The Hospitalist

 

The use of proton pump inhibitors increased the odds of a patient having hospital-onset Clostridium difficile infection (HO CDI) as did the use of third- and fourth-generation cephalosporins, carbapenems, and piperacillin/tazobactam, according to the results of a retrospective database study of more than 1 million patients at 150 U.S. hospitals.

PPIs increased the odds of HO CDI by 44% (P less than .001), whereas the use of H2 antagonists increased the odds ratio for HO CDI to a lesser, but still significant, extent (13% increase, P less than .001), according to the report published online in Clinical Infectious Diseases.

Overall, the odds of HO CDI were significantly higher in patients taking carbapenems, third- and fourth-generation cephalosporins, metronidazole, and piperacillin/tazobactam, as well as patients on multiple antibiotics. However, treatment with tetracyclines, macrolides, or clindamycin significantly reduced the odds of HO CDI.

The combination of PPIs with fluoroquinolones, third-generation cephalosporins, fourth-generation cephalosporins, clindamycin, or carbapenems did not significantly alter the odds of HO CDI, which was in contrast with a previous meta-analysis (Am J Gastroenterol. 2012;107[7]:1011-9).

CDC/Jennifer Hulsey

“Whether or not there are common pathways by which these medications increase the risk for development of a CDI remains to be determined,” the authors stated. “This study leveraged a large database and confirms and supports previous studies demonstrating an increased odds of HO CDI associated with the use of PPIs and certain high-risk antibiotics,” noted Troy Watson, PharmD, and his colleagues at the Hospital Corporation of America, Nashville, Tenn.

In addition to the drug associations, the odds of a patient having HO CDI increased by 0.5% for each year in age. The odds of CDI in women was 1.2 times as likely as in men, and admission from a long-term care facility, the presence of the comorbidities of diabetes, Crohn’s disease or ulcerative colitis, as well as days in the ICU and antibiotic days of therapy all significantly increased the odds of a patient having HO CDI. (Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112).

“The results support the need for stewardship practices around both high-risk antibiotics and medications that alter gastric acid regulation. Furthermore, the impact of deprescribing acid suppression therapy coupled with antibiotic stewardship could greatly reduce the incidence of HO CDI,” the researchers concluded.

The authors reported that they had no conflicts or funding source for this work.

[email protected]

SOURCE: Watson, T. et al. Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112.

 

The use of proton pump inhibitors increased the odds of a patient having hospital-onset Clostridium difficile infection (HO CDI) as did the use of third- and fourth-generation cephalosporins, carbapenems, and piperacillin/tazobactam, according to the results of a retrospective database study of more than 1 million patients at 150 U.S. hospitals.

PPIs increased the odds of HO CDI by 44% (P less than .001), whereas the use of H2 antagonists increased the odds ratio for HO CDI to a lesser, but still significant, extent (13% increase, P less than .001), according to the report published online in Clinical Infectious Diseases.

Overall, the odds of HO CDI were significantly higher in patients taking carbapenems, third- and fourth-generation cephalosporins, metronidazole, and piperacillin/tazobactam, as well as patients on multiple antibiotics. However, treatment with tetracyclines, macrolides, or clindamycin significantly reduced the odds of HO CDI.

The combination of PPIs with fluoroquinolones, third-generation cephalosporins, fourth-generation cephalosporins, clindamycin, or carbapenems did not significantly alter the odds of HO CDI, which was in contrast with a previous meta-analysis (Am J Gastroenterol. 2012;107[7]:1011-9).

CDC/Jennifer Hulsey

“Whether or not there are common pathways by which these medications increase the risk for development of a CDI remains to be determined,” the authors stated. “This study leveraged a large database and confirms and supports previous studies demonstrating an increased odds of HO CDI associated with the use of PPIs and certain high-risk antibiotics,” noted Troy Watson, PharmD, and his colleagues at the Hospital Corporation of America, Nashville, Tenn.

In addition to the drug associations, the odds of a patient having HO CDI increased by 0.5% for each year in age. The odds of CDI in women was 1.2 times as likely as in men, and admission from a long-term care facility, the presence of the comorbidities of diabetes, Crohn’s disease or ulcerative colitis, as well as days in the ICU and antibiotic days of therapy all significantly increased the odds of a patient having HO CDI. (Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112).

“The results support the need for stewardship practices around both high-risk antibiotics and medications that alter gastric acid regulation. Furthermore, the impact of deprescribing acid suppression therapy coupled with antibiotic stewardship could greatly reduce the incidence of HO CDI,” the researchers concluded.

The authors reported that they had no conflicts or funding source for this work.

[email protected]

SOURCE: Watson, T. et al. Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112.

 

The use of proton pump inhibitors increased the odds of a patient having hospital-onset Clostridium difficile infection (HO CDI) as did the use of third- and fourth-generation cephalosporins, carbapenems, and piperacillin/tazobactam, according to the results of a retrospective database study of more than 1 million patients at 150 U.S. hospitals.

PPIs increased the odds of HO CDI by 44% (P less than .001), whereas the use of H2 antagonists increased the odds ratio for HO CDI to a lesser, but still significant, extent (13% increase, P less than .001), according to the report published online in Clinical Infectious Diseases.

Overall, the odds of HO CDI were significantly higher in patients taking carbapenems, third- and fourth-generation cephalosporins, metronidazole, and piperacillin/tazobactam, as well as patients on multiple antibiotics. However, treatment with tetracyclines, macrolides, or clindamycin significantly reduced the odds of HO CDI.

The combination of PPIs with fluoroquinolones, third-generation cephalosporins, fourth-generation cephalosporins, clindamycin, or carbapenems did not significantly alter the odds of HO CDI, which was in contrast with a previous meta-analysis (Am J Gastroenterol. 2012;107[7]:1011-9).

CDC/Jennifer Hulsey

“Whether or not there are common pathways by which these medications increase the risk for development of a CDI remains to be determined,” the authors stated. “This study leveraged a large database and confirms and supports previous studies demonstrating an increased odds of HO CDI associated with the use of PPIs and certain high-risk antibiotics,” noted Troy Watson, PharmD, and his colleagues at the Hospital Corporation of America, Nashville, Tenn.

In addition to the drug associations, the odds of a patient having HO CDI increased by 0.5% for each year in age. The odds of CDI in women was 1.2 times as likely as in men, and admission from a long-term care facility, the presence of the comorbidities of diabetes, Crohn’s disease or ulcerative colitis, as well as days in the ICU and antibiotic days of therapy all significantly increased the odds of a patient having HO CDI. (Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112).

“The results support the need for stewardship practices around both high-risk antibiotics and medications that alter gastric acid regulation. Furthermore, the impact of deprescribing acid suppression therapy coupled with antibiotic stewardship could greatly reduce the incidence of HO CDI,” the researchers concluded.

The authors reported that they had no conflicts or funding source for this work.

[email protected]

SOURCE: Watson, T. et al. Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112.

Clinical question: What percent of inpatient health care spending by hospitalists can be attributed to defensive medicine?

Background: Defensive medicine contributes an estimated $45 billion to annual U.S. health care expenditures. The prevalence of defensive medicine among hospitalists is unknown.

Study design: Survey of U.S.-based hospitalists.

Setting: National survey sent to 1,753 hospitalists from all 50 states identified through the Society of Hospital Medicine database of members and meeting attendees.

Synopsis: The survey contained two primary topics: an estimation of defensive spending and liability history. The hospitalists, who had an average of 11 years in practice, completed 1,020 surveys. Participants estimated that defensive medicine accounted for 37.5% of all health care costs. Decreased estimate rates were seen among VA hospitalists (5.5% less), male respondents (36.4% vs. 39.4% for female), non-Hispanic white respondents (32.5% vs. 44.7% for other) and having more years in practice (decrease of 3% for every 10 years in practice). One in four respondents reported being sued at least once, with higher risk seen in those with greater years in practice. There was no association between liability experience and perception of defensive medicine spending. Differences between academic and community settings were not addressed. Because only 30% of practicing hospitalists are members of SHM, it may be difficult to generalize these findings.

Bottom line: Hospitalists perceive that defensive medicine is a major contributor to inpatient health care expenditures.

Citation: Saint S et al. Perception of resources spent on defensive medicine and history of being sued among hospitalists: Results from a national survey. J Hosp Med. 2017 Aug 23. doi: 10.12788/jhm.2800.

Dr. Lublin is a hospitalist at the University of Colorado School of Medicine.

Clinical question: What percent of inpatient health care spending by hospitalists can be attributed to defensive medicine?

Background: Defensive medicine contributes an estimated $45 billion to annual U.S. health care expenditures. The prevalence of defensive medicine among hospitalists is unknown.

Study design: Survey of U.S.-based hospitalists.

Setting: National survey sent to 1,753 hospitalists from all 50 states identified through the Society of Hospital Medicine database of members and meeting attendees.

Synopsis: The survey contained two primary topics: an estimation of defensive spending and liability history. The hospitalists, who had an average of 11 years in practice, completed 1,020 surveys. Participants estimated that defensive medicine accounted for 37.5% of all health care costs. Decreased estimate rates were seen among VA hospitalists (5.5% less), male respondents (36.4% vs. 39.4% for female), non-Hispanic white respondents (32.5% vs. 44.7% for other) and having more years in practice (decrease of 3% for every 10 years in practice). One in four respondents reported being sued at least once, with higher risk seen in those with greater years in practice. There was no association between liability experience and perception of defensive medicine spending. Differences between academic and community settings were not addressed. Because only 30% of practicing hospitalists are members of SHM, it may be difficult to generalize these findings.

Bottom line: Hospitalists perceive that defensive medicine is a major contributor to inpatient health care expenditures.

Citation: Saint S et al. Perception of resources spent on defensive medicine and history of being sued among hospitalists: Results from a national survey. J Hosp Med. 2017 Aug 23. doi: 10.12788/jhm.2800.

Dr. Lublin is a hospitalist at the University of Colorado School of Medicine.

Clinical question: What percent of inpatient health care spending by hospitalists can be attributed to defensive medicine?

Background: Defensive medicine contributes an estimated $45 billion to annual U.S. health care expenditures. The prevalence of defensive medicine among hospitalists is unknown.

Study design: Survey of U.S.-based hospitalists.

Setting: National survey sent to 1,753 hospitalists from all 50 states identified through the Society of Hospital Medicine database of members and meeting attendees.

Synopsis: The survey contained two primary topics: an estimation of defensive spending and liability history. The hospitalists, who had an average of 11 years in practice, completed 1,020 surveys. Participants estimated that defensive medicine accounted for 37.5% of all health care costs. Decreased estimate rates were seen among VA hospitalists (5.5% less), male respondents (36.4% vs. 39.4% for female), non-Hispanic white respondents (32.5% vs. 44.7% for other) and having more years in practice (decrease of 3% for every 10 years in practice). One in four respondents reported being sued at least once, with higher risk seen in those with greater years in practice. There was no association between liability experience and perception of defensive medicine spending. Differences between academic and community settings were not addressed. Because only 30% of practicing hospitalists are members of SHM, it may be difficult to generalize these findings.

Bottom line: Hospitalists perceive that defensive medicine is a major contributor to inpatient health care expenditures.

Citation: Saint S et al. Perception of resources spent on defensive medicine and history of being sued among hospitalists: Results from a national survey. J Hosp Med. 2017 Aug 23. doi: 10.12788/jhm.2800.

Dr. Lublin is a hospitalist at the University of Colorado School of Medicine.

 

Clinical question: Does cost messaging at the time of ordering reduce prescriber use of high-cost medications?

Background: Overprescribing expensive medications contributes to inpatient health care expenditures and may be avoidable when low-cost alternatives are available.

Study design: Retrospective, observational analysis of a quality improvement project.

Setting: Single center, 1,145-bed, tertiary-care academic medical center.

Synopsis: Nine medications were chosen by committee to be targeted for intervention: intravenous voriconazole, IV levetiracetam, IV levothyroxine, IV linezolid, IV eculizumab, IV pantoprazole, IV calcitonin, inhaled ribavirin, and IV mycophenolate. The costs for these nine medications plus lower-cost alternatives were displayed for providers in the order entry system after about 2 years of baseline data had been collected. There was no change in the number of orders or ordering trends for eight of the nine high-cost medications after the intervention. Only ribavirin was ordered less after cost messaging was implemented (16.3 fewer orders per 10,000 patient-days). Lower IV pantoprazole use (73% reduction), correlated with a national shortage unrelated to the study intervention, a potential confounder. Data on dosing frequency and duration were not collected.

Bottom line: Displaying medication costs and alternatives did not alter the use of these nine high-cost medications.

Citation: Conway SJ et al. Impact of displaying inpatient pharmaceutical costs at the time of order entry: Lessons from a tertiary care center. J Hosp Med. 2017 Aug;12(8):639-45.

Dr. Lublin is a hospitalist at the University of Colorado School of Medicine.

 

Clinical question: Does cost messaging at the time of ordering reduce prescriber use of high-cost medications?

Background: Overprescribing expensive medications contributes to inpatient health care expenditures and may be avoidable when low-cost alternatives are available.

Study design: Retrospective, observational analysis of a quality improvement project.

Setting: Single center, 1,145-bed, tertiary-care academic medical center.

Synopsis: Nine medications were chosen by committee to be targeted for intervention: intravenous voriconazole, IV levetiracetam, IV levothyroxine, IV linezolid, IV eculizumab, IV pantoprazole, IV calcitonin, inhaled ribavirin, and IV mycophenolate. The costs for these nine medications plus lower-cost alternatives were displayed for providers in the order entry system after about 2 years of baseline data had been collected. There was no change in the number of orders or ordering trends for eight of the nine high-cost medications after the intervention. Only ribavirin was ordered less after cost messaging was implemented (16.3 fewer orders per 10,000 patient-days). Lower IV pantoprazole use (73% reduction), correlated with a national shortage unrelated to the study intervention, a potential confounder. Data on dosing frequency and duration were not collected.

Bottom line: Displaying medication costs and alternatives did not alter the use of these nine high-cost medications.

Citation: Conway SJ et al. Impact of displaying inpatient pharmaceutical costs at the time of order entry: Lessons from a tertiary care center. J Hosp Med. 2017 Aug;12(8):639-45.

Dr. Lublin is a hospitalist at the University of Colorado School of Medicine.

 

Clinical question: Does cost messaging at the time of ordering reduce prescriber use of high-cost medications?

Background: Overprescribing expensive medications contributes to inpatient health care expenditures and may be avoidable when low-cost alternatives are available.

Study design: Retrospective, observational analysis of a quality improvement project.

Setting: Single center, 1,145-bed, tertiary-care academic medical center.

Synopsis: Nine medications were chosen by committee to be targeted for intervention: intravenous voriconazole, IV levetiracetam, IV levothyroxine, IV linezolid, IV eculizumab, IV pantoprazole, IV calcitonin, inhaled ribavirin, and IV mycophenolate. The costs for these nine medications plus lower-cost alternatives were displayed for providers in the order entry system after about 2 years of baseline data had been collected. There was no change in the number of orders or ordering trends for eight of the nine high-cost medications after the intervention. Only ribavirin was ordered less after cost messaging was implemented (16.3 fewer orders per 10,000 patient-days). Lower IV pantoprazole use (73% reduction), correlated with a national shortage unrelated to the study intervention, a potential confounder. Data on dosing frequency and duration were not collected.

Bottom line: Displaying medication costs and alternatives did not alter the use of these nine high-cost medications.

Citation: Conway SJ et al. Impact of displaying inpatient pharmaceutical costs at the time of order entry: Lessons from a tertiary care center. J Hosp Med. 2017 Aug;12(8):639-45.

Dr. Lublin is a hospitalist at the University of Colorado School of Medicine.

Background: Although neck and low back pain are leading causes of pain and disability, there is no consensus first-line pharmacologic therapy for treatment. Recent research has pointed to acetaminophen as being ineffective, which – in combination with increased awareness of opioid dependency and adverse risks – could lead to greater use of NSAIDs.

Study design: Systematic review and meta-analysis.

Setting: Randomized controlled trials.

Synopsis: Researchers used MEDLINE, EMBASE, CINAHL, CENTRAL, and LILACS to select 35 randomized, placebo-controlled trials evaluating the impact of NSAIDs on reducing spinal pain and disability from a total of 302 full-text articles. Trial data were pooled based on follow-up time and outcomes. Pain and disability outcomes were converted to a 100-point scale with a 10-point difference between groups defined as “clinically important.” NSAIDs were found to offer greater pain reduction than placebo in the immediate (number needed to treat, 5; 95% confidence interval, 4-6) and short (NNT, 6; 95% CI, 4-10) range. However, this effect did not meet the specified 10-point difference to support “clinical importance,” despite having favorable numbers needed to treat. Limited corresponding safety analysis did not find significant adverse event rate differences other than increased reporting of gastrointestinal symptoms.

Bottom line: NSAIDs reduce spinal pain, compared with placebo, with low numbers needed to treat, but nevertheless were not determined to have a “clinically important” effect.

Citation: Machado GC et al. Nonsteroidal anti-inflammatory drugs for spinal pain: A systematic review and meta-analysis. Ann Rheum Dis. 2017 Jul;76(7):1269-78.

Background: Although neck and low back pain are leading causes of pain and disability, there is no consensus first-line pharmacologic therapy for treatment. Recent research has pointed to acetaminophen as being ineffective, which – in combination with increased awareness of opioid dependency and adverse risks – could lead to greater use of NSAIDs.

Study design: Systematic review and meta-analysis.

Setting: Randomized controlled trials.

Synopsis: Researchers used MEDLINE, EMBASE, CINAHL, CENTRAL, and LILACS to select 35 randomized, placebo-controlled trials evaluating the impact of NSAIDs on reducing spinal pain and disability from a total of 302 full-text articles. Trial data were pooled based on follow-up time and outcomes. Pain and disability outcomes were converted to a 100-point scale with a 10-point difference between groups defined as “clinically important.” NSAIDs were found to offer greater pain reduction than placebo in the immediate (number needed to treat, 5; 95% confidence interval, 4-6) and short (NNT, 6; 95% CI, 4-10) range. However, this effect did not meet the specified 10-point difference to support “clinical importance,” despite having favorable numbers needed to treat. Limited corresponding safety analysis did not find significant adverse event rate differences other than increased reporting of gastrointestinal symptoms.

Bottom line: NSAIDs reduce spinal pain, compared with placebo, with low numbers needed to treat, but nevertheless were not determined to have a “clinically important” effect.

Citation: Machado GC et al. Nonsteroidal anti-inflammatory drugs for spinal pain: A systematic review and meta-analysis. Ann Rheum Dis. 2017 Jul;76(7):1269-78.

Background: Although neck and low back pain are leading causes of pain and disability, there is no consensus first-line pharmacologic therapy for treatment. Recent research has pointed to acetaminophen as being ineffective, which – in combination with increased awareness of opioid dependency and adverse risks – could lead to greater use of NSAIDs.

Study design: Systematic review and meta-analysis.

Setting: Randomized controlled trials.

Synopsis: Researchers used MEDLINE, EMBASE, CINAHL, CENTRAL, and LILACS to select 35 randomized, placebo-controlled trials evaluating the impact of NSAIDs on reducing spinal pain and disability from a total of 302 full-text articles. Trial data were pooled based on follow-up time and outcomes. Pain and disability outcomes were converted to a 100-point scale with a 10-point difference between groups defined as “clinically important.” NSAIDs were found to offer greater pain reduction than placebo in the immediate (number needed to treat, 5; 95% confidence interval, 4-6) and short (NNT, 6; 95% CI, 4-10) range. However, this effect did not meet the specified 10-point difference to support “clinical importance,” despite having favorable numbers needed to treat. Limited corresponding safety analysis did not find significant adverse event rate differences other than increased reporting of gastrointestinal symptoms.

Bottom line: NSAIDs reduce spinal pain, compared with placebo, with low numbers needed to treat, but nevertheless were not determined to have a “clinically important” effect.

Citation: Machado GC et al. Nonsteroidal anti-inflammatory drugs for spinal pain: A systematic review and meta-analysis. Ann Rheum Dis. 2017 Jul;76(7):1269-78.

 

A drug overdose victim is admitted to a hospital. Providers focus on treating the overdose and blame it for some of the patient’s troubling vital signs, including low blood pressure and increased heart rate. Prior to admission, however, the patient had vomited and aspirated, leading to an infection. In fact, the patient is developing sepsis.

This real-world incident is but one of many ways that sepsis can fool hospitalists and other providers, often with rapidly deteriorating and deadly consequences. A range of quality improvement (QI) projects, however, are demonstrating how earlier identification and treatment may help to set a new course for addressing a condition that has remained stubbornly difficult to manage.

Every year, more than 1.5 million Americans develop sepsis – arising from the body’s overwhelming and self-destructive response to infection – and roughly 250,000 die from it. According to the Centers for Disease Control and Prevention, about one in three hospital deaths can be at least partially linked to sepsis.

Devin J. Horton, MD, an academic hospitalist at University Hospital in Salt Lake City, sometimes compares sepsis to acute MI to illustrate the difficulty of early detection. A patient complaining of chest pain immediately sets in motion a well-rehearsed chain of events. “But the patient doesn’t look at you and say, ‘You know, I think I’m having SIRS [systemic inflammatory response syndrome] criteria in the setting of infection,’ ” he said. “And yet, the mortality of severe septic shock is at least as bad as acute myocardial infarction.” The trick is generating the same sense of urgency without a clear warning.

The location in a hospital also can present a major obstacle for early identification. Hospitalist Andy Odden, MD, SFHM, patient safety officer in the department of medicine at Washington University in St. Louis, calls hospital wards the “third space” of sepsis care, after the ICU and ED. “A lot of the historical improvement efforts and research has really focused on streamlining care in the ICU and streamlining care in the emergency department,” he said. Often, however, sepsis or septic shock isn’t recognized until a patient is admitted to a medical or surgical ward.

Patients on the wards, though, usually begin with a nonsepsis diagnosis, which can produce an anchoring bias. Furthermore, Dr. Odden said, the data needed to identify sepsis may arrive asynchronously, increasingly the difficulty of pulling it all together for a timely diagnosis. As Dr. Horton points out, the trigger for transferring a decompensating sepsis patient from the wards to the ICU is murkier as well. “We don’t know what is too sick for the floor,” he said. “A lot of it is kind of a gestalt.”

Observational studies by the Surviving Sepsis Campaign suggested that patients diagnosed on the floor had mortality rates comparable to and substantially higher than theoretically sicker patients diagnosed in the ICU and ED, respectively.¹ “That was kind of a sea change for a lot of people and really articulated what a lot of us on the wards had been feeling,” Dr. Odden said. “We can’t simply apply the lessons that we’ve learned from the emergency department and the ICU to the wards if we’re going to provide the right care for these patients,” he said.
 

Dueling definitions

Better sepsis care in hospital wards will require a better understanding of shifting management guidelines. Confusing and contradictory definitions haven’t helped. In October 2015, the Centers for Medicare & Medicaid Services instituted its Sepsis Core Measure (SEP-1) for Medicare, requiring every hospital to audit a percentage of patients treated with best-practice 3- and 6-hour bundles for severe sepsis and septic shock. The SEP-1 measure uses the traditional definition of severe sepsis as two or more SIRS criteria, a suspected or proven infection, and organ dysfunction.

A separate set of guidelines issued by the international Sepsis-3 task force in February 2016, by contrast, concluded that the term “severe sepsis” is redundant.² The update defines sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection” and asserts that the condition can be represented by an increase in the SOFA (Sequential Organ Failure Assessment) score of 2 or more points.

For hospital wards, the task force recommended a bedside scoring system called qSOFA (quickSOFA) for adult patients with a suspected infection. The risk stratification tool may help rapidly identify those who are likely to have poorer outcomes typical of sepsis if they meet two of the following three clinical criteria: a “respiratory rate of 22 [breaths]/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.”

CMS doesn’t recognize the Sepsis-3 definition at all and multiple providers have described widespread skepticism and uncertainty over how to reconcile it with the prior definition. Dr. Odden says the dueling definitions have “caused a tremendous amount of confusion” over diagnoses, the necessary sense of urgency, and whether severe sepsis is still a recognized entity. “When people aren’t speaking the same language with the same terminology, there is enormous opportunity for miscommunication to occur,” he said.

Hospitalist Lisa Shieh, MD, PhD, medical director of quality in the department of medicine at Stanford (Calif.) University Medical Center, said Sepsis-3 was never meant to be a screening tool. It can, however, help doctors identify patients at higher risk. Craig A. Umscheid, MD, MSCE, of the department of epidemiology and vice chair for quality and safety in the department of medicine at the University of Pennsylvania, Philadelphia, said many providers agree that, at least theoretically, changes in a patient’s qSOFA score can predict bad outcomes better than SIRS criteria.

Obtaining reliable scores is another matter. The qSOFA blood pressure score generally is measured accurately, he said. On noncritical care units, though, nurses aren’t always trained to consistently and accurately document a patient’s mental status. Likewise, he said, documentation of respiratory rate often is subjective, and an abnormal rate can be easily missed. Changing that dynamic, he stressed, will require coordination with nursing leadership to ensure more consistent and accurate measurements.

Another big issue is that sepsis screening still is based on early recognition, Dr. Shieh said. “The problem with Sepsis-3 is that it is later in the continuum of sepsis.” As such, she recommends sticking with the CMS definition for now. “It catches sepsis earlier, which is the whole strategy for improving sepsis mortality,” she said.
 

 

Reshaping sepsis pathways

So how can hospitals identify sepsis sooner? Some hospitals have relied more on EMR-based screening methods; others have relied more on nurses to lead the charge. Either way, Dr. Shieh said, the field is trying to encourage the use of set pathways. Almost every medical center that performs well on sepsis measures, she says, has a good screening program, a pathway implemented through an order set or nursing staff, and a highly trained sepsis team that ensures patients get the treatment they need.

At Middlesex Hospital in Middletown, Conn., a major QI project led to significant improvements in sepsis mortality, total mortality, sepsis-related serious safety events and sepsis length of stay. Terri Savino, MSN, RN, CPHQ, the hospital’s manager of patient experience and service excellence, said the project sprang from concerns by the hospital’s Rapid Response Review Committee about some serious safety events involving a delay in sepsis diagnosis and treatment.

As part of a QI effort led by an interdepartmental task force, the hospital first updated its inpatient and ED sepsis pathways to incorporate the Surviving Sepsis Campaign’s 2012 guidelines. “We continued to tweak our pathways, so they’ve now embedded other infection pathways into the sepsis pathway to make sure that we’re not missing anybody,” Ms. Savino said. The hospital also launched an early recognition and treatment educational effort targeting all health care staff and rolled out a new electronic early-warning system in February 2014.

In 2013, the hospital documented three serious safety events related to a delay in diagnosis and treatment of sepsis. In 2014, it recorded only one event and has had none since then. From 2014 to 2015, sepsis-related mortality fell by more than 20%, saving an estimated 25 lives. Sepsis length of stay also declined. “We’re identifying them sooner and treating them sooner so they’re not getting as sick or requiring critical care and longer length of stays,” Ms. Savino said.

Dr. Odden has participated in two multicenter QI initiatives on sepsis. One, a partnership led by the Institute for Healthcare Improvement in Cambridge, Mass., and New York’s North Shore-LIJ Health System, focused on how to diagnose sepsis in hospital ward patients as quickly as possible and how to successfully deliver the 3-hour sepsis bundle.³ Beyond getting everyone on the same page regarding definitions, he said, the collaborators discussed and shared strategies for identifying patients. “One hospital would often have a solution for a problem that other hospitals could either take directly or modify based on their own understanding of their own processes,” he said.

Dr. Odden also participated in a national project sponsored by the Surviving Sepsis Campaign that focused on developing protocols for nurse-led screening processes in hospital wards. Within a pilot unit of each participating hospital, bedside nurses screened every patient for sepsis during every shift. For positive screens, the hospitals then developed protocols for order sets, like blood work and fluids.

The initiative suggested that a nurse-based, every-shift screening method might be one feasible way to identify sick patients as early as possible. “Going through the screening process really seemed to empower the nurses to take a much more active role in partnering with the physicians and in recognizing some of the early warning signs,” Dr. Odden said. The project led to other benefits as well, including improved identification of strokes, delirium, and even a gastrointestinal bleed because the “barriers in communication had been broken down,” he said.

To help medical providers recognize sepsis earlier, Dr. Shieh and her colleagues created a free game called Septris as an adjunctive teaching tool. Based on a player’s diagnosis and treatment decisions, patient outcomes either rise or fall – often rapidly. “I’m an educator and what I know is that the best way you learn is by doing,” she said. The interactive and repetitive nature of Septris, she said, helps its take-home messages stick in a player’s mind without the expense of patient simulations. Dr. Shieh said the game has been adapted for German and British medical institutions as well, and that she collects data from players around the world about their experiences and scores.
 

Winning interdisciplinary buy-in

To maximize the chances for success, several doctors emphasize the importance of forming an interdisciplinary task force that includes every department affected by a QI project. Ms. Savino said executive sponsorship of her hospital’s QI project was key as well. So was meeting frequently with the carefully chosen team members representing key stakeholders throughout the hospital. “It was a lot of work,” she said. “But I really think that was one reason why it was so successful. We had everybody’s buy-in, and we kept our short-term goals on track.”

 

Dr. Horton and collaborator Kencee K. Graves, MD, an academic hospitalist at the University of Utah, Salt Lake City, agreed that “face time” was the best way to get buy-in throughout their hospital during their own QI initiative. “We spent a lot of time sitting and listening to concerns and feedback from providers,” Dr. Graves said. “We would then integrate some of their feedback into the process, so people they knew they were heard.” Securing the buy-in of nursing staff was another huge key to their success in improving the quality of sepsis care and reducing costs.⁴ “Honestly, they were the secret sauce of the whole project,” Dr. Horton said. Changing the culture in the hospital helped immensely but required considerable time and patience to build both trust and acceptance within different units.

Based on their success, the QI initiative has spread to two other hospitals in the University of Utah’s network. “Once the culture changes have been made and the project’s up and going, it’s kind of self-sufficient,” Dr. Horton said. “But it was so much work.” He and Dr. Graves are careful to emphasize that there are other options for sepsis-related QI efforts. “I think it is better to start something small than to believe you can’t do anything at all,” Dr. Graves said.

No matter what the size, assembling a motivated and multidisciplinary team is critical, she said. So is empowering nurses to talk to physicians about decompensating patients and other aspects of sepsis care. Being available and willing to listen to other providers also can pay big dividends. “Knowing that we cared about the project’s success was important to people working on it,” Dr. Graves said.

Despite the remaining challenges, Dr. Shieh points out that sepsis mortality rates have improved significantly, thanks in large part to more awareness and ambitious QI projects. “I do want to say that we have come a long way,” she said.
 

References

1. Levy MM et al. Surviving Sepsis Campaign: Association between performance metrics and outcomes in a 7.5-year study. Intensive Care Med. 2014 Nov;40(11):1623-33.

2. Singer M et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-10.

3. Schorr C et al. Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards. J Hosp Med. 2016 Nov;11:S32-9.

4. Lee VS et al. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016 Sep 13;316(10):1061-72.

 

A drug overdose victim is admitted to a hospital. Providers focus on treating the overdose and blame it for some of the patient’s troubling vital signs, including low blood pressure and increased heart rate. Prior to admission, however, the patient had vomited and aspirated, leading to an infection. In fact, the patient is developing sepsis.

This real-world incident is but one of many ways that sepsis can fool hospitalists and other providers, often with rapidly deteriorating and deadly consequences. A range of quality improvement (QI) projects, however, are demonstrating how earlier identification and treatment may help to set a new course for addressing a condition that has remained stubbornly difficult to manage.

Every year, more than 1.5 million Americans develop sepsis – arising from the body’s overwhelming and self-destructive response to infection – and roughly 250,000 die from it. According to the Centers for Disease Control and Prevention, about one in three hospital deaths can be at least partially linked to sepsis.

Devin J. Horton, MD, an academic hospitalist at University Hospital in Salt Lake City, sometimes compares sepsis to acute MI to illustrate the difficulty of early detection. A patient complaining of chest pain immediately sets in motion a well-rehearsed chain of events. “But the patient doesn’t look at you and say, ‘You know, I think I’m having SIRS [systemic inflammatory response syndrome] criteria in the setting of infection,’ ” he said. “And yet, the mortality of severe septic shock is at least as bad as acute myocardial infarction.” The trick is generating the same sense of urgency without a clear warning.

The location in a hospital also can present a major obstacle for early identification. Hospitalist Andy Odden, MD, SFHM, patient safety officer in the department of medicine at Washington University in St. Louis, calls hospital wards the “third space” of sepsis care, after the ICU and ED. “A lot of the historical improvement efforts and research has really focused on streamlining care in the ICU and streamlining care in the emergency department,” he said. Often, however, sepsis or septic shock isn’t recognized until a patient is admitted to a medical or surgical ward.

Patients on the wards, though, usually begin with a nonsepsis diagnosis, which can produce an anchoring bias. Furthermore, Dr. Odden said, the data needed to identify sepsis may arrive asynchronously, increasingly the difficulty of pulling it all together for a timely diagnosis. As Dr. Horton points out, the trigger for transferring a decompensating sepsis patient from the wards to the ICU is murkier as well. “We don’t know what is too sick for the floor,” he said. “A lot of it is kind of a gestalt.”

Observational studies by the Surviving Sepsis Campaign suggested that patients diagnosed on the floor had mortality rates comparable to and substantially higher than theoretically sicker patients diagnosed in the ICU and ED, respectively.¹ “That was kind of a sea change for a lot of people and really articulated what a lot of us on the wards had been feeling,” Dr. Odden said. “We can’t simply apply the lessons that we’ve learned from the emergency department and the ICU to the wards if we’re going to provide the right care for these patients,” he said.
 

Dueling definitions

Better sepsis care in hospital wards will require a better understanding of shifting management guidelines. Confusing and contradictory definitions haven’t helped. In October 2015, the Centers for Medicare & Medicaid Services instituted its Sepsis Core Measure (SEP-1) for Medicare, requiring every hospital to audit a percentage of patients treated with best-practice 3- and 6-hour bundles for severe sepsis and septic shock. The SEP-1 measure uses the traditional definition of severe sepsis as two or more SIRS criteria, a suspected or proven infection, and organ dysfunction.

A separate set of guidelines issued by the international Sepsis-3 task force in February 2016, by contrast, concluded that the term “severe sepsis” is redundant.² The update defines sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection” and asserts that the condition can be represented by an increase in the SOFA (Sequential Organ Failure Assessment) score of 2 or more points.

For hospital wards, the task force recommended a bedside scoring system called qSOFA (quickSOFA) for adult patients with a suspected infection. The risk stratification tool may help rapidly identify those who are likely to have poorer outcomes typical of sepsis if they meet two of the following three clinical criteria: a “respiratory rate of 22 [breaths]/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.”

CMS doesn’t recognize the Sepsis-3 definition at all and multiple providers have described widespread skepticism and uncertainty over how to reconcile it with the prior definition. Dr. Odden says the dueling definitions have “caused a tremendous amount of confusion” over diagnoses, the necessary sense of urgency, and whether severe sepsis is still a recognized entity. “When people aren’t speaking the same language with the same terminology, there is enormous opportunity for miscommunication to occur,” he said.

Hospitalist Lisa Shieh, MD, PhD, medical director of quality in the department of medicine at Stanford (Calif.) University Medical Center, said Sepsis-3 was never meant to be a screening tool. It can, however, help doctors identify patients at higher risk. Craig A. Umscheid, MD, MSCE, of the department of epidemiology and vice chair for quality and safety in the department of medicine at the University of Pennsylvania, Philadelphia, said many providers agree that, at least theoretically, changes in a patient’s qSOFA score can predict bad outcomes better than SIRS criteria.

Obtaining reliable scores is another matter. The qSOFA blood pressure score generally is measured accurately, he said. On noncritical care units, though, nurses aren’t always trained to consistently and accurately document a patient’s mental status. Likewise, he said, documentation of respiratory rate often is subjective, and an abnormal rate can be easily missed. Changing that dynamic, he stressed, will require coordination with nursing leadership to ensure more consistent and accurate measurements.

Another big issue is that sepsis screening still is based on early recognition, Dr. Shieh said. “The problem with Sepsis-3 is that it is later in the continuum of sepsis.” As such, she recommends sticking with the CMS definition for now. “It catches sepsis earlier, which is the whole strategy for improving sepsis mortality,” she said.
 

 

Reshaping sepsis pathways

So how can hospitals identify sepsis sooner? Some hospitals have relied more on EMR-based screening methods; others have relied more on nurses to lead the charge. Either way, Dr. Shieh said, the field is trying to encourage the use of set pathways. Almost every medical center that performs well on sepsis measures, she says, has a good screening program, a pathway implemented through an order set or nursing staff, and a highly trained sepsis team that ensures patients get the treatment they need.

At Middlesex Hospital in Middletown, Conn., a major QI project led to significant improvements in sepsis mortality, total mortality, sepsis-related serious safety events and sepsis length of stay. Terri Savino, MSN, RN, CPHQ, the hospital’s manager of patient experience and service excellence, said the project sprang from concerns by the hospital’s Rapid Response Review Committee about some serious safety events involving a delay in sepsis diagnosis and treatment.

As part of a QI effort led by an interdepartmental task force, the hospital first updated its inpatient and ED sepsis pathways to incorporate the Surviving Sepsis Campaign’s 2012 guidelines. “We continued to tweak our pathways, so they’ve now embedded other infection pathways into the sepsis pathway to make sure that we’re not missing anybody,” Ms. Savino said. The hospital also launched an early recognition and treatment educational effort targeting all health care staff and rolled out a new electronic early-warning system in February 2014.

In 2013, the hospital documented three serious safety events related to a delay in diagnosis and treatment of sepsis. In 2014, it recorded only one event and has had none since then. From 2014 to 2015, sepsis-related mortality fell by more than 20%, saving an estimated 25 lives. Sepsis length of stay also declined. “We’re identifying them sooner and treating them sooner so they’re not getting as sick or requiring critical care and longer length of stays,” Ms. Savino said.

Dr. Odden has participated in two multicenter QI initiatives on sepsis. One, a partnership led by the Institute for Healthcare Improvement in Cambridge, Mass., and New York’s North Shore-LIJ Health System, focused on how to diagnose sepsis in hospital ward patients as quickly as possible and how to successfully deliver the 3-hour sepsis bundle.³ Beyond getting everyone on the same page regarding definitions, he said, the collaborators discussed and shared strategies for identifying patients. “One hospital would often have a solution for a problem that other hospitals could either take directly or modify based on their own understanding of their own processes,” he said.

Dr. Odden also participated in a national project sponsored by the Surviving Sepsis Campaign that focused on developing protocols for nurse-led screening processes in hospital wards. Within a pilot unit of each participating hospital, bedside nurses screened every patient for sepsis during every shift. For positive screens, the hospitals then developed protocols for order sets, like blood work and fluids.

The initiative suggested that a nurse-based, every-shift screening method might be one feasible way to identify sick patients as early as possible. “Going through the screening process really seemed to empower the nurses to take a much more active role in partnering with the physicians and in recognizing some of the early warning signs,” Dr. Odden said. The project led to other benefits as well, including improved identification of strokes, delirium, and even a gastrointestinal bleed because the “barriers in communication had been broken down,” he said.

To help medical providers recognize sepsis earlier, Dr. Shieh and her colleagues created a free game called Septris as an adjunctive teaching tool. Based on a player’s diagnosis and treatment decisions, patient outcomes either rise or fall – often rapidly. “I’m an educator and what I know is that the best way you learn is by doing,” she said. The interactive and repetitive nature of Septris, she said, helps its take-home messages stick in a player’s mind without the expense of patient simulations. Dr. Shieh said the game has been adapted for German and British medical institutions as well, and that she collects data from players around the world about their experiences and scores.
 

Winning interdisciplinary buy-in

To maximize the chances for success, several doctors emphasize the importance of forming an interdisciplinary task force that includes every department affected by a QI project. Ms. Savino said executive sponsorship of her hospital’s QI project was key as well. So was meeting frequently with the carefully chosen team members representing key stakeholders throughout the hospital. “It was a lot of work,” she said. “But I really think that was one reason why it was so successful. We had everybody’s buy-in, and we kept our short-term goals on track.”

 

Dr. Horton and collaborator Kencee K. Graves, MD, an academic hospitalist at the University of Utah, Salt Lake City, agreed that “face time” was the best way to get buy-in throughout their hospital during their own QI initiative. “We spent a lot of time sitting and listening to concerns and feedback from providers,” Dr. Graves said. “We would then integrate some of their feedback into the process, so people they knew they were heard.” Securing the buy-in of nursing staff was another huge key to their success in improving the quality of sepsis care and reducing costs.⁴ “Honestly, they were the secret sauce of the whole project,” Dr. Horton said. Changing the culture in the hospital helped immensely but required considerable time and patience to build both trust and acceptance within different units.

Based on their success, the QI initiative has spread to two other hospitals in the University of Utah’s network. “Once the culture changes have been made and the project’s up and going, it’s kind of self-sufficient,” Dr. Horton said. “But it was so much work.” He and Dr. Graves are careful to emphasize that there are other options for sepsis-related QI efforts. “I think it is better to start something small than to believe you can’t do anything at all,” Dr. Graves said.

No matter what the size, assembling a motivated and multidisciplinary team is critical, she said. So is empowering nurses to talk to physicians about decompensating patients and other aspects of sepsis care. Being available and willing to listen to other providers also can pay big dividends. “Knowing that we cared about the project’s success was important to people working on it,” Dr. Graves said.

Despite the remaining challenges, Dr. Shieh points out that sepsis mortality rates have improved significantly, thanks in large part to more awareness and ambitious QI projects. “I do want to say that we have come a long way,” she said.
 

References

1. Levy MM et al. Surviving Sepsis Campaign: Association between performance metrics and outcomes in a 7.5-year study. Intensive Care Med. 2014 Nov;40(11):1623-33.

2. Singer M et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-10.

3. Schorr C et al. Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards. J Hosp Med. 2016 Nov;11:S32-9.

4. Lee VS et al. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016 Sep 13;316(10):1061-72.

 

A drug overdose victim is admitted to a hospital. Providers focus on treating the overdose and blame it for some of the patient’s troubling vital signs, including low blood pressure and increased heart rate. Prior to admission, however, the patient had vomited and aspirated, leading to an infection. In fact, the patient is developing sepsis.

This real-world incident is but one of many ways that sepsis can fool hospitalists and other providers, often with rapidly deteriorating and deadly consequences. A range of quality improvement (QI) projects, however, are demonstrating how earlier identification and treatment may help to set a new course for addressing a condition that has remained stubbornly difficult to manage.

Every year, more than 1.5 million Americans develop sepsis – arising from the body’s overwhelming and self-destructive response to infection – and roughly 250,000 die from it. According to the Centers for Disease Control and Prevention, about one in three hospital deaths can be at least partially linked to sepsis.

Devin J. Horton, MD, an academic hospitalist at University Hospital in Salt Lake City, sometimes compares sepsis to acute MI to illustrate the difficulty of early detection. A patient complaining of chest pain immediately sets in motion a well-rehearsed chain of events. “But the patient doesn’t look at you and say, ‘You know, I think I’m having SIRS [systemic inflammatory response syndrome] criteria in the setting of infection,’ ” he said. “And yet, the mortality of severe septic shock is at least as bad as acute myocardial infarction.” The trick is generating the same sense of urgency without a clear warning.

The location in a hospital also can present a major obstacle for early identification. Hospitalist Andy Odden, MD, SFHM, patient safety officer in the department of medicine at Washington University in St. Louis, calls hospital wards the “third space” of sepsis care, after the ICU and ED. “A lot of the historical improvement efforts and research has really focused on streamlining care in the ICU and streamlining care in the emergency department,” he said. Often, however, sepsis or septic shock isn’t recognized until a patient is admitted to a medical or surgical ward.

Patients on the wards, though, usually begin with a nonsepsis diagnosis, which can produce an anchoring bias. Furthermore, Dr. Odden said, the data needed to identify sepsis may arrive asynchronously, increasingly the difficulty of pulling it all together for a timely diagnosis. As Dr. Horton points out, the trigger for transferring a decompensating sepsis patient from the wards to the ICU is murkier as well. “We don’t know what is too sick for the floor,” he said. “A lot of it is kind of a gestalt.”

Observational studies by the Surviving Sepsis Campaign suggested that patients diagnosed on the floor had mortality rates comparable to and substantially higher than theoretically sicker patients diagnosed in the ICU and ED, respectively.¹ “That was kind of a sea change for a lot of people and really articulated what a lot of us on the wards had been feeling,” Dr. Odden said. “We can’t simply apply the lessons that we’ve learned from the emergency department and the ICU to the wards if we’re going to provide the right care for these patients,” he said.
 

Dueling definitions

Better sepsis care in hospital wards will require a better understanding of shifting management guidelines. Confusing and contradictory definitions haven’t helped. In October 2015, the Centers for Medicare & Medicaid Services instituted its Sepsis Core Measure (SEP-1) for Medicare, requiring every hospital to audit a percentage of patients treated with best-practice 3- and 6-hour bundles for severe sepsis and septic shock. The SEP-1 measure uses the traditional definition of severe sepsis as two or more SIRS criteria, a suspected or proven infection, and organ dysfunction.

A separate set of guidelines issued by the international Sepsis-3 task force in February 2016, by contrast, concluded that the term “severe sepsis” is redundant.² The update defines sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection” and asserts that the condition can be represented by an increase in the SOFA (Sequential Organ Failure Assessment) score of 2 or more points.

For hospital wards, the task force recommended a bedside scoring system called qSOFA (quickSOFA) for adult patients with a suspected infection. The risk stratification tool may help rapidly identify those who are likely to have poorer outcomes typical of sepsis if they meet two of the following three clinical criteria: a “respiratory rate of 22 [breaths]/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.”

CMS doesn’t recognize the Sepsis-3 definition at all and multiple providers have described widespread skepticism and uncertainty over how to reconcile it with the prior definition. Dr. Odden says the dueling definitions have “caused a tremendous amount of confusion” over diagnoses, the necessary sense of urgency, and whether severe sepsis is still a recognized entity. “When people aren’t speaking the same language with the same terminology, there is enormous opportunity for miscommunication to occur,” he said.

Hospitalist Lisa Shieh, MD, PhD, medical director of quality in the department of medicine at Stanford (Calif.) University Medical Center, said Sepsis-3 was never meant to be a screening tool. It can, however, help doctors identify patients at higher risk. Craig A. Umscheid, MD, MSCE, of the department of epidemiology and vice chair for quality and safety in the department of medicine at the University of Pennsylvania, Philadelphia, said many providers agree that, at least theoretically, changes in a patient’s qSOFA score can predict bad outcomes better than SIRS criteria.

Obtaining reliable scores is another matter. The qSOFA blood pressure score generally is measured accurately, he said. On noncritical care units, though, nurses aren’t always trained to consistently and accurately document a patient’s mental status. Likewise, he said, documentation of respiratory rate often is subjective, and an abnormal rate can be easily missed. Changing that dynamic, he stressed, will require coordination with nursing leadership to ensure more consistent and accurate measurements.

Another big issue is that sepsis screening still is based on early recognition, Dr. Shieh said. “The problem with Sepsis-3 is that it is later in the continuum of sepsis.” As such, she recommends sticking with the CMS definition for now. “It catches sepsis earlier, which is the whole strategy for improving sepsis mortality,” she said.
 

 

Reshaping sepsis pathways

So how can hospitals identify sepsis sooner? Some hospitals have relied more on EMR-based screening methods; others have relied more on nurses to lead the charge. Either way, Dr. Shieh said, the field is trying to encourage the use of set pathways. Almost every medical center that performs well on sepsis measures, she says, has a good screening program, a pathway implemented through an order set or nursing staff, and a highly trained sepsis team that ensures patients get the treatment they need.

At Middlesex Hospital in Middletown, Conn., a major QI project led to significant improvements in sepsis mortality, total mortality, sepsis-related serious safety events and sepsis length of stay. Terri Savino, MSN, RN, CPHQ, the hospital’s manager of patient experience and service excellence, said the project sprang from concerns by the hospital’s Rapid Response Review Committee about some serious safety events involving a delay in sepsis diagnosis and treatment.

As part of a QI effort led by an interdepartmental task force, the hospital first updated its inpatient and ED sepsis pathways to incorporate the Surviving Sepsis Campaign’s 2012 guidelines. “We continued to tweak our pathways, so they’ve now embedded other infection pathways into the sepsis pathway to make sure that we’re not missing anybody,” Ms. Savino said. The hospital also launched an early recognition and treatment educational effort targeting all health care staff and rolled out a new electronic early-warning system in February 2014.

In 2013, the hospital documented three serious safety events related to a delay in diagnosis and treatment of sepsis. In 2014, it recorded only one event and has had none since then. From 2014 to 2015, sepsis-related mortality fell by more than 20%, saving an estimated 25 lives. Sepsis length of stay also declined. “We’re identifying them sooner and treating them sooner so they’re not getting as sick or requiring critical care and longer length of stays,” Ms. Savino said.

Dr. Odden has participated in two multicenter QI initiatives on sepsis. One, a partnership led by the Institute for Healthcare Improvement in Cambridge, Mass., and New York’s North Shore-LIJ Health System, focused on how to diagnose sepsis in hospital ward patients as quickly as possible and how to successfully deliver the 3-hour sepsis bundle.³ Beyond getting everyone on the same page regarding definitions, he said, the collaborators discussed and shared strategies for identifying patients. “One hospital would often have a solution for a problem that other hospitals could either take directly or modify based on their own understanding of their own processes,” he said.

Dr. Odden also participated in a national project sponsored by the Surviving Sepsis Campaign that focused on developing protocols for nurse-led screening processes in hospital wards. Within a pilot unit of each participating hospital, bedside nurses screened every patient for sepsis during every shift. For positive screens, the hospitals then developed protocols for order sets, like blood work and fluids.

The initiative suggested that a nurse-based, every-shift screening method might be one feasible way to identify sick patients as early as possible. “Going through the screening process really seemed to empower the nurses to take a much more active role in partnering with the physicians and in recognizing some of the early warning signs,” Dr. Odden said. The project led to other benefits as well, including improved identification of strokes, delirium, and even a gastrointestinal bleed because the “barriers in communication had been broken down,” he said.

To help medical providers recognize sepsis earlier, Dr. Shieh and her colleagues created a free game called Septris as an adjunctive teaching tool. Based on a player’s diagnosis and treatment decisions, patient outcomes either rise or fall – often rapidly. “I’m an educator and what I know is that the best way you learn is by doing,” she said. The interactive and repetitive nature of Septris, she said, helps its take-home messages stick in a player’s mind without the expense of patient simulations. Dr. Shieh said the game has been adapted for German and British medical institutions as well, and that she collects data from players around the world about their experiences and scores.
 

Winning interdisciplinary buy-in

To maximize the chances for success, several doctors emphasize the importance of forming an interdisciplinary task force that includes every department affected by a QI project. Ms. Savino said executive sponsorship of her hospital’s QI project was key as well. So was meeting frequently with the carefully chosen team members representing key stakeholders throughout the hospital. “It was a lot of work,” she said. “But I really think that was one reason why it was so successful. We had everybody’s buy-in, and we kept our short-term goals on track.”

 

Dr. Horton and collaborator Kencee K. Graves, MD, an academic hospitalist at the University of Utah, Salt Lake City, agreed that “face time” was the best way to get buy-in throughout their hospital during their own QI initiative. “We spent a lot of time sitting and listening to concerns and feedback from providers,” Dr. Graves said. “We would then integrate some of their feedback into the process, so people they knew they were heard.” Securing the buy-in of nursing staff was another huge key to their success in improving the quality of sepsis care and reducing costs.⁴ “Honestly, they were the secret sauce of the whole project,” Dr. Horton said. Changing the culture in the hospital helped immensely but required considerable time and patience to build both trust and acceptance within different units.

Based on their success, the QI initiative has spread to two other hospitals in the University of Utah’s network. “Once the culture changes have been made and the project’s up and going, it’s kind of self-sufficient,” Dr. Horton said. “But it was so much work.” He and Dr. Graves are careful to emphasize that there are other options for sepsis-related QI efforts. “I think it is better to start something small than to believe you can’t do anything at all,” Dr. Graves said.

No matter what the size, assembling a motivated and multidisciplinary team is critical, she said. So is empowering nurses to talk to physicians about decompensating patients and other aspects of sepsis care. Being available and willing to listen to other providers also can pay big dividends. “Knowing that we cared about the project’s success was important to people working on it,” Dr. Graves said.

Despite the remaining challenges, Dr. Shieh points out that sepsis mortality rates have improved significantly, thanks in large part to more awareness and ambitious QI projects. “I do want to say that we have come a long way,” she said.
 

References

1. Levy MM et al. Surviving Sepsis Campaign: Association between performance metrics and outcomes in a 7.5-year study. Intensive Care Med. 2014 Nov;40(11):1623-33.

2. Singer M et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-10.

3. Schorr C et al. Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards. J Hosp Med. 2016 Nov;11:S32-9.

4. Lee VS et al. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016 Sep 13;316(10):1061-72.

 

I had the privilege of teaching two seminars at the recent Society of Hospital Medicine Leadership Academy in Scottsdale, Ariz. The theme of my second seminar was “Swarm Leadership,” the topic of my September column. There seemed to be enthusiasm and interest in the topic. Participants were intrigued at the notion of leveraging instinctual responses to encourage team spirit and collective outcomes.

The key principles of these swarm-like behaviors are: 1) unity of mission, 2) generosity of spirit, 3) staying in lanes and helping others succeed in theirs, 4) no ego/no blame, and 5) a foundation of trust among those working together. Leaders create the conditions in which these behaviors are more likely to emerge. The resulting team spirit and productivity raise morale and increase the sense of work-related purpose and mission.

Despite the interest in the topic, an underlying objection arose in questions and comments. These remarks countered the intentions and opportunities for swarm-like connectivity.

People expressed their sense of being burned out and overworked, even to the extent of being exploited. I was stunned at the prevalence of this sensation in the room. Not everyone spoke though many people identified with the theme.

What I heard was enough to raise the question here: For hospitalist leaders, to what extent is burnout significant enough to give it serious attention? (I want to be abundantly clear: I report observations as anecdotal and impressionistic. There is no implied critique of hospitalists on the whole nor any individual or groups.)

Burnout includes sensations of being exhausted, overburdened, underappreciated, undercompensated, cynical, and depressed. These phenomena together can affect your productivity, the quality of your work, and your endurance when the workload gets tough.

By contrast, the opposite of burnout is balance, including sensations of being engaged, enthusiastic, energetic, absorbed, challenged, and dedicated. Work is part of the equilibrium you establish in your life, which includes a variety of fulfilling and motivating experiences and accomplishments.

Ideal balance would have all the different parts of your life – from family to hobbies to work – in perfect synergy with one another. Complete burnout would have all parts of your life imploding on one another, with little room for joy, personal contentment, and professional satisfaction.

How do you assess the differences between burnout and balance? First, this is a very individual metric. What one person might consider challenging and engaging another would experience as overwhelming and alienating. When you assess a group of people, these differences are important and could inform how work assignments and heavy lifting are assigned.

During the SHM session and in private comments, people described this rise in burnout not as a personal phenomena. Rather, it results from the health system expecting more of hospitalists than they can reasonably and reliably produce. People described hospitalists getting to the breaking point with no relief in sight. What can be done about this phenomenon?

First, hold a mirror up to yourself. You cannot help others as a leader if you are not clear with your own state of burnout and balance. The questions for you – a leader of other hospitalists – include: To what extent are you burned out? If so, why? If not, why not? If you were to draw a continuum between burned out and balanced, where on that range would you place yourself? Where would others in your group or department pinpoint themselves, relative to one another, on this continuum?

How might burnout develop for hospitalist leaders? Like a car, even a high performance vehicle, you can only go so fast and so far. Push too hard on the accelerator and the vehicle begins to shake as performance declines. If your system is expecting the pace and productivity to outstrip what you consider reasonable, your performance, job satisfaction and morale drops. Impose those demands upon a group of people and the unhappiness can become infectious.

With a decline in performance comes a decline in confidence. You and your colleagues strive for top-rate outcomes. Fatigue, pressure, and unreasonable expectations challenge your ability to feel good about what you are doing. That satisfaction is part of why you chose hospital medicine and without it, you wonder about what you are doing and why you are doing it.

When you and your colleagues sense that you are unappreciated, it can spark a profound sense of disappointment. That realization could express itself in many forms, including unhappiness about pay and workload to dissatisfaction with professional support or acknowledgment. When the system on the whole is driving so fast that it cannot stop to ensure and reward good work, the rattling can have a stunting effect on performance.

When I first began teaching at SHM conferences and had hospitalists in my classes at the Harvard School of Public Health – way back when – the field was novel, revolutionary, and striving to establish a newly effective and efficient way to provide patient services. It is useful to keep these roots in perspective – hospital medicine over the arc of time – from what WAS, to what IS and eventually what WILL BE. The cleverness of hospitalist leaders has been their capacity to understand this evolution and work with it. Hospitalist medicine built opportunities in response to high costs, the lack of continuity of care, and problems of communication. It was a solution.

How might you diagnose your burnout – and that of others with whom you work – in order to build solutions? Is it a phenomenon that involves just several individuals or is it characteristic of your group as a whole? What are the causes? What are the symptoms and what are the core issues? Some are system problems in which expectations for performance – and the resources to meet those objectives – are not reasonably aligned. There is a cost for trying to reduce costs on the backs of overworked clinicians.

If this is more than an individual problem, systematically ask the question and seek systematic answers. The better you document root causes and implications, the better are you able to make a data-driven case for change. Interview, survey, and with all this, you demonstrate your concern for staff, their work, and their work experience.

Showing that you care about the professional and personal well-being and balance of your workforce, in and of itself, is the beginning of an intervention. Be honest with yourself about your own experience. And then be open to the experiences of others. As a leader, your colleagues may suggest changes you make in your own leadership that could ameliorate some of that burnout. Better communication? Improved organization? Enhanced flexibility as appropriate? These are problems you can fix.

Other solutions must be negotiated with others on the systems level. With documentation in hand, build your case for the necessary changes, whatever that might entail. Hospitalist leaders negotiated their way into respected and productive positions in the health care system. Similarly, they must negotiate the right balance now to ensure the quality, morale, and reasonable productivity of their departments and workforce.

As a hospitalist leader, you know that each day will bring its complexities, challenges, and at times, its burdens. Your objective is to encourage – for yourself, for your colleagues, and for your system – resilience that is both personal and organizational. That resilience – the ability to take a hit and bounce back – is an encouraging signal of hope and recovery, for your workforce as well as the people for whom you care. The principles of swarm leadership – reinvigorated for your group – could very well provide signposts on that everyday quest for personal and group resilience.

 

Leonard J. Marcus, PhD, is coauthor of “Renegotiating Health Care: Resolving Conflict to Build Collaboration,” Second Edition (San Francisco: Jossey-Bass Publishers, 2011) and is director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard T.H. Chan School of Public Health. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected].

 

I had the privilege of teaching two seminars at the recent Society of Hospital Medicine Leadership Academy in Scottsdale, Ariz. The theme of my second seminar was “Swarm Leadership,” the topic of my September column. There seemed to be enthusiasm and interest in the topic. Participants were intrigued at the notion of leveraging instinctual responses to encourage team spirit and collective outcomes.

The key principles of these swarm-like behaviors are: 1) unity of mission, 2) generosity of spirit, 3) staying in lanes and helping others succeed in theirs, 4) no ego/no blame, and 5) a foundation of trust among those working together. Leaders create the conditions in which these behaviors are more likely to emerge. The resulting team spirit and productivity raise morale and increase the sense of work-related purpose and mission.

Despite the interest in the topic, an underlying objection arose in questions and comments. These remarks countered the intentions and opportunities for swarm-like connectivity.

People expressed their sense of being burned out and overworked, even to the extent of being exploited. I was stunned at the prevalence of this sensation in the room. Not everyone spoke though many people identified with the theme.

What I heard was enough to raise the question here: For hospitalist leaders, to what extent is burnout significant enough to give it serious attention? (I want to be abundantly clear: I report observations as anecdotal and impressionistic. There is no implied critique of hospitalists on the whole nor any individual or groups.)

Burnout includes sensations of being exhausted, overburdened, underappreciated, undercompensated, cynical, and depressed. These phenomena together can affect your productivity, the quality of your work, and your endurance when the workload gets tough.

By contrast, the opposite of burnout is balance, including sensations of being engaged, enthusiastic, energetic, absorbed, challenged, and dedicated. Work is part of the equilibrium you establish in your life, which includes a variety of fulfilling and motivating experiences and accomplishments.

Ideal balance would have all the different parts of your life – from family to hobbies to work – in perfect synergy with one another. Complete burnout would have all parts of your life imploding on one another, with little room for joy, personal contentment, and professional satisfaction.

How do you assess the differences between burnout and balance? First, this is a very individual metric. What one person might consider challenging and engaging another would experience as overwhelming and alienating. When you assess a group of people, these differences are important and could inform how work assignments and heavy lifting are assigned.

During the SHM session and in private comments, people described this rise in burnout not as a personal phenomena. Rather, it results from the health system expecting more of hospitalists than they can reasonably and reliably produce. People described hospitalists getting to the breaking point with no relief in sight. What can be done about this phenomenon?

First, hold a mirror up to yourself. You cannot help others as a leader if you are not clear with your own state of burnout and balance. The questions for you – a leader of other hospitalists – include: To what extent are you burned out? If so, why? If not, why not? If you were to draw a continuum between burned out and balanced, where on that range would you place yourself? Where would others in your group or department pinpoint themselves, relative to one another, on this continuum?

How might burnout develop for hospitalist leaders? Like a car, even a high performance vehicle, you can only go so fast and so far. Push too hard on the accelerator and the vehicle begins to shake as performance declines. If your system is expecting the pace and productivity to outstrip what you consider reasonable, your performance, job satisfaction and morale drops. Impose those demands upon a group of people and the unhappiness can become infectious.

With a decline in performance comes a decline in confidence. You and your colleagues strive for top-rate outcomes. Fatigue, pressure, and unreasonable expectations challenge your ability to feel good about what you are doing. That satisfaction is part of why you chose hospital medicine and without it, you wonder about what you are doing and why you are doing it.

When you and your colleagues sense that you are unappreciated, it can spark a profound sense of disappointment. That realization could express itself in many forms, including unhappiness about pay and workload to dissatisfaction with professional support or acknowledgment. When the system on the whole is driving so fast that it cannot stop to ensure and reward good work, the rattling can have a stunting effect on performance.

When I first began teaching at SHM conferences and had hospitalists in my classes at the Harvard School of Public Health – way back when – the field was novel, revolutionary, and striving to establish a newly effective and efficient way to provide patient services. It is useful to keep these roots in perspective – hospital medicine over the arc of time – from what WAS, to what IS and eventually what WILL BE. The cleverness of hospitalist leaders has been their capacity to understand this evolution and work with it. Hospitalist medicine built opportunities in response to high costs, the lack of continuity of care, and problems of communication. It was a solution.

How might you diagnose your burnout – and that of others with whom you work – in order to build solutions? Is it a phenomenon that involves just several individuals or is it characteristic of your group as a whole? What are the causes? What are the symptoms and what are the core issues? Some are system problems in which expectations for performance – and the resources to meet those objectives – are not reasonably aligned. There is a cost for trying to reduce costs on the backs of overworked clinicians.

If this is more than an individual problem, systematically ask the question and seek systematic answers. The better you document root causes and implications, the better are you able to make a data-driven case for change. Interview, survey, and with all this, you demonstrate your concern for staff, their work, and their work experience.

Showing that you care about the professional and personal well-being and balance of your workforce, in and of itself, is the beginning of an intervention. Be honest with yourself about your own experience. And then be open to the experiences of others. As a leader, your colleagues may suggest changes you make in your own leadership that could ameliorate some of that burnout. Better communication? Improved organization? Enhanced flexibility as appropriate? These are problems you can fix.

Other solutions must be negotiated with others on the systems level. With documentation in hand, build your case for the necessary changes, whatever that might entail. Hospitalist leaders negotiated their way into respected and productive positions in the health care system. Similarly, they must negotiate the right balance now to ensure the quality, morale, and reasonable productivity of their departments and workforce.

As a hospitalist leader, you know that each day will bring its complexities, challenges, and at times, its burdens. Your objective is to encourage – for yourself, for your colleagues, and for your system – resilience that is both personal and organizational. That resilience – the ability to take a hit and bounce back – is an encouraging signal of hope and recovery, for your workforce as well as the people for whom you care. The principles of swarm leadership – reinvigorated for your group – could very well provide signposts on that everyday quest for personal and group resilience.

 

Leonard J. Marcus, PhD, is coauthor of “Renegotiating Health Care: Resolving Conflict to Build Collaboration,” Second Edition (San Francisco: Jossey-Bass Publishers, 2011) and is director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard T.H. Chan School of Public Health. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected].

 

I had the privilege of teaching two seminars at the recent Society of Hospital Medicine Leadership Academy in Scottsdale, Ariz. The theme of my second seminar was “Swarm Leadership,” the topic of my September column. There seemed to be enthusiasm and interest in the topic. Participants were intrigued at the notion of leveraging instinctual responses to encourage team spirit and collective outcomes.

The key principles of these swarm-like behaviors are: 1) unity of mission, 2) generosity of spirit, 3) staying in lanes and helping others succeed in theirs, 4) no ego/no blame, and 5) a foundation of trust among those working together. Leaders create the conditions in which these behaviors are more likely to emerge. The resulting team spirit and productivity raise morale and increase the sense of work-related purpose and mission.

Despite the interest in the topic, an underlying objection arose in questions and comments. These remarks countered the intentions and opportunities for swarm-like connectivity.

People expressed their sense of being burned out and overworked, even to the extent of being exploited. I was stunned at the prevalence of this sensation in the room. Not everyone spoke though many people identified with the theme.

What I heard was enough to raise the question here: For hospitalist leaders, to what extent is burnout significant enough to give it serious attention? (I want to be abundantly clear: I report observations as anecdotal and impressionistic. There is no implied critique of hospitalists on the whole nor any individual or groups.)

Burnout includes sensations of being exhausted, overburdened, underappreciated, undercompensated, cynical, and depressed. These phenomena together can affect your productivity, the quality of your work, and your endurance when the workload gets tough.

By contrast, the opposite of burnout is balance, including sensations of being engaged, enthusiastic, energetic, absorbed, challenged, and dedicated. Work is part of the equilibrium you establish in your life, which includes a variety of fulfilling and motivating experiences and accomplishments.

Ideal balance would have all the different parts of your life – from family to hobbies to work – in perfect synergy with one another. Complete burnout would have all parts of your life imploding on one another, with little room for joy, personal contentment, and professional satisfaction.

How do you assess the differences between burnout and balance? First, this is a very individual metric. What one person might consider challenging and engaging another would experience as overwhelming and alienating. When you assess a group of people, these differences are important and could inform how work assignments and heavy lifting are assigned.

During the SHM session and in private comments, people described this rise in burnout not as a personal phenomena. Rather, it results from the health system expecting more of hospitalists than they can reasonably and reliably produce. People described hospitalists getting to the breaking point with no relief in sight. What can be done about this phenomenon?

First, hold a mirror up to yourself. You cannot help others as a leader if you are not clear with your own state of burnout and balance. The questions for you – a leader of other hospitalists – include: To what extent are you burned out? If so, why? If not, why not? If you were to draw a continuum between burned out and balanced, where on that range would you place yourself? Where would others in your group or department pinpoint themselves, relative to one another, on this continuum?

How might burnout develop for hospitalist leaders? Like a car, even a high performance vehicle, you can only go so fast and so far. Push too hard on the accelerator and the vehicle begins to shake as performance declines. If your system is expecting the pace and productivity to outstrip what you consider reasonable, your performance, job satisfaction and morale drops. Impose those demands upon a group of people and the unhappiness can become infectious.

With a decline in performance comes a decline in confidence. You and your colleagues strive for top-rate outcomes. Fatigue, pressure, and unreasonable expectations challenge your ability to feel good about what you are doing. That satisfaction is part of why you chose hospital medicine and without it, you wonder about what you are doing and why you are doing it.

When you and your colleagues sense that you are unappreciated, it can spark a profound sense of disappointment. That realization could express itself in many forms, including unhappiness about pay and workload to dissatisfaction with professional support or acknowledgment. When the system on the whole is driving so fast that it cannot stop to ensure and reward good work, the rattling can have a stunting effect on performance.

When I first began teaching at SHM conferences and had hospitalists in my classes at the Harvard School of Public Health – way back when – the field was novel, revolutionary, and striving to establish a newly effective and efficient way to provide patient services. It is useful to keep these roots in perspective – hospital medicine over the arc of time – from what WAS, to what IS and eventually what WILL BE. The cleverness of hospitalist leaders has been their capacity to understand this evolution and work with it. Hospitalist medicine built opportunities in response to high costs, the lack of continuity of care, and problems of communication. It was a solution.

How might you diagnose your burnout – and that of others with whom you work – in order to build solutions? Is it a phenomenon that involves just several individuals or is it characteristic of your group as a whole? What are the causes? What are the symptoms and what are the core issues? Some are system problems in which expectations for performance – and the resources to meet those objectives – are not reasonably aligned. There is a cost for trying to reduce costs on the backs of overworked clinicians.

If this is more than an individual problem, systematically ask the question and seek systematic answers. The better you document root causes and implications, the better are you able to make a data-driven case for change. Interview, survey, and with all this, you demonstrate your concern for staff, their work, and their work experience.

Showing that you care about the professional and personal well-being and balance of your workforce, in and of itself, is the beginning of an intervention. Be honest with yourself about your own experience. And then be open to the experiences of others. As a leader, your colleagues may suggest changes you make in your own leadership that could ameliorate some of that burnout. Better communication? Improved organization? Enhanced flexibility as appropriate? These are problems you can fix.

Other solutions must be negotiated with others on the systems level. With documentation in hand, build your case for the necessary changes, whatever that might entail. Hospitalist leaders negotiated their way into respected and productive positions in the health care system. Similarly, they must negotiate the right balance now to ensure the quality, morale, and reasonable productivity of their departments and workforce.

As a hospitalist leader, you know that each day will bring its complexities, challenges, and at times, its burdens. Your objective is to encourage – for yourself, for your colleagues, and for your system – resilience that is both personal and organizational. That resilience – the ability to take a hit and bounce back – is an encouraging signal of hope and recovery, for your workforce as well as the people for whom you care. The principles of swarm leadership – reinvigorated for your group – could very well provide signposts on that everyday quest for personal and group resilience.

 

Leonard J. Marcus, PhD, is coauthor of “Renegotiating Health Care: Resolving Conflict to Build Collaboration,” Second Edition (San Francisco: Jossey-Bass Publishers, 2011) and is director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard T.H. Chan School of Public Health. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected].

 

Background: Severe hypoglycemia caused by glucose-lowering medications is a known public health and patient safety issue. Identifying patients with T2D at risk of severe hypoglycemia might facilitate interventions to offset that risk.

Study design: Prospective cohort.

Setting: Kaiser Permanente Northern California (derivation and internal validation cohort); Veterans Affairs Diabetes Epidemiology Cohort and Group Health Cooperative (external validation cohorts).

Synopsis: Through EHR data, 206,435 eligible patients with T2D were randomly split into derivation (80%) and internal validation (20%) samples. EHR data were reviewed for preselected clinical risk factors for hypoglycemia with a primary outcome of ED visit or hospital admission with a primary diagnosis of hypoglycemia over the ensuing year. A predictive tool was built based on six variables: prior hypoglycemia episodes, number of ED encounters for any reason in the prior year, insulin use, sulfonylurea use, presence of severe or end-stage kidney disease, and age. Predicted 12-month risk was categorized as high (greater than 5%), intermediate (1%-5%) or low (less than 1%). In the internal validation sample, 2.0%, 10.7%, and 87.3% of patients were categorized as high, intermediate, and low risk, respectively. Observed 12-month hypoglycemia-related health care utilization rates were 6.7%, 1.4%, and 0.2%, respectively. The external validation cohorts performed similarly.

Bottom line: A simple tool using readily available data can be used to estimate the 12-month risk of severe hypoglycemia in patients with T2D.

Citation: Karter AJ et al. Development and validation of a tool to identify patients with type 2 diabetes at high risk of hypoglycemia-related emergency department or hospital use. JAMA Intern Med. 2017 Oct 1;177(10):1461-70.

Dr. Hoegh is a hospitalist at the University of Colorado School of Medicine. 

 

Background: Severe hypoglycemia caused by glucose-lowering medications is a known public health and patient safety issue. Identifying patients with T2D at risk of severe hypoglycemia might facilitate interventions to offset that risk.

Study design: Prospective cohort.

Setting: Kaiser Permanente Northern California (derivation and internal validation cohort); Veterans Affairs Diabetes Epidemiology Cohort and Group Health Cooperative (external validation cohorts).

Synopsis: Through EHR data, 206,435 eligible patients with T2D were randomly split into derivation (80%) and internal validation (20%) samples. EHR data were reviewed for preselected clinical risk factors for hypoglycemia with a primary outcome of ED visit or hospital admission with a primary diagnosis of hypoglycemia over the ensuing year. A predictive tool was built based on six variables: prior hypoglycemia episodes, number of ED encounters for any reason in the prior year, insulin use, sulfonylurea use, presence of severe or end-stage kidney disease, and age. Predicted 12-month risk was categorized as high (greater than 5%), intermediate (1%-5%) or low (less than 1%). In the internal validation sample, 2.0%, 10.7%, and 87.3% of patients were categorized as high, intermediate, and low risk, respectively. Observed 12-month hypoglycemia-related health care utilization rates were 6.7%, 1.4%, and 0.2%, respectively. The external validation cohorts performed similarly.

Bottom line: A simple tool using readily available data can be used to estimate the 12-month risk of severe hypoglycemia in patients with T2D.

Citation: Karter AJ et al. Development and validation of a tool to identify patients with type 2 diabetes at high risk of hypoglycemia-related emergency department or hospital use. JAMA Intern Med. 2017 Oct 1;177(10):1461-70.

Dr. Hoegh is a hospitalist at the University of Colorado School of Medicine. 

 

Background: Severe hypoglycemia caused by glucose-lowering medications is a known public health and patient safety issue. Identifying patients with T2D at risk of severe hypoglycemia might facilitate interventions to offset that risk.

Study design: Prospective cohort.

Setting: Kaiser Permanente Northern California (derivation and internal validation cohort); Veterans Affairs Diabetes Epidemiology Cohort and Group Health Cooperative (external validation cohorts).

Synopsis: Through EHR data, 206,435 eligible patients with T2D were randomly split into derivation (80%) and internal validation (20%) samples. EHR data were reviewed for preselected clinical risk factors for hypoglycemia with a primary outcome of ED visit or hospital admission with a primary diagnosis of hypoglycemia over the ensuing year. A predictive tool was built based on six variables: prior hypoglycemia episodes, number of ED encounters for any reason in the prior year, insulin use, sulfonylurea use, presence of severe or end-stage kidney disease, and age. Predicted 12-month risk was categorized as high (greater than 5%), intermediate (1%-5%) or low (less than 1%). In the internal validation sample, 2.0%, 10.7%, and 87.3% of patients were categorized as high, intermediate, and low risk, respectively. Observed 12-month hypoglycemia-related health care utilization rates were 6.7%, 1.4%, and 0.2%, respectively. The external validation cohorts performed similarly.

Bottom line: A simple tool using readily available data can be used to estimate the 12-month risk of severe hypoglycemia in patients with T2D.

Citation: Karter AJ et al. Development and validation of a tool to identify patients with type 2 diabetes at high risk of hypoglycemia-related emergency department or hospital use. JAMA Intern Med. 2017 Oct 1;177(10):1461-70.

Dr. Hoegh is a hospitalist at the University of Colorado School of Medicine. 

 

Michael Rader, MD, has been named the chief medical officer of the Department of Veterans Affairs New York/New Jersey Health Care Network. The network serves upward of a half-million veterans in 76 counties in New York, New Jersey, and Pennsylvania. Dr. Rader’s appointment began on Oct. 15, 2017.

Previously, Dr. Rader was chief medical officer at Prospect East Orange (N.J.) General. In his new position, the 35-year veteran will be charged with overseeing care at VA facilities in Albany Stratton, Bath, Canandaigua, and Syracuse in New York, as well as the VA Western New York Health System, the New York Harbor Health System, the New Jersey Health Care System, Hudson Valley Healthcare System, the James J. Peters and Northport VA Medical Centers, as well as 66 community-based outpatient clinics.

The Rhode Island Medical Society has elected Bradley Collins, MD, as its new president. An internist and hospitalist, Dr. Collins practices at Miriam Hospital in Providence, R.I., where he started in 2006 as a staff hospitalist. He’s now the medical director of appeals for Lifespan at Miriam.

Dr. Collins is an assistant professor of clinical medicine at Brown University’s Alpert Medical School, while also serving as a fellow for the Society of Hospital Medicine.

Tracy Cardin, ACNP, SFHM, has been named associate director of clinical integration at Adfinitas Health, a private hospitalist company based in Maryland that serves more than 50 hospitals and post-acute care centers across the Mid-Atlantic region. Cardin is responsible for advancing the company’s training and onboarding infrastructure to support the full integration of physicians, nurse practitioners, and physician assistants into the Adfinitas care delivery model.

Jeffrey Millard, MD, has been named Patient Experience Provider of the Year by the employees and staff at Hardin Memorial Health (Elizabethtown, Ky.). Dr. Millard has been a hospitalist at Hardin Memorial Hospital since 2012.

The Patient Experience Provider of the Year award recognizes a provider who exceeds the company’s mission and vision with patients and their families, as well as with the hospital’s staff. Dr. Millard was chosen from a list of more than 800 nominations.

Benjamin Keidan, MD, has been appointed as chief medical officer for Boulder (Colo.) Community Health. Dr. Keidan advances from his previous role as medical director of quality and population health for outpatient primary care and specialty clinics.

Dr. Keidan is a former internist and hospitalist for BCH and has worked in Boulder County for the past 12 years. He is only the second CMO in BCH’s history.

Dinesh Bande, MD, has been selected as the new chair of the department of internal medicine at the University of North Dakota, Grand Forks. Dr. Bande is a clinical associate professor at the school and a hospitalist with Sanford Health.

Dr. Bande has been the clerkship director for third-year medical students at UND for the past 2 years. As chair of internal medicine, he will oversee education, research, clinical care, training, and service programs within the department.

Vicki Iannotti, MD, has been named chief medical officer at the Elizabeth Ann Seton Pediatric Center in Yonkers, N.Y. Dr. Iannotti joins Seton after spending 12 years as associate chief of pediatrics and pediatric hospital medicine at Maria Fareri Children’s Hospital in Valhalla, N.Y.

At Seton, Dr. Iannotti will oversee 100 medical professionals at the 201,000-square-foot facility, which is the largest provider of children’s acute care in the United States.
 

Business moves

Management Service Organization Continuum Health (Marlton, N.J.) has signed an agreement with the Mid-Atlantic region’s largest private hospitalist group, Adfinitas Health (Hanover, Md.), to be its revenue management cycle partner. Founded in 1999, Continuum Health now serves more than 1,500 providers in more than 400 locations.

Colquitt Regional Medical Center in Moultrie, Ga., has expanded its hospitalist program, adding 5 physicians to increase its total to 10 on-staff hospitalists. Colquitt Regional’s program began in 2012 with four hospitalists.

In the past, Colquitt Regional has shared hospitalists with surrounding hospitals to meet the demand for care. With the addition of the five new physicians, the hospital can provide full-time hospital medicine care with physicians employed by Colquitt Regional.


 

 

Michael Rader, MD, has been named the chief medical officer of the Department of Veterans Affairs New York/New Jersey Health Care Network. The network serves upward of a half-million veterans in 76 counties in New York, New Jersey, and Pennsylvania. Dr. Rader’s appointment began on Oct. 15, 2017.

Previously, Dr. Rader was chief medical officer at Prospect East Orange (N.J.) General. In his new position, the 35-year veteran will be charged with overseeing care at VA facilities in Albany Stratton, Bath, Canandaigua, and Syracuse in New York, as well as the VA Western New York Health System, the New York Harbor Health System, the New Jersey Health Care System, Hudson Valley Healthcare System, the James J. Peters and Northport VA Medical Centers, as well as 66 community-based outpatient clinics.

The Rhode Island Medical Society has elected Bradley Collins, MD, as its new president. An internist and hospitalist, Dr. Collins practices at Miriam Hospital in Providence, R.I., where he started in 2006 as a staff hospitalist. He’s now the medical director of appeals for Lifespan at Miriam.

Dr. Collins is an assistant professor of clinical medicine at Brown University’s Alpert Medical School, while also serving as a fellow for the Society of Hospital Medicine.

Tracy Cardin, ACNP, SFHM, has been named associate director of clinical integration at Adfinitas Health, a private hospitalist company based in Maryland that serves more than 50 hospitals and post-acute care centers across the Mid-Atlantic region. Cardin is responsible for advancing the company’s training and onboarding infrastructure to support the full integration of physicians, nurse practitioners, and physician assistants into the Adfinitas care delivery model.

Jeffrey Millard, MD, has been named Patient Experience Provider of the Year by the employees and staff at Hardin Memorial Health (Elizabethtown, Ky.). Dr. Millard has been a hospitalist at Hardin Memorial Hospital since 2012.

The Patient Experience Provider of the Year award recognizes a provider who exceeds the company’s mission and vision with patients and their families, as well as with the hospital’s staff. Dr. Millard was chosen from a list of more than 800 nominations.

Benjamin Keidan, MD, has been appointed as chief medical officer for Boulder (Colo.) Community Health. Dr. Keidan advances from his previous role as medical director of quality and population health for outpatient primary care and specialty clinics.

Dr. Keidan is a former internist and hospitalist for BCH and has worked in Boulder County for the past 12 years. He is only the second CMO in BCH’s history.

Dinesh Bande, MD, has been selected as the new chair of the department of internal medicine at the University of North Dakota, Grand Forks. Dr. Bande is a clinical associate professor at the school and a hospitalist with Sanford Health.

Dr. Bande has been the clerkship director for third-year medical students at UND for the past 2 years. As chair of internal medicine, he will oversee education, research, clinical care, training, and service programs within the department.

Vicki Iannotti, MD, has been named chief medical officer at the Elizabeth Ann Seton Pediatric Center in Yonkers, N.Y. Dr. Iannotti joins Seton after spending 12 years as associate chief of pediatrics and pediatric hospital medicine at Maria Fareri Children’s Hospital in Valhalla, N.Y.

At Seton, Dr. Iannotti will oversee 100 medical professionals at the 201,000-square-foot facility, which is the largest provider of children’s acute care in the United States.
 

Business moves

Management Service Organization Continuum Health (Marlton, N.J.) has signed an agreement with the Mid-Atlantic region’s largest private hospitalist group, Adfinitas Health (Hanover, Md.), to be its revenue management cycle partner. Founded in 1999, Continuum Health now serves more than 1,500 providers in more than 400 locations.

Colquitt Regional Medical Center in Moultrie, Ga., has expanded its hospitalist program, adding 5 physicians to increase its total to 10 on-staff hospitalists. Colquitt Regional’s program began in 2012 with four hospitalists.

In the past, Colquitt Regional has shared hospitalists with surrounding hospitals to meet the demand for care. With the addition of the five new physicians, the hospital can provide full-time hospital medicine care with physicians employed by Colquitt Regional.


 

 

Michael Rader, MD, has been named the chief medical officer of the Department of Veterans Affairs New York/New Jersey Health Care Network. The network serves upward of a half-million veterans in 76 counties in New York, New Jersey, and Pennsylvania. Dr. Rader’s appointment began on Oct. 15, 2017.

Previously, Dr. Rader was chief medical officer at Prospect East Orange (N.J.) General. In his new position, the 35-year veteran will be charged with overseeing care at VA facilities in Albany Stratton, Bath, Canandaigua, and Syracuse in New York, as well as the VA Western New York Health System, the New York Harbor Health System, the New Jersey Health Care System, Hudson Valley Healthcare System, the James J. Peters and Northport VA Medical Centers, as well as 66 community-based outpatient clinics.

The Rhode Island Medical Society has elected Bradley Collins, MD, as its new president. An internist and hospitalist, Dr. Collins practices at Miriam Hospital in Providence, R.I., where he started in 2006 as a staff hospitalist. He’s now the medical director of appeals for Lifespan at Miriam.

Dr. Collins is an assistant professor of clinical medicine at Brown University’s Alpert Medical School, while also serving as a fellow for the Society of Hospital Medicine.

Tracy Cardin, ACNP, SFHM, has been named associate director of clinical integration at Adfinitas Health, a private hospitalist company based in Maryland that serves more than 50 hospitals and post-acute care centers across the Mid-Atlantic region. Cardin is responsible for advancing the company’s training and onboarding infrastructure to support the full integration of physicians, nurse practitioners, and physician assistants into the Adfinitas care delivery model.

Jeffrey Millard, MD, has been named Patient Experience Provider of the Year by the employees and staff at Hardin Memorial Health (Elizabethtown, Ky.). Dr. Millard has been a hospitalist at Hardin Memorial Hospital since 2012.

The Patient Experience Provider of the Year award recognizes a provider who exceeds the company’s mission and vision with patients and their families, as well as with the hospital’s staff. Dr. Millard was chosen from a list of more than 800 nominations.

Benjamin Keidan, MD, has been appointed as chief medical officer for Boulder (Colo.) Community Health. Dr. Keidan advances from his previous role as medical director of quality and population health for outpatient primary care and specialty clinics.

Dr. Keidan is a former internist and hospitalist for BCH and has worked in Boulder County for the past 12 years. He is only the second CMO in BCH’s history.

Dinesh Bande, MD, has been selected as the new chair of the department of internal medicine at the University of North Dakota, Grand Forks. Dr. Bande is a clinical associate professor at the school and a hospitalist with Sanford Health.

Dr. Bande has been the clerkship director for third-year medical students at UND for the past 2 years. As chair of internal medicine, he will oversee education, research, clinical care, training, and service programs within the department.

Vicki Iannotti, MD, has been named chief medical officer at the Elizabeth Ann Seton Pediatric Center in Yonkers, N.Y. Dr. Iannotti joins Seton after spending 12 years as associate chief of pediatrics and pediatric hospital medicine at Maria Fareri Children’s Hospital in Valhalla, N.Y.

At Seton, Dr. Iannotti will oversee 100 medical professionals at the 201,000-square-foot facility, which is the largest provider of children’s acute care in the United States.
 

Business moves

Management Service Organization Continuum Health (Marlton, N.J.) has signed an agreement with the Mid-Atlantic region’s largest private hospitalist group, Adfinitas Health (Hanover, Md.), to be its revenue management cycle partner. Founded in 1999, Continuum Health now serves more than 1,500 providers in more than 400 locations.

Colquitt Regional Medical Center in Moultrie, Ga., has expanded its hospitalist program, adding 5 physicians to increase its total to 10 on-staff hospitalists. Colquitt Regional’s program began in 2012 with four hospitalists.

In the past, Colquitt Regional has shared hospitalists with surrounding hospitals to meet the demand for care. With the addition of the five new physicians, the hospital can provide full-time hospital medicine care with physicians employed by Colquitt Regional.


 

 

Background: Elective operations have become increasingly more common in the elderly. This population is at a higher risk for postsurgical complications. Previous research into preoperative risk assessment relied on geriatricians, of whom there is a national shortage.

Study design: Prospective cohort study.

Setting: Preoperative surgery clinics at the University of Michigan Health System.

Synopsis: A total of 736 elderly patients had a preoperative Vulnerable Elders Surgical Pathways and Outcomes Assessment (VESPA) administered by a surgical physician assistant in clinic. VESPA assessed activities of daily living, history of falling or gait impairment, and depressive symptoms. Patients underwent a Mini-Cog examination and a Timed Up and Go assessment. Patients were asked whether they expected they could manage themselves alone after discharge. One in seven patients reported difficulty with one or more of the activities of daily living and one in three stated they would be unable to manage postoperative self-care alone. Overall, 25.3% of patients had geriatric or surgical complications. The VESPA score predicted postoperative complications (area under the curve, 0.76). More specifically, preexisting difficulties with activities of daily living, anticipated self-care difficulty, a Charlson Comorbidity score of 2 or greater, male sex, or higher surgical relative value units were all independently associated with postoperative complications.

Bottom line: Elderly patients at an increased risk of postoperative complications can be identified by nonphysician staff using the VESPA preoperative assessment.

Citation: Min L et al. Estimating risk of postsurgical general and geriatric complications using the VESPA preoperative tool. JAMA Surg. 2017 Aug 2. doi: 10.1001/jamasurg.2017.2635.

Dr. Hoegh is a hospitalist at the University of Colorado School of Medicine. 

 

Background: Elective operations have become increasingly more common in the elderly. This population is at a higher risk for postsurgical complications. Previous research into preoperative risk assessment relied on geriatricians, of whom there is a national shortage.

Study design: Prospective cohort study.

Setting: Preoperative surgery clinics at the University of Michigan Health System.

Synopsis: A total of 736 elderly patients had a preoperative Vulnerable Elders Surgical Pathways and Outcomes Assessment (VESPA) administered by a surgical physician assistant in clinic. VESPA assessed activities of daily living, history of falling or gait impairment, and depressive symptoms. Patients underwent a Mini-Cog examination and a Timed Up and Go assessment. Patients were asked whether they expected they could manage themselves alone after discharge. One in seven patients reported difficulty with one or more of the activities of daily living and one in three stated they would be unable to manage postoperative self-care alone. Overall, 25.3% of patients had geriatric or surgical complications. The VESPA score predicted postoperative complications (area under the curve, 0.76). More specifically, preexisting difficulties with activities of daily living, anticipated self-care difficulty, a Charlson Comorbidity score of 2 or greater, male sex, or higher surgical relative value units were all independently associated with postoperative complications.

Bottom line: Elderly patients at an increased risk of postoperative complications can be identified by nonphysician staff using the VESPA preoperative assessment.

Citation: Min L et al. Estimating risk of postsurgical general and geriatric complications using the VESPA preoperative tool. JAMA Surg. 2017 Aug 2. doi: 10.1001/jamasurg.2017.2635.

Dr. Hoegh is a hospitalist at the University of Colorado School of Medicine. 

 

Background: Elective operations have become increasingly more common in the elderly. This population is at a higher risk for postsurgical complications. Previous research into preoperative risk assessment relied on geriatricians, of whom there is a national shortage.

Study design: Prospective cohort study.

Setting: Preoperative surgery clinics at the University of Michigan Health System.

Synopsis: A total of 736 elderly patients had a preoperative Vulnerable Elders Surgical Pathways and Outcomes Assessment (VESPA) administered by a surgical physician assistant in clinic. VESPA assessed activities of daily living, history of falling or gait impairment, and depressive symptoms. Patients underwent a Mini-Cog examination and a Timed Up and Go assessment. Patients were asked whether they expected they could manage themselves alone after discharge. One in seven patients reported difficulty with one or more of the activities of daily living and one in three stated they would be unable to manage postoperative self-care alone. Overall, 25.3% of patients had geriatric or surgical complications. The VESPA score predicted postoperative complications (area under the curve, 0.76). More specifically, preexisting difficulties with activities of daily living, anticipated self-care difficulty, a Charlson Comorbidity score of 2 or greater, male sex, or higher surgical relative value units were all independently associated with postoperative complications.

Bottom line: Elderly patients at an increased risk of postoperative complications can be identified by nonphysician staff using the VESPA preoperative assessment.

Citation: Min L et al. Estimating risk of postsurgical general and geriatric complications using the VESPA preoperative tool. JAMA Surg. 2017 Aug 2. doi: 10.1001/jamasurg.2017.2635.

Dr. Hoegh is a hospitalist at the University of Colorado School of Medicine. 

 

As far as the influenza virus is concerned, the new year started in the same way as the old one ended: with almost half of the states at the highest level of flu activity, according to the Centers for Disease Control and Prevention.

For the week ending Jan. 6, 2018, there were 23 states – including California, Illinois, and Texas – at level 10 on the CDC’s 1-10 scale for influenza-like illness (ILI) activity, which was up from 22 for the last full week of 2017. Joining the 23 states in the “high” range were New Jersey and Ohio at level 9 and Colorado at level 8, the CDC’s influenza division reported Jan. 12.

Nationwide, the proportion of outpatient visits for ILI was 5.8% for the week ending Jan. 6, which is up 166% from just 5 weeks ago, when it was at the national baseline of 2.2% for the week ending Dec. 2, and is higher than at any time during the 2016-2017 flu season, the CDC data show.

Seven flu-related pediatric deaths were reported during the week ending Jan. 6, although one occurred during the week ending Dec. 16 and two were during the week ending Dec. 23. There have been a total of 20 pediatric deaths related to influenza so far for the 2017-2018 season, the CDC said. In 2016-2017, there were 110 pediatric deaths from the flu.
 

[email protected]

 

As far as the influenza virus is concerned, the new year started in the same way as the old one ended: with almost half of the states at the highest level of flu activity, according to the Centers for Disease Control and Prevention.

For the week ending Jan. 6, 2018, there were 23 states – including California, Illinois, and Texas – at level 10 on the CDC’s 1-10 scale for influenza-like illness (ILI) activity, which was up from 22 for the last full week of 2017. Joining the 23 states in the “high” range were New Jersey and Ohio at level 9 and Colorado at level 8, the CDC’s influenza division reported Jan. 12.

Nationwide, the proportion of outpatient visits for ILI was 5.8% for the week ending Jan. 6, which is up 166% from just 5 weeks ago, when it was at the national baseline of 2.2% for the week ending Dec. 2, and is higher than at any time during the 2016-2017 flu season, the CDC data show.

Seven flu-related pediatric deaths were reported during the week ending Jan. 6, although one occurred during the week ending Dec. 16 and two were during the week ending Dec. 23. There have been a total of 20 pediatric deaths related to influenza so far for the 2017-2018 season, the CDC said. In 2016-2017, there were 110 pediatric deaths from the flu.
 

[email protected]

 

As far as the influenza virus is concerned, the new year started in the same way as the old one ended: with almost half of the states at the highest level of flu activity, according to the Centers for Disease Control and Prevention.

For the week ending Jan. 6, 2018, there were 23 states – including California, Illinois, and Texas – at level 10 on the CDC’s 1-10 scale for influenza-like illness (ILI) activity, which was up from 22 for the last full week of 2017. Joining the 23 states in the “high” range were New Jersey and Ohio at level 9 and Colorado at level 8, the CDC’s influenza division reported Jan. 12.

Nationwide, the proportion of outpatient visits for ILI was 5.8% for the week ending Jan. 6, which is up 166% from just 5 weeks ago, when it was at the national baseline of 2.2% for the week ending Dec. 2, and is higher than at any time during the 2016-2017 flu season, the CDC data show.

Seven flu-related pediatric deaths were reported during the week ending Jan. 6, although one occurred during the week ending Dec. 16 and two were during the week ending Dec. 23. There have been a total of 20 pediatric deaths related to influenza so far for the 2017-2018 season, the CDC said. In 2016-2017, there were 110 pediatric deaths from the flu.
 

[email protected]