Clinical

 

LAS VEGAS – Hyponatremia is not a salt problem, it’s a water problem.

That was the lead message in a well-attended rapid-fire session on hyponatremia at the annual meeting of the Society of Hospital Medicine.

“It’s almost always associated with pathologic elevations of ADH [antidiuretic hormone], and it’s that retention of water that dilutes the serum and drops the sodium, which causes the cerebral edema,” said Thomas Yacovella, MD, assistant professor of medicine at the University of Minnesota, Minneapolis.

Treatment of hyponatremia should always be predicated on how long it took for the condition to develop and the pathophysiology of the situation, Dr. Yacovella said. “It’s not quite as asymptomatic as you think,” he noted. Patients who present with several other medical issues often have low sodium levels, impaired cognitive abilities, and unstable gait. These could be cases of hyponatremia, he said.

“Remember that hyponatremia is a bad actor, especially when associated with a chronic disease,” Dr. Yacovella said. Serum sodium levels are a reliable surrogate for chronic heart failure related to hyponatremia. End-stage disease is when sodium levels are at 125 or less.

A basic work-up for hyponatremia starts with assessing fluid intake, history of medications and of any causes of ADH release, volume status assessment, and laboratory evaluations of blood and urine. The three keys to knowing how quickly hyponatremia can be reversed are severity of symptoms, how long it took for the condition to develop, and the risk of herniation vs. the risk of osmotic demyelination, he said.

In cases of osmotic demyelination, Dr. Yacovella advised monitoring urine osmolality and cases where ADH release could be quickly reversed. “When you don’t know for sure, go slow,” he said.

Exercise-associated hyponatremia is often caused by the perfect storm of sodium loss, high emotion, vomiting, pain, excessive water intake, and high ADH levels. This form of hyponatremia can occur postoperatively, but is more typically associated with the copious water ingestion that can occur during psychosis, extreme exercise, ecstasy ingestion, and “stupid” contests that involve extreme behavior, Dr. Yacovella said. His pearls for acute management of these kinds of hyponatremia were to administer a 100-mL bolus of hypertonic saline, and that a large output of dilute urine indicates corrective aquaresis.

Dr. Yacovella emphasized that in addition to remembering that hyponatremia is a water and not a salt problem, physicians should always look to “the path of physiology of the disease, and how long it took to develop the hyponatremia, and that will inform how quickly you can treat the patient.”

He had nothing to disclose.

[email protected]

On Twitter @whitneymcknight

 

LAS VEGAS – Hyponatremia is not a salt problem, it’s a water problem.

That was the lead message in a well-attended rapid-fire session on hyponatremia at the annual meeting of the Society of Hospital Medicine.

“It’s almost always associated with pathologic elevations of ADH [antidiuretic hormone], and it’s that retention of water that dilutes the serum and drops the sodium, which causes the cerebral edema,” said Thomas Yacovella, MD, assistant professor of medicine at the University of Minnesota, Minneapolis.

Treatment of hyponatremia should always be predicated on how long it took for the condition to develop and the pathophysiology of the situation, Dr. Yacovella said. “It’s not quite as asymptomatic as you think,” he noted. Patients who present with several other medical issues often have low sodium levels, impaired cognitive abilities, and unstable gait. These could be cases of hyponatremia, he said.

“Remember that hyponatremia is a bad actor, especially when associated with a chronic disease,” Dr. Yacovella said. Serum sodium levels are a reliable surrogate for chronic heart failure related to hyponatremia. End-stage disease is when sodium levels are at 125 or less.

A basic work-up for hyponatremia starts with assessing fluid intake, history of medications and of any causes of ADH release, volume status assessment, and laboratory evaluations of blood and urine. The three keys to knowing how quickly hyponatremia can be reversed are severity of symptoms, how long it took for the condition to develop, and the risk of herniation vs. the risk of osmotic demyelination, he said.

In cases of osmotic demyelination, Dr. Yacovella advised monitoring urine osmolality and cases where ADH release could be quickly reversed. “When you don’t know for sure, go slow,” he said.

Exercise-associated hyponatremia is often caused by the perfect storm of sodium loss, high emotion, vomiting, pain, excessive water intake, and high ADH levels. This form of hyponatremia can occur postoperatively, but is more typically associated with the copious water ingestion that can occur during psychosis, extreme exercise, ecstasy ingestion, and “stupid” contests that involve extreme behavior, Dr. Yacovella said. His pearls for acute management of these kinds of hyponatremia were to administer a 100-mL bolus of hypertonic saline, and that a large output of dilute urine indicates corrective aquaresis.

Dr. Yacovella emphasized that in addition to remembering that hyponatremia is a water and not a salt problem, physicians should always look to “the path of physiology of the disease, and how long it took to develop the hyponatremia, and that will inform how quickly you can treat the patient.”

He had nothing to disclose.

[email protected]

On Twitter @whitneymcknight

 

LAS VEGAS – Hyponatremia is not a salt problem, it’s a water problem.

That was the lead message in a well-attended rapid-fire session on hyponatremia at the annual meeting of the Society of Hospital Medicine.

“It’s almost always associated with pathologic elevations of ADH [antidiuretic hormone], and it’s that retention of water that dilutes the serum and drops the sodium, which causes the cerebral edema,” said Thomas Yacovella, MD, assistant professor of medicine at the University of Minnesota, Minneapolis.

Treatment of hyponatremia should always be predicated on how long it took for the condition to develop and the pathophysiology of the situation, Dr. Yacovella said. “It’s not quite as asymptomatic as you think,” he noted. Patients who present with several other medical issues often have low sodium levels, impaired cognitive abilities, and unstable gait. These could be cases of hyponatremia, he said.

“Remember that hyponatremia is a bad actor, especially when associated with a chronic disease,” Dr. Yacovella said. Serum sodium levels are a reliable surrogate for chronic heart failure related to hyponatremia. End-stage disease is when sodium levels are at 125 or less.

A basic work-up for hyponatremia starts with assessing fluid intake, history of medications and of any causes of ADH release, volume status assessment, and laboratory evaluations of blood and urine. The three keys to knowing how quickly hyponatremia can be reversed are severity of symptoms, how long it took for the condition to develop, and the risk of herniation vs. the risk of osmotic demyelination, he said.

In cases of osmotic demyelination, Dr. Yacovella advised monitoring urine osmolality and cases where ADH release could be quickly reversed. “When you don’t know for sure, go slow,” he said.

Exercise-associated hyponatremia is often caused by the perfect storm of sodium loss, high emotion, vomiting, pain, excessive water intake, and high ADH levels. This form of hyponatremia can occur postoperatively, but is more typically associated with the copious water ingestion that can occur during psychosis, extreme exercise, ecstasy ingestion, and “stupid” contests that involve extreme behavior, Dr. Yacovella said. His pearls for acute management of these kinds of hyponatremia were to administer a 100-mL bolus of hypertonic saline, and that a large output of dilute urine indicates corrective aquaresis.

Dr. Yacovella emphasized that in addition to remembering that hyponatremia is a water and not a salt problem, physicians should always look to “the path of physiology of the disease, and how long it took to develop the hyponatremia, and that will inform how quickly you can treat the patient.”

He had nothing to disclose.

[email protected]

On Twitter @whitneymcknight

CLINICAL QUESTION: How does the clinical decompensation of a ward patient affect the likelihood of another patient’s decompensation?

BACKGROUND: Previous research has attempted to identify patient-specific characteristics for risk of decompensation, but there may be environmental factors that contribute.

STUDY DESIGN: Observational cohort study.

SETTING: Thirteen geographically distinct, adult medical-surgical wards at an academic medical center.

SYNOPSIS: Of 83,723 admissions to medical-surgical wards, 4,286 patients experienced cardiac arrest (179) or were transferred to the ICU (4,107). When one or more of these events occurred, other patients on the same ward had an increased risk for either event over the subsequent 6 (OR 1.18; CI, 1.07-1.31) and 12 hours and the risk was higher if more than one event occurred. Importantly, for patients exposed to other patients on the same ward decompensating, there were no differences in the severity of illness for patients transferred to ICU or in overall mortality.

Intuitively, when one patient becomes critically ill, other patients receive less attention. Though the effect was small, this study highlights that diversion of resources may increase other patients to greater risk. Surprisingly, the increased risk was not significant during night-time hours, when resources are more limited, but data collection may have been also affected.

BOTTOM LINE: When a patient becomes critically ill, another patient on the same ward is more likely to decompensate within the next 6-12 hours, but the effect is small.

CITATIONS: Volchenboum SL, Mayampurath A, Göksu-Gürsoy G, et al. Association between in-hospital critical illness events and outcomes in patients on the same ward. JAMA. 2016;316(24):2674-5.

Dr. Anstett is Hospital Medicine Fellow in Quality and Systems Leadership, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.

CLINICAL QUESTION: How does the clinical decompensation of a ward patient affect the likelihood of another patient’s decompensation?

BACKGROUND: Previous research has attempted to identify patient-specific characteristics for risk of decompensation, but there may be environmental factors that contribute.

STUDY DESIGN: Observational cohort study.

SETTING: Thirteen geographically distinct, adult medical-surgical wards at an academic medical center.

SYNOPSIS: Of 83,723 admissions to medical-surgical wards, 4,286 patients experienced cardiac arrest (179) or were transferred to the ICU (4,107). When one or more of these events occurred, other patients on the same ward had an increased risk for either event over the subsequent 6 (OR 1.18; CI, 1.07-1.31) and 12 hours and the risk was higher if more than one event occurred. Importantly, for patients exposed to other patients on the same ward decompensating, there were no differences in the severity of illness for patients transferred to ICU or in overall mortality.

Intuitively, when one patient becomes critically ill, other patients receive less attention. Though the effect was small, this study highlights that diversion of resources may increase other patients to greater risk. Surprisingly, the increased risk was not significant during night-time hours, when resources are more limited, but data collection may have been also affected.

BOTTOM LINE: When a patient becomes critically ill, another patient on the same ward is more likely to decompensate within the next 6-12 hours, but the effect is small.

CITATIONS: Volchenboum SL, Mayampurath A, Göksu-Gürsoy G, et al. Association between in-hospital critical illness events and outcomes in patients on the same ward. JAMA. 2016;316(24):2674-5.

Dr. Anstett is Hospital Medicine Fellow in Quality and Systems Leadership, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.

CLINICAL QUESTION: How does the clinical decompensation of a ward patient affect the likelihood of another patient’s decompensation?

BACKGROUND: Previous research has attempted to identify patient-specific characteristics for risk of decompensation, but there may be environmental factors that contribute.

STUDY DESIGN: Observational cohort study.

SETTING: Thirteen geographically distinct, adult medical-surgical wards at an academic medical center.

SYNOPSIS: Of 83,723 admissions to medical-surgical wards, 4,286 patients experienced cardiac arrest (179) or were transferred to the ICU (4,107). When one or more of these events occurred, other patients on the same ward had an increased risk for either event over the subsequent 6 (OR 1.18; CI, 1.07-1.31) and 12 hours and the risk was higher if more than one event occurred. Importantly, for patients exposed to other patients on the same ward decompensating, there were no differences in the severity of illness for patients transferred to ICU or in overall mortality.

Intuitively, when one patient becomes critically ill, other patients receive less attention. Though the effect was small, this study highlights that diversion of resources may increase other patients to greater risk. Surprisingly, the increased risk was not significant during night-time hours, when resources are more limited, but data collection may have been also affected.

BOTTOM LINE: When a patient becomes critically ill, another patient on the same ward is more likely to decompensate within the next 6-12 hours, but the effect is small.

CITATIONS: Volchenboum SL, Mayampurath A, Göksu-Gürsoy G, et al. Association between in-hospital critical illness events and outcomes in patients on the same ward. JAMA. 2016;316(24):2674-5.

Dr. Anstett is Hospital Medicine Fellow in Quality and Systems Leadership, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.

 

CLINICAL QUESTION: Can a single institution’s VTE prophylaxis program be scaled to increase prophylaxis and reduce HA-VTEs across multiple institutions?

Background: HA-VTEs are a preventable cause of avoidable harm. Despite recommendations and use as a quality benchmark, inpatient VTE prophylaxis is suboptimal. By implementing a quality improvement program, the University of California, San Diego increased VTE prophylaxis and reduced the number of HA-VTEs.

STUDY DESIGN: prospective, unblinded, open-intervention study

SETTING: Inpatient medical and surgical services at five independent, cooperating academic hospitals

SYNOPSIS: Each site used common principles to develop their own multi-pronged VTE prophylaxis program including structured order-sets, simplified risk-assessment, feedback to providers, and education programs.

306,906 inpatient discharges were evaluated with average VTE prophylaxis bundle compliance reaching 89% across all institutions. HA-VTE rates declined from 0.90% to 0.69% (RR, 0.76; CI, 0.68-0.85) – equivalent to averting 81 pulmonary emboli and 89 deep venous thrombi. Of note, HA-VTE rates only declined at three of the five institutions with the greatest improvement at those with the highest baseline rates. Further, while HA-VTE rates improved across all patient populations, the incidence reduction was statistically significant in Oncologic and Surgical populations.

BOTTOM LINE: Hospital systems can reduce HA-VTE and increase VTE prophylaxis by implementing a bundle of interventions and these efforts are highest yield for Oncologic and Surgical populations.

CITATIONS: Jenkins IH, White RH, Amin AN, et al. Reducing the incidence of hospital-associated venous thromboembolism within a network of academic hospitals: findings from five University of California medical centers. J Hosp Med. 2016;11:S22-8.

 

Dr. Anstett is Hospital Medicine Fellow in Quality and Systems Leadership, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.

 

CLINICAL QUESTION: Can a single institution’s VTE prophylaxis program be scaled to increase prophylaxis and reduce HA-VTEs across multiple institutions?

Background: HA-VTEs are a preventable cause of avoidable harm. Despite recommendations and use as a quality benchmark, inpatient VTE prophylaxis is suboptimal. By implementing a quality improvement program, the University of California, San Diego increased VTE prophylaxis and reduced the number of HA-VTEs.

STUDY DESIGN: prospective, unblinded, open-intervention study

SETTING: Inpatient medical and surgical services at five independent, cooperating academic hospitals

SYNOPSIS: Each site used common principles to develop their own multi-pronged VTE prophylaxis program including structured order-sets, simplified risk-assessment, feedback to providers, and education programs.

306,906 inpatient discharges were evaluated with average VTE prophylaxis bundle compliance reaching 89% across all institutions. HA-VTE rates declined from 0.90% to 0.69% (RR, 0.76; CI, 0.68-0.85) – equivalent to averting 81 pulmonary emboli and 89 deep venous thrombi. Of note, HA-VTE rates only declined at three of the five institutions with the greatest improvement at those with the highest baseline rates. Further, while HA-VTE rates improved across all patient populations, the incidence reduction was statistically significant in Oncologic and Surgical populations.

BOTTOM LINE: Hospital systems can reduce HA-VTE and increase VTE prophylaxis by implementing a bundle of interventions and these efforts are highest yield for Oncologic and Surgical populations.

CITATIONS: Jenkins IH, White RH, Amin AN, et al. Reducing the incidence of hospital-associated venous thromboembolism within a network of academic hospitals: findings from five University of California medical centers. J Hosp Med. 2016;11:S22-8.

 

Dr. Anstett is Hospital Medicine Fellow in Quality and Systems Leadership, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.

 

CLINICAL QUESTION: Can a single institution’s VTE prophylaxis program be scaled to increase prophylaxis and reduce HA-VTEs across multiple institutions?

Background: HA-VTEs are a preventable cause of avoidable harm. Despite recommendations and use as a quality benchmark, inpatient VTE prophylaxis is suboptimal. By implementing a quality improvement program, the University of California, San Diego increased VTE prophylaxis and reduced the number of HA-VTEs.

STUDY DESIGN: prospective, unblinded, open-intervention study

SETTING: Inpatient medical and surgical services at five independent, cooperating academic hospitals

SYNOPSIS: Each site used common principles to develop their own multi-pronged VTE prophylaxis program including structured order-sets, simplified risk-assessment, feedback to providers, and education programs.

306,906 inpatient discharges were evaluated with average VTE prophylaxis bundle compliance reaching 89% across all institutions. HA-VTE rates declined from 0.90% to 0.69% (RR, 0.76; CI, 0.68-0.85) – equivalent to averting 81 pulmonary emboli and 89 deep venous thrombi. Of note, HA-VTE rates only declined at three of the five institutions with the greatest improvement at those with the highest baseline rates. Further, while HA-VTE rates improved across all patient populations, the incidence reduction was statistically significant in Oncologic and Surgical populations.

BOTTOM LINE: Hospital systems can reduce HA-VTE and increase VTE prophylaxis by implementing a bundle of interventions and these efforts are highest yield for Oncologic and Surgical populations.

CITATIONS: Jenkins IH, White RH, Amin AN, et al. Reducing the incidence of hospital-associated venous thromboembolism within a network of academic hospitals: findings from five University of California medical centers. J Hosp Med. 2016;11:S22-8.

 

Dr. Anstett is Hospital Medicine Fellow in Quality and Systems Leadership, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.

CLINICAL QUESTION: Are alpha blockers efficacious in patients with ureteric stones?

BACKGROUND: A multicenter, randomized controlled trial by Pickard and colleagues demonstrated an alpha blocker to be no more efficacious than placebo as medical expulsive therapy. There are no systematic reviews that include this recent study.

STUDY DESIGN: Systematic review & meta-analysis.

SETTING: Randomized controlled trials (RCTs); most conducted in Europe and Asia.

SYNOPSIS: Fifty-five unique RCTs (5,990 subjects) examining alpha blockers as the main treatment of ureteric stones versus placebo or control were included regardless of language and publication status.

Treatment with alpha blockers resulted in a 49% greater likelihood of stone passage (RR, 1.49; CI, 1.39-1.61) with a number needed to treat of four. A priori subgroup analysis revealed treatment was only beneficial in patients with larger stones (5mm or greater) independent of stone location or type of alpha blocker.

Secondary outcomes included reduced time to stone passage, fewer episodes of pain, decreased risk of surgical intervention, and lower risk of hospital admission with alpha blocker treatment without an increase in serious adverse events.

The meta-analysis was limited by the overall lack of methodological rigor of and clinical heterogeneity between the pooled studies.

BOTTOM LINE: Based on available evidence, it is reasonable to utilize an alpha blocker as medical expulsive therapy in patients with larger ureteric stones.

CITATIONS: Hollingsworth JM, Canales BK, Rogers MA, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016;355:i6112.

Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.

CLINICAL QUESTION: Are alpha blockers efficacious in patients with ureteric stones?

BACKGROUND: A multicenter, randomized controlled trial by Pickard and colleagues demonstrated an alpha blocker to be no more efficacious than placebo as medical expulsive therapy. There are no systematic reviews that include this recent study.

STUDY DESIGN: Systematic review & meta-analysis.

SETTING: Randomized controlled trials (RCTs); most conducted in Europe and Asia.

SYNOPSIS: Fifty-five unique RCTs (5,990 subjects) examining alpha blockers as the main treatment of ureteric stones versus placebo or control were included regardless of language and publication status.

Treatment with alpha blockers resulted in a 49% greater likelihood of stone passage (RR, 1.49; CI, 1.39-1.61) with a number needed to treat of four. A priori subgroup analysis revealed treatment was only beneficial in patients with larger stones (5mm or greater) independent of stone location or type of alpha blocker.

Secondary outcomes included reduced time to stone passage, fewer episodes of pain, decreased risk of surgical intervention, and lower risk of hospital admission with alpha blocker treatment without an increase in serious adverse events.

The meta-analysis was limited by the overall lack of methodological rigor of and clinical heterogeneity between the pooled studies.

BOTTOM LINE: Based on available evidence, it is reasonable to utilize an alpha blocker as medical expulsive therapy in patients with larger ureteric stones.

CITATIONS: Hollingsworth JM, Canales BK, Rogers MA, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016;355:i6112.

Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.

CLINICAL QUESTION: Are alpha blockers efficacious in patients with ureteric stones?

BACKGROUND: A multicenter, randomized controlled trial by Pickard and colleagues demonstrated an alpha blocker to be no more efficacious than placebo as medical expulsive therapy. There are no systematic reviews that include this recent study.

STUDY DESIGN: Systematic review & meta-analysis.

SETTING: Randomized controlled trials (RCTs); most conducted in Europe and Asia.

SYNOPSIS: Fifty-five unique RCTs (5,990 subjects) examining alpha blockers as the main treatment of ureteric stones versus placebo or control were included regardless of language and publication status.

Treatment with alpha blockers resulted in a 49% greater likelihood of stone passage (RR, 1.49; CI, 1.39-1.61) with a number needed to treat of four. A priori subgroup analysis revealed treatment was only beneficial in patients with larger stones (5mm or greater) independent of stone location or type of alpha blocker.

Secondary outcomes included reduced time to stone passage, fewer episodes of pain, decreased risk of surgical intervention, and lower risk of hospital admission with alpha blocker treatment without an increase in serious adverse events.

The meta-analysis was limited by the overall lack of methodological rigor of and clinical heterogeneity between the pooled studies.

BOTTOM LINE: Based on available evidence, it is reasonable to utilize an alpha blocker as medical expulsive therapy in patients with larger ureteric stones.

CITATIONS: Hollingsworth JM, Canales BK, Rogers MA, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016;355:i6112.

Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.

CLINICAL QUESTION: How efficacious are interventions to reduce burnout in physicians?

BACKGROUND: Burnout is characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. It is driven by workplace stressors and affects nearly half of physicians practicing in the U.S.

Study Design: Systematic review & meta-analysis.

SETTING: Randomized controlled trials and controlled before-after studies in primary, secondary, or intensive care settings; most conducted in North America and Europe.

SYNOPSIS: Twenty independent comparisons from 19 studies (1,550 physicians of any specialty including trainees) were included. All reported burnout outcomes after either physician- or organization-directed interventions designed to relieve stress and/or improve physician performance. Most physician-directed interventions utilized mindfulness-based stress reduction techniques or other educational interventions. Most organizational-directed interventions introduced reductions in workload or schedule changes.

Interventions were associated with small, significant reductions in burnout (standardized mean difference, –0.29; CI –0.42 to –0.16). A pre-specified subgroup analysis revealed organization-directed interventions had significantly improved effects, compared with physician-directed ones.

The generalizability of this meta-analysis is limited as the included studies significantly differed in their methodologies.

BOTTOM LINE: Burnout intervention programs for physicians are associated with small benefits, and the increased efficacy of organization-directed interventions suggest burnout is a problem of the health care system, rather than of individuals.

CITATIONS: Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.

 

Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.

CLINICAL QUESTION: How efficacious are interventions to reduce burnout in physicians?

BACKGROUND: Burnout is characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. It is driven by workplace stressors and affects nearly half of physicians practicing in the U.S.

Study Design: Systematic review & meta-analysis.

SETTING: Randomized controlled trials and controlled before-after studies in primary, secondary, or intensive care settings; most conducted in North America and Europe.

SYNOPSIS: Twenty independent comparisons from 19 studies (1,550 physicians of any specialty including trainees) were included. All reported burnout outcomes after either physician- or organization-directed interventions designed to relieve stress and/or improve physician performance. Most physician-directed interventions utilized mindfulness-based stress reduction techniques or other educational interventions. Most organizational-directed interventions introduced reductions in workload or schedule changes.

Interventions were associated with small, significant reductions in burnout (standardized mean difference, –0.29; CI –0.42 to –0.16). A pre-specified subgroup analysis revealed organization-directed interventions had significantly improved effects, compared with physician-directed ones.

The generalizability of this meta-analysis is limited as the included studies significantly differed in their methodologies.

BOTTOM LINE: Burnout intervention programs for physicians are associated with small benefits, and the increased efficacy of organization-directed interventions suggest burnout is a problem of the health care system, rather than of individuals.

CITATIONS: Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.

 

Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.

CLINICAL QUESTION: How efficacious are interventions to reduce burnout in physicians?

BACKGROUND: Burnout is characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. It is driven by workplace stressors and affects nearly half of physicians practicing in the U.S.

Study Design: Systematic review & meta-analysis.

SETTING: Randomized controlled trials and controlled before-after studies in primary, secondary, or intensive care settings; most conducted in North America and Europe.

SYNOPSIS: Twenty independent comparisons from 19 studies (1,550 physicians of any specialty including trainees) were included. All reported burnout outcomes after either physician- or organization-directed interventions designed to relieve stress and/or improve physician performance. Most physician-directed interventions utilized mindfulness-based stress reduction techniques or other educational interventions. Most organizational-directed interventions introduced reductions in workload or schedule changes.

Interventions were associated with small, significant reductions in burnout (standardized mean difference, –0.29; CI –0.42 to –0.16). A pre-specified subgroup analysis revealed organization-directed interventions had significantly improved effects, compared with physician-directed ones.

The generalizability of this meta-analysis is limited as the included studies significantly differed in their methodologies.

BOTTOM LINE: Burnout intervention programs for physicians are associated with small benefits, and the increased efficacy of organization-directed interventions suggest burnout is a problem of the health care system, rather than of individuals.

CITATIONS: Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.

 

Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.

PARIS – Unwarranted prescriptions for proton pump inhibitors tripled the rate at which patients with atrial fibrillation needed hospitalization for a first episode of acute heart failure, in a retrospective study of 172 patients at a single center in Portugal.

About a third of the atrial fibrillation patients received a proton pump inhibitor (PPI) without a clear indication, and the PPI recipients developed heart failure at 2.9 times the rate as patients not on a PPI, a statistically significant difference, João B. Augusto, MD, reported at a meeting held by the Heart Failure Association of the European Society of Cardiology. Dr. Augusto believes that these patients largely had no need for PPI treatment, and the drug may have cut iron and vitamin B12 absorption by lowering gastric acid, resulting in deficiencies that produced anemia, and following that, heart failure, he suggested.

Mitchel L. Zoler/Frontline Medical News

Iron and vitamin B12 deficiencies caused by PPI treatment provide “the best explanation” for the strong link the data showed between PPI use and new onset heart failure in this vulnerable patient population, said Dr. Augusto, a cardiologist at Fernando da Fonseca Hospital in Amadora, Portugal. The findings suggest that in practice “PPI use in patients with atrial fibrillation needs to be carefully weighed,” he said.

The study focused on 423 patients admitted to Fernando da Fonseca Hospital during January 2014–June 2015 with a primary or secondary diagnosis of atrial fibrillation. He excluded 101 patients with a history of heart failure, 109 patients on antiplatelet therapy, and 33 patients with a clear need for PPI treatment because of a gastrointestinal condition. Another 11 patients were lost to follow-up, leaving 172 patients followed for 1 year.

At the time of their initial hospitalization, 53 patients (31%) received a prescription for a PPI despite having no gastrointestinal diagnosis, likely a prophylactic step for patients receiving an oral anticoagulant, Dr. Augusto said. The patients averaged 69 years old, and nearly two-thirds were men.

During 1-year follow-up, the incidence of hospitalization for acute heart failure was 8% in the patients not on a PPI and 23% among those on a PPI, a statistically significant difference. In a regression analysis that controlled for age and chronic kidney disease, the incidence of acute heart failure was 2.9 times more common among patients on a PPI, Dr. Augusto said. He and his associates used these findings to educate their hospital’s staff to not needlessly prescribe a PPI to atrial fibrillation patients.

Dr. Augusto had no disclosures.

[email protected]

On Twitter @mitchelzoler

PARIS – Unwarranted prescriptions for proton pump inhibitors tripled the rate at which patients with atrial fibrillation needed hospitalization for a first episode of acute heart failure, in a retrospective study of 172 patients at a single center in Portugal.

About a third of the atrial fibrillation patients received a proton pump inhibitor (PPI) without a clear indication, and the PPI recipients developed heart failure at 2.9 times the rate as patients not on a PPI, a statistically significant difference, João B. Augusto, MD, reported at a meeting held by the Heart Failure Association of the European Society of Cardiology. Dr. Augusto believes that these patients largely had no need for PPI treatment, and the drug may have cut iron and vitamin B12 absorption by lowering gastric acid, resulting in deficiencies that produced anemia, and following that, heart failure, he suggested.

Mitchel L. Zoler/Frontline Medical News

Iron and vitamin B12 deficiencies caused by PPI treatment provide “the best explanation” for the strong link the data showed between PPI use and new onset heart failure in this vulnerable patient population, said Dr. Augusto, a cardiologist at Fernando da Fonseca Hospital in Amadora, Portugal. The findings suggest that in practice “PPI use in patients with atrial fibrillation needs to be carefully weighed,” he said.

The study focused on 423 patients admitted to Fernando da Fonseca Hospital during January 2014–June 2015 with a primary or secondary diagnosis of atrial fibrillation. He excluded 101 patients with a history of heart failure, 109 patients on antiplatelet therapy, and 33 patients with a clear need for PPI treatment because of a gastrointestinal condition. Another 11 patients were lost to follow-up, leaving 172 patients followed for 1 year.

At the time of their initial hospitalization, 53 patients (31%) received a prescription for a PPI despite having no gastrointestinal diagnosis, likely a prophylactic step for patients receiving an oral anticoagulant, Dr. Augusto said. The patients averaged 69 years old, and nearly two-thirds were men.

During 1-year follow-up, the incidence of hospitalization for acute heart failure was 8% in the patients not on a PPI and 23% among those on a PPI, a statistically significant difference. In a regression analysis that controlled for age and chronic kidney disease, the incidence of acute heart failure was 2.9 times more common among patients on a PPI, Dr. Augusto said. He and his associates used these findings to educate their hospital’s staff to not needlessly prescribe a PPI to atrial fibrillation patients.

Dr. Augusto had no disclosures.

[email protected]

On Twitter @mitchelzoler

PARIS – Unwarranted prescriptions for proton pump inhibitors tripled the rate at which patients with atrial fibrillation needed hospitalization for a first episode of acute heart failure, in a retrospective study of 172 patients at a single center in Portugal.

About a third of the atrial fibrillation patients received a proton pump inhibitor (PPI) without a clear indication, and the PPI recipients developed heart failure at 2.9 times the rate as patients not on a PPI, a statistically significant difference, João B. Augusto, MD, reported at a meeting held by the Heart Failure Association of the European Society of Cardiology. Dr. Augusto believes that these patients largely had no need for PPI treatment, and the drug may have cut iron and vitamin B12 absorption by lowering gastric acid, resulting in deficiencies that produced anemia, and following that, heart failure, he suggested.

Mitchel L. Zoler/Frontline Medical News

Iron and vitamin B12 deficiencies caused by PPI treatment provide “the best explanation” for the strong link the data showed between PPI use and new onset heart failure in this vulnerable patient population, said Dr. Augusto, a cardiologist at Fernando da Fonseca Hospital in Amadora, Portugal. The findings suggest that in practice “PPI use in patients with atrial fibrillation needs to be carefully weighed,” he said.

The study focused on 423 patients admitted to Fernando da Fonseca Hospital during January 2014–June 2015 with a primary or secondary diagnosis of atrial fibrillation. He excluded 101 patients with a history of heart failure, 109 patients on antiplatelet therapy, and 33 patients with a clear need for PPI treatment because of a gastrointestinal condition. Another 11 patients were lost to follow-up, leaving 172 patients followed for 1 year.

At the time of their initial hospitalization, 53 patients (31%) received a prescription for a PPI despite having no gastrointestinal diagnosis, likely a prophylactic step for patients receiving an oral anticoagulant, Dr. Augusto said. The patients averaged 69 years old, and nearly two-thirds were men.

During 1-year follow-up, the incidence of hospitalization for acute heart failure was 8% in the patients not on a PPI and 23% among those on a PPI, a statistically significant difference. In a regression analysis that controlled for age and chronic kidney disease, the incidence of acute heart failure was 2.9 times more common among patients on a PPI, Dr. Augusto said. He and his associates used these findings to educate their hospital’s staff to not needlessly prescribe a PPI to atrial fibrillation patients.

Dr. Augusto had no disclosures.

[email protected]

On Twitter @mitchelzoler

 

Within hospital medicine, there has been a recent increase in programs that provide virtual or telehealth hospitalists, primarily to hospitals that are small, remote, and/or understaffed. According to a 2013 Cisco health care customer experience report, the number of telehealth consumers will likely markedly increase to at least 7 million by 2018.¹

Since telehospitalist programs are still relatively new, there are many questions about why and how they exist and how they are (and can be) funded. Questions also remain about some limitations of telehospitalist programs for both the “givers” and the “receivers” of the services. I tackle some of these questions in this article.

What is a telehospitalist?

A telehospitalist is a hospitalist who provides remote services to patients and providers in need of such services. These services can range from initial encounters, follow-up encounters, post-acute care visits, home visits, consultations, and emergency care.

What are the drivers of telehospitalist programs?

One primary driver of telehealth (and specifically telehospitalist) programs is an ongoing shortage of hospitalists, especially in remote areas and critical access hospitals where coverage issues are especially prominent at night and/or on weekends. In many hospitals, there is also a growing unwillingness on the part of physicians to be routinely on call at night. Although working on call used to be on par with being a physician, many younger-generation physicians are less willing to blur “work and life.” This increases the need for dedicated night coverage in many hospitals.

Another driver for some programs (especially at tertiary care medical centers) is a desire to more thoroughly assess patients prior to transfer to their respective centers (the alternative being a phone conversation with the transferring center about the patient’s status). There is also a growing desire to keep patients local if possible, which is usually better for the patient and the family and can decrease the total cost of their care.

Another catalyst to telehospitalist program growth is the growing cultural comfort level with two-way video interactions, such as Skype and FaceTime. Since videoconferencing has permeated most of our professional and personal lives, telehealth seems familiar and comfortable for both providers and patients. In a recent consumer survey, three out of every four consumers responded that they are very comfortable communicating with providers via technology, as opposed to seeing them in person.¹

Another driver for some programs is financial. Depending on the way the program is structured, it can be not only financially feasible but financially beneficial, especially if the program can consolidate coverage across multiple sites (more on this later).

One other driver for some health care systems is the need to cover areas with on-site nurse practitioners and physician assistants. Using a telehospitalist makes it easier to get appropriate and required oversight for this coverage model across time and space.

What are the advantages of being a telehospitalist?

Some of the career advantages of being a telehospitalist include the shift flexibility and convenience. This work allows a hospitalist to serve a shift from anywhere in the world and from the convenience of their home. Some telehospitalists can easily work local night shifts when they live many time zones away (and therefore, don’t actually have to work a night shift). Many programs are designed to have a single hospitalist cover many hospitals over a wide geography, which would be logistically impossible to do in person. This is especially appealing for multihospital systems that cannot afford to have a hospitalist on site at each location.

The earning potential can also be appealing, depending on the number of shifts a hospitalist is willing to work.

What are the limitations of being a telehospitalist?

There are limits to what a telehospitalist can perform, many of which depend on the manner in which the program and the technology are arranged. Telehealth can vary from a cart-based videoconferencing system that is transported into a patient’s room to an independent robot that travels throughout sites. The primary limitation is the need to rely on someone in the patient’s room to act as virtual hands. This usually falls to the bedside nurse and requires a good working relationship and patience on their part. The bedside nurses have to “buy into” the program in advance and may need to have scripting for how to explain the process to the patients.

Another major challenge is interacting with different electronic health record systems. Becoming agile with a single EHR is challenging enough, but maneuvering several of them in a single shift can be extremely trying. Telehospitalists can also be challenged by technology glitches or failures that need troubleshooting both on their end and on-site. Although these problems are rare, there will always be a concern that the patient will not get his or her needs met if the technology fails.

 

How does the financing work?

Although this is a rapidly changing landscape, telehospitalists are not currently able to generate much revenue from professional billing. Unlike in-person visits, Medicare will not reimburse professional fees for telehospitalist visits. Although each payer is unique, most other (nonMedicare) payers are also not willing to reimburse for televisits. This may change in the future, however, as Medicare does pay for virtual specialty services such as telestroke. In addition, many states have enacted telemedicine parity laws, which require private payers to pay for all health care services equally, regardless of modality (audio, video, or in person).

For now, the financial case for employing telehospitalists for most programs has to be made using benfits other than the generation of professional fees. For telehospitalist programs that can cover several sites, the cost is substantially less than employing individual on-site hospitalists to do low-volume work. Telehospitalist programs are also, likely, less costly than is locum tenens staffing. For programs that evaluate the need for transfers, a case can be made that keeping a patient in a smaller, low-cost venue, rather than transferring them to a larger, higher-cost venue, can also reduce overall cost for a health care system.

What about licensing and credentialing?

Telehospitalists can be hindered by the need to have a license in several states and to be credentialed in several systems. This can be cumbersome, time-consuming, and expensive. To ease the multistate licensing burden, the Interstate Medical Licensure Compact has been established.² This is an accelerated licensure process for eligible physicians that improves license portability across states. There are currently 18 states that participate, and the number continues to increase.

For credentialing, most hospitals require initial credentialing and full recredentialing every 2 years. Maintaining credentials at several sites can be extremely time consuming. To ease this burden, some hospitals with telehealth programs have adopted “credentialing by proxy,” which means that one hospital will accept the credentialing process of another facility.

What next?

In summary, there has been and will likely continue to be explosive growth of telehospitalist programs and providers for all the reasons outlined above. Although some barriers to efficient and effective practice do exist, many of those barriers are being overcome quite rapidly. I expect this growth to continue for the betterment of hospitalists, our patients, and the systems in which we work. For a more in-depth look into telemedicine in hospital medicine, view a report created by a work group of SHM's Practice Management Committee.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1.Cisco. (2013 March 4). Cisco Study Reveals 74 Percent of Consumers Open to Virtual Doctor Visit. Cisco: The Network. Retrieved from https://newsroom.cisco.com/press-release-content?type=webcontent&articleId=1148539.

2. Interstate Medical Licensure Compact Commission. (2017). Interstate Medical Licensure Compact. Retrieved from http://www.licenseportability.org/index.html.

 

Within hospital medicine, there has been a recent increase in programs that provide virtual or telehealth hospitalists, primarily to hospitals that are small, remote, and/or understaffed. According to a 2013 Cisco health care customer experience report, the number of telehealth consumers will likely markedly increase to at least 7 million by 2018.¹

Since telehospitalist programs are still relatively new, there are many questions about why and how they exist and how they are (and can be) funded. Questions also remain about some limitations of telehospitalist programs for both the “givers” and the “receivers” of the services. I tackle some of these questions in this article.

What is a telehospitalist?

A telehospitalist is a hospitalist who provides remote services to patients and providers in need of such services. These services can range from initial encounters, follow-up encounters, post-acute care visits, home visits, consultations, and emergency care.

What are the drivers of telehospitalist programs?

One primary driver of telehealth (and specifically telehospitalist) programs is an ongoing shortage of hospitalists, especially in remote areas and critical access hospitals where coverage issues are especially prominent at night and/or on weekends. In many hospitals, there is also a growing unwillingness on the part of physicians to be routinely on call at night. Although working on call used to be on par with being a physician, many younger-generation physicians are less willing to blur “work and life.” This increases the need for dedicated night coverage in many hospitals.

Another driver for some programs (especially at tertiary care medical centers) is a desire to more thoroughly assess patients prior to transfer to their respective centers (the alternative being a phone conversation with the transferring center about the patient’s status). There is also a growing desire to keep patients local if possible, which is usually better for the patient and the family and can decrease the total cost of their care.

Another catalyst to telehospitalist program growth is the growing cultural comfort level with two-way video interactions, such as Skype and FaceTime. Since videoconferencing has permeated most of our professional and personal lives, telehealth seems familiar and comfortable for both providers and patients. In a recent consumer survey, three out of every four consumers responded that they are very comfortable communicating with providers via technology, as opposed to seeing them in person.¹

Another driver for some programs is financial. Depending on the way the program is structured, it can be not only financially feasible but financially beneficial, especially if the program can consolidate coverage across multiple sites (more on this later).

One other driver for some health care systems is the need to cover areas with on-site nurse practitioners and physician assistants. Using a telehospitalist makes it easier to get appropriate and required oversight for this coverage model across time and space.

What are the advantages of being a telehospitalist?

Some of the career advantages of being a telehospitalist include the shift flexibility and convenience. This work allows a hospitalist to serve a shift from anywhere in the world and from the convenience of their home. Some telehospitalists can easily work local night shifts when they live many time zones away (and therefore, don’t actually have to work a night shift). Many programs are designed to have a single hospitalist cover many hospitals over a wide geography, which would be logistically impossible to do in person. This is especially appealing for multihospital systems that cannot afford to have a hospitalist on site at each location.

The earning potential can also be appealing, depending on the number of shifts a hospitalist is willing to work.

What are the limitations of being a telehospitalist?

There are limits to what a telehospitalist can perform, many of which depend on the manner in which the program and the technology are arranged. Telehealth can vary from a cart-based videoconferencing system that is transported into a patient’s room to an independent robot that travels throughout sites. The primary limitation is the need to rely on someone in the patient’s room to act as virtual hands. This usually falls to the bedside nurse and requires a good working relationship and patience on their part. The bedside nurses have to “buy into” the program in advance and may need to have scripting for how to explain the process to the patients.

Another major challenge is interacting with different electronic health record systems. Becoming agile with a single EHR is challenging enough, but maneuvering several of them in a single shift can be extremely trying. Telehospitalists can also be challenged by technology glitches or failures that need troubleshooting both on their end and on-site. Although these problems are rare, there will always be a concern that the patient will not get his or her needs met if the technology fails.

 

How does the financing work?

Although this is a rapidly changing landscape, telehospitalists are not currently able to generate much revenue from professional billing. Unlike in-person visits, Medicare will not reimburse professional fees for telehospitalist visits. Although each payer is unique, most other (nonMedicare) payers are also not willing to reimburse for televisits. This may change in the future, however, as Medicare does pay for virtual specialty services such as telestroke. In addition, many states have enacted telemedicine parity laws, which require private payers to pay for all health care services equally, regardless of modality (audio, video, or in person).

For now, the financial case for employing telehospitalists for most programs has to be made using benfits other than the generation of professional fees. For telehospitalist programs that can cover several sites, the cost is substantially less than employing individual on-site hospitalists to do low-volume work. Telehospitalist programs are also, likely, less costly than is locum tenens staffing. For programs that evaluate the need for transfers, a case can be made that keeping a patient in a smaller, low-cost venue, rather than transferring them to a larger, higher-cost venue, can also reduce overall cost for a health care system.

What about licensing and credentialing?

Telehospitalists can be hindered by the need to have a license in several states and to be credentialed in several systems. This can be cumbersome, time-consuming, and expensive. To ease the multistate licensing burden, the Interstate Medical Licensure Compact has been established.² This is an accelerated licensure process for eligible physicians that improves license portability across states. There are currently 18 states that participate, and the number continues to increase.

For credentialing, most hospitals require initial credentialing and full recredentialing every 2 years. Maintaining credentials at several sites can be extremely time consuming. To ease this burden, some hospitals with telehealth programs have adopted “credentialing by proxy,” which means that one hospital will accept the credentialing process of another facility.

What next?

In summary, there has been and will likely continue to be explosive growth of telehospitalist programs and providers for all the reasons outlined above. Although some barriers to efficient and effective practice do exist, many of those barriers are being overcome quite rapidly. I expect this growth to continue for the betterment of hospitalists, our patients, and the systems in which we work. For a more in-depth look into telemedicine in hospital medicine, view a report created by a work group of SHM's Practice Management Committee.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1.Cisco. (2013 March 4). Cisco Study Reveals 74 Percent of Consumers Open to Virtual Doctor Visit. Cisco: The Network. Retrieved from https://newsroom.cisco.com/press-release-content?type=webcontent&articleId=1148539.

2. Interstate Medical Licensure Compact Commission. (2017). Interstate Medical Licensure Compact. Retrieved from http://www.licenseportability.org/index.html.

 

Within hospital medicine, there has been a recent increase in programs that provide virtual or telehealth hospitalists, primarily to hospitals that are small, remote, and/or understaffed. According to a 2013 Cisco health care customer experience report, the number of telehealth consumers will likely markedly increase to at least 7 million by 2018.¹

Since telehospitalist programs are still relatively new, there are many questions about why and how they exist and how they are (and can be) funded. Questions also remain about some limitations of telehospitalist programs for both the “givers” and the “receivers” of the services. I tackle some of these questions in this article.

What is a telehospitalist?

A telehospitalist is a hospitalist who provides remote services to patients and providers in need of such services. These services can range from initial encounters, follow-up encounters, post-acute care visits, home visits, consultations, and emergency care.

What are the drivers of telehospitalist programs?

One primary driver of telehealth (and specifically telehospitalist) programs is an ongoing shortage of hospitalists, especially in remote areas and critical access hospitals where coverage issues are especially prominent at night and/or on weekends. In many hospitals, there is also a growing unwillingness on the part of physicians to be routinely on call at night. Although working on call used to be on par with being a physician, many younger-generation physicians are less willing to blur “work and life.” This increases the need for dedicated night coverage in many hospitals.

Another driver for some programs (especially at tertiary care medical centers) is a desire to more thoroughly assess patients prior to transfer to their respective centers (the alternative being a phone conversation with the transferring center about the patient’s status). There is also a growing desire to keep patients local if possible, which is usually better for the patient and the family and can decrease the total cost of their care.

Another catalyst to telehospitalist program growth is the growing cultural comfort level with two-way video interactions, such as Skype and FaceTime. Since videoconferencing has permeated most of our professional and personal lives, telehealth seems familiar and comfortable for both providers and patients. In a recent consumer survey, three out of every four consumers responded that they are very comfortable communicating with providers via technology, as opposed to seeing them in person.¹

Another driver for some programs is financial. Depending on the way the program is structured, it can be not only financially feasible but financially beneficial, especially if the program can consolidate coverage across multiple sites (more on this later).

One other driver for some health care systems is the need to cover areas with on-site nurse practitioners and physician assistants. Using a telehospitalist makes it easier to get appropriate and required oversight for this coverage model across time and space.

What are the advantages of being a telehospitalist?

Some of the career advantages of being a telehospitalist include the shift flexibility and convenience. This work allows a hospitalist to serve a shift from anywhere in the world and from the convenience of their home. Some telehospitalists can easily work local night shifts when they live many time zones away (and therefore, don’t actually have to work a night shift). Many programs are designed to have a single hospitalist cover many hospitals over a wide geography, which would be logistically impossible to do in person. This is especially appealing for multihospital systems that cannot afford to have a hospitalist on site at each location.

The earning potential can also be appealing, depending on the number of shifts a hospitalist is willing to work.

What are the limitations of being a telehospitalist?

There are limits to what a telehospitalist can perform, many of which depend on the manner in which the program and the technology are arranged. Telehealth can vary from a cart-based videoconferencing system that is transported into a patient’s room to an independent robot that travels throughout sites. The primary limitation is the need to rely on someone in the patient’s room to act as virtual hands. This usually falls to the bedside nurse and requires a good working relationship and patience on their part. The bedside nurses have to “buy into” the program in advance and may need to have scripting for how to explain the process to the patients.

Another major challenge is interacting with different electronic health record systems. Becoming agile with a single EHR is challenging enough, but maneuvering several of them in a single shift can be extremely trying. Telehospitalists can also be challenged by technology glitches or failures that need troubleshooting both on their end and on-site. Although these problems are rare, there will always be a concern that the patient will not get his or her needs met if the technology fails.

 

How does the financing work?

Although this is a rapidly changing landscape, telehospitalists are not currently able to generate much revenue from professional billing. Unlike in-person visits, Medicare will not reimburse professional fees for telehospitalist visits. Although each payer is unique, most other (nonMedicare) payers are also not willing to reimburse for televisits. This may change in the future, however, as Medicare does pay for virtual specialty services such as telestroke. In addition, many states have enacted telemedicine parity laws, which require private payers to pay for all health care services equally, regardless of modality (audio, video, or in person).

For now, the financial case for employing telehospitalists for most programs has to be made using benfits other than the generation of professional fees. For telehospitalist programs that can cover several sites, the cost is substantially less than employing individual on-site hospitalists to do low-volume work. Telehospitalist programs are also, likely, less costly than is locum tenens staffing. For programs that evaluate the need for transfers, a case can be made that keeping a patient in a smaller, low-cost venue, rather than transferring them to a larger, higher-cost venue, can also reduce overall cost for a health care system.

What about licensing and credentialing?

Telehospitalists can be hindered by the need to have a license in several states and to be credentialed in several systems. This can be cumbersome, time-consuming, and expensive. To ease the multistate licensing burden, the Interstate Medical Licensure Compact has been established.² This is an accelerated licensure process for eligible physicians that improves license portability across states. There are currently 18 states that participate, and the number continues to increase.

For credentialing, most hospitals require initial credentialing and full recredentialing every 2 years. Maintaining credentials at several sites can be extremely time consuming. To ease this burden, some hospitals with telehealth programs have adopted “credentialing by proxy,” which means that one hospital will accept the credentialing process of another facility.

What next?

In summary, there has been and will likely continue to be explosive growth of telehospitalist programs and providers for all the reasons outlined above. Although some barriers to efficient and effective practice do exist, many of those barriers are being overcome quite rapidly. I expect this growth to continue for the betterment of hospitalists, our patients, and the systems in which we work. For a more in-depth look into telemedicine in hospital medicine, view a report created by a work group of SHM's Practice Management Committee.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1.Cisco. (2013 March 4). Cisco Study Reveals 74 Percent of Consumers Open to Virtual Doctor Visit. Cisco: The Network. Retrieved from https://newsroom.cisco.com/press-release-content?type=webcontent&articleId=1148539.

2. Interstate Medical Licensure Compact Commission. (2017). Interstate Medical Licensure Compact. Retrieved from http://www.licenseportability.org/index.html.

 

LAS VEGAS – Masih Shinwa, MD, stood beside a half-circle of judges at SHM’s annual Research, Innovations, and Clinical Vignettes poster competition and argued why his entry, already a finalist, should win.

To think, his work, “Please ‘THINK’ Before You Order: A Multidisciplinary Approach to Decreasing Overutilization of Daily Labs,” was borne simply of a group of medical students who incredulously said that they were amazed patients would be woken up in the night for tests.

Now it was a poster at RIV, one of the biggest highlights of SHM’s annual meeting. The Scientific Abstracts Competition – the event’s formal name – has exploded in popularity over the past few years. Submissions for posters rose from 634 in 2010 to 1,712 this year, and presenters ranged from first-year residents to a former SHM president.

Dr. Shinwa’s project shows just how an idea can blossom into a recognized poster.

Some 18 months ago, the students he works with at Mount Sinai Hospital in New York just couldn’t understand why so many tests had to be done overnight while a patient slept. So, Dr. Shinwa and his colleagues looked at ways to reduce unnecessary lab tests and chemistry testing.

Now, Dr. Shinwa was humbled to think his work and that of his colleagues could be a pathway to eliminating tests that don’t need to happen across the country, a focal point of SHM and the American Board of Internal Medicine Foundation’s Choosing Wisely Campaign.

“This is a way to make it national,” he said. “You may have affected the lives of the patients in your hospital, but, unless you attend these types of national meetings, it’s hard to get that perspective across (the country).”

That level of personal and professional collaboration is the purpose of the RIV, said Margaret Fang, MD, MPH, FHM, program chair for the HM17 competition.

“One of the amazing things is, everyone has their own poster. They’re doing their work,” she added. “But then they start up conversations with the people next to them. ... Seeing the organic networking and discussion that arise from that is really exciting. RIV serves as a way of connecting people who might not have know the other person was doing that kind of work.”

Dr. Fang said that the intergenerational aspect of the RIV, where early-career hospitalists mingle with the field’s founders and leaders, creates an environment where research is encouraged.

“Just seeing the intense interest that more senior hospitalists have in mentoring and guiding the next generation is delightful,” she added.

Dr. Shinwa said that the specialty’s focus on both clinical research and systems-level change is important, as the work positions the field to be leaders not just in patient care but for hospitals as a whole.

“We are physicians,” he said. “Our role is taking care of patients. Knowing that there are people who are not just focusing on taking care of specific patients but are actually there to improve the entire system and the process – that’s really gratifying.”

That’s the word that Merideth Prevost, MD, of New Mexico VA Health Care System, Albuquerque also used to describe presenting her poster, “Improving Accuracy in Measuring Fluid Balance on a General Medicine Ward.”

“If we can improve our little microcosm, then spread it to other folks, then patients all over the country can be helped by what we do,” she said. “And that’s a really cool thought.”

The RIV also has the unique advantage of letting people have immediate and direct access to lead researchers at the exact moment of reading their research. HM17 attendees had conversations that usually went beyond just the results, which can be downloaded at www.shmabstracts.com.

Dr. Prevost believes that the chats can helpfully highlight the behind-the-scenes pitfalls and mistakes of research that can sometimes be just as valuable as the published results.

“The things that don’t make it to the posters are all the challenges that people experienced on the way to get to this particular work,” she added. “Like ‘Oh, well, I’ve tried this before, and it didn’t work at all.’ Or, ‘Oh yeah we tried this and it didn’t work at all, but we tried this other thing that worked really great.’ Or, ‘This was the key to our success.’ You can brainstorm with every poster that you’re interested in, which is really exciting.”

 

LAS VEGAS – Masih Shinwa, MD, stood beside a half-circle of judges at SHM’s annual Research, Innovations, and Clinical Vignettes poster competition and argued why his entry, already a finalist, should win.

To think, his work, “Please ‘THINK’ Before You Order: A Multidisciplinary Approach to Decreasing Overutilization of Daily Labs,” was borne simply of a group of medical students who incredulously said that they were amazed patients would be woken up in the night for tests.

Now it was a poster at RIV, one of the biggest highlights of SHM’s annual meeting. The Scientific Abstracts Competition – the event’s formal name – has exploded in popularity over the past few years. Submissions for posters rose from 634 in 2010 to 1,712 this year, and presenters ranged from first-year residents to a former SHM president.

Dr. Shinwa’s project shows just how an idea can blossom into a recognized poster.

Some 18 months ago, the students he works with at Mount Sinai Hospital in New York just couldn’t understand why so many tests had to be done overnight while a patient slept. So, Dr. Shinwa and his colleagues looked at ways to reduce unnecessary lab tests and chemistry testing.

Now, Dr. Shinwa was humbled to think his work and that of his colleagues could be a pathway to eliminating tests that don’t need to happen across the country, a focal point of SHM and the American Board of Internal Medicine Foundation’s Choosing Wisely Campaign.

“This is a way to make it national,” he said. “You may have affected the lives of the patients in your hospital, but, unless you attend these types of national meetings, it’s hard to get that perspective across (the country).”

That level of personal and professional collaboration is the purpose of the RIV, said Margaret Fang, MD, MPH, FHM, program chair for the HM17 competition.

“One of the amazing things is, everyone has their own poster. They’re doing their work,” she added. “But then they start up conversations with the people next to them. ... Seeing the organic networking and discussion that arise from that is really exciting. RIV serves as a way of connecting people who might not have know the other person was doing that kind of work.”

Dr. Fang said that the intergenerational aspect of the RIV, where early-career hospitalists mingle with the field’s founders and leaders, creates an environment where research is encouraged.

“Just seeing the intense interest that more senior hospitalists have in mentoring and guiding the next generation is delightful,” she added.

Dr. Shinwa said that the specialty’s focus on both clinical research and systems-level change is important, as the work positions the field to be leaders not just in patient care but for hospitals as a whole.

“We are physicians,” he said. “Our role is taking care of patients. Knowing that there are people who are not just focusing on taking care of specific patients but are actually there to improve the entire system and the process – that’s really gratifying.”

That’s the word that Merideth Prevost, MD, of New Mexico VA Health Care System, Albuquerque also used to describe presenting her poster, “Improving Accuracy in Measuring Fluid Balance on a General Medicine Ward.”

“If we can improve our little microcosm, then spread it to other folks, then patients all over the country can be helped by what we do,” she said. “And that’s a really cool thought.”

The RIV also has the unique advantage of letting people have immediate and direct access to lead researchers at the exact moment of reading their research. HM17 attendees had conversations that usually went beyond just the results, which can be downloaded at www.shmabstracts.com.

Dr. Prevost believes that the chats can helpfully highlight the behind-the-scenes pitfalls and mistakes of research that can sometimes be just as valuable as the published results.

“The things that don’t make it to the posters are all the challenges that people experienced on the way to get to this particular work,” she added. “Like ‘Oh, well, I’ve tried this before, and it didn’t work at all.’ Or, ‘Oh yeah we tried this and it didn’t work at all, but we tried this other thing that worked really great.’ Or, ‘This was the key to our success.’ You can brainstorm with every poster that you’re interested in, which is really exciting.”

 

LAS VEGAS – Masih Shinwa, MD, stood beside a half-circle of judges at SHM’s annual Research, Innovations, and Clinical Vignettes poster competition and argued why his entry, already a finalist, should win.

To think, his work, “Please ‘THINK’ Before You Order: A Multidisciplinary Approach to Decreasing Overutilization of Daily Labs,” was borne simply of a group of medical students who incredulously said that they were amazed patients would be woken up in the night for tests.

Now it was a poster at RIV, one of the biggest highlights of SHM’s annual meeting. The Scientific Abstracts Competition – the event’s formal name – has exploded in popularity over the past few years. Submissions for posters rose from 634 in 2010 to 1,712 this year, and presenters ranged from first-year residents to a former SHM president.

Dr. Shinwa’s project shows just how an idea can blossom into a recognized poster.

Some 18 months ago, the students he works with at Mount Sinai Hospital in New York just couldn’t understand why so many tests had to be done overnight while a patient slept. So, Dr. Shinwa and his colleagues looked at ways to reduce unnecessary lab tests and chemistry testing.

Now, Dr. Shinwa was humbled to think his work and that of his colleagues could be a pathway to eliminating tests that don’t need to happen across the country, a focal point of SHM and the American Board of Internal Medicine Foundation’s Choosing Wisely Campaign.

“This is a way to make it national,” he said. “You may have affected the lives of the patients in your hospital, but, unless you attend these types of national meetings, it’s hard to get that perspective across (the country).”

That level of personal and professional collaboration is the purpose of the RIV, said Margaret Fang, MD, MPH, FHM, program chair for the HM17 competition.

“One of the amazing things is, everyone has their own poster. They’re doing their work,” she added. “But then they start up conversations with the people next to them. ... Seeing the organic networking and discussion that arise from that is really exciting. RIV serves as a way of connecting people who might not have know the other person was doing that kind of work.”

Dr. Fang said that the intergenerational aspect of the RIV, where early-career hospitalists mingle with the field’s founders and leaders, creates an environment where research is encouraged.

“Just seeing the intense interest that more senior hospitalists have in mentoring and guiding the next generation is delightful,” she added.

Dr. Shinwa said that the specialty’s focus on both clinical research and systems-level change is important, as the work positions the field to be leaders not just in patient care but for hospitals as a whole.

“We are physicians,” he said. “Our role is taking care of patients. Knowing that there are people who are not just focusing on taking care of specific patients but are actually there to improve the entire system and the process – that’s really gratifying.”

That’s the word that Merideth Prevost, MD, of New Mexico VA Health Care System, Albuquerque also used to describe presenting her poster, “Improving Accuracy in Measuring Fluid Balance on a General Medicine Ward.”

“If we can improve our little microcosm, then spread it to other folks, then patients all over the country can be helped by what we do,” she said. “And that’s a really cool thought.”

The RIV also has the unique advantage of letting people have immediate and direct access to lead researchers at the exact moment of reading their research. HM17 attendees had conversations that usually went beyond just the results, which can be downloaded at www.shmabstracts.com.

Dr. Prevost believes that the chats can helpfully highlight the behind-the-scenes pitfalls and mistakes of research that can sometimes be just as valuable as the published results.

“The things that don’t make it to the posters are all the challenges that people experienced on the way to get to this particular work,” she added. “Like ‘Oh, well, I’ve tried this before, and it didn’t work at all.’ Or, ‘Oh yeah we tried this and it didn’t work at all, but we tried this other thing that worked really great.’ Or, ‘This was the key to our success.’ You can brainstorm with every poster that you’re interested in, which is really exciting.”

 

It’s hard to rank anything in hospital medicine much higher than making sure patients receive the medications they need. When mistakes happen, the care is less than optimal, and, in the worst cases, there can be disastrous consequences. Yet, the pharmacy process – involving interplay between hospitalists and pharmacists – can sometimes be clunky and inefficient, even in the age of electronic health records (EHRs).

The Hospitalist surveyed a half-dozen experts, who touched on the need for extra vigilance, areas at high risk for miscues, ways to refine communications and, ultimately, how to improve the care of patients. The following are tips and helpful hints for front-line hospitalists caring for hospitalized patients.

1. Avoid assumptions and shortcuts when reviewing a patient’s home medication list.

“As the saying goes, ‘garbage in, garbage out.’ This applies to completing a comprehensive medication review for a patient at the time of admission to the hospital, to ensure the patient is started on the right medications,” said Lisa Kroon, PharmD, chair of the department of clinical pharmacy at the University of California, San Francisco.

Even though EHRs are becoming more connected, they don’t provide all the details. Just because a medication is on the medication list doesn’t mean patients are actually taking it. They also might be taking it differently than prescribed, Dr. Kroon said. Patients and caregivers should be asked what medications they’re actually taking, as well as the strength of the tablet, how many at a time and how often, and at what time of the day they are taking them.

The EHR “is often more of a record of which medications have been ordered by a provider at some point,” she notes.

Doug Humber, PharmD, clinical professor of pharmacy at the University of California, San Diego, said hospitalists should be sure to ask patients about over-the-counter drugs, herbals, and nutraceuticals.

“Some of those medications may interact with prescribed medication in the hospital,” he said. “The most complete data that we have on a patient’s medication list coming in clearly sets [us] up for success, in terms of making medication therapy safer for the patients while they’re here.”

Dr. Kroon encourages hospitalists to conduct a complete medication review, which helps determine what should be continued at discharge.

“Sometimes, not all medications a patient was taking at home need to be restarted, such as vitamins or supplements, so avoid just entering, ‘Restart all home meds,’ ” she said.

2. Pay close attention to adjustments based on liver and kidney function.

“A hospitalist may take a more hands-off approach and just make the assumption that their medications are dose-adjusted appropriately, and I think that might be a bad assumption. [Don’t assume] that things are just automatically going to be adjusted,” Dr. Humber said.

Mohamed Jalloh, PharmD, a pharmacist and a spokesman for the American Pharmacists Association, concurs. He said that most mistakes are related to “kidney [or] liver adjustments.”

That said, hospitalists also need to be cognizant of adjustments for reasons that aren’t kidney or liver related.

“It is well known that patients with renal and hepatic disease often require dosage adjustments for optimal therapeutic response, but patients with other characteristics and conditions also may require dosage adjustments due to variations in pharmacokinetics and pharmacodynamics,” said Erika Thomas, MBA, RPh,, a pharmacist and director of the Inpatient Care Practitioners section of the American Society of Health-System Pharmacists. “Patients who are obese, elderly, neonatal, pediatric, and those with other comorbidities also may require dosage adjustment.”

Drug-drug interactions might call for unique dosage adjustments, too, she adds.

3. Carefully choose drug-information sources.

Dr. Jalloh said that one of the roots of inappropriate dosing is simply “a lack of time and money to look at credible resources.” Free drug-information apps might not have the extensive information needed to make all the right decisions, such as adjustments for organ function, he said. More comprehensive apps are expensive, he admits, and sometimes even those apps contain gaps.

“Hospitalists can contact drug-information centers that answer complex clinical questions about drugs if they do not have the time to explore themselves,” he said.

Creighton University, Omaha, Neb., for example, has such a center that has been nationally recognized.

4. Carefully review patients’ medications when they transfer from different levels of care.

Certain medications are started in the ICU that may not need to be continued on the non-ICU floor or at discharge, said MacKenzie Clark, PharmD, program pharmacist at the University of California, San Francisco. One example is quetiapine, which is used in the ICU for delirium.

 

“Unfortunately, we are seeing patients erroneously continued on this [medication] on the floor. Some are even discharged on this [med],” Clark said, adding that a specific order set can be developed that has a 72-hour automatic stop date for all orders for quetiapine when used specifically for delirium.

“[The order set] can help reduce the chance that it be continued unnecessarily when a patient transfers out of the ICU,” she explains.

Another class of medication that is often initiated in the ICU is proton pump inhibitors for stress ulcer prophylaxis. Continuing these on the floor or at discharge, Clark said, should be carefully considered to avoid unnecessary use and potential adverse effects.

5. Seek opportunities to change from intravenous to oral medications – it could mean big savings.

Intravenous medications usually are more expensive than oral formulations. They also increase the risk of infection. Those are two good reasons to switch patients from IV to oral (PO) as early as possible.

“We find that physicians often don’t know how much drugs cost,” said Marilyn Stebbins, PharmD, vice chair of clinical innovation at University of California, San Francisco.

A common example, she said, is IV acetaminophen, the cost of which skyrocketed in 2014. Institutions can save significant dollars by limiting use of IV acetaminophen outside the perioperative area to patients unable to tolerate oral medications. For patients who are candidates for IV acetaminophen, consider setting an automatic expiration of the order at 24 hours.

Hospitalists can help reduce the drug budget by supporting IV-to-PO programs, in which pharmacists can automatically change an IV medication to PO formulation after verifying a patient is able to tolerate orals.

6. Consider a patient’s health insurance coverage when prescribing a drug at discharge.

“Don’t start the fancy drug that the patient can’t continue at home,” said Ian Jenkins, MD, SFHM, a hospitalist and health sciences clinical professor at the University of California, San Diego, and member of the UCSD pharmacy and therapeutics committee. “New anticoagulants are a great example. We run outpatient claims against their insurance before starting anything, as a policy to avoid this.”

7. Tell the pharmacist what you’re thinking.

Dr. Jenkins uses a case of sepsis as an example:

“If you make it clear that’s what’s happening, you can get a stat loading-dose infused and meet [The Joint Commission] goals for management and improve care, rather than just routine antibiotic starts,” he said.

Another example is anticoagulants:

“Why are you starting the anticoagulant? Recommendations could differ if it’s for acute PE (pulmonary embolism) versus just bridging, which pharmacists these days might catch as overtreatment,” he said. “Keep [the pharmacy] posted about upcoming changes, so they can do discharge planning and anticipate things like glucose management changes with steroid-dose fluctuations.”

8. Beware chronic medications that are not on the hospital formulary.

Your hospital likely has a formulary for chronic medications, such as ACE inhibitors, angiotensin receptor blockers, and statins, which might be different than what the patient was taking at home. So, changes might need to be made, Dr. Clark.

“Pharmacists can assist in this,” she said. “Often, a ‘therapeutic interchange program’ can be established whereby a pharmacist can automatically change the medication to a therapeutically equivalent one and ensure the appropriate dose conversion.”

At discharge, the reverse process is required.

“Be sure you are not discharging the patient on the hospital formulary drug [e.g., ramipril] ... when they already have lisinopril in their medicine cabinet at home,” Clark said. “This can lead to confusion by the patient about which medication to take and result in unintended duplicate drug therapy or worse. A patient may not take either medication because they aren’t sure just what to take.”

9. Don’t hesitate to rely on pharmacists’ expertise.

“To ensure that patients enter and leave the hospital on the right medications and [that they are] taken at the right dose and time, do not forget to enlist your pharmacists to provide support during care transitions,” Dr. Stebbins said.

Dr. Humber said pharmacists are “uniquely qualified” to be medication experts in a facility, and that “kind of experience and that type of expertise to the care of the hospitalized patient is paramount.”

Dr. Thomas said that pharmacists can save hospitalists time.

“Check with your pharmacist on available decision-support tools, available infusion devices, institutional medication-related protocols, and medications within a drug class.”Additionally, encourage pharmacists to join you for rounds, if they’re not already doing so. Dr. Humber also said hospitalists should consider more one-on-one communications, noting that it’s always better to chat “face to face than it is over the phone or with a text message. Things can certainly get misinterpreted.”

 

10. Consider asking a pharmacist for advice on how to administer complicated regimens.

“Drugs can be administered in a variety of ways, including nasogastric, sublingual, oral, rectal, IV infusion, epidural, intra-arterial, topical, extracorporeal, and intrathecal,” Dr. Thomas said. “Not all drug formulations can be administered by all routes for a variety of reasons. Pharmacists can assist in determining the safest and most effective route of administration for drug formulations.”

11. Not all patients need broad-spectrum antibiotics for a prolonged period of time.

According to the Centers for Disease Control and Prevention, 20%-50% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate, Dr. Kroon said.

“Specifying the dose, duration, and indication for all courses of antibiotics helps promote the appropriate use of antibiotics,” she noted.

Pharmacists play a large role in antibiotic dosing based on therapeutic levels, such as with vancomycin or on organ function, as with renal dose-adjustments; and in identifying drug-drug interactions that occur frequently with antibiotics, such as with the separation of quinolones from many supplements.

12. When ordering medications, a complete and legible signature is required.

With new computerized physician order entry ordering, it seems intuitive that what a physician orders is what they want, Dr. Kroon said. But, if medication orders are not completely clear, errors can arise at steps in the medication management process, such as when a pharmacist verifies and approves the medication order or at medication administration by a nurse. To avoid errors, she suggests that every medication order have the drug name, dose, route, and frequency. She also suggested that all “PRN” – as needed – orders need an indication and additional specificity if there are multiple medications.

For pain medications, an example might be: “Tylenol 1,000 mg PO q8h prn mild pain; Norco 5-325mg, 1 tab PO q4h prn moderate pain; oxycodone 5mg PO q4h prn severe pain.” This, Dr. Kroon explains, allows nurses to know when a specific medication should be administered to a patient. “Writing complete orders alleviates unnecessary paging to the ordering providers and ensures the timely administration of medications to patients,” she said.

 

It’s hard to rank anything in hospital medicine much higher than making sure patients receive the medications they need. When mistakes happen, the care is less than optimal, and, in the worst cases, there can be disastrous consequences. Yet, the pharmacy process – involving interplay between hospitalists and pharmacists – can sometimes be clunky and inefficient, even in the age of electronic health records (EHRs).

The Hospitalist surveyed a half-dozen experts, who touched on the need for extra vigilance, areas at high risk for miscues, ways to refine communications and, ultimately, how to improve the care of patients. The following are tips and helpful hints for front-line hospitalists caring for hospitalized patients.

1. Avoid assumptions and shortcuts when reviewing a patient’s home medication list.

“As the saying goes, ‘garbage in, garbage out.’ This applies to completing a comprehensive medication review for a patient at the time of admission to the hospital, to ensure the patient is started on the right medications,” said Lisa Kroon, PharmD, chair of the department of clinical pharmacy at the University of California, San Francisco.

Even though EHRs are becoming more connected, they don’t provide all the details. Just because a medication is on the medication list doesn’t mean patients are actually taking it. They also might be taking it differently than prescribed, Dr. Kroon said. Patients and caregivers should be asked what medications they’re actually taking, as well as the strength of the tablet, how many at a time and how often, and at what time of the day they are taking them.

The EHR “is often more of a record of which medications have been ordered by a provider at some point,” she notes.

Doug Humber, PharmD, clinical professor of pharmacy at the University of California, San Diego, said hospitalists should be sure to ask patients about over-the-counter drugs, herbals, and nutraceuticals.

“Some of those medications may interact with prescribed medication in the hospital,” he said. “The most complete data that we have on a patient’s medication list coming in clearly sets [us] up for success, in terms of making medication therapy safer for the patients while they’re here.”

Dr. Kroon encourages hospitalists to conduct a complete medication review, which helps determine what should be continued at discharge.

“Sometimes, not all medications a patient was taking at home need to be restarted, such as vitamins or supplements, so avoid just entering, ‘Restart all home meds,’ ” she said.

2. Pay close attention to adjustments based on liver and kidney function.

“A hospitalist may take a more hands-off approach and just make the assumption that their medications are dose-adjusted appropriately, and I think that might be a bad assumption. [Don’t assume] that things are just automatically going to be adjusted,” Dr. Humber said.

Mohamed Jalloh, PharmD, a pharmacist and a spokesman for the American Pharmacists Association, concurs. He said that most mistakes are related to “kidney [or] liver adjustments.”

That said, hospitalists also need to be cognizant of adjustments for reasons that aren’t kidney or liver related.

“It is well known that patients with renal and hepatic disease often require dosage adjustments for optimal therapeutic response, but patients with other characteristics and conditions also may require dosage adjustments due to variations in pharmacokinetics and pharmacodynamics,” said Erika Thomas, MBA, RPh,, a pharmacist and director of the Inpatient Care Practitioners section of the American Society of Health-System Pharmacists. “Patients who are obese, elderly, neonatal, pediatric, and those with other comorbidities also may require dosage adjustment.”

Drug-drug interactions might call for unique dosage adjustments, too, she adds.

3. Carefully choose drug-information sources.

Dr. Jalloh said that one of the roots of inappropriate dosing is simply “a lack of time and money to look at credible resources.” Free drug-information apps might not have the extensive information needed to make all the right decisions, such as adjustments for organ function, he said. More comprehensive apps are expensive, he admits, and sometimes even those apps contain gaps.

“Hospitalists can contact drug-information centers that answer complex clinical questions about drugs if they do not have the time to explore themselves,” he said.

Creighton University, Omaha, Neb., for example, has such a center that has been nationally recognized.

4. Carefully review patients’ medications when they transfer from different levels of care.

Certain medications are started in the ICU that may not need to be continued on the non-ICU floor or at discharge, said MacKenzie Clark, PharmD, program pharmacist at the University of California, San Francisco. One example is quetiapine, which is used in the ICU for delirium.

 

“Unfortunately, we are seeing patients erroneously continued on this [medication] on the floor. Some are even discharged on this [med],” Clark said, adding that a specific order set can be developed that has a 72-hour automatic stop date for all orders for quetiapine when used specifically for delirium.

“[The order set] can help reduce the chance that it be continued unnecessarily when a patient transfers out of the ICU,” she explains.

Another class of medication that is often initiated in the ICU is proton pump inhibitors for stress ulcer prophylaxis. Continuing these on the floor or at discharge, Clark said, should be carefully considered to avoid unnecessary use and potential adverse effects.

5. Seek opportunities to change from intravenous to oral medications – it could mean big savings.

Intravenous medications usually are more expensive than oral formulations. They also increase the risk of infection. Those are two good reasons to switch patients from IV to oral (PO) as early as possible.

“We find that physicians often don’t know how much drugs cost,” said Marilyn Stebbins, PharmD, vice chair of clinical innovation at University of California, San Francisco.

A common example, she said, is IV acetaminophen, the cost of which skyrocketed in 2014. Institutions can save significant dollars by limiting use of IV acetaminophen outside the perioperative area to patients unable to tolerate oral medications. For patients who are candidates for IV acetaminophen, consider setting an automatic expiration of the order at 24 hours.

Hospitalists can help reduce the drug budget by supporting IV-to-PO programs, in which pharmacists can automatically change an IV medication to PO formulation after verifying a patient is able to tolerate orals.

6. Consider a patient’s health insurance coverage when prescribing a drug at discharge.

“Don’t start the fancy drug that the patient can’t continue at home,” said Ian Jenkins, MD, SFHM, a hospitalist and health sciences clinical professor at the University of California, San Diego, and member of the UCSD pharmacy and therapeutics committee. “New anticoagulants are a great example. We run outpatient claims against their insurance before starting anything, as a policy to avoid this.”

7. Tell the pharmacist what you’re thinking.

Dr. Jenkins uses a case of sepsis as an example:

“If you make it clear that’s what’s happening, you can get a stat loading-dose infused and meet [The Joint Commission] goals for management and improve care, rather than just routine antibiotic starts,” he said.

Another example is anticoagulants:

“Why are you starting the anticoagulant? Recommendations could differ if it’s for acute PE (pulmonary embolism) versus just bridging, which pharmacists these days might catch as overtreatment,” he said. “Keep [the pharmacy] posted about upcoming changes, so they can do discharge planning and anticipate things like glucose management changes with steroid-dose fluctuations.”

8. Beware chronic medications that are not on the hospital formulary.

Your hospital likely has a formulary for chronic medications, such as ACE inhibitors, angiotensin receptor blockers, and statins, which might be different than what the patient was taking at home. So, changes might need to be made, Dr. Clark.

“Pharmacists can assist in this,” she said. “Often, a ‘therapeutic interchange program’ can be established whereby a pharmacist can automatically change the medication to a therapeutically equivalent one and ensure the appropriate dose conversion.”

At discharge, the reverse process is required.

“Be sure you are not discharging the patient on the hospital formulary drug [e.g., ramipril] ... when they already have lisinopril in their medicine cabinet at home,” Clark said. “This can lead to confusion by the patient about which medication to take and result in unintended duplicate drug therapy or worse. A patient may not take either medication because they aren’t sure just what to take.”

9. Don’t hesitate to rely on pharmacists’ expertise.

“To ensure that patients enter and leave the hospital on the right medications and [that they are] taken at the right dose and time, do not forget to enlist your pharmacists to provide support during care transitions,” Dr. Stebbins said.

Dr. Humber said pharmacists are “uniquely qualified” to be medication experts in a facility, and that “kind of experience and that type of expertise to the care of the hospitalized patient is paramount.”

Dr. Thomas said that pharmacists can save hospitalists time.

“Check with your pharmacist on available decision-support tools, available infusion devices, institutional medication-related protocols, and medications within a drug class.”Additionally, encourage pharmacists to join you for rounds, if they’re not already doing so. Dr. Humber also said hospitalists should consider more one-on-one communications, noting that it’s always better to chat “face to face than it is over the phone or with a text message. Things can certainly get misinterpreted.”

 

10. Consider asking a pharmacist for advice on how to administer complicated regimens.

“Drugs can be administered in a variety of ways, including nasogastric, sublingual, oral, rectal, IV infusion, epidural, intra-arterial, topical, extracorporeal, and intrathecal,” Dr. Thomas said. “Not all drug formulations can be administered by all routes for a variety of reasons. Pharmacists can assist in determining the safest and most effective route of administration for drug formulations.”

11. Not all patients need broad-spectrum antibiotics for a prolonged period of time.

According to the Centers for Disease Control and Prevention, 20%-50% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate, Dr. Kroon said.

“Specifying the dose, duration, and indication for all courses of antibiotics helps promote the appropriate use of antibiotics,” she noted.

Pharmacists play a large role in antibiotic dosing based on therapeutic levels, such as with vancomycin or on organ function, as with renal dose-adjustments; and in identifying drug-drug interactions that occur frequently with antibiotics, such as with the separation of quinolones from many supplements.

12. When ordering medications, a complete and legible signature is required.

With new computerized physician order entry ordering, it seems intuitive that what a physician orders is what they want, Dr. Kroon said. But, if medication orders are not completely clear, errors can arise at steps in the medication management process, such as when a pharmacist verifies and approves the medication order or at medication administration by a nurse. To avoid errors, she suggests that every medication order have the drug name, dose, route, and frequency. She also suggested that all “PRN” – as needed – orders need an indication and additional specificity if there are multiple medications.

For pain medications, an example might be: “Tylenol 1,000 mg PO q8h prn mild pain; Norco 5-325mg, 1 tab PO q4h prn moderate pain; oxycodone 5mg PO q4h prn severe pain.” This, Dr. Kroon explains, allows nurses to know when a specific medication should be administered to a patient. “Writing complete orders alleviates unnecessary paging to the ordering providers and ensures the timely administration of medications to patients,” she said.

 

It’s hard to rank anything in hospital medicine much higher than making sure patients receive the medications they need. When mistakes happen, the care is less than optimal, and, in the worst cases, there can be disastrous consequences. Yet, the pharmacy process – involving interplay between hospitalists and pharmacists – can sometimes be clunky and inefficient, even in the age of electronic health records (EHRs).

The Hospitalist surveyed a half-dozen experts, who touched on the need for extra vigilance, areas at high risk for miscues, ways to refine communications and, ultimately, how to improve the care of patients. The following are tips and helpful hints for front-line hospitalists caring for hospitalized patients.

1. Avoid assumptions and shortcuts when reviewing a patient’s home medication list.

“As the saying goes, ‘garbage in, garbage out.’ This applies to completing a comprehensive medication review for a patient at the time of admission to the hospital, to ensure the patient is started on the right medications,” said Lisa Kroon, PharmD, chair of the department of clinical pharmacy at the University of California, San Francisco.

Even though EHRs are becoming more connected, they don’t provide all the details. Just because a medication is on the medication list doesn’t mean patients are actually taking it. They also might be taking it differently than prescribed, Dr. Kroon said. Patients and caregivers should be asked what medications they’re actually taking, as well as the strength of the tablet, how many at a time and how often, and at what time of the day they are taking them.

The EHR “is often more of a record of which medications have been ordered by a provider at some point,” she notes.

Doug Humber, PharmD, clinical professor of pharmacy at the University of California, San Diego, said hospitalists should be sure to ask patients about over-the-counter drugs, herbals, and nutraceuticals.

“Some of those medications may interact with prescribed medication in the hospital,” he said. “The most complete data that we have on a patient’s medication list coming in clearly sets [us] up for success, in terms of making medication therapy safer for the patients while they’re here.”

Dr. Kroon encourages hospitalists to conduct a complete medication review, which helps determine what should be continued at discharge.

“Sometimes, not all medications a patient was taking at home need to be restarted, such as vitamins or supplements, so avoid just entering, ‘Restart all home meds,’ ” she said.

2. Pay close attention to adjustments based on liver and kidney function.

“A hospitalist may take a more hands-off approach and just make the assumption that their medications are dose-adjusted appropriately, and I think that might be a bad assumption. [Don’t assume] that things are just automatically going to be adjusted,” Dr. Humber said.

Mohamed Jalloh, PharmD, a pharmacist and a spokesman for the American Pharmacists Association, concurs. He said that most mistakes are related to “kidney [or] liver adjustments.”

That said, hospitalists also need to be cognizant of adjustments for reasons that aren’t kidney or liver related.

“It is well known that patients with renal and hepatic disease often require dosage adjustments for optimal therapeutic response, but patients with other characteristics and conditions also may require dosage adjustments due to variations in pharmacokinetics and pharmacodynamics,” said Erika Thomas, MBA, RPh,, a pharmacist and director of the Inpatient Care Practitioners section of the American Society of Health-System Pharmacists. “Patients who are obese, elderly, neonatal, pediatric, and those with other comorbidities also may require dosage adjustment.”

Drug-drug interactions might call for unique dosage adjustments, too, she adds.

3. Carefully choose drug-information sources.

Dr. Jalloh said that one of the roots of inappropriate dosing is simply “a lack of time and money to look at credible resources.” Free drug-information apps might not have the extensive information needed to make all the right decisions, such as adjustments for organ function, he said. More comprehensive apps are expensive, he admits, and sometimes even those apps contain gaps.

“Hospitalists can contact drug-information centers that answer complex clinical questions about drugs if they do not have the time to explore themselves,” he said.

Creighton University, Omaha, Neb., for example, has such a center that has been nationally recognized.

4. Carefully review patients’ medications when they transfer from different levels of care.

Certain medications are started in the ICU that may not need to be continued on the non-ICU floor or at discharge, said MacKenzie Clark, PharmD, program pharmacist at the University of California, San Francisco. One example is quetiapine, which is used in the ICU for delirium.

 

“Unfortunately, we are seeing patients erroneously continued on this [medication] on the floor. Some are even discharged on this [med],” Clark said, adding that a specific order set can be developed that has a 72-hour automatic stop date for all orders for quetiapine when used specifically for delirium.

“[The order set] can help reduce the chance that it be continued unnecessarily when a patient transfers out of the ICU,” she explains.

Another class of medication that is often initiated in the ICU is proton pump inhibitors for stress ulcer prophylaxis. Continuing these on the floor or at discharge, Clark said, should be carefully considered to avoid unnecessary use and potential adverse effects.

5. Seek opportunities to change from intravenous to oral medications – it could mean big savings.

Intravenous medications usually are more expensive than oral formulations. They also increase the risk of infection. Those are two good reasons to switch patients from IV to oral (PO) as early as possible.

“We find that physicians often don’t know how much drugs cost,” said Marilyn Stebbins, PharmD, vice chair of clinical innovation at University of California, San Francisco.

A common example, she said, is IV acetaminophen, the cost of which skyrocketed in 2014. Institutions can save significant dollars by limiting use of IV acetaminophen outside the perioperative area to patients unable to tolerate oral medications. For patients who are candidates for IV acetaminophen, consider setting an automatic expiration of the order at 24 hours.

Hospitalists can help reduce the drug budget by supporting IV-to-PO programs, in which pharmacists can automatically change an IV medication to PO formulation after verifying a patient is able to tolerate orals.

6. Consider a patient’s health insurance coverage when prescribing a drug at discharge.

“Don’t start the fancy drug that the patient can’t continue at home,” said Ian Jenkins, MD, SFHM, a hospitalist and health sciences clinical professor at the University of California, San Diego, and member of the UCSD pharmacy and therapeutics committee. “New anticoagulants are a great example. We run outpatient claims against their insurance before starting anything, as a policy to avoid this.”

7. Tell the pharmacist what you’re thinking.

Dr. Jenkins uses a case of sepsis as an example:

“If you make it clear that’s what’s happening, you can get a stat loading-dose infused and meet [The Joint Commission] goals for management and improve care, rather than just routine antibiotic starts,” he said.

Another example is anticoagulants:

“Why are you starting the anticoagulant? Recommendations could differ if it’s for acute PE (pulmonary embolism) versus just bridging, which pharmacists these days might catch as overtreatment,” he said. “Keep [the pharmacy] posted about upcoming changes, so they can do discharge planning and anticipate things like glucose management changes with steroid-dose fluctuations.”

8. Beware chronic medications that are not on the hospital formulary.

Your hospital likely has a formulary for chronic medications, such as ACE inhibitors, angiotensin receptor blockers, and statins, which might be different than what the patient was taking at home. So, changes might need to be made, Dr. Clark.

“Pharmacists can assist in this,” she said. “Often, a ‘therapeutic interchange program’ can be established whereby a pharmacist can automatically change the medication to a therapeutically equivalent one and ensure the appropriate dose conversion.”

At discharge, the reverse process is required.

“Be sure you are not discharging the patient on the hospital formulary drug [e.g., ramipril] ... when they already have lisinopril in their medicine cabinet at home,” Clark said. “This can lead to confusion by the patient about which medication to take and result in unintended duplicate drug therapy or worse. A patient may not take either medication because they aren’t sure just what to take.”

9. Don’t hesitate to rely on pharmacists’ expertise.

“To ensure that patients enter and leave the hospital on the right medications and [that they are] taken at the right dose and time, do not forget to enlist your pharmacists to provide support during care transitions,” Dr. Stebbins said.

Dr. Humber said pharmacists are “uniquely qualified” to be medication experts in a facility, and that “kind of experience and that type of expertise to the care of the hospitalized patient is paramount.”

Dr. Thomas said that pharmacists can save hospitalists time.

“Check with your pharmacist on available decision-support tools, available infusion devices, institutional medication-related protocols, and medications within a drug class.”Additionally, encourage pharmacists to join you for rounds, if they’re not already doing so. Dr. Humber also said hospitalists should consider more one-on-one communications, noting that it’s always better to chat “face to face than it is over the phone or with a text message. Things can certainly get misinterpreted.”

 

10. Consider asking a pharmacist for advice on how to administer complicated regimens.

“Drugs can be administered in a variety of ways, including nasogastric, sublingual, oral, rectal, IV infusion, epidural, intra-arterial, topical, extracorporeal, and intrathecal,” Dr. Thomas said. “Not all drug formulations can be administered by all routes for a variety of reasons. Pharmacists can assist in determining the safest and most effective route of administration for drug formulations.”

11. Not all patients need broad-spectrum antibiotics for a prolonged period of time.

According to the Centers for Disease Control and Prevention, 20%-50% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate, Dr. Kroon said.

“Specifying the dose, duration, and indication for all courses of antibiotics helps promote the appropriate use of antibiotics,” she noted.

Pharmacists play a large role in antibiotic dosing based on therapeutic levels, such as with vancomycin or on organ function, as with renal dose-adjustments; and in identifying drug-drug interactions that occur frequently with antibiotics, such as with the separation of quinolones from many supplements.

12. When ordering medications, a complete and legible signature is required.

With new computerized physician order entry ordering, it seems intuitive that what a physician orders is what they want, Dr. Kroon said. But, if medication orders are not completely clear, errors can arise at steps in the medication management process, such as when a pharmacist verifies and approves the medication order or at medication administration by a nurse. To avoid errors, she suggests that every medication order have the drug name, dose, route, and frequency. She also suggested that all “PRN” – as needed – orders need an indication and additional specificity if there are multiple medications.

For pain medications, an example might be: “Tylenol 1,000 mg PO q8h prn mild pain; Norco 5-325mg, 1 tab PO q4h prn moderate pain; oxycodone 5mg PO q4h prn severe pain.” This, Dr. Kroon explains, allows nurses to know when a specific medication should be administered to a patient. “Writing complete orders alleviates unnecessary paging to the ordering providers and ensures the timely administration of medications to patients,” she said.

 

CLINICAL QUESTION: Can shock index (SI) in the ED predict the likelihood for hospital admission and inpatient mortality?

BACKGROUND: SI is defined as heart rate divided by systolic blood pressure. It is postulated to have an inverse relationship to cardiac output. SI has been studied as a prognostic metric of poor outcomes in patients with myocardial infarction, gastrointestinal hemorrhage, sepsis, and trauma. There are no large studies on SI in the general ED population.

STUDY DESIGN: Retrospective chart review.

SETTING: Academic tertiary care center.

SYNOPSIS: All ED patients over 18 years of age over a 12-month period were included in the study for a total of 58,633 charts. Charts were excluded if the patient presented in cardiac arrest, left prior to full evaluation in the ED, or had an incomplete or absent first set of vital signs. Likelihood ratio (LR) values of greater than 5 and 10 were considered moderate and large increases in the outcomes, respectively. Authors found SI greater than 1.2 had a positive LR of 11.69 for admission to the hospital and a positive LR of 5.82 for inpatient mortality.

This study identified potential thresholds for SI but did not validate them. Whether SI would be a useful tool for triage remains unanswered.

BOTTOM LINE: Initial SI greater than 1.2 at presentation to the ED was associated with increased likelihood of hospital admission and inpatient mortality.

CITATIONS: Balhara KS, Hsieh YH, Hamade B, et al. Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality. Emerg Med J. 2017 Feb;34(2):89-94.

Dr. Dietsche is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.

 

CLINICAL QUESTION: Can shock index (SI) in the ED predict the likelihood for hospital admission and inpatient mortality?

BACKGROUND: SI is defined as heart rate divided by systolic blood pressure. It is postulated to have an inverse relationship to cardiac output. SI has been studied as a prognostic metric of poor outcomes in patients with myocardial infarction, gastrointestinal hemorrhage, sepsis, and trauma. There are no large studies on SI in the general ED population.

STUDY DESIGN: Retrospective chart review.

SETTING: Academic tertiary care center.

SYNOPSIS: All ED patients over 18 years of age over a 12-month period were included in the study for a total of 58,633 charts. Charts were excluded if the patient presented in cardiac arrest, left prior to full evaluation in the ED, or had an incomplete or absent first set of vital signs. Likelihood ratio (LR) values of greater than 5 and 10 were considered moderate and large increases in the outcomes, respectively. Authors found SI greater than 1.2 had a positive LR of 11.69 for admission to the hospital and a positive LR of 5.82 for inpatient mortality.

This study identified potential thresholds for SI but did not validate them. Whether SI would be a useful tool for triage remains unanswered.

BOTTOM LINE: Initial SI greater than 1.2 at presentation to the ED was associated with increased likelihood of hospital admission and inpatient mortality.

CITATIONS: Balhara KS, Hsieh YH, Hamade B, et al. Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality. Emerg Med J. 2017 Feb;34(2):89-94.

Dr. Dietsche is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.

 

CLINICAL QUESTION: Can shock index (SI) in the ED predict the likelihood for hospital admission and inpatient mortality?

BACKGROUND: SI is defined as heart rate divided by systolic blood pressure. It is postulated to have an inverse relationship to cardiac output. SI has been studied as a prognostic metric of poor outcomes in patients with myocardial infarction, gastrointestinal hemorrhage, sepsis, and trauma. There are no large studies on SI in the general ED population.

STUDY DESIGN: Retrospective chart review.

SETTING: Academic tertiary care center.

SYNOPSIS: All ED patients over 18 years of age over a 12-month period were included in the study for a total of 58,633 charts. Charts were excluded if the patient presented in cardiac arrest, left prior to full evaluation in the ED, or had an incomplete or absent first set of vital signs. Likelihood ratio (LR) values of greater than 5 and 10 were considered moderate and large increases in the outcomes, respectively. Authors found SI greater than 1.2 had a positive LR of 11.69 for admission to the hospital and a positive LR of 5.82 for inpatient mortality.

This study identified potential thresholds for SI but did not validate them. Whether SI would be a useful tool for triage remains unanswered.

BOTTOM LINE: Initial SI greater than 1.2 at presentation to the ED was associated with increased likelihood of hospital admission and inpatient mortality.

CITATIONS: Balhara KS, Hsieh YH, Hamade B, et al. Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality. Emerg Med J. 2017 Feb;34(2):89-94.

Dr. Dietsche is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.