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Percutaneous coronary intervention (PCI) does not improve exercise time in patients with stable angina
Clinical question: Does PCI provide symptom relief in patients with stable angina?
Background: More than 500,000 PCIs are done yearly worldwide in patients with stable angina. Meta-analyses have demonstrated no impact of PCI on rates of death and myocardial infarction in patients with stable angina. Rather, relief of angina is the main reason for performance of PCI in patients with stable coronary artery disease, and this effect is frequently noted. However, there have been no data from double-blind, randomized, controlled trials to confirm the efficacy of PCI in relieving anginal pain.
Study design: Multicenter, double-blind, randomized, controlled trial.
Setting: Five sites in the United Kingdom.
Synopsis: The Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA) trial was designed to evaluate the effect of PCI, compared with placebo, on exercise time in patients with stable angina. The 230 patients who were enrolled in ORBITA had severe (70% or more), single-vessel stenosis. After enrolling, patients’ medication regimens were optimized so that almost all were taking aspirin, a second antiplatelet drug, and a statin. Beta-blockers and calcium channel blockers also were widely used by trial participants. Two hundred patients were randomized to either PCI (105 patients) or placebo procedure (95 patients). The primary endpoint was exercise time, and no difference was observed between the two groups. ORBITA’s results apply to patients with stable angina but not to those who undergo PCI for acute coronary syndrome (which includes ST-elevation MI); in the latter population, PCI has been demonstrated to reduce morbidity and mortality.
Bottom line: In patients with stable angina, PCI does not increase exercise time.
Citation: Al-Lamee R et al. Percutaneous coronary intervention in stable angina (ORBITA): A double-blind, randomised controlled trial. Lancet. 2018 Jan;391(10115);31-40.
Dr. Clarke is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Clinical question: Does PCI provide symptom relief in patients with stable angina?
Background: More than 500,000 PCIs are done yearly worldwide in patients with stable angina. Meta-analyses have demonstrated no impact of PCI on rates of death and myocardial infarction in patients with stable angina. Rather, relief of angina is the main reason for performance of PCI in patients with stable coronary artery disease, and this effect is frequently noted. However, there have been no data from double-blind, randomized, controlled trials to confirm the efficacy of PCI in relieving anginal pain.
Study design: Multicenter, double-blind, randomized, controlled trial.
Setting: Five sites in the United Kingdom.
Synopsis: The Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA) trial was designed to evaluate the effect of PCI, compared with placebo, on exercise time in patients with stable angina. The 230 patients who were enrolled in ORBITA had severe (70% or more), single-vessel stenosis. After enrolling, patients’ medication regimens were optimized so that almost all were taking aspirin, a second antiplatelet drug, and a statin. Beta-blockers and calcium channel blockers also were widely used by trial participants. Two hundred patients were randomized to either PCI (105 patients) or placebo procedure (95 patients). The primary endpoint was exercise time, and no difference was observed between the two groups. ORBITA’s results apply to patients with stable angina but not to those who undergo PCI for acute coronary syndrome (which includes ST-elevation MI); in the latter population, PCI has been demonstrated to reduce morbidity and mortality.
Bottom line: In patients with stable angina, PCI does not increase exercise time.
Citation: Al-Lamee R et al. Percutaneous coronary intervention in stable angina (ORBITA): A double-blind, randomised controlled trial. Lancet. 2018 Jan;391(10115);31-40.
Dr. Clarke is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Clinical question: Does PCI provide symptom relief in patients with stable angina?
Background: More than 500,000 PCIs are done yearly worldwide in patients with stable angina. Meta-analyses have demonstrated no impact of PCI on rates of death and myocardial infarction in patients with stable angina. Rather, relief of angina is the main reason for performance of PCI in patients with stable coronary artery disease, and this effect is frequently noted. However, there have been no data from double-blind, randomized, controlled trials to confirm the efficacy of PCI in relieving anginal pain.
Study design: Multicenter, double-blind, randomized, controlled trial.
Setting: Five sites in the United Kingdom.
Synopsis: The Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA) trial was designed to evaluate the effect of PCI, compared with placebo, on exercise time in patients with stable angina. The 230 patients who were enrolled in ORBITA had severe (70% or more), single-vessel stenosis. After enrolling, patients’ medication regimens were optimized so that almost all were taking aspirin, a second antiplatelet drug, and a statin. Beta-blockers and calcium channel blockers also were widely used by trial participants. Two hundred patients were randomized to either PCI (105 patients) or placebo procedure (95 patients). The primary endpoint was exercise time, and no difference was observed between the two groups. ORBITA’s results apply to patients with stable angina but not to those who undergo PCI for acute coronary syndrome (which includes ST-elevation MI); in the latter population, PCI has been demonstrated to reduce morbidity and mortality.
Bottom line: In patients with stable angina, PCI does not increase exercise time.
Citation: Al-Lamee R et al. Percutaneous coronary intervention in stable angina (ORBITA): A double-blind, randomised controlled trial. Lancet. 2018 Jan;391(10115);31-40.
Dr. Clarke is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Unusual antibiotic resistance found in more than 200 bacteria
The Centers for Disease Control and Prevention’s Antibiotic Resistance (AR) Lab Network has detected 221 instances of bacteria with especially rare resistance genes in the United States, according to a Vital Signs report published online and expanded upon in CDC’s MMWR Weekly.
The MMWR Weekly report, “Containment of Novel Multidrug-Resistant Organisms and Resistance Mechanisms,” which goes deeper into the science behind the issue, shows that in 9 months, in all states and Puerto Rico, health department workers in the AR lab network tested 5,776 samples of highly resistant bacteria, according to Anne Schuchat, MD, principal deputy director of the CDC. These bacteria were immediately tested for unusual resistance – “those genes that were highly resistant, or rare, with special resistance that could spread,” she said.
“Of the 5,776, about 1 in 4 of the bacteria had a gene that helped it spread its resistance. And there were 221 instances of an especially rare resistance gene,” she added. This prompted intense screening, revealing “that 1 in 10 tests were also positive. Meaning the unusual resistance may have spread to other patients. And could have continued spreading if left undetected.”
The report looked at carbapenem-resistant Enterobacteriaceae (CRE) and Enterobacteriaceae with extended-spectrum beta-lactamases (ESBL) infection data from the National Healthcare Safety Network from 2006-2015 to calculate changes in the year over year proportions of these infections and how an enhanced detection and control strategy curbs carbapenem resistance.
This strategy includes components such as timely implementation of appropriate infection control measures, conducting a health care and contact investigation with follow-up, and implementing a system to ensure adherence to infection control measures.
“With independent, or single facility approaches to control spread, a dangerous type of unusual resistance in Enterobacteriaceae [ESBL phenotype] decreased by about 2% per year [(risk ratio [RR] = 0.98, P less than .001)].” With a more aggressive approach, using guidance such as CDC’s CRE toolkit, released in 2009, another type of unusual resistance [CRE] in the same bacteria (Enterobacteriaceae) decreased by nearly 15% per year (RR = 0.85, P less than .01).
The difference may be due in part to the more directed response utilized to slow the spread of the “nightmare bacteria,” once it was identified, said Dr. Schuchat.
These results show massive promise even if only partially effective, specifically for CRE.
“CDC estimates show that if only 20% effective, the containment strategy can reduce the number of nightmare bacteria [CRE] cases by 76% over 3 years in one area.”
Due to the nature of antibiotic resistance and its ability to spread, this poses a significant public health threat. Antibiotics are not simply used to treat infections but are a safety net that is used in cancer treatment, surgery, and ICU care, Dr. Schuchat pointed out. The rise of antibiotic resistance is a threat to that safety net and accounts for nearly 2,000,000 antibiotic resistant infections and approximately 23,000 deaths per year.
But aggressive responses to these infections can control their spread. Dr. Schuchat used the analogy of controlling a fire to illustrate the concept.
“Much like a fire, finding and stopping unusual resistance early when it’s just a spark protects people.”
Dr. Schuchat reiterated that simply identifying the issue is only part of the equation.
“Detection is not enough on its own. When there is a fire, somebody needs to put it out. CDC supports more than 500 local staff across the country to combat antibiotic resistance wherever it emerges.”
While the report highlights the strides that have been made in combating antibiotic resistance, Paul Auwaerter, MD, president of the Infectious Diseases Society of America, released a statement highlighting the need to further fund these efforts.
“The report spells out the need to accelerate efforts to curb resistance or face an increasing burden including novel resistance mutations that threaten health,” stated Dr. Auwaerter. “The efforts detailed in the Vital Signs report were made possible through new congressional funding in 2016 to combat antibiotic resistance. We urge Congress to sustain and to grow that investment so that further progress will prepare us to meet the future challenges of antibiotic resistance from a position of strength,” he added.
A fact sheet with a brief summation of the vital signs report is available here.
The Centers for Disease Control and Prevention’s Antibiotic Resistance (AR) Lab Network has detected 221 instances of bacteria with especially rare resistance genes in the United States, according to a Vital Signs report published online and expanded upon in CDC’s MMWR Weekly.
The MMWR Weekly report, “Containment of Novel Multidrug-Resistant Organisms and Resistance Mechanisms,” which goes deeper into the science behind the issue, shows that in 9 months, in all states and Puerto Rico, health department workers in the AR lab network tested 5,776 samples of highly resistant bacteria, according to Anne Schuchat, MD, principal deputy director of the CDC. These bacteria were immediately tested for unusual resistance – “those genes that were highly resistant, or rare, with special resistance that could spread,” she said.
“Of the 5,776, about 1 in 4 of the bacteria had a gene that helped it spread its resistance. And there were 221 instances of an especially rare resistance gene,” she added. This prompted intense screening, revealing “that 1 in 10 tests were also positive. Meaning the unusual resistance may have spread to other patients. And could have continued spreading if left undetected.”
The report looked at carbapenem-resistant Enterobacteriaceae (CRE) and Enterobacteriaceae with extended-spectrum beta-lactamases (ESBL) infection data from the National Healthcare Safety Network from 2006-2015 to calculate changes in the year over year proportions of these infections and how an enhanced detection and control strategy curbs carbapenem resistance.
This strategy includes components such as timely implementation of appropriate infection control measures, conducting a health care and contact investigation with follow-up, and implementing a system to ensure adherence to infection control measures.
“With independent, or single facility approaches to control spread, a dangerous type of unusual resistance in Enterobacteriaceae [ESBL phenotype] decreased by about 2% per year [(risk ratio [RR] = 0.98, P less than .001)].” With a more aggressive approach, using guidance such as CDC’s CRE toolkit, released in 2009, another type of unusual resistance [CRE] in the same bacteria (Enterobacteriaceae) decreased by nearly 15% per year (RR = 0.85, P less than .01).
The difference may be due in part to the more directed response utilized to slow the spread of the “nightmare bacteria,” once it was identified, said Dr. Schuchat.
These results show massive promise even if only partially effective, specifically for CRE.
“CDC estimates show that if only 20% effective, the containment strategy can reduce the number of nightmare bacteria [CRE] cases by 76% over 3 years in one area.”
Due to the nature of antibiotic resistance and its ability to spread, this poses a significant public health threat. Antibiotics are not simply used to treat infections but are a safety net that is used in cancer treatment, surgery, and ICU care, Dr. Schuchat pointed out. The rise of antibiotic resistance is a threat to that safety net and accounts for nearly 2,000,000 antibiotic resistant infections and approximately 23,000 deaths per year.
But aggressive responses to these infections can control their spread. Dr. Schuchat used the analogy of controlling a fire to illustrate the concept.
“Much like a fire, finding and stopping unusual resistance early when it’s just a spark protects people.”
Dr. Schuchat reiterated that simply identifying the issue is only part of the equation.
“Detection is not enough on its own. When there is a fire, somebody needs to put it out. CDC supports more than 500 local staff across the country to combat antibiotic resistance wherever it emerges.”
While the report highlights the strides that have been made in combating antibiotic resistance, Paul Auwaerter, MD, president of the Infectious Diseases Society of America, released a statement highlighting the need to further fund these efforts.
“The report spells out the need to accelerate efforts to curb resistance or face an increasing burden including novel resistance mutations that threaten health,” stated Dr. Auwaerter. “The efforts detailed in the Vital Signs report were made possible through new congressional funding in 2016 to combat antibiotic resistance. We urge Congress to sustain and to grow that investment so that further progress will prepare us to meet the future challenges of antibiotic resistance from a position of strength,” he added.
A fact sheet with a brief summation of the vital signs report is available here.
The Centers for Disease Control and Prevention’s Antibiotic Resistance (AR) Lab Network has detected 221 instances of bacteria with especially rare resistance genes in the United States, according to a Vital Signs report published online and expanded upon in CDC’s MMWR Weekly.
The MMWR Weekly report, “Containment of Novel Multidrug-Resistant Organisms and Resistance Mechanisms,” which goes deeper into the science behind the issue, shows that in 9 months, in all states and Puerto Rico, health department workers in the AR lab network tested 5,776 samples of highly resistant bacteria, according to Anne Schuchat, MD, principal deputy director of the CDC. These bacteria were immediately tested for unusual resistance – “those genes that were highly resistant, or rare, with special resistance that could spread,” she said.
“Of the 5,776, about 1 in 4 of the bacteria had a gene that helped it spread its resistance. And there were 221 instances of an especially rare resistance gene,” she added. This prompted intense screening, revealing “that 1 in 10 tests were also positive. Meaning the unusual resistance may have spread to other patients. And could have continued spreading if left undetected.”
The report looked at carbapenem-resistant Enterobacteriaceae (CRE) and Enterobacteriaceae with extended-spectrum beta-lactamases (ESBL) infection data from the National Healthcare Safety Network from 2006-2015 to calculate changes in the year over year proportions of these infections and how an enhanced detection and control strategy curbs carbapenem resistance.
This strategy includes components such as timely implementation of appropriate infection control measures, conducting a health care and contact investigation with follow-up, and implementing a system to ensure adherence to infection control measures.
“With independent, or single facility approaches to control spread, a dangerous type of unusual resistance in Enterobacteriaceae [ESBL phenotype] decreased by about 2% per year [(risk ratio [RR] = 0.98, P less than .001)].” With a more aggressive approach, using guidance such as CDC’s CRE toolkit, released in 2009, another type of unusual resistance [CRE] in the same bacteria (Enterobacteriaceae) decreased by nearly 15% per year (RR = 0.85, P less than .01).
The difference may be due in part to the more directed response utilized to slow the spread of the “nightmare bacteria,” once it was identified, said Dr. Schuchat.
These results show massive promise even if only partially effective, specifically for CRE.
“CDC estimates show that if only 20% effective, the containment strategy can reduce the number of nightmare bacteria [CRE] cases by 76% over 3 years in one area.”
Due to the nature of antibiotic resistance and its ability to spread, this poses a significant public health threat. Antibiotics are not simply used to treat infections but are a safety net that is used in cancer treatment, surgery, and ICU care, Dr. Schuchat pointed out. The rise of antibiotic resistance is a threat to that safety net and accounts for nearly 2,000,000 antibiotic resistant infections and approximately 23,000 deaths per year.
But aggressive responses to these infections can control their spread. Dr. Schuchat used the analogy of controlling a fire to illustrate the concept.
“Much like a fire, finding and stopping unusual resistance early when it’s just a spark protects people.”
Dr. Schuchat reiterated that simply identifying the issue is only part of the equation.
“Detection is not enough on its own. When there is a fire, somebody needs to put it out. CDC supports more than 500 local staff across the country to combat antibiotic resistance wherever it emerges.”
While the report highlights the strides that have been made in combating antibiotic resistance, Paul Auwaerter, MD, president of the Infectious Diseases Society of America, released a statement highlighting the need to further fund these efforts.
“The report spells out the need to accelerate efforts to curb resistance or face an increasing burden including novel resistance mutations that threaten health,” stated Dr. Auwaerter. “The efforts detailed in the Vital Signs report were made possible through new congressional funding in 2016 to combat antibiotic resistance. We urge Congress to sustain and to grow that investment so that further progress will prepare us to meet the future challenges of antibiotic resistance from a position of strength,” he added.
A fact sheet with a brief summation of the vital signs report is available here.
FROM A CDC TELEBRIEFING
Any detectable high-sensitivity cardiac troponin T (hs-cTn) level is associated with adverse outcomes
Clinical question: What is the association between high-sensitivity cardiac troponin T (hs-cTn) levels and outcomes in patients with chest pain?
Background: There are few data on the link between hs-cTn levels and outcomes in patients with chest pain but no myocardial infarction or any other condition that can cause acute increases in troponin levels.
Study design: Observational cohort study.
Setting: Patients older than 25 years old with chest pain presenting to the emergency department at a university hospital in Sweden.
Synopsis: 19,460 patients with chest pain who had at least one hs-cTn level obtained during their ED visit were included in this study. In comparison with patients who had hs-cTn less than 5 ng/L, the adjusted hazard ratios for all-cause mortality were 2.00, 2.92, 4.07, 6.77, and 9.68, in patients with hs-cTn levels of 5-9, 10-14, 15-29, 30-49, and 50 or greater ng/L, respectively. The yearly rates of MI were 0.3% and 4.5% in patients with hs-cTn levels less than 5 ng/L and 50 or greater ng/L, respectively. The yearly rates of hospitalization for heart failure were 0.1%, 1%, 2.8%, and 20% in patients with hs-cTn levels less than 5, 5-9, 10-14, and 50 or greater ng/L, respectively. There was a clear and graded association between any detectable levels of hs-cTn and risk factors for cardiovascular and noncardiovascular mortality, MI, and heart failure.
Bottom line: For patients with chest pain and stable troponin levels, there is an elevated risk of death, hospitalization for heart failure, and MI, if there is any detectable level of hs-cTn.
Citation: Roos A et al. Stable high-sensitivity cardiac troponin T levels and outcomes in patients with chest pain. J Am Coll Cardiol. 2017 Oct 31;70(18):2226-36. doi: 10.1016/j.jacc.2017.08.064.
Dr. Clarke is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Clinical question: What is the association between high-sensitivity cardiac troponin T (hs-cTn) levels and outcomes in patients with chest pain?
Background: There are few data on the link between hs-cTn levels and outcomes in patients with chest pain but no myocardial infarction or any other condition that can cause acute increases in troponin levels.
Study design: Observational cohort study.
Setting: Patients older than 25 years old with chest pain presenting to the emergency department at a university hospital in Sweden.
Synopsis: 19,460 patients with chest pain who had at least one hs-cTn level obtained during their ED visit were included in this study. In comparison with patients who had hs-cTn less than 5 ng/L, the adjusted hazard ratios for all-cause mortality were 2.00, 2.92, 4.07, 6.77, and 9.68, in patients with hs-cTn levels of 5-9, 10-14, 15-29, 30-49, and 50 or greater ng/L, respectively. The yearly rates of MI were 0.3% and 4.5% in patients with hs-cTn levels less than 5 ng/L and 50 or greater ng/L, respectively. The yearly rates of hospitalization for heart failure were 0.1%, 1%, 2.8%, and 20% in patients with hs-cTn levels less than 5, 5-9, 10-14, and 50 or greater ng/L, respectively. There was a clear and graded association between any detectable levels of hs-cTn and risk factors for cardiovascular and noncardiovascular mortality, MI, and heart failure.
Bottom line: For patients with chest pain and stable troponin levels, there is an elevated risk of death, hospitalization for heart failure, and MI, if there is any detectable level of hs-cTn.
Citation: Roos A et al. Stable high-sensitivity cardiac troponin T levels and outcomes in patients with chest pain. J Am Coll Cardiol. 2017 Oct 31;70(18):2226-36. doi: 10.1016/j.jacc.2017.08.064.
Dr. Clarke is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Clinical question: What is the association between high-sensitivity cardiac troponin T (hs-cTn) levels and outcomes in patients with chest pain?
Background: There are few data on the link between hs-cTn levels and outcomes in patients with chest pain but no myocardial infarction or any other condition that can cause acute increases in troponin levels.
Study design: Observational cohort study.
Setting: Patients older than 25 years old with chest pain presenting to the emergency department at a university hospital in Sweden.
Synopsis: 19,460 patients with chest pain who had at least one hs-cTn level obtained during their ED visit were included in this study. In comparison with patients who had hs-cTn less than 5 ng/L, the adjusted hazard ratios for all-cause mortality were 2.00, 2.92, 4.07, 6.77, and 9.68, in patients with hs-cTn levels of 5-9, 10-14, 15-29, 30-49, and 50 or greater ng/L, respectively. The yearly rates of MI were 0.3% and 4.5% in patients with hs-cTn levels less than 5 ng/L and 50 or greater ng/L, respectively. The yearly rates of hospitalization for heart failure were 0.1%, 1%, 2.8%, and 20% in patients with hs-cTn levels less than 5, 5-9, 10-14, and 50 or greater ng/L, respectively. There was a clear and graded association between any detectable levels of hs-cTn and risk factors for cardiovascular and noncardiovascular mortality, MI, and heart failure.
Bottom line: For patients with chest pain and stable troponin levels, there is an elevated risk of death, hospitalization for heart failure, and MI, if there is any detectable level of hs-cTn.
Citation: Roos A et al. Stable high-sensitivity cardiac troponin T levels and outcomes in patients with chest pain. J Am Coll Cardiol. 2017 Oct 31;70(18):2226-36. doi: 10.1016/j.jacc.2017.08.064.
Dr. Clarke is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Admitting medicine patients to off-service, nonmedicine units linked with increased in-hospital mortality
Background: Increased saturation of hospital capacity compromises patient outcomes. This creates additional challenges for the provision of appropriate specialized care. In some hospitals, patients are “bed-spaced,” or admitted to non–internal medicine service locations, such as a surgical ward, in order to free up space in the emergency department. Whether bed-spacing reduces quality of care or patient outcomes has not been previously studied.
Study design: Retrospective cohort study.
Setting: Large tertiary care academic hospital in Canada, during Jan. 1, 2015-Jan. 1, 2016.
Synopsis: There were 3,243 patients included in the analysis, of which 1,125 (35%) were bed-spaced to the off-service wards. The remaining 2,118 patients (65%) were admitted to the assigned internal medicine units. In the first week of hospitalization, in-hospital mortality among bed-spaced patients was approximately three times that of patients admitted to the assigned internal medicine wards. Upon admission, in-hospital mortality for the bed-spaced patients had a hazard ratio of 3.42 (95% confidence interval, 2.23-5.26; P less than .0001) with subsequent decrease by 0.97 (95% CI, 0.94-0.99; P = .0133) per day in the hospital. By the third week of hospitalization, the mortality risks had equalized. Sensitivity analyses revealed similar results.
Bottom line: This retrospective study is based on a single center; however, the observed increased mortality among the bed-spaced patients merits further investigation. Assessment of study generalizability and formulation of strategies for improving patient safety are needed.
Citation: Bai AD et al. Mortality of hospitalised internal medicine patients bed-spaced to non–internal medicine inpatient units: Retrospective cohort study. BMJ Qual Saf. 2018 Jan;27(1):11-20. doi: 10.1136/bmjqs-2017-006925.
Dr. Burklin is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Background: Increased saturation of hospital capacity compromises patient outcomes. This creates additional challenges for the provision of appropriate specialized care. In some hospitals, patients are “bed-spaced,” or admitted to non–internal medicine service locations, such as a surgical ward, in order to free up space in the emergency department. Whether bed-spacing reduces quality of care or patient outcomes has not been previously studied.
Study design: Retrospective cohort study.
Setting: Large tertiary care academic hospital in Canada, during Jan. 1, 2015-Jan. 1, 2016.
Synopsis: There were 3,243 patients included in the analysis, of which 1,125 (35%) were bed-spaced to the off-service wards. The remaining 2,118 patients (65%) were admitted to the assigned internal medicine units. In the first week of hospitalization, in-hospital mortality among bed-spaced patients was approximately three times that of patients admitted to the assigned internal medicine wards. Upon admission, in-hospital mortality for the bed-spaced patients had a hazard ratio of 3.42 (95% confidence interval, 2.23-5.26; P less than .0001) with subsequent decrease by 0.97 (95% CI, 0.94-0.99; P = .0133) per day in the hospital. By the third week of hospitalization, the mortality risks had equalized. Sensitivity analyses revealed similar results.
Bottom line: This retrospective study is based on a single center; however, the observed increased mortality among the bed-spaced patients merits further investigation. Assessment of study generalizability and formulation of strategies for improving patient safety are needed.
Citation: Bai AD et al. Mortality of hospitalised internal medicine patients bed-spaced to non–internal medicine inpatient units: Retrospective cohort study. BMJ Qual Saf. 2018 Jan;27(1):11-20. doi: 10.1136/bmjqs-2017-006925.
Dr. Burklin is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Background: Increased saturation of hospital capacity compromises patient outcomes. This creates additional challenges for the provision of appropriate specialized care. In some hospitals, patients are “bed-spaced,” or admitted to non–internal medicine service locations, such as a surgical ward, in order to free up space in the emergency department. Whether bed-spacing reduces quality of care or patient outcomes has not been previously studied.
Study design: Retrospective cohort study.
Setting: Large tertiary care academic hospital in Canada, during Jan. 1, 2015-Jan. 1, 2016.
Synopsis: There were 3,243 patients included in the analysis, of which 1,125 (35%) were bed-spaced to the off-service wards. The remaining 2,118 patients (65%) were admitted to the assigned internal medicine units. In the first week of hospitalization, in-hospital mortality among bed-spaced patients was approximately three times that of patients admitted to the assigned internal medicine wards. Upon admission, in-hospital mortality for the bed-spaced patients had a hazard ratio of 3.42 (95% confidence interval, 2.23-5.26; P less than .0001) with subsequent decrease by 0.97 (95% CI, 0.94-0.99; P = .0133) per day in the hospital. By the third week of hospitalization, the mortality risks had equalized. Sensitivity analyses revealed similar results.
Bottom line: This retrospective study is based on a single center; however, the observed increased mortality among the bed-spaced patients merits further investigation. Assessment of study generalizability and formulation of strategies for improving patient safety are needed.
Citation: Bai AD et al. Mortality of hospitalised internal medicine patients bed-spaced to non–internal medicine inpatient units: Retrospective cohort study. BMJ Qual Saf. 2018 Jan;27(1):11-20. doi: 10.1136/bmjqs-2017-006925.
Dr. Burklin is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Few acutely ill hospitalized patients receive VTE prophylaxis
SAN DIEGO – Among patients hospitalized for acute medical illnesses, the risk of venous thromboembolism (VTE) remained elevated 30-40 days after discharge, results from a large analysis of national data showed.
Moreover, only 7% of at-risk patients received VTE prophylaxis in both the inpatient and outpatient setting.
“The results of this real-world study imply that there is a significantly unmet medical need for effective VTE prophylaxis in both the inpatient and outpatient continuum of care among patients hospitalized for acute medical illnesses,” researchers led by Alpesh Amin, MD, wrote in a poster presented at the biennial summit of the Thrombosis & Hemostasis Societies of North America.
According to Dr. Amin, who chairs the department of medicine at the University of California, Irvine, hospitalized patients with acute medical illnesses face an increased risk for VTE during hospital discharge, mainly within 40 days following hospital admission. However, the treatment patterns of VTE prophylaxis in this patient population have not been well studied in the “real-world” setting. In an effort to improve this area of clinical practice, the researchers used the Marketscan database between Jan. 1, 2012, and June 30, 2015, to identify acutely ill hospitalized patients, such as those with heart failure, respiratory diseases, ischemic stroke, cancer, infectious diseases, and rheumatic diseases. The key outcomes of interest were the proportion of patients receiving inpatient and outpatient VTE prophylaxis and the proportion of patients with VTE events during and after the index hospitalization. They used Kaplan-Meier analysis to examine the risk for VTE events after the index inpatient admission.
The mean age of the 17,895 patients was 58 years, 55% were female, and most (77%) were from the Southern area of the United States. Their mean Charlson Comborbidity Index score prior to hospitalization was 2.2. Nearly all hospitals (87%) were urban based, nonteaching (95%), and large, with 68% having at least 300 beds. Nearly three-quarters of patients (72%) were hospitalized for infectious and respiratory diseases, and the mean length of stay was 5 days.
Dr. Amin and his associates found that 59% of hospitalized patients did not receive any VTE prophylaxis, while only 7% received prophylaxis in both the inpatient and outpatient continuum of care. At the same time, cumulative VTE rates within 40 days of index admission were highest among patients hospitalized for infectious diseases and cancer (3.4% each), followed by those with heart failure (3.1%), respiratory diseases (2%), ischemic stroke (1.5%), and rheumatic diseases (1.3%). The cumulative VTE event rate for the overall study population within 40 days from index hospitalization was nearly 3%, with 60% of VTE events having occurred within 40 days.
The study was funded by Portola Pharmaceuticals. Dr. Amin reported having no financial disclosures.
SOURCE: Amin A et al. THSNA 2018, Poster 51.
SAN DIEGO – Among patients hospitalized for acute medical illnesses, the risk of venous thromboembolism (VTE) remained elevated 30-40 days after discharge, results from a large analysis of national data showed.
Moreover, only 7% of at-risk patients received VTE prophylaxis in both the inpatient and outpatient setting.
“The results of this real-world study imply that there is a significantly unmet medical need for effective VTE prophylaxis in both the inpatient and outpatient continuum of care among patients hospitalized for acute medical illnesses,” researchers led by Alpesh Amin, MD, wrote in a poster presented at the biennial summit of the Thrombosis & Hemostasis Societies of North America.
According to Dr. Amin, who chairs the department of medicine at the University of California, Irvine, hospitalized patients with acute medical illnesses face an increased risk for VTE during hospital discharge, mainly within 40 days following hospital admission. However, the treatment patterns of VTE prophylaxis in this patient population have not been well studied in the “real-world” setting. In an effort to improve this area of clinical practice, the researchers used the Marketscan database between Jan. 1, 2012, and June 30, 2015, to identify acutely ill hospitalized patients, such as those with heart failure, respiratory diseases, ischemic stroke, cancer, infectious diseases, and rheumatic diseases. The key outcomes of interest were the proportion of patients receiving inpatient and outpatient VTE prophylaxis and the proportion of patients with VTE events during and after the index hospitalization. They used Kaplan-Meier analysis to examine the risk for VTE events after the index inpatient admission.
The mean age of the 17,895 patients was 58 years, 55% were female, and most (77%) were from the Southern area of the United States. Their mean Charlson Comborbidity Index score prior to hospitalization was 2.2. Nearly all hospitals (87%) were urban based, nonteaching (95%), and large, with 68% having at least 300 beds. Nearly three-quarters of patients (72%) were hospitalized for infectious and respiratory diseases, and the mean length of stay was 5 days.
Dr. Amin and his associates found that 59% of hospitalized patients did not receive any VTE prophylaxis, while only 7% received prophylaxis in both the inpatient and outpatient continuum of care. At the same time, cumulative VTE rates within 40 days of index admission were highest among patients hospitalized for infectious diseases and cancer (3.4% each), followed by those with heart failure (3.1%), respiratory diseases (2%), ischemic stroke (1.5%), and rheumatic diseases (1.3%). The cumulative VTE event rate for the overall study population within 40 days from index hospitalization was nearly 3%, with 60% of VTE events having occurred within 40 days.
The study was funded by Portola Pharmaceuticals. Dr. Amin reported having no financial disclosures.
SOURCE: Amin A et al. THSNA 2018, Poster 51.
SAN DIEGO – Among patients hospitalized for acute medical illnesses, the risk of venous thromboembolism (VTE) remained elevated 30-40 days after discharge, results from a large analysis of national data showed.
Moreover, only 7% of at-risk patients received VTE prophylaxis in both the inpatient and outpatient setting.
“The results of this real-world study imply that there is a significantly unmet medical need for effective VTE prophylaxis in both the inpatient and outpatient continuum of care among patients hospitalized for acute medical illnesses,” researchers led by Alpesh Amin, MD, wrote in a poster presented at the biennial summit of the Thrombosis & Hemostasis Societies of North America.
According to Dr. Amin, who chairs the department of medicine at the University of California, Irvine, hospitalized patients with acute medical illnesses face an increased risk for VTE during hospital discharge, mainly within 40 days following hospital admission. However, the treatment patterns of VTE prophylaxis in this patient population have not been well studied in the “real-world” setting. In an effort to improve this area of clinical practice, the researchers used the Marketscan database between Jan. 1, 2012, and June 30, 2015, to identify acutely ill hospitalized patients, such as those with heart failure, respiratory diseases, ischemic stroke, cancer, infectious diseases, and rheumatic diseases. The key outcomes of interest were the proportion of patients receiving inpatient and outpatient VTE prophylaxis and the proportion of patients with VTE events during and after the index hospitalization. They used Kaplan-Meier analysis to examine the risk for VTE events after the index inpatient admission.
The mean age of the 17,895 patients was 58 years, 55% were female, and most (77%) were from the Southern area of the United States. Their mean Charlson Comborbidity Index score prior to hospitalization was 2.2. Nearly all hospitals (87%) were urban based, nonteaching (95%), and large, with 68% having at least 300 beds. Nearly three-quarters of patients (72%) were hospitalized for infectious and respiratory diseases, and the mean length of stay was 5 days.
Dr. Amin and his associates found that 59% of hospitalized patients did not receive any VTE prophylaxis, while only 7% received prophylaxis in both the inpatient and outpatient continuum of care. At the same time, cumulative VTE rates within 40 days of index admission were highest among patients hospitalized for infectious diseases and cancer (3.4% each), followed by those with heart failure (3.1%), respiratory diseases (2%), ischemic stroke (1.5%), and rheumatic diseases (1.3%). The cumulative VTE event rate for the overall study population within 40 days from index hospitalization was nearly 3%, with 60% of VTE events having occurred within 40 days.
The study was funded by Portola Pharmaceuticals. Dr. Amin reported having no financial disclosures.
SOURCE: Amin A et al. THSNA 2018, Poster 51.
REPORTING FROM THSNA 2018
Key clinical point: There is a significant unmet medical need for VTE prophylaxis in the continuum of care of patients hospitalized for acute medical illnesses.
Major finding: Of the overall study population, only 7% received both inpatient and outpatient VTE prophylaxis.
Study details: An analysis of national data from 17,895 acutely ill hospitalized patients.
Disclosures: The study was funded by Portola Pharmaceuticals. The presenter reported having no financial conflicts.
Source: Amin A et al. THSNA 2018, Poster 51.
A SNF-based enhanced care program may help reduce 30-day readmissions
Background: The acuity of many patients recently discharged from an acute care facility is high. Some of these patients are being transferred to a SNF upon hospital discharge. Currently existing SNF care systems may not be prepared sufficiently for the challenges that arise with the admission of such patients to the SNFs after hospital discharge, resulting in readmissions.
Study design: Observational, retrospective cohort analysis.
Setting: Collaborative effort among a large, urban, acute care center, interdisciplinary clinical team, 124 community physicians, and eight SNFs.
Synopsis: In addition to standard care, the Enhanced Care Program (ECP) included a team of nurse practitioners participating in the care of SNF patients, a pharmacist-driven medication reconciliation at the time of transfer, and educational in-services for SNF nursing staff. Following introduction of the three ECP interventions, 30-day readmission rates were compared for both ECP and non-ECP patient groups. After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P less than .001). Multivariate analyses confirmed similar results. Major caveats include that this was a single-hospital study and that selection of the enrolled patients was not random, but rather, was determined by their primary care providers, potentially leading to some confounding.
Bottom line: For patients discharged to SNFs, an interdisciplinary care approach may reduce 30-day hospital readmissions.
Citation: Rosen BT et al. The Enhanced Care Program: Impact of a care transition program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities. J Hosp Med. 2017 Oct 4:E1-E7. doi: 10.12788/jhm.2852
Dr. Burklin is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Background: The acuity of many patients recently discharged from an acute care facility is high. Some of these patients are being transferred to a SNF upon hospital discharge. Currently existing SNF care systems may not be prepared sufficiently for the challenges that arise with the admission of such patients to the SNFs after hospital discharge, resulting in readmissions.
Study design: Observational, retrospective cohort analysis.
Setting: Collaborative effort among a large, urban, acute care center, interdisciplinary clinical team, 124 community physicians, and eight SNFs.
Synopsis: In addition to standard care, the Enhanced Care Program (ECP) included a team of nurse practitioners participating in the care of SNF patients, a pharmacist-driven medication reconciliation at the time of transfer, and educational in-services for SNF nursing staff. Following introduction of the three ECP interventions, 30-day readmission rates were compared for both ECP and non-ECP patient groups. After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P less than .001). Multivariate analyses confirmed similar results. Major caveats include that this was a single-hospital study and that selection of the enrolled patients was not random, but rather, was determined by their primary care providers, potentially leading to some confounding.
Bottom line: For patients discharged to SNFs, an interdisciplinary care approach may reduce 30-day hospital readmissions.
Citation: Rosen BT et al. The Enhanced Care Program: Impact of a care transition program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities. J Hosp Med. 2017 Oct 4:E1-E7. doi: 10.12788/jhm.2852
Dr. Burklin is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Background: The acuity of many patients recently discharged from an acute care facility is high. Some of these patients are being transferred to a SNF upon hospital discharge. Currently existing SNF care systems may not be prepared sufficiently for the challenges that arise with the admission of such patients to the SNFs after hospital discharge, resulting in readmissions.
Study design: Observational, retrospective cohort analysis.
Setting: Collaborative effort among a large, urban, acute care center, interdisciplinary clinical team, 124 community physicians, and eight SNFs.
Synopsis: In addition to standard care, the Enhanced Care Program (ECP) included a team of nurse practitioners participating in the care of SNF patients, a pharmacist-driven medication reconciliation at the time of transfer, and educational in-services for SNF nursing staff. Following introduction of the three ECP interventions, 30-day readmission rates were compared for both ECP and non-ECP patient groups. After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P less than .001). Multivariate analyses confirmed similar results. Major caveats include that this was a single-hospital study and that selection of the enrolled patients was not random, but rather, was determined by their primary care providers, potentially leading to some confounding.
Bottom line: For patients discharged to SNFs, an interdisciplinary care approach may reduce 30-day hospital readmissions.
Citation: Rosen BT et al. The Enhanced Care Program: Impact of a care transition program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities. J Hosp Med. 2017 Oct 4:E1-E7. doi: 10.12788/jhm.2852
Dr. Burklin is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Sustaining the evolution of PAs in hospital medicine
Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Visit www.hospitalmedicine.org for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.
This month, The Hospitalist spotlights Meredith K. Wold, PA-C, APC supervisor, Hospital Medicine and Critical Care, at Regions Hospital in St. Paul, Minn., and adjunct faculty, Augsburg University Physician Assistant Program. Ms. Wold is a long-time member of SHM and the recipient of this year’s Clinical Excellence Award for Nurse Practitioners and Physician Assistants.
How did you first hear of SHM and why did you decide to become a member?
I’ve always recognized the importance of engaging in a community beyond my daily practice. Shortly after starting my career in hospital medicine, I quickly recognized this was a belief shared and cultivated by my hospital medicine group as well. Our HM group at HealthPartners has a long history of SHM participation. As our advanced practice clinician (APC) group grew, I knew engagement at the national level was critical to ensure that our ongoing evolution was supported, sustained, and shared.
What does it mean to you to receive SHM’s Clinical Excellence Award for nurse practitioners and physician assistants?
Being awarded the SHM Clinical Excellence Award is remarkable. I work alongside really, really amazing people, and every day I strive toward the exceptionally high bar they set. I’m passionate and committed to hospital medicine, and I’m so very grateful this is appreciated.
Which SHM conferences have you attended? Tell us about some of the highlights from these courses.
The first SHM annual conference I attended was in 2008 in sunny San Diego. I’d been a physician assistant (PA) for barely a year. I remember being so energized by the passion and commitment of the speakers and attendees. I harnessed that energy and spent the next several years being part of a growing APC group at Regions Hospital in St. Paul, Minn., where our HM group holds partnership and innovation at its core. You can imagine my excitement when I was asked to speak about APC practice models at HM16. Fellow APC Emily Thornhill Davis and I spoke to a standing-room only audience! Emily and I partnered again as faculty at HM17. I look forward to being part of a panel discussion at HM18 in Orlando (alongside some SHM trailblazers!).
Closer to home, I’ve taken advantage of phenomenal opportunities hosted by our local chapter of SHM. My colleagues Benji Mathews, MD, and Kreegan Reierson, MD, have led Point-of-Care Ultrasound (POCUS) training courses regionally and nationally. Their comprehensive, hands-on course ensured that I had the foundation to incorporate portable ultrasound into my practice. Thank goodness for their refresher course as well; my skills were rusty after a long maternity leave!
Given the tremendous clinical growth I have absorbed through local and national SHM offerings, I look forward to my leadership and operations skills being bolstered at SHM’s Leadership Academy this fall in Vancouver. As APCs hold more and more vital roles within HM groups, it’s integral that, along the way, our leadership skills are recognized and honed as well.
As an SHM member of over 10 years, what has been most valuable for you as a physician assistant?
The relationships. Networking, sharing ideas, pushing the status quo with other like-minded clinicians from around the country is invigorating. Because of SHM, I have an APC network from coast to coast – a lattice of clinicians that are linked by dedication and enthusiasm to hospital medicine.
What advice do you have for early-career physician assistants looking to work in hospital medicine?
Find a hospital medicine group whose culture allows and supports your growth as an advanced practice clinician. In an exemplary HM model, the delegated autonomy of an APC should widen and deepen over time. Seek out a team that appreciates the importance of this evolution.
Ms. Steele is marketing communications specialist at the Society of Hospital Medicine.
Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Visit www.hospitalmedicine.org for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.
This month, The Hospitalist spotlights Meredith K. Wold, PA-C, APC supervisor, Hospital Medicine and Critical Care, at Regions Hospital in St. Paul, Minn., and adjunct faculty, Augsburg University Physician Assistant Program. Ms. Wold is a long-time member of SHM and the recipient of this year’s Clinical Excellence Award for Nurse Practitioners and Physician Assistants.
How did you first hear of SHM and why did you decide to become a member?
I’ve always recognized the importance of engaging in a community beyond my daily practice. Shortly after starting my career in hospital medicine, I quickly recognized this was a belief shared and cultivated by my hospital medicine group as well. Our HM group at HealthPartners has a long history of SHM participation. As our advanced practice clinician (APC) group grew, I knew engagement at the national level was critical to ensure that our ongoing evolution was supported, sustained, and shared.
What does it mean to you to receive SHM’s Clinical Excellence Award for nurse practitioners and physician assistants?
Being awarded the SHM Clinical Excellence Award is remarkable. I work alongside really, really amazing people, and every day I strive toward the exceptionally high bar they set. I’m passionate and committed to hospital medicine, and I’m so very grateful this is appreciated.
Which SHM conferences have you attended? Tell us about some of the highlights from these courses.
The first SHM annual conference I attended was in 2008 in sunny San Diego. I’d been a physician assistant (PA) for barely a year. I remember being so energized by the passion and commitment of the speakers and attendees. I harnessed that energy and spent the next several years being part of a growing APC group at Regions Hospital in St. Paul, Minn., where our HM group holds partnership and innovation at its core. You can imagine my excitement when I was asked to speak about APC practice models at HM16. Fellow APC Emily Thornhill Davis and I spoke to a standing-room only audience! Emily and I partnered again as faculty at HM17. I look forward to being part of a panel discussion at HM18 in Orlando (alongside some SHM trailblazers!).
Closer to home, I’ve taken advantage of phenomenal opportunities hosted by our local chapter of SHM. My colleagues Benji Mathews, MD, and Kreegan Reierson, MD, have led Point-of-Care Ultrasound (POCUS) training courses regionally and nationally. Their comprehensive, hands-on course ensured that I had the foundation to incorporate portable ultrasound into my practice. Thank goodness for their refresher course as well; my skills were rusty after a long maternity leave!
Given the tremendous clinical growth I have absorbed through local and national SHM offerings, I look forward to my leadership and operations skills being bolstered at SHM’s Leadership Academy this fall in Vancouver. As APCs hold more and more vital roles within HM groups, it’s integral that, along the way, our leadership skills are recognized and honed as well.
As an SHM member of over 10 years, what has been most valuable for you as a physician assistant?
The relationships. Networking, sharing ideas, pushing the status quo with other like-minded clinicians from around the country is invigorating. Because of SHM, I have an APC network from coast to coast – a lattice of clinicians that are linked by dedication and enthusiasm to hospital medicine.
What advice do you have for early-career physician assistants looking to work in hospital medicine?
Find a hospital medicine group whose culture allows and supports your growth as an advanced practice clinician. In an exemplary HM model, the delegated autonomy of an APC should widen and deepen over time. Seek out a team that appreciates the importance of this evolution.
Ms. Steele is marketing communications specialist at the Society of Hospital Medicine.
Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Visit www.hospitalmedicine.org for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.
This month, The Hospitalist spotlights Meredith K. Wold, PA-C, APC supervisor, Hospital Medicine and Critical Care, at Regions Hospital in St. Paul, Minn., and adjunct faculty, Augsburg University Physician Assistant Program. Ms. Wold is a long-time member of SHM and the recipient of this year’s Clinical Excellence Award for Nurse Practitioners and Physician Assistants.
How did you first hear of SHM and why did you decide to become a member?
I’ve always recognized the importance of engaging in a community beyond my daily practice. Shortly after starting my career in hospital medicine, I quickly recognized this was a belief shared and cultivated by my hospital medicine group as well. Our HM group at HealthPartners has a long history of SHM participation. As our advanced practice clinician (APC) group grew, I knew engagement at the national level was critical to ensure that our ongoing evolution was supported, sustained, and shared.
What does it mean to you to receive SHM’s Clinical Excellence Award for nurse practitioners and physician assistants?
Being awarded the SHM Clinical Excellence Award is remarkable. I work alongside really, really amazing people, and every day I strive toward the exceptionally high bar they set. I’m passionate and committed to hospital medicine, and I’m so very grateful this is appreciated.
Which SHM conferences have you attended? Tell us about some of the highlights from these courses.
The first SHM annual conference I attended was in 2008 in sunny San Diego. I’d been a physician assistant (PA) for barely a year. I remember being so energized by the passion and commitment of the speakers and attendees. I harnessed that energy and spent the next several years being part of a growing APC group at Regions Hospital in St. Paul, Minn., where our HM group holds partnership and innovation at its core. You can imagine my excitement when I was asked to speak about APC practice models at HM16. Fellow APC Emily Thornhill Davis and I spoke to a standing-room only audience! Emily and I partnered again as faculty at HM17. I look forward to being part of a panel discussion at HM18 in Orlando (alongside some SHM trailblazers!).
Closer to home, I’ve taken advantage of phenomenal opportunities hosted by our local chapter of SHM. My colleagues Benji Mathews, MD, and Kreegan Reierson, MD, have led Point-of-Care Ultrasound (POCUS) training courses regionally and nationally. Their comprehensive, hands-on course ensured that I had the foundation to incorporate portable ultrasound into my practice. Thank goodness for their refresher course as well; my skills were rusty after a long maternity leave!
Given the tremendous clinical growth I have absorbed through local and national SHM offerings, I look forward to my leadership and operations skills being bolstered at SHM’s Leadership Academy this fall in Vancouver. As APCs hold more and more vital roles within HM groups, it’s integral that, along the way, our leadership skills are recognized and honed as well.
As an SHM member of over 10 years, what has been most valuable for you as a physician assistant?
The relationships. Networking, sharing ideas, pushing the status quo with other like-minded clinicians from around the country is invigorating. Because of SHM, I have an APC network from coast to coast – a lattice of clinicians that are linked by dedication and enthusiasm to hospital medicine.
What advice do you have for early-career physician assistants looking to work in hospital medicine?
Find a hospital medicine group whose culture allows and supports your growth as an advanced practice clinician. In an exemplary HM model, the delegated autonomy of an APC should widen and deepen over time. Seek out a team that appreciates the importance of this evolution.
Ms. Steele is marketing communications specialist at the Society of Hospital Medicine.
Protocol helped identify hospitalized children at risk for VTE
SAN DIEGO – Following simple institutional care guidelines helped clinicians identify pediatric patients at moderate-to-severe risk of venous thromboembolism (VTE), results from a single-center study showed.
“Hospital-acquired VTE is on the rise in the pediatric population,” lead study author Emily Southard, MD, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “This consists of a DVT or [pulmonary embolism] 48 hours or more after admission, or any time at the site of a central venous catheter.”
One published study found a 70% increased incidence in the pediatric population from 2001-2007 (Pediatrics 2009;124[4]:1001-8). More than half of the children in that study (63%) had at least one coexisting complex medical condition, with malignancy being the most common.
Hospital-acquired VTE cases tend to harbor a number of complications, said Dr. Southard, who is a pediatric hematology/oncology fellow at Children’s Hospital Colorado, Aurora. For example, 15%-20% of patients with a DVT will have a pulmonary embolism (PE) as well, 26% of patients with upper or lower extremity DVT develop post-thrombotic syndrome, and 3% of patients with PE develop chronic pulmonary hypertension.
“Medical costs are also impacted,” she said. “The cost for a hospital-acquired VTE in pediatrics increased the length of stay by about 8 days and increased the cost of hospital admission by more than $27,000.”
Known risk factors for VTE in this patient population include ICU admission (Odds Ratio, 2.14), presence of a central venous catheter (OR, 2.12), mechanical ventilation (OR, 1.56), and prolonged admission (OR, 1.03 for each day).
Risk factors in pediatric trauma patients include ICU admission (OR, 6.25), transfusion of blood products (OR, 2.1), lower extremity fracture (OR, 1.8), and neurosurgery (OR, 2.13). She and her associates hypothesized that understanding the relative contributions of clinical, biological, and genetic risk factors for pediatric VTE would help appropriately risk-stratify patients and allow better prophylactic approaches.
In 2012, Children’s Hospital Colorado implemented a VTE risk assessment tool as part of a hospital-wide patient safety initiative. The assessment is triggered via an Epic Best Practice Advisory to complete in certain higher-risk patients, including ICU patients, hematology/oncology floor patients, any patients with a central line catheter, and those who are over age 12 and obese.
Clinicians also assess for risk factors such as significant infection, recent surgery, and personal or family history of thrombophilia. Next, they classify each patient’s risk of hospital-acquired VTE as high, moderate, or low risk.
In a pilot study, Dr. Southard and her associates set out to validate the accuracy of the institution’s VTE risk assessment tool since it was implemented in 2012. She presented findings from 215 hospital-acquired VTE cases in patients younger than age 18, compared with age-matched inpatient controls. Data from patients under 6 months of age is available after October 2016, coinciding with a change in definition of pediatric hospital-acquired VTE.
Most hospital-acquired VTE patients (77.2%) ranged in age from 1-17 years. The number of patients admitted for a trauma diagnosis was similar between VTE cases and controls (7.4% vs. 7.9%, respectively). However, compared with controls, a significantly greater number of VTE cases were immobile (41.8% vs. 10.3%, respectively), required ICU admission (86.4% vs. 26.5%), had a central venous catheter (80.4% vs. 10.9%), had a positive blood culture (16.7% vs. 1.9%), required surgery or a medical procedure (57.7% vs. 36.7%), and had a longer procedure time (a mean of 151 vs. 133 minutes).
The researchers also found that upon initial admission, 7.9% of VTE cases were identified as high risk and another 21.9% were identified as moderate risk, compared with 1.2% and 3.7% in the controls, respectively.
“Patients identified as moderate or high risk for VTE were generally more medically complex patients,” Dr. Southard said.
Future directions of this project include expanding the patient population that has a risk assessment performed.
Dr. Southard reported having no financial disclosures.
SOURCE: Southard E et al. THSNA 2018.
SAN DIEGO – Following simple institutional care guidelines helped clinicians identify pediatric patients at moderate-to-severe risk of venous thromboembolism (VTE), results from a single-center study showed.
“Hospital-acquired VTE is on the rise in the pediatric population,” lead study author Emily Southard, MD, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “This consists of a DVT or [pulmonary embolism] 48 hours or more after admission, or any time at the site of a central venous catheter.”
One published study found a 70% increased incidence in the pediatric population from 2001-2007 (Pediatrics 2009;124[4]:1001-8). More than half of the children in that study (63%) had at least one coexisting complex medical condition, with malignancy being the most common.
Hospital-acquired VTE cases tend to harbor a number of complications, said Dr. Southard, who is a pediatric hematology/oncology fellow at Children’s Hospital Colorado, Aurora. For example, 15%-20% of patients with a DVT will have a pulmonary embolism (PE) as well, 26% of patients with upper or lower extremity DVT develop post-thrombotic syndrome, and 3% of patients with PE develop chronic pulmonary hypertension.
“Medical costs are also impacted,” she said. “The cost for a hospital-acquired VTE in pediatrics increased the length of stay by about 8 days and increased the cost of hospital admission by more than $27,000.”
Known risk factors for VTE in this patient population include ICU admission (Odds Ratio, 2.14), presence of a central venous catheter (OR, 2.12), mechanical ventilation (OR, 1.56), and prolonged admission (OR, 1.03 for each day).
Risk factors in pediatric trauma patients include ICU admission (OR, 6.25), transfusion of blood products (OR, 2.1), lower extremity fracture (OR, 1.8), and neurosurgery (OR, 2.13). She and her associates hypothesized that understanding the relative contributions of clinical, biological, and genetic risk factors for pediatric VTE would help appropriately risk-stratify patients and allow better prophylactic approaches.
In 2012, Children’s Hospital Colorado implemented a VTE risk assessment tool as part of a hospital-wide patient safety initiative. The assessment is triggered via an Epic Best Practice Advisory to complete in certain higher-risk patients, including ICU patients, hematology/oncology floor patients, any patients with a central line catheter, and those who are over age 12 and obese.
Clinicians also assess for risk factors such as significant infection, recent surgery, and personal or family history of thrombophilia. Next, they classify each patient’s risk of hospital-acquired VTE as high, moderate, or low risk.
In a pilot study, Dr. Southard and her associates set out to validate the accuracy of the institution’s VTE risk assessment tool since it was implemented in 2012. She presented findings from 215 hospital-acquired VTE cases in patients younger than age 18, compared with age-matched inpatient controls. Data from patients under 6 months of age is available after October 2016, coinciding with a change in definition of pediatric hospital-acquired VTE.
Most hospital-acquired VTE patients (77.2%) ranged in age from 1-17 years. The number of patients admitted for a trauma diagnosis was similar between VTE cases and controls (7.4% vs. 7.9%, respectively). However, compared with controls, a significantly greater number of VTE cases were immobile (41.8% vs. 10.3%, respectively), required ICU admission (86.4% vs. 26.5%), had a central venous catheter (80.4% vs. 10.9%), had a positive blood culture (16.7% vs. 1.9%), required surgery or a medical procedure (57.7% vs. 36.7%), and had a longer procedure time (a mean of 151 vs. 133 minutes).
The researchers also found that upon initial admission, 7.9% of VTE cases were identified as high risk and another 21.9% were identified as moderate risk, compared with 1.2% and 3.7% in the controls, respectively.
“Patients identified as moderate or high risk for VTE were generally more medically complex patients,” Dr. Southard said.
Future directions of this project include expanding the patient population that has a risk assessment performed.
Dr. Southard reported having no financial disclosures.
SOURCE: Southard E et al. THSNA 2018.
SAN DIEGO – Following simple institutional care guidelines helped clinicians identify pediatric patients at moderate-to-severe risk of venous thromboembolism (VTE), results from a single-center study showed.
“Hospital-acquired VTE is on the rise in the pediatric population,” lead study author Emily Southard, MD, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “This consists of a DVT or [pulmonary embolism] 48 hours or more after admission, or any time at the site of a central venous catheter.”
One published study found a 70% increased incidence in the pediatric population from 2001-2007 (Pediatrics 2009;124[4]:1001-8). More than half of the children in that study (63%) had at least one coexisting complex medical condition, with malignancy being the most common.
Hospital-acquired VTE cases tend to harbor a number of complications, said Dr. Southard, who is a pediatric hematology/oncology fellow at Children’s Hospital Colorado, Aurora. For example, 15%-20% of patients with a DVT will have a pulmonary embolism (PE) as well, 26% of patients with upper or lower extremity DVT develop post-thrombotic syndrome, and 3% of patients with PE develop chronic pulmonary hypertension.
“Medical costs are also impacted,” she said. “The cost for a hospital-acquired VTE in pediatrics increased the length of stay by about 8 days and increased the cost of hospital admission by more than $27,000.”
Known risk factors for VTE in this patient population include ICU admission (Odds Ratio, 2.14), presence of a central venous catheter (OR, 2.12), mechanical ventilation (OR, 1.56), and prolonged admission (OR, 1.03 for each day).
Risk factors in pediatric trauma patients include ICU admission (OR, 6.25), transfusion of blood products (OR, 2.1), lower extremity fracture (OR, 1.8), and neurosurgery (OR, 2.13). She and her associates hypothesized that understanding the relative contributions of clinical, biological, and genetic risk factors for pediatric VTE would help appropriately risk-stratify patients and allow better prophylactic approaches.
In 2012, Children’s Hospital Colorado implemented a VTE risk assessment tool as part of a hospital-wide patient safety initiative. The assessment is triggered via an Epic Best Practice Advisory to complete in certain higher-risk patients, including ICU patients, hematology/oncology floor patients, any patients with a central line catheter, and those who are over age 12 and obese.
Clinicians also assess for risk factors such as significant infection, recent surgery, and personal or family history of thrombophilia. Next, they classify each patient’s risk of hospital-acquired VTE as high, moderate, or low risk.
In a pilot study, Dr. Southard and her associates set out to validate the accuracy of the institution’s VTE risk assessment tool since it was implemented in 2012. She presented findings from 215 hospital-acquired VTE cases in patients younger than age 18, compared with age-matched inpatient controls. Data from patients under 6 months of age is available after October 2016, coinciding with a change in definition of pediatric hospital-acquired VTE.
Most hospital-acquired VTE patients (77.2%) ranged in age from 1-17 years. The number of patients admitted for a trauma diagnosis was similar between VTE cases and controls (7.4% vs. 7.9%, respectively). However, compared with controls, a significantly greater number of VTE cases were immobile (41.8% vs. 10.3%, respectively), required ICU admission (86.4% vs. 26.5%), had a central venous catheter (80.4% vs. 10.9%), had a positive blood culture (16.7% vs. 1.9%), required surgery or a medical procedure (57.7% vs. 36.7%), and had a longer procedure time (a mean of 151 vs. 133 minutes).
The researchers also found that upon initial admission, 7.9% of VTE cases were identified as high risk and another 21.9% were identified as moderate risk, compared with 1.2% and 3.7% in the controls, respectively.
“Patients identified as moderate or high risk for VTE were generally more medically complex patients,” Dr. Southard said.
Future directions of this project include expanding the patient population that has a risk assessment performed.
Dr. Southard reported having no financial disclosures.
SOURCE: Southard E et al. THSNA 2018.
REPORTING FROM THSNA 2018
Key clinical point:
Major finding: A significantly greater number of VTE patients were immobile (41.8% vs. 10.3%, respectively), required ICU admission (86.4% vs. 26.5%), and had a central venous catheter (80.4% vs. 10.9%), compared with controls.
Study details: A retrospective analysis of 215 hospital-acquired VTE cases in patients younger than age 18.
Disclosures: Dr. Southard reported having no financial disclosures.
Source: Southard E et al. THSNA 2018.
Warfarin dose capping avoided supratherapeutic INRs in hospitalized elderly
SAN DIEGO – A simple intervention of initial warfarin dose capping in hospitalized patients aged 85 years and older led to significant reductions in supratherapeutic INRs without a significant change in length of stay, a single-center study showed.
“We’re excited to see if these results are reproducible,” Jonathan Falsetta, PharmD, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “We do feel that it may represent an important step forward in warfarin safety in a vulnerable patient population.”
“From this we gathered that we had an issue with dosing,” said Dr. Falsetta, who is assistant director of pharmacy clinical educational services at Plainview Hospital. “These patients were spiking dangerously high INRs, and we needed to do something about it.”
A review of current medical literature revealed a lack of well-validated recommendations regarding warfarin initiation in older patients, so Dr. Falsetta and his associates set out to create their own dose-capping recommendation. This involved limiting the initial dose of warfarin to 2.5 mg or less for hospitalized patients aged 85 years and older.
“We wanted this to be applicable to patients regardless if they were warfarin naïve or if they had been on warfarin prior to admission,” he said.
Before the roll out, clinical pharmacists and pharmacy residents conducted provider education on the initial dose capping protocol. Providers could order initial doses that exceeded 2.5 mg with valid clinical reasoning. Outcomes of interest were dosing protocol compliance and post-intervention analysis of INRs in this patient population. The pre-intervention period spanned from Nov. 1, 2014 through Oct. 31, 2015, while the post-intervention period spanned from Nov. 1, 2015 through Oct. 31, 2017. Dr. Falsetta reported data from 768 patients.
Between the pre-intervention and post-intervention periods, compliance with dose capping rose from 38.5% to 64.2% (P less than .001), the supratherapeutic INR rate dropped from 20.9% to 13.3% (P= .004), and the length of hospital stay in hours rose from a mean of 145.8 to a mean of 155.8, which was not statistically significant (P= .13).
Following the post-intervention period, the number of peak INRs in the 1 to 2 range rose by 15% and the number of peak INRs in the 2 to 3 range rose by 6%. At the same time, the number of peak INRs in the 3 to 4 range fell by 6%, the number of peak INRs in the 4 to 5 range fell by 36%, and the number of peak INRs in the 5 and greater range fell by 53%. These INR percentages represent relative increases and/or decreases.
“This was a relatively simple intervention that resulted in significant reductions in supratherapeutic INRs,” Dr. Falsetta said.
The researchers also observed that there was less IV vitamin K use after the dose capping intervention. “We can’t say for sure that this was tied to the intervention, but it was interesting, and it is something for us to take a look at, as well as roll this out in future iterations,” he said. “We are on the cusp of rolling this out at some of the tertiary sites within our health care system, and some of the community sites as well.”
He acknowledged certain limitations of the study, including its single-center design, relatively small sample size, and lack of clinical endpoints. “I’d like to be able to tie this to something like reduced bleeding events,” Dr. Falsetta said. “I think that’s something we need to explore in the future.”
Dr. Falsetta reported having no financial disclosures.
SOURCE: Falsetta J et al. THSNA 2018.
SAN DIEGO – A simple intervention of initial warfarin dose capping in hospitalized patients aged 85 years and older led to significant reductions in supratherapeutic INRs without a significant change in length of stay, a single-center study showed.
“We’re excited to see if these results are reproducible,” Jonathan Falsetta, PharmD, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “We do feel that it may represent an important step forward in warfarin safety in a vulnerable patient population.”
“From this we gathered that we had an issue with dosing,” said Dr. Falsetta, who is assistant director of pharmacy clinical educational services at Plainview Hospital. “These patients were spiking dangerously high INRs, and we needed to do something about it.”
A review of current medical literature revealed a lack of well-validated recommendations regarding warfarin initiation in older patients, so Dr. Falsetta and his associates set out to create their own dose-capping recommendation. This involved limiting the initial dose of warfarin to 2.5 mg or less for hospitalized patients aged 85 years and older.
“We wanted this to be applicable to patients regardless if they were warfarin naïve or if they had been on warfarin prior to admission,” he said.
Before the roll out, clinical pharmacists and pharmacy residents conducted provider education on the initial dose capping protocol. Providers could order initial doses that exceeded 2.5 mg with valid clinical reasoning. Outcomes of interest were dosing protocol compliance and post-intervention analysis of INRs in this patient population. The pre-intervention period spanned from Nov. 1, 2014 through Oct. 31, 2015, while the post-intervention period spanned from Nov. 1, 2015 through Oct. 31, 2017. Dr. Falsetta reported data from 768 patients.
Between the pre-intervention and post-intervention periods, compliance with dose capping rose from 38.5% to 64.2% (P less than .001), the supratherapeutic INR rate dropped from 20.9% to 13.3% (P= .004), and the length of hospital stay in hours rose from a mean of 145.8 to a mean of 155.8, which was not statistically significant (P= .13).
Following the post-intervention period, the number of peak INRs in the 1 to 2 range rose by 15% and the number of peak INRs in the 2 to 3 range rose by 6%. At the same time, the number of peak INRs in the 3 to 4 range fell by 6%, the number of peak INRs in the 4 to 5 range fell by 36%, and the number of peak INRs in the 5 and greater range fell by 53%. These INR percentages represent relative increases and/or decreases.
“This was a relatively simple intervention that resulted in significant reductions in supratherapeutic INRs,” Dr. Falsetta said.
The researchers also observed that there was less IV vitamin K use after the dose capping intervention. “We can’t say for sure that this was tied to the intervention, but it was interesting, and it is something for us to take a look at, as well as roll this out in future iterations,” he said. “We are on the cusp of rolling this out at some of the tertiary sites within our health care system, and some of the community sites as well.”
He acknowledged certain limitations of the study, including its single-center design, relatively small sample size, and lack of clinical endpoints. “I’d like to be able to tie this to something like reduced bleeding events,” Dr. Falsetta said. “I think that’s something we need to explore in the future.”
Dr. Falsetta reported having no financial disclosures.
SOURCE: Falsetta J et al. THSNA 2018.
SAN DIEGO – A simple intervention of initial warfarin dose capping in hospitalized patients aged 85 years and older led to significant reductions in supratherapeutic INRs without a significant change in length of stay, a single-center study showed.
“We’re excited to see if these results are reproducible,” Jonathan Falsetta, PharmD, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “We do feel that it may represent an important step forward in warfarin safety in a vulnerable patient population.”
“From this we gathered that we had an issue with dosing,” said Dr. Falsetta, who is assistant director of pharmacy clinical educational services at Plainview Hospital. “These patients were spiking dangerously high INRs, and we needed to do something about it.”
A review of current medical literature revealed a lack of well-validated recommendations regarding warfarin initiation in older patients, so Dr. Falsetta and his associates set out to create their own dose-capping recommendation. This involved limiting the initial dose of warfarin to 2.5 mg or less for hospitalized patients aged 85 years and older.
“We wanted this to be applicable to patients regardless if they were warfarin naïve or if they had been on warfarin prior to admission,” he said.
Before the roll out, clinical pharmacists and pharmacy residents conducted provider education on the initial dose capping protocol. Providers could order initial doses that exceeded 2.5 mg with valid clinical reasoning. Outcomes of interest were dosing protocol compliance and post-intervention analysis of INRs in this patient population. The pre-intervention period spanned from Nov. 1, 2014 through Oct. 31, 2015, while the post-intervention period spanned from Nov. 1, 2015 through Oct. 31, 2017. Dr. Falsetta reported data from 768 patients.
Between the pre-intervention and post-intervention periods, compliance with dose capping rose from 38.5% to 64.2% (P less than .001), the supratherapeutic INR rate dropped from 20.9% to 13.3% (P= .004), and the length of hospital stay in hours rose from a mean of 145.8 to a mean of 155.8, which was not statistically significant (P= .13).
Following the post-intervention period, the number of peak INRs in the 1 to 2 range rose by 15% and the number of peak INRs in the 2 to 3 range rose by 6%. At the same time, the number of peak INRs in the 3 to 4 range fell by 6%, the number of peak INRs in the 4 to 5 range fell by 36%, and the number of peak INRs in the 5 and greater range fell by 53%. These INR percentages represent relative increases and/or decreases.
“This was a relatively simple intervention that resulted in significant reductions in supratherapeutic INRs,” Dr. Falsetta said.
The researchers also observed that there was less IV vitamin K use after the dose capping intervention. “We can’t say for sure that this was tied to the intervention, but it was interesting, and it is something for us to take a look at, as well as roll this out in future iterations,” he said. “We are on the cusp of rolling this out at some of the tertiary sites within our health care system, and some of the community sites as well.”
He acknowledged certain limitations of the study, including its single-center design, relatively small sample size, and lack of clinical endpoints. “I’d like to be able to tie this to something like reduced bleeding events,” Dr. Falsetta said. “I think that’s something we need to explore in the future.”
Dr. Falsetta reported having no financial disclosures.
SOURCE: Falsetta J et al. THSNA 2018.
REPORTING FROM THSNA 2018
Key clinical point:
Major finding: The supratherapeutic INR rate dropped from 20.9% to 13.3% (P= .004) between the pre- and post-intervention period.
Study details: A single-center study of 768 hospitalized patients aged 85 years and older.
Disclosures: Dr. Falsetta reported having no financial disclosures.
Source: Falsetta J et al., THSNA 2018.
New IDSA guidelines for managing infectious diarrhea
Clinical question: What is the best management of acute or persistent infectious diarrhea in adults and children?
Background: The last set of guidelines from the Infectious Diseases Society of America (IDSA) regarding acute or persistent infectious diarrhea in adults and children was published in 2001. This provides a comprehensive evidence-based update.
Setting: Expert panel assembled by IDSA.
Synopsis: A panel of experts convened by IDSA reviewed studies through December 2013, focusing on acute or persistent infectious diarrhea in infants, children, adolescents, and adults in the United States. Using GRADE criteria, the panel generated 60 recommendations. Recommendations of interest to hospitalists include those for testing and treating acute diarrhea. Testing stool for bacterial pathogens is recommended for patients with diarrhea and fever, bloody or mucoid stools, severe abdominal cramping or tenderness, or sepsis (additional testing is recommended in immunocompromised patients). Blood cultures are recommended for those who are less than 3 months of age, septic, or at risk for enteric fever. Antibiotics are not recommended for immunocompetent adults or children with either watery or bloody diarrhea, unless sepsis is present or the patient is less than 3 months of age with a presumed bacterial etiology in the latter. Recommendations regarding Clostridium difficile infections are not included in these guidelines.
Bottom line: These updated guidelines provide evidence-based recommendations for the management of acute or persistent diarrhea in infants, children, adolescents, and adults.
Citation: Shane AL et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017 Nov 29; 65(12):1963-73. doi: 10.1093/cid/cix959.
Dr. Bonsall is associate professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Clinical question: What is the best management of acute or persistent infectious diarrhea in adults and children?
Background: The last set of guidelines from the Infectious Diseases Society of America (IDSA) regarding acute or persistent infectious diarrhea in adults and children was published in 2001. This provides a comprehensive evidence-based update.
Setting: Expert panel assembled by IDSA.
Synopsis: A panel of experts convened by IDSA reviewed studies through December 2013, focusing on acute or persistent infectious diarrhea in infants, children, adolescents, and adults in the United States. Using GRADE criteria, the panel generated 60 recommendations. Recommendations of interest to hospitalists include those for testing and treating acute diarrhea. Testing stool for bacterial pathogens is recommended for patients with diarrhea and fever, bloody or mucoid stools, severe abdominal cramping or tenderness, or sepsis (additional testing is recommended in immunocompromised patients). Blood cultures are recommended for those who are less than 3 months of age, septic, or at risk for enteric fever. Antibiotics are not recommended for immunocompetent adults or children with either watery or bloody diarrhea, unless sepsis is present or the patient is less than 3 months of age with a presumed bacterial etiology in the latter. Recommendations regarding Clostridium difficile infections are not included in these guidelines.
Bottom line: These updated guidelines provide evidence-based recommendations for the management of acute or persistent diarrhea in infants, children, adolescents, and adults.
Citation: Shane AL et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017 Nov 29; 65(12):1963-73. doi: 10.1093/cid/cix959.
Dr. Bonsall is associate professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Clinical question: What is the best management of acute or persistent infectious diarrhea in adults and children?
Background: The last set of guidelines from the Infectious Diseases Society of America (IDSA) regarding acute or persistent infectious diarrhea in adults and children was published in 2001. This provides a comprehensive evidence-based update.
Setting: Expert panel assembled by IDSA.
Synopsis: A panel of experts convened by IDSA reviewed studies through December 2013, focusing on acute or persistent infectious diarrhea in infants, children, adolescents, and adults in the United States. Using GRADE criteria, the panel generated 60 recommendations. Recommendations of interest to hospitalists include those for testing and treating acute diarrhea. Testing stool for bacterial pathogens is recommended for patients with diarrhea and fever, bloody or mucoid stools, severe abdominal cramping or tenderness, or sepsis (additional testing is recommended in immunocompromised patients). Blood cultures are recommended for those who are less than 3 months of age, septic, or at risk for enteric fever. Antibiotics are not recommended for immunocompetent adults or children with either watery or bloody diarrhea, unless sepsis is present or the patient is less than 3 months of age with a presumed bacterial etiology in the latter. Recommendations regarding Clostridium difficile infections are not included in these guidelines.
Bottom line: These updated guidelines provide evidence-based recommendations for the management of acute or persistent diarrhea in infants, children, adolescents, and adults.
Citation: Shane AL et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017 Nov 29; 65(12):1963-73. doi: 10.1093/cid/cix959.
Dr. Bonsall is associate professor of medicine in the division of hospital medicine, Emory University, Atlanta.