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Presenters: Alison Holmes, MD, MPH; Michele Long, MD; Carrie Rossbach, MD; Jennifer Rosenthal, MD

Being a hospitalist naturally lends itself to participating in education. Whether teaching on the wards at the bedside, giving didactic lectures in the classroom, or divulging informal clinical pearls throughout the day, the hospitalists’ role is entrenched in teaching. And while hospitalists make every attempt to stay current on the latest medical and clinical information, much of their teaching toolbox remains outdated.

Active learning is not a new concept, but is becoming more and more of a hot topic in the educational field. In the 1900s, medical education had become so cumbersome that the educators began bringing the students into the laboratory setting to more actively engage them. By the 1950s, constructivism brought the idea that learners obtain knowledge best by using real experiences with real subject matter and using interaction. In the 1970s, Malcolm Knowles revolutionized education for the adult by bringing forth the idea of andragogy.

However, despite these advances, it wasn’t until the 1990s that active learning began being applied to the medical community. Despite numerous studies validating the adult learning principles in both the medical school and residency settings, there were numerous barriers that prevented active learning from being integrated into the curricula.

Formal medical lectures tend to be geared to large audiences making active learning unwieldy. Residents are often under time constraints and are fatigued, making them passive learners by default. Faculty members commonly find transforming large volumes of information into an active process a daunting task.

The presenters provided four different active learning applications that could be used in virtually any setting with any source material.

• Case Based Discussions allow the transformation of a passive power point into an interactive session with leading questions and giving information in a “morning report” style.
• Quizzes promote pre-reading and then immediate feedback of their knowledge gaps, often providing increased learner satisfaction by showing improvement in retaking the quiz at the end of the session.
• Case Applications are exercises where groups apply content of reading to a challenging and sophisticated case, forcing them to move beyond their current knowledge and to test the boundaries of their logical applications.
• Role Playing can allow a dramatic, live presentation of a case and re-enact in live time a clinical scenario.

The session then broke into individual small groups and developed a lecture based on one of the four modalities. Every group successfully produced an interesting, active learning lecture in just 15 minutes. This demonstrated that with minimal effort and time, such applications can be used to prepare an active learning session that would encompass as little as ten minutes or as much as an hour. By thoughtfully considering these techniques and applying them to old, worn out lectures, the material can be easily brought to life, enhancing the educational experience.

Travis W. Crook, MD, FAAP

Assistant Professor, Pediatrics

Assistant Pediatric Clerkship Director

Division of Hospitalist Medicine

Department of Pediatrics

Vanderbilt University School of Medicine

Monroe Carell Jr Children's Hospital at Vanderbilt

Presenters: Alison Holmes, MD, MPH; Michele Long, MD; Carrie Rossbach, MD; Jennifer Rosenthal, MD

Being a hospitalist naturally lends itself to participating in education. Whether teaching on the wards at the bedside, giving didactic lectures in the classroom, or divulging informal clinical pearls throughout the day, the hospitalists’ role is entrenched in teaching. And while hospitalists make every attempt to stay current on the latest medical and clinical information, much of their teaching toolbox remains outdated.

Active learning is not a new concept, but is becoming more and more of a hot topic in the educational field. In the 1900s, medical education had become so cumbersome that the educators began bringing the students into the laboratory setting to more actively engage them. By the 1950s, constructivism brought the idea that learners obtain knowledge best by using real experiences with real subject matter and using interaction. In the 1970s, Malcolm Knowles revolutionized education for the adult by bringing forth the idea of andragogy.

However, despite these advances, it wasn’t until the 1990s that active learning began being applied to the medical community. Despite numerous studies validating the adult learning principles in both the medical school and residency settings, there were numerous barriers that prevented active learning from being integrated into the curricula.

Formal medical lectures tend to be geared to large audiences making active learning unwieldy. Residents are often under time constraints and are fatigued, making them passive learners by default. Faculty members commonly find transforming large volumes of information into an active process a daunting task.

The presenters provided four different active learning applications that could be used in virtually any setting with any source material.

• Case Based Discussions allow the transformation of a passive power point into an interactive session with leading questions and giving information in a “morning report” style.
• Quizzes promote pre-reading and then immediate feedback of their knowledge gaps, often providing increased learner satisfaction by showing improvement in retaking the quiz at the end of the session.
• Case Applications are exercises where groups apply content of reading to a challenging and sophisticated case, forcing them to move beyond their current knowledge and to test the boundaries of their logical applications.
• Role Playing can allow a dramatic, live presentation of a case and re-enact in live time a clinical scenario.

The session then broke into individual small groups and developed a lecture based on one of the four modalities. Every group successfully produced an interesting, active learning lecture in just 15 minutes. This demonstrated that with minimal effort and time, such applications can be used to prepare an active learning session that would encompass as little as ten minutes or as much as an hour. By thoughtfully considering these techniques and applying them to old, worn out lectures, the material can be easily brought to life, enhancing the educational experience.

Travis W. Crook, MD, FAAP

Assistant Professor, Pediatrics

Assistant Pediatric Clerkship Director

Division of Hospitalist Medicine

Department of Pediatrics

Vanderbilt University School of Medicine

Monroe Carell Jr Children's Hospital at Vanderbilt

Presenters: Alison Holmes, MD, MPH; Michele Long, MD; Carrie Rossbach, MD; Jennifer Rosenthal, MD

Being a hospitalist naturally lends itself to participating in education. Whether teaching on the wards at the bedside, giving didactic lectures in the classroom, or divulging informal clinical pearls throughout the day, the hospitalists’ role is entrenched in teaching. And while hospitalists make every attempt to stay current on the latest medical and clinical information, much of their teaching toolbox remains outdated.

Active learning is not a new concept, but is becoming more and more of a hot topic in the educational field. In the 1900s, medical education had become so cumbersome that the educators began bringing the students into the laboratory setting to more actively engage them. By the 1950s, constructivism brought the idea that learners obtain knowledge best by using real experiences with real subject matter and using interaction. In the 1970s, Malcolm Knowles revolutionized education for the adult by bringing forth the idea of andragogy.

However, despite these advances, it wasn’t until the 1990s that active learning began being applied to the medical community. Despite numerous studies validating the adult learning principles in both the medical school and residency settings, there were numerous barriers that prevented active learning from being integrated into the curricula.

Formal medical lectures tend to be geared to large audiences making active learning unwieldy. Residents are often under time constraints and are fatigued, making them passive learners by default. Faculty members commonly find transforming large volumes of information into an active process a daunting task.

The presenters provided four different active learning applications that could be used in virtually any setting with any source material.

• Case Based Discussions allow the transformation of a passive power point into an interactive session with leading questions and giving information in a “morning report” style.
• Quizzes promote pre-reading and then immediate feedback of their knowledge gaps, often providing increased learner satisfaction by showing improvement in retaking the quiz at the end of the session.
• Case Applications are exercises where groups apply content of reading to a challenging and sophisticated case, forcing them to move beyond their current knowledge and to test the boundaries of their logical applications.
• Role Playing can allow a dramatic, live presentation of a case and re-enact in live time a clinical scenario.

The session then broke into individual small groups and developed a lecture based on one of the four modalities. Every group successfully produced an interesting, active learning lecture in just 15 minutes. This demonstrated that with minimal effort and time, such applications can be used to prepare an active learning session that would encompass as little as ten minutes or as much as an hour. By thoughtfully considering these techniques and applying them to old, worn out lectures, the material can be easily brought to life, enhancing the educational experience.

Travis W. Crook, MD, FAAP

Assistant Professor, Pediatrics

Assistant Pediatric Clerkship Director

Division of Hospitalist Medicine

Department of Pediatrics

Vanderbilt University School of Medicine

Monroe Carell Jr Children's Hospital at Vanderbilt

Summary:

Presenters of the PHM15 session "Evidence Based Diagnostic Evaluation of Infants Presenting with an Apparent Life Threatening Event" discussed four main diagnostic categories for ALTEs: cardiac, infectious, non-accidental trauma/neurologic, and gastrointestinal. They reviewed the incidence of each of these diagnoses in infants presenting with ALTE, discussed the utility of various diagnostic modalities, and suggested elements of the history and physical that might make those etiologies higher on the differential.

The evidence shows a 0%-2% rate of cardiac disease in infants presenting with ALTE. Given low sensitivity and low specificity for echocardiograms in these patients, the presenters did not recommend routine echocardiograms in all patients. Given high sensitivity and low specificity for EKGs, they suggested EKGs could be considered to help exclude cardiac etiologies, but cautioned that the high false positive rate could lead to additional unnecessary testing. They did not find a high association between most historical facts and an increased likelihood of cardiac etiologies in patients presenting with an ALTE.

Infectious etiologies discussed included bacteremia (0%-2.5%), UTI (0%-7.7%), meningitis (0%-1.2%) and pertussis (0.6%-9.2%), with rates in ALTE as noted.

Again, the literature does not support the use of routine testing for these diagnoses unless there are suggestive clinical findings. Findings that might warrant further infectious investigations:

• Multiple events,
• Prematurity,
• Fever/hypothermia,
• Toxic appearance,
• Altered mental status, or
• Clinical signs of pertussis.

From their literature review, the speakers found a 1.4%-3.7% rate of non-accidental trauma in infants presenting with an ALTE. They did not feel there was sufficient evidence to support skeletal surveys or dilated ophthalmologic exams as part of a standard ALTE workup. Historical clues that might lead the provider to consider NAT include recurrent events, a history of SIDS or ALTE in siblings, delay in seeking care or a confusing history. Suggestive physical exam findings included blood in the nose/mouth, abnormal neurological exam, ear bruising, oral injuries, or bruising in a non-mobile child.

Regarding GE reflux, the presenters discussed the difficulty in identifying the incidence since temporal association does not necessarily equate with causation. They did not recommend routine testing for GER or acid suppression in low risk patients, but said patients could be counseled on various behavioral interventions such as avoiding tobacco and overfeeding, providing frequent burping and upright positioning and exclusive breastfeeding.

Finally, the speakers discussed the upcoming practice guideline for the management of patients with ALTE. They reviewed the proposed change in nomenclature, with the transition to "BRUE" (brief resolved unexplained event), as well as a new algorithm for the evaluation of low-risk patients. The new guidelines currently are being reviewed, with plans to be published and available for general dissemination within the next 12 months. TH

Amanda Rogers, MD, is a hospitalist and assistant professor in the Department of Pediatrics, Section of Hospital Medicine, at the Medical College of Wisconsin in Milwaukee.

Summary:

Presenters of the PHM15 session "Evidence Based Diagnostic Evaluation of Infants Presenting with an Apparent Life Threatening Event" discussed four main diagnostic categories for ALTEs: cardiac, infectious, non-accidental trauma/neurologic, and gastrointestinal. They reviewed the incidence of each of these diagnoses in infants presenting with ALTE, discussed the utility of various diagnostic modalities, and suggested elements of the history and physical that might make those etiologies higher on the differential.

The evidence shows a 0%-2% rate of cardiac disease in infants presenting with ALTE. Given low sensitivity and low specificity for echocardiograms in these patients, the presenters did not recommend routine echocardiograms in all patients. Given high sensitivity and low specificity for EKGs, they suggested EKGs could be considered to help exclude cardiac etiologies, but cautioned that the high false positive rate could lead to additional unnecessary testing. They did not find a high association between most historical facts and an increased likelihood of cardiac etiologies in patients presenting with an ALTE.

Infectious etiologies discussed included bacteremia (0%-2.5%), UTI (0%-7.7%), meningitis (0%-1.2%) and pertussis (0.6%-9.2%), with rates in ALTE as noted.

Again, the literature does not support the use of routine testing for these diagnoses unless there are suggestive clinical findings. Findings that might warrant further infectious investigations:

• Multiple events,
• Prematurity,
• Fever/hypothermia,
• Toxic appearance,
• Altered mental status, or
• Clinical signs of pertussis.

From their literature review, the speakers found a 1.4%-3.7% rate of non-accidental trauma in infants presenting with an ALTE. They did not feel there was sufficient evidence to support skeletal surveys or dilated ophthalmologic exams as part of a standard ALTE workup. Historical clues that might lead the provider to consider NAT include recurrent events, a history of SIDS or ALTE in siblings, delay in seeking care or a confusing history. Suggestive physical exam findings included blood in the nose/mouth, abnormal neurological exam, ear bruising, oral injuries, or bruising in a non-mobile child.

Regarding GE reflux, the presenters discussed the difficulty in identifying the incidence since temporal association does not necessarily equate with causation. They did not recommend routine testing for GER or acid suppression in low risk patients, but said patients could be counseled on various behavioral interventions such as avoiding tobacco and overfeeding, providing frequent burping and upright positioning and exclusive breastfeeding.

Finally, the speakers discussed the upcoming practice guideline for the management of patients with ALTE. They reviewed the proposed change in nomenclature, with the transition to "BRUE" (brief resolved unexplained event), as well as a new algorithm for the evaluation of low-risk patients. The new guidelines currently are being reviewed, with plans to be published and available for general dissemination within the next 12 months. TH

Amanda Rogers, MD, is a hospitalist and assistant professor in the Department of Pediatrics, Section of Hospital Medicine, at the Medical College of Wisconsin in Milwaukee.

Summary:

Presenters of the PHM15 session "Evidence Based Diagnostic Evaluation of Infants Presenting with an Apparent Life Threatening Event" discussed four main diagnostic categories for ALTEs: cardiac, infectious, non-accidental trauma/neurologic, and gastrointestinal. They reviewed the incidence of each of these diagnoses in infants presenting with ALTE, discussed the utility of various diagnostic modalities, and suggested elements of the history and physical that might make those etiologies higher on the differential.

The evidence shows a 0%-2% rate of cardiac disease in infants presenting with ALTE. Given low sensitivity and low specificity for echocardiograms in these patients, the presenters did not recommend routine echocardiograms in all patients. Given high sensitivity and low specificity for EKGs, they suggested EKGs could be considered to help exclude cardiac etiologies, but cautioned that the high false positive rate could lead to additional unnecessary testing. They did not find a high association between most historical facts and an increased likelihood of cardiac etiologies in patients presenting with an ALTE.

Infectious etiologies discussed included bacteremia (0%-2.5%), UTI (0%-7.7%), meningitis (0%-1.2%) and pertussis (0.6%-9.2%), with rates in ALTE as noted.

Again, the literature does not support the use of routine testing for these diagnoses unless there are suggestive clinical findings. Findings that might warrant further infectious investigations:

• Multiple events,
• Prematurity,
• Fever/hypothermia,
• Toxic appearance,
• Altered mental status, or
• Clinical signs of pertussis.

From their literature review, the speakers found a 1.4%-3.7% rate of non-accidental trauma in infants presenting with an ALTE. They did not feel there was sufficient evidence to support skeletal surveys or dilated ophthalmologic exams as part of a standard ALTE workup. Historical clues that might lead the provider to consider NAT include recurrent events, a history of SIDS or ALTE in siblings, delay in seeking care or a confusing history. Suggestive physical exam findings included blood in the nose/mouth, abnormal neurological exam, ear bruising, oral injuries, or bruising in a non-mobile child.

Regarding GE reflux, the presenters discussed the difficulty in identifying the incidence since temporal association does not necessarily equate with causation. They did not recommend routine testing for GER or acid suppression in low risk patients, but said patients could be counseled on various behavioral interventions such as avoiding tobacco and overfeeding, providing frequent burping and upright positioning and exclusive breastfeeding.

Finally, the speakers discussed the upcoming practice guideline for the management of patients with ALTE. They reviewed the proposed change in nomenclature, with the transition to "BRUE" (brief resolved unexplained event), as well as a new algorithm for the evaluation of low-risk patients. The new guidelines currently are being reviewed, with plans to be published and available for general dissemination within the next 12 months. TH

Amanda Rogers, MD, is a hospitalist and assistant professor in the Department of Pediatrics, Section of Hospital Medicine, at the Medical College of Wisconsin in Milwaukee.

The Society of Hospital Medicine has launched a new scholarship program to bring the "best and brightest" medical students into the specialty.

The Student Hospitalist Scholar Grant program awards eligible students a $5,000 summer stipend for scholarly work on a project related to patient safety, quality improvement (QI), or other areas relevant to the field of hospital medicine. The program also provides up to $1,500 in travel-related reimbursement for students to attend the SHM annual meeting.

This summer's inaugural class has three students, all going into their second year of medical school: Frank Zadravecz Jr. of the University of Illinois College of Medicine at Chicago, Miriam Zander of Touro College of Osteopathic Medicine in New York City, and Monica Shah of Wayne State University School of Medicine in Detroit.

"Getting medical students involved is important for us," says hospitalist Darlene Tad-y, MD, an assistant professor of medicine at the University of Colorado in Denver and chair of SHM's Physicians in Training Committee. It means "the future of medicine will have people who know how to do this work, people who will be more skilled and effective at this work."

Dr. Tad-y says it makes sense to merge efforts to recruit the "best and brightest" medical students to HM with QI research. This year's projects include examinations of post-hospital syndrome and physiologic alarm responses.

The program drew about a dozen applicants in its first year. Over the next few years, SHM hopes to award 10 scholarships each summer.

"QI work is really only getting off the ground broadly with people who've been in the field for a really long time," Dr. Tad-y says. "To have that many students early on in their medical school career already understand some of these concepts and be aware that this is going on, for us, it's really exciting." TH

Visit our website for more information on engaging young physicians in HM.

The Society of Hospital Medicine has launched a new scholarship program to bring the "best and brightest" medical students into the specialty.

The Student Hospitalist Scholar Grant program awards eligible students a $5,000 summer stipend for scholarly work on a project related to patient safety, quality improvement (QI), or other areas relevant to the field of hospital medicine. The program also provides up to $1,500 in travel-related reimbursement for students to attend the SHM annual meeting.

This summer's inaugural class has three students, all going into their second year of medical school: Frank Zadravecz Jr. of the University of Illinois College of Medicine at Chicago, Miriam Zander of Touro College of Osteopathic Medicine in New York City, and Monica Shah of Wayne State University School of Medicine in Detroit.

"Getting medical students involved is important for us," says hospitalist Darlene Tad-y, MD, an assistant professor of medicine at the University of Colorado in Denver and chair of SHM's Physicians in Training Committee. It means "the future of medicine will have people who know how to do this work, people who will be more skilled and effective at this work."

Dr. Tad-y says it makes sense to merge efforts to recruit the "best and brightest" medical students to HM with QI research. This year's projects include examinations of post-hospital syndrome and physiologic alarm responses.

The program drew about a dozen applicants in its first year. Over the next few years, SHM hopes to award 10 scholarships each summer.

"QI work is really only getting off the ground broadly with people who've been in the field for a really long time," Dr. Tad-y says. "To have that many students early on in their medical school career already understand some of these concepts and be aware that this is going on, for us, it's really exciting." TH

Visit our website for more information on engaging young physicians in HM.

The Society of Hospital Medicine has launched a new scholarship program to bring the "best and brightest" medical students into the specialty.

The Student Hospitalist Scholar Grant program awards eligible students a $5,000 summer stipend for scholarly work on a project related to patient safety, quality improvement (QI), or other areas relevant to the field of hospital medicine. The program also provides up to $1,500 in travel-related reimbursement for students to attend the SHM annual meeting.

This summer's inaugural class has three students, all going into their second year of medical school: Frank Zadravecz Jr. of the University of Illinois College of Medicine at Chicago, Miriam Zander of Touro College of Osteopathic Medicine in New York City, and Monica Shah of Wayne State University School of Medicine in Detroit.

"Getting medical students involved is important for us," says hospitalist Darlene Tad-y, MD, an assistant professor of medicine at the University of Colorado in Denver and chair of SHM's Physicians in Training Committee. It means "the future of medicine will have people who know how to do this work, people who will be more skilled and effective at this work."

Dr. Tad-y says it makes sense to merge efforts to recruit the "best and brightest" medical students to HM with QI research. This year's projects include examinations of post-hospital syndrome and physiologic alarm responses.

The program drew about a dozen applicants in its first year. Over the next few years, SHM hopes to award 10 scholarships each summer.

"QI work is really only getting off the ground broadly with people who've been in the field for a really long time," Dr. Tad-y says. "To have that many students early on in their medical school career already understand some of these concepts and be aware that this is going on, for us, it's really exciting." TH

Visit our website for more information on engaging young physicians in HM.

Presenters: Nichole Chandler MD, Suresh Nagappan MD MSPH, Angela Hartsell MD MPH, and Emily Hodnett MD

This workshop focused on interactive cases to highlight healthcare issues specific to the population of refugee/immigrant children in the US. It was an interactive format with small groups to allow the participants to work through the diagnoses by discovery. The cases included a Burmese infant with macrocephaly due to congenital toxoplasmosis and a school-age Eritrean child with abdominal pain due to Plasmodium vivax malaria. In addition to discussing the clinical presentation and work up of the patients, there were accompanying ethical dilemmas that were a part of taking care these patients. The presenters emphasized the importance of culturally sensitive communication and seeking competent translation for key clinical discussions. At the end, they supplied a list of resources for more information on refugees in the US and refugee healthcare.

Bethany Hodge MD MPH

Just for Kids Pediatric Hospitalists, Kosair Children’s Hospital

Assistant professor, Department of Pediatrics

Director of the Distinction in Global Health Track

University of Louisville School of Medicine

Presenters: Nichole Chandler MD, Suresh Nagappan MD MSPH, Angela Hartsell MD MPH, and Emily Hodnett MD

This workshop focused on interactive cases to highlight healthcare issues specific to the population of refugee/immigrant children in the US. It was an interactive format with small groups to allow the participants to work through the diagnoses by discovery. The cases included a Burmese infant with macrocephaly due to congenital toxoplasmosis and a school-age Eritrean child with abdominal pain due to Plasmodium vivax malaria. In addition to discussing the clinical presentation and work up of the patients, there were accompanying ethical dilemmas that were a part of taking care these patients. The presenters emphasized the importance of culturally sensitive communication and seeking competent translation for key clinical discussions. At the end, they supplied a list of resources for more information on refugees in the US and refugee healthcare.

Bethany Hodge MD MPH

Just for Kids Pediatric Hospitalists, Kosair Children’s Hospital

Assistant professor, Department of Pediatrics

Director of the Distinction in Global Health Track

University of Louisville School of Medicine

Presenters: Nichole Chandler MD, Suresh Nagappan MD MSPH, Angela Hartsell MD MPH, and Emily Hodnett MD

This workshop focused on interactive cases to highlight healthcare issues specific to the population of refugee/immigrant children in the US. It was an interactive format with small groups to allow the participants to work through the diagnoses by discovery. The cases included a Burmese infant with macrocephaly due to congenital toxoplasmosis and a school-age Eritrean child with abdominal pain due to Plasmodium vivax malaria. In addition to discussing the clinical presentation and work up of the patients, there were accompanying ethical dilemmas that were a part of taking care these patients. The presenters emphasized the importance of culturally sensitive communication and seeking competent translation for key clinical discussions. At the end, they supplied a list of resources for more information on refugees in the US and refugee healthcare.

Bethany Hodge MD MPH

Just for Kids Pediatric Hospitalists, Kosair Children’s Hospital

Assistant professor, Department of Pediatrics

Director of the Distinction in Global Health Track

University of Louisville School of Medicine

NEW YORK (Reuters Health) - The "vast majority" of elderly patients admitted with small bowel obstruction (SBO) are hospitalized for more than two days, and the diagnosis alone should allow appropriate Medicare coverage, according to a new study.

In a paper online July 1 in Annals of Surgery, Dr. Zara Cooper, of Brigham and Women's Hospital, Boston, and colleagues noted that their study was prompted by the Two-Midnight Rule established by the Centers for Medicare & Medicaid Services (CMS) in 2013.

The authors explained that if a physician expects a patient to need a hospital stay that crosses two midnights and thus admits the patient, related costs may be covered. However, shorter stays are deemed as observational and can raise the possibility of non-reimbursement for hospitals.

For example, if someone is admitted as an inpatient, but discharged in less than two days, payment will be made only if it can be documented that a longer stay was reasonably expected and unforeseen circumstances led to the shorter stay. Hospital stays that are incorrectly classified or have improperly documented changes in admission status will not be paid.

However, Dr. Cooper told Reuters Health by email, "Older patients with SBO, a very common diagnosis, should be presumed to be admitted for more than two midnights and hospitals should not get penalized."

She and her colleagues pointed out that SBO accounts for about 15% of surgical admissions to U.S. hospitals and more than $1 billion in annual hospital charges. However, diagnosis requires surgeons to observe patients to determine if surgery is warranted.

Thus, the authors wrote, "It is critically important for surgeons to correctly assign admission status for patients with SBO to ensure that hospitals are reimbursed appropriately, and patients are not unduly burdened."

The investigators examined data on 855 older patients admitted with SBO from 2006 and 2013. Of these, 816 (95%) stayed for two midnights or longer. This was true of all patients aged 85 years or older (n=108, approximately 13%).

The only significant difference in clinical characteristics was the presence of inflammatory bowel disease. Of five such patients, only one stayed for less than two midnights.

"Based on our study and others," the investigators wrote, "we propose that hospital admission for SBO in elderly patients is sufficient justification for the reasonable expectation" of the required length of stay for reimbursement.

This also may be true of other conditions. Dr. Cooper concluded, "More studies like this are needed in surgical patients to better understand the impact of CMS admission guidelines. The rule may not make sense in certain populations, leading to heavy and unfair penalties for hospitals."

The authors reported no disclosures.

NEW YORK (Reuters Health) - The "vast majority" of elderly patients admitted with small bowel obstruction (SBO) are hospitalized for more than two days, and the diagnosis alone should allow appropriate Medicare coverage, according to a new study.

In a paper online July 1 in Annals of Surgery, Dr. Zara Cooper, of Brigham and Women's Hospital, Boston, and colleagues noted that their study was prompted by the Two-Midnight Rule established by the Centers for Medicare & Medicaid Services (CMS) in 2013.

The authors explained that if a physician expects a patient to need a hospital stay that crosses two midnights and thus admits the patient, related costs may be covered. However, shorter stays are deemed as observational and can raise the possibility of non-reimbursement for hospitals.

For example, if someone is admitted as an inpatient, but discharged in less than two days, payment will be made only if it can be documented that a longer stay was reasonably expected and unforeseen circumstances led to the shorter stay. Hospital stays that are incorrectly classified or have improperly documented changes in admission status will not be paid.

However, Dr. Cooper told Reuters Health by email, "Older patients with SBO, a very common diagnosis, should be presumed to be admitted for more than two midnights and hospitals should not get penalized."

She and her colleagues pointed out that SBO accounts for about 15% of surgical admissions to U.S. hospitals and more than $1 billion in annual hospital charges. However, diagnosis requires surgeons to observe patients to determine if surgery is warranted.

Thus, the authors wrote, "It is critically important for surgeons to correctly assign admission status for patients with SBO to ensure that hospitals are reimbursed appropriately, and patients are not unduly burdened."

The investigators examined data on 855 older patients admitted with SBO from 2006 and 2013. Of these, 816 (95%) stayed for two midnights or longer. This was true of all patients aged 85 years or older (n=108, approximately 13%).

The only significant difference in clinical characteristics was the presence of inflammatory bowel disease. Of five such patients, only one stayed for less than two midnights.

"Based on our study and others," the investigators wrote, "we propose that hospital admission for SBO in elderly patients is sufficient justification for the reasonable expectation" of the required length of stay for reimbursement.

This also may be true of other conditions. Dr. Cooper concluded, "More studies like this are needed in surgical patients to better understand the impact of CMS admission guidelines. The rule may not make sense in certain populations, leading to heavy and unfair penalties for hospitals."

The authors reported no disclosures.

NEW YORK (Reuters Health) - The "vast majority" of elderly patients admitted with small bowel obstruction (SBO) are hospitalized for more than two days, and the diagnosis alone should allow appropriate Medicare coverage, according to a new study.

In a paper online July 1 in Annals of Surgery, Dr. Zara Cooper, of Brigham and Women's Hospital, Boston, and colleagues noted that their study was prompted by the Two-Midnight Rule established by the Centers for Medicare & Medicaid Services (CMS) in 2013.

The authors explained that if a physician expects a patient to need a hospital stay that crosses two midnights and thus admits the patient, related costs may be covered. However, shorter stays are deemed as observational and can raise the possibility of non-reimbursement for hospitals.

For example, if someone is admitted as an inpatient, but discharged in less than two days, payment will be made only if it can be documented that a longer stay was reasonably expected and unforeseen circumstances led to the shorter stay. Hospital stays that are incorrectly classified or have improperly documented changes in admission status will not be paid.

However, Dr. Cooper told Reuters Health by email, "Older patients with SBO, a very common diagnosis, should be presumed to be admitted for more than two midnights and hospitals should not get penalized."

She and her colleagues pointed out that SBO accounts for about 15% of surgical admissions to U.S. hospitals and more than $1 billion in annual hospital charges. However, diagnosis requires surgeons to observe patients to determine if surgery is warranted.

Thus, the authors wrote, "It is critically important for surgeons to correctly assign admission status for patients with SBO to ensure that hospitals are reimbursed appropriately, and patients are not unduly burdened."

The investigators examined data on 855 older patients admitted with SBO from 2006 and 2013. Of these, 816 (95%) stayed for two midnights or longer. This was true of all patients aged 85 years or older (n=108, approximately 13%).

The only significant difference in clinical characteristics was the presence of inflammatory bowel disease. Of five such patients, only one stayed for less than two midnights.

"Based on our study and others," the investigators wrote, "we propose that hospital admission for SBO in elderly patients is sufficient justification for the reasonable expectation" of the required length of stay for reimbursement.

This also may be true of other conditions. Dr. Cooper concluded, "More studies like this are needed in surgical patients to better understand the impact of CMS admission guidelines. The rule may not make sense in certain populations, leading to heavy and unfair penalties for hospitals."

The authors reported no disclosures.

NEW YORK (Reuters Health) - In certain circumstances one widely used test for vitamin D intoxication, the Diasorin radioimmunoassay, may not be entirely reliable, according to two case studies by U.S. and Irish investigators.

"Our study," Dr. Michael A. Levine told Reuters Health by email, "highlights the continuing challenge that we face when using current assay technologies to measure vitamin D metabolites." The patients involved "developed vitamin D toxicity from inadvertent overdosage using standard over-the-counter preparations of vitamin D."

In a June 22 online paper in the Journal of Clinical Endocrinology & Metabolism, Dr. Levine, of the University of Pennsylvania, Philadelphia, and colleagues note that vitamin D intoxication is characterized by elevated serum 25-hydroxyvitamin D (25(OH)D) and suppressed serum 1,25-dihydroxvitamin D (1,25(OH)2D).

The team used both the Diasorin radioimmunaossay test (RIA) and liquid chromatography and tandem mass spectrometry (LC-MS/MS) to evaluate samples from two retrospectively identified patients with hypercalcemia. One was a 15-year-old male with a two-week history of postprandial vomiting, abdominal pain and polyuria. The other, a 17-year old female, had a history of weight loss.

Both had elevated serum 1,25(OH)2D by RIA, but normal serum 1,25(OH)2D concentrations by LC-MS/MS. To help explain these surprising findings the team conducted further in vitro experiments on serum samples from a random set of inpatients and outpatients.

The team noted that concentrations of 25(OH)D2 or 25(OH)D3 increased as expected based on the amount of vitamin D metabolite added to pooled serum samples or artificial serum matrix in all experiments.

The addition of 100 ng/mL of 25(OH)D3 to pooled patient serum resulted in a median increase of 114% in measured 1,25(OH)D2 via RIA and a 21% increase via LC-MS/MS. At 700 ng/mL, the increase was 349% with RIA and 117% with LC-MS/MS.

Thus, wrote the researchers, "We recommend measurement of serum 24,25(OH)2D and use of LC-MS/MS, which appears less susceptible to this interference, to reassess serum levels of 1,25(OH)2D when the clinical scenario is confusing."

Summing up, Dr. Levine said, "Assessment of plasma levels of the most active vitamin D metabolite, 1,25(OH)2D, using a common laboratory immunoassay pointed away from nutritional vitamin D intoxication and suggested other more worrisome diagnoses. Repeating the testing with a mass spectrometer assay confirmed the clinical diagnosis of vitamin D intoxication."

He concluded, "Clinicians must remember that laboratory tests are not 100% reliable, and they must continue to rely upon their clinical judgment when confronted with test results that do not make sense."

Diasorin did not respond to a request for comment.

The authors reported no financial disclosures or competing interests.

NEW YORK (Reuters Health) - In certain circumstances one widely used test for vitamin D intoxication, the Diasorin radioimmunoassay, may not be entirely reliable, according to two case studies by U.S. and Irish investigators.

"Our study," Dr. Michael A. Levine told Reuters Health by email, "highlights the continuing challenge that we face when using current assay technologies to measure vitamin D metabolites." The patients involved "developed vitamin D toxicity from inadvertent overdosage using standard over-the-counter preparations of vitamin D."

In a June 22 online paper in the Journal of Clinical Endocrinology & Metabolism, Dr. Levine, of the University of Pennsylvania, Philadelphia, and colleagues note that vitamin D intoxication is characterized by elevated serum 25-hydroxyvitamin D (25(OH)D) and suppressed serum 1,25-dihydroxvitamin D (1,25(OH)2D).

The team used both the Diasorin radioimmunaossay test (RIA) and liquid chromatography and tandem mass spectrometry (LC-MS/MS) to evaluate samples from two retrospectively identified patients with hypercalcemia. One was a 15-year-old male with a two-week history of postprandial vomiting, abdominal pain and polyuria. The other, a 17-year old female, had a history of weight loss.

Both had elevated serum 1,25(OH)2D by RIA, but normal serum 1,25(OH)2D concentrations by LC-MS/MS. To help explain these surprising findings the team conducted further in vitro experiments on serum samples from a random set of inpatients and outpatients.

The team noted that concentrations of 25(OH)D2 or 25(OH)D3 increased as expected based on the amount of vitamin D metabolite added to pooled serum samples or artificial serum matrix in all experiments.

The addition of 100 ng/mL of 25(OH)D3 to pooled patient serum resulted in a median increase of 114% in measured 1,25(OH)D2 via RIA and a 21% increase via LC-MS/MS. At 700 ng/mL, the increase was 349% with RIA and 117% with LC-MS/MS.

Thus, wrote the researchers, "We recommend measurement of serum 24,25(OH)2D and use of LC-MS/MS, which appears less susceptible to this interference, to reassess serum levels of 1,25(OH)2D when the clinical scenario is confusing."

Summing up, Dr. Levine said, "Assessment of plasma levels of the most active vitamin D metabolite, 1,25(OH)2D, using a common laboratory immunoassay pointed away from nutritional vitamin D intoxication and suggested other more worrisome diagnoses. Repeating the testing with a mass spectrometer assay confirmed the clinical diagnosis of vitamin D intoxication."

He concluded, "Clinicians must remember that laboratory tests are not 100% reliable, and they must continue to rely upon their clinical judgment when confronted with test results that do not make sense."

Diasorin did not respond to a request for comment.

The authors reported no financial disclosures or competing interests.

NEW YORK (Reuters Health) - In certain circumstances one widely used test for vitamin D intoxication, the Diasorin radioimmunoassay, may not be entirely reliable, according to two case studies by U.S. and Irish investigators.

"Our study," Dr. Michael A. Levine told Reuters Health by email, "highlights the continuing challenge that we face when using current assay technologies to measure vitamin D metabolites." The patients involved "developed vitamin D toxicity from inadvertent overdosage using standard over-the-counter preparations of vitamin D."

In a June 22 online paper in the Journal of Clinical Endocrinology & Metabolism, Dr. Levine, of the University of Pennsylvania, Philadelphia, and colleagues note that vitamin D intoxication is characterized by elevated serum 25-hydroxyvitamin D (25(OH)D) and suppressed serum 1,25-dihydroxvitamin D (1,25(OH)2D).

The team used both the Diasorin radioimmunaossay test (RIA) and liquid chromatography and tandem mass spectrometry (LC-MS/MS) to evaluate samples from two retrospectively identified patients with hypercalcemia. One was a 15-year-old male with a two-week history of postprandial vomiting, abdominal pain and polyuria. The other, a 17-year old female, had a history of weight loss.

Both had elevated serum 1,25(OH)2D by RIA, but normal serum 1,25(OH)2D concentrations by LC-MS/MS. To help explain these surprising findings the team conducted further in vitro experiments on serum samples from a random set of inpatients and outpatients.

The team noted that concentrations of 25(OH)D2 or 25(OH)D3 increased as expected based on the amount of vitamin D metabolite added to pooled serum samples or artificial serum matrix in all experiments.

The addition of 100 ng/mL of 25(OH)D3 to pooled patient serum resulted in a median increase of 114% in measured 1,25(OH)D2 via RIA and a 21% increase via LC-MS/MS. At 700 ng/mL, the increase was 349% with RIA and 117% with LC-MS/MS.

Thus, wrote the researchers, "We recommend measurement of serum 24,25(OH)2D and use of LC-MS/MS, which appears less susceptible to this interference, to reassess serum levels of 1,25(OH)2D when the clinical scenario is confusing."

Summing up, Dr. Levine said, "Assessment of plasma levels of the most active vitamin D metabolite, 1,25(OH)2D, using a common laboratory immunoassay pointed away from nutritional vitamin D intoxication and suggested other more worrisome diagnoses. Repeating the testing with a mass spectrometer assay confirmed the clinical diagnosis of vitamin D intoxication."

He concluded, "Clinicians must remember that laboratory tests are not 100% reliable, and they must continue to rely upon their clinical judgment when confronted with test results that do not make sense."

Diasorin did not respond to a request for comment.

The authors reported no financial disclosures or competing interests.

Summary:

One of PHM15's first sessions was a workshop led by Dr. Rachna May focusing on the role of pediatric hospitalists in end-of-life conversations.

Medically complex pediatric patients are more likely to have end-of-life care in the hospital, placing the pediatric hospitalist in a unique position to address end-of-life issues. Medically complex patients may have waxing and waning courses, with frequent admissions for acute illness. Following these admissions, they may not fully return to their pre-illness baseline, leading to an overall gradual decline in health. An opportunity for discussing quality of life is available with each acute illness and hospitalization.

These conversations, however, can be difficult to initiate and present several barriers to overcome. These barriers include:

• Unknown parental expectations regarding outcome,
• Lack of an established relationship with the patient and family, and
• Lack of readiness of the patient and family to discuss end-of-life decisions.

To overcome these barriers, providers must develop tools for delivery. They must find the right setting for the conversation, limit distractions, and avoid medical jargon. Begin with asking the patient and family's perceptions of the clinical prognosis and be honest when discussing the predicted medical outcomes for the patient. Open discussion of the prognosis allows autonomy in decision making, helps families feel supported, and can help them manage distress surrounding end-of-life care.

Such terminology as "do not resuscitate" can be interpreted as “doing nothing,” and result in feelings of guilt for a family desiring care for their child. Using a phrase such as "allowing a natural death" can alleviate feelings of guilt over end-of-life decisions and help the family actively provide care while optimizing quality of life. TH

Dr. Player is a hospitalist and assistant professor in the Department of Pediatrics at Medical College of Wisconsin, Children’s Hospital of Wisconsin in Milwaukee.

Summary:

One of PHM15's first sessions was a workshop led by Dr. Rachna May focusing on the role of pediatric hospitalists in end-of-life conversations.

Medically complex pediatric patients are more likely to have end-of-life care in the hospital, placing the pediatric hospitalist in a unique position to address end-of-life issues. Medically complex patients may have waxing and waning courses, with frequent admissions for acute illness. Following these admissions, they may not fully return to their pre-illness baseline, leading to an overall gradual decline in health. An opportunity for discussing quality of life is available with each acute illness and hospitalization.

These conversations, however, can be difficult to initiate and present several barriers to overcome. These barriers include:

• Unknown parental expectations regarding outcome,
• Lack of an established relationship with the patient and family, and
• Lack of readiness of the patient and family to discuss end-of-life decisions.

To overcome these barriers, providers must develop tools for delivery. They must find the right setting for the conversation, limit distractions, and avoid medical jargon. Begin with asking the patient and family's perceptions of the clinical prognosis and be honest when discussing the predicted medical outcomes for the patient. Open discussion of the prognosis allows autonomy in decision making, helps families feel supported, and can help them manage distress surrounding end-of-life care.

Such terminology as "do not resuscitate" can be interpreted as “doing nothing,” and result in feelings of guilt for a family desiring care for their child. Using a phrase such as "allowing a natural death" can alleviate feelings of guilt over end-of-life decisions and help the family actively provide care while optimizing quality of life. TH

Dr. Player is a hospitalist and assistant professor in the Department of Pediatrics at Medical College of Wisconsin, Children’s Hospital of Wisconsin in Milwaukee.

Summary:

One of PHM15's first sessions was a workshop led by Dr. Rachna May focusing on the role of pediatric hospitalists in end-of-life conversations.

Medically complex pediatric patients are more likely to have end-of-life care in the hospital, placing the pediatric hospitalist in a unique position to address end-of-life issues. Medically complex patients may have waxing and waning courses, with frequent admissions for acute illness. Following these admissions, they may not fully return to their pre-illness baseline, leading to an overall gradual decline in health. An opportunity for discussing quality of life is available with each acute illness and hospitalization.

These conversations, however, can be difficult to initiate and present several barriers to overcome. These barriers include:

• Unknown parental expectations regarding outcome,
• Lack of an established relationship with the patient and family, and
• Lack of readiness of the patient and family to discuss end-of-life decisions.

To overcome these barriers, providers must develop tools for delivery. They must find the right setting for the conversation, limit distractions, and avoid medical jargon. Begin with asking the patient and family's perceptions of the clinical prognosis and be honest when discussing the predicted medical outcomes for the patient. Open discussion of the prognosis allows autonomy in decision making, helps families feel supported, and can help them manage distress surrounding end-of-life care.

Such terminology as "do not resuscitate" can be interpreted as “doing nothing,” and result in feelings of guilt for a family desiring care for their child. Using a phrase such as "allowing a natural death" can alleviate feelings of guilt over end-of-life decisions and help the family actively provide care while optimizing quality of life. TH

Dr. Player is a hospitalist and assistant professor in the Department of Pediatrics at Medical College of Wisconsin, Children’s Hospital of Wisconsin in Milwaukee.

Summary:

In an era where a majority of the pediatric hospital workforce is just starting to recognize fish bone diagrams, five why questions, root cause analysis, IHI, Lean, six sigma and pareto charts, hospitalists can be daunted as they try to serve as the home for quality improvement and patient safety in hospitals. Hospitalists are expected to know, understand, and practice these models for improvement with limited training and expertise. Beyond being looked at as experts, they are expected to teach residents and other learners when they are unsure of it ourselves. Governing education bodies (i.e., ACGME and CLER) have made it a requirement that residents have these concepts integrated into their curriculums and tracked.

Presented by an inter-professional team from Floating Hospital for Children at Tufts Medical Center in Boston, this PHM15 workshop focused on how to work in multidisciplinary teams to identify, analyze, and create patient-safety solutions, and, therefore, set the stage for systems- or department-based QI projects.

“It is OK to make mistakes, but it is not OK to not learn from them,” stated the presenters.

Starting with a near-miss event that led to a department/resident-led root cause analysis, the importance of system improvement became apparent. Presenters discussed the 12-week curriculum they created for pediatric residents and nursing students, which includes:

• Didactics,
• Online, self-directed learning, and
• An inter-professional, small-group project.

Trainees present their analysis and action items to their departments and, at times, even administration. This helps align hospital goals with resident teaching, while simultaneously providing an environment where discussing errors safely in order to prevent further harms.

Attendees of the workshop walked away with a generalizable, step-by-step toolkit to take home to their home institution.

Key Takeaways:

1. Convene a leadership team of nurses and physicians to develop the inter-professional program
2. Consider scheduling demands of nurses, physicians and residents.
3. Implement administrative support to assist with scheduling of meetings, maintenance of documents and email distribution.
4. Program participation must bring value to the staff such as CME credits
5. Make the educational experience program flexible in a blended learning environment.
6. Recognize staff’s completion of the program with a certificate.
7. Provide the opportunity, mentorship and support for staff willing to continue the project as a quality improvement initiative. TH

Dr. Hopkins is a pediatric hospitalist at All Children's Hospital Johns Hopkins Medicine, and an instructor at Johns Hopkins Medicine in St. Petersburg, Fla.

Summary:

In an era where a majority of the pediatric hospital workforce is just starting to recognize fish bone diagrams, five why questions, root cause analysis, IHI, Lean, six sigma and pareto charts, hospitalists can be daunted as they try to serve as the home for quality improvement and patient safety in hospitals. Hospitalists are expected to know, understand, and practice these models for improvement with limited training and expertise. Beyond being looked at as experts, they are expected to teach residents and other learners when they are unsure of it ourselves. Governing education bodies (i.e., ACGME and CLER) have made it a requirement that residents have these concepts integrated into their curriculums and tracked.

Presented by an inter-professional team from Floating Hospital for Children at Tufts Medical Center in Boston, this PHM15 workshop focused on how to work in multidisciplinary teams to identify, analyze, and create patient-safety solutions, and, therefore, set the stage for systems- or department-based QI projects.

“It is OK to make mistakes, but it is not OK to not learn from them,” stated the presenters.

Starting with a near-miss event that led to a department/resident-led root cause analysis, the importance of system improvement became apparent. Presenters discussed the 12-week curriculum they created for pediatric residents and nursing students, which includes:

• Didactics,
• Online, self-directed learning, and
• An inter-professional, small-group project.

Trainees present their analysis and action items to their departments and, at times, even administration. This helps align hospital goals with resident teaching, while simultaneously providing an environment where discussing errors safely in order to prevent further harms.

Attendees of the workshop walked away with a generalizable, step-by-step toolkit to take home to their home institution.

Key Takeaways:

1. Convene a leadership team of nurses and physicians to develop the inter-professional program
2. Consider scheduling demands of nurses, physicians and residents.
3. Implement administrative support to assist with scheduling of meetings, maintenance of documents and email distribution.
4. Program participation must bring value to the staff such as CME credits
5. Make the educational experience program flexible in a blended learning environment.
6. Recognize staff’s completion of the program with a certificate.
7. Provide the opportunity, mentorship and support for staff willing to continue the project as a quality improvement initiative. TH

Dr. Hopkins is a pediatric hospitalist at All Children's Hospital Johns Hopkins Medicine, and an instructor at Johns Hopkins Medicine in St. Petersburg, Fla.

Summary:

In an era where a majority of the pediatric hospital workforce is just starting to recognize fish bone diagrams, five why questions, root cause analysis, IHI, Lean, six sigma and pareto charts, hospitalists can be daunted as they try to serve as the home for quality improvement and patient safety in hospitals. Hospitalists are expected to know, understand, and practice these models for improvement with limited training and expertise. Beyond being looked at as experts, they are expected to teach residents and other learners when they are unsure of it ourselves. Governing education bodies (i.e., ACGME and CLER) have made it a requirement that residents have these concepts integrated into their curriculums and tracked.

Presented by an inter-professional team from Floating Hospital for Children at Tufts Medical Center in Boston, this PHM15 workshop focused on how to work in multidisciplinary teams to identify, analyze, and create patient-safety solutions, and, therefore, set the stage for systems- or department-based QI projects.

“It is OK to make mistakes, but it is not OK to not learn from them,” stated the presenters.

Starting with a near-miss event that led to a department/resident-led root cause analysis, the importance of system improvement became apparent. Presenters discussed the 12-week curriculum they created for pediatric residents and nursing students, which includes:

• Didactics,
• Online, self-directed learning, and
• An inter-professional, small-group project.

Trainees present their analysis and action items to their departments and, at times, even administration. This helps align hospital goals with resident teaching, while simultaneously providing an environment where discussing errors safely in order to prevent further harms.

Attendees of the workshop walked away with a generalizable, step-by-step toolkit to take home to their home institution.

Key Takeaways:

1. Convene a leadership team of nurses and physicians to develop the inter-professional program
2. Consider scheduling demands of nurses, physicians and residents.
3. Implement administrative support to assist with scheduling of meetings, maintenance of documents and email distribution.
4. Program participation must bring value to the staff such as CME credits
5. Make the educational experience program flexible in a blended learning environment.
6. Recognize staff’s completion of the program with a certificate.
7. Provide the opportunity, mentorship and support for staff willing to continue the project as a quality improvement initiative. TH

Dr. Hopkins is a pediatric hospitalist at All Children's Hospital Johns Hopkins Medicine, and an instructor at Johns Hopkins Medicine in St. Petersburg, Fla.

Presenters: Kelly Basaldua, MD; Daniel Sedillo, MD, MBA, and Jason Reynolds, MD

Summary:

In an environment where medicine is becoming ever more specialized and the scope of practice for many is ever narrowing into corridors of expertise, the hospitalist remains a bastion of generalism with an ever-diversifying skill set. One of the skills acquired by many hospitalists to aid in the overall efficiency of the hospital is intranasal (IN) sedation.

Intranasal sedation is becoming more popular given the rapid onset and offset and the relative safety of the sedation of patients without the need for intravenous catheters. This phenomenon is accomplished by avoiding the gut and thus avoiding first-pass metabolism. This allows for greatly increased bioavailability compared with oral administration. In addition, the nasal mucosa is in near direct contact with the CSF via the cribriform plate, allowing for rapid and effective action.

To maximize the effectiveness of intranasal sedation, low volumes with high concentrations, atomization, and minimal nasal occlusion are vital. The ideal volume per nostril is approximately 0.5 ml as using any greater volume results in oversaturation and minimal additional absorption. Thus, concentrating the medications into minimal volumes provides for more efficacious usage. Atomization aids in ensuring thorough surface area coverage and higher absorption. This is a far more efficacious method of delivery than liquid/drop administration.

Because intranasally administered agents have a delayed and widened serum peak compared to IV, IN sedation carries less of a chance to reach serum levels high enough to cause respiratory depression, though monitoring is still necessary. When compared to IV sedation, IN does have a delay in onset, but also provides for a more gentle recovery process, often resulting in a less disorienting recovery for the patient, while also providing for a wider safety profile.

The presenters covered three primary agents:

• midazolam,
• dexmedetomidine, and
• fentanyl

Midazolam is useful for non-painful, minimally invasive procedures. Fentanyl is more useful for painful or more invasive procedures. Dexmedetomidine is off-label use for intranasal sedation at this time, but has promising initial research given its safety profile and longer duration of action compared to most intranasal agents. Also, dexmedetomidine works extremely effectively in combination with other agents, particularly midazolam, to prolong sedations, making it very useful for longer procedures like combination MRIs.

The presenters then provided a practical workshop to practice the delivery of intranasal medication effectively. One of the pearls provided involved proper positioning of the patient in a reclined position as sitting to erect will cause the medication to drip out and having the patient lying flat will result in the medication dripping down the posterior pharynx. This position should be held for 30 seconds after delivery of the medication. Practicing with atomizers to achieve effective aerosolization was discussed. The target of medication should avoid the nasal septum given its poor absorption.

Key Takeaway:

With hospitalists being called to assist in ever-expanding roles within the hospital system while improving efficiency and throughput, intranasal sedation may provide reduced imaging wait times, bedside and ED procedure times in a safe and effective manner. TH

Dr. Crook is a hospitalist in the division of hospitalist medicine, assistant professor of pediatrics, and assistant pediatric clerkship director in the Department of Pediatrics at Vanderbilt University School of Medicine and Monroe Carell Jr. Children's Hospital at Vanderbilt in Nashville.

Presenters: Kelly Basaldua, MD; Daniel Sedillo, MD, MBA, and Jason Reynolds, MD

Summary:

In an environment where medicine is becoming ever more specialized and the scope of practice for many is ever narrowing into corridors of expertise, the hospitalist remains a bastion of generalism with an ever-diversifying skill set. One of the skills acquired by many hospitalists to aid in the overall efficiency of the hospital is intranasal (IN) sedation.

Intranasal sedation is becoming more popular given the rapid onset and offset and the relative safety of the sedation of patients without the need for intravenous catheters. This phenomenon is accomplished by avoiding the gut and thus avoiding first-pass metabolism. This allows for greatly increased bioavailability compared with oral administration. In addition, the nasal mucosa is in near direct contact with the CSF via the cribriform plate, allowing for rapid and effective action.

To maximize the effectiveness of intranasal sedation, low volumes with high concentrations, atomization, and minimal nasal occlusion are vital. The ideal volume per nostril is approximately 0.5 ml as using any greater volume results in oversaturation and minimal additional absorption. Thus, concentrating the medications into minimal volumes provides for more efficacious usage. Atomization aids in ensuring thorough surface area coverage and higher absorption. This is a far more efficacious method of delivery than liquid/drop administration.

Because intranasally administered agents have a delayed and widened serum peak compared to IV, IN sedation carries less of a chance to reach serum levels high enough to cause respiratory depression, though monitoring is still necessary. When compared to IV sedation, IN does have a delay in onset, but also provides for a more gentle recovery process, often resulting in a less disorienting recovery for the patient, while also providing for a wider safety profile.

The presenters covered three primary agents:

• midazolam,
• dexmedetomidine, and
• fentanyl

Midazolam is useful for non-painful, minimally invasive procedures. Fentanyl is more useful for painful or more invasive procedures. Dexmedetomidine is off-label use for intranasal sedation at this time, but has promising initial research given its safety profile and longer duration of action compared to most intranasal agents. Also, dexmedetomidine works extremely effectively in combination with other agents, particularly midazolam, to prolong sedations, making it very useful for longer procedures like combination MRIs.

The presenters then provided a practical workshop to practice the delivery of intranasal medication effectively. One of the pearls provided involved proper positioning of the patient in a reclined position as sitting to erect will cause the medication to drip out and having the patient lying flat will result in the medication dripping down the posterior pharynx. This position should be held for 30 seconds after delivery of the medication. Practicing with atomizers to achieve effective aerosolization was discussed. The target of medication should avoid the nasal septum given its poor absorption.

Key Takeaway:

With hospitalists being called to assist in ever-expanding roles within the hospital system while improving efficiency and throughput, intranasal sedation may provide reduced imaging wait times, bedside and ED procedure times in a safe and effective manner. TH

Dr. Crook is a hospitalist in the division of hospitalist medicine, assistant professor of pediatrics, and assistant pediatric clerkship director in the Department of Pediatrics at Vanderbilt University School of Medicine and Monroe Carell Jr. Children's Hospital at Vanderbilt in Nashville.

Presenters: Kelly Basaldua, MD; Daniel Sedillo, MD, MBA, and Jason Reynolds, MD

Summary:

In an environment where medicine is becoming ever more specialized and the scope of practice for many is ever narrowing into corridors of expertise, the hospitalist remains a bastion of generalism with an ever-diversifying skill set. One of the skills acquired by many hospitalists to aid in the overall efficiency of the hospital is intranasal (IN) sedation.

Intranasal sedation is becoming more popular given the rapid onset and offset and the relative safety of the sedation of patients without the need for intravenous catheters. This phenomenon is accomplished by avoiding the gut and thus avoiding first-pass metabolism. This allows for greatly increased bioavailability compared with oral administration. In addition, the nasal mucosa is in near direct contact with the CSF via the cribriform plate, allowing for rapid and effective action.

To maximize the effectiveness of intranasal sedation, low volumes with high concentrations, atomization, and minimal nasal occlusion are vital. The ideal volume per nostril is approximately 0.5 ml as using any greater volume results in oversaturation and minimal additional absorption. Thus, concentrating the medications into minimal volumes provides for more efficacious usage. Atomization aids in ensuring thorough surface area coverage and higher absorption. This is a far more efficacious method of delivery than liquid/drop administration.

Because intranasally administered agents have a delayed and widened serum peak compared to IV, IN sedation carries less of a chance to reach serum levels high enough to cause respiratory depression, though monitoring is still necessary. When compared to IV sedation, IN does have a delay in onset, but also provides for a more gentle recovery process, often resulting in a less disorienting recovery for the patient, while also providing for a wider safety profile.

The presenters covered three primary agents:

• midazolam,
• dexmedetomidine, and
• fentanyl

Midazolam is useful for non-painful, minimally invasive procedures. Fentanyl is more useful for painful or more invasive procedures. Dexmedetomidine is off-label use for intranasal sedation at this time, but has promising initial research given its safety profile and longer duration of action compared to most intranasal agents. Also, dexmedetomidine works extremely effectively in combination with other agents, particularly midazolam, to prolong sedations, making it very useful for longer procedures like combination MRIs.

The presenters then provided a practical workshop to practice the delivery of intranasal medication effectively. One of the pearls provided involved proper positioning of the patient in a reclined position as sitting to erect will cause the medication to drip out and having the patient lying flat will result in the medication dripping down the posterior pharynx. This position should be held for 30 seconds after delivery of the medication. Practicing with atomizers to achieve effective aerosolization was discussed. The target of medication should avoid the nasal septum given its poor absorption.

Key Takeaway:

With hospitalists being called to assist in ever-expanding roles within the hospital system while improving efficiency and throughput, intranasal sedation may provide reduced imaging wait times, bedside and ED procedure times in a safe and effective manner. TH

Dr. Crook is a hospitalist in the division of hospitalist medicine, assistant professor of pediatrics, and assistant pediatric clerkship director in the Department of Pediatrics at Vanderbilt University School of Medicine and Monroe Carell Jr. Children's Hospital at Vanderbilt in Nashville.

Presenters: Gitanjli Arora, Phuc Le, and Christiana Russ

Summary:

Overseas medical missions can be rewarding experiences for both trainees as part of a supervised program and attending physicians. There is substantial inequity in the global distribution of disease versus health care providers with most providers being located in developed countries and higher disease burdens in underdeveloped countries.  The goal of global healthcare training is mutual benefit, where the provider gains clinical experience and the host country gains enhanced medical care. Both provider and hosts gain increased cultural awareness.

The American Academy of Pediatrics guidelines for a meaningful international experience recommend 4 components:

• Pre-trip Training.  Don’t go without some idea of what to expect
• Pre-travel preparations.  Get your vaccines, travel plans, licensure, scope of practice taken care of.
• Preceptorship by host and US faculty
• Post-travel evaluation and feedback

Key Takeaways:

Providers in overseas medical missions will encounter challenging situations—culturally, ethically and medically. Get as much information beforehand. Be respectful of different cultural norms. Get a cultural ambassador. Keep in mind the Serenity Prayer. TH

Presenters: Gitanjli Arora, Phuc Le, and Christiana Russ

Summary:

Overseas medical missions can be rewarding experiences for both trainees as part of a supervised program and attending physicians. There is substantial inequity in the global distribution of disease versus health care providers with most providers being located in developed countries and higher disease burdens in underdeveloped countries.  The goal of global healthcare training is mutual benefit, where the provider gains clinical experience and the host country gains enhanced medical care. Both provider and hosts gain increased cultural awareness.

The American Academy of Pediatrics guidelines for a meaningful international experience recommend 4 components:

• Pre-trip Training.  Don’t go without some idea of what to expect
• Pre-travel preparations.  Get your vaccines, travel plans, licensure, scope of practice taken care of.
• Preceptorship by host and US faculty
• Post-travel evaluation and feedback

Key Takeaways:

Providers in overseas medical missions will encounter challenging situations—culturally, ethically and medically. Get as much information beforehand. Be respectful of different cultural norms. Get a cultural ambassador. Keep in mind the Serenity Prayer. TH

Presenters: Gitanjli Arora, Phuc Le, and Christiana Russ

Summary:

Overseas medical missions can be rewarding experiences for both trainees as part of a supervised program and attending physicians. There is substantial inequity in the global distribution of disease versus health care providers with most providers being located in developed countries and higher disease burdens in underdeveloped countries.  The goal of global healthcare training is mutual benefit, where the provider gains clinical experience and the host country gains enhanced medical care. Both provider and hosts gain increased cultural awareness.

The American Academy of Pediatrics guidelines for a meaningful international experience recommend 4 components:

• Pre-trip Training.  Don’t go without some idea of what to expect
• Pre-travel preparations.  Get your vaccines, travel plans, licensure, scope of practice taken care of.
• Preceptorship by host and US faculty
• Post-travel evaluation and feedback

Key Takeaways:

Providers in overseas medical missions will encounter challenging situations—culturally, ethically and medically. Get as much information beforehand. Be respectful of different cultural norms. Get a cultural ambassador. Keep in mind the Serenity Prayer. TH