Patient Care

A new study on transitions of care gives hospitalists a view from the other side.

Published recently online in the Journal of Hospital Medicine, the authors surveyed 22 primary-care physician leaders in California-based post-discharge clinics and asked them about ways to improve care transitions.

Physicians' responses focused on several areas that need work, most notably aligned financial incentives, regulations to standardize interoperability among electronic health records (EHR) and data sharing, and more opportunities for professional networking, the authors note.

Although the qualitative study takes a broad view of the healthcare system, its lead author says hospitalists should view "systems change" as a long-term goal achievable via incremental improvements that can start now.

"National policy change is needed to move the needle for the whole health system," says hospitalist Oanh Kieu Nguyen, MD, MAS, of the University of Texas Southwestern Medical Center in Dallas. "But locally, you can innovate within these domains and start to make changes to improve practice settings more immediately. National policy to align financial incentives and improve EHR interoperability will be key to helping local changes take hold and spread across systems. Otherwise, there will continue to be a lot of variability and fragmentation around care transitions on a national level."

Dr. Nguyen, who has practiced as both a hospitalist and PCP, says that because policies and studies on post-discharge care transitions primarily have focused on the hospital perspective, it is important to gain an understanding of the primary-care point of view.

"As a hospitalist, it's really easy to get caught up in just wanting to get patients teed up and sent home. Once they're out, we think they're no longer really our problem," Dr. Nguyen adds. "It's easy to forget that primary care is an important part of the other side of the equation. The way our healthcare system is designed doesn't really give physicians an incentive to look at the whole picture of a patient across all the environments they're in."

Many hospitalists are sharing their challenges and successes in care transitions through HMX. Join the conversation now.

Visit our website for more information on transitions of care.

A new study on transitions of care gives hospitalists a view from the other side.

Published recently online in the Journal of Hospital Medicine, the authors surveyed 22 primary-care physician leaders in California-based post-discharge clinics and asked them about ways to improve care transitions.

Physicians' responses focused on several areas that need work, most notably aligned financial incentives, regulations to standardize interoperability among electronic health records (EHR) and data sharing, and more opportunities for professional networking, the authors note.

Although the qualitative study takes a broad view of the healthcare system, its lead author says hospitalists should view "systems change" as a long-term goal achievable via incremental improvements that can start now.

"National policy change is needed to move the needle for the whole health system," says hospitalist Oanh Kieu Nguyen, MD, MAS, of the University of Texas Southwestern Medical Center in Dallas. "But locally, you can innovate within these domains and start to make changes to improve practice settings more immediately. National policy to align financial incentives and improve EHR interoperability will be key to helping local changes take hold and spread across systems. Otherwise, there will continue to be a lot of variability and fragmentation around care transitions on a national level."

Dr. Nguyen, who has practiced as both a hospitalist and PCP, says that because policies and studies on post-discharge care transitions primarily have focused on the hospital perspective, it is important to gain an understanding of the primary-care point of view.

"As a hospitalist, it's really easy to get caught up in just wanting to get patients teed up and sent home. Once they're out, we think they're no longer really our problem," Dr. Nguyen adds. "It's easy to forget that primary care is an important part of the other side of the equation. The way our healthcare system is designed doesn't really give physicians an incentive to look at the whole picture of a patient across all the environments they're in."

Many hospitalists are sharing their challenges and successes in care transitions through HMX. Join the conversation now.

Visit our website for more information on transitions of care.

A new study on transitions of care gives hospitalists a view from the other side.

Published recently online in the Journal of Hospital Medicine, the authors surveyed 22 primary-care physician leaders in California-based post-discharge clinics and asked them about ways to improve care transitions.

Physicians' responses focused on several areas that need work, most notably aligned financial incentives, regulations to standardize interoperability among electronic health records (EHR) and data sharing, and more opportunities for professional networking, the authors note.

Although the qualitative study takes a broad view of the healthcare system, its lead author says hospitalists should view "systems change" as a long-term goal achievable via incremental improvements that can start now.

"National policy change is needed to move the needle for the whole health system," says hospitalist Oanh Kieu Nguyen, MD, MAS, of the University of Texas Southwestern Medical Center in Dallas. "But locally, you can innovate within these domains and start to make changes to improve practice settings more immediately. National policy to align financial incentives and improve EHR interoperability will be key to helping local changes take hold and spread across systems. Otherwise, there will continue to be a lot of variability and fragmentation around care transitions on a national level."

Dr. Nguyen, who has practiced as both a hospitalist and PCP, says that because policies and studies on post-discharge care transitions primarily have focused on the hospital perspective, it is important to gain an understanding of the primary-care point of view.

"As a hospitalist, it's really easy to get caught up in just wanting to get patients teed up and sent home. Once they're out, we think they're no longer really our problem," Dr. Nguyen adds. "It's easy to forget that primary care is an important part of the other side of the equation. The way our healthcare system is designed doesn't really give physicians an incentive to look at the whole picture of a patient across all the environments they're in."

Many hospitalists are sharing their challenges and successes in care transitions through HMX. Join the conversation now.

Visit our website for more information on transitions of care.

At A Glance

Series: Hospital Medicine: Current Concepts

Title: Becoming a Consummate Clinician: What Every Student, House Officer and Hospital Practitioner Needs to Know.

Authors: Ary L. Goldberger, MD, and Zachary D. Goldberger, MD, MS, eds.

Published: 2012

Pages: 224

EDITOR’S NOTE: Second in an occasional series of reviews of the Hospital Medicine: Current Concepts series by members of Team Hospitalist.

Summary

The third installment in the Hospital Medicine: Current Concepts series, Becoming a Consummate Clinician is written in two parts. Part 1, “Medical Musts and Must-Nots,” is focused on the basics of being a clinician: gathering an appropriate history, performing an effective physical examination, and formulating differential diagnoses. This section in particular is geared toward house officers and attending physicians on teaching teams. While the audience here is primarily clinicians on a teaching service, there is good advice for those in any practice setting about avoiding common mistakes and developing clinical sagacity.

In this first section, we are given advisement on treatment of and with medications. Regardless of a clinician’s level of experience, it is worth reading this text to review and internalize these authors’ advice regarding medication pitfalls. Simply putting this advice into one’s daily practice of medicine will take any practitioner a long way toward becoming a “consummate clinician.”

Part 2, “Medical Masteries,” logically builds upon material presented in Part 1. The final section of the book addresses aspects of critical analysis of medical data and encourages engagement of critical thinking skills in all aspects of clinical decision-making. Specific topics addressed include reducing medical errors, reevaluating evidence-based medicine, deconstructing several widely cited medical aphorisms, identifying sources of cognitive errors, and transforming information into understanding.

The authors devoted the final chapter to the discussion of “What is disease?” and “What is health?” which, quite frankly, adds little value to the book.

Drs. Goldberger and Goldberger discuss what they term the “interstitial curriculum”—what is not explicitly taught but should be. Included in the “interstitial curriculum” is examination of cognitive errors and how we are more apt to make these in the era of “high-throughput” patient care. Another topic included in their “interstitial curriculum” is the paucity of attention paid to addressing uncertainty in all aspects of medicine. These topics are worth the cost of this book, even if it only helps promote awareness of these important ideas and bring the discussion to a larger audience.

Analysis

There are times in this book, particularly in the beginning, when the reader feels this text was written for the benefit of the house officer and those practitioners serving on inpatient teaching services. Continued reading, however, finds brilliant advice for clinicians in all practice settings and in all stages of their careers.

The encouragement of all readers to rethink everything we assume to be true and to seek a deeper understanding of what we “know” is priceless.

The quotes included throughout the book were both valuable and enjoyable. The authors included quotes from Plutarch to Hector Barbosa from Pirates of the Caribbean. One quote that is particularly germane to the practice of hospital medicine in this age of the Hospital Consumer Assessment of Healthcare Providers and Systems comes from Sir William Osler:

“Remember…that every patient upon whom you wait will examine you critically and form an estimate of you by the way in which you conduct yourself at the bedside. Skill and nicety in manipulation, in the simple act of feeling the pulse or in the performance of any minor operation, will do more towards establishing confidence in you than a string of diplomas, or the reputation of extensive hospital experience.”

Conversely, the computer-generated graphics added no value and were, in fact, a detractor. Hopefully, the next edition will not feature the sophomorically rendered bridge advising us to “bridge the classroom-to-clinic gap,” the flamingo, or the zigzagging line, among others.

Dr. Lindsey is chief operations officer and strategist of Synergy Surgicalists, and a member of Team Hospitalist.

At A Glance

Series: Hospital Medicine: Current Concepts

Title: Becoming a Consummate Clinician: What Every Student, House Officer and Hospital Practitioner Needs to Know.

Authors: Ary L. Goldberger, MD, and Zachary D. Goldberger, MD, MS, eds.

Published: 2012

Pages: 224

EDITOR’S NOTE: Second in an occasional series of reviews of the Hospital Medicine: Current Concepts series by members of Team Hospitalist.

Summary

The third installment in the Hospital Medicine: Current Concepts series, Becoming a Consummate Clinician is written in two parts. Part 1, “Medical Musts and Must-Nots,” is focused on the basics of being a clinician: gathering an appropriate history, performing an effective physical examination, and formulating differential diagnoses. This section in particular is geared toward house officers and attending physicians on teaching teams. While the audience here is primarily clinicians on a teaching service, there is good advice for those in any practice setting about avoiding common mistakes and developing clinical sagacity.

In this first section, we are given advisement on treatment of and with medications. Regardless of a clinician’s level of experience, it is worth reading this text to review and internalize these authors’ advice regarding medication pitfalls. Simply putting this advice into one’s daily practice of medicine will take any practitioner a long way toward becoming a “consummate clinician.”

Part 2, “Medical Masteries,” logically builds upon material presented in Part 1. The final section of the book addresses aspects of critical analysis of medical data and encourages engagement of critical thinking skills in all aspects of clinical decision-making. Specific topics addressed include reducing medical errors, reevaluating evidence-based medicine, deconstructing several widely cited medical aphorisms, identifying sources of cognitive errors, and transforming information into understanding.

The authors devoted the final chapter to the discussion of “What is disease?” and “What is health?” which, quite frankly, adds little value to the book.

Drs. Goldberger and Goldberger discuss what they term the “interstitial curriculum”—what is not explicitly taught but should be. Included in the “interstitial curriculum” is examination of cognitive errors and how we are more apt to make these in the era of “high-throughput” patient care. Another topic included in their “interstitial curriculum” is the paucity of attention paid to addressing uncertainty in all aspects of medicine. These topics are worth the cost of this book, even if it only helps promote awareness of these important ideas and bring the discussion to a larger audience.

Analysis

There are times in this book, particularly in the beginning, when the reader feels this text was written for the benefit of the house officer and those practitioners serving on inpatient teaching services. Continued reading, however, finds brilliant advice for clinicians in all practice settings and in all stages of their careers.

The encouragement of all readers to rethink everything we assume to be true and to seek a deeper understanding of what we “know” is priceless.

The quotes included throughout the book were both valuable and enjoyable. The authors included quotes from Plutarch to Hector Barbosa from Pirates of the Caribbean. One quote that is particularly germane to the practice of hospital medicine in this age of the Hospital Consumer Assessment of Healthcare Providers and Systems comes from Sir William Osler:

“Remember…that every patient upon whom you wait will examine you critically and form an estimate of you by the way in which you conduct yourself at the bedside. Skill and nicety in manipulation, in the simple act of feeling the pulse or in the performance of any minor operation, will do more towards establishing confidence in you than a string of diplomas, or the reputation of extensive hospital experience.”

Conversely, the computer-generated graphics added no value and were, in fact, a detractor. Hopefully, the next edition will not feature the sophomorically rendered bridge advising us to “bridge the classroom-to-clinic gap,” the flamingo, or the zigzagging line, among others.

Dr. Lindsey is chief operations officer and strategist of Synergy Surgicalists, and a member of Team Hospitalist.

At A Glance

Series: Hospital Medicine: Current Concepts

Title: Becoming a Consummate Clinician: What Every Student, House Officer and Hospital Practitioner Needs to Know.

Authors: Ary L. Goldberger, MD, and Zachary D. Goldberger, MD, MS, eds.

Published: 2012

Pages: 224

EDITOR’S NOTE: Second in an occasional series of reviews of the Hospital Medicine: Current Concepts series by members of Team Hospitalist.

Summary

The third installment in the Hospital Medicine: Current Concepts series, Becoming a Consummate Clinician is written in two parts. Part 1, “Medical Musts and Must-Nots,” is focused on the basics of being a clinician: gathering an appropriate history, performing an effective physical examination, and formulating differential diagnoses. This section in particular is geared toward house officers and attending physicians on teaching teams. While the audience here is primarily clinicians on a teaching service, there is good advice for those in any practice setting about avoiding common mistakes and developing clinical sagacity.

In this first section, we are given advisement on treatment of and with medications. Regardless of a clinician’s level of experience, it is worth reading this text to review and internalize these authors’ advice regarding medication pitfalls. Simply putting this advice into one’s daily practice of medicine will take any practitioner a long way toward becoming a “consummate clinician.”

Part 2, “Medical Masteries,” logically builds upon material presented in Part 1. The final section of the book addresses aspects of critical analysis of medical data and encourages engagement of critical thinking skills in all aspects of clinical decision-making. Specific topics addressed include reducing medical errors, reevaluating evidence-based medicine, deconstructing several widely cited medical aphorisms, identifying sources of cognitive errors, and transforming information into understanding.

The authors devoted the final chapter to the discussion of “What is disease?” and “What is health?” which, quite frankly, adds little value to the book.

Drs. Goldberger and Goldberger discuss what they term the “interstitial curriculum”—what is not explicitly taught but should be. Included in the “interstitial curriculum” is examination of cognitive errors and how we are more apt to make these in the era of “high-throughput” patient care. Another topic included in their “interstitial curriculum” is the paucity of attention paid to addressing uncertainty in all aspects of medicine. These topics are worth the cost of this book, even if it only helps promote awareness of these important ideas and bring the discussion to a larger audience.

Analysis

There are times in this book, particularly in the beginning, when the reader feels this text was written for the benefit of the house officer and those practitioners serving on inpatient teaching services. Continued reading, however, finds brilliant advice for clinicians in all practice settings and in all stages of their careers.

The encouragement of all readers to rethink everything we assume to be true and to seek a deeper understanding of what we “know” is priceless.

The quotes included throughout the book were both valuable and enjoyable. The authors included quotes from Plutarch to Hector Barbosa from Pirates of the Caribbean. One quote that is particularly germane to the practice of hospital medicine in this age of the Hospital Consumer Assessment of Healthcare Providers and Systems comes from Sir William Osler:

“Remember…that every patient upon whom you wait will examine you critically and form an estimate of you by the way in which you conduct yourself at the bedside. Skill and nicety in manipulation, in the simple act of feeling the pulse or in the performance of any minor operation, will do more towards establishing confidence in you than a string of diplomas, or the reputation of extensive hospital experience.”

Conversely, the computer-generated graphics added no value and were, in fact, a detractor. Hopefully, the next edition will not feature the sophomorically rendered bridge advising us to “bridge the classroom-to-clinic gap,” the flamingo, or the zigzagging line, among others.

Dr. Lindsey is chief operations officer and strategist of Synergy Surgicalists, and a member of Team Hospitalist.

Case

A 45-year-old previously healthy female was admitted to the ICU with sepsis caused by community-acquired pneumonia. Per hospital policy, all patients admitted to the ICU are screened for MRSA colonization. If the nasal screen is positive, contact isolation is initiated and the hospital’s MRSA decolonization protocol is implemented. Her nasal screen was positive for MRSA.

Overview

MRSA infections are associated with significant morbidity and mortality, and death occurs in almost 5% of patients who develop a MRSA infection. In 2005, invasive MRSA was responsible for approximately 278,000 hospitalizations and 19,000 deaths. MRSA is a common cause of healthcare-associated infections (HAIs) and is the most common pathogen in surgical site infections (SSIs) and ventilator-associated pneumonias. The cost of treating MRSA infections is substantial; in 2003, $14.5 billion was spent on MRSA-related hospitalizations.

It is well known that MRSA colonization is a risk factor for the subsequent development of a MRSA infection. This risk persists over time, and approximately 25% of individuals who are colonized with MRSA for more than one year will develop a late-onset MRSA infection.¹ It is estimated that between 0.8% and 6% of people in the U.S. are asymptomatically colonized with MRSA.

One infection control strategy for reducing the transmission of MRSA among hospitalized patients involves screening for the presence of this organism and then placing colonized and/or infected patients in isolation; however, there is considerable controversy about which patients should be screened.

An additional element of many infection control strategies involves MRSA decolonization, but there is uncertainty about which patients benefit from it and significant variability in its reported success rates.² Additionally, several studies have indicated that MRSA decolonization is only temporary and that patients become recolonized over time.

Treatment

It is estimated that 10% to 20% of MRSA carriers will develop an infection while they are hospitalized. Furthermore, even after they have been discharged from the hospital, their risk for developing a MRSA infection persists.

Most patients who develop a MRSA infection have been colonized prior to infection, and these patients usually develop an infection caused by the same strain as the colonization. In view of this fact, a primary goal of decolonization is reducing the likelihood of “auto-infection.” Another goal of decolonization is reducing the transmission of MRSA to other patients.

In order to determine whether MRSA colonization is present, patients undergo screening, and specimens are collected from the nares using nasal swabs. Specimens from extranasal sites, such as the groin, are sometimes also obtained for screening. These screening tests are usually done with either cultures or polymerase chain reaction testing.

There is significant variability in the details of screening and decolonization protocols among different healthcare facilities. Typically, the screening test costs more than the agents used for decolonization. Partly for this reason, some facilities forego screening altogether, instead treating all patients with a decolonization regimen; however, there is concern that administering decolonizing medications to all patients would lead to the unnecessary treatment of large numbers of patients. Such widespread use of the decolonizing agents might promote the development of resistance to these medications.

Medications. Decolonization typically involves the use of a topical antibiotic, most commonly mupirocin, which is applied to the nares. This may be used in conjunction with an oral antimicrobial agent. While the nares are the anatomical locations most commonly colonized by MRSA, extranasal colonization occurs in 50% of those who are nasally colonized.

Of the topical medications available for decolonization, mupirocin has the highest efficacy, with eradication of MRSA and methicillin-sensitive Staphylococcus aureus (MSSA) colonization ranging from 81% to 93%. To increase the likelihood of successful decolonization, an antiseptic agent, such as chlorhexidine gluconate, may also be applied to the skin. Chlorhexidine gluconate is also commonly used to prevent other HAIs.

Neomycin is sometimes used for decolonization, but its efficacy for this purpose is questionable. There are also concerns about resistance, but it may be an option in cases of documented mupirocin resistance. Preparations that contain tea tree oil appear to be more effective for decolonization of skin sites than for nasal decolonization. Table 1 lists the topical antibiotics and antiseptics that may be utilized for decolonization, while Table 2 lists the oral medications that can be used for this purpose. Table 3 lists investigational agents being evaluated for their ability to decolonize patients.

It has been suggested that the patients who might derive the most benefit from decolonization are those at increased risk for developing a MRSA infection during a specific time interval. This would include patients who are admitted to the ICU for an acute illness and cardiothoracic surgery patients. A benefit from decolonization has also been observed in hemodialysis patients, who have an incidence of invasive MRSA infections 100 times greater than the general population. Otherwise, there are no data to support the routine use of decolonization in nonsurgical patients.

It is not uncommon for hospitals to screen patients admitted to the ICU for MRSA nasal colonization; in fact, screening is mandatory in nine states. If the nasal screen is positive, contact precautions are instituted. The decision about whether or not to initiate a decolonization protocol varies among different ICUs, but most do not carry out universal decolonization.

Some studies show decolonization is beneficial for ICU patients. These studies include a large cluster-randomized trial called REDUCE MRSA,³ which took place in 43 hospitals and involved 74,256 patients in 74 ICUs. The study showed that universal (i.e., without screening) decolonization using mupirocin and chlorhexidine was effective in reducing rates of MRSA clinical isolates, as well as bloodstream infection from any pathogen. Other studies have demonstrated benefits from the decolonization of ICU patients.^4,5

Surgical Site Infections. Meanwhile, SSIs are often associated with increased mortality rates and substantial healthcare costs, including increased hospital lengths of stay and readmission rates. Staphylococcus aureus is the pathogen most commonly isolated from SSIs. In surgical patients, colonization with MRSA is associated with an elevated rate of MRSA SSIs. The goal of decolonization in surgical patients is not to permanently eliminate MRSA but to prevent SSIs by suppressing the presence of this organism for a relatively brief duration.

There is evidence that decolonization reduces SSIs for cardiothoracic surgeries.⁶ For these patients, it is cost effective to screen for nasal carriage of MRSA and then treat carriers with a combination of pre-operative mupirocin and chlorhexidine. It may be reasonable to delay cardiothoracic surgery in colonized patients who will require implantation of prosthetic material until they complete MRSA decolonization.

In addition to reducing the risk of auto-infection, another goal of decolonization is limiting the possibility of transmission of MRSA from a colonized patient to a susceptible individual; however, there are only limited data available that measure the efficacy of decolonization for preventing transmission.

Concerns about the potential hazards of decolonization therapy have impacted its widespread implementation. The biggest concern is that patients may develop resistance to the antimicrobial agents used for decolonization, particularly if they are used at increased frequency. Mupirocin resistance monitoring is valuable, but, unfortunately, the susceptibility of Staphylococcus aureus to mupirocin is not routinely evaluated, so the prevalence of mupirocin resistance in local strains is often unknown. Another concern about decolonization is the cost of screening and decolonizing patients.

Back to the Case

The patient in this case required admission to an ICU and, based on the results of the REDUCE MRSA clinical trial, she would likely benefit from undergoing decolonization to reduce her risk of both MRSA-positive clinical cultures and bloodstream infections caused by any pathogen.

Bottom Line

Decolonization is beneficial for patients at increased risk of developing a MRSA infection during a specific period, such as patients admitted to the ICU and those undergoing cardiothoracic surgery.

Dr. Clarke is assistant professor in the division of hospital medicine at Emory University Hospital and a faculty member in the Emory University Department of Medicine, both in Atlanta.

References

1. Dow G, Field D, Mancuso M, Allard J. Decolonization of methicillin-resistant Staphylococcus aureus during routine hospital care: Efficacy and long-term follow-up. Can J Infect Dis Med Microbiol. 2010;21(1):38-44.
2. Simor AE. Staphylococcal decolonisation: An effective strategy for prevention of infection? Lancet Infect Dis. 2011;11(12):952-962.
3. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265.
4. Fraser T, Fatica C, Scarpelli M, et al. Decrease in Staphylococcus aureus colonization and hospital-acquired infection in a medical intensive care unit after institution of an active surveillance and decolonization program. Infect Control Hosp Epidemiol. 2010;31(8):779-783.
5. Robotham J, Graves N, Cookson B, et al. Screening, isolation, and decolonisation strategies in the control of methicillin-resistant Staphylococcus aureus in intensive care units: Cost effectiveness evaluation. BMJ. 2011;343:d5694.
6. Schweizer M, Perencevich E, McDanel J, et al. Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: Systematic review and meta-analysis. BMJ. 2013;346:f2743.

Case

A 45-year-old previously healthy female was admitted to the ICU with sepsis caused by community-acquired pneumonia. Per hospital policy, all patients admitted to the ICU are screened for MRSA colonization. If the nasal screen is positive, contact isolation is initiated and the hospital’s MRSA decolonization protocol is implemented. Her nasal screen was positive for MRSA.

Overview

MRSA infections are associated with significant morbidity and mortality, and death occurs in almost 5% of patients who develop a MRSA infection. In 2005, invasive MRSA was responsible for approximately 278,000 hospitalizations and 19,000 deaths. MRSA is a common cause of healthcare-associated infections (HAIs) and is the most common pathogen in surgical site infections (SSIs) and ventilator-associated pneumonias. The cost of treating MRSA infections is substantial; in 2003, $14.5 billion was spent on MRSA-related hospitalizations.

It is well known that MRSA colonization is a risk factor for the subsequent development of a MRSA infection. This risk persists over time, and approximately 25% of individuals who are colonized with MRSA for more than one year will develop a late-onset MRSA infection.¹ It is estimated that between 0.8% and 6% of people in the U.S. are asymptomatically colonized with MRSA.

One infection control strategy for reducing the transmission of MRSA among hospitalized patients involves screening for the presence of this organism and then placing colonized and/or infected patients in isolation; however, there is considerable controversy about which patients should be screened.

An additional element of many infection control strategies involves MRSA decolonization, but there is uncertainty about which patients benefit from it and significant variability in its reported success rates.² Additionally, several studies have indicated that MRSA decolonization is only temporary and that patients become recolonized over time.

Treatment

It is estimated that 10% to 20% of MRSA carriers will develop an infection while they are hospitalized. Furthermore, even after they have been discharged from the hospital, their risk for developing a MRSA infection persists.

Most patients who develop a MRSA infection have been colonized prior to infection, and these patients usually develop an infection caused by the same strain as the colonization. In view of this fact, a primary goal of decolonization is reducing the likelihood of “auto-infection.” Another goal of decolonization is reducing the transmission of MRSA to other patients.

In order to determine whether MRSA colonization is present, patients undergo screening, and specimens are collected from the nares using nasal swabs. Specimens from extranasal sites, such as the groin, are sometimes also obtained for screening. These screening tests are usually done with either cultures or polymerase chain reaction testing.

There is significant variability in the details of screening and decolonization protocols among different healthcare facilities. Typically, the screening test costs more than the agents used for decolonization. Partly for this reason, some facilities forego screening altogether, instead treating all patients with a decolonization regimen; however, there is concern that administering decolonizing medications to all patients would lead to the unnecessary treatment of large numbers of patients. Such widespread use of the decolonizing agents might promote the development of resistance to these medications.

Medications. Decolonization typically involves the use of a topical antibiotic, most commonly mupirocin, which is applied to the nares. This may be used in conjunction with an oral antimicrobial agent. While the nares are the anatomical locations most commonly colonized by MRSA, extranasal colonization occurs in 50% of those who are nasally colonized.

Of the topical medications available for decolonization, mupirocin has the highest efficacy, with eradication of MRSA and methicillin-sensitive Staphylococcus aureus (MSSA) colonization ranging from 81% to 93%. To increase the likelihood of successful decolonization, an antiseptic agent, such as chlorhexidine gluconate, may also be applied to the skin. Chlorhexidine gluconate is also commonly used to prevent other HAIs.

Neomycin is sometimes used for decolonization, but its efficacy for this purpose is questionable. There are also concerns about resistance, but it may be an option in cases of documented mupirocin resistance. Preparations that contain tea tree oil appear to be more effective for decolonization of skin sites than for nasal decolonization. Table 1 lists the topical antibiotics and antiseptics that may be utilized for decolonization, while Table 2 lists the oral medications that can be used for this purpose. Table 3 lists investigational agents being evaluated for their ability to decolonize patients.

It has been suggested that the patients who might derive the most benefit from decolonization are those at increased risk for developing a MRSA infection during a specific time interval. This would include patients who are admitted to the ICU for an acute illness and cardiothoracic surgery patients. A benefit from decolonization has also been observed in hemodialysis patients, who have an incidence of invasive MRSA infections 100 times greater than the general population. Otherwise, there are no data to support the routine use of decolonization in nonsurgical patients.

It is not uncommon for hospitals to screen patients admitted to the ICU for MRSA nasal colonization; in fact, screening is mandatory in nine states. If the nasal screen is positive, contact precautions are instituted. The decision about whether or not to initiate a decolonization protocol varies among different ICUs, but most do not carry out universal decolonization.

Some studies show decolonization is beneficial for ICU patients. These studies include a large cluster-randomized trial called REDUCE MRSA,³ which took place in 43 hospitals and involved 74,256 patients in 74 ICUs. The study showed that universal (i.e., without screening) decolonization using mupirocin and chlorhexidine was effective in reducing rates of MRSA clinical isolates, as well as bloodstream infection from any pathogen. Other studies have demonstrated benefits from the decolonization of ICU patients.^4,5

Surgical Site Infections. Meanwhile, SSIs are often associated with increased mortality rates and substantial healthcare costs, including increased hospital lengths of stay and readmission rates. Staphylococcus aureus is the pathogen most commonly isolated from SSIs. In surgical patients, colonization with MRSA is associated with an elevated rate of MRSA SSIs. The goal of decolonization in surgical patients is not to permanently eliminate MRSA but to prevent SSIs by suppressing the presence of this organism for a relatively brief duration.

There is evidence that decolonization reduces SSIs for cardiothoracic surgeries.⁶ For these patients, it is cost effective to screen for nasal carriage of MRSA and then treat carriers with a combination of pre-operative mupirocin and chlorhexidine. It may be reasonable to delay cardiothoracic surgery in colonized patients who will require implantation of prosthetic material until they complete MRSA decolonization.

In addition to reducing the risk of auto-infection, another goal of decolonization is limiting the possibility of transmission of MRSA from a colonized patient to a susceptible individual; however, there are only limited data available that measure the efficacy of decolonization for preventing transmission.

Concerns about the potential hazards of decolonization therapy have impacted its widespread implementation. The biggest concern is that patients may develop resistance to the antimicrobial agents used for decolonization, particularly if they are used at increased frequency. Mupirocin resistance monitoring is valuable, but, unfortunately, the susceptibility of Staphylococcus aureus to mupirocin is not routinely evaluated, so the prevalence of mupirocin resistance in local strains is often unknown. Another concern about decolonization is the cost of screening and decolonizing patients.

Back to the Case

The patient in this case required admission to an ICU and, based on the results of the REDUCE MRSA clinical trial, she would likely benefit from undergoing decolonization to reduce her risk of both MRSA-positive clinical cultures and bloodstream infections caused by any pathogen.

Bottom Line

Decolonization is beneficial for patients at increased risk of developing a MRSA infection during a specific period, such as patients admitted to the ICU and those undergoing cardiothoracic surgery.

Dr. Clarke is assistant professor in the division of hospital medicine at Emory University Hospital and a faculty member in the Emory University Department of Medicine, both in Atlanta.

References

1. Dow G, Field D, Mancuso M, Allard J. Decolonization of methicillin-resistant Staphylococcus aureus during routine hospital care: Efficacy and long-term follow-up. Can J Infect Dis Med Microbiol. 2010;21(1):38-44.
2. Simor AE. Staphylococcal decolonisation: An effective strategy for prevention of infection? Lancet Infect Dis. 2011;11(12):952-962.
3. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265.
4. Fraser T, Fatica C, Scarpelli M, et al. Decrease in Staphylococcus aureus colonization and hospital-acquired infection in a medical intensive care unit after institution of an active surveillance and decolonization program. Infect Control Hosp Epidemiol. 2010;31(8):779-783.
5. Robotham J, Graves N, Cookson B, et al. Screening, isolation, and decolonisation strategies in the control of methicillin-resistant Staphylococcus aureus in intensive care units: Cost effectiveness evaluation. BMJ. 2011;343:d5694.
6. Schweizer M, Perencevich E, McDanel J, et al. Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: Systematic review and meta-analysis. BMJ. 2013;346:f2743.

Case

A 45-year-old previously healthy female was admitted to the ICU with sepsis caused by community-acquired pneumonia. Per hospital policy, all patients admitted to the ICU are screened for MRSA colonization. If the nasal screen is positive, contact isolation is initiated and the hospital’s MRSA decolonization protocol is implemented. Her nasal screen was positive for MRSA.

Overview

MRSA infections are associated with significant morbidity and mortality, and death occurs in almost 5% of patients who develop a MRSA infection. In 2005, invasive MRSA was responsible for approximately 278,000 hospitalizations and 19,000 deaths. MRSA is a common cause of healthcare-associated infections (HAIs) and is the most common pathogen in surgical site infections (SSIs) and ventilator-associated pneumonias. The cost of treating MRSA infections is substantial; in 2003, $14.5 billion was spent on MRSA-related hospitalizations.

It is well known that MRSA colonization is a risk factor for the subsequent development of a MRSA infection. This risk persists over time, and approximately 25% of individuals who are colonized with MRSA for more than one year will develop a late-onset MRSA infection.¹ It is estimated that between 0.8% and 6% of people in the U.S. are asymptomatically colonized with MRSA.

One infection control strategy for reducing the transmission of MRSA among hospitalized patients involves screening for the presence of this organism and then placing colonized and/or infected patients in isolation; however, there is considerable controversy about which patients should be screened.

An additional element of many infection control strategies involves MRSA decolonization, but there is uncertainty about which patients benefit from it and significant variability in its reported success rates.² Additionally, several studies have indicated that MRSA decolonization is only temporary and that patients become recolonized over time.

Treatment

It is estimated that 10% to 20% of MRSA carriers will develop an infection while they are hospitalized. Furthermore, even after they have been discharged from the hospital, their risk for developing a MRSA infection persists.

Most patients who develop a MRSA infection have been colonized prior to infection, and these patients usually develop an infection caused by the same strain as the colonization. In view of this fact, a primary goal of decolonization is reducing the likelihood of “auto-infection.” Another goal of decolonization is reducing the transmission of MRSA to other patients.

In order to determine whether MRSA colonization is present, patients undergo screening, and specimens are collected from the nares using nasal swabs. Specimens from extranasal sites, such as the groin, are sometimes also obtained for screening. These screening tests are usually done with either cultures or polymerase chain reaction testing.

There is significant variability in the details of screening and decolonization protocols among different healthcare facilities. Typically, the screening test costs more than the agents used for decolonization. Partly for this reason, some facilities forego screening altogether, instead treating all patients with a decolonization regimen; however, there is concern that administering decolonizing medications to all patients would lead to the unnecessary treatment of large numbers of patients. Such widespread use of the decolonizing agents might promote the development of resistance to these medications.

Medications. Decolonization typically involves the use of a topical antibiotic, most commonly mupirocin, which is applied to the nares. This may be used in conjunction with an oral antimicrobial agent. While the nares are the anatomical locations most commonly colonized by MRSA, extranasal colonization occurs in 50% of those who are nasally colonized.

Of the topical medications available for decolonization, mupirocin has the highest efficacy, with eradication of MRSA and methicillin-sensitive Staphylococcus aureus (MSSA) colonization ranging from 81% to 93%. To increase the likelihood of successful decolonization, an antiseptic agent, such as chlorhexidine gluconate, may also be applied to the skin. Chlorhexidine gluconate is also commonly used to prevent other HAIs.

Neomycin is sometimes used for decolonization, but its efficacy for this purpose is questionable. There are also concerns about resistance, but it may be an option in cases of documented mupirocin resistance. Preparations that contain tea tree oil appear to be more effective for decolonization of skin sites than for nasal decolonization. Table 1 lists the topical antibiotics and antiseptics that may be utilized for decolonization, while Table 2 lists the oral medications that can be used for this purpose. Table 3 lists investigational agents being evaluated for their ability to decolonize patients.

It has been suggested that the patients who might derive the most benefit from decolonization are those at increased risk for developing a MRSA infection during a specific time interval. This would include patients who are admitted to the ICU for an acute illness and cardiothoracic surgery patients. A benefit from decolonization has also been observed in hemodialysis patients, who have an incidence of invasive MRSA infections 100 times greater than the general population. Otherwise, there are no data to support the routine use of decolonization in nonsurgical patients.

It is not uncommon for hospitals to screen patients admitted to the ICU for MRSA nasal colonization; in fact, screening is mandatory in nine states. If the nasal screen is positive, contact precautions are instituted. The decision about whether or not to initiate a decolonization protocol varies among different ICUs, but most do not carry out universal decolonization.

Some studies show decolonization is beneficial for ICU patients. These studies include a large cluster-randomized trial called REDUCE MRSA,³ which took place in 43 hospitals and involved 74,256 patients in 74 ICUs. The study showed that universal (i.e., without screening) decolonization using mupirocin and chlorhexidine was effective in reducing rates of MRSA clinical isolates, as well as bloodstream infection from any pathogen. Other studies have demonstrated benefits from the decolonization of ICU patients.^4,5

Surgical Site Infections. Meanwhile, SSIs are often associated with increased mortality rates and substantial healthcare costs, including increased hospital lengths of stay and readmission rates. Staphylococcus aureus is the pathogen most commonly isolated from SSIs. In surgical patients, colonization with MRSA is associated with an elevated rate of MRSA SSIs. The goal of decolonization in surgical patients is not to permanently eliminate MRSA but to prevent SSIs by suppressing the presence of this organism for a relatively brief duration.

There is evidence that decolonization reduces SSIs for cardiothoracic surgeries.⁶ For these patients, it is cost effective to screen for nasal carriage of MRSA and then treat carriers with a combination of pre-operative mupirocin and chlorhexidine. It may be reasonable to delay cardiothoracic surgery in colonized patients who will require implantation of prosthetic material until they complete MRSA decolonization.

In addition to reducing the risk of auto-infection, another goal of decolonization is limiting the possibility of transmission of MRSA from a colonized patient to a susceptible individual; however, there are only limited data available that measure the efficacy of decolonization for preventing transmission.

Concerns about the potential hazards of decolonization therapy have impacted its widespread implementation. The biggest concern is that patients may develop resistance to the antimicrobial agents used for decolonization, particularly if they are used at increased frequency. Mupirocin resistance monitoring is valuable, but, unfortunately, the susceptibility of Staphylococcus aureus to mupirocin is not routinely evaluated, so the prevalence of mupirocin resistance in local strains is often unknown. Another concern about decolonization is the cost of screening and decolonizing patients.

Back to the Case

The patient in this case required admission to an ICU and, based on the results of the REDUCE MRSA clinical trial, she would likely benefit from undergoing decolonization to reduce her risk of both MRSA-positive clinical cultures and bloodstream infections caused by any pathogen.

Bottom Line

Decolonization is beneficial for patients at increased risk of developing a MRSA infection during a specific period, such as patients admitted to the ICU and those undergoing cardiothoracic surgery.

Dr. Clarke is assistant professor in the division of hospital medicine at Emory University Hospital and a faculty member in the Emory University Department of Medicine, both in Atlanta.

References

1. Dow G, Field D, Mancuso M, Allard J. Decolonization of methicillin-resistant Staphylococcus aureus during routine hospital care: Efficacy and long-term follow-up. Can J Infect Dis Med Microbiol. 2010;21(1):38-44.
2. Simor AE. Staphylococcal decolonisation: An effective strategy for prevention of infection? Lancet Infect Dis. 2011;11(12):952-962.
3. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265.
4. Fraser T, Fatica C, Scarpelli M, et al. Decrease in Staphylococcus aureus colonization and hospital-acquired infection in a medical intensive care unit after institution of an active surveillance and decolonization program. Infect Control Hosp Epidemiol. 2010;31(8):779-783.
5. Robotham J, Graves N, Cookson B, et al. Screening, isolation, and decolonisation strategies in the control of methicillin-resistant Staphylococcus aureus in intensive care units: Cost effectiveness evaluation. BMJ. 2011;343:d5694.
6. Schweizer M, Perencevich E, McDanel J, et al. Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: Systematic review and meta-analysis. BMJ. 2013;346:f2743.

If you haven’t checked out SHM’s online Learning Portal, now is the time. SHM will be introducing new content for pediatric hospitalists and more information on the use of anticoagulants. Access to the SHM Learning Portal is free for members: www.shmlearningportal.org.

If you haven’t checked out SHM’s online Learning Portal, now is the time. SHM will be introducing new content for pediatric hospitalists and more information on the use of anticoagulants. Access to the SHM Learning Portal is free for members: www.shmlearningportal.org.

If you haven’t checked out SHM’s online Learning Portal, now is the time. SHM will be introducing new content for pediatric hospitalists and more information on the use of anticoagulants. Access to the SHM Learning Portal is free for members: www.shmlearningportal.org.

Controlling diabetes in the hospital is one of the most predominant challenges hospitalists face. In addition to the condition’s increased prevalence among the general population, patients with diabetes are commonly admitted to the hospital multiple times. And the treatment of diabetes can make the treatment of other conditions more difficult.

In fact, a 2014 study conducted in California by the UCLA Center for Health Policy Research and the California Center for Public Health Advocacy revealed that one-third of hospitalized patients older than 34 in California have diabetes.

For hospitalists ready to tackle a condition like diabetes—increasingly common and challenging to treat—SHM now has more resources than ever. And hospitalists can start to take advantage of them today.

Glycemic Control Implementation Toolkit

SHM’s Glycemic Control Implementation Toolkit gives hospitalists the first advantages in treating hyperglycemia in the hospital. Using SHM’s proven approach to quality improvement, including personal experience and evidence-based medicine, the toolkit enables hospitalists to implement effective regimens and protocols that optimize glycemic control and minimize hypoglycemia.

The toolkit (www.hospitalmedicine.org/gcmi) is easy to use and includes step-by-step instructions, from first steps to performance tracking to continuing improvement.

Hospital Medicine 2015

Ready to learn directly from the experts in inpatient glycemic control and share experiences with thousands of other hospitalists? HM15 will feature the most current information and research from the leading authorities on glycemic control.

For more information and to register online, visit www.hospitalmedicine2015.org.

Glycemic Control Mentored Implementation

SHM’s signature mentored implementation model helps hospitals create and implement programs that make a difference. The Glycemic Control Mentored Implementation (GCMI) Program links hospitals with national leaders in the field for a mentored relationship, critical data benchmarking, and collaboration with peers.

GCMI has now moved to a rolling acceptance model, so hospitals can now apply any time to start preventing hypoglycemia and better managing their inpatients with hyperglycemia and diabetes. For more information, visit www.hospitalmedicine.org/gcmi.

Brendon Shank is SHM’s associate vice president of communications.

Controlling diabetes in the hospital is one of the most predominant challenges hospitalists face. In addition to the condition’s increased prevalence among the general population, patients with diabetes are commonly admitted to the hospital multiple times. And the treatment of diabetes can make the treatment of other conditions more difficult.

In fact, a 2014 study conducted in California by the UCLA Center for Health Policy Research and the California Center for Public Health Advocacy revealed that one-third of hospitalized patients older than 34 in California have diabetes.

For hospitalists ready to tackle a condition like diabetes—increasingly common and challenging to treat—SHM now has more resources than ever. And hospitalists can start to take advantage of them today.

Glycemic Control Implementation Toolkit

SHM’s Glycemic Control Implementation Toolkit gives hospitalists the first advantages in treating hyperglycemia in the hospital. Using SHM’s proven approach to quality improvement, including personal experience and evidence-based medicine, the toolkit enables hospitalists to implement effective regimens and protocols that optimize glycemic control and minimize hypoglycemia.

The toolkit (www.hospitalmedicine.org/gcmi) is easy to use and includes step-by-step instructions, from first steps to performance tracking to continuing improvement.

Hospital Medicine 2015

Ready to learn directly from the experts in inpatient glycemic control and share experiences with thousands of other hospitalists? HM15 will feature the most current information and research from the leading authorities on glycemic control.

For more information and to register online, visit www.hospitalmedicine2015.org.

Glycemic Control Mentored Implementation

SHM’s signature mentored implementation model helps hospitals create and implement programs that make a difference. The Glycemic Control Mentored Implementation (GCMI) Program links hospitals with national leaders in the field for a mentored relationship, critical data benchmarking, and collaboration with peers.

GCMI has now moved to a rolling acceptance model, so hospitals can now apply any time to start preventing hypoglycemia and better managing their inpatients with hyperglycemia and diabetes. For more information, visit www.hospitalmedicine.org/gcmi.

Brendon Shank is SHM’s associate vice president of communications.

Controlling diabetes in the hospital is one of the most predominant challenges hospitalists face. In addition to the condition’s increased prevalence among the general population, patients with diabetes are commonly admitted to the hospital multiple times. And the treatment of diabetes can make the treatment of other conditions more difficult.

In fact, a 2014 study conducted in California by the UCLA Center for Health Policy Research and the California Center for Public Health Advocacy revealed that one-third of hospitalized patients older than 34 in California have diabetes.

For hospitalists ready to tackle a condition like diabetes—increasingly common and challenging to treat—SHM now has more resources than ever. And hospitalists can start to take advantage of them today.

Glycemic Control Implementation Toolkit

SHM’s Glycemic Control Implementation Toolkit gives hospitalists the first advantages in treating hyperglycemia in the hospital. Using SHM’s proven approach to quality improvement, including personal experience and evidence-based medicine, the toolkit enables hospitalists to implement effective regimens and protocols that optimize glycemic control and minimize hypoglycemia.

The toolkit (www.hospitalmedicine.org/gcmi) is easy to use and includes step-by-step instructions, from first steps to performance tracking to continuing improvement.

Hospital Medicine 2015

Ready to learn directly from the experts in inpatient glycemic control and share experiences with thousands of other hospitalists? HM15 will feature the most current information and research from the leading authorities on glycemic control.

For more information and to register online, visit www.hospitalmedicine2015.org.

Glycemic Control Mentored Implementation

SHM’s signature mentored implementation model helps hospitals create and implement programs that make a difference. The Glycemic Control Mentored Implementation (GCMI) Program links hospitals with national leaders in the field for a mentored relationship, critical data benchmarking, and collaboration with peers.

GCMI has now moved to a rolling acceptance model, so hospitals can now apply any time to start preventing hypoglycemia and better managing their inpatients with hyperglycemia and diabetes. For more information, visit www.hospitalmedicine.org/gcmi.

Brendon Shank is SHM’s associate vice president of communications.

Many hospitalists feel an understandable wave of trepidation when confronted with treating a pregnant woman. They are unfamiliar with the special concerns of pregnancy and unacquainted with how pregnancy can affect preexisting conditions. Historically, most pregnant women have been young and have not yet experienced the typical health challenges that emerge as people age; however, expectant mothers still appear as patients in hospitals.¹

With more women putting off pregnancy until their late 30s or early 40s, advances in reproductive medicine that allow pregnancies at more advanced ages, and a rise in obesity and related conditions, more and more pregnant women find themselves in the ED or admitted to the hospital.²

To increase the comfort level of practitioners nationwide, The Hospitalist spoke with several obstetricians (OBs) and hospitalists about what they thought were the most important things you should know when treating a mother-to-be. Here are their answers.

1 Involve an OB in the decision-making process as early as possible.

The most efficient and most comfortable way to proceed is to get input from an OB early in the process of treating a pregnant woman. The specialist can give expert opinions on what tests should be ordered and any special precautions to take to protect the fetus.³ Determining which medications can be prescribed safely is an area of particular discomfort for internal medicine hospitalists.

Edward Ma, MD, a hospitalist at the Coatesville VA Medical Center in Coatesville, Pa., explains the dilemma: “I am comfortable using Category A drugs and usually Category B medications, but because I do not [treat pregnant women] very often, I feel very uncomfortable giving a Category C medication unless I’ve spoken with an OB. This is where I really want guidance.”

In cases where the usual medication for a condition may not be indicated for pregnancy, an OB can help you balance the interests of the mother and child. Making these decisions is made much more comfortable when a physician who treats pregnancy on a daily basis can help.

2 Perform the tests you would perform if the patient were not pregnant.

An important axiom to remember when assessing a pregnant woman is that unless the mother is healthy, the baby cannot be healthy. Therefore, you must do what needs to be done to properly diagnose and treat the mother, and this includes the studies that would be performed if she were not pregnant.

Robert Olson, MD, an OB/GYN hospitalist at PeaceHealth St. Joseph Medical Center in Bellingham, Wash., and founding president of the Society of OB/GYN Hospitalists, cautions hospitalists to proceed as normal with testing. “Whether she’s pregnant or not,” he says, “she needs all the studies a nonpregnant woman would get. If an asthma patient needs a chest X-ray to rule out pneumonia, then do it, because if the mother is not getting enough oxygen, the baby is not getting enough oxygen.”

The tests should be performed as responsibly as possible, Dr. Olson adds. During that chest X-ray, for example, shield the abdomen with a lead apron.⁴

3 When analyzing test results, make sure you are familiar with what is “normal” for a pregnant woman.

The physiological changes in the body during pregnancy can be extreme, and as a result, the parameters of what is considered acceptable in test results may be dramatically different from those seen in nonpregnant patients. For example, early in pregnancy, progesterone causes respiratory alkalosis, so maternal carbon dioxide parameters that range between 28 and 30 are much lower than the nonpregnant normal of 40. A result of 40 from a blood gases test in pregnancy indicates that the woman is on the verge of respiratory failure.

A hospitalist unfamiliar with the correct parameters in pregnancy could make a significant and life-threatening misjudgment.⁵

4 Thromboembolism and pulmonary embolism are some of the most common causes of maternal death.⁶

According to Carolyn M. Zelop, MD, board certified maternal-fetal medicine specialist and director of perinatal ultrasound and research at Valley Hospital in Ridgewood, N.J., “Thromboembolism and pulmonary embolism should always remain part of your differential, even if they are not at the top of the list of possible diagnoses.

“Tests required to exclude these diagnoses, even though they involve very small amounts of radiation, are important to perform,” says Dr. Zelop, a clinical professor at NYU School of Medicine in New York City.

Approaching these diagnostic tests with caution is justified, but it is trumped by the necessity of excluding a life-threatening condition.

5 Prior to 20 weeks, admit the patient to the physician treating her chief complaint.

“Whatever medical condition brings a patient to the hospital prior to 20 weeks, that is the physician that should do the admission,” Dr. Olson says. “If she is suffering from asthma, the internal medicine hospitalist or pulmonologist should admit. If it is appendicitis, the surgeon should do the admission.

“We need to take care of pregnant patients just as well as if they weren’t pregnant.”

During the first half of the pregnancy, care should be directed to the mother. Up until 20 weeks, what is best for the mother is what is best for the baby because the fetus is not viable. It cannot survive outside the mother, so the mother must be saved in order to save the fetus. That means you must give the mother all necessary care to return her to health.

6 After 20 weeks, make sure a pregnant woman is always tilted toward her left side—never supine.

Once an expectant mother reaches 20 weeks, the weight of her expanding uterus can compress the aorta and inferior vena cava, resulting in inadequate blood flow to the baby and to the mother’s brain. A supine position is detrimental not only because it can cause a pregnant woman to feel faint, but also because the interruption in normal blood flow can throw off test results during assessment. Shifting a woman to her left, even with a small tilt from an IV bag under her right hip, can return hemodynamics to homeostasis.

“Left lateral uterine displacement is particularly critical during surgery and while trying to resuscitate a pregnant woman who has coded,” Dr. Zelop says. “The supine position dramatically alters cardiac output. It is nearly impossible to revive someone when the blood flow is compromised by the compression of the uterus in the latter half of pregnancy.”

Click here to listen to Dr. Carolyn Zelop discuss cardiovascular emergencies in pregnant patients.

Remember, however, that the 20-week rule applies to single pregnancies—multiples create a heavier uterus earlier in the pregnancy, so base the timing of lateral uterine displacement on size, not gestational age.

7 Almost all medications can be used in pregnancy.

Despite the stated pregnancy category you read on Hippocrates and warnings pharmaceutical companies place on drug labels, almost all medications can be used in an acute crisis, and even in a subacute situation. As with the choice to perform the necessary tests to correctly diagnose a pregnant woman, the correct drugs to treat the mother must be used. Although there are medications to which you would not chronically expose a fetus, in an emergency situation, they may be acceptable.

This is an area where an OB consult can be especially helpful to balance the needs of mother and baby. If a particular drug is not the best choice for a fetus, an OB can help find the next best option. The specialist’s familiarity with the use of medications in pregnancy may also shed light on a drug labeled “unsafe”: it may be problematic only during certain gestational ages or in concert with a particular drug.

“Sometimes right medication use is not obvious,” says Brigid McCue, MD, chief of the department of OB/GYN at Jordan Hospital in Plymouth, Mass. “Most people would not assume a pregnant woman could undergo chemotherapy for breast cancer or leukemia, but there are options out there. Many patients have been treated for cancer during their pregnancy and have perfectly healthy babies.

“It is a challenge, and every decision is weighed carefully. There is usually some consequence to the baby—maybe it is delivered early or is smaller. But it’s so much nicer for the mom to survive her cancer and be there for the baby.”

8 You can determine gestational age by the position of the uterus relative to the umbilicus.

To make a correct judgment about which medications to use, as well as other treatment decisions, it is vital to ascertain the gestational age of the fetus, but in an acute emergency, there may not be time to do an ultrasound to determine gestational age.

A good way to determine gestational age is to use the umbilicus as a landmark during the physical exam. The rule of thumb is that the uterus touches the umbilicus at 20 weeks and travels one centimeter above it every week thereafter until week 36 or so. As with left lateral uterine displacement after 20 weeks, this rule applies to singleton pregnancies. Multiple fetuses cause a larger uterus earlier in the pregnancy.

9 Do not use lower extremities for vascular access in a pregnant woman.

Dr. Zelop points out that the weight of a pregnant uterus can “significantly compromise intravascular blood flow in the lower extremities.”

“Going below the waist for access can be problematic,” she adds. “Although there may be cases of trauma that make access in the upper limbs difficult or impossible, the lower extremities are not a viable choice.”

Some resuscitation protocols recommend intraosseous access; however, the lower extremities are still not recommended for access in a pregnant woman.

10 The pregnant airway must be treated with respect.

The pregnant airway differs from that of a nonpregnant woman in many important ways, so if intubation becomes necessary, make sure you are familiar with what you are facing. The airway is edematous, which varies the usual landmarks. Increased progesterone causes relaxation of the sphincters between the esophagus and the stomach, and this change predisposes pregnant women to aspiration and loss of consciousness.

In some studies, a failure rate as high as one in 250 is reported. If the patient’s airway needs to be secured, find the most experienced person available to do the intubation. Also, use a smaller tube than would be used for a nonpregnant intubation, usually one size down.

Always ask a woman in labor if she has had any complications during her pregnancy before doing a vaginal exam.

In most cases, deliveries go well for mother and baby; however, certain conditions not immediately apparent upon observation can cause severe problems. For example, a vaginal exam in a pregnant woman with placenta previa can result in a massive hemorrhage.

“In the third trimester, 500 cc of blood per minute flows to the uterus, so a tremendous amount of blood can be lost very quickly,” Dr. Zelop cautions. “Even in cases of women who appear healthy and normal, your radar must be up because an unknown complication can result in major bleeding.”

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Ma, Edward. Coatesville VA Medical Center, Coatesville, Pa. Telephone interview. October 31, 2013.
2. Martin JA, Hamilton BE, Ventura SJ, et al. National Vital Statistics Reports: Volume 62, Number 1. June 28, 2013. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf. Accessed October 6, 2014.
3. McCue, Brigid. Chief, department of OB/GYN, Jordan Hospital, Plymouth, Mass. Telephone interview. October 28, 2013.
4. Olson, Robert. Founding president, Society of OB/GYN Hospitalists; OB/GYN hospitalist at PeaceHealth St. Joseph Medical Center, Bellingham, Wash. Telephone interview. October 31, 2013.
5. Zelop, Carolyn M. Director, perinatal ultrasound and research, Valley Hospital, Ridgewood, N.J. Telephone interview. October 30, 2013.
6. Callahan, William. Chief, Maternal and Infant Health Branch, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. E-mail interview. November 12, 2013.

Many hospitalists feel an understandable wave of trepidation when confronted with treating a pregnant woman. They are unfamiliar with the special concerns of pregnancy and unacquainted with how pregnancy can affect preexisting conditions. Historically, most pregnant women have been young and have not yet experienced the typical health challenges that emerge as people age; however, expectant mothers still appear as patients in hospitals.¹

With more women putting off pregnancy until their late 30s or early 40s, advances in reproductive medicine that allow pregnancies at more advanced ages, and a rise in obesity and related conditions, more and more pregnant women find themselves in the ED or admitted to the hospital.²

To increase the comfort level of practitioners nationwide, The Hospitalist spoke with several obstetricians (OBs) and hospitalists about what they thought were the most important things you should know when treating a mother-to-be. Here are their answers.

1 Involve an OB in the decision-making process as early as possible.

The most efficient and most comfortable way to proceed is to get input from an OB early in the process of treating a pregnant woman. The specialist can give expert opinions on what tests should be ordered and any special precautions to take to protect the fetus.³ Determining which medications can be prescribed safely is an area of particular discomfort for internal medicine hospitalists.

Edward Ma, MD, a hospitalist at the Coatesville VA Medical Center in Coatesville, Pa., explains the dilemma: “I am comfortable using Category A drugs and usually Category B medications, but because I do not [treat pregnant women] very often, I feel very uncomfortable giving a Category C medication unless I’ve spoken with an OB. This is where I really want guidance.”

In cases where the usual medication for a condition may not be indicated for pregnancy, an OB can help you balance the interests of the mother and child. Making these decisions is made much more comfortable when a physician who treats pregnancy on a daily basis can help.

2 Perform the tests you would perform if the patient were not pregnant.

An important axiom to remember when assessing a pregnant woman is that unless the mother is healthy, the baby cannot be healthy. Therefore, you must do what needs to be done to properly diagnose and treat the mother, and this includes the studies that would be performed if she were not pregnant.

Robert Olson, MD, an OB/GYN hospitalist at PeaceHealth St. Joseph Medical Center in Bellingham, Wash., and founding president of the Society of OB/GYN Hospitalists, cautions hospitalists to proceed as normal with testing. “Whether she’s pregnant or not,” he says, “she needs all the studies a nonpregnant woman would get. If an asthma patient needs a chest X-ray to rule out pneumonia, then do it, because if the mother is not getting enough oxygen, the baby is not getting enough oxygen.”

The tests should be performed as responsibly as possible, Dr. Olson adds. During that chest X-ray, for example, shield the abdomen with a lead apron.⁴

3 When analyzing test results, make sure you are familiar with what is “normal” for a pregnant woman.

The physiological changes in the body during pregnancy can be extreme, and as a result, the parameters of what is considered acceptable in test results may be dramatically different from those seen in nonpregnant patients. For example, early in pregnancy, progesterone causes respiratory alkalosis, so maternal carbon dioxide parameters that range between 28 and 30 are much lower than the nonpregnant normal of 40. A result of 40 from a blood gases test in pregnancy indicates that the woman is on the verge of respiratory failure.

A hospitalist unfamiliar with the correct parameters in pregnancy could make a significant and life-threatening misjudgment.⁵

4 Thromboembolism and pulmonary embolism are some of the most common causes of maternal death.⁶

According to Carolyn M. Zelop, MD, board certified maternal-fetal medicine specialist and director of perinatal ultrasound and research at Valley Hospital in Ridgewood, N.J., “Thromboembolism and pulmonary embolism should always remain part of your differential, even if they are not at the top of the list of possible diagnoses.

“Tests required to exclude these diagnoses, even though they involve very small amounts of radiation, are important to perform,” says Dr. Zelop, a clinical professor at NYU School of Medicine in New York City.

Approaching these diagnostic tests with caution is justified, but it is trumped by the necessity of excluding a life-threatening condition.

5 Prior to 20 weeks, admit the patient to the physician treating her chief complaint.

“Whatever medical condition brings a patient to the hospital prior to 20 weeks, that is the physician that should do the admission,” Dr. Olson says. “If she is suffering from asthma, the internal medicine hospitalist or pulmonologist should admit. If it is appendicitis, the surgeon should do the admission.

“We need to take care of pregnant patients just as well as if they weren’t pregnant.”

During the first half of the pregnancy, care should be directed to the mother. Up until 20 weeks, what is best for the mother is what is best for the baby because the fetus is not viable. It cannot survive outside the mother, so the mother must be saved in order to save the fetus. That means you must give the mother all necessary care to return her to health.

6 After 20 weeks, make sure a pregnant woman is always tilted toward her left side—never supine.

Once an expectant mother reaches 20 weeks, the weight of her expanding uterus can compress the aorta and inferior vena cava, resulting in inadequate blood flow to the baby and to the mother’s brain. A supine position is detrimental not only because it can cause a pregnant woman to feel faint, but also because the interruption in normal blood flow can throw off test results during assessment. Shifting a woman to her left, even with a small tilt from an IV bag under her right hip, can return hemodynamics to homeostasis.

“Left lateral uterine displacement is particularly critical during surgery and while trying to resuscitate a pregnant woman who has coded,” Dr. Zelop says. “The supine position dramatically alters cardiac output. It is nearly impossible to revive someone when the blood flow is compromised by the compression of the uterus in the latter half of pregnancy.”

Click here to listen to Dr. Carolyn Zelop discuss cardiovascular emergencies in pregnant patients.

Remember, however, that the 20-week rule applies to single pregnancies—multiples create a heavier uterus earlier in the pregnancy, so base the timing of lateral uterine displacement on size, not gestational age.

7 Almost all medications can be used in pregnancy.

Despite the stated pregnancy category you read on Hippocrates and warnings pharmaceutical companies place on drug labels, almost all medications can be used in an acute crisis, and even in a subacute situation. As with the choice to perform the necessary tests to correctly diagnose a pregnant woman, the correct drugs to treat the mother must be used. Although there are medications to which you would not chronically expose a fetus, in an emergency situation, they may be acceptable.

This is an area where an OB consult can be especially helpful to balance the needs of mother and baby. If a particular drug is not the best choice for a fetus, an OB can help find the next best option. The specialist’s familiarity with the use of medications in pregnancy may also shed light on a drug labeled “unsafe”: it may be problematic only during certain gestational ages or in concert with a particular drug.

“Sometimes right medication use is not obvious,” says Brigid McCue, MD, chief of the department of OB/GYN at Jordan Hospital in Plymouth, Mass. “Most people would not assume a pregnant woman could undergo chemotherapy for breast cancer or leukemia, but there are options out there. Many patients have been treated for cancer during their pregnancy and have perfectly healthy babies.

“It is a challenge, and every decision is weighed carefully. There is usually some consequence to the baby—maybe it is delivered early or is smaller. But it’s so much nicer for the mom to survive her cancer and be there for the baby.”

8 You can determine gestational age by the position of the uterus relative to the umbilicus.

To make a correct judgment about which medications to use, as well as other treatment decisions, it is vital to ascertain the gestational age of the fetus, but in an acute emergency, there may not be time to do an ultrasound to determine gestational age.

A good way to determine gestational age is to use the umbilicus as a landmark during the physical exam. The rule of thumb is that the uterus touches the umbilicus at 20 weeks and travels one centimeter above it every week thereafter until week 36 or so. As with left lateral uterine displacement after 20 weeks, this rule applies to singleton pregnancies. Multiple fetuses cause a larger uterus earlier in the pregnancy.

9 Do not use lower extremities for vascular access in a pregnant woman.

Dr. Zelop points out that the weight of a pregnant uterus can “significantly compromise intravascular blood flow in the lower extremities.”

“Going below the waist for access can be problematic,” she adds. “Although there may be cases of trauma that make access in the upper limbs difficult or impossible, the lower extremities are not a viable choice.”

Some resuscitation protocols recommend intraosseous access; however, the lower extremities are still not recommended for access in a pregnant woman.

10 The pregnant airway must be treated with respect.

The pregnant airway differs from that of a nonpregnant woman in many important ways, so if intubation becomes necessary, make sure you are familiar with what you are facing. The airway is edematous, which varies the usual landmarks. Increased progesterone causes relaxation of the sphincters between the esophagus and the stomach, and this change predisposes pregnant women to aspiration and loss of consciousness.

In some studies, a failure rate as high as one in 250 is reported. If the patient’s airway needs to be secured, find the most experienced person available to do the intubation. Also, use a smaller tube than would be used for a nonpregnant intubation, usually one size down.

Always ask a woman in labor if she has had any complications during her pregnancy before doing a vaginal exam.

In most cases, deliveries go well for mother and baby; however, certain conditions not immediately apparent upon observation can cause severe problems. For example, a vaginal exam in a pregnant woman with placenta previa can result in a massive hemorrhage.

“In the third trimester, 500 cc of blood per minute flows to the uterus, so a tremendous amount of blood can be lost very quickly,” Dr. Zelop cautions. “Even in cases of women who appear healthy and normal, your radar must be up because an unknown complication can result in major bleeding.”

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Ma, Edward. Coatesville VA Medical Center, Coatesville, Pa. Telephone interview. October 31, 2013.
2. Martin JA, Hamilton BE, Ventura SJ, et al. National Vital Statistics Reports: Volume 62, Number 1. June 28, 2013. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf. Accessed October 6, 2014.
3. McCue, Brigid. Chief, department of OB/GYN, Jordan Hospital, Plymouth, Mass. Telephone interview. October 28, 2013.
4. Olson, Robert. Founding president, Society of OB/GYN Hospitalists; OB/GYN hospitalist at PeaceHealth St. Joseph Medical Center, Bellingham, Wash. Telephone interview. October 31, 2013.
5. Zelop, Carolyn M. Director, perinatal ultrasound and research, Valley Hospital, Ridgewood, N.J. Telephone interview. October 30, 2013.
6. Callahan, William. Chief, Maternal and Infant Health Branch, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. E-mail interview. November 12, 2013.

Many hospitalists feel an understandable wave of trepidation when confronted with treating a pregnant woman. They are unfamiliar with the special concerns of pregnancy and unacquainted with how pregnancy can affect preexisting conditions. Historically, most pregnant women have been young and have not yet experienced the typical health challenges that emerge as people age; however, expectant mothers still appear as patients in hospitals.¹

With more women putting off pregnancy until their late 30s or early 40s, advances in reproductive medicine that allow pregnancies at more advanced ages, and a rise in obesity and related conditions, more and more pregnant women find themselves in the ED or admitted to the hospital.²

To increase the comfort level of practitioners nationwide, The Hospitalist spoke with several obstetricians (OBs) and hospitalists about what they thought were the most important things you should know when treating a mother-to-be. Here are their answers.

1 Involve an OB in the decision-making process as early as possible.

The most efficient and most comfortable way to proceed is to get input from an OB early in the process of treating a pregnant woman. The specialist can give expert opinions on what tests should be ordered and any special precautions to take to protect the fetus.³ Determining which medications can be prescribed safely is an area of particular discomfort for internal medicine hospitalists.

Edward Ma, MD, a hospitalist at the Coatesville VA Medical Center in Coatesville, Pa., explains the dilemma: “I am comfortable using Category A drugs and usually Category B medications, but because I do not [treat pregnant women] very often, I feel very uncomfortable giving a Category C medication unless I’ve spoken with an OB. This is where I really want guidance.”

In cases where the usual medication for a condition may not be indicated for pregnancy, an OB can help you balance the interests of the mother and child. Making these decisions is made much more comfortable when a physician who treats pregnancy on a daily basis can help.

2 Perform the tests you would perform if the patient were not pregnant.

An important axiom to remember when assessing a pregnant woman is that unless the mother is healthy, the baby cannot be healthy. Therefore, you must do what needs to be done to properly diagnose and treat the mother, and this includes the studies that would be performed if she were not pregnant.

Robert Olson, MD, an OB/GYN hospitalist at PeaceHealth St. Joseph Medical Center in Bellingham, Wash., and founding president of the Society of OB/GYN Hospitalists, cautions hospitalists to proceed as normal with testing. “Whether she’s pregnant or not,” he says, “she needs all the studies a nonpregnant woman would get. If an asthma patient needs a chest X-ray to rule out pneumonia, then do it, because if the mother is not getting enough oxygen, the baby is not getting enough oxygen.”

The tests should be performed as responsibly as possible, Dr. Olson adds. During that chest X-ray, for example, shield the abdomen with a lead apron.⁴

3 When analyzing test results, make sure you are familiar with what is “normal” for a pregnant woman.

The physiological changes in the body during pregnancy can be extreme, and as a result, the parameters of what is considered acceptable in test results may be dramatically different from those seen in nonpregnant patients. For example, early in pregnancy, progesterone causes respiratory alkalosis, so maternal carbon dioxide parameters that range between 28 and 30 are much lower than the nonpregnant normal of 40. A result of 40 from a blood gases test in pregnancy indicates that the woman is on the verge of respiratory failure.

A hospitalist unfamiliar with the correct parameters in pregnancy could make a significant and life-threatening misjudgment.⁵

4 Thromboembolism and pulmonary embolism are some of the most common causes of maternal death.⁶

According to Carolyn M. Zelop, MD, board certified maternal-fetal medicine specialist and director of perinatal ultrasound and research at Valley Hospital in Ridgewood, N.J., “Thromboembolism and pulmonary embolism should always remain part of your differential, even if they are not at the top of the list of possible diagnoses.

“Tests required to exclude these diagnoses, even though they involve very small amounts of radiation, are important to perform,” says Dr. Zelop, a clinical professor at NYU School of Medicine in New York City.

Approaching these diagnostic tests with caution is justified, but it is trumped by the necessity of excluding a life-threatening condition.

5 Prior to 20 weeks, admit the patient to the physician treating her chief complaint.

“Whatever medical condition brings a patient to the hospital prior to 20 weeks, that is the physician that should do the admission,” Dr. Olson says. “If she is suffering from asthma, the internal medicine hospitalist or pulmonologist should admit. If it is appendicitis, the surgeon should do the admission.

“We need to take care of pregnant patients just as well as if they weren’t pregnant.”

During the first half of the pregnancy, care should be directed to the mother. Up until 20 weeks, what is best for the mother is what is best for the baby because the fetus is not viable. It cannot survive outside the mother, so the mother must be saved in order to save the fetus. That means you must give the mother all necessary care to return her to health.

6 After 20 weeks, make sure a pregnant woman is always tilted toward her left side—never supine.

Once an expectant mother reaches 20 weeks, the weight of her expanding uterus can compress the aorta and inferior vena cava, resulting in inadequate blood flow to the baby and to the mother’s brain. A supine position is detrimental not only because it can cause a pregnant woman to feel faint, but also because the interruption in normal blood flow can throw off test results during assessment. Shifting a woman to her left, even with a small tilt from an IV bag under her right hip, can return hemodynamics to homeostasis.

“Left lateral uterine displacement is particularly critical during surgery and while trying to resuscitate a pregnant woman who has coded,” Dr. Zelop says. “The supine position dramatically alters cardiac output. It is nearly impossible to revive someone when the blood flow is compromised by the compression of the uterus in the latter half of pregnancy.”

Click here to listen to Dr. Carolyn Zelop discuss cardiovascular emergencies in pregnant patients.

Remember, however, that the 20-week rule applies to single pregnancies—multiples create a heavier uterus earlier in the pregnancy, so base the timing of lateral uterine displacement on size, not gestational age.

7 Almost all medications can be used in pregnancy.

Despite the stated pregnancy category you read on Hippocrates and warnings pharmaceutical companies place on drug labels, almost all medications can be used in an acute crisis, and even in a subacute situation. As with the choice to perform the necessary tests to correctly diagnose a pregnant woman, the correct drugs to treat the mother must be used. Although there are medications to which you would not chronically expose a fetus, in an emergency situation, they may be acceptable.

This is an area where an OB consult can be especially helpful to balance the needs of mother and baby. If a particular drug is not the best choice for a fetus, an OB can help find the next best option. The specialist’s familiarity with the use of medications in pregnancy may also shed light on a drug labeled “unsafe”: it may be problematic only during certain gestational ages or in concert with a particular drug.

“Sometimes right medication use is not obvious,” says Brigid McCue, MD, chief of the department of OB/GYN at Jordan Hospital in Plymouth, Mass. “Most people would not assume a pregnant woman could undergo chemotherapy for breast cancer or leukemia, but there are options out there. Many patients have been treated for cancer during their pregnancy and have perfectly healthy babies.

“It is a challenge, and every decision is weighed carefully. There is usually some consequence to the baby—maybe it is delivered early or is smaller. But it’s so much nicer for the mom to survive her cancer and be there for the baby.”

8 You can determine gestational age by the position of the uterus relative to the umbilicus.

To make a correct judgment about which medications to use, as well as other treatment decisions, it is vital to ascertain the gestational age of the fetus, but in an acute emergency, there may not be time to do an ultrasound to determine gestational age.

A good way to determine gestational age is to use the umbilicus as a landmark during the physical exam. The rule of thumb is that the uterus touches the umbilicus at 20 weeks and travels one centimeter above it every week thereafter until week 36 or so. As with left lateral uterine displacement after 20 weeks, this rule applies to singleton pregnancies. Multiple fetuses cause a larger uterus earlier in the pregnancy.

9 Do not use lower extremities for vascular access in a pregnant woman.

Dr. Zelop points out that the weight of a pregnant uterus can “significantly compromise intravascular blood flow in the lower extremities.”

“Going below the waist for access can be problematic,” she adds. “Although there may be cases of trauma that make access in the upper limbs difficult or impossible, the lower extremities are not a viable choice.”

Some resuscitation protocols recommend intraosseous access; however, the lower extremities are still not recommended for access in a pregnant woman.

10 The pregnant airway must be treated with respect.

The pregnant airway differs from that of a nonpregnant woman in many important ways, so if intubation becomes necessary, make sure you are familiar with what you are facing. The airway is edematous, which varies the usual landmarks. Increased progesterone causes relaxation of the sphincters between the esophagus and the stomach, and this change predisposes pregnant women to aspiration and loss of consciousness.

In some studies, a failure rate as high as one in 250 is reported. If the patient’s airway needs to be secured, find the most experienced person available to do the intubation. Also, use a smaller tube than would be used for a nonpregnant intubation, usually one size down.

Always ask a woman in labor if she has had any complications during her pregnancy before doing a vaginal exam.

In most cases, deliveries go well for mother and baby; however, certain conditions not immediately apparent upon observation can cause severe problems. For example, a vaginal exam in a pregnant woman with placenta previa can result in a massive hemorrhage.

“In the third trimester, 500 cc of blood per minute flows to the uterus, so a tremendous amount of blood can be lost very quickly,” Dr. Zelop cautions. “Even in cases of women who appear healthy and normal, your radar must be up because an unknown complication can result in major bleeding.”

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Ma, Edward. Coatesville VA Medical Center, Coatesville, Pa. Telephone interview. October 31, 2013.
2. Martin JA, Hamilton BE, Ventura SJ, et al. National Vital Statistics Reports: Volume 62, Number 1. June 28, 2013. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf. Accessed October 6, 2014.
3. McCue, Brigid. Chief, department of OB/GYN, Jordan Hospital, Plymouth, Mass. Telephone interview. October 28, 2013.
4. Olson, Robert. Founding president, Society of OB/GYN Hospitalists; OB/GYN hospitalist at PeaceHealth St. Joseph Medical Center, Bellingham, Wash. Telephone interview. October 31, 2013.
5. Zelop, Carolyn M. Director, perinatal ultrasound and research, Valley Hospital, Ridgewood, N.J. Telephone interview. October 30, 2013.
6. Callahan, William. Chief, Maternal and Infant Health Branch, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. E-mail interview. November 12, 2013.

Inpatient hyperglycemia, defined as a blood glucose greater than 140, is present in more than half of patients in intensive care units (ICUs) and approximately 30%-40% of patients in the non-ICU setting, according to the American Diabetes Association (ADA).

Joshua D. Lenchus, DO, RPh, FACP, SFHM, a hospitalist and associate professor of clinical medicine and anesthesiology at the University of Miami Miller School of Medicine, can attest to the growing problem. “Patients with diabetes are ubiquitous in our hospital,” he says. “Because I work in an urban, tertiary care, safety net teaching hospital, most of our cases are on the severe end of the acuity scale. Some arrive in full-blown diabetic ketoacidosis (DKA) or hyperosmolar nonketotic hyperglycemia; others are admitted with profound fluid and electrolyte abnormalities from chronically uncontrolled diabetes.”

Caitlin Foxley, MD, FHM, an assistant professor of medicine and the lead hospitalist at Private Hospitalist Service at the University of Nebraska Medical Center in Omaha, says most inpatients have at least one complication of diabetes—usually chronic kidney disease and/or circulatory complications.

“For us, patients of a lower socioeconomic status seem to be hospitalized more frequently with complications related to diabetes due to barriers to access of care,” she says. Barriers include difficulty obtaining supplies, particularly glucose strips and insulin, and finding transportation to appointments.

The University of New Mexico in Albuquerque is seeing more patients who are newly diagnosed with diabetes.

“Management wise, these inpatients are less complicated, but it’s alarming that we are seeing more of them,” says UNM hospitalist Kendall Rogers, MD, CPE, FACP, SFHM, a lead mentor in SHM’s glycemic control quality improvement program. “Overall inpatient management is becoming more complex: Inpatients are frequently on steroids, their nutritional intake varies, and kidney issues make glycemic control more challenging, while therapeutic options for outpatient therapies are escalating.”

Regardless of an inpatient diabetic’s status, hospitalists should play a vital role in their treatment. “Bread and butter diabetics—and even some pretty complex cases—should be owned by hospitalists,” says Dr. Rogers, who notes that more than 95% of diabetic patients at his 650-bed hospital are managed by hospitalists. “Every hospitalist should know how to treat simple to complex glycemic control in the inpatient setting.”

Kristen Kulasa, MD, assistant clinical professor of medicine and director of inpatient glycemic control in the division of endocrinology, diabetes, and metabolism at the University of California San Diego, agrees, especially if no one else is on hand to help treat diabetic patients.

“Many inpatient glycemic control efforts are spearheaded by hospitalists,” she says. “They are in the driver’s seat.”

Order Sets: What Works Best?

While there is consensus that hospitalists should play a primary role in treating inpatient diabetics, debate is ongoing regarding just how standardized order sets should be.

“Each patient is different and should be treated uniquely,” Dr. Lenchus says. “But standardized order sets are beneficial. They remind us of what should be ordered, reviewed, and addressed.”

For example, order sets that address an insulin correction factor should be designed to minimize the potential for hypoglycemic episodes by standardizing the amount of insulin a patient receives. Standard order sets for DKA could assist the physician and nursing staff in ensuring that the appropriate laboratory tests are accomplished within the prescribed time period.

At Jackson Memorial Hospital in Miami, most order sets are designed as a collaborative effort among endocrinologists, hospitalists, nurses, and pharmacists. Some organizations, including SHM, offer order set templates.

Guillermo Umpierrez, MD, CDE, FACE, FACP, professor of medicine at Emory University in Atlanta, Ga., and a member of the ADA board of directors, maintains that hospitalists should work with their information technology (IT) departments to set up appropriate insulin orders.

“Most hospitals have electronic medical records, so the IT department should be involved in having a set of orders to facilitate care,” he says.

Guideline Implementation

National guidelines regarding the management of hyperglycemia in inpatients set goals and explain how to achieve them. “But they are not granular enough to simply implement,” says Paul M. Szumita, PharmD, BCPS, clinical pharmacy practice manager director at Brigham and Women’s Hospital in Boston. “Goal glucose targets change slightly from organization to organization and from year to year, but how to achieve them hasn’t changed much in the past decade.”

To implement the recommendations from national guidelines, institutions must create guidelines and order sets to operationalize the guidelines on a local level.

“When general guidelines and order sets have been created, vetted, implemented, and assessed for efficacy and safety, then there is typically a need to create additional guidelines and order sets to capture practices not supported by the general guidelines [e.g. insulin pumps, patient self-management, peri-procedural, DKA],” Dr. Szumita says. “This approach typically requires a team of dedicated, multidisciplinary, physical champions to create, implement, assess, and refine.”

Hospitalists should be aware of recently revised guidelines for ICU and non-ICU settings. The ADA and American Association of Clinical Endocrinologists recommend using a target blood glucose between 140-180 mg/dl for most patients in the ICU and a lower range, between 110-140, for cardiovascular surgery patients. The Society of Critical Care Medicine, however, recommends a target blood glucose of less than 150 mg/dl for ICU patients.

“Both guidelines recommend careful monitoring to prevent hypoglycemia,” Dr. Umpierrez says.

In the non-ICU setting, the ADA and the Endocrine Society recommend maintaining a pre-meal blood glucose of less than 140 mg/dl and a random blood glucose of less than 180 mg/dl.¹

“We provide a lot of education regarding timing and clinical assessment of the value. If a value seems like an outlier, nurses should question whether it’s an erroneous sample and if they should repeat the test or if there is a clinical scenario to explain the outlier, such as recent snack or interruption in tube feeds.”—Kristen Kulasa, MD, assistant clinical professor of medicine and director of inpatient glycemic control, division of endocrinology, diabetes, and metabolism, University of California San Diego

Resolving Issues

A variety of challenges can occur in the treatment of inpatient diabetics. Here’s a look at some of the more common ones, as well as some suggested solutions.

Coordinating tasks of the care team. Ensuring that glucose levels remain acceptable at all times is perhaps the biggest challenge that involves multiple staff. “You need to coordinate the food tray’s arrival time, obtain pre-meal fingersticks, assess how much the patient eats, and administer insulin accordingly,” Dr. Kulasa says.

To ensure a smooth process, she emphasizes the importance of communication and suggests as much standardization as possible.

“Standardization will help give nurses an idea of when to expect the meal tray and, therefore, when they should obtain their point of care blood glucose test and administer the nutritional and correctional insulin,” Dr. Kulasa says. “This way they can plan their workflow accordingly.”

Listen to Dr. Kulasa explain how hospitalists can work with nutritionists and dieticians to attain glycemic control.

The University of New Mexico has found success in having nurses control every step of the process. “A nurse takes a capillary blood glucose (CBG) reading, draws up the insulin, and then delivers the meal tray,” Dr. Rogers says.

Nurses only deliver diabetic trays, which are color coded. “But other facilities, and even floors within our own hospital, have found this to be controversial because nurses don’t feel that they should be responsible for checking CBGs or delivering trays.” Perhaps adding a second person to perform steps one and three would be more acceptable to other institutions.

NPO patients awaiting tests. When patients are NPO [nil per os, or nothing by mouth], they can be at an increased risk for hypoglycemia; however, if patients are properly dosed on basal/bolus regimens, only the bolus dose should be held when they go NPO.

“Nurses must be taught not to hold basal just because a patient is NPO,” Dr. Rogers says. “However, we sometimes see institutions with an overreliance on basal insulin compared to bolus doses, to the point that the basal dose is covering some nutritional needs. This could increase risk for hypoglycemia if continuing basal insulin at full dose when NPO.”

If there is a 50-50 split between basal and bolus insulin, then it should be safe for patients to continue their full basal insulin when they’re NPO, although some institutions choose to halve this dose for patients who are NPO. Basal insulin should not be routinely held, however. Each institution should standardize its practice in these instances and write them into insulin order sets.

“We try to explain that [those inpatients newly diagnosed] must tend to their disease every day. I think we lose a lot of folks at this crucial point, and those patients end up being readmitted. In addition, their ability to obtain medications and adhere to regimens is quite difficult.”—Joshua D. Lenchus, DO, RPh, FACP, SFHM, hospitalist, associate professor of medicine and anesthesiology, University of Miami Miller School of Medicine

Monitoring and adjusting blood sugar. Dr. Rogers finds that many physicians and nurses don’t recognize high as problematic. “Often physicians don’t even list hyperglycemia or hypoglycemia as an issue in their notes, and adjustments are not made to medications on a daily basis,” he says.

Nurses perform four CBG readings on eating patients throughout the day, and patients on a basal/bolus regimen receive four doses of insulin. “Each dose of insulin is evaluated by one of these blood glucose monitoring values,” he says. “This allows for customized tailoring of a patient’s needs.”

Dr. Rogers says some hospitals administer the same insulin order three times a day with every meal. “Patients may vary in their nutritional intake, and their insulin should be customized to match,” he maintains. “There should be separate insulin orders for each meal to allow for this.”

The biggest issue related to this is that physicians don’t make changes to insulin doses on a daily basis in uncontrolled patients—which he would encourage. There are different methods to achieve this. Dr. Rogers would suggest adding up the amount of correction scale insulin the patient received the previous day and appropriately redistributing this within the scheduled basal and bolus doses.

Listen to Dr. Rogers's advice to hospitalists when working as part of a quality team in achieving glycemic control.

Endocrinologists at UC San Diego stress the importance of performing point of care blood glucose testing within 30 minutes before a meal. This is important in order to calculate an appropriate dose of correction insulin. “We provide a lot of education regarding timing and clinical assessment of the value,” Dr. Kulasa says. “If a value seems like an outlier, nurses should question whether it’s an erroneous sample and if they should repeat the test or if there is a clinical scenario to explain the outlier, such as recent snack or interruption in tube feeds.”

Medication reconciliation. A big mistake is to continue a patient’s in-hospital treatment regimen at discharge. The discharging physician should reevaluate an outbound patient, Dr. Rogers says, and prescribe treatment based on what the patient took prior to admission.

Dr. Kulasa says the inpatient team should make medication adjustments based on a patient’s hemoglobin A1c and the amount of insulin a patient required in the hospital, as well as any changes that might occur upon departure. Does the patient have an infection that’s improving? Is the patient tapering steroids at discharge? These factors should be considered when making adjustments. “We get a lot of information during the inpatient stay that we need to account for when designing an outpatient regimen,” she says.

Transitioning care to the primary care physician. Communication is key when handing off a diabetic patient to another physician. “The primary care physician needs to know what was changed and why it was changed,” Dr. Kulasa says. “Perhaps a medication was discontinued because the patient suffered acute kidney injury or a new medication was added based on an elevated hemoglobin A1c.”

UNM hospitalists request that new diabetics and patients with a hemoglobin A1c greater than 10 visit the hospital’s diabetes clinic within a week of discharge to allow for further titration of their disease.

“I recommend that each hospital have a plan to handle new diabetics and patients who are out of control,” Dr. Rogers says.

Patient Education. When patients are hospitalized without a prior diagnosis of diabetes and leave diagnosed with diabetes, they are discharged with a number of prescriptions, follow-up appointments, and lifestyle instructions. “We try to explain that they must tend to their disease every day,” Dr. Lenchus says. “I think we lose a lot of folks at this crucial point, and those patients end up being readmitted. In addition, their ability to obtain medications and adhere to regimens is quite difficult.”

As a potential solution, a robust discharge counseling session should occur. “Medications should be reviewed, appointments explained, and lifestyle modifications underscored,” Dr. Lenchus says.

On a similar note, Dr. Foxley finds it challenging to manage discharged patients who go home on insulin for the first time. “Plan ahead and begin the education process at least several days in advance, or you’ll set up a patient to fail,” she says.

Karen Appold is a freelance writer in Pennsylvania.

Reference

1. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(1):16-38.
2. American Diabetes Association. Statistics About Diabetes: Data from the National Diabetes Statistics Report, 2014 (released June 10, 2014). Available at: www.diabetes.org/diabetes-basics/statistics/?loc=db-slabnav. Accessed October 5, 2014.
3. Gregg EW, Zhuo X, Cheng YJ, Albright AL, Narayan KMV, Thompson TJ. Trends in lifetime risk and years of life lost due to diabetes in the USA, 1985—2011: a modelling study. The Lancet Diabetes & Endocrinology. Available at: www.thelancet.com/journals/landia/article/PIIS2213-8587(14)70161-5/abstract. Accessed October 5, 2014.

Inpatient hyperglycemia, defined as a blood glucose greater than 140, is present in more than half of patients in intensive care units (ICUs) and approximately 30%-40% of patients in the non-ICU setting, according to the American Diabetes Association (ADA).

Joshua D. Lenchus, DO, RPh, FACP, SFHM, a hospitalist and associate professor of clinical medicine and anesthesiology at the University of Miami Miller School of Medicine, can attest to the growing problem. “Patients with diabetes are ubiquitous in our hospital,” he says. “Because I work in an urban, tertiary care, safety net teaching hospital, most of our cases are on the severe end of the acuity scale. Some arrive in full-blown diabetic ketoacidosis (DKA) or hyperosmolar nonketotic hyperglycemia; others are admitted with profound fluid and electrolyte abnormalities from chronically uncontrolled diabetes.”

Caitlin Foxley, MD, FHM, an assistant professor of medicine and the lead hospitalist at Private Hospitalist Service at the University of Nebraska Medical Center in Omaha, says most inpatients have at least one complication of diabetes—usually chronic kidney disease and/or circulatory complications.

“For us, patients of a lower socioeconomic status seem to be hospitalized more frequently with complications related to diabetes due to barriers to access of care,” she says. Barriers include difficulty obtaining supplies, particularly glucose strips and insulin, and finding transportation to appointments.

The University of New Mexico in Albuquerque is seeing more patients who are newly diagnosed with diabetes.

“Management wise, these inpatients are less complicated, but it’s alarming that we are seeing more of them,” says UNM hospitalist Kendall Rogers, MD, CPE, FACP, SFHM, a lead mentor in SHM’s glycemic control quality improvement program. “Overall inpatient management is becoming more complex: Inpatients are frequently on steroids, their nutritional intake varies, and kidney issues make glycemic control more challenging, while therapeutic options for outpatient therapies are escalating.”

Regardless of an inpatient diabetic’s status, hospitalists should play a vital role in their treatment. “Bread and butter diabetics—and even some pretty complex cases—should be owned by hospitalists,” says Dr. Rogers, who notes that more than 95% of diabetic patients at his 650-bed hospital are managed by hospitalists. “Every hospitalist should know how to treat simple to complex glycemic control in the inpatient setting.”

Kristen Kulasa, MD, assistant clinical professor of medicine and director of inpatient glycemic control in the division of endocrinology, diabetes, and metabolism at the University of California San Diego, agrees, especially if no one else is on hand to help treat diabetic patients.

“Many inpatient glycemic control efforts are spearheaded by hospitalists,” she says. “They are in the driver’s seat.”

Order Sets: What Works Best?

While there is consensus that hospitalists should play a primary role in treating inpatient diabetics, debate is ongoing regarding just how standardized order sets should be.

“Each patient is different and should be treated uniquely,” Dr. Lenchus says. “But standardized order sets are beneficial. They remind us of what should be ordered, reviewed, and addressed.”

For example, order sets that address an insulin correction factor should be designed to minimize the potential for hypoglycemic episodes by standardizing the amount of insulin a patient receives. Standard order sets for DKA could assist the physician and nursing staff in ensuring that the appropriate laboratory tests are accomplished within the prescribed time period.

At Jackson Memorial Hospital in Miami, most order sets are designed as a collaborative effort among endocrinologists, hospitalists, nurses, and pharmacists. Some organizations, including SHM, offer order set templates.

Guillermo Umpierrez, MD, CDE, FACE, FACP, professor of medicine at Emory University in Atlanta, Ga., and a member of the ADA board of directors, maintains that hospitalists should work with their information technology (IT) departments to set up appropriate insulin orders.

“Most hospitals have electronic medical records, so the IT department should be involved in having a set of orders to facilitate care,” he says.

Guideline Implementation

National guidelines regarding the management of hyperglycemia in inpatients set goals and explain how to achieve them. “But they are not granular enough to simply implement,” says Paul M. Szumita, PharmD, BCPS, clinical pharmacy practice manager director at Brigham and Women’s Hospital in Boston. “Goal glucose targets change slightly from organization to organization and from year to year, but how to achieve them hasn’t changed much in the past decade.”

To implement the recommendations from national guidelines, institutions must create guidelines and order sets to operationalize the guidelines on a local level.

“When general guidelines and order sets have been created, vetted, implemented, and assessed for efficacy and safety, then there is typically a need to create additional guidelines and order sets to capture practices not supported by the general guidelines [e.g. insulin pumps, patient self-management, peri-procedural, DKA],” Dr. Szumita says. “This approach typically requires a team of dedicated, multidisciplinary, physical champions to create, implement, assess, and refine.”

Hospitalists should be aware of recently revised guidelines for ICU and non-ICU settings. The ADA and American Association of Clinical Endocrinologists recommend using a target blood glucose between 140-180 mg/dl for most patients in the ICU and a lower range, between 110-140, for cardiovascular surgery patients. The Society of Critical Care Medicine, however, recommends a target blood glucose of less than 150 mg/dl for ICU patients.

“Both guidelines recommend careful monitoring to prevent hypoglycemia,” Dr. Umpierrez says.

In the non-ICU setting, the ADA and the Endocrine Society recommend maintaining a pre-meal blood glucose of less than 140 mg/dl and a random blood glucose of less than 180 mg/dl.¹

“We provide a lot of education regarding timing and clinical assessment of the value. If a value seems like an outlier, nurses should question whether it’s an erroneous sample and if they should repeat the test or if there is a clinical scenario to explain the outlier, such as recent snack or interruption in tube feeds.”—Kristen Kulasa, MD, assistant clinical professor of medicine and director of inpatient glycemic control, division of endocrinology, diabetes, and metabolism, University of California San Diego

Resolving Issues

A variety of challenges can occur in the treatment of inpatient diabetics. Here’s a look at some of the more common ones, as well as some suggested solutions.

Coordinating tasks of the care team. Ensuring that glucose levels remain acceptable at all times is perhaps the biggest challenge that involves multiple staff. “You need to coordinate the food tray’s arrival time, obtain pre-meal fingersticks, assess how much the patient eats, and administer insulin accordingly,” Dr. Kulasa says.

To ensure a smooth process, she emphasizes the importance of communication and suggests as much standardization as possible.

“Standardization will help give nurses an idea of when to expect the meal tray and, therefore, when they should obtain their point of care blood glucose test and administer the nutritional and correctional insulin,” Dr. Kulasa says. “This way they can plan their workflow accordingly.”

Listen to Dr. Kulasa explain how hospitalists can work with nutritionists and dieticians to attain glycemic control.

The University of New Mexico has found success in having nurses control every step of the process. “A nurse takes a capillary blood glucose (CBG) reading, draws up the insulin, and then delivers the meal tray,” Dr. Rogers says.

Nurses only deliver diabetic trays, which are color coded. “But other facilities, and even floors within our own hospital, have found this to be controversial because nurses don’t feel that they should be responsible for checking CBGs or delivering trays.” Perhaps adding a second person to perform steps one and three would be more acceptable to other institutions.

NPO patients awaiting tests. When patients are NPO [nil per os, or nothing by mouth], they can be at an increased risk for hypoglycemia; however, if patients are properly dosed on basal/bolus regimens, only the bolus dose should be held when they go NPO.

“Nurses must be taught not to hold basal just because a patient is NPO,” Dr. Rogers says. “However, we sometimes see institutions with an overreliance on basal insulin compared to bolus doses, to the point that the basal dose is covering some nutritional needs. This could increase risk for hypoglycemia if continuing basal insulin at full dose when NPO.”

If there is a 50-50 split between basal and bolus insulin, then it should be safe for patients to continue their full basal insulin when they’re NPO, although some institutions choose to halve this dose for patients who are NPO. Basal insulin should not be routinely held, however. Each institution should standardize its practice in these instances and write them into insulin order sets.

“We try to explain that [those inpatients newly diagnosed] must tend to their disease every day. I think we lose a lot of folks at this crucial point, and those patients end up being readmitted. In addition, their ability to obtain medications and adhere to regimens is quite difficult.”—Joshua D. Lenchus, DO, RPh, FACP, SFHM, hospitalist, associate professor of medicine and anesthesiology, University of Miami Miller School of Medicine

Monitoring and adjusting blood sugar. Dr. Rogers finds that many physicians and nurses don’t recognize high as problematic. “Often physicians don’t even list hyperglycemia or hypoglycemia as an issue in their notes, and adjustments are not made to medications on a daily basis,” he says.

Nurses perform four CBG readings on eating patients throughout the day, and patients on a basal/bolus regimen receive four doses of insulin. “Each dose of insulin is evaluated by one of these blood glucose monitoring values,” he says. “This allows for customized tailoring of a patient’s needs.”

Dr. Rogers says some hospitals administer the same insulin order three times a day with every meal. “Patients may vary in their nutritional intake, and their insulin should be customized to match,” he maintains. “There should be separate insulin orders for each meal to allow for this.”

The biggest issue related to this is that physicians don’t make changes to insulin doses on a daily basis in uncontrolled patients—which he would encourage. There are different methods to achieve this. Dr. Rogers would suggest adding up the amount of correction scale insulin the patient received the previous day and appropriately redistributing this within the scheduled basal and bolus doses.

Listen to Dr. Rogers's advice to hospitalists when working as part of a quality team in achieving glycemic control.

Endocrinologists at UC San Diego stress the importance of performing point of care blood glucose testing within 30 minutes before a meal. This is important in order to calculate an appropriate dose of correction insulin. “We provide a lot of education regarding timing and clinical assessment of the value,” Dr. Kulasa says. “If a value seems like an outlier, nurses should question whether it’s an erroneous sample and if they should repeat the test or if there is a clinical scenario to explain the outlier, such as recent snack or interruption in tube feeds.”

Medication reconciliation. A big mistake is to continue a patient’s in-hospital treatment regimen at discharge. The discharging physician should reevaluate an outbound patient, Dr. Rogers says, and prescribe treatment based on what the patient took prior to admission.

Dr. Kulasa says the inpatient team should make medication adjustments based on a patient’s hemoglobin A1c and the amount of insulin a patient required in the hospital, as well as any changes that might occur upon departure. Does the patient have an infection that’s improving? Is the patient tapering steroids at discharge? These factors should be considered when making adjustments. “We get a lot of information during the inpatient stay that we need to account for when designing an outpatient regimen,” she says.

Transitioning care to the primary care physician. Communication is key when handing off a diabetic patient to another physician. “The primary care physician needs to know what was changed and why it was changed,” Dr. Kulasa says. “Perhaps a medication was discontinued because the patient suffered acute kidney injury or a new medication was added based on an elevated hemoglobin A1c.”

UNM hospitalists request that new diabetics and patients with a hemoglobin A1c greater than 10 visit the hospital’s diabetes clinic within a week of discharge to allow for further titration of their disease.

“I recommend that each hospital have a plan to handle new diabetics and patients who are out of control,” Dr. Rogers says.

Patient Education. When patients are hospitalized without a prior diagnosis of diabetes and leave diagnosed with diabetes, they are discharged with a number of prescriptions, follow-up appointments, and lifestyle instructions. “We try to explain that they must tend to their disease every day,” Dr. Lenchus says. “I think we lose a lot of folks at this crucial point, and those patients end up being readmitted. In addition, their ability to obtain medications and adhere to regimens is quite difficult.”

As a potential solution, a robust discharge counseling session should occur. “Medications should be reviewed, appointments explained, and lifestyle modifications underscored,” Dr. Lenchus says.

On a similar note, Dr. Foxley finds it challenging to manage discharged patients who go home on insulin for the first time. “Plan ahead and begin the education process at least several days in advance, or you’ll set up a patient to fail,” she says.

Karen Appold is a freelance writer in Pennsylvania.

Reference

1. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(1):16-38.
2. American Diabetes Association. Statistics About Diabetes: Data from the National Diabetes Statistics Report, 2014 (released June 10, 2014). Available at: www.diabetes.org/diabetes-basics/statistics/?loc=db-slabnav. Accessed October 5, 2014.
3. Gregg EW, Zhuo X, Cheng YJ, Albright AL, Narayan KMV, Thompson TJ. Trends in lifetime risk and years of life lost due to diabetes in the USA, 1985—2011: a modelling study. The Lancet Diabetes & Endocrinology. Available at: www.thelancet.com/journals/landia/article/PIIS2213-8587(14)70161-5/abstract. Accessed October 5, 2014.

Inpatient hyperglycemia, defined as a blood glucose greater than 140, is present in more than half of patients in intensive care units (ICUs) and approximately 30%-40% of patients in the non-ICU setting, according to the American Diabetes Association (ADA).

Joshua D. Lenchus, DO, RPh, FACP, SFHM, a hospitalist and associate professor of clinical medicine and anesthesiology at the University of Miami Miller School of Medicine, can attest to the growing problem. “Patients with diabetes are ubiquitous in our hospital,” he says. “Because I work in an urban, tertiary care, safety net teaching hospital, most of our cases are on the severe end of the acuity scale. Some arrive in full-blown diabetic ketoacidosis (DKA) or hyperosmolar nonketotic hyperglycemia; others are admitted with profound fluid and electrolyte abnormalities from chronically uncontrolled diabetes.”

Caitlin Foxley, MD, FHM, an assistant professor of medicine and the lead hospitalist at Private Hospitalist Service at the University of Nebraska Medical Center in Omaha, says most inpatients have at least one complication of diabetes—usually chronic kidney disease and/or circulatory complications.

“For us, patients of a lower socioeconomic status seem to be hospitalized more frequently with complications related to diabetes due to barriers to access of care,” she says. Barriers include difficulty obtaining supplies, particularly glucose strips and insulin, and finding transportation to appointments.

The University of New Mexico in Albuquerque is seeing more patients who are newly diagnosed with diabetes.

“Management wise, these inpatients are less complicated, but it’s alarming that we are seeing more of them,” says UNM hospitalist Kendall Rogers, MD, CPE, FACP, SFHM, a lead mentor in SHM’s glycemic control quality improvement program. “Overall inpatient management is becoming more complex: Inpatients are frequently on steroids, their nutritional intake varies, and kidney issues make glycemic control more challenging, while therapeutic options for outpatient therapies are escalating.”

Regardless of an inpatient diabetic’s status, hospitalists should play a vital role in their treatment. “Bread and butter diabetics—and even some pretty complex cases—should be owned by hospitalists,” says Dr. Rogers, who notes that more than 95% of diabetic patients at his 650-bed hospital are managed by hospitalists. “Every hospitalist should know how to treat simple to complex glycemic control in the inpatient setting.”

Kristen Kulasa, MD, assistant clinical professor of medicine and director of inpatient glycemic control in the division of endocrinology, diabetes, and metabolism at the University of California San Diego, agrees, especially if no one else is on hand to help treat diabetic patients.

“Many inpatient glycemic control efforts are spearheaded by hospitalists,” she says. “They are in the driver’s seat.”

Order Sets: What Works Best?

While there is consensus that hospitalists should play a primary role in treating inpatient diabetics, debate is ongoing regarding just how standardized order sets should be.

“Each patient is different and should be treated uniquely,” Dr. Lenchus says. “But standardized order sets are beneficial. They remind us of what should be ordered, reviewed, and addressed.”

For example, order sets that address an insulin correction factor should be designed to minimize the potential for hypoglycemic episodes by standardizing the amount of insulin a patient receives. Standard order sets for DKA could assist the physician and nursing staff in ensuring that the appropriate laboratory tests are accomplished within the prescribed time period.

At Jackson Memorial Hospital in Miami, most order sets are designed as a collaborative effort among endocrinologists, hospitalists, nurses, and pharmacists. Some organizations, including SHM, offer order set templates.

Guillermo Umpierrez, MD, CDE, FACE, FACP, professor of medicine at Emory University in Atlanta, Ga., and a member of the ADA board of directors, maintains that hospitalists should work with their information technology (IT) departments to set up appropriate insulin orders.

“Most hospitals have electronic medical records, so the IT department should be involved in having a set of orders to facilitate care,” he says.

Guideline Implementation

National guidelines regarding the management of hyperglycemia in inpatients set goals and explain how to achieve them. “But they are not granular enough to simply implement,” says Paul M. Szumita, PharmD, BCPS, clinical pharmacy practice manager director at Brigham and Women’s Hospital in Boston. “Goal glucose targets change slightly from organization to organization and from year to year, but how to achieve them hasn’t changed much in the past decade.”

To implement the recommendations from national guidelines, institutions must create guidelines and order sets to operationalize the guidelines on a local level.

“When general guidelines and order sets have been created, vetted, implemented, and assessed for efficacy and safety, then there is typically a need to create additional guidelines and order sets to capture practices not supported by the general guidelines [e.g. insulin pumps, patient self-management, peri-procedural, DKA],” Dr. Szumita says. “This approach typically requires a team of dedicated, multidisciplinary, physical champions to create, implement, assess, and refine.”

Hospitalists should be aware of recently revised guidelines for ICU and non-ICU settings. The ADA and American Association of Clinical Endocrinologists recommend using a target blood glucose between 140-180 mg/dl for most patients in the ICU and a lower range, between 110-140, for cardiovascular surgery patients. The Society of Critical Care Medicine, however, recommends a target blood glucose of less than 150 mg/dl for ICU patients.

“Both guidelines recommend careful monitoring to prevent hypoglycemia,” Dr. Umpierrez says.

In the non-ICU setting, the ADA and the Endocrine Society recommend maintaining a pre-meal blood glucose of less than 140 mg/dl and a random blood glucose of less than 180 mg/dl.¹

“We provide a lot of education regarding timing and clinical assessment of the value. If a value seems like an outlier, nurses should question whether it’s an erroneous sample and if they should repeat the test or if there is a clinical scenario to explain the outlier, such as recent snack or interruption in tube feeds.”—Kristen Kulasa, MD, assistant clinical professor of medicine and director of inpatient glycemic control, division of endocrinology, diabetes, and metabolism, University of California San Diego

Resolving Issues

A variety of challenges can occur in the treatment of inpatient diabetics. Here’s a look at some of the more common ones, as well as some suggested solutions.

Coordinating tasks of the care team. Ensuring that glucose levels remain acceptable at all times is perhaps the biggest challenge that involves multiple staff. “You need to coordinate the food tray’s arrival time, obtain pre-meal fingersticks, assess how much the patient eats, and administer insulin accordingly,” Dr. Kulasa says.

To ensure a smooth process, she emphasizes the importance of communication and suggests as much standardization as possible.

“Standardization will help give nurses an idea of when to expect the meal tray and, therefore, when they should obtain their point of care blood glucose test and administer the nutritional and correctional insulin,” Dr. Kulasa says. “This way they can plan their workflow accordingly.”

Listen to Dr. Kulasa explain how hospitalists can work with nutritionists and dieticians to attain glycemic control.

The University of New Mexico has found success in having nurses control every step of the process. “A nurse takes a capillary blood glucose (CBG) reading, draws up the insulin, and then delivers the meal tray,” Dr. Rogers says.

Nurses only deliver diabetic trays, which are color coded. “But other facilities, and even floors within our own hospital, have found this to be controversial because nurses don’t feel that they should be responsible for checking CBGs or delivering trays.” Perhaps adding a second person to perform steps one and three would be more acceptable to other institutions.

NPO patients awaiting tests. When patients are NPO [nil per os, or nothing by mouth], they can be at an increased risk for hypoglycemia; however, if patients are properly dosed on basal/bolus regimens, only the bolus dose should be held when they go NPO.

“Nurses must be taught not to hold basal just because a patient is NPO,” Dr. Rogers says. “However, we sometimes see institutions with an overreliance on basal insulin compared to bolus doses, to the point that the basal dose is covering some nutritional needs. This could increase risk for hypoglycemia if continuing basal insulin at full dose when NPO.”

If there is a 50-50 split between basal and bolus insulin, then it should be safe for patients to continue their full basal insulin when they’re NPO, although some institutions choose to halve this dose for patients who are NPO. Basal insulin should not be routinely held, however. Each institution should standardize its practice in these instances and write them into insulin order sets.

“We try to explain that [those inpatients newly diagnosed] must tend to their disease every day. I think we lose a lot of folks at this crucial point, and those patients end up being readmitted. In addition, their ability to obtain medications and adhere to regimens is quite difficult.”—Joshua D. Lenchus, DO, RPh, FACP, SFHM, hospitalist, associate professor of medicine and anesthesiology, University of Miami Miller School of Medicine

Monitoring and adjusting blood sugar. Dr. Rogers finds that many physicians and nurses don’t recognize high as problematic. “Often physicians don’t even list hyperglycemia or hypoglycemia as an issue in their notes, and adjustments are not made to medications on a daily basis,” he says.

Nurses perform four CBG readings on eating patients throughout the day, and patients on a basal/bolus regimen receive four doses of insulin. “Each dose of insulin is evaluated by one of these blood glucose monitoring values,” he says. “This allows for customized tailoring of a patient’s needs.”

Dr. Rogers says some hospitals administer the same insulin order three times a day with every meal. “Patients may vary in their nutritional intake, and their insulin should be customized to match,” he maintains. “There should be separate insulin orders for each meal to allow for this.”

The biggest issue related to this is that physicians don’t make changes to insulin doses on a daily basis in uncontrolled patients—which he would encourage. There are different methods to achieve this. Dr. Rogers would suggest adding up the amount of correction scale insulin the patient received the previous day and appropriately redistributing this within the scheduled basal and bolus doses.

Listen to Dr. Rogers's advice to hospitalists when working as part of a quality team in achieving glycemic control.

Endocrinologists at UC San Diego stress the importance of performing point of care blood glucose testing within 30 minutes before a meal. This is important in order to calculate an appropriate dose of correction insulin. “We provide a lot of education regarding timing and clinical assessment of the value,” Dr. Kulasa says. “If a value seems like an outlier, nurses should question whether it’s an erroneous sample and if they should repeat the test or if there is a clinical scenario to explain the outlier, such as recent snack or interruption in tube feeds.”

Medication reconciliation. A big mistake is to continue a patient’s in-hospital treatment regimen at discharge. The discharging physician should reevaluate an outbound patient, Dr. Rogers says, and prescribe treatment based on what the patient took prior to admission.

Dr. Kulasa says the inpatient team should make medication adjustments based on a patient’s hemoglobin A1c and the amount of insulin a patient required in the hospital, as well as any changes that might occur upon departure. Does the patient have an infection that’s improving? Is the patient tapering steroids at discharge? These factors should be considered when making adjustments. “We get a lot of information during the inpatient stay that we need to account for when designing an outpatient regimen,” she says.

Transitioning care to the primary care physician. Communication is key when handing off a diabetic patient to another physician. “The primary care physician needs to know what was changed and why it was changed,” Dr. Kulasa says. “Perhaps a medication was discontinued because the patient suffered acute kidney injury or a new medication was added based on an elevated hemoglobin A1c.”

UNM hospitalists request that new diabetics and patients with a hemoglobin A1c greater than 10 visit the hospital’s diabetes clinic within a week of discharge to allow for further titration of their disease.

“I recommend that each hospital have a plan to handle new diabetics and patients who are out of control,” Dr. Rogers says.

Patient Education. When patients are hospitalized without a prior diagnosis of diabetes and leave diagnosed with diabetes, they are discharged with a number of prescriptions, follow-up appointments, and lifestyle instructions. “We try to explain that they must tend to their disease every day,” Dr. Lenchus says. “I think we lose a lot of folks at this crucial point, and those patients end up being readmitted. In addition, their ability to obtain medications and adhere to regimens is quite difficult.”

As a potential solution, a robust discharge counseling session should occur. “Medications should be reviewed, appointments explained, and lifestyle modifications underscored,” Dr. Lenchus says.

On a similar note, Dr. Foxley finds it challenging to manage discharged patients who go home on insulin for the first time. “Plan ahead and begin the education process at least several days in advance, or you’ll set up a patient to fail,” she says.

Karen Appold is a freelance writer in Pennsylvania.

Reference

1. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(1):16-38.
2. American Diabetes Association. Statistics About Diabetes: Data from the National Diabetes Statistics Report, 2014 (released June 10, 2014). Available at: www.diabetes.org/diabetes-basics/statistics/?loc=db-slabnav. Accessed October 5, 2014.
3. Gregg EW, Zhuo X, Cheng YJ, Albright AL, Narayan KMV, Thompson TJ. Trends in lifetime risk and years of life lost due to diabetes in the USA, 1985—2011: a modelling study. The Lancet Diabetes & Endocrinology. Available at: www.thelancet.com/journals/landia/article/PIIS2213-8587(14)70161-5/abstract. Accessed October 5, 2014.

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

Clinical question: Does antibiotic prophylaxis prevent future episodes of urinary tract infections?

Background: Recurrent urinary tract infections (UTI) in children might be associated with renal scarring and subsequent clinical consequences associated with long-term morbidity. Historically, antibiotic prophylaxis has been recommended for children who might have risk factors for recurrent infection, most commonly vesicoureteral reflux. However, scars may be present in the absence of known risk factors and upon first UTI. The efficacy of antibiotic prophylaxis in preventing recurrent UTIs is unclear.

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

Setting: Four centers in Australia.

Synopsis: The study looked at 576 children under the age of 18 with a history of at least one symptomatic UTI. The patients were randomized to receive trimethoprim-sulfamethoxazole (TMP-SMX) or placebo for 12 months. Children with vesicoureteral reflux were included, but those with known neurologic, skeletal, or urologic predispositions were excluded.

Thirteen percent of patients in the antibiotic group developed a UTI compared with 19% of patients in the placebo group (P=0.02). The authors calculate that at 12 months, 14 patients would need to be treated to prevent one UTI.

This study was unable to enroll the planned number of children but remained adequately powered to show a reduction in the primary outcome (rate of symptomatic UTI). However, a significant number of patients (approximately 28%) in each arm stopped taking the medication, the majority for undisclosed reasons. Despite an intention-to-treat analysis, this degree of dropout raises questions about the true effect size. Additionally, this study does not answer the more important clinical question regarding the effect of prophylaxis on potential future renal damage, specifically in children with vesicoureteral reflux.

Bottom line: Antibiotic prophylaxis might be modestly effective in preventing recurrent UTIs.

Citation: Craig JC, Simpson JM, Williams GJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. 2009;361(18):1748-1759.

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

Clinical question: Does antibiotic prophylaxis prevent future episodes of urinary tract infections?

Background: Recurrent urinary tract infections (UTI) in children might be associated with renal scarring and subsequent clinical consequences associated with long-term morbidity. Historically, antibiotic prophylaxis has been recommended for children who might have risk factors for recurrent infection, most commonly vesicoureteral reflux. However, scars may be present in the absence of known risk factors and upon first UTI. The efficacy of antibiotic prophylaxis in preventing recurrent UTIs is unclear.

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

Setting: Four centers in Australia.

Synopsis: The study looked at 576 children under the age of 18 with a history of at least one symptomatic UTI. The patients were randomized to receive trimethoprim-sulfamethoxazole (TMP-SMX) or placebo for 12 months. Children with vesicoureteral reflux were included, but those with known neurologic, skeletal, or urologic predispositions were excluded.

Thirteen percent of patients in the antibiotic group developed a UTI compared with 19% of patients in the placebo group (P=0.02). The authors calculate that at 12 months, 14 patients would need to be treated to prevent one UTI.

This study was unable to enroll the planned number of children but remained adequately powered to show a reduction in the primary outcome (rate of symptomatic UTI). However, a significant number of patients (approximately 28%) in each arm stopped taking the medication, the majority for undisclosed reasons. Despite an intention-to-treat analysis, this degree of dropout raises questions about the true effect size. Additionally, this study does not answer the more important clinical question regarding the effect of prophylaxis on potential future renal damage, specifically in children with vesicoureteral reflux.

Bottom line: Antibiotic prophylaxis might be modestly effective in preventing recurrent UTIs.

Citation: Craig JC, Simpson JM, Williams GJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. 2009;361(18):1748-1759.

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

Clinical question: Does antibiotic prophylaxis prevent future episodes of urinary tract infections?

Background: Recurrent urinary tract infections (UTI) in children might be associated with renal scarring and subsequent clinical consequences associated with long-term morbidity. Historically, antibiotic prophylaxis has been recommended for children who might have risk factors for recurrent infection, most commonly vesicoureteral reflux. However, scars may be present in the absence of known risk factors and upon first UTI. The efficacy of antibiotic prophylaxis in preventing recurrent UTIs is unclear.

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

Setting: Four centers in Australia.

Synopsis: The study looked at 576 children under the age of 18 with a history of at least one symptomatic UTI. The patients were randomized to receive trimethoprim-sulfamethoxazole (TMP-SMX) or placebo for 12 months. Children with vesicoureteral reflux were included, but those with known neurologic, skeletal, or urologic predispositions were excluded.

Thirteen percent of patients in the antibiotic group developed a UTI compared with 19% of patients in the placebo group (P=0.02). The authors calculate that at 12 months, 14 patients would need to be treated to prevent one UTI.

This study was unable to enroll the planned number of children but remained adequately powered to show a reduction in the primary outcome (rate of symptomatic UTI). However, a significant number of patients (approximately 28%) in each arm stopped taking the medication, the majority for undisclosed reasons. Despite an intention-to-treat analysis, this degree of dropout raises questions about the true effect size. Additionally, this study does not answer the more important clinical question regarding the effect of prophylaxis on potential future renal damage, specifically in children with vesicoureteral reflux.

Bottom line: Antibiotic prophylaxis might be modestly effective in preventing recurrent UTIs.

Citation: Craig JC, Simpson JM, Williams GJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. 2009;361(18):1748-1759.

Clinical question: Does understanding the expected clinical course of advanced dementia influence end-of-life decisions by proxy decision-makers?

Background: Advanced dementia is a leading cause of death in the United States, but the clinical course of advanced dementia has not been described in a rigorous, prospective manner. The lack of information might cause risk to be underestimated, and patients might receive suboptimal palliative care.

Study design: Multicenter prospective cohort study.

Setting: Twenty-two nursing homes in a single U.S. city.

Synopsis: The survey examined 323 nursing home residents with advanced dementia. The patients were clinically assessed at baseline and quarterly for 18 months through chart reviews, nursing interviews, and physical examinations. Additionally, their proxies were surveyed regarding their understanding of the subjects’ prognoses.

During the survey period, 41.1% of patients developed pneumonia, 52.6% of patients experienced a febrile episode, and 85.8% of patients developed an eating problem; cumulative all-cause mortality was 54.8%. Adjusted for age, sex, and disease duration, the six-month mortality rate for subjects who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%.

Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last three months of life, 40.7% of subjects underwent at least one burdensome intervention (defined as hospitalization, ED visit, parenteral therapy, or tube feeding).

Subjects whose proxies reported an understanding of the poor prognosis and expected clinical complications of advanced dementia underwent significantly fewer burdensome interventions (adjusted odds ratio 0.12).

Bottom line: Advanced dementia is associated with frequent complications, including infections and eating problems, with high six-month mortality and significant associated morbidity. Patients whose healthcare proxies have a good understanding of the expected clinical course and prognosis receive less-aggressive end-of-life care.

Citation: Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538. TH

Clinical question: Does understanding the expected clinical course of advanced dementia influence end-of-life decisions by proxy decision-makers?

Background: Advanced dementia is a leading cause of death in the United States, but the clinical course of advanced dementia has not been described in a rigorous, prospective manner. The lack of information might cause risk to be underestimated, and patients might receive suboptimal palliative care.

Study design: Multicenter prospective cohort study.

Setting: Twenty-two nursing homes in a single U.S. city.

Synopsis: The survey examined 323 nursing home residents with advanced dementia. The patients were clinically assessed at baseline and quarterly for 18 months through chart reviews, nursing interviews, and physical examinations. Additionally, their proxies were surveyed regarding their understanding of the subjects’ prognoses.

During the survey period, 41.1% of patients developed pneumonia, 52.6% of patients experienced a febrile episode, and 85.8% of patients developed an eating problem; cumulative all-cause mortality was 54.8%. Adjusted for age, sex, and disease duration, the six-month mortality rate for subjects who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%.

Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last three months of life, 40.7% of subjects underwent at least one burdensome intervention (defined as hospitalization, ED visit, parenteral therapy, or tube feeding).

Subjects whose proxies reported an understanding of the poor prognosis and expected clinical complications of advanced dementia underwent significantly fewer burdensome interventions (adjusted odds ratio 0.12).

Bottom line: Advanced dementia is associated with frequent complications, including infections and eating problems, with high six-month mortality and significant associated morbidity. Patients whose healthcare proxies have a good understanding of the expected clinical course and prognosis receive less-aggressive end-of-life care.

Citation: Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538. TH

Clinical question: Does understanding the expected clinical course of advanced dementia influence end-of-life decisions by proxy decision-makers?

Background: Advanced dementia is a leading cause of death in the United States, but the clinical course of advanced dementia has not been described in a rigorous, prospective manner. The lack of information might cause risk to be underestimated, and patients might receive suboptimal palliative care.

Study design: Multicenter prospective cohort study.

Setting: Twenty-two nursing homes in a single U.S. city.

Synopsis: The survey examined 323 nursing home residents with advanced dementia. The patients were clinically assessed at baseline and quarterly for 18 months through chart reviews, nursing interviews, and physical examinations. Additionally, their proxies were surveyed regarding their understanding of the subjects’ prognoses.

During the survey period, 41.1% of patients developed pneumonia, 52.6% of patients experienced a febrile episode, and 85.8% of patients developed an eating problem; cumulative all-cause mortality was 54.8%. Adjusted for age, sex, and disease duration, the six-month mortality rate for subjects who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%.

Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last three months of life, 40.7% of subjects underwent at least one burdensome intervention (defined as hospitalization, ED visit, parenteral therapy, or tube feeding).

Subjects whose proxies reported an understanding of the poor prognosis and expected clinical complications of advanced dementia underwent significantly fewer burdensome interventions (adjusted odds ratio 0.12).

Bottom line: Advanced dementia is associated with frequent complications, including infections and eating problems, with high six-month mortality and significant associated morbidity. Patients whose healthcare proxies have a good understanding of the expected clinical course and prognosis receive less-aggressive end-of-life care.

Citation: Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538. TH

Clinical question: When added to oral diabetic agents, which insulin regimen (biphasic, prandial or basal) best achieves glycemic control in patients with Type 2 diabetes?

Background: Most patients with Type 2 diabetes mellitus (DM2) require insulin when oral agents provide suboptimal glycemic control. Little is known about which insulin regimen is most effective.

Study design: Three-year, open-label, multicenter trial.

Setting: Fifty-eight clinical centers in the United Kingdom and Ireland.

Synopsis: The authors randomized 708 insulin-naïve DM2 patients (median age 62 years) with HgbA1c 7% to 10% on maximum-dose metformin or sulfonylurea to one of three regimens: biphasic insulin twice daily; prandial insulin three times daily; or basal insulin once daily. Outcomes were HgbA1c, hypoglycemia rates, and weight gain. Sulfonylureas were replaced by another insulin if glycemic control was unacceptable.

The patients were mostly Caucasian and overweight. At three years of followup, median HgbA1c was similar in all groups (7.1% biphasic, 6.8% prandial, 6.9% basal); however, more patients who received prandial or basal insulin achieved HgbA1c less than 6.5% (45% and 43%, respectively) than in the biphasic group (32%).

Hypoglycemia was significantly less frequent in the basal insulin group (1.7 per patient per year versus 3.0 and 5.5 with biphasic and prandial, respectively). Patients gained weight in all groups; the greatest gain was with prandial insulin. At three years, there were no significant between-group differences in blood pressure, cholesterol, albuminuria, or quality of life.

Bottom line: Adding insulin to oral diabetic regimens improves glycemic control. Basal or prandial insulin regimens achieve glycemic targets more frequently than biphasic dosing.

Citation: Holman RR, Farmer AJ, Davies MJ, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med. 2009;361(18):1736-1747.

Clinical question: When added to oral diabetic agents, which insulin regimen (biphasic, prandial or basal) best achieves glycemic control in patients with Type 2 diabetes?

Background: Most patients with Type 2 diabetes mellitus (DM2) require insulin when oral agents provide suboptimal glycemic control. Little is known about which insulin regimen is most effective.

Study design: Three-year, open-label, multicenter trial.

Setting: Fifty-eight clinical centers in the United Kingdom and Ireland.

Synopsis: The authors randomized 708 insulin-naïve DM2 patients (median age 62 years) with HgbA1c 7% to 10% on maximum-dose metformin or sulfonylurea to one of three regimens: biphasic insulin twice daily; prandial insulin three times daily; or basal insulin once daily. Outcomes were HgbA1c, hypoglycemia rates, and weight gain. Sulfonylureas were replaced by another insulin if glycemic control was unacceptable.

The patients were mostly Caucasian and overweight. At three years of followup, median HgbA1c was similar in all groups (7.1% biphasic, 6.8% prandial, 6.9% basal); however, more patients who received prandial or basal insulin achieved HgbA1c less than 6.5% (45% and 43%, respectively) than in the biphasic group (32%).

Hypoglycemia was significantly less frequent in the basal insulin group (1.7 per patient per year versus 3.0 and 5.5 with biphasic and prandial, respectively). Patients gained weight in all groups; the greatest gain was with prandial insulin. At three years, there were no significant between-group differences in blood pressure, cholesterol, albuminuria, or quality of life.

Bottom line: Adding insulin to oral diabetic regimens improves glycemic control. Basal or prandial insulin regimens achieve glycemic targets more frequently than biphasic dosing.

Citation: Holman RR, Farmer AJ, Davies MJ, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med. 2009;361(18):1736-1747.

Clinical question: When added to oral diabetic agents, which insulin regimen (biphasic, prandial or basal) best achieves glycemic control in patients with Type 2 diabetes?

Background: Most patients with Type 2 diabetes mellitus (DM2) require insulin when oral agents provide suboptimal glycemic control. Little is known about which insulin regimen is most effective.

Study design: Three-year, open-label, multicenter trial.

Setting: Fifty-eight clinical centers in the United Kingdom and Ireland.

Synopsis: The authors randomized 708 insulin-naïve DM2 patients (median age 62 years) with HgbA1c 7% to 10% on maximum-dose metformin or sulfonylurea to one of three regimens: biphasic insulin twice daily; prandial insulin three times daily; or basal insulin once daily. Outcomes were HgbA1c, hypoglycemia rates, and weight gain. Sulfonylureas were replaced by another insulin if glycemic control was unacceptable.

The patients were mostly Caucasian and overweight. At three years of followup, median HgbA1c was similar in all groups (7.1% biphasic, 6.8% prandial, 6.9% basal); however, more patients who received prandial or basal insulin achieved HgbA1c less than 6.5% (45% and 43%, respectively) than in the biphasic group (32%).

Hypoglycemia was significantly less frequent in the basal insulin group (1.7 per patient per year versus 3.0 and 5.5 with biphasic and prandial, respectively). Patients gained weight in all groups; the greatest gain was with prandial insulin. At three years, there were no significant between-group differences in blood pressure, cholesterol, albuminuria, or quality of life.

Bottom line: Adding insulin to oral diabetic regimens improves glycemic control. Basal or prandial insulin regimens achieve glycemic targets more frequently than biphasic dosing.

Citation: Holman RR, Farmer AJ, Davies MJ, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med. 2009;361(18):1736-1747.