The Hospitalist

Fragmented, essentializing, simplistic. That’s how students at Perelman School of Medicine at the University of Pennsylvania, Philadelphia, described their required course on cultural competence. Lectures and discussions about cultural groups and communication issues weren’t providing them with the skills they needed to navigate doctor-patient relationships.

Courtesy Penn Medicine

Their criticism was a wake-up call that Horace Delisser, MD, associate dean for diversity and inclusion at the school, took to heart. He enlisted medical students to help reinvent the curriculum. The result, Introduction to Medicine and Society, launched in 2013 and described in an article published in 2017 (Acad Med. 2017;92[3]:335-43), emphasizes self-awareness and reflection about one’s own biases and the adoption of a less hierarchical and more respectful “other-oriented” approach to the patient relationship.

The course examines social determinants of health (SDHs) – the influences of society, government, culture, and health systems. Students analyze how health and health outcomes are affected by a patient’s income, education, and living and working conditions, as well as access to healthy food, safe water, and transportation.

The Perelman School of Medicine is just one of the many medical schools across the country that is revising training, both didactic and experiential, to teach students about SDHs. A host of policy makers, advisory groups, and organized medicine groups have called in recent years for educational efforts to boost all physicians’ working knowledge of health inequities and SDHs.

Dr. Delisser, associate professor of medicine who also practices as a pulmonologist at the Harron Lung Center in the Perelman Center for Advanced Medicine, said SDHs play into daily care.

Students driving practice change

Students nationally are “the most important” drivers of the increasing focus on SDHs in medical education, according to Dr. Fair. “They are demanding experiences to learn about the entire patient. We know that only 20% of a patient’s health is dependent on their health care. Our students are demanding education about the other 80%.”

More and more, communities are identifying needs and “students will then come up with initiatives to meet those needs,” Dr. Fair said.

Others interviewed for this story predicted this trend will only intensify, since not-for-profit hospitals are required under the Affordable Care Act regulations to assess community health needs every few years and to intervene accordingly.

Education on health care systems is also advancing. Penn State University, for instance, utilized a million-dollar grant from the AMA’s Accelerating Change in Medical Education initiative to design and implement a 4-year curriculum on the health system sciences that started in 2014. The curriculum includes an immersive experience in patient navigation.

“Students were taught to be patient navigators, and they were assigned within the clinical context to work on issues like, why are [patients] having trouble getting their medications?” said Susan E. Skochelak, MD, MPH, who leads the 6-year-old Accelerating Change initiative as vice president for medical education at the AMA.

From the start, she noted, students at Penn State are encouraged to question inequities, social and structural barriers to health, and faults in the health care system. “The message given at their white coat ceremony is ‘Welcome to medicine. Now that you’re here, you’re a member of the health care team, and we want you to speak up if you think there are things that need to be addressed. We want you to tell us when the system is working and not working,’ ” said Dr Skochelak, who previously served as the senior associate dean for academic affairs at the University of Wisconsin School of Medicine and Public Health, where she had been a tenured professor of family medicine.
 

Tomorrow’s physician partners

Approximately 80% of medical school graduates who participated in the AAMC’s 2018 survey of graduates said they had received significant training on health disparities—up from 71% in 2014.

“There’s a huge amount [of innovation] happening, but on the flip side, there’s not really a set of accepted tools and practices, and certainly no robust evaluation [of the training],” said Philip M. Alberti, PhD, senior director for health equity research and policy at the American Association of Medical Colleges. A recently published review (J Gen Intern Med. 2019;34[5]:720-30) shows growing interest in the teaching of SDHs in undergraduate medical education but variable content, strategies, and instructional practices.

Correction, 8/26/2019: An earlier version of this story misstated the title of Aletha Maybank, MD. Dr. Maybank's correct title is the first chief health equity officer of the American Medical Association.

Fragmented, essentializing, simplistic. That’s how students at Perelman School of Medicine at the University of Pennsylvania, Philadelphia, described their required course on cultural competence. Lectures and discussions about cultural groups and communication issues weren’t providing them with the skills they needed to navigate doctor-patient relationships.

Courtesy Penn Medicine

Their criticism was a wake-up call that Horace Delisser, MD, associate dean for diversity and inclusion at the school, took to heart. He enlisted medical students to help reinvent the curriculum. The result, Introduction to Medicine and Society, launched in 2013 and described in an article published in 2017 (Acad Med. 2017;92[3]:335-43), emphasizes self-awareness and reflection about one’s own biases and the adoption of a less hierarchical and more respectful “other-oriented” approach to the patient relationship.

The course examines social determinants of health (SDHs) – the influences of society, government, culture, and health systems. Students analyze how health and health outcomes are affected by a patient’s income, education, and living and working conditions, as well as access to healthy food, safe water, and transportation.

The Perelman School of Medicine is just one of the many medical schools across the country that is revising training, both didactic and experiential, to teach students about SDHs. A host of policy makers, advisory groups, and organized medicine groups have called in recent years for educational efforts to boost all physicians’ working knowledge of health inequities and SDHs.

Dr. Delisser, associate professor of medicine who also practices as a pulmonologist at the Harron Lung Center in the Perelman Center for Advanced Medicine, said SDHs play into daily care.

Students driving practice change

Students nationally are “the most important” drivers of the increasing focus on SDHs in medical education, according to Dr. Fair. “They are demanding experiences to learn about the entire patient. We know that only 20% of a patient’s health is dependent on their health care. Our students are demanding education about the other 80%.”

More and more, communities are identifying needs and “students will then come up with initiatives to meet those needs,” Dr. Fair said.

Others interviewed for this story predicted this trend will only intensify, since not-for-profit hospitals are required under the Affordable Care Act regulations to assess community health needs every few years and to intervene accordingly.

Education on health care systems is also advancing. Penn State University, for instance, utilized a million-dollar grant from the AMA’s Accelerating Change in Medical Education initiative to design and implement a 4-year curriculum on the health system sciences that started in 2014. The curriculum includes an immersive experience in patient navigation.

“Students were taught to be patient navigators, and they were assigned within the clinical context to work on issues like, why are [patients] having trouble getting their medications?” said Susan E. Skochelak, MD, MPH, who leads the 6-year-old Accelerating Change initiative as vice president for medical education at the AMA.

From the start, she noted, students at Penn State are encouraged to question inequities, social and structural barriers to health, and faults in the health care system. “The message given at their white coat ceremony is ‘Welcome to medicine. Now that you’re here, you’re a member of the health care team, and we want you to speak up if you think there are things that need to be addressed. We want you to tell us when the system is working and not working,’ ” said Dr Skochelak, who previously served as the senior associate dean for academic affairs at the University of Wisconsin School of Medicine and Public Health, where she had been a tenured professor of family medicine.
 

Tomorrow’s physician partners

Approximately 80% of medical school graduates who participated in the AAMC’s 2018 survey of graduates said they had received significant training on health disparities—up from 71% in 2014.

“There’s a huge amount [of innovation] happening, but on the flip side, there’s not really a set of accepted tools and practices, and certainly no robust evaluation [of the training],” said Philip M. Alberti, PhD, senior director for health equity research and policy at the American Association of Medical Colleges. A recently published review (J Gen Intern Med. 2019;34[5]:720-30) shows growing interest in the teaching of SDHs in undergraduate medical education but variable content, strategies, and instructional practices.

Correction, 8/26/2019: An earlier version of this story misstated the title of Aletha Maybank, MD. Dr. Maybank's correct title is the first chief health equity officer of the American Medical Association.

Fragmented, essentializing, simplistic. That’s how students at Perelman School of Medicine at the University of Pennsylvania, Philadelphia, described their required course on cultural competence. Lectures and discussions about cultural groups and communication issues weren’t providing them with the skills they needed to navigate doctor-patient relationships.

Courtesy Penn Medicine

Their criticism was a wake-up call that Horace Delisser, MD, associate dean for diversity and inclusion at the school, took to heart. He enlisted medical students to help reinvent the curriculum. The result, Introduction to Medicine and Society, launched in 2013 and described in an article published in 2017 (Acad Med. 2017;92[3]:335-43), emphasizes self-awareness and reflection about one’s own biases and the adoption of a less hierarchical and more respectful “other-oriented” approach to the patient relationship.

The course examines social determinants of health (SDHs) – the influences of society, government, culture, and health systems. Students analyze how health and health outcomes are affected by a patient’s income, education, and living and working conditions, as well as access to healthy food, safe water, and transportation.

The Perelman School of Medicine is just one of the many medical schools across the country that is revising training, both didactic and experiential, to teach students about SDHs. A host of policy makers, advisory groups, and organized medicine groups have called in recent years for educational efforts to boost all physicians’ working knowledge of health inequities and SDHs.

Dr. Delisser, associate professor of medicine who also practices as a pulmonologist at the Harron Lung Center in the Perelman Center for Advanced Medicine, said SDHs play into daily care.

Students driving practice change

Students nationally are “the most important” drivers of the increasing focus on SDHs in medical education, according to Dr. Fair. “They are demanding experiences to learn about the entire patient. We know that only 20% of a patient’s health is dependent on their health care. Our students are demanding education about the other 80%.”

More and more, communities are identifying needs and “students will then come up with initiatives to meet those needs,” Dr. Fair said.

Others interviewed for this story predicted this trend will only intensify, since not-for-profit hospitals are required under the Affordable Care Act regulations to assess community health needs every few years and to intervene accordingly.

Education on health care systems is also advancing. Penn State University, for instance, utilized a million-dollar grant from the AMA’s Accelerating Change in Medical Education initiative to design and implement a 4-year curriculum on the health system sciences that started in 2014. The curriculum includes an immersive experience in patient navigation.

“Students were taught to be patient navigators, and they were assigned within the clinical context to work on issues like, why are [patients] having trouble getting their medications?” said Susan E. Skochelak, MD, MPH, who leads the 6-year-old Accelerating Change initiative as vice president for medical education at the AMA.

From the start, she noted, students at Penn State are encouraged to question inequities, social and structural barriers to health, and faults in the health care system. “The message given at their white coat ceremony is ‘Welcome to medicine. Now that you’re here, you’re a member of the health care team, and we want you to speak up if you think there are things that need to be addressed. We want you to tell us when the system is working and not working,’ ” said Dr Skochelak, who previously served as the senior associate dean for academic affairs at the University of Wisconsin School of Medicine and Public Health, where she had been a tenured professor of family medicine.
 

Tomorrow’s physician partners

Approximately 80% of medical school graduates who participated in the AAMC’s 2018 survey of graduates said they had received significant training on health disparities—up from 71% in 2014.

“There’s a huge amount [of innovation] happening, but on the flip side, there’s not really a set of accepted tools and practices, and certainly no robust evaluation [of the training],” said Philip M. Alberti, PhD, senior director for health equity research and policy at the American Association of Medical Colleges. A recently published review (J Gen Intern Med. 2019;34[5]:720-30) shows growing interest in the teaching of SDHs in undergraduate medical education but variable content, strategies, and instructional practices.

Correction, 8/26/2019: An earlier version of this story misstated the title of Aletha Maybank, MD. Dr. Maybank's correct title is the first chief health equity officer of the American Medical Association.

The Centers for Disease Control and Prevention has updated its recommendation for serologic detection of Lyme disease, according to CDC investigators.

At the 1994 Second National Conference on Serologic Diagnosis of Lyme Disease, several groups and organizations convened, recommending a two-test methodology for Lyme disease detection. First, an enzyme immunoassay (EIA) or immunofluorescence assay should be used, followed by a western immunoblot assay for specimens yielding positive or equivocal results. The guideline advised that all future tests should be evaluated against a challenge panel, and that new assays should only move forward if their specificity, sensitivity, and precision equaled or surpassed the performance of tests used in the recommended two-test procedure.

On July 29, 2019, the Food and Drug Administration approved several Lyme disease serologic assays with new indications for use based on a modified two-test methodology, with a second EIA replacing the western immunoblot assay.

“Clearance by FDA of the new Lyme disease assays indicates that test performance has been evaluated and is ‘substantially equivalent to or better than’ a legally marketed predicate test,” the CDC investigators noted (MMWR Morb Mortal Wkly Rep. 2019 Aug 15;68(32):703).

The recommendation advises that FDA-cleared “serologic assays that utilize EIA rather than western immunoblot assay in a two-test format are acceptable alternatives for the laboratory diagnosis of Lyme disease.”

[email protected]

The Centers for Disease Control and Prevention has updated its recommendation for serologic detection of Lyme disease, according to CDC investigators.

At the 1994 Second National Conference on Serologic Diagnosis of Lyme Disease, several groups and organizations convened, recommending a two-test methodology for Lyme disease detection. First, an enzyme immunoassay (EIA) or immunofluorescence assay should be used, followed by a western immunoblot assay for specimens yielding positive or equivocal results. The guideline advised that all future tests should be evaluated against a challenge panel, and that new assays should only move forward if their specificity, sensitivity, and precision equaled or surpassed the performance of tests used in the recommended two-test procedure.

On July 29, 2019, the Food and Drug Administration approved several Lyme disease serologic assays with new indications for use based on a modified two-test methodology, with a second EIA replacing the western immunoblot assay.

“Clearance by FDA of the new Lyme disease assays indicates that test performance has been evaluated and is ‘substantially equivalent to or better than’ a legally marketed predicate test,” the CDC investigators noted (MMWR Morb Mortal Wkly Rep. 2019 Aug 15;68(32):703).

The recommendation advises that FDA-cleared “serologic assays that utilize EIA rather than western immunoblot assay in a two-test format are acceptable alternatives for the laboratory diagnosis of Lyme disease.”

[email protected]

The Centers for Disease Control and Prevention has updated its recommendation for serologic detection of Lyme disease, according to CDC investigators.

At the 1994 Second National Conference on Serologic Diagnosis of Lyme Disease, several groups and organizations convened, recommending a two-test methodology for Lyme disease detection. First, an enzyme immunoassay (EIA) or immunofluorescence assay should be used, followed by a western immunoblot assay for specimens yielding positive or equivocal results. The guideline advised that all future tests should be evaluated against a challenge panel, and that new assays should only move forward if their specificity, sensitivity, and precision equaled or surpassed the performance of tests used in the recommended two-test procedure.

On July 29, 2019, the Food and Drug Administration approved several Lyme disease serologic assays with new indications for use based on a modified two-test methodology, with a second EIA replacing the western immunoblot assay.

“Clearance by FDA of the new Lyme disease assays indicates that test performance has been evaluated and is ‘substantially equivalent to or better than’ a legally marketed predicate test,” the CDC investigators noted (MMWR Morb Mortal Wkly Rep. 2019 Aug 15;68(32):703).

The recommendation advises that FDA-cleared “serologic assays that utilize EIA rather than western immunoblot assay in a two-test format are acceptable alternatives for the laboratory diagnosis of Lyme disease.”

[email protected]

SEATTLE – Levine Children’s Hospital, in Charlotte, N.C., dropped its central line–associated bloodstream infection rate from 1.13 per 1,000 line days to 0.67 in just a few months, with a mix of common sense steps and public accountability.

M. Alexander Otto/MDedge News

Levine Children’s was at about the 50th percentile for CLABSIs, compared with other children’s hospitals, but dropped to the 10th percentile after the changes. There were 21 CLABSIs in 2017, but only 12 in 2018. The hospital went 6 straight months without a CLABSI after the changes were made. The efforts saved about $300,000 and 63 patient days.

“We really had great success,” said Kayla S. Koch, MD, a pediatric hospitalist at Levine Children’s, who presented the findings at Pediatric Hospital Medicine.

Hospital units had been working to reduce CLABSIs, but they were each doing their own thing. “Many of our units were already dabbling, so we just sort of brought them together. We standardized the process and got everyone on the same page,” said copresenter Ketan P. Nadkarni, MD, also a pediatric hospitalist at Levine Children’s.

It wasn’t hard to get buy-in. “I don’t think the units were aware that everyone was doing it differently,” and were on board once the problem was explained. Also, using the same approach throughout the hospital made it easier for nurses and physicians moving between units, he said.

Each morning, the nurse supervisor and patient nurse would partner up at the bedside to check that central venous lines were set up correctly. They examined the alcohol disinfectant caps to make sure they were clean; determined that children were getting chlorhexidine gluconate baths; checked the dressings for bleeding and soiling; noted in the electronic medical record why the patient had a central line; and discussed with hospitalists if it were still needed. Problems were addressed immediately.

These quality processes were all tracked on wall racks placed in plain sight on each unit, including the neonatal and pediatric ICUs. Each central line patient had a card that listed what needed to be done, with a green stripe on one side and a red stripe on the other. If everything was done right, the green side faced out; if even one thing was done wrong, the red side was displayed, for all to see. It brought accountability to the process, the presenters said at the meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

The wall rack also had the central line audit schedule, plus diagrams that showed every failed item, the reason for it, and the unit’s compliance rate. Anyone walking by could see at a glance how the unit was doing that day and overall.

The number of dressing options was reduced from 10 to 2, a SorbaView SHIELD and a Tegaderm-like dressing, which made it easier to standardize the efforts. A protocol also was put in place to reinforce oozing dressings, instead of automatically changing them. “We were doing too many changes,” Dr. Koch said.

Compliance with the bundle was almost 90%. Staff “really got into it, and it was great to see,” she said.

The “initial success was almost unexpected, and so dramatic.” The goal now is to sustain the improvements, and roll them out to radiology and other places were central lines are placed, Dr. Nadkarni said.

There was no external funding, and the investigators had no disclosures.

[email protected]

SEATTLE – Levine Children’s Hospital, in Charlotte, N.C., dropped its central line–associated bloodstream infection rate from 1.13 per 1,000 line days to 0.67 in just a few months, with a mix of common sense steps and public accountability.

M. Alexander Otto/MDedge News

Levine Children’s was at about the 50th percentile for CLABSIs, compared with other children’s hospitals, but dropped to the 10th percentile after the changes. There were 21 CLABSIs in 2017, but only 12 in 2018. The hospital went 6 straight months without a CLABSI after the changes were made. The efforts saved about $300,000 and 63 patient days.

“We really had great success,” said Kayla S. Koch, MD, a pediatric hospitalist at Levine Children’s, who presented the findings at Pediatric Hospital Medicine.

Hospital units had been working to reduce CLABSIs, but they were each doing their own thing. “Many of our units were already dabbling, so we just sort of brought them together. We standardized the process and got everyone on the same page,” said copresenter Ketan P. Nadkarni, MD, also a pediatric hospitalist at Levine Children’s.

It wasn’t hard to get buy-in. “I don’t think the units were aware that everyone was doing it differently,” and were on board once the problem was explained. Also, using the same approach throughout the hospital made it easier for nurses and physicians moving between units, he said.

Each morning, the nurse supervisor and patient nurse would partner up at the bedside to check that central venous lines were set up correctly. They examined the alcohol disinfectant caps to make sure they were clean; determined that children were getting chlorhexidine gluconate baths; checked the dressings for bleeding and soiling; noted in the electronic medical record why the patient had a central line; and discussed with hospitalists if it were still needed. Problems were addressed immediately.

These quality processes were all tracked on wall racks placed in plain sight on each unit, including the neonatal and pediatric ICUs. Each central line patient had a card that listed what needed to be done, with a green stripe on one side and a red stripe on the other. If everything was done right, the green side faced out; if even one thing was done wrong, the red side was displayed, for all to see. It brought accountability to the process, the presenters said at the meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

The wall rack also had the central line audit schedule, plus diagrams that showed every failed item, the reason for it, and the unit’s compliance rate. Anyone walking by could see at a glance how the unit was doing that day and overall.

The number of dressing options was reduced from 10 to 2, a SorbaView SHIELD and a Tegaderm-like dressing, which made it easier to standardize the efforts. A protocol also was put in place to reinforce oozing dressings, instead of automatically changing them. “We were doing too many changes,” Dr. Koch said.

Compliance with the bundle was almost 90%. Staff “really got into it, and it was great to see,” she said.

The “initial success was almost unexpected, and so dramatic.” The goal now is to sustain the improvements, and roll them out to radiology and other places were central lines are placed, Dr. Nadkarni said.

There was no external funding, and the investigators had no disclosures.

[email protected]

SEATTLE – Levine Children’s Hospital, in Charlotte, N.C., dropped its central line–associated bloodstream infection rate from 1.13 per 1,000 line days to 0.67 in just a few months, with a mix of common sense steps and public accountability.

M. Alexander Otto/MDedge News

Levine Children’s was at about the 50th percentile for CLABSIs, compared with other children’s hospitals, but dropped to the 10th percentile after the changes. There were 21 CLABSIs in 2017, but only 12 in 2018. The hospital went 6 straight months without a CLABSI after the changes were made. The efforts saved about $300,000 and 63 patient days.

“We really had great success,” said Kayla S. Koch, MD, a pediatric hospitalist at Levine Children’s, who presented the findings at Pediatric Hospital Medicine.

Hospital units had been working to reduce CLABSIs, but they were each doing their own thing. “Many of our units were already dabbling, so we just sort of brought them together. We standardized the process and got everyone on the same page,” said copresenter Ketan P. Nadkarni, MD, also a pediatric hospitalist at Levine Children’s.

It wasn’t hard to get buy-in. “I don’t think the units were aware that everyone was doing it differently,” and were on board once the problem was explained. Also, using the same approach throughout the hospital made it easier for nurses and physicians moving between units, he said.

Each morning, the nurse supervisor and patient nurse would partner up at the bedside to check that central venous lines were set up correctly. They examined the alcohol disinfectant caps to make sure they were clean; determined that children were getting chlorhexidine gluconate baths; checked the dressings for bleeding and soiling; noted in the electronic medical record why the patient had a central line; and discussed with hospitalists if it were still needed. Problems were addressed immediately.

These quality processes were all tracked on wall racks placed in plain sight on each unit, including the neonatal and pediatric ICUs. Each central line patient had a card that listed what needed to be done, with a green stripe on one side and a red stripe on the other. If everything was done right, the green side faced out; if even one thing was done wrong, the red side was displayed, for all to see. It brought accountability to the process, the presenters said at the meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

The wall rack also had the central line audit schedule, plus diagrams that showed every failed item, the reason for it, and the unit’s compliance rate. Anyone walking by could see at a glance how the unit was doing that day and overall.

The number of dressing options was reduced from 10 to 2, a SorbaView SHIELD and a Tegaderm-like dressing, which made it easier to standardize the efforts. A protocol also was put in place to reinforce oozing dressings, instead of automatically changing them. “We were doing too many changes,” Dr. Koch said.

Compliance with the bundle was almost 90%. Staff “really got into it, and it was great to see,” she said.

The “initial success was almost unexpected, and so dramatic.” The goal now is to sustain the improvements, and roll them out to radiology and other places were central lines are placed, Dr. Nadkarni said.

There was no external funding, and the investigators had no disclosures.

[email protected]

The U.S. Food and Drug Administration granted special approval to a new drug combo intended for the treatment of “a limited and specific population of adult patients with extensively drug resistant, treatment-intolerant or nonresponsive multidrug-resistant pulmonary” tuberculosis, according to an FDA news release.

The effectiveness of the combination treatment of pretomanid tablets with bedaquiline and linezolid was shown in a clinical study of patients with extensively drug-resistant, treatment-intolerant, or nonresponsive multidrug-resistant pulmonary tuberculosis of the lungs. Of 107 infected patients who were evaluated 6 months after the end of therapy, 95 (89%) were deemed successes, which significantly exceeded the historical success rates for treatment of extensively drug-resistant TB, the FDA reported. The trial is sponsored by the Global Alliance for TB Drug Development.

The most common adverse effects reported included peripheral neuropathy, anemia, nausea, vomiting, headache, increased liver enzymes, dyspepsia, rash, visual impairment, low blood sugar, and diarrhea, according to the release.

“Multidrug-resistant TB and extensively drug-resistant TB are public health threats due to limited treatment options. New treatments are important to meet patient national and global health needs,” stated FDA Principal Deputy Commissioner Amy Abernethy, MD, PhD, in the release. She also explained that the approval marked the second time a drug was approved under the “Limited Population Pathway for Antibacterial and Antifungal Drugs, a pathway advanced by Congress to spur development of drugs targeting infections that lack effective therapies.”

In 2016, the World Health Organization reported that there were an estimated 490,000 new cases of multidrug-resistant TB worldwide, with a smaller portion of cases of extensively drug-resistant TB, according to the release, demonstrating the need for new therapeutics.
 

[email protected]

SOURCE: U.S. Food and Drug Administration. Aug. 14, 2019. News release.

The U.S. Food and Drug Administration granted special approval to a new drug combo intended for the treatment of “a limited and specific population of adult patients with extensively drug resistant, treatment-intolerant or nonresponsive multidrug-resistant pulmonary” tuberculosis, according to an FDA news release.

The effectiveness of the combination treatment of pretomanid tablets with bedaquiline and linezolid was shown in a clinical study of patients with extensively drug-resistant, treatment-intolerant, or nonresponsive multidrug-resistant pulmonary tuberculosis of the lungs. Of 107 infected patients who were evaluated 6 months after the end of therapy, 95 (89%) were deemed successes, which significantly exceeded the historical success rates for treatment of extensively drug-resistant TB, the FDA reported. The trial is sponsored by the Global Alliance for TB Drug Development.

The most common adverse effects reported included peripheral neuropathy, anemia, nausea, vomiting, headache, increased liver enzymes, dyspepsia, rash, visual impairment, low blood sugar, and diarrhea, according to the release.

“Multidrug-resistant TB and extensively drug-resistant TB are public health threats due to limited treatment options. New treatments are important to meet patient national and global health needs,” stated FDA Principal Deputy Commissioner Amy Abernethy, MD, PhD, in the release. She also explained that the approval marked the second time a drug was approved under the “Limited Population Pathway for Antibacterial and Antifungal Drugs, a pathway advanced by Congress to spur development of drugs targeting infections that lack effective therapies.”

In 2016, the World Health Organization reported that there were an estimated 490,000 new cases of multidrug-resistant TB worldwide, with a smaller portion of cases of extensively drug-resistant TB, according to the release, demonstrating the need for new therapeutics.
 

[email protected]

SOURCE: U.S. Food and Drug Administration. Aug. 14, 2019. News release.

The U.S. Food and Drug Administration granted special approval to a new drug combo intended for the treatment of “a limited and specific population of adult patients with extensively drug resistant, treatment-intolerant or nonresponsive multidrug-resistant pulmonary” tuberculosis, according to an FDA news release.

The effectiveness of the combination treatment of pretomanid tablets with bedaquiline and linezolid was shown in a clinical study of patients with extensively drug-resistant, treatment-intolerant, or nonresponsive multidrug-resistant pulmonary tuberculosis of the lungs. Of 107 infected patients who were evaluated 6 months after the end of therapy, 95 (89%) were deemed successes, which significantly exceeded the historical success rates for treatment of extensively drug-resistant TB, the FDA reported. The trial is sponsored by the Global Alliance for TB Drug Development.

The most common adverse effects reported included peripheral neuropathy, anemia, nausea, vomiting, headache, increased liver enzymes, dyspepsia, rash, visual impairment, low blood sugar, and diarrhea, according to the release.

“Multidrug-resistant TB and extensively drug-resistant TB are public health threats due to limited treatment options. New treatments are important to meet patient national and global health needs,” stated FDA Principal Deputy Commissioner Amy Abernethy, MD, PhD, in the release. She also explained that the approval marked the second time a drug was approved under the “Limited Population Pathway for Antibacterial and Antifungal Drugs, a pathway advanced by Congress to spur development of drugs targeting infections that lack effective therapies.”

In 2016, the World Health Organization reported that there were an estimated 490,000 new cases of multidrug-resistant TB worldwide, with a smaller portion of cases of extensively drug-resistant TB, according to the release, demonstrating the need for new therapeutics.
 

[email protected]

SOURCE: U.S. Food and Drug Administration. Aug. 14, 2019. News release.

Cardiac biomarkers were used to predict the likelihood of cardiovascular events at day 1 and day 30 in patients with community-acquired pneumonia, in a recently conducted study.

Thomas Northcut/Thinkstock

These biomarkers were also used to predict late cardiovascular events at day 30 of community-acquired pneumonia (CAP) in patients who did not have a history of cardiovascular disease, according to Rosario Menéndez, MD, from the Hospital Universitario y Politécnico La Fe and Instituto de Investigación Sanitaria La Fe in Valencia, Spain, and colleagues.

“Some patients have still high levels of inflammatory and cardiac biomarkers at 30 days, when they are usually referred to primary care without receiving any specific additional recommendations,” Dr. Menéndez and colleagues wrote in CHEST. “Our results suggest that a change in usual practice is needed to reduce current and further cardiovascular CAP complications.”

Dr. Menéndez and colleagues prospectively followed 730 patients for 1 year who were hospitalized for CAP, measuring the cardiac biomarkers proadrenomedullin (proADM), pro b-type natriuretic peptide (proBNP), proendothelin-1, and troponin T, and the inflammatory biomarkers interleukin 6 (IL-6), C-reactive protein (CRP), and procalcitonin (PCT). The researchers also collected data on age, gender, smoking status, and vaccination history, as well as whether patients had any cardiac, renal, pulmonary, neurological or diabetes-related comorbidities.

Overall, 95 patients experienced early cardiovascular events, 67 patients had long-term cardiovascular events, and 20 patients experienced both early and late events. In hospital, the mortality rate was 4.7%; the 30-day mortality rate was 5.3%, and the 1-year mortality rate was 9.9%.

With regard to biomarkers, patients who experienced both early and late cardiovascular events had significantly higher initial levels of proADM, proendothelin-1, troponin, proBNP, and IL-6. Patients who experienced later events had consistent levels of these biomarkers until day 30, except for a decrease at day 4 or day 5.

After adjustment for age, sepsis, previous cardiac disease, and a partial pressure of oxygen in the alveoli to fractional inspired oxygen ratio (PaO₂/FiO₂) of less than 250mm Hg, cardiac biomarkers proendothelin-1 (odds ratio, 2.25; 95% confidence interval, 1.34-3.79), proADM (OR, 2.53; 95% CI, 1.53-4.20), proBNP (OR, 2.67; 95% CI, 1.59-4.49), and troponin T (OR, 2.70; 95% CI, 1.62-4.49) significantly predicted early cardiovascular events, while proendothelin-1 (OR, 3.13; 95% CI, 1.41-7.80), proADM (2.29; 95% CI, 1.01-5.19) and proBNP (OR, 2.34; 95% CI, 1.01-5.56) significantly predicted late cardiovascular events. For day 30 results, when researchers added IL-6 levels to proendothelin-1, the odds ratio for late events increased to 3.53, and when they added IL-6 levels to proADM, the odds ratio increased to 2.80.

Researchers noted the limitations of the study included that they did not analyze cardiac biomarkers to predict specific cardiovascular events, did not identify the cause for mortality at 1 year in most patients, and did not include a control group.

This study was supported in part by funding from Instituto de Salud Carlos III, Sociedad Española de Neumología y Cirugía Torácica, and the Center for Biomedical Research Network in Respiratory Diseases. The authors reported no relevant conflicts of interest.
 

SOURCE: Menéndez R et al. Chest. 2019 Aug 2. doi: 10.1016/j.chest.2019.06.040.

Cardiac biomarkers were used to predict the likelihood of cardiovascular events at day 1 and day 30 in patients with community-acquired pneumonia, in a recently conducted study.

Thomas Northcut/Thinkstock

These biomarkers were also used to predict late cardiovascular events at day 30 of community-acquired pneumonia (CAP) in patients who did not have a history of cardiovascular disease, according to Rosario Menéndez, MD, from the Hospital Universitario y Politécnico La Fe and Instituto de Investigación Sanitaria La Fe in Valencia, Spain, and colleagues.

“Some patients have still high levels of inflammatory and cardiac biomarkers at 30 days, when they are usually referred to primary care without receiving any specific additional recommendations,” Dr. Menéndez and colleagues wrote in CHEST. “Our results suggest that a change in usual practice is needed to reduce current and further cardiovascular CAP complications.”

Dr. Menéndez and colleagues prospectively followed 730 patients for 1 year who were hospitalized for CAP, measuring the cardiac biomarkers proadrenomedullin (proADM), pro b-type natriuretic peptide (proBNP), proendothelin-1, and troponin T, and the inflammatory biomarkers interleukin 6 (IL-6), C-reactive protein (CRP), and procalcitonin (PCT). The researchers also collected data on age, gender, smoking status, and vaccination history, as well as whether patients had any cardiac, renal, pulmonary, neurological or diabetes-related comorbidities.

Overall, 95 patients experienced early cardiovascular events, 67 patients had long-term cardiovascular events, and 20 patients experienced both early and late events. In hospital, the mortality rate was 4.7%; the 30-day mortality rate was 5.3%, and the 1-year mortality rate was 9.9%.

With regard to biomarkers, patients who experienced both early and late cardiovascular events had significantly higher initial levels of proADM, proendothelin-1, troponin, proBNP, and IL-6. Patients who experienced later events had consistent levels of these biomarkers until day 30, except for a decrease at day 4 or day 5.

After adjustment for age, sepsis, previous cardiac disease, and a partial pressure of oxygen in the alveoli to fractional inspired oxygen ratio (PaO₂/FiO₂) of less than 250mm Hg, cardiac biomarkers proendothelin-1 (odds ratio, 2.25; 95% confidence interval, 1.34-3.79), proADM (OR, 2.53; 95% CI, 1.53-4.20), proBNP (OR, 2.67; 95% CI, 1.59-4.49), and troponin T (OR, 2.70; 95% CI, 1.62-4.49) significantly predicted early cardiovascular events, while proendothelin-1 (OR, 3.13; 95% CI, 1.41-7.80), proADM (2.29; 95% CI, 1.01-5.19) and proBNP (OR, 2.34; 95% CI, 1.01-5.56) significantly predicted late cardiovascular events. For day 30 results, when researchers added IL-6 levels to proendothelin-1, the odds ratio for late events increased to 3.53, and when they added IL-6 levels to proADM, the odds ratio increased to 2.80.

Researchers noted the limitations of the study included that they did not analyze cardiac biomarkers to predict specific cardiovascular events, did not identify the cause for mortality at 1 year in most patients, and did not include a control group.

This study was supported in part by funding from Instituto de Salud Carlos III, Sociedad Española de Neumología y Cirugía Torácica, and the Center for Biomedical Research Network in Respiratory Diseases. The authors reported no relevant conflicts of interest.
 

SOURCE: Menéndez R et al. Chest. 2019 Aug 2. doi: 10.1016/j.chest.2019.06.040.

Cardiac biomarkers were used to predict the likelihood of cardiovascular events at day 1 and day 30 in patients with community-acquired pneumonia, in a recently conducted study.

Thomas Northcut/Thinkstock

These biomarkers were also used to predict late cardiovascular events at day 30 of community-acquired pneumonia (CAP) in patients who did not have a history of cardiovascular disease, according to Rosario Menéndez, MD, from the Hospital Universitario y Politécnico La Fe and Instituto de Investigación Sanitaria La Fe in Valencia, Spain, and colleagues.

“Some patients have still high levels of inflammatory and cardiac biomarkers at 30 days, when they are usually referred to primary care without receiving any specific additional recommendations,” Dr. Menéndez and colleagues wrote in CHEST. “Our results suggest that a change in usual practice is needed to reduce current and further cardiovascular CAP complications.”

Dr. Menéndez and colleagues prospectively followed 730 patients for 1 year who were hospitalized for CAP, measuring the cardiac biomarkers proadrenomedullin (proADM), pro b-type natriuretic peptide (proBNP), proendothelin-1, and troponin T, and the inflammatory biomarkers interleukin 6 (IL-6), C-reactive protein (CRP), and procalcitonin (PCT). The researchers also collected data on age, gender, smoking status, and vaccination history, as well as whether patients had any cardiac, renal, pulmonary, neurological or diabetes-related comorbidities.

Overall, 95 patients experienced early cardiovascular events, 67 patients had long-term cardiovascular events, and 20 patients experienced both early and late events. In hospital, the mortality rate was 4.7%; the 30-day mortality rate was 5.3%, and the 1-year mortality rate was 9.9%.

With regard to biomarkers, patients who experienced both early and late cardiovascular events had significantly higher initial levels of proADM, proendothelin-1, troponin, proBNP, and IL-6. Patients who experienced later events had consistent levels of these biomarkers until day 30, except for a decrease at day 4 or day 5.

After adjustment for age, sepsis, previous cardiac disease, and a partial pressure of oxygen in the alveoli to fractional inspired oxygen ratio (PaO₂/FiO₂) of less than 250mm Hg, cardiac biomarkers proendothelin-1 (odds ratio, 2.25; 95% confidence interval, 1.34-3.79), proADM (OR, 2.53; 95% CI, 1.53-4.20), proBNP (OR, 2.67; 95% CI, 1.59-4.49), and troponin T (OR, 2.70; 95% CI, 1.62-4.49) significantly predicted early cardiovascular events, while proendothelin-1 (OR, 3.13; 95% CI, 1.41-7.80), proADM (2.29; 95% CI, 1.01-5.19) and proBNP (OR, 2.34; 95% CI, 1.01-5.56) significantly predicted late cardiovascular events. For day 30 results, when researchers added IL-6 levels to proendothelin-1, the odds ratio for late events increased to 3.53, and when they added IL-6 levels to proADM, the odds ratio increased to 2.80.

Researchers noted the limitations of the study included that they did not analyze cardiac biomarkers to predict specific cardiovascular events, did not identify the cause for mortality at 1 year in most patients, and did not include a control group.

This study was supported in part by funding from Instituto de Salud Carlos III, Sociedad Española de Neumología y Cirugía Torácica, and the Center for Biomedical Research Network in Respiratory Diseases. The authors reported no relevant conflicts of interest.
 

SOURCE: Menéndez R et al. Chest. 2019 Aug 2. doi: 10.1016/j.chest.2019.06.040.

LJUBLJANA, SLOVENIA – A new age-adjusted quick Sequential Organ Failure Assessment (qSOFA) score designed for use in children presenting to the ED with fever showed good predictive value for admission to critical care within the next 48 hours, Aakash Khanijau, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

Bruce Jancin/MDedge News

“In the needle-in-a-haystack scenario that’s seen in pediatric emergency departments, our novel, age-adjusted qSOFA score could potentially improve the rapid identification and treatment of children with suspected sepsis presenting to the ED,” said Dr. Khanijau of the University of Liverpool (England).

He presented an exceptionally large retrospective validation study of the score’s performance in 12,393 children (median age, 2.5 years) who presented to EDs with fever, of whom 1,521 were admitted for suspected sepsis. Of the hospitalized children, 145 were admitted to critical care within the first 48 hours.

The pediatric qSOFA score had 72% sensitivity and 85% specificity for critical care admission within 48 hours, with a positive predictive value of 5.4% and, more importantly, a whopping negative predictive value of 99.6%.

“That very high negative predictive value underlines the powerful discriminatory nature of our tool in the emergency department setting,” Dr. Khanijau observed, adding that the score’s area under the receiver operating characteristic curve was 0.81, which is considered a good predictive value.

The impetus for developing an age-adjusted pediatric qSOFA score stems from the fact that the original qSOFA score was designed for rapid assessment of adults with suspected sepsis and isn’t applicable in children. Other existing scores, including SIRS (the Systemic Inflammatory Response Syndrome criteria), the full SOFA, and PELOD-2 (the Pediatric Logistic Organ Dysfunction score), take longer to determine than the adapted qSOFA in a setting where speed is of the essence, he explained.

The original qSOFA components are altered mentation, systolic blood pressure, and respiratory rate. The novel score developed by Dr. Khanijau and coworkers swaps out systolic BP in favor of capillary refill time and age-adjusted heart rate using the thresholds previously established in a landmark study from the Children’s Hospital of Philadelphia (Pediatrics. 2013 Apr;131[4]:e1150-7.)

“Our reasoning here is that arterial hypertension is known to be a much later sign of circulatory compromise in children and may provide less discriminatory value than signs such as delayed capillary refill time and tachycardia early in presentation in the emergency department,” according to Dr. Khanijau.


The novel scoring system features four criteria. One point each is given for a capillary refill time of 3 seconds or longer; anything less than “Alert” on the Alert, Responds to Voice, Respond to Pain, and Unresponsive scale; a heart rate above the 99th percentile on the age-adjusted curves; and a respiratory rate above the age-adjusted 99th percentile. Thus, scores can range from 0 to 4. In the validation study, a score of 2 or more spelled a 890% increased likelihood of being admitted to a critical care setting within 48 hours. It was also associated with a 100-fold increased likelihood of death during the hospitalization, which occurred in 10 children.

Asked how the new predictive score could change clinical management, Dr. Khanijau replied, “I think the key thing it does here is it identifies the children at risk of requiring critical care and should therefore motivate us in the children achieving that threshold to promptly investigate thoroughly for suspected sepsis using the more comprehensive tools, like the full SOFA.”

He reported having no financial conflicts of interest regarding his study.

[email protected]

SOURCE: Khanijau A et al. ESPID 2019, Abstract.

LJUBLJANA, SLOVENIA – A new age-adjusted quick Sequential Organ Failure Assessment (qSOFA) score designed for use in children presenting to the ED with fever showed good predictive value for admission to critical care within the next 48 hours, Aakash Khanijau, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

Bruce Jancin/MDedge News

“In the needle-in-a-haystack scenario that’s seen in pediatric emergency departments, our novel, age-adjusted qSOFA score could potentially improve the rapid identification and treatment of children with suspected sepsis presenting to the ED,” said Dr. Khanijau of the University of Liverpool (England).

He presented an exceptionally large retrospective validation study of the score’s performance in 12,393 children (median age, 2.5 years) who presented to EDs with fever, of whom 1,521 were admitted for suspected sepsis. Of the hospitalized children, 145 were admitted to critical care within the first 48 hours.

The pediatric qSOFA score had 72% sensitivity and 85% specificity for critical care admission within 48 hours, with a positive predictive value of 5.4% and, more importantly, a whopping negative predictive value of 99.6%.

“That very high negative predictive value underlines the powerful discriminatory nature of our tool in the emergency department setting,” Dr. Khanijau observed, adding that the score’s area under the receiver operating characteristic curve was 0.81, which is considered a good predictive value.

The impetus for developing an age-adjusted pediatric qSOFA score stems from the fact that the original qSOFA score was designed for rapid assessment of adults with suspected sepsis and isn’t applicable in children. Other existing scores, including SIRS (the Systemic Inflammatory Response Syndrome criteria), the full SOFA, and PELOD-2 (the Pediatric Logistic Organ Dysfunction score), take longer to determine than the adapted qSOFA in a setting where speed is of the essence, he explained.

The original qSOFA components are altered mentation, systolic blood pressure, and respiratory rate. The novel score developed by Dr. Khanijau and coworkers swaps out systolic BP in favor of capillary refill time and age-adjusted heart rate using the thresholds previously established in a landmark study from the Children’s Hospital of Philadelphia (Pediatrics. 2013 Apr;131[4]:e1150-7.)

“Our reasoning here is that arterial hypertension is known to be a much later sign of circulatory compromise in children and may provide less discriminatory value than signs such as delayed capillary refill time and tachycardia early in presentation in the emergency department,” according to Dr. Khanijau.


The novel scoring system features four criteria. One point each is given for a capillary refill time of 3 seconds or longer; anything less than “Alert” on the Alert, Responds to Voice, Respond to Pain, and Unresponsive scale; a heart rate above the 99th percentile on the age-adjusted curves; and a respiratory rate above the age-adjusted 99th percentile. Thus, scores can range from 0 to 4. In the validation study, a score of 2 or more spelled a 890% increased likelihood of being admitted to a critical care setting within 48 hours. It was also associated with a 100-fold increased likelihood of death during the hospitalization, which occurred in 10 children.

Asked how the new predictive score could change clinical management, Dr. Khanijau replied, “I think the key thing it does here is it identifies the children at risk of requiring critical care and should therefore motivate us in the children achieving that threshold to promptly investigate thoroughly for suspected sepsis using the more comprehensive tools, like the full SOFA.”

He reported having no financial conflicts of interest regarding his study.

[email protected]

SOURCE: Khanijau A et al. ESPID 2019, Abstract.

LJUBLJANA, SLOVENIA – A new age-adjusted quick Sequential Organ Failure Assessment (qSOFA) score designed for use in children presenting to the ED with fever showed good predictive value for admission to critical care within the next 48 hours, Aakash Khanijau, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

Bruce Jancin/MDedge News

“In the needle-in-a-haystack scenario that’s seen in pediatric emergency departments, our novel, age-adjusted qSOFA score could potentially improve the rapid identification and treatment of children with suspected sepsis presenting to the ED,” said Dr. Khanijau of the University of Liverpool (England).

He presented an exceptionally large retrospective validation study of the score’s performance in 12,393 children (median age, 2.5 years) who presented to EDs with fever, of whom 1,521 were admitted for suspected sepsis. Of the hospitalized children, 145 were admitted to critical care within the first 48 hours.

The pediatric qSOFA score had 72% sensitivity and 85% specificity for critical care admission within 48 hours, with a positive predictive value of 5.4% and, more importantly, a whopping negative predictive value of 99.6%.

“That very high negative predictive value underlines the powerful discriminatory nature of our tool in the emergency department setting,” Dr. Khanijau observed, adding that the score’s area under the receiver operating characteristic curve was 0.81, which is considered a good predictive value.

The impetus for developing an age-adjusted pediatric qSOFA score stems from the fact that the original qSOFA score was designed for rapid assessment of adults with suspected sepsis and isn’t applicable in children. Other existing scores, including SIRS (the Systemic Inflammatory Response Syndrome criteria), the full SOFA, and PELOD-2 (the Pediatric Logistic Organ Dysfunction score), take longer to determine than the adapted qSOFA in a setting where speed is of the essence, he explained.

The original qSOFA components are altered mentation, systolic blood pressure, and respiratory rate. The novel score developed by Dr. Khanijau and coworkers swaps out systolic BP in favor of capillary refill time and age-adjusted heart rate using the thresholds previously established in a landmark study from the Children’s Hospital of Philadelphia (Pediatrics. 2013 Apr;131[4]:e1150-7.)

“Our reasoning here is that arterial hypertension is known to be a much later sign of circulatory compromise in children and may provide less discriminatory value than signs such as delayed capillary refill time and tachycardia early in presentation in the emergency department,” according to Dr. Khanijau.


The novel scoring system features four criteria. One point each is given for a capillary refill time of 3 seconds or longer; anything less than “Alert” on the Alert, Responds to Voice, Respond to Pain, and Unresponsive scale; a heart rate above the 99th percentile on the age-adjusted curves; and a respiratory rate above the age-adjusted 99th percentile. Thus, scores can range from 0 to 4. In the validation study, a score of 2 or more spelled a 890% increased likelihood of being admitted to a critical care setting within 48 hours. It was also associated with a 100-fold increased likelihood of death during the hospitalization, which occurred in 10 children.

Asked how the new predictive score could change clinical management, Dr. Khanijau replied, “I think the key thing it does here is it identifies the children at risk of requiring critical care and should therefore motivate us in the children achieving that threshold to promptly investigate thoroughly for suspected sepsis using the more comprehensive tools, like the full SOFA.”

He reported having no financial conflicts of interest regarding his study.

[email protected]

SOURCE: Khanijau A et al. ESPID 2019, Abstract.

SEATTLE – Procalcitonin, a marker of bacterial infection, rises and peaks sooner than C-reactive protein (CRP), and is especially useful to help rule out invasive bacterial infections in young infants and pediatric community acquired pneumonia due to typical bacteria, according to a presentation at the 2019 Pediatric Hospital Medicine Conference.

M. Alexander Otto/MDedge News

It’s “excellent for identifying low risk patients” and has the potential to decrease lumbar punctures and antibiotic exposure, but “the specificity isn’t great,” so there’s the potential for false positives, said Russell McCulloh, MD, a pediatric infectious disease specialist at the University of Nebraska Medical Center, Omaha.

There was great interest in procalcitonin at the meeting; the presentation room was packed, with a line out the door. It’s used mostly in Europe at this point. Testing is available in many U.S. hospitals, but a large majority of audience members, when polled, said they don’t currently use it in clinical practice, and that it’s not a part of diagnostic algorithms at their institutions.

Levels of procalcitonin, a calcitonin precursor normally produced by the thyroid, are low or undetectable in healthy people, but inflammation, be it from infectious or noninfectious causes, triggers production by parenchymal cells throughout the body.

Levels began to rise as early as 2.5 hours after healthy subjects in one study were injected with bacterial endotoxins, and peaked as early as 6 hours; CRP, in contrast, started to rise after 12 hours, and peaked at 30 hours. Procalcitonin levels also seem to correlate with bacterial load and severity of infection, said Nivedita Srinivas, MD, a pediatric infectious disease specialist at Stanford (Calif.) University (J Pediatr Intensive Care. 2016 Dec;5[4]:162-71).

Due to time, the presenters focused their talk on community acquired pneumonia (CAP) and invasive bacterial infections (IBI) in young infants, meaning essentially bacteremia and meningitis.

Different studies use different cutoffs, but a procalcitonin below, for instance, 0.5 ng/mL is “certainly more sensitive [for IBI] than any single biomarker we currently use,” including CRP, white blood cells, and absolute neutrophil count (ANC). “If it’s negative, you’re really confident it’s negative,” but “a positive test does not necessarily indicate the presence of IBI,” Dr. McCulloh said (Pediatrics. 2012 Nov;130[5]:815-22).

“Procalcitonin works really well as part of a validated step-wise rule” that includes, for instance, CRP and ANC; “I think that’s where its utility is. On its own, it is not a substitute for you examining the patient and doing your basic risk stratification, but it may enhance your decision making incrementally above what we currently have,” he said.

Meanwhile, in a study of 532 children a median age of 2.4 years with radiographically confirmed CAP, procalcitonin levels were a median of 6.1 ng/mL in children whose pneumonia was caused by Streptococcus pneumoniae or other typical bacteria, and no child infected with typical bacteria had a level under 0.1 ng/mL. Below that level, “you can be very sure you do not have typical bacteria pneumonia,” said Marie Wang, MD, also a pediatric infectious disease specialist at Stanford (J Pediatric Infect Dis Soc. 2018 Feb 19;7[1]:46-53).

As procalcitonin levels went up, the likelihood of having bacterial pneumonia increased; at 2 ng/mL, 26% of subjects were infected with typical bacteria, “but even in that group, 58% still had viral infection, so you are still detecting a lot of viral” disease, she said.

Prolcalcitonin-guided therapy – antibiotics until patients fall below a level of 0.25 ng/ml, for instance – has also been associated with decreased antibiotic exposure (Respir Med. 2011 Dec;105[12]:1939-45).

The speakers had no disclosures. The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

[email protected]

SEATTLE – Procalcitonin, a marker of bacterial infection, rises and peaks sooner than C-reactive protein (CRP), and is especially useful to help rule out invasive bacterial infections in young infants and pediatric community acquired pneumonia due to typical bacteria, according to a presentation at the 2019 Pediatric Hospital Medicine Conference.

M. Alexander Otto/MDedge News

It’s “excellent for identifying low risk patients” and has the potential to decrease lumbar punctures and antibiotic exposure, but “the specificity isn’t great,” so there’s the potential for false positives, said Russell McCulloh, MD, a pediatric infectious disease specialist at the University of Nebraska Medical Center, Omaha.

There was great interest in procalcitonin at the meeting; the presentation room was packed, with a line out the door. It’s used mostly in Europe at this point. Testing is available in many U.S. hospitals, but a large majority of audience members, when polled, said they don’t currently use it in clinical practice, and that it’s not a part of diagnostic algorithms at their institutions.

Levels of procalcitonin, a calcitonin precursor normally produced by the thyroid, are low or undetectable in healthy people, but inflammation, be it from infectious or noninfectious causes, triggers production by parenchymal cells throughout the body.

Levels began to rise as early as 2.5 hours after healthy subjects in one study were injected with bacterial endotoxins, and peaked as early as 6 hours; CRP, in contrast, started to rise after 12 hours, and peaked at 30 hours. Procalcitonin levels also seem to correlate with bacterial load and severity of infection, said Nivedita Srinivas, MD, a pediatric infectious disease specialist at Stanford (Calif.) University (J Pediatr Intensive Care. 2016 Dec;5[4]:162-71).

Due to time, the presenters focused their talk on community acquired pneumonia (CAP) and invasive bacterial infections (IBI) in young infants, meaning essentially bacteremia and meningitis.

Different studies use different cutoffs, but a procalcitonin below, for instance, 0.5 ng/mL is “certainly more sensitive [for IBI] than any single biomarker we currently use,” including CRP, white blood cells, and absolute neutrophil count (ANC). “If it’s negative, you’re really confident it’s negative,” but “a positive test does not necessarily indicate the presence of IBI,” Dr. McCulloh said (Pediatrics. 2012 Nov;130[5]:815-22).

“Procalcitonin works really well as part of a validated step-wise rule” that includes, for instance, CRP and ANC; “I think that’s where its utility is. On its own, it is not a substitute for you examining the patient and doing your basic risk stratification, but it may enhance your decision making incrementally above what we currently have,” he said.

Meanwhile, in a study of 532 children a median age of 2.4 years with radiographically confirmed CAP, procalcitonin levels were a median of 6.1 ng/mL in children whose pneumonia was caused by Streptococcus pneumoniae or other typical bacteria, and no child infected with typical bacteria had a level under 0.1 ng/mL. Below that level, “you can be very sure you do not have typical bacteria pneumonia,” said Marie Wang, MD, also a pediatric infectious disease specialist at Stanford (J Pediatric Infect Dis Soc. 2018 Feb 19;7[1]:46-53).

As procalcitonin levels went up, the likelihood of having bacterial pneumonia increased; at 2 ng/mL, 26% of subjects were infected with typical bacteria, “but even in that group, 58% still had viral infection, so you are still detecting a lot of viral” disease, she said.

Prolcalcitonin-guided therapy – antibiotics until patients fall below a level of 0.25 ng/ml, for instance – has also been associated with decreased antibiotic exposure (Respir Med. 2011 Dec;105[12]:1939-45).

The speakers had no disclosures. The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

[email protected]

SEATTLE – Procalcitonin, a marker of bacterial infection, rises and peaks sooner than C-reactive protein (CRP), and is especially useful to help rule out invasive bacterial infections in young infants and pediatric community acquired pneumonia due to typical bacteria, according to a presentation at the 2019 Pediatric Hospital Medicine Conference.

M. Alexander Otto/MDedge News

It’s “excellent for identifying low risk patients” and has the potential to decrease lumbar punctures and antibiotic exposure, but “the specificity isn’t great,” so there’s the potential for false positives, said Russell McCulloh, MD, a pediatric infectious disease specialist at the University of Nebraska Medical Center, Omaha.

There was great interest in procalcitonin at the meeting; the presentation room was packed, with a line out the door. It’s used mostly in Europe at this point. Testing is available in many U.S. hospitals, but a large majority of audience members, when polled, said they don’t currently use it in clinical practice, and that it’s not a part of diagnostic algorithms at their institutions.

Levels of procalcitonin, a calcitonin precursor normally produced by the thyroid, are low or undetectable in healthy people, but inflammation, be it from infectious or noninfectious causes, triggers production by parenchymal cells throughout the body.

Levels began to rise as early as 2.5 hours after healthy subjects in one study were injected with bacterial endotoxins, and peaked as early as 6 hours; CRP, in contrast, started to rise after 12 hours, and peaked at 30 hours. Procalcitonin levels also seem to correlate with bacterial load and severity of infection, said Nivedita Srinivas, MD, a pediatric infectious disease specialist at Stanford (Calif.) University (J Pediatr Intensive Care. 2016 Dec;5[4]:162-71).

Due to time, the presenters focused their talk on community acquired pneumonia (CAP) and invasive bacterial infections (IBI) in young infants, meaning essentially bacteremia and meningitis.

Different studies use different cutoffs, but a procalcitonin below, for instance, 0.5 ng/mL is “certainly more sensitive [for IBI] than any single biomarker we currently use,” including CRP, white blood cells, and absolute neutrophil count (ANC). “If it’s negative, you’re really confident it’s negative,” but “a positive test does not necessarily indicate the presence of IBI,” Dr. McCulloh said (Pediatrics. 2012 Nov;130[5]:815-22).

“Procalcitonin works really well as part of a validated step-wise rule” that includes, for instance, CRP and ANC; “I think that’s where its utility is. On its own, it is not a substitute for you examining the patient and doing your basic risk stratification, but it may enhance your decision making incrementally above what we currently have,” he said.

Meanwhile, in a study of 532 children a median age of 2.4 years with radiographically confirmed CAP, procalcitonin levels were a median of 6.1 ng/mL in children whose pneumonia was caused by Streptococcus pneumoniae or other typical bacteria, and no child infected with typical bacteria had a level under 0.1 ng/mL. Below that level, “you can be very sure you do not have typical bacteria pneumonia,” said Marie Wang, MD, also a pediatric infectious disease specialist at Stanford (J Pediatric Infect Dis Soc. 2018 Feb 19;7[1]:46-53).

As procalcitonin levels went up, the likelihood of having bacterial pneumonia increased; at 2 ng/mL, 26% of subjects were infected with typical bacteria, “but even in that group, 58% still had viral infection, so you are still detecting a lot of viral” disease, she said.

Prolcalcitonin-guided therapy – antibiotics until patients fall below a level of 0.25 ng/ml, for instance – has also been associated with decreased antibiotic exposure (Respir Med. 2011 Dec;105[12]:1939-45).

The speakers had no disclosures. The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

[email protected]

Adding electrocardiogram findings and clinical assessment to high-sensitivity cardiac troponin measurements in patients presenting with chest pain could improve predictions of their risk of 30-day major adverse cardiac events, particularly unstable angina, research suggests.

Investigators reported outcomes of a prospective study involving 3,123 patients with suspected acute myocardial infarction. The findings are in the Journal of the American College of Cardiology.

The aim of the researchers was to validate an extended algorithm that combined the European Society of Cardiology’s high-sensitivity cardiac troponin measurement at presentation and after 1 hour (ESC hs-cTn 0/1 h algorithm) with clinical assessment and ECG findings to aid prediction of major adverse cardiac events (MACE) within 30 days.

The clinical assessment involved the treating ED physician’s use of a visual analog scale to assess the patient’s pretest probability for an acute coronary syndrome (ACS), with a score above 70% qualifying as high likelihood.

The researchers found that the ESC hs-cTn 0/1 h algorithm alone triaged significantly more patients toward rule-out for MACE than did the extended algorithm (60% vs. 45%, P less than .001). This resulted in 487 patients being reclassified toward “observe” by the extended algorithm, and among this group the 30-day MACE rate was 1.1%.

However, the 30-day MACE rates were similar in the two groups – 0.6% among those ruled out by the ESC hs-cTn 0/1 h algorithm alone and 0.4% in those ruled out by the extended algorithm – resulting in a similar negative predictive value.

“These estimates will help clinicians to appropriately manage patients triaged toward rule-out according to the ESC hs-cTnT 0/1 h algorithm, in whom either the [visual analog scale] for ACS or the ECG still suggests the presence of an ACS,” wrote Thomas Nestelberger, MD, of the Cardiovascular Research Institute Basel (Switzerland) at the University of Basel, and coinvestigators.

The ESC hs-cTn 0/1 h algorithm also ruled in fewer patients than did the extended algorithm (16% vs. 26%, P less than .001), giving it a higher positive predictive value.


When the researchers added unstable angina to the major adverse cardiac event outcome, they found the ESC hs-cTn 0/1 h algorithm had a lower negative predictive value and a higher negative likelihood ratio compared with the extended algorithm for patients ruled out, but a higher positive predictive value and positive likelihood ratio for patients ruled in.

“Our findings corroborate and extend previous research regarding the development and validation of algorithms for the safe and effective rule-out and rule-in of MACE in patients with symptoms suggestive of AMI,” the authors wrote.

This study was supported by the Swiss National Science Foundation, the Swiss Heart Foundation, the European Union, the Cardiovascular Research Foundation Basel, the University Hospital Basel, Abbott, Beckman Coulter, Biomerieux, BRAHMS, Roche, Nanosphere, Siemens, Ortho Diagnostics, and Singulex. Several authors reported grants and support from the pharmaceutical sector.

SOURCE: Nestelberger T et al. J Am Coll Cardiol. 2019 Aug 20. doi: 10.1016/j.jacc.2019.06.025.

Adding electrocardiogram findings and clinical assessment to high-sensitivity cardiac troponin measurements in patients presenting with chest pain could improve predictions of their risk of 30-day major adverse cardiac events, particularly unstable angina, research suggests.

Investigators reported outcomes of a prospective study involving 3,123 patients with suspected acute myocardial infarction. The findings are in the Journal of the American College of Cardiology.

The aim of the researchers was to validate an extended algorithm that combined the European Society of Cardiology’s high-sensitivity cardiac troponin measurement at presentation and after 1 hour (ESC hs-cTn 0/1 h algorithm) with clinical assessment and ECG findings to aid prediction of major adverse cardiac events (MACE) within 30 days.

The clinical assessment involved the treating ED physician’s use of a visual analog scale to assess the patient’s pretest probability for an acute coronary syndrome (ACS), with a score above 70% qualifying as high likelihood.

The researchers found that the ESC hs-cTn 0/1 h algorithm alone triaged significantly more patients toward rule-out for MACE than did the extended algorithm (60% vs. 45%, P less than .001). This resulted in 487 patients being reclassified toward “observe” by the extended algorithm, and among this group the 30-day MACE rate was 1.1%.

However, the 30-day MACE rates were similar in the two groups – 0.6% among those ruled out by the ESC hs-cTn 0/1 h algorithm alone and 0.4% in those ruled out by the extended algorithm – resulting in a similar negative predictive value.

“These estimates will help clinicians to appropriately manage patients triaged toward rule-out according to the ESC hs-cTnT 0/1 h algorithm, in whom either the [visual analog scale] for ACS or the ECG still suggests the presence of an ACS,” wrote Thomas Nestelberger, MD, of the Cardiovascular Research Institute Basel (Switzerland) at the University of Basel, and coinvestigators.

The ESC hs-cTn 0/1 h algorithm also ruled in fewer patients than did the extended algorithm (16% vs. 26%, P less than .001), giving it a higher positive predictive value.


When the researchers added unstable angina to the major adverse cardiac event outcome, they found the ESC hs-cTn 0/1 h algorithm had a lower negative predictive value and a higher negative likelihood ratio compared with the extended algorithm for patients ruled out, but a higher positive predictive value and positive likelihood ratio for patients ruled in.

“Our findings corroborate and extend previous research regarding the development and validation of algorithms for the safe and effective rule-out and rule-in of MACE in patients with symptoms suggestive of AMI,” the authors wrote.

This study was supported by the Swiss National Science Foundation, the Swiss Heart Foundation, the European Union, the Cardiovascular Research Foundation Basel, the University Hospital Basel, Abbott, Beckman Coulter, Biomerieux, BRAHMS, Roche, Nanosphere, Siemens, Ortho Diagnostics, and Singulex. Several authors reported grants and support from the pharmaceutical sector.

SOURCE: Nestelberger T et al. J Am Coll Cardiol. 2019 Aug 20. doi: 10.1016/j.jacc.2019.06.025.

Adding electrocardiogram findings and clinical assessment to high-sensitivity cardiac troponin measurements in patients presenting with chest pain could improve predictions of their risk of 30-day major adverse cardiac events, particularly unstable angina, research suggests.

Investigators reported outcomes of a prospective study involving 3,123 patients with suspected acute myocardial infarction. The findings are in the Journal of the American College of Cardiology.

The aim of the researchers was to validate an extended algorithm that combined the European Society of Cardiology’s high-sensitivity cardiac troponin measurement at presentation and after 1 hour (ESC hs-cTn 0/1 h algorithm) with clinical assessment and ECG findings to aid prediction of major adverse cardiac events (MACE) within 30 days.

The clinical assessment involved the treating ED physician’s use of a visual analog scale to assess the patient’s pretest probability for an acute coronary syndrome (ACS), with a score above 70% qualifying as high likelihood.

The researchers found that the ESC hs-cTn 0/1 h algorithm alone triaged significantly more patients toward rule-out for MACE than did the extended algorithm (60% vs. 45%, P less than .001). This resulted in 487 patients being reclassified toward “observe” by the extended algorithm, and among this group the 30-day MACE rate was 1.1%.

However, the 30-day MACE rates were similar in the two groups – 0.6% among those ruled out by the ESC hs-cTn 0/1 h algorithm alone and 0.4% in those ruled out by the extended algorithm – resulting in a similar negative predictive value.

“These estimates will help clinicians to appropriately manage patients triaged toward rule-out according to the ESC hs-cTnT 0/1 h algorithm, in whom either the [visual analog scale] for ACS or the ECG still suggests the presence of an ACS,” wrote Thomas Nestelberger, MD, of the Cardiovascular Research Institute Basel (Switzerland) at the University of Basel, and coinvestigators.

The ESC hs-cTn 0/1 h algorithm also ruled in fewer patients than did the extended algorithm (16% vs. 26%, P less than .001), giving it a higher positive predictive value.


When the researchers added unstable angina to the major adverse cardiac event outcome, they found the ESC hs-cTn 0/1 h algorithm had a lower negative predictive value and a higher negative likelihood ratio compared with the extended algorithm for patients ruled out, but a higher positive predictive value and positive likelihood ratio for patients ruled in.

“Our findings corroborate and extend previous research regarding the development and validation of algorithms for the safe and effective rule-out and rule-in of MACE in patients with symptoms suggestive of AMI,” the authors wrote.

This study was supported by the Swiss National Science Foundation, the Swiss Heart Foundation, the European Union, the Cardiovascular Research Foundation Basel, the University Hospital Basel, Abbott, Beckman Coulter, Biomerieux, BRAHMS, Roche, Nanosphere, Siemens, Ortho Diagnostics, and Singulex. Several authors reported grants and support from the pharmaceutical sector.

SOURCE: Nestelberger T et al. J Am Coll Cardiol. 2019 Aug 20. doi: 10.1016/j.jacc.2019.06.025.

“I need to get out of here! I haven’t gotten any sleep, my medications never come on time, and I feel like a pincushion. I am leaving NOW!” The commotion interrupts your intern’s meticulous presentation as your team quickly files into the room. You find a disheveled, visibly frustrated man tearing at his intravenous line, surrounded by his half-eaten breakfast and multiple urinals filled to various levels. His IV pump is beeping, and telemetry wires hang haphazardly off his chest.

Mr. Smith had been admitted for a heart failure exacerbation. You’d been making steady progress with diuresis but are now faced with a likely discharge against medical advice if you can’t defuse the situation.

As hospitalists, this scenario might feel eerily familiar. Perhaps Mr. Smith had enough of being in the hospital and just wanted to go home to see his dog, or maybe the food was not up to his standards.

However, his next line stops your team dead in its tracks. “I feel like I am in Vietnam all over again. I am tied up with all these wires and feel like a prisoner! Please let me go.” It turns out that Mr. Smith had a comorbidity that was overlooked during his initial intake: posttraumatic stress disorder.

Impact of PTSD

PTSD is a diagnosis characterized by intrusive recurrent thoughts, dreams, or flashbacks that follow exposure to a traumatic event or series of events (see Table 1). While more common among veterans (for example, Vietnam veterans have an estimated lifetime prevalence of PTSD of 30.9% for men and 26.9% for women),¹ a national survey of U.S. households estimated the lifetime prevalence of PTSD among adult Americans to be 6.8%.² PTSD is often underdiagnosed and underreported by patients in the outpatient setting, leading to underrecognition and undertreatment of these patients in the inpatient setting.

Although it may not be surprising that patients with PTSD use more mental health services, they are also more likely to use nonmental health services. In one study, total utilization of outpatient nonmental health services was 91% greater in veterans with PTSD, and these patients were three times more likely to be hospitalized than those without any mental health diagnoses.³ Additionally, they are likely to present later and stay longer when compared with patients without PTSD. One study estimated the cost of PTSD-related hospitalization in the United States from 2002 to 2011 as being $34.9 billion.⁴ Notably, close to 95% of hospitalizations in this study listed PTSD as a secondary rather than primary diagnosis, suggesting that the vast majority of these admitted patients are cared for by frontline providers who are not trained mental health professionals.

How PTSD manifests in the hospital

But, how exactly can the hospital environment contribute to decompensation of PTSD symptoms? Unfortunately, there is little empiric data to guide us. Based on what we do know of PTSD, we offer the following hypotheses.

Patients with PTSD may feel a loss of control or helplessness when admitted to the inpatient setting. For example, they cannot control when they receive their medications or when they get their meals. The act of showering or going outside requires approval. In addition, they might perceive they are being “ordered around” by staff and may be carted off to a study without knowing why the study is being done in the first place.

Triggers in the hospital environment may contribute to PTSD flares. Think about the loud, beeping IV pump that constantly goes off at random intervals, disrupting sleep. What about a blood draw in the early morning where the phlebotomist sticks a needle into the arm of a sleeping patient? Or the well-intentioned provider doing prerounds who wakes a sleeping patient with a shake of the shoulder or some other form of physical touch? The multidisciplinary team crowding around their hospital bed? For a patient suffering from PTSD, any of these could easily set off a cascade of escalating symptoms.

Knowing that these triggers exist, can anything be done to ameliorate their effects? We propose some practical suggestions for improving the hospital experience for patients with PTSD.

Strategies to combat PTSD in the inpatient setting

Perhaps the most practical place to start is with preserving sleep in hospitalized patients with PTSD. The majority of patients with PTSD have sleep disturbances, and interrupted sleep routines in these patients can exacerbate nightmares and underlying psychiatric issues.⁵ Therefore, we should strive to avoid unnecessary awakenings.

While this principle holds true for all hospitalized patients, it must be especially prioritized in patients with PTSD. Ask yourself these questions during your next admission: Must intravenous fluids run 24 hours a day, or could they be stopped at 6 p.m.? Are vital signs needed overnight? Could the last dose of furosemide occur at 4 p.m. to avoid nocturia?

Another strategy involves bedtime routines. Many of these patients may already follow a home sleep routine as part of their chronic PTSD management. To honor these habits in the hospital might mean that staff encourage turning the lights and the television off at a designated time. Additionally, the literature suggests music therapy can have a significant impact on enhanced sleep quality. When available, music therapy may reduce insomnia and decrease the amount of time prior to falling asleep.⁶

Other methods to counteract PTSD fall under the general principle of “trauma-informed care.” Trauma-informed care comprises practices promoting a culture of safety, empowerment, and healing.⁷ It is a mindful and sensitive approach that acknowledges the pervasive nature of trauma exposure, the reality of ongoing adverse effects in trauma survivors, and the fact that recovery is highly personal and complex.⁸

By definition, patients with PTSD have endured some traumatic event. Therefore, ideal care teams will ask patients about things that may trigger their anxiety and then work to mitigate them. For example, some patients with PTSD have a severe startle response when woken up by someone touching them. When patients feel that they can share their concerns with their care team and their team honors that observation by waking them in a different way, trust and control may be gained. This process of asking for patient guidance and adjusting accordingly is consistent with a trauma-informed care approach.⁹ A true trauma-informed care approach involves the entire practice environment but examining and adjusting our own behavior and assumptions are good places to start.

Summary of recommended treatments

Psychotherapy is preferable over pharmacotherapy, but both can be combined as needed. Individual trauma-focused psychotherapies utilizing a primary component of exposure and/or cognitive restructuring have strong evidence for effectiveness but are primarily outpatient based.

For pharmacologic treatment, selective serotonin reuptake inhibitors (for example, sertraline, paroxetine, or fluoxetine) and serotonin norepinephrine reuptake inhibitors (for example, venlafaxine) monotherapy have strong evidence for effectiveness and can be started while inpatient. However, these medications typically take weeks to produce benefits. Recent trials studying prazosin, an alpha1-adrenergic receptor antagonist used to alleviate nightmares associated with PTSD, have demonstrated inefficacy or even harm,leading experts to caution against its use.^10,11 Finally, benzodiazepine and atypical antipsychotic usage should be restricted and used as a last resort.¹²

In summary, PTSD is common among veterans and nonveterans. While hospitalists may rarely admit patients because of their PTSD, they will often take care of patients who have PTSD as a comorbidity. Therefore, understanding the basics of PTSD and how hospitalization may exacerbate its symptoms can meaningfully improve care for these patients.

Dr. Fletcher is a hospitalist at the Milwaukee Veterans Affairs Medical Center and Froedtert Hospital in Wauwatosa, Wis. She is professor of internal medicine and program director for the internal medicine residency program at the Medical College of Wisconsin, Milwaukee. She is also faculty mentor for the VA’s Chief Resident for Quality and Safety. Dr. Kwan is a hospitalist at the VA San Diego Healthcare System and is associate professor at the University of California, San Diego, in the division of hospital medicine. He serves as an associate clerkship director of both the internal medicine clerkship and the medicine subinternship. He is the chair of SHM’s Physicians in Training committee. Dr. Steinbach is chief of hospital medicine at the Atlanta VA Medical Center and assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

References

1. Kang HK et al. Posttraumatic stress disorder and chronic fatigue syndrome–like illness among Gulf War veterans: A population-based survey of 30,000 veterans. Am J Epidemiol. 2003;157(2):141-8.

2. Kessler RC et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005; 62(6):593-602.

3. Cohen BE et al. Mental health diagnoses and utilization of VA nonmental health medical services among returning Iraq and Afghanistan veterans. J Gen Intern Med. 2010;25(1):18-24.

4. Haviland MG et al. Posttraumatic stress disorder–related hospitalizations in the United States (2002-2011): Rates, co-occurring illnesses, suicidal ideation/self-harm, and hospital charges. J Nerv Ment Dis. 2016; 204(2):78-86.

5. Aurora RN et al. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med. 2010;6(4):389-401.

6. Blanaru M et al. The effects of music relaxation and muscle relaxation techniques on sleep quality and emotional measures among individuals with posttraumatic stress disorder. Ment Illn. 2012;4(2):e13.

7. Tello M. (2018, Oct 16). Trauma-informed care: What it is, and why it’s important. Retrieved March 18, 2019, from https://www.health.harvard.edu/blog/trauma-informed-care-what-it-is-and-why-its-important-2018101613562.

8. Harris M et al. Using trauma theory to design service systems. San Francisco: 2001.

9. Substance abuse and mental health services administration. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS publication no. SMA 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.

10. Raskind MA et al. Trial of prazosin for posttraumatic stress disorder in military veterans. N Engl J Med. 2018 Feb 8;378(6):507-7.

11. McCall WV et al. A pilot, randomized clinical trial of bedtime doses of prazosin versus placebo in suicidal posttraumatic stress disorder patients with nightmares. J Clin Psychopharmacol. 2018 Dec;38(6):618-21.

12. U.S. Department of Veterans Affairs/U.S. Department of Defense. Clinical practice guideline for the management of posttraumatic stress disorder and acute stress reaction 2017. Accessed February 18, 2019.

“I need to get out of here! I haven’t gotten any sleep, my medications never come on time, and I feel like a pincushion. I am leaving NOW!” The commotion interrupts your intern’s meticulous presentation as your team quickly files into the room. You find a disheveled, visibly frustrated man tearing at his intravenous line, surrounded by his half-eaten breakfast and multiple urinals filled to various levels. His IV pump is beeping, and telemetry wires hang haphazardly off his chest.

Mr. Smith had been admitted for a heart failure exacerbation. You’d been making steady progress with diuresis but are now faced with a likely discharge against medical advice if you can’t defuse the situation.

As hospitalists, this scenario might feel eerily familiar. Perhaps Mr. Smith had enough of being in the hospital and just wanted to go home to see his dog, or maybe the food was not up to his standards.

However, his next line stops your team dead in its tracks. “I feel like I am in Vietnam all over again. I am tied up with all these wires and feel like a prisoner! Please let me go.” It turns out that Mr. Smith had a comorbidity that was overlooked during his initial intake: posttraumatic stress disorder.

Impact of PTSD

PTSD is a diagnosis characterized by intrusive recurrent thoughts, dreams, or flashbacks that follow exposure to a traumatic event or series of events (see Table 1). While more common among veterans (for example, Vietnam veterans have an estimated lifetime prevalence of PTSD of 30.9% for men and 26.9% for women),¹ a national survey of U.S. households estimated the lifetime prevalence of PTSD among adult Americans to be 6.8%.² PTSD is often underdiagnosed and underreported by patients in the outpatient setting, leading to underrecognition and undertreatment of these patients in the inpatient setting.

Although it may not be surprising that patients with PTSD use more mental health services, they are also more likely to use nonmental health services. In one study, total utilization of outpatient nonmental health services was 91% greater in veterans with PTSD, and these patients were three times more likely to be hospitalized than those without any mental health diagnoses.³ Additionally, they are likely to present later and stay longer when compared with patients without PTSD. One study estimated the cost of PTSD-related hospitalization in the United States from 2002 to 2011 as being $34.9 billion.⁴ Notably, close to 95% of hospitalizations in this study listed PTSD as a secondary rather than primary diagnosis, suggesting that the vast majority of these admitted patients are cared for by frontline providers who are not trained mental health professionals.

How PTSD manifests in the hospital

But, how exactly can the hospital environment contribute to decompensation of PTSD symptoms? Unfortunately, there is little empiric data to guide us. Based on what we do know of PTSD, we offer the following hypotheses.

Patients with PTSD may feel a loss of control or helplessness when admitted to the inpatient setting. For example, they cannot control when they receive their medications or when they get their meals. The act of showering or going outside requires approval. In addition, they might perceive they are being “ordered around” by staff and may be carted off to a study without knowing why the study is being done in the first place.

Triggers in the hospital environment may contribute to PTSD flares. Think about the loud, beeping IV pump that constantly goes off at random intervals, disrupting sleep. What about a blood draw in the early morning where the phlebotomist sticks a needle into the arm of a sleeping patient? Or the well-intentioned provider doing prerounds who wakes a sleeping patient with a shake of the shoulder or some other form of physical touch? The multidisciplinary team crowding around their hospital bed? For a patient suffering from PTSD, any of these could easily set off a cascade of escalating symptoms.

Knowing that these triggers exist, can anything be done to ameliorate their effects? We propose some practical suggestions for improving the hospital experience for patients with PTSD.

Strategies to combat PTSD in the inpatient setting

Perhaps the most practical place to start is with preserving sleep in hospitalized patients with PTSD. The majority of patients with PTSD have sleep disturbances, and interrupted sleep routines in these patients can exacerbate nightmares and underlying psychiatric issues.⁵ Therefore, we should strive to avoid unnecessary awakenings.

While this principle holds true for all hospitalized patients, it must be especially prioritized in patients with PTSD. Ask yourself these questions during your next admission: Must intravenous fluids run 24 hours a day, or could they be stopped at 6 p.m.? Are vital signs needed overnight? Could the last dose of furosemide occur at 4 p.m. to avoid nocturia?

Another strategy involves bedtime routines. Many of these patients may already follow a home sleep routine as part of their chronic PTSD management. To honor these habits in the hospital might mean that staff encourage turning the lights and the television off at a designated time. Additionally, the literature suggests music therapy can have a significant impact on enhanced sleep quality. When available, music therapy may reduce insomnia and decrease the amount of time prior to falling asleep.⁶

Other methods to counteract PTSD fall under the general principle of “trauma-informed care.” Trauma-informed care comprises practices promoting a culture of safety, empowerment, and healing.⁷ It is a mindful and sensitive approach that acknowledges the pervasive nature of trauma exposure, the reality of ongoing adverse effects in trauma survivors, and the fact that recovery is highly personal and complex.⁸

By definition, patients with PTSD have endured some traumatic event. Therefore, ideal care teams will ask patients about things that may trigger their anxiety and then work to mitigate them. For example, some patients with PTSD have a severe startle response when woken up by someone touching them. When patients feel that they can share their concerns with their care team and their team honors that observation by waking them in a different way, trust and control may be gained. This process of asking for patient guidance and adjusting accordingly is consistent with a trauma-informed care approach.⁹ A true trauma-informed care approach involves the entire practice environment but examining and adjusting our own behavior and assumptions are good places to start.

Summary of recommended treatments

Psychotherapy is preferable over pharmacotherapy, but both can be combined as needed. Individual trauma-focused psychotherapies utilizing a primary component of exposure and/or cognitive restructuring have strong evidence for effectiveness but are primarily outpatient based.

For pharmacologic treatment, selective serotonin reuptake inhibitors (for example, sertraline, paroxetine, or fluoxetine) and serotonin norepinephrine reuptake inhibitors (for example, venlafaxine) monotherapy have strong evidence for effectiveness and can be started while inpatient. However, these medications typically take weeks to produce benefits. Recent trials studying prazosin, an alpha1-adrenergic receptor antagonist used to alleviate nightmares associated with PTSD, have demonstrated inefficacy or even harm,leading experts to caution against its use.^10,11 Finally, benzodiazepine and atypical antipsychotic usage should be restricted and used as a last resort.¹²

In summary, PTSD is common among veterans and nonveterans. While hospitalists may rarely admit patients because of their PTSD, they will often take care of patients who have PTSD as a comorbidity. Therefore, understanding the basics of PTSD and how hospitalization may exacerbate its symptoms can meaningfully improve care for these patients.

Dr. Fletcher is a hospitalist at the Milwaukee Veterans Affairs Medical Center and Froedtert Hospital in Wauwatosa, Wis. She is professor of internal medicine and program director for the internal medicine residency program at the Medical College of Wisconsin, Milwaukee. She is also faculty mentor for the VA’s Chief Resident for Quality and Safety. Dr. Kwan is a hospitalist at the VA San Diego Healthcare System and is associate professor at the University of California, San Diego, in the division of hospital medicine. He serves as an associate clerkship director of both the internal medicine clerkship and the medicine subinternship. He is the chair of SHM’s Physicians in Training committee. Dr. Steinbach is chief of hospital medicine at the Atlanta VA Medical Center and assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

References

1. Kang HK et al. Posttraumatic stress disorder and chronic fatigue syndrome–like illness among Gulf War veterans: A population-based survey of 30,000 veterans. Am J Epidemiol. 2003;157(2):141-8.

2. Kessler RC et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005; 62(6):593-602.

3. Cohen BE et al. Mental health diagnoses and utilization of VA nonmental health medical services among returning Iraq and Afghanistan veterans. J Gen Intern Med. 2010;25(1):18-24.

4. Haviland MG et al. Posttraumatic stress disorder–related hospitalizations in the United States (2002-2011): Rates, co-occurring illnesses, suicidal ideation/self-harm, and hospital charges. J Nerv Ment Dis. 2016; 204(2):78-86.

5. Aurora RN et al. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med. 2010;6(4):389-401.

6. Blanaru M et al. The effects of music relaxation and muscle relaxation techniques on sleep quality and emotional measures among individuals with posttraumatic stress disorder. Ment Illn. 2012;4(2):e13.

7. Tello M. (2018, Oct 16). Trauma-informed care: What it is, and why it’s important. Retrieved March 18, 2019, from https://www.health.harvard.edu/blog/trauma-informed-care-what-it-is-and-why-its-important-2018101613562.

8. Harris M et al. Using trauma theory to design service systems. San Francisco: 2001.

9. Substance abuse and mental health services administration. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS publication no. SMA 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.

10. Raskind MA et al. Trial of prazosin for posttraumatic stress disorder in military veterans. N Engl J Med. 2018 Feb 8;378(6):507-7.

11. McCall WV et al. A pilot, randomized clinical trial of bedtime doses of prazosin versus placebo in suicidal posttraumatic stress disorder patients with nightmares. J Clin Psychopharmacol. 2018 Dec;38(6):618-21.

12. U.S. Department of Veterans Affairs/U.S. Department of Defense. Clinical practice guideline for the management of posttraumatic stress disorder and acute stress reaction 2017. Accessed February 18, 2019.

“I need to get out of here! I haven’t gotten any sleep, my medications never come on time, and I feel like a pincushion. I am leaving NOW!” The commotion interrupts your intern’s meticulous presentation as your team quickly files into the room. You find a disheveled, visibly frustrated man tearing at his intravenous line, surrounded by his half-eaten breakfast and multiple urinals filled to various levels. His IV pump is beeping, and telemetry wires hang haphazardly off his chest.

Mr. Smith had been admitted for a heart failure exacerbation. You’d been making steady progress with diuresis but are now faced with a likely discharge against medical advice if you can’t defuse the situation.

As hospitalists, this scenario might feel eerily familiar. Perhaps Mr. Smith had enough of being in the hospital and just wanted to go home to see his dog, or maybe the food was not up to his standards.

However, his next line stops your team dead in its tracks. “I feel like I am in Vietnam all over again. I am tied up with all these wires and feel like a prisoner! Please let me go.” It turns out that Mr. Smith had a comorbidity that was overlooked during his initial intake: posttraumatic stress disorder.

Impact of PTSD

PTSD is a diagnosis characterized by intrusive recurrent thoughts, dreams, or flashbacks that follow exposure to a traumatic event or series of events (see Table 1). While more common among veterans (for example, Vietnam veterans have an estimated lifetime prevalence of PTSD of 30.9% for men and 26.9% for women),¹ a national survey of U.S. households estimated the lifetime prevalence of PTSD among adult Americans to be 6.8%.² PTSD is often underdiagnosed and underreported by patients in the outpatient setting, leading to underrecognition and undertreatment of these patients in the inpatient setting.

Although it may not be surprising that patients with PTSD use more mental health services, they are also more likely to use nonmental health services. In one study, total utilization of outpatient nonmental health services was 91% greater in veterans with PTSD, and these patients were three times more likely to be hospitalized than those without any mental health diagnoses.³ Additionally, they are likely to present later and stay longer when compared with patients without PTSD. One study estimated the cost of PTSD-related hospitalization in the United States from 2002 to 2011 as being $34.9 billion.⁴ Notably, close to 95% of hospitalizations in this study listed PTSD as a secondary rather than primary diagnosis, suggesting that the vast majority of these admitted patients are cared for by frontline providers who are not trained mental health professionals.

How PTSD manifests in the hospital

But, how exactly can the hospital environment contribute to decompensation of PTSD symptoms? Unfortunately, there is little empiric data to guide us. Based on what we do know of PTSD, we offer the following hypotheses.

Patients with PTSD may feel a loss of control or helplessness when admitted to the inpatient setting. For example, they cannot control when they receive their medications or when they get their meals. The act of showering or going outside requires approval. In addition, they might perceive they are being “ordered around” by staff and may be carted off to a study without knowing why the study is being done in the first place.

Triggers in the hospital environment may contribute to PTSD flares. Think about the loud, beeping IV pump that constantly goes off at random intervals, disrupting sleep. What about a blood draw in the early morning where the phlebotomist sticks a needle into the arm of a sleeping patient? Or the well-intentioned provider doing prerounds who wakes a sleeping patient with a shake of the shoulder or some other form of physical touch? The multidisciplinary team crowding around their hospital bed? For a patient suffering from PTSD, any of these could easily set off a cascade of escalating symptoms.

Knowing that these triggers exist, can anything be done to ameliorate their effects? We propose some practical suggestions for improving the hospital experience for patients with PTSD.

Strategies to combat PTSD in the inpatient setting

Perhaps the most practical place to start is with preserving sleep in hospitalized patients with PTSD. The majority of patients with PTSD have sleep disturbances, and interrupted sleep routines in these patients can exacerbate nightmares and underlying psychiatric issues.⁵ Therefore, we should strive to avoid unnecessary awakenings.

While this principle holds true for all hospitalized patients, it must be especially prioritized in patients with PTSD. Ask yourself these questions during your next admission: Must intravenous fluids run 24 hours a day, or could they be stopped at 6 p.m.? Are vital signs needed overnight? Could the last dose of furosemide occur at 4 p.m. to avoid nocturia?

Another strategy involves bedtime routines. Many of these patients may already follow a home sleep routine as part of their chronic PTSD management. To honor these habits in the hospital might mean that staff encourage turning the lights and the television off at a designated time. Additionally, the literature suggests music therapy can have a significant impact on enhanced sleep quality. When available, music therapy may reduce insomnia and decrease the amount of time prior to falling asleep.⁶

Other methods to counteract PTSD fall under the general principle of “trauma-informed care.” Trauma-informed care comprises practices promoting a culture of safety, empowerment, and healing.⁷ It is a mindful and sensitive approach that acknowledges the pervasive nature of trauma exposure, the reality of ongoing adverse effects in trauma survivors, and the fact that recovery is highly personal and complex.⁸

By definition, patients with PTSD have endured some traumatic event. Therefore, ideal care teams will ask patients about things that may trigger their anxiety and then work to mitigate them. For example, some patients with PTSD have a severe startle response when woken up by someone touching them. When patients feel that they can share their concerns with their care team and their team honors that observation by waking them in a different way, trust and control may be gained. This process of asking for patient guidance and adjusting accordingly is consistent with a trauma-informed care approach.⁹ A true trauma-informed care approach involves the entire practice environment but examining and adjusting our own behavior and assumptions are good places to start.

Summary of recommended treatments

Psychotherapy is preferable over pharmacotherapy, but both can be combined as needed. Individual trauma-focused psychotherapies utilizing a primary component of exposure and/or cognitive restructuring have strong evidence for effectiveness but are primarily outpatient based.

For pharmacologic treatment, selective serotonin reuptake inhibitors (for example, sertraline, paroxetine, or fluoxetine) and serotonin norepinephrine reuptake inhibitors (for example, venlafaxine) monotherapy have strong evidence for effectiveness and can be started while inpatient. However, these medications typically take weeks to produce benefits. Recent trials studying prazosin, an alpha1-adrenergic receptor antagonist used to alleviate nightmares associated with PTSD, have demonstrated inefficacy or even harm,leading experts to caution against its use.^10,11 Finally, benzodiazepine and atypical antipsychotic usage should be restricted and used as a last resort.¹²

In summary, PTSD is common among veterans and nonveterans. While hospitalists may rarely admit patients because of their PTSD, they will often take care of patients who have PTSD as a comorbidity. Therefore, understanding the basics of PTSD and how hospitalization may exacerbate its symptoms can meaningfully improve care for these patients.

Dr. Fletcher is a hospitalist at the Milwaukee Veterans Affairs Medical Center and Froedtert Hospital in Wauwatosa, Wis. She is professor of internal medicine and program director for the internal medicine residency program at the Medical College of Wisconsin, Milwaukee. She is also faculty mentor for the VA’s Chief Resident for Quality and Safety. Dr. Kwan is a hospitalist at the VA San Diego Healthcare System and is associate professor at the University of California, San Diego, in the division of hospital medicine. He serves as an associate clerkship director of both the internal medicine clerkship and the medicine subinternship. He is the chair of SHM’s Physicians in Training committee. Dr. Steinbach is chief of hospital medicine at the Atlanta VA Medical Center and assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

References

1. Kang HK et al. Posttraumatic stress disorder and chronic fatigue syndrome–like illness among Gulf War veterans: A population-based survey of 30,000 veterans. Am J Epidemiol. 2003;157(2):141-8.

2. Kessler RC et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005; 62(6):593-602.

3. Cohen BE et al. Mental health diagnoses and utilization of VA nonmental health medical services among returning Iraq and Afghanistan veterans. J Gen Intern Med. 2010;25(1):18-24.

4. Haviland MG et al. Posttraumatic stress disorder–related hospitalizations in the United States (2002-2011): Rates, co-occurring illnesses, suicidal ideation/self-harm, and hospital charges. J Nerv Ment Dis. 2016; 204(2):78-86.

5. Aurora RN et al. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med. 2010;6(4):389-401.

6. Blanaru M et al. The effects of music relaxation and muscle relaxation techniques on sleep quality and emotional measures among individuals with posttraumatic stress disorder. Ment Illn. 2012;4(2):e13.

7. Tello M. (2018, Oct 16). Trauma-informed care: What it is, and why it’s important. Retrieved March 18, 2019, from https://www.health.harvard.edu/blog/trauma-informed-care-what-it-is-and-why-its-important-2018101613562.

8. Harris M et al. Using trauma theory to design service systems. San Francisco: 2001.

9. Substance abuse and mental health services administration. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS publication no. SMA 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.

10. Raskind MA et al. Trial of prazosin for posttraumatic stress disorder in military veterans. N Engl J Med. 2018 Feb 8;378(6):507-7.

11. McCall WV et al. A pilot, randomized clinical trial of bedtime doses of prazosin versus placebo in suicidal posttraumatic stress disorder patients with nightmares. J Clin Psychopharmacol. 2018 Dec;38(6):618-21.

12. U.S. Department of Veterans Affairs/U.S. Department of Defense. Clinical practice guideline for the management of posttraumatic stress disorder and acute stress reaction 2017. Accessed February 18, 2019.

It’s Monday morning, and your intern is presenting an overnight admission. Lost in the details of his disorganized introduction, your mind wanders. “Why doesn’t this intern know how to present? When I trained, all those admissions during long sleepless nights really taught me to do this right.” But can we equate hours worked with competency achieved? And if not, what is the alternative? This article introduces some major changes in medical education and their implications for hospitalists.

Most hospitalists trained in an educational system influenced by Sir William Osler. In the early 1900s, he introduced the natural method of teaching, positing that student exposure to patients and experience over time ensured that physicians in training would become competent doctors.¹ His influence led to the current structure of medical education, which includes conventional third-year clerkships and time-limited rotations (such as a 2-week nephrology block).

While familiarity may be comforting, there are signs our current model of medical education is inefficient, inadequate, and obsolete.

For one, the traditional system is failing to adequately prepare physicians to provide safe and complex care. Reports, such as the Institute of Medicine’s (IOM) “To Err is Human,”² describe a high rate of preventable errors, highlighting considerable room for improvement in training the next generation of physicians.^3,4

Meanwhile, trainees are still largely being deemed ready for the workforce by length of training completed (for example, completion of four-year medical school) rather than a skill set distinctly achieved. Our system leaves little flexibility to individualize learner goals, which is significant given some students and residents take shorter or longer periods of time to achieve proficiency. In addition, learner outcomes can be quite variable, as we have all experienced.

Even our methods of assessment may not adequately evaluate trainees’ skill sets. For example, most clerkships still rely heavily on the shelf exam⁵ as a surrogate for medical knowledge. As such, learners may conclude that testing performance trumps development of other professional skills.⁶ Efforts are being made to revamp evaluation systems to reflect mastery (such as Entrustable Professional Activities, or EPAs) toward competencies.⁷ Still, many institutions continue to rely on faculty evaluations that often reflect interpersonal dynamics rather than true critical thinking skills.⁶

Recognizing the above limitations, many educators have called for changing to outcome-based, or competency-based, training (CBME). CBME targets attainment of skills in performing concrete critical clinical activities,⁸ such as identifying unstable patients, providing initial management, and obtaining help. To be successful, supervisors must directly observe trainees, assess demonstrated skills, and provide feedback about progress.

Unfortunately, this considerable investment of time and effort is often poorly compensated. Additionally, unanswered questions remain. For example, how will residency programs continue to challenge physicians deemed “competent” in a required skill? What happens when a trainee is deficient and not appropriately progressing in a required skill? Is flexible training time part of the future of medical education? While CBME appears to be a more effective method of education, questions like these must be addressed during implementation.

Beyond the fact that hours worked cannot be used as a surrogate for competency, excessive unregulated work hours can be detrimental to learners, their supervisors, and patients. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented a major change in medical education: duty hour limitations. The premise that sleep-deprived providers are more prone to error is well established. However, controversy remains as to whether these regulations translate into improved patient care and provider well-being. Studies published following the ACGME change demonstrate increasing burnout among physicians,^9-11 which has led some educators to explore the potential relationship between burnout and duty hour restrictions.

The recent “iCOMPARE” trial, which compared internal medicine (IM) residencies with “standard duty-hour” policies to those with “flexible” policies (that is, they did not specify limits on shift length or mandatory time off between shifts), supported a lack of correlation between hours worked and burnout.¹² Researchers administered the Maslach Burnout Inventory to all participants.¹³ While those in the “flexible hours” arm reported greater dissatisfaction with the effect of the program on their personal lives, both groups reported significant burnout, with interns recording high scores in emotional exhaustion (79% in flexible programs vs. 72% in standard), depersonalization (75% vs. 72%), and lack of personal accomplishment (71% vs. 69%).

Disturbingly, these scores were not restricted to interns but were present in all residents. The good news? Limiting duty hours does not cause burnout. On the other hand, it does not protect from burnout. Trainee burnout appears to transcend the issue of hours worked. Clearly, we need to address the systemic flaws in our work environments that contribute to this epidemic. Nationwide, educators and organizations are continuing to define causes of burnout and test interventions to improve wellness.

A final front of change in medical education worth mentioning is the use of the electronic medical record (EMR). While the EMR has improved many aspects of patient care, its implementation is associated with decreased time spent with patients and parallels the rise in burnout. Another unforeseen consequence has been its disruptive impact on medical student documentation. A national survey of clerkship directors found that, while 64% of programs allowed students to use the EMR, only two-thirds of those programs permitted students to document electronically.¹⁴

Many institutions limit student access because of either liability concerns or the fact that student notes cannot be used to support medical billing. Concerning workarounds among preceptors, such as logging in students under their own credentials to write notes, have been identified.¹⁵ Yet medical students need to learn how to document a clinical encounter and maintain medical records.^7,16 Authoring notes engages students, promotes a sense of patient ownership, and empowers them to feel like essential team members. Participating in the EMR also allows for critical feedback and skill development.

In 2016, the Society of Hospital Medicine joined several major internal medicine organizations in asking the federal government to reconsider guidelines prohibiting attendings from referring to medical student notes. In February 2018, the Centers for Medicare & Medicaid Services (CMS) revised its student documentation guidelines (see Box A), allowing teaching physicians to use all student documentation (not just Review of Systems, Family History, and Social History) for billable services.

While the guidelines officially went into effect in March 2018, many institutions are still fine-tuning their implementation, in part because of nonspecific policy language. For instance, if a student composes a note and a resident edits and signs it, can the attending physician simply cosign the resident note? Also, once a student has presented a case, can the attending see the patient and verify findings without the student present?

Despite the above challenges, the revision to CMS guidelines is a significant “win” and can potentially reduce the documentation burden on teaching physicians. With more oversight of their notes, the next generation of students will be encouraged to produce accurate, high-quality documentation.

In summary, these changes in the way we define competency, in duty hours, and in the use of the EMR demonstrate that medical education is continuously improving via robust critique and educator engagement in outcomes. We are fortunate to train in a system that respects the scientific method and utilizes data and critical events to drive important changes in practice. Understanding these changes might help hospitalists relate to the backgrounds and needs of learners. And who knows – maybe next time that intern will do a better job presenting!
 

Dr. Kwan is a hospitalist at the Veterans Affairs San Diego Healthcare System (VASDHS) and an associate professor at the University of California, San Diego, in the division of hospital medicine. He is the chair of the SHM Physicians in Training committee. Dr. Sebasky is an associate clinical professor at UCSD in the division of hospital medicine. Dr. Muchmore is a hematologist/oncologist and professor of clinical medicine in the department of medicine at UCSD and associate chief of staff for education at VASDHS.

References

1. Osler W. “The Hospital as a College.” In Aequanimitas. Osler W, Ed. (Philadelphia: P. Blakiston’s Son & Co., 1932).

2. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health Care System. (Washington: National Academies Press, 1999).

3. Ten Cate O. Competency-based postgraduate medical education: Past, present and future. GMS J Med Educ. 2017 Nov 15. doi: 10.3205/zma001146.

4. Carraccio C, Englander R, Van Melle E, et al. Advancing competency-based medical education: A charter for clinician–educators. Acad Med. 2016;91(5):645-9.

5. 2016 NBME Clinical Clerkship Subject Examination Survey.

6. Mehta NB, Hull AL, Young JB, et al. Just imagine: New paradigms for medical education. Acad Med. 2013;88(10):1418-23.

7. Fazio SB, Ledford CH, Aronowitz PB, et al. Competency-based medical education in the internal medicine clerkship: A report from the Alliance for Academic Internal Medicine Undergraduate Medical Education Task Force. Acad Med. 2018;93(3):421-7.

8. Ten Cate O, Scheele F. Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Acad Med. 2007 Jun;82(6):542-7.

9. Dewa CS, Loong D, Bonato S, et al. The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: A systematic review. BMJ Open. 2017. doi: 10.1136/bmjopen-2016-015141.

10. Hall LH, Johnson J, Watt I, et al. Healthcare Staff wellbeing, burnout, and patient safety: A systematic review. PLoS ONE. 2016. doi: 10.1371/journal.pone.0159015.

11. Salyers MP, Bonfils KA, Luther L, et al. The relationship between professional burnout and quality and safety in healthcare: A meta-analysis. Gen Intern Med. 2017 Apr; 32(4):475-82.

12. Desai SV, Asch DA, Bellini LM, et al. Education outcomes in a duty hour flexibility trial in internal medicine. N Engl J Med. 2018 378:1494-508.

13. Maslach C, Jackson SE, Leiter MP. Maslach burnout inventory manual. 3rd ed. (Palo Alto, CA: Consulting Psychologists Press, 1996).

14. Hammoud MM, Margo K, Christner JG, et al. Opportunities and challenges in integrating electronic health records into undergraduate medical education: A national survey of clerkship directors. Teach Learn Med. 2012;24(3):219-24.

15. White J, Anthony D, WinklerPrins V, et al. Electronic medical records, medical students, and ambulatory family physicians: A multi-institution study. Acad Med. 2017;92(10):1485-90.

16. Pageler NM, Friedman CP, Longhurst CA. Refocusing medical education in the EMR era. JAMA 2013;310(21):2249-50.
 

Box A

“Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam, and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.”
 

It’s Monday morning, and your intern is presenting an overnight admission. Lost in the details of his disorganized introduction, your mind wanders. “Why doesn’t this intern know how to present? When I trained, all those admissions during long sleepless nights really taught me to do this right.” But can we equate hours worked with competency achieved? And if not, what is the alternative? This article introduces some major changes in medical education and their implications for hospitalists.

Most hospitalists trained in an educational system influenced by Sir William Osler. In the early 1900s, he introduced the natural method of teaching, positing that student exposure to patients and experience over time ensured that physicians in training would become competent doctors.¹ His influence led to the current structure of medical education, which includes conventional third-year clerkships and time-limited rotations (such as a 2-week nephrology block).

While familiarity may be comforting, there are signs our current model of medical education is inefficient, inadequate, and obsolete.

For one, the traditional system is failing to adequately prepare physicians to provide safe and complex care. Reports, such as the Institute of Medicine’s (IOM) “To Err is Human,”² describe a high rate of preventable errors, highlighting considerable room for improvement in training the next generation of physicians.^3,4

Meanwhile, trainees are still largely being deemed ready for the workforce by length of training completed (for example, completion of four-year medical school) rather than a skill set distinctly achieved. Our system leaves little flexibility to individualize learner goals, which is significant given some students and residents take shorter or longer periods of time to achieve proficiency. In addition, learner outcomes can be quite variable, as we have all experienced.

Even our methods of assessment may not adequately evaluate trainees’ skill sets. For example, most clerkships still rely heavily on the shelf exam⁵ as a surrogate for medical knowledge. As such, learners may conclude that testing performance trumps development of other professional skills.⁶ Efforts are being made to revamp evaluation systems to reflect mastery (such as Entrustable Professional Activities, or EPAs) toward competencies.⁷ Still, many institutions continue to rely on faculty evaluations that often reflect interpersonal dynamics rather than true critical thinking skills.⁶

Recognizing the above limitations, many educators have called for changing to outcome-based, or competency-based, training (CBME). CBME targets attainment of skills in performing concrete critical clinical activities,⁸ such as identifying unstable patients, providing initial management, and obtaining help. To be successful, supervisors must directly observe trainees, assess demonstrated skills, and provide feedback about progress.

Unfortunately, this considerable investment of time and effort is often poorly compensated. Additionally, unanswered questions remain. For example, how will residency programs continue to challenge physicians deemed “competent” in a required skill? What happens when a trainee is deficient and not appropriately progressing in a required skill? Is flexible training time part of the future of medical education? While CBME appears to be a more effective method of education, questions like these must be addressed during implementation.

Beyond the fact that hours worked cannot be used as a surrogate for competency, excessive unregulated work hours can be detrimental to learners, their supervisors, and patients. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented a major change in medical education: duty hour limitations. The premise that sleep-deprived providers are more prone to error is well established. However, controversy remains as to whether these regulations translate into improved patient care and provider well-being. Studies published following the ACGME change demonstrate increasing burnout among physicians,^9-11 which has led some educators to explore the potential relationship between burnout and duty hour restrictions.

The recent “iCOMPARE” trial, which compared internal medicine (IM) residencies with “standard duty-hour” policies to those with “flexible” policies (that is, they did not specify limits on shift length or mandatory time off between shifts), supported a lack of correlation between hours worked and burnout.¹² Researchers administered the Maslach Burnout Inventory to all participants.¹³ While those in the “flexible hours” arm reported greater dissatisfaction with the effect of the program on their personal lives, both groups reported significant burnout, with interns recording high scores in emotional exhaustion (79% in flexible programs vs. 72% in standard), depersonalization (75% vs. 72%), and lack of personal accomplishment (71% vs. 69%).

Disturbingly, these scores were not restricted to interns but were present in all residents. The good news? Limiting duty hours does not cause burnout. On the other hand, it does not protect from burnout. Trainee burnout appears to transcend the issue of hours worked. Clearly, we need to address the systemic flaws in our work environments that contribute to this epidemic. Nationwide, educators and organizations are continuing to define causes of burnout and test interventions to improve wellness.

A final front of change in medical education worth mentioning is the use of the electronic medical record (EMR). While the EMR has improved many aspects of patient care, its implementation is associated with decreased time spent with patients and parallels the rise in burnout. Another unforeseen consequence has been its disruptive impact on medical student documentation. A national survey of clerkship directors found that, while 64% of programs allowed students to use the EMR, only two-thirds of those programs permitted students to document electronically.¹⁴

Many institutions limit student access because of either liability concerns or the fact that student notes cannot be used to support medical billing. Concerning workarounds among preceptors, such as logging in students under their own credentials to write notes, have been identified.¹⁵ Yet medical students need to learn how to document a clinical encounter and maintain medical records.^7,16 Authoring notes engages students, promotes a sense of patient ownership, and empowers them to feel like essential team members. Participating in the EMR also allows for critical feedback and skill development.

In 2016, the Society of Hospital Medicine joined several major internal medicine organizations in asking the federal government to reconsider guidelines prohibiting attendings from referring to medical student notes. In February 2018, the Centers for Medicare & Medicaid Services (CMS) revised its student documentation guidelines (see Box A), allowing teaching physicians to use all student documentation (not just Review of Systems, Family History, and Social History) for billable services.

While the guidelines officially went into effect in March 2018, many institutions are still fine-tuning their implementation, in part because of nonspecific policy language. For instance, if a student composes a note and a resident edits and signs it, can the attending physician simply cosign the resident note? Also, once a student has presented a case, can the attending see the patient and verify findings without the student present?

Despite the above challenges, the revision to CMS guidelines is a significant “win” and can potentially reduce the documentation burden on teaching physicians. With more oversight of their notes, the next generation of students will be encouraged to produce accurate, high-quality documentation.

In summary, these changes in the way we define competency, in duty hours, and in the use of the EMR demonstrate that medical education is continuously improving via robust critique and educator engagement in outcomes. We are fortunate to train in a system that respects the scientific method and utilizes data and critical events to drive important changes in practice. Understanding these changes might help hospitalists relate to the backgrounds and needs of learners. And who knows – maybe next time that intern will do a better job presenting!
 

Dr. Kwan is a hospitalist at the Veterans Affairs San Diego Healthcare System (VASDHS) and an associate professor at the University of California, San Diego, in the division of hospital medicine. He is the chair of the SHM Physicians in Training committee. Dr. Sebasky is an associate clinical professor at UCSD in the division of hospital medicine. Dr. Muchmore is a hematologist/oncologist and professor of clinical medicine in the department of medicine at UCSD and associate chief of staff for education at VASDHS.

References

1. Osler W. “The Hospital as a College.” In Aequanimitas. Osler W, Ed. (Philadelphia: P. Blakiston’s Son & Co., 1932).

2. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health Care System. (Washington: National Academies Press, 1999).

3. Ten Cate O. Competency-based postgraduate medical education: Past, present and future. GMS J Med Educ. 2017 Nov 15. doi: 10.3205/zma001146.

4. Carraccio C, Englander R, Van Melle E, et al. Advancing competency-based medical education: A charter for clinician–educators. Acad Med. 2016;91(5):645-9.

5. 2016 NBME Clinical Clerkship Subject Examination Survey.

6. Mehta NB, Hull AL, Young JB, et al. Just imagine: New paradigms for medical education. Acad Med. 2013;88(10):1418-23.

7. Fazio SB, Ledford CH, Aronowitz PB, et al. Competency-based medical education in the internal medicine clerkship: A report from the Alliance for Academic Internal Medicine Undergraduate Medical Education Task Force. Acad Med. 2018;93(3):421-7.

8. Ten Cate O, Scheele F. Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Acad Med. 2007 Jun;82(6):542-7.

9. Dewa CS, Loong D, Bonato S, et al. The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: A systematic review. BMJ Open. 2017. doi: 10.1136/bmjopen-2016-015141.

10. Hall LH, Johnson J, Watt I, et al. Healthcare Staff wellbeing, burnout, and patient safety: A systematic review. PLoS ONE. 2016. doi: 10.1371/journal.pone.0159015.

11. Salyers MP, Bonfils KA, Luther L, et al. The relationship between professional burnout and quality and safety in healthcare: A meta-analysis. Gen Intern Med. 2017 Apr; 32(4):475-82.

12. Desai SV, Asch DA, Bellini LM, et al. Education outcomes in a duty hour flexibility trial in internal medicine. N Engl J Med. 2018 378:1494-508.

13. Maslach C, Jackson SE, Leiter MP. Maslach burnout inventory manual. 3rd ed. (Palo Alto, CA: Consulting Psychologists Press, 1996).

14. Hammoud MM, Margo K, Christner JG, et al. Opportunities and challenges in integrating electronic health records into undergraduate medical education: A national survey of clerkship directors. Teach Learn Med. 2012;24(3):219-24.

15. White J, Anthony D, WinklerPrins V, et al. Electronic medical records, medical students, and ambulatory family physicians: A multi-institution study. Acad Med. 2017;92(10):1485-90.

16. Pageler NM, Friedman CP, Longhurst CA. Refocusing medical education in the EMR era. JAMA 2013;310(21):2249-50.
 

Box A

“Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam, and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.”
 

It’s Monday morning, and your intern is presenting an overnight admission. Lost in the details of his disorganized introduction, your mind wanders. “Why doesn’t this intern know how to present? When I trained, all those admissions during long sleepless nights really taught me to do this right.” But can we equate hours worked with competency achieved? And if not, what is the alternative? This article introduces some major changes in medical education and their implications for hospitalists.

Most hospitalists trained in an educational system influenced by Sir William Osler. In the early 1900s, he introduced the natural method of teaching, positing that student exposure to patients and experience over time ensured that physicians in training would become competent doctors.¹ His influence led to the current structure of medical education, which includes conventional third-year clerkships and time-limited rotations (such as a 2-week nephrology block).

While familiarity may be comforting, there are signs our current model of medical education is inefficient, inadequate, and obsolete.

For one, the traditional system is failing to adequately prepare physicians to provide safe and complex care. Reports, such as the Institute of Medicine’s (IOM) “To Err is Human,”² describe a high rate of preventable errors, highlighting considerable room for improvement in training the next generation of physicians.^3,4

Meanwhile, trainees are still largely being deemed ready for the workforce by length of training completed (for example, completion of four-year medical school) rather than a skill set distinctly achieved. Our system leaves little flexibility to individualize learner goals, which is significant given some students and residents take shorter or longer periods of time to achieve proficiency. In addition, learner outcomes can be quite variable, as we have all experienced.

Even our methods of assessment may not adequately evaluate trainees’ skill sets. For example, most clerkships still rely heavily on the shelf exam⁵ as a surrogate for medical knowledge. As such, learners may conclude that testing performance trumps development of other professional skills.⁶ Efforts are being made to revamp evaluation systems to reflect mastery (such as Entrustable Professional Activities, or EPAs) toward competencies.⁷ Still, many institutions continue to rely on faculty evaluations that often reflect interpersonal dynamics rather than true critical thinking skills.⁶

Recognizing the above limitations, many educators have called for changing to outcome-based, or competency-based, training (CBME). CBME targets attainment of skills in performing concrete critical clinical activities,⁸ such as identifying unstable patients, providing initial management, and obtaining help. To be successful, supervisors must directly observe trainees, assess demonstrated skills, and provide feedback about progress.

Unfortunately, this considerable investment of time and effort is often poorly compensated. Additionally, unanswered questions remain. For example, how will residency programs continue to challenge physicians deemed “competent” in a required skill? What happens when a trainee is deficient and not appropriately progressing in a required skill? Is flexible training time part of the future of medical education? While CBME appears to be a more effective method of education, questions like these must be addressed during implementation.

Beyond the fact that hours worked cannot be used as a surrogate for competency, excessive unregulated work hours can be detrimental to learners, their supervisors, and patients. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented a major change in medical education: duty hour limitations. The premise that sleep-deprived providers are more prone to error is well established. However, controversy remains as to whether these regulations translate into improved patient care and provider well-being. Studies published following the ACGME change demonstrate increasing burnout among physicians,^9-11 which has led some educators to explore the potential relationship between burnout and duty hour restrictions.

The recent “iCOMPARE” trial, which compared internal medicine (IM) residencies with “standard duty-hour” policies to those with “flexible” policies (that is, they did not specify limits on shift length or mandatory time off between shifts), supported a lack of correlation between hours worked and burnout.¹² Researchers administered the Maslach Burnout Inventory to all participants.¹³ While those in the “flexible hours” arm reported greater dissatisfaction with the effect of the program on their personal lives, both groups reported significant burnout, with interns recording high scores in emotional exhaustion (79% in flexible programs vs. 72% in standard), depersonalization (75% vs. 72%), and lack of personal accomplishment (71% vs. 69%).

Disturbingly, these scores were not restricted to interns but were present in all residents. The good news? Limiting duty hours does not cause burnout. On the other hand, it does not protect from burnout. Trainee burnout appears to transcend the issue of hours worked. Clearly, we need to address the systemic flaws in our work environments that contribute to this epidemic. Nationwide, educators and organizations are continuing to define causes of burnout and test interventions to improve wellness.

A final front of change in medical education worth mentioning is the use of the electronic medical record (EMR). While the EMR has improved many aspects of patient care, its implementation is associated with decreased time spent with patients and parallels the rise in burnout. Another unforeseen consequence has been its disruptive impact on medical student documentation. A national survey of clerkship directors found that, while 64% of programs allowed students to use the EMR, only two-thirds of those programs permitted students to document electronically.¹⁴

Many institutions limit student access because of either liability concerns or the fact that student notes cannot be used to support medical billing. Concerning workarounds among preceptors, such as logging in students under their own credentials to write notes, have been identified.¹⁵ Yet medical students need to learn how to document a clinical encounter and maintain medical records.^7,16 Authoring notes engages students, promotes a sense of patient ownership, and empowers them to feel like essential team members. Participating in the EMR also allows for critical feedback and skill development.

In 2016, the Society of Hospital Medicine joined several major internal medicine organizations in asking the federal government to reconsider guidelines prohibiting attendings from referring to medical student notes. In February 2018, the Centers for Medicare & Medicaid Services (CMS) revised its student documentation guidelines (see Box A), allowing teaching physicians to use all student documentation (not just Review of Systems, Family History, and Social History) for billable services.

While the guidelines officially went into effect in March 2018, many institutions are still fine-tuning their implementation, in part because of nonspecific policy language. For instance, if a student composes a note and a resident edits and signs it, can the attending physician simply cosign the resident note? Also, once a student has presented a case, can the attending see the patient and verify findings without the student present?

Despite the above challenges, the revision to CMS guidelines is a significant “win” and can potentially reduce the documentation burden on teaching physicians. With more oversight of their notes, the next generation of students will be encouraged to produce accurate, high-quality documentation.

In summary, these changes in the way we define competency, in duty hours, and in the use of the EMR demonstrate that medical education is continuously improving via robust critique and educator engagement in outcomes. We are fortunate to train in a system that respects the scientific method and utilizes data and critical events to drive important changes in practice. Understanding these changes might help hospitalists relate to the backgrounds and needs of learners. And who knows – maybe next time that intern will do a better job presenting!
 

Dr. Kwan is a hospitalist at the Veterans Affairs San Diego Healthcare System (VASDHS) and an associate professor at the University of California, San Diego, in the division of hospital medicine. He is the chair of the SHM Physicians in Training committee. Dr. Sebasky is an associate clinical professor at UCSD in the division of hospital medicine. Dr. Muchmore is a hematologist/oncologist and professor of clinical medicine in the department of medicine at UCSD and associate chief of staff for education at VASDHS.

References

1. Osler W. “The Hospital as a College.” In Aequanimitas. Osler W, Ed. (Philadelphia: P. Blakiston’s Son & Co., 1932).

2. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health Care System. (Washington: National Academies Press, 1999).

3. Ten Cate O. Competency-based postgraduate medical education: Past, present and future. GMS J Med Educ. 2017 Nov 15. doi: 10.3205/zma001146.

4. Carraccio C, Englander R, Van Melle E, et al. Advancing competency-based medical education: A charter for clinician–educators. Acad Med. 2016;91(5):645-9.

5. 2016 NBME Clinical Clerkship Subject Examination Survey.

6. Mehta NB, Hull AL, Young JB, et al. Just imagine: New paradigms for medical education. Acad Med. 2013;88(10):1418-23.

7. Fazio SB, Ledford CH, Aronowitz PB, et al. Competency-based medical education in the internal medicine clerkship: A report from the Alliance for Academic Internal Medicine Undergraduate Medical Education Task Force. Acad Med. 2018;93(3):421-7.

8. Ten Cate O, Scheele F. Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Acad Med. 2007 Jun;82(6):542-7.

9. Dewa CS, Loong D, Bonato S, et al. The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: A systematic review. BMJ Open. 2017. doi: 10.1136/bmjopen-2016-015141.

10. Hall LH, Johnson J, Watt I, et al. Healthcare Staff wellbeing, burnout, and patient safety: A systematic review. PLoS ONE. 2016. doi: 10.1371/journal.pone.0159015.

11. Salyers MP, Bonfils KA, Luther L, et al. The relationship between professional burnout and quality and safety in healthcare: A meta-analysis. Gen Intern Med. 2017 Apr; 32(4):475-82.

12. Desai SV, Asch DA, Bellini LM, et al. Education outcomes in a duty hour flexibility trial in internal medicine. N Engl J Med. 2018 378:1494-508.

13. Maslach C, Jackson SE, Leiter MP. Maslach burnout inventory manual. 3rd ed. (Palo Alto, CA: Consulting Psychologists Press, 1996).

14. Hammoud MM, Margo K, Christner JG, et al. Opportunities and challenges in integrating electronic health records into undergraduate medical education: A national survey of clerkship directors. Teach Learn Med. 2012;24(3):219-24.

15. White J, Anthony D, WinklerPrins V, et al. Electronic medical records, medical students, and ambulatory family physicians: A multi-institution study. Acad Med. 2017;92(10):1485-90.

16. Pageler NM, Friedman CP, Longhurst CA. Refocusing medical education in the EMR era. JAMA 2013;310(21):2249-50.
 

Box A

“Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam, and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.”