HM15 presenters: Joshua D. Lenchus, DO, FACP, SFHM, and Nilam Soni, MD, FHM
Summary: Drs. Lenchus and Soni focused on the forces that are driving the value and success of established procedure teams in hospital medicine groups (HMGs). These stem from a need to rapidly address the growing shortage of skilled internists who can perform diagnostic and therapeutic procedures, thus leading to a subset of hospitalists who are willing to provide these services, particularly with the assistance of bedside ultrasonography.
They stressed the importance of providing a platform that is preemptive, proprietary, and scalable. With a defined set of value-creating metrics such as faster turn-around times, a reduction in complication rates, and ultimately a reduction in cost, LOS, and utilization, data must be collected to adequately measure the impact of these services on the institution.
They also discussed the key components necessary to create a procedure service, starting with the logistics of adequate training and demonstration of competence, proper staffing, supplies and equipment, ultrasound image archiving, and the use of documentation templates. The process is followed by the development of pre-procedure and post-procedure guidelines, as well as standardized procedural techniques.
The session also reviewed billing practices and professional fees. An analysis was made comparing Medicare reimbursement and work RVUs for each procedure service with and without a full procedure consultation. A complete consultation significantly increases the allowable fee and associated wRVU. The caveat is that billing for consults is limited to services rendered for patients that are not cared for by the same hospitalist group.
Furthermore, sub-specialists historically perform these procedures. The argument can be made that hospitalists will reduce an unnecessary burden on interventional radiologists, thereby enabling them to focus on more acomplex invasive and highly technical procedures.
The key to success is the ability to find a strategic partner in the C-suite who will directly or indirectly provide the financial and political support. Other sources of funding include private foundations, medical schools, the Department of Veteran Affairs, and such patient safety organizations as AHRQ, IOM, and IHI. HMG leaders also should consider scalability across other hospitalist groups.
“If you build it, they will come."
HM takeaways
Create a business plan;
Find institutional financial and political support;
Start small and selective;
Plan for standardization and training of colleagues;
Create a credentialing/privileging process;
Bill for services and consider billing for full consults; and
HM15 presenters: Joshua D. Lenchus, DO, FACP, SFHM, and Nilam Soni, MD, FHM
Summary: Drs. Lenchus and Soni focused on the forces that are driving the value and success of established procedure teams in hospital medicine groups (HMGs). These stem from a need to rapidly address the growing shortage of skilled internists who can perform diagnostic and therapeutic procedures, thus leading to a subset of hospitalists who are willing to provide these services, particularly with the assistance of bedside ultrasonography.
They stressed the importance of providing a platform that is preemptive, proprietary, and scalable. With a defined set of value-creating metrics such as faster turn-around times, a reduction in complication rates, and ultimately a reduction in cost, LOS, and utilization, data must be collected to adequately measure the impact of these services on the institution.
They also discussed the key components necessary to create a procedure service, starting with the logistics of adequate training and demonstration of competence, proper staffing, supplies and equipment, ultrasound image archiving, and the use of documentation templates. The process is followed by the development of pre-procedure and post-procedure guidelines, as well as standardized procedural techniques.
The session also reviewed billing practices and professional fees. An analysis was made comparing Medicare reimbursement and work RVUs for each procedure service with and without a full procedure consultation. A complete consultation significantly increases the allowable fee and associated wRVU. The caveat is that billing for consults is limited to services rendered for patients that are not cared for by the same hospitalist group.
Furthermore, sub-specialists historically perform these procedures. The argument can be made that hospitalists will reduce an unnecessary burden on interventional radiologists, thereby enabling them to focus on more acomplex invasive and highly technical procedures.
The key to success is the ability to find a strategic partner in the C-suite who will directly or indirectly provide the financial and political support. Other sources of funding include private foundations, medical schools, the Department of Veteran Affairs, and such patient safety organizations as AHRQ, IOM, and IHI. HMG leaders also should consider scalability across other hospitalist groups.
“If you build it, they will come."
HM takeaways
Create a business plan;
Find institutional financial and political support;
Start small and selective;
Plan for standardization and training of colleagues;
Create a credentialing/privileging process;
Bill for services and consider billing for full consults; and
Gather baseline and follow-up data.
HM15 presenters: Joshua D. Lenchus, DO, FACP, SFHM, and Nilam Soni, MD, FHM
Summary: Drs. Lenchus and Soni focused on the forces that are driving the value and success of established procedure teams in hospital medicine groups (HMGs). These stem from a need to rapidly address the growing shortage of skilled internists who can perform diagnostic and therapeutic procedures, thus leading to a subset of hospitalists who are willing to provide these services, particularly with the assistance of bedside ultrasonography.
They stressed the importance of providing a platform that is preemptive, proprietary, and scalable. With a defined set of value-creating metrics such as faster turn-around times, a reduction in complication rates, and ultimately a reduction in cost, LOS, and utilization, data must be collected to adequately measure the impact of these services on the institution.
They also discussed the key components necessary to create a procedure service, starting with the logistics of adequate training and demonstration of competence, proper staffing, supplies and equipment, ultrasound image archiving, and the use of documentation templates. The process is followed by the development of pre-procedure and post-procedure guidelines, as well as standardized procedural techniques.
The session also reviewed billing practices and professional fees. An analysis was made comparing Medicare reimbursement and work RVUs for each procedure service with and without a full procedure consultation. A complete consultation significantly increases the allowable fee and associated wRVU. The caveat is that billing for consults is limited to services rendered for patients that are not cared for by the same hospitalist group.
Furthermore, sub-specialists historically perform these procedures. The argument can be made that hospitalists will reduce an unnecessary burden on interventional radiologists, thereby enabling them to focus on more acomplex invasive and highly technical procedures.
The key to success is the ability to find a strategic partner in the C-suite who will directly or indirectly provide the financial and political support. Other sources of funding include private foundations, medical schools, the Department of Veteran Affairs, and such patient safety organizations as AHRQ, IOM, and IHI. HMG leaders also should consider scalability across other hospitalist groups.
“If you build it, they will come."
HM takeaways
Create a business plan;
Find institutional financial and political support;
Start small and selective;
Plan for standardization and training of colleagues;
Create a credentialing/privileging process;
Bill for services and consider billing for full consults; and
HM15 presenters: Verity Schaye, Michael Janjigian, Frank Volpicelli, Susan Hunt.
Performing a physical exam is the standard of care for evaluating patients. It has been shown to have higher diagnostic utility than many technology based tests. The physical exam is the Gold Standard for dermatological and mental status assessment for which technological tests are not readily available. The tradition “laying on of hands” has important benefits for the physician patient relationship.
The teaching of physical exam skills is increasingly problematic. Barriers include attending time, comfort and skill level as well as challenges of patient comfort and potential isolation issues.
The Peyton Model provides a better means of teaching physical exam skills than the traditional “See one, do one, teach one” model. The Peyton Model has four steps:
Demonstration. The teacher performs the exam at normal speed without commentary.
Deconstruction. The teacher performs the exam while describing the steps.
Comprehension. The teacher performs the exam while the learner describes the steps.
Performance. The learner performs the exam while also describing the steps.
This approach can be abbreviated for more advanced learners with the middle two steps being combined to a discussion between the teacher and learner to highlight any differences or changes in technique. TH
HM15 presenters: Verity Schaye, Michael Janjigian, Frank Volpicelli, Susan Hunt.
Performing a physical exam is the standard of care for evaluating patients. It has been shown to have higher diagnostic utility than many technology based tests. The physical exam is the Gold Standard for dermatological and mental status assessment for which technological tests are not readily available. The tradition “laying on of hands” has important benefits for the physician patient relationship.
The teaching of physical exam skills is increasingly problematic. Barriers include attending time, comfort and skill level as well as challenges of patient comfort and potential isolation issues.
The Peyton Model provides a better means of teaching physical exam skills than the traditional “See one, do one, teach one” model. The Peyton Model has four steps:
Demonstration. The teacher performs the exam at normal speed without commentary.
Deconstruction. The teacher performs the exam while describing the steps.
Comprehension. The teacher performs the exam while the learner describes the steps.
Performance. The learner performs the exam while also describing the steps.
This approach can be abbreviated for more advanced learners with the middle two steps being combined to a discussion between the teacher and learner to highlight any differences or changes in technique. TH
HM15 presenters: Verity Schaye, Michael Janjigian, Frank Volpicelli, Susan Hunt.
Performing a physical exam is the standard of care for evaluating patients. It has been shown to have higher diagnostic utility than many technology based tests. The physical exam is the Gold Standard for dermatological and mental status assessment for which technological tests are not readily available. The tradition “laying on of hands” has important benefits for the physician patient relationship.
The teaching of physical exam skills is increasingly problematic. Barriers include attending time, comfort and skill level as well as challenges of patient comfort and potential isolation issues.
The Peyton Model provides a better means of teaching physical exam skills than the traditional “See one, do one, teach one” model. The Peyton Model has four steps:
Demonstration. The teacher performs the exam at normal speed without commentary.
Deconstruction. The teacher performs the exam while describing the steps.
Comprehension. The teacher performs the exam while the learner describes the steps.
Performance. The learner performs the exam while also describing the steps.
This approach can be abbreviated for more advanced learners with the middle two steps being combined to a discussion between the teacher and learner to highlight any differences or changes in technique. TH
Kathleen Finn, MD, FHM and Jeffrey Greenwald, MD, SFHM engaged the audience with their playful banter while reviewing medical literature of clinical significance for the hospitalist in Update in Hospital Medicine. The studies presented were high-quality, practical and addressed questions that arise in our day-to-day practice. A wide variety of topics were addressed and key points are summarized below.
Key takeaways
In the PARADIGM-HF study, Angiotensin Receptor Blocker (ARB) + Neprilysin Inhibitor decreased cardiovascular mortality and reduced CHF hospitalization by 20% when compared to Enalapril alone in heart failure patients. The combination drug is an alternative choice to ACE inhibitors. FDA approval is forthcoming.
Is the risk of contrast-induced nephrotoxicity really as great as we have come to believe? Review of propensity matched studies suggests that AKI, 30 day need for emergent hemodi
alysis and death are unrelated to contrast. If CT with contrast makes a difference to the patient, consider using it if GFR>30 ml/min.
SAGES trial and Project Recovery developed a delirium screening method in hospitalized patients. The CAM (Confusion Assessment Method) scoring system assesses delirium severity in elderly patients (70+). Hospital and post-hospital outcomes in delirious vs. non-delirious patients showed that the more severe the delirium, the longer the patient stayed in the hospital. Further, the rate of new SNF placement and 90 day mortality was higher in the delirious group. The CAM score correlates with prognosis in medical patients. Addressing long-term goals of care in this patient population may be warranted.
A randomized placebo-controlled trail looked at the preventive effects of Ramelteon (melatonin receptor agonist) on delirium. Ramelteon 8mg was given to patients at 9pm for 7 days (or d/c). Although this was a small and short study, Ramelteon appears to reduce incident delirium in medical and non-intubated ICU patients.
The HELP randomized clinical trial compared Lactulose vs. Polyethylene Glycol (PEG) electrolyte solution for treatment of overt hepatic encephalopathy. Patients received either PEG (4L in 4 hours) or Lactulose (20-30g 3+doses/24hrs). Primary outcome was an improvement in HESA (Hepatic Encephalopathy Scoring Algorithm ) score by 1 at 24 hours. HESA score improved and patients had a shorter length of stay in the PEG group. In addition, patients requested PEG at discharge because it tasted better.
A retrospective study looked at Nonselective beta blockers (NSBB) in patients with Spontaneous Bacterial Peritonitis (SBP). It suggests that the use of NSBB after SBP onset increases the risk of AKI, Hepatorenal Syndrome and mortality by 58%. NSBB appear beneficial before SBP onset suggesting that as cirrhosis becomes more severe, NSBB may not be effective.
A retrospective cohort trial (Michigan Hospital Medicine Safety Consortium) assessed hospital performance of VTE prophylaxis. The rate of clinically evident, confirmed VTE was measured. There was no difference in VTE occurrence during hospitalization, 90 day VTE rates and PE vs. DVT rates. No clear benefit was evident from VTE prophylaxis for medical patients. This could indicate the need to risk stratify patients’ VTE risk.
Direct oral anticoagulants (DOACs) were compared with Vitamin K antagonists (VKA) for treatment of acute VTE in a meta-analysis reviewed by the speakers. Death, safety and bleeding were assessed. DOACs seem to work as well as VKAs for VTE. They also had a better safety profile. In cancer patients, DOACs vs. LMWH study is still needed. In patients with atrial fibrillation (AF), DOACs prevent AF-associated strokes better than VKAs. They also reduce hemorrhagic stroke and intracranial hemorrhage.
In the elderly (75 or older) patient, DOACs are as safe as VKAs and LMWH for AF and VTE treatment.
Randomized control trails compared once weekly Dalbavancin or single-dose Oritavancin vs. daily conventional therapy for acute bacterial skin infections (cellulitis, major abscess, wound infection, 75cm² erythema). Outcomes measured were cessation of spread of erythema and no fever X3 readings in 48-72 hours. Dalbavancin once weekly was non-inferior to Vancomycin in safety profile and outcome measures. Direct cost of Dalbavancin was higher although patients on this drug had shorter length of stays which is cost effective. FDA approved for skin infections.
The presence of family during CPR decreased PTSD, anxiety and depression symptoms in family members. Outcomes were similar when participants were assesses at 90 days and 1 year. While this study was conducted in an out of hospital setting, it may be worthwhile to assess if it is applicable to patients who code in the hospital.
Kathleen Finn, MD, FHM and Jeffrey Greenwald, MD, SFHM engaged the audience with their playful banter while reviewing medical literature of clinical significance for the hospitalist in Update in Hospital Medicine. The studies presented were high-quality, practical and addressed questions that arise in our day-to-day practice. A wide variety of topics were addressed and key points are summarized below.
Key takeaways
In the PARADIGM-HF study, Angiotensin Receptor Blocker (ARB) + Neprilysin Inhibitor decreased cardiovascular mortality and reduced CHF hospitalization by 20% when compared to Enalapril alone in heart failure patients. The combination drug is an alternative choice to ACE inhibitors. FDA approval is forthcoming.
Is the risk of contrast-induced nephrotoxicity really as great as we have come to believe? Review of propensity matched studies suggests that AKI, 30 day need for emergent hemodi
alysis and death are unrelated to contrast. If CT with contrast makes a difference to the patient, consider using it if GFR>30 ml/min.
SAGES trial and Project Recovery developed a delirium screening method in hospitalized patients. The CAM (Confusion Assessment Method) scoring system assesses delirium severity in elderly patients (70+). Hospital and post-hospital outcomes in delirious vs. non-delirious patients showed that the more severe the delirium, the longer the patient stayed in the hospital. Further, the rate of new SNF placement and 90 day mortality was higher in the delirious group. The CAM score correlates with prognosis in medical patients. Addressing long-term goals of care in this patient population may be warranted.
A randomized placebo-controlled trail looked at the preventive effects of Ramelteon (melatonin receptor agonist) on delirium. Ramelteon 8mg was given to patients at 9pm for 7 days (or d/c). Although this was a small and short study, Ramelteon appears to reduce incident delirium in medical and non-intubated ICU patients.
The HELP randomized clinical trial compared Lactulose vs. Polyethylene Glycol (PEG) electrolyte solution for treatment of overt hepatic encephalopathy. Patients received either PEG (4L in 4 hours) or Lactulose (20-30g 3+doses/24hrs). Primary outcome was an improvement in HESA (Hepatic Encephalopathy Scoring Algorithm ) score by 1 at 24 hours. HESA score improved and patients had a shorter length of stay in the PEG group. In addition, patients requested PEG at discharge because it tasted better.
A retrospective study looked at Nonselective beta blockers (NSBB) in patients with Spontaneous Bacterial Peritonitis (SBP). It suggests that the use of NSBB after SBP onset increases the risk of AKI, Hepatorenal Syndrome and mortality by 58%. NSBB appear beneficial before SBP onset suggesting that as cirrhosis becomes more severe, NSBB may not be effective.
A retrospective cohort trial (Michigan Hospital Medicine Safety Consortium) assessed hospital performance of VTE prophylaxis. The rate of clinically evident, confirmed VTE was measured. There was no difference in VTE occurrence during hospitalization, 90 day VTE rates and PE vs. DVT rates. No clear benefit was evident from VTE prophylaxis for medical patients. This could indicate the need to risk stratify patients’ VTE risk.
Direct oral anticoagulants (DOACs) were compared with Vitamin K antagonists (VKA) for treatment of acute VTE in a meta-analysis reviewed by the speakers. Death, safety and bleeding were assessed. DOACs seem to work as well as VKAs for VTE. They also had a better safety profile. In cancer patients, DOACs vs. LMWH study is still needed. In patients with atrial fibrillation (AF), DOACs prevent AF-associated strokes better than VKAs. They also reduce hemorrhagic stroke and intracranial hemorrhage.
In the elderly (75 or older) patient, DOACs are as safe as VKAs and LMWH for AF and VTE treatment.
Randomized control trails compared once weekly Dalbavancin or single-dose Oritavancin vs. daily conventional therapy for acute bacterial skin infections (cellulitis, major abscess, wound infection, 75cm² erythema). Outcomes measured were cessation of spread of erythema and no fever X3 readings in 48-72 hours. Dalbavancin once weekly was non-inferior to Vancomycin in safety profile and outcome measures. Direct cost of Dalbavancin was higher although patients on this drug had shorter length of stays which is cost effective. FDA approved for skin infections.
The presence of family during CPR decreased PTSD, anxiety and depression symptoms in family members. Outcomes were similar when participants were assesses at 90 days and 1 year. While this study was conducted in an out of hospital setting, it may be worthwhile to assess if it is applicable to patients who code in the hospital.
Kathleen Finn, MD, FHM and Jeffrey Greenwald, MD, SFHM engaged the audience with their playful banter while reviewing medical literature of clinical significance for the hospitalist in Update in Hospital Medicine. The studies presented were high-quality, practical and addressed questions that arise in our day-to-day practice. A wide variety of topics were addressed and key points are summarized below.
Key takeaways
In the PARADIGM-HF study, Angiotensin Receptor Blocker (ARB) + Neprilysin Inhibitor decreased cardiovascular mortality and reduced CHF hospitalization by 20% when compared to Enalapril alone in heart failure patients. The combination drug is an alternative choice to ACE inhibitors. FDA approval is forthcoming.
Is the risk of contrast-induced nephrotoxicity really as great as we have come to believe? Review of propensity matched studies suggests that AKI, 30 day need for emergent hemodi
alysis and death are unrelated to contrast. If CT with contrast makes a difference to the patient, consider using it if GFR>30 ml/min.
SAGES trial and Project Recovery developed a delirium screening method in hospitalized patients. The CAM (Confusion Assessment Method) scoring system assesses delirium severity in elderly patients (70+). Hospital and post-hospital outcomes in delirious vs. non-delirious patients showed that the more severe the delirium, the longer the patient stayed in the hospital. Further, the rate of new SNF placement and 90 day mortality was higher in the delirious group. The CAM score correlates with prognosis in medical patients. Addressing long-term goals of care in this patient population may be warranted.
A randomized placebo-controlled trail looked at the preventive effects of Ramelteon (melatonin receptor agonist) on delirium. Ramelteon 8mg was given to patients at 9pm for 7 days (or d/c). Although this was a small and short study, Ramelteon appears to reduce incident delirium in medical and non-intubated ICU patients.
The HELP randomized clinical trial compared Lactulose vs. Polyethylene Glycol (PEG) electrolyte solution for treatment of overt hepatic encephalopathy. Patients received either PEG (4L in 4 hours) or Lactulose (20-30g 3+doses/24hrs). Primary outcome was an improvement in HESA (Hepatic Encephalopathy Scoring Algorithm ) score by 1 at 24 hours. HESA score improved and patients had a shorter length of stay in the PEG group. In addition, patients requested PEG at discharge because it tasted better.
A retrospective study looked at Nonselective beta blockers (NSBB) in patients with Spontaneous Bacterial Peritonitis (SBP). It suggests that the use of NSBB after SBP onset increases the risk of AKI, Hepatorenal Syndrome and mortality by 58%. NSBB appear beneficial before SBP onset suggesting that as cirrhosis becomes more severe, NSBB may not be effective.
A retrospective cohort trial (Michigan Hospital Medicine Safety Consortium) assessed hospital performance of VTE prophylaxis. The rate of clinically evident, confirmed VTE was measured. There was no difference in VTE occurrence during hospitalization, 90 day VTE rates and PE vs. DVT rates. No clear benefit was evident from VTE prophylaxis for medical patients. This could indicate the need to risk stratify patients’ VTE risk.
Direct oral anticoagulants (DOACs) were compared with Vitamin K antagonists (VKA) for treatment of acute VTE in a meta-analysis reviewed by the speakers. Death, safety and bleeding were assessed. DOACs seem to work as well as VKAs for VTE. They also had a better safety profile. In cancer patients, DOACs vs. LMWH study is still needed. In patients with atrial fibrillation (AF), DOACs prevent AF-associated strokes better than VKAs. They also reduce hemorrhagic stroke and intracranial hemorrhage.
In the elderly (75 or older) patient, DOACs are as safe as VKAs and LMWH for AF and VTE treatment.
Randomized control trails compared once weekly Dalbavancin or single-dose Oritavancin vs. daily conventional therapy for acute bacterial skin infections (cellulitis, major abscess, wound infection, 75cm² erythema). Outcomes measured were cessation of spread of erythema and no fever X3 readings in 48-72 hours. Dalbavancin once weekly was non-inferior to Vancomycin in safety profile and outcome measures. Direct cost of Dalbavancin was higher although patients on this drug had shorter length of stays which is cost effective. FDA approved for skin infections.
The presence of family during CPR decreased PTSD, anxiety and depression symptoms in family members. Outcomes were similar when participants were assesses at 90 days and 1 year. While this study was conducted in an out of hospital setting, it may be worthwhile to assess if it is applicable to patients who code in the hospital.
John Bulger, DO, MBA reviewed the components of the Choosing Wisely campaign and SHM’s recommendations in an era where providing high value cost-conscious care is key to optimizing the health of our patients. Choosing Wisely is an initiative of the ABIM foundation to foster communication between physicians and patients about common tests and procedures that may fail to provide value or enhance patient outcomes. It’s a partnership with 70-plus medical societies including an innovative partnership with Consumer Reports. SHM’s evidence-based recommendations are:
Don’t leave urinary catheters in place for convenience or monitoring of output for non-critically ill patients.
Don’t prescribe stress ulcer prophylaxis to hospitalized patients unless they are at high risk for GI complications.
Avoid transfusion of PRBC for arbitrary hemoglobin in the absence of CAD, CHF or CVA.
Don’t order continuous telemetry monitoring outside of the ICU without a protocol.
Don’t perform repetitive CBC and chemistry testing in a clinically stable patient.
Dr. Bulger highlighted that the Choosing Wisely campaign is designed to encourage conversations to
improve patient care. While cost-conscious care is a natural by-product of this effort, the primary focus when these guidelines were developed was to provide better healthcare for our patients. This year, SHM’s Choosing Wisely Case Competition has triggered the application of the above recommendations in institutions across the country. A summary of these efforts will be published in the near future to assist fellow hospitalists with their efforts to minimize waste and improve care in their own institutions. Look for the Hospitalist Guide to Choosing Wisely which is expected to be published in spring 2015. Choosing Wisely has now become a world-wide effort with Canada, Europe and Brazil implementing similar recommendations to improve healthcare.
Dr.Bulger concluded that while tradition is hard to change, it is of paramount importance to think differently to find innovative solutions to common problems in healthcare. Join the conversation using #ChoosingWisely or #LessIsMore on twitter.
Key Takeaways
Choosing Wisely is an ABIM campaign developed to address and promote conversations about common tests and procedures that are of low-value.
SHM’s recommendations were implemented in institutions with positive results as evidenced by the Choosing Wisely case competition at #HospMed15.
Look for a summary of these efforts to be published in the spring of 2015.
Use these guidelines to educate, provoke dialogue and achieve optimal patient outcomes in your institution.
John Bulger, DO, MBA reviewed the components of the Choosing Wisely campaign and SHM’s recommendations in an era where providing high value cost-conscious care is key to optimizing the health of our patients. Choosing Wisely is an initiative of the ABIM foundation to foster communication between physicians and patients about common tests and procedures that may fail to provide value or enhance patient outcomes. It’s a partnership with 70-plus medical societies including an innovative partnership with Consumer Reports. SHM’s evidence-based recommendations are:
Don’t leave urinary catheters in place for convenience or monitoring of output for non-critically ill patients.
Don’t prescribe stress ulcer prophylaxis to hospitalized patients unless they are at high risk for GI complications.
Avoid transfusion of PRBC for arbitrary hemoglobin in the absence of CAD, CHF or CVA.
Don’t order continuous telemetry monitoring outside of the ICU without a protocol.
Don’t perform repetitive CBC and chemistry testing in a clinically stable patient.
Dr. Bulger highlighted that the Choosing Wisely campaign is designed to encourage conversations to
improve patient care. While cost-conscious care is a natural by-product of this effort, the primary focus when these guidelines were developed was to provide better healthcare for our patients. This year, SHM’s Choosing Wisely Case Competition has triggered the application of the above recommendations in institutions across the country. A summary of these efforts will be published in the near future to assist fellow hospitalists with their efforts to minimize waste and improve care in their own institutions. Look for the Hospitalist Guide to Choosing Wisely which is expected to be published in spring 2015. Choosing Wisely has now become a world-wide effort with Canada, Europe and Brazil implementing similar recommendations to improve healthcare.
Dr.Bulger concluded that while tradition is hard to change, it is of paramount importance to think differently to find innovative solutions to common problems in healthcare. Join the conversation using #ChoosingWisely or #LessIsMore on twitter.
Key Takeaways
Choosing Wisely is an ABIM campaign developed to address and promote conversations about common tests and procedures that are of low-value.
SHM’s recommendations were implemented in institutions with positive results as evidenced by the Choosing Wisely case competition at #HospMed15.
Look for a summary of these efforts to be published in the spring of 2015.
Use these guidelines to educate, provoke dialogue and achieve optimal patient outcomes in your institution.
John Bulger, DO, MBA reviewed the components of the Choosing Wisely campaign and SHM’s recommendations in an era where providing high value cost-conscious care is key to optimizing the health of our patients. Choosing Wisely is an initiative of the ABIM foundation to foster communication between physicians and patients about common tests and procedures that may fail to provide value or enhance patient outcomes. It’s a partnership with 70-plus medical societies including an innovative partnership with Consumer Reports. SHM’s evidence-based recommendations are:
Don’t leave urinary catheters in place for convenience or monitoring of output for non-critically ill patients.
Don’t prescribe stress ulcer prophylaxis to hospitalized patients unless they are at high risk for GI complications.
Avoid transfusion of PRBC for arbitrary hemoglobin in the absence of CAD, CHF or CVA.
Don’t order continuous telemetry monitoring outside of the ICU without a protocol.
Don’t perform repetitive CBC and chemistry testing in a clinically stable patient.
Dr. Bulger highlighted that the Choosing Wisely campaign is designed to encourage conversations to
improve patient care. While cost-conscious care is a natural by-product of this effort, the primary focus when these guidelines were developed was to provide better healthcare for our patients. This year, SHM’s Choosing Wisely Case Competition has triggered the application of the above recommendations in institutions across the country. A summary of these efforts will be published in the near future to assist fellow hospitalists with their efforts to minimize waste and improve care in their own institutions. Look for the Hospitalist Guide to Choosing Wisely which is expected to be published in spring 2015. Choosing Wisely has now become a world-wide effort with Canada, Europe and Brazil implementing similar recommendations to improve healthcare.
Dr.Bulger concluded that while tradition is hard to change, it is of paramount importance to think differently to find innovative solutions to common problems in healthcare. Join the conversation using #ChoosingWisely or #LessIsMore on twitter.
Key Takeaways
Choosing Wisely is an ABIM campaign developed to address and promote conversations about common tests and procedures that are of low-value.
SHM’s recommendations were implemented in institutions with positive results as evidenced by the Choosing Wisely case competition at #HospMed15.
Look for a summary of these efforts to be published in the spring of 2015.
Use these guidelines to educate, provoke dialogue and achieve optimal patient outcomes in your institution.
Although patients with blood clots are oftentimes not admitted to the hospital, there are some exceptions. Monal Shah, MD, physician advisor for Parkland Hospital in Dallas, Texas, and the former section head of hospital medicine at the University of Texas Southwestern Medical Center, discusses some exceptions.
Although patients with blood clots are oftentimes not admitted to the hospital, there are some exceptions. Monal Shah, MD, physician advisor for Parkland Hospital in Dallas, Texas, and the former section head of hospital medicine at the University of Texas Southwestern Medical Center, discusses some exceptions.
Although patients with blood clots are oftentimes not admitted to the hospital, there are some exceptions. Monal Shah, MD, physician advisor for Parkland Hospital in Dallas, Texas, and the former section head of hospital medicine at the University of Texas Southwestern Medical Center, discusses some exceptions.
Adam E. Fall, MD, SFHM, who recently worked as the senior regional medical director for hospital medicine at TeamHealth in Chattanooga, Tenn., discusses the importance of allowing nuance and gradation to govern patient care in the treatment of thromboembolism in an era where hospitalists can be overly reliant on electronic medical records.
Adam E. Fall, MD, SFHM, who recently worked as the senior regional medical director for hospital medicine at TeamHealth in Chattanooga, Tenn., discusses the importance of allowing nuance and gradation to govern patient care in the treatment of thromboembolism in an era where hospitalists can be overly reliant on electronic medical records.
Adam E. Fall, MD, SFHM, who recently worked as the senior regional medical director for hospital medicine at TeamHealth in Chattanooga, Tenn., discusses the importance of allowing nuance and gradation to govern patient care in the treatment of thromboembolism in an era where hospitalists can be overly reliant on electronic medical records.
David Lichtman, PA, director of the Johns Hopkins Central Procedure Service in Baltimore, Md., says bedside procedure training should be consistent and thorough, regardless of whether the trainee is a medical student, a resident, a fellow, or an established physician. He is a strong advocate for training that includes well-designed computer coursework, evaluates practitioners from start to finish, and demonstrates that they are meeting established benchmarks.
“That’s what keeps patients safe,” he says.
Experienced, capable, and proven educators are also critical.
“Let’s face it: Not everybody is a very good teacher,” he adds.
Currently, many medical residents can do rotations that will give them hands-on experience. But some physicians question why certain procedures are still being taught to internal medicine residents if the ABIM no longer requires hands-on experience. Other programs may simply lack the resources, including experienced supervisors, to provide proper training.
The demand for more training is clearly there, however. Sally Wang, MD, FHM, director of procedure education at Brigham and Women’s Hospital and a clinical instructor at Harvard Medical School in Boston, co-leads the procedures pre-course at the SHM annual meeting. She compares the logistically complicated event to throwing a wedding. It consistently sells out despite having doubled in size, to 60 slots for a basic procedure course and 60 slots for a second course that emphasizes ultrasound. At the HM14 pre-course in Las Vegas, Dr. Wang counted enough people on the waiting list to fill an additional course.
“It was mind-boggling,” she says.
Several companies have taken notice of the pent-up demand and are offering their own courses and workshops. Joshua Lenchus, DO, RPh, FACP, SFHM, medical director of the University of Miami-Jackson Memorial Hospital’s procedure service, and others see many of these offerings as introductions only, however. At the University of Miami, he says, his rigorous, simulation-based invasive bedside procedures curriculum is mandatory for all internal medicine residents. The curriculum includes central line, thoracentesis, paracentesis, lumbar puncture, and sometimes arthrocentesis as its core procedures, though Dr. Lenchus says others can easily be added. This fall, for instance, he plans to add chest tube and arterial line placement.
He notes a dramatic reduction in central line placement and thoracentesis complications after his team began performing them to the “four pillars” of his program. Rigorous simulation-based training, strict adherence to a critical skills checklist, consistent use of ultrasound, and direct supervision can form a very effective bundle of safety measures, he says, just like a combination of seat belts, speed reduction, and other precautions can lead to fewer automobile-associated injuries and deaths. TH
David Lichtman, PA, director of the Johns Hopkins Central Procedure Service in Baltimore, Md., says bedside procedure training should be consistent and thorough, regardless of whether the trainee is a medical student, a resident, a fellow, or an established physician. He is a strong advocate for training that includes well-designed computer coursework, evaluates practitioners from start to finish, and demonstrates that they are meeting established benchmarks.
“That’s what keeps patients safe,” he says.
Experienced, capable, and proven educators are also critical.
“Let’s face it: Not everybody is a very good teacher,” he adds.
Currently, many medical residents can do rotations that will give them hands-on experience. But some physicians question why certain procedures are still being taught to internal medicine residents if the ABIM no longer requires hands-on experience. Other programs may simply lack the resources, including experienced supervisors, to provide proper training.
The demand for more training is clearly there, however. Sally Wang, MD, FHM, director of procedure education at Brigham and Women’s Hospital and a clinical instructor at Harvard Medical School in Boston, co-leads the procedures pre-course at the SHM annual meeting. She compares the logistically complicated event to throwing a wedding. It consistently sells out despite having doubled in size, to 60 slots for a basic procedure course and 60 slots for a second course that emphasizes ultrasound. At the HM14 pre-course in Las Vegas, Dr. Wang counted enough people on the waiting list to fill an additional course.
“It was mind-boggling,” she says.
Several companies have taken notice of the pent-up demand and are offering their own courses and workshops. Joshua Lenchus, DO, RPh, FACP, SFHM, medical director of the University of Miami-Jackson Memorial Hospital’s procedure service, and others see many of these offerings as introductions only, however. At the University of Miami, he says, his rigorous, simulation-based invasive bedside procedures curriculum is mandatory for all internal medicine residents. The curriculum includes central line, thoracentesis, paracentesis, lumbar puncture, and sometimes arthrocentesis as its core procedures, though Dr. Lenchus says others can easily be added. This fall, for instance, he plans to add chest tube and arterial line placement.
He notes a dramatic reduction in central line placement and thoracentesis complications after his team began performing them to the “four pillars” of his program. Rigorous simulation-based training, strict adherence to a critical skills checklist, consistent use of ultrasound, and direct supervision can form a very effective bundle of safety measures, he says, just like a combination of seat belts, speed reduction, and other precautions can lead to fewer automobile-associated injuries and deaths. TH
David Lichtman, PA, director of the Johns Hopkins Central Procedure Service in Baltimore, Md., says bedside procedure training should be consistent and thorough, regardless of whether the trainee is a medical student, a resident, a fellow, or an established physician. He is a strong advocate for training that includes well-designed computer coursework, evaluates practitioners from start to finish, and demonstrates that they are meeting established benchmarks.
“That’s what keeps patients safe,” he says.
Experienced, capable, and proven educators are also critical.
“Let’s face it: Not everybody is a very good teacher,” he adds.
Currently, many medical residents can do rotations that will give them hands-on experience. But some physicians question why certain procedures are still being taught to internal medicine residents if the ABIM no longer requires hands-on experience. Other programs may simply lack the resources, including experienced supervisors, to provide proper training.
The demand for more training is clearly there, however. Sally Wang, MD, FHM, director of procedure education at Brigham and Women’s Hospital and a clinical instructor at Harvard Medical School in Boston, co-leads the procedures pre-course at the SHM annual meeting. She compares the logistically complicated event to throwing a wedding. It consistently sells out despite having doubled in size, to 60 slots for a basic procedure course and 60 slots for a second course that emphasizes ultrasound. At the HM14 pre-course in Las Vegas, Dr. Wang counted enough people on the waiting list to fill an additional course.
“It was mind-boggling,” she says.
Several companies have taken notice of the pent-up demand and are offering their own courses and workshops. Joshua Lenchus, DO, RPh, FACP, SFHM, medical director of the University of Miami-Jackson Memorial Hospital’s procedure service, and others see many of these offerings as introductions only, however. At the University of Miami, he says, his rigorous, simulation-based invasive bedside procedures curriculum is mandatory for all internal medicine residents. The curriculum includes central line, thoracentesis, paracentesis, lumbar puncture, and sometimes arthrocentesis as its core procedures, though Dr. Lenchus says others can easily be added. This fall, for instance, he plans to add chest tube and arterial line placement.
He notes a dramatic reduction in central line placement and thoracentesis complications after his team began performing them to the “four pillars” of his program. Rigorous simulation-based training, strict adherence to a critical skills checklist, consistent use of ultrasound, and direct supervision can form a very effective bundle of safety measures, he says, just like a combination of seat belts, speed reduction, and other precautions can lead to fewer automobile-associated injuries and deaths. TH
A 66-year-old homeless man with a history of smoking and cirrhosis due to alcoholism presents to the hospital with a productive cough and fever for one month. He has traveled around Arizona and New Mexico but has never left the country. His complete blood count (CBC) is notable for a white blood cell count of 13,000. His chest X-ray reveals a 1.7-cm right upper lobe cavitary lung lesion (see Figure 1). What is the best approach to this patient’s cavitary lung lesion?
Overview
Cavitary lung lesions are relatively common findings on chest imaging and often pose a diagnostic challenge to the hospitalist. Having a standard approach to the evaluation of a cavitary lung lesion can facilitate an expedited workup.
Figure 1. Right upper lobe cavitary lung lesion
A lung cavity is defined radiographically as a lucent area contained within a consolidation, mass, or nodule.1 Cavities usually are accompanied by thick walls, greater than 4 mm. These should be differentiated from cysts, which are not surrounded by consolidation, mass, or nodule, and are accompanied by a thinner wall.2
The differential diagnosis of a cavitary lung lesion is broad and can be delineated into categories of infectious and noninfectious etiologies (see Figure 2). Infectious causes include bacterial, fungal, and, rarely, parasitic agents. Noninfectious causes encompass malignant, rheumatologic, and other less common etiologies such as infarct related to pulmonary embolism.
The clinical presentation and assessment of risk factors for a particular patient are of the utmost importance in delineating next steps for evaluation and management (see Table 1). For those patients of older age with smoking history, specific occupational or environmental exposures, and weight loss, the most common etiology is neoplasm. Common infectious causes include lung abscess and necrotizing pneumonia, as well as tuberculosis. The approach to diagnosis should be based on a composite of the clinical presentation, patient characteristics, and radiographic appearance of the cavity.
(click for larger image)Table 1. Patient traits and radiologic appearance suggesting specific etiologies of cavitary lung lesions
Guidelines for the approach to cavitary lung lesions are lacking, yet a thorough understanding of the initial approach is important for those practicing hospital medicine. Key components in the approach to diagnosis of a solitary cavitary lesion are outlined in this article.
Diagnosis of Infectious Causes
In the initial evaluation of a cavitary lung lesion, it is important to first determine if the cause is an infectious process. The infectious etiologies to consider include lung abscess and necrotizing pneumonia, tuberculosis, and septic emboli. Important components in the clinical presentation include presence of cough, fever, night sweats, chills, and symptoms that have lasted less than one month, as well as comorbid conditions, drug or alcohol abuse, and history of immunocompromise (e.g. HIV, immunosuppressive therapy, or organ transplant).
Given the public health considerations and impact of treatment, tuberculosis (TB) will be discussed in its own category.
Tuberculosis. Given the fact that TB patients require airborne isolation, the disease must be considered early in the evaluation of a cavitary lung lesion. Patients with TB often present with more chronic symptoms, such as fevers, night sweats, weight loss, and hemoptysis. Immunocompromised state, travel to endemic regions, and incarceration increase the likelihood of TB. Nontuberculous mycobacterium (i.e., M. kansasii) should also be considered in endemic areas.
For those patients in whom TB is suspected, airborne isolation must be initiated promptly. The provider should obtain three sputum samples for acid-fast bacillus (AFB) smear and culture when risk factors are present. Most patients with reactivation TB have abnormal chest X-rays, with approximately 20% of those patients having air-fluid levels and the majority of cases affecting the upper lobes.3 Cavities may be seen in patients with primary or reactivation TB.3
Lung abscess and necrotizing pneumonia. Lung abscesses are cavities associated with necrosis caused by a microbial infection. The term necrotizing pneumonia typically is used when there are multiple smaller (smaller than 2 cm) associated lung abscesses, although both lung abscess and necrotizing pneumonia represent a similar pathophysiologic process and are along the same continuum. Lung abscess is suspected with the presence of predisposing risk factors to aspiration (e.g. alcoholism) and poor dentition. History of cough, fever, putrid sputum, night sweats, and weight loss may indicate subacute or chronic development of a lung abscess. Physical examination might be significant for signs of pneumonia and gingivitis.
Organisms that cause lung abscesses include anaerobes (most common), TB, methicillin-resistant Staphylococcus aureus (MRSA), post-influenza illness, endemic fungi, and Nocardia, among others.4 In immunocompromised patients, more common considerations include TB, Mycobacterium avium complex, other mycobacteria, Pseudomonas aeruginosa, Nocardia, Cryptococcus, Aspergillus, endemic fungi (e.g. Coccidiodes in the Southwest and Histoplasma in the Midwest), and, less commonly, Pneumocystis jiroveci.4 The likelihood of each organism is dependent on the patient’s risk factors. Initial laboratory testing includes sputum and blood cultures, as well as serologic testing for endemic fungi, especially in immunocompromised patients.
Imaging may reveal a cavitary lesion in the dependent pulmonary segments (posterior segments of the upper lobes or superior segments of the lower lobes), at times associated with a pleural effusion or infiltrate. The most common appearance of a lung abscess is an asymmetric cavity with an air-fluid level and a wall with a ragged or smooth border. CT scan is often indicated when X-rays are equivocal and when cases are of uncertain cause or are unresponsive to antibiotic therapy. Bronchoscopy is reserved for patients with an immunocompromising condition, atypical presentation, or lack of response to treatment.
For those cavitary lesions in which there is a high degree of suspicion for lung abscess, empiric treatment should include antibiotics active against anaerobes and MRSA if the patient has risk factors. Patients often receive an empiric trial of antibiotics prior to biopsy unless there are clear indications that the cavitary lung lesion is related to cancer. Lung abscesses typically drain spontaneously, and transthoracic or endobronchial drainage is not usually recommended as initial management due to risk of pneumothorax and formation of bronchopleural fistula.
Lung abscesses should be followed to resolution with serial chest imaging. If the lung abscess does not resolve, it would be appropriate to consult thoracic surgery, interventional radiology, or pulmonary, depending on the location of the abscess and the local expertise with transthoracic or endobronchial drainage and surgical resection.
Septic emboli. Septic emboli are a less common cause of cavitary lung lesions. This entity should be considered in patients with a history of IV drug use or infected indwelling devices (central venous catheters, pacemaker wires, and right-sided prosthetic heart valves). Physical examination should include an assessment for signs of endocarditis and inspection for infected indwelling devices. In patients with IV drug use, the likely pathogen is S. aureus.
Oropharyngeal infection or indwelling catheters may predispose patients to septic thrombophlebitis of the internal jugular vein, also known as Lemierre’s syndrome, a rare but important cause of septic emboli.5 Laboratory testing includes culture for sputum and blood and culture of the infected device if applicable. On chest X-ray, septic emboli commonly appear as nodules located in the lung periphery. CT scan is more sensitive for detecting cavitation associated with septic emboli.
Diagnosis of Noninfectious Causes
Upon identification of a cavitary lung lesion, noninfectious etiologies must also be entertained. Noninfectious etiologies include malignancy, rheumatologic diseases, pulmonary embolism, and other causes. Important components in the clinical presentation include the presence of constitutional symptoms (fevers, weight loss, night sweats), smoking history, family history, and an otherwise complete review of systems. Physical exam should include evaluation for lymphadenopathy, cachexia, rash, clubbing, and other symptoms pertinent to the suspected etiology.
Malignancy. Perhaps most important among noninfectious causes of cavitary lung lesions is malignancy, and a high index of suspicion is warranted given that it is commonly the first diagnosis to consider overall.2 Cavities can form in primary lung cancers (e.g. bronchogenic carcinomas), lung tumors such as lymphoma or Kaposi’s sarcoma, or in metastatic disease. Cavitation has been detected in 7%-11% of primary lung cancers by plain radiography and in 22% by computed tomography.5 Cancers of squamous cell origin are the most likely to cavitate; this holds true for both primary lung tumors and metastatic tumors.6 Additionally, cavitation portends a worse prognosis.7
Clinicians should review any available prior chest imaging studies to look for a change in the quality or size of a cavitary lung lesion. Neoplasms are typically of variable size with irregular thick walls (greater than 4 mm) on CT scan, with higher specificity for neoplasm in those with a wall thickness greater than 15 mm.2
When the diagnosis is less clear, the decision to embark on more advanced diagnostic methods, such as biopsy, should rest on the provider’s clinical suspicion for a certain disease process. When a lung cancer is suspected, consultation with pulmonary and interventional radiology should be obtained to determine the best approach for biopsy.
Rheumatologic. Less common causes of cavitary lesions include those related to rheumatologic diseases (e.g. granulomatosis with polyangiitis, formerly known as Wegener’s granulomatosis). One study demonstrated that cavitary lung nodules occur in 37% of patients with granulomatosis with polyangiitis.8
Although uncommon, cavitary nodules can also be seen in rheumatoid arthritis and sarcoidosis. Given that patients with rheumatologic diseases are often treated with immunosuppressive agents, infection must remain high on the differential. Suspicion of a rheumatologic cause should prompt the clinician to obtain appropriate serologic testing and consultation as needed.
(click for larger image)Figure 2. An Algorithmic Approach to Cavitary Lung Lesions
Pulmonary embolism. Although often not considered in the evaluation of cavitary lung lesions, pulmonary embolism (PE) can lead to infarction and the formation of a cavitary lesion. Pulmonary infarction has been reported to occur in as many as one third of cases of PE.9 Cavitary lesions also have been described in chronic thromboembolic disease.10
Other. Uncommon causes of cavitary lesions include bronchiolitis obliterans with organizing pneumonia, Langerhans cell histiocytosis, and amyloidosis, among others. The hospitalist should keep a broad differential and involve consultants if the diagnosis remains unclear after initial diagnostic evaluation.
Back to the Case
The patient’s fever and productive cough, in combination with recent travel and location of the cavitary lesion, increase his risk for tuberculosis and endemic fungi, such as Coccidioides. This patient was placed on respiratory isolation with AFBs obtained to rule out TB, with Coccidioides antibodies, Cyptococcal antigen titers, and sputum for fungus sent to evaluate for an endemic fungus. He had a chest CT, which revealed a 17-mm cavitary mass within the right upper lobe that contained an air-fluid level indicating lung abscess. Coccidioides, cryptococcal, fungal sputum, and TB studies were negative.
The patient was treated empirically with clindamycin given the high prevalence of anaerobes in lung abscess. He was followed as an outpatient and had a chest X-ray showing resolution of the lesion at six months. The purpose of the X-ray was two-fold: to monitor the effect of antibiotic treatment and to evaluate for persistence of the cavitation given the neoplastic risk factors of older age and smoking.
Bottom Line
The best approach to a patient with a cavitary lung lesion includes assessing the clinical presentation and risk factors, differentiating infectious from noninfectious causes, and then utilizing this information to further direct the diagnostic evaluation. Consultation with a subspecialist or further testing such as biopsy should be considered if the etiology remains undefined after the initial evaluation.
Drs. Rendon, Pizanis, Montanaro, and Kraai are hospitalists in the department of internal medicine at the University of New Mexico School of Medicine in Albuquerque.
Key Points
Use associated clinical and radiographic features of the cavitary lung lesion to determine the likely etiology and diagnostic strategy.
There are several branching points in the approach to a cavitary lung lesion, the first being to establish whether the condition is infectious or noninfectious.
If it is more likely to be infectious, then risk factors and underlying immunocompromise must be considered in the empiric treatment and diagnostic strategy.
If it is more likely to be noninfectious, then the patient should be evaluated with biopsy if there is concern for malignancy, appropriate serologies for suspected rheumatologic diseases, or further imaging if the condition is considered related to pulmonary infarct or other, more rare, etiologies.
A 66-year-old homeless man with a history of smoking and cirrhosis due to alcoholism presents to the hospital with a productive cough and fever for one month. He has traveled around Arizona and New Mexico but has never left the country. His complete blood count (CBC) is notable for a white blood cell count of 13,000. His chest X-ray reveals a 1.7-cm right upper lobe cavitary lung lesion (see Figure 1). What is the best approach to this patient’s cavitary lung lesion?
Overview
Cavitary lung lesions are relatively common findings on chest imaging and often pose a diagnostic challenge to the hospitalist. Having a standard approach to the evaluation of a cavitary lung lesion can facilitate an expedited workup.
Figure 1. Right upper lobe cavitary lung lesion
A lung cavity is defined radiographically as a lucent area contained within a consolidation, mass, or nodule.1 Cavities usually are accompanied by thick walls, greater than 4 mm. These should be differentiated from cysts, which are not surrounded by consolidation, mass, or nodule, and are accompanied by a thinner wall.2
The differential diagnosis of a cavitary lung lesion is broad and can be delineated into categories of infectious and noninfectious etiologies (see Figure 2). Infectious causes include bacterial, fungal, and, rarely, parasitic agents. Noninfectious causes encompass malignant, rheumatologic, and other less common etiologies such as infarct related to pulmonary embolism.
The clinical presentation and assessment of risk factors for a particular patient are of the utmost importance in delineating next steps for evaluation and management (see Table 1). For those patients of older age with smoking history, specific occupational or environmental exposures, and weight loss, the most common etiology is neoplasm. Common infectious causes include lung abscess and necrotizing pneumonia, as well as tuberculosis. The approach to diagnosis should be based on a composite of the clinical presentation, patient characteristics, and radiographic appearance of the cavity.
(click for larger image)Table 1. Patient traits and radiologic appearance suggesting specific etiologies of cavitary lung lesions
Guidelines for the approach to cavitary lung lesions are lacking, yet a thorough understanding of the initial approach is important for those practicing hospital medicine. Key components in the approach to diagnosis of a solitary cavitary lesion are outlined in this article.
Diagnosis of Infectious Causes
In the initial evaluation of a cavitary lung lesion, it is important to first determine if the cause is an infectious process. The infectious etiologies to consider include lung abscess and necrotizing pneumonia, tuberculosis, and septic emboli. Important components in the clinical presentation include presence of cough, fever, night sweats, chills, and symptoms that have lasted less than one month, as well as comorbid conditions, drug or alcohol abuse, and history of immunocompromise (e.g. HIV, immunosuppressive therapy, or organ transplant).
Given the public health considerations and impact of treatment, tuberculosis (TB) will be discussed in its own category.
Tuberculosis. Given the fact that TB patients require airborne isolation, the disease must be considered early in the evaluation of a cavitary lung lesion. Patients with TB often present with more chronic symptoms, such as fevers, night sweats, weight loss, and hemoptysis. Immunocompromised state, travel to endemic regions, and incarceration increase the likelihood of TB. Nontuberculous mycobacterium (i.e., M. kansasii) should also be considered in endemic areas.
For those patients in whom TB is suspected, airborne isolation must be initiated promptly. The provider should obtain three sputum samples for acid-fast bacillus (AFB) smear and culture when risk factors are present. Most patients with reactivation TB have abnormal chest X-rays, with approximately 20% of those patients having air-fluid levels and the majority of cases affecting the upper lobes.3 Cavities may be seen in patients with primary or reactivation TB.3
Lung abscess and necrotizing pneumonia. Lung abscesses are cavities associated with necrosis caused by a microbial infection. The term necrotizing pneumonia typically is used when there are multiple smaller (smaller than 2 cm) associated lung abscesses, although both lung abscess and necrotizing pneumonia represent a similar pathophysiologic process and are along the same continuum. Lung abscess is suspected with the presence of predisposing risk factors to aspiration (e.g. alcoholism) and poor dentition. History of cough, fever, putrid sputum, night sweats, and weight loss may indicate subacute or chronic development of a lung abscess. Physical examination might be significant for signs of pneumonia and gingivitis.
Organisms that cause lung abscesses include anaerobes (most common), TB, methicillin-resistant Staphylococcus aureus (MRSA), post-influenza illness, endemic fungi, and Nocardia, among others.4 In immunocompromised patients, more common considerations include TB, Mycobacterium avium complex, other mycobacteria, Pseudomonas aeruginosa, Nocardia, Cryptococcus, Aspergillus, endemic fungi (e.g. Coccidiodes in the Southwest and Histoplasma in the Midwest), and, less commonly, Pneumocystis jiroveci.4 The likelihood of each organism is dependent on the patient’s risk factors. Initial laboratory testing includes sputum and blood cultures, as well as serologic testing for endemic fungi, especially in immunocompromised patients.
Imaging may reveal a cavitary lesion in the dependent pulmonary segments (posterior segments of the upper lobes or superior segments of the lower lobes), at times associated with a pleural effusion or infiltrate. The most common appearance of a lung abscess is an asymmetric cavity with an air-fluid level and a wall with a ragged or smooth border. CT scan is often indicated when X-rays are equivocal and when cases are of uncertain cause or are unresponsive to antibiotic therapy. Bronchoscopy is reserved for patients with an immunocompromising condition, atypical presentation, or lack of response to treatment.
For those cavitary lesions in which there is a high degree of suspicion for lung abscess, empiric treatment should include antibiotics active against anaerobes and MRSA if the patient has risk factors. Patients often receive an empiric trial of antibiotics prior to biopsy unless there are clear indications that the cavitary lung lesion is related to cancer. Lung abscesses typically drain spontaneously, and transthoracic or endobronchial drainage is not usually recommended as initial management due to risk of pneumothorax and formation of bronchopleural fistula.
Lung abscesses should be followed to resolution with serial chest imaging. If the lung abscess does not resolve, it would be appropriate to consult thoracic surgery, interventional radiology, or pulmonary, depending on the location of the abscess and the local expertise with transthoracic or endobronchial drainage and surgical resection.
Septic emboli. Septic emboli are a less common cause of cavitary lung lesions. This entity should be considered in patients with a history of IV drug use or infected indwelling devices (central venous catheters, pacemaker wires, and right-sided prosthetic heart valves). Physical examination should include an assessment for signs of endocarditis and inspection for infected indwelling devices. In patients with IV drug use, the likely pathogen is S. aureus.
Oropharyngeal infection or indwelling catheters may predispose patients to septic thrombophlebitis of the internal jugular vein, also known as Lemierre’s syndrome, a rare but important cause of septic emboli.5 Laboratory testing includes culture for sputum and blood and culture of the infected device if applicable. On chest X-ray, septic emboli commonly appear as nodules located in the lung periphery. CT scan is more sensitive for detecting cavitation associated with septic emboli.
Diagnosis of Noninfectious Causes
Upon identification of a cavitary lung lesion, noninfectious etiologies must also be entertained. Noninfectious etiologies include malignancy, rheumatologic diseases, pulmonary embolism, and other causes. Important components in the clinical presentation include the presence of constitutional symptoms (fevers, weight loss, night sweats), smoking history, family history, and an otherwise complete review of systems. Physical exam should include evaluation for lymphadenopathy, cachexia, rash, clubbing, and other symptoms pertinent to the suspected etiology.
Malignancy. Perhaps most important among noninfectious causes of cavitary lung lesions is malignancy, and a high index of suspicion is warranted given that it is commonly the first diagnosis to consider overall.2 Cavities can form in primary lung cancers (e.g. bronchogenic carcinomas), lung tumors such as lymphoma or Kaposi’s sarcoma, or in metastatic disease. Cavitation has been detected in 7%-11% of primary lung cancers by plain radiography and in 22% by computed tomography.5 Cancers of squamous cell origin are the most likely to cavitate; this holds true for both primary lung tumors and metastatic tumors.6 Additionally, cavitation portends a worse prognosis.7
Clinicians should review any available prior chest imaging studies to look for a change in the quality or size of a cavitary lung lesion. Neoplasms are typically of variable size with irregular thick walls (greater than 4 mm) on CT scan, with higher specificity for neoplasm in those with a wall thickness greater than 15 mm.2
When the diagnosis is less clear, the decision to embark on more advanced diagnostic methods, such as biopsy, should rest on the provider’s clinical suspicion for a certain disease process. When a lung cancer is suspected, consultation with pulmonary and interventional radiology should be obtained to determine the best approach for biopsy.
Rheumatologic. Less common causes of cavitary lesions include those related to rheumatologic diseases (e.g. granulomatosis with polyangiitis, formerly known as Wegener’s granulomatosis). One study demonstrated that cavitary lung nodules occur in 37% of patients with granulomatosis with polyangiitis.8
Although uncommon, cavitary nodules can also be seen in rheumatoid arthritis and sarcoidosis. Given that patients with rheumatologic diseases are often treated with immunosuppressive agents, infection must remain high on the differential. Suspicion of a rheumatologic cause should prompt the clinician to obtain appropriate serologic testing and consultation as needed.
(click for larger image)Figure 2. An Algorithmic Approach to Cavitary Lung Lesions
Pulmonary embolism. Although often not considered in the evaluation of cavitary lung lesions, pulmonary embolism (PE) can lead to infarction and the formation of a cavitary lesion. Pulmonary infarction has been reported to occur in as many as one third of cases of PE.9 Cavitary lesions also have been described in chronic thromboembolic disease.10
Other. Uncommon causes of cavitary lesions include bronchiolitis obliterans with organizing pneumonia, Langerhans cell histiocytosis, and amyloidosis, among others. The hospitalist should keep a broad differential and involve consultants if the diagnosis remains unclear after initial diagnostic evaluation.
Back to the Case
The patient’s fever and productive cough, in combination with recent travel and location of the cavitary lesion, increase his risk for tuberculosis and endemic fungi, such as Coccidioides. This patient was placed on respiratory isolation with AFBs obtained to rule out TB, with Coccidioides antibodies, Cyptococcal antigen titers, and sputum for fungus sent to evaluate for an endemic fungus. He had a chest CT, which revealed a 17-mm cavitary mass within the right upper lobe that contained an air-fluid level indicating lung abscess. Coccidioides, cryptococcal, fungal sputum, and TB studies were negative.
The patient was treated empirically with clindamycin given the high prevalence of anaerobes in lung abscess. He was followed as an outpatient and had a chest X-ray showing resolution of the lesion at six months. The purpose of the X-ray was two-fold: to monitor the effect of antibiotic treatment and to evaluate for persistence of the cavitation given the neoplastic risk factors of older age and smoking.
Bottom Line
The best approach to a patient with a cavitary lung lesion includes assessing the clinical presentation and risk factors, differentiating infectious from noninfectious causes, and then utilizing this information to further direct the diagnostic evaluation. Consultation with a subspecialist or further testing such as biopsy should be considered if the etiology remains undefined after the initial evaluation.
Drs. Rendon, Pizanis, Montanaro, and Kraai are hospitalists in the department of internal medicine at the University of New Mexico School of Medicine in Albuquerque.
Key Points
Use associated clinical and radiographic features of the cavitary lung lesion to determine the likely etiology and diagnostic strategy.
There are several branching points in the approach to a cavitary lung lesion, the first being to establish whether the condition is infectious or noninfectious.
If it is more likely to be infectious, then risk factors and underlying immunocompromise must be considered in the empiric treatment and diagnostic strategy.
If it is more likely to be noninfectious, then the patient should be evaluated with biopsy if there is concern for malignancy, appropriate serologies for suspected rheumatologic diseases, or further imaging if the condition is considered related to pulmonary infarct or other, more rare, etiologies.
A 66-year-old homeless man with a history of smoking and cirrhosis due to alcoholism presents to the hospital with a productive cough and fever for one month. He has traveled around Arizona and New Mexico but has never left the country. His complete blood count (CBC) is notable for a white blood cell count of 13,000. His chest X-ray reveals a 1.7-cm right upper lobe cavitary lung lesion (see Figure 1). What is the best approach to this patient’s cavitary lung lesion?
Overview
Cavitary lung lesions are relatively common findings on chest imaging and often pose a diagnostic challenge to the hospitalist. Having a standard approach to the evaluation of a cavitary lung lesion can facilitate an expedited workup.
Figure 1. Right upper lobe cavitary lung lesion
A lung cavity is defined radiographically as a lucent area contained within a consolidation, mass, or nodule.1 Cavities usually are accompanied by thick walls, greater than 4 mm. These should be differentiated from cysts, which are not surrounded by consolidation, mass, or nodule, and are accompanied by a thinner wall.2
The differential diagnosis of a cavitary lung lesion is broad and can be delineated into categories of infectious and noninfectious etiologies (see Figure 2). Infectious causes include bacterial, fungal, and, rarely, parasitic agents. Noninfectious causes encompass malignant, rheumatologic, and other less common etiologies such as infarct related to pulmonary embolism.
The clinical presentation and assessment of risk factors for a particular patient are of the utmost importance in delineating next steps for evaluation and management (see Table 1). For those patients of older age with smoking history, specific occupational or environmental exposures, and weight loss, the most common etiology is neoplasm. Common infectious causes include lung abscess and necrotizing pneumonia, as well as tuberculosis. The approach to diagnosis should be based on a composite of the clinical presentation, patient characteristics, and radiographic appearance of the cavity.
(click for larger image)Table 1. Patient traits and radiologic appearance suggesting specific etiologies of cavitary lung lesions
Guidelines for the approach to cavitary lung lesions are lacking, yet a thorough understanding of the initial approach is important for those practicing hospital medicine. Key components in the approach to diagnosis of a solitary cavitary lesion are outlined in this article.
Diagnosis of Infectious Causes
In the initial evaluation of a cavitary lung lesion, it is important to first determine if the cause is an infectious process. The infectious etiologies to consider include lung abscess and necrotizing pneumonia, tuberculosis, and septic emboli. Important components in the clinical presentation include presence of cough, fever, night sweats, chills, and symptoms that have lasted less than one month, as well as comorbid conditions, drug or alcohol abuse, and history of immunocompromise (e.g. HIV, immunosuppressive therapy, or organ transplant).
Given the public health considerations and impact of treatment, tuberculosis (TB) will be discussed in its own category.
Tuberculosis. Given the fact that TB patients require airborne isolation, the disease must be considered early in the evaluation of a cavitary lung lesion. Patients with TB often present with more chronic symptoms, such as fevers, night sweats, weight loss, and hemoptysis. Immunocompromised state, travel to endemic regions, and incarceration increase the likelihood of TB. Nontuberculous mycobacterium (i.e., M. kansasii) should also be considered in endemic areas.
For those patients in whom TB is suspected, airborne isolation must be initiated promptly. The provider should obtain three sputum samples for acid-fast bacillus (AFB) smear and culture when risk factors are present. Most patients with reactivation TB have abnormal chest X-rays, with approximately 20% of those patients having air-fluid levels and the majority of cases affecting the upper lobes.3 Cavities may be seen in patients with primary or reactivation TB.3
Lung abscess and necrotizing pneumonia. Lung abscesses are cavities associated with necrosis caused by a microbial infection. The term necrotizing pneumonia typically is used when there are multiple smaller (smaller than 2 cm) associated lung abscesses, although both lung abscess and necrotizing pneumonia represent a similar pathophysiologic process and are along the same continuum. Lung abscess is suspected with the presence of predisposing risk factors to aspiration (e.g. alcoholism) and poor dentition. History of cough, fever, putrid sputum, night sweats, and weight loss may indicate subacute or chronic development of a lung abscess. Physical examination might be significant for signs of pneumonia and gingivitis.
Organisms that cause lung abscesses include anaerobes (most common), TB, methicillin-resistant Staphylococcus aureus (MRSA), post-influenza illness, endemic fungi, and Nocardia, among others.4 In immunocompromised patients, more common considerations include TB, Mycobacterium avium complex, other mycobacteria, Pseudomonas aeruginosa, Nocardia, Cryptococcus, Aspergillus, endemic fungi (e.g. Coccidiodes in the Southwest and Histoplasma in the Midwest), and, less commonly, Pneumocystis jiroveci.4 The likelihood of each organism is dependent on the patient’s risk factors. Initial laboratory testing includes sputum and blood cultures, as well as serologic testing for endemic fungi, especially in immunocompromised patients.
Imaging may reveal a cavitary lesion in the dependent pulmonary segments (posterior segments of the upper lobes or superior segments of the lower lobes), at times associated with a pleural effusion or infiltrate. The most common appearance of a lung abscess is an asymmetric cavity with an air-fluid level and a wall with a ragged or smooth border. CT scan is often indicated when X-rays are equivocal and when cases are of uncertain cause or are unresponsive to antibiotic therapy. Bronchoscopy is reserved for patients with an immunocompromising condition, atypical presentation, or lack of response to treatment.
For those cavitary lesions in which there is a high degree of suspicion for lung abscess, empiric treatment should include antibiotics active against anaerobes and MRSA if the patient has risk factors. Patients often receive an empiric trial of antibiotics prior to biopsy unless there are clear indications that the cavitary lung lesion is related to cancer. Lung abscesses typically drain spontaneously, and transthoracic or endobronchial drainage is not usually recommended as initial management due to risk of pneumothorax and formation of bronchopleural fistula.
Lung abscesses should be followed to resolution with serial chest imaging. If the lung abscess does not resolve, it would be appropriate to consult thoracic surgery, interventional radiology, or pulmonary, depending on the location of the abscess and the local expertise with transthoracic or endobronchial drainage and surgical resection.
Septic emboli. Septic emboli are a less common cause of cavitary lung lesions. This entity should be considered in patients with a history of IV drug use or infected indwelling devices (central venous catheters, pacemaker wires, and right-sided prosthetic heart valves). Physical examination should include an assessment for signs of endocarditis and inspection for infected indwelling devices. In patients with IV drug use, the likely pathogen is S. aureus.
Oropharyngeal infection or indwelling catheters may predispose patients to septic thrombophlebitis of the internal jugular vein, also known as Lemierre’s syndrome, a rare but important cause of septic emboli.5 Laboratory testing includes culture for sputum and blood and culture of the infected device if applicable. On chest X-ray, septic emboli commonly appear as nodules located in the lung periphery. CT scan is more sensitive for detecting cavitation associated with septic emboli.
Diagnosis of Noninfectious Causes
Upon identification of a cavitary lung lesion, noninfectious etiologies must also be entertained. Noninfectious etiologies include malignancy, rheumatologic diseases, pulmonary embolism, and other causes. Important components in the clinical presentation include the presence of constitutional symptoms (fevers, weight loss, night sweats), smoking history, family history, and an otherwise complete review of systems. Physical exam should include evaluation for lymphadenopathy, cachexia, rash, clubbing, and other symptoms pertinent to the suspected etiology.
Malignancy. Perhaps most important among noninfectious causes of cavitary lung lesions is malignancy, and a high index of suspicion is warranted given that it is commonly the first diagnosis to consider overall.2 Cavities can form in primary lung cancers (e.g. bronchogenic carcinomas), lung tumors such as lymphoma or Kaposi’s sarcoma, or in metastatic disease. Cavitation has been detected in 7%-11% of primary lung cancers by plain radiography and in 22% by computed tomography.5 Cancers of squamous cell origin are the most likely to cavitate; this holds true for both primary lung tumors and metastatic tumors.6 Additionally, cavitation portends a worse prognosis.7
Clinicians should review any available prior chest imaging studies to look for a change in the quality or size of a cavitary lung lesion. Neoplasms are typically of variable size with irregular thick walls (greater than 4 mm) on CT scan, with higher specificity for neoplasm in those with a wall thickness greater than 15 mm.2
When the diagnosis is less clear, the decision to embark on more advanced diagnostic methods, such as biopsy, should rest on the provider’s clinical suspicion for a certain disease process. When a lung cancer is suspected, consultation with pulmonary and interventional radiology should be obtained to determine the best approach for biopsy.
Rheumatologic. Less common causes of cavitary lesions include those related to rheumatologic diseases (e.g. granulomatosis with polyangiitis, formerly known as Wegener’s granulomatosis). One study demonstrated that cavitary lung nodules occur in 37% of patients with granulomatosis with polyangiitis.8
Although uncommon, cavitary nodules can also be seen in rheumatoid arthritis and sarcoidosis. Given that patients with rheumatologic diseases are often treated with immunosuppressive agents, infection must remain high on the differential. Suspicion of a rheumatologic cause should prompt the clinician to obtain appropriate serologic testing and consultation as needed.
(click for larger image)Figure 2. An Algorithmic Approach to Cavitary Lung Lesions
Pulmonary embolism. Although often not considered in the evaluation of cavitary lung lesions, pulmonary embolism (PE) can lead to infarction and the formation of a cavitary lesion. Pulmonary infarction has been reported to occur in as many as one third of cases of PE.9 Cavitary lesions also have been described in chronic thromboembolic disease.10
Other. Uncommon causes of cavitary lesions include bronchiolitis obliterans with organizing pneumonia, Langerhans cell histiocytosis, and amyloidosis, among others. The hospitalist should keep a broad differential and involve consultants if the diagnosis remains unclear after initial diagnostic evaluation.
Back to the Case
The patient’s fever and productive cough, in combination with recent travel and location of the cavitary lesion, increase his risk for tuberculosis and endemic fungi, such as Coccidioides. This patient was placed on respiratory isolation with AFBs obtained to rule out TB, with Coccidioides antibodies, Cyptococcal antigen titers, and sputum for fungus sent to evaluate for an endemic fungus. He had a chest CT, which revealed a 17-mm cavitary mass within the right upper lobe that contained an air-fluid level indicating lung abscess. Coccidioides, cryptococcal, fungal sputum, and TB studies were negative.
The patient was treated empirically with clindamycin given the high prevalence of anaerobes in lung abscess. He was followed as an outpatient and had a chest X-ray showing resolution of the lesion at six months. The purpose of the X-ray was two-fold: to monitor the effect of antibiotic treatment and to evaluate for persistence of the cavitation given the neoplastic risk factors of older age and smoking.
Bottom Line
The best approach to a patient with a cavitary lung lesion includes assessing the clinical presentation and risk factors, differentiating infectious from noninfectious causes, and then utilizing this information to further direct the diagnostic evaluation. Consultation with a subspecialist or further testing such as biopsy should be considered if the etiology remains undefined after the initial evaluation.
Drs. Rendon, Pizanis, Montanaro, and Kraai are hospitalists in the department of internal medicine at the University of New Mexico School of Medicine in Albuquerque.
Key Points
Use associated clinical and radiographic features of the cavitary lung lesion to determine the likely etiology and diagnostic strategy.
There are several branching points in the approach to a cavitary lung lesion, the first being to establish whether the condition is infectious or noninfectious.
If it is more likely to be infectious, then risk factors and underlying immunocompromise must be considered in the empiric treatment and diagnostic strategy.
If it is more likely to be noninfectious, then the patient should be evaluated with biopsy if there is concern for malignancy, appropriate serologies for suspected rheumatologic diseases, or further imaging if the condition is considered related to pulmonary infarct or other, more rare, etiologies.
“While VTE may not be the No. 1 reason for hospitalization, hospitalists very frequently care for patients with VTE,” says Sowmya Kanikkannan, MD, FACP, SFHM, hospitalist medical director and assistant professor of medicine at Rowan University School of Osteopathic Medicine in Stratford, N.J. “Hospitalists usually are the frontline providers that diagnose and manage hospital-acquired VTEs in hospitalized patients.”
Dr. Kanikkannan, a member of Team Hospitalist, sees a wide range of VTE cases caused by two related conditions—deep vein thrombosis (DVT) and pulmonary embolism (PE).
“Some patients present with a straightforward diagnosis of DVT, while others have extensive DVT,” she says. “In other instances, patients present with acute PE with or without hemodynamic compromise. I’ve also diagnosed and managed hospital-acquired VTEs in medical patients, as well as post-operatively in surgical co-management.”
(click for larger image)Table 1. Drug-specific dosing and administration recommendations for target-specific oral anticoagulants: dabigatran, rivaroxaban, apixaban, and edoxaban.Source: Yong Lee, PharmD, BCPS, clinical pharmacy specialist, Parkland Health and Hospital System, Dallas.
It is estimated that between 350,000 to 900,000 Americans are affected by DVT or PE each year, with up to 100,000 dying as a result. Twenty to 50% of people who experience DVT develop long-term complications.1VTE costs the U.S. healthcare system more than $1.5 billion annually.2
As lieutenants in the war against VTE, hospitalists are finding that new treatments, continued efforts to standardize VTE prophylaxis, and increased transparency in performance reporting are the tools needed to combat these common conditions—and hospitalists are being held accountable for optimal patient care.
New Treatments Show Promise
Diagnosing and treating VTE early helps to prevent progression and hemodynamic instability. Although the accepted treatment for VTE used to be heparin, or a low molecular weight heparin (LMWH) (Fragmin, Innohep and Lovenox) with a transition to warfarin, three target-specific oral anticoagulants (TSOACs)—dabigatran, rivaroxaban, and apixaban—are now being prescribed. The FDA has approved rivaroxaban and apixaban for the prevention of VTE after knee and hip surgery and for treatment of VTE, while dabigatran is FDA approved only for the treatment of VTE. All three are approved for use in nonvalvular atrial fibrillation (Afib). A fourth TSOAC, edoxaban, received FDA approval in January for VTE treatment and nonvalvular atrial fibrillation.
“The drawback of warfarin is that patients need frequent international normalized ratio (INR) monitoring,” Dr. Kanikkannan says. “Discharge planning is time consuming because patients need to be educated on warfarin, and follow-up appointments need to be arranged before discharge to ensure patient safety.”
“Their [TSOACs] ease of administration and easy dosing helps hospitalists to manage patients with VTE more efficiently,” Dr. Kanikkannan says. “Patients like having lab testing less frequently but equal efficacy in treatment.”
Rivaroxaban used to have the most approved indications by the FDA; however, based on three clinical trials—ADVANCE-1, 2, and 3—apixaban has the same six FDA indications as rivaroxaban.
The majority of clinical trials suggest noninferiority or superiority of the oral agents compared to LMWH, and safety appears to be similar across treatment groups, other than an increased risk in bleeding with oral agents (see Table 1).
“The increased risk of bleeding seen in trials is something hospitalists need to consider,” says Yong Lee, PharmD, BCPS, clinical pharmacy specialist at Parkland Health and Hospital System in Dallas, Texas. Warfarin is easily reversed; the new anticoagulants don’t have any specific reversal agent (see new table about reversal options). Consequently, the American College of Chest Physicians still recommends unfractionated heparin or a LMWH for VTE prophylaxis. “These agents will still likely remain the best available options to hospitalists for VTE prevention,” he adds.
(click for larger image)Table 2. Assessing Bleed RiskSource: Baron TH, Kamath PS, McBane RD. N Engl J Med. 2013;368(22):2113-2124.
Julianna Lindsey, MD, MBA, FACP, FHM, chief of staff and hospitalist at Victory Medical Center in McKinney, Texas, says there are instances when it would be helpful to know what the therapeutic level of a TSOAC’s anticoagulation effect is, such as in a patient with active bleeding or one who requires major emergent surgery. But there is no coagulation assay to date that is readily available to test the effect of apixaban; the anticoagulation effect for dabigatran can be roughly estimated by the activated partial thromboplastin time (aPTT) and thrombin time (TT), and the anticoagulation effect for rivaroxaban can be roughly estimated by the prothrombin time (PT).
“The drawback of warfarin is that patients need frequent international normalized ratio (INR) monitoring. Discharge planning is time consuming because patients need to be educated on warfarin, and follow-up appointments need to be arranged before discharge to ensure patient safety.” —Dr. Kanikkannan
Dr. Lee expects the new FDA approvals to expand the utilization of oral anti-Xa inhibitors in practice. “This will, hopefully, make the new oral anticoagulant market more competitive, driving down their costs,” he says, referring to one of the biggest barriers to current use of these agents. Warfarin still remains the most cost-effective option, despite the need for regular INR monitoring.
“Studies are looking not only at effectiveness but also the safety profile of these anticoagulants,” Dr. Kanikkannan says, as long-term safety data is not yet available on these oral agents.8,9
(click for larger image) Table 3. Peri-Procedural Management: TSOACs Source: Management of Anticoagulation in the Peri-procedural Period (MAP) Tool.Available at http://qio.ipro.org/drug-safety/drug-safety-resources or http://excellence.acforum.org/.
Researchers also are looking at the comparative effects of other medications. For example, a Journal of Hospital Medicine study concluded that, compared with other anticoagulants, aspirin is associated with a higher risk of DVT following hip fracture repair but similar rates of DVT risk following hip-knee arthroplasty. Bleeding rates with aspirin, however, were substantially lower.10
(click for larger image) Table 4. Management of Severe Bleeding: TSOACsSource: Kaatz S, Kouides PA, Garcia DA, et al. Am J Hematol. 2012;87 Suppl 1:S141-S145.
Improvement Efforts
In an effort to improve VTE prophylaxis in hospitalized patients, The Joint Commission developed a VTE standardized performance measure set in 2009, which has been reported on www.qualitycheck.org since then. The VTE measure set comprises six different measures evaluating the prophylaxis of VTE, treatment of VTE, warfarin discharge education, and hospital-acquired VTE. Since reporting started, most hospitals have implemented VTE risk assessment models and VTE process improvement programs; data trends have shown improvement, says Denise Krusenoski, MSN, RN, CMSRN, CHTS-CP, associate project director at The Joint Commission, which is based in Oakbrook Terrace, Ill.
“We have to continue to make sure that our practice of medicine remains based in evidence and not succumb to the pull of getting a check-box ticked.” —Dr. Lindsey
“While a lot of good, evidence-based data is available, no single VTE risk assessment tool has been prospectively validated as superior,” she says. “Involving key members of medical staff to create and approve protocols based on proven data will increase the buy-in and adoption for using these tools.”
E-Measures Promote Excellence
(click for larger image)Table 5. TSOACs: Dosing (FDA Labeling)* Adjusted for rental impairment, drug interactions, age, low weight, or a combination of these factors ° Treatment doses of rivaroxaban should be taken with largest meal of the day
Many hospitals are now moving from traditional chart abstracting for VTE measures to electronic measures (e-measures), which allow for more rapid and automated reporting of these quality metrics. In order for e-measures to be accurate, documentation necessary for measure computation must be present in defined standardized fields in the medical record. “With no human interpretation, data must be documented in a precise fashion,” Krusenoski says. “Providers will need to be flexible in learning new documentation skills.”
Dr. Lindsey, a member of Team Hospitalist, cautions that e-measures have the potential to increase unwanted events by overutilization of pharmacologic VTE prophylaxis and associated hemorrhagic events.
“We have to continue to make sure that our practice of medicine remains based in evidence and not succumb to the pull of getting a check-box ticked,” she warns.
VTE remains a significant problem in hospitalized patients today. Hospitalists should consider the pros and cons of using newer treatment methods over traditional agents. Efforts are under way to improve VTE prophylaxis by standardizing best practice and moving from traditional chart abstracting to using e-measures for performance reporting.
Karen Appold is a freelance medical writer in Pennsylvania.
Getting the Upper Hand
Getting involved in your hospital’s venous thromboembolism (VTE) task force is a great opportunity to have your voice heard and become involved in the implementation of change in your hospital’s VTE management process. It also is a forum in which you could learn more about VTE, including appropriate prophylaxis methods for various patient populations.
Some other VTE resources:
The American College of Chest Physicians offers evidence-based practice guidelines on the management and prevention of VTE.
SHM is airing a seven-part webinar series on anticoagulation, which is free to members via the Learning/Education portal. By participating in all of the sessions, members earn 6.5 AMA PRA category 1 credit hours. “The knowledge imparted will help me to improve my practice of hospital medicine and treatment of patients requiring anticoagulants, which is the majority of our patients,” Dr. Lindsey says.
—Karen Appold
Bringing Awareness to VTE
Thromboembolisms (VTEs) are the most common cause of preventable death in the hospitalized patient. Given the adverse outcomes and economic burden associated with VTEs, it is truly a public health concern. As Dr. Kanikkannan suggests, “Why not use the month of March—VTE awareness month—as an opportunity to educate patients about healthy lifestyle practices to prevent VTE?
“Patients can learn to identify their risk factors and become aware of symptoms that may be a cause for concern, prompting them to seek medical attention,” she says.
“It might be helpful for hospitals to arrange review sessions for VTE prophylaxis for providers and staff.” —Dr. Suehler
Hospitalists could also organize or participate in community health fairs—a great venue to spread the word about VTE and create awareness among the public. Because hospitalists frequently sit on VTE task forces in hospitals and take a lead role in implementing VTE prophylaxis efforts, they are in a prime position to implement a hospital campaign during VTE awareness month.
Keeping staff abreast of advancements is also advisable.
“It might be helpful for hospitals to arrange review sessions for VTE prophylaxis for providers and staff,” says Klaus Suehler, MD, FHM, hospitalist at Mercy Hospital Allina Health in Coon Rapids, Minn., who believes that creating awareness makes a 0% failure rate on VTE prophylaxis achievable.
“While VTE may not be the No. 1 reason for hospitalization, hospitalists very frequently care for patients with VTE,” says Sowmya Kanikkannan, MD, FACP, SFHM, hospitalist medical director and assistant professor of medicine at Rowan University School of Osteopathic Medicine in Stratford, N.J. “Hospitalists usually are the frontline providers that diagnose and manage hospital-acquired VTEs in hospitalized patients.”
Dr. Kanikkannan, a member of Team Hospitalist, sees a wide range of VTE cases caused by two related conditions—deep vein thrombosis (DVT) and pulmonary embolism (PE).
“Some patients present with a straightforward diagnosis of DVT, while others have extensive DVT,” she says. “In other instances, patients present with acute PE with or without hemodynamic compromise. I’ve also diagnosed and managed hospital-acquired VTEs in medical patients, as well as post-operatively in surgical co-management.”
(click for larger image)Table 1. Drug-specific dosing and administration recommendations for target-specific oral anticoagulants: dabigatran, rivaroxaban, apixaban, and edoxaban.Source: Yong Lee, PharmD, BCPS, clinical pharmacy specialist, Parkland Health and Hospital System, Dallas.
It is estimated that between 350,000 to 900,000 Americans are affected by DVT or PE each year, with up to 100,000 dying as a result. Twenty to 50% of people who experience DVT develop long-term complications.1VTE costs the U.S. healthcare system more than $1.5 billion annually.2
As lieutenants in the war against VTE, hospitalists are finding that new treatments, continued efforts to standardize VTE prophylaxis, and increased transparency in performance reporting are the tools needed to combat these common conditions—and hospitalists are being held accountable for optimal patient care.
New Treatments Show Promise
Diagnosing and treating VTE early helps to prevent progression and hemodynamic instability. Although the accepted treatment for VTE used to be heparin, or a low molecular weight heparin (LMWH) (Fragmin, Innohep and Lovenox) with a transition to warfarin, three target-specific oral anticoagulants (TSOACs)—dabigatran, rivaroxaban, and apixaban—are now being prescribed. The FDA has approved rivaroxaban and apixaban for the prevention of VTE after knee and hip surgery and for treatment of VTE, while dabigatran is FDA approved only for the treatment of VTE. All three are approved for use in nonvalvular atrial fibrillation (Afib). A fourth TSOAC, edoxaban, received FDA approval in January for VTE treatment and nonvalvular atrial fibrillation.
“The drawback of warfarin is that patients need frequent international normalized ratio (INR) monitoring,” Dr. Kanikkannan says. “Discharge planning is time consuming because patients need to be educated on warfarin, and follow-up appointments need to be arranged before discharge to ensure patient safety.”
“Their [TSOACs] ease of administration and easy dosing helps hospitalists to manage patients with VTE more efficiently,” Dr. Kanikkannan says. “Patients like having lab testing less frequently but equal efficacy in treatment.”
Rivaroxaban used to have the most approved indications by the FDA; however, based on three clinical trials—ADVANCE-1, 2, and 3—apixaban has the same six FDA indications as rivaroxaban.
The majority of clinical trials suggest noninferiority or superiority of the oral agents compared to LMWH, and safety appears to be similar across treatment groups, other than an increased risk in bleeding with oral agents (see Table 1).
“The increased risk of bleeding seen in trials is something hospitalists need to consider,” says Yong Lee, PharmD, BCPS, clinical pharmacy specialist at Parkland Health and Hospital System in Dallas, Texas. Warfarin is easily reversed; the new anticoagulants don’t have any specific reversal agent (see new table about reversal options). Consequently, the American College of Chest Physicians still recommends unfractionated heparin or a LMWH for VTE prophylaxis. “These agents will still likely remain the best available options to hospitalists for VTE prevention,” he adds.
(click for larger image)Table 2. Assessing Bleed RiskSource: Baron TH, Kamath PS, McBane RD. N Engl J Med. 2013;368(22):2113-2124.
Julianna Lindsey, MD, MBA, FACP, FHM, chief of staff and hospitalist at Victory Medical Center in McKinney, Texas, says there are instances when it would be helpful to know what the therapeutic level of a TSOAC’s anticoagulation effect is, such as in a patient with active bleeding or one who requires major emergent surgery. But there is no coagulation assay to date that is readily available to test the effect of apixaban; the anticoagulation effect for dabigatran can be roughly estimated by the activated partial thromboplastin time (aPTT) and thrombin time (TT), and the anticoagulation effect for rivaroxaban can be roughly estimated by the prothrombin time (PT).
“The drawback of warfarin is that patients need frequent international normalized ratio (INR) monitoring. Discharge planning is time consuming because patients need to be educated on warfarin, and follow-up appointments need to be arranged before discharge to ensure patient safety.” —Dr. Kanikkannan
Dr. Lee expects the new FDA approvals to expand the utilization of oral anti-Xa inhibitors in practice. “This will, hopefully, make the new oral anticoagulant market more competitive, driving down their costs,” he says, referring to one of the biggest barriers to current use of these agents. Warfarin still remains the most cost-effective option, despite the need for regular INR monitoring.
“Studies are looking not only at effectiveness but also the safety profile of these anticoagulants,” Dr. Kanikkannan says, as long-term safety data is not yet available on these oral agents.8,9
(click for larger image) Table 3. Peri-Procedural Management: TSOACs Source: Management of Anticoagulation in the Peri-procedural Period (MAP) Tool.Available at http://qio.ipro.org/drug-safety/drug-safety-resources or http://excellence.acforum.org/.
Researchers also are looking at the comparative effects of other medications. For example, a Journal of Hospital Medicine study concluded that, compared with other anticoagulants, aspirin is associated with a higher risk of DVT following hip fracture repair but similar rates of DVT risk following hip-knee arthroplasty. Bleeding rates with aspirin, however, were substantially lower.10
(click for larger image) Table 4. Management of Severe Bleeding: TSOACsSource: Kaatz S, Kouides PA, Garcia DA, et al. Am J Hematol. 2012;87 Suppl 1:S141-S145.
Improvement Efforts
In an effort to improve VTE prophylaxis in hospitalized patients, The Joint Commission developed a VTE standardized performance measure set in 2009, which has been reported on www.qualitycheck.org since then. The VTE measure set comprises six different measures evaluating the prophylaxis of VTE, treatment of VTE, warfarin discharge education, and hospital-acquired VTE. Since reporting started, most hospitals have implemented VTE risk assessment models and VTE process improvement programs; data trends have shown improvement, says Denise Krusenoski, MSN, RN, CMSRN, CHTS-CP, associate project director at The Joint Commission, which is based in Oakbrook Terrace, Ill.
“We have to continue to make sure that our practice of medicine remains based in evidence and not succumb to the pull of getting a check-box ticked.” —Dr. Lindsey
“While a lot of good, evidence-based data is available, no single VTE risk assessment tool has been prospectively validated as superior,” she says. “Involving key members of medical staff to create and approve protocols based on proven data will increase the buy-in and adoption for using these tools.”
E-Measures Promote Excellence
(click for larger image)Table 5. TSOACs: Dosing (FDA Labeling)* Adjusted for rental impairment, drug interactions, age, low weight, or a combination of these factors ° Treatment doses of rivaroxaban should be taken with largest meal of the day
Many hospitals are now moving from traditional chart abstracting for VTE measures to electronic measures (e-measures), which allow for more rapid and automated reporting of these quality metrics. In order for e-measures to be accurate, documentation necessary for measure computation must be present in defined standardized fields in the medical record. “With no human interpretation, data must be documented in a precise fashion,” Krusenoski says. “Providers will need to be flexible in learning new documentation skills.”
Dr. Lindsey, a member of Team Hospitalist, cautions that e-measures have the potential to increase unwanted events by overutilization of pharmacologic VTE prophylaxis and associated hemorrhagic events.
“We have to continue to make sure that our practice of medicine remains based in evidence and not succumb to the pull of getting a check-box ticked,” she warns.
VTE remains a significant problem in hospitalized patients today. Hospitalists should consider the pros and cons of using newer treatment methods over traditional agents. Efforts are under way to improve VTE prophylaxis by standardizing best practice and moving from traditional chart abstracting to using e-measures for performance reporting.
Karen Appold is a freelance medical writer in Pennsylvania.
Getting the Upper Hand
Getting involved in your hospital’s venous thromboembolism (VTE) task force is a great opportunity to have your voice heard and become involved in the implementation of change in your hospital’s VTE management process. It also is a forum in which you could learn more about VTE, including appropriate prophylaxis methods for various patient populations.
Some other VTE resources:
The American College of Chest Physicians offers evidence-based practice guidelines on the management and prevention of VTE.
SHM is airing a seven-part webinar series on anticoagulation, which is free to members via the Learning/Education portal. By participating in all of the sessions, members earn 6.5 AMA PRA category 1 credit hours. “The knowledge imparted will help me to improve my practice of hospital medicine and treatment of patients requiring anticoagulants, which is the majority of our patients,” Dr. Lindsey says.
—Karen Appold
Bringing Awareness to VTE
Thromboembolisms (VTEs) are the most common cause of preventable death in the hospitalized patient. Given the adverse outcomes and economic burden associated with VTEs, it is truly a public health concern. As Dr. Kanikkannan suggests, “Why not use the month of March—VTE awareness month—as an opportunity to educate patients about healthy lifestyle practices to prevent VTE?
“Patients can learn to identify their risk factors and become aware of symptoms that may be a cause for concern, prompting them to seek medical attention,” she says.
“It might be helpful for hospitals to arrange review sessions for VTE prophylaxis for providers and staff.” —Dr. Suehler
Hospitalists could also organize or participate in community health fairs—a great venue to spread the word about VTE and create awareness among the public. Because hospitalists frequently sit on VTE task forces in hospitals and take a lead role in implementing VTE prophylaxis efforts, they are in a prime position to implement a hospital campaign during VTE awareness month.
Keeping staff abreast of advancements is also advisable.
“It might be helpful for hospitals to arrange review sessions for VTE prophylaxis for providers and staff,” says Klaus Suehler, MD, FHM, hospitalist at Mercy Hospital Allina Health in Coon Rapids, Minn., who believes that creating awareness makes a 0% failure rate on VTE prophylaxis achievable.
“While VTE may not be the No. 1 reason for hospitalization, hospitalists very frequently care for patients with VTE,” says Sowmya Kanikkannan, MD, FACP, SFHM, hospitalist medical director and assistant professor of medicine at Rowan University School of Osteopathic Medicine in Stratford, N.J. “Hospitalists usually are the frontline providers that diagnose and manage hospital-acquired VTEs in hospitalized patients.”
Dr. Kanikkannan, a member of Team Hospitalist, sees a wide range of VTE cases caused by two related conditions—deep vein thrombosis (DVT) and pulmonary embolism (PE).
“Some patients present with a straightforward diagnosis of DVT, while others have extensive DVT,” she says. “In other instances, patients present with acute PE with or without hemodynamic compromise. I’ve also diagnosed and managed hospital-acquired VTEs in medical patients, as well as post-operatively in surgical co-management.”
(click for larger image)Table 1. Drug-specific dosing and administration recommendations for target-specific oral anticoagulants: dabigatran, rivaroxaban, apixaban, and edoxaban.Source: Yong Lee, PharmD, BCPS, clinical pharmacy specialist, Parkland Health and Hospital System, Dallas.
It is estimated that between 350,000 to 900,000 Americans are affected by DVT or PE each year, with up to 100,000 dying as a result. Twenty to 50% of people who experience DVT develop long-term complications.1VTE costs the U.S. healthcare system more than $1.5 billion annually.2
As lieutenants in the war against VTE, hospitalists are finding that new treatments, continued efforts to standardize VTE prophylaxis, and increased transparency in performance reporting are the tools needed to combat these common conditions—and hospitalists are being held accountable for optimal patient care.
New Treatments Show Promise
Diagnosing and treating VTE early helps to prevent progression and hemodynamic instability. Although the accepted treatment for VTE used to be heparin, or a low molecular weight heparin (LMWH) (Fragmin, Innohep and Lovenox) with a transition to warfarin, three target-specific oral anticoagulants (TSOACs)—dabigatran, rivaroxaban, and apixaban—are now being prescribed. The FDA has approved rivaroxaban and apixaban for the prevention of VTE after knee and hip surgery and for treatment of VTE, while dabigatran is FDA approved only for the treatment of VTE. All three are approved for use in nonvalvular atrial fibrillation (Afib). A fourth TSOAC, edoxaban, received FDA approval in January for VTE treatment and nonvalvular atrial fibrillation.
“The drawback of warfarin is that patients need frequent international normalized ratio (INR) monitoring,” Dr. Kanikkannan says. “Discharge planning is time consuming because patients need to be educated on warfarin, and follow-up appointments need to be arranged before discharge to ensure patient safety.”
“Their [TSOACs] ease of administration and easy dosing helps hospitalists to manage patients with VTE more efficiently,” Dr. Kanikkannan says. “Patients like having lab testing less frequently but equal efficacy in treatment.”
Rivaroxaban used to have the most approved indications by the FDA; however, based on three clinical trials—ADVANCE-1, 2, and 3—apixaban has the same six FDA indications as rivaroxaban.
The majority of clinical trials suggest noninferiority or superiority of the oral agents compared to LMWH, and safety appears to be similar across treatment groups, other than an increased risk in bleeding with oral agents (see Table 1).
“The increased risk of bleeding seen in trials is something hospitalists need to consider,” says Yong Lee, PharmD, BCPS, clinical pharmacy specialist at Parkland Health and Hospital System in Dallas, Texas. Warfarin is easily reversed; the new anticoagulants don’t have any specific reversal agent (see new table about reversal options). Consequently, the American College of Chest Physicians still recommends unfractionated heparin or a LMWH for VTE prophylaxis. “These agents will still likely remain the best available options to hospitalists for VTE prevention,” he adds.
(click for larger image)Table 2. Assessing Bleed RiskSource: Baron TH, Kamath PS, McBane RD. N Engl J Med. 2013;368(22):2113-2124.
Julianna Lindsey, MD, MBA, FACP, FHM, chief of staff and hospitalist at Victory Medical Center in McKinney, Texas, says there are instances when it would be helpful to know what the therapeutic level of a TSOAC’s anticoagulation effect is, such as in a patient with active bleeding or one who requires major emergent surgery. But there is no coagulation assay to date that is readily available to test the effect of apixaban; the anticoagulation effect for dabigatran can be roughly estimated by the activated partial thromboplastin time (aPTT) and thrombin time (TT), and the anticoagulation effect for rivaroxaban can be roughly estimated by the prothrombin time (PT).
“The drawback of warfarin is that patients need frequent international normalized ratio (INR) monitoring. Discharge planning is time consuming because patients need to be educated on warfarin, and follow-up appointments need to be arranged before discharge to ensure patient safety.” —Dr. Kanikkannan
Dr. Lee expects the new FDA approvals to expand the utilization of oral anti-Xa inhibitors in practice. “This will, hopefully, make the new oral anticoagulant market more competitive, driving down their costs,” he says, referring to one of the biggest barriers to current use of these agents. Warfarin still remains the most cost-effective option, despite the need for regular INR monitoring.
“Studies are looking not only at effectiveness but also the safety profile of these anticoagulants,” Dr. Kanikkannan says, as long-term safety data is not yet available on these oral agents.8,9
(click for larger image) Table 3. Peri-Procedural Management: TSOACs Source: Management of Anticoagulation in the Peri-procedural Period (MAP) Tool.Available at http://qio.ipro.org/drug-safety/drug-safety-resources or http://excellence.acforum.org/.
Researchers also are looking at the comparative effects of other medications. For example, a Journal of Hospital Medicine study concluded that, compared with other anticoagulants, aspirin is associated with a higher risk of DVT following hip fracture repair but similar rates of DVT risk following hip-knee arthroplasty. Bleeding rates with aspirin, however, were substantially lower.10
(click for larger image) Table 4. Management of Severe Bleeding: TSOACsSource: Kaatz S, Kouides PA, Garcia DA, et al. Am J Hematol. 2012;87 Suppl 1:S141-S145.
Improvement Efforts
In an effort to improve VTE prophylaxis in hospitalized patients, The Joint Commission developed a VTE standardized performance measure set in 2009, which has been reported on www.qualitycheck.org since then. The VTE measure set comprises six different measures evaluating the prophylaxis of VTE, treatment of VTE, warfarin discharge education, and hospital-acquired VTE. Since reporting started, most hospitals have implemented VTE risk assessment models and VTE process improvement programs; data trends have shown improvement, says Denise Krusenoski, MSN, RN, CMSRN, CHTS-CP, associate project director at The Joint Commission, which is based in Oakbrook Terrace, Ill.
“We have to continue to make sure that our practice of medicine remains based in evidence and not succumb to the pull of getting a check-box ticked.” —Dr. Lindsey
“While a lot of good, evidence-based data is available, no single VTE risk assessment tool has been prospectively validated as superior,” she says. “Involving key members of medical staff to create and approve protocols based on proven data will increase the buy-in and adoption for using these tools.”
E-Measures Promote Excellence
(click for larger image)Table 5. TSOACs: Dosing (FDA Labeling)* Adjusted for rental impairment, drug interactions, age, low weight, or a combination of these factors ° Treatment doses of rivaroxaban should be taken with largest meal of the day
Many hospitals are now moving from traditional chart abstracting for VTE measures to electronic measures (e-measures), which allow for more rapid and automated reporting of these quality metrics. In order for e-measures to be accurate, documentation necessary for measure computation must be present in defined standardized fields in the medical record. “With no human interpretation, data must be documented in a precise fashion,” Krusenoski says. “Providers will need to be flexible in learning new documentation skills.”
Dr. Lindsey, a member of Team Hospitalist, cautions that e-measures have the potential to increase unwanted events by overutilization of pharmacologic VTE prophylaxis and associated hemorrhagic events.
“We have to continue to make sure that our practice of medicine remains based in evidence and not succumb to the pull of getting a check-box ticked,” she warns.
VTE remains a significant problem in hospitalized patients today. Hospitalists should consider the pros and cons of using newer treatment methods over traditional agents. Efforts are under way to improve VTE prophylaxis by standardizing best practice and moving from traditional chart abstracting to using e-measures for performance reporting.
Karen Appold is a freelance medical writer in Pennsylvania.
Getting the Upper Hand
Getting involved in your hospital’s venous thromboembolism (VTE) task force is a great opportunity to have your voice heard and become involved in the implementation of change in your hospital’s VTE management process. It also is a forum in which you could learn more about VTE, including appropriate prophylaxis methods for various patient populations.
Some other VTE resources:
The American College of Chest Physicians offers evidence-based practice guidelines on the management and prevention of VTE.
SHM is airing a seven-part webinar series on anticoagulation, which is free to members via the Learning/Education portal. By participating in all of the sessions, members earn 6.5 AMA PRA category 1 credit hours. “The knowledge imparted will help me to improve my practice of hospital medicine and treatment of patients requiring anticoagulants, which is the majority of our patients,” Dr. Lindsey says.
—Karen Appold
Bringing Awareness to VTE
Thromboembolisms (VTEs) are the most common cause of preventable death in the hospitalized patient. Given the adverse outcomes and economic burden associated with VTEs, it is truly a public health concern. As Dr. Kanikkannan suggests, “Why not use the month of March—VTE awareness month—as an opportunity to educate patients about healthy lifestyle practices to prevent VTE?
“Patients can learn to identify their risk factors and become aware of symptoms that may be a cause for concern, prompting them to seek medical attention,” she says.
“It might be helpful for hospitals to arrange review sessions for VTE prophylaxis for providers and staff.” —Dr. Suehler
Hospitalists could also organize or participate in community health fairs—a great venue to spread the word about VTE and create awareness among the public. Because hospitalists frequently sit on VTE task forces in hospitals and take a lead role in implementing VTE prophylaxis efforts, they are in a prime position to implement a hospital campaign during VTE awareness month.
Keeping staff abreast of advancements is also advisable.
“It might be helpful for hospitals to arrange review sessions for VTE prophylaxis for providers and staff,” says Klaus Suehler, MD, FHM, hospitalist at Mercy Hospital Allina Health in Coon Rapids, Minn., who believes that creating awareness makes a 0% failure rate on VTE prophylaxis achievable.
