The Hospitalist

Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.

I am currently working with my mentor, Ian Jenkins, MD, an attending in the Division of Hospital Medicine at the University of California, San Diego, to begin preliminary data collection for our project to cut catheter-associated urinary tract infections (CAUTI). The project time line is on track, and we hope to have things up and running in the next month.

Up to this point, we have been working to identify the most relevant data to collect to best explore our outcome variable. A key goal for our project is to show that increased education measures can ultimately lead to reductions in patient harm. Rather than directly measuring harm reduction, we have settled on tracking the closely identified process measure of the number of inappropriate Foley catheters removed. This measure is potentially more accessible for health care providers than measuring CAUTI rates would be because individual CAUTI events are rare.

In addition to starting data collection, I am quickly learning that conducting a quality improvement project requires a large amount of upfront preparation. Namely, it requires not only identifying the outcome measures you would like to track but also prospectively strategizing about how to track this measure to facilitate future data presentation and publication. Dr. Jenkins has been instrumental as a resource for bouncing off various ideas regarding how to streamline data collection and presentation. He has also been valuable in helping me to identify appropriate units for data collection and teaching me to be forward thinking regarding the best way to collect data for my project. This has truly saved me a significant amount of time and increased the project’s efficiency.

Outside of data collection, we have continued to engage as many stakeholders as we can to ensure the success of the project. Because our project was deemed high priority because of the high CAUTI rates at UCSD, we engaged higher-level hospital administrators who could be onboard with the project, as well as provide their own input to improve project’s effects. Separately, we have continued to collaborate directly with nursing and physician staff to not only share our ongoing project with them but also directly engage them in the project so we can better ensure that the project is not only theoretically palatable but will be realistically implemented as well.

A quality improvement project certainly presents its own unique set of challenges, but I am truly enjoying collaborating and troubleshooting in hopes of ultimately improving patient care.

Victor Ekuta is a third-year medical student at UC San Diego.

Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.

I am currently working with my mentor, Ian Jenkins, MD, an attending in the Division of Hospital Medicine at the University of California, San Diego, to begin preliminary data collection for our project to cut catheter-associated urinary tract infections (CAUTI). The project time line is on track, and we hope to have things up and running in the next month.

Up to this point, we have been working to identify the most relevant data to collect to best explore our outcome variable. A key goal for our project is to show that increased education measures can ultimately lead to reductions in patient harm. Rather than directly measuring harm reduction, we have settled on tracking the closely identified process measure of the number of inappropriate Foley catheters removed. This measure is potentially more accessible for health care providers than measuring CAUTI rates would be because individual CAUTI events are rare.

In addition to starting data collection, I am quickly learning that conducting a quality improvement project requires a large amount of upfront preparation. Namely, it requires not only identifying the outcome measures you would like to track but also prospectively strategizing about how to track this measure to facilitate future data presentation and publication. Dr. Jenkins has been instrumental as a resource for bouncing off various ideas regarding how to streamline data collection and presentation. He has also been valuable in helping me to identify appropriate units for data collection and teaching me to be forward thinking regarding the best way to collect data for my project. This has truly saved me a significant amount of time and increased the project’s efficiency.

Outside of data collection, we have continued to engage as many stakeholders as we can to ensure the success of the project. Because our project was deemed high priority because of the high CAUTI rates at UCSD, we engaged higher-level hospital administrators who could be onboard with the project, as well as provide their own input to improve project’s effects. Separately, we have continued to collaborate directly with nursing and physician staff to not only share our ongoing project with them but also directly engage them in the project so we can better ensure that the project is not only theoretically palatable but will be realistically implemented as well.

A quality improvement project certainly presents its own unique set of challenges, but I am truly enjoying collaborating and troubleshooting in hopes of ultimately improving patient care.

Victor Ekuta is a third-year medical student at UC San Diego.

Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.

I am currently working with my mentor, Ian Jenkins, MD, an attending in the Division of Hospital Medicine at the University of California, San Diego, to begin preliminary data collection for our project to cut catheter-associated urinary tract infections (CAUTI). The project time line is on track, and we hope to have things up and running in the next month.

Up to this point, we have been working to identify the most relevant data to collect to best explore our outcome variable. A key goal for our project is to show that increased education measures can ultimately lead to reductions in patient harm. Rather than directly measuring harm reduction, we have settled on tracking the closely identified process measure of the number of inappropriate Foley catheters removed. This measure is potentially more accessible for health care providers than measuring CAUTI rates would be because individual CAUTI events are rare.

In addition to starting data collection, I am quickly learning that conducting a quality improvement project requires a large amount of upfront preparation. Namely, it requires not only identifying the outcome measures you would like to track but also prospectively strategizing about how to track this measure to facilitate future data presentation and publication. Dr. Jenkins has been instrumental as a resource for bouncing off various ideas regarding how to streamline data collection and presentation. He has also been valuable in helping me to identify appropriate units for data collection and teaching me to be forward thinking regarding the best way to collect data for my project. This has truly saved me a significant amount of time and increased the project’s efficiency.

Outside of data collection, we have continued to engage as many stakeholders as we can to ensure the success of the project. Because our project was deemed high priority because of the high CAUTI rates at UCSD, we engaged higher-level hospital administrators who could be onboard with the project, as well as provide their own input to improve project’s effects. Separately, we have continued to collaborate directly with nursing and physician staff to not only share our ongoing project with them but also directly engage them in the project so we can better ensure that the project is not only theoretically palatable but will be realistically implemented as well.

A quality improvement project certainly presents its own unique set of challenges, but I am truly enjoying collaborating and troubleshooting in hopes of ultimately improving patient care.

Victor Ekuta is a third-year medical student at UC San Diego.

Compared with conventional anticoagulants, both dabigatran and rivaroxaban conferred small but statistically significant increases in the risk of major gastrointestinal bleeding in a systematic review and meta-analysis of randomized trials reported in the November issue of Clinical Gastroenterology and Hepatology. (doi: 10.1016/j.cgh.2017.04.031)

But other novel oral anticoagulants (NOACs) showed no such effect compared with warfarin, aspirin, or placebo, reported Corey S. Miller, MD, of McGill University, Montreal, and his associates. “The potentially increased risk of GI bleeding associated with dabigatran and rivaroxaban observed in some of our subgroup analyses merits further consideration,” they wrote.

The NOACs (also known as non–vitamin K antagonist oral anticoagulants) help prevent stroke in patients with atrial fibrillation and prevent and treat venous thromboembolism. However, large AF trials have linked all except apixaban to an increased risk of major GI bleeding compared with warfarin. Dabigatran currently is the only NOAC with an approved reversal agent, “making the question of GI bleeding risk even more consequential,” the authors wrote.

They searched the MEDLINE, EMBASE, Cochrane, and ISI Web of Knowledge databases for reports of randomized trials of NOACs for approved indications published between 1980 and January 2016, which identified 43 trials of 166,289 patients. Most used warfarin as the comparator, but one study compared apixaban with aspirin and six studies compared apixaban, rivaroxaban, or dabigatran with placebo. Fifteen trials failed to specify bleeding sources and therefore could not be evaluated for the primary endpoint, the reviewers noted.

In the remaining 28 trials, 1.5% of NOAC recipients developed major GI bleeding, compared with 1.3% of recipients of conventional anticoagulants (odds ratio, 0.98; 95% confidence interval, 0.80-1.21). Five trials of dabigatran showed a 2% risk of major GI bleeding, compared with 1.4% with conventional anticoagulation, a slight but significant increase (OR, 1.27; 95% CI, 1.04-1.55). Eight trials of rivaroxaban showed a similar trend (bleeding risk, 1.7% vs. 1.3%; OR, 1.40; 95% CI, 1.15-1.70). In contrast, subgroup analyses of apixaban and edoxaban found no difference in risk of major GI bleeding versus conventional treatment.

Subgroup analyses by region found no differences except in Asia, where NOACs were associated with a significantly lower odds of major GI bleeding (0.5% and 1.2%, respectively; OR, 0.45; 95% CI, 0.22-0.91).

Most studies did not report minor or nonsevere bleeds or specify bleeding location within the GI tract, the reviewers noted. Given those caveats, NOACs and conventional anticoagulants conferred similar risks of clinically relevant nonmajor bleeding (0.6% and 0.6%, respectively), upper GI bleeding (1.5% and 1.6%), and lower GI bleeding (1.0% and 1.0%).

A post hoc analysis using a random-effects model found no significant difference in risk of major GI bleeding between either rivaroxaban or dabigatran and conventional therapy, the reviewers said. In addition, the increased risk of bleeding with dabigatran was confined to the RELY and ROCKET trials of AF, both of which exposed patients to longer treatment periods. Dabigatran is coated with tartaric acid, which might have a “direct caustic effect on the intestinal lumen,” they wrote. Also, NOACs are incompletely absorbed across the GI mucosa and therefore have some anticoagulant activity in the GI lumen, unlike warfarin or parenteral anticoagulants.

The reviewers disclosed no funding sources. Dr. Miller and another author reported having no conflicts of interest. One author received research grants and speaker honoraria from Boehringer Ingelheim Canada, Bayer Canada, Daiichi Sankyo, Bristol Myers Squibb, and Pfizer Canada; another author disclosed serving as a consultant to Pendopharm, Boston Scientific, and Cook.
 

Compared with conventional anticoagulants, both dabigatran and rivaroxaban conferred small but statistically significant increases in the risk of major gastrointestinal bleeding in a systematic review and meta-analysis of randomized trials reported in the November issue of Clinical Gastroenterology and Hepatology. (doi: 10.1016/j.cgh.2017.04.031)

But other novel oral anticoagulants (NOACs) showed no such effect compared with warfarin, aspirin, or placebo, reported Corey S. Miller, MD, of McGill University, Montreal, and his associates. “The potentially increased risk of GI bleeding associated with dabigatran and rivaroxaban observed in some of our subgroup analyses merits further consideration,” they wrote.

The NOACs (also known as non–vitamin K antagonist oral anticoagulants) help prevent stroke in patients with atrial fibrillation and prevent and treat venous thromboembolism. However, large AF trials have linked all except apixaban to an increased risk of major GI bleeding compared with warfarin. Dabigatran currently is the only NOAC with an approved reversal agent, “making the question of GI bleeding risk even more consequential,” the authors wrote.

They searched the MEDLINE, EMBASE, Cochrane, and ISI Web of Knowledge databases for reports of randomized trials of NOACs for approved indications published between 1980 and January 2016, which identified 43 trials of 166,289 patients. Most used warfarin as the comparator, but one study compared apixaban with aspirin and six studies compared apixaban, rivaroxaban, or dabigatran with placebo. Fifteen trials failed to specify bleeding sources and therefore could not be evaluated for the primary endpoint, the reviewers noted.

In the remaining 28 trials, 1.5% of NOAC recipients developed major GI bleeding, compared with 1.3% of recipients of conventional anticoagulants (odds ratio, 0.98; 95% confidence interval, 0.80-1.21). Five trials of dabigatran showed a 2% risk of major GI bleeding, compared with 1.4% with conventional anticoagulation, a slight but significant increase (OR, 1.27; 95% CI, 1.04-1.55). Eight trials of rivaroxaban showed a similar trend (bleeding risk, 1.7% vs. 1.3%; OR, 1.40; 95% CI, 1.15-1.70). In contrast, subgroup analyses of apixaban and edoxaban found no difference in risk of major GI bleeding versus conventional treatment.

Subgroup analyses by region found no differences except in Asia, where NOACs were associated with a significantly lower odds of major GI bleeding (0.5% and 1.2%, respectively; OR, 0.45; 95% CI, 0.22-0.91).

Most studies did not report minor or nonsevere bleeds or specify bleeding location within the GI tract, the reviewers noted. Given those caveats, NOACs and conventional anticoagulants conferred similar risks of clinically relevant nonmajor bleeding (0.6% and 0.6%, respectively), upper GI bleeding (1.5% and 1.6%), and lower GI bleeding (1.0% and 1.0%).

A post hoc analysis using a random-effects model found no significant difference in risk of major GI bleeding between either rivaroxaban or dabigatran and conventional therapy, the reviewers said. In addition, the increased risk of bleeding with dabigatran was confined to the RELY and ROCKET trials of AF, both of which exposed patients to longer treatment periods. Dabigatran is coated with tartaric acid, which might have a “direct caustic effect on the intestinal lumen,” they wrote. Also, NOACs are incompletely absorbed across the GI mucosa and therefore have some anticoagulant activity in the GI lumen, unlike warfarin or parenteral anticoagulants.

The reviewers disclosed no funding sources. Dr. Miller and another author reported having no conflicts of interest. One author received research grants and speaker honoraria from Boehringer Ingelheim Canada, Bayer Canada, Daiichi Sankyo, Bristol Myers Squibb, and Pfizer Canada; another author disclosed serving as a consultant to Pendopharm, Boston Scientific, and Cook.
 

Compared with conventional anticoagulants, both dabigatran and rivaroxaban conferred small but statistically significant increases in the risk of major gastrointestinal bleeding in a systematic review and meta-analysis of randomized trials reported in the November issue of Clinical Gastroenterology and Hepatology. (doi: 10.1016/j.cgh.2017.04.031)

But other novel oral anticoagulants (NOACs) showed no such effect compared with warfarin, aspirin, or placebo, reported Corey S. Miller, MD, of McGill University, Montreal, and his associates. “The potentially increased risk of GI bleeding associated with dabigatran and rivaroxaban observed in some of our subgroup analyses merits further consideration,” they wrote.

The NOACs (also known as non–vitamin K antagonist oral anticoagulants) help prevent stroke in patients with atrial fibrillation and prevent and treat venous thromboembolism. However, large AF trials have linked all except apixaban to an increased risk of major GI bleeding compared with warfarin. Dabigatran currently is the only NOAC with an approved reversal agent, “making the question of GI bleeding risk even more consequential,” the authors wrote.

They searched the MEDLINE, EMBASE, Cochrane, and ISI Web of Knowledge databases for reports of randomized trials of NOACs for approved indications published between 1980 and January 2016, which identified 43 trials of 166,289 patients. Most used warfarin as the comparator, but one study compared apixaban with aspirin and six studies compared apixaban, rivaroxaban, or dabigatran with placebo. Fifteen trials failed to specify bleeding sources and therefore could not be evaluated for the primary endpoint, the reviewers noted.

In the remaining 28 trials, 1.5% of NOAC recipients developed major GI bleeding, compared with 1.3% of recipients of conventional anticoagulants (odds ratio, 0.98; 95% confidence interval, 0.80-1.21). Five trials of dabigatran showed a 2% risk of major GI bleeding, compared with 1.4% with conventional anticoagulation, a slight but significant increase (OR, 1.27; 95% CI, 1.04-1.55). Eight trials of rivaroxaban showed a similar trend (bleeding risk, 1.7% vs. 1.3%; OR, 1.40; 95% CI, 1.15-1.70). In contrast, subgroup analyses of apixaban and edoxaban found no difference in risk of major GI bleeding versus conventional treatment.

Subgroup analyses by region found no differences except in Asia, where NOACs were associated with a significantly lower odds of major GI bleeding (0.5% and 1.2%, respectively; OR, 0.45; 95% CI, 0.22-0.91).

Most studies did not report minor or nonsevere bleeds or specify bleeding location within the GI tract, the reviewers noted. Given those caveats, NOACs and conventional anticoagulants conferred similar risks of clinically relevant nonmajor bleeding (0.6% and 0.6%, respectively), upper GI bleeding (1.5% and 1.6%), and lower GI bleeding (1.0% and 1.0%).

A post hoc analysis using a random-effects model found no significant difference in risk of major GI bleeding between either rivaroxaban or dabigatran and conventional therapy, the reviewers said. In addition, the increased risk of bleeding with dabigatran was confined to the RELY and ROCKET trials of AF, both of which exposed patients to longer treatment periods. Dabigatran is coated with tartaric acid, which might have a “direct caustic effect on the intestinal lumen,” they wrote. Also, NOACs are incompletely absorbed across the GI mucosa and therefore have some anticoagulant activity in the GI lumen, unlike warfarin or parenteral anticoagulants.

The reviewers disclosed no funding sources. Dr. Miller and another author reported having no conflicts of interest. One author received research grants and speaker honoraria from Boehringer Ingelheim Canada, Bayer Canada, Daiichi Sankyo, Bristol Myers Squibb, and Pfizer Canada; another author disclosed serving as a consultant to Pendopharm, Boston Scientific, and Cook.
 

Measuring hospital-acquired infection in a new way

Every day, hospitalists struggle with health care–associated infections, which 1 in 25 patients experiences, according to the Centers for Disease Control and Prevention.

These infections are often discussed in terms of the standardized infection ratio (SIR), but that measure may not assess overall performance, according to a study suggesting a new measure that could help large hospital systems better evaluate their infection outcomes by comparing them with those of their peers.

References

1. Centers for Disease Control and Prevention. Healthcare-associated infections. https://www.cdc.gov/hai/surveillance/. Accessed April 10, 2017.

2. Fakih MG, Skierczynski B, Bufalino A, et al. Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts. American Journal of Infection Control. (2016);44(12):1578-81.

Hospitalists lead in palliative care

According to a recent report, hospitalists made nearly half (48%) of all palliative care referrals in hospitals in 2015. The report comes from the Center to Advance Palliative Care and the National Palliative Care Research Center.

“The most important finding from this analysis is the near doubling of the number of people receiving palliative care services in U.S. hospital palliative care programs, from an average of 2.7% in 2009 to an average of 4.8% in 2015,” said Diane Meier, MD, director of the Center to Advance Palliative Care. “This suggests increasing recognition of the benefits of palliative care by health professionals and greater likelihood that those living with serious illness will receive state-of-the-art care.”

The report shows that hospitalists are the No. 1 source of referral to palliative care teams. “They see up close the suffering of their patients and families, their need for comprehensive whole-person care, and the beneficial impact of the added layer of support that palliative care provides,” she said.

“Hospitalists should work alongside their palliative care colleagues to develop standardized screening tools so that all patients and families who could benefit have access to the best quality of care during serious and complex illness,” Dr. Meier said. Hospitalists can also gain skills in communicating about prognosis and conducting family meetings, as well as safe and effective symptom management, through the online clinical training curriculum available at capc.org.
 

Reference

1. National Palliative Care Registry. How We Work: Trends and Insights in Hospital Palliative Care. https://registry.capc.org/wp-content/uploads/2017/02/How-We-Work-Trends-and-Insights-in-Hospital-Palliative-Care-2009-2015.pdf. Accessed April 7, 2017.

Improving outcomes for children with chronic conditions

Cincinnati Children’s Hospital Medical Center improved outcomes for 50% of pediatric patients by redesigning the way it cares for children with active chronic conditions, according to a new study.

The hospital implemented a Condition Outcomes Improvement Initiative, in which specialized clinical teams applied quality improvement principles to improve outcomes for pediatric patients with chronic illnesses.

Each improvement team focused on a specific chronic condition, such as juvenile arthritis, asthma, chronic kidney disease, or sickle cell disease. The improvement processes implemented included reviewing evidence to choose which outcomes to measure, developing condition-specific patient registries and data collection tools, classifying patients into defined risk groups, planning care before and after visits, and providing self-management and caregiver/parent support for patients and their families.

Study lead author Jennifer Lail, MD, FAAP, analyzed data from more than 27,000 pediatric patients from 18 improvement teams. Following implementation of the changes, half of patients had an improved outcome, and 11 of the 18 chronic condition teams achieved the goal of 20% improvement in their chosen clinical outcome, suggesting that clinical teams implementing quality improvement methods with multidisciplinary support can improve outcomes for populations with chronic conditions.
 

Reference

1. Lail J, et al. Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center. Joint Commission Journal on Quality and Patient Safety. 2017;43(3):101-112.

FDA approves two new antibiotic tests

Hospitalists have two new FDA-approved tools available to help them make antibiotic treatment decisions.

The first is the expanded use of the Vidas Brahms PCT Assay, intended to be used in the hospital or emergency room. The test uses – for the first time – procalcitonin (PCT), a protein associated with the body’s response to a bacterial infection, as a biomarker that can help hospitalists make antibiotic management decisions in patients with those conditions. The results can help them determine if antibiotic treatment should be started or stopped in patients with lower respiratory tract infections (such as community-acquired pneumonia) and stopped in patients with sepsis.

The FDA has also allowed marketing of the PhenoTest BC Kit. This one is another first, the first test to identify organisms causing bloodstream infections and provide information about the antibiotics to which the organism is likely to respond.

The test can identify bacteria or yeast from a positive blood culture in approximately 1.5 hours (compared with traditional identification and antibiotic susceptibility tests, which can take one to two days). The test can identify 14 different species of bacteria and two species of yeast that cause bloodstream infections. It also provides antibiotic sensitivity information on 18 antibiotics. In addition, the test will identify the presence of two indicators of antibiotic resistance.
 

Quick byte

About a third of adverse events during hospitalizations involve a drug-related harm, resulting in longer hospital stays and increased costs, according to the New York Times. “The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.”

Reference

1 Frakt A. How Many Pills Are Too Many? The New York Times. 2017 Apr 10. https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health&region=stream&module=stream_unit&version=latest&contentPlacement=6&pgtype=sectionfront&_r=0. Accessed April 9, 2017.

Measuring hospital-acquired infection in a new way

Every day, hospitalists struggle with health care–associated infections, which 1 in 25 patients experiences, according to the Centers for Disease Control and Prevention.

These infections are often discussed in terms of the standardized infection ratio (SIR), but that measure may not assess overall performance, according to a study suggesting a new measure that could help large hospital systems better evaluate their infection outcomes by comparing them with those of their peers.

References

1. Centers for Disease Control and Prevention. Healthcare-associated infections. https://www.cdc.gov/hai/surveillance/. Accessed April 10, 2017.

2. Fakih MG, Skierczynski B, Bufalino A, et al. Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts. American Journal of Infection Control. (2016);44(12):1578-81.

Hospitalists lead in palliative care

According to a recent report, hospitalists made nearly half (48%) of all palliative care referrals in hospitals in 2015. The report comes from the Center to Advance Palliative Care and the National Palliative Care Research Center.

“The most important finding from this analysis is the near doubling of the number of people receiving palliative care services in U.S. hospital palliative care programs, from an average of 2.7% in 2009 to an average of 4.8% in 2015,” said Diane Meier, MD, director of the Center to Advance Palliative Care. “This suggests increasing recognition of the benefits of palliative care by health professionals and greater likelihood that those living with serious illness will receive state-of-the-art care.”

The report shows that hospitalists are the No. 1 source of referral to palliative care teams. “They see up close the suffering of their patients and families, their need for comprehensive whole-person care, and the beneficial impact of the added layer of support that palliative care provides,” she said.

“Hospitalists should work alongside their palliative care colleagues to develop standardized screening tools so that all patients and families who could benefit have access to the best quality of care during serious and complex illness,” Dr. Meier said. Hospitalists can also gain skills in communicating about prognosis and conducting family meetings, as well as safe and effective symptom management, through the online clinical training curriculum available at capc.org.
 

Reference

1. National Palliative Care Registry. How We Work: Trends and Insights in Hospital Palliative Care. https://registry.capc.org/wp-content/uploads/2017/02/How-We-Work-Trends-and-Insights-in-Hospital-Palliative-Care-2009-2015.pdf. Accessed April 7, 2017.

Improving outcomes for children with chronic conditions

Cincinnati Children’s Hospital Medical Center improved outcomes for 50% of pediatric patients by redesigning the way it cares for children with active chronic conditions, according to a new study.

The hospital implemented a Condition Outcomes Improvement Initiative, in which specialized clinical teams applied quality improvement principles to improve outcomes for pediatric patients with chronic illnesses.

Each improvement team focused on a specific chronic condition, such as juvenile arthritis, asthma, chronic kidney disease, or sickle cell disease. The improvement processes implemented included reviewing evidence to choose which outcomes to measure, developing condition-specific patient registries and data collection tools, classifying patients into defined risk groups, planning care before and after visits, and providing self-management and caregiver/parent support for patients and their families.

Study lead author Jennifer Lail, MD, FAAP, analyzed data from more than 27,000 pediatric patients from 18 improvement teams. Following implementation of the changes, half of patients had an improved outcome, and 11 of the 18 chronic condition teams achieved the goal of 20% improvement in their chosen clinical outcome, suggesting that clinical teams implementing quality improvement methods with multidisciplinary support can improve outcomes for populations with chronic conditions.
 

Reference

1. Lail J, et al. Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center. Joint Commission Journal on Quality and Patient Safety. 2017;43(3):101-112.

FDA approves two new antibiotic tests

Hospitalists have two new FDA-approved tools available to help them make antibiotic treatment decisions.

The first is the expanded use of the Vidas Brahms PCT Assay, intended to be used in the hospital or emergency room. The test uses – for the first time – procalcitonin (PCT), a protein associated with the body’s response to a bacterial infection, as a biomarker that can help hospitalists make antibiotic management decisions in patients with those conditions. The results can help them determine if antibiotic treatment should be started or stopped in patients with lower respiratory tract infections (such as community-acquired pneumonia) and stopped in patients with sepsis.

The FDA has also allowed marketing of the PhenoTest BC Kit. This one is another first, the first test to identify organisms causing bloodstream infections and provide information about the antibiotics to which the organism is likely to respond.

The test can identify bacteria or yeast from a positive blood culture in approximately 1.5 hours (compared with traditional identification and antibiotic susceptibility tests, which can take one to two days). The test can identify 14 different species of bacteria and two species of yeast that cause bloodstream infections. It also provides antibiotic sensitivity information on 18 antibiotics. In addition, the test will identify the presence of two indicators of antibiotic resistance.
 

Quick byte

About a third of adverse events during hospitalizations involve a drug-related harm, resulting in longer hospital stays and increased costs, according to the New York Times. “The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.”

Reference

1 Frakt A. How Many Pills Are Too Many? The New York Times. 2017 Apr 10. https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health&region=stream&module=stream_unit&version=latest&contentPlacement=6&pgtype=sectionfront&_r=0. Accessed April 9, 2017.

Measuring hospital-acquired infection in a new way

Every day, hospitalists struggle with health care–associated infections, which 1 in 25 patients experiences, according to the Centers for Disease Control and Prevention.

These infections are often discussed in terms of the standardized infection ratio (SIR), but that measure may not assess overall performance, according to a study suggesting a new measure that could help large hospital systems better evaluate their infection outcomes by comparing them with those of their peers.

References

1. Centers for Disease Control and Prevention. Healthcare-associated infections. https://www.cdc.gov/hai/surveillance/. Accessed April 10, 2017.

2. Fakih MG, Skierczynski B, Bufalino A, et al. Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts. American Journal of Infection Control. (2016);44(12):1578-81.

Hospitalists lead in palliative care

According to a recent report, hospitalists made nearly half (48%) of all palliative care referrals in hospitals in 2015. The report comes from the Center to Advance Palliative Care and the National Palliative Care Research Center.

“The most important finding from this analysis is the near doubling of the number of people receiving palliative care services in U.S. hospital palliative care programs, from an average of 2.7% in 2009 to an average of 4.8% in 2015,” said Diane Meier, MD, director of the Center to Advance Palliative Care. “This suggests increasing recognition of the benefits of palliative care by health professionals and greater likelihood that those living with serious illness will receive state-of-the-art care.”

The report shows that hospitalists are the No. 1 source of referral to palliative care teams. “They see up close the suffering of their patients and families, their need for comprehensive whole-person care, and the beneficial impact of the added layer of support that palliative care provides,” she said.

“Hospitalists should work alongside their palliative care colleagues to develop standardized screening tools so that all patients and families who could benefit have access to the best quality of care during serious and complex illness,” Dr. Meier said. Hospitalists can also gain skills in communicating about prognosis and conducting family meetings, as well as safe and effective symptom management, through the online clinical training curriculum available at capc.org.
 

Reference

1. National Palliative Care Registry. How We Work: Trends and Insights in Hospital Palliative Care. https://registry.capc.org/wp-content/uploads/2017/02/How-We-Work-Trends-and-Insights-in-Hospital-Palliative-Care-2009-2015.pdf. Accessed April 7, 2017.

Improving outcomes for children with chronic conditions

Cincinnati Children’s Hospital Medical Center improved outcomes for 50% of pediatric patients by redesigning the way it cares for children with active chronic conditions, according to a new study.

The hospital implemented a Condition Outcomes Improvement Initiative, in which specialized clinical teams applied quality improvement principles to improve outcomes for pediatric patients with chronic illnesses.

Each improvement team focused on a specific chronic condition, such as juvenile arthritis, asthma, chronic kidney disease, or sickle cell disease. The improvement processes implemented included reviewing evidence to choose which outcomes to measure, developing condition-specific patient registries and data collection tools, classifying patients into defined risk groups, planning care before and after visits, and providing self-management and caregiver/parent support for patients and their families.

Study lead author Jennifer Lail, MD, FAAP, analyzed data from more than 27,000 pediatric patients from 18 improvement teams. Following implementation of the changes, half of patients had an improved outcome, and 11 of the 18 chronic condition teams achieved the goal of 20% improvement in their chosen clinical outcome, suggesting that clinical teams implementing quality improvement methods with multidisciplinary support can improve outcomes for populations with chronic conditions.
 

Reference

1. Lail J, et al. Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center. Joint Commission Journal on Quality and Patient Safety. 2017;43(3):101-112.

FDA approves two new antibiotic tests

Hospitalists have two new FDA-approved tools available to help them make antibiotic treatment decisions.

The first is the expanded use of the Vidas Brahms PCT Assay, intended to be used in the hospital or emergency room. The test uses – for the first time – procalcitonin (PCT), a protein associated with the body’s response to a bacterial infection, as a biomarker that can help hospitalists make antibiotic management decisions in patients with those conditions. The results can help them determine if antibiotic treatment should be started or stopped in patients with lower respiratory tract infections (such as community-acquired pneumonia) and stopped in patients with sepsis.

The FDA has also allowed marketing of the PhenoTest BC Kit. This one is another first, the first test to identify organisms causing bloodstream infections and provide information about the antibiotics to which the organism is likely to respond.

The test can identify bacteria or yeast from a positive blood culture in approximately 1.5 hours (compared with traditional identification and antibiotic susceptibility tests, which can take one to two days). The test can identify 14 different species of bacteria and two species of yeast that cause bloodstream infections. It also provides antibiotic sensitivity information on 18 antibiotics. In addition, the test will identify the presence of two indicators of antibiotic resistance.
 

Quick byte

About a third of adverse events during hospitalizations involve a drug-related harm, resulting in longer hospital stays and increased costs, according to the New York Times. “The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.”

Reference

1 Frakt A. How Many Pills Are Too Many? The New York Times. 2017 Apr 10. https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health&region=stream&module=stream_unit&version=latest&contentPlacement=6&pgtype=sectionfront&_r=0. Accessed April 9, 2017.

Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.

Since finishing up the initial planning phase of our project, my mentors and I have continued with even more planning as we head into the fall. Coming up with a good plan is the first step in making sure everything goes smoothly later on in a project. The same goes for coming up with a well-thought-out discharge plan when sending a patient to the next level of care.

Monisha Bhatia, a native of Nashville, Tenn., is a fourth-year medical student at Vanderbilt University in Nashville. She is hoping to pursue either a residency in internal medicine or a combined internal medicine/emergency medicine program. Prior to medical school, she completed a JD/MPH program at Boston University, and she hopes to use her legal training in working with regulatory authorities to improve access to health care for all Americans.

Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.

Since finishing up the initial planning phase of our project, my mentors and I have continued with even more planning as we head into the fall. Coming up with a good plan is the first step in making sure everything goes smoothly later on in a project. The same goes for coming up with a well-thought-out discharge plan when sending a patient to the next level of care.

Monisha Bhatia, a native of Nashville, Tenn., is a fourth-year medical student at Vanderbilt University in Nashville. She is hoping to pursue either a residency in internal medicine or a combined internal medicine/emergency medicine program. Prior to medical school, she completed a JD/MPH program at Boston University, and she hopes to use her legal training in working with regulatory authorities to improve access to health care for all Americans.

Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.

Since finishing up the initial planning phase of our project, my mentors and I have continued with even more planning as we head into the fall. Coming up with a good plan is the first step in making sure everything goes smoothly later on in a project. The same goes for coming up with a well-thought-out discharge plan when sending a patient to the next level of care.

Monisha Bhatia, a native of Nashville, Tenn., is a fourth-year medical student at Vanderbilt University in Nashville. She is hoping to pursue either a residency in internal medicine or a combined internal medicine/emergency medicine program. Prior to medical school, she completed a JD/MPH program at Boston University, and she hopes to use her legal training in working with regulatory authorities to improve access to health care for all Americans.

Clinical question: Should patients with liver cirrhosis with portal vein thrombosis be treated with anticoagulation?

Background: Portal vein thrombosis occurs in about 20% of patients with liver cirrhosis. Previously these patients were not often treated with anticoagulation due to concern for increased bleeding risk associated with advanced liver disease. However, restoring portal vein patency may prevent further sequelae, including intestinal infarction and portal hypertension and may also affect candidacy for liver transplantation.

Clinical question: Should patients with liver cirrhosis with portal vein thrombosis be treated with anticoagulation?

Background: Portal vein thrombosis occurs in about 20% of patients with liver cirrhosis. Previously these patients were not often treated with anticoagulation due to concern for increased bleeding risk associated with advanced liver disease. However, restoring portal vein patency may prevent further sequelae, including intestinal infarction and portal hypertension and may also affect candidacy for liver transplantation.

Clinical question: Should patients with liver cirrhosis with portal vein thrombosis be treated with anticoagulation?

Background: Portal vein thrombosis occurs in about 20% of patients with liver cirrhosis. Previously these patients were not often treated with anticoagulation due to concern for increased bleeding risk associated with advanced liver disease. However, restoring portal vein patency may prevent further sequelae, including intestinal infarction and portal hypertension and may also affect candidacy for liver transplantation.

The Institute of Medicine, in its report “Hospital-Based Emergency Care – At the Breaking Point,” has identified Observation Units (OUs) as a “particularly promising” technique to improve patient flow.¹ Many hospitals across the country either already have them or are in the process of establishing such units.

Multiple studies have shown that a highly efficient OU can save billions in health care costs.² Historically, such units have existed within and are staffed by emergency departments. Since the implementation of the two-midnight rule in Oct. 2013, the complexities of observation care changed dramatically from run of the mill 30- to 40-year-old chest pain patients to 80- to 90-year-olds with multiple comorbidities being placed in observation.³ In many cases, this shifted the care out of the emergency department and into the arena of hospital medicine.

Dr. Nand is medical director, care management & observation unit, and associate program director, internal medicine residency program, at the University of Illinois College of Medicine/Advocate Christ Medical Center.

References

1. “Hospital-Based Emergency Care: At the Breaking Point” (Washington: National Academies Press, 2006) 2. Baugh, CJ et al. “Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year” Health Aff (Millwood). 2012 Oct;31(10):2314-23

3. Fact Sheet: Two-Midnight Rule. 2015. Available at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-01-2.html. Accessed March 29, 2016.

4. Society of Hospital Medicine. The observation unit white paper. http://www.hospitalmedicine.org, April 3, 2013.

5. Yousuf T. et al. “Intermediate chest pain protocol in an observation unit” Won first place award for innovation at the Midwest Regional SGIM conference, August 2015.

6. Sarfraz S et al. “Hand hygiene intervention increases compliance in observation unit” Poster: May 2016, Macy Midwest GME Conference, Michigan.

7. “Impact of syncope protocol in an observation unit of an academic tertiary care center” Poster for Oct 2016 AAIM skills development conference, National Harbor, Md.

8. Metgud S et al. “Integrating residents in providing high-value care via improved results of the ACGME annual resident survey” Poster: May 2016, Macy Midwest GME Conference, Michigan.

The Institute of Medicine, in its report “Hospital-Based Emergency Care – At the Breaking Point,” has identified Observation Units (OUs) as a “particularly promising” technique to improve patient flow.¹ Many hospitals across the country either already have them or are in the process of establishing such units.

Multiple studies have shown that a highly efficient OU can save billions in health care costs.² Historically, such units have existed within and are staffed by emergency departments. Since the implementation of the two-midnight rule in Oct. 2013, the complexities of observation care changed dramatically from run of the mill 30- to 40-year-old chest pain patients to 80- to 90-year-olds with multiple comorbidities being placed in observation.³ In many cases, this shifted the care out of the emergency department and into the arena of hospital medicine.

Dr. Nand is medical director, care management & observation unit, and associate program director, internal medicine residency program, at the University of Illinois College of Medicine/Advocate Christ Medical Center.

References

1. “Hospital-Based Emergency Care: At the Breaking Point” (Washington: National Academies Press, 2006) 2. Baugh, CJ et al. “Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year” Health Aff (Millwood). 2012 Oct;31(10):2314-23

3. Fact Sheet: Two-Midnight Rule. 2015. Available at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-01-2.html. Accessed March 29, 2016.

4. Society of Hospital Medicine. The observation unit white paper. http://www.hospitalmedicine.org, April 3, 2013.

5. Yousuf T. et al. “Intermediate chest pain protocol in an observation unit” Won first place award for innovation at the Midwest Regional SGIM conference, August 2015.

6. Sarfraz S et al. “Hand hygiene intervention increases compliance in observation unit” Poster: May 2016, Macy Midwest GME Conference, Michigan.

7. “Impact of syncope protocol in an observation unit of an academic tertiary care center” Poster for Oct 2016 AAIM skills development conference, National Harbor, Md.

8. Metgud S et al. “Integrating residents in providing high-value care via improved results of the ACGME annual resident survey” Poster: May 2016, Macy Midwest GME Conference, Michigan.

The Institute of Medicine, in its report “Hospital-Based Emergency Care – At the Breaking Point,” has identified Observation Units (OUs) as a “particularly promising” technique to improve patient flow.¹ Many hospitals across the country either already have them or are in the process of establishing such units.

Multiple studies have shown that a highly efficient OU can save billions in health care costs.² Historically, such units have existed within and are staffed by emergency departments. Since the implementation of the two-midnight rule in Oct. 2013, the complexities of observation care changed dramatically from run of the mill 30- to 40-year-old chest pain patients to 80- to 90-year-olds with multiple comorbidities being placed in observation.³ In many cases, this shifted the care out of the emergency department and into the arena of hospital medicine.

Dr. Nand is medical director, care management & observation unit, and associate program director, internal medicine residency program, at the University of Illinois College of Medicine/Advocate Christ Medical Center.

References

1. “Hospital-Based Emergency Care: At the Breaking Point” (Washington: National Academies Press, 2006) 2. Baugh, CJ et al. “Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year” Health Aff (Millwood). 2012 Oct;31(10):2314-23

3. Fact Sheet: Two-Midnight Rule. 2015. Available at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-01-2.html. Accessed March 29, 2016.

4. Society of Hospital Medicine. The observation unit white paper. http://www.hospitalmedicine.org, April 3, 2013.

5. Yousuf T. et al. “Intermediate chest pain protocol in an observation unit” Won first place award for innovation at the Midwest Regional SGIM conference, August 2015.

6. Sarfraz S et al. “Hand hygiene intervention increases compliance in observation unit” Poster: May 2016, Macy Midwest GME Conference, Michigan.

7. “Impact of syncope protocol in an observation unit of an academic tertiary care center” Poster for Oct 2016 AAIM skills development conference, National Harbor, Md.

8. Metgud S et al. “Integrating residents in providing high-value care via improved results of the ACGME annual resident survey” Poster: May 2016, Macy Midwest GME Conference, Michigan.

Clinical question: When should you start enteral feedings in patients with acute pancreatitis?

Background: Oral intake stimulates pancreatic exocrine activity and therefore bowel rest has been one of the mainstays of acute pancreatitis treatment. However, some studies suggest that enteral nutrition may reduce the risk of infection by supporting the gut’s protective barrier limiting bacterial translocation and sepsis. Studies thus far comparing early versus delayed enteral nutrition in acute pancreatitis have been conflicting.

The authors found and analyzed 11 randomized trials comprising 948 patients in which early and delayed feeding strategies were compared. Their review suggests that early feeding in patients with acute pancreatitis is not associated with increased adverse events and may reduce length of hospital stay. Their analysis was limited by markedly different feeding protocols that precluded performing a meta-analysis. Their analysis was also limited by including studies that had high risk or unclear risk of bias and by the small size of most trials limiting power to detect differences in outcome.

Bottom line: Optimal route and timing of nutrition in patients with acute pancreatitis remains unsettled.

Citation: Vaughn VM, Shuster D, Rogers MAM, et al. Early versus delayed feeding in patients with acute pancreatitis: a systematic review. Ann Intern Med. 2017;166(12):883-92.
 

Dr. Teixeira is a hospitalist at Ochsner Health System, New Orleans.

Clinical question: When should you start enteral feedings in patients with acute pancreatitis?

Background: Oral intake stimulates pancreatic exocrine activity and therefore bowel rest has been one of the mainstays of acute pancreatitis treatment. However, some studies suggest that enteral nutrition may reduce the risk of infection by supporting the gut’s protective barrier limiting bacterial translocation and sepsis. Studies thus far comparing early versus delayed enteral nutrition in acute pancreatitis have been conflicting.

The authors found and analyzed 11 randomized trials comprising 948 patients in which early and delayed feeding strategies were compared. Their review suggests that early feeding in patients with acute pancreatitis is not associated with increased adverse events and may reduce length of hospital stay. Their analysis was limited by markedly different feeding protocols that precluded performing a meta-analysis. Their analysis was also limited by including studies that had high risk or unclear risk of bias and by the small size of most trials limiting power to detect differences in outcome.

Bottom line: Optimal route and timing of nutrition in patients with acute pancreatitis remains unsettled.

Citation: Vaughn VM, Shuster D, Rogers MAM, et al. Early versus delayed feeding in patients with acute pancreatitis: a systematic review. Ann Intern Med. 2017;166(12):883-92.
 

Dr. Teixeira is a hospitalist at Ochsner Health System, New Orleans.

Clinical question: When should you start enteral feedings in patients with acute pancreatitis?

Background: Oral intake stimulates pancreatic exocrine activity and therefore bowel rest has been one of the mainstays of acute pancreatitis treatment. However, some studies suggest that enteral nutrition may reduce the risk of infection by supporting the gut’s protective barrier limiting bacterial translocation and sepsis. Studies thus far comparing early versus delayed enteral nutrition in acute pancreatitis have been conflicting.

The authors found and analyzed 11 randomized trials comprising 948 patients in which early and delayed feeding strategies were compared. Their review suggests that early feeding in patients with acute pancreatitis is not associated with increased adverse events and may reduce length of hospital stay. Their analysis was limited by markedly different feeding protocols that precluded performing a meta-analysis. Their analysis was also limited by including studies that had high risk or unclear risk of bias and by the small size of most trials limiting power to detect differences in outcome.

Bottom line: Optimal route and timing of nutrition in patients with acute pancreatitis remains unsettled.

Citation: Vaughn VM, Shuster D, Rogers MAM, et al. Early versus delayed feeding in patients with acute pancreatitis: a systematic review. Ann Intern Med. 2017;166(12):883-92.
 

Dr. Teixeira is a hospitalist at Ochsner Health System, New Orleans.

Editor’s note: “Everything We Say and Do” provides readers with thoughtful and actionable communication tactics that can positively impact patients’ experience of care. In the next series of columns, physicians will share how their experiences as patients have shaped their professional approach.

In May 2007, I received my acceptance letter for medical school. One month later, I was diagnosed with cancer.

The clinic visit was only supposed to be a routine postoperative follow-up after a simple cyst resection. I really hoped that my doctor was mistaken as he walked me through what to expect, and when he was finished, the desperate look in my eyes demanded answers.

What I say and do

I employ active listening and practice patience, especially when it comes to family members.

As both a cancer survivor and a physician, I am able to integrate empathy and diligence by putting myself in my patients’ shoes. My experience in a hospital bed during medical school granted me an extremely intriguing perspective towards medicine.
 

Why I do it

When I was a patient, the most crucial thing to my family was information. Most physicians did not take the time to explain my course of care, which elevated my family’s angst and anxiety. The experience taught me the importance of patience and communication.

But there were good examples. I still remember the physician who comforted my mother and assuaged her concerns. She held my mother’s hand and showed empathy. When my mother cried, she cried. That physician taught me that it was acceptable for physicians to express emotions.

When my surgeon rounded on me in the morning after my procedure, she was not wearing a white coat, which made her appear relatable. Her contagious confidence and humble demeanor were endorsement enough for her capabilities, showing me that a physician’s persona supersedes the conventional coat.
 

How I do it

I try to put myself in my patients’ shoes. I rejoice with them. I mourn with them. My uninhibited display of emotions affirms empathy. I dissolve all barriers by not wearing a white coat and ask my patients for a partnership. After all, I once walked miles in those shoes.

Dr. Sharma is a chief hospitalist for Sound Physicians at the Sierra Campus of The Hospitals of Providence, El Paso, Texas. She is a columnist for the El Paso Times and the medical contributor for KVIA Channel 7 ABC News. Her work has appeared on kevinmd.com, Thrive Global, and in El Paso magazine.

Editor’s note: “Everything We Say and Do” provides readers with thoughtful and actionable communication tactics that can positively impact patients’ experience of care. In the next series of columns, physicians will share how their experiences as patients have shaped their professional approach.

In May 2007, I received my acceptance letter for medical school. One month later, I was diagnosed with cancer.

The clinic visit was only supposed to be a routine postoperative follow-up after a simple cyst resection. I really hoped that my doctor was mistaken as he walked me through what to expect, and when he was finished, the desperate look in my eyes demanded answers.

What I say and do

I employ active listening and practice patience, especially when it comes to family members.

As both a cancer survivor and a physician, I am able to integrate empathy and diligence by putting myself in my patients’ shoes. My experience in a hospital bed during medical school granted me an extremely intriguing perspective towards medicine.
 

Why I do it

When I was a patient, the most crucial thing to my family was information. Most physicians did not take the time to explain my course of care, which elevated my family’s angst and anxiety. The experience taught me the importance of patience and communication.

But there were good examples. I still remember the physician who comforted my mother and assuaged her concerns. She held my mother’s hand and showed empathy. When my mother cried, she cried. That physician taught me that it was acceptable for physicians to express emotions.

When my surgeon rounded on me in the morning after my procedure, she was not wearing a white coat, which made her appear relatable. Her contagious confidence and humble demeanor were endorsement enough for her capabilities, showing me that a physician’s persona supersedes the conventional coat.
 

How I do it

I try to put myself in my patients’ shoes. I rejoice with them. I mourn with them. My uninhibited display of emotions affirms empathy. I dissolve all barriers by not wearing a white coat and ask my patients for a partnership. After all, I once walked miles in those shoes.

Dr. Sharma is a chief hospitalist for Sound Physicians at the Sierra Campus of The Hospitals of Providence, El Paso, Texas. She is a columnist for the El Paso Times and the medical contributor for KVIA Channel 7 ABC News. Her work has appeared on kevinmd.com, Thrive Global, and in El Paso magazine.

Editor’s note: “Everything We Say and Do” provides readers with thoughtful and actionable communication tactics that can positively impact patients’ experience of care. In the next series of columns, physicians will share how their experiences as patients have shaped their professional approach.

In May 2007, I received my acceptance letter for medical school. One month later, I was diagnosed with cancer.

The clinic visit was only supposed to be a routine postoperative follow-up after a simple cyst resection. I really hoped that my doctor was mistaken as he walked me through what to expect, and when he was finished, the desperate look in my eyes demanded answers.

What I say and do

I employ active listening and practice patience, especially when it comes to family members.

As both a cancer survivor and a physician, I am able to integrate empathy and diligence by putting myself in my patients’ shoes. My experience in a hospital bed during medical school granted me an extremely intriguing perspective towards medicine.
 

Why I do it

When I was a patient, the most crucial thing to my family was information. Most physicians did not take the time to explain my course of care, which elevated my family’s angst and anxiety. The experience taught me the importance of patience and communication.

But there were good examples. I still remember the physician who comforted my mother and assuaged her concerns. She held my mother’s hand and showed empathy. When my mother cried, she cried. That physician taught me that it was acceptable for physicians to express emotions.

When my surgeon rounded on me in the morning after my procedure, she was not wearing a white coat, which made her appear relatable. Her contagious confidence and humble demeanor were endorsement enough for her capabilities, showing me that a physician’s persona supersedes the conventional coat.
 

How I do it

I try to put myself in my patients’ shoes. I rejoice with them. I mourn with them. My uninhibited display of emotions affirms empathy. I dissolve all barriers by not wearing a white coat and ask my patients for a partnership. After all, I once walked miles in those shoes.

Dr. Sharma is a chief hospitalist for Sound Physicians at the Sierra Campus of The Hospitals of Providence, El Paso, Texas. She is a columnist for the El Paso Times and the medical contributor for KVIA Channel 7 ABC News. Her work has appeared on kevinmd.com, Thrive Global, and in El Paso magazine.

Clinical question: Can a modified Hospital Elder Life Program (mHELP) reduce delirium and hospital LOS in older patients undergoing abdominal surgery?

Background: Development of delirium in the hospitalized patient, especially postsurgical patients, can have detrimental effects on the clinical recovery and LOS. Delirium occurs in 13%-50% of patients undergoing noncardiac surgery, and older surgical patients are at a higher risk.

Study design: Cluster randomized clinical trial.

Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.

Clinical question: Can a modified Hospital Elder Life Program (mHELP) reduce delirium and hospital LOS in older patients undergoing abdominal surgery?

Background: Development of delirium in the hospitalized patient, especially postsurgical patients, can have detrimental effects on the clinical recovery and LOS. Delirium occurs in 13%-50% of patients undergoing noncardiac surgery, and older surgical patients are at a higher risk.

Study design: Cluster randomized clinical trial.

Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.

Clinical question: Can a modified Hospital Elder Life Program (mHELP) reduce delirium and hospital LOS in older patients undergoing abdominal surgery?

Background: Development of delirium in the hospitalized patient, especially postsurgical patients, can have detrimental effects on the clinical recovery and LOS. Delirium occurs in 13%-50% of patients undergoing noncardiac surgery, and older surgical patients are at a higher risk.

Study design: Cluster randomized clinical trial.

Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.

BALTIMORE – A pain management protocol implemented in a trauma service reduced opioid intake in trauma patients while improving patient satisfaction, according to a retrospective study.

The opioid epidemic continues to grow every day, partly as a result of irresponsible overprescribing of opioid medication, according to Jessica Gross, MB BAO BCh, FACS, a trauma surgeon from Wake Forest (N.C.) Baptist Health at the American Association for the Surgery of Trauma annual meeting. Dr. Gross and her colleagues developed a pain management protocol (PMP) to provide adequate pain control while using fewer opioids in the postdischarge setting. They tested their PMP through a retrospective chart review of 498 patients admitted to the trauma service between January 2015 and December 2016, half of which were admitted before the PMP was initiated and half of which were admitted afterward.

The PMP involved a stepped approach to treating pain, with acetaminophen or ibuprofen as needed for mild pain, one 5-mg tablet of oxycodone/acetaminophen every 6 hours for moderate pain, two tablets for severe pain, and 50-100 mg of tramadol every 6 hours for breakthrough pain.

Counseling services for patients who were found to be in danger of substance use were provided in the hospital, and at discharge, patients received a weaning plan for their medication, according to Dr. Gross.

If the short-acting medications were found to be inadequate to control pain, patients were given slow-release pain medication as needed.

Average total medication, including at discharge and for refills, prescribed after PMP initiation was 1,242 morphine milligram equivalents (MME), compared with 2,421 MME prior to the protocol (P less than .0001).

After the protocol was implemented, Dr. Gross and her colleagues found the number of patients prescribed a refill dropped from 39.7% to 28.1%, with the size of those refills dropping from 1,032 MME to 213 MME on average.

“By having a comprehensive pain management protocol, we can reduce the amount of pain medications we prescribe for outpatient use, from discharge from the trauma service,” said Dr. Gross. “Additionally, we have shown that by having a protocol in place, we not only decreased the number of refills we were providing, but also the amount of pain medications that was prescribed within these refills.”

Through a Press Ganey survey analysis of patients during the month before and the month after the PMP implementation, investigators found a significant increase in patient satisfaction and overall pain management, according to Dr. Gross,

In addition, the main trauma floor where the PMP was implemented was recognized for the most improvement in overall hospital rating and pain management, compared with the previous year.

Discussant Oscar Guillamondegui MD,FACS, medical director of the trauma ICU at Vanderbilt University, Nashville, Tenn., acknowledged the importance of PMPs and the work investigators presented.

“I would consider this the next generation of ERAS [enhanced recovery after surgery], or ERAT [enhanced recovery after trauma] in pain perception modification,” said Dr. Guillamondegui. “Dr. Gross and the multidisciplinary group at Wake Forest have provided compelling evidence to help alleviate [the opioid epidemic].”

In a question-and-answer session following the presentation, attendees voiced concern over how a PMP would be used among patients who are more familiar with hospital systems, in particular concerning self-reported pain levels.

“Most of us employed at acute care centers are not working in utopia. Many of our patients are heroin addicts, are very bright, and know how to identify 10 on those silly smiley faces so that they get more medicine,” said Charles Lucas, MD, FACS, professor of surgeon at Wayne State University, Detroit. Dr. Lucas also pointed out that even when patients report false levels of pain, doctors still are required to put it into the electronic medical record for fear of repercussions,

In response, Dr. Gross said doctors on the floor reviewed patients to make sure they were receiving all doses of pain medications. If doctors felt the patient’s pain regimen was adequate, despite the patient reporting otherwise, no changes were made.

Certain limitations include not being able to confirm whether patients received prescription medication elsewhere, nor any concrete data on patient satisfaction after discharge other than an inference based on fewer refills and lower refill MME.

Investigators reported no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

BALTIMORE – A pain management protocol implemented in a trauma service reduced opioid intake in trauma patients while improving patient satisfaction, according to a retrospective study.

The opioid epidemic continues to grow every day, partly as a result of irresponsible overprescribing of opioid medication, according to Jessica Gross, MB BAO BCh, FACS, a trauma surgeon from Wake Forest (N.C.) Baptist Health at the American Association for the Surgery of Trauma annual meeting. Dr. Gross and her colleagues developed a pain management protocol (PMP) to provide adequate pain control while using fewer opioids in the postdischarge setting. They tested their PMP through a retrospective chart review of 498 patients admitted to the trauma service between January 2015 and December 2016, half of which were admitted before the PMP was initiated and half of which were admitted afterward.

The PMP involved a stepped approach to treating pain, with acetaminophen or ibuprofen as needed for mild pain, one 5-mg tablet of oxycodone/acetaminophen every 6 hours for moderate pain, two tablets for severe pain, and 50-100 mg of tramadol every 6 hours for breakthrough pain.

Counseling services for patients who were found to be in danger of substance use were provided in the hospital, and at discharge, patients received a weaning plan for their medication, according to Dr. Gross.

If the short-acting medications were found to be inadequate to control pain, patients were given slow-release pain medication as needed.

Average total medication, including at discharge and for refills, prescribed after PMP initiation was 1,242 morphine milligram equivalents (MME), compared with 2,421 MME prior to the protocol (P less than .0001).

After the protocol was implemented, Dr. Gross and her colleagues found the number of patients prescribed a refill dropped from 39.7% to 28.1%, with the size of those refills dropping from 1,032 MME to 213 MME on average.

“By having a comprehensive pain management protocol, we can reduce the amount of pain medications we prescribe for outpatient use, from discharge from the trauma service,” said Dr. Gross. “Additionally, we have shown that by having a protocol in place, we not only decreased the number of refills we were providing, but also the amount of pain medications that was prescribed within these refills.”

Through a Press Ganey survey analysis of patients during the month before and the month after the PMP implementation, investigators found a significant increase in patient satisfaction and overall pain management, according to Dr. Gross,

In addition, the main trauma floor where the PMP was implemented was recognized for the most improvement in overall hospital rating and pain management, compared with the previous year.

Discussant Oscar Guillamondegui MD,FACS, medical director of the trauma ICU at Vanderbilt University, Nashville, Tenn., acknowledged the importance of PMPs and the work investigators presented.

“I would consider this the next generation of ERAS [enhanced recovery after surgery], or ERAT [enhanced recovery after trauma] in pain perception modification,” said Dr. Guillamondegui. “Dr. Gross and the multidisciplinary group at Wake Forest have provided compelling evidence to help alleviate [the opioid epidemic].”

In a question-and-answer session following the presentation, attendees voiced concern over how a PMP would be used among patients who are more familiar with hospital systems, in particular concerning self-reported pain levels.

“Most of us employed at acute care centers are not working in utopia. Many of our patients are heroin addicts, are very bright, and know how to identify 10 on those silly smiley faces so that they get more medicine,” said Charles Lucas, MD, FACS, professor of surgeon at Wayne State University, Detroit. Dr. Lucas also pointed out that even when patients report false levels of pain, doctors still are required to put it into the electronic medical record for fear of repercussions,

In response, Dr. Gross said doctors on the floor reviewed patients to make sure they were receiving all doses of pain medications. If doctors felt the patient’s pain regimen was adequate, despite the patient reporting otherwise, no changes were made.

Certain limitations include not being able to confirm whether patients received prescription medication elsewhere, nor any concrete data on patient satisfaction after discharge other than an inference based on fewer refills and lower refill MME.

Investigators reported no relevant financial disclosures.

[email protected]

On Twitter @eaztweets

BALTIMORE – A pain management protocol implemented in a trauma service reduced opioid intake in trauma patients while improving patient satisfaction, according to a retrospective study.

The opioid epidemic continues to grow every day, partly as a result of irresponsible overprescribing of opioid medication, according to Jessica Gross, MB BAO BCh, FACS, a trauma surgeon from Wake Forest (N.C.) Baptist Health at the American Association for the Surgery of Trauma annual meeting. Dr. Gross and her colleagues developed a pain management protocol (PMP) to provide adequate pain control while using fewer opioids in the postdischarge setting. They tested their PMP through a retrospective chart review of 498 patients admitted to the trauma service between January 2015 and December 2016, half of which were admitted before the PMP was initiated and half of which were admitted afterward.

The PMP involved a stepped approach to treating pain, with acetaminophen or ibuprofen as needed for mild pain, one 5-mg tablet of oxycodone/acetaminophen every 6 hours for moderate pain, two tablets for severe pain, and 50-100 mg of tramadol every 6 hours for breakthrough pain.

Counseling services for patients who were found to be in danger of substance use were provided in the hospital, and at discharge, patients received a weaning plan for their medication, according to Dr. Gross.

If the short-acting medications were found to be inadequate to control pain, patients were given slow-release pain medication as needed.

Average total medication, including at discharge and for refills, prescribed after PMP initiation was 1,242 morphine milligram equivalents (MME), compared with 2,421 MME prior to the protocol (P less than .0001).

After the protocol was implemented, Dr. Gross and her colleagues found the number of patients prescribed a refill dropped from 39.7% to 28.1%, with the size of those refills dropping from 1,032 MME to 213 MME on average.

“By having a comprehensive pain management protocol, we can reduce the amount of pain medications we prescribe for outpatient use, from discharge from the trauma service,” said Dr. Gross. “Additionally, we have shown that by having a protocol in place, we not only decreased the number of refills we were providing, but also the amount of pain medications that was prescribed within these refills.”

Through a Press Ganey survey analysis of patients during the month before and the month after the PMP implementation, investigators found a significant increase in patient satisfaction and overall pain management, according to Dr. Gross,

In addition, the main trauma floor where the PMP was implemented was recognized for the most improvement in overall hospital rating and pain management, compared with the previous year.

Discussant Oscar Guillamondegui MD,FACS, medical director of the trauma ICU at Vanderbilt University, Nashville, Tenn., acknowledged the importance of PMPs and the work investigators presented.

“I would consider this the next generation of ERAS [enhanced recovery after surgery], or ERAT [enhanced recovery after trauma] in pain perception modification,” said Dr. Guillamondegui. “Dr. Gross and the multidisciplinary group at Wake Forest have provided compelling evidence to help alleviate [the opioid epidemic].”

In a question-and-answer session following the presentation, attendees voiced concern over how a PMP would be used among patients who are more familiar with hospital systems, in particular concerning self-reported pain levels.

“Most of us employed at acute care centers are not working in utopia. Many of our patients are heroin addicts, are very bright, and know how to identify 10 on those silly smiley faces so that they get more medicine,” said Charles Lucas, MD, FACS, professor of surgeon at Wayne State University, Detroit. Dr. Lucas also pointed out that even when patients report false levels of pain, doctors still are required to put it into the electronic medical record for fear of repercussions,

In response, Dr. Gross said doctors on the floor reviewed patients to make sure they were receiving all doses of pain medications. If doctors felt the patient’s pain regimen was adequate, despite the patient reporting otherwise, no changes were made.

Certain limitations include not being able to confirm whether patients received prescription medication elsewhere, nor any concrete data on patient satisfaction after discharge other than an inference based on fewer refills and lower refill MME.

Investigators reported no relevant financial disclosures.

[email protected]

On Twitter @eaztweets