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Responding to the heroin epidemic one patient at a time
Once regarded as a curse of the urban poor, heroin now has a stronghold on many suburban, middle class communities.I was stunned to learn that heroin use is so prevalent in the quiet Baltimore suburb where I work that our local police officers carry Narcan kits. Use has become so ubiquitous in our country that U.S. Attorney General Eric Holder has said law enforcement officials should consider carrying heroin’s antidote. From Smalltown U.S.A. to booming metropolises, this inexpensive narcotic is wreaking havoc on individuals and their families.
Sure, I admit an occasional patient with "a history of heroin abuse" who takes methadone. Rarely, I may see physical evidence of heroin use. But in most cases, patients who use heroin present as overdose cases in the ED, where they are discharged home when they are stable or admitted directly to the intensive care unit. Sadly, I recently received from the ICU a transfer of a heroin overdose patient – a handsome young man in his 20s, his entire life ahead of him, loving parents and siblings at his bedside. He was completely oblivious to everything around him – comatose, on hospice, dying before he had a real chance to live.
There was nothing I could do for him or his family other than to provide comfort. But perhaps I can do more for future potential overdose victims. You know, the heroin users admitted for a skin abscess after missing a vein or for DKA because they were too high to remember to take their insulin. Yes, we are busy; but we need to take 5-10 minutes to address the issue, to listen to the user’s story and encourage them, uplift them. Substance abuse counselors are invaluable, but by taking the time to care about our patients as individuals, hospitalists might just be the straw to break the camel’s back of heroin use for someone. Considering that most heroin addicts these days are young adults, a 10 minute investment of our time now may help buy those patients back another 40 or 50 years of their lives.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
Once regarded as a curse of the urban poor, heroin now has a stronghold on many suburban, middle class communities.I was stunned to learn that heroin use is so prevalent in the quiet Baltimore suburb where I work that our local police officers carry Narcan kits. Use has become so ubiquitous in our country that U.S. Attorney General Eric Holder has said law enforcement officials should consider carrying heroin’s antidote. From Smalltown U.S.A. to booming metropolises, this inexpensive narcotic is wreaking havoc on individuals and their families.
Sure, I admit an occasional patient with "a history of heroin abuse" who takes methadone. Rarely, I may see physical evidence of heroin use. But in most cases, patients who use heroin present as overdose cases in the ED, where they are discharged home when they are stable or admitted directly to the intensive care unit. Sadly, I recently received from the ICU a transfer of a heroin overdose patient – a handsome young man in his 20s, his entire life ahead of him, loving parents and siblings at his bedside. He was completely oblivious to everything around him – comatose, on hospice, dying before he had a real chance to live.
There was nothing I could do for him or his family other than to provide comfort. But perhaps I can do more for future potential overdose victims. You know, the heroin users admitted for a skin abscess after missing a vein or for DKA because they were too high to remember to take their insulin. Yes, we are busy; but we need to take 5-10 minutes to address the issue, to listen to the user’s story and encourage them, uplift them. Substance abuse counselors are invaluable, but by taking the time to care about our patients as individuals, hospitalists might just be the straw to break the camel’s back of heroin use for someone. Considering that most heroin addicts these days are young adults, a 10 minute investment of our time now may help buy those patients back another 40 or 50 years of their lives.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
Once regarded as a curse of the urban poor, heroin now has a stronghold on many suburban, middle class communities.I was stunned to learn that heroin use is so prevalent in the quiet Baltimore suburb where I work that our local police officers carry Narcan kits. Use has become so ubiquitous in our country that U.S. Attorney General Eric Holder has said law enforcement officials should consider carrying heroin’s antidote. From Smalltown U.S.A. to booming metropolises, this inexpensive narcotic is wreaking havoc on individuals and their families.
Sure, I admit an occasional patient with "a history of heroin abuse" who takes methadone. Rarely, I may see physical evidence of heroin use. But in most cases, patients who use heroin present as overdose cases in the ED, where they are discharged home when they are stable or admitted directly to the intensive care unit. Sadly, I recently received from the ICU a transfer of a heroin overdose patient – a handsome young man in his 20s, his entire life ahead of him, loving parents and siblings at his bedside. He was completely oblivious to everything around him – comatose, on hospice, dying before he had a real chance to live.
There was nothing I could do for him or his family other than to provide comfort. But perhaps I can do more for future potential overdose victims. You know, the heroin users admitted for a skin abscess after missing a vein or for DKA because they were too high to remember to take their insulin. Yes, we are busy; but we need to take 5-10 minutes to address the issue, to listen to the user’s story and encourage them, uplift them. Substance abuse counselors are invaluable, but by taking the time to care about our patients as individuals, hospitalists might just be the straw to break the camel’s back of heroin use for someone. Considering that most heroin addicts these days are young adults, a 10 minute investment of our time now may help buy those patients back another 40 or 50 years of their lives.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
The ACA Is a Call to Do Better
By now, anyone who isn't vacationing off the grid in a remote tropical paradise probably knows that the U.S. Supreme Court upheld the Affordable Care Act. Within hours of the court’s announcement, there were already fresh plans underway to repeal the hotly contested health care reform law signed by President Obama in March 2010. Nevertheless, for now, it is law and it will impact millions of patients, as well as the doctors and hospitals that serve them.
In February 2011, Dr. Donald M. Berwick, then Centers for Medicare and Medicaid Services chief, pointed out to the House Committee on Ways and Means that millions of Americans were already benefiting from this law, while many major provisions had not even kicked in yet. While we can all agree that the law is not perfect, what is? Most of us can find something very positive about the ACA.
Many changes are on the horizon – changes that will impact hospitalists significantly.
One important goal of the ACA is to reduce waste in the system. Although there are various ways by which this is projected to occur, one of the most meaningful for hospitalists is the scrutiny of Hospital-Acquired Conditions (HACs). Under the Affordable Care Act, hospitals whose HAC rate is significantly higher than average will receive reduced payments.
When I first learned about this provision and the financial penalty for excess HACs, I thought it was unreasonable. Can we realistically prevent every catheter-related UTI and pressure ulcer in our patients? No, but through more rigid surveillance, we can dramatically decrease their incidence, and we (and our patients) cannot afford for this to be taken lightly. The Centers for Disease Control and Prevention estimates that 100,000 Americans die from hospital-acquired infections, and millions more suffer, adding tens billions of dollars to hospital costs yearly. Those numbers are staggering!
Another component of the ACA is to link financial incentives to readmission rates, as an estimated 20% of Medicare beneficiaries are readmitted within 30 days of discharge. Although some readmissions may be unpreventable (such as some patients with end-stage chronic obstructive pulmonary disease), others may be preventable. For instance, if patients see their primary care provider (PCP) within a couple of days of discharge, and again soon thereafter, the PCP may be able to spot and treat a downward decline that would otherwise culminate in a readmission.
The teachable moment this time is for hospitalists, more so than for our patients. We have plenty to learn in pursuit of our very best, but with the help of innovative hospital administrators, medical directors, and our own ingenuity, we can make tremendous strides helping the patients whom we serve and improving the U.S. health care system as a whole.
This column, "Teachable Moments," regularly appears in Hospitalist News, an Elsevier publication. Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.
By now, anyone who isn't vacationing off the grid in a remote tropical paradise probably knows that the U.S. Supreme Court upheld the Affordable Care Act. Within hours of the court’s announcement, there were already fresh plans underway to repeal the hotly contested health care reform law signed by President Obama in March 2010. Nevertheless, for now, it is law and it will impact millions of patients, as well as the doctors and hospitals that serve them.
In February 2011, Dr. Donald M. Berwick, then Centers for Medicare and Medicaid Services chief, pointed out to the House Committee on Ways and Means that millions of Americans were already benefiting from this law, while many major provisions had not even kicked in yet. While we can all agree that the law is not perfect, what is? Most of us can find something very positive about the ACA.
Many changes are on the horizon – changes that will impact hospitalists significantly.
One important goal of the ACA is to reduce waste in the system. Although there are various ways by which this is projected to occur, one of the most meaningful for hospitalists is the scrutiny of Hospital-Acquired Conditions (HACs). Under the Affordable Care Act, hospitals whose HAC rate is significantly higher than average will receive reduced payments.
When I first learned about this provision and the financial penalty for excess HACs, I thought it was unreasonable. Can we realistically prevent every catheter-related UTI and pressure ulcer in our patients? No, but through more rigid surveillance, we can dramatically decrease their incidence, and we (and our patients) cannot afford for this to be taken lightly. The Centers for Disease Control and Prevention estimates that 100,000 Americans die from hospital-acquired infections, and millions more suffer, adding tens billions of dollars to hospital costs yearly. Those numbers are staggering!
Another component of the ACA is to link financial incentives to readmission rates, as an estimated 20% of Medicare beneficiaries are readmitted within 30 days of discharge. Although some readmissions may be unpreventable (such as some patients with end-stage chronic obstructive pulmonary disease), others may be preventable. For instance, if patients see their primary care provider (PCP) within a couple of days of discharge, and again soon thereafter, the PCP may be able to spot and treat a downward decline that would otherwise culminate in a readmission.
The teachable moment this time is for hospitalists, more so than for our patients. We have plenty to learn in pursuit of our very best, but with the help of innovative hospital administrators, medical directors, and our own ingenuity, we can make tremendous strides helping the patients whom we serve and improving the U.S. health care system as a whole.
This column, "Teachable Moments," regularly appears in Hospitalist News, an Elsevier publication. Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.
By now, anyone who isn't vacationing off the grid in a remote tropical paradise probably knows that the U.S. Supreme Court upheld the Affordable Care Act. Within hours of the court’s announcement, there were already fresh plans underway to repeal the hotly contested health care reform law signed by President Obama in March 2010. Nevertheless, for now, it is law and it will impact millions of patients, as well as the doctors and hospitals that serve them.
In February 2011, Dr. Donald M. Berwick, then Centers for Medicare and Medicaid Services chief, pointed out to the House Committee on Ways and Means that millions of Americans were already benefiting from this law, while many major provisions had not even kicked in yet. While we can all agree that the law is not perfect, what is? Most of us can find something very positive about the ACA.
Many changes are on the horizon – changes that will impact hospitalists significantly.
One important goal of the ACA is to reduce waste in the system. Although there are various ways by which this is projected to occur, one of the most meaningful for hospitalists is the scrutiny of Hospital-Acquired Conditions (HACs). Under the Affordable Care Act, hospitals whose HAC rate is significantly higher than average will receive reduced payments.
When I first learned about this provision and the financial penalty for excess HACs, I thought it was unreasonable. Can we realistically prevent every catheter-related UTI and pressure ulcer in our patients? No, but through more rigid surveillance, we can dramatically decrease their incidence, and we (and our patients) cannot afford for this to be taken lightly. The Centers for Disease Control and Prevention estimates that 100,000 Americans die from hospital-acquired infections, and millions more suffer, adding tens billions of dollars to hospital costs yearly. Those numbers are staggering!
Another component of the ACA is to link financial incentives to readmission rates, as an estimated 20% of Medicare beneficiaries are readmitted within 30 days of discharge. Although some readmissions may be unpreventable (such as some patients with end-stage chronic obstructive pulmonary disease), others may be preventable. For instance, if patients see their primary care provider (PCP) within a couple of days of discharge, and again soon thereafter, the PCP may be able to spot and treat a downward decline that would otherwise culminate in a readmission.
The teachable moment this time is for hospitalists, more so than for our patients. We have plenty to learn in pursuit of our very best, but with the help of innovative hospital administrators, medical directors, and our own ingenuity, we can make tremendous strides helping the patients whom we serve and improving the U.S. health care system as a whole.
This column, "Teachable Moments," regularly appears in Hospitalist News, an Elsevier publication. Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.
Insulin-Pump Therapy: No Need to Fear It
If you are like I am (or used to be), the thought of an insulin pump injecting insulin continuously into my patients can be quite scary.
What if the patient was sick or distracted and didn't eat as much as she should have? Wouldn't she be at risk for going into a hypoglycemic coma in the middle of the night when no one would even notice? When the nurses did their early morning rounds, if there were no reason to awaken the patient for meds or blood draws, wouldn't they just document "patient resting comfortably," never realizing that the patient was teetering between life and death with a blood sugar level of 15? Wouldn't it just be easier to simply turn the pump off during an acute hospitalization?
These and many other questions have raced through my mind many times as I contemplated patients using insulin pumps. Though insulin-pump therapy was introduced over 3 decades ago, it still concerns me. As with anything, I suppose, it is a lack of familiarity with writing insulin pump orders, though my lack of experience does not negate the potential beneficial effects for my patients. Fortunately, at my institution endocrinologists write the insulin pump orders, period. So there is no chance that an inexperienced physician writes an inappropriate order (and I am most grateful for this). Nevertheless, it is important for me, and other hospitalists, to have a certain level of comfort with continuous insulin therapy for the benefit of our patients, both short term and long term.
A landmark study, the DCCT (Diabetes Control and Complications Trial), proved beyond a shadow of a doubt that the most dreaded complications of Type 1 diabetes were closely linked to blood sugar levels. Specifically, the DCCT demonstrated that intensive blood glucose control reduces the risk of diabetic retinopathy by 76%, diabetic neuropathy by 60%, and diabetic nephropathy by 50%, all very impressive reductions.
However, as practicing clinicians, we know that intensive blood glucose control comes with the potential risk of serious hypoglycemic events, especially in those patients who have hypoglycemic unawareness and may be oblivious to the fact that their blood sugar level has fallen to a dangerous level. Managing glucose levels in the hospital setting can be a particularly daunting task considering that the drugs we use, particularly steroids, can have drastic effects on blood sugar.
Nevertheless, maintaining blood glucose levels in an acceptable range during an acute illness can mean the difference between a great outcome and a horrific one. So, what can hospitalists do to improve both the acute and long-term outcomes for our patients?
A recent article in the New England Journal of Medicine titled "Insulin-Pump Therapy for Type 1 Diabetes Mellitus," has certainly helped to assuage some of my fears. My main fear of the pump, namely, hypoglycemia, was actually shown to occur much more often with multiple daily insulin injections than with the insulin pump. As a matter of fact, "continued disabling hypoglycemia" while on multiple daily insulin injections is actually an indication to consider insulin-pump therapy (N. Engl. J. Med. 2012;366:1616-24).
In addition, several meta-analyses of randomized, controlled trials comparing insulin-pump therapy to multiple daily insulin injections found that the average glycated hemoglobin levels were not only lower with insulin-pump therapy, the amount of insulin it took to achieve these levels was 10-20% lower than that used by individuals with higher glycated hemoglobin levels who were taking multiple daily injections.
While insulin-pump therapy is rarely, if ever, initiated in the hospital setting, we can still make recommendations for patients and their primary care physicians.
Routinely checking glycated hemoglobin levels on our diabetic patients and taking a good history regarding their home blood sugar readings may spark us to educate patients about the potential benefits of insulin-pump therapy after discharge. We may be prompted to include a brief recommendation for the primary care physician to consider referral for this modality as an outpatient. Doing so may just prevent some of our patients from presenting to the hospital years later with end-stage renal disease.
Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.
If you are like I am (or used to be), the thought of an insulin pump injecting insulin continuously into my patients can be quite scary.
What if the patient was sick or distracted and didn't eat as much as she should have? Wouldn't she be at risk for going into a hypoglycemic coma in the middle of the night when no one would even notice? When the nurses did their early morning rounds, if there were no reason to awaken the patient for meds or blood draws, wouldn't they just document "patient resting comfortably," never realizing that the patient was teetering between life and death with a blood sugar level of 15? Wouldn't it just be easier to simply turn the pump off during an acute hospitalization?
These and many other questions have raced through my mind many times as I contemplated patients using insulin pumps. Though insulin-pump therapy was introduced over 3 decades ago, it still concerns me. As with anything, I suppose, it is a lack of familiarity with writing insulin pump orders, though my lack of experience does not negate the potential beneficial effects for my patients. Fortunately, at my institution endocrinologists write the insulin pump orders, period. So there is no chance that an inexperienced physician writes an inappropriate order (and I am most grateful for this). Nevertheless, it is important for me, and other hospitalists, to have a certain level of comfort with continuous insulin therapy for the benefit of our patients, both short term and long term.
A landmark study, the DCCT (Diabetes Control and Complications Trial), proved beyond a shadow of a doubt that the most dreaded complications of Type 1 diabetes were closely linked to blood sugar levels. Specifically, the DCCT demonstrated that intensive blood glucose control reduces the risk of diabetic retinopathy by 76%, diabetic neuropathy by 60%, and diabetic nephropathy by 50%, all very impressive reductions.
However, as practicing clinicians, we know that intensive blood glucose control comes with the potential risk of serious hypoglycemic events, especially in those patients who have hypoglycemic unawareness and may be oblivious to the fact that their blood sugar level has fallen to a dangerous level. Managing glucose levels in the hospital setting can be a particularly daunting task considering that the drugs we use, particularly steroids, can have drastic effects on blood sugar.
Nevertheless, maintaining blood glucose levels in an acceptable range during an acute illness can mean the difference between a great outcome and a horrific one. So, what can hospitalists do to improve both the acute and long-term outcomes for our patients?
A recent article in the New England Journal of Medicine titled "Insulin-Pump Therapy for Type 1 Diabetes Mellitus," has certainly helped to assuage some of my fears. My main fear of the pump, namely, hypoglycemia, was actually shown to occur much more often with multiple daily insulin injections than with the insulin pump. As a matter of fact, "continued disabling hypoglycemia" while on multiple daily insulin injections is actually an indication to consider insulin-pump therapy (N. Engl. J. Med. 2012;366:1616-24).
In addition, several meta-analyses of randomized, controlled trials comparing insulin-pump therapy to multiple daily insulin injections found that the average glycated hemoglobin levels were not only lower with insulin-pump therapy, the amount of insulin it took to achieve these levels was 10-20% lower than that used by individuals with higher glycated hemoglobin levels who were taking multiple daily injections.
While insulin-pump therapy is rarely, if ever, initiated in the hospital setting, we can still make recommendations for patients and their primary care physicians.
Routinely checking glycated hemoglobin levels on our diabetic patients and taking a good history regarding their home blood sugar readings may spark us to educate patients about the potential benefits of insulin-pump therapy after discharge. We may be prompted to include a brief recommendation for the primary care physician to consider referral for this modality as an outpatient. Doing so may just prevent some of our patients from presenting to the hospital years later with end-stage renal disease.
Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.
If you are like I am (or used to be), the thought of an insulin pump injecting insulin continuously into my patients can be quite scary.
What if the patient was sick or distracted and didn't eat as much as she should have? Wouldn't she be at risk for going into a hypoglycemic coma in the middle of the night when no one would even notice? When the nurses did their early morning rounds, if there were no reason to awaken the patient for meds or blood draws, wouldn't they just document "patient resting comfortably," never realizing that the patient was teetering between life and death with a blood sugar level of 15? Wouldn't it just be easier to simply turn the pump off during an acute hospitalization?
These and many other questions have raced through my mind many times as I contemplated patients using insulin pumps. Though insulin-pump therapy was introduced over 3 decades ago, it still concerns me. As with anything, I suppose, it is a lack of familiarity with writing insulin pump orders, though my lack of experience does not negate the potential beneficial effects for my patients. Fortunately, at my institution endocrinologists write the insulin pump orders, period. So there is no chance that an inexperienced physician writes an inappropriate order (and I am most grateful for this). Nevertheless, it is important for me, and other hospitalists, to have a certain level of comfort with continuous insulin therapy for the benefit of our patients, both short term and long term.
A landmark study, the DCCT (Diabetes Control and Complications Trial), proved beyond a shadow of a doubt that the most dreaded complications of Type 1 diabetes were closely linked to blood sugar levels. Specifically, the DCCT demonstrated that intensive blood glucose control reduces the risk of diabetic retinopathy by 76%, diabetic neuropathy by 60%, and diabetic nephropathy by 50%, all very impressive reductions.
However, as practicing clinicians, we know that intensive blood glucose control comes with the potential risk of serious hypoglycemic events, especially in those patients who have hypoglycemic unawareness and may be oblivious to the fact that their blood sugar level has fallen to a dangerous level. Managing glucose levels in the hospital setting can be a particularly daunting task considering that the drugs we use, particularly steroids, can have drastic effects on blood sugar.
Nevertheless, maintaining blood glucose levels in an acceptable range during an acute illness can mean the difference between a great outcome and a horrific one. So, what can hospitalists do to improve both the acute and long-term outcomes for our patients?
A recent article in the New England Journal of Medicine titled "Insulin-Pump Therapy for Type 1 Diabetes Mellitus," has certainly helped to assuage some of my fears. My main fear of the pump, namely, hypoglycemia, was actually shown to occur much more often with multiple daily insulin injections than with the insulin pump. As a matter of fact, "continued disabling hypoglycemia" while on multiple daily insulin injections is actually an indication to consider insulin-pump therapy (N. Engl. J. Med. 2012;366:1616-24).
In addition, several meta-analyses of randomized, controlled trials comparing insulin-pump therapy to multiple daily insulin injections found that the average glycated hemoglobin levels were not only lower with insulin-pump therapy, the amount of insulin it took to achieve these levels was 10-20% lower than that used by individuals with higher glycated hemoglobin levels who were taking multiple daily injections.
While insulin-pump therapy is rarely, if ever, initiated in the hospital setting, we can still make recommendations for patients and their primary care physicians.
Routinely checking glycated hemoglobin levels on our diabetic patients and taking a good history regarding their home blood sugar readings may spark us to educate patients about the potential benefits of insulin-pump therapy after discharge. We may be prompted to include a brief recommendation for the primary care physician to consider referral for this modality as an outpatient. Doing so may just prevent some of our patients from presenting to the hospital years later with end-stage renal disease.
Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.