Dan Hale, MD, FAAP

Presenters: Dahlia Rizk, Alfred Burger, Reza Samad, Beth Israel Medical Center, New York City

Summary: Disasters can happen anywhere. The team at Beth Israel Medical Center shared their experience with disaster pre-planning and also with severe storm effects of Hurricane Sandy in lower Manhattan in New York City in 2012.

Disaster pre-planning is a very helpful tool. Beth Israel Medical Center (BIMC) had regular leadership planning meetings and mock disaster situations in advance of Hurricane Sandy. Their overall disaster plan included triage of existing patients to a lower acuity setting or discharge. Planning for staff needs, including places to stay if they cannot safely travel home, is part of the disaster plan.

Hurricane Sandy was a disaster in multiple areas including power loss, closure of other healthcare facilities, trauma, infrastructure impairment, and flooding. Some patients were trapped at home. Many ambulatory centers were closed including dialysis units. Hospitals only had partial power because they were working on emergency generators. Infrastructure was not functioning properly. Cell towers and paging system were not functioning.

BIMC received a surge of patients after the storm because of decreased access to medical care in the storm area. One way they dealt with the surge was opening new patient units on two revamped substance abuse units.

There were many lessons learned. A command center for internal communication is required. Communication with outside entities is also important.

Surge planning is also a key consideration. Making bed space, alternative use of staff, patient supplies, staff supplies, staff quarters are all aspects of planning. Disposition enhancement is important for patient care. Social workers and nursing home collaboration are needed. Human resources is needed for short and long term surge staffing. Relationships with other institutions and staffing companies can assist with staffing needs.

Key Takeaways:

• Disasters happen and are often unpredictable.
• Preparation is essential.
• Leadership among staff is crucial.
• Teamwork is a must and will get the organization through a disaster.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, and a member of Team Hospitalist.

 

Presenters: Dahlia Rizk, Alfred Burger, Reza Samad, Beth Israel Medical Center, New York City

Summary: Disasters can happen anywhere. The team at Beth Israel Medical Center shared their experience with disaster pre-planning and also with severe storm effects of Hurricane Sandy in lower Manhattan in New York City in 2012.

Disaster pre-planning is a very helpful tool. Beth Israel Medical Center (BIMC) had regular leadership planning meetings and mock disaster situations in advance of Hurricane Sandy. Their overall disaster plan included triage of existing patients to a lower acuity setting or discharge. Planning for staff needs, including places to stay if they cannot safely travel home, is part of the disaster plan.

Hurricane Sandy was a disaster in multiple areas including power loss, closure of other healthcare facilities, trauma, infrastructure impairment, and flooding. Some patients were trapped at home. Many ambulatory centers were closed including dialysis units. Hospitals only had partial power because they were working on emergency generators. Infrastructure was not functioning properly. Cell towers and paging system were not functioning.

BIMC received a surge of patients after the storm because of decreased access to medical care in the storm area. One way they dealt with the surge was opening new patient units on two revamped substance abuse units.

There were many lessons learned. A command center for internal communication is required. Communication with outside entities is also important.

Surge planning is also a key consideration. Making bed space, alternative use of staff, patient supplies, staff supplies, staff quarters are all aspects of planning. Disposition enhancement is important for patient care. Social workers and nursing home collaboration are needed. Human resources is needed for short and long term surge staffing. Relationships with other institutions and staffing companies can assist with staffing needs.

Key Takeaways:

• Disasters happen and are often unpredictable.
• Preparation is essential.
• Leadership among staff is crucial.
• Teamwork is a must and will get the organization through a disaster.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, and a member of Team Hospitalist.

 

Presenters: Dahlia Rizk, Alfred Burger, Reza Samad, Beth Israel Medical Center, New York City

Summary: Disasters can happen anywhere. The team at Beth Israel Medical Center shared their experience with disaster pre-planning and also with severe storm effects of Hurricane Sandy in lower Manhattan in New York City in 2012.

Disaster pre-planning is a very helpful tool. Beth Israel Medical Center (BIMC) had regular leadership planning meetings and mock disaster situations in advance of Hurricane Sandy. Their overall disaster plan included triage of existing patients to a lower acuity setting or discharge. Planning for staff needs, including places to stay if they cannot safely travel home, is part of the disaster plan.

Hurricane Sandy was a disaster in multiple areas including power loss, closure of other healthcare facilities, trauma, infrastructure impairment, and flooding. Some patients were trapped at home. Many ambulatory centers were closed including dialysis units. Hospitals only had partial power because they were working on emergency generators. Infrastructure was not functioning properly. Cell towers and paging system were not functioning.

BIMC received a surge of patients after the storm because of decreased access to medical care in the storm area. One way they dealt with the surge was opening new patient units on two revamped substance abuse units.

There were many lessons learned. A command center for internal communication is required. Communication with outside entities is also important.

Surge planning is also a key consideration. Making bed space, alternative use of staff, patient supplies, staff supplies, staff quarters are all aspects of planning. Disposition enhancement is important for patient care. Social workers and nursing home collaboration are needed. Human resources is needed for short and long term surge staffing. Relationships with other institutions and staffing companies can assist with staffing needs.

Key Takeaways:

• Disasters happen and are often unpredictable.
• Preparation is essential.
• Leadership among staff is crucial.
• Teamwork is a must and will get the organization through a disaster.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, and a member of Team Hospitalist.

 

HM13 is off to a strong start with a clear overarching goal of improving patient care in a global way. David Feinberg, MD, MBA, President of the UCLA Health System, gave a wonderful perspective of leading a large health care system as an “outsider.” His training as a child psychiatrist helped him look at the human perspective of health care. Dr. Feinberg gave the example of his first 100 days as interim CEO, in which he spent up to two hours a day just visiting hospital patients to hear their perspective.

After continuing on as president of the UCLA Health System, Dr. Feinberg continued this philosophy of “healing patients, one patient at a time.” UCLA is a top-rated medical institution, but even they have had low patient satisfaction scores in the past. By focusing institutional resources on individual patients, UCLA’s satisfaction scores rose from the 38th percentile to the 99th percentile.

Dr. Feinberg also discussed the advantages of having a strong professional staff. In addition to assessing core certifications before a potential new employee is hired, the service perspective is extremely important in health care. Dr. Feinberg has employed the “Talent Plus” model used by the Ritz-Carlton luxury hotels and resorts. This is a program designed to assess service skills in new staff and teach service techniques to new hires.

Takeaways:

• “Healing patients one patient at a time” is an incredible hospital approach that leads to better health care, improved patient satisfaction, and even financial success.

• A strong professional staff who is looking out for a patient’s comfort and well-being while providing high quality health care is the touch that will help improve several areas of health care, not just patient satisfaction.

Dan Hale, MD, FAAP, is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center, Boston, MA

HM13 is off to a strong start with a clear overarching goal of improving patient care in a global way. David Feinberg, MD, MBA, President of the UCLA Health System, gave a wonderful perspective of leading a large health care system as an “outsider.” His training as a child psychiatrist helped him look at the human perspective of health care. Dr. Feinberg gave the example of his first 100 days as interim CEO, in which he spent up to two hours a day just visiting hospital patients to hear their perspective.

After continuing on as president of the UCLA Health System, Dr. Feinberg continued this philosophy of “healing patients, one patient at a time.” UCLA is a top-rated medical institution, but even they have had low patient satisfaction scores in the past. By focusing institutional resources on individual patients, UCLA’s satisfaction scores rose from the 38th percentile to the 99th percentile.

Dr. Feinberg also discussed the advantages of having a strong professional staff. In addition to assessing core certifications before a potential new employee is hired, the service perspective is extremely important in health care. Dr. Feinberg has employed the “Talent Plus” model used by the Ritz-Carlton luxury hotels and resorts. This is a program designed to assess service skills in new staff and teach service techniques to new hires.

Takeaways:

• “Healing patients one patient at a time” is an incredible hospital approach that leads to better health care, improved patient satisfaction, and even financial success.

• A strong professional staff who is looking out for a patient’s comfort and well-being while providing high quality health care is the touch that will help improve several areas of health care, not just patient satisfaction.

Dan Hale, MD, FAAP, is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center, Boston, MA

HM13 is off to a strong start with a clear overarching goal of improving patient care in a global way. David Feinberg, MD, MBA, President of the UCLA Health System, gave a wonderful perspective of leading a large health care system as an “outsider.” His training as a child psychiatrist helped him look at the human perspective of health care. Dr. Feinberg gave the example of his first 100 days as interim CEO, in which he spent up to two hours a day just visiting hospital patients to hear their perspective.

After continuing on as president of the UCLA Health System, Dr. Feinberg continued this philosophy of “healing patients, one patient at a time.” UCLA is a top-rated medical institution, but even they have had low patient satisfaction scores in the past. By focusing institutional resources on individual patients, UCLA’s satisfaction scores rose from the 38th percentile to the 99th percentile.

Dr. Feinberg also discussed the advantages of having a strong professional staff. In addition to assessing core certifications before a potential new employee is hired, the service perspective is extremely important in health care. Dr. Feinberg has employed the “Talent Plus” model used by the Ritz-Carlton luxury hotels and resorts. This is a program designed to assess service skills in new staff and teach service techniques to new hires.

Takeaways:

• “Healing patients one patient at a time” is an incredible hospital approach that leads to better health care, improved patient satisfaction, and even financial success.

• A strong professional staff who is looking out for a patient’s comfort and well-being while providing high quality health care is the touch that will help improve several areas of health care, not just patient satisfaction.

Dan Hale, MD, FAAP, is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center, Boston, MA

Diagnostic reasoning is an essential skill for all physicians. There are multiple tools to refine this skill in physicians and to teach diagnostic reasoning to learners.

The session “Strategies for Promoting Clinical Reasoning to Avoid Diagnostic Errors” sought to review these skills in depth. According to Mary Ottolini, MD, of Children’s National Medical Center, the fundamentals of diagnostic reasoning are 1) Co-selection, in which 2-3 hypotheses or diagnoses are actively considered, 2) looking at the “big picture”, and 3) analyzing the information.

Looking at the big picture includes using appropriate adjectives to describe the patient and the illness presentation in medical and efficient terms. A well worded “one-liner” can frame the patient well for the team and for the next steps in diagnosis. Careful problem representation promotes thoughtful case presentations.

Analyzing the information includes comparing and contrasting key findings. Discriminating features should be discussed and competing evidence should be acknowledged.

Illness scripts is a method of looking at an illness in its entirety as a diagnosis is approached. The four parts of an illness script are mechanism of disease, epidemiology, clinical presentation (signs and symptoms), and time course.

Presentations can include diagnostic reasoning. The PBEAR format consists of:

• P- Problem Presentation
• BE – Background Evidence
• A- Analysis (including differential diagnoses)
• R- Recommendations (including goals and plan)

Key Takeaways:

• Diagnostic reasoning during case presentations is a valuable tool for patient care.
• Three fundamentals of diagnostic reasoning are 1) Co-selection of potential diagnoses, 2) looking at the “big picture”, and 3) analyzing the information.
• The PBEAR format (Problem Presentation, Background Evidence, Analysis , and Recommendations) can streamline presentations.
• Illness scripts (mechanism of disease, epidemiology, clinical presentation, and time course) are a helpful approach in diagnosis.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston

Diagnostic reasoning is an essential skill for all physicians. There are multiple tools to refine this skill in physicians and to teach diagnostic reasoning to learners.

The session “Strategies for Promoting Clinical Reasoning to Avoid Diagnostic Errors” sought to review these skills in depth. According to Mary Ottolini, MD, of Children’s National Medical Center, the fundamentals of diagnostic reasoning are 1) Co-selection, in which 2-3 hypotheses or diagnoses are actively considered, 2) looking at the “big picture”, and 3) analyzing the information.

Looking at the big picture includes using appropriate adjectives to describe the patient and the illness presentation in medical and efficient terms. A well worded “one-liner” can frame the patient well for the team and for the next steps in diagnosis. Careful problem representation promotes thoughtful case presentations.

Analyzing the information includes comparing and contrasting key findings. Discriminating features should be discussed and competing evidence should be acknowledged.

Illness scripts is a method of looking at an illness in its entirety as a diagnosis is approached. The four parts of an illness script are mechanism of disease, epidemiology, clinical presentation (signs and symptoms), and time course.

Presentations can include diagnostic reasoning. The PBEAR format consists of:

• P- Problem Presentation
• BE – Background Evidence
• A- Analysis (including differential diagnoses)
• R- Recommendations (including goals and plan)

Key Takeaways:

• Diagnostic reasoning during case presentations is a valuable tool for patient care.
• Three fundamentals of diagnostic reasoning are 1) Co-selection of potential diagnoses, 2) looking at the “big picture”, and 3) analyzing the information.
• The PBEAR format (Problem Presentation, Background Evidence, Analysis , and Recommendations) can streamline presentations.
• Illness scripts (mechanism of disease, epidemiology, clinical presentation, and time course) are a helpful approach in diagnosis.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston

Diagnostic reasoning is an essential skill for all physicians. There are multiple tools to refine this skill in physicians and to teach diagnostic reasoning to learners.

The session “Strategies for Promoting Clinical Reasoning to Avoid Diagnostic Errors” sought to review these skills in depth. According to Mary Ottolini, MD, of Children’s National Medical Center, the fundamentals of diagnostic reasoning are 1) Co-selection, in which 2-3 hypotheses or diagnoses are actively considered, 2) looking at the “big picture”, and 3) analyzing the information.

Looking at the big picture includes using appropriate adjectives to describe the patient and the illness presentation in medical and efficient terms. A well worded “one-liner” can frame the patient well for the team and for the next steps in diagnosis. Careful problem representation promotes thoughtful case presentations.

Analyzing the information includes comparing and contrasting key findings. Discriminating features should be discussed and competing evidence should be acknowledged.

Illness scripts is a method of looking at an illness in its entirety as a diagnosis is approached. The four parts of an illness script are mechanism of disease, epidemiology, clinical presentation (signs and symptoms), and time course.

Presentations can include diagnostic reasoning. The PBEAR format consists of:

• P- Problem Presentation
• BE – Background Evidence
• A- Analysis (including differential diagnoses)
• R- Recommendations (including goals and plan)

Key Takeaways:

• Diagnostic reasoning during case presentations is a valuable tool for patient care.
• Three fundamentals of diagnostic reasoning are 1) Co-selection of potential diagnoses, 2) looking at the “big picture”, and 3) analyzing the information.
• The PBEAR format (Problem Presentation, Background Evidence, Analysis , and Recommendations) can streamline presentations.
• Illness scripts (mechanism of disease, epidemiology, clinical presentation, and time course) are a helpful approach in diagnosis.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston

Denice Cora-Bramble, MD, of Children’s National Medical Center in Washington, D.C., presented “The Business of Medicine” breakout Friday at HM13.

Key Points

• Whether you are salaried, work for productivity, or have a combination of the two, it is important for hospitalists to understand the business side of medicine.
• Even if you are not a hospitalist group leader, there are several things that you should know about the finances of your hospitalist program. Dr. Cora-Bramble reviewed the basics of financial statements, hospital revenue reports, and expense reports. She also reviewed how the hospitalist division partners with the entire hospital.
• After understanding the basic finances of your program, there are ways to enhance your financial performance. These include noting any lack of payments, billing and patient trends, and looking at program losses.

Key Takeaways

• It is important to understand the general principles of financial statements, budgets and financial decision making.
• There are multiple strategies to improve your division’s financial performance.
• There are financial challenges inherent in leading an academic division.

 

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, and a Team Hospitalist member.

 

Denice Cora-Bramble, MD, of Children’s National Medical Center in Washington, D.C., presented “The Business of Medicine” breakout Friday at HM13.

Key Points

• Whether you are salaried, work for productivity, or have a combination of the two, it is important for hospitalists to understand the business side of medicine.
• Even if you are not a hospitalist group leader, there are several things that you should know about the finances of your hospitalist program. Dr. Cora-Bramble reviewed the basics of financial statements, hospital revenue reports, and expense reports. She also reviewed how the hospitalist division partners with the entire hospital.
• After understanding the basic finances of your program, there are ways to enhance your financial performance. These include noting any lack of payments, billing and patient trends, and looking at program losses.

Key Takeaways

• It is important to understand the general principles of financial statements, budgets and financial decision making.
• There are multiple strategies to improve your division’s financial performance.
• There are financial challenges inherent in leading an academic division.

 

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, and a Team Hospitalist member.

 

Denice Cora-Bramble, MD, of Children’s National Medical Center in Washington, D.C., presented “The Business of Medicine” breakout Friday at HM13.

Key Points

• Whether you are salaried, work for productivity, or have a combination of the two, it is important for hospitalists to understand the business side of medicine.
• Even if you are not a hospitalist group leader, there are several things that you should know about the finances of your hospitalist program. Dr. Cora-Bramble reviewed the basics of financial statements, hospital revenue reports, and expense reports. She also reviewed how the hospitalist division partners with the entire hospital.
• After understanding the basic finances of your program, there are ways to enhance your financial performance. These include noting any lack of payments, billing and patient trends, and looking at program losses.

Key Takeaways

• It is important to understand the general principles of financial statements, budgets and financial decision making.
• There are multiple strategies to improve your division’s financial performance.
• There are financial challenges inherent in leading an academic division.

 

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, and a Team Hospitalist member.

 

All hospitalists have seen the phenomenon of "surgical signature," when different surgeons appear to have different rates of surgical intervention. Residents know different physicians often treat a single condition in varying ways. The losers in practice variation are the patients, learners, and the overall healthcare system.

Mark Shen, MD, the pediatric editor for The Hospitalist and presenter of this Tuesday afternoon session at HM12, said he has gone through the five stages of grief in the past when dealing with different care plans in a hospital setting, finally settling on acceptance. Now, he said it is important to move past acceptance and recognize variations in physician practice. Further, it's critical to understand the unintended consequences of unwarranted variation.

There are many factors in variation, said Dr. Shen. Examples include preference-sensitive care, in which a physician has a particular model that she or he follows that is specific to that physician, and supply-sensitive care, the trend where certain procedures are more frequently utilized when they are more readily available. A specific example of variation is the rate of tonsillectomy between surgeons.

Variation arises easily in medicine because of inherent uncertainty in medicine. Uncertainty arises because of the challenges of defining disease, making a diagnosis, selecting a procedure, observing outcomes, and assessing preferences.

Variation can be mitigated by formal protocols individualized to each patient. An example of successful protocols is modern pediatric oncology, which has dramatically improved patient outcomes.

Takeaways

• Hospitalists must recognize variation in care.
• Addressing variation improves patient care and offers improved utilization of limited healthcare resources.
• There are several approaches to mitigate variation, including practice guidelines.
• Shared decision making with the patient and family will also improve individual patient care.

All hospitalists have seen the phenomenon of "surgical signature," when different surgeons appear to have different rates of surgical intervention. Residents know different physicians often treat a single condition in varying ways. The losers in practice variation are the patients, learners, and the overall healthcare system.

Mark Shen, MD, the pediatric editor for The Hospitalist and presenter of this Tuesday afternoon session at HM12, said he has gone through the five stages of grief in the past when dealing with different care plans in a hospital setting, finally settling on acceptance. Now, he said it is important to move past acceptance and recognize variations in physician practice. Further, it's critical to understand the unintended consequences of unwarranted variation.

There are many factors in variation, said Dr. Shen. Examples include preference-sensitive care, in which a physician has a particular model that she or he follows that is specific to that physician, and supply-sensitive care, the trend where certain procedures are more frequently utilized when they are more readily available. A specific example of variation is the rate of tonsillectomy between surgeons.

Variation arises easily in medicine because of inherent uncertainty in medicine. Uncertainty arises because of the challenges of defining disease, making a diagnosis, selecting a procedure, observing outcomes, and assessing preferences.

Variation can be mitigated by formal protocols individualized to each patient. An example of successful protocols is modern pediatric oncology, which has dramatically improved patient outcomes.

Takeaways

• Hospitalists must recognize variation in care.
• Addressing variation improves patient care and offers improved utilization of limited healthcare resources.
• There are several approaches to mitigate variation, including practice guidelines.
• Shared decision making with the patient and family will also improve individual patient care.

All hospitalists have seen the phenomenon of "surgical signature," when different surgeons appear to have different rates of surgical intervention. Residents know different physicians often treat a single condition in varying ways. The losers in practice variation are the patients, learners, and the overall healthcare system.

Mark Shen, MD, the pediatric editor for The Hospitalist and presenter of this Tuesday afternoon session at HM12, said he has gone through the five stages of grief in the past when dealing with different care plans in a hospital setting, finally settling on acceptance. Now, he said it is important to move past acceptance and recognize variations in physician practice. Further, it's critical to understand the unintended consequences of unwarranted variation.

There are many factors in variation, said Dr. Shen. Examples include preference-sensitive care, in which a physician has a particular model that she or he follows that is specific to that physician, and supply-sensitive care, the trend where certain procedures are more frequently utilized when they are more readily available. A specific example of variation is the rate of tonsillectomy between surgeons.

Variation arises easily in medicine because of inherent uncertainty in medicine. Uncertainty arises because of the challenges of defining disease, making a diagnosis, selecting a procedure, observing outcomes, and assessing preferences.

Variation can be mitigated by formal protocols individualized to each patient. An example of successful protocols is modern pediatric oncology, which has dramatically improved patient outcomes.

Takeaways

• Hospitalists must recognize variation in care.
• Addressing variation improves patient care and offers improved utilization of limited healthcare resources.
• There are several approaches to mitigate variation, including practice guidelines.
• Shared decision making with the patient and family will also improve individual patient care.

Vineet Arora, MD, FHM, has had extensive experience in patient handoffs, and highlighted the importance of handoffs for the transfer of patient information in a Monday afternoon breakout session at HM12. Safe and successful handoffs include several steps for the transfer of information, said Dr. Arora. These steps include pre-handoff, the arrival of the incoming physician, dialogue, and post-handoff.

Effective handoffs strategies include standardized information, updated information, limited interruptions, and specific structure including read-backs. Face-to-face handoffs are ideal.

Takeaways

• Beware of egocentric heuristic, the assumption that the receiving physician has the exact same information and fund of knowledge as the initial or sending physician.
• Checklists can be helpful but can have flaws when not used appropriately.
• "If-then" and "to do" lists are the most retained form of information from handoffs.
• Prioritize the most-ill patients during handoffs.
• Assess receiver understanding.
• Beware of too much information during handoffs.
• Programatic changes, such as protected handoff time and space, can support proper handoffs.

Vineet Arora, MD, FHM, has had extensive experience in patient handoffs, and highlighted the importance of handoffs for the transfer of patient information in a Monday afternoon breakout session at HM12. Safe and successful handoffs include several steps for the transfer of information, said Dr. Arora. These steps include pre-handoff, the arrival of the incoming physician, dialogue, and post-handoff.

Effective handoffs strategies include standardized information, updated information, limited interruptions, and specific structure including read-backs. Face-to-face handoffs are ideal.

Takeaways

• Beware of egocentric heuristic, the assumption that the receiving physician has the exact same information and fund of knowledge as the initial or sending physician.
• Checklists can be helpful but can have flaws when not used appropriately.
• "If-then" and "to do" lists are the most retained form of information from handoffs.
• Prioritize the most-ill patients during handoffs.
• Assess receiver understanding.
• Beware of too much information during handoffs.
• Programatic changes, such as protected handoff time and space, can support proper handoffs.

Vineet Arora, MD, FHM, has had extensive experience in patient handoffs, and highlighted the importance of handoffs for the transfer of patient information in a Monday afternoon breakout session at HM12. Safe and successful handoffs include several steps for the transfer of information, said Dr. Arora. These steps include pre-handoff, the arrival of the incoming physician, dialogue, and post-handoff.

Effective handoffs strategies include standardized information, updated information, limited interruptions, and specific structure including read-backs. Face-to-face handoffs are ideal.

Takeaways

• Beware of egocentric heuristic, the assumption that the receiving physician has the exact same information and fund of knowledge as the initial or sending physician.
• Checklists can be helpful but can have flaws when not used appropriately.
• "If-then" and "to do" lists are the most retained form of information from handoffs.
• Prioritize the most-ill patients during handoffs.
• Assess receiver understanding.
• Beware of too much information during handoffs.
• Programatic changes, such as protected handoff time and space, can support proper handoffs.

The etiologic agents for complicated pneumonias and osteomyelitis have changed recently, according to presenters Drs. William and Creech, who assisted pediatric hospitalists in updated diagnosis and intervention strategies.

The increase in complicated pneumonias and empyemas is mostly due to the increase in Streptococcus pneumoniae serotype 19a. After introduction of the PCV-7 vaccine, incidence of serotype 19a infections increased to 98% of infections. Serotype 19a is now included in the PCV-13 vaccine, approved by the FDA in 2011. There are multiple interventions available for empyemas including chest tube alone, chest tube with fibrinolysis, and VATS. Current research is being done to assess efficacy for these measures.

Osteomyelitis may be caused by direct inoculation, spread from local infection, or hematogenous spread. S. Aureus is causative agent in 80-90% of patients. MRSA infection has a more complicated course. Based on patient response and inflammatory markers, a short course of intravenous antibiotics followed by oral antibiotics may be appropriate.

Key Takeaways:

1. Surgical intervention for empyemas is patient specific and depends on clinical status, effusion, status, presence of loculations, and expertise of consultants.

2. Hematogenous spread is the most common cause of osteomyelitis in children.

3. MRI is diagnostic modality of choice for osteomyelitis.

4. Bone aspiration and blood cultures are very helpful in treatment of osteomyelitis.

5. Clindamycin can be considered for first line osteomyelitis treatment if it is not a life threatening infection, a limb threatening infection, or a high likelihood of bacteremia. Beta lactam coverage should be considered in toddlers due to Kingella.

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts Medical Center in Boston.

 

The etiologic agents for complicated pneumonias and osteomyelitis have changed recently, according to presenters Drs. William and Creech, who assisted pediatric hospitalists in updated diagnosis and intervention strategies.

The increase in complicated pneumonias and empyemas is mostly due to the increase in Streptococcus pneumoniae serotype 19a. After introduction of the PCV-7 vaccine, incidence of serotype 19a infections increased to 98% of infections. Serotype 19a is now included in the PCV-13 vaccine, approved by the FDA in 2011. There are multiple interventions available for empyemas including chest tube alone, chest tube with fibrinolysis, and VATS. Current research is being done to assess efficacy for these measures.

Osteomyelitis may be caused by direct inoculation, spread from local infection, or hematogenous spread. S. Aureus is causative agent in 80-90% of patients. MRSA infection has a more complicated course. Based on patient response and inflammatory markers, a short course of intravenous antibiotics followed by oral antibiotics may be appropriate.

Key Takeaways:

1. Surgical intervention for empyemas is patient specific and depends on clinical status, effusion, status, presence of loculations, and expertise of consultants.

2. Hematogenous spread is the most common cause of osteomyelitis in children.

3. MRI is diagnostic modality of choice for osteomyelitis.

4. Bone aspiration and blood cultures are very helpful in treatment of osteomyelitis.

5. Clindamycin can be considered for first line osteomyelitis treatment if it is not a life threatening infection, a limb threatening infection, or a high likelihood of bacteremia. Beta lactam coverage should be considered in toddlers due to Kingella.

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts Medical Center in Boston.

 

The etiologic agents for complicated pneumonias and osteomyelitis have changed recently, according to presenters Drs. William and Creech, who assisted pediatric hospitalists in updated diagnosis and intervention strategies.

The increase in complicated pneumonias and empyemas is mostly due to the increase in Streptococcus pneumoniae serotype 19a. After introduction of the PCV-7 vaccine, incidence of serotype 19a infections increased to 98% of infections. Serotype 19a is now included in the PCV-13 vaccine, approved by the FDA in 2011. There are multiple interventions available for empyemas including chest tube alone, chest tube with fibrinolysis, and VATS. Current research is being done to assess efficacy for these measures.

Osteomyelitis may be caused by direct inoculation, spread from local infection, or hematogenous spread. S. Aureus is causative agent in 80-90% of patients. MRSA infection has a more complicated course. Based on patient response and inflammatory markers, a short course of intravenous antibiotics followed by oral antibiotics may be appropriate.

Key Takeaways:

1. Surgical intervention for empyemas is patient specific and depends on clinical status, effusion, status, presence of loculations, and expertise of consultants.

2. Hematogenous spread is the most common cause of osteomyelitis in children.

3. MRI is diagnostic modality of choice for osteomyelitis.

4. Bone aspiration and blood cultures are very helpful in treatment of osteomyelitis.

5. Clindamycin can be considered for first line osteomyelitis treatment if it is not a life threatening infection, a limb threatening infection, or a high likelihood of bacteremia. Beta lactam coverage should be considered in toddlers due to Kingella.

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts Medical Center in Boston.

 

Adriana Tremoulet, MD, reviewed the classic presentation as well as the incomplete disease presentation of Kawasaki disease (KD) at a breakout session Monday morning at HM12.

Clinical KD is an immunologic reaction triggered by a presumed infectious agent in a genetically susceptible host. The clinical outcome, including coronary aneurysm, is also likely genetically pre-determined. Early identification is essential for proper treatment to decrease the risk of coronary artery aneurysms. Most KD patients will have some elevation of biomarkers, including CRP, ESR, CSF pleocytosis, GGT, ALT, platelets, and WBC. Anemia may also be present. There are ongoing trials of potential laboratory analysis panels.

IVIG remains standard first line therapy for KD. IVIG-resistant KD is defined as persistent fever 36 hours after initial IVIG treatment. Twenty-two percent of patients with IVIG-resistant KD will develop coronary artery aneurysms, a rate similar to untreated KD. There are multiple treatment options for IVIG-resistant KD including a second dose of IVIG, infliximab, steroids, plasmapheresis, cyclophosphamide, methotrexate, and cyclosporine.

Bottom Line

• Hospitalists should remain vigilant to identify children with acute KD, including atypical or late presentations.
• Treatment options for IVIG-resistant KD patients are available but protocols are still being evaluated for efficacy.
• There is a potential role of biomarkers in diagnosing KD. These include stratification of patients by inflammatory markers in first 10 days of illness that can diagnose incomplete KD in 90% of children.
• Be aware of potential Kawasaki Disease Shock Syndrome, and continue to give IVIG for these patients.

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children, Tufts Medical Center in Boston.

Adriana Tremoulet, MD, reviewed the classic presentation as well as the incomplete disease presentation of Kawasaki disease (KD) at a breakout session Monday morning at HM12.

Clinical KD is an immunologic reaction triggered by a presumed infectious agent in a genetically susceptible host. The clinical outcome, including coronary aneurysm, is also likely genetically pre-determined. Early identification is essential for proper treatment to decrease the risk of coronary artery aneurysms. Most KD patients will have some elevation of biomarkers, including CRP, ESR, CSF pleocytosis, GGT, ALT, platelets, and WBC. Anemia may also be present. There are ongoing trials of potential laboratory analysis panels.

IVIG remains standard first line therapy for KD. IVIG-resistant KD is defined as persistent fever 36 hours after initial IVIG treatment. Twenty-two percent of patients with IVIG-resistant KD will develop coronary artery aneurysms, a rate similar to untreated KD. There are multiple treatment options for IVIG-resistant KD including a second dose of IVIG, infliximab, steroids, plasmapheresis, cyclophosphamide, methotrexate, and cyclosporine.

Bottom Line

• Hospitalists should remain vigilant to identify children with acute KD, including atypical or late presentations.
• Treatment options for IVIG-resistant KD patients are available but protocols are still being evaluated for efficacy.
• There is a potential role of biomarkers in diagnosing KD. These include stratification of patients by inflammatory markers in first 10 days of illness that can diagnose incomplete KD in 90% of children.
• Be aware of potential Kawasaki Disease Shock Syndrome, and continue to give IVIG for these patients.

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children, Tufts Medical Center in Boston.

Adriana Tremoulet, MD, reviewed the classic presentation as well as the incomplete disease presentation of Kawasaki disease (KD) at a breakout session Monday morning at HM12.

Clinical KD is an immunologic reaction triggered by a presumed infectious agent in a genetically susceptible host. The clinical outcome, including coronary aneurysm, is also likely genetically pre-determined. Early identification is essential for proper treatment to decrease the risk of coronary artery aneurysms. Most KD patients will have some elevation of biomarkers, including CRP, ESR, CSF pleocytosis, GGT, ALT, platelets, and WBC. Anemia may also be present. There are ongoing trials of potential laboratory analysis panels.

IVIG remains standard first line therapy for KD. IVIG-resistant KD is defined as persistent fever 36 hours after initial IVIG treatment. Twenty-two percent of patients with IVIG-resistant KD will develop coronary artery aneurysms, a rate similar to untreated KD. There are multiple treatment options for IVIG-resistant KD including a second dose of IVIG, infliximab, steroids, plasmapheresis, cyclophosphamide, methotrexate, and cyclosporine.

Bottom Line

• Hospitalists should remain vigilant to identify children with acute KD, including atypical or late presentations.
• Treatment options for IVIG-resistant KD patients are available but protocols are still being evaluated for efficacy.
• There is a potential role of biomarkers in diagnosing KD. These include stratification of patients by inflammatory markers in first 10 days of illness that can diagnose incomplete KD in 90% of children.
• Be aware of potential Kawasaki Disease Shock Syndrome, and continue to give IVIG for these patients.

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children, Tufts Medical Center in Boston.

Why was President Obama in South Korea visiting the DMZ? Couldn't he get his driver's license here like everyone else? With our current state of politics, sometimes it seems that the only thing to do is laugh. Norm Ornstein, PhD, one of the opening speakers at HM12 on Monday, had the record-number audience laughing at our current challenges during his opening political comical insights.

Ornstein moved quickly into the history of why our current national government is deadlocked. A shift of population and culture has created a two-party system that no longer has the ability to enact laws that are accepted by the general public. The United States has a system of "tribal politics" that impact the freedom of even rational national leaders.

Bottom Line

1. It will be an extremely bumpy ride during this current political period.

2. Political compromise is necessary to further current ideas.

3. Even when the Affordable Care Act decisions are made and the current election cycle is complete, there will be difficult initial planning years for the future of healthcare.

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts Medical Center in Boston.

Why was President Obama in South Korea visiting the DMZ? Couldn't he get his driver's license here like everyone else? With our current state of politics, sometimes it seems that the only thing to do is laugh. Norm Ornstein, PhD, one of the opening speakers at HM12 on Monday, had the record-number audience laughing at our current challenges during his opening political comical insights.

Ornstein moved quickly into the history of why our current national government is deadlocked. A shift of population and culture has created a two-party system that no longer has the ability to enact laws that are accepted by the general public. The United States has a system of "tribal politics" that impact the freedom of even rational national leaders.

Bottom Line

1. It will be an extremely bumpy ride during this current political period.

2. Political compromise is necessary to further current ideas.

3. Even when the Affordable Care Act decisions are made and the current election cycle is complete, there will be difficult initial planning years for the future of healthcare.

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts Medical Center in Boston.

Why was President Obama in South Korea visiting the DMZ? Couldn't he get his driver's license here like everyone else? With our current state of politics, sometimes it seems that the only thing to do is laugh. Norm Ornstein, PhD, one of the opening speakers at HM12 on Monday, had the record-number audience laughing at our current challenges during his opening political comical insights.

Ornstein moved quickly into the history of why our current national government is deadlocked. A shift of population and culture has created a two-party system that no longer has the ability to enact laws that are accepted by the general public. The United States has a system of "tribal politics" that impact the freedom of even rational national leaders.

Bottom Line

1. It will be an extremely bumpy ride during this current political period.

2. Political compromise is necessary to further current ideas.

3. Even when the Affordable Care Act decisions are made and the current election cycle is complete, there will be difficult initial planning years for the future of healthcare.

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts Medical Center in Boston.