The Hospitalist

 

Presenters

Roberta Himebaugh MBA, SHM; John Nelson, MD, FACP, MHM; Jerome Siy, MD, SFHM

Session summary

Creating a “culture of ownership” by recruiting the right people, promoting physician leadership, and improving structural elements such as compensation model and schedule were topics discussed in this practice management precourse at HM17.

The presenters said leaders must reduce hierarchy and promote shared decision making among the group, while instilling a “thank you culture” that recognizes motivations such as autonomy, mastery, and purpose.

Current challenges related to most hospitalist groups include excessive documentation, clerical and administrative duties, and frequent low-value interruptions. One potential solution discussed was delegation of some of these duties to registered nurses, medical assistants, and possibly scribes, although the latter is currently in early adoption stages.

Leaders must also consider current changes in health care payment models, such as MIPS (Merit-based Incentive Payment System), bundled payments, and Hospital Value-based Purchasing. Hospitalist groups must be prepared for these changes by learning about them and looking for potential cost reduction opportunities (e.g., reducing the number of patients going to skilled nursing facilities after joint replacement by sending patients home whenever possible).

Promoting a culture of engagement might include the development of interpersonal support strategies (e.g., meditation and mindfulness), innovative staffing (is 7 on/7 off right for everyone?), and comprehensive support for career and leadership development.

Finally, hospitalists should give special attention to the value formula by focusing on improving patient outcomes and experience, but also reducing direct and indirect costs. This is crucial for the sustainability of any hospitalist group.

Key takeaways for HM

• Create a culture of ownership to promote engagement and job satisfaction.

• Make adjustments to schedule and workflow to improve efficiency.

• Prepare for evolving pay-for-performance programs.

• Demonstrate the value of the group by setting expectations with key stakeholders, developing a practice score, and providing effective feedback to providers.
 

Dr. Villagra is a chief hospitalist in Batesville, Ark., and an editorial board member of The Hospitalist.

 

Presenters

Roberta Himebaugh MBA, SHM; John Nelson, MD, FACP, MHM; Jerome Siy, MD, SFHM

Session summary

Creating a “culture of ownership” by recruiting the right people, promoting physician leadership, and improving structural elements such as compensation model and schedule were topics discussed in this practice management precourse at HM17.

The presenters said leaders must reduce hierarchy and promote shared decision making among the group, while instilling a “thank you culture” that recognizes motivations such as autonomy, mastery, and purpose.

Current challenges related to most hospitalist groups include excessive documentation, clerical and administrative duties, and frequent low-value interruptions. One potential solution discussed was delegation of some of these duties to registered nurses, medical assistants, and possibly scribes, although the latter is currently in early adoption stages.

Leaders must also consider current changes in health care payment models, such as MIPS (Merit-based Incentive Payment System), bundled payments, and Hospital Value-based Purchasing. Hospitalist groups must be prepared for these changes by learning about them and looking for potential cost reduction opportunities (e.g., reducing the number of patients going to skilled nursing facilities after joint replacement by sending patients home whenever possible).

Promoting a culture of engagement might include the development of interpersonal support strategies (e.g., meditation and mindfulness), innovative staffing (is 7 on/7 off right for everyone?), and comprehensive support for career and leadership development.

Finally, hospitalists should give special attention to the value formula by focusing on improving patient outcomes and experience, but also reducing direct and indirect costs. This is crucial for the sustainability of any hospitalist group.

Key takeaways for HM

• Create a culture of ownership to promote engagement and job satisfaction.

• Make adjustments to schedule and workflow to improve efficiency.

• Prepare for evolving pay-for-performance programs.

• Demonstrate the value of the group by setting expectations with key stakeholders, developing a practice score, and providing effective feedback to providers.
 

Dr. Villagra is a chief hospitalist in Batesville, Ark., and an editorial board member of The Hospitalist.

 

Presenters

Roberta Himebaugh MBA, SHM; John Nelson, MD, FACP, MHM; Jerome Siy, MD, SFHM

Session summary

Creating a “culture of ownership” by recruiting the right people, promoting physician leadership, and improving structural elements such as compensation model and schedule were topics discussed in this practice management precourse at HM17.

The presenters said leaders must reduce hierarchy and promote shared decision making among the group, while instilling a “thank you culture” that recognizes motivations such as autonomy, mastery, and purpose.

Current challenges related to most hospitalist groups include excessive documentation, clerical and administrative duties, and frequent low-value interruptions. One potential solution discussed was delegation of some of these duties to registered nurses, medical assistants, and possibly scribes, although the latter is currently in early adoption stages.

Leaders must also consider current changes in health care payment models, such as MIPS (Merit-based Incentive Payment System), bundled payments, and Hospital Value-based Purchasing. Hospitalist groups must be prepared for these changes by learning about them and looking for potential cost reduction opportunities (e.g., reducing the number of patients going to skilled nursing facilities after joint replacement by sending patients home whenever possible).

Promoting a culture of engagement might include the development of interpersonal support strategies (e.g., meditation and mindfulness), innovative staffing (is 7 on/7 off right for everyone?), and comprehensive support for career and leadership development.

Finally, hospitalists should give special attention to the value formula by focusing on improving patient outcomes and experience, but also reducing direct and indirect costs. This is crucial for the sustainability of any hospitalist group.

Key takeaways for HM

• Create a culture of ownership to promote engagement and job satisfaction.

• Make adjustments to schedule and workflow to improve efficiency.

• Prepare for evolving pay-for-performance programs.

• Demonstrate the value of the group by setting expectations with key stakeholders, developing a practice score, and providing effective feedback to providers.
 

Dr. Villagra is a chief hospitalist in Batesville, Ark., and an editorial board member of The Hospitalist.

PARIS – A strategy of switching from prasugrel or ticagrelor to clopidogrel 1 month after percutaneous coronary intervention for acute coronary syndrome is superior to the guideline-recommended full 12 months of dual-antiplatelet therapy with either of the newer P2Y12 inhibitors, according to Thomas Cuisset, MD.

In the randomized TOPIC (Timing of Platelet Inhibition After Acute Coronary Syndrome) trial, this switch strategy resulted in a marked reduction in bleeding without an increased risk of ischemic events, compared with a full 12 months of standard dual-antiplatelet therapy (DAPT) using prasugrel (Effient) or ticagrelor (Brilinta).

Bruce Jancin/Frontline Medical News

“The clinical implication of this study is that it provides a new potential strategy of DAPT that integrates the concept of dynamic risk post ACS [acute coronary syndrome],” Dr. Cuisset said at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

He added that the cost savings of this switch strategy would be enormous, since generic clopidogrel is vastly less expensive than prasugrel or ticagrelor.

Twelve months of DAPT with aspirin plus either prasugrel or ticagrelor is the guideline-recommended DAPT regimen following PCI for ACS on the strength of the TRITON and PLATO trials, respectively, which showed that those agents were more effective than clopidogrel for the prevention of thrombotic events. But Dr. Cuisset and his coinvestigators noted that the risk of ischemic events was highest in the first month or so following ACS, while the risk of DAPT-related serious bleeding increased after the first month and continued for the duration.

“We need to use the new drugs, and we need to go for 1 year with DAPT. But does that mean we need to go for 1 year with the new drugs?” he asked.

This question was the impetus for TOPIC, an open-label, single-center randomized trial that included 646 ACS patients who were free of major adverse cardiovascular events during their first month on DAPT with prasugrel or ticagrelor. At that point they were randomized to remain on their standard regimen or switch to aspirin at 75 mg/day plus clopidogrel at 75 mg/day for months 2-12. The switch strategy is similar to the way pulmonary embolism is managed: an early phase of high-intensity therapy followed by a backing off to a less intensive regimen, said Dr. Cuisset, a cardiologist at Aix-Marseille University, Provence, France.

The primary endpoint in TOPIC was the cumulative 1-year rate of a composite of all-cause mortality, stroke, urgent revascularization, or clinically significant bleeding as reflected in a Bleeding Academic Research Consortium (BARC) grade 2 or greater bleeding. The primary endpoint occurred in 13.4% of the switch group, a 52% relative risk reduction, compared with the 26.3% cumulative incidence with standard DAPT.

This difference wasn’t due to any between-group disparity in ischemic events, but rather to a 70% reduction in the risk of BARC grade 2 or greater bleeding in the switch group: 4.0% vs. 14.9%.

Some physicians have already been switching to clopidogrel for DAPT after ACS, either because of safety or cost concerns. Now their practice is evidence based, Dr. Cuisset noted.

Asked why TOPIC didn’t use the more stringent bleeding endpoint of BARC grade 3-5 bleeding, the cardiologist replied that it would have required a larger trial to show a significant difference. Besides, he added, BARC grade 2 bleeding is clinically important because it has a negative impact on quality of life and can cause patients to discontinue DAPT, thereby increasing their risk of thrombosis.

The TOPIC protocol didn’t utilize a loading dose of clopidogrel when making the switch. Investigators started clopidogrel the day after stopping prasugrel and at least 12 hours after the final dose of ticagrelor.

Ideally, the novel TOPIC findings should be confirmed in a much larger, randomized, double-blind clinical trial capable of detecting any small differences in stent thrombosis or MI rates before physicians adopt a change in practice, but discussant Chaim Lotan, MD, director of the Heart Institute at Hadassah Medical Center in Jerusalem, dismissed that prospect as unlikely.

“I tried myself to do a similar study and found I got a lot of opposition from the pharma companies as well as from physicians who said, ‘How can you go against the guidelines?’ ” he said.

“I want to congratulate your team because I think this is a groundbreaking study that is going to dictate a changing of the guidelines,” he told Dr. Cuisset.

Dr. Cuisset reported having no financial conflicts regarding this investigator-driven study funded without commercial support.

Simultaneous with his presentation in Paris, the TOPIC findings were published online (Eur Heart J. 2017 May 16. doi: 10.1093/eurheartj/ehx175).

Dr. Cuisset reported no financial conflicts regarding this investigator-driven study funded without commercial support.

[email protected]

 

PARIS – A strategy of switching from prasugrel or ticagrelor to clopidogrel 1 month after percutaneous coronary intervention for acute coronary syndrome is superior to the guideline-recommended full 12 months of dual-antiplatelet therapy with either of the newer P2Y12 inhibitors, according to Thomas Cuisset, MD.

In the randomized TOPIC (Timing of Platelet Inhibition After Acute Coronary Syndrome) trial, this switch strategy resulted in a marked reduction in bleeding without an increased risk of ischemic events, compared with a full 12 months of standard dual-antiplatelet therapy (DAPT) using prasugrel (Effient) or ticagrelor (Brilinta).

Bruce Jancin/Frontline Medical News

“The clinical implication of this study is that it provides a new potential strategy of DAPT that integrates the concept of dynamic risk post ACS [acute coronary syndrome],” Dr. Cuisset said at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

He added that the cost savings of this switch strategy would be enormous, since generic clopidogrel is vastly less expensive than prasugrel or ticagrelor.

Twelve months of DAPT with aspirin plus either prasugrel or ticagrelor is the guideline-recommended DAPT regimen following PCI for ACS on the strength of the TRITON and PLATO trials, respectively, which showed that those agents were more effective than clopidogrel for the prevention of thrombotic events. But Dr. Cuisset and his coinvestigators noted that the risk of ischemic events was highest in the first month or so following ACS, while the risk of DAPT-related serious bleeding increased after the first month and continued for the duration.

“We need to use the new drugs, and we need to go for 1 year with DAPT. But does that mean we need to go for 1 year with the new drugs?” he asked.

This question was the impetus for TOPIC, an open-label, single-center randomized trial that included 646 ACS patients who were free of major adverse cardiovascular events during their first month on DAPT with prasugrel or ticagrelor. At that point they were randomized to remain on their standard regimen or switch to aspirin at 75 mg/day plus clopidogrel at 75 mg/day for months 2-12. The switch strategy is similar to the way pulmonary embolism is managed: an early phase of high-intensity therapy followed by a backing off to a less intensive regimen, said Dr. Cuisset, a cardiologist at Aix-Marseille University, Provence, France.

The primary endpoint in TOPIC was the cumulative 1-year rate of a composite of all-cause mortality, stroke, urgent revascularization, or clinically significant bleeding as reflected in a Bleeding Academic Research Consortium (BARC) grade 2 or greater bleeding. The primary endpoint occurred in 13.4% of the switch group, a 52% relative risk reduction, compared with the 26.3% cumulative incidence with standard DAPT.

This difference wasn’t due to any between-group disparity in ischemic events, but rather to a 70% reduction in the risk of BARC grade 2 or greater bleeding in the switch group: 4.0% vs. 14.9%.

Some physicians have already been switching to clopidogrel for DAPT after ACS, either because of safety or cost concerns. Now their practice is evidence based, Dr. Cuisset noted.

Asked why TOPIC didn’t use the more stringent bleeding endpoint of BARC grade 3-5 bleeding, the cardiologist replied that it would have required a larger trial to show a significant difference. Besides, he added, BARC grade 2 bleeding is clinically important because it has a negative impact on quality of life and can cause patients to discontinue DAPT, thereby increasing their risk of thrombosis.

The TOPIC protocol didn’t utilize a loading dose of clopidogrel when making the switch. Investigators started clopidogrel the day after stopping prasugrel and at least 12 hours after the final dose of ticagrelor.

Ideally, the novel TOPIC findings should be confirmed in a much larger, randomized, double-blind clinical trial capable of detecting any small differences in stent thrombosis or MI rates before physicians adopt a change in practice, but discussant Chaim Lotan, MD, director of the Heart Institute at Hadassah Medical Center in Jerusalem, dismissed that prospect as unlikely.

“I tried myself to do a similar study and found I got a lot of opposition from the pharma companies as well as from physicians who said, ‘How can you go against the guidelines?’ ” he said.

“I want to congratulate your team because I think this is a groundbreaking study that is going to dictate a changing of the guidelines,” he told Dr. Cuisset.

Dr. Cuisset reported having no financial conflicts regarding this investigator-driven study funded without commercial support.

Simultaneous with his presentation in Paris, the TOPIC findings were published online (Eur Heart J. 2017 May 16. doi: 10.1093/eurheartj/ehx175).

Dr. Cuisset reported no financial conflicts regarding this investigator-driven study funded without commercial support.

[email protected]

 

PARIS – A strategy of switching from prasugrel or ticagrelor to clopidogrel 1 month after percutaneous coronary intervention for acute coronary syndrome is superior to the guideline-recommended full 12 months of dual-antiplatelet therapy with either of the newer P2Y12 inhibitors, according to Thomas Cuisset, MD.

In the randomized TOPIC (Timing of Platelet Inhibition After Acute Coronary Syndrome) trial, this switch strategy resulted in a marked reduction in bleeding without an increased risk of ischemic events, compared with a full 12 months of standard dual-antiplatelet therapy (DAPT) using prasugrel (Effient) or ticagrelor (Brilinta).

Bruce Jancin/Frontline Medical News

“The clinical implication of this study is that it provides a new potential strategy of DAPT that integrates the concept of dynamic risk post ACS [acute coronary syndrome],” Dr. Cuisset said at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

He added that the cost savings of this switch strategy would be enormous, since generic clopidogrel is vastly less expensive than prasugrel or ticagrelor.

Twelve months of DAPT with aspirin plus either prasugrel or ticagrelor is the guideline-recommended DAPT regimen following PCI for ACS on the strength of the TRITON and PLATO trials, respectively, which showed that those agents were more effective than clopidogrel for the prevention of thrombotic events. But Dr. Cuisset and his coinvestigators noted that the risk of ischemic events was highest in the first month or so following ACS, while the risk of DAPT-related serious bleeding increased after the first month and continued for the duration.

“We need to use the new drugs, and we need to go for 1 year with DAPT. But does that mean we need to go for 1 year with the new drugs?” he asked.

This question was the impetus for TOPIC, an open-label, single-center randomized trial that included 646 ACS patients who were free of major adverse cardiovascular events during their first month on DAPT with prasugrel or ticagrelor. At that point they were randomized to remain on their standard regimen or switch to aspirin at 75 mg/day plus clopidogrel at 75 mg/day for months 2-12. The switch strategy is similar to the way pulmonary embolism is managed: an early phase of high-intensity therapy followed by a backing off to a less intensive regimen, said Dr. Cuisset, a cardiologist at Aix-Marseille University, Provence, France.

The primary endpoint in TOPIC was the cumulative 1-year rate of a composite of all-cause mortality, stroke, urgent revascularization, or clinically significant bleeding as reflected in a Bleeding Academic Research Consortium (BARC) grade 2 or greater bleeding. The primary endpoint occurred in 13.4% of the switch group, a 52% relative risk reduction, compared with the 26.3% cumulative incidence with standard DAPT.

This difference wasn’t due to any between-group disparity in ischemic events, but rather to a 70% reduction in the risk of BARC grade 2 or greater bleeding in the switch group: 4.0% vs. 14.9%.

Some physicians have already been switching to clopidogrel for DAPT after ACS, either because of safety or cost concerns. Now their practice is evidence based, Dr. Cuisset noted.

Asked why TOPIC didn’t use the more stringent bleeding endpoint of BARC grade 3-5 bleeding, the cardiologist replied that it would have required a larger trial to show a significant difference. Besides, he added, BARC grade 2 bleeding is clinically important because it has a negative impact on quality of life and can cause patients to discontinue DAPT, thereby increasing their risk of thrombosis.

The TOPIC protocol didn’t utilize a loading dose of clopidogrel when making the switch. Investigators started clopidogrel the day after stopping prasugrel and at least 12 hours after the final dose of ticagrelor.

Ideally, the novel TOPIC findings should be confirmed in a much larger, randomized, double-blind clinical trial capable of detecting any small differences in stent thrombosis or MI rates before physicians adopt a change in practice, but discussant Chaim Lotan, MD, director of the Heart Institute at Hadassah Medical Center in Jerusalem, dismissed that prospect as unlikely.

“I tried myself to do a similar study and found I got a lot of opposition from the pharma companies as well as from physicians who said, ‘How can you go against the guidelines?’ ” he said.

“I want to congratulate your team because I think this is a groundbreaking study that is going to dictate a changing of the guidelines,” he told Dr. Cuisset.

Dr. Cuisset reported having no financial conflicts regarding this investigator-driven study funded without commercial support.

Simultaneous with his presentation in Paris, the TOPIC findings were published online (Eur Heart J. 2017 May 16. doi: 10.1093/eurheartj/ehx175).

Dr. Cuisset reported no financial conflicts regarding this investigator-driven study funded without commercial support.

[email protected]

 

 

Presenters

Nilam Soni, MD, FHM; Thomas Conlon, MD; Ria Dancel, MD, FAAP, FHM; Daniel Schnobrich, MD

Summary

Point-of-care ultrasound (POCUS) is rapidly gaining acceptance in the medical community as a goal-directed examination that answers a specific diagnostic question or guides a bedside invasive procedure. Adoption by pediatric hospitalists is increasing, aided by multiple training pathways, opportunities for scholarship, and organization development.

The use of POCUS is increasing among nonradiologist physicians due to the expectation for perfection, desire for improved patient experience, and increased availability of ultrasound machines. POCUS is rapid and safe, and can be used serially to monitor, provide procedural guidance, and lead to initiation of appropriate therapies.

Training in POCUS in limited applications is possible in short periods of time. One recent study showed that approximately 40% of POCUS cases led to new findings or alteration of treatment. However, POCUS requires training, monitoring for competence, transparency of training/competence, and a QA process that supports the training. One solution at Children’s Hospital of Philadelphia was to use American College of Emergency Physician guidelines for POCUS training.

Pediatric applications include guidance of bladder catheterization, identifying occult abscesses, diagnosis of pneumonia and associated parapneumonic effusion, and IV placement. More advanced applications include diagnosis of appendicitis, intussusception, and increased intracranial pressure. Novel applications conceived by nonradiologist physicians have included sinus ultrasound.

Initial training can be provided by “in-house experts,” such as pediatric ED physicians and PICU physicians. Alternatively, an on-site commercial course can be arranged for larger groups. Consideration should be given to mentorship, with comparison to formal imaging and/or clinical progression. Relationships with traditional imagers should be cultivated, as POCUS can potentially be misunderstood. In fact, formal US utilization has been found to increase once clinicals begin to use POCUS.

Key takeaways for HM

• Point-of-care ultrasound (POCUS) is rapidly being adopted by pediatric hospitalists.
• Pediatric applications are still being developed, but include guidance of bladder catheterization, identifying occult abscesses, diagnosis of pneumonia/associated effusions, and IV placement.
• Initial training can be provided by pediatric ED physicians/PICU physicians or an on-site commercial course can be arranged for larger groups.
• Relationships with radiologists should be established at the outset to avoid misunderstanding of POCUS.

Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital and is the pediatric editor of The Hospitalist.

 

Presenters

Nilam Soni, MD, FHM; Thomas Conlon, MD; Ria Dancel, MD, FAAP, FHM; Daniel Schnobrich, MD

Summary

Point-of-care ultrasound (POCUS) is rapidly gaining acceptance in the medical community as a goal-directed examination that answers a specific diagnostic question or guides a bedside invasive procedure. Adoption by pediatric hospitalists is increasing, aided by multiple training pathways, opportunities for scholarship, and organization development.

The use of POCUS is increasing among nonradiologist physicians due to the expectation for perfection, desire for improved patient experience, and increased availability of ultrasound machines. POCUS is rapid and safe, and can be used serially to monitor, provide procedural guidance, and lead to initiation of appropriate therapies.

Training in POCUS in limited applications is possible in short periods of time. One recent study showed that approximately 40% of POCUS cases led to new findings or alteration of treatment. However, POCUS requires training, monitoring for competence, transparency of training/competence, and a QA process that supports the training. One solution at Children’s Hospital of Philadelphia was to use American College of Emergency Physician guidelines for POCUS training.

Pediatric applications include guidance of bladder catheterization, identifying occult abscesses, diagnosis of pneumonia and associated parapneumonic effusion, and IV placement. More advanced applications include diagnosis of appendicitis, intussusception, and increased intracranial pressure. Novel applications conceived by nonradiologist physicians have included sinus ultrasound.

Initial training can be provided by “in-house experts,” such as pediatric ED physicians and PICU physicians. Alternatively, an on-site commercial course can be arranged for larger groups. Consideration should be given to mentorship, with comparison to formal imaging and/or clinical progression. Relationships with traditional imagers should be cultivated, as POCUS can potentially be misunderstood. In fact, formal US utilization has been found to increase once clinicals begin to use POCUS.

Key takeaways for HM

• Point-of-care ultrasound (POCUS) is rapidly being adopted by pediatric hospitalists.
• Pediatric applications are still being developed, but include guidance of bladder catheterization, identifying occult abscesses, diagnosis of pneumonia/associated effusions, and IV placement.
• Initial training can be provided by pediatric ED physicians/PICU physicians or an on-site commercial course can be arranged for larger groups.
• Relationships with radiologists should be established at the outset to avoid misunderstanding of POCUS.

Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital and is the pediatric editor of The Hospitalist.

 

Presenters

Nilam Soni, MD, FHM; Thomas Conlon, MD; Ria Dancel, MD, FAAP, FHM; Daniel Schnobrich, MD

Summary

Point-of-care ultrasound (POCUS) is rapidly gaining acceptance in the medical community as a goal-directed examination that answers a specific diagnostic question or guides a bedside invasive procedure. Adoption by pediatric hospitalists is increasing, aided by multiple training pathways, opportunities for scholarship, and organization development.

The use of POCUS is increasing among nonradiologist physicians due to the expectation for perfection, desire for improved patient experience, and increased availability of ultrasound machines. POCUS is rapid and safe, and can be used serially to monitor, provide procedural guidance, and lead to initiation of appropriate therapies.

Training in POCUS in limited applications is possible in short periods of time. One recent study showed that approximately 40% of POCUS cases led to new findings or alteration of treatment. However, POCUS requires training, monitoring for competence, transparency of training/competence, and a QA process that supports the training. One solution at Children’s Hospital of Philadelphia was to use American College of Emergency Physician guidelines for POCUS training.

Pediatric applications include guidance of bladder catheterization, identifying occult abscesses, diagnosis of pneumonia and associated parapneumonic effusion, and IV placement. More advanced applications include diagnosis of appendicitis, intussusception, and increased intracranial pressure. Novel applications conceived by nonradiologist physicians have included sinus ultrasound.

Initial training can be provided by “in-house experts,” such as pediatric ED physicians and PICU physicians. Alternatively, an on-site commercial course can be arranged for larger groups. Consideration should be given to mentorship, with comparison to formal imaging and/or clinical progression. Relationships with traditional imagers should be cultivated, as POCUS can potentially be misunderstood. In fact, formal US utilization has been found to increase once clinicals begin to use POCUS.

Key takeaways for HM

• Point-of-care ultrasound (POCUS) is rapidly being adopted by pediatric hospitalists.
• Pediatric applications are still being developed, but include guidance of bladder catheterization, identifying occult abscesses, diagnosis of pneumonia/associated effusions, and IV placement.
• Initial training can be provided by pediatric ED physicians/PICU physicians or an on-site commercial course can be arranged for larger groups.
• Relationships with radiologists should be established at the outset to avoid misunderstanding of POCUS.

Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital and is the pediatric editor of The Hospitalist.

 

Inpatient hyperglycemia is a very common condition, affecting approximately 38% of patients in the non–intensive care unit setting.

Enhance the efficiency and reliability of your quality improvement efforts to close the gap between best practices and methods for caring for inpatients with hyperglycemia with SHM’s Glycemic Control (GC) Electronic Quality Improvement Program (eQUIPS). The GC eQUIPS program supports the development and implementation of GC programs at hospitals nationwide.

iStock/ThinkStock

This program offers 2-year access to a data center for performance tracking and benchmarking and aims to support your institution in:

• Gaining understanding in the principles of glycemic control
• Improving glycemic control data collection/analysis/and reporting
• Building and obtaining approval for protocols/policies for glycemic control
• Creating a culture for change and change management

When you enroll in the Glycemic Control eQUIPS, you’ll receive:

• Data center for performance tracking. Helps track performance on project milestones and outcomes, and benchmark performance against comparison groups at your institution and other participating facilities.
• Implementation toolkit. Provides stepwise instruction for improving glycemic control, preventing hypoglycemia and optimizing care of the inpatient with hyperglycemia and diabetes.
• Online glycemic control toolkit. Includes clinical tools and interventions, research materials and literature review, informational papers and case studies, teaching slide sets, and more.
• Online community and collaborative:

– Glycemic Control Library of site-created tools and documents allows you to view sample order sets and protocols, awareness campaigns, patient education materials, and various articles.

– National Discussion Forum lets you share professional questions and discuss topics related to the planning, implementation and evaluation of glycemic control interventions.

– Access to on-demand webinar, facilitated by national experts, topics include IV Insulin Management Strategies, Change Management and Introduction to Glycemic Control.



Join the webinar on June 28 from 1–2 p.m., ET, to receive additional information about SHM’s GC programs. Visit hospitalmedicine.org/gc to register or learn more. If you have questions on the program, please email Sara Platt at [email protected].
 

Brett Radler is communications specialist at the Society of Hospital Medicine.

 

Inpatient hyperglycemia is a very common condition, affecting approximately 38% of patients in the non–intensive care unit setting.

Enhance the efficiency and reliability of your quality improvement efforts to close the gap between best practices and methods for caring for inpatients with hyperglycemia with SHM’s Glycemic Control (GC) Electronic Quality Improvement Program (eQUIPS). The GC eQUIPS program supports the development and implementation of GC programs at hospitals nationwide.

iStock/ThinkStock

This program offers 2-year access to a data center for performance tracking and benchmarking and aims to support your institution in:

• Gaining understanding in the principles of glycemic control
• Improving glycemic control data collection/analysis/and reporting
• Building and obtaining approval for protocols/policies for glycemic control
• Creating a culture for change and change management

When you enroll in the Glycemic Control eQUIPS, you’ll receive:

• Data center for performance tracking. Helps track performance on project milestones and outcomes, and benchmark performance against comparison groups at your institution and other participating facilities.
• Implementation toolkit. Provides stepwise instruction for improving glycemic control, preventing hypoglycemia and optimizing care of the inpatient with hyperglycemia and diabetes.
• Online glycemic control toolkit. Includes clinical tools and interventions, research materials and literature review, informational papers and case studies, teaching slide sets, and more.
• Online community and collaborative:

– Glycemic Control Library of site-created tools and documents allows you to view sample order sets and protocols, awareness campaigns, patient education materials, and various articles.

– National Discussion Forum lets you share professional questions and discuss topics related to the planning, implementation and evaluation of glycemic control interventions.

– Access to on-demand webinar, facilitated by national experts, topics include IV Insulin Management Strategies, Change Management and Introduction to Glycemic Control.



Join the webinar on June 28 from 1–2 p.m., ET, to receive additional information about SHM’s GC programs. Visit hospitalmedicine.org/gc to register or learn more. If you have questions on the program, please email Sara Platt at [email protected].
 

Brett Radler is communications specialist at the Society of Hospital Medicine.

 

Inpatient hyperglycemia is a very common condition, affecting approximately 38% of patients in the non–intensive care unit setting.

Enhance the efficiency and reliability of your quality improvement efforts to close the gap between best practices and methods for caring for inpatients with hyperglycemia with SHM’s Glycemic Control (GC) Electronic Quality Improvement Program (eQUIPS). The GC eQUIPS program supports the development and implementation of GC programs at hospitals nationwide.

iStock/ThinkStock

This program offers 2-year access to a data center for performance tracking and benchmarking and aims to support your institution in:

• Gaining understanding in the principles of glycemic control
• Improving glycemic control data collection/analysis/and reporting
• Building and obtaining approval for protocols/policies for glycemic control
• Creating a culture for change and change management

When you enroll in the Glycemic Control eQUIPS, you’ll receive:

• Data center for performance tracking. Helps track performance on project milestones and outcomes, and benchmark performance against comparison groups at your institution and other participating facilities.
• Implementation toolkit. Provides stepwise instruction for improving glycemic control, preventing hypoglycemia and optimizing care of the inpatient with hyperglycemia and diabetes.
• Online glycemic control toolkit. Includes clinical tools and interventions, research materials and literature review, informational papers and case studies, teaching slide sets, and more.
• Online community and collaborative:

– Glycemic Control Library of site-created tools and documents allows you to view sample order sets and protocols, awareness campaigns, patient education materials, and various articles.

– National Discussion Forum lets you share professional questions and discuss topics related to the planning, implementation and evaluation of glycemic control interventions.

– Access to on-demand webinar, facilitated by national experts, topics include IV Insulin Management Strategies, Change Management and Introduction to Glycemic Control.



Join the webinar on June 28 from 1–2 p.m., ET, to receive additional information about SHM’s GC programs. Visit hospitalmedicine.org/gc to register or learn more. If you have questions on the program, please email Sara Platt at [email protected].
 

Brett Radler is communications specialist at the Society of Hospital Medicine.

 

The latest update to U.S. guidelines for heart failure management, released at the end of April , puts unprecedented emphasis on heart failure prevention and also shines a brighter light on patients at risk for developing heart failure – people with hypertension, diabetes, or coronary artery disease.

“We have embraced the fact that heart failure can be prevented and that the progression of heart failure can be interrupted, and we articulated how we can use biomarkers to screen patients with asymptomatic left ventricular dysfunction,” said Clyde W. Yancy, MD, chair of the writing group that issued the 2017 focused update to the heart failure management guidelines on behalf of the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America. (Circulation. 2017 Apr 28. doi: 10.1161/CIR.0000000000000509).

“The writing committee thought very strongly about the possibility of prevention. We tried to emphasize prevention” and the delay of heart failure onset, said panel vice chair Mariell Jessup, MD, chief scientific officer for the Leducq organization in Boston.

This means that, for the first time, these guidelines focus on stage A heart failure patients, those without symptoms or detectable left ventricular dysfunction but at risk for heart failure, a heart failure subgroup that was ignored in the past. Prevention is most immediate for stage A patients. The new guidelines cite the stage A definition from the 2009 guidelines: patients with “risk factors that clearly predispose toward the development of heart failure. For example, patients with coronary artery disease, hypertension, or diabetes mellitus who do not yet demonstrate impaired left ventricular function.”

The number of patients with coronary artery disease, hypertension, or diabetes is pretty large. The new heart failure guidelines apply to many people.

“The mindset [on heart failure] has been on treatment, not prevention. There is far more focus [in the new guidelines] on prevention than ever before,” commented Javed Butler, MD, professor and chief of cardiology at Stony Brook (N.Y.) University and a member of the guideline writing panel.

“One reason why heart failure prevention has not been a focus was because people thought that, if you prevented coronary artery disease, you prevented heart failure. What we’ve learned is that a lot of heart failure is not ischemic and not from overt coronary disease, especially age-related HFpEF [heart failure with preserved ejection fraction]. Hopefully, these guidelines will spur more interest in prevention and risk factor control,” Dr. Butler said in an interview.

It starts with blood pressure

The guidelines contain an entirely new section devoted to blood pressure, and, while part of the section deals with a target blood pressure for symptomatic (stage C) heart failure patients (a goal systolic pressure of less than 130 mm Hg for patients with either a preserved or reduced ejection fraction), the first entry is a target blood pressure of less than 130/80 mm Hg for all stage A heart failure patients.

Dr. Jessup called hypertension the most powerful risk factor for heart failure. “Think of hypertension as pre–heart failure,” she advised. Many patients who develop symptomatic heart failure are older women who have experienced years of poorly controlled hypertension.

Because stage A is defined to include any adult with hypertension, the new heart failure guidelines set a new blood pressure treatment goal for all U.S. adults with hypertension at a time when the long-awaited revision to U.S. hypertension management guidelines from the ACC and AHA are still pending. Until the new hypertension guidelines come out – they’re expected later this year – the blood pressure target set in the heart failure guidelines will have to suffice.

Indeed, the less than 130/80-mm Hg target for on-treatment blood pressure set for heart failure prevention in the new guidelines was picked to “harmonize” with the guidelines that the ACC and AHA hypertension panel will soon release, Dr. Jessup said in an interview.

The main evidence for this target, lower than in most prior U.S. hypertension guidelines, comes from SPRINT (Systolic Blood Pressure Intervention Trial) (N Engl J Med. 2015 Nov 26;373[22]:2103-16). In that trial, the goal blood pressure that linked with the best outcomes was less than 120/80 mm Hg, although the average achieved systolic blood pressure was above that goal with a mean systolic pressure of 121.5 mm Hg. One reason for setting a higher goal systolic pressure for practice was that analyses have shown that blood pressure measurement in SPRINT did not perform like conventional measurements in routine practice. SPRINT patients appeared to have lower measured pressures than they would have recorded had they been measured by more conventional means (Hypertension. 2017 January;69[1]:15-9).

“The way that blood pressures were measured in SPRINT, a pressure of 120/80 mm Hg in the trial was akin to a pressure of 130/80 mm Hg in an office,” Dr. Yancy, chief of cardiology at Northwestern University, Chicago, said in an interview. “To avoid dangerous hypotension and to approximate SPRINT, an office pressure of less than 130 mm Hg is a reasonable number.”

Courtesy Stony Brook University

Besides, quibbling over whether the target systolic pressure should be less than 120 mm Hg or 130 mm Hg “is somewhat moot,” noted Dr. Butler, at a time when many patients go untreated and many others are undertreated and have on-treatment blood pressures substantially above their target level. “If we could get 95% of patients to a systolic blood pressure of 140 mm Hg, we’d see tremendous benefit,” he noted.

 

New role for BNP screening

Stage A patients are more than just the target for more aggressive hypertension control. They are now also potential candidates for screening for an elevated blood level of brain natriuretic peptide (BNP) or N-terminal (NT)–proBNP. The guidelines panel makes this a level IIa recommendation, saying that a screening BNP test in patients at risk for developing heart failure can be useful if followed by team-based care and optimized guideline directed medical therapy.

This guideline follows the lead of two successful controlled trials that focused more aggressive preventive treatments on stage A patients with an elevated level of BNP or NT-proBNP – the STOP-HF (JAMA. 2013 July 3;310[1]:66-74) and PONTIAC (J Am Coll Cardiol. 2013 Oct;62[15]:1365-72) trials. The target population for some type of BNP screening are patients with cardiovascular disease, vascular disease, diabetes, obesity, or hypertension, Dr. Yancy said. “It was evident in STOP-HF that, if you screened and intervened, you could make a difference” in the development of heart failure.

The STOP-HF intervention included “optimal risk factor management” and “coaching by a specialist nurse who emphasized individual risk status and the importance of adherence to medication and healthy lifestyle behaviors.”

The guidelines aren’t clear on which patients at risk for developing heart failure, stage A patients, should get screened with BNP or NT-proBNP. Dr. Jessup said that it’s for patients in whom a positive result would trigger more aggressive management.

Focusing BNP testing on patients with some clinical indication of risk for heart failure is the best way to boost diagnostic efficiency, suggested James L. Januzzi, MD, professor of medicine at Harvard Medical School and a heart failure cardiologist at Massachusetts General Hospital, both in Boston. He said that both BNP and NT-proBNP are equally good options for screening at-risk patients as markers of incident heart failure. Positive levels flagging left ventricular involvement would be a BNP of at least 50 pg/mL or an NT-pro-BNP of at least 125 pg/mL. Patients with levels like these need echocardiographic assessment, as well as optimization of blood pressure control, optimization of statin treatment, optimization of all their other medications, and, if the patient has diabetes, assessment for possible silent ischemia, said Dr. Januzzi.

Getting a BNP on a suspect patient can raise a red flag to the patient, as well as to the physician, that more intervention is needed. “It’s easy for a physician to ignore a high-risk patient who looks okay and feels okay.” A BNP or NT-proBNP test can pick out the patients who shouldn’t be ignored, Dr. Januzzi said.

HFpEF treatment now possible

Another groundbreaking change in the guidelines is inclusion, for the first time, of a medical treatment specific for HFpEF. The aldosterone receptor antagonists (ARAs) spironolactone and eplerenone received a class IIb recommendation: An ARA might be considered to decrease hospitalizations in patients with HFpEF with an ejection fraction of at least 45%, an elevated BNP or recent hospitalization, and good renal function and potassium level.

The “might be considered” recommendation is guarded but understandable given that the evidence comes from the somewhat controversial, post-hoc analysis of data from the pivotal TOPCAT trial (N Engl J Med. 2014 Apr 10;370[15]:1383-92) that focused on just the roughly half of patients seen at centers in North or South America (Circulation. 2015 Jan 6;131[1]:34-42).

“It would be irresponsible to overlook the potential that [ARAs] may help patients who looks like the ones enrolled in TOPCAT in the Americas,” said Dr. Yancy. “We blended evidence and pragmatism and said that the field needs this” treatment. He said that an ARA was a reasonable option for HFpEF patients with symptoms of heart failure and a positive biomarker test result.

Dr. Butler largely agreed. ARA treatment is for HFpEF patients with symptomatic heart failure and either a history of hospitalization or a high BNP level, he said.

“I was surprised by how strongly the committee felt there was a reasonable signal of help from ARAs in HFpEF,” said Dr. Jessup. “I believe in them too,” she added.

Dr. Jessup suggested targeting an ARA to a HFpEF patient with some hypertension, some volume problem, some peripheral edema, and a lot of breathlessness but with no underlying ischemia. “I use an ARA on these patients pretty quickly,” Dr. Jessup said. It’s best to start with a low dosage and see how the patient responds. “The best responders have a really stiff heart” and are usually not the more elderly HFpEF patients. ARA treatment also provides more steady volume control, superior to furosemide, she said.

 

Yet more additions

The revised guidelines contain even more changes. “We say that checking for anemia is important and how iron is an intervention that might make a difference,” said Dr. Jessup. Also, primary care physicians and cardiologists “should look for obstructive sleep apnea” in heart failure patients for whom “intervention with weight loss might help,” she said.

Another feature is the focus on tailored treatment, with many treatment elements that need customizing to each different type of heart failure patient. “Not every drug needs to be given to every patient,” Dr. Yancy warned.

The specifics of how to orchestrate all the guidelines into a coherent management plan may become clearer later this year, when the ACC/AHA group will release a follow-up “Heart Failure Pathways” document, aimed at bridging the gap between guidelines and actual clinical practice, Dr. Yancy said. “We want more value from writing the guidelines. The biggest obstacle is how to implement them,” and that’s what the pathways follow-up will address.

“The biggest challenge the societies have is how to motivate physicians and nurses to more aggressively treat heart failure,” said Dr. Butler.

Dr. Yancy and Dr. Jessup had no disclosures. Dr. Butler has been a consultant to 11 companies. Dr. Januzzi has been a consultant to Critical Diagnostics, Novartis, Phillips, Roche Diagnostics, and Sphingotec, and he has received research support from Amgen, Boehringer Ingelheim, Janssen, and Prevencio.

[email protected]

On Twitter @mitchelzoler

 

The latest update to U.S. guidelines for heart failure management, released at the end of April , puts unprecedented emphasis on heart failure prevention and also shines a brighter light on patients at risk for developing heart failure – people with hypertension, diabetes, or coronary artery disease.

“We have embraced the fact that heart failure can be prevented and that the progression of heart failure can be interrupted, and we articulated how we can use biomarkers to screen patients with asymptomatic left ventricular dysfunction,” said Clyde W. Yancy, MD, chair of the writing group that issued the 2017 focused update to the heart failure management guidelines on behalf of the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America. (Circulation. 2017 Apr 28. doi: 10.1161/CIR.0000000000000509).

“The writing committee thought very strongly about the possibility of prevention. We tried to emphasize prevention” and the delay of heart failure onset, said panel vice chair Mariell Jessup, MD, chief scientific officer for the Leducq organization in Boston.

This means that, for the first time, these guidelines focus on stage A heart failure patients, those without symptoms or detectable left ventricular dysfunction but at risk for heart failure, a heart failure subgroup that was ignored in the past. Prevention is most immediate for stage A patients. The new guidelines cite the stage A definition from the 2009 guidelines: patients with “risk factors that clearly predispose toward the development of heart failure. For example, patients with coronary artery disease, hypertension, or diabetes mellitus who do not yet demonstrate impaired left ventricular function.”

The number of patients with coronary artery disease, hypertension, or diabetes is pretty large. The new heart failure guidelines apply to many people.

“The mindset [on heart failure] has been on treatment, not prevention. There is far more focus [in the new guidelines] on prevention than ever before,” commented Javed Butler, MD, professor and chief of cardiology at Stony Brook (N.Y.) University and a member of the guideline writing panel.

“One reason why heart failure prevention has not been a focus was because people thought that, if you prevented coronary artery disease, you prevented heart failure. What we’ve learned is that a lot of heart failure is not ischemic and not from overt coronary disease, especially age-related HFpEF [heart failure with preserved ejection fraction]. Hopefully, these guidelines will spur more interest in prevention and risk factor control,” Dr. Butler said in an interview.

It starts with blood pressure

The guidelines contain an entirely new section devoted to blood pressure, and, while part of the section deals with a target blood pressure for symptomatic (stage C) heart failure patients (a goal systolic pressure of less than 130 mm Hg for patients with either a preserved or reduced ejection fraction), the first entry is a target blood pressure of less than 130/80 mm Hg for all stage A heart failure patients.

Dr. Jessup called hypertension the most powerful risk factor for heart failure. “Think of hypertension as pre–heart failure,” she advised. Many patients who develop symptomatic heart failure are older women who have experienced years of poorly controlled hypertension.

Because stage A is defined to include any adult with hypertension, the new heart failure guidelines set a new blood pressure treatment goal for all U.S. adults with hypertension at a time when the long-awaited revision to U.S. hypertension management guidelines from the ACC and AHA are still pending. Until the new hypertension guidelines come out – they’re expected later this year – the blood pressure target set in the heart failure guidelines will have to suffice.

Indeed, the less than 130/80-mm Hg target for on-treatment blood pressure set for heart failure prevention in the new guidelines was picked to “harmonize” with the guidelines that the ACC and AHA hypertension panel will soon release, Dr. Jessup said in an interview.

The main evidence for this target, lower than in most prior U.S. hypertension guidelines, comes from SPRINT (Systolic Blood Pressure Intervention Trial) (N Engl J Med. 2015 Nov 26;373[22]:2103-16). In that trial, the goal blood pressure that linked with the best outcomes was less than 120/80 mm Hg, although the average achieved systolic blood pressure was above that goal with a mean systolic pressure of 121.5 mm Hg. One reason for setting a higher goal systolic pressure for practice was that analyses have shown that blood pressure measurement in SPRINT did not perform like conventional measurements in routine practice. SPRINT patients appeared to have lower measured pressures than they would have recorded had they been measured by more conventional means (Hypertension. 2017 January;69[1]:15-9).

“The way that blood pressures were measured in SPRINT, a pressure of 120/80 mm Hg in the trial was akin to a pressure of 130/80 mm Hg in an office,” Dr. Yancy, chief of cardiology at Northwestern University, Chicago, said in an interview. “To avoid dangerous hypotension and to approximate SPRINT, an office pressure of less than 130 mm Hg is a reasonable number.”

Courtesy Stony Brook University

Besides, quibbling over whether the target systolic pressure should be less than 120 mm Hg or 130 mm Hg “is somewhat moot,” noted Dr. Butler, at a time when many patients go untreated and many others are undertreated and have on-treatment blood pressures substantially above their target level. “If we could get 95% of patients to a systolic blood pressure of 140 mm Hg, we’d see tremendous benefit,” he noted.

 

New role for BNP screening

Stage A patients are more than just the target for more aggressive hypertension control. They are now also potential candidates for screening for an elevated blood level of brain natriuretic peptide (BNP) or N-terminal (NT)–proBNP. The guidelines panel makes this a level IIa recommendation, saying that a screening BNP test in patients at risk for developing heart failure can be useful if followed by team-based care and optimized guideline directed medical therapy.

This guideline follows the lead of two successful controlled trials that focused more aggressive preventive treatments on stage A patients with an elevated level of BNP or NT-proBNP – the STOP-HF (JAMA. 2013 July 3;310[1]:66-74) and PONTIAC (J Am Coll Cardiol. 2013 Oct;62[15]:1365-72) trials. The target population for some type of BNP screening are patients with cardiovascular disease, vascular disease, diabetes, obesity, or hypertension, Dr. Yancy said. “It was evident in STOP-HF that, if you screened and intervened, you could make a difference” in the development of heart failure.

The STOP-HF intervention included “optimal risk factor management” and “coaching by a specialist nurse who emphasized individual risk status and the importance of adherence to medication and healthy lifestyle behaviors.”

The guidelines aren’t clear on which patients at risk for developing heart failure, stage A patients, should get screened with BNP or NT-proBNP. Dr. Jessup said that it’s for patients in whom a positive result would trigger more aggressive management.

Focusing BNP testing on patients with some clinical indication of risk for heart failure is the best way to boost diagnostic efficiency, suggested James L. Januzzi, MD, professor of medicine at Harvard Medical School and a heart failure cardiologist at Massachusetts General Hospital, both in Boston. He said that both BNP and NT-proBNP are equally good options for screening at-risk patients as markers of incident heart failure. Positive levels flagging left ventricular involvement would be a BNP of at least 50 pg/mL or an NT-pro-BNP of at least 125 pg/mL. Patients with levels like these need echocardiographic assessment, as well as optimization of blood pressure control, optimization of statin treatment, optimization of all their other medications, and, if the patient has diabetes, assessment for possible silent ischemia, said Dr. Januzzi.

Getting a BNP on a suspect patient can raise a red flag to the patient, as well as to the physician, that more intervention is needed. “It’s easy for a physician to ignore a high-risk patient who looks okay and feels okay.” A BNP or NT-proBNP test can pick out the patients who shouldn’t be ignored, Dr. Januzzi said.

HFpEF treatment now possible

Another groundbreaking change in the guidelines is inclusion, for the first time, of a medical treatment specific for HFpEF. The aldosterone receptor antagonists (ARAs) spironolactone and eplerenone received a class IIb recommendation: An ARA might be considered to decrease hospitalizations in patients with HFpEF with an ejection fraction of at least 45%, an elevated BNP or recent hospitalization, and good renal function and potassium level.

The “might be considered” recommendation is guarded but understandable given that the evidence comes from the somewhat controversial, post-hoc analysis of data from the pivotal TOPCAT trial (N Engl J Med. 2014 Apr 10;370[15]:1383-92) that focused on just the roughly half of patients seen at centers in North or South America (Circulation. 2015 Jan 6;131[1]:34-42).

“It would be irresponsible to overlook the potential that [ARAs] may help patients who looks like the ones enrolled in TOPCAT in the Americas,” said Dr. Yancy. “We blended evidence and pragmatism and said that the field needs this” treatment. He said that an ARA was a reasonable option for HFpEF patients with symptoms of heart failure and a positive biomarker test result.

Dr. Butler largely agreed. ARA treatment is for HFpEF patients with symptomatic heart failure and either a history of hospitalization or a high BNP level, he said.

“I was surprised by how strongly the committee felt there was a reasonable signal of help from ARAs in HFpEF,” said Dr. Jessup. “I believe in them too,” she added.

Dr. Jessup suggested targeting an ARA to a HFpEF patient with some hypertension, some volume problem, some peripheral edema, and a lot of breathlessness but with no underlying ischemia. “I use an ARA on these patients pretty quickly,” Dr. Jessup said. It’s best to start with a low dosage and see how the patient responds. “The best responders have a really stiff heart” and are usually not the more elderly HFpEF patients. ARA treatment also provides more steady volume control, superior to furosemide, she said.

 

Yet more additions

The revised guidelines contain even more changes. “We say that checking for anemia is important and how iron is an intervention that might make a difference,” said Dr. Jessup. Also, primary care physicians and cardiologists “should look for obstructive sleep apnea” in heart failure patients for whom “intervention with weight loss might help,” she said.

Another feature is the focus on tailored treatment, with many treatment elements that need customizing to each different type of heart failure patient. “Not every drug needs to be given to every patient,” Dr. Yancy warned.

The specifics of how to orchestrate all the guidelines into a coherent management plan may become clearer later this year, when the ACC/AHA group will release a follow-up “Heart Failure Pathways” document, aimed at bridging the gap between guidelines and actual clinical practice, Dr. Yancy said. “We want more value from writing the guidelines. The biggest obstacle is how to implement them,” and that’s what the pathways follow-up will address.

“The biggest challenge the societies have is how to motivate physicians and nurses to more aggressively treat heart failure,” said Dr. Butler.

Dr. Yancy and Dr. Jessup had no disclosures. Dr. Butler has been a consultant to 11 companies. Dr. Januzzi has been a consultant to Critical Diagnostics, Novartis, Phillips, Roche Diagnostics, and Sphingotec, and he has received research support from Amgen, Boehringer Ingelheim, Janssen, and Prevencio.

[email protected]

On Twitter @mitchelzoler

 

The latest update to U.S. guidelines for heart failure management, released at the end of April , puts unprecedented emphasis on heart failure prevention and also shines a brighter light on patients at risk for developing heart failure – people with hypertension, diabetes, or coronary artery disease.

“We have embraced the fact that heart failure can be prevented and that the progression of heart failure can be interrupted, and we articulated how we can use biomarkers to screen patients with asymptomatic left ventricular dysfunction,” said Clyde W. Yancy, MD, chair of the writing group that issued the 2017 focused update to the heart failure management guidelines on behalf of the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America. (Circulation. 2017 Apr 28. doi: 10.1161/CIR.0000000000000509).

“The writing committee thought very strongly about the possibility of prevention. We tried to emphasize prevention” and the delay of heart failure onset, said panel vice chair Mariell Jessup, MD, chief scientific officer for the Leducq organization in Boston.

This means that, for the first time, these guidelines focus on stage A heart failure patients, those without symptoms or detectable left ventricular dysfunction but at risk for heart failure, a heart failure subgroup that was ignored in the past. Prevention is most immediate for stage A patients. The new guidelines cite the stage A definition from the 2009 guidelines: patients with “risk factors that clearly predispose toward the development of heart failure. For example, patients with coronary artery disease, hypertension, or diabetes mellitus who do not yet demonstrate impaired left ventricular function.”

The number of patients with coronary artery disease, hypertension, or diabetes is pretty large. The new heart failure guidelines apply to many people.

“The mindset [on heart failure] has been on treatment, not prevention. There is far more focus [in the new guidelines] on prevention than ever before,” commented Javed Butler, MD, professor and chief of cardiology at Stony Brook (N.Y.) University and a member of the guideline writing panel.

“One reason why heart failure prevention has not been a focus was because people thought that, if you prevented coronary artery disease, you prevented heart failure. What we’ve learned is that a lot of heart failure is not ischemic and not from overt coronary disease, especially age-related HFpEF [heart failure with preserved ejection fraction]. Hopefully, these guidelines will spur more interest in prevention and risk factor control,” Dr. Butler said in an interview.

It starts with blood pressure

The guidelines contain an entirely new section devoted to blood pressure, and, while part of the section deals with a target blood pressure for symptomatic (stage C) heart failure patients (a goal systolic pressure of less than 130 mm Hg for patients with either a preserved or reduced ejection fraction), the first entry is a target blood pressure of less than 130/80 mm Hg for all stage A heart failure patients.

Dr. Jessup called hypertension the most powerful risk factor for heart failure. “Think of hypertension as pre–heart failure,” she advised. Many patients who develop symptomatic heart failure are older women who have experienced years of poorly controlled hypertension.

Because stage A is defined to include any adult with hypertension, the new heart failure guidelines set a new blood pressure treatment goal for all U.S. adults with hypertension at a time when the long-awaited revision to U.S. hypertension management guidelines from the ACC and AHA are still pending. Until the new hypertension guidelines come out – they’re expected later this year – the blood pressure target set in the heart failure guidelines will have to suffice.

Indeed, the less than 130/80-mm Hg target for on-treatment blood pressure set for heart failure prevention in the new guidelines was picked to “harmonize” with the guidelines that the ACC and AHA hypertension panel will soon release, Dr. Jessup said in an interview.

The main evidence for this target, lower than in most prior U.S. hypertension guidelines, comes from SPRINT (Systolic Blood Pressure Intervention Trial) (N Engl J Med. 2015 Nov 26;373[22]:2103-16). In that trial, the goal blood pressure that linked with the best outcomes was less than 120/80 mm Hg, although the average achieved systolic blood pressure was above that goal with a mean systolic pressure of 121.5 mm Hg. One reason for setting a higher goal systolic pressure for practice was that analyses have shown that blood pressure measurement in SPRINT did not perform like conventional measurements in routine practice. SPRINT patients appeared to have lower measured pressures than they would have recorded had they been measured by more conventional means (Hypertension. 2017 January;69[1]:15-9).

“The way that blood pressures were measured in SPRINT, a pressure of 120/80 mm Hg in the trial was akin to a pressure of 130/80 mm Hg in an office,” Dr. Yancy, chief of cardiology at Northwestern University, Chicago, said in an interview. “To avoid dangerous hypotension and to approximate SPRINT, an office pressure of less than 130 mm Hg is a reasonable number.”

Courtesy Stony Brook University

Besides, quibbling over whether the target systolic pressure should be less than 120 mm Hg or 130 mm Hg “is somewhat moot,” noted Dr. Butler, at a time when many patients go untreated and many others are undertreated and have on-treatment blood pressures substantially above their target level. “If we could get 95% of patients to a systolic blood pressure of 140 mm Hg, we’d see tremendous benefit,” he noted.

 

New role for BNP screening

Stage A patients are more than just the target for more aggressive hypertension control. They are now also potential candidates for screening for an elevated blood level of brain natriuretic peptide (BNP) or N-terminal (NT)–proBNP. The guidelines panel makes this a level IIa recommendation, saying that a screening BNP test in patients at risk for developing heart failure can be useful if followed by team-based care and optimized guideline directed medical therapy.

This guideline follows the lead of two successful controlled trials that focused more aggressive preventive treatments on stage A patients with an elevated level of BNP or NT-proBNP – the STOP-HF (JAMA. 2013 July 3;310[1]:66-74) and PONTIAC (J Am Coll Cardiol. 2013 Oct;62[15]:1365-72) trials. The target population for some type of BNP screening are patients with cardiovascular disease, vascular disease, diabetes, obesity, or hypertension, Dr. Yancy said. “It was evident in STOP-HF that, if you screened and intervened, you could make a difference” in the development of heart failure.

The STOP-HF intervention included “optimal risk factor management” and “coaching by a specialist nurse who emphasized individual risk status and the importance of adherence to medication and healthy lifestyle behaviors.”

The guidelines aren’t clear on which patients at risk for developing heart failure, stage A patients, should get screened with BNP or NT-proBNP. Dr. Jessup said that it’s for patients in whom a positive result would trigger more aggressive management.

Focusing BNP testing on patients with some clinical indication of risk for heart failure is the best way to boost diagnostic efficiency, suggested James L. Januzzi, MD, professor of medicine at Harvard Medical School and a heart failure cardiologist at Massachusetts General Hospital, both in Boston. He said that both BNP and NT-proBNP are equally good options for screening at-risk patients as markers of incident heart failure. Positive levels flagging left ventricular involvement would be a BNP of at least 50 pg/mL or an NT-pro-BNP of at least 125 pg/mL. Patients with levels like these need echocardiographic assessment, as well as optimization of blood pressure control, optimization of statin treatment, optimization of all their other medications, and, if the patient has diabetes, assessment for possible silent ischemia, said Dr. Januzzi.

Getting a BNP on a suspect patient can raise a red flag to the patient, as well as to the physician, that more intervention is needed. “It’s easy for a physician to ignore a high-risk patient who looks okay and feels okay.” A BNP or NT-proBNP test can pick out the patients who shouldn’t be ignored, Dr. Januzzi said.

HFpEF treatment now possible

Another groundbreaking change in the guidelines is inclusion, for the first time, of a medical treatment specific for HFpEF. The aldosterone receptor antagonists (ARAs) spironolactone and eplerenone received a class IIb recommendation: An ARA might be considered to decrease hospitalizations in patients with HFpEF with an ejection fraction of at least 45%, an elevated BNP or recent hospitalization, and good renal function and potassium level.

The “might be considered” recommendation is guarded but understandable given that the evidence comes from the somewhat controversial, post-hoc analysis of data from the pivotal TOPCAT trial (N Engl J Med. 2014 Apr 10;370[15]:1383-92) that focused on just the roughly half of patients seen at centers in North or South America (Circulation. 2015 Jan 6;131[1]:34-42).

“It would be irresponsible to overlook the potential that [ARAs] may help patients who looks like the ones enrolled in TOPCAT in the Americas,” said Dr. Yancy. “We blended evidence and pragmatism and said that the field needs this” treatment. He said that an ARA was a reasonable option for HFpEF patients with symptoms of heart failure and a positive biomarker test result.

Dr. Butler largely agreed. ARA treatment is for HFpEF patients with symptomatic heart failure and either a history of hospitalization or a high BNP level, he said.

“I was surprised by how strongly the committee felt there was a reasonable signal of help from ARAs in HFpEF,” said Dr. Jessup. “I believe in them too,” she added.

Dr. Jessup suggested targeting an ARA to a HFpEF patient with some hypertension, some volume problem, some peripheral edema, and a lot of breathlessness but with no underlying ischemia. “I use an ARA on these patients pretty quickly,” Dr. Jessup said. It’s best to start with a low dosage and see how the patient responds. “The best responders have a really stiff heart” and are usually not the more elderly HFpEF patients. ARA treatment also provides more steady volume control, superior to furosemide, she said.

 

Yet more additions

The revised guidelines contain even more changes. “We say that checking for anemia is important and how iron is an intervention that might make a difference,” said Dr. Jessup. Also, primary care physicians and cardiologists “should look for obstructive sleep apnea” in heart failure patients for whom “intervention with weight loss might help,” she said.

Another feature is the focus on tailored treatment, with many treatment elements that need customizing to each different type of heart failure patient. “Not every drug needs to be given to every patient,” Dr. Yancy warned.

The specifics of how to orchestrate all the guidelines into a coherent management plan may become clearer later this year, when the ACC/AHA group will release a follow-up “Heart Failure Pathways” document, aimed at bridging the gap between guidelines and actual clinical practice, Dr. Yancy said. “We want more value from writing the guidelines. The biggest obstacle is how to implement them,” and that’s what the pathways follow-up will address.

“The biggest challenge the societies have is how to motivate physicians and nurses to more aggressively treat heart failure,” said Dr. Butler.

Dr. Yancy and Dr. Jessup had no disclosures. Dr. Butler has been a consultant to 11 companies. Dr. Januzzi has been a consultant to Critical Diagnostics, Novartis, Phillips, Roche Diagnostics, and Sphingotec, and he has received research support from Amgen, Boehringer Ingelheim, Janssen, and Prevencio.

[email protected]

On Twitter @mitchelzoler

 

Dear Editor,

It is with great interest that we read the article “Hospitalists trained in family medicine seek critical care training pathway” by Claudia Stahl.¹ We would like to thank the authors for the article and at the same time emphasize the relevance and necessity of critical care knowledge for hospitalists taking care of critically ill patients.

It is a well-known fact that hospitalists provide an ICU level of services, especially in community hospitals. There are step-down or intermediate-care units across large hospitals, which also are staffed mostly by hospitalists. So we strongly support the family medicine track having a critical care training pathway, and at the same time encourage internal medicine graduates to pursue a critical care certification program. It not only is helpful, but at times also proven to be beneficial for hospitalists who care for critically ill patients to have critical care knowledge.

There was lot of excitement in 2012 when SHM and the Society of Critical Care Medicine (SCCM) issued a joint position paper proposing an expedited, 1-year, critical care fellowship for hospitalists with at least 3 years of clinical job experience, instead of the 2-year fellowship.² However, there was a quick backlash from the American College of Chest Physicians (ACCP) and the American Association of Critical-Care Nurses (AACN), who criticized the “inadequacy” of 1 year of fellowship training for HM physicians^3, and so the excitement abated.

It may not be possible for hospitalists to take 2- to 3-year breaks from their career to pursue a critical care fellowship. There are certain courses, like Fundamental Critical Care Support (FCCS) and critical care updates for hospitalists; however, the duration of these courses is not enough to give the exhaustive training that we need. Many hospitalists work week-on/week-off schedules, and we are willing to invest some of our off time to pursue a year-long course. We believe a year-long course, if structurally sound, might be able to teach the skill sets to provide quality care to our critically ill patients.

Considering the paucity of available critical care training, we believe there is a strong necessity to develop long-term critical care training targeted at hospitalists caring for critically ill patients. Whether you are a family medicine graduate, an internal medicine graduate, or an advanced practitioner, once you are a hospitalist you are a hospitalist for life – irrespective of your future practice – as you continuously strive for quality of patient care and patient safety and satisfaction.

Primary author

Venkatrao Medarametla, MBBS

Assistant Professor of Medicine, University of Massachusetts Medical School

Medical Director, Intermediate Care Unit, Baystate Medical Center

Hospital Medicine, Baystate Medical Center

[email protected]

Secondary authors

Prasanth Prabhakaran, MD

Sureshkumar Chirumamilla, MD

Hospital Medicine, Baystate Medical Center
 

References

1. http://www.the-hospitalist.org/hospitalist/article/133078/hospitalists-trained-family-medicine-seek-critical-care-training-pathway

2. Siegal EM, Dressler DD, Dichter JR, Gorman MJ, Lipsett PA. Training a hospitalist workforce to address the intensivist shortage in American hospitals: a position paper from the Society of Hospital Medicine and the Society of Critical Care Medicine. J Hosp Med. 2012;7:359-364.

3. Baumann MH, Simpson SQ, Stahl M, et al. First, do no harm: less training ≠ quality care. Chest. 2012;142:5-7.
 

 

Dear Editor,

It is with great interest that we read the article “Hospitalists trained in family medicine seek critical care training pathway” by Claudia Stahl.¹ We would like to thank the authors for the article and at the same time emphasize the relevance and necessity of critical care knowledge for hospitalists taking care of critically ill patients.

It is a well-known fact that hospitalists provide an ICU level of services, especially in community hospitals. There are step-down or intermediate-care units across large hospitals, which also are staffed mostly by hospitalists. So we strongly support the family medicine track having a critical care training pathway, and at the same time encourage internal medicine graduates to pursue a critical care certification program. It not only is helpful, but at times also proven to be beneficial for hospitalists who care for critically ill patients to have critical care knowledge.

There was lot of excitement in 2012 when SHM and the Society of Critical Care Medicine (SCCM) issued a joint position paper proposing an expedited, 1-year, critical care fellowship for hospitalists with at least 3 years of clinical job experience, instead of the 2-year fellowship.² However, there was a quick backlash from the American College of Chest Physicians (ACCP) and the American Association of Critical-Care Nurses (AACN), who criticized the “inadequacy” of 1 year of fellowship training for HM physicians^3, and so the excitement abated.

It may not be possible for hospitalists to take 2- to 3-year breaks from their career to pursue a critical care fellowship. There are certain courses, like Fundamental Critical Care Support (FCCS) and critical care updates for hospitalists; however, the duration of these courses is not enough to give the exhaustive training that we need. Many hospitalists work week-on/week-off schedules, and we are willing to invest some of our off time to pursue a year-long course. We believe a year-long course, if structurally sound, might be able to teach the skill sets to provide quality care to our critically ill patients.

Considering the paucity of available critical care training, we believe there is a strong necessity to develop long-term critical care training targeted at hospitalists caring for critically ill patients. Whether you are a family medicine graduate, an internal medicine graduate, or an advanced practitioner, once you are a hospitalist you are a hospitalist for life – irrespective of your future practice – as you continuously strive for quality of patient care and patient safety and satisfaction.

Primary author

Venkatrao Medarametla, MBBS

Assistant Professor of Medicine, University of Massachusetts Medical School

Medical Director, Intermediate Care Unit, Baystate Medical Center

Hospital Medicine, Baystate Medical Center

[email protected]

Secondary authors

Prasanth Prabhakaran, MD

Sureshkumar Chirumamilla, MD

Hospital Medicine, Baystate Medical Center
 

References

1. http://www.the-hospitalist.org/hospitalist/article/133078/hospitalists-trained-family-medicine-seek-critical-care-training-pathway

2. Siegal EM, Dressler DD, Dichter JR, Gorman MJ, Lipsett PA. Training a hospitalist workforce to address the intensivist shortage in American hospitals: a position paper from the Society of Hospital Medicine and the Society of Critical Care Medicine. J Hosp Med. 2012;7:359-364.

3. Baumann MH, Simpson SQ, Stahl M, et al. First, do no harm: less training ≠ quality care. Chest. 2012;142:5-7.
 

 

Dear Editor,

It is with great interest that we read the article “Hospitalists trained in family medicine seek critical care training pathway” by Claudia Stahl.¹ We would like to thank the authors for the article and at the same time emphasize the relevance and necessity of critical care knowledge for hospitalists taking care of critically ill patients.

It is a well-known fact that hospitalists provide an ICU level of services, especially in community hospitals. There are step-down or intermediate-care units across large hospitals, which also are staffed mostly by hospitalists. So we strongly support the family medicine track having a critical care training pathway, and at the same time encourage internal medicine graduates to pursue a critical care certification program. It not only is helpful, but at times also proven to be beneficial for hospitalists who care for critically ill patients to have critical care knowledge.

There was lot of excitement in 2012 when SHM and the Society of Critical Care Medicine (SCCM) issued a joint position paper proposing an expedited, 1-year, critical care fellowship for hospitalists with at least 3 years of clinical job experience, instead of the 2-year fellowship.² However, there was a quick backlash from the American College of Chest Physicians (ACCP) and the American Association of Critical-Care Nurses (AACN), who criticized the “inadequacy” of 1 year of fellowship training for HM physicians^3, and so the excitement abated.

It may not be possible for hospitalists to take 2- to 3-year breaks from their career to pursue a critical care fellowship. There are certain courses, like Fundamental Critical Care Support (FCCS) and critical care updates for hospitalists; however, the duration of these courses is not enough to give the exhaustive training that we need. Many hospitalists work week-on/week-off schedules, and we are willing to invest some of our off time to pursue a year-long course. We believe a year-long course, if structurally sound, might be able to teach the skill sets to provide quality care to our critically ill patients.

Considering the paucity of available critical care training, we believe there is a strong necessity to develop long-term critical care training targeted at hospitalists caring for critically ill patients. Whether you are a family medicine graduate, an internal medicine graduate, or an advanced practitioner, once you are a hospitalist you are a hospitalist for life – irrespective of your future practice – as you continuously strive for quality of patient care and patient safety and satisfaction.

Primary author

Venkatrao Medarametla, MBBS

Assistant Professor of Medicine, University of Massachusetts Medical School

Medical Director, Intermediate Care Unit, Baystate Medical Center

Hospital Medicine, Baystate Medical Center

[email protected]

Secondary authors

Prasanth Prabhakaran, MD

Sureshkumar Chirumamilla, MD

Hospital Medicine, Baystate Medical Center
 

References

1. http://www.the-hospitalist.org/hospitalist/article/133078/hospitalists-trained-family-medicine-seek-critical-care-training-pathway

2. Siegal EM, Dressler DD, Dichter JR, Gorman MJ, Lipsett PA. Training a hospitalist workforce to address the intensivist shortage in American hospitals: a position paper from the Society of Hospital Medicine and the Society of Critical Care Medicine. J Hosp Med. 2012;7:359-364.

3. Baumann MH, Simpson SQ, Stahl M, et al. First, do no harm: less training ≠ quality care. Chest. 2012;142:5-7.
 

 

We go to the altar together.

Last month, I wrote about onboarding and the important responsibility that everyone associated with a hospitalist program has to ensure that each new provider quickly comes to believe he or she made a terrific choice to join the group.

Upon reflection, it seems important to address the other side of this equation. I’m talking about the responsibilities that each candidate has when deciding whether to apply for a job, to interview, and to accept or reject a group’s offer.

The relationship between a hospitalist and the group he or she is part of is a lot like a marriage. Both parties go to the altar together, and the relationship is most likely to be successful when both enter it with their eyes open, having done their due diligence, and with an intention to align their interests and support each other. Here are some things every hospitalist should be thinking about as they assess potential job opportunities:

1. Be clear about your own needs, goals, and priorities. Before you embark on the job-hunting process, take time to do some careful introspection. My partner John Nelson is fond of saying that one of the key reasons many doctors choose to become hospitalists is that they prefer to “date” their practice rather than “marry” it. Which do you want? Are you willing to accept both the benefits and the costs of your preference? What are your short- and long-term career goals? In what part of the country do you want to live, and are you looking for an urban, suburban, or small-town environment? Is it important to be in a teaching setting? Are there specific pieces of work, such as ICU care or procedures, that you want to either pursue or avoid? What personal considerations, such as the needs of your spouse or kids, might limit your options? What structural aspects of the job are most important to you? Schedule? Daily workload? Compensation? I encourage you to think through these and other similar questions so that you are clear in your own mind about your personal job selection criteria. This will enable you to honestly articulate these things to others and to assess potential job opportunities in light of them.

Read the full text of this blog post at hospitalleader.org.
 

Leslie Flores is a founding partner at Nelson Flores Hospital Medicine Consultants, a consulting practice that has specialized in helping clients enhance the effectiveness and value of hospital medicine programs.

Also on The Hospital Leader …

Don’t Compare HM Group Part B Costs Hospital to Hospital by Brad Flansbaum, DO, MPH, MHM

Overcoming a Continued Physician Shortage by Danielle Scheurer, MD, MSCR, SFHM

Is Patient-Centered Care Bad for Resident Education? by Vineet Arora, MD, MPP, MHM

 

We go to the altar together.

Last month, I wrote about onboarding and the important responsibility that everyone associated with a hospitalist program has to ensure that each new provider quickly comes to believe he or she made a terrific choice to join the group.

Upon reflection, it seems important to address the other side of this equation. I’m talking about the responsibilities that each candidate has when deciding whether to apply for a job, to interview, and to accept or reject a group’s offer.

The relationship between a hospitalist and the group he or she is part of is a lot like a marriage. Both parties go to the altar together, and the relationship is most likely to be successful when both enter it with their eyes open, having done their due diligence, and with an intention to align their interests and support each other. Here are some things every hospitalist should be thinking about as they assess potential job opportunities:

1. Be clear about your own needs, goals, and priorities. Before you embark on the job-hunting process, take time to do some careful introspection. My partner John Nelson is fond of saying that one of the key reasons many doctors choose to become hospitalists is that they prefer to “date” their practice rather than “marry” it. Which do you want? Are you willing to accept both the benefits and the costs of your preference? What are your short- and long-term career goals? In what part of the country do you want to live, and are you looking for an urban, suburban, or small-town environment? Is it important to be in a teaching setting? Are there specific pieces of work, such as ICU care or procedures, that you want to either pursue or avoid? What personal considerations, such as the needs of your spouse or kids, might limit your options? What structural aspects of the job are most important to you? Schedule? Daily workload? Compensation? I encourage you to think through these and other similar questions so that you are clear in your own mind about your personal job selection criteria. This will enable you to honestly articulate these things to others and to assess potential job opportunities in light of them.

Read the full text of this blog post at hospitalleader.org.
 

Leslie Flores is a founding partner at Nelson Flores Hospital Medicine Consultants, a consulting practice that has specialized in helping clients enhance the effectiveness and value of hospital medicine programs.

Also on The Hospital Leader …

Don’t Compare HM Group Part B Costs Hospital to Hospital by Brad Flansbaum, DO, MPH, MHM

Overcoming a Continued Physician Shortage by Danielle Scheurer, MD, MSCR, SFHM

Is Patient-Centered Care Bad for Resident Education? by Vineet Arora, MD, MPP, MHM

 

We go to the altar together.

Last month, I wrote about onboarding and the important responsibility that everyone associated with a hospitalist program has to ensure that each new provider quickly comes to believe he or she made a terrific choice to join the group.

Upon reflection, it seems important to address the other side of this equation. I’m talking about the responsibilities that each candidate has when deciding whether to apply for a job, to interview, and to accept or reject a group’s offer.

The relationship between a hospitalist and the group he or she is part of is a lot like a marriage. Both parties go to the altar together, and the relationship is most likely to be successful when both enter it with their eyes open, having done their due diligence, and with an intention to align their interests and support each other. Here are some things every hospitalist should be thinking about as they assess potential job opportunities:

1. Be clear about your own needs, goals, and priorities. Before you embark on the job-hunting process, take time to do some careful introspection. My partner John Nelson is fond of saying that one of the key reasons many doctors choose to become hospitalists is that they prefer to “date” their practice rather than “marry” it. Which do you want? Are you willing to accept both the benefits and the costs of your preference? What are your short- and long-term career goals? In what part of the country do you want to live, and are you looking for an urban, suburban, or small-town environment? Is it important to be in a teaching setting? Are there specific pieces of work, such as ICU care or procedures, that you want to either pursue or avoid? What personal considerations, such as the needs of your spouse or kids, might limit your options? What structural aspects of the job are most important to you? Schedule? Daily workload? Compensation? I encourage you to think through these and other similar questions so that you are clear in your own mind about your personal job selection criteria. This will enable you to honestly articulate these things to others and to assess potential job opportunities in light of them.

Read the full text of this blog post at hospitalleader.org.
 

Leslie Flores is a founding partner at Nelson Flores Hospital Medicine Consultants, a consulting practice that has specialized in helping clients enhance the effectiveness and value of hospital medicine programs.

Also on The Hospital Leader …

Don’t Compare HM Group Part B Costs Hospital to Hospital by Brad Flansbaum, DO, MPH, MHM

Overcoming a Continued Physician Shortage by Danielle Scheurer, MD, MSCR, SFHM

Is Patient-Centered Care Bad for Resident Education? by Vineet Arora, MD, MPP, MHM

 

BACKGROUND: Antimicrobial stewardship programs (ASPs) have been advocated to improve antimicrobial utilization, but program implementation is variable.

OBJECTIVE: To determine associations of ASPs with facility characteristics and inpatient antimicrobial utilization measures in the Veterans Affairs (VA) system in 2012.

DESIGN: In 2012, the VA administered a survey on antimicrobial stewardship practices to designated ASP contacts at VA acute-care hospitals. From the survey, we identified 34 variables across three domains (evidence, organizational context, and facilitation) that were assessed, using multivariable LASSO (least absolute shrinkage and selection operator) regression, against four antimicrobial utilization measures: aggregate acute care antimicrobial use, antimicrobial use in patients with noninfectious primary discharge diagnoses, missed opportunities to convert from parenteral to oral antimicrobial therapy, and double anaerobic coverage.

SETTING: All 130 VA facilities with acute care services.

RESULTS: Variables associated with at least three favorable changes in antimicrobial utilization included presence of postgraduate physician/pharmacy training programs, number of antimicrobial-specific order sets, frequency of systematic de-escalation review, presence of pharmacists and/or infectious diseases (ID) attendings on acute care ward teams, and formal ID training of the lead ASP pharmacist. Variables associated with two unfavorable measures included bed size, the level of engagement with VA Antimicrobial Stewardship Task Force online resources, and utilization of antimicrobial stop orders.

CONCLUSIONS: Formalization of ASP processes and presence of pharmacy and ID expertise are associated with favorable utilization. Systematic de-escalation review and order set establishment may be high-yield interventions.

Also in JHM

High prevalence of inappropriate benzodiazepine and sedative hypnotic prescriptions among hospitalized older adults

AUTHORS: Elisabeth Anna Pek, MD, Andrew Remfry, MD, Ciara Pendrith, MSc, Chris Fan-Lun, BScPhm, R. Sacha Bhatia, MD, and Christine Soong, MD, MSc, SFHM

Incidence, predictors, and outcomes of hospital-acquired anemia

AUTHORS: Anil N. Makam, MD, MAS, Oanh K. Nguyen, MD, MAS, Christopher Clark, MPA, and Ethan A. Halm, MD, MPH

Association between radiologic incidental findings and resource utilization in patients admitted with chest pain in an urban medical center

AUTHORS: Venkat P. Gundareddy, MD, MPH, SFHM, Nisa M. Maruthur, MD, MHS, Abednego Chibungu, MD, Preetam Bollampally, MD, Regina Landis, MS, abd Shaker M. Eid, MD, MBA

Clinical utility of routine CBC testing in patients with community-acquired pneumonia

AUTHORS: Neelaysh Vukkadala, BS, and Andrew Auerbach, MD, MPH, SFHM

Overuse of troponin? A comprehensive evaluation of testing in a large hospital system

AUTHORS: Gibbs Wilson, MD, Kyler Barkley, MD, Kipp Slicker, DO, Robert Kowal, MD, PhD, Brandon Pope, PhD, and Jeffrey Michel, MD

 

BACKGROUND: Antimicrobial stewardship programs (ASPs) have been advocated to improve antimicrobial utilization, but program implementation is variable.

OBJECTIVE: To determine associations of ASPs with facility characteristics and inpatient antimicrobial utilization measures in the Veterans Affairs (VA) system in 2012.

DESIGN: In 2012, the VA administered a survey on antimicrobial stewardship practices to designated ASP contacts at VA acute-care hospitals. From the survey, we identified 34 variables across three domains (evidence, organizational context, and facilitation) that were assessed, using multivariable LASSO (least absolute shrinkage and selection operator) regression, against four antimicrobial utilization measures: aggregate acute care antimicrobial use, antimicrobial use in patients with noninfectious primary discharge diagnoses, missed opportunities to convert from parenteral to oral antimicrobial therapy, and double anaerobic coverage.

SETTING: All 130 VA facilities with acute care services.

RESULTS: Variables associated with at least three favorable changes in antimicrobial utilization included presence of postgraduate physician/pharmacy training programs, number of antimicrobial-specific order sets, frequency of systematic de-escalation review, presence of pharmacists and/or infectious diseases (ID) attendings on acute care ward teams, and formal ID training of the lead ASP pharmacist. Variables associated with two unfavorable measures included bed size, the level of engagement with VA Antimicrobial Stewardship Task Force online resources, and utilization of antimicrobial stop orders.

CONCLUSIONS: Formalization of ASP processes and presence of pharmacy and ID expertise are associated with favorable utilization. Systematic de-escalation review and order set establishment may be high-yield interventions.

Also in JHM

High prevalence of inappropriate benzodiazepine and sedative hypnotic prescriptions among hospitalized older adults

AUTHORS: Elisabeth Anna Pek, MD, Andrew Remfry, MD, Ciara Pendrith, MSc, Chris Fan-Lun, BScPhm, R. Sacha Bhatia, MD, and Christine Soong, MD, MSc, SFHM

Incidence, predictors, and outcomes of hospital-acquired anemia

AUTHORS: Anil N. Makam, MD, MAS, Oanh K. Nguyen, MD, MAS, Christopher Clark, MPA, and Ethan A. Halm, MD, MPH

Association between radiologic incidental findings and resource utilization in patients admitted with chest pain in an urban medical center

AUTHORS: Venkat P. Gundareddy, MD, MPH, SFHM, Nisa M. Maruthur, MD, MHS, Abednego Chibungu, MD, Preetam Bollampally, MD, Regina Landis, MS, abd Shaker M. Eid, MD, MBA

Clinical utility of routine CBC testing in patients with community-acquired pneumonia

AUTHORS: Neelaysh Vukkadala, BS, and Andrew Auerbach, MD, MPH, SFHM

Overuse of troponin? A comprehensive evaluation of testing in a large hospital system

AUTHORS: Gibbs Wilson, MD, Kyler Barkley, MD, Kipp Slicker, DO, Robert Kowal, MD, PhD, Brandon Pope, PhD, and Jeffrey Michel, MD

 

BACKGROUND: Antimicrobial stewardship programs (ASPs) have been advocated to improve antimicrobial utilization, but program implementation is variable.

OBJECTIVE: To determine associations of ASPs with facility characteristics and inpatient antimicrobial utilization measures in the Veterans Affairs (VA) system in 2012.

DESIGN: In 2012, the VA administered a survey on antimicrobial stewardship practices to designated ASP contacts at VA acute-care hospitals. From the survey, we identified 34 variables across three domains (evidence, organizational context, and facilitation) that were assessed, using multivariable LASSO (least absolute shrinkage and selection operator) regression, against four antimicrobial utilization measures: aggregate acute care antimicrobial use, antimicrobial use in patients with noninfectious primary discharge diagnoses, missed opportunities to convert from parenteral to oral antimicrobial therapy, and double anaerobic coverage.

SETTING: All 130 VA facilities with acute care services.

RESULTS: Variables associated with at least three favorable changes in antimicrobial utilization included presence of postgraduate physician/pharmacy training programs, number of antimicrobial-specific order sets, frequency of systematic de-escalation review, presence of pharmacists and/or infectious diseases (ID) attendings on acute care ward teams, and formal ID training of the lead ASP pharmacist. Variables associated with two unfavorable measures included bed size, the level of engagement with VA Antimicrobial Stewardship Task Force online resources, and utilization of antimicrobial stop orders.

CONCLUSIONS: Formalization of ASP processes and presence of pharmacy and ID expertise are associated with favorable utilization. Systematic de-escalation review and order set establishment may be high-yield interventions.

Also in JHM

High prevalence of inappropriate benzodiazepine and sedative hypnotic prescriptions among hospitalized older adults

AUTHORS: Elisabeth Anna Pek, MD, Andrew Remfry, MD, Ciara Pendrith, MSc, Chris Fan-Lun, BScPhm, R. Sacha Bhatia, MD, and Christine Soong, MD, MSc, SFHM

Incidence, predictors, and outcomes of hospital-acquired anemia

AUTHORS: Anil N. Makam, MD, MAS, Oanh K. Nguyen, MD, MAS, Christopher Clark, MPA, and Ethan A. Halm, MD, MPH

Association between radiologic incidental findings and resource utilization in patients admitted with chest pain in an urban medical center

AUTHORS: Venkat P. Gundareddy, MD, MPH, SFHM, Nisa M. Maruthur, MD, MHS, Abednego Chibungu, MD, Preetam Bollampally, MD, Regina Landis, MS, abd Shaker M. Eid, MD, MBA

Clinical utility of routine CBC testing in patients with community-acquired pneumonia

AUTHORS: Neelaysh Vukkadala, BS, and Andrew Auerbach, MD, MPH, SFHM

Overuse of troponin? A comprehensive evaluation of testing in a large hospital system

AUTHORS: Gibbs Wilson, MD, Kyler Barkley, MD, Kipp Slicker, DO, Robert Kowal, MD, PhD, Brandon Pope, PhD, and Jeffrey Michel, MD

 

High-dose oral iron therapy doesn’t improve exercise capacity in the estimated 50% of patients with symptomatic heart failure who also have iron deficiency, according to a report published online May 16 in JAMA.

Iron deficiency in patients with HF, regardless of their hemoglobin status, is associated with reduced functional capacity, poorer quality of life, and increased mortality. Iron plays a crucial role in the delivery and utilization of oxygen, and “cells with high-energy demands, including skeletal and cardiac myocytes, are particularly sensitive to depleted iron stores,” said Gregory D. Lewis, MD, of the pulmonary critical care unit of Massachusetts General Hospital, Boston, and his associates.

Saipg/iStockphoto

Intravenous iron repletion produces consistent clinical benefit in symptomatic HF patients with reduced left ventricular ejection fraction (LVEF) who also have iron deficiency. But repeated IV treatments are impractical for many patients, and clinicians have turned to prescribing oral iron supplements in the hope of achieving similar results. However, until now, no large randomized, controlled clinical trials have examined the effectiveness of the oral route of administration, Dr. Lewis and his associates noted.

The IRONOUT study was conducted at 23 U.S. medical centers, where outcomes after 16 weeks of oral iron therapy (150 mg twice daily) were compared against matching placebo in 225 patients. The median patient age was 63 years, and the median duration of HF was 5.7 years. Ischemic heart disease was the primary cause of HF in 78% of the study participants.

These patients had low LVEF and poor exercise capacity, despite having high rates of guideline-directed treatment with medications.

The primary endpoint was a change in peak oxygen uptake (peak VO₂) at the conclusion of treatment, a measure that “reflects the multiple mechanisms by which iron repletion is expected to improve systemic oxygen delivery and utilization.” Change in peak VO₂ was not significantly different between the 111 participants who took oral iron supplements (+23 mL/min) and the 114 who took placebo (–2 mL/min), the investigators wrote (JAMA Pediatr. 2017 May 16. doi: 10.1001/jama.2017.5427).

In subgroup analyses, oral iron also failed to improve peak VO₂ in any subgroup of patients: neither men nor women; neither those with decreased hemoglobin nor those with normal hemoglobin levels; nor patients with or without venous congestion at baseline. Oral iron also failed to improve secondary endpoints including 6-minute walk distance, quality of life scores, NT-proBNP levels, and ventilatory efficiency.

In contrast to previous studies of IV iron repletion, oral iron supplementation “produced minimal improvement in iron stores, implicating the route of administration rather than the strategy of iron repletion in the lack of clinical benefit,” Dr. Lewis and his associates said.

This study was funded by the National Heart, Lung, and Blood Institute, which also conceived, designed, and conducted the trial. Dr. Lewis reported ties to Abbott, Novartis, Shape Systems, Stealth Bio Therapeutics, Ironwood, Cheetah Medical, Luitpold, and SoniVie. His associates reported ties to numerous industry sources.

 

High-dose oral iron therapy doesn’t improve exercise capacity in the estimated 50% of patients with symptomatic heart failure who also have iron deficiency, according to a report published online May 16 in JAMA.

Iron deficiency in patients with HF, regardless of their hemoglobin status, is associated with reduced functional capacity, poorer quality of life, and increased mortality. Iron plays a crucial role in the delivery and utilization of oxygen, and “cells with high-energy demands, including skeletal and cardiac myocytes, are particularly sensitive to depleted iron stores,” said Gregory D. Lewis, MD, of the pulmonary critical care unit of Massachusetts General Hospital, Boston, and his associates.

Saipg/iStockphoto

Intravenous iron repletion produces consistent clinical benefit in symptomatic HF patients with reduced left ventricular ejection fraction (LVEF) who also have iron deficiency. But repeated IV treatments are impractical for many patients, and clinicians have turned to prescribing oral iron supplements in the hope of achieving similar results. However, until now, no large randomized, controlled clinical trials have examined the effectiveness of the oral route of administration, Dr. Lewis and his associates noted.

The IRONOUT study was conducted at 23 U.S. medical centers, where outcomes after 16 weeks of oral iron therapy (150 mg twice daily) were compared against matching placebo in 225 patients. The median patient age was 63 years, and the median duration of HF was 5.7 years. Ischemic heart disease was the primary cause of HF in 78% of the study participants.

These patients had low LVEF and poor exercise capacity, despite having high rates of guideline-directed treatment with medications.

The primary endpoint was a change in peak oxygen uptake (peak VO₂) at the conclusion of treatment, a measure that “reflects the multiple mechanisms by which iron repletion is expected to improve systemic oxygen delivery and utilization.” Change in peak VO₂ was not significantly different between the 111 participants who took oral iron supplements (+23 mL/min) and the 114 who took placebo (–2 mL/min), the investigators wrote (JAMA Pediatr. 2017 May 16. doi: 10.1001/jama.2017.5427).

In subgroup analyses, oral iron also failed to improve peak VO₂ in any subgroup of patients: neither men nor women; neither those with decreased hemoglobin nor those with normal hemoglobin levels; nor patients with or without venous congestion at baseline. Oral iron also failed to improve secondary endpoints including 6-minute walk distance, quality of life scores, NT-proBNP levels, and ventilatory efficiency.

In contrast to previous studies of IV iron repletion, oral iron supplementation “produced minimal improvement in iron stores, implicating the route of administration rather than the strategy of iron repletion in the lack of clinical benefit,” Dr. Lewis and his associates said.

This study was funded by the National Heart, Lung, and Blood Institute, which also conceived, designed, and conducted the trial. Dr. Lewis reported ties to Abbott, Novartis, Shape Systems, Stealth Bio Therapeutics, Ironwood, Cheetah Medical, Luitpold, and SoniVie. His associates reported ties to numerous industry sources.

 

High-dose oral iron therapy doesn’t improve exercise capacity in the estimated 50% of patients with symptomatic heart failure who also have iron deficiency, according to a report published online May 16 in JAMA.

Iron deficiency in patients with HF, regardless of their hemoglobin status, is associated with reduced functional capacity, poorer quality of life, and increased mortality. Iron plays a crucial role in the delivery and utilization of oxygen, and “cells with high-energy demands, including skeletal and cardiac myocytes, are particularly sensitive to depleted iron stores,” said Gregory D. Lewis, MD, of the pulmonary critical care unit of Massachusetts General Hospital, Boston, and his associates.

Saipg/iStockphoto

Intravenous iron repletion produces consistent clinical benefit in symptomatic HF patients with reduced left ventricular ejection fraction (LVEF) who also have iron deficiency. But repeated IV treatments are impractical for many patients, and clinicians have turned to prescribing oral iron supplements in the hope of achieving similar results. However, until now, no large randomized, controlled clinical trials have examined the effectiveness of the oral route of administration, Dr. Lewis and his associates noted.

The IRONOUT study was conducted at 23 U.S. medical centers, where outcomes after 16 weeks of oral iron therapy (150 mg twice daily) were compared against matching placebo in 225 patients. The median patient age was 63 years, and the median duration of HF was 5.7 years. Ischemic heart disease was the primary cause of HF in 78% of the study participants.

These patients had low LVEF and poor exercise capacity, despite having high rates of guideline-directed treatment with medications.

The primary endpoint was a change in peak oxygen uptake (peak VO₂) at the conclusion of treatment, a measure that “reflects the multiple mechanisms by which iron repletion is expected to improve systemic oxygen delivery and utilization.” Change in peak VO₂ was not significantly different between the 111 participants who took oral iron supplements (+23 mL/min) and the 114 who took placebo (–2 mL/min), the investigators wrote (JAMA Pediatr. 2017 May 16. doi: 10.1001/jama.2017.5427).

In subgroup analyses, oral iron also failed to improve peak VO₂ in any subgroup of patients: neither men nor women; neither those with decreased hemoglobin nor those with normal hemoglobin levels; nor patients with or without venous congestion at baseline. Oral iron also failed to improve secondary endpoints including 6-minute walk distance, quality of life scores, NT-proBNP levels, and ventilatory efficiency.

In contrast to previous studies of IV iron repletion, oral iron supplementation “produced minimal improvement in iron stores, implicating the route of administration rather than the strategy of iron repletion in the lack of clinical benefit,” Dr. Lewis and his associates said.

This study was funded by the National Heart, Lung, and Blood Institute, which also conceived, designed, and conducted the trial. Dr. Lewis reported ties to Abbott, Novartis, Shape Systems, Stealth Bio Therapeutics, Ironwood, Cheetah Medical, Luitpold, and SoniVie. His associates reported ties to numerous industry sources.

 

LAS VEGAS – Hyponatremia is not a salt problem, it’s a water problem.

That was the lead message in a well-attended rapid-fire session on hyponatremia at the annual meeting of the Society of Hospital Medicine.

“It’s almost always associated with pathologic elevations of ADH [antidiuretic hormone], and it’s that retention of water that dilutes the serum and drops the sodium, which causes the cerebral edema,” said Thomas Yacovella, MD, assistant professor of medicine at the University of Minnesota, Minneapolis.

Treatment of hyponatremia should always be predicated on how long it took for the condition to develop and the pathophysiology of the situation, Dr. Yacovella said. “It’s not quite as asymptomatic as you think,” he noted. Patients who present with several other medical issues often have low sodium levels, impaired cognitive abilities, and unstable gait. These could be cases of hyponatremia, he said.

“Remember that hyponatremia is a bad actor, especially when associated with a chronic disease,” Dr. Yacovella said. Serum sodium levels are a reliable surrogate for chronic heart failure related to hyponatremia. End-stage disease is when sodium levels are at 125 or less.

A basic work-up for hyponatremia starts with assessing fluid intake, history of medications and of any causes of ADH release, volume status assessment, and laboratory evaluations of blood and urine. The three keys to knowing how quickly hyponatremia can be reversed are severity of symptoms, how long it took for the condition to develop, and the risk of herniation vs. the risk of osmotic demyelination, he said.

In cases of osmotic demyelination, Dr. Yacovella advised monitoring urine osmolality and cases where ADH release could be quickly reversed. “When you don’t know for sure, go slow,” he said.

Exercise-associated hyponatremia is often caused by the perfect storm of sodium loss, high emotion, vomiting, pain, excessive water intake, and high ADH levels. This form of hyponatremia can occur postoperatively, but is more typically associated with the copious water ingestion that can occur during psychosis, extreme exercise, ecstasy ingestion, and “stupid” contests that involve extreme behavior, Dr. Yacovella said. His pearls for acute management of these kinds of hyponatremia were to administer a 100-mL bolus of hypertonic saline, and that a large output of dilute urine indicates corrective aquaresis.

Dr. Yacovella emphasized that in addition to remembering that hyponatremia is a water and not a salt problem, physicians should always look to “the path of physiology of the disease, and how long it took to develop the hyponatremia, and that will inform how quickly you can treat the patient.”

He had nothing to disclose.

[email protected]

On Twitter @whitneymcknight

 

LAS VEGAS – Hyponatremia is not a salt problem, it’s a water problem.

That was the lead message in a well-attended rapid-fire session on hyponatremia at the annual meeting of the Society of Hospital Medicine.

“It’s almost always associated with pathologic elevations of ADH [antidiuretic hormone], and it’s that retention of water that dilutes the serum and drops the sodium, which causes the cerebral edema,” said Thomas Yacovella, MD, assistant professor of medicine at the University of Minnesota, Minneapolis.

Treatment of hyponatremia should always be predicated on how long it took for the condition to develop and the pathophysiology of the situation, Dr. Yacovella said. “It’s not quite as asymptomatic as you think,” he noted. Patients who present with several other medical issues often have low sodium levels, impaired cognitive abilities, and unstable gait. These could be cases of hyponatremia, he said.

“Remember that hyponatremia is a bad actor, especially when associated with a chronic disease,” Dr. Yacovella said. Serum sodium levels are a reliable surrogate for chronic heart failure related to hyponatremia. End-stage disease is when sodium levels are at 125 or less.

A basic work-up for hyponatremia starts with assessing fluid intake, history of medications and of any causes of ADH release, volume status assessment, and laboratory evaluations of blood and urine. The three keys to knowing how quickly hyponatremia can be reversed are severity of symptoms, how long it took for the condition to develop, and the risk of herniation vs. the risk of osmotic demyelination, he said.

In cases of osmotic demyelination, Dr. Yacovella advised monitoring urine osmolality and cases where ADH release could be quickly reversed. “When you don’t know for sure, go slow,” he said.

Exercise-associated hyponatremia is often caused by the perfect storm of sodium loss, high emotion, vomiting, pain, excessive water intake, and high ADH levels. This form of hyponatremia can occur postoperatively, but is more typically associated with the copious water ingestion that can occur during psychosis, extreme exercise, ecstasy ingestion, and “stupid” contests that involve extreme behavior, Dr. Yacovella said. His pearls for acute management of these kinds of hyponatremia were to administer a 100-mL bolus of hypertonic saline, and that a large output of dilute urine indicates corrective aquaresis.

Dr. Yacovella emphasized that in addition to remembering that hyponatremia is a water and not a salt problem, physicians should always look to “the path of physiology of the disease, and how long it took to develop the hyponatremia, and that will inform how quickly you can treat the patient.”

He had nothing to disclose.

[email protected]

On Twitter @whitneymcknight

 

LAS VEGAS – Hyponatremia is not a salt problem, it’s a water problem.

That was the lead message in a well-attended rapid-fire session on hyponatremia at the annual meeting of the Society of Hospital Medicine.

“It’s almost always associated with pathologic elevations of ADH [antidiuretic hormone], and it’s that retention of water that dilutes the serum and drops the sodium, which causes the cerebral edema,” said Thomas Yacovella, MD, assistant professor of medicine at the University of Minnesota, Minneapolis.

Treatment of hyponatremia should always be predicated on how long it took for the condition to develop and the pathophysiology of the situation, Dr. Yacovella said. “It’s not quite as asymptomatic as you think,” he noted. Patients who present with several other medical issues often have low sodium levels, impaired cognitive abilities, and unstable gait. These could be cases of hyponatremia, he said.

“Remember that hyponatremia is a bad actor, especially when associated with a chronic disease,” Dr. Yacovella said. Serum sodium levels are a reliable surrogate for chronic heart failure related to hyponatremia. End-stage disease is when sodium levels are at 125 or less.

A basic work-up for hyponatremia starts with assessing fluid intake, history of medications and of any causes of ADH release, volume status assessment, and laboratory evaluations of blood and urine. The three keys to knowing how quickly hyponatremia can be reversed are severity of symptoms, how long it took for the condition to develop, and the risk of herniation vs. the risk of osmotic demyelination, he said.

In cases of osmotic demyelination, Dr. Yacovella advised monitoring urine osmolality and cases where ADH release could be quickly reversed. “When you don’t know for sure, go slow,” he said.

Exercise-associated hyponatremia is often caused by the perfect storm of sodium loss, high emotion, vomiting, pain, excessive water intake, and high ADH levels. This form of hyponatremia can occur postoperatively, but is more typically associated with the copious water ingestion that can occur during psychosis, extreme exercise, ecstasy ingestion, and “stupid” contests that involve extreme behavior, Dr. Yacovella said. His pearls for acute management of these kinds of hyponatremia were to administer a 100-mL bolus of hypertonic saline, and that a large output of dilute urine indicates corrective aquaresis.

Dr. Yacovella emphasized that in addition to remembering that hyponatremia is a water and not a salt problem, physicians should always look to “the path of physiology of the disease, and how long it took to develop the hyponatremia, and that will inform how quickly you can treat the patient.”

He had nothing to disclose.

[email protected]

On Twitter @whitneymcknight