Latest News for HOSP

Background: Falls are the leading cause of unintentional injuries and injury-related deaths among adults aged 65 years and older. FRIDs (such as antidepressants, sedatives-hypnotics, and opioids) continue to be a major contributor for risk of falls. At the same time, little is known about prevalence of use or interventions directed toward reduction of use in older adults presenting with fall.

Study design: Systematic review.

Setting: PubMed and Embase databases were used to search for studies published in English on or before June 30, 2019. Search terms included older adults, falls, medication classes, and hospitalizations among other related terms.

Synopsis: The review included a total of 14 articles (10 observational studies and 4 prospective intervention studies). High prevalence of FRID use (65%-93%) was seen in older adults with fall-related injury. Use of FRIDs continued to remain high at 1 month and 6 months follow-up after a fall. Antidepressants, sedative-hypnotics, opioids, and antipsychotics were the most commonly used FRIDs. Three randomized controlled trials showed no effect of reducing FRID use on reduction in falls. An outpatient clinic pre-post assessment study based on intervention by geriatrician and communication with prescribing physicians led to reduction in FRID use and falls.

Limitations of this review included high risk of bias in observational studies and unclear timeline definitions of interventions or outcome measurements in the intervention studies. In conclusion, there is a significant need for well-designed interventions targeted at reducing FRID use in conjunction with other risk factors to decrease the incidence of falls comprehensively. An aggressive approach directed toward patient education along with primary care communication may be the key to reducing FRID use in this population.

Bottom line: With limited evidence, there is a high prevalence of FRID use in older adults presenting with falls and no reduction in FRID use following the encounter.

Citation: Hart LA et al. Use of fall risk-increasing drugs around a fall-related injury in older adults: A systematic review. J Am Geriatr Soc. 2020 Feb 17. doi: 10.1111/jgs.16369.

Dr. Yarra is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Falls are the leading cause of unintentional injuries and injury-related deaths among adults aged 65 years and older. FRIDs (such as antidepressants, sedatives-hypnotics, and opioids) continue to be a major contributor for risk of falls. At the same time, little is known about prevalence of use or interventions directed toward reduction of use in older adults presenting with fall.

Study design: Systematic review.

Setting: PubMed and Embase databases were used to search for studies published in English on or before June 30, 2019. Search terms included older adults, falls, medication classes, and hospitalizations among other related terms.

Synopsis: The review included a total of 14 articles (10 observational studies and 4 prospective intervention studies). High prevalence of FRID use (65%-93%) was seen in older adults with fall-related injury. Use of FRIDs continued to remain high at 1 month and 6 months follow-up after a fall. Antidepressants, sedative-hypnotics, opioids, and antipsychotics were the most commonly used FRIDs. Three randomized controlled trials showed no effect of reducing FRID use on reduction in falls. An outpatient clinic pre-post assessment study based on intervention by geriatrician and communication with prescribing physicians led to reduction in FRID use and falls.

Limitations of this review included high risk of bias in observational studies and unclear timeline definitions of interventions or outcome measurements in the intervention studies. In conclusion, there is a significant need for well-designed interventions targeted at reducing FRID use in conjunction with other risk factors to decrease the incidence of falls comprehensively. An aggressive approach directed toward patient education along with primary care communication may be the key to reducing FRID use in this population.

Bottom line: With limited evidence, there is a high prevalence of FRID use in older adults presenting with falls and no reduction in FRID use following the encounter.

Citation: Hart LA et al. Use of fall risk-increasing drugs around a fall-related injury in older adults: A systematic review. J Am Geriatr Soc. 2020 Feb 17. doi: 10.1111/jgs.16369.

Dr. Yarra is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Falls are the leading cause of unintentional injuries and injury-related deaths among adults aged 65 years and older. FRIDs (such as antidepressants, sedatives-hypnotics, and opioids) continue to be a major contributor for risk of falls. At the same time, little is known about prevalence of use or interventions directed toward reduction of use in older adults presenting with fall.

Study design: Systematic review.

Setting: PubMed and Embase databases were used to search for studies published in English on or before June 30, 2019. Search terms included older adults, falls, medication classes, and hospitalizations among other related terms.

Synopsis: The review included a total of 14 articles (10 observational studies and 4 prospective intervention studies). High prevalence of FRID use (65%-93%) was seen in older adults with fall-related injury. Use of FRIDs continued to remain high at 1 month and 6 months follow-up after a fall. Antidepressants, sedative-hypnotics, opioids, and antipsychotics were the most commonly used FRIDs. Three randomized controlled trials showed no effect of reducing FRID use on reduction in falls. An outpatient clinic pre-post assessment study based on intervention by geriatrician and communication with prescribing physicians led to reduction in FRID use and falls.

Limitations of this review included high risk of bias in observational studies and unclear timeline definitions of interventions or outcome measurements in the intervention studies. In conclusion, there is a significant need for well-designed interventions targeted at reducing FRID use in conjunction with other risk factors to decrease the incidence of falls comprehensively. An aggressive approach directed toward patient education along with primary care communication may be the key to reducing FRID use in this population.

Bottom line: With limited evidence, there is a high prevalence of FRID use in older adults presenting with falls and no reduction in FRID use following the encounter.

Citation: Hart LA et al. Use of fall risk-increasing drugs around a fall-related injury in older adults: A systematic review. J Am Geriatr Soc. 2020 Feb 17. doi: 10.1111/jgs.16369.

Dr. Yarra is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Despite advances in perioperative care, postoperative pulmonary complications represent a leading cause of morbidity and mortality that are associated with increased risk of admission to critical care and prolonged length of hospital stay. There are multiple interventions that are used, despite there being no consensus guidelines aimed at reducing the risk of PPCs.

Study design: Systemic review and meta-analysis of randomized controlled trials.

Setting: Literature search from Medline, Embase, CINHAL, and the Cochrane Central Register of Controlled Trials from January 1990 to December 2017, including trials investigating short-term, protocolized medical interventions around noncardiac surgeries with clinical diagnostic criteria for PPC outcomes.

Synopsis: The authors reviewed 117 trials that included 21,940 participants. The meta-analysis comprised 95 randomized controlled trials with 18,062 patients. The authors identified 11 categories of perioperative care interventions that were tested to reduce PPCs. None of the interventions evaluated was supported by high-quality evidence. There were seven interventions that showed a probable reduction in PPCs. Goal-directed fluid therapy was the only one that was supported by both moderate quality evidence and trial sequential analysis. Lung protective intraoperative ventilation was supported by moderate quality evidence, but not trial sequential analysis. Five interventions had low-quality evidence of benefit: enhanced recovery pathways, prophylactic mucolytics, postoperative continuous positive airway pressure ventilation, prophylactic respiratory physiotherapy, and epidural analgesia.

Unfortunately, only a minority of the trials reviewed were large, multi-center studies with a low risk of bias. The studies were also heterogeneous, posing a challenge for meta-analysis.

Bottom line: There is limited evidence supporting the efficacy of any intervention preventing postoperative pulmonary complications, with moderate-quality evidence supporting intraoperative lung protective ventilation and goal-directed hemodynamic strategies reducing PPCs.

Citation: Odor PM et al. Perioperative interventions for prevention of postoperative pulmonary complication: Systemic review and meta-analysis. BMJ. 2020 Mar 11. doi: 10.1136/bmj.m540.

Dr. Weaver is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Despite advances in perioperative care, postoperative pulmonary complications represent a leading cause of morbidity and mortality that are associated with increased risk of admission to critical care and prolonged length of hospital stay. There are multiple interventions that are used, despite there being no consensus guidelines aimed at reducing the risk of PPCs.

Study design: Systemic review and meta-analysis of randomized controlled trials.

Setting: Literature search from Medline, Embase, CINHAL, and the Cochrane Central Register of Controlled Trials from January 1990 to December 2017, including trials investigating short-term, protocolized medical interventions around noncardiac surgeries with clinical diagnostic criteria for PPC outcomes.

Synopsis: The authors reviewed 117 trials that included 21,940 participants. The meta-analysis comprised 95 randomized controlled trials with 18,062 patients. The authors identified 11 categories of perioperative care interventions that were tested to reduce PPCs. None of the interventions evaluated was supported by high-quality evidence. There were seven interventions that showed a probable reduction in PPCs. Goal-directed fluid therapy was the only one that was supported by both moderate quality evidence and trial sequential analysis. Lung protective intraoperative ventilation was supported by moderate quality evidence, but not trial sequential analysis. Five interventions had low-quality evidence of benefit: enhanced recovery pathways, prophylactic mucolytics, postoperative continuous positive airway pressure ventilation, prophylactic respiratory physiotherapy, and epidural analgesia.

Unfortunately, only a minority of the trials reviewed were large, multi-center studies with a low risk of bias. The studies were also heterogeneous, posing a challenge for meta-analysis.

Bottom line: There is limited evidence supporting the efficacy of any intervention preventing postoperative pulmonary complications, with moderate-quality evidence supporting intraoperative lung protective ventilation and goal-directed hemodynamic strategies reducing PPCs.

Citation: Odor PM et al. Perioperative interventions for prevention of postoperative pulmonary complication: Systemic review and meta-analysis. BMJ. 2020 Mar 11. doi: 10.1136/bmj.m540.

Dr. Weaver is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Despite advances in perioperative care, postoperative pulmonary complications represent a leading cause of morbidity and mortality that are associated with increased risk of admission to critical care and prolonged length of hospital stay. There are multiple interventions that are used, despite there being no consensus guidelines aimed at reducing the risk of PPCs.

Study design: Systemic review and meta-analysis of randomized controlled trials.

Setting: Literature search from Medline, Embase, CINHAL, and the Cochrane Central Register of Controlled Trials from January 1990 to December 2017, including trials investigating short-term, protocolized medical interventions around noncardiac surgeries with clinical diagnostic criteria for PPC outcomes.

Synopsis: The authors reviewed 117 trials that included 21,940 participants. The meta-analysis comprised 95 randomized controlled trials with 18,062 patients. The authors identified 11 categories of perioperative care interventions that were tested to reduce PPCs. None of the interventions evaluated was supported by high-quality evidence. There were seven interventions that showed a probable reduction in PPCs. Goal-directed fluid therapy was the only one that was supported by both moderate quality evidence and trial sequential analysis. Lung protective intraoperative ventilation was supported by moderate quality evidence, but not trial sequential analysis. Five interventions had low-quality evidence of benefit: enhanced recovery pathways, prophylactic mucolytics, postoperative continuous positive airway pressure ventilation, prophylactic respiratory physiotherapy, and epidural analgesia.

Unfortunately, only a minority of the trials reviewed were large, multi-center studies with a low risk of bias. The studies were also heterogeneous, posing a challenge for meta-analysis.

Bottom line: There is limited evidence supporting the efficacy of any intervention preventing postoperative pulmonary complications, with moderate-quality evidence supporting intraoperative lung protective ventilation and goal-directed hemodynamic strategies reducing PPCs.

Citation: Odor PM et al. Perioperative interventions for prevention of postoperative pulmonary complication: Systemic review and meta-analysis. BMJ. 2020 Mar 11. doi: 10.1136/bmj.m540.

Dr. Weaver is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Both observational studies and clinical trials have found that a liberal oxygenation strategy in multiple inpatient settings may be harmful. Furthermore, a conservative strategy is what has been recommended in guidelines. Conversely, the relevance of this recent concept has been challenged in a large trial of a critically ill population (ICU-ROX).

Study design: Randomized clinical trial, unblinded.

Setting: Thirteen sites in France.

Synopsis: In a multicenter randomized clinical trial, investigators enrolled patients with ARDS to either a liberal oxygenation group (PaO₂ target 90-105 mm Hg or SpO₂ of 96% or greater) or a conservative oxygenation group (PaO₂ target 55-70 mm Hg or SpO2 88%-92%). The trial was planned for inclusion of 850 patients, but the data and safety monitoring board decided to stop the trial after inclusion of 205 patients. Although the primary outcome (28-day all-cause mortality) was not significantly different between groups (34.3% vs 26.5%; absolute difference, 7.8%; 95% confidence interval, –4.8 to 20.6), the direction was signaling possible harm and there were five episodes of mesenteric ischemia in the conservative oxygenation group (none in the liberal oxygenation group).

Bottom line: A conservative oxygenation strategy cannot be currently recommended to patients with ARDS in the ICU. A minimum SpO₂ of 90% was suggested in an accompanying editorial.

Editorial commentary: Interestingly, the supplemental results of the article show that prone positioning was used much less frequently in the conservative oxygenation group (34.3 vs 51.0%). If the impressive results of Guerin (2013) would be repeated in this population, this difference could help explain the higher observed mortality in the conservative oxygenation group. It is possible that, by aiming to be less aggressive in improving the PaO₂, clinicians inadvertently withheld effective treatments for ARDS. The results of this trial bring up several interesting questions, but provide the bedside clinician with few answers. The complex interplay of treatment factors needs to be dissected in future trials.

Citation: Barrot L et al. Liberal or conservative oxygen therapy for acute respiratory distress syndrome. N Eng J Med. 2020;382:999-1008.

Dr. Saraiva is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Both observational studies and clinical trials have found that a liberal oxygenation strategy in multiple inpatient settings may be harmful. Furthermore, a conservative strategy is what has been recommended in guidelines. Conversely, the relevance of this recent concept has been challenged in a large trial of a critically ill population (ICU-ROX).

Study design: Randomized clinical trial, unblinded.

Setting: Thirteen sites in France.

Synopsis: In a multicenter randomized clinical trial, investigators enrolled patients with ARDS to either a liberal oxygenation group (PaO₂ target 90-105 mm Hg or SpO₂ of 96% or greater) or a conservative oxygenation group (PaO₂ target 55-70 mm Hg or SpO2 88%-92%). The trial was planned for inclusion of 850 patients, but the data and safety monitoring board decided to stop the trial after inclusion of 205 patients. Although the primary outcome (28-day all-cause mortality) was not significantly different between groups (34.3% vs 26.5%; absolute difference, 7.8%; 95% confidence interval, –4.8 to 20.6), the direction was signaling possible harm and there were five episodes of mesenteric ischemia in the conservative oxygenation group (none in the liberal oxygenation group).

Bottom line: A conservative oxygenation strategy cannot be currently recommended to patients with ARDS in the ICU. A minimum SpO₂ of 90% was suggested in an accompanying editorial.

Editorial commentary: Interestingly, the supplemental results of the article show that prone positioning was used much less frequently in the conservative oxygenation group (34.3 vs 51.0%). If the impressive results of Guerin (2013) would be repeated in this population, this difference could help explain the higher observed mortality in the conservative oxygenation group. It is possible that, by aiming to be less aggressive in improving the PaO₂, clinicians inadvertently withheld effective treatments for ARDS. The results of this trial bring up several interesting questions, but provide the bedside clinician with few answers. The complex interplay of treatment factors needs to be dissected in future trials.

Citation: Barrot L et al. Liberal or conservative oxygen therapy for acute respiratory distress syndrome. N Eng J Med. 2020;382:999-1008.

Dr. Saraiva is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Both observational studies and clinical trials have found that a liberal oxygenation strategy in multiple inpatient settings may be harmful. Furthermore, a conservative strategy is what has been recommended in guidelines. Conversely, the relevance of this recent concept has been challenged in a large trial of a critically ill population (ICU-ROX).

Study design: Randomized clinical trial, unblinded.

Setting: Thirteen sites in France.

Synopsis: In a multicenter randomized clinical trial, investigators enrolled patients with ARDS to either a liberal oxygenation group (PaO₂ target 90-105 mm Hg or SpO₂ of 96% or greater) or a conservative oxygenation group (PaO₂ target 55-70 mm Hg or SpO2 88%-92%). The trial was planned for inclusion of 850 patients, but the data and safety monitoring board decided to stop the trial after inclusion of 205 patients. Although the primary outcome (28-day all-cause mortality) was not significantly different between groups (34.3% vs 26.5%; absolute difference, 7.8%; 95% confidence interval, –4.8 to 20.6), the direction was signaling possible harm and there were five episodes of mesenteric ischemia in the conservative oxygenation group (none in the liberal oxygenation group).

Bottom line: A conservative oxygenation strategy cannot be currently recommended to patients with ARDS in the ICU. A minimum SpO₂ of 90% was suggested in an accompanying editorial.

Editorial commentary: Interestingly, the supplemental results of the article show that prone positioning was used much less frequently in the conservative oxygenation group (34.3 vs 51.0%). If the impressive results of Guerin (2013) would be repeated in this population, this difference could help explain the higher observed mortality in the conservative oxygenation group. It is possible that, by aiming to be less aggressive in improving the PaO₂, clinicians inadvertently withheld effective treatments for ARDS. The results of this trial bring up several interesting questions, but provide the bedside clinician with few answers. The complex interplay of treatment factors needs to be dissected in future trials.

Citation: Barrot L et al. Liberal or conservative oxygen therapy for acute respiratory distress syndrome. N Eng J Med. 2020;382:999-1008.

Dr. Saraiva is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Many articles have been published on sepsis and mortality in ICUs, but there are not many analyzing outcomes in patients with infections, nor types of infections. More information on the infection rate, types of infection, and possible impact on mortality should heighten awareness of infection effects, as well as guide resource allocation and help direct policy development for diagnosis and treatment.

Study design: 24-hour point-prevalence study with longitudinal follow-up.

Setting: ICUs in 1,150 centers in 88 countries.

Synopsis: The study included 15,202 patients who were aged 18 or older (mean, 61.6) within a 24-hour time period on Sept. 13, 2017, who were admitted to the ICU in participating centers and had documented, confirmed, or suspected infection. The investigators looked at prevalence of infection and antibiotic exposure on the study day and the main outcome measure was all cause in-hospital mortality, which was compiled 60 days later. The prevalence of suspected or proven infection in ICUs was 54% (8,135) and that of ICU-acquired infection was 22%. Of confirmed or suspected infection, 65% (5,259) had at least one positive microbiology culture. Of those cultures, 67% were gram-negative and 37% gram-positive bacteria, and 16% were fungal. 70% of ICU patients received at least one antibiotic. The in-hospital mortality rate with proven or suspected infection was 30% (2,404 of 7,936). Multilevel analysis disclosed two independent risk factors for mortality, which were ICU-acquired infections and antibiotic-resistant organisms, specifically, vancomycin-resistant Enterococcus, Klebsiella resistant to beta-lactam antibiotics, and carbapenem-resistant Acinetobacter.

Despite limitations related to being an observational study, 24-hour point evaluation, a centrally controlled database, and different geographic locations, this study elucidated the world-wide prevalence of ICU infection and high hospital-in mortality in those patients.

Bottom line: There is a high prevalence of infection in ICUs: 43%-60% depending on location. This is associated with 30% in-hospital mortality.

Citation: Vincent J-L et al. Prevalance and outcomes of infection among patients in intensive care units in 2017. JAMA. 2020 Mar 24;323(15):1478-87.

Dr. Rogozinska is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Many articles have been published on sepsis and mortality in ICUs, but there are not many analyzing outcomes in patients with infections, nor types of infections. More information on the infection rate, types of infection, and possible impact on mortality should heighten awareness of infection effects, as well as guide resource allocation and help direct policy development for diagnosis and treatment.

Study design: 24-hour point-prevalence study with longitudinal follow-up.

Setting: ICUs in 1,150 centers in 88 countries.

Synopsis: The study included 15,202 patients who were aged 18 or older (mean, 61.6) within a 24-hour time period on Sept. 13, 2017, who were admitted to the ICU in participating centers and had documented, confirmed, or suspected infection. The investigators looked at prevalence of infection and antibiotic exposure on the study day and the main outcome measure was all cause in-hospital mortality, which was compiled 60 days later. The prevalence of suspected or proven infection in ICUs was 54% (8,135) and that of ICU-acquired infection was 22%. Of confirmed or suspected infection, 65% (5,259) had at least one positive microbiology culture. Of those cultures, 67% were gram-negative and 37% gram-positive bacteria, and 16% were fungal. 70% of ICU patients received at least one antibiotic. The in-hospital mortality rate with proven or suspected infection was 30% (2,404 of 7,936). Multilevel analysis disclosed two independent risk factors for mortality, which were ICU-acquired infections and antibiotic-resistant organisms, specifically, vancomycin-resistant Enterococcus, Klebsiella resistant to beta-lactam antibiotics, and carbapenem-resistant Acinetobacter.

Despite limitations related to being an observational study, 24-hour point evaluation, a centrally controlled database, and different geographic locations, this study elucidated the world-wide prevalence of ICU infection and high hospital-in mortality in those patients.

Bottom line: There is a high prevalence of infection in ICUs: 43%-60% depending on location. This is associated with 30% in-hospital mortality.

Citation: Vincent J-L et al. Prevalance and outcomes of infection among patients in intensive care units in 2017. JAMA. 2020 Mar 24;323(15):1478-87.

Dr. Rogozinska is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Many articles have been published on sepsis and mortality in ICUs, but there are not many analyzing outcomes in patients with infections, nor types of infections. More information on the infection rate, types of infection, and possible impact on mortality should heighten awareness of infection effects, as well as guide resource allocation and help direct policy development for diagnosis and treatment.

Study design: 24-hour point-prevalence study with longitudinal follow-up.

Setting: ICUs in 1,150 centers in 88 countries.

Synopsis: The study included 15,202 patients who were aged 18 or older (mean, 61.6) within a 24-hour time period on Sept. 13, 2017, who were admitted to the ICU in participating centers and had documented, confirmed, or suspected infection. The investigators looked at prevalence of infection and antibiotic exposure on the study day and the main outcome measure was all cause in-hospital mortality, which was compiled 60 days later. The prevalence of suspected or proven infection in ICUs was 54% (8,135) and that of ICU-acquired infection was 22%. Of confirmed or suspected infection, 65% (5,259) had at least one positive microbiology culture. Of those cultures, 67% were gram-negative and 37% gram-positive bacteria, and 16% were fungal. 70% of ICU patients received at least one antibiotic. The in-hospital mortality rate with proven or suspected infection was 30% (2,404 of 7,936). Multilevel analysis disclosed two independent risk factors for mortality, which were ICU-acquired infections and antibiotic-resistant organisms, specifically, vancomycin-resistant Enterococcus, Klebsiella resistant to beta-lactam antibiotics, and carbapenem-resistant Acinetobacter.

Despite limitations related to being an observational study, 24-hour point evaluation, a centrally controlled database, and different geographic locations, this study elucidated the world-wide prevalence of ICU infection and high hospital-in mortality in those patients.

Bottom line: There is a high prevalence of infection in ICUs: 43%-60% depending on location. This is associated with 30% in-hospital mortality.

Citation: Vincent J-L et al. Prevalance and outcomes of infection among patients in intensive care units in 2017. JAMA. 2020 Mar 24;323(15):1478-87.

Dr. Rogozinska is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Afib is often asymp­tomatic until a patient presents with an acute stroke. Current screening strategies for Afib fail to detect a large portion of patients, especially since most Afib is paroxysmal. Better screening strategies that increase diagnostic yield are needed.

Study design: Randomized controlled trial (part of the LOOP trial).

Setting: Four centers in Denmark.

Synopsis: Patients over the age of 70 years, with at least one stroke risk factor, were monitored over the course of 3 years using an implantable loop recorder to obtain complete heart rhythm histories and to monitor for the development of Afib. Researchers then applied different sampling strategies to simulate different Afib screening scenarios on this set of rhythm data. A single 10-second EKG yielded a sensitivity of 1.5% for Afib detection and a negative predictive value (NPV) of 66%, increasing to 2.3% and 71% for annual EKGs during 3 years. Twice-daily 30-second EKGs during 14 consecutive days yielded a sensitivity of 8.3%, while a single 24-h monitoring yielded a sensitivity of 11%, increasing to 13%, 15%, and 21% for a 48-hour, 72-hour, and 7-day monitoring, respectively. The highest performance was achieved with annual 30-day monitoring which had a sensitivity of 34%-55% and a NPV of 74%-84% over 1-3 years.

The authors acknowledged many limitations including: The algorithm used had a sensitivity of 95%, there is no valid cutoffs for time-in-Afib, and the simulations assumed 100% patient compliance.

Bottom line: Screening for atrial fibrillation improves by increasing the duration of, spacing between, and number of screenings.

Citation: Diederichsen SZ et al. Comprehensive evaluation of rhythm monitoring strategies in screening for atrial fibrillation: Insights from patients at risk long-term monitored with implantable loop recorder. Circulation. 2020 May 12;141(19):1510-22.

Dr. Mastbergen is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Afib is often asymp­tomatic until a patient presents with an acute stroke. Current screening strategies for Afib fail to detect a large portion of patients, especially since most Afib is paroxysmal. Better screening strategies that increase diagnostic yield are needed.

Study design: Randomized controlled trial (part of the LOOP trial).

Setting: Four centers in Denmark.

Synopsis: Patients over the age of 70 years, with at least one stroke risk factor, were monitored over the course of 3 years using an implantable loop recorder to obtain complete heart rhythm histories and to monitor for the development of Afib. Researchers then applied different sampling strategies to simulate different Afib screening scenarios on this set of rhythm data. A single 10-second EKG yielded a sensitivity of 1.5% for Afib detection and a negative predictive value (NPV) of 66%, increasing to 2.3% and 71% for annual EKGs during 3 years. Twice-daily 30-second EKGs during 14 consecutive days yielded a sensitivity of 8.3%, while a single 24-h monitoring yielded a sensitivity of 11%, increasing to 13%, 15%, and 21% for a 48-hour, 72-hour, and 7-day monitoring, respectively. The highest performance was achieved with annual 30-day monitoring which had a sensitivity of 34%-55% and a NPV of 74%-84% over 1-3 years.

The authors acknowledged many limitations including: The algorithm used had a sensitivity of 95%, there is no valid cutoffs for time-in-Afib, and the simulations assumed 100% patient compliance.

Bottom line: Screening for atrial fibrillation improves by increasing the duration of, spacing between, and number of screenings.

Citation: Diederichsen SZ et al. Comprehensive evaluation of rhythm monitoring strategies in screening for atrial fibrillation: Insights from patients at risk long-term monitored with implantable loop recorder. Circulation. 2020 May 12;141(19):1510-22.

Dr. Mastbergen is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Afib is often asymp­tomatic until a patient presents with an acute stroke. Current screening strategies for Afib fail to detect a large portion of patients, especially since most Afib is paroxysmal. Better screening strategies that increase diagnostic yield are needed.

Study design: Randomized controlled trial (part of the LOOP trial).

Setting: Four centers in Denmark.

Synopsis: Patients over the age of 70 years, with at least one stroke risk factor, were monitored over the course of 3 years using an implantable loop recorder to obtain complete heart rhythm histories and to monitor for the development of Afib. Researchers then applied different sampling strategies to simulate different Afib screening scenarios on this set of rhythm data. A single 10-second EKG yielded a sensitivity of 1.5% for Afib detection and a negative predictive value (NPV) of 66%, increasing to 2.3% and 71% for annual EKGs during 3 years. Twice-daily 30-second EKGs during 14 consecutive days yielded a sensitivity of 8.3%, while a single 24-h monitoring yielded a sensitivity of 11%, increasing to 13%, 15%, and 21% for a 48-hour, 72-hour, and 7-day monitoring, respectively. The highest performance was achieved with annual 30-day monitoring which had a sensitivity of 34%-55% and a NPV of 74%-84% over 1-3 years.

The authors acknowledged many limitations including: The algorithm used had a sensitivity of 95%, there is no valid cutoffs for time-in-Afib, and the simulations assumed 100% patient compliance.

Bottom line: Screening for atrial fibrillation improves by increasing the duration of, spacing between, and number of screenings.

Citation: Diederichsen SZ et al. Comprehensive evaluation of rhythm monitoring strategies in screening for atrial fibrillation: Insights from patients at risk long-term monitored with implantable loop recorder. Circulation. 2020 May 12;141(19):1510-22.

Dr. Mastbergen is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: ACE-I and ARB therapy is widely used for hypertension, albuminuric chronic kidney disease, heart failure with reduced ejection fraction, and coronary artery disease. They are known to potentially cause hemodynamic reductions in eGFR, hyperkalemia, and acute kidney injury. We know to temporarily discontinue ACE-I or ARB in patients with eGFR less than 60 mL/min per 1.73 m² who have serious intercurrent illness that increases the risk of acute kidney injury, but existing literature evaluating the risks and benefits of using ACE-I and ARBs in individuals with advanced chronic kidney disease is conflicting.

Study design: Retrospective, propensity score–matched cohort study.

Setting: Geisinger Health System, serving central and northeastern Pennsylvania.

Synopsis: Total of 3,909 individuals were included in the study who were receiving ACE-I or ARB and experienced eGFR below 30 mL/min per 1.73 m². Of these 1,235 discontinued ACE-I or ARB therapy within 6 months after the eGFR decrease and 2,674 did not. At median 2.9 years’ follow-up, 434 (35.1%) patients who discontinued ACE-I or ARB therapy had died versus 786 (29.1%) who did not discontinue. Similarly, the risk of MACE (major adverse cardiovascular events) was higher among those who discontinued therapy (n = 494; 40.0%) than it was among those who did not discontinue therapy (n = 910; 34.0%). Among those who discontinued, 87 individuals (7.0%) developed end-stage kidney disease, compared with the 176 (6.6%) who did not discontinue. Additionally, in individuals with an eGFR decrease by 40% or more for 1 year while receiving ACE-I or ARB therapy, discontinuing therapy was associated with higher risk of mortality (32.6% vs. 20.5%).

Although this study is observational it has a large sample size and confounding factors have been accounted for by propensity score matching. The results are clinically relevant in daily practice.

Bottom line: Continuing ACE-I or ARB after an eGFR decrease to below 30 mL/min per m² is associated with lower risk of mortality and MACE without significant increased risk of end-stage kidney disease.

Citation: Qiao Y et al. Association between renin-angiotensin system blockade discontinuation and all-cause mortality among persons with low estimated glomerular filtration rate. JAMA Intern Med. 2020 Mar 9;180(5):718-26.

Dr. Kumar is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: ACE-I and ARB therapy is widely used for hypertension, albuminuric chronic kidney disease, heart failure with reduced ejection fraction, and coronary artery disease. They are known to potentially cause hemodynamic reductions in eGFR, hyperkalemia, and acute kidney injury. We know to temporarily discontinue ACE-I or ARB in patients with eGFR less than 60 mL/min per 1.73 m² who have serious intercurrent illness that increases the risk of acute kidney injury, but existing literature evaluating the risks and benefits of using ACE-I and ARBs in individuals with advanced chronic kidney disease is conflicting.

Study design: Retrospective, propensity score–matched cohort study.

Setting: Geisinger Health System, serving central and northeastern Pennsylvania.

Synopsis: Total of 3,909 individuals were included in the study who were receiving ACE-I or ARB and experienced eGFR below 30 mL/min per 1.73 m². Of these 1,235 discontinued ACE-I or ARB therapy within 6 months after the eGFR decrease and 2,674 did not. At median 2.9 years’ follow-up, 434 (35.1%) patients who discontinued ACE-I or ARB therapy had died versus 786 (29.1%) who did not discontinue. Similarly, the risk of MACE (major adverse cardiovascular events) was higher among those who discontinued therapy (n = 494; 40.0%) than it was among those who did not discontinue therapy (n = 910; 34.0%). Among those who discontinued, 87 individuals (7.0%) developed end-stage kidney disease, compared with the 176 (6.6%) who did not discontinue. Additionally, in individuals with an eGFR decrease by 40% or more for 1 year while receiving ACE-I or ARB therapy, discontinuing therapy was associated with higher risk of mortality (32.6% vs. 20.5%).

Although this study is observational it has a large sample size and confounding factors have been accounted for by propensity score matching. The results are clinically relevant in daily practice.

Bottom line: Continuing ACE-I or ARB after an eGFR decrease to below 30 mL/min per m² is associated with lower risk of mortality and MACE without significant increased risk of end-stage kidney disease.

Citation: Qiao Y et al. Association between renin-angiotensin system blockade discontinuation and all-cause mortality among persons with low estimated glomerular filtration rate. JAMA Intern Med. 2020 Mar 9;180(5):718-26.

Dr. Kumar is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: ACE-I and ARB therapy is widely used for hypertension, albuminuric chronic kidney disease, heart failure with reduced ejection fraction, and coronary artery disease. They are known to potentially cause hemodynamic reductions in eGFR, hyperkalemia, and acute kidney injury. We know to temporarily discontinue ACE-I or ARB in patients with eGFR less than 60 mL/min per 1.73 m² who have serious intercurrent illness that increases the risk of acute kidney injury, but existing literature evaluating the risks and benefits of using ACE-I and ARBs in individuals with advanced chronic kidney disease is conflicting.

Study design: Retrospective, propensity score–matched cohort study.

Setting: Geisinger Health System, serving central and northeastern Pennsylvania.

Synopsis: Total of 3,909 individuals were included in the study who were receiving ACE-I or ARB and experienced eGFR below 30 mL/min per 1.73 m². Of these 1,235 discontinued ACE-I or ARB therapy within 6 months after the eGFR decrease and 2,674 did not. At median 2.9 years’ follow-up, 434 (35.1%) patients who discontinued ACE-I or ARB therapy had died versus 786 (29.1%) who did not discontinue. Similarly, the risk of MACE (major adverse cardiovascular events) was higher among those who discontinued therapy (n = 494; 40.0%) than it was among those who did not discontinue therapy (n = 910; 34.0%). Among those who discontinued, 87 individuals (7.0%) developed end-stage kidney disease, compared with the 176 (6.6%) who did not discontinue. Additionally, in individuals with an eGFR decrease by 40% or more for 1 year while receiving ACE-I or ARB therapy, discontinuing therapy was associated with higher risk of mortality (32.6% vs. 20.5%).

Although this study is observational it has a large sample size and confounding factors have been accounted for by propensity score matching. The results are clinically relevant in daily practice.

Bottom line: Continuing ACE-I or ARB after an eGFR decrease to below 30 mL/min per m² is associated with lower risk of mortality and MACE without significant increased risk of end-stage kidney disease.

Citation: Qiao Y et al. Association between renin-angiotensin system blockade discontinuation and all-cause mortality among persons with low estimated glomerular filtration rate. JAMA Intern Med. 2020 Mar 9;180(5):718-26.

Dr. Kumar is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Up to 30 million people in the United States meet criteria for alcohol use disorder. Gabapentin addresses symptoms of protracted withdrawal such as insomnia, irritability, difficulty with attention, dysphoria, and anxiety. It does that by acting on voltage-gated calcium channels and, in turn, influencing GABA and glutamate tone and activity.

Study design: Double-blind, placebo-controlled, randomized clinical trial.

Settings: Academic ambulatory setting at the Medical University of South Carolina.

Synopsis: A total of 96 community-recruited participants were randomly assigned to gabapentin and placebo arm then treated and followed for a total of 16 weeks. The gabapentin arm received gradual increments of gabapentin reaching up to 1,200 mg/day by day 5. The control group received placebo in blister packs. Individuals in the gabapentin arm, compared with those in the placebo arm, showed 18.6% (P = .02) more no heavy–drinking days, with a number needed to treat (NNT) of 5.4, and 13.8% (P = .04) more total abstinence days, with an NNT of 6.2. The prestudy high–alcohol withdrawal group in particular had significantly less relapse to heavy drinking (P = .02; NNT, 3.1) and more total abstinence (P = .03; NNT, 2.7) when treated with gabapentin.

A couple of study limitations were a significant noncompletion rate (30% in gabapentin arm and 39% in the placebo arm) and self-reported alcohol withdrawal symptoms prior to entry into the study.

Bottom line: Gabapentin helps in reducing drinking and maintaining alcohol abstinence in individuals with alcohol use disorder, especially those with high–alcohol withdrawal symptoms.

Citation: Anton RF et al. Efficacy of gabapentin for the treatment of alcohol use disorder in patients with alcohol withdrawal symptoms: A randomized clinical trial. JAMA Intern Med. 2020 Mar 9;180(5):728-36.

Dr. Gaddam is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Up to 30 million people in the United States meet criteria for alcohol use disorder. Gabapentin addresses symptoms of protracted withdrawal such as insomnia, irritability, difficulty with attention, dysphoria, and anxiety. It does that by acting on voltage-gated calcium channels and, in turn, influencing GABA and glutamate tone and activity.

Study design: Double-blind, placebo-controlled, randomized clinical trial.

Settings: Academic ambulatory setting at the Medical University of South Carolina.

Synopsis: A total of 96 community-recruited participants were randomly assigned to gabapentin and placebo arm then treated and followed for a total of 16 weeks. The gabapentin arm received gradual increments of gabapentin reaching up to 1,200 mg/day by day 5. The control group received placebo in blister packs. Individuals in the gabapentin arm, compared with those in the placebo arm, showed 18.6% (P = .02) more no heavy–drinking days, with a number needed to treat (NNT) of 5.4, and 13.8% (P = .04) more total abstinence days, with an NNT of 6.2. The prestudy high–alcohol withdrawal group in particular had significantly less relapse to heavy drinking (P = .02; NNT, 3.1) and more total abstinence (P = .03; NNT, 2.7) when treated with gabapentin.

A couple of study limitations were a significant noncompletion rate (30% in gabapentin arm and 39% in the placebo arm) and self-reported alcohol withdrawal symptoms prior to entry into the study.

Bottom line: Gabapentin helps in reducing drinking and maintaining alcohol abstinence in individuals with alcohol use disorder, especially those with high–alcohol withdrawal symptoms.

Citation: Anton RF et al. Efficacy of gabapentin for the treatment of alcohol use disorder in patients with alcohol withdrawal symptoms: A randomized clinical trial. JAMA Intern Med. 2020 Mar 9;180(5):728-36.

Dr. Gaddam is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Up to 30 million people in the United States meet criteria for alcohol use disorder. Gabapentin addresses symptoms of protracted withdrawal such as insomnia, irritability, difficulty with attention, dysphoria, and anxiety. It does that by acting on voltage-gated calcium channels and, in turn, influencing GABA and glutamate tone and activity.

Study design: Double-blind, placebo-controlled, randomized clinical trial.

Settings: Academic ambulatory setting at the Medical University of South Carolina.

Synopsis: A total of 96 community-recruited participants were randomly assigned to gabapentin and placebo arm then treated and followed for a total of 16 weeks. The gabapentin arm received gradual increments of gabapentin reaching up to 1,200 mg/day by day 5. The control group received placebo in blister packs. Individuals in the gabapentin arm, compared with those in the placebo arm, showed 18.6% (P = .02) more no heavy–drinking days, with a number needed to treat (NNT) of 5.4, and 13.8% (P = .04) more total abstinence days, with an NNT of 6.2. The prestudy high–alcohol withdrawal group in particular had significantly less relapse to heavy drinking (P = .02; NNT, 3.1) and more total abstinence (P = .03; NNT, 2.7) when treated with gabapentin.

A couple of study limitations were a significant noncompletion rate (30% in gabapentin arm and 39% in the placebo arm) and self-reported alcohol withdrawal symptoms prior to entry into the study.

Bottom line: Gabapentin helps in reducing drinking and maintaining alcohol abstinence in individuals with alcohol use disorder, especially those with high–alcohol withdrawal symptoms.

Citation: Anton RF et al. Efficacy of gabapentin for the treatment of alcohol use disorder in patients with alcohol withdrawal symptoms: A randomized clinical trial. JAMA Intern Med. 2020 Mar 9;180(5):728-36.

Dr. Gaddam is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: In the United States, CAP was responsible for nearly 50,000 deaths in 2017. Prompt and accurate diagnosis promotes early treatment and avoids unnecessary antibiotic treatment for nonpneumonia lower respiratory tract infection patients. Diagnosis is based on signs and symptoms, as well as available imaging. Inflammatory markers such as CRP, white blood cell count, and procalcitonin are readily available in the ED and outpatient settings.

Study design: Bivariate meta-­analysis.

Setting: A systematic review of literature was done via PubMed search to identify prospective studies evaluating the accuracy of biomarkers in patients with cough or suspected CAP.

Synopsis: Fourteen studies met the criteria to be included in the meta-analysis. Summary receiver operating characteristic (ROC) curves generated reported area under the curve of 0.802 for CRP (95% confidence interval, 0.78-0.85), 0.777 for leukocytosis (95% CI, 0.74-0.81), and 0.771 for procalcitonin (95% CI, 0.74-0.81). The combination of CRP greater than 49.5 mg/L and procalcitonin greater than 0.1 mcg/L had a positive likelihood ratio of 2.24 and a negative likelihood ratio of 0.44.

The study had a some of limitations. The blinding of the person performing the index test to the reference standard and vice versa was not clear. Further, it was unclear if the person interpreting the reference standard was blinded to the index test in five studies and absent in one. Other limitations were inconsistent reporting of abnormal post hoc cutoffs and only two biomarkers being reported in a single study.

Combining a biomarker with signs and symptoms has the potential to improve diagnostic accuracy in the outpatient setting further. CRP was found to be most accurate regardless of the cutoff used; however, further studies without threshold effect will prove beneficial.

Bottom line: CRP is a more accurate and useful biomarker for outpatient CAP diagnosis than procalcitonin or leukocytosis.

Citation: Ebell MH et al. Accuracy of biomarkers for the diagnosis of adult community-acquired pneumonia: A meta-analysis. Acad Emerg Med. 2020;27(3):195-206.

Dr. Castellanos is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: In the United States, CAP was responsible for nearly 50,000 deaths in 2017. Prompt and accurate diagnosis promotes early treatment and avoids unnecessary antibiotic treatment for nonpneumonia lower respiratory tract infection patients. Diagnosis is based on signs and symptoms, as well as available imaging. Inflammatory markers such as CRP, white blood cell count, and procalcitonin are readily available in the ED and outpatient settings.

Study design: Bivariate meta-­analysis.

Setting: A systematic review of literature was done via PubMed search to identify prospective studies evaluating the accuracy of biomarkers in patients with cough or suspected CAP.

Synopsis: Fourteen studies met the criteria to be included in the meta-analysis. Summary receiver operating characteristic (ROC) curves generated reported area under the curve of 0.802 for CRP (95% confidence interval, 0.78-0.85), 0.777 for leukocytosis (95% CI, 0.74-0.81), and 0.771 for procalcitonin (95% CI, 0.74-0.81). The combination of CRP greater than 49.5 mg/L and procalcitonin greater than 0.1 mcg/L had a positive likelihood ratio of 2.24 and a negative likelihood ratio of 0.44.

The study had a some of limitations. The blinding of the person performing the index test to the reference standard and vice versa was not clear. Further, it was unclear if the person interpreting the reference standard was blinded to the index test in five studies and absent in one. Other limitations were inconsistent reporting of abnormal post hoc cutoffs and only two biomarkers being reported in a single study.

Combining a biomarker with signs and symptoms has the potential to improve diagnostic accuracy in the outpatient setting further. CRP was found to be most accurate regardless of the cutoff used; however, further studies without threshold effect will prove beneficial.

Bottom line: CRP is a more accurate and useful biomarker for outpatient CAP diagnosis than procalcitonin or leukocytosis.

Citation: Ebell MH et al. Accuracy of biomarkers for the diagnosis of adult community-acquired pneumonia: A meta-analysis. Acad Emerg Med. 2020;27(3):195-206.

Dr. Castellanos is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: In the United States, CAP was responsible for nearly 50,000 deaths in 2017. Prompt and accurate diagnosis promotes early treatment and avoids unnecessary antibiotic treatment for nonpneumonia lower respiratory tract infection patients. Diagnosis is based on signs and symptoms, as well as available imaging. Inflammatory markers such as CRP, white blood cell count, and procalcitonin are readily available in the ED and outpatient settings.

Study design: Bivariate meta-­analysis.

Setting: A systematic review of literature was done via PubMed search to identify prospective studies evaluating the accuracy of biomarkers in patients with cough or suspected CAP.

Synopsis: Fourteen studies met the criteria to be included in the meta-analysis. Summary receiver operating characteristic (ROC) curves generated reported area under the curve of 0.802 for CRP (95% confidence interval, 0.78-0.85), 0.777 for leukocytosis (95% CI, 0.74-0.81), and 0.771 for procalcitonin (95% CI, 0.74-0.81). The combination of CRP greater than 49.5 mg/L and procalcitonin greater than 0.1 mcg/L had a positive likelihood ratio of 2.24 and a negative likelihood ratio of 0.44.

The study had a some of limitations. The blinding of the person performing the index test to the reference standard and vice versa was not clear. Further, it was unclear if the person interpreting the reference standard was blinded to the index test in five studies and absent in one. Other limitations were inconsistent reporting of abnormal post hoc cutoffs and only two biomarkers being reported in a single study.

Combining a biomarker with signs and symptoms has the potential to improve diagnostic accuracy in the outpatient setting further. CRP was found to be most accurate regardless of the cutoff used; however, further studies without threshold effect will prove beneficial.

Bottom line: CRP is a more accurate and useful biomarker for outpatient CAP diagnosis than procalcitonin or leukocytosis.

Citation: Ebell MH et al. Accuracy of biomarkers for the diagnosis of adult community-acquired pneumonia: A meta-analysis. Acad Emerg Med. 2020;27(3):195-206.

Dr. Castellanos is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Direct oral anticoagulants have proven to be more efficacious, safe, and easy to use, compared with warfarin, in patients with atrial fibrillation (Afib). An indirect comparison showed apixaban to be more effective and safer than rivaroxaban. But randomized controlled trials and head-to-head comparison data regarding the same have been lacking until now.

Study design: Retrospective cohort study.

Setting: A U.S. nationwide commercial health care claims database was searched for persons older than 18 years, with a new diagnosis of atrial fibrillation or flutter who were started on apixaban or rivaroxaban from Dec. 28, 2012, to Jan. 1, 2019.

Synopsis: Optum Clinformatics was used to identify a total of 99,878 patients who were eligible for the analysis. Of these patients, 39,531 newly prescribed apixaban patients were propensity score matched to 39,351 newly prescribed rivaroxaban patients. After propensity score matching, the study found ischemic stroke or systemic embolism rate for new apixaban users to be 6.6 events per 1,000 person-years versus 8.0 events per 1,000 person-years for new rivaroxaban users (hazard ratio, 0.82; 95% confidence interval, 0.68-0.98). The rate of major bleeding after propensity score matching was 12.9 per 1,000 person-years for new apixaban users versus 21.9 per 1,000 person-years for new rivaroxaban users (HR, 0.58; 95% CI, 0.52-0.66).

This observational study has several limitations including an inability to balance unmeasured confounding factors, both ICD-9 and ICD-10 codes being used for defined outcomes, an inability to account for time-varying confounders for stroke or bleeding, an inability to capture patients from locations other than primary internist and cardiologists, and a shorter follow-up period, compared with that of clinical trials.

Bottom line: In routine practice, apixaban is more effective and safer than rivaroxaban with a lower rate of strokes, systemic embolism, and major bleeding.

Citation: Fralick M et al. Effectiveness and safety of apixaban compared with rivaroxaban for patients with atrial fibrillation in routine practice: a cohort study. Ann Intern Med. 2020 Apr 7. doi: 10.7326/M19-2522.

Dr. Almagdub is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Direct oral anticoagulants have proven to be more efficacious, safe, and easy to use, compared with warfarin, in patients with atrial fibrillation (Afib). An indirect comparison showed apixaban to be more effective and safer than rivaroxaban. But randomized controlled trials and head-to-head comparison data regarding the same have been lacking until now.

Study design: Retrospective cohort study.

Setting: A U.S. nationwide commercial health care claims database was searched for persons older than 18 years, with a new diagnosis of atrial fibrillation or flutter who were started on apixaban or rivaroxaban from Dec. 28, 2012, to Jan. 1, 2019.

Synopsis: Optum Clinformatics was used to identify a total of 99,878 patients who were eligible for the analysis. Of these patients, 39,531 newly prescribed apixaban patients were propensity score matched to 39,351 newly prescribed rivaroxaban patients. After propensity score matching, the study found ischemic stroke or systemic embolism rate for new apixaban users to be 6.6 events per 1,000 person-years versus 8.0 events per 1,000 person-years for new rivaroxaban users (hazard ratio, 0.82; 95% confidence interval, 0.68-0.98). The rate of major bleeding after propensity score matching was 12.9 per 1,000 person-years for new apixaban users versus 21.9 per 1,000 person-years for new rivaroxaban users (HR, 0.58; 95% CI, 0.52-0.66).

This observational study has several limitations including an inability to balance unmeasured confounding factors, both ICD-9 and ICD-10 codes being used for defined outcomes, an inability to account for time-varying confounders for stroke or bleeding, an inability to capture patients from locations other than primary internist and cardiologists, and a shorter follow-up period, compared with that of clinical trials.

Bottom line: In routine practice, apixaban is more effective and safer than rivaroxaban with a lower rate of strokes, systemic embolism, and major bleeding.

Citation: Fralick M et al. Effectiveness and safety of apixaban compared with rivaroxaban for patients with atrial fibrillation in routine practice: a cohort study. Ann Intern Med. 2020 Apr 7. doi: 10.7326/M19-2522.

Dr. Almagdub is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

Background: Direct oral anticoagulants have proven to be more efficacious, safe, and easy to use, compared with warfarin, in patients with atrial fibrillation (Afib). An indirect comparison showed apixaban to be more effective and safer than rivaroxaban. But randomized controlled trials and head-to-head comparison data regarding the same have been lacking until now.

Study design: Retrospective cohort study.

Setting: A U.S. nationwide commercial health care claims database was searched for persons older than 18 years, with a new diagnosis of atrial fibrillation or flutter who were started on apixaban or rivaroxaban from Dec. 28, 2012, to Jan. 1, 2019.

Synopsis: Optum Clinformatics was used to identify a total of 99,878 patients who were eligible for the analysis. Of these patients, 39,531 newly prescribed apixaban patients were propensity score matched to 39,351 newly prescribed rivaroxaban patients. After propensity score matching, the study found ischemic stroke or systemic embolism rate for new apixaban users to be 6.6 events per 1,000 person-years versus 8.0 events per 1,000 person-years for new rivaroxaban users (hazard ratio, 0.82; 95% confidence interval, 0.68-0.98). The rate of major bleeding after propensity score matching was 12.9 per 1,000 person-years for new apixaban users versus 21.9 per 1,000 person-years for new rivaroxaban users (HR, 0.58; 95% CI, 0.52-0.66).

This observational study has several limitations including an inability to balance unmeasured confounding factors, both ICD-9 and ICD-10 codes being used for defined outcomes, an inability to account for time-varying confounders for stroke or bleeding, an inability to capture patients from locations other than primary internist and cardiologists, and a shorter follow-up period, compared with that of clinical trials.

Bottom line: In routine practice, apixaban is more effective and safer than rivaroxaban with a lower rate of strokes, systemic embolism, and major bleeding.

Citation: Fralick M et al. Effectiveness and safety of apixaban compared with rivaroxaban for patients with atrial fibrillation in routine practice: a cohort study. Ann Intern Med. 2020 Apr 7. doi: 10.7326/M19-2522.

Dr. Almagdub is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.

The COVID-19 pandemic has tested disaster preparedness in hospitals across the nation. The pandemic brought many unique disaster planning challenges not commonly seen with other emergencies disasters. These included an uncertain and prolonged time frame, the implementation of physical distancing, and the challenges of preserving the health care work force.

But how do we prepare for the next disaster when the health care system and staff are already stretched thin? Here, we discuss the concept of maintaining a state of preparedness through and beyond COVID-19, using a disaster preparedness cycle – including continuous assessments of vulnerabilities, dynamic staffing adjustments to support patient and hospital needs, and broadening of the pandemic response to incorporate planning for the next disaster.

 

Disaster preparedness and assessing ongoing needs

Disaster preparedness cycle and Hazard Vulnerability Assessment

The disaster preparedness cycle illustrates that disaster preparedness is continuous. Disaster preparedness is achieved with the non-stop cycle of planning, coordinating, and recognizing vulnerable areas.^1-5 Hazard vulnerability analysis (HVA) can play a critical role in recognizing areas in which a hospital system has strengths and weaknesses for different disaster scenarios. There are several tools available, but the overarching goal is to provide an objective and systematic approach to evaluate the potential damage and impact a disaster could have on the health care system and surrounding community.

The HVA can also be utilized to reassess system or personnel vulnerabilities that may have been exposed or highlighted during the pandemic.^6,7 These vulnerabilities must be addressed during preparations for the next disaster while concurrently “assuming the incident happens at the worst possible time.”⁷

Disaster preparedness staffing considerations

Management, communication, and staffing issues are critical to disaster response. Key leadership responses during COVID-19 included providing frequent and transparent communication, down-staffing for physical distancing during low census, and prioritizing staff well-being. These measures serve as a strong foundation moving into preparations for the next disaster.⁸

To ensure adequate staffing during an unexpected natural disaster, we recommend creating “ride-out” and “relief teams” as part of disaster staffing preparedness.^9,10 The ride-out team provides the initial care and these providers are expected to stay in the hospital during the primary impact of the event. Once the initial threat of disaster is over and it is deemed safe to travel, the relief team is activated and offers reprieve to the ride-out team. Leaders and backup leaders within these teams should be identified in the event teams are activated. These assignments should be made at the start of the year and updated yearly or more frequently, if needed.

While the COVID-19 pandemic did not significantly affect children, our ride-out and relief teams would have played a significant role in case a surge of pediatric cases had occurred.

Other considerations for disaster staffing include expanding backup coverage and for multisite groups, identifying site leads to help field specific questions or concerns. Lastly, understanding the staffing needs of the hospital during a disaster is vital – bidirectional communication between physicians and hospital leadership optimizes preparedness plans. These measures will help staff feel supported before, during, and after a disaster.
 

 

Dynamic disaster response

Supporting patient and hospital needs

The next step in the disaster preparedness cycle is adjusting to changing needs during the disaster. The pediatric inpatient population was less affected initially by COVID-19, allowing hospitalists to support the unpredicted needs of the pandemic. A dynamic and flexible physician response is important to disaster preparedness.

As there has been a continued shift to telehealth during the pandemic, our group has engaged in telehealth calls related to COVID-19. Seizing these new opportunities not only provided additional services to our patients, but also strengthened community support, physician worth, and the hospital’s financial state. This is also an opportunity for higher-risk clinicians or quarantined faculty to offer patient care during the pandemic.

Cram et al. describe the importance of “unspecializing” during the COVID-19 pandemic.¹¹ Starting discussions early with adult and pediatric critical care colleagues is vital. Hospitalists take care of a broad patient population, and therefore, can adapt to where the clinical need may be. Optimizing and expanding our skill sets can bring value to the hospital system during uncertain times.

Hospitalists are also instrumental for patient flow during the pandemic. To address this, our group partnered with hospital leadership from many different areas including administration, nursing, emergency medicine, critical care, and ancillary services. By collaborating as one cohesive hospital unit, we were able to efficiently develop, implement, and update best clinical care guidelines and algorithms for COVID-19–related topics such as testing indications, admission criteria, infection control, and proper personal protective equipment use. Lastly, working with specialists to consolidate teams during a pandemic presents an opportunity for hospitalists to highlight expertise while bringing value to the hospital.
 

Unique staffing situations related to COVID-19

Different from other disasters, the COVID-19 pandemic affected older or immunocompromised staff in a unique way. Beauhaus et al. note that 20% of the physician workforce in the United Sates is between 55 and 64 years of age, and 9% are 65 years and older.¹² Hospitalist groups should focus on how to optimize and preserve their workforce, specifically those that are higher risk due to age or other health conditions.

We used a tiered guide to safely accommodate our physicians that were determined to be at higher-risk for complications of COVID-19; these recommendations included limiting exposure to patients with acute respiratory illnesses and shifting some providers to a different clinical environments with a lower exposure risk, such as telemedicine visits.

Other COVID-19 preparedness considerations that affected our group in particular include the changes in learner staffing. Similar to attending down-staffing to encourage physical distancing during low census, learners (residents, medical students, and physician assistant students) also experienced decreased hours or suspension of rotations. To maintain optimal patient care, adjusting to changing disaster needs may include assessing attendings’ capacity to assume responsibilities typically supported by learners.

Due to the ongoing nature of the pandemic, we have had to maintain a dynamic response while adjusting to changing and ongoing needs during recovery. Creating a measured and staggered approach helps facilitate a smooth transition back to nonemergent activities. The education of learners, academic and scholarly work, and administrative duties will resume, but likely in a different steady state. Also, awareness of physician burnout and fatigue is critical as an institution enters a phase of recovery.
 

 

Preparing for the next disaster during the pandemic

This brings us back to the beginning of the disaster preparedness cycle and the need to plan for the next disaster. Current disaster preparedness plans among physician groups and hospitals are likely focused on an individual disaster scenario, but adjusting current disaster plans to account for the uncertain time frame of an event like the COVID-19 pandemic is critical. Several articles in the national news posed similar questions, although these publications focused mainly on the Federal Emergency Management Agency and the governmental response to prepare for the next disaster when resources are already stretched.^13-15

How do we adequately plan, maintain a dynamic response, and continue to efficiently move through the disaster staffing cycle during an event like the COVID-19 pandemic? Being aware of current vulnerabilities and addressing gaps at the department and hospital level are vital to disaster preparedness. For example, we reassessed disaster (ride-out/relief) teams and the minimum number of staff needed to maintain safe and quality care, and what in-house arrangements would be needed (food, supplies, sleeping arrangements) while having to maintain physical distance.

Newman et al. explain “in disaster planning, having as many physicians as possible on hand may seem like an advantage, but being overstaffed in tight quarters was almost as bad as being understaffed.”⁹ This has been particularly true during the COVID-19 pandemic. It is crucial to have backup plans for faculty that are unable to serve ride-out duties from unexpected issues – such as availability, illnesses/quarantines, childcare/dependents. Also, it is important to be aware that some supply chains are already strained because of the pandemic and how this may play a role in the availability of certain supplies. Being aware and proactive about specific constraints allows for a better level of preparedness. Continued collaboration and communication with other services to provide care should be ongoing throughout the disaster preparedness cycle.
 

Conclusion

Providing and maintaining optimal and safe patient care should be the overarching goal throughout disaster preparedness. Being aware of group and institutional vulnerabilities, collaboration with hospital leadership, and remaining flexible as hospitalists are critical components for successful preparedness amid disasters. A dynamic and responsive disaster plan has been vital amid COVID-19, and for the next disasters we will certainly encounter.

Dr. Hadvani is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Uremovich is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Quinonez is associate professor of pediatrics and chief of pediatric hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Lopez is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Mothner is associate professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital and is the pediatric hospital medicine medical director for the main campus.

References

1. Malilay J et al. The role of applied epidemiology methods in the disaster management cycle. Am J Public Health. 2014;104(11):2092-102. doi: 10.2105/AJPH.2014.302010.

2. Federal Emergency Management Agency. Developing and maintaining emergency operations plans. 2010 Nov.

3. Federal Emergency Management Agency. National preparedness system. 2020 Jul 31.

4. Federal Emergency Management Agency. National preparedness goal. 2011 Sep.

5. Environmental health in emergencies and disasters: A practical guide. World Health Organization, Geneva. 2002:9-24. Edited by B. Wisner and J. Adams.

6. U.S. Department of Health and Human Services. Topic collection: Hazard vulnerability/risk assessment.

7. Hospital Association of Southern California. Hazard and vulnerability analysis.

8. Meier K et al. Pediatric hospital medicine management, staffing, and well-being in the face of COVID-19. J Hosp Med. 2020 May;15(5):308-10. doi: 10.12788/jhm.3435.

9. Newman B and Gallion C. Hurricane Harvey: Firsthand preparedness in graduate medical education. Acad Med. 2019 Sep;94(9):1267-69. doi: 10.1097/ACM.0000000000002696.

10. Brevard S et al. Analysis of disaster response plans and the aftermath of Hurricane Katrina: Lessons learned from a level I trauma center. J Trauma. 2008 Nov;65(5):1126-32. doi: 10.1097/TA.0b013e318188d6e5.

11. Cram P et al. All hands on deck learning to “un-specialize” in the COVID-19 pandemic. J Hosp Med. 2020 May;15(5):314-5. doi: 10.12788/jhm.3426.

12. Buerhaus P et al. Older clinicians and the surge in novel coronavirus disease 2019 (COVID-19). JAMA. 2020 May 12;323(18):1777-8. doi: 10.1001/jama.2020.4978.

13. VOX Media. Imagine Hurricane Katrina during a pandemic. The US needs to prepare for that – now. 2020 May 27.

14. The Hill. Democratic lawmakers ask how FEMA is planning to balance natural disasters, COVID-19 response. 2020 Apr 20.

15. The Atlantic. What happens if a ‘big one’ strikes during the pandemic? 2020 May 9.

The COVID-19 pandemic has tested disaster preparedness in hospitals across the nation. The pandemic brought many unique disaster planning challenges not commonly seen with other emergencies disasters. These included an uncertain and prolonged time frame, the implementation of physical distancing, and the challenges of preserving the health care work force.

But how do we prepare for the next disaster when the health care system and staff are already stretched thin? Here, we discuss the concept of maintaining a state of preparedness through and beyond COVID-19, using a disaster preparedness cycle – including continuous assessments of vulnerabilities, dynamic staffing adjustments to support patient and hospital needs, and broadening of the pandemic response to incorporate planning for the next disaster.

 

Disaster preparedness and assessing ongoing needs

Disaster preparedness cycle and Hazard Vulnerability Assessment

The disaster preparedness cycle illustrates that disaster preparedness is continuous. Disaster preparedness is achieved with the non-stop cycle of planning, coordinating, and recognizing vulnerable areas.^1-5 Hazard vulnerability analysis (HVA) can play a critical role in recognizing areas in which a hospital system has strengths and weaknesses for different disaster scenarios. There are several tools available, but the overarching goal is to provide an objective and systematic approach to evaluate the potential damage and impact a disaster could have on the health care system and surrounding community.

The HVA can also be utilized to reassess system or personnel vulnerabilities that may have been exposed or highlighted during the pandemic.^6,7 These vulnerabilities must be addressed during preparations for the next disaster while concurrently “assuming the incident happens at the worst possible time.”⁷

Disaster preparedness staffing considerations

Management, communication, and staffing issues are critical to disaster response. Key leadership responses during COVID-19 included providing frequent and transparent communication, down-staffing for physical distancing during low census, and prioritizing staff well-being. These measures serve as a strong foundation moving into preparations for the next disaster.⁸

To ensure adequate staffing during an unexpected natural disaster, we recommend creating “ride-out” and “relief teams” as part of disaster staffing preparedness.^9,10 The ride-out team provides the initial care and these providers are expected to stay in the hospital during the primary impact of the event. Once the initial threat of disaster is over and it is deemed safe to travel, the relief team is activated and offers reprieve to the ride-out team. Leaders and backup leaders within these teams should be identified in the event teams are activated. These assignments should be made at the start of the year and updated yearly or more frequently, if needed.

While the COVID-19 pandemic did not significantly affect children, our ride-out and relief teams would have played a significant role in case a surge of pediatric cases had occurred.

Other considerations for disaster staffing include expanding backup coverage and for multisite groups, identifying site leads to help field specific questions or concerns. Lastly, understanding the staffing needs of the hospital during a disaster is vital – bidirectional communication between physicians and hospital leadership optimizes preparedness plans. These measures will help staff feel supported before, during, and after a disaster.
 

 

Dynamic disaster response

Supporting patient and hospital needs

The next step in the disaster preparedness cycle is adjusting to changing needs during the disaster. The pediatric inpatient population was less affected initially by COVID-19, allowing hospitalists to support the unpredicted needs of the pandemic. A dynamic and flexible physician response is important to disaster preparedness.

As there has been a continued shift to telehealth during the pandemic, our group has engaged in telehealth calls related to COVID-19. Seizing these new opportunities not only provided additional services to our patients, but also strengthened community support, physician worth, and the hospital’s financial state. This is also an opportunity for higher-risk clinicians or quarantined faculty to offer patient care during the pandemic.

Cram et al. describe the importance of “unspecializing” during the COVID-19 pandemic.¹¹ Starting discussions early with adult and pediatric critical care colleagues is vital. Hospitalists take care of a broad patient population, and therefore, can adapt to where the clinical need may be. Optimizing and expanding our skill sets can bring value to the hospital system during uncertain times.

Hospitalists are also instrumental for patient flow during the pandemic. To address this, our group partnered with hospital leadership from many different areas including administration, nursing, emergency medicine, critical care, and ancillary services. By collaborating as one cohesive hospital unit, we were able to efficiently develop, implement, and update best clinical care guidelines and algorithms for COVID-19–related topics such as testing indications, admission criteria, infection control, and proper personal protective equipment use. Lastly, working with specialists to consolidate teams during a pandemic presents an opportunity for hospitalists to highlight expertise while bringing value to the hospital.
 

Unique staffing situations related to COVID-19

Different from other disasters, the COVID-19 pandemic affected older or immunocompromised staff in a unique way. Beauhaus et al. note that 20% of the physician workforce in the United Sates is between 55 and 64 years of age, and 9% are 65 years and older.¹² Hospitalist groups should focus on how to optimize and preserve their workforce, specifically those that are higher risk due to age or other health conditions.

We used a tiered guide to safely accommodate our physicians that were determined to be at higher-risk for complications of COVID-19; these recommendations included limiting exposure to patients with acute respiratory illnesses and shifting some providers to a different clinical environments with a lower exposure risk, such as telemedicine visits.

Other COVID-19 preparedness considerations that affected our group in particular include the changes in learner staffing. Similar to attending down-staffing to encourage physical distancing during low census, learners (residents, medical students, and physician assistant students) also experienced decreased hours or suspension of rotations. To maintain optimal patient care, adjusting to changing disaster needs may include assessing attendings’ capacity to assume responsibilities typically supported by learners.

Due to the ongoing nature of the pandemic, we have had to maintain a dynamic response while adjusting to changing and ongoing needs during recovery. Creating a measured and staggered approach helps facilitate a smooth transition back to nonemergent activities. The education of learners, academic and scholarly work, and administrative duties will resume, but likely in a different steady state. Also, awareness of physician burnout and fatigue is critical as an institution enters a phase of recovery.
 

 

Preparing for the next disaster during the pandemic

This brings us back to the beginning of the disaster preparedness cycle and the need to plan for the next disaster. Current disaster preparedness plans among physician groups and hospitals are likely focused on an individual disaster scenario, but adjusting current disaster plans to account for the uncertain time frame of an event like the COVID-19 pandemic is critical. Several articles in the national news posed similar questions, although these publications focused mainly on the Federal Emergency Management Agency and the governmental response to prepare for the next disaster when resources are already stretched.^13-15

How do we adequately plan, maintain a dynamic response, and continue to efficiently move through the disaster staffing cycle during an event like the COVID-19 pandemic? Being aware of current vulnerabilities and addressing gaps at the department and hospital level are vital to disaster preparedness. For example, we reassessed disaster (ride-out/relief) teams and the minimum number of staff needed to maintain safe and quality care, and what in-house arrangements would be needed (food, supplies, sleeping arrangements) while having to maintain physical distance.

Newman et al. explain “in disaster planning, having as many physicians as possible on hand may seem like an advantage, but being overstaffed in tight quarters was almost as bad as being understaffed.”⁹ This has been particularly true during the COVID-19 pandemic. It is crucial to have backup plans for faculty that are unable to serve ride-out duties from unexpected issues – such as availability, illnesses/quarantines, childcare/dependents. Also, it is important to be aware that some supply chains are already strained because of the pandemic and how this may play a role in the availability of certain supplies. Being aware and proactive about specific constraints allows for a better level of preparedness. Continued collaboration and communication with other services to provide care should be ongoing throughout the disaster preparedness cycle.
 

Conclusion

Providing and maintaining optimal and safe patient care should be the overarching goal throughout disaster preparedness. Being aware of group and institutional vulnerabilities, collaboration with hospital leadership, and remaining flexible as hospitalists are critical components for successful preparedness amid disasters. A dynamic and responsive disaster plan has been vital amid COVID-19, and for the next disasters we will certainly encounter.

Dr. Hadvani is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Uremovich is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Quinonez is associate professor of pediatrics and chief of pediatric hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Lopez is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Mothner is associate professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital and is the pediatric hospital medicine medical director for the main campus.

References

1. Malilay J et al. The role of applied epidemiology methods in the disaster management cycle. Am J Public Health. 2014;104(11):2092-102. doi: 10.2105/AJPH.2014.302010.

2. Federal Emergency Management Agency. Developing and maintaining emergency operations plans. 2010 Nov.

3. Federal Emergency Management Agency. National preparedness system. 2020 Jul 31.

4. Federal Emergency Management Agency. National preparedness goal. 2011 Sep.

5. Environmental health in emergencies and disasters: A practical guide. World Health Organization, Geneva. 2002:9-24. Edited by B. Wisner and J. Adams.

6. U.S. Department of Health and Human Services. Topic collection: Hazard vulnerability/risk assessment.

7. Hospital Association of Southern California. Hazard and vulnerability analysis.

8. Meier K et al. Pediatric hospital medicine management, staffing, and well-being in the face of COVID-19. J Hosp Med. 2020 May;15(5):308-10. doi: 10.12788/jhm.3435.

9. Newman B and Gallion C. Hurricane Harvey: Firsthand preparedness in graduate medical education. Acad Med. 2019 Sep;94(9):1267-69. doi: 10.1097/ACM.0000000000002696.

10. Brevard S et al. Analysis of disaster response plans and the aftermath of Hurricane Katrina: Lessons learned from a level I trauma center. J Trauma. 2008 Nov;65(5):1126-32. doi: 10.1097/TA.0b013e318188d6e5.

11. Cram P et al. All hands on deck learning to “un-specialize” in the COVID-19 pandemic. J Hosp Med. 2020 May;15(5):314-5. doi: 10.12788/jhm.3426.

12. Buerhaus P et al. Older clinicians and the surge in novel coronavirus disease 2019 (COVID-19). JAMA. 2020 May 12;323(18):1777-8. doi: 10.1001/jama.2020.4978.

13. VOX Media. Imagine Hurricane Katrina during a pandemic. The US needs to prepare for that – now. 2020 May 27.

14. The Hill. Democratic lawmakers ask how FEMA is planning to balance natural disasters, COVID-19 response. 2020 Apr 20.

15. The Atlantic. What happens if a ‘big one’ strikes during the pandemic? 2020 May 9.

The COVID-19 pandemic has tested disaster preparedness in hospitals across the nation. The pandemic brought many unique disaster planning challenges not commonly seen with other emergencies disasters. These included an uncertain and prolonged time frame, the implementation of physical distancing, and the challenges of preserving the health care work force.

But how do we prepare for the next disaster when the health care system and staff are already stretched thin? Here, we discuss the concept of maintaining a state of preparedness through and beyond COVID-19, using a disaster preparedness cycle – including continuous assessments of vulnerabilities, dynamic staffing adjustments to support patient and hospital needs, and broadening of the pandemic response to incorporate planning for the next disaster.

 

Disaster preparedness and assessing ongoing needs

Disaster preparedness cycle and Hazard Vulnerability Assessment

The disaster preparedness cycle illustrates that disaster preparedness is continuous. Disaster preparedness is achieved with the non-stop cycle of planning, coordinating, and recognizing vulnerable areas.^1-5 Hazard vulnerability analysis (HVA) can play a critical role in recognizing areas in which a hospital system has strengths and weaknesses for different disaster scenarios. There are several tools available, but the overarching goal is to provide an objective and systematic approach to evaluate the potential damage and impact a disaster could have on the health care system and surrounding community.

The HVA can also be utilized to reassess system or personnel vulnerabilities that may have been exposed or highlighted during the pandemic.^6,7 These vulnerabilities must be addressed during preparations for the next disaster while concurrently “assuming the incident happens at the worst possible time.”⁷

Disaster preparedness staffing considerations

Management, communication, and staffing issues are critical to disaster response. Key leadership responses during COVID-19 included providing frequent and transparent communication, down-staffing for physical distancing during low census, and prioritizing staff well-being. These measures serve as a strong foundation moving into preparations for the next disaster.⁸

To ensure adequate staffing during an unexpected natural disaster, we recommend creating “ride-out” and “relief teams” as part of disaster staffing preparedness.^9,10 The ride-out team provides the initial care and these providers are expected to stay in the hospital during the primary impact of the event. Once the initial threat of disaster is over and it is deemed safe to travel, the relief team is activated and offers reprieve to the ride-out team. Leaders and backup leaders within these teams should be identified in the event teams are activated. These assignments should be made at the start of the year and updated yearly or more frequently, if needed.

While the COVID-19 pandemic did not significantly affect children, our ride-out and relief teams would have played a significant role in case a surge of pediatric cases had occurred.

Other considerations for disaster staffing include expanding backup coverage and for multisite groups, identifying site leads to help field specific questions or concerns. Lastly, understanding the staffing needs of the hospital during a disaster is vital – bidirectional communication between physicians and hospital leadership optimizes preparedness plans. These measures will help staff feel supported before, during, and after a disaster.
 

 

Dynamic disaster response

Supporting patient and hospital needs

The next step in the disaster preparedness cycle is adjusting to changing needs during the disaster. The pediatric inpatient population was less affected initially by COVID-19, allowing hospitalists to support the unpredicted needs of the pandemic. A dynamic and flexible physician response is important to disaster preparedness.

As there has been a continued shift to telehealth during the pandemic, our group has engaged in telehealth calls related to COVID-19. Seizing these new opportunities not only provided additional services to our patients, but also strengthened community support, physician worth, and the hospital’s financial state. This is also an opportunity for higher-risk clinicians or quarantined faculty to offer patient care during the pandemic.

Cram et al. describe the importance of “unspecializing” during the COVID-19 pandemic.¹¹ Starting discussions early with adult and pediatric critical care colleagues is vital. Hospitalists take care of a broad patient population, and therefore, can adapt to where the clinical need may be. Optimizing and expanding our skill sets can bring value to the hospital system during uncertain times.

Hospitalists are also instrumental for patient flow during the pandemic. To address this, our group partnered with hospital leadership from many different areas including administration, nursing, emergency medicine, critical care, and ancillary services. By collaborating as one cohesive hospital unit, we were able to efficiently develop, implement, and update best clinical care guidelines and algorithms for COVID-19–related topics such as testing indications, admission criteria, infection control, and proper personal protective equipment use. Lastly, working with specialists to consolidate teams during a pandemic presents an opportunity for hospitalists to highlight expertise while bringing value to the hospital.
 

Unique staffing situations related to COVID-19

Different from other disasters, the COVID-19 pandemic affected older or immunocompromised staff in a unique way. Beauhaus et al. note that 20% of the physician workforce in the United Sates is between 55 and 64 years of age, and 9% are 65 years and older.¹² Hospitalist groups should focus on how to optimize and preserve their workforce, specifically those that are higher risk due to age or other health conditions.

We used a tiered guide to safely accommodate our physicians that were determined to be at higher-risk for complications of COVID-19; these recommendations included limiting exposure to patients with acute respiratory illnesses and shifting some providers to a different clinical environments with a lower exposure risk, such as telemedicine visits.

Other COVID-19 preparedness considerations that affected our group in particular include the changes in learner staffing. Similar to attending down-staffing to encourage physical distancing during low census, learners (residents, medical students, and physician assistant students) also experienced decreased hours or suspension of rotations. To maintain optimal patient care, adjusting to changing disaster needs may include assessing attendings’ capacity to assume responsibilities typically supported by learners.

Due to the ongoing nature of the pandemic, we have had to maintain a dynamic response while adjusting to changing and ongoing needs during recovery. Creating a measured and staggered approach helps facilitate a smooth transition back to nonemergent activities. The education of learners, academic and scholarly work, and administrative duties will resume, but likely in a different steady state. Also, awareness of physician burnout and fatigue is critical as an institution enters a phase of recovery.
 

 

Preparing for the next disaster during the pandemic

This brings us back to the beginning of the disaster preparedness cycle and the need to plan for the next disaster. Current disaster preparedness plans among physician groups and hospitals are likely focused on an individual disaster scenario, but adjusting current disaster plans to account for the uncertain time frame of an event like the COVID-19 pandemic is critical. Several articles in the national news posed similar questions, although these publications focused mainly on the Federal Emergency Management Agency and the governmental response to prepare for the next disaster when resources are already stretched.^13-15

How do we adequately plan, maintain a dynamic response, and continue to efficiently move through the disaster staffing cycle during an event like the COVID-19 pandemic? Being aware of current vulnerabilities and addressing gaps at the department and hospital level are vital to disaster preparedness. For example, we reassessed disaster (ride-out/relief) teams and the minimum number of staff needed to maintain safe and quality care, and what in-house arrangements would be needed (food, supplies, sleeping arrangements) while having to maintain physical distance.

Newman et al. explain “in disaster planning, having as many physicians as possible on hand may seem like an advantage, but being overstaffed in tight quarters was almost as bad as being understaffed.”⁹ This has been particularly true during the COVID-19 pandemic. It is crucial to have backup plans for faculty that are unable to serve ride-out duties from unexpected issues – such as availability, illnesses/quarantines, childcare/dependents. Also, it is important to be aware that some supply chains are already strained because of the pandemic and how this may play a role in the availability of certain supplies. Being aware and proactive about specific constraints allows for a better level of preparedness. Continued collaboration and communication with other services to provide care should be ongoing throughout the disaster preparedness cycle.
 

Conclusion

Providing and maintaining optimal and safe patient care should be the overarching goal throughout disaster preparedness. Being aware of group and institutional vulnerabilities, collaboration with hospital leadership, and remaining flexible as hospitalists are critical components for successful preparedness amid disasters. A dynamic and responsive disaster plan has been vital amid COVID-19, and for the next disasters we will certainly encounter.

Dr. Hadvani is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Uremovich is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Quinonez is associate professor of pediatrics and chief of pediatric hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Lopez is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Mothner is associate professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital and is the pediatric hospital medicine medical director for the main campus.

References

1. Malilay J et al. The role of applied epidemiology methods in the disaster management cycle. Am J Public Health. 2014;104(11):2092-102. doi: 10.2105/AJPH.2014.302010.

2. Federal Emergency Management Agency. Developing and maintaining emergency operations plans. 2010 Nov.

3. Federal Emergency Management Agency. National preparedness system. 2020 Jul 31.

4. Federal Emergency Management Agency. National preparedness goal. 2011 Sep.

5. Environmental health in emergencies and disasters: A practical guide. World Health Organization, Geneva. 2002:9-24. Edited by B. Wisner and J. Adams.

6. U.S. Department of Health and Human Services. Topic collection: Hazard vulnerability/risk assessment.

7. Hospital Association of Southern California. Hazard and vulnerability analysis.

8. Meier K et al. Pediatric hospital medicine management, staffing, and well-being in the face of COVID-19. J Hosp Med. 2020 May;15(5):308-10. doi: 10.12788/jhm.3435.

9. Newman B and Gallion C. Hurricane Harvey: Firsthand preparedness in graduate medical education. Acad Med. 2019 Sep;94(9):1267-69. doi: 10.1097/ACM.0000000000002696.

10. Brevard S et al. Analysis of disaster response plans and the aftermath of Hurricane Katrina: Lessons learned from a level I trauma center. J Trauma. 2008 Nov;65(5):1126-32. doi: 10.1097/TA.0b013e318188d6e5.

11. Cram P et al. All hands on deck learning to “un-specialize” in the COVID-19 pandemic. J Hosp Med. 2020 May;15(5):314-5. doi: 10.12788/jhm.3426.

12. Buerhaus P et al. Older clinicians and the surge in novel coronavirus disease 2019 (COVID-19). JAMA. 2020 May 12;323(18):1777-8. doi: 10.1001/jama.2020.4978.

13. VOX Media. Imagine Hurricane Katrina during a pandemic. The US needs to prepare for that – now. 2020 May 27.

14. The Hill. Democratic lawmakers ask how FEMA is planning to balance natural disasters, COVID-19 response. 2020 Apr 20.

15. The Atlantic. What happens if a ‘big one’ strikes during the pandemic? 2020 May 9.