Chimeric antigen receptor-modified T cells represent a new approach to immune therapy in the treatment of hematologic malignancies. The clinical activity of chimeric antigen receptors (CARs) has been published in acute lymphoblastic leukemia (ALL)and chronic lymphocytic leukemia (CLL).¹ The results have been remarkable, although only a very small number of patients have been treated. We are anticipating further clinical trials and further development of this technology for more wide spread treatment opportunities for patients. The CARs that have been the most successful clinically have a similar basic make-up. They are genetically modified T cells. The T cells are collected from the patients through leukapheresis, then they are genetically
modified to express an extracellular recognition domain that is connected in the intracellular signaling domains of the T cells. Various extracellular recognition domains have been engineered, but the target of CD19 has proven most successful in patients with B cell malignancies, and CD19 is widely expressed on CLL and B-cell ALL. The cells are infused back into the patient, sometimes after undergoing chemotherapy to lymphodeplete the patient (which may improve the recovery and persistence of the cells after treatment). The infusion responses have been
dramatic in some patients, with severe cytokine storm described in reports, usually several days after treatment.² This is thought to reflect the very rapid identification of the target protein and response of the T cells to the target. Those patients with acute leukemia who have responded also appear to respond rapidly, with disappearance of blasts from the peripheral blood within a month. The cells have been detectable in some patients for months after treatment.

Please click here to view the PDF.

Chimeric antigen receptor-modified T cells represent a new approach to immune therapy in the treatment of hematologic malignancies. The clinical activity of chimeric antigen receptors (CARs) has been published in acute lymphoblastic leukemia (ALL)and chronic lymphocytic leukemia (CLL).¹ The results have been remarkable, although only a very small number of patients have been treated. We are anticipating further clinical trials and further development of this technology for more wide spread treatment opportunities for patients. The CARs that have been the most successful clinically have a similar basic make-up. They are genetically modified T cells. The T cells are collected from the patients through leukapheresis, then they are genetically
modified to express an extracellular recognition domain that is connected in the intracellular signaling domains of the T cells. Various extracellular recognition domains have been engineered, but the target of CD19 has proven most successful in patients with B cell malignancies, and CD19 is widely expressed on CLL and B-cell ALL. The cells are infused back into the patient, sometimes after undergoing chemotherapy to lymphodeplete the patient (which may improve the recovery and persistence of the cells after treatment). The infusion responses have been
dramatic in some patients, with severe cytokine storm described in reports, usually several days after treatment.² This is thought to reflect the very rapid identification of the target protein and response of the T cells to the target. Those patients with acute leukemia who have responded also appear to respond rapidly, with disappearance of blasts from the peripheral blood within a month. The cells have been detectable in some patients for months after treatment.

Please click here to view the PDF.

Chimeric antigen receptor-modified T cells represent a new approach to immune therapy in the treatment of hematologic malignancies. The clinical activity of chimeric antigen receptors (CARs) has been published in acute lymphoblastic leukemia (ALL)and chronic lymphocytic leukemia (CLL).¹ The results have been remarkable, although only a very small number of patients have been treated. We are anticipating further clinical trials and further development of this technology for more wide spread treatment opportunities for patients. The CARs that have been the most successful clinically have a similar basic make-up. They are genetically modified T cells. The T cells are collected from the patients through leukapheresis, then they are genetically
modified to express an extracellular recognition domain that is connected in the intracellular signaling domains of the T cells. Various extracellular recognition domains have been engineered, but the target of CD19 has proven most successful in patients with B cell malignancies, and CD19 is widely expressed on CLL and B-cell ALL. The cells are infused back into the patient, sometimes after undergoing chemotherapy to lymphodeplete the patient (which may improve the recovery and persistence of the cells after treatment). The infusion responses have been
dramatic in some patients, with severe cytokine storm described in reports, usually several days after treatment.² This is thought to reflect the very rapid identification of the target protein and response of the T cells to the target. Those patients with acute leukemia who have responded also appear to respond rapidly, with disappearance of blasts from the peripheral blood within a month. The cells have been detectable in some patients for months after treatment.

Please click here to view the PDF.

A new report that shows double-digit gains in hospitals’ electronic health information exchanges with other providers is a boon to healthcare, says one of SHM’s leading health information technology experts.

Published last month at HealthAffairs.org, “Hospital Electronic Health Information Exchange Grew Substantially in 2008-2012,” found that nearly 6 in 10 hospitals actively exchanged electronic health information with providers and hospitals outside of their own organization in 2012, a 41% jump since 2008.

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, says in an email to The Hospitalist that the growth is a good thing.

“Obviously, flow of information is never a bad thing for hospital medicine,” writes Dr. Rogers, chair of SHM’s Information Technology Executive Committee. “I think we have made more progress getting information back out to providers in the community, [and] helping with a safer transition (though we still have a long way to go), but we still lack significantly [in] getting info from providers or other hospitals on admission.”

The report notes that while more information has flowed among hospitals and providers, exchanges of clinical-care summaries and medication lists remain limited. The authors suggest that “new and ongoing policy initiatives and payment reforms may accelerate” the process.

Dr. Rogers adds that making systems more user-friendly may also encourage meaningful participation. “We have a health information exchange here in New Mexico that includes most hospitals”; however, he writes, “it is cumbersome and not routinely used, but definitely a step in the right direction.”

Visit our website for more information on health information technology.

A new report that shows double-digit gains in hospitals’ electronic health information exchanges with other providers is a boon to healthcare, says one of SHM’s leading health information technology experts.

Published last month at HealthAffairs.org, “Hospital Electronic Health Information Exchange Grew Substantially in 2008-2012,” found that nearly 6 in 10 hospitals actively exchanged electronic health information with providers and hospitals outside of their own organization in 2012, a 41% jump since 2008.

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, says in an email to The Hospitalist that the growth is a good thing.

“Obviously, flow of information is never a bad thing for hospital medicine,” writes Dr. Rogers, chair of SHM’s Information Technology Executive Committee. “I think we have made more progress getting information back out to providers in the community, [and] helping with a safer transition (though we still have a long way to go), but we still lack significantly [in] getting info from providers or other hospitals on admission.”

The report notes that while more information has flowed among hospitals and providers, exchanges of clinical-care summaries and medication lists remain limited. The authors suggest that “new and ongoing policy initiatives and payment reforms may accelerate” the process.

Dr. Rogers adds that making systems more user-friendly may also encourage meaningful participation. “We have a health information exchange here in New Mexico that includes most hospitals”; however, he writes, “it is cumbersome and not routinely used, but definitely a step in the right direction.”

Visit our website for more information on health information technology.

A new report that shows double-digit gains in hospitals’ electronic health information exchanges with other providers is a boon to healthcare, says one of SHM’s leading health information technology experts.

Published last month at HealthAffairs.org, “Hospital Electronic Health Information Exchange Grew Substantially in 2008-2012,” found that nearly 6 in 10 hospitals actively exchanged electronic health information with providers and hospitals outside of their own organization in 2012, a 41% jump since 2008.

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, says in an email to The Hospitalist that the growth is a good thing.

“Obviously, flow of information is never a bad thing for hospital medicine,” writes Dr. Rogers, chair of SHM’s Information Technology Executive Committee. “I think we have made more progress getting information back out to providers in the community, [and] helping with a safer transition (though we still have a long way to go), but we still lack significantly [in] getting info from providers or other hospitals on admission.”

The report notes that while more information has flowed among hospitals and providers, exchanges of clinical-care summaries and medication lists remain limited. The authors suggest that “new and ongoing policy initiatives and payment reforms may accelerate” the process.

Dr. Rogers adds that making systems more user-friendly may also encourage meaningful participation. “We have a health information exchange here in New Mexico that includes most hospitals”; however, he writes, “it is cumbersome and not routinely used, but definitely a step in the right direction.”

Visit our website for more information on health information technology.

When it comes to controlling healthcare costs, only 36% of physicians agree that practicing physicians have a “major responsibility” to participate in cost containment, according to a recently published Journal of the American Medical Association study, "Views of U.S. Physicians About Controlling Health Care Costs.”

More than half of the 2,556 physicians who responded to a survey said trial lawyers, health insurance companies, hospitals and health systems, pharmaceutical and device manufacturers, and patients have a major responsibility for controlling healthcare costs.

In an accompanying editorial, Ezekiel Emanuel, MD, PhD, and Andrew Steinmetz, BA, of the department of medical ethics and health policy at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, labeled the responses as “somewhat discouraging” and “a denial of responsibility” by physicians about their role in bringing costs under control.

Christopher Moriates, MD, a hospitalist at the University of California at San Francisco (UCSF) who developed a cost-awareness curriculum for physicians and serves as co-chair of UCSF’s High Value Care Committee, calls the survey a snapshot of changing attitudes in medicine because it does not include medical students or residents who, he says, are more engaged in fighting wasteful spending.

“Younger physicians are growing up in a medical world that has stressed systems-thinking and teamwork,” Dr. Moriates says. “They are ready to take that major responsibility for our healthcare system. We just need to make sure that we are teaching them how.”

Visit our website for more information on controlling healthcare costs.

When it comes to controlling healthcare costs, only 36% of physicians agree that practicing physicians have a “major responsibility” to participate in cost containment, according to a recently published Journal of the American Medical Association study, "Views of U.S. Physicians About Controlling Health Care Costs.”

More than half of the 2,556 physicians who responded to a survey said trial lawyers, health insurance companies, hospitals and health systems, pharmaceutical and device manufacturers, and patients have a major responsibility for controlling healthcare costs.

In an accompanying editorial, Ezekiel Emanuel, MD, PhD, and Andrew Steinmetz, BA, of the department of medical ethics and health policy at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, labeled the responses as “somewhat discouraging” and “a denial of responsibility” by physicians about their role in bringing costs under control.

Christopher Moriates, MD, a hospitalist at the University of California at San Francisco (UCSF) who developed a cost-awareness curriculum for physicians and serves as co-chair of UCSF’s High Value Care Committee, calls the survey a snapshot of changing attitudes in medicine because it does not include medical students or residents who, he says, are more engaged in fighting wasteful spending.

“Younger physicians are growing up in a medical world that has stressed systems-thinking and teamwork,” Dr. Moriates says. “They are ready to take that major responsibility for our healthcare system. We just need to make sure that we are teaching them how.”

Visit our website for more information on controlling healthcare costs.

When it comes to controlling healthcare costs, only 36% of physicians agree that practicing physicians have a “major responsibility” to participate in cost containment, according to a recently published Journal of the American Medical Association study, "Views of U.S. Physicians About Controlling Health Care Costs.”

More than half of the 2,556 physicians who responded to a survey said trial lawyers, health insurance companies, hospitals and health systems, pharmaceutical and device manufacturers, and patients have a major responsibility for controlling healthcare costs.

In an accompanying editorial, Ezekiel Emanuel, MD, PhD, and Andrew Steinmetz, BA, of the department of medical ethics and health policy at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, labeled the responses as “somewhat discouraging” and “a denial of responsibility” by physicians about their role in bringing costs under control.

Christopher Moriates, MD, a hospitalist at the University of California at San Francisco (UCSF) who developed a cost-awareness curriculum for physicians and serves as co-chair of UCSF’s High Value Care Committee, calls the survey a snapshot of changing attitudes in medicine because it does not include medical students or residents who, he says, are more engaged in fighting wasteful spending.

“Younger physicians are growing up in a medical world that has stressed systems-thinking and teamwork,” Dr. Moriates says. “They are ready to take that major responsibility for our healthcare system. We just need to make sure that we are teaching them how.”

Visit our website for more information on controlling healthcare costs.

We as hospitalists have been missing a huge piece of the puzzle when it comes to readmissions. With such a huge push to reduce the readmission rate at our hospitals and avoid the resultant penalties, have we been too internally focused?

In a recent article in, titled, "A primary care physician’s ideal transitions of care – where’s the evidence?" Dr. Ning Tang gives a PCP’s perspective on how outpatient providers can greatly facilitate our common goal of optimizing patients’ transition from hospital to home (J. Hosp. Med. 2013;8:472-7). After all, most of our patients do have a PCP, who has known them for a long time and who will have much more insight into their values and support systems, their idiosyncrasies, what they will and won’t follow through on, and even their pet peeves. When we who may interact with them for only a couple of hours try to use a cookie-cutter approach to care, it simply may not be received well, if at all.

Dr. Tang suggests that PCP communication begins at the point of admission. While some ERs and admissions offices have automated systems in place to contact PCPs when their patients are admitted, for most of us, this communication comes by way of a phone call or as an electronic or faxed copy of the admission note. While I do not think anyone would argue that early involvement by the PCP has a tremendous potential to improve both the patient’s transition from home into the hospital and vice versa, in real life doctors are frequently too busy and stressed to meet this basic expectation. Hopefully that will change in the future.

Some PCPs have no desire to talk with a hospitalist each time a patient is admitted because it takes them away from seeing patients in their office. Yet others would welcome the opportunity for early involvement. It is an individual preference, one we should strive to understand in order to optimize our patients’ experience – and the experience of the physician who has entrusted patients to us.

Medication reconciliation is but the tip of the iceberg of issues the PCP could assist with, and the realization that their patient may not actually be taking all the medications they prescribed (or taking medications they didn’t) can help improve the level of care patients receive once discharged.

In the midst of brutal day, we have all had medication nightmares that make us cringe, as we slowly count to three while practicing deep-breathing exercises. You know, the patient who pulls out a crumpled list of medications. Some have been crossed out and others are too illegible to read. Then, the spouse pulls out another "updated" list, and the physician and pharmacist each have their own list, and no two lists are exactly alike.

But these nightmares could soon end. I was surprised to find out that in January of this year, the Centers for Medicare and Medicaid Services introduced new codes to reimburse primary care providers for care coordination after hospital discharge. These codes, 99495 and 99496 reimburse a substantial fee, carrying weights of 3.96 and 5.81 RVUs (relative value units), respectively, a lot more than we typically make for even an extended history and physical.

So, I have to agree with Dr. Tang. We, PCPs and hospitalists alike, are missing a huge potential to optimize care transitions, decrease our readmission rate, and lower medical costs. Dialogue needs to take place between hospitalist and the PCPs they serve to bridge some of these gaps.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

We as hospitalists have been missing a huge piece of the puzzle when it comes to readmissions. With such a huge push to reduce the readmission rate at our hospitals and avoid the resultant penalties, have we been too internally focused?

In a recent article in, titled, "A primary care physician’s ideal transitions of care – where’s the evidence?" Dr. Ning Tang gives a PCP’s perspective on how outpatient providers can greatly facilitate our common goal of optimizing patients’ transition from hospital to home (J. Hosp. Med. 2013;8:472-7). After all, most of our patients do have a PCP, who has known them for a long time and who will have much more insight into their values and support systems, their idiosyncrasies, what they will and won’t follow through on, and even their pet peeves. When we who may interact with them for only a couple of hours try to use a cookie-cutter approach to care, it simply may not be received well, if at all.

Dr. Tang suggests that PCP communication begins at the point of admission. While some ERs and admissions offices have automated systems in place to contact PCPs when their patients are admitted, for most of us, this communication comes by way of a phone call or as an electronic or faxed copy of the admission note. While I do not think anyone would argue that early involvement by the PCP has a tremendous potential to improve both the patient’s transition from home into the hospital and vice versa, in real life doctors are frequently too busy and stressed to meet this basic expectation. Hopefully that will change in the future.

Some PCPs have no desire to talk with a hospitalist each time a patient is admitted because it takes them away from seeing patients in their office. Yet others would welcome the opportunity for early involvement. It is an individual preference, one we should strive to understand in order to optimize our patients’ experience – and the experience of the physician who has entrusted patients to us.

Medication reconciliation is but the tip of the iceberg of issues the PCP could assist with, and the realization that their patient may not actually be taking all the medications they prescribed (or taking medications they didn’t) can help improve the level of care patients receive once discharged.

In the midst of brutal day, we have all had medication nightmares that make us cringe, as we slowly count to three while practicing deep-breathing exercises. You know, the patient who pulls out a crumpled list of medications. Some have been crossed out and others are too illegible to read. Then, the spouse pulls out another "updated" list, and the physician and pharmacist each have their own list, and no two lists are exactly alike.

But these nightmares could soon end. I was surprised to find out that in January of this year, the Centers for Medicare and Medicaid Services introduced new codes to reimburse primary care providers for care coordination after hospital discharge. These codes, 99495 and 99496 reimburse a substantial fee, carrying weights of 3.96 and 5.81 RVUs (relative value units), respectively, a lot more than we typically make for even an extended history and physical.

So, I have to agree with Dr. Tang. We, PCPs and hospitalists alike, are missing a huge potential to optimize care transitions, decrease our readmission rate, and lower medical costs. Dialogue needs to take place between hospitalist and the PCPs they serve to bridge some of these gaps.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

We as hospitalists have been missing a huge piece of the puzzle when it comes to readmissions. With such a huge push to reduce the readmission rate at our hospitals and avoid the resultant penalties, have we been too internally focused?

In a recent article in, titled, "A primary care physician’s ideal transitions of care – where’s the evidence?" Dr. Ning Tang gives a PCP’s perspective on how outpatient providers can greatly facilitate our common goal of optimizing patients’ transition from hospital to home (J. Hosp. Med. 2013;8:472-7). After all, most of our patients do have a PCP, who has known them for a long time and who will have much more insight into their values and support systems, their idiosyncrasies, what they will and won’t follow through on, and even their pet peeves. When we who may interact with them for only a couple of hours try to use a cookie-cutter approach to care, it simply may not be received well, if at all.

Dr. Tang suggests that PCP communication begins at the point of admission. While some ERs and admissions offices have automated systems in place to contact PCPs when their patients are admitted, for most of us, this communication comes by way of a phone call or as an electronic or faxed copy of the admission note. While I do not think anyone would argue that early involvement by the PCP has a tremendous potential to improve both the patient’s transition from home into the hospital and vice versa, in real life doctors are frequently too busy and stressed to meet this basic expectation. Hopefully that will change in the future.

Some PCPs have no desire to talk with a hospitalist each time a patient is admitted because it takes them away from seeing patients in their office. Yet others would welcome the opportunity for early involvement. It is an individual preference, one we should strive to understand in order to optimize our patients’ experience – and the experience of the physician who has entrusted patients to us.

Medication reconciliation is but the tip of the iceberg of issues the PCP could assist with, and the realization that their patient may not actually be taking all the medications they prescribed (or taking medications they didn’t) can help improve the level of care patients receive once discharged.

In the midst of brutal day, we have all had medication nightmares that make us cringe, as we slowly count to three while practicing deep-breathing exercises. You know, the patient who pulls out a crumpled list of medications. Some have been crossed out and others are too illegible to read. Then, the spouse pulls out another "updated" list, and the physician and pharmacist each have their own list, and no two lists are exactly alike.

But these nightmares could soon end. I was surprised to find out that in January of this year, the Centers for Medicare and Medicaid Services introduced new codes to reimburse primary care providers for care coordination after hospital discharge. These codes, 99495 and 99496 reimburse a substantial fee, carrying weights of 3.96 and 5.81 RVUs (relative value units), respectively, a lot more than we typically make for even an extended history and physical.

So, I have to agree with Dr. Tang. We, PCPs and hospitalists alike, are missing a huge potential to optimize care transitions, decrease our readmission rate, and lower medical costs. Dialogue needs to take place between hospitalist and the PCPs they serve to bridge some of these gaps.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

NEW YORK – Physicians at Boston Children’s Hospital replaced the mitral valves of eight infants with irreparable mitral valve disease with a valve that offers the opportunity of sequential expansion as the child grows, according to Dr. Sitaram M. Emani. The results were presented at the 2013 Mitral Valve Conclave earlier this year.

"The Melody valve retains its competence if you expand it before putting it in. We asked whether the valve retains the ability to maintain competence even if expansion is performed after implantation as the patient grows," said Dr. Emani, a pediatric cardiac surgeon at Boston Children’s Hospital.

 All photos courtesy Dr. Sitaram M. Emani

According to Dr. Emani, the current options for infants with damaged mitral valves that are beyond repair are replacement with mechanical or bioprosthetic valves or the Ross mitral procedure. Perhaps the main disadvantage of these options is the lack of a prosthetic valve small enough for an infant, one that is less than 12 mm in diameter. Another problem is the possibility of stenosis developing as the child grows, since the diameters of the prosthetics are fixed. Other drawbacks are that supra-annular fixation is generally associated with poor outcomes and that annular fixation limits the ability to upsize at reoperation.

The Melody valve is an externally stented bovine jugular vein graft that was designed for transcatheter pulmonary valve replacement. In this study, the valve was inserted surgically. The valve maintains competence over a range of sizes up to 22 mm. Although this valve is not approved for use for mitral valve replacement, the hope of using such a prosthetic is that it can be enlarged in the catheterization laboratory as the child grows.

Dr. Emani did a retrospective study of his experience with the Melody valve for mitral valve replacement in eight infants less than 12 months of age. The median age at implantation was 6 months (range, 1-9 months). Four infants had an atrioventricular canal (AVC) defect and four had congenital mitral valve stenosis. Most of the children had two prior operations for mitral valve repair. The longest follow-up to date has been 2 years.

At a median follow-up of 8 months, regurgitation on the echocardiogram was considered to be mild or less in all patients. The median gradient was 3 mm Hg (range, 2-7 mm Hg) on the immediate postoperative echocardiogram. Three patients developed a mild paravalvular leak; one of these patients had undergone aggressive stent resection, a modification Dr. Emani does not recommend. One patient developed left ventricular outflow tract obstruction (LVOTO), which Dr. Emani attributed to the lack of distal stent fixation in this patient. Another patient with an AVC defect developed complete heart block.

One patient who died 3 days postoperatively had heterotaxy, severe mitral regurgitation, and prior ventricular failure on extracorporeal membrane oxygenation support. That patient had undergone valve implantation as a last resort.

Three patients underwent sequential expansion about 6 months after implantation. After valve expansion, the median balloon size was 12 mm, ranging from 12 to 16 mm. None of the patients developed worsening valvular function and all had relief of obstruction. Transcatheter intervention was used to correct a paravalvular leak in one patient and to treat a left ventricular outflow tract problem in another. None of the patients developed endocarditis or a strut fracture, "although I worry about strut fracture if aggressive stent resection and manipulation is performed," he said at the meeting, which was sponsored by the AATS.

Dr. Emani offered some procedural tips. First, the Melody valve must be optimized for surgical implantation in infants. The length of the valve must be reduced by trimming it to reduce the chance of LVOTO or pulmonary vein obstruction. He recommends sizing the valves by echocardiogram and fixating the distal stent to the inferior free wall of the ventricle.

He reported that friction of the stent against the annulus prevents leakage. Early on he used a pericardial cuff to anchor to the annulus, particularly in patients who had undergone failed AVC repair. He tries to preserve at least part of the anterior leaflet to facilitate suture placement and create a "stand-off" from the LVOTO.

Dr. Emani also advised limiting intraoperative dilation to no more than 1 mm greater than the measured annulus. "Try not to overdilate at implantation to avoid heart block, LVOTO, and coronary compression. The nice thing is you don’t have to decide then and there what size you want. You can go back to the cath lab and, under direct visualization with the coronary view, you can dilate it under more controlled circumstances.

"The hope is that we will be able to dilate these valves as the patients grow into adolescence. If we can dilate them up to 22 mm, hopefully we will decrease the number of repeat replacements, delay the time to reoperation, and perhaps modify our thresholds for tolerating significant disease after unsuccessful repairs."

Dr. Emani reported no disclosures.

NEW YORK – Physicians at Boston Children’s Hospital replaced the mitral valves of eight infants with irreparable mitral valve disease with a valve that offers the opportunity of sequential expansion as the child grows, according to Dr. Sitaram M. Emani. The results were presented at the 2013 Mitral Valve Conclave earlier this year.

"The Melody valve retains its competence if you expand it before putting it in. We asked whether the valve retains the ability to maintain competence even if expansion is performed after implantation as the patient grows," said Dr. Emani, a pediatric cardiac surgeon at Boston Children’s Hospital.

 All photos courtesy Dr. Sitaram M. Emani

According to Dr. Emani, the current options for infants with damaged mitral valves that are beyond repair are replacement with mechanical or bioprosthetic valves or the Ross mitral procedure. Perhaps the main disadvantage of these options is the lack of a prosthetic valve small enough for an infant, one that is less than 12 mm in diameter. Another problem is the possibility of stenosis developing as the child grows, since the diameters of the prosthetics are fixed. Other drawbacks are that supra-annular fixation is generally associated with poor outcomes and that annular fixation limits the ability to upsize at reoperation.

The Melody valve is an externally stented bovine jugular vein graft that was designed for transcatheter pulmonary valve replacement. In this study, the valve was inserted surgically. The valve maintains competence over a range of sizes up to 22 mm. Although this valve is not approved for use for mitral valve replacement, the hope of using such a prosthetic is that it can be enlarged in the catheterization laboratory as the child grows.

Dr. Emani did a retrospective study of his experience with the Melody valve for mitral valve replacement in eight infants less than 12 months of age. The median age at implantation was 6 months (range, 1-9 months). Four infants had an atrioventricular canal (AVC) defect and four had congenital mitral valve stenosis. Most of the children had two prior operations for mitral valve repair. The longest follow-up to date has been 2 years.

At a median follow-up of 8 months, regurgitation on the echocardiogram was considered to be mild or less in all patients. The median gradient was 3 mm Hg (range, 2-7 mm Hg) on the immediate postoperative echocardiogram. Three patients developed a mild paravalvular leak; one of these patients had undergone aggressive stent resection, a modification Dr. Emani does not recommend. One patient developed left ventricular outflow tract obstruction (LVOTO), which Dr. Emani attributed to the lack of distal stent fixation in this patient. Another patient with an AVC defect developed complete heart block.

One patient who died 3 days postoperatively had heterotaxy, severe mitral regurgitation, and prior ventricular failure on extracorporeal membrane oxygenation support. That patient had undergone valve implantation as a last resort.

Three patients underwent sequential expansion about 6 months after implantation. After valve expansion, the median balloon size was 12 mm, ranging from 12 to 16 mm. None of the patients developed worsening valvular function and all had relief of obstruction. Transcatheter intervention was used to correct a paravalvular leak in one patient and to treat a left ventricular outflow tract problem in another. None of the patients developed endocarditis or a strut fracture, "although I worry about strut fracture if aggressive stent resection and manipulation is performed," he said at the meeting, which was sponsored by the AATS.

Dr. Emani offered some procedural tips. First, the Melody valve must be optimized for surgical implantation in infants. The length of the valve must be reduced by trimming it to reduce the chance of LVOTO or pulmonary vein obstruction. He recommends sizing the valves by echocardiogram and fixating the distal stent to the inferior free wall of the ventricle.

He reported that friction of the stent against the annulus prevents leakage. Early on he used a pericardial cuff to anchor to the annulus, particularly in patients who had undergone failed AVC repair. He tries to preserve at least part of the anterior leaflet to facilitate suture placement and create a "stand-off" from the LVOTO.

Dr. Emani also advised limiting intraoperative dilation to no more than 1 mm greater than the measured annulus. "Try not to overdilate at implantation to avoid heart block, LVOTO, and coronary compression. The nice thing is you don’t have to decide then and there what size you want. You can go back to the cath lab and, under direct visualization with the coronary view, you can dilate it under more controlled circumstances.

"The hope is that we will be able to dilate these valves as the patients grow into adolescence. If we can dilate them up to 22 mm, hopefully we will decrease the number of repeat replacements, delay the time to reoperation, and perhaps modify our thresholds for tolerating significant disease after unsuccessful repairs."

Dr. Emani reported no disclosures.

NEW YORK – Physicians at Boston Children’s Hospital replaced the mitral valves of eight infants with irreparable mitral valve disease with a valve that offers the opportunity of sequential expansion as the child grows, according to Dr. Sitaram M. Emani. The results were presented at the 2013 Mitral Valve Conclave earlier this year.

"The Melody valve retains its competence if you expand it before putting it in. We asked whether the valve retains the ability to maintain competence even if expansion is performed after implantation as the patient grows," said Dr. Emani, a pediatric cardiac surgeon at Boston Children’s Hospital.

 All photos courtesy Dr. Sitaram M. Emani

According to Dr. Emani, the current options for infants with damaged mitral valves that are beyond repair are replacement with mechanical or bioprosthetic valves or the Ross mitral procedure. Perhaps the main disadvantage of these options is the lack of a prosthetic valve small enough for an infant, one that is less than 12 mm in diameter. Another problem is the possibility of stenosis developing as the child grows, since the diameters of the prosthetics are fixed. Other drawbacks are that supra-annular fixation is generally associated with poor outcomes and that annular fixation limits the ability to upsize at reoperation.

The Melody valve is an externally stented bovine jugular vein graft that was designed for transcatheter pulmonary valve replacement. In this study, the valve was inserted surgically. The valve maintains competence over a range of sizes up to 22 mm. Although this valve is not approved for use for mitral valve replacement, the hope of using such a prosthetic is that it can be enlarged in the catheterization laboratory as the child grows.

Dr. Emani did a retrospective study of his experience with the Melody valve for mitral valve replacement in eight infants less than 12 months of age. The median age at implantation was 6 months (range, 1-9 months). Four infants had an atrioventricular canal (AVC) defect and four had congenital mitral valve stenosis. Most of the children had two prior operations for mitral valve repair. The longest follow-up to date has been 2 years.

At a median follow-up of 8 months, regurgitation on the echocardiogram was considered to be mild or less in all patients. The median gradient was 3 mm Hg (range, 2-7 mm Hg) on the immediate postoperative echocardiogram. Three patients developed a mild paravalvular leak; one of these patients had undergone aggressive stent resection, a modification Dr. Emani does not recommend. One patient developed left ventricular outflow tract obstruction (LVOTO), which Dr. Emani attributed to the lack of distal stent fixation in this patient. Another patient with an AVC defect developed complete heart block.

One patient who died 3 days postoperatively had heterotaxy, severe mitral regurgitation, and prior ventricular failure on extracorporeal membrane oxygenation support. That patient had undergone valve implantation as a last resort.

Three patients underwent sequential expansion about 6 months after implantation. After valve expansion, the median balloon size was 12 mm, ranging from 12 to 16 mm. None of the patients developed worsening valvular function and all had relief of obstruction. Transcatheter intervention was used to correct a paravalvular leak in one patient and to treat a left ventricular outflow tract problem in another. None of the patients developed endocarditis or a strut fracture, "although I worry about strut fracture if aggressive stent resection and manipulation is performed," he said at the meeting, which was sponsored by the AATS.

Dr. Emani offered some procedural tips. First, the Melody valve must be optimized for surgical implantation in infants. The length of the valve must be reduced by trimming it to reduce the chance of LVOTO or pulmonary vein obstruction. He recommends sizing the valves by echocardiogram and fixating the distal stent to the inferior free wall of the ventricle.

He reported that friction of the stent against the annulus prevents leakage. Early on he used a pericardial cuff to anchor to the annulus, particularly in patients who had undergone failed AVC repair. He tries to preserve at least part of the anterior leaflet to facilitate suture placement and create a "stand-off" from the LVOTO.

Dr. Emani also advised limiting intraoperative dilation to no more than 1 mm greater than the measured annulus. "Try not to overdilate at implantation to avoid heart block, LVOTO, and coronary compression. The nice thing is you don’t have to decide then and there what size you want. You can go back to the cath lab and, under direct visualization with the coronary view, you can dilate it under more controlled circumstances.

"The hope is that we will be able to dilate these valves as the patients grow into adolescence. If we can dilate them up to 22 mm, hopefully we will decrease the number of repeat replacements, delay the time to reoperation, and perhaps modify our thresholds for tolerating significant disease after unsuccessful repairs."

Dr. Emani reported no disclosures.

What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?

Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.

"How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?" said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.

“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.

Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.

An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.¹

“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.

The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.

Listen to more of our interview with MARQUIS principal investigator Jeffrey Schnipper MD, MPH, FHM.

Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.

Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.

The MARQUIS toolkit is available on the SHM website. TH

Larry Beresford is a freelance writer in San Francisco.

Reference

1. Schnipper JL, Mueller SK, Salanitro AH, Stein J. Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). PowerPoint presentation at Society of Hospital Medicine annual meeting, May 16-19, 2013, National Harbor, Md.

What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?

Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.

"How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?" said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.

“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.

Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.

An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.¹

“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.

The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.

Listen to more of our interview with MARQUIS principal investigator Jeffrey Schnipper MD, MPH, FHM.

Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.

Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.

The MARQUIS toolkit is available on the SHM website. TH

Larry Beresford is a freelance writer in San Francisco.

Reference

1. Schnipper JL, Mueller SK, Salanitro AH, Stein J. Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). PowerPoint presentation at Society of Hospital Medicine annual meeting, May 16-19, 2013, National Harbor, Md.

What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?

Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.

"How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?" said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.

“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.

Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.

An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.¹

“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.

The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.

Listen to more of our interview with MARQUIS principal investigator Jeffrey Schnipper MD, MPH, FHM.

Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.

Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.

The MARQUIS toolkit is available on the SHM website. TH

Larry Beresford is a freelance writer in San Francisco.

Reference

1. Schnipper JL, Mueller SK, Salanitro AH, Stein J. Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). PowerPoint presentation at Society of Hospital Medicine annual meeting, May 16-19, 2013, National Harbor, Md.

She presented to the trauma bay after transfer from another hospital. She had fallen out of bed at the nursing home, and they had sent her to the emergency department for evaluation. Her head CT demonstrated a subacute chronic subdural hematoma. She had fallen a month ago and had been seen at the same hospital and was transferred to us then, too, but not as a trauma. Admitted to another service for a few days, she had subsequently been sent to the nursing home with weekly head CT scans for follow-up. Today’s CT showed continued resolution of her subdural hematoma, but since she had fallen and had an abnormal CT scan, she was transferred to us as a trauma for further evaluation.

The patient was elderly, in her 90s, with end-stage dementia. The trauma team descended on her as we do with all traumas – to evaluate for life-threatening injuries. Airway, breathing, circulation. Does she need to be intubated? What is her blood pressure? Place IVs and draw blood. Put her quickly on the monitors, undress her completely. Roll her on her side to examine her back. Make sure she is in a rigid C-collar and cannot move her neck until we are sure it isn’t fractured. She cannot sit up despite her desire to do so, thus requiring us to hold her down, so she doesn’t injure herself or others. In the midst of all this, she kept screaming, "Why do you keep doing this to me?" That was all she said. Repeatedly. As I sorted out the events of the past month, read the radiologist report from the referring institution that documented improvement in her scans, and reviewed all the CTs on disc, I wondered the same, "Why are we doing this to you?" She didn’t need a trauma center or the trauma team. What she needed was a goals of care discussion and POLST (Physician Orders for Life-Sustaining Treatment) document.

We, as doctors, are poor at discussing goals of care. Even for those patients who are expected to do well, we do not address code status, or ask them what they want if things go poorly. Recently, the University of California published their results with a quality improvement program to document advance care planning discussions. Between July 2011 and May 2012 on the medical service, they created an incentive program for documentation of goals of care and identification of a surrogate decision maker. If 75% of patients had the two items documented in the medical record, then the residents received a $400 incentive. Documentation (and likely actual discussion) increased from 22% in July to 90% by October and remained at that level. There were reminders and feedback, and it seems likely a component of peer pressure among the residents to ensure everyone received the incentive. The study did not track outcomes or documentation rates after the program was over. The study did show that behavior of initiating difficult end-of-life (EOL) planning discussions can be improved in a quality improvement program. (JAMA Intern. Med. 2013 [doi: 10.1001/jamainternmed.2013.8158]).

Ideally, the next step would be to document the use of POLST (www.polst.org) orders. POLST is a bright pink form that documents the patient’s preferences for code status, treatment options (full including ICU, limited, or comfort measures including no transport to hospital) artificial nutrition and hydration, and antibiotics. POLST is signed by a physician and, therefore, it can be applied across care settings. If it is signed by the patient, it cannot be overridden by the surrogate, and there are legal protections for health care providers.

We admitted the patient in the trauma bay, not because she needed acute care, but because she needed goals of care defined. We consulted Palliative Medicine and had the social worker identify a decision maker. Palliative Medicine worked with the surrogate decision maker to set goals of care: feeding tube, follow-up scans, code status, and most importantly POLST orders. Regrettably, it took a trip to the Trauma Bay after multiple interactions with the health care system to evaluate what really was in the best interest of the patient and what she would have wanted. She told us as best she could that she did not want what we were doing to her. This time, we listened.

Dr Toevs is a trauma critical care surgeon at Allegheny General Hospital in Pittsburgh, Pa. She has a Masters degree in bioethics and board-certification in hospice and palliative medicine.

She presented to the trauma bay after transfer from another hospital. She had fallen out of bed at the nursing home, and they had sent her to the emergency department for evaluation. Her head CT demonstrated a subacute chronic subdural hematoma. She had fallen a month ago and had been seen at the same hospital and was transferred to us then, too, but not as a trauma. Admitted to another service for a few days, she had subsequently been sent to the nursing home with weekly head CT scans for follow-up. Today’s CT showed continued resolution of her subdural hematoma, but since she had fallen and had an abnormal CT scan, she was transferred to us as a trauma for further evaluation.

The patient was elderly, in her 90s, with end-stage dementia. The trauma team descended on her as we do with all traumas – to evaluate for life-threatening injuries. Airway, breathing, circulation. Does she need to be intubated? What is her blood pressure? Place IVs and draw blood. Put her quickly on the monitors, undress her completely. Roll her on her side to examine her back. Make sure she is in a rigid C-collar and cannot move her neck until we are sure it isn’t fractured. She cannot sit up despite her desire to do so, thus requiring us to hold her down, so she doesn’t injure herself or others. In the midst of all this, she kept screaming, "Why do you keep doing this to me?" That was all she said. Repeatedly. As I sorted out the events of the past month, read the radiologist report from the referring institution that documented improvement in her scans, and reviewed all the CTs on disc, I wondered the same, "Why are we doing this to you?" She didn’t need a trauma center or the trauma team. What she needed was a goals of care discussion and POLST (Physician Orders for Life-Sustaining Treatment) document.

We, as doctors, are poor at discussing goals of care. Even for those patients who are expected to do well, we do not address code status, or ask them what they want if things go poorly. Recently, the University of California published their results with a quality improvement program to document advance care planning discussions. Between July 2011 and May 2012 on the medical service, they created an incentive program for documentation of goals of care and identification of a surrogate decision maker. If 75% of patients had the two items documented in the medical record, then the residents received a $400 incentive. Documentation (and likely actual discussion) increased from 22% in July to 90% by October and remained at that level. There were reminders and feedback, and it seems likely a component of peer pressure among the residents to ensure everyone received the incentive. The study did not track outcomes or documentation rates after the program was over. The study did show that behavior of initiating difficult end-of-life (EOL) planning discussions can be improved in a quality improvement program. (JAMA Intern. Med. 2013 [doi: 10.1001/jamainternmed.2013.8158]).

Ideally, the next step would be to document the use of POLST (www.polst.org) orders. POLST is a bright pink form that documents the patient’s preferences for code status, treatment options (full including ICU, limited, or comfort measures including no transport to hospital) artificial nutrition and hydration, and antibiotics. POLST is signed by a physician and, therefore, it can be applied across care settings. If it is signed by the patient, it cannot be overridden by the surrogate, and there are legal protections for health care providers.

We admitted the patient in the trauma bay, not because she needed acute care, but because she needed goals of care defined. We consulted Palliative Medicine and had the social worker identify a decision maker. Palliative Medicine worked with the surrogate decision maker to set goals of care: feeding tube, follow-up scans, code status, and most importantly POLST orders. Regrettably, it took a trip to the Trauma Bay after multiple interactions with the health care system to evaluate what really was in the best interest of the patient and what she would have wanted. She told us as best she could that she did not want what we were doing to her. This time, we listened.

Dr Toevs is a trauma critical care surgeon at Allegheny General Hospital in Pittsburgh, Pa. She has a Masters degree in bioethics and board-certification in hospice and palliative medicine.

She presented to the trauma bay after transfer from another hospital. She had fallen out of bed at the nursing home, and they had sent her to the emergency department for evaluation. Her head CT demonstrated a subacute chronic subdural hematoma. She had fallen a month ago and had been seen at the same hospital and was transferred to us then, too, but not as a trauma. Admitted to another service for a few days, she had subsequently been sent to the nursing home with weekly head CT scans for follow-up. Today’s CT showed continued resolution of her subdural hematoma, but since she had fallen and had an abnormal CT scan, she was transferred to us as a trauma for further evaluation.

The patient was elderly, in her 90s, with end-stage dementia. The trauma team descended on her as we do with all traumas – to evaluate for life-threatening injuries. Airway, breathing, circulation. Does she need to be intubated? What is her blood pressure? Place IVs and draw blood. Put her quickly on the monitors, undress her completely. Roll her on her side to examine her back. Make sure she is in a rigid C-collar and cannot move her neck until we are sure it isn’t fractured. She cannot sit up despite her desire to do so, thus requiring us to hold her down, so she doesn’t injure herself or others. In the midst of all this, she kept screaming, "Why do you keep doing this to me?" That was all she said. Repeatedly. As I sorted out the events of the past month, read the radiologist report from the referring institution that documented improvement in her scans, and reviewed all the CTs on disc, I wondered the same, "Why are we doing this to you?" She didn’t need a trauma center or the trauma team. What she needed was a goals of care discussion and POLST (Physician Orders for Life-Sustaining Treatment) document.

We, as doctors, are poor at discussing goals of care. Even for those patients who are expected to do well, we do not address code status, or ask them what they want if things go poorly. Recently, the University of California published their results with a quality improvement program to document advance care planning discussions. Between July 2011 and May 2012 on the medical service, they created an incentive program for documentation of goals of care and identification of a surrogate decision maker. If 75% of patients had the two items documented in the medical record, then the residents received a $400 incentive. Documentation (and likely actual discussion) increased from 22% in July to 90% by October and remained at that level. There were reminders and feedback, and it seems likely a component of peer pressure among the residents to ensure everyone received the incentive. The study did not track outcomes or documentation rates after the program was over. The study did show that behavior of initiating difficult end-of-life (EOL) planning discussions can be improved in a quality improvement program. (JAMA Intern. Med. 2013 [doi: 10.1001/jamainternmed.2013.8158]).

Ideally, the next step would be to document the use of POLST (www.polst.org) orders. POLST is a bright pink form that documents the patient’s preferences for code status, treatment options (full including ICU, limited, or comfort measures including no transport to hospital) artificial nutrition and hydration, and antibiotics. POLST is signed by a physician and, therefore, it can be applied across care settings. If it is signed by the patient, it cannot be overridden by the surrogate, and there are legal protections for health care providers.

We admitted the patient in the trauma bay, not because she needed acute care, but because she needed goals of care defined. We consulted Palliative Medicine and had the social worker identify a decision maker. Palliative Medicine worked with the surrogate decision maker to set goals of care: feeding tube, follow-up scans, code status, and most importantly POLST orders. Regrettably, it took a trip to the Trauma Bay after multiple interactions with the health care system to evaluate what really was in the best interest of the patient and what she would have wanted. She told us as best she could that she did not want what we were doing to her. This time, we listened.

Dr Toevs is a trauma critical care surgeon at Allegheny General Hospital in Pittsburgh, Pa. She has a Masters degree in bioethics and board-certification in hospice and palliative medicine.