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‘The kids will be all right,’ won’t they?
Pediatric patients and COVID-19
The coronavirus disease 2019 (COVID-19) pandemic affects us in many ways. Pediatric patients, interestingly, are largely unaffected clinically by this disease. Less than 1% of documented infections occur in children under 10 years old, according to a review of over 72,000 cases from China.1 In that review, most children were asymptomatic or had mild illness, only three required intensive care, and only one death had been reported as of March 10, 2020. This is in stark contrast to the shocking morbidity and mortality statistics we are becoming all too familiar with on the adult side.
From a social standpoint, however, our pediatric patients’ lives have been turned upside down. Their schedules and routines upended, their education and friendships interrupted, and many are likely experiencing real anxiety and fear.2 For countless children, school is a major source of social, emotional, and nutritional support that has been cut off. Some will lose parents, grandparents, or other loved ones to this disease. Parents will lose jobs and will be unable to afford necessities. Pediatric patients will experience delays of procedures or treatments because of the pandemic. Some have projected that rates of child abuse will increase as has been reported during natural disasters.3
Pediatricians around the country are coming together to tackle these issues in creative ways, including the rapid expansion of virtual/telehealth programs. The school systems are developing strategies to deliver online content, and even food, to their students’ homes. Hopefully these tactics will mitigate some of the potential effects on the mental and physical well-being of these patients.
How about my kids? Will they be all right? I am lucky that my husband and I will have jobs throughout this ordeal. Unfortunately, given my role as a hospitalist and my husband’s as a pulmonary/critical care physician, these same jobs that will keep our kids nourished and supported pose the greatest threat to them. As health care workers, we are worried about protecting our families, which may include vulnerable members. The Spanish health ministry announced that medical professionals account for approximately one in eight documented COVID-19 infections in Spain.4 With inadequate supplies of personal protective equipment (PPE) in our own nation, we are concerned that our statistics could be similar.
There are multiple strategies to protect ourselves and our families during this difficult time. First, appropriate PPE is essential and integrity with the process must be maintained always. Hospital leaders can protect us by tirelessly working to acquire PPE. In Grand Rapids, Mich., our health system has partnered with multiple local manufacturing companies, including Steelcase, who are producing PPE for our workforce.5 Leaders can diligently update their system’s PPE recommendations to be in line with the latest CDC recommendations and disseminate the information regularly. Hospitalists should frequently check with their Infection Prevention department to make sure they understand if there have been any changes to the recommendations. Innovative solutions for sterilization of PPE, stethoscopes, badges and other equipment, such as with the use of UV boxes or hydrogen peroxide vapor,6 should be explored to minimize contamination. Hospitalists should bring a set of clothes and shoes to change into upon arrival to work and to change out of prior to leaving the hospital.
We must also keep our heads strong. Currently the anxiety amongst physicians is palpable but there is solidarity. Hospital leaders must ensure that hospitalists have easy access to free mental health resources, such as virtual counseling. Wellness teams must rise to the occasion with innovative tactics to support us. For example, Spectrum Health’s wellness team is sponsoring a blog where physicians can discuss COVID-19–related challenges openly. Hospitalist leaders should ensure that there is a structure for debriefing after critical incidents, which are sure to increase in frequency. Email lists and discussion boards sponsored by professional society also provide a collaborative venue for some of these discussions. We must take advantage of these resources and communicate with each other.
For me, in the end it comes back to the kids. My kids and most pediatric patients are not likely to be hospitalized from COVID-19, but they are also not immune to the toll that fighting this pandemic will take on our families. We took an oath to protect our patients, but what do we owe to our own children? At a minimum we can optimize how we protect ourselves every day, both physically and mentally. As we come together as a strong community to fight this pandemic, in addition to saving lives, we are working to ensure that, in the end, the kids will be all right.
Dr. Hadley is chief of pediatric hospital medicine at Spectrum Health/Helen DeVos Children’s Hospital in Grand Rapids, Mich., and clinical assistant professor at Michigan State University, East Lansing.
References
1. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020 Feb 24. doi: 10.1001/jama.2020.2648.
2. Hagan JF Jr; American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health; Task Force on Terrorism. Psychosocial implications of disaster or terrorism on children: A guide for the pediatrician. Pediatrics. 2005;116(3):787-795.
3. Gearhart S et al. The impact of natural disasters on domestic violence: An analysis of reports of simple assault in Florida (1997-2007). Violence Gend. 2018 Jun. doi: 10.1089/vio.2017.0077.
4. Minder R, Peltier E. Virus knocks thousands of health workers out of action in Europe. The New York Times. March 24, 2020.
5. McVicar B. West Michigan businesses hustle to produce medical supplies amid coronavirus pandemic. MLive. March 25, 2020.
6. Kenney PA et al. Hydrogen Peroxide Vapor sterilization of N95 respirators for reuse. medRxiv preprint. 2020 Mar. doi: 10.1101/2020.03.24.20041087.
Pediatric patients and COVID-19
Pediatric patients and COVID-19
The coronavirus disease 2019 (COVID-19) pandemic affects us in many ways. Pediatric patients, interestingly, are largely unaffected clinically by this disease. Less than 1% of documented infections occur in children under 10 years old, according to a review of over 72,000 cases from China.1 In that review, most children were asymptomatic or had mild illness, only three required intensive care, and only one death had been reported as of March 10, 2020. This is in stark contrast to the shocking morbidity and mortality statistics we are becoming all too familiar with on the adult side.
From a social standpoint, however, our pediatric patients’ lives have been turned upside down. Their schedules and routines upended, their education and friendships interrupted, and many are likely experiencing real anxiety and fear.2 For countless children, school is a major source of social, emotional, and nutritional support that has been cut off. Some will lose parents, grandparents, or other loved ones to this disease. Parents will lose jobs and will be unable to afford necessities. Pediatric patients will experience delays of procedures or treatments because of the pandemic. Some have projected that rates of child abuse will increase as has been reported during natural disasters.3
Pediatricians around the country are coming together to tackle these issues in creative ways, including the rapid expansion of virtual/telehealth programs. The school systems are developing strategies to deliver online content, and even food, to their students’ homes. Hopefully these tactics will mitigate some of the potential effects on the mental and physical well-being of these patients.
How about my kids? Will they be all right? I am lucky that my husband and I will have jobs throughout this ordeal. Unfortunately, given my role as a hospitalist and my husband’s as a pulmonary/critical care physician, these same jobs that will keep our kids nourished and supported pose the greatest threat to them. As health care workers, we are worried about protecting our families, which may include vulnerable members. The Spanish health ministry announced that medical professionals account for approximately one in eight documented COVID-19 infections in Spain.4 With inadequate supplies of personal protective equipment (PPE) in our own nation, we are concerned that our statistics could be similar.
There are multiple strategies to protect ourselves and our families during this difficult time. First, appropriate PPE is essential and integrity with the process must be maintained always. Hospital leaders can protect us by tirelessly working to acquire PPE. In Grand Rapids, Mich., our health system has partnered with multiple local manufacturing companies, including Steelcase, who are producing PPE for our workforce.5 Leaders can diligently update their system’s PPE recommendations to be in line with the latest CDC recommendations and disseminate the information regularly. Hospitalists should frequently check with their Infection Prevention department to make sure they understand if there have been any changes to the recommendations. Innovative solutions for sterilization of PPE, stethoscopes, badges and other equipment, such as with the use of UV boxes or hydrogen peroxide vapor,6 should be explored to minimize contamination. Hospitalists should bring a set of clothes and shoes to change into upon arrival to work and to change out of prior to leaving the hospital.
We must also keep our heads strong. Currently the anxiety amongst physicians is palpable but there is solidarity. Hospital leaders must ensure that hospitalists have easy access to free mental health resources, such as virtual counseling. Wellness teams must rise to the occasion with innovative tactics to support us. For example, Spectrum Health’s wellness team is sponsoring a blog where physicians can discuss COVID-19–related challenges openly. Hospitalist leaders should ensure that there is a structure for debriefing after critical incidents, which are sure to increase in frequency. Email lists and discussion boards sponsored by professional society also provide a collaborative venue for some of these discussions. We must take advantage of these resources and communicate with each other.
For me, in the end it comes back to the kids. My kids and most pediatric patients are not likely to be hospitalized from COVID-19, but they are also not immune to the toll that fighting this pandemic will take on our families. We took an oath to protect our patients, but what do we owe to our own children? At a minimum we can optimize how we protect ourselves every day, both physically and mentally. As we come together as a strong community to fight this pandemic, in addition to saving lives, we are working to ensure that, in the end, the kids will be all right.
Dr. Hadley is chief of pediatric hospital medicine at Spectrum Health/Helen DeVos Children’s Hospital in Grand Rapids, Mich., and clinical assistant professor at Michigan State University, East Lansing.
References
1. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020 Feb 24. doi: 10.1001/jama.2020.2648.
2. Hagan JF Jr; American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health; Task Force on Terrorism. Psychosocial implications of disaster or terrorism on children: A guide for the pediatrician. Pediatrics. 2005;116(3):787-795.
3. Gearhart S et al. The impact of natural disasters on domestic violence: An analysis of reports of simple assault in Florida (1997-2007). Violence Gend. 2018 Jun. doi: 10.1089/vio.2017.0077.
4. Minder R, Peltier E. Virus knocks thousands of health workers out of action in Europe. The New York Times. March 24, 2020.
5. McVicar B. West Michigan businesses hustle to produce medical supplies amid coronavirus pandemic. MLive. March 25, 2020.
6. Kenney PA et al. Hydrogen Peroxide Vapor sterilization of N95 respirators for reuse. medRxiv preprint. 2020 Mar. doi: 10.1101/2020.03.24.20041087.
The coronavirus disease 2019 (COVID-19) pandemic affects us in many ways. Pediatric patients, interestingly, are largely unaffected clinically by this disease. Less than 1% of documented infections occur in children under 10 years old, according to a review of over 72,000 cases from China.1 In that review, most children were asymptomatic or had mild illness, only three required intensive care, and only one death had been reported as of March 10, 2020. This is in stark contrast to the shocking morbidity and mortality statistics we are becoming all too familiar with on the adult side.
From a social standpoint, however, our pediatric patients’ lives have been turned upside down. Their schedules and routines upended, their education and friendships interrupted, and many are likely experiencing real anxiety and fear.2 For countless children, school is a major source of social, emotional, and nutritional support that has been cut off. Some will lose parents, grandparents, or other loved ones to this disease. Parents will lose jobs and will be unable to afford necessities. Pediatric patients will experience delays of procedures or treatments because of the pandemic. Some have projected that rates of child abuse will increase as has been reported during natural disasters.3
Pediatricians around the country are coming together to tackle these issues in creative ways, including the rapid expansion of virtual/telehealth programs. The school systems are developing strategies to deliver online content, and even food, to their students’ homes. Hopefully these tactics will mitigate some of the potential effects on the mental and physical well-being of these patients.
How about my kids? Will they be all right? I am lucky that my husband and I will have jobs throughout this ordeal. Unfortunately, given my role as a hospitalist and my husband’s as a pulmonary/critical care physician, these same jobs that will keep our kids nourished and supported pose the greatest threat to them. As health care workers, we are worried about protecting our families, which may include vulnerable members. The Spanish health ministry announced that medical professionals account for approximately one in eight documented COVID-19 infections in Spain.4 With inadequate supplies of personal protective equipment (PPE) in our own nation, we are concerned that our statistics could be similar.
There are multiple strategies to protect ourselves and our families during this difficult time. First, appropriate PPE is essential and integrity with the process must be maintained always. Hospital leaders can protect us by tirelessly working to acquire PPE. In Grand Rapids, Mich., our health system has partnered with multiple local manufacturing companies, including Steelcase, who are producing PPE for our workforce.5 Leaders can diligently update their system’s PPE recommendations to be in line with the latest CDC recommendations and disseminate the information regularly. Hospitalists should frequently check with their Infection Prevention department to make sure they understand if there have been any changes to the recommendations. Innovative solutions for sterilization of PPE, stethoscopes, badges and other equipment, such as with the use of UV boxes or hydrogen peroxide vapor,6 should be explored to minimize contamination. Hospitalists should bring a set of clothes and shoes to change into upon arrival to work and to change out of prior to leaving the hospital.
We must also keep our heads strong. Currently the anxiety amongst physicians is palpable but there is solidarity. Hospital leaders must ensure that hospitalists have easy access to free mental health resources, such as virtual counseling. Wellness teams must rise to the occasion with innovative tactics to support us. For example, Spectrum Health’s wellness team is sponsoring a blog where physicians can discuss COVID-19–related challenges openly. Hospitalist leaders should ensure that there is a structure for debriefing after critical incidents, which are sure to increase in frequency. Email lists and discussion boards sponsored by professional society also provide a collaborative venue for some of these discussions. We must take advantage of these resources and communicate with each other.
For me, in the end it comes back to the kids. My kids and most pediatric patients are not likely to be hospitalized from COVID-19, but they are also not immune to the toll that fighting this pandemic will take on our families. We took an oath to protect our patients, but what do we owe to our own children? At a minimum we can optimize how we protect ourselves every day, both physically and mentally. As we come together as a strong community to fight this pandemic, in addition to saving lives, we are working to ensure that, in the end, the kids will be all right.
Dr. Hadley is chief of pediatric hospital medicine at Spectrum Health/Helen DeVos Children’s Hospital in Grand Rapids, Mich., and clinical assistant professor at Michigan State University, East Lansing.
References
1. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020 Feb 24. doi: 10.1001/jama.2020.2648.
2. Hagan JF Jr; American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health; Task Force on Terrorism. Psychosocial implications of disaster or terrorism on children: A guide for the pediatrician. Pediatrics. 2005;116(3):787-795.
3. Gearhart S et al. The impact of natural disasters on domestic violence: An analysis of reports of simple assault in Florida (1997-2007). Violence Gend. 2018 Jun. doi: 10.1089/vio.2017.0077.
4. Minder R, Peltier E. Virus knocks thousands of health workers out of action in Europe. The New York Times. March 24, 2020.
5. McVicar B. West Michigan businesses hustle to produce medical supplies amid coronavirus pandemic. MLive. March 25, 2020.
6. Kenney PA et al. Hydrogen Peroxide Vapor sterilization of N95 respirators for reuse. medRxiv preprint. 2020 Mar. doi: 10.1101/2020.03.24.20041087.
The future of hospital medicine
Assured? Or a definite maybe?
When I started at SHM in 2000, there were fewer than 1,000 hospitalists in the US, and now there are more than 60,000. SHM (back then, we were the National Association of Inpatient Physicians) had about 300 members; now, we have more than 20,000.
Today, hospitalists are part of the medical staff at virtually every hospital in the country, and hospital medicine is recognized as a unique medical specialty with our own knowledge base, textbooks, competencies, meetings, and medical professional society. In a health care environment swirling with change, we are one of the few specialties forged with the ability to adapt and, at times, lead this change. Yet there is so much disruption and instability that there are still many twists and turns in the road that will affect hospitalists’ ability to carve out an even brighter future.
Consolidation has come to health care on a large scale. Hospitals are merging. Health insurers are combining, and even large hospital medicine companies like TeamHealth, Sound, Envision, and others are merging, growing, and acquiring.
At the same time, outside forces from industries not usually associated with health care or inpatient care are swarming into our world: CVS acquires Aetna and aims to reshape primary care; Amazon dominates health care supply chains and moves into pharmacy benefits, and even gets into health care delivery via their partnership with Berkshire Hathaway and JP Morgan; Walmart merges with Humana to create one of the biggest players in Medicare; and Apple expands their inroads into wearables and chronic disease management.
Employment of clinicians has grown logarithmically, especially with inpatient physicians, reshaping the medical staff compensation and accountability. At the same time, payers, both government and private, are evolving into population health with an emphasis not so much on transactions (visits and procedures), but more aligned with outcomes, effectiveness, and efficiency.
All of this leads to a new paradigm of what is important and a new set of values that seems at times more like corporate America where the loyalty of employees can be torn between their employer and the patient. This is especially troublesome in a field traditionally based on the primacy of the doctor-patient relationship. This can put the hospitalist right in the middle at the time when the patient can be most vulnerable.
This has led to new ways to deliver the care that hospitalists provide. First as a pilot and now moving more mainstream, patients with several diagnoses (e.g., heart failure, dehydration, or pneumonia) are now managed not in bricks and mortar hospitals, but in “hospitals at home.” The last few days of a typical hospitalization now take place outside the hospital in a skilled nursing facility (SNF). Fear of uncompensated and unnecessary readmissions leads hospitals to engage hospitalists to handle the first few post-discharge outpatient visits.
This is just a small part of the expanding scope for hospitalists. In addition to managing SNFs and the discharge clinic, hospitalists are now the major providers of perioperative care and play a growing role in palliative care, especially for inpatients. As other specialties that abut hospital medicine have increasing demands and yet fewer new specialists, hospitalists are taking on more critical care and geriatrics, providing procedures, and occupy an evolving role in the emergency room.
There is a lot of work coming towards hospital medicine, and to expand our workforce, hospital medicine groups have incorporated advanced practice providers, including nurse practitioners and physician assistants. But building a true team of health professionals is not seamless or easy with each constituency having a unique scope of practice, limits on their licensure, their own culture, and a distinct training background.
But wait. There will be more new players on the hospital medicine team going forward – some we cannot even anticipate at the present time. In the future, the hospitalist may not even touch the electronic health record (EHR). Clinicians have never excelled at data entry or analysis, and it is time to use a combination of artificial intelligence (AI), voice-activated gathering of history into the record, and staff trained to manage the EHR on both the input and the output sides.
While there may be cheering for this new approach to the EHR – especially because it is a major factor in hospitalist burnout – this will refocus the role and work of the hospitalist to be more of a reviewer and integrator of data, and a strategist and decision-maker overseeing 30 or more patients. As Amazon, CVS, and Walmart move into health care, they will look for the best way to utilize the $300-400/hour hospitalist to the top of our skill level.
In the end, this all comes back to how hospitalists add value, how we can create a career that is rewarding, and how we can help hospitalists be resilient and avoid burnout.
The good news is that hospitalists will not be replaced by AI, nor should we expect to have our incomes cut as less well-trained alternatives replace highly compensated physicians in other specialties. This is a real prospect for many other specialties like dermatology, radiology, pathology, anesthesiology, and even cardiology. But hospitalists will need to adapt to changes in what is valued (i.e., how you can be the most effective and efficient) and to a new job description (i.e., overseeing more patients and managing a team that does more of the H&P, data collecting, and bedside work).
After 20 years of coming out of nowhere to being in the middle of everything in health care, I am confident that hospitalists, with the help of SHM, can continue to forge a path where we can be key difference makers and where we can create a rewarding and sustainable career. It won’t “just happen.” It is not inevitable. But if the past 20 years is any example, we are well-positioned to make the adaptation to succeed in the next 20 years. It is up to all of us to make it happen.
Dr. Wellikson is the CEO of SHM and is retiring from his role in 2020. This article is the second in a series celebrating Dr. Wellikson’s tenure as CEO.
Assured? Or a definite maybe?
Assured? Or a definite maybe?
When I started at SHM in 2000, there were fewer than 1,000 hospitalists in the US, and now there are more than 60,000. SHM (back then, we were the National Association of Inpatient Physicians) had about 300 members; now, we have more than 20,000.
Today, hospitalists are part of the medical staff at virtually every hospital in the country, and hospital medicine is recognized as a unique medical specialty with our own knowledge base, textbooks, competencies, meetings, and medical professional society. In a health care environment swirling with change, we are one of the few specialties forged with the ability to adapt and, at times, lead this change. Yet there is so much disruption and instability that there are still many twists and turns in the road that will affect hospitalists’ ability to carve out an even brighter future.
Consolidation has come to health care on a large scale. Hospitals are merging. Health insurers are combining, and even large hospital medicine companies like TeamHealth, Sound, Envision, and others are merging, growing, and acquiring.
At the same time, outside forces from industries not usually associated with health care or inpatient care are swarming into our world: CVS acquires Aetna and aims to reshape primary care; Amazon dominates health care supply chains and moves into pharmacy benefits, and even gets into health care delivery via their partnership with Berkshire Hathaway and JP Morgan; Walmart merges with Humana to create one of the biggest players in Medicare; and Apple expands their inroads into wearables and chronic disease management.
Employment of clinicians has grown logarithmically, especially with inpatient physicians, reshaping the medical staff compensation and accountability. At the same time, payers, both government and private, are evolving into population health with an emphasis not so much on transactions (visits and procedures), but more aligned with outcomes, effectiveness, and efficiency.
All of this leads to a new paradigm of what is important and a new set of values that seems at times more like corporate America where the loyalty of employees can be torn between their employer and the patient. This is especially troublesome in a field traditionally based on the primacy of the doctor-patient relationship. This can put the hospitalist right in the middle at the time when the patient can be most vulnerable.
This has led to new ways to deliver the care that hospitalists provide. First as a pilot and now moving more mainstream, patients with several diagnoses (e.g., heart failure, dehydration, or pneumonia) are now managed not in bricks and mortar hospitals, but in “hospitals at home.” The last few days of a typical hospitalization now take place outside the hospital in a skilled nursing facility (SNF). Fear of uncompensated and unnecessary readmissions leads hospitals to engage hospitalists to handle the first few post-discharge outpatient visits.
This is just a small part of the expanding scope for hospitalists. In addition to managing SNFs and the discharge clinic, hospitalists are now the major providers of perioperative care and play a growing role in palliative care, especially for inpatients. As other specialties that abut hospital medicine have increasing demands and yet fewer new specialists, hospitalists are taking on more critical care and geriatrics, providing procedures, and occupy an evolving role in the emergency room.
There is a lot of work coming towards hospital medicine, and to expand our workforce, hospital medicine groups have incorporated advanced practice providers, including nurse practitioners and physician assistants. But building a true team of health professionals is not seamless or easy with each constituency having a unique scope of practice, limits on their licensure, their own culture, and a distinct training background.
But wait. There will be more new players on the hospital medicine team going forward – some we cannot even anticipate at the present time. In the future, the hospitalist may not even touch the electronic health record (EHR). Clinicians have never excelled at data entry or analysis, and it is time to use a combination of artificial intelligence (AI), voice-activated gathering of history into the record, and staff trained to manage the EHR on both the input and the output sides.
While there may be cheering for this new approach to the EHR – especially because it is a major factor in hospitalist burnout – this will refocus the role and work of the hospitalist to be more of a reviewer and integrator of data, and a strategist and decision-maker overseeing 30 or more patients. As Amazon, CVS, and Walmart move into health care, they will look for the best way to utilize the $300-400/hour hospitalist to the top of our skill level.
In the end, this all comes back to how hospitalists add value, how we can create a career that is rewarding, and how we can help hospitalists be resilient and avoid burnout.
The good news is that hospitalists will not be replaced by AI, nor should we expect to have our incomes cut as less well-trained alternatives replace highly compensated physicians in other specialties. This is a real prospect for many other specialties like dermatology, radiology, pathology, anesthesiology, and even cardiology. But hospitalists will need to adapt to changes in what is valued (i.e., how you can be the most effective and efficient) and to a new job description (i.e., overseeing more patients and managing a team that does more of the H&P, data collecting, and bedside work).
After 20 years of coming out of nowhere to being in the middle of everything in health care, I am confident that hospitalists, with the help of SHM, can continue to forge a path where we can be key difference makers and where we can create a rewarding and sustainable career. It won’t “just happen.” It is not inevitable. But if the past 20 years is any example, we are well-positioned to make the adaptation to succeed in the next 20 years. It is up to all of us to make it happen.
Dr. Wellikson is the CEO of SHM and is retiring from his role in 2020. This article is the second in a series celebrating Dr. Wellikson’s tenure as CEO.
When I started at SHM in 2000, there were fewer than 1,000 hospitalists in the US, and now there are more than 60,000. SHM (back then, we were the National Association of Inpatient Physicians) had about 300 members; now, we have more than 20,000.
Today, hospitalists are part of the medical staff at virtually every hospital in the country, and hospital medicine is recognized as a unique medical specialty with our own knowledge base, textbooks, competencies, meetings, and medical professional society. In a health care environment swirling with change, we are one of the few specialties forged with the ability to adapt and, at times, lead this change. Yet there is so much disruption and instability that there are still many twists and turns in the road that will affect hospitalists’ ability to carve out an even brighter future.
Consolidation has come to health care on a large scale. Hospitals are merging. Health insurers are combining, and even large hospital medicine companies like TeamHealth, Sound, Envision, and others are merging, growing, and acquiring.
At the same time, outside forces from industries not usually associated with health care or inpatient care are swarming into our world: CVS acquires Aetna and aims to reshape primary care; Amazon dominates health care supply chains and moves into pharmacy benefits, and even gets into health care delivery via their partnership with Berkshire Hathaway and JP Morgan; Walmart merges with Humana to create one of the biggest players in Medicare; and Apple expands their inroads into wearables and chronic disease management.
Employment of clinicians has grown logarithmically, especially with inpatient physicians, reshaping the medical staff compensation and accountability. At the same time, payers, both government and private, are evolving into population health with an emphasis not so much on transactions (visits and procedures), but more aligned with outcomes, effectiveness, and efficiency.
All of this leads to a new paradigm of what is important and a new set of values that seems at times more like corporate America where the loyalty of employees can be torn between their employer and the patient. This is especially troublesome in a field traditionally based on the primacy of the doctor-patient relationship. This can put the hospitalist right in the middle at the time when the patient can be most vulnerable.
This has led to new ways to deliver the care that hospitalists provide. First as a pilot and now moving more mainstream, patients with several diagnoses (e.g., heart failure, dehydration, or pneumonia) are now managed not in bricks and mortar hospitals, but in “hospitals at home.” The last few days of a typical hospitalization now take place outside the hospital in a skilled nursing facility (SNF). Fear of uncompensated and unnecessary readmissions leads hospitals to engage hospitalists to handle the first few post-discharge outpatient visits.
This is just a small part of the expanding scope for hospitalists. In addition to managing SNFs and the discharge clinic, hospitalists are now the major providers of perioperative care and play a growing role in palliative care, especially for inpatients. As other specialties that abut hospital medicine have increasing demands and yet fewer new specialists, hospitalists are taking on more critical care and geriatrics, providing procedures, and occupy an evolving role in the emergency room.
There is a lot of work coming towards hospital medicine, and to expand our workforce, hospital medicine groups have incorporated advanced practice providers, including nurse practitioners and physician assistants. But building a true team of health professionals is not seamless or easy with each constituency having a unique scope of practice, limits on their licensure, their own culture, and a distinct training background.
But wait. There will be more new players on the hospital medicine team going forward – some we cannot even anticipate at the present time. In the future, the hospitalist may not even touch the electronic health record (EHR). Clinicians have never excelled at data entry or analysis, and it is time to use a combination of artificial intelligence (AI), voice-activated gathering of history into the record, and staff trained to manage the EHR on both the input and the output sides.
While there may be cheering for this new approach to the EHR – especially because it is a major factor in hospitalist burnout – this will refocus the role and work of the hospitalist to be more of a reviewer and integrator of data, and a strategist and decision-maker overseeing 30 or more patients. As Amazon, CVS, and Walmart move into health care, they will look for the best way to utilize the $300-400/hour hospitalist to the top of our skill level.
In the end, this all comes back to how hospitalists add value, how we can create a career that is rewarding, and how we can help hospitalists be resilient and avoid burnout.
The good news is that hospitalists will not be replaced by AI, nor should we expect to have our incomes cut as less well-trained alternatives replace highly compensated physicians in other specialties. This is a real prospect for many other specialties like dermatology, radiology, pathology, anesthesiology, and even cardiology. But hospitalists will need to adapt to changes in what is valued (i.e., how you can be the most effective and efficient) and to a new job description (i.e., overseeing more patients and managing a team that does more of the H&P, data collecting, and bedside work).
After 20 years of coming out of nowhere to being in the middle of everything in health care, I am confident that hospitalists, with the help of SHM, can continue to forge a path where we can be key difference makers and where we can create a rewarding and sustainable career. It won’t “just happen.” It is not inevitable. But if the past 20 years is any example, we are well-positioned to make the adaptation to succeed in the next 20 years. It is up to all of us to make it happen.
Dr. Wellikson is the CEO of SHM and is retiring from his role in 2020. This article is the second in a series celebrating Dr. Wellikson’s tenure as CEO.
Meet the new SHM president: Dr. Danielle Scheurer
Danielle Scheurer, MD, MSRC, SFHM, is the chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is the outgoing medical editor of The Hospitalist, and the new president of the Society of Hospital Medicine. She assumes the role from immediate past-president Christopher Frost, MD, SFHM.
As a hospitalist for 17 years, Dr. Scheurer has practiced in both academic tertiary care, as well as community hospital settings. As a chief quality officer, she has worked to improve quality and safety in all health care settings, including ambulatory care, nursing homes, home health, and surgical centers. She brings a broad experience in the medical industry to the SHM presidency.
At what point in your education/training did you decide to practice hospital medicine?
I always loved inpatient medicine throughout my entire meds-peds residency training at Duke University in Durham, N.C. I honestly never had a doubt that hospital medicine was going to be my career. What appeals to me is that each hour and each day is different, which is invigorating.
What are your favorite aspects of clinical practice and of your administrative duties?
I like doing both administrative work and clinical work because I believe having a view of both worlds helps me to be a better physician and a better administrator. It greatly helps me bring realistic solutions to the front lines since I have a good understanding of what needs to be done, but also what is likely to actually work.
As president of SHM over the next year, what are your primary goals?
My primary goal is to deeply connect with the SHM membership and understand what their needs are. There is enormous change happening in the medical industry, and SHM should be a conduit for information sharing, resources, and most importantly, answers to all our difficult problems. Hospitalists are critical to success for our hospitals and our communities during the COVID-19 pandemic. We must be able to give and receive information quickly and seamlessly to effectively help each other across the country and the world. SHM must be seen as a critical convener, especially in times of crisis.
Additionally, SHM has always fostered a “big tent” philosophy, so we will continue to explore ways to expand membership beyond “the core” of internal medicine, family medicine, and pediatrics and reach a better understanding of what our constituents need and how we can add value to their work lives and careers. In addition to expanding membership within our borders, other expansions already include working with international chapters and members with an “all teach, all learn” attitude to better understand mutually beneficial partnerships with international members. Through all these expansions, we will come closer to truly realizing our mission at SHM, which is to “promote exceptional care for hospitalized patients.”
You mention COVID-19. What resources is SHM offering to members?
We have opened up the SHM Learning Portal to help members and non-members address upcoming challenges, such as expanding ICU coverage or cross-training providers for hospital medicine. Several modules in SHM’s “Critical Care for the Hospitalist” series may be especially relevant during the COVID-19 crisis:
- Fluid Resuscitation in the Critically Ill
- Mechanical Ventilation Part I – The Basics
- Mechanical Ventilation Part II – Beyond the Basics
- Mechanical Ventilation Part III – ARDS
Finally, in this time when so many hospitalists are busy dealing with COVID-19, SHM is committed to offering valuable resources and is in the process of offering new material, including Twitter chats, webinars, blogs, and podcasts to help hospitalists share best practices. Please bookmark SHM’s compilation of COVID-19 resources at hospitalmedicine.org/coronavirus.
We also continue to forge ahead with our publications, The Hospitalist and the Journal of Hospital Medicine, by adding online content as it becomes available. Visit the COVID-19 news feed on The Hospitalist website at www.the-hospitalist.org/hospitalist/coronavirus-updates.
In this trying time, we can still connect as a community and continue to learn from each other. We encourage you to use SHM’s online community, HMX, to share resources and crowd-source solutions. Ideas for SHM resources can be submitted via email at [email protected].
What are some of the current challenges for hospital medicine?
The demands placed on hospitalists are greater than ever. With shortening length of stay, rising acuity and complexity, increasing administrative burdens, and high emphasis on care transitions, our skills (and our patience) need to rise to these increasing demands. As a member-based society, SHM (and the board of directors) seeks to ensure we are helping hospitalists be the very best they can be, regardless of hospitalist type or practice setting.
The good news is that we are still in high demand. Within the medical industry, there has been an explosive growth in the need for hospitalists, and we can now be found in almost every hospital setting in the United States. But as a current commodity, it is imperative that we continue to prove the value we are adding to our patients and their families, the systems in which we work, and the industry as a whole.
How will hospital medicine change in the next decade?
I believe one of the biggest changes we will see is the shift to ambulatory settings and the use of telehealth, and we all need to gain significant comfort with both to be effective.
Do you have any advice for students and residents interested in hospital medicine?
It is an incredibly dynamic and invigorating career; I can’t imagine doing anything else.
Danielle Scheurer, MD, MSRC, SFHM, is the chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is the outgoing medical editor of The Hospitalist, and the new president of the Society of Hospital Medicine. She assumes the role from immediate past-president Christopher Frost, MD, SFHM.
As a hospitalist for 17 years, Dr. Scheurer has practiced in both academic tertiary care, as well as community hospital settings. As a chief quality officer, she has worked to improve quality and safety in all health care settings, including ambulatory care, nursing homes, home health, and surgical centers. She brings a broad experience in the medical industry to the SHM presidency.
At what point in your education/training did you decide to practice hospital medicine?
I always loved inpatient medicine throughout my entire meds-peds residency training at Duke University in Durham, N.C. I honestly never had a doubt that hospital medicine was going to be my career. What appeals to me is that each hour and each day is different, which is invigorating.
What are your favorite aspects of clinical practice and of your administrative duties?
I like doing both administrative work and clinical work because I believe having a view of both worlds helps me to be a better physician and a better administrator. It greatly helps me bring realistic solutions to the front lines since I have a good understanding of what needs to be done, but also what is likely to actually work.
As president of SHM over the next year, what are your primary goals?
My primary goal is to deeply connect with the SHM membership and understand what their needs are. There is enormous change happening in the medical industry, and SHM should be a conduit for information sharing, resources, and most importantly, answers to all our difficult problems. Hospitalists are critical to success for our hospitals and our communities during the COVID-19 pandemic. We must be able to give and receive information quickly and seamlessly to effectively help each other across the country and the world. SHM must be seen as a critical convener, especially in times of crisis.
Additionally, SHM has always fostered a “big tent” philosophy, so we will continue to explore ways to expand membership beyond “the core” of internal medicine, family medicine, and pediatrics and reach a better understanding of what our constituents need and how we can add value to their work lives and careers. In addition to expanding membership within our borders, other expansions already include working with international chapters and members with an “all teach, all learn” attitude to better understand mutually beneficial partnerships with international members. Through all these expansions, we will come closer to truly realizing our mission at SHM, which is to “promote exceptional care for hospitalized patients.”
You mention COVID-19. What resources is SHM offering to members?
We have opened up the SHM Learning Portal to help members and non-members address upcoming challenges, such as expanding ICU coverage or cross-training providers for hospital medicine. Several modules in SHM’s “Critical Care for the Hospitalist” series may be especially relevant during the COVID-19 crisis:
- Fluid Resuscitation in the Critically Ill
- Mechanical Ventilation Part I – The Basics
- Mechanical Ventilation Part II – Beyond the Basics
- Mechanical Ventilation Part III – ARDS
Finally, in this time when so many hospitalists are busy dealing with COVID-19, SHM is committed to offering valuable resources and is in the process of offering new material, including Twitter chats, webinars, blogs, and podcasts to help hospitalists share best practices. Please bookmark SHM’s compilation of COVID-19 resources at hospitalmedicine.org/coronavirus.
We also continue to forge ahead with our publications, The Hospitalist and the Journal of Hospital Medicine, by adding online content as it becomes available. Visit the COVID-19 news feed on The Hospitalist website at www.the-hospitalist.org/hospitalist/coronavirus-updates.
In this trying time, we can still connect as a community and continue to learn from each other. We encourage you to use SHM’s online community, HMX, to share resources and crowd-source solutions. Ideas for SHM resources can be submitted via email at [email protected].
What are some of the current challenges for hospital medicine?
The demands placed on hospitalists are greater than ever. With shortening length of stay, rising acuity and complexity, increasing administrative burdens, and high emphasis on care transitions, our skills (and our patience) need to rise to these increasing demands. As a member-based society, SHM (and the board of directors) seeks to ensure we are helping hospitalists be the very best they can be, regardless of hospitalist type or practice setting.
The good news is that we are still in high demand. Within the medical industry, there has been an explosive growth in the need for hospitalists, and we can now be found in almost every hospital setting in the United States. But as a current commodity, it is imperative that we continue to prove the value we are adding to our patients and their families, the systems in which we work, and the industry as a whole.
How will hospital medicine change in the next decade?
I believe one of the biggest changes we will see is the shift to ambulatory settings and the use of telehealth, and we all need to gain significant comfort with both to be effective.
Do you have any advice for students and residents interested in hospital medicine?
It is an incredibly dynamic and invigorating career; I can’t imagine doing anything else.
Danielle Scheurer, MD, MSRC, SFHM, is the chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is the outgoing medical editor of The Hospitalist, and the new president of the Society of Hospital Medicine. She assumes the role from immediate past-president Christopher Frost, MD, SFHM.
As a hospitalist for 17 years, Dr. Scheurer has practiced in both academic tertiary care, as well as community hospital settings. As a chief quality officer, she has worked to improve quality and safety in all health care settings, including ambulatory care, nursing homes, home health, and surgical centers. She brings a broad experience in the medical industry to the SHM presidency.
At what point in your education/training did you decide to practice hospital medicine?
I always loved inpatient medicine throughout my entire meds-peds residency training at Duke University in Durham, N.C. I honestly never had a doubt that hospital medicine was going to be my career. What appeals to me is that each hour and each day is different, which is invigorating.
What are your favorite aspects of clinical practice and of your administrative duties?
I like doing both administrative work and clinical work because I believe having a view of both worlds helps me to be a better physician and a better administrator. It greatly helps me bring realistic solutions to the front lines since I have a good understanding of what needs to be done, but also what is likely to actually work.
As president of SHM over the next year, what are your primary goals?
My primary goal is to deeply connect with the SHM membership and understand what their needs are. There is enormous change happening in the medical industry, and SHM should be a conduit for information sharing, resources, and most importantly, answers to all our difficult problems. Hospitalists are critical to success for our hospitals and our communities during the COVID-19 pandemic. We must be able to give and receive information quickly and seamlessly to effectively help each other across the country and the world. SHM must be seen as a critical convener, especially in times of crisis.
Additionally, SHM has always fostered a “big tent” philosophy, so we will continue to explore ways to expand membership beyond “the core” of internal medicine, family medicine, and pediatrics and reach a better understanding of what our constituents need and how we can add value to their work lives and careers. In addition to expanding membership within our borders, other expansions already include working with international chapters and members with an “all teach, all learn” attitude to better understand mutually beneficial partnerships with international members. Through all these expansions, we will come closer to truly realizing our mission at SHM, which is to “promote exceptional care for hospitalized patients.”
You mention COVID-19. What resources is SHM offering to members?
We have opened up the SHM Learning Portal to help members and non-members address upcoming challenges, such as expanding ICU coverage or cross-training providers for hospital medicine. Several modules in SHM’s “Critical Care for the Hospitalist” series may be especially relevant during the COVID-19 crisis:
- Fluid Resuscitation in the Critically Ill
- Mechanical Ventilation Part I – The Basics
- Mechanical Ventilation Part II – Beyond the Basics
- Mechanical Ventilation Part III – ARDS
Finally, in this time when so many hospitalists are busy dealing with COVID-19, SHM is committed to offering valuable resources and is in the process of offering new material, including Twitter chats, webinars, blogs, and podcasts to help hospitalists share best practices. Please bookmark SHM’s compilation of COVID-19 resources at hospitalmedicine.org/coronavirus.
We also continue to forge ahead with our publications, The Hospitalist and the Journal of Hospital Medicine, by adding online content as it becomes available. Visit the COVID-19 news feed on The Hospitalist website at www.the-hospitalist.org/hospitalist/coronavirus-updates.
In this trying time, we can still connect as a community and continue to learn from each other. We encourage you to use SHM’s online community, HMX, to share resources and crowd-source solutions. Ideas for SHM resources can be submitted via email at [email protected].
What are some of the current challenges for hospital medicine?
The demands placed on hospitalists are greater than ever. With shortening length of stay, rising acuity and complexity, increasing administrative burdens, and high emphasis on care transitions, our skills (and our patience) need to rise to these increasing demands. As a member-based society, SHM (and the board of directors) seeks to ensure we are helping hospitalists be the very best they can be, regardless of hospitalist type or practice setting.
The good news is that we are still in high demand. Within the medical industry, there has been an explosive growth in the need for hospitalists, and we can now be found in almost every hospital setting in the United States. But as a current commodity, it is imperative that we continue to prove the value we are adding to our patients and their families, the systems in which we work, and the industry as a whole.
How will hospital medicine change in the next decade?
I believe one of the biggest changes we will see is the shift to ambulatory settings and the use of telehealth, and we all need to gain significant comfort with both to be effective.
Do you have any advice for students and residents interested in hospital medicine?
It is an incredibly dynamic and invigorating career; I can’t imagine doing anything else.
HM20 canceled: SHM explains why
COVID-19 made holding meeting impossible
In mid-March, the Society of Hospital Medicine board of directors concluded that it was impossible for SHM to move forward with Hospital Medicine 2020 because of the continued spread of virus that causes Coronavirus Disease 2019 (COVID-19).
Given the most recent information available from the Centers for Disease Control & Prevention and the World Health Organization about the evolving global pandemic and the number of institutions that had travel bans in place, SHM leadership concluded that canceling the Annual Conference was the only path forward.
“Canceling the conference during this unprecedented time is the right thing to do,” said Benji K. Mathews, MD, SFHM, CLHM, course director for HM20. “With the evolving circumstances out of our control, there were risks to our community as it would have gathered, communities we connect with on our travels, and our home communities and hospitals – canceling was the best way to mitigate these risks. Through it all, I couldn’t have asked for a better leadership team and the larger SHM community for their support.”
Because hospitalists are on the front lines of patient care at their institutions, they will be needed more than ever as the pandemic continues to grow in order to manage care of hospitalized patients with COVID-19 and other illnesses. As the only medical society dedicated to hospital medicine, SHM will continue to support hospitalists with resources and research specific to COVID-19 and its impact on the practice of hospital medicine.
SHM is aware that this necessary cancellation impacts many from both a financial and logistical perspective. As such, SHM will refund all conference registration fees for HM20 in full. SHM is also providing the opportunity to defer your HM20 registration to HM21, taking place May 4-7, 2021 in Las Vegas, or Pediatric Hospital Medicine 2020, taking place July 23-26, 2020 in Lake Buena Vista, Fla.
For accommodation or travel cancellations, SHM requests that individuals please refer to their respective hotel or carrier’s customer service team and related cancellation policies.
To provide the world-class education that conference attendees have come to expect from SHM over the years, the SHM team is exploring virtual options to offer select content originally anticipated at HM20. SHM also offers online education via the SHM Learning Portal and the new SHM Education app.
Visit shmannualconference.org/faqs for a full list of FAQs. For additional questions, please contact [email protected].
SHM will continue to monitor the COVID-19 pandemic and provide hospitalists with useful resources in this time of need at hospitalmedicine.org/coronavirus. For news coverage of COVID-19, visit https://www.the-hospitalist.org/hospitalist/coronavirus-updates.
COVID-19 made holding meeting impossible
COVID-19 made holding meeting impossible
In mid-March, the Society of Hospital Medicine board of directors concluded that it was impossible for SHM to move forward with Hospital Medicine 2020 because of the continued spread of virus that causes Coronavirus Disease 2019 (COVID-19).
Given the most recent information available from the Centers for Disease Control & Prevention and the World Health Organization about the evolving global pandemic and the number of institutions that had travel bans in place, SHM leadership concluded that canceling the Annual Conference was the only path forward.
“Canceling the conference during this unprecedented time is the right thing to do,” said Benji K. Mathews, MD, SFHM, CLHM, course director for HM20. “With the evolving circumstances out of our control, there were risks to our community as it would have gathered, communities we connect with on our travels, and our home communities and hospitals – canceling was the best way to mitigate these risks. Through it all, I couldn’t have asked for a better leadership team and the larger SHM community for their support.”
Because hospitalists are on the front lines of patient care at their institutions, they will be needed more than ever as the pandemic continues to grow in order to manage care of hospitalized patients with COVID-19 and other illnesses. As the only medical society dedicated to hospital medicine, SHM will continue to support hospitalists with resources and research specific to COVID-19 and its impact on the practice of hospital medicine.
SHM is aware that this necessary cancellation impacts many from both a financial and logistical perspective. As such, SHM will refund all conference registration fees for HM20 in full. SHM is also providing the opportunity to defer your HM20 registration to HM21, taking place May 4-7, 2021 in Las Vegas, or Pediatric Hospital Medicine 2020, taking place July 23-26, 2020 in Lake Buena Vista, Fla.
For accommodation or travel cancellations, SHM requests that individuals please refer to their respective hotel or carrier’s customer service team and related cancellation policies.
To provide the world-class education that conference attendees have come to expect from SHM over the years, the SHM team is exploring virtual options to offer select content originally anticipated at HM20. SHM also offers online education via the SHM Learning Portal and the new SHM Education app.
Visit shmannualconference.org/faqs for a full list of FAQs. For additional questions, please contact [email protected].
SHM will continue to monitor the COVID-19 pandemic and provide hospitalists with useful resources in this time of need at hospitalmedicine.org/coronavirus. For news coverage of COVID-19, visit https://www.the-hospitalist.org/hospitalist/coronavirus-updates.
In mid-March, the Society of Hospital Medicine board of directors concluded that it was impossible for SHM to move forward with Hospital Medicine 2020 because of the continued spread of virus that causes Coronavirus Disease 2019 (COVID-19).
Given the most recent information available from the Centers for Disease Control & Prevention and the World Health Organization about the evolving global pandemic and the number of institutions that had travel bans in place, SHM leadership concluded that canceling the Annual Conference was the only path forward.
“Canceling the conference during this unprecedented time is the right thing to do,” said Benji K. Mathews, MD, SFHM, CLHM, course director for HM20. “With the evolving circumstances out of our control, there were risks to our community as it would have gathered, communities we connect with on our travels, and our home communities and hospitals – canceling was the best way to mitigate these risks. Through it all, I couldn’t have asked for a better leadership team and the larger SHM community for their support.”
Because hospitalists are on the front lines of patient care at their institutions, they will be needed more than ever as the pandemic continues to grow in order to manage care of hospitalized patients with COVID-19 and other illnesses. As the only medical society dedicated to hospital medicine, SHM will continue to support hospitalists with resources and research specific to COVID-19 and its impact on the practice of hospital medicine.
SHM is aware that this necessary cancellation impacts many from both a financial and logistical perspective. As such, SHM will refund all conference registration fees for HM20 in full. SHM is also providing the opportunity to defer your HM20 registration to HM21, taking place May 4-7, 2021 in Las Vegas, or Pediatric Hospital Medicine 2020, taking place July 23-26, 2020 in Lake Buena Vista, Fla.
For accommodation or travel cancellations, SHM requests that individuals please refer to their respective hotel or carrier’s customer service team and related cancellation policies.
To provide the world-class education that conference attendees have come to expect from SHM over the years, the SHM team is exploring virtual options to offer select content originally anticipated at HM20. SHM also offers online education via the SHM Learning Portal and the new SHM Education app.
Visit shmannualconference.org/faqs for a full list of FAQs. For additional questions, please contact [email protected].
SHM will continue to monitor the COVID-19 pandemic and provide hospitalists with useful resources in this time of need at hospitalmedicine.org/coronavirus. For news coverage of COVID-19, visit https://www.the-hospitalist.org/hospitalist/coronavirus-updates.
Comorbidities more common in hospitalized COVID-19 patients
Greater prevalence of underlying health conditions such as diabetes and chronic lung disease was seen among nearly 7,200 Americans hospitalized with coronavirus disease 2019 (COVID-19), according to the Centers for Disease Control and Prevention.
Of the 122,653 laboratory-confirmed COVID-19 cases reported to the CDC as of March 28, the COVID-19 Response Team had access to data on the presence or absence of underlying health conditions and other recognized risk factors for severe outcomes from respiratory infections for 7,162 (5.8%) patients.
“Among these patients, higher percentages of patients with underlying conditions were admitted to the hospital and to an ICU than patients without reported underlying conditions. These results are consistent with findings from China and Italy,” Katherine Fleming-Dutra, MD, and associates said in the MMWR.
Individuals with underlying health conditions/risk factors made up 37.6% of all COVID-19 patients in the study but represented a majority of ICU (78%) and non-ICU (71%) hospital admissions. In contrast, 73% of COVID-19 patients who were not hospitalized had no underlying conditions, Dr. Fleming-Dutra and the CDC COVID-19 Response Team reported.
With a prevalence of 10.9%, diabetes mellitus was the most common condition reported among all COVID-19 patients, followed by chronic lung disease (9.2%) and cardiovascular disease (9.0%), the investigators said.
Another look at the data shows that 40.5% of those with underlying conditions were hospitalized, compared with 9.0% of the 4,470 COVID-19 patients without any risk factors.
“Strategies to protect all persons and especially those with underlying health conditions, including social distancing and handwashing, should be implemented by all communities and all persons to help slow the spread of COVID-19,” the response team wrote.
SOURCE: Fleming-Dutra K et al. MMWR. 2020 Mar 31;69 (early release):1-5.
Greater prevalence of underlying health conditions such as diabetes and chronic lung disease was seen among nearly 7,200 Americans hospitalized with coronavirus disease 2019 (COVID-19), according to the Centers for Disease Control and Prevention.
Of the 122,653 laboratory-confirmed COVID-19 cases reported to the CDC as of March 28, the COVID-19 Response Team had access to data on the presence or absence of underlying health conditions and other recognized risk factors for severe outcomes from respiratory infections for 7,162 (5.8%) patients.
“Among these patients, higher percentages of patients with underlying conditions were admitted to the hospital and to an ICU than patients without reported underlying conditions. These results are consistent with findings from China and Italy,” Katherine Fleming-Dutra, MD, and associates said in the MMWR.
Individuals with underlying health conditions/risk factors made up 37.6% of all COVID-19 patients in the study but represented a majority of ICU (78%) and non-ICU (71%) hospital admissions. In contrast, 73% of COVID-19 patients who were not hospitalized had no underlying conditions, Dr. Fleming-Dutra and the CDC COVID-19 Response Team reported.
With a prevalence of 10.9%, diabetes mellitus was the most common condition reported among all COVID-19 patients, followed by chronic lung disease (9.2%) and cardiovascular disease (9.0%), the investigators said.
Another look at the data shows that 40.5% of those with underlying conditions were hospitalized, compared with 9.0% of the 4,470 COVID-19 patients without any risk factors.
“Strategies to protect all persons and especially those with underlying health conditions, including social distancing and handwashing, should be implemented by all communities and all persons to help slow the spread of COVID-19,” the response team wrote.
SOURCE: Fleming-Dutra K et al. MMWR. 2020 Mar 31;69 (early release):1-5.
Greater prevalence of underlying health conditions such as diabetes and chronic lung disease was seen among nearly 7,200 Americans hospitalized with coronavirus disease 2019 (COVID-19), according to the Centers for Disease Control and Prevention.
Of the 122,653 laboratory-confirmed COVID-19 cases reported to the CDC as of March 28, the COVID-19 Response Team had access to data on the presence or absence of underlying health conditions and other recognized risk factors for severe outcomes from respiratory infections for 7,162 (5.8%) patients.
“Among these patients, higher percentages of patients with underlying conditions were admitted to the hospital and to an ICU than patients without reported underlying conditions. These results are consistent with findings from China and Italy,” Katherine Fleming-Dutra, MD, and associates said in the MMWR.
Individuals with underlying health conditions/risk factors made up 37.6% of all COVID-19 patients in the study but represented a majority of ICU (78%) and non-ICU (71%) hospital admissions. In contrast, 73% of COVID-19 patients who were not hospitalized had no underlying conditions, Dr. Fleming-Dutra and the CDC COVID-19 Response Team reported.
With a prevalence of 10.9%, diabetes mellitus was the most common condition reported among all COVID-19 patients, followed by chronic lung disease (9.2%) and cardiovascular disease (9.0%), the investigators said.
Another look at the data shows that 40.5% of those with underlying conditions were hospitalized, compared with 9.0% of the 4,470 COVID-19 patients without any risk factors.
“Strategies to protect all persons and especially those with underlying health conditions, including social distancing and handwashing, should be implemented by all communities and all persons to help slow the spread of COVID-19,” the response team wrote.
SOURCE: Fleming-Dutra K et al. MMWR. 2020 Mar 31;69 (early release):1-5.
FROM MMWR
Which tube placement is best for a patient requiring enteral nutrition?
Comparative advantages of EN tubes
Case
A 68-year-old diabetic nonverbal female presents to the ED because of “seizure” 1 hour ago. On exam, her blood glucose is 200. She is unable to speak and has dysphagia because of a stroke she sustained last month. The patient’s husband adds that she hasn’t been eating and drinking sufficiently in the past couple of days. Imaging was negative for any acute intracranial bleeds or lesions. Labs showed a serum sodium level of 150 milliequivalents/L. D5W is started, and the following day, the patient has a sodium level of 154 milliequivalents/L.
Brief overview
Many hospitalized patients are unable to maintain hydration and/or nutritional status by mouth and will need enteral nutrition. Variables such as past medical history, swallowing ability, history of aspiration, prognosis, and functional capacity of each gastrointestinal segment will determine the best option for enteral nutrition for each patient. Each type of enteral tube feeding has advantages, disadvantages, and complications.
Overview of the data
Enteral nutrition should be started within 24-48 hours in a critically ill patient who is unable to maintain intake according to the American Society of Parenteral and Enteral Nutrition.1 This can be provided through a nasogastric (NG) tube, percutaneous endoscopic gastrostomy (PEG) tube, PEG tube with jejunal extension (PEG-J), or a percutaneous endoscopic jejunal (PEJ) tube.1
NG tubes are often the first method deployed because of their low cost and convenience. They are also suitable for the patient who requires this type of feeding for less than 4 weeks. However, NG tubes do require some patient cooperation (to place and maintain)and are contraindicated in some patients with orofacial trauma, upper GI tumors, inadequate lower esophageal sphincter tone, and gastroparesis.2
Another option is a PEG tube, which is a good alternative for patients who are sedated; ventilated; or have neurodegenerative processes, stroke with dysphagia, or head and neck cancers. These are typically recommended when enteral nutrition will be needed for more than 4 weeks. Disadvantages of PEG tubes include tube obstruction or displacement, gastroesophageal reflux, and leakage of gastric content around the percutaneous site or into the peritoneum.
PEG-J tubes, PEJ tubes, or jejunostomy tubes are best suited for patients with GI dysmotility, patients who have unsuccessfully undergone the aforementioned methods, patients with histories of partial gastrectomies, or patients with gastric or pancreatic cancers/multiple traumas. The PEG-J tube extends into the distal duodenum; because it is longer and more narrow, it is more likely to coil and occlude the flow of nutrients during feedings.2,3 Jejunal feeding methods incorporate a continuous pump controlled infusion; if set too rapidly, this could cause dumping syndrome. A benefit of jejunal nutrition is a lower risk of aspiration, compared with other enteral tubes.4
It is best to appraise the selected method for its efficacy and patient preference. The American College of Gastroenterology recommends starting with orogastric or nasogastric feeds, and switching to postpyloric or jejunal feeds for those intolerant to or at high risk for aspiration.5 The most important aspect is early enteral nutrition in hospitalized patients unable to maintain oral nutrition.
Application of the data to the original case
This is a severely hypernatremic diabetic patient unable to swallow. On day 2 of her hospitalization, the clinical team provided the patient with an NG tube for increased free-water intake to gradually decrease her serum sodium. By hospital day 4, the patient’s sodium had normalized. Considering the patient’s long-term prognosis and dysphagia, discussions were held with the patient and husband for PEG tube placement. The patient received a PEG tube and was subsequently discharged 2 days later.
Bottom line
Enteral nutrition is a common need among hospitalized patients. Modality of enteral nutrition will depend on the patient’s past medical history, anticipated duration, and preferences.
Dr. Basnet is the hospitalist program director for Apogee Physicians Group at Eastern New Mexico Medical Center in Roswell. Ms. Tayes is a third-year medical student at Burrell College of Osteopathic Medicine in Las Cruces, N.M., with interests in surgery, internal medicine, and emergency medicine. Ms. Gallivan is a third-year medical student at Burrell College of Osteopathic Medicine, with interests in cardiothoracic surgery, general surgery, and internal medicine.
References
1. Boullata JI et al. ASPEN Safe Practices for Enteral Nutrition Therapy. J Parenter Enteral Nutr. 2016;1-89.
2. Kirby DF et al. American Gastroenterological Association technical review on tube feeding for enteral nutrition. Gastroenterology. 1995;108:1282.
3. Lazarus BA et al. Aspiration associated with long-term gastric versus jejunal feeding: A critical analysis of the literature. Arch Phys Med Rehabil. 1990;71:46.
4. Alkhawaja S et al. Postpyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults. Cochrane Database Syst Rev. 2015 Aug 4;(8):CD008875.
5. McCalve SA et al. ACG Clinical Guideline: Nutrition therapy in the hospitalized patient. Am J Gastroenterol. 2016;111:315-34. doi: 10.1038/ajg.2016.28.
Additional reading
Bellini LM. Nutrition Support in Advanced Lung Disease. UptoDate. https://www-uptodate-com.ezproxy.ad.bcomnm.org/contents/nutritional-support-in-advanced-lung-disease?. Published April 20, 2018.
Commercial Formulas for the Feeding Tube. The Oral Cancer Foundation. https://oralcancerfoundation.org/nutrition/commercial-formulas-feeding-tube/. Published June 5, 2018.
Marik Z. Immunonutrition in critically ill patients: A systematic review and analysis of the literature. Intensive Care Med. 2008;34(11). doi: 10.1007/s00134-008-1213-6.
Wischmeyer PE. Enteral nutrition can be given to patients on vasopressors. Crit Care Med. 2020;48(1):122-5. doi: 10.1097/CCM.0000000000003965.
Comparative advantages of EN tubes
Comparative advantages of EN tubes
Case
A 68-year-old diabetic nonverbal female presents to the ED because of “seizure” 1 hour ago. On exam, her blood glucose is 200. She is unable to speak and has dysphagia because of a stroke she sustained last month. The patient’s husband adds that she hasn’t been eating and drinking sufficiently in the past couple of days. Imaging was negative for any acute intracranial bleeds or lesions. Labs showed a serum sodium level of 150 milliequivalents/L. D5W is started, and the following day, the patient has a sodium level of 154 milliequivalents/L.
Brief overview
Many hospitalized patients are unable to maintain hydration and/or nutritional status by mouth and will need enteral nutrition. Variables such as past medical history, swallowing ability, history of aspiration, prognosis, and functional capacity of each gastrointestinal segment will determine the best option for enteral nutrition for each patient. Each type of enteral tube feeding has advantages, disadvantages, and complications.
Overview of the data
Enteral nutrition should be started within 24-48 hours in a critically ill patient who is unable to maintain intake according to the American Society of Parenteral and Enteral Nutrition.1 This can be provided through a nasogastric (NG) tube, percutaneous endoscopic gastrostomy (PEG) tube, PEG tube with jejunal extension (PEG-J), or a percutaneous endoscopic jejunal (PEJ) tube.1
NG tubes are often the first method deployed because of their low cost and convenience. They are also suitable for the patient who requires this type of feeding for less than 4 weeks. However, NG tubes do require some patient cooperation (to place and maintain)and are contraindicated in some patients with orofacial trauma, upper GI tumors, inadequate lower esophageal sphincter tone, and gastroparesis.2
Another option is a PEG tube, which is a good alternative for patients who are sedated; ventilated; or have neurodegenerative processes, stroke with dysphagia, or head and neck cancers. These are typically recommended when enteral nutrition will be needed for more than 4 weeks. Disadvantages of PEG tubes include tube obstruction or displacement, gastroesophageal reflux, and leakage of gastric content around the percutaneous site or into the peritoneum.
PEG-J tubes, PEJ tubes, or jejunostomy tubes are best suited for patients with GI dysmotility, patients who have unsuccessfully undergone the aforementioned methods, patients with histories of partial gastrectomies, or patients with gastric or pancreatic cancers/multiple traumas. The PEG-J tube extends into the distal duodenum; because it is longer and more narrow, it is more likely to coil and occlude the flow of nutrients during feedings.2,3 Jejunal feeding methods incorporate a continuous pump controlled infusion; if set too rapidly, this could cause dumping syndrome. A benefit of jejunal nutrition is a lower risk of aspiration, compared with other enteral tubes.4
It is best to appraise the selected method for its efficacy and patient preference. The American College of Gastroenterology recommends starting with orogastric or nasogastric feeds, and switching to postpyloric or jejunal feeds for those intolerant to or at high risk for aspiration.5 The most important aspect is early enteral nutrition in hospitalized patients unable to maintain oral nutrition.
Application of the data to the original case
This is a severely hypernatremic diabetic patient unable to swallow. On day 2 of her hospitalization, the clinical team provided the patient with an NG tube for increased free-water intake to gradually decrease her serum sodium. By hospital day 4, the patient’s sodium had normalized. Considering the patient’s long-term prognosis and dysphagia, discussions were held with the patient and husband for PEG tube placement. The patient received a PEG tube and was subsequently discharged 2 days later.
Bottom line
Enteral nutrition is a common need among hospitalized patients. Modality of enteral nutrition will depend on the patient’s past medical history, anticipated duration, and preferences.
Dr. Basnet is the hospitalist program director for Apogee Physicians Group at Eastern New Mexico Medical Center in Roswell. Ms. Tayes is a third-year medical student at Burrell College of Osteopathic Medicine in Las Cruces, N.M., with interests in surgery, internal medicine, and emergency medicine. Ms. Gallivan is a third-year medical student at Burrell College of Osteopathic Medicine, with interests in cardiothoracic surgery, general surgery, and internal medicine.
References
1. Boullata JI et al. ASPEN Safe Practices for Enteral Nutrition Therapy. J Parenter Enteral Nutr. 2016;1-89.
2. Kirby DF et al. American Gastroenterological Association technical review on tube feeding for enteral nutrition. Gastroenterology. 1995;108:1282.
3. Lazarus BA et al. Aspiration associated with long-term gastric versus jejunal feeding: A critical analysis of the literature. Arch Phys Med Rehabil. 1990;71:46.
4. Alkhawaja S et al. Postpyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults. Cochrane Database Syst Rev. 2015 Aug 4;(8):CD008875.
5. McCalve SA et al. ACG Clinical Guideline: Nutrition therapy in the hospitalized patient. Am J Gastroenterol. 2016;111:315-34. doi: 10.1038/ajg.2016.28.
Additional reading
Bellini LM. Nutrition Support in Advanced Lung Disease. UptoDate. https://www-uptodate-com.ezproxy.ad.bcomnm.org/contents/nutritional-support-in-advanced-lung-disease?. Published April 20, 2018.
Commercial Formulas for the Feeding Tube. The Oral Cancer Foundation. https://oralcancerfoundation.org/nutrition/commercial-formulas-feeding-tube/. Published June 5, 2018.
Marik Z. Immunonutrition in critically ill patients: A systematic review and analysis of the literature. Intensive Care Med. 2008;34(11). doi: 10.1007/s00134-008-1213-6.
Wischmeyer PE. Enteral nutrition can be given to patients on vasopressors. Crit Care Med. 2020;48(1):122-5. doi: 10.1097/CCM.0000000000003965.
Case
A 68-year-old diabetic nonverbal female presents to the ED because of “seizure” 1 hour ago. On exam, her blood glucose is 200. She is unable to speak and has dysphagia because of a stroke she sustained last month. The patient’s husband adds that she hasn’t been eating and drinking sufficiently in the past couple of days. Imaging was negative for any acute intracranial bleeds or lesions. Labs showed a serum sodium level of 150 milliequivalents/L. D5W is started, and the following day, the patient has a sodium level of 154 milliequivalents/L.
Brief overview
Many hospitalized patients are unable to maintain hydration and/or nutritional status by mouth and will need enteral nutrition. Variables such as past medical history, swallowing ability, history of aspiration, prognosis, and functional capacity of each gastrointestinal segment will determine the best option for enteral nutrition for each patient. Each type of enteral tube feeding has advantages, disadvantages, and complications.
Overview of the data
Enteral nutrition should be started within 24-48 hours in a critically ill patient who is unable to maintain intake according to the American Society of Parenteral and Enteral Nutrition.1 This can be provided through a nasogastric (NG) tube, percutaneous endoscopic gastrostomy (PEG) tube, PEG tube with jejunal extension (PEG-J), or a percutaneous endoscopic jejunal (PEJ) tube.1
NG tubes are often the first method deployed because of their low cost and convenience. They are also suitable for the patient who requires this type of feeding for less than 4 weeks. However, NG tubes do require some patient cooperation (to place and maintain)and are contraindicated in some patients with orofacial trauma, upper GI tumors, inadequate lower esophageal sphincter tone, and gastroparesis.2
Another option is a PEG tube, which is a good alternative for patients who are sedated; ventilated; or have neurodegenerative processes, stroke with dysphagia, or head and neck cancers. These are typically recommended when enteral nutrition will be needed for more than 4 weeks. Disadvantages of PEG tubes include tube obstruction or displacement, gastroesophageal reflux, and leakage of gastric content around the percutaneous site or into the peritoneum.
PEG-J tubes, PEJ tubes, or jejunostomy tubes are best suited for patients with GI dysmotility, patients who have unsuccessfully undergone the aforementioned methods, patients with histories of partial gastrectomies, or patients with gastric or pancreatic cancers/multiple traumas. The PEG-J tube extends into the distal duodenum; because it is longer and more narrow, it is more likely to coil and occlude the flow of nutrients during feedings.2,3 Jejunal feeding methods incorporate a continuous pump controlled infusion; if set too rapidly, this could cause dumping syndrome. A benefit of jejunal nutrition is a lower risk of aspiration, compared with other enteral tubes.4
It is best to appraise the selected method for its efficacy and patient preference. The American College of Gastroenterology recommends starting with orogastric or nasogastric feeds, and switching to postpyloric or jejunal feeds for those intolerant to or at high risk for aspiration.5 The most important aspect is early enteral nutrition in hospitalized patients unable to maintain oral nutrition.
Application of the data to the original case
This is a severely hypernatremic diabetic patient unable to swallow. On day 2 of her hospitalization, the clinical team provided the patient with an NG tube for increased free-water intake to gradually decrease her serum sodium. By hospital day 4, the patient’s sodium had normalized. Considering the patient’s long-term prognosis and dysphagia, discussions were held with the patient and husband for PEG tube placement. The patient received a PEG tube and was subsequently discharged 2 days later.
Bottom line
Enteral nutrition is a common need among hospitalized patients. Modality of enteral nutrition will depend on the patient’s past medical history, anticipated duration, and preferences.
Dr. Basnet is the hospitalist program director for Apogee Physicians Group at Eastern New Mexico Medical Center in Roswell. Ms. Tayes is a third-year medical student at Burrell College of Osteopathic Medicine in Las Cruces, N.M., with interests in surgery, internal medicine, and emergency medicine. Ms. Gallivan is a third-year medical student at Burrell College of Osteopathic Medicine, with interests in cardiothoracic surgery, general surgery, and internal medicine.
References
1. Boullata JI et al. ASPEN Safe Practices for Enteral Nutrition Therapy. J Parenter Enteral Nutr. 2016;1-89.
2. Kirby DF et al. American Gastroenterological Association technical review on tube feeding for enteral nutrition. Gastroenterology. 1995;108:1282.
3. Lazarus BA et al. Aspiration associated with long-term gastric versus jejunal feeding: A critical analysis of the literature. Arch Phys Med Rehabil. 1990;71:46.
4. Alkhawaja S et al. Postpyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults. Cochrane Database Syst Rev. 2015 Aug 4;(8):CD008875.
5. McCalve SA et al. ACG Clinical Guideline: Nutrition therapy in the hospitalized patient. Am J Gastroenterol. 2016;111:315-34. doi: 10.1038/ajg.2016.28.
Additional reading
Bellini LM. Nutrition Support in Advanced Lung Disease. UptoDate. https://www-uptodate-com.ezproxy.ad.bcomnm.org/contents/nutritional-support-in-advanced-lung-disease?. Published April 20, 2018.
Commercial Formulas for the Feeding Tube. The Oral Cancer Foundation. https://oralcancerfoundation.org/nutrition/commercial-formulas-feeding-tube/. Published June 5, 2018.
Marik Z. Immunonutrition in critically ill patients: A systematic review and analysis of the literature. Intensive Care Med. 2008;34(11). doi: 10.1007/s00134-008-1213-6.
Wischmeyer PE. Enteral nutrition can be given to patients on vasopressors. Crit Care Med. 2020;48(1):122-5. doi: 10.1097/CCM.0000000000003965.
Predictors of bacteremia in children hospitalized with community-acquired pneumonia
Children with bacteremia had longer lengths of stay
Clinical question: Are blood cultures warranted in specific subsets of children hospitalized with community-acquired pneumonia (CAP)?
Background: Guidelines from the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America recommend obtaining blood cultures in children hospitalized with moderate to severe community-acquired pneumonia. This group of authors recently published a study showing the prevalence of bacteremia of 2.5% in a cohort of generally healthy children hospitalized with CAP who had blood cultures obtained, with only 0.4% harboring a pathogen not susceptible to penicillin. They found low yield for blood cultures in children hospitalized with CAP.
Study design: Retrospective Cohort Study.
Setting: Pediatric Health Information System Plus (PHIS+) database (six institutions).
Synopsis: Secondary analysis of prior study of children aged 3 months to 18 years hospitalized with CAP between 2007 to 2011. For the secondary analysis only children in whom a blood culture was obtained on the initial or second day of hospitalization were studied. CAP was defined by a primary ICD-9 discharge diagnosis code for pneumonia or a primary ICD-9 discharge diagnosis code for pleural effusion with a secondary diagnosis code for pneumonia. Children transferred into the study institution and children with complex chronic conditions were excluded from the study. The primary outcome was the presence of bacteremia based on pathogen detection in the initial blood culture. Bacteria were labeled as pathogens or contaminants.
A total of 7,509 children were included in the initial study. Of them, 2,568 (34.2%) had a blood culture obtained on the initial or second day of hospitalization; 65 (2.5%) of the children with blood cultures obtained on admission had bacteremia. The most common penicillin-susceptible blood pathogen isolated was Streptococcus pneumoniae (n = 47). Eleven children (0.4%) had bacteremia with a pathogen not susceptible to penicillin. Children with bacteremia had a higher median admission white blood cell (WBC) count than did those without bacteremia (17.5 × 103 cells per mcL vs. 12.4 × 103 cells per mcL; P < .01) and definite radiographic pneumonia on admission chest radiograph (P < .01). C-reactive protein and erythrocyte sedimentation rate were also higher in children with bacteremia but were only obtained in 35% and 15% of patients, respectively. Children with bacteremia had a higher prevalence of complicated pneumonia on admission (P = .06) than did children without bacteremia. Children with bacteremia had longer lengths of stay (4 days vs. 2 days; P < .01) and were more likely to be admitted to an ICU (P < .01) than were children without bacteremia.
This study is limited by its sample because all of the patients were cared for at tertiary care hospitals. It is also limited by its timing; the PHIS+ data set spans the introduction of the 13-valent pneumococcal vaccine, and so the current prevalence of bacteremia in CAP may be lower than that found in the study.
Bottom line: The prevalence of bacteremia was low among a cohort of generally healthy children hospitalized with CAP, and no features strongly predicted the presence of bacteremia. The authors recommend that blood cultures in children with CAP should be limited to patients admitted to the ICU.
Citation: Lipsett SC et al. Predictors of Bacteremia in Children Hospitalized With Community-Acquired Pneumonia. Hosp Pediatr. 2019 Oct;9(10):770-8.
Dr. Kumar is a pediatric hospitalist at Cleveland Clinic Children’s. She is a clinical assistant professor of pediatrics at Case Western Reserve University, Cleveland, and serves as the Pediatrics Editor for The Hospitalist.
Children with bacteremia had longer lengths of stay
Children with bacteremia had longer lengths of stay
Clinical question: Are blood cultures warranted in specific subsets of children hospitalized with community-acquired pneumonia (CAP)?
Background: Guidelines from the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America recommend obtaining blood cultures in children hospitalized with moderate to severe community-acquired pneumonia. This group of authors recently published a study showing the prevalence of bacteremia of 2.5% in a cohort of generally healthy children hospitalized with CAP who had blood cultures obtained, with only 0.4% harboring a pathogen not susceptible to penicillin. They found low yield for blood cultures in children hospitalized with CAP.
Study design: Retrospective Cohort Study.
Setting: Pediatric Health Information System Plus (PHIS+) database (six institutions).
Synopsis: Secondary analysis of prior study of children aged 3 months to 18 years hospitalized with CAP between 2007 to 2011. For the secondary analysis only children in whom a blood culture was obtained on the initial or second day of hospitalization were studied. CAP was defined by a primary ICD-9 discharge diagnosis code for pneumonia or a primary ICD-9 discharge diagnosis code for pleural effusion with a secondary diagnosis code for pneumonia. Children transferred into the study institution and children with complex chronic conditions were excluded from the study. The primary outcome was the presence of bacteremia based on pathogen detection in the initial blood culture. Bacteria were labeled as pathogens or contaminants.
A total of 7,509 children were included in the initial study. Of them, 2,568 (34.2%) had a blood culture obtained on the initial or second day of hospitalization; 65 (2.5%) of the children with blood cultures obtained on admission had bacteremia. The most common penicillin-susceptible blood pathogen isolated was Streptococcus pneumoniae (n = 47). Eleven children (0.4%) had bacteremia with a pathogen not susceptible to penicillin. Children with bacteremia had a higher median admission white blood cell (WBC) count than did those without bacteremia (17.5 × 103 cells per mcL vs. 12.4 × 103 cells per mcL; P < .01) and definite radiographic pneumonia on admission chest radiograph (P < .01). C-reactive protein and erythrocyte sedimentation rate were also higher in children with bacteremia but were only obtained in 35% and 15% of patients, respectively. Children with bacteremia had a higher prevalence of complicated pneumonia on admission (P = .06) than did children without bacteremia. Children with bacteremia had longer lengths of stay (4 days vs. 2 days; P < .01) and were more likely to be admitted to an ICU (P < .01) than were children without bacteremia.
This study is limited by its sample because all of the patients were cared for at tertiary care hospitals. It is also limited by its timing; the PHIS+ data set spans the introduction of the 13-valent pneumococcal vaccine, and so the current prevalence of bacteremia in CAP may be lower than that found in the study.
Bottom line: The prevalence of bacteremia was low among a cohort of generally healthy children hospitalized with CAP, and no features strongly predicted the presence of bacteremia. The authors recommend that blood cultures in children with CAP should be limited to patients admitted to the ICU.
Citation: Lipsett SC et al. Predictors of Bacteremia in Children Hospitalized With Community-Acquired Pneumonia. Hosp Pediatr. 2019 Oct;9(10):770-8.
Dr. Kumar is a pediatric hospitalist at Cleveland Clinic Children’s. She is a clinical assistant professor of pediatrics at Case Western Reserve University, Cleveland, and serves as the Pediatrics Editor for The Hospitalist.
Clinical question: Are blood cultures warranted in specific subsets of children hospitalized with community-acquired pneumonia (CAP)?
Background: Guidelines from the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America recommend obtaining blood cultures in children hospitalized with moderate to severe community-acquired pneumonia. This group of authors recently published a study showing the prevalence of bacteremia of 2.5% in a cohort of generally healthy children hospitalized with CAP who had blood cultures obtained, with only 0.4% harboring a pathogen not susceptible to penicillin. They found low yield for blood cultures in children hospitalized with CAP.
Study design: Retrospective Cohort Study.
Setting: Pediatric Health Information System Plus (PHIS+) database (six institutions).
Synopsis: Secondary analysis of prior study of children aged 3 months to 18 years hospitalized with CAP between 2007 to 2011. For the secondary analysis only children in whom a blood culture was obtained on the initial or second day of hospitalization were studied. CAP was defined by a primary ICD-9 discharge diagnosis code for pneumonia or a primary ICD-9 discharge diagnosis code for pleural effusion with a secondary diagnosis code for pneumonia. Children transferred into the study institution and children with complex chronic conditions were excluded from the study. The primary outcome was the presence of bacteremia based on pathogen detection in the initial blood culture. Bacteria were labeled as pathogens or contaminants.
A total of 7,509 children were included in the initial study. Of them, 2,568 (34.2%) had a blood culture obtained on the initial or second day of hospitalization; 65 (2.5%) of the children with blood cultures obtained on admission had bacteremia. The most common penicillin-susceptible blood pathogen isolated was Streptococcus pneumoniae (n = 47). Eleven children (0.4%) had bacteremia with a pathogen not susceptible to penicillin. Children with bacteremia had a higher median admission white blood cell (WBC) count than did those without bacteremia (17.5 × 103 cells per mcL vs. 12.4 × 103 cells per mcL; P < .01) and definite radiographic pneumonia on admission chest radiograph (P < .01). C-reactive protein and erythrocyte sedimentation rate were also higher in children with bacteremia but were only obtained in 35% and 15% of patients, respectively. Children with bacteremia had a higher prevalence of complicated pneumonia on admission (P = .06) than did children without bacteremia. Children with bacteremia had longer lengths of stay (4 days vs. 2 days; P < .01) and were more likely to be admitted to an ICU (P < .01) than were children without bacteremia.
This study is limited by its sample because all of the patients were cared for at tertiary care hospitals. It is also limited by its timing; the PHIS+ data set spans the introduction of the 13-valent pneumococcal vaccine, and so the current prevalence of bacteremia in CAP may be lower than that found in the study.
Bottom line: The prevalence of bacteremia was low among a cohort of generally healthy children hospitalized with CAP, and no features strongly predicted the presence of bacteremia. The authors recommend that blood cultures in children with CAP should be limited to patients admitted to the ICU.
Citation: Lipsett SC et al. Predictors of Bacteremia in Children Hospitalized With Community-Acquired Pneumonia. Hosp Pediatr. 2019 Oct;9(10):770-8.
Dr. Kumar is a pediatric hospitalist at Cleveland Clinic Children’s. She is a clinical assistant professor of pediatrics at Case Western Reserve University, Cleveland, and serves as the Pediatrics Editor for The Hospitalist.
Critical care and COVID-19: Dr. Matt Aldrich
Matt Aldrich, MD, is an anesthesiologist and medical director of critical care at UCSF Health in San Francisco. Robert Wachter, MD,MHM, spoke with him about critical care issues in COVID-19, including clinical presentation, PPE in the ICU, whether the health system has enough ventilators for a surge, and ethical dilemmas that ICUs may face during the pandemic.
Matt Aldrich, MD, is an anesthesiologist and medical director of critical care at UCSF Health in San Francisco. Robert Wachter, MD,MHM, spoke with him about critical care issues in COVID-19, including clinical presentation, PPE in the ICU, whether the health system has enough ventilators for a surge, and ethical dilemmas that ICUs may face during the pandemic.
Matt Aldrich, MD, is an anesthesiologist and medical director of critical care at UCSF Health in San Francisco. Robert Wachter, MD,MHM, spoke with him about critical care issues in COVID-19, including clinical presentation, PPE in the ICU, whether the health system has enough ventilators for a surge, and ethical dilemmas that ICUs may face during the pandemic.
Before the COVID-19 surge hits your facility, take steps to boost capacity
, according to a physician leader and a health workforce expert.
Polly Pittman, PhD, is hearing a lot of concern among health care workers that it’s difficult to find definitive and accurate information about how best to protect themselves and their families, she said during a webinar by the Alliance for Health Policy titled Health System Capacity: Protecting Frontline Health Workers. “The knowledge base is evolving very quickly,” said Dr. Pittman, Fitzhugh Mullan Professor of Health Workforce Equity at the Milken Institute School of Public Health, George Washington University, Washington.
Stephen Parodi, MD, agreed that effective communication is job one in the health care workplace during the crisis. “I can’t stress enough ... that communications are paramount and you can’t overcommunicate,” said Dr. Parodi, executive vice president of external affairs, communications, and brand at the Permanente Federation and associate executive director of the Permanente Medical Group, Vallejo, Calif.
“We’re in a situation of confusion and improvisation right now,” regarding protection of health care workers, said Dr. Pittman. The potential exists for “a downward spiral where you have the lack of training, the shortages in terms of protective gear, weakening of guidelines, and confusion regarding guidelines at federal level, creating a potential cascade” that may result in “moral distress and fatigue. ... That’s not occurring now, but that’s the danger” unless the personal protective equipment (PPE) situation is adequately addressed very soon, she said.
Dr. Pittman also pointed out the concerns that many of the 18 million U.S. health care workers have for their families should they themselves fall ill or transmit coronavirus to family members. “The danger exists of a mass exodus. People don’t have to show up at work, and they won’t show up at work if they don’t feel supported and safe.”
Dr. Parodi said that the Permanente organization is on a better footing than many workplaces. “We actually had an early experience because of the work that we did to support the Diamond Princess cruise ship evacuees from Yokahama in February.” That ship was quarantined upon arrival in Yokahama on Feb. 3 because a passenger had a confirmed test for SARS-CoV-2 infection, and a quarter of the 428 Americans on board subsequently tested positive. Most of them were evacuated to California or Texas. “That actually gave us the experience for providing care within the hospital setting – and also for containment strategies,” he said.
“We quickly understood that we needed to move to a mitigation strategy,” said Dr. Parodi. Use of PPE has been “tailored for how the virus is spread.” In the absence of the risk of aerosol transmission from certain procedures, health care workers use gowns, gloves, surgical masks, and goggles.
Because of anticipated “supply chain shortfalls,” Dr. Parodi said that his organization implemented Centers for Disease Control and Prevention guidelines for reuse and extended use of N95 respirators early on. “Even if you’re not in a locale that’s been hit, you need to be on wartime footing for preserving PPE.”
Telehealth, said Dr. Parodi, has been implemented “in a huge way” throughout the Permanente system. “We have reduced primary care visits by 90% in the past week, and also subspecialty visits by 50%. … A large amount of the workforce can work from home. We turned off elective surgeries more than a week ago to reduce the number of patients who are requiring intensive care.” Making these changes means the organization is more prepared now for a surge they expect in the coming weeks.
Dr. Pittman voiced an opinion widely shared by those who are implementing large-scale telehealth efforts “We’re going to learn a lot. Many of the traditional doctor-patient visits can be done by telemedicine in the future.”
Knowledge about local trends in infection rates is key to preparedness. “We’ve ramped up testing, to understand what’s happening in the community,” said Dr. Parodi, noting that test turnaround time is currently running 8-24 hours. Tightening up this window can free up resources when an admitted patient’s test is negative.
Still, some national projections forecast a need for hospital beds at two to three times current capacity – or even more, said Dr. Parodi.
He noted that Permanente is “working hand in glove with state authorities throughout the country.” Efforts include establishing alternative sites for assessment and testing, as well as opening up closed hospitals and working with the National Guard and the Department of Defense to prepare mobile hospital units that can be deployed in areas with peak infection rates. “Having all of those options available to us is critically important,” he said.
To mitigate potential provider shortages, Dr. Pittman said, “All members of the care team could potentially do more” than their current licenses allow. Expanding the scope of practice for pharmacists, clinical laboratory staff, licensed practical nurses, and medical assistants can help with efficient care delivery.
Other measures include expedited licensing for near-graduates and nonpracticing foreign medical graduates, as well as relicensing for retired health care personnel and those who are not currently working directly with patients, she said.
Getting these things done “requires leadership on behalf of the licensing bodies,” as well as coordination with state regulatory authorities, Dr. Pittman pointed out.
Dr. Parodi called for state and federal governments to implement emergency declarations that suspend some existing health codes to achieve repurposing of staff. Getting these measures in place now will allow facilities “to be able to provide that in-time training now before the surge occurs. ... We are actively developing plans knowing that there’s going to be a need for more critical care.”
The game plan at Permanente, he said, is to repurpose critical care physicians to provide consultations to multiple hospitalists who are providing the bulk of frontline care. At the same time, they plan to repurpose other specialists to backfill the hospitalists, and to repurpose family medicine physicians to supplement staff in emergency departments and other frontline intake areas.
All the organizational measures being taken won’t be in vain if they increase preparedness for the long battle ahead, he said. “We need to double down on the work. ... We need to continue social distancing, and we’ve got to ramp up testing. Until we do that we have to hold the line on basic public health measures.”
Dr. Parodi is employed by Permanente. The panelists reported no disclosures relevant to the presentation, which was sponsored by the Alliance for Health Policy, the Commonwealth Fund, and the National Institute for Health Care Management Foundation.
, according to a physician leader and a health workforce expert.
Polly Pittman, PhD, is hearing a lot of concern among health care workers that it’s difficult to find definitive and accurate information about how best to protect themselves and their families, she said during a webinar by the Alliance for Health Policy titled Health System Capacity: Protecting Frontline Health Workers. “The knowledge base is evolving very quickly,” said Dr. Pittman, Fitzhugh Mullan Professor of Health Workforce Equity at the Milken Institute School of Public Health, George Washington University, Washington.
Stephen Parodi, MD, agreed that effective communication is job one in the health care workplace during the crisis. “I can’t stress enough ... that communications are paramount and you can’t overcommunicate,” said Dr. Parodi, executive vice president of external affairs, communications, and brand at the Permanente Federation and associate executive director of the Permanente Medical Group, Vallejo, Calif.
“We’re in a situation of confusion and improvisation right now,” regarding protection of health care workers, said Dr. Pittman. The potential exists for “a downward spiral where you have the lack of training, the shortages in terms of protective gear, weakening of guidelines, and confusion regarding guidelines at federal level, creating a potential cascade” that may result in “moral distress and fatigue. ... That’s not occurring now, but that’s the danger” unless the personal protective equipment (PPE) situation is adequately addressed very soon, she said.
Dr. Pittman also pointed out the concerns that many of the 18 million U.S. health care workers have for their families should they themselves fall ill or transmit coronavirus to family members. “The danger exists of a mass exodus. People don’t have to show up at work, and they won’t show up at work if they don’t feel supported and safe.”
Dr. Parodi said that the Permanente organization is on a better footing than many workplaces. “We actually had an early experience because of the work that we did to support the Diamond Princess cruise ship evacuees from Yokahama in February.” That ship was quarantined upon arrival in Yokahama on Feb. 3 because a passenger had a confirmed test for SARS-CoV-2 infection, and a quarter of the 428 Americans on board subsequently tested positive. Most of them were evacuated to California or Texas. “That actually gave us the experience for providing care within the hospital setting – and also for containment strategies,” he said.
“We quickly understood that we needed to move to a mitigation strategy,” said Dr. Parodi. Use of PPE has been “tailored for how the virus is spread.” In the absence of the risk of aerosol transmission from certain procedures, health care workers use gowns, gloves, surgical masks, and goggles.
Because of anticipated “supply chain shortfalls,” Dr. Parodi said that his organization implemented Centers for Disease Control and Prevention guidelines for reuse and extended use of N95 respirators early on. “Even if you’re not in a locale that’s been hit, you need to be on wartime footing for preserving PPE.”
Telehealth, said Dr. Parodi, has been implemented “in a huge way” throughout the Permanente system. “We have reduced primary care visits by 90% in the past week, and also subspecialty visits by 50%. … A large amount of the workforce can work from home. We turned off elective surgeries more than a week ago to reduce the number of patients who are requiring intensive care.” Making these changes means the organization is more prepared now for a surge they expect in the coming weeks.
Dr. Pittman voiced an opinion widely shared by those who are implementing large-scale telehealth efforts “We’re going to learn a lot. Many of the traditional doctor-patient visits can be done by telemedicine in the future.”
Knowledge about local trends in infection rates is key to preparedness. “We’ve ramped up testing, to understand what’s happening in the community,” said Dr. Parodi, noting that test turnaround time is currently running 8-24 hours. Tightening up this window can free up resources when an admitted patient’s test is negative.
Still, some national projections forecast a need for hospital beds at two to three times current capacity – or even more, said Dr. Parodi.
He noted that Permanente is “working hand in glove with state authorities throughout the country.” Efforts include establishing alternative sites for assessment and testing, as well as opening up closed hospitals and working with the National Guard and the Department of Defense to prepare mobile hospital units that can be deployed in areas with peak infection rates. “Having all of those options available to us is critically important,” he said.
To mitigate potential provider shortages, Dr. Pittman said, “All members of the care team could potentially do more” than their current licenses allow. Expanding the scope of practice for pharmacists, clinical laboratory staff, licensed practical nurses, and medical assistants can help with efficient care delivery.
Other measures include expedited licensing for near-graduates and nonpracticing foreign medical graduates, as well as relicensing for retired health care personnel and those who are not currently working directly with patients, she said.
Getting these things done “requires leadership on behalf of the licensing bodies,” as well as coordination with state regulatory authorities, Dr. Pittman pointed out.
Dr. Parodi called for state and federal governments to implement emergency declarations that suspend some existing health codes to achieve repurposing of staff. Getting these measures in place now will allow facilities “to be able to provide that in-time training now before the surge occurs. ... We are actively developing plans knowing that there’s going to be a need for more critical care.”
The game plan at Permanente, he said, is to repurpose critical care physicians to provide consultations to multiple hospitalists who are providing the bulk of frontline care. At the same time, they plan to repurpose other specialists to backfill the hospitalists, and to repurpose family medicine physicians to supplement staff in emergency departments and other frontline intake areas.
All the organizational measures being taken won’t be in vain if they increase preparedness for the long battle ahead, he said. “We need to double down on the work. ... We need to continue social distancing, and we’ve got to ramp up testing. Until we do that we have to hold the line on basic public health measures.”
Dr. Parodi is employed by Permanente. The panelists reported no disclosures relevant to the presentation, which was sponsored by the Alliance for Health Policy, the Commonwealth Fund, and the National Institute for Health Care Management Foundation.
, according to a physician leader and a health workforce expert.
Polly Pittman, PhD, is hearing a lot of concern among health care workers that it’s difficult to find definitive and accurate information about how best to protect themselves and their families, she said during a webinar by the Alliance for Health Policy titled Health System Capacity: Protecting Frontline Health Workers. “The knowledge base is evolving very quickly,” said Dr. Pittman, Fitzhugh Mullan Professor of Health Workforce Equity at the Milken Institute School of Public Health, George Washington University, Washington.
Stephen Parodi, MD, agreed that effective communication is job one in the health care workplace during the crisis. “I can’t stress enough ... that communications are paramount and you can’t overcommunicate,” said Dr. Parodi, executive vice president of external affairs, communications, and brand at the Permanente Federation and associate executive director of the Permanente Medical Group, Vallejo, Calif.
“We’re in a situation of confusion and improvisation right now,” regarding protection of health care workers, said Dr. Pittman. The potential exists for “a downward spiral where you have the lack of training, the shortages in terms of protective gear, weakening of guidelines, and confusion regarding guidelines at federal level, creating a potential cascade” that may result in “moral distress and fatigue. ... That’s not occurring now, but that’s the danger” unless the personal protective equipment (PPE) situation is adequately addressed very soon, she said.
Dr. Pittman also pointed out the concerns that many of the 18 million U.S. health care workers have for their families should they themselves fall ill or transmit coronavirus to family members. “The danger exists of a mass exodus. People don’t have to show up at work, and they won’t show up at work if they don’t feel supported and safe.”
Dr. Parodi said that the Permanente organization is on a better footing than many workplaces. “We actually had an early experience because of the work that we did to support the Diamond Princess cruise ship evacuees from Yokahama in February.” That ship was quarantined upon arrival in Yokahama on Feb. 3 because a passenger had a confirmed test for SARS-CoV-2 infection, and a quarter of the 428 Americans on board subsequently tested positive. Most of them were evacuated to California or Texas. “That actually gave us the experience for providing care within the hospital setting – and also for containment strategies,” he said.
“We quickly understood that we needed to move to a mitigation strategy,” said Dr. Parodi. Use of PPE has been “tailored for how the virus is spread.” In the absence of the risk of aerosol transmission from certain procedures, health care workers use gowns, gloves, surgical masks, and goggles.
Because of anticipated “supply chain shortfalls,” Dr. Parodi said that his organization implemented Centers for Disease Control and Prevention guidelines for reuse and extended use of N95 respirators early on. “Even if you’re not in a locale that’s been hit, you need to be on wartime footing for preserving PPE.”
Telehealth, said Dr. Parodi, has been implemented “in a huge way” throughout the Permanente system. “We have reduced primary care visits by 90% in the past week, and also subspecialty visits by 50%. … A large amount of the workforce can work from home. We turned off elective surgeries more than a week ago to reduce the number of patients who are requiring intensive care.” Making these changes means the organization is more prepared now for a surge they expect in the coming weeks.
Dr. Pittman voiced an opinion widely shared by those who are implementing large-scale telehealth efforts “We’re going to learn a lot. Many of the traditional doctor-patient visits can be done by telemedicine in the future.”
Knowledge about local trends in infection rates is key to preparedness. “We’ve ramped up testing, to understand what’s happening in the community,” said Dr. Parodi, noting that test turnaround time is currently running 8-24 hours. Tightening up this window can free up resources when an admitted patient’s test is negative.
Still, some national projections forecast a need for hospital beds at two to three times current capacity – or even more, said Dr. Parodi.
He noted that Permanente is “working hand in glove with state authorities throughout the country.” Efforts include establishing alternative sites for assessment and testing, as well as opening up closed hospitals and working with the National Guard and the Department of Defense to prepare mobile hospital units that can be deployed in areas with peak infection rates. “Having all of those options available to us is critically important,” he said.
To mitigate potential provider shortages, Dr. Pittman said, “All members of the care team could potentially do more” than their current licenses allow. Expanding the scope of practice for pharmacists, clinical laboratory staff, licensed practical nurses, and medical assistants can help with efficient care delivery.
Other measures include expedited licensing for near-graduates and nonpracticing foreign medical graduates, as well as relicensing for retired health care personnel and those who are not currently working directly with patients, she said.
Getting these things done “requires leadership on behalf of the licensing bodies,” as well as coordination with state regulatory authorities, Dr. Pittman pointed out.
Dr. Parodi called for state and federal governments to implement emergency declarations that suspend some existing health codes to achieve repurposing of staff. Getting these measures in place now will allow facilities “to be able to provide that in-time training now before the surge occurs. ... We are actively developing plans knowing that there’s going to be a need for more critical care.”
The game plan at Permanente, he said, is to repurpose critical care physicians to provide consultations to multiple hospitalists who are providing the bulk of frontline care. At the same time, they plan to repurpose other specialists to backfill the hospitalists, and to repurpose family medicine physicians to supplement staff in emergency departments and other frontline intake areas.
All the organizational measures being taken won’t be in vain if they increase preparedness for the long battle ahead, he said. “We need to double down on the work. ... We need to continue social distancing, and we’ve got to ramp up testing. Until we do that we have to hold the line on basic public health measures.”
Dr. Parodi is employed by Permanente. The panelists reported no disclosures relevant to the presentation, which was sponsored by the Alliance for Health Policy, the Commonwealth Fund, and the National Institute for Health Care Management Foundation.
REPORTING FROM AN ALLIANCE FOR HEALTH POLICY WEBINAR
Two decades of leadership
In recognition of Dr. Larry Wellikson’s contributions to SHM
It’s already been a few years since I exited the Society of Hospital Medicine’s Board of Directors (2 years, or maybe 3 – I’ve already lost count), and sitting in my proverbial rocking chair in the Old Hospitalists’ Home, I heard, as many of you did, that Larry Wellikson, MD, MHM, the first and only CEO in the Society’s history, is stepping down soon.
With all the idle time that I find myself with these days, I have had the opportunity to ruminate on what Larry has brought to SHM in his 2 decades of leadership. And among the many answers, two stand out for me.
The first is Larry’s deep appreciation of the value of relationships that he has developed and nurtured, an attribute which he has imprinted on many of us who have worked with him over the years. Although Larry speaks of the camaraderie of the first years of SHM and the bonds that he, Bob Wachter, Win Whitcomb, and John Nelson established, he also has kept in touch with a vast network of hospitalists over the last 20-plus years.
Go to lunch with Larry, and be amazed at how much he knows about the goings-on of many of our colleagues. The fondness that Larry has for the people in his life is without parallel. These aren’t just professional colleagues who have impacted him in some way – for Larry, every one of these is a true lifetime friendship, and he continues to establish new ones every year. He makes each of his friends feel truly special to him.
The second is the critical value of and need for change and disruption. The specialty of hospital medicine was, from its beginning, disruptive, and from his career as a physician executive, Larry understood and has brought to SHM an understanding of the necessity of disruption to encourage growth and fresh thinking. If one steps back and looks at, for example, the composition of the Board over the years, or the Journal of Hospital Medicine’s editorial staff, or of our committees, one sees a pattern – a commitment to continuously bringing on young leaders who are still on the early and ascending part of their career paths.
Other organizations identify Board candidates at the peak of their careers, but at SHM, many of us were elected when we had just enough experience to contribute but then continued to grow in our careers after finishing our terms. I joined the Board in 2012 (I think) and while I would probably be a more seasoned and stately Board member if I joined at this point in my life, I would also have less new and novel to offer – and therefore be less effective for what the Society needs. While SHM respects its past leaders, it does not revere them. Our past is important, but our present and future are more important. Larry brought that mentality to SHM.
Ironically, the one position within SHM which has not, until this year, been subject to that same kind of transition is the CEO position itself. And this year, that domino will fall as well. While transitions are hard, change is good – and I am confident that our Society’s commitment to seeking out new, talented leaders, and making transitions at all levels – Board, committees, chapters, speakers – with the intent of bringing new perspectives and creativity, is firmly entrenched in our culture. And Larry can join me in the rocking chair as we relive our common SHM experiences together – and create new memories as well.
Congratulations Larry, and thank you.
Dr. Harte is a past president of SHM, and president of Cleveland Clinic Akron (Ohio) General and the Southern Region. He formerly served as president of Cleveland Clinic Hillcrest Hospital and Cleveland Clinic South Pointe Hospital.
In recognition of Dr. Larry Wellikson’s contributions to SHM
In recognition of Dr. Larry Wellikson’s contributions to SHM
It’s already been a few years since I exited the Society of Hospital Medicine’s Board of Directors (2 years, or maybe 3 – I’ve already lost count), and sitting in my proverbial rocking chair in the Old Hospitalists’ Home, I heard, as many of you did, that Larry Wellikson, MD, MHM, the first and only CEO in the Society’s history, is stepping down soon.
With all the idle time that I find myself with these days, I have had the opportunity to ruminate on what Larry has brought to SHM in his 2 decades of leadership. And among the many answers, two stand out for me.
The first is Larry’s deep appreciation of the value of relationships that he has developed and nurtured, an attribute which he has imprinted on many of us who have worked with him over the years. Although Larry speaks of the camaraderie of the first years of SHM and the bonds that he, Bob Wachter, Win Whitcomb, and John Nelson established, he also has kept in touch with a vast network of hospitalists over the last 20-plus years.
Go to lunch with Larry, and be amazed at how much he knows about the goings-on of many of our colleagues. The fondness that Larry has for the people in his life is without parallel. These aren’t just professional colleagues who have impacted him in some way – for Larry, every one of these is a true lifetime friendship, and he continues to establish new ones every year. He makes each of his friends feel truly special to him.
The second is the critical value of and need for change and disruption. The specialty of hospital medicine was, from its beginning, disruptive, and from his career as a physician executive, Larry understood and has brought to SHM an understanding of the necessity of disruption to encourage growth and fresh thinking. If one steps back and looks at, for example, the composition of the Board over the years, or the Journal of Hospital Medicine’s editorial staff, or of our committees, one sees a pattern – a commitment to continuously bringing on young leaders who are still on the early and ascending part of their career paths.
Other organizations identify Board candidates at the peak of their careers, but at SHM, many of us were elected when we had just enough experience to contribute but then continued to grow in our careers after finishing our terms. I joined the Board in 2012 (I think) and while I would probably be a more seasoned and stately Board member if I joined at this point in my life, I would also have less new and novel to offer – and therefore be less effective for what the Society needs. While SHM respects its past leaders, it does not revere them. Our past is important, but our present and future are more important. Larry brought that mentality to SHM.
Ironically, the one position within SHM which has not, until this year, been subject to that same kind of transition is the CEO position itself. And this year, that domino will fall as well. While transitions are hard, change is good – and I am confident that our Society’s commitment to seeking out new, talented leaders, and making transitions at all levels – Board, committees, chapters, speakers – with the intent of bringing new perspectives and creativity, is firmly entrenched in our culture. And Larry can join me in the rocking chair as we relive our common SHM experiences together – and create new memories as well.
Congratulations Larry, and thank you.
Dr. Harte is a past president of SHM, and president of Cleveland Clinic Akron (Ohio) General and the Southern Region. He formerly served as president of Cleveland Clinic Hillcrest Hospital and Cleveland Clinic South Pointe Hospital.
It’s already been a few years since I exited the Society of Hospital Medicine’s Board of Directors (2 years, or maybe 3 – I’ve already lost count), and sitting in my proverbial rocking chair in the Old Hospitalists’ Home, I heard, as many of you did, that Larry Wellikson, MD, MHM, the first and only CEO in the Society’s history, is stepping down soon.
With all the idle time that I find myself with these days, I have had the opportunity to ruminate on what Larry has brought to SHM in his 2 decades of leadership. And among the many answers, two stand out for me.
The first is Larry’s deep appreciation of the value of relationships that he has developed and nurtured, an attribute which he has imprinted on many of us who have worked with him over the years. Although Larry speaks of the camaraderie of the first years of SHM and the bonds that he, Bob Wachter, Win Whitcomb, and John Nelson established, he also has kept in touch with a vast network of hospitalists over the last 20-plus years.
Go to lunch with Larry, and be amazed at how much he knows about the goings-on of many of our colleagues. The fondness that Larry has for the people in his life is without parallel. These aren’t just professional colleagues who have impacted him in some way – for Larry, every one of these is a true lifetime friendship, and he continues to establish new ones every year. He makes each of his friends feel truly special to him.
The second is the critical value of and need for change and disruption. The specialty of hospital medicine was, from its beginning, disruptive, and from his career as a physician executive, Larry understood and has brought to SHM an understanding of the necessity of disruption to encourage growth and fresh thinking. If one steps back and looks at, for example, the composition of the Board over the years, or the Journal of Hospital Medicine’s editorial staff, or of our committees, one sees a pattern – a commitment to continuously bringing on young leaders who are still on the early and ascending part of their career paths.
Other organizations identify Board candidates at the peak of their careers, but at SHM, many of us were elected when we had just enough experience to contribute but then continued to grow in our careers after finishing our terms. I joined the Board in 2012 (I think) and while I would probably be a more seasoned and stately Board member if I joined at this point in my life, I would also have less new and novel to offer – and therefore be less effective for what the Society needs. While SHM respects its past leaders, it does not revere them. Our past is important, but our present and future are more important. Larry brought that mentality to SHM.
Ironically, the one position within SHM which has not, until this year, been subject to that same kind of transition is the CEO position itself. And this year, that domino will fall as well. While transitions are hard, change is good – and I am confident that our Society’s commitment to seeking out new, talented leaders, and making transitions at all levels – Board, committees, chapters, speakers – with the intent of bringing new perspectives and creativity, is firmly entrenched in our culture. And Larry can join me in the rocking chair as we relive our common SHM experiences together – and create new memories as well.
Congratulations Larry, and thank you.
Dr. Harte is a past president of SHM, and president of Cleveland Clinic Akron (Ohio) General and the Southern Region. He formerly served as president of Cleveland Clinic Hillcrest Hospital and Cleveland Clinic South Pointe Hospital.