Society of Hospital Medicine (SHM): Hospital Medicine 2012 (SHM Annual Meeting)

SAN DIEGO (EGMN) – Giving acetaminophen to patients who reported consuming ethanol did not adversely affect markers of liver damage in a meta-analysis of randomized, controlled trials.

"One of the questions we often get asked is the role of acetaminophen in patients with liver disease," said Dr. Kennon J. Heard, an emergency medicine physician at the University of Colorado and director of the Medical Toxicology Fellowship at the Rocky Mountain Poison and Drug Center, Denver.

The findings of the meta-analysis suggest that "acetaminophen is safe in alcoholics," he said at the annual meeting of the Society of Hospital Medicine.

The meta-analysis included five trials involving 901 subjects (including patients who reported drinking ethanol) who were randomized to receive acetaminophen or placebo. Dr. Heard and his associates looked at daily ALT measurements out to a mean of 4 days, a time period for which most of the studies had data. They also looked for any evidence of liver injury or dysfunction, hepatotoxicity, or death.

The alanine aminotransferase (ALT) levels changed by a mean of 0.04 IU/L after starting acetaminophen or placebo, "less than a tenth of a point in ALT," reported Dr. Heard. "Essentially, in this group of patients who consume alcohol, if you give them acetaminophen for 4 days, you don’t see any change in their ALT."

The study is to be published in the journal Pharmacotherapy.

When acetaminophen consumption continued beyond 4 days, ALT levels increased in most patients who consumed alcohol but also increased in 60% of non-drinkers. "The changes in the alcoholics look exactly like the changes in the non-alcoholics," he said. The median increase in ALT was between 10-20 IU/L.

Among patients who drink alcohol, the highest ALT level in the acetaminophen group was 312 IU/L, "which is pretty impressive until you see that in the placebo group, somebody went up 288" IU/L, he said. The biggest increase in ALT was in a healthy nondrinking patient on acetaminophen, whose ALT increased by 638 IU/L.

Most importantly, none of the 551 people who received acetaminophen in those trials developed an increase in International Normalized Ratio, bilirubin level, or symptomatic liver injury, he added.

Dr. Heard and his associates are now finishing a separate study that appears to confirm that these are asymptomatic, self-limiting elevations in ALT that will go away even if people stay on acetaminophen.

"It is worth knowing that if you have someone who has an ALT elevation while taking acetaminophen, it may be the cause, and it is reasonable to stop the acetaminophen and see if their ALT elevations go away rather than do an extensive workup for hepatitis," he said.

Dr. Heard has been a consultant or received research grants from Cadence Pharmaceuticals, McNeil Consumer Healthcare, and Cumberland Pharmaceuticals.

SAN DIEGO (EGMN) – Giving acetaminophen to patients who reported consuming ethanol did not adversely affect markers of liver damage in a meta-analysis of randomized, controlled trials.

"One of the questions we often get asked is the role of acetaminophen in patients with liver disease," said Dr. Kennon J. Heard, an emergency medicine physician at the University of Colorado and director of the Medical Toxicology Fellowship at the Rocky Mountain Poison and Drug Center, Denver.

The findings of the meta-analysis suggest that "acetaminophen is safe in alcoholics," he said at the annual meeting of the Society of Hospital Medicine.

The meta-analysis included five trials involving 901 subjects (including patients who reported drinking ethanol) who were randomized to receive acetaminophen or placebo. Dr. Heard and his associates looked at daily ALT measurements out to a mean of 4 days, a time period for which most of the studies had data. They also looked for any evidence of liver injury or dysfunction, hepatotoxicity, or death.

The alanine aminotransferase (ALT) levels changed by a mean of 0.04 IU/L after starting acetaminophen or placebo, "less than a tenth of a point in ALT," reported Dr. Heard. "Essentially, in this group of patients who consume alcohol, if you give them acetaminophen for 4 days, you don’t see any change in their ALT."

The study is to be published in the journal Pharmacotherapy.

When acetaminophen consumption continued beyond 4 days, ALT levels increased in most patients who consumed alcohol but also increased in 60% of non-drinkers. "The changes in the alcoholics look exactly like the changes in the non-alcoholics," he said. The median increase in ALT was between 10-20 IU/L.

Among patients who drink alcohol, the highest ALT level in the acetaminophen group was 312 IU/L, "which is pretty impressive until you see that in the placebo group, somebody went up 288" IU/L, he said. The biggest increase in ALT was in a healthy nondrinking patient on acetaminophen, whose ALT increased by 638 IU/L.

Most importantly, none of the 551 people who received acetaminophen in those trials developed an increase in International Normalized Ratio, bilirubin level, or symptomatic liver injury, he added.

Dr. Heard and his associates are now finishing a separate study that appears to confirm that these are asymptomatic, self-limiting elevations in ALT that will go away even if people stay on acetaminophen.

"It is worth knowing that if you have someone who has an ALT elevation while taking acetaminophen, it may be the cause, and it is reasonable to stop the acetaminophen and see if their ALT elevations go away rather than do an extensive workup for hepatitis," he said.

Dr. Heard has been a consultant or received research grants from Cadence Pharmaceuticals, McNeil Consumer Healthcare, and Cumberland Pharmaceuticals.

SAN DIEGO (EGMN) – Giving acetaminophen to patients who reported consuming ethanol did not adversely affect markers of liver damage in a meta-analysis of randomized, controlled trials.

"One of the questions we often get asked is the role of acetaminophen in patients with liver disease," said Dr. Kennon J. Heard, an emergency medicine physician at the University of Colorado and director of the Medical Toxicology Fellowship at the Rocky Mountain Poison and Drug Center, Denver.

The findings of the meta-analysis suggest that "acetaminophen is safe in alcoholics," he said at the annual meeting of the Society of Hospital Medicine.

The meta-analysis included five trials involving 901 subjects (including patients who reported drinking ethanol) who were randomized to receive acetaminophen or placebo. Dr. Heard and his associates looked at daily ALT measurements out to a mean of 4 days, a time period for which most of the studies had data. They also looked for any evidence of liver injury or dysfunction, hepatotoxicity, or death.

The alanine aminotransferase (ALT) levels changed by a mean of 0.04 IU/L after starting acetaminophen or placebo, "less than a tenth of a point in ALT," reported Dr. Heard. "Essentially, in this group of patients who consume alcohol, if you give them acetaminophen for 4 days, you don’t see any change in their ALT."

The study is to be published in the journal Pharmacotherapy.

When acetaminophen consumption continued beyond 4 days, ALT levels increased in most patients who consumed alcohol but also increased in 60% of non-drinkers. "The changes in the alcoholics look exactly like the changes in the non-alcoholics," he said. The median increase in ALT was between 10-20 IU/L.

Among patients who drink alcohol, the highest ALT level in the acetaminophen group was 312 IU/L, "which is pretty impressive until you see that in the placebo group, somebody went up 288" IU/L, he said. The biggest increase in ALT was in a healthy nondrinking patient on acetaminophen, whose ALT increased by 638 IU/L.

Most importantly, none of the 551 people who received acetaminophen in those trials developed an increase in International Normalized Ratio, bilirubin level, or symptomatic liver injury, he added.

Dr. Heard and his associates are now finishing a separate study that appears to confirm that these are asymptomatic, self-limiting elevations in ALT that will go away even if people stay on acetaminophen.

"It is worth knowing that if you have someone who has an ALT elevation while taking acetaminophen, it may be the cause, and it is reasonable to stop the acetaminophen and see if their ALT elevations go away rather than do an extensive workup for hepatitis," he said.

Dr. Heard has been a consultant or received research grants from Cadence Pharmaceuticals, McNeil Consumer Healthcare, and Cumberland Pharmaceuticals.

The aftermath of a medical error can be an endless tangle of bad feelings, or it can yield valuable lessons for hospital teams.

Adverse events need to be approached as learning opportunities, and a short checklist can start the process, according to Dr. Kimberly D. Manning of Emory University, Atlanta.

(See the list)

©rangizzz/fotolia.com

She and her colleague Dr. Neil H. Winawer have developed a standardized list of questions for assessing one’s role in adverse events and medical errors. The checklist gets at what went right, what could have been done better, and how to approach similar situations differently in the future.

Taking a standardized approach to medical errors is aimed at bringing more personal accountability into the analysis of adverse events, said Dr. Winawer, director of the hospital medicine unit at Grady Memorial Hospital, Atlanta. "Not every mistake has its origins inside of a system, and there needs to a balance of a no-fault systems culture and accountability," he said.

Dr. Manning added that not every adverse event requires a systems change. "Sometimes it just involves ... sitting down with your team, or alone, and working through exactly what happened to get the lessons and move forward," she said.

The checklist includes a series of must-ask questions, starting with a description of the adverse outcome or pivotal event. Other questions elicit explanations of what the physician did (or did not do) that was not ideal for the patient. And the checklist asks physicians to think about what they did that was good for the patient.

"What we found from having these discussions with our house staff is that the patients we tend to feel the most terrible about are usually the people that we’ve invested a lot into," said Dr. Manning, who is the director of Emory’s transitional year residency program.

It’s important to think about all the high-quality care that was provided, before and after something went wrong, rather than just dwelling on the adverse event, she said.

The checklist also focuses on the future, asking physicians what they could have done differently, what they have learned from the situation, and what safeguards could be implemented to avoid a similar outcome going forward.

The goal is to provide closure, but even more importantly, to honor the patient, Dr. Manning and Dr. Winawer explained.

To help physicians deal with the complex emotions surrounding an adverse event, the checklist includes some follow-up questions. The idea, Dr. Manning said, is to avoid the depression and burnout that can result unless perceived errors in care are discussed and dealt with.

The checklist can be used by individuals or with colleagues as a group. But it’s important to keep in mind that different members of the care team have different levels of responsibility and may have different views about the same event. Sometimes, the intern on the team did everything that he or she could do, Dr. Manning said, but the more senior physician could have done more to help the patient.

Because many adverse events are discovered by colleagues, the checklist also offers an objective way to discuss the problem and minimize some of the awkwardness.

Dr. Manning and Dr. Winawer spoke at the annual meeting of the Society of Hospital Medicine.

Checklist for Processing Errors and Adverse Events

Must-Ask Questions

• What was the adverse outcome or medical error?
• What did I do that was good for this patient?
• What did I do or not do that was not ideal?
• How high are the stakes?
• What could I have done differently?
• What did I learn?
• What can I do to avoid this happening again?

Follow-Up Questions

• How do I feel about what happened?
• What bothers me the most about this situation?
• What advice would you give to someone who was in this situation?
• How can I honor my patient now?
• What can I do to be of further support to my team members?

The aftermath of a medical error can be an endless tangle of bad feelings, or it can yield valuable lessons for hospital teams.

Adverse events need to be approached as learning opportunities, and a short checklist can start the process, according to Dr. Kimberly D. Manning of Emory University, Atlanta.

(See the list)

©rangizzz/fotolia.com

She and her colleague Dr. Neil H. Winawer have developed a standardized list of questions for assessing one’s role in adverse events and medical errors. The checklist gets at what went right, what could have been done better, and how to approach similar situations differently in the future.

Taking a standardized approach to medical errors is aimed at bringing more personal accountability into the analysis of adverse events, said Dr. Winawer, director of the hospital medicine unit at Grady Memorial Hospital, Atlanta. "Not every mistake has its origins inside of a system, and there needs to a balance of a no-fault systems culture and accountability," he said.

Dr. Manning added that not every adverse event requires a systems change. "Sometimes it just involves ... sitting down with your team, or alone, and working through exactly what happened to get the lessons and move forward," she said.

The checklist includes a series of must-ask questions, starting with a description of the adverse outcome or pivotal event. Other questions elicit explanations of what the physician did (or did not do) that was not ideal for the patient. And the checklist asks physicians to think about what they did that was good for the patient.

"What we found from having these discussions with our house staff is that the patients we tend to feel the most terrible about are usually the people that we’ve invested a lot into," said Dr. Manning, who is the director of Emory’s transitional year residency program.

It’s important to think about all the high-quality care that was provided, before and after something went wrong, rather than just dwelling on the adverse event, she said.

The checklist also focuses on the future, asking physicians what they could have done differently, what they have learned from the situation, and what safeguards could be implemented to avoid a similar outcome going forward.

The goal is to provide closure, but even more importantly, to honor the patient, Dr. Manning and Dr. Winawer explained.

To help physicians deal with the complex emotions surrounding an adverse event, the checklist includes some follow-up questions. The idea, Dr. Manning said, is to avoid the depression and burnout that can result unless perceived errors in care are discussed and dealt with.

The checklist can be used by individuals or with colleagues as a group. But it’s important to keep in mind that different members of the care team have different levels of responsibility and may have different views about the same event. Sometimes, the intern on the team did everything that he or she could do, Dr. Manning said, but the more senior physician could have done more to help the patient.

Because many adverse events are discovered by colleagues, the checklist also offers an objective way to discuss the problem and minimize some of the awkwardness.

Dr. Manning and Dr. Winawer spoke at the annual meeting of the Society of Hospital Medicine.

Checklist for Processing Errors and Adverse Events

Must-Ask Questions

• What was the adverse outcome or medical error?
• What did I do that was good for this patient?
• What did I do or not do that was not ideal?
• How high are the stakes?
• What could I have done differently?
• What did I learn?
• What can I do to avoid this happening again?

Follow-Up Questions

• How do I feel about what happened?
• What bothers me the most about this situation?
• What advice would you give to someone who was in this situation?
• How can I honor my patient now?
• What can I do to be of further support to my team members?

The aftermath of a medical error can be an endless tangle of bad feelings, or it can yield valuable lessons for hospital teams.

Adverse events need to be approached as learning opportunities, and a short checklist can start the process, according to Dr. Kimberly D. Manning of Emory University, Atlanta.

(See the list)

©rangizzz/fotolia.com

She and her colleague Dr. Neil H. Winawer have developed a standardized list of questions for assessing one’s role in adverse events and medical errors. The checklist gets at what went right, what could have been done better, and how to approach similar situations differently in the future.

Taking a standardized approach to medical errors is aimed at bringing more personal accountability into the analysis of adverse events, said Dr. Winawer, director of the hospital medicine unit at Grady Memorial Hospital, Atlanta. "Not every mistake has its origins inside of a system, and there needs to a balance of a no-fault systems culture and accountability," he said.

Dr. Manning added that not every adverse event requires a systems change. "Sometimes it just involves ... sitting down with your team, or alone, and working through exactly what happened to get the lessons and move forward," she said.

The checklist includes a series of must-ask questions, starting with a description of the adverse outcome or pivotal event. Other questions elicit explanations of what the physician did (or did not do) that was not ideal for the patient. And the checklist asks physicians to think about what they did that was good for the patient.

"What we found from having these discussions with our house staff is that the patients we tend to feel the most terrible about are usually the people that we’ve invested a lot into," said Dr. Manning, who is the director of Emory’s transitional year residency program.

It’s important to think about all the high-quality care that was provided, before and after something went wrong, rather than just dwelling on the adverse event, she said.

The checklist also focuses on the future, asking physicians what they could have done differently, what they have learned from the situation, and what safeguards could be implemented to avoid a similar outcome going forward.

The goal is to provide closure, but even more importantly, to honor the patient, Dr. Manning and Dr. Winawer explained.

To help physicians deal with the complex emotions surrounding an adverse event, the checklist includes some follow-up questions. The idea, Dr. Manning said, is to avoid the depression and burnout that can result unless perceived errors in care are discussed and dealt with.

The checklist can be used by individuals or with colleagues as a group. But it’s important to keep in mind that different members of the care team have different levels of responsibility and may have different views about the same event. Sometimes, the intern on the team did everything that he or she could do, Dr. Manning said, but the more senior physician could have done more to help the patient.

Because many adverse events are discovered by colleagues, the checklist also offers an objective way to discuss the problem and minimize some of the awkwardness.

Dr. Manning and Dr. Winawer spoke at the annual meeting of the Society of Hospital Medicine.

Checklist for Processing Errors and Adverse Events

Must-Ask Questions

• What was the adverse outcome or medical error?
• What did I do that was good for this patient?
• What did I do or not do that was not ideal?
• How high are the stakes?
• What could I have done differently?
• What did I learn?
• What can I do to avoid this happening again?

Follow-Up Questions

• How do I feel about what happened?
• What bothers me the most about this situation?
• What advice would you give to someone who was in this situation?
• How can I honor my patient now?
• What can I do to be of further support to my team members?

SAN DIEGO – Cirrhotics with spontaneous bacterial peritonitis probably need albumin only if their total bilirubin is above 4 mg/dL and/or their blood urea nitrogen (BUN) is above 30 mg/dL, according to transplant hepatologist Dr. James Burton.

Supplementation expands plasma volume to attenuate the splanchnic and systemic vasodilation associated with spontaneous bacterial peritonitis (SBP), increasing blood flow to the kidneys and preserving renal function, said Dr. Burton, medical director of liver transplantation at the University of Colorado Hospital, Aurora.

But it seems to be needed only when SBP patients are at high risk for renal failure, according to two studies.

The first randomized 63 cirrhotic SBP patients to cefotaxime alone and 63 to cefotaxime plus albumin, 1.5 g/kg on day 1 and 1.0 g/kg on day 3. The regimen wiped out the infection in most patients. Renal impairment and mortality were significantly lower in the albumin group, but only patients with total baseline bilirubins above 4 mg/dL and/or BUNs greater than 30 mg/dL benefited from albumin, Dr. Burton said (N. Engl. J. Med. 1999;341:403-9).

A follow-up 28-subject study limited albumin supplementation, again 1.5 g/kg on day 1 and 1.0 g/kg on day 3, to SBP patients with similar parameters or creatinines above 1 mg/dL. It was the right choice; none of the 15 patients with lower baseline values developed renal impairment, Dr. Burton said (Gut 2007;56:597-9).

He noted that it’s possible for patients to have SBP without obvious symptoms, so "if you’re sick enough to have cirrhosis and be in the hospital, you need a needle in your abdomen to rule out" the condition.

In general, cirrhotics have low levels of albumin, which is responsible for about 80% of plasma’s oncotic pressure. Also, what they have "may not work as well" to transport fatty acids, hormones, and enzymes, and drugs.

Outpatient supplementation for cirrhotics not only seems to reduce the need for paracentesis, but also makes patients feel better. "I am a believer because my patients tell me it works. Some of my patients refer to it as ‘nectar of the gods.’ This is more than just the oncotic things. I also think they are transporting hormones, carrying drugs, and other stuff better. So I am a big believer," Dr. Burton said.

He opts for 25% albumin instead of 5%, to reduce fluid load and also because "there is a lot of sodium in 5% albumin. Obviously, these patients need to have their sodium restricted," he said.

When paracentesis is needed, "studies suggest you can probably [remove] 4-6 liters without giving albumin." Even so, "we often give albumin during paracentesis," he said.

Dr. Burton said he has no relevant financial disclosures.

SAN DIEGO – Cirrhotics with spontaneous bacterial peritonitis probably need albumin only if their total bilirubin is above 4 mg/dL and/or their blood urea nitrogen (BUN) is above 30 mg/dL, according to transplant hepatologist Dr. James Burton.

Supplementation expands plasma volume to attenuate the splanchnic and systemic vasodilation associated with spontaneous bacterial peritonitis (SBP), increasing blood flow to the kidneys and preserving renal function, said Dr. Burton, medical director of liver transplantation at the University of Colorado Hospital, Aurora.

But it seems to be needed only when SBP patients are at high risk for renal failure, according to two studies.

The first randomized 63 cirrhotic SBP patients to cefotaxime alone and 63 to cefotaxime plus albumin, 1.5 g/kg on day 1 and 1.0 g/kg on day 3. The regimen wiped out the infection in most patients. Renal impairment and mortality were significantly lower in the albumin group, but only patients with total baseline bilirubins above 4 mg/dL and/or BUNs greater than 30 mg/dL benefited from albumin, Dr. Burton said (N. Engl. J. Med. 1999;341:403-9).

A follow-up 28-subject study limited albumin supplementation, again 1.5 g/kg on day 1 and 1.0 g/kg on day 3, to SBP patients with similar parameters or creatinines above 1 mg/dL. It was the right choice; none of the 15 patients with lower baseline values developed renal impairment, Dr. Burton said (Gut 2007;56:597-9).

He noted that it’s possible for patients to have SBP without obvious symptoms, so "if you’re sick enough to have cirrhosis and be in the hospital, you need a needle in your abdomen to rule out" the condition.

In general, cirrhotics have low levels of albumin, which is responsible for about 80% of plasma’s oncotic pressure. Also, what they have "may not work as well" to transport fatty acids, hormones, and enzymes, and drugs.

Outpatient supplementation for cirrhotics not only seems to reduce the need for paracentesis, but also makes patients feel better. "I am a believer because my patients tell me it works. Some of my patients refer to it as ‘nectar of the gods.’ This is more than just the oncotic things. I also think they are transporting hormones, carrying drugs, and other stuff better. So I am a big believer," Dr. Burton said.

He opts for 25% albumin instead of 5%, to reduce fluid load and also because "there is a lot of sodium in 5% albumin. Obviously, these patients need to have their sodium restricted," he said.

When paracentesis is needed, "studies suggest you can probably [remove] 4-6 liters without giving albumin." Even so, "we often give albumin during paracentesis," he said.

Dr. Burton said he has no relevant financial disclosures.

SAN DIEGO – Cirrhotics with spontaneous bacterial peritonitis probably need albumin only if their total bilirubin is above 4 mg/dL and/or their blood urea nitrogen (BUN) is above 30 mg/dL, according to transplant hepatologist Dr. James Burton.

Supplementation expands plasma volume to attenuate the splanchnic and systemic vasodilation associated with spontaneous bacterial peritonitis (SBP), increasing blood flow to the kidneys and preserving renal function, said Dr. Burton, medical director of liver transplantation at the University of Colorado Hospital, Aurora.

But it seems to be needed only when SBP patients are at high risk for renal failure, according to two studies.

The first randomized 63 cirrhotic SBP patients to cefotaxime alone and 63 to cefotaxime plus albumin, 1.5 g/kg on day 1 and 1.0 g/kg on day 3. The regimen wiped out the infection in most patients. Renal impairment and mortality were significantly lower in the albumin group, but only patients with total baseline bilirubins above 4 mg/dL and/or BUNs greater than 30 mg/dL benefited from albumin, Dr. Burton said (N. Engl. J. Med. 1999;341:403-9).

A follow-up 28-subject study limited albumin supplementation, again 1.5 g/kg on day 1 and 1.0 g/kg on day 3, to SBP patients with similar parameters or creatinines above 1 mg/dL. It was the right choice; none of the 15 patients with lower baseline values developed renal impairment, Dr. Burton said (Gut 2007;56:597-9).

He noted that it’s possible for patients to have SBP without obvious symptoms, so "if you’re sick enough to have cirrhosis and be in the hospital, you need a needle in your abdomen to rule out" the condition.

In general, cirrhotics have low levels of albumin, which is responsible for about 80% of plasma’s oncotic pressure. Also, what they have "may not work as well" to transport fatty acids, hormones, and enzymes, and drugs.

Outpatient supplementation for cirrhotics not only seems to reduce the need for paracentesis, but also makes patients feel better. "I am a believer because my patients tell me it works. Some of my patients refer to it as ‘nectar of the gods.’ This is more than just the oncotic things. I also think they are transporting hormones, carrying drugs, and other stuff better. So I am a big believer," Dr. Burton said.

He opts for 25% albumin instead of 5%, to reduce fluid load and also because "there is a lot of sodium in 5% albumin. Obviously, these patients need to have their sodium restricted," he said.

When paracentesis is needed, "studies suggest you can probably [remove] 4-6 liters without giving albumin." Even so, "we often give albumin during paracentesis," he said.

Dr. Burton said he has no relevant financial disclosures.

SAN DIEGO – Patients with bileaflet aortic valves have a low risk of perioperative thromboembolism, as long as they don’t have atrial fibrillation or other stroke risks, according to recent perioperative antithrombotic therapy guidelines from the American College of Chest Physicians.

That means they’ll likely be okay if their anticoagulation therapy is temporarily discontinued for an invasive procedure; they do not need to bridged with low-molecular-weight or unfractionated heparin, said Dr. Daniel Brotman of the department of medicine and director of the hospitalist program at Johns Hopkins Hospital in Baltimore (Chest 2012;141:e326S-50S).

Even so, there’s a good chance those patients will be bridged anyway because "we are petrified not to bridge patients with valves," even though "we are comfortable not bridging patients with [uncomplicated] atrial fibrillation," who have a similar perioperative thromboembolism risk, he said at the annual meeting of the Society of Hospital Medicine.

Maybe it’s because older caged-ball and tilting-disc aortic valves were more thrombogenic, so "we got in the habit" of bridging, "but the data just don’t support that with [bileaflet] aortic valves," he said. The guidelines do note that patients with caged-ball and tilting-disc aortic valves, and mitral valves, are at high-risk for perioperative thromboembolic events.

In general, bridging practices vary considerably in the United States, and bridging itself is not without risks, Dr. Brotman and his colleagues found in a study of nine hospital centers.

Two bridged more than 80% of their anticoagulation patients with full-dose perioperative heparin; the remaining seven used full-dose heparin in just 22%. The variation persisted after adjustment for patient characteristics.

Patients "at one of these more aggressive centers were three to four times more likely to have a bleeding episode. Not surprisingly, if you take patients who have recently been through surgery and treat them with full-dose heparin products, they are likely to bleed," he said (Am. J. Med. 2010;123:141-150).

When needed, Dr. Brotman prefers to bridge with low-molecular-weight heparin (enoxaparin), delivered on an outpatient basis. "This is a much more cost effective than admitting [valve patients] for unfractionated heparin treatment," he said.

Some might worry about the approach because of an "ugly history related to the [Food and Drug Administration] getting very upset about some very bad outcomes in a small number" of mitral valve patients bridged with low-molecular-weight heparin several years ago, he said.

"They put in a black box warning against using enoxaparin in valve patients, but subsequently realized that patients on anticoagulation with prosthetic mitral valves are at high risk for having bad things happen to them, and that when they have periods of anticoagulation cessation, they are at risk of having something happen regardless of what you bridge them with," Dr. Brotman said. The black box was eventually removed (Circulation 2006;113:470-2).

So "anybody who says it’s safer to bridge patients with unfractionated heparin, you can ask them, ‘well, show me the data.’ There are no head-to-head trials vs. low-molecular-weight heparin, and the data for unfractionated heparin are over 30 years old. It’s not safer; it’s just something that’s been traditional. Anecdotally, I’ve had patients have adverse outcomes with unfractionated heparin," he said.

Dr. Brotman said he has no disclosures.

SAN DIEGO – Patients with bileaflet aortic valves have a low risk of perioperative thromboembolism, as long as they don’t have atrial fibrillation or other stroke risks, according to recent perioperative antithrombotic therapy guidelines from the American College of Chest Physicians.

That means they’ll likely be okay if their anticoagulation therapy is temporarily discontinued for an invasive procedure; they do not need to bridged with low-molecular-weight or unfractionated heparin, said Dr. Daniel Brotman of the department of medicine and director of the hospitalist program at Johns Hopkins Hospital in Baltimore (Chest 2012;141:e326S-50S).

Even so, there’s a good chance those patients will be bridged anyway because "we are petrified not to bridge patients with valves," even though "we are comfortable not bridging patients with [uncomplicated] atrial fibrillation," who have a similar perioperative thromboembolism risk, he said at the annual meeting of the Society of Hospital Medicine.

Maybe it’s because older caged-ball and tilting-disc aortic valves were more thrombogenic, so "we got in the habit" of bridging, "but the data just don’t support that with [bileaflet] aortic valves," he said. The guidelines do note that patients with caged-ball and tilting-disc aortic valves, and mitral valves, are at high-risk for perioperative thromboembolic events.

In general, bridging practices vary considerably in the United States, and bridging itself is not without risks, Dr. Brotman and his colleagues found in a study of nine hospital centers.

Two bridged more than 80% of their anticoagulation patients with full-dose perioperative heparin; the remaining seven used full-dose heparin in just 22%. The variation persisted after adjustment for patient characteristics.

Patients "at one of these more aggressive centers were three to four times more likely to have a bleeding episode. Not surprisingly, if you take patients who have recently been through surgery and treat them with full-dose heparin products, they are likely to bleed," he said (Am. J. Med. 2010;123:141-150).

When needed, Dr. Brotman prefers to bridge with low-molecular-weight heparin (enoxaparin), delivered on an outpatient basis. "This is a much more cost effective than admitting [valve patients] for unfractionated heparin treatment," he said.

Some might worry about the approach because of an "ugly history related to the [Food and Drug Administration] getting very upset about some very bad outcomes in a small number" of mitral valve patients bridged with low-molecular-weight heparin several years ago, he said.

"They put in a black box warning against using enoxaparin in valve patients, but subsequently realized that patients on anticoagulation with prosthetic mitral valves are at high risk for having bad things happen to them, and that when they have periods of anticoagulation cessation, they are at risk of having something happen regardless of what you bridge them with," Dr. Brotman said. The black box was eventually removed (Circulation 2006;113:470-2).

So "anybody who says it’s safer to bridge patients with unfractionated heparin, you can ask them, ‘well, show me the data.’ There are no head-to-head trials vs. low-molecular-weight heparin, and the data for unfractionated heparin are over 30 years old. It’s not safer; it’s just something that’s been traditional. Anecdotally, I’ve had patients have adverse outcomes with unfractionated heparin," he said.

Dr. Brotman said he has no disclosures.

SAN DIEGO – Patients with bileaflet aortic valves have a low risk of perioperative thromboembolism, as long as they don’t have atrial fibrillation or other stroke risks, according to recent perioperative antithrombotic therapy guidelines from the American College of Chest Physicians.

That means they’ll likely be okay if their anticoagulation therapy is temporarily discontinued for an invasive procedure; they do not need to bridged with low-molecular-weight or unfractionated heparin, said Dr. Daniel Brotman of the department of medicine and director of the hospitalist program at Johns Hopkins Hospital in Baltimore (Chest 2012;141:e326S-50S).

Even so, there’s a good chance those patients will be bridged anyway because "we are petrified not to bridge patients with valves," even though "we are comfortable not bridging patients with [uncomplicated] atrial fibrillation," who have a similar perioperative thromboembolism risk, he said at the annual meeting of the Society of Hospital Medicine.

Maybe it’s because older caged-ball and tilting-disc aortic valves were more thrombogenic, so "we got in the habit" of bridging, "but the data just don’t support that with [bileaflet] aortic valves," he said. The guidelines do note that patients with caged-ball and tilting-disc aortic valves, and mitral valves, are at high-risk for perioperative thromboembolic events.

In general, bridging practices vary considerably in the United States, and bridging itself is not without risks, Dr. Brotman and his colleagues found in a study of nine hospital centers.

Two bridged more than 80% of their anticoagulation patients with full-dose perioperative heparin; the remaining seven used full-dose heparin in just 22%. The variation persisted after adjustment for patient characteristics.

Patients "at one of these more aggressive centers were three to four times more likely to have a bleeding episode. Not surprisingly, if you take patients who have recently been through surgery and treat them with full-dose heparin products, they are likely to bleed," he said (Am. J. Med. 2010;123:141-150).

When needed, Dr. Brotman prefers to bridge with low-molecular-weight heparin (enoxaparin), delivered on an outpatient basis. "This is a much more cost effective than admitting [valve patients] for unfractionated heparin treatment," he said.

Some might worry about the approach because of an "ugly history related to the [Food and Drug Administration] getting very upset about some very bad outcomes in a small number" of mitral valve patients bridged with low-molecular-weight heparin several years ago, he said.

"They put in a black box warning against using enoxaparin in valve patients, but subsequently realized that patients on anticoagulation with prosthetic mitral valves are at high risk for having bad things happen to them, and that when they have periods of anticoagulation cessation, they are at risk of having something happen regardless of what you bridge them with," Dr. Brotman said. The black box was eventually removed (Circulation 2006;113:470-2).

So "anybody who says it’s safer to bridge patients with unfractionated heparin, you can ask them, ‘well, show me the data.’ There are no head-to-head trials vs. low-molecular-weight heparin, and the data for unfractionated heparin are over 30 years old. It’s not safer; it’s just something that’s been traditional. Anecdotally, I’ve had patients have adverse outcomes with unfractionated heparin," he said.

Dr. Brotman said he has no disclosures.

SAN DIEGO – Hospitals that employed more hospitalists had modestly higher patient satisfaction scores in an analysis of 2009 Medicare data for 135,722 patients at 2,843 hospitals.

Patient satisfaction scores came from the Hospital Consumer Assessment of Healthcare Providers and System, a 27-item survey that, starting in 2006, was administered to random adult patients within 48 hours to 6 weeks after discharge from the hospitals.

Approximately 63.5% patients at nonhospitalist hospitals would recommend the hospital to others, as would approximately 64.5% of patients at mixed hospitals and 66% of patients at hospitalist hospitals,

Use of hospitalists varied widely, with no hospitalists caring for general medicine patients at 17% of hospitals and all general medicine patients being cared for by hospitalists at less than 4% of hospitals. The analysis grouped hospitals as one of three types. "Nonhospitalist" facilities had 0%-20% of patients cared for by hospitalists. "Mixed" hospitals used hospitalists for 21%-50% of general medicine patients, and "hospitalist" hospitals placed 61%-100% of general medicine patients under hospitalist care.

Overall patient satisfaction rates were approximately 64% for nonhospitalist or mixed hospitals and nearly 66% for hospitalist facilities, Dr. Lena M. Chen and her associates reported at the annual meeting of the Society of Hospital Medicine.

Approximately 63.5% of the 33,265 patients at nonhospitalist hospitals would recommend the hospital to others, as would approximately 64.5% of the 52,844 patients at mixed hospitals and 66% of the 46,705 patients at hospitalist hospitals, said Dr. Chen of the University of Michigan, Ann Arbor.

On individual items, the largest difference between facilities was in patient satisfaction with discharge – an 80% rating at hospitalist facilities, which was significantly higher than the 78% rating for nonhospitalist hospitals. Smaller, but still statistically significant, differences were seen in higher satisfaction scores for hospitalist vs. nonhospitalist facilities in ratings on nursing services, quiet, communication with nurses, pain control, and communication about medications.

Starting in October 2012, Medicare will base part of its hospital payments on patient satisfaction scores, Dr. Chen noted. Inpatients increasingly are likely to be cared for by hospitalists.

"Given efforts to increase patient satisfaction, it would be important to understand why hospitals with more hospitalist care have higher patient satisfaction," she said.

The analysis adjusted for potentially confounding effects of various differences between types of hospitals. Nonhospitalist hospitals were significantly less likely to be teaching hospitals and significantly more likely to be in urban locations. Hospitalist facilities were significantly more likely to have a medical ICU and to have a higher nurse-to-bed ratio compared with nonhospitalist hospitals.

Hospitalists were defined as general internists with at least five Medicare billings in a year and with 90% or more of these billings from the care of hospitalized patients.

The 5% sample of elderly fee-for-service Medicare beneficiaries excluded patients with surgical admissions or readmissions, patients who did not have an acute care hospital stay, patients who were not cared for by a general internist, and patients who were cared for by both a hospitalist and nonhospitalists.

Dr. Chen reported having no financial disclosures.

SAN DIEGO – Hospitals that employed more hospitalists had modestly higher patient satisfaction scores in an analysis of 2009 Medicare data for 135,722 patients at 2,843 hospitals.

Patient satisfaction scores came from the Hospital Consumer Assessment of Healthcare Providers and System, a 27-item survey that, starting in 2006, was administered to random adult patients within 48 hours to 6 weeks after discharge from the hospitals.

Approximately 63.5% patients at nonhospitalist hospitals would recommend the hospital to others, as would approximately 64.5% of patients at mixed hospitals and 66% of patients at hospitalist hospitals,

Use of hospitalists varied widely, with no hospitalists caring for general medicine patients at 17% of hospitals and all general medicine patients being cared for by hospitalists at less than 4% of hospitals. The analysis grouped hospitals as one of three types. "Nonhospitalist" facilities had 0%-20% of patients cared for by hospitalists. "Mixed" hospitals used hospitalists for 21%-50% of general medicine patients, and "hospitalist" hospitals placed 61%-100% of general medicine patients under hospitalist care.

Overall patient satisfaction rates were approximately 64% for nonhospitalist or mixed hospitals and nearly 66% for hospitalist facilities, Dr. Lena M. Chen and her associates reported at the annual meeting of the Society of Hospital Medicine.

Approximately 63.5% of the 33,265 patients at nonhospitalist hospitals would recommend the hospital to others, as would approximately 64.5% of the 52,844 patients at mixed hospitals and 66% of the 46,705 patients at hospitalist hospitals, said Dr. Chen of the University of Michigan, Ann Arbor.

On individual items, the largest difference between facilities was in patient satisfaction with discharge – an 80% rating at hospitalist facilities, which was significantly higher than the 78% rating for nonhospitalist hospitals. Smaller, but still statistically significant, differences were seen in higher satisfaction scores for hospitalist vs. nonhospitalist facilities in ratings on nursing services, quiet, communication with nurses, pain control, and communication about medications.

Starting in October 2012, Medicare will base part of its hospital payments on patient satisfaction scores, Dr. Chen noted. Inpatients increasingly are likely to be cared for by hospitalists.

"Given efforts to increase patient satisfaction, it would be important to understand why hospitals with more hospitalist care have higher patient satisfaction," she said.

The analysis adjusted for potentially confounding effects of various differences between types of hospitals. Nonhospitalist hospitals were significantly less likely to be teaching hospitals and significantly more likely to be in urban locations. Hospitalist facilities were significantly more likely to have a medical ICU and to have a higher nurse-to-bed ratio compared with nonhospitalist hospitals.

Hospitalists were defined as general internists with at least five Medicare billings in a year and with 90% or more of these billings from the care of hospitalized patients.

The 5% sample of elderly fee-for-service Medicare beneficiaries excluded patients with surgical admissions or readmissions, patients who did not have an acute care hospital stay, patients who were not cared for by a general internist, and patients who were cared for by both a hospitalist and nonhospitalists.

Dr. Chen reported having no financial disclosures.

SAN DIEGO – Hospitals that employed more hospitalists had modestly higher patient satisfaction scores in an analysis of 2009 Medicare data for 135,722 patients at 2,843 hospitals.

Patient satisfaction scores came from the Hospital Consumer Assessment of Healthcare Providers and System, a 27-item survey that, starting in 2006, was administered to random adult patients within 48 hours to 6 weeks after discharge from the hospitals.

Approximately 63.5% patients at nonhospitalist hospitals would recommend the hospital to others, as would approximately 64.5% of patients at mixed hospitals and 66% of patients at hospitalist hospitals,

Use of hospitalists varied widely, with no hospitalists caring for general medicine patients at 17% of hospitals and all general medicine patients being cared for by hospitalists at less than 4% of hospitals. The analysis grouped hospitals as one of three types. "Nonhospitalist" facilities had 0%-20% of patients cared for by hospitalists. "Mixed" hospitals used hospitalists for 21%-50% of general medicine patients, and "hospitalist" hospitals placed 61%-100% of general medicine patients under hospitalist care.

Overall patient satisfaction rates were approximately 64% for nonhospitalist or mixed hospitals and nearly 66% for hospitalist facilities, Dr. Lena M. Chen and her associates reported at the annual meeting of the Society of Hospital Medicine.

Approximately 63.5% of the 33,265 patients at nonhospitalist hospitals would recommend the hospital to others, as would approximately 64.5% of the 52,844 patients at mixed hospitals and 66% of the 46,705 patients at hospitalist hospitals, said Dr. Chen of the University of Michigan, Ann Arbor.

On individual items, the largest difference between facilities was in patient satisfaction with discharge – an 80% rating at hospitalist facilities, which was significantly higher than the 78% rating for nonhospitalist hospitals. Smaller, but still statistically significant, differences were seen in higher satisfaction scores for hospitalist vs. nonhospitalist facilities in ratings on nursing services, quiet, communication with nurses, pain control, and communication about medications.

Starting in October 2012, Medicare will base part of its hospital payments on patient satisfaction scores, Dr. Chen noted. Inpatients increasingly are likely to be cared for by hospitalists.

"Given efforts to increase patient satisfaction, it would be important to understand why hospitals with more hospitalist care have higher patient satisfaction," she said.

The analysis adjusted for potentially confounding effects of various differences between types of hospitals. Nonhospitalist hospitals were significantly less likely to be teaching hospitals and significantly more likely to be in urban locations. Hospitalist facilities were significantly more likely to have a medical ICU and to have a higher nurse-to-bed ratio compared with nonhospitalist hospitals.

Hospitalists were defined as general internists with at least five Medicare billings in a year and with 90% or more of these billings from the care of hospitalized patients.

The 5% sample of elderly fee-for-service Medicare beneficiaries excluded patients with surgical admissions or readmissions, patients who did not have an acute care hospital stay, patients who were not cared for by a general internist, and patients who were cared for by both a hospitalist and nonhospitalists.

Dr. Chen reported having no financial disclosures.

SAN DIEGO – Terlipressin, widely used in Europe for hepatorenal syndrome but not yet approved in the United States, would be a useful option for this difficult-to-treat condition, said transplant hepatologist Dr. James Burton at the annual meeting of the Society of Hospital Medicine.

Currently, U.S. clinicians do their best with albumin and vasoconstrictors such as octreotide and midodrine to counteract the intense splanchnic vasodilatation that causes the condition (J. Clin. Gastroenterol. 2009;43:680-5).

Hepatorenal syndrome is a complication of advanced cirrhosis that can lead to renal failure. Liver transplantation is "the only treatment we currently have available to us that is very effective," especially for rapidly progressing type 1 HRS [hepatorenal syndrome]," said Dr. Burton, associate professor of medicine and the medical director of liver transplantation at the University of Colorado Hospital, Aurora.

The European vasopressin analogue terlipressin (Lucassin) has a long half-life that allows for bolus dosing every 4-6 hours. Several studies found evidence that the drug might be beneficial.

In one study, 56 patients with type 1 HRS were randomized to terlipressin (1 mg intravenously every 6 hours) plus albumin. Another 56 patients received placebo plus albumin.

Serum creatinine level decreased to 1.5 mg/dL or less in 14 (25%) terlipressin patients, but in only 7 (12.5%) placebo patients by day 14. This difference was not statistically significant, however. The two groups had similar adverse event rates (Gastroenterology 2008;134:1360-8).

A significant benefit was found in a randomized study of 46 patients. Serum creatinine fell below 1.5 mg/dL or decreased 50% from baseline in 10 (43.5%) patients treated with albumin and terlipressin (1-2 mg/4 hours), vs. 2 (8.7%) patients treated with albumin alone (P = .017). Ten terlipressin patients and four albumin-only patients had cardiovascular complications (Gastroenterology 2008;134:1352-9).

In a third study, which was also randomized, 24 HRS patients received albumin and terlipressin (3 mg/24 hours with escalation based on response) and 17 received standard U.S. treatment – albumin plus midodrine and octreotide, also escalated according to response.

Serum creatinine in that study fell below 1.5 mg/dL in 13 (54%) terlipressin patients and renal function improved in three-quarters. Creatinine fell below 1.5 mg/dL in just 2 (12%) of the standard-treatment patients, and renal function improved in about a third (Angeli et al. The Liver Meeting 2011, American Association for the Study of Liver Diseases).

However, in all three studies, people didn’t live any longer when they were given terlipressin, and this is what is holding up FDA approval, said Dr. Burton, who noted that he and his colleagues are working on a new study "to try to show a survival benefit" for the drug.

He said he hopes the FDA approves terlipressin "because it will be a very effective treatment for hepatorenal syndrome. It would be amazing and wonderful if I could prevent people from going on dialysis" as they wait for a new liver.

Dr. Burton said he has no relevant financial disclosures.

SAN DIEGO – Terlipressin, widely used in Europe for hepatorenal syndrome but not yet approved in the United States, would be a useful option for this difficult-to-treat condition, said transplant hepatologist Dr. James Burton at the annual meeting of the Society of Hospital Medicine.

Currently, U.S. clinicians do their best with albumin and vasoconstrictors such as octreotide and midodrine to counteract the intense splanchnic vasodilatation that causes the condition (J. Clin. Gastroenterol. 2009;43:680-5).

Hepatorenal syndrome is a complication of advanced cirrhosis that can lead to renal failure. Liver transplantation is "the only treatment we currently have available to us that is very effective," especially for rapidly progressing type 1 HRS [hepatorenal syndrome]," said Dr. Burton, associate professor of medicine and the medical director of liver transplantation at the University of Colorado Hospital, Aurora.

The European vasopressin analogue terlipressin (Lucassin) has a long half-life that allows for bolus dosing every 4-6 hours. Several studies found evidence that the drug might be beneficial.

In one study, 56 patients with type 1 HRS were randomized to terlipressin (1 mg intravenously every 6 hours) plus albumin. Another 56 patients received placebo plus albumin.

Serum creatinine level decreased to 1.5 mg/dL or less in 14 (25%) terlipressin patients, but in only 7 (12.5%) placebo patients by day 14. This difference was not statistically significant, however. The two groups had similar adverse event rates (Gastroenterology 2008;134:1360-8).

A significant benefit was found in a randomized study of 46 patients. Serum creatinine fell below 1.5 mg/dL or decreased 50% from baseline in 10 (43.5%) patients treated with albumin and terlipressin (1-2 mg/4 hours), vs. 2 (8.7%) patients treated with albumin alone (P = .017). Ten terlipressin patients and four albumin-only patients had cardiovascular complications (Gastroenterology 2008;134:1352-9).

In a third study, which was also randomized, 24 HRS patients received albumin and terlipressin (3 mg/24 hours with escalation based on response) and 17 received standard U.S. treatment – albumin plus midodrine and octreotide, also escalated according to response.

Serum creatinine in that study fell below 1.5 mg/dL in 13 (54%) terlipressin patients and renal function improved in three-quarters. Creatinine fell below 1.5 mg/dL in just 2 (12%) of the standard-treatment patients, and renal function improved in about a third (Angeli et al. The Liver Meeting 2011, American Association for the Study of Liver Diseases).

However, in all three studies, people didn’t live any longer when they were given terlipressin, and this is what is holding up FDA approval, said Dr. Burton, who noted that he and his colleagues are working on a new study "to try to show a survival benefit" for the drug.

He said he hopes the FDA approves terlipressin "because it will be a very effective treatment for hepatorenal syndrome. It would be amazing and wonderful if I could prevent people from going on dialysis" as they wait for a new liver.

Dr. Burton said he has no relevant financial disclosures.

SAN DIEGO – Terlipressin, widely used in Europe for hepatorenal syndrome but not yet approved in the United States, would be a useful option for this difficult-to-treat condition, said transplant hepatologist Dr. James Burton at the annual meeting of the Society of Hospital Medicine.

Currently, U.S. clinicians do their best with albumin and vasoconstrictors such as octreotide and midodrine to counteract the intense splanchnic vasodilatation that causes the condition (J. Clin. Gastroenterol. 2009;43:680-5).

Hepatorenal syndrome is a complication of advanced cirrhosis that can lead to renal failure. Liver transplantation is "the only treatment we currently have available to us that is very effective," especially for rapidly progressing type 1 HRS [hepatorenal syndrome]," said Dr. Burton, associate professor of medicine and the medical director of liver transplantation at the University of Colorado Hospital, Aurora.

The European vasopressin analogue terlipressin (Lucassin) has a long half-life that allows for bolus dosing every 4-6 hours. Several studies found evidence that the drug might be beneficial.

In one study, 56 patients with type 1 HRS were randomized to terlipressin (1 mg intravenously every 6 hours) plus albumin. Another 56 patients received placebo plus albumin.

Serum creatinine level decreased to 1.5 mg/dL or less in 14 (25%) terlipressin patients, but in only 7 (12.5%) placebo patients by day 14. This difference was not statistically significant, however. The two groups had similar adverse event rates (Gastroenterology 2008;134:1360-8).

A significant benefit was found in a randomized study of 46 patients. Serum creatinine fell below 1.5 mg/dL or decreased 50% from baseline in 10 (43.5%) patients treated with albumin and terlipressin (1-2 mg/4 hours), vs. 2 (8.7%) patients treated with albumin alone (P = .017). Ten terlipressin patients and four albumin-only patients had cardiovascular complications (Gastroenterology 2008;134:1352-9).

In a third study, which was also randomized, 24 HRS patients received albumin and terlipressin (3 mg/24 hours with escalation based on response) and 17 received standard U.S. treatment – albumin plus midodrine and octreotide, also escalated according to response.

Serum creatinine in that study fell below 1.5 mg/dL in 13 (54%) terlipressin patients and renal function improved in three-quarters. Creatinine fell below 1.5 mg/dL in just 2 (12%) of the standard-treatment patients, and renal function improved in about a third (Angeli et al. The Liver Meeting 2011, American Association for the Study of Liver Diseases).

However, in all three studies, people didn’t live any longer when they were given terlipressin, and this is what is holding up FDA approval, said Dr. Burton, who noted that he and his colleagues are working on a new study "to try to show a survival benefit" for the drug.

He said he hopes the FDA approves terlipressin "because it will be a very effective treatment for hepatorenal syndrome. It would be amazing and wonderful if I could prevent people from going on dialysis" as they wait for a new liver.

Dr. Burton said he has no relevant financial disclosures.

SAN DIEGO – Infliximab is the optimal rescue therapy for severe, acute, steroid-refractory ulcerative colitis, gastroenterologist Dr. Derek R. Patel said at the annual meeting of the Society of Hospital Medicine.

The tumor necrosis factor–alpha inhibitor, which carries ulcerative colitis (UC) indications, works as well as cyclosporine, the traditional option, without its complications, which include a 1% mortality rate and the need for extensive monitoring.

Infliximab (Remicade) also works better than azathioprine, the agent to which steroid-refractory patients often are switched once they leave the hospital, said Dr. Patel of the department of medicine at the University of California, San Diego.

Alex Otto/IMNG Medical Media

In a randomized trial by Dr. D. Laharie and colleagues that compared infliximab in 56 steroid-refractory UC patients with cyclosporine in 55 similar patients, about 85% of those in each arm responded to treatment within 1 week; 10 (18%) of the cyclosporine patients and 13 (23%) in the infliximab group had undergone a colectomy by the third month of follow-up. Serious adverse events were reported in 9 (16%) cyclosporine patients and 16 (29%) infliximab patients. There were no deaths.

"If you look at all the important end points, whether they be early response, overall treatment failure, or colectomy, there are no significant short-term differences between cyclosporine and infliximab, suggesting that infliximab is not inferior to cyclosporine. [It also] is much easier to use and requires minimal monitoring," Dr. Patel said.

"I think infliximab would be the optimal medical rescue therapy for these patients" in most cases, he said.

Another study – a 16-week, randomized, double-blind, controlled trial by Dr. R. Panccione and colleagues – compared azathioprine monotherapy, infliximab monotherapy, and combination therapy in 239 steroid-refractory UC patients.

"In the two most important end points of steroid-free clinical remission and mucosal healing, infliximab-based therapy, whether monotherapy or combination therapy, was significantly better than azathioprine monotherapy," Dr. Patel said.

Steroid failure can generally be predicted after 3 days of treatment by the Travis or Lindgren indexes, which take into account number of bowel movements per day, C-reactive protein levels, and other factors. Those and other indexes "allow you to move on to medical or surgical rescue therapy early on," he said.

"But remember medical therapy isn’t for everyone. Some patients probably should have a colectomy," despite the possible complications, Dr. Patel cautioned.

Patients who are likely to need surgery include those with massive unrelenting hemorrhage, toxic megacolon, coexisting cancer or dysplasia, and intractable UC of long duration, as well as noncompliant patients.

"Patients and physicians alike tend to assume surgery is failure, [but] that’s not true. At the end of the day, our goal is to save lives and quality of life, not necessarily colons," Dr. Patel said.

Dr. Patel said he has no disclosures.

SAN DIEGO – Infliximab is the optimal rescue therapy for severe, acute, steroid-refractory ulcerative colitis, gastroenterologist Dr. Derek R. Patel said at the annual meeting of the Society of Hospital Medicine.

The tumor necrosis factor–alpha inhibitor, which carries ulcerative colitis (UC) indications, works as well as cyclosporine, the traditional option, without its complications, which include a 1% mortality rate and the need for extensive monitoring.

Infliximab (Remicade) also works better than azathioprine, the agent to which steroid-refractory patients often are switched once they leave the hospital, said Dr. Patel of the department of medicine at the University of California, San Diego.

Alex Otto/IMNG Medical Media

In a randomized trial by Dr. D. Laharie and colleagues that compared infliximab in 56 steroid-refractory UC patients with cyclosporine in 55 similar patients, about 85% of those in each arm responded to treatment within 1 week; 10 (18%) of the cyclosporine patients and 13 (23%) in the infliximab group had undergone a colectomy by the third month of follow-up. Serious adverse events were reported in 9 (16%) cyclosporine patients and 16 (29%) infliximab patients. There were no deaths.

"If you look at all the important end points, whether they be early response, overall treatment failure, or colectomy, there are no significant short-term differences between cyclosporine and infliximab, suggesting that infliximab is not inferior to cyclosporine. [It also] is much easier to use and requires minimal monitoring," Dr. Patel said.

"I think infliximab would be the optimal medical rescue therapy for these patients" in most cases, he said.

Another study – a 16-week, randomized, double-blind, controlled trial by Dr. R. Panccione and colleagues – compared azathioprine monotherapy, infliximab monotherapy, and combination therapy in 239 steroid-refractory UC patients.

"In the two most important end points of steroid-free clinical remission and mucosal healing, infliximab-based therapy, whether monotherapy or combination therapy, was significantly better than azathioprine monotherapy," Dr. Patel said.

Steroid failure can generally be predicted after 3 days of treatment by the Travis or Lindgren indexes, which take into account number of bowel movements per day, C-reactive protein levels, and other factors. Those and other indexes "allow you to move on to medical or surgical rescue therapy early on," he said.

"But remember medical therapy isn’t for everyone. Some patients probably should have a colectomy," despite the possible complications, Dr. Patel cautioned.

Patients who are likely to need surgery include those with massive unrelenting hemorrhage, toxic megacolon, coexisting cancer or dysplasia, and intractable UC of long duration, as well as noncompliant patients.

"Patients and physicians alike tend to assume surgery is failure, [but] that’s not true. At the end of the day, our goal is to save lives and quality of life, not necessarily colons," Dr. Patel said.

Dr. Patel said he has no disclosures.

SAN DIEGO – Infliximab is the optimal rescue therapy for severe, acute, steroid-refractory ulcerative colitis, gastroenterologist Dr. Derek R. Patel said at the annual meeting of the Society of Hospital Medicine.

The tumor necrosis factor–alpha inhibitor, which carries ulcerative colitis (UC) indications, works as well as cyclosporine, the traditional option, without its complications, which include a 1% mortality rate and the need for extensive monitoring.

Infliximab (Remicade) also works better than azathioprine, the agent to which steroid-refractory patients often are switched once they leave the hospital, said Dr. Patel of the department of medicine at the University of California, San Diego.

Alex Otto/IMNG Medical Media

In a randomized trial by Dr. D. Laharie and colleagues that compared infliximab in 56 steroid-refractory UC patients with cyclosporine in 55 similar patients, about 85% of those in each arm responded to treatment within 1 week; 10 (18%) of the cyclosporine patients and 13 (23%) in the infliximab group had undergone a colectomy by the third month of follow-up. Serious adverse events were reported in 9 (16%) cyclosporine patients and 16 (29%) infliximab patients. There were no deaths.

"If you look at all the important end points, whether they be early response, overall treatment failure, or colectomy, there are no significant short-term differences between cyclosporine and infliximab, suggesting that infliximab is not inferior to cyclosporine. [It also] is much easier to use and requires minimal monitoring," Dr. Patel said.

"I think infliximab would be the optimal medical rescue therapy for these patients" in most cases, he said.

Another study – a 16-week, randomized, double-blind, controlled trial by Dr. R. Panccione and colleagues – compared azathioprine monotherapy, infliximab monotherapy, and combination therapy in 239 steroid-refractory UC patients.

"In the two most important end points of steroid-free clinical remission and mucosal healing, infliximab-based therapy, whether monotherapy or combination therapy, was significantly better than azathioprine monotherapy," Dr. Patel said.

Steroid failure can generally be predicted after 3 days of treatment by the Travis or Lindgren indexes, which take into account number of bowel movements per day, C-reactive protein levels, and other factors. Those and other indexes "allow you to move on to medical or surgical rescue therapy early on," he said.

"But remember medical therapy isn’t for everyone. Some patients probably should have a colectomy," despite the possible complications, Dr. Patel cautioned.

Patients who are likely to need surgery include those with massive unrelenting hemorrhage, toxic megacolon, coexisting cancer or dysplasia, and intractable UC of long duration, as well as noncompliant patients.

"Patients and physicians alike tend to assume surgery is failure, [but] that’s not true. At the end of the day, our goal is to save lives and quality of life, not necessarily colons," Dr. Patel said.

Dr. Patel said he has no disclosures.

SAN DIEGO – Less continuity of inpatient care by hospitalists significantly increased costs but didn’t increase readmissions in an analysis of 11,234 hospitalizations at one academic medical center.

In fact, lower continuity of care among hospitalists was associated with lower readmission rates, but this reduction was significant only in some models in the analysis, Jonathan Turner, Ph.D. and his associates reported at the annual meeting of the Society of Hospital Medicine.

Sherry Boschert/IMNG Medical Media

The total cost of a hospitalization increased by 7% for each hospitalist that cared for the patient. For each 10% decrease in a Usual Provider of Care index, based on the largest fraction of notes written by one provider, total costs increased by 12%, said Dr. Turner, a quality and innovation engineer at Northwestern Memorial Hospital, Chicago. Neither of those parameters significantly affected the likelihood of readmission.

The study was honored by the society as one of the three best presentations at the meeting.

The large non-teaching hospitalist service works blocks of 7 days on and 7 days off at the 900-bed academic hospital, with the schedule switch and case hand-offs on Mondays. The study included only patients whose primary service was provided exclusively by hospitalists, including no ICU days. Data were collected for June 2008 to May 2011.

The investigators used the authors of progress notes to calculate the number of providers. "We’re interested in changes in the driver of care – who is directing the plan of care? When that changes, does that affect costs and readmissions?" he said.

Because hospitalist shifts changed on Mondays, subanalyses in the study compared continuity of care for admissions on Mondays vs. Tuesdays through Sundays, or on weekdays instead of weekends, or on Mondays through Wednesdays rather than Thursdays through Sundays. Results were consistent, Dr. Turner said.

Higher costs with less continuity of care may be due to changes in the plan of care by the new provider and/or additional and possibly duplicate ordering of lab tests and imaging, he speculated. Lower readmission rates in some of the analytical models might be because additional orders turned out to be beneficial to the patient, or because the change in management was beneficial.

The findings may have implications for emerging efforts to improve patient handoff design and to reduce handoffs, perhaps by modifying work schedules to increase continuity of care, he suggested.

"We don’t talk much about handoff reduction," but interest in this is increasing, he said. "There are limited things we can do to decrease length of stay. Maybe we can focus on decreasing handoffs."

Previous studies have shown that continuity in outpatient care is associated with better control of hypertension, fewer hospitalizations or emergency department visits, and higher patient satisfaction, but little is known about continuity of inpatient care. Other research found that lower continuity of inpatient care was associated with significantly increased length of stay (J. Hosp. Med. 2010;5:335-338). From 1996 to 2006, the percentage of hospitalized patients who received care from one generalist physician declined from 71% to 59% (J. Hosp. Med. 2011;6:438-444).

In the current study, an average of 1.9 hospitalists managed each hospitalization. The average Usual Provider of Care index was 0.76. The readmission rate averaged 22% and the average length of stay was 3.5 days. Hospitalists averaged 33 years in age, and patients averaged 58 years of age. The patient cohort was 46% male, 53% white, 35% black, 8% Hispanic, and 4% other races/ethnicities. Medicaid or Medicare covered 58% of hospitalizations, private insurers covered 34%, and 8% were self-pay or other situations.

The investigators plan to conduct a similar study of nursing continuity of care.

The findings were limited by data collection from a single site, and only an academic institution, and exclusion of patients with ICU stays, who are the costliest, highest-risk patients. It’s possible that the continuity metrics were not optimal, and it’s unknown if patients were readmitted to other hospitals.

Dr. Turner reported having no financial disclosures.

SAN DIEGO – Less continuity of inpatient care by hospitalists significantly increased costs but didn’t increase readmissions in an analysis of 11,234 hospitalizations at one academic medical center.

In fact, lower continuity of care among hospitalists was associated with lower readmission rates, but this reduction was significant only in some models in the analysis, Jonathan Turner, Ph.D. and his associates reported at the annual meeting of the Society of Hospital Medicine.

Sherry Boschert/IMNG Medical Media

The total cost of a hospitalization increased by 7% for each hospitalist that cared for the patient. For each 10% decrease in a Usual Provider of Care index, based on the largest fraction of notes written by one provider, total costs increased by 12%, said Dr. Turner, a quality and innovation engineer at Northwestern Memorial Hospital, Chicago. Neither of those parameters significantly affected the likelihood of readmission.

The study was honored by the society as one of the three best presentations at the meeting.

The large non-teaching hospitalist service works blocks of 7 days on and 7 days off at the 900-bed academic hospital, with the schedule switch and case hand-offs on Mondays. The study included only patients whose primary service was provided exclusively by hospitalists, including no ICU days. Data were collected for June 2008 to May 2011.

The investigators used the authors of progress notes to calculate the number of providers. "We’re interested in changes in the driver of care – who is directing the plan of care? When that changes, does that affect costs and readmissions?" he said.

Because hospitalist shifts changed on Mondays, subanalyses in the study compared continuity of care for admissions on Mondays vs. Tuesdays through Sundays, or on weekdays instead of weekends, or on Mondays through Wednesdays rather than Thursdays through Sundays. Results were consistent, Dr. Turner said.

Higher costs with less continuity of care may be due to changes in the plan of care by the new provider and/or additional and possibly duplicate ordering of lab tests and imaging, he speculated. Lower readmission rates in some of the analytical models might be because additional orders turned out to be beneficial to the patient, or because the change in management was beneficial.

The findings may have implications for emerging efforts to improve patient handoff design and to reduce handoffs, perhaps by modifying work schedules to increase continuity of care, he suggested.

"We don’t talk much about handoff reduction," but interest in this is increasing, he said. "There are limited things we can do to decrease length of stay. Maybe we can focus on decreasing handoffs."

Previous studies have shown that continuity in outpatient care is associated with better control of hypertension, fewer hospitalizations or emergency department visits, and higher patient satisfaction, but little is known about continuity of inpatient care. Other research found that lower continuity of inpatient care was associated with significantly increased length of stay (J. Hosp. Med. 2010;5:335-338). From 1996 to 2006, the percentage of hospitalized patients who received care from one generalist physician declined from 71% to 59% (J. Hosp. Med. 2011;6:438-444).

In the current study, an average of 1.9 hospitalists managed each hospitalization. The average Usual Provider of Care index was 0.76. The readmission rate averaged 22% and the average length of stay was 3.5 days. Hospitalists averaged 33 years in age, and patients averaged 58 years of age. The patient cohort was 46% male, 53% white, 35% black, 8% Hispanic, and 4% other races/ethnicities. Medicaid or Medicare covered 58% of hospitalizations, private insurers covered 34%, and 8% were self-pay or other situations.

The investigators plan to conduct a similar study of nursing continuity of care.

The findings were limited by data collection from a single site, and only an academic institution, and exclusion of patients with ICU stays, who are the costliest, highest-risk patients. It’s possible that the continuity metrics were not optimal, and it’s unknown if patients were readmitted to other hospitals.

Dr. Turner reported having no financial disclosures.

SAN DIEGO – Less continuity of inpatient care by hospitalists significantly increased costs but didn’t increase readmissions in an analysis of 11,234 hospitalizations at one academic medical center.

In fact, lower continuity of care among hospitalists was associated with lower readmission rates, but this reduction was significant only in some models in the analysis, Jonathan Turner, Ph.D. and his associates reported at the annual meeting of the Society of Hospital Medicine.

Sherry Boschert/IMNG Medical Media

The total cost of a hospitalization increased by 7% for each hospitalist that cared for the patient. For each 10% decrease in a Usual Provider of Care index, based on the largest fraction of notes written by one provider, total costs increased by 12%, said Dr. Turner, a quality and innovation engineer at Northwestern Memorial Hospital, Chicago. Neither of those parameters significantly affected the likelihood of readmission.

The study was honored by the society as one of the three best presentations at the meeting.

The large non-teaching hospitalist service works blocks of 7 days on and 7 days off at the 900-bed academic hospital, with the schedule switch and case hand-offs on Mondays. The study included only patients whose primary service was provided exclusively by hospitalists, including no ICU days. Data were collected for June 2008 to May 2011.

The investigators used the authors of progress notes to calculate the number of providers. "We’re interested in changes in the driver of care – who is directing the plan of care? When that changes, does that affect costs and readmissions?" he said.

Because hospitalist shifts changed on Mondays, subanalyses in the study compared continuity of care for admissions on Mondays vs. Tuesdays through Sundays, or on weekdays instead of weekends, or on Mondays through Wednesdays rather than Thursdays through Sundays. Results were consistent, Dr. Turner said.

Higher costs with less continuity of care may be due to changes in the plan of care by the new provider and/or additional and possibly duplicate ordering of lab tests and imaging, he speculated. Lower readmission rates in some of the analytical models might be because additional orders turned out to be beneficial to the patient, or because the change in management was beneficial.

The findings may have implications for emerging efforts to improve patient handoff design and to reduce handoffs, perhaps by modifying work schedules to increase continuity of care, he suggested.

"We don’t talk much about handoff reduction," but interest in this is increasing, he said. "There are limited things we can do to decrease length of stay. Maybe we can focus on decreasing handoffs."

Previous studies have shown that continuity in outpatient care is associated with better control of hypertension, fewer hospitalizations or emergency department visits, and higher patient satisfaction, but little is known about continuity of inpatient care. Other research found that lower continuity of inpatient care was associated with significantly increased length of stay (J. Hosp. Med. 2010;5:335-338). From 1996 to 2006, the percentage of hospitalized patients who received care from one generalist physician declined from 71% to 59% (J. Hosp. Med. 2011;6:438-444).

In the current study, an average of 1.9 hospitalists managed each hospitalization. The average Usual Provider of Care index was 0.76. The readmission rate averaged 22% and the average length of stay was 3.5 days. Hospitalists averaged 33 years in age, and patients averaged 58 years of age. The patient cohort was 46% male, 53% white, 35% black, 8% Hispanic, and 4% other races/ethnicities. Medicaid or Medicare covered 58% of hospitalizations, private insurers covered 34%, and 8% were self-pay or other situations.

The investigators plan to conduct a similar study of nursing continuity of care.

The findings were limited by data collection from a single site, and only an academic institution, and exclusion of patients with ICU stays, who are the costliest, highest-risk patients. It’s possible that the continuity metrics were not optimal, and it’s unknown if patients were readmitted to other hospitals.

Dr. Turner reported having no financial disclosures.

SAN DIEGO – Moving the timing of discharge orders from afternoon to morning did not get patients out the door earlier in the day in a study at Mount Sinai Medical Center, New York.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times," Dr. Ramiro Jervis said at the annual meeting of the Society of Hospital Medicine.

After 6 months of employing multiple strategies to get discharge orders written before 11 a.m., the mean time of discharge orders for patients on medical wards improved by 78 minutes, from 1 p.m. to before noon, but patients left the hospital only 12 minutes earlier on average, closer to 4 p.m., said Dr. Jervis, director of the quality hospitalist division at the medical center.

Results were similar for teaching and nonteaching services at the 1,171-bed tertiary-care urban teaching facility.

To determine why patients didn’t leave earlier, Dr. Jervis reviewed 51 charts for patients discharged after 3 p.m. from a teaching medicine unit during a 30-day period, with those discharges happening more than 4 hours after the actual discharge order.

In about 63% of those cases, the hospital had to arrange transportation for the patient, which may have delayed discharge. Sixteen percent of patients were awaiting family, and approximately 16% had tests pending. Some 4% were awaiting a physician or consultant.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times."

The hospital will continue to offer incentives to physicians for discharge orders to be completed before 11 a.m. and will prospectively investigate why patients don’t leave soon after the orders are given, Dr. Jervis said. The investigators also plan to add incentives for nurses, social workers, and patients for early discharges.

Dr. Jervis and his associates received an honorable mention from judges picking the best research presentation at the meeting.

The medicine service at the hospital handles 1,000 discharges per month, excluding interventional cardiology. To shift the timing of discharge orders, the study organized discussions and recording of discharge order times at resident reports each morning. House staff and hospitalists received weekly feedback. Each month, the two top-performing teaching teams received awards – such as $30 gift cards for house staff members – for completing earlier discharge orders.

In addition, organization of medical teams shifted to geographic localization. Providers participated in daily interdisciplinary rounds. Teaching rounds were moved to afternoons so that the morning focus would be on work rounds, Dr. Jervis said.

Other potential reasons why discharge times didn’t shift as much as discharge order times could be that nurses were holding off on discharges or perhaps patients were staying for meals, he speculated.

Another possibility, albeit doubtful, he said, is that the residents were gaming the system which he explains this way: "If you discharge all your patients in the morning, and then cancel discharges, you’ll have lots of discharge orders in the morning and win the prize, even though patients don’t leave earlier."

As the project continues, unit directors will now assess and prioritize potential discharges with staff after interdisciplinary rounds, he said.

Mount Sinai Medical Center had 57,913 discharges in 2011, approximately one-fifth of which were from medical services. The hospital typically operates at approximately 80% capacity.

Improving "throughput" can help maintain a high volume in the face of limited inpatient capacity, Dr. Jervis said. Earlier discharges may free up inpatient beds, decrease strain on crowded emergency departments, and provide timely inpatient care to patients admitted from the emergency room.

The timing of discharge orders often has been considered to be the main factor in the timing of patient discharge, but this assumption had not been tested until the current study, he said.

Dr. Jervis did not report his financial disclosures.

SAN DIEGO – Moving the timing of discharge orders from afternoon to morning did not get patients out the door earlier in the day in a study at Mount Sinai Medical Center, New York.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times," Dr. Ramiro Jervis said at the annual meeting of the Society of Hospital Medicine.

After 6 months of employing multiple strategies to get discharge orders written before 11 a.m., the mean time of discharge orders for patients on medical wards improved by 78 minutes, from 1 p.m. to before noon, but patients left the hospital only 12 minutes earlier on average, closer to 4 p.m., said Dr. Jervis, director of the quality hospitalist division at the medical center.

Results were similar for teaching and nonteaching services at the 1,171-bed tertiary-care urban teaching facility.

To determine why patients didn’t leave earlier, Dr. Jervis reviewed 51 charts for patients discharged after 3 p.m. from a teaching medicine unit during a 30-day period, with those discharges happening more than 4 hours after the actual discharge order.

In about 63% of those cases, the hospital had to arrange transportation for the patient, which may have delayed discharge. Sixteen percent of patients were awaiting family, and approximately 16% had tests pending. Some 4% were awaiting a physician or consultant.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times."

The hospital will continue to offer incentives to physicians for discharge orders to be completed before 11 a.m. and will prospectively investigate why patients don’t leave soon after the orders are given, Dr. Jervis said. The investigators also plan to add incentives for nurses, social workers, and patients for early discharges.

Dr. Jervis and his associates received an honorable mention from judges picking the best research presentation at the meeting.

The medicine service at the hospital handles 1,000 discharges per month, excluding interventional cardiology. To shift the timing of discharge orders, the study organized discussions and recording of discharge order times at resident reports each morning. House staff and hospitalists received weekly feedback. Each month, the two top-performing teaching teams received awards – such as $30 gift cards for house staff members – for completing earlier discharge orders.

In addition, organization of medical teams shifted to geographic localization. Providers participated in daily interdisciplinary rounds. Teaching rounds were moved to afternoons so that the morning focus would be on work rounds, Dr. Jervis said.

Other potential reasons why discharge times didn’t shift as much as discharge order times could be that nurses were holding off on discharges or perhaps patients were staying for meals, he speculated.

Another possibility, albeit doubtful, he said, is that the residents were gaming the system which he explains this way: "If you discharge all your patients in the morning, and then cancel discharges, you’ll have lots of discharge orders in the morning and win the prize, even though patients don’t leave earlier."

As the project continues, unit directors will now assess and prioritize potential discharges with staff after interdisciplinary rounds, he said.

Mount Sinai Medical Center had 57,913 discharges in 2011, approximately one-fifth of which were from medical services. The hospital typically operates at approximately 80% capacity.

Improving "throughput" can help maintain a high volume in the face of limited inpatient capacity, Dr. Jervis said. Earlier discharges may free up inpatient beds, decrease strain on crowded emergency departments, and provide timely inpatient care to patients admitted from the emergency room.

The timing of discharge orders often has been considered to be the main factor in the timing of patient discharge, but this assumption had not been tested until the current study, he said.

Dr. Jervis did not report his financial disclosures.

SAN DIEGO – Moving the timing of discharge orders from afternoon to morning did not get patients out the door earlier in the day in a study at Mount Sinai Medical Center, New York.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times," Dr. Ramiro Jervis said at the annual meeting of the Society of Hospital Medicine.

After 6 months of employing multiple strategies to get discharge orders written before 11 a.m., the mean time of discharge orders for patients on medical wards improved by 78 minutes, from 1 p.m. to before noon, but patients left the hospital only 12 minutes earlier on average, closer to 4 p.m., said Dr. Jervis, director of the quality hospitalist division at the medical center.

Results were similar for teaching and nonteaching services at the 1,171-bed tertiary-care urban teaching facility.

To determine why patients didn’t leave earlier, Dr. Jervis reviewed 51 charts for patients discharged after 3 p.m. from a teaching medicine unit during a 30-day period, with those discharges happening more than 4 hours after the actual discharge order.

In about 63% of those cases, the hospital had to arrange transportation for the patient, which may have delayed discharge. Sixteen percent of patients were awaiting family, and approximately 16% had tests pending. Some 4% were awaiting a physician or consultant.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times."

The hospital will continue to offer incentives to physicians for discharge orders to be completed before 11 a.m. and will prospectively investigate why patients don’t leave soon after the orders are given, Dr. Jervis said. The investigators also plan to add incentives for nurses, social workers, and patients for early discharges.

Dr. Jervis and his associates received an honorable mention from judges picking the best research presentation at the meeting.

The medicine service at the hospital handles 1,000 discharges per month, excluding interventional cardiology. To shift the timing of discharge orders, the study organized discussions and recording of discharge order times at resident reports each morning. House staff and hospitalists received weekly feedback. Each month, the two top-performing teaching teams received awards – such as $30 gift cards for house staff members – for completing earlier discharge orders.

In addition, organization of medical teams shifted to geographic localization. Providers participated in daily interdisciplinary rounds. Teaching rounds were moved to afternoons so that the morning focus would be on work rounds, Dr. Jervis said.

Other potential reasons why discharge times didn’t shift as much as discharge order times could be that nurses were holding off on discharges or perhaps patients were staying for meals, he speculated.

Another possibility, albeit doubtful, he said, is that the residents were gaming the system which he explains this way: "If you discharge all your patients in the morning, and then cancel discharges, you’ll have lots of discharge orders in the morning and win the prize, even though patients don’t leave earlier."

As the project continues, unit directors will now assess and prioritize potential discharges with staff after interdisciplinary rounds, he said.

Mount Sinai Medical Center had 57,913 discharges in 2011, approximately one-fifth of which were from medical services. The hospital typically operates at approximately 80% capacity.

Improving "throughput" can help maintain a high volume in the face of limited inpatient capacity, Dr. Jervis said. Earlier discharges may free up inpatient beds, decrease strain on crowded emergency departments, and provide timely inpatient care to patients admitted from the emergency room.

The timing of discharge orders often has been considered to be the main factor in the timing of patient discharge, but this assumption had not been tested until the current study, he said.

Dr. Jervis did not report his financial disclosures.