Patient Care

Editor's Note: Listen to Dr. Smith share more of his views on the State of Hospital Medicine report.

Hospitalist groups and their stakeholders must continually adapt to evolving reimbursement models and their attendant financial foci on quality. Even in the midst of care models that rely less heavily on volume of care as a marker for reimbursement, the use of criteria by insurers to separate hospital stays into inpatient or observation status remains widespread. Hospitalist groups vary in the reimbursement model environment they work in, and different reimbursement models can drive hospitalist group behavior in different ways.

SHM’s 2016 State of Hospital Medicine Report revisits the issue of observation status utilization raised in previous surveys.1 The 2012 survey’s methodology reports admissions classified as observation status based on CPT coding.2 The 2016 survey continues the 2014 survey methodology of using discharges classified as observation status based on CPT coding, along with same-day admission and discharge reported as a third hospitalization status category. In groups serving adults only, observation discharges accounted for 21.2% of all discharges, which represents an increase from 16.1% in the 2014 survey3 and a general return to the 2012-reported percentage of 20%. If same-day admissions and discharges, many of which are likely classified as observation status, are added, then observation status use in the 2016 survey may be as high as 24% of all admissions. This represents a considerable increase from the combined 19.6% rate in 2014.

Changes in non-academic status hospitalist groups largely account for this increase. Academic hospitalist groups reported an observation status utilization rate of 15.3% of admissions in 2012 and 19.4% in 2014, with a subsequent decrease to 17.5% reported in the 2016 survey. Inclusion of same-day admission and discharge with reported observation status use also reveals a decrease from 22.8% in 2014 to 20.8% in the new survey. In contrast, non-academic hospitalist groups now report a substantial change in observation status utilization, up to 21.4% in the 2016 survey from 15.6% in 2014 and similar to the 2012 level of 20.4%. When same-day admission and discharge codes are also included, the totals for non-academic hospitalist groups also evidence an increase, to 24.3% in the new survey from 19.2% in 2014.

I postulated in 2015 that the comparative increase in observation status utilization by academic groups as compared with non-academic groups in the 2014 survey may have been associated with greater proficiency in documentation and related billing inherent in a bedside clinical workforce entirely composed of physicians who have completed postgraduate training. Other phenomena may now potentially explain the increase in observation status use we see in the 2016 survey. These include adoption of the two-midnight rule by the Centers for Medicare & Medicaid Services, use of readmission rates in hospitalist group incentive structures, sharing of cost savings between hospitalist groups and healthcare organizations mutually engaged in third-party bundled payment arrangements, or risk-avoidant strategies executed by clinicians and institutional coders perhaps in excess of their institutions’ needs for risk avoidance. For many of these events, the 2016 State of Hospital Medicine Report provides further benchmark data, in a national and regional context, to inform understanding for hospitalist groups facing challenges associated with observation status utilization.

G. Randy Smith Jr., MD, MS, FRCP(Edin), SFHM, is an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago.

References

1. 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
2. 2012 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
3. 2014 State of Hospital Medicine Report. Society of Hospital Medicine website.

   Accessed September 11, 2016.

Editor's Note: Listen to Dr. Smith share more of his views on the State of Hospital Medicine report.

Hospitalist groups and their stakeholders must continually adapt to evolving reimbursement models and their attendant financial foci on quality. Even in the midst of care models that rely less heavily on volume of care as a marker for reimbursement, the use of criteria by insurers to separate hospital stays into inpatient or observation status remains widespread. Hospitalist groups vary in the reimbursement model environment they work in, and different reimbursement models can drive hospitalist group behavior in different ways.

SHM’s 2016 State of Hospital Medicine Report revisits the issue of observation status utilization raised in previous surveys.1 The 2012 survey’s methodology reports admissions classified as observation status based on CPT coding.2 The 2016 survey continues the 2014 survey methodology of using discharges classified as observation status based on CPT coding, along with same-day admission and discharge reported as a third hospitalization status category. In groups serving adults only, observation discharges accounted for 21.2% of all discharges, which represents an increase from 16.1% in the 2014 survey3 and a general return to the 2012-reported percentage of 20%. If same-day admissions and discharges, many of which are likely classified as observation status, are added, then observation status use in the 2016 survey may be as high as 24% of all admissions. This represents a considerable increase from the combined 19.6% rate in 2014.

Changes in non-academic status hospitalist groups largely account for this increase. Academic hospitalist groups reported an observation status utilization rate of 15.3% of admissions in 2012 and 19.4% in 2014, with a subsequent decrease to 17.5% reported in the 2016 survey. Inclusion of same-day admission and discharge with reported observation status use also reveals a decrease from 22.8% in 2014 to 20.8% in the new survey. In contrast, non-academic hospitalist groups now report a substantial change in observation status utilization, up to 21.4% in the 2016 survey from 15.6% in 2014 and similar to the 2012 level of 20.4%. When same-day admission and discharge codes are also included, the totals for non-academic hospitalist groups also evidence an increase, to 24.3% in the new survey from 19.2% in 2014.

I postulated in 2015 that the comparative increase in observation status utilization by academic groups as compared with non-academic groups in the 2014 survey may have been associated with greater proficiency in documentation and related billing inherent in a bedside clinical workforce entirely composed of physicians who have completed postgraduate training. Other phenomena may now potentially explain the increase in observation status use we see in the 2016 survey. These include adoption of the two-midnight rule by the Centers for Medicare & Medicaid Services, use of readmission rates in hospitalist group incentive structures, sharing of cost savings between hospitalist groups and healthcare organizations mutually engaged in third-party bundled payment arrangements, or risk-avoidant strategies executed by clinicians and institutional coders perhaps in excess of their institutions’ needs for risk avoidance. For many of these events, the 2016 State of Hospital Medicine Report provides further benchmark data, in a national and regional context, to inform understanding for hospitalist groups facing challenges associated with observation status utilization.

G. Randy Smith Jr., MD, MS, FRCP(Edin), SFHM, is an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago.

References

1. 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
2. 2012 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
3. 2014 State of Hospital Medicine Report. Society of Hospital Medicine website.

   Accessed September 11, 2016.

Editor's Note: Listen to Dr. Smith share more of his views on the State of Hospital Medicine report.

Hospitalist groups and their stakeholders must continually adapt to evolving reimbursement models and their attendant financial foci on quality. Even in the midst of care models that rely less heavily on volume of care as a marker for reimbursement, the use of criteria by insurers to separate hospital stays into inpatient or observation status remains widespread. Hospitalist groups vary in the reimbursement model environment they work in, and different reimbursement models can drive hospitalist group behavior in different ways.

SHM’s 2016 State of Hospital Medicine Report revisits the issue of observation status utilization raised in previous surveys.1 The 2012 survey’s methodology reports admissions classified as observation status based on CPT coding.2 The 2016 survey continues the 2014 survey methodology of using discharges classified as observation status based on CPT coding, along with same-day admission and discharge reported as a third hospitalization status category. In groups serving adults only, observation discharges accounted for 21.2% of all discharges, which represents an increase from 16.1% in the 2014 survey3 and a general return to the 2012-reported percentage of 20%. If same-day admissions and discharges, many of which are likely classified as observation status, are added, then observation status use in the 2016 survey may be as high as 24% of all admissions. This represents a considerable increase from the combined 19.6% rate in 2014.

Changes in non-academic status hospitalist groups largely account for this increase. Academic hospitalist groups reported an observation status utilization rate of 15.3% of admissions in 2012 and 19.4% in 2014, with a subsequent decrease to 17.5% reported in the 2016 survey. Inclusion of same-day admission and discharge with reported observation status use also reveals a decrease from 22.8% in 2014 to 20.8% in the new survey. In contrast, non-academic hospitalist groups now report a substantial change in observation status utilization, up to 21.4% in the 2016 survey from 15.6% in 2014 and similar to the 2012 level of 20.4%. When same-day admission and discharge codes are also included, the totals for non-academic hospitalist groups also evidence an increase, to 24.3% in the new survey from 19.2% in 2014.

I postulated in 2015 that the comparative increase in observation status utilization by academic groups as compared with non-academic groups in the 2014 survey may have been associated with greater proficiency in documentation and related billing inherent in a bedside clinical workforce entirely composed of physicians who have completed postgraduate training. Other phenomena may now potentially explain the increase in observation status use we see in the 2016 survey. These include adoption of the two-midnight rule by the Centers for Medicare & Medicaid Services, use of readmission rates in hospitalist group incentive structures, sharing of cost savings between hospitalist groups and healthcare organizations mutually engaged in third-party bundled payment arrangements, or risk-avoidant strategies executed by clinicians and institutional coders perhaps in excess of their institutions’ needs for risk avoidance. For many of these events, the 2016 State of Hospital Medicine Report provides further benchmark data, in a national and regional context, to inform understanding for hospitalist groups facing challenges associated with observation status utilization.

G. Randy Smith Jr., MD, MS, FRCP(Edin), SFHM, is an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago.

References

1. 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
2. 2012 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
3. 2014 State of Hospital Medicine Report. Society of Hospital Medicine website.

   Accessed September 11, 2016.

IHS is partnering with the renowned Roswell Park Cancer Institute to reduce cancer’s impact on American Indian and Alaska Native communities.

Related: IHS Pilots Improved Version of Health Records

Roswell Park, founded in 1898, is one of the first cancer centers in the U.S. to be named a National Cancer Institute-designated comprehensive cancer center. It will collaborate with IHS in research addressing health disparities; cancer risk reduction, prevention, and early detection; cancer-related medical care; community outreach and training, and expanded career and education opportunities in oncology for Native Americans.

IHS will use its resources and expertise to facilitate “relationships of trust” among Roswell Park and the members and leaders of native communities. Those relationships will allow them to ascertain needs and address disparities that are unique or prevalent in native communities, IHS says.

Related: IHS and CMS Partner for Patient Safety Improvements

Rodney Haring, PhD, MSW, assistant professor of oncology in the Office of Cancer Health Disparities Research at Roswell Park, member of the Seneca Nation, and a delegate to the American Indian and Alaska Native Health Research Advisory Council in HHS, says, “The values and traditions of Native American culture will inform and enhance our efforts to reduce the devastating burden of cancer, not only in Native communities but for everyone.”

IHS is partnering with the renowned Roswell Park Cancer Institute to reduce cancer’s impact on American Indian and Alaska Native communities.

Related: IHS Pilots Improved Version of Health Records

Roswell Park, founded in 1898, is one of the first cancer centers in the U.S. to be named a National Cancer Institute-designated comprehensive cancer center. It will collaborate with IHS in research addressing health disparities; cancer risk reduction, prevention, and early detection; cancer-related medical care; community outreach and training, and expanded career and education opportunities in oncology for Native Americans.

IHS will use its resources and expertise to facilitate “relationships of trust” among Roswell Park and the members and leaders of native communities. Those relationships will allow them to ascertain needs and address disparities that are unique or prevalent in native communities, IHS says.

Related: IHS and CMS Partner for Patient Safety Improvements

Rodney Haring, PhD, MSW, assistant professor of oncology in the Office of Cancer Health Disparities Research at Roswell Park, member of the Seneca Nation, and a delegate to the American Indian and Alaska Native Health Research Advisory Council in HHS, says, “The values and traditions of Native American culture will inform and enhance our efforts to reduce the devastating burden of cancer, not only in Native communities but for everyone.”

IHS is partnering with the renowned Roswell Park Cancer Institute to reduce cancer’s impact on American Indian and Alaska Native communities.

Related: IHS Pilots Improved Version of Health Records

Roswell Park, founded in 1898, is one of the first cancer centers in the U.S. to be named a National Cancer Institute-designated comprehensive cancer center. It will collaborate with IHS in research addressing health disparities; cancer risk reduction, prevention, and early detection; cancer-related medical care; community outreach and training, and expanded career and education opportunities in oncology for Native Americans.

IHS will use its resources and expertise to facilitate “relationships of trust” among Roswell Park and the members and leaders of native communities. Those relationships will allow them to ascertain needs and address disparities that are unique or prevalent in native communities, IHS says.

Related: IHS and CMS Partner for Patient Safety Improvements

Rodney Haring, PhD, MSW, assistant professor of oncology in the Office of Cancer Health Disparities Research at Roswell Park, member of the Seneca Nation, and a delegate to the American Indian and Alaska Native Health Research Advisory Council in HHS, says, “The values and traditions of Native American culture will inform and enhance our efforts to reduce the devastating burden of cancer, not only in Native communities but for everyone.”

NEW YORK (Reuters Health) - The American Academy of Pediatrics (AAP) today released six clinical reports and one policy statement covering a range of timely topics relevant to the health and care of children. Here is a snapshot.

1) Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies. 

This report focuses on the issues relevant to children and adolescents presenting to the emergency department (ED) or primary care clinic with a mental health condition or emergency and covers the following topics: medical clearance of pediatric psychiatric patients; suicidal ideation and suicide attempts; involuntary hospitalization; restraint of the agitated patient (verbal restraint, chemical restraint and physical restraint); coordination with the medical home.

2) Evaluation and Management of Children With Acute Mental Health or Behavioral Problems. Part II: Recognition of Clinically Challenging Mental Health Related Conditions Presenting With Medical or Uncertain Symptoms. 

This clinical report focuses on the challenges a pediatrician may face when evaluating patients with a mental health condition, which may be contributing to or complicating a medical or indeterminate clinical presentation. Topics include somatic symptom and related disorders; adverse effects of psychiatric medications (antipsychotic adverse effects, neuroleptic malignant syndrome, serotonin syndrome); children with special needs in the ED (autism spectrum and developmental disorders); mental health screening in the ED.

Both reports are from the AAP Committee on Pediatric Emergency Medicine and the American College of Emergency Physicians Pediatric Emergency Medicine Committee and include an executive summary.

3) Mind-Body Therapies in Children and Youth

From the AAP Section on Integrative Medicine, this report notes that a "growing body of evidence supports the effectiveness and safety of mind-body therapies in pediatrics. This clinical report outlines popular mind-body therapies for children and youth and examines the best-available evidence for a variety of mind-body therapies and practices, including biofeedback, clinical hypnosis, guided imagery, meditation, and yoga. The report is intended to help health care professionals guide their patients to nonpharmacologic approaches to improve concentration, help decrease pain, control discomfort, or ease anxiety."

4) Preventing Obesity and Eating Disorders in Adolescents 

This report, from the AAP Committee on Nutrition, Committee on Adolescence, Section on Obesity, notes that "messages from pediatricians addressing obesity and reviewing constructive ways to manage weight can be safely and supportively incorporated into health care visits. Avoiding certain weight-based language and using motivational interviewing (MI) techniques may improve communication and promote successful outcomes when providing weight-management counseling. This clinical report addresses the interaction between obesity prevention and eating disorders (EDs) in teenagers, provides the pediatrician with evidence-informed tools to identify behaviors that predispose to both obesity and EDs, and provides guidance about obesity and ED prevention messages. The focus should be on a healthy lifestyle rather than on weight. Evidence suggests that obesity prevention and treatment, if conducted correctly, do not predispose to EDs."

5) Parental Presence During Treatment of Ebola or Other Highly Consequential Infection 

From the AAP Committee on Infectious Diseases, this report offers "guidance to health care providers and hospitals on options to consider regarding parental presence at the bedside while caring for a child with suspected or proven Ebola virus disease (Ebola) or other highly consequential infection. Options are presented to help meet the needs of the patient and the family while also posing the least risk to providers and health care organizations."

6) Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns 

This report, from the Committee on Fetus and Newborn, Task Force on Sudden Infant Death Syndrome, notes that skin-to-skin care (SSC) and rooming-in are now common in the newborn period for healthy newborns with the implementation of maternity care practices that support breastfeeding as outlined in the World Health Organization's "Ten Steps to Successful Breastfeeding." The evidence indicates that implementation of these practices "increases overall and exclusive breastfeeding, safer and healthier transitions, and improved maternal-infant bonding. In some cases, however, the practice of SSC and rooming-in may pose safety concerns, particularly with regard to sleep. This clinical report is intended for birthing centers and delivery hospitals caring for healthy newborns to assist in the establishment of appropriate SSC and safe sleep policies."

The policy statement - Medication-Assisted Treatment of Adolescents With Opioid Use Disorders - is from the Committee on Substance Use and Prevention. It notes that opioid use disorder is "a leading cause of morbidity and mortality among US youth. Effective treatments, both medications and substance use disorder counseling, are available but underused, and access to developmentally appropriate treatment is severely restricted for adolescents and young adults. Resources to disseminate available therapies and to develop new treatments specifically for this age group are needed to save and improve lives of youth with opioid addiction."

"The AAP recommends that pediatricians consider offering medication-assisted treatment to their adolescent and young adult patients with severe opioid use disorders or discuss referrals to other providers for this service," the statement advises.

The six clinical reports and one policy statement are published in the September issue of Pediatrics and were released online August 22.

SOURCE: http://bit.ly/2bfNEj8

Pediatrics 2016.

(c) Copyright Thomson Reuters 2016.

NEW YORK (Reuters Health) - The American Academy of Pediatrics (AAP) today released six clinical reports and one policy statement covering a range of timely topics relevant to the health and care of children. Here is a snapshot.

1) Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies. 

This report focuses on the issues relevant to children and adolescents presenting to the emergency department (ED) or primary care clinic with a mental health condition or emergency and covers the following topics: medical clearance of pediatric psychiatric patients; suicidal ideation and suicide attempts; involuntary hospitalization; restraint of the agitated patient (verbal restraint, chemical restraint and physical restraint); coordination with the medical home.

2) Evaluation and Management of Children With Acute Mental Health or Behavioral Problems. Part II: Recognition of Clinically Challenging Mental Health Related Conditions Presenting With Medical or Uncertain Symptoms. 

This clinical report focuses on the challenges a pediatrician may face when evaluating patients with a mental health condition, which may be contributing to or complicating a medical or indeterminate clinical presentation. Topics include somatic symptom and related disorders; adverse effects of psychiatric medications (antipsychotic adverse effects, neuroleptic malignant syndrome, serotonin syndrome); children with special needs in the ED (autism spectrum and developmental disorders); mental health screening in the ED.

Both reports are from the AAP Committee on Pediatric Emergency Medicine and the American College of Emergency Physicians Pediatric Emergency Medicine Committee and include an executive summary.

3) Mind-Body Therapies in Children and Youth

From the AAP Section on Integrative Medicine, this report notes that a "growing body of evidence supports the effectiveness and safety of mind-body therapies in pediatrics. This clinical report outlines popular mind-body therapies for children and youth and examines the best-available evidence for a variety of mind-body therapies and practices, including biofeedback, clinical hypnosis, guided imagery, meditation, and yoga. The report is intended to help health care professionals guide their patients to nonpharmacologic approaches to improve concentration, help decrease pain, control discomfort, or ease anxiety."

4) Preventing Obesity and Eating Disorders in Adolescents 

This report, from the AAP Committee on Nutrition, Committee on Adolescence, Section on Obesity, notes that "messages from pediatricians addressing obesity and reviewing constructive ways to manage weight can be safely and supportively incorporated into health care visits. Avoiding certain weight-based language and using motivational interviewing (MI) techniques may improve communication and promote successful outcomes when providing weight-management counseling. This clinical report addresses the interaction between obesity prevention and eating disorders (EDs) in teenagers, provides the pediatrician with evidence-informed tools to identify behaviors that predispose to both obesity and EDs, and provides guidance about obesity and ED prevention messages. The focus should be on a healthy lifestyle rather than on weight. Evidence suggests that obesity prevention and treatment, if conducted correctly, do not predispose to EDs."

5) Parental Presence During Treatment of Ebola or Other Highly Consequential Infection 

From the AAP Committee on Infectious Diseases, this report offers "guidance to health care providers and hospitals on options to consider regarding parental presence at the bedside while caring for a child with suspected or proven Ebola virus disease (Ebola) or other highly consequential infection. Options are presented to help meet the needs of the patient and the family while also posing the least risk to providers and health care organizations."

6) Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns 

This report, from the Committee on Fetus and Newborn, Task Force on Sudden Infant Death Syndrome, notes that skin-to-skin care (SSC) and rooming-in are now common in the newborn period for healthy newborns with the implementation of maternity care practices that support breastfeeding as outlined in the World Health Organization's "Ten Steps to Successful Breastfeeding." The evidence indicates that implementation of these practices "increases overall and exclusive breastfeeding, safer and healthier transitions, and improved maternal-infant bonding. In some cases, however, the practice of SSC and rooming-in may pose safety concerns, particularly with regard to sleep. This clinical report is intended for birthing centers and delivery hospitals caring for healthy newborns to assist in the establishment of appropriate SSC and safe sleep policies."

The policy statement - Medication-Assisted Treatment of Adolescents With Opioid Use Disorders - is from the Committee on Substance Use and Prevention. It notes that opioid use disorder is "a leading cause of morbidity and mortality among US youth. Effective treatments, both medications and substance use disorder counseling, are available but underused, and access to developmentally appropriate treatment is severely restricted for adolescents and young adults. Resources to disseminate available therapies and to develop new treatments specifically for this age group are needed to save and improve lives of youth with opioid addiction."

"The AAP recommends that pediatricians consider offering medication-assisted treatment to their adolescent and young adult patients with severe opioid use disorders or discuss referrals to other providers for this service," the statement advises.

The six clinical reports and one policy statement are published in the September issue of Pediatrics and were released online August 22.

SOURCE: http://bit.ly/2bfNEj8

Pediatrics 2016.

(c) Copyright Thomson Reuters 2016.

NEW YORK (Reuters Health) - The American Academy of Pediatrics (AAP) today released six clinical reports and one policy statement covering a range of timely topics relevant to the health and care of children. Here is a snapshot.

1) Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies. 

This report focuses on the issues relevant to children and adolescents presenting to the emergency department (ED) or primary care clinic with a mental health condition or emergency and covers the following topics: medical clearance of pediatric psychiatric patients; suicidal ideation and suicide attempts; involuntary hospitalization; restraint of the agitated patient (verbal restraint, chemical restraint and physical restraint); coordination with the medical home.

2) Evaluation and Management of Children With Acute Mental Health or Behavioral Problems. Part II: Recognition of Clinically Challenging Mental Health Related Conditions Presenting With Medical or Uncertain Symptoms. 

This clinical report focuses on the challenges a pediatrician may face when evaluating patients with a mental health condition, which may be contributing to or complicating a medical or indeterminate clinical presentation. Topics include somatic symptom and related disorders; adverse effects of psychiatric medications (antipsychotic adverse effects, neuroleptic malignant syndrome, serotonin syndrome); children with special needs in the ED (autism spectrum and developmental disorders); mental health screening in the ED.

Both reports are from the AAP Committee on Pediatric Emergency Medicine and the American College of Emergency Physicians Pediatric Emergency Medicine Committee and include an executive summary.

3) Mind-Body Therapies in Children and Youth

From the AAP Section on Integrative Medicine, this report notes that a "growing body of evidence supports the effectiveness and safety of mind-body therapies in pediatrics. This clinical report outlines popular mind-body therapies for children and youth and examines the best-available evidence for a variety of mind-body therapies and practices, including biofeedback, clinical hypnosis, guided imagery, meditation, and yoga. The report is intended to help health care professionals guide their patients to nonpharmacologic approaches to improve concentration, help decrease pain, control discomfort, or ease anxiety."

4) Preventing Obesity and Eating Disorders in Adolescents 

This report, from the AAP Committee on Nutrition, Committee on Adolescence, Section on Obesity, notes that "messages from pediatricians addressing obesity and reviewing constructive ways to manage weight can be safely and supportively incorporated into health care visits. Avoiding certain weight-based language and using motivational interviewing (MI) techniques may improve communication and promote successful outcomes when providing weight-management counseling. This clinical report addresses the interaction between obesity prevention and eating disorders (EDs) in teenagers, provides the pediatrician with evidence-informed tools to identify behaviors that predispose to both obesity and EDs, and provides guidance about obesity and ED prevention messages. The focus should be on a healthy lifestyle rather than on weight. Evidence suggests that obesity prevention and treatment, if conducted correctly, do not predispose to EDs."

5) Parental Presence During Treatment of Ebola or Other Highly Consequential Infection 

From the AAP Committee on Infectious Diseases, this report offers "guidance to health care providers and hospitals on options to consider regarding parental presence at the bedside while caring for a child with suspected or proven Ebola virus disease (Ebola) or other highly consequential infection. Options are presented to help meet the needs of the patient and the family while also posing the least risk to providers and health care organizations."

6) Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns 

This report, from the Committee on Fetus and Newborn, Task Force on Sudden Infant Death Syndrome, notes that skin-to-skin care (SSC) and rooming-in are now common in the newborn period for healthy newborns with the implementation of maternity care practices that support breastfeeding as outlined in the World Health Organization's "Ten Steps to Successful Breastfeeding." The evidence indicates that implementation of these practices "increases overall and exclusive breastfeeding, safer and healthier transitions, and improved maternal-infant bonding. In some cases, however, the practice of SSC and rooming-in may pose safety concerns, particularly with regard to sleep. This clinical report is intended for birthing centers and delivery hospitals caring for healthy newborns to assist in the establishment of appropriate SSC and safe sleep policies."

The policy statement - Medication-Assisted Treatment of Adolescents With Opioid Use Disorders - is from the Committee on Substance Use and Prevention. It notes that opioid use disorder is "a leading cause of morbidity and mortality among US youth. Effective treatments, both medications and substance use disorder counseling, are available but underused, and access to developmentally appropriate treatment is severely restricted for adolescents and young adults. Resources to disseminate available therapies and to develop new treatments specifically for this age group are needed to save and improve lives of youth with opioid addiction."

"The AAP recommends that pediatricians consider offering medication-assisted treatment to their adolescent and young adult patients with severe opioid use disorders or discuss referrals to other providers for this service," the statement advises.

The six clinical reports and one policy statement are published in the September issue of Pediatrics and were released online August 22.

SOURCE: http://bit.ly/2bfNEj8

Pediatrics 2016.

(c) Copyright Thomson Reuters 2016.

(Reuters Health) - Older people who break a bone are often receiving medications that can increase the risk of a fracture - and even after a fracture, less than 10 percent of them stop taking those drugs, according to a new study.

"One would expect that a significant health event like a fracture would result in some change in the use of prescription drugs that might have contributed to that event," said lead author Dr. Jeffrey C. Munson of the Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire. "In contrast to this expectation, we observed that for the overwhelming majority of patients we studied, a fragility fracture did not lead to any change in medications that have been linked to fracture risk."

The authors used data on 168,000 Medicare beneficiaries, more than 80 percent of whom were women, on average age 80, who had experienced a hip, shoulder or wrist fracture. They compared these records with retail pharmacy claims to identify which patients had been taking medicines that increase the risk of a fall, decrease bone density or are otherwise tied to an increased risk of fracture.

About 75 percent of fracture patients had been taking one of these medications. While seven percent of people stopped taking the medication after their fracture, a similar number started to take a new medication also tied to fracture risk, the authors reported in JAMA Internal Medicine, online August 22.

"Some drugs affect balance and memory, like the sleeping pills, which can lead to a fall," said Dr. Sarah D. Berry of the Institute for Aging Research at Hebrew SeniorLife in Boston, Massachusetts, who coauthored a linked editorial.

Blood pressure medications cause changes in blood pressure that could lead to a fall. Other drugs, like prednisone or medications for heartburn, increase bone loss which can lead to a fracture, Berry told Reuters Health by email.

"Fractures are the leading cause of death from injury and one of the main reasons for nursing home placement in persons over the age of 65," she said.

"When a patient has a hip, shoulder or wrist fracture, it is important for healthcare providers to examine all the prescription medications he or she is taking, and carefully assess whether there is an opportunity to eliminate those that might cause a future fracture," Munson told Reuters Health by email.

However, he said, "In many cases, the benefits of a drug may outweigh its risks, even when those risks are significant."

Which drugs can be stopped will vary from case to case, Munson noted.

"For many of the drugs we studied, there are alternative drugs that treat the same conditions but with a lower risk of fracture," he said. "In other cases, it may be possible to eliminate a drug altogether."

SOURCE: http://bit.ly/2bc6PIN

JAMA Intern Med 2016.

(c) Copyright Thomson Reuters 2016.

(Reuters Health) - Older people who break a bone are often receiving medications that can increase the risk of a fracture - and even after a fracture, less than 10 percent of them stop taking those drugs, according to a new study.

"One would expect that a significant health event like a fracture would result in some change in the use of prescription drugs that might have contributed to that event," said lead author Dr. Jeffrey C. Munson of the Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire. "In contrast to this expectation, we observed that for the overwhelming majority of patients we studied, a fragility fracture did not lead to any change in medications that have been linked to fracture risk."

The authors used data on 168,000 Medicare beneficiaries, more than 80 percent of whom were women, on average age 80, who had experienced a hip, shoulder or wrist fracture. They compared these records with retail pharmacy claims to identify which patients had been taking medicines that increase the risk of a fall, decrease bone density or are otherwise tied to an increased risk of fracture.

About 75 percent of fracture patients had been taking one of these medications. While seven percent of people stopped taking the medication after their fracture, a similar number started to take a new medication also tied to fracture risk, the authors reported in JAMA Internal Medicine, online August 22.

"Some drugs affect balance and memory, like the sleeping pills, which can lead to a fall," said Dr. Sarah D. Berry of the Institute for Aging Research at Hebrew SeniorLife in Boston, Massachusetts, who coauthored a linked editorial.

Blood pressure medications cause changes in blood pressure that could lead to a fall. Other drugs, like prednisone or medications for heartburn, increase bone loss which can lead to a fracture, Berry told Reuters Health by email.

"Fractures are the leading cause of death from injury and one of the main reasons for nursing home placement in persons over the age of 65," she said.

"When a patient has a hip, shoulder or wrist fracture, it is important for healthcare providers to examine all the prescription medications he or she is taking, and carefully assess whether there is an opportunity to eliminate those that might cause a future fracture," Munson told Reuters Health by email.

However, he said, "In many cases, the benefits of a drug may outweigh its risks, even when those risks are significant."

Which drugs can be stopped will vary from case to case, Munson noted.

"For many of the drugs we studied, there are alternative drugs that treat the same conditions but with a lower risk of fracture," he said. "In other cases, it may be possible to eliminate a drug altogether."

SOURCE: http://bit.ly/2bc6PIN

JAMA Intern Med 2016.

(c) Copyright Thomson Reuters 2016.

(Reuters Health) - Older people who break a bone are often receiving medications that can increase the risk of a fracture - and even after a fracture, less than 10 percent of them stop taking those drugs, according to a new study.

"One would expect that a significant health event like a fracture would result in some change in the use of prescription drugs that might have contributed to that event," said lead author Dr. Jeffrey C. Munson of the Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire. "In contrast to this expectation, we observed that for the overwhelming majority of patients we studied, a fragility fracture did not lead to any change in medications that have been linked to fracture risk."

The authors used data on 168,000 Medicare beneficiaries, more than 80 percent of whom were women, on average age 80, who had experienced a hip, shoulder or wrist fracture. They compared these records with retail pharmacy claims to identify which patients had been taking medicines that increase the risk of a fall, decrease bone density or are otherwise tied to an increased risk of fracture.

About 75 percent of fracture patients had been taking one of these medications. While seven percent of people stopped taking the medication after their fracture, a similar number started to take a new medication also tied to fracture risk, the authors reported in JAMA Internal Medicine, online August 22.

"Some drugs affect balance and memory, like the sleeping pills, which can lead to a fall," said Dr. Sarah D. Berry of the Institute for Aging Research at Hebrew SeniorLife in Boston, Massachusetts, who coauthored a linked editorial.

Blood pressure medications cause changes in blood pressure that could lead to a fall. Other drugs, like prednisone or medications for heartburn, increase bone loss which can lead to a fracture, Berry told Reuters Health by email.

"Fractures are the leading cause of death from injury and one of the main reasons for nursing home placement in persons over the age of 65," she said.

"When a patient has a hip, shoulder or wrist fracture, it is important for healthcare providers to examine all the prescription medications he or she is taking, and carefully assess whether there is an opportunity to eliminate those that might cause a future fracture," Munson told Reuters Health by email.

However, he said, "In many cases, the benefits of a drug may outweigh its risks, even when those risks are significant."

Which drugs can be stopped will vary from case to case, Munson noted.

"For many of the drugs we studied, there are alternative drugs that treat the same conditions but with a lower risk of fracture," he said. "In other cases, it may be possible to eliminate a drug altogether."

SOURCE: http://bit.ly/2bc6PIN

JAMA Intern Med 2016.

(c) Copyright Thomson Reuters 2016.

Background: Service handovers contribute to discontinuity of care in hospitalized patients. Research on hospitalist service handovers is limited, and no previous study has examined the service handover from the patient’s perspective.

Study design: Interview-based, qualitative analysis.

Setting: Urban academic medical center.

Synopsis: Researchers interviewed 40 hospitalized patients using a semi-structured nine-question interview regarding their attending hospitalist service change. The constant comparative method was used to identify recurrent themes in patient responses. The research team identified six themes representative of patient concerns during service change: physician-patient communication, transparency in communication, hospitalist-specialist communication, new opportunities due to transition, bedside manner, and indifference toward the transition.

Authors used the six themes to develop a model for the ideal service handover, utilizing open lines of communication, facilitated by multiple modalities and disciplines, and recognizing the patient’s role as the primary stakeholder in the transition of care.

Bottom line: Incorporating patients’ perspective presents an opportunity to improve communication and efficiency during hospitalist service transitions.

Citation: Wray CM, Farnan JM, Arora VM, Meltzer DO. A qualitative analysis of patients’ experience with hospitalist service handovers [published online ahead of print May 11, 2016]. J Hosp Med. doi:10.1002/jhm.2608.

Background: Service handovers contribute to discontinuity of care in hospitalized patients. Research on hospitalist service handovers is limited, and no previous study has examined the service handover from the patient’s perspective.

Study design: Interview-based, qualitative analysis.

Setting: Urban academic medical center.

Synopsis: Researchers interviewed 40 hospitalized patients using a semi-structured nine-question interview regarding their attending hospitalist service change. The constant comparative method was used to identify recurrent themes in patient responses. The research team identified six themes representative of patient concerns during service change: physician-patient communication, transparency in communication, hospitalist-specialist communication, new opportunities due to transition, bedside manner, and indifference toward the transition.

Authors used the six themes to develop a model for the ideal service handover, utilizing open lines of communication, facilitated by multiple modalities and disciplines, and recognizing the patient’s role as the primary stakeholder in the transition of care.

Bottom line: Incorporating patients’ perspective presents an opportunity to improve communication and efficiency during hospitalist service transitions.

Citation: Wray CM, Farnan JM, Arora VM, Meltzer DO. A qualitative analysis of patients’ experience with hospitalist service handovers [published online ahead of print May 11, 2016]. J Hosp Med. doi:10.1002/jhm.2608.

Background: Service handovers contribute to discontinuity of care in hospitalized patients. Research on hospitalist service handovers is limited, and no previous study has examined the service handover from the patient’s perspective.

Study design: Interview-based, qualitative analysis.

Setting: Urban academic medical center.

Synopsis: Researchers interviewed 40 hospitalized patients using a semi-structured nine-question interview regarding their attending hospitalist service change. The constant comparative method was used to identify recurrent themes in patient responses. The research team identified six themes representative of patient concerns during service change: physician-patient communication, transparency in communication, hospitalist-specialist communication, new opportunities due to transition, bedside manner, and indifference toward the transition.

Authors used the six themes to develop a model for the ideal service handover, utilizing open lines of communication, facilitated by multiple modalities and disciplines, and recognizing the patient’s role as the primary stakeholder in the transition of care.

Bottom line: Incorporating patients’ perspective presents an opportunity to improve communication and efficiency during hospitalist service transitions.

Citation: Wray CM, Farnan JM, Arora VM, Meltzer DO. A qualitative analysis of patients’ experience with hospitalist service handovers [published online ahead of print May 11, 2016]. J Hosp Med. doi:10.1002/jhm.2608.

Background: For patients with atrial fibrillation and history of intracranial hemorrhage (ICH), the risk of further ICH and the benefit of antithrombotic agents for stroke risk reduction remain unclear.

Study design: Retrospective cohort study.

Setting: National Health Research Institutes, Taiwan.

Synopsis: Using the National Health Insurance Research Database in Taiwan, researchers identified 307,640 patients with atrial fibrillation and a CHA2DS2-VASc score >/= 2. Of this group, 12,917 patients with a history of ICH were identified and separated into three groups: no treatment, antiplatelet treatment, or warfarin. Among the no treatment group, the rate of ICH and ischemic cerebrovascular accident were 4.2 and 5.8 per 100 person-years, respectively. Among patients on antiplatelet therapy, the rates were 5.3% and 5.2%, respectively. Among patients on warfarin, the number needed to treat (NNT) for preventing one ischemic stroke was lower than the number needed to harm (NNH) for producing one ICH among patients with a CHA2DS2-VASc score >/= 6. In patients with lower CHA2DS2-VASc scores, the NNT was higher than NNH.

Bottom line: Treatment with warfarin may benefit patients with atrial fibrillation and prior ICH with CHA2DS2-VASc scores >/= 6, but risk likely outweighs benefit in patients with lower scores.

Citation: Chao TF, Liu CJ, Liao JN, et al. Use of oral anticoagulants for stroke prevention in patients with atrial fibrillation who have a history of intracranial hemorrhage. Circulation. 2016;133(16):1540-1547.

Background: For patients with atrial fibrillation and history of intracranial hemorrhage (ICH), the risk of further ICH and the benefit of antithrombotic agents for stroke risk reduction remain unclear.

Study design: Retrospective cohort study.

Setting: National Health Research Institutes, Taiwan.

Synopsis: Using the National Health Insurance Research Database in Taiwan, researchers identified 307,640 patients with atrial fibrillation and a CHA2DS2-VASc score >/= 2. Of this group, 12,917 patients with a history of ICH were identified and separated into three groups: no treatment, antiplatelet treatment, or warfarin. Among the no treatment group, the rate of ICH and ischemic cerebrovascular accident were 4.2 and 5.8 per 100 person-years, respectively. Among patients on antiplatelet therapy, the rates were 5.3% and 5.2%, respectively. Among patients on warfarin, the number needed to treat (NNT) for preventing one ischemic stroke was lower than the number needed to harm (NNH) for producing one ICH among patients with a CHA2DS2-VASc score >/= 6. In patients with lower CHA2DS2-VASc scores, the NNT was higher than NNH.

Bottom line: Treatment with warfarin may benefit patients with atrial fibrillation and prior ICH with CHA2DS2-VASc scores >/= 6, but risk likely outweighs benefit in patients with lower scores.

Citation: Chao TF, Liu CJ, Liao JN, et al. Use of oral anticoagulants for stroke prevention in patients with atrial fibrillation who have a history of intracranial hemorrhage. Circulation. 2016;133(16):1540-1547.

Background: For patients with atrial fibrillation and history of intracranial hemorrhage (ICH), the risk of further ICH and the benefit of antithrombotic agents for stroke risk reduction remain unclear.

Study design: Retrospective cohort study.

Setting: National Health Research Institutes, Taiwan.

Synopsis: Using the National Health Insurance Research Database in Taiwan, researchers identified 307,640 patients with atrial fibrillation and a CHA2DS2-VASc score >/= 2. Of this group, 12,917 patients with a history of ICH were identified and separated into three groups: no treatment, antiplatelet treatment, or warfarin. Among the no treatment group, the rate of ICH and ischemic cerebrovascular accident were 4.2 and 5.8 per 100 person-years, respectively. Among patients on antiplatelet therapy, the rates were 5.3% and 5.2%, respectively. Among patients on warfarin, the number needed to treat (NNT) for preventing one ischemic stroke was lower than the number needed to harm (NNH) for producing one ICH among patients with a CHA2DS2-VASc score >/= 6. In patients with lower CHA2DS2-VASc scores, the NNT was higher than NNH.

Bottom line: Treatment with warfarin may benefit patients with atrial fibrillation and prior ICH with CHA2DS2-VASc scores >/= 6, but risk likely outweighs benefit in patients with lower scores.

Citation: Chao TF, Liu CJ, Liao JN, et al. Use of oral anticoagulants for stroke prevention in patients with atrial fibrillation who have a history of intracranial hemorrhage. Circulation. 2016;133(16):1540-1547.

Background: Older hospitalized patients experience decreased mobility while in the hospital and suffer from impaired function and mobility after they are discharged. The efficacy and safety of inpatient mobility programs are unknown.

Study design: Randomized, single-blinded controlled trial.

Setting: Birmingham Veterans Affairs Medical Center, Alabama.

Synopsis: The study included 100 patients age 65 years and older admitted to general medical wards. Researchers excluded cognitively impaired patients and patients with limited life expectancy. Intervention patients received a standardized hospital mobility protocol, with up to twice daily 15- to 20-minute visits by research personnel. Visits sought to progressively increase mobility from assisted sitting to ambulation. Physical activity was coupled with a behavioral intervention focused on goal setting and mobility barrier resolution. The comparison group received usual care. Outcomes included changes in activities of daily living (ADLs) and community mobility one month after hospital discharge.

One month after hospitalization, there were no differences in ADLs between intervention and control patients. Patients in the mobility protocol arm, however, maintained their prehospital community mobility, whereas usual-care patients had a statistically significant decrease in mobility as measured by the Life-Space Assessment. There was no difference in falls between groups.

Bottom line: A hospital mobility intervention was a safe and effective means of preserving community mobility. Future effectiveness studies are needed to demonstrate feasibility and outcomes in real-world settings.

Citation: Brown CJ, Foley KT, Lowman JD Jr, et al. Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: a randomized clinical trial. JAMA Intern Med. 2016;176(7):921-927.

Short Take

Topical NSAIDs Effective for Back Pain

Using ketoprofen gel in addition to intravenous dexketoprofen improves pain relief in patients presenting to the emergency department with low back pain.

Citation: Serinken M, Eken C, Tunay K, Golcuk Y. Ketoprofen gel improves low back pain in addition to IV dexkeoprofen: a randomized placebo-controlled trial. Am J Emerg Med. 2016;34(8):1458-1461.

Background: Older hospitalized patients experience decreased mobility while in the hospital and suffer from impaired function and mobility after they are discharged. The efficacy and safety of inpatient mobility programs are unknown.

Study design: Randomized, single-blinded controlled trial.

Setting: Birmingham Veterans Affairs Medical Center, Alabama.

Synopsis: The study included 100 patients age 65 years and older admitted to general medical wards. Researchers excluded cognitively impaired patients and patients with limited life expectancy. Intervention patients received a standardized hospital mobility protocol, with up to twice daily 15- to 20-minute visits by research personnel. Visits sought to progressively increase mobility from assisted sitting to ambulation. Physical activity was coupled with a behavioral intervention focused on goal setting and mobility barrier resolution. The comparison group received usual care. Outcomes included changes in activities of daily living (ADLs) and community mobility one month after hospital discharge.

One month after hospitalization, there were no differences in ADLs between intervention and control patients. Patients in the mobility protocol arm, however, maintained their prehospital community mobility, whereas usual-care patients had a statistically significant decrease in mobility as measured by the Life-Space Assessment. There was no difference in falls between groups.

Bottom line: A hospital mobility intervention was a safe and effective means of preserving community mobility. Future effectiveness studies are needed to demonstrate feasibility and outcomes in real-world settings.

Citation: Brown CJ, Foley KT, Lowman JD Jr, et al. Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: a randomized clinical trial. JAMA Intern Med. 2016;176(7):921-927.

Short Take

Topical NSAIDs Effective for Back Pain

Using ketoprofen gel in addition to intravenous dexketoprofen improves pain relief in patients presenting to the emergency department with low back pain.

Citation: Serinken M, Eken C, Tunay K, Golcuk Y. Ketoprofen gel improves low back pain in addition to IV dexkeoprofen: a randomized placebo-controlled trial. Am J Emerg Med. 2016;34(8):1458-1461.

Background: Older hospitalized patients experience decreased mobility while in the hospital and suffer from impaired function and mobility after they are discharged. The efficacy and safety of inpatient mobility programs are unknown.

Study design: Randomized, single-blinded controlled trial.

Setting: Birmingham Veterans Affairs Medical Center, Alabama.

Synopsis: The study included 100 patients age 65 years and older admitted to general medical wards. Researchers excluded cognitively impaired patients and patients with limited life expectancy. Intervention patients received a standardized hospital mobility protocol, with up to twice daily 15- to 20-minute visits by research personnel. Visits sought to progressively increase mobility from assisted sitting to ambulation. Physical activity was coupled with a behavioral intervention focused on goal setting and mobility barrier resolution. The comparison group received usual care. Outcomes included changes in activities of daily living (ADLs) and community mobility one month after hospital discharge.

One month after hospitalization, there were no differences in ADLs between intervention and control patients. Patients in the mobility protocol arm, however, maintained their prehospital community mobility, whereas usual-care patients had a statistically significant decrease in mobility as measured by the Life-Space Assessment. There was no difference in falls between groups.

Bottom line: A hospital mobility intervention was a safe and effective means of preserving community mobility. Future effectiveness studies are needed to demonstrate feasibility and outcomes in real-world settings.

Citation: Brown CJ, Foley KT, Lowman JD Jr, et al. Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: a randomized clinical trial. JAMA Intern Med. 2016;176(7):921-927.

Short Take

Topical NSAIDs Effective for Back Pain

Using ketoprofen gel in addition to intravenous dexketoprofen improves pain relief in patients presenting to the emergency department with low back pain.

Citation: Serinken M, Eken C, Tunay K, Golcuk Y. Ketoprofen gel improves low back pain in addition to IV dexkeoprofen: a randomized placebo-controlled trial. Am J Emerg Med. 2016;34(8):1458-1461.

Background: Checklists, goal assessment, and clinician prompting have shown promise in improving communication, care-process adherence, and clinical outcomes in ICUs and acute-care settings, but existing studies are limited by nonrandomized design and high-income settings.

Study design: Cluster randomized trial.

Setting: 118 academic and nonacademic ICUs in Brazil.

Synopsis: Researchers randomized 6,761 patients to a quality improvement (QI) intervention with daily round checklists, goal setting, and clinician prompting. Analyses were adjusted for patient’s severity of illness and the ICU’s adjusted mortality ratio. There was no significant difference in in-hospital mortality (odds ratio, 1.02; 95% CI, 0.82–1.26). The QI intervention had no effect on 10 secondary clinical outcomes (e.g., ventilator-associated pneumonia). The intervention improved adherence with four of seven care processes (e.g., use of low tidal volumes) and two of six factors of the safety climate. After adjusting for multiple comparisons, only urinary catheter use remained statistically significant.

Strengths of this study are the large number of ICUs involved and a high rate of QI adherence. Limitations include the setting in a resource-constrained nation, limited success with adopting changes in care processes, and relatively short intervention period of six months.

Bottom line: In a large Brazilian randomized control trial, implementation of daily round checklists, along with goal setting and clinician prompting, did not change in-hospital mortality. It is possible that a longer intervention period would have found improved outcomes.

Citation: Writing Group for the CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet), Cavalcanti AB, Bozza FA, et al. Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: a randomized clinical trial. JAMA. 2016;315(14):1480-1490.

Short Take

More Restrictions on Fluoroquinolones

The U.S. Food and Drug Administration has recommended avoidance of fluoroquinolone drugs, which are often used for patients with acute bronchitis, acute sinusitis, and uncomplicated UTI, due to the potential of serious side effects. Exceptions should be made for cases with no other treatment options.

Citation: Fluoroquinolone antibacterial drugs: drug safety communication - FDA advises restricting use for certain uncomplicated infections. U.S. Food and Drug Administration website.

Background: Checklists, goal assessment, and clinician prompting have shown promise in improving communication, care-process adherence, and clinical outcomes in ICUs and acute-care settings, but existing studies are limited by nonrandomized design and high-income settings.

Study design: Cluster randomized trial.

Setting: 118 academic and nonacademic ICUs in Brazil.

Synopsis: Researchers randomized 6,761 patients to a quality improvement (QI) intervention with daily round checklists, goal setting, and clinician prompting. Analyses were adjusted for patient’s severity of illness and the ICU’s adjusted mortality ratio. There was no significant difference in in-hospital mortality (odds ratio, 1.02; 95% CI, 0.82–1.26). The QI intervention had no effect on 10 secondary clinical outcomes (e.g., ventilator-associated pneumonia). The intervention improved adherence with four of seven care processes (e.g., use of low tidal volumes) and two of six factors of the safety climate. After adjusting for multiple comparisons, only urinary catheter use remained statistically significant.

Strengths of this study are the large number of ICUs involved and a high rate of QI adherence. Limitations include the setting in a resource-constrained nation, limited success with adopting changes in care processes, and relatively short intervention period of six months.

Bottom line: In a large Brazilian randomized control trial, implementation of daily round checklists, along with goal setting and clinician prompting, did not change in-hospital mortality. It is possible that a longer intervention period would have found improved outcomes.

Citation: Writing Group for the CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet), Cavalcanti AB, Bozza FA, et al. Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: a randomized clinical trial. JAMA. 2016;315(14):1480-1490.

Short Take

More Restrictions on Fluoroquinolones

The U.S. Food and Drug Administration has recommended avoidance of fluoroquinolone drugs, which are often used for patients with acute bronchitis, acute sinusitis, and uncomplicated UTI, due to the potential of serious side effects. Exceptions should be made for cases with no other treatment options.

Citation: Fluoroquinolone antibacterial drugs: drug safety communication - FDA advises restricting use for certain uncomplicated infections. U.S. Food and Drug Administration website.

Background: Checklists, goal assessment, and clinician prompting have shown promise in improving communication, care-process adherence, and clinical outcomes in ICUs and acute-care settings, but existing studies are limited by nonrandomized design and high-income settings.

Study design: Cluster randomized trial.

Setting: 118 academic and nonacademic ICUs in Brazil.

Synopsis: Researchers randomized 6,761 patients to a quality improvement (QI) intervention with daily round checklists, goal setting, and clinician prompting. Analyses were adjusted for patient’s severity of illness and the ICU’s adjusted mortality ratio. There was no significant difference in in-hospital mortality (odds ratio, 1.02; 95% CI, 0.82–1.26). The QI intervention had no effect on 10 secondary clinical outcomes (e.g., ventilator-associated pneumonia). The intervention improved adherence with four of seven care processes (e.g., use of low tidal volumes) and two of six factors of the safety climate. After adjusting for multiple comparisons, only urinary catheter use remained statistically significant.

Strengths of this study are the large number of ICUs involved and a high rate of QI adherence. Limitations include the setting in a resource-constrained nation, limited success with adopting changes in care processes, and relatively short intervention period of six months.

Bottom line: In a large Brazilian randomized control trial, implementation of daily round checklists, along with goal setting and clinician prompting, did not change in-hospital mortality. It is possible that a longer intervention period would have found improved outcomes.

Citation: Writing Group for the CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet), Cavalcanti AB, Bozza FA, et al. Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: a randomized clinical trial. JAMA. 2016;315(14):1480-1490.

Short Take

More Restrictions on Fluoroquinolones

The U.S. Food and Drug Administration has recommended avoidance of fluoroquinolone drugs, which are often used for patients with acute bronchitis, acute sinusitis, and uncomplicated UTI, due to the potential of serious side effects. Exceptions should be made for cases with no other treatment options.

Citation: Fluoroquinolone antibacterial drugs: drug safety communication - FDA advises restricting use for certain uncomplicated infections. U.S. Food and Drug Administration website.

Background: Patients with dementia often exhibit behavioral problems, such as agitation and psychosis. The American Psychiatric Association (APA) produced a consensus report on the use of antipsychotics in patients with dementia who also exhibit agitation/psychosis.

Study design: Expert panel review of multiple studies and consensus opinions of experienced clinicians.

Synopsis: While the use of antipsychotics to treat behavioral symptoms in patients with dementia is common, it is important to use these medications judiciously, especially in nonemergency cases. The APA recommends antipsychotics for treatment of agitation in these patients only when symptoms are severe or dangerous or cause significant distress to the patient.

When providers determine that benefits exceed risks, antipsychotic treatment should be initiated at a low dose and carefully titrated up to the minimum effective dose. If there is no significant response after a four-week trial of an adequate dose, tapering and withdrawing antipsychotic medication is recommended. Haloperidol should not be used as a first-line agent. The APA guidelines are not intended to apply to treatment in an urgent context, such as acute delirium.

Bottom line: The APA has provided practical guidelines to direct care of dementia patients. These guidelines are not intended to apply to individuals who are receiving antipsychotics in an urgent context or who receive antipsychotics for other disorders (e.g., chronic psychotic illness).

Citation: Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543-546.

Short Take

Colistin-Resistant E. coli in the U.S.

The presence of mcr-1, a plasmid-borne colistin resistance gene indicating the presence of a truly pan-drug-resistant bacteria, has been identified for the first time in the United States.

Citation: McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: first report of mcr-1 in the United States. Antimicrob Agents Chemother. 2016;60(7):4420-4421.

Background: Patients with dementia often exhibit behavioral problems, such as agitation and psychosis. The American Psychiatric Association (APA) produced a consensus report on the use of antipsychotics in patients with dementia who also exhibit agitation/psychosis.

Study design: Expert panel review of multiple studies and consensus opinions of experienced clinicians.

Synopsis: While the use of antipsychotics to treat behavioral symptoms in patients with dementia is common, it is important to use these medications judiciously, especially in nonemergency cases. The APA recommends antipsychotics for treatment of agitation in these patients only when symptoms are severe or dangerous or cause significant distress to the patient.

When providers determine that benefits exceed risks, antipsychotic treatment should be initiated at a low dose and carefully titrated up to the minimum effective dose. If there is no significant response after a four-week trial of an adequate dose, tapering and withdrawing antipsychotic medication is recommended. Haloperidol should not be used as a first-line agent. The APA guidelines are not intended to apply to treatment in an urgent context, such as acute delirium.

Bottom line: The APA has provided practical guidelines to direct care of dementia patients. These guidelines are not intended to apply to individuals who are receiving antipsychotics in an urgent context or who receive antipsychotics for other disorders (e.g., chronic psychotic illness).

Citation: Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543-546.

Short Take

Colistin-Resistant E. coli in the U.S.

The presence of mcr-1, a plasmid-borne colistin resistance gene indicating the presence of a truly pan-drug-resistant bacteria, has been identified for the first time in the United States.

Citation: McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: first report of mcr-1 in the United States. Antimicrob Agents Chemother. 2016;60(7):4420-4421.

Background: Patients with dementia often exhibit behavioral problems, such as agitation and psychosis. The American Psychiatric Association (APA) produced a consensus report on the use of antipsychotics in patients with dementia who also exhibit agitation/psychosis.

Study design: Expert panel review of multiple studies and consensus opinions of experienced clinicians.

Synopsis: While the use of antipsychotics to treat behavioral symptoms in patients with dementia is common, it is important to use these medications judiciously, especially in nonemergency cases. The APA recommends antipsychotics for treatment of agitation in these patients only when symptoms are severe or dangerous or cause significant distress to the patient.

When providers determine that benefits exceed risks, antipsychotic treatment should be initiated at a low dose and carefully titrated up to the minimum effective dose. If there is no significant response after a four-week trial of an adequate dose, tapering and withdrawing antipsychotic medication is recommended. Haloperidol should not be used as a first-line agent. The APA guidelines are not intended to apply to treatment in an urgent context, such as acute delirium.

Bottom line: The APA has provided practical guidelines to direct care of dementia patients. These guidelines are not intended to apply to individuals who are receiving antipsychotics in an urgent context or who receive antipsychotics for other disorders (e.g., chronic psychotic illness).

Citation: Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543-546.

Short Take

Colistin-Resistant E. coli in the U.S.

The presence of mcr-1, a plasmid-borne colistin resistance gene indicating the presence of a truly pan-drug-resistant bacteria, has been identified for the first time in the United States.

Citation: McGann P, Snesrud E, Maybank R, et al. Escherichia coli harboring mcr-1 and blaCTX-M on a novel IncF plasmid: first report of mcr-1 in the United States. Antimicrob Agents Chemother. 2016;60(7):4420-4421.

Background: Research has shown that frail hospital patients are at increased risk of readmission and death. Although several frailty assessment tools have been developed, few studies have examined the application of such tools to predict post-discharge outcomes of hospitalized patients.

Study design: Prospective cohort study.

Setting: General medical wards in Edmonton, Canada.

Synopsis: Researchers enrolled 495 adult patients from general medicine wards in two teaching hospitals. Long-term care residents and patients with limited life expectancy were excluded. Each patient was assessed using three different frailty assessment tools: the Clinical Frailty Scale (CFS), the Fried score, and the Timed Up and Go Test (TUGT). The primary outcomes were 30-day readmission and all-cause mortality. Outcomes were assessed by research personnel blinded to frailty status.

Overall, 211 (43%) patients were classified as frail by at least one tool. In general, frail patients were older, had more comorbidities, and had more frequent hospitalizations than non-frail patients. Agreement among the tools was poor, and only 49 patients met frailty criteria by all three definitions. The CFS was the only tool found to be an independent predictor of adverse 30-day outcomes (23% versus 14% for not frail, P=0.005; adjusted odds ratio, 2.02; 95% CI, 1.19–3.41).

Bottom line: As an independent predictor of adverse post-discharge outcomes, the CFS is a useful tool in both research and clinical settings. The CFS requires little time and no special equipment to administer.

Citation: Belga S, Majumdar SR, Kahlon S, et al. Comparing three different measures of frailty in medical inpatients: multicenter prospective cohort study examining 30-day risk of readmission or death. J Hosp Med. 2016;11(8):556-562.

Short Take

National Program Reduces CAUTI

A national prevention program aimed at reducing catheter-associated urinary tract infections (CAUTIs) has been shown to reduce both catheter use and rates of CAUTI in non-ICU patients.

Citation: Saint S, Greene MT, Krein SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med. 2016;374(22):2111-2119.

Background: Research has shown that frail hospital patients are at increased risk of readmission and death. Although several frailty assessment tools have been developed, few studies have examined the application of such tools to predict post-discharge outcomes of hospitalized patients.

Study design: Prospective cohort study.

Setting: General medical wards in Edmonton, Canada.

Synopsis: Researchers enrolled 495 adult patients from general medicine wards in two teaching hospitals. Long-term care residents and patients with limited life expectancy were excluded. Each patient was assessed using three different frailty assessment tools: the Clinical Frailty Scale (CFS), the Fried score, and the Timed Up and Go Test (TUGT). The primary outcomes were 30-day readmission and all-cause mortality. Outcomes were assessed by research personnel blinded to frailty status.

Overall, 211 (43%) patients were classified as frail by at least one tool. In general, frail patients were older, had more comorbidities, and had more frequent hospitalizations than non-frail patients. Agreement among the tools was poor, and only 49 patients met frailty criteria by all three definitions. The CFS was the only tool found to be an independent predictor of adverse 30-day outcomes (23% versus 14% for not frail, P=0.005; adjusted odds ratio, 2.02; 95% CI, 1.19–3.41).

Bottom line: As an independent predictor of adverse post-discharge outcomes, the CFS is a useful tool in both research and clinical settings. The CFS requires little time and no special equipment to administer.

Citation: Belga S, Majumdar SR, Kahlon S, et al. Comparing three different measures of frailty in medical inpatients: multicenter prospective cohort study examining 30-day risk of readmission or death. J Hosp Med. 2016;11(8):556-562.

Short Take

National Program Reduces CAUTI

A national prevention program aimed at reducing catheter-associated urinary tract infections (CAUTIs) has been shown to reduce both catheter use and rates of CAUTI in non-ICU patients.

Citation: Saint S, Greene MT, Krein SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med. 2016;374(22):2111-2119.

Background: Research has shown that frail hospital patients are at increased risk of readmission and death. Although several frailty assessment tools have been developed, few studies have examined the application of such tools to predict post-discharge outcomes of hospitalized patients.

Study design: Prospective cohort study.

Setting: General medical wards in Edmonton, Canada.

Synopsis: Researchers enrolled 495 adult patients from general medicine wards in two teaching hospitals. Long-term care residents and patients with limited life expectancy were excluded. Each patient was assessed using three different frailty assessment tools: the Clinical Frailty Scale (CFS), the Fried score, and the Timed Up and Go Test (TUGT). The primary outcomes were 30-day readmission and all-cause mortality. Outcomes were assessed by research personnel blinded to frailty status.

Overall, 211 (43%) patients were classified as frail by at least one tool. In general, frail patients were older, had more comorbidities, and had more frequent hospitalizations than non-frail patients. Agreement among the tools was poor, and only 49 patients met frailty criteria by all three definitions. The CFS was the only tool found to be an independent predictor of adverse 30-day outcomes (23% versus 14% for not frail, P=0.005; adjusted odds ratio, 2.02; 95% CI, 1.19–3.41).

Bottom line: As an independent predictor of adverse post-discharge outcomes, the CFS is a useful tool in both research and clinical settings. The CFS requires little time and no special equipment to administer.

Citation: Belga S, Majumdar SR, Kahlon S, et al. Comparing three different measures of frailty in medical inpatients: multicenter prospective cohort study examining 30-day risk of readmission or death. J Hosp Med. 2016;11(8):556-562.

Short Take

National Program Reduces CAUTI

A national prevention program aimed at reducing catheter-associated urinary tract infections (CAUTIs) has been shown to reduce both catheter use and rates of CAUTI in non-ICU patients.

Citation: Saint S, Greene MT, Krein SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med. 2016;374(22):2111-2119.