Erin A. Egan, MD, JD

PRO

When the community is in need, physicians must honor call to duty

Dr. Cereste is a hospitalist and assistant professor of public health in the division of medical ethics at Weill Cornell Medical School and Medical Center in New York City. She is a member of Team Hospitalist.

As the American Medical Association (AMA) states in its inaugural Code of Ethics from 1847: “When pestilence prevails, it is their duty to face the danger and to continue their labors for the alleviation of the suffering, even at the jeopardy of their own lives.”1 It meant doctors have taken on a calling and social duty to treat sick patients, even at personal expense.

Today, the AMA’s Code of Ethics puts it this way: “Physicians should balance immediate benefits to individual patients with ability to care for patients in future.”2 Over two centuries, the focus remains on the physician’s duty to patient and society.

As a former Air Force physician, I believe in this deontological stance. In the Air Force, we often spoke of our sense of duty, of “service before self, and integrity in everything we do.” This code of conduct applies to combat as well as the peacetime challenges of pandemic flu. If the medical corps’ mantra is to “preserve the fighting force,” the mission of the civilian physician is the community’s survival. This implicit contract with society extends from moments of tranquillity to when the peace is disrupted by either manmade disasters (e.g., war) or biological threats (e.g., pandemic disease).

Having made this assertion, a physician’s obligation is not without its limitations. Doctors have a responsibility to protect themselves and their families from undue harm. We have to stay alive for utilitarian reasons in order to serve others. A society without its physician workforce is imperiled and at enhanced risk, so a physician’s self-preservation is also in the interest of the collective.3

All of this compels doctors to stay alive and remain healthy. Our duty can only be achieved by careful action and avoiding forays into Hollywood heroism. No one asked us to be heroes, only dutiful physicians.4

We have to prepare doctors to meet this challenge. Alexander and Wynia surveyed senior physicians: While 80% were willing to treat high-risk patients, as in bioterrorism or a pandemic, only 21% felt logistically prepared to meet such a challenge in practice.5

If we expect physicians to answer the call, we need to equip them with the knowledge, skills, and equipment necessary to safely and effectively meet their professional responsibilities.

That responsibility is one that society owes its physicians. TH

References

1. Code of Medical Ethics of the American Medical Association. American Medical Association Web site. Available at: www.ama-assn.org. Accessed Nov. 30, 2009.
2. American Medical Association. Physician Obligation in Disaster Preparedness and Response. Chicago: American Medical Association; 2004.
3. Simonds AK, Sokol DK. Lives on the line? Ethics and practicalities of duty of care in pandemics and disasters. Eur Respir J. 2009;34(2):303-309.
4. Sokol D. Virulent epidemics and scope of healthcare workers’ duty of care. Emerg Infect Dis. 2006;12(8):1238-1241.
5. Alexander GC, Wynia MK. Ready and willing? Physicians’ sense of preparedness for bioterrorism. Health Aff (Millwood). 2003;22(5):189-197.

CON

Some healthcare providers should be considered exceptions to rule

Dr. Egan is a hospitalist at the University of Colorado Denver and a member of SHM’s Ethics Committee.

Infectious illnesses frequently affect healthcare providers disproportionately. Whether physicians are obligated to put themselves at risk is not clear. Many sources argue that participation in infectious epidemic or pandemic events is obligatory, but there is another side to the discussion. Healthcare providers might have risk factors that mitigate this obligation. Two such subgroups are providers with pre-existing health concerns and providers who are caregivers for others.

Studies show that not all providers will report to work in the face of an epidemic. One self-reporting study found that 20% of physicians would report to work.1 Every hospital effected by the SARS epidemic had difficulty with employee attrition.2 Thus, the concern is more than hypothetical.

There is a difference in putting oneself at risk for an illness and putting oneself at risk of death. Providers might be immunosuppressed or have, say, an underlying lung disease. Should higher-risk providers with direct patient contact responsibilities have the same obligation as providers who are not?

Providers who care for others will face different challenges. First, if social distancing becomes widespread and schools and daycare centers are closed, providers will face a dilemma over how to care for their dependents. A second issue for providers with responsibilities to care for others is that those dependent populations are likely to be at higher risk of bad outcomes if they are affected. A provider who is infectious puts their family at risk. Children may be disproportionately affected, and people who require assistance are more likely to have comorbid conditions. Should providers with other responsibilities have the same obligation as providers who do not?

Given that risk is not the same among providers, it is unfair to say that responsibility is the same. Parents simply cannot abandon their children. Risk of death is a serious concern for providers at higher risk. Hospitals should have an explicit plan in place for a pandemic; most do have a plan. The plan needs to consider these issues and have explicit provisions.

Another approach would be to ask providers to state their availability. If the hospital knows that a certain group of providers has specific concerns, the plan can take into account what impact those concerns will have. Transparency in the plan, expectations, and resources will better prepare hospitals.

There is a fundamental duty to provide care to patients who need it, and failure to do so is a violation of a societal and professional trust. However, this duty is not absolute. Giving providers that benefit of the doubt—that they will honor their duty to ill or injured patients—means that providers can be trusted to opt out only for valid reasons. The system must be designed to accommodate special needs. A one-size-fits-all approach is bound to fail. TH

References

1. Alexander GC, Wynia MK. Ready and willing? Physicians’ sense of preparedness for bioterrorism. Health Aff (Millwood). 2003;22(5):189-197.
2. Wynia MK. Ethics and public health emergencies: encouraging responsibility. Am J Bioeth. 2007;7(4):1-4.

The opinions expressed herein are those of the authors and do not represent those of the Society of Hospital Medicine or The Hospitalist.

PRO

When the community is in need, physicians must honor call to duty

Dr. Cereste is a hospitalist and assistant professor of public health in the division of medical ethics at Weill Cornell Medical School and Medical Center in New York City. She is a member of Team Hospitalist.

As the American Medical Association (AMA) states in its inaugural Code of Ethics from 1847: “When pestilence prevails, it is their duty to face the danger and to continue their labors for the alleviation of the suffering, even at the jeopardy of their own lives.”1 It meant doctors have taken on a calling and social duty to treat sick patients, even at personal expense.

Today, the AMA’s Code of Ethics puts it this way: “Physicians should balance immediate benefits to individual patients with ability to care for patients in future.”2 Over two centuries, the focus remains on the physician’s duty to patient and society.

As a former Air Force physician, I believe in this deontological stance. In the Air Force, we often spoke of our sense of duty, of “service before self, and integrity in everything we do.” This code of conduct applies to combat as well as the peacetime challenges of pandemic flu. If the medical corps’ mantra is to “preserve the fighting force,” the mission of the civilian physician is the community’s survival. This implicit contract with society extends from moments of tranquillity to when the peace is disrupted by either manmade disasters (e.g., war) or biological threats (e.g., pandemic disease).

Having made this assertion, a physician’s obligation is not without its limitations. Doctors have a responsibility to protect themselves and their families from undue harm. We have to stay alive for utilitarian reasons in order to serve others. A society without its physician workforce is imperiled and at enhanced risk, so a physician’s self-preservation is also in the interest of the collective.3

All of this compels doctors to stay alive and remain healthy. Our duty can only be achieved by careful action and avoiding forays into Hollywood heroism. No one asked us to be heroes, only dutiful physicians.4

We have to prepare doctors to meet this challenge. Alexander and Wynia surveyed senior physicians: While 80% were willing to treat high-risk patients, as in bioterrorism or a pandemic, only 21% felt logistically prepared to meet such a challenge in practice.5

If we expect physicians to answer the call, we need to equip them with the knowledge, skills, and equipment necessary to safely and effectively meet their professional responsibilities.

That responsibility is one that society owes its physicians. TH

References

1. Code of Medical Ethics of the American Medical Association. American Medical Association Web site. Available at: www.ama-assn.org. Accessed Nov. 30, 2009.
2. American Medical Association. Physician Obligation in Disaster Preparedness and Response. Chicago: American Medical Association; 2004.
3. Simonds AK, Sokol DK. Lives on the line? Ethics and practicalities of duty of care in pandemics and disasters. Eur Respir J. 2009;34(2):303-309.
4. Sokol D. Virulent epidemics and scope of healthcare workers’ duty of care. Emerg Infect Dis. 2006;12(8):1238-1241.
5. Alexander GC, Wynia MK. Ready and willing? Physicians’ sense of preparedness for bioterrorism. Health Aff (Millwood). 2003;22(5):189-197.

CON

Some healthcare providers should be considered exceptions to rule

Dr. Egan is a hospitalist at the University of Colorado Denver and a member of SHM’s Ethics Committee.

Infectious illnesses frequently affect healthcare providers disproportionately. Whether physicians are obligated to put themselves at risk is not clear. Many sources argue that participation in infectious epidemic or pandemic events is obligatory, but there is another side to the discussion. Healthcare providers might have risk factors that mitigate this obligation. Two such subgroups are providers with pre-existing health concerns and providers who are caregivers for others.

Studies show that not all providers will report to work in the face of an epidemic. One self-reporting study found that 20% of physicians would report to work.1 Every hospital effected by the SARS epidemic had difficulty with employee attrition.2 Thus, the concern is more than hypothetical.

There is a difference in putting oneself at risk for an illness and putting oneself at risk of death. Providers might be immunosuppressed or have, say, an underlying lung disease. Should higher-risk providers with direct patient contact responsibilities have the same obligation as providers who are not?

Providers who care for others will face different challenges. First, if social distancing becomes widespread and schools and daycare centers are closed, providers will face a dilemma over how to care for their dependents. A second issue for providers with responsibilities to care for others is that those dependent populations are likely to be at higher risk of bad outcomes if they are affected. A provider who is infectious puts their family at risk. Children may be disproportionately affected, and people who require assistance are more likely to have comorbid conditions. Should providers with other responsibilities have the same obligation as providers who do not?

Given that risk is not the same among providers, it is unfair to say that responsibility is the same. Parents simply cannot abandon their children. Risk of death is a serious concern for providers at higher risk. Hospitals should have an explicit plan in place for a pandemic; most do have a plan. The plan needs to consider these issues and have explicit provisions.

Another approach would be to ask providers to state their availability. If the hospital knows that a certain group of providers has specific concerns, the plan can take into account what impact those concerns will have. Transparency in the plan, expectations, and resources will better prepare hospitals.

There is a fundamental duty to provide care to patients who need it, and failure to do so is a violation of a societal and professional trust. However, this duty is not absolute. Giving providers that benefit of the doubt—that they will honor their duty to ill or injured patients—means that providers can be trusted to opt out only for valid reasons. The system must be designed to accommodate special needs. A one-size-fits-all approach is bound to fail. TH

References

1. Alexander GC, Wynia MK. Ready and willing? Physicians’ sense of preparedness for bioterrorism. Health Aff (Millwood). 2003;22(5):189-197.
2. Wynia MK. Ethics and public health emergencies: encouraging responsibility. Am J Bioeth. 2007;7(4):1-4.

The opinions expressed herein are those of the authors and do not represent those of the Society of Hospital Medicine or The Hospitalist.

PRO

When the community is in need, physicians must honor call to duty

Dr. Cereste is a hospitalist and assistant professor of public health in the division of medical ethics at Weill Cornell Medical School and Medical Center in New York City. She is a member of Team Hospitalist.

As the American Medical Association (AMA) states in its inaugural Code of Ethics from 1847: “When pestilence prevails, it is their duty to face the danger and to continue their labors for the alleviation of the suffering, even at the jeopardy of their own lives.”1 It meant doctors have taken on a calling and social duty to treat sick patients, even at personal expense.

Today, the AMA’s Code of Ethics puts it this way: “Physicians should balance immediate benefits to individual patients with ability to care for patients in future.”2 Over two centuries, the focus remains on the physician’s duty to patient and society.

As a former Air Force physician, I believe in this deontological stance. In the Air Force, we often spoke of our sense of duty, of “service before self, and integrity in everything we do.” This code of conduct applies to combat as well as the peacetime challenges of pandemic flu. If the medical corps’ mantra is to “preserve the fighting force,” the mission of the civilian physician is the community’s survival. This implicit contract with society extends from moments of tranquillity to when the peace is disrupted by either manmade disasters (e.g., war) or biological threats (e.g., pandemic disease).

Having made this assertion, a physician’s obligation is not without its limitations. Doctors have a responsibility to protect themselves and their families from undue harm. We have to stay alive for utilitarian reasons in order to serve others. A society without its physician workforce is imperiled and at enhanced risk, so a physician’s self-preservation is also in the interest of the collective.3

All of this compels doctors to stay alive and remain healthy. Our duty can only be achieved by careful action and avoiding forays into Hollywood heroism. No one asked us to be heroes, only dutiful physicians.4

We have to prepare doctors to meet this challenge. Alexander and Wynia surveyed senior physicians: While 80% were willing to treat high-risk patients, as in bioterrorism or a pandemic, only 21% felt logistically prepared to meet such a challenge in practice.5

If we expect physicians to answer the call, we need to equip them with the knowledge, skills, and equipment necessary to safely and effectively meet their professional responsibilities.

That responsibility is one that society owes its physicians. TH

References

1. Code of Medical Ethics of the American Medical Association. American Medical Association Web site. Available at: www.ama-assn.org. Accessed Nov. 30, 2009.
2. American Medical Association. Physician Obligation in Disaster Preparedness and Response. Chicago: American Medical Association; 2004.
3. Simonds AK, Sokol DK. Lives on the line? Ethics and practicalities of duty of care in pandemics and disasters. Eur Respir J. 2009;34(2):303-309.
4. Sokol D. Virulent epidemics and scope of healthcare workers’ duty of care. Emerg Infect Dis. 2006;12(8):1238-1241.
5. Alexander GC, Wynia MK. Ready and willing? Physicians’ sense of preparedness for bioterrorism. Health Aff (Millwood). 2003;22(5):189-197.

CON

Some healthcare providers should be considered exceptions to rule

Dr. Egan is a hospitalist at the University of Colorado Denver and a member of SHM’s Ethics Committee.

Infectious illnesses frequently affect healthcare providers disproportionately. Whether physicians are obligated to put themselves at risk is not clear. Many sources argue that participation in infectious epidemic or pandemic events is obligatory, but there is another side to the discussion. Healthcare providers might have risk factors that mitigate this obligation. Two such subgroups are providers with pre-existing health concerns and providers who are caregivers for others.

Studies show that not all providers will report to work in the face of an epidemic. One self-reporting study found that 20% of physicians would report to work.1 Every hospital effected by the SARS epidemic had difficulty with employee attrition.2 Thus, the concern is more than hypothetical.

There is a difference in putting oneself at risk for an illness and putting oneself at risk of death. Providers might be immunosuppressed or have, say, an underlying lung disease. Should higher-risk providers with direct patient contact responsibilities have the same obligation as providers who are not?

Providers who care for others will face different challenges. First, if social distancing becomes widespread and schools and daycare centers are closed, providers will face a dilemma over how to care for their dependents. A second issue for providers with responsibilities to care for others is that those dependent populations are likely to be at higher risk of bad outcomes if they are affected. A provider who is infectious puts their family at risk. Children may be disproportionately affected, and people who require assistance are more likely to have comorbid conditions. Should providers with other responsibilities have the same obligation as providers who do not?

Given that risk is not the same among providers, it is unfair to say that responsibility is the same. Parents simply cannot abandon their children. Risk of death is a serious concern for providers at higher risk. Hospitals should have an explicit plan in place for a pandemic; most do have a plan. The plan needs to consider these issues and have explicit provisions.

Another approach would be to ask providers to state their availability. If the hospital knows that a certain group of providers has specific concerns, the plan can take into account what impact those concerns will have. Transparency in the plan, expectations, and resources will better prepare hospitals.

There is a fundamental duty to provide care to patients who need it, and failure to do so is a violation of a societal and professional trust. However, this duty is not absolute. Giving providers that benefit of the doubt—that they will honor their duty to ill or injured patients—means that providers can be trusted to opt out only for valid reasons. The system must be designed to accommodate special needs. A one-size-fits-all approach is bound to fail. TH

References

1. Alexander GC, Wynia MK. Ready and willing? Physicians’ sense of preparedness for bioterrorism. Health Aff (Millwood). 2003;22(5):189-197.
2. Wynia MK. Ethics and public health emergencies: encouraging responsibility. Am J Bioeth. 2007;7(4):1-4.

The opinions expressed herein are those of the authors and do not represent those of the Society of Hospital Medicine or The Hospitalist.

In This Edition

Literature at a Glance

A guide to this month’s studies

• PE and COPD exacerbations.
• Care bundles and readmission rates.
• Family history and VTE risk.
• Vasopressor choice and mortality in sepsis.
• Vitamin K use in overanticoagulation.
• Appropriate treatment of asymptomatic bacteriuria.
• Guideline adherence in thrombocytopenia.

Pulmonary Embolism Frequently Complicates COPD Exacerbations

Clinical question: What percentage of patients with acute chronic obstructive pulmonary disease (COPD) exacerbations has pulmonary emboli?

Background: As many as 30% of COPD exacerbations have no apparent precipitating event. Even in patients with evidence of a precipitating event, such as an upper-respiratory illness or increased environmental irritants, pulmonary emboli (PE) may coexist and warrant evaluation.

Study design: Literature review.

Setting: Multiple studies in Europe and the U.S.

Synopsis: This literature review included five studies to estimate the rate of PE in patients with a COPD exacerbation. Overall incidence of PE in COPD exacerbations was 19.9%, but of those patients requiring hospitalization, the incidence was as high as 25.5%. Incidence estimates varied based on interpretation of data that were missing or inconsistent between studies. Patients most commonly present with dyspnea, chest pain, hemoptysis, cough, and palpitations. Six percent of PE patients presented with syncope; no patients with an exacerbation without a PE presented with syncope.

Risk of mortality from PE is almost twice as high in patients with a COPD exacerbation compared with PE in other settings. A significant number of patients have PE without history or evidence of DVT, so in situ thrombosis is a significant factor. The interpretation of these results is limited by the heterogeneity of the study designs, and by the relatively low number of cases. Larger trials are necessary.

Bottom line: Pulmonary emboli are present in as many as 25% of all COPD exacerbations. Delay in diagnosis of PE in COPD patients affects morbidity and mortality. PE should be a consideration in many COPD exacerbations.

Citation: Rizkallah J, Man SF, Din DD. Prevalence of pulmonary embolism in acute exacerbations of COPD: a systematic review and metaanalysis. Chest. 2009;135(3):786-793.

Targeted-Care Bundle Can Reduce ED Visits and Readmission Rates in High-Risk Elderly Patients

Clinical question: Can a care coordination bundle reduce length of stay (LOS), ED visits, or readmissions within 30 days of a hospital admission?

Background: Hospital-based care coordination interventions have shown mixed results in affecting LOS, post-discharge ED visits, and readmission rates. Although there has been some success with particular interventions, no consistent benefit has been demonstrated. Most notably, a recent meta-analysis of several different interventions showed no improvement in mortality, LOS, or readmission rates.

Study design: A randomized, controlled trial of select high-risk elderly patients.

Setting: A large teaching hospital at Baylor University Medical Center.

Synopsis: A “targeted-care bundle” was implemented with high-risk elderly patients to try to reduce LOS, readmissions, and ED visits. High-risk patients were identified by age, diagnosis-related group (DRG), number of medications at admission, comorbid conditions, and need for assistance in activities of daily living. Subjects were randomized to usual care or to receive a targeted-care bundle. The targeted-care bundle included multiple interventions. A study care coordinator provided daily patient education, including condition-specific teaching, discharge teaching and planning, and a follow-up phone call at five to seven days after discharge. A clinical pharmacist intervened for medication reconciliation at admission and discharge, medication teaching, and a follow-up phone call at five to seven days after discharge. Structured documents, including a personal health record and supplemental discharge form, were implemented.

The study had low enrollment, largely due to the requirement to obtain informed consent from all participants. Therefore, the study was underpowered to detect such target endpoints as LOS. A significant decrease in 30-day readmission rates/ED visits was noticed, but there was no persistent effect at 60 days.

The intervention was designed to use existing hospital staff in order to be practical for broad utilization. Future studies need to focus on increased enrollment to demonstrate beneficial effect.

Bottom line: Targeted health interventions focusing on education and coordination of care might effect some significant outcomes, most notably readmissions or ED visits within 30 days, but the nature of the clinical problem makes rigorous testing of interventions a challenge.

Citation: Kohler BE, Richter KM, Youngblood L, et al. Reduction of 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J Hosp Med. 2009;4(4):211-218.

Family History Is a Risk Factor for Venous Thrombosis

Clinical question: Is family history of additional value in predicting an individual’s risk of venous thrombosis once a genetic risk factor is identified?

Background: A positive family history of venous thrombosis might suggest the presence of genetic risk factors in a given family. However, it is not known whether family history is of additional significance—once a risk factor is identified—in predicting an individual’s risk for venous thrombosis.

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

Setting: Participants in the Multiple Environmental and Genetic Assessment (MEGA) of risk factors for venous thrombosis study.

Synopsis: Recruitment, data collection, and blood samples were obtained from individuals in the MEGA study. Participants completed a questionnaire about risk factors for venous thrombosis and family history. A positive family history more than doubled the risk of venous thrombosis, and when more than one family member was affected, the risk increased fourfold. The risk for venous thrombosis increased 64 times for individuals who had a family history, genetic risk factor, and environmental risk factor when compared with those with a negative family history and no known risk factors.

The underreporting or overestimation of the prevalence of a positive family history might limit this study.

Bottom line: Family history is a risk indictor for a first venous thrombosis, despite the presence of other risk factors.

Citation: Bezemer ID, van der Meer FJ, Eikenboom JC, Rosendaal FR, Doggen CJ. The value of family history as a risk indicator for venous thrombosis. Arch Intern Med. 2009;169(6):610-615.

Vasopressor Choice Predicts Mortality in Septic Shock

Clinical question: Does vasopressor choice affect mortality in patients with community-acquired septic shock?

Background: Community-acquired septic shock is a common illness and, despite aggressive care, a leading cause of death. Randomized clinical control trials evaluating the efficacy and safety of different adrenergic supportive agents are lacking. Thus, both norepinephrine and dopamine are recommended as first-line agents in the treatment of septic shock by the Surviving Sepsis Campaign guidelines.

Study design: Multicenter, cohort observational study.

Setting: Seventeen intensive-care units in Portugal.

Synopsis: In adjusted analysis controlling for Simplified Acute Physiology Score (SAPS) II, use of norepinephrine in community-acquired septic shock was associated with higher hospital mortality and lower 28-day survival when compared with dopamine. Specifically, patients treated with norepinephrine had a statistically significant higher hospital mortality rate than those treated with dopamine (52% and 38.5%, respectively, P=0.002) and a lower 28-day survival (log rank=22.6; P<0.001). While this data is valuable, the nonrandomized, observational study design limits firm conclusions regarding vasopressor choice. Further results from three large trials comparing vasopressor use in septic shock should continue to shed light on this debate.

Bottom line: Norepinephrine administration is associated with higher hospital mortality and lower 28-day survival when compared with dopamine in patients with community-acquired septic shock.

Citation: Póvoa PR, Carneiro AH, Ribeiro OS, Pereira AC, Portuguese Community-Acquired Sepsis Study Group. Influence of vasopressor agent in septic shock mortality. Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI study). Crit Care Med. 2009;37(2):410-416.

Oral Vitamin K Versus Placebo to Correct Excess Anticoagulation in Warfarin Patients

Clinical question: In nonbleeding patients with warfarin-associated coagulopathy, does oral vitamin K reduce bleeding events when compared to placebo?

Background: Warfarin is a common drug for primary and secondary prevention of thromboembolism, but it requires continued monitoring of the international normalized ratio (INR) value. INR values >4.0 are associated with an increase in bleeding complications, with specific concern for intracranial bleeding when INR values exceed 4.5. Small, randomized trials have shown that single, low-dose administration of oral vitamin K effectively reduces the INR in nonbleeding, overanticoagulated patients.

However, these studies have not shown if vitamin K reduces risk for bleeding without increasing the risk for thromboembolism.

Study design: Randomized, placebo-controlled trial.

Setting: Fourteen anticoagulation clinics in Canada, Italy, and the U.S.

Synopsis: Nonbleeding patients with supratherapeutic INR values between 4.5 and 10.0 were randomly assigned to receive 1.25 mg of oral vitamin K or placebo, then evaluated for all forms of bleeding for 90 days. Bleeding events were defined as “major bleeding,” “minor bleeding,” and “trivial bleeding.”

Though patients who received oral vitamin K had a significantly more rapid INR decrease, there were no differences between the two groups with regard to all bleeding events, thromboembolism, or death. The study was underpowered to detect differences in major bleeding.

Bottom line: Low-dose oral vitamin K leads to more rapid correction of the INR in overanticoagulated patients on warfarin therapy, but has little effect on clinical outcomes at 90 days.

Citation: Crowther MA, Ageno W, Garcia D, et al. Oral vitamin K versus placebo to correct excessive anticoagulation in patients receiving warfarin: a randomized trial. Ann Intern Med. 2009;150(5):293-300.

Inappropriate Treatment of Catheter-Associated Asymptomatic Bacteriuria

Clinical question: Are hospitalized patients with urinary catheters inappropriately treated with antibiotics for asymptomatic bacteriuria?

Background: Persons with catheters acquire bacteriuria at the rate of 3% to 10% per day, but in the majority of cases, no symptoms or secondary complications occur. Evidenced-based guidelines state that asymptomatic bacteriuria is not a clinically significant infection, and numerous studies have shown that treatment is unlikely to confer clinical benefit.

Study design: Retrospective cohort study.

Setting: A single-site Veterans Affairs hospital.

Synopsis: Using urine culture results over a three-month period from a single VA medical center, 280 cases were analyzed: 164 catheter-associated asymptomatic bacteriuria and 116 catheter-associated urinary tract infections (UTIs). A UTI was defined as having one or more of these symptoms: fever, urgency, frequency, dysuria, suprapubic tenderness, altered mental status, or hypotension in a patient without another recognized infection and a positive urine culture. Of the asymptomatic bacteriuria cases, 68% were managed appropriately with no antibiotic treatment; 32% were inappropriately treated with antibiotics.

In multivariate analysis, older patient age, predominance of gram-negative bacteria, and higher urine white blood cell count were significantly associated with inappropriate treatment.

This study highlights the fact that antibiotics continue to be used inappropriately in patients with catheters. Current guidelines do not distinguish well between asymptomatic bacteriuria and UTI, so there might be a knowledge gap. This study was based on urine culture data, not urinalysis of all patients with a catheter, so the symptomatic patients were likely over-represented.

An associated editorial observes that the study extrapolates data from studies that involved patients with uncomplicated UTIs and, therefore, might reach erroneous conclusions. Further, viewing catheter-associated symptomatic UTIs and catheter-associated asymptomatic bactiuria as dichotomous and warranting inherently different management fails to encompass a number of clinical factors, including co-infection, and further fails to acknowledge that removal of the catheter is the first step in treatment. However, the finding that antibiotics continue to be used inappropriately is useful.

Bottom line: A clinical determination of whether a patient with a catheter really has a symptomatic UTI/urosepsis or only has asymptomatic bacteriuria should precede starting antibiotics in hospitalized patients.

Citations: Cope M, Cevallos ME, Cadle RM, Darouiche RO, Musher DM, Trautner BW. Inappropriate treatment of catheter-associated asymptomatic bateriuria in a tertiary care hospital. Clin Infect Dis. 2009;48(9):1182-1188.

Kunin CM. Catheter-associated urinary tract infections: a syllogism compounded by a questionable dichotomy. Clin Infect Dis. 2009;48:1189-1190.

Current Practices in the Evaluation and Management of Thrombocytopenia in Heparin Patients

Clinical question: Are the current American College of Chest Physicians (ACCP) guidelines for the recognition, treatment, and prevention of heparin-induced thrombocytopenia (HIT) being followed?

Background: Heparin-based anticoagulation is frequently given to hospitalized patients, and approximately 1% to 5% of these patients develop HIT. In 2004, the ACCP published a consensus statement on the evaluation, management, and prevention of HIT.

Study design: Prospective, observational study.

Setting: Forty-eight U.S. hospitals in the Complications After Thrombocytopenia Caused by Heparin (CATCH) registry.

Synopsis: The CATCH trial enrolled patients receiving any form of heparin for >96 hours (n=2,420), cardiac-care-unit patients treated with heparin (n=1,090), and patients who had an HIT antibody assay performed (n=449), for a total of 3,536 total patients. The study included patients on unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). Thrombocytopenia was defined at a platelet count <150,000, or a decrease of 50% when compared with admission.

In the prolonged heparin group, 36.4% of patients developed thrombocytopenia; however, HIT was suspected in only 19.8% of these high-risk patients. While physicians were more likely to consider HIT in the cardiac-care patients (37.6%), the diagnosis was considered>24 hours after the thrombocytopenia developed. Physicians often waited until after a thromboembolic complication occurred before evaluating for HIT. More often than not, preventive measures were missed (e.g., failing to check for HIT antibodies, continuing heparin after HIT was suspected).

Bottom line: Thrombocytopenia is a common occurrence in patients receiving heparin and, despite the risk of devastating complications from HIT, treatment infrequently conforms to the established guidelines.

Citation: Crespo EM, Oliveira GBF, Honeycutt EF, et al. Evaluation and management of thrombocytopenia and suspected heparin-induced thrombocytopenia in hospitalized patients: The Complications After Thrombocytopenia Caused by Heparin (CATCH) registry. Am Heart J. 2009;157(4):651-657. TH

PEDIATRIC HM LITerature

Epinephrine and Dexamethasone Alone Do Not Reduce Hospital Admissions in Infants with Bronchiolitis

By Mark Shen, MD

Clinical question: Does nebulized epinephrine, oral dexamethasone, or a combination of the two result in a decrease in hospital admissions when given in the ED to infants with bronchiolitis?

Background: Bronchiolitis is the most common lower-respiratory-tract infection of infancy. Rates of admission have climbed in the past two decades. Bronchodilators and corticosteroids are not routinely recommended, and the evidence surrounding epinephrine and dexamethasone has shown varying results.

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

Setting: Eight Canadian pediatric EDs.

Synopsis: Eight hundred infants ages six weeks to 12 months with a first episode of bronchiolitis were randomized to nebulized epinephrine and oral dexamethasone, epinephrine and oral placebo, dexamethasone and nebulized placebo, or oral and nebulized placebo. Epinephrine was delivered as two nebulizations 30 minutes apart, and dexamethasone was given as a 1 mg/kg oral dose, followed by five once-daily doses of 0.6 mg/kg. In unadjusted analysis, only the infants who received epinephrine and dexamethasone were less likely to be admitted to the hospital by day seven.

Limitations of this study include a small effect size and a non-statistically-significant difference between the epinephrine/dexamethasone group and placebo after statistical adjustment for multiple comparisons. Given that admission rates did not decrease in the epinephrine/placebo group and the dexamethasone/placebo group, this study supports national guidelines that do not recommend the routine use of these agents in bronchiolitis. The authors suggest that synergy between epinephrine and dexamethasone in bronchiolitis be further studied.

Bottom line: When given alone, epinephrine and dexamethasone do not reduce hospital admissions in infants with bronchiolitis.

Citation: Plint AC, Johnson DW, Patel H, et al. Epinephrine and dexamethasone in children with bronchiolitis. N Engl J Med. 2009;360(20):2079-2089.

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

In This Edition

Literature at a Glance

A guide to this month’s studies

• PE and COPD exacerbations.
• Care bundles and readmission rates.
• Family history and VTE risk.
• Vasopressor choice and mortality in sepsis.
• Vitamin K use in overanticoagulation.
• Appropriate treatment of asymptomatic bacteriuria.
• Guideline adherence in thrombocytopenia.

Pulmonary Embolism Frequently Complicates COPD Exacerbations

Clinical question: What percentage of patients with acute chronic obstructive pulmonary disease (COPD) exacerbations has pulmonary emboli?

Background: As many as 30% of COPD exacerbations have no apparent precipitating event. Even in patients with evidence of a precipitating event, such as an upper-respiratory illness or increased environmental irritants, pulmonary emboli (PE) may coexist and warrant evaluation.

Study design: Literature review.

Setting: Multiple studies in Europe and the U.S.

Synopsis: This literature review included five studies to estimate the rate of PE in patients with a COPD exacerbation. Overall incidence of PE in COPD exacerbations was 19.9%, but of those patients requiring hospitalization, the incidence was as high as 25.5%. Incidence estimates varied based on interpretation of data that were missing or inconsistent between studies. Patients most commonly present with dyspnea, chest pain, hemoptysis, cough, and palpitations. Six percent of PE patients presented with syncope; no patients with an exacerbation without a PE presented with syncope.

Risk of mortality from PE is almost twice as high in patients with a COPD exacerbation compared with PE in other settings. A significant number of patients have PE without history or evidence of DVT, so in situ thrombosis is a significant factor. The interpretation of these results is limited by the heterogeneity of the study designs, and by the relatively low number of cases. Larger trials are necessary.

Bottom line: Pulmonary emboli are present in as many as 25% of all COPD exacerbations. Delay in diagnosis of PE in COPD patients affects morbidity and mortality. PE should be a consideration in many COPD exacerbations.

Citation: Rizkallah J, Man SF, Din DD. Prevalence of pulmonary embolism in acute exacerbations of COPD: a systematic review and metaanalysis. Chest. 2009;135(3):786-793.

Targeted-Care Bundle Can Reduce ED Visits and Readmission Rates in High-Risk Elderly Patients

Clinical question: Can a care coordination bundle reduce length of stay (LOS), ED visits, or readmissions within 30 days of a hospital admission?

Background: Hospital-based care coordination interventions have shown mixed results in affecting LOS, post-discharge ED visits, and readmission rates. Although there has been some success with particular interventions, no consistent benefit has been demonstrated. Most notably, a recent meta-analysis of several different interventions showed no improvement in mortality, LOS, or readmission rates.

Study design: A randomized, controlled trial of select high-risk elderly patients.

Setting: A large teaching hospital at Baylor University Medical Center.

Synopsis: A “targeted-care bundle” was implemented with high-risk elderly patients to try to reduce LOS, readmissions, and ED visits. High-risk patients were identified by age, diagnosis-related group (DRG), number of medications at admission, comorbid conditions, and need for assistance in activities of daily living. Subjects were randomized to usual care or to receive a targeted-care bundle. The targeted-care bundle included multiple interventions. A study care coordinator provided daily patient education, including condition-specific teaching, discharge teaching and planning, and a follow-up phone call at five to seven days after discharge. A clinical pharmacist intervened for medication reconciliation at admission and discharge, medication teaching, and a follow-up phone call at five to seven days after discharge. Structured documents, including a personal health record and supplemental discharge form, were implemented.

The study had low enrollment, largely due to the requirement to obtain informed consent from all participants. Therefore, the study was underpowered to detect such target endpoints as LOS. A significant decrease in 30-day readmission rates/ED visits was noticed, but there was no persistent effect at 60 days.

The intervention was designed to use existing hospital staff in order to be practical for broad utilization. Future studies need to focus on increased enrollment to demonstrate beneficial effect.

Bottom line: Targeted health interventions focusing on education and coordination of care might effect some significant outcomes, most notably readmissions or ED visits within 30 days, but the nature of the clinical problem makes rigorous testing of interventions a challenge.

Citation: Kohler BE, Richter KM, Youngblood L, et al. Reduction of 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J Hosp Med. 2009;4(4):211-218.

Family History Is a Risk Factor for Venous Thrombosis

Clinical question: Is family history of additional value in predicting an individual’s risk of venous thrombosis once a genetic risk factor is identified?

Background: A positive family history of venous thrombosis might suggest the presence of genetic risk factors in a given family. However, it is not known whether family history is of additional significance—once a risk factor is identified—in predicting an individual’s risk for venous thrombosis.

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

Setting: Participants in the Multiple Environmental and Genetic Assessment (MEGA) of risk factors for venous thrombosis study.

Synopsis: Recruitment, data collection, and blood samples were obtained from individuals in the MEGA study. Participants completed a questionnaire about risk factors for venous thrombosis and family history. A positive family history more than doubled the risk of venous thrombosis, and when more than one family member was affected, the risk increased fourfold. The risk for venous thrombosis increased 64 times for individuals who had a family history, genetic risk factor, and environmental risk factor when compared with those with a negative family history and no known risk factors.

The underreporting or overestimation of the prevalence of a positive family history might limit this study.

Bottom line: Family history is a risk indictor for a first venous thrombosis, despite the presence of other risk factors.

Citation: Bezemer ID, van der Meer FJ, Eikenboom JC, Rosendaal FR, Doggen CJ. The value of family history as a risk indicator for venous thrombosis. Arch Intern Med. 2009;169(6):610-615.

Vasopressor Choice Predicts Mortality in Septic Shock

Clinical question: Does vasopressor choice affect mortality in patients with community-acquired septic shock?

Background: Community-acquired septic shock is a common illness and, despite aggressive care, a leading cause of death. Randomized clinical control trials evaluating the efficacy and safety of different adrenergic supportive agents are lacking. Thus, both norepinephrine and dopamine are recommended as first-line agents in the treatment of septic shock by the Surviving Sepsis Campaign guidelines.

Study design: Multicenter, cohort observational study.

Setting: Seventeen intensive-care units in Portugal.

Synopsis: In adjusted analysis controlling for Simplified Acute Physiology Score (SAPS) II, use of norepinephrine in community-acquired septic shock was associated with higher hospital mortality and lower 28-day survival when compared with dopamine. Specifically, patients treated with norepinephrine had a statistically significant higher hospital mortality rate than those treated with dopamine (52% and 38.5%, respectively, P=0.002) and a lower 28-day survival (log rank=22.6; P<0.001). While this data is valuable, the nonrandomized, observational study design limits firm conclusions regarding vasopressor choice. Further results from three large trials comparing vasopressor use in septic shock should continue to shed light on this debate.

Bottom line: Norepinephrine administration is associated with higher hospital mortality and lower 28-day survival when compared with dopamine in patients with community-acquired septic shock.

Citation: Póvoa PR, Carneiro AH, Ribeiro OS, Pereira AC, Portuguese Community-Acquired Sepsis Study Group. Influence of vasopressor agent in septic shock mortality. Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI study). Crit Care Med. 2009;37(2):410-416.

Oral Vitamin K Versus Placebo to Correct Excess Anticoagulation in Warfarin Patients

Clinical question: In nonbleeding patients with warfarin-associated coagulopathy, does oral vitamin K reduce bleeding events when compared to placebo?

Background: Warfarin is a common drug for primary and secondary prevention of thromboembolism, but it requires continued monitoring of the international normalized ratio (INR) value. INR values >4.0 are associated with an increase in bleeding complications, with specific concern for intracranial bleeding when INR values exceed 4.5. Small, randomized trials have shown that single, low-dose administration of oral vitamin K effectively reduces the INR in nonbleeding, overanticoagulated patients.

However, these studies have not shown if vitamin K reduces risk for bleeding without increasing the risk for thromboembolism.

Study design: Randomized, placebo-controlled trial.

Setting: Fourteen anticoagulation clinics in Canada, Italy, and the U.S.

Synopsis: Nonbleeding patients with supratherapeutic INR values between 4.5 and 10.0 were randomly assigned to receive 1.25 mg of oral vitamin K or placebo, then evaluated for all forms of bleeding for 90 days. Bleeding events were defined as “major bleeding,” “minor bleeding,” and “trivial bleeding.”

Though patients who received oral vitamin K had a significantly more rapid INR decrease, there were no differences between the two groups with regard to all bleeding events, thromboembolism, or death. The study was underpowered to detect differences in major bleeding.

Bottom line: Low-dose oral vitamin K leads to more rapid correction of the INR in overanticoagulated patients on warfarin therapy, but has little effect on clinical outcomes at 90 days.

Citation: Crowther MA, Ageno W, Garcia D, et al. Oral vitamin K versus placebo to correct excessive anticoagulation in patients receiving warfarin: a randomized trial. Ann Intern Med. 2009;150(5):293-300.

Inappropriate Treatment of Catheter-Associated Asymptomatic Bacteriuria

Clinical question: Are hospitalized patients with urinary catheters inappropriately treated with antibiotics for asymptomatic bacteriuria?

Background: Persons with catheters acquire bacteriuria at the rate of 3% to 10% per day, but in the majority of cases, no symptoms or secondary complications occur. Evidenced-based guidelines state that asymptomatic bacteriuria is not a clinically significant infection, and numerous studies have shown that treatment is unlikely to confer clinical benefit.

Study design: Retrospective cohort study.

Setting: A single-site Veterans Affairs hospital.

Synopsis: Using urine culture results over a three-month period from a single VA medical center, 280 cases were analyzed: 164 catheter-associated asymptomatic bacteriuria and 116 catheter-associated urinary tract infections (UTIs). A UTI was defined as having one or more of these symptoms: fever, urgency, frequency, dysuria, suprapubic tenderness, altered mental status, or hypotension in a patient without another recognized infection and a positive urine culture. Of the asymptomatic bacteriuria cases, 68% were managed appropriately with no antibiotic treatment; 32% were inappropriately treated with antibiotics.

In multivariate analysis, older patient age, predominance of gram-negative bacteria, and higher urine white blood cell count were significantly associated with inappropriate treatment.

This study highlights the fact that antibiotics continue to be used inappropriately in patients with catheters. Current guidelines do not distinguish well between asymptomatic bacteriuria and UTI, so there might be a knowledge gap. This study was based on urine culture data, not urinalysis of all patients with a catheter, so the symptomatic patients were likely over-represented.

An associated editorial observes that the study extrapolates data from studies that involved patients with uncomplicated UTIs and, therefore, might reach erroneous conclusions. Further, viewing catheter-associated symptomatic UTIs and catheter-associated asymptomatic bactiuria as dichotomous and warranting inherently different management fails to encompass a number of clinical factors, including co-infection, and further fails to acknowledge that removal of the catheter is the first step in treatment. However, the finding that antibiotics continue to be used inappropriately is useful.

Bottom line: A clinical determination of whether a patient with a catheter really has a symptomatic UTI/urosepsis or only has asymptomatic bacteriuria should precede starting antibiotics in hospitalized patients.

Citations: Cope M, Cevallos ME, Cadle RM, Darouiche RO, Musher DM, Trautner BW. Inappropriate treatment of catheter-associated asymptomatic bateriuria in a tertiary care hospital. Clin Infect Dis. 2009;48(9):1182-1188.

Kunin CM. Catheter-associated urinary tract infections: a syllogism compounded by a questionable dichotomy. Clin Infect Dis. 2009;48:1189-1190.

Current Practices in the Evaluation and Management of Thrombocytopenia in Heparin Patients

Clinical question: Are the current American College of Chest Physicians (ACCP) guidelines for the recognition, treatment, and prevention of heparin-induced thrombocytopenia (HIT) being followed?

Background: Heparin-based anticoagulation is frequently given to hospitalized patients, and approximately 1% to 5% of these patients develop HIT. In 2004, the ACCP published a consensus statement on the evaluation, management, and prevention of HIT.

Study design: Prospective, observational study.

Setting: Forty-eight U.S. hospitals in the Complications After Thrombocytopenia Caused by Heparin (CATCH) registry.

Synopsis: The CATCH trial enrolled patients receiving any form of heparin for >96 hours (n=2,420), cardiac-care-unit patients treated with heparin (n=1,090), and patients who had an HIT antibody assay performed (n=449), for a total of 3,536 total patients. The study included patients on unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). Thrombocytopenia was defined at a platelet count <150,000, or a decrease of 50% when compared with admission.

In the prolonged heparin group, 36.4% of patients developed thrombocytopenia; however, HIT was suspected in only 19.8% of these high-risk patients. While physicians were more likely to consider HIT in the cardiac-care patients (37.6%), the diagnosis was considered>24 hours after the thrombocytopenia developed. Physicians often waited until after a thromboembolic complication occurred before evaluating for HIT. More often than not, preventive measures were missed (e.g., failing to check for HIT antibodies, continuing heparin after HIT was suspected).

Bottom line: Thrombocytopenia is a common occurrence in patients receiving heparin and, despite the risk of devastating complications from HIT, treatment infrequently conforms to the established guidelines.

Citation: Crespo EM, Oliveira GBF, Honeycutt EF, et al. Evaluation and management of thrombocytopenia and suspected heparin-induced thrombocytopenia in hospitalized patients: The Complications After Thrombocytopenia Caused by Heparin (CATCH) registry. Am Heart J. 2009;157(4):651-657. TH

PEDIATRIC HM LITerature

Epinephrine and Dexamethasone Alone Do Not Reduce Hospital Admissions in Infants with Bronchiolitis

By Mark Shen, MD

Clinical question: Does nebulized epinephrine, oral dexamethasone, or a combination of the two result in a decrease in hospital admissions when given in the ED to infants with bronchiolitis?

Background: Bronchiolitis is the most common lower-respiratory-tract infection of infancy. Rates of admission have climbed in the past two decades. Bronchodilators and corticosteroids are not routinely recommended, and the evidence surrounding epinephrine and dexamethasone has shown varying results.

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

Setting: Eight Canadian pediatric EDs.

Synopsis: Eight hundred infants ages six weeks to 12 months with a first episode of bronchiolitis were randomized to nebulized epinephrine and oral dexamethasone, epinephrine and oral placebo, dexamethasone and nebulized placebo, or oral and nebulized placebo. Epinephrine was delivered as two nebulizations 30 minutes apart, and dexamethasone was given as a 1 mg/kg oral dose, followed by five once-daily doses of 0.6 mg/kg. In unadjusted analysis, only the infants who received epinephrine and dexamethasone were less likely to be admitted to the hospital by day seven.

Limitations of this study include a small effect size and a non-statistically-significant difference between the epinephrine/dexamethasone group and placebo after statistical adjustment for multiple comparisons. Given that admission rates did not decrease in the epinephrine/placebo group and the dexamethasone/placebo group, this study supports national guidelines that do not recommend the routine use of these agents in bronchiolitis. The authors suggest that synergy between epinephrine and dexamethasone in bronchiolitis be further studied.

Bottom line: When given alone, epinephrine and dexamethasone do not reduce hospital admissions in infants with bronchiolitis.

Citation: Plint AC, Johnson DW, Patel H, et al. Epinephrine and dexamethasone in children with bronchiolitis. N Engl J Med. 2009;360(20):2079-2089.

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

In This Edition

Literature at a Glance

A guide to this month’s studies

• PE and COPD exacerbations.
• Care bundles and readmission rates.
• Family history and VTE risk.
• Vasopressor choice and mortality in sepsis.
• Vitamin K use in overanticoagulation.
• Appropriate treatment of asymptomatic bacteriuria.
• Guideline adherence in thrombocytopenia.

Pulmonary Embolism Frequently Complicates COPD Exacerbations

Clinical question: What percentage of patients with acute chronic obstructive pulmonary disease (COPD) exacerbations has pulmonary emboli?

Background: As many as 30% of COPD exacerbations have no apparent precipitating event. Even in patients with evidence of a precipitating event, such as an upper-respiratory illness or increased environmental irritants, pulmonary emboli (PE) may coexist and warrant evaluation.

Study design: Literature review.

Setting: Multiple studies in Europe and the U.S.

Synopsis: This literature review included five studies to estimate the rate of PE in patients with a COPD exacerbation. Overall incidence of PE in COPD exacerbations was 19.9%, but of those patients requiring hospitalization, the incidence was as high as 25.5%. Incidence estimates varied based on interpretation of data that were missing or inconsistent between studies. Patients most commonly present with dyspnea, chest pain, hemoptysis, cough, and palpitations. Six percent of PE patients presented with syncope; no patients with an exacerbation without a PE presented with syncope.

Risk of mortality from PE is almost twice as high in patients with a COPD exacerbation compared with PE in other settings. A significant number of patients have PE without history or evidence of DVT, so in situ thrombosis is a significant factor. The interpretation of these results is limited by the heterogeneity of the study designs, and by the relatively low number of cases. Larger trials are necessary.

Bottom line: Pulmonary emboli are present in as many as 25% of all COPD exacerbations. Delay in diagnosis of PE in COPD patients affects morbidity and mortality. PE should be a consideration in many COPD exacerbations.

Citation: Rizkallah J, Man SF, Din DD. Prevalence of pulmonary embolism in acute exacerbations of COPD: a systematic review and metaanalysis. Chest. 2009;135(3):786-793.

Targeted-Care Bundle Can Reduce ED Visits and Readmission Rates in High-Risk Elderly Patients

Clinical question: Can a care coordination bundle reduce length of stay (LOS), ED visits, or readmissions within 30 days of a hospital admission?

Background: Hospital-based care coordination interventions have shown mixed results in affecting LOS, post-discharge ED visits, and readmission rates. Although there has been some success with particular interventions, no consistent benefit has been demonstrated. Most notably, a recent meta-analysis of several different interventions showed no improvement in mortality, LOS, or readmission rates.

Study design: A randomized, controlled trial of select high-risk elderly patients.

Setting: A large teaching hospital at Baylor University Medical Center.

Synopsis: A “targeted-care bundle” was implemented with high-risk elderly patients to try to reduce LOS, readmissions, and ED visits. High-risk patients were identified by age, diagnosis-related group (DRG), number of medications at admission, comorbid conditions, and need for assistance in activities of daily living. Subjects were randomized to usual care or to receive a targeted-care bundle. The targeted-care bundle included multiple interventions. A study care coordinator provided daily patient education, including condition-specific teaching, discharge teaching and planning, and a follow-up phone call at five to seven days after discharge. A clinical pharmacist intervened for medication reconciliation at admission and discharge, medication teaching, and a follow-up phone call at five to seven days after discharge. Structured documents, including a personal health record and supplemental discharge form, were implemented.

The study had low enrollment, largely due to the requirement to obtain informed consent from all participants. Therefore, the study was underpowered to detect such target endpoints as LOS. A significant decrease in 30-day readmission rates/ED visits was noticed, but there was no persistent effect at 60 days.

The intervention was designed to use existing hospital staff in order to be practical for broad utilization. Future studies need to focus on increased enrollment to demonstrate beneficial effect.

Bottom line: Targeted health interventions focusing on education and coordination of care might effect some significant outcomes, most notably readmissions or ED visits within 30 days, but the nature of the clinical problem makes rigorous testing of interventions a challenge.

Citation: Kohler BE, Richter KM, Youngblood L, et al. Reduction of 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J Hosp Med. 2009;4(4):211-218.

Family History Is a Risk Factor for Venous Thrombosis

Clinical question: Is family history of additional value in predicting an individual’s risk of venous thrombosis once a genetic risk factor is identified?

Background: A positive family history of venous thrombosis might suggest the presence of genetic risk factors in a given family. However, it is not known whether family history is of additional significance—once a risk factor is identified—in predicting an individual’s risk for venous thrombosis.

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

Setting: Participants in the Multiple Environmental and Genetic Assessment (MEGA) of risk factors for venous thrombosis study.

Synopsis: Recruitment, data collection, and blood samples were obtained from individuals in the MEGA study. Participants completed a questionnaire about risk factors for venous thrombosis and family history. A positive family history more than doubled the risk of venous thrombosis, and when more than one family member was affected, the risk increased fourfold. The risk for venous thrombosis increased 64 times for individuals who had a family history, genetic risk factor, and environmental risk factor when compared with those with a negative family history and no known risk factors.

The underreporting or overestimation of the prevalence of a positive family history might limit this study.

Bottom line: Family history is a risk indictor for a first venous thrombosis, despite the presence of other risk factors.

Citation: Bezemer ID, van der Meer FJ, Eikenboom JC, Rosendaal FR, Doggen CJ. The value of family history as a risk indicator for venous thrombosis. Arch Intern Med. 2009;169(6):610-615.

Vasopressor Choice Predicts Mortality in Septic Shock

Clinical question: Does vasopressor choice affect mortality in patients with community-acquired septic shock?

Background: Community-acquired septic shock is a common illness and, despite aggressive care, a leading cause of death. Randomized clinical control trials evaluating the efficacy and safety of different adrenergic supportive agents are lacking. Thus, both norepinephrine and dopamine are recommended as first-line agents in the treatment of septic shock by the Surviving Sepsis Campaign guidelines.

Study design: Multicenter, cohort observational study.

Setting: Seventeen intensive-care units in Portugal.

Synopsis: In adjusted analysis controlling for Simplified Acute Physiology Score (SAPS) II, use of norepinephrine in community-acquired septic shock was associated with higher hospital mortality and lower 28-day survival when compared with dopamine. Specifically, patients treated with norepinephrine had a statistically significant higher hospital mortality rate than those treated with dopamine (52% and 38.5%, respectively, P=0.002) and a lower 28-day survival (log rank=22.6; P<0.001). While this data is valuable, the nonrandomized, observational study design limits firm conclusions regarding vasopressor choice. Further results from three large trials comparing vasopressor use in septic shock should continue to shed light on this debate.

Bottom line: Norepinephrine administration is associated with higher hospital mortality and lower 28-day survival when compared with dopamine in patients with community-acquired septic shock.

Citation: Póvoa PR, Carneiro AH, Ribeiro OS, Pereira AC, Portuguese Community-Acquired Sepsis Study Group. Influence of vasopressor agent in septic shock mortality. Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI study). Crit Care Med. 2009;37(2):410-416.

Oral Vitamin K Versus Placebo to Correct Excess Anticoagulation in Warfarin Patients

Clinical question: In nonbleeding patients with warfarin-associated coagulopathy, does oral vitamin K reduce bleeding events when compared to placebo?

Background: Warfarin is a common drug for primary and secondary prevention of thromboembolism, but it requires continued monitoring of the international normalized ratio (INR) value. INR values >4.0 are associated with an increase in bleeding complications, with specific concern for intracranial bleeding when INR values exceed 4.5. Small, randomized trials have shown that single, low-dose administration of oral vitamin K effectively reduces the INR in nonbleeding, overanticoagulated patients.

However, these studies have not shown if vitamin K reduces risk for bleeding without increasing the risk for thromboembolism.

Study design: Randomized, placebo-controlled trial.

Setting: Fourteen anticoagulation clinics in Canada, Italy, and the U.S.

Synopsis: Nonbleeding patients with supratherapeutic INR values between 4.5 and 10.0 were randomly assigned to receive 1.25 mg of oral vitamin K or placebo, then evaluated for all forms of bleeding for 90 days. Bleeding events were defined as “major bleeding,” “minor bleeding,” and “trivial bleeding.”

Though patients who received oral vitamin K had a significantly more rapid INR decrease, there were no differences between the two groups with regard to all bleeding events, thromboembolism, or death. The study was underpowered to detect differences in major bleeding.

Bottom line: Low-dose oral vitamin K leads to more rapid correction of the INR in overanticoagulated patients on warfarin therapy, but has little effect on clinical outcomes at 90 days.

Citation: Crowther MA, Ageno W, Garcia D, et al. Oral vitamin K versus placebo to correct excessive anticoagulation in patients receiving warfarin: a randomized trial. Ann Intern Med. 2009;150(5):293-300.

Inappropriate Treatment of Catheter-Associated Asymptomatic Bacteriuria

Clinical question: Are hospitalized patients with urinary catheters inappropriately treated with antibiotics for asymptomatic bacteriuria?

Background: Persons with catheters acquire bacteriuria at the rate of 3% to 10% per day, but in the majority of cases, no symptoms or secondary complications occur. Evidenced-based guidelines state that asymptomatic bacteriuria is not a clinically significant infection, and numerous studies have shown that treatment is unlikely to confer clinical benefit.

Study design: Retrospective cohort study.

Setting: A single-site Veterans Affairs hospital.

Synopsis: Using urine culture results over a three-month period from a single VA medical center, 280 cases were analyzed: 164 catheter-associated asymptomatic bacteriuria and 116 catheter-associated urinary tract infections (UTIs). A UTI was defined as having one or more of these symptoms: fever, urgency, frequency, dysuria, suprapubic tenderness, altered mental status, or hypotension in a patient without another recognized infection and a positive urine culture. Of the asymptomatic bacteriuria cases, 68% were managed appropriately with no antibiotic treatment; 32% were inappropriately treated with antibiotics.

In multivariate analysis, older patient age, predominance of gram-negative bacteria, and higher urine white blood cell count were significantly associated with inappropriate treatment.

This study highlights the fact that antibiotics continue to be used inappropriately in patients with catheters. Current guidelines do not distinguish well between asymptomatic bacteriuria and UTI, so there might be a knowledge gap. This study was based on urine culture data, not urinalysis of all patients with a catheter, so the symptomatic patients were likely over-represented.

An associated editorial observes that the study extrapolates data from studies that involved patients with uncomplicated UTIs and, therefore, might reach erroneous conclusions. Further, viewing catheter-associated symptomatic UTIs and catheter-associated asymptomatic bactiuria as dichotomous and warranting inherently different management fails to encompass a number of clinical factors, including co-infection, and further fails to acknowledge that removal of the catheter is the first step in treatment. However, the finding that antibiotics continue to be used inappropriately is useful.

Bottom line: A clinical determination of whether a patient with a catheter really has a symptomatic UTI/urosepsis or only has asymptomatic bacteriuria should precede starting antibiotics in hospitalized patients.

Citations: Cope M, Cevallos ME, Cadle RM, Darouiche RO, Musher DM, Trautner BW. Inappropriate treatment of catheter-associated asymptomatic bateriuria in a tertiary care hospital. Clin Infect Dis. 2009;48(9):1182-1188.

Kunin CM. Catheter-associated urinary tract infections: a syllogism compounded by a questionable dichotomy. Clin Infect Dis. 2009;48:1189-1190.

Current Practices in the Evaluation and Management of Thrombocytopenia in Heparin Patients

Clinical question: Are the current American College of Chest Physicians (ACCP) guidelines for the recognition, treatment, and prevention of heparin-induced thrombocytopenia (HIT) being followed?

Background: Heparin-based anticoagulation is frequently given to hospitalized patients, and approximately 1% to 5% of these patients develop HIT. In 2004, the ACCP published a consensus statement on the evaluation, management, and prevention of HIT.

Study design: Prospective, observational study.

Setting: Forty-eight U.S. hospitals in the Complications After Thrombocytopenia Caused by Heparin (CATCH) registry.

Synopsis: The CATCH trial enrolled patients receiving any form of heparin for >96 hours (n=2,420), cardiac-care-unit patients treated with heparin (n=1,090), and patients who had an HIT antibody assay performed (n=449), for a total of 3,536 total patients. The study included patients on unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). Thrombocytopenia was defined at a platelet count <150,000, or a decrease of 50% when compared with admission.

In the prolonged heparin group, 36.4% of patients developed thrombocytopenia; however, HIT was suspected in only 19.8% of these high-risk patients. While physicians were more likely to consider HIT in the cardiac-care patients (37.6%), the diagnosis was considered>24 hours after the thrombocytopenia developed. Physicians often waited until after a thromboembolic complication occurred before evaluating for HIT. More often than not, preventive measures were missed (e.g., failing to check for HIT antibodies, continuing heparin after HIT was suspected).

Bottom line: Thrombocytopenia is a common occurrence in patients receiving heparin and, despite the risk of devastating complications from HIT, treatment infrequently conforms to the established guidelines.

Citation: Crespo EM, Oliveira GBF, Honeycutt EF, et al. Evaluation and management of thrombocytopenia and suspected heparin-induced thrombocytopenia in hospitalized patients: The Complications After Thrombocytopenia Caused by Heparin (CATCH) registry. Am Heart J. 2009;157(4):651-657. TH

PEDIATRIC HM LITerature

Epinephrine and Dexamethasone Alone Do Not Reduce Hospital Admissions in Infants with Bronchiolitis

By Mark Shen, MD

Clinical question: Does nebulized epinephrine, oral dexamethasone, or a combination of the two result in a decrease in hospital admissions when given in the ED to infants with bronchiolitis?

Background: Bronchiolitis is the most common lower-respiratory-tract infection of infancy. Rates of admission have climbed in the past two decades. Bronchodilators and corticosteroids are not routinely recommended, and the evidence surrounding epinephrine and dexamethasone has shown varying results.

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

Setting: Eight Canadian pediatric EDs.

Synopsis: Eight hundred infants ages six weeks to 12 months with a first episode of bronchiolitis were randomized to nebulized epinephrine and oral dexamethasone, epinephrine and oral placebo, dexamethasone and nebulized placebo, or oral and nebulized placebo. Epinephrine was delivered as two nebulizations 30 minutes apart, and dexamethasone was given as a 1 mg/kg oral dose, followed by five once-daily doses of 0.6 mg/kg. In unadjusted analysis, only the infants who received epinephrine and dexamethasone were less likely to be admitted to the hospital by day seven.

Limitations of this study include a small effect size and a non-statistically-significant difference between the epinephrine/dexamethasone group and placebo after statistical adjustment for multiple comparisons. Given that admission rates did not decrease in the epinephrine/placebo group and the dexamethasone/placebo group, this study supports national guidelines that do not recommend the routine use of these agents in bronchiolitis. The authors suggest that synergy between epinephrine and dexamethasone in bronchiolitis be further studied.

Bottom line: When given alone, epinephrine and dexamethasone do not reduce hospital admissions in infants with bronchiolitis.

Citation: Plint AC, Johnson DW, Patel H, et al. Epinephrine and dexamethasone in children with bronchiolitis. N Engl J Med. 2009;360(20):2079-2089.

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

Most healthcare providers are inexperienced in caring for people in disasters. However, in a national disaster that hinders mobility both into and out of an affected area, available skilled personnel are limited. A disaster response asks more of the scarce manpower: Providers must work longer hours and extend their customary scope of expertise to aid the largest number of victims. While these mandates are designed to maximize the care provided, the emotional and physical burdens on providers and victims in these circumstances are significant, and it is important that we remember the fundamental duty to prevent unnecessary harm in the provision of healthcare.

Should healthcare providers be held to different standards in times of disaster? If so, what are acceptable limits to disaster care, and what ethical dilemmas result during such exceptional times?

Unique Circumstances Call for Unique Standards of Care

Standards in a variety of areas differ in the face of a large-scale disaster, but the fact that standards must change to accommodate the circumstances does not mean that they cease to exist entirely. In the event of a large-scale disaster where populations become isolated and no new resources will arrive in the immediate future, the risks of inaction are magnified and we accept a higher risk resulting from relief action. When only one doctor is available, that doctor is obligated to provide whatever care he or she can to whoever is in need.

When the alternative is that no help will be given, any able doctor should provide whatever help they can. However, there are limits to this responsibility. Greater risks may be justified, and standards may be different, but physicians’ fundamental duties to patients are unchanged and avoidable mistakes causing injuries still need to be prevented. The basic duties of beneficence and non-malfeasance must still guide physician behavior, and the reality of the circumstances in disaster response favors pre-emptive determination on the safety limits that physicians should observe in providing disaster assistance.

Disasters inherently influence doctors to both continue to provide care when they are impaired by sleep or grief and to provide care that under other circumstances they would consider their experience inadequate to undertake. These are realities of disaster response, and all skilled personnel can and should exceed the limits that normally exist in a fully functional system with adequate resources. However, at some point a doctor becomes too impaired or too inexperienced to provide care to patients—even if no one else is available. Doctors are neither trained nor encouraged to weigh the global risks and benefits in this manner; in fact, we are trained to push ourselves beyond our reasonable limits even when absolute scarcity of resources isn’t an issue. People are quite willing to compromise their own comfort and safety in the event of a disaster, but there comes a point at which they may do more harm than good.

There is extensive evidence that sleep deprivation impairs judgment and performance in the medical setting.1-2 Despite the fact that standards change in emergencies and greater risk must be undertaken by both providers and victims, there must still be safety limits. At some point a doctor becomes so sleep deprived that he or she is more dangerous providing care than leaving people entirely without a provider, and further may have impaired judgment on the severity of the various conditions they are facing and the reasonable limits on their expertise. This problem is inherent to the setting. How much risk should doctors subject patients to? In the face of a life-threatening condition should a completely inexperienced physician undertake care? What if the doctor is mistaken as to the severity of the illness or the proper response to it?

In response to Hurricane Katrina, state and national regulatory agencies had to create emergency exceptions to licensing regulations and to HIPAA and EMTALA requirements in order to facilitate patient care.3 Both the Model State Emergency Health Powers Act (legislation designed to serve as template for states to use to create emergency health response mechanisms) and the Louisiana legislation that governed provision of medical care in a state of emergency limit liability of any provider assisting in an emergency.4-5 Providers assisting in an emergency will not be held liable for any injury resulting from action or inaction except for intentional or grossly negligent acts or omissions. Such limitation of liability is essential to ensure that all available resources are utilized in an emergency. However, given that patients will have limited remedies for injuries caused, it is increasingly important to proactively define limitations on provider activity during emergencies. Because other remedies and regulatory structures are relaxed, ethical self-regulation becomes increasingly important.

The first priority in emergency disaster response must be ensuring that providers are available and do not encounter unnecessary barriers to providing care to ill or injured patients. However, a secondary goal must be ensuring that the safest and most effective care is provided under the circumstances. As with many things in disaster response, once the disaster has occurred there is little time for contemplation. Therefore, disaster response plans should include guidelines for providers on how to ensure safety in the care they provide.

Disaster response issues must be dealt with proactively because resources cannot be diverted to these issues in the thick of emergency response. Some organizations and providers have experience with disaster response and can provide guidance. A major goal of medical relief organizations is to provide relief for fatigued providers. When relief is not available and not likely to arrive soon, providers should be encouraged to self-impose sleep periods despite the apparent urgency of the situations they face. Urging providers to ensure that they eat at least twice and sleep for two to four hours in any 24-hour period is a reasonable limit on the physical activity of providers.

Providers and patients need to understand that this is essential to ensure that providers are capable of giving safe care in a sustained fashion. Emergency responders must maintain adequate perspective on their own abilities and patients’ needs to ensure that unnecessary risks are not undertaken nor avoidable injures inflicted. Importantly, these limitations should not be legislated or imposed externally, but should be defined by the profession and self-enforced by providers.

There have been significant discussion of what aspects of the U.S. system of response to large-scale disasters need to be improved. The Katrina disaster has given us the opportunity to enhance essential response mechanisms, whether the cause of the disaster is natural, infectious, or terrorist. A good disaster plan takes steps to ensure availability of care, but also to ensure that the care is as ethical, safe and effective as possible.

References

1. Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA. Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. JAMA. 2005;294(9):1025-1033.
2. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Eng J Med. 2004;351(18):1838-1848.
3. Hyland, et al. Federal, State Regulations Relaxed for Providers Affected by Hurricane. BNA Health Law Reporter. 2005;15(36):1190-1191.
4. Gostin, LO, Model State Emergency Health Powers Act, §608 Licensing and Appointment of Health Care Personnel, December 21, 2001. Available at www.publichealthlaw.net/MSEHPA/MSEHPA2.pdf. Last accessed Dec. 1, 2005.
5. La. R.S. 29:656 (2005).

FROM THE PUBLIC POLICY COMMITTEE

Make a Positive Difference in the Politics of Healthcare

SHM to sponsor Legislative Advocacy Day on May 3

By Eric Siegal, MD, committee chair

“The stakes are too high for government to be a spectator sport.”

—Barbara Jordan, former U.S. Congresswoman

SHM is taking advantage of its 2006 annual meeting location in Washington, D.C., and sponsoring its first Legislative Advocacy Day on May 3. The Public Policy Committee is excited about the opportunity this initiative presents for hospitalists to learn more about how government really works and to speak with members of Congress about issues that are vital to patient care and clinical practice.

Are you concerned about continued Medicare cuts? Worried about how pending pay-for-performance legislation will affect hospitalists? SHM members registering for Advocacy Day will meet with their members of Congress and staff to discuss these and other important issues affecting hospital medicine.

I encourage you to register for Advocacy Day. There is no better way to influence how health policy is made in Washington than by meeting directly with your elected officials and their staffs. Lawmakers need constituent input to be effective legislators. Whether your legislator is a newly elected representative or a veteran senator with years of experience, he or she wants—and needs—to hear what you have to say about issues under consideration by the U.S. Congress, particularly in an election year. Input from their constituents always receives attention and consideration and can frequently make the difference in the way a lawmaker votes. Who better to educate members of Congress on changes to Medicare than the physicians directly involved in caring for the program’s beneficiaries?

We will give you the tools and information you need to make the most of your meetings on Capitol Hill. Legislative appointments will be scheduled by SHM as part of the registration process. SHM members will be grouped together by congressional district for House meetings and by state for Senate meetings and each registrant will have a minimum of three Hill appointments. To familiarize you with SHM’s legislative objectives for the second session of the 109th Congress, Laura Allendorf, SHM’s Washington representative, and I will conduct a pre-visit breakfast briefing from 7 a.m. to 8:30 a.m. on May 3. This briefing will cover procedural tips on how to have a successful meeting and update you on the status of the key health issues you will be discussing while on Capitol Hill. These meetings will take place from 9 a.m. to 5 p.m. that day.

Join us on May 3 and help educate members of Congress about the unique role hospitalists play in the delivery of medical care in our nation’s hospitals. We hope Advocacy Day will be the start of regular contact by hospitalists with their elected representatives in Washington.

FROM THE PEDIATRICS COMMITTEE

CME, Pediatric Core Curriculum on the Horizon

Multiple initiatives keep committee active

The Pediatric Committee at SHM is both the center of pediatric activity within SHM and a clearinghouse for SHM committee and task force activity as it relates to pediatrics.

The major pediatric activity in SHM continues to be CME activities and the Pediatric Core Curriculum. The dramatic success of the Pediatric Hospital Medicine Meeting was documented in the October issue of The Hospitalist (p. 33.)

Evaluations of the meeting overwhelmingly favored staging a three- to four-day Pediatric Hospital Medicine meeting on an annual basis during the late summer as a stand-alone meeting, with sponsorship rotating among SHM, the AAP, and the APA. There was insufficient lead time to offer a comprehensive meeting in 2006, but a meeting is scheduled for 2007 sponsored by AAP, with SHM taking the lead in 2008. More information to follow both in the SHM online discussion communities and through these committee reports.

The Pediatric Core Curriculum is nearly complete and should be at the review stage by early 2006. This curriculum is modeled after the adult core curriculum. It will serve as a framework for residency and fellowship directors, as well as a basis for the topics addressed at the Pediatric Hospital Medicine Meetings. Thanks to Tim Cornell, MD, Dan Rauch, MD, and all the authors and editors who have contributed to this work.

We will offer a full pediatric track in May at the SHM Annual Meeting in Washington, D.C., as we have in prior years. Registration is available online. Meetings of both the Pediatric Committee and the Pediatric Forum will be held during the meeting. This year’s meeting immediately precedes the PAS Meetings in San Francisco, and we encourage you to plan early so that at least one member of your program is able to attend the SHM Meeting. Once the Pediatric Hospital Medicine Meetings are held on an annual basis, we will need to decide how to balance SHM meeting offerings between the summer stand-alone Denver meeting and the SHM Annual Meeting.

The second function of Pediatric Committee involves having pediatric representatives on the various SHM committees and task forces report on their individual group’s activities, particularly as it relates to pediatrics. This keeps the broader group of pediatric leadership within SHM informed about the society’s global picture. SHM is committed to having a pediatric representative on each committee. You never know when or where an important issue for pediatricians may arise. Even geriatrics overlaps with pediatrics with regard to both family-centered care and proxy decision-makers.

Major endeavors at this point include the activities of the Benchmark and Career Satisfaction groups. SHM continues to make a strong effort to collect and generate data for workload and compensation, and to provide specific “pediatric only” subsets. Efforts regarding credentialing, sub-specialty designation/certification, and board re-certification are an active focus of SHM for adult hospitalists with ongoing discussions with the Board of Internal Medicine. We pediatricians stand on the sidelines of this battle, with the expectation that once the adults figure out how to do it, we can modify their approach with lower casualties on both sides.

The clinical Resource Rooms on the SHM Web site are clearly targeted toward adult topics. We intend to develop similar resources for pediatrics and are exploring possibilities of doing this collaboratively with the AAP and the APA. Sub-committees on pediatric hospital medicine topics are developing under a loose and shared structure with the AAP’s Section on Hospital Medicine. For example, SHM has taken the lead on a palliative care task force. Maggie Hood is the pediatric representative to this task force and wants to involve other interested pediatric hospitalists in a sub-committee on this topic. The AAP’s Karen Kingry has taken the lead on developing a sub-committee for community (pediatric) hospitalists; membership on her committee is open to SHM members. Expect other topics to develop as well.

If you have any comments, feedback or suggestions for the SHM Pediatric Committee, please contact co-chairs, David Zipes ([email protected]) or Jack Percelay ([email protected]). TH

Most healthcare providers are inexperienced in caring for people in disasters. However, in a national disaster that hinders mobility both into and out of an affected area, available skilled personnel are limited. A disaster response asks more of the scarce manpower: Providers must work longer hours and extend their customary scope of expertise to aid the largest number of victims. While these mandates are designed to maximize the care provided, the emotional and physical burdens on providers and victims in these circumstances are significant, and it is important that we remember the fundamental duty to prevent unnecessary harm in the provision of healthcare.

Should healthcare providers be held to different standards in times of disaster? If so, what are acceptable limits to disaster care, and what ethical dilemmas result during such exceptional times?

Unique Circumstances Call for Unique Standards of Care

Standards in a variety of areas differ in the face of a large-scale disaster, but the fact that standards must change to accommodate the circumstances does not mean that they cease to exist entirely. In the event of a large-scale disaster where populations become isolated and no new resources will arrive in the immediate future, the risks of inaction are magnified and we accept a higher risk resulting from relief action. When only one doctor is available, that doctor is obligated to provide whatever care he or she can to whoever is in need.

When the alternative is that no help will be given, any able doctor should provide whatever help they can. However, there are limits to this responsibility. Greater risks may be justified, and standards may be different, but physicians’ fundamental duties to patients are unchanged and avoidable mistakes causing injuries still need to be prevented. The basic duties of beneficence and non-malfeasance must still guide physician behavior, and the reality of the circumstances in disaster response favors pre-emptive determination on the safety limits that physicians should observe in providing disaster assistance.

Disasters inherently influence doctors to both continue to provide care when they are impaired by sleep or grief and to provide care that under other circumstances they would consider their experience inadequate to undertake. These are realities of disaster response, and all skilled personnel can and should exceed the limits that normally exist in a fully functional system with adequate resources. However, at some point a doctor becomes too impaired or too inexperienced to provide care to patients—even if no one else is available. Doctors are neither trained nor encouraged to weigh the global risks and benefits in this manner; in fact, we are trained to push ourselves beyond our reasonable limits even when absolute scarcity of resources isn’t an issue. People are quite willing to compromise their own comfort and safety in the event of a disaster, but there comes a point at which they may do more harm than good.

There is extensive evidence that sleep deprivation impairs judgment and performance in the medical setting.1-2 Despite the fact that standards change in emergencies and greater risk must be undertaken by both providers and victims, there must still be safety limits. At some point a doctor becomes so sleep deprived that he or she is more dangerous providing care than leaving people entirely without a provider, and further may have impaired judgment on the severity of the various conditions they are facing and the reasonable limits on their expertise. This problem is inherent to the setting. How much risk should doctors subject patients to? In the face of a life-threatening condition should a completely inexperienced physician undertake care? What if the doctor is mistaken as to the severity of the illness or the proper response to it?

In response to Hurricane Katrina, state and national regulatory agencies had to create emergency exceptions to licensing regulations and to HIPAA and EMTALA requirements in order to facilitate patient care.3 Both the Model State Emergency Health Powers Act (legislation designed to serve as template for states to use to create emergency health response mechanisms) and the Louisiana legislation that governed provision of medical care in a state of emergency limit liability of any provider assisting in an emergency.4-5 Providers assisting in an emergency will not be held liable for any injury resulting from action or inaction except for intentional or grossly negligent acts or omissions. Such limitation of liability is essential to ensure that all available resources are utilized in an emergency. However, given that patients will have limited remedies for injuries caused, it is increasingly important to proactively define limitations on provider activity during emergencies. Because other remedies and regulatory structures are relaxed, ethical self-regulation becomes increasingly important.

The first priority in emergency disaster response must be ensuring that providers are available and do not encounter unnecessary barriers to providing care to ill or injured patients. However, a secondary goal must be ensuring that the safest and most effective care is provided under the circumstances. As with many things in disaster response, once the disaster has occurred there is little time for contemplation. Therefore, disaster response plans should include guidelines for providers on how to ensure safety in the care they provide.

Disaster response issues must be dealt with proactively because resources cannot be diverted to these issues in the thick of emergency response. Some organizations and providers have experience with disaster response and can provide guidance. A major goal of medical relief organizations is to provide relief for fatigued providers. When relief is not available and not likely to arrive soon, providers should be encouraged to self-impose sleep periods despite the apparent urgency of the situations they face. Urging providers to ensure that they eat at least twice and sleep for two to four hours in any 24-hour period is a reasonable limit on the physical activity of providers.

Providers and patients need to understand that this is essential to ensure that providers are capable of giving safe care in a sustained fashion. Emergency responders must maintain adequate perspective on their own abilities and patients’ needs to ensure that unnecessary risks are not undertaken nor avoidable injures inflicted. Importantly, these limitations should not be legislated or imposed externally, but should be defined by the profession and self-enforced by providers.

There have been significant discussion of what aspects of the U.S. system of response to large-scale disasters need to be improved. The Katrina disaster has given us the opportunity to enhance essential response mechanisms, whether the cause of the disaster is natural, infectious, or terrorist. A good disaster plan takes steps to ensure availability of care, but also to ensure that the care is as ethical, safe and effective as possible.

References

1. Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA. Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. JAMA. 2005;294(9):1025-1033.
2. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Eng J Med. 2004;351(18):1838-1848.
3. Hyland, et al. Federal, State Regulations Relaxed for Providers Affected by Hurricane. BNA Health Law Reporter. 2005;15(36):1190-1191.
4. Gostin, LO, Model State Emergency Health Powers Act, §608 Licensing and Appointment of Health Care Personnel, December 21, 2001. Available at www.publichealthlaw.net/MSEHPA/MSEHPA2.pdf. Last accessed Dec. 1, 2005.
5. La. R.S. 29:656 (2005).

FROM THE PUBLIC POLICY COMMITTEE

Make a Positive Difference in the Politics of Healthcare

SHM to sponsor Legislative Advocacy Day on May 3

By Eric Siegal, MD, committee chair

“The stakes are too high for government to be a spectator sport.”

—Barbara Jordan, former U.S. Congresswoman

SHM is taking advantage of its 2006 annual meeting location in Washington, D.C., and sponsoring its first Legislative Advocacy Day on May 3. The Public Policy Committee is excited about the opportunity this initiative presents for hospitalists to learn more about how government really works and to speak with members of Congress about issues that are vital to patient care and clinical practice.

Are you concerned about continued Medicare cuts? Worried about how pending pay-for-performance legislation will affect hospitalists? SHM members registering for Advocacy Day will meet with their members of Congress and staff to discuss these and other important issues affecting hospital medicine.

I encourage you to register for Advocacy Day. There is no better way to influence how health policy is made in Washington than by meeting directly with your elected officials and their staffs. Lawmakers need constituent input to be effective legislators. Whether your legislator is a newly elected representative or a veteran senator with years of experience, he or she wants—and needs—to hear what you have to say about issues under consideration by the U.S. Congress, particularly in an election year. Input from their constituents always receives attention and consideration and can frequently make the difference in the way a lawmaker votes. Who better to educate members of Congress on changes to Medicare than the physicians directly involved in caring for the program’s beneficiaries?

We will give you the tools and information you need to make the most of your meetings on Capitol Hill. Legislative appointments will be scheduled by SHM as part of the registration process. SHM members will be grouped together by congressional district for House meetings and by state for Senate meetings and each registrant will have a minimum of three Hill appointments. To familiarize you with SHM’s legislative objectives for the second session of the 109th Congress, Laura Allendorf, SHM’s Washington representative, and I will conduct a pre-visit breakfast briefing from 7 a.m. to 8:30 a.m. on May 3. This briefing will cover procedural tips on how to have a successful meeting and update you on the status of the key health issues you will be discussing while on Capitol Hill. These meetings will take place from 9 a.m. to 5 p.m. that day.

Join us on May 3 and help educate members of Congress about the unique role hospitalists play in the delivery of medical care in our nation’s hospitals. We hope Advocacy Day will be the start of regular contact by hospitalists with their elected representatives in Washington.

FROM THE PEDIATRICS COMMITTEE

CME, Pediatric Core Curriculum on the Horizon

Multiple initiatives keep committee active

The Pediatric Committee at SHM is both the center of pediatric activity within SHM and a clearinghouse for SHM committee and task force activity as it relates to pediatrics.

The major pediatric activity in SHM continues to be CME activities and the Pediatric Core Curriculum. The dramatic success of the Pediatric Hospital Medicine Meeting was documented in the October issue of The Hospitalist (p. 33.)

Evaluations of the meeting overwhelmingly favored staging a three- to four-day Pediatric Hospital Medicine meeting on an annual basis during the late summer as a stand-alone meeting, with sponsorship rotating among SHM, the AAP, and the APA. There was insufficient lead time to offer a comprehensive meeting in 2006, but a meeting is scheduled for 2007 sponsored by AAP, with SHM taking the lead in 2008. More information to follow both in the SHM online discussion communities and through these committee reports.

The Pediatric Core Curriculum is nearly complete and should be at the review stage by early 2006. This curriculum is modeled after the adult core curriculum. It will serve as a framework for residency and fellowship directors, as well as a basis for the topics addressed at the Pediatric Hospital Medicine Meetings. Thanks to Tim Cornell, MD, Dan Rauch, MD, and all the authors and editors who have contributed to this work.

We will offer a full pediatric track in May at the SHM Annual Meeting in Washington, D.C., as we have in prior years. Registration is available online. Meetings of both the Pediatric Committee and the Pediatric Forum will be held during the meeting. This year’s meeting immediately precedes the PAS Meetings in San Francisco, and we encourage you to plan early so that at least one member of your program is able to attend the SHM Meeting. Once the Pediatric Hospital Medicine Meetings are held on an annual basis, we will need to decide how to balance SHM meeting offerings between the summer stand-alone Denver meeting and the SHM Annual Meeting.

The second function of Pediatric Committee involves having pediatric representatives on the various SHM committees and task forces report on their individual group’s activities, particularly as it relates to pediatrics. This keeps the broader group of pediatric leadership within SHM informed about the society’s global picture. SHM is committed to having a pediatric representative on each committee. You never know when or where an important issue for pediatricians may arise. Even geriatrics overlaps with pediatrics with regard to both family-centered care and proxy decision-makers.

Major endeavors at this point include the activities of the Benchmark and Career Satisfaction groups. SHM continues to make a strong effort to collect and generate data for workload and compensation, and to provide specific “pediatric only” subsets. Efforts regarding credentialing, sub-specialty designation/certification, and board re-certification are an active focus of SHM for adult hospitalists with ongoing discussions with the Board of Internal Medicine. We pediatricians stand on the sidelines of this battle, with the expectation that once the adults figure out how to do it, we can modify their approach with lower casualties on both sides.

The clinical Resource Rooms on the SHM Web site are clearly targeted toward adult topics. We intend to develop similar resources for pediatrics and are exploring possibilities of doing this collaboratively with the AAP and the APA. Sub-committees on pediatric hospital medicine topics are developing under a loose and shared structure with the AAP’s Section on Hospital Medicine. For example, SHM has taken the lead on a palliative care task force. Maggie Hood is the pediatric representative to this task force and wants to involve other interested pediatric hospitalists in a sub-committee on this topic. The AAP’s Karen Kingry has taken the lead on developing a sub-committee for community (pediatric) hospitalists; membership on her committee is open to SHM members. Expect other topics to develop as well.

If you have any comments, feedback or suggestions for the SHM Pediatric Committee, please contact co-chairs, David Zipes ([email protected]) or Jack Percelay ([email protected]). TH

Most healthcare providers are inexperienced in caring for people in disasters. However, in a national disaster that hinders mobility both into and out of an affected area, available skilled personnel are limited. A disaster response asks more of the scarce manpower: Providers must work longer hours and extend their customary scope of expertise to aid the largest number of victims. While these mandates are designed to maximize the care provided, the emotional and physical burdens on providers and victims in these circumstances are significant, and it is important that we remember the fundamental duty to prevent unnecessary harm in the provision of healthcare.

Should healthcare providers be held to different standards in times of disaster? If so, what are acceptable limits to disaster care, and what ethical dilemmas result during such exceptional times?

Unique Circumstances Call for Unique Standards of Care

Standards in a variety of areas differ in the face of a large-scale disaster, but the fact that standards must change to accommodate the circumstances does not mean that they cease to exist entirely. In the event of a large-scale disaster where populations become isolated and no new resources will arrive in the immediate future, the risks of inaction are magnified and we accept a higher risk resulting from relief action. When only one doctor is available, that doctor is obligated to provide whatever care he or she can to whoever is in need.

When the alternative is that no help will be given, any able doctor should provide whatever help they can. However, there are limits to this responsibility. Greater risks may be justified, and standards may be different, but physicians’ fundamental duties to patients are unchanged and avoidable mistakes causing injuries still need to be prevented. The basic duties of beneficence and non-malfeasance must still guide physician behavior, and the reality of the circumstances in disaster response favors pre-emptive determination on the safety limits that physicians should observe in providing disaster assistance.

Disasters inherently influence doctors to both continue to provide care when they are impaired by sleep or grief and to provide care that under other circumstances they would consider their experience inadequate to undertake. These are realities of disaster response, and all skilled personnel can and should exceed the limits that normally exist in a fully functional system with adequate resources. However, at some point a doctor becomes too impaired or too inexperienced to provide care to patients—even if no one else is available. Doctors are neither trained nor encouraged to weigh the global risks and benefits in this manner; in fact, we are trained to push ourselves beyond our reasonable limits even when absolute scarcity of resources isn’t an issue. People are quite willing to compromise their own comfort and safety in the event of a disaster, but there comes a point at which they may do more harm than good.

There is extensive evidence that sleep deprivation impairs judgment and performance in the medical setting.1-2 Despite the fact that standards change in emergencies and greater risk must be undertaken by both providers and victims, there must still be safety limits. At some point a doctor becomes so sleep deprived that he or she is more dangerous providing care than leaving people entirely without a provider, and further may have impaired judgment on the severity of the various conditions they are facing and the reasonable limits on their expertise. This problem is inherent to the setting. How much risk should doctors subject patients to? In the face of a life-threatening condition should a completely inexperienced physician undertake care? What if the doctor is mistaken as to the severity of the illness or the proper response to it?

In response to Hurricane Katrina, state and national regulatory agencies had to create emergency exceptions to licensing regulations and to HIPAA and EMTALA requirements in order to facilitate patient care.3 Both the Model State Emergency Health Powers Act (legislation designed to serve as template for states to use to create emergency health response mechanisms) and the Louisiana legislation that governed provision of medical care in a state of emergency limit liability of any provider assisting in an emergency.4-5 Providers assisting in an emergency will not be held liable for any injury resulting from action or inaction except for intentional or grossly negligent acts or omissions. Such limitation of liability is essential to ensure that all available resources are utilized in an emergency. However, given that patients will have limited remedies for injuries caused, it is increasingly important to proactively define limitations on provider activity during emergencies. Because other remedies and regulatory structures are relaxed, ethical self-regulation becomes increasingly important.

The first priority in emergency disaster response must be ensuring that providers are available and do not encounter unnecessary barriers to providing care to ill or injured patients. However, a secondary goal must be ensuring that the safest and most effective care is provided under the circumstances. As with many things in disaster response, once the disaster has occurred there is little time for contemplation. Therefore, disaster response plans should include guidelines for providers on how to ensure safety in the care they provide.

Disaster response issues must be dealt with proactively because resources cannot be diverted to these issues in the thick of emergency response. Some organizations and providers have experience with disaster response and can provide guidance. A major goal of medical relief organizations is to provide relief for fatigued providers. When relief is not available and not likely to arrive soon, providers should be encouraged to self-impose sleep periods despite the apparent urgency of the situations they face. Urging providers to ensure that they eat at least twice and sleep for two to four hours in any 24-hour period is a reasonable limit on the physical activity of providers.

Providers and patients need to understand that this is essential to ensure that providers are capable of giving safe care in a sustained fashion. Emergency responders must maintain adequate perspective on their own abilities and patients’ needs to ensure that unnecessary risks are not undertaken nor avoidable injures inflicted. Importantly, these limitations should not be legislated or imposed externally, but should be defined by the profession and self-enforced by providers.

There have been significant discussion of what aspects of the U.S. system of response to large-scale disasters need to be improved. The Katrina disaster has given us the opportunity to enhance essential response mechanisms, whether the cause of the disaster is natural, infectious, or terrorist. A good disaster plan takes steps to ensure availability of care, but also to ensure that the care is as ethical, safe and effective as possible.

References

1. Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA. Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. JAMA. 2005;294(9):1025-1033.
2. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Eng J Med. 2004;351(18):1838-1848.
3. Hyland, et al. Federal, State Regulations Relaxed for Providers Affected by Hurricane. BNA Health Law Reporter. 2005;15(36):1190-1191.
4. Gostin, LO, Model State Emergency Health Powers Act, §608 Licensing and Appointment of Health Care Personnel, December 21, 2001. Available at www.publichealthlaw.net/MSEHPA/MSEHPA2.pdf. Last accessed Dec. 1, 2005.
5. La. R.S. 29:656 (2005).

FROM THE PUBLIC POLICY COMMITTEE

Make a Positive Difference in the Politics of Healthcare

SHM to sponsor Legislative Advocacy Day on May 3

By Eric Siegal, MD, committee chair

“The stakes are too high for government to be a spectator sport.”

—Barbara Jordan, former U.S. Congresswoman

SHM is taking advantage of its 2006 annual meeting location in Washington, D.C., and sponsoring its first Legislative Advocacy Day on May 3. The Public Policy Committee is excited about the opportunity this initiative presents for hospitalists to learn more about how government really works and to speak with members of Congress about issues that are vital to patient care and clinical practice.

Are you concerned about continued Medicare cuts? Worried about how pending pay-for-performance legislation will affect hospitalists? SHM members registering for Advocacy Day will meet with their members of Congress and staff to discuss these and other important issues affecting hospital medicine.

I encourage you to register for Advocacy Day. There is no better way to influence how health policy is made in Washington than by meeting directly with your elected officials and their staffs. Lawmakers need constituent input to be effective legislators. Whether your legislator is a newly elected representative or a veteran senator with years of experience, he or she wants—and needs—to hear what you have to say about issues under consideration by the U.S. Congress, particularly in an election year. Input from their constituents always receives attention and consideration and can frequently make the difference in the way a lawmaker votes. Who better to educate members of Congress on changes to Medicare than the physicians directly involved in caring for the program’s beneficiaries?

We will give you the tools and information you need to make the most of your meetings on Capitol Hill. Legislative appointments will be scheduled by SHM as part of the registration process. SHM members will be grouped together by congressional district for House meetings and by state for Senate meetings and each registrant will have a minimum of three Hill appointments. To familiarize you with SHM’s legislative objectives for the second session of the 109th Congress, Laura Allendorf, SHM’s Washington representative, and I will conduct a pre-visit breakfast briefing from 7 a.m. to 8:30 a.m. on May 3. This briefing will cover procedural tips on how to have a successful meeting and update you on the status of the key health issues you will be discussing while on Capitol Hill. These meetings will take place from 9 a.m. to 5 p.m. that day.

Join us on May 3 and help educate members of Congress about the unique role hospitalists play in the delivery of medical care in our nation’s hospitals. We hope Advocacy Day will be the start of regular contact by hospitalists with their elected representatives in Washington.

FROM THE PEDIATRICS COMMITTEE

CME, Pediatric Core Curriculum on the Horizon

Multiple initiatives keep committee active

The Pediatric Committee at SHM is both the center of pediatric activity within SHM and a clearinghouse for SHM committee and task force activity as it relates to pediatrics.

The major pediatric activity in SHM continues to be CME activities and the Pediatric Core Curriculum. The dramatic success of the Pediatric Hospital Medicine Meeting was documented in the October issue of The Hospitalist (p. 33.)

Evaluations of the meeting overwhelmingly favored staging a three- to four-day Pediatric Hospital Medicine meeting on an annual basis during the late summer as a stand-alone meeting, with sponsorship rotating among SHM, the AAP, and the APA. There was insufficient lead time to offer a comprehensive meeting in 2006, but a meeting is scheduled for 2007 sponsored by AAP, with SHM taking the lead in 2008. More information to follow both in the SHM online discussion communities and through these committee reports.

The Pediatric Core Curriculum is nearly complete and should be at the review stage by early 2006. This curriculum is modeled after the adult core curriculum. It will serve as a framework for residency and fellowship directors, as well as a basis for the topics addressed at the Pediatric Hospital Medicine Meetings. Thanks to Tim Cornell, MD, Dan Rauch, MD, and all the authors and editors who have contributed to this work.

We will offer a full pediatric track in May at the SHM Annual Meeting in Washington, D.C., as we have in prior years. Registration is available online. Meetings of both the Pediatric Committee and the Pediatric Forum will be held during the meeting. This year’s meeting immediately precedes the PAS Meetings in San Francisco, and we encourage you to plan early so that at least one member of your program is able to attend the SHM Meeting. Once the Pediatric Hospital Medicine Meetings are held on an annual basis, we will need to decide how to balance SHM meeting offerings between the summer stand-alone Denver meeting and the SHM Annual Meeting.

The second function of Pediatric Committee involves having pediatric representatives on the various SHM committees and task forces report on their individual group’s activities, particularly as it relates to pediatrics. This keeps the broader group of pediatric leadership within SHM informed about the society’s global picture. SHM is committed to having a pediatric representative on each committee. You never know when or where an important issue for pediatricians may arise. Even geriatrics overlaps with pediatrics with regard to both family-centered care and proxy decision-makers.

Major endeavors at this point include the activities of the Benchmark and Career Satisfaction groups. SHM continues to make a strong effort to collect and generate data for workload and compensation, and to provide specific “pediatric only” subsets. Efforts regarding credentialing, sub-specialty designation/certification, and board re-certification are an active focus of SHM for adult hospitalists with ongoing discussions with the Board of Internal Medicine. We pediatricians stand on the sidelines of this battle, with the expectation that once the adults figure out how to do it, we can modify their approach with lower casualties on both sides.

The clinical Resource Rooms on the SHM Web site are clearly targeted toward adult topics. We intend to develop similar resources for pediatrics and are exploring possibilities of doing this collaboratively with the AAP and the APA. Sub-committees on pediatric hospital medicine topics are developing under a loose and shared structure with the AAP’s Section on Hospital Medicine. For example, SHM has taken the lead on a palliative care task force. Maggie Hood is the pediatric representative to this task force and wants to involve other interested pediatric hospitalists in a sub-committee on this topic. The AAP’s Karen Kingry has taken the lead on developing a sub-committee for community (pediatric) hospitalists; membership on her committee is open to SHM members. Expect other topics to develop as well.

If you have any comments, feedback or suggestions for the SHM Pediatric Committee, please contact co-chairs, David Zipes ([email protected]) or Jack Percelay ([email protected]). TH