Clinical question: Do patients receiving pre-operative angiotensin axis blockade (AAB) prior to elective major orthopedic surgery have an increased risk of peri-operative hypotension and acute kidney injury (AKI)?

Background: Patients with pre-operative AAB from angiotensin-converting enzyme inhibitors or angiotensin receptor blockers have an increased incidence of peri-operative hypotension. Patients undergoing cardiothoracic and vascular surgery with pre-operative AAB have increased incidence of post-operative AKI; however, there is scant literature evaluating the hypotensive and renal effects of pre-operative AAB prior to elective major orthopedic surgery.

Study design: Retrospective, cohort study.

Setting: Academic medical center.

Synopsis: Retrospective review of 922 patients undergoing spinal fusion, total knee arthroplasty, or total hip arthroplasty in one academic medical center in 2010 found that 37% received pre-operative AAB. Post-induction hypotension (systolic blood pressure ≤80 mm Hg for five minutes) was significantly higher in patients receiving AAB (12.2% vs. 6.7%; odds ratio [OR] 1.93, P=0.005). Post-operative AKI was significantly higher in patients receiving AAB (8.3% vs. 1.7%; OR 5.40, P<0.001), remaining significant after adjusting for intra-operative hypotension (OR 2.60, P=0.042). Developing AKI resulted in a significantly higher mean length of stay (5.76 vs. 3.28 days, P<0.001) but no difference in two-year mortality.

The findings suggest an association exists between pre-operative angiotensin-converting enzyme inhibitors/ARB, hypotension, and AKI following major orthopedic surgeries but does not demonstrate causality. A prospective, multi-center, randomized trial is needed to confirm that holding pre-operative AAB would decrease the incidence of AKI in patients undergoing major orthopedic procedures under general anesthesia.

Bottom line: Patients who underwent elective major orthopedic surgery who received pre-operative AAB therapy had an associated increased risk of post-induction hypotension and post-operative AKI, resulting in a greater hospital length of stay.

Citation: Nielson E, Hennrikus E, Lehman E, Mets B. Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery. J Hosp Med. 2014;9(5):283-288.

Clinical question: Do patients receiving pre-operative angiotensin axis blockade (AAB) prior to elective major orthopedic surgery have an increased risk of peri-operative hypotension and acute kidney injury (AKI)?

Background: Patients with pre-operative AAB from angiotensin-converting enzyme inhibitors or angiotensin receptor blockers have an increased incidence of peri-operative hypotension. Patients undergoing cardiothoracic and vascular surgery with pre-operative AAB have increased incidence of post-operative AKI; however, there is scant literature evaluating the hypotensive and renal effects of pre-operative AAB prior to elective major orthopedic surgery.

Study design: Retrospective, cohort study.

Setting: Academic medical center.

Synopsis: Retrospective review of 922 patients undergoing spinal fusion, total knee arthroplasty, or total hip arthroplasty in one academic medical center in 2010 found that 37% received pre-operative AAB. Post-induction hypotension (systolic blood pressure ≤80 mm Hg for five minutes) was significantly higher in patients receiving AAB (12.2% vs. 6.7%; odds ratio [OR] 1.93, P=0.005). Post-operative AKI was significantly higher in patients receiving AAB (8.3% vs. 1.7%; OR 5.40, P<0.001), remaining significant after adjusting for intra-operative hypotension (OR 2.60, P=0.042). Developing AKI resulted in a significantly higher mean length of stay (5.76 vs. 3.28 days, P<0.001) but no difference in two-year mortality.

The findings suggest an association exists between pre-operative angiotensin-converting enzyme inhibitors/ARB, hypotension, and AKI following major orthopedic surgeries but does not demonstrate causality. A prospective, multi-center, randomized trial is needed to confirm that holding pre-operative AAB would decrease the incidence of AKI in patients undergoing major orthopedic procedures under general anesthesia.

Bottom line: Patients who underwent elective major orthopedic surgery who received pre-operative AAB therapy had an associated increased risk of post-induction hypotension and post-operative AKI, resulting in a greater hospital length of stay.

Citation: Nielson E, Hennrikus E, Lehman E, Mets B. Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery. J Hosp Med. 2014;9(5):283-288.

Clinical question: Do patients receiving pre-operative angiotensin axis blockade (AAB) prior to elective major orthopedic surgery have an increased risk of peri-operative hypotension and acute kidney injury (AKI)?

Background: Patients with pre-operative AAB from angiotensin-converting enzyme inhibitors or angiotensin receptor blockers have an increased incidence of peri-operative hypotension. Patients undergoing cardiothoracic and vascular surgery with pre-operative AAB have increased incidence of post-operative AKI; however, there is scant literature evaluating the hypotensive and renal effects of pre-operative AAB prior to elective major orthopedic surgery.

Study design: Retrospective, cohort study.

Setting: Academic medical center.

Synopsis: Retrospective review of 922 patients undergoing spinal fusion, total knee arthroplasty, or total hip arthroplasty in one academic medical center in 2010 found that 37% received pre-operative AAB. Post-induction hypotension (systolic blood pressure ≤80 mm Hg for five minutes) was significantly higher in patients receiving AAB (12.2% vs. 6.7%; odds ratio [OR] 1.93, P=0.005). Post-operative AKI was significantly higher in patients receiving AAB (8.3% vs. 1.7%; OR 5.40, P<0.001), remaining significant after adjusting for intra-operative hypotension (OR 2.60, P=0.042). Developing AKI resulted in a significantly higher mean length of stay (5.76 vs. 3.28 days, P<0.001) but no difference in two-year mortality.

The findings suggest an association exists between pre-operative angiotensin-converting enzyme inhibitors/ARB, hypotension, and AKI following major orthopedic surgeries but does not demonstrate causality. A prospective, multi-center, randomized trial is needed to confirm that holding pre-operative AAB would decrease the incidence of AKI in patients undergoing major orthopedic procedures under general anesthesia.

Bottom line: Patients who underwent elective major orthopedic surgery who received pre-operative AAB therapy had an associated increased risk of post-induction hypotension and post-operative AKI, resulting in a greater hospital length of stay.

Citation: Nielson E, Hennrikus E, Lehman E, Mets B. Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery. J Hosp Med. 2014;9(5):283-288.

Clinical question: What is the recommended threshold for red blood cell (RBC) transfusion and erythropoiesis-stimulating agents (ESA) in anemic hospitalized patients with coronary heart disease?

Background: Anemia can worsen cardiac function and is associated with increased risk of hospitalization and death in patients with coronary heart disease (CHD) or congestive heart failure (CHF). It is unclear if treatments such as RBC transfusion, ESA, or iron replacement improve outcomes in patients with heart disease.

Study design: Systematic review.

Setting: Studies of hospitalized medical and surgical patients.

Synopsis: The guideline was developed by reviewing studies evaluating anemia treatment outcomes, including mortality, hospitalization, exercise tolerance, quality of life, and cardiovascular events. Six studies evaluated the benefits and harms resulting from RBC transfusion, each determined to be low-quality evidence. The current evidence showed no benefit when comparing liberal (hemoglobin (Hgb) >10 g/dL) versus restrictive (Hgb <10 g/dL) transfusion thresholds. Potential harms of transfusion included fever, transfusion-related acute lung injury, and CHF.

Given the low-quality evidence, the American College of Physicians (ACP) makes a weak recommendation for a restrictive transfusion strategy of Hgb 7-8 g/dL in patients with CHD.

A review of 16 RCTs (moderate-quality evidence) evaluated the effects of ESAs in mild to moderate anemia and showed no difference in outcomes for patients with CHD and CHF. Harms associated with ESA therapy included hypertension and venous thrombosis. The ACP makes a strong recommendation not to use ESAs in patients with heart disease.

Bottom line: The ACP recommends restrictive transfusion with hemoglobin threshold of 7-8 g/dL in hospitalized patients with CHD (weak recommendation, low-quality evidence) and recommends against using erythropoiesis-stimulating agents for mild to moderate anemia in patients with CHF or CHD (strong recommendation, moderate-quality evidence).

Citation: Qaseem A, Humphrey LL, Fitterman N, Starkey M, Shekelle P. Treatment of anemia in patients with heart disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013;159(11):770-779.

Clinical question: What is the recommended threshold for red blood cell (RBC) transfusion and erythropoiesis-stimulating agents (ESA) in anemic hospitalized patients with coronary heart disease?

Background: Anemia can worsen cardiac function and is associated with increased risk of hospitalization and death in patients with coronary heart disease (CHD) or congestive heart failure (CHF). It is unclear if treatments such as RBC transfusion, ESA, or iron replacement improve outcomes in patients with heart disease.

Study design: Systematic review.

Setting: Studies of hospitalized medical and surgical patients.

Synopsis: The guideline was developed by reviewing studies evaluating anemia treatment outcomes, including mortality, hospitalization, exercise tolerance, quality of life, and cardiovascular events. Six studies evaluated the benefits and harms resulting from RBC transfusion, each determined to be low-quality evidence. The current evidence showed no benefit when comparing liberal (hemoglobin (Hgb) >10 g/dL) versus restrictive (Hgb <10 g/dL) transfusion thresholds. Potential harms of transfusion included fever, transfusion-related acute lung injury, and CHF.

Given the low-quality evidence, the American College of Physicians (ACP) makes a weak recommendation for a restrictive transfusion strategy of Hgb 7-8 g/dL in patients with CHD.

A review of 16 RCTs (moderate-quality evidence) evaluated the effects of ESAs in mild to moderate anemia and showed no difference in outcomes for patients with CHD and CHF. Harms associated with ESA therapy included hypertension and venous thrombosis. The ACP makes a strong recommendation not to use ESAs in patients with heart disease.

Bottom line: The ACP recommends restrictive transfusion with hemoglobin threshold of 7-8 g/dL in hospitalized patients with CHD (weak recommendation, low-quality evidence) and recommends against using erythropoiesis-stimulating agents for mild to moderate anemia in patients with CHF or CHD (strong recommendation, moderate-quality evidence).

Citation: Qaseem A, Humphrey LL, Fitterman N, Starkey M, Shekelle P. Treatment of anemia in patients with heart disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013;159(11):770-779.

Clinical question: What is the recommended threshold for red blood cell (RBC) transfusion and erythropoiesis-stimulating agents (ESA) in anemic hospitalized patients with coronary heart disease?

Background: Anemia can worsen cardiac function and is associated with increased risk of hospitalization and death in patients with coronary heart disease (CHD) or congestive heart failure (CHF). It is unclear if treatments such as RBC transfusion, ESA, or iron replacement improve outcomes in patients with heart disease.

Study design: Systematic review.

Setting: Studies of hospitalized medical and surgical patients.

Synopsis: The guideline was developed by reviewing studies evaluating anemia treatment outcomes, including mortality, hospitalization, exercise tolerance, quality of life, and cardiovascular events. Six studies evaluated the benefits and harms resulting from RBC transfusion, each determined to be low-quality evidence. The current evidence showed no benefit when comparing liberal (hemoglobin (Hgb) >10 g/dL) versus restrictive (Hgb <10 g/dL) transfusion thresholds. Potential harms of transfusion included fever, transfusion-related acute lung injury, and CHF.

Given the low-quality evidence, the American College of Physicians (ACP) makes a weak recommendation for a restrictive transfusion strategy of Hgb 7-8 g/dL in patients with CHD.

A review of 16 RCTs (moderate-quality evidence) evaluated the effects of ESAs in mild to moderate anemia and showed no difference in outcomes for patients with CHD and CHF. Harms associated with ESA therapy included hypertension and venous thrombosis. The ACP makes a strong recommendation not to use ESAs in patients with heart disease.

Bottom line: The ACP recommends restrictive transfusion with hemoglobin threshold of 7-8 g/dL in hospitalized patients with CHD (weak recommendation, low-quality evidence) and recommends against using erythropoiesis-stimulating agents for mild to moderate anemia in patients with CHF or CHD (strong recommendation, moderate-quality evidence).

Citation: Qaseem A, Humphrey LL, Fitterman N, Starkey M, Shekelle P. Treatment of anemia in patients with heart disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013;159(11):770-779.

Clinical question: Can right ventricular (RV) dysfunction and troponin levels be used to risk stratify hemodynamically stable patients with acute pulmonary embolism (PE)?

Background: PE can present with varying degrees of clinical severity, necessitating appropriate risk stratification for decision making and management. Observational studies have demonstrated that RV dysfunction and injury provide important prognostic information in patients with acute PE, but this has not been confirmed in large prospective studies.

Study design: Prospective, cohort study.

Setting: Multicenter registry of academic and community hospitals in Italy.

Synopsis: Using the Italian Pulmonary Embolism Registry database of 860 hemodynamically stable patients with PE who underwent troponin measurement and echocardiogram, this study demonstrated that a model including RV dysfunction and injury has an incremental prognostic value for risk stratification of in-hospital death or clinical deterioration. The negative predictive value of negative echocardiography with negative troponin was 100% for in-hospital death and 99% for in-hospital clinical deterioration.

This study was limited by its observational approach; in addition, it did not provide its metrics for defining hemodynamic stability and did not standardize or report treatment strategies for these patients.

The predictive value of this study is impressive and could lead to the identification of patients in whom early discharge or brief hospitalization is appropriate; however, its application could be challenging in clinical environments where timely echocardiography resources are not readily available to a hemodynamically stable patient population.

Bottom line: Negative troponin and absence of RV dysfunction predict clinically stable pulmonary embolism.

Citation: Becattini C, Casazza F, Forgione C, et al. Acute pulmonary embolism: external validation of an integrated risk stratification model. Chest. 2013;144(5):1539-1545.

Clinical question: Can right ventricular (RV) dysfunction and troponin levels be used to risk stratify hemodynamically stable patients with acute pulmonary embolism (PE)?

Background: PE can present with varying degrees of clinical severity, necessitating appropriate risk stratification for decision making and management. Observational studies have demonstrated that RV dysfunction and injury provide important prognostic information in patients with acute PE, but this has not been confirmed in large prospective studies.

Study design: Prospective, cohort study.

Setting: Multicenter registry of academic and community hospitals in Italy.

Synopsis: Using the Italian Pulmonary Embolism Registry database of 860 hemodynamically stable patients with PE who underwent troponin measurement and echocardiogram, this study demonstrated that a model including RV dysfunction and injury has an incremental prognostic value for risk stratification of in-hospital death or clinical deterioration. The negative predictive value of negative echocardiography with negative troponin was 100% for in-hospital death and 99% for in-hospital clinical deterioration.

This study was limited by its observational approach; in addition, it did not provide its metrics for defining hemodynamic stability and did not standardize or report treatment strategies for these patients.

The predictive value of this study is impressive and could lead to the identification of patients in whom early discharge or brief hospitalization is appropriate; however, its application could be challenging in clinical environments where timely echocardiography resources are not readily available to a hemodynamically stable patient population.

Bottom line: Negative troponin and absence of RV dysfunction predict clinically stable pulmonary embolism.

Citation: Becattini C, Casazza F, Forgione C, et al. Acute pulmonary embolism: external validation of an integrated risk stratification model. Chest. 2013;144(5):1539-1545.

Clinical question: Can right ventricular (RV) dysfunction and troponin levels be used to risk stratify hemodynamically stable patients with acute pulmonary embolism (PE)?

Background: PE can present with varying degrees of clinical severity, necessitating appropriate risk stratification for decision making and management. Observational studies have demonstrated that RV dysfunction and injury provide important prognostic information in patients with acute PE, but this has not been confirmed in large prospective studies.

Study design: Prospective, cohort study.

Setting: Multicenter registry of academic and community hospitals in Italy.

Synopsis: Using the Italian Pulmonary Embolism Registry database of 860 hemodynamically stable patients with PE who underwent troponin measurement and echocardiogram, this study demonstrated that a model including RV dysfunction and injury has an incremental prognostic value for risk stratification of in-hospital death or clinical deterioration. The negative predictive value of negative echocardiography with negative troponin was 100% for in-hospital death and 99% for in-hospital clinical deterioration.

This study was limited by its observational approach; in addition, it did not provide its metrics for defining hemodynamic stability and did not standardize or report treatment strategies for these patients.

The predictive value of this study is impressive and could lead to the identification of patients in whom early discharge or brief hospitalization is appropriate; however, its application could be challenging in clinical environments where timely echocardiography resources are not readily available to a hemodynamically stable patient population.

Bottom line: Negative troponin and absence of RV dysfunction predict clinically stable pulmonary embolism.

Citation: Becattini C, Casazza F, Forgione C, et al. Acute pulmonary embolism: external validation of an integrated risk stratification model. Chest. 2013;144(5):1539-1545.

Clinical question: In patients with possible cardiac chest pain, does an accelerated diagnostic protocol result in higher rates of successful early discharge when compared with the standard care pathway?

Background: An accelerated diagnostic pathway (ADP), which combines TIMI [thrombolysis in myocardial infarction] score, EKG, and zero- and two-hour troponin levels, can identify low-risk patients presenting with chest pain; however, little is known about its effect on the rates of early, successful discharge in a real-world population.

Study design: RCT.

Setting: An academic general and tertiary care hospital in Christchurch, New Zealand.

Synopsis: This study of 542 patients ages 18 years and older who presented with chest pain demonstrated that when compared with a conventional pathway, an ADP results in nearly twice the proportion of patients (19.3% vs. 11.0%; P=0.008) achieving safe, early discharge from the ED, defined as discharge within six hours and no major adverse cardiac events within 30 days. This was a single-center trial in New Zealand, which limits its sample size and its generalizability; however, if larger studies led to the implementation of ADP by ED physicians, there would likely be fewer low-risk patients admitted to hospitalist services for evaluation of chest pain.

Bottom line: An accelerated diagnostic chest pain protocol results in earlier discharge of low-risk patients.

Citation: Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med. 2014;174(1):51-58.

Clinical question: In patients with possible cardiac chest pain, does an accelerated diagnostic protocol result in higher rates of successful early discharge when compared with the standard care pathway?

Background: An accelerated diagnostic pathway (ADP), which combines TIMI [thrombolysis in myocardial infarction] score, EKG, and zero- and two-hour troponin levels, can identify low-risk patients presenting with chest pain; however, little is known about its effect on the rates of early, successful discharge in a real-world population.

Study design: RCT.

Setting: An academic general and tertiary care hospital in Christchurch, New Zealand.

Synopsis: This study of 542 patients ages 18 years and older who presented with chest pain demonstrated that when compared with a conventional pathway, an ADP results in nearly twice the proportion of patients (19.3% vs. 11.0%; P=0.008) achieving safe, early discharge from the ED, defined as discharge within six hours and no major adverse cardiac events within 30 days. This was a single-center trial in New Zealand, which limits its sample size and its generalizability; however, if larger studies led to the implementation of ADP by ED physicians, there would likely be fewer low-risk patients admitted to hospitalist services for evaluation of chest pain.

Bottom line: An accelerated diagnostic chest pain protocol results in earlier discharge of low-risk patients.

Citation: Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med. 2014;174(1):51-58.

Clinical question: In patients with possible cardiac chest pain, does an accelerated diagnostic protocol result in higher rates of successful early discharge when compared with the standard care pathway?

Background: An accelerated diagnostic pathway (ADP), which combines TIMI [thrombolysis in myocardial infarction] score, EKG, and zero- and two-hour troponin levels, can identify low-risk patients presenting with chest pain; however, little is known about its effect on the rates of early, successful discharge in a real-world population.

Study design: RCT.

Setting: An academic general and tertiary care hospital in Christchurch, New Zealand.

Synopsis: This study of 542 patients ages 18 years and older who presented with chest pain demonstrated that when compared with a conventional pathway, an ADP results in nearly twice the proportion of patients (19.3% vs. 11.0%; P=0.008) achieving safe, early discharge from the ED, defined as discharge within six hours and no major adverse cardiac events within 30 days. This was a single-center trial in New Zealand, which limits its sample size and its generalizability; however, if larger studies led to the implementation of ADP by ED physicians, there would likely be fewer low-risk patients admitted to hospitalist services for evaluation of chest pain.

Bottom line: An accelerated diagnostic chest pain protocol results in earlier discharge of low-risk patients.

Citation: Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med. 2014;174(1):51-58.

Clinical question: What effect does a restrictive hemoglobin transfusion trigger of <7 g/dL have on clinical outcomes compared to more liberal transfusion triggers?

Background: Blood transfusions are standard of care in managing anemia despite sparse evidence that they improve clinical outcomes. As more evidence mounts that blood transfusions are associated with worse outcomes, the threshold hemoglobin level for transfusion has decreased. The safest hemoglobin trigger for blood transfusion remains unknown.

Study design: Meta-analysis of randomized control trials (RCTs) and systematic review of observational studies.

Setting: Data from MEDLINE.

Synopsis: Pooled data from three RCTs, including 2364 patients, compared outcomes between a restrictive hemoglobin transfusion trigger of <7 g/dL with a more liberal trigger. The restrictive strategy resulted in decreased in-hospital mortality (RR 0.74, CI 0.6-0.92), total mortality (RR 0.8, CI 0.65-0.98), rebleeding (RR 0.64, CI 0.45-0.9), acute coronary syndrome (RR 0.44, CI 0.22-0.89), and pulmonary edema (RR 0.48, CI 0.33-0.72). Using the restrictive strategy, the number needed to treat to prevent one death was 33.

A second meta-analysis of 16 RCTs found that less restrictive transfusion strategies (triggers of 7.5 to 10 g/dL) were not effective in improving outcomes. A systematic review of observational studies suggested that normovolemic patients can tolerate hemoglobins of 5-6 g/dL without affecting oxygen delivery.

The primary meta-analysis was limited by the inclusion of adult and pediatric patients and different indications for transfusion (critical illness, gastrointestinal bleed), which could have introduced some bias. Although the safest transfusion trigger remains unknown, this study demonstrates that <7 g/dL is safer than more liberal triggers.

Bottom line: A restrictive blood transfusion strategy with hemoglobin trigger of <7 g/dL in patients with critical illness or bleeding significantly decreases rebleeding, cardiac events, and total mortality.

Citation: Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. Am J Med. 2014;127(2): 124-131.

Clinical question: What effect does a restrictive hemoglobin transfusion trigger of <7 g/dL have on clinical outcomes compared to more liberal transfusion triggers?

Background: Blood transfusions are standard of care in managing anemia despite sparse evidence that they improve clinical outcomes. As more evidence mounts that blood transfusions are associated with worse outcomes, the threshold hemoglobin level for transfusion has decreased. The safest hemoglobin trigger for blood transfusion remains unknown.

Study design: Meta-analysis of randomized control trials (RCTs) and systematic review of observational studies.

Setting: Data from MEDLINE.

Synopsis: Pooled data from three RCTs, including 2364 patients, compared outcomes between a restrictive hemoglobin transfusion trigger of <7 g/dL with a more liberal trigger. The restrictive strategy resulted in decreased in-hospital mortality (RR 0.74, CI 0.6-0.92), total mortality (RR 0.8, CI 0.65-0.98), rebleeding (RR 0.64, CI 0.45-0.9), acute coronary syndrome (RR 0.44, CI 0.22-0.89), and pulmonary edema (RR 0.48, CI 0.33-0.72). Using the restrictive strategy, the number needed to treat to prevent one death was 33.

A second meta-analysis of 16 RCTs found that less restrictive transfusion strategies (triggers of 7.5 to 10 g/dL) were not effective in improving outcomes. A systematic review of observational studies suggested that normovolemic patients can tolerate hemoglobins of 5-6 g/dL without affecting oxygen delivery.

The primary meta-analysis was limited by the inclusion of adult and pediatric patients and different indications for transfusion (critical illness, gastrointestinal bleed), which could have introduced some bias. Although the safest transfusion trigger remains unknown, this study demonstrates that <7 g/dL is safer than more liberal triggers.

Bottom line: A restrictive blood transfusion strategy with hemoglobin trigger of <7 g/dL in patients with critical illness or bleeding significantly decreases rebleeding, cardiac events, and total mortality.

Citation: Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. Am J Med. 2014;127(2): 124-131.

Clinical question: What effect does a restrictive hemoglobin transfusion trigger of <7 g/dL have on clinical outcomes compared to more liberal transfusion triggers?

Background: Blood transfusions are standard of care in managing anemia despite sparse evidence that they improve clinical outcomes. As more evidence mounts that blood transfusions are associated with worse outcomes, the threshold hemoglobin level for transfusion has decreased. The safest hemoglobin trigger for blood transfusion remains unknown.

Study design: Meta-analysis of randomized control trials (RCTs) and systematic review of observational studies.

Setting: Data from MEDLINE.

Synopsis: Pooled data from three RCTs, including 2364 patients, compared outcomes between a restrictive hemoglobin transfusion trigger of <7 g/dL with a more liberal trigger. The restrictive strategy resulted in decreased in-hospital mortality (RR 0.74, CI 0.6-0.92), total mortality (RR 0.8, CI 0.65-0.98), rebleeding (RR 0.64, CI 0.45-0.9), acute coronary syndrome (RR 0.44, CI 0.22-0.89), and pulmonary edema (RR 0.48, CI 0.33-0.72). Using the restrictive strategy, the number needed to treat to prevent one death was 33.

A second meta-analysis of 16 RCTs found that less restrictive transfusion strategies (triggers of 7.5 to 10 g/dL) were not effective in improving outcomes. A systematic review of observational studies suggested that normovolemic patients can tolerate hemoglobins of 5-6 g/dL without affecting oxygen delivery.

The primary meta-analysis was limited by the inclusion of adult and pediatric patients and different indications for transfusion (critical illness, gastrointestinal bleed), which could have introduced some bias. Although the safest transfusion trigger remains unknown, this study demonstrates that <7 g/dL is safer than more liberal triggers.

Bottom line: A restrictive blood transfusion strategy with hemoglobin trigger of <7 g/dL in patients with critical illness or bleeding significantly decreases rebleeding, cardiac events, and total mortality.

Citation: Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. Am J Med. 2014;127(2): 124-131.

Clinical question: Can an ED observation syncope protocol decrease resource utilization without adversely affecting outcomes?

Background: Syncope is a common complaint in EDs. Uncertainty in the best way to manage older adults at intermediate risk for adverse outcomes results in frequent, costly hospitalizations without clear improvement in outcomes. An observation syncope protocol may standardize care and reduce admissions without worsening safety.

Study design: Randomized, non-blinded, clinical trial.

Setting: Five EDs in the United States.

Synopsis: One hundred twenty-four intermediate-risk adults (≥50 years) presenting with syncope or near syncope were randomized to an ED observation syncope protocol vs. routine admission. The observation protocol resulted in a lower admission rate (15% vs. 92%), shorter stay (29 vs. 47 hours), and decreased index hospital costs ($629); however, there were no significant differences in serious outcomes after discharge at 30 days (3% vs. 0%) or six months (8% vs. 10%), 30-day quality of life scores, or patient satisfaction. Limitations include the small study size, the fact that half of eligible patients were excluded as high risk, higher number of abnormal ECGs in the control group, and a cost savings that was attenuated at 30 days.

This ED observation syncope protocol demonstrated an impressive decrease in admission rates and length of stay without compromising safety, but only a small fraction of patients met the inclusion criteria, and the cost savings were small and transient.

Bottom line: An ED observation syncope protocol for intermediate-risk patients decreased admission rates, length of stay, and index hospitalization costs without a difference in safety events, patient satisfaction, or quality of life.

Citation: Sun BC, McCreath H, Liang L, et al. Randomized clinical trial of an emergency department observation syncope protocol versus routine inpatient admission [published online ahead of print November 13, 2013]. Ann Emerg Med.

Clinical question: Can an ED observation syncope protocol decrease resource utilization without adversely affecting outcomes?

Background: Syncope is a common complaint in EDs. Uncertainty in the best way to manage older adults at intermediate risk for adverse outcomes results in frequent, costly hospitalizations without clear improvement in outcomes. An observation syncope protocol may standardize care and reduce admissions without worsening safety.

Study design: Randomized, non-blinded, clinical trial.

Setting: Five EDs in the United States.

Synopsis: One hundred twenty-four intermediate-risk adults (≥50 years) presenting with syncope or near syncope were randomized to an ED observation syncope protocol vs. routine admission. The observation protocol resulted in a lower admission rate (15% vs. 92%), shorter stay (29 vs. 47 hours), and decreased index hospital costs ($629); however, there were no significant differences in serious outcomes after discharge at 30 days (3% vs. 0%) or six months (8% vs. 10%), 30-day quality of life scores, or patient satisfaction. Limitations include the small study size, the fact that half of eligible patients were excluded as high risk, higher number of abnormal ECGs in the control group, and a cost savings that was attenuated at 30 days.

This ED observation syncope protocol demonstrated an impressive decrease in admission rates and length of stay without compromising safety, but only a small fraction of patients met the inclusion criteria, and the cost savings were small and transient.

Bottom line: An ED observation syncope protocol for intermediate-risk patients decreased admission rates, length of stay, and index hospitalization costs without a difference in safety events, patient satisfaction, or quality of life.

Citation: Sun BC, McCreath H, Liang L, et al. Randomized clinical trial of an emergency department observation syncope protocol versus routine inpatient admission [published online ahead of print November 13, 2013]. Ann Emerg Med.

Clinical question: Can an ED observation syncope protocol decrease resource utilization without adversely affecting outcomes?

Background: Syncope is a common complaint in EDs. Uncertainty in the best way to manage older adults at intermediate risk for adverse outcomes results in frequent, costly hospitalizations without clear improvement in outcomes. An observation syncope protocol may standardize care and reduce admissions without worsening safety.

Study design: Randomized, non-blinded, clinical trial.

Setting: Five EDs in the United States.

Synopsis: One hundred twenty-four intermediate-risk adults (≥50 years) presenting with syncope or near syncope were randomized to an ED observation syncope protocol vs. routine admission. The observation protocol resulted in a lower admission rate (15% vs. 92%), shorter stay (29 vs. 47 hours), and decreased index hospital costs ($629); however, there were no significant differences in serious outcomes after discharge at 30 days (3% vs. 0%) or six months (8% vs. 10%), 30-day quality of life scores, or patient satisfaction. Limitations include the small study size, the fact that half of eligible patients were excluded as high risk, higher number of abnormal ECGs in the control group, and a cost savings that was attenuated at 30 days.

This ED observation syncope protocol demonstrated an impressive decrease in admission rates and length of stay without compromising safety, but only a small fraction of patients met the inclusion criteria, and the cost savings were small and transient.

Bottom line: An ED observation syncope protocol for intermediate-risk patients decreased admission rates, length of stay, and index hospitalization costs without a difference in safety events, patient satisfaction, or quality of life.

Citation: Sun BC, McCreath H, Liang L, et al. Randomized clinical trial of an emergency department observation syncope protocol versus routine inpatient admission [published online ahead of print November 13, 2013]. Ann Emerg Med.

Leadership is a skill that must be developed, and hospitalists are increasingly being thrust into leadership positions in hospitals across the country.

SHM’s Leadership Academy is made up of three separate courses, each especially designed to help hospitalists take on leadership positions with confidence—and to reach even higher.

Leadership Foundations

This four-day educational offering serves as a prerequisite to all other Leadership Academy courses. Attendees learn how to evaluate personal leadership strengths and weaknesses, create and execute a communication strategy for key team members, understand key hospital drivers, examine how hospital metrics are derived, and more. Participants are grouped at tables of 10, each with a skilled facilitator to ensure meaningful, relevant application of concepts to hands-on activities. Course objectives:

• Evaluate personal leadership strengths and weaknesses and apply them to everyday leadership and management challenges;
• Effectively advocate the value of their hospitalist programs;
• Predict and plan for the near-term challenges affecting the viability of their hospitalist programs;
• Improve patient outcomes through successful planning, allocation of resources, collaboration, teamwork, and execution;
• Create and execute a communication strategy for all key constituencies;
• Understand key hospital drivers and examine how hospital performance metrics are derived, as well as how hospital medicine practices can influence and impact these metrics;
• Implement methods of effective change through leadership, shared vision, and management of organizational culture; and
• Utilize strategic planning to define a vision for their programs, prioritize efforts, and achieve designated goals.

Advanced Leadership: Influential Management

Through world-renowned faculty and applied exercises, this course provides skill building around driving culture change through specific leadership behaviors and actions, financial storytelling, engagement in effective professional negotiation activities with proven techniques, and more. Prerequisites: Leadership Foundations or an advanced management degree. Course objectives:

• Drive culture change through specific leadership behaviors and actions;
• Use financial reports to drive clinical/operational practice decision making;
• Recruit and retain the best physicians for their groups;
• Build exceptional physician satisfaction; and
• Engage in effective professional negotiation activities using proven techniques.

Advanced Leadership: Mastering Teamwork

Developed in response to high demand from academy attendees, this course is focused on strengthening teams and institutions. Participants learn how to critically assess program growth opportunities and develop operational plans; lead, manage, and motivate teams in complex hospital environments; and communicate effectively. Prerequisite: Leadership Foundations or an advanced management degree. Course objectives:

• Apply communication strategies that allow others to fully experience your message;
• Lead teams in complex environments to achieve the best results;
• Invest in yourself as a leader to optimize your professional growth and career path; and
• Critically assess program growth opportunities and implement the necessary infrastructure for success.

Leadership is a skill that must be developed, and hospitalists are increasingly being thrust into leadership positions in hospitals across the country.

SHM’s Leadership Academy is made up of three separate courses, each especially designed to help hospitalists take on leadership positions with confidence—and to reach even higher.

Leadership Foundations

This four-day educational offering serves as a prerequisite to all other Leadership Academy courses. Attendees learn how to evaluate personal leadership strengths and weaknesses, create and execute a communication strategy for key team members, understand key hospital drivers, examine how hospital metrics are derived, and more. Participants are grouped at tables of 10, each with a skilled facilitator to ensure meaningful, relevant application of concepts to hands-on activities. Course objectives:

• Evaluate personal leadership strengths and weaknesses and apply them to everyday leadership and management challenges;
• Effectively advocate the value of their hospitalist programs;
• Predict and plan for the near-term challenges affecting the viability of their hospitalist programs;
• Improve patient outcomes through successful planning, allocation of resources, collaboration, teamwork, and execution;
• Create and execute a communication strategy for all key constituencies;
• Understand key hospital drivers and examine how hospital performance metrics are derived, as well as how hospital medicine practices can influence and impact these metrics;
• Implement methods of effective change through leadership, shared vision, and management of organizational culture; and
• Utilize strategic planning to define a vision for their programs, prioritize efforts, and achieve designated goals.

Advanced Leadership: Influential Management

Through world-renowned faculty and applied exercises, this course provides skill building around driving culture change through specific leadership behaviors and actions, financial storytelling, engagement in effective professional negotiation activities with proven techniques, and more. Prerequisites: Leadership Foundations or an advanced management degree. Course objectives:

• Drive culture change through specific leadership behaviors and actions;
• Use financial reports to drive clinical/operational practice decision making;
• Recruit and retain the best physicians for their groups;
• Build exceptional physician satisfaction; and
• Engage in effective professional negotiation activities using proven techniques.

Advanced Leadership: Mastering Teamwork

Developed in response to high demand from academy attendees, this course is focused on strengthening teams and institutions. Participants learn how to critically assess program growth opportunities and develop operational plans; lead, manage, and motivate teams in complex hospital environments; and communicate effectively. Prerequisite: Leadership Foundations or an advanced management degree. Course objectives:

• Apply communication strategies that allow others to fully experience your message;
• Lead teams in complex environments to achieve the best results;
• Invest in yourself as a leader to optimize your professional growth and career path; and
• Critically assess program growth opportunities and implement the necessary infrastructure for success.

Leadership is a skill that must be developed, and hospitalists are increasingly being thrust into leadership positions in hospitals across the country.

SHM’s Leadership Academy is made up of three separate courses, each especially designed to help hospitalists take on leadership positions with confidence—and to reach even higher.

Leadership Foundations

This four-day educational offering serves as a prerequisite to all other Leadership Academy courses. Attendees learn how to evaluate personal leadership strengths and weaknesses, create and execute a communication strategy for key team members, understand key hospital drivers, examine how hospital metrics are derived, and more. Participants are grouped at tables of 10, each with a skilled facilitator to ensure meaningful, relevant application of concepts to hands-on activities. Course objectives:

• Evaluate personal leadership strengths and weaknesses and apply them to everyday leadership and management challenges;
• Effectively advocate the value of their hospitalist programs;
• Predict and plan for the near-term challenges affecting the viability of their hospitalist programs;
• Improve patient outcomes through successful planning, allocation of resources, collaboration, teamwork, and execution;
• Create and execute a communication strategy for all key constituencies;
• Understand key hospital drivers and examine how hospital performance metrics are derived, as well as how hospital medicine practices can influence and impact these metrics;
• Implement methods of effective change through leadership, shared vision, and management of organizational culture; and
• Utilize strategic planning to define a vision for their programs, prioritize efforts, and achieve designated goals.

Advanced Leadership: Influential Management

Through world-renowned faculty and applied exercises, this course provides skill building around driving culture change through specific leadership behaviors and actions, financial storytelling, engagement in effective professional negotiation activities with proven techniques, and more. Prerequisites: Leadership Foundations or an advanced management degree. Course objectives:

• Drive culture change through specific leadership behaviors and actions;
• Use financial reports to drive clinical/operational practice decision making;
• Recruit and retain the best physicians for their groups;
• Build exceptional physician satisfaction; and
• Engage in effective professional negotiation activities using proven techniques.

Advanced Leadership: Mastering Teamwork

Developed in response to high demand from academy attendees, this course is focused on strengthening teams and institutions. Participants learn how to critically assess program growth opportunities and develop operational plans; lead, manage, and motivate teams in complex hospital environments; and communicate effectively. Prerequisite: Leadership Foundations or an advanced management degree. Course objectives:

• Apply communication strategies that allow others to fully experience your message;
• Lead teams in complex environments to achieve the best results;
• Invest in yourself as a leader to optimize your professional growth and career path; and
• Critically assess program growth opportunities and implement the necessary infrastructure for success.

Hyperglycemia is associated with poor outcomes in a broad range of hospitalized patients, and several studies demonstrate improved outcomes with improved glycemic control. Hospitalization presents a frequently missed opportunity to diagnose diabetes, identify those at risk for diabetes, and optimize the care of patients with diabetes via education and medical therapy.

Despite authoritative guidelines and effective methods to achieve good glycemic control safely, poor glycemic control, suboptimal medication regimens, incomplete patient education, and uneven communication with outpatient care providers are prevalent problems in medical centers.

SHM is accepting applications to the Fall 2014 Glycemic Control Mentored Implementation (GCMI) Program (www.hospitalmedicine.org/gcmi). Participants will work directly with SHM mentors, benchmark against other participants, and join the Glycemic Control Community to network with peers.

Hyperglycemia is associated with poor outcomes in a broad range of hospitalized patients, and several studies demonstrate improved outcomes with improved glycemic control. Hospitalization presents a frequently missed opportunity to diagnose diabetes, identify those at risk for diabetes, and optimize the care of patients with diabetes via education and medical therapy.

Despite authoritative guidelines and effective methods to achieve good glycemic control safely, poor glycemic control, suboptimal medication regimens, incomplete patient education, and uneven communication with outpatient care providers are prevalent problems in medical centers.

SHM is accepting applications to the Fall 2014 Glycemic Control Mentored Implementation (GCMI) Program (www.hospitalmedicine.org/gcmi). Participants will work directly with SHM mentors, benchmark against other participants, and join the Glycemic Control Community to network with peers.

Hyperglycemia is associated with poor outcomes in a broad range of hospitalized patients, and several studies demonstrate improved outcomes with improved glycemic control. Hospitalization presents a frequently missed opportunity to diagnose diabetes, identify those at risk for diabetes, and optimize the care of patients with diabetes via education and medical therapy.

Despite authoritative guidelines and effective methods to achieve good glycemic control safely, poor glycemic control, suboptimal medication regimens, incomplete patient education, and uneven communication with outpatient care providers are prevalent problems in medical centers.

SHM is accepting applications to the Fall 2014 Glycemic Control Mentored Implementation (GCMI) Program (www.hospitalmedicine.org/gcmi). Participants will work directly with SHM mentors, benchmark against other participants, and join the Glycemic Control Community to network with peers.

Reducing unnecessary readmissions continues to be a priority for hospitals across the country, which is why so many hospitals have already enrolled in SHM’s Project BOOST. Project BOOST is an award-winning program that pairs hospitals with the national experts in reducing readmissions and resources to implement programs that work in the real world.

Early research indicates that Project BOOST can be effective: According to research published in the Journal of Hospital Medicine last year, participation in Project BOOST among a small sample set of hospitals appeared to be associated with a decrease in readmission rates.

And hospitals reducing readmissions through Project BOOST are receiving attention from their local communities, too. Recently, Lakes Region General Hospital was featured in an article in the local newspaper, The Laconia Daily Sun, entitled “LRGH finds preventable readmissions program is paying off.”

SHM is accepting applications to the 2014 Project BOOST cohort through August. For more information, visit www.hospitalmedicine.org/boost.

Reducing unnecessary readmissions continues to be a priority for hospitals across the country, which is why so many hospitals have already enrolled in SHM’s Project BOOST. Project BOOST is an award-winning program that pairs hospitals with the national experts in reducing readmissions and resources to implement programs that work in the real world.

Early research indicates that Project BOOST can be effective: According to research published in the Journal of Hospital Medicine last year, participation in Project BOOST among a small sample set of hospitals appeared to be associated with a decrease in readmission rates.

And hospitals reducing readmissions through Project BOOST are receiving attention from their local communities, too. Recently, Lakes Region General Hospital was featured in an article in the local newspaper, The Laconia Daily Sun, entitled “LRGH finds preventable readmissions program is paying off.”

SHM is accepting applications to the 2014 Project BOOST cohort through August. For more information, visit www.hospitalmedicine.org/boost.

Reducing unnecessary readmissions continues to be a priority for hospitals across the country, which is why so many hospitals have already enrolled in SHM’s Project BOOST. Project BOOST is an award-winning program that pairs hospitals with the national experts in reducing readmissions and resources to implement programs that work in the real world.

Early research indicates that Project BOOST can be effective: According to research published in the Journal of Hospital Medicine last year, participation in Project BOOST among a small sample set of hospitals appeared to be associated with a decrease in readmission rates.

And hospitals reducing readmissions through Project BOOST are receiving attention from their local communities, too. Recently, Lakes Region General Hospital was featured in an article in the local newspaper, The Laconia Daily Sun, entitled “LRGH finds preventable readmissions program is paying off.”

SHM is accepting applications to the 2014 Project BOOST cohort through August. For more information, visit www.hospitalmedicine.org/boost.

Dr. Bulger

In 2013, SHM was the first medical specialty to submit two separate lists to the popular Choosing Wisely campaign, created by the ABIM Foundation. The lists—one for hospitalists treating adult patients and another for pediatric hospitalists—were developed to help providers have important conversations with their patients about providing the highest value care at the best time.

This year, SHM is asking hospitalists to show how they have implemented any one of the recommendations from SHM’s two lists. And SHM is offering up to $4,000 to the hospitalist/group that submits the best case study. The committee that developed SHM’s Choosing Wisely recommendations will judge the case studies.

“The competition gives hospitalists the opportunity to highlight the wonderful work they do every day aimed at creating patient-centered value,” says John Bulger, DO, MBA, FACP, SFHM, who chaired SHM’s Choosing Wisely committee. “By sharing, hospitalists have the chance to impact the care of larger populations outside of their own hospitals and help colleagues across the nation and around the globe. Finally, the cash prize adds a little extra incentive.”

According to Dr. Bulger, the activity should be centered around one of SHM’s adult or pediatric Choosing Wisely recommendations, and the improvement work should have started after Jan. 1, 2013. Submissions are due Sept. 9.

SHM’s Choosing Wisely case study competition is made possible by a grant awarded by the ABIM Foundation and the Robert Wood Johnson Foundation to help extend the reach of the Choosing Wisely campaign.

“We hope to spur interest in hospitals sharing their successes and challenges with implementing the Choosing Wisely guidelines,” Dr. Bulger adds. “Competition is sometimes a powerful motivator. In addition, we plan to broadly share the case studies we receive as part of a Compendium of Hospitalists Guide to Choosing Wisely.”

To submit a Choosing Wisely case study to SHM or to review SHM’s Choosing Wisely recommendations, visit www.hospitalmedicine.org/choosingwisely.

Dr. Bulger

In 2013, SHM was the first medical specialty to submit two separate lists to the popular Choosing Wisely campaign, created by the ABIM Foundation. The lists—one for hospitalists treating adult patients and another for pediatric hospitalists—were developed to help providers have important conversations with their patients about providing the highest value care at the best time.

This year, SHM is asking hospitalists to show how they have implemented any one of the recommendations from SHM’s two lists. And SHM is offering up to $4,000 to the hospitalist/group that submits the best case study. The committee that developed SHM’s Choosing Wisely recommendations will judge the case studies.

“The competition gives hospitalists the opportunity to highlight the wonderful work they do every day aimed at creating patient-centered value,” says John Bulger, DO, MBA, FACP, SFHM, who chaired SHM’s Choosing Wisely committee. “By sharing, hospitalists have the chance to impact the care of larger populations outside of their own hospitals and help colleagues across the nation and around the globe. Finally, the cash prize adds a little extra incentive.”

According to Dr. Bulger, the activity should be centered around one of SHM’s adult or pediatric Choosing Wisely recommendations, and the improvement work should have started after Jan. 1, 2013. Submissions are due Sept. 9.

SHM’s Choosing Wisely case study competition is made possible by a grant awarded by the ABIM Foundation and the Robert Wood Johnson Foundation to help extend the reach of the Choosing Wisely campaign.

“We hope to spur interest in hospitals sharing their successes and challenges with implementing the Choosing Wisely guidelines,” Dr. Bulger adds. “Competition is sometimes a powerful motivator. In addition, we plan to broadly share the case studies we receive as part of a Compendium of Hospitalists Guide to Choosing Wisely.”

To submit a Choosing Wisely case study to SHM or to review SHM’s Choosing Wisely recommendations, visit www.hospitalmedicine.org/choosingwisely.

Dr. Bulger

In 2013, SHM was the first medical specialty to submit two separate lists to the popular Choosing Wisely campaign, created by the ABIM Foundation. The lists—one for hospitalists treating adult patients and another for pediatric hospitalists—were developed to help providers have important conversations with their patients about providing the highest value care at the best time.

This year, SHM is asking hospitalists to show how they have implemented any one of the recommendations from SHM’s two lists. And SHM is offering up to $4,000 to the hospitalist/group that submits the best case study. The committee that developed SHM’s Choosing Wisely recommendations will judge the case studies.

“The competition gives hospitalists the opportunity to highlight the wonderful work they do every day aimed at creating patient-centered value,” says John Bulger, DO, MBA, FACP, SFHM, who chaired SHM’s Choosing Wisely committee. “By sharing, hospitalists have the chance to impact the care of larger populations outside of their own hospitals and help colleagues across the nation and around the globe. Finally, the cash prize adds a little extra incentive.”

According to Dr. Bulger, the activity should be centered around one of SHM’s adult or pediatric Choosing Wisely recommendations, and the improvement work should have started after Jan. 1, 2013. Submissions are due Sept. 9.

SHM’s Choosing Wisely case study competition is made possible by a grant awarded by the ABIM Foundation and the Robert Wood Johnson Foundation to help extend the reach of the Choosing Wisely campaign.

“We hope to spur interest in hospitals sharing their successes and challenges with implementing the Choosing Wisely guidelines,” Dr. Bulger adds. “Competition is sometimes a powerful motivator. In addition, we plan to broadly share the case studies we receive as part of a Compendium of Hospitalists Guide to Choosing Wisely.”

To submit a Choosing Wisely case study to SHM or to review SHM’s Choosing Wisely recommendations, visit www.hospitalmedicine.org/choosingwisely.