The Hospitalist

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

I explain my role as a hospitalist and my connection to the patient’s primary care physician (PCP) on first meeting the patient. I look for ways to reinforce this throughout the hospitalization.

Why I Do It

Even when I was hospitalized at my own institution, it was difficult for me to remember all of the providers involved in my care and their roles. My injuries and the large number of doctors caring for me interfered with my ability to absorb this information. I imagine that this is amplified for patients who have little or no experience with the medical system and are unfamiliar with the role that we play in their care.

During a recent initiative to improve the patient experience at my institution, we found it difficult to collect specific feedback on individual providers because many patients did not know their inpatient doctors’ names, frequently referencing their PCPs when asked for feedback on their care. This is common: A 2009 study showed that 75% of patients were unable to name the inpatient physician in charge of their care. Of those who could identify a name, only 40% correctly identified a member of their primary inpatient team, often identifying the PCP or a specialist instead.1

Clarifying our role on the care team, identifying ourselves as the point person for questions or concerns, and reinforcing our relationship with the PCP can help engender trust in the relationship, eliminate confusion, and improve the patient experience.

How I Do It

After introducing myself, I explain to patients that I will notify their PCP of the admission, and I state that I will be acting as the head of the inpatient team on behalf of their PCP. I often explain that most PCPs do not see their own patients in the hospital.

When multiple teams or house staff are involved in care, I clarify my role in relation to other team members. I look for opportunities throughout the hospitalization to reinforce this. For example, I tell patients when I have updated their PCP on significant events, and I clarify my role in simple terms, such as “quarterback,” when there are multiple subspecialists involved in care. I try to avoid terms like “attending,” which are often meaningless to patients.

In my hospitalist group, we help to reinforce our role and identity by providing a business card that includes a headshot. TH

Dr. Moore is a hospitalist at Beth Israel Deaconess Medical Center and an instructor of medicine at Harvard Medical School, both in Boston. She is a member of SHM’s Patient Experience Committee.

Reference

1. Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D. Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med. 2009;169(2):199-201.

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

I explain my role as a hospitalist and my connection to the patient’s primary care physician (PCP) on first meeting the patient. I look for ways to reinforce this throughout the hospitalization.

Why I Do It

Even when I was hospitalized at my own institution, it was difficult for me to remember all of the providers involved in my care and their roles. My injuries and the large number of doctors caring for me interfered with my ability to absorb this information. I imagine that this is amplified for patients who have little or no experience with the medical system and are unfamiliar with the role that we play in their care.

During a recent initiative to improve the patient experience at my institution, we found it difficult to collect specific feedback on individual providers because many patients did not know their inpatient doctors’ names, frequently referencing their PCPs when asked for feedback on their care. This is common: A 2009 study showed that 75% of patients were unable to name the inpatient physician in charge of their care. Of those who could identify a name, only 40% correctly identified a member of their primary inpatient team, often identifying the PCP or a specialist instead.1

Clarifying our role on the care team, identifying ourselves as the point person for questions or concerns, and reinforcing our relationship with the PCP can help engender trust in the relationship, eliminate confusion, and improve the patient experience.

How I Do It

After introducing myself, I explain to patients that I will notify their PCP of the admission, and I state that I will be acting as the head of the inpatient team on behalf of their PCP. I often explain that most PCPs do not see their own patients in the hospital.

When multiple teams or house staff are involved in care, I clarify my role in relation to other team members. I look for opportunities throughout the hospitalization to reinforce this. For example, I tell patients when I have updated their PCP on significant events, and I clarify my role in simple terms, such as “quarterback,” when there are multiple subspecialists involved in care. I try to avoid terms like “attending,” which are often meaningless to patients.

In my hospitalist group, we help to reinforce our role and identity by providing a business card that includes a headshot. TH

Dr. Moore is a hospitalist at Beth Israel Deaconess Medical Center and an instructor of medicine at Harvard Medical School, both in Boston. She is a member of SHM’s Patient Experience Committee.

Reference

1. Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D. Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med. 2009;169(2):199-201.

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

I explain my role as a hospitalist and my connection to the patient’s primary care physician (PCP) on first meeting the patient. I look for ways to reinforce this throughout the hospitalization.

Why I Do It

Even when I was hospitalized at my own institution, it was difficult for me to remember all of the providers involved in my care and their roles. My injuries and the large number of doctors caring for me interfered with my ability to absorb this information. I imagine that this is amplified for patients who have little or no experience with the medical system and are unfamiliar with the role that we play in their care.

During a recent initiative to improve the patient experience at my institution, we found it difficult to collect specific feedback on individual providers because many patients did not know their inpatient doctors’ names, frequently referencing their PCPs when asked for feedback on their care. This is common: A 2009 study showed that 75% of patients were unable to name the inpatient physician in charge of their care. Of those who could identify a name, only 40% correctly identified a member of their primary inpatient team, often identifying the PCP or a specialist instead.1

Clarifying our role on the care team, identifying ourselves as the point person for questions or concerns, and reinforcing our relationship with the PCP can help engender trust in the relationship, eliminate confusion, and improve the patient experience.

How I Do It

After introducing myself, I explain to patients that I will notify their PCP of the admission, and I state that I will be acting as the head of the inpatient team on behalf of their PCP. I often explain that most PCPs do not see their own patients in the hospital.

When multiple teams or house staff are involved in care, I clarify my role in relation to other team members. I look for opportunities throughout the hospitalization to reinforce this. For example, I tell patients when I have updated their PCP on significant events, and I clarify my role in simple terms, such as “quarterback,” when there are multiple subspecialists involved in care. I try to avoid terms like “attending,” which are often meaningless to patients.

In my hospitalist group, we help to reinforce our role and identity by providing a business card that includes a headshot. TH

Dr. Moore is a hospitalist at Beth Israel Deaconess Medical Center and an instructor of medicine at Harvard Medical School, both in Boston. She is a member of SHM’s Patient Experience Committee.

Reference

1. Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D. Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med. 2009;169(2):199-201.

Clinical question: Does the use of disinfection caps on catheter hubs on central venous catheters (CVCs) reduce central-line-associated bloodstream infection (CLABSI) and blood culture contamination (BCC) in hematology-oncology patients?

Background: CVCs have facilitated the administration of chemotherapy, blood products, and fluids in cancer patients; however, their use has also brought about risk of infections. Use of an antiseptic barrier cap may result in decreased rates of CLABSI and BCC.

Study design: Multiphase prospective study

Setting: Memorial Sloan Kettering Cancer Center, New York City.

Synopsis: Disinfection caps on CVCs were sequentially introduced on high-risk units (HRUs) followed by hospital-wide implementation. The primary outcome was hospital-wide and unit-specific rates of hospital-acquired (HA) CLABSI. In Phase 1 and 2, the CDC guidelines for catheter maintenance were followed. In Phase 3, the intervention was implemented in the HRUs. In Phase 4, the intervention extended hospital-wide. HA-CLABSI declined significantly compared to baseline only in HRUs. A possible explanation is that reduction in CLABSI on general wards was not apparent due to the short follow-up period as opposed to the longer follow-up period for the HRUs. The secondary outcome was that the rates of BCC declined significantly in Phase 3 and 4 when compared to Phase 1 and 2. As for limitations, the study is not a randomized controlled trial; variable follow-up periods may have contributed to different outcomes observed on the different units.

Bottom line: Implementation of disinfection caps significantly reduces rates of CLABSI in HRUs and reduces BCCs in both HRUs and general oncology units, with substantial clinical and cost-savings implications.

Citation: Kamboj M, Blair R, Bell N, et al. Use of disinfection cap to reduce central-line-associated bloodstream infection and blood culture contamination among hematology-oncology patients. Infect Control Hosp Epidemiol. 2015;36(12):1401-1408.

Short Take

High Workload among Attending Physicians Has Negative Outcomes

Retrospective study found associations between higher attending physician workload and lower teaching evaluation scores from residents as well as increased risks to patient safety.

Citation: Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. Associations between attending physician workload, teaching effectiveness, and patient safety. J Hosp Med. 2016;11(3):169-173.

Clinical question: Does the use of disinfection caps on catheter hubs on central venous catheters (CVCs) reduce central-line-associated bloodstream infection (CLABSI) and blood culture contamination (BCC) in hematology-oncology patients?

Background: CVCs have facilitated the administration of chemotherapy, blood products, and fluids in cancer patients; however, their use has also brought about risk of infections. Use of an antiseptic barrier cap may result in decreased rates of CLABSI and BCC.

Study design: Multiphase prospective study

Setting: Memorial Sloan Kettering Cancer Center, New York City.

Synopsis: Disinfection caps on CVCs were sequentially introduced on high-risk units (HRUs) followed by hospital-wide implementation. The primary outcome was hospital-wide and unit-specific rates of hospital-acquired (HA) CLABSI. In Phase 1 and 2, the CDC guidelines for catheter maintenance were followed. In Phase 3, the intervention was implemented in the HRUs. In Phase 4, the intervention extended hospital-wide. HA-CLABSI declined significantly compared to baseline only in HRUs. A possible explanation is that reduction in CLABSI on general wards was not apparent due to the short follow-up period as opposed to the longer follow-up period for the HRUs. The secondary outcome was that the rates of BCC declined significantly in Phase 3 and 4 when compared to Phase 1 and 2. As for limitations, the study is not a randomized controlled trial; variable follow-up periods may have contributed to different outcomes observed on the different units.

Bottom line: Implementation of disinfection caps significantly reduces rates of CLABSI in HRUs and reduces BCCs in both HRUs and general oncology units, with substantial clinical and cost-savings implications.

Citation: Kamboj M, Blair R, Bell N, et al. Use of disinfection cap to reduce central-line-associated bloodstream infection and blood culture contamination among hematology-oncology patients. Infect Control Hosp Epidemiol. 2015;36(12):1401-1408.

Short Take

High Workload among Attending Physicians Has Negative Outcomes

Retrospective study found associations between higher attending physician workload and lower teaching evaluation scores from residents as well as increased risks to patient safety.

Citation: Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. Associations between attending physician workload, teaching effectiveness, and patient safety. J Hosp Med. 2016;11(3):169-173.

Clinical question: Does the use of disinfection caps on catheter hubs on central venous catheters (CVCs) reduce central-line-associated bloodstream infection (CLABSI) and blood culture contamination (BCC) in hematology-oncology patients?

Background: CVCs have facilitated the administration of chemotherapy, blood products, and fluids in cancer patients; however, their use has also brought about risk of infections. Use of an antiseptic barrier cap may result in decreased rates of CLABSI and BCC.

Study design: Multiphase prospective study

Setting: Memorial Sloan Kettering Cancer Center, New York City.

Synopsis: Disinfection caps on CVCs were sequentially introduced on high-risk units (HRUs) followed by hospital-wide implementation. The primary outcome was hospital-wide and unit-specific rates of hospital-acquired (HA) CLABSI. In Phase 1 and 2, the CDC guidelines for catheter maintenance were followed. In Phase 3, the intervention was implemented in the HRUs. In Phase 4, the intervention extended hospital-wide. HA-CLABSI declined significantly compared to baseline only in HRUs. A possible explanation is that reduction in CLABSI on general wards was not apparent due to the short follow-up period as opposed to the longer follow-up period for the HRUs. The secondary outcome was that the rates of BCC declined significantly in Phase 3 and 4 when compared to Phase 1 and 2. As for limitations, the study is not a randomized controlled trial; variable follow-up periods may have contributed to different outcomes observed on the different units.

Bottom line: Implementation of disinfection caps significantly reduces rates of CLABSI in HRUs and reduces BCCs in both HRUs and general oncology units, with substantial clinical and cost-savings implications.

Citation: Kamboj M, Blair R, Bell N, et al. Use of disinfection cap to reduce central-line-associated bloodstream infection and blood culture contamination among hematology-oncology patients. Infect Control Hosp Epidemiol. 2015;36(12):1401-1408.

Short Take

High Workload among Attending Physicians Has Negative Outcomes

Retrospective study found associations between higher attending physician workload and lower teaching evaluation scores from residents as well as increased risks to patient safety.

Citation: Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. Associations between attending physician workload, teaching effectiveness, and patient safety. J Hosp Med. 2016;11(3):169-173.

Clinical question: Does inhaled isopropyl alcohol alleviate nausea as compared to inhaled saline solution among patients presenting to the ED with a chief complaint of nausea?

Background: Nausea and vomiting account for 4.8 million ED visits each year; however, antiemetics have not shown superiority compared to placebo. Isopropyl alcohol nasal inhalation is more effective than saline solution in treating postoperative nausea and vomiting; however, there have been no investigations of this therapy in the ED setting.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Emergency department at the San Antonio Military Medical Center, Texas.

Synopsis: Investigators randomized a convenience sample of 80 patients in the ED presenting with nausea or vomiting to either inhaled isopropyl alcohol (37) or saline solution (43). Subjects would nasally inhale at 0, 2, and 4 minutes. Nausea outcomes were self-rated on a scale of 0–10, with 0 being no nausea and 10 being worst nausea imaginable. Responses were taken at 0, 2, 4, 6, and 10 minutes postintervention. Primary outcome was the score at 10 minutes postintervention. The minimally significant difference was two points.

Patients in the intervention arm reported lower scores during every study period than the patients in the placebo arm. Median nausea scores at 10 minutes postintervention were lower by three in the intervention arm compared to placebo arm (P<0.001). Limitations include the short (10-minute) evaluation period, which limits identification of any adverse events; limited information on duration of symptom relief and whether the isopropyl alcohol effect persisted; possible selection bias due to utilizing a convenience sample; and use of a subjective scale for the primary outcome.

Bottom line: Isopropyl alcohol inhalation is effective in reducing nausea 10 minutes after intervention as compared with placebo in the ED setting.

Citation: Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl alcohol nasal inhalation for nausea in the emergency department: a randomized controlled trial [published online ahead of print November 21, 2015]. Ann Emerg Med. doi:10.1016/j.annemergmed.2015.09.031.

Clinical question: Does inhaled isopropyl alcohol alleviate nausea as compared to inhaled saline solution among patients presenting to the ED with a chief complaint of nausea?

Background: Nausea and vomiting account for 4.8 million ED visits each year; however, antiemetics have not shown superiority compared to placebo. Isopropyl alcohol nasal inhalation is more effective than saline solution in treating postoperative nausea and vomiting; however, there have been no investigations of this therapy in the ED setting.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Emergency department at the San Antonio Military Medical Center, Texas.

Synopsis: Investigators randomized a convenience sample of 80 patients in the ED presenting with nausea or vomiting to either inhaled isopropyl alcohol (37) or saline solution (43). Subjects would nasally inhale at 0, 2, and 4 minutes. Nausea outcomes were self-rated on a scale of 0–10, with 0 being no nausea and 10 being worst nausea imaginable. Responses were taken at 0, 2, 4, 6, and 10 minutes postintervention. Primary outcome was the score at 10 minutes postintervention. The minimally significant difference was two points.

Patients in the intervention arm reported lower scores during every study period than the patients in the placebo arm. Median nausea scores at 10 minutes postintervention were lower by three in the intervention arm compared to placebo arm (P<0.001). Limitations include the short (10-minute) evaluation period, which limits identification of any adverse events; limited information on duration of symptom relief and whether the isopropyl alcohol effect persisted; possible selection bias due to utilizing a convenience sample; and use of a subjective scale for the primary outcome.

Bottom line: Isopropyl alcohol inhalation is effective in reducing nausea 10 minutes after intervention as compared with placebo in the ED setting.

Citation: Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl alcohol nasal inhalation for nausea in the emergency department: a randomized controlled trial [published online ahead of print November 21, 2015]. Ann Emerg Med. doi:10.1016/j.annemergmed.2015.09.031.

Clinical question: Does inhaled isopropyl alcohol alleviate nausea as compared to inhaled saline solution among patients presenting to the ED with a chief complaint of nausea?

Background: Nausea and vomiting account for 4.8 million ED visits each year; however, antiemetics have not shown superiority compared to placebo. Isopropyl alcohol nasal inhalation is more effective than saline solution in treating postoperative nausea and vomiting; however, there have been no investigations of this therapy in the ED setting.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Emergency department at the San Antonio Military Medical Center, Texas.

Synopsis: Investigators randomized a convenience sample of 80 patients in the ED presenting with nausea or vomiting to either inhaled isopropyl alcohol (37) or saline solution (43). Subjects would nasally inhale at 0, 2, and 4 minutes. Nausea outcomes were self-rated on a scale of 0–10, with 0 being no nausea and 10 being worst nausea imaginable. Responses were taken at 0, 2, 4, 6, and 10 minutes postintervention. Primary outcome was the score at 10 minutes postintervention. The minimally significant difference was two points.

Patients in the intervention arm reported lower scores during every study period than the patients in the placebo arm. Median nausea scores at 10 minutes postintervention were lower by three in the intervention arm compared to placebo arm (P<0.001). Limitations include the short (10-minute) evaluation period, which limits identification of any adverse events; limited information on duration of symptom relief and whether the isopropyl alcohol effect persisted; possible selection bias due to utilizing a convenience sample; and use of a subjective scale for the primary outcome.

Bottom line: Isopropyl alcohol inhalation is effective in reducing nausea 10 minutes after intervention as compared with placebo in the ED setting.

Citation: Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl alcohol nasal inhalation for nausea in the emergency department: a randomized controlled trial [published online ahead of print November 21, 2015]. Ann Emerg Med. doi:10.1016/j.annemergmed.2015.09.031.

Reference

1. Jacobs LR, Mettler S. Liking health reform but turned off by toxic politics [published online ahead of print April 2016]. Health Aff. doi:10.1377/hlthaff.2015.1313.

Reference

1. Jacobs LR, Mettler S. Liking health reform but turned off by toxic politics [published online ahead of print April 2016]. Health Aff. doi:10.1377/hlthaff.2015.1313.

Reference

1. Jacobs LR, Mettler S. Liking health reform but turned off by toxic politics [published online ahead of print April 2016]. Health Aff. doi:10.1377/hlthaff.2015.1313.

Discharging patients before noon has many advantages: It creates open beds to accommodate the surge in admissions in the afternoon and helps minimize the bottleneck in system-wide patient flow, says Ragu P. Sanjeev, MD, unit-based medical director at Christiana Hospital in Newark, Del.

“Doing so can reduce ER wait times, reduce the percentage of patients leaving the ED without being seen—a safety issue for those patients—and also help to place the right patient in the right bed in a timely manner,” he says. “It’s a not just a patient flow issue; it’s a patient safety issue, as well.”

At his hospital, hospitalists developed a “Discharge by Appointment” process to address the issue systematically and completed a pilot project to test it. Their “‘Discharge by Appointment’ Improves Patient Flow, by Increasing Number of Discharges Before Noon,” was an abstract presented at HM16.1

“Giving patients that have a high predictability of being discharged next day, an appointment, and set off a series of steps to be completed the day before discharge including, notifying the transport team/family members of the appointment, helped improve the number of discharges before noon significantly,” according to the abstract.

Their successful pilot project has led to lasting changes, Dr. Sanjeev says. For about 16 months, the number of discharges before noon has been steadily increasing, helping the acute medicine service line perform better than its “Discharge by Noon” goal by 44.4% this fiscal year.

“As hospitalists, we have a great potential to positively impact the hospital-wide issues like patient flow and patient safety,” Dr. Sanjeev says. “By actively participating in important hospital committees, you can understand better and get inspired by the ongoing improvement efforts. By partnering with your care team, including bedside nurses, case managers, and social workers, we can make a big difference in early discharges. This success can be expanded to discharges throughout the day with appointments, thereby keeping the flow faucet open at all times.”

Reference

1. Sanjeev R, McMillen J, Fedyk A. ‘discharge by Appointment’ Improves Patient Flow, by Increasing Number of Discharges Before Noon [abstract]. J Hosp Med. http://www.shmabstracts.com/abstract/discharge-by-appointment-improves-patient-flow-by-increasing-number-of-discharges-before-noon/. Accessed April 27, 2016.

Discharging patients before noon has many advantages: It creates open beds to accommodate the surge in admissions in the afternoon and helps minimize the bottleneck in system-wide patient flow, says Ragu P. Sanjeev, MD, unit-based medical director at Christiana Hospital in Newark, Del.

“Doing so can reduce ER wait times, reduce the percentage of patients leaving the ED without being seen—a safety issue for those patients—and also help to place the right patient in the right bed in a timely manner,” he says. “It’s a not just a patient flow issue; it’s a patient safety issue, as well.”

At his hospital, hospitalists developed a “Discharge by Appointment” process to address the issue systematically and completed a pilot project to test it. Their “‘Discharge by Appointment’ Improves Patient Flow, by Increasing Number of Discharges Before Noon,” was an abstract presented at HM16.1

“Giving patients that have a high predictability of being discharged next day, an appointment, and set off a series of steps to be completed the day before discharge including, notifying the transport team/family members of the appointment, helped improve the number of discharges before noon significantly,” according to the abstract.

Their successful pilot project has led to lasting changes, Dr. Sanjeev says. For about 16 months, the number of discharges before noon has been steadily increasing, helping the acute medicine service line perform better than its “Discharge by Noon” goal by 44.4% this fiscal year.

“As hospitalists, we have a great potential to positively impact the hospital-wide issues like patient flow and patient safety,” Dr. Sanjeev says. “By actively participating in important hospital committees, you can understand better and get inspired by the ongoing improvement efforts. By partnering with your care team, including bedside nurses, case managers, and social workers, we can make a big difference in early discharges. This success can be expanded to discharges throughout the day with appointments, thereby keeping the flow faucet open at all times.”

Reference

1. Sanjeev R, McMillen J, Fedyk A. ‘discharge by Appointment’ Improves Patient Flow, by Increasing Number of Discharges Before Noon [abstract]. J Hosp Med. http://www.shmabstracts.com/abstract/discharge-by-appointment-improves-patient-flow-by-increasing-number-of-discharges-before-noon/. Accessed April 27, 2016.

Discharging patients before noon has many advantages: It creates open beds to accommodate the surge in admissions in the afternoon and helps minimize the bottleneck in system-wide patient flow, says Ragu P. Sanjeev, MD, unit-based medical director at Christiana Hospital in Newark, Del.

“Doing so can reduce ER wait times, reduce the percentage of patients leaving the ED without being seen—a safety issue for those patients—and also help to place the right patient in the right bed in a timely manner,” he says. “It’s a not just a patient flow issue; it’s a patient safety issue, as well.”

At his hospital, hospitalists developed a “Discharge by Appointment” process to address the issue systematically and completed a pilot project to test it. Their “‘Discharge by Appointment’ Improves Patient Flow, by Increasing Number of Discharges Before Noon,” was an abstract presented at HM16.1

“Giving patients that have a high predictability of being discharged next day, an appointment, and set off a series of steps to be completed the day before discharge including, notifying the transport team/family members of the appointment, helped improve the number of discharges before noon significantly,” according to the abstract.

Their successful pilot project has led to lasting changes, Dr. Sanjeev says. For about 16 months, the number of discharges before noon has been steadily increasing, helping the acute medicine service line perform better than its “Discharge by Noon” goal by 44.4% this fiscal year.

“As hospitalists, we have a great potential to positively impact the hospital-wide issues like patient flow and patient safety,” Dr. Sanjeev says. “By actively participating in important hospital committees, you can understand better and get inspired by the ongoing improvement efforts. By partnering with your care team, including bedside nurses, case managers, and social workers, we can make a big difference in early discharges. This success can be expanded to discharges throughout the day with appointments, thereby keeping the flow faucet open at all times.”

Reference

1. Sanjeev R, McMillen J, Fedyk A. ‘discharge by Appointment’ Improves Patient Flow, by Increasing Number of Discharges Before Noon [abstract]. J Hosp Med. http://www.shmabstracts.com/abstract/discharge-by-appointment-improves-patient-flow-by-increasing-number-of-discharges-before-noon/. Accessed April 27, 2016.

PHM16 will provide in-depth review and challenge participants in various areas, including clinical practice, medical education, quality improvement, and professional development. Time will also be dedicated to networking and meeting with leaders in the field.

Register, book your hotel, and see the full course schedule at www.phmmeeting.org.

Brett Radler is SHM’s communications coordinator.

PHM16 will provide in-depth review and challenge participants in various areas, including clinical practice, medical education, quality improvement, and professional development. Time will also be dedicated to networking and meeting with leaders in the field.

Register, book your hotel, and see the full course schedule at www.phmmeeting.org.

Brett Radler is SHM’s communications coordinator.

PHM16 will provide in-depth review and challenge participants in various areas, including clinical practice, medical education, quality improvement, and professional development. Time will also be dedicated to networking and meeting with leaders in the field.

Register, book your hotel, and see the full course schedule at www.phmmeeting.org.

Brett Radler is SHM’s communications coordinator.

B. Abdalsm, MD, MPH, Alabama

A. Aboutalib, Alabama

D. Adams, MD, Arkansas

A. Afzal, MD, FACP, Arizona

J. Aheam, MD, California

S. Ahluwalia, MBBS, California

A. Alhusseini, MD, FAACP, MBchB, California

L. Anderson, MD, California

K. Arunachalam, MD, California

B. Asalone, California

L. Atkins, MD, California

T. Aultman, MD, California

T. Ayangade, MD, California

A. Azizi, MD, California

F. Azizi, MD, California

S. Balu, MD, California

K. Basra, APRN, FNP, California

N. Bassi, California

C. Batchelor, MD, California

K. Beinlich, MD, California

S. Bhat, MD, MBBS, California

H. Bilal, MBBS, California

G. Bismack, MD, California

M. Bokhari, MD, California

M. Brandenbug, MD, Colorado

H. Briggs, MD, PhD, Colorado

E. Burgh, MD, Colorado

M. Cabrera, BC, Delaware

J. Camden, BA, Delaware

P. Chandra Mohan, MD, Delaware

D. Chau, MD, Delaware

M. Chen, Florida

V. Chennamaneni, Florida

L. Cler, Florida

D. Cooks, Florida

S. Crenshaw, Florida

K. Cunningham, MD, FACP, Florida

V. De Guzman, APRN, MSN, NP, Florida

M. Del Rosario, MD, Florida

D. DeVere, MD, Florida

S. Dharmapuri, Florida

P. Dodson, MD, Florida

A. Domaoal, Georgia

J. Duncan, MD, Georgia

B. Dyck, BSC, MD, PhD, Georgia

J. Dzundza, MD, Georgia

A. Ellis, FNP, Georgia

R. Erickson, Idaho

A. Faraj, Idaho

S. Fernandez, MD, Illinois

G. Ferrari, MD, Illinois

W. Folad, MD, Illinois

L. Fowler, ACNP, APRN, MBA, Illinois

J. Golderberg, MD, Illinois

G. Goldman, MD, Illinois

L. Gonzales, MD, Indiana

A. Gonzalez, Kansas

W. Griffo, MD, Kansas

R. Guzman, Kansas

L. Guzman Vinasco, MD, Kansas

K. Hageman, DO, Kentucky

M. Haggerty, PA-C, Kentucky

B. Hammond, Louisiana

G. Harris, MD, Louisiana

J. Hasan-Jones, RN, FACHE, Louisiana

J. Herring, Louisiana

L. Hsu, MD, Massachusetts

A. C. Hunag, DO, Massachusetts

M. Huq, Massachusetts

M. Jandrin, PA-C, Massachusetts

C. Janish, MD, Maryland

J. Jarin, MD, Maine

A. Jenkins, Maine

S. Jindal, MD, Michigan

M. Johl, Michigan

T. John, Michigan

N. Kapadia, MD, Michigan

L. Katona, Michigan

K. Kaye, Michigan

M. Keating, Michigan

L. Keeton, MD, Michigan

L. Kendall, Michigan

M. Kerlin, Michigan

A. Kia, MD, Minnesota

R. Klett, Minnesota

L. Knapp, DO, Minnesota

K. Knox, Missouri

M. Kraynak, MD, Missouri

P. Kuppireddy, MBBS, Missouri

W. Landrum, MD, Missouri

C. Larion, ACNP, Missouri

E. Latcheva, MD, Mississippi

D. Leforce, North Carolina

V. Leigh, DO, North Carolina

C. Leon, North Carolina

T. Li, MD, North Dakota

X. Li, MD, Nebraska

Y. Li, New Hampshire

J. Liu, New Hampshire

L. Lu, DO, New Jersey

S. Mathapathi, New Jersey

L. McGann, New Jersey

S. Melkaveri, MD, Nevada

R. Mercado Garcia, New York

S. Merry, MD, New York

P. Meyer, DO, New York

J. Mikulca, PharmD, New York

Z. Moyenda, MD, MBA, New York

K. Murphy, DO, MPH, New York

J. Musenze, New York

P. Mutungi, New York

G. Nanna, USA, New York

I. Nasir, New York

U. Nazario-Vidah, MD, New York

D. Nguyen, New York

C. Ojha, MBBS, New York

K. Olson, MD, Ohio

V. Paulson, MD, Ohio

R. Pearson, DO, PhD, Ohio

A. Peel, MD, Ohio

S. Pettis, PA-C, Ohio

E. Picloglou, MD, Ohio

H. Pokhrel, MD, Ohio

H. Bush, Oklahoma

R. Porter, PA, Oklahoma

P. Prabhakar, Oklahoma

U. Qamar, Oklahoma

R. Quansah, MD, Oklahoma

M. Rahman, Oklahoma

R. Rajeshwar, Oregon

E. Randal, Oregon

A. Ray, Oregon

V. Reddy, Oregon

J. Reed, MD, RN, Oregon

R. Regidor, Oregon

A. Reitsma-Mathias, MD, Oregon

R. Reyes, MD, Oregon

T. Richardson, NP, Oregon

T. Ringer, Oregon

L. Rivera-Crespo, Pennsylvania

T. Rothwell, PA, Pennsylvania

E. Sacolick, MD, Pennsylvania

E. Saluke, MD, Pennsylvania

M. Santinelli, NP, Pennsylvania

M. Sapon-Amoah, FNP, Pennsylvania

D. Scarine, NP, Pennsylvania

K. Seger, Pennsylvania

A. Shah, Pennsylvania

K. Shah, MD, Pennsylvania

S. Shah, MD, Pennsylvania

G. Sharma, MD, Pennsylvania

K. Shaukat, MD, Pennsylvania

E. Sheindler, Rhode Island

D. Sheps, South Carolina

J. Shipe-Spotloe, South Carolina

S. Sim, South Carolina

M. Simon, MD, MMM, CPE, South Carolina

A. Singh, South Carolina

S. Singh-Patel, PO, South Dakota

M. Snyder, South Dakota

A. Srikanth, MBBS, Tennessee

B. Staats, Tennessee

C. Standley, Texas

R. Stanhiser, Texas

M. Stevens, Texas

K. Stuart, Texas

A. Summers, Texas

E. Taylo, Texas

L. Taylor, PA-C, Texas

L. Theaker, Texas

M. Thieman, Texas

J. Tong, Texas

N. Trivedi, MD, Texas

L. Tuazon, MD, FACP, Texas

S. Tummalapalli, Texas

A. Ufferman, MD, Virginia

R. Urrea, MD, Virginia

N. Van Groningen, Virginia

D. Vaughn, MD, Vermont

R. Vento, MD, MPH, Washington

Y. Villaran, MD, Washington

L. Viscome, DO, Washington

K. Vo, Washington

H. Vu, MD, Washington

T. Washko, MD, Washington

T. Waters, DO, Wisconsin

L. Weisberger, USA, Wisconsin

A. Whitehead, Wisconsin

A. Workman, West Virginia

F. Yasin, MD, West Virginia

A. Yoon, MD, West Virginia

M. Yu, West Virginia

A. Yuen, DO, West Virginia

K. Zwieg, West Virginia

B. Abdalsm, MD, MPH, Alabama

A. Aboutalib, Alabama

D. Adams, MD, Arkansas

A. Afzal, MD, FACP, Arizona

J. Aheam, MD, California

S. Ahluwalia, MBBS, California

A. Alhusseini, MD, FAACP, MBchB, California

L. Anderson, MD, California

K. Arunachalam, MD, California

B. Asalone, California

L. Atkins, MD, California

T. Aultman, MD, California

T. Ayangade, MD, California

A. Azizi, MD, California

F. Azizi, MD, California

S. Balu, MD, California

K. Basra, APRN, FNP, California

N. Bassi, California

C. Batchelor, MD, California

K. Beinlich, MD, California

S. Bhat, MD, MBBS, California

H. Bilal, MBBS, California

G. Bismack, MD, California

M. Bokhari, MD, California

M. Brandenbug, MD, Colorado

H. Briggs, MD, PhD, Colorado

E. Burgh, MD, Colorado

M. Cabrera, BC, Delaware

J. Camden, BA, Delaware

P. Chandra Mohan, MD, Delaware

D. Chau, MD, Delaware

M. Chen, Florida

V. Chennamaneni, Florida

L. Cler, Florida

D. Cooks, Florida

S. Crenshaw, Florida

K. Cunningham, MD, FACP, Florida

V. De Guzman, APRN, MSN, NP, Florida

M. Del Rosario, MD, Florida

D. DeVere, MD, Florida

S. Dharmapuri, Florida

P. Dodson, MD, Florida

A. Domaoal, Georgia

J. Duncan, MD, Georgia

B. Dyck, BSC, MD, PhD, Georgia

J. Dzundza, MD, Georgia

A. Ellis, FNP, Georgia

R. Erickson, Idaho

A. Faraj, Idaho

S. Fernandez, MD, Illinois

G. Ferrari, MD, Illinois

W. Folad, MD, Illinois

L. Fowler, ACNP, APRN, MBA, Illinois

J. Golderberg, MD, Illinois

G. Goldman, MD, Illinois

L. Gonzales, MD, Indiana

A. Gonzalez, Kansas

W. Griffo, MD, Kansas

R. Guzman, Kansas

L. Guzman Vinasco, MD, Kansas

K. Hageman, DO, Kentucky

M. Haggerty, PA-C, Kentucky

B. Hammond, Louisiana

G. Harris, MD, Louisiana

J. Hasan-Jones, RN, FACHE, Louisiana

J. Herring, Louisiana

L. Hsu, MD, Massachusetts

A. C. Hunag, DO, Massachusetts

M. Huq, Massachusetts

M. Jandrin, PA-C, Massachusetts

C. Janish, MD, Maryland

J. Jarin, MD, Maine

A. Jenkins, Maine

S. Jindal, MD, Michigan

M. Johl, Michigan

T. John, Michigan

N. Kapadia, MD, Michigan

L. Katona, Michigan

K. Kaye, Michigan

M. Keating, Michigan

L. Keeton, MD, Michigan

L. Kendall, Michigan

M. Kerlin, Michigan

A. Kia, MD, Minnesota

R. Klett, Minnesota

L. Knapp, DO, Minnesota

K. Knox, Missouri

M. Kraynak, MD, Missouri

P. Kuppireddy, MBBS, Missouri

W. Landrum, MD, Missouri

C. Larion, ACNP, Missouri

E. Latcheva, MD, Mississippi

D. Leforce, North Carolina

V. Leigh, DO, North Carolina

C. Leon, North Carolina

T. Li, MD, North Dakota

X. Li, MD, Nebraska

Y. Li, New Hampshire

J. Liu, New Hampshire

L. Lu, DO, New Jersey

S. Mathapathi, New Jersey

L. McGann, New Jersey

S. Melkaveri, MD, Nevada

R. Mercado Garcia, New York

S. Merry, MD, New York

P. Meyer, DO, New York

J. Mikulca, PharmD, New York

Z. Moyenda, MD, MBA, New York

K. Murphy, DO, MPH, New York

J. Musenze, New York

P. Mutungi, New York

G. Nanna, USA, New York

I. Nasir, New York

U. Nazario-Vidah, MD, New York

D. Nguyen, New York

C. Ojha, MBBS, New York

K. Olson, MD, Ohio

V. Paulson, MD, Ohio

R. Pearson, DO, PhD, Ohio

A. Peel, MD, Ohio

S. Pettis, PA-C, Ohio

E. Picloglou, MD, Ohio

H. Pokhrel, MD, Ohio

H. Bush, Oklahoma

R. Porter, PA, Oklahoma

P. Prabhakar, Oklahoma

U. Qamar, Oklahoma

R. Quansah, MD, Oklahoma

M. Rahman, Oklahoma

R. Rajeshwar, Oregon

E. Randal, Oregon

A. Ray, Oregon

V. Reddy, Oregon

J. Reed, MD, RN, Oregon

R. Regidor, Oregon

A. Reitsma-Mathias, MD, Oregon

R. Reyes, MD, Oregon

T. Richardson, NP, Oregon

T. Ringer, Oregon

L. Rivera-Crespo, Pennsylvania

T. Rothwell, PA, Pennsylvania

E. Sacolick, MD, Pennsylvania

E. Saluke, MD, Pennsylvania

M. Santinelli, NP, Pennsylvania

M. Sapon-Amoah, FNP, Pennsylvania

D. Scarine, NP, Pennsylvania

K. Seger, Pennsylvania

A. Shah, Pennsylvania

K. Shah, MD, Pennsylvania

S. Shah, MD, Pennsylvania

G. Sharma, MD, Pennsylvania

K. Shaukat, MD, Pennsylvania

E. Sheindler, Rhode Island

D. Sheps, South Carolina

J. Shipe-Spotloe, South Carolina

S. Sim, South Carolina

M. Simon, MD, MMM, CPE, South Carolina

A. Singh, South Carolina

S. Singh-Patel, PO, South Dakota

M. Snyder, South Dakota

A. Srikanth, MBBS, Tennessee

B. Staats, Tennessee

C. Standley, Texas

R. Stanhiser, Texas

M. Stevens, Texas

K. Stuart, Texas

A. Summers, Texas

E. Taylo, Texas

L. Taylor, PA-C, Texas

L. Theaker, Texas

M. Thieman, Texas

J. Tong, Texas

N. Trivedi, MD, Texas

L. Tuazon, MD, FACP, Texas

S. Tummalapalli, Texas

A. Ufferman, MD, Virginia

R. Urrea, MD, Virginia

N. Van Groningen, Virginia

D. Vaughn, MD, Vermont

R. Vento, MD, MPH, Washington

Y. Villaran, MD, Washington

L. Viscome, DO, Washington

K. Vo, Washington

H. Vu, MD, Washington

T. Washko, MD, Washington

T. Waters, DO, Wisconsin

L. Weisberger, USA, Wisconsin

A. Whitehead, Wisconsin

A. Workman, West Virginia

F. Yasin, MD, West Virginia

A. Yoon, MD, West Virginia

M. Yu, West Virginia

A. Yuen, DO, West Virginia

K. Zwieg, West Virginia

B. Abdalsm, MD, MPH, Alabama

A. Aboutalib, Alabama

D. Adams, MD, Arkansas

A. Afzal, MD, FACP, Arizona

J. Aheam, MD, California

S. Ahluwalia, MBBS, California

A. Alhusseini, MD, FAACP, MBchB, California

L. Anderson, MD, California

K. Arunachalam, MD, California

B. Asalone, California

L. Atkins, MD, California

T. Aultman, MD, California

T. Ayangade, MD, California

A. Azizi, MD, California

F. Azizi, MD, California

S. Balu, MD, California

K. Basra, APRN, FNP, California

N. Bassi, California

C. Batchelor, MD, California

K. Beinlich, MD, California

S. Bhat, MD, MBBS, California

H. Bilal, MBBS, California

G. Bismack, MD, California

M. Bokhari, MD, California

M. Brandenbug, MD, Colorado

H. Briggs, MD, PhD, Colorado

E. Burgh, MD, Colorado

M. Cabrera, BC, Delaware

J. Camden, BA, Delaware

P. Chandra Mohan, MD, Delaware

D. Chau, MD, Delaware

M. Chen, Florida

V. Chennamaneni, Florida

L. Cler, Florida

D. Cooks, Florida

S. Crenshaw, Florida

K. Cunningham, MD, FACP, Florida

V. De Guzman, APRN, MSN, NP, Florida

M. Del Rosario, MD, Florida

D. DeVere, MD, Florida

S. Dharmapuri, Florida

P. Dodson, MD, Florida

A. Domaoal, Georgia

J. Duncan, MD, Georgia

B. Dyck, BSC, MD, PhD, Georgia

J. Dzundza, MD, Georgia

A. Ellis, FNP, Georgia

R. Erickson, Idaho

A. Faraj, Idaho

S. Fernandez, MD, Illinois

G. Ferrari, MD, Illinois

W. Folad, MD, Illinois

L. Fowler, ACNP, APRN, MBA, Illinois

J. Golderberg, MD, Illinois

G. Goldman, MD, Illinois

L. Gonzales, MD, Indiana

A. Gonzalez, Kansas

W. Griffo, MD, Kansas

R. Guzman, Kansas

L. Guzman Vinasco, MD, Kansas

K. Hageman, DO, Kentucky

M. Haggerty, PA-C, Kentucky

B. Hammond, Louisiana

G. Harris, MD, Louisiana

J. Hasan-Jones, RN, FACHE, Louisiana

J. Herring, Louisiana

L. Hsu, MD, Massachusetts

A. C. Hunag, DO, Massachusetts

M. Huq, Massachusetts

M. Jandrin, PA-C, Massachusetts

C. Janish, MD, Maryland

J. Jarin, MD, Maine

A. Jenkins, Maine

S. Jindal, MD, Michigan

M. Johl, Michigan

T. John, Michigan

N. Kapadia, MD, Michigan

L. Katona, Michigan

K. Kaye, Michigan

M. Keating, Michigan

L. Keeton, MD, Michigan

L. Kendall, Michigan

M. Kerlin, Michigan

A. Kia, MD, Minnesota

R. Klett, Minnesota

L. Knapp, DO, Minnesota

K. Knox, Missouri

M. Kraynak, MD, Missouri

P. Kuppireddy, MBBS, Missouri

W. Landrum, MD, Missouri

C. Larion, ACNP, Missouri

E. Latcheva, MD, Mississippi

D. Leforce, North Carolina

V. Leigh, DO, North Carolina

C. Leon, North Carolina

T. Li, MD, North Dakota

X. Li, MD, Nebraska

Y. Li, New Hampshire

J. Liu, New Hampshire

L. Lu, DO, New Jersey

S. Mathapathi, New Jersey

L. McGann, New Jersey

S. Melkaveri, MD, Nevada

R. Mercado Garcia, New York

S. Merry, MD, New York

P. Meyer, DO, New York

J. Mikulca, PharmD, New York

Z. Moyenda, MD, MBA, New York

K. Murphy, DO, MPH, New York

J. Musenze, New York

P. Mutungi, New York

G. Nanna, USA, New York

I. Nasir, New York

U. Nazario-Vidah, MD, New York

D. Nguyen, New York

C. Ojha, MBBS, New York

K. Olson, MD, Ohio

V. Paulson, MD, Ohio

R. Pearson, DO, PhD, Ohio

A. Peel, MD, Ohio

S. Pettis, PA-C, Ohio

E. Picloglou, MD, Ohio

H. Pokhrel, MD, Ohio

H. Bush, Oklahoma

R. Porter, PA, Oklahoma

P. Prabhakar, Oklahoma

U. Qamar, Oklahoma

R. Quansah, MD, Oklahoma

M. Rahman, Oklahoma

R. Rajeshwar, Oregon

E. Randal, Oregon

A. Ray, Oregon

V. Reddy, Oregon

J. Reed, MD, RN, Oregon

R. Regidor, Oregon

A. Reitsma-Mathias, MD, Oregon

R. Reyes, MD, Oregon

T. Richardson, NP, Oregon

T. Ringer, Oregon

L. Rivera-Crespo, Pennsylvania

T. Rothwell, PA, Pennsylvania

E. Sacolick, MD, Pennsylvania

E. Saluke, MD, Pennsylvania

M. Santinelli, NP, Pennsylvania

M. Sapon-Amoah, FNP, Pennsylvania

D. Scarine, NP, Pennsylvania

K. Seger, Pennsylvania

A. Shah, Pennsylvania

K. Shah, MD, Pennsylvania

S. Shah, MD, Pennsylvania

G. Sharma, MD, Pennsylvania

K. Shaukat, MD, Pennsylvania

E. Sheindler, Rhode Island

D. Sheps, South Carolina

J. Shipe-Spotloe, South Carolina

S. Sim, South Carolina

M. Simon, MD, MMM, CPE, South Carolina

A. Singh, South Carolina

S. Singh-Patel, PO, South Dakota

M. Snyder, South Dakota

A. Srikanth, MBBS, Tennessee

B. Staats, Tennessee

C. Standley, Texas

R. Stanhiser, Texas

M. Stevens, Texas

K. Stuart, Texas

A. Summers, Texas

E. Taylo, Texas

L. Taylor, PA-C, Texas

L. Theaker, Texas

M. Thieman, Texas

J. Tong, Texas

N. Trivedi, MD, Texas

L. Tuazon, MD, FACP, Texas

S. Tummalapalli, Texas

A. Ufferman, MD, Virginia

R. Urrea, MD, Virginia

N. Van Groningen, Virginia

D. Vaughn, MD, Vermont

R. Vento, MD, MPH, Washington

Y. Villaran, MD, Washington

L. Viscome, DO, Washington

K. Vo, Washington

H. Vu, MD, Washington

T. Washko, MD, Washington

T. Waters, DO, Wisconsin

L. Weisberger, USA, Wisconsin

A. Whitehead, Wisconsin

A. Workman, West Virginia

F. Yasin, MD, West Virginia

A. Yoon, MD, West Virginia

M. Yu, West Virginia

A. Yuen, DO, West Virginia

K. Zwieg, West Virginia

Clinical question: What is the association between proton pump inhibitor (PPI) use and incident chronic kidney disease (CKD)?

Background: Medication use may play a potential role in the increasing prevalence of CKD. PPIs are commonly prescribed, and several observational studies have linked their use with multiple adverse outcomes, including acute interstitial nephritis. The risk for CKD with PPI use has never been evaluated.

Study design: Prospective cohort study.

Setting: U.S., multi-center.

Synopsis: Among 10,482 patients in the Atherosclerosis Risk in Communities study (ARIC) with an estimated glomerular filtration rate of at least 60 mL/min/1.73 m2, PPI use was associated with a 1.50 times risk of incident CKD (95% CI, 1.14–1.96; P=0.003) and a 1.64 times risk of incident acute kidney injury (95% CI, 1.22–2.21; P<0.001) when compared to nonusers. PPI use continued to have an association with incident CKD even when compared directly with H2 receptor antagonist users (adjusted HR, 1.39; 95% CI, 1.01–1.91). Findings were replicated in a cohort of 248,751 patients in the Geisinger Health System, and in all analyses, PPI use was associated with CKD.

One limitation is that this was an observational study and causality between PPI use and CKD cannot be established.

Bottom line: PPIs are associated with risk for CKD, and in patients on therapy, its use should be reevaluated.

Citation: Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med. 2016;176(2):238-246.

Clinical question: What is the association between proton pump inhibitor (PPI) use and incident chronic kidney disease (CKD)?

Background: Medication use may play a potential role in the increasing prevalence of CKD. PPIs are commonly prescribed, and several observational studies have linked their use with multiple adverse outcomes, including acute interstitial nephritis. The risk for CKD with PPI use has never been evaluated.

Study design: Prospective cohort study.

Setting: U.S., multi-center.

Synopsis: Among 10,482 patients in the Atherosclerosis Risk in Communities study (ARIC) with an estimated glomerular filtration rate of at least 60 mL/min/1.73 m2, PPI use was associated with a 1.50 times risk of incident CKD (95% CI, 1.14–1.96; P=0.003) and a 1.64 times risk of incident acute kidney injury (95% CI, 1.22–2.21; P<0.001) when compared to nonusers. PPI use continued to have an association with incident CKD even when compared directly with H2 receptor antagonist users (adjusted HR, 1.39; 95% CI, 1.01–1.91). Findings were replicated in a cohort of 248,751 patients in the Geisinger Health System, and in all analyses, PPI use was associated with CKD.

One limitation is that this was an observational study and causality between PPI use and CKD cannot be established.

Bottom line: PPIs are associated with risk for CKD, and in patients on therapy, its use should be reevaluated.

Citation: Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med. 2016;176(2):238-246.

Clinical question: What is the association between proton pump inhibitor (PPI) use and incident chronic kidney disease (CKD)?

Background: Medication use may play a potential role in the increasing prevalence of CKD. PPIs are commonly prescribed, and several observational studies have linked their use with multiple adverse outcomes, including acute interstitial nephritis. The risk for CKD with PPI use has never been evaluated.

Study design: Prospective cohort study.

Setting: U.S., multi-center.

Synopsis: Among 10,482 patients in the Atherosclerosis Risk in Communities study (ARIC) with an estimated glomerular filtration rate of at least 60 mL/min/1.73 m2, PPI use was associated with a 1.50 times risk of incident CKD (95% CI, 1.14–1.96; P=0.003) and a 1.64 times risk of incident acute kidney injury (95% CI, 1.22–2.21; P<0.001) when compared to nonusers. PPI use continued to have an association with incident CKD even when compared directly with H2 receptor antagonist users (adjusted HR, 1.39; 95% CI, 1.01–1.91). Findings were replicated in a cohort of 248,751 patients in the Geisinger Health System, and in all analyses, PPI use was associated with CKD.

One limitation is that this was an observational study and causality between PPI use and CKD cannot be established.

Bottom line: PPIs are associated with risk for CKD, and in patients on therapy, its use should be reevaluated.

Citation: Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med. 2016;176(2):238-246.

Clinical question: What risk factors could predict the likelihood of Pseudomonas and methicillin-resistant Staphylococcus aureus (MRSA) in patients hospitalized with healthcare-associated pneumonia (HCAP)?

Background: Patients identified with HCAP have an increased risk for multi-drug-resistant pathogens, such as gram-negative (GNR) organisms and MRSA. Meeting criteria for HCAP does not discriminate between the different infections, which require different antibiotic classes for treatment. Risk factors need to be identified to determine the most likely infectious organism to help guide initial empiric antibiotic therapy.

Study design: Retrospective cohort study.

Setting: Veterans Affairs hospitals.

Synopsis: Of 61,651 veterans with HCAP diagnosis, 1,156 (1.9%) had a discharge diagnosis of Pseudomonas pneumonia and were found to be younger and more likely to be immunocompromised; have hemiplegia; have a history of chronic obstructive pulmonary disease; have had corticosteroid exposure; and have been exposed to a fluoroquinolone, β-lactam, cephalosporin, or carbapenem antiobiotic within 90 days prior to admission. Pseudomonas pneumonia was negatively associated with age >84, drug abuse, diabetes, and higher socioeconomic status. A discharge diagnosis of MRSA pneumonia was found in 641 patients (1.0%), who also were positively associated with the male gender, age >74, recent nursing home stay, and recent exposure to fluoroquinolone antibiotics within 90 days prior to admission.

MRSA pneumonia was negatively associated with complicated diabetes. Neither diagnosis was present in 59,854 patients (97.1%).

This study was limited due to its predominantly male veteran population, low incidence of Pseudomonas and MRSA pneumonia being identified, and Pseudomonas as the only GNR organism analyzed.

Bottom line: Risk factors identified for Pseudomonas and MRSA pneumonia can help guide targeted antibiotics for HCAP patients.

Citation: Metersky ML, Frei CR, Mortenson EM. Predictors of Pseudomonas and methicillin-resistant Staphylococcus aureus in hospitalized patients with healthcare-associated pneumonia. Respirology. 2016;21(1):157-163.

Short Take

Hematuria as Marker of Urologic Cancer

Narrative literature review did not demonstrate beneficial role of screening urinalysis for cancer detection in asymptomatic patients, but it did suggest including gross hematuria as part of routine review of systems.

Citation: Nielsen M, Qaseem A, High Value Care Task Force of the American College of Physicians. Hematuria as a marker of occult urinary tract cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2016;164(7):488-497. doi:10.7326/M15-1496.

Clinical question: What risk factors could predict the likelihood of Pseudomonas and methicillin-resistant Staphylococcus aureus (MRSA) in patients hospitalized with healthcare-associated pneumonia (HCAP)?

Background: Patients identified with HCAP have an increased risk for multi-drug-resistant pathogens, such as gram-negative (GNR) organisms and MRSA. Meeting criteria for HCAP does not discriminate between the different infections, which require different antibiotic classes for treatment. Risk factors need to be identified to determine the most likely infectious organism to help guide initial empiric antibiotic therapy.

Study design: Retrospective cohort study.

Setting: Veterans Affairs hospitals.

Synopsis: Of 61,651 veterans with HCAP diagnosis, 1,156 (1.9%) had a discharge diagnosis of Pseudomonas pneumonia and were found to be younger and more likely to be immunocompromised; have hemiplegia; have a history of chronic obstructive pulmonary disease; have had corticosteroid exposure; and have been exposed to a fluoroquinolone, β-lactam, cephalosporin, or carbapenem antiobiotic within 90 days prior to admission. Pseudomonas pneumonia was negatively associated with age >84, drug abuse, diabetes, and higher socioeconomic status. A discharge diagnosis of MRSA pneumonia was found in 641 patients (1.0%), who also were positively associated with the male gender, age >74, recent nursing home stay, and recent exposure to fluoroquinolone antibiotics within 90 days prior to admission.

MRSA pneumonia was negatively associated with complicated diabetes. Neither diagnosis was present in 59,854 patients (97.1%).

This study was limited due to its predominantly male veteran population, low incidence of Pseudomonas and MRSA pneumonia being identified, and Pseudomonas as the only GNR organism analyzed.

Bottom line: Risk factors identified for Pseudomonas and MRSA pneumonia can help guide targeted antibiotics for HCAP patients.

Citation: Metersky ML, Frei CR, Mortenson EM. Predictors of Pseudomonas and methicillin-resistant Staphylococcus aureus in hospitalized patients with healthcare-associated pneumonia. Respirology. 2016;21(1):157-163.

Short Take

Hematuria as Marker of Urologic Cancer

Narrative literature review did not demonstrate beneficial role of screening urinalysis for cancer detection in asymptomatic patients, but it did suggest including gross hematuria as part of routine review of systems.

Citation: Nielsen M, Qaseem A, High Value Care Task Force of the American College of Physicians. Hematuria as a marker of occult urinary tract cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2016;164(7):488-497. doi:10.7326/M15-1496.

Clinical question: What risk factors could predict the likelihood of Pseudomonas and methicillin-resistant Staphylococcus aureus (MRSA) in patients hospitalized with healthcare-associated pneumonia (HCAP)?

Background: Patients identified with HCAP have an increased risk for multi-drug-resistant pathogens, such as gram-negative (GNR) organisms and MRSA. Meeting criteria for HCAP does not discriminate between the different infections, which require different antibiotic classes for treatment. Risk factors need to be identified to determine the most likely infectious organism to help guide initial empiric antibiotic therapy.

Study design: Retrospective cohort study.

Setting: Veterans Affairs hospitals.

Synopsis: Of 61,651 veterans with HCAP diagnosis, 1,156 (1.9%) had a discharge diagnosis of Pseudomonas pneumonia and were found to be younger and more likely to be immunocompromised; have hemiplegia; have a history of chronic obstructive pulmonary disease; have had corticosteroid exposure; and have been exposed to a fluoroquinolone, β-lactam, cephalosporin, or carbapenem antiobiotic within 90 days prior to admission. Pseudomonas pneumonia was negatively associated with age >84, drug abuse, diabetes, and higher socioeconomic status. A discharge diagnosis of MRSA pneumonia was found in 641 patients (1.0%), who also were positively associated with the male gender, age >74, recent nursing home stay, and recent exposure to fluoroquinolone antibiotics within 90 days prior to admission.

MRSA pneumonia was negatively associated with complicated diabetes. Neither diagnosis was present in 59,854 patients (97.1%).

This study was limited due to its predominantly male veteran population, low incidence of Pseudomonas and MRSA pneumonia being identified, and Pseudomonas as the only GNR organism analyzed.

Bottom line: Risk factors identified for Pseudomonas and MRSA pneumonia can help guide targeted antibiotics for HCAP patients.

Citation: Metersky ML, Frei CR, Mortenson EM. Predictors of Pseudomonas and methicillin-resistant Staphylococcus aureus in hospitalized patients with healthcare-associated pneumonia. Respirology. 2016;21(1):157-163.

Short Take

Hematuria as Marker of Urologic Cancer

Narrative literature review did not demonstrate beneficial role of screening urinalysis for cancer detection in asymptomatic patients, but it did suggest including gross hematuria as part of routine review of systems.

Citation: Nielsen M, Qaseem A, High Value Care Task Force of the American College of Physicians. Hematuria as a marker of occult urinary tract cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2016;164(7):488-497. doi:10.7326/M15-1496.

1. Enroll in the Focused Practice in Hospital Medicine MOC program by August 1 at www.abim.org.
2. Schedule a seat for the exam before August 15 at www.abim.org.
3. Order SHM SPARK, the missing piece of the MOC exam-prep puzzle.

SHM recently developed the only MOC exam-preparation tool by hospitalists for hospitalists, SHM SPARK. It complements tools already on the market and will help hospitalists succeed on the upcoming exam. SHM SPARK delivers 175 vignette-style multiple-choice questions that bridge the primary knowledge gaps found within existing MOC exam-preparation products and provides in-depth review on:

• Palliative care, ethics, and decision making
• Patient safety
• Perioperative care and consultative co-management
• Quality, cost, and clinical reasoning

SHM SPARK offers detailed learning objectives and discussion points and allows users to define individual areas of strengths and weaknesses. Users can claim 58 ABIM MOC Medical Knowledge points upon completion of all four modules with a minimum passing score of 80%. After successful completion of all four modules, participants may claim up to 10.5 AMA PRA Category 1 credits.

1. Enroll in the Focused Practice in Hospital Medicine MOC program by August 1 at www.abim.org.
2. Schedule a seat for the exam before August 15 at www.abim.org.
3. Order SHM SPARK, the missing piece of the MOC exam-prep puzzle.

SHM recently developed the only MOC exam-preparation tool by hospitalists for hospitalists, SHM SPARK. It complements tools already on the market and will help hospitalists succeed on the upcoming exam. SHM SPARK delivers 175 vignette-style multiple-choice questions that bridge the primary knowledge gaps found within existing MOC exam-preparation products and provides in-depth review on:

• Palliative care, ethics, and decision making
• Patient safety
• Perioperative care and consultative co-management
• Quality, cost, and clinical reasoning

SHM SPARK offers detailed learning objectives and discussion points and allows users to define individual areas of strengths and weaknesses. Users can claim 58 ABIM MOC Medical Knowledge points upon completion of all four modules with a minimum passing score of 80%. After successful completion of all four modules, participants may claim up to 10.5 AMA PRA Category 1 credits.

1. Enroll in the Focused Practice in Hospital Medicine MOC program by August 1 at www.abim.org.
2. Schedule a seat for the exam before August 15 at www.abim.org.
3. Order SHM SPARK, the missing piece of the MOC exam-prep puzzle.

SHM recently developed the only MOC exam-preparation tool by hospitalists for hospitalists, SHM SPARK. It complements tools already on the market and will help hospitalists succeed on the upcoming exam. SHM SPARK delivers 175 vignette-style multiple-choice questions that bridge the primary knowledge gaps found within existing MOC exam-preparation products and provides in-depth review on:

• Palliative care, ethics, and decision making
• Patient safety
• Perioperative care and consultative co-management
• Quality, cost, and clinical reasoning

SHM SPARK offers detailed learning objectives and discussion points and allows users to define individual areas of strengths and weaknesses. Users can claim 58 ABIM MOC Medical Knowledge points upon completion of all four modules with a minimum passing score of 80%. After successful completion of all four modules, participants may claim up to 10.5 AMA PRA Category 1 credits.