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Innovations: Quality, patient safety, and technology initiatives
Measuring hospital-acquired infection in a new way
Every day, hospitalists struggle with health care–associated infections, which 1 in 25 patients experiences, according to the Centers for Disease Control and Prevention.
These infections are often discussed in terms of the standardized infection ratio (SIR), but that measure may not assess overall performance, according to a study suggesting a new measure that could help large hospital systems better evaluate their infection outcomes by comparing them with those of their peers.
This gives hospitals a more current picture of how they’re doing, compared with the SIR, said Mohamad G. Fakih, MD, MPH, of Ascension Health, Grosse Pointe Woods, Mich., lead author of the study. “The SIR is a ratio based on a baseline that’s usually a few years prior; it’s not the year directly before. So, when we published this paper, some of the infections had a baseline of 2006 through 2008 for the central line infections.”
Another difference is that the ICS gives the six infections the same weight, rather than combining them. “So, if you add them up together and then you divide by six, you get a score that tells you how you’re doing for infection, compared [with] the whole system. If they have a problem that’s related to many infections, then you know the culture of infection prevention in that hospital is much worse. It’s not just one product. There’s something much more worrisome for that hospital.”
This simple score can be adjusted according to a particular hospital’s needs. “Let’s say you want to focus on additional infections that are publicly reported. You can add them to that score,” Dr. Fakih says. “And you can change the weight in a way depending on what you want to focus on, or, if you want to focus on something more than others, you can increase the weight.”
References
1. Centers for Disease Control and Prevention. Healthcare-associated infections. https://www.cdc.gov/hai/surveillance/. Accessed April 10, 2017.
2. Fakih MG, Skierczynski B, Bufalino A, et al. Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts. American Journal of Infection Control. (2016);44(12):1578-81.
Hospitalists lead in palliative care
According to a recent report, hospitalists made nearly half (48%) of all palliative care referrals in hospitals in 2015. The report comes from the Center to Advance Palliative Care and the National Palliative Care Research Center.
“The most important finding from this analysis is the near doubling of the number of people receiving palliative care services in U.S. hospital palliative care programs, from an average of 2.7% in 2009 to an average of 4.8% in 2015,” said Diane Meier, MD, director of the Center to Advance Palliative Care. “This suggests increasing recognition of the benefits of palliative care by health professionals and greater likelihood that those living with serious illness will receive state-of-the-art care.”
The report shows that hospitalists are the No. 1 source of referral to palliative care teams. “They see up close the suffering of their patients and families, their need for comprehensive whole-person care, and the beneficial impact of the added layer of support that palliative care provides,” she said.
“Hospitalists should work alongside their palliative care colleagues to develop standardized screening tools so that all patients and families who could benefit have access to the best quality of care during serious and complex illness,” Dr. Meier said. Hospitalists can also gain skills in communicating about prognosis and conducting family meetings, as well as safe and effective symptom management, through the online clinical training curriculum available at capc.org.
Reference
1. National Palliative Care Registry. How We Work: Trends and Insights in Hospital Palliative Care. https://registry.capc.org/wp-content/uploads/2017/02/How-We-Work-Trends-and-Insights-in-Hospital-Palliative-Care-2009-2015.pdf. Accessed April 7, 2017.
Improving outcomes for children with chronic conditions
Cincinnati Children’s Hospital Medical Center improved outcomes for 50% of pediatric patients by redesigning the way it cares for children with active chronic conditions, according to a new study.
The hospital implemented a Condition Outcomes Improvement Initiative, in which specialized clinical teams applied quality improvement principles to improve outcomes for pediatric patients with chronic illnesses.
Each improvement team focused on a specific chronic condition, such as juvenile arthritis, asthma, chronic kidney disease, or sickle cell disease. The improvement processes implemented included reviewing evidence to choose which outcomes to measure, developing condition-specific patient registries and data collection tools, classifying patients into defined risk groups, planning care before and after visits, and providing self-management and caregiver/parent support for patients and their families.
Study lead author Jennifer Lail, MD, FAAP, analyzed data from more than 27,000 pediatric patients from 18 improvement teams. Following implementation of the changes, half of patients had an improved outcome, and 11 of the 18 chronic condition teams achieved the goal of 20% improvement in their chosen clinical outcome, suggesting that clinical teams implementing quality improvement methods with multidisciplinary support can improve outcomes for populations with chronic conditions.
Reference
1. Lail J, et al. Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center. Joint Commission Journal on Quality and Patient Safety. 2017;43(3):101-112.
FDA approves two new antibiotic tests
Hospitalists have two new FDA-approved tools available to help them make antibiotic treatment decisions.
The first is the expanded use of the Vidas Brahms PCT Assay, intended to be used in the hospital or emergency room. The test uses – for the first time – procalcitonin (PCT), a protein associated with the body’s response to a bacterial infection, as a biomarker that can help hospitalists make antibiotic management decisions in patients with those conditions. The results can help them determine if antibiotic treatment should be started or stopped in patients with lower respiratory tract infections (such as community-acquired pneumonia) and stopped in patients with sepsis.
The FDA has also allowed marketing of the PhenoTest BC Kit. This one is another first, the first test to identify organisms causing bloodstream infections and provide information about the antibiotics to which the organism is likely to respond.
The test can identify bacteria or yeast from a positive blood culture in approximately 1.5 hours (compared with traditional identification and antibiotic susceptibility tests, which can take one to two days). The test can identify 14 different species of bacteria and two species of yeast that cause bloodstream infections. It also provides antibiotic sensitivity information on 18 antibiotics. In addition, the test will identify the presence of two indicators of antibiotic resistance.
Quick byte
About a third of adverse events during hospitalizations involve a drug-related harm, resulting in longer hospital stays and increased costs, according to the New York Times. “The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.”
Reference
1 Frakt A. How Many Pills Are Too Many? The New York Times. 2017 Apr 10. https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health®ion=stream&module=stream_unit&version=latest&contentPlacement=6&pgtype=sectionfront&_r=0. Accessed April 9, 2017.
Measuring hospital-acquired infection in a new way
Every day, hospitalists struggle with health care–associated infections, which 1 in 25 patients experiences, according to the Centers for Disease Control and Prevention.
These infections are often discussed in terms of the standardized infection ratio (SIR), but that measure may not assess overall performance, according to a study suggesting a new measure that could help large hospital systems better evaluate their infection outcomes by comparing them with those of their peers.
This gives hospitals a more current picture of how they’re doing, compared with the SIR, said Mohamad G. Fakih, MD, MPH, of Ascension Health, Grosse Pointe Woods, Mich., lead author of the study. “The SIR is a ratio based on a baseline that’s usually a few years prior; it’s not the year directly before. So, when we published this paper, some of the infections had a baseline of 2006 through 2008 for the central line infections.”
Another difference is that the ICS gives the six infections the same weight, rather than combining them. “So, if you add them up together and then you divide by six, you get a score that tells you how you’re doing for infection, compared [with] the whole system. If they have a problem that’s related to many infections, then you know the culture of infection prevention in that hospital is much worse. It’s not just one product. There’s something much more worrisome for that hospital.”
This simple score can be adjusted according to a particular hospital’s needs. “Let’s say you want to focus on additional infections that are publicly reported. You can add them to that score,” Dr. Fakih says. “And you can change the weight in a way depending on what you want to focus on, or, if you want to focus on something more than others, you can increase the weight.”
References
1. Centers for Disease Control and Prevention. Healthcare-associated infections. https://www.cdc.gov/hai/surveillance/. Accessed April 10, 2017.
2. Fakih MG, Skierczynski B, Bufalino A, et al. Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts. American Journal of Infection Control. (2016);44(12):1578-81.
Hospitalists lead in palliative care
According to a recent report, hospitalists made nearly half (48%) of all palliative care referrals in hospitals in 2015. The report comes from the Center to Advance Palliative Care and the National Palliative Care Research Center.
“The most important finding from this analysis is the near doubling of the number of people receiving palliative care services in U.S. hospital palliative care programs, from an average of 2.7% in 2009 to an average of 4.8% in 2015,” said Diane Meier, MD, director of the Center to Advance Palliative Care. “This suggests increasing recognition of the benefits of palliative care by health professionals and greater likelihood that those living with serious illness will receive state-of-the-art care.”
The report shows that hospitalists are the No. 1 source of referral to palliative care teams. “They see up close the suffering of their patients and families, their need for comprehensive whole-person care, and the beneficial impact of the added layer of support that palliative care provides,” she said.
“Hospitalists should work alongside their palliative care colleagues to develop standardized screening tools so that all patients and families who could benefit have access to the best quality of care during serious and complex illness,” Dr. Meier said. Hospitalists can also gain skills in communicating about prognosis and conducting family meetings, as well as safe and effective symptom management, through the online clinical training curriculum available at capc.org.
Reference
1. National Palliative Care Registry. How We Work: Trends and Insights in Hospital Palliative Care. https://registry.capc.org/wp-content/uploads/2017/02/How-We-Work-Trends-and-Insights-in-Hospital-Palliative-Care-2009-2015.pdf. Accessed April 7, 2017.
Improving outcomes for children with chronic conditions
Cincinnati Children’s Hospital Medical Center improved outcomes for 50% of pediatric patients by redesigning the way it cares for children with active chronic conditions, according to a new study.
The hospital implemented a Condition Outcomes Improvement Initiative, in which specialized clinical teams applied quality improvement principles to improve outcomes for pediatric patients with chronic illnesses.
Each improvement team focused on a specific chronic condition, such as juvenile arthritis, asthma, chronic kidney disease, or sickle cell disease. The improvement processes implemented included reviewing evidence to choose which outcomes to measure, developing condition-specific patient registries and data collection tools, classifying patients into defined risk groups, planning care before and after visits, and providing self-management and caregiver/parent support for patients and their families.
Study lead author Jennifer Lail, MD, FAAP, analyzed data from more than 27,000 pediatric patients from 18 improvement teams. Following implementation of the changes, half of patients had an improved outcome, and 11 of the 18 chronic condition teams achieved the goal of 20% improvement in their chosen clinical outcome, suggesting that clinical teams implementing quality improvement methods with multidisciplinary support can improve outcomes for populations with chronic conditions.
Reference
1. Lail J, et al. Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center. Joint Commission Journal on Quality and Patient Safety. 2017;43(3):101-112.
FDA approves two new antibiotic tests
Hospitalists have two new FDA-approved tools available to help them make antibiotic treatment decisions.
The first is the expanded use of the Vidas Brahms PCT Assay, intended to be used in the hospital or emergency room. The test uses – for the first time – procalcitonin (PCT), a protein associated with the body’s response to a bacterial infection, as a biomarker that can help hospitalists make antibiotic management decisions in patients with those conditions. The results can help them determine if antibiotic treatment should be started or stopped in patients with lower respiratory tract infections (such as community-acquired pneumonia) and stopped in patients with sepsis.
The FDA has also allowed marketing of the PhenoTest BC Kit. This one is another first, the first test to identify organisms causing bloodstream infections and provide information about the antibiotics to which the organism is likely to respond.
The test can identify bacteria or yeast from a positive blood culture in approximately 1.5 hours (compared with traditional identification and antibiotic susceptibility tests, which can take one to two days). The test can identify 14 different species of bacteria and two species of yeast that cause bloodstream infections. It also provides antibiotic sensitivity information on 18 antibiotics. In addition, the test will identify the presence of two indicators of antibiotic resistance.
Quick byte
About a third of adverse events during hospitalizations involve a drug-related harm, resulting in longer hospital stays and increased costs, according to the New York Times. “The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.”
Reference
1 Frakt A. How Many Pills Are Too Many? The New York Times. 2017 Apr 10. https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health®ion=stream&module=stream_unit&version=latest&contentPlacement=6&pgtype=sectionfront&_r=0. Accessed April 9, 2017.
Measuring hospital-acquired infection in a new way
Every day, hospitalists struggle with health care–associated infections, which 1 in 25 patients experiences, according to the Centers for Disease Control and Prevention.
These infections are often discussed in terms of the standardized infection ratio (SIR), but that measure may not assess overall performance, according to a study suggesting a new measure that could help large hospital systems better evaluate their infection outcomes by comparing them with those of their peers.
This gives hospitals a more current picture of how they’re doing, compared with the SIR, said Mohamad G. Fakih, MD, MPH, of Ascension Health, Grosse Pointe Woods, Mich., lead author of the study. “The SIR is a ratio based on a baseline that’s usually a few years prior; it’s not the year directly before. So, when we published this paper, some of the infections had a baseline of 2006 through 2008 for the central line infections.”
Another difference is that the ICS gives the six infections the same weight, rather than combining them. “So, if you add them up together and then you divide by six, you get a score that tells you how you’re doing for infection, compared [with] the whole system. If they have a problem that’s related to many infections, then you know the culture of infection prevention in that hospital is much worse. It’s not just one product. There’s something much more worrisome for that hospital.”
This simple score can be adjusted according to a particular hospital’s needs. “Let’s say you want to focus on additional infections that are publicly reported. You can add them to that score,” Dr. Fakih says. “And you can change the weight in a way depending on what you want to focus on, or, if you want to focus on something more than others, you can increase the weight.”
References
1. Centers for Disease Control and Prevention. Healthcare-associated infections. https://www.cdc.gov/hai/surveillance/. Accessed April 10, 2017.
2. Fakih MG, Skierczynski B, Bufalino A, et al. Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts. American Journal of Infection Control. (2016);44(12):1578-81.
Hospitalists lead in palliative care
According to a recent report, hospitalists made nearly half (48%) of all palliative care referrals in hospitals in 2015. The report comes from the Center to Advance Palliative Care and the National Palliative Care Research Center.
“The most important finding from this analysis is the near doubling of the number of people receiving palliative care services in U.S. hospital palliative care programs, from an average of 2.7% in 2009 to an average of 4.8% in 2015,” said Diane Meier, MD, director of the Center to Advance Palliative Care. “This suggests increasing recognition of the benefits of palliative care by health professionals and greater likelihood that those living with serious illness will receive state-of-the-art care.”
The report shows that hospitalists are the No. 1 source of referral to palliative care teams. “They see up close the suffering of their patients and families, their need for comprehensive whole-person care, and the beneficial impact of the added layer of support that palliative care provides,” she said.
“Hospitalists should work alongside their palliative care colleagues to develop standardized screening tools so that all patients and families who could benefit have access to the best quality of care during serious and complex illness,” Dr. Meier said. Hospitalists can also gain skills in communicating about prognosis and conducting family meetings, as well as safe and effective symptom management, through the online clinical training curriculum available at capc.org.
Reference
1. National Palliative Care Registry. How We Work: Trends and Insights in Hospital Palliative Care. https://registry.capc.org/wp-content/uploads/2017/02/How-We-Work-Trends-and-Insights-in-Hospital-Palliative-Care-2009-2015.pdf. Accessed April 7, 2017.
Improving outcomes for children with chronic conditions
Cincinnati Children’s Hospital Medical Center improved outcomes for 50% of pediatric patients by redesigning the way it cares for children with active chronic conditions, according to a new study.
The hospital implemented a Condition Outcomes Improvement Initiative, in which specialized clinical teams applied quality improvement principles to improve outcomes for pediatric patients with chronic illnesses.
Each improvement team focused on a specific chronic condition, such as juvenile arthritis, asthma, chronic kidney disease, or sickle cell disease. The improvement processes implemented included reviewing evidence to choose which outcomes to measure, developing condition-specific patient registries and data collection tools, classifying patients into defined risk groups, planning care before and after visits, and providing self-management and caregiver/parent support for patients and their families.
Study lead author Jennifer Lail, MD, FAAP, analyzed data from more than 27,000 pediatric patients from 18 improvement teams. Following implementation of the changes, half of patients had an improved outcome, and 11 of the 18 chronic condition teams achieved the goal of 20% improvement in their chosen clinical outcome, suggesting that clinical teams implementing quality improvement methods with multidisciplinary support can improve outcomes for populations with chronic conditions.
Reference
1. Lail J, et al. Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center. Joint Commission Journal on Quality and Patient Safety. 2017;43(3):101-112.
FDA approves two new antibiotic tests
Hospitalists have two new FDA-approved tools available to help them make antibiotic treatment decisions.
The first is the expanded use of the Vidas Brahms PCT Assay, intended to be used in the hospital or emergency room. The test uses – for the first time – procalcitonin (PCT), a protein associated with the body’s response to a bacterial infection, as a biomarker that can help hospitalists make antibiotic management decisions in patients with those conditions. The results can help them determine if antibiotic treatment should be started or stopped in patients with lower respiratory tract infections (such as community-acquired pneumonia) and stopped in patients with sepsis.
The FDA has also allowed marketing of the PhenoTest BC Kit. This one is another first, the first test to identify organisms causing bloodstream infections and provide information about the antibiotics to which the organism is likely to respond.
The test can identify bacteria or yeast from a positive blood culture in approximately 1.5 hours (compared with traditional identification and antibiotic susceptibility tests, which can take one to two days). The test can identify 14 different species of bacteria and two species of yeast that cause bloodstream infections. It also provides antibiotic sensitivity information on 18 antibiotics. In addition, the test will identify the presence of two indicators of antibiotic resistance.
Quick byte
About a third of adverse events during hospitalizations involve a drug-related harm, resulting in longer hospital stays and increased costs, according to the New York Times. “The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.”
Reference
1 Frakt A. How Many Pills Are Too Many? The New York Times. 2017 Apr 10. https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health®ion=stream&module=stream_unit&version=latest&contentPlacement=6&pgtype=sectionfront&_r=0. Accessed April 9, 2017.
Improving our approach to discharge planning
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
Since finishing up the initial planning phase of our project, my mentors and I have continued with even more planning as we head into the fall. Coming up with a good plan is the first step in making sure everything goes smoothly later on in a project. The same goes for coming up with a well-thought-out discharge plan when sending a patient to the next level of care.
Getting a patient out of the hospital and into their next destination – whether it’s a long-term acute care facility, skilled nursing facility, inpatient rehabilitation, home, or elsewhere – can approach the same level of complexity as the medical care received in the hospital. Getting a patient to any post-acute care facility can be time-consuming because it involves the coordination of two health care entities and their employees.
Discharge planning for post-acute care placement can take many forms and involve many resources. Some studies have shown that certain discharge planning interventions can reduce costs and 30-day readmissions. Many physicians think that discharge planning would help improve outcomes in most groups, but so far the aggregate data do not show that discharge planning account for much improvement in any of these outcomes. Targeting certain groups of hospitalized patients, however, could improve the effect that discharge planning has on these outcomes because more of these scarce resources might be devoted to the right patients earlier in their hospital stays.
A post-acute care placement prediction tool would help hospitalists determine how to allocate their discharge planning resources, including social work, case management, pharmacies, physical therapy, and occupational therapy. While we are working towards integrating this kind of tool in our own institution’s practice, we are also hopeful that we can create a generalizable tool that assists in helping care teams decide how to link patients to the right resources elsewhere.
Monisha Bhatia, a native of Nashville, Tenn., is a fourth-year medical student at Vanderbilt University in Nashville. She is hoping to pursue either a residency in internal medicine or a combined internal medicine/emergency medicine program. Prior to medical school, she completed a JD/MPH program at Boston University, and she hopes to use her legal training in working with regulatory authorities to improve access to health care for all Americans.
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
Since finishing up the initial planning phase of our project, my mentors and I have continued with even more planning as we head into the fall. Coming up with a good plan is the first step in making sure everything goes smoothly later on in a project. The same goes for coming up with a well-thought-out discharge plan when sending a patient to the next level of care.
Getting a patient out of the hospital and into their next destination – whether it’s a long-term acute care facility, skilled nursing facility, inpatient rehabilitation, home, or elsewhere – can approach the same level of complexity as the medical care received in the hospital. Getting a patient to any post-acute care facility can be time-consuming because it involves the coordination of two health care entities and their employees.
Discharge planning for post-acute care placement can take many forms and involve many resources. Some studies have shown that certain discharge planning interventions can reduce costs and 30-day readmissions. Many physicians think that discharge planning would help improve outcomes in most groups, but so far the aggregate data do not show that discharge planning account for much improvement in any of these outcomes. Targeting certain groups of hospitalized patients, however, could improve the effect that discharge planning has on these outcomes because more of these scarce resources might be devoted to the right patients earlier in their hospital stays.
A post-acute care placement prediction tool would help hospitalists determine how to allocate their discharge planning resources, including social work, case management, pharmacies, physical therapy, and occupational therapy. While we are working towards integrating this kind of tool in our own institution’s practice, we are also hopeful that we can create a generalizable tool that assists in helping care teams decide how to link patients to the right resources elsewhere.
Monisha Bhatia, a native of Nashville, Tenn., is a fourth-year medical student at Vanderbilt University in Nashville. She is hoping to pursue either a residency in internal medicine or a combined internal medicine/emergency medicine program. Prior to medical school, she completed a JD/MPH program at Boston University, and she hopes to use her legal training in working with regulatory authorities to improve access to health care for all Americans.
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
Since finishing up the initial planning phase of our project, my mentors and I have continued with even more planning as we head into the fall. Coming up with a good plan is the first step in making sure everything goes smoothly later on in a project. The same goes for coming up with a well-thought-out discharge plan when sending a patient to the next level of care.
Getting a patient out of the hospital and into their next destination – whether it’s a long-term acute care facility, skilled nursing facility, inpatient rehabilitation, home, or elsewhere – can approach the same level of complexity as the medical care received in the hospital. Getting a patient to any post-acute care facility can be time-consuming because it involves the coordination of two health care entities and their employees.
Discharge planning for post-acute care placement can take many forms and involve many resources. Some studies have shown that certain discharge planning interventions can reduce costs and 30-day readmissions. Many physicians think that discharge planning would help improve outcomes in most groups, but so far the aggregate data do not show that discharge planning account for much improvement in any of these outcomes. Targeting certain groups of hospitalized patients, however, could improve the effect that discharge planning has on these outcomes because more of these scarce resources might be devoted to the right patients earlier in their hospital stays.
A post-acute care placement prediction tool would help hospitalists determine how to allocate their discharge planning resources, including social work, case management, pharmacies, physical therapy, and occupational therapy. While we are working towards integrating this kind of tool in our own institution’s practice, we are also hopeful that we can create a generalizable tool that assists in helping care teams decide how to link patients to the right resources elsewhere.
Monisha Bhatia, a native of Nashville, Tenn., is a fourth-year medical student at Vanderbilt University in Nashville. She is hoping to pursue either a residency in internal medicine or a combined internal medicine/emergency medicine program. Prior to medical school, she completed a JD/MPH program at Boston University, and she hopes to use her legal training in working with regulatory authorities to improve access to health care for all Americans.
Anticoagulation for patients with liver cirrhosis and portal vein thrombosis
Clinical question: Should patients with liver cirrhosis with portal vein thrombosis be treated with anticoagulation?
Background: Portal vein thrombosis occurs in about 20% of patients with liver cirrhosis. Previously these patients were not often treated with anticoagulation due to concern for increased bleeding risk associated with advanced liver disease. However, restoring portal vein patency may prevent further sequelae, including intestinal infarction and portal hypertension and may also affect candidacy for liver transplantation.
Setting: Multiple sites throughout the world.
Synopsis: The authors of this meta-analysis pooled data from eight clinical trials, comprising 353 patients with liver cirrhosis and portal vein thrombosis, to assess the rates of complete and partial recanalization with anticoagulation therapy (warfarin or low molecular weight heparin) versus no therapy. The authors also assessed the rate of minor and major bleeding complications in patients who received anticoagulation, compared with those who received no therapy. Patients who received anticoagulation therapy had increased recanalization and reduced progression of thrombosis without excessive major and minor bleeding.
Bottom line: This meta-analysis suggests anticoagulation might be safe and effective in treating portal vein thrombosis in patients with cirrhosis; however, this analysis was based on nonrandomized clinical trials and did not address long-term important endpoints, such as the effect of anticoagulation on mortality.
Citation: Loffredo L, Pastori D, Farcomeni A, Violi F. Effects of anticoagulants in patients with cirrhosis and portal vein thrombosis: A systematic review and meta-analysis. Gastroenterology. 2017 May 4. E-published ahead of print.
Dr. Teixeira is a hospitalist at Ochsner Health System, New Orleans.
Clinical question: Should patients with liver cirrhosis with portal vein thrombosis be treated with anticoagulation?
Background: Portal vein thrombosis occurs in about 20% of patients with liver cirrhosis. Previously these patients were not often treated with anticoagulation due to concern for increased bleeding risk associated with advanced liver disease. However, restoring portal vein patency may prevent further sequelae, including intestinal infarction and portal hypertension and may also affect candidacy for liver transplantation.
Setting: Multiple sites throughout the world.
Synopsis: The authors of this meta-analysis pooled data from eight clinical trials, comprising 353 patients with liver cirrhosis and portal vein thrombosis, to assess the rates of complete and partial recanalization with anticoagulation therapy (warfarin or low molecular weight heparin) versus no therapy. The authors also assessed the rate of minor and major bleeding complications in patients who received anticoagulation, compared with those who received no therapy. Patients who received anticoagulation therapy had increased recanalization and reduced progression of thrombosis without excessive major and minor bleeding.
Bottom line: This meta-analysis suggests anticoagulation might be safe and effective in treating portal vein thrombosis in patients with cirrhosis; however, this analysis was based on nonrandomized clinical trials and did not address long-term important endpoints, such as the effect of anticoagulation on mortality.
Citation: Loffredo L, Pastori D, Farcomeni A, Violi F. Effects of anticoagulants in patients with cirrhosis and portal vein thrombosis: A systematic review and meta-analysis. Gastroenterology. 2017 May 4. E-published ahead of print.
Dr. Teixeira is a hospitalist at Ochsner Health System, New Orleans.
Clinical question: Should patients with liver cirrhosis with portal vein thrombosis be treated with anticoagulation?
Background: Portal vein thrombosis occurs in about 20% of patients with liver cirrhosis. Previously these patients were not often treated with anticoagulation due to concern for increased bleeding risk associated with advanced liver disease. However, restoring portal vein patency may prevent further sequelae, including intestinal infarction and portal hypertension and may also affect candidacy for liver transplantation.
Setting: Multiple sites throughout the world.
Synopsis: The authors of this meta-analysis pooled data from eight clinical trials, comprising 353 patients with liver cirrhosis and portal vein thrombosis, to assess the rates of complete and partial recanalization with anticoagulation therapy (warfarin or low molecular weight heparin) versus no therapy. The authors also assessed the rate of minor and major bleeding complications in patients who received anticoagulation, compared with those who received no therapy. Patients who received anticoagulation therapy had increased recanalization and reduced progression of thrombosis without excessive major and minor bleeding.
Bottom line: This meta-analysis suggests anticoagulation might be safe and effective in treating portal vein thrombosis in patients with cirrhosis; however, this analysis was based on nonrandomized clinical trials and did not address long-term important endpoints, such as the effect of anticoagulation on mortality.
Citation: Loffredo L, Pastori D, Farcomeni A, Violi F. Effects of anticoagulants in patients with cirrhosis and portal vein thrombosis: A systematic review and meta-analysis. Gastroenterology. 2017 May 4. E-published ahead of print.
Dr. Teixeira is a hospitalist at Ochsner Health System, New Orleans.
‘Observationists’: Ready for prime time in an internal medicine residency program
The Institute of Medicine, in its report “Hospital-Based Emergency Care – At the Breaking Point,” has identified Observation Units (OUs) as a “particularly promising” technique to improve patient flow.1 Many hospitals across the country either already have them or are in the process of establishing such units.
Multiple studies have shown that a highly efficient OU can save billions in health care costs.2 Historically, such units have existed within and are staffed by emergency departments. Since the implementation of the two-midnight rule in Oct. 2013, the complexities of observation care changed dramatically from run of the mill 30- to 40-year-old chest pain patients to 80- to 90-year-olds with multiple comorbidities being placed in observation.3 In many cases, this shifted the care out of the emergency department and into the arena of hospital medicine.
At our institution OUs are staffed by internal medicine residents supervised by faculty 24/7 year round. This, we believe, is a unique model. We implemented our model after a mini SWOT (strengths, weaknesses, opportunities, and threats ) analysis in August 2014. The biggest strength was that we were educating the next generation of “Observationists” as we improved the quality of care delivered to our patients. Our biggest opportunity was no existing curriculum for teaching internal medicine residents the art of observation medicine. So we designed our own. Just like Peter Drucker said, “The best way to predict the future is to create it.”
The curriculum is extremely innovative and exposes our residents to both the business and administrative aspect of OUs. Upon surveying our own residents anonymously within 6 months of instituting this rotation, over 90% felt this to be a valuable rotation towards their training. Since we went live, some of our residents who have graduated are now leading OUs at other hospitals.
To measure our program outcomes, we developed a dashboard with multiple metrics for our team. With such data, this rotation became an incubator for our residents for quality improvement projects. They have developed, implemented, and published multiple abstracts, presented posters and even won the first place for innovation at the Midwest Regional Society of General Internal Medicine conference.5-8
We have learned many lessons, and every challenge has been addressed as an opportunity. The first lesson was that we needed strong physician leadership to act as the gatekeeper to the unit. Second, as the rotation matured, we always kept our focus on high-quality patient care; we created a quality dashboard which includes length of stay, falls, and patient satisfaction as examples. Last but not least, we stayed mindful of stakeholder buy in, which for us was primarily our residents. We created the curriculum that provides the next generation of internists the broad experience of medicine, with the appropriate amount of autonomy and supervision. This, we believe, is a win-win proposition for all stakeholders – hospitals, physicians, residents, and most importantly the patients we serve. Additionally, data at our institution shows that our resident-run units are educationally, clinically, and financially beneficial to the residency programs and the hospitals.
Teaching and exposure to observation medicine is not currently a mainstay in many internal medicine residency programs. Our program provides a framework to establish an observation medicine rotation, which exposes residents to quality metrics and expands their scope of medical education.
Dr. Nand is medical director, care management & observation unit, and associate program director, internal medicine residency program, at the University of Illinois College of Medicine/Advocate Christ Medical Center.
References
1. “Hospital-Based Emergency Care: At the Breaking Point” (Washington: National Academies Press, 2006) 2. Baugh, CJ et al. “Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year” Health Aff (Millwood). 2012 Oct;31(10):2314-23
3. Fact Sheet: Two-Midnight Rule. 2015. Available at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-01-2.html. Accessed March 29, 2016.
4. Society of Hospital Medicine. The observation unit white paper. http://www.hospitalmedicine.org, April 3, 2013.
5. Yousuf T. et al. “Intermediate chest pain protocol in an observation unit” Won first place award for innovation at the Midwest Regional SGIM conference, August 2015.
6. Sarfraz S et al. “Hand hygiene intervention increases compliance in observation unit” Poster: May 2016, Macy Midwest GME Conference, Michigan.
7. “Impact of syncope protocol in an observation unit of an academic tertiary care center” Poster for Oct 2016 AAIM skills development conference, National Harbor, Md.
8. Metgud S et al. “Integrating residents in providing high-value care via improved results of the ACGME annual resident survey” Poster: May 2016, Macy Midwest GME Conference, Michigan.
The Institute of Medicine, in its report “Hospital-Based Emergency Care – At the Breaking Point,” has identified Observation Units (OUs) as a “particularly promising” technique to improve patient flow.1 Many hospitals across the country either already have them or are in the process of establishing such units.
Multiple studies have shown that a highly efficient OU can save billions in health care costs.2 Historically, such units have existed within and are staffed by emergency departments. Since the implementation of the two-midnight rule in Oct. 2013, the complexities of observation care changed dramatically from run of the mill 30- to 40-year-old chest pain patients to 80- to 90-year-olds with multiple comorbidities being placed in observation.3 In many cases, this shifted the care out of the emergency department and into the arena of hospital medicine.
At our institution OUs are staffed by internal medicine residents supervised by faculty 24/7 year round. This, we believe, is a unique model. We implemented our model after a mini SWOT (strengths, weaknesses, opportunities, and threats ) analysis in August 2014. The biggest strength was that we were educating the next generation of “Observationists” as we improved the quality of care delivered to our patients. Our biggest opportunity was no existing curriculum for teaching internal medicine residents the art of observation medicine. So we designed our own. Just like Peter Drucker said, “The best way to predict the future is to create it.”
The curriculum is extremely innovative and exposes our residents to both the business and administrative aspect of OUs. Upon surveying our own residents anonymously within 6 months of instituting this rotation, over 90% felt this to be a valuable rotation towards their training. Since we went live, some of our residents who have graduated are now leading OUs at other hospitals.
To measure our program outcomes, we developed a dashboard with multiple metrics for our team. With such data, this rotation became an incubator for our residents for quality improvement projects. They have developed, implemented, and published multiple abstracts, presented posters and even won the first place for innovation at the Midwest Regional Society of General Internal Medicine conference.5-8
We have learned many lessons, and every challenge has been addressed as an opportunity. The first lesson was that we needed strong physician leadership to act as the gatekeeper to the unit. Second, as the rotation matured, we always kept our focus on high-quality patient care; we created a quality dashboard which includes length of stay, falls, and patient satisfaction as examples. Last but not least, we stayed mindful of stakeholder buy in, which for us was primarily our residents. We created the curriculum that provides the next generation of internists the broad experience of medicine, with the appropriate amount of autonomy and supervision. This, we believe, is a win-win proposition for all stakeholders – hospitals, physicians, residents, and most importantly the patients we serve. Additionally, data at our institution shows that our resident-run units are educationally, clinically, and financially beneficial to the residency programs and the hospitals.
Teaching and exposure to observation medicine is not currently a mainstay in many internal medicine residency programs. Our program provides a framework to establish an observation medicine rotation, which exposes residents to quality metrics and expands their scope of medical education.
Dr. Nand is medical director, care management & observation unit, and associate program director, internal medicine residency program, at the University of Illinois College of Medicine/Advocate Christ Medical Center.
References
1. “Hospital-Based Emergency Care: At the Breaking Point” (Washington: National Academies Press, 2006) 2. Baugh, CJ et al. “Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year” Health Aff (Millwood). 2012 Oct;31(10):2314-23
3. Fact Sheet: Two-Midnight Rule. 2015. Available at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-01-2.html. Accessed March 29, 2016.
4. Society of Hospital Medicine. The observation unit white paper. http://www.hospitalmedicine.org, April 3, 2013.
5. Yousuf T. et al. “Intermediate chest pain protocol in an observation unit” Won first place award for innovation at the Midwest Regional SGIM conference, August 2015.
6. Sarfraz S et al. “Hand hygiene intervention increases compliance in observation unit” Poster: May 2016, Macy Midwest GME Conference, Michigan.
7. “Impact of syncope protocol in an observation unit of an academic tertiary care center” Poster for Oct 2016 AAIM skills development conference, National Harbor, Md.
8. Metgud S et al. “Integrating residents in providing high-value care via improved results of the ACGME annual resident survey” Poster: May 2016, Macy Midwest GME Conference, Michigan.
The Institute of Medicine, in its report “Hospital-Based Emergency Care – At the Breaking Point,” has identified Observation Units (OUs) as a “particularly promising” technique to improve patient flow.1 Many hospitals across the country either already have them or are in the process of establishing such units.
Multiple studies have shown that a highly efficient OU can save billions in health care costs.2 Historically, such units have existed within and are staffed by emergency departments. Since the implementation of the two-midnight rule in Oct. 2013, the complexities of observation care changed dramatically from run of the mill 30- to 40-year-old chest pain patients to 80- to 90-year-olds with multiple comorbidities being placed in observation.3 In many cases, this shifted the care out of the emergency department and into the arena of hospital medicine.
At our institution OUs are staffed by internal medicine residents supervised by faculty 24/7 year round. This, we believe, is a unique model. We implemented our model after a mini SWOT (strengths, weaknesses, opportunities, and threats ) analysis in August 2014. The biggest strength was that we were educating the next generation of “Observationists” as we improved the quality of care delivered to our patients. Our biggest opportunity was no existing curriculum for teaching internal medicine residents the art of observation medicine. So we designed our own. Just like Peter Drucker said, “The best way to predict the future is to create it.”
The curriculum is extremely innovative and exposes our residents to both the business and administrative aspect of OUs. Upon surveying our own residents anonymously within 6 months of instituting this rotation, over 90% felt this to be a valuable rotation towards their training. Since we went live, some of our residents who have graduated are now leading OUs at other hospitals.
To measure our program outcomes, we developed a dashboard with multiple metrics for our team. With such data, this rotation became an incubator for our residents for quality improvement projects. They have developed, implemented, and published multiple abstracts, presented posters and even won the first place for innovation at the Midwest Regional Society of General Internal Medicine conference.5-8
We have learned many lessons, and every challenge has been addressed as an opportunity. The first lesson was that we needed strong physician leadership to act as the gatekeeper to the unit. Second, as the rotation matured, we always kept our focus on high-quality patient care; we created a quality dashboard which includes length of stay, falls, and patient satisfaction as examples. Last but not least, we stayed mindful of stakeholder buy in, which for us was primarily our residents. We created the curriculum that provides the next generation of internists the broad experience of medicine, with the appropriate amount of autonomy and supervision. This, we believe, is a win-win proposition for all stakeholders – hospitals, physicians, residents, and most importantly the patients we serve. Additionally, data at our institution shows that our resident-run units are educationally, clinically, and financially beneficial to the residency programs and the hospitals.
Teaching and exposure to observation medicine is not currently a mainstay in many internal medicine residency programs. Our program provides a framework to establish an observation medicine rotation, which exposes residents to quality metrics and expands their scope of medical education.
Dr. Nand is medical director, care management & observation unit, and associate program director, internal medicine residency program, at the University of Illinois College of Medicine/Advocate Christ Medical Center.
References
1. “Hospital-Based Emergency Care: At the Breaking Point” (Washington: National Academies Press, 2006) 2. Baugh, CJ et al. “Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year” Health Aff (Millwood). 2012 Oct;31(10):2314-23
3. Fact Sheet: Two-Midnight Rule. 2015. Available at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-01-2.html. Accessed March 29, 2016.
4. Society of Hospital Medicine. The observation unit white paper. http://www.hospitalmedicine.org, April 3, 2013.
5. Yousuf T. et al. “Intermediate chest pain protocol in an observation unit” Won first place award for innovation at the Midwest Regional SGIM conference, August 2015.
6. Sarfraz S et al. “Hand hygiene intervention increases compliance in observation unit” Poster: May 2016, Macy Midwest GME Conference, Michigan.
7. “Impact of syncope protocol in an observation unit of an academic tertiary care center” Poster for Oct 2016 AAIM skills development conference, National Harbor, Md.
8. Metgud S et al. “Integrating residents in providing high-value care via improved results of the ACGME annual resident survey” Poster: May 2016, Macy Midwest GME Conference, Michigan.
Bowel rest or early feeding for acute pancreatitis
Clinical question: When should you start enteral feedings in patients with acute pancreatitis?
Background: Oral intake stimulates pancreatic exocrine activity and therefore bowel rest has been one of the mainstays of acute pancreatitis treatment. However, some studies suggest that enteral nutrition may reduce the risk of infection by supporting the gut’s protective barrier limiting bacterial translocation and sepsis. Studies thus far comparing early versus delayed enteral nutrition in acute pancreatitis have been conflicting.
Setting: Europe, New Zealand, United States, and China.
Synopsis: Study authors attempted to compare the length of hospital stay, mortality, and readmission in hospitalized patients with acute pancreatitis who received early versus delayed feeding. The authors searched for randomized clinical trials that compared early feeding (less than 48 hours after hospitalization) versus delayed feeding (more than 48 hours after hospitalization).
The authors found and analyzed 11 randomized trials comprising 948 patients in which early and delayed feeding strategies were compared. Their review suggests that early feeding in patients with acute pancreatitis is not associated with increased adverse events and may reduce length of hospital stay. Their analysis was limited by markedly different feeding protocols that precluded performing a meta-analysis. Their analysis was also limited by including studies that had high risk or unclear risk of bias and by the small size of most trials limiting power to detect differences in outcome.
Bottom line: Optimal route and timing of nutrition in patients with acute pancreatitis remains unsettled.
Citation: Vaughn VM, Shuster D, Rogers MAM, et al. Early versus delayed feeding in patients with acute pancreatitis: a systematic review. Ann Intern Med. 2017;166(12):883-92.
Dr. Teixeira is a hospitalist at Ochsner Health System, New Orleans.
Clinical question: When should you start enteral feedings in patients with acute pancreatitis?
Background: Oral intake stimulates pancreatic exocrine activity and therefore bowel rest has been one of the mainstays of acute pancreatitis treatment. However, some studies suggest that enteral nutrition may reduce the risk of infection by supporting the gut’s protective barrier limiting bacterial translocation and sepsis. Studies thus far comparing early versus delayed enteral nutrition in acute pancreatitis have been conflicting.
Setting: Europe, New Zealand, United States, and China.
Synopsis: Study authors attempted to compare the length of hospital stay, mortality, and readmission in hospitalized patients with acute pancreatitis who received early versus delayed feeding. The authors searched for randomized clinical trials that compared early feeding (less than 48 hours after hospitalization) versus delayed feeding (more than 48 hours after hospitalization).
The authors found and analyzed 11 randomized trials comprising 948 patients in which early and delayed feeding strategies were compared. Their review suggests that early feeding in patients with acute pancreatitis is not associated with increased adverse events and may reduce length of hospital stay. Their analysis was limited by markedly different feeding protocols that precluded performing a meta-analysis. Their analysis was also limited by including studies that had high risk or unclear risk of bias and by the small size of most trials limiting power to detect differences in outcome.
Bottom line: Optimal route and timing of nutrition in patients with acute pancreatitis remains unsettled.
Citation: Vaughn VM, Shuster D, Rogers MAM, et al. Early versus delayed feeding in patients with acute pancreatitis: a systematic review. Ann Intern Med. 2017;166(12):883-92.
Dr. Teixeira is a hospitalist at Ochsner Health System, New Orleans.
Clinical question: When should you start enteral feedings in patients with acute pancreatitis?
Background: Oral intake stimulates pancreatic exocrine activity and therefore bowel rest has been one of the mainstays of acute pancreatitis treatment. However, some studies suggest that enteral nutrition may reduce the risk of infection by supporting the gut’s protective barrier limiting bacterial translocation and sepsis. Studies thus far comparing early versus delayed enteral nutrition in acute pancreatitis have been conflicting.
Setting: Europe, New Zealand, United States, and China.
Synopsis: Study authors attempted to compare the length of hospital stay, mortality, and readmission in hospitalized patients with acute pancreatitis who received early versus delayed feeding. The authors searched for randomized clinical trials that compared early feeding (less than 48 hours after hospitalization) versus delayed feeding (more than 48 hours after hospitalization).
The authors found and analyzed 11 randomized trials comprising 948 patients in which early and delayed feeding strategies were compared. Their review suggests that early feeding in patients with acute pancreatitis is not associated with increased adverse events and may reduce length of hospital stay. Their analysis was limited by markedly different feeding protocols that precluded performing a meta-analysis. Their analysis was also limited by including studies that had high risk or unclear risk of bias and by the small size of most trials limiting power to detect differences in outcome.
Bottom line: Optimal route and timing of nutrition in patients with acute pancreatitis remains unsettled.
Citation: Vaughn VM, Shuster D, Rogers MAM, et al. Early versus delayed feeding in patients with acute pancreatitis: a systematic review. Ann Intern Med. 2017;166(12):883-92.
Dr. Teixeira is a hospitalist at Ochsner Health System, New Orleans.
Everything We Say And Do: The physician patient
Editor’s note: “Everything We Say and Do” provides readers with thoughtful and actionable communication tactics that can positively impact patients’ experience of care. In the next series of columns, physicians will share how their experiences as patients have shaped their professional approach.
In May 2007, I received my acceptance letter for medical school. One month later, I was diagnosed with cancer.
The clinic visit was only supposed to be a routine postoperative follow-up after a simple cyst resection. I really hoped that my doctor was mistaken as he walked me through what to expect, and when he was finished, the desperate look in my eyes demanded answers.
After I fully absorbed the initial shock of the grave news, I eventually found the strength to analyze the situation at hand. Ultimately, I adopted a more positive outlook and fought cancer head on. Contending with cancer while tackling the rigors of medical school was tedious, but despite the hardships, my experience catalyzed my determination and molded my personality as a physician.
What I say and do
I employ active listening and practice patience, especially when it comes to family members.
As both a cancer survivor and a physician, I am able to integrate empathy and diligence by putting myself in my patients’ shoes. My experience in a hospital bed during medical school granted me an extremely intriguing perspective towards medicine.
Why I do it
When I was a patient, the most crucial thing to my family was information. Most physicians did not take the time to explain my course of care, which elevated my family’s angst and anxiety. The experience taught me the importance of patience and communication.
But there were good examples. I still remember the physician who comforted my mother and assuaged her concerns. She held my mother’s hand and showed empathy. When my mother cried, she cried. That physician taught me that it was acceptable for physicians to express emotions.
When my surgeon rounded on me in the morning after my procedure, she was not wearing a white coat, which made her appear relatable. Her contagious confidence and humble demeanor were endorsement enough for her capabilities, showing me that a physician’s persona supersedes the conventional coat.
How I do it
I try to put myself in my patients’ shoes. I rejoice with them. I mourn with them. My uninhibited display of emotions affirms empathy. I dissolve all barriers by not wearing a white coat and ask my patients for a partnership. After all, I once walked miles in those shoes.
Dr. Sharma is a chief hospitalist for Sound Physicians at the Sierra Campus of The Hospitals of Providence, El Paso, Texas. She is a columnist for the El Paso Times and the medical contributor for KVIA Channel 7 ABC News. Her work has appeared on kevinmd.com, Thrive Global, and in El Paso magazine.
Editor’s note: “Everything We Say and Do” provides readers with thoughtful and actionable communication tactics that can positively impact patients’ experience of care. In the next series of columns, physicians will share how their experiences as patients have shaped their professional approach.
In May 2007, I received my acceptance letter for medical school. One month later, I was diagnosed with cancer.
The clinic visit was only supposed to be a routine postoperative follow-up after a simple cyst resection. I really hoped that my doctor was mistaken as he walked me through what to expect, and when he was finished, the desperate look in my eyes demanded answers.
After I fully absorbed the initial shock of the grave news, I eventually found the strength to analyze the situation at hand. Ultimately, I adopted a more positive outlook and fought cancer head on. Contending with cancer while tackling the rigors of medical school was tedious, but despite the hardships, my experience catalyzed my determination and molded my personality as a physician.
What I say and do
I employ active listening and practice patience, especially when it comes to family members.
As both a cancer survivor and a physician, I am able to integrate empathy and diligence by putting myself in my patients’ shoes. My experience in a hospital bed during medical school granted me an extremely intriguing perspective towards medicine.
Why I do it
When I was a patient, the most crucial thing to my family was information. Most physicians did not take the time to explain my course of care, which elevated my family’s angst and anxiety. The experience taught me the importance of patience and communication.
But there were good examples. I still remember the physician who comforted my mother and assuaged her concerns. She held my mother’s hand and showed empathy. When my mother cried, she cried. That physician taught me that it was acceptable for physicians to express emotions.
When my surgeon rounded on me in the morning after my procedure, she was not wearing a white coat, which made her appear relatable. Her contagious confidence and humble demeanor were endorsement enough for her capabilities, showing me that a physician’s persona supersedes the conventional coat.
How I do it
I try to put myself in my patients’ shoes. I rejoice with them. I mourn with them. My uninhibited display of emotions affirms empathy. I dissolve all barriers by not wearing a white coat and ask my patients for a partnership. After all, I once walked miles in those shoes.
Dr. Sharma is a chief hospitalist for Sound Physicians at the Sierra Campus of The Hospitals of Providence, El Paso, Texas. She is a columnist for the El Paso Times and the medical contributor for KVIA Channel 7 ABC News. Her work has appeared on kevinmd.com, Thrive Global, and in El Paso magazine.
Editor’s note: “Everything We Say and Do” provides readers with thoughtful and actionable communication tactics that can positively impact patients’ experience of care. In the next series of columns, physicians will share how their experiences as patients have shaped their professional approach.
In May 2007, I received my acceptance letter for medical school. One month later, I was diagnosed with cancer.
The clinic visit was only supposed to be a routine postoperative follow-up after a simple cyst resection. I really hoped that my doctor was mistaken as he walked me through what to expect, and when he was finished, the desperate look in my eyes demanded answers.
After I fully absorbed the initial shock of the grave news, I eventually found the strength to analyze the situation at hand. Ultimately, I adopted a more positive outlook and fought cancer head on. Contending with cancer while tackling the rigors of medical school was tedious, but despite the hardships, my experience catalyzed my determination and molded my personality as a physician.
What I say and do
I employ active listening and practice patience, especially when it comes to family members.
As both a cancer survivor and a physician, I am able to integrate empathy and diligence by putting myself in my patients’ shoes. My experience in a hospital bed during medical school granted me an extremely intriguing perspective towards medicine.
Why I do it
When I was a patient, the most crucial thing to my family was information. Most physicians did not take the time to explain my course of care, which elevated my family’s angst and anxiety. The experience taught me the importance of patience and communication.
But there were good examples. I still remember the physician who comforted my mother and assuaged her concerns. She held my mother’s hand and showed empathy. When my mother cried, she cried. That physician taught me that it was acceptable for physicians to express emotions.
When my surgeon rounded on me in the morning after my procedure, she was not wearing a white coat, which made her appear relatable. Her contagious confidence and humble demeanor were endorsement enough for her capabilities, showing me that a physician’s persona supersedes the conventional coat.
How I do it
I try to put myself in my patients’ shoes. I rejoice with them. I mourn with them. My uninhibited display of emotions affirms empathy. I dissolve all barriers by not wearing a white coat and ask my patients for a partnership. After all, I once walked miles in those shoes.
Dr. Sharma is a chief hospitalist for Sound Physicians at the Sierra Campus of The Hospitals of Providence, El Paso, Texas. She is a columnist for the El Paso Times and the medical contributor for KVIA Channel 7 ABC News. Her work has appeared on kevinmd.com, Thrive Global, and in El Paso magazine.
Impact of elder program on delirium and LOS for abdominal surgery patients
Clinical question: Can a modified Hospital Elder Life Program (mHELP) reduce delirium and hospital LOS in older patients undergoing abdominal surgery?
Background: Development of delirium in the hospitalized patient, especially postsurgical patients, can have detrimental effects on the clinical recovery and LOS. Delirium occurs in 13%-50% of patients undergoing noncardiac surgery, and older surgical patients are at a higher risk.
Study design: Cluster randomized clinical trial.
Synopsis: There were 377 older patients (65 years of age or older) who were admitted for elective abdominal surgery (gastrectomy, pancreaticoduodenectomy, or colectomy) with an expected LOS greater than 6 days enrolled and randomly assigned to mHELP group (197 patients) or control group (180 patients). The mHELP intervention consisted of three core nursing protocols that occurred daily by a trained nurse: orienting communication, oral and nutritional assistance, and early mobilization. Delirium developed in 13 cases (6.6%) in the mHELP group and in 27 cases (15.1%) in the control group. This is a risk reduction of 56% indicating the need to treat 11.8 patients to prevent one case of delirium. The mHELP group had a 2-day hospital LOS reduction, compared with the control group. The effect of mHELP could be underestimated as crossover effects were not accounted for in the study. Data were not collected on postoperative complications which can have a significant effect on delirium occurrence.
Bottom line: The three nursing protocols of mHELP reduced rates of delirium and hospital LOS in older adults undergoing abdominal surgeries and could be a quick intervention to reduce the most common surgical complication in older patients.
Citation: Chen CC, Li HC, Liang JT, et al. Effect of a modified hospital elder life program on delirium and length of hospital stay in patients undergoing abdominal surgery. JAMA Surg. Published online May 24, 2017. doi: 10.1001/jamasurg.2017.1083.
Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.
Clinical question: Can a modified Hospital Elder Life Program (mHELP) reduce delirium and hospital LOS in older patients undergoing abdominal surgery?
Background: Development of delirium in the hospitalized patient, especially postsurgical patients, can have detrimental effects on the clinical recovery and LOS. Delirium occurs in 13%-50% of patients undergoing noncardiac surgery, and older surgical patients are at a higher risk.
Study design: Cluster randomized clinical trial.
Synopsis: There were 377 older patients (65 years of age or older) who were admitted for elective abdominal surgery (gastrectomy, pancreaticoduodenectomy, or colectomy) with an expected LOS greater than 6 days enrolled and randomly assigned to mHELP group (197 patients) or control group (180 patients). The mHELP intervention consisted of three core nursing protocols that occurred daily by a trained nurse: orienting communication, oral and nutritional assistance, and early mobilization. Delirium developed in 13 cases (6.6%) in the mHELP group and in 27 cases (15.1%) in the control group. This is a risk reduction of 56% indicating the need to treat 11.8 patients to prevent one case of delirium. The mHELP group had a 2-day hospital LOS reduction, compared with the control group. The effect of mHELP could be underestimated as crossover effects were not accounted for in the study. Data were not collected on postoperative complications which can have a significant effect on delirium occurrence.
Bottom line: The three nursing protocols of mHELP reduced rates of delirium and hospital LOS in older adults undergoing abdominal surgeries and could be a quick intervention to reduce the most common surgical complication in older patients.
Citation: Chen CC, Li HC, Liang JT, et al. Effect of a modified hospital elder life program on delirium and length of hospital stay in patients undergoing abdominal surgery. JAMA Surg. Published online May 24, 2017. doi: 10.1001/jamasurg.2017.1083.
Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.
Clinical question: Can a modified Hospital Elder Life Program (mHELP) reduce delirium and hospital LOS in older patients undergoing abdominal surgery?
Background: Development of delirium in the hospitalized patient, especially postsurgical patients, can have detrimental effects on the clinical recovery and LOS. Delirium occurs in 13%-50% of patients undergoing noncardiac surgery, and older surgical patients are at a higher risk.
Study design: Cluster randomized clinical trial.
Synopsis: There were 377 older patients (65 years of age or older) who were admitted for elective abdominal surgery (gastrectomy, pancreaticoduodenectomy, or colectomy) with an expected LOS greater than 6 days enrolled and randomly assigned to mHELP group (197 patients) or control group (180 patients). The mHELP intervention consisted of three core nursing protocols that occurred daily by a trained nurse: orienting communication, oral and nutritional assistance, and early mobilization. Delirium developed in 13 cases (6.6%) in the mHELP group and in 27 cases (15.1%) in the control group. This is a risk reduction of 56% indicating the need to treat 11.8 patients to prevent one case of delirium. The mHELP group had a 2-day hospital LOS reduction, compared with the control group. The effect of mHELP could be underestimated as crossover effects were not accounted for in the study. Data were not collected on postoperative complications which can have a significant effect on delirium occurrence.
Bottom line: The three nursing protocols of mHELP reduced rates of delirium and hospital LOS in older adults undergoing abdominal surgeries and could be a quick intervention to reduce the most common surgical complication in older patients.
Citation: Chen CC, Li HC, Liang JT, et al. Effect of a modified hospital elder life program on delirium and length of hospital stay in patients undergoing abdominal surgery. JAMA Surg. Published online May 24, 2017. doi: 10.1001/jamasurg.2017.1083.
Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.
Opioid management protocol lowered trauma patient pain medication use
BALTIMORE – A pain management protocol implemented in a trauma service reduced opioid intake in trauma patients while improving patient satisfaction, according to a retrospective study.
The opioid epidemic continues to grow every day, partly as a result of irresponsible overprescribing of opioid medication, according to Jessica Gross, MB BAO BCh, FACS, a trauma surgeon from Wake Forest (N.C.) Baptist Health at the American Association for the Surgery of Trauma annual meeting. Dr. Gross and her colleagues developed a pain management protocol (PMP) to provide adequate pain control while using fewer opioids in the postdischarge setting. They tested their PMP through a retrospective chart review of 498 patients admitted to the trauma service between January 2015 and December 2016, half of which were admitted before the PMP was initiated and half of which were admitted afterward.
The PMP involved a stepped approach to treating pain, with acetaminophen or ibuprofen as needed for mild pain, one 5-mg tablet of oxycodone/acetaminophen every 6 hours for moderate pain, two tablets for severe pain, and 50-100 mg of tramadol every 6 hours for breakthrough pain.
Counseling services for patients who were found to be in danger of substance use were provided in the hospital, and at discharge, patients received a weaning plan for their medication, according to Dr. Gross.
If the short-acting medications were found to be inadequate to control pain, patients were given slow-release pain medication as needed.
Average total medication, including at discharge and for refills, prescribed after PMP initiation was 1,242 morphine milligram equivalents (MME), compared with 2,421 MME prior to the protocol (P less than .0001).
After the protocol was implemented, Dr. Gross and her colleagues found the number of patients prescribed a refill dropped from 39.7% to 28.1%, with the size of those refills dropping from 1,032 MME to 213 MME on average.
“By having a comprehensive pain management protocol, we can reduce the amount of pain medications we prescribe for outpatient use, from discharge from the trauma service,” said Dr. Gross. “Additionally, we have shown that by having a protocol in place, we not only decreased the number of refills we were providing, but also the amount of pain medications that was prescribed within these refills.”
Through a Press Ganey survey analysis of patients during the month before and the month after the PMP implementation, investigators found a significant increase in patient satisfaction and overall pain management, according to Dr. Gross,
In addition, the main trauma floor where the PMP was implemented was recognized for the most improvement in overall hospital rating and pain management, compared with the previous year.
Discussant Oscar Guillamondegui MD,FACS, medical director of the trauma ICU at Vanderbilt University, Nashville, Tenn., acknowledged the importance of PMPs and the work investigators presented.
“I would consider this the next generation of ERAS [enhanced recovery after surgery], or ERAT [enhanced recovery after trauma] in pain perception modification,” said Dr. Guillamondegui. “Dr. Gross and the multidisciplinary group at Wake Forest have provided compelling evidence to help alleviate [the opioid epidemic].”
In a question-and-answer session following the presentation, attendees voiced concern over how a PMP would be used among patients who are more familiar with hospital systems, in particular concerning self-reported pain levels.
“Most of us employed at acute care centers are not working in utopia. Many of our patients are heroin addicts, are very bright, and know how to identify 10 on those silly smiley faces so that they get more medicine,” said Charles Lucas, MD, FACS, professor of surgeon at Wayne State University, Detroit. Dr. Lucas also pointed out that even when patients report false levels of pain, doctors still are required to put it into the electronic medical record for fear of repercussions,
In response, Dr. Gross said doctors on the floor reviewed patients to make sure they were receiving all doses of pain medications. If doctors felt the patient’s pain regimen was adequate, despite the patient reporting otherwise, no changes were made.
Certain limitations include not being able to confirm whether patients received prescription medication elsewhere, nor any concrete data on patient satisfaction after discharge other than an inference based on fewer refills and lower refill MME.
Investigators reported no relevant financial disclosures.
[email protected]
On Twitter @eaztweets
BALTIMORE – A pain management protocol implemented in a trauma service reduced opioid intake in trauma patients while improving patient satisfaction, according to a retrospective study.
The opioid epidemic continues to grow every day, partly as a result of irresponsible overprescribing of opioid medication, according to Jessica Gross, MB BAO BCh, FACS, a trauma surgeon from Wake Forest (N.C.) Baptist Health at the American Association for the Surgery of Trauma annual meeting. Dr. Gross and her colleagues developed a pain management protocol (PMP) to provide adequate pain control while using fewer opioids in the postdischarge setting. They tested their PMP through a retrospective chart review of 498 patients admitted to the trauma service between January 2015 and December 2016, half of which were admitted before the PMP was initiated and half of which were admitted afterward.
The PMP involved a stepped approach to treating pain, with acetaminophen or ibuprofen as needed for mild pain, one 5-mg tablet of oxycodone/acetaminophen every 6 hours for moderate pain, two tablets for severe pain, and 50-100 mg of tramadol every 6 hours for breakthrough pain.
Counseling services for patients who were found to be in danger of substance use were provided in the hospital, and at discharge, patients received a weaning plan for their medication, according to Dr. Gross.
If the short-acting medications were found to be inadequate to control pain, patients were given slow-release pain medication as needed.
Average total medication, including at discharge and for refills, prescribed after PMP initiation was 1,242 morphine milligram equivalents (MME), compared with 2,421 MME prior to the protocol (P less than .0001).
After the protocol was implemented, Dr. Gross and her colleagues found the number of patients prescribed a refill dropped from 39.7% to 28.1%, with the size of those refills dropping from 1,032 MME to 213 MME on average.
“By having a comprehensive pain management protocol, we can reduce the amount of pain medications we prescribe for outpatient use, from discharge from the trauma service,” said Dr. Gross. “Additionally, we have shown that by having a protocol in place, we not only decreased the number of refills we were providing, but also the amount of pain medications that was prescribed within these refills.”
Through a Press Ganey survey analysis of patients during the month before and the month after the PMP implementation, investigators found a significant increase in patient satisfaction and overall pain management, according to Dr. Gross,
In addition, the main trauma floor where the PMP was implemented was recognized for the most improvement in overall hospital rating and pain management, compared with the previous year.
Discussant Oscar Guillamondegui MD,FACS, medical director of the trauma ICU at Vanderbilt University, Nashville, Tenn., acknowledged the importance of PMPs and the work investigators presented.
“I would consider this the next generation of ERAS [enhanced recovery after surgery], or ERAT [enhanced recovery after trauma] in pain perception modification,” said Dr. Guillamondegui. “Dr. Gross and the multidisciplinary group at Wake Forest have provided compelling evidence to help alleviate [the opioid epidemic].”
In a question-and-answer session following the presentation, attendees voiced concern over how a PMP would be used among patients who are more familiar with hospital systems, in particular concerning self-reported pain levels.
“Most of us employed at acute care centers are not working in utopia. Many of our patients are heroin addicts, are very bright, and know how to identify 10 on those silly smiley faces so that they get more medicine,” said Charles Lucas, MD, FACS, professor of surgeon at Wayne State University, Detroit. Dr. Lucas also pointed out that even when patients report false levels of pain, doctors still are required to put it into the electronic medical record for fear of repercussions,
In response, Dr. Gross said doctors on the floor reviewed patients to make sure they were receiving all doses of pain medications. If doctors felt the patient’s pain regimen was adequate, despite the patient reporting otherwise, no changes were made.
Certain limitations include not being able to confirm whether patients received prescription medication elsewhere, nor any concrete data on patient satisfaction after discharge other than an inference based on fewer refills and lower refill MME.
Investigators reported no relevant financial disclosures.
[email protected]
On Twitter @eaztweets
BALTIMORE – A pain management protocol implemented in a trauma service reduced opioid intake in trauma patients while improving patient satisfaction, according to a retrospective study.
The opioid epidemic continues to grow every day, partly as a result of irresponsible overprescribing of opioid medication, according to Jessica Gross, MB BAO BCh, FACS, a trauma surgeon from Wake Forest (N.C.) Baptist Health at the American Association for the Surgery of Trauma annual meeting. Dr. Gross and her colleagues developed a pain management protocol (PMP) to provide adequate pain control while using fewer opioids in the postdischarge setting. They tested their PMP through a retrospective chart review of 498 patients admitted to the trauma service between January 2015 and December 2016, half of which were admitted before the PMP was initiated and half of which were admitted afterward.
The PMP involved a stepped approach to treating pain, with acetaminophen or ibuprofen as needed for mild pain, one 5-mg tablet of oxycodone/acetaminophen every 6 hours for moderate pain, two tablets for severe pain, and 50-100 mg of tramadol every 6 hours for breakthrough pain.
Counseling services for patients who were found to be in danger of substance use were provided in the hospital, and at discharge, patients received a weaning plan for their medication, according to Dr. Gross.
If the short-acting medications were found to be inadequate to control pain, patients were given slow-release pain medication as needed.
Average total medication, including at discharge and for refills, prescribed after PMP initiation was 1,242 morphine milligram equivalents (MME), compared with 2,421 MME prior to the protocol (P less than .0001).
After the protocol was implemented, Dr. Gross and her colleagues found the number of patients prescribed a refill dropped from 39.7% to 28.1%, with the size of those refills dropping from 1,032 MME to 213 MME on average.
“By having a comprehensive pain management protocol, we can reduce the amount of pain medications we prescribe for outpatient use, from discharge from the trauma service,” said Dr. Gross. “Additionally, we have shown that by having a protocol in place, we not only decreased the number of refills we were providing, but also the amount of pain medications that was prescribed within these refills.”
Through a Press Ganey survey analysis of patients during the month before and the month after the PMP implementation, investigators found a significant increase in patient satisfaction and overall pain management, according to Dr. Gross,
In addition, the main trauma floor where the PMP was implemented was recognized for the most improvement in overall hospital rating and pain management, compared with the previous year.
Discussant Oscar Guillamondegui MD,FACS, medical director of the trauma ICU at Vanderbilt University, Nashville, Tenn., acknowledged the importance of PMPs and the work investigators presented.
“I would consider this the next generation of ERAS [enhanced recovery after surgery], or ERAT [enhanced recovery after trauma] in pain perception modification,” said Dr. Guillamondegui. “Dr. Gross and the multidisciplinary group at Wake Forest have provided compelling evidence to help alleviate [the opioid epidemic].”
In a question-and-answer session following the presentation, attendees voiced concern over how a PMP would be used among patients who are more familiar with hospital systems, in particular concerning self-reported pain levels.
“Most of us employed at acute care centers are not working in utopia. Many of our patients are heroin addicts, are very bright, and know how to identify 10 on those silly smiley faces so that they get more medicine,” said Charles Lucas, MD, FACS, professor of surgeon at Wayne State University, Detroit. Dr. Lucas also pointed out that even when patients report false levels of pain, doctors still are required to put it into the electronic medical record for fear of repercussions,
In response, Dr. Gross said doctors on the floor reviewed patients to make sure they were receiving all doses of pain medications. If doctors felt the patient’s pain regimen was adequate, despite the patient reporting otherwise, no changes were made.
Certain limitations include not being able to confirm whether patients received prescription medication elsewhere, nor any concrete data on patient satisfaction after discharge other than an inference based on fewer refills and lower refill MME.
Investigators reported no relevant financial disclosures.
[email protected]
On Twitter @eaztweets
AT THE AAST ANNUAL MEETING
Key clinical point:
Major finding: Average prescription fell to 1,242 morphine milligram equivalents (MME) per prescription, compared with 2,421 MME per prescription prior to the protocol.
Data Source: Retrospective chart review of 498 trauma patients from Jan. 1, 2015, and Dec. 31, 2016.
Disclosures: Investigators reported no relevant financial disclosures.
Hospital-acquired anemia
Clinical question: Is hospital acquired anemia associated with increased postdischarge adverse outcomes?
Background: Hospital acquired anemia (HAA) is defined as the development of anemia during the course of a hospitalization when starting with a normal hemoglobin on admission. The incidence of HAA is at least 25% when using the last hemoglobin prior to discharge as the index value. HAA is felt to be potentially preventable and usually iatrogenic due to phlebotomy.
Setting: Six northern Texas hospitals.
Synopsis: There were 11,309 index hospitalizations with a median hematocrit value on admission of 40.6 g/dL. The authors defined HAA as a normal hematocrit value within the first 24 hours of admission and a hematocrit value lower than the WHO sex-specific cut points at the time of discharge: mild HAA (hematocrit greater than 33% and less than 36% in women, greater than 33% and less than 40% in men), moderate HAA (greater than 27% and less than 33%), and severe HAA (less than 27%). Mild HAA occurred in 21.6% of patients, with 10.1% of patients developing moderate HAA, and 1.4% developing severe HAA (85% underwent major procedure, diagnosis of hemorrhage or coagulation/hemorrhagic disorder). Predictors of developing moderate/severe HAA included undergoing a major diagnostic or therapeutic procedure, female sex, elective admission, hospital LOS, BUN to creatinine ratio greater than 20:1, and serum creatinine on admission. Development of severe HAA was associated with a 41% increase in the odds of 30-day readmission and a 39% increase in the odds of the composite outcome (30-day mortality and 30-day readmission).
Bottom line: Severe HAA had significant increased odds of 30-day readmission and mortality, but might not be as preventable as initially thought given the frequency of major procedures and hemorrhage in those that developed severe HAA.
Citation: Makam AN, Nguyen OK, Clark C, Halm EA. Incidence, predictors, and outcomes of hospital-acquired anemia. J Hosp Med. 2017;12(5):317-22.
Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.
Clinical question: Is hospital acquired anemia associated with increased postdischarge adverse outcomes?
Background: Hospital acquired anemia (HAA) is defined as the development of anemia during the course of a hospitalization when starting with a normal hemoglobin on admission. The incidence of HAA is at least 25% when using the last hemoglobin prior to discharge as the index value. HAA is felt to be potentially preventable and usually iatrogenic due to phlebotomy.
Setting: Six northern Texas hospitals.
Synopsis: There were 11,309 index hospitalizations with a median hematocrit value on admission of 40.6 g/dL. The authors defined HAA as a normal hematocrit value within the first 24 hours of admission and a hematocrit value lower than the WHO sex-specific cut points at the time of discharge: mild HAA (hematocrit greater than 33% and less than 36% in women, greater than 33% and less than 40% in men), moderate HAA (greater than 27% and less than 33%), and severe HAA (less than 27%). Mild HAA occurred in 21.6% of patients, with 10.1% of patients developing moderate HAA, and 1.4% developing severe HAA (85% underwent major procedure, diagnosis of hemorrhage or coagulation/hemorrhagic disorder). Predictors of developing moderate/severe HAA included undergoing a major diagnostic or therapeutic procedure, female sex, elective admission, hospital LOS, BUN to creatinine ratio greater than 20:1, and serum creatinine on admission. Development of severe HAA was associated with a 41% increase in the odds of 30-day readmission and a 39% increase in the odds of the composite outcome (30-day mortality and 30-day readmission).
Bottom line: Severe HAA had significant increased odds of 30-day readmission and mortality, but might not be as preventable as initially thought given the frequency of major procedures and hemorrhage in those that developed severe HAA.
Citation: Makam AN, Nguyen OK, Clark C, Halm EA. Incidence, predictors, and outcomes of hospital-acquired anemia. J Hosp Med. 2017;12(5):317-22.
Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.
Clinical question: Is hospital acquired anemia associated with increased postdischarge adverse outcomes?
Background: Hospital acquired anemia (HAA) is defined as the development of anemia during the course of a hospitalization when starting with a normal hemoglobin on admission. The incidence of HAA is at least 25% when using the last hemoglobin prior to discharge as the index value. HAA is felt to be potentially preventable and usually iatrogenic due to phlebotomy.
Setting: Six northern Texas hospitals.
Synopsis: There were 11,309 index hospitalizations with a median hematocrit value on admission of 40.6 g/dL. The authors defined HAA as a normal hematocrit value within the first 24 hours of admission and a hematocrit value lower than the WHO sex-specific cut points at the time of discharge: mild HAA (hematocrit greater than 33% and less than 36% in women, greater than 33% and less than 40% in men), moderate HAA (greater than 27% and less than 33%), and severe HAA (less than 27%). Mild HAA occurred in 21.6% of patients, with 10.1% of patients developing moderate HAA, and 1.4% developing severe HAA (85% underwent major procedure, diagnosis of hemorrhage or coagulation/hemorrhagic disorder). Predictors of developing moderate/severe HAA included undergoing a major diagnostic or therapeutic procedure, female sex, elective admission, hospital LOS, BUN to creatinine ratio greater than 20:1, and serum creatinine on admission. Development of severe HAA was associated with a 41% increase in the odds of 30-day readmission and a 39% increase in the odds of the composite outcome (30-day mortality and 30-day readmission).
Bottom line: Severe HAA had significant increased odds of 30-day readmission and mortality, but might not be as preventable as initially thought given the frequency of major procedures and hemorrhage in those that developed severe HAA.
Citation: Makam AN, Nguyen OK, Clark C, Halm EA. Incidence, predictors, and outcomes of hospital-acquired anemia. J Hosp Med. 2017;12(5):317-22.
Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.
No benefit seen for routine low-dose oxygen after stroke
Routine use of low-dose oxygen supplementation in the first days after stroke doesn’t improve overall survival or reduce disability, according to a large new study.
The poststroke death and disability odds ratio was 0.97 for those receiving one of two continuous low-dose oxygen protocols, compared with the control group (95% confidence interval, 0.89-1.05; P = .47).
Participants, who were not hypoxic at enrollment, were randomized 1:1:1 to receive continuous oxygen supplementation for the first 72 hours after stroke, to receive supplementation only at night, or to receive oxygen when indicated by usual care protocols. The average participant age was 72 years and 55% were men in all study arms, and all stroke severity levels were included in the study.
Patients in the two intervention arms received 2 L of oxygen by nasal cannula when their baseline oxygen saturation was greater than 93%, and 3 L when oxygen saturation at baseline was 93% or less. Participation in the study did not preclude more intensive respiratory support when clinically indicated.
Nocturnal supplementation was included as a study arm for two reasons: Poststroke hypoxia is more common at night, and night-only supplementation would avoid any interference with early rehabilitation caused by cumbersome oxygen apparatus and tubing.
Not only was no benefit seen for patients in the pooled intervention arm cohorts, but no benefit was seen for night-time versus continuous oxygen as well. The odds ratio for a better outcome was 1.03 when comparing those receiving continuous oxygen to those who only received nocturnal supplementation (95% CI, 0.93-1.13; P = .61).
First author Christine Roffe, MD, and her collaborators in the Stroke Oxygen Study Collaborative Group also performed subgroup analyses and did not see benefit of oxygen supplementation for older or younger patients, or for patients with chronic obstructive pulmonary disease, heart failure, or more severe strokes.
“Supplemental oxygen could improve outcomes by preventing hypoxia and secondary brain damage but could also have adverse effects,” according to Dr. Roffe, consultant at Keele (England) University and her collaborators.
A much smaller SOS pilot study, they said, had shown improved early neurologic recovery for patients who received supplemental oxygen after stroke, but the pilot also “suggested that oxygen might adversely affect outcome in patients with mild strokes, possibly through formation of toxic free radicals,” wrote the investigators.
These were effects not seen in the larger SO2S study, which was designed to have statistical power to detect even small differences and to do detailed subgroup analysis. For patients like those included in the study, “These findings do not support low-dose oxygen in this setting,” wrote Dr. Roffe and her collaborators.
Dr. Roffe reported receiving compensation from Air Liquide. The study was funded by the United Kingdom’s National Institute for Health Research.
[email protected]
On Twitter @karioakes
Routine use of low-dose oxygen supplementation in the first days after stroke doesn’t improve overall survival or reduce disability, according to a large new study.
The poststroke death and disability odds ratio was 0.97 for those receiving one of two continuous low-dose oxygen protocols, compared with the control group (95% confidence interval, 0.89-1.05; P = .47).
Participants, who were not hypoxic at enrollment, were randomized 1:1:1 to receive continuous oxygen supplementation for the first 72 hours after stroke, to receive supplementation only at night, or to receive oxygen when indicated by usual care protocols. The average participant age was 72 years and 55% were men in all study arms, and all stroke severity levels were included in the study.
Patients in the two intervention arms received 2 L of oxygen by nasal cannula when their baseline oxygen saturation was greater than 93%, and 3 L when oxygen saturation at baseline was 93% or less. Participation in the study did not preclude more intensive respiratory support when clinically indicated.
Nocturnal supplementation was included as a study arm for two reasons: Poststroke hypoxia is more common at night, and night-only supplementation would avoid any interference with early rehabilitation caused by cumbersome oxygen apparatus and tubing.
Not only was no benefit seen for patients in the pooled intervention arm cohorts, but no benefit was seen for night-time versus continuous oxygen as well. The odds ratio for a better outcome was 1.03 when comparing those receiving continuous oxygen to those who only received nocturnal supplementation (95% CI, 0.93-1.13; P = .61).
First author Christine Roffe, MD, and her collaborators in the Stroke Oxygen Study Collaborative Group also performed subgroup analyses and did not see benefit of oxygen supplementation for older or younger patients, or for patients with chronic obstructive pulmonary disease, heart failure, or more severe strokes.
“Supplemental oxygen could improve outcomes by preventing hypoxia and secondary brain damage but could also have adverse effects,” according to Dr. Roffe, consultant at Keele (England) University and her collaborators.
A much smaller SOS pilot study, they said, had shown improved early neurologic recovery for patients who received supplemental oxygen after stroke, but the pilot also “suggested that oxygen might adversely affect outcome in patients with mild strokes, possibly through formation of toxic free radicals,” wrote the investigators.
These were effects not seen in the larger SO2S study, which was designed to have statistical power to detect even small differences and to do detailed subgroup analysis. For patients like those included in the study, “These findings do not support low-dose oxygen in this setting,” wrote Dr. Roffe and her collaborators.
Dr. Roffe reported receiving compensation from Air Liquide. The study was funded by the United Kingdom’s National Institute for Health Research.
[email protected]
On Twitter @karioakes
Routine use of low-dose oxygen supplementation in the first days after stroke doesn’t improve overall survival or reduce disability, according to a large new study.
The poststroke death and disability odds ratio was 0.97 for those receiving one of two continuous low-dose oxygen protocols, compared with the control group (95% confidence interval, 0.89-1.05; P = .47).
Participants, who were not hypoxic at enrollment, were randomized 1:1:1 to receive continuous oxygen supplementation for the first 72 hours after stroke, to receive supplementation only at night, or to receive oxygen when indicated by usual care protocols. The average participant age was 72 years and 55% were men in all study arms, and all stroke severity levels were included in the study.
Patients in the two intervention arms received 2 L of oxygen by nasal cannula when their baseline oxygen saturation was greater than 93%, and 3 L when oxygen saturation at baseline was 93% or less. Participation in the study did not preclude more intensive respiratory support when clinically indicated.
Nocturnal supplementation was included as a study arm for two reasons: Poststroke hypoxia is more common at night, and night-only supplementation would avoid any interference with early rehabilitation caused by cumbersome oxygen apparatus and tubing.
Not only was no benefit seen for patients in the pooled intervention arm cohorts, but no benefit was seen for night-time versus continuous oxygen as well. The odds ratio for a better outcome was 1.03 when comparing those receiving continuous oxygen to those who only received nocturnal supplementation (95% CI, 0.93-1.13; P = .61).
First author Christine Roffe, MD, and her collaborators in the Stroke Oxygen Study Collaborative Group also performed subgroup analyses and did not see benefit of oxygen supplementation for older or younger patients, or for patients with chronic obstructive pulmonary disease, heart failure, or more severe strokes.
“Supplemental oxygen could improve outcomes by preventing hypoxia and secondary brain damage but could also have adverse effects,” according to Dr. Roffe, consultant at Keele (England) University and her collaborators.
A much smaller SOS pilot study, they said, had shown improved early neurologic recovery for patients who received supplemental oxygen after stroke, but the pilot also “suggested that oxygen might adversely affect outcome in patients with mild strokes, possibly through formation of toxic free radicals,” wrote the investigators.
These were effects not seen in the larger SO2S study, which was designed to have statistical power to detect even small differences and to do detailed subgroup analysis. For patients like those included in the study, “These findings do not support low-dose oxygen in this setting,” wrote Dr. Roffe and her collaborators.
Dr. Roffe reported receiving compensation from Air Liquide. The study was funded by the United Kingdom’s National Institute for Health Research.
[email protected]
On Twitter @karioakes
FROM JAMA
Key clinical point:
Major finding: The poststroke death and disability odds ratio was 0.97 for those receiving continuous low-dose oxygen, compared with controls.
Data source: Single-blind, multisite, randomized, controlled trial of 8,003 patients admitted with acute stroke.
Disclosures: Dr. Roffe reported receiving compensation from Air Liquide. The study was funded by the United Kingdom’s National Institute for Health Research.