HM18

This morning’s “Primary Palliative Care – What Every Hospitalist Should Know” is an introductory session on primary palliative care to help define the concept, illustrate the problem, and help troubleshoot barriers to practicing high-quality primary palliative care, according to Brett Hendel-Paterson, MD, FHM, a hospitalist at Region’s Hospital in St. Paul, Minn. and a presenter for this session.

Dr. Hendel-Paterson, Jeffrey L. Greenwald, MD, SFHM, of Massachusetts General Hospital, Boston, and Jeffrey Frank, MD, MBA, of Vituity, will each present on the topic of administering palliative care as a hospitalist and why it is important for hospitalists to better understand this area of medicine.

A common misunderstanding about palliative care is that it is end-of-life care only, a misconception within both the medical and patient community. Most people believe that palliative care is associated with the “angel of death,” as Dr. Greenwald stated. Palliative care does encompass end-of-life care but is also associated with life-limiting illness. Both areas of palliative can be improved with better patient communication and symptom management.

As frontline providers at times of critical illness, and throughout illness, hospitalists are ideally positioned to provide palliative care services, Dr. Greenwald stated during an interview.

With hospitalists in such a prominent role in providing palliative care, Dr. Hendel-Paterson offered a detailed explanation about why the information from this session is important for hospitalists.

“The majority of Americans who die in this country die in hospitals. We see and we know that patients sometimes get more aggressive care leading to greater suffering in their final days,” he said. “As hospitalists, we are expected to be the primary physicians in the hospital caring for patients with a variety of health conditions. We are expected to have a basic expertise and be able to independently manage health conditions. For example, we are expected to be able to diagnose and treat pneumonia without consulting infectious disease or pulmonology specialists for basic care. In the same way, we must be able to communicate well with our patients and families and help lead them through discussions of prognosis and advance care planning. Primary palliative care refers to the skill set that includes communications about serious illness and basic symptom management.”

Dr. Greenwald expanded on Dr. Hendel-Paterson’s point concerning the growing need for hospitalists who are competent in palliative care.

“As the population ages, this issue is going to become more and more important for our field, because there isn’t a sufficient pipeline, current state – or predicted future state – of palliative care providers in hospitals to meet the need. So there’s a gap in the need, and that need is increasing.”

Primary Palliative Care – What Every Hospitalist Should Know
Wednesday, 10:00-10:40 a.m.
Crystal Ballroom J1

This morning’s “Primary Palliative Care – What Every Hospitalist Should Know” is an introductory session on primary palliative care to help define the concept, illustrate the problem, and help troubleshoot barriers to practicing high-quality primary palliative care, according to Brett Hendel-Paterson, MD, FHM, a hospitalist at Region’s Hospital in St. Paul, Minn. and a presenter for this session.

Dr. Hendel-Paterson, Jeffrey L. Greenwald, MD, SFHM, of Massachusetts General Hospital, Boston, and Jeffrey Frank, MD, MBA, of Vituity, will each present on the topic of administering palliative care as a hospitalist and why it is important for hospitalists to better understand this area of medicine.

A common misunderstanding about palliative care is that it is end-of-life care only, a misconception within both the medical and patient community. Most people believe that palliative care is associated with the “angel of death,” as Dr. Greenwald stated. Palliative care does encompass end-of-life care but is also associated with life-limiting illness. Both areas of palliative can be improved with better patient communication and symptom management.

As frontline providers at times of critical illness, and throughout illness, hospitalists are ideally positioned to provide palliative care services, Dr. Greenwald stated during an interview.

With hospitalists in such a prominent role in providing palliative care, Dr. Hendel-Paterson offered a detailed explanation about why the information from this session is important for hospitalists.

“The majority of Americans who die in this country die in hospitals. We see and we know that patients sometimes get more aggressive care leading to greater suffering in their final days,” he said. “As hospitalists, we are expected to be the primary physicians in the hospital caring for patients with a variety of health conditions. We are expected to have a basic expertise and be able to independently manage health conditions. For example, we are expected to be able to diagnose and treat pneumonia without consulting infectious disease or pulmonology specialists for basic care. In the same way, we must be able to communicate well with our patients and families and help lead them through discussions of prognosis and advance care planning. Primary palliative care refers to the skill set that includes communications about serious illness and basic symptom management.”

Dr. Greenwald expanded on Dr. Hendel-Paterson’s point concerning the growing need for hospitalists who are competent in palliative care.

“As the population ages, this issue is going to become more and more important for our field, because there isn’t a sufficient pipeline, current state – or predicted future state – of palliative care providers in hospitals to meet the need. So there’s a gap in the need, and that need is increasing.”

Primary Palliative Care – What Every Hospitalist Should Know
Wednesday, 10:00-10:40 a.m.
Crystal Ballroom J1

This morning’s “Primary Palliative Care – What Every Hospitalist Should Know” is an introductory session on primary palliative care to help define the concept, illustrate the problem, and help troubleshoot barriers to practicing high-quality primary palliative care, according to Brett Hendel-Paterson, MD, FHM, a hospitalist at Region’s Hospital in St. Paul, Minn. and a presenter for this session.

Dr. Hendel-Paterson, Jeffrey L. Greenwald, MD, SFHM, of Massachusetts General Hospital, Boston, and Jeffrey Frank, MD, MBA, of Vituity, will each present on the topic of administering palliative care as a hospitalist and why it is important for hospitalists to better understand this area of medicine.

A common misunderstanding about palliative care is that it is end-of-life care only, a misconception within both the medical and patient community. Most people believe that palliative care is associated with the “angel of death,” as Dr. Greenwald stated. Palliative care does encompass end-of-life care but is also associated with life-limiting illness. Both areas of palliative can be improved with better patient communication and symptom management.

As frontline providers at times of critical illness, and throughout illness, hospitalists are ideally positioned to provide palliative care services, Dr. Greenwald stated during an interview.

With hospitalists in such a prominent role in providing palliative care, Dr. Hendel-Paterson offered a detailed explanation about why the information from this session is important for hospitalists.

“The majority of Americans who die in this country die in hospitals. We see and we know that patients sometimes get more aggressive care leading to greater suffering in their final days,” he said. “As hospitalists, we are expected to be the primary physicians in the hospital caring for patients with a variety of health conditions. We are expected to have a basic expertise and be able to independently manage health conditions. For example, we are expected to be able to diagnose and treat pneumonia without consulting infectious disease or pulmonology specialists for basic care. In the same way, we must be able to communicate well with our patients and families and help lead them through discussions of prognosis and advance care planning. Primary palliative care refers to the skill set that includes communications about serious illness and basic symptom management.”

Dr. Greenwald expanded on Dr. Hendel-Paterson’s point concerning the growing need for hospitalists who are competent in palliative care.

“As the population ages, this issue is going to become more and more important for our field, because there isn’t a sufficient pipeline, current state – or predicted future state – of palliative care providers in hospitals to meet the need. So there’s a gap in the need, and that need is increasing.”

Primary Palliative Care – What Every Hospitalist Should Know
Wednesday, 10:00-10:40 a.m.
Crystal Ballroom J1

Measuring and analyzing data is essential for any quality improvement project. Data can validate whether an anecdotal assumption indicates the need for a quality improvement initiative and can help showcase the success of any intervention.

At today’s session, “Using Data to Inform Quality Improvement,” attendees will learn how to develop balanced metrics for quality improvement projects, understand distinctions between quality improvement and traditional research projects, and identify how different measures of the same data can tell vastly different stories.

The session will be divided into three 20-minute sections. Ethan Kuperman, MD, MSc, FHM, clinical assistant professor, University of Iowa Health Care, Iowa City, will begin by discussing how to develop balanced metrics by exploring a venous thromboembolism prophylaxis quality improvement project.

Next, Aparna Kamath, MD, MS, SFHM, assistant professor and academic hospitalist, Duke University Health System, Durham, N.C., will demonstrate the distinction between quality improvement and research by exploring medication reconciliation. “I will also emphasize the need for feasibility and rigor in data gathering and analysis in addition to accuracy when doing a quality improvement project,” she said. “Our workshop will make these tasks less daunting for hospitalists doing quality improvement projects.”

Finally, Justin Glasgow, MD, PhD, inpatient medicine faculty and Value Institute senior clinical scholar, Christiana Care Health System, Newark, Del., will explore how improper data definitions led to differing interpretations while developing and deploying an early warning system. “Attendees will learn how to design a quality improvement project to ensure that they measure interventions in a manner that ensures they have had true success, while not creating any unintended consequences,” Dr. Glasgow said.

“The session is important as it will help attendees develop successful projects that their colleagues will respect and that their bosses will admire,” added Dr. Glasgow. “They will gain confidence to turn their experience into distributable scholarship.”

“Hospitalists at all stages of their careers can benefit from this presentation,” Dr. Kuperman said. “Whether you’re preparing for your first quality improvement project or getting ready for a systemwide redesign, collecting the wrong data or misusing collected data can ruin your results or lead you to the wrong conclusions.”

Using Data to Inform Quality Improvement
Wednesday, 8:40-9:40 a.m.
Crystal Ballroom G1/A&B

Measuring and analyzing data is essential for any quality improvement project. Data can validate whether an anecdotal assumption indicates the need for a quality improvement initiative and can help showcase the success of any intervention.

At today’s session, “Using Data to Inform Quality Improvement,” attendees will learn how to develop balanced metrics for quality improvement projects, understand distinctions between quality improvement and traditional research projects, and identify how different measures of the same data can tell vastly different stories.

The session will be divided into three 20-minute sections. Ethan Kuperman, MD, MSc, FHM, clinical assistant professor, University of Iowa Health Care, Iowa City, will begin by discussing how to develop balanced metrics by exploring a venous thromboembolism prophylaxis quality improvement project.

Next, Aparna Kamath, MD, MS, SFHM, assistant professor and academic hospitalist, Duke University Health System, Durham, N.C., will demonstrate the distinction between quality improvement and research by exploring medication reconciliation. “I will also emphasize the need for feasibility and rigor in data gathering and analysis in addition to accuracy when doing a quality improvement project,” she said. “Our workshop will make these tasks less daunting for hospitalists doing quality improvement projects.”

Finally, Justin Glasgow, MD, PhD, inpatient medicine faculty and Value Institute senior clinical scholar, Christiana Care Health System, Newark, Del., will explore how improper data definitions led to differing interpretations while developing and deploying an early warning system. “Attendees will learn how to design a quality improvement project to ensure that they measure interventions in a manner that ensures they have had true success, while not creating any unintended consequences,” Dr. Glasgow said.

“The session is important as it will help attendees develop successful projects that their colleagues will respect and that their bosses will admire,” added Dr. Glasgow. “They will gain confidence to turn their experience into distributable scholarship.”

“Hospitalists at all stages of their careers can benefit from this presentation,” Dr. Kuperman said. “Whether you’re preparing for your first quality improvement project or getting ready for a systemwide redesign, collecting the wrong data or misusing collected data can ruin your results or lead you to the wrong conclusions.”

Using Data to Inform Quality Improvement
Wednesday, 8:40-9:40 a.m.
Crystal Ballroom G1/A&B

Measuring and analyzing data is essential for any quality improvement project. Data can validate whether an anecdotal assumption indicates the need for a quality improvement initiative and can help showcase the success of any intervention.

At today’s session, “Using Data to Inform Quality Improvement,” attendees will learn how to develop balanced metrics for quality improvement projects, understand distinctions between quality improvement and traditional research projects, and identify how different measures of the same data can tell vastly different stories.

The session will be divided into three 20-minute sections. Ethan Kuperman, MD, MSc, FHM, clinical assistant professor, University of Iowa Health Care, Iowa City, will begin by discussing how to develop balanced metrics by exploring a venous thromboembolism prophylaxis quality improvement project.

Next, Aparna Kamath, MD, MS, SFHM, assistant professor and academic hospitalist, Duke University Health System, Durham, N.C., will demonstrate the distinction between quality improvement and research by exploring medication reconciliation. “I will also emphasize the need for feasibility and rigor in data gathering and analysis in addition to accuracy when doing a quality improvement project,” she said. “Our workshop will make these tasks less daunting for hospitalists doing quality improvement projects.”

Finally, Justin Glasgow, MD, PhD, inpatient medicine faculty and Value Institute senior clinical scholar, Christiana Care Health System, Newark, Del., will explore how improper data definitions led to differing interpretations while developing and deploying an early warning system. “Attendees will learn how to design a quality improvement project to ensure that they measure interventions in a manner that ensures they have had true success, while not creating any unintended consequences,” Dr. Glasgow said.

“The session is important as it will help attendees develop successful projects that their colleagues will respect and that their bosses will admire,” added Dr. Glasgow. “They will gain confidence to turn their experience into distributable scholarship.”

“Hospitalists at all stages of their careers can benefit from this presentation,” Dr. Kuperman said. “Whether you’re preparing for your first quality improvement project or getting ready for a systemwide redesign, collecting the wrong data or misusing collected data can ruin your results or lead you to the wrong conclusions.”

Using Data to Inform Quality Improvement
Wednesday, 8:40-9:40 a.m.
Crystal Ballroom G1/A&B

As has become tradition, Robert Wachter, MD, MHM, of the University of California, San Francisco, will close the conference today and will focus on the broader changes that must happen as the role of the hospitalist continues to evolve.

“I am going to talk about the changes in the world of hospital care and the importance of the field to innovate,” Dr. Wachter said. “To me, there are gravitational forces in the health care world that are making … patients who are in hospitals sicker than they were before. More and more patients are going to be cared for in outpatient settings and at home. We are going start to ... see things like sensors and telemedicine to enable more care outside of the hospital.”

Dr. Wachter said hospital medicine must evolve and mature to continue to prove that hospitalists are indispensable staff members within the hospital.

“That was why the field became the fastest-growing profession in medical history. We can’t sit on our laurels. We have to continue to innovate,” he said. “Even as the system changes around us, I am confident that we will innovate. My talk will be a pep talk and will include reflections on how the world of health care is changing and what those changes will mean to hospitalists.”

Dr. Wachter noted that the trend of steering patients who are less sick to the outpatient setting, as well as other economic factors, would change the nature of hospitalist practice.

“It will be more acuity, more intensity, more complex relationships with your own hospital and often with partner hospitals,” he said. “More of the work will be digitally enabled than it would have been 5 or 10 years ago.”

As has become tradition, Robert Wachter, MD, MHM, of the University of California, San Francisco, will close the conference today and will focus on the broader changes that must happen as the role of the hospitalist continues to evolve.

“I am going to talk about the changes in the world of hospital care and the importance of the field to innovate,” Dr. Wachter said. “To me, there are gravitational forces in the health care world that are making … patients who are in hospitals sicker than they were before. More and more patients are going to be cared for in outpatient settings and at home. We are going start to ... see things like sensors and telemedicine to enable more care outside of the hospital.”

Dr. Wachter said hospital medicine must evolve and mature to continue to prove that hospitalists are indispensable staff members within the hospital.

“That was why the field became the fastest-growing profession in medical history. We can’t sit on our laurels. We have to continue to innovate,” he said. “Even as the system changes around us, I am confident that we will innovate. My talk will be a pep talk and will include reflections on how the world of health care is changing and what those changes will mean to hospitalists.”

Dr. Wachter noted that the trend of steering patients who are less sick to the outpatient setting, as well as other economic factors, would change the nature of hospitalist practice.

“It will be more acuity, more intensity, more complex relationships with your own hospital and often with partner hospitals,” he said. “More of the work will be digitally enabled than it would have been 5 or 10 years ago.”

As has become tradition, Robert Wachter, MD, MHM, of the University of California, San Francisco, will close the conference today and will focus on the broader changes that must happen as the role of the hospitalist continues to evolve.

“I am going to talk about the changes in the world of hospital care and the importance of the field to innovate,” Dr. Wachter said. “To me, there are gravitational forces in the health care world that are making … patients who are in hospitals sicker than they were before. More and more patients are going to be cared for in outpatient settings and at home. We are going start to ... see things like sensors and telemedicine to enable more care outside of the hospital.”

Dr. Wachter said hospital medicine must evolve and mature to continue to prove that hospitalists are indispensable staff members within the hospital.

“That was why the field became the fastest-growing profession in medical history. We can’t sit on our laurels. We have to continue to innovate,” he said. “Even as the system changes around us, I am confident that we will innovate. My talk will be a pep talk and will include reflections on how the world of health care is changing and what those changes will mean to hospitalists.”

Dr. Wachter noted that the trend of steering patients who are less sick to the outpatient setting, as well as other economic factors, would change the nature of hospitalist practice.

“It will be more acuity, more intensity, more complex relationships with your own hospital and often with partner hospitals,” he said. “More of the work will be digitally enabled than it would have been 5 or 10 years ago.”

Many health care providers are guilty of having implicit or unconscious biases against patients, which can negatively affect the care they give. “Once providers come to this realization, they can make a conscious effort to neutralize these biases from manifesting throughout a practice,” said Aziz Ansari, DO, SFHM, associate chief medical officer, Clinical Optimization and Revenue Integrity, and associate professor of medicine, Loyola University Medical Center, Maywood, Ill., who will present today’s session “Winning Hearts and Minds at the Bedside: Battling Unconscious Bias Through Cultural Humility.”

By practicing cultural humility, hospitalists can gain trust from patients and their families, whom they do not know in their everyday practice. This encourages providers to be humble, ascertain what is important to the patient, and learn from every patient encounter.

The session will begin with a case study involving bias, followed by a self-reflection exercise. To determine whether you may be biased against some patient groups, Dr. Ansari recommends taking the online implicit association test at Implicit.harvard.edu.

As a palliative care specialist, Dr. Ansari has repeatedly faced situations in which a lack of cultural humility caused patients or their family member to foster mistrust toward a provider. Consequently, patients and family members may choose aggressive measures that providers might consider futile.

Dr. Ansari also will define what implicit or unconscious biases entail in greater detail. The discussion will then circle back to the original case and reveal how providers can improve their mindset when facing difficult situations by employing a tool called “The 5 Rs of Cultural Humility,” which include reflection, respect, regard, relevance, and resiliency.

Dr. Ansari spearheaded the development of the 5 Rs tool when he chaired the Cultural Humility Workgroup of SHM’s Practice Management Committee. “The goal is to use the tool to attain cultural humility and transform a potentially negative encounter into a gratifying one,” he said.

At a minimum, attendees should take time during the session to reflect on their own thoughts and biases. “This introspection can bring to light practices that providers may have been unaware of and, ultimately, can change their behaviors so every patient and their family feels that they are being seen and heard,” Dr. Ansari said. “In today’s current climate it is more important than ever for providers to self-reflect on their attitudes and perceptions because an increasing number of groups in our diverse society are feeling more marginalized.”

Winning Hearts and Minds at the Bedside: Battling Unconscious Bias Through Cultural Humility
Wednesday, 9:10-9:50 a.m.
​Crystal Ballroom G2/C-F

Many health care providers are guilty of having implicit or unconscious biases against patients, which can negatively affect the care they give. “Once providers come to this realization, they can make a conscious effort to neutralize these biases from manifesting throughout a practice,” said Aziz Ansari, DO, SFHM, associate chief medical officer, Clinical Optimization and Revenue Integrity, and associate professor of medicine, Loyola University Medical Center, Maywood, Ill., who will present today’s session “Winning Hearts and Minds at the Bedside: Battling Unconscious Bias Through Cultural Humility.”

By practicing cultural humility, hospitalists can gain trust from patients and their families, whom they do not know in their everyday practice. This encourages providers to be humble, ascertain what is important to the patient, and learn from every patient encounter.

The session will begin with a case study involving bias, followed by a self-reflection exercise. To determine whether you may be biased against some patient groups, Dr. Ansari recommends taking the online implicit association test at Implicit.harvard.edu.

As a palliative care specialist, Dr. Ansari has repeatedly faced situations in which a lack of cultural humility caused patients or their family member to foster mistrust toward a provider. Consequently, patients and family members may choose aggressive measures that providers might consider futile.

Dr. Ansari also will define what implicit or unconscious biases entail in greater detail. The discussion will then circle back to the original case and reveal how providers can improve their mindset when facing difficult situations by employing a tool called “The 5 Rs of Cultural Humility,” which include reflection, respect, regard, relevance, and resiliency.

Dr. Ansari spearheaded the development of the 5 Rs tool when he chaired the Cultural Humility Workgroup of SHM’s Practice Management Committee. “The goal is to use the tool to attain cultural humility and transform a potentially negative encounter into a gratifying one,” he said.

At a minimum, attendees should take time during the session to reflect on their own thoughts and biases. “This introspection can bring to light practices that providers may have been unaware of and, ultimately, can change their behaviors so every patient and their family feels that they are being seen and heard,” Dr. Ansari said. “In today’s current climate it is more important than ever for providers to self-reflect on their attitudes and perceptions because an increasing number of groups in our diverse society are feeling more marginalized.”

Winning Hearts and Minds at the Bedside: Battling Unconscious Bias Through Cultural Humility
Wednesday, 9:10-9:50 a.m.
​Crystal Ballroom G2/C-F

Many health care providers are guilty of having implicit or unconscious biases against patients, which can negatively affect the care they give. “Once providers come to this realization, they can make a conscious effort to neutralize these biases from manifesting throughout a practice,” said Aziz Ansari, DO, SFHM, associate chief medical officer, Clinical Optimization and Revenue Integrity, and associate professor of medicine, Loyola University Medical Center, Maywood, Ill., who will present today’s session “Winning Hearts and Minds at the Bedside: Battling Unconscious Bias Through Cultural Humility.”

By practicing cultural humility, hospitalists can gain trust from patients and their families, whom they do not know in their everyday practice. This encourages providers to be humble, ascertain what is important to the patient, and learn from every patient encounter.

The session will begin with a case study involving bias, followed by a self-reflection exercise. To determine whether you may be biased against some patient groups, Dr. Ansari recommends taking the online implicit association test at Implicit.harvard.edu.

As a palliative care specialist, Dr. Ansari has repeatedly faced situations in which a lack of cultural humility caused patients or their family member to foster mistrust toward a provider. Consequently, patients and family members may choose aggressive measures that providers might consider futile.

Dr. Ansari also will define what implicit or unconscious biases entail in greater detail. The discussion will then circle back to the original case and reveal how providers can improve their mindset when facing difficult situations by employing a tool called “The 5 Rs of Cultural Humility,” which include reflection, respect, regard, relevance, and resiliency.

Dr. Ansari spearheaded the development of the 5 Rs tool when he chaired the Cultural Humility Workgroup of SHM’s Practice Management Committee. “The goal is to use the tool to attain cultural humility and transform a potentially negative encounter into a gratifying one,” he said.

At a minimum, attendees should take time during the session to reflect on their own thoughts and biases. “This introspection can bring to light practices that providers may have been unaware of and, ultimately, can change their behaviors so every patient and their family feels that they are being seen and heard,” Dr. Ansari said. “In today’s current climate it is more important than ever for providers to self-reflect on their attitudes and perceptions because an increasing number of groups in our diverse society are feeling more marginalized.”

Winning Hearts and Minds at the Bedside: Battling Unconscious Bias Through Cultural Humility
Wednesday, 9:10-9:50 a.m.
​Crystal Ballroom G2/C-F

As the field of hospital medicine continues to grow, it is experiencing more requests for assistance with pre- and posthospital care. These increasing demands will be the focus of today’s session “Addressing the Expanding Scope of Practice in Hospital Medicine.”

“As hospital medicine continues to advance, we are being asked to help hospitals and health care systems with challenges that extend beyond the hospital,” presenter Nick Fitterman, MD, SFHM, vice chair of hospital medicine of Northwell Health in Long Island, N.Y., explained in an interview. “Sometimes, this is a natural extension of hospital medicine; other times, it may reflect gaps in primary care or the health care system in general. Hospital medicine can be supportive, but our course must be deliberate and not extend beyond our scope of practice.

“The health care system is facing a variety of challenges, which, in turn, make an impact on hospital medicine,” stated Dr. Fitterman. “Factors that result in increased demands on the field include lack of access to posthospitalization care, high-acuity patients in subacute rehabilitation, rising health care costs, and value-based payments that include ‘bundles’ of care stretching beyond hospitalization. Finally, the nation has a population that’s aging,” he continued, “thanks to the ‘silver tsunami’ of baby boomers.”

The session will include presentations by leaders in the fields of post-acute clinics and hospitals at home. Lauren Doctoroff, MD, FHM, of Beth Israel Deaconess Medical Center in Boston will discuss post-acute care clinics; David Levine, MD, of Brigham and Women’s Hospital and Harvard Medical School, both in Boston, will cover some hospital-at-home developments; and Efren Manjarrez, MD, SFHM, of the University of Miami Health System will speak about preoperative care. Dr. Fitterman will provide examples of the expanded scope of practice issues that can arise in a large health care system.

“There are a finite number of beds in any given hospital and extending our reach into pre- or posthospitalization care is an avenue to expand our book of business, cultivate new skills, and engage patients and colleagues in new settings,” Dr. Fitterman explained. “Done with a clear vision and plan and within our scope of practice, this can be quite rewarding. Executed only to meet a demand but without proper resources, this can pose a new challenge and become frustrating.”

“HM18 participants who attend the session will receive some insights into what works and what doesn’t work regarding extrahospital care for hospital medicine,” continued Dr. Fitterman. “And we hope it will help hospital medicine practitioners and groups as they determine where to focus their efforts.”

Addressing the Expanding Scope of Practice in Hospital Medicine
Wednesday, 7:30-8:30 a.m.
​Grand Ballroom 7B

As the field of hospital medicine continues to grow, it is experiencing more requests for assistance with pre- and posthospital care. These increasing demands will be the focus of today’s session “Addressing the Expanding Scope of Practice in Hospital Medicine.”

“As hospital medicine continues to advance, we are being asked to help hospitals and health care systems with challenges that extend beyond the hospital,” presenter Nick Fitterman, MD, SFHM, vice chair of hospital medicine of Northwell Health in Long Island, N.Y., explained in an interview. “Sometimes, this is a natural extension of hospital medicine; other times, it may reflect gaps in primary care or the health care system in general. Hospital medicine can be supportive, but our course must be deliberate and not extend beyond our scope of practice.

“The health care system is facing a variety of challenges, which, in turn, make an impact on hospital medicine,” stated Dr. Fitterman. “Factors that result in increased demands on the field include lack of access to posthospitalization care, high-acuity patients in subacute rehabilitation, rising health care costs, and value-based payments that include ‘bundles’ of care stretching beyond hospitalization. Finally, the nation has a population that’s aging,” he continued, “thanks to the ‘silver tsunami’ of baby boomers.”

The session will include presentations by leaders in the fields of post-acute clinics and hospitals at home. Lauren Doctoroff, MD, FHM, of Beth Israel Deaconess Medical Center in Boston will discuss post-acute care clinics; David Levine, MD, of Brigham and Women’s Hospital and Harvard Medical School, both in Boston, will cover some hospital-at-home developments; and Efren Manjarrez, MD, SFHM, of the University of Miami Health System will speak about preoperative care. Dr. Fitterman will provide examples of the expanded scope of practice issues that can arise in a large health care system.

“There are a finite number of beds in any given hospital and extending our reach into pre- or posthospitalization care is an avenue to expand our book of business, cultivate new skills, and engage patients and colleagues in new settings,” Dr. Fitterman explained. “Done with a clear vision and plan and within our scope of practice, this can be quite rewarding. Executed only to meet a demand but without proper resources, this can pose a new challenge and become frustrating.”

“HM18 participants who attend the session will receive some insights into what works and what doesn’t work regarding extrahospital care for hospital medicine,” continued Dr. Fitterman. “And we hope it will help hospital medicine practitioners and groups as they determine where to focus their efforts.”

Addressing the Expanding Scope of Practice in Hospital Medicine
Wednesday, 7:30-8:30 a.m.
​Grand Ballroom 7B

As the field of hospital medicine continues to grow, it is experiencing more requests for assistance with pre- and posthospital care. These increasing demands will be the focus of today’s session “Addressing the Expanding Scope of Practice in Hospital Medicine.”

“As hospital medicine continues to advance, we are being asked to help hospitals and health care systems with challenges that extend beyond the hospital,” presenter Nick Fitterman, MD, SFHM, vice chair of hospital medicine of Northwell Health in Long Island, N.Y., explained in an interview. “Sometimes, this is a natural extension of hospital medicine; other times, it may reflect gaps in primary care or the health care system in general. Hospital medicine can be supportive, but our course must be deliberate and not extend beyond our scope of practice.

“The health care system is facing a variety of challenges, which, in turn, make an impact on hospital medicine,” stated Dr. Fitterman. “Factors that result in increased demands on the field include lack of access to posthospitalization care, high-acuity patients in subacute rehabilitation, rising health care costs, and value-based payments that include ‘bundles’ of care stretching beyond hospitalization. Finally, the nation has a population that’s aging,” he continued, “thanks to the ‘silver tsunami’ of baby boomers.”

The session will include presentations by leaders in the fields of post-acute clinics and hospitals at home. Lauren Doctoroff, MD, FHM, of Beth Israel Deaconess Medical Center in Boston will discuss post-acute care clinics; David Levine, MD, of Brigham and Women’s Hospital and Harvard Medical School, both in Boston, will cover some hospital-at-home developments; and Efren Manjarrez, MD, SFHM, of the University of Miami Health System will speak about preoperative care. Dr. Fitterman will provide examples of the expanded scope of practice issues that can arise in a large health care system.

“There are a finite number of beds in any given hospital and extending our reach into pre- or posthospitalization care is an avenue to expand our book of business, cultivate new skills, and engage patients and colleagues in new settings,” Dr. Fitterman explained. “Done with a clear vision and plan and within our scope of practice, this can be quite rewarding. Executed only to meet a demand but without proper resources, this can pose a new challenge and become frustrating.”

“HM18 participants who attend the session will receive some insights into what works and what doesn’t work regarding extrahospital care for hospital medicine,” continued Dr. Fitterman. “And we hope it will help hospital medicine practitioners and groups as they determine where to focus their efforts.”

Addressing the Expanding Scope of Practice in Hospital Medicine
Wednesday, 7:30-8:30 a.m.
​Grand Ballroom 7B

What an amazing 3 days! As we spoke on the first day, delivering higher value of care has been a highlight of this annual conference. With thought-provoking sessions from Kate Goodrich, MD, MHS, on payment reform; Eric Howell, MD, on “Value is NOT a 4-Letter Word”; and Lenny Feldman, MD, SFHM, on “Things We Do for No Reason,” hospital medicine’s focus on value is clear. I hope you also had the chance to attend the sessions on clinical topics of medicine, education, and practice management.

The final day of the conference is no exception when it comes to topics with impact. Starting off at 7:30 a.m., there is a diverse group of sessions on clinical medicine for adults and pediatrics, including “Peter Pan Grows Up: How to Care for Your Patients with Chronic Pediatric Conditions,” topics in health policy, how to advance in academic medicine with a focus on writing a winning abstract, and applying what you have learned at HM18 back home.

This day also offers sessions on advancement with topics for mid-career hospitalists and those aspiring to leadership roles. Promotion in academic medicine also will be addressed.

You can further strengthen your presentation skills in sessions that will teach you how to create valuable teaching points on the fly and deliver memorable lectures and talks. Other sessions will enhance your skills in emotional intelligence.

As always, we are extremely fortunate to wrap up the day with Bob Wachter, MD, MHM, who is sure to deliver a thought-provoking and entertaining presentation entitled “Hospitalists as Drivers of Innovation and System Change: Are We Doing Enough?”

As you wrap up your final day, I wish you a safe journey back home. Please continue your engagement with the Society through chapter meetings in your area, signing up for committees and interest groups, and dropping us a line – we look forward to continuing to work for you in the coming year.
 

Dr. Afsar is the incoming president of the Society of Hospital Medicine and the chief ambulatory officer & CMO for ACOs at UC Irvine Health in Orange, Calif.

What an amazing 3 days! As we spoke on the first day, delivering higher value of care has been a highlight of this annual conference. With thought-provoking sessions from Kate Goodrich, MD, MHS, on payment reform; Eric Howell, MD, on “Value is NOT a 4-Letter Word”; and Lenny Feldman, MD, SFHM, on “Things We Do for No Reason,” hospital medicine’s focus on value is clear. I hope you also had the chance to attend the sessions on clinical topics of medicine, education, and practice management.

The final day of the conference is no exception when it comes to topics with impact. Starting off at 7:30 a.m., there is a diverse group of sessions on clinical medicine for adults and pediatrics, including “Peter Pan Grows Up: How to Care for Your Patients with Chronic Pediatric Conditions,” topics in health policy, how to advance in academic medicine with a focus on writing a winning abstract, and applying what you have learned at HM18 back home.

This day also offers sessions on advancement with topics for mid-career hospitalists and those aspiring to leadership roles. Promotion in academic medicine also will be addressed.

You can further strengthen your presentation skills in sessions that will teach you how to create valuable teaching points on the fly and deliver memorable lectures and talks. Other sessions will enhance your skills in emotional intelligence.

As always, we are extremely fortunate to wrap up the day with Bob Wachter, MD, MHM, who is sure to deliver a thought-provoking and entertaining presentation entitled “Hospitalists as Drivers of Innovation and System Change: Are We Doing Enough?”

As you wrap up your final day, I wish you a safe journey back home. Please continue your engagement with the Society through chapter meetings in your area, signing up for committees and interest groups, and dropping us a line – we look forward to continuing to work for you in the coming year.
 

Dr. Afsar is the incoming president of the Society of Hospital Medicine and the chief ambulatory officer & CMO for ACOs at UC Irvine Health in Orange, Calif.

What an amazing 3 days! As we spoke on the first day, delivering higher value of care has been a highlight of this annual conference. With thought-provoking sessions from Kate Goodrich, MD, MHS, on payment reform; Eric Howell, MD, on “Value is NOT a 4-Letter Word”; and Lenny Feldman, MD, SFHM, on “Things We Do for No Reason,” hospital medicine’s focus on value is clear. I hope you also had the chance to attend the sessions on clinical topics of medicine, education, and practice management.

The final day of the conference is no exception when it comes to topics with impact. Starting off at 7:30 a.m., there is a diverse group of sessions on clinical medicine for adults and pediatrics, including “Peter Pan Grows Up: How to Care for Your Patients with Chronic Pediatric Conditions,” topics in health policy, how to advance in academic medicine with a focus on writing a winning abstract, and applying what you have learned at HM18 back home.

This day also offers sessions on advancement with topics for mid-career hospitalists and those aspiring to leadership roles. Promotion in academic medicine also will be addressed.

You can further strengthen your presentation skills in sessions that will teach you how to create valuable teaching points on the fly and deliver memorable lectures and talks. Other sessions will enhance your skills in emotional intelligence.

As always, we are extremely fortunate to wrap up the day with Bob Wachter, MD, MHM, who is sure to deliver a thought-provoking and entertaining presentation entitled “Hospitalists as Drivers of Innovation and System Change: Are We Doing Enough?”

As you wrap up your final day, I wish you a safe journey back home. Please continue your engagement with the Society through chapter meetings in your area, signing up for committees and interest groups, and dropping us a line – we look forward to continuing to work for you in the coming year.
 

Dr. Afsar is the incoming president of the Society of Hospital Medicine and the chief ambulatory officer & CMO for ACOs at UC Irvine Health in Orange, Calif.

ORLANDO – In a video interview, Ms. Tiffani Panek, SFHM, CLHM, who is the division manager of administration at the Johns Hopkins Bayview Medical Center, Baltimore, discussed the scope of SHM resources available for practice administrators.

She details how there are “an incredible number of resources for practice administrators that are available from SHM,” and she recommends the SHM website’s practice administrator’s page, with helpful links, including to their mentorship program. She describes how, just this year, “we are launching a podcast series called ‘The Leadership Launchpad Essentials.’ ”

In addition: “We [also] have our own HMX [Hospital Medicine Exchange] community, and I would say of any resource the practice administrator should access on a regular basis, that would be the one.” That’s the place that practice managers can go to network with their community, according to Ms. Panek.
 

ORLANDO – In a video interview, Ms. Tiffani Panek, SFHM, CLHM, who is the division manager of administration at the Johns Hopkins Bayview Medical Center, Baltimore, discussed the scope of SHM resources available for practice administrators.

She details how there are “an incredible number of resources for practice administrators that are available from SHM,” and she recommends the SHM website’s practice administrator’s page, with helpful links, including to their mentorship program. She describes how, just this year, “we are launching a podcast series called ‘The Leadership Launchpad Essentials.’ ”

In addition: “We [also] have our own HMX [Hospital Medicine Exchange] community, and I would say of any resource the practice administrator should access on a regular basis, that would be the one.” That’s the place that practice managers can go to network with their community, according to Ms. Panek.
 

ORLANDO – In a video interview, Ms. Tiffani Panek, SFHM, CLHM, who is the division manager of administration at the Johns Hopkins Bayview Medical Center, Baltimore, discussed the scope of SHM resources available for practice administrators.

She details how there are “an incredible number of resources for practice administrators that are available from SHM,” and she recommends the SHM website’s practice administrator’s page, with helpful links, including to their mentorship program. She describes how, just this year, “we are launching a podcast series called ‘The Leadership Launchpad Essentials.’ ”

In addition: “We [also] have our own HMX [Hospital Medicine Exchange] community, and I would say of any resource the practice administrator should access on a regular basis, that would be the one.” That’s the place that practice managers can go to network with their community, according to Ms. Panek.
 

ORLANDO – If you think enough progress is being made to fix gender disparity in medical leadership, consider this observation made in an HM18 session on Tuesday by speaker Elizabeth Harry, MD, SFHM, assistant program director, internal medicine residency: director of wellness,  Brigham and Women’s Hospital, Boston.*

“One might say, ‘Well, that’s okay, we’ll just let it even itself out. I mean, it’s getting better and we’re getting more women positions of leadership,’ ” she said. “But if we continue at the current rate that we are at, of women getting positions of leadership, we will get gender parity in leadership in 67 years – so the year 2085 ... I’m hoping that we as a group can say, ‘That’s a little too slow for our taste. We would like to accelerate this process a little bit.’ ”

The jarring number came near the start of the “Gender Disparities in Hospital Medicine: Where Do We Stand?” session, in which Dr. Harry explored the ways in which gender disparity manifests itself and coaxed ideas for improvement from the audience.

But that was just one of the jarring numbers. Even though women make up 78% of the health care workforce, only 14% of executive officers are women, Dr. Harry said.

And it’s not that large numbers of women joining the physician workforce is a relatively recent phenomenon. There is close to a 50/50 gender split in medical school applicants, students, and residents. But, after that, the parity falls away. Only 38% of medical school faculty members are women, only 21% of full professors are women, and only 16% of deans (Pediatr Res. 2015 Nov;78[5]:589-93).

“There’s definitely a leaky pipeline here,” Dr. Harry said.

She highlighted the ways in which gender disparity seems to be baked into medical education, research, and culture. One study found that women used professional titles 95% of the time when introducing men at internal medicine grand rounds, compared with 49% when men were introducing women (J Womens Health 2017 May;26[5]:413-9).

In hospital medicine, a 2015 study found that women make $14,000 a year less than men, and about $30,000 less in pediatrics. (J Hosp Med. 2015 Aug;10[8]:486-90).

Dr. Harry told the audience to think about the gender disparity problem in a structured way, similar to a design process, by defining the problem, thinking of ideas, developing prototypes to put those ideas into action, and testing them.

During this session, audience members made some suggestions to simplify some of life’s logistics: creating rooms in which physicians could nurse their babies, with a phone and a laptop to make use of the room more practical; building flexible schedules to allow for picking up children and running errands; and – Dr. Harry’s favorite – installing an Amazon locker at hospitals that would allow doctors to pick up packages and make returns.

One audience member asked why the tenor of the conversation seemed to involve an implicit acceptance that it was up to women to handle errands, wondering, “Why are we anchoring on to that?” Dr. Harry agreed that it is up to each household to decide how to divide those responsibilities, and that, personally, she and her husband divide them evenly.

“So what I want to encourage you to do is actually take one of these prototypes home and try it – and it’s not going to work the first time,” Dr. Harry said. “This is culture change, and culture change is really, really hard. That means it takes time and means you’ll have to knock on lots of doors to get to where you want to be eventually.”

Correction, 4/11/18: An earlier version of this article misstated Dr. Harry's position at Brigham and Women's.

ORLANDO – If you think enough progress is being made to fix gender disparity in medical leadership, consider this observation made in an HM18 session on Tuesday by speaker Elizabeth Harry, MD, SFHM, assistant program director, internal medicine residency: director of wellness,  Brigham and Women’s Hospital, Boston.*

“One might say, ‘Well, that’s okay, we’ll just let it even itself out. I mean, it’s getting better and we’re getting more women positions of leadership,’ ” she said. “But if we continue at the current rate that we are at, of women getting positions of leadership, we will get gender parity in leadership in 67 years – so the year 2085 ... I’m hoping that we as a group can say, ‘That’s a little too slow for our taste. We would like to accelerate this process a little bit.’ ”

The jarring number came near the start of the “Gender Disparities in Hospital Medicine: Where Do We Stand?” session, in which Dr. Harry explored the ways in which gender disparity manifests itself and coaxed ideas for improvement from the audience.

But that was just one of the jarring numbers. Even though women make up 78% of the health care workforce, only 14% of executive officers are women, Dr. Harry said.

And it’s not that large numbers of women joining the physician workforce is a relatively recent phenomenon. There is close to a 50/50 gender split in medical school applicants, students, and residents. But, after that, the parity falls away. Only 38% of medical school faculty members are women, only 21% of full professors are women, and only 16% of deans (Pediatr Res. 2015 Nov;78[5]:589-93).

“There’s definitely a leaky pipeline here,” Dr. Harry said.

She highlighted the ways in which gender disparity seems to be baked into medical education, research, and culture. One study found that women used professional titles 95% of the time when introducing men at internal medicine grand rounds, compared with 49% when men were introducing women (J Womens Health 2017 May;26[5]:413-9).

In hospital medicine, a 2015 study found that women make $14,000 a year less than men, and about $30,000 less in pediatrics. (J Hosp Med. 2015 Aug;10[8]:486-90).

Dr. Harry told the audience to think about the gender disparity problem in a structured way, similar to a design process, by defining the problem, thinking of ideas, developing prototypes to put those ideas into action, and testing them.

During this session, audience members made some suggestions to simplify some of life’s logistics: creating rooms in which physicians could nurse their babies, with a phone and a laptop to make use of the room more practical; building flexible schedules to allow for picking up children and running errands; and – Dr. Harry’s favorite – installing an Amazon locker at hospitals that would allow doctors to pick up packages and make returns.

One audience member asked why the tenor of the conversation seemed to involve an implicit acceptance that it was up to women to handle errands, wondering, “Why are we anchoring on to that?” Dr. Harry agreed that it is up to each household to decide how to divide those responsibilities, and that, personally, she and her husband divide them evenly.

“So what I want to encourage you to do is actually take one of these prototypes home and try it – and it’s not going to work the first time,” Dr. Harry said. “This is culture change, and culture change is really, really hard. That means it takes time and means you’ll have to knock on lots of doors to get to where you want to be eventually.”

Correction, 4/11/18: An earlier version of this article misstated Dr. Harry's position at Brigham and Women's.

ORLANDO – If you think enough progress is being made to fix gender disparity in medical leadership, consider this observation made in an HM18 session on Tuesday by speaker Elizabeth Harry, MD, SFHM, assistant program director, internal medicine residency: director of wellness,  Brigham and Women’s Hospital, Boston.*

“One might say, ‘Well, that’s okay, we’ll just let it even itself out. I mean, it’s getting better and we’re getting more women positions of leadership,’ ” she said. “But if we continue at the current rate that we are at, of women getting positions of leadership, we will get gender parity in leadership in 67 years – so the year 2085 ... I’m hoping that we as a group can say, ‘That’s a little too slow for our taste. We would like to accelerate this process a little bit.’ ”

The jarring number came near the start of the “Gender Disparities in Hospital Medicine: Where Do We Stand?” session, in which Dr. Harry explored the ways in which gender disparity manifests itself and coaxed ideas for improvement from the audience.

But that was just one of the jarring numbers. Even though women make up 78% of the health care workforce, only 14% of executive officers are women, Dr. Harry said.

And it’s not that large numbers of women joining the physician workforce is a relatively recent phenomenon. There is close to a 50/50 gender split in medical school applicants, students, and residents. But, after that, the parity falls away. Only 38% of medical school faculty members are women, only 21% of full professors are women, and only 16% of deans (Pediatr Res. 2015 Nov;78[5]:589-93).

“There’s definitely a leaky pipeline here,” Dr. Harry said.

She highlighted the ways in which gender disparity seems to be baked into medical education, research, and culture. One study found that women used professional titles 95% of the time when introducing men at internal medicine grand rounds, compared with 49% when men were introducing women (J Womens Health 2017 May;26[5]:413-9).

In hospital medicine, a 2015 study found that women make $14,000 a year less than men, and about $30,000 less in pediatrics. (J Hosp Med. 2015 Aug;10[8]:486-90).

Dr. Harry told the audience to think about the gender disparity problem in a structured way, similar to a design process, by defining the problem, thinking of ideas, developing prototypes to put those ideas into action, and testing them.

During this session, audience members made some suggestions to simplify some of life’s logistics: creating rooms in which physicians could nurse their babies, with a phone and a laptop to make use of the room more practical; building flexible schedules to allow for picking up children and running errands; and – Dr. Harry’s favorite – installing an Amazon locker at hospitals that would allow doctors to pick up packages and make returns.

One audience member asked why the tenor of the conversation seemed to involve an implicit acceptance that it was up to women to handle errands, wondering, “Why are we anchoring on to that?” Dr. Harry agreed that it is up to each household to decide how to divide those responsibilities, and that, personally, she and her husband divide them evenly.

“So what I want to encourage you to do is actually take one of these prototypes home and try it – and it’s not going to work the first time,” Dr. Harry said. “This is culture change, and culture change is really, really hard. That means it takes time and means you’ll have to knock on lots of doors to get to where you want to be eventually.”

Correction, 4/11/18: An earlier version of this article misstated Dr. Harry's position at Brigham and Women's.

ORLANDO – Hospitalists in attendance at a Rapid Fire session at the Society of Hospital Medicine’s annual conference came away with updated information about stroke and intracranial hemorrhage, among the neurologic emergencies commonly seen in hospitalized patients.

Aaron Lord, MD, chief of neurocritical care at New York University Langone Health, provided hopeful news about thrombectomy for ischemic stroke and confirmed the importance of blood pressure management in intracranial hemorrhage in his review of several common neurologic emergencies.

Dr. Lord said that, for ischemic stroke, the evidence is now very good for mechanical thrombectomy, with newer data pointing to a prolonged treatment window for some patients.

Though IV tissue plasminogen activator (TPA) is the only Food and Drug Administration–approved pharmacologic treatment for acute stroke, said Dr. Lord, “It’s good, but it’s not perfect. It doesn’t necessarily target the clot or concentrate in it. ... The big kicker is that not all patients are candidates for IV TPA. They either present too late or have comorbidities.”

“Frustratingly, even for those who do present on time, TPA doesn’t work for everyone. This is especially true for large or long clots,” said Dr. Lord. In 2015, he said, a half-dozen trials examining mechanical thrombectomy for acute stroke were all positive, giving assurance to physicians and patients of this therapy’s efficacy within the 6-8 hour acute stroke window. Pooled analysis of the 2015 trials showed a number needed to treat (NNT) of 5 for regaining functional independence, and a NNT of 2.6 for decreased disability.

Further, he said, two additional trials have examined thrombectomy’s utility when patients have a large stroke penumbra, with a relatively small core infarct, using “tissue-based parameters rather than time” to select patients for thrombectomy. “These trials were just as positive as the initial trials,” said Dr. Lord; the trials showed NNTs of 2.9 and 3.6 for reduced disability in a population of patients who were 6-24 hours poststroke.

The takeaway for hospitalists? Even when it’s unknown how much time has passed since the onset of stroke symptoms, step No. 1 is still to activate the stroke team’s resources, giving patients the best hope for recovery. “We now have the luxury of treating patients up to 24 hours. This has revolutionized the way that we treat acute stroke,” said Dr. Lord.

For intracranial hemorrhage, the story is a little different. Here, “initial management focuses on preventing hematoma expansion,” said Dr. Lord.

After tending to airway, breathing, and circulation and activation of the stroke team, the managing clinician should turn to blood pressure management and reversal of any anticoagulation or antiplatelet therapy.

The medical literature gives some guidance about goal blood pressures, he said. Although all of the trials did not use the same parameters for “highest” or “lower” systolic blood pressures, the best data available point toward a systolic goal of about 140.

“Blood pressure treatment is still important,” said Dr. Lord. In larger hemorrhages or with hydrocephalus, he advised always at least considering placement of an intracranial pressure monitor.

If a patient is anticoagulated with a vitamin K antagonist, he said, the INCH trial showed that intracranial bleeds are best reversed by use of prothrombin complex concentration (PCC), rather than fresh frozen plasma (FFP). The trial, stopped early for safety, showed that the primary outcome of internationalized normal ratio of less than 1.2 by the 3-hour mark was reached by just 9% of the FFP group, compared with 67% of those who received PCC. Mortality was 35% for the FFP cohort, compared with 19% who received PCC.

Dr. Lord finds these data compelling. “When I ask my residents what the appropriate agent is for vitamin K reversal in acute ICH, and they answer FFP, I tell them, ‘That’s a great answer ... for 2012.’ ”

ORLANDO – Hospitalists in attendance at a Rapid Fire session at the Society of Hospital Medicine’s annual conference came away with updated information about stroke and intracranial hemorrhage, among the neurologic emergencies commonly seen in hospitalized patients.

Aaron Lord, MD, chief of neurocritical care at New York University Langone Health, provided hopeful news about thrombectomy for ischemic stroke and confirmed the importance of blood pressure management in intracranial hemorrhage in his review of several common neurologic emergencies.

Dr. Lord said that, for ischemic stroke, the evidence is now very good for mechanical thrombectomy, with newer data pointing to a prolonged treatment window for some patients.

Though IV tissue plasminogen activator (TPA) is the only Food and Drug Administration–approved pharmacologic treatment for acute stroke, said Dr. Lord, “It’s good, but it’s not perfect. It doesn’t necessarily target the clot or concentrate in it. ... The big kicker is that not all patients are candidates for IV TPA. They either present too late or have comorbidities.”

“Frustratingly, even for those who do present on time, TPA doesn’t work for everyone. This is especially true for large or long clots,” said Dr. Lord. In 2015, he said, a half-dozen trials examining mechanical thrombectomy for acute stroke were all positive, giving assurance to physicians and patients of this therapy’s efficacy within the 6-8 hour acute stroke window. Pooled analysis of the 2015 trials showed a number needed to treat (NNT) of 5 for regaining functional independence, and a NNT of 2.6 for decreased disability.

Further, he said, two additional trials have examined thrombectomy’s utility when patients have a large stroke penumbra, with a relatively small core infarct, using “tissue-based parameters rather than time” to select patients for thrombectomy. “These trials were just as positive as the initial trials,” said Dr. Lord; the trials showed NNTs of 2.9 and 3.6 for reduced disability in a population of patients who were 6-24 hours poststroke.

The takeaway for hospitalists? Even when it’s unknown how much time has passed since the onset of stroke symptoms, step No. 1 is still to activate the stroke team’s resources, giving patients the best hope for recovery. “We now have the luxury of treating patients up to 24 hours. This has revolutionized the way that we treat acute stroke,” said Dr. Lord.

For intracranial hemorrhage, the story is a little different. Here, “initial management focuses on preventing hematoma expansion,” said Dr. Lord.

After tending to airway, breathing, and circulation and activation of the stroke team, the managing clinician should turn to blood pressure management and reversal of any anticoagulation or antiplatelet therapy.

The medical literature gives some guidance about goal blood pressures, he said. Although all of the trials did not use the same parameters for “highest” or “lower” systolic blood pressures, the best data available point toward a systolic goal of about 140.

“Blood pressure treatment is still important,” said Dr. Lord. In larger hemorrhages or with hydrocephalus, he advised always at least considering placement of an intracranial pressure monitor.

If a patient is anticoagulated with a vitamin K antagonist, he said, the INCH trial showed that intracranial bleeds are best reversed by use of prothrombin complex concentration (PCC), rather than fresh frozen plasma (FFP). The trial, stopped early for safety, showed that the primary outcome of internationalized normal ratio of less than 1.2 by the 3-hour mark was reached by just 9% of the FFP group, compared with 67% of those who received PCC. Mortality was 35% for the FFP cohort, compared with 19% who received PCC.

Dr. Lord finds these data compelling. “When I ask my residents what the appropriate agent is for vitamin K reversal in acute ICH, and they answer FFP, I tell them, ‘That’s a great answer ... for 2012.’ ”

ORLANDO – Hospitalists in attendance at a Rapid Fire session at the Society of Hospital Medicine’s annual conference came away with updated information about stroke and intracranial hemorrhage, among the neurologic emergencies commonly seen in hospitalized patients.

Aaron Lord, MD, chief of neurocritical care at New York University Langone Health, provided hopeful news about thrombectomy for ischemic stroke and confirmed the importance of blood pressure management in intracranial hemorrhage in his review of several common neurologic emergencies.

Dr. Lord said that, for ischemic stroke, the evidence is now very good for mechanical thrombectomy, with newer data pointing to a prolonged treatment window for some patients.

Though IV tissue plasminogen activator (TPA) is the only Food and Drug Administration–approved pharmacologic treatment for acute stroke, said Dr. Lord, “It’s good, but it’s not perfect. It doesn’t necessarily target the clot or concentrate in it. ... The big kicker is that not all patients are candidates for IV TPA. They either present too late or have comorbidities.”

“Frustratingly, even for those who do present on time, TPA doesn’t work for everyone. This is especially true for large or long clots,” said Dr. Lord. In 2015, he said, a half-dozen trials examining mechanical thrombectomy for acute stroke were all positive, giving assurance to physicians and patients of this therapy’s efficacy within the 6-8 hour acute stroke window. Pooled analysis of the 2015 trials showed a number needed to treat (NNT) of 5 for regaining functional independence, and a NNT of 2.6 for decreased disability.

Further, he said, two additional trials have examined thrombectomy’s utility when patients have a large stroke penumbra, with a relatively small core infarct, using “tissue-based parameters rather than time” to select patients for thrombectomy. “These trials were just as positive as the initial trials,” said Dr. Lord; the trials showed NNTs of 2.9 and 3.6 for reduced disability in a population of patients who were 6-24 hours poststroke.

The takeaway for hospitalists? Even when it’s unknown how much time has passed since the onset of stroke symptoms, step No. 1 is still to activate the stroke team’s resources, giving patients the best hope for recovery. “We now have the luxury of treating patients up to 24 hours. This has revolutionized the way that we treat acute stroke,” said Dr. Lord.

For intracranial hemorrhage, the story is a little different. Here, “initial management focuses on preventing hematoma expansion,” said Dr. Lord.

After tending to airway, breathing, and circulation and activation of the stroke team, the managing clinician should turn to blood pressure management and reversal of any anticoagulation or antiplatelet therapy.

The medical literature gives some guidance about goal blood pressures, he said. Although all of the trials did not use the same parameters for “highest” or “lower” systolic blood pressures, the best data available point toward a systolic goal of about 140.

“Blood pressure treatment is still important,” said Dr. Lord. In larger hemorrhages or with hydrocephalus, he advised always at least considering placement of an intracranial pressure monitor.

If a patient is anticoagulated with a vitamin K antagonist, he said, the INCH trial showed that intracranial bleeds are best reversed by use of prothrombin complex concentration (PCC), rather than fresh frozen plasma (FFP). The trial, stopped early for safety, showed that the primary outcome of internationalized normal ratio of less than 1.2 by the 3-hour mark was reached by just 9% of the FFP group, compared with 67% of those who received PCC. Mortality was 35% for the FFP cohort, compared with 19% who received PCC.

Dr. Lord finds these data compelling. “When I ask my residents what the appropriate agent is for vitamin K reversal in acute ICH, and they answer FFP, I tell them, ‘That’s a great answer ... for 2012.’ ”