Clinical

When diagnosing a patient, it can be tempting to run all types of tests to expedite the process—and protect yourself from litigation. Patients may push for more tests, too, thinking “the more the better.” But that may not be the best course of action. In fact, according to recommendations of the ABIM Foundations’ Choosing Wisely campaign, more tests can actually bring a host of negative consequences.

In an effort to help hospitalists decide which tests to perform and which to forgo, The Hospitalist asked medical societies that contributed to the Choosing Wisely campaign to tell us which one of their recommendations was the most applicable to hospitalists. Then, we asked some hospitalists to discuss how they might implement each recommendation.

1 American Gastroenterological Association (AGA)

Recommendation: For a patient with functional abdominal pain syndrome (as per Rome criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.

When a patient first complains of abdominal pain, a CT scan usually is done prior to a gastroenterological consultation. Despite this initial scan, many patients with chronic abdominal pain receive unnecessary repeated CT scans to evaluate their pain even if they have previous negative studies.

“It is important for the hospitalist to know that functional abdominal pain can be managed without additional diagnostic studies,” says John M. Inadomi, MD, head of the division of gastroenterology at the University of Washington School of Medicine in Seattle. “Some doctors are uncomfortable with the uncertainty of a diagnosis of chronic abdominal pain without evidence of biochemical or structural disease [functional abdominal pain syndrome] and fear litigation.”

An abdominal CT scan is one of the higher radiation exposure tests, equivalent to three years of natural background radiation.¹

“Due to this risk and the high costs of this procedure, CT scans should be limited to situations in which they are likely to provide useful information that changes patient management,” Dr. Inadomi says.

According to Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics at Cleveland Clinic Lerner College of Medicine of Case Western University in Cleveland, Ohio, it should not be a difficult choice for hospitalists, “as the clinical context provides a safeguard to justify the rationale for a conservative approach. Hospitalists must be educated on the appropriate use of Rome criteria, as well as how to appropriately document it in the chart to justify a decision to avoid unnecessary testing.”

2 American College of Rheumatology (ACR)

Recommendation: Don’t test anti-nuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.

“A fever of unknown origin is among the most common diagnoses the hospitalist encounters,” Dr. Auron says. “Nowadays, given the ease to order tests, as well as the increased awareness of patients with immune-mediated diseases, it may be tempting to order large panels of immunologic tests to minimize the risk of missing a diagnosis; however, because ANA has high sensitivity and poor specificity, it should only be ordered if the clinical context supports its use.”

Jinoos Yazdany, MD, MPH, assistant professor of medicine at the University of California at San Francisco and co-chair of the task force that developed the ACR’s Choosing Wisely list, points out that if you use ANAs as a broad screening test when the pretest probability of specific ANA-associated diseases is low, there is an increased chance of a false positive ANA result. This can lead to unnecessary further testing and additional costs. Furthermore, ANA sub-serologies are usually negative if the ANA (done by immunofluorescence) is negative.

“So it is recommended to order sub-serologies only once it is known that the ANA is positive,” she says. The exceptions to this are anti-SSA and anti-Jo-1 antibodies, which can sometimes be positive when the ANA is negative.

Mangla S. Gulati, MD, FACP, FHM, medical director for clinical effectiveness at the University of Maryland School of Medicine in Baltimore, says a positive ANA in conjunction with clinical information “will help to guide appropriate and cost-conscious testing. Hospitalists could implement this through a clinical decision support approach if using an electronic medical record.”

LISTEN NOW to Daniel Wolfson, MHSA, executive vice president and CEO of the ABIM Foundation, discuss how the Choosing Wisely campaign got started and its significance in U.S. healthcare.

3 American College of Physicians (ACP)

Recommendation: In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.

VTE, a common problem in hospitalized patients, has high mortality rates. “However, recent statistics suggest that we may be overdiagnosing non-clinically significant disease and exposing large numbers of patients to high doses of radiation unnecessarily in an attempt to rule out VTE disease,” says Cynthia D. Smith, MD, FACP, ACP senior medical associate for content development and adjunct associate professor of medicine at the Perelman School of Medicine in Philadelphia.

Instead, physicians should estimate pretest probability of disease using a validated risk assessment tool (i.e., Wells score). For patients with low clinical probability of VTE, hospitalists should use a negative high-sensitive D-dimer measurement as the initial diagnostic test.

Dr. Auron says the litigious environment of American medicine may trigger clinicians to order testing to minimize the risk of missing potential conditions; however, an adequate, evidence-based approach with appropriate documentation should be sufficient. In this case, that would entail using D-dimer testing to outline the low pretest probability of VTE and explaining to the patient the rationale for not pursuing further imaging.

Dr. Gulati adds that hospitalists should have little difficulty implementing this cost-effective approach.

“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan.”

—Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics, Cleveland Clinic

4 American Geriatrics Society (AGS)

Recommendation: Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

Older adults with asymptomatic bacteriuria who received antimicrobial treatment show no benefit, according to multiple studies.² In fact, increased adverse antimicrobial effects occurred, such as greater resistance patterns and super-infections (e.g. Clostridium difficile).

The truth is that as many as 30% of frail elders (particularly women) have bacterial colonization of the urinary tract without infection, also known as asymptomatic bacteriuria, says Heidi Wald, MD, MSPH, associate professor of medicine and vice chair for quality in the department of medicine at the University of Colorado School of Medicine in Aurora. Therefore, before being prescribed antimicrobials, a patient should exhibit symptoms of urinary tract infection such as fever, frequent urination, urgency to urinate, painful urination, or suprapubic tenderness.

“Without localizing symptoms, you can’t assume bacteriuria equals infection,” Dr. Wald adds. “Too often, we make the urine a scapegoat for unrelated presentations, such as mild confusion.”

If the patient is stable and doesn’t have UTI symptoms, Dr. Wald says hospitalists should consider hydration and monitor the patient without antibiotics.

“This should not be difficult to implement,” Dr. Auron says, “as hospitalists are on the front lines of antibiotic stewardship in hospitals.”

LISTEN NOW to Linda Cox, MD, owner of Allergy and Asthma Center in Ft. Lauderdale, Fla., and president of American Academy of Allergy, Asthma & Immunology, discuss why it's important for hospitalists to not diagnose or manage asthma without spirometry.

5 American Society of Echocardiography (ASE)

Recommendation: Avoid echocardiograms for pre-operative/peri-operative assessment of patients with no history or symptoms of heart disease.

Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside.

“These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt,” says James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at Cleveland Clinic and ASE past president. “Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”

If a patient has no history of heart disease, no positive physical findings, or no symptoms, then an echo probably won’t be helpful. Hospitalists need to be aware of the lack of value of a presumed normal study, Dr. Auron says.

“Having appropriate standards of care allows clinicians in pre-operative areas to use risk stratification tools in an adequate fashion,” he notes.

6 American Society of Nephrology (ASN)

Recommendation: Do not place peripherally inserted central venous catheters (PICC) in stage three to five chronic kidney disease (CKD) patients without consulting nephrology.

Given the increase in patients with CKD in the later stages, as well as end-stage renal disease, clinicians need to protect patients’ upper extremity veins in order to be able to have an adequate vascular substrate for subsequent creation of an arteriovenous fistula (AVF), Dr. Auron maintains.

PICCs, along with other central venous catheters, damage veins and destroy sites for future hemodialysis vascular access, explains Amy W. Williams, MD, medical director of hospital operations and consultant in the division of nephrology and hypertension at Mayo Clinic in Rochester, Minn. If there are no options for AVF or grafts, patients starting or being maintained on hemodialysis will need a tunneled central venous catheter for dialysis access.

Studies have shown that AVFs have better patency rates and fewer complications compared to catheters, and there is a direct correlation of increased mortality and inadequate dialysis with tunneled central catheters.³ In addition, dialysis patients with a tunneled central venous catheter have a five-fold increase of infection compared to those with an AVF.⁴ The incidence of central venous stenosis associated with PICC lines has been shown to be 42% and the incidence of thrombosis 38%.^5,6 There is no significant difference in the rate of central venous complications based on the duration of catheter use or catheter size. In addition, prior PICC use has been shown to be an independent predictor of lack of a functioning AVF (odds ratio 2.8 [95 % CI, 1.5 to 5.5]).⁷

A better choice for extended venous access in patients with advanced CKD is a tunneled internal jugular vein catheter, which is associated with a lower risk of permanent vascular damage, says Dr. Williams, who is chair of the ASN’s Quality and Patient Safety Task Force.

Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses, such as bronchiolitis and croup, remain a leading cause of admission.

—James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital at the University of Washington, Team Hospitalist member

7 The Society of Thoracic Surgeons (STS)

Recommendation: Patients who have no cardiac history and good functional status do not require pre-operative stress testing prior to non-cardiac thoracic surgery.

By eliminating routine stress testing prior to non-cardiac thoracic surgery for patients without a history of cardiac symptoms, hospitalists can reduce the burden of costs on patients and eliminate the possibility of adverse outcomes due to inappropriate testing.

“Functional status has been shown to be reliable to predict peri-operative and long-term cardiac events,” says Douglas E. Wood, MD, chief of the division of cardiothoracic surgery at the University of Washington in Seattle and president of the STS. “In highly functional asymptomatic patients, management is rarely changed by pre-operative stress testing. Furthermore, abnormalities identified in testing often require additional investigation, with negative consequences related to the risks of more procedures or tests, delays in therapies, and additional costs.”

Pre-operative stress testing should be reserved for patients with low functional capacity or clinical risk factors for cardiac complications. It is important to identify patients pre-operatively who are at risk for these complications by doing a thorough history, physical examination, and resting electrocardiogram.

8 Society of Nuclear Medicine and Molecular Imaging (SNMMI)

Recommendation: Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung (V/Q) study instead.

Hospitalists should be knowledgeable of the diagnostic options that will result in the lowest radiation exposure when evaluating young women for PE.

“When a chest radiograph is normal or nearly normal, a computed tomography angiogram or a V/Q lung scan can be used to evaluate these patients. While both exams have low radiation exposure, the V/Q lung scan results in less radiation to the breast tissue,” says society president Gary L. Dillehay, MD, FACNM, FACR, professor of radiology at Northwestern Memorial Hospital in Chicago. “Recent literature cites concerns over radiation exposure from mammography; therefore, reducing radiation exposure to breast tissue, when evaluating patients for suspected PE, is desirable.”

Hospitalists might have difficulty obtaining a V/Q lung scan when nuclear medicine departments are closed.

“The caveat is that CT scans are much more readily available,” Dr. Auron says. In addition, a CT scan provides additional information. But unless the differential diagnosis is much higher for PE than other possibilities, just having a V/Q scan should suffice.

Hospitalists could help implement protocols for chest pain evaluation in premenopausal women by having checklists for risk factors for coronary artery disease, connective tissue disease (essentially aortic dissection), and VTE (e.g. Wells and Geneva scores, use of oral contraceptives, smoking), Dr. Auron says. If the diagnostic branch supports the risk of PE, then nuclear imaging should be available.

“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan,” he says.

LISTEN NOW to Rahul Shah, MD, FACS, FAAP, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, and co-chair of the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s Patient Safety Quality Improvement Committee, explain why hospitalists should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.

9 American Academy of Pediatrics (AAP)

Recommendation: Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).

Respiratory illnesses are the most common reason for hospitalization in pediatrics. Recent studies and surveys continue to demonstrate antibiotic overuse in the pediatric population, especially when prescribed for apparent viral respiratory illnesses.^8,9

“Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses such as bronchiolitis and croup remain a leading cause of admission,” says James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics at the University of Washington School of Medicine in Seattle.

Many respiratory problems, such as bronchiolitis, asthma, and even some pneumonias are caused or exacerbated by viruses, points out Ricardo Quiñonez, MD, FAAP, FHM, section head of pediatric hospital medicine at the Children’s Hospital of San Antonio and the Baylor College of Medicine, and chair of the AAP’s section on hospital medicine. In particular, there are national guidelines for bronchiolitis and asthma that recommend against the use of systemic antibiotics.

This recommendation may be difficult for hospitalists to implement, because antibiotics are frequently started by other providers (PCP or ED), Dr. O’Callaghan admits. It can be tricky to change or stop therapy without undermining patients’ or parents’ confidence in their medical decision-making. Hospitalists may need to collaborate with new partners, such as community-wide antibiotic reduction campaigns, in order to affect this culture change.

“Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside. These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt. Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”

—James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at the Cleveland Clinic in Ohio and past president of the American Society of Echocardiography.

10 American College of Obstetricians and Gynecologists (ACOB)

Recommendation: Don’t schedule elective inductions prior to 39 weeks, and don’t schedule elective inductions of labor after 39 weeks without a favorable cervix.

Studies show an increased risk to newborns that are electively inducted between 37 and 39 weeks. Complications include increased admission to the neonatal intensive care unit, increased risk of respiratory distress and need for respiratory support, and increased incidence of infection and sepsis.

This recommendation may be difficult for hospitalists to implement, because obstetrical providers typically schedule elective inductions. Implementation of this recommendation would involve collaboration with obstetrical providers, with possible support from maternal-fetal and neonatal providers.

“Recent quality measures and initiatives from such organizations such as CMS and the National Quality Forum … may help to galvanize institutional support for its successful implementation,” says Dr. O’Callaghan, a Team Hospitalist member.

Elective surgeries should only be done in cases where there is a medical necessity, such as when the mother is diabetic or has hypertension, adds Rob Olson, MD, FACOG, an OB/GYN hospitalist for PeaceHealth at St. Joseph Medical Center in Bellingham, Wash. “Hospitalists should not give in to pressures from patients who are either tired of the discomforts of pregnancy or have family pressure to end the pregnancy early.”

Karen Appold is a freelance writer in Pennsylvania.

References

1. U.S. Food and Drug Administration. Reducing radiation from medical X-rays. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm095505.htm. Accessed May 12, 2014.
2. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654.
3. Hoggard J, Saad T, Schon D, et al. Guidelines for venous access in patients with chronic kidney disease. A position statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Semin Dial. 2008;21(2):186-191.
4. Rayner HC, Besarab A, Brown WW, Disney A, Saito A, Pisoni RL. Vascular access results from the dialysis outcomes and practice patterns study (DOPPS): Performance against kidney disease outcomes quality initiative (K/DOQI)clinical practice guidelines. Am J Kidney Dis. 2004;44(5 Suppl 2):22-26.
5. Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N, Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol. 2003;26(2):123-127.
6. Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(10):1309-1314.
7. El Ters M, Schears GJ, Taler SJ, et al. Association between prior peripherally inserted central catheters and lack of functioning ateriovenous fistulas: A case control study in hemodialysis patients. Am J Kidney Dis. 2012;60(4):601-608.
8. Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053-1061.
9. Knapp JF, Simon SD, Sharma V. Quality of care for common pediatric respiratory illnesses in United States emergency departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey data. Pediatrics. 2008;122(6):1165-1170.

When diagnosing a patient, it can be tempting to run all types of tests to expedite the process—and protect yourself from litigation. Patients may push for more tests, too, thinking “the more the better.” But that may not be the best course of action. In fact, according to recommendations of the ABIM Foundations’ Choosing Wisely campaign, more tests can actually bring a host of negative consequences.

In an effort to help hospitalists decide which tests to perform and which to forgo, The Hospitalist asked medical societies that contributed to the Choosing Wisely campaign to tell us which one of their recommendations was the most applicable to hospitalists. Then, we asked some hospitalists to discuss how they might implement each recommendation.

1 American Gastroenterological Association (AGA)

Recommendation: For a patient with functional abdominal pain syndrome (as per Rome criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.

When a patient first complains of abdominal pain, a CT scan usually is done prior to a gastroenterological consultation. Despite this initial scan, many patients with chronic abdominal pain receive unnecessary repeated CT scans to evaluate their pain even if they have previous negative studies.

“It is important for the hospitalist to know that functional abdominal pain can be managed without additional diagnostic studies,” says John M. Inadomi, MD, head of the division of gastroenterology at the University of Washington School of Medicine in Seattle. “Some doctors are uncomfortable with the uncertainty of a diagnosis of chronic abdominal pain without evidence of biochemical or structural disease [functional abdominal pain syndrome] and fear litigation.”

An abdominal CT scan is one of the higher radiation exposure tests, equivalent to three years of natural background radiation.¹

“Due to this risk and the high costs of this procedure, CT scans should be limited to situations in which they are likely to provide useful information that changes patient management,” Dr. Inadomi says.

According to Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics at Cleveland Clinic Lerner College of Medicine of Case Western University in Cleveland, Ohio, it should not be a difficult choice for hospitalists, “as the clinical context provides a safeguard to justify the rationale for a conservative approach. Hospitalists must be educated on the appropriate use of Rome criteria, as well as how to appropriately document it in the chart to justify a decision to avoid unnecessary testing.”

2 American College of Rheumatology (ACR)

Recommendation: Don’t test anti-nuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.

“A fever of unknown origin is among the most common diagnoses the hospitalist encounters,” Dr. Auron says. “Nowadays, given the ease to order tests, as well as the increased awareness of patients with immune-mediated diseases, it may be tempting to order large panels of immunologic tests to minimize the risk of missing a diagnosis; however, because ANA has high sensitivity and poor specificity, it should only be ordered if the clinical context supports its use.”

Jinoos Yazdany, MD, MPH, assistant professor of medicine at the University of California at San Francisco and co-chair of the task force that developed the ACR’s Choosing Wisely list, points out that if you use ANAs as a broad screening test when the pretest probability of specific ANA-associated diseases is low, there is an increased chance of a false positive ANA result. This can lead to unnecessary further testing and additional costs. Furthermore, ANA sub-serologies are usually negative if the ANA (done by immunofluorescence) is negative.

“So it is recommended to order sub-serologies only once it is known that the ANA is positive,” she says. The exceptions to this are anti-SSA and anti-Jo-1 antibodies, which can sometimes be positive when the ANA is negative.

Mangla S. Gulati, MD, FACP, FHM, medical director for clinical effectiveness at the University of Maryland School of Medicine in Baltimore, says a positive ANA in conjunction with clinical information “will help to guide appropriate and cost-conscious testing. Hospitalists could implement this through a clinical decision support approach if using an electronic medical record.”

LISTEN NOW to Daniel Wolfson, MHSA, executive vice president and CEO of the ABIM Foundation, discuss how the Choosing Wisely campaign got started and its significance in U.S. healthcare.

3 American College of Physicians (ACP)

Recommendation: In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.

VTE, a common problem in hospitalized patients, has high mortality rates. “However, recent statistics suggest that we may be overdiagnosing non-clinically significant disease and exposing large numbers of patients to high doses of radiation unnecessarily in an attempt to rule out VTE disease,” says Cynthia D. Smith, MD, FACP, ACP senior medical associate for content development and adjunct associate professor of medicine at the Perelman School of Medicine in Philadelphia.

Instead, physicians should estimate pretest probability of disease using a validated risk assessment tool (i.e., Wells score). For patients with low clinical probability of VTE, hospitalists should use a negative high-sensitive D-dimer measurement as the initial diagnostic test.

Dr. Auron says the litigious environment of American medicine may trigger clinicians to order testing to minimize the risk of missing potential conditions; however, an adequate, evidence-based approach with appropriate documentation should be sufficient. In this case, that would entail using D-dimer testing to outline the low pretest probability of VTE and explaining to the patient the rationale for not pursuing further imaging.

Dr. Gulati adds that hospitalists should have little difficulty implementing this cost-effective approach.

“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan.”

—Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics, Cleveland Clinic

4 American Geriatrics Society (AGS)

Recommendation: Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

Older adults with asymptomatic bacteriuria who received antimicrobial treatment show no benefit, according to multiple studies.² In fact, increased adverse antimicrobial effects occurred, such as greater resistance patterns and super-infections (e.g. Clostridium difficile).

The truth is that as many as 30% of frail elders (particularly women) have bacterial colonization of the urinary tract without infection, also known as asymptomatic bacteriuria, says Heidi Wald, MD, MSPH, associate professor of medicine and vice chair for quality in the department of medicine at the University of Colorado School of Medicine in Aurora. Therefore, before being prescribed antimicrobials, a patient should exhibit symptoms of urinary tract infection such as fever, frequent urination, urgency to urinate, painful urination, or suprapubic tenderness.

“Without localizing symptoms, you can’t assume bacteriuria equals infection,” Dr. Wald adds. “Too often, we make the urine a scapegoat for unrelated presentations, such as mild confusion.”

If the patient is stable and doesn’t have UTI symptoms, Dr. Wald says hospitalists should consider hydration and monitor the patient without antibiotics.

“This should not be difficult to implement,” Dr. Auron says, “as hospitalists are on the front lines of antibiotic stewardship in hospitals.”

LISTEN NOW to Linda Cox, MD, owner of Allergy and Asthma Center in Ft. Lauderdale, Fla., and president of American Academy of Allergy, Asthma & Immunology, discuss why it's important for hospitalists to not diagnose or manage asthma without spirometry.

5 American Society of Echocardiography (ASE)

Recommendation: Avoid echocardiograms for pre-operative/peri-operative assessment of patients with no history or symptoms of heart disease.

Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside.

“These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt,” says James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at Cleveland Clinic and ASE past president. “Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”

If a patient has no history of heart disease, no positive physical findings, or no symptoms, then an echo probably won’t be helpful. Hospitalists need to be aware of the lack of value of a presumed normal study, Dr. Auron says.

“Having appropriate standards of care allows clinicians in pre-operative areas to use risk stratification tools in an adequate fashion,” he notes.

6 American Society of Nephrology (ASN)

Recommendation: Do not place peripherally inserted central venous catheters (PICC) in stage three to five chronic kidney disease (CKD) patients without consulting nephrology.

Given the increase in patients with CKD in the later stages, as well as end-stage renal disease, clinicians need to protect patients’ upper extremity veins in order to be able to have an adequate vascular substrate for subsequent creation of an arteriovenous fistula (AVF), Dr. Auron maintains.

PICCs, along with other central venous catheters, damage veins and destroy sites for future hemodialysis vascular access, explains Amy W. Williams, MD, medical director of hospital operations and consultant in the division of nephrology and hypertension at Mayo Clinic in Rochester, Minn. If there are no options for AVF or grafts, patients starting or being maintained on hemodialysis will need a tunneled central venous catheter for dialysis access.

Studies have shown that AVFs have better patency rates and fewer complications compared to catheters, and there is a direct correlation of increased mortality and inadequate dialysis with tunneled central catheters.³ In addition, dialysis patients with a tunneled central venous catheter have a five-fold increase of infection compared to those with an AVF.⁴ The incidence of central venous stenosis associated with PICC lines has been shown to be 42% and the incidence of thrombosis 38%.^5,6 There is no significant difference in the rate of central venous complications based on the duration of catheter use or catheter size. In addition, prior PICC use has been shown to be an independent predictor of lack of a functioning AVF (odds ratio 2.8 [95 % CI, 1.5 to 5.5]).⁷

A better choice for extended venous access in patients with advanced CKD is a tunneled internal jugular vein catheter, which is associated with a lower risk of permanent vascular damage, says Dr. Williams, who is chair of the ASN’s Quality and Patient Safety Task Force.

Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses, such as bronchiolitis and croup, remain a leading cause of admission.

—James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital at the University of Washington, Team Hospitalist member

7 The Society of Thoracic Surgeons (STS)

Recommendation: Patients who have no cardiac history and good functional status do not require pre-operative stress testing prior to non-cardiac thoracic surgery.

By eliminating routine stress testing prior to non-cardiac thoracic surgery for patients without a history of cardiac symptoms, hospitalists can reduce the burden of costs on patients and eliminate the possibility of adverse outcomes due to inappropriate testing.

“Functional status has been shown to be reliable to predict peri-operative and long-term cardiac events,” says Douglas E. Wood, MD, chief of the division of cardiothoracic surgery at the University of Washington in Seattle and president of the STS. “In highly functional asymptomatic patients, management is rarely changed by pre-operative stress testing. Furthermore, abnormalities identified in testing often require additional investigation, with negative consequences related to the risks of more procedures or tests, delays in therapies, and additional costs.”

Pre-operative stress testing should be reserved for patients with low functional capacity or clinical risk factors for cardiac complications. It is important to identify patients pre-operatively who are at risk for these complications by doing a thorough history, physical examination, and resting electrocardiogram.

8 Society of Nuclear Medicine and Molecular Imaging (SNMMI)

Recommendation: Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung (V/Q) study instead.

Hospitalists should be knowledgeable of the diagnostic options that will result in the lowest radiation exposure when evaluating young women for PE.

“When a chest radiograph is normal or nearly normal, a computed tomography angiogram or a V/Q lung scan can be used to evaluate these patients. While both exams have low radiation exposure, the V/Q lung scan results in less radiation to the breast tissue,” says society president Gary L. Dillehay, MD, FACNM, FACR, professor of radiology at Northwestern Memorial Hospital in Chicago. “Recent literature cites concerns over radiation exposure from mammography; therefore, reducing radiation exposure to breast tissue, when evaluating patients for suspected PE, is desirable.”

Hospitalists might have difficulty obtaining a V/Q lung scan when nuclear medicine departments are closed.

“The caveat is that CT scans are much more readily available,” Dr. Auron says. In addition, a CT scan provides additional information. But unless the differential diagnosis is much higher for PE than other possibilities, just having a V/Q scan should suffice.

Hospitalists could help implement protocols for chest pain evaluation in premenopausal women by having checklists for risk factors for coronary artery disease, connective tissue disease (essentially aortic dissection), and VTE (e.g. Wells and Geneva scores, use of oral contraceptives, smoking), Dr. Auron says. If the diagnostic branch supports the risk of PE, then nuclear imaging should be available.

“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan,” he says.

LISTEN NOW to Rahul Shah, MD, FACS, FAAP, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, and co-chair of the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s Patient Safety Quality Improvement Committee, explain why hospitalists should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.

9 American Academy of Pediatrics (AAP)

Recommendation: Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).

Respiratory illnesses are the most common reason for hospitalization in pediatrics. Recent studies and surveys continue to demonstrate antibiotic overuse in the pediatric population, especially when prescribed for apparent viral respiratory illnesses.^8,9

“Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses such as bronchiolitis and croup remain a leading cause of admission,” says James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics at the University of Washington School of Medicine in Seattle.

Many respiratory problems, such as bronchiolitis, asthma, and even some pneumonias are caused or exacerbated by viruses, points out Ricardo Quiñonez, MD, FAAP, FHM, section head of pediatric hospital medicine at the Children’s Hospital of San Antonio and the Baylor College of Medicine, and chair of the AAP’s section on hospital medicine. In particular, there are national guidelines for bronchiolitis and asthma that recommend against the use of systemic antibiotics.

This recommendation may be difficult for hospitalists to implement, because antibiotics are frequently started by other providers (PCP or ED), Dr. O’Callaghan admits. It can be tricky to change or stop therapy without undermining patients’ or parents’ confidence in their medical decision-making. Hospitalists may need to collaborate with new partners, such as community-wide antibiotic reduction campaigns, in order to affect this culture change.

“Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside. These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt. Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”

—James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at the Cleveland Clinic in Ohio and past president of the American Society of Echocardiography.

10 American College of Obstetricians and Gynecologists (ACOB)

Recommendation: Don’t schedule elective inductions prior to 39 weeks, and don’t schedule elective inductions of labor after 39 weeks without a favorable cervix.

Studies show an increased risk to newborns that are electively inducted between 37 and 39 weeks. Complications include increased admission to the neonatal intensive care unit, increased risk of respiratory distress and need for respiratory support, and increased incidence of infection and sepsis.

This recommendation may be difficult for hospitalists to implement, because obstetrical providers typically schedule elective inductions. Implementation of this recommendation would involve collaboration with obstetrical providers, with possible support from maternal-fetal and neonatal providers.

“Recent quality measures and initiatives from such organizations such as CMS and the National Quality Forum … may help to galvanize institutional support for its successful implementation,” says Dr. O’Callaghan, a Team Hospitalist member.

Elective surgeries should only be done in cases where there is a medical necessity, such as when the mother is diabetic or has hypertension, adds Rob Olson, MD, FACOG, an OB/GYN hospitalist for PeaceHealth at St. Joseph Medical Center in Bellingham, Wash. “Hospitalists should not give in to pressures from patients who are either tired of the discomforts of pregnancy or have family pressure to end the pregnancy early.”

Karen Appold is a freelance writer in Pennsylvania.

References

1. U.S. Food and Drug Administration. Reducing radiation from medical X-rays. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm095505.htm. Accessed May 12, 2014.
2. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654.
3. Hoggard J, Saad T, Schon D, et al. Guidelines for venous access in patients with chronic kidney disease. A position statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Semin Dial. 2008;21(2):186-191.
4. Rayner HC, Besarab A, Brown WW, Disney A, Saito A, Pisoni RL. Vascular access results from the dialysis outcomes and practice patterns study (DOPPS): Performance against kidney disease outcomes quality initiative (K/DOQI)clinical practice guidelines. Am J Kidney Dis. 2004;44(5 Suppl 2):22-26.
5. Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N, Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol. 2003;26(2):123-127.
6. Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(10):1309-1314.
7. El Ters M, Schears GJ, Taler SJ, et al. Association between prior peripherally inserted central catheters and lack of functioning ateriovenous fistulas: A case control study in hemodialysis patients. Am J Kidney Dis. 2012;60(4):601-608.
8. Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053-1061.
9. Knapp JF, Simon SD, Sharma V. Quality of care for common pediatric respiratory illnesses in United States emergency departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey data. Pediatrics. 2008;122(6):1165-1170.

When diagnosing a patient, it can be tempting to run all types of tests to expedite the process—and protect yourself from litigation. Patients may push for more tests, too, thinking “the more the better.” But that may not be the best course of action. In fact, according to recommendations of the ABIM Foundations’ Choosing Wisely campaign, more tests can actually bring a host of negative consequences.

In an effort to help hospitalists decide which tests to perform and which to forgo, The Hospitalist asked medical societies that contributed to the Choosing Wisely campaign to tell us which one of their recommendations was the most applicable to hospitalists. Then, we asked some hospitalists to discuss how they might implement each recommendation.

1 American Gastroenterological Association (AGA)

Recommendation: For a patient with functional abdominal pain syndrome (as per Rome criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.

When a patient first complains of abdominal pain, a CT scan usually is done prior to a gastroenterological consultation. Despite this initial scan, many patients with chronic abdominal pain receive unnecessary repeated CT scans to evaluate their pain even if they have previous negative studies.

“It is important for the hospitalist to know that functional abdominal pain can be managed without additional diagnostic studies,” says John M. Inadomi, MD, head of the division of gastroenterology at the University of Washington School of Medicine in Seattle. “Some doctors are uncomfortable with the uncertainty of a diagnosis of chronic abdominal pain without evidence of biochemical or structural disease [functional abdominal pain syndrome] and fear litigation.”

An abdominal CT scan is one of the higher radiation exposure tests, equivalent to three years of natural background radiation.¹

“Due to this risk and the high costs of this procedure, CT scans should be limited to situations in which they are likely to provide useful information that changes patient management,” Dr. Inadomi says.

According to Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics at Cleveland Clinic Lerner College of Medicine of Case Western University in Cleveland, Ohio, it should not be a difficult choice for hospitalists, “as the clinical context provides a safeguard to justify the rationale for a conservative approach. Hospitalists must be educated on the appropriate use of Rome criteria, as well as how to appropriately document it in the chart to justify a decision to avoid unnecessary testing.”

2 American College of Rheumatology (ACR)

Recommendation: Don’t test anti-nuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.

“A fever of unknown origin is among the most common diagnoses the hospitalist encounters,” Dr. Auron says. “Nowadays, given the ease to order tests, as well as the increased awareness of patients with immune-mediated diseases, it may be tempting to order large panels of immunologic tests to minimize the risk of missing a diagnosis; however, because ANA has high sensitivity and poor specificity, it should only be ordered if the clinical context supports its use.”

Jinoos Yazdany, MD, MPH, assistant professor of medicine at the University of California at San Francisco and co-chair of the task force that developed the ACR’s Choosing Wisely list, points out that if you use ANAs as a broad screening test when the pretest probability of specific ANA-associated diseases is low, there is an increased chance of a false positive ANA result. This can lead to unnecessary further testing and additional costs. Furthermore, ANA sub-serologies are usually negative if the ANA (done by immunofluorescence) is negative.

“So it is recommended to order sub-serologies only once it is known that the ANA is positive,” she says. The exceptions to this are anti-SSA and anti-Jo-1 antibodies, which can sometimes be positive when the ANA is negative.

Mangla S. Gulati, MD, FACP, FHM, medical director for clinical effectiveness at the University of Maryland School of Medicine in Baltimore, says a positive ANA in conjunction with clinical information “will help to guide appropriate and cost-conscious testing. Hospitalists could implement this through a clinical decision support approach if using an electronic medical record.”

LISTEN NOW to Daniel Wolfson, MHSA, executive vice president and CEO of the ABIM Foundation, discuss how the Choosing Wisely campaign got started and its significance in U.S. healthcare.

3 American College of Physicians (ACP)

Recommendation: In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.

VTE, a common problem in hospitalized patients, has high mortality rates. “However, recent statistics suggest that we may be overdiagnosing non-clinically significant disease and exposing large numbers of patients to high doses of radiation unnecessarily in an attempt to rule out VTE disease,” says Cynthia D. Smith, MD, FACP, ACP senior medical associate for content development and adjunct associate professor of medicine at the Perelman School of Medicine in Philadelphia.

Instead, physicians should estimate pretest probability of disease using a validated risk assessment tool (i.e., Wells score). For patients with low clinical probability of VTE, hospitalists should use a negative high-sensitive D-dimer measurement as the initial diagnostic test.

Dr. Auron says the litigious environment of American medicine may trigger clinicians to order testing to minimize the risk of missing potential conditions; however, an adequate, evidence-based approach with appropriate documentation should be sufficient. In this case, that would entail using D-dimer testing to outline the low pretest probability of VTE and explaining to the patient the rationale for not pursuing further imaging.

Dr. Gulati adds that hospitalists should have little difficulty implementing this cost-effective approach.

“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan.”

—Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics, Cleveland Clinic

4 American Geriatrics Society (AGS)

Recommendation: Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

Older adults with asymptomatic bacteriuria who received antimicrobial treatment show no benefit, according to multiple studies.² In fact, increased adverse antimicrobial effects occurred, such as greater resistance patterns and super-infections (e.g. Clostridium difficile).

The truth is that as many as 30% of frail elders (particularly women) have bacterial colonization of the urinary tract without infection, also known as asymptomatic bacteriuria, says Heidi Wald, MD, MSPH, associate professor of medicine and vice chair for quality in the department of medicine at the University of Colorado School of Medicine in Aurora. Therefore, before being prescribed antimicrobials, a patient should exhibit symptoms of urinary tract infection such as fever, frequent urination, urgency to urinate, painful urination, or suprapubic tenderness.

“Without localizing symptoms, you can’t assume bacteriuria equals infection,” Dr. Wald adds. “Too often, we make the urine a scapegoat for unrelated presentations, such as mild confusion.”

If the patient is stable and doesn’t have UTI symptoms, Dr. Wald says hospitalists should consider hydration and monitor the patient without antibiotics.

“This should not be difficult to implement,” Dr. Auron says, “as hospitalists are on the front lines of antibiotic stewardship in hospitals.”

LISTEN NOW to Linda Cox, MD, owner of Allergy and Asthma Center in Ft. Lauderdale, Fla., and president of American Academy of Allergy, Asthma & Immunology, discuss why it's important for hospitalists to not diagnose or manage asthma without spirometry.

5 American Society of Echocardiography (ASE)

Recommendation: Avoid echocardiograms for pre-operative/peri-operative assessment of patients with no history or symptoms of heart disease.

Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside.

“These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt,” says James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at Cleveland Clinic and ASE past president. “Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”

If a patient has no history of heart disease, no positive physical findings, or no symptoms, then an echo probably won’t be helpful. Hospitalists need to be aware of the lack of value of a presumed normal study, Dr. Auron says.

“Having appropriate standards of care allows clinicians in pre-operative areas to use risk stratification tools in an adequate fashion,” he notes.

6 American Society of Nephrology (ASN)

Recommendation: Do not place peripherally inserted central venous catheters (PICC) in stage three to five chronic kidney disease (CKD) patients without consulting nephrology.

Given the increase in patients with CKD in the later stages, as well as end-stage renal disease, clinicians need to protect patients’ upper extremity veins in order to be able to have an adequate vascular substrate for subsequent creation of an arteriovenous fistula (AVF), Dr. Auron maintains.

PICCs, along with other central venous catheters, damage veins and destroy sites for future hemodialysis vascular access, explains Amy W. Williams, MD, medical director of hospital operations and consultant in the division of nephrology and hypertension at Mayo Clinic in Rochester, Minn. If there are no options for AVF or grafts, patients starting or being maintained on hemodialysis will need a tunneled central venous catheter for dialysis access.

Studies have shown that AVFs have better patency rates and fewer complications compared to catheters, and there is a direct correlation of increased mortality and inadequate dialysis with tunneled central catheters.³ In addition, dialysis patients with a tunneled central venous catheter have a five-fold increase of infection compared to those with an AVF.⁴ The incidence of central venous stenosis associated with PICC lines has been shown to be 42% and the incidence of thrombosis 38%.^5,6 There is no significant difference in the rate of central venous complications based on the duration of catheter use or catheter size. In addition, prior PICC use has been shown to be an independent predictor of lack of a functioning AVF (odds ratio 2.8 [95 % CI, 1.5 to 5.5]).⁷

A better choice for extended venous access in patients with advanced CKD is a tunneled internal jugular vein catheter, which is associated with a lower risk of permanent vascular damage, says Dr. Williams, who is chair of the ASN’s Quality and Patient Safety Task Force.

Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses, such as bronchiolitis and croup, remain a leading cause of admission.

—James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital at the University of Washington, Team Hospitalist member

7 The Society of Thoracic Surgeons (STS)

Recommendation: Patients who have no cardiac history and good functional status do not require pre-operative stress testing prior to non-cardiac thoracic surgery.

By eliminating routine stress testing prior to non-cardiac thoracic surgery for patients without a history of cardiac symptoms, hospitalists can reduce the burden of costs on patients and eliminate the possibility of adverse outcomes due to inappropriate testing.

“Functional status has been shown to be reliable to predict peri-operative and long-term cardiac events,” says Douglas E. Wood, MD, chief of the division of cardiothoracic surgery at the University of Washington in Seattle and president of the STS. “In highly functional asymptomatic patients, management is rarely changed by pre-operative stress testing. Furthermore, abnormalities identified in testing often require additional investigation, with negative consequences related to the risks of more procedures or tests, delays in therapies, and additional costs.”

Pre-operative stress testing should be reserved for patients with low functional capacity or clinical risk factors for cardiac complications. It is important to identify patients pre-operatively who are at risk for these complications by doing a thorough history, physical examination, and resting electrocardiogram.

8 Society of Nuclear Medicine and Molecular Imaging (SNMMI)

Recommendation: Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung (V/Q) study instead.

Hospitalists should be knowledgeable of the diagnostic options that will result in the lowest radiation exposure when evaluating young women for PE.

“When a chest radiograph is normal or nearly normal, a computed tomography angiogram or a V/Q lung scan can be used to evaluate these patients. While both exams have low radiation exposure, the V/Q lung scan results in less radiation to the breast tissue,” says society president Gary L. Dillehay, MD, FACNM, FACR, professor of radiology at Northwestern Memorial Hospital in Chicago. “Recent literature cites concerns over radiation exposure from mammography; therefore, reducing radiation exposure to breast tissue, when evaluating patients for suspected PE, is desirable.”

Hospitalists might have difficulty obtaining a V/Q lung scan when nuclear medicine departments are closed.

“The caveat is that CT scans are much more readily available,” Dr. Auron says. In addition, a CT scan provides additional information. But unless the differential diagnosis is much higher for PE than other possibilities, just having a V/Q scan should suffice.

Hospitalists could help implement protocols for chest pain evaluation in premenopausal women by having checklists for risk factors for coronary artery disease, connective tissue disease (essentially aortic dissection), and VTE (e.g. Wells and Geneva scores, use of oral contraceptives, smoking), Dr. Auron says. If the diagnostic branch supports the risk of PE, then nuclear imaging should be available.

“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan,” he says.

LISTEN NOW to Rahul Shah, MD, FACS, FAAP, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, and co-chair of the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s Patient Safety Quality Improvement Committee, explain why hospitalists should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.

9 American Academy of Pediatrics (AAP)

Recommendation: Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).

Respiratory illnesses are the most common reason for hospitalization in pediatrics. Recent studies and surveys continue to demonstrate antibiotic overuse in the pediatric population, especially when prescribed for apparent viral respiratory illnesses.^8,9

“Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses such as bronchiolitis and croup remain a leading cause of admission,” says James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics at the University of Washington School of Medicine in Seattle.

Many respiratory problems, such as bronchiolitis, asthma, and even some pneumonias are caused or exacerbated by viruses, points out Ricardo Quiñonez, MD, FAAP, FHM, section head of pediatric hospital medicine at the Children’s Hospital of San Antonio and the Baylor College of Medicine, and chair of the AAP’s section on hospital medicine. In particular, there are national guidelines for bronchiolitis and asthma that recommend against the use of systemic antibiotics.

This recommendation may be difficult for hospitalists to implement, because antibiotics are frequently started by other providers (PCP or ED), Dr. O’Callaghan admits. It can be tricky to change or stop therapy without undermining patients’ or parents’ confidence in their medical decision-making. Hospitalists may need to collaborate with new partners, such as community-wide antibiotic reduction campaigns, in order to affect this culture change.

“Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside. These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt. Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”

—James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at the Cleveland Clinic in Ohio and past president of the American Society of Echocardiography.

10 American College of Obstetricians and Gynecologists (ACOB)

Recommendation: Don’t schedule elective inductions prior to 39 weeks, and don’t schedule elective inductions of labor after 39 weeks without a favorable cervix.

Studies show an increased risk to newborns that are electively inducted between 37 and 39 weeks. Complications include increased admission to the neonatal intensive care unit, increased risk of respiratory distress and need for respiratory support, and increased incidence of infection and sepsis.

This recommendation may be difficult for hospitalists to implement, because obstetrical providers typically schedule elective inductions. Implementation of this recommendation would involve collaboration with obstetrical providers, with possible support from maternal-fetal and neonatal providers.

“Recent quality measures and initiatives from such organizations such as CMS and the National Quality Forum … may help to galvanize institutional support for its successful implementation,” says Dr. O’Callaghan, a Team Hospitalist member.

Elective surgeries should only be done in cases where there is a medical necessity, such as when the mother is diabetic or has hypertension, adds Rob Olson, MD, FACOG, an OB/GYN hospitalist for PeaceHealth at St. Joseph Medical Center in Bellingham, Wash. “Hospitalists should not give in to pressures from patients who are either tired of the discomforts of pregnancy or have family pressure to end the pregnancy early.”

Karen Appold is a freelance writer in Pennsylvania.

References

1. U.S. Food and Drug Administration. Reducing radiation from medical X-rays. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm095505.htm. Accessed May 12, 2014.
2. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654.
3. Hoggard J, Saad T, Schon D, et al. Guidelines for venous access in patients with chronic kidney disease. A position statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Semin Dial. 2008;21(2):186-191.
4. Rayner HC, Besarab A, Brown WW, Disney A, Saito A, Pisoni RL. Vascular access results from the dialysis outcomes and practice patterns study (DOPPS): Performance against kidney disease outcomes quality initiative (K/DOQI)clinical practice guidelines. Am J Kidney Dis. 2004;44(5 Suppl 2):22-26.
5. Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N, Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol. 2003;26(2):123-127.
6. Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(10):1309-1314.
7. El Ters M, Schears GJ, Taler SJ, et al. Association between prior peripherally inserted central catheters and lack of functioning ateriovenous fistulas: A case control study in hemodialysis patients. Am J Kidney Dis. 2012;60(4):601-608.
8. Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053-1061.
9. Knapp JF, Simon SD, Sharma V. Quality of care for common pediatric respiratory illnesses in United States emergency departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey data. Pediatrics. 2008;122(6):1165-1170.

Listen to Dr. Cox, owner of Allergy and Asthma Center in Ft. Lauderdale, Fla., discuss why it's important for hospitalists to avoid diagnosing or managing asthma without spirometry.

Click here to listen to Dr. Shah, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, tell hospitalists why they should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.

Listen to Dr. Cox, owner of Allergy and Asthma Center in Ft. Lauderdale, Fla., discuss why it's important for hospitalists to avoid diagnosing or managing asthma without spirometry.

Click here to listen to Dr. Shah, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, tell hospitalists why they should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.

Listen to Dr. Cox, owner of Allergy and Asthma Center in Ft. Lauderdale, Fla., discuss why it's important for hospitalists to avoid diagnosing or managing asthma without spirometry.

Click here to listen to Dr. Shah, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, tell hospitalists why they should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.

It has been a couple of years since Jason Stein, MD, SFHM, a hospitalist at Emory University School of Medicine in Atlanta, first reported on his experience with accountable care units (ACUs) and structured interdisciplinary bedside rounds (SIBR). With ACUs, Jason and his team undertook an “extreme makeover” of care on the hospital ward. Because most hospitalist groups are endeavoring to address team-based care, I took the opportunity to catch up with and learn from Jason, who has created an exciting and compelling approach to multidisciplinary, collaborative care in the hospital.

In 2012, Jason’s team won SHM’s Excellence in Teamwork in Quality Improvement Award, and Jason was selected as an innovation advisor to the Center for Medicare and Medicaid Innovation. Since then, ACUs and SIBR have been implemented at a number of sites in the U.S. and abroad, and the work has been referenced by the Agency for Healthcare Research and Quality and the Harvard Business Review. Jason has created Centripital, a nonprofit that trains members of the hospital team to collaborate optimally around the patient and family, the central focus of care.

Here are some excerpts from my interview with Jason:

Question: What is an accountable care unit (ACU)?

Answer: We defined an ACU as a geographic inpatient care area consistently responsible for the clinical, service, and cost outcomes it produces. There are four essential design features of ACUs: 1) unit-based physician teams; 2) structured interdisciplinary bedside rounds, or SIBR; 3) unit-level performance reports; and 4) unit co-management by nurse and physician directors.

Q: What were you observing in the care of the hospitalized patient that led you to create ACUs?

A: We saw fragmentation. We saw weak cohesiveness and poor communication among doctors, nurses, and allied health professionals. HM physicians who travel all over the hospital seeing patients are living with an illusion of teamwork. In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.

Q: What makes an ACU successful?

A: In a word, control. An ACU creates new control levers for all of the key players to have greater influence on other members of the team—nurses with doctors, doctors with nurses, patients with everyone, and vice versa. It’s actually quite simple how this happens. The ACU clinical team spends the day together, caring for the same group of patients. Everyone communicates face to face, rather than by page, text, or phone. Stronger relationships are built, and clinicians are more respectful of one another. A different level of responsiveness and accountability is created. The feeling that every person is accountable to the patient and to the other team members allows the team to gain greater control over what happens on the unit. That’s a very powerful dynamic.

SIBR further reinforces the mutual accountability on an ACU. During SIBR, each person has a chance to hear and be heard, to share their perspective, and to contribute to the care plan. Day after day, SIBR creates a positive, collaborative culture of patient care. Once clinicians realize how much control and how much self-actualization they gain on an ACU, it seems impossible to go back to the old way.

“In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.”

—Jason Stein, MD, SFHM

Q: What is the biggest challenge in implementing and sustaining an ACU?

A: The first challenge, of course, is that this is change. And up front—before they realize they will actually gain greater control from the ACU-SIBR model—nurses and, particularly, doctors can perceive this change as a loss of control. “You’re telling me I have to SIBR every morning? At what time? And I have to do all my primary data gathering, including a patient interview and physical exam, before SIBR? Let me stop you right there. I’m way too busy for that.”

Naturally, not everyone immediately sees that they can gain rather than lose efficiency.

Another challenge is the logistics of implementing and then maintaining unit-based physician teams. There are multiple forces that can make geographic units a challenge to create and sustain, but all the logistics are manageable.

Q: How have you helped hospitals transition from a physician-centric model to the geographic-based model?

A: The most important factor in transitioning to an ACU model is for physicians to come to terms with the reality that geography must be the primary driver of physician assignments to patients. Nurses figured this out a long time ago. Do any of us know, bedside nurses who care for patients on multiple different units? As physicians, we’re due for the same realization.

But this means sacrificing long-practiced physician-centric methods of assigning ourselves to patients: call schedules, load balancing across practice partners—even the cherished concept of continuity is a force that can be at odds with geography as the driver. The way to approach the transition to unit-based teams is to have an honest dialogue. Why do we come to work in the hospital every day? If it’s to serve physician needs first, the old model deserves our loyalty. But if the needs of our patients and families are our focus, then we should embrace models that enable us to work effectively together, to become a great team.

Q: How have ACUs performed so far?

A: In the highest-acuity ACUs, we’ve seen mortality reductions of nearly 50%. In addition, there is a wide range of anecdotal outcomes reported. Most ACUs appear to be seeing reductions in length of stay and improvements in patient satisfaction and employee engagement. One ACU reports significant reductions in average cost per patient per day. Another ACU in a geriatric unit has seen dramatic reductions in falls. Some ACUs have seen improvements in glycemic control and VTE prophylaxis, and reductions in catheter utilization.

The benefits of the model seem to be many and probably depend on the patient population, severity of illness, baseline level of performance, and the focus and ability of the unit leadership team to get the most out of the model.

Q: Will ACUs or ACU features become de rigueur in a transformed healthcare landscape?

A: It’s hard to imagine a reality where features of ACUs do not become the standard of care. Once patients and professionals experience the impact of the ACU model, there’ll be no going back. It feels like exactly what we should be doing together. Several ACU design features are reinforced pretty cogently by Richard Bohmer in a New England Journal of Medicine perspective called “The Four Habits of High-Value Health Care Organizations.”¹

Q: Any final thoughts?

A: I did not imagine my career as a QI practitioner at Emory becoming so immersed in social and industrial engineering. Of course, it’s obvious to me now that it’s happened, but six years ago when I first started directing SHM’s quality course, I thought the future in HM was health IT and real-time dashboards. Now I know those things will be important, but only if we first figure out how to get our frontline interdisciplinary clinicians to work as an effective team.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

Reference

1. Bohmer RM. The four habits of high-value health care organizations. New Engl J Med. 2011;365(22):2045-2047.

It has been a couple of years since Jason Stein, MD, SFHM, a hospitalist at Emory University School of Medicine in Atlanta, first reported on his experience with accountable care units (ACUs) and structured interdisciplinary bedside rounds (SIBR). With ACUs, Jason and his team undertook an “extreme makeover” of care on the hospital ward. Because most hospitalist groups are endeavoring to address team-based care, I took the opportunity to catch up with and learn from Jason, who has created an exciting and compelling approach to multidisciplinary, collaborative care in the hospital.

In 2012, Jason’s team won SHM’s Excellence in Teamwork in Quality Improvement Award, and Jason was selected as an innovation advisor to the Center for Medicare and Medicaid Innovation. Since then, ACUs and SIBR have been implemented at a number of sites in the U.S. and abroad, and the work has been referenced by the Agency for Healthcare Research and Quality and the Harvard Business Review. Jason has created Centripital, a nonprofit that trains members of the hospital team to collaborate optimally around the patient and family, the central focus of care.

Here are some excerpts from my interview with Jason:

Question: What is an accountable care unit (ACU)?

Answer: We defined an ACU as a geographic inpatient care area consistently responsible for the clinical, service, and cost outcomes it produces. There are four essential design features of ACUs: 1) unit-based physician teams; 2) structured interdisciplinary bedside rounds, or SIBR; 3) unit-level performance reports; and 4) unit co-management by nurse and physician directors.

Q: What were you observing in the care of the hospitalized patient that led you to create ACUs?

A: We saw fragmentation. We saw weak cohesiveness and poor communication among doctors, nurses, and allied health professionals. HM physicians who travel all over the hospital seeing patients are living with an illusion of teamwork. In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.

Q: What makes an ACU successful?

A: In a word, control. An ACU creates new control levers for all of the key players to have greater influence on other members of the team—nurses with doctors, doctors with nurses, patients with everyone, and vice versa. It’s actually quite simple how this happens. The ACU clinical team spends the day together, caring for the same group of patients. Everyone communicates face to face, rather than by page, text, or phone. Stronger relationships are built, and clinicians are more respectful of one another. A different level of responsiveness and accountability is created. The feeling that every person is accountable to the patient and to the other team members allows the team to gain greater control over what happens on the unit. That’s a very powerful dynamic.

SIBR further reinforces the mutual accountability on an ACU. During SIBR, each person has a chance to hear and be heard, to share their perspective, and to contribute to the care plan. Day after day, SIBR creates a positive, collaborative culture of patient care. Once clinicians realize how much control and how much self-actualization they gain on an ACU, it seems impossible to go back to the old way.

“In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.”

—Jason Stein, MD, SFHM

Q: What is the biggest challenge in implementing and sustaining an ACU?

A: The first challenge, of course, is that this is change. And up front—before they realize they will actually gain greater control from the ACU-SIBR model—nurses and, particularly, doctors can perceive this change as a loss of control. “You’re telling me I have to SIBR every morning? At what time? And I have to do all my primary data gathering, including a patient interview and physical exam, before SIBR? Let me stop you right there. I’m way too busy for that.”

Naturally, not everyone immediately sees that they can gain rather than lose efficiency.

Another challenge is the logistics of implementing and then maintaining unit-based physician teams. There are multiple forces that can make geographic units a challenge to create and sustain, but all the logistics are manageable.

Q: How have you helped hospitals transition from a physician-centric model to the geographic-based model?

A: The most important factor in transitioning to an ACU model is for physicians to come to terms with the reality that geography must be the primary driver of physician assignments to patients. Nurses figured this out a long time ago. Do any of us know, bedside nurses who care for patients on multiple different units? As physicians, we’re due for the same realization.

But this means sacrificing long-practiced physician-centric methods of assigning ourselves to patients: call schedules, load balancing across practice partners—even the cherished concept of continuity is a force that can be at odds with geography as the driver. The way to approach the transition to unit-based teams is to have an honest dialogue. Why do we come to work in the hospital every day? If it’s to serve physician needs first, the old model deserves our loyalty. But if the needs of our patients and families are our focus, then we should embrace models that enable us to work effectively together, to become a great team.

Q: How have ACUs performed so far?

A: In the highest-acuity ACUs, we’ve seen mortality reductions of nearly 50%. In addition, there is a wide range of anecdotal outcomes reported. Most ACUs appear to be seeing reductions in length of stay and improvements in patient satisfaction and employee engagement. One ACU reports significant reductions in average cost per patient per day. Another ACU in a geriatric unit has seen dramatic reductions in falls. Some ACUs have seen improvements in glycemic control and VTE prophylaxis, and reductions in catheter utilization.

The benefits of the model seem to be many and probably depend on the patient population, severity of illness, baseline level of performance, and the focus and ability of the unit leadership team to get the most out of the model.

Q: Will ACUs or ACU features become de rigueur in a transformed healthcare landscape?

A: It’s hard to imagine a reality where features of ACUs do not become the standard of care. Once patients and professionals experience the impact of the ACU model, there’ll be no going back. It feels like exactly what we should be doing together. Several ACU design features are reinforced pretty cogently by Richard Bohmer in a New England Journal of Medicine perspective called “The Four Habits of High-Value Health Care Organizations.”¹

Q: Any final thoughts?

A: I did not imagine my career as a QI practitioner at Emory becoming so immersed in social and industrial engineering. Of course, it’s obvious to me now that it’s happened, but six years ago when I first started directing SHM’s quality course, I thought the future in HM was health IT and real-time dashboards. Now I know those things will be important, but only if we first figure out how to get our frontline interdisciplinary clinicians to work as an effective team.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

Reference

1. Bohmer RM. The four habits of high-value health care organizations. New Engl J Med. 2011;365(22):2045-2047.

It has been a couple of years since Jason Stein, MD, SFHM, a hospitalist at Emory University School of Medicine in Atlanta, first reported on his experience with accountable care units (ACUs) and structured interdisciplinary bedside rounds (SIBR). With ACUs, Jason and his team undertook an “extreme makeover” of care on the hospital ward. Because most hospitalist groups are endeavoring to address team-based care, I took the opportunity to catch up with and learn from Jason, who has created an exciting and compelling approach to multidisciplinary, collaborative care in the hospital.

In 2012, Jason’s team won SHM’s Excellence in Teamwork in Quality Improvement Award, and Jason was selected as an innovation advisor to the Center for Medicare and Medicaid Innovation. Since then, ACUs and SIBR have been implemented at a number of sites in the U.S. and abroad, and the work has been referenced by the Agency for Healthcare Research and Quality and the Harvard Business Review. Jason has created Centripital, a nonprofit that trains members of the hospital team to collaborate optimally around the patient and family, the central focus of care.

Here are some excerpts from my interview with Jason:

Question: What is an accountable care unit (ACU)?

Answer: We defined an ACU as a geographic inpatient care area consistently responsible for the clinical, service, and cost outcomes it produces. There are four essential design features of ACUs: 1) unit-based physician teams; 2) structured interdisciplinary bedside rounds, or SIBR; 3) unit-level performance reports; and 4) unit co-management by nurse and physician directors.

Q: What were you observing in the care of the hospitalized patient that led you to create ACUs?

A: We saw fragmentation. We saw weak cohesiveness and poor communication among doctors, nurses, and allied health professionals. HM physicians who travel all over the hospital seeing patients are living with an illusion of teamwork. In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.

Q: What makes an ACU successful?

A: In a word, control. An ACU creates new control levers for all of the key players to have greater influence on other members of the team—nurses with doctors, doctors with nurses, patients with everyone, and vice versa. It’s actually quite simple how this happens. The ACU clinical team spends the day together, caring for the same group of patients. Everyone communicates face to face, rather than by page, text, or phone. Stronger relationships are built, and clinicians are more respectful of one another. A different level of responsiveness and accountability is created. The feeling that every person is accountable to the patient and to the other team members allows the team to gain greater control over what happens on the unit. That’s a very powerful dynamic.

SIBR further reinforces the mutual accountability on an ACU. During SIBR, each person has a chance to hear and be heard, to share their perspective, and to contribute to the care plan. Day after day, SIBR creates a positive, collaborative culture of patient care. Once clinicians realize how much control and how much self-actualization they gain on an ACU, it seems impossible to go back to the old way.

“In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.”

—Jason Stein, MD, SFHM

Q: What is the biggest challenge in implementing and sustaining an ACU?

A: The first challenge, of course, is that this is change. And up front—before they realize they will actually gain greater control from the ACU-SIBR model—nurses and, particularly, doctors can perceive this change as a loss of control. “You’re telling me I have to SIBR every morning? At what time? And I have to do all my primary data gathering, including a patient interview and physical exam, before SIBR? Let me stop you right there. I’m way too busy for that.”

Naturally, not everyone immediately sees that they can gain rather than lose efficiency.

Another challenge is the logistics of implementing and then maintaining unit-based physician teams. There are multiple forces that can make geographic units a challenge to create and sustain, but all the logistics are manageable.

Q: How have you helped hospitals transition from a physician-centric model to the geographic-based model?

A: The most important factor in transitioning to an ACU model is for physicians to come to terms with the reality that geography must be the primary driver of physician assignments to patients. Nurses figured this out a long time ago. Do any of us know, bedside nurses who care for patients on multiple different units? As physicians, we’re due for the same realization.

But this means sacrificing long-practiced physician-centric methods of assigning ourselves to patients: call schedules, load balancing across practice partners—even the cherished concept of continuity is a force that can be at odds with geography as the driver. The way to approach the transition to unit-based teams is to have an honest dialogue. Why do we come to work in the hospital every day? If it’s to serve physician needs first, the old model deserves our loyalty. But if the needs of our patients and families are our focus, then we should embrace models that enable us to work effectively together, to become a great team.

Q: How have ACUs performed so far?

A: In the highest-acuity ACUs, we’ve seen mortality reductions of nearly 50%. In addition, there is a wide range of anecdotal outcomes reported. Most ACUs appear to be seeing reductions in length of stay and improvements in patient satisfaction and employee engagement. One ACU reports significant reductions in average cost per patient per day. Another ACU in a geriatric unit has seen dramatic reductions in falls. Some ACUs have seen improvements in glycemic control and VTE prophylaxis, and reductions in catheter utilization.

The benefits of the model seem to be many and probably depend on the patient population, severity of illness, baseline level of performance, and the focus and ability of the unit leadership team to get the most out of the model.

Q: Will ACUs or ACU features become de rigueur in a transformed healthcare landscape?

A: It’s hard to imagine a reality where features of ACUs do not become the standard of care. Once patients and professionals experience the impact of the ACU model, there’ll be no going back. It feels like exactly what we should be doing together. Several ACU design features are reinforced pretty cogently by Richard Bohmer in a New England Journal of Medicine perspective called “The Four Habits of High-Value Health Care Organizations.”¹

Q: Any final thoughts?

A: I did not imagine my career as a QI practitioner at Emory becoming so immersed in social and industrial engineering. Of course, it’s obvious to me now that it’s happened, but six years ago when I first started directing SHM’s quality course, I thought the future in HM was health IT and real-time dashboards. Now I know those things will be important, but only if we first figure out how to get our frontline interdisciplinary clinicians to work as an effective team.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

Reference

1. Bohmer RM. The four habits of high-value health care organizations. New Engl J Med. 2011;365(22):2045-2047.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Healthcare-associated infections financially impact the U.S. system
2. No mortality benefit with treatment of single peripheral pulmonary emboli
3. Modified (shorter) IV acetylcysteine infusion reduces adverse effects
4. Comorbidities contribute to potentially avoidable hospital readmissions
5. Resident handoff bundle reduces medical errors and adverse events, improves handoff quality
6. Uncomplicated skin infections in the ambulatory setting commonly involve avoidable antibiotic exposure
7. Warfarin initiation in atrial fibrillation associated with increased short-term risk of stroke
8. Multifaceted discharge interventions reduce rates of pediatric readmission and post-hospital ED utilization
9. Sepsis diagnoses are common, but many septic patients in ED do not receive antibiotics
10. New oral anticoagulants safe, effective for atrial fibrillation treatment

Healthcare-Associated Infections Continue to Impact the U.S. Healthcare System Financially

Clinical question: What is the estimated cost of healthcare-associated infections (HAI) to the U.S. healthcare system?

Background: In spite of education efforts, HAIs occur frequently and contribute to high healthcare costs in the U.S. This study sought to estimate the costs of HAIs to the U.S. system using statistical analyses of published data.

Study design: Simulations of published data.

Setting: Published studies on five major HAIs.

Synopsis: Monte Carlo simulations based upon published point estimates were used to estimate per-case cost and confidence intervals, with extrapolation to total costs to the U.S. healthcare system. Overall, five major HAIs occur approximately 440,000 times annually and cost the healthcare system an estimated $9.78 billion (range $8.28 to $11.5 billion) in 2009.

Surgical site infections (36.0%) were the most common of the studied HAIs, with increased per-case cost of $20,785, equating to an estimated $3.30 billion annually (33.7% of total HAI costs). Clostridium difficile infection accounted for 30.3% of HAI but only 15.4% of costs ($1.51 billion). Central line-associated bloodstream infections were most costly per case ($45,814), with total costs of $1.85 billion (18.9% of costs). Ventilator-associated pneumonia accounted for $3.09 billion, or 31.7% of total costs. Catheter-associated urinary tract infection only represented 0.3% of total costs, or $27.9 million annually.

The authors suggest that changes in payment reform likely will drive hospitals to further invest in HAI reduction efforts.

Bottom line: HAIs remain frequent and expensive complications of hospitalization, in spite of improvement efforts to date.

Citation: Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-2046.

No Mortality Benefit with Treatment of Single Peripheral Pulmonary Emboli

Clinical question: Does treatment of single peripheral pulmonary emboli impact mortality and rates of post-discharge venous thromboembolism (VTE)?

Background: With the increase in CT pulmonary angiography (CTPA) use the past decade, there has been an increased rate of detection of peripheral filling defects. When confronted with a single peripheral filling defect (SPFD), clinicians face the dilemma of whether treatment is necessary, given the risks associated with anticoagulation.

Study design: Retrospective cohort.

Setting: Community teaching hospital in Norwalk, Conn.

Synopsis: A total of 4,906 CTPAs were screened, revealing 153 scans with an SPFD. Primary analysis included 134 patients 18 years or older. Of these patients, 61 (45.5%) received treatment with anticoagulation (n=51) or IVC filter alone (n=10).

This study revealed no difference in adjusted 90-day mortality between treated and untreated groups. No statistically significant difference was found in the rate of post-discharge VTE within 90 days.

Characteristics associated with treatment for SPFD were patient immobility, previous VTE, and radiology labeling the filling defect as a pulmonary embolus. It is important to note that none of the patients who had a normal second imaging study (e.g. V/Q scan or ultrasound) were treated; therefore, the use of secondary studies could mitigate some of the uncertainty around SPFD management, though this is not recommended in current diagnostic algorithms. Because this is a single-center study with a modest sample size, the comparability of findings to other centers might be limited. Larger studies are needed to help clarify these findings.

Bottom line: Treatment of SPFD was not associated with a difference in mortality or post-discharge VTE within 90 days.

Citation: Green O, Lempel J, Kolodziej A, et al. Treatment of single peripheral pulmonary emboli: patient outcomes and factors associated with decision to treat. J Hosp Med. 2014;9(1):42-47.

Modified IV Acetylcysteine Infusion Reduces Adverse Effects

Clinical question: Does a shorter regimen of IV acetylcysteine reduce adverse effects compared to the standard regimen?

Background: Acetaminophen poisoning is common, and recommended treatment is IV acetylcysteine; however, the standard regimen has many adverse effects, including vomiting and anaphylactoid reactions. Although studies have outlined these side effects, no published trials have compared their frequency to that of a shorter protocol.

Study design: Double-blinded, randomized controlled trial.

Setting: Three acute care hospitals in the United Kingdom.

Synopsis: Of 3,311 patients who presented with acetaminophen overdose, 222 underwent randomization to the standard (duration 20-25 hours) or modified (12 hours) acetylcysteine regimen, with or without pre-treatment with IV ondansetron 4 mg. The primary outcome of vomiting, retching, or need for rescue antiemetic treatment within two hours of acetylcysteine initiation was significantly less frequent in patients who received the shorter regimen, compared to those allocated to the standard regimen.

Specifically, the adjusted odds ratio was 0.26 with the modified regimen (97.5% CI, 0.13-0.52; P<0.0001). The primary outcome was significantly less in patients pre-treated with ondansetron compared to placebo (OR 0.41, 97.5% CI 0.2-0.8; P=0.003). Anaphylactic reactions were significantly reduced with the shorter protocol; no significant difference in hepatotoxicity was noted.

It is reasonable to infer that the shorter acetylcysteine regimen substantially reduces the frequency of vomiting and serious anaphylactoid reactions when compared with the standard schedule; however, hospitalists should note that this study was not powered to assess for non-inferiority of the shorter regimen with regard to prevention of acetaminophen’s hepatotoxic effects. Further studies are needed to confirm the efficacy and safety of the modified regimen before widespread adoption into clinical practice.

Bottom line: A shorter acetylcysteine regimen is associated with decreased occurrence of vomiting and anaphylactoid reactions compared to the standard protocol for treating acetaminophen toxicity. Additional research is needed to assess non-inferiority of this modified regimen for prevention of hepatotoxic effects.

Citation: Bateman DN, Dear JW, Thanacoody HK, et al. Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomized controlled trial. Lancet. 2014;383(9918):697-704.

Comorbidities Contribute to Potentially Avoidable Hospital Readmissions

Clinical question: What is the role of comorbidities in 30-day potentially avoidable readmissions?

Background: Higher comorbidity burden has been associated with 30-day readmissions. This study evaluated the role of comorbidities in the 30-day rate of potentially avoidable readmissions from a tertiary-care medical center.

Study design: Retrospective cohort.

Setting: Tertiary-care teaching hospital and affiliated network.

Synopsis: Investigators tested the hypothesis that comorbidities significantly contribute to 30-day, potentially avoidable readmissions in a cohort of consecutively discharged medical patients at an academic medical center over a 12-month period. Out of a total of 10,731 discharges, there were 2,398 readmissions to hospitals in the same health system. Of those 2,398 readmissions, 858 (35.8%) were judged potentially avoidable using a validated algorithm. Frequently, the reason for readmission was not related to the index discharge diagnosis but to a complication of known comorbidities.

The authors identified the top five diagnoses for readmission as infection, neoplasm, heart failure, gastrointestinal disorder, and liver disorder. Among those patients who had a readmission diagnosis different from the index-case discharge diagnosis, the comorbidities of neoplastic disease, heart failure, and chronic kidney disease significantly contributed to readmission as compared to those without similar comorbidities.

Bottom line: The reason for readmission often is not related to the index hospitalization diagnosis but, rather, to comorbidities present at the index episode of care; thus, attention to management of comorbidities in the post-discharge period is important in circumventing potentially avoidable readmissions.

Citation: Donzé J, Lipsitz S, Bates DW, Schnipper JL. Causes and patterns of readmissions in patients with common comorbidities: retrospective cohort study. BMJ. 2013;347:F7171.

Resident Handoff Bundle Reduces Medical Errors and Adverse Events, Improves Handoff Quality

Clinical question: In a pediatric inpatient setting, is the use of a handoff program associated with improved patient safety measures and handoff quality?

Background: Sentinel events related to errors in communication are a significant patient safety dilemma and an impetus for ongoing efforts to improve handoffs in postgraduate medical education. Various strategies to be incorporated into the handoff process have been suggested in the literature, but research is limited with regard to the relationship between handoffs and patient safety.

Study design: Prospective, pre-post study.

Setting: Academic, pediatric hospital in an urban setting.

Synopsis: Overall, 1,255 patient admissions (642 pre-/613 post-handoff intervention) were evaluated on two inpatient units during the periods of July 2009-September 2009 (pre-intervention) and November 2009-January 2010 (post-intervention). The intervention was a handoff “bundle” consisting of a standardized communication and handoff training session, a verbal mnemonic to standardize handoffs, and a new unified resident-intern handoff structure in a private, quiet setting. A computerized handoff tool was also added in one unit. Primary outcomes were a comparison of the rate of medical errors per 100 admissions and rates of preventable adverse events before and after the intervention.

Implementation of the bundle resulted in a significant decrease in medical errors (18.3 from 33.8 per 100 admissions, P<0.001) and preventable adverse events (1.5 from 3.3 per 100 admissions, P=0.04). Secondary outcomes included reductions in omissions of key data in the written handoff (even greater in the group using the computerized tool) and increased percentage of time spent in direct patient care, with no change in handoff duration. Additionally, handoffs were more likely to occur in a quiet, private location.

Limitations included the potential for confounding in a pre-post intervention design, the difficulty in ascertaining the value of the individual components of the bundle, and the potential lack of generalizability.

Bottom line: In a pediatric hospital setting, a multifaceted handoff bundle is associated with improved handoff quality and reductions in medical errors and preventable adverse events.

Citation: Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310(21):2262-2270.

Uncomplicated Skin Infections in Ambulatory Setting Commonly Involve Avoidable Antibiotic Exposure

Clinical question: What are the current prescribing practices for antibiotics used to treat skin and soft tissue infections in the outpatient setting?

Background: Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotic use. Because antibiotic use is associated with bacterial resistance and adverse events, understanding antibiotic prescribing practices is necessary to minimize these types of complications.

Study design: Retrospective cohort.

Setting: Ambulatory care setting in the Denver Health System.

Synopsis: Data from 364 adults and children who presented to an ambulatory setting with a primary diagnosis of skin and soft tissue infection were analyzed using a stepwise multivariate logistic regression in order to determine factors associated with avoidable antibiotic exposure. Among cellulitis cases, 61% of patients were prescribed antibiotics to treat methicillin-resistant Staphylococcus aureus. Avoidable antibiotic exposure occurred in 46% of cases, including use of antibiotics with broad Gram-negative activity (4%), combination therapy (12%), and treatment for ≥10 days (42%). Use of short-course, single-antibiotic treatment approaches consistent with national guidelines would have reduced prescribed antibiotic days by 19%, to 55%.

Bottom line: Avoidable antibiotic exposure frequently occurs in the treatment of uncomplicated skin infections; using short-course, single-antibiotic treatment strategies could significantly reduce total antibiotic use.

Citation: Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med. 2013;126(12):1099-1106.

Warfarin Initiation in Atrial Fibrillation Associated with Increased Short-Term Risk of Stroke

Clinical question: Is the initiation of warfarin associated with an increased risk of ischemic stroke in patients with atrial fibrillation (Afib)?

Background: Two Afib trials of oral factor Xa inhibitors showed an increased risk of stroke when patients were transitioned to open label warfarin at the end of the study. Warfarin can, theoretically, lead to a transient hypercoagulable state upon treatment initiation, so further study is indicated to determine if the initiation of warfarin is associated with increased stroke risk among Afib patients.

Study design: Population-based, nested case-control.

Setting: UK Clinical Practice Research Datalink.

Synopsis: A cohort of 70,766 patients with newly diagnosed Afib was identified from a large primary care database. Conditional logistic regression was used to estimate adjusted rate ratios (RR) of stroke associated with warfarin monotherapy, classified according to time since initiation of treatment when compared to patients not on antithrombotic therapy.

Warfarin was associated with a 71% increased risk of stroke in the first 30 days of use (RR 1.71, 95% CI 1.39-2.12). Risk was highest in the first week of warfarin treatment, which is consistent with the known transient pro-coagulant effect of warfarin. Decreased risks were observed with warfarin initiation >30 days before the ischemic event (31-90 days: RR 0.50, 95% CI 0.34-0.75; >90 days: RR 0.55, 95% CI 0.50-0.61).

Limitations included the extraction of data from a database, which could lead to misclassification of diagnosis or therapy, and the observational nature of the study.

Bottom line: There may be an increased risk of ischemic stroke during the first 30 days of treatment with warfarin in patients with Afib.

Citation: Azoulay L, Dell-Aniello S, Simon T, Renoux C, Suissa S. Initiation of warfarin in patients with atrial fibrillation: early effects on ischaemic strokes [published online ahead of print December 18, 2013]. Eur Heart J.

Multifaceted Discharge Interventions Reduce Rates of Pediatric Readmission and Post-Hospital ED Utilization

Clinical question: Do interventions at discharge reduce the rate of readmissions and post-hospitalization ED visits among pediatric patients?

Background: Readmissions are a high-priority quality measure in both the adult and pediatric settings. Although a broadening body of literature is evaluating the impact of interventions on readmissions in adult populations, the literature does not contain a similar breadth of assessments of interventions in the pediatric setting.

Study design: Systematic review.

Setting: English-language articles studying pediatric inpatient discharge interventions.

Synopsis: A total of 1,296 unique articles were identified from PubMed and the Cumulative Index to Nursing and Allied Health Literature. Additional articles were identified on review of references, yielding 14 articles that met inclusion criteria. Included studies evaluated the effect of pediatric discharge interventions on the primary outcomes of hospital readmission or post-hospitalization ED visits. Interventions focused on three main patient populations: asthma, cancer, and prematurity.

Six studies demonstrated statistically significant reductions in readmissions and/or ED visits, while two studies actually demonstrated an increase in post-discharge utilization. All successful interventions began in the inpatient setting and were multifaceted, with four of six studies including an educational component and a post-discharge follow-up component.

While all of the studies evaluated sought to enhance the transitional care from the inpatient to outpatient setting, only the interventions that included one responsible party (individual or team) with expertise in the medical condition providing oversight and support were successful in reducing the specified outcomes. A significant limitation was that many of the studies identified were not sufficiently powered to detect either outcome of interest.

Bottom line: A multifaceted intervention involving educational and post-discharge follow-up components with an experienced individual or team supporting the transition is associated with a reduction in hospital readmissions and post-discharge ED utilization.

Citation: Auger KA, Kenyon CC, Feudtner C, Davis MM. Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review [published online ahead of print December 20, 2013]. J Hosp Med.

Sepsis Diagnoses Are Common in ED, but Many Septic Patients in the ED Do Not Receive Antibiotics

Clinical question: Has the frequency of sepsis rates, along with administration of antibiotics in U.S. emergency departments (EDs), changed over time?

Background: Prior studies reviewing discharge data from hospitals suggest an increase of sepsis over time; however, little epidemiological research has evaluated the diagnosis of sepsis and antibiotic use in ED settings.

Study design: Retrospective, four-stage probability sample.

Setting: National Hospital Ambulatory Medical Care Survey (NHAMCS).

Synopsis: The NHAMCS includes a sample of all U.S. ED visits, except federal, military, and VA hospitals. According to NHAMCS data, an estimated 1.3 billion visits by adults to U.S. EDs occurred from 1994-2009, or approximately 81 million visits per year. Explicit sepsis was defined by the presence of the following, with ICD-9 codes: septicemia (038), sepsis (995.91), severe sepsis (995.92), or septic shock (785.52). Implicit sepsis was defined as a code indicating infection plus a code indicting organ dysfunction.

In U.S. EDs, explicit sepsis did not become more prevalent from 1994-2009; however, implicitly diagnosed sepsis increased by 7% every two years. There were 260,000 explicit sepsis-related ED visits per year, or 1.23 visits per 1,000 U.S. population. In-hospital mortality was 17% and 9% for the explicit and implicit diagnosis groups, respectively. On review of the explicit sepsis group, only 61% of the patients were found to have received antibiotics in the ED. The rate did increase over the time studied, from 52% in 1994-1997 to 69% in 2006-2009.

The study was limited by the retrospective analysis of data not designed to track sepsis or antibiotic use.

Bottom Line: Explicitly recognized sepsis remained stable in the ED setting from 1994-2009, and early antibiotic use has improved during this time, but there is still much opportunity for improvement.

Citation: Filbin MR, Arias SA, Camargo CA Jr, Barche A, Pallin DJ. Sepsis visits and antibiotic utilization in the U.S. emergency departments. Crit Care Med. 2014;42(3):528-535.

New Oral Anticoagulants Safe and Effective for Atrial Fibrillation Treatment

Clinical question: Is there a difference in efficacy and safety among new oral anticoagulants compared to warfarin in subgroups of patients with atrial fibrillation (Afib)?

Background: Studies of new oral anticoagulants have demonstrated that these agents are at least as safe and effective as warfarin for prevention of stroke and systemic embolism in Afib. This study was designed to look at available phase 3 randomized trials, with the goal of subgroup analysis for both efficacy and bleeding risks.

Study design: Meta-analysis.

Setting: Phase 3 randomized controlled trials of patients with Afib.

Synopsis: The analysis included four trials of Afib patients randomized to receive warfarin or a novel oral anticoagulant (NOAC), including dabigatran, rivaroxaban, apixaban, and edoxaban. In total, 42,411 patients received an NOAC and 29,272 patients received warfarin. Separate analyses were performed for high-dose and low-dose NOACs.

The high-dose NOAC demonstrated a 19% reduction in stroke and systemic embolic events as compared to warfarin, largely due to the reduction of hemorrhagic strokes by the NOAC. The low-dose NOAC showed similar efficacy to warfarin for reduction of stroke and systemic embolic events, with an increase noted in the subset of ischemic stroke in low-dose NOAC. Both doses of NOAC demonstrated a significant reduction in all-cause mortality. NOAC showed a non-significant reduction in bleeding compared to warfarin; however, subset analysis demonstrated an increase in gastrointestinal bleeding with high-dose NOAC and a significant reduction in intracranial hemorrhage with low-dose NOAC.

A notable limitation of the study is that it only included clinical trials in the analysis.

Bottom line: In relation to stroke, systemic embolic events, and all-cause mortality, new oral anticoagulants showed a favorable efficacy and safety profile as compared to warfarin in Afib patients.

Citation: Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Healthcare-associated infections financially impact the U.S. system
2. No mortality benefit with treatment of single peripheral pulmonary emboli
3. Modified (shorter) IV acetylcysteine infusion reduces adverse effects
4. Comorbidities contribute to potentially avoidable hospital readmissions
5. Resident handoff bundle reduces medical errors and adverse events, improves handoff quality
6. Uncomplicated skin infections in the ambulatory setting commonly involve avoidable antibiotic exposure
7. Warfarin initiation in atrial fibrillation associated with increased short-term risk of stroke
8. Multifaceted discharge interventions reduce rates of pediatric readmission and post-hospital ED utilization
9. Sepsis diagnoses are common, but many septic patients in ED do not receive antibiotics
10. New oral anticoagulants safe, effective for atrial fibrillation treatment

Healthcare-Associated Infections Continue to Impact the U.S. Healthcare System Financially

Clinical question: What is the estimated cost of healthcare-associated infections (HAI) to the U.S. healthcare system?

Background: In spite of education efforts, HAIs occur frequently and contribute to high healthcare costs in the U.S. This study sought to estimate the costs of HAIs to the U.S. system using statistical analyses of published data.

Study design: Simulations of published data.

Setting: Published studies on five major HAIs.

Synopsis: Monte Carlo simulations based upon published point estimates were used to estimate per-case cost and confidence intervals, with extrapolation to total costs to the U.S. healthcare system. Overall, five major HAIs occur approximately 440,000 times annually and cost the healthcare system an estimated $9.78 billion (range $8.28 to $11.5 billion) in 2009.

Surgical site infections (36.0%) were the most common of the studied HAIs, with increased per-case cost of $20,785, equating to an estimated $3.30 billion annually (33.7% of total HAI costs). Clostridium difficile infection accounted for 30.3% of HAI but only 15.4% of costs ($1.51 billion). Central line-associated bloodstream infections were most costly per case ($45,814), with total costs of $1.85 billion (18.9% of costs). Ventilator-associated pneumonia accounted for $3.09 billion, or 31.7% of total costs. Catheter-associated urinary tract infection only represented 0.3% of total costs, or $27.9 million annually.

The authors suggest that changes in payment reform likely will drive hospitals to further invest in HAI reduction efforts.

Bottom line: HAIs remain frequent and expensive complications of hospitalization, in spite of improvement efforts to date.

Citation: Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-2046.

No Mortality Benefit with Treatment of Single Peripheral Pulmonary Emboli

Clinical question: Does treatment of single peripheral pulmonary emboli impact mortality and rates of post-discharge venous thromboembolism (VTE)?

Background: With the increase in CT pulmonary angiography (CTPA) use the past decade, there has been an increased rate of detection of peripheral filling defects. When confronted with a single peripheral filling defect (SPFD), clinicians face the dilemma of whether treatment is necessary, given the risks associated with anticoagulation.

Study design: Retrospective cohort.

Setting: Community teaching hospital in Norwalk, Conn.

Synopsis: A total of 4,906 CTPAs were screened, revealing 153 scans with an SPFD. Primary analysis included 134 patients 18 years or older. Of these patients, 61 (45.5%) received treatment with anticoagulation (n=51) or IVC filter alone (n=10).

This study revealed no difference in adjusted 90-day mortality between treated and untreated groups. No statistically significant difference was found in the rate of post-discharge VTE within 90 days.

Characteristics associated with treatment for SPFD were patient immobility, previous VTE, and radiology labeling the filling defect as a pulmonary embolus. It is important to note that none of the patients who had a normal second imaging study (e.g. V/Q scan or ultrasound) were treated; therefore, the use of secondary studies could mitigate some of the uncertainty around SPFD management, though this is not recommended in current diagnostic algorithms. Because this is a single-center study with a modest sample size, the comparability of findings to other centers might be limited. Larger studies are needed to help clarify these findings.

Bottom line: Treatment of SPFD was not associated with a difference in mortality or post-discharge VTE within 90 days.

Citation: Green O, Lempel J, Kolodziej A, et al. Treatment of single peripheral pulmonary emboli: patient outcomes and factors associated with decision to treat. J Hosp Med. 2014;9(1):42-47.

Modified IV Acetylcysteine Infusion Reduces Adverse Effects

Clinical question: Does a shorter regimen of IV acetylcysteine reduce adverse effects compared to the standard regimen?

Background: Acetaminophen poisoning is common, and recommended treatment is IV acetylcysteine; however, the standard regimen has many adverse effects, including vomiting and anaphylactoid reactions. Although studies have outlined these side effects, no published trials have compared their frequency to that of a shorter protocol.

Study design: Double-blinded, randomized controlled trial.

Setting: Three acute care hospitals in the United Kingdom.

Synopsis: Of 3,311 patients who presented with acetaminophen overdose, 222 underwent randomization to the standard (duration 20-25 hours) or modified (12 hours) acetylcysteine regimen, with or without pre-treatment with IV ondansetron 4 mg. The primary outcome of vomiting, retching, or need for rescue antiemetic treatment within two hours of acetylcysteine initiation was significantly less frequent in patients who received the shorter regimen, compared to those allocated to the standard regimen.

Specifically, the adjusted odds ratio was 0.26 with the modified regimen (97.5% CI, 0.13-0.52; P<0.0001). The primary outcome was significantly less in patients pre-treated with ondansetron compared to placebo (OR 0.41, 97.5% CI 0.2-0.8; P=0.003). Anaphylactic reactions were significantly reduced with the shorter protocol; no significant difference in hepatotoxicity was noted.

It is reasonable to infer that the shorter acetylcysteine regimen substantially reduces the frequency of vomiting and serious anaphylactoid reactions when compared with the standard schedule; however, hospitalists should note that this study was not powered to assess for non-inferiority of the shorter regimen with regard to prevention of acetaminophen’s hepatotoxic effects. Further studies are needed to confirm the efficacy and safety of the modified regimen before widespread adoption into clinical practice.

Bottom line: A shorter acetylcysteine regimen is associated with decreased occurrence of vomiting and anaphylactoid reactions compared to the standard protocol for treating acetaminophen toxicity. Additional research is needed to assess non-inferiority of this modified regimen for prevention of hepatotoxic effects.

Citation: Bateman DN, Dear JW, Thanacoody HK, et al. Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomized controlled trial. Lancet. 2014;383(9918):697-704.

Comorbidities Contribute to Potentially Avoidable Hospital Readmissions

Clinical question: What is the role of comorbidities in 30-day potentially avoidable readmissions?

Background: Higher comorbidity burden has been associated with 30-day readmissions. This study evaluated the role of comorbidities in the 30-day rate of potentially avoidable readmissions from a tertiary-care medical center.

Study design: Retrospective cohort.

Setting: Tertiary-care teaching hospital and affiliated network.

Synopsis: Investigators tested the hypothesis that comorbidities significantly contribute to 30-day, potentially avoidable readmissions in a cohort of consecutively discharged medical patients at an academic medical center over a 12-month period. Out of a total of 10,731 discharges, there were 2,398 readmissions to hospitals in the same health system. Of those 2,398 readmissions, 858 (35.8%) were judged potentially avoidable using a validated algorithm. Frequently, the reason for readmission was not related to the index discharge diagnosis but to a complication of known comorbidities.

The authors identified the top five diagnoses for readmission as infection, neoplasm, heart failure, gastrointestinal disorder, and liver disorder. Among those patients who had a readmission diagnosis different from the index-case discharge diagnosis, the comorbidities of neoplastic disease, heart failure, and chronic kidney disease significantly contributed to readmission as compared to those without similar comorbidities.

Bottom line: The reason for readmission often is not related to the index hospitalization diagnosis but, rather, to comorbidities present at the index episode of care; thus, attention to management of comorbidities in the post-discharge period is important in circumventing potentially avoidable readmissions.

Citation: Donzé J, Lipsitz S, Bates DW, Schnipper JL. Causes and patterns of readmissions in patients with common comorbidities: retrospective cohort study. BMJ. 2013;347:F7171.

Resident Handoff Bundle Reduces Medical Errors and Adverse Events, Improves Handoff Quality

Clinical question: In a pediatric inpatient setting, is the use of a handoff program associated with improved patient safety measures and handoff quality?

Background: Sentinel events related to errors in communication are a significant patient safety dilemma and an impetus for ongoing efforts to improve handoffs in postgraduate medical education. Various strategies to be incorporated into the handoff process have been suggested in the literature, but research is limited with regard to the relationship between handoffs and patient safety.

Study design: Prospective, pre-post study.

Setting: Academic, pediatric hospital in an urban setting.

Synopsis: Overall, 1,255 patient admissions (642 pre-/613 post-handoff intervention) were evaluated on two inpatient units during the periods of July 2009-September 2009 (pre-intervention) and November 2009-January 2010 (post-intervention). The intervention was a handoff “bundle” consisting of a standardized communication and handoff training session, a verbal mnemonic to standardize handoffs, and a new unified resident-intern handoff structure in a private, quiet setting. A computerized handoff tool was also added in one unit. Primary outcomes were a comparison of the rate of medical errors per 100 admissions and rates of preventable adverse events before and after the intervention.

Implementation of the bundle resulted in a significant decrease in medical errors (18.3 from 33.8 per 100 admissions, P<0.001) and preventable adverse events (1.5 from 3.3 per 100 admissions, P=0.04). Secondary outcomes included reductions in omissions of key data in the written handoff (even greater in the group using the computerized tool) and increased percentage of time spent in direct patient care, with no change in handoff duration. Additionally, handoffs were more likely to occur in a quiet, private location.

Limitations included the potential for confounding in a pre-post intervention design, the difficulty in ascertaining the value of the individual components of the bundle, and the potential lack of generalizability.

Bottom line: In a pediatric hospital setting, a multifaceted handoff bundle is associated with improved handoff quality and reductions in medical errors and preventable adverse events.

Citation: Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310(21):2262-2270.

Uncomplicated Skin Infections in Ambulatory Setting Commonly Involve Avoidable Antibiotic Exposure

Clinical question: What are the current prescribing practices for antibiotics used to treat skin and soft tissue infections in the outpatient setting?

Background: Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotic use. Because antibiotic use is associated with bacterial resistance and adverse events, understanding antibiotic prescribing practices is necessary to minimize these types of complications.

Study design: Retrospective cohort.

Setting: Ambulatory care setting in the Denver Health System.

Synopsis: Data from 364 adults and children who presented to an ambulatory setting with a primary diagnosis of skin and soft tissue infection were analyzed using a stepwise multivariate logistic regression in order to determine factors associated with avoidable antibiotic exposure. Among cellulitis cases, 61% of patients were prescribed antibiotics to treat methicillin-resistant Staphylococcus aureus. Avoidable antibiotic exposure occurred in 46% of cases, including use of antibiotics with broad Gram-negative activity (4%), combination therapy (12%), and treatment for ≥10 days (42%). Use of short-course, single-antibiotic treatment approaches consistent with national guidelines would have reduced prescribed antibiotic days by 19%, to 55%.

Bottom line: Avoidable antibiotic exposure frequently occurs in the treatment of uncomplicated skin infections; using short-course, single-antibiotic treatment strategies could significantly reduce total antibiotic use.

Citation: Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med. 2013;126(12):1099-1106.

Warfarin Initiation in Atrial Fibrillation Associated with Increased Short-Term Risk of Stroke

Clinical question: Is the initiation of warfarin associated with an increased risk of ischemic stroke in patients with atrial fibrillation (Afib)?

Background: Two Afib trials of oral factor Xa inhibitors showed an increased risk of stroke when patients were transitioned to open label warfarin at the end of the study. Warfarin can, theoretically, lead to a transient hypercoagulable state upon treatment initiation, so further study is indicated to determine if the initiation of warfarin is associated with increased stroke risk among Afib patients.

Study design: Population-based, nested case-control.

Setting: UK Clinical Practice Research Datalink.

Synopsis: A cohort of 70,766 patients with newly diagnosed Afib was identified from a large primary care database. Conditional logistic regression was used to estimate adjusted rate ratios (RR) of stroke associated with warfarin monotherapy, classified according to time since initiation of treatment when compared to patients not on antithrombotic therapy.

Warfarin was associated with a 71% increased risk of stroke in the first 30 days of use (RR 1.71, 95% CI 1.39-2.12). Risk was highest in the first week of warfarin treatment, which is consistent with the known transient pro-coagulant effect of warfarin. Decreased risks were observed with warfarin initiation >30 days before the ischemic event (31-90 days: RR 0.50, 95% CI 0.34-0.75; >90 days: RR 0.55, 95% CI 0.50-0.61).

Limitations included the extraction of data from a database, which could lead to misclassification of diagnosis or therapy, and the observational nature of the study.

Bottom line: There may be an increased risk of ischemic stroke during the first 30 days of treatment with warfarin in patients with Afib.

Citation: Azoulay L, Dell-Aniello S, Simon T, Renoux C, Suissa S. Initiation of warfarin in patients with atrial fibrillation: early effects on ischaemic strokes [published online ahead of print December 18, 2013]. Eur Heart J.

Multifaceted Discharge Interventions Reduce Rates of Pediatric Readmission and Post-Hospital ED Utilization

Clinical question: Do interventions at discharge reduce the rate of readmissions and post-hospitalization ED visits among pediatric patients?

Background: Readmissions are a high-priority quality measure in both the adult and pediatric settings. Although a broadening body of literature is evaluating the impact of interventions on readmissions in adult populations, the literature does not contain a similar breadth of assessments of interventions in the pediatric setting.

Study design: Systematic review.

Setting: English-language articles studying pediatric inpatient discharge interventions.

Synopsis: A total of 1,296 unique articles were identified from PubMed and the Cumulative Index to Nursing and Allied Health Literature. Additional articles were identified on review of references, yielding 14 articles that met inclusion criteria. Included studies evaluated the effect of pediatric discharge interventions on the primary outcomes of hospital readmission or post-hospitalization ED visits. Interventions focused on three main patient populations: asthma, cancer, and prematurity.

Six studies demonstrated statistically significant reductions in readmissions and/or ED visits, while two studies actually demonstrated an increase in post-discharge utilization. All successful interventions began in the inpatient setting and were multifaceted, with four of six studies including an educational component and a post-discharge follow-up component.

While all of the studies evaluated sought to enhance the transitional care from the inpatient to outpatient setting, only the interventions that included one responsible party (individual or team) with expertise in the medical condition providing oversight and support were successful in reducing the specified outcomes. A significant limitation was that many of the studies identified were not sufficiently powered to detect either outcome of interest.

Bottom line: A multifaceted intervention involving educational and post-discharge follow-up components with an experienced individual or team supporting the transition is associated with a reduction in hospital readmissions and post-discharge ED utilization.

Citation: Auger KA, Kenyon CC, Feudtner C, Davis MM. Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review [published online ahead of print December 20, 2013]. J Hosp Med.

Sepsis Diagnoses Are Common in ED, but Many Septic Patients in the ED Do Not Receive Antibiotics

Clinical question: Has the frequency of sepsis rates, along with administration of antibiotics in U.S. emergency departments (EDs), changed over time?

Background: Prior studies reviewing discharge data from hospitals suggest an increase of sepsis over time; however, little epidemiological research has evaluated the diagnosis of sepsis and antibiotic use in ED settings.

Study design: Retrospective, four-stage probability sample.

Setting: National Hospital Ambulatory Medical Care Survey (NHAMCS).

Synopsis: The NHAMCS includes a sample of all U.S. ED visits, except federal, military, and VA hospitals. According to NHAMCS data, an estimated 1.3 billion visits by adults to U.S. EDs occurred from 1994-2009, or approximately 81 million visits per year. Explicit sepsis was defined by the presence of the following, with ICD-9 codes: septicemia (038), sepsis (995.91), severe sepsis (995.92), or septic shock (785.52). Implicit sepsis was defined as a code indicating infection plus a code indicting organ dysfunction.

In U.S. EDs, explicit sepsis did not become more prevalent from 1994-2009; however, implicitly diagnosed sepsis increased by 7% every two years. There were 260,000 explicit sepsis-related ED visits per year, or 1.23 visits per 1,000 U.S. population. In-hospital mortality was 17% and 9% for the explicit and implicit diagnosis groups, respectively. On review of the explicit sepsis group, only 61% of the patients were found to have received antibiotics in the ED. The rate did increase over the time studied, from 52% in 1994-1997 to 69% in 2006-2009.

The study was limited by the retrospective analysis of data not designed to track sepsis or antibiotic use.

Bottom Line: Explicitly recognized sepsis remained stable in the ED setting from 1994-2009, and early antibiotic use has improved during this time, but there is still much opportunity for improvement.

Citation: Filbin MR, Arias SA, Camargo CA Jr, Barche A, Pallin DJ. Sepsis visits and antibiotic utilization in the U.S. emergency departments. Crit Care Med. 2014;42(3):528-535.

New Oral Anticoagulants Safe and Effective for Atrial Fibrillation Treatment

Clinical question: Is there a difference in efficacy and safety among new oral anticoagulants compared to warfarin in subgroups of patients with atrial fibrillation (Afib)?

Background: Studies of new oral anticoagulants have demonstrated that these agents are at least as safe and effective as warfarin for prevention of stroke and systemic embolism in Afib. This study was designed to look at available phase 3 randomized trials, with the goal of subgroup analysis for both efficacy and bleeding risks.

Study design: Meta-analysis.

Setting: Phase 3 randomized controlled trials of patients with Afib.

Synopsis: The analysis included four trials of Afib patients randomized to receive warfarin or a novel oral anticoagulant (NOAC), including dabigatran, rivaroxaban, apixaban, and edoxaban. In total, 42,411 patients received an NOAC and 29,272 patients received warfarin. Separate analyses were performed for high-dose and low-dose NOACs.

The high-dose NOAC demonstrated a 19% reduction in stroke and systemic embolic events as compared to warfarin, largely due to the reduction of hemorrhagic strokes by the NOAC. The low-dose NOAC showed similar efficacy to warfarin for reduction of stroke and systemic embolic events, with an increase noted in the subset of ischemic stroke in low-dose NOAC. Both doses of NOAC demonstrated a significant reduction in all-cause mortality. NOAC showed a non-significant reduction in bleeding compared to warfarin; however, subset analysis demonstrated an increase in gastrointestinal bleeding with high-dose NOAC and a significant reduction in intracranial hemorrhage with low-dose NOAC.

A notable limitation of the study is that it only included clinical trials in the analysis.

Bottom line: In relation to stroke, systemic embolic events, and all-cause mortality, new oral anticoagulants showed a favorable efficacy and safety profile as compared to warfarin in Afib patients.

Citation: Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Healthcare-associated infections financially impact the U.S. system
2. No mortality benefit with treatment of single peripheral pulmonary emboli
3. Modified (shorter) IV acetylcysteine infusion reduces adverse effects
4. Comorbidities contribute to potentially avoidable hospital readmissions
5. Resident handoff bundle reduces medical errors and adverse events, improves handoff quality
6. Uncomplicated skin infections in the ambulatory setting commonly involve avoidable antibiotic exposure
7. Warfarin initiation in atrial fibrillation associated with increased short-term risk of stroke
8. Multifaceted discharge interventions reduce rates of pediatric readmission and post-hospital ED utilization
9. Sepsis diagnoses are common, but many septic patients in ED do not receive antibiotics
10. New oral anticoagulants safe, effective for atrial fibrillation treatment

Healthcare-Associated Infections Continue to Impact the U.S. Healthcare System Financially

Clinical question: What is the estimated cost of healthcare-associated infections (HAI) to the U.S. healthcare system?

Background: In spite of education efforts, HAIs occur frequently and contribute to high healthcare costs in the U.S. This study sought to estimate the costs of HAIs to the U.S. system using statistical analyses of published data.

Study design: Simulations of published data.

Setting: Published studies on five major HAIs.

Synopsis: Monte Carlo simulations based upon published point estimates were used to estimate per-case cost and confidence intervals, with extrapolation to total costs to the U.S. healthcare system. Overall, five major HAIs occur approximately 440,000 times annually and cost the healthcare system an estimated $9.78 billion (range $8.28 to $11.5 billion) in 2009.

Surgical site infections (36.0%) were the most common of the studied HAIs, with increased per-case cost of $20,785, equating to an estimated $3.30 billion annually (33.7% of total HAI costs). Clostridium difficile infection accounted for 30.3% of HAI but only 15.4% of costs ($1.51 billion). Central line-associated bloodstream infections were most costly per case ($45,814), with total costs of $1.85 billion (18.9% of costs). Ventilator-associated pneumonia accounted for $3.09 billion, or 31.7% of total costs. Catheter-associated urinary tract infection only represented 0.3% of total costs, or $27.9 million annually.

The authors suggest that changes in payment reform likely will drive hospitals to further invest in HAI reduction efforts.

Bottom line: HAIs remain frequent and expensive complications of hospitalization, in spite of improvement efforts to date.

Citation: Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-2046.

No Mortality Benefit with Treatment of Single Peripheral Pulmonary Emboli

Clinical question: Does treatment of single peripheral pulmonary emboli impact mortality and rates of post-discharge venous thromboembolism (VTE)?

Background: With the increase in CT pulmonary angiography (CTPA) use the past decade, there has been an increased rate of detection of peripheral filling defects. When confronted with a single peripheral filling defect (SPFD), clinicians face the dilemma of whether treatment is necessary, given the risks associated with anticoagulation.

Study design: Retrospective cohort.

Setting: Community teaching hospital in Norwalk, Conn.

Synopsis: A total of 4,906 CTPAs were screened, revealing 153 scans with an SPFD. Primary analysis included 134 patients 18 years or older. Of these patients, 61 (45.5%) received treatment with anticoagulation (n=51) or IVC filter alone (n=10).

This study revealed no difference in adjusted 90-day mortality between treated and untreated groups. No statistically significant difference was found in the rate of post-discharge VTE within 90 days.

Characteristics associated with treatment for SPFD were patient immobility, previous VTE, and radiology labeling the filling defect as a pulmonary embolus. It is important to note that none of the patients who had a normal second imaging study (e.g. V/Q scan or ultrasound) were treated; therefore, the use of secondary studies could mitigate some of the uncertainty around SPFD management, though this is not recommended in current diagnostic algorithms. Because this is a single-center study with a modest sample size, the comparability of findings to other centers might be limited. Larger studies are needed to help clarify these findings.

Bottom line: Treatment of SPFD was not associated with a difference in mortality or post-discharge VTE within 90 days.

Citation: Green O, Lempel J, Kolodziej A, et al. Treatment of single peripheral pulmonary emboli: patient outcomes and factors associated with decision to treat. J Hosp Med. 2014;9(1):42-47.

Modified IV Acetylcysteine Infusion Reduces Adverse Effects

Clinical question: Does a shorter regimen of IV acetylcysteine reduce adverse effects compared to the standard regimen?

Background: Acetaminophen poisoning is common, and recommended treatment is IV acetylcysteine; however, the standard regimen has many adverse effects, including vomiting and anaphylactoid reactions. Although studies have outlined these side effects, no published trials have compared their frequency to that of a shorter protocol.

Study design: Double-blinded, randomized controlled trial.

Setting: Three acute care hospitals in the United Kingdom.

Synopsis: Of 3,311 patients who presented with acetaminophen overdose, 222 underwent randomization to the standard (duration 20-25 hours) or modified (12 hours) acetylcysteine regimen, with or without pre-treatment with IV ondansetron 4 mg. The primary outcome of vomiting, retching, or need for rescue antiemetic treatment within two hours of acetylcysteine initiation was significantly less frequent in patients who received the shorter regimen, compared to those allocated to the standard regimen.

Specifically, the adjusted odds ratio was 0.26 with the modified regimen (97.5% CI, 0.13-0.52; P<0.0001). The primary outcome was significantly less in patients pre-treated with ondansetron compared to placebo (OR 0.41, 97.5% CI 0.2-0.8; P=0.003). Anaphylactic reactions were significantly reduced with the shorter protocol; no significant difference in hepatotoxicity was noted.

It is reasonable to infer that the shorter acetylcysteine regimen substantially reduces the frequency of vomiting and serious anaphylactoid reactions when compared with the standard schedule; however, hospitalists should note that this study was not powered to assess for non-inferiority of the shorter regimen with regard to prevention of acetaminophen’s hepatotoxic effects. Further studies are needed to confirm the efficacy and safety of the modified regimen before widespread adoption into clinical practice.

Bottom line: A shorter acetylcysteine regimen is associated with decreased occurrence of vomiting and anaphylactoid reactions compared to the standard protocol for treating acetaminophen toxicity. Additional research is needed to assess non-inferiority of this modified regimen for prevention of hepatotoxic effects.

Citation: Bateman DN, Dear JW, Thanacoody HK, et al. Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomized controlled trial. Lancet. 2014;383(9918):697-704.

Comorbidities Contribute to Potentially Avoidable Hospital Readmissions

Clinical question: What is the role of comorbidities in 30-day potentially avoidable readmissions?

Background: Higher comorbidity burden has been associated with 30-day readmissions. This study evaluated the role of comorbidities in the 30-day rate of potentially avoidable readmissions from a tertiary-care medical center.

Study design: Retrospective cohort.

Setting: Tertiary-care teaching hospital and affiliated network.

Synopsis: Investigators tested the hypothesis that comorbidities significantly contribute to 30-day, potentially avoidable readmissions in a cohort of consecutively discharged medical patients at an academic medical center over a 12-month period. Out of a total of 10,731 discharges, there were 2,398 readmissions to hospitals in the same health system. Of those 2,398 readmissions, 858 (35.8%) were judged potentially avoidable using a validated algorithm. Frequently, the reason for readmission was not related to the index discharge diagnosis but to a complication of known comorbidities.

The authors identified the top five diagnoses for readmission as infection, neoplasm, heart failure, gastrointestinal disorder, and liver disorder. Among those patients who had a readmission diagnosis different from the index-case discharge diagnosis, the comorbidities of neoplastic disease, heart failure, and chronic kidney disease significantly contributed to readmission as compared to those without similar comorbidities.

Bottom line: The reason for readmission often is not related to the index hospitalization diagnosis but, rather, to comorbidities present at the index episode of care; thus, attention to management of comorbidities in the post-discharge period is important in circumventing potentially avoidable readmissions.

Citation: Donzé J, Lipsitz S, Bates DW, Schnipper JL. Causes and patterns of readmissions in patients with common comorbidities: retrospective cohort study. BMJ. 2013;347:F7171.

Resident Handoff Bundle Reduces Medical Errors and Adverse Events, Improves Handoff Quality

Clinical question: In a pediatric inpatient setting, is the use of a handoff program associated with improved patient safety measures and handoff quality?

Background: Sentinel events related to errors in communication are a significant patient safety dilemma and an impetus for ongoing efforts to improve handoffs in postgraduate medical education. Various strategies to be incorporated into the handoff process have been suggested in the literature, but research is limited with regard to the relationship between handoffs and patient safety.

Study design: Prospective, pre-post study.

Setting: Academic, pediatric hospital in an urban setting.

Synopsis: Overall, 1,255 patient admissions (642 pre-/613 post-handoff intervention) were evaluated on two inpatient units during the periods of July 2009-September 2009 (pre-intervention) and November 2009-January 2010 (post-intervention). The intervention was a handoff “bundle” consisting of a standardized communication and handoff training session, a verbal mnemonic to standardize handoffs, and a new unified resident-intern handoff structure in a private, quiet setting. A computerized handoff tool was also added in one unit. Primary outcomes were a comparison of the rate of medical errors per 100 admissions and rates of preventable adverse events before and after the intervention.

Implementation of the bundle resulted in a significant decrease in medical errors (18.3 from 33.8 per 100 admissions, P<0.001) and preventable adverse events (1.5 from 3.3 per 100 admissions, P=0.04). Secondary outcomes included reductions in omissions of key data in the written handoff (even greater in the group using the computerized tool) and increased percentage of time spent in direct patient care, with no change in handoff duration. Additionally, handoffs were more likely to occur in a quiet, private location.

Limitations included the potential for confounding in a pre-post intervention design, the difficulty in ascertaining the value of the individual components of the bundle, and the potential lack of generalizability.

Bottom line: In a pediatric hospital setting, a multifaceted handoff bundle is associated with improved handoff quality and reductions in medical errors and preventable adverse events.

Citation: Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310(21):2262-2270.

Uncomplicated Skin Infections in Ambulatory Setting Commonly Involve Avoidable Antibiotic Exposure

Clinical question: What are the current prescribing practices for antibiotics used to treat skin and soft tissue infections in the outpatient setting?

Background: Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotic use. Because antibiotic use is associated with bacterial resistance and adverse events, understanding antibiotic prescribing practices is necessary to minimize these types of complications.

Study design: Retrospective cohort.

Setting: Ambulatory care setting in the Denver Health System.

Synopsis: Data from 364 adults and children who presented to an ambulatory setting with a primary diagnosis of skin and soft tissue infection were analyzed using a stepwise multivariate logistic regression in order to determine factors associated with avoidable antibiotic exposure. Among cellulitis cases, 61% of patients were prescribed antibiotics to treat methicillin-resistant Staphylococcus aureus. Avoidable antibiotic exposure occurred in 46% of cases, including use of antibiotics with broad Gram-negative activity (4%), combination therapy (12%), and treatment for ≥10 days (42%). Use of short-course, single-antibiotic treatment approaches consistent with national guidelines would have reduced prescribed antibiotic days by 19%, to 55%.

Bottom line: Avoidable antibiotic exposure frequently occurs in the treatment of uncomplicated skin infections; using short-course, single-antibiotic treatment strategies could significantly reduce total antibiotic use.

Citation: Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med. 2013;126(12):1099-1106.

Warfarin Initiation in Atrial Fibrillation Associated with Increased Short-Term Risk of Stroke

Clinical question: Is the initiation of warfarin associated with an increased risk of ischemic stroke in patients with atrial fibrillation (Afib)?

Background: Two Afib trials of oral factor Xa inhibitors showed an increased risk of stroke when patients were transitioned to open label warfarin at the end of the study. Warfarin can, theoretically, lead to a transient hypercoagulable state upon treatment initiation, so further study is indicated to determine if the initiation of warfarin is associated with increased stroke risk among Afib patients.

Study design: Population-based, nested case-control.

Setting: UK Clinical Practice Research Datalink.

Synopsis: A cohort of 70,766 patients with newly diagnosed Afib was identified from a large primary care database. Conditional logistic regression was used to estimate adjusted rate ratios (RR) of stroke associated with warfarin monotherapy, classified according to time since initiation of treatment when compared to patients not on antithrombotic therapy.

Warfarin was associated with a 71% increased risk of stroke in the first 30 days of use (RR 1.71, 95% CI 1.39-2.12). Risk was highest in the first week of warfarin treatment, which is consistent with the known transient pro-coagulant effect of warfarin. Decreased risks were observed with warfarin initiation >30 days before the ischemic event (31-90 days: RR 0.50, 95% CI 0.34-0.75; >90 days: RR 0.55, 95% CI 0.50-0.61).

Limitations included the extraction of data from a database, which could lead to misclassification of diagnosis or therapy, and the observational nature of the study.

Bottom line: There may be an increased risk of ischemic stroke during the first 30 days of treatment with warfarin in patients with Afib.

Citation: Azoulay L, Dell-Aniello S, Simon T, Renoux C, Suissa S. Initiation of warfarin in patients with atrial fibrillation: early effects on ischaemic strokes [published online ahead of print December 18, 2013]. Eur Heart J.

Multifaceted Discharge Interventions Reduce Rates of Pediatric Readmission and Post-Hospital ED Utilization

Clinical question: Do interventions at discharge reduce the rate of readmissions and post-hospitalization ED visits among pediatric patients?

Background: Readmissions are a high-priority quality measure in both the adult and pediatric settings. Although a broadening body of literature is evaluating the impact of interventions on readmissions in adult populations, the literature does not contain a similar breadth of assessments of interventions in the pediatric setting.

Study design: Systematic review.

Setting: English-language articles studying pediatric inpatient discharge interventions.

Synopsis: A total of 1,296 unique articles were identified from PubMed and the Cumulative Index to Nursing and Allied Health Literature. Additional articles were identified on review of references, yielding 14 articles that met inclusion criteria. Included studies evaluated the effect of pediatric discharge interventions on the primary outcomes of hospital readmission or post-hospitalization ED visits. Interventions focused on three main patient populations: asthma, cancer, and prematurity.

Six studies demonstrated statistically significant reductions in readmissions and/or ED visits, while two studies actually demonstrated an increase in post-discharge utilization. All successful interventions began in the inpatient setting and were multifaceted, with four of six studies including an educational component and a post-discharge follow-up component.

While all of the studies evaluated sought to enhance the transitional care from the inpatient to outpatient setting, only the interventions that included one responsible party (individual or team) with expertise in the medical condition providing oversight and support were successful in reducing the specified outcomes. A significant limitation was that many of the studies identified were not sufficiently powered to detect either outcome of interest.

Bottom line: A multifaceted intervention involving educational and post-discharge follow-up components with an experienced individual or team supporting the transition is associated with a reduction in hospital readmissions and post-discharge ED utilization.

Citation: Auger KA, Kenyon CC, Feudtner C, Davis MM. Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review [published online ahead of print December 20, 2013]. J Hosp Med.

Sepsis Diagnoses Are Common in ED, but Many Septic Patients in the ED Do Not Receive Antibiotics

Clinical question: Has the frequency of sepsis rates, along with administration of antibiotics in U.S. emergency departments (EDs), changed over time?

Background: Prior studies reviewing discharge data from hospitals suggest an increase of sepsis over time; however, little epidemiological research has evaluated the diagnosis of sepsis and antibiotic use in ED settings.

Study design: Retrospective, four-stage probability sample.

Setting: National Hospital Ambulatory Medical Care Survey (NHAMCS).

Synopsis: The NHAMCS includes a sample of all U.S. ED visits, except federal, military, and VA hospitals. According to NHAMCS data, an estimated 1.3 billion visits by adults to U.S. EDs occurred from 1994-2009, or approximately 81 million visits per year. Explicit sepsis was defined by the presence of the following, with ICD-9 codes: septicemia (038), sepsis (995.91), severe sepsis (995.92), or septic shock (785.52). Implicit sepsis was defined as a code indicating infection plus a code indicting organ dysfunction.

In U.S. EDs, explicit sepsis did not become more prevalent from 1994-2009; however, implicitly diagnosed sepsis increased by 7% every two years. There were 260,000 explicit sepsis-related ED visits per year, or 1.23 visits per 1,000 U.S. population. In-hospital mortality was 17% and 9% for the explicit and implicit diagnosis groups, respectively. On review of the explicit sepsis group, only 61% of the patients were found to have received antibiotics in the ED. The rate did increase over the time studied, from 52% in 1994-1997 to 69% in 2006-2009.

The study was limited by the retrospective analysis of data not designed to track sepsis or antibiotic use.

Bottom Line: Explicitly recognized sepsis remained stable in the ED setting from 1994-2009, and early antibiotic use has improved during this time, but there is still much opportunity for improvement.

Citation: Filbin MR, Arias SA, Camargo CA Jr, Barche A, Pallin DJ. Sepsis visits and antibiotic utilization in the U.S. emergency departments. Crit Care Med. 2014;42(3):528-535.

New Oral Anticoagulants Safe and Effective for Atrial Fibrillation Treatment

Clinical question: Is there a difference in efficacy and safety among new oral anticoagulants compared to warfarin in subgroups of patients with atrial fibrillation (Afib)?

Background: Studies of new oral anticoagulants have demonstrated that these agents are at least as safe and effective as warfarin for prevention of stroke and systemic embolism in Afib. This study was designed to look at available phase 3 randomized trials, with the goal of subgroup analysis for both efficacy and bleeding risks.

Study design: Meta-analysis.

Setting: Phase 3 randomized controlled trials of patients with Afib.

Synopsis: The analysis included four trials of Afib patients randomized to receive warfarin or a novel oral anticoagulant (NOAC), including dabigatran, rivaroxaban, apixaban, and edoxaban. In total, 42,411 patients received an NOAC and 29,272 patients received warfarin. Separate analyses were performed for high-dose and low-dose NOACs.

The high-dose NOAC demonstrated a 19% reduction in stroke and systemic embolic events as compared to warfarin, largely due to the reduction of hemorrhagic strokes by the NOAC. The low-dose NOAC showed similar efficacy to warfarin for reduction of stroke and systemic embolic events, with an increase noted in the subset of ischemic stroke in low-dose NOAC. Both doses of NOAC demonstrated a significant reduction in all-cause mortality. NOAC showed a non-significant reduction in bleeding compared to warfarin; however, subset analysis demonstrated an increase in gastrointestinal bleeding with high-dose NOAC and a significant reduction in intracranial hemorrhage with low-dose NOAC.

A notable limitation of the study is that it only included clinical trials in the analysis.

Bottom line: In relation to stroke, systemic embolic events, and all-cause mortality, new oral anticoagulants showed a favorable efficacy and safety profile as compared to warfarin in Afib patients.

Citation: Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962.

LAS VEGAS—Hospitalist Amy Knight, MD, isn’t a chief medical informatics officer (CMIO). She calls herself a “CMIO lite,” a nod to her title as medical advisor to the department of information services at her home hospital, Johns Hopkins Bayview Medical Center in Baltimore.

But, CMIO or not, she was among the first cohort of 450 medical professionals to be board-certified in medical informatics last fall after an exam for the specialty was created by the American Board of Medical Specialties.

Now Dr. Knight, who serves as a technology advocate for SHM, thinks more hospitalists should follow her lead.

“I had a little chip on my shoulder because I didn’t do a fellowship in informatics,” said Dr. Knight, who nonetheless worked on Bayview’s implementation of computerized provider order entry and electronic provider documentation systems. “I wanted some sort of recognition for everything I’d been doing. We’re already doing it, so let’s get some recognition for it, some credentials—and also, some standards for what the minimum needed to do a good job are.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee, agrees. He wants as many hospitalists as possible to “establish ourselves for the informatics role we have taken.”

Whether it was lamenting clunky electronic health records (EHR) systems, discussing Dr. Rogers’ push for so-called “techno-docs” to consider the new board certification, or lobbying for people to interact more with SHM’s Hospital Medicine Exchange (HMX), hospitalists at HM14 took the opportunity to focus on the growing pains of health information technology (IT).

For Mohammed Morad, MD, a hospitalist at Indiana University Health Ball Memorial Hospital in Muncie, the paramount frustration is the trouble providers have with EHR systems that are built for physicians but don’t seem to consider the end user.

“These EHRs are designed to make your billing easier,” Dr. Morad said. “[They’re] not designed for patient safety or quality measures. Now they’re trying to implement some of these tools, but the usability...is very challenging, especially for physicians who are not tech-savvy enough. Even [for] newly graduated doctors with iPhones, it’s still a challenge. It’s not user-friendly.”

Dr. Morad’s biggest frustration with the technology is how time-consuming it is. Although electronic input is clearly more advanced, more communal, and more privacy-focused than hand-written notes, current systems that require physicians to spend hours upon hours building order sets or typing out notes waste too much valuable time, he said.

“You spend more time with these EHRs than you spend with your patients, because you have to put the orders in, you have to write the note, you have to look at previous reports,” Dr. Morad added. “In a way, it helps in gathering the information that you need in one place so before I even see the patient I know what the echo[cardiogram] showed, what the chest X-ray showed, what the previous consultant had seen....but how easy is it to get all this? It takes more time than it should.”

Despite expressing frustration with current systems, most hospitalists are cautiously optimistic about advances in technology. Dr. Morad is hopeful that future iterations of the systems will be “more intuitive” and consider physicians’ needs instead of creating templates that individual institutions have to spend time and money customizing.

“Compared to any other software, they’re behind,” he said. “They’re not going to get better unless some people step up and try to make them better, especially from a physician perspective.”

Gaurav Chaturvedi, MD, head of the hospitalist team at Northwestern Lake Forest (Ill.) Hospital and chair of SHM’s IT Quality Subcommittee, said part of the problem is that vendors have a captive audience. Hospitals are motivated to take advantage of health IT incentive payments, which were funded under the Health Information Technology for Economic and Clinical Health Act provisions of the American Recovery and Reinvestment Act of 2009. Because healthcare reform is pushing the industry to digitize medical records, IT firms have built-in customers. That, Dr. Chaturvedi said, has stifled competition and hampered innovations tailored to doctors’ needs.

Hospitalists must work together to discuss end-user issues and prompt improvement, he added. To that end, SHM technology committees are working on white papers that will recommend best practices related to health information technology. While the papers are still in the planning and polishing phase, the idea is to view the overall landscape to give HM group leaders a framework of what they should be focused on.

“We want to keep vendor-neutral,” Dr. Chaturvedi said. “We all have the same types of issues to work with. We should work it out together.”

Dr. Rogers noted that SHM has met proactively with vendors to provide input on potential improvements, but that the process is ongoing and will likely take years.

“The best is still pretty bad out there,” he added.

Meanwhile, he urged hospitalists to share concerns, complaints, and success stories via HMX, an online portal hospitalists can use to communicate their views on a variety of topics, post responses, and share files. The online community—launched three years ago but rebranded under its current name in 2012—can be a repository for advice, ideas, or commiseration but is useful only if it is adopted. If more hospitalists log into the system and begin to use it, participation will breed greater value and vice versa, he added.

“We’re still in the build-up phase,” Dr. Rogers said. “We want to get people in all discussion forums to a tipping point.”

LAS VEGAS—Hospitalist Amy Knight, MD, isn’t a chief medical informatics officer (CMIO). She calls herself a “CMIO lite,” a nod to her title as medical advisor to the department of information services at her home hospital, Johns Hopkins Bayview Medical Center in Baltimore.

But, CMIO or not, she was among the first cohort of 450 medical professionals to be board-certified in medical informatics last fall after an exam for the specialty was created by the American Board of Medical Specialties.

Now Dr. Knight, who serves as a technology advocate for SHM, thinks more hospitalists should follow her lead.

“I had a little chip on my shoulder because I didn’t do a fellowship in informatics,” said Dr. Knight, who nonetheless worked on Bayview’s implementation of computerized provider order entry and electronic provider documentation systems. “I wanted some sort of recognition for everything I’d been doing. We’re already doing it, so let’s get some recognition for it, some credentials—and also, some standards for what the minimum needed to do a good job are.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee, agrees. He wants as many hospitalists as possible to “establish ourselves for the informatics role we have taken.”

Whether it was lamenting clunky electronic health records (EHR) systems, discussing Dr. Rogers’ push for so-called “techno-docs” to consider the new board certification, or lobbying for people to interact more with SHM’s Hospital Medicine Exchange (HMX), hospitalists at HM14 took the opportunity to focus on the growing pains of health information technology (IT).

For Mohammed Morad, MD, a hospitalist at Indiana University Health Ball Memorial Hospital in Muncie, the paramount frustration is the trouble providers have with EHR systems that are built for physicians but don’t seem to consider the end user.

“These EHRs are designed to make your billing easier,” Dr. Morad said. “[They’re] not designed for patient safety or quality measures. Now they’re trying to implement some of these tools, but the usability...is very challenging, especially for physicians who are not tech-savvy enough. Even [for] newly graduated doctors with iPhones, it’s still a challenge. It’s not user-friendly.”

Dr. Morad’s biggest frustration with the technology is how time-consuming it is. Although electronic input is clearly more advanced, more communal, and more privacy-focused than hand-written notes, current systems that require physicians to spend hours upon hours building order sets or typing out notes waste too much valuable time, he said.

“You spend more time with these EHRs than you spend with your patients, because you have to put the orders in, you have to write the note, you have to look at previous reports,” Dr. Morad added. “In a way, it helps in gathering the information that you need in one place so before I even see the patient I know what the echo[cardiogram] showed, what the chest X-ray showed, what the previous consultant had seen....but how easy is it to get all this? It takes more time than it should.”

Despite expressing frustration with current systems, most hospitalists are cautiously optimistic about advances in technology. Dr. Morad is hopeful that future iterations of the systems will be “more intuitive” and consider physicians’ needs instead of creating templates that individual institutions have to spend time and money customizing.

“Compared to any other software, they’re behind,” he said. “They’re not going to get better unless some people step up and try to make them better, especially from a physician perspective.”

Gaurav Chaturvedi, MD, head of the hospitalist team at Northwestern Lake Forest (Ill.) Hospital and chair of SHM’s IT Quality Subcommittee, said part of the problem is that vendors have a captive audience. Hospitals are motivated to take advantage of health IT incentive payments, which were funded under the Health Information Technology for Economic and Clinical Health Act provisions of the American Recovery and Reinvestment Act of 2009. Because healthcare reform is pushing the industry to digitize medical records, IT firms have built-in customers. That, Dr. Chaturvedi said, has stifled competition and hampered innovations tailored to doctors’ needs.

Hospitalists must work together to discuss end-user issues and prompt improvement, he added. To that end, SHM technology committees are working on white papers that will recommend best practices related to health information technology. While the papers are still in the planning and polishing phase, the idea is to view the overall landscape to give HM group leaders a framework of what they should be focused on.

“We want to keep vendor-neutral,” Dr. Chaturvedi said. “We all have the same types of issues to work with. We should work it out together.”

Dr. Rogers noted that SHM has met proactively with vendors to provide input on potential improvements, but that the process is ongoing and will likely take years.

“The best is still pretty bad out there,” he added.

Meanwhile, he urged hospitalists to share concerns, complaints, and success stories via HMX, an online portal hospitalists can use to communicate their views on a variety of topics, post responses, and share files. The online community—launched three years ago but rebranded under its current name in 2012—can be a repository for advice, ideas, or commiseration but is useful only if it is adopted. If more hospitalists log into the system and begin to use it, participation will breed greater value and vice versa, he added.

“We’re still in the build-up phase,” Dr. Rogers said. “We want to get people in all discussion forums to a tipping point.”

LAS VEGAS—Hospitalist Amy Knight, MD, isn’t a chief medical informatics officer (CMIO). She calls herself a “CMIO lite,” a nod to her title as medical advisor to the department of information services at her home hospital, Johns Hopkins Bayview Medical Center in Baltimore.

But, CMIO or not, she was among the first cohort of 450 medical professionals to be board-certified in medical informatics last fall after an exam for the specialty was created by the American Board of Medical Specialties.

Now Dr. Knight, who serves as a technology advocate for SHM, thinks more hospitalists should follow her lead.

“I had a little chip on my shoulder because I didn’t do a fellowship in informatics,” said Dr. Knight, who nonetheless worked on Bayview’s implementation of computerized provider order entry and electronic provider documentation systems. “I wanted some sort of recognition for everything I’d been doing. We’re already doing it, so let’s get some recognition for it, some credentials—and also, some standards for what the minimum needed to do a good job are.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee, agrees. He wants as many hospitalists as possible to “establish ourselves for the informatics role we have taken.”

Whether it was lamenting clunky electronic health records (EHR) systems, discussing Dr. Rogers’ push for so-called “techno-docs” to consider the new board certification, or lobbying for people to interact more with SHM’s Hospital Medicine Exchange (HMX), hospitalists at HM14 took the opportunity to focus on the growing pains of health information technology (IT).

For Mohammed Morad, MD, a hospitalist at Indiana University Health Ball Memorial Hospital in Muncie, the paramount frustration is the trouble providers have with EHR systems that are built for physicians but don’t seem to consider the end user.

“These EHRs are designed to make your billing easier,” Dr. Morad said. “[They’re] not designed for patient safety or quality measures. Now they’re trying to implement some of these tools, but the usability...is very challenging, especially for physicians who are not tech-savvy enough. Even [for] newly graduated doctors with iPhones, it’s still a challenge. It’s not user-friendly.”

Dr. Morad’s biggest frustration with the technology is how time-consuming it is. Although electronic input is clearly more advanced, more communal, and more privacy-focused than hand-written notes, current systems that require physicians to spend hours upon hours building order sets or typing out notes waste too much valuable time, he said.

“You spend more time with these EHRs than you spend with your patients, because you have to put the orders in, you have to write the note, you have to look at previous reports,” Dr. Morad added. “In a way, it helps in gathering the information that you need in one place so before I even see the patient I know what the echo[cardiogram] showed, what the chest X-ray showed, what the previous consultant had seen....but how easy is it to get all this? It takes more time than it should.”

Despite expressing frustration with current systems, most hospitalists are cautiously optimistic about advances in technology. Dr. Morad is hopeful that future iterations of the systems will be “more intuitive” and consider physicians’ needs instead of creating templates that individual institutions have to spend time and money customizing.

“Compared to any other software, they’re behind,” he said. “They’re not going to get better unless some people step up and try to make them better, especially from a physician perspective.”

Gaurav Chaturvedi, MD, head of the hospitalist team at Northwestern Lake Forest (Ill.) Hospital and chair of SHM’s IT Quality Subcommittee, said part of the problem is that vendors have a captive audience. Hospitals are motivated to take advantage of health IT incentive payments, which were funded under the Health Information Technology for Economic and Clinical Health Act provisions of the American Recovery and Reinvestment Act of 2009. Because healthcare reform is pushing the industry to digitize medical records, IT firms have built-in customers. That, Dr. Chaturvedi said, has stifled competition and hampered innovations tailored to doctors’ needs.

Hospitalists must work together to discuss end-user issues and prompt improvement, he added. To that end, SHM technology committees are working on white papers that will recommend best practices related to health information technology. While the papers are still in the planning and polishing phase, the idea is to view the overall landscape to give HM group leaders a framework of what they should be focused on.

“We want to keep vendor-neutral,” Dr. Chaturvedi said. “We all have the same types of issues to work with. We should work it out together.”

Dr. Rogers noted that SHM has met proactively with vendors to provide input on potential improvements, but that the process is ongoing and will likely take years.

“The best is still pretty bad out there,” he added.

Meanwhile, he urged hospitalists to share concerns, complaints, and success stories via HMX, an online portal hospitalists can use to communicate their views on a variety of topics, post responses, and share files. The online community—launched three years ago but rebranded under its current name in 2012—can be a repository for advice, ideas, or commiseration but is useful only if it is adopted. If more hospitalists log into the system and begin to use it, participation will breed greater value and vice versa, he added.

“We’re still in the build-up phase,” Dr. Rogers said. “We want to get people in all discussion forums to a tipping point.”

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LAS VEGAS—To an untrained eye, the poster looked a lot like the hundreds of others that lined the exhibit hall here at Mandalay Bay Resort and Casino. But this one belonged to hospitalist Cathy Jones, MD, an associate chief medical officer (CMO) for medical services at Wake Forest Baptist Medical Center in Winston-Salem, N.C.

The poster, “The Daily Safety Check-In: A Strategy For Reducing Serious Harm to Patients,” highlighted the hospital’s use of a daily safety check-in (DSCI) that gathers hospitalists, nurses, infection-control staff, and at least one representative from its CMO office to discuss the patient census. The meeting—held without fail each morning at 9:05, 365 days a year, including holidays—takes at least 30 minutes, time that might seem like too much to some observers who couldn’t imagine squeezing another half-hour meeting into their schedule.

But to Dr. Jones, the DSCI is worth every second, and she wanted—practically needed—to share it. “We think this is saving lives in our organization,” she says. “Maybe somebody else will see this and say, ‘We could do that,’ and maybe it would make a difference there, too.”

Therein lies the point of the annual Research, Innovations, and Clinical Vignettes (RIV) poster competition: hospitalists sharing profound thoughts, creative pilot programs, and unique cases with their brethren from around the country.

“Sometimes you’re so close to a problem, you just can’t figure it out,” says Dr. Jones, whose poster came in second place in the Innovations category. “You keep trying the same old things and they don’t work. Then you come here and you say, ‘Oh, they’ve done some training (on) that problem at our hospital.’ And often you have the opportunity to talk to the person and say, “Tell me, what’s your curriculum? Who teaches it?’... This sharing of ideas is what’s so nice about the poster sessions.”

Some ideas, such as Dr. Jones’ DSCI, might seem too big to tackle. Others, like a paper presented by third-year internal medicine resident Lekshmi Santhosh, MD, from the University of California at San Francisco (UCSF), can be as simple as an innovative update on how doctors send and receive electronic pages.

Dr. Santhosh’s poster, “CareWeb Messenger: A Facebook/Twitter/Paging Hybrid for Collaborative Care,” showcases a web-based paging tool that combines features of Facebook and Twitter and allows users to send, receive, view, search, and store messages on a patient’s “wall,” while routing each message to a provider’s pager and wireless phone. The idea is to ease the perceived burden of answering pages while also improving communication skills.

The concept resonates well; a panel of judges awarded it the best poster by a trainee in the Innovations competition. And, while Dr. Santhosh was humbly honored, she says talking to other physicians is the reason she was excited to present.

“Somebody from (the University of Pennsylvania) came up to me—totally opposite coast—and he showed me what they’re using, which is basically an SMS text-based system,” Dr. Santhosh adds. “I was sharing ideas with him. I would never have been able to meet him or even hear about what they’re doing at Penn if not for forums like this.”

The ability to crowd-source ideas at the poster competition appealed to Susan Hunt, MD, a hospitalist at Seattle Children’s Hospital and the University of Washington Medical Center and one of SHM’s judges for the Innovations portion of the poster competition. Dr. Hunt says it’s difficult choosing winners because there are so many good presentations, but, more importantly, hospitalists should use the competition as a chance to see the best of the best and then pick out concepts that might work at their hospital.

“How translatable is it?” Dr. Hunt says, listing off judging criteria. “How applicable is it to the general hospitalist population? Community hospitalists? Academic hospitalists? How will this help them provide better care for their patients, better job satisfaction, better training? Some of the ones that didn’t win are still great ideas.”

Take the project presented by a trio of hospitalists from Rush University Medical Center in Chicago. The poster, “Guidelines, Education, and Email Alerts Can Decrease Transfusions in General Medicine Patients,” explained a project to “increase adherence to a restrictive transfusion guideline for patients admitted to general medicine floors.” The intervention suggested a transfusion threshold of Hgb<7 in upper GI bleed patients, except in cases of hemodynamic instability. In all other indications, the threshold was Hgb<8.

The research found that when samples from three months before the intervention were compared with samples collected three months post-intervention, the number of transfused units dropped to 273 from 481. In the pre-intervention sample, there were 95 units of blood delivered with a pre-transfusion Hgb>8; in the post-intervention group, only 18 units were delivered.

But Rush hospitalist Jisu Kim, MD, FHM, isn’t stopping with a poster. “This is one of the endpoints,” Dr. Kim says. “We want to see how much further we can go. Can this be a publishable paper? What’s the next step for our other projects? We’re getting motivated by it.”

Dr. Kim believes that in addition to sharing information, getting the next generation of physicians involved in the poster competition inspires young physicians to further engage in their specialty. To that end, residents Manya Gupta, MD, and Lesley Schmaltz, MD, say they are grateful to be part of the presentation.

“It’s very rewarding because it makes you want to keep moving forward and keep making those improvements,” says Dr. Schmaltz. “That’s why I think we all do our posters and presentations: to help the greater good of all physicians throughout the country.”

“It’s been a really great learning experience to get your feet wet,” Dr. Gupta says. “You just have to try it out once and find out what it’s like; otherwise it seems so daunting. Then you realize, ‘We can do this.’”

LAS VEGAS—To an untrained eye, the poster looked a lot like the hundreds of others that lined the exhibit hall here at Mandalay Bay Resort and Casino. But this one belonged to hospitalist Cathy Jones, MD, an associate chief medical officer (CMO) for medical services at Wake Forest Baptist Medical Center in Winston-Salem, N.C.

The poster, “The Daily Safety Check-In: A Strategy For Reducing Serious Harm to Patients,” highlighted the hospital’s use of a daily safety check-in (DSCI) that gathers hospitalists, nurses, infection-control staff, and at least one representative from its CMO office to discuss the patient census. The meeting—held without fail each morning at 9:05, 365 days a year, including holidays—takes at least 30 minutes, time that might seem like too much to some observers who couldn’t imagine squeezing another half-hour meeting into their schedule.

But to Dr. Jones, the DSCI is worth every second, and she wanted—practically needed—to share it. “We think this is saving lives in our organization,” she says. “Maybe somebody else will see this and say, ‘We could do that,’ and maybe it would make a difference there, too.”

Therein lies the point of the annual Research, Innovations, and Clinical Vignettes (RIV) poster competition: hospitalists sharing profound thoughts, creative pilot programs, and unique cases with their brethren from around the country.

“Sometimes you’re so close to a problem, you just can’t figure it out,” says Dr. Jones, whose poster came in second place in the Innovations category. “You keep trying the same old things and they don’t work. Then you come here and you say, ‘Oh, they’ve done some training (on) that problem at our hospital.’ And often you have the opportunity to talk to the person and say, “Tell me, what’s your curriculum? Who teaches it?’... This sharing of ideas is what’s so nice about the poster sessions.”

Some ideas, such as Dr. Jones’ DSCI, might seem too big to tackle. Others, like a paper presented by third-year internal medicine resident Lekshmi Santhosh, MD, from the University of California at San Francisco (UCSF), can be as simple as an innovative update on how doctors send and receive electronic pages.

Dr. Santhosh’s poster, “CareWeb Messenger: A Facebook/Twitter/Paging Hybrid for Collaborative Care,” showcases a web-based paging tool that combines features of Facebook and Twitter and allows users to send, receive, view, search, and store messages on a patient’s “wall,” while routing each message to a provider’s pager and wireless phone. The idea is to ease the perceived burden of answering pages while also improving communication skills.

The concept resonates well; a panel of judges awarded it the best poster by a trainee in the Innovations competition. And, while Dr. Santhosh was humbly honored, she says talking to other physicians is the reason she was excited to present.

“Somebody from (the University of Pennsylvania) came up to me—totally opposite coast—and he showed me what they’re using, which is basically an SMS text-based system,” Dr. Santhosh adds. “I was sharing ideas with him. I would never have been able to meet him or even hear about what they’re doing at Penn if not for forums like this.”

The ability to crowd-source ideas at the poster competition appealed to Susan Hunt, MD, a hospitalist at Seattle Children’s Hospital and the University of Washington Medical Center and one of SHM’s judges for the Innovations portion of the poster competition. Dr. Hunt says it’s difficult choosing winners because there are so many good presentations, but, more importantly, hospitalists should use the competition as a chance to see the best of the best and then pick out concepts that might work at their hospital.

“How translatable is it?” Dr. Hunt says, listing off judging criteria. “How applicable is it to the general hospitalist population? Community hospitalists? Academic hospitalists? How will this help them provide better care for their patients, better job satisfaction, better training? Some of the ones that didn’t win are still great ideas.”

Take the project presented by a trio of hospitalists from Rush University Medical Center in Chicago. The poster, “Guidelines, Education, and Email Alerts Can Decrease Transfusions in General Medicine Patients,” explained a project to “increase adherence to a restrictive transfusion guideline for patients admitted to general medicine floors.” The intervention suggested a transfusion threshold of Hgb<7 in upper GI bleed patients, except in cases of hemodynamic instability. In all other indications, the threshold was Hgb<8.

The research found that when samples from three months before the intervention were compared with samples collected three months post-intervention, the number of transfused units dropped to 273 from 481. In the pre-intervention sample, there were 95 units of blood delivered with a pre-transfusion Hgb>8; in the post-intervention group, only 18 units were delivered.

But Rush hospitalist Jisu Kim, MD, FHM, isn’t stopping with a poster. “This is one of the endpoints,” Dr. Kim says. “We want to see how much further we can go. Can this be a publishable paper? What’s the next step for our other projects? We’re getting motivated by it.”

Dr. Kim believes that in addition to sharing information, getting the next generation of physicians involved in the poster competition inspires young physicians to further engage in their specialty. To that end, residents Manya Gupta, MD, and Lesley Schmaltz, MD, say they are grateful to be part of the presentation.

“It’s very rewarding because it makes you want to keep moving forward and keep making those improvements,” says Dr. Schmaltz. “That’s why I think we all do our posters and presentations: to help the greater good of all physicians throughout the country.”

“It’s been a really great learning experience to get your feet wet,” Dr. Gupta says. “You just have to try it out once and find out what it’s like; otherwise it seems so daunting. Then you realize, ‘We can do this.’”

LAS VEGAS—To an untrained eye, the poster looked a lot like the hundreds of others that lined the exhibit hall here at Mandalay Bay Resort and Casino. But this one belonged to hospitalist Cathy Jones, MD, an associate chief medical officer (CMO) for medical services at Wake Forest Baptist Medical Center in Winston-Salem, N.C.

The poster, “The Daily Safety Check-In: A Strategy For Reducing Serious Harm to Patients,” highlighted the hospital’s use of a daily safety check-in (DSCI) that gathers hospitalists, nurses, infection-control staff, and at least one representative from its CMO office to discuss the patient census. The meeting—held without fail each morning at 9:05, 365 days a year, including holidays—takes at least 30 minutes, time that might seem like too much to some observers who couldn’t imagine squeezing another half-hour meeting into their schedule.

But to Dr. Jones, the DSCI is worth every second, and she wanted—practically needed—to share it. “We think this is saving lives in our organization,” she says. “Maybe somebody else will see this and say, ‘We could do that,’ and maybe it would make a difference there, too.”

Therein lies the point of the annual Research, Innovations, and Clinical Vignettes (RIV) poster competition: hospitalists sharing profound thoughts, creative pilot programs, and unique cases with their brethren from around the country.

“Sometimes you’re so close to a problem, you just can’t figure it out,” says Dr. Jones, whose poster came in second place in the Innovations category. “You keep trying the same old things and they don’t work. Then you come here and you say, ‘Oh, they’ve done some training (on) that problem at our hospital.’ And often you have the opportunity to talk to the person and say, “Tell me, what’s your curriculum? Who teaches it?’... This sharing of ideas is what’s so nice about the poster sessions.”

Some ideas, such as Dr. Jones’ DSCI, might seem too big to tackle. Others, like a paper presented by third-year internal medicine resident Lekshmi Santhosh, MD, from the University of California at San Francisco (UCSF), can be as simple as an innovative update on how doctors send and receive electronic pages.

Dr. Santhosh’s poster, “CareWeb Messenger: A Facebook/Twitter/Paging Hybrid for Collaborative Care,” showcases a web-based paging tool that combines features of Facebook and Twitter and allows users to send, receive, view, search, and store messages on a patient’s “wall,” while routing each message to a provider’s pager and wireless phone. The idea is to ease the perceived burden of answering pages while also improving communication skills.

The concept resonates well; a panel of judges awarded it the best poster by a trainee in the Innovations competition. And, while Dr. Santhosh was humbly honored, she says talking to other physicians is the reason she was excited to present.

“Somebody from (the University of Pennsylvania) came up to me—totally opposite coast—and he showed me what they’re using, which is basically an SMS text-based system,” Dr. Santhosh adds. “I was sharing ideas with him. I would never have been able to meet him or even hear about what they’re doing at Penn if not for forums like this.”

The ability to crowd-source ideas at the poster competition appealed to Susan Hunt, MD, a hospitalist at Seattle Children’s Hospital and the University of Washington Medical Center and one of SHM’s judges for the Innovations portion of the poster competition. Dr. Hunt says it’s difficult choosing winners because there are so many good presentations, but, more importantly, hospitalists should use the competition as a chance to see the best of the best and then pick out concepts that might work at their hospital.

“How translatable is it?” Dr. Hunt says, listing off judging criteria. “How applicable is it to the general hospitalist population? Community hospitalists? Academic hospitalists? How will this help them provide better care for their patients, better job satisfaction, better training? Some of the ones that didn’t win are still great ideas.”

Take the project presented by a trio of hospitalists from Rush University Medical Center in Chicago. The poster, “Guidelines, Education, and Email Alerts Can Decrease Transfusions in General Medicine Patients,” explained a project to “increase adherence to a restrictive transfusion guideline for patients admitted to general medicine floors.” The intervention suggested a transfusion threshold of Hgb<7 in upper GI bleed patients, except in cases of hemodynamic instability. In all other indications, the threshold was Hgb<8.

The research found that when samples from three months before the intervention were compared with samples collected three months post-intervention, the number of transfused units dropped to 273 from 481. In the pre-intervention sample, there were 95 units of blood delivered with a pre-transfusion Hgb>8; in the post-intervention group, only 18 units were delivered.

But Rush hospitalist Jisu Kim, MD, FHM, isn’t stopping with a poster. “This is one of the endpoints,” Dr. Kim says. “We want to see how much further we can go. Can this be a publishable paper? What’s the next step for our other projects? We’re getting motivated by it.”

Dr. Kim believes that in addition to sharing information, getting the next generation of physicians involved in the poster competition inspires young physicians to further engage in their specialty. To that end, residents Manya Gupta, MD, and Lesley Schmaltz, MD, say they are grateful to be part of the presentation.

“It’s very rewarding because it makes you want to keep moving forward and keep making those improvements,” says Dr. Schmaltz. “That’s why I think we all do our posters and presentations: to help the greater good of all physicians throughout the country.”

“It’s been a really great learning experience to get your feet wet,” Dr. Gupta says. “You just have to try it out once and find out what it’s like; otherwise it seems so daunting. Then you realize, ‘We can do this.’”

LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.

Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.

“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”

Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.

Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”

After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”

John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”

“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”

Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.

“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.

He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.

“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”

In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.

An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.

“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”

Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.

“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”

One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.

“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”

The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.

And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.

“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”

LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.

Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.

“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”

Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.

Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”

After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”

John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”

“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”

Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.

“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.

He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.

“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”

In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.

An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.

“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”

Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.

“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”

One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.

“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”

The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.

And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.

“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”

LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.

Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.

“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”

Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.

Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”

After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”

John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”

“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”

Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.

“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.

He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.

“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”

In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.

An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.

“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”

Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.

“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”

One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.

“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”

The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.

And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.

“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”

LAS VEGAS—Susan Eschenburg, practice program manager at Independent Hospitalist Practice in Jackson, Mich., sat in the practice management pre-course at HM14 and listened to a panel of experts discuss hospitalists’ growing role in post-acute care centers such as skilled nursing facilities.

You could almost hear the bell go off in her head.

“We work in an underserved area, and we’ve just [been asked] if we would be interested in supplying a hospitalist in some of these nursing homes,” Eschenburg said. “We’re going to listen to a spiel next month about that. That was real-time and interesting to listen to.”

That was the point of the practice management sessions at SHM’s annual meeting here at the Mandalay Bay Resort and Casino: to give the most current updates available to administrators, group leaders, and rank-and-file hospitalists about best practices in the day-to-day operation of a group.

For Eschenburg, the lessons learned here are particularly helpful; her group just launched its hospitalist program in September and is dealing with a variety of implementation questions, including whether to use scribes to enhance patient-physician interaction, improve documentation, save physician time, and reduce technology-related errors. Other issues that resonate with her include scheduling and the amount of time that administrative leaders should spend in the clinical setting.

The meeting helped “[us] to see if there’s anything out there that we haven’t thought about or talked about,” Eschenburg said. “We’re not this big corporate giant that can’t make quick movements.”

Whether a hospitalist is working at a new practice in an underserved area or as a department head at a massive academic institution, a new white paper from SHM can provide information on how to move toward those best practices. “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” (http://onlinelibrary.wiley.com/doi/10.1002/jhm.2119/full), published in February in the Journal of Hospital Medicine, lists 10 guiding principles and 47 individual characteristics as a launching point for best practices.

Although the white paper is a first-of-its-kind initiative, SHM isn’t stopping there. Society staff and committee members are working to roll out a pilot program later this year that will ask group leaders to validate the key characteristics. SHM will provide back-up documentation, such as sample business plans or other toolkits, to implement some of the recommendations. Group leaders will be asked to use the documentation to determine whether or not it helps them achieve the goals.

“What we’re saying to you and your colleagues is that some of you aren’t performing necessarily at the best level you can. We want to give you a pathway to get better, because at the end of the day, we’re all in this to deliver the best care we can to our patients. So we recognize where we aren’t perfect, and we try to improve.”

–Dr. Wellikson

“One valuable thing that could come out of the pilot is not just feedback from you that will help us refine the key characteristics, but also ideas about resources that SHM can provide to help you better accomplish the things the key characteristics set forth,” said Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and a co-director for the popular practice management pre-course, “Where the Rubber Meets the Road: Managing in the Era of Healthcare Reform.”

Put more simply by Flores’ consulting colleague, John Nelson, MD, MHM, FACP: “We’ll learn from each other the best ways to do this.”

SHM senior vice president Joe Miller added that the white paper “simply identifies the characteristics and includes a rationale as to why they’re included.” The pilot program, however, will produce “a more enriched tool that you can use in a more directed fashion,” Miller said, “but we felt it was important to get this out right now and get the sense that we’ve identified the right issues.”

SHM CEO Larry Wellikson, MD, SFHM, said the initiative is “bold” and encouraged HM groups that are below standard in any area to step up their games.

“What we’re saying to you and your colleagues is that some of you aren’t performing necessarily at the best level you can,” Dr. Wellikson said. “We want to give you a pathway to get better, because at the end of the day, we’re all in this to deliver the best care we can to our patients. So we recognize where we aren’t perfect, and we try to improve.”

Those seeking practice management advice said they’re always thinking about ways to improve, and being with 3,600 like-minded folks often helps tease out tidbits and strategies to get better.

Sunil Kartham, MD, a hospitalist at Altru Health System in Grand Forks, N.D., said he enjoys hearing HM leaders give advice, whether they’re practice administrators in individual sessions or keynote speakers in large ballrooms.

“When you’re [an] individual physician, you don’t know what to expect in the future,” Dr. Kartham said. “When the leaders come and speak, they lay out a map for you…so you can prepare yourself.”

Preparing for what the future might bring is what drew Angelo Barile, MD, to the meeting. As the head of the hospitalist group at Cleveland Clinic Lorain Family Health and Surgery Center in Lorain, Ohio, he’s always looking for tips on how to improve the practical side of running a 12-FTE group.

“It helps to see how other people do it, and you get a nice framework of how to do it,” said Dr. Barile. “As busy as we are, running the group [and] seeing patients, it’s nice to get away from the pager [and] get away from my administrators and my bosses and say, ‘I want to try to learn something here.’ It is refreshing.”

Education doesn’t end with the meeting’s finale. Dr. Barile traditionally holds a sit-down with his staff as soon as he returns home. The doctors discuss the new ideas Dr. Barile learned and determine as a group what could work in their practice.

Eschenburg, the nascent program manager in Michigan, said she gets the same reaction when she returns from professional meetings.

“It’s certainly something that people are looking for when you get back,” she said. “What did you learn? What can you share with us?”

LAS VEGAS—Susan Eschenburg, practice program manager at Independent Hospitalist Practice in Jackson, Mich., sat in the practice management pre-course at HM14 and listened to a panel of experts discuss hospitalists’ growing role in post-acute care centers such as skilled nursing facilities.

You could almost hear the bell go off in her head.

“We work in an underserved area, and we’ve just [been asked] if we would be interested in supplying a hospitalist in some of these nursing homes,” Eschenburg said. “We’re going to listen to a spiel next month about that. That was real-time and interesting to listen to.”

That was the point of the practice management sessions at SHM’s annual meeting here at the Mandalay Bay Resort and Casino: to give the most current updates available to administrators, group leaders, and rank-and-file hospitalists about best practices in the day-to-day operation of a group.

For Eschenburg, the lessons learned here are particularly helpful; her group just launched its hospitalist program in September and is dealing with a variety of implementation questions, including whether to use scribes to enhance patient-physician interaction, improve documentation, save physician time, and reduce technology-related errors. Other issues that resonate with her include scheduling and the amount of time that administrative leaders should spend in the clinical setting.

The meeting helped “[us] to see if there’s anything out there that we haven’t thought about or talked about,” Eschenburg said. “We’re not this big corporate giant that can’t make quick movements.”

Whether a hospitalist is working at a new practice in an underserved area or as a department head at a massive academic institution, a new white paper from SHM can provide information on how to move toward those best practices. “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” (http://onlinelibrary.wiley.com/doi/10.1002/jhm.2119/full), published in February in the Journal of Hospital Medicine, lists 10 guiding principles and 47 individual characteristics as a launching point for best practices.

Although the white paper is a first-of-its-kind initiative, SHM isn’t stopping there. Society staff and committee members are working to roll out a pilot program later this year that will ask group leaders to validate the key characteristics. SHM will provide back-up documentation, such as sample business plans or other toolkits, to implement some of the recommendations. Group leaders will be asked to use the documentation to determine whether or not it helps them achieve the goals.

“What we’re saying to you and your colleagues is that some of you aren’t performing necessarily at the best level you can. We want to give you a pathway to get better, because at the end of the day, we’re all in this to deliver the best care we can to our patients. So we recognize where we aren’t perfect, and we try to improve.”

–Dr. Wellikson

“One valuable thing that could come out of the pilot is not just feedback from you that will help us refine the key characteristics, but also ideas about resources that SHM can provide to help you better accomplish the things the key characteristics set forth,” said Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and a co-director for the popular practice management pre-course, “Where the Rubber Meets the Road: Managing in the Era of Healthcare Reform.”

Put more simply by Flores’ consulting colleague, John Nelson, MD, MHM, FACP: “We’ll learn from each other the best ways to do this.”

SHM senior vice president Joe Miller added that the white paper “simply identifies the characteristics and includes a rationale as to why they’re included.” The pilot program, however, will produce “a more enriched tool that you can use in a more directed fashion,” Miller said, “but we felt it was important to get this out right now and get the sense that we’ve identified the right issues.”

SHM CEO Larry Wellikson, MD, SFHM, said the initiative is “bold” and encouraged HM groups that are below standard in any area to step up their games.

“What we’re saying to you and your colleagues is that some of you aren’t performing necessarily at the best level you can,” Dr. Wellikson said. “We want to give you a pathway to get better, because at the end of the day, we’re all in this to deliver the best care we can to our patients. So we recognize where we aren’t perfect, and we try to improve.”

Those seeking practice management advice said they’re always thinking about ways to improve, and being with 3,600 like-minded folks often helps tease out tidbits and strategies to get better.

Sunil Kartham, MD, a hospitalist at Altru Health System in Grand Forks, N.D., said he enjoys hearing HM leaders give advice, whether they’re practice administrators in individual sessions or keynote speakers in large ballrooms.

“When you’re [an] individual physician, you don’t know what to expect in the future,” Dr. Kartham said. “When the leaders come and speak, they lay out a map for you…so you can prepare yourself.”

Preparing for what the future might bring is what drew Angelo Barile, MD, to the meeting. As the head of the hospitalist group at Cleveland Clinic Lorain Family Health and Surgery Center in Lorain, Ohio, he’s always looking for tips on how to improve the practical side of running a 12-FTE group.

“It helps to see how other people do it, and you get a nice framework of how to do it,” said Dr. Barile. “As busy as we are, running the group [and] seeing patients, it’s nice to get away from the pager [and] get away from my administrators and my bosses and say, ‘I want to try to learn something here.’ It is refreshing.”

Education doesn’t end with the meeting’s finale. Dr. Barile traditionally holds a sit-down with his staff as soon as he returns home. The doctors discuss the new ideas Dr. Barile learned and determine as a group what could work in their practice.

Eschenburg, the nascent program manager in Michigan, said she gets the same reaction when she returns from professional meetings.

“It’s certainly something that people are looking for when you get back,” she said. “What did you learn? What can you share with us?”

LAS VEGAS—Susan Eschenburg, practice program manager at Independent Hospitalist Practice in Jackson, Mich., sat in the practice management pre-course at HM14 and listened to a panel of experts discuss hospitalists’ growing role in post-acute care centers such as skilled nursing facilities.

You could almost hear the bell go off in her head.

“We work in an underserved area, and we’ve just [been asked] if we would be interested in supplying a hospitalist in some of these nursing homes,” Eschenburg said. “We’re going to listen to a spiel next month about that. That was real-time and interesting to listen to.”

That was the point of the practice management sessions at SHM’s annual meeting here at the Mandalay Bay Resort and Casino: to give the most current updates available to administrators, group leaders, and rank-and-file hospitalists about best practices in the day-to-day operation of a group.

For Eschenburg, the lessons learned here are particularly helpful; her group just launched its hospitalist program in September and is dealing with a variety of implementation questions, including whether to use scribes to enhance patient-physician interaction, improve documentation, save physician time, and reduce technology-related errors. Other issues that resonate with her include scheduling and the amount of time that administrative leaders should spend in the clinical setting.

The meeting helped “[us] to see if there’s anything out there that we haven’t thought about or talked about,” Eschenburg said. “We’re not this big corporate giant that can’t make quick movements.”

Whether a hospitalist is working at a new practice in an underserved area or as a department head at a massive academic institution, a new white paper from SHM can provide information on how to move toward those best practices. “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” (http://onlinelibrary.wiley.com/doi/10.1002/jhm.2119/full), published in February in the Journal of Hospital Medicine, lists 10 guiding principles and 47 individual characteristics as a launching point for best practices.

Although the white paper is a first-of-its-kind initiative, SHM isn’t stopping there. Society staff and committee members are working to roll out a pilot program later this year that will ask group leaders to validate the key characteristics. SHM will provide back-up documentation, such as sample business plans or other toolkits, to implement some of the recommendations. Group leaders will be asked to use the documentation to determine whether or not it helps them achieve the goals.

“What we’re saying to you and your colleagues is that some of you aren’t performing necessarily at the best level you can. We want to give you a pathway to get better, because at the end of the day, we’re all in this to deliver the best care we can to our patients. So we recognize where we aren’t perfect, and we try to improve.”

–Dr. Wellikson

“One valuable thing that could come out of the pilot is not just feedback from you that will help us refine the key characteristics, but also ideas about resources that SHM can provide to help you better accomplish the things the key characteristics set forth,” said Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and a co-director for the popular practice management pre-course, “Where the Rubber Meets the Road: Managing in the Era of Healthcare Reform.”

Put more simply by Flores’ consulting colleague, John Nelson, MD, MHM, FACP: “We’ll learn from each other the best ways to do this.”

SHM senior vice president Joe Miller added that the white paper “simply identifies the characteristics and includes a rationale as to why they’re included.” The pilot program, however, will produce “a more enriched tool that you can use in a more directed fashion,” Miller said, “but we felt it was important to get this out right now and get the sense that we’ve identified the right issues.”

SHM CEO Larry Wellikson, MD, SFHM, said the initiative is “bold” and encouraged HM groups that are below standard in any area to step up their games.

“What we’re saying to you and your colleagues is that some of you aren’t performing necessarily at the best level you can,” Dr. Wellikson said. “We want to give you a pathway to get better, because at the end of the day, we’re all in this to deliver the best care we can to our patients. So we recognize where we aren’t perfect, and we try to improve.”

Those seeking practice management advice said they’re always thinking about ways to improve, and being with 3,600 like-minded folks often helps tease out tidbits and strategies to get better.

Sunil Kartham, MD, a hospitalist at Altru Health System in Grand Forks, N.D., said he enjoys hearing HM leaders give advice, whether they’re practice administrators in individual sessions or keynote speakers in large ballrooms.

“When you’re [an] individual physician, you don’t know what to expect in the future,” Dr. Kartham said. “When the leaders come and speak, they lay out a map for you…so you can prepare yourself.”

Preparing for what the future might bring is what drew Angelo Barile, MD, to the meeting. As the head of the hospitalist group at Cleveland Clinic Lorain Family Health and Surgery Center in Lorain, Ohio, he’s always looking for tips on how to improve the practical side of running a 12-FTE group.

“It helps to see how other people do it, and you get a nice framework of how to do it,” said Dr. Barile. “As busy as we are, running the group [and] seeing patients, it’s nice to get away from the pager [and] get away from my administrators and my bosses and say, ‘I want to try to learn something here.’ It is refreshing.”

Education doesn’t end with the meeting’s finale. Dr. Barile traditionally holds a sit-down with his staff as soon as he returns home. The doctors discuss the new ideas Dr. Barile learned and determine as a group what could work in their practice.

Eschenburg, the nascent program manager in Michigan, said she gets the same reaction when she returns from professional meetings.

“It’s certainly something that people are looking for when you get back,” she said. “What did you learn? What can you share with us?”

"“Your Song” became “Your Hospitalist Song”—the crowd gave him a standing ovation, perhaps as much for his chutzpah and piano playing as for his voice."

LAS VEGAS—Bob Wachter, MD, MHM, hyped the final six minutes of his annual meeting address as something hospitalists at HM14 conference wouldn’t forget. As usual, he was right.

The man who helped coin the term “hospitalist,” and whose penultimate pep talk has come to signal the unofficial end of SHM’s annual meeting, finished his plenary on the confab’s last day and returned minutes later in a white suit, yellowed wig, and sunglasses worthy of the man he was portraying: Elton John.

After enjoying Dr. Wachter’s retooled lyrics—in which “Your Song” became “Your Hospitalist Song”—the crowd gave him a standing ovation, perhaps as much for his chutzpah and piano playing as for his voice.

“That was just phenomenal,” said hospitalist Kevin Gilroy, MD, of Greenville, S.C. “What other conference does that? You find another society that is that down to Earth.”—RQ

"“Your Song” became “Your Hospitalist Song”—the crowd gave him a standing ovation, perhaps as much for his chutzpah and piano playing as for his voice."

LAS VEGAS—Bob Wachter, MD, MHM, hyped the final six minutes of his annual meeting address as something hospitalists at HM14 conference wouldn’t forget. As usual, he was right.

The man who helped coin the term “hospitalist,” and whose penultimate pep talk has come to signal the unofficial end of SHM’s annual meeting, finished his plenary on the confab’s last day and returned minutes later in a white suit, yellowed wig, and sunglasses worthy of the man he was portraying: Elton John.

After enjoying Dr. Wachter’s retooled lyrics—in which “Your Song” became “Your Hospitalist Song”—the crowd gave him a standing ovation, perhaps as much for his chutzpah and piano playing as for his voice.

“That was just phenomenal,” said hospitalist Kevin Gilroy, MD, of Greenville, S.C. “What other conference does that? You find another society that is that down to Earth.”—RQ

"“Your Song” became “Your Hospitalist Song”—the crowd gave him a standing ovation, perhaps as much for his chutzpah and piano playing as for his voice."

LAS VEGAS—Bob Wachter, MD, MHM, hyped the final six minutes of his annual meeting address as something hospitalists at HM14 conference wouldn’t forget. As usual, he was right.

The man who helped coin the term “hospitalist,” and whose penultimate pep talk has come to signal the unofficial end of SHM’s annual meeting, finished his plenary on the confab’s last day and returned minutes later in a white suit, yellowed wig, and sunglasses worthy of the man he was portraying: Elton John.

After enjoying Dr. Wachter’s retooled lyrics—in which “Your Song” became “Your Hospitalist Song”—the crowd gave him a standing ovation, perhaps as much for his chutzpah and piano playing as for his voice.

“That was just phenomenal,” said hospitalist Kevin Gilroy, MD, of Greenville, S.C. “What other conference does that? You find another society that is that down to Earth.”—RQ