surgical site infection following gastrointestinal surgery: a multi-institutional study. Ann Surg. 2010;252 (2):325-329. TH

Pediatric HM Literature

Nebulized Hypertonic Saline Alone Safe to Study in Bronchiolitis

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: Is nebulized 3% saline solution safe to use alone in infants with bronchiolitis?

Background: Nebulized 3% (hypertonic) saline is increasingly used in the treatment of infants hospitalized with bronchiolitis. Studies to date have primarily investigated its efficacy in conjunction with bronchodilators due to a theoretical risk of bronchospasm. The safety profile of hypertonic saline alone in bronchiolitis is unknown.

Study design: Retrospective cohort study.

Setting: A single children’s hospital.

Synopsis: An existing QI database was reviewed during one winter season. One hundred fifty-four records were analyzed, comprising previously healthy infants with acute bronchiolitis. Hypertonic (3%) saline delivered more than four hours before and after albuterol was considered to have been given alone. Adverse events were not defined a priori, and documentation of symptoms related to medication administration was encouraged via a new comment section of a pathway scoring system.

Sixty-eight patients received 444 doses of hypertonic saline, 377 (85%) of which were administered alone. Four adverse events (1.0%) occurred in the group without adjunctive bronchodilator therapy; one adverse event (1.1%) occurred after concomitant delivery of albuterol and 3% saline. Rates of readmission and transfer to higher level of care were similar between those that did and did not receive hypertonic saline.

The potential for under-ascertainment of adverse events is significant with the retrospective design and frequency of underreporting in most hospitals. In addition, adverse events related to medication administration might be particularly difficult to assess in such dynamic diseases as bronchiolitis. Nevertheless, this study does suggest that adverse event rates are low with hypertonic saline alone, paving the way for future studies to assess its efficacy without bronchodilators clouding the picture.

Bottom line: Nebulized 3% saline has a low rate of adverse events in infants with acute bronchiolitis.

Citation: Ralston S, Hill V, Martinez M. Nebulized hypertonic saline without adjunctive bronchodilators for children with bronchiolitis. Pediatrics. 2010;126(3):e520-e525.

In This Edition

Literature at a Glance

A guide to this month’s studies

• Characteristics of CA-MRSA
• Association of gurgling with morbidity and mortality
• Antibiotics for active ulcerative colitis
• TIPS for cirrhosis-induced variceal bleeding
• Steroid dose, route in COPD exacerbations
• Effect of reminders and stop orders on urinary catheter use
• Outcomes of chest-compression-only CPR
• Albumin levels and risk of surgical-site infections

Characteristics of Community-Acquired methicillin-resistant Staphylococcus aureus Pneumonia in an Academic Medical Center

Clinical question: What are the clinical features and epidemiology of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) pneumonia?

Background: CA-MRSA is an emerging cause of pneumonia. The genetic makeup of most CA-MRSA strains is different than that of nosocomial MRSA. Typically, CA-MRSA is resistant to methicillin, beta-lactams, and erythromycin, but it retains susceptibility to trimethoprim-sulfamethoxazole (TMP/sulfa) and clindamycin.

In addition, the most common strain of CA-MRSA carries the Panton-Valentine leukocidin (PVL) toxin, which is associated with necrotizing pneumonia and high mortality rates.

Study design: Retrospective case series.

Setting: A 1,100-bed teaching hospital in Chicago.

Synopsis: Of the 5,955 discharges with a diagnosis-related group (DRG) code of pneumonia, 15 met criteria for CA-MRSA, or <1% of all inpatient community-acquired pneumonia cases. All 15 CA-MRSA strains were positive for PVL.

Seven of the 15 patients never were admitted to the ICU, while seven patients required mechanical ventilation. Seven patients were immunocompromised; one patient presented with preceding influenza; seven patients presented with hemoptysis; and eight patients demonstrated findings of lung necrosis on CT scan. Two patients died; both were immunocompromised.

Although the initial antibiotic regimen varied considerably, 14 patients ultimately received either clindamycin or linezolid.

Bottom line: CA-MRSA pneumonia is an uncommon subset of community-acquired pneumonia admissions. Approximately half the patients admitted with CA-MRSA presented with features of severe pneumonia. Nearly all were treated with antibiotics that inhibit exotoxin production, and the associated mortality rate of 13% was lower than previously reported.

Citation: Lobo JL, Reed KD, Wunderink RG. Expanded clinical presentation of community-acquired methicillin-resistant Staphylococcus aureus pneumonia. Chest. 2010;138(1):130-136.

Gurgling Breath Sounds in Hospitalized Patients Might Predict Subsequent Pneumonia Development

Clinical question: Can gurgling sounds over the glottis during speech or quiet breathing predict hospital-acquired pneumonia (HAP)?

Background: HAP is a relatively frequent complication of hospitalization. HAP usually portends an increase in morbidity and mortality. Patients in the hospital might have disease states that inhibit the reflexes that normally eliminate secretions from above or below their glottis, increasing the risk of pneumonia.

Study design: Prospective cohort.

Setting: A 350-bed community teaching hospital in Bridgeport, Conn.

Synopsis: All patients admitted to a respiratory-care unit and general medical ward from December 2008 to April 2009 underwent auscultation over their glottis by study personnel. Patients with gurgles heard during speech or quiet breathing on auscultation and patients without gurgles were entered into the study in a 1:3 fashion, until 20 patients with gurgles and 60 patients without gurgles had been enrolled. Patients were followed for the development of clinical and radiographic evidence of HAP, ICU transfer, and in-hospital death.

Both dementia and treatment with opiates were independent predictors of gurgle in multivariate analysis. HAP occurred in 55% of the patients with gurgle versus 1.7% of patients without gurgle. In addition, 50% of the patients with gurgle required transfer to the ICU, compared with only 3.3% of patients without gurgle. In-hospital mortality was 30% among patients with gurgle versus 11.7% among patients without gurgle.

Bottom line: In patients admitted to the medical service of a community teaching hospital, gurgling sounds heard over the glottis during speech or quiet inspiration are independently associated with the development of HAP, ICU transfer, and in-hospital mortality.

Citation: Vazquez R, Gheorghe C, Ramos F, Dadu R, Amoateng-Adjepong Y, Manthous CA. Gurgling breath sounds may predict hospital-acquired pneumonia. Chest. 2010;138(2):284-288.

Treatment of Active Ulcerative Colitis with Triple Antibiotic Therapy Provides Better Response than Placebo

Clinical question: Does combination antibiotic therapy induce and/or maintain remission of active ulcerative colitis (UC)?

Background: Mouse models and other experimental evidence have suggested a pathogenic role for microbes in the development and/or exacerbation of ulcerative colitis, although antibiotic human trials have produced conflicting results. Recently, Fusobacterium varium was shown to be present in the gastrointestinal (GI) tract of most UC patients, and a pilot study using targeted antibacterials demonstrated efficacy in treating active UC.

Study design: Randomized, double-blind, placebo-controlled, multicenter trial.

Setting: Eleven hospitals in Japan.

Synopsis: Patients with mild to severe chronic relapsing UC were randomly assigned to either combination antibiotic therapy or placebo. All previous UC treatment regimens were continued in study patients, with the exception of steroids, which were tapered slowly if possible. Patients in the antibiotic group received a two-week combination therapy of amoxicillin, tetracycline, and metronidazole. Patients were followed weekly or monthly and underwent periodic exams and colonoscopies to assess clinical and endoscopic improvement for 12 months.

One hundred five patients were enrolled in each group. The clinical response rate at one year in patients treated with antibiotics was 44.8% versus 22.8% in the placebo group. Remission at one year was achieved in 26.7% of patients treated with antibiotics versus 14.9% of placebo patients. Endoscopic response rates and steroid discontinuation rates were higher in the antibiotic-treated groups. Effects were most pronounced in the group of patients with active disease.

Bottom line: Triple antibiotic therapy with amoxicillin, tetracycline, and metronidazole, when compared with placebo, was associated with improvement in clinical symptoms, endoscopic findings, remission rates, and steroid withdrawal in patients with active ulcerative colitis.

Citation: Ohkusa T, Kato K, Terao S, et al. Newly developed antibiotic combination therapy for ulcerative colitis: a double-blind placebo-controlled multicenter trial. Am J Gastroenterol. 2010;105(8):1820-1829.

Early TIPS Outperformed Optimal Medical Therapy in Patients with Advanced Cirrhosis and Variceal Bleeding

Clinical question: Does early treatment with a transjugular intrahepatic portosystemic shunt (TIPS) improve outcomes in patients with advanced cirrhosis and variceal bleeding?

Background: Current management guidelines for variceal bleeding include treatment with vasoactive drugs and serial endoscopy, yet treatment failure occurs in 10% to 15% of patients. TIPS is highly effective in controlling bleeding in such patients, but it historically has been reserved for patients who repeatedly fail preventive strategies.

Study design: Randomized controlled trial.

Setting: Nine European centers.

Synopsis: Sixty-three patients with advanced cirrhosis and acute esophageal variceal bleeding treated with optimal medical therapy were randomized within 24 hours of admission to either 1) early TIPS (polytetrafluoroethylene-covered stents) within 72 hours of randomization, or 2) ongoing optimal medical therapy with vasoactive drugs, treatment with a nonselective beta-blocker, and endoscopic band ligation.

During the median 16-month follow-up, rebleeding or failure to control bleeding occurred in 45% of patients in the optimal medical therapy group versus 3% of patients in the early TIPS group. One-year actuarial survival was 61% in the optimal medical therapy group versus 86% in the early-TIPS group. Remarkably, encephalopathy was less common in the early-TIPS group, and adverse events as a whole were similar in both groups.

Bottom line: Early use of TIPS was superior to optimal medical therapy for patients with advanced cirrhosis hospitalized for acute variceal bleeding at high risk for treatment failure.

Citation: García-Pagán JC, Caca K, Bureau C, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362(25):2370-2379.

Low-Dose Oral Corticosteroids As Effective As High-Dose Intravenous Therapy in COPD Exacerbations

Clinical question: In patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD), what are the outcomes of those initially treated with low doses of steroids administered orally compared with those initially treated with higher doses intravenously?

Background: COPD affects 6% of adults in the U.S., and acute exacerbation of COPD is one of the leading causes of hospitalization nationwide. Systemic corticosteroids are beneficial for patients hospitalized with acute exacerbation of COPD; however, optimal dose and route of administration are uncertain.

Study design: Retrospective cohort.

Setting: Four hundred fourteen U.S. acute-care hospitals; most were small to midsize nonteaching facilities serving urban patient populations.

Synopsis: Almost 80,000 patients admitted to a non-ICU setting with a diagnosis of acute exacerbation of COPD from 2006 to 2007, and who received systemic corticosteroids during the first two hospital days, were included in the study. In contrast to clinical guidelines recommending the use of low-dose oral corticosteroids, 92% of study participants were treated initially with intravenous steroids, whereas 8% received oral treatment. The primary composite outcome measure—need for mechanical ventilation after the second hospital day, inpatient mortality, or readmission for COPD within 30 days—was no worse in patients treated with oral steroids. Risk of treatment failure, length of stay, and cost were significantly lower among orally treated patients.

Bottom line: High-dose intravenous steroids appear to be no more effective than low-dose oral steroids for acute exacerbation of COPD. The authors recommend a randomized controlled trial be conducted to compare these two management strategies.

Citation: Lindenauer PK, Pekow PS, Lahti MC, Lee Y, Benjamin EM, Rothberg MB. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA. 2010;303(23):2359-2367.

Reminders and Stop Orders Reduce Catheter-Associated Urinary Tract Infections

Clinical question: Do interventions that remind clinicians of the presence of urinary catheters and prompt timely removal decrease the rate of catheter-associated urinary tract infections (CA-UTI)?

Background: CA-UTI is a common yet preventable hospital-acquired infection. Many catheters are placed unnecessarily, remain in use without physician awareness, and are not removed promptly when no longer needed.

Study design: Systematic review and meta-analysis of 13 preintervention and postintervention quasi-experimental trials and one randomized controlled trial.

Setting: Studies conducted in the U.S., Canada, Europe, and Asia.

Synopsis: This literature search revealed 14 articles that used a reminder or stop-order intervention to prompt removal of urinary catheters and reported pre- and postintervention outcomes for CA-UTI rates, duration of urinary catheter use, and recatheterization need. Five studies used stop orders and nine studies used reminder interventions.

Use of a stop order or reminder reduced the rate of CA-UTI (episodes per 1,000 catheter days) by 52%. Mean duration of catheterization decreased by 37%, which resulted in 2.61 fewer days of catheterization per patient in the intervention versus control groups. Recatheterization rates were similar in the control and intervention groups.

Bottom line: Urinary catheter reminders and stop orders are low-cost strategies that appear to reduce the rate of CA-UTI.

Citation: Meddings J, Rogers MA, Macy M, Saint S. Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis. 2010;51(5):550-560.

Chest-Compression-Only Bystander CPR Increases Survival

Clinical question: Is bystander cardiopulmonary resuscitation (CPR) with chest compressions alone or chest compressions with rescue breathing superior in out-of-hospital adult cardiac arrest?

Background: Out-of-hospital cardiac arrest claims hundreds of thousands of lives each year. Early initiation of CPR by a layperson can increase a patient’s chances of surviving and having a favorable long-term neurologic recovery. Although traditional CPR consists of chest compression with rescue breathing, chest compression alone might be more acceptable to many laypersons and has the potential advantage of fewer compression interruptions.

Study design: Multicenter randomized trial.

Setting: Two EMSs in Washington state and one in London.

Synopsis: Patients were initially eligible for this study if a dispatcher determined that the patient was unconscious and not breathing, and that bystander CPR was not yet under way. If the caller was willing to undertake CPR with the dispatcher’s assistance, a randomization envelope containing CPR instructions was opened. Patients with arrest due to trauma, drowning, or asphyxiation were excluded, as were those under 18 years of age.

No significant difference was observed between the two groups in the percentage of patients who survived to hospital discharge or who survived with a favorable neurologic outcome. However, subgroup analyses showed a trend toward a higher percentage of patients surviving to hospital discharge with chest compressions alone, as compared with chest compressions with rescue breathing for patients with a cardiac cause of arrest and for those with shockable rhythms.

Bottom line: Dispatcher CPR instruction consisting of chest compression alone was noninferior to conventional CPR with rescue breathing, and it showed a trend toward better outcomes in cardiac cause of arrest.

Citation: Rea TD, Fahrenbruch C, Culley L, et al. CPR with chest compression alone or with rescue breathing. N Engl J Med. 2010;363(5):423-433.

Low Albumin Is Associated with Postoperative Wound Infections

Clinical question: What is the relationship between preoperative serum albumin levels and postoperative surgical-site infections (SSI)?

Background: Poor nutritional status is associated with adverse surgical outcomes. Serum albumin can both reflect nutritional status and function as a negative acute phase reactant, i.e., decreases in the setting of inflammation. It is uncertain whether low preoperative albumin levels are associated with postoperative SSI risk.

Study design: Retrospective cohort with multivariate analysis.

Setting: Four centers in Ireland.

Synopsis: Patients undergoing GI surgery (n=524) were prospectively followed as part of an SSI database. Demographic data, American Society of Anesthesia class, serum albumin levels, and presence and severity of SSI data were collected on all patients. Follow-up extended to 30 days.

SSI developed in 20% of patients. Patients who developed a SSI had lower serum albumin levels (mean 3.0 g/dL versus 3.6 g/dL). A serum albumin level less than 3.0 g/dL was associated with greater risk of SSI (relative risk 5.68), deeper SSI, and prolonged length of stay.

Bottom line: After controlling for other variables, serum albumin lower than 3.0 g/dL is independently associated with SSI frequency and severity.

Citation: Hennessey DB, Burke JP, Ni-Dhonochu T, Shields C, Winter DC, Mealy K. Preoperative hypoalbuminemia is an independent risk factor for the development of surgical site infection following gastrointestinal surgery: a multi-institutional study. Ann Surg. 2010;252 (2):325-329. TH

Pediatric HM Literature

Nebulized Hypertonic Saline Alone Safe to Study in Bronchiolitis

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: Is nebulized 3% saline solution safe to use alone in infants with bronchiolitis?

Background: Nebulized 3% (hypertonic) saline is increasingly used in the treatment of infants hospitalized with bronchiolitis. Studies to date have primarily investigated its efficacy in conjunction with bronchodilators due to a theoretical risk of bronchospasm. The safety profile of hypertonic saline alone in bronchiolitis is unknown.

Study design: Retrospective cohort study.

Setting: A single children’s hospital.

Synopsis: An existing QI database was reviewed during one winter season. One hundred fifty-four records were analyzed, comprising previously healthy infants with acute bronchiolitis. Hypertonic (3%) saline delivered more than four hours before and after albuterol was considered to have been given alone. Adverse events were not defined a priori, and documentation of symptoms related to medication administration was encouraged via a new comment section of a pathway scoring system.

Sixty-eight patients received 444 doses of hypertonic saline, 377 (85%) of which were administered alone. Four adverse events (1.0%) occurred in the group without adjunctive bronchodilator therapy; one adverse event (1.1%) occurred after concomitant delivery of albuterol and 3% saline. Rates of readmission and transfer to higher level of care were similar between those that did and did not receive hypertonic saline.

The potential for under-ascertainment of adverse events is significant with the retrospective design and frequency of underreporting in most hospitals. In addition, adverse events related to medication administration might be particularly difficult to assess in such dynamic diseases as bronchiolitis. Nevertheless, this study does suggest that adverse event rates are low with hypertonic saline alone, paving the way for future studies to assess its efficacy without bronchodilators clouding the picture.

Bottom line: Nebulized 3% saline has a low rate of adverse events in infants with acute bronchiolitis.

Citation: Ralston S, Hill V, Martinez M. Nebulized hypertonic saline without adjunctive bronchodilators for children with bronchiolitis. Pediatrics. 2010;126(3):e520-e525.

In This Edition

Literature at a Glance

A guide to this month’s studies

• Characteristics of CA-MRSA
• Association of gurgling with morbidity and mortality
• Antibiotics for active ulcerative colitis
• TIPS for cirrhosis-induced variceal bleeding
• Steroid dose, route in COPD exacerbations
• Effect of reminders and stop orders on urinary catheter use
• Outcomes of chest-compression-only CPR
• Albumin levels and risk of surgical-site infections

Characteristics of Community-Acquired methicillin-resistant Staphylococcus aureus Pneumonia in an Academic Medical Center

Clinical question: What are the clinical features and epidemiology of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) pneumonia?

Background: CA-MRSA is an emerging cause of pneumonia. The genetic makeup of most CA-MRSA strains is different than that of nosocomial MRSA. Typically, CA-MRSA is resistant to methicillin, beta-lactams, and erythromycin, but it retains susceptibility to trimethoprim-sulfamethoxazole (TMP/sulfa) and clindamycin.

In addition, the most common strain of CA-MRSA carries the Panton-Valentine leukocidin (PVL) toxin, which is associated with necrotizing pneumonia and high mortality rates.

Study design: Retrospective case series.

Setting: A 1,100-bed teaching hospital in Chicago.

Synopsis: Of the 5,955 discharges with a diagnosis-related group (DRG) code of pneumonia, 15 met criteria for CA-MRSA, or <1% of all inpatient community-acquired pneumonia cases. All 15 CA-MRSA strains were positive for PVL.

Seven of the 15 patients never were admitted to the ICU, while seven patients required mechanical ventilation. Seven patients were immunocompromised; one patient presented with preceding influenza; seven patients presented with hemoptysis; and eight patients demonstrated findings of lung necrosis on CT scan. Two patients died; both were immunocompromised.

Although the initial antibiotic regimen varied considerably, 14 patients ultimately received either clindamycin or linezolid.

Bottom line: CA-MRSA pneumonia is an uncommon subset of community-acquired pneumonia admissions. Approximately half the patients admitted with CA-MRSA presented with features of severe pneumonia. Nearly all were treated with antibiotics that inhibit exotoxin production, and the associated mortality rate of 13% was lower than previously reported.

Citation: Lobo JL, Reed KD, Wunderink RG. Expanded clinical presentation of community-acquired methicillin-resistant Staphylococcus aureus pneumonia. Chest. 2010;138(1):130-136.

Gurgling Breath Sounds in Hospitalized Patients Might Predict Subsequent Pneumonia Development

Clinical question: Can gurgling sounds over the glottis during speech or quiet breathing predict hospital-acquired pneumonia (HAP)?

Background: HAP is a relatively frequent complication of hospitalization. HAP usually portends an increase in morbidity and mortality. Patients in the hospital might have disease states that inhibit the reflexes that normally eliminate secretions from above or below their glottis, increasing the risk of pneumonia.

Study design: Prospective cohort.

Setting: A 350-bed community teaching hospital in Bridgeport, Conn.

Synopsis: All patients admitted to a respiratory-care unit and general medical ward from December 2008 to April 2009 underwent auscultation over their glottis by study personnel. Patients with gurgles heard during speech or quiet breathing on auscultation and patients without gurgles were entered into the study in a 1:3 fashion, until 20 patients with gurgles and 60 patients without gurgles had been enrolled. Patients were followed for the development of clinical and radiographic evidence of HAP, ICU transfer, and in-hospital death.

Both dementia and treatment with opiates were independent predictors of gurgle in multivariate analysis. HAP occurred in 55% of the patients with gurgle versus 1.7% of patients without gurgle. In addition, 50% of the patients with gurgle required transfer to the ICU, compared with only 3.3% of patients without gurgle. In-hospital mortality was 30% among patients with gurgle versus 11.7% among patients without gurgle.

Bottom line: In patients admitted to the medical service of a community teaching hospital, gurgling sounds heard over the glottis during speech or quiet inspiration are independently associated with the development of HAP, ICU transfer, and in-hospital mortality.

Citation: Vazquez R, Gheorghe C, Ramos F, Dadu R, Amoateng-Adjepong Y, Manthous CA. Gurgling breath sounds may predict hospital-acquired pneumonia. Chest. 2010;138(2):284-288.

Treatment of Active Ulcerative Colitis with Triple Antibiotic Therapy Provides Better Response than Placebo

Clinical question: Does combination antibiotic therapy induce and/or maintain remission of active ulcerative colitis (UC)?

Background: Mouse models and other experimental evidence have suggested a pathogenic role for microbes in the development and/or exacerbation of ulcerative colitis, although antibiotic human trials have produced conflicting results. Recently, Fusobacterium varium was shown to be present in the gastrointestinal (GI) tract of most UC patients, and a pilot study using targeted antibacterials demonstrated efficacy in treating active UC.

Study design: Randomized, double-blind, placebo-controlled, multicenter trial.

Setting: Eleven hospitals in Japan.

Synopsis: Patients with mild to severe chronic relapsing UC were randomly assigned to either combination antibiotic therapy or placebo. All previous UC treatment regimens were continued in study patients, with the exception of steroids, which were tapered slowly if possible. Patients in the antibiotic group received a two-week combination therapy of amoxicillin, tetracycline, and metronidazole. Patients were followed weekly or monthly and underwent periodic exams and colonoscopies to assess clinical and endoscopic improvement for 12 months.

One hundred five patients were enrolled in each group. The clinical response rate at one year in patients treated with antibiotics was 44.8% versus 22.8% in the placebo group. Remission at one year was achieved in 26.7% of patients treated with antibiotics versus 14.9% of placebo patients. Endoscopic response rates and steroid discontinuation rates were higher in the antibiotic-treated groups. Effects were most pronounced in the group of patients with active disease.

Bottom line: Triple antibiotic therapy with amoxicillin, tetracycline, and metronidazole, when compared with placebo, was associated with improvement in clinical symptoms, endoscopic findings, remission rates, and steroid withdrawal in patients with active ulcerative colitis.

Citation: Ohkusa T, Kato K, Terao S, et al. Newly developed antibiotic combination therapy for ulcerative colitis: a double-blind placebo-controlled multicenter trial. Am J Gastroenterol. 2010;105(8):1820-1829.

Early TIPS Outperformed Optimal Medical Therapy in Patients with Advanced Cirrhosis and Variceal Bleeding

Clinical question: Does early treatment with a transjugular intrahepatic portosystemic shunt (TIPS) improve outcomes in patients with advanced cirrhosis and variceal bleeding?

Background: Current management guidelines for variceal bleeding include treatment with vasoactive drugs and serial endoscopy, yet treatment failure occurs in 10% to 15% of patients. TIPS is highly effective in controlling bleeding in such patients, but it historically has been reserved for patients who repeatedly fail preventive strategies.

Study design: Randomized controlled trial.

Setting: Nine European centers.

Synopsis: Sixty-three patients with advanced cirrhosis and acute esophageal variceal bleeding treated with optimal medical therapy were randomized within 24 hours of admission to either 1) early TIPS (polytetrafluoroethylene-covered stents) within 72 hours of randomization, or 2) ongoing optimal medical therapy with vasoactive drugs, treatment with a nonselective beta-blocker, and endoscopic band ligation.

During the median 16-month follow-up, rebleeding or failure to control bleeding occurred in 45% of patients in the optimal medical therapy group versus 3% of patients in the early TIPS group. One-year actuarial survival was 61% in the optimal medical therapy group versus 86% in the early-TIPS group. Remarkably, encephalopathy was less common in the early-TIPS group, and adverse events as a whole were similar in both groups.

Bottom line: Early use of TIPS was superior to optimal medical therapy for patients with advanced cirrhosis hospitalized for acute variceal bleeding at high risk for treatment failure.

Citation: García-Pagán JC, Caca K, Bureau C, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362(25):2370-2379.

Low-Dose Oral Corticosteroids As Effective As High-Dose Intravenous Therapy in COPD Exacerbations

Clinical question: In patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD), what are the outcomes of those initially treated with low doses of steroids administered orally compared with those initially treated with higher doses intravenously?

Background: COPD affects 6% of adults in the U.S., and acute exacerbation of COPD is one of the leading causes of hospitalization nationwide. Systemic corticosteroids are beneficial for patients hospitalized with acute exacerbation of COPD; however, optimal dose and route of administration are uncertain.

Study design: Retrospective cohort.

Setting: Four hundred fourteen U.S. acute-care hospitals; most were small to midsize nonteaching facilities serving urban patient populations.

Synopsis: Almost 80,000 patients admitted to a non-ICU setting with a diagnosis of acute exacerbation of COPD from 2006 to 2007, and who received systemic corticosteroids during the first two hospital days, were included in the study. In contrast to clinical guidelines recommending the use of low-dose oral corticosteroids, 92% of study participants were treated initially with intravenous steroids, whereas 8% received oral treatment. The primary composite outcome measure—need for mechanical ventilation after the second hospital day, inpatient mortality, or readmission for COPD within 30 days—was no worse in patients treated with oral steroids. Risk of treatment failure, length of stay, and cost were significantly lower among orally treated patients.

Bottom line: High-dose intravenous steroids appear to be no more effective than low-dose oral steroids for acute exacerbation of COPD. The authors recommend a randomized controlled trial be conducted to compare these two management strategies.

Citation: Lindenauer PK, Pekow PS, Lahti MC, Lee Y, Benjamin EM, Rothberg MB. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA. 2010;303(23):2359-2367.

Reminders and Stop Orders Reduce Catheter-Associated Urinary Tract Infections

Clinical question: Do interventions that remind clinicians of the presence of urinary catheters and prompt timely removal decrease the rate of catheter-associated urinary tract infections (CA-UTI)?

Background: CA-UTI is a common yet preventable hospital-acquired infection. Many catheters are placed unnecessarily, remain in use without physician awareness, and are not removed promptly when no longer needed.

Study design: Systematic review and meta-analysis of 13 preintervention and postintervention quasi-experimental trials and one randomized controlled trial.

Setting: Studies conducted in the U.S., Canada, Europe, and Asia.

Synopsis: This literature search revealed 14 articles that used a reminder or stop-order intervention to prompt removal of urinary catheters and reported pre- and postintervention outcomes for CA-UTI rates, duration of urinary catheter use, and recatheterization need. Five studies used stop orders and nine studies used reminder interventions.

Use of a stop order or reminder reduced the rate of CA-UTI (episodes per 1,000 catheter days) by 52%. Mean duration of catheterization decreased by 37%, which resulted in 2.61 fewer days of catheterization per patient in the intervention versus control groups. Recatheterization rates were similar in the control and intervention groups.

Bottom line: Urinary catheter reminders and stop orders are low-cost strategies that appear to reduce the rate of CA-UTI.

Citation: Meddings J, Rogers MA, Macy M, Saint S. Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis. 2010;51(5):550-560.

Chest-Compression-Only Bystander CPR Increases Survival

Clinical question: Is bystander cardiopulmonary resuscitation (CPR) with chest compressions alone or chest compressions with rescue breathing superior in out-of-hospital adult cardiac arrest?

Background: Out-of-hospital cardiac arrest claims hundreds of thousands of lives each year. Early initiation of CPR by a layperson can increase a patient’s chances of surviving and having a favorable long-term neurologic recovery. Although traditional CPR consists of chest compression with rescue breathing, chest compression alone might be more acceptable to many laypersons and has the potential advantage of fewer compression interruptions.

Study design: Multicenter randomized trial.

Setting: Two EMSs in Washington state and one in London.

Synopsis: Patients were initially eligible for this study if a dispatcher determined that the patient was unconscious and not breathing, and that bystander CPR was not yet under way. If the caller was willing to undertake CPR with the dispatcher’s assistance, a randomization envelope containing CPR instructions was opened. Patients with arrest due to trauma, drowning, or asphyxiation were excluded, as were those under 18 years of age.

No significant difference was observed between the two groups in the percentage of patients who survived to hospital discharge or who survived with a favorable neurologic outcome. However, subgroup analyses showed a trend toward a higher percentage of patients surviving to hospital discharge with chest compressions alone, as compared with chest compressions with rescue breathing for patients with a cardiac cause of arrest and for those with shockable rhythms.

Bottom line: Dispatcher CPR instruction consisting of chest compression alone was noninferior to conventional CPR with rescue breathing, and it showed a trend toward better outcomes in cardiac cause of arrest.

Citation: Rea TD, Fahrenbruch C, Culley L, et al. CPR with chest compression alone or with rescue breathing. N Engl J Med. 2010;363(5):423-433.

Low Albumin Is Associated with Postoperative Wound Infections

Clinical question: What is the relationship between preoperative serum albumin levels and postoperative surgical-site infections (SSI)?

Background: Poor nutritional status is associated with adverse surgical outcomes. Serum albumin can both reflect nutritional status and function as a negative acute phase reactant, i.e., decreases in the setting of inflammation. It is uncertain whether low preoperative albumin levels are associated with postoperative SSI risk.

Study design: Retrospective cohort with multivariate analysis.

Setting: Four centers in Ireland.

Synopsis: Patients undergoing GI surgery (n=524) were prospectively followed as part of an SSI database. Demographic data, American Society of Anesthesia class, serum albumin levels, and presence and severity of SSI data were collected on all patients. Follow-up extended to 30 days.

SSI developed in 20% of patients. Patients who developed a SSI had lower serum albumin levels (mean 3.0 g/dL versus 3.6 g/dL). A serum albumin level less than 3.0 g/dL was associated with greater risk of SSI (relative risk 5.68), deeper SSI, and prolonged length of stay.

Bottom line: After controlling for other variables, serum albumin lower than 3.0 g/dL is independently associated with SSI frequency and severity.

Citation: Hennessey DB, Burke JP, Ni-Dhonochu T, Shields C, Winter DC, Mealy K. Preoperative hypoalbuminemia is an independent risk factor for the development of surgical site infection following gastrointestinal surgery: a multi-institutional study. Ann Surg. 2010;252 (2):325-329. TH

Pediatric HM Literature

Nebulized Hypertonic Saline Alone Safe to Study in Bronchiolitis

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: Is nebulized 3% saline solution safe to use alone in infants with bronchiolitis?

Background: Nebulized 3% (hypertonic) saline is increasingly used in the treatment of infants hospitalized with bronchiolitis. Studies to date have primarily investigated its efficacy in conjunction with bronchodilators due to a theoretical risk of bronchospasm. The safety profile of hypertonic saline alone in bronchiolitis is unknown.

Study design: Retrospective cohort study.

Setting: A single children’s hospital.

Synopsis: An existing QI database was reviewed during one winter season. One hundred fifty-four records were analyzed, comprising previously healthy infants with acute bronchiolitis. Hypertonic (3%) saline delivered more than four hours before and after albuterol was considered to have been given alone. Adverse events were not defined a priori, and documentation of symptoms related to medication administration was encouraged via a new comment section of a pathway scoring system.

Sixty-eight patients received 444 doses of hypertonic saline, 377 (85%) of which were administered alone. Four adverse events (1.0%) occurred in the group without adjunctive bronchodilator therapy; one adverse event (1.1%) occurred after concomitant delivery of albuterol and 3% saline. Rates of readmission and transfer to higher level of care were similar between those that did and did not receive hypertonic saline.

The potential for under-ascertainment of adverse events is significant with the retrospective design and frequency of underreporting in most hospitals. In addition, adverse events related to medication administration might be particularly difficult to assess in such dynamic diseases as bronchiolitis. Nevertheless, this study does suggest that adverse event rates are low with hypertonic saline alone, paving the way for future studies to assess its efficacy without bronchodilators clouding the picture.

Bottom line: Nebulized 3% saline has a low rate of adverse events in infants with acute bronchiolitis.

Citation: Ralston S, Hill V, Martinez M. Nebulized hypertonic saline without adjunctive bronchodilators for children with bronchiolitis. Pediatrics. 2010;126(3):e520-e525.

The Centers for Medicare & Medicaid Services (CMS) in November announced the official launch of the Center for Medicare & Medicaid Innovation (CMMI). The CMI was authorized under the Affordable Care Act (ACA) to test innovative ways to reduce costs, while preserving or enhancing the quality. This sounds very similar to many other reform initiatives, so why have a separate center when ACOs, value-based purchasing, and payment bundling already are in the ACA?

A quick glance at the CMMI website didn’t provide much detail beyond uplifting language about the promise that the center represents. Don Berwick, MD, the new CMS administrator, has even gone so far as to call the center the “jewel in the crown” of the ACA.

Inspirational language aside, the center can be summed up using a simple analogy: The “other” ACA initiatives (bundling, VBP, etc.) are like a factory floor. The tools are in place, the processes are more or less defined, and they will be carried out regardless of the degree of positive impact. CMMI is more like a research and development lab, with the freedom to tinker with new ideas before wide-scale implementation.

The keys to CMMI success are twofold. First, it will implement pilot projects rather than demonstrations. A pilot gives the Secretary of Health and Human Services the power to implement and expand promising projects without Congressional approval. A demonstration requires Congressional approval for its continuation.. Second, CMMI does not require proposals to be budget neutral. Initial training and staffing costs alone can disqualify a program on budget neutrality grounds. Since CMMI does not require budget neutrality, promising programs with significant start-up costs are less likely to be cast aside.

Dr. Berwick has asked for provider partnership and input, and says he “would like to help forge an unprecedented level of shared aim, shared vision, and synergy in action among the public and private stewards and leaders of healthcare.” This vision and a $10 billion appropriation over the next decade present a tremendous opportunity for SHM’s quality initiatives, and the promising hospitalist-created protocol.

However, this large appropriation presents both the greatest strength and the greatest threat to the center. With the Republican takeover of the House of Representatives, the CMMI budget likely is to be a target for the “repeal, replace, or revise” agenda. Therefore, increasing awareness of CMMI’s role will be imperative over the coming months. Hospitalists can help by educating themselves, then passing their knowledge along to those who might not understand the importance of the center. TH

The Centers for Medicare & Medicaid Services (CMS) in November announced the official launch of the Center for Medicare & Medicaid Innovation (CMMI). The CMI was authorized under the Affordable Care Act (ACA) to test innovative ways to reduce costs, while preserving or enhancing the quality. This sounds very similar to many other reform initiatives, so why have a separate center when ACOs, value-based purchasing, and payment bundling already are in the ACA?

A quick glance at the CMMI website didn’t provide much detail beyond uplifting language about the promise that the center represents. Don Berwick, MD, the new CMS administrator, has even gone so far as to call the center the “jewel in the crown” of the ACA.

Inspirational language aside, the center can be summed up using a simple analogy: The “other” ACA initiatives (bundling, VBP, etc.) are like a factory floor. The tools are in place, the processes are more or less defined, and they will be carried out regardless of the degree of positive impact. CMMI is more like a research and development lab, with the freedom to tinker with new ideas before wide-scale implementation.

The keys to CMMI success are twofold. First, it will implement pilot projects rather than demonstrations. A pilot gives the Secretary of Health and Human Services the power to implement and expand promising projects without Congressional approval. A demonstration requires Congressional approval for its continuation.. Second, CMMI does not require proposals to be budget neutral. Initial training and staffing costs alone can disqualify a program on budget neutrality grounds. Since CMMI does not require budget neutrality, promising programs with significant start-up costs are less likely to be cast aside.

Dr. Berwick has asked for provider partnership and input, and says he “would like to help forge an unprecedented level of shared aim, shared vision, and synergy in action among the public and private stewards and leaders of healthcare.” This vision and a $10 billion appropriation over the next decade present a tremendous opportunity for SHM’s quality initiatives, and the promising hospitalist-created protocol.

However, this large appropriation presents both the greatest strength and the greatest threat to the center. With the Republican takeover of the House of Representatives, the CMMI budget likely is to be a target for the “repeal, replace, or revise” agenda. Therefore, increasing awareness of CMMI’s role will be imperative over the coming months. Hospitalists can help by educating themselves, then passing their knowledge along to those who might not understand the importance of the center. TH

The Centers for Medicare & Medicaid Services (CMS) in November announced the official launch of the Center for Medicare & Medicaid Innovation (CMMI). The CMI was authorized under the Affordable Care Act (ACA) to test innovative ways to reduce costs, while preserving or enhancing the quality. This sounds very similar to many other reform initiatives, so why have a separate center when ACOs, value-based purchasing, and payment bundling already are in the ACA?

A quick glance at the CMMI website didn’t provide much detail beyond uplifting language about the promise that the center represents. Don Berwick, MD, the new CMS administrator, has even gone so far as to call the center the “jewel in the crown” of the ACA.

Inspirational language aside, the center can be summed up using a simple analogy: The “other” ACA initiatives (bundling, VBP, etc.) are like a factory floor. The tools are in place, the processes are more or less defined, and they will be carried out regardless of the degree of positive impact. CMMI is more like a research and development lab, with the freedom to tinker with new ideas before wide-scale implementation.

The keys to CMMI success are twofold. First, it will implement pilot projects rather than demonstrations. A pilot gives the Secretary of Health and Human Services the power to implement and expand promising projects without Congressional approval. A demonstration requires Congressional approval for its continuation.. Second, CMMI does not require proposals to be budget neutral. Initial training and staffing costs alone can disqualify a program on budget neutrality grounds. Since CMMI does not require budget neutrality, promising programs with significant start-up costs are less likely to be cast aside.

Dr. Berwick has asked for provider partnership and input, and says he “would like to help forge an unprecedented level of shared aim, shared vision, and synergy in action among the public and private stewards and leaders of healthcare.” This vision and a $10 billion appropriation over the next decade present a tremendous opportunity for SHM’s quality initiatives, and the promising hospitalist-created protocol.

However, this large appropriation presents both the greatest strength and the greatest threat to the center. With the Republican takeover of the House of Representatives, the CMMI budget likely is to be a target for the “repeal, replace, or revise” agenda. Therefore, increasing awareness of CMMI’s role will be imperative over the coming months. Hospitalists can help by educating themselves, then passing their knowledge along to those who might not understand the importance of the center. TH

Every clinician in HM depends on a smooth-running hospitalist program to ensure the best possible patient care and efficiency. Even though they might not be visible to hospitalized patients, practice administration issues (e.g. compensation and incentives, reporting return on investment, or the Physician’s Quality Reporting System) are vital components to effectively running an HM group. And that’s what explains the growing popularity of SHM’s new resources for administrators.

In 2010, SHM presented five free online discussions for hospitalist practice leaders. Each session in the Practice Administrators’ Roundtable Series began with a formal presentation and was followed with open discussion from administrators and leaders from around the country.

SHM will continue the program in 2011 with such topics as Hospitalist Recruitment, Retention, & Orientation (Feb. 24) and Patient Satisfaction (May 26).

“The response to new programs for hospitalist administrators has been very positive,” says Kim Dickinson, MA, regional COO for Cogent Healthcare and a member of SHM’s Administrators’ Task Force, which has taken the lead on planning the roundtables. “As hospital medicine programs continue to evolve, there will be a growing need to address their administrative issues, too.”

The program will break new ground in 2011 with the first SHM Award for Excellence in Hospital Medicine. The new award, to be presented at HM11, will recognize a physician assistant, nurse practitioner, RN, pharmacist, administrator, case manager, or a nonphysician member of SHM.

“Hospital medicine groups depend on effective leadership, communication and administration,” says SHM president Jeff Wiese, MD, SFHM. “That’s why these new programs are so critical to improving quality, safety, and efficiency in hospital care. It is appropriate then that the best of the best should be recognized in this regard. I am personally excited to present the first SHM Award for Excellence in Hospital Medicine at the SHM annual meeting in Dallas.”

All of the roundtable discussions are archived in SHM’s Practice Management Institute (www.hospitalmedicine.org/practiceresources).

Every clinician in HM depends on a smooth-running hospitalist program to ensure the best possible patient care and efficiency. Even though they might not be visible to hospitalized patients, practice administration issues (e.g. compensation and incentives, reporting return on investment, or the Physician’s Quality Reporting System) are vital components to effectively running an HM group. And that’s what explains the growing popularity of SHM’s new resources for administrators.

In 2010, SHM presented five free online discussions for hospitalist practice leaders. Each session in the Practice Administrators’ Roundtable Series began with a formal presentation and was followed with open discussion from administrators and leaders from around the country.

SHM will continue the program in 2011 with such topics as Hospitalist Recruitment, Retention, & Orientation (Feb. 24) and Patient Satisfaction (May 26).

“The response to new programs for hospitalist administrators has been very positive,” says Kim Dickinson, MA, regional COO for Cogent Healthcare and a member of SHM’s Administrators’ Task Force, which has taken the lead on planning the roundtables. “As hospital medicine programs continue to evolve, there will be a growing need to address their administrative issues, too.”

The program will break new ground in 2011 with the first SHM Award for Excellence in Hospital Medicine. The new award, to be presented at HM11, will recognize a physician assistant, nurse practitioner, RN, pharmacist, administrator, case manager, or a nonphysician member of SHM.

“Hospital medicine groups depend on effective leadership, communication and administration,” says SHM president Jeff Wiese, MD, SFHM. “That’s why these new programs are so critical to improving quality, safety, and efficiency in hospital care. It is appropriate then that the best of the best should be recognized in this regard. I am personally excited to present the first SHM Award for Excellence in Hospital Medicine at the SHM annual meeting in Dallas.”

All of the roundtable discussions are archived in SHM’s Practice Management Institute (www.hospitalmedicine.org/practiceresources).

Every clinician in HM depends on a smooth-running hospitalist program to ensure the best possible patient care and efficiency. Even though they might not be visible to hospitalized patients, practice administration issues (e.g. compensation and incentives, reporting return on investment, or the Physician’s Quality Reporting System) are vital components to effectively running an HM group. And that’s what explains the growing popularity of SHM’s new resources for administrators.

In 2010, SHM presented five free online discussions for hospitalist practice leaders. Each session in the Practice Administrators’ Roundtable Series began with a formal presentation and was followed with open discussion from administrators and leaders from around the country.

SHM will continue the program in 2011 with such topics as Hospitalist Recruitment, Retention, & Orientation (Feb. 24) and Patient Satisfaction (May 26).

“The response to new programs for hospitalist administrators has been very positive,” says Kim Dickinson, MA, regional COO for Cogent Healthcare and a member of SHM’s Administrators’ Task Force, which has taken the lead on planning the roundtables. “As hospital medicine programs continue to evolve, there will be a growing need to address their administrative issues, too.”

The program will break new ground in 2011 with the first SHM Award for Excellence in Hospital Medicine. The new award, to be presented at HM11, will recognize a physician assistant, nurse practitioner, RN, pharmacist, administrator, case manager, or a nonphysician member of SHM.

“Hospital medicine groups depend on effective leadership, communication and administration,” says SHM president Jeff Wiese, MD, SFHM. “That’s why these new programs are so critical to improving quality, safety, and efficiency in hospital care. It is appropriate then that the best of the best should be recognized in this regard. I am personally excited to present the first SHM Award for Excellence in Hospital Medicine at the SHM annual meeting in Dallas.”

All of the roundtable discussions are archived in SHM’s Practice Management Institute (www.hospitalmedicine.org/practiceresources).

Some of the country’s most forward-looking hospitalists will begin the year with the first recognition of Focused Practice in Hospital Medicine (FPHM) from the American Board of Hospital Medicine (ABIM).

According to ABIM, “completion of the program identifies diplomates as ABIM board-certified in internal medicine with a Focused Practice in Hospital Medicine.”

The new program, which requires attestations from supervisors, a self-evaluation, and the completion of a secure examination, is the first time the unique skill sets and experience of hospitalists have been recognized by ABIM, the national leader in certification and standards in internal medicine.

SHM’s leadership has played a key role in the development of the FPHM program. SHM president Jeff Wiese, MD, SFHM, chaired the ABIM committee in charge of writing the FPHM exam. “Any serious hospitalist should consider applying for the FPHM designation,” Dr. Wiese says. “It is an important way to continually build credibility for both the individual hospitalist and the specialty.”

Hospitalists can apply for ABIM Focused Practice in Hospital Medicine Maintenance of Certification (MOC) as part of their regular MOC process. Alternatively, you can enter the process before your MOC is due to expire. While the 2011 exam will be held in October, now is the time to begin planning the application process. SHM’s support for the program extends to education for its members, including a pre-course at HM11 dedicated to preparing for the ABIM exam. Pre-course attendees will earn 20 self-evaluation points toward the FPHM designation.

For details on the program and resources for applying for FPHM, visit www.hospitalmedicine.org/moc.

Some of the country’s most forward-looking hospitalists will begin the year with the first recognition of Focused Practice in Hospital Medicine (FPHM) from the American Board of Hospital Medicine (ABIM).

According to ABIM, “completion of the program identifies diplomates as ABIM board-certified in internal medicine with a Focused Practice in Hospital Medicine.”

The new program, which requires attestations from supervisors, a self-evaluation, and the completion of a secure examination, is the first time the unique skill sets and experience of hospitalists have been recognized by ABIM, the national leader in certification and standards in internal medicine.

SHM’s leadership has played a key role in the development of the FPHM program. SHM president Jeff Wiese, MD, SFHM, chaired the ABIM committee in charge of writing the FPHM exam. “Any serious hospitalist should consider applying for the FPHM designation,” Dr. Wiese says. “It is an important way to continually build credibility for both the individual hospitalist and the specialty.”

Hospitalists can apply for ABIM Focused Practice in Hospital Medicine Maintenance of Certification (MOC) as part of their regular MOC process. Alternatively, you can enter the process before your MOC is due to expire. While the 2011 exam will be held in October, now is the time to begin planning the application process. SHM’s support for the program extends to education for its members, including a pre-course at HM11 dedicated to preparing for the ABIM exam. Pre-course attendees will earn 20 self-evaluation points toward the FPHM designation.

For details on the program and resources for applying for FPHM, visit www.hospitalmedicine.org/moc.

Some of the country’s most forward-looking hospitalists will begin the year with the first recognition of Focused Practice in Hospital Medicine (FPHM) from the American Board of Hospital Medicine (ABIM).

According to ABIM, “completion of the program identifies diplomates as ABIM board-certified in internal medicine with a Focused Practice in Hospital Medicine.”

The new program, which requires attestations from supervisors, a self-evaluation, and the completion of a secure examination, is the first time the unique skill sets and experience of hospitalists have been recognized by ABIM, the national leader in certification and standards in internal medicine.

SHM’s leadership has played a key role in the development of the FPHM program. SHM president Jeff Wiese, MD, SFHM, chaired the ABIM committee in charge of writing the FPHM exam. “Any serious hospitalist should consider applying for the FPHM designation,” Dr. Wiese says. “It is an important way to continually build credibility for both the individual hospitalist and the specialty.”

Hospitalists can apply for ABIM Focused Practice in Hospital Medicine Maintenance of Certification (MOC) as part of their regular MOC process. Alternatively, you can enter the process before your MOC is due to expire. While the 2011 exam will be held in October, now is the time to begin planning the application process. SHM’s support for the program extends to education for its members, including a pre-course at HM11 dedicated to preparing for the ABIM exam. Pre-course attendees will earn 20 self-evaluation points toward the FPHM designation.

For details on the program and resources for applying for FPHM, visit www.hospitalmedicine.org/moc.

Health reform continues to be a white-hot topic in hospitals, and SHM is bringing one of Washington’s top experts to speak at HM11.

Bob Kocher, MD, who recently served in the Obama administration as special assistant to the president for healthcare and economic policy and as a member of the National Economic Council, will be the featured speaker on May 11, the first day of HM11 at the Gaylord Texan Resort & Convention Center in Grapevine, Texas.

Dr. Kocher’s session, “Coming to Your Hospital: Healthcare Reform. What Does This Mean for Hospitalists?” will unravel the complexities in the new health reform laws and dispel myths about its impact on patient care in the hospital.

When he worked at the White House, Dr. Kocher was one of President Obama’s leading shapers of the healthcare reform legislation. Today, he is a principal with the global management-consulting firm McKinsey and Company, where he leads the McKinsey Center for Health Reform. He also is a nonresident senior fellow at the Brookings Institution’s Engelberg Center for Health Care Reform.

“We’re thrilled to bring this kind of top-level perspective to hospitalists at HM11,” says Geri Barnes, senior director for education and meetings at SHM. “His insight can alleviate the confusion and uncertainty that surround a complicated topic like health reform.”

Later that day, hospitalists will provide their perspective on health reform in a session titled “The Biggest Changes in Healthcare Reform: What We Know Now.”

View the complete HM11 schedule at www.hospital medicine2011.org/schedule.

Health reform continues to be a white-hot topic in hospitals, and SHM is bringing one of Washington’s top experts to speak at HM11.

Bob Kocher, MD, who recently served in the Obama administration as special assistant to the president for healthcare and economic policy and as a member of the National Economic Council, will be the featured speaker on May 11, the first day of HM11 at the Gaylord Texan Resort & Convention Center in Grapevine, Texas.

Dr. Kocher’s session, “Coming to Your Hospital: Healthcare Reform. What Does This Mean for Hospitalists?” will unravel the complexities in the new health reform laws and dispel myths about its impact on patient care in the hospital.

When he worked at the White House, Dr. Kocher was one of President Obama’s leading shapers of the healthcare reform legislation. Today, he is a principal with the global management-consulting firm McKinsey and Company, where he leads the McKinsey Center for Health Reform. He also is a nonresident senior fellow at the Brookings Institution’s Engelberg Center for Health Care Reform.

“We’re thrilled to bring this kind of top-level perspective to hospitalists at HM11,” says Geri Barnes, senior director for education and meetings at SHM. “His insight can alleviate the confusion and uncertainty that surround a complicated topic like health reform.”

Later that day, hospitalists will provide their perspective on health reform in a session titled “The Biggest Changes in Healthcare Reform: What We Know Now.”

View the complete HM11 schedule at www.hospital medicine2011.org/schedule.

Health reform continues to be a white-hot topic in hospitals, and SHM is bringing one of Washington’s top experts to speak at HM11.

Bob Kocher, MD, who recently served in the Obama administration as special assistant to the president for healthcare and economic policy and as a member of the National Economic Council, will be the featured speaker on May 11, the first day of HM11 at the Gaylord Texan Resort & Convention Center in Grapevine, Texas.

Dr. Kocher’s session, “Coming to Your Hospital: Healthcare Reform. What Does This Mean for Hospitalists?” will unravel the complexities in the new health reform laws and dispel myths about its impact on patient care in the hospital.

When he worked at the White House, Dr. Kocher was one of President Obama’s leading shapers of the healthcare reform legislation. Today, he is a principal with the global management-consulting firm McKinsey and Company, where he leads the McKinsey Center for Health Reform. He also is a nonresident senior fellow at the Brookings Institution’s Engelberg Center for Health Care Reform.

“We’re thrilled to bring this kind of top-level perspective to hospitalists at HM11,” says Geri Barnes, senior director for education and meetings at SHM. “His insight can alleviate the confusion and uncertainty that surround a complicated topic like health reform.”

Later that day, hospitalists will provide their perspective on health reform in a session titled “The Biggest Changes in Healthcare Reform: What We Know Now.”

View the complete HM11 schedule at www.hospital medicine2011.org/schedule.

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Just 15 years since the term “hospitalist” was first coined, hospital medicine and SHM are on the leading edge of unprecedented growth and influence within healthcare.

New data from the American Hospital Association estimate that there are now more than 34,000 hospitalists in service in hospitals throughout the country. And those hospitals quickly are becoming the front line in the transformation of healthcare.

The growth and influence of the specialty creates opportunities for hospitalists of all stripes and interests to develop professionally and exercise new leadership—inside their hospitals and throughout their communities.

Through new quality-improvement (QI) programs, online events, and face-to-face meetings, SHM is creating a platform for ambitious, patient-focused hospitalists to lead and collaborate.

“This is a new era of unprecedented opportunity for hospitalists,” says SHM president Jeff Wiese, MD, SFHM. “The demand for our skills is evident. Our numbers and credibility as a specialty continue to grow. And now, hospitalists have the tools to implement real change that will improve patient care and how it is delivered.”

But the scope of the HM movement shouldn’t deter hospitalists from taking the first step, Dr. Wiese says.

“It all starts with registering for the annual meeting for the first time, or applying for SHM’s Leadership Academy, or downloading the Project BOOST toolkit to reduce readmissions in your hospital, or attending an online webinar,” says Dr. Wiese.

For many hospitalists, that first step has led to additional opportunities for collaboration with leaders in the specialty, bringing new skill sets to their hospitals, and improving their careers.

Just 15 years since the term “hospitalist” was first coined, hospital medicine and SHM are on the leading edge of unprecedented growth and influence within healthcare.

New data from the American Hospital Association estimate that there are now more than 34,000 hospitalists in service in hospitals throughout the country. And those hospitals quickly are becoming the front line in the transformation of healthcare.

The growth and influence of the specialty creates opportunities for hospitalists of all stripes and interests to develop professionally and exercise new leadership—inside their hospitals and throughout their communities.

Through new quality-improvement (QI) programs, online events, and face-to-face meetings, SHM is creating a platform for ambitious, patient-focused hospitalists to lead and collaborate.

“This is a new era of unprecedented opportunity for hospitalists,” says SHM president Jeff Wiese, MD, SFHM. “The demand for our skills is evident. Our numbers and credibility as a specialty continue to grow. And now, hospitalists have the tools to implement real change that will improve patient care and how it is delivered.”

But the scope of the HM movement shouldn’t deter hospitalists from taking the first step, Dr. Wiese says.

“It all starts with registering for the annual meeting for the first time, or applying for SHM’s Leadership Academy, or downloading the Project BOOST toolkit to reduce readmissions in your hospital, or attending an online webinar,” says Dr. Wiese.

For many hospitalists, that first step has led to additional opportunities for collaboration with leaders in the specialty, bringing new skill sets to their hospitals, and improving their careers.

Just 15 years since the term “hospitalist” was first coined, hospital medicine and SHM are on the leading edge of unprecedented growth and influence within healthcare.

New data from the American Hospital Association estimate that there are now more than 34,000 hospitalists in service in hospitals throughout the country. And those hospitals quickly are becoming the front line in the transformation of healthcare.

The growth and influence of the specialty creates opportunities for hospitalists of all stripes and interests to develop professionally and exercise new leadership—inside their hospitals and throughout their communities.

Through new quality-improvement (QI) programs, online events, and face-to-face meetings, SHM is creating a platform for ambitious, patient-focused hospitalists to lead and collaborate.

“This is a new era of unprecedented opportunity for hospitalists,” says SHM president Jeff Wiese, MD, SFHM. “The demand for our skills is evident. Our numbers and credibility as a specialty continue to grow. And now, hospitalists have the tools to implement real change that will improve patient care and how it is delivered.”

But the scope of the HM movement shouldn’t deter hospitalists from taking the first step, Dr. Wiese says.

“It all starts with registering for the annual meeting for the first time, or applying for SHM’s Leadership Academy, or downloading the Project BOOST toolkit to reduce readmissions in your hospital, or attending an online webinar,” says Dr. Wiese.

For many hospitalists, that first step has led to additional opportunities for collaboration with leaders in the specialty, bringing new skill sets to their hospitals, and improving their careers.

It is hard to think of medical hospitalists as the establishment, but with more than 30,000 hospitalists nationwide working at most U.S. hospitals, HM is a firm part of today’s medical practice. While, dare I say, “traditional” HM is still very much in its evolution, other specialties of HM have not only cropped up on the scene, but some also have developed enough of a presence to be worthy of drawing some early conclusions.

OB-GYN hospitalists, also known as laborists, now practice at more than 100 hospitals in more than 35 states, according to http://obgynhospitalist.com. In many ways, the OB hospitalist movement is tracking the HM movement of 10 years ago. Although there are several similarities, there are more differences than just what the doctors do in their medical practices.

New “Partners” Drive Down Costs

HM has been driven as much by hospital payment by DRGs as anything else. As hospitals realized that hospitalists could better utilize resources and still maintain quality, the ability to reduce length of stay allowed hospitals to have the capital to support the early development of HM groups.

In obstetrics, the ability of laborists to reduce liability risks, and therefore malpractice premiums, for the hospital is a major driver of the recent growth in OB-GYN hospitalist groups. Some hospitals have been able to reduce the amount they must hold in reserve for future OB-related malpractice claims by more than $1 million after the first year of starting a laborist program. Additionally, hospitals’ annual malpractice premiums have dropped significantly.

Availability of on-site hospitalists has played a crucial role in this new delivery model for most of the hospitalist specialties. For hospitals with laborists, this has meant a significant decrease (for some, a total relief) in unattended deliveries, which in some hospitals was as high as 10% before the new breed of hospitalist arrived on the scene. This 24/7 obstetrician presence has reduced complications from many labor and delivery emergencies, and has led to improved patient safety and improved overall performance at the crucial moment of delivery. This is especially true for high-risk and emergency situations.

Just as in the rest of HM, the 24/7 availability has been complementary, not competitive, to community-based obstetricians: Unassigned patients now have someone to deliver their baby; community obstetricians have a hospital-based “partner” who is ready to fill any gaps in the community obstetricians’ presence in the hospital; and there is a ready assistant surgeon to those patients who require a C-section delivery.

Solution to the Insane Schedule?

The advent of laborists also has created some key professional options for established OB-GYN physicians, as well as for those just coming out of training. Some older obstetricians would stop delivering babies altogether, even though they enjoyed that part of their practice, because of the time demands on having to simultaneously deliver babies randomly in the middle of the night, then show up the next day for a full gynecology surgery schedule or office practice. Their only option seemed to be to concentrate on gynecology and shelve the obstetrics. Now, community obstetricians can partner with the laborists and still provide prenatal care and perform some deliveries, or they can leave their private OB-GYN practice altogether and become full-time OB hospitalists.

This point was driven home recently when a hospital in Oregon started an OB hospitalist group and needed only four hospitalists. The hospital received more than 40 applications, most from practicing obstetricians.

This points to another difference with laborists. You can start a fully staffed group with just four OB hospitalists, each working a 24-hour shift every third day. Medical HM groups might start out with four hospitalists, but they quickly need to grow to 10, 15, or more as responsibilities for more unassigned patients, surgical comanagement, etc., require more hands on deck.

The similarities between OB hospitalists and the rest of HM include the increased demand for accountability for patient safety and for meeting measureable performance standards, which are difficult to achieve while practicing both in the acute setting of the hospital and the more chronic setting of an office-based practice. In addition, there is a clear movement afoot for significant evolution in medical practice more broadly, where younger, and even established, physicians are looking for a more predictable lifestyle and compensation in a medical world that is clearly shifting to a new model.

Change Is All Around

In some specialties, predictability has led to the narrowing of practice by setting or subspecialty. For example, OB-GYNs are selecting to focus solely on gynecology, OB hospital medicine, or prenatal care. In general internal medicine, there are those who only do office-based medicine and those who are hospitalists. Some surgeons are now doing shifts as acute-care surgeons and limiting their practice to just inpatient care.

As much as a change in practice style, there is a resurgence of employment of physicians, either by medical groups, independent physician organizations, or hospitals. Even the strong, revenue-producing specialties like cardiology are seeing a new paradigm. Today, almost 60% of cardiologists are employed by some entity, and 38% of cardiologists are employed by the hospital.

As healthcare reform, payment reform, and new entities like accountable care organizations (ACOs) take shape, physician-provided medical care is moving from a cottage industry of individual and small group private practice to employment and amalgamation.

Change is inevitable, and it is coming from a variety of viewpoints. Patients want better access to the best and safest care available. America’s businesses and the government, which fund healthcare, want predictable costs and measurable quality for the care they buy. Physicians want help in meeting new standards, predictable compensation for their work, and a lifestyle that meets their professional and personal aspirations.

The movement to the hospitalist model, first in the care of medical patients, and more recently for obstetrical, surgical, and other patients, is just one piece of a medical system in evolution. Stay tuned. We are still very much at the early stages of this course change. We all still have much work to do to create a future that works for our patients, our funders, and our providers of healthcare. TH

Dr. Wellikson is CEO of SHM.

It is hard to think of medical hospitalists as the establishment, but with more than 30,000 hospitalists nationwide working at most U.S. hospitals, HM is a firm part of today’s medical practice. While, dare I say, “traditional” HM is still very much in its evolution, other specialties of HM have not only cropped up on the scene, but some also have developed enough of a presence to be worthy of drawing some early conclusions.

OB-GYN hospitalists, also known as laborists, now practice at more than 100 hospitals in more than 35 states, according to http://obgynhospitalist.com. In many ways, the OB hospitalist movement is tracking the HM movement of 10 years ago. Although there are several similarities, there are more differences than just what the doctors do in their medical practices.

New “Partners” Drive Down Costs

HM has been driven as much by hospital payment by DRGs as anything else. As hospitals realized that hospitalists could better utilize resources and still maintain quality, the ability to reduce length of stay allowed hospitals to have the capital to support the early development of HM groups.

In obstetrics, the ability of laborists to reduce liability risks, and therefore malpractice premiums, for the hospital is a major driver of the recent growth in OB-GYN hospitalist groups. Some hospitals have been able to reduce the amount they must hold in reserve for future OB-related malpractice claims by more than $1 million after the first year of starting a laborist program. Additionally, hospitals’ annual malpractice premiums have dropped significantly.

Availability of on-site hospitalists has played a crucial role in this new delivery model for most of the hospitalist specialties. For hospitals with laborists, this has meant a significant decrease (for some, a total relief) in unattended deliveries, which in some hospitals was as high as 10% before the new breed of hospitalist arrived on the scene. This 24/7 obstetrician presence has reduced complications from many labor and delivery emergencies, and has led to improved patient safety and improved overall performance at the crucial moment of delivery. This is especially true for high-risk and emergency situations.

Just as in the rest of HM, the 24/7 availability has been complementary, not competitive, to community-based obstetricians: Unassigned patients now have someone to deliver their baby; community obstetricians have a hospital-based “partner” who is ready to fill any gaps in the community obstetricians’ presence in the hospital; and there is a ready assistant surgeon to those patients who require a C-section delivery.

Solution to the Insane Schedule?

The advent of laborists also has created some key professional options for established OB-GYN physicians, as well as for those just coming out of training. Some older obstetricians would stop delivering babies altogether, even though they enjoyed that part of their practice, because of the time demands on having to simultaneously deliver babies randomly in the middle of the night, then show up the next day for a full gynecology surgery schedule or office practice. Their only option seemed to be to concentrate on gynecology and shelve the obstetrics. Now, community obstetricians can partner with the laborists and still provide prenatal care and perform some deliveries, or they can leave their private OB-GYN practice altogether and become full-time OB hospitalists.

This point was driven home recently when a hospital in Oregon started an OB hospitalist group and needed only four hospitalists. The hospital received more than 40 applications, most from practicing obstetricians.

This points to another difference with laborists. You can start a fully staffed group with just four OB hospitalists, each working a 24-hour shift every third day. Medical HM groups might start out with four hospitalists, but they quickly need to grow to 10, 15, or more as responsibilities for more unassigned patients, surgical comanagement, etc., require more hands on deck.

The similarities between OB hospitalists and the rest of HM include the increased demand for accountability for patient safety and for meeting measureable performance standards, which are difficult to achieve while practicing both in the acute setting of the hospital and the more chronic setting of an office-based practice. In addition, there is a clear movement afoot for significant evolution in medical practice more broadly, where younger, and even established, physicians are looking for a more predictable lifestyle and compensation in a medical world that is clearly shifting to a new model.

Change Is All Around

In some specialties, predictability has led to the narrowing of practice by setting or subspecialty. For example, OB-GYNs are selecting to focus solely on gynecology, OB hospital medicine, or prenatal care. In general internal medicine, there are those who only do office-based medicine and those who are hospitalists. Some surgeons are now doing shifts as acute-care surgeons and limiting their practice to just inpatient care.

As much as a change in practice style, there is a resurgence of employment of physicians, either by medical groups, independent physician organizations, or hospitals. Even the strong, revenue-producing specialties like cardiology are seeing a new paradigm. Today, almost 60% of cardiologists are employed by some entity, and 38% of cardiologists are employed by the hospital.

As healthcare reform, payment reform, and new entities like accountable care organizations (ACOs) take shape, physician-provided medical care is moving from a cottage industry of individual and small group private practice to employment and amalgamation.

Change is inevitable, and it is coming from a variety of viewpoints. Patients want better access to the best and safest care available. America’s businesses and the government, which fund healthcare, want predictable costs and measurable quality for the care they buy. Physicians want help in meeting new standards, predictable compensation for their work, and a lifestyle that meets their professional and personal aspirations.

The movement to the hospitalist model, first in the care of medical patients, and more recently for obstetrical, surgical, and other patients, is just one piece of a medical system in evolution. Stay tuned. We are still very much at the early stages of this course change. We all still have much work to do to create a future that works for our patients, our funders, and our providers of healthcare. TH

Dr. Wellikson is CEO of SHM.

It is hard to think of medical hospitalists as the establishment, but with more than 30,000 hospitalists nationwide working at most U.S. hospitals, HM is a firm part of today’s medical practice. While, dare I say, “traditional” HM is still very much in its evolution, other specialties of HM have not only cropped up on the scene, but some also have developed enough of a presence to be worthy of drawing some early conclusions.

OB-GYN hospitalists, also known as laborists, now practice at more than 100 hospitals in more than 35 states, according to http://obgynhospitalist.com. In many ways, the OB hospitalist movement is tracking the HM movement of 10 years ago. Although there are several similarities, there are more differences than just what the doctors do in their medical practices.

New “Partners” Drive Down Costs

HM has been driven as much by hospital payment by DRGs as anything else. As hospitals realized that hospitalists could better utilize resources and still maintain quality, the ability to reduce length of stay allowed hospitals to have the capital to support the early development of HM groups.

In obstetrics, the ability of laborists to reduce liability risks, and therefore malpractice premiums, for the hospital is a major driver of the recent growth in OB-GYN hospitalist groups. Some hospitals have been able to reduce the amount they must hold in reserve for future OB-related malpractice claims by more than $1 million after the first year of starting a laborist program. Additionally, hospitals’ annual malpractice premiums have dropped significantly.

Availability of on-site hospitalists has played a crucial role in this new delivery model for most of the hospitalist specialties. For hospitals with laborists, this has meant a significant decrease (for some, a total relief) in unattended deliveries, which in some hospitals was as high as 10% before the new breed of hospitalist arrived on the scene. This 24/7 obstetrician presence has reduced complications from many labor and delivery emergencies, and has led to improved patient safety and improved overall performance at the crucial moment of delivery. This is especially true for high-risk and emergency situations.

Just as in the rest of HM, the 24/7 availability has been complementary, not competitive, to community-based obstetricians: Unassigned patients now have someone to deliver their baby; community obstetricians have a hospital-based “partner” who is ready to fill any gaps in the community obstetricians’ presence in the hospital; and there is a ready assistant surgeon to those patients who require a C-section delivery.

Solution to the Insane Schedule?

The advent of laborists also has created some key professional options for established OB-GYN physicians, as well as for those just coming out of training. Some older obstetricians would stop delivering babies altogether, even though they enjoyed that part of their practice, because of the time demands on having to simultaneously deliver babies randomly in the middle of the night, then show up the next day for a full gynecology surgery schedule or office practice. Their only option seemed to be to concentrate on gynecology and shelve the obstetrics. Now, community obstetricians can partner with the laborists and still provide prenatal care and perform some deliveries, or they can leave their private OB-GYN practice altogether and become full-time OB hospitalists.

This point was driven home recently when a hospital in Oregon started an OB hospitalist group and needed only four hospitalists. The hospital received more than 40 applications, most from practicing obstetricians.

This points to another difference with laborists. You can start a fully staffed group with just four OB hospitalists, each working a 24-hour shift every third day. Medical HM groups might start out with four hospitalists, but they quickly need to grow to 10, 15, or more as responsibilities for more unassigned patients, surgical comanagement, etc., require more hands on deck.

The similarities between OB hospitalists and the rest of HM include the increased demand for accountability for patient safety and for meeting measureable performance standards, which are difficult to achieve while practicing both in the acute setting of the hospital and the more chronic setting of an office-based practice. In addition, there is a clear movement afoot for significant evolution in medical practice more broadly, where younger, and even established, physicians are looking for a more predictable lifestyle and compensation in a medical world that is clearly shifting to a new model.

Change Is All Around

In some specialties, predictability has led to the narrowing of practice by setting or subspecialty. For example, OB-GYNs are selecting to focus solely on gynecology, OB hospital medicine, or prenatal care. In general internal medicine, there are those who only do office-based medicine and those who are hospitalists. Some surgeons are now doing shifts as acute-care surgeons and limiting their practice to just inpatient care.

As much as a change in practice style, there is a resurgence of employment of physicians, either by medical groups, independent physician organizations, or hospitals. Even the strong, revenue-producing specialties like cardiology are seeing a new paradigm. Today, almost 60% of cardiologists are employed by some entity, and 38% of cardiologists are employed by the hospital.

As healthcare reform, payment reform, and new entities like accountable care organizations (ACOs) take shape, physician-provided medical care is moving from a cottage industry of individual and small group private practice to employment and amalgamation.

Change is inevitable, and it is coming from a variety of viewpoints. Patients want better access to the best and safest care available. America’s businesses and the government, which fund healthcare, want predictable costs and measurable quality for the care they buy. Physicians want help in meeting new standards, predictable compensation for their work, and a lifestyle that meets their professional and personal aspirations.

The movement to the hospitalist model, first in the care of medical patients, and more recently for obstetrical, surgical, and other patients, is just one piece of a medical system in evolution. Stay tuned. We are still very much at the early stages of this course change. We all still have much work to do to create a future that works for our patients, our funders, and our providers of healthcare. TH

Dr. Wellikson is CEO of SHM.

She couldn’t have been more than two weeks old, a newborn. Tussling in her mother’s arms just outside the patient’s room, she let out a gurgle of a cry. Her two brothers, twins by the look of it, clung to Mom’s pant leg for answers. Mom was speechless, tears burning lava tracks down her face. Her husband lay splayed as the centerpiece on display. Cords draped his chest, radioing green tachycardia to an overhead monitor. The man’s breathing was a tangle of labored dyspnea, harsh coughing and raw panic. A nurse suctioned his mouth while an intern vultured over his wrist, eagerly attempting his first arterial line.

I surveyed this scene through the unsullied eyes of a medical student, figuratively clinging to my resident’s pant leg for answers. I was young, confused, and scared by the drama. I didn’t know it yet, but by morning light, this “great case” would morph from “a 29-year-old with acute lymphoblastic leukemia complicated by severe community-acquired pneumonia” to one of the most powerful lessons of my career.

A lesson I wasn’t intended to learn.

Hidden Curriculum

For those of you unfamiliar with the term, the “hidden curriculum” is the things we are “taught” when no one thinks they are teaching. It’s not what teachers necessarily say; it’s how they say it, how they act, what they do. It’s nearly always unconscious, unintentional. We learn these things by watching people interact, the inflections and tone of their voices, their bedside manner, the way they treat staff and patients.

This is not just an issue for teaching hospitalists who are imparting these unwitting lessons daily. Rather, it is important to recognize that all of us have been exposed to, and our careers and practices shaped by, these hidden messages. Sometimes these lessons impart such helpful tools as noting how a skilled clinician puts a patient at ease before palpating their abdomen. Other times, the tutorial is less beneficial (e.g. subconsciously teaching bias or impatience). And sometimes the message conveyed is much more malignant.

I, unfortunately, was about to be taught the latter.

Room 118

The man, stripped of his shirt, his pants, his dignity, winced with the pain of the third radial art-line attempt. He tried to hitch himself up in bed, drawing a scowl from the intern who had to readjust his sterile field—a rebuke from the nurse who got lubricant on her shirt. “Can’t you see that I’m trying to place a catheter in your penis?” she implored. Of course he could—as could I, his family, and much of the ICU. That was part of the lesson.

To be fair, I honestly doubt that anyone in room 118 intended to treat Mr. Davis in such a callous way. They didn’t intend to depersonalize the situation—make him an object, another cog in the wheel of their daily grind. They simply were trying to do their jobs—to save this new admission’s life. A noble intention, indeed.

However, in doing this, they employed a career’s worth of defense mechanisms aimed at fending off the stress of a life-threatening situation. And each of these actions moved them ever so slightly away from the compassion that defines our field and toward the seemingly uncaring automatons they had become.

The Lesson Continues

By now, Mr. Davis was breathing 40 times a minute. A neb of medications, a drip of antibiotics, and a facemask of oxygen did little to prevent his slide. Exposed, shivering, lights reflecting off the paunch of his naked stomach, he cried out for his wife. Coming to him, she was halted by the icy stare of the grizzled charge nurse called in to hold the combatant down. “You’re lucky we even allow you in the ICU with those kids,” she thundered.

The ABG was still pending, but the critical-care fellow was confident of its results. To nobody, he declared, “We have to tube this guy.” Terror was etched in the “guy’s” eyes as he searched the room for answers. What does “tubing” mean? he must have wondered. Am I going to die? Would my sons remember me? Would my daughter be OK? How will my wife do it without me?

Again, he called out for his wife.

It didn’t take long for the excitement to reverberate throughout the hospital. A surgical intern stopped by room 118 to see if he could put in any lines, while the respiratory therapist prepared a vent and a few more medical students rubbernecked in the hall. The oncology fellow took a moment to teach us about a recent article she read that showed that pneumonia was uniformly fatal in acute leukemic patients who got intubated. “Do you mean tubing him is essentially a death sentence?” I asked, death confronting me for the first time in my career. Meeting the patient’s eyes, she turned and lowered her voice to reply, leaving me to wonder if this was the kind of thing we should keep secret.

The wife, managing to momentarily penetrate the critical-care zone defense, was holding Mr. Davis’ hand while she filled his ear with whispers. With his daughter’s face mere inches from his, he appeared calmer. He tried to speak but was drowned out by the charge nurse who demanded he remove his wedding band. “But … I … don’t … want … ”

“I know you don’t want to take it off, sir, but you have to,” she demanded, shooing the wife from the bedside. “Your hands are going to get edematous in the next few days and you don’t want me to have to cut it off, do you?” she asked rhetorically. Crestfallen, he extended his ring finger to his wife, as he no doubt did years earlier, an understanding of his fate crossing his face. Missing the cue, the nurse deftly intercepted the ring off his finger, placing it in her pocket as she swooped out of the room to get the intubation kit, leaving Mr. Davis further agitated.

The critical-care fellow lowered the head of the bed, leaving Mr. Davis upright and calling for his wife. “My … ring … ” he panted, his breathing worsening by the breath. “I … need … to tell … my … wife … ” he gasped as the charge nurse thrust him a bit too harshly to the bed, adding that there wasn’t time to talk now—his message would have to wait. “But … ” the patient protested as the sedative coursed into this vein. “I need … her … to … know … ”

“Quiet now, sir, you have to calm down, you’re just making this harder.” The wife tore closer to him, no doubt wondering what could possibly make this harder. “I love you, John,” she said. “I … ” he replied.

The tube slipped in.

Reflections

It’s been 15 years, but I think of this night often. In some ways, I am haunted by it; in many ways, my practice style was fashioned by it; in all ways, I was changed by it. I wonder if the same can be said for the other providers.

I also wonder about Mr. Davis. How did the world look through his eyes? Did he see us as his saviors or his tormentors? Did he worry for his well-being, or was he too absorbed in the welfare of his kids and wife to fret about himself? Did he worry about his kids seeing him sick, the impact that might have on them? Was he scared? How must he have felt to be left so powerless? To have no control over his situation. To have his wedding band taken by a complete stranger. To not be able to give his wife an urgent message.

Did it have to be this way? Could we have better balanced the urgency of the situation with the humanity it required? In doing our jobs, did we have to dismiss the one person who entrusted us to help him?

I also think about how that night influenced me. How it shaped my approach to the patients who privilege me to care for them during their most vulnerable times. I wonder what came of the Davis family. That newborn daughter is learning to drive, the boys preparing for college. And I also wonder what it was John so urgently wanted to tell his wife that night. As, no doubt, does she.

For Mr. Davis died that night, his words forever lost. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

She couldn’t have been more than two weeks old, a newborn. Tussling in her mother’s arms just outside the patient’s room, she let out a gurgle of a cry. Her two brothers, twins by the look of it, clung to Mom’s pant leg for answers. Mom was speechless, tears burning lava tracks down her face. Her husband lay splayed as the centerpiece on display. Cords draped his chest, radioing green tachycardia to an overhead monitor. The man’s breathing was a tangle of labored dyspnea, harsh coughing and raw panic. A nurse suctioned his mouth while an intern vultured over his wrist, eagerly attempting his first arterial line.

I surveyed this scene through the unsullied eyes of a medical student, figuratively clinging to my resident’s pant leg for answers. I was young, confused, and scared by the drama. I didn’t know it yet, but by morning light, this “great case” would morph from “a 29-year-old with acute lymphoblastic leukemia complicated by severe community-acquired pneumonia” to one of the most powerful lessons of my career.

A lesson I wasn’t intended to learn.

Hidden Curriculum

For those of you unfamiliar with the term, the “hidden curriculum” is the things we are “taught” when no one thinks they are teaching. It’s not what teachers necessarily say; it’s how they say it, how they act, what they do. It’s nearly always unconscious, unintentional. We learn these things by watching people interact, the inflections and tone of their voices, their bedside manner, the way they treat staff and patients.

This is not just an issue for teaching hospitalists who are imparting these unwitting lessons daily. Rather, it is important to recognize that all of us have been exposed to, and our careers and practices shaped by, these hidden messages. Sometimes these lessons impart such helpful tools as noting how a skilled clinician puts a patient at ease before palpating their abdomen. Other times, the tutorial is less beneficial (e.g. subconsciously teaching bias or impatience). And sometimes the message conveyed is much more malignant.

I, unfortunately, was about to be taught the latter.

Room 118

The man, stripped of his shirt, his pants, his dignity, winced with the pain of the third radial art-line attempt. He tried to hitch himself up in bed, drawing a scowl from the intern who had to readjust his sterile field—a rebuke from the nurse who got lubricant on her shirt. “Can’t you see that I’m trying to place a catheter in your penis?” she implored. Of course he could—as could I, his family, and much of the ICU. That was part of the lesson.

To be fair, I honestly doubt that anyone in room 118 intended to treat Mr. Davis in such a callous way. They didn’t intend to depersonalize the situation—make him an object, another cog in the wheel of their daily grind. They simply were trying to do their jobs—to save this new admission’s life. A noble intention, indeed.

However, in doing this, they employed a career’s worth of defense mechanisms aimed at fending off the stress of a life-threatening situation. And each of these actions moved them ever so slightly away from the compassion that defines our field and toward the seemingly uncaring automatons they had become.

The Lesson Continues

By now, Mr. Davis was breathing 40 times a minute. A neb of medications, a drip of antibiotics, and a facemask of oxygen did little to prevent his slide. Exposed, shivering, lights reflecting off the paunch of his naked stomach, he cried out for his wife. Coming to him, she was halted by the icy stare of the grizzled charge nurse called in to hold the combatant down. “You’re lucky we even allow you in the ICU with those kids,” she thundered.

The ABG was still pending, but the critical-care fellow was confident of its results. To nobody, he declared, “We have to tube this guy.” Terror was etched in the “guy’s” eyes as he searched the room for answers. What does “tubing” mean? he must have wondered. Am I going to die? Would my sons remember me? Would my daughter be OK? How will my wife do it without me?

Again, he called out for his wife.

It didn’t take long for the excitement to reverberate throughout the hospital. A surgical intern stopped by room 118 to see if he could put in any lines, while the respiratory therapist prepared a vent and a few more medical students rubbernecked in the hall. The oncology fellow took a moment to teach us about a recent article she read that showed that pneumonia was uniformly fatal in acute leukemic patients who got intubated. “Do you mean tubing him is essentially a death sentence?” I asked, death confronting me for the first time in my career. Meeting the patient’s eyes, she turned and lowered her voice to reply, leaving me to wonder if this was the kind of thing we should keep secret.

The wife, managing to momentarily penetrate the critical-care zone defense, was holding Mr. Davis’ hand while she filled his ear with whispers. With his daughter’s face mere inches from his, he appeared calmer. He tried to speak but was drowned out by the charge nurse who demanded he remove his wedding band. “But … I … don’t … want … ”

“I know you don’t want to take it off, sir, but you have to,” she demanded, shooing the wife from the bedside. “Your hands are going to get edematous in the next few days and you don’t want me to have to cut it off, do you?” she asked rhetorically. Crestfallen, he extended his ring finger to his wife, as he no doubt did years earlier, an understanding of his fate crossing his face. Missing the cue, the nurse deftly intercepted the ring off his finger, placing it in her pocket as she swooped out of the room to get the intubation kit, leaving Mr. Davis further agitated.

The critical-care fellow lowered the head of the bed, leaving Mr. Davis upright and calling for his wife. “My … ring … ” he panted, his breathing worsening by the breath. “I … need … to tell … my … wife … ” he gasped as the charge nurse thrust him a bit too harshly to the bed, adding that there wasn’t time to talk now—his message would have to wait. “But … ” the patient protested as the sedative coursed into this vein. “I need … her … to … know … ”

“Quiet now, sir, you have to calm down, you’re just making this harder.” The wife tore closer to him, no doubt wondering what could possibly make this harder. “I love you, John,” she said. “I … ” he replied.

The tube slipped in.

Reflections

It’s been 15 years, but I think of this night often. In some ways, I am haunted by it; in many ways, my practice style was fashioned by it; in all ways, I was changed by it. I wonder if the same can be said for the other providers.

I also wonder about Mr. Davis. How did the world look through his eyes? Did he see us as his saviors or his tormentors? Did he worry for his well-being, or was he too absorbed in the welfare of his kids and wife to fret about himself? Did he worry about his kids seeing him sick, the impact that might have on them? Was he scared? How must he have felt to be left so powerless? To have no control over his situation. To have his wedding band taken by a complete stranger. To not be able to give his wife an urgent message.

Did it have to be this way? Could we have better balanced the urgency of the situation with the humanity it required? In doing our jobs, did we have to dismiss the one person who entrusted us to help him?

I also think about how that night influenced me. How it shaped my approach to the patients who privilege me to care for them during their most vulnerable times. I wonder what came of the Davis family. That newborn daughter is learning to drive, the boys preparing for college. And I also wonder what it was John so urgently wanted to tell his wife that night. As, no doubt, does she.

For Mr. Davis died that night, his words forever lost. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

She couldn’t have been more than two weeks old, a newborn. Tussling in her mother’s arms just outside the patient’s room, she let out a gurgle of a cry. Her two brothers, twins by the look of it, clung to Mom’s pant leg for answers. Mom was speechless, tears burning lava tracks down her face. Her husband lay splayed as the centerpiece on display. Cords draped his chest, radioing green tachycardia to an overhead monitor. The man’s breathing was a tangle of labored dyspnea, harsh coughing and raw panic. A nurse suctioned his mouth while an intern vultured over his wrist, eagerly attempting his first arterial line.

I surveyed this scene through the unsullied eyes of a medical student, figuratively clinging to my resident’s pant leg for answers. I was young, confused, and scared by the drama. I didn’t know it yet, but by morning light, this “great case” would morph from “a 29-year-old with acute lymphoblastic leukemia complicated by severe community-acquired pneumonia” to one of the most powerful lessons of my career.

A lesson I wasn’t intended to learn.

Hidden Curriculum

For those of you unfamiliar with the term, the “hidden curriculum” is the things we are “taught” when no one thinks they are teaching. It’s not what teachers necessarily say; it’s how they say it, how they act, what they do. It’s nearly always unconscious, unintentional. We learn these things by watching people interact, the inflections and tone of their voices, their bedside manner, the way they treat staff and patients.

This is not just an issue for teaching hospitalists who are imparting these unwitting lessons daily. Rather, it is important to recognize that all of us have been exposed to, and our careers and practices shaped by, these hidden messages. Sometimes these lessons impart such helpful tools as noting how a skilled clinician puts a patient at ease before palpating their abdomen. Other times, the tutorial is less beneficial (e.g. subconsciously teaching bias or impatience). And sometimes the message conveyed is much more malignant.

I, unfortunately, was about to be taught the latter.

Room 118

The man, stripped of his shirt, his pants, his dignity, winced with the pain of the third radial art-line attempt. He tried to hitch himself up in bed, drawing a scowl from the intern who had to readjust his sterile field—a rebuke from the nurse who got lubricant on her shirt. “Can’t you see that I’m trying to place a catheter in your penis?” she implored. Of course he could—as could I, his family, and much of the ICU. That was part of the lesson.

To be fair, I honestly doubt that anyone in room 118 intended to treat Mr. Davis in such a callous way. They didn’t intend to depersonalize the situation—make him an object, another cog in the wheel of their daily grind. They simply were trying to do their jobs—to save this new admission’s life. A noble intention, indeed.

However, in doing this, they employed a career’s worth of defense mechanisms aimed at fending off the stress of a life-threatening situation. And each of these actions moved them ever so slightly away from the compassion that defines our field and toward the seemingly uncaring automatons they had become.

The Lesson Continues

By now, Mr. Davis was breathing 40 times a minute. A neb of medications, a drip of antibiotics, and a facemask of oxygen did little to prevent his slide. Exposed, shivering, lights reflecting off the paunch of his naked stomach, he cried out for his wife. Coming to him, she was halted by the icy stare of the grizzled charge nurse called in to hold the combatant down. “You’re lucky we even allow you in the ICU with those kids,” she thundered.

The ABG was still pending, but the critical-care fellow was confident of its results. To nobody, he declared, “We have to tube this guy.” Terror was etched in the “guy’s” eyes as he searched the room for answers. What does “tubing” mean? he must have wondered. Am I going to die? Would my sons remember me? Would my daughter be OK? How will my wife do it without me?

Again, he called out for his wife.

It didn’t take long for the excitement to reverberate throughout the hospital. A surgical intern stopped by room 118 to see if he could put in any lines, while the respiratory therapist prepared a vent and a few more medical students rubbernecked in the hall. The oncology fellow took a moment to teach us about a recent article she read that showed that pneumonia was uniformly fatal in acute leukemic patients who got intubated. “Do you mean tubing him is essentially a death sentence?” I asked, death confronting me for the first time in my career. Meeting the patient’s eyes, she turned and lowered her voice to reply, leaving me to wonder if this was the kind of thing we should keep secret.

The wife, managing to momentarily penetrate the critical-care zone defense, was holding Mr. Davis’ hand while she filled his ear with whispers. With his daughter’s face mere inches from his, he appeared calmer. He tried to speak but was drowned out by the charge nurse who demanded he remove his wedding band. “But … I … don’t … want … ”

“I know you don’t want to take it off, sir, but you have to,” she demanded, shooing the wife from the bedside. “Your hands are going to get edematous in the next few days and you don’t want me to have to cut it off, do you?” she asked rhetorically. Crestfallen, he extended his ring finger to his wife, as he no doubt did years earlier, an understanding of his fate crossing his face. Missing the cue, the nurse deftly intercepted the ring off his finger, placing it in her pocket as she swooped out of the room to get the intubation kit, leaving Mr. Davis further agitated.

The critical-care fellow lowered the head of the bed, leaving Mr. Davis upright and calling for his wife. “My … ring … ” he panted, his breathing worsening by the breath. “I … need … to tell … my … wife … ” he gasped as the charge nurse thrust him a bit too harshly to the bed, adding that there wasn’t time to talk now—his message would have to wait. “But … ” the patient protested as the sedative coursed into this vein. “I need … her … to … know … ”

“Quiet now, sir, you have to calm down, you’re just making this harder.” The wife tore closer to him, no doubt wondering what could possibly make this harder. “I love you, John,” she said. “I … ” he replied.

The tube slipped in.

Reflections

It’s been 15 years, but I think of this night often. In some ways, I am haunted by it; in many ways, my practice style was fashioned by it; in all ways, I was changed by it. I wonder if the same can be said for the other providers.

I also wonder about Mr. Davis. How did the world look through his eyes? Did he see us as his saviors or his tormentors? Did he worry for his well-being, or was he too absorbed in the welfare of his kids and wife to fret about himself? Did he worry about his kids seeing him sick, the impact that might have on them? Was he scared? How must he have felt to be left so powerless? To have no control over his situation. To have his wedding band taken by a complete stranger. To not be able to give his wife an urgent message.

Did it have to be this way? Could we have better balanced the urgency of the situation with the humanity it required? In doing our jobs, did we have to dismiss the one person who entrusted us to help him?

I also think about how that night influenced me. How it shaped my approach to the patients who privilege me to care for them during their most vulnerable times. I wonder what came of the Davis family. That newborn daughter is learning to drive, the boys preparing for college. And I also wonder what it was John so urgently wanted to tell his wife that night. As, no doubt, does she.

For Mr. Davis died that night, his words forever lost. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.