Clinical question: What is the benefit of routine colonic evaluation after an episode of acute diverticulitis?

Background: Currently accepted guidelines recommend routine colonic evaluation (colonoscopy, computed tomography (CT) colonography) after an episode of acute diverticulitis to confirm the diagnosis and exclude malignancy. Increased use of CT to confirm the diagnosis of acute diverticulitis and exclude associated complications has brought into question the recommendation for routine colonic evaluation after an episode of acute diverticulitis.

Study design: Meta-analysis.

Setting: Search of online databases and the Cochrane Library.

Synopsis: Eleven studies from seven countries included 1,970 patients who had a colonic evaluation after an episode of acute diverticulitis. The risk of finding a malignancy was 1.6%. Within this population, 1,497 patients were identified as having uncomplicated diverticulitis. Cancer was found in only five patients (proportional risk estimate 0.7%).

For the 79 patients identified as having complicated diverticulitis, the risk of finding a malignancy on subsequent screening was 10.8%.

Every systematic review is limited by the quality of the studies available for review and the differences in design and methodology of the studies. In this meta-analysis, the risk of finding cancer after an episode of uncomplicated diverticulitis appears to be low. Given the limited resources of the healthcare system and the small but real risk of morbidity and mortality associated with invasive colonic procedures, the routine recommendation for colon cancer screening after an episode of acute uncomplicated diverticulitis should be further evaluated.

Bottom line: The risk of malignancy after a radiologically proven episode of acute uncomplicated diverticulitis is low. In the absence of other indications, additional routine colonic evaluation may not be necessary.

Citation: Sharma PV, Eglinton T, Hider P, Frizelle F. Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg. 2014;259(2):263-272.

Clinical question: What is the benefit of routine colonic evaluation after an episode of acute diverticulitis?

Background: Currently accepted guidelines recommend routine colonic evaluation (colonoscopy, computed tomography (CT) colonography) after an episode of acute diverticulitis to confirm the diagnosis and exclude malignancy. Increased use of CT to confirm the diagnosis of acute diverticulitis and exclude associated complications has brought into question the recommendation for routine colonic evaluation after an episode of acute diverticulitis.

Study design: Meta-analysis.

Setting: Search of online databases and the Cochrane Library.

Synopsis: Eleven studies from seven countries included 1,970 patients who had a colonic evaluation after an episode of acute diverticulitis. The risk of finding a malignancy was 1.6%. Within this population, 1,497 patients were identified as having uncomplicated diverticulitis. Cancer was found in only five patients (proportional risk estimate 0.7%).

For the 79 patients identified as having complicated diverticulitis, the risk of finding a malignancy on subsequent screening was 10.8%.

Every systematic review is limited by the quality of the studies available for review and the differences in design and methodology of the studies. In this meta-analysis, the risk of finding cancer after an episode of uncomplicated diverticulitis appears to be low. Given the limited resources of the healthcare system and the small but real risk of morbidity and mortality associated with invasive colonic procedures, the routine recommendation for colon cancer screening after an episode of acute uncomplicated diverticulitis should be further evaluated.

Bottom line: The risk of malignancy after a radiologically proven episode of acute uncomplicated diverticulitis is low. In the absence of other indications, additional routine colonic evaluation may not be necessary.

Citation: Sharma PV, Eglinton T, Hider P, Frizelle F. Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg. 2014;259(2):263-272.

Clinical question: What is the benefit of routine colonic evaluation after an episode of acute diverticulitis?

Background: Currently accepted guidelines recommend routine colonic evaluation (colonoscopy, computed tomography (CT) colonography) after an episode of acute diverticulitis to confirm the diagnosis and exclude malignancy. Increased use of CT to confirm the diagnosis of acute diverticulitis and exclude associated complications has brought into question the recommendation for routine colonic evaluation after an episode of acute diverticulitis.

Study design: Meta-analysis.

Setting: Search of online databases and the Cochrane Library.

Synopsis: Eleven studies from seven countries included 1,970 patients who had a colonic evaluation after an episode of acute diverticulitis. The risk of finding a malignancy was 1.6%. Within this population, 1,497 patients were identified as having uncomplicated diverticulitis. Cancer was found in only five patients (proportional risk estimate 0.7%).

For the 79 patients identified as having complicated diverticulitis, the risk of finding a malignancy on subsequent screening was 10.8%.

Every systematic review is limited by the quality of the studies available for review and the differences in design and methodology of the studies. In this meta-analysis, the risk of finding cancer after an episode of uncomplicated diverticulitis appears to be low. Given the limited resources of the healthcare system and the small but real risk of morbidity and mortality associated with invasive colonic procedures, the routine recommendation for colon cancer screening after an episode of acute uncomplicated diverticulitis should be further evaluated.

Bottom line: The risk of malignancy after a radiologically proven episode of acute uncomplicated diverticulitis is low. In the absence of other indications, additional routine colonic evaluation may not be necessary.

Citation: Sharma PV, Eglinton T, Hider P, Frizelle F. Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg. 2014;259(2):263-272.

Clinical question: Does an intervention involving a facilitated physician small group result in improvement in well-being and reduction in burnout?

Background: Burnout affects nearly half of medical students, residents, and practicing physicians in the U.S.; however, very few interventions have been tested to address this problem.

Study design: Randomized controlled trial (RCT).

Setting: Department of Medicine at the Mayo Clinic, Rochester, Minn.

Synopsis: Practicing physicians were randomly assigned to facilitated, small-group intervention curriculum for one hour every two weeks (N=37) or control with unstructured, protected time for one hour every two weeks (N=37). A non-trial cohort of 350 practicing physicians was surveyed annually. This study showed a significant increase in empowerment and engagement at three months that was sustained for 12 months, and a significant decrease in high depersonalization scores was seen at both three and 12 months in the intervention group. There were no significant differences in stress, depression, quality of life, or job satisfaction.

Compared to the non-trial cohort, depersonalization, emotional exhaustion, and overall burnout decreased substantially in the intervention arm and slightly in the control arm.

Sample size was small and results may not be generalizable. Topics covered included reflection, self-awareness, and mindfulness, with a combination of community building and skill acquisition to promote connectedness and meaning in work. It is not clear which elements of the curriculum were most effective.

Bottom line: A facilitated, small-group intervention with institution-provided protected time can improve physician empowerment and engagement and reduce depersonalization, an important component of burnout.

Citation: West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.

Clinical question: Does an intervention involving a facilitated physician small group result in improvement in well-being and reduction in burnout?

Background: Burnout affects nearly half of medical students, residents, and practicing physicians in the U.S.; however, very few interventions have been tested to address this problem.

Study design: Randomized controlled trial (RCT).

Setting: Department of Medicine at the Mayo Clinic, Rochester, Minn.

Synopsis: Practicing physicians were randomly assigned to facilitated, small-group intervention curriculum for one hour every two weeks (N=37) or control with unstructured, protected time for one hour every two weeks (N=37). A non-trial cohort of 350 practicing physicians was surveyed annually. This study showed a significant increase in empowerment and engagement at three months that was sustained for 12 months, and a significant decrease in high depersonalization scores was seen at both three and 12 months in the intervention group. There were no significant differences in stress, depression, quality of life, or job satisfaction.

Compared to the non-trial cohort, depersonalization, emotional exhaustion, and overall burnout decreased substantially in the intervention arm and slightly in the control arm.

Sample size was small and results may not be generalizable. Topics covered included reflection, self-awareness, and mindfulness, with a combination of community building and skill acquisition to promote connectedness and meaning in work. It is not clear which elements of the curriculum were most effective.

Bottom line: A facilitated, small-group intervention with institution-provided protected time can improve physician empowerment and engagement and reduce depersonalization, an important component of burnout.

Citation: West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.

Clinical question: Does an intervention involving a facilitated physician small group result in improvement in well-being and reduction in burnout?

Background: Burnout affects nearly half of medical students, residents, and practicing physicians in the U.S.; however, very few interventions have been tested to address this problem.

Study design: Randomized controlled trial (RCT).

Setting: Department of Medicine at the Mayo Clinic, Rochester, Minn.

Synopsis: Practicing physicians were randomly assigned to facilitated, small-group intervention curriculum for one hour every two weeks (N=37) or control with unstructured, protected time for one hour every two weeks (N=37). A non-trial cohort of 350 practicing physicians was surveyed annually. This study showed a significant increase in empowerment and engagement at three months that was sustained for 12 months, and a significant decrease in high depersonalization scores was seen at both three and 12 months in the intervention group. There were no significant differences in stress, depression, quality of life, or job satisfaction.

Compared to the non-trial cohort, depersonalization, emotional exhaustion, and overall burnout decreased substantially in the intervention arm and slightly in the control arm.

Sample size was small and results may not be generalizable. Topics covered included reflection, self-awareness, and mindfulness, with a combination of community building and skill acquisition to promote connectedness and meaning in work. It is not clear which elements of the curriculum were most effective.

Bottom line: A facilitated, small-group intervention with institution-provided protected time can improve physician empowerment and engagement and reduce depersonalization, an important component of burnout.

Citation: West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.

Financial pressures to reduce 30-day hospital readmissions and improve discharge processes continue to grow. The Centers for Medicare and Medicaid Services started by penalizing hospitals for up to 1% of their Medicare reimbursement via the Hospital Readmissions Reduction Program. By 2015, the program will penalize hospitals up to 3%.

This is no longer news to the hospital C-suite. A 2013 survey reported that 85% of hospital leaders had addressed the readmissions penalty in their business plan (http://content.hcpro.com/pdf/content/296905.pdf); however, the same survey revealed that only 62% of hospital leaders reported changes to clinical protocols and practices during acute care, and even fewer were providing care navigators or coaches for high-risk patients.

That’s where hospitalists can help. Through SHM’s Project BOOST, hospitalists and hospital-based care teams improve transition from hospital to home. Project BOOST also helps hospitals identify high-risk patients and target risk-specific interventions, a critical part of reducing readmissions.

Beyond the immediate financial implications, implementing programs like Project BOOST to reduce readmissions can position hospitals as leaders for better healthcare in their communities.

“I recommend Project BOOST enthusiastically and unequivocally,” says Manasi Kekan, MD, MS, FACP, medical director for Houston Methodist Hospital. “If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers.”

SHM is accepting applications for the 2014 Project BOOST cohort through August 30. For details and application, visit www.hospitalmedicine.org/boost.

Financial pressures to reduce 30-day hospital readmissions and improve discharge processes continue to grow. The Centers for Medicare and Medicaid Services started by penalizing hospitals for up to 1% of their Medicare reimbursement via the Hospital Readmissions Reduction Program. By 2015, the program will penalize hospitals up to 3%.

This is no longer news to the hospital C-suite. A 2013 survey reported that 85% of hospital leaders had addressed the readmissions penalty in their business plan (http://content.hcpro.com/pdf/content/296905.pdf); however, the same survey revealed that only 62% of hospital leaders reported changes to clinical protocols and practices during acute care, and even fewer were providing care navigators or coaches for high-risk patients.

That’s where hospitalists can help. Through SHM’s Project BOOST, hospitalists and hospital-based care teams improve transition from hospital to home. Project BOOST also helps hospitals identify high-risk patients and target risk-specific interventions, a critical part of reducing readmissions.

Beyond the immediate financial implications, implementing programs like Project BOOST to reduce readmissions can position hospitals as leaders for better healthcare in their communities.

“I recommend Project BOOST enthusiastically and unequivocally,” says Manasi Kekan, MD, MS, FACP, medical director for Houston Methodist Hospital. “If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers.”

SHM is accepting applications for the 2014 Project BOOST cohort through August 30. For details and application, visit www.hospitalmedicine.org/boost.

Financial pressures to reduce 30-day hospital readmissions and improve discharge processes continue to grow. The Centers for Medicare and Medicaid Services started by penalizing hospitals for up to 1% of their Medicare reimbursement via the Hospital Readmissions Reduction Program. By 2015, the program will penalize hospitals up to 3%.

This is no longer news to the hospital C-suite. A 2013 survey reported that 85% of hospital leaders had addressed the readmissions penalty in their business plan (http://content.hcpro.com/pdf/content/296905.pdf); however, the same survey revealed that only 62% of hospital leaders reported changes to clinical protocols and practices during acute care, and even fewer were providing care navigators or coaches for high-risk patients.

That’s where hospitalists can help. Through SHM’s Project BOOST, hospitalists and hospital-based care teams improve transition from hospital to home. Project BOOST also helps hospitals identify high-risk patients and target risk-specific interventions, a critical part of reducing readmissions.

Beyond the immediate financial implications, implementing programs like Project BOOST to reduce readmissions can position hospitals as leaders for better healthcare in their communities.

“I recommend Project BOOST enthusiastically and unequivocally,” says Manasi Kekan, MD, MS, FACP, medical director for Houston Methodist Hospital. “If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers.”

SHM is accepting applications for the 2014 Project BOOST cohort through August 30. For details and application, visit www.hospitalmedicine.org/boost.

With more than 44,000 hospitalists nationwide, HM continues to grow and change faster than any other medical specialty. That change can be dizzying for academic hospitalists, especially those at the beginning of their careers.

Academic Hospitalist Academy (www.academichospitalist.org), now in its sixth year, helps academic hospitalists map out a rewarding and productive career path in education and scholarship. The academy helps hospitalists:

1. Learn how to be effective teachers;
2. Understand the process necessary to create and disseminate scholarly work;
3. Become aware of the basics of promotion within an academic institution;
4. Ascertain the skills necessary to be an asset to their academic institutions;
5. Engage the skills necessary to actively participate in a mentor-mentee relationship;
6. Understand the business drivers of healthcare; and
7. Learn the basics of quality improvement and patient safety.

Academic Hospitalist Academy is an intensive, four-day program that provides a diverse array of learning formats, including didactic sessions, small-group exercises, and skill-building breakout sessions, all facilitated by leaders in the field, with small faculty-to-student ratios. The agenda also includes time for networking activities.

According to a 2013 survey of academy attendees, 100% rated it positively and 99% said they would recommend it to their colleagues.

Tuition is $2,250 for registration before Oct. 13 and $2,500 thereafter.

Academic Hospitalist Academy is co-sponsored by SHM, the Society of General Internal Medicine and the Association of Chiefs and Leaders of General Internal Medicine.

With more than 44,000 hospitalists nationwide, HM continues to grow and change faster than any other medical specialty. That change can be dizzying for academic hospitalists, especially those at the beginning of their careers.

Academic Hospitalist Academy (www.academichospitalist.org), now in its sixth year, helps academic hospitalists map out a rewarding and productive career path in education and scholarship. The academy helps hospitalists:

1. Learn how to be effective teachers;
2. Understand the process necessary to create and disseminate scholarly work;
3. Become aware of the basics of promotion within an academic institution;
4. Ascertain the skills necessary to be an asset to their academic institutions;
5. Engage the skills necessary to actively participate in a mentor-mentee relationship;
6. Understand the business drivers of healthcare; and
7. Learn the basics of quality improvement and patient safety.

Academic Hospitalist Academy is an intensive, four-day program that provides a diverse array of learning formats, including didactic sessions, small-group exercises, and skill-building breakout sessions, all facilitated by leaders in the field, with small faculty-to-student ratios. The agenda also includes time for networking activities.

According to a 2013 survey of academy attendees, 100% rated it positively and 99% said they would recommend it to their colleagues.

Tuition is $2,250 for registration before Oct. 13 and $2,500 thereafter.

Academic Hospitalist Academy is co-sponsored by SHM, the Society of General Internal Medicine and the Association of Chiefs and Leaders of General Internal Medicine.

With more than 44,000 hospitalists nationwide, HM continues to grow and change faster than any other medical specialty. That change can be dizzying for academic hospitalists, especially those at the beginning of their careers.

Academic Hospitalist Academy (www.academichospitalist.org), now in its sixth year, helps academic hospitalists map out a rewarding and productive career path in education and scholarship. The academy helps hospitalists:

1. Learn how to be effective teachers;
2. Understand the process necessary to create and disseminate scholarly work;
3. Become aware of the basics of promotion within an academic institution;
4. Ascertain the skills necessary to be an asset to their academic institutions;
5. Engage the skills necessary to actively participate in a mentor-mentee relationship;
6. Understand the business drivers of healthcare; and
7. Learn the basics of quality improvement and patient safety.

Academic Hospitalist Academy is an intensive, four-day program that provides a diverse array of learning formats, including didactic sessions, small-group exercises, and skill-building breakout sessions, all facilitated by leaders in the field, with small faculty-to-student ratios. The agenda also includes time for networking activities.

According to a 2013 survey of academy attendees, 100% rated it positively and 99% said they would recommend it to their colleagues.

Tuition is $2,250 for registration before Oct. 13 and $2,500 thereafter.

Academic Hospitalist Academy is co-sponsored by SHM, the Society of General Internal Medicine and the Association of Chiefs and Leaders of General Internal Medicine.

Safety and Brazilian Hospital

Medicine 2014

August 6-8

Rio de Janeiro, Brazil

[email protected]

SHM’s Glycemic Control Program Informational Webinar

August 14, 2 p.m.

https://www4.gotomeeting.com/register/907579183

Palliative Medicine and Supportive Oncology 2014, The 17th International Symposium

September 18-20

Green Valley Ranch, Las Vegas

www.ccfcme.org/PM

Society of OB/GYN Hospitalists Annual Clinical Meeting OB/GYN Hospitalists: Recognition, Response, Results

September 18-20

Embassy Suites Downtown, Denver

www.societyofobgynhospitalists.com

Academic Hospitalist Academy

October 20-23

Inverness Hotel and Conference

Center, Englewood, Colo.

www.academichospitalist.org

Adult Hospital Medicine Boot Camp

October 1-5

The Westin Peachtree Plaza, Atlanta, Ga.

www.aapa.org/bootcamp

SHM Leadership Academy

November 3-6

Hilton Hawaiian Village Waikiki Beach Resort, Honolulu

www.hospitalmedicine.org/leadership

Hospital Medicine 2015

March 29-April 1, 2015

Gaylord National Resort & Convention Center, National Harbor, Md.

www.hospitalmedicine2015.org

Safety and Brazilian Hospital

Medicine 2014

August 6-8

Rio de Janeiro, Brazil

[email protected]

SHM’s Glycemic Control Program Informational Webinar

August 14, 2 p.m.

https://www4.gotomeeting.com/register/907579183

Palliative Medicine and Supportive Oncology 2014, The 17th International Symposium

September 18-20

Green Valley Ranch, Las Vegas

www.ccfcme.org/PM

Society of OB/GYN Hospitalists Annual Clinical Meeting OB/GYN Hospitalists: Recognition, Response, Results

September 18-20

Embassy Suites Downtown, Denver

www.societyofobgynhospitalists.com

Academic Hospitalist Academy

October 20-23

Inverness Hotel and Conference

Center, Englewood, Colo.

www.academichospitalist.org

Adult Hospital Medicine Boot Camp

October 1-5

The Westin Peachtree Plaza, Atlanta, Ga.

www.aapa.org/bootcamp

SHM Leadership Academy

November 3-6

Hilton Hawaiian Village Waikiki Beach Resort, Honolulu

www.hospitalmedicine.org/leadership

Hospital Medicine 2015

March 29-April 1, 2015

Gaylord National Resort & Convention Center, National Harbor, Md.

www.hospitalmedicine2015.org

Safety and Brazilian Hospital

Medicine 2014

August 6-8

Rio de Janeiro, Brazil

[email protected]

SHM’s Glycemic Control Program Informational Webinar

August 14, 2 p.m.

https://www4.gotomeeting.com/register/907579183

Palliative Medicine and Supportive Oncology 2014, The 17th International Symposium

September 18-20

Green Valley Ranch, Las Vegas

www.ccfcme.org/PM

Society of OB/GYN Hospitalists Annual Clinical Meeting OB/GYN Hospitalists: Recognition, Response, Results

September 18-20

Embassy Suites Downtown, Denver

www.societyofobgynhospitalists.com

Academic Hospitalist Academy

October 20-23

Inverness Hotel and Conference

Center, Englewood, Colo.

www.academichospitalist.org

Adult Hospital Medicine Boot Camp

October 1-5

The Westin Peachtree Plaza, Atlanta, Ga.

www.aapa.org/bootcamp

SHM Leadership Academy

November 3-6

Hilton Hawaiian Village Waikiki Beach Resort, Honolulu

www.hospitalmedicine.org/leadership

Hospital Medicine 2015

March 29-April 1, 2015

Gaylord National Resort & Convention Center, National Harbor, Md.

www.hospitalmedicine2015.org

Illustrative case
A healthy neonate is born through clear amniotic fluid with no meconium. She is vigorous and has no major congenital anomalies. Does she need oronasopharyngeal suctioning?

No, she does not need suctioning. Although it is still standard practice to perform oronasopharyngeal suctioning with a bulb syringe immediately after delivery, multiple studies have found no benefit to routine suctioning.^2-7 Guidelines from the Neonatal Resuscitation Program (NRP) and other organizations recommend against the practice, even for neonates born through meconium-stained amniotic fluid.^8,9 Suctioning is done because some clinicians believe it reduces the risk of aspiration, especially if there is meconium, and to stimulate breathing, but the evidence suggests that suctioning can stimulate the vagus nerve, which can lead to bradycardia.² Studies that compared babies who did and didn’t receive suctioning found that those who received it had lower Apgar scores and oxygen saturation levels.^2-4

Wiping the neonate’s mouth and nose with a towel is an alternative to suctioning, but until now no trials have compared the outcomes of these 2 methods. Kelleher et al¹ conducted an equivalency trial to determine if wiping the mouth and nose is as effective as oronasopharyngeal suctioning.

STUDY SUMMARY: No difference in breathing 
after wiping or suctioning

Kelleher et al¹ studied neonates born after at least 35 weeks gestation, excluding those who had major congenital anomalies or were non-vigorous (depressed muscle tone or respiration, heart rate <100 beats/min, or both) and born into meconium-stained amniotic fluid, as well as those whom they anticipated would need advanced resuscitation. Neonates were randomly assigned to receive either oronasopharyngeal suctioning with a bulb syringe or wiping of the face and mouth with a towel, starting immediately after the umbilical cord was cut and lasting as long as needed while in the delivery room. The primary outcome was the mean respiratory rate in the first 24 hours after birth. The predefined range of clinical equivalence between the 2 groups was a respiratory rate within 4 breaths/min.

Of 506 neonates randomized, 15 were excluded because they were not vigorous and had meconium-stained fluid, and 3 were excluded when their parents withdrew consent. Baseline characteristics for the 2 groups—including maternal age, presence of chronic medical conditions, and body mass index; vaginal vs cesarean delivery; umbilical artery pH; and neonatal sex, ethnic origin, and birth weight—were similar.

In the first 24 hours after birth, the average respiratory rate in the wiping group was 51 breaths/min (standard deviation [SD] ± 8) vs 50 breaths/min (SD ± 6) in the suctioning group. There was no difference in respiratory rates between the 2 groups at 1, 8, or 16 hours after birth. There was also no difference between the 2 groups in Apgar scores or need for advanced resuscitation. More neonates in the wiping group than in the suctioning group were admitted to the neonatal intensive care unit (45 of 246 [18%] vs 30 of 242 [12%]; P=.07), but the study was not powered to assess this outcome.

WHAT'S NEW: Wiping is as effective as suctioning,
 but there are no adverse effects

This study gives us evidence that wiping the face, mouth, and nose is equivalent to suctioning newborns at delivery, and it supports the NRP recommendation against routine suctioning in vigorous neonates born at term. Wiping avoids the potential adverse effects on the respiratory mucosa, bradycardia, and lower Apgar scores associated with suctioning via bulb syringes.

CAVEATS: Wiping is not best 
if a neonate’s airway is obstructed

This study looked only at neonates born after 35 weeks’ gestation who did not have meconium-stained amniotic fluid or congenital abnormalities. Also, NRP guidelines do recommend clearing the airways with a bulb syringe or suction catheter if airway obstruction is evident or positive-pressure ventilation is required.⁸

Another caveat ... In this study,¹ there were 98 treatment crossovers: 64 of the 246 neonates in the wiping group received suctioning, and 34 of the 242 neonates in the suctioning group received wiping. However, this was not likely to change the study’s overall conclusion because a per-treatment analysis also found that wiping and suctioning were equivalent.

CHALLENGES TO IMPLEMENTATION: “We’ve always done it this way”
Practice patterns in a delivery room can be difficult to change. As we work on improving our delivery room environment and changing ingrained habits, the evidence from this study should help support the use of wiping in place of suctioning. The transition from suctioning to wiping also would be facilitated by having easily accessible towels designated for wiping.

 

Acknowledgement
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

PURL METHODOLOGY

…..

Illustrative case
A healthy neonate is born through clear amniotic fluid with no meconium. She is vigorous and has no major congenital anomalies. Does she need oronasopharyngeal suctioning?

No, she does not need suctioning. Although it is still standard practice to perform oronasopharyngeal suctioning with a bulb syringe immediately after delivery, multiple studies have found no benefit to routine suctioning.^2-7 Guidelines from the Neonatal Resuscitation Program (NRP) and other organizations recommend against the practice, even for neonates born through meconium-stained amniotic fluid.^8,9 Suctioning is done because some clinicians believe it reduces the risk of aspiration, especially if there is meconium, and to stimulate breathing, but the evidence suggests that suctioning can stimulate the vagus nerve, which can lead to bradycardia.² Studies that compared babies who did and didn’t receive suctioning found that those who received it had lower Apgar scores and oxygen saturation levels.^2-4

Wiping the neonate’s mouth and nose with a towel is an alternative to suctioning, but until now no trials have compared the outcomes of these 2 methods. Kelleher et al¹ conducted an equivalency trial to determine if wiping the mouth and nose is as effective as oronasopharyngeal suctioning.

STUDY SUMMARY: No difference in breathing 
after wiping or suctioning

Kelleher et al¹ studied neonates born after at least 35 weeks gestation, excluding those who had major congenital anomalies or were non-vigorous (depressed muscle tone or respiration, heart rate <100 beats/min, or both) and born into meconium-stained amniotic fluid, as well as those whom they anticipated would need advanced resuscitation. Neonates were randomly assigned to receive either oronasopharyngeal suctioning with a bulb syringe or wiping of the face and mouth with a towel, starting immediately after the umbilical cord was cut and lasting as long as needed while in the delivery room. The primary outcome was the mean respiratory rate in the first 24 hours after birth. The predefined range of clinical equivalence between the 2 groups was a respiratory rate within 4 breaths/min.

Of 506 neonates randomized, 15 were excluded because they were not vigorous and had meconium-stained fluid, and 3 were excluded when their parents withdrew consent. Baseline characteristics for the 2 groups—including maternal age, presence of chronic medical conditions, and body mass index; vaginal vs cesarean delivery; umbilical artery pH; and neonatal sex, ethnic origin, and birth weight—were similar.

In the first 24 hours after birth, the average respiratory rate in the wiping group was 51 breaths/min (standard deviation [SD] ± 8) vs 50 breaths/min (SD ± 6) in the suctioning group. There was no difference in respiratory rates between the 2 groups at 1, 8, or 16 hours after birth. There was also no difference between the 2 groups in Apgar scores or need for advanced resuscitation. More neonates in the wiping group than in the suctioning group were admitted to the neonatal intensive care unit (45 of 246 [18%] vs 30 of 242 [12%]; P=.07), but the study was not powered to assess this outcome.

WHAT'S NEW: Wiping is as effective as suctioning,
 but there are no adverse effects

This study gives us evidence that wiping the face, mouth, and nose is equivalent to suctioning newborns at delivery, and it supports the NRP recommendation against routine suctioning in vigorous neonates born at term. Wiping avoids the potential adverse effects on the respiratory mucosa, bradycardia, and lower Apgar scores associated with suctioning via bulb syringes.

CAVEATS: Wiping is not best 
if a neonate’s airway is obstructed

This study looked only at neonates born after 35 weeks’ gestation who did not have meconium-stained amniotic fluid or congenital abnormalities. Also, NRP guidelines do recommend clearing the airways with a bulb syringe or suction catheter if airway obstruction is evident or positive-pressure ventilation is required.⁸

Another caveat ... In this study,¹ there were 98 treatment crossovers: 64 of the 246 neonates in the wiping group received suctioning, and 34 of the 242 neonates in the suctioning group received wiping. However, this was not likely to change the study’s overall conclusion because a per-treatment analysis also found that wiping and suctioning were equivalent.

CHALLENGES TO IMPLEMENTATION: “We’ve always done it this way”
Practice patterns in a delivery room can be difficult to change. As we work on improving our delivery room environment and changing ingrained habits, the evidence from this study should help support the use of wiping in place of suctioning. The transition from suctioning to wiping also would be facilitated by having easily accessible towels designated for wiping.

 

Acknowledgement
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

PURL METHODOLOGY

…..

Illustrative case
A healthy neonate is born through clear amniotic fluid with no meconium. She is vigorous and has no major congenital anomalies. Does she need oronasopharyngeal suctioning?

No, she does not need suctioning. Although it is still standard practice to perform oronasopharyngeal suctioning with a bulb syringe immediately after delivery, multiple studies have found no benefit to routine suctioning.^2-7 Guidelines from the Neonatal Resuscitation Program (NRP) and other organizations recommend against the practice, even for neonates born through meconium-stained amniotic fluid.^8,9 Suctioning is done because some clinicians believe it reduces the risk of aspiration, especially if there is meconium, and to stimulate breathing, but the evidence suggests that suctioning can stimulate the vagus nerve, which can lead to bradycardia.² Studies that compared babies who did and didn’t receive suctioning found that those who received it had lower Apgar scores and oxygen saturation levels.^2-4

Wiping the neonate’s mouth and nose with a towel is an alternative to suctioning, but until now no trials have compared the outcomes of these 2 methods. Kelleher et al¹ conducted an equivalency trial to determine if wiping the mouth and nose is as effective as oronasopharyngeal suctioning.

STUDY SUMMARY: No difference in breathing 
after wiping or suctioning

Kelleher et al¹ studied neonates born after at least 35 weeks gestation, excluding those who had major congenital anomalies or were non-vigorous (depressed muscle tone or respiration, heart rate <100 beats/min, or both) and born into meconium-stained amniotic fluid, as well as those whom they anticipated would need advanced resuscitation. Neonates were randomly assigned to receive either oronasopharyngeal suctioning with a bulb syringe or wiping of the face and mouth with a towel, starting immediately after the umbilical cord was cut and lasting as long as needed while in the delivery room. The primary outcome was the mean respiratory rate in the first 24 hours after birth. The predefined range of clinical equivalence between the 2 groups was a respiratory rate within 4 breaths/min.

Of 506 neonates randomized, 15 were excluded because they were not vigorous and had meconium-stained fluid, and 3 were excluded when their parents withdrew consent. Baseline characteristics for the 2 groups—including maternal age, presence of chronic medical conditions, and body mass index; vaginal vs cesarean delivery; umbilical artery pH; and neonatal sex, ethnic origin, and birth weight—were similar.

In the first 24 hours after birth, the average respiratory rate in the wiping group was 51 breaths/min (standard deviation [SD] ± 8) vs 50 breaths/min (SD ± 6) in the suctioning group. There was no difference in respiratory rates between the 2 groups at 1, 8, or 16 hours after birth. There was also no difference between the 2 groups in Apgar scores or need for advanced resuscitation. More neonates in the wiping group than in the suctioning group were admitted to the neonatal intensive care unit (45 of 246 [18%] vs 30 of 242 [12%]; P=.07), but the study was not powered to assess this outcome.

WHAT'S NEW: Wiping is as effective as suctioning,
 but there are no adverse effects

This study gives us evidence that wiping the face, mouth, and nose is equivalent to suctioning newborns at delivery, and it supports the NRP recommendation against routine suctioning in vigorous neonates born at term. Wiping avoids the potential adverse effects on the respiratory mucosa, bradycardia, and lower Apgar scores associated with suctioning via bulb syringes.

CAVEATS: Wiping is not best 
if a neonate’s airway is obstructed

This study looked only at neonates born after 35 weeks’ gestation who did not have meconium-stained amniotic fluid or congenital abnormalities. Also, NRP guidelines do recommend clearing the airways with a bulb syringe or suction catheter if airway obstruction is evident or positive-pressure ventilation is required.⁸

Another caveat ... In this study,¹ there were 98 treatment crossovers: 64 of the 246 neonates in the wiping group received suctioning, and 34 of the 242 neonates in the suctioning group received wiping. However, this was not likely to change the study’s overall conclusion because a per-treatment analysis also found that wiping and suctioning were equivalent.

CHALLENGES TO IMPLEMENTATION: “We’ve always done it this way”
Practice patterns in a delivery room can be difficult to change. As we work on improving our delivery room environment and changing ingrained habits, the evidence from this study should help support the use of wiping in place of suctioning. The transition from suctioning to wiping also would be facilitated by having easily accessible towels designated for wiping.

 

Acknowledgement
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

PURL METHODOLOGY

…..

 

Illustrative case

A healthy neonate is born through clear amniotic fluid with no meconium. She is vigorous and has no major congenital anomalies. Does she need oronasopharyngeal suctioning?

No, she does not need suctioning. Although it is still standard practice to perform oronasopharyngeal suctioning with a bulb syringe immediately after delivery, multiple studies have found no benefit to routine suctioning.^2-7 Guidelines from the Neonatal Resuscitation Program (NRP) and other organizations recommend against the practice, even for neonates born through meconium-stained amniotic fluid.^8,9 Suctioning is done because some clinicians believe it reduces the risk of aspiration, especially if there is meconium, and to stimulate breathing, but the evidence suggests that suctioning can stimulate the vagus nerve, which can lead to bradycardia.² Studies that compared babies who did and didn’t receive suctioning found that those who received it had lower Apgar scores and oxygen saturation levels.^2-4

Wiping the neonate’s mouth and nose with a towel is an alternative to suctioning, but until now no trials have compared the outcomes of these 2 methods. Kelleher et al¹ conducted an equivalency trial to determine if wiping the mouth and nose is as effective as oronasopharyngeal suctioning.

STUDY SUMMARY: No difference in breathing 
after wiping or suctioning


Kelleher et al¹ studied neonates born after at least 35 weeks gestation, excluding those who had major congenital anomalies or were non-vigorous (depressed muscle tone or respiration, heart rate <100 beats/min, or both) and born into meconium-stained amniotic fluid, as well as those whom they anticipated would need advanced resuscitation. Neonates were randomly assigned to receive either oronasopharyngeal suctioning with a bulb syringe or wiping of the face and mouth with a towel, starting immediately after the umbilical cord was cut and lasting as long as needed while in the delivery room. The primary outcome was the mean respiratory rate in the first 24 hours after birth. The predefined range of clinical equivalence between the 2 groups was a respiratory rate within 4 breaths/min.

Of 506 neonates randomized, 15 were excluded because they were not vigorous and had meconium-stained fluid, and 3 were excluded when their parents withdrew consent. Baseline characteristics for the 2 groups—including maternal age, presence of chronic medical conditions, and body mass index; vaginal vs cesarean delivery; umbilical artery pH; and neonatal sex, ethnic origin, and birth weight—were similar.

There was no difference in respiratory rates between the suctioning and wiping groups within the first 24 hours of birth. In the first 24 hours after birth, the average respiratory rate in the wiping group was 51 breaths/min (standard deviation [SD] ± 8) vs 50 breaths/min (SD ± 6) in the suctioning group. There was no difference in respiratory rates between the 2 groups at 1, 8, or 16 hours after birth. There was also no difference between the 2 groups in Apgar scores or need for advanced resuscitation. More neonates in the wiping group than in the suctioning group were admitted to the neonatal intensive care unit (45 of 246 [18%] vs 30 of 242 [12%]; P=.07), but the study was not powered to assess this outcome.

WHAT'S NEW: Wiping is as effective as suctioning,
 but there are no adverse effects


This study gives us evidence that wiping the face, mouth, and nose is equivalent to suctioning newborns at delivery, and it supports the NRP recommendation against routine suctioning in vigorous neonates born at term. Wiping avoids the potential adverse effects on the respiratory mucosa, bradycardia, and lower Apgar scores associated with suctioning via bulb syringes.

CAVEATS: Wiping is not best 
if a neonate’s airway is obstructed


This study looked only at neonates born after 35 weeks’ gestation who did not have meconium-stained amniotic fluid or congenital abnormalities. Also, NRP guidelines do recommend clearing the airways with a bulb syringe or suction catheter if airway obstruction is evident or positive-pressure ventilation is required.⁸

Another caveat ... In this study,¹ there were 98 treatment crossovers: 64 of the 246 neonates in the wiping group received suctioning, and 34 of the 242 neonates in the suctioning group received wiping. However, this was not likely to change the study’s overall conclusion because a per-treatment analysis also found that wiping and suctioning were equivalent.

 

CHALLENGES TO IMPLEMENTATION: “We’ve always done it this way”

Practice patterns in a delivery room can be difficult to change. As we work on improving our delivery room environment and changing ingrained habits, the evidence from this study should help support the use of wiping in place of suctioning. The transition from suctioning to wiping also would be facilitated by having easily accessible towels designated for wiping.

Acknowledgement
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

 

Illustrative case

A healthy neonate is born through clear amniotic fluid with no meconium. She is vigorous and has no major congenital anomalies. Does she need oronasopharyngeal suctioning?

No, she does not need suctioning. Although it is still standard practice to perform oronasopharyngeal suctioning with a bulb syringe immediately after delivery, multiple studies have found no benefit to routine suctioning.^2-7 Guidelines from the Neonatal Resuscitation Program (NRP) and other organizations recommend against the practice, even for neonates born through meconium-stained amniotic fluid.^8,9 Suctioning is done because some clinicians believe it reduces the risk of aspiration, especially if there is meconium, and to stimulate breathing, but the evidence suggests that suctioning can stimulate the vagus nerve, which can lead to bradycardia.² Studies that compared babies who did and didn’t receive suctioning found that those who received it had lower Apgar scores and oxygen saturation levels.^2-4

Wiping the neonate’s mouth and nose with a towel is an alternative to suctioning, but until now no trials have compared the outcomes of these 2 methods. Kelleher et al¹ conducted an equivalency trial to determine if wiping the mouth and nose is as effective as oronasopharyngeal suctioning.

STUDY SUMMARY: No difference in breathing 
after wiping or suctioning


Kelleher et al¹ studied neonates born after at least 35 weeks gestation, excluding those who had major congenital anomalies or were non-vigorous (depressed muscle tone or respiration, heart rate <100 beats/min, or both) and born into meconium-stained amniotic fluid, as well as those whom they anticipated would need advanced resuscitation. Neonates were randomly assigned to receive either oronasopharyngeal suctioning with a bulb syringe or wiping of the face and mouth with a towel, starting immediately after the umbilical cord was cut and lasting as long as needed while in the delivery room. The primary outcome was the mean respiratory rate in the first 24 hours after birth. The predefined range of clinical equivalence between the 2 groups was a respiratory rate within 4 breaths/min.

Of 506 neonates randomized, 15 were excluded because they were not vigorous and had meconium-stained fluid, and 3 were excluded when their parents withdrew consent. Baseline characteristics for the 2 groups—including maternal age, presence of chronic medical conditions, and body mass index; vaginal vs cesarean delivery; umbilical artery pH; and neonatal sex, ethnic origin, and birth weight—were similar.

There was no difference in respiratory rates between the suctioning and wiping groups within the first 24 hours of birth. In the first 24 hours after birth, the average respiratory rate in the wiping group was 51 breaths/min (standard deviation [SD] ± 8) vs 50 breaths/min (SD ± 6) in the suctioning group. There was no difference in respiratory rates between the 2 groups at 1, 8, or 16 hours after birth. There was also no difference between the 2 groups in Apgar scores or need for advanced resuscitation. More neonates in the wiping group than in the suctioning group were admitted to the neonatal intensive care unit (45 of 246 [18%] vs 30 of 242 [12%]; P=.07), but the study was not powered to assess this outcome.

WHAT'S NEW: Wiping is as effective as suctioning,
 but there are no adverse effects


This study gives us evidence that wiping the face, mouth, and nose is equivalent to suctioning newborns at delivery, and it supports the NRP recommendation against routine suctioning in vigorous neonates born at term. Wiping avoids the potential adverse effects on the respiratory mucosa, bradycardia, and lower Apgar scores associated with suctioning via bulb syringes.

CAVEATS: Wiping is not best 
if a neonate’s airway is obstructed


This study looked only at neonates born after 35 weeks’ gestation who did not have meconium-stained amniotic fluid or congenital abnormalities. Also, NRP guidelines do recommend clearing the airways with a bulb syringe or suction catheter if airway obstruction is evident or positive-pressure ventilation is required.⁸

Another caveat ... In this study,¹ there were 98 treatment crossovers: 64 of the 246 neonates in the wiping group received suctioning, and 34 of the 242 neonates in the suctioning group received wiping. However, this was not likely to change the study’s overall conclusion because a per-treatment analysis also found that wiping and suctioning were equivalent.

 

CHALLENGES TO IMPLEMENTATION: “We’ve always done it this way”

Practice patterns in a delivery room can be difficult to change. As we work on improving our delivery room environment and changing ingrained habits, the evidence from this study should help support the use of wiping in place of suctioning. The transition from suctioning to wiping also would be facilitated by having easily accessible towels designated for wiping.

Acknowledgement
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

 

Illustrative case

A healthy neonate is born through clear amniotic fluid with no meconium. She is vigorous and has no major congenital anomalies. Does she need oronasopharyngeal suctioning?

No, she does not need suctioning. Although it is still standard practice to perform oronasopharyngeal suctioning with a bulb syringe immediately after delivery, multiple studies have found no benefit to routine suctioning.^2-7 Guidelines from the Neonatal Resuscitation Program (NRP) and other organizations recommend against the practice, even for neonates born through meconium-stained amniotic fluid.^8,9 Suctioning is done because some clinicians believe it reduces the risk of aspiration, especially if there is meconium, and to stimulate breathing, but the evidence suggests that suctioning can stimulate the vagus nerve, which can lead to bradycardia.² Studies that compared babies who did and didn’t receive suctioning found that those who received it had lower Apgar scores and oxygen saturation levels.^2-4

Wiping the neonate’s mouth and nose with a towel is an alternative to suctioning, but until now no trials have compared the outcomes of these 2 methods. Kelleher et al¹ conducted an equivalency trial to determine if wiping the mouth and nose is as effective as oronasopharyngeal suctioning.

STUDY SUMMARY: No difference in breathing 
after wiping or suctioning


Kelleher et al¹ studied neonates born after at least 35 weeks gestation, excluding those who had major congenital anomalies or were non-vigorous (depressed muscle tone or respiration, heart rate <100 beats/min, or both) and born into meconium-stained amniotic fluid, as well as those whom they anticipated would need advanced resuscitation. Neonates were randomly assigned to receive either oronasopharyngeal suctioning with a bulb syringe or wiping of the face and mouth with a towel, starting immediately after the umbilical cord was cut and lasting as long as needed while in the delivery room. The primary outcome was the mean respiratory rate in the first 24 hours after birth. The predefined range of clinical equivalence between the 2 groups was a respiratory rate within 4 breaths/min.

Of 506 neonates randomized, 15 were excluded because they were not vigorous and had meconium-stained fluid, and 3 were excluded when their parents withdrew consent. Baseline characteristics for the 2 groups—including maternal age, presence of chronic medical conditions, and body mass index; vaginal vs cesarean delivery; umbilical artery pH; and neonatal sex, ethnic origin, and birth weight—were similar.

There was no difference in respiratory rates between the suctioning and wiping groups within the first 24 hours of birth. In the first 24 hours after birth, the average respiratory rate in the wiping group was 51 breaths/min (standard deviation [SD] ± 8) vs 50 breaths/min (SD ± 6) in the suctioning group. There was no difference in respiratory rates between the 2 groups at 1, 8, or 16 hours after birth. There was also no difference between the 2 groups in Apgar scores or need for advanced resuscitation. More neonates in the wiping group than in the suctioning group were admitted to the neonatal intensive care unit (45 of 246 [18%] vs 30 of 242 [12%]; P=.07), but the study was not powered to assess this outcome.

WHAT'S NEW: Wiping is as effective as suctioning,
 but there are no adverse effects


This study gives us evidence that wiping the face, mouth, and nose is equivalent to suctioning newborns at delivery, and it supports the NRP recommendation against routine suctioning in vigorous neonates born at term. Wiping avoids the potential adverse effects on the respiratory mucosa, bradycardia, and lower Apgar scores associated with suctioning via bulb syringes.

CAVEATS: Wiping is not best 
if a neonate’s airway is obstructed


This study looked only at neonates born after 35 weeks’ gestation who did not have meconium-stained amniotic fluid or congenital abnormalities. Also, NRP guidelines do recommend clearing the airways with a bulb syringe or suction catheter if airway obstruction is evident or positive-pressure ventilation is required.⁸

Another caveat ... In this study,¹ there were 98 treatment crossovers: 64 of the 246 neonates in the wiping group received suctioning, and 34 of the 242 neonates in the suctioning group received wiping. However, this was not likely to change the study’s overall conclusion because a per-treatment analysis also found that wiping and suctioning were equivalent.

 

CHALLENGES TO IMPLEMENTATION: “We’ve always done it this way”

Practice patterns in a delivery room can be difficult to change. As we work on improving our delivery room environment and changing ingrained habits, the evidence from this study should help support the use of wiping in place of suctioning. The transition from suctioning to wiping also would be facilitated by having easily accessible towels designated for wiping.

Acknowledgement
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

Last year, SHM was one of a number of healthcare and nutrition organizations to join the new Alliance to Advance Patient Nutrition campaign to address nutrition issues for hospitalized patients. In June, the Alliance was honored with the public relations industry’s most distinguished award recognizing the very best campaigns in PR: the Silver Anvil. The award was bestowed by the Public Relations Society of America, and CooperKatz, the firm that launched the campaign, accepted the award on behalf of the team.

The launch of the Alliance was awarded the outstanding public service campaign for 2013.

Last year, SHM was one of a number of healthcare and nutrition organizations to join the new Alliance to Advance Patient Nutrition campaign to address nutrition issues for hospitalized patients. In June, the Alliance was honored with the public relations industry’s most distinguished award recognizing the very best campaigns in PR: the Silver Anvil. The award was bestowed by the Public Relations Society of America, and CooperKatz, the firm that launched the campaign, accepted the award on behalf of the team.

The launch of the Alliance was awarded the outstanding public service campaign for 2013.

Last year, SHM was one of a number of healthcare and nutrition organizations to join the new Alliance to Advance Patient Nutrition campaign to address nutrition issues for hospitalized patients. In June, the Alliance was honored with the public relations industry’s most distinguished award recognizing the very best campaigns in PR: the Silver Anvil. The award was bestowed by the Public Relations Society of America, and CooperKatz, the firm that launched the campaign, accepted the award on behalf of the team.

The launch of the Alliance was awarded the outstanding public service campaign for 2013.

Are you helping your hospital choose wisely? You could receive thousands of dollars in return for your good work in providing high-value care to hospitalized patients through SHM’s Choosing Wisely case study competition.

SHM will be awarding a total of $20,000 to hospitalists who submit winning case studies illustrating their implementation of the Choosing Wisely principles published by SHM in 2013. Grand prize winners for both adult and pediatric HM will receive $4,000 each, and three honorable mention winners in both categories will each receive $2,000.

But don’t wait long. The deadline for submissions is September 9. For information and submission forms, visit www.hospitalmedicine.org/choosingwisely.

Are you helping your hospital choose wisely? You could receive thousands of dollars in return for your good work in providing high-value care to hospitalized patients through SHM’s Choosing Wisely case study competition.

SHM will be awarding a total of $20,000 to hospitalists who submit winning case studies illustrating their implementation of the Choosing Wisely principles published by SHM in 2013. Grand prize winners for both adult and pediatric HM will receive $4,000 each, and three honorable mention winners in both categories will each receive $2,000.

But don’t wait long. The deadline for submissions is September 9. For information and submission forms, visit www.hospitalmedicine.org/choosingwisely.

Are you helping your hospital choose wisely? You could receive thousands of dollars in return for your good work in providing high-value care to hospitalized patients through SHM’s Choosing Wisely case study competition.

SHM will be awarding a total of $20,000 to hospitalists who submit winning case studies illustrating their implementation of the Choosing Wisely principles published by SHM in 2013. Grand prize winners for both adult and pediatric HM will receive $4,000 each, and three honorable mention winners in both categories will each receive $2,000.

But don’t wait long. The deadline for submissions is September 9. For information and submission forms, visit www.hospitalmedicine.org/choosingwisely.

Don’t wait until the last minute to apply for the Fellow and Senior Fellow in Hospital Medicine designation. Start your application today at www.hospitalmedicine.org/fellows.

The FHM and SFHM designation are open to all hospitalists, not just physicians. Physician assistants, nurse practitioners, and practice administrators are all eligible candidates for Fellow status. All inductees will be recognized at a plenary session at HM15 in National Harbor, Md.

The deadline for the 2015 class of Fellows is Jan. 9, 2015.

Don’t wait until the last minute to apply for the Fellow and Senior Fellow in Hospital Medicine designation. Start your application today at www.hospitalmedicine.org/fellows.

The FHM and SFHM designation are open to all hospitalists, not just physicians. Physician assistants, nurse practitioners, and practice administrators are all eligible candidates for Fellow status. All inductees will be recognized at a plenary session at HM15 in National Harbor, Md.

The deadline for the 2015 class of Fellows is Jan. 9, 2015.

Don’t wait until the last minute to apply for the Fellow and Senior Fellow in Hospital Medicine designation. Start your application today at www.hospitalmedicine.org/fellows.

The FHM and SFHM designation are open to all hospitalists, not just physicians. Physician assistants, nurse practitioners, and practice administrators are all eligible candidates for Fellow status. All inductees will be recognized at a plenary session at HM15 in National Harbor, Md.

The deadline for the 2015 class of Fellows is Jan. 9, 2015.