The Hospitalist

New tools to help minimize the risk of opioid-related adverse events are becoming more widely available, although providers are still struggling over how best to implement them.

A recent study by Shane Mueller, MSW, and Ingrid Binswanger, MD, at Kaiser Permanente Colorado Institute for Health Research, Denver, for instance, found that doctors are frequently uncomfortable prescribing the opioid antagonist naloxone to counteract a potential overdose.¹

References

1. Mueller SR, Koester S, Glanz JM, et al. Attitudes toward naloxone prescribing in clinical settings: A qualitative study of patients prescribed high dose opioids for chronic non-cancer pain. J Gen Intern Med. 2017 March;32(3):277-83.
 

New tools to help minimize the risk of opioid-related adverse events are becoming more widely available, although providers are still struggling over how best to implement them.

A recent study by Shane Mueller, MSW, and Ingrid Binswanger, MD, at Kaiser Permanente Colorado Institute for Health Research, Denver, for instance, found that doctors are frequently uncomfortable prescribing the opioid antagonist naloxone to counteract a potential overdose.¹

References

1. Mueller SR, Koester S, Glanz JM, et al. Attitudes toward naloxone prescribing in clinical settings: A qualitative study of patients prescribed high dose opioids for chronic non-cancer pain. J Gen Intern Med. 2017 March;32(3):277-83.
 

New tools to help minimize the risk of opioid-related adverse events are becoming more widely available, although providers are still struggling over how best to implement them.

A recent study by Shane Mueller, MSW, and Ingrid Binswanger, MD, at Kaiser Permanente Colorado Institute for Health Research, Denver, for instance, found that doctors are frequently uncomfortable prescribing the opioid antagonist naloxone to counteract a potential overdose.¹

References

1. Mueller SR, Koester S, Glanz JM, et al. Attitudes toward naloxone prescribing in clinical settings: A qualitative study of patients prescribed high dose opioids for chronic non-cancer pain. J Gen Intern Med. 2017 March;32(3):277-83.
 

WASHINGTON – Treatment with carvedilol reduced the incidence of sepsis and acute kidney injury and improved survival at 28 days but did not significantly reduce the progression of esophageal varices in patients with acute-on-chronic liver failure.

A total of 136 patients with acute-on-chronic liver failure with small or no esophageal varices and a hepatic venous pressure gradient (HVPG) of 12 mm Hg or greater were enrolled in a single center, prospective, open-label, randomized controlled trial: 66 were randomized to carvedilol and 70 to placebo, according to Sumeet Kainth, MD, of the Institute of Liver and Biliary Sciences in New Delhi.

The study was sponsored by Institute of Liver and Biliary Sciences. Dr. Kainth reported no relevant conflicts of interest.

[email protected]

On Twitter @denisefulton

WASHINGTON – Treatment with carvedilol reduced the incidence of sepsis and acute kidney injury and improved survival at 28 days but did not significantly reduce the progression of esophageal varices in patients with acute-on-chronic liver failure.

A total of 136 patients with acute-on-chronic liver failure with small or no esophageal varices and a hepatic venous pressure gradient (HVPG) of 12 mm Hg or greater were enrolled in a single center, prospective, open-label, randomized controlled trial: 66 were randomized to carvedilol and 70 to placebo, according to Sumeet Kainth, MD, of the Institute of Liver and Biliary Sciences in New Delhi.

The study was sponsored by Institute of Liver and Biliary Sciences. Dr. Kainth reported no relevant conflicts of interest.

[email protected]

On Twitter @denisefulton

WASHINGTON – Treatment with carvedilol reduced the incidence of sepsis and acute kidney injury and improved survival at 28 days but did not significantly reduce the progression of esophageal varices in patients with acute-on-chronic liver failure.

A total of 136 patients with acute-on-chronic liver failure with small or no esophageal varices and a hepatic venous pressure gradient (HVPG) of 12 mm Hg or greater were enrolled in a single center, prospective, open-label, randomized controlled trial: 66 were randomized to carvedilol and 70 to placebo, according to Sumeet Kainth, MD, of the Institute of Liver and Biliary Sciences in New Delhi.

The study was sponsored by Institute of Liver and Biliary Sciences. Dr. Kainth reported no relevant conflicts of interest.

[email protected]

On Twitter @denisefulton

SAN DIEGO – The true impact of firearms injuries may be greatly underestimated, according to a study presented at the American College of Surgeons Clinical Congress.

An analysis released earlier this month estimated that firearms injuries cost nearly $3 billion a year in emergency department and inpatient treatment costs. The real cost is likely to be 10-20 times higher, said the lead author of the study, Faiz Gani, MD, a research fellow with the Johns Hopkins Surgery Center for Outcomes Research, Baltimore.

“This is just a drop in the bucket,” Dr. Gani said in an interview at the annual clinical congress of the American College of Surgeons.

SAN DIEGO – The true impact of firearms injuries may be greatly underestimated, according to a study presented at the American College of Surgeons Clinical Congress.

An analysis released earlier this month estimated that firearms injuries cost nearly $3 billion a year in emergency department and inpatient treatment costs. The real cost is likely to be 10-20 times higher, said the lead author of the study, Faiz Gani, MD, a research fellow with the Johns Hopkins Surgery Center for Outcomes Research, Baltimore.

“This is just a drop in the bucket,” Dr. Gani said in an interview at the annual clinical congress of the American College of Surgeons.

SAN DIEGO – The true impact of firearms injuries may be greatly underestimated, according to a study presented at the American College of Surgeons Clinical Congress.

An analysis released earlier this month estimated that firearms injuries cost nearly $3 billion a year in emergency department and inpatient treatment costs. The real cost is likely to be 10-20 times higher, said the lead author of the study, Faiz Gani, MD, a research fellow with the Johns Hopkins Surgery Center for Outcomes Research, Baltimore.

“This is just a drop in the bucket,” Dr. Gani said in an interview at the annual clinical congress of the American College of Surgeons.

The United States is in the midst of a public health crisis. Every day, 91 Americans die from opioid overdoses.¹ Opioid addiction has a tremendous negative effect on parents and children by destroying lives and breaking up families. When used appropriately, these drugs, such as morphine, hydrocodone, oxycodone, and fentanyl, provide much needed pain relief to patients, especially after a surgical procedure or during treatment for cancer. Unfortunately, opioids also have qualities that make them addictive and prone to overuse and abuse.

Heroin and other opioid drugs are affecting social, health, and economic welfare in communities throughout the United States. Opioid addiction does not discriminate among occupations, socioeconomic statuses, or ethnicities. Once addicted, users find it difficult to fight and overcome the habit. In this context, hospitalists who develop and use opioid policies and tactics are better equipped to deal with the increasing prevalence of opioid addiction and overdoses seen in the medical center environment.

Overview of opioid addiction

Opioids are more prevalent and easily available today in part because of the intense marketing campaigns by pharmaceutical companies. In fact, according to the 2014 National Survey on Drug Use and Health, almost 2 million Americans were dependent on or abused prescription opioids.² Opioids create artificial endorphins in the brain, amplifying positive feelings and euphoria. Once they become dependent, patients feel sick and become depressed when they aren’t using narcotics. They experience uncontrollable cravings, relieved only by increasing opioid use. Personal relationships and finances are severely affected because patients will do whatever they can to acquire more opioids. Some resort to doctor shopping to obtain more opioids, while others will engage in drug trafficking to purchase and sell narcotics. Most new heroin users report that they started with nonmedical use of opioid pain relievers.³

Unfortunately, in 2015, there were more than 20,000 prescription opioid overdose deaths and almost 13,000 overdose deaths related to heroin.⁴ In addition to addiction and death, overuse of narcotics can cause many medical issues, including dizziness, constipation, depression, and immune dysfunction.

As with any addiction, there are many problems related to opiate withdrawal. Some of these include anxiety, rhinorrhea, lacrimation, piloerection, mydriasis, nausea, vomiting, abdominal pain, diarrhea, tachycardia, and hypertension. Methadone, buprenorphine, and extended-release naltrexone typically are used to help alleviate cravings and the symptoms of withdrawal. With more than 1,000 patients treated daily by emergency departments for misuse of prescription opioids, it’s imperative for the medical community to address this health care crisis.⁵
 

Impact on first responders and hospitalists

The impact of this epidemic on the medical community is dramatic. Emergency system resources, already on overload, are further taxed and drained by the increased 911 calls for overdose incidents. This means that instead of responding to heart attacks, strokes, or other emergencies, first responders are spending time stabilizing overdose patients and taking them to hospitals. This resource drain spreads to emergency rooms and hospitals as they treat these patients. Eventually, the epidemic results in higher insurance costs to cover the impact on medical resources.

Strategies for hospitalists

A multifaceted approach is required to combat this crisis, and hospitalists are one component of that solution. Here are strategies hospitalists can employ to combat the growing use and abuse of narcotics:

• Screen for high-risk conditions. Before prescribing opioids, screen patients for conditions that may be exacerbated by opioid use, including sleep apnea, obesity COPD, and heart failure, as well as whether they are using medications that cause sedation and respiratory depression.
• Develop and follow pain management clinical pathway protocols. For example, start with nonopioid analgesics, such as acetaminophen, ibuprofen, and naproxen, for patients with mild pain. If the patient is in moderate pain, or if the mild pain was unrelieved by the first type of medicine, continue with opioid analgesics including codeine, oxycodone, hydrocodone, or morphine. Finally, if the patient is experiencing severe pain, or if the mild to moderate pain was unrelieved by previous medications, prescribe higher doses of morphine, fentanyl, or hydromorphone or use a patient-controlled analgesia delivery of an intravenous opioid.
• Discuss other treatment options. Instead of prescribing narcotics, assess whether other treatment options are viable. These include physical and occupational therapy, steroid shots, massage, local nerve blocks, and muscle relaxers.
• Evaluate the reason(s) for current use of prescribed narcotics. It’s crucial to determine why patients are using opioids. The medical condition for which they were prescribed these medications may have resolved. If patients are using opioids without a medically indicated reason, offer alternative medications, such as methadone or naltrexone, and provide education to help them slowly taper off the drugs. Do not cease opioid use altogether unless the use is contraindicated because of other medical conditions or unstable vital signs (for example, low blood pressure).
• Train nurses on opioid use and addiction. Educate nurses about opioid addiction risk factors and symptoms of addiction. Instruct them on managing the Ramsay Sedation Scale and using an opioid sedation scale with patients receiving IV narcotics.
• Educate families on opioid use and addiction. Counsel patients and their families on the long-term effects of opioid use and about the warning signs of addiction. Teach them about alternatives to narcotics.
• Offer referrals to specialized clinics. Work with social workers, case managers, and local mental health professionals to refer patients to behavioral counseling, patient and family support groups, and monitored detoxification clinics qualified to treat opioid addiction.

Socioeconomic impact

The effects of the opioid epidemic are felt in all areas of the United States, especially in the health care industry. Emergency department visits are mounting while billions of dollars are spent on medical care for those addicted to opioids. Additionally, the socioeconomic effects of this crisis contribute to increasing depression, anxiety, missed days of work or school, unemployment, drop-out rates, and loss of productivity among those addicted to opioids. Also, the epidemic is adversely affecting families, leading to increased divorce rates, single parent families, and child abuse and neglect. By creating strategies and protocols for medical staff, patients, and families affected by opioid use, addiction, or overdose, hospitalists can have a positive influence on patients’ lives and ultimately the opioid epidemic.

Dr. Kasarla is a hospitalist with Apogee Physicians at Parkway Surgical & Cardiovascular Hospital in Fort Worth, Tex. He also works for Texas Health Physicians Group at Texas Health Harris Methodist Hospital and Texas Health Harris Methodist Hospital Southwest in Fort Worth, as well as at Texas Health Harris Methodist Hospital in Azle, Tex.

You can contact him at [email protected] or [email protected].

References

1. Understanding the Epidemic: Drug overdose deaths in the United States continue to increase in 2015. Accessed Sept. 11, 2017.

2. Behavioral health trends in the United States: Results from the 2014 national survey on drug use and health. Accessed Sept. 11, 2017.

3. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132(1-2):95-100.

4. Rudd RA et al. Increases in drug and opioid-involved overdose deaths – United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(50-51):1445-52.

5. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. Accessed Sept. 11, 2017.
 

The United States is in the midst of a public health crisis. Every day, 91 Americans die from opioid overdoses.¹ Opioid addiction has a tremendous negative effect on parents and children by destroying lives and breaking up families. When used appropriately, these drugs, such as morphine, hydrocodone, oxycodone, and fentanyl, provide much needed pain relief to patients, especially after a surgical procedure or during treatment for cancer. Unfortunately, opioids also have qualities that make them addictive and prone to overuse and abuse.

Heroin and other opioid drugs are affecting social, health, and economic welfare in communities throughout the United States. Opioid addiction does not discriminate among occupations, socioeconomic statuses, or ethnicities. Once addicted, users find it difficult to fight and overcome the habit. In this context, hospitalists who develop and use opioid policies and tactics are better equipped to deal with the increasing prevalence of opioid addiction and overdoses seen in the medical center environment.

Overview of opioid addiction

Opioids are more prevalent and easily available today in part because of the intense marketing campaigns by pharmaceutical companies. In fact, according to the 2014 National Survey on Drug Use and Health, almost 2 million Americans were dependent on or abused prescription opioids.² Opioids create artificial endorphins in the brain, amplifying positive feelings and euphoria. Once they become dependent, patients feel sick and become depressed when they aren’t using narcotics. They experience uncontrollable cravings, relieved only by increasing opioid use. Personal relationships and finances are severely affected because patients will do whatever they can to acquire more opioids. Some resort to doctor shopping to obtain more opioids, while others will engage in drug trafficking to purchase and sell narcotics. Most new heroin users report that they started with nonmedical use of opioid pain relievers.³

Unfortunately, in 2015, there were more than 20,000 prescription opioid overdose deaths and almost 13,000 overdose deaths related to heroin.⁴ In addition to addiction and death, overuse of narcotics can cause many medical issues, including dizziness, constipation, depression, and immune dysfunction.

As with any addiction, there are many problems related to opiate withdrawal. Some of these include anxiety, rhinorrhea, lacrimation, piloerection, mydriasis, nausea, vomiting, abdominal pain, diarrhea, tachycardia, and hypertension. Methadone, buprenorphine, and extended-release naltrexone typically are used to help alleviate cravings and the symptoms of withdrawal. With more than 1,000 patients treated daily by emergency departments for misuse of prescription opioids, it’s imperative for the medical community to address this health care crisis.⁵
 

Impact on first responders and hospitalists

The impact of this epidemic on the medical community is dramatic. Emergency system resources, already on overload, are further taxed and drained by the increased 911 calls for overdose incidents. This means that instead of responding to heart attacks, strokes, or other emergencies, first responders are spending time stabilizing overdose patients and taking them to hospitals. This resource drain spreads to emergency rooms and hospitals as they treat these patients. Eventually, the epidemic results in higher insurance costs to cover the impact on medical resources.

Strategies for hospitalists

A multifaceted approach is required to combat this crisis, and hospitalists are one component of that solution. Here are strategies hospitalists can employ to combat the growing use and abuse of narcotics:

• Screen for high-risk conditions. Before prescribing opioids, screen patients for conditions that may be exacerbated by opioid use, including sleep apnea, obesity COPD, and heart failure, as well as whether they are using medications that cause sedation and respiratory depression.
• Develop and follow pain management clinical pathway protocols. For example, start with nonopioid analgesics, such as acetaminophen, ibuprofen, and naproxen, for patients with mild pain. If the patient is in moderate pain, or if the mild pain was unrelieved by the first type of medicine, continue with opioid analgesics including codeine, oxycodone, hydrocodone, or morphine. Finally, if the patient is experiencing severe pain, or if the mild to moderate pain was unrelieved by previous medications, prescribe higher doses of morphine, fentanyl, or hydromorphone or use a patient-controlled analgesia delivery of an intravenous opioid.
• Discuss other treatment options. Instead of prescribing narcotics, assess whether other treatment options are viable. These include physical and occupational therapy, steroid shots, massage, local nerve blocks, and muscle relaxers.
• Evaluate the reason(s) for current use of prescribed narcotics. It’s crucial to determine why patients are using opioids. The medical condition for which they were prescribed these medications may have resolved. If patients are using opioids without a medically indicated reason, offer alternative medications, such as methadone or naltrexone, and provide education to help them slowly taper off the drugs. Do not cease opioid use altogether unless the use is contraindicated because of other medical conditions or unstable vital signs (for example, low blood pressure).
• Train nurses on opioid use and addiction. Educate nurses about opioid addiction risk factors and symptoms of addiction. Instruct them on managing the Ramsay Sedation Scale and using an opioid sedation scale with patients receiving IV narcotics.
• Educate families on opioid use and addiction. Counsel patients and their families on the long-term effects of opioid use and about the warning signs of addiction. Teach them about alternatives to narcotics.
• Offer referrals to specialized clinics. Work with social workers, case managers, and local mental health professionals to refer patients to behavioral counseling, patient and family support groups, and monitored detoxification clinics qualified to treat opioid addiction.

Socioeconomic impact

The effects of the opioid epidemic are felt in all areas of the United States, especially in the health care industry. Emergency department visits are mounting while billions of dollars are spent on medical care for those addicted to opioids. Additionally, the socioeconomic effects of this crisis contribute to increasing depression, anxiety, missed days of work or school, unemployment, drop-out rates, and loss of productivity among those addicted to opioids. Also, the epidemic is adversely affecting families, leading to increased divorce rates, single parent families, and child abuse and neglect. By creating strategies and protocols for medical staff, patients, and families affected by opioid use, addiction, or overdose, hospitalists can have a positive influence on patients’ lives and ultimately the opioid epidemic.

Dr. Kasarla is a hospitalist with Apogee Physicians at Parkway Surgical & Cardiovascular Hospital in Fort Worth, Tex. He also works for Texas Health Physicians Group at Texas Health Harris Methodist Hospital and Texas Health Harris Methodist Hospital Southwest in Fort Worth, as well as at Texas Health Harris Methodist Hospital in Azle, Tex.

You can contact him at [email protected] or [email protected].

References

1. Understanding the Epidemic: Drug overdose deaths in the United States continue to increase in 2015. Accessed Sept. 11, 2017.

2. Behavioral health trends in the United States: Results from the 2014 national survey on drug use and health. Accessed Sept. 11, 2017.

3. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132(1-2):95-100.

4. Rudd RA et al. Increases in drug and opioid-involved overdose deaths – United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(50-51):1445-52.

5. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. Accessed Sept. 11, 2017.
 

The United States is in the midst of a public health crisis. Every day, 91 Americans die from opioid overdoses.¹ Opioid addiction has a tremendous negative effect on parents and children by destroying lives and breaking up families. When used appropriately, these drugs, such as morphine, hydrocodone, oxycodone, and fentanyl, provide much needed pain relief to patients, especially after a surgical procedure or during treatment for cancer. Unfortunately, opioids also have qualities that make them addictive and prone to overuse and abuse.

Heroin and other opioid drugs are affecting social, health, and economic welfare in communities throughout the United States. Opioid addiction does not discriminate among occupations, socioeconomic statuses, or ethnicities. Once addicted, users find it difficult to fight and overcome the habit. In this context, hospitalists who develop and use opioid policies and tactics are better equipped to deal with the increasing prevalence of opioid addiction and overdoses seen in the medical center environment.

Overview of opioid addiction

Opioids are more prevalent and easily available today in part because of the intense marketing campaigns by pharmaceutical companies. In fact, according to the 2014 National Survey on Drug Use and Health, almost 2 million Americans were dependent on or abused prescription opioids.² Opioids create artificial endorphins in the brain, amplifying positive feelings and euphoria. Once they become dependent, patients feel sick and become depressed when they aren’t using narcotics. They experience uncontrollable cravings, relieved only by increasing opioid use. Personal relationships and finances are severely affected because patients will do whatever they can to acquire more opioids. Some resort to doctor shopping to obtain more opioids, while others will engage in drug trafficking to purchase and sell narcotics. Most new heroin users report that they started with nonmedical use of opioid pain relievers.³

Unfortunately, in 2015, there were more than 20,000 prescription opioid overdose deaths and almost 13,000 overdose deaths related to heroin.⁴ In addition to addiction and death, overuse of narcotics can cause many medical issues, including dizziness, constipation, depression, and immune dysfunction.

As with any addiction, there are many problems related to opiate withdrawal. Some of these include anxiety, rhinorrhea, lacrimation, piloerection, mydriasis, nausea, vomiting, abdominal pain, diarrhea, tachycardia, and hypertension. Methadone, buprenorphine, and extended-release naltrexone typically are used to help alleviate cravings and the symptoms of withdrawal. With more than 1,000 patients treated daily by emergency departments for misuse of prescription opioids, it’s imperative for the medical community to address this health care crisis.⁵
 

Impact on first responders and hospitalists

The impact of this epidemic on the medical community is dramatic. Emergency system resources, already on overload, are further taxed and drained by the increased 911 calls for overdose incidents. This means that instead of responding to heart attacks, strokes, or other emergencies, first responders are spending time stabilizing overdose patients and taking them to hospitals. This resource drain spreads to emergency rooms and hospitals as they treat these patients. Eventually, the epidemic results in higher insurance costs to cover the impact on medical resources.

Strategies for hospitalists

A multifaceted approach is required to combat this crisis, and hospitalists are one component of that solution. Here are strategies hospitalists can employ to combat the growing use and abuse of narcotics:

• Screen for high-risk conditions. Before prescribing opioids, screen patients for conditions that may be exacerbated by opioid use, including sleep apnea, obesity COPD, and heart failure, as well as whether they are using medications that cause sedation and respiratory depression.
• Develop and follow pain management clinical pathway protocols. For example, start with nonopioid analgesics, such as acetaminophen, ibuprofen, and naproxen, for patients with mild pain. If the patient is in moderate pain, or if the mild pain was unrelieved by the first type of medicine, continue with opioid analgesics including codeine, oxycodone, hydrocodone, or morphine. Finally, if the patient is experiencing severe pain, or if the mild to moderate pain was unrelieved by previous medications, prescribe higher doses of morphine, fentanyl, or hydromorphone or use a patient-controlled analgesia delivery of an intravenous opioid.
• Discuss other treatment options. Instead of prescribing narcotics, assess whether other treatment options are viable. These include physical and occupational therapy, steroid shots, massage, local nerve blocks, and muscle relaxers.
• Evaluate the reason(s) for current use of prescribed narcotics. It’s crucial to determine why patients are using opioids. The medical condition for which they were prescribed these medications may have resolved. If patients are using opioids without a medically indicated reason, offer alternative medications, such as methadone or naltrexone, and provide education to help them slowly taper off the drugs. Do not cease opioid use altogether unless the use is contraindicated because of other medical conditions or unstable vital signs (for example, low blood pressure).
• Train nurses on opioid use and addiction. Educate nurses about opioid addiction risk factors and symptoms of addiction. Instruct them on managing the Ramsay Sedation Scale and using an opioid sedation scale with patients receiving IV narcotics.
• Educate families on opioid use and addiction. Counsel patients and their families on the long-term effects of opioid use and about the warning signs of addiction. Teach them about alternatives to narcotics.
• Offer referrals to specialized clinics. Work with social workers, case managers, and local mental health professionals to refer patients to behavioral counseling, patient and family support groups, and monitored detoxification clinics qualified to treat opioid addiction.

Socioeconomic impact

The effects of the opioid epidemic are felt in all areas of the United States, especially in the health care industry. Emergency department visits are mounting while billions of dollars are spent on medical care for those addicted to opioids. Additionally, the socioeconomic effects of this crisis contribute to increasing depression, anxiety, missed days of work or school, unemployment, drop-out rates, and loss of productivity among those addicted to opioids. Also, the epidemic is adversely affecting families, leading to increased divorce rates, single parent families, and child abuse and neglect. By creating strategies and protocols for medical staff, patients, and families affected by opioid use, addiction, or overdose, hospitalists can have a positive influence on patients’ lives and ultimately the opioid epidemic.

Dr. Kasarla is a hospitalist with Apogee Physicians at Parkway Surgical & Cardiovascular Hospital in Fort Worth, Tex. He also works for Texas Health Physicians Group at Texas Health Harris Methodist Hospital and Texas Health Harris Methodist Hospital Southwest in Fort Worth, as well as at Texas Health Harris Methodist Hospital in Azle, Tex.

You can contact him at [email protected] or [email protected].

References

1. Understanding the Epidemic: Drug overdose deaths in the United States continue to increase in 2015. Accessed Sept. 11, 2017.

2. Behavioral health trends in the United States: Results from the 2014 national survey on drug use and health. Accessed Sept. 11, 2017.

3. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132(1-2):95-100.

4. Rudd RA et al. Increases in drug and opioid-involved overdose deaths – United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(50-51):1445-52.

5. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. Accessed Sept. 11, 2017.
 

Case

A 54-year old gentleman with a history of type 2 diabetes mellitus presents with several days of progressive left lower extremity redness, pain, swelling, and subjective fevers.

On physical examination the patient is afebrile and hemodynamically stable. The left lower extremity is swollen, warm, and tender to light palpation with an irregular area of erythema extending anteriorly from the ankle to just below the knee. There are no areas of purulence or fluctuance. Labs are notable for a mild leukocytosis of 11,500 cells/mcL. An ultrasound shows no evidence of deep vein thrombosis and the patient is started on vancomycin and ceftazidime and admitted for intravenous antibiotics.

Does the patient require hospital admission and continuation of intravenous antibiotics?

Introduction

The clinical presentation of SSTIs can vary greatly. Consequently, the management of SSTIs can be as simple as a short course of outpatient oral antibiotics or escalate to as complicated as surgical intervention and/or prolonged courses of IV antibiotics. Given the frequency with which these infections result in hospital admission, it is essential for the practicing hospitalist to be able to appropriately triage and treat SSTIs in order to assure adequate therapy, while simultaneously reducing unnecessary hospital days and avoiding indiscriminate exposure to broad spectrum antibiotics.
 

Pathophysiology and clinical presentation

SSTIs represent a diverse range of presentations and severities from superficial impetigo to life-threatening necrotizing infections, with abscesses and cellulitis being most commonly diagnosed.¹

All SSTIs emerge from microbial invasion of the layers of the skin and underlying soft tissues. The accepted minimal criteria for diagnosis of an SSTI are erythema, edema, and warmth and tenderness of the affected area. Comorbid conditions that impair skin integrity, such as lymphedema, chronic inflammation (for example, eczema), intertrigo, or venous insufficiency therefore increase the risk of infection. However, the strongest risk factor for development of an SSTI is disruption of the skin barrier via trauma (foreign body, bite wound), ulceration, laceration, fissures, or surgical wound.^2,3

The hallmark features of SSTI are present in other noninfectious skin disorders, thus often yielding misdiagnosis. In a study of 259 patients hospitalized for lower extremity cellulitis, 79 patients (30.5%) were misdiagnosed.⁴ The most common mimic of SSTI is stasis dermatitis due to chronic venous insufficiency. Other conditions that are often misdiagnosed as SSTI include lymphedema, lipodermatosclerosis, contact dermatitis, papular urticaria and deep venous thrombosis. Differentiating between true SSTI and these “pseudo-cellulitic” conditions is essential to reducing unnecessary hospitalization and exposure to antibiotics, which contribute to nosocomial infection, iatrogenic injury (that is, Clostridium difficile infection, anaphylaxis) and avoidable health care costs.


 

Microbiology

In the majority of cases, the causative pathogen is not identified; superficial culture data is often confounded and positive results do not guarantee pathogenicity of the identified organism. However, the mechanism of bacterial entry, location of infection, and presence of underlying medical conditions also influence the infectious organism(s). For example, infections of the lower extremities may involve enteric organisms such as E. coli and Enterococcus due to fecal runoff. SSTIs due to cat and dog bites commonly involve Pasteurella multocida, while hot tub exposure and intravenous drug use increase the risk of infection with Pseudomonas aeruginosa. Patients with neutropenia are at increased risk for fungal and yeast infections. Consequently, an assessment for potential risk factors is essential in determining appropriate management. Common pathogens associated with various clinical presentations and risk factors are outlined in Table 2.

In addition to host risk factors, the type of SSTI may hint at the most likely organisms. Among purulent (“culturable”) SSTIs, up to 76% of infections are due to S. aureus, whereas in diffuse (“nonculturable”) cellulitis, the majority of cases are attributable to B-hemolytic streptococcus.⁷ The role of S. aureus in SSTIs is further complicated by the rise of methicillin-resistant S. aureus (MRSA), both nosocomial and community-acquired. It is estimated that between 25%-50% of all S. aureus isolates in the United States show methicillin resistance.^6,8 Despite the rising prevalence of MRSA, reflexive treatment for MRSA should be avoided in the absence of high-risk presentations (for example, purulent SSTI) or patient risk factors for MRSA (Table 3).
 

Severity of infection

Given the variety of clinical presentations of SSTIs, an evaluation of the severity of disease is essential to determining appropriate initial management, including the need for hospitalization and intravenous antibiotics. Several grading systems have been proposed to assist in determining severity. High-risk features that are common to these systems include:

• Evidence of systemic infection (fever, tachycardia, altered mental status, tachypnea, hypotension);

• Location of infection with increased risk of local complication (face, brain, hand, perineum);

• Indication of deep tissue infection (for example, crepitus, bullae, or hemorrhage);

• Comorbid conditions predisposing to more severe infection (liver or renal disease, immunocompromised state including neutropenia or active chemotherapy, vascular insufficiency).

Management

Nonpurulent disease

Nonpurulent SSTIs include cellulitis and necrotizing infections such as necrotizing fasciitis. In the absence of risk factors for particular infectious agents (see above), mild infections can be managed with a trial of oral antibiotics with coverage for streptococcal species such as cephalexin, clindamycin, or amoxicillin-clavulanate.

Empiric coverage for MRSA is not recommended and has been shown to have little benefit. In a trial of 146 patients with mild nonpurulent cellulitis, there was no significant difference in cure rate at 2 weeks between cephalexin monotherapy and dual therapy with cephalexin and trimethoprim-sulfamethoxazole.¹³

Moderate infections warrant admission for intravenous antibiotics, also with coverage for streptococcal species and MSSA such as penicillin or cefazolin. In most cases, coverage for MRSA is not required but may be considered in patients with risk factors for MRSA. Generally, blood or cutaneous cultures are not recommended given an expected yield of positive culture to be less than 5%,¹⁴ but may be considered in patients with immunosuppression or neutropenia or evidence of systemic inflammatory response.

Severe infections should be evaluated for the need for surgical debridement. Empiric antibiotic coverage for Streptococcus pyogenes, MRSA, and gram-negative and anaerobic species is warranted. If necrotizing infection is suspected or diagnosed, immediate surgical debridement is indicated. Culture data from surgical debridement should be obtained and can be useful for tailoring therapy. While blood cultures remain unlikely to yield useful data, it is reasonable to obtain them in severe disease. Empiric antibiotic coverage should be broad and narrowed based on surgical specimens. The general recommendation regarding duration of antibiotics is 5 days; however, longer courses of up to 10-14 days may be required if there is minimal improvement after initial therapy.⁹

Purulent disease

Purulent SSTIs by definition involve collections of pus and include abscesses, furuncles, and carbuncles. In all purulent SSTIs, incision and drainage is indicated.

For mild disease, incision and drainage is considered definitive management and deep wound cultures and antibiotics are not required. In moderate purulent SSTI, culture of the drained fluid should be obtained, and antibiotics administered with empiric therapy to include coverage for MRSA. Patients at risk for community-acquired MRSA can be given oral agents such as trimethoprim-sulfamethoxazole, clindamycin, or doxycycline (depending upon local antibiogram data) with antibiotics narrowed based on culture data.

In order to minimize treatment failure with oral agents, dosing should be weight based with a minimum of 5 mg/kg per day of bactrim or 10 mg/kg per day of clindamycin.¹⁵ Those with risk factors for nosocomial MRSA may warrant intravenous antibiotics, even in moderate disease. Patients with severe purulent disease require intravenous antibiotics with coverage for MRSA with vancomycin, daptomycin or linezolid and subsequently narrowed based on culture data.⁹

Back to the case

Our patient presented with a case of mild, nonpurulent cellulitis. While he does have a mildly elevated white blood cell count, he has no other signs of systemic infection or underlying conditions predisposing to more severe disease. Hospital admission is not required and de-escalation of antibiotics to an oral agent is appropriate.

If the patient exhibited other signs of systemic infection (that is, fever or tachycardia) hospital admission or admission to observation status for IV antibiotics would be appropriate; however, de-escalation would still be recommended as MRSA coverage is not warranted. We suggest discharge from the emergency department with oral cephalexin, provided no prohibitive allergy is known, with outpatient follow-up to ensure resolution of infection.
 

Bottom line

SSTIs encompass a wide variety of clinical presentations and severity, and can be mimicked by a number of noninfectious medical conditions. If an infectious process is considered most likely, the need for hospitalization and broad-spectrum antibiotics should be individually determined based on specific criteria, and not empirically initiated for all presentations.

Dr. Perry is an instructor in the Yale Academic Hospitalist Program at Yale University, New Haven, Conn. Dr. Fogerty is associate professor of medicine in the Yale Academic Hospitalist Program. Dr. Sankey is assistant professor of medicine and interim inpatient medicine clerkship director in the Yale Academic Hospitalist Program.

Key Points

• SSTIs encompass a wide variety of clinical presentations and severity, and can be mimicked by a number of noninfectious medical conditions

• The majority of SSTIs are caused by gram-positive organisms, most notably Staphylococcus aureus and B-hemolytic streptococci

• Evaluation of the severity of disease, using a grading system, is essential to determining appropriate initial management

• Hospitalization and broad-spectrum antibiotics should be individually determined based on specific criteria, not empirically initiated for all presentations

References

1. Miller L, Eisenberg D, Liu H, et al. Incidence of skin and soft tissue infections in ambulatory and inpatient settings, 2005-2010. BMC Infect Dis. 2015 Aug 21;15:362.

2. Dupuy A, Benchikhi H, Roujeau JC, et al. Risk factors for erysipelas of the leg (cellulitis): case control study. BMJ. 1999;318(7198):1591-4.

3. Ki V, Rotstein C. Bacterial skin and soft tissue infections in adults: A review of their epidemiology, pathogenesis, diagnosis, treatment and site of care. Can J Infect Dis Med Microbiol. 2008 Mar;19(2):173-84.

4. Weng QY, Raff AB, Cohen JM, et al. Costs and Consequences Associated with Misdiagnosed Lower Extremity Cellulitis. JAMA Dermatol. 2016 Nov 2.

5. Keller E, Tomecki K, Alraies M. Distinguishing cellulitis from its mimics. Cleve Clin J Med. 2012 Aug;79(8)547-52.

6. Bassetti, M, Carmelutti A, Righi E. The role of methicillin-resistant Staphylococcus aureus in skin and soft tissue infections. Curr Opin Infect Dis. 2017 Apr.

7. Jeng A, Beheshti M, Li J, Ramesh N. The Role of B-hemolytic Streptococci in Causing Diffuse, Nonculturable Cellulitis. Medicine (Baltimore). 2010 Jul;89(4):217-26.

8. Moran G, Krishnadasan A, Gorwitz R. Methicillin-Resistant S. aureus Infections among Patients in the Emergency Department. N Engl J Med. 2006; 355:666-74.

9. Stevens D, Bisno A, Chambers H, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft tissue Infections: 2014 Update by the Infectious Disease Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.

10. Raff, AB and Kroshinsky D. Cellulitis: A Review. JAMA. 2016 Jul;316(3):325-37.

11. Wong, CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004 Jul;32(7):1535-41.

12. Gunderson CG. Cellulitis: Definition, etiology and clinical features. Am J Med 2011 Dec;124(12):1113-22.

13. Pallin D, et al. Comparative Effectiveness of Cephalexin Plus Trimethoprim-Sulfamethoxazole versus Cephalexin Alone for Treatment of Uncomplicated Cellulitis: A Randomized Controlled Trial. Clin Infect Dis. 2013 Jun;56(12):1754-62.

14. Gunderson CG, Martinello RA. A systematic review of bacteremias in cellulitis and erysipelas. J Infect. 2012;64(2):148-55.

15. Halilovic J, Heintz BH, Brown J.. Risk factors for clinical failure in patients hospitalized with cellulitis and cutaneous abscess. J Infect. 2012;65(2):128-34.

Case

A 54-year old gentleman with a history of type 2 diabetes mellitus presents with several days of progressive left lower extremity redness, pain, swelling, and subjective fevers.

On physical examination the patient is afebrile and hemodynamically stable. The left lower extremity is swollen, warm, and tender to light palpation with an irregular area of erythema extending anteriorly from the ankle to just below the knee. There are no areas of purulence or fluctuance. Labs are notable for a mild leukocytosis of 11,500 cells/mcL. An ultrasound shows no evidence of deep vein thrombosis and the patient is started on vancomycin and ceftazidime and admitted for intravenous antibiotics.

Does the patient require hospital admission and continuation of intravenous antibiotics?

Introduction

The clinical presentation of SSTIs can vary greatly. Consequently, the management of SSTIs can be as simple as a short course of outpatient oral antibiotics or escalate to as complicated as surgical intervention and/or prolonged courses of IV antibiotics. Given the frequency with which these infections result in hospital admission, it is essential for the practicing hospitalist to be able to appropriately triage and treat SSTIs in order to assure adequate therapy, while simultaneously reducing unnecessary hospital days and avoiding indiscriminate exposure to broad spectrum antibiotics.
 

Pathophysiology and clinical presentation

SSTIs represent a diverse range of presentations and severities from superficial impetigo to life-threatening necrotizing infections, with abscesses and cellulitis being most commonly diagnosed.¹

All SSTIs emerge from microbial invasion of the layers of the skin and underlying soft tissues. The accepted minimal criteria for diagnosis of an SSTI are erythema, edema, and warmth and tenderness of the affected area. Comorbid conditions that impair skin integrity, such as lymphedema, chronic inflammation (for example, eczema), intertrigo, or venous insufficiency therefore increase the risk of infection. However, the strongest risk factor for development of an SSTI is disruption of the skin barrier via trauma (foreign body, bite wound), ulceration, laceration, fissures, or surgical wound.^2,3

The hallmark features of SSTI are present in other noninfectious skin disorders, thus often yielding misdiagnosis. In a study of 259 patients hospitalized for lower extremity cellulitis, 79 patients (30.5%) were misdiagnosed.⁴ The most common mimic of SSTI is stasis dermatitis due to chronic venous insufficiency. Other conditions that are often misdiagnosed as SSTI include lymphedema, lipodermatosclerosis, contact dermatitis, papular urticaria and deep venous thrombosis. Differentiating between true SSTI and these “pseudo-cellulitic” conditions is essential to reducing unnecessary hospitalization and exposure to antibiotics, which contribute to nosocomial infection, iatrogenic injury (that is, Clostridium difficile infection, anaphylaxis) and avoidable health care costs.


 

Microbiology

In the majority of cases, the causative pathogen is not identified; superficial culture data is often confounded and positive results do not guarantee pathogenicity of the identified organism. However, the mechanism of bacterial entry, location of infection, and presence of underlying medical conditions also influence the infectious organism(s). For example, infections of the lower extremities may involve enteric organisms such as E. coli and Enterococcus due to fecal runoff. SSTIs due to cat and dog bites commonly involve Pasteurella multocida, while hot tub exposure and intravenous drug use increase the risk of infection with Pseudomonas aeruginosa. Patients with neutropenia are at increased risk for fungal and yeast infections. Consequently, an assessment for potential risk factors is essential in determining appropriate management. Common pathogens associated with various clinical presentations and risk factors are outlined in Table 2.

In addition to host risk factors, the type of SSTI may hint at the most likely organisms. Among purulent (“culturable”) SSTIs, up to 76% of infections are due to S. aureus, whereas in diffuse (“nonculturable”) cellulitis, the majority of cases are attributable to B-hemolytic streptococcus.⁷ The role of S. aureus in SSTIs is further complicated by the rise of methicillin-resistant S. aureus (MRSA), both nosocomial and community-acquired. It is estimated that between 25%-50% of all S. aureus isolates in the United States show methicillin resistance.^6,8 Despite the rising prevalence of MRSA, reflexive treatment for MRSA should be avoided in the absence of high-risk presentations (for example, purulent SSTI) or patient risk factors for MRSA (Table 3).
 

Severity of infection

Given the variety of clinical presentations of SSTIs, an evaluation of the severity of disease is essential to determining appropriate initial management, including the need for hospitalization and intravenous antibiotics. Several grading systems have been proposed to assist in determining severity. High-risk features that are common to these systems include:

• Evidence of systemic infection (fever, tachycardia, altered mental status, tachypnea, hypotension);

• Location of infection with increased risk of local complication (face, brain, hand, perineum);

• Indication of deep tissue infection (for example, crepitus, bullae, or hemorrhage);

• Comorbid conditions predisposing to more severe infection (liver or renal disease, immunocompromised state including neutropenia or active chemotherapy, vascular insufficiency).

Management

Nonpurulent disease

Nonpurulent SSTIs include cellulitis and necrotizing infections such as necrotizing fasciitis. In the absence of risk factors for particular infectious agents (see above), mild infections can be managed with a trial of oral antibiotics with coverage for streptococcal species such as cephalexin, clindamycin, or amoxicillin-clavulanate.

Empiric coverage for MRSA is not recommended and has been shown to have little benefit. In a trial of 146 patients with mild nonpurulent cellulitis, there was no significant difference in cure rate at 2 weeks between cephalexin monotherapy and dual therapy with cephalexin and trimethoprim-sulfamethoxazole.¹³

Moderate infections warrant admission for intravenous antibiotics, also with coverage for streptococcal species and MSSA such as penicillin or cefazolin. In most cases, coverage for MRSA is not required but may be considered in patients with risk factors for MRSA. Generally, blood or cutaneous cultures are not recommended given an expected yield of positive culture to be less than 5%,¹⁴ but may be considered in patients with immunosuppression or neutropenia or evidence of systemic inflammatory response.

Severe infections should be evaluated for the need for surgical debridement. Empiric antibiotic coverage for Streptococcus pyogenes, MRSA, and gram-negative and anaerobic species is warranted. If necrotizing infection is suspected or diagnosed, immediate surgical debridement is indicated. Culture data from surgical debridement should be obtained and can be useful for tailoring therapy. While blood cultures remain unlikely to yield useful data, it is reasonable to obtain them in severe disease. Empiric antibiotic coverage should be broad and narrowed based on surgical specimens. The general recommendation regarding duration of antibiotics is 5 days; however, longer courses of up to 10-14 days may be required if there is minimal improvement after initial therapy.⁹

Purulent disease

Purulent SSTIs by definition involve collections of pus and include abscesses, furuncles, and carbuncles. In all purulent SSTIs, incision and drainage is indicated.

For mild disease, incision and drainage is considered definitive management and deep wound cultures and antibiotics are not required. In moderate purulent SSTI, culture of the drained fluid should be obtained, and antibiotics administered with empiric therapy to include coverage for MRSA. Patients at risk for community-acquired MRSA can be given oral agents such as trimethoprim-sulfamethoxazole, clindamycin, or doxycycline (depending upon local antibiogram data) with antibiotics narrowed based on culture data.

In order to minimize treatment failure with oral agents, dosing should be weight based with a minimum of 5 mg/kg per day of bactrim or 10 mg/kg per day of clindamycin.¹⁵ Those with risk factors for nosocomial MRSA may warrant intravenous antibiotics, even in moderate disease. Patients with severe purulent disease require intravenous antibiotics with coverage for MRSA with vancomycin, daptomycin or linezolid and subsequently narrowed based on culture data.⁹

Back to the case

Our patient presented with a case of mild, nonpurulent cellulitis. While he does have a mildly elevated white blood cell count, he has no other signs of systemic infection or underlying conditions predisposing to more severe disease. Hospital admission is not required and de-escalation of antibiotics to an oral agent is appropriate.

If the patient exhibited other signs of systemic infection (that is, fever or tachycardia) hospital admission or admission to observation status for IV antibiotics would be appropriate; however, de-escalation would still be recommended as MRSA coverage is not warranted. We suggest discharge from the emergency department with oral cephalexin, provided no prohibitive allergy is known, with outpatient follow-up to ensure resolution of infection.
 

Bottom line

SSTIs encompass a wide variety of clinical presentations and severity, and can be mimicked by a number of noninfectious medical conditions. If an infectious process is considered most likely, the need for hospitalization and broad-spectrum antibiotics should be individually determined based on specific criteria, and not empirically initiated for all presentations.

Dr. Perry is an instructor in the Yale Academic Hospitalist Program at Yale University, New Haven, Conn. Dr. Fogerty is associate professor of medicine in the Yale Academic Hospitalist Program. Dr. Sankey is assistant professor of medicine and interim inpatient medicine clerkship director in the Yale Academic Hospitalist Program.

Key Points

• SSTIs encompass a wide variety of clinical presentations and severity, and can be mimicked by a number of noninfectious medical conditions

• The majority of SSTIs are caused by gram-positive organisms, most notably Staphylococcus aureus and B-hemolytic streptococci

• Evaluation of the severity of disease, using a grading system, is essential to determining appropriate initial management

• Hospitalization and broad-spectrum antibiotics should be individually determined based on specific criteria, not empirically initiated for all presentations

References

1. Miller L, Eisenberg D, Liu H, et al. Incidence of skin and soft tissue infections in ambulatory and inpatient settings, 2005-2010. BMC Infect Dis. 2015 Aug 21;15:362.

2. Dupuy A, Benchikhi H, Roujeau JC, et al. Risk factors for erysipelas of the leg (cellulitis): case control study. BMJ. 1999;318(7198):1591-4.

3. Ki V, Rotstein C. Bacterial skin and soft tissue infections in adults: A review of their epidemiology, pathogenesis, diagnosis, treatment and site of care. Can J Infect Dis Med Microbiol. 2008 Mar;19(2):173-84.

4. Weng QY, Raff AB, Cohen JM, et al. Costs and Consequences Associated with Misdiagnosed Lower Extremity Cellulitis. JAMA Dermatol. 2016 Nov 2.

5. Keller E, Tomecki K, Alraies M. Distinguishing cellulitis from its mimics. Cleve Clin J Med. 2012 Aug;79(8)547-52.

6. Bassetti, M, Carmelutti A, Righi E. The role of methicillin-resistant Staphylococcus aureus in skin and soft tissue infections. Curr Opin Infect Dis. 2017 Apr.

7. Jeng A, Beheshti M, Li J, Ramesh N. The Role of B-hemolytic Streptococci in Causing Diffuse, Nonculturable Cellulitis. Medicine (Baltimore). 2010 Jul;89(4):217-26.

8. Moran G, Krishnadasan A, Gorwitz R. Methicillin-Resistant S. aureus Infections among Patients in the Emergency Department. N Engl J Med. 2006; 355:666-74.

9. Stevens D, Bisno A, Chambers H, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft tissue Infections: 2014 Update by the Infectious Disease Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.

10. Raff, AB and Kroshinsky D. Cellulitis: A Review. JAMA. 2016 Jul;316(3):325-37.

11. Wong, CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004 Jul;32(7):1535-41.

12. Gunderson CG. Cellulitis: Definition, etiology and clinical features. Am J Med 2011 Dec;124(12):1113-22.

13. Pallin D, et al. Comparative Effectiveness of Cephalexin Plus Trimethoprim-Sulfamethoxazole versus Cephalexin Alone for Treatment of Uncomplicated Cellulitis: A Randomized Controlled Trial. Clin Infect Dis. 2013 Jun;56(12):1754-62.

14. Gunderson CG, Martinello RA. A systematic review of bacteremias in cellulitis and erysipelas. J Infect. 2012;64(2):148-55.

15. Halilovic J, Heintz BH, Brown J.. Risk factors for clinical failure in patients hospitalized with cellulitis and cutaneous abscess. J Infect. 2012;65(2):128-34.

Case

A 54-year old gentleman with a history of type 2 diabetes mellitus presents with several days of progressive left lower extremity redness, pain, swelling, and subjective fevers.

On physical examination the patient is afebrile and hemodynamically stable. The left lower extremity is swollen, warm, and tender to light palpation with an irregular area of erythema extending anteriorly from the ankle to just below the knee. There are no areas of purulence or fluctuance. Labs are notable for a mild leukocytosis of 11,500 cells/mcL. An ultrasound shows no evidence of deep vein thrombosis and the patient is started on vancomycin and ceftazidime and admitted for intravenous antibiotics.

Does the patient require hospital admission and continuation of intravenous antibiotics?

Introduction

The clinical presentation of SSTIs can vary greatly. Consequently, the management of SSTIs can be as simple as a short course of outpatient oral antibiotics or escalate to as complicated as surgical intervention and/or prolonged courses of IV antibiotics. Given the frequency with which these infections result in hospital admission, it is essential for the practicing hospitalist to be able to appropriately triage and treat SSTIs in order to assure adequate therapy, while simultaneously reducing unnecessary hospital days and avoiding indiscriminate exposure to broad spectrum antibiotics.
 

Pathophysiology and clinical presentation

SSTIs represent a diverse range of presentations and severities from superficial impetigo to life-threatening necrotizing infections, with abscesses and cellulitis being most commonly diagnosed.¹

All SSTIs emerge from microbial invasion of the layers of the skin and underlying soft tissues. The accepted minimal criteria for diagnosis of an SSTI are erythema, edema, and warmth and tenderness of the affected area. Comorbid conditions that impair skin integrity, such as lymphedema, chronic inflammation (for example, eczema), intertrigo, or venous insufficiency therefore increase the risk of infection. However, the strongest risk factor for development of an SSTI is disruption of the skin barrier via trauma (foreign body, bite wound), ulceration, laceration, fissures, or surgical wound.^2,3

The hallmark features of SSTI are present in other noninfectious skin disorders, thus often yielding misdiagnosis. In a study of 259 patients hospitalized for lower extremity cellulitis, 79 patients (30.5%) were misdiagnosed.⁴ The most common mimic of SSTI is stasis dermatitis due to chronic venous insufficiency. Other conditions that are often misdiagnosed as SSTI include lymphedema, lipodermatosclerosis, contact dermatitis, papular urticaria and deep venous thrombosis. Differentiating between true SSTI and these “pseudo-cellulitic” conditions is essential to reducing unnecessary hospitalization and exposure to antibiotics, which contribute to nosocomial infection, iatrogenic injury (that is, Clostridium difficile infection, anaphylaxis) and avoidable health care costs.


 

Microbiology

In the majority of cases, the causative pathogen is not identified; superficial culture data is often confounded and positive results do not guarantee pathogenicity of the identified organism. However, the mechanism of bacterial entry, location of infection, and presence of underlying medical conditions also influence the infectious organism(s). For example, infections of the lower extremities may involve enteric organisms such as E. coli and Enterococcus due to fecal runoff. SSTIs due to cat and dog bites commonly involve Pasteurella multocida, while hot tub exposure and intravenous drug use increase the risk of infection with Pseudomonas aeruginosa. Patients with neutropenia are at increased risk for fungal and yeast infections. Consequently, an assessment for potential risk factors is essential in determining appropriate management. Common pathogens associated with various clinical presentations and risk factors are outlined in Table 2.

In addition to host risk factors, the type of SSTI may hint at the most likely organisms. Among purulent (“culturable”) SSTIs, up to 76% of infections are due to S. aureus, whereas in diffuse (“nonculturable”) cellulitis, the majority of cases are attributable to B-hemolytic streptococcus.⁷ The role of S. aureus in SSTIs is further complicated by the rise of methicillin-resistant S. aureus (MRSA), both nosocomial and community-acquired. It is estimated that between 25%-50% of all S. aureus isolates in the United States show methicillin resistance.^6,8 Despite the rising prevalence of MRSA, reflexive treatment for MRSA should be avoided in the absence of high-risk presentations (for example, purulent SSTI) or patient risk factors for MRSA (Table 3).
 

Severity of infection

Given the variety of clinical presentations of SSTIs, an evaluation of the severity of disease is essential to determining appropriate initial management, including the need for hospitalization and intravenous antibiotics. Several grading systems have been proposed to assist in determining severity. High-risk features that are common to these systems include:

• Evidence of systemic infection (fever, tachycardia, altered mental status, tachypnea, hypotension);

• Location of infection with increased risk of local complication (face, brain, hand, perineum);

• Indication of deep tissue infection (for example, crepitus, bullae, or hemorrhage);

• Comorbid conditions predisposing to more severe infection (liver or renal disease, immunocompromised state including neutropenia or active chemotherapy, vascular insufficiency).

Management

Nonpurulent disease

Nonpurulent SSTIs include cellulitis and necrotizing infections such as necrotizing fasciitis. In the absence of risk factors for particular infectious agents (see above), mild infections can be managed with a trial of oral antibiotics with coverage for streptococcal species such as cephalexin, clindamycin, or amoxicillin-clavulanate.

Empiric coverage for MRSA is not recommended and has been shown to have little benefit. In a trial of 146 patients with mild nonpurulent cellulitis, there was no significant difference in cure rate at 2 weeks between cephalexin monotherapy and dual therapy with cephalexin and trimethoprim-sulfamethoxazole.¹³

Moderate infections warrant admission for intravenous antibiotics, also with coverage for streptococcal species and MSSA such as penicillin or cefazolin. In most cases, coverage for MRSA is not required but may be considered in patients with risk factors for MRSA. Generally, blood or cutaneous cultures are not recommended given an expected yield of positive culture to be less than 5%,¹⁴ but may be considered in patients with immunosuppression or neutropenia or evidence of systemic inflammatory response.

Severe infections should be evaluated for the need for surgical debridement. Empiric antibiotic coverage for Streptococcus pyogenes, MRSA, and gram-negative and anaerobic species is warranted. If necrotizing infection is suspected or diagnosed, immediate surgical debridement is indicated. Culture data from surgical debridement should be obtained and can be useful for tailoring therapy. While blood cultures remain unlikely to yield useful data, it is reasonable to obtain them in severe disease. Empiric antibiotic coverage should be broad and narrowed based on surgical specimens. The general recommendation regarding duration of antibiotics is 5 days; however, longer courses of up to 10-14 days may be required if there is minimal improvement after initial therapy.⁹

Purulent disease

Purulent SSTIs by definition involve collections of pus and include abscesses, furuncles, and carbuncles. In all purulent SSTIs, incision and drainage is indicated.

For mild disease, incision and drainage is considered definitive management and deep wound cultures and antibiotics are not required. In moderate purulent SSTI, culture of the drained fluid should be obtained, and antibiotics administered with empiric therapy to include coverage for MRSA. Patients at risk for community-acquired MRSA can be given oral agents such as trimethoprim-sulfamethoxazole, clindamycin, or doxycycline (depending upon local antibiogram data) with antibiotics narrowed based on culture data.

In order to minimize treatment failure with oral agents, dosing should be weight based with a minimum of 5 mg/kg per day of bactrim or 10 mg/kg per day of clindamycin.¹⁵ Those with risk factors for nosocomial MRSA may warrant intravenous antibiotics, even in moderate disease. Patients with severe purulent disease require intravenous antibiotics with coverage for MRSA with vancomycin, daptomycin or linezolid and subsequently narrowed based on culture data.⁹

Back to the case

Our patient presented with a case of mild, nonpurulent cellulitis. While he does have a mildly elevated white blood cell count, he has no other signs of systemic infection or underlying conditions predisposing to more severe disease. Hospital admission is not required and de-escalation of antibiotics to an oral agent is appropriate.

If the patient exhibited other signs of systemic infection (that is, fever or tachycardia) hospital admission or admission to observation status for IV antibiotics would be appropriate; however, de-escalation would still be recommended as MRSA coverage is not warranted. We suggest discharge from the emergency department with oral cephalexin, provided no prohibitive allergy is known, with outpatient follow-up to ensure resolution of infection.
 

Bottom line

SSTIs encompass a wide variety of clinical presentations and severity, and can be mimicked by a number of noninfectious medical conditions. If an infectious process is considered most likely, the need for hospitalization and broad-spectrum antibiotics should be individually determined based on specific criteria, and not empirically initiated for all presentations.

Dr. Perry is an instructor in the Yale Academic Hospitalist Program at Yale University, New Haven, Conn. Dr. Fogerty is associate professor of medicine in the Yale Academic Hospitalist Program. Dr. Sankey is assistant professor of medicine and interim inpatient medicine clerkship director in the Yale Academic Hospitalist Program.

Key Points

• SSTIs encompass a wide variety of clinical presentations and severity, and can be mimicked by a number of noninfectious medical conditions

• The majority of SSTIs are caused by gram-positive organisms, most notably Staphylococcus aureus and B-hemolytic streptococci

• Evaluation of the severity of disease, using a grading system, is essential to determining appropriate initial management

• Hospitalization and broad-spectrum antibiotics should be individually determined based on specific criteria, not empirically initiated for all presentations

References

1. Miller L, Eisenberg D, Liu H, et al. Incidence of skin and soft tissue infections in ambulatory and inpatient settings, 2005-2010. BMC Infect Dis. 2015 Aug 21;15:362.

2. Dupuy A, Benchikhi H, Roujeau JC, et al. Risk factors for erysipelas of the leg (cellulitis): case control study. BMJ. 1999;318(7198):1591-4.

3. Ki V, Rotstein C. Bacterial skin and soft tissue infections in adults: A review of their epidemiology, pathogenesis, diagnosis, treatment and site of care. Can J Infect Dis Med Microbiol. 2008 Mar;19(2):173-84.

4. Weng QY, Raff AB, Cohen JM, et al. Costs and Consequences Associated with Misdiagnosed Lower Extremity Cellulitis. JAMA Dermatol. 2016 Nov 2.

5. Keller E, Tomecki K, Alraies M. Distinguishing cellulitis from its mimics. Cleve Clin J Med. 2012 Aug;79(8)547-52.

6. Bassetti, M, Carmelutti A, Righi E. The role of methicillin-resistant Staphylococcus aureus in skin and soft tissue infections. Curr Opin Infect Dis. 2017 Apr.

7. Jeng A, Beheshti M, Li J, Ramesh N. The Role of B-hemolytic Streptococci in Causing Diffuse, Nonculturable Cellulitis. Medicine (Baltimore). 2010 Jul;89(4):217-26.

8. Moran G, Krishnadasan A, Gorwitz R. Methicillin-Resistant S. aureus Infections among Patients in the Emergency Department. N Engl J Med. 2006; 355:666-74.

9. Stevens D, Bisno A, Chambers H, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft tissue Infections: 2014 Update by the Infectious Disease Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.

10. Raff, AB and Kroshinsky D. Cellulitis: A Review. JAMA. 2016 Jul;316(3):325-37.

11. Wong, CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004 Jul;32(7):1535-41.

12. Gunderson CG. Cellulitis: Definition, etiology and clinical features. Am J Med 2011 Dec;124(12):1113-22.

13. Pallin D, et al. Comparative Effectiveness of Cephalexin Plus Trimethoprim-Sulfamethoxazole versus Cephalexin Alone for Treatment of Uncomplicated Cellulitis: A Randomized Controlled Trial. Clin Infect Dis. 2013 Jun;56(12):1754-62.

14. Gunderson CG, Martinello RA. A systematic review of bacteremias in cellulitis and erysipelas. J Infect. 2012;64(2):148-55.

15. Halilovic J, Heintz BH, Brown J.. Risk factors for clinical failure in patients hospitalized with cellulitis and cutaneous abscess. J Infect. 2012;65(2):128-34.

A sepsis response team did not have a positive effect on mortality or organ dysfunction in septic patients, compared with standard treatment by a primary care team, according to a study abstract scheduled to be presented at CHEST 2017.

DigitalVision/Thinkstock

[email protected]

A sepsis response team did not have a positive effect on mortality or organ dysfunction in septic patients, compared with standard treatment by a primary care team, according to a study abstract scheduled to be presented at CHEST 2017.

DigitalVision/Thinkstock

[email protected]

A sepsis response team did not have a positive effect on mortality or organ dysfunction in septic patients, compared with standard treatment by a primary care team, according to a study abstract scheduled to be presented at CHEST 2017.

DigitalVision/Thinkstock

[email protected]

BARCELONA – A serum potassium level of at least 5.0 mmol/L or 3.5 mmol/L or less at admission for suspected acute coronary syndrome is a red flag for increased risk of in-hospital mortality and cardiac arrest, according to a Swedish study of nearly 33,000 consecutive patients.

That’s true even if, as so often ultimately proves to be the case, the patient turns out not to have ACS, Jonas Faxén, MD, of the Karolinska Institute, Stockholm, reported at the annual congress of the European Society of Cardiology.

“This study highlights that, if you have a patient in the emergency department with a possible ACS and potassium imbalance, you should really be cautious,” Dr. Faxén said.

Bruce Jancin/Frontline Medical News

[email protected]

BARCELONA – A serum potassium level of at least 5.0 mmol/L or 3.5 mmol/L or less at admission for suspected acute coronary syndrome is a red flag for increased risk of in-hospital mortality and cardiac arrest, according to a Swedish study of nearly 33,000 consecutive patients.

That’s true even if, as so often ultimately proves to be the case, the patient turns out not to have ACS, Jonas Faxén, MD, of the Karolinska Institute, Stockholm, reported at the annual congress of the European Society of Cardiology.

“This study highlights that, if you have a patient in the emergency department with a possible ACS and potassium imbalance, you should really be cautious,” Dr. Faxén said.

Bruce Jancin/Frontline Medical News

[email protected]

BARCELONA – A serum potassium level of at least 5.0 mmol/L or 3.5 mmol/L or less at admission for suspected acute coronary syndrome is a red flag for increased risk of in-hospital mortality and cardiac arrest, according to a Swedish study of nearly 33,000 consecutive patients.

That’s true even if, as so often ultimately proves to be the case, the patient turns out not to have ACS, Jonas Faxén, MD, of the Karolinska Institute, Stockholm, reported at the annual congress of the European Society of Cardiology.

“This study highlights that, if you have a patient in the emergency department with a possible ACS and potassium imbalance, you should really be cautious,” Dr. Faxén said.

Bruce Jancin/Frontline Medical News

[email protected]

Malpractice claims involving the use of electronic health records (EHRs) are on the rise, according to data from The Doctors Company.

Cases in which EHRs were a factor grew from 2 claims during 2007-2010 to 161 claims from 2011 to December 2016, according an analysis published Oct. 16 by The Doctors Company, a national medical malpractice insurer.

[email protected]

On Twitter @legal_med

Malpractice claims involving the use of electronic health records (EHRs) are on the rise, according to data from The Doctors Company.

Cases in which EHRs were a factor grew from 2 claims during 2007-2010 to 161 claims from 2011 to December 2016, according an analysis published Oct. 16 by The Doctors Company, a national medical malpractice insurer.

[email protected]

On Twitter @legal_med

Malpractice claims involving the use of electronic health records (EHRs) are on the rise, according to data from The Doctors Company.

Cases in which EHRs were a factor grew from 2 claims during 2007-2010 to 161 claims from 2011 to December 2016, according an analysis published Oct. 16 by The Doctors Company, a national medical malpractice insurer.

[email protected]

On Twitter @legal_med

The 2017 MGMA survey data on compensation and productivity were released last June. While the numbers aren’t surprising, reviewing them always gets me thinking about factors that influence reasonable expectations for compensation and productivity in any individual hospitalist group.

The data were collected in early 2017, reflecting work done in 2016, and show a national median hospitalist compensation for internal medicine physicians of $284,000, up from $278,500 the year before. Since MGMA added a hospitalist category to the survey, compensation has been growing significantly faster than inflation, even though productivity has been essentially flat. I’ve always thought that the high demand for hospitalists, which isn’t letting up much, in the face of a limited supply is probably the most significant force causing hospitalist compensation to rise faster than in most other specialties.

The survey shows a median of 2,114 billed encounters and 4,159 wRVUs (work relative value units) generated per internal medicine hospitalist annually (family medicine hospitalists are reported separately). These numbers have been pretty stable for many years.

Whether it is reasonable to expect hospitalists in your group to produce at this level is a question that can unspool into a lengthy conversation. Below are several assertions I regularly hear others make about productivity, and following each is my commentary.

“Surveys show only what is most typical, not what is optimal. Our field suffers from concerning levels of burnout, essentially proving that median levels of productivity shown in surveys is too high.”

I share this concern, but this is a complicated issue. You’ll have to make up your own mind regarding how significantly workload influences hospitalist burnout. But the modest amount of published research on this topic suggests that workload itself isn’t as strongly associated with burnout as you might think. I’m certain workload does play a role, but other factors such as “occupational solidarity” seem to matter more. Lowering workload in some settings might be appropriate, but without other interventions may not influence work-related stress and burnout as much as might be hoped.

“Surveys don’t capture unbillable activities (‘unbillable wRVUs’), so are a poor frame of reference when thinking about productivity expectations in our own group.”

It’s true that hospitalists do a lot of work that isn’t captured in wRVUs. My work with many groups around the country suggests the amount and difficulty of this unbillable work is reasonably similar across most groups. We all spend time with handoffs, managing paperwork such as charge capture and completing forms, responding to a rapid response call that doesn’t lead to a billable charge, etc. The average amount of this sort of work is built into the survey. Clearly some groups are outliers with meaningfully more unbillable work than elsewhere, but that can be a difficult or impossible thing to prove.

“My hospital has unique barriers to efficiency/productivity, so it’s more difficult to achieve levels of productivity shown in surveys.”

This is another way of expressing the previous issue. To support this assertion hospitalists will mention that it is tougher to be productive at their hospital because they’re a referral center with unusually sick and complicated patients; they teach trainees in addition to clinical care; and/or their patients and families are unusually demanding, so they take much more time than at other places.

Yet for each of these issues I also hear the reverse argument regularly. Hospitalists point out that because they’re a small hospital (not a referral center) they lack the support of other specialties so must manage all aspects of care themselves; they don’t have residents to help do some of the work; and their patients are unsophisticated and lack social support. For these reasons, the argument goes, they shouldn’t be expected to achieve levels of productivity shown in surveys.

I have worked with hospitalist groups that I am convinced do face unusual barriers to efficiency that are meaningful enough that unless the barriers can be addressed, I think productivity expectations should be lower than survey benchmarks. For example, in most academic medical centers and a very small number of nonacademic hospitals, only the attending physician writes orders; consulting doctors don’t. This means that the attending hospitalist must check a patient’s chart repeatedly through the day just to see if the consultant proposed even small things like ordering a routine lab test, advancing the diet, etc., that the hospitalist must order.

A separate daytime admitter shift is a modest barrier to efficiency that is so common it is clearly factored into survey results. Most hospitalist groups with more than about five doctors working daily have one doctor (or more than one in large groups) manage admissions while the rest round and are protected from admissions. While this may have a number of benefits, overall hospitalist efficiency isn’t one of them. It means that all patients, not just those admitted at night, will have a handoff from the admitting provider to a new attending for the first rounding visit. This new attending will spend additional time becoming familiar with the patient – time that wouldn’t be necessary had that doctor performed the admission visit herself.

“Our hospitalist group is always being asked to take on more duties, such as managing med reconciliation, taking referrals from an additional PCP group, or serving as admitting and attending physician for patients previously admitted by a different specialty (which now serves in the consultant role). For this reason, it’s necessary to steadily lower hospitalist productivity expectations over time.”

A hospitalist today probably spends a quarter of the day doing things I didn’t have to do at the outset of my career in the 1980s. So my impulse is to agree that as the breadth of our responsibilities expands, expected wRVU productivity should fall. But surveys over the last 15-20 years don’t show this happening, and the pressure to maintain productivity levels isn’t likely to let up. Rather than generating fewer wRVUs (seeing fewer patients), hospital medicine, like health care as a whole, faces the challenge of continually improving our efficiency.

“Surveys are only one frame of reference for determining expectations at my particular hospitalist group. There are other factors to consider as well.”

This is absolutely true. There may be many reasons for your group to set expectations that are meaningfully different from survey figures. Just make sure your rationale for doing so is well considered and effectively communicated to other stakeholders, such as those in finance and organizational leadership at your organization.
 

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. [email protected]

The 2017 MGMA survey data on compensation and productivity were released last June. While the numbers aren’t surprising, reviewing them always gets me thinking about factors that influence reasonable expectations for compensation and productivity in any individual hospitalist group.

The data were collected in early 2017, reflecting work done in 2016, and show a national median hospitalist compensation for internal medicine physicians of $284,000, up from $278,500 the year before. Since MGMA added a hospitalist category to the survey, compensation has been growing significantly faster than inflation, even though productivity has been essentially flat. I’ve always thought that the high demand for hospitalists, which isn’t letting up much, in the face of a limited supply is probably the most significant force causing hospitalist compensation to rise faster than in most other specialties.

The survey shows a median of 2,114 billed encounters and 4,159 wRVUs (work relative value units) generated per internal medicine hospitalist annually (family medicine hospitalists are reported separately). These numbers have been pretty stable for many years.

Whether it is reasonable to expect hospitalists in your group to produce at this level is a question that can unspool into a lengthy conversation. Below are several assertions I regularly hear others make about productivity, and following each is my commentary.

“Surveys show only what is most typical, not what is optimal. Our field suffers from concerning levels of burnout, essentially proving that median levels of productivity shown in surveys is too high.”

I share this concern, but this is a complicated issue. You’ll have to make up your own mind regarding how significantly workload influences hospitalist burnout. But the modest amount of published research on this topic suggests that workload itself isn’t as strongly associated with burnout as you might think. I’m certain workload does play a role, but other factors such as “occupational solidarity” seem to matter more. Lowering workload in some settings might be appropriate, but without other interventions may not influence work-related stress and burnout as much as might be hoped.

“Surveys don’t capture unbillable activities (‘unbillable wRVUs’), so are a poor frame of reference when thinking about productivity expectations in our own group.”

It’s true that hospitalists do a lot of work that isn’t captured in wRVUs. My work with many groups around the country suggests the amount and difficulty of this unbillable work is reasonably similar across most groups. We all spend time with handoffs, managing paperwork such as charge capture and completing forms, responding to a rapid response call that doesn’t lead to a billable charge, etc. The average amount of this sort of work is built into the survey. Clearly some groups are outliers with meaningfully more unbillable work than elsewhere, but that can be a difficult or impossible thing to prove.

“My hospital has unique barriers to efficiency/productivity, so it’s more difficult to achieve levels of productivity shown in surveys.”

This is another way of expressing the previous issue. To support this assertion hospitalists will mention that it is tougher to be productive at their hospital because they’re a referral center with unusually sick and complicated patients; they teach trainees in addition to clinical care; and/or their patients and families are unusually demanding, so they take much more time than at other places.

Yet for each of these issues I also hear the reverse argument regularly. Hospitalists point out that because they’re a small hospital (not a referral center) they lack the support of other specialties so must manage all aspects of care themselves; they don’t have residents to help do some of the work; and their patients are unsophisticated and lack social support. For these reasons, the argument goes, they shouldn’t be expected to achieve levels of productivity shown in surveys.

I have worked with hospitalist groups that I am convinced do face unusual barriers to efficiency that are meaningful enough that unless the barriers can be addressed, I think productivity expectations should be lower than survey benchmarks. For example, in most academic medical centers and a very small number of nonacademic hospitals, only the attending physician writes orders; consulting doctors don’t. This means that the attending hospitalist must check a patient’s chart repeatedly through the day just to see if the consultant proposed even small things like ordering a routine lab test, advancing the diet, etc., that the hospitalist must order.

A separate daytime admitter shift is a modest barrier to efficiency that is so common it is clearly factored into survey results. Most hospitalist groups with more than about five doctors working daily have one doctor (or more than one in large groups) manage admissions while the rest round and are protected from admissions. While this may have a number of benefits, overall hospitalist efficiency isn’t one of them. It means that all patients, not just those admitted at night, will have a handoff from the admitting provider to a new attending for the first rounding visit. This new attending will spend additional time becoming familiar with the patient – time that wouldn’t be necessary had that doctor performed the admission visit herself.

“Our hospitalist group is always being asked to take on more duties, such as managing med reconciliation, taking referrals from an additional PCP group, or serving as admitting and attending physician for patients previously admitted by a different specialty (which now serves in the consultant role). For this reason, it’s necessary to steadily lower hospitalist productivity expectations over time.”

A hospitalist today probably spends a quarter of the day doing things I didn’t have to do at the outset of my career in the 1980s. So my impulse is to agree that as the breadth of our responsibilities expands, expected wRVU productivity should fall. But surveys over the last 15-20 years don’t show this happening, and the pressure to maintain productivity levels isn’t likely to let up. Rather than generating fewer wRVUs (seeing fewer patients), hospital medicine, like health care as a whole, faces the challenge of continually improving our efficiency.

“Surveys are only one frame of reference for determining expectations at my particular hospitalist group. There are other factors to consider as well.”

This is absolutely true. There may be many reasons for your group to set expectations that are meaningfully different from survey figures. Just make sure your rationale for doing so is well considered and effectively communicated to other stakeholders, such as those in finance and organizational leadership at your organization.
 

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. [email protected]

The 2017 MGMA survey data on compensation and productivity were released last June. While the numbers aren’t surprising, reviewing them always gets me thinking about factors that influence reasonable expectations for compensation and productivity in any individual hospitalist group.

The data were collected in early 2017, reflecting work done in 2016, and show a national median hospitalist compensation for internal medicine physicians of $284,000, up from $278,500 the year before. Since MGMA added a hospitalist category to the survey, compensation has been growing significantly faster than inflation, even though productivity has been essentially flat. I’ve always thought that the high demand for hospitalists, which isn’t letting up much, in the face of a limited supply is probably the most significant force causing hospitalist compensation to rise faster than in most other specialties.

The survey shows a median of 2,114 billed encounters and 4,159 wRVUs (work relative value units) generated per internal medicine hospitalist annually (family medicine hospitalists are reported separately). These numbers have been pretty stable for many years.

Whether it is reasonable to expect hospitalists in your group to produce at this level is a question that can unspool into a lengthy conversation. Below are several assertions I regularly hear others make about productivity, and following each is my commentary.

“Surveys show only what is most typical, not what is optimal. Our field suffers from concerning levels of burnout, essentially proving that median levels of productivity shown in surveys is too high.”

I share this concern, but this is a complicated issue. You’ll have to make up your own mind regarding how significantly workload influences hospitalist burnout. But the modest amount of published research on this topic suggests that workload itself isn’t as strongly associated with burnout as you might think. I’m certain workload does play a role, but other factors such as “occupational solidarity” seem to matter more. Lowering workload in some settings might be appropriate, but without other interventions may not influence work-related stress and burnout as much as might be hoped.

“Surveys don’t capture unbillable activities (‘unbillable wRVUs’), so are a poor frame of reference when thinking about productivity expectations in our own group.”

It’s true that hospitalists do a lot of work that isn’t captured in wRVUs. My work with many groups around the country suggests the amount and difficulty of this unbillable work is reasonably similar across most groups. We all spend time with handoffs, managing paperwork such as charge capture and completing forms, responding to a rapid response call that doesn’t lead to a billable charge, etc. The average amount of this sort of work is built into the survey. Clearly some groups are outliers with meaningfully more unbillable work than elsewhere, but that can be a difficult or impossible thing to prove.

“My hospital has unique barriers to efficiency/productivity, so it’s more difficult to achieve levels of productivity shown in surveys.”

This is another way of expressing the previous issue. To support this assertion hospitalists will mention that it is tougher to be productive at their hospital because they’re a referral center with unusually sick and complicated patients; they teach trainees in addition to clinical care; and/or their patients and families are unusually demanding, so they take much more time than at other places.

Yet for each of these issues I also hear the reverse argument regularly. Hospitalists point out that because they’re a small hospital (not a referral center) they lack the support of other specialties so must manage all aspects of care themselves; they don’t have residents to help do some of the work; and their patients are unsophisticated and lack social support. For these reasons, the argument goes, they shouldn’t be expected to achieve levels of productivity shown in surveys.

I have worked with hospitalist groups that I am convinced do face unusual barriers to efficiency that are meaningful enough that unless the barriers can be addressed, I think productivity expectations should be lower than survey benchmarks. For example, in most academic medical centers and a very small number of nonacademic hospitals, only the attending physician writes orders; consulting doctors don’t. This means that the attending hospitalist must check a patient’s chart repeatedly through the day just to see if the consultant proposed even small things like ordering a routine lab test, advancing the diet, etc., that the hospitalist must order.

A separate daytime admitter shift is a modest barrier to efficiency that is so common it is clearly factored into survey results. Most hospitalist groups with more than about five doctors working daily have one doctor (or more than one in large groups) manage admissions while the rest round and are protected from admissions. While this may have a number of benefits, overall hospitalist efficiency isn’t one of them. It means that all patients, not just those admitted at night, will have a handoff from the admitting provider to a new attending for the first rounding visit. This new attending will spend additional time becoming familiar with the patient – time that wouldn’t be necessary had that doctor performed the admission visit herself.

“Our hospitalist group is always being asked to take on more duties, such as managing med reconciliation, taking referrals from an additional PCP group, or serving as admitting and attending physician for patients previously admitted by a different specialty (which now serves in the consultant role). For this reason, it’s necessary to steadily lower hospitalist productivity expectations over time.”

A hospitalist today probably spends a quarter of the day doing things I didn’t have to do at the outset of my career in the 1980s. So my impulse is to agree that as the breadth of our responsibilities expands, expected wRVU productivity should fall. But surveys over the last 15-20 years don’t show this happening, and the pressure to maintain productivity levels isn’t likely to let up. Rather than generating fewer wRVUs (seeing fewer patients), hospital medicine, like health care as a whole, faces the challenge of continually improving our efficiency.

“Surveys are only one frame of reference for determining expectations at my particular hospitalist group. There are other factors to consider as well.”

This is absolutely true. There may be many reasons for your group to set expectations that are meaningfully different from survey figures. Just make sure your rationale for doing so is well considered and effectively communicated to other stakeholders, such as those in finance and organizational leadership at your organization.
 

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. [email protected]

When Carol Glaser, MD, was in training, the philosophy around antibiotic prescribing often went something like this: “Ten days of antibiotics is good, but let’s do a few more days just to be sure,” she said.

Today, however, the new mantra is “less is more.” Dr. Glaser is an experienced pediatric infectious disease physician and the lead physician for pediatric antimicrobial stewardship at The Permanente Medical Group, Kaiser Permanente, at the Oakland (Calif.) Medical Center. While antibiotic stewardship is an issue relevant to nearly all hospitalists, for pediatric patients, the considerations can be unique and particularly serious.

References

1. Keren R, Shah SS, Srivastava R, et al. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015 Feb:169(2):120-8.

2. Shah SS, Srivastava R, Wu S, et al. Intravenous versus oral antibiotics for postdischarge treatment of complicated pneumonia. Pediatrics. 2016 Dec;138(6). pii: e20161692.

When Carol Glaser, MD, was in training, the philosophy around antibiotic prescribing often went something like this: “Ten days of antibiotics is good, but let’s do a few more days just to be sure,” she said.

Today, however, the new mantra is “less is more.” Dr. Glaser is an experienced pediatric infectious disease physician and the lead physician for pediatric antimicrobial stewardship at The Permanente Medical Group, Kaiser Permanente, at the Oakland (Calif.) Medical Center. While antibiotic stewardship is an issue relevant to nearly all hospitalists, for pediatric patients, the considerations can be unique and particularly serious.

References

1. Keren R, Shah SS, Srivastava R, et al. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015 Feb:169(2):120-8.

2. Shah SS, Srivastava R, Wu S, et al. Intravenous versus oral antibiotics for postdischarge treatment of complicated pneumonia. Pediatrics. 2016 Dec;138(6). pii: e20161692.

When Carol Glaser, MD, was in training, the philosophy around antibiotic prescribing often went something like this: “Ten days of antibiotics is good, but let’s do a few more days just to be sure,” she said.

Today, however, the new mantra is “less is more.” Dr. Glaser is an experienced pediatric infectious disease physician and the lead physician for pediatric antimicrobial stewardship at The Permanente Medical Group, Kaiser Permanente, at the Oakland (Calif.) Medical Center. While antibiotic stewardship is an issue relevant to nearly all hospitalists, for pediatric patients, the considerations can be unique and particularly serious.

References

1. Keren R, Shah SS, Srivastava R, et al. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015 Feb:169(2):120-8.

2. Shah SS, Srivastava R, Wu S, et al. Intravenous versus oral antibiotics for postdischarge treatment of complicated pneumonia. Pediatrics. 2016 Dec;138(6). pii: e20161692.