Quality Improvement

A computerized pathway for managing patients with chronic obstructive pulmonary disease (COPD), described in a Research, Innovations, and Clinical Vignettes poster/abstract presented at HM13, brings together evidence-based computerized physician order entry order sets for managing COPD with links to pulmonology and respiratory therapy protocols, and with established care transitions processes at the University of California at San Diego.¹

“When I started this journey, examining how we were doing in adhering to national and international guidelines for COPD care, it turned out we were not doing such a great job,” says lead author Weijen Chang, MD, SFHM, FAAP, who works as a med-peds hospitalist at UCSD and is pediatric editor of The Hospitalist. “We were providing ideal care as defined in the guidelines only about 60 percent of the time.”

Dr. Chang found that UCSD pulmonologists were simultaneously working on their own QI project, so they combined forces around a COPD Inpatient Care Workgroup comprising hospitalists, pulmonologists, respiratory therapists, pharmacists, and information system specialists. The group developed a COPD Longitudinal Inpatient Pathway and Transition Pathway (CLIPT) addressing appropriate referrals for subspecialist care and rehabilitation in and out of the hospital.

The key was not just to create order sets for optimal COPD care, but also to improve access, continuity of care, and post-discharge follow-up through the pathway, which is available for initiation in the ED, at or after admission, or at discharge, Dr. Chang explains. Transition nurse specialists trained as part of a separate initiative at the medical center provide COPD case management. The group is exploring the use of respiratory therapists to actively case-manage COPD patients going home. Patients are connected with a COPD discharge clinic staffed part-time by a UCSD pulmonologist.

According to the abstract, the CLIPT pathway was initiated in 46% of patients admitted with acute exacerbations of COPD. Dr. Chang says further study is needed to assess outcomes during and after hospitalization.

More ideas on enhancing hospital care for the COPD population in order to manage their high risk of readmissions was presented at the recent COPD and Readmissions Summit sponsored by the COPD Foundation (www.copdfoundation.org) in October in Washington, D.C.

References

1. Chang W, Maynard G, Clay B. Implementation of a computerized COPD inpatient pathway and transition pathway [abstract]. J Hosp Med. 2013;8 Suppl 1:709.
2. Schmitt S, McQuillen DP, Nahass R, et al. Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs [published online ahead of print September 25, 2013]. Clin Infect Dis.
3. Torio CM, Andrews RM. National inpatient hospital costs: the most expensive conditions by payer, 2011. Healthcare Cost and Utilization Project Statistical Brief #160. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb160.jsp. Accessed October 26, 2013.
4. Herman B. Top 20 most expensive inpatient conditions. Becker’s Hospital Review. Oct. 9, 2013. Available at: http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/top-20-most-expensive-inpatient-conditions.html. Accessed October 26, 2013.

Quality Improvement

A computerized pathway for managing patients with chronic obstructive pulmonary disease (COPD), described in a Research, Innovations, and Clinical Vignettes poster/abstract presented at HM13, brings together evidence-based computerized physician order entry order sets for managing COPD with links to pulmonology and respiratory therapy protocols, and with established care transitions processes at the University of California at San Diego.¹

“When I started this journey, examining how we were doing in adhering to national and international guidelines for COPD care, it turned out we were not doing such a great job,” says lead author Weijen Chang, MD, SFHM, FAAP, who works as a med-peds hospitalist at UCSD and is pediatric editor of The Hospitalist. “We were providing ideal care as defined in the guidelines only about 60 percent of the time.”

Dr. Chang found that UCSD pulmonologists were simultaneously working on their own QI project, so they combined forces around a COPD Inpatient Care Workgroup comprising hospitalists, pulmonologists, respiratory therapists, pharmacists, and information system specialists. The group developed a COPD Longitudinal Inpatient Pathway and Transition Pathway (CLIPT) addressing appropriate referrals for subspecialist care and rehabilitation in and out of the hospital.

The key was not just to create order sets for optimal COPD care, but also to improve access, continuity of care, and post-discharge follow-up through the pathway, which is available for initiation in the ED, at or after admission, or at discharge, Dr. Chang explains. Transition nurse specialists trained as part of a separate initiative at the medical center provide COPD case management. The group is exploring the use of respiratory therapists to actively case-manage COPD patients going home. Patients are connected with a COPD discharge clinic staffed part-time by a UCSD pulmonologist.

According to the abstract, the CLIPT pathway was initiated in 46% of patients admitted with acute exacerbations of COPD. Dr. Chang says further study is needed to assess outcomes during and after hospitalization.

More ideas on enhancing hospital care for the COPD population in order to manage their high risk of readmissions was presented at the recent COPD and Readmissions Summit sponsored by the COPD Foundation (www.copdfoundation.org) in October in Washington, D.C.

References

1. Chang W, Maynard G, Clay B. Implementation of a computerized COPD inpatient pathway and transition pathway [abstract]. J Hosp Med. 2013;8 Suppl 1:709.
2. Schmitt S, McQuillen DP, Nahass R, et al. Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs [published online ahead of print September 25, 2013]. Clin Infect Dis.
3. Torio CM, Andrews RM. National inpatient hospital costs: the most expensive conditions by payer, 2011. Healthcare Cost and Utilization Project Statistical Brief #160. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb160.jsp. Accessed October 26, 2013.
4. Herman B. Top 20 most expensive inpatient conditions. Becker’s Hospital Review. Oct. 9, 2013. Available at: http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/top-20-most-expensive-inpatient-conditions.html. Accessed October 26, 2013.

Quality Improvement

A computerized pathway for managing patients with chronic obstructive pulmonary disease (COPD), described in a Research, Innovations, and Clinical Vignettes poster/abstract presented at HM13, brings together evidence-based computerized physician order entry order sets for managing COPD with links to pulmonology and respiratory therapy protocols, and with established care transitions processes at the University of California at San Diego.¹

“When I started this journey, examining how we were doing in adhering to national and international guidelines for COPD care, it turned out we were not doing such a great job,” says lead author Weijen Chang, MD, SFHM, FAAP, who works as a med-peds hospitalist at UCSD and is pediatric editor of The Hospitalist. “We were providing ideal care as defined in the guidelines only about 60 percent of the time.”

Dr. Chang found that UCSD pulmonologists were simultaneously working on their own QI project, so they combined forces around a COPD Inpatient Care Workgroup comprising hospitalists, pulmonologists, respiratory therapists, pharmacists, and information system specialists. The group developed a COPD Longitudinal Inpatient Pathway and Transition Pathway (CLIPT) addressing appropriate referrals for subspecialist care and rehabilitation in and out of the hospital.

The key was not just to create order sets for optimal COPD care, but also to improve access, continuity of care, and post-discharge follow-up through the pathway, which is available for initiation in the ED, at or after admission, or at discharge, Dr. Chang explains. Transition nurse specialists trained as part of a separate initiative at the medical center provide COPD case management. The group is exploring the use of respiratory therapists to actively case-manage COPD patients going home. Patients are connected with a COPD discharge clinic staffed part-time by a UCSD pulmonologist.

According to the abstract, the CLIPT pathway was initiated in 46% of patients admitted with acute exacerbations of COPD. Dr. Chang says further study is needed to assess outcomes during and after hospitalization.

More ideas on enhancing hospital care for the COPD population in order to manage their high risk of readmissions was presented at the recent COPD and Readmissions Summit sponsored by the COPD Foundation (www.copdfoundation.org) in October in Washington, D.C.

References

1. Chang W, Maynard G, Clay B. Implementation of a computerized COPD inpatient pathway and transition pathway [abstract]. J Hosp Med. 2013;8 Suppl 1:709.
2. Schmitt S, McQuillen DP, Nahass R, et al. Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs [published online ahead of print September 25, 2013]. Clin Infect Dis.
3. Torio CM, Andrews RM. National inpatient hospital costs: the most expensive conditions by payer, 2011. Healthcare Cost and Utilization Project Statistical Brief #160. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb160.jsp. Accessed October 26, 2013.
4. Herman B. Top 20 most expensive inpatient conditions. Becker’s Hospital Review. Oct. 9, 2013. Available at: http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/top-20-most-expensive-inpatient-conditions.html. Accessed October 26, 2013.

The National Commission on Certification of Physician Assistants (NCCPA), the organization responsible for credentialing PAs, recently announced an opportunity for certified physician assistants (PA-C) to obtain a Certificate of Added Qualifications (CAQ) in Hospital Medicine. An examination for this voluntary credential will be given for the first time in September 2014.

In the meantime, eligible PAs can register for the process and start gathering the prerequisites, which include 3,000 hours of work in hospital medicine, 150 credits of HM-relevant continuing medical education, and a supervising physician’s sign-off on their ability to perform 10 procedures and patient care requirements derived from SHM’s core competencies (http://www.hospitalmedicine.org/Content/NavigationMenu/Education/CoreCurriculum/Core_Competencies.htm).

NCCPA, which estimates that 3,000 PAs currently work in hospital medicine, certifies PAs in general medical knowledge and experience and has implemented five specialized CAQs.

Zachary Hartsell, PA-C, who has 12 years of experience and directs PA services at Wake Forest Baptist Medical Center in Winston-Salem, N.C., is one of the question writers for the upcoming CAQ-HM exam. “I also look forward to taking the exam,” he says. “As a hospitalist PA, this is one way to show my hospital-based skills and expertise.”

Hartsell expects the qualification to become an important consideration in hiring PAs for jobs in hospital settings.

“As an administrator, it represents to me that this person has specific skills,” he says. But he emphasizes that the new voluntary qualification should not be viewed as locking PAs into a single setting or specialization. “Our certifying exam as PAs is based on general medicine, and PAs have to keep up general medicine skills to pass that exam every six years,” he notes.

For information about the HM CAQ, visit www.nccpa.net/HospitalMedicine.

Larry Beresford is a freelance writer in San Francisco, Calif.

References

1. Chang W, Maynard G, Clay B. Implementation of a computerized COPD inpatient pathway and transition pathway [abstract]. J Hosp Med. 2013;8 Suppl 1:709.
2. Schmitt S, McQuillen DP, Nahass R, et al. Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs [published online ahead of print September 25, 2013]. Clin Infect Dis.
3. Torio CM, Andrews RM. National inpatient hospital costs: the most expensive conditions by payer, 2011. Healthcare Cost and Utilization Project Statistical Brief #160. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb160.jsp. Accessed October 26, 2013.
4. Herman B. Top 20 most expensive inpatient conditions. Becker’s Hospital Review. Oct. 9, 2013. Available at: http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/top-20-most-expensive-inpatient-conditions.html. Accessed October 26, 2013.

The National Commission on Certification of Physician Assistants (NCCPA), the organization responsible for credentialing PAs, recently announced an opportunity for certified physician assistants (PA-C) to obtain a Certificate of Added Qualifications (CAQ) in Hospital Medicine. An examination for this voluntary credential will be given for the first time in September 2014.

In the meantime, eligible PAs can register for the process and start gathering the prerequisites, which include 3,000 hours of work in hospital medicine, 150 credits of HM-relevant continuing medical education, and a supervising physician’s sign-off on their ability to perform 10 procedures and patient care requirements derived from SHM’s core competencies (http://www.hospitalmedicine.org/Content/NavigationMenu/Education/CoreCurriculum/Core_Competencies.htm).

NCCPA, which estimates that 3,000 PAs currently work in hospital medicine, certifies PAs in general medical knowledge and experience and has implemented five specialized CAQs.

Zachary Hartsell, PA-C, who has 12 years of experience and directs PA services at Wake Forest Baptist Medical Center in Winston-Salem, N.C., is one of the question writers for the upcoming CAQ-HM exam. “I also look forward to taking the exam,” he says. “As a hospitalist PA, this is one way to show my hospital-based skills and expertise.”

Hartsell expects the qualification to become an important consideration in hiring PAs for jobs in hospital settings.

“As an administrator, it represents to me that this person has specific skills,” he says. But he emphasizes that the new voluntary qualification should not be viewed as locking PAs into a single setting or specialization. “Our certifying exam as PAs is based on general medicine, and PAs have to keep up general medicine skills to pass that exam every six years,” he notes.

For information about the HM CAQ, visit www.nccpa.net/HospitalMedicine.

Larry Beresford is a freelance writer in San Francisco, Calif.

References

1. Chang W, Maynard G, Clay B. Implementation of a computerized COPD inpatient pathway and transition pathway [abstract]. J Hosp Med. 2013;8 Suppl 1:709.
2. Schmitt S, McQuillen DP, Nahass R, et al. Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs [published online ahead of print September 25, 2013]. Clin Infect Dis.
3. Torio CM, Andrews RM. National inpatient hospital costs: the most expensive conditions by payer, 2011. Healthcare Cost and Utilization Project Statistical Brief #160. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb160.jsp. Accessed October 26, 2013.
4. Herman B. Top 20 most expensive inpatient conditions. Becker’s Hospital Review. Oct. 9, 2013. Available at: http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/top-20-most-expensive-inpatient-conditions.html. Accessed October 26, 2013.

The National Commission on Certification of Physician Assistants (NCCPA), the organization responsible for credentialing PAs, recently announced an opportunity for certified physician assistants (PA-C) to obtain a Certificate of Added Qualifications (CAQ) in Hospital Medicine. An examination for this voluntary credential will be given for the first time in September 2014.

In the meantime, eligible PAs can register for the process and start gathering the prerequisites, which include 3,000 hours of work in hospital medicine, 150 credits of HM-relevant continuing medical education, and a supervising physician’s sign-off on their ability to perform 10 procedures and patient care requirements derived from SHM’s core competencies (http://www.hospitalmedicine.org/Content/NavigationMenu/Education/CoreCurriculum/Core_Competencies.htm).

NCCPA, which estimates that 3,000 PAs currently work in hospital medicine, certifies PAs in general medical knowledge and experience and has implemented five specialized CAQs.

Zachary Hartsell, PA-C, who has 12 years of experience and directs PA services at Wake Forest Baptist Medical Center in Winston-Salem, N.C., is one of the question writers for the upcoming CAQ-HM exam. “I also look forward to taking the exam,” he says. “As a hospitalist PA, this is one way to show my hospital-based skills and expertise.”

Hartsell expects the qualification to become an important consideration in hiring PAs for jobs in hospital settings.

“As an administrator, it represents to me that this person has specific skills,” he says. But he emphasizes that the new voluntary qualification should not be viewed as locking PAs into a single setting or specialization. “Our certifying exam as PAs is based on general medicine, and PAs have to keep up general medicine skills to pass that exam every six years,” he notes.

For information about the HM CAQ, visit www.nccpa.net/HospitalMedicine.

Larry Beresford is a freelance writer in San Francisco, Calif.

References

1. Chang W, Maynard G, Clay B. Implementation of a computerized COPD inpatient pathway and transition pathway [abstract]. J Hosp Med. 2013;8 Suppl 1:709.
2. Schmitt S, McQuillen DP, Nahass R, et al. Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs [published online ahead of print September 25, 2013]. Clin Infect Dis.
3. Torio CM, Andrews RM. National inpatient hospital costs: the most expensive conditions by payer, 2011. Healthcare Cost and Utilization Project Statistical Brief #160. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb160.jsp. Accessed October 26, 2013.
4. Herman B. Top 20 most expensive inpatient conditions. Becker’s Hospital Review. Oct. 9, 2013. Available at: http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/top-20-most-expensive-inpatient-conditions.html. Accessed October 26, 2013.

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Two Cases

A 76-year-old female with a history of hypertension, diabetes, atrial fibrillation, and diverticulosis is admitted with acute onset of dizziness and several episodes of bright red blood per rectum. Her labs show a new anemia at hemoglobin level 6.9 g/dL and an international normalized ratio (INR) of 2.7. She is transfused several units of packed red blood cells and fresh frozen plasma without further bleeding. She undergoes an esophagogastroduodenoscopy (EGD) and colonoscopy, which are notable only for extensive diverticulosis. In preparing the discharge medication reconciliation, you are uncertain what to do with the patient’s anticoagulation.

An 85-year-old male with coronary artery disease status post-percutaneous coronary intervention, with placement of a drug-eluting stent several years prior, is admitted with multiple weeks of epigastric discomfort and acute onset of hematemesis. His laboratory tests are notable for a new anemia at hemoglobin level 6.5 g/dL. Urgent EGD demonstrates a bleeding ulcer, which is cauterized. He is started on a proton-pump inhibitor (PPI). He inquires as to when he can restart his home medications, including aspirin.

Overview

Gastrointestinal (GI) bleeding is a serious complication of anticoagulant and antiplatelet therapy. Risks for GI bleeding include older age, history of peptic ulcer disease, NSAID or steroid use, and the use of antiplatelet or anticoagulation therapy. The estimated incidence of GI bleeding in the general population is 48 to 160 cases (upper GI) and 21 cases (lower GI) per 1,000 adults per year, with a case-mortality rate between 5% and 14%.¹

Although there is consensus on ceasing anticoagulant and antiplatelet agents during an acute GI bleed, debate remains over the appropriate approach to restarting these agents.

Anticoagulant Resumption

A recent study published in Archives of Internal Medicine supports a quick resumption of anticoagulation following a GI bleed.2 Although previous studies on restarting anticoagulants were small and demonstrated mixed results, this retrospective cohort study examined more than 442 warfarin-associated GI bleeds. After adjusting for various clinical indicators (e.g. clinical seriousness of bleeding, requirement of transfusions), the investigators found that the decision not to resume warfarin within 90 days of an initial GI hemorrhage was associated with an increased risk of thrombosis and death. Of note, in those patients restarted on warfarin, the mean time to medication initiation was four days following the initial GI bleed. In those not restarted on warfarin, the earliest incidence of thrombosis was documented at eight days following cessation of anticoagulation.²

Though its clinical implications are limited by the retrospective design, this study is helpful in guiding management decisions. Randomized control trials and society recommendations on this topic are lacking, so the decision to resume anticoagulants rests on patient-specific estimates of the risk of recurrent bleeding and the benefits of resuming anticoagulants.

In identifying those patients most likely to benefit from restarting anticoagulation, the risk of thromboembolism should be determined using an established risk stratification framework, such as Antithrombotic Therapy and Prevention of Thrombosis, 9th edition (see Table 1).³ According to the guidelines, patients at highest risk of thromboembolism (in the absence of anticoagulation) are those with:

• mitral valve prostheses;
• atrial fibrillation with a CHADS2 score of five to six or cerebrovascular accidents (CVA) within the last three months; and/or
• venous thromboembolism (VTE) within the last three months or history of severe thrombophilia.

Patients at the lowest risk of thromboembolism are those with:

• mechanical aortic prostheses with no other stroke risk factors;
• atrial fibrillation with a CHADS2 score of zero to two; and/or
• a single VTE that occurred >12 months prior.

There are several approaches to identifying patients at greatest risk for bleeding. Location-specific modeling for upper GI bleeds (e.g. Rockall score) and lower GI bleeds (e.g. BLEED score) focus on the clinical presentation and/or endoscopic findings. General hemorrhage risk scores (e.g. HAS-BLED, ATRIA) focus on medical comorbidities. While easy to use, the predictive value of such scores as part of anticoagulation resumption after a GI hemorrhage remains uncertain.

Based on the above methods of risk stratification, patients at higher risk of thromboembolism and lower risk of bleeding will likely benefit from waiting only a short time interval before restarting anticoagulation. Based on the trial conducted by Witt and colleagues, anticoagulation typically can be reinitiated within four days of obtaining hemostatic and hemodynamic stability.² Conversely, those at highest risk of bleeding and lower risk of thromboembolism will benefit from a delayed resumption of anticoagulation. Involvement of a specialist, such as a gastroenterologist, could help further clarify the risk of rebleeding.

The ideal approach for patients with a high risk of both bleeding and thromboembolism remains uncertain. Such cases highlight the need for an informed discussion with the patient and any involved caregivers, as well as involvement of inpatient subspecialists and outpatient longitudinal providers.

There remains a lack of evidence on the best method to restart anticoagulation. Based on small and retrospective trials, we recommend restarting warfarin at the patient’s previous home dose. The duration of inpatient monitoring following warfarin initiation should be individualized, but warfarin is not expected to impair coagulation for four to six days after initiation.

Little data is available with respect to the role of novel oral anticoagulants after a GI bleed. Given the lack of reversing agents for these drugs, we recommend exercising caution in populations with a high risk of rebleeding. Theoretically, given that these agents reach peak effect faster than warfarin, waiting an additional four days after the time frame recommended for starting warfarin is a prudent resumption strategy for novel oral anticoagulants.

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Resumption of Antiplatelet Agents

The decision to resume antiplatelet therapy should also be highly individualized. In addition to weighing the risk of bleeding (as described in the previous section), the physician must also estimate the benefits of antiplatelet therapy in decreasing the risk of cardiovascular events.

In low-risk patients on antiplatelet therapy (i.e., for primary cardiovascular prevention) reinitiation after a bleeding episode can be reasonably delayed, because the risk of rebleeding likely outweighs the potential benefit of restarting therapy.

For patients who are at intermediate risk (i.e., those on antiplatelet agents for secondary prevention of cardiovascular disease), emerging evidence argues for early reinstitution after a GI bleed. In a trial published in Annals of Internal Medicine, Sung and colleagues randomized 156 patients to aspirin or placebo therapy immediately following endoscopically obtained hemostasis for peptic ulcer bleeding.⁴ All patients received PPIs. There was no significant difference in bleeding rates between the two groups, but delayed resumption of aspirin was associated with a significant increase in all-cause mortality.

Two recent meta-analyses provide further insight into the risks of withholding aspirin therapy. The first, which included 50,279 patients on aspirin for secondary prevention, found that aspirin non-adherence or withdrawal after a GI bleed was associated with a three-fold higher risk of major adverse cardiac events.⁵ Cardiac event rates were highest in the subgroup of patients with a history of prior percutaneous coronary stenting.

A second meta-analysis evaluated patients who had aspirin held perioperatively. In a population of patients on aspirin for secondary prevention, the mean time after withholding aspirin was 8.5 days to coronary events, 14.3 days to cerebrovascular events, and 25.8 days to peripheral arterial events.⁶ Events occurred as early as five days after withdrawal of aspirin.

Patients with recent intracoronary stenting are at highest risk of thrombosis. In patients with a bare metal stent placed within six weeks, or a drug-eluting stent placed within six months, every effort should be made to minimize interruptions of dual antiplatelet therapy.

Based on the data presented above, for patients at intermediate and/or high risk of adverse cardiac events, we recommend reinstitution of aspirin as soon as possible following a GI hemorrhage, preferably within five days. PPI co-therapy is a mainstay for secondary prevention of upper GI bleeding in patients on antiplatelet therapy. Current research and guidelines have not addressed specifically the role of withholding and reinitiating aspirin in lower GI bleeding, non-peptic ulcer, or upper-GI bleeding, however, a similar strategy is likely appropriate. As with the decision for restarting anticoagulants, discussion with relevant specialists is essential to best define the risk of re-bleeding.

Back to the Cases

Given her CHADS2 score of three, the patient with a diverticular bleed has a 9.6% annual risk of stroke if she does not resume anticoagulation. Using the HAS-BLED and ATRIA scores, this patient has 2.6% to 5.8% annual risk of hemorrhage. We recommend resuming warfarin anticoagulation therapy within four days of achieving hemostasis.

For the patient with coronary artery disease with remote drug-eluting stent placement and upper GI bleed, evidence supports early resumption of appropriate antiplatelet therapy following endoscopic therapy and hemostasis. We recommend resuming aspirin during the current hospitalization and concomitant treatment with a PPI indefinitely.

Bottom Line

Following a GI bleed, the risks and benefits of restarting anticoagulant and antiplatelet agents need to be carefully considered. In patients on oral anticoagulants at high risk for thromboembolism and low risk for rebleeding, consider restarting anticoagulation within four to five days. Patients on antiplatelet agents for secondary prevention should have the medication restarted during hospitalization after endoscopically obtained hemostasis of a peptic ulcer.

In all cases, hospitalists should engage the patient, gastroenterologist, and outpatient provider to best determine when resumption of anticoagulant and/or antiplatelet agents should occur.

Dr. Allen-Dicker is a hospitalist and clinical instructor at Mount Sinai Medical Center in New York City. Dr. Briones is director of perioperative services in the division of hospital medicine and an assistant professor; Dr. Berman is a hospitalist and a clinical instructor, and Dr. Dunn is a professor of medicine and chief of the division of hospital medicine, all at Mount Sinai Medical Center.

References

1. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101-113.
2. Witt DM, Delate T, Garcia DA, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for gastrointestinal tract bleeding. Arch Intern Med. 2012;172(19):1484-1491.
3. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e326S-350S.
4. Sung JJ, Lau JY, Ching JY, et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding: A randomized trial. Ann Intern Med. 2010;152(1):1-9.
5. Biondi-Zoccai GG, Lotrionte M, Agostoni P, et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J. 2006;27(22):2667-2674.
6. Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose aspirin for secondary cardiovascular prevention – cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation – review and meta-analysis. J Intern Med. 2005;257(5):399-414.

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Two Cases

A 76-year-old female with a history of hypertension, diabetes, atrial fibrillation, and diverticulosis is admitted with acute onset of dizziness and several episodes of bright red blood per rectum. Her labs show a new anemia at hemoglobin level 6.9 g/dL and an international normalized ratio (INR) of 2.7. She is transfused several units of packed red blood cells and fresh frozen plasma without further bleeding. She undergoes an esophagogastroduodenoscopy (EGD) and colonoscopy, which are notable only for extensive diverticulosis. In preparing the discharge medication reconciliation, you are uncertain what to do with the patient’s anticoagulation.

An 85-year-old male with coronary artery disease status post-percutaneous coronary intervention, with placement of a drug-eluting stent several years prior, is admitted with multiple weeks of epigastric discomfort and acute onset of hematemesis. His laboratory tests are notable for a new anemia at hemoglobin level 6.5 g/dL. Urgent EGD demonstrates a bleeding ulcer, which is cauterized. He is started on a proton-pump inhibitor (PPI). He inquires as to when he can restart his home medications, including aspirin.

Overview

Gastrointestinal (GI) bleeding is a serious complication of anticoagulant and antiplatelet therapy. Risks for GI bleeding include older age, history of peptic ulcer disease, NSAID or steroid use, and the use of antiplatelet or anticoagulation therapy. The estimated incidence of GI bleeding in the general population is 48 to 160 cases (upper GI) and 21 cases (lower GI) per 1,000 adults per year, with a case-mortality rate between 5% and 14%.¹

Although there is consensus on ceasing anticoagulant and antiplatelet agents during an acute GI bleed, debate remains over the appropriate approach to restarting these agents.

Anticoagulant Resumption

A recent study published in Archives of Internal Medicine supports a quick resumption of anticoagulation following a GI bleed.2 Although previous studies on restarting anticoagulants were small and demonstrated mixed results, this retrospective cohort study examined more than 442 warfarin-associated GI bleeds. After adjusting for various clinical indicators (e.g. clinical seriousness of bleeding, requirement of transfusions), the investigators found that the decision not to resume warfarin within 90 days of an initial GI hemorrhage was associated with an increased risk of thrombosis and death. Of note, in those patients restarted on warfarin, the mean time to medication initiation was four days following the initial GI bleed. In those not restarted on warfarin, the earliest incidence of thrombosis was documented at eight days following cessation of anticoagulation.²

Though its clinical implications are limited by the retrospective design, this study is helpful in guiding management decisions. Randomized control trials and society recommendations on this topic are lacking, so the decision to resume anticoagulants rests on patient-specific estimates of the risk of recurrent bleeding and the benefits of resuming anticoagulants.

In identifying those patients most likely to benefit from restarting anticoagulation, the risk of thromboembolism should be determined using an established risk stratification framework, such as Antithrombotic Therapy and Prevention of Thrombosis, 9th edition (see Table 1).³ According to the guidelines, patients at highest risk of thromboembolism (in the absence of anticoagulation) are those with:

• mitral valve prostheses;
• atrial fibrillation with a CHADS2 score of five to six or cerebrovascular accidents (CVA) within the last three months; and/or
• venous thromboembolism (VTE) within the last three months or history of severe thrombophilia.

Patients at the lowest risk of thromboembolism are those with:

• mechanical aortic prostheses with no other stroke risk factors;
• atrial fibrillation with a CHADS2 score of zero to two; and/or
• a single VTE that occurred >12 months prior.

There are several approaches to identifying patients at greatest risk for bleeding. Location-specific modeling for upper GI bleeds (e.g. Rockall score) and lower GI bleeds (e.g. BLEED score) focus on the clinical presentation and/or endoscopic findings. General hemorrhage risk scores (e.g. HAS-BLED, ATRIA) focus on medical comorbidities. While easy to use, the predictive value of such scores as part of anticoagulation resumption after a GI hemorrhage remains uncertain.

Based on the above methods of risk stratification, patients at higher risk of thromboembolism and lower risk of bleeding will likely benefit from waiting only a short time interval before restarting anticoagulation. Based on the trial conducted by Witt and colleagues, anticoagulation typically can be reinitiated within four days of obtaining hemostatic and hemodynamic stability.² Conversely, those at highest risk of bleeding and lower risk of thromboembolism will benefit from a delayed resumption of anticoagulation. Involvement of a specialist, such as a gastroenterologist, could help further clarify the risk of rebleeding.

The ideal approach for patients with a high risk of both bleeding and thromboembolism remains uncertain. Such cases highlight the need for an informed discussion with the patient and any involved caregivers, as well as involvement of inpatient subspecialists and outpatient longitudinal providers.

There remains a lack of evidence on the best method to restart anticoagulation. Based on small and retrospective trials, we recommend restarting warfarin at the patient’s previous home dose. The duration of inpatient monitoring following warfarin initiation should be individualized, but warfarin is not expected to impair coagulation for four to six days after initiation.

Little data is available with respect to the role of novel oral anticoagulants after a GI bleed. Given the lack of reversing agents for these drugs, we recommend exercising caution in populations with a high risk of rebleeding. Theoretically, given that these agents reach peak effect faster than warfarin, waiting an additional four days after the time frame recommended for starting warfarin is a prudent resumption strategy for novel oral anticoagulants.

click for large version

Resumption of Antiplatelet Agents

The decision to resume antiplatelet therapy should also be highly individualized. In addition to weighing the risk of bleeding (as described in the previous section), the physician must also estimate the benefits of antiplatelet therapy in decreasing the risk of cardiovascular events.

In low-risk patients on antiplatelet therapy (i.e., for primary cardiovascular prevention) reinitiation after a bleeding episode can be reasonably delayed, because the risk of rebleeding likely outweighs the potential benefit of restarting therapy.

For patients who are at intermediate risk (i.e., those on antiplatelet agents for secondary prevention of cardiovascular disease), emerging evidence argues for early reinstitution after a GI bleed. In a trial published in Annals of Internal Medicine, Sung and colleagues randomized 156 patients to aspirin or placebo therapy immediately following endoscopically obtained hemostasis for peptic ulcer bleeding.⁴ All patients received PPIs. There was no significant difference in bleeding rates between the two groups, but delayed resumption of aspirin was associated with a significant increase in all-cause mortality.

Two recent meta-analyses provide further insight into the risks of withholding aspirin therapy. The first, which included 50,279 patients on aspirin for secondary prevention, found that aspirin non-adherence or withdrawal after a GI bleed was associated with a three-fold higher risk of major adverse cardiac events.⁵ Cardiac event rates were highest in the subgroup of patients with a history of prior percutaneous coronary stenting.

A second meta-analysis evaluated patients who had aspirin held perioperatively. In a population of patients on aspirin for secondary prevention, the mean time after withholding aspirin was 8.5 days to coronary events, 14.3 days to cerebrovascular events, and 25.8 days to peripheral arterial events.⁶ Events occurred as early as five days after withdrawal of aspirin.

Patients with recent intracoronary stenting are at highest risk of thrombosis. In patients with a bare metal stent placed within six weeks, or a drug-eluting stent placed within six months, every effort should be made to minimize interruptions of dual antiplatelet therapy.

Based on the data presented above, for patients at intermediate and/or high risk of adverse cardiac events, we recommend reinstitution of aspirin as soon as possible following a GI hemorrhage, preferably within five days. PPI co-therapy is a mainstay for secondary prevention of upper GI bleeding in patients on antiplatelet therapy. Current research and guidelines have not addressed specifically the role of withholding and reinitiating aspirin in lower GI bleeding, non-peptic ulcer, or upper-GI bleeding, however, a similar strategy is likely appropriate. As with the decision for restarting anticoagulants, discussion with relevant specialists is essential to best define the risk of re-bleeding.

Back to the Cases

Given her CHADS2 score of three, the patient with a diverticular bleed has a 9.6% annual risk of stroke if she does not resume anticoagulation. Using the HAS-BLED and ATRIA scores, this patient has 2.6% to 5.8% annual risk of hemorrhage. We recommend resuming warfarin anticoagulation therapy within four days of achieving hemostasis.

For the patient with coronary artery disease with remote drug-eluting stent placement and upper GI bleed, evidence supports early resumption of appropriate antiplatelet therapy following endoscopic therapy and hemostasis. We recommend resuming aspirin during the current hospitalization and concomitant treatment with a PPI indefinitely.

Bottom Line

Following a GI bleed, the risks and benefits of restarting anticoagulant and antiplatelet agents need to be carefully considered. In patients on oral anticoagulants at high risk for thromboembolism and low risk for rebleeding, consider restarting anticoagulation within four to five days. Patients on antiplatelet agents for secondary prevention should have the medication restarted during hospitalization after endoscopically obtained hemostasis of a peptic ulcer.

In all cases, hospitalists should engage the patient, gastroenterologist, and outpatient provider to best determine when resumption of anticoagulant and/or antiplatelet agents should occur.

Dr. Allen-Dicker is a hospitalist and clinical instructor at Mount Sinai Medical Center in New York City. Dr. Briones is director of perioperative services in the division of hospital medicine and an assistant professor; Dr. Berman is a hospitalist and a clinical instructor, and Dr. Dunn is a professor of medicine and chief of the division of hospital medicine, all at Mount Sinai Medical Center.

References

1. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101-113.
2. Witt DM, Delate T, Garcia DA, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for gastrointestinal tract bleeding. Arch Intern Med. 2012;172(19):1484-1491.
3. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e326S-350S.
4. Sung JJ, Lau JY, Ching JY, et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding: A randomized trial. Ann Intern Med. 2010;152(1):1-9.
5. Biondi-Zoccai GG, Lotrionte M, Agostoni P, et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J. 2006;27(22):2667-2674.
6. Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose aspirin for secondary cardiovascular prevention – cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation – review and meta-analysis. J Intern Med. 2005;257(5):399-414.

click for large version

Two Cases

A 76-year-old female with a history of hypertension, diabetes, atrial fibrillation, and diverticulosis is admitted with acute onset of dizziness and several episodes of bright red blood per rectum. Her labs show a new anemia at hemoglobin level 6.9 g/dL and an international normalized ratio (INR) of 2.7. She is transfused several units of packed red blood cells and fresh frozen plasma without further bleeding. She undergoes an esophagogastroduodenoscopy (EGD) and colonoscopy, which are notable only for extensive diverticulosis. In preparing the discharge medication reconciliation, you are uncertain what to do with the patient’s anticoagulation.

An 85-year-old male with coronary artery disease status post-percutaneous coronary intervention, with placement of a drug-eluting stent several years prior, is admitted with multiple weeks of epigastric discomfort and acute onset of hematemesis. His laboratory tests are notable for a new anemia at hemoglobin level 6.5 g/dL. Urgent EGD demonstrates a bleeding ulcer, which is cauterized. He is started on a proton-pump inhibitor (PPI). He inquires as to when he can restart his home medications, including aspirin.

Overview

Gastrointestinal (GI) bleeding is a serious complication of anticoagulant and antiplatelet therapy. Risks for GI bleeding include older age, history of peptic ulcer disease, NSAID or steroid use, and the use of antiplatelet or anticoagulation therapy. The estimated incidence of GI bleeding in the general population is 48 to 160 cases (upper GI) and 21 cases (lower GI) per 1,000 adults per year, with a case-mortality rate between 5% and 14%.¹

Although there is consensus on ceasing anticoagulant and antiplatelet agents during an acute GI bleed, debate remains over the appropriate approach to restarting these agents.

Anticoagulant Resumption

A recent study published in Archives of Internal Medicine supports a quick resumption of anticoagulation following a GI bleed.2 Although previous studies on restarting anticoagulants were small and demonstrated mixed results, this retrospective cohort study examined more than 442 warfarin-associated GI bleeds. After adjusting for various clinical indicators (e.g. clinical seriousness of bleeding, requirement of transfusions), the investigators found that the decision not to resume warfarin within 90 days of an initial GI hemorrhage was associated with an increased risk of thrombosis and death. Of note, in those patients restarted on warfarin, the mean time to medication initiation was four days following the initial GI bleed. In those not restarted on warfarin, the earliest incidence of thrombosis was documented at eight days following cessation of anticoagulation.²

Though its clinical implications are limited by the retrospective design, this study is helpful in guiding management decisions. Randomized control trials and society recommendations on this topic are lacking, so the decision to resume anticoagulants rests on patient-specific estimates of the risk of recurrent bleeding and the benefits of resuming anticoagulants.

In identifying those patients most likely to benefit from restarting anticoagulation, the risk of thromboembolism should be determined using an established risk stratification framework, such as Antithrombotic Therapy and Prevention of Thrombosis, 9th edition (see Table 1).³ According to the guidelines, patients at highest risk of thromboembolism (in the absence of anticoagulation) are those with:

• mitral valve prostheses;
• atrial fibrillation with a CHADS2 score of five to six or cerebrovascular accidents (CVA) within the last three months; and/or
• venous thromboembolism (VTE) within the last three months or history of severe thrombophilia.

Patients at the lowest risk of thromboembolism are those with:

• mechanical aortic prostheses with no other stroke risk factors;
• atrial fibrillation with a CHADS2 score of zero to two; and/or
• a single VTE that occurred >12 months prior.

There are several approaches to identifying patients at greatest risk for bleeding. Location-specific modeling for upper GI bleeds (e.g. Rockall score) and lower GI bleeds (e.g. BLEED score) focus on the clinical presentation and/or endoscopic findings. General hemorrhage risk scores (e.g. HAS-BLED, ATRIA) focus on medical comorbidities. While easy to use, the predictive value of such scores as part of anticoagulation resumption after a GI hemorrhage remains uncertain.

Based on the above methods of risk stratification, patients at higher risk of thromboembolism and lower risk of bleeding will likely benefit from waiting only a short time interval before restarting anticoagulation. Based on the trial conducted by Witt and colleagues, anticoagulation typically can be reinitiated within four days of obtaining hemostatic and hemodynamic stability.² Conversely, those at highest risk of bleeding and lower risk of thromboembolism will benefit from a delayed resumption of anticoagulation. Involvement of a specialist, such as a gastroenterologist, could help further clarify the risk of rebleeding.

The ideal approach for patients with a high risk of both bleeding and thromboembolism remains uncertain. Such cases highlight the need for an informed discussion with the patient and any involved caregivers, as well as involvement of inpatient subspecialists and outpatient longitudinal providers.

There remains a lack of evidence on the best method to restart anticoagulation. Based on small and retrospective trials, we recommend restarting warfarin at the patient’s previous home dose. The duration of inpatient monitoring following warfarin initiation should be individualized, but warfarin is not expected to impair coagulation for four to six days after initiation.

Little data is available with respect to the role of novel oral anticoagulants after a GI bleed. Given the lack of reversing agents for these drugs, we recommend exercising caution in populations with a high risk of rebleeding. Theoretically, given that these agents reach peak effect faster than warfarin, waiting an additional four days after the time frame recommended for starting warfarin is a prudent resumption strategy for novel oral anticoagulants.

click for large version

Resumption of Antiplatelet Agents

The decision to resume antiplatelet therapy should also be highly individualized. In addition to weighing the risk of bleeding (as described in the previous section), the physician must also estimate the benefits of antiplatelet therapy in decreasing the risk of cardiovascular events.

In low-risk patients on antiplatelet therapy (i.e., for primary cardiovascular prevention) reinitiation after a bleeding episode can be reasonably delayed, because the risk of rebleeding likely outweighs the potential benefit of restarting therapy.

For patients who are at intermediate risk (i.e., those on antiplatelet agents for secondary prevention of cardiovascular disease), emerging evidence argues for early reinstitution after a GI bleed. In a trial published in Annals of Internal Medicine, Sung and colleagues randomized 156 patients to aspirin or placebo therapy immediately following endoscopically obtained hemostasis for peptic ulcer bleeding.⁴ All patients received PPIs. There was no significant difference in bleeding rates between the two groups, but delayed resumption of aspirin was associated with a significant increase in all-cause mortality.

Two recent meta-analyses provide further insight into the risks of withholding aspirin therapy. The first, which included 50,279 patients on aspirin for secondary prevention, found that aspirin non-adherence or withdrawal after a GI bleed was associated with a three-fold higher risk of major adverse cardiac events.⁵ Cardiac event rates were highest in the subgroup of patients with a history of prior percutaneous coronary stenting.

A second meta-analysis evaluated patients who had aspirin held perioperatively. In a population of patients on aspirin for secondary prevention, the mean time after withholding aspirin was 8.5 days to coronary events, 14.3 days to cerebrovascular events, and 25.8 days to peripheral arterial events.⁶ Events occurred as early as five days after withdrawal of aspirin.

Patients with recent intracoronary stenting are at highest risk of thrombosis. In patients with a bare metal stent placed within six weeks, or a drug-eluting stent placed within six months, every effort should be made to minimize interruptions of dual antiplatelet therapy.

Based on the data presented above, for patients at intermediate and/or high risk of adverse cardiac events, we recommend reinstitution of aspirin as soon as possible following a GI hemorrhage, preferably within five days. PPI co-therapy is a mainstay for secondary prevention of upper GI bleeding in patients on antiplatelet therapy. Current research and guidelines have not addressed specifically the role of withholding and reinitiating aspirin in lower GI bleeding, non-peptic ulcer, or upper-GI bleeding, however, a similar strategy is likely appropriate. As with the decision for restarting anticoagulants, discussion with relevant specialists is essential to best define the risk of re-bleeding.

Back to the Cases

Given her CHADS2 score of three, the patient with a diverticular bleed has a 9.6% annual risk of stroke if she does not resume anticoagulation. Using the HAS-BLED and ATRIA scores, this patient has 2.6% to 5.8% annual risk of hemorrhage. We recommend resuming warfarin anticoagulation therapy within four days of achieving hemostasis.

For the patient with coronary artery disease with remote drug-eluting stent placement and upper GI bleed, evidence supports early resumption of appropriate antiplatelet therapy following endoscopic therapy and hemostasis. We recommend resuming aspirin during the current hospitalization and concomitant treatment with a PPI indefinitely.

Bottom Line

Following a GI bleed, the risks and benefits of restarting anticoagulant and antiplatelet agents need to be carefully considered. In patients on oral anticoagulants at high risk for thromboembolism and low risk for rebleeding, consider restarting anticoagulation within four to five days. Patients on antiplatelet agents for secondary prevention should have the medication restarted during hospitalization after endoscopically obtained hemostasis of a peptic ulcer.

In all cases, hospitalists should engage the patient, gastroenterologist, and outpatient provider to best determine when resumption of anticoagulant and/or antiplatelet agents should occur.

Dr. Allen-Dicker is a hospitalist and clinical instructor at Mount Sinai Medical Center in New York City. Dr. Briones is director of perioperative services in the division of hospital medicine and an assistant professor; Dr. Berman is a hospitalist and a clinical instructor, and Dr. Dunn is a professor of medicine and chief of the division of hospital medicine, all at Mount Sinai Medical Center.

References

1. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101-113.
2. Witt DM, Delate T, Garcia DA, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for gastrointestinal tract bleeding. Arch Intern Med. 2012;172(19):1484-1491.
3. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e326S-350S.
4. Sung JJ, Lau JY, Ching JY, et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding: A randomized trial. Ann Intern Med. 2010;152(1):1-9.
5. Biondi-Zoccai GG, Lotrionte M, Agostoni P, et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J. 2006;27(22):2667-2674.
6. Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose aspirin for secondary cardiovascular prevention – cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation – review and meta-analysis. J Intern Med. 2005;257(5):399-414.

Weijen Chang, MD, SFHM, FAAP

Clinical question: What is the benefit of oseltamivir treatment to previously healthy children hospitalized with confirmed influenza infection?

Background: Influenza is generally a mild, self-limited infection that affects all ages but can lead to more serious illness. During the 2012-2013 season, laboratory-confirmed influenza in children zero to four years was associated with a hospitalization rate of 66.4 per 100,000 and 164 pediatric deaths. Currently, the American Academy of Pediatrics and the CDC recommend treatment with either oseltamivir or zanamivir for children hospitalized with influenza. However, despite the recommendations, data are limited regarding the benefits resulting from treating otherwise healthy children hospitalized with influenza.

Study design: Multi-center retrospective study.

Setting: Ten public hospitals in Madrid, Spain, between September 2010 and June 2012.

Synopsis: Researchers identified children ≤14 years admitted to participating hospitals by positive testing with either rapid diagnostic testing or polymerase chain reaction assay of nasal washings. Patients at high risk of serious disease were excluded, including those with chronic disease, immunodeficiency, prematurity (less than 32 weeks gestation), age less than six months at admission, nosocomial infection, and those requiring ICU-level care upon admission. Patients with asthma were included. Decision to treat with oseltamivir was determined by hospital guidelines, with some hospitals treating all hospitalized children with confirmed influenza and others only treating patients with risk factors for severe disease. In addition, only children who had manifested symptoms within 48 hours of admission were included.

Of the 287 children included in the final analysis, 93 were treated with oseltamivir (32%). There were no significant differences between treatment and non-treatment groups in duration of fever, duration of hypoxia, length of stay, or rates of ICU transfer. In addition, the lack of differences in outcomes persisted after subgroup analysis of patients less than one year old.

Bottom line: Treatment with oseltamivir of otherwise healthy children hospitalized with influenza not requiring ICU care is unlikely to yield measurable benefit.

Citation: Bueno M, Calvo C, Mendez-Echevarría A, et al. Oseltamivir treatment for influenza in hospitalized children without underlying diseases. Pediatr Infect Dis J. 2013;32(10):1066-1069.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Weijen Chang, MD, SFHM, FAAP

Clinical question: What is the benefit of oseltamivir treatment to previously healthy children hospitalized with confirmed influenza infection?

Background: Influenza is generally a mild, self-limited infection that affects all ages but can lead to more serious illness. During the 2012-2013 season, laboratory-confirmed influenza in children zero to four years was associated with a hospitalization rate of 66.4 per 100,000 and 164 pediatric deaths. Currently, the American Academy of Pediatrics and the CDC recommend treatment with either oseltamivir or zanamivir for children hospitalized with influenza. However, despite the recommendations, data are limited regarding the benefits resulting from treating otherwise healthy children hospitalized with influenza.

Study design: Multi-center retrospective study.

Setting: Ten public hospitals in Madrid, Spain, between September 2010 and June 2012.

Synopsis: Researchers identified children ≤14 years admitted to participating hospitals by positive testing with either rapid diagnostic testing or polymerase chain reaction assay of nasal washings. Patients at high risk of serious disease were excluded, including those with chronic disease, immunodeficiency, prematurity (less than 32 weeks gestation), age less than six months at admission, nosocomial infection, and those requiring ICU-level care upon admission. Patients with asthma were included. Decision to treat with oseltamivir was determined by hospital guidelines, with some hospitals treating all hospitalized children with confirmed influenza and others only treating patients with risk factors for severe disease. In addition, only children who had manifested symptoms within 48 hours of admission were included.

Of the 287 children included in the final analysis, 93 were treated with oseltamivir (32%). There were no significant differences between treatment and non-treatment groups in duration of fever, duration of hypoxia, length of stay, or rates of ICU transfer. In addition, the lack of differences in outcomes persisted after subgroup analysis of patients less than one year old.

Bottom line: Treatment with oseltamivir of otherwise healthy children hospitalized with influenza not requiring ICU care is unlikely to yield measurable benefit.

Citation: Bueno M, Calvo C, Mendez-Echevarría A, et al. Oseltamivir treatment for influenza in hospitalized children without underlying diseases. Pediatr Infect Dis J. 2013;32(10):1066-1069.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Weijen Chang, MD, SFHM, FAAP

Clinical question: What is the benefit of oseltamivir treatment to previously healthy children hospitalized with confirmed influenza infection?

Background: Influenza is generally a mild, self-limited infection that affects all ages but can lead to more serious illness. During the 2012-2013 season, laboratory-confirmed influenza in children zero to four years was associated with a hospitalization rate of 66.4 per 100,000 and 164 pediatric deaths. Currently, the American Academy of Pediatrics and the CDC recommend treatment with either oseltamivir or zanamivir for children hospitalized with influenza. However, despite the recommendations, data are limited regarding the benefits resulting from treating otherwise healthy children hospitalized with influenza.

Study design: Multi-center retrospective study.

Setting: Ten public hospitals in Madrid, Spain, between September 2010 and June 2012.

Synopsis: Researchers identified children ≤14 years admitted to participating hospitals by positive testing with either rapid diagnostic testing or polymerase chain reaction assay of nasal washings. Patients at high risk of serious disease were excluded, including those with chronic disease, immunodeficiency, prematurity (less than 32 weeks gestation), age less than six months at admission, nosocomial infection, and those requiring ICU-level care upon admission. Patients with asthma were included. Decision to treat with oseltamivir was determined by hospital guidelines, with some hospitals treating all hospitalized children with confirmed influenza and others only treating patients with risk factors for severe disease. In addition, only children who had manifested symptoms within 48 hours of admission were included.

Of the 287 children included in the final analysis, 93 were treated with oseltamivir (32%). There were no significant differences between treatment and non-treatment groups in duration of fever, duration of hypoxia, length of stay, or rates of ICU transfer. In addition, the lack of differences in outcomes persisted after subgroup analysis of patients less than one year old.

Bottom line: Treatment with oseltamivir of otherwise healthy children hospitalized with influenza not requiring ICU care is unlikely to yield measurable benefit.

Citation: Bueno M, Calvo C, Mendez-Echevarría A, et al. Oseltamivir treatment for influenza in hospitalized children without underlying diseases. Pediatr Infect Dis J. 2013;32(10):1066-1069.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Intravenous haloperidol does not prevent ICU delirium
2. Predicting delirium risk in hospitalized adults
3. Oral PPIs as effective as IV PPIs in peptic ulcer bleeding
4. Probiotic benefit questioned in the elderly
5. Colchicine and NSAID better than NSAID alone for acute pericarditis
6. Improvement needed in patient understanding at hospital discharge
7. Effectiveness of a multihospital effort to reduce rehospitalization
8. Hospitals profit from preventing surgical site infections
9. Prothrombin complex concentrate safer than fresh frozen plasma in rapidly reversing INR
10. Hospital-acquired anemia associated with higher mortality, increased LOS
11. Thrombolytics and stroke: the faster the better

Intravenous Haloperidol Does Not Prevent ICU Delirium

Clinical question: Can haloperidol reduce delirium in critically ill patients if initiated early in ICU stay?

Background: Prior studies suggest antipsychotics reduce intensity and duration of delirium in hospitalized patients. Evidence is mixed for preventing delirium. A trial of risperidone demonstrated delirium rate reduction in coronary artery bypass grafting (CABG) patients, but another trial of haloperidol in hip surgery patients failed to prevent onset of delirium. There is little evidence on antipsychotics in ICU delirium.

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

Setting: Single, adult ICU in England.

Synopsis: The study randomized 142 critically ill patients to receive 2.5 mg of intravenous haloperidol versus placebo every eight hours for up to 14 days. There was no significant difference between groups in the total time spent free of delirium or coma. Limitations include the use of open-label haloperidol in 21% of the placebo group patients. More sedation but less agitation was seen with the use of haloperidol, which also prolonged QTc. No severe adverse effects were observed.

This study supports the idea that scheduled antipsychotics should not be used to reduce ICU delirium. Addressing modifiable risk factors and using dexmedetomidine rather than lorazepam for sedation in the ICU continue to be first-line strategies to lower delirium rates.

Bottom line: Prophylactic haloperidol should not be used to prevent ICU delirium.

Citation: Page VJ, Ely EW, Gates S, et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomized, double-blind, placebo-controlled trial. Lancet Respir Med. 2013;1(7):515-523.

Predicting Delirium Risk in Hospitalized Adults

Clinical question: Can a simple tool be developed and used for predicting delirium in hospitalized adults?

Background: Delirium is a common condition that results in higher mortality, longer length of stays, and higher probability of discharge to nursing home. Current delirium prediction tools are complicated, or restricted to surgical or critically ill patients.

Study design: Prospective cohort study, with separate derivation and validation cohorts.

Setting: Two academic hospitals and a VA hospital in San Francisco.

Synopsis: Investigators enrolled 374 hospitalized patients who were more than 50 years of age and not delirious at time of admission (209 patients in the derivation and 165 in the validation). The authors identified four predictors of delirium: Age >80; failure to spell “World” backwards; disOrientation to place; and higher nurse-rated iLlness severity (AWOL). The authors found that rates of delirium increased with increasing number of predictors (with zero predictors, 2% developed delirium; one predictor, 4%; two predictors, 14%; three predictors, 20%; four predictors, 64%).

These predictors are similar to other previously identified risk factors, as well as to prediction tools that are in use for surgical patients. However, this tool is quick and can be completed by nursing staff, so it may have a role to play in helping triage patients to units more specialized in preventing delirium.

Bottom line: The AWOL prediction tool is simple to use, broadly applicable, and adds another tool to the literature to determine delirium risk.

Citation: Douglas VC, Hessler CS, Dhaliwal G, et al. The AWOL tool: derivation and validation of a delirium prediction rule. J Hosp Med. 2013;8(9);493-499.

Oral Proton Pump Inhibitors (PPIs) as Effective as IV PPIs in Peptic Ulcer Bleeding

Clinical question: In patients with peptic ulcer bleeding, are oral PPIs of equal benefit to intravenous PPIs?

Background: PPI therapy has been shown in several studies to reduce re-bleeding risk in patients when used adjunctively for peptic ulcer bleeding. In spite of this data, there is still uncertainty about the optimal dose and route of administration.

Study design: Meta-analysis of prospective, randomized control trials.

Setting: OVID database search in June 2012.

Synopsis: A literature search identified six prospective, randomized control trials. Overall, 615 patients were included across the six trials. No significant difference in risk of re-bleeding was discovered between the two groups (8.6% oral vs. 9.3% IV, RR: 0.92, 95% CI: 0.56-1.5). Length of hospital stay was statistically significantly lower for oral PPIs (-0.74 day, 95% CI: -1.10 to -0.39 day).

Because these findings are based on a meta-analysis of studies with notable flaws—including lack of blinding—it is difficult to draw any definitive conclusions from this data. Hospitalists should use care before changing their practice patterns, given the risk of bias and need for further study.

Bottom line: Oral PPIs may reduce hospital length of stay without an increased risk of re-bleeding; however, further study with a well-powered, double-blind, randomized control trial is necessary.

Citation: Tsoi KK, Hirai HW, Sung JJ. Meta-analysis: comparison of oral vs. intravenous proton pump inhibitors in patients with peptic ulcer bleeding. Aliment Pharmacol Ther. 2013;38(7):721-728.

Probiotic Benefit Questioned in the Elderly

Clinical question: Do probiotics prevent antibiotic-associated diarrhea (AAD) in patients 65 and older?

Background: Individual studies using different protocols to assess the efficacy of probiotics in preventing AAD, including Clostridium difficile-associated diarrhea (CDAD), suggest a decreased incidence of AAD when taking probiotics. Meta-analysis of this data also suggests that probiotics are effective in prevention of AAD; however, these results are undermined by the high heterogeneity of the studies included.

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

Setting: Multicenter trial in the United Kingdom.

Synopsis: Nearly 3,000 patients ages 65 years and older who had received one or more antibiotics within seven days were randomized to receive placebo or high-dose probiotics for 21 days. After recruitment, the patients were assessed for AAD up to eight weeks and CDAD up to 12 weeks. Results did not demonstrate a reduction of AAD or CDAD in patients taking probiotics. AAD occurred in 10.8% of patients taking the probiotic and 10.4% of patients taking placebo (95% confidence interval 0.83-1.32). CDAD occurred in 0.8% of patients taking the probiotic and 1.2% of patients taking placebo (95% confidence interval 0.34-1.47).

Based on the results of this double-blind, placebo-controlled trial, there is insufficient evidence to support initiation of probiotics for the prevention of AAD and CDAD in patients 65 years and older. Future studies utilizing standardized protocols against specific antibiotics, along with improved understanding of the underlying mechanisms of AAD prevention, are needed.

Bottom line: High-dose probiotics (lactobacillus acidophilus and bifidobacterium bifidum) do not prevent AAD in elderly patients.

Citation: Allen S, Wareham K, Wang D, et al. Lactobacilli and bifidobacteria in the prevention of antibiotic-associated diarrhoea and Clostridium difficile diarrhoea in older inpatients (PLACIDE): a randomised, double-blind, placebo-controlled, multicentre trial. Lancet. 2013;382(9900):1249-1257.

Colchicine and NSAID Better than NSAID Alone for Acute Pericarditis

Clinical question: Is colchicine safe, effective, and able to prevent recurrence in acute pericarditis?

Background: Colchicine is effective for the treatment of recurrent pericarditis. More recent open-label trials have established its role in acute pericarditis when combined with conventional NSAID therapy. However, a definitive randomized control trial has not been performed to establish colchicine’s role in acute pericarditis.

Study design: Double-blinded, randomized, controlled trial.

Setting: Multicenter in Northern Italy.

Synopsis: Investigators randomized 240 patients to receive either colchicine or placebo in addition to standard therapy of either aspirin or ibuprofen. Incessant or recurrent pericarditis occurred in 16.7% of patients treated with colchicine versus 37.5% in patients receiving placebo (RR 0.56; 95% CI 0.30-0.72; P<0.001). The number needed to treat to prevent one episode of incessant or recurrent pericarditis was four. Colchicine therapy also reduced the frequency of symptom persistence at 72 hours, number of recurrences per patient, rate of hospitalization, and the rate of readmission within one week.

It should be noted that the study excluded the following groups: patients with an elevated troponin, elevated transaminases (>1.5 upper limit of normal), and serum creatinine >2.5.

Bottom line: In addition to conventional therapy, colchicine reduces incessant or recurrent pericarditis in patients with a first episode of acute pericarditis.

Citation: Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013;369(16):1522-1528.

Improvement Needed in Patient Understanding at Hospital Discharge

Clinical question: How well do older patients with heart failure, pneumonia, or acute coronary syndrome understand their diagnosis and post-discharge follow-up plans compared with medical record data?

Background: As hospitals across the country work on preventing 30-day readmissions, more attention has been given to assessing the quality of discharge processes; few evaluations have been conducted from a patient-centered perspective.

Study Design: Prospective, observational cohort study.

Setting: An urban, academic medical center.

Synopsis: This study evaluated the quality of the discharge process among 377 hospitalized patients >65 years old. Medical record data were compared with patient responses during a telephone interview within one week of discharge. By medical records, every patient received discharge instructions that in 97% of cases included discharge diagnosis, activity instructions, follow-up physician information, and warning signs. The authors determined that discharge diagnosis was not written in lay terms 26% of the time. By patient report, 90% expressed that they understood their discharge diagnosis, yet only around 60% fully understood their diagnosis as it was written in the medical record. Although about half of patients reported having a follow-up appointment upon discharge, only about a third of patients had a documented follow-up appointment in the medical record.

Bottom line: Multiple discrepancies were identified between medical record review and patients’ understanding of their discharge diagnosis and plans. Improvements in discharge processes (such as making follow-up appointments) and in patient education (such as increased use of layperson language) are needed.

Citation: Horwitz LI, Moriarty JP, Chen C, et al. Quality of discharge practices and patient understanding at an academic medical center [published online ahead of print August 19, 2013]. JAMA Intern Med.

Effectiveness of a Multihospital Effort to Reduce Rehospitalization

Clinical question: Does Project BOOST reduce 30-day rehospitalization for hospitals participating in a quality improvement collaborative?

Background: With the advent of penalties for hospitals with excessive 30-day readmissions among Medicare beneficiaries, hospitals nationwide are attempting to reduce 30-day readmission rates. Few interventions aimed at reducing 30-day hospital readmissions have been effective, and successful interventions have limited generalizability.

Study design: Semi-controlled, pre-post study.

Setting: Volunteer sample of acute care pilot units within a nationally representative sample of 11 academic and non-academic hospitals.

Synopsis: The 11 hospitals enrolled in this quality improvement collaborative planned and implemented Project BOOST tools over 12 months with support from an external quality improvement mentor. Each hospital tailored the BOOST tools that they implemented based on a needs assessment. Reporting of clinical outcome data was voluntary; administrative sources at each hospital provided these data. Although 30 hospitals participated in this collaborative, only 11 hospitals reported data for this analysis.

Average 30-day rehospitalization rates among BOOST units fell from pre- to post-implementation (14.7% to 12.7%, P=0.010); 30-day rehospitalization rates among control units did not change during this same time period (14.1% to 14.0%, respectively, P=0.831).

Bottom line: Although the 11 hospitals in this collaborative found reduced 30-day readmissions in association with BOOST implementation, this finding may be biased due to voluntary reporting of data and improvements at one hospital driving the overall effect of the intervention. More rigorous evaluation of Project BOOST is needed.

Citation: Hansen LO, Greewald JL, Budnitz T, et al. Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-427.

Hospitals Profit from Preventing Surgical Site Infections

Clinical question: Does quality improvement, in this case preventing surgical site infections (SSIs), necessarily lead to improvement in hospital profit?

Background: It’s clear that preventing SSIs benefits patients and saves money for health insurance providers, but it’s unclear what financial impact SSIs have on hospitals and how best to calculate it. This quantification is needed for cost-benefit analyses of interventions designed to prevent SSIs.

Study design: Retrospective study.

Setting: Four Johns Hopkins-affiliated, tertiary care hospitals.

Synopsis: This retrospective study included all patients admitted to or having certain surgical procedures at four Johns Hopkins-affiliated hospitals between Jan. 1, 2007, and Dec. 31, 2010. Patients were first stratified by complexity, and then those who had a SSI (618) were compared to those without SSIs (399,627 admissions and 25,849 surgeries) for differences in daily hospital charges, length of stay, 30-day readmission rates, and hospital profit.

Although daily charges were essentially the same between the groups, patients with SSIs had almost double the mean length of stay than patients without SSIs. SSI patients also had a drastically higher 30-day readmission rate.

The authors propose equations to determine the change in hospital profit due to a single SSI and calculated that preventing one SSI led to an increase in hospital profit between $4,147 and $22,239. These numbers haven’t included the cost of a SSI prevention program, and the limitations in applying these numbers to all hospitals include widely varying hospital costs and differing ability to fill empty beds.

Bottom line: In these four tertiary care hospitals, each SSI prevented could increase hospital profit by thousands of dollars, as well as significantly decrease length of stay and 30-day readmission rates.

Citation: Shepard J, Ward W, Milstone A, et al. Financial impact of surgical site infections on hospitals: the hospital management perspective. JAMA Surg. 2013;148(10):907-914.

Prothrombin Complex Concentrate Is Safer than Fresh Frozen Plasma in Rapidly Reversing INR

Clinical question: Is prothrombin complex concentrate (PCC) safer and more effective than fresh frozen plasma (FFP) in reversing international normalized ratio (INR)?

Background: In Canada, PCC has become the standard of care over FFP for reversal of critical INR due to decreased time of administration, faster preparation, lack of allergic reactions, and small volume. Few studies compare these two products in their adverse effects, time to INR reversal, length of stay, and blood transfusion requirements.

Study design: Retrospective cohort study.

Setting: Two tertiary care EDs in Canada.

Synopsis: Health records of adult patients with an INR ≥1.8 who received FFP over a two-year period prior to PCC introduction (n=149) were compared to those who received PCC in the two years after PCC introduction (n=165). Total serious adverse events, which include mortality, myocardial infarction, and heart failure, were higher in the FFP group (19.5% versus 9.7%, P=0.0164). Heart failure exacerbations, time to reversal of INR, and units of blood transfused were increased in the FFP group. There was no difference in thromboembolic events or in length of stay.

Due to this study’s retrospective nature, there were issues with documentation of INR measurements, so true rapidity of INR reversal is unknown. In the United States, the FDA only recently approved PCC for use, so availability might be limited.

Bottom line: Prothrombin complex concentrate is an effective and fast alternative to FFP for reversal of critical INR levels.

Citation: Hickey M, Gatien M, Taljaard M, Aujnarain A, Giulivi A, Perry JJ. Outcomes of urgent warfarin reversal with frozen plasma versus prothombin complex concentrate in the emergency department. Circulation. 2013;128(4):360-364.

Hospital-Acquired Anemia Associated with Higher Mortality, Increased LOS

Clinical question: What is the prevalence of hospital-acquired anemia (HAA), and does it lead to increased mortality and resource utilization?

Background: HAA is a multifactorial care-based problem that occurs as a result of hemodilution, phlebotomy, blood loss from procedures, and impaired erythropoiesis. In the general hospital population, very little is known about HAA prevalence or whether HAA is associated with increased mortality, greater length of stay (LOS), or higher costs.

Study design: Retrospective cohort study.

Setting: Large academic health system in Ohio.

Synopsis: Using administrative data and electronic health record data, an analysis of 188,447 hospitalizations showed that HAA prevalence was 74%. Worsening HAA was correlated to an increase in mortality, so that the odds ratio of mortality with moderate anemia (Hgb between >9 and ≤11) was 1.51 (95% confidence interval 1.33-1.71, P<0.001) and severe anemia (Hgb ≤9) was 3.28 (95% confidence interval 2.90-3.72, P<0.001). Increased degree of HAA was correlated to increasing LOS (up to 1.88 extra days for patients with severe anemia) and higher hospital costs.

Because this is a retrospective observational study, no true causal relationship can be discerned from this study. However, the body of evidence linking iatrogenic causes of anemia to negative outcomes is compelling. Hospitalists should attempt to limit blood loss through judicious use of phlebotomy and procedures in their patients, so as to avoid anemia and subsequent unnecessary transfusions.

Bottom line: Hospital-acquired anemia is associated with higher mortality, LOS, and hospital costs in all hospitalized patients.

Citation: Koch CG, Li L, Sun Z, et al. Hospital-acquired anemia: prevalence, outcomes, and healthcare implications. J Hosp Med. 2013;8(9):506-512.

Thrombolytics and Stroke: The Faster the Better

Clinical question: Does time from ischemic stroke onset to treatment with intravenous thrombolysis make a difference?

Background: Previous studies have shown that “time is brain.” Quicker treatment with intravenous thrombolysis improves outcomes. Multicenter comparison of very early treatment (i.e., <90 minutes) to a later onset to treatment has not been done.

Study design: Observational study.

Setting: Patient information from 1998 to 2012 from 10 European stroke centers.

Synopsis: A total of 6,856 patients were included, of which 19% received thrombolysis in <90 minutes. None of the patients received endovascular treatment for stroke. Modified Rankin score, a functional assessment, was used to determine outcome. A score of 0 or 1, an “excellent” outcome, was seen more often in patients with a moderate severity stroke (NIH stroke scale of 7-12) who received thrombolysis in <90 minutes, but not in other groups. Thrombolysis in <90 minutes was associated with fewer intracerebral hemorrhages (ICH), but symptomatic ICH was not statistically significantly different. Mortality at three months was not different in the two time groups.

Limitations to this study included an unknown presumed cause of stroke in more than a quarter of patients. Deviations from acute stroke protocols are not described. This study adds to the body of literature supporting the early use of intravenous thrombolysis in eligible acute stroke patients.

Bottom line: Expedient treatment with intravenous thrombolysis should occur in acute stroke patients.

Citation: Strbian D, Ringleb P, Michel P, et al. Ultra-early intravenous stroke thrombolysis: do all patients benefit similarly? Stroke. 2013;44(10):2913-2916.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Intravenous haloperidol does not prevent ICU delirium
2. Predicting delirium risk in hospitalized adults
3. Oral PPIs as effective as IV PPIs in peptic ulcer bleeding
4. Probiotic benefit questioned in the elderly
5. Colchicine and NSAID better than NSAID alone for acute pericarditis
6. Improvement needed in patient understanding at hospital discharge
7. Effectiveness of a multihospital effort to reduce rehospitalization
8. Hospitals profit from preventing surgical site infections
9. Prothrombin complex concentrate safer than fresh frozen plasma in rapidly reversing INR
10. Hospital-acquired anemia associated with higher mortality, increased LOS
11. Thrombolytics and stroke: the faster the better

Intravenous Haloperidol Does Not Prevent ICU Delirium

Clinical question: Can haloperidol reduce delirium in critically ill patients if initiated early in ICU stay?

Background: Prior studies suggest antipsychotics reduce intensity and duration of delirium in hospitalized patients. Evidence is mixed for preventing delirium. A trial of risperidone demonstrated delirium rate reduction in coronary artery bypass grafting (CABG) patients, but another trial of haloperidol in hip surgery patients failed to prevent onset of delirium. There is little evidence on antipsychotics in ICU delirium.

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

Setting: Single, adult ICU in England.

Synopsis: The study randomized 142 critically ill patients to receive 2.5 mg of intravenous haloperidol versus placebo every eight hours for up to 14 days. There was no significant difference between groups in the total time spent free of delirium or coma. Limitations include the use of open-label haloperidol in 21% of the placebo group patients. More sedation but less agitation was seen with the use of haloperidol, which also prolonged QTc. No severe adverse effects were observed.

This study supports the idea that scheduled antipsychotics should not be used to reduce ICU delirium. Addressing modifiable risk factors and using dexmedetomidine rather than lorazepam for sedation in the ICU continue to be first-line strategies to lower delirium rates.

Bottom line: Prophylactic haloperidol should not be used to prevent ICU delirium.

Citation: Page VJ, Ely EW, Gates S, et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomized, double-blind, placebo-controlled trial. Lancet Respir Med. 2013;1(7):515-523.

Predicting Delirium Risk in Hospitalized Adults

Clinical question: Can a simple tool be developed and used for predicting delirium in hospitalized adults?

Background: Delirium is a common condition that results in higher mortality, longer length of stays, and higher probability of discharge to nursing home. Current delirium prediction tools are complicated, or restricted to surgical or critically ill patients.

Study design: Prospective cohort study, with separate derivation and validation cohorts.

Setting: Two academic hospitals and a VA hospital in San Francisco.

Synopsis: Investigators enrolled 374 hospitalized patients who were more than 50 years of age and not delirious at time of admission (209 patients in the derivation and 165 in the validation). The authors identified four predictors of delirium: Age >80; failure to spell “World” backwards; disOrientation to place; and higher nurse-rated iLlness severity (AWOL). The authors found that rates of delirium increased with increasing number of predictors (with zero predictors, 2% developed delirium; one predictor, 4%; two predictors, 14%; three predictors, 20%; four predictors, 64%).

These predictors are similar to other previously identified risk factors, as well as to prediction tools that are in use for surgical patients. However, this tool is quick and can be completed by nursing staff, so it may have a role to play in helping triage patients to units more specialized in preventing delirium.

Bottom line: The AWOL prediction tool is simple to use, broadly applicable, and adds another tool to the literature to determine delirium risk.

Citation: Douglas VC, Hessler CS, Dhaliwal G, et al. The AWOL tool: derivation and validation of a delirium prediction rule. J Hosp Med. 2013;8(9);493-499.

Oral Proton Pump Inhibitors (PPIs) as Effective as IV PPIs in Peptic Ulcer Bleeding

Clinical question: In patients with peptic ulcer bleeding, are oral PPIs of equal benefit to intravenous PPIs?

Background: PPI therapy has been shown in several studies to reduce re-bleeding risk in patients when used adjunctively for peptic ulcer bleeding. In spite of this data, there is still uncertainty about the optimal dose and route of administration.

Study design: Meta-analysis of prospective, randomized control trials.

Setting: OVID database search in June 2012.

Synopsis: A literature search identified six prospective, randomized control trials. Overall, 615 patients were included across the six trials. No significant difference in risk of re-bleeding was discovered between the two groups (8.6% oral vs. 9.3% IV, RR: 0.92, 95% CI: 0.56-1.5). Length of hospital stay was statistically significantly lower for oral PPIs (-0.74 day, 95% CI: -1.10 to -0.39 day).

Because these findings are based on a meta-analysis of studies with notable flaws—including lack of blinding—it is difficult to draw any definitive conclusions from this data. Hospitalists should use care before changing their practice patterns, given the risk of bias and need for further study.

Bottom line: Oral PPIs may reduce hospital length of stay without an increased risk of re-bleeding; however, further study with a well-powered, double-blind, randomized control trial is necessary.

Citation: Tsoi KK, Hirai HW, Sung JJ. Meta-analysis: comparison of oral vs. intravenous proton pump inhibitors in patients with peptic ulcer bleeding. Aliment Pharmacol Ther. 2013;38(7):721-728.

Probiotic Benefit Questioned in the Elderly

Clinical question: Do probiotics prevent antibiotic-associated diarrhea (AAD) in patients 65 and older?

Background: Individual studies using different protocols to assess the efficacy of probiotics in preventing AAD, including Clostridium difficile-associated diarrhea (CDAD), suggest a decreased incidence of AAD when taking probiotics. Meta-analysis of this data also suggests that probiotics are effective in prevention of AAD; however, these results are undermined by the high heterogeneity of the studies included.

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

Setting: Multicenter trial in the United Kingdom.

Synopsis: Nearly 3,000 patients ages 65 years and older who had received one or more antibiotics within seven days were randomized to receive placebo or high-dose probiotics for 21 days. After recruitment, the patients were assessed for AAD up to eight weeks and CDAD up to 12 weeks. Results did not demonstrate a reduction of AAD or CDAD in patients taking probiotics. AAD occurred in 10.8% of patients taking the probiotic and 10.4% of patients taking placebo (95% confidence interval 0.83-1.32). CDAD occurred in 0.8% of patients taking the probiotic and 1.2% of patients taking placebo (95% confidence interval 0.34-1.47).

Based on the results of this double-blind, placebo-controlled trial, there is insufficient evidence to support initiation of probiotics for the prevention of AAD and CDAD in patients 65 years and older. Future studies utilizing standardized protocols against specific antibiotics, along with improved understanding of the underlying mechanisms of AAD prevention, are needed.

Bottom line: High-dose probiotics (lactobacillus acidophilus and bifidobacterium bifidum) do not prevent AAD in elderly patients.

Citation: Allen S, Wareham K, Wang D, et al. Lactobacilli and bifidobacteria in the prevention of antibiotic-associated diarrhoea and Clostridium difficile diarrhoea in older inpatients (PLACIDE): a randomised, double-blind, placebo-controlled, multicentre trial. Lancet. 2013;382(9900):1249-1257.

Colchicine and NSAID Better than NSAID Alone for Acute Pericarditis

Clinical question: Is colchicine safe, effective, and able to prevent recurrence in acute pericarditis?

Background: Colchicine is effective for the treatment of recurrent pericarditis. More recent open-label trials have established its role in acute pericarditis when combined with conventional NSAID therapy. However, a definitive randomized control trial has not been performed to establish colchicine’s role in acute pericarditis.

Study design: Double-blinded, randomized, controlled trial.

Setting: Multicenter in Northern Italy.

Synopsis: Investigators randomized 240 patients to receive either colchicine or placebo in addition to standard therapy of either aspirin or ibuprofen. Incessant or recurrent pericarditis occurred in 16.7% of patients treated with colchicine versus 37.5% in patients receiving placebo (RR 0.56; 95% CI 0.30-0.72; P<0.001). The number needed to treat to prevent one episode of incessant or recurrent pericarditis was four. Colchicine therapy also reduced the frequency of symptom persistence at 72 hours, number of recurrences per patient, rate of hospitalization, and the rate of readmission within one week.

It should be noted that the study excluded the following groups: patients with an elevated troponin, elevated transaminases (>1.5 upper limit of normal), and serum creatinine >2.5.

Bottom line: In addition to conventional therapy, colchicine reduces incessant or recurrent pericarditis in patients with a first episode of acute pericarditis.

Citation: Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013;369(16):1522-1528.

Improvement Needed in Patient Understanding at Hospital Discharge

Clinical question: How well do older patients with heart failure, pneumonia, or acute coronary syndrome understand their diagnosis and post-discharge follow-up plans compared with medical record data?

Background: As hospitals across the country work on preventing 30-day readmissions, more attention has been given to assessing the quality of discharge processes; few evaluations have been conducted from a patient-centered perspective.

Study Design: Prospective, observational cohort study.

Setting: An urban, academic medical center.

Synopsis: This study evaluated the quality of the discharge process among 377 hospitalized patients >65 years old. Medical record data were compared with patient responses during a telephone interview within one week of discharge. By medical records, every patient received discharge instructions that in 97% of cases included discharge diagnosis, activity instructions, follow-up physician information, and warning signs. The authors determined that discharge diagnosis was not written in lay terms 26% of the time. By patient report, 90% expressed that they understood their discharge diagnosis, yet only around 60% fully understood their diagnosis as it was written in the medical record. Although about half of patients reported having a follow-up appointment upon discharge, only about a third of patients had a documented follow-up appointment in the medical record.

Bottom line: Multiple discrepancies were identified between medical record review and patients’ understanding of their discharge diagnosis and plans. Improvements in discharge processes (such as making follow-up appointments) and in patient education (such as increased use of layperson language) are needed.

Citation: Horwitz LI, Moriarty JP, Chen C, et al. Quality of discharge practices and patient understanding at an academic medical center [published online ahead of print August 19, 2013]. JAMA Intern Med.

Effectiveness of a Multihospital Effort to Reduce Rehospitalization

Clinical question: Does Project BOOST reduce 30-day rehospitalization for hospitals participating in a quality improvement collaborative?

Background: With the advent of penalties for hospitals with excessive 30-day readmissions among Medicare beneficiaries, hospitals nationwide are attempting to reduce 30-day readmission rates. Few interventions aimed at reducing 30-day hospital readmissions have been effective, and successful interventions have limited generalizability.

Study design: Semi-controlled, pre-post study.

Setting: Volunteer sample of acute care pilot units within a nationally representative sample of 11 academic and non-academic hospitals.

Synopsis: The 11 hospitals enrolled in this quality improvement collaborative planned and implemented Project BOOST tools over 12 months with support from an external quality improvement mentor. Each hospital tailored the BOOST tools that they implemented based on a needs assessment. Reporting of clinical outcome data was voluntary; administrative sources at each hospital provided these data. Although 30 hospitals participated in this collaborative, only 11 hospitals reported data for this analysis.

Average 30-day rehospitalization rates among BOOST units fell from pre- to post-implementation (14.7% to 12.7%, P=0.010); 30-day rehospitalization rates among control units did not change during this same time period (14.1% to 14.0%, respectively, P=0.831).

Bottom line: Although the 11 hospitals in this collaborative found reduced 30-day readmissions in association with BOOST implementation, this finding may be biased due to voluntary reporting of data and improvements at one hospital driving the overall effect of the intervention. More rigorous evaluation of Project BOOST is needed.

Citation: Hansen LO, Greewald JL, Budnitz T, et al. Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-427.

Hospitals Profit from Preventing Surgical Site Infections

Clinical question: Does quality improvement, in this case preventing surgical site infections (SSIs), necessarily lead to improvement in hospital profit?

Background: It’s clear that preventing SSIs benefits patients and saves money for health insurance providers, but it’s unclear what financial impact SSIs have on hospitals and how best to calculate it. This quantification is needed for cost-benefit analyses of interventions designed to prevent SSIs.

Study design: Retrospective study.

Setting: Four Johns Hopkins-affiliated, tertiary care hospitals.

Synopsis: This retrospective study included all patients admitted to or having certain surgical procedures at four Johns Hopkins-affiliated hospitals between Jan. 1, 2007, and Dec. 31, 2010. Patients were first stratified by complexity, and then those who had a SSI (618) were compared to those without SSIs (399,627 admissions and 25,849 surgeries) for differences in daily hospital charges, length of stay, 30-day readmission rates, and hospital profit.

Although daily charges were essentially the same between the groups, patients with SSIs had almost double the mean length of stay than patients without SSIs. SSI patients also had a drastically higher 30-day readmission rate.

The authors propose equations to determine the change in hospital profit due to a single SSI and calculated that preventing one SSI led to an increase in hospital profit between $4,147 and $22,239. These numbers haven’t included the cost of a SSI prevention program, and the limitations in applying these numbers to all hospitals include widely varying hospital costs and differing ability to fill empty beds.

Bottom line: In these four tertiary care hospitals, each SSI prevented could increase hospital profit by thousands of dollars, as well as significantly decrease length of stay and 30-day readmission rates.

Citation: Shepard J, Ward W, Milstone A, et al. Financial impact of surgical site infections on hospitals: the hospital management perspective. JAMA Surg. 2013;148(10):907-914.

Prothrombin Complex Concentrate Is Safer than Fresh Frozen Plasma in Rapidly Reversing INR

Clinical question: Is prothrombin complex concentrate (PCC) safer and more effective than fresh frozen plasma (FFP) in reversing international normalized ratio (INR)?

Background: In Canada, PCC has become the standard of care over FFP for reversal of critical INR due to decreased time of administration, faster preparation, lack of allergic reactions, and small volume. Few studies compare these two products in their adverse effects, time to INR reversal, length of stay, and blood transfusion requirements.

Study design: Retrospective cohort study.

Setting: Two tertiary care EDs in Canada.

Synopsis: Health records of adult patients with an INR ≥1.8 who received FFP over a two-year period prior to PCC introduction (n=149) were compared to those who received PCC in the two years after PCC introduction (n=165). Total serious adverse events, which include mortality, myocardial infarction, and heart failure, were higher in the FFP group (19.5% versus 9.7%, P=0.0164). Heart failure exacerbations, time to reversal of INR, and units of blood transfused were increased in the FFP group. There was no difference in thromboembolic events or in length of stay.

Due to this study’s retrospective nature, there were issues with documentation of INR measurements, so true rapidity of INR reversal is unknown. In the United States, the FDA only recently approved PCC for use, so availability might be limited.

Bottom line: Prothrombin complex concentrate is an effective and fast alternative to FFP for reversal of critical INR levels.

Citation: Hickey M, Gatien M, Taljaard M, Aujnarain A, Giulivi A, Perry JJ. Outcomes of urgent warfarin reversal with frozen plasma versus prothombin complex concentrate in the emergency department. Circulation. 2013;128(4):360-364.

Hospital-Acquired Anemia Associated with Higher Mortality, Increased LOS

Clinical question: What is the prevalence of hospital-acquired anemia (HAA), and does it lead to increased mortality and resource utilization?

Background: HAA is a multifactorial care-based problem that occurs as a result of hemodilution, phlebotomy, blood loss from procedures, and impaired erythropoiesis. In the general hospital population, very little is known about HAA prevalence or whether HAA is associated with increased mortality, greater length of stay (LOS), or higher costs.

Study design: Retrospective cohort study.

Setting: Large academic health system in Ohio.

Synopsis: Using administrative data and electronic health record data, an analysis of 188,447 hospitalizations showed that HAA prevalence was 74%. Worsening HAA was correlated to an increase in mortality, so that the odds ratio of mortality with moderate anemia (Hgb between >9 and ≤11) was 1.51 (95% confidence interval 1.33-1.71, P<0.001) and severe anemia (Hgb ≤9) was 3.28 (95% confidence interval 2.90-3.72, P<0.001). Increased degree of HAA was correlated to increasing LOS (up to 1.88 extra days for patients with severe anemia) and higher hospital costs.

Because this is a retrospective observational study, no true causal relationship can be discerned from this study. However, the body of evidence linking iatrogenic causes of anemia to negative outcomes is compelling. Hospitalists should attempt to limit blood loss through judicious use of phlebotomy and procedures in their patients, so as to avoid anemia and subsequent unnecessary transfusions.

Bottom line: Hospital-acquired anemia is associated with higher mortality, LOS, and hospital costs in all hospitalized patients.

Citation: Koch CG, Li L, Sun Z, et al. Hospital-acquired anemia: prevalence, outcomes, and healthcare implications. J Hosp Med. 2013;8(9):506-512.

Thrombolytics and Stroke: The Faster the Better

Clinical question: Does time from ischemic stroke onset to treatment with intravenous thrombolysis make a difference?

Background: Previous studies have shown that “time is brain.” Quicker treatment with intravenous thrombolysis improves outcomes. Multicenter comparison of very early treatment (i.e., <90 minutes) to a later onset to treatment has not been done.

Study design: Observational study.

Setting: Patient information from 1998 to 2012 from 10 European stroke centers.

Synopsis: A total of 6,856 patients were included, of which 19% received thrombolysis in <90 minutes. None of the patients received endovascular treatment for stroke. Modified Rankin score, a functional assessment, was used to determine outcome. A score of 0 or 1, an “excellent” outcome, was seen more often in patients with a moderate severity stroke (NIH stroke scale of 7-12) who received thrombolysis in <90 minutes, but not in other groups. Thrombolysis in <90 minutes was associated with fewer intracerebral hemorrhages (ICH), but symptomatic ICH was not statistically significantly different. Mortality at three months was not different in the two time groups.

Limitations to this study included an unknown presumed cause of stroke in more than a quarter of patients. Deviations from acute stroke protocols are not described. This study adds to the body of literature supporting the early use of intravenous thrombolysis in eligible acute stroke patients.

Bottom line: Expedient treatment with intravenous thrombolysis should occur in acute stroke patients.

Citation: Strbian D, Ringleb P, Michel P, et al. Ultra-early intravenous stroke thrombolysis: do all patients benefit similarly? Stroke. 2013;44(10):2913-2916.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Intravenous haloperidol does not prevent ICU delirium
2. Predicting delirium risk in hospitalized adults
3. Oral PPIs as effective as IV PPIs in peptic ulcer bleeding
4. Probiotic benefit questioned in the elderly
5. Colchicine and NSAID better than NSAID alone for acute pericarditis
6. Improvement needed in patient understanding at hospital discharge
7. Effectiveness of a multihospital effort to reduce rehospitalization
8. Hospitals profit from preventing surgical site infections
9. Prothrombin complex concentrate safer than fresh frozen plasma in rapidly reversing INR
10. Hospital-acquired anemia associated with higher mortality, increased LOS
11. Thrombolytics and stroke: the faster the better

Intravenous Haloperidol Does Not Prevent ICU Delirium

Clinical question: Can haloperidol reduce delirium in critically ill patients if initiated early in ICU stay?

Background: Prior studies suggest antipsychotics reduce intensity and duration of delirium in hospitalized patients. Evidence is mixed for preventing delirium. A trial of risperidone demonstrated delirium rate reduction in coronary artery bypass grafting (CABG) patients, but another trial of haloperidol in hip surgery patients failed to prevent onset of delirium. There is little evidence on antipsychotics in ICU delirium.

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

Setting: Single, adult ICU in England.

Synopsis: The study randomized 142 critically ill patients to receive 2.5 mg of intravenous haloperidol versus placebo every eight hours for up to 14 days. There was no significant difference between groups in the total time spent free of delirium or coma. Limitations include the use of open-label haloperidol in 21% of the placebo group patients. More sedation but less agitation was seen with the use of haloperidol, which also prolonged QTc. No severe adverse effects were observed.

This study supports the idea that scheduled antipsychotics should not be used to reduce ICU delirium. Addressing modifiable risk factors and using dexmedetomidine rather than lorazepam for sedation in the ICU continue to be first-line strategies to lower delirium rates.

Bottom line: Prophylactic haloperidol should not be used to prevent ICU delirium.

Citation: Page VJ, Ely EW, Gates S, et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomized, double-blind, placebo-controlled trial. Lancet Respir Med. 2013;1(7):515-523.

Predicting Delirium Risk in Hospitalized Adults

Clinical question: Can a simple tool be developed and used for predicting delirium in hospitalized adults?

Background: Delirium is a common condition that results in higher mortality, longer length of stays, and higher probability of discharge to nursing home. Current delirium prediction tools are complicated, or restricted to surgical or critically ill patients.

Study design: Prospective cohort study, with separate derivation and validation cohorts.

Setting: Two academic hospitals and a VA hospital in San Francisco.

Synopsis: Investigators enrolled 374 hospitalized patients who were more than 50 years of age and not delirious at time of admission (209 patients in the derivation and 165 in the validation). The authors identified four predictors of delirium: Age >80; failure to spell “World” backwards; disOrientation to place; and higher nurse-rated iLlness severity (AWOL). The authors found that rates of delirium increased with increasing number of predictors (with zero predictors, 2% developed delirium; one predictor, 4%; two predictors, 14%; three predictors, 20%; four predictors, 64%).

These predictors are similar to other previously identified risk factors, as well as to prediction tools that are in use for surgical patients. However, this tool is quick and can be completed by nursing staff, so it may have a role to play in helping triage patients to units more specialized in preventing delirium.

Bottom line: The AWOL prediction tool is simple to use, broadly applicable, and adds another tool to the literature to determine delirium risk.

Citation: Douglas VC, Hessler CS, Dhaliwal G, et al. The AWOL tool: derivation and validation of a delirium prediction rule. J Hosp Med. 2013;8(9);493-499.

Oral Proton Pump Inhibitors (PPIs) as Effective as IV PPIs in Peptic Ulcer Bleeding

Clinical question: In patients with peptic ulcer bleeding, are oral PPIs of equal benefit to intravenous PPIs?

Background: PPI therapy has been shown in several studies to reduce re-bleeding risk in patients when used adjunctively for peptic ulcer bleeding. In spite of this data, there is still uncertainty about the optimal dose and route of administration.

Study design: Meta-analysis of prospective, randomized control trials.

Setting: OVID database search in June 2012.

Synopsis: A literature search identified six prospective, randomized control trials. Overall, 615 patients were included across the six trials. No significant difference in risk of re-bleeding was discovered between the two groups (8.6% oral vs. 9.3% IV, RR: 0.92, 95% CI: 0.56-1.5). Length of hospital stay was statistically significantly lower for oral PPIs (-0.74 day, 95% CI: -1.10 to -0.39 day).

Because these findings are based on a meta-analysis of studies with notable flaws—including lack of blinding—it is difficult to draw any definitive conclusions from this data. Hospitalists should use care before changing their practice patterns, given the risk of bias and need for further study.

Bottom line: Oral PPIs may reduce hospital length of stay without an increased risk of re-bleeding; however, further study with a well-powered, double-blind, randomized control trial is necessary.

Citation: Tsoi KK, Hirai HW, Sung JJ. Meta-analysis: comparison of oral vs. intravenous proton pump inhibitors in patients with peptic ulcer bleeding. Aliment Pharmacol Ther. 2013;38(7):721-728.

Probiotic Benefit Questioned in the Elderly

Clinical question: Do probiotics prevent antibiotic-associated diarrhea (AAD) in patients 65 and older?

Background: Individual studies using different protocols to assess the efficacy of probiotics in preventing AAD, including Clostridium difficile-associated diarrhea (CDAD), suggest a decreased incidence of AAD when taking probiotics. Meta-analysis of this data also suggests that probiotics are effective in prevention of AAD; however, these results are undermined by the high heterogeneity of the studies included.

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

Setting: Multicenter trial in the United Kingdom.

Synopsis: Nearly 3,000 patients ages 65 years and older who had received one or more antibiotics within seven days were randomized to receive placebo or high-dose probiotics for 21 days. After recruitment, the patients were assessed for AAD up to eight weeks and CDAD up to 12 weeks. Results did not demonstrate a reduction of AAD or CDAD in patients taking probiotics. AAD occurred in 10.8% of patients taking the probiotic and 10.4% of patients taking placebo (95% confidence interval 0.83-1.32). CDAD occurred in 0.8% of patients taking the probiotic and 1.2% of patients taking placebo (95% confidence interval 0.34-1.47).

Based on the results of this double-blind, placebo-controlled trial, there is insufficient evidence to support initiation of probiotics for the prevention of AAD and CDAD in patients 65 years and older. Future studies utilizing standardized protocols against specific antibiotics, along with improved understanding of the underlying mechanisms of AAD prevention, are needed.

Bottom line: High-dose probiotics (lactobacillus acidophilus and bifidobacterium bifidum) do not prevent AAD in elderly patients.

Citation: Allen S, Wareham K, Wang D, et al. Lactobacilli and bifidobacteria in the prevention of antibiotic-associated diarrhoea and Clostridium difficile diarrhoea in older inpatients (PLACIDE): a randomised, double-blind, placebo-controlled, multicentre trial. Lancet. 2013;382(9900):1249-1257.

Colchicine and NSAID Better than NSAID Alone for Acute Pericarditis

Clinical question: Is colchicine safe, effective, and able to prevent recurrence in acute pericarditis?

Background: Colchicine is effective for the treatment of recurrent pericarditis. More recent open-label trials have established its role in acute pericarditis when combined with conventional NSAID therapy. However, a definitive randomized control trial has not been performed to establish colchicine’s role in acute pericarditis.

Study design: Double-blinded, randomized, controlled trial.

Setting: Multicenter in Northern Italy.

Synopsis: Investigators randomized 240 patients to receive either colchicine or placebo in addition to standard therapy of either aspirin or ibuprofen. Incessant or recurrent pericarditis occurred in 16.7% of patients treated with colchicine versus 37.5% in patients receiving placebo (RR 0.56; 95% CI 0.30-0.72; P<0.001). The number needed to treat to prevent one episode of incessant or recurrent pericarditis was four. Colchicine therapy also reduced the frequency of symptom persistence at 72 hours, number of recurrences per patient, rate of hospitalization, and the rate of readmission within one week.

It should be noted that the study excluded the following groups: patients with an elevated troponin, elevated transaminases (>1.5 upper limit of normal), and serum creatinine >2.5.

Bottom line: In addition to conventional therapy, colchicine reduces incessant or recurrent pericarditis in patients with a first episode of acute pericarditis.

Citation: Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013;369(16):1522-1528.

Improvement Needed in Patient Understanding at Hospital Discharge

Clinical question: How well do older patients with heart failure, pneumonia, or acute coronary syndrome understand their diagnosis and post-discharge follow-up plans compared with medical record data?

Background: As hospitals across the country work on preventing 30-day readmissions, more attention has been given to assessing the quality of discharge processes; few evaluations have been conducted from a patient-centered perspective.

Study Design: Prospective, observational cohort study.

Setting: An urban, academic medical center.

Synopsis: This study evaluated the quality of the discharge process among 377 hospitalized patients >65 years old. Medical record data were compared with patient responses during a telephone interview within one week of discharge. By medical records, every patient received discharge instructions that in 97% of cases included discharge diagnosis, activity instructions, follow-up physician information, and warning signs. The authors determined that discharge diagnosis was not written in lay terms 26% of the time. By patient report, 90% expressed that they understood their discharge diagnosis, yet only around 60% fully understood their diagnosis as it was written in the medical record. Although about half of patients reported having a follow-up appointment upon discharge, only about a third of patients had a documented follow-up appointment in the medical record.

Bottom line: Multiple discrepancies were identified between medical record review and patients’ understanding of their discharge diagnosis and plans. Improvements in discharge processes (such as making follow-up appointments) and in patient education (such as increased use of layperson language) are needed.

Citation: Horwitz LI, Moriarty JP, Chen C, et al. Quality of discharge practices and patient understanding at an academic medical center [published online ahead of print August 19, 2013]. JAMA Intern Med.

Effectiveness of a Multihospital Effort to Reduce Rehospitalization

Clinical question: Does Project BOOST reduce 30-day rehospitalization for hospitals participating in a quality improvement collaborative?

Background: With the advent of penalties for hospitals with excessive 30-day readmissions among Medicare beneficiaries, hospitals nationwide are attempting to reduce 30-day readmission rates. Few interventions aimed at reducing 30-day hospital readmissions have been effective, and successful interventions have limited generalizability.

Study design: Semi-controlled, pre-post study.

Setting: Volunteer sample of acute care pilot units within a nationally representative sample of 11 academic and non-academic hospitals.

Synopsis: The 11 hospitals enrolled in this quality improvement collaborative planned and implemented Project BOOST tools over 12 months with support from an external quality improvement mentor. Each hospital tailored the BOOST tools that they implemented based on a needs assessment. Reporting of clinical outcome data was voluntary; administrative sources at each hospital provided these data. Although 30 hospitals participated in this collaborative, only 11 hospitals reported data for this analysis.

Average 30-day rehospitalization rates among BOOST units fell from pre- to post-implementation (14.7% to 12.7%, P=0.010); 30-day rehospitalization rates among control units did not change during this same time period (14.1% to 14.0%, respectively, P=0.831).

Bottom line: Although the 11 hospitals in this collaborative found reduced 30-day readmissions in association with BOOST implementation, this finding may be biased due to voluntary reporting of data and improvements at one hospital driving the overall effect of the intervention. More rigorous evaluation of Project BOOST is needed.

Citation: Hansen LO, Greewald JL, Budnitz T, et al. Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-427.

Hospitals Profit from Preventing Surgical Site Infections

Clinical question: Does quality improvement, in this case preventing surgical site infections (SSIs), necessarily lead to improvement in hospital profit?

Background: It’s clear that preventing SSIs benefits patients and saves money for health insurance providers, but it’s unclear what financial impact SSIs have on hospitals and how best to calculate it. This quantification is needed for cost-benefit analyses of interventions designed to prevent SSIs.

Study design: Retrospective study.

Setting: Four Johns Hopkins-affiliated, tertiary care hospitals.

Synopsis: This retrospective study included all patients admitted to or having certain surgical procedures at four Johns Hopkins-affiliated hospitals between Jan. 1, 2007, and Dec. 31, 2010. Patients were first stratified by complexity, and then those who had a SSI (618) were compared to those without SSIs (399,627 admissions and 25,849 surgeries) for differences in daily hospital charges, length of stay, 30-day readmission rates, and hospital profit.

Although daily charges were essentially the same between the groups, patients with SSIs had almost double the mean length of stay than patients without SSIs. SSI patients also had a drastically higher 30-day readmission rate.

The authors propose equations to determine the change in hospital profit due to a single SSI and calculated that preventing one SSI led to an increase in hospital profit between $4,147 and $22,239. These numbers haven’t included the cost of a SSI prevention program, and the limitations in applying these numbers to all hospitals include widely varying hospital costs and differing ability to fill empty beds.

Bottom line: In these four tertiary care hospitals, each SSI prevented could increase hospital profit by thousands of dollars, as well as significantly decrease length of stay and 30-day readmission rates.

Citation: Shepard J, Ward W, Milstone A, et al. Financial impact of surgical site infections on hospitals: the hospital management perspective. JAMA Surg. 2013;148(10):907-914.

Prothrombin Complex Concentrate Is Safer than Fresh Frozen Plasma in Rapidly Reversing INR

Clinical question: Is prothrombin complex concentrate (PCC) safer and more effective than fresh frozen plasma (FFP) in reversing international normalized ratio (INR)?

Background: In Canada, PCC has become the standard of care over FFP for reversal of critical INR due to decreased time of administration, faster preparation, lack of allergic reactions, and small volume. Few studies compare these two products in their adverse effects, time to INR reversal, length of stay, and blood transfusion requirements.

Study design: Retrospective cohort study.

Setting: Two tertiary care EDs in Canada.

Synopsis: Health records of adult patients with an INR ≥1.8 who received FFP over a two-year period prior to PCC introduction (n=149) were compared to those who received PCC in the two years after PCC introduction (n=165). Total serious adverse events, which include mortality, myocardial infarction, and heart failure, were higher in the FFP group (19.5% versus 9.7%, P=0.0164). Heart failure exacerbations, time to reversal of INR, and units of blood transfused were increased in the FFP group. There was no difference in thromboembolic events or in length of stay.

Due to this study’s retrospective nature, there were issues with documentation of INR measurements, so true rapidity of INR reversal is unknown. In the United States, the FDA only recently approved PCC for use, so availability might be limited.

Bottom line: Prothrombin complex concentrate is an effective and fast alternative to FFP for reversal of critical INR levels.

Citation: Hickey M, Gatien M, Taljaard M, Aujnarain A, Giulivi A, Perry JJ. Outcomes of urgent warfarin reversal with frozen plasma versus prothombin complex concentrate in the emergency department. Circulation. 2013;128(4):360-364.

Hospital-Acquired Anemia Associated with Higher Mortality, Increased LOS

Clinical question: What is the prevalence of hospital-acquired anemia (HAA), and does it lead to increased mortality and resource utilization?

Background: HAA is a multifactorial care-based problem that occurs as a result of hemodilution, phlebotomy, blood loss from procedures, and impaired erythropoiesis. In the general hospital population, very little is known about HAA prevalence or whether HAA is associated with increased mortality, greater length of stay (LOS), or higher costs.

Study design: Retrospective cohort study.

Setting: Large academic health system in Ohio.

Synopsis: Using administrative data and electronic health record data, an analysis of 188,447 hospitalizations showed that HAA prevalence was 74%. Worsening HAA was correlated to an increase in mortality, so that the odds ratio of mortality with moderate anemia (Hgb between >9 and ≤11) was 1.51 (95% confidence interval 1.33-1.71, P<0.001) and severe anemia (Hgb ≤9) was 3.28 (95% confidence interval 2.90-3.72, P<0.001). Increased degree of HAA was correlated to increasing LOS (up to 1.88 extra days for patients with severe anemia) and higher hospital costs.

Because this is a retrospective observational study, no true causal relationship can be discerned from this study. However, the body of evidence linking iatrogenic causes of anemia to negative outcomes is compelling. Hospitalists should attempt to limit blood loss through judicious use of phlebotomy and procedures in their patients, so as to avoid anemia and subsequent unnecessary transfusions.

Bottom line: Hospital-acquired anemia is associated with higher mortality, LOS, and hospital costs in all hospitalized patients.

Citation: Koch CG, Li L, Sun Z, et al. Hospital-acquired anemia: prevalence, outcomes, and healthcare implications. J Hosp Med. 2013;8(9):506-512.

Thrombolytics and Stroke: The Faster the Better

Clinical question: Does time from ischemic stroke onset to treatment with intravenous thrombolysis make a difference?

Background: Previous studies have shown that “time is brain.” Quicker treatment with intravenous thrombolysis improves outcomes. Multicenter comparison of very early treatment (i.e., <90 minutes) to a later onset to treatment has not been done.

Study design: Observational study.

Setting: Patient information from 1998 to 2012 from 10 European stroke centers.

Synopsis: A total of 6,856 patients were included, of which 19% received thrombolysis in <90 minutes. None of the patients received endovascular treatment for stroke. Modified Rankin score, a functional assessment, was used to determine outcome. A score of 0 or 1, an “excellent” outcome, was seen more often in patients with a moderate severity stroke (NIH stroke scale of 7-12) who received thrombolysis in <90 minutes, but not in other groups. Thrombolysis in <90 minutes was associated with fewer intracerebral hemorrhages (ICH), but symptomatic ICH was not statistically significantly different. Mortality at three months was not different in the two time groups.

Limitations to this study included an unknown presumed cause of stroke in more than a quarter of patients. Deviations from acute stroke protocols are not described. This study adds to the body of literature supporting the early use of intravenous thrombolysis in eligible acute stroke patients.

Bottom line: Expedient treatment with intravenous thrombolysis should occur in acute stroke patients.

Citation: Strbian D, Ringleb P, Michel P, et al. Ultra-early intravenous stroke thrombolysis: do all patients benefit similarly? Stroke. 2013;44(10):2913-2916.

This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or at changes in the patient’s health, health-related condition, or care setting.

Although inevitable, death is often difficult to conceptualize and even more sensitive to discuss. For hospitalists and other care providers, conversations about the end of life with families and caregivers can be fraught with emotion. The fact that something is uncomfortable does not mean it is not useful or valuable, however. Patients must be able to vocalize their end-of-life wishes and should feel confident that the healthcare system is able to respond.

To help with this effort, the Society of Hospital Medicine is supporting legislation that would encourage voluntary end-of-life conversations between patients and their healthcare providers. Sponsored by U.S. Rep. Earl Blumenauer (D-Ore.), the Personalize Your Care Act of 2013 (H.R. 1173) would make Medicare reimbursement available for advance-care planning consultations, establish grants for state-level physician orders for life-sustaining treatment (POLST) programs, and require that advance directives be honored across state lines.

Hospitalists are integral team leaders for coordinating care and, as such, are often highly involved in end-of-life care for patients. They are at the front lines of these conversations, often tasked to plan end-of-life care and then carry out those plans. Many of their patients are acutely ill and need to face these critical decisions, often in real time.

End-of-life planning, like many other cognitive medical services, is not adequately reimbursed under current Medicare payment policy. This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or following changes in health, health-related condition, or care setting of the patient.

SHM is strongly supportive of adequate reimbursement for the counseling these patients require in planning their end-of-life care. The bill would make these conversations a practicable addition to the care and counseling workflow for healthcare providers and would ensure that they could occur at reasonable intervals and at significant changes in health or life events. These conversations would help ensure that patient wishes are respected at the end of life and prevent the use of unwanted treatments or interventions.

As the healthcare system works toward being more coordinated and more patient-centered, voluntary advance care planning is essential. Patients often see multiple providers at the end of their lives and—particularly as questions arise—it is imperative that providers have access to the most up-to-date advance care plans. H.R. 1173 works to address this gap by moving toward electronic health record display of advance directives and POLST.

Hospitalists may be eligible for reimbursement for these consultations, particularly in cases where these discussions did not occur in the outpatient setting. SHM is actively working with Rep. Blumenauer to ensure that all providers in a position to have these important conversations would be appropriately reimbursed. Patients need to have an active mechanism to ensure that their wishes are appropriately followed; this legislation would give them better access to these important and difficult conversations.

Joshua Lapps is SHM’s government relations specialist.

This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or at changes in the patient’s health, health-related condition, or care setting.

Although inevitable, death is often difficult to conceptualize and even more sensitive to discuss. For hospitalists and other care providers, conversations about the end of life with families and caregivers can be fraught with emotion. The fact that something is uncomfortable does not mean it is not useful or valuable, however. Patients must be able to vocalize their end-of-life wishes and should feel confident that the healthcare system is able to respond.

To help with this effort, the Society of Hospital Medicine is supporting legislation that would encourage voluntary end-of-life conversations between patients and their healthcare providers. Sponsored by U.S. Rep. Earl Blumenauer (D-Ore.), the Personalize Your Care Act of 2013 (H.R. 1173) would make Medicare reimbursement available for advance-care planning consultations, establish grants for state-level physician orders for life-sustaining treatment (POLST) programs, and require that advance directives be honored across state lines.

Hospitalists are integral team leaders for coordinating care and, as such, are often highly involved in end-of-life care for patients. They are at the front lines of these conversations, often tasked to plan end-of-life care and then carry out those plans. Many of their patients are acutely ill and need to face these critical decisions, often in real time.

End-of-life planning, like many other cognitive medical services, is not adequately reimbursed under current Medicare payment policy. This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or following changes in health, health-related condition, or care setting of the patient.

SHM is strongly supportive of adequate reimbursement for the counseling these patients require in planning their end-of-life care. The bill would make these conversations a practicable addition to the care and counseling workflow for healthcare providers and would ensure that they could occur at reasonable intervals and at significant changes in health or life events. These conversations would help ensure that patient wishes are respected at the end of life and prevent the use of unwanted treatments or interventions.

As the healthcare system works toward being more coordinated and more patient-centered, voluntary advance care planning is essential. Patients often see multiple providers at the end of their lives and—particularly as questions arise—it is imperative that providers have access to the most up-to-date advance care plans. H.R. 1173 works to address this gap by moving toward electronic health record display of advance directives and POLST.

Hospitalists may be eligible for reimbursement for these consultations, particularly in cases where these discussions did not occur in the outpatient setting. SHM is actively working with Rep. Blumenauer to ensure that all providers in a position to have these important conversations would be appropriately reimbursed. Patients need to have an active mechanism to ensure that their wishes are appropriately followed; this legislation would give them better access to these important and difficult conversations.

Joshua Lapps is SHM’s government relations specialist.

This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or at changes in the patient’s health, health-related condition, or care setting.

Although inevitable, death is often difficult to conceptualize and even more sensitive to discuss. For hospitalists and other care providers, conversations about the end of life with families and caregivers can be fraught with emotion. The fact that something is uncomfortable does not mean it is not useful or valuable, however. Patients must be able to vocalize their end-of-life wishes and should feel confident that the healthcare system is able to respond.

To help with this effort, the Society of Hospital Medicine is supporting legislation that would encourage voluntary end-of-life conversations between patients and their healthcare providers. Sponsored by U.S. Rep. Earl Blumenauer (D-Ore.), the Personalize Your Care Act of 2013 (H.R. 1173) would make Medicare reimbursement available for advance-care planning consultations, establish grants for state-level physician orders for life-sustaining treatment (POLST) programs, and require that advance directives be honored across state lines.

Hospitalists are integral team leaders for coordinating care and, as such, are often highly involved in end-of-life care for patients. They are at the front lines of these conversations, often tasked to plan end-of-life care and then carry out those plans. Many of their patients are acutely ill and need to face these critical decisions, often in real time.

End-of-life planning, like many other cognitive medical services, is not adequately reimbursed under current Medicare payment policy. This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or following changes in health, health-related condition, or care setting of the patient.

SHM is strongly supportive of adequate reimbursement for the counseling these patients require in planning their end-of-life care. The bill would make these conversations a practicable addition to the care and counseling workflow for healthcare providers and would ensure that they could occur at reasonable intervals and at significant changes in health or life events. These conversations would help ensure that patient wishes are respected at the end of life and prevent the use of unwanted treatments or interventions.

As the healthcare system works toward being more coordinated and more patient-centered, voluntary advance care planning is essential. Patients often see multiple providers at the end of their lives and—particularly as questions arise—it is imperative that providers have access to the most up-to-date advance care plans. H.R. 1173 works to address this gap by moving toward electronic health record display of advance directives and POLST.

Hospitalists may be eligible for reimbursement for these consultations, particularly in cases where these discussions did not occur in the outpatient setting. SHM is actively working with Rep. Blumenauer to ensure that all providers in a position to have these important conversations would be appropriately reimbursed. Patients need to have an active mechanism to ensure that their wishes are appropriately followed; this legislation would give them better access to these important and difficult conversations.

Joshua Lapps is SHM’s government relations specialist.

Beth Papetti

Having nocturnist coverage in your practice is a coveted position to be in for many hospital medicine providers. Rick Washington, MD, medical director for WellStar Kennestone Hospital in Marietta, Ga., says that “not only does it make it easier to recruit and retain daytime physicians when you have nocturnists as a part of your program, but they also serve a very valuable role in the continuity of the program throughout the nighttime hours, providing a stable admitting presence in the emergency department at all times.”

According to the 2012 State of Hospital Medicine Report, nearly half of all hospital medicine groups (HMGs) serving adults only incorporate nocturnists into their programs. Nocturnists are most common in HMGs employed by universities or medical schools (67%) and hospitals/integrated delivery systems (50%). The prevalence among management company-employed groups is much lower (25%), and no data was available for multispecialty groups or private hospitalist-only groups (see Figure 1).

As could be expected, the prevalence of nocturnists increases dramatically as the number of total FTEs of the practice increases. As the number of patients on a service, and thus the number of FTEs, grows, so does the expectation to provide on-site night coverage.

The percentage of compensation paid as base salary also has an impact; in general, the higher the percentage of compensation in base salary, the more likely that practice is to have nocturnists. Typically, night shifts tend to be less productive from a billable encounter perspective, so having a base rate of pay tends to be an essential factor in successfully maintaining nocturnists.

click for large version

However, surprisingly, in the 63% of groups that reported paying a nocturnist differential, the clinicians earned only a median of 15% more in total compensation than their non-nocturnist counterparts. Perhaps this has to do with other factors that programs are utilizing in order to entice and retain nocturnists, which includes the possibility of doing fewer shifts or shorter shifts than their colleagues. In fact, 49% of respondent groups reported implementing a nocturnist schedule differential, most commonly in the range of one to 20% fewer shifts than non-nocturnist hospitalists in the same practice.

Other practices implement a schedule differential by shortening the length of nocturnist shifts, instead of reducing the number of shifts worked.

“For me, the key to doing this long term has been the ability to have an eight-hour shift rather than 12 hours,” says Dr. Nancy Maignan, who soon will celebrate five years as a nocturnist at WellStar Kennestone Hospital. “Another factor is flexibility with our schedule. We do not work 7-on/7-off. My schedule is dependent on my family’s schedule…this allows me to attend field trips and be off for most of their [her kids] school break.”

Although she points out that a supportive family is crucial, a supportive HMG is key. I would encourage groups thinking of implementing a nocturnist role to think carefully about how to make the job one that hospitalists can successfully do for a long time, rather than just trying to attract people to the role by making it financially lucrative.

Beth Papetti is assistant vice president of WellStar Medical Group in Marrietta, Ga. She is a member of SHM’s Practice Analysis Committee.

Beth Papetti

Having nocturnist coverage in your practice is a coveted position to be in for many hospital medicine providers. Rick Washington, MD, medical director for WellStar Kennestone Hospital in Marietta, Ga., says that “not only does it make it easier to recruit and retain daytime physicians when you have nocturnists as a part of your program, but they also serve a very valuable role in the continuity of the program throughout the nighttime hours, providing a stable admitting presence in the emergency department at all times.”

According to the 2012 State of Hospital Medicine Report, nearly half of all hospital medicine groups (HMGs) serving adults only incorporate nocturnists into their programs. Nocturnists are most common in HMGs employed by universities or medical schools (67%) and hospitals/integrated delivery systems (50%). The prevalence among management company-employed groups is much lower (25%), and no data was available for multispecialty groups or private hospitalist-only groups (see Figure 1).

As could be expected, the prevalence of nocturnists increases dramatically as the number of total FTEs of the practice increases. As the number of patients on a service, and thus the number of FTEs, grows, so does the expectation to provide on-site night coverage.

The percentage of compensation paid as base salary also has an impact; in general, the higher the percentage of compensation in base salary, the more likely that practice is to have nocturnists. Typically, night shifts tend to be less productive from a billable encounter perspective, so having a base rate of pay tends to be an essential factor in successfully maintaining nocturnists.

click for large version

However, surprisingly, in the 63% of groups that reported paying a nocturnist differential, the clinicians earned only a median of 15% more in total compensation than their non-nocturnist counterparts. Perhaps this has to do with other factors that programs are utilizing in order to entice and retain nocturnists, which includes the possibility of doing fewer shifts or shorter shifts than their colleagues. In fact, 49% of respondent groups reported implementing a nocturnist schedule differential, most commonly in the range of one to 20% fewer shifts than non-nocturnist hospitalists in the same practice.

Other practices implement a schedule differential by shortening the length of nocturnist shifts, instead of reducing the number of shifts worked.

“For me, the key to doing this long term has been the ability to have an eight-hour shift rather than 12 hours,” says Dr. Nancy Maignan, who soon will celebrate five years as a nocturnist at WellStar Kennestone Hospital. “Another factor is flexibility with our schedule. We do not work 7-on/7-off. My schedule is dependent on my family’s schedule…this allows me to attend field trips and be off for most of their [her kids] school break.”

Although she points out that a supportive family is crucial, a supportive HMG is key. I would encourage groups thinking of implementing a nocturnist role to think carefully about how to make the job one that hospitalists can successfully do for a long time, rather than just trying to attract people to the role by making it financially lucrative.

Beth Papetti is assistant vice president of WellStar Medical Group in Marrietta, Ga. She is a member of SHM’s Practice Analysis Committee.

Beth Papetti

Having nocturnist coverage in your practice is a coveted position to be in for many hospital medicine providers. Rick Washington, MD, medical director for WellStar Kennestone Hospital in Marietta, Ga., says that “not only does it make it easier to recruit and retain daytime physicians when you have nocturnists as a part of your program, but they also serve a very valuable role in the continuity of the program throughout the nighttime hours, providing a stable admitting presence in the emergency department at all times.”

According to the 2012 State of Hospital Medicine Report, nearly half of all hospital medicine groups (HMGs) serving adults only incorporate nocturnists into their programs. Nocturnists are most common in HMGs employed by universities or medical schools (67%) and hospitals/integrated delivery systems (50%). The prevalence among management company-employed groups is much lower (25%), and no data was available for multispecialty groups or private hospitalist-only groups (see Figure 1).

As could be expected, the prevalence of nocturnists increases dramatically as the number of total FTEs of the practice increases. As the number of patients on a service, and thus the number of FTEs, grows, so does the expectation to provide on-site night coverage.

The percentage of compensation paid as base salary also has an impact; in general, the higher the percentage of compensation in base salary, the more likely that practice is to have nocturnists. Typically, night shifts tend to be less productive from a billable encounter perspective, so having a base rate of pay tends to be an essential factor in successfully maintaining nocturnists.

click for large version

However, surprisingly, in the 63% of groups that reported paying a nocturnist differential, the clinicians earned only a median of 15% more in total compensation than their non-nocturnist counterparts. Perhaps this has to do with other factors that programs are utilizing in order to entice and retain nocturnists, which includes the possibility of doing fewer shifts or shorter shifts than their colleagues. In fact, 49% of respondent groups reported implementing a nocturnist schedule differential, most commonly in the range of one to 20% fewer shifts than non-nocturnist hospitalists in the same practice.

Other practices implement a schedule differential by shortening the length of nocturnist shifts, instead of reducing the number of shifts worked.

“For me, the key to doing this long term has been the ability to have an eight-hour shift rather than 12 hours,” says Dr. Nancy Maignan, who soon will celebrate five years as a nocturnist at WellStar Kennestone Hospital. “Another factor is flexibility with our schedule. We do not work 7-on/7-off. My schedule is dependent on my family’s schedule…this allows me to attend field trips and be off for most of their [her kids] school break.”

Although she points out that a supportive family is crucial, a supportive HMG is key. I would encourage groups thinking of implementing a nocturnist role to think carefully about how to make the job one that hospitalists can successfully do for a long time, rather than just trying to attract people to the role by making it financially lucrative.

Beth Papetti is assistant vice president of WellStar Medical Group in Marrietta, Ga. She is a member of SHM’s Practice Analysis Committee.

HMX in 3 Minutes or Less

More than 2,500 hospitalists have logged into HMX to share their experiences and ask questions on a wide variety of topics, from HM group practice management to clinical details about glycemic control.

New communities are being added regularly, so be sure to set up your account, sign up for customizable e-mail notifications, and check back regularly to follow your favorite discussions.

Have a question or idea for other hospitalists? Share it today.

Here’s how to get started. All you need are your SHM login credentials.

1. Go to www.hmxchange.org.
2. In the top right-hand corner, click the link that reads, “Login to see members only content.”
3. Enter your SHM login credentials and click login.
4. Now you’re logged in. On the right-hand side, you will find a box with a list of the various communities. Click on the community you would like to view and/or post in.
5. Click the “Discussions” tab and, on the right, click the square button that says “+ Post New Message.”
6. Compose your message with subject and body (and you can include an attachment if you want).
7. Click “Send.”

Hospitalists can now follow their favorite discussions on the go with the Member Centric app for HMX.

1. Go to your preferred app store and download “MemberCentric.”
2. Search for “Society of Hospital Medicine” in the list of organizations.
3. Log in with your SHM/HMX username and password.
4. Get access to your discussions, contacts, private message inbox, and events calendar.

HMX in 3 Minutes or Less

More than 2,500 hospitalists have logged into HMX to share their experiences and ask questions on a wide variety of topics, from HM group practice management to clinical details about glycemic control.

New communities are being added regularly, so be sure to set up your account, sign up for customizable e-mail notifications, and check back regularly to follow your favorite discussions.

Have a question or idea for other hospitalists? Share it today.

Here’s how to get started. All you need are your SHM login credentials.

1. Go to www.hmxchange.org.
2. In the top right-hand corner, click the link that reads, “Login to see members only content.”
3. Enter your SHM login credentials and click login.
4. Now you’re logged in. On the right-hand side, you will find a box with a list of the various communities. Click on the community you would like to view and/or post in.
5. Click the “Discussions” tab and, on the right, click the square button that says “+ Post New Message.”
6. Compose your message with subject and body (and you can include an attachment if you want).
7. Click “Send.”

Hospitalists can now follow their favorite discussions on the go with the Member Centric app for HMX.

1. Go to your preferred app store and download “MemberCentric.”
2. Search for “Society of Hospital Medicine” in the list of organizations.
3. Log in with your SHM/HMX username and password.
4. Get access to your discussions, contacts, private message inbox, and events calendar.

HMX in 3 Minutes or Less

More than 2,500 hospitalists have logged into HMX to share their experiences and ask questions on a wide variety of topics, from HM group practice management to clinical details about glycemic control.

New communities are being added regularly, so be sure to set up your account, sign up for customizable e-mail notifications, and check back regularly to follow your favorite discussions.

Have a question or idea for other hospitalists? Share it today.

Here’s how to get started. All you need are your SHM login credentials.

1. Go to www.hmxchange.org.
2. In the top right-hand corner, click the link that reads, “Login to see members only content.”
3. Enter your SHM login credentials and click login.
4. Now you’re logged in. On the right-hand side, you will find a box with a list of the various communities. Click on the community you would like to view and/or post in.
5. Click the “Discussions” tab and, on the right, click the square button that says “+ Post New Message.”
6. Compose your message with subject and body (and you can include an attachment if you want).
7. Click “Send.”

Hospitalists can now follow their favorite discussions on the go with the Member Centric app for HMX.

1. Go to your preferred app store and download “MemberCentric.”
2. Search for “Society of Hospital Medicine” in the list of organizations.
3. Log in with your SHM/HMX username and password.
4. Get access to your discussions, contacts, private message inbox, and events calendar.

Randy J. Ferrance, DC, MD, FHM

Dr. Ferrance is medical director of the hospitalist service, hospice, and hospital-based quality at Riverside Tappahannock Hospital in Virginia. He began his medical career as a chiropractor before deciding to take a different path, entering medical school, and finding that he loved inpatient care. He is triple board-certified in internal medicine, pediatrics, and palliative care; this last specialty is the area he is most passionate about.

Undergraduate education: Indiana University of Pennsylvania for two years before gaining early admission into Life University College of Chiropractic in Marietta, Ga. After several years in private practice, Dr. Ferrance entered medical school. Thus, he holds two doctorates and no bachelor’s degree.

Medical school: The Medical College of Virginia in Richmond.

Notable: Riverside Tappahannock Hospital is a closed, rural hospital, so Dr. Ferrance and his team of four hospitalists and one nurse practitioner handle all medical admissions, as well as most of the surgical admissions. They manage the ICU and do most of their own procedures.

FYI: He has authored two fiction articles published in the Journal of Hospital Medicine, titled “Death is a crafty adversary” and “Death is a crafty old friend.”^1,2 He also makes custom pens as a hobby, using exotic woods and acrylics.

Quotable: “To me, being a SHM fellow is recognition of the time and energy I’ve given to hospital medicine. I have worked hard to bring good quality care to my small hospital through the use of standardized order sets, real-time chart review, and mentoring.”

Caitlin Cromley

References

1. Ferrance RJ. Death is a crafty adversary. J Hosp Med. 2006;1(2):133-135.
2. Ferrance RJ. Death is a crafty old friend. J Hosp Med. 2008;3(6):495-497.

Randy J. Ferrance, DC, MD, FHM

Dr. Ferrance is medical director of the hospitalist service, hospice, and hospital-based quality at Riverside Tappahannock Hospital in Virginia. He began his medical career as a chiropractor before deciding to take a different path, entering medical school, and finding that he loved inpatient care. He is triple board-certified in internal medicine, pediatrics, and palliative care; this last specialty is the area he is most passionate about.

Undergraduate education: Indiana University of Pennsylvania for two years before gaining early admission into Life University College of Chiropractic in Marietta, Ga. After several years in private practice, Dr. Ferrance entered medical school. Thus, he holds two doctorates and no bachelor’s degree.

Medical school: The Medical College of Virginia in Richmond.

Notable: Riverside Tappahannock Hospital is a closed, rural hospital, so Dr. Ferrance and his team of four hospitalists and one nurse practitioner handle all medical admissions, as well as most of the surgical admissions. They manage the ICU and do most of their own procedures.

FYI: He has authored two fiction articles published in the Journal of Hospital Medicine, titled “Death is a crafty adversary” and “Death is a crafty old friend.”^1,2 He also makes custom pens as a hobby, using exotic woods and acrylics.

Quotable: “To me, being a SHM fellow is recognition of the time and energy I’ve given to hospital medicine. I have worked hard to bring good quality care to my small hospital through the use of standardized order sets, real-time chart review, and mentoring.”

Caitlin Cromley

References

1. Ferrance RJ. Death is a crafty adversary. J Hosp Med. 2006;1(2):133-135.
2. Ferrance RJ. Death is a crafty old friend. J Hosp Med. 2008;3(6):495-497.

Randy J. Ferrance, DC, MD, FHM

Dr. Ferrance is medical director of the hospitalist service, hospice, and hospital-based quality at Riverside Tappahannock Hospital in Virginia. He began his medical career as a chiropractor before deciding to take a different path, entering medical school, and finding that he loved inpatient care. He is triple board-certified in internal medicine, pediatrics, and palliative care; this last specialty is the area he is most passionate about.

Undergraduate education: Indiana University of Pennsylvania for two years before gaining early admission into Life University College of Chiropractic in Marietta, Ga. After several years in private practice, Dr. Ferrance entered medical school. Thus, he holds two doctorates and no bachelor’s degree.

Medical school: The Medical College of Virginia in Richmond.

Notable: Riverside Tappahannock Hospital is a closed, rural hospital, so Dr. Ferrance and his team of four hospitalists and one nurse practitioner handle all medical admissions, as well as most of the surgical admissions. They manage the ICU and do most of their own procedures.

FYI: He has authored two fiction articles published in the Journal of Hospital Medicine, titled “Death is a crafty adversary” and “Death is a crafty old friend.”^1,2 He also makes custom pens as a hobby, using exotic woods and acrylics.

Quotable: “To me, being a SHM fellow is recognition of the time and energy I’ve given to hospital medicine. I have worked hard to bring good quality care to my small hospital through the use of standardized order sets, real-time chart review, and mentoring.”

Caitlin Cromley

References

1. Ferrance RJ. Death is a crafty adversary. J Hosp Med. 2006;1(2):133-135.
2. Ferrance RJ. Death is a crafty old friend. J Hosp Med. 2008;3(6):495-497.

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