Perioperative Medicine

Monitoring of rates of surgical site infection, as well as reporting of those rates to the public, vary dramatically from state to state, according to a study published online March 2 in the Journal for Healthcare Quality.

Monitoring and publicly reporting data on surgical site infections (SSIs) has been demonstrated to markedly improve patient outcomes, and the Centers for Medicare and Medicaid Services recently announced that hospitals must report such data (for certain procedures) and meet benchmarks to avoid financial penalties. Yet currently there is no standardized system for collecting or reporting SSI data, with each state addressing the issue through its own individual laws, regulations, or "plans," said Dr. Martin A. Makary, a laparoscopic and pancreatic surgeon at Johns Hopkins University, Baltimore, and his associates.

"It is critical to standardize the reporting process before SSIs are incorporated into the Medicare payment scheme," they noted.

Dr. Makary and his colleagues reviewed the legislation on SSI monitoring and reporting for all 50 states and the District of Columbia, then assessed each state’s actual reporting of such data for a single month – September 2010.

They found that only 21 states mandate the monitoring of SSI rates and only 20 require public reporting; the remaining states had no such laws. And despite these legal mandates, only 8 of the 21 states had SSI data available in an easily accessible manner.

These states were South Carolina, Missouri, Colorado, Massachusetts, New York, Ohio, Vermont, and Oregon.

Among these eight states, SSI reporting still varied widely, with each state tracking different procedures. Seven states reported on CABG, six on hip or knee replacements, four on hysterectomies, and two each on colon surgeries or herniorrphaphies. One state reported on breast surgeries, one on gallbladder procedures, one on cesarean sections, and one on spinal fusions.

"Interestingly, colon surgery, which has the highest rate of SSIs nationally, was only reported by two states. And gallbladder surgery, which is among the most common surgical procedures ... was only reported by one state," the investigators said (J. Healthc. Qual. 2012 March 2 [doi: 10.1111/j.1945-1474.2011.00176.x]).

The data collection itself varied greatly by state. For example, some states monitored only in-hospital SSIs for colorectal surgery, while others monitored 30-day SSIs for the same procedure. This resulted in a nearly 40% discrepancy in colorectal SSIs between these states, since many of these infections don’t develop until after hospital discharge, the researchers said.

The lag time between collection of the information and its publication tended to be long, with some states failing to post their SSI data until 11 months after it was obtained.

"Without the same quality and type of data, it is difficult for consumers, payers, or regulators to compare infections within or across states, potentially making inaccurate inferences about the quality of care," Dr. Makary and his associates said.

"Our study highlights the need for the federal government to set the rules for how hospitals define, monitor, and report SSIs," they added.

No conflicts of interest were reported.

Monitoring of rates of surgical site infection, as well as reporting of those rates to the public, vary dramatically from state to state, according to a study published online March 2 in the Journal for Healthcare Quality.

Monitoring and publicly reporting data on surgical site infections (SSIs) has been demonstrated to markedly improve patient outcomes, and the Centers for Medicare and Medicaid Services recently announced that hospitals must report such data (for certain procedures) and meet benchmarks to avoid financial penalties. Yet currently there is no standardized system for collecting or reporting SSI data, with each state addressing the issue through its own individual laws, regulations, or "plans," said Dr. Martin A. Makary, a laparoscopic and pancreatic surgeon at Johns Hopkins University, Baltimore, and his associates.

"It is critical to standardize the reporting process before SSIs are incorporated into the Medicare payment scheme," they noted.

Dr. Makary and his colleagues reviewed the legislation on SSI monitoring and reporting for all 50 states and the District of Columbia, then assessed each state’s actual reporting of such data for a single month – September 2010.

They found that only 21 states mandate the monitoring of SSI rates and only 20 require public reporting; the remaining states had no such laws. And despite these legal mandates, only 8 of the 21 states had SSI data available in an easily accessible manner.

These states were South Carolina, Missouri, Colorado, Massachusetts, New York, Ohio, Vermont, and Oregon.

Among these eight states, SSI reporting still varied widely, with each state tracking different procedures. Seven states reported on CABG, six on hip or knee replacements, four on hysterectomies, and two each on colon surgeries or herniorrphaphies. One state reported on breast surgeries, one on gallbladder procedures, one on cesarean sections, and one on spinal fusions.

"Interestingly, colon surgery, which has the highest rate of SSIs nationally, was only reported by two states. And gallbladder surgery, which is among the most common surgical procedures ... was only reported by one state," the investigators said (J. Healthc. Qual. 2012 March 2 [doi: 10.1111/j.1945-1474.2011.00176.x]).

The data collection itself varied greatly by state. For example, some states monitored only in-hospital SSIs for colorectal surgery, while others monitored 30-day SSIs for the same procedure. This resulted in a nearly 40% discrepancy in colorectal SSIs between these states, since many of these infections don’t develop until after hospital discharge, the researchers said.

The lag time between collection of the information and its publication tended to be long, with some states failing to post their SSI data until 11 months after it was obtained.

"Without the same quality and type of data, it is difficult for consumers, payers, or regulators to compare infections within or across states, potentially making inaccurate inferences about the quality of care," Dr. Makary and his associates said.

"Our study highlights the need for the federal government to set the rules for how hospitals define, monitor, and report SSIs," they added.

No conflicts of interest were reported.

Monitoring of rates of surgical site infection, as well as reporting of those rates to the public, vary dramatically from state to state, according to a study published online March 2 in the Journal for Healthcare Quality.

Monitoring and publicly reporting data on surgical site infections (SSIs) has been demonstrated to markedly improve patient outcomes, and the Centers for Medicare and Medicaid Services recently announced that hospitals must report such data (for certain procedures) and meet benchmarks to avoid financial penalties. Yet currently there is no standardized system for collecting or reporting SSI data, with each state addressing the issue through its own individual laws, regulations, or "plans," said Dr. Martin A. Makary, a laparoscopic and pancreatic surgeon at Johns Hopkins University, Baltimore, and his associates.

"It is critical to standardize the reporting process before SSIs are incorporated into the Medicare payment scheme," they noted.

Dr. Makary and his colleagues reviewed the legislation on SSI monitoring and reporting for all 50 states and the District of Columbia, then assessed each state’s actual reporting of such data for a single month – September 2010.

They found that only 21 states mandate the monitoring of SSI rates and only 20 require public reporting; the remaining states had no such laws. And despite these legal mandates, only 8 of the 21 states had SSI data available in an easily accessible manner.

These states were South Carolina, Missouri, Colorado, Massachusetts, New York, Ohio, Vermont, and Oregon.

Among these eight states, SSI reporting still varied widely, with each state tracking different procedures. Seven states reported on CABG, six on hip or knee replacements, four on hysterectomies, and two each on colon surgeries or herniorrphaphies. One state reported on breast surgeries, one on gallbladder procedures, one on cesarean sections, and one on spinal fusions.

"Interestingly, colon surgery, which has the highest rate of SSIs nationally, was only reported by two states. And gallbladder surgery, which is among the most common surgical procedures ... was only reported by one state," the investigators said (J. Healthc. Qual. 2012 March 2 [doi: 10.1111/j.1945-1474.2011.00176.x]).

The data collection itself varied greatly by state. For example, some states monitored only in-hospital SSIs for colorectal surgery, while others monitored 30-day SSIs for the same procedure. This resulted in a nearly 40% discrepancy in colorectal SSIs between these states, since many of these infections don’t develop until after hospital discharge, the researchers said.

The lag time between collection of the information and its publication tended to be long, with some states failing to post their SSI data until 11 months after it was obtained.

"Without the same quality and type of data, it is difficult for consumers, payers, or regulators to compare infections within or across states, potentially making inaccurate inferences about the quality of care," Dr. Makary and his associates said.

"Our study highlights the need for the federal government to set the rules for how hospitals define, monitor, and report SSIs," they added.

No conflicts of interest were reported.

MIAMI BEACH – An internist and an orthopedic surgery recently squared off on the best strategy to prevent deep vein thrombosis following major joint-replacement surgery.

Anticoagulant agents effectively prevent deep vein thrombosis (DVT) after total hip replacement or total knee replacement, according to a large body of scientific studies, the internist argued. In contrast to the well studied, relatively small number of anticoagulants, the myriad of mechanical devices are supported by more limited, less rigorous research in the medical literature, Dr. James D. Douketis said at a meeting on perioperative medicine sponsored by the University of Miami.

The risk of major or clinically relevant bleeding associated with anticoagulant use can be minimized with appropriate administration, such as waiting at least 12 hours after surgery to start therapy, said Dr. Douketis, director of the vascular medicine program at St. Joseph’s Healthcare in Hamilton, Ont.

"I agree that the bleeding risk is relatively low if these drugs are used properly, but why do you have to take any risk?" orthopedic surgeon Dr. Clifford W. Colwell Jr. asked at the meeting.

Most bleeding episodes, when they do occur, are easy to mitigate, Dr. Douketis said. Unlike DVTs, most of these events do not have long-term consequences, he said. In addition, mechanical methods are not always benign. There are reports of trauma associated with use of intermittent compression devices, for example.

Dr. Colwell countered that a zero risk of an adverse bleeding event is one of the main benefits of mechanical devices to prevent DVT. For this reason, these devices are ideal for patients at a high risk for bleeding who cannot take anticoagulants, he said. Enhancement of the effectiveness of drug-based thromboprophylaxis and reduced leg swelling are other potential benefits of these devices.

The effectiveness of mechanical compression devices is directly correlated with how much time they are worn and these devices are nearly complication free, said Dr. Colwell, medical director at the Shiley Center for Orthopaedic Research and Education at Scripps Clinic in La Jolla, Calif.

But why can’t these devices be more portable? The ActiveCare+S.F.T. Portable Intermittent Compression Device, or PICD (Medical Compression Systems Ltd.), is a miniature, battery-powered device that overcomes a major limitation of some mechanical devices: Their design and size can impede ambulation after surgery. The PICD can be worn out of bed and out of the hospital, Dr. Colwell said. It synchronizes compression with the patient’s respiratory phase so it provides a naturalistic phasic venous flow.

An initial study of its efficacy in 121 patients "was small ... I was not convinced," Dr. Colwell said (J. Arthroplasty 2006;21;206-14). A more recent multicenter, prospective study that Dr. Colwell performed with his associates compared effectiveness of the portable device to low-molecular-weight heparin for 10 days for total hip arthroplasties and was more compelling (J. Bone Joint Surg. Am. 2010:92:527-35).

At 3 months, the DVT rate was "essentially the same" at 4.1% in the device group compared with 4.2% in the anticoagulant cohort. There was no fatal PE or any deaths among the 410 randomized participants. In addition, major bleeding occurred for 0% of the device wearers and 5.6% of the pharmacologically treated patients.

"I acknowledge that mechanical prophylaxis has a role after major orthopedic surgery major, but it’s a second-line strategy," said Dr. Douketis, who also is on the medicine faculty at McMaster University. Pharmacologic prophylaxis should be first-line therapy because it has been shown to prevent DVT, and pulmonary embolism (PE), including fatal PE, he said.

A meta-analysis Dr. Douketis performed with his colleagues showed extended duration prophylaxis with heparin or warfarin significantly decreased the frequency of symptomatic venous thromboembolism, compared with placebo after total hip or knee replacement (Lancet 2001;358:9-15).

There is less confidence about prevention of proximal DVTs with mechanical devices, Dr. Douketis said.

The risks should be weighed against this efficacy, Dr. Douketis said. In a study, researchers determined the risk of major or clinically-relevant bleeding was 4% of 1,501 patients treated with apixaban and 5% of 1,508 patients treated with enoxaparin (Lancet 2010;375:807-15).

American College of Chest Physician (ACCP) guidelines recommend use of low-molecular weight heparin to prevent DVT in these surgical populations but list a number of other pharmacologic prophylaxis options (supported by grade 2C/2B evidence). They also recommend addition of an intermittent pneumatic compressive device during the hospital stay of patients taking anticoagulants, but supported by grade 2C evidence. The authors also recommend one of these devices or no prophylaxis for patients at increased bleeding risk (again, grade 2C evidence). The full recommendations were published in February (Chest 2012;141:e278S-325S).

Dr. Colwell said patient compliance is monitored by and clearly reported on the screen of the PICD. Compliance with wearing the device was 86% in an unpublished study that included 3,060 total hip and total knee surgery patients. These patients wore the device a mean of 20 hr/day.

Dr. Douketis remained unconvinced about the PICD and said he preferred to withhold judgment until more studies are completed. "We are much more confident with anticoagulants than mechanical strategies."

Dr. Colwell said the new PICD is akin to an iPhone. "You don’t need 30 years of experience to know it’s a good product."

Dr. Douketis disclosed that he is a consultant for AGEN, Ortho-Janssen, Boehringer Ingelheim, Pfizer, and Bristol-Myers Squibb. He also receives indirect payment as part of the event adjudication and advisory board for Sanofi Aventis, Bayer, Bristol-Myers Squibb, Astra Zeneca, and Boehringer Ingelheim. Dr. Colwell disclosed that he is a consultant for and receives research grants from Medical Compression Systems Inc.

MIAMI BEACH – An internist and an orthopedic surgery recently squared off on the best strategy to prevent deep vein thrombosis following major joint-replacement surgery.

Anticoagulant agents effectively prevent deep vein thrombosis (DVT) after total hip replacement or total knee replacement, according to a large body of scientific studies, the internist argued. In contrast to the well studied, relatively small number of anticoagulants, the myriad of mechanical devices are supported by more limited, less rigorous research in the medical literature, Dr. James D. Douketis said at a meeting on perioperative medicine sponsored by the University of Miami.

The risk of major or clinically relevant bleeding associated with anticoagulant use can be minimized with appropriate administration, such as waiting at least 12 hours after surgery to start therapy, said Dr. Douketis, director of the vascular medicine program at St. Joseph’s Healthcare in Hamilton, Ont.

"I agree that the bleeding risk is relatively low if these drugs are used properly, but why do you have to take any risk?" orthopedic surgeon Dr. Clifford W. Colwell Jr. asked at the meeting.

Most bleeding episodes, when they do occur, are easy to mitigate, Dr. Douketis said. Unlike DVTs, most of these events do not have long-term consequences, he said. In addition, mechanical methods are not always benign. There are reports of trauma associated with use of intermittent compression devices, for example.

Dr. Colwell countered that a zero risk of an adverse bleeding event is one of the main benefits of mechanical devices to prevent DVT. For this reason, these devices are ideal for patients at a high risk for bleeding who cannot take anticoagulants, he said. Enhancement of the effectiveness of drug-based thromboprophylaxis and reduced leg swelling are other potential benefits of these devices.

The effectiveness of mechanical compression devices is directly correlated with how much time they are worn and these devices are nearly complication free, said Dr. Colwell, medical director at the Shiley Center for Orthopaedic Research and Education at Scripps Clinic in La Jolla, Calif.

But why can’t these devices be more portable? The ActiveCare+S.F.T. Portable Intermittent Compression Device, or PICD (Medical Compression Systems Ltd.), is a miniature, battery-powered device that overcomes a major limitation of some mechanical devices: Their design and size can impede ambulation after surgery. The PICD can be worn out of bed and out of the hospital, Dr. Colwell said. It synchronizes compression with the patient’s respiratory phase so it provides a naturalistic phasic venous flow.

An initial study of its efficacy in 121 patients "was small ... I was not convinced," Dr. Colwell said (J. Arthroplasty 2006;21;206-14). A more recent multicenter, prospective study that Dr. Colwell performed with his associates compared effectiveness of the portable device to low-molecular-weight heparin for 10 days for total hip arthroplasties and was more compelling (J. Bone Joint Surg. Am. 2010:92:527-35).

At 3 months, the DVT rate was "essentially the same" at 4.1% in the device group compared with 4.2% in the anticoagulant cohort. There was no fatal PE or any deaths among the 410 randomized participants. In addition, major bleeding occurred for 0% of the device wearers and 5.6% of the pharmacologically treated patients.

"I acknowledge that mechanical prophylaxis has a role after major orthopedic surgery major, but it’s a second-line strategy," said Dr. Douketis, who also is on the medicine faculty at McMaster University. Pharmacologic prophylaxis should be first-line therapy because it has been shown to prevent DVT, and pulmonary embolism (PE), including fatal PE, he said.

A meta-analysis Dr. Douketis performed with his colleagues showed extended duration prophylaxis with heparin or warfarin significantly decreased the frequency of symptomatic venous thromboembolism, compared with placebo after total hip or knee replacement (Lancet 2001;358:9-15).

There is less confidence about prevention of proximal DVTs with mechanical devices, Dr. Douketis said.

The risks should be weighed against this efficacy, Dr. Douketis said. In a study, researchers determined the risk of major or clinically-relevant bleeding was 4% of 1,501 patients treated with apixaban and 5% of 1,508 patients treated with enoxaparin (Lancet 2010;375:807-15).

American College of Chest Physician (ACCP) guidelines recommend use of low-molecular weight heparin to prevent DVT in these surgical populations but list a number of other pharmacologic prophylaxis options (supported by grade 2C/2B evidence). They also recommend addition of an intermittent pneumatic compressive device during the hospital stay of patients taking anticoagulants, but supported by grade 2C evidence. The authors also recommend one of these devices or no prophylaxis for patients at increased bleeding risk (again, grade 2C evidence). The full recommendations were published in February (Chest 2012;141:e278S-325S).

Dr. Colwell said patient compliance is monitored by and clearly reported on the screen of the PICD. Compliance with wearing the device was 86% in an unpublished study that included 3,060 total hip and total knee surgery patients. These patients wore the device a mean of 20 hr/day.

Dr. Douketis remained unconvinced about the PICD and said he preferred to withhold judgment until more studies are completed. "We are much more confident with anticoagulants than mechanical strategies."

Dr. Colwell said the new PICD is akin to an iPhone. "You don’t need 30 years of experience to know it’s a good product."

Dr. Douketis disclosed that he is a consultant for AGEN, Ortho-Janssen, Boehringer Ingelheim, Pfizer, and Bristol-Myers Squibb. He also receives indirect payment as part of the event adjudication and advisory board for Sanofi Aventis, Bayer, Bristol-Myers Squibb, Astra Zeneca, and Boehringer Ingelheim. Dr. Colwell disclosed that he is a consultant for and receives research grants from Medical Compression Systems Inc.

MIAMI BEACH – An internist and an orthopedic surgery recently squared off on the best strategy to prevent deep vein thrombosis following major joint-replacement surgery.

Anticoagulant agents effectively prevent deep vein thrombosis (DVT) after total hip replacement or total knee replacement, according to a large body of scientific studies, the internist argued. In contrast to the well studied, relatively small number of anticoagulants, the myriad of mechanical devices are supported by more limited, less rigorous research in the medical literature, Dr. James D. Douketis said at a meeting on perioperative medicine sponsored by the University of Miami.

The risk of major or clinically relevant bleeding associated with anticoagulant use can be minimized with appropriate administration, such as waiting at least 12 hours after surgery to start therapy, said Dr. Douketis, director of the vascular medicine program at St. Joseph’s Healthcare in Hamilton, Ont.

"I agree that the bleeding risk is relatively low if these drugs are used properly, but why do you have to take any risk?" orthopedic surgeon Dr. Clifford W. Colwell Jr. asked at the meeting.

Most bleeding episodes, when they do occur, are easy to mitigate, Dr. Douketis said. Unlike DVTs, most of these events do not have long-term consequences, he said. In addition, mechanical methods are not always benign. There are reports of trauma associated with use of intermittent compression devices, for example.

Dr. Colwell countered that a zero risk of an adverse bleeding event is one of the main benefits of mechanical devices to prevent DVT. For this reason, these devices are ideal for patients at a high risk for bleeding who cannot take anticoagulants, he said. Enhancement of the effectiveness of drug-based thromboprophylaxis and reduced leg swelling are other potential benefits of these devices.

The effectiveness of mechanical compression devices is directly correlated with how much time they are worn and these devices are nearly complication free, said Dr. Colwell, medical director at the Shiley Center for Orthopaedic Research and Education at Scripps Clinic in La Jolla, Calif.

But why can’t these devices be more portable? The ActiveCare+S.F.T. Portable Intermittent Compression Device, or PICD (Medical Compression Systems Ltd.), is a miniature, battery-powered device that overcomes a major limitation of some mechanical devices: Their design and size can impede ambulation after surgery. The PICD can be worn out of bed and out of the hospital, Dr. Colwell said. It synchronizes compression with the patient’s respiratory phase so it provides a naturalistic phasic venous flow.

An initial study of its efficacy in 121 patients "was small ... I was not convinced," Dr. Colwell said (J. Arthroplasty 2006;21;206-14). A more recent multicenter, prospective study that Dr. Colwell performed with his associates compared effectiveness of the portable device to low-molecular-weight heparin for 10 days for total hip arthroplasties and was more compelling (J. Bone Joint Surg. Am. 2010:92:527-35).

At 3 months, the DVT rate was "essentially the same" at 4.1% in the device group compared with 4.2% in the anticoagulant cohort. There was no fatal PE or any deaths among the 410 randomized participants. In addition, major bleeding occurred for 0% of the device wearers and 5.6% of the pharmacologically treated patients.

"I acknowledge that mechanical prophylaxis has a role after major orthopedic surgery major, but it’s a second-line strategy," said Dr. Douketis, who also is on the medicine faculty at McMaster University. Pharmacologic prophylaxis should be first-line therapy because it has been shown to prevent DVT, and pulmonary embolism (PE), including fatal PE, he said.

A meta-analysis Dr. Douketis performed with his colleagues showed extended duration prophylaxis with heparin or warfarin significantly decreased the frequency of symptomatic venous thromboembolism, compared with placebo after total hip or knee replacement (Lancet 2001;358:9-15).

There is less confidence about prevention of proximal DVTs with mechanical devices, Dr. Douketis said.

The risks should be weighed against this efficacy, Dr. Douketis said. In a study, researchers determined the risk of major or clinically-relevant bleeding was 4% of 1,501 patients treated with apixaban and 5% of 1,508 patients treated with enoxaparin (Lancet 2010;375:807-15).

American College of Chest Physician (ACCP) guidelines recommend use of low-molecular weight heparin to prevent DVT in these surgical populations but list a number of other pharmacologic prophylaxis options (supported by grade 2C/2B evidence). They also recommend addition of an intermittent pneumatic compressive device during the hospital stay of patients taking anticoagulants, but supported by grade 2C evidence. The authors also recommend one of these devices or no prophylaxis for patients at increased bleeding risk (again, grade 2C evidence). The full recommendations were published in February (Chest 2012;141:e278S-325S).

Dr. Colwell said patient compliance is monitored by and clearly reported on the screen of the PICD. Compliance with wearing the device was 86% in an unpublished study that included 3,060 total hip and total knee surgery patients. These patients wore the device a mean of 20 hr/day.

Dr. Douketis remained unconvinced about the PICD and said he preferred to withhold judgment until more studies are completed. "We are much more confident with anticoagulants than mechanical strategies."

Dr. Colwell said the new PICD is akin to an iPhone. "You don’t need 30 years of experience to know it’s a good product."

Dr. Douketis disclosed that he is a consultant for AGEN, Ortho-Janssen, Boehringer Ingelheim, Pfizer, and Bristol-Myers Squibb. He also receives indirect payment as part of the event adjudication and advisory board for Sanofi Aventis, Bayer, Bristol-Myers Squibb, Astra Zeneca, and Boehringer Ingelheim. Dr. Colwell disclosed that he is a consultant for and receives research grants from Medical Compression Systems Inc.

MIAMI – Patients who are likely to eat up a high proportion of hospital resources after surgery can be identified and risk stratified, a study has shown.

A Holy Grail of hospital medicine has been to identify – ahead of time – those most likely to require additional services, an increased length of stay, and essentially more attention and closer monitoring from a multidisciplinary team of clinicians.

At Geisinger Health System in Danville, Pa., use of the Proactive Risk Stratification and Preemptive Mitigation (PRiSM) continuum of care model has resulted in significant reductions in mortality, for example, for surgical patients compared with historical controls, the pilot study has shown

Most of the benefit was realized because higher-risk patients were transferred to a step-down unit or "progressive care unit" (PCU) versus going to the hospital ward and waiting for them to turn "sour," Dr. Thanjuvar S. Ravikumar said at a meeting on perioperative medicine sponsored by the University of Miami. "This is a safety net. You identify patients during rounds at risk of potential deterioration," he added. "You can improve patient outcomes significantly."

The focus is not surgical ICU mortality. "The focus is to improve mortality, the efficiency, and the length of stay outside of the ICU," he said.

Overall reductions in length of stay and hospital costs also emerged, said Dr. Ravikumar, who was the chief quality officer in surgery and interventional procedures at Geisinger until February of this year. He is now director and CEO of Jawaharlal Institute of Postgraduate Medical Education and Research in India. He is also president and CEO of Integrated Health Strategies, which includes PRiSM Healthcare and owns the PRiSM concept.

"When you put this program in place, you see a dramatic difference in length of stay within 2 months," Dr. Ravikumar said.

Even hospitalists working at institutions with "fantastic" length of stay rates will see their pre–11 a.m. discharges happen more efficiently with this model, Dr. Ravikumar said.

Although the pilot study focused on surgical patients, PRiSM also features descriptive criteria tailored for use during medical rounds. The idea is to predict and direct closer monitoring toward "hawks" or those postoperative patients who need to be "watched like hawks," Dr. Ravikumar said. Normal-risk patients are termed "doves."

Transfer from an ICU, a body mass index greater than 40 kg/m², or an ejection fraction below 30% are among the "hawk’" preoperative criteria for surgery patients. Exacerbated chronic obstructive pulmonary disorder, borderline heart failure decompensation, and pneumonia requiring oxygen or bilevel positive airway pressure therapy are examples of "hawk" criteria for medical patients.

PRiSM saves an estimated $851,111-$2,007,388 from postoperative care unit throughput and decreased ICU utilization, Dr. Ravikumar said. In addition, decreases in utilization of pharmacy, radiology, blood bank, and laboratory services are estimated at $500,000 per top 10 diagnostic-related group codes. Postoperative complications decreased 25%, for an estimated cost savings of $3,000-$18,000 per complication.

A subanalysis of the pilot study data compared a cohort of surgical patients stratified with PRiSM to patients at a comparable hospital with the same number of surgeons. Overall mortality was lower for the PRiSM cohort, 1% vs. 1.4%, as was mortality in the postoperative care unit, 0.4% vs. 1.6%, and the surgical ICU, 8% vs. 9.3%.

Length of stay measured in a variety of settings also was shorter for the PRiSM patients versus the comparator hospital patients. For example, PRiSM patients stayed a mean of 2.7 days vs. 3.7 days in the postoperative care unit and a mean of 4.4 days vs. 4.5 in the surgical ICU. The difference in surgical ICU stays was not statistically significant.

During the question and answer session, Dr. Frank Michota said the Center for Medicaid and Medicare Innovation is promoting the use of a standardized continuum of care model. He asked Dr. Ravikumar if such a model can be achieved on a national rather than a local level. Dr. Michota is director of academic affairs, department of hospital medicine, Cleveland Clinic Ohio.

"There are principles of what you want to do – team building, communication – but the local culture is very important. In terms of how you implement in every hospital, there has to be [some] latitude. If you don’t have hospitalists and you have PAs, you have to work on the PA system," Dr. Ravikumar said. In addition some weighting based on the hospital profile is warranted. For example, if a hospital has a fantastic cardiology program and a weaker renal program, the risk stratification has to be weighted to detect patients at risk for renal complications or whatever is the weaker service at that hospital.

Dr. Ravikumar outlined how a typical day works using the PRiSM strategy. At 7:30 a.m., hospitalist handoff occurs. Pre-rounding on the patient floor, during which time the hospitalist consults with the surgeons, continues until 9 a.m. An agreement to comanage patients with surgery is an essential component, Dr. Ravikumar said.

From 9-10 a.m., simultaneous continuum of care rounds are performed by the multidisciplinary team: hospitalists, surgical team, nurses, care managers, pharmacists, and residents. "Everyone sits in and finishes seeing all those patients in 1 hour, mostly ... for discharge planning in the hospital," Dr. Ravikumar said. From 10-10:30 a.m., the hospitalist and continuum of care physician do the "hawk huddle" to confer on the list of patients who will require more scrutiny.

The use of a rounding tool (either mobile or based in the electronic medical record system) is required to make this multidisciplinary assessment effective, Dr. Ravikumar said. The tool needs to be easily accessible during rounds and easily navigated for each patient by the providers, nurses, occupational therapists, physical therapists, and pharmacists.

Although the hawk criteria are currently descriptive, "we have developed a model composite score based on preoperative variables, intraoperative happenings, and postoperatively, things that happen in the first 2 hours," Dr. Ravikumar said. Decision support based on the score is essential, he added, "so you know what to do in the next hour for this individual patient."

Dr. Ravikumar said that he had no relevant financial disclosures. Dr. Michota is the medical editor of Hospitalist News, an Elsevier publication.

MIAMI – Patients who are likely to eat up a high proportion of hospital resources after surgery can be identified and risk stratified, a study has shown.

A Holy Grail of hospital medicine has been to identify – ahead of time – those most likely to require additional services, an increased length of stay, and essentially more attention and closer monitoring from a multidisciplinary team of clinicians.

At Geisinger Health System in Danville, Pa., use of the Proactive Risk Stratification and Preemptive Mitigation (PRiSM) continuum of care model has resulted in significant reductions in mortality, for example, for surgical patients compared with historical controls, the pilot study has shown

Most of the benefit was realized because higher-risk patients were transferred to a step-down unit or "progressive care unit" (PCU) versus going to the hospital ward and waiting for them to turn "sour," Dr. Thanjuvar S. Ravikumar said at a meeting on perioperative medicine sponsored by the University of Miami. "This is a safety net. You identify patients during rounds at risk of potential deterioration," he added. "You can improve patient outcomes significantly."

The focus is not surgical ICU mortality. "The focus is to improve mortality, the efficiency, and the length of stay outside of the ICU," he said.

Overall reductions in length of stay and hospital costs also emerged, said Dr. Ravikumar, who was the chief quality officer in surgery and interventional procedures at Geisinger until February of this year. He is now director and CEO of Jawaharlal Institute of Postgraduate Medical Education and Research in India. He is also president and CEO of Integrated Health Strategies, which includes PRiSM Healthcare and owns the PRiSM concept.

"When you put this program in place, you see a dramatic difference in length of stay within 2 months," Dr. Ravikumar said.

Even hospitalists working at institutions with "fantastic" length of stay rates will see their pre–11 a.m. discharges happen more efficiently with this model, Dr. Ravikumar said.

Although the pilot study focused on surgical patients, PRiSM also features descriptive criteria tailored for use during medical rounds. The idea is to predict and direct closer monitoring toward "hawks" or those postoperative patients who need to be "watched like hawks," Dr. Ravikumar said. Normal-risk patients are termed "doves."

Transfer from an ICU, a body mass index greater than 40 kg/m², or an ejection fraction below 30% are among the "hawk’" preoperative criteria for surgery patients. Exacerbated chronic obstructive pulmonary disorder, borderline heart failure decompensation, and pneumonia requiring oxygen or bilevel positive airway pressure therapy are examples of "hawk" criteria for medical patients.

PRiSM saves an estimated $851,111-$2,007,388 from postoperative care unit throughput and decreased ICU utilization, Dr. Ravikumar said. In addition, decreases in utilization of pharmacy, radiology, blood bank, and laboratory services are estimated at $500,000 per top 10 diagnostic-related group codes. Postoperative complications decreased 25%, for an estimated cost savings of $3,000-$18,000 per complication.

A subanalysis of the pilot study data compared a cohort of surgical patients stratified with PRiSM to patients at a comparable hospital with the same number of surgeons. Overall mortality was lower for the PRiSM cohort, 1% vs. 1.4%, as was mortality in the postoperative care unit, 0.4% vs. 1.6%, and the surgical ICU, 8% vs. 9.3%.

Length of stay measured in a variety of settings also was shorter for the PRiSM patients versus the comparator hospital patients. For example, PRiSM patients stayed a mean of 2.7 days vs. 3.7 days in the postoperative care unit and a mean of 4.4 days vs. 4.5 in the surgical ICU. The difference in surgical ICU stays was not statistically significant.

During the question and answer session, Dr. Frank Michota said the Center for Medicaid and Medicare Innovation is promoting the use of a standardized continuum of care model. He asked Dr. Ravikumar if such a model can be achieved on a national rather than a local level. Dr. Michota is director of academic affairs, department of hospital medicine, Cleveland Clinic Ohio.

"There are principles of what you want to do – team building, communication – but the local culture is very important. In terms of how you implement in every hospital, there has to be [some] latitude. If you don’t have hospitalists and you have PAs, you have to work on the PA system," Dr. Ravikumar said. In addition some weighting based on the hospital profile is warranted. For example, if a hospital has a fantastic cardiology program and a weaker renal program, the risk stratification has to be weighted to detect patients at risk for renal complications or whatever is the weaker service at that hospital.

Dr. Ravikumar outlined how a typical day works using the PRiSM strategy. At 7:30 a.m., hospitalist handoff occurs. Pre-rounding on the patient floor, during which time the hospitalist consults with the surgeons, continues until 9 a.m. An agreement to comanage patients with surgery is an essential component, Dr. Ravikumar said.

From 9-10 a.m., simultaneous continuum of care rounds are performed by the multidisciplinary team: hospitalists, surgical team, nurses, care managers, pharmacists, and residents. "Everyone sits in and finishes seeing all those patients in 1 hour, mostly ... for discharge planning in the hospital," Dr. Ravikumar said. From 10-10:30 a.m., the hospitalist and continuum of care physician do the "hawk huddle" to confer on the list of patients who will require more scrutiny.

The use of a rounding tool (either mobile or based in the electronic medical record system) is required to make this multidisciplinary assessment effective, Dr. Ravikumar said. The tool needs to be easily accessible during rounds and easily navigated for each patient by the providers, nurses, occupational therapists, physical therapists, and pharmacists.

Although the hawk criteria are currently descriptive, "we have developed a model composite score based on preoperative variables, intraoperative happenings, and postoperatively, things that happen in the first 2 hours," Dr. Ravikumar said. Decision support based on the score is essential, he added, "so you know what to do in the next hour for this individual patient."

Dr. Ravikumar said that he had no relevant financial disclosures. Dr. Michota is the medical editor of Hospitalist News, an Elsevier publication.

MIAMI – Patients who are likely to eat up a high proportion of hospital resources after surgery can be identified and risk stratified, a study has shown.

A Holy Grail of hospital medicine has been to identify – ahead of time – those most likely to require additional services, an increased length of stay, and essentially more attention and closer monitoring from a multidisciplinary team of clinicians.

At Geisinger Health System in Danville, Pa., use of the Proactive Risk Stratification and Preemptive Mitigation (PRiSM) continuum of care model has resulted in significant reductions in mortality, for example, for surgical patients compared with historical controls, the pilot study has shown

Most of the benefit was realized because higher-risk patients were transferred to a step-down unit or "progressive care unit" (PCU) versus going to the hospital ward and waiting for them to turn "sour," Dr. Thanjuvar S. Ravikumar said at a meeting on perioperative medicine sponsored by the University of Miami. "This is a safety net. You identify patients during rounds at risk of potential deterioration," he added. "You can improve patient outcomes significantly."

The focus is not surgical ICU mortality. "The focus is to improve mortality, the efficiency, and the length of stay outside of the ICU," he said.

Overall reductions in length of stay and hospital costs also emerged, said Dr. Ravikumar, who was the chief quality officer in surgery and interventional procedures at Geisinger until February of this year. He is now director and CEO of Jawaharlal Institute of Postgraduate Medical Education and Research in India. He is also president and CEO of Integrated Health Strategies, which includes PRiSM Healthcare and owns the PRiSM concept.

"When you put this program in place, you see a dramatic difference in length of stay within 2 months," Dr. Ravikumar said.

Even hospitalists working at institutions with "fantastic" length of stay rates will see their pre–11 a.m. discharges happen more efficiently with this model, Dr. Ravikumar said.

Although the pilot study focused on surgical patients, PRiSM also features descriptive criteria tailored for use during medical rounds. The idea is to predict and direct closer monitoring toward "hawks" or those postoperative patients who need to be "watched like hawks," Dr. Ravikumar said. Normal-risk patients are termed "doves."

Transfer from an ICU, a body mass index greater than 40 kg/m², or an ejection fraction below 30% are among the "hawk’" preoperative criteria for surgery patients. Exacerbated chronic obstructive pulmonary disorder, borderline heart failure decompensation, and pneumonia requiring oxygen or bilevel positive airway pressure therapy are examples of "hawk" criteria for medical patients.

PRiSM saves an estimated $851,111-$2,007,388 from postoperative care unit throughput and decreased ICU utilization, Dr. Ravikumar said. In addition, decreases in utilization of pharmacy, radiology, blood bank, and laboratory services are estimated at $500,000 per top 10 diagnostic-related group codes. Postoperative complications decreased 25%, for an estimated cost savings of $3,000-$18,000 per complication.

A subanalysis of the pilot study data compared a cohort of surgical patients stratified with PRiSM to patients at a comparable hospital with the same number of surgeons. Overall mortality was lower for the PRiSM cohort, 1% vs. 1.4%, as was mortality in the postoperative care unit, 0.4% vs. 1.6%, and the surgical ICU, 8% vs. 9.3%.

Length of stay measured in a variety of settings also was shorter for the PRiSM patients versus the comparator hospital patients. For example, PRiSM patients stayed a mean of 2.7 days vs. 3.7 days in the postoperative care unit and a mean of 4.4 days vs. 4.5 in the surgical ICU. The difference in surgical ICU stays was not statistically significant.

During the question and answer session, Dr. Frank Michota said the Center for Medicaid and Medicare Innovation is promoting the use of a standardized continuum of care model. He asked Dr. Ravikumar if such a model can be achieved on a national rather than a local level. Dr. Michota is director of academic affairs, department of hospital medicine, Cleveland Clinic Ohio.

"There are principles of what you want to do – team building, communication – but the local culture is very important. In terms of how you implement in every hospital, there has to be [some] latitude. If you don’t have hospitalists and you have PAs, you have to work on the PA system," Dr. Ravikumar said. In addition some weighting based on the hospital profile is warranted. For example, if a hospital has a fantastic cardiology program and a weaker renal program, the risk stratification has to be weighted to detect patients at risk for renal complications or whatever is the weaker service at that hospital.

Dr. Ravikumar outlined how a typical day works using the PRiSM strategy. At 7:30 a.m., hospitalist handoff occurs. Pre-rounding on the patient floor, during which time the hospitalist consults with the surgeons, continues until 9 a.m. An agreement to comanage patients with surgery is an essential component, Dr. Ravikumar said.

From 9-10 a.m., simultaneous continuum of care rounds are performed by the multidisciplinary team: hospitalists, surgical team, nurses, care managers, pharmacists, and residents. "Everyone sits in and finishes seeing all those patients in 1 hour, mostly ... for discharge planning in the hospital," Dr. Ravikumar said. From 10-10:30 a.m., the hospitalist and continuum of care physician do the "hawk huddle" to confer on the list of patients who will require more scrutiny.

The use of a rounding tool (either mobile or based in the electronic medical record system) is required to make this multidisciplinary assessment effective, Dr. Ravikumar said. The tool needs to be easily accessible during rounds and easily navigated for each patient by the providers, nurses, occupational therapists, physical therapists, and pharmacists.

Although the hawk criteria are currently descriptive, "we have developed a model composite score based on preoperative variables, intraoperative happenings, and postoperatively, things that happen in the first 2 hours," Dr. Ravikumar said. Decision support based on the score is essential, he added, "so you know what to do in the next hour for this individual patient."

Dr. Ravikumar said that he had no relevant financial disclosures. Dr. Michota is the medical editor of Hospitalist News, an Elsevier publication.

MIAMI BEACH – Knowing if immunomodulators should be stopped in the perioperative period and when would be helpful for hospitalists, surgeons, other clinicians and, ultimately, for patients.

It is important to balance the concerns of patient optimization for surgery vs. the risk of triggering a recurrent inflammatory cascade or organ rejection during cessation, Dr. Christopher Whinney said at a meeting on perioperative medicine sponsored by the University of Miami.

Although there is a dearth of randomized controlled trials to address immunomodulator cessation around the time of surgery, Dr. Whinney reviewed what evidence is available (mostly observational and/or retrospective studies). He provided specific advice regarding tumor necrosis factor (TNF) alpha inhibitors, corticosteroids, calcineurin inhibitors, antiproliferative agents such as mycophenolate mofetil, and mammalian target of rapamycin inhibitors (mTOR).

There is some controversy regarding continuation of TNF-alpha inhibitors during the perioperative period, for example, said Dr. Whinney, chairman of the department of hospital medicine at the Cleveland Clinic. "Some studies suggest an increased risk for [surgical site] infection and others do not. The literature is heterogenous in this area."

Continuation of TNF-alpha agents in patients with rheumatoid arthritis, for example, was not associated with increased risk of surgical site infections in a retrospective study of 1,219 surgical procedures performed in 768 patients (J. Rheum. 2007;34:689-95). In contrast, other researchers conducted a systematic literature review and determined there is evidence of an increased risk of serious infection with TNF-alpha inhibitor use, in general, among patients with rheumatoid arthritis (JAMA 2006;295:2275-85).

"It’s a judgment call," Dr. Whinney said. "Although the weight of evidence suggests the safety of continuation ... my practice would be to withhold these 2 weeks preoperatively, of course in discussion with the rheumatologist or person prescribing these agents."

Corticosteroid supplementation in the perioperative setting is another question with no definitive answer in the literature. Whether or not to provide high "stress dose" steroids on the morning of surgery to minimize the potential for an adrenal crisis in patients with adrenal insufficiency is a question. The stress of surgery can activate the brain’s hypothalamic-pituitary-adrenal (HPA) axis and trigger a rare but serious adrenal crisis. The thinking is that high-dose steroids will suppress the HPA axis activation and prevent these rare crises.

"Current supplementation is probably excessive. We probably give way too [many] stress dose steroids ... and are probably treating ourselves more than we are treating our patients," Dr. Whinney said.

A Cochrane database review supports this position (Cochrane Database Syst. Rev. 2009;4:CD005367).Dr. Whinney said this review revealed that for patients on basal steroid doses, "it was not possible to refute or support perioperative steroid supplementation."

"For most patients who are on steroids for a reason other than existing HPA axis disease, for most surgeries, their daily steroid regimen is acceptable."

Other researchers recommended an amount of steroid supplementation to administer according to surgery type: superficial, minor, moderate, or major (Semin. Arthritis Rheum. 2007;36:278-86).

Aminosalicylates are another type of immunomodulator relevant in the perioperative period. These anti-inflammatory agents are taken by patients with ulcerative colitis or Crohn’s disease. There are little data on perioperative use of these agents, which include sulfasalazine or 5-aminosalicylate, Dr. Whinney said.

Some researchers suggest holding aminosalicylates on the day of surgery for patients with inflammatory bowel disease who are renally cleared, if they have a diminished glomerular filtration rate (for example, patients older than 65 years, those with ASA physical status score of 4 or 5, and/or patients with a revised cardiac risk index score greater than 2) (Mayo Clin. Proc. 2011;86:748-57). This protocol permits reinitiating aminosalicylates on postoperative day 3.

Patients also might present for surgery taking one of the potent calcineurin inhibitors such as cyclosporine or tacrolimus. Although there is no evidence of increased postoperative complications when these agents are continued perioperatively, continue to watch patients for infection and continue to monitor drug levels, Dr. Whinney said. He also recommended switching patients to an intravenous form if they are NPO (nothing by mouth) for an extended time or are placed on mechanical ventilation for more than 24 hours. It is important to consult a transplant surgeon regarding these agents.

Azathioprine and 6-mercaptopurine are antiproliferative agents often administered for their steroid sparing effects. There have been no consistent effects on surgical outcomes or mortality reported, Dr. Whinney said. However, it is probably reasonable to hold these agents on the day of surgery and resume on the third postoperative day, mostly to avoid any adverse effect on anesthesia. Have a conversation with the prescribing physician, he added, before you stop these agents perioperatively.

Mycophenolate mofetil is another antiproliferative agent. Hepatic and renal testing is appropriate if someone is already on these agents. Although there are little to no data to guide perioperative use, "it can be continued in the perioperative period in absence of infection or liver or renal disease," according to Dr. Whinney.

Sirolimus and everolimus are potent antiproliferative agents in the mTOR inhibitor class. An increased risk for wound complications or wound seromas is a relevant perioperative issue. Obesity and concomitant use of steroids add to this risk. A systematic wound care program can reduce the rate of wound healing complications back to baseline, Dr. Whinney said.

Dr. Whinney recommended stopping sirolimus or everolimus 2-4 weeks prior to major or abdominal surgery to allow clearance of this long half-life agent from the body. Replace the agent with an appropriate calcineurin inhibitor. "Again, if you are unfamiliar with these agents, use them in conjunction with a transplant specialist."

Dr. Whinney is a speaker and consultant for Sanofi Aventis.

MIAMI BEACH – Knowing if immunomodulators should be stopped in the perioperative period and when would be helpful for hospitalists, surgeons, other clinicians and, ultimately, for patients.

It is important to balance the concerns of patient optimization for surgery vs. the risk of triggering a recurrent inflammatory cascade or organ rejection during cessation, Dr. Christopher Whinney said at a meeting on perioperative medicine sponsored by the University of Miami.

Although there is a dearth of randomized controlled trials to address immunomodulator cessation around the time of surgery, Dr. Whinney reviewed what evidence is available (mostly observational and/or retrospective studies). He provided specific advice regarding tumor necrosis factor (TNF) alpha inhibitors, corticosteroids, calcineurin inhibitors, antiproliferative agents such as mycophenolate mofetil, and mammalian target of rapamycin inhibitors (mTOR).

There is some controversy regarding continuation of TNF-alpha inhibitors during the perioperative period, for example, said Dr. Whinney, chairman of the department of hospital medicine at the Cleveland Clinic. "Some studies suggest an increased risk for [surgical site] infection and others do not. The literature is heterogenous in this area."

Continuation of TNF-alpha agents in patients with rheumatoid arthritis, for example, was not associated with increased risk of surgical site infections in a retrospective study of 1,219 surgical procedures performed in 768 patients (J. Rheum. 2007;34:689-95). In contrast, other researchers conducted a systematic literature review and determined there is evidence of an increased risk of serious infection with TNF-alpha inhibitor use, in general, among patients with rheumatoid arthritis (JAMA 2006;295:2275-85).

"It’s a judgment call," Dr. Whinney said. "Although the weight of evidence suggests the safety of continuation ... my practice would be to withhold these 2 weeks preoperatively, of course in discussion with the rheumatologist or person prescribing these agents."

Corticosteroid supplementation in the perioperative setting is another question with no definitive answer in the literature. Whether or not to provide high "stress dose" steroids on the morning of surgery to minimize the potential for an adrenal crisis in patients with adrenal insufficiency is a question. The stress of surgery can activate the brain’s hypothalamic-pituitary-adrenal (HPA) axis and trigger a rare but serious adrenal crisis. The thinking is that high-dose steroids will suppress the HPA axis activation and prevent these rare crises.

"Current supplementation is probably excessive. We probably give way too [many] stress dose steroids ... and are probably treating ourselves more than we are treating our patients," Dr. Whinney said.

A Cochrane database review supports this position (Cochrane Database Syst. Rev. 2009;4:CD005367).Dr. Whinney said this review revealed that for patients on basal steroid doses, "it was not possible to refute or support perioperative steroid supplementation."

"For most patients who are on steroids for a reason other than existing HPA axis disease, for most surgeries, their daily steroid regimen is acceptable."

Other researchers recommended an amount of steroid supplementation to administer according to surgery type: superficial, minor, moderate, or major (Semin. Arthritis Rheum. 2007;36:278-86).

Aminosalicylates are another type of immunomodulator relevant in the perioperative period. These anti-inflammatory agents are taken by patients with ulcerative colitis or Crohn’s disease. There are little data on perioperative use of these agents, which include sulfasalazine or 5-aminosalicylate, Dr. Whinney said.

Some researchers suggest holding aminosalicylates on the day of surgery for patients with inflammatory bowel disease who are renally cleared, if they have a diminished glomerular filtration rate (for example, patients older than 65 years, those with ASA physical status score of 4 or 5, and/or patients with a revised cardiac risk index score greater than 2) (Mayo Clin. Proc. 2011;86:748-57). This protocol permits reinitiating aminosalicylates on postoperative day 3.

Patients also might present for surgery taking one of the potent calcineurin inhibitors such as cyclosporine or tacrolimus. Although there is no evidence of increased postoperative complications when these agents are continued perioperatively, continue to watch patients for infection and continue to monitor drug levels, Dr. Whinney said. He also recommended switching patients to an intravenous form if they are NPO (nothing by mouth) for an extended time or are placed on mechanical ventilation for more than 24 hours. It is important to consult a transplant surgeon regarding these agents.

Azathioprine and 6-mercaptopurine are antiproliferative agents often administered for their steroid sparing effects. There have been no consistent effects on surgical outcomes or mortality reported, Dr. Whinney said. However, it is probably reasonable to hold these agents on the day of surgery and resume on the third postoperative day, mostly to avoid any adverse effect on anesthesia. Have a conversation with the prescribing physician, he added, before you stop these agents perioperatively.

Mycophenolate mofetil is another antiproliferative agent. Hepatic and renal testing is appropriate if someone is already on these agents. Although there are little to no data to guide perioperative use, "it can be continued in the perioperative period in absence of infection or liver or renal disease," according to Dr. Whinney.

Sirolimus and everolimus are potent antiproliferative agents in the mTOR inhibitor class. An increased risk for wound complications or wound seromas is a relevant perioperative issue. Obesity and concomitant use of steroids add to this risk. A systematic wound care program can reduce the rate of wound healing complications back to baseline, Dr. Whinney said.

Dr. Whinney recommended stopping sirolimus or everolimus 2-4 weeks prior to major or abdominal surgery to allow clearance of this long half-life agent from the body. Replace the agent with an appropriate calcineurin inhibitor. "Again, if you are unfamiliar with these agents, use them in conjunction with a transplant specialist."

Dr. Whinney is a speaker and consultant for Sanofi Aventis.

MIAMI BEACH – Knowing if immunomodulators should be stopped in the perioperative period and when would be helpful for hospitalists, surgeons, other clinicians and, ultimately, for patients.

It is important to balance the concerns of patient optimization for surgery vs. the risk of triggering a recurrent inflammatory cascade or organ rejection during cessation, Dr. Christopher Whinney said at a meeting on perioperative medicine sponsored by the University of Miami.

Although there is a dearth of randomized controlled trials to address immunomodulator cessation around the time of surgery, Dr. Whinney reviewed what evidence is available (mostly observational and/or retrospective studies). He provided specific advice regarding tumor necrosis factor (TNF) alpha inhibitors, corticosteroids, calcineurin inhibitors, antiproliferative agents such as mycophenolate mofetil, and mammalian target of rapamycin inhibitors (mTOR).

There is some controversy regarding continuation of TNF-alpha inhibitors during the perioperative period, for example, said Dr. Whinney, chairman of the department of hospital medicine at the Cleveland Clinic. "Some studies suggest an increased risk for [surgical site] infection and others do not. The literature is heterogenous in this area."

Continuation of TNF-alpha agents in patients with rheumatoid arthritis, for example, was not associated with increased risk of surgical site infections in a retrospective study of 1,219 surgical procedures performed in 768 patients (J. Rheum. 2007;34:689-95). In contrast, other researchers conducted a systematic literature review and determined there is evidence of an increased risk of serious infection with TNF-alpha inhibitor use, in general, among patients with rheumatoid arthritis (JAMA 2006;295:2275-85).

"It’s a judgment call," Dr. Whinney said. "Although the weight of evidence suggests the safety of continuation ... my practice would be to withhold these 2 weeks preoperatively, of course in discussion with the rheumatologist or person prescribing these agents."

Corticosteroid supplementation in the perioperative setting is another question with no definitive answer in the literature. Whether or not to provide high "stress dose" steroids on the morning of surgery to minimize the potential for an adrenal crisis in patients with adrenal insufficiency is a question. The stress of surgery can activate the brain’s hypothalamic-pituitary-adrenal (HPA) axis and trigger a rare but serious adrenal crisis. The thinking is that high-dose steroids will suppress the HPA axis activation and prevent these rare crises.

"Current supplementation is probably excessive. We probably give way too [many] stress dose steroids ... and are probably treating ourselves more than we are treating our patients," Dr. Whinney said.

A Cochrane database review supports this position (Cochrane Database Syst. Rev. 2009;4:CD005367).Dr. Whinney said this review revealed that for patients on basal steroid doses, "it was not possible to refute or support perioperative steroid supplementation."

"For most patients who are on steroids for a reason other than existing HPA axis disease, for most surgeries, their daily steroid regimen is acceptable."

Other researchers recommended an amount of steroid supplementation to administer according to surgery type: superficial, minor, moderate, or major (Semin. Arthritis Rheum. 2007;36:278-86).

Aminosalicylates are another type of immunomodulator relevant in the perioperative period. These anti-inflammatory agents are taken by patients with ulcerative colitis or Crohn’s disease. There are little data on perioperative use of these agents, which include sulfasalazine or 5-aminosalicylate, Dr. Whinney said.

Some researchers suggest holding aminosalicylates on the day of surgery for patients with inflammatory bowel disease who are renally cleared, if they have a diminished glomerular filtration rate (for example, patients older than 65 years, those with ASA physical status score of 4 or 5, and/or patients with a revised cardiac risk index score greater than 2) (Mayo Clin. Proc. 2011;86:748-57). This protocol permits reinitiating aminosalicylates on postoperative day 3.

Patients also might present for surgery taking one of the potent calcineurin inhibitors such as cyclosporine or tacrolimus. Although there is no evidence of increased postoperative complications when these agents are continued perioperatively, continue to watch patients for infection and continue to monitor drug levels, Dr. Whinney said. He also recommended switching patients to an intravenous form if they are NPO (nothing by mouth) for an extended time or are placed on mechanical ventilation for more than 24 hours. It is important to consult a transplant surgeon regarding these agents.

Azathioprine and 6-mercaptopurine are antiproliferative agents often administered for their steroid sparing effects. There have been no consistent effects on surgical outcomes or mortality reported, Dr. Whinney said. However, it is probably reasonable to hold these agents on the day of surgery and resume on the third postoperative day, mostly to avoid any adverse effect on anesthesia. Have a conversation with the prescribing physician, he added, before you stop these agents perioperatively.

Mycophenolate mofetil is another antiproliferative agent. Hepatic and renal testing is appropriate if someone is already on these agents. Although there are little to no data to guide perioperative use, "it can be continued in the perioperative period in absence of infection or liver or renal disease," according to Dr. Whinney.

Sirolimus and everolimus are potent antiproliferative agents in the mTOR inhibitor class. An increased risk for wound complications or wound seromas is a relevant perioperative issue. Obesity and concomitant use of steroids add to this risk. A systematic wound care program can reduce the rate of wound healing complications back to baseline, Dr. Whinney said.

Dr. Whinney recommended stopping sirolimus or everolimus 2-4 weeks prior to major or abdominal surgery to allow clearance of this long half-life agent from the body. Replace the agent with an appropriate calcineurin inhibitor. "Again, if you are unfamiliar with these agents, use them in conjunction with a transplant specialist."

Dr. Whinney is a speaker and consultant for Sanofi Aventis.

Greater patient satisfaction with physicians was associated with increased hospitalization, higher health care expenditures, and a higher mortality risk within a few years, according to a survey of over 36,000 patients.

Some experts hold that "systematic routine measurement of patient satisfaction is a powerful quality-improvement tool for physicians and health plans," assuming that it correlates with more efficient use of the health care system, lower costs, and better results for patients. In contrast, "our data suggest that we do not fully understand what drives patient satisfaction ... or how [it] affect[s] health care use and outcomes," said Dr. Joshua J. Fenton and his associates in the department of family and community medicine and the Center for Healthcare Policy and Research, University of California–Davis.

"An overemphasis on patient satisfaction could have unintended adverse effects on health care utilization, expenditures, and outcomes," they noted. The study was published in Archives of Internal Medicine.

The researchers assessed the relationships among these factors and patient satisfaction in a prospective cohort study using data from the Medical Expenditure Panel Survey (MEPS). The MEPS is an annual, nationally representative sampling of adults who answer questionnaires pertaining to their access to, use of, and costs associated with health care.

For this study, 36,428 participants’ responses to questions about satisfaction with their physicians were assessed for the baseline year, then health care utilization and costs were assessed for the subsequent year, and mortality was assessed for up to 6 years (mean follow-up duration, 3.9 years).

The study subjects also responded to the Consumer Assessment of Health Plans Survey, which included queries about how often in the past year their physicians listened carefully, explained things in a way that was easy to understand, showed respect for what they had to say, and spent enough time with them.

The data were adjusted to account for potential confounders such as sociodemographic factors, health behaviors, access to health care, health status, insurance status, and comorbidities.

The odds that a study subject would have an inpatient admission were higher among the most satisfied patients, compared with the least satisfied (adjusted odds ratio, 1.12). And patients in the highest quartile of satisfaction showed a 9% higher total of health care expenditures and a 9% higher total of expenditures on prescription drugs, compared with those in the lowest quartile, Dr. Fenton and his colleagues said (Arch. Intern. Med. 2012;172:405-11).

In an analysis that excluded data on patients who rated their overall health as "poor" and those who had three or more chronic diseases, these associations between patient satisfaction on the one hand and health care utilization and costs on the other did not change appreciably.

During follow-up, 1,396 of the study subjects (3.8%) died. Compared with the least satisfied patients, "the most satisfied patients had a 26% greater mortality risk." This association between patient satisfaction and mortality risk remained significant in a further analysis that excluded patients who rated themselves as having "poor" health and those who had three or more chronic diseases.

Compared with the least satisfied patients, those who were most satisfied were less likely to present to the emergency department. Taken together with the other results, this finding "raises the question of whether more-satisfied patients may be differentially hospitalized for elective or less urgent indications, because nonelective urgent hospitalizations often begin with ED visits," the researchers said.

However, an alternative explanation is that people who are the least satisfied with their physicians may be more likely to seek health care at an ED rather than at their doctor’s office, they added.

This study was not designed to elucidate the reasons underlying these associations, but one possible explanation might be that patient satisfaction is a marker for illness, "identifying patients who rely more on support from their physicians and thus report higher satisfaction," Dr. Fenton and his associates said.

Overall, the study results "suggest that we may not fully understand the factors associated with patient satisfaction," they said.

"Patients typically bring expectations to medical encounters, often making specific requests of physicians, and satisfaction correlates with the extent to which physicians fulfill patient expectations." However, physicians are often required to challenge or disturb patients’ beliefs and expectations, such as when they explain the risks of requested tests or treatments and when they address lifestyle issues such as substance abuse, poor diet, or smoking.

"Relaxing patient satisfaction incentives may encourage physicians to prioritize the benefits of truthful therapeutic discourse, despite the risks of dissatisfying some patients," the investigators said.

Among the study’s limitations is that the patient satisfaction measure involved the physician and not other domains of health care, although satisfaction with one’s physician correlates with other dimensions, such as global satisfaction, the authors wrote. They also noted the possibility that patient satisfaction could differ with longer-term use and expenditure.

Greater patient satisfaction with physicians was associated with increased hospitalization, higher health care expenditures, and a higher mortality risk within a few years, according to a survey of over 36,000 patients.

Some experts hold that "systematic routine measurement of patient satisfaction is a powerful quality-improvement tool for physicians and health plans," assuming that it correlates with more efficient use of the health care system, lower costs, and better results for patients. In contrast, "our data suggest that we do not fully understand what drives patient satisfaction ... or how [it] affect[s] health care use and outcomes," said Dr. Joshua J. Fenton and his associates in the department of family and community medicine and the Center for Healthcare Policy and Research, University of California–Davis.

"An overemphasis on patient satisfaction could have unintended adverse effects on health care utilization, expenditures, and outcomes," they noted. The study was published in Archives of Internal Medicine.

The researchers assessed the relationships among these factors and patient satisfaction in a prospective cohort study using data from the Medical Expenditure Panel Survey (MEPS). The MEPS is an annual, nationally representative sampling of adults who answer questionnaires pertaining to their access to, use of, and costs associated with health care.

For this study, 36,428 participants’ responses to questions about satisfaction with their physicians were assessed for the baseline year, then health care utilization and costs were assessed for the subsequent year, and mortality was assessed for up to 6 years (mean follow-up duration, 3.9 years).

The study subjects also responded to the Consumer Assessment of Health Plans Survey, which included queries about how often in the past year their physicians listened carefully, explained things in a way that was easy to understand, showed respect for what they had to say, and spent enough time with them.

The data were adjusted to account for potential confounders such as sociodemographic factors, health behaviors, access to health care, health status, insurance status, and comorbidities.

The odds that a study subject would have an inpatient admission were higher among the most satisfied patients, compared with the least satisfied (adjusted odds ratio, 1.12). And patients in the highest quartile of satisfaction showed a 9% higher total of health care expenditures and a 9% higher total of expenditures on prescription drugs, compared with those in the lowest quartile, Dr. Fenton and his colleagues said (Arch. Intern. Med. 2012;172:405-11).

In an analysis that excluded data on patients who rated their overall health as "poor" and those who had three or more chronic diseases, these associations between patient satisfaction on the one hand and health care utilization and costs on the other did not change appreciably.

During follow-up, 1,396 of the study subjects (3.8%) died. Compared with the least satisfied patients, "the most satisfied patients had a 26% greater mortality risk." This association between patient satisfaction and mortality risk remained significant in a further analysis that excluded patients who rated themselves as having "poor" health and those who had three or more chronic diseases.

Compared with the least satisfied patients, those who were most satisfied were less likely to present to the emergency department. Taken together with the other results, this finding "raises the question of whether more-satisfied patients may be differentially hospitalized for elective or less urgent indications, because nonelective urgent hospitalizations often begin with ED visits," the researchers said.

However, an alternative explanation is that people who are the least satisfied with their physicians may be more likely to seek health care at an ED rather than at their doctor’s office, they added.

This study was not designed to elucidate the reasons underlying these associations, but one possible explanation might be that patient satisfaction is a marker for illness, "identifying patients who rely more on support from their physicians and thus report higher satisfaction," Dr. Fenton and his associates said.

Overall, the study results "suggest that we may not fully understand the factors associated with patient satisfaction," they said.

"Patients typically bring expectations to medical encounters, often making specific requests of physicians, and satisfaction correlates with the extent to which physicians fulfill patient expectations." However, physicians are often required to challenge or disturb patients’ beliefs and expectations, such as when they explain the risks of requested tests or treatments and when they address lifestyle issues such as substance abuse, poor diet, or smoking.

"Relaxing patient satisfaction incentives may encourage physicians to prioritize the benefits of truthful therapeutic discourse, despite the risks of dissatisfying some patients," the investigators said.

Among the study’s limitations is that the patient satisfaction measure involved the physician and not other domains of health care, although satisfaction with one’s physician correlates with other dimensions, such as global satisfaction, the authors wrote. They also noted the possibility that patient satisfaction could differ with longer-term use and expenditure.

Greater patient satisfaction with physicians was associated with increased hospitalization, higher health care expenditures, and a higher mortality risk within a few years, according to a survey of over 36,000 patients.

Some experts hold that "systematic routine measurement of patient satisfaction is a powerful quality-improvement tool for physicians and health plans," assuming that it correlates with more efficient use of the health care system, lower costs, and better results for patients. In contrast, "our data suggest that we do not fully understand what drives patient satisfaction ... or how [it] affect[s] health care use and outcomes," said Dr. Joshua J. Fenton and his associates in the department of family and community medicine and the Center for Healthcare Policy and Research, University of California–Davis.

"An overemphasis on patient satisfaction could have unintended adverse effects on health care utilization, expenditures, and outcomes," they noted. The study was published in Archives of Internal Medicine.

The researchers assessed the relationships among these factors and patient satisfaction in a prospective cohort study using data from the Medical Expenditure Panel Survey (MEPS). The MEPS is an annual, nationally representative sampling of adults who answer questionnaires pertaining to their access to, use of, and costs associated with health care.

For this study, 36,428 participants’ responses to questions about satisfaction with their physicians were assessed for the baseline year, then health care utilization and costs were assessed for the subsequent year, and mortality was assessed for up to 6 years (mean follow-up duration, 3.9 years).

The study subjects also responded to the Consumer Assessment of Health Plans Survey, which included queries about how often in the past year their physicians listened carefully, explained things in a way that was easy to understand, showed respect for what they had to say, and spent enough time with them.

The data were adjusted to account for potential confounders such as sociodemographic factors, health behaviors, access to health care, health status, insurance status, and comorbidities.

The odds that a study subject would have an inpatient admission were higher among the most satisfied patients, compared with the least satisfied (adjusted odds ratio, 1.12). And patients in the highest quartile of satisfaction showed a 9% higher total of health care expenditures and a 9% higher total of expenditures on prescription drugs, compared with those in the lowest quartile, Dr. Fenton and his colleagues said (Arch. Intern. Med. 2012;172:405-11).

In an analysis that excluded data on patients who rated their overall health as "poor" and those who had three or more chronic diseases, these associations between patient satisfaction on the one hand and health care utilization and costs on the other did not change appreciably.

During follow-up, 1,396 of the study subjects (3.8%) died. Compared with the least satisfied patients, "the most satisfied patients had a 26% greater mortality risk." This association between patient satisfaction and mortality risk remained significant in a further analysis that excluded patients who rated themselves as having "poor" health and those who had three or more chronic diseases.

Compared with the least satisfied patients, those who were most satisfied were less likely to present to the emergency department. Taken together with the other results, this finding "raises the question of whether more-satisfied patients may be differentially hospitalized for elective or less urgent indications, because nonelective urgent hospitalizations often begin with ED visits," the researchers said.

However, an alternative explanation is that people who are the least satisfied with their physicians may be more likely to seek health care at an ED rather than at their doctor’s office, they added.

This study was not designed to elucidate the reasons underlying these associations, but one possible explanation might be that patient satisfaction is a marker for illness, "identifying patients who rely more on support from their physicians and thus report higher satisfaction," Dr. Fenton and his associates said.

Overall, the study results "suggest that we may not fully understand the factors associated with patient satisfaction," they said.

"Patients typically bring expectations to medical encounters, often making specific requests of physicians, and satisfaction correlates with the extent to which physicians fulfill patient expectations." However, physicians are often required to challenge or disturb patients’ beliefs and expectations, such as when they explain the risks of requested tests or treatments and when they address lifestyle issues such as substance abuse, poor diet, or smoking.

"Relaxing patient satisfaction incentives may encourage physicians to prioritize the benefits of truthful therapeutic discourse, despite the risks of dissatisfying some patients," the investigators said.

Among the study’s limitations is that the patient satisfaction measure involved the physician and not other domains of health care, although satisfaction with one’s physician correlates with other dimensions, such as global satisfaction, the authors wrote. They also noted the possibility that patient satisfaction could differ with longer-term use and expenditure.

CHICAGO – A reduced-dose regimen of tissue plasminogen activator and parenteral anticoagulant safely led to improved outcomes in hemodynamically stable patients with a pulmonary embolism in a pilot study with a total of 121 patients treated at one U.S. center.

None of the 61 patients treated with the regimen, which halved the standard dosage of tissue plasminogen activator (TPA) and cut the dosage of enoxaparin or heparin by about 20%-30%, had an intracranial hemorrhage or a major bleeding event, compared with a historic 2%-6% incidence of intracranial hemorrhage and a 6%-20% incidence of major bleeds in hemodynamically unstable pulmonary embolism patients who receive the standard, full dose of both the thrombolytic and anticoagulant, Dr. Mohsen Sharifi said at the meeting.

Mitchel L. Zoler/IMNG Medical Media

While he acknowledged that the results need confirmation in a larger study, "in our experience treating deep vein thrombosis [with a similarly low dosage of TPA], we are comfortable that this amount of TPA can be given safely," said Dr. Sharifi, an interventional cardiologist who practices in Mesa, Ariz.

The findings also showed that applying this reduced-dose intervention to hemodynamically stable patients with a pulmonary embolism (PE), who are typically not treated, substantially improved their long-term prognosis by reducing their development of pulmonary hypertension. After an average of 28 months follow-up, 9 of the 58 patients (16%) followed long term and treated with the reduced-dose regimen had pulmonary hypertension, defined as a pulmonary artery systolic pressure greater than 40 mm Hg, compared with pulmonary hypertension in 32 of the 56 control patients (57%) managed by standard treatment with anticoagulation only.

Current guidelines from the American Heart Association call for fibrinolytic treatment only in patients with a massive, acute PE, or in patients with a submassive PE who are hemodynamically unstable or have other clinical evidence of an adverse prognosis (Circulation 2011;123:1788-830). According to Dr. Sharifi, about 5% of all PE patients fall into this category. He estimated that broadening thrombolytic treatment to hemodynamically stable patients who met his study’s inclusion criteria could broaden TPA treatment to an additional 70% of PE patients currently seen in emergency departments.

"I think that, based on the results of this pilot study, you won’t get broad acceptance of treating hemodynamically stable PE patients with thrombolysis," commented Dr. Michael Crawford, chief of general cardiology at the University of California, San Francisco. Two larger studies nearing completion are both examining the efficacy and safety of thrombolysis in patients with submassive PE.

Dr. Sharifi said that despite the small study size, he and his associates were convinced enough by their findings to use the reduced TPA dosage tested in this study on a routine basis when they see patients who meet their enrollment criteria.

The MOPETT (Moderate Pulmonary Embolism Treated with Thrombolysis) study enrolled patients with a PE affecting at least two lobar segments, pulmonary artery systolic pressure greater than 40 mm Hg; right ventricular hypokinesia and enlargement; and at least two symptoms, which could include chest pain, tachypnea greater than 22 respirations/min, tachycardia with a resting heart rate of more than 90 beats/min, dyspnea, cough, oxygen desaturation, and jugular venous pressure more than 12 mm H₂O. The average age of the patients was about 59 years, and slightly more than half were women. Their average pulmonary artery systolic pressure at entry was about 50 mm Hg.

Dr. Sharifi and his associates randomized half the patients to receive conventional treatment with anticoagulant only, either enoxaparin or heparin plus warfarin. The other patients received thrombolytic treatment with an infusion of TPA at half the standard dosage, starting in patients who weighed at least 50 kg with a loading dose of 10 mg delivered in 1 minute, and followed by a 40-mg total additional dose administered over 2 hours. Patients who weighed less received the same 10-mg initial dose, but their total dose including the subsequent 2-hour infusion was limited to 0.5 mg/kg. The patients treated with TPA also received concomitant anticoagulation, with either enoxaparin given at 1 mg/kg but not to exceed 80 mg as an initial dose, or heparin at an initial dose of 70 U/kg but capped at 6,000 U, followed by heparin maintenance at 10 U/kg per hour during the TPA infusion (but not exceeding 1,000 U/hour), and then rising to 18 U/kg per hour starting 1 hour after TPA treatment stopped. About 80% of all patients in the study received enoxaparin, and about 20% received heparin.

At 48 hours after starting treatment, average pulmonary artery systolic pressure dropped by 16 mm Hg in the TPA group and by 5 mm Hg in the control patients. By the end of the average 28-month follow-up, average pulmonary artery systolic pressure was 28 mm Hg in the TPA patients and 43 mm Hg in the controls. Dr. Sharifi attributed the efficacy of reduced-dose TPA to the "exquisite sensitivity" of blood clots lodged in a patient’s lungs to the drug, a consequence of all the infused TPA passing through the lung’s arterial circulation.

In addition to showing a statistically significant benefit from TPA for the study’s primary end point, the average duration of hospitalization in the TPA recipients was 2.2 days, compared with an average of 4.9 days in the control patients, a statistically significant difference. And at the end of the average 28 months of follow-up, three patients in the control arm had a recurrent PE and another three had died, significantly more than the no recurrent PEs and one death in the TPA arm.

Dr. Sharifi and Dr. Crawford said that they had no relevant disclosures.

CHICAGO – A reduced-dose regimen of tissue plasminogen activator and parenteral anticoagulant safely led to improved outcomes in hemodynamically stable patients with a pulmonary embolism in a pilot study with a total of 121 patients treated at one U.S. center.

None of the 61 patients treated with the regimen, which halved the standard dosage of tissue plasminogen activator (TPA) and cut the dosage of enoxaparin or heparin by about 20%-30%, had an intracranial hemorrhage or a major bleeding event, compared with a historic 2%-6% incidence of intracranial hemorrhage and a 6%-20% incidence of major bleeds in hemodynamically unstable pulmonary embolism patients who receive the standard, full dose of both the thrombolytic and anticoagulant, Dr. Mohsen Sharifi said at the meeting.

Mitchel L. Zoler/IMNG Medical Media

While he acknowledged that the results need confirmation in a larger study, "in our experience treating deep vein thrombosis [with a similarly low dosage of TPA], we are comfortable that this amount of TPA can be given safely," said Dr. Sharifi, an interventional cardiologist who practices in Mesa, Ariz.

The findings also showed that applying this reduced-dose intervention to hemodynamically stable patients with a pulmonary embolism (PE), who are typically not treated, substantially improved their long-term prognosis by reducing their development of pulmonary hypertension. After an average of 28 months follow-up, 9 of the 58 patients (16%) followed long term and treated with the reduced-dose regimen had pulmonary hypertension, defined as a pulmonary artery systolic pressure greater than 40 mm Hg, compared with pulmonary hypertension in 32 of the 56 control patients (57%) managed by standard treatment with anticoagulation only.

Current guidelines from the American Heart Association call for fibrinolytic treatment only in patients with a massive, acute PE, or in patients with a submassive PE who are hemodynamically unstable or have other clinical evidence of an adverse prognosis (Circulation 2011;123:1788-830). According to Dr. Sharifi, about 5% of all PE patients fall into this category. He estimated that broadening thrombolytic treatment to hemodynamically stable patients who met his study’s inclusion criteria could broaden TPA treatment to an additional 70% of PE patients currently seen in emergency departments.

"I think that, based on the results of this pilot study, you won’t get broad acceptance of treating hemodynamically stable PE patients with thrombolysis," commented Dr. Michael Crawford, chief of general cardiology at the University of California, San Francisco. Two larger studies nearing completion are both examining the efficacy and safety of thrombolysis in patients with submassive PE.

Dr. Sharifi said that despite the small study size, he and his associates were convinced enough by their findings to use the reduced TPA dosage tested in this study on a routine basis when they see patients who meet their enrollment criteria.

The MOPETT (Moderate Pulmonary Embolism Treated with Thrombolysis) study enrolled patients with a PE affecting at least two lobar segments, pulmonary artery systolic pressure greater than 40 mm Hg; right ventricular hypokinesia and enlargement; and at least two symptoms, which could include chest pain, tachypnea greater than 22 respirations/min, tachycardia with a resting heart rate of more than 90 beats/min, dyspnea, cough, oxygen desaturation, and jugular venous pressure more than 12 mm H₂O. The average age of the patients was about 59 years, and slightly more than half were women. Their average pulmonary artery systolic pressure at entry was about 50 mm Hg.

Dr. Sharifi and his associates randomized half the patients to receive conventional treatment with anticoagulant only, either enoxaparin or heparin plus warfarin. The other patients received thrombolytic treatment with an infusion of TPA at half the standard dosage, starting in patients who weighed at least 50 kg with a loading dose of 10 mg delivered in 1 minute, and followed by a 40-mg total additional dose administered over 2 hours. Patients who weighed less received the same 10-mg initial dose, but their total dose including the subsequent 2-hour infusion was limited to 0.5 mg/kg. The patients treated with TPA also received concomitant anticoagulation, with either enoxaparin given at 1 mg/kg but not to exceed 80 mg as an initial dose, or heparin at an initial dose of 70 U/kg but capped at 6,000 U, followed by heparin maintenance at 10 U/kg per hour during the TPA infusion (but not exceeding 1,000 U/hour), and then rising to 18 U/kg per hour starting 1 hour after TPA treatment stopped. About 80% of all patients in the study received enoxaparin, and about 20% received heparin.

At 48 hours after starting treatment, average pulmonary artery systolic pressure dropped by 16 mm Hg in the TPA group and by 5 mm Hg in the control patients. By the end of the average 28-month follow-up, average pulmonary artery systolic pressure was 28 mm Hg in the TPA patients and 43 mm Hg in the controls. Dr. Sharifi attributed the efficacy of reduced-dose TPA to the "exquisite sensitivity" of blood clots lodged in a patient’s lungs to the drug, a consequence of all the infused TPA passing through the lung’s arterial circulation.

In addition to showing a statistically significant benefit from TPA for the study’s primary end point, the average duration of hospitalization in the TPA recipients was 2.2 days, compared with an average of 4.9 days in the control patients, a statistically significant difference. And at the end of the average 28 months of follow-up, three patients in the control arm had a recurrent PE and another three had died, significantly more than the no recurrent PEs and one death in the TPA arm.

Dr. Sharifi and Dr. Crawford said that they had no relevant disclosures.

CHICAGO – A reduced-dose regimen of tissue plasminogen activator and parenteral anticoagulant safely led to improved outcomes in hemodynamically stable patients with a pulmonary embolism in a pilot study with a total of 121 patients treated at one U.S. center.

None of the 61 patients treated with the regimen, which halved the standard dosage of tissue plasminogen activator (TPA) and cut the dosage of enoxaparin or heparin by about 20%-30%, had an intracranial hemorrhage or a major bleeding event, compared with a historic 2%-6% incidence of intracranial hemorrhage and a 6%-20% incidence of major bleeds in hemodynamically unstable pulmonary embolism patients who receive the standard, full dose of both the thrombolytic and anticoagulant, Dr. Mohsen Sharifi said at the meeting.

Mitchel L. Zoler/IMNG Medical Media

While he acknowledged that the results need confirmation in a larger study, "in our experience treating deep vein thrombosis [with a similarly low dosage of TPA], we are comfortable that this amount of TPA can be given safely," said Dr. Sharifi, an interventional cardiologist who practices in Mesa, Ariz.

The findings also showed that applying this reduced-dose intervention to hemodynamically stable patients with a pulmonary embolism (PE), who are typically not treated, substantially improved their long-term prognosis by reducing their development of pulmonary hypertension. After an average of 28 months follow-up, 9 of the 58 patients (16%) followed long term and treated with the reduced-dose regimen had pulmonary hypertension, defined as a pulmonary artery systolic pressure greater than 40 mm Hg, compared with pulmonary hypertension in 32 of the 56 control patients (57%) managed by standard treatment with anticoagulation only.

Current guidelines from the American Heart Association call for fibrinolytic treatment only in patients with a massive, acute PE, or in patients with a submassive PE who are hemodynamically unstable or have other clinical evidence of an adverse prognosis (Circulation 2011;123:1788-830). According to Dr. Sharifi, about 5% of all PE patients fall into this category. He estimated that broadening thrombolytic treatment to hemodynamically stable patients who met his study’s inclusion criteria could broaden TPA treatment to an additional 70% of PE patients currently seen in emergency departments.

"I think that, based on the results of this pilot study, you won’t get broad acceptance of treating hemodynamically stable PE patients with thrombolysis," commented Dr. Michael Crawford, chief of general cardiology at the University of California, San Francisco. Two larger studies nearing completion are both examining the efficacy and safety of thrombolysis in patients with submassive PE.

Dr. Sharifi said that despite the small study size, he and his associates were convinced enough by their findings to use the reduced TPA dosage tested in this study on a routine basis when they see patients who meet their enrollment criteria.

The MOPETT (Moderate Pulmonary Embolism Treated with Thrombolysis) study enrolled patients with a PE affecting at least two lobar segments, pulmonary artery systolic pressure greater than 40 mm Hg; right ventricular hypokinesia and enlargement; and at least two symptoms, which could include chest pain, tachypnea greater than 22 respirations/min, tachycardia with a resting heart rate of more than 90 beats/min, dyspnea, cough, oxygen desaturation, and jugular venous pressure more than 12 mm H₂O. The average age of the patients was about 59 years, and slightly more than half were women. Their average pulmonary artery systolic pressure at entry was about 50 mm Hg.

Dr. Sharifi and his associates randomized half the patients to receive conventional treatment with anticoagulant only, either enoxaparin or heparin plus warfarin. The other patients received thrombolytic treatment with an infusion of TPA at half the standard dosage, starting in patients who weighed at least 50 kg with a loading dose of 10 mg delivered in 1 minute, and followed by a 40-mg total additional dose administered over 2 hours. Patients who weighed less received the same 10-mg initial dose, but their total dose including the subsequent 2-hour infusion was limited to 0.5 mg/kg. The patients treated with TPA also received concomitant anticoagulation, with either enoxaparin given at 1 mg/kg but not to exceed 80 mg as an initial dose, or heparin at an initial dose of 70 U/kg but capped at 6,000 U, followed by heparin maintenance at 10 U/kg per hour during the TPA infusion (but not exceeding 1,000 U/hour), and then rising to 18 U/kg per hour starting 1 hour after TPA treatment stopped. About 80% of all patients in the study received enoxaparin, and about 20% received heparin.

At 48 hours after starting treatment, average pulmonary artery systolic pressure dropped by 16 mm Hg in the TPA group and by 5 mm Hg in the control patients. By the end of the average 28-month follow-up, average pulmonary artery systolic pressure was 28 mm Hg in the TPA patients and 43 mm Hg in the controls. Dr. Sharifi attributed the efficacy of reduced-dose TPA to the "exquisite sensitivity" of blood clots lodged in a patient’s lungs to the drug, a consequence of all the infused TPA passing through the lung’s arterial circulation.

In addition to showing a statistically significant benefit from TPA for the study’s primary end point, the average duration of hospitalization in the TPA recipients was 2.2 days, compared with an average of 4.9 days in the control patients, a statistically significant difference. And at the end of the average 28 months of follow-up, three patients in the control arm had a recurrent PE and another three had died, significantly more than the no recurrent PEs and one death in the TPA arm.

Dr. Sharifi and Dr. Crawford said that they had no relevant disclosures.

With the advantage of around-the-clock hospitalist services, one community hospital has been able to offer catheter-directed thrombolytic therapy – a procedure typically available only at tertiary-care hospitals.

Dr. Brian A. Carpenter, medical director of the adult hospitalist service at Shady Grove Adventist Hospital in Rockville, Md., said that at least 12 patients with massive or submassive pulmonary embolisms have undergone catheter-directed thrombolysis at the hospital. Many others have undergone the procedure for deep vein thrombosis in a lower extremity with vascular extension into the larger vessels of the pelvis.

Before the service was introduced, patients with massive or submassive pulmonary embolism were sent to a tertiary-care hospital if they were stable enough for transfer. Otherwise, they were monitored in the ICU, managed medically with systemic anticoagulation, and transferred later if they still needed further treatment.

Systemic anticoagulation is the mainstay of treatment for pulmonary embolism, but the American Heart Association and the American College of Chest Physicians recommend a more aggressive approach for massive and submassive PE. Up to 60% of patients with massive PE die, data suggest, with two-thirds of the deaths occurring in the first hour after the embolus forms. Within 30 days after submassive PE, 15%-20% of patients die secondary to pulmonary hypertension and subsequent cor pulmonale, according to a data presented at the annual meeting of the Southern Association for Vascular Surgery.

The catheter-directed thrombolytic therapy at Shady Grove Adventist largely owes its success to a vascular surgeon who took the lead in establishing protocols and training support staff, with hospitalists as a key part of the team.

The vascular surgeon, Dr. Jeffrey Y. Wang, reported on the outcomes of the first 12 patients, in whom the procedures were all technically successful. One patient developed hemodynamically significant bradycardia, but all patients were off supplemental oxygen within 24 hours of the procedure. There were no bleeding complications.

One patient died 14 hours after the procedure, most likely because of a paradoxical embolus to the intestine. The 11 surviving patients were discharged to home within 48 hours of the intervention, according to Dr. Wang of Horizon Vascular Specialists. The group contracts to provide vascular surgical care at Shady Grove Adventist and two other hospitals in Maryland.

Catheter-directed thrombolytic therapy can shorten stays in the ICU and the hospital, reduce or eliminate the need for home oxygen therapy, and help restore right heart function in patients with massive or submassive pulmonary embolism, Dr. Wang said. Patients with massive or submassive PE are offered catheter-directed thrombolytic therapy if they are hemodynamically unstable; if they have right heart dysfunction, elevated troponin, or pulmonary artery pressures greater than 70 mmHg; or if they are not weaning off intubation for oxygen within 5 days, Dr. Wang said. He excludes patients who are actively bleeding or who are not able to tolerate any systemic anticoagulation.

Recent surgery was not a disqualifying factor in his case series. "Typically, those patients were orthopedic in nature, with a hip or knee replacement," Dr. Wang said. The patient would develop a big pulmonary embolus, and the orthopedist would give a green light for aggressive treatment.

But most of the patients who have received catheter-directed thrombolytic procedures presented to the emergency department with lower extremity swelling, and were found on sonography to have a thrombus extending into the large pelvic vessels. Dr. Carpenter’s service admits approximately 90% of adult inpatients, so the hospitalists usually are the ones to determine which patients should be considered for the interventional approach and which ones get medical therapy.

Dr. Wang emphasized that the protocols are as important as technical expertise in catheter-directed thrombolysis. Protocols are in place for the ED, the ICU, and the hospitalist team for the early detection of DVT and pulmonary emboli, notification of the appropriate staff, and posttreatment care of patients. Dr. Wang also took the lead on the anticoagulation aspect of computerized physician order entry.

"In our institution, we use the same protocols for call-in and transport to the cath lab as for ST-elevation myocardial infarction, which allows us to get the patient up and into the fluoroscopy suite within 30 minutes," Dr. Wang said. The fluoroscopy suite must be available on an emergency basis.

"It’s amazing to see such a dramatic improvement in patient symptoms almost immediately post procedure," said Dr. Carpenter.

Patients who undergo catheter-directed thrombolysis require close postoperative monitoring, said Dr. Carpenter, who is with Inpatient Specialists, a group that contracts with hospitals to provide hospitalist services. The main risks are bleeding, low blood pressure, or respiratory distress. "The bleeding might not necessarily be obvious," as the antithrombotic agent is given locally and bleeding can be local as well.

Community hospitals that offer catheter-directed thrombolysis need sufficient commitment from vascular surgeons and robust postprocedure support, Dr. Carpenter said. The vascular surgery group should be able to offer the procedure to all patients who need it.

Around-the-clock hospitalist availability is a good idea, especially if the surgeon is not on the in-house staff. "Don’t do [this procedure] if the hospitalist is providing triage services at night," he advised.

With 23 full-time positions (translating into 40 full-time or part-time physicians), the adult hospitalist service at Shady Grove Adventist, a 339-bed hospital, typically provides 10 hospitalists during weekdays (including one medical-psychiatric physician) and 8 on weekend days.

Besides the adult hospitalist group, the hospital has a pediatric hospitalist service, 24-hour in-house ICU hospitalist coverage, and a surgical hospitalist group. "Not many hospitals have surgical hospitalists," Dr. Carpenter noted. Laborists also are available 24 hours a day for in-house ob.gyn. consultations.

Dr. Carpenter, who has been a hospitalist since 2006, said that this "is how hospital-based medicine is progressing. "Shady Grove has been an early adopter" of expanded hospitalist services.

Dr. Carpenter and Dr. Wang reported having no financial disclosures.

With the advantage of around-the-clock hospitalist services, one community hospital has been able to offer catheter-directed thrombolytic therapy – a procedure typically available only at tertiary-care hospitals.

Dr. Brian A. Carpenter, medical director of the adult hospitalist service at Shady Grove Adventist Hospital in Rockville, Md., said that at least 12 patients with massive or submassive pulmonary embolisms have undergone catheter-directed thrombolysis at the hospital. Many others have undergone the procedure for deep vein thrombosis in a lower extremity with vascular extension into the larger vessels of the pelvis.

Before the service was introduced, patients with massive or submassive pulmonary embolism were sent to a tertiary-care hospital if they were stable enough for transfer. Otherwise, they were monitored in the ICU, managed medically with systemic anticoagulation, and transferred later if they still needed further treatment.

Systemic anticoagulation is the mainstay of treatment for pulmonary embolism, but the American Heart Association and the American College of Chest Physicians recommend a more aggressive approach for massive and submassive PE. Up to 60% of patients with massive PE die, data suggest, with two-thirds of the deaths occurring in the first hour after the embolus forms. Within 30 days after submassive PE, 15%-20% of patients die secondary to pulmonary hypertension and subsequent cor pulmonale, according to a data presented at the annual meeting of the Southern Association for Vascular Surgery.

The catheter-directed thrombolytic therapy at Shady Grove Adventist largely owes its success to a vascular surgeon who took the lead in establishing protocols and training support staff, with hospitalists as a key part of the team.

The vascular surgeon, Dr. Jeffrey Y. Wang, reported on the outcomes of the first 12 patients, in whom the procedures were all technically successful. One patient developed hemodynamically significant bradycardia, but all patients were off supplemental oxygen within 24 hours of the procedure. There were no bleeding complications.

One patient died 14 hours after the procedure, most likely because of a paradoxical embolus to the intestine. The 11 surviving patients were discharged to home within 48 hours of the intervention, according to Dr. Wang of Horizon Vascular Specialists. The group contracts to provide vascular surgical care at Shady Grove Adventist and two other hospitals in Maryland.

Catheter-directed thrombolytic therapy can shorten stays in the ICU and the hospital, reduce or eliminate the need for home oxygen therapy, and help restore right heart function in patients with massive or submassive pulmonary embolism, Dr. Wang said. Patients with massive or submassive PE are offered catheter-directed thrombolytic therapy if they are hemodynamically unstable; if they have right heart dysfunction, elevated troponin, or pulmonary artery pressures greater than 70 mmHg; or if they are not weaning off intubation for oxygen within 5 days, Dr. Wang said. He excludes patients who are actively bleeding or who are not able to tolerate any systemic anticoagulation.

Recent surgery was not a disqualifying factor in his case series. "Typically, those patients were orthopedic in nature, with a hip or knee replacement," Dr. Wang said. The patient would develop a big pulmonary embolus, and the orthopedist would give a green light for aggressive treatment.

But most of the patients who have received catheter-directed thrombolytic procedures presented to the emergency department with lower extremity swelling, and were found on sonography to have a thrombus extending into the large pelvic vessels. Dr. Carpenter’s service admits approximately 90% of adult inpatients, so the hospitalists usually are the ones to determine which patients should be considered for the interventional approach and which ones get medical therapy.

Dr. Wang emphasized that the protocols are as important as technical expertise in catheter-directed thrombolysis. Protocols are in place for the ED, the ICU, and the hospitalist team for the early detection of DVT and pulmonary emboli, notification of the appropriate staff, and posttreatment care of patients. Dr. Wang also took the lead on the anticoagulation aspect of computerized physician order entry.

"In our institution, we use the same protocols for call-in and transport to the cath lab as for ST-elevation myocardial infarction, which allows us to get the patient up and into the fluoroscopy suite within 30 minutes," Dr. Wang said. The fluoroscopy suite must be available on an emergency basis.

"It’s amazing to see such a dramatic improvement in patient symptoms almost immediately post procedure," said Dr. Carpenter.

Patients who undergo catheter-directed thrombolysis require close postoperative monitoring, said Dr. Carpenter, who is with Inpatient Specialists, a group that contracts with hospitals to provide hospitalist services. The main risks are bleeding, low blood pressure, or respiratory distress. "The bleeding might not necessarily be obvious," as the antithrombotic agent is given locally and bleeding can be local as well.

Community hospitals that offer catheter-directed thrombolysis need sufficient commitment from vascular surgeons and robust postprocedure support, Dr. Carpenter said. The vascular surgery group should be able to offer the procedure to all patients who need it.

Around-the-clock hospitalist availability is a good idea, especially if the surgeon is not on the in-house staff. "Don’t do [this procedure] if the hospitalist is providing triage services at night," he advised.

With 23 full-time positions (translating into 40 full-time or part-time physicians), the adult hospitalist service at Shady Grove Adventist, a 339-bed hospital, typically provides 10 hospitalists during weekdays (including one medical-psychiatric physician) and 8 on weekend days.

Besides the adult hospitalist group, the hospital has a pediatric hospitalist service, 24-hour in-house ICU hospitalist coverage, and a surgical hospitalist group. "Not many hospitals have surgical hospitalists," Dr. Carpenter noted. Laborists also are available 24 hours a day for in-house ob.gyn. consultations.

Dr. Carpenter, who has been a hospitalist since 2006, said that this "is how hospital-based medicine is progressing. "Shady Grove has been an early adopter" of expanded hospitalist services.

Dr. Carpenter and Dr. Wang reported having no financial disclosures.

With the advantage of around-the-clock hospitalist services, one community hospital has been able to offer catheter-directed thrombolytic therapy – a procedure typically available only at tertiary-care hospitals.

Dr. Brian A. Carpenter, medical director of the adult hospitalist service at Shady Grove Adventist Hospital in Rockville, Md., said that at least 12 patients with massive or submassive pulmonary embolisms have undergone catheter-directed thrombolysis at the hospital. Many others have undergone the procedure for deep vein thrombosis in a lower extremity with vascular extension into the larger vessels of the pelvis.

Before the service was introduced, patients with massive or submassive pulmonary embolism were sent to a tertiary-care hospital if they were stable enough for transfer. Otherwise, they were monitored in the ICU, managed medically with systemic anticoagulation, and transferred later if they still needed further treatment.

Systemic anticoagulation is the mainstay of treatment for pulmonary embolism, but the American Heart Association and the American College of Chest Physicians recommend a more aggressive approach for massive and submassive PE. Up to 60% of patients with massive PE die, data suggest, with two-thirds of the deaths occurring in the first hour after the embolus forms. Within 30 days after submassive PE, 15%-20% of patients die secondary to pulmonary hypertension and subsequent cor pulmonale, according to a data presented at the annual meeting of the Southern Association for Vascular Surgery.

The catheter-directed thrombolytic therapy at Shady Grove Adventist largely owes its success to a vascular surgeon who took the lead in establishing protocols and training support staff, with hospitalists as a key part of the team.

The vascular surgeon, Dr. Jeffrey Y. Wang, reported on the outcomes of the first 12 patients, in whom the procedures were all technically successful. One patient developed hemodynamically significant bradycardia, but all patients were off supplemental oxygen within 24 hours of the procedure. There were no bleeding complications.

One patient died 14 hours after the procedure, most likely because of a paradoxical embolus to the intestine. The 11 surviving patients were discharged to home within 48 hours of the intervention, according to Dr. Wang of Horizon Vascular Specialists. The group contracts to provide vascular surgical care at Shady Grove Adventist and two other hospitals in Maryland.

Catheter-directed thrombolytic therapy can shorten stays in the ICU and the hospital, reduce or eliminate the need for home oxygen therapy, and help restore right heart function in patients with massive or submassive pulmonary embolism, Dr. Wang said. Patients with massive or submassive PE are offered catheter-directed thrombolytic therapy if they are hemodynamically unstable; if they have right heart dysfunction, elevated troponin, or pulmonary artery pressures greater than 70 mmHg; or if they are not weaning off intubation for oxygen within 5 days, Dr. Wang said. He excludes patients who are actively bleeding or who are not able to tolerate any systemic anticoagulation.

Recent surgery was not a disqualifying factor in his case series. "Typically, those patients were orthopedic in nature, with a hip or knee replacement," Dr. Wang said. The patient would develop a big pulmonary embolus, and the orthopedist would give a green light for aggressive treatment.

But most of the patients who have received catheter-directed thrombolytic procedures presented to the emergency department with lower extremity swelling, and were found on sonography to have a thrombus extending into the large pelvic vessels. Dr. Carpenter’s service admits approximately 90% of adult inpatients, so the hospitalists usually are the ones to determine which patients should be considered for the interventional approach and which ones get medical therapy.

Dr. Wang emphasized that the protocols are as important as technical expertise in catheter-directed thrombolysis. Protocols are in place for the ED, the ICU, and the hospitalist team for the early detection of DVT and pulmonary emboli, notification of the appropriate staff, and posttreatment care of patients. Dr. Wang also took the lead on the anticoagulation aspect of computerized physician order entry.

"In our institution, we use the same protocols for call-in and transport to the cath lab as for ST-elevation myocardial infarction, which allows us to get the patient up and into the fluoroscopy suite within 30 minutes," Dr. Wang said. The fluoroscopy suite must be available on an emergency basis.

"It’s amazing to see such a dramatic improvement in patient symptoms almost immediately post procedure," said Dr. Carpenter.

Patients who undergo catheter-directed thrombolysis require close postoperative monitoring, said Dr. Carpenter, who is with Inpatient Specialists, a group that contracts with hospitals to provide hospitalist services. The main risks are bleeding, low blood pressure, or respiratory distress. "The bleeding might not necessarily be obvious," as the antithrombotic agent is given locally and bleeding can be local as well.

Community hospitals that offer catheter-directed thrombolysis need sufficient commitment from vascular surgeons and robust postprocedure support, Dr. Carpenter said. The vascular surgery group should be able to offer the procedure to all patients who need it.

Around-the-clock hospitalist availability is a good idea, especially if the surgeon is not on the in-house staff. "Don’t do [this procedure] if the hospitalist is providing triage services at night," he advised.

With 23 full-time positions (translating into 40 full-time or part-time physicians), the adult hospitalist service at Shady Grove Adventist, a 339-bed hospital, typically provides 10 hospitalists during weekdays (including one medical-psychiatric physician) and 8 on weekend days.

Besides the adult hospitalist group, the hospital has a pediatric hospitalist service, 24-hour in-house ICU hospitalist coverage, and a surgical hospitalist group. "Not many hospitals have surgical hospitalists," Dr. Carpenter noted. Laborists also are available 24 hours a day for in-house ob.gyn. consultations.

Dr. Carpenter, who has been a hospitalist since 2006, said that this "is how hospital-based medicine is progressing. "Shady Grove has been an early adopter" of expanded hospitalist services.

Dr. Carpenter and Dr. Wang reported having no financial disclosures.

MIAMI BEACH – Although hospitalists are gaining more and more recognition for shrinking both costs and lengths of stay, one expert says it’s time to promote yourself and your services using with the V word: value.

"Hospitalists have been known over the last 10 to 15 years to be able to decrease the length of stay and decrease the cost of care within the hospital," said Dr. Joseph Ming Wah Li, director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston. "But I’ve never been entirely comfortable with the notion that people view me as the money saver. I would much rather be perceived as a high-value or high-quality provider."

"Consumers in this country don’t want the cheapest care. They want the highest-value care," noted Dr. Li, who is also president of the Society of Hospital Medicine.

"When I meet with hospitalists around the country, I find a lot are confused about what value really means. But it’s pretty simple ... it’s health care quality divided by costs," he said at a meeting on perioperative medicine sponsored by the University of Miami.

It was value that Dr. Li emphasized when National Public Radio (NPR) news asked him to comment on a 2011 study about hospitalists and costs. Compared with inpatients who did not see a hospitalist, the group of Medicare Part A and B recipients cared for by hospitalists during their stay cost the hospitals less ($338 lower hospital charges per patient) and left the hospitals sooner (0.64 days earlier) (Ann. Intern. Med. 2011;155:152-9).

However, there was a catch. "For the 30 days post-hospital, they found that if you were cared for by a hospitalist, you were less likely to have a follow-up visit with your PCP [primary care physician] within 30 days; you were more likely to be discharged to a nursing home or other facility instead of home; you were more likely to be readmitted to the hospital within 30 days; and the cost of care was about $50 higher per admission, but higher than if you were cared for by a PCP," Dr. Li said. "They were essentially saying that hospitalists were just cost-shifting all these costs to the next 30 days."

Dr. Li decided not to criticize the observational design of the study or its use of a billing database, he said, when speaking with NPR. Instead, he explained that with health care reform, hospitalists and other physicians are trying to improve the value of health care in the United States. For example, the researchers found that a lower proportion of patients was discharged home after care from a hospitalist. The researchers pointed to higher costs, for example, of treating patients transferred to a nursing home setting. Dr. Li explained that it could be that patients not seen by hospitalists and discharged directly home did not receive enough care and therefore were more likely to be readmitted.

"This study could have been true, but we know nothing about the quality of care these patients received. Some may have needed to be readmitted," Dr. Li said.

One lesson Dr. Li learned from having been a hospitalist since 1998 is that it is difficult to improve if you do not know what you are doing. In other words, if you want to demonstrate health care value, start with assessment and tracking of performance measures.

As an example, in 2006 there was a question about whether or not the critical care unit at Beth Israel Deaconess had enough beds. Intensivists alerted hospitalists that they were transferring the least-sick patients out of the ICU earlier than they would have otherwise, because they did not have enough beds. Clinicians approached administration and asked them to construct another ICU.

"Property is not [inexpensive] in Boston. It would have cost tens of millions," Dr. Li said.

The administration asked if instead an appropriate way to shorten length of stay in the existing unit could be identified.

The hospitalists, critical care medicine specialists, and other clinicians targeted ventilator-associated pneumonia (VAP), which played a significant role in high utilization of the ICU. In April 2006, 90% or more of ICU patients received some of the VAP prevention measures recommended in the Institute for Healthcare Improvement Bundle.

"We thought we were doing pretty well," Dr. Li said. However, all of the bundle’s five measures are required for it to count. "Our bundle performance score was in the range of 74% to 83%," Dr. Li said. "We would like to think we were providing high-quality care, but at end of the day, one quarter of patients were not getting the very appropriate care that we were supposed to be providing."

A key strategy – formation of a multidisciplinary team – improved performance measures. "This is not a doctor thing. This is a nurse, a respiratory therapist, a pharmacist, and probably with the least amount of involvement, a physician [thing]." He added: "VAP rates dropped. That new ICU was never built. We don’t have a shortage of beds in our ICU."

Ongoing maintenance and feedback are important components of any intervention to improve value of care based on measurable performance outcomes, Dr. Li said. He applauded transparent efforts by Beth Israel Deaconess Medical Center to post their performance measures online. For the first quarter of 2012, the institution reported 97% performance on VAP prevention efforts, exceeding their 90% goal.

Communication and working together in a true multidisciplinary effort are essential. Dr. Li suggested attendees go back to their institutions, choose a patient at random, and open up chart notes written by physicians and compare them to the notes written by nurses. Often you will discover two different accounts written by clinicians working in parallel but with little interdisciplinary communication, he said.

Dr. Li disclosed that he receives honoraria from publishers Elsevier and Wiley. Elsevier is the parent company of this news service. Dr. Li is also a member of the American Board of Internal Medicine Hospital Medicine Maintenance of Certification Test Committee.

MIAMI BEACH – Although hospitalists are gaining more and more recognition for shrinking both costs and lengths of stay, one expert says it’s time to promote yourself and your services using with the V word: value.

"Hospitalists have been known over the last 10 to 15 years to be able to decrease the length of stay and decrease the cost of care within the hospital," said Dr. Joseph Ming Wah Li, director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston. "But I’ve never been entirely comfortable with the notion that people view me as the money saver. I would much rather be perceived as a high-value or high-quality provider."

"Consumers in this country don’t want the cheapest care. They want the highest-value care," noted Dr. Li, who is also president of the Society of Hospital Medicine.

"When I meet with hospitalists around the country, I find a lot are confused about what value really means. But it’s pretty simple ... it’s health care quality divided by costs," he said at a meeting on perioperative medicine sponsored by the University of Miami.

It was value that Dr. Li emphasized when National Public Radio (NPR) news asked him to comment on a 2011 study about hospitalists and costs. Compared with inpatients who did not see a hospitalist, the group of Medicare Part A and B recipients cared for by hospitalists during their stay cost the hospitals less ($338 lower hospital charges per patient) and left the hospitals sooner (0.64 days earlier) (Ann. Intern. Med. 2011;155:152-9).

However, there was a catch. "For the 30 days post-hospital, they found that if you were cared for by a hospitalist, you were less likely to have a follow-up visit with your PCP [primary care physician] within 30 days; you were more likely to be discharged to a nursing home or other facility instead of home; you were more likely to be readmitted to the hospital within 30 days; and the cost of care was about $50 higher per admission, but higher than if you were cared for by a PCP," Dr. Li said. "They were essentially saying that hospitalists were just cost-shifting all these costs to the next 30 days."

Dr. Li decided not to criticize the observational design of the study or its use of a billing database, he said, when speaking with NPR. Instead, he explained that with health care reform, hospitalists and other physicians are trying to improve the value of health care in the United States. For example, the researchers found that a lower proportion of patients was discharged home after care from a hospitalist. The researchers pointed to higher costs, for example, of treating patients transferred to a nursing home setting. Dr. Li explained that it could be that patients not seen by hospitalists and discharged directly home did not receive enough care and therefore were more likely to be readmitted.

"This study could have been true, but we know nothing about the quality of care these patients received. Some may have needed to be readmitted," Dr. Li said.

One lesson Dr. Li learned from having been a hospitalist since 1998 is that it is difficult to improve if you do not know what you are doing. In other words, if you want to demonstrate health care value, start with assessment and tracking of performance measures.

As an example, in 2006 there was a question about whether or not the critical care unit at Beth Israel Deaconess had enough beds. Intensivists alerted hospitalists that they were transferring the least-sick patients out of the ICU earlier than they would have otherwise, because they did not have enough beds. Clinicians approached administration and asked them to construct another ICU.

"Property is not [inexpensive] in Boston. It would have cost tens of millions," Dr. Li said.

The administration asked if instead an appropriate way to shorten length of stay in the existing unit could be identified.

The hospitalists, critical care medicine specialists, and other clinicians targeted ventilator-associated pneumonia (VAP), which played a significant role in high utilization of the ICU. In April 2006, 90% or more of ICU patients received some of the VAP prevention measures recommended in the Institute for Healthcare Improvement Bundle.

"We thought we were doing pretty well," Dr. Li said. However, all of the bundle’s five measures are required for it to count. "Our bundle performance score was in the range of 74% to 83%," Dr. Li said. "We would like to think we were providing high-quality care, but at end of the day, one quarter of patients were not getting the very appropriate care that we were supposed to be providing."

A key strategy – formation of a multidisciplinary team – improved performance measures. "This is not a doctor thing. This is a nurse, a respiratory therapist, a pharmacist, and probably with the least amount of involvement, a physician [thing]." He added: "VAP rates dropped. That new ICU was never built. We don’t have a shortage of beds in our ICU."

Ongoing maintenance and feedback are important components of any intervention to improve value of care based on measurable performance outcomes, Dr. Li said. He applauded transparent efforts by Beth Israel Deaconess Medical Center to post their performance measures online. For the first quarter of 2012, the institution reported 97% performance on VAP prevention efforts, exceeding their 90% goal.

Communication and working together in a true multidisciplinary effort are essential. Dr. Li suggested attendees go back to their institutions, choose a patient at random, and open up chart notes written by physicians and compare them to the notes written by nurses. Often you will discover two different accounts written by clinicians working in parallel but with little interdisciplinary communication, he said.

Dr. Li disclosed that he receives honoraria from publishers Elsevier and Wiley. Elsevier is the parent company of this news service. Dr. Li is also a member of the American Board of Internal Medicine Hospital Medicine Maintenance of Certification Test Committee.

MIAMI BEACH – Although hospitalists are gaining more and more recognition for shrinking both costs and lengths of stay, one expert says it’s time to promote yourself and your services using with the V word: value.

"Hospitalists have been known over the last 10 to 15 years to be able to decrease the length of stay and decrease the cost of care within the hospital," said Dr. Joseph Ming Wah Li, director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston. "But I’ve never been entirely comfortable with the notion that people view me as the money saver. I would much rather be perceived as a high-value or high-quality provider."

"Consumers in this country don’t want the cheapest care. They want the highest-value care," noted Dr. Li, who is also president of the Society of Hospital Medicine.

"When I meet with hospitalists around the country, I find a lot are confused about what value really means. But it’s pretty simple ... it’s health care quality divided by costs," he said at a meeting on perioperative medicine sponsored by the University of Miami.

It was value that Dr. Li emphasized when National Public Radio (NPR) news asked him to comment on a 2011 study about hospitalists and costs. Compared with inpatients who did not see a hospitalist, the group of Medicare Part A and B recipients cared for by hospitalists during their stay cost the hospitals less ($338 lower hospital charges per patient) and left the hospitals sooner (0.64 days earlier) (Ann. Intern. Med. 2011;155:152-9).

However, there was a catch. "For the 30 days post-hospital, they found that if you were cared for by a hospitalist, you were less likely to have a follow-up visit with your PCP [primary care physician] within 30 days; you were more likely to be discharged to a nursing home or other facility instead of home; you were more likely to be readmitted to the hospital within 30 days; and the cost of care was about $50 higher per admission, but higher than if you were cared for by a PCP," Dr. Li said. "They were essentially saying that hospitalists were just cost-shifting all these costs to the next 30 days."

Dr. Li decided not to criticize the observational design of the study or its use of a billing database, he said, when speaking with NPR. Instead, he explained that with health care reform, hospitalists and other physicians are trying to improve the value of health care in the United States. For example, the researchers found that a lower proportion of patients was discharged home after care from a hospitalist. The researchers pointed to higher costs, for example, of treating patients transferred to a nursing home setting. Dr. Li explained that it could be that patients not seen by hospitalists and discharged directly home did not receive enough care and therefore were more likely to be readmitted.

"This study could have been true, but we know nothing about the quality of care these patients received. Some may have needed to be readmitted," Dr. Li said.

One lesson Dr. Li learned from having been a hospitalist since 1998 is that it is difficult to improve if you do not know what you are doing. In other words, if you want to demonstrate health care value, start with assessment and tracking of performance measures.

As an example, in 2006 there was a question about whether or not the critical care unit at Beth Israel Deaconess had enough beds. Intensivists alerted hospitalists that they were transferring the least-sick patients out of the ICU earlier than they would have otherwise, because they did not have enough beds. Clinicians approached administration and asked them to construct another ICU.

"Property is not [inexpensive] in Boston. It would have cost tens of millions," Dr. Li said.

The administration asked if instead an appropriate way to shorten length of stay in the existing unit could be identified.

The hospitalists, critical care medicine specialists, and other clinicians targeted ventilator-associated pneumonia (VAP), which played a significant role in high utilization of the ICU. In April 2006, 90% or more of ICU patients received some of the VAP prevention measures recommended in the Institute for Healthcare Improvement Bundle.

"We thought we were doing pretty well," Dr. Li said. However, all of the bundle’s five measures are required for it to count. "Our bundle performance score was in the range of 74% to 83%," Dr. Li said. "We would like to think we were providing high-quality care, but at end of the day, one quarter of patients were not getting the very appropriate care that we were supposed to be providing."

A key strategy – formation of a multidisciplinary team – improved performance measures. "This is not a doctor thing. This is a nurse, a respiratory therapist, a pharmacist, and probably with the least amount of involvement, a physician [thing]." He added: "VAP rates dropped. That new ICU was never built. We don’t have a shortage of beds in our ICU."

Ongoing maintenance and feedback are important components of any intervention to improve value of care based on measurable performance outcomes, Dr. Li said. He applauded transparent efforts by Beth Israel Deaconess Medical Center to post their performance measures online. For the first quarter of 2012, the institution reported 97% performance on VAP prevention efforts, exceeding their 90% goal.

Communication and working together in a true multidisciplinary effort are essential. Dr. Li suggested attendees go back to their institutions, choose a patient at random, and open up chart notes written by physicians and compare them to the notes written by nurses. Often you will discover two different accounts written by clinicians working in parallel but with little interdisciplinary communication, he said.

Dr. Li disclosed that he receives honoraria from publishers Elsevier and Wiley. Elsevier is the parent company of this news service. Dr. Li is also a member of the American Board of Internal Medicine Hospital Medicine Maintenance of Certification Test Committee.

FT. LAUDERDALE, FLA. – Transfusion of packed red blood cells during cardiac surgery is independently associated with increased risk of major infection, researchers reported, and – in a related study – pneumonia was found to be the most common infection associated with cardiac surgery.

Cardiac procedures with transfusions were associated with a significant risk of infection, such that "with every unit of blood, you had a significant increase in the risk of infection for the patient. It appears that there might be some sort of threshold in the 2- to 4-unit range, whereafter the risk really seems to increase. But statistically, even that first drop of blood carried an additional infectious risk," Dr. Keith A. Horvath said at the annual meeting of the Society of Thoracic Surgeons.

In a related study, researchers found pneumonia to be the most common infection associated with cardiac surgery. "Pneumonia, surprisingly, was the most common infection, at 2.4%. This was much more common than other infections that we certainly worry about and get a fair amount of press and literature on, specifically sternal wound infections," said Dr. Gorav Ailawadi of the University of Virginia in Charlottesville.

Data for 5,184 adult cardiac patients were used for both studies. The patients were prospectively enrolled in a 10-center infection registry between February and September, 2010. Captured data included infection occurrence, type, and organism. Adjudication was performed by an independent panel of infectious diseases experts.

Major infections evaluated in the study included deep incisional surgical (chest), deep incisional surgical (second incisions), empyema, endocarditis, mediastinitis, myocarditis, pneumonia, bloodstream infections, Clostridium difficile colitis, and cardiac device infections. Infections were defined by a combination of clinical, laboratory, and/or radiologic evidence (according to Centers for Disease Control and Prevention surveillance definitions) for a follow-up of 65 days.

The researchers included several types of surgical interventions: isolated coronary artery bypass graft (CABG), isolated valve surgery, CABG with valve surgery, surgery for heart failure, thoracic aortic surgery, and other procedures.

The mean patient age was 64 years, mean bypass time was 115 minutes, two-thirds (67%) were men, 71% had heart failure, a quarter (27%) had diabetes, 14% had chronic obstructive pulmonary disease (COPD), and 19% had prior cardiac surgery. Mean hemoglobin was 13.2 mg/dL.

There was a significant dose-dependent association between quantity of packed red blood cells (PRBCs) and risk of infection, with the crude risk increasing by an average of 29% with each PRBC unit.

Several factors increased the risk of infection, including severe COPD (relative risk, 1.85), preoperative creatinine levels greater than 1.5 mg/dL (RR, 1.72), heart failure (RR, 1.49), mild to moderate COPD (RR, 1.36), PRBCs per unit (RR, 1.24), and surgery time per 60 minutes (RR, 1.19).

Platelet transfusion occurred in 31% of patients. However, the use of platelets was associated with a decreased risk of infection (RR, 0.71). Cell Saver use was not related to infection.

Creatinine levels greater than 1.5 mg/dL (RR, 2.40) and PRBCs per unit (RR, 1.23) significantly increased the risk of death. Many factors significantly increased the length of stay, including creatinine levels greater than 1.5 mg/dL (RR, 1.26), severe COPD (RR, 1.41), mild to moderate COPD (RR, 1.14), heart failure (RR, 1.36), PRBCs (RR, 1.12), surgery time per 60 minutes (RR, 1.11), age of 65-79 years (RR, 1.21), and age older than 80 years (RR, 1.44). The use of platelets was associated with a decreased length of stay (RR, 0.71).

All risks of transfusion must be weighed against toleration anemia, which is also associated with adverse outcomes, according to Dr. Horvath, who is the director of the Cardiothoracic Surgery Research Program for the National Heart, Lung, and Blood Institute and a member of the Cardiothoracic Surgery Trials Network.

Efforts to reduce PRBC transfusions may significantly reduce major postoperative infections. Cell salvage and ultrafiltration could be viable alternatives, he noted.

In the second study, the researchers used the same dataset. Captured data included infection occurrence, type, timing, and organisms. Infections were adjudicated by an independent panel of infectious disease experts. The risk of pneumonia, mortality, and length of stay (time to discharge) were analyzed.

Major infections included bloodstream, pneumonia, C. difficile, deep sternal incisional, mediastinitis, deep groin/leg incisional, endocarditis, and empyema.

Pneumonia was diagnosed using the 2010 surveillance criteria from the CDC/National Healthcare Safety Network, including chest x-ray with new or progressive and persistent infiltrate; fever greater than 38° C; leukopenia (defined as fewer than 4,000 leukocytes per cc); leukocytosis (at least 12,000 leukocytes per cc); or altered mental status. At least two of the following must have been present as well: purulent sputum or change; cough, dyspnea, or tachypnea; rales or bronchial breath sounds; or worsening gas exchange. Duration of follow-up was 65 days.

In all, 31% had isolated CABG, 30% had isolated valve surgery, 11% had CABG and valve surgery, 6% had thoracic aortic surgery, 2% had left ventricular assist device (LVAD) implantation/heart transplant, and 20% were categorized as other.

Overall, 2.4% of patients in the registry had pneumonia, 1.1% had blood stream infection, 1% had C. difficile colitis, and 0.5% had deep sternal infections.

The overall mean time to infection was 19 days and the median was 14 days. The mean time to infection for pneumonia was 15 days. Overall, more than 40% of infections occurred after the index hospitalization. However, 68% and 66% of pneumonias and blood stream infections, respectively, occurred during hospitalization. The three most common organisms were Pseudomonas aeruginosa (12%), Enterobacter cloacae (8%), and Klebsiella pneumoniae (7%).

Increased risk of pneumonia was associated with surgery time (RR, 1.42), a creatinine level of at least 1.5 mg/dL (RR, 1.94), mild to moderate COPD (RR, 1.78), severe COPD (RR, 4.12), and heart failure (RR, 1.76). The reference category was those without COPD.

In terms of process-of-care factors, only nasal decontamination with mupirocin was associated with reduced risk of pneumonia (RR, 0.77). Nasal decontamination with other agents (RR, 1.44); antibiotics given within 24 hours after surgery (RR, 1.26) and within 48 hours postop (RR, 2.70); ventilator use of 24-48 hours (RR, 2.31) and more than 48 hours (RR, 4.58); nasogastric tube (RR, 2.07); and use of PRBCs (RR, 1.10) were all associated with increased risk of pneumonia.

In terms of mortality, "pneumonia, among all the factors analyzed, had the greatest association with mortality, with an odds ratio greater than seven ... which was far and away greater than anything else that was examined," said Dr. Ailawadi.

Pneumonia was significantly associated with an increased risk of mortality (RR, 7.07), as were heart failure (RR, 1.87), creatinine levels of at least 1.5 mg/dL (RR, 2.97), and surgery duration (1.27). However, black race appeared to be protective, with a significantly decreased risk of pneumonia (RR, 0.43).

Pneumonia significantly increased the length of stay by a median of 13 days (19 days with pneumonia and 6 days without). A number of factors – mild to moderate COPD, severe COPD, heart failure, creatinine levels of at least 1.5 mg/dL, surgery time, age of 65-79 years, age 80 years and older, and black or Hispanic race – were significantly associated with increased risk of longer length of stay. Male sex was significantly associated with decreased length of stay (RR, 0.79).

Both Dr. Horvath and Dr. Ailawadi reported that they have no relevant financial disclosures.

FT. LAUDERDALE, FLA. – Transfusion of packed red blood cells during cardiac surgery is independently associated with increased risk of major infection, researchers reported, and – in a related study – pneumonia was found to be the most common infection associated with cardiac surgery.

Cardiac procedures with transfusions were associated with a significant risk of infection, such that "with every unit of blood, you had a significant increase in the risk of infection for the patient. It appears that there might be some sort of threshold in the 2- to 4-unit range, whereafter the risk really seems to increase. But statistically, even that first drop of blood carried an additional infectious risk," Dr. Keith A. Horvath said at the annual meeting of the Society of Thoracic Surgeons.

In a related study, researchers found pneumonia to be the most common infection associated with cardiac surgery. "Pneumonia, surprisingly, was the most common infection, at 2.4%. This was much more common than other infections that we certainly worry about and get a fair amount of press and literature on, specifically sternal wound infections," said Dr. Gorav Ailawadi of the University of Virginia in Charlottesville.

Data for 5,184 adult cardiac patients were used for both studies. The patients were prospectively enrolled in a 10-center infection registry between February and September, 2010. Captured data included infection occurrence, type, and organism. Adjudication was performed by an independent panel of infectious diseases experts.

Major infections evaluated in the study included deep incisional surgical (chest), deep incisional surgical (second incisions), empyema, endocarditis, mediastinitis, myocarditis, pneumonia, bloodstream infections, Clostridium difficile colitis, and cardiac device infections. Infections were defined by a combination of clinical, laboratory, and/or radiologic evidence (according to Centers for Disease Control and Prevention surveillance definitions) for a follow-up of 65 days.

The researchers included several types of surgical interventions: isolated coronary artery bypass graft (CABG), isolated valve surgery, CABG with valve surgery, surgery for heart failure, thoracic aortic surgery, and other procedures.

The mean patient age was 64 years, mean bypass time was 115 minutes, two-thirds (67%) were men, 71% had heart failure, a quarter (27%) had diabetes, 14% had chronic obstructive pulmonary disease (COPD), and 19% had prior cardiac surgery. Mean hemoglobin was 13.2 mg/dL.

There was a significant dose-dependent association between quantity of packed red blood cells (PRBCs) and risk of infection, with the crude risk increasing by an average of 29% with each PRBC unit.

Several factors increased the risk of infection, including severe COPD (relative risk, 1.85), preoperative creatinine levels greater than 1.5 mg/dL (RR, 1.72), heart failure (RR, 1.49), mild to moderate COPD (RR, 1.36), PRBCs per unit (RR, 1.24), and surgery time per 60 minutes (RR, 1.19).

Platelet transfusion occurred in 31% of patients. However, the use of platelets was associated with a decreased risk of infection (RR, 0.71). Cell Saver use was not related to infection.

Creatinine levels greater than 1.5 mg/dL (RR, 2.40) and PRBCs per unit (RR, 1.23) significantly increased the risk of death. Many factors significantly increased the length of stay, including creatinine levels greater than 1.5 mg/dL (RR, 1.26), severe COPD (RR, 1.41), mild to moderate COPD (RR, 1.14), heart failure (RR, 1.36), PRBCs (RR, 1.12), surgery time per 60 minutes (RR, 1.11), age of 65-79 years (RR, 1.21), and age older than 80 years (RR, 1.44). The use of platelets was associated with a decreased length of stay (RR, 0.71).

All risks of transfusion must be weighed against toleration anemia, which is also associated with adverse outcomes, according to Dr. Horvath, who is the director of the Cardiothoracic Surgery Research Program for the National Heart, Lung, and Blood Institute and a member of the Cardiothoracic Surgery Trials Network.

Efforts to reduce PRBC transfusions may significantly reduce major postoperative infections. Cell salvage and ultrafiltration could be viable alternatives, he noted.

In the second study, the researchers used the same dataset. Captured data included infection occurrence, type, timing, and organisms. Infections were adjudicated by an independent panel of infectious disease experts. The risk of pneumonia, mortality, and length of stay (time to discharge) were analyzed.

Major infections included bloodstream, pneumonia, C. difficile, deep sternal incisional, mediastinitis, deep groin/leg incisional, endocarditis, and empyema.

Pneumonia was diagnosed using the 2010 surveillance criteria from the CDC/National Healthcare Safety Network, including chest x-ray with new or progressive and persistent infiltrate; fever greater than 38° C; leukopenia (defined as fewer than 4,000 leukocytes per cc); leukocytosis (at least 12,000 leukocytes per cc); or altered mental status. At least two of the following must have been present as well: purulent sputum or change; cough, dyspnea, or tachypnea; rales or bronchial breath sounds; or worsening gas exchange. Duration of follow-up was 65 days.

In all, 31% had isolated CABG, 30% had isolated valve surgery, 11% had CABG and valve surgery, 6% had thoracic aortic surgery, 2% had left ventricular assist device (LVAD) implantation/heart transplant, and 20% were categorized as other.

Overall, 2.4% of patients in the registry had pneumonia, 1.1% had blood stream infection, 1% had C. difficile colitis, and 0.5% had deep sternal infections.

The overall mean time to infection was 19 days and the median was 14 days. The mean time to infection for pneumonia was 15 days. Overall, more than 40% of infections occurred after the index hospitalization. However, 68% and 66% of pneumonias and blood stream infections, respectively, occurred during hospitalization. The three most common organisms were Pseudomonas aeruginosa (12%), Enterobacter cloacae (8%), and Klebsiella pneumoniae (7%).

Increased risk of pneumonia was associated with surgery time (RR, 1.42), a creatinine level of at least 1.5 mg/dL (RR, 1.94), mild to moderate COPD (RR, 1.78), severe COPD (RR, 4.12), and heart failure (RR, 1.76). The reference category was those without COPD.

In terms of process-of-care factors, only nasal decontamination with mupirocin was associated with reduced risk of pneumonia (RR, 0.77). Nasal decontamination with other agents (RR, 1.44); antibiotics given within 24 hours after surgery (RR, 1.26) and within 48 hours postop (RR, 2.70); ventilator use of 24-48 hours (RR, 2.31) and more than 48 hours (RR, 4.58); nasogastric tube (RR, 2.07); and use of PRBCs (RR, 1.10) were all associated with increased risk of pneumonia.

In terms of mortality, "pneumonia, among all the factors analyzed, had the greatest association with mortality, with an odds ratio greater than seven ... which was far and away greater than anything else that was examined," said Dr. Ailawadi.

Pneumonia was significantly associated with an increased risk of mortality (RR, 7.07), as were heart failure (RR, 1.87), creatinine levels of at least 1.5 mg/dL (RR, 2.97), and surgery duration (1.27). However, black race appeared to be protective, with a significantly decreased risk of pneumonia (RR, 0.43).

Pneumonia significantly increased the length of stay by a median of 13 days (19 days with pneumonia and 6 days without). A number of factors – mild to moderate COPD, severe COPD, heart failure, creatinine levels of at least 1.5 mg/dL, surgery time, age of 65-79 years, age 80 years and older, and black or Hispanic race – were significantly associated with increased risk of longer length of stay. Male sex was significantly associated with decreased length of stay (RR, 0.79).

Both Dr. Horvath and Dr. Ailawadi reported that they have no relevant financial disclosures.

FT. LAUDERDALE, FLA. – Transfusion of packed red blood cells during cardiac surgery is independently associated with increased risk of major infection, researchers reported, and – in a related study – pneumonia was found to be the most common infection associated with cardiac surgery.

Cardiac procedures with transfusions were associated with a significant risk of infection, such that "with every unit of blood, you had a significant increase in the risk of infection for the patient. It appears that there might be some sort of threshold in the 2- to 4-unit range, whereafter the risk really seems to increase. But statistically, even that first drop of blood carried an additional infectious risk," Dr. Keith A. Horvath said at the annual meeting of the Society of Thoracic Surgeons.

In a related study, researchers found pneumonia to be the most common infection associated with cardiac surgery. "Pneumonia, surprisingly, was the most common infection, at 2.4%. This was much more common than other infections that we certainly worry about and get a fair amount of press and literature on, specifically sternal wound infections," said Dr. Gorav Ailawadi of the University of Virginia in Charlottesville.

Data for 5,184 adult cardiac patients were used for both studies. The patients were prospectively enrolled in a 10-center infection registry between February and September, 2010. Captured data included infection occurrence, type, and organism. Adjudication was performed by an independent panel of infectious diseases experts.

Major infections evaluated in the study included deep incisional surgical (chest), deep incisional surgical (second incisions), empyema, endocarditis, mediastinitis, myocarditis, pneumonia, bloodstream infections, Clostridium difficile colitis, and cardiac device infections. Infections were defined by a combination of clinical, laboratory, and/or radiologic evidence (according to Centers for Disease Control and Prevention surveillance definitions) for a follow-up of 65 days.

The researchers included several types of surgical interventions: isolated coronary artery bypass graft (CABG), isolated valve surgery, CABG with valve surgery, surgery for heart failure, thoracic aortic surgery, and other procedures.

The mean patient age was 64 years, mean bypass time was 115 minutes, two-thirds (67%) were men, 71% had heart failure, a quarter (27%) had diabetes, 14% had chronic obstructive pulmonary disease (COPD), and 19% had prior cardiac surgery. Mean hemoglobin was 13.2 mg/dL.

There was a significant dose-dependent association between quantity of packed red blood cells (PRBCs) and risk of infection, with the crude risk increasing by an average of 29% with each PRBC unit.

Several factors increased the risk of infection, including severe COPD (relative risk, 1.85), preoperative creatinine levels greater than 1.5 mg/dL (RR, 1.72), heart failure (RR, 1.49), mild to moderate COPD (RR, 1.36), PRBCs per unit (RR, 1.24), and surgery time per 60 minutes (RR, 1.19).

Platelet transfusion occurred in 31% of patients. However, the use of platelets was associated with a decreased risk of infection (RR, 0.71). Cell Saver use was not related to infection.

Creatinine levels greater than 1.5 mg/dL (RR, 2.40) and PRBCs per unit (RR, 1.23) significantly increased the risk of death. Many factors significantly increased the length of stay, including creatinine levels greater than 1.5 mg/dL (RR, 1.26), severe COPD (RR, 1.41), mild to moderate COPD (RR, 1.14), heart failure (RR, 1.36), PRBCs (RR, 1.12), surgery time per 60 minutes (RR, 1.11), age of 65-79 years (RR, 1.21), and age older than 80 years (RR, 1.44). The use of platelets was associated with a decreased length of stay (RR, 0.71).

All risks of transfusion must be weighed against toleration anemia, which is also associated with adverse outcomes, according to Dr. Horvath, who is the director of the Cardiothoracic Surgery Research Program for the National Heart, Lung, and Blood Institute and a member of the Cardiothoracic Surgery Trials Network.

Efforts to reduce PRBC transfusions may significantly reduce major postoperative infections. Cell salvage and ultrafiltration could be viable alternatives, he noted.

In the second study, the researchers used the same dataset. Captured data included infection occurrence, type, timing, and organisms. Infections were adjudicated by an independent panel of infectious disease experts. The risk of pneumonia, mortality, and length of stay (time to discharge) were analyzed.

Major infections included bloodstream, pneumonia, C. difficile, deep sternal incisional, mediastinitis, deep groin/leg incisional, endocarditis, and empyema.

Pneumonia was diagnosed using the 2010 surveillance criteria from the CDC/National Healthcare Safety Network, including chest x-ray with new or progressive and persistent infiltrate; fever greater than 38° C; leukopenia (defined as fewer than 4,000 leukocytes per cc); leukocytosis (at least 12,000 leukocytes per cc); or altered mental status. At least two of the following must have been present as well: purulent sputum or change; cough, dyspnea, or tachypnea; rales or bronchial breath sounds; or worsening gas exchange. Duration of follow-up was 65 days.

In all, 31% had isolated CABG, 30% had isolated valve surgery, 11% had CABG and valve surgery, 6% had thoracic aortic surgery, 2% had left ventricular assist device (LVAD) implantation/heart transplant, and 20% were categorized as other.

Overall, 2.4% of patients in the registry had pneumonia, 1.1% had blood stream infection, 1% had C. difficile colitis, and 0.5% had deep sternal infections.

The overall mean time to infection was 19 days and the median was 14 days. The mean time to infection for pneumonia was 15 days. Overall, more than 40% of infections occurred after the index hospitalization. However, 68% and 66% of pneumonias and blood stream infections, respectively, occurred during hospitalization. The three most common organisms were Pseudomonas aeruginosa (12%), Enterobacter cloacae (8%), and Klebsiella pneumoniae (7%).

Increased risk of pneumonia was associated with surgery time (RR, 1.42), a creatinine level of at least 1.5 mg/dL (RR, 1.94), mild to moderate COPD (RR, 1.78), severe COPD (RR, 4.12), and heart failure (RR, 1.76). The reference category was those without COPD.

In terms of process-of-care factors, only nasal decontamination with mupirocin was associated with reduced risk of pneumonia (RR, 0.77). Nasal decontamination with other agents (RR, 1.44); antibiotics given within 24 hours after surgery (RR, 1.26) and within 48 hours postop (RR, 2.70); ventilator use of 24-48 hours (RR, 2.31) and more than 48 hours (RR, 4.58); nasogastric tube (RR, 2.07); and use of PRBCs (RR, 1.10) were all associated with increased risk of pneumonia.

In terms of mortality, "pneumonia, among all the factors analyzed, had the greatest association with mortality, with an odds ratio greater than seven ... which was far and away greater than anything else that was examined," said Dr. Ailawadi.

Pneumonia was significantly associated with an increased risk of mortality (RR, 7.07), as were heart failure (RR, 1.87), creatinine levels of at least 1.5 mg/dL (RR, 2.97), and surgery duration (1.27). However, black race appeared to be protective, with a significantly decreased risk of pneumonia (RR, 0.43).

Pneumonia significantly increased the length of stay by a median of 13 days (19 days with pneumonia and 6 days without). A number of factors – mild to moderate COPD, severe COPD, heart failure, creatinine levels of at least 1.5 mg/dL, surgery time, age of 65-79 years, age 80 years and older, and black or Hispanic race – were significantly associated with increased risk of longer length of stay. Male sex was significantly associated with decreased length of stay (RR, 0.79).

Both Dr. Horvath and Dr. Ailawadi reported that they have no relevant financial disclosures.

MADISON, WIS. – Implementation of a small bowel obstruction guideline increased admissions to surgery, shortened the time to surgery, and decreased hospital length of stay, according to a review of 730 admissions.

"A multidisciplinary approach to guideline development and implementation for small bowel obstruction improved overall efficiency and resource utilization in the hospital, and appeared to decrease readmission for SBO [small bowel obstruction] in the short term," Dr. Wendy L. Wahl said at the annual meeting of the Central Surgical Association.

Patrice Wendling/IMNG Medical Media

She observed that prior to the guidelines, a controversy existed at the University of Michigan, Ann Arbor, over where SBO patients should be admitted, particularly those who didn’t need surgery or who had partial obstructions. This raised questions of whether there were delays in operative intervention or delays in admission from the emergency room. For some, there was also a sense that too many patients were being admitted to the medicine service with partial, or even full, obstructions.

As a result, the university’s Surgery Quality Improvement Committee partnered with the departments of surgery, medicine, and emergency medicine to create an SBO service triage and initial management guideline that was instituted in 2011. The new guidelines spell out that a patient will be admitted to a surgical service if a transition point or other concerning signs for bowel strangulation were identified on computed tomography (CT) or if the patient has had an abdominal surgery within the last 30 days.

Exceptions that may warrant medical service admission could be patients with: intra-abdominal metastases or active inflammatory bowel disease scheduled for a systemic therapy trial and acute, severe conditions requiring stabilization, explained Dr. Wahl, now the medical director of surgical quality at St. Joseph Mercy Hospital, also in Ann Arbor. Patients with known dilated bowel secondary to dysmotility problems or other medical conditions such cystic fibrosis or mental/developmental disorders could also be admitted to medicine.

The guidelines de-emphasize the use of CT scans in the absence of an absolute indication for an emergent surgical consultation such as free air, peritonitis, nonreducible symptomatic hernia, or abdominal surgery in the last 30 days. The guidelines also stress an early general surgical consultation as part of initial therapy, she added.

The investigators compared data for 490 patients admitted for SBO during 2010 with 240 patients admitted for SBO during the first 6 months of 2011 after guideline implementation. Age (roughly 57 years) and sex did not differ significantly between groups for the two time periods. All-Patient Refined Diagnostic Related Groups scores pre- and post-implementation were lower at 1.78 and 1.56 in the surgical service, compared with 3.52 and 2.23 in the medical service.

After implementation, the mean time to surgery fell significantly from 0.9 days to 0.4 days among surgical patients (P value less than .05) and from 7.6 days to 3.6 days among those admitted to medicine (P less than .001).

The percent of patients admitted to a medicine service requiring surgery for SBO did not change significantly from 14% in 2010 to 7% in 2011, but the reasons did, Dr. Wahl said. Of the 26 patients admitted to a medicine service in 2010, five had clear bowel obstructions and no reason for a medical admission, four had a missed SBO in the emergency room, and four had a late surgery consultation.

"About half of the patients could have had their process improved," she observed.

In contrast, all seven SBO patients admitted to medicine in 2011 had documented active medical issues such as myocardial infarction and lobe transplant rejection.

After guideline implementation, time to general surgery consultation among medical patients was significantly shorter at 1.7 days vs. 3.4 days (P less than .001).

The rate of SBO admissions to surgery also rose from 55% to 66% (P less than .01), while the rate of operative interventions increased from 36% to 45% (P less than .05).

Notably, the rate of readmission for SBO nonoperative patients fell from 16% to 6% after guideline implementation (P less than .01), Dr. Wahl said. Hospital length of stay decreased from 8 days to 6 days in the surgical group and from 31 days to 13 days in the medical group.

Invited discussant Dr. Fred Luchette, professor of surgery at Loyola University Chicago, Maywood, Ill., observed that SBO accounts for 15% of surgical admissions in the United States and that treatment costs exceed $1 billion.

"The improvement in care for these patients with your guideline is a step in the right direction for improving patient outcomes," he stated.

Notably, the average cost of care did not change significantly from $20,530 to $22,554 in the surgical group and from $49,956 to $36,726 in the medical group.

Dr. Luchette asked why the medical service is allowed to admit any patient with a bowel obstruction, and why medical patients waited 3 days for surgery whereas surgical patients underwent surgery that day. The surgical delay is particularly vexing given the "liberal" use of CT scans post guideline implementation at 83% among medical patients.

Dr. Wahl agreed that CT use for the medical service was liberal, but pointed out that the vast majority of these patients had other medical issues that required further investigation to differentiate whether surgery was indicated. The delay in time to laparotomy could be explained by the need to stabilize medical patients prior to surgery or the need to wait to assess improvement following medical therapy.

Dr. Wahl admitted to being somewhat surprised at the number of SBO patients who went to the medical service before guideline implementation, but reminded the audience that a lot of patients with small bowel obstructions may simply feel a "little burpy" and may not manifest with full-blown symptoms.

"There’s probably a lot of people with bowel obstructions that are never seen by a surgeon that you don’t really know about until you look, unfortunately," she said. "In this day and age where there is a limit to the amount of resident and physician capacity, you really want patients to go where they’d be best served."

When asked by the audience how the university achieved buy-in for the project and how the guidelines were disseminated, Dr. Wahl said buy-in was relatively easy since practitioners recognized there was a problem and the guidelines were posted on-line.

Dr. Wahl and her coauthors reported no conflicts of interest.

MADISON, WIS. – Implementation of a small bowel obstruction guideline increased admissions to surgery, shortened the time to surgery, and decreased hospital length of stay, according to a review of 730 admissions.

"A multidisciplinary approach to guideline development and implementation for small bowel obstruction improved overall efficiency and resource utilization in the hospital, and appeared to decrease readmission for SBO [small bowel obstruction] in the short term," Dr. Wendy L. Wahl said at the annual meeting of the Central Surgical Association.

Patrice Wendling/IMNG Medical Media

She observed that prior to the guidelines, a controversy existed at the University of Michigan, Ann Arbor, over where SBO patients should be admitted, particularly those who didn’t need surgery or who had partial obstructions. This raised questions of whether there were delays in operative intervention or delays in admission from the emergency room. For some, there was also a sense that too many patients were being admitted to the medicine service with partial, or even full, obstructions.

As a result, the university’s Surgery Quality Improvement Committee partnered with the departments of surgery, medicine, and emergency medicine to create an SBO service triage and initial management guideline that was instituted in 2011. The new guidelines spell out that a patient will be admitted to a surgical service if a transition point or other concerning signs for bowel strangulation were identified on computed tomography (CT) or if the patient has had an abdominal surgery within the last 30 days.

Exceptions that may warrant medical service admission could be patients with: intra-abdominal metastases or active inflammatory bowel disease scheduled for a systemic therapy trial and acute, severe conditions requiring stabilization, explained Dr. Wahl, now the medical director of surgical quality at St. Joseph Mercy Hospital, also in Ann Arbor. Patients with known dilated bowel secondary to dysmotility problems or other medical conditions such cystic fibrosis or mental/developmental disorders could also be admitted to medicine.

The guidelines de-emphasize the use of CT scans in the absence of an absolute indication for an emergent surgical consultation such as free air, peritonitis, nonreducible symptomatic hernia, or abdominal surgery in the last 30 days. The guidelines also stress an early general surgical consultation as part of initial therapy, she added.

The investigators compared data for 490 patients admitted for SBO during 2010 with 240 patients admitted for SBO during the first 6 months of 2011 after guideline implementation. Age (roughly 57 years) and sex did not differ significantly between groups for the two time periods. All-Patient Refined Diagnostic Related Groups scores pre- and post-implementation were lower at 1.78 and 1.56 in the surgical service, compared with 3.52 and 2.23 in the medical service.

After implementation, the mean time to surgery fell significantly from 0.9 days to 0.4 days among surgical patients (P value less than .05) and from 7.6 days to 3.6 days among those admitted to medicine (P less than .001).

The percent of patients admitted to a medicine service requiring surgery for SBO did not change significantly from 14% in 2010 to 7% in 2011, but the reasons did, Dr. Wahl said. Of the 26 patients admitted to a medicine service in 2010, five had clear bowel obstructions and no reason for a medical admission, four had a missed SBO in the emergency room, and four had a late surgery consultation.

"About half of the patients could have had their process improved," she observed.

In contrast, all seven SBO patients admitted to medicine in 2011 had documented active medical issues such as myocardial infarction and lobe transplant rejection.

After guideline implementation, time to general surgery consultation among medical patients was significantly shorter at 1.7 days vs. 3.4 days (P less than .001).

The rate of SBO admissions to surgery also rose from 55% to 66% (P less than .01), while the rate of operative interventions increased from 36% to 45% (P less than .05).

Notably, the rate of readmission for SBO nonoperative patients fell from 16% to 6% after guideline implementation (P less than .01), Dr. Wahl said. Hospital length of stay decreased from 8 days to 6 days in the surgical group and from 31 days to 13 days in the medical group.

Invited discussant Dr. Fred Luchette, professor of surgery at Loyola University Chicago, Maywood, Ill., observed that SBO accounts for 15% of surgical admissions in the United States and that treatment costs exceed $1 billion.

"The improvement in care for these patients with your guideline is a step in the right direction for improving patient outcomes," he stated.

Notably, the average cost of care did not change significantly from $20,530 to $22,554 in the surgical group and from $49,956 to $36,726 in the medical group.

Dr. Luchette asked why the medical service is allowed to admit any patient with a bowel obstruction, and why medical patients waited 3 days for surgery whereas surgical patients underwent surgery that day. The surgical delay is particularly vexing given the "liberal" use of CT scans post guideline implementation at 83% among medical patients.

Dr. Wahl agreed that CT use for the medical service was liberal, but pointed out that the vast majority of these patients had other medical issues that required further investigation to differentiate whether surgery was indicated. The delay in time to laparotomy could be explained by the need to stabilize medical patients prior to surgery or the need to wait to assess improvement following medical therapy.

Dr. Wahl admitted to being somewhat surprised at the number of SBO patients who went to the medical service before guideline implementation, but reminded the audience that a lot of patients with small bowel obstructions may simply feel a "little burpy" and may not manifest with full-blown symptoms.

"There’s probably a lot of people with bowel obstructions that are never seen by a surgeon that you don’t really know about until you look, unfortunately," she said. "In this day and age where there is a limit to the amount of resident and physician capacity, you really want patients to go where they’d be best served."

When asked by the audience how the university achieved buy-in for the project and how the guidelines were disseminated, Dr. Wahl said buy-in was relatively easy since practitioners recognized there was a problem and the guidelines were posted on-line.

Dr. Wahl and her coauthors reported no conflicts of interest.

MADISON, WIS. – Implementation of a small bowel obstruction guideline increased admissions to surgery, shortened the time to surgery, and decreased hospital length of stay, according to a review of 730 admissions.

"A multidisciplinary approach to guideline development and implementation for small bowel obstruction improved overall efficiency and resource utilization in the hospital, and appeared to decrease readmission for SBO [small bowel obstruction] in the short term," Dr. Wendy L. Wahl said at the annual meeting of the Central Surgical Association.

Patrice Wendling/IMNG Medical Media

She observed that prior to the guidelines, a controversy existed at the University of Michigan, Ann Arbor, over where SBO patients should be admitted, particularly those who didn’t need surgery or who had partial obstructions. This raised questions of whether there were delays in operative intervention or delays in admission from the emergency room. For some, there was also a sense that too many patients were being admitted to the medicine service with partial, or even full, obstructions.

As a result, the university’s Surgery Quality Improvement Committee partnered with the departments of surgery, medicine, and emergency medicine to create an SBO service triage and initial management guideline that was instituted in 2011. The new guidelines spell out that a patient will be admitted to a surgical service if a transition point or other concerning signs for bowel strangulation were identified on computed tomography (CT) or if the patient has had an abdominal surgery within the last 30 days.

Exceptions that may warrant medical service admission could be patients with: intra-abdominal metastases or active inflammatory bowel disease scheduled for a systemic therapy trial and acute, severe conditions requiring stabilization, explained Dr. Wahl, now the medical director of surgical quality at St. Joseph Mercy Hospital, also in Ann Arbor. Patients with known dilated bowel secondary to dysmotility problems or other medical conditions such cystic fibrosis or mental/developmental disorders could also be admitted to medicine.

The guidelines de-emphasize the use of CT scans in the absence of an absolute indication for an emergent surgical consultation such as free air, peritonitis, nonreducible symptomatic hernia, or abdominal surgery in the last 30 days. The guidelines also stress an early general surgical consultation as part of initial therapy, she added.

The investigators compared data for 490 patients admitted for SBO during 2010 with 240 patients admitted for SBO during the first 6 months of 2011 after guideline implementation. Age (roughly 57 years) and sex did not differ significantly between groups for the two time periods. All-Patient Refined Diagnostic Related Groups scores pre- and post-implementation were lower at 1.78 and 1.56 in the surgical service, compared with 3.52 and 2.23 in the medical service.

After implementation, the mean time to surgery fell significantly from 0.9 days to 0.4 days among surgical patients (P value less than .05) and from 7.6 days to 3.6 days among those admitted to medicine (P less than .001).

The percent of patients admitted to a medicine service requiring surgery for SBO did not change significantly from 14% in 2010 to 7% in 2011, but the reasons did, Dr. Wahl said. Of the 26 patients admitted to a medicine service in 2010, five had clear bowel obstructions and no reason for a medical admission, four had a missed SBO in the emergency room, and four had a late surgery consultation.

"About half of the patients could have had their process improved," she observed.

In contrast, all seven SBO patients admitted to medicine in 2011 had documented active medical issues such as myocardial infarction and lobe transplant rejection.

After guideline implementation, time to general surgery consultation among medical patients was significantly shorter at 1.7 days vs. 3.4 days (P less than .001).

The rate of SBO admissions to surgery also rose from 55% to 66% (P less than .01), while the rate of operative interventions increased from 36% to 45% (P less than .05).

Notably, the rate of readmission for SBO nonoperative patients fell from 16% to 6% after guideline implementation (P less than .01), Dr. Wahl said. Hospital length of stay decreased from 8 days to 6 days in the surgical group and from 31 days to 13 days in the medical group.

Invited discussant Dr. Fred Luchette, professor of surgery at Loyola University Chicago, Maywood, Ill., observed that SBO accounts for 15% of surgical admissions in the United States and that treatment costs exceed $1 billion.

"The improvement in care for these patients with your guideline is a step in the right direction for improving patient outcomes," he stated.

Notably, the average cost of care did not change significantly from $20,530 to $22,554 in the surgical group and from $49,956 to $36,726 in the medical group.

Dr. Luchette asked why the medical service is allowed to admit any patient with a bowel obstruction, and why medical patients waited 3 days for surgery whereas surgical patients underwent surgery that day. The surgical delay is particularly vexing given the "liberal" use of CT scans post guideline implementation at 83% among medical patients.

Dr. Wahl agreed that CT use for the medical service was liberal, but pointed out that the vast majority of these patients had other medical issues that required further investigation to differentiate whether surgery was indicated. The delay in time to laparotomy could be explained by the need to stabilize medical patients prior to surgery or the need to wait to assess improvement following medical therapy.

Dr. Wahl admitted to being somewhat surprised at the number of SBO patients who went to the medical service before guideline implementation, but reminded the audience that a lot of patients with small bowel obstructions may simply feel a "little burpy" and may not manifest with full-blown symptoms.

"There’s probably a lot of people with bowel obstructions that are never seen by a surgeon that you don’t really know about until you look, unfortunately," she said. "In this day and age where there is a limit to the amount of resident and physician capacity, you really want patients to go where they’d be best served."

When asked by the audience how the university achieved buy-in for the project and how the guidelines were disseminated, Dr. Wahl said buy-in was relatively easy since practitioners recognized there was a problem and the guidelines were posted on-line.

Dr. Wahl and her coauthors reported no conflicts of interest.