The Hospitalist

SAN DIEGO – Rising rates of pediatric venous thromboembolism in the United States underscore the need to carefully weigh the risks and benefits of placing central lines, Julie Jaffray, MD, said at the annual meeting of the American Society of Hematology.

Peripherally inserted central catheters (PICCs) are especially likely to lead to deep vein thrombosis in children, said Dr. Jaffray of Children’s Hospital Los Angeles, University of Southern California. Children and adolescents who received PICCs had about fourfold the rate of this outcome in the next 6 months as did those who received tunneled lines, based on interim results from her first-in-kind, prospective multicenter observational study.

Amy Karon

Earlier research has shown that the placement of PICCs approximately doubled at Children’s Hospital Los Angeles between 2005 and 2012, while the use of tunneled lines remained constant at a much-lower rate, Dr. Jaffray noted.

To better understand how central lines contribute to pediatric thrombotic events, she and her associates at the Children’s Hospital of Philadelphia and Texas Children’s Hospital in Houston are studying patients aged 6 months to 18 years who had these devices placed at their centers starting in 2013. To parse out risk factors, the investigators are analyzing numerous relevant keywords from nursing notes and other parts of electronic health records.

As of October 2016, the study included 1,096 patients who received a total of 1,233 central lines related to the treatment of cancer, infection, and other serious conditions. Among 827 PICC recipients, the 6-month cumulative rate of venous thromboembolism was 7.5%. In contrast, only 406 patients received tunneled lines, and only 2% developed venous thromboembolism (P = .004).

But tunneled lines had their own risks. About 16% of recipients developed CLABSI within 6 months, compared with 9% of children who received PICCs (P = .005). The overall rate of CLABSI was 12%, Dr. Jaffray noted.

Thromboses were identified a median of 15 days after PICC placement and 40 days after tunneled line placement, she said. Children with leukemia, other cancers, and congenital heart disease were at significantly increased risk of venous thromboembolism, as were children who received multilumen catheters, she noted.

Ongoing analyses should lead to new guidelines on pediatric catheter selection, insertion techniques, and the prophylactic use of anticoagulation or antiseptics, Dr. Jaffray said. She also is planning a separate study of children younger than 6 months, to examine their unique coagulation systems, she added.

The conclusion at this point is that two-thirds of this cohort received PICCs instead of tunneled lines, and 85% of venous thromboembolism episodes occurred in PICC recipients, Dr. Jaffray emphasized. “Due to their ease of insertion, PICCs are being placed at increasing rates in some pediatric centers, [and] this may be the leading factor for the increasing incidence of pediatric venous thromboembolism,” she commented. “A lot of us pediatric treaters aren’t necessarily giving anticoagulation for an incidental clot, but I think this is something we certainly need to look at. And maybe if we can choose the patients who are at highest risk of VTE, we can consider prophylactic anticoagulation in those kids.”

Dr. Jaffray did not report funding sources and had no relevant financial disclosures.

SAN DIEGO – Rising rates of pediatric venous thromboembolism in the United States underscore the need to carefully weigh the risks and benefits of placing central lines, Julie Jaffray, MD, said at the annual meeting of the American Society of Hematology.

Peripherally inserted central catheters (PICCs) are especially likely to lead to deep vein thrombosis in children, said Dr. Jaffray of Children’s Hospital Los Angeles, University of Southern California. Children and adolescents who received PICCs had about fourfold the rate of this outcome in the next 6 months as did those who received tunneled lines, based on interim results from her first-in-kind, prospective multicenter observational study.

Amy Karon

Earlier research has shown that the placement of PICCs approximately doubled at Children’s Hospital Los Angeles between 2005 and 2012, while the use of tunneled lines remained constant at a much-lower rate, Dr. Jaffray noted.

To better understand how central lines contribute to pediatric thrombotic events, she and her associates at the Children’s Hospital of Philadelphia and Texas Children’s Hospital in Houston are studying patients aged 6 months to 18 years who had these devices placed at their centers starting in 2013. To parse out risk factors, the investigators are analyzing numerous relevant keywords from nursing notes and other parts of electronic health records.

As of October 2016, the study included 1,096 patients who received a total of 1,233 central lines related to the treatment of cancer, infection, and other serious conditions. Among 827 PICC recipients, the 6-month cumulative rate of venous thromboembolism was 7.5%. In contrast, only 406 patients received tunneled lines, and only 2% developed venous thromboembolism (P = .004).

But tunneled lines had their own risks. About 16% of recipients developed CLABSI within 6 months, compared with 9% of children who received PICCs (P = .005). The overall rate of CLABSI was 12%, Dr. Jaffray noted.

Thromboses were identified a median of 15 days after PICC placement and 40 days after tunneled line placement, she said. Children with leukemia, other cancers, and congenital heart disease were at significantly increased risk of venous thromboembolism, as were children who received multilumen catheters, she noted.

Ongoing analyses should lead to new guidelines on pediatric catheter selection, insertion techniques, and the prophylactic use of anticoagulation or antiseptics, Dr. Jaffray said. She also is planning a separate study of children younger than 6 months, to examine their unique coagulation systems, she added.

The conclusion at this point is that two-thirds of this cohort received PICCs instead of tunneled lines, and 85% of venous thromboembolism episodes occurred in PICC recipients, Dr. Jaffray emphasized. “Due to their ease of insertion, PICCs are being placed at increasing rates in some pediatric centers, [and] this may be the leading factor for the increasing incidence of pediatric venous thromboembolism,” she commented. “A lot of us pediatric treaters aren’t necessarily giving anticoagulation for an incidental clot, but I think this is something we certainly need to look at. And maybe if we can choose the patients who are at highest risk of VTE, we can consider prophylactic anticoagulation in those kids.”

Dr. Jaffray did not report funding sources and had no relevant financial disclosures.

SAN DIEGO – Rising rates of pediatric venous thromboembolism in the United States underscore the need to carefully weigh the risks and benefits of placing central lines, Julie Jaffray, MD, said at the annual meeting of the American Society of Hematology.

Peripherally inserted central catheters (PICCs) are especially likely to lead to deep vein thrombosis in children, said Dr. Jaffray of Children’s Hospital Los Angeles, University of Southern California. Children and adolescents who received PICCs had about fourfold the rate of this outcome in the next 6 months as did those who received tunneled lines, based on interim results from her first-in-kind, prospective multicenter observational study.

Amy Karon

Earlier research has shown that the placement of PICCs approximately doubled at Children’s Hospital Los Angeles between 2005 and 2012, while the use of tunneled lines remained constant at a much-lower rate, Dr. Jaffray noted.

To better understand how central lines contribute to pediatric thrombotic events, she and her associates at the Children’s Hospital of Philadelphia and Texas Children’s Hospital in Houston are studying patients aged 6 months to 18 years who had these devices placed at their centers starting in 2013. To parse out risk factors, the investigators are analyzing numerous relevant keywords from nursing notes and other parts of electronic health records.

As of October 2016, the study included 1,096 patients who received a total of 1,233 central lines related to the treatment of cancer, infection, and other serious conditions. Among 827 PICC recipients, the 6-month cumulative rate of venous thromboembolism was 7.5%. In contrast, only 406 patients received tunneled lines, and only 2% developed venous thromboembolism (P = .004).

But tunneled lines had their own risks. About 16% of recipients developed CLABSI within 6 months, compared with 9% of children who received PICCs (P = .005). The overall rate of CLABSI was 12%, Dr. Jaffray noted.

Thromboses were identified a median of 15 days after PICC placement and 40 days after tunneled line placement, she said. Children with leukemia, other cancers, and congenital heart disease were at significantly increased risk of venous thromboembolism, as were children who received multilumen catheters, she noted.

Ongoing analyses should lead to new guidelines on pediatric catheter selection, insertion techniques, and the prophylactic use of anticoagulation or antiseptics, Dr. Jaffray said. She also is planning a separate study of children younger than 6 months, to examine their unique coagulation systems, she added.

The conclusion at this point is that two-thirds of this cohort received PICCs instead of tunneled lines, and 85% of venous thromboembolism episodes occurred in PICC recipients, Dr. Jaffray emphasized. “Due to their ease of insertion, PICCs are being placed at increasing rates in some pediatric centers, [and] this may be the leading factor for the increasing incidence of pediatric venous thromboembolism,” she commented. “A lot of us pediatric treaters aren’t necessarily giving anticoagulation for an incidental clot, but I think this is something we certainly need to look at. And maybe if we can choose the patients who are at highest risk of VTE, we can consider prophylactic anticoagulation in those kids.”

Dr. Jaffray did not report funding sources and had no relevant financial disclosures.

NEW ORLEANS – The Centers for Medicare & Medicaid Services policy providing financial incentives for hospitals to readmit patients for heart failure for an observational stay rather than as an inpatient is antithetical to the patients’ best interests, according to data presented at the American Heart Association scientific sessions.

“We showed that if you get admitted under observation, the risk of you coming back is much higher than if you’re under an inpatient stay,” said Ahmad Masri, MBBS, of the University of Pittsburgh.

Bruce Jancin/Frontline Medical News

[email protected]
 

NEW ORLEANS – The Centers for Medicare & Medicaid Services policy providing financial incentives for hospitals to readmit patients for heart failure for an observational stay rather than as an inpatient is antithetical to the patients’ best interests, according to data presented at the American Heart Association scientific sessions.

“We showed that if you get admitted under observation, the risk of you coming back is much higher than if you’re under an inpatient stay,” said Ahmad Masri, MBBS, of the University of Pittsburgh.

Bruce Jancin/Frontline Medical News

[email protected]
 

NEW ORLEANS – The Centers for Medicare & Medicaid Services policy providing financial incentives for hospitals to readmit patients for heart failure for an observational stay rather than as an inpatient is antithetical to the patients’ best interests, according to data presented at the American Heart Association scientific sessions.

“We showed that if you get admitted under observation, the risk of you coming back is much higher than if you’re under an inpatient stay,” said Ahmad Masri, MBBS, of the University of Pittsburgh.

Bruce Jancin/Frontline Medical News

[email protected]
 

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

At every opportunity, I position and endorse my colleagues who are or will be participating in my patient’s care by describing their roles and expressing my confidence in their abilities.

Why I Do It

It is vital that our patients feel assured they are being cared for by a high-functioning team of experts. During any given hospital stay, our patients will meet consulting physicians, nurses, therapists, case managers … The list goes on and on. Each person plays a vital part in patients’ care. But it can be difficult for patients to understand every person’s role and to feel assured that each person is highly skilled and aligned with the care plan.

As hospitalists, we are in a unique position to provide a foundation of assuredness and confidence that is a cornerstone of patient experience before our teammates meet patients. When we miss this opportunity, our patients perceive us as a sea of white coats passing in and out of their rooms rather than a cohesive team with their best interests at heart.

How I Do It

Let’s take the example of an elderly patient admitted for a hip fracture after a fall. Alongside the hospitalist will be the orthopedic surgeon, nurse, physical therapist, and case manager, all working toward an optimal outcome. In each case, the hospitalist can choose to provide no information about these team members or to position them for a positive first impression.

Here are the steps to take when positioning colleagues with patients:

1. Identify team members and explain their roles.
2. Endorse colleagues by expressing honest confidence in their expertise and ability.
3. Describe how communication between you and your team members will work.
4. Assure the patient that during handoff, your colleagues will be up-to-date and aligned with the plan.
5. Tell your patients they are part of a team dedicated to a safe and effective hospitalization.

Mark Shapiro, MD, is medical director for hospital medicine at St. Joseph Health Medical Group in Santa Rosa, Calif., and producer and host of Explore the Space podcast (explorethespaceshow.com).

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

At every opportunity, I position and endorse my colleagues who are or will be participating in my patient’s care by describing their roles and expressing my confidence in their abilities.

Why I Do It

It is vital that our patients feel assured they are being cared for by a high-functioning team of experts. During any given hospital stay, our patients will meet consulting physicians, nurses, therapists, case managers … The list goes on and on. Each person plays a vital part in patients’ care. But it can be difficult for patients to understand every person’s role and to feel assured that each person is highly skilled and aligned with the care plan.

As hospitalists, we are in a unique position to provide a foundation of assuredness and confidence that is a cornerstone of patient experience before our teammates meet patients. When we miss this opportunity, our patients perceive us as a sea of white coats passing in and out of their rooms rather than a cohesive team with their best interests at heart.

How I Do It

Let’s take the example of an elderly patient admitted for a hip fracture after a fall. Alongside the hospitalist will be the orthopedic surgeon, nurse, physical therapist, and case manager, all working toward an optimal outcome. In each case, the hospitalist can choose to provide no information about these team members or to position them for a positive first impression.

Here are the steps to take when positioning colleagues with patients:

1. Identify team members and explain their roles.
2. Endorse colleagues by expressing honest confidence in their expertise and ability.
3. Describe how communication between you and your team members will work.
4. Assure the patient that during handoff, your colleagues will be up-to-date and aligned with the plan.
5. Tell your patients they are part of a team dedicated to a safe and effective hospitalization.

Mark Shapiro, MD, is medical director for hospital medicine at St. Joseph Health Medical Group in Santa Rosa, Calif., and producer and host of Explore the Space podcast (explorethespaceshow.com).

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

At every opportunity, I position and endorse my colleagues who are or will be participating in my patient’s care by describing their roles and expressing my confidence in their abilities.

Why I Do It

It is vital that our patients feel assured they are being cared for by a high-functioning team of experts. During any given hospital stay, our patients will meet consulting physicians, nurses, therapists, case managers … The list goes on and on. Each person plays a vital part in patients’ care. But it can be difficult for patients to understand every person’s role and to feel assured that each person is highly skilled and aligned with the care plan.

As hospitalists, we are in a unique position to provide a foundation of assuredness and confidence that is a cornerstone of patient experience before our teammates meet patients. When we miss this opportunity, our patients perceive us as a sea of white coats passing in and out of their rooms rather than a cohesive team with their best interests at heart.

How I Do It

Let’s take the example of an elderly patient admitted for a hip fracture after a fall. Alongside the hospitalist will be the orthopedic surgeon, nurse, physical therapist, and case manager, all working toward an optimal outcome. In each case, the hospitalist can choose to provide no information about these team members or to position them for a positive first impression.

Here are the steps to take when positioning colleagues with patients:

1. Identify team members and explain their roles.
2. Endorse colleagues by expressing honest confidence in their expertise and ability.
3. Describe how communication between you and your team members will work.
4. Assure the patient that during handoff, your colleagues will be up-to-date and aligned with the plan.
5. Tell your patients they are part of a team dedicated to a safe and effective hospitalization.

Mark Shapiro, MD, is medical director for hospital medicine at St. Joseph Health Medical Group in Santa Rosa, Calif., and producer and host of Explore the Space podcast (explorethespaceshow.com).

Patients with normal platelet counts who have a GI bleed while on antiplatelets were almost six times more likely to die in the hospital if they had a platelet transfusion in a retrospective cohort study from the Yale University in New Haven, Conn.

Ten of the 14 deaths in the 204 transfused patients – versus none of the 3 deaths in the 204 nontransfused patients - were due to bleeding, so it’s possible that the mortality difference was simply because patients with worse bleeding were more likely to get transfused. “On the other hand, the adjusted [odds ratios] for mortality (4.5-6.8 with different sensitivity analyses) [were] large, increasing the likelihood of a cause-and-effect relationship,” said investigators led by gastroenterologist Liam Zakko, MD, now at the Mayo Clinic in Rochester, Minn. (Clin Gastroenterol Hepatol. 2016 Jul 25. doi: 10.1016/j.cgh.2016.07.017).

Current guidelines suggest platelet transfusions are an option for antiplatelet patients with serious GI bleeds, but the Yale team found that they did not reduce rebleeding. “The observation of increased mortality without documentation of clinical benefit suggests a very cautious approach to the use of platelet transfusion. ... We do not support the use of platelet transfusions in patients with GI [bleeds] who are taking antiplatelet agents,” the investigators wrote.

Subjects in the two groups were matched for sex, age, and GI bleed location, and all had platelet counts above 100 × 10⁹/L. Almost everyone was on aspirin for cardiovascular protection, and 30% were on also on clopidogrel.

Just over half in both groups had upper GI bleeds, and about 40% in each group had colonic bleeds. Transfused patients had more-severe bleeding, with overall lower blood pressure and lower hemoglobin; a larger proportion was admitted to the ICU.

On univariate analyses, platelet patients had more cardiovascular events (23% vs. 13%) while in the hospital. They were also more likely to stay in the hospital for more than 4 days (47% vs. 33%) and more likely to die while there (7% vs. 1%). On multivariable analysis, only the greater risk for death during admission remained statistically significant (odds ratio, 5.57; 95% confidence interval, 1.52-27.1). The adjusted odds ratio for recurrent bleeding was not significant.

Four patients in the platelet group died from cardiovascular causes. One patient in the control group had a fatal cardiovascular event.

Although counterintuitive, the authors said that it’s possible that platelet transfusions might actually increase the risk of severe and fatal GI bleeding. “Mechanisms by which platelet transfusion would increase mortality or [GI bleeding]–related mortality are not clear,” but “platelet transfusions are reported to be proinflammatory and alter recipient immunity,” they said.

At least for now, “the most prudent way to manage patients on antiplatelet agents with [GI bleeding] is to follow current evidence-based recommendations,” including early endoscopy, endoscopic hemostatic therapy for high-risk lesions, and intensive proton pump inhibitor therapy in patients with ulcers and high-risk endoscopic features.

“Although not based on high-quality evidence, we believe that hemostatic techniques that do not cause significant tissue damage (e.g., clips rather than thermal devices or sclerosants) should be used in patients on antiplatelet agents, especially if patients are expected to remain on these agents in the future,” they said.

The mean age in the study was 74 years, and about two-thirds of the subjects were men.

The authors had no disclosures.

[email protected]

Patients with normal platelet counts who have a GI bleed while on antiplatelets were almost six times more likely to die in the hospital if they had a platelet transfusion in a retrospective cohort study from the Yale University in New Haven, Conn.

Ten of the 14 deaths in the 204 transfused patients – versus none of the 3 deaths in the 204 nontransfused patients - were due to bleeding, so it’s possible that the mortality difference was simply because patients with worse bleeding were more likely to get transfused. “On the other hand, the adjusted [odds ratios] for mortality (4.5-6.8 with different sensitivity analyses) [were] large, increasing the likelihood of a cause-and-effect relationship,” said investigators led by gastroenterologist Liam Zakko, MD, now at the Mayo Clinic in Rochester, Minn. (Clin Gastroenterol Hepatol. 2016 Jul 25. doi: 10.1016/j.cgh.2016.07.017).

Current guidelines suggest platelet transfusions are an option for antiplatelet patients with serious GI bleeds, but the Yale team found that they did not reduce rebleeding. “The observation of increased mortality without documentation of clinical benefit suggests a very cautious approach to the use of platelet transfusion. ... We do not support the use of platelet transfusions in patients with GI [bleeds] who are taking antiplatelet agents,” the investigators wrote.

Subjects in the two groups were matched for sex, age, and GI bleed location, and all had platelet counts above 100 × 10⁹/L. Almost everyone was on aspirin for cardiovascular protection, and 30% were on also on clopidogrel.

Just over half in both groups had upper GI bleeds, and about 40% in each group had colonic bleeds. Transfused patients had more-severe bleeding, with overall lower blood pressure and lower hemoglobin; a larger proportion was admitted to the ICU.

On univariate analyses, platelet patients had more cardiovascular events (23% vs. 13%) while in the hospital. They were also more likely to stay in the hospital for more than 4 days (47% vs. 33%) and more likely to die while there (7% vs. 1%). On multivariable analysis, only the greater risk for death during admission remained statistically significant (odds ratio, 5.57; 95% confidence interval, 1.52-27.1). The adjusted odds ratio for recurrent bleeding was not significant.

Four patients in the platelet group died from cardiovascular causes. One patient in the control group had a fatal cardiovascular event.

Although counterintuitive, the authors said that it’s possible that platelet transfusions might actually increase the risk of severe and fatal GI bleeding. “Mechanisms by which platelet transfusion would increase mortality or [GI bleeding]–related mortality are not clear,” but “platelet transfusions are reported to be proinflammatory and alter recipient immunity,” they said.

At least for now, “the most prudent way to manage patients on antiplatelet agents with [GI bleeding] is to follow current evidence-based recommendations,” including early endoscopy, endoscopic hemostatic therapy for high-risk lesions, and intensive proton pump inhibitor therapy in patients with ulcers and high-risk endoscopic features.

“Although not based on high-quality evidence, we believe that hemostatic techniques that do not cause significant tissue damage (e.g., clips rather than thermal devices or sclerosants) should be used in patients on antiplatelet agents, especially if patients are expected to remain on these agents in the future,” they said.

The mean age in the study was 74 years, and about two-thirds of the subjects were men.

The authors had no disclosures.

[email protected]

Patients with normal platelet counts who have a GI bleed while on antiplatelets were almost six times more likely to die in the hospital if they had a platelet transfusion in a retrospective cohort study from the Yale University in New Haven, Conn.

Ten of the 14 deaths in the 204 transfused patients – versus none of the 3 deaths in the 204 nontransfused patients - were due to bleeding, so it’s possible that the mortality difference was simply because patients with worse bleeding were more likely to get transfused. “On the other hand, the adjusted [odds ratios] for mortality (4.5-6.8 with different sensitivity analyses) [were] large, increasing the likelihood of a cause-and-effect relationship,” said investigators led by gastroenterologist Liam Zakko, MD, now at the Mayo Clinic in Rochester, Minn. (Clin Gastroenterol Hepatol. 2016 Jul 25. doi: 10.1016/j.cgh.2016.07.017).

Current guidelines suggest platelet transfusions are an option for antiplatelet patients with serious GI bleeds, but the Yale team found that they did not reduce rebleeding. “The observation of increased mortality without documentation of clinical benefit suggests a very cautious approach to the use of platelet transfusion. ... We do not support the use of platelet transfusions in patients with GI [bleeds] who are taking antiplatelet agents,” the investigators wrote.

Subjects in the two groups were matched for sex, age, and GI bleed location, and all had platelet counts above 100 × 10⁹/L. Almost everyone was on aspirin for cardiovascular protection, and 30% were on also on clopidogrel.

Just over half in both groups had upper GI bleeds, and about 40% in each group had colonic bleeds. Transfused patients had more-severe bleeding, with overall lower blood pressure and lower hemoglobin; a larger proportion was admitted to the ICU.

On univariate analyses, platelet patients had more cardiovascular events (23% vs. 13%) while in the hospital. They were also more likely to stay in the hospital for more than 4 days (47% vs. 33%) and more likely to die while there (7% vs. 1%). On multivariable analysis, only the greater risk for death during admission remained statistically significant (odds ratio, 5.57; 95% confidence interval, 1.52-27.1). The adjusted odds ratio for recurrent bleeding was not significant.

Four patients in the platelet group died from cardiovascular causes. One patient in the control group had a fatal cardiovascular event.

Although counterintuitive, the authors said that it’s possible that platelet transfusions might actually increase the risk of severe and fatal GI bleeding. “Mechanisms by which platelet transfusion would increase mortality or [GI bleeding]–related mortality are not clear,” but “platelet transfusions are reported to be proinflammatory and alter recipient immunity,” they said.

At least for now, “the most prudent way to manage patients on antiplatelet agents with [GI bleeding] is to follow current evidence-based recommendations,” including early endoscopy, endoscopic hemostatic therapy for high-risk lesions, and intensive proton pump inhibitor therapy in patients with ulcers and high-risk endoscopic features.

“Although not based on high-quality evidence, we believe that hemostatic techniques that do not cause significant tissue damage (e.g., clips rather than thermal devices or sclerosants) should be used in patients on antiplatelet agents, especially if patients are expected to remain on these agents in the future,” they said.

The mean age in the study was 74 years, and about two-thirds of the subjects were men.

The authors had no disclosures.

[email protected]

CORONADO, CALIF. – Variation in readmission risk across hospitals following certain surgical procedures is more attributable to hospital factors than to patient characteristics, results from a large analysis demonstrated.

Such is the impact of the care delivery macro environment (CDM), which Sarah A. Brownlee and coauthors defined as a series of complex interactions between patient characteristics and imposed hospital attributes than can impact patient outcomes postoperatively.

[email protected]

CORONADO, CALIF. – Variation in readmission risk across hospitals following certain surgical procedures is more attributable to hospital factors than to patient characteristics, results from a large analysis demonstrated.

Such is the impact of the care delivery macro environment (CDM), which Sarah A. Brownlee and coauthors defined as a series of complex interactions between patient characteristics and imposed hospital attributes than can impact patient outcomes postoperatively.

[email protected]

CORONADO, CALIF. – Variation in readmission risk across hospitals following certain surgical procedures is more attributable to hospital factors than to patient characteristics, results from a large analysis demonstrated.

Such is the impact of the care delivery macro environment (CDM), which Sarah A. Brownlee and coauthors defined as a series of complex interactions between patient characteristics and imposed hospital attributes than can impact patient outcomes postoperatively.

[email protected]

Venous thromboembolism (VTE), which includes deep venous thrombosis (DVT) and pulmonary embolism (PE), continues to be a major cause of morbidity and mortality among hospitalized patients. Although it is well-known that anticoagulation therapy is effective in the prevention and treatment of VTE events, these agents are some of the highest-risk medications a hospitalist will prescribe given the danger of major bleeding. With the recent approval of several newer anticoagulants, it is important for the practicing hospitalist to be comfortable initiating, maintaining, and stopping these agents in a wide variety of patient populations.

Guideline Updates

In February 2016, an update to the ninth edition of the antithrombotic guideline from the American College of Chest Physician (ACCP) was published and included updated recommendations on 12 topics in addition to three new topics. This 10th-edition guideline update is referred to as AT10.1

One of the most notable changes in the updated guideline is the recommended choice of anticoagulant in patients with acute DVT or PE without cancer. Now, the direct oral anticoagulants (DOACs) dabigatran, rivaroxaban, apixaban, or edoxaban are recommended over warfarin. Although this is a weak recommendation based on moderate-quality evidence (grade 2B), this is the first time that warfarin is not considered first-line therapy. It should be emphasized that none of the four FDA-approved DOACs are preferred over another, and they should be avoided in patients who are pregnant or have severe renal disease. In patients with DVT or PE and cancer, low-molecular-weight heparin (LMWH) is still the preferred medication. If LMWH is not prescribed, AT10 does not have a preference for either a DOAC or warfarin for patients with cancer.

When it comes to duration of anticoagulation following a VTE event, the updated guideline continues to recommend three months for a provoked VTE event, with consideration for lifelong anticoagulation for an unprovoked event for patients at low or moderate bleeding risk. However, it now suggests that the recurrence risk factors of male sex and a positive D-dimer measured one month after stopping anticoagulant therapy should be taken into consideration when deciding whether extended anticoagulation is indicated.

AT10 also includes new recommendations concerning the role of aspirin for extended VTE treatment. Interestingly, the 2008 ACCP guideline gave a strong recommendation against the use of aspirin for VTE management in any patient population. In the 2012 guideline, the role of aspirin was not addressed for VTE treatment. Now, AT10 states that low-dose aspirin can be used in patients who stop anticoagulant therapy for treatment of an unprovoked proximal DVT or PE as an extended therapy (grade 2B). The significant change in this recommendation stems from two recent randomized trials that compared aspirin with placebo for the prevention of VTE recurrence in patients who have completed a course of anticoagulation for a first unprovoked proximal DVT or PE.2,3 Although the guideline doesn’t consider aspirin to be a reasonable alternative to anticoagulation for patients who require extended therapy and are agreeable to continue, for patients who have decided to stop anticoagulation, aspirin appears to reduce recurrent VTE by approximately one-third, with no significant increased risk of bleeding.

Another significant change in AT10 is the recommendation against the routine use of compression stockings to prevent postthrombotic syndrome (PTS). This change was influenced by a recent multicenter randomized trial showing that elastic compression stockings did not prevent PTS after an acute proximal DVT.4 The guideline authors remark that this recommendation focuses on the prevention of the chronic complications of PTS rather than treatment of the symptoms. Thus, for patients with acute or chronic leg pain or swelling from DVT, compression stockings may be justified.

A topic that was not addressed in the previous guideline was whether patients with a subsegmental PE should be treated. The guideline now suggests that patients with only subsegmental PE and no ultrasound-proven proximal DVT of the legs should undergo “clinical surveillance” rather than anticoagulation (grade 2C). Exceptions include patients at high risk for recurrent VTE (e.g., hospitalization, reduced mobility, active cancer, or irreversible VTE risk factors) and those with a low cardiopulmonary reserve or marked symptoms thought to be from PE. AT10 also states that patient preferences regarding anticoagulation treatment as well as the patient’s risk of bleeding should be taken into consideration. If the decision is made to not prescribe anticoagulation for subsegmental PE, patients should be advised to seek reevaluation if their symptoms persist or worsen.

The 2012 guideline included a new recommendation that patients with low-risk PE (typically defined by a low Pulmonary Embolism Severity Index [PESI] score) could be discharged “early” from the hospital. This recommendation has now been modified to state that patients with low-risk PE may be treated entirely at home. It is worth noting that outpatient management of low-risk PE has become much less complicated if using a DOAC, particularly rivaroxaban and apixaban as neither require initial treatment with parenteral anticoagulation.

AT10 has not changed the recommendation for which patients should receive thrombolytic therapy for treatment of PE. It recommends systemic thrombolytic therapy for patients with acute PE associated with hypotension (defined as systolic blood pressure less than 90 mmHg for 15 minutes) who are not at high risk for bleeding (grade 2B). Likewise, for patients with acute PE not associated with hypotension, the guideline recommends against systemic thrombolytics (grade 1B). If thrombolytics are implemented, AT10 favors systemic administration over catheter-directed thrombolysis (CDT) due to the higher-quality evidence available. However, the authors state that CDT may be preferred for patients at higher risk of bleeding and when local expertise is available. Lastly, catheter-assisted thrombus removal should be considered in patients with acute PE and hypotension who have a high bleeding risk, who have failed systemic thrombolytics, or who are in shock and likely to die before systemic thrombolytics become therapeutic.

Although no prospective trials have evaluated the management of patients with recurrent VTE events while on anticoagulation therapy, AT10 offers some guidance. After ensuring the patient truly had a recurrent VTE event while on therapeutic warfarin or compliant with a DOAC, the authors suggest switching to LMWH for at least one month (grade 2C). Furthermore, for patients who have a recurrent VTE event while compliant on long-term LMWH, the guideline suggests increasing the dose of LMWH by about one-quarter to one-third (grade 2C).

Guideline Analysis

It is important to note that of the 54 recommendations included in the complete guideline update, only 20 were strong recommendations (grade 1), and none were based on high-quality evidence (level A). It is obvious that more research is needed in this field. Regardless, the ACCP antithrombotic guideline remains the authoritative source in VTE management and has a strong influence on practice behavior. With the recent addition of several newer anticoagulants, AT10 is particularly useful in helping providers understand when and when not to use them. The authors indicate that future iterations will be continually updated, describing them as “living guidelines.” The format of AT10 was designed to facilitate this method with the goal of having discrete topics discussed as new evidence becomes available.

Hospital Medicine Takeaways

Despite the lack of randomized and prospective clinical trials, the updated recommendations from AT10 provide important information on challenging VTE issues that the hospitalist can apply to most patients most of the time. Important updates include:

• Prescribe DOACs as first-line agents for the treatment of acute VTE in patients without cancer.
• Use aspirin for the prevention of recurrent VTE in patients who stop anticoagulation for treatment of an unprovoked DVT or PE.
• Avoid compression stockings for the sole purpose of preventing postthrombotic syndrome.
• Do not admit patients with low-risk PE (as determined by the PESI score) to the hospital but rather treat them entirely at home.

Lastly, it is important to remember that VTE treatment decisions need to be individualized based on the clinical, imaging, and biochemical features of your patient.

Paul J. Grant, MD, SFHM, is assistant professor of medicine and director of perioperative and consultative medicine within the Department of Internal Medicine at the University of Michigan Health System in Ann Arbor.

References

1. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149(2):315-352.
2. Brighton TA, Eikelboom JW, Mann K, et al. Low-dose aspirin for preventing recurrent venous thromboembolism. N Engl J Med. 2012;367(21):1979-1987.
3. Becattini C, Agnelli G, Schenone A, et al. Aspirin for preventing the recurrence of venous thromboembolism. N Engl J Med. 2012;366(21):1959-1967.
4. Kahn SR, Shapiro S, Wells PS, et al. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo controlled trial. Lancet. 2014;383(9920):880-888.

Venous thromboembolism (VTE), which includes deep venous thrombosis (DVT) and pulmonary embolism (PE), continues to be a major cause of morbidity and mortality among hospitalized patients. Although it is well-known that anticoagulation therapy is effective in the prevention and treatment of VTE events, these agents are some of the highest-risk medications a hospitalist will prescribe given the danger of major bleeding. With the recent approval of several newer anticoagulants, it is important for the practicing hospitalist to be comfortable initiating, maintaining, and stopping these agents in a wide variety of patient populations.

Guideline Updates

In February 2016, an update to the ninth edition of the antithrombotic guideline from the American College of Chest Physician (ACCP) was published and included updated recommendations on 12 topics in addition to three new topics. This 10th-edition guideline update is referred to as AT10.1

One of the most notable changes in the updated guideline is the recommended choice of anticoagulant in patients with acute DVT or PE without cancer. Now, the direct oral anticoagulants (DOACs) dabigatran, rivaroxaban, apixaban, or edoxaban are recommended over warfarin. Although this is a weak recommendation based on moderate-quality evidence (grade 2B), this is the first time that warfarin is not considered first-line therapy. It should be emphasized that none of the four FDA-approved DOACs are preferred over another, and they should be avoided in patients who are pregnant or have severe renal disease. In patients with DVT or PE and cancer, low-molecular-weight heparin (LMWH) is still the preferred medication. If LMWH is not prescribed, AT10 does not have a preference for either a DOAC or warfarin for patients with cancer.

When it comes to duration of anticoagulation following a VTE event, the updated guideline continues to recommend three months for a provoked VTE event, with consideration for lifelong anticoagulation for an unprovoked event for patients at low or moderate bleeding risk. However, it now suggests that the recurrence risk factors of male sex and a positive D-dimer measured one month after stopping anticoagulant therapy should be taken into consideration when deciding whether extended anticoagulation is indicated.

AT10 also includes new recommendations concerning the role of aspirin for extended VTE treatment. Interestingly, the 2008 ACCP guideline gave a strong recommendation against the use of aspirin for VTE management in any patient population. In the 2012 guideline, the role of aspirin was not addressed for VTE treatment. Now, AT10 states that low-dose aspirin can be used in patients who stop anticoagulant therapy for treatment of an unprovoked proximal DVT or PE as an extended therapy (grade 2B). The significant change in this recommendation stems from two recent randomized trials that compared aspirin with placebo for the prevention of VTE recurrence in patients who have completed a course of anticoagulation for a first unprovoked proximal DVT or PE.2,3 Although the guideline doesn’t consider aspirin to be a reasonable alternative to anticoagulation for patients who require extended therapy and are agreeable to continue, for patients who have decided to stop anticoagulation, aspirin appears to reduce recurrent VTE by approximately one-third, with no significant increased risk of bleeding.

Another significant change in AT10 is the recommendation against the routine use of compression stockings to prevent postthrombotic syndrome (PTS). This change was influenced by a recent multicenter randomized trial showing that elastic compression stockings did not prevent PTS after an acute proximal DVT.4 The guideline authors remark that this recommendation focuses on the prevention of the chronic complications of PTS rather than treatment of the symptoms. Thus, for patients with acute or chronic leg pain or swelling from DVT, compression stockings may be justified.

A topic that was not addressed in the previous guideline was whether patients with a subsegmental PE should be treated. The guideline now suggests that patients with only subsegmental PE and no ultrasound-proven proximal DVT of the legs should undergo “clinical surveillance” rather than anticoagulation (grade 2C). Exceptions include patients at high risk for recurrent VTE (e.g., hospitalization, reduced mobility, active cancer, or irreversible VTE risk factors) and those with a low cardiopulmonary reserve or marked symptoms thought to be from PE. AT10 also states that patient preferences regarding anticoagulation treatment as well as the patient’s risk of bleeding should be taken into consideration. If the decision is made to not prescribe anticoagulation for subsegmental PE, patients should be advised to seek reevaluation if their symptoms persist or worsen.

The 2012 guideline included a new recommendation that patients with low-risk PE (typically defined by a low Pulmonary Embolism Severity Index [PESI] score) could be discharged “early” from the hospital. This recommendation has now been modified to state that patients with low-risk PE may be treated entirely at home. It is worth noting that outpatient management of low-risk PE has become much less complicated if using a DOAC, particularly rivaroxaban and apixaban as neither require initial treatment with parenteral anticoagulation.

AT10 has not changed the recommendation for which patients should receive thrombolytic therapy for treatment of PE. It recommends systemic thrombolytic therapy for patients with acute PE associated with hypotension (defined as systolic blood pressure less than 90 mmHg for 15 minutes) who are not at high risk for bleeding (grade 2B). Likewise, for patients with acute PE not associated with hypotension, the guideline recommends against systemic thrombolytics (grade 1B). If thrombolytics are implemented, AT10 favors systemic administration over catheter-directed thrombolysis (CDT) due to the higher-quality evidence available. However, the authors state that CDT may be preferred for patients at higher risk of bleeding and when local expertise is available. Lastly, catheter-assisted thrombus removal should be considered in patients with acute PE and hypotension who have a high bleeding risk, who have failed systemic thrombolytics, or who are in shock and likely to die before systemic thrombolytics become therapeutic.

Although no prospective trials have evaluated the management of patients with recurrent VTE events while on anticoagulation therapy, AT10 offers some guidance. After ensuring the patient truly had a recurrent VTE event while on therapeutic warfarin or compliant with a DOAC, the authors suggest switching to LMWH for at least one month (grade 2C). Furthermore, for patients who have a recurrent VTE event while compliant on long-term LMWH, the guideline suggests increasing the dose of LMWH by about one-quarter to one-third (grade 2C).

Guideline Analysis

It is important to note that of the 54 recommendations included in the complete guideline update, only 20 were strong recommendations (grade 1), and none were based on high-quality evidence (level A). It is obvious that more research is needed in this field. Regardless, the ACCP antithrombotic guideline remains the authoritative source in VTE management and has a strong influence on practice behavior. With the recent addition of several newer anticoagulants, AT10 is particularly useful in helping providers understand when and when not to use them. The authors indicate that future iterations will be continually updated, describing them as “living guidelines.” The format of AT10 was designed to facilitate this method with the goal of having discrete topics discussed as new evidence becomes available.

Hospital Medicine Takeaways

Despite the lack of randomized and prospective clinical trials, the updated recommendations from AT10 provide important information on challenging VTE issues that the hospitalist can apply to most patients most of the time. Important updates include:

• Prescribe DOACs as first-line agents for the treatment of acute VTE in patients without cancer.
• Use aspirin for the prevention of recurrent VTE in patients who stop anticoagulation for treatment of an unprovoked DVT or PE.
• Avoid compression stockings for the sole purpose of preventing postthrombotic syndrome.
• Do not admit patients with low-risk PE (as determined by the PESI score) to the hospital but rather treat them entirely at home.

Lastly, it is important to remember that VTE treatment decisions need to be individualized based on the clinical, imaging, and biochemical features of your patient.

Paul J. Grant, MD, SFHM, is assistant professor of medicine and director of perioperative and consultative medicine within the Department of Internal Medicine at the University of Michigan Health System in Ann Arbor.

References

1. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149(2):315-352.
2. Brighton TA, Eikelboom JW, Mann K, et al. Low-dose aspirin for preventing recurrent venous thromboembolism. N Engl J Med. 2012;367(21):1979-1987.
3. Becattini C, Agnelli G, Schenone A, et al. Aspirin for preventing the recurrence of venous thromboembolism. N Engl J Med. 2012;366(21):1959-1967.
4. Kahn SR, Shapiro S, Wells PS, et al. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo controlled trial. Lancet. 2014;383(9920):880-888.

Venous thromboembolism (VTE), which includes deep venous thrombosis (DVT) and pulmonary embolism (PE), continues to be a major cause of morbidity and mortality among hospitalized patients. Although it is well-known that anticoagulation therapy is effective in the prevention and treatment of VTE events, these agents are some of the highest-risk medications a hospitalist will prescribe given the danger of major bleeding. With the recent approval of several newer anticoagulants, it is important for the practicing hospitalist to be comfortable initiating, maintaining, and stopping these agents in a wide variety of patient populations.

Guideline Updates

In February 2016, an update to the ninth edition of the antithrombotic guideline from the American College of Chest Physician (ACCP) was published and included updated recommendations on 12 topics in addition to three new topics. This 10th-edition guideline update is referred to as AT10.1

One of the most notable changes in the updated guideline is the recommended choice of anticoagulant in patients with acute DVT or PE without cancer. Now, the direct oral anticoagulants (DOACs) dabigatran, rivaroxaban, apixaban, or edoxaban are recommended over warfarin. Although this is a weak recommendation based on moderate-quality evidence (grade 2B), this is the first time that warfarin is not considered first-line therapy. It should be emphasized that none of the four FDA-approved DOACs are preferred over another, and they should be avoided in patients who are pregnant or have severe renal disease. In patients with DVT or PE and cancer, low-molecular-weight heparin (LMWH) is still the preferred medication. If LMWH is not prescribed, AT10 does not have a preference for either a DOAC or warfarin for patients with cancer.

When it comes to duration of anticoagulation following a VTE event, the updated guideline continues to recommend three months for a provoked VTE event, with consideration for lifelong anticoagulation for an unprovoked event for patients at low or moderate bleeding risk. However, it now suggests that the recurrence risk factors of male sex and a positive D-dimer measured one month after stopping anticoagulant therapy should be taken into consideration when deciding whether extended anticoagulation is indicated.

AT10 also includes new recommendations concerning the role of aspirin for extended VTE treatment. Interestingly, the 2008 ACCP guideline gave a strong recommendation against the use of aspirin for VTE management in any patient population. In the 2012 guideline, the role of aspirin was not addressed for VTE treatment. Now, AT10 states that low-dose aspirin can be used in patients who stop anticoagulant therapy for treatment of an unprovoked proximal DVT or PE as an extended therapy (grade 2B). The significant change in this recommendation stems from two recent randomized trials that compared aspirin with placebo for the prevention of VTE recurrence in patients who have completed a course of anticoagulation for a first unprovoked proximal DVT or PE.2,3 Although the guideline doesn’t consider aspirin to be a reasonable alternative to anticoagulation for patients who require extended therapy and are agreeable to continue, for patients who have decided to stop anticoagulation, aspirin appears to reduce recurrent VTE by approximately one-third, with no significant increased risk of bleeding.

Another significant change in AT10 is the recommendation against the routine use of compression stockings to prevent postthrombotic syndrome (PTS). This change was influenced by a recent multicenter randomized trial showing that elastic compression stockings did not prevent PTS after an acute proximal DVT.4 The guideline authors remark that this recommendation focuses on the prevention of the chronic complications of PTS rather than treatment of the symptoms. Thus, for patients with acute or chronic leg pain or swelling from DVT, compression stockings may be justified.

A topic that was not addressed in the previous guideline was whether patients with a subsegmental PE should be treated. The guideline now suggests that patients with only subsegmental PE and no ultrasound-proven proximal DVT of the legs should undergo “clinical surveillance” rather than anticoagulation (grade 2C). Exceptions include patients at high risk for recurrent VTE (e.g., hospitalization, reduced mobility, active cancer, or irreversible VTE risk factors) and those with a low cardiopulmonary reserve or marked symptoms thought to be from PE. AT10 also states that patient preferences regarding anticoagulation treatment as well as the patient’s risk of bleeding should be taken into consideration. If the decision is made to not prescribe anticoagulation for subsegmental PE, patients should be advised to seek reevaluation if their symptoms persist or worsen.

The 2012 guideline included a new recommendation that patients with low-risk PE (typically defined by a low Pulmonary Embolism Severity Index [PESI] score) could be discharged “early” from the hospital. This recommendation has now been modified to state that patients with low-risk PE may be treated entirely at home. It is worth noting that outpatient management of low-risk PE has become much less complicated if using a DOAC, particularly rivaroxaban and apixaban as neither require initial treatment with parenteral anticoagulation.

AT10 has not changed the recommendation for which patients should receive thrombolytic therapy for treatment of PE. It recommends systemic thrombolytic therapy for patients with acute PE associated with hypotension (defined as systolic blood pressure less than 90 mmHg for 15 minutes) who are not at high risk for bleeding (grade 2B). Likewise, for patients with acute PE not associated with hypotension, the guideline recommends against systemic thrombolytics (grade 1B). If thrombolytics are implemented, AT10 favors systemic administration over catheter-directed thrombolysis (CDT) due to the higher-quality evidence available. However, the authors state that CDT may be preferred for patients at higher risk of bleeding and when local expertise is available. Lastly, catheter-assisted thrombus removal should be considered in patients with acute PE and hypotension who have a high bleeding risk, who have failed systemic thrombolytics, or who are in shock and likely to die before systemic thrombolytics become therapeutic.

Although no prospective trials have evaluated the management of patients with recurrent VTE events while on anticoagulation therapy, AT10 offers some guidance. After ensuring the patient truly had a recurrent VTE event while on therapeutic warfarin or compliant with a DOAC, the authors suggest switching to LMWH for at least one month (grade 2C). Furthermore, for patients who have a recurrent VTE event while compliant on long-term LMWH, the guideline suggests increasing the dose of LMWH by about one-quarter to one-third (grade 2C).

Guideline Analysis

It is important to note that of the 54 recommendations included in the complete guideline update, only 20 were strong recommendations (grade 1), and none were based on high-quality evidence (level A). It is obvious that more research is needed in this field. Regardless, the ACCP antithrombotic guideline remains the authoritative source in VTE management and has a strong influence on practice behavior. With the recent addition of several newer anticoagulants, AT10 is particularly useful in helping providers understand when and when not to use them. The authors indicate that future iterations will be continually updated, describing them as “living guidelines.” The format of AT10 was designed to facilitate this method with the goal of having discrete topics discussed as new evidence becomes available.

Hospital Medicine Takeaways

Despite the lack of randomized and prospective clinical trials, the updated recommendations from AT10 provide important information on challenging VTE issues that the hospitalist can apply to most patients most of the time. Important updates include:

• Prescribe DOACs as first-line agents for the treatment of acute VTE in patients without cancer.
• Use aspirin for the prevention of recurrent VTE in patients who stop anticoagulation for treatment of an unprovoked DVT or PE.
• Avoid compression stockings for the sole purpose of preventing postthrombotic syndrome.
• Do not admit patients with low-risk PE (as determined by the PESI score) to the hospital but rather treat them entirely at home.

Lastly, it is important to remember that VTE treatment decisions need to be individualized based on the clinical, imaging, and biochemical features of your patient.

Paul J. Grant, MD, SFHM, is assistant professor of medicine and director of perioperative and consultative medicine within the Department of Internal Medicine at the University of Michigan Health System in Ann Arbor.

References

1. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149(2):315-352.
2. Brighton TA, Eikelboom JW, Mann K, et al. Low-dose aspirin for preventing recurrent venous thromboembolism. N Engl J Med. 2012;367(21):1979-1987.
3. Becattini C, Agnelli G, Schenone A, et al. Aspirin for preventing the recurrence of venous thromboembolism. N Engl J Med. 2012;366(21):1959-1967.
4. Kahn SR, Shapiro S, Wells PS, et al. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo controlled trial. Lancet. 2014;383(9920):880-888.

Tracy Gulling-Leftwich, DO, remembers Chewy very well. He was a 70-pound English bulldog she was caring for last year on behalf of the Rescue Ohio English Bulldogs, an English bulldog rescue group.

She soon learned that Chewy was anemic and suffered from bone cancer of the jaw. Ironically, considering his name, he could barely chew, so Dr. Gulling-Leftwich and her husband, Samuel Leftwich, pureed his food, spoon-fed the animal, and administered around-the-clock pain medications for roughly two weeks. But his pain grew too intense, and Chewy had to be euthanized.

For many people, that would end their experience with an animal organization. People typically compare the heartbreaking experience to losing a beloved family member or friend. But as an animal lover and hospitalist at the Cleveland Clinic, Dr. Gulling-Leftwich has no intentions of looking the other way whenever an animal—or human—is in need. Ever since she was in college, she has been rescuing lab rats and dogs, trying to keep them happy, healthy, and loved throughout their relatively short lives.

Underground Railroad

Dr. Gulling-Leftwich graduated from the Lake Erie College of Osteopathic Medicine in Erie, Penn., in 2007. The following year, she pursued an osteopathic rotating internship at the University of Connecticut. While attending the same university from 2008 to 2010, she completed a traditional, categorical, allopathic medicine residency.

After completing her medical education, she held several positions. She worked as a teaching hospitalist at the Hartford Hospital for one year, served as a primary-care physician for the next three years at The Hospital of Central Connecticut, and then joined the Cleveland Clinic as a hospitalist in 2014.

Her involvement in animal rescue began many years earlier while attending undergraduate school at Westminster College in New Wilmington, Penn. She tells the story how one student at the college kidnapped a rat from the school’s neuroscience lab just before Christmas break.

Since the student’s mother would not allow her to bring a rat home over the six-week holiday, Dr. Gulling-Leftwich babysat him until she returned. However, the student intended on releasing him into the wild. Fearing the worst, that the rat could not fend for itself since it had been caged and fed for many months, Dr. Gulling-Leftwich convinced the student to relinquish custody of the rat to her.

That’s how it all began. Dr. Gulling-Leftwich named the rat Templeton. She suspects he died of a pituitary tumor four years later; still, that’s a long life for a rat. Most live just two years. Just shows what a little love can do.

Since then, she has rescued approximately 21 rats from Kentucky and Connecticut. Years ago, she says, there were multiple Yahoo chat groups of people involved in an underground railroad of sorts for rescued lab rats. People would often drive the rats to different cities, even across state borders, so these rats could enjoy a permanent home.

While she has never broken into a research lab, her opinion is torn on animal research. She believes it is not necessary for consumer products, such as makeup, but can see its value in other fields of science like the development of new medications.

“What I can hope for is that we work toward finding a way of not requiring animals for research in the future,” she says.

Full House

After getting married in 2013, Dr. Gulling-Leftwich told her husband she wanted a dog. But because of their hectic schedules, no one would be home to care for the animal, so the couple waited another two years to adopt a rescue animal.

In 2015, they had purchased a house in Cleveland when they adopted Boomer, a pug and beagle designer breed, as their family pet.

“I had really wanted an English bulldog. They’re just cute, their face is squishy,” she says, adding she had been monitoring English bulldog rescue websites. “I won’t buy a puppy. I will only get a dog that needs a home.”

In September that year, the rescue organization emailed a desperate plea to its followers. Can anyone rescue an English bulldog named Chewy? Dr. Gulling-Leftwich immediately filled out the paperwork and adopted him. But Chewy only stayed with them for two weeks before he was euthanized. She brought him to the vet after he attacked Boomer.

“Chewy wasn’t being a jerk,” she says. “His attacking behavior had to do with his pain and discomfort. He had blood everywhere around his mouth. We had a hard time letting him go.”

One month later, another English bulldog named Olive joined their family. She’s roughly two years old and weighs only 30 pounds mainly because of her disease: congenital cardiomyopathy. They plan to care for Olive until she dies.

She says Olive takes six pills a day for her condition and occasionally receives nitroglycerin when she overexerts herself and passes out.

Meanwhile, Dr. Gulling-Leftwich and her husband care for one rat named Harvey and a cat called Lily in addition to the two dogs. Boomer doesn’t like Olive. Olive doesn’t like the cat. And both dogs and the cat pay no attention to the rat.

“My husband says rescuing animals and taking care of people is one of my more endearing qualities,” she says. “Then he follows it up with, ‘No, you can’t have that bunny that needs a home.’”

She believes caring for these animals balances her work in hospital medicine. While hospital patients often are in pain, act grouchy, and appear unappreciative, she says her four-legged family members are always excited to see her and routinely demonstrate unconditional love.

“You definitely have to be open-minded because you never know what you’ll be walking into when you rescue an animal,” she says, adding that rescue groups tend to pay for vet bills and medicine. “You have to be prepared for what potentially could be the worst.”

Carol Patton is a freelance writer in Las Vegas.

Tracy Gulling-Leftwich, DO, remembers Chewy very well. He was a 70-pound English bulldog she was caring for last year on behalf of the Rescue Ohio English Bulldogs, an English bulldog rescue group.

She soon learned that Chewy was anemic and suffered from bone cancer of the jaw. Ironically, considering his name, he could barely chew, so Dr. Gulling-Leftwich and her husband, Samuel Leftwich, pureed his food, spoon-fed the animal, and administered around-the-clock pain medications for roughly two weeks. But his pain grew too intense, and Chewy had to be euthanized.

For many people, that would end their experience with an animal organization. People typically compare the heartbreaking experience to losing a beloved family member or friend. But as an animal lover and hospitalist at the Cleveland Clinic, Dr. Gulling-Leftwich has no intentions of looking the other way whenever an animal—or human—is in need. Ever since she was in college, she has been rescuing lab rats and dogs, trying to keep them happy, healthy, and loved throughout their relatively short lives.

Underground Railroad

Dr. Gulling-Leftwich graduated from the Lake Erie College of Osteopathic Medicine in Erie, Penn., in 2007. The following year, she pursued an osteopathic rotating internship at the University of Connecticut. While attending the same university from 2008 to 2010, she completed a traditional, categorical, allopathic medicine residency.

After completing her medical education, she held several positions. She worked as a teaching hospitalist at the Hartford Hospital for one year, served as a primary-care physician for the next three years at The Hospital of Central Connecticut, and then joined the Cleveland Clinic as a hospitalist in 2014.

Her involvement in animal rescue began many years earlier while attending undergraduate school at Westminster College in New Wilmington, Penn. She tells the story how one student at the college kidnapped a rat from the school’s neuroscience lab just before Christmas break.

Since the student’s mother would not allow her to bring a rat home over the six-week holiday, Dr. Gulling-Leftwich babysat him until she returned. However, the student intended on releasing him into the wild. Fearing the worst, that the rat could not fend for itself since it had been caged and fed for many months, Dr. Gulling-Leftwich convinced the student to relinquish custody of the rat to her.

That’s how it all began. Dr. Gulling-Leftwich named the rat Templeton. She suspects he died of a pituitary tumor four years later; still, that’s a long life for a rat. Most live just two years. Just shows what a little love can do.

Since then, she has rescued approximately 21 rats from Kentucky and Connecticut. Years ago, she says, there were multiple Yahoo chat groups of people involved in an underground railroad of sorts for rescued lab rats. People would often drive the rats to different cities, even across state borders, so these rats could enjoy a permanent home.

While she has never broken into a research lab, her opinion is torn on animal research. She believes it is not necessary for consumer products, such as makeup, but can see its value in other fields of science like the development of new medications.

“What I can hope for is that we work toward finding a way of not requiring animals for research in the future,” she says.

Full House

After getting married in 2013, Dr. Gulling-Leftwich told her husband she wanted a dog. But because of their hectic schedules, no one would be home to care for the animal, so the couple waited another two years to adopt a rescue animal.

In 2015, they had purchased a house in Cleveland when they adopted Boomer, a pug and beagle designer breed, as their family pet.

“I had really wanted an English bulldog. They’re just cute, their face is squishy,” she says, adding she had been monitoring English bulldog rescue websites. “I won’t buy a puppy. I will only get a dog that needs a home.”

In September that year, the rescue organization emailed a desperate plea to its followers. Can anyone rescue an English bulldog named Chewy? Dr. Gulling-Leftwich immediately filled out the paperwork and adopted him. But Chewy only stayed with them for two weeks before he was euthanized. She brought him to the vet after he attacked Boomer.

“Chewy wasn’t being a jerk,” she says. “His attacking behavior had to do with his pain and discomfort. He had blood everywhere around his mouth. We had a hard time letting him go.”

One month later, another English bulldog named Olive joined their family. She’s roughly two years old and weighs only 30 pounds mainly because of her disease: congenital cardiomyopathy. They plan to care for Olive until she dies.

She says Olive takes six pills a day for her condition and occasionally receives nitroglycerin when she overexerts herself and passes out.

Meanwhile, Dr. Gulling-Leftwich and her husband care for one rat named Harvey and a cat called Lily in addition to the two dogs. Boomer doesn’t like Olive. Olive doesn’t like the cat. And both dogs and the cat pay no attention to the rat.

“My husband says rescuing animals and taking care of people is one of my more endearing qualities,” she says. “Then he follows it up with, ‘No, you can’t have that bunny that needs a home.’”

She believes caring for these animals balances her work in hospital medicine. While hospital patients often are in pain, act grouchy, and appear unappreciative, she says her four-legged family members are always excited to see her and routinely demonstrate unconditional love.

“You definitely have to be open-minded because you never know what you’ll be walking into when you rescue an animal,” she says, adding that rescue groups tend to pay for vet bills and medicine. “You have to be prepared for what potentially could be the worst.”

Carol Patton is a freelance writer in Las Vegas.

Tracy Gulling-Leftwich, DO, remembers Chewy very well. He was a 70-pound English bulldog she was caring for last year on behalf of the Rescue Ohio English Bulldogs, an English bulldog rescue group.

She soon learned that Chewy was anemic and suffered from bone cancer of the jaw. Ironically, considering his name, he could barely chew, so Dr. Gulling-Leftwich and her husband, Samuel Leftwich, pureed his food, spoon-fed the animal, and administered around-the-clock pain medications for roughly two weeks. But his pain grew too intense, and Chewy had to be euthanized.

For many people, that would end their experience with an animal organization. People typically compare the heartbreaking experience to losing a beloved family member or friend. But as an animal lover and hospitalist at the Cleveland Clinic, Dr. Gulling-Leftwich has no intentions of looking the other way whenever an animal—or human—is in need. Ever since she was in college, she has been rescuing lab rats and dogs, trying to keep them happy, healthy, and loved throughout their relatively short lives.

Underground Railroad

Dr. Gulling-Leftwich graduated from the Lake Erie College of Osteopathic Medicine in Erie, Penn., in 2007. The following year, she pursued an osteopathic rotating internship at the University of Connecticut. While attending the same university from 2008 to 2010, she completed a traditional, categorical, allopathic medicine residency.

After completing her medical education, she held several positions. She worked as a teaching hospitalist at the Hartford Hospital for one year, served as a primary-care physician for the next three years at The Hospital of Central Connecticut, and then joined the Cleveland Clinic as a hospitalist in 2014.

Her involvement in animal rescue began many years earlier while attending undergraduate school at Westminster College in New Wilmington, Penn. She tells the story how one student at the college kidnapped a rat from the school’s neuroscience lab just before Christmas break.

Since the student’s mother would not allow her to bring a rat home over the six-week holiday, Dr. Gulling-Leftwich babysat him until she returned. However, the student intended on releasing him into the wild. Fearing the worst, that the rat could not fend for itself since it had been caged and fed for many months, Dr. Gulling-Leftwich convinced the student to relinquish custody of the rat to her.

That’s how it all began. Dr. Gulling-Leftwich named the rat Templeton. She suspects he died of a pituitary tumor four years later; still, that’s a long life for a rat. Most live just two years. Just shows what a little love can do.

Since then, she has rescued approximately 21 rats from Kentucky and Connecticut. Years ago, she says, there were multiple Yahoo chat groups of people involved in an underground railroad of sorts for rescued lab rats. People would often drive the rats to different cities, even across state borders, so these rats could enjoy a permanent home.

While she has never broken into a research lab, her opinion is torn on animal research. She believes it is not necessary for consumer products, such as makeup, but can see its value in other fields of science like the development of new medications.

“What I can hope for is that we work toward finding a way of not requiring animals for research in the future,” she says.

Full House

After getting married in 2013, Dr. Gulling-Leftwich told her husband she wanted a dog. But because of their hectic schedules, no one would be home to care for the animal, so the couple waited another two years to adopt a rescue animal.

In 2015, they had purchased a house in Cleveland when they adopted Boomer, a pug and beagle designer breed, as their family pet.

“I had really wanted an English bulldog. They’re just cute, their face is squishy,” she says, adding she had been monitoring English bulldog rescue websites. “I won’t buy a puppy. I will only get a dog that needs a home.”

In September that year, the rescue organization emailed a desperate plea to its followers. Can anyone rescue an English bulldog named Chewy? Dr. Gulling-Leftwich immediately filled out the paperwork and adopted him. But Chewy only stayed with them for two weeks before he was euthanized. She brought him to the vet after he attacked Boomer.

“Chewy wasn’t being a jerk,” she says. “His attacking behavior had to do with his pain and discomfort. He had blood everywhere around his mouth. We had a hard time letting him go.”

One month later, another English bulldog named Olive joined their family. She’s roughly two years old and weighs only 30 pounds mainly because of her disease: congenital cardiomyopathy. They plan to care for Olive until she dies.

She says Olive takes six pills a day for her condition and occasionally receives nitroglycerin when she overexerts herself and passes out.

Meanwhile, Dr. Gulling-Leftwich and her husband care for one rat named Harvey and a cat called Lily in addition to the two dogs. Boomer doesn’t like Olive. Olive doesn’t like the cat. And both dogs and the cat pay no attention to the rat.

“My husband says rescuing animals and taking care of people is one of my more endearing qualities,” she says. “Then he follows it up with, ‘No, you can’t have that bunny that needs a home.’”

She believes caring for these animals balances her work in hospital medicine. While hospital patients often are in pain, act grouchy, and appear unappreciative, she says her four-legged family members are always excited to see her and routinely demonstrate unconditional love.

“You definitely have to be open-minded because you never know what you’ll be walking into when you rescue an animal,” she says, adding that rescue groups tend to pay for vet bills and medicine. “You have to be prepared for what potentially could be the worst.”

Carol Patton is a freelance writer in Las Vegas.

The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.

Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.

And hospitalists are right in the middle of this changing dynamic.

Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.

At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.

Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.

But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.

Palliative Care

There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.

Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.

Critical Care

Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.

Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.

Post-Acute Care

For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.

In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.

Preoperative Care

Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.

Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.

SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.

Working through a Dilemma

The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.

SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.

Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.

The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.

Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.

And hospitalists are right in the middle of this changing dynamic.

Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.

At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.

Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.

But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.

Palliative Care

There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.

Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.

Critical Care

Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.

Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.

Post-Acute Care

For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.

In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.

Preoperative Care

Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.

Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.

SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.

Working through a Dilemma

The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.

SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.

Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.

The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.

Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.

And hospitalists are right in the middle of this changing dynamic.

Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.

At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.

Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.

But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.

Palliative Care

There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.

Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.

Critical Care

Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.

Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.

Post-Acute Care

For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.

In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.

Preoperative Care

Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.

Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.

SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.

Working through a Dilemma

The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.

SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.

Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.

Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/getinvolved for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.

This month, The Hospitalist spotlights Scott Kaatz, DO, MSc, FACP, SFHM, a hospitalist at Henry Ford Hospital in Detroit. In addition to being an active SHM member, he is immediate past president of SHM’s Michigan Chapter and has been involved in multiple mentored implementation (MI) programs offered by SHM’s Center for Hospital Innovation and Improvement.

Question: What inspired you to begin working in hospital medicine and later join and become so involved with SHM?

Answer: For most of my career, I’ve been at Henry Ford Hospital in Detroit, including during my internal medicine residency. After residency, I was a primary-care physician there, and I rounded three to four months out of the year in the hospital with traditional house staff model. Four years ago, I transitioned to another role as a chief quality officer at Hurley Medical Center in Flint, Mich. While in Flint, I didn’t have a clinic and was strictly a hospitalist, spending about four months a year rounding.

When my career path led me to mostly inpatient work in the hospital, I became more involved not only with hospital medicine but with SHM. As of this past June, I went back home to Henry Ford as a full-time hospitalist. I now focus my attention on hospital medicine for eight months of the year, with some protected time for faculty development and scholarly activities for residents and junior faculty in the division of hospital medicine.

Q: How has your involvement with SHM’s mentored implementation programs impacted your practice and led to improved patient care?

A: After participating in the venous thromboembolism (VTE) mentored implementation program, I became a participant as a mentee site for I-PASS, a program focused on improving communication between providers during patient handoffs. During my time with the I-PASS team, I could sense the commitment and energy to improving handoffs not only at my site but at other participant sites nationwide during our regular check-in calls. Mentored implementation programs are brilliant because they go beyond providing sites with data, a few research papers, and some written recommendations. They really dig down into the true spirit of mentoring with a team.

At Hurley Medical Center, we went “all in” with our pediatric residency. What was most encouraging was that by the end of the year, the I-PASS recommendations and processes were standard practice and fully integrated into the culture and workflow of the care teams.

I applaud these programs tremendously. That’s really how you impact change, and it’s the spark, energy, and momentum from both mentors and mentees that keeps the team on track.

Q: You are the immediate past president of the Michigan Chapter of SHM. What have been some of the biggest benefits of being involved with an SHM chapter?

A: When I first became involved with SHM, there had been a Northern Michigan Chapter, but since SHM seeks to have regional chapters that cater to local audiences, I and some of my colleagues set out to develop a Southern Michigan Chapter. We developed our chapter and designed our meetings with support from SHM’s Chapter Support Committee.

At a typical meeting, we typically host an hour of cocktails with some hors d’oeuvres to provide an opportunity for networking and fellowship. The personal connections are at the heart of these meetings. From the content side, we always have a speaker to talk about issues germane to hospitalists. These are not just run-of-the-mill grand rounds discussions but rather information on clinical updates or the business and policy side of hospital medicine.

In our chapter, we also cycle leadership each year, using a “see one, do one, teach one” approach with our vice president-elect, president, and immediate past president to ensure proper development and continuity.

Moving forward, we are trying to reach out to medical students on a more regular basis. If you’re in your third year of medical school, it’s beneficial to start talking informally to hospitalists from multiple organizations in the state and get a feel for what a career in hospital medicine is like. How amazing would it be to walk in and interview for residency with a person you had dinner with a few months ago?

Q: SHM’s Board of Directors recently approved a Chapter Development Fund to support innovative initiatives that drive engagement on a local level. Explain the potential impact you see this having on chapters and, more broadly, SHM’s membership and hospital medicine.

A: Since our chapter’s inception, we have been able to expand our reach and stream our content to other parts of the state on the Internet. Part of the reason we have been able to do this is due to support from a Chapter Development Fund recently approved by SHM’s Board of Directors. As a result, we have turned our Southern Michigan Chapter into a statewide chapter with virtual sites. At the last meeting, we had over 75 attendees between our physical site and our “satellite site” in Michigan.

Our next project is to apply for funding to provide first- and second-year residents with free membership for a year through our chapter to expose them to the resources SHM has available to them and get their foot in the door with the organization. At a recent co-sponsored statewide meeting with the American College of Physicians, we were able to sign up 20 residents as new members of SHM, and our chapter paid their dues as an investment into our specialty.

Q: Any closing thoughts?

A: If there’s one thing I haven’t yet shared that I feel quite passionately about, it’s that SHM has such a robust library of educational resources that all hospitalists should be aware of, especially SHM’s annual meeting. It’s extraordinarily clinical and features a sizeable amount of content for grassroots clinicians and hospital leaders, including the best speakers in the field. On top of the educational components, the networking possibilities with hospitalists across the country make the annual meeting a prime example of the value SHM offers.

I’ve also been fortunate to have been involved with developing enduring materials on SHM’s Learning Portal, some of which are available without cost due to grant funding. The fact that SHM has pursued this funding and made some of these resources available to hospitalists outside of SHM’s membership embodies the organization’s mission of not only teaching doctors how to take better care of patients but helping patients get better—one of many reasons I am proud to be an active member. TH

Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/getinvolved for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.

This month, The Hospitalist spotlights Scott Kaatz, DO, MSc, FACP, SFHM, a hospitalist at Henry Ford Hospital in Detroit. In addition to being an active SHM member, he is immediate past president of SHM’s Michigan Chapter and has been involved in multiple mentored implementation (MI) programs offered by SHM’s Center for Hospital Innovation and Improvement.

Question: What inspired you to begin working in hospital medicine and later join and become so involved with SHM?

Answer: For most of my career, I’ve been at Henry Ford Hospital in Detroit, including during my internal medicine residency. After residency, I was a primary-care physician there, and I rounded three to four months out of the year in the hospital with traditional house staff model. Four years ago, I transitioned to another role as a chief quality officer at Hurley Medical Center in Flint, Mich. While in Flint, I didn’t have a clinic and was strictly a hospitalist, spending about four months a year rounding.

When my career path led me to mostly inpatient work in the hospital, I became more involved not only with hospital medicine but with SHM. As of this past June, I went back home to Henry Ford as a full-time hospitalist. I now focus my attention on hospital medicine for eight months of the year, with some protected time for faculty development and scholarly activities for residents and junior faculty in the division of hospital medicine.

Q: How has your involvement with SHM’s mentored implementation programs impacted your practice and led to improved patient care?

A: After participating in the venous thromboembolism (VTE) mentored implementation program, I became a participant as a mentee site for I-PASS, a program focused on improving communication between providers during patient handoffs. During my time with the I-PASS team, I could sense the commitment and energy to improving handoffs not only at my site but at other participant sites nationwide during our regular check-in calls. Mentored implementation programs are brilliant because they go beyond providing sites with data, a few research papers, and some written recommendations. They really dig down into the true spirit of mentoring with a team.

At Hurley Medical Center, we went “all in” with our pediatric residency. What was most encouraging was that by the end of the year, the I-PASS recommendations and processes were standard practice and fully integrated into the culture and workflow of the care teams.

I applaud these programs tremendously. That’s really how you impact change, and it’s the spark, energy, and momentum from both mentors and mentees that keeps the team on track.

Q: You are the immediate past president of the Michigan Chapter of SHM. What have been some of the biggest benefits of being involved with an SHM chapter?

A: When I first became involved with SHM, there had been a Northern Michigan Chapter, but since SHM seeks to have regional chapters that cater to local audiences, I and some of my colleagues set out to develop a Southern Michigan Chapter. We developed our chapter and designed our meetings with support from SHM’s Chapter Support Committee.

At a typical meeting, we typically host an hour of cocktails with some hors d’oeuvres to provide an opportunity for networking and fellowship. The personal connections are at the heart of these meetings. From the content side, we always have a speaker to talk about issues germane to hospitalists. These are not just run-of-the-mill grand rounds discussions but rather information on clinical updates or the business and policy side of hospital medicine.

In our chapter, we also cycle leadership each year, using a “see one, do one, teach one” approach with our vice president-elect, president, and immediate past president to ensure proper development and continuity.

Moving forward, we are trying to reach out to medical students on a more regular basis. If you’re in your third year of medical school, it’s beneficial to start talking informally to hospitalists from multiple organizations in the state and get a feel for what a career in hospital medicine is like. How amazing would it be to walk in and interview for residency with a person you had dinner with a few months ago?

Q: SHM’s Board of Directors recently approved a Chapter Development Fund to support innovative initiatives that drive engagement on a local level. Explain the potential impact you see this having on chapters and, more broadly, SHM’s membership and hospital medicine.

A: Since our chapter’s inception, we have been able to expand our reach and stream our content to other parts of the state on the Internet. Part of the reason we have been able to do this is due to support from a Chapter Development Fund recently approved by SHM’s Board of Directors. As a result, we have turned our Southern Michigan Chapter into a statewide chapter with virtual sites. At the last meeting, we had over 75 attendees between our physical site and our “satellite site” in Michigan.

Our next project is to apply for funding to provide first- and second-year residents with free membership for a year through our chapter to expose them to the resources SHM has available to them and get their foot in the door with the organization. At a recent co-sponsored statewide meeting with the American College of Physicians, we were able to sign up 20 residents as new members of SHM, and our chapter paid their dues as an investment into our specialty.

Q: Any closing thoughts?

A: If there’s one thing I haven’t yet shared that I feel quite passionately about, it’s that SHM has such a robust library of educational resources that all hospitalists should be aware of, especially SHM’s annual meeting. It’s extraordinarily clinical and features a sizeable amount of content for grassroots clinicians and hospital leaders, including the best speakers in the field. On top of the educational components, the networking possibilities with hospitalists across the country make the annual meeting a prime example of the value SHM offers.

I’ve also been fortunate to have been involved with developing enduring materials on SHM’s Learning Portal, some of which are available without cost due to grant funding. The fact that SHM has pursued this funding and made some of these resources available to hospitalists outside of SHM’s membership embodies the organization’s mission of not only teaching doctors how to take better care of patients but helping patients get better—one of many reasons I am proud to be an active member. TH

Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/getinvolved for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.

This month, The Hospitalist spotlights Scott Kaatz, DO, MSc, FACP, SFHM, a hospitalist at Henry Ford Hospital in Detroit. In addition to being an active SHM member, he is immediate past president of SHM’s Michigan Chapter and has been involved in multiple mentored implementation (MI) programs offered by SHM’s Center for Hospital Innovation and Improvement.

Question: What inspired you to begin working in hospital medicine and later join and become so involved with SHM?

Answer: For most of my career, I’ve been at Henry Ford Hospital in Detroit, including during my internal medicine residency. After residency, I was a primary-care physician there, and I rounded three to four months out of the year in the hospital with traditional house staff model. Four years ago, I transitioned to another role as a chief quality officer at Hurley Medical Center in Flint, Mich. While in Flint, I didn’t have a clinic and was strictly a hospitalist, spending about four months a year rounding.

When my career path led me to mostly inpatient work in the hospital, I became more involved not only with hospital medicine but with SHM. As of this past June, I went back home to Henry Ford as a full-time hospitalist. I now focus my attention on hospital medicine for eight months of the year, with some protected time for faculty development and scholarly activities for residents and junior faculty in the division of hospital medicine.

Q: How has your involvement with SHM’s mentored implementation programs impacted your practice and led to improved patient care?

A: After participating in the venous thromboembolism (VTE) mentored implementation program, I became a participant as a mentee site for I-PASS, a program focused on improving communication between providers during patient handoffs. During my time with the I-PASS team, I could sense the commitment and energy to improving handoffs not only at my site but at other participant sites nationwide during our regular check-in calls. Mentored implementation programs are brilliant because they go beyond providing sites with data, a few research papers, and some written recommendations. They really dig down into the true spirit of mentoring with a team.

At Hurley Medical Center, we went “all in” with our pediatric residency. What was most encouraging was that by the end of the year, the I-PASS recommendations and processes were standard practice and fully integrated into the culture and workflow of the care teams.

I applaud these programs tremendously. That’s really how you impact change, and it’s the spark, energy, and momentum from both mentors and mentees that keeps the team on track.

Q: You are the immediate past president of the Michigan Chapter of SHM. What have been some of the biggest benefits of being involved with an SHM chapter?

A: When I first became involved with SHM, there had been a Northern Michigan Chapter, but since SHM seeks to have regional chapters that cater to local audiences, I and some of my colleagues set out to develop a Southern Michigan Chapter. We developed our chapter and designed our meetings with support from SHM’s Chapter Support Committee.

At a typical meeting, we typically host an hour of cocktails with some hors d’oeuvres to provide an opportunity for networking and fellowship. The personal connections are at the heart of these meetings. From the content side, we always have a speaker to talk about issues germane to hospitalists. These are not just run-of-the-mill grand rounds discussions but rather information on clinical updates or the business and policy side of hospital medicine.

In our chapter, we also cycle leadership each year, using a “see one, do one, teach one” approach with our vice president-elect, president, and immediate past president to ensure proper development and continuity.

Moving forward, we are trying to reach out to medical students on a more regular basis. If you’re in your third year of medical school, it’s beneficial to start talking informally to hospitalists from multiple organizations in the state and get a feel for what a career in hospital medicine is like. How amazing would it be to walk in and interview for residency with a person you had dinner with a few months ago?

Q: SHM’s Board of Directors recently approved a Chapter Development Fund to support innovative initiatives that drive engagement on a local level. Explain the potential impact you see this having on chapters and, more broadly, SHM’s membership and hospital medicine.

A: Since our chapter’s inception, we have been able to expand our reach and stream our content to other parts of the state on the Internet. Part of the reason we have been able to do this is due to support from a Chapter Development Fund recently approved by SHM’s Board of Directors. As a result, we have turned our Southern Michigan Chapter into a statewide chapter with virtual sites. At the last meeting, we had over 75 attendees between our physical site and our “satellite site” in Michigan.

Our next project is to apply for funding to provide first- and second-year residents with free membership for a year through our chapter to expose them to the resources SHM has available to them and get their foot in the door with the organization. At a recent co-sponsored statewide meeting with the American College of Physicians, we were able to sign up 20 residents as new members of SHM, and our chapter paid their dues as an investment into our specialty.

Q: Any closing thoughts?

A: If there’s one thing I haven’t yet shared that I feel quite passionately about, it’s that SHM has such a robust library of educational resources that all hospitalists should be aware of, especially SHM’s annual meeting. It’s extraordinarily clinical and features a sizeable amount of content for grassroots clinicians and hospital leaders, including the best speakers in the field. On top of the educational components, the networking possibilities with hospitalists across the country make the annual meeting a prime example of the value SHM offers.

I’ve also been fortunate to have been involved with developing enduring materials on SHM’s Learning Portal, some of which are available without cost due to grant funding. The fact that SHM has pursued this funding and made some of these resources available to hospitalists outside of SHM’s membership embodies the organization’s mission of not only teaching doctors how to take better care of patients but helping patients get better—one of many reasons I am proud to be an active member. TH

Acute kidney injury is common in children and young adults admitted to ICUs, and cannot always be identified by plasma creatinine level alone, according to the authors of a study presented at the meeting sponsored by the American Society of Nephrology.

The Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) study was a prospective, international, observational study in 4,683 patients aged 3 months to 25 years, recruited from 32 pediatric ICUs over the course of 3 months.

Hemera Technologies/Thinkstock

Acute kidney injury is common in children and young adults admitted to ICUs, and cannot always be identified by plasma creatinine level alone, according to the authors of a study presented at the meeting sponsored by the American Society of Nephrology.

The Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) study was a prospective, international, observational study in 4,683 patients aged 3 months to 25 years, recruited from 32 pediatric ICUs over the course of 3 months.

Hemera Technologies/Thinkstock

Acute kidney injury is common in children and young adults admitted to ICUs, and cannot always be identified by plasma creatinine level alone, according to the authors of a study presented at the meeting sponsored by the American Society of Nephrology.

The Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) study was a prospective, international, observational study in 4,683 patients aged 3 months to 25 years, recruited from 32 pediatric ICUs over the course of 3 months.

Hemera Technologies/Thinkstock