User login
Is COVID-19 accelerating progress toward high-value care?
As Rachna Rawal, MD, was donning her personal protective equipment (PPE), a process that has become deeply ingrained into her muscle memory, a nurse approached her to ask, “Hey, for Mr. Smith, any chance we can time these labs to be done together with his medication administration? We’ve been in and out of that room a few times already.”
As someone who embraces high-value care, this simple suggestion surprised her. What an easy strategy to minimize room entry with full PPE, lab testing, and patient interruptions. That same day, someone else asked, “Do we need overnight vitals?”
COVID-19 has forced hospitalists to reconsider almost every aspect of care. It feels like every decision we make including things we do routinely – labs, vital signs, imaging – needs to be reassessed to determine the actual benefit to the patient balanced against concerns about staff safety, dwindling PPE supplies, and medication reserves. We are all faced with frequently answering the question, “How will this intervention help the patient?” This question lies at the heart of delivering high-value care.
High-value care is providing the best care possible through efficient use of resources, achieving optimal results for each patient. While high-value care has become a prominent focus over the past decade, COVID-19’s high transmissibility without a cure – and associated scarcity of health care resources – have sparked additional discussions on the front lines about promoting patient outcomes while avoiding waste. Clinicians may not have realized that these were high-value care conversations.
The United States’ health care quality and cost crises, worsened in the face of the current pandemic, have been glaringly apparent for years. Our country is spending more money on health care than anywhere else in the world without desired improvements in patient outcomes. A 2019 JAMA study found that 25% of all health care spending, an estimated $760 to $935 billion, is considered waste, and a significant proportion of this waste is due to repetitive care, overuse and unnecessary care in the U.S.1
Examples of low-value care tests include ordering daily labs in stable medicine inpatients, routine urine electrolytes in acute kidney injury, and folate testing in anemia. The Choosing Wisely® national campaign, Journal of Hospital Medicine’s “Things We Do For No Reason,” and JAMA Internal Medicine’s “Teachable Moment” series have provided guidance on areas where common testing or interventions may not benefit patient outcomes.
The COVID-19 pandemic has raised questions related to other widely-utilized practices: Can medication times be readjusted to allow only one entry into the room? Will these labs or imaging studies actually change management? Are vital checks every 4 hours needed?
Why did it take the COVID-19 threat to our medical system to force many of us to have these discussions? Despite prior efforts to integrate high-value care into hospital practices, long-standing habits and deep-seeded culture are challenging to overcome. Once clinicians develop practice habits, these behaviors tend to persist throughout their careers.2 In many ways, COVID-19 was like hitting a “reset button” as health care professionals were forced to rapidly confront their deeply-ingrained hospital practices and habits. From new protocols for patient rounding to universal masking and social distancing to ground-breaking strategies like awake proning, the response to COVID-19 has represented an unprecedented rapid shift in practice. Previously, consequences of overuse were too downstream or too abstract for clinicians to see in real-time. However, now the ramifications of these choices hit closer to home with obvious potential consequences – like spreading a terrifying virus.
There are three interventions that hospitalists should consider implementing immediately in the COVID-19 era that accelerate us toward high-value care. Routine lab tests, imaging, and overnight vitals represent opportunities to provide patient-centered care while also remaining cognizant of resource utilization.
One area in hospital medicine that has proven challenging to significantly change practice has been routine daily labs. Patients on a general medical inpatient service who are clinically stable generally do not benefit from routine lab work.3 Avoiding these tests does not increase mortality or length of stay in clinically stable patients.3 However, despite this evidence, many patients with COVID-19 and other conditions experience lab draws that are not timed together and are done each morning out of “routine.” Choosing Wisely® recommendations from the Society of Hospital Medicine encourage clinicians to question routine lab work for COVID-19 patients and to consider batching them, if possible.3,4 In COVID-19 patients, the risks of not batching tests are magnified, both in terms of the patient-centered experience and for clinician safety. In essence, COVID-19 has pushed us to consider the elements of safety, PPE conservation and other factors, rather than making decisions based solely on their own comfort, convenience, or historical practice.
Clinicians are also reconsidering the necessity of imaging during the pandemic. The “Things We Do For No Reason” article on “Choosing Wisely® in the COVID-19 era” highlights this well.4 It is more important now than ever to decide whether the timing and type of imaging will change management for your patient. Questions to ask include: Can a portable x-ray be used to avoid patient travel and will that CT scan help your patient? A posterior-anterior/lateral x-ray can potentially provide more information depending on the clinical scenario. However, we now need to assess if that extra information is going to impact patient management. Downstream consequences of these decisions include not only risks to the patient but also infectious exposures for staff and others during patient travel.
Lastly, overnight vital sign checks are another intervention we should analyze through this high-value care lens. The Journal of Hospital Medicine released a “Things We Do For No Reason” article about minimizing overnight vitals to promote uninterrupted sleep at night.5 Deleterious effects of interrupting the sleep of our patients include delirium and patient dissatisfaction.5 Studies have shown the benefits of this approach, yet the shift away from routine overnight vitals has not yet widely occurred.
COVID-19 has pressed us to save PPE and minimize exposure risk; hence, some centers are coordinating the timing of vitals with medication administration times, when feasible. In the stable patient recovering from COVID-19, overnight vitals may not be necessary, particularly if remote monitoring is available. This accomplishes multiple goals: Providing high quality patient care, reducing resource utilization, and minimizing patient nighttime interruptions – all culminating in high-value care.
Even though the COVID-19 pandemic has brought unforeseen emotional, physical, and financial challenges for the health care system and its workers, there may be a silver lining. The pandemic has sparked high-value care discussions, and the urgency of the crisis may be instilling new practices in our daily work. This virus has indeed left a terrible wake of destruction, but may also be a nudge to permanently change our culture of overuse to help us shape the habits of all trainees during this tumultuous time. This experience will hopefully culminate in a culture in which clinicians routinely ask, “How will this intervention help the patient?”
Dr. Rawal is clinical assistant professor of medicine, University of Pittsburgh. Dr. Linker is assistant professor of medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York. Dr. Moriates is associate professor of internal medicine, Dell Medical School at the University of Texas at Austin.
References
1. Shrank W et al. Waste in The US healthcare system. JAMA. 2019;322(15):1501-9.
2. Chen C et al. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA. 2014;312(22):2385-93.
3. Eaton KP et al. Evidence-based guidelines to eliminate repetitive laboratory testing. JAMA Intern Med. 2017;177(12):1833-9.
4. Cho H et al. Choosing Wisely in the COVID-19 Era: Preventing harm to healthcare workers. J Hosp Med. 2020;15(6):360-2.
5. Orlov N and Arora V. Things we do for no reason: Routine overnight vital sign checks. J Hosp Med. 2020;15(5):272-27.
As Rachna Rawal, MD, was donning her personal protective equipment (PPE), a process that has become deeply ingrained into her muscle memory, a nurse approached her to ask, “Hey, for Mr. Smith, any chance we can time these labs to be done together with his medication administration? We’ve been in and out of that room a few times already.”
As someone who embraces high-value care, this simple suggestion surprised her. What an easy strategy to minimize room entry with full PPE, lab testing, and patient interruptions. That same day, someone else asked, “Do we need overnight vitals?”
COVID-19 has forced hospitalists to reconsider almost every aspect of care. It feels like every decision we make including things we do routinely – labs, vital signs, imaging – needs to be reassessed to determine the actual benefit to the patient balanced against concerns about staff safety, dwindling PPE supplies, and medication reserves. We are all faced with frequently answering the question, “How will this intervention help the patient?” This question lies at the heart of delivering high-value care.
High-value care is providing the best care possible through efficient use of resources, achieving optimal results for each patient. While high-value care has become a prominent focus over the past decade, COVID-19’s high transmissibility without a cure – and associated scarcity of health care resources – have sparked additional discussions on the front lines about promoting patient outcomes while avoiding waste. Clinicians may not have realized that these were high-value care conversations.
The United States’ health care quality and cost crises, worsened in the face of the current pandemic, have been glaringly apparent for years. Our country is spending more money on health care than anywhere else in the world without desired improvements in patient outcomes. A 2019 JAMA study found that 25% of all health care spending, an estimated $760 to $935 billion, is considered waste, and a significant proportion of this waste is due to repetitive care, overuse and unnecessary care in the U.S.1
Examples of low-value care tests include ordering daily labs in stable medicine inpatients, routine urine electrolytes in acute kidney injury, and folate testing in anemia. The Choosing Wisely® national campaign, Journal of Hospital Medicine’s “Things We Do For No Reason,” and JAMA Internal Medicine’s “Teachable Moment” series have provided guidance on areas where common testing or interventions may not benefit patient outcomes.
The COVID-19 pandemic has raised questions related to other widely-utilized practices: Can medication times be readjusted to allow only one entry into the room? Will these labs or imaging studies actually change management? Are vital checks every 4 hours needed?
Why did it take the COVID-19 threat to our medical system to force many of us to have these discussions? Despite prior efforts to integrate high-value care into hospital practices, long-standing habits and deep-seeded culture are challenging to overcome. Once clinicians develop practice habits, these behaviors tend to persist throughout their careers.2 In many ways, COVID-19 was like hitting a “reset button” as health care professionals were forced to rapidly confront their deeply-ingrained hospital practices and habits. From new protocols for patient rounding to universal masking and social distancing to ground-breaking strategies like awake proning, the response to COVID-19 has represented an unprecedented rapid shift in practice. Previously, consequences of overuse were too downstream or too abstract for clinicians to see in real-time. However, now the ramifications of these choices hit closer to home with obvious potential consequences – like spreading a terrifying virus.
There are three interventions that hospitalists should consider implementing immediately in the COVID-19 era that accelerate us toward high-value care. Routine lab tests, imaging, and overnight vitals represent opportunities to provide patient-centered care while also remaining cognizant of resource utilization.
One area in hospital medicine that has proven challenging to significantly change practice has been routine daily labs. Patients on a general medical inpatient service who are clinically stable generally do not benefit from routine lab work.3 Avoiding these tests does not increase mortality or length of stay in clinically stable patients.3 However, despite this evidence, many patients with COVID-19 and other conditions experience lab draws that are not timed together and are done each morning out of “routine.” Choosing Wisely® recommendations from the Society of Hospital Medicine encourage clinicians to question routine lab work for COVID-19 patients and to consider batching them, if possible.3,4 In COVID-19 patients, the risks of not batching tests are magnified, both in terms of the patient-centered experience and for clinician safety. In essence, COVID-19 has pushed us to consider the elements of safety, PPE conservation and other factors, rather than making decisions based solely on their own comfort, convenience, or historical practice.
Clinicians are also reconsidering the necessity of imaging during the pandemic. The “Things We Do For No Reason” article on “Choosing Wisely® in the COVID-19 era” highlights this well.4 It is more important now than ever to decide whether the timing and type of imaging will change management for your patient. Questions to ask include: Can a portable x-ray be used to avoid patient travel and will that CT scan help your patient? A posterior-anterior/lateral x-ray can potentially provide more information depending on the clinical scenario. However, we now need to assess if that extra information is going to impact patient management. Downstream consequences of these decisions include not only risks to the patient but also infectious exposures for staff and others during patient travel.
Lastly, overnight vital sign checks are another intervention we should analyze through this high-value care lens. The Journal of Hospital Medicine released a “Things We Do For No Reason” article about minimizing overnight vitals to promote uninterrupted sleep at night.5 Deleterious effects of interrupting the sleep of our patients include delirium and patient dissatisfaction.5 Studies have shown the benefits of this approach, yet the shift away from routine overnight vitals has not yet widely occurred.
COVID-19 has pressed us to save PPE and minimize exposure risk; hence, some centers are coordinating the timing of vitals with medication administration times, when feasible. In the stable patient recovering from COVID-19, overnight vitals may not be necessary, particularly if remote monitoring is available. This accomplishes multiple goals: Providing high quality patient care, reducing resource utilization, and minimizing patient nighttime interruptions – all culminating in high-value care.
Even though the COVID-19 pandemic has brought unforeseen emotional, physical, and financial challenges for the health care system and its workers, there may be a silver lining. The pandemic has sparked high-value care discussions, and the urgency of the crisis may be instilling new practices in our daily work. This virus has indeed left a terrible wake of destruction, but may also be a nudge to permanently change our culture of overuse to help us shape the habits of all trainees during this tumultuous time. This experience will hopefully culminate in a culture in which clinicians routinely ask, “How will this intervention help the patient?”
Dr. Rawal is clinical assistant professor of medicine, University of Pittsburgh. Dr. Linker is assistant professor of medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York. Dr. Moriates is associate professor of internal medicine, Dell Medical School at the University of Texas at Austin.
References
1. Shrank W et al. Waste in The US healthcare system. JAMA. 2019;322(15):1501-9.
2. Chen C et al. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA. 2014;312(22):2385-93.
3. Eaton KP et al. Evidence-based guidelines to eliminate repetitive laboratory testing. JAMA Intern Med. 2017;177(12):1833-9.
4. Cho H et al. Choosing Wisely in the COVID-19 Era: Preventing harm to healthcare workers. J Hosp Med. 2020;15(6):360-2.
5. Orlov N and Arora V. Things we do for no reason: Routine overnight vital sign checks. J Hosp Med. 2020;15(5):272-27.
As Rachna Rawal, MD, was donning her personal protective equipment (PPE), a process that has become deeply ingrained into her muscle memory, a nurse approached her to ask, “Hey, for Mr. Smith, any chance we can time these labs to be done together with his medication administration? We’ve been in and out of that room a few times already.”
As someone who embraces high-value care, this simple suggestion surprised her. What an easy strategy to minimize room entry with full PPE, lab testing, and patient interruptions. That same day, someone else asked, “Do we need overnight vitals?”
COVID-19 has forced hospitalists to reconsider almost every aspect of care. It feels like every decision we make including things we do routinely – labs, vital signs, imaging – needs to be reassessed to determine the actual benefit to the patient balanced against concerns about staff safety, dwindling PPE supplies, and medication reserves. We are all faced with frequently answering the question, “How will this intervention help the patient?” This question lies at the heart of delivering high-value care.
High-value care is providing the best care possible through efficient use of resources, achieving optimal results for each patient. While high-value care has become a prominent focus over the past decade, COVID-19’s high transmissibility without a cure – and associated scarcity of health care resources – have sparked additional discussions on the front lines about promoting patient outcomes while avoiding waste. Clinicians may not have realized that these were high-value care conversations.
The United States’ health care quality and cost crises, worsened in the face of the current pandemic, have been glaringly apparent for years. Our country is spending more money on health care than anywhere else in the world without desired improvements in patient outcomes. A 2019 JAMA study found that 25% of all health care spending, an estimated $760 to $935 billion, is considered waste, and a significant proportion of this waste is due to repetitive care, overuse and unnecessary care in the U.S.1
Examples of low-value care tests include ordering daily labs in stable medicine inpatients, routine urine electrolytes in acute kidney injury, and folate testing in anemia. The Choosing Wisely® national campaign, Journal of Hospital Medicine’s “Things We Do For No Reason,” and JAMA Internal Medicine’s “Teachable Moment” series have provided guidance on areas where common testing or interventions may not benefit patient outcomes.
The COVID-19 pandemic has raised questions related to other widely-utilized practices: Can medication times be readjusted to allow only one entry into the room? Will these labs or imaging studies actually change management? Are vital checks every 4 hours needed?
Why did it take the COVID-19 threat to our medical system to force many of us to have these discussions? Despite prior efforts to integrate high-value care into hospital practices, long-standing habits and deep-seeded culture are challenging to overcome. Once clinicians develop practice habits, these behaviors tend to persist throughout their careers.2 In many ways, COVID-19 was like hitting a “reset button” as health care professionals were forced to rapidly confront their deeply-ingrained hospital practices and habits. From new protocols for patient rounding to universal masking and social distancing to ground-breaking strategies like awake proning, the response to COVID-19 has represented an unprecedented rapid shift in practice. Previously, consequences of overuse were too downstream or too abstract for clinicians to see in real-time. However, now the ramifications of these choices hit closer to home with obvious potential consequences – like spreading a terrifying virus.
There are three interventions that hospitalists should consider implementing immediately in the COVID-19 era that accelerate us toward high-value care. Routine lab tests, imaging, and overnight vitals represent opportunities to provide patient-centered care while also remaining cognizant of resource utilization.
One area in hospital medicine that has proven challenging to significantly change practice has been routine daily labs. Patients on a general medical inpatient service who are clinically stable generally do not benefit from routine lab work.3 Avoiding these tests does not increase mortality or length of stay in clinically stable patients.3 However, despite this evidence, many patients with COVID-19 and other conditions experience lab draws that are not timed together and are done each morning out of “routine.” Choosing Wisely® recommendations from the Society of Hospital Medicine encourage clinicians to question routine lab work for COVID-19 patients and to consider batching them, if possible.3,4 In COVID-19 patients, the risks of not batching tests are magnified, both in terms of the patient-centered experience and for clinician safety. In essence, COVID-19 has pushed us to consider the elements of safety, PPE conservation and other factors, rather than making decisions based solely on their own comfort, convenience, or historical practice.
Clinicians are also reconsidering the necessity of imaging during the pandemic. The “Things We Do For No Reason” article on “Choosing Wisely® in the COVID-19 era” highlights this well.4 It is more important now than ever to decide whether the timing and type of imaging will change management for your patient. Questions to ask include: Can a portable x-ray be used to avoid patient travel and will that CT scan help your patient? A posterior-anterior/lateral x-ray can potentially provide more information depending on the clinical scenario. However, we now need to assess if that extra information is going to impact patient management. Downstream consequences of these decisions include not only risks to the patient but also infectious exposures for staff and others during patient travel.
Lastly, overnight vital sign checks are another intervention we should analyze through this high-value care lens. The Journal of Hospital Medicine released a “Things We Do For No Reason” article about minimizing overnight vitals to promote uninterrupted sleep at night.5 Deleterious effects of interrupting the sleep of our patients include delirium and patient dissatisfaction.5 Studies have shown the benefits of this approach, yet the shift away from routine overnight vitals has not yet widely occurred.
COVID-19 has pressed us to save PPE and minimize exposure risk; hence, some centers are coordinating the timing of vitals with medication administration times, when feasible. In the stable patient recovering from COVID-19, overnight vitals may not be necessary, particularly if remote monitoring is available. This accomplishes multiple goals: Providing high quality patient care, reducing resource utilization, and minimizing patient nighttime interruptions – all culminating in high-value care.
Even though the COVID-19 pandemic has brought unforeseen emotional, physical, and financial challenges for the health care system and its workers, there may be a silver lining. The pandemic has sparked high-value care discussions, and the urgency of the crisis may be instilling new practices in our daily work. This virus has indeed left a terrible wake of destruction, but may also be a nudge to permanently change our culture of overuse to help us shape the habits of all trainees during this tumultuous time. This experience will hopefully culminate in a culture in which clinicians routinely ask, “How will this intervention help the patient?”
Dr. Rawal is clinical assistant professor of medicine, University of Pittsburgh. Dr. Linker is assistant professor of medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York. Dr. Moriates is associate professor of internal medicine, Dell Medical School at the University of Texas at Austin.
References
1. Shrank W et al. Waste in The US healthcare system. JAMA. 2019;322(15):1501-9.
2. Chen C et al. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA. 2014;312(22):2385-93.
3. Eaton KP et al. Evidence-based guidelines to eliminate repetitive laboratory testing. JAMA Intern Med. 2017;177(12):1833-9.
4. Cho H et al. Choosing Wisely in the COVID-19 Era: Preventing harm to healthcare workers. J Hosp Med. 2020;15(6):360-2.
5. Orlov N and Arora V. Things we do for no reason: Routine overnight vital sign checks. J Hosp Med. 2020;15(5):272-27.
SARS-CoV-2 in hospitalized children and youth
Clinical syndromes and predictors of disease severity
Clinical questions: What are the demographics and clinical features of pediatric severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) syndromes, and which admitting demographics and clinical features are predictive of disease severity?
Background: In children, SARS-CoV-2 causes respiratory disease and multisystem inflammatory syndrome in children (MIS-C) as well as other clinical manifestations. The authors of this study chose to address the gap of identifying characteristics for severe disease caused by SARS-CoV-2, including respiratory disease, MIS-C and other manifestations.
Study design: Retrospective and prospective cohort analysis of hospitalized children
Setting: Participating hospitals in Tri-State Pediatric COVID-19 Consortium, including hospitals in New York, New Jersey, and Connecticut.
Synopsis: The authors identified hospitalized patients 22 years old or younger who had a positive SARS-CoV-2 test or met the U.S. Centers for Disease Control and Preventions’ MIS-C case definition. For comparative analysis, patients were divided into a respiratory disease group (based on the World Health Organization’s criteria for COVID-19), MIS-C group or other group (based on the primary reason for hospitalization).
The authors included 281 patients in the study. 51% of the patients presented with respiratory disease, 25% with MIS-C and 25% with other symptoms, including gastrointestinal, or fever. 51% of all patients were Hispanic and 23% were non-Black Hispanic. The most common pre-existing comorbidities amongst all groups were obesity (34%) and asthma (14%).
Patients with respiratory disease had a median age of 14 years while those with MIS-C had a median age of 7 years. Patients more commonly identified as non-Hispanic Black in the MIS-C group vs the respiratory group (35% vs. 18%). Obesity and medical complexity were more prevalent in the respiratory group relative to the MIS-C group. 75% of patients with MIS-C had gastrointestinal symptoms. 44% of respiratory patients had a chest radiograph with bilateral infiltrates on admission, and 18% or respiratory patients required invasive mechanical ventilation. The most common complications in the respiratory group were acute respiratory distress syndrome (17%) and acute kidney injury (11%), whereas shock (35%) and cardiac dysfunction (25%) were the most common complications in the MIS-C group. The median length of stay for all patients was 4 days (IQR 2-8 days).
Patients with MIS-C were more likely to be admitted to the intensive care unit (ICU) but all deaths (7 patients) occurred in the respiratory group. 40% of patients with respiratory disease, 56% of patients with MIS-C, and 6% of other patients met the authors’ definition of severe disease (ICU admission > 48 hours). For the respiratory group, younger age, obesity, increasing white blood cell count, hypoxia, and bilateral infiltrates on chest radiograph were independent predictors of severe disease based on multivariate analyses. For the MIS-C group, lower absolute lymphocyte count and increasing CRP at admission were independent predictors of severity.
Bottom line: Mortality in pediatric patients is low. Ethnicity and race were not predictive of disease severity in this model, even though 51% of the patients studied were Hispanic and 23% were non-Hispanic Black. Severity of illness for patients with respiratory disease was found to be associated with younger age, obesity, increasing white blood cell count, hypoxia, and bilateral infiltrates on chest radiograph. Severity of illness in patients with MIS-C was associated with lower absolute lymphocyte count and increasing CRP.
Citation: Fernandes DM, et al. Severe acute respiratory syndrome coronavirus 2 clinical syndromes and predictors of disease severity in hospitalized children and youth. J Pediatr. 2020 Nov 14;S0022-3476(20):31393-7. DOI: 10.1016/j.jpeds.2020.11.016.
Dr. Kumar is an assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and a pediatric hospitalist at Cleveland Clinic Children’s. She is the pediatric editor of The Hospitalist.
Clinical syndromes and predictors of disease severity
Clinical syndromes and predictors of disease severity
Clinical questions: What are the demographics and clinical features of pediatric severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) syndromes, and which admitting demographics and clinical features are predictive of disease severity?
Background: In children, SARS-CoV-2 causes respiratory disease and multisystem inflammatory syndrome in children (MIS-C) as well as other clinical manifestations. The authors of this study chose to address the gap of identifying characteristics for severe disease caused by SARS-CoV-2, including respiratory disease, MIS-C and other manifestations.
Study design: Retrospective and prospective cohort analysis of hospitalized children
Setting: Participating hospitals in Tri-State Pediatric COVID-19 Consortium, including hospitals in New York, New Jersey, and Connecticut.
Synopsis: The authors identified hospitalized patients 22 years old or younger who had a positive SARS-CoV-2 test or met the U.S. Centers for Disease Control and Preventions’ MIS-C case definition. For comparative analysis, patients were divided into a respiratory disease group (based on the World Health Organization’s criteria for COVID-19), MIS-C group or other group (based on the primary reason for hospitalization).
The authors included 281 patients in the study. 51% of the patients presented with respiratory disease, 25% with MIS-C and 25% with other symptoms, including gastrointestinal, or fever. 51% of all patients were Hispanic and 23% were non-Black Hispanic. The most common pre-existing comorbidities amongst all groups were obesity (34%) and asthma (14%).
Patients with respiratory disease had a median age of 14 years while those with MIS-C had a median age of 7 years. Patients more commonly identified as non-Hispanic Black in the MIS-C group vs the respiratory group (35% vs. 18%). Obesity and medical complexity were more prevalent in the respiratory group relative to the MIS-C group. 75% of patients with MIS-C had gastrointestinal symptoms. 44% of respiratory patients had a chest radiograph with bilateral infiltrates on admission, and 18% or respiratory patients required invasive mechanical ventilation. The most common complications in the respiratory group were acute respiratory distress syndrome (17%) and acute kidney injury (11%), whereas shock (35%) and cardiac dysfunction (25%) were the most common complications in the MIS-C group. The median length of stay for all patients was 4 days (IQR 2-8 days).
Patients with MIS-C were more likely to be admitted to the intensive care unit (ICU) but all deaths (7 patients) occurred in the respiratory group. 40% of patients with respiratory disease, 56% of patients with MIS-C, and 6% of other patients met the authors’ definition of severe disease (ICU admission > 48 hours). For the respiratory group, younger age, obesity, increasing white blood cell count, hypoxia, and bilateral infiltrates on chest radiograph were independent predictors of severe disease based on multivariate analyses. For the MIS-C group, lower absolute lymphocyte count and increasing CRP at admission were independent predictors of severity.
Bottom line: Mortality in pediatric patients is low. Ethnicity and race were not predictive of disease severity in this model, even though 51% of the patients studied were Hispanic and 23% were non-Hispanic Black. Severity of illness for patients with respiratory disease was found to be associated with younger age, obesity, increasing white blood cell count, hypoxia, and bilateral infiltrates on chest radiograph. Severity of illness in patients with MIS-C was associated with lower absolute lymphocyte count and increasing CRP.
Citation: Fernandes DM, et al. Severe acute respiratory syndrome coronavirus 2 clinical syndromes and predictors of disease severity in hospitalized children and youth. J Pediatr. 2020 Nov 14;S0022-3476(20):31393-7. DOI: 10.1016/j.jpeds.2020.11.016.
Dr. Kumar is an assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and a pediatric hospitalist at Cleveland Clinic Children’s. She is the pediatric editor of The Hospitalist.
Clinical questions: What are the demographics and clinical features of pediatric severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) syndromes, and which admitting demographics and clinical features are predictive of disease severity?
Background: In children, SARS-CoV-2 causes respiratory disease and multisystem inflammatory syndrome in children (MIS-C) as well as other clinical manifestations. The authors of this study chose to address the gap of identifying characteristics for severe disease caused by SARS-CoV-2, including respiratory disease, MIS-C and other manifestations.
Study design: Retrospective and prospective cohort analysis of hospitalized children
Setting: Participating hospitals in Tri-State Pediatric COVID-19 Consortium, including hospitals in New York, New Jersey, and Connecticut.
Synopsis: The authors identified hospitalized patients 22 years old or younger who had a positive SARS-CoV-2 test or met the U.S. Centers for Disease Control and Preventions’ MIS-C case definition. For comparative analysis, patients were divided into a respiratory disease group (based on the World Health Organization’s criteria for COVID-19), MIS-C group or other group (based on the primary reason for hospitalization).
The authors included 281 patients in the study. 51% of the patients presented with respiratory disease, 25% with MIS-C and 25% with other symptoms, including gastrointestinal, or fever. 51% of all patients were Hispanic and 23% were non-Black Hispanic. The most common pre-existing comorbidities amongst all groups were obesity (34%) and asthma (14%).
Patients with respiratory disease had a median age of 14 years while those with MIS-C had a median age of 7 years. Patients more commonly identified as non-Hispanic Black in the MIS-C group vs the respiratory group (35% vs. 18%). Obesity and medical complexity were more prevalent in the respiratory group relative to the MIS-C group. 75% of patients with MIS-C had gastrointestinal symptoms. 44% of respiratory patients had a chest radiograph with bilateral infiltrates on admission, and 18% or respiratory patients required invasive mechanical ventilation. The most common complications in the respiratory group were acute respiratory distress syndrome (17%) and acute kidney injury (11%), whereas shock (35%) and cardiac dysfunction (25%) were the most common complications in the MIS-C group. The median length of stay for all patients was 4 days (IQR 2-8 days).
Patients with MIS-C were more likely to be admitted to the intensive care unit (ICU) but all deaths (7 patients) occurred in the respiratory group. 40% of patients with respiratory disease, 56% of patients with MIS-C, and 6% of other patients met the authors’ definition of severe disease (ICU admission > 48 hours). For the respiratory group, younger age, obesity, increasing white blood cell count, hypoxia, and bilateral infiltrates on chest radiograph were independent predictors of severe disease based on multivariate analyses. For the MIS-C group, lower absolute lymphocyte count and increasing CRP at admission were independent predictors of severity.
Bottom line: Mortality in pediatric patients is low. Ethnicity and race were not predictive of disease severity in this model, even though 51% of the patients studied were Hispanic and 23% were non-Hispanic Black. Severity of illness for patients with respiratory disease was found to be associated with younger age, obesity, increasing white blood cell count, hypoxia, and bilateral infiltrates on chest radiograph. Severity of illness in patients with MIS-C was associated with lower absolute lymphocyte count and increasing CRP.
Citation: Fernandes DM, et al. Severe acute respiratory syndrome coronavirus 2 clinical syndromes and predictors of disease severity in hospitalized children and youth. J Pediatr. 2020 Nov 14;S0022-3476(20):31393-7. DOI: 10.1016/j.jpeds.2020.11.016.
Dr. Kumar is an assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and a pediatric hospitalist at Cleveland Clinic Children’s. She is the pediatric editor of The Hospitalist.
FROM THE JOURNAL OF PEDIATRICS
The journey from burnout to wellbeing
A check-in for you and your peers
COVID-19 did not discriminate when it came to the impact it imposed on our hospitalist community. As the nomenclature moves away from the negative connotations of ‘burnout’ to ‘wellbeing,’ the pandemic has taught us something important about being intentional about our personal health: we must secure our own oxygen masks before helping others.
In February 2020, the Society of Hospital Medicine’s Wellbeing Taskforce efforts quickly changed focus from addressing general wellbeing, to wellbeing during COVID-19. Our Taskforce was commissioned by SHM’s Board with a new charge: Address immediate and ongoing needs of well-being and resiliency support for hospitalists during the COVID-19 pandemic. In this essay, I will discuss how our SHM Wellbeing Taskforce approached the overall topic of wellbeing for hospitalists during the COVID-19 pandemic, including some of our Taskforce group experiences.
The Taskforce started with a framework to aide in cultivating open and authentic conversations within hospital medicine groups. Creating spaces for honest sharing around how providers are doing is a crucial first step to reducing stigma, building mutual support within a group, and elevating issues of wellbeing to the level where structural change can take place. The Taskforce established two objectives for normalizing and mitigating stressors we face as hospitalists during the COVID-19 pandemic:
- Provide a framework for hospitalists to take their own emotional pulse
- Provide an approach to reduce stigma of hospitalists who are suffering from pandemic stress
While a more typical approach to fix stress and burnout is using formal institutional interventions, we used the value and insight provided by SHM’s 7 Drivers of Burnout in Hospital Medicine to help guide the creation of SHM resources in addressing the severe emotional strain being felt across the country by hospitalists. The 7 Drivers support the idea that the social role peers and hospital leaders can make a crucial difference in mitigating stress and burnout. Two examples of social support come to mind from the Wellbeing Taskforce experience:
- Participate in your meetings. One example comes from a member of our group who had underestimated the “healing power” that our group meetings had provided to his psyche. The simple act of participating in our Taskforce meeting and being in the presence of our group had provided such a positive impact that he was better able to face the “death and misery” in his unit with a smile on his face.
- Share what is stressful. The second example of social support comes from an hour of Zoom-based facilitation meetings between the SHM’s Wellbeing Taskforce members and Chapter Leaders in late October. During our Taskforce debrief after the meeting, we came to realize the enormous burden of grief our peers were carrying as one hospitalist had lost a group colleague the previous week due to suicide. Our member who led this meeting was moved – as were we – at how this had impacted his small team, and he was reminded he was not alone.
To form meaningful relationships that foster support, there needs to be a space where people can safely come together at times that initially might feel awkward. After taking steps toward your peers, these conversations can become normalized and contribute to meaningful relationships, providing the opportunity for healthy exchanges on vulnerable topics like emotional and psychological wellbeing. A printable guide for this specific purpose (“HM COVID-19 Check-In Guide for Self and Peers”) was designed to help hospitalists move into safe and supportive conversations with each other. While it is difficult to place a value on the importance these types of conversations have on individual wellbeing, it is known that the quality of a positive work environment where people feel supported can moderate stress, morale, and depression. In other words, hospitalist groups can positively contribute to their social environment during stressful times by sharing meaningful and difficult experiences with one another.
Second, the Taskforce created a social media campaign to provide a public social space for sharing hospitalists’ COVID-19 experiences. We believed that sharing collective experiences with the theme of #YouAreNotAlone and a complementary social media campaign, SHM Cares, on SHM’s social media channels, would further connect the national hospitalist community and provide a different communication pathway to decrease a sense of isolation. This idea came from the second social support idea mentioned earlier to share what is stressful with others in a safe space. We understood that some hospitalists would be more comfortable sharing publicly their comments, photos, and videos in achieving a sense of hospitalist unity.
Using our shared experiences, we identified three pillars for the final structure of the HM COVID-19 Check-In Guide for Self and Peers:
- Pillar 1. Recognize your issues. Recall our oxygen mask metaphor and this is what we mean by recognizing symptoms of new stressors (e.g., sleeplessness, irritability, forgetfulness).
- Pillar 2. Know what to say. A simple open-ended question about how the other person is working through the pandemic is an easy way to start a connection. We learned from a mental health perspective that it is unlikely that you could say anything to make a situation worse by offering a listening ear.
- Pillar 3. Check in with others. Listen to others without trying to fix the person or the situation. When appropriate, offer humorous reflections without diminishing the problem. Be a partner and commit to check in regularly with the other person.
Cultivating human connections outside of your immediate peer group can be valuable and offer additional perspective to stressful situations. For instance, one of my roles as a hospitalist administrator has been offering support by regularly listening as my physicians ‘talk out’ their day confidentially for as long as they needed. Offering open conversation in a safe and confidential way can have a healing effect. As one of my former hospitalists used to say, if issues are not addressed, they will “ooze out somewhere else.”
The HM COVID-19 Check-In Guide for Self and Peers and the SHM Cares social media campaign was the result of the Taskforce’s collective observations to help others normalize the feeling that ‘it’s OK not to be OK.’ Using the pandemic as context, the 7 Drivers of Hospitalist Burnout reminded us that the increased burnout issues we face will require continued attention past the pandemic. The value in cultivating human connections has never been more important. The SHM Wellbeing Taskforce is committed to provide continued resources. Checking in with others and listening to peers are all part of a personal wellbeing and resilience strategy. On behalf of the SHM Wellbeing Taskforce, we hope the information in this article will highlight the importance of continued attention to personal wellbeing during and after the pandemic.
Dr. Robinson received her PhD in organizational learning, performance and change from Colorado State University in 2019. Her dissertation topic was exploring hospitalist burnout, engagement, and social support. She is administrative director of inpatient medicine at St. Mary’s Medical Center in Grand Junction, Colo., a part of SCL Health. She has volunteered in numerous SHM committees, and currently serves on the SHM Wellbeing Taskforce.
A check-in for you and your peers
A check-in for you and your peers
COVID-19 did not discriminate when it came to the impact it imposed on our hospitalist community. As the nomenclature moves away from the negative connotations of ‘burnout’ to ‘wellbeing,’ the pandemic has taught us something important about being intentional about our personal health: we must secure our own oxygen masks before helping others.
In February 2020, the Society of Hospital Medicine’s Wellbeing Taskforce efforts quickly changed focus from addressing general wellbeing, to wellbeing during COVID-19. Our Taskforce was commissioned by SHM’s Board with a new charge: Address immediate and ongoing needs of well-being and resiliency support for hospitalists during the COVID-19 pandemic. In this essay, I will discuss how our SHM Wellbeing Taskforce approached the overall topic of wellbeing for hospitalists during the COVID-19 pandemic, including some of our Taskforce group experiences.
The Taskforce started with a framework to aide in cultivating open and authentic conversations within hospital medicine groups. Creating spaces for honest sharing around how providers are doing is a crucial first step to reducing stigma, building mutual support within a group, and elevating issues of wellbeing to the level where structural change can take place. The Taskforce established two objectives for normalizing and mitigating stressors we face as hospitalists during the COVID-19 pandemic:
- Provide a framework for hospitalists to take their own emotional pulse
- Provide an approach to reduce stigma of hospitalists who are suffering from pandemic stress
While a more typical approach to fix stress and burnout is using formal institutional interventions, we used the value and insight provided by SHM’s 7 Drivers of Burnout in Hospital Medicine to help guide the creation of SHM resources in addressing the severe emotional strain being felt across the country by hospitalists. The 7 Drivers support the idea that the social role peers and hospital leaders can make a crucial difference in mitigating stress and burnout. Two examples of social support come to mind from the Wellbeing Taskforce experience:
- Participate in your meetings. One example comes from a member of our group who had underestimated the “healing power” that our group meetings had provided to his psyche. The simple act of participating in our Taskforce meeting and being in the presence of our group had provided such a positive impact that he was better able to face the “death and misery” in his unit with a smile on his face.
- Share what is stressful. The second example of social support comes from an hour of Zoom-based facilitation meetings between the SHM’s Wellbeing Taskforce members and Chapter Leaders in late October. During our Taskforce debrief after the meeting, we came to realize the enormous burden of grief our peers were carrying as one hospitalist had lost a group colleague the previous week due to suicide. Our member who led this meeting was moved – as were we – at how this had impacted his small team, and he was reminded he was not alone.
To form meaningful relationships that foster support, there needs to be a space where people can safely come together at times that initially might feel awkward. After taking steps toward your peers, these conversations can become normalized and contribute to meaningful relationships, providing the opportunity for healthy exchanges on vulnerable topics like emotional and psychological wellbeing. A printable guide for this specific purpose (“HM COVID-19 Check-In Guide for Self and Peers”) was designed to help hospitalists move into safe and supportive conversations with each other. While it is difficult to place a value on the importance these types of conversations have on individual wellbeing, it is known that the quality of a positive work environment where people feel supported can moderate stress, morale, and depression. In other words, hospitalist groups can positively contribute to their social environment during stressful times by sharing meaningful and difficult experiences with one another.
Second, the Taskforce created a social media campaign to provide a public social space for sharing hospitalists’ COVID-19 experiences. We believed that sharing collective experiences with the theme of #YouAreNotAlone and a complementary social media campaign, SHM Cares, on SHM’s social media channels, would further connect the national hospitalist community and provide a different communication pathway to decrease a sense of isolation. This idea came from the second social support idea mentioned earlier to share what is stressful with others in a safe space. We understood that some hospitalists would be more comfortable sharing publicly their comments, photos, and videos in achieving a sense of hospitalist unity.
Using our shared experiences, we identified three pillars for the final structure of the HM COVID-19 Check-In Guide for Self and Peers:
- Pillar 1. Recognize your issues. Recall our oxygen mask metaphor and this is what we mean by recognizing symptoms of new stressors (e.g., sleeplessness, irritability, forgetfulness).
- Pillar 2. Know what to say. A simple open-ended question about how the other person is working through the pandemic is an easy way to start a connection. We learned from a mental health perspective that it is unlikely that you could say anything to make a situation worse by offering a listening ear.
- Pillar 3. Check in with others. Listen to others without trying to fix the person or the situation. When appropriate, offer humorous reflections without diminishing the problem. Be a partner and commit to check in regularly with the other person.
Cultivating human connections outside of your immediate peer group can be valuable and offer additional perspective to stressful situations. For instance, one of my roles as a hospitalist administrator has been offering support by regularly listening as my physicians ‘talk out’ their day confidentially for as long as they needed. Offering open conversation in a safe and confidential way can have a healing effect. As one of my former hospitalists used to say, if issues are not addressed, they will “ooze out somewhere else.”
The HM COVID-19 Check-In Guide for Self and Peers and the SHM Cares social media campaign was the result of the Taskforce’s collective observations to help others normalize the feeling that ‘it’s OK not to be OK.’ Using the pandemic as context, the 7 Drivers of Hospitalist Burnout reminded us that the increased burnout issues we face will require continued attention past the pandemic. The value in cultivating human connections has never been more important. The SHM Wellbeing Taskforce is committed to provide continued resources. Checking in with others and listening to peers are all part of a personal wellbeing and resilience strategy. On behalf of the SHM Wellbeing Taskforce, we hope the information in this article will highlight the importance of continued attention to personal wellbeing during and after the pandemic.
Dr. Robinson received her PhD in organizational learning, performance and change from Colorado State University in 2019. Her dissertation topic was exploring hospitalist burnout, engagement, and social support. She is administrative director of inpatient medicine at St. Mary’s Medical Center in Grand Junction, Colo., a part of SCL Health. She has volunteered in numerous SHM committees, and currently serves on the SHM Wellbeing Taskforce.
COVID-19 did not discriminate when it came to the impact it imposed on our hospitalist community. As the nomenclature moves away from the negative connotations of ‘burnout’ to ‘wellbeing,’ the pandemic has taught us something important about being intentional about our personal health: we must secure our own oxygen masks before helping others.
In February 2020, the Society of Hospital Medicine’s Wellbeing Taskforce efforts quickly changed focus from addressing general wellbeing, to wellbeing during COVID-19. Our Taskforce was commissioned by SHM’s Board with a new charge: Address immediate and ongoing needs of well-being and resiliency support for hospitalists during the COVID-19 pandemic. In this essay, I will discuss how our SHM Wellbeing Taskforce approached the overall topic of wellbeing for hospitalists during the COVID-19 pandemic, including some of our Taskforce group experiences.
The Taskforce started with a framework to aide in cultivating open and authentic conversations within hospital medicine groups. Creating spaces for honest sharing around how providers are doing is a crucial first step to reducing stigma, building mutual support within a group, and elevating issues of wellbeing to the level where structural change can take place. The Taskforce established two objectives for normalizing and mitigating stressors we face as hospitalists during the COVID-19 pandemic:
- Provide a framework for hospitalists to take their own emotional pulse
- Provide an approach to reduce stigma of hospitalists who are suffering from pandemic stress
While a more typical approach to fix stress and burnout is using formal institutional interventions, we used the value and insight provided by SHM’s 7 Drivers of Burnout in Hospital Medicine to help guide the creation of SHM resources in addressing the severe emotional strain being felt across the country by hospitalists. The 7 Drivers support the idea that the social role peers and hospital leaders can make a crucial difference in mitigating stress and burnout. Two examples of social support come to mind from the Wellbeing Taskforce experience:
- Participate in your meetings. One example comes from a member of our group who had underestimated the “healing power” that our group meetings had provided to his psyche. The simple act of participating in our Taskforce meeting and being in the presence of our group had provided such a positive impact that he was better able to face the “death and misery” in his unit with a smile on his face.
- Share what is stressful. The second example of social support comes from an hour of Zoom-based facilitation meetings between the SHM’s Wellbeing Taskforce members and Chapter Leaders in late October. During our Taskforce debrief after the meeting, we came to realize the enormous burden of grief our peers were carrying as one hospitalist had lost a group colleague the previous week due to suicide. Our member who led this meeting was moved – as were we – at how this had impacted his small team, and he was reminded he was not alone.
To form meaningful relationships that foster support, there needs to be a space where people can safely come together at times that initially might feel awkward. After taking steps toward your peers, these conversations can become normalized and contribute to meaningful relationships, providing the opportunity for healthy exchanges on vulnerable topics like emotional and psychological wellbeing. A printable guide for this specific purpose (“HM COVID-19 Check-In Guide for Self and Peers”) was designed to help hospitalists move into safe and supportive conversations with each other. While it is difficult to place a value on the importance these types of conversations have on individual wellbeing, it is known that the quality of a positive work environment where people feel supported can moderate stress, morale, and depression. In other words, hospitalist groups can positively contribute to their social environment during stressful times by sharing meaningful and difficult experiences with one another.
Second, the Taskforce created a social media campaign to provide a public social space for sharing hospitalists’ COVID-19 experiences. We believed that sharing collective experiences with the theme of #YouAreNotAlone and a complementary social media campaign, SHM Cares, on SHM’s social media channels, would further connect the national hospitalist community and provide a different communication pathway to decrease a sense of isolation. This idea came from the second social support idea mentioned earlier to share what is stressful with others in a safe space. We understood that some hospitalists would be more comfortable sharing publicly their comments, photos, and videos in achieving a sense of hospitalist unity.
Using our shared experiences, we identified three pillars for the final structure of the HM COVID-19 Check-In Guide for Self and Peers:
- Pillar 1. Recognize your issues. Recall our oxygen mask metaphor and this is what we mean by recognizing symptoms of new stressors (e.g., sleeplessness, irritability, forgetfulness).
- Pillar 2. Know what to say. A simple open-ended question about how the other person is working through the pandemic is an easy way to start a connection. We learned from a mental health perspective that it is unlikely that you could say anything to make a situation worse by offering a listening ear.
- Pillar 3. Check in with others. Listen to others without trying to fix the person or the situation. When appropriate, offer humorous reflections without diminishing the problem. Be a partner and commit to check in regularly with the other person.
Cultivating human connections outside of your immediate peer group can be valuable and offer additional perspective to stressful situations. For instance, one of my roles as a hospitalist administrator has been offering support by regularly listening as my physicians ‘talk out’ their day confidentially for as long as they needed. Offering open conversation in a safe and confidential way can have a healing effect. As one of my former hospitalists used to say, if issues are not addressed, they will “ooze out somewhere else.”
The HM COVID-19 Check-In Guide for Self and Peers and the SHM Cares social media campaign was the result of the Taskforce’s collective observations to help others normalize the feeling that ‘it’s OK not to be OK.’ Using the pandemic as context, the 7 Drivers of Hospitalist Burnout reminded us that the increased burnout issues we face will require continued attention past the pandemic. The value in cultivating human connections has never been more important. The SHM Wellbeing Taskforce is committed to provide continued resources. Checking in with others and listening to peers are all part of a personal wellbeing and resilience strategy. On behalf of the SHM Wellbeing Taskforce, we hope the information in this article will highlight the importance of continued attention to personal wellbeing during and after the pandemic.
Dr. Robinson received her PhD in organizational learning, performance and change from Colorado State University in 2019. Her dissertation topic was exploring hospitalist burnout, engagement, and social support. She is administrative director of inpatient medicine at St. Mary’s Medical Center in Grand Junction, Colo., a part of SCL Health. She has volunteered in numerous SHM committees, and currently serves on the SHM Wellbeing Taskforce.
Poor sensitivity for blood cultures drawn after antibiotics
Background: Early antibiotic administration reduces mortality in patients with severe sepsis. Administering antibiotics before blood cultures could potentially decrease time to treatment and improve outcomes, but the diagnostic yield of blood cultures drawn shortly after antibiotics is unknown.
Study design: Prospective, patient-level, pre- and post-study.
Setting: Multicenter study in USA & Canada.
Synopsis: During 2013-2018, 330 adult patients were recruited from seven urban EDs. Patients with severe manifestations of sepsis (spontaneous bacterial peritonitis [SBP] less than 90 mm Hg and lactic acid of 4 or more) had blood cultures drawn before and after empiric antibiotic administration. Blood cultures were positive for one or more microbial pathogens in 31.4% of patients when drawn before antibiotics and in 19.4% of patients when drawn after antibiotics (absolute difference of 12.0% (95% confidence interval, 5.4%-18.6%; P less than .001). The sensitivity of blood cultures after antibiotic administration was 52.9% (95% CI, 43%-63%).
There were several study limitations including: lack of sequential recruitment, lower than expected proportion of bacteremic patients, and variation in blood culture collection. Despite this, the magnitude of the findings are convincing and support current practice.
Bottom line: Continue to obtain blood cultures before antibiotics.
Citation: Cheng MP et al. Blood culture results before and after antimicrobial administration in patients with severe manifestations of sepsis. Ann Intern Med. 2019 Oct 15;171(8):547-54.
Dr. Waner is clinical instructor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.
Background: Early antibiotic administration reduces mortality in patients with severe sepsis. Administering antibiotics before blood cultures could potentially decrease time to treatment and improve outcomes, but the diagnostic yield of blood cultures drawn shortly after antibiotics is unknown.
Study design: Prospective, patient-level, pre- and post-study.
Setting: Multicenter study in USA & Canada.
Synopsis: During 2013-2018, 330 adult patients were recruited from seven urban EDs. Patients with severe manifestations of sepsis (spontaneous bacterial peritonitis [SBP] less than 90 mm Hg and lactic acid of 4 or more) had blood cultures drawn before and after empiric antibiotic administration. Blood cultures were positive for one or more microbial pathogens in 31.4% of patients when drawn before antibiotics and in 19.4% of patients when drawn after antibiotics (absolute difference of 12.0% (95% confidence interval, 5.4%-18.6%; P less than .001). The sensitivity of blood cultures after antibiotic administration was 52.9% (95% CI, 43%-63%).
There were several study limitations including: lack of sequential recruitment, lower than expected proportion of bacteremic patients, and variation in blood culture collection. Despite this, the magnitude of the findings are convincing and support current practice.
Bottom line: Continue to obtain blood cultures before antibiotics.
Citation: Cheng MP et al. Blood culture results before and after antimicrobial administration in patients with severe manifestations of sepsis. Ann Intern Med. 2019 Oct 15;171(8):547-54.
Dr. Waner is clinical instructor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.
Background: Early antibiotic administration reduces mortality in patients with severe sepsis. Administering antibiotics before blood cultures could potentially decrease time to treatment and improve outcomes, but the diagnostic yield of blood cultures drawn shortly after antibiotics is unknown.
Study design: Prospective, patient-level, pre- and post-study.
Setting: Multicenter study in USA & Canada.
Synopsis: During 2013-2018, 330 adult patients were recruited from seven urban EDs. Patients with severe manifestations of sepsis (spontaneous bacterial peritonitis [SBP] less than 90 mm Hg and lactic acid of 4 or more) had blood cultures drawn before and after empiric antibiotic administration. Blood cultures were positive for one or more microbial pathogens in 31.4% of patients when drawn before antibiotics and in 19.4% of patients when drawn after antibiotics (absolute difference of 12.0% (95% confidence interval, 5.4%-18.6%; P less than .001). The sensitivity of blood cultures after antibiotic administration was 52.9% (95% CI, 43%-63%).
There were several study limitations including: lack of sequential recruitment, lower than expected proportion of bacteremic patients, and variation in blood culture collection. Despite this, the magnitude of the findings are convincing and support current practice.
Bottom line: Continue to obtain blood cultures before antibiotics.
Citation: Cheng MP et al. Blood culture results before and after antimicrobial administration in patients with severe manifestations of sepsis. Ann Intern Med. 2019 Oct 15;171(8):547-54.
Dr. Waner is clinical instructor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.
Regular medical masks no different than N95 respirator masks in preventing flu transmission
Background: While it is recognized that N95 respirator masks are better than regular medical masks at preventing the inhalation of aerosols, the question of whether they are better at preventing the transmission of infectious viral micro-organisms has never been studied in a robust randomized trial. Prior studies have shown mixed results, from noninferiority of medical masks to superiority of N95 masks, but these studies were stopped early or calibrated to detect outcomes of questionable clinical significance.
Study design: Cluster randomized, investigator-blinded pragmatic effectiveness study.
Setting: Seven outpatient health systems throughout the United States.
Synopsis: Data from 2,862 participants from 137 sites were gathered during the 12 weeks of peak influenza season during 2011-2015. Following analysis, there was no difference in objective laboratory evidence (by polymerase chain reaction or serum influenza seroconversion not attributable to vaccination) between the groups randomized to N95 masks and the groups randomized to regular medical masks. No significant difference in self-reported “flulike illness” or self-reported adherence to the intervention was noted between groups. Participants self-reported “never” adhering to the intervention about 10% of the time in both groups and adhering only “sometimes” about 25% of the time.
The study limitations included: most testing for infection occurred for self-reported symptoms with only a minor component of testing occurring at random; the self-reporting of secondary outcomes; and the somewhat high rate of nonadherence to either intervention. Although these are likely necessary trade-offs in a pragmatic trial.
Bottom line: N95 respirator masks are no better than regular medical masks are at preventing the transmission of influenza and other viral respiratory illnesses.
Citation: Radonovich LJ et al. N95 respirators vs. medical masks for preventing influenza among health care personnel: A randomized clinical trial. JAMA. 2019 Sep 3;322(9):824-33.
Dr. Porter is chief quality and safety resident at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.
Background: While it is recognized that N95 respirator masks are better than regular medical masks at preventing the inhalation of aerosols, the question of whether they are better at preventing the transmission of infectious viral micro-organisms has never been studied in a robust randomized trial. Prior studies have shown mixed results, from noninferiority of medical masks to superiority of N95 masks, but these studies were stopped early or calibrated to detect outcomes of questionable clinical significance.
Study design: Cluster randomized, investigator-blinded pragmatic effectiveness study.
Setting: Seven outpatient health systems throughout the United States.
Synopsis: Data from 2,862 participants from 137 sites were gathered during the 12 weeks of peak influenza season during 2011-2015. Following analysis, there was no difference in objective laboratory evidence (by polymerase chain reaction or serum influenza seroconversion not attributable to vaccination) between the groups randomized to N95 masks and the groups randomized to regular medical masks. No significant difference in self-reported “flulike illness” or self-reported adherence to the intervention was noted between groups. Participants self-reported “never” adhering to the intervention about 10% of the time in both groups and adhering only “sometimes” about 25% of the time.
The study limitations included: most testing for infection occurred for self-reported symptoms with only a minor component of testing occurring at random; the self-reporting of secondary outcomes; and the somewhat high rate of nonadherence to either intervention. Although these are likely necessary trade-offs in a pragmatic trial.
Bottom line: N95 respirator masks are no better than regular medical masks are at preventing the transmission of influenza and other viral respiratory illnesses.
Citation: Radonovich LJ et al. N95 respirators vs. medical masks for preventing influenza among health care personnel: A randomized clinical trial. JAMA. 2019 Sep 3;322(9):824-33.
Dr. Porter is chief quality and safety resident at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.
Background: While it is recognized that N95 respirator masks are better than regular medical masks at preventing the inhalation of aerosols, the question of whether they are better at preventing the transmission of infectious viral micro-organisms has never been studied in a robust randomized trial. Prior studies have shown mixed results, from noninferiority of medical masks to superiority of N95 masks, but these studies were stopped early or calibrated to detect outcomes of questionable clinical significance.
Study design: Cluster randomized, investigator-blinded pragmatic effectiveness study.
Setting: Seven outpatient health systems throughout the United States.
Synopsis: Data from 2,862 participants from 137 sites were gathered during the 12 weeks of peak influenza season during 2011-2015. Following analysis, there was no difference in objective laboratory evidence (by polymerase chain reaction or serum influenza seroconversion not attributable to vaccination) between the groups randomized to N95 masks and the groups randomized to regular medical masks. No significant difference in self-reported “flulike illness” or self-reported adherence to the intervention was noted between groups. Participants self-reported “never” adhering to the intervention about 10% of the time in both groups and adhering only “sometimes” about 25% of the time.
The study limitations included: most testing for infection occurred for self-reported symptoms with only a minor component of testing occurring at random; the self-reporting of secondary outcomes; and the somewhat high rate of nonadherence to either intervention. Although these are likely necessary trade-offs in a pragmatic trial.
Bottom line: N95 respirator masks are no better than regular medical masks are at preventing the transmission of influenza and other viral respiratory illnesses.
Citation: Radonovich LJ et al. N95 respirators vs. medical masks for preventing influenza among health care personnel: A randomized clinical trial. JAMA. 2019 Sep 3;322(9):824-33.
Dr. Porter is chief quality and safety resident at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.
Complete PCI beats culprit-lesion-only PCI in STEMI patients with multivessel CAD
Background: Previous trials have shown a reduction in composite outcomes if STEMI patients undergo staged PCI of nonculprit lesions discovered incidentally at the time of primary PCI for STEMI. However, no randomized trial has had the power to assess if staged PCI of nonculprit lesions reduces cardiovascular death or MI.
Study design: Prospective randomized clinical trial.
Setting: PCI-capable centers in 31 countries.
Synopsis: In this study, if multivessel disease was identified during primary PCI for STEMI, patients were randomized to either culprit-lesion-only PCI or complete revascularization with staged PCI of all suitable nonculprit lesions (either during the index hospitalization or up to 45 days after randomization).
Overall, 4,041 patients from 140 centers were randomized with median 3-year follow-up. The complete revascularization group had lower rates of the primary composite outcome of death from cardiovascular disease or new MI (absolute reduction, 2.7%; 7.8% vs. 10.5%; number needed to treat, 37; hazard ratio, 0.74; 95% confidence interval, 0.60-0.91; P = .004). This finding was driven by lower incidence of new MI in the complete revascularization group – the incidence of death was similar between the groups. A coprimary composite outcome of death from cardiovascular causes, new MI, or ischemia-driven revascularization also favored complete revascularization, with an absolute risk reduction of 7.8% (8.9% vs. 16.7%; NNT, 13; HR, 0.51; 95% CI, 0.43-0.61; P less than .001). No statistically significant differences between groups were noted for the safety outcomes of major bleeding, stroke, stent thrombosis, or contrast-induced kidney injury.
Bottom line: Patients with STEMI who have multivessel disease incidentally discovered during primary PCI have a lower incidence of new MI and ischemia-driven revascularization when they undergo complete revascularization of all suitable lesions, as opposed to PCI of only their culprit lesion.
Citation: Mehta SR et al. Complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med. 2019 Oct 10;381:1411-21.
Dr. Porter is chief quality and safety resident at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.
Background: Previous trials have shown a reduction in composite outcomes if STEMI patients undergo staged PCI of nonculprit lesions discovered incidentally at the time of primary PCI for STEMI. However, no randomized trial has had the power to assess if staged PCI of nonculprit lesions reduces cardiovascular death or MI.
Study design: Prospective randomized clinical trial.
Setting: PCI-capable centers in 31 countries.
Synopsis: In this study, if multivessel disease was identified during primary PCI for STEMI, patients were randomized to either culprit-lesion-only PCI or complete revascularization with staged PCI of all suitable nonculprit lesions (either during the index hospitalization or up to 45 days after randomization).
Overall, 4,041 patients from 140 centers were randomized with median 3-year follow-up. The complete revascularization group had lower rates of the primary composite outcome of death from cardiovascular disease or new MI (absolute reduction, 2.7%; 7.8% vs. 10.5%; number needed to treat, 37; hazard ratio, 0.74; 95% confidence interval, 0.60-0.91; P = .004). This finding was driven by lower incidence of new MI in the complete revascularization group – the incidence of death was similar between the groups. A coprimary composite outcome of death from cardiovascular causes, new MI, or ischemia-driven revascularization also favored complete revascularization, with an absolute risk reduction of 7.8% (8.9% vs. 16.7%; NNT, 13; HR, 0.51; 95% CI, 0.43-0.61; P less than .001). No statistically significant differences between groups were noted for the safety outcomes of major bleeding, stroke, stent thrombosis, or contrast-induced kidney injury.
Bottom line: Patients with STEMI who have multivessel disease incidentally discovered during primary PCI have a lower incidence of new MI and ischemia-driven revascularization when they undergo complete revascularization of all suitable lesions, as opposed to PCI of only their culprit lesion.
Citation: Mehta SR et al. Complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med. 2019 Oct 10;381:1411-21.
Dr. Porter is chief quality and safety resident at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.
Background: Previous trials have shown a reduction in composite outcomes if STEMI patients undergo staged PCI of nonculprit lesions discovered incidentally at the time of primary PCI for STEMI. However, no randomized trial has had the power to assess if staged PCI of nonculprit lesions reduces cardiovascular death or MI.
Study design: Prospective randomized clinical trial.
Setting: PCI-capable centers in 31 countries.
Synopsis: In this study, if multivessel disease was identified during primary PCI for STEMI, patients were randomized to either culprit-lesion-only PCI or complete revascularization with staged PCI of all suitable nonculprit lesions (either during the index hospitalization or up to 45 days after randomization).
Overall, 4,041 patients from 140 centers were randomized with median 3-year follow-up. The complete revascularization group had lower rates of the primary composite outcome of death from cardiovascular disease or new MI (absolute reduction, 2.7%; 7.8% vs. 10.5%; number needed to treat, 37; hazard ratio, 0.74; 95% confidence interval, 0.60-0.91; P = .004). This finding was driven by lower incidence of new MI in the complete revascularization group – the incidence of death was similar between the groups. A coprimary composite outcome of death from cardiovascular causes, new MI, or ischemia-driven revascularization also favored complete revascularization, with an absolute risk reduction of 7.8% (8.9% vs. 16.7%; NNT, 13; HR, 0.51; 95% CI, 0.43-0.61; P less than .001). No statistically significant differences between groups were noted for the safety outcomes of major bleeding, stroke, stent thrombosis, or contrast-induced kidney injury.
Bottom line: Patients with STEMI who have multivessel disease incidentally discovered during primary PCI have a lower incidence of new MI and ischemia-driven revascularization when they undergo complete revascularization of all suitable lesions, as opposed to PCI of only their culprit lesion.
Citation: Mehta SR et al. Complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med. 2019 Oct 10;381:1411-21.
Dr. Porter is chief quality and safety resident at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.
The Blitz and COVID-19
Lessons from history for hospitalists
The Blitz was a Nazi bombing campaign targeting London. It was designed to break the spirit of the British. Knowing London would be the centerpiece of the campaign, the British rather hastily established several psychiatric hospitals for the expected panic in the streets. However, despite 9 months of bombing, 43,000 civilians killed and 139,000 more wounded, the predicted chaos in the streets did not manifest. Civilians continued to work, industry continued to churn, and eventually, Hitler’s eye turned east toward Russia.
The surprising lack of pandemonium in London inspired Dr. John T. MacCurdy, who chronicled his findings in a book The Structure of Morale, more recently popularized in Malcolm Gladwell’s David and Goliath. A brief summary of Dr. MacCurdy’s theory divides the targeted Londoners into the following categories:
- Direct hit
- Near miss
- Remote miss
The direct hit group was defined as those killed by the bombing. However, As Dr. MacCurdy stated, “The morale of the community depends on the reaction of the survivors…Put this way, the fact is obvious, corpses do not run about spreading panic.”
A near miss were those for whom wounds were inflicted or loved ones were killed. This group felt the real repercussions of the bombing. However, with 139,000 wounded out of a city of 8 million people, they were a small minority.
The majority of Londoners, then, fit into the third group – the remote miss. These people faced a serious fear, but survived, often totally unscathed. The process of facing that fear without having panicked or having been harmed, then, led to “a feeling of excitement with a flavour of invulnerability.”
Therefore, rather than a city of millions running in fear in the streets, requiring military presence to control the chaos, London became a city of people who felt themselves, perhaps, invincible.
A similar threat passed through the world in the first several months of the COVID-19 pandemic. Hospitals were expected to be overrun, and ethics committees convened to discuss allocation of scarce ventilators. However, due, at least in part, to the impressive efforts of the populace of the United States, the majority of civilians did not feel the burden of this frightening disease. Certainly, in a few places, hospitals were overwhelmed, and resources were unavailable due to sheer numbers. These places saw those who suffered direct hits with the highest frequency. However, a disease with an infection fatality ratio recently estimated at 0.5-1%, with a relatively high rate of asymptomatic disease, led to a large majority of people who experienced the first wave of COVID-19 in the United States as a remote miss. COVID-19’s flattened first peak gave much of the population a sense of relief, and, perhaps, a “flavour of invulnerability.”
An anonymous, but concerned, household contact wrote The New York Times and illustrated perfectly the invulnerable feelings of a remote miss:
“I’m doing my best to avoid social contact, along with two other members of my household. We have sufficient supplies for a month. Despite that, one member insists on going out for trivial reasons, such as not liking the kind of apples we have. He’s 92. I’ve tried explaining and cajoling, using graphs and anecdotes to make the danger to all of us seem ‘real.’ It doesn’t take. His risk of death is many times greater than mine, and he’s poking holes in a lifeboat we all have to rely on. What is the correct path?”
American culture expects certainty from science. Therein lies the problem with a new disease no medical provider or researcher had seen prior to November 2019. Action was required in the effort to slow the spread with little to no data as a guide. Therefore, messages that seemed contradictory reached the public. “A mask less than N-95 grade will not protect you,” evolved to, “everyone should wear a homemade cloth mask.” As the pandemic evolved and data was gathered, new recommendations were presented. Unfortunately, such well-meaning and necessary changes led to confusion, mistrust, and conspiracy theories.
Psychologists have weighed in regarding other aspects of our culture that allow for the flourishing of misinformation. A photograph even loosely related to the information presented has been shown to increase the initial sense of trustworthiness. Simple repetition can also make a point seem more trustworthy. As social media pushes the daily deluge of information (with pictures!) to new heights, it is a small wonder misinformation remains in circulation.
Medicine’s response
The science of COVID-19 carries phenomenal uncertainties, but the psychology of those who have suffered direct hits or near misses are the daily bedside challenge of all physicians, but particularly of hospitalists. We live at the front lines of disease – as one colleague put it to me, “we are the watchers on the wall.” Though we do not yet have our hoped-for, evidence-based treatment for this virus, we are familiar with acute illness. We know the rapid change of health to disease, and we know the chronically ill who suffer exacerbations of such illness. Supporting patients and their loved ones through those times is our daily practice.
On the other hand, those who have experienced only remote misses remain vulnerable in this pandemic, despite their feelings of invincibility. Those that feel invincible may be the least interested in our advice. This, too, is no strange position for a physician. We have tools to reach patients who do not reach out to us. Traditional media outlets have been saturated with headlines and talking points about this disease. Physicians who have taken to social media have been met with appreciation in some situations, but ignored, doubted, or shunned in others. In May 2020, NBC News reported an ED doctor’s attempt to dispel some COVID myths on social media. Unfortunately, his remarks were summarily dismissed. Through the frustration, we persevere.
Out of the many responsible authorities who help battle misinformation, the World Health Organization’s mythbusting website (www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters) directly confronts many incorrect circulating ideas. My personal favorite at the time of this writing is: “Being able to hold your breath for 10 seconds or more without coughing or feeling discomfort DOES NOT mean you are free from COVID-19.”
For the policy and communication side of medicine in the midst of this pandemic, I will not claim to have a silver bullet. There are many intelligent, policy-minded people who are working on that very problem. However, as individual practitioners and as individual citizens, I can see two powerful tools that may help us move forward.
1) Confidence and humility: We live in a world of uncertainty, and we struggle against that every day. This pandemic has put our uncertainty clearly on display. However, we may also be confident in providing the best currently known care, even while holding the humility that what we know will likely change. Before COVID-19, we have all seen patients who received multiple different answers from multiple different providers. When I am willing to admit my uncertainty, I have witnessed patients’ skepticism transform into assuming an active role in their care.
For those who have suffered a direct hit or a near miss, honest conversations are vital to build a trusting physician-patient relationship. For the remote miss group, speaking candidly about our uncertainty displays our authenticity and helps combat conspiracy-type theories of ulterior motives. This becomes all the more crucial when new technologies are being deployed – for instance, a September 2020 CBS News survey showed only 21% of Americans planned to get a COVID-19 vaccine “as soon as possible.”
2) Insight into our driving emotions: While the near miss patients are likely ready to continue prevention measures, the remote miss group is often more difficult. When we do have the opportunity to discuss actions to impede the virus’ spread with the remote miss group, understanding their potentially unrecognized motivations helps with that conversation. I have shared the story of the London Blitz and the remote miss and seen people connect the dots with their own emotions. Effective counseling – expecting the feelings of invulnerability amongst the remote miss group – can support endurance with prevention measures amongst that group and help flatten the curve.
Communicating our strengths, transparently discussing our weaknesses, and better understanding underlying emotions for ourselves and our patients may help save lives. As physicians, that is our daily practice, unchanged even as medicine takes center stage in our national conversation.
Dr. Walthall completed his internal medicine residency at the Medical University of South Carolina in Charleston, SC. After residency, he joined the faculty at MUSC in the Division of Hospital Medicine. He is also interested in systems-based care and has taken on the role of physician advisor. This essay appeared first on The Hospital Leader, the official blog of SHM.
Lessons from history for hospitalists
Lessons from history for hospitalists
The Blitz was a Nazi bombing campaign targeting London. It was designed to break the spirit of the British. Knowing London would be the centerpiece of the campaign, the British rather hastily established several psychiatric hospitals for the expected panic in the streets. However, despite 9 months of bombing, 43,000 civilians killed and 139,000 more wounded, the predicted chaos in the streets did not manifest. Civilians continued to work, industry continued to churn, and eventually, Hitler’s eye turned east toward Russia.
The surprising lack of pandemonium in London inspired Dr. John T. MacCurdy, who chronicled his findings in a book The Structure of Morale, more recently popularized in Malcolm Gladwell’s David and Goliath. A brief summary of Dr. MacCurdy’s theory divides the targeted Londoners into the following categories:
- Direct hit
- Near miss
- Remote miss
The direct hit group was defined as those killed by the bombing. However, As Dr. MacCurdy stated, “The morale of the community depends on the reaction of the survivors…Put this way, the fact is obvious, corpses do not run about spreading panic.”
A near miss were those for whom wounds were inflicted or loved ones were killed. This group felt the real repercussions of the bombing. However, with 139,000 wounded out of a city of 8 million people, they were a small minority.
The majority of Londoners, then, fit into the third group – the remote miss. These people faced a serious fear, but survived, often totally unscathed. The process of facing that fear without having panicked or having been harmed, then, led to “a feeling of excitement with a flavour of invulnerability.”
Therefore, rather than a city of millions running in fear in the streets, requiring military presence to control the chaos, London became a city of people who felt themselves, perhaps, invincible.
A similar threat passed through the world in the first several months of the COVID-19 pandemic. Hospitals were expected to be overrun, and ethics committees convened to discuss allocation of scarce ventilators. However, due, at least in part, to the impressive efforts of the populace of the United States, the majority of civilians did not feel the burden of this frightening disease. Certainly, in a few places, hospitals were overwhelmed, and resources were unavailable due to sheer numbers. These places saw those who suffered direct hits with the highest frequency. However, a disease with an infection fatality ratio recently estimated at 0.5-1%, with a relatively high rate of asymptomatic disease, led to a large majority of people who experienced the first wave of COVID-19 in the United States as a remote miss. COVID-19’s flattened first peak gave much of the population a sense of relief, and, perhaps, a “flavour of invulnerability.”
An anonymous, but concerned, household contact wrote The New York Times and illustrated perfectly the invulnerable feelings of a remote miss:
“I’m doing my best to avoid social contact, along with two other members of my household. We have sufficient supplies for a month. Despite that, one member insists on going out for trivial reasons, such as not liking the kind of apples we have. He’s 92. I’ve tried explaining and cajoling, using graphs and anecdotes to make the danger to all of us seem ‘real.’ It doesn’t take. His risk of death is many times greater than mine, and he’s poking holes in a lifeboat we all have to rely on. What is the correct path?”
American culture expects certainty from science. Therein lies the problem with a new disease no medical provider or researcher had seen prior to November 2019. Action was required in the effort to slow the spread with little to no data as a guide. Therefore, messages that seemed contradictory reached the public. “A mask less than N-95 grade will not protect you,” evolved to, “everyone should wear a homemade cloth mask.” As the pandemic evolved and data was gathered, new recommendations were presented. Unfortunately, such well-meaning and necessary changes led to confusion, mistrust, and conspiracy theories.
Psychologists have weighed in regarding other aspects of our culture that allow for the flourishing of misinformation. A photograph even loosely related to the information presented has been shown to increase the initial sense of trustworthiness. Simple repetition can also make a point seem more trustworthy. As social media pushes the daily deluge of information (with pictures!) to new heights, it is a small wonder misinformation remains in circulation.
Medicine’s response
The science of COVID-19 carries phenomenal uncertainties, but the psychology of those who have suffered direct hits or near misses are the daily bedside challenge of all physicians, but particularly of hospitalists. We live at the front lines of disease – as one colleague put it to me, “we are the watchers on the wall.” Though we do not yet have our hoped-for, evidence-based treatment for this virus, we are familiar with acute illness. We know the rapid change of health to disease, and we know the chronically ill who suffer exacerbations of such illness. Supporting patients and their loved ones through those times is our daily practice.
On the other hand, those who have experienced only remote misses remain vulnerable in this pandemic, despite their feelings of invincibility. Those that feel invincible may be the least interested in our advice. This, too, is no strange position for a physician. We have tools to reach patients who do not reach out to us. Traditional media outlets have been saturated with headlines and talking points about this disease. Physicians who have taken to social media have been met with appreciation in some situations, but ignored, doubted, or shunned in others. In May 2020, NBC News reported an ED doctor’s attempt to dispel some COVID myths on social media. Unfortunately, his remarks were summarily dismissed. Through the frustration, we persevere.
Out of the many responsible authorities who help battle misinformation, the World Health Organization’s mythbusting website (www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters) directly confronts many incorrect circulating ideas. My personal favorite at the time of this writing is: “Being able to hold your breath for 10 seconds or more without coughing or feeling discomfort DOES NOT mean you are free from COVID-19.”
For the policy and communication side of medicine in the midst of this pandemic, I will not claim to have a silver bullet. There are many intelligent, policy-minded people who are working on that very problem. However, as individual practitioners and as individual citizens, I can see two powerful tools that may help us move forward.
1) Confidence and humility: We live in a world of uncertainty, and we struggle against that every day. This pandemic has put our uncertainty clearly on display. However, we may also be confident in providing the best currently known care, even while holding the humility that what we know will likely change. Before COVID-19, we have all seen patients who received multiple different answers from multiple different providers. When I am willing to admit my uncertainty, I have witnessed patients’ skepticism transform into assuming an active role in their care.
For those who have suffered a direct hit or a near miss, honest conversations are vital to build a trusting physician-patient relationship. For the remote miss group, speaking candidly about our uncertainty displays our authenticity and helps combat conspiracy-type theories of ulterior motives. This becomes all the more crucial when new technologies are being deployed – for instance, a September 2020 CBS News survey showed only 21% of Americans planned to get a COVID-19 vaccine “as soon as possible.”
2) Insight into our driving emotions: While the near miss patients are likely ready to continue prevention measures, the remote miss group is often more difficult. When we do have the opportunity to discuss actions to impede the virus’ spread with the remote miss group, understanding their potentially unrecognized motivations helps with that conversation. I have shared the story of the London Blitz and the remote miss and seen people connect the dots with their own emotions. Effective counseling – expecting the feelings of invulnerability amongst the remote miss group – can support endurance with prevention measures amongst that group and help flatten the curve.
Communicating our strengths, transparently discussing our weaknesses, and better understanding underlying emotions for ourselves and our patients may help save lives. As physicians, that is our daily practice, unchanged even as medicine takes center stage in our national conversation.
Dr. Walthall completed his internal medicine residency at the Medical University of South Carolina in Charleston, SC. After residency, he joined the faculty at MUSC in the Division of Hospital Medicine. He is also interested in systems-based care and has taken on the role of physician advisor. This essay appeared first on The Hospital Leader, the official blog of SHM.
The Blitz was a Nazi bombing campaign targeting London. It was designed to break the spirit of the British. Knowing London would be the centerpiece of the campaign, the British rather hastily established several psychiatric hospitals for the expected panic in the streets. However, despite 9 months of bombing, 43,000 civilians killed and 139,000 more wounded, the predicted chaos in the streets did not manifest. Civilians continued to work, industry continued to churn, and eventually, Hitler’s eye turned east toward Russia.
The surprising lack of pandemonium in London inspired Dr. John T. MacCurdy, who chronicled his findings in a book The Structure of Morale, more recently popularized in Malcolm Gladwell’s David and Goliath. A brief summary of Dr. MacCurdy’s theory divides the targeted Londoners into the following categories:
- Direct hit
- Near miss
- Remote miss
The direct hit group was defined as those killed by the bombing. However, As Dr. MacCurdy stated, “The morale of the community depends on the reaction of the survivors…Put this way, the fact is obvious, corpses do not run about spreading panic.”
A near miss were those for whom wounds were inflicted or loved ones were killed. This group felt the real repercussions of the bombing. However, with 139,000 wounded out of a city of 8 million people, they were a small minority.
The majority of Londoners, then, fit into the third group – the remote miss. These people faced a serious fear, but survived, often totally unscathed. The process of facing that fear without having panicked or having been harmed, then, led to “a feeling of excitement with a flavour of invulnerability.”
Therefore, rather than a city of millions running in fear in the streets, requiring military presence to control the chaos, London became a city of people who felt themselves, perhaps, invincible.
A similar threat passed through the world in the first several months of the COVID-19 pandemic. Hospitals were expected to be overrun, and ethics committees convened to discuss allocation of scarce ventilators. However, due, at least in part, to the impressive efforts of the populace of the United States, the majority of civilians did not feel the burden of this frightening disease. Certainly, in a few places, hospitals were overwhelmed, and resources were unavailable due to sheer numbers. These places saw those who suffered direct hits with the highest frequency. However, a disease with an infection fatality ratio recently estimated at 0.5-1%, with a relatively high rate of asymptomatic disease, led to a large majority of people who experienced the first wave of COVID-19 in the United States as a remote miss. COVID-19’s flattened first peak gave much of the population a sense of relief, and, perhaps, a “flavour of invulnerability.”
An anonymous, but concerned, household contact wrote The New York Times and illustrated perfectly the invulnerable feelings of a remote miss:
“I’m doing my best to avoid social contact, along with two other members of my household. We have sufficient supplies for a month. Despite that, one member insists on going out for trivial reasons, such as not liking the kind of apples we have. He’s 92. I’ve tried explaining and cajoling, using graphs and anecdotes to make the danger to all of us seem ‘real.’ It doesn’t take. His risk of death is many times greater than mine, and he’s poking holes in a lifeboat we all have to rely on. What is the correct path?”
American culture expects certainty from science. Therein lies the problem with a new disease no medical provider or researcher had seen prior to November 2019. Action was required in the effort to slow the spread with little to no data as a guide. Therefore, messages that seemed contradictory reached the public. “A mask less than N-95 grade will not protect you,” evolved to, “everyone should wear a homemade cloth mask.” As the pandemic evolved and data was gathered, new recommendations were presented. Unfortunately, such well-meaning and necessary changes led to confusion, mistrust, and conspiracy theories.
Psychologists have weighed in regarding other aspects of our culture that allow for the flourishing of misinformation. A photograph even loosely related to the information presented has been shown to increase the initial sense of trustworthiness. Simple repetition can also make a point seem more trustworthy. As social media pushes the daily deluge of information (with pictures!) to new heights, it is a small wonder misinformation remains in circulation.
Medicine’s response
The science of COVID-19 carries phenomenal uncertainties, but the psychology of those who have suffered direct hits or near misses are the daily bedside challenge of all physicians, but particularly of hospitalists. We live at the front lines of disease – as one colleague put it to me, “we are the watchers on the wall.” Though we do not yet have our hoped-for, evidence-based treatment for this virus, we are familiar with acute illness. We know the rapid change of health to disease, and we know the chronically ill who suffer exacerbations of such illness. Supporting patients and their loved ones through those times is our daily practice.
On the other hand, those who have experienced only remote misses remain vulnerable in this pandemic, despite their feelings of invincibility. Those that feel invincible may be the least interested in our advice. This, too, is no strange position for a physician. We have tools to reach patients who do not reach out to us. Traditional media outlets have been saturated with headlines and talking points about this disease. Physicians who have taken to social media have been met with appreciation in some situations, but ignored, doubted, or shunned in others. In May 2020, NBC News reported an ED doctor’s attempt to dispel some COVID myths on social media. Unfortunately, his remarks were summarily dismissed. Through the frustration, we persevere.
Out of the many responsible authorities who help battle misinformation, the World Health Organization’s mythbusting website (www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters) directly confronts many incorrect circulating ideas. My personal favorite at the time of this writing is: “Being able to hold your breath for 10 seconds or more without coughing or feeling discomfort DOES NOT mean you are free from COVID-19.”
For the policy and communication side of medicine in the midst of this pandemic, I will not claim to have a silver bullet. There are many intelligent, policy-minded people who are working on that very problem. However, as individual practitioners and as individual citizens, I can see two powerful tools that may help us move forward.
1) Confidence and humility: We live in a world of uncertainty, and we struggle against that every day. This pandemic has put our uncertainty clearly on display. However, we may also be confident in providing the best currently known care, even while holding the humility that what we know will likely change. Before COVID-19, we have all seen patients who received multiple different answers from multiple different providers. When I am willing to admit my uncertainty, I have witnessed patients’ skepticism transform into assuming an active role in their care.
For those who have suffered a direct hit or a near miss, honest conversations are vital to build a trusting physician-patient relationship. For the remote miss group, speaking candidly about our uncertainty displays our authenticity and helps combat conspiracy-type theories of ulterior motives. This becomes all the more crucial when new technologies are being deployed – for instance, a September 2020 CBS News survey showed only 21% of Americans planned to get a COVID-19 vaccine “as soon as possible.”
2) Insight into our driving emotions: While the near miss patients are likely ready to continue prevention measures, the remote miss group is often more difficult. When we do have the opportunity to discuss actions to impede the virus’ spread with the remote miss group, understanding their potentially unrecognized motivations helps with that conversation. I have shared the story of the London Blitz and the remote miss and seen people connect the dots with their own emotions. Effective counseling – expecting the feelings of invulnerability amongst the remote miss group – can support endurance with prevention measures amongst that group and help flatten the curve.
Communicating our strengths, transparently discussing our weaknesses, and better understanding underlying emotions for ourselves and our patients may help save lives. As physicians, that is our daily practice, unchanged even as medicine takes center stage in our national conversation.
Dr. Walthall completed his internal medicine residency at the Medical University of South Carolina in Charleston, SC. After residency, he joined the faculty at MUSC in the Division of Hospital Medicine. He is also interested in systems-based care and has taken on the role of physician advisor. This essay appeared first on The Hospital Leader, the official blog of SHM.
DAPT increases bleeding without decreasing mortality in patients with coronary disease and diabetes
Background: The PARTHENON clinical development program has conducted several clinical trials to assess the effectiveness of ticagrelor in multiple cardiovascular diseases. A prior study revealed the addition of ticagrelor to aspirin in patients with history of MI showed a small benefit in cardiovascular outcomes but with increased bleeding risk. While this effect was seen in both patients with and without diabetes, the absolute benefit for those with diabetes was considered large because of their higher baseline risk. Given this, investigators wanted to know if addition of ticagrelor to aspirin could also be beneficial in diabetics with known coronary disease but without history of MI or stroke.
Study design: Randomized, double-blind trial, intention-to-treat analysis.
Setting: Multicenter, 950 centers across 35 countries.
Synopsis: In this AstraZeneca-funded trial, 19,000 patients with diabetes and coronary disease without prior MI or stroke received either aspirin or DAPT (aspirin + ticagrelor). The composite outcome including cardiovascular death, MI, stroke, or death from any cause at 36 months was reduced in the DAPT arm (6.9% vs. 7.6%; hazard ratio, 0.90; 95% confidence interval, 0.81-0.99; P = .04) with a number needed to treat of 138. This composite outcome was driven by MI and stroke without differences in cardiovascular death or death from any cause. However, the primary safety outcome of major bleeding was higher with DAPT (2.2% vs. 1.0%; HR, 2.32; 95% CI, 1.82-2.94; P less than .001) with a number needed to treat of 93. Intracranial bleeding was higher with DAPT. Incidence of irreversible harm measured by death, MI, stroke, fatal bleeding, or intracranial hemorrhage showed no difference.
Further studies into risk stratification based on prothrombotic versus bleeding risk could be beneficial in identifying specific groups that could benefit from DAPT. Conclusions from this study suggest the benefit of DAPT in diabetics does not outweigh its risk.
Bottom line: Addition of ticagrelor to aspirin in diabetic patients with stable coronary disease and no prior MI or stroke is not recommended.
Citation: Steg PG et al. Ticagrelor in patients with stable coronary disease and diabetes. N Eng J Med. 2019 Oct 3;381(14):1309-20.
Dr. Breitbach is assistant professor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.
Background: The PARTHENON clinical development program has conducted several clinical trials to assess the effectiveness of ticagrelor in multiple cardiovascular diseases. A prior study revealed the addition of ticagrelor to aspirin in patients with history of MI showed a small benefit in cardiovascular outcomes but with increased bleeding risk. While this effect was seen in both patients with and without diabetes, the absolute benefit for those with diabetes was considered large because of their higher baseline risk. Given this, investigators wanted to know if addition of ticagrelor to aspirin could also be beneficial in diabetics with known coronary disease but without history of MI or stroke.
Study design: Randomized, double-blind trial, intention-to-treat analysis.
Setting: Multicenter, 950 centers across 35 countries.
Synopsis: In this AstraZeneca-funded trial, 19,000 patients with diabetes and coronary disease without prior MI or stroke received either aspirin or DAPT (aspirin + ticagrelor). The composite outcome including cardiovascular death, MI, stroke, or death from any cause at 36 months was reduced in the DAPT arm (6.9% vs. 7.6%; hazard ratio, 0.90; 95% confidence interval, 0.81-0.99; P = .04) with a number needed to treat of 138. This composite outcome was driven by MI and stroke without differences in cardiovascular death or death from any cause. However, the primary safety outcome of major bleeding was higher with DAPT (2.2% vs. 1.0%; HR, 2.32; 95% CI, 1.82-2.94; P less than .001) with a number needed to treat of 93. Intracranial bleeding was higher with DAPT. Incidence of irreversible harm measured by death, MI, stroke, fatal bleeding, or intracranial hemorrhage showed no difference.
Further studies into risk stratification based on prothrombotic versus bleeding risk could be beneficial in identifying specific groups that could benefit from DAPT. Conclusions from this study suggest the benefit of DAPT in diabetics does not outweigh its risk.
Bottom line: Addition of ticagrelor to aspirin in diabetic patients with stable coronary disease and no prior MI or stroke is not recommended.
Citation: Steg PG et al. Ticagrelor in patients with stable coronary disease and diabetes. N Eng J Med. 2019 Oct 3;381(14):1309-20.
Dr. Breitbach is assistant professor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.
Background: The PARTHENON clinical development program has conducted several clinical trials to assess the effectiveness of ticagrelor in multiple cardiovascular diseases. A prior study revealed the addition of ticagrelor to aspirin in patients with history of MI showed a small benefit in cardiovascular outcomes but with increased bleeding risk. While this effect was seen in both patients with and without diabetes, the absolute benefit for those with diabetes was considered large because of their higher baseline risk. Given this, investigators wanted to know if addition of ticagrelor to aspirin could also be beneficial in diabetics with known coronary disease but without history of MI or stroke.
Study design: Randomized, double-blind trial, intention-to-treat analysis.
Setting: Multicenter, 950 centers across 35 countries.
Synopsis: In this AstraZeneca-funded trial, 19,000 patients with diabetes and coronary disease without prior MI or stroke received either aspirin or DAPT (aspirin + ticagrelor). The composite outcome including cardiovascular death, MI, stroke, or death from any cause at 36 months was reduced in the DAPT arm (6.9% vs. 7.6%; hazard ratio, 0.90; 95% confidence interval, 0.81-0.99; P = .04) with a number needed to treat of 138. This composite outcome was driven by MI and stroke without differences in cardiovascular death or death from any cause. However, the primary safety outcome of major bleeding was higher with DAPT (2.2% vs. 1.0%; HR, 2.32; 95% CI, 1.82-2.94; P less than .001) with a number needed to treat of 93. Intracranial bleeding was higher with DAPT. Incidence of irreversible harm measured by death, MI, stroke, fatal bleeding, or intracranial hemorrhage showed no difference.
Further studies into risk stratification based on prothrombotic versus bleeding risk could be beneficial in identifying specific groups that could benefit from DAPT. Conclusions from this study suggest the benefit of DAPT in diabetics does not outweigh its risk.
Bottom line: Addition of ticagrelor to aspirin in diabetic patients with stable coronary disease and no prior MI or stroke is not recommended.
Citation: Steg PG et al. Ticagrelor in patients with stable coronary disease and diabetes. N Eng J Med. 2019 Oct 3;381(14):1309-20.
Dr. Breitbach is assistant professor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.
JHM Twitter chat sparks connections
Monthly social media event links editors, authors, and readers
Once upon a time, physicians wrote letters to peers and colleagues around the world, sharing their medical discoveries, theories, case reports, and questions; conferring on problems; and then waiting for return mail to bring a reply. And the science of medicine advanced at a glacial pace.
Today, communication in multiple mediums flows much faster, almost instantaneously, between many more physicians, regardless of distance, addressing a much greater complexity of medical topics and treatments. And one of the chief mediums for this rapid electronic conversation among doctors is Twitter, according to Charlie Wray, DO, MS, a hospitalist at the University of California, San Francisco.
Dr. Wray, associate editor and digital media editor for the Journal of Hospital Medicine, is one of the moderators of #JHMchat, a monthly get-together on Twitter for interested hospitalists to link up virtually; respond to questions posed by JHM editors and other moderators; exchange perspectives, experiences, and tips with their peers; and build professional relationships and personal friendships. Relationship building has become particularly important in the age of COVID-19, when opportunities to connect in person at events such as SHM’s annual conferences have been curtailed.
The online #JHMchat community began in 2015, shortly after Dr. Wray completed a hospitalist research fellowship at the University of Chicago. His fellowship mentor, Vineet Arora, MD, MAPP, MHM, associate chief medical officer for the clinical learning environment at University of Chicago Medicine, had noticed how other online medical communities were engaging in discussions around different topics.
“She thought it could be a great way for hospitalists to meet online and talk about the articles published in JHM,” Dr. Wray explained. “We were all getting into social media and learning how to moderate interactive discussions such as Twitter.”
The chat’s founders approached JHM’s then-editor Andrew Auerbach, MD, MHM, a hospitalist at UCSF, who agreed that it was a great idea. They asked Christopher Moriates, MD, author of a recently published paper on the advisability of nebulized bronchodilators for obstructive pulmonary symptoms and assistant dean for health care value at the University of Texas, Austin, to come on the chat and talk about his paper. Visiting Dr. Arora at the time, he joined her in her living room for the first chat on Oct. 12, 2015. Seventy-five participants posted 431 tweets, with a total of 2 million Twitter impressions, suggesting that they had tapped a latent need.
How the chat works
To participate in the JHM chats on Twitter, one needs to open an account on the platform (it’s free) and follow the Journal’s Twitter feed (@jhospmedicine). But that’s pretty much it, Dr. Wray said. The group convenes on a Monday evening each month for an hour, starting at 9 p.m. Eastern time. Upcoming chats and topics are announced on Twitter and at SHM’s website.
The chats have grown and evolved since 2015, shifting in focus given recent social upheavals over the pandemic and heated discussions about diversity, equity, and racial justice in medicine, he said. “When COVID hit, the journal’s editor – Dr. Samir Shah – recognized that we were in a unique moment with the pandemic. The journal took advantage of the opportunity to publish a lot more personal perspectives and viewpoints around COVID, along with a special issue devoted to social justice.”
Moderators for the chat typically choose three or four questions based on recently published articles or other relevant topics, such as racial inequities in health care or how to apply military principles to hospital medicine leadership. “We reach out to authors and tell them they can explain their articles to interested readers through the chat. I can’t think of a single one who said no. They see the opportunity to highlight their work and engage with readers who want to ask them questions,” Dr. Wray said.
The moderators’ questions are posed to stimulate participation, but another goal is to use that hour for networking. “It’s a powerful tool to allow SHM members to engage with each other,” he said. “Sometimes the chat has the feeling of trying to drink water from a fire hose – with the messages flashing past so quickly. But the key is not to try to respond to everything but rather to follow those threads that particularly interest you. We encourage you to engage, but it’s totally fine if you just sit back and observe. One thing we have done to make it a little more formal is to offer CME credits for participants.”
The chat welcomes hospitalists and nonhospitalists, nurse practitioners, physician assistants, academics, and nonacademics. “No matter how engaged you are with Twitter, if you have 10,000 followers or 10, we’ll amplify your voice,” he said. “We also have medical students participating and consider their perspectives valuable, too.”
Dr. Wray identified three main types of participants in the monthly chats. The first are regulars who come every month, rain or shine. Like the character Norm in the old television comedy “Cheers,” everybody knows their name. They become friends, sharing and reveling in each other’s accomplishments. “These are people who have multiple connections, personally and professionally, at a lot of different levels. I probably know a hundred or more people who I’ve primarily gotten to know online.”
A second and larger group might be drawn in because of an interest in a specific topic or article, but they’re also welcome to participate in the chat. And the third group may lurk in the background, following along but not commenting. The size of that third group is unknown, but metrics from SHM show a total of 796 participants posting 4,088 tweets during chats in 2020 (for an average of 132 participants and 681 tweets per chat). This adds up to a total of 34 million impressions across the platform for #JHMchat tweets for the year.
Creating community online
“Why do we do it? It’s difficult to read all of the relevant published articles and keep up to date,” said Dr. Arora, a medical educator whose job at Chicago Medicine is to improve the clinical learning environment for trainees and staff by aligning learning with the health system’s institutional quality, safety and value missions.
“Our idea was to bring together a kind of virtual journal club and have discussions around topics such as: how do you create a shared vision on rounds? How do you integrate that into clinical practice? How do we preserve work/life balance or address structural racism?” she said. Other topics have included work flow concerns, burnout, difficult conversations with patients, and career planning.
“The people we’re trying to reach are hospitalists – and they’re busy at the front lines of care. We also thought this was an interesting way to raise the journal’s profile and spark broader interest in the articles it publishes. But it’s really about creating community, with people who look forward to talking and connecting with each other each month through the chats,” Dr. Arora said. If they miss a chat, they feel they’ve missed important interactions.
“Many times when people log onto the chat, they give a status report on where they are at, such as ‘I’m home putting my kids to bed,’ or ‘I’m on call tonight,’ ” she added. “People are willing to engage with the medium because it’s easy to engage with. We can forget that physicians are like everyone else. They like to learn, but they want that learning to be fun.”
On Dec. 14, 2020, at 9 p.m. Eastern time, the first question for the monthly #JHMchat was posted: How will caring for COVID-19 patients this winter differ from caring for patients in the first wave? Given that another surge of hospitalized COVID patients is looming, participants posted that they feel familiar and more confident with effective clinical strategies for hospitalized COVID patients, having learned so much more about the virus. But they’re facing greater numbers of patients than in prior surges. “In March, we were in crisis, now we’re in complexity,” one noted.
Joining the moderators was the Pediatric Overflow Planning Contingency Response Network (POPCoRN), a group formed earlier this year to help mobilize pediatric medical capacity for COVID patients during pandemic surges (see “POPCoRN network mobilizes pediatric capacity during pandemic,” The Hospitalist, April 30, 2020). One of its questions involved the redeployment of physicians in response to COVID demands and what, for example, pediatric hospitalists need as resources and tools when they are reassigned to adult patients or to new roles in unfamiliar settings. A variety of educational resources were cited from POPCoRN, SHM, and ImproveDX, among others.
Defining medical communication
Another chat moderator is Angela Castellanos, MD, a pediatric hospitalist at Tufts Medical Center in Boston. Dr. Castellanos did a 1-year, full-time fellowship right after residency at the New England Journal of Medicine, participating hands-on as a member of the editorial team for the print and online editions of the venerable journal. She is now doing a digital media fellowship with JHM, a part-time commitment while holding down a full-time job as a hospitalist. She also puts together a Spanish language podcast covering primary care pediatric issues for parents and families.
“I’m interested in medical communication generally, as I try to figure out what that means,” she said. “I have continued to look for ways to be part of the social media community and to be more creative about it. The JHM fellowship came at a perfect time for me to learn to do more in digital media.”
COVID has created new opportunities for more immediate dialogue with colleagues – what are they seeing and what’s working in the absence of clinical trials, she explained. “That’s how we communicate, as a way to get information out fast, such as when hospitals began proning COVID patients to make it easier for them to breathe.”
Dr. Castellanos said she grew up with text messaging and social media and wants to continue to grow her skills in this area. “I think I developed some skills at NEJM, but the opportunity to see how they do things at another journal with a different mission was also valuable. I get to share the space with people in academic settings and leaders in my field. I tweet at them; they tweet at me. These two fellowships have given me unique insights and mentorships. I know I want to continue doing pediatric hospital medicine and to engage academically and learn how to do research.”
Twitter sometimes gets a bad reputation for hostile or incendiary posts, Dr. Wray noted. “If you look at social media writ large, it can sometimes seem like a dumpster fire.” But what has happened in the medical community and in most medical Twitter encounters is a more cordial approach to conversations. “People who work in medicine converse with each other, with room for respectful disagreements. We’re extra supportive of each other,” he said.
“I think if hospitalists are looking for a community of peers, to engage with them and network and to find colleagues in similar circumstances, the JHM chat is such a fantastic place,” Dr. Wray concluded. “Don’t just come once, come several times, meet people along the way. For me, one of the most beneficial ways to advance my career has been by connecting with people through the chat. It allows me to share my work and success with the hospitalist community, as well as highlighting my trainees’ and colleagues’ successes, and it has created opportunities I never would have expected for getting involved in other projects.”
Monthly social media event links editors, authors, and readers
Monthly social media event links editors, authors, and readers
Once upon a time, physicians wrote letters to peers and colleagues around the world, sharing their medical discoveries, theories, case reports, and questions; conferring on problems; and then waiting for return mail to bring a reply. And the science of medicine advanced at a glacial pace.
Today, communication in multiple mediums flows much faster, almost instantaneously, between many more physicians, regardless of distance, addressing a much greater complexity of medical topics and treatments. And one of the chief mediums for this rapid electronic conversation among doctors is Twitter, according to Charlie Wray, DO, MS, a hospitalist at the University of California, San Francisco.
Dr. Wray, associate editor and digital media editor for the Journal of Hospital Medicine, is one of the moderators of #JHMchat, a monthly get-together on Twitter for interested hospitalists to link up virtually; respond to questions posed by JHM editors and other moderators; exchange perspectives, experiences, and tips with their peers; and build professional relationships and personal friendships. Relationship building has become particularly important in the age of COVID-19, when opportunities to connect in person at events such as SHM’s annual conferences have been curtailed.
The online #JHMchat community began in 2015, shortly after Dr. Wray completed a hospitalist research fellowship at the University of Chicago. His fellowship mentor, Vineet Arora, MD, MAPP, MHM, associate chief medical officer for the clinical learning environment at University of Chicago Medicine, had noticed how other online medical communities were engaging in discussions around different topics.
“She thought it could be a great way for hospitalists to meet online and talk about the articles published in JHM,” Dr. Wray explained. “We were all getting into social media and learning how to moderate interactive discussions such as Twitter.”
The chat’s founders approached JHM’s then-editor Andrew Auerbach, MD, MHM, a hospitalist at UCSF, who agreed that it was a great idea. They asked Christopher Moriates, MD, author of a recently published paper on the advisability of nebulized bronchodilators for obstructive pulmonary symptoms and assistant dean for health care value at the University of Texas, Austin, to come on the chat and talk about his paper. Visiting Dr. Arora at the time, he joined her in her living room for the first chat on Oct. 12, 2015. Seventy-five participants posted 431 tweets, with a total of 2 million Twitter impressions, suggesting that they had tapped a latent need.
How the chat works
To participate in the JHM chats on Twitter, one needs to open an account on the platform (it’s free) and follow the Journal’s Twitter feed (@jhospmedicine). But that’s pretty much it, Dr. Wray said. The group convenes on a Monday evening each month for an hour, starting at 9 p.m. Eastern time. Upcoming chats and topics are announced on Twitter and at SHM’s website.
The chats have grown and evolved since 2015, shifting in focus given recent social upheavals over the pandemic and heated discussions about diversity, equity, and racial justice in medicine, he said. “When COVID hit, the journal’s editor – Dr. Samir Shah – recognized that we were in a unique moment with the pandemic. The journal took advantage of the opportunity to publish a lot more personal perspectives and viewpoints around COVID, along with a special issue devoted to social justice.”
Moderators for the chat typically choose three or four questions based on recently published articles or other relevant topics, such as racial inequities in health care or how to apply military principles to hospital medicine leadership. “We reach out to authors and tell them they can explain their articles to interested readers through the chat. I can’t think of a single one who said no. They see the opportunity to highlight their work and engage with readers who want to ask them questions,” Dr. Wray said.
The moderators’ questions are posed to stimulate participation, but another goal is to use that hour for networking. “It’s a powerful tool to allow SHM members to engage with each other,” he said. “Sometimes the chat has the feeling of trying to drink water from a fire hose – with the messages flashing past so quickly. But the key is not to try to respond to everything but rather to follow those threads that particularly interest you. We encourage you to engage, but it’s totally fine if you just sit back and observe. One thing we have done to make it a little more formal is to offer CME credits for participants.”
The chat welcomes hospitalists and nonhospitalists, nurse practitioners, physician assistants, academics, and nonacademics. “No matter how engaged you are with Twitter, if you have 10,000 followers or 10, we’ll amplify your voice,” he said. “We also have medical students participating and consider their perspectives valuable, too.”
Dr. Wray identified three main types of participants in the monthly chats. The first are regulars who come every month, rain or shine. Like the character Norm in the old television comedy “Cheers,” everybody knows their name. They become friends, sharing and reveling in each other’s accomplishments. “These are people who have multiple connections, personally and professionally, at a lot of different levels. I probably know a hundred or more people who I’ve primarily gotten to know online.”
A second and larger group might be drawn in because of an interest in a specific topic or article, but they’re also welcome to participate in the chat. And the third group may lurk in the background, following along but not commenting. The size of that third group is unknown, but metrics from SHM show a total of 796 participants posting 4,088 tweets during chats in 2020 (for an average of 132 participants and 681 tweets per chat). This adds up to a total of 34 million impressions across the platform for #JHMchat tweets for the year.
Creating community online
“Why do we do it? It’s difficult to read all of the relevant published articles and keep up to date,” said Dr. Arora, a medical educator whose job at Chicago Medicine is to improve the clinical learning environment for trainees and staff by aligning learning with the health system’s institutional quality, safety and value missions.
“Our idea was to bring together a kind of virtual journal club and have discussions around topics such as: how do you create a shared vision on rounds? How do you integrate that into clinical practice? How do we preserve work/life balance or address structural racism?” she said. Other topics have included work flow concerns, burnout, difficult conversations with patients, and career planning.
“The people we’re trying to reach are hospitalists – and they’re busy at the front lines of care. We also thought this was an interesting way to raise the journal’s profile and spark broader interest in the articles it publishes. But it’s really about creating community, with people who look forward to talking and connecting with each other each month through the chats,” Dr. Arora said. If they miss a chat, they feel they’ve missed important interactions.
“Many times when people log onto the chat, they give a status report on where they are at, such as ‘I’m home putting my kids to bed,’ or ‘I’m on call tonight,’ ” she added. “People are willing to engage with the medium because it’s easy to engage with. We can forget that physicians are like everyone else. They like to learn, but they want that learning to be fun.”
On Dec. 14, 2020, at 9 p.m. Eastern time, the first question for the monthly #JHMchat was posted: How will caring for COVID-19 patients this winter differ from caring for patients in the first wave? Given that another surge of hospitalized COVID patients is looming, participants posted that they feel familiar and more confident with effective clinical strategies for hospitalized COVID patients, having learned so much more about the virus. But they’re facing greater numbers of patients than in prior surges. “In March, we were in crisis, now we’re in complexity,” one noted.
Joining the moderators was the Pediatric Overflow Planning Contingency Response Network (POPCoRN), a group formed earlier this year to help mobilize pediatric medical capacity for COVID patients during pandemic surges (see “POPCoRN network mobilizes pediatric capacity during pandemic,” The Hospitalist, April 30, 2020). One of its questions involved the redeployment of physicians in response to COVID demands and what, for example, pediatric hospitalists need as resources and tools when they are reassigned to adult patients or to new roles in unfamiliar settings. A variety of educational resources were cited from POPCoRN, SHM, and ImproveDX, among others.
Defining medical communication
Another chat moderator is Angela Castellanos, MD, a pediatric hospitalist at Tufts Medical Center in Boston. Dr. Castellanos did a 1-year, full-time fellowship right after residency at the New England Journal of Medicine, participating hands-on as a member of the editorial team for the print and online editions of the venerable journal. She is now doing a digital media fellowship with JHM, a part-time commitment while holding down a full-time job as a hospitalist. She also puts together a Spanish language podcast covering primary care pediatric issues for parents and families.
“I’m interested in medical communication generally, as I try to figure out what that means,” she said. “I have continued to look for ways to be part of the social media community and to be more creative about it. The JHM fellowship came at a perfect time for me to learn to do more in digital media.”
COVID has created new opportunities for more immediate dialogue with colleagues – what are they seeing and what’s working in the absence of clinical trials, she explained. “That’s how we communicate, as a way to get information out fast, such as when hospitals began proning COVID patients to make it easier for them to breathe.”
Dr. Castellanos said she grew up with text messaging and social media and wants to continue to grow her skills in this area. “I think I developed some skills at NEJM, but the opportunity to see how they do things at another journal with a different mission was also valuable. I get to share the space with people in academic settings and leaders in my field. I tweet at them; they tweet at me. These two fellowships have given me unique insights and mentorships. I know I want to continue doing pediatric hospital medicine and to engage academically and learn how to do research.”
Twitter sometimes gets a bad reputation for hostile or incendiary posts, Dr. Wray noted. “If you look at social media writ large, it can sometimes seem like a dumpster fire.” But what has happened in the medical community and in most medical Twitter encounters is a more cordial approach to conversations. “People who work in medicine converse with each other, with room for respectful disagreements. We’re extra supportive of each other,” he said.
“I think if hospitalists are looking for a community of peers, to engage with them and network and to find colleagues in similar circumstances, the JHM chat is such a fantastic place,” Dr. Wray concluded. “Don’t just come once, come several times, meet people along the way. For me, one of the most beneficial ways to advance my career has been by connecting with people through the chat. It allows me to share my work and success with the hospitalist community, as well as highlighting my trainees’ and colleagues’ successes, and it has created opportunities I never would have expected for getting involved in other projects.”
Once upon a time, physicians wrote letters to peers and colleagues around the world, sharing their medical discoveries, theories, case reports, and questions; conferring on problems; and then waiting for return mail to bring a reply. And the science of medicine advanced at a glacial pace.
Today, communication in multiple mediums flows much faster, almost instantaneously, between many more physicians, regardless of distance, addressing a much greater complexity of medical topics and treatments. And one of the chief mediums for this rapid electronic conversation among doctors is Twitter, according to Charlie Wray, DO, MS, a hospitalist at the University of California, San Francisco.
Dr. Wray, associate editor and digital media editor for the Journal of Hospital Medicine, is one of the moderators of #JHMchat, a monthly get-together on Twitter for interested hospitalists to link up virtually; respond to questions posed by JHM editors and other moderators; exchange perspectives, experiences, and tips with their peers; and build professional relationships and personal friendships. Relationship building has become particularly important in the age of COVID-19, when opportunities to connect in person at events such as SHM’s annual conferences have been curtailed.
The online #JHMchat community began in 2015, shortly after Dr. Wray completed a hospitalist research fellowship at the University of Chicago. His fellowship mentor, Vineet Arora, MD, MAPP, MHM, associate chief medical officer for the clinical learning environment at University of Chicago Medicine, had noticed how other online medical communities were engaging in discussions around different topics.
“She thought it could be a great way for hospitalists to meet online and talk about the articles published in JHM,” Dr. Wray explained. “We were all getting into social media and learning how to moderate interactive discussions such as Twitter.”
The chat’s founders approached JHM’s then-editor Andrew Auerbach, MD, MHM, a hospitalist at UCSF, who agreed that it was a great idea. They asked Christopher Moriates, MD, author of a recently published paper on the advisability of nebulized bronchodilators for obstructive pulmonary symptoms and assistant dean for health care value at the University of Texas, Austin, to come on the chat and talk about his paper. Visiting Dr. Arora at the time, he joined her in her living room for the first chat on Oct. 12, 2015. Seventy-five participants posted 431 tweets, with a total of 2 million Twitter impressions, suggesting that they had tapped a latent need.
How the chat works
To participate in the JHM chats on Twitter, one needs to open an account on the platform (it’s free) and follow the Journal’s Twitter feed (@jhospmedicine). But that’s pretty much it, Dr. Wray said. The group convenes on a Monday evening each month for an hour, starting at 9 p.m. Eastern time. Upcoming chats and topics are announced on Twitter and at SHM’s website.
The chats have grown and evolved since 2015, shifting in focus given recent social upheavals over the pandemic and heated discussions about diversity, equity, and racial justice in medicine, he said. “When COVID hit, the journal’s editor – Dr. Samir Shah – recognized that we were in a unique moment with the pandemic. The journal took advantage of the opportunity to publish a lot more personal perspectives and viewpoints around COVID, along with a special issue devoted to social justice.”
Moderators for the chat typically choose three or four questions based on recently published articles or other relevant topics, such as racial inequities in health care or how to apply military principles to hospital medicine leadership. “We reach out to authors and tell them they can explain their articles to interested readers through the chat. I can’t think of a single one who said no. They see the opportunity to highlight their work and engage with readers who want to ask them questions,” Dr. Wray said.
The moderators’ questions are posed to stimulate participation, but another goal is to use that hour for networking. “It’s a powerful tool to allow SHM members to engage with each other,” he said. “Sometimes the chat has the feeling of trying to drink water from a fire hose – with the messages flashing past so quickly. But the key is not to try to respond to everything but rather to follow those threads that particularly interest you. We encourage you to engage, but it’s totally fine if you just sit back and observe. One thing we have done to make it a little more formal is to offer CME credits for participants.”
The chat welcomes hospitalists and nonhospitalists, nurse practitioners, physician assistants, academics, and nonacademics. “No matter how engaged you are with Twitter, if you have 10,000 followers or 10, we’ll amplify your voice,” he said. “We also have medical students participating and consider their perspectives valuable, too.”
Dr. Wray identified three main types of participants in the monthly chats. The first are regulars who come every month, rain or shine. Like the character Norm in the old television comedy “Cheers,” everybody knows their name. They become friends, sharing and reveling in each other’s accomplishments. “These are people who have multiple connections, personally and professionally, at a lot of different levels. I probably know a hundred or more people who I’ve primarily gotten to know online.”
A second and larger group might be drawn in because of an interest in a specific topic or article, but they’re also welcome to participate in the chat. And the third group may lurk in the background, following along but not commenting. The size of that third group is unknown, but metrics from SHM show a total of 796 participants posting 4,088 tweets during chats in 2020 (for an average of 132 participants and 681 tweets per chat). This adds up to a total of 34 million impressions across the platform for #JHMchat tweets for the year.
Creating community online
“Why do we do it? It’s difficult to read all of the relevant published articles and keep up to date,” said Dr. Arora, a medical educator whose job at Chicago Medicine is to improve the clinical learning environment for trainees and staff by aligning learning with the health system’s institutional quality, safety and value missions.
“Our idea was to bring together a kind of virtual journal club and have discussions around topics such as: how do you create a shared vision on rounds? How do you integrate that into clinical practice? How do we preserve work/life balance or address structural racism?” she said. Other topics have included work flow concerns, burnout, difficult conversations with patients, and career planning.
“The people we’re trying to reach are hospitalists – and they’re busy at the front lines of care. We also thought this was an interesting way to raise the journal’s profile and spark broader interest in the articles it publishes. But it’s really about creating community, with people who look forward to talking and connecting with each other each month through the chats,” Dr. Arora said. If they miss a chat, they feel they’ve missed important interactions.
“Many times when people log onto the chat, they give a status report on where they are at, such as ‘I’m home putting my kids to bed,’ or ‘I’m on call tonight,’ ” she added. “People are willing to engage with the medium because it’s easy to engage with. We can forget that physicians are like everyone else. They like to learn, but they want that learning to be fun.”
On Dec. 14, 2020, at 9 p.m. Eastern time, the first question for the monthly #JHMchat was posted: How will caring for COVID-19 patients this winter differ from caring for patients in the first wave? Given that another surge of hospitalized COVID patients is looming, participants posted that they feel familiar and more confident with effective clinical strategies for hospitalized COVID patients, having learned so much more about the virus. But they’re facing greater numbers of patients than in prior surges. “In March, we were in crisis, now we’re in complexity,” one noted.
Joining the moderators was the Pediatric Overflow Planning Contingency Response Network (POPCoRN), a group formed earlier this year to help mobilize pediatric medical capacity for COVID patients during pandemic surges (see “POPCoRN network mobilizes pediatric capacity during pandemic,” The Hospitalist, April 30, 2020). One of its questions involved the redeployment of physicians in response to COVID demands and what, for example, pediatric hospitalists need as resources and tools when they are reassigned to adult patients or to new roles in unfamiliar settings. A variety of educational resources were cited from POPCoRN, SHM, and ImproveDX, among others.
Defining medical communication
Another chat moderator is Angela Castellanos, MD, a pediatric hospitalist at Tufts Medical Center in Boston. Dr. Castellanos did a 1-year, full-time fellowship right after residency at the New England Journal of Medicine, participating hands-on as a member of the editorial team for the print and online editions of the venerable journal. She is now doing a digital media fellowship with JHM, a part-time commitment while holding down a full-time job as a hospitalist. She also puts together a Spanish language podcast covering primary care pediatric issues for parents and families.
“I’m interested in medical communication generally, as I try to figure out what that means,” she said. “I have continued to look for ways to be part of the social media community and to be more creative about it. The JHM fellowship came at a perfect time for me to learn to do more in digital media.”
COVID has created new opportunities for more immediate dialogue with colleagues – what are they seeing and what’s working in the absence of clinical trials, she explained. “That’s how we communicate, as a way to get information out fast, such as when hospitals began proning COVID patients to make it easier for them to breathe.”
Dr. Castellanos said she grew up with text messaging and social media and wants to continue to grow her skills in this area. “I think I developed some skills at NEJM, but the opportunity to see how they do things at another journal with a different mission was also valuable. I get to share the space with people in academic settings and leaders in my field. I tweet at them; they tweet at me. These two fellowships have given me unique insights and mentorships. I know I want to continue doing pediatric hospital medicine and to engage academically and learn how to do research.”
Twitter sometimes gets a bad reputation for hostile or incendiary posts, Dr. Wray noted. “If you look at social media writ large, it can sometimes seem like a dumpster fire.” But what has happened in the medical community and in most medical Twitter encounters is a more cordial approach to conversations. “People who work in medicine converse with each other, with room for respectful disagreements. We’re extra supportive of each other,” he said.
“I think if hospitalists are looking for a community of peers, to engage with them and network and to find colleagues in similar circumstances, the JHM chat is such a fantastic place,” Dr. Wray concluded. “Don’t just come once, come several times, meet people along the way. For me, one of the most beneficial ways to advance my career has been by connecting with people through the chat. It allows me to share my work and success with the hospitalist community, as well as highlighting my trainees’ and colleagues’ successes, and it has created opportunities I never would have expected for getting involved in other projects.”
New updates for Choosing Wisely in hospitalized patients with infection
Background: A new update to the Choosing Wisely Campaign was released September 2019.
Study design: Expert consensus recommendations from the American Society for Clinical Pathology.
Synopsis: Eleven of the 30 Choosing Wisely recommendations directly affect hospital medicine. Half of these recommendations are related to infectious diseases. Highlights include:
- Not routinely using broad respiratory viral testing and instead using more targeted approaches to respiratory pathogen tests (e.g., respiratory syncytial virus, influenza A/B, or group A pharyngitis) unless the results will lead to changes to or discontinuations of antimicrobial therapy or isolation.
- Not routinely testing for community gastrointestinal pathogens in patients that develop diarrhea 3 days after hospitalization and to primarily test for Clostridiodes difficile in these patients, unless they are immunocompromised or older adults.
- Not checking procalcitonin unless a specific evidence-based guideline is used for antibiotic stewardship, as it is often used incorrectly without benefit to the patient.
- Not ordering serology for Helicobacter pylori and instead ordering the stool antigen or breath test to test for active infection given higher sensitivity and specificity.
- Not repeating antibody tests for patients with history of hepatitis C and instead ordering a viral load if there is concern for reinfection.
Bottom line: Only order infectious disease tests that will guide changes in clinical management.
Citation: ASCP Effective Test Utilization Steering Committee. Thirty things patients and physicians should question. 2019 Sep 9. Choosingwisely.org.
Dr. Blount is clinical instructor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.
Background: A new update to the Choosing Wisely Campaign was released September 2019.
Study design: Expert consensus recommendations from the American Society for Clinical Pathology.
Synopsis: Eleven of the 30 Choosing Wisely recommendations directly affect hospital medicine. Half of these recommendations are related to infectious diseases. Highlights include:
- Not routinely using broad respiratory viral testing and instead using more targeted approaches to respiratory pathogen tests (e.g., respiratory syncytial virus, influenza A/B, or group A pharyngitis) unless the results will lead to changes to or discontinuations of antimicrobial therapy or isolation.
- Not routinely testing for community gastrointestinal pathogens in patients that develop diarrhea 3 days after hospitalization and to primarily test for Clostridiodes difficile in these patients, unless they are immunocompromised or older adults.
- Not checking procalcitonin unless a specific evidence-based guideline is used for antibiotic stewardship, as it is often used incorrectly without benefit to the patient.
- Not ordering serology for Helicobacter pylori and instead ordering the stool antigen or breath test to test for active infection given higher sensitivity and specificity.
- Not repeating antibody tests for patients with history of hepatitis C and instead ordering a viral load if there is concern for reinfection.
Bottom line: Only order infectious disease tests that will guide changes in clinical management.
Citation: ASCP Effective Test Utilization Steering Committee. Thirty things patients and physicians should question. 2019 Sep 9. Choosingwisely.org.
Dr. Blount is clinical instructor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.
Background: A new update to the Choosing Wisely Campaign was released September 2019.
Study design: Expert consensus recommendations from the American Society for Clinical Pathology.
Synopsis: Eleven of the 30 Choosing Wisely recommendations directly affect hospital medicine. Half of these recommendations are related to infectious diseases. Highlights include:
- Not routinely using broad respiratory viral testing and instead using more targeted approaches to respiratory pathogen tests (e.g., respiratory syncytial virus, influenza A/B, or group A pharyngitis) unless the results will lead to changes to or discontinuations of antimicrobial therapy or isolation.
- Not routinely testing for community gastrointestinal pathogens in patients that develop diarrhea 3 days after hospitalization and to primarily test for Clostridiodes difficile in these patients, unless they are immunocompromised or older adults.
- Not checking procalcitonin unless a specific evidence-based guideline is used for antibiotic stewardship, as it is often used incorrectly without benefit to the patient.
- Not ordering serology for Helicobacter pylori and instead ordering the stool antigen or breath test to test for active infection given higher sensitivity and specificity.
- Not repeating antibody tests for patients with history of hepatitis C and instead ordering a viral load if there is concern for reinfection.
Bottom line: Only order infectious disease tests that will guide changes in clinical management.
Citation: ASCP Effective Test Utilization Steering Committee. Thirty things patients and physicians should question. 2019 Sep 9. Choosingwisely.org.
Dr. Blount is clinical instructor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.