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Asymptomatic C. diff carriers have increased risk of symptomatic infection
Background: C. difficile infections (CDI) are significant with more than 400,000 cases and almost 30,000 deaths annually. However, there is uncertainty regarding asymptomatic C. difficile carriers and whether they have higher rates of progression to symptomatic infections.
Study design: Prospective cohort study.
Setting: Large university hospital in the New York from July 2017 through March 2018.
Synopsis: Patients admitted were screened, enrolled, and tested to include an adequate sample of nursing facility residents because of prior studies that showed nursing facility residents with a higher prevalence of carriage. Patients underwent perirectal swabbing and stool swabbing if available. Test swab soilage, noted as any visible material on the swab, was noted and recorded. Two stool-testing methods were used to test for carriage. A C. difficile carrier was defined as any patient with a positive test without diarrhea. Patients were followed for 6 months or until death; 220 patients were enrolled, with 21 patients (9.6%) asymptomatic C. difficile carriers. Having a soiled swab was the only statistically significant characteristic, including previous antibiotic exposure within the past 90 days, to be associated with carriage; 8 of 21 (38.1%) carriage patients progressed to CDI within 6 months versus 4 of 199 (2.0%) noncarriage patients. Most carriers that progressed to CDI did so within 2 weeks of enrollment. Limitations included lower numbers of expected carriage patients, diarrhea diagnosing variability, and perirectal swabbing was used rather than rectal swabbing/stool testing.
Bottom line: Asymptomatic carriage of C. difficile has increased risk of progression to symptomatic CDI and could present an opportunity for screening to reduce CDI in the inpatient setting.
Citation: Baron SW et al. Screening of Clostridioides difficile carriers in an urban academic medical center: Understanding implications of disease. Infect Control Hosp Epidemiol. 2020;41(2):149-53.
Dr. Wang is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.
Background: C. difficile infections (CDI) are significant with more than 400,000 cases and almost 30,000 deaths annually. However, there is uncertainty regarding asymptomatic C. difficile carriers and whether they have higher rates of progression to symptomatic infections.
Study design: Prospective cohort study.
Setting: Large university hospital in the New York from July 2017 through March 2018.
Synopsis: Patients admitted were screened, enrolled, and tested to include an adequate sample of nursing facility residents because of prior studies that showed nursing facility residents with a higher prevalence of carriage. Patients underwent perirectal swabbing and stool swabbing if available. Test swab soilage, noted as any visible material on the swab, was noted and recorded. Two stool-testing methods were used to test for carriage. A C. difficile carrier was defined as any patient with a positive test without diarrhea. Patients were followed for 6 months or until death; 220 patients were enrolled, with 21 patients (9.6%) asymptomatic C. difficile carriers. Having a soiled swab was the only statistically significant characteristic, including previous antibiotic exposure within the past 90 days, to be associated with carriage; 8 of 21 (38.1%) carriage patients progressed to CDI within 6 months versus 4 of 199 (2.0%) noncarriage patients. Most carriers that progressed to CDI did so within 2 weeks of enrollment. Limitations included lower numbers of expected carriage patients, diarrhea diagnosing variability, and perirectal swabbing was used rather than rectal swabbing/stool testing.
Bottom line: Asymptomatic carriage of C. difficile has increased risk of progression to symptomatic CDI and could present an opportunity for screening to reduce CDI in the inpatient setting.
Citation: Baron SW et al. Screening of Clostridioides difficile carriers in an urban academic medical center: Understanding implications of disease. Infect Control Hosp Epidemiol. 2020;41(2):149-53.
Dr. Wang is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.
Background: C. difficile infections (CDI) are significant with more than 400,000 cases and almost 30,000 deaths annually. However, there is uncertainty regarding asymptomatic C. difficile carriers and whether they have higher rates of progression to symptomatic infections.
Study design: Prospective cohort study.
Setting: Large university hospital in the New York from July 2017 through March 2018.
Synopsis: Patients admitted were screened, enrolled, and tested to include an adequate sample of nursing facility residents because of prior studies that showed nursing facility residents with a higher prevalence of carriage. Patients underwent perirectal swabbing and stool swabbing if available. Test swab soilage, noted as any visible material on the swab, was noted and recorded. Two stool-testing methods were used to test for carriage. A C. difficile carrier was defined as any patient with a positive test without diarrhea. Patients were followed for 6 months or until death; 220 patients were enrolled, with 21 patients (9.6%) asymptomatic C. difficile carriers. Having a soiled swab was the only statistically significant characteristic, including previous antibiotic exposure within the past 90 days, to be associated with carriage; 8 of 21 (38.1%) carriage patients progressed to CDI within 6 months versus 4 of 199 (2.0%) noncarriage patients. Most carriers that progressed to CDI did so within 2 weeks of enrollment. Limitations included lower numbers of expected carriage patients, diarrhea diagnosing variability, and perirectal swabbing was used rather than rectal swabbing/stool testing.
Bottom line: Asymptomatic carriage of C. difficile has increased risk of progression to symptomatic CDI and could present an opportunity for screening to reduce CDI in the inpatient setting.
Citation: Baron SW et al. Screening of Clostridioides difficile carriers in an urban academic medical center: Understanding implications of disease. Infect Control Hosp Epidemiol. 2020;41(2):149-53.
Dr. Wang is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.
Default EMR settings can influence opioid prescribing
Background: The opioid crisis is in the forefront as a public health emergency and there are concerns regarding addiction stemming from opioid prescriptions written in the acute setting, such as the ED and hospitals.
Study design: Quality improvement project, randomized.
Setting: Two large EDs in San Francisco and Oakland, Calif.
Synopsis: In five 4-week blocks, the prepopulated opioid dispense quantities were altered on a block randomized treatment schedule without prior knowledge by the prescribing practitioners with the default dispense quantities of 5, 10, 15, and null (prescriber determined dispense quantity). Opiates included oxycodone, oxycodone/acetaminophen, and hydrocodone/acetaminophen. The primary outcome was number of opioid tablets prescribed at discharge from the ED. In this study, a total of 104 health care professionals issued 4,320 opioid study prescriptions. With use of linear regression, an increase of 0.19 tablets prescribed was found for each tablet increase in default quantity. When comparing default pairs – that is, 5 versus 15 tablets – a lower default was associated with a lower number of pills prescribed in more than half of the comparisons. Limitations of this study include a small sample of EDs, and local prescribing patterns can vary greatly for opioid prescriptions written. In addition, the reasons for the prescriptions were not noted.
Bottom line: Default EMR opioid quantity settings can be used to decrease the quantity of opioids prescribed.
Citation: Montoy JCC et al. Association of default electronic medical record settings with health care professional patterns of opioid prescribing in emergency departments: A randomized quality improvement study. JAMA Intern Med. 2020;180(4):487-93.
Dr. Wang is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.
Background: The opioid crisis is in the forefront as a public health emergency and there are concerns regarding addiction stemming from opioid prescriptions written in the acute setting, such as the ED and hospitals.
Study design: Quality improvement project, randomized.
Setting: Two large EDs in San Francisco and Oakland, Calif.
Synopsis: In five 4-week blocks, the prepopulated opioid dispense quantities were altered on a block randomized treatment schedule without prior knowledge by the prescribing practitioners with the default dispense quantities of 5, 10, 15, and null (prescriber determined dispense quantity). Opiates included oxycodone, oxycodone/acetaminophen, and hydrocodone/acetaminophen. The primary outcome was number of opioid tablets prescribed at discharge from the ED. In this study, a total of 104 health care professionals issued 4,320 opioid study prescriptions. With use of linear regression, an increase of 0.19 tablets prescribed was found for each tablet increase in default quantity. When comparing default pairs – that is, 5 versus 15 tablets – a lower default was associated with a lower number of pills prescribed in more than half of the comparisons. Limitations of this study include a small sample of EDs, and local prescribing patterns can vary greatly for opioid prescriptions written. In addition, the reasons for the prescriptions were not noted.
Bottom line: Default EMR opioid quantity settings can be used to decrease the quantity of opioids prescribed.
Citation: Montoy JCC et al. Association of default electronic medical record settings with health care professional patterns of opioid prescribing in emergency departments: A randomized quality improvement study. JAMA Intern Med. 2020;180(4):487-93.
Dr. Wang is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.
Background: The opioid crisis is in the forefront as a public health emergency and there are concerns regarding addiction stemming from opioid prescriptions written in the acute setting, such as the ED and hospitals.
Study design: Quality improvement project, randomized.
Setting: Two large EDs in San Francisco and Oakland, Calif.
Synopsis: In five 4-week blocks, the prepopulated opioid dispense quantities were altered on a block randomized treatment schedule without prior knowledge by the prescribing practitioners with the default dispense quantities of 5, 10, 15, and null (prescriber determined dispense quantity). Opiates included oxycodone, oxycodone/acetaminophen, and hydrocodone/acetaminophen. The primary outcome was number of opioid tablets prescribed at discharge from the ED. In this study, a total of 104 health care professionals issued 4,320 opioid study prescriptions. With use of linear regression, an increase of 0.19 tablets prescribed was found for each tablet increase in default quantity. When comparing default pairs – that is, 5 versus 15 tablets – a lower default was associated with a lower number of pills prescribed in more than half of the comparisons. Limitations of this study include a small sample of EDs, and local prescribing patterns can vary greatly for opioid prescriptions written. In addition, the reasons for the prescriptions were not noted.
Bottom line: Default EMR opioid quantity settings can be used to decrease the quantity of opioids prescribed.
Citation: Montoy JCC et al. Association of default electronic medical record settings with health care professional patterns of opioid prescribing in emergency departments: A randomized quality improvement study. JAMA Intern Med. 2020;180(4):487-93.
Dr. Wang is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.
POCUS for hospitalists: The SHM position statement
Background: POCUS is becoming more prevalent in the daily practice of hospitalists; however, there are currently no established standards or guidelines for the use of POCUS for hospitalists.
Study design: Position statement.
Setting: SHM Executive Committee and Multi-Institutional POCUS faculty meeting through the Society of Hospital Medicine 2018 Annual Conference reviewed and approved this statement.
Synopsis: In contrast to the comprehensive ultrasound exam, POCUS is used by hospitalists to answer focused questions, by the same clinician who is generating the clinical question, to evaluate multiple body systems, or to serially investigate changes clinical status or evaluate responses to therapy.
This position statement provides guidance on the use of POCUS by hospitalists and the administrators who oversee it by outlining POCUS in terms of common diagnostic and procedural applications; training; assessments by the categories of basic knowledge, image acquisition, interpretation, clinical integration, and certification and maintenance of skills; and program management.
Bottom line: This position statement by the SHM provides guidance for hospitalists and administrators on the use and oversight of POCUS.
Citation: Soni NJ et al. Point-of-care ultrasound for hospitalists: A position statement of the Society of Hospital Medicine. J Hosp Med. 2019 Jan 2;14:E1-E6.
Dr. Wang is an associate professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.
Background: POCUS is becoming more prevalent in the daily practice of hospitalists; however, there are currently no established standards or guidelines for the use of POCUS for hospitalists.
Study design: Position statement.
Setting: SHM Executive Committee and Multi-Institutional POCUS faculty meeting through the Society of Hospital Medicine 2018 Annual Conference reviewed and approved this statement.
Synopsis: In contrast to the comprehensive ultrasound exam, POCUS is used by hospitalists to answer focused questions, by the same clinician who is generating the clinical question, to evaluate multiple body systems, or to serially investigate changes clinical status or evaluate responses to therapy.
This position statement provides guidance on the use of POCUS by hospitalists and the administrators who oversee it by outlining POCUS in terms of common diagnostic and procedural applications; training; assessments by the categories of basic knowledge, image acquisition, interpretation, clinical integration, and certification and maintenance of skills; and program management.
Bottom line: This position statement by the SHM provides guidance for hospitalists and administrators on the use and oversight of POCUS.
Citation: Soni NJ et al. Point-of-care ultrasound for hospitalists: A position statement of the Society of Hospital Medicine. J Hosp Med. 2019 Jan 2;14:E1-E6.
Dr. Wang is an associate professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.
Background: POCUS is becoming more prevalent in the daily practice of hospitalists; however, there are currently no established standards or guidelines for the use of POCUS for hospitalists.
Study design: Position statement.
Setting: SHM Executive Committee and Multi-Institutional POCUS faculty meeting through the Society of Hospital Medicine 2018 Annual Conference reviewed and approved this statement.
Synopsis: In contrast to the comprehensive ultrasound exam, POCUS is used by hospitalists to answer focused questions, by the same clinician who is generating the clinical question, to evaluate multiple body systems, or to serially investigate changes clinical status or evaluate responses to therapy.
This position statement provides guidance on the use of POCUS by hospitalists and the administrators who oversee it by outlining POCUS in terms of common diagnostic and procedural applications; training; assessments by the categories of basic knowledge, image acquisition, interpretation, clinical integration, and certification and maintenance of skills; and program management.
Bottom line: This position statement by the SHM provides guidance for hospitalists and administrators on the use and oversight of POCUS.
Citation: Soni NJ et al. Point-of-care ultrasound for hospitalists: A position statement of the Society of Hospital Medicine. J Hosp Med. 2019 Jan 2;14:E1-E6.
Dr. Wang is an associate professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.
Effects of hospitalization on readmission rate
Background: There is increasing concern that the patient experience in the hospital may be associated with post-hospital adverse outcomes, including new or recurrent illnesses after discharge or unplanned return to the hospital or readmission.
Study design: Prospective cohort that included 207 patients.
Setting: Two academic hospitals in Toronto.
Synopsis: These patients had been admitted to the internal medicine ward for more than 48 hours and were interviewed at discharge using a standardized questionnaire to assess four domains of the trauma of hospitalization defined as the cumulative effects of patient-reported sleep disturbance, mobility, nutrition, and mood. Among these patients, 64.3% experienced disturbance in more than one domain, and patients who experienced disturbance in three to four domains had a 15.8% greater absolute risk of 30-day readmission or ED visit.
Because this is an observational study, causal inferences were not possible; however, hospitalists should keep in mind the possible association of the patient experience and the link to clinical outcomes.
Bottom line: Trauma of hospitalization is common and may be associated with an increased 30-day risk of readmission or ED visit.
Citation: Rawal J et al. Association of the trauma of hospitalization with 30-day readmission or emergency department visit. JAMA Intern Med. 2019;179(1):38-45.
Dr. Wang is an associate professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.
Background: There is increasing concern that the patient experience in the hospital may be associated with post-hospital adverse outcomes, including new or recurrent illnesses after discharge or unplanned return to the hospital or readmission.
Study design: Prospective cohort that included 207 patients.
Setting: Two academic hospitals in Toronto.
Synopsis: These patients had been admitted to the internal medicine ward for more than 48 hours and were interviewed at discharge using a standardized questionnaire to assess four domains of the trauma of hospitalization defined as the cumulative effects of patient-reported sleep disturbance, mobility, nutrition, and mood. Among these patients, 64.3% experienced disturbance in more than one domain, and patients who experienced disturbance in three to four domains had a 15.8% greater absolute risk of 30-day readmission or ED visit.
Because this is an observational study, causal inferences were not possible; however, hospitalists should keep in mind the possible association of the patient experience and the link to clinical outcomes.
Bottom line: Trauma of hospitalization is common and may be associated with an increased 30-day risk of readmission or ED visit.
Citation: Rawal J et al. Association of the trauma of hospitalization with 30-day readmission or emergency department visit. JAMA Intern Med. 2019;179(1):38-45.
Dr. Wang is an associate professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.
Background: There is increasing concern that the patient experience in the hospital may be associated with post-hospital adverse outcomes, including new or recurrent illnesses after discharge or unplanned return to the hospital or readmission.
Study design: Prospective cohort that included 207 patients.
Setting: Two academic hospitals in Toronto.
Synopsis: These patients had been admitted to the internal medicine ward for more than 48 hours and were interviewed at discharge using a standardized questionnaire to assess four domains of the trauma of hospitalization defined as the cumulative effects of patient-reported sleep disturbance, mobility, nutrition, and mood. Among these patients, 64.3% experienced disturbance in more than one domain, and patients who experienced disturbance in three to four domains had a 15.8% greater absolute risk of 30-day readmission or ED visit.
Because this is an observational study, causal inferences were not possible; however, hospitalists should keep in mind the possible association of the patient experience and the link to clinical outcomes.
Bottom line: Trauma of hospitalization is common and may be associated with an increased 30-day risk of readmission or ED visit.
Citation: Rawal J et al. Association of the trauma of hospitalization with 30-day readmission or emergency department visit. JAMA Intern Med. 2019;179(1):38-45.
Dr. Wang is an associate professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.