User login
Elderly Patient Care Guide Goes Beyond Textbooks, Treatment Guidelines
Summary
Older patients comprise an increasingly large part of the population we serve as hospitalists. We are all very familiar with the standard medical problems—congestive heart failure, COPD, or stroke—that these individuals present to us in the inpatient setting; however, this patient population has special needs and challenges that often are inadequately covered in textbooks and treatment guidelines.
The Hospitalists’ Guide to the Care of Older Patients serves as an excellent guide for the day-to-day management of geriatric patients. All 13 of its chapters are written in a concise, to-the-point style. The authors have a sound understanding of the needs and challenges of today’s practicing hospitalists.
The authors focus entire chapters on geriatric assessment and exam and communication with older patients. They remind hospitalists to be aware that these patients need a thoughtful approach in our interactions, because vision, hearing, or cognition might be impaired.
The 269-page book provides a great overview on decision making and decision-making capacity (DMC). Patients might have partial DMC, in spite of cognitive impairment or neurological or psychiatric illness. Surrogate decision makers and their limitations also are discussed.
One chapter is dedicated to end-of-life care, with special attention to debility and dementia.
Another major focus is geriatric pharmacotherapy and polypharmacy in the elderly. Attention is given to the fact that drug studies frequently fail to include the elderly and that pharmacokinetics may be significantly altered in this population. The chapter includes a table of “high-risk meds” prescribed by hospitalists.
Delirium and management of behavioral disturbances are described in two chapters and include very helpful tables to guide in its treatment.
The authors also review nutrition management, including a customized approach to patients with dysphagia at risk for aspiration and managing complex medical patients with hip fractures, including pre-op evaluation, post-op care, pain management, and delirium. Narcotic pain medications are of obvious concern in the elderly, but it is pointed out that uncontrolled pain in itself can cause delirium.
Special attention is given to mobility and fall risk, as well as prevention strategies, in hospitalized patients.
Pressure ulcers are a concern in all patients but especially the elderly. This guide outlines mechanisms of ulcer formation, staging, and treatment options.
The book concludes with a chapter on transitional care planning for a safe discharge. It describes potential risks for errors and poor handoffs, including failure to adequately communicate complex discharge plans to elderly patients.
Analysis
The Hospitalists’ Guide to the Care of Older Patients is an excellent, hands-on manual for managing elderly patients. It describes standard situations frequently encountered by hospitalists and provides pertinent information that can be acted upon.
Written with a genuine understanding of what matters most for hospitalists in their daily practice, the chapters are focused and concise enough to serve as a quick reference, yet detailed enough to supply the hospitalist with sufficient information to be able to put a patient management plan into action.
After reading this book, hospitalists will have a solid and rational basis for the thoughtful and effective management of elderly patients.
Dr. Suehler is a hospitalist with Midwest Internal Medicine Hospitalists at Mercy Hospital in Coon Rapids, Minn., and a member of Team Hospitalist since 2013.
Summary
Older patients comprise an increasingly large part of the population we serve as hospitalists. We are all very familiar with the standard medical problems—congestive heart failure, COPD, or stroke—that these individuals present to us in the inpatient setting; however, this patient population has special needs and challenges that often are inadequately covered in textbooks and treatment guidelines.
The Hospitalists’ Guide to the Care of Older Patients serves as an excellent guide for the day-to-day management of geriatric patients. All 13 of its chapters are written in a concise, to-the-point style. The authors have a sound understanding of the needs and challenges of today’s practicing hospitalists.
The authors focus entire chapters on geriatric assessment and exam and communication with older patients. They remind hospitalists to be aware that these patients need a thoughtful approach in our interactions, because vision, hearing, or cognition might be impaired.
The 269-page book provides a great overview on decision making and decision-making capacity (DMC). Patients might have partial DMC, in spite of cognitive impairment or neurological or psychiatric illness. Surrogate decision makers and their limitations also are discussed.
One chapter is dedicated to end-of-life care, with special attention to debility and dementia.
Another major focus is geriatric pharmacotherapy and polypharmacy in the elderly. Attention is given to the fact that drug studies frequently fail to include the elderly and that pharmacokinetics may be significantly altered in this population. The chapter includes a table of “high-risk meds” prescribed by hospitalists.
Delirium and management of behavioral disturbances are described in two chapters and include very helpful tables to guide in its treatment.
The authors also review nutrition management, including a customized approach to patients with dysphagia at risk for aspiration and managing complex medical patients with hip fractures, including pre-op evaluation, post-op care, pain management, and delirium. Narcotic pain medications are of obvious concern in the elderly, but it is pointed out that uncontrolled pain in itself can cause delirium.
Special attention is given to mobility and fall risk, as well as prevention strategies, in hospitalized patients.
Pressure ulcers are a concern in all patients but especially the elderly. This guide outlines mechanisms of ulcer formation, staging, and treatment options.
The book concludes with a chapter on transitional care planning for a safe discharge. It describes potential risks for errors and poor handoffs, including failure to adequately communicate complex discharge plans to elderly patients.
Analysis
The Hospitalists’ Guide to the Care of Older Patients is an excellent, hands-on manual for managing elderly patients. It describes standard situations frequently encountered by hospitalists and provides pertinent information that can be acted upon.
Written with a genuine understanding of what matters most for hospitalists in their daily practice, the chapters are focused and concise enough to serve as a quick reference, yet detailed enough to supply the hospitalist with sufficient information to be able to put a patient management plan into action.
After reading this book, hospitalists will have a solid and rational basis for the thoughtful and effective management of elderly patients.
Dr. Suehler is a hospitalist with Midwest Internal Medicine Hospitalists at Mercy Hospital in Coon Rapids, Minn., and a member of Team Hospitalist since 2013.
Summary
Older patients comprise an increasingly large part of the population we serve as hospitalists. We are all very familiar with the standard medical problems—congestive heart failure, COPD, or stroke—that these individuals present to us in the inpatient setting; however, this patient population has special needs and challenges that often are inadequately covered in textbooks and treatment guidelines.
The Hospitalists’ Guide to the Care of Older Patients serves as an excellent guide for the day-to-day management of geriatric patients. All 13 of its chapters are written in a concise, to-the-point style. The authors have a sound understanding of the needs and challenges of today’s practicing hospitalists.
The authors focus entire chapters on geriatric assessment and exam and communication with older patients. They remind hospitalists to be aware that these patients need a thoughtful approach in our interactions, because vision, hearing, or cognition might be impaired.
The 269-page book provides a great overview on decision making and decision-making capacity (DMC). Patients might have partial DMC, in spite of cognitive impairment or neurological or psychiatric illness. Surrogate decision makers and their limitations also are discussed.
One chapter is dedicated to end-of-life care, with special attention to debility and dementia.
Another major focus is geriatric pharmacotherapy and polypharmacy in the elderly. Attention is given to the fact that drug studies frequently fail to include the elderly and that pharmacokinetics may be significantly altered in this population. The chapter includes a table of “high-risk meds” prescribed by hospitalists.
Delirium and management of behavioral disturbances are described in two chapters and include very helpful tables to guide in its treatment.
The authors also review nutrition management, including a customized approach to patients with dysphagia at risk for aspiration and managing complex medical patients with hip fractures, including pre-op evaluation, post-op care, pain management, and delirium. Narcotic pain medications are of obvious concern in the elderly, but it is pointed out that uncontrolled pain in itself can cause delirium.
Special attention is given to mobility and fall risk, as well as prevention strategies, in hospitalized patients.
Pressure ulcers are a concern in all patients but especially the elderly. This guide outlines mechanisms of ulcer formation, staging, and treatment options.
The book concludes with a chapter on transitional care planning for a safe discharge. It describes potential risks for errors and poor handoffs, including failure to adequately communicate complex discharge plans to elderly patients.
Analysis
The Hospitalists’ Guide to the Care of Older Patients is an excellent, hands-on manual for managing elderly patients. It describes standard situations frequently encountered by hospitalists and provides pertinent information that can be acted upon.
Written with a genuine understanding of what matters most for hospitalists in their daily practice, the chapters are focused and concise enough to serve as a quick reference, yet detailed enough to supply the hospitalist with sufficient information to be able to put a patient management plan into action.
After reading this book, hospitalists will have a solid and rational basis for the thoughtful and effective management of elderly patients.
Dr. Suehler is a hospitalist with Midwest Internal Medicine Hospitalists at Mercy Hospital in Coon Rapids, Minn., and a member of Team Hospitalist since 2013.
LISTEN NOW: The Doctor as Patient
[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/01/Doctor-As-Patient.mp3"][/audio]
[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/01/Doctor-As-Patient.mp3"][/audio]
[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/01/Doctor-As-Patient.mp3"][/audio]
LISTEN NOW: Highlights of the January 2015 issue of The Hospitalist
[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/01/2015-January-Highlights.mp3"][/audio]
[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/01/2015-January-Highlights.mp3"][/audio]
[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/01/2015-January-Highlights.mp3"][/audio]
LISTEN NOW: Co-Management in Hospital Medicine
[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/01/Hospital-Medicine-co-management-Jan2015.mp3"][/audio]
[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/01/Hospital-Medicine-co-management-Jan2015.mp3"][/audio]
[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/01/Hospital-Medicine-co-management-Jan2015.mp3"][/audio]
Depletive Fluid Management Strategy During Weaning from Mechanical Ventilation Can Lower VAP Rates
Clinical question: What is the benefit associated with a depletive fluid management strategy on ventilator-associated complication (VAC) and ventilator-associated pneumonia (VAP) during weaning from mechanical ventilation?
Background: VAP is common in the ICU. Pulmonary edema predisposes patients to pneumonia by altering the alveolar microenvironment through enhancement of bacterial colonization and infectivity and a decrease in host bactericidal capacities. A fluid management strategy aimed at lowering lung fluid balance may prove useful in reducing both VAC and VAP.
Study design: Randomized controlled trial.
Setting: Nine ICUs in Europe and South America, between May 2007 and July 2009.
Synopsis: Data from the B-type Natriuretic Peptide for the Management of Weaning (BMW) trial was used to compare the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid management group and the usual care group during the 14 days following randomization. The trial enrolled 304 randomized patients, 152 in each group.
Compared with usual care, the interventional strategy was associated with a higher proportion of patients receiving diuretics, in higher doses, resulting in a significantly more negative fluid balance during weaning and a shorter duration of mechanical ventilation. VAC (as defined by worsening oxygenation) occurred in 13.2% of patients during the 14 days following randomization: 17.8% in the usual care group and 8.6% in the interventional group. VAP occurred in 13.5% during the 14 days following randomization: 17.8% in the usual care group and 9.2% in the interventional group.
Bottom line: A biomarker-driven, depletive fluid strategy decreases the cumulative incidence of VAC and VAP.
Citation: Mekontso Dessap A, Katsahian S, Roche-Campo F, et al. Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management. Chest. 2014;146(1):58-65.
Visit our website for more physician reviews of HM-related research.
Clinical question: What is the benefit associated with a depletive fluid management strategy on ventilator-associated complication (VAC) and ventilator-associated pneumonia (VAP) during weaning from mechanical ventilation?
Background: VAP is common in the ICU. Pulmonary edema predisposes patients to pneumonia by altering the alveolar microenvironment through enhancement of bacterial colonization and infectivity and a decrease in host bactericidal capacities. A fluid management strategy aimed at lowering lung fluid balance may prove useful in reducing both VAC and VAP.
Study design: Randomized controlled trial.
Setting: Nine ICUs in Europe and South America, between May 2007 and July 2009.
Synopsis: Data from the B-type Natriuretic Peptide for the Management of Weaning (BMW) trial was used to compare the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid management group and the usual care group during the 14 days following randomization. The trial enrolled 304 randomized patients, 152 in each group.
Compared with usual care, the interventional strategy was associated with a higher proportion of patients receiving diuretics, in higher doses, resulting in a significantly more negative fluid balance during weaning and a shorter duration of mechanical ventilation. VAC (as defined by worsening oxygenation) occurred in 13.2% of patients during the 14 days following randomization: 17.8% in the usual care group and 8.6% in the interventional group. VAP occurred in 13.5% during the 14 days following randomization: 17.8% in the usual care group and 9.2% in the interventional group.
Bottom line: A biomarker-driven, depletive fluid strategy decreases the cumulative incidence of VAC and VAP.
Citation: Mekontso Dessap A, Katsahian S, Roche-Campo F, et al. Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management. Chest. 2014;146(1):58-65.
Visit our website for more physician reviews of HM-related research.
Clinical question: What is the benefit associated with a depletive fluid management strategy on ventilator-associated complication (VAC) and ventilator-associated pneumonia (VAP) during weaning from mechanical ventilation?
Background: VAP is common in the ICU. Pulmonary edema predisposes patients to pneumonia by altering the alveolar microenvironment through enhancement of bacterial colonization and infectivity and a decrease in host bactericidal capacities. A fluid management strategy aimed at lowering lung fluid balance may prove useful in reducing both VAC and VAP.
Study design: Randomized controlled trial.
Setting: Nine ICUs in Europe and South America, between May 2007 and July 2009.
Synopsis: Data from the B-type Natriuretic Peptide for the Management of Weaning (BMW) trial was used to compare the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid management group and the usual care group during the 14 days following randomization. The trial enrolled 304 randomized patients, 152 in each group.
Compared with usual care, the interventional strategy was associated with a higher proportion of patients receiving diuretics, in higher doses, resulting in a significantly more negative fluid balance during weaning and a shorter duration of mechanical ventilation. VAC (as defined by worsening oxygenation) occurred in 13.2% of patients during the 14 days following randomization: 17.8% in the usual care group and 8.6% in the interventional group. VAP occurred in 13.5% during the 14 days following randomization: 17.8% in the usual care group and 9.2% in the interventional group.
Bottom line: A biomarker-driven, depletive fluid strategy decreases the cumulative incidence of VAC and VAP.
Citation: Mekontso Dessap A, Katsahian S, Roche-Campo F, et al. Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management. Chest. 2014;146(1):58-65.
Visit our website for more physician reviews of HM-related research.
Antibiotic Therapy Guidelines for Pediatric Pneumonia Helpful, Not Hurtful
Hospitalists need not fear negative consequences when prescribing guideline-recommended antibiotic therapy for children hospitalized with community-acquired pneumonia (CAP), according to a recent study conducted at Cincinnati Children’s Hospital Medical Center (CCHMC).
"Guideline-recommended therapy for pediatric pneumonia did not result in different outcomes than nonrecommended [largely cephalosporin] therapy," lead author and CCHMC-based hospitalist Joanna Thomson MD, MPH, says in an email to The Hospitalist.
Published in the Journal of Hospital Medicine, the study followed the outcomes of 168 pediatric inpatients ages 3 months to 18 years who were prescribed empiric guideline-recommended therapy, which advises using an aminopenicillin first rather than a broad-spectrum antibiotic. The study focused on patients’ outcomes, specifically length of stay (LOS), total cost of hospitalization, and inpatient pharmacy costs, and found no difference in LOS or costs for patients treated according to guidelines compared with those whose treatment varied from the recommendations.
"Given growing concerns regarding antimicrobial resistance, it is pretty easy to extrapolate the benefits of using narrow-spectrum therapy, but we wanted to make sure that it wasn't resulting in negative unintended consequences," Dr. Thomson says. "Indeed, use of guideline-recommended therapy did not change our outcomes."
However, most patients hospitalized with CAP do not currently receive guideline-recommended therapy, according to Dr. Thomson. CCHMC had been one of those institutions overprescribing cephalosporin, with nearly 70% of children admitted with pneumonia receiving the antibiotic. That practice has since changed, she notes.
"The majority of hospitalized patients in the U.S. still receive broad-spectrum cephalosporins," Dr. Thomson says. "I suspect that this may partially be due to fears of unintended negative consequences. We should all be good stewards and prescribe guideline-recommended therapy whenever possible."
Visit our website for more information on antibiotic prescription practices.
Hospitalists need not fear negative consequences when prescribing guideline-recommended antibiotic therapy for children hospitalized with community-acquired pneumonia (CAP), according to a recent study conducted at Cincinnati Children’s Hospital Medical Center (CCHMC).
"Guideline-recommended therapy for pediatric pneumonia did not result in different outcomes than nonrecommended [largely cephalosporin] therapy," lead author and CCHMC-based hospitalist Joanna Thomson MD, MPH, says in an email to The Hospitalist.
Published in the Journal of Hospital Medicine, the study followed the outcomes of 168 pediatric inpatients ages 3 months to 18 years who were prescribed empiric guideline-recommended therapy, which advises using an aminopenicillin first rather than a broad-spectrum antibiotic. The study focused on patients’ outcomes, specifically length of stay (LOS), total cost of hospitalization, and inpatient pharmacy costs, and found no difference in LOS or costs for patients treated according to guidelines compared with those whose treatment varied from the recommendations.
"Given growing concerns regarding antimicrobial resistance, it is pretty easy to extrapolate the benefits of using narrow-spectrum therapy, but we wanted to make sure that it wasn't resulting in negative unintended consequences," Dr. Thomson says. "Indeed, use of guideline-recommended therapy did not change our outcomes."
However, most patients hospitalized with CAP do not currently receive guideline-recommended therapy, according to Dr. Thomson. CCHMC had been one of those institutions overprescribing cephalosporin, with nearly 70% of children admitted with pneumonia receiving the antibiotic. That practice has since changed, she notes.
"The majority of hospitalized patients in the U.S. still receive broad-spectrum cephalosporins," Dr. Thomson says. "I suspect that this may partially be due to fears of unintended negative consequences. We should all be good stewards and prescribe guideline-recommended therapy whenever possible."
Visit our website for more information on antibiotic prescription practices.
Hospitalists need not fear negative consequences when prescribing guideline-recommended antibiotic therapy for children hospitalized with community-acquired pneumonia (CAP), according to a recent study conducted at Cincinnati Children’s Hospital Medical Center (CCHMC).
"Guideline-recommended therapy for pediatric pneumonia did not result in different outcomes than nonrecommended [largely cephalosporin] therapy," lead author and CCHMC-based hospitalist Joanna Thomson MD, MPH, says in an email to The Hospitalist.
Published in the Journal of Hospital Medicine, the study followed the outcomes of 168 pediatric inpatients ages 3 months to 18 years who were prescribed empiric guideline-recommended therapy, which advises using an aminopenicillin first rather than a broad-spectrum antibiotic. The study focused on patients’ outcomes, specifically length of stay (LOS), total cost of hospitalization, and inpatient pharmacy costs, and found no difference in LOS or costs for patients treated according to guidelines compared with those whose treatment varied from the recommendations.
"Given growing concerns regarding antimicrobial resistance, it is pretty easy to extrapolate the benefits of using narrow-spectrum therapy, but we wanted to make sure that it wasn't resulting in negative unintended consequences," Dr. Thomson says. "Indeed, use of guideline-recommended therapy did not change our outcomes."
However, most patients hospitalized with CAP do not currently receive guideline-recommended therapy, according to Dr. Thomson. CCHMC had been one of those institutions overprescribing cephalosporin, with nearly 70% of children admitted with pneumonia receiving the antibiotic. That practice has since changed, she notes.
"The majority of hospitalized patients in the U.S. still receive broad-spectrum cephalosporins," Dr. Thomson says. "I suspect that this may partially be due to fears of unintended negative consequences. We should all be good stewards and prescribe guideline-recommended therapy whenever possible."
Visit our website for more information on antibiotic prescription practices.
Oncology, Surgical Hospitalists Most Common as Subspecialties Gain Followers
The recent rise of specialty hospitalists, particularly in the surgery and oncology fields, has benefitted hospitals and patients alike. Consider the growing ranks of oncology hospitalists, a small but quickly expanding HM specialty that has applied hospitalist principles to inpatient cancer and end-of-life care.
One such program at M.D. Anderson Cancer Center in Houston has attracted nine hospital-based physicians, four advanced-practice nurses, and two pharmacists since its launch in 2006. More doctors and nurse practitioners are being recruited, and the group is piloting an observation unit geared toward symptom management for an average of five oncology patients per day.
Although most inpatients cared for M.D. Anderson hospitalists are being treated for cancer, many have general medical needs, such as managing diabetes or high blood pressure, explains hospitalist Maria-Claudia Campagna, MD, FHM, assistant professor in the division of internal medicine at MD Anderson. Other patients, including those who don't yet have a confirmed cancer diagnosis, and family members of cancer patients may also be seen by the hospitalists. MD Anderson also has an established palliative-care service.
Increasingly, hospitals have employed specialty hospitalist teams, staffed by general oncologists or internal medicine hospitalists skilled at complex cancer care to care for inpatients with cancer, and the trend shows no signs of slowing.
Likewise, the practice of employing surgical hospitalists in non-trauma centers is gaining steam. Some non-trauma hospitals have reported improved patient outcomes and greater efficiency with surgical hospitalists.
A retrospective review of emergency surgical operations performed over five years at Sutter Medical Center, in Sacramento, Calif., found that an acute-care surgery model resulted in fewer overall complications, shorter lengths of stay, and lower hospital costs.
This approach by Surgical Affiliates Management Group, Inc. of Sacramento—the group contracted to perform the surgeries at SMC—combines elements of trauma, critical care, emergency surgical medicine, and elective general surgery, and it could be applied to emergency general surgeries at other hospitals that lack a trauma service without jeopardizing quality of care, the authors state.
Visit our website for more information on specialty hospitalist programs.
The recent rise of specialty hospitalists, particularly in the surgery and oncology fields, has benefitted hospitals and patients alike. Consider the growing ranks of oncology hospitalists, a small but quickly expanding HM specialty that has applied hospitalist principles to inpatient cancer and end-of-life care.
One such program at M.D. Anderson Cancer Center in Houston has attracted nine hospital-based physicians, four advanced-practice nurses, and two pharmacists since its launch in 2006. More doctors and nurse practitioners are being recruited, and the group is piloting an observation unit geared toward symptom management for an average of five oncology patients per day.
Although most inpatients cared for M.D. Anderson hospitalists are being treated for cancer, many have general medical needs, such as managing diabetes or high blood pressure, explains hospitalist Maria-Claudia Campagna, MD, FHM, assistant professor in the division of internal medicine at MD Anderson. Other patients, including those who don't yet have a confirmed cancer diagnosis, and family members of cancer patients may also be seen by the hospitalists. MD Anderson also has an established palliative-care service.
Increasingly, hospitals have employed specialty hospitalist teams, staffed by general oncologists or internal medicine hospitalists skilled at complex cancer care to care for inpatients with cancer, and the trend shows no signs of slowing.
Likewise, the practice of employing surgical hospitalists in non-trauma centers is gaining steam. Some non-trauma hospitals have reported improved patient outcomes and greater efficiency with surgical hospitalists.
A retrospective review of emergency surgical operations performed over five years at Sutter Medical Center, in Sacramento, Calif., found that an acute-care surgery model resulted in fewer overall complications, shorter lengths of stay, and lower hospital costs.
This approach by Surgical Affiliates Management Group, Inc. of Sacramento—the group contracted to perform the surgeries at SMC—combines elements of trauma, critical care, emergency surgical medicine, and elective general surgery, and it could be applied to emergency general surgeries at other hospitals that lack a trauma service without jeopardizing quality of care, the authors state.
Visit our website for more information on specialty hospitalist programs.
The recent rise of specialty hospitalists, particularly in the surgery and oncology fields, has benefitted hospitals and patients alike. Consider the growing ranks of oncology hospitalists, a small but quickly expanding HM specialty that has applied hospitalist principles to inpatient cancer and end-of-life care.
One such program at M.D. Anderson Cancer Center in Houston has attracted nine hospital-based physicians, four advanced-practice nurses, and two pharmacists since its launch in 2006. More doctors and nurse practitioners are being recruited, and the group is piloting an observation unit geared toward symptom management for an average of five oncology patients per day.
Although most inpatients cared for M.D. Anderson hospitalists are being treated for cancer, many have general medical needs, such as managing diabetes or high blood pressure, explains hospitalist Maria-Claudia Campagna, MD, FHM, assistant professor in the division of internal medicine at MD Anderson. Other patients, including those who don't yet have a confirmed cancer diagnosis, and family members of cancer patients may also be seen by the hospitalists. MD Anderson also has an established palliative-care service.
Increasingly, hospitals have employed specialty hospitalist teams, staffed by general oncologists or internal medicine hospitalists skilled at complex cancer care to care for inpatients with cancer, and the trend shows no signs of slowing.
Likewise, the practice of employing surgical hospitalists in non-trauma centers is gaining steam. Some non-trauma hospitals have reported improved patient outcomes and greater efficiency with surgical hospitalists.
A retrospective review of emergency surgical operations performed over five years at Sutter Medical Center, in Sacramento, Calif., found that an acute-care surgery model resulted in fewer overall complications, shorter lengths of stay, and lower hospital costs.
This approach by Surgical Affiliates Management Group, Inc. of Sacramento—the group contracted to perform the surgeries at SMC—combines elements of trauma, critical care, emergency surgical medicine, and elective general surgery, and it could be applied to emergency general surgeries at other hospitals that lack a trauma service without jeopardizing quality of care, the authors state.
Visit our website for more information on specialty hospitalist programs.
Hospitalist Management Giant Emerges as Sound Physicians, Cogent Healthcare Merge
Sound Physicians' recent acquisition of Cogent Healthcare creates the largest hospitalist management group in the country, which may or may not be a good thing, one hospitalist expert notes.
The deal, which closed last month, creates a company with more than 1,750 hospitalists in 180 hospitals nationwide. Reuters estimated the sale price at more than $375 million.
"We certainly don't care so much about biggest," says Robert Bessler, MD, chief executive officer of Sound Physicians, which will be the merged firms' name moving forward. "We're focused on trying to be the practice of choice for docs and provider of choice for hospitals—and really focus on performance as a business model to drive results."
John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants and regular columnist for The Hospitalist, says he believes the impact of the merger will vary by market.
"Hospitalists in competing groups could benefit, for example, by being seen as a more attractive alternative for candidates in the market to join a practice, and large companies may be able to invest in innovation that might benefit all of us," Dr. Nelson says in an email. "But for others, it may seem to make things worse, for example, by influencing the local market toward lower compensation or higher workload. It will be very market-dependent."
Dr. Bessler says he believes the merger "creates incredible synergy." For example, Cogent has The Intensivist Group, which operates full-service intensivist programs, and it can now potentially expand to hospitals where Sound hospitalists work.
Conversely, Sound’s post-acute-care program can be expanded to hospitals where Cogent has a presence.
Dr. Bessler understands that being the largest group can be seen as a good or a bad thing by industry watchers. "I think it leads to further innovation," he says. "It pools resources to do better things for hospital medicine, for hospitals, for patients, and for docs. And the reality is that even on a combined basis, we have less than 5% of the market. It's a massive market."
Visit our website for more information on mergers in hospital medicine.
Sound Physicians' recent acquisition of Cogent Healthcare creates the largest hospitalist management group in the country, which may or may not be a good thing, one hospitalist expert notes.
The deal, which closed last month, creates a company with more than 1,750 hospitalists in 180 hospitals nationwide. Reuters estimated the sale price at more than $375 million.
"We certainly don't care so much about biggest," says Robert Bessler, MD, chief executive officer of Sound Physicians, which will be the merged firms' name moving forward. "We're focused on trying to be the practice of choice for docs and provider of choice for hospitals—and really focus on performance as a business model to drive results."
John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants and regular columnist for The Hospitalist, says he believes the impact of the merger will vary by market.
"Hospitalists in competing groups could benefit, for example, by being seen as a more attractive alternative for candidates in the market to join a practice, and large companies may be able to invest in innovation that might benefit all of us," Dr. Nelson says in an email. "But for others, it may seem to make things worse, for example, by influencing the local market toward lower compensation or higher workload. It will be very market-dependent."
Dr. Bessler says he believes the merger "creates incredible synergy." For example, Cogent has The Intensivist Group, which operates full-service intensivist programs, and it can now potentially expand to hospitals where Sound hospitalists work.
Conversely, Sound’s post-acute-care program can be expanded to hospitals where Cogent has a presence.
Dr. Bessler understands that being the largest group can be seen as a good or a bad thing by industry watchers. "I think it leads to further innovation," he says. "It pools resources to do better things for hospital medicine, for hospitals, for patients, and for docs. And the reality is that even on a combined basis, we have less than 5% of the market. It's a massive market."
Visit our website for more information on mergers in hospital medicine.
Sound Physicians' recent acquisition of Cogent Healthcare creates the largest hospitalist management group in the country, which may or may not be a good thing, one hospitalist expert notes.
The deal, which closed last month, creates a company with more than 1,750 hospitalists in 180 hospitals nationwide. Reuters estimated the sale price at more than $375 million.
"We certainly don't care so much about biggest," says Robert Bessler, MD, chief executive officer of Sound Physicians, which will be the merged firms' name moving forward. "We're focused on trying to be the practice of choice for docs and provider of choice for hospitals—and really focus on performance as a business model to drive results."
John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants and regular columnist for The Hospitalist, says he believes the impact of the merger will vary by market.
"Hospitalists in competing groups could benefit, for example, by being seen as a more attractive alternative for candidates in the market to join a practice, and large companies may be able to invest in innovation that might benefit all of us," Dr. Nelson says in an email. "But for others, it may seem to make things worse, for example, by influencing the local market toward lower compensation or higher workload. It will be very market-dependent."
Dr. Bessler says he believes the merger "creates incredible synergy." For example, Cogent has The Intensivist Group, which operates full-service intensivist programs, and it can now potentially expand to hospitals where Sound hospitalists work.
Conversely, Sound’s post-acute-care program can be expanded to hospitals where Cogent has a presence.
Dr. Bessler understands that being the largest group can be seen as a good or a bad thing by industry watchers. "I think it leads to further innovation," he says. "It pools resources to do better things for hospital medicine, for hospitals, for patients, and for docs. And the reality is that even on a combined basis, we have less than 5% of the market. It's a massive market."
Visit our website for more information on mergers in hospital medicine.
Hospitalist Vivek Murthy, 37, Confirmed as U.S. Surgeon General
He has aged a year since President Obama nominated him for U.S. Surgeon General in November 2013, but on Monday Boston hospitalist Vivek Murthy, MD, was confirmed as the highest physician in America.
According to multiple sources, Dr. Murthy’s outspoken support for stricter gun laws and belief that guns are a public health issue delayed his confirmation due to opposition from the National Rifle Association (NRA), which in a letter to Senate leadership in February said Dr. Murthy’s confirmation would be a “prescription for disaster for America’s gun owners.”
Despite this, Senate Democrats approved his four-year appointment in a 51-43 vote that cut along party lines. In his confirmation hearing in February, Dr. Murthy said he does not “intend to use the surgeon general’s office as a bully pulpit for gun control.”
Dr. Murthy, 37, earned his medical and business degrees from Yale and for the last decade has worked as both an internist and a hospitalist at Brigham and Women’s Hospital in Boston. He is the youngest Surgeon General ever, and the first of Indian-American descent.
"On behalf of America's 44,000 hospitalists, I congratulate Dr. Murthy, a fellow hospitalist and one of our SHM members, on his historic appointment to U.S. Surgeon General," says Society of Hospital Medicine President Burke Kealey, MD, SFHM. "Being America’s doctor requires many of the same traits required of hospitalists: leadership, sharp clinical skills, and the ability to engage with patients. And, like hospitalists in thousands of hospitals across the country, I am confident Dr. Murthy will become an agent of change to improve delivery of care in our country."
In 2008, Dr. Murthy founded Doctors for Obama, a non-profit, grassroots organization of 16,000 physicians and medical students dedicated to transforming the healthcare system. After the election, he changed the name of the organization to Doctors for America. He also started the software company TrialNetworks in 2007 to aid in drug development, and, in 1995, he started an HIV and AIDS education non-profit in India called VISIONS Worldwide.
In a statement from the White House Monday, President Obama applauded the Senate for Dr. Murthy’s confirmation, saying: “Vivek’s confirmation makes us better positioned to save lives around the world and protect the American people here at home.”
Dr. Murthy replaces acting Surgeon General Boris Lushniak, who took over when Regina Benjamin resigned in July 2013. The surgeon general is the U.S.’ top spokesperson on all matters of public health and oversees the 6,700 members of the U.S. Public Health Service Commissioned Corps.
Kelly April Tyrrell is a freelance writer in Madison, Wis.
Information for this report was published online at cnn.com and usatoday.com.
He has aged a year since President Obama nominated him for U.S. Surgeon General in November 2013, but on Monday Boston hospitalist Vivek Murthy, MD, was confirmed as the highest physician in America.
According to multiple sources, Dr. Murthy’s outspoken support for stricter gun laws and belief that guns are a public health issue delayed his confirmation due to opposition from the National Rifle Association (NRA), which in a letter to Senate leadership in February said Dr. Murthy’s confirmation would be a “prescription for disaster for America’s gun owners.”
Despite this, Senate Democrats approved his four-year appointment in a 51-43 vote that cut along party lines. In his confirmation hearing in February, Dr. Murthy said he does not “intend to use the surgeon general’s office as a bully pulpit for gun control.”
Dr. Murthy, 37, earned his medical and business degrees from Yale and for the last decade has worked as both an internist and a hospitalist at Brigham and Women’s Hospital in Boston. He is the youngest Surgeon General ever, and the first of Indian-American descent.
"On behalf of America's 44,000 hospitalists, I congratulate Dr. Murthy, a fellow hospitalist and one of our SHM members, on his historic appointment to U.S. Surgeon General," says Society of Hospital Medicine President Burke Kealey, MD, SFHM. "Being America’s doctor requires many of the same traits required of hospitalists: leadership, sharp clinical skills, and the ability to engage with patients. And, like hospitalists in thousands of hospitals across the country, I am confident Dr. Murthy will become an agent of change to improve delivery of care in our country."
In 2008, Dr. Murthy founded Doctors for Obama, a non-profit, grassroots organization of 16,000 physicians and medical students dedicated to transforming the healthcare system. After the election, he changed the name of the organization to Doctors for America. He also started the software company TrialNetworks in 2007 to aid in drug development, and, in 1995, he started an HIV and AIDS education non-profit in India called VISIONS Worldwide.
In a statement from the White House Monday, President Obama applauded the Senate for Dr. Murthy’s confirmation, saying: “Vivek’s confirmation makes us better positioned to save lives around the world and protect the American people here at home.”
Dr. Murthy replaces acting Surgeon General Boris Lushniak, who took over when Regina Benjamin resigned in July 2013. The surgeon general is the U.S.’ top spokesperson on all matters of public health and oversees the 6,700 members of the U.S. Public Health Service Commissioned Corps.
Kelly April Tyrrell is a freelance writer in Madison, Wis.
Information for this report was published online at cnn.com and usatoday.com.
He has aged a year since President Obama nominated him for U.S. Surgeon General in November 2013, but on Monday Boston hospitalist Vivek Murthy, MD, was confirmed as the highest physician in America.
According to multiple sources, Dr. Murthy’s outspoken support for stricter gun laws and belief that guns are a public health issue delayed his confirmation due to opposition from the National Rifle Association (NRA), which in a letter to Senate leadership in February said Dr. Murthy’s confirmation would be a “prescription for disaster for America’s gun owners.”
Despite this, Senate Democrats approved his four-year appointment in a 51-43 vote that cut along party lines. In his confirmation hearing in February, Dr. Murthy said he does not “intend to use the surgeon general’s office as a bully pulpit for gun control.”
Dr. Murthy, 37, earned his medical and business degrees from Yale and for the last decade has worked as both an internist and a hospitalist at Brigham and Women’s Hospital in Boston. He is the youngest Surgeon General ever, and the first of Indian-American descent.
"On behalf of America's 44,000 hospitalists, I congratulate Dr. Murthy, a fellow hospitalist and one of our SHM members, on his historic appointment to U.S. Surgeon General," says Society of Hospital Medicine President Burke Kealey, MD, SFHM. "Being America’s doctor requires many of the same traits required of hospitalists: leadership, sharp clinical skills, and the ability to engage with patients. And, like hospitalists in thousands of hospitals across the country, I am confident Dr. Murthy will become an agent of change to improve delivery of care in our country."
In 2008, Dr. Murthy founded Doctors for Obama, a non-profit, grassroots organization of 16,000 physicians and medical students dedicated to transforming the healthcare system. After the election, he changed the name of the organization to Doctors for America. He also started the software company TrialNetworks in 2007 to aid in drug development, and, in 1995, he started an HIV and AIDS education non-profit in India called VISIONS Worldwide.
In a statement from the White House Monday, President Obama applauded the Senate for Dr. Murthy’s confirmation, saying: “Vivek’s confirmation makes us better positioned to save lives around the world and protect the American people here at home.”
Dr. Murthy replaces acting Surgeon General Boris Lushniak, who took over when Regina Benjamin resigned in July 2013. The surgeon general is the U.S.’ top spokesperson on all matters of public health and oversees the 6,700 members of the U.S. Public Health Service Commissioned Corps.
Kelly April Tyrrell is a freelance writer in Madison, Wis.
Information for this report was published online at cnn.com and usatoday.com.
No Survival Benefit With Early Goal-Directed Therapy for Septic Shock
For patients presenting with early septic shock, does early goal-directed therapy reduce mortality?
Bottom line
As compared with usual resuscitation care, early goal-directed therapy (EGDT) using central venous monitoring does not improve mortality in patients presenting to the emergency department with septic shock.
Reference
Study design
Randomized controlled trial (nonblinded); (LOE: 1b)
Setting
Inpatient (ICU only)
Synopsis
A recent trial showed that protocolized care using EGDT for the treatment of septic shock does not decrease mortality (N Engl J Med 2014;370:1683-1693). The current study supports these findings. Using concealed allocation, investigators randomized patients presenting to the emergency department with evidence of septic shock to either EGDT or usual care. For the EGDT group (n = 793), clinicians followed a 6-hour resuscitation protocol with central venous hemodynamic monitoring to guide the use of fluids, vasopressors, inotropes, and transfusions. For the usual care group (n = 798), care was at the discretion of the treating physicians, but central venous monitoring was not permitted during the 6-hour intervention. Analysis was by intention to treat and the 2 groups were similar at baseline. Additionally, adherence to the EGDT protocol was high and loss to follow-up was low. During the 6-hour resuscitation, patients in the EGDT group received a greater volume of intravenous fluids and were more likely to have received vasopressors (67% vs 58%), transfusions (14% vs 7%), or dobutamine (15% vs 3%). For the primary outcome of 90-day mortality, however, there was no significant difference detected between the 2 groups. Furthermore, there were no significant differences in the use of renal replacement therapy, in-hospital mortality, or length of hospital stay.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
For patients presenting with early septic shock, does early goal-directed therapy reduce mortality?
Bottom line
As compared with usual resuscitation care, early goal-directed therapy (EGDT) using central venous monitoring does not improve mortality in patients presenting to the emergency department with septic shock.
Reference
Study design
Randomized controlled trial (nonblinded); (LOE: 1b)
Setting
Inpatient (ICU only)
Synopsis
A recent trial showed that protocolized care using EGDT for the treatment of septic shock does not decrease mortality (N Engl J Med 2014;370:1683-1693). The current study supports these findings. Using concealed allocation, investigators randomized patients presenting to the emergency department with evidence of septic shock to either EGDT or usual care. For the EGDT group (n = 793), clinicians followed a 6-hour resuscitation protocol with central venous hemodynamic monitoring to guide the use of fluids, vasopressors, inotropes, and transfusions. For the usual care group (n = 798), care was at the discretion of the treating physicians, but central venous monitoring was not permitted during the 6-hour intervention. Analysis was by intention to treat and the 2 groups were similar at baseline. Additionally, adherence to the EGDT protocol was high and loss to follow-up was low. During the 6-hour resuscitation, patients in the EGDT group received a greater volume of intravenous fluids and were more likely to have received vasopressors (67% vs 58%), transfusions (14% vs 7%), or dobutamine (15% vs 3%). For the primary outcome of 90-day mortality, however, there was no significant difference detected between the 2 groups. Furthermore, there were no significant differences in the use of renal replacement therapy, in-hospital mortality, or length of hospital stay.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
For patients presenting with early septic shock, does early goal-directed therapy reduce mortality?
Bottom line
As compared with usual resuscitation care, early goal-directed therapy (EGDT) using central venous monitoring does not improve mortality in patients presenting to the emergency department with septic shock.
Reference
Study design
Randomized controlled trial (nonblinded); (LOE: 1b)
Setting
Inpatient (ICU only)
Synopsis
A recent trial showed that protocolized care using EGDT for the treatment of septic shock does not decrease mortality (N Engl J Med 2014;370:1683-1693). The current study supports these findings. Using concealed allocation, investigators randomized patients presenting to the emergency department with evidence of septic shock to either EGDT or usual care. For the EGDT group (n = 793), clinicians followed a 6-hour resuscitation protocol with central venous hemodynamic monitoring to guide the use of fluids, vasopressors, inotropes, and transfusions. For the usual care group (n = 798), care was at the discretion of the treating physicians, but central venous monitoring was not permitted during the 6-hour intervention. Analysis was by intention to treat and the 2 groups were similar at baseline. Additionally, adherence to the EGDT protocol was high and loss to follow-up was low. During the 6-hour resuscitation, patients in the EGDT group received a greater volume of intravenous fluids and were more likely to have received vasopressors (67% vs 58%), transfusions (14% vs 7%), or dobutamine (15% vs 3%). For the primary outcome of 90-day mortality, however, there was no significant difference detected between the 2 groups. Furthermore, there were no significant differences in the use of renal replacement therapy, in-hospital mortality, or length of hospital stay.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
