Team

I attended the HM13 breakout session “Success Stories: How to Integrate NPs and PAs into a Hospitalist Practice,” which featured Timothy Capstack, MD, a hospitalist at Maryland Inpatient Care Specialists, James Levy, a physician assistant/hospitalist at Hospitalists of Northern Michigan, Kaine Brown, MD, a hospitalist at Tift Regional Medical Center, and Justin Psaila, MD, a hospitalist at St. Luke’s University Hospital and Health Network. Judging from the attendance, this is a very relevant topic. It seems every group is looking to hire NP/PAs, and most want to learn how to successfully incorporate them into a hospitalist practice.

Dr. Psaila explained the first key to success is hiring “beyond the basics,” meaning that it is not enough to be a good clinician, you must also hire a good fit to your practice culture. Additionally, NPs/PAs need to be part of a team they can rely on. He said critical-thinking skills are a much better asset for an NP/PA than technical procedural skills.

Levy agreed, and noted successful integration starts with getting the “right people on the bus.” HM groups should develop a thoughtful, consistent hiring process—and be willing to cut loose a provider if they are not a good fit. He also thinks it is important to have a lead NP/PA, so new hires know where to turn.

Dr. Brown found successful integration when his group turned to NP/PAs to run the post-discharge transition clinic. His group’s NP/PAs are helping reduce readmissions, improve patient/provider communication, and supporting the social and emotional needs of patients.

Watch a 2-minute video clip of Bob Wachter's HM13 keynote address

Dr. Capstack agreed that HM groups have to “hire right.” Hospitalist NP/PAs need to communicate well and be a team player, but also “know what they don’t know.” If the skill set is right, and you create a culture of collaboration, he said success is guaranteed.

All of the presenters agreed NP/PAs in hospital medicine are here to stay, and that they can be an asset to any HM group. TH

Tracy Cardin is a nurse practitioner in the Section of Hospital Medicine at the University of Chicago.

I attended the HM13 breakout session “Success Stories: How to Integrate NPs and PAs into a Hospitalist Practice,” which featured Timothy Capstack, MD, a hospitalist at Maryland Inpatient Care Specialists, James Levy, a physician assistant/hospitalist at Hospitalists of Northern Michigan, Kaine Brown, MD, a hospitalist at Tift Regional Medical Center, and Justin Psaila, MD, a hospitalist at St. Luke’s University Hospital and Health Network. Judging from the attendance, this is a very relevant topic. It seems every group is looking to hire NP/PAs, and most want to learn how to successfully incorporate them into a hospitalist practice.

Dr. Psaila explained the first key to success is hiring “beyond the basics,” meaning that it is not enough to be a good clinician, you must also hire a good fit to your practice culture. Additionally, NPs/PAs need to be part of a team they can rely on. He said critical-thinking skills are a much better asset for an NP/PA than technical procedural skills.

Levy agreed, and noted successful integration starts with getting the “right people on the bus.” HM groups should develop a thoughtful, consistent hiring process—and be willing to cut loose a provider if they are not a good fit. He also thinks it is important to have a lead NP/PA, so new hires know where to turn.

Dr. Brown found successful integration when his group turned to NP/PAs to run the post-discharge transition clinic. His group’s NP/PAs are helping reduce readmissions, improve patient/provider communication, and supporting the social and emotional needs of patients.

Watch a 2-minute video clip of Bob Wachter's HM13 keynote address

Dr. Capstack agreed that HM groups have to “hire right.” Hospitalist NP/PAs need to communicate well and be a team player, but also “know what they don’t know.” If the skill set is right, and you create a culture of collaboration, he said success is guaranteed.

All of the presenters agreed NP/PAs in hospital medicine are here to stay, and that they can be an asset to any HM group. TH

Tracy Cardin is a nurse practitioner in the Section of Hospital Medicine at the University of Chicago.

I attended the HM13 breakout session “Success Stories: How to Integrate NPs and PAs into a Hospitalist Practice,” which featured Timothy Capstack, MD, a hospitalist at Maryland Inpatient Care Specialists, James Levy, a physician assistant/hospitalist at Hospitalists of Northern Michigan, Kaine Brown, MD, a hospitalist at Tift Regional Medical Center, and Justin Psaila, MD, a hospitalist at St. Luke’s University Hospital and Health Network. Judging from the attendance, this is a very relevant topic. It seems every group is looking to hire NP/PAs, and most want to learn how to successfully incorporate them into a hospitalist practice.

Dr. Psaila explained the first key to success is hiring “beyond the basics,” meaning that it is not enough to be a good clinician, you must also hire a good fit to your practice culture. Additionally, NPs/PAs need to be part of a team they can rely on. He said critical-thinking skills are a much better asset for an NP/PA than technical procedural skills.

Levy agreed, and noted successful integration starts with getting the “right people on the bus.” HM groups should develop a thoughtful, consistent hiring process—and be willing to cut loose a provider if they are not a good fit. He also thinks it is important to have a lead NP/PA, so new hires know where to turn.

Dr. Brown found successful integration when his group turned to NP/PAs to run the post-discharge transition clinic. His group’s NP/PAs are helping reduce readmissions, improve patient/provider communication, and supporting the social and emotional needs of patients.

Watch a 2-minute video clip of Bob Wachter's HM13 keynote address

Dr. Capstack agreed that HM groups have to “hire right.” Hospitalist NP/PAs need to communicate well and be a team player, but also “know what they don’t know.” If the skill set is right, and you create a culture of collaboration, he said success is guaranteed.

All of the presenters agreed NP/PAs in hospital medicine are here to stay, and that they can be an asset to any HM group. TH

Tracy Cardin is a nurse practitioner in the Section of Hospital Medicine at the University of Chicago.

Scott Flanders, MD, SFHM, director of the hospitalist program at the University of Michigan in Ann Arbor set out to answer three key questions in “rapid-fire” format during the “Pneumonia Update” at HM13.

1. Is procalcitonin ready for “prime time” in determining community-acquired pneumonia (CAP) treatment duration?
2. What is the utility of diagnostic testing in CAP patients?
3. How do you decide which pneumonia patients need broad-spectrum antibiotic coverage?

It turns out that lots of other countries follow procalcitonin levels as a marker of inflammation during CAP treatment. A 2012 Archives of Internal Medicine article notes that U.S. compliance with measuring procalcitonin levels is less than 40%, and monitoring these levels can help diagnosis and guide treatment and the duration of treatment. Procalcitonin is released in the blood in response to bacterial infection. It rises within four hours of infection (earlier than other markers such as CRP and ESR.) The degree and rate of rise is associated with severity; the rate of decline is associated with resolution. Numerous studies show that when providers correlate CAP treatment with procalcitonin levels there is a safe reduction in antibiotic days.

Dr. Flanders also examined the utility of diagnostic tests. In general, CAP outcomes are unchanged and management rarely is impacted by sputum collection. Within the ICU setting it is recommended to get sputum cultures, as it may have a role in healthcare-associated pneumonia, especially if a patient has a history of drug-resistant organisms.

With regard to blood culture analysis, only 4% to 7% of blood cultures are positive in CAP, with many of them being false positives. False positive cultures lead to a 50% increase in charges, and increase length of stay by 65%. A 2004 American Journal of Respiratory and Critical Care Medicine article recommends targeted blood culture screen that correctly detect 90% of bacteremia with 40% fewer cultures. It recommends that patients who are at risk for bacteremia (those with prior antibiotics, WBC count greater than 20, systolic BP less than 90, history of liver disease, temperature greater than 40 degrees or less than 35 degrees celsius, elevated BUN greater than 30, sodium less than 130, pulse greater than 125) be given a point for each risk factor. Those with no risk and no prior antibiotics were deemed safe to forgo cultures. Those with one risk factor, with prior antibiotics were recommended to get one set of cultures. Those with more than one risk factor were recommended to receive two sets of cultures.

Pneumococcal urinary antigen was evaluated. It is noted to have great specificity, but lousy sensitivity. Patients with bacteremia might have false negative results. In general, the antigen might be appropriate in non-severe cases if it will help you narrow therapy. But it shouldn’t be ordered if it is not going to change therapy.

Dr. Flanders also noted that urinary legionella antigen is 80% sensitive for legionella.

Answering the question about the need for broad-spectrum antibiotics, it was thought that any patient receiving home care or home wound care, goes to a dialysis center, lives in a NH or LTC facility would need broad-spectrum antibiotics for HCAP. But Dr. Flanders states it may be a case of doing too much too fast. He recommends patients that reside in nursing homes or who receive home care be treated as a CAP, as the risk of drug-resistant organisms isn’t actually that high in that group. But if a patient had previous admission to the hospital, he recommends treatment for HCAP.

Strong risk factors for resistant organisms include prior hospitalization in past 90 days, LTAC/SNF patients if they have had prior antibiotics and have poor functional status, critically-ill patients, or those with prior MRSA/pseudomonal infections. The data for nursing home patients, home health or home wound care or dialysis patients is less clear. TH

Tracy Cardin is a nurse practitioner in the section of hospital medicine at University of Chicago.

Scott Flanders, MD, SFHM, director of the hospitalist program at the University of Michigan in Ann Arbor set out to answer three key questions in “rapid-fire” format during the “Pneumonia Update” at HM13.

1. Is procalcitonin ready for “prime time” in determining community-acquired pneumonia (CAP) treatment duration?
2. What is the utility of diagnostic testing in CAP patients?
3. How do you decide which pneumonia patients need broad-spectrum antibiotic coverage?

It turns out that lots of other countries follow procalcitonin levels as a marker of inflammation during CAP treatment. A 2012 Archives of Internal Medicine article notes that U.S. compliance with measuring procalcitonin levels is less than 40%, and monitoring these levels can help diagnosis and guide treatment and the duration of treatment. Procalcitonin is released in the blood in response to bacterial infection. It rises within four hours of infection (earlier than other markers such as CRP and ESR.) The degree and rate of rise is associated with severity; the rate of decline is associated with resolution. Numerous studies show that when providers correlate CAP treatment with procalcitonin levels there is a safe reduction in antibiotic days.

Dr. Flanders also examined the utility of diagnostic tests. In general, CAP outcomes are unchanged and management rarely is impacted by sputum collection. Within the ICU setting it is recommended to get sputum cultures, as it may have a role in healthcare-associated pneumonia, especially if a patient has a history of drug-resistant organisms.

With regard to blood culture analysis, only 4% to 7% of blood cultures are positive in CAP, with many of them being false positives. False positive cultures lead to a 50% increase in charges, and increase length of stay by 65%. A 2004 American Journal of Respiratory and Critical Care Medicine article recommends targeted blood culture screen that correctly detect 90% of bacteremia with 40% fewer cultures. It recommends that patients who are at risk for bacteremia (those with prior antibiotics, WBC count greater than 20, systolic BP less than 90, history of liver disease, temperature greater than 40 degrees or less than 35 degrees celsius, elevated BUN greater than 30, sodium less than 130, pulse greater than 125) be given a point for each risk factor. Those with no risk and no prior antibiotics were deemed safe to forgo cultures. Those with one risk factor, with prior antibiotics were recommended to get one set of cultures. Those with more than one risk factor were recommended to receive two sets of cultures.

Pneumococcal urinary antigen was evaluated. It is noted to have great specificity, but lousy sensitivity. Patients with bacteremia might have false negative results. In general, the antigen might be appropriate in non-severe cases if it will help you narrow therapy. But it shouldn’t be ordered if it is not going to change therapy.

Dr. Flanders also noted that urinary legionella antigen is 80% sensitive for legionella.

Answering the question about the need for broad-spectrum antibiotics, it was thought that any patient receiving home care or home wound care, goes to a dialysis center, lives in a NH or LTC facility would need broad-spectrum antibiotics for HCAP. But Dr. Flanders states it may be a case of doing too much too fast. He recommends patients that reside in nursing homes or who receive home care be treated as a CAP, as the risk of drug-resistant organisms isn’t actually that high in that group. But if a patient had previous admission to the hospital, he recommends treatment for HCAP.

Strong risk factors for resistant organisms include prior hospitalization in past 90 days, LTAC/SNF patients if they have had prior antibiotics and have poor functional status, critically-ill patients, or those with prior MRSA/pseudomonal infections. The data for nursing home patients, home health or home wound care or dialysis patients is less clear. TH

Tracy Cardin is a nurse practitioner in the section of hospital medicine at University of Chicago.

Scott Flanders, MD, SFHM, director of the hospitalist program at the University of Michigan in Ann Arbor set out to answer three key questions in “rapid-fire” format during the “Pneumonia Update” at HM13.

1. Is procalcitonin ready for “prime time” in determining community-acquired pneumonia (CAP) treatment duration?
2. What is the utility of diagnostic testing in CAP patients?
3. How do you decide which pneumonia patients need broad-spectrum antibiotic coverage?

It turns out that lots of other countries follow procalcitonin levels as a marker of inflammation during CAP treatment. A 2012 Archives of Internal Medicine article notes that U.S. compliance with measuring procalcitonin levels is less than 40%, and monitoring these levels can help diagnosis and guide treatment and the duration of treatment. Procalcitonin is released in the blood in response to bacterial infection. It rises within four hours of infection (earlier than other markers such as CRP and ESR.) The degree and rate of rise is associated with severity; the rate of decline is associated with resolution. Numerous studies show that when providers correlate CAP treatment with procalcitonin levels there is a safe reduction in antibiotic days.

Dr. Flanders also examined the utility of diagnostic tests. In general, CAP outcomes are unchanged and management rarely is impacted by sputum collection. Within the ICU setting it is recommended to get sputum cultures, as it may have a role in healthcare-associated pneumonia, especially if a patient has a history of drug-resistant organisms.

With regard to blood culture analysis, only 4% to 7% of blood cultures are positive in CAP, with many of them being false positives. False positive cultures lead to a 50% increase in charges, and increase length of stay by 65%. A 2004 American Journal of Respiratory and Critical Care Medicine article recommends targeted blood culture screen that correctly detect 90% of bacteremia with 40% fewer cultures. It recommends that patients who are at risk for bacteremia (those with prior antibiotics, WBC count greater than 20, systolic BP less than 90, history of liver disease, temperature greater than 40 degrees or less than 35 degrees celsius, elevated BUN greater than 30, sodium less than 130, pulse greater than 125) be given a point for each risk factor. Those with no risk and no prior antibiotics were deemed safe to forgo cultures. Those with one risk factor, with prior antibiotics were recommended to get one set of cultures. Those with more than one risk factor were recommended to receive two sets of cultures.

Pneumococcal urinary antigen was evaluated. It is noted to have great specificity, but lousy sensitivity. Patients with bacteremia might have false negative results. In general, the antigen might be appropriate in non-severe cases if it will help you narrow therapy. But it shouldn’t be ordered if it is not going to change therapy.

Dr. Flanders also noted that urinary legionella antigen is 80% sensitive for legionella.

Answering the question about the need for broad-spectrum antibiotics, it was thought that any patient receiving home care or home wound care, goes to a dialysis center, lives in a NH or LTC facility would need broad-spectrum antibiotics for HCAP. But Dr. Flanders states it may be a case of doing too much too fast. He recommends patients that reside in nursing homes or who receive home care be treated as a CAP, as the risk of drug-resistant organisms isn’t actually that high in that group. But if a patient had previous admission to the hospital, he recommends treatment for HCAP.

Strong risk factors for resistant organisms include prior hospitalization in past 90 days, LTAC/SNF patients if they have had prior antibiotics and have poor functional status, critically-ill patients, or those with prior MRSA/pseudomonal infections. The data for nursing home patients, home health or home wound care or dialysis patients is less clear. TH

Tracy Cardin is a nurse practitioner in the section of hospital medicine at University of Chicago.

This presentation was a playful banter between two experts—Steven Cohn of Miller School of Medicine in Miami and Lenny Feldman of Johns Hopkins in Baltimore—who showed us the evidence (and lack thereof) for several perioperative matters.

Issue No. 1: Timing of non-cardiac surgery after cardiac stent placement. The AHA/ACC guidelines suggest waiting 12 months after placement of a drug-eluting stent and 30-45 days for bare -metal stents. The speakers suggested that, based on limited data, waiting only 6 months might be sufficient time for patients to undergo non cardiac surgery. They were in support of the 30-45 day waiting period for bare-metal stents.

Issue No. 2: Care approach for hip fracture patients. Current models include admission to the hospitalist or orthopaedic service, with varying thresholds for medical consultations and subsequent follow ups. Other systems utilize true comanagement models. Experience suggests higher satisfaction from nurses and surgeons when patients are comanaged by hospitalists, but do we as a specialty have enough resources in terms of manpower to be involved in comanaging all ortho and other surgical patients? Is it professionally satisfying for hospitalists to comanage and, ultimately, how are patient outcomes impacted when patients are comanaged by hospitalists?

Dr. Cohn suggested there is limited benefit in hospitalist comanagement of low-risk, straightforward cases. There is data suggesting decrease in time to surgery, decrease in uti,DVT, and pressure ulcers with medical comanagement.

Issue No. 3: Routine, post-operative troponin monitoring for silent myocardial infarcts. Data showed 65% of patients with post-op MIs will not have symptoms. They may have a troponin leak or ECG changes. The controversy is that even if we detect a post-op MI, there is no good data that any interventions (eg, aspirin and statins, transferring to CCU or telemetry, performing cardiac catherization) would improve the patient mortality. There is data that shows the higher the troponin leak in post-operative patients, the higher the mortality except in low risk patients.

Issue No. 4: Preoperative dosing of glargine insulin. There are no guidelines in the U.S. In the U.K., the National Health Services recommends continuing glargine at 100%, which is what Dr. Cohn recommends for patients with sugars greater than 120 and without kidney disease. Dr. Lenny Feldman was more inclined to reduce the glargine dosing for patients, taking it the night before or the morning of surgery. Reduction could be anywhere from 50% to 80% of the patient's usual dose. Certainly it is more safe to deal with hyperglycemia than it is to deal with hypoglycemia. However, we need to be mindful still of the complications associated with perioperative hypergylcemia. Ultimately, the dosing needs to be individualized and we can find the right balance to minimize both hypo and hyperglycemia in the perioperative period.

Dr. Ma is a member of Team Hospitalist.

This presentation was a playful banter between two experts—Steven Cohn of Miller School of Medicine in Miami and Lenny Feldman of Johns Hopkins in Baltimore—who showed us the evidence (and lack thereof) for several perioperative matters.

Issue No. 1: Timing of non-cardiac surgery after cardiac stent placement. The AHA/ACC guidelines suggest waiting 12 months after placement of a drug-eluting stent and 30-45 days for bare -metal stents. The speakers suggested that, based on limited data, waiting only 6 months might be sufficient time for patients to undergo non cardiac surgery. They were in support of the 30-45 day waiting period for bare-metal stents.

Issue No. 2: Care approach for hip fracture patients. Current models include admission to the hospitalist or orthopaedic service, with varying thresholds for medical consultations and subsequent follow ups. Other systems utilize true comanagement models. Experience suggests higher satisfaction from nurses and surgeons when patients are comanaged by hospitalists, but do we as a specialty have enough resources in terms of manpower to be involved in comanaging all ortho and other surgical patients? Is it professionally satisfying for hospitalists to comanage and, ultimately, how are patient outcomes impacted when patients are comanaged by hospitalists?

Dr. Cohn suggested there is limited benefit in hospitalist comanagement of low-risk, straightforward cases. There is data suggesting decrease in time to surgery, decrease in uti,DVT, and pressure ulcers with medical comanagement.

Issue No. 3: Routine, post-operative troponin monitoring for silent myocardial infarcts. Data showed 65% of patients with post-op MIs will not have symptoms. They may have a troponin leak or ECG changes. The controversy is that even if we detect a post-op MI, there is no good data that any interventions (eg, aspirin and statins, transferring to CCU or telemetry, performing cardiac catherization) would improve the patient mortality. There is data that shows the higher the troponin leak in post-operative patients, the higher the mortality except in low risk patients.

Issue No. 4: Preoperative dosing of glargine insulin. There are no guidelines in the U.S. In the U.K., the National Health Services recommends continuing glargine at 100%, which is what Dr. Cohn recommends for patients with sugars greater than 120 and without kidney disease. Dr. Lenny Feldman was more inclined to reduce the glargine dosing for patients, taking it the night before or the morning of surgery. Reduction could be anywhere from 50% to 80% of the patient's usual dose. Certainly it is more safe to deal with hyperglycemia than it is to deal with hypoglycemia. However, we need to be mindful still of the complications associated with perioperative hypergylcemia. Ultimately, the dosing needs to be individualized and we can find the right balance to minimize both hypo and hyperglycemia in the perioperative period.

Dr. Ma is a member of Team Hospitalist.

This presentation was a playful banter between two experts—Steven Cohn of Miller School of Medicine in Miami and Lenny Feldman of Johns Hopkins in Baltimore—who showed us the evidence (and lack thereof) for several perioperative matters.

Issue No. 1: Timing of non-cardiac surgery after cardiac stent placement. The AHA/ACC guidelines suggest waiting 12 months after placement of a drug-eluting stent and 30-45 days for bare -metal stents. The speakers suggested that, based on limited data, waiting only 6 months might be sufficient time for patients to undergo non cardiac surgery. They were in support of the 30-45 day waiting period for bare-metal stents.

Issue No. 2: Care approach for hip fracture patients. Current models include admission to the hospitalist or orthopaedic service, with varying thresholds for medical consultations and subsequent follow ups. Other systems utilize true comanagement models. Experience suggests higher satisfaction from nurses and surgeons when patients are comanaged by hospitalists, but do we as a specialty have enough resources in terms of manpower to be involved in comanaging all ortho and other surgical patients? Is it professionally satisfying for hospitalists to comanage and, ultimately, how are patient outcomes impacted when patients are comanaged by hospitalists?

Dr. Cohn suggested there is limited benefit in hospitalist comanagement of low-risk, straightforward cases. There is data suggesting decrease in time to surgery, decrease in uti,DVT, and pressure ulcers with medical comanagement.

Issue No. 3: Routine, post-operative troponin monitoring for silent myocardial infarcts. Data showed 65% of patients with post-op MIs will not have symptoms. They may have a troponin leak or ECG changes. The controversy is that even if we detect a post-op MI, there is no good data that any interventions (eg, aspirin and statins, transferring to CCU or telemetry, performing cardiac catherization) would improve the patient mortality. There is data that shows the higher the troponin leak in post-operative patients, the higher the mortality except in low risk patients.

Issue No. 4: Preoperative dosing of glargine insulin. There are no guidelines in the U.S. In the U.K., the National Health Services recommends continuing glargine at 100%, which is what Dr. Cohn recommends for patients with sugars greater than 120 and without kidney disease. Dr. Lenny Feldman was more inclined to reduce the glargine dosing for patients, taking it the night before or the morning of surgery. Reduction could be anywhere from 50% to 80% of the patient's usual dose. Certainly it is more safe to deal with hyperglycemia than it is to deal with hypoglycemia. However, we need to be mindful still of the complications associated with perioperative hypergylcemia. Ultimately, the dosing needs to be individualized and we can find the right balance to minimize both hypo and hyperglycemia in the perioperative period.

Dr. Ma is a member of Team Hospitalist.

I attended the practice-management session with an intriguing title, “Hospitalist Workload: Is 15 the Right Number?” My own group, as I am sure many are, is struggling with this very question.

Henry Michtalik, assistant professor and hospitalist from Johns Hopkins and associate faculty at the Armstrong Institute for Patient Safety and Quality talked about physician perceptions of workload and the impact of that perception on patient safety. He noted that 40% of physicans report that their typical census exceeds “safe” levels at least monthly. Multiple factors impact that perception, including the physicians’ years of experience and the presence of housestaff, as well as the total amount of clinical time yearly. Other factors that can influence this perception include the type of hospital, the ancillary team make-up, and the patient’s payer mix and acuity. Twenty percent of physicians reported that workload negatively impacted the hospitalist’s ability to discuss the plan of care or delayed discharge.

The JAMA Internal Medicine article from April 2013 that he wrote also noted, most interestingly, that fixed census caps decreased the odds of reporting an unsafe census by 34%. Bring ’em on!

Daniel Elliott presented data from his role as acting associate chair for research and co-director of ambulatory research and Clinical Outcomes at Chistiana Care Department of Medicine in Wilmington, Del. He undertook a study designed to answer the question: What is the impact of increased workload on clinical outcomes? He looked at key variables of length of stay, continuity, 24-hour average occupancy, and turn-around time (i.e., time between ordering a test until the time completed on five most commonly ordered tests by hospitalists).

What he learned is that a higher physician workload is associated with increasing LOS, but notably this association decreases as hospital occupancy increases, meaning that a less-busy hospital means that LOS is a hospitalist dependent variable and MORE sensitive to workload. Conversely, a more busy hospital’s LOS is hospital dependent and LESS sensitive to physician workload. This reveals the importance in collaboration between hospitals and hospitalists, as they both contribute to outcomes that impact LOS.

Jill Menzel program manager for the hospitalist program business unit for Thedacare, said her group utilizes a balanced approach to evaluate workload, looking at safety/quality by evaluating 30-day readmission rates, financial stewardship by evaluating productivity (which she defines as units of service divided by the number of hours worked), and by evaluating people’s perception of the manageability of their workload, all surrounding the central tenet of the customer. They don’t look at a RVU metric, but instead focus on tracking the average amount of time to do work by provider. This tracking method allows them to accurately see where more help was needed and get it there.

And finally John Nelson, a hospitalist in suburban Seattle and practice management consultant summed up the session with the information that there is no clear correlation between a specific workload and burnout or stress, but there definitely IS a correlation between perceived workload and burnout. The take-home message? If you feel as if you are working too hard, then you are. A specific number is not clear.

Basically, there is no right number. But there is some data noting that higher workload leads to increased LOS, and that if you feel like you are working at an unsafe level your patients may be at risk of a longer hospitalization with less communication and more unnecessary tests, and you may personally be at risk for burnout. TH

Tracy Cardin is a nurse practitioner in the section of hospital medicine at the University of Chicago Hospital.

I attended the practice-management session with an intriguing title, “Hospitalist Workload: Is 15 the Right Number?” My own group, as I am sure many are, is struggling with this very question.

Henry Michtalik, assistant professor and hospitalist from Johns Hopkins and associate faculty at the Armstrong Institute for Patient Safety and Quality talked about physician perceptions of workload and the impact of that perception on patient safety. He noted that 40% of physicans report that their typical census exceeds “safe” levels at least monthly. Multiple factors impact that perception, including the physicians’ years of experience and the presence of housestaff, as well as the total amount of clinical time yearly. Other factors that can influence this perception include the type of hospital, the ancillary team make-up, and the patient’s payer mix and acuity. Twenty percent of physicians reported that workload negatively impacted the hospitalist’s ability to discuss the plan of care or delayed discharge.

The JAMA Internal Medicine article from April 2013 that he wrote also noted, most interestingly, that fixed census caps decreased the odds of reporting an unsafe census by 34%. Bring ’em on!

Daniel Elliott presented data from his role as acting associate chair for research and co-director of ambulatory research and Clinical Outcomes at Chistiana Care Department of Medicine in Wilmington, Del. He undertook a study designed to answer the question: What is the impact of increased workload on clinical outcomes? He looked at key variables of length of stay, continuity, 24-hour average occupancy, and turn-around time (i.e., time between ordering a test until the time completed on five most commonly ordered tests by hospitalists).

What he learned is that a higher physician workload is associated with increasing LOS, but notably this association decreases as hospital occupancy increases, meaning that a less-busy hospital means that LOS is a hospitalist dependent variable and MORE sensitive to workload. Conversely, a more busy hospital’s LOS is hospital dependent and LESS sensitive to physician workload. This reveals the importance in collaboration between hospitals and hospitalists, as they both contribute to outcomes that impact LOS.

Jill Menzel program manager for the hospitalist program business unit for Thedacare, said her group utilizes a balanced approach to evaluate workload, looking at safety/quality by evaluating 30-day readmission rates, financial stewardship by evaluating productivity (which she defines as units of service divided by the number of hours worked), and by evaluating people’s perception of the manageability of their workload, all surrounding the central tenet of the customer. They don’t look at a RVU metric, but instead focus on tracking the average amount of time to do work by provider. This tracking method allows them to accurately see where more help was needed and get it there.

And finally John Nelson, a hospitalist in suburban Seattle and practice management consultant summed up the session with the information that there is no clear correlation between a specific workload and burnout or stress, but there definitely IS a correlation between perceived workload and burnout. The take-home message? If you feel as if you are working too hard, then you are. A specific number is not clear.

Basically, there is no right number. But there is some data noting that higher workload leads to increased LOS, and that if you feel like you are working at an unsafe level your patients may be at risk of a longer hospitalization with less communication and more unnecessary tests, and you may personally be at risk for burnout. TH

Tracy Cardin is a nurse practitioner in the section of hospital medicine at the University of Chicago Hospital.

I attended the practice-management session with an intriguing title, “Hospitalist Workload: Is 15 the Right Number?” My own group, as I am sure many are, is struggling with this very question.

Henry Michtalik, assistant professor and hospitalist from Johns Hopkins and associate faculty at the Armstrong Institute for Patient Safety and Quality talked about physician perceptions of workload and the impact of that perception on patient safety. He noted that 40% of physicans report that their typical census exceeds “safe” levels at least monthly. Multiple factors impact that perception, including the physicians’ years of experience and the presence of housestaff, as well as the total amount of clinical time yearly. Other factors that can influence this perception include the type of hospital, the ancillary team make-up, and the patient’s payer mix and acuity. Twenty percent of physicians reported that workload negatively impacted the hospitalist’s ability to discuss the plan of care or delayed discharge.

The JAMA Internal Medicine article from April 2013 that he wrote also noted, most interestingly, that fixed census caps decreased the odds of reporting an unsafe census by 34%. Bring ’em on!

Daniel Elliott presented data from his role as acting associate chair for research and co-director of ambulatory research and Clinical Outcomes at Chistiana Care Department of Medicine in Wilmington, Del. He undertook a study designed to answer the question: What is the impact of increased workload on clinical outcomes? He looked at key variables of length of stay, continuity, 24-hour average occupancy, and turn-around time (i.e., time between ordering a test until the time completed on five most commonly ordered tests by hospitalists).

What he learned is that a higher physician workload is associated with increasing LOS, but notably this association decreases as hospital occupancy increases, meaning that a less-busy hospital means that LOS is a hospitalist dependent variable and MORE sensitive to workload. Conversely, a more busy hospital’s LOS is hospital dependent and LESS sensitive to physician workload. This reveals the importance in collaboration between hospitals and hospitalists, as they both contribute to outcomes that impact LOS.

Jill Menzel program manager for the hospitalist program business unit for Thedacare, said her group utilizes a balanced approach to evaluate workload, looking at safety/quality by evaluating 30-day readmission rates, financial stewardship by evaluating productivity (which she defines as units of service divided by the number of hours worked), and by evaluating people’s perception of the manageability of their workload, all surrounding the central tenet of the customer. They don’t look at a RVU metric, but instead focus on tracking the average amount of time to do work by provider. This tracking method allows them to accurately see where more help was needed and get it there.

And finally John Nelson, a hospitalist in suburban Seattle and practice management consultant summed up the session with the information that there is no clear correlation between a specific workload and burnout or stress, but there definitely IS a correlation between perceived workload and burnout. The take-home message? If you feel as if you are working too hard, then you are. A specific number is not clear.

Basically, there is no right number. But there is some data noting that higher workload leads to increased LOS, and that if you feel like you are working at an unsafe level your patients may be at risk of a longer hospitalization with less communication and more unnecessary tests, and you may personally be at risk for burnout. TH

Tracy Cardin is a nurse practitioner in the section of hospital medicine at the University of Chicago Hospital.

Diagnostic reasoning is an essential skill for all physicians. There are multiple tools to refine this skill in physicians and to teach diagnostic reasoning to learners.

The session “Strategies for Promoting Clinical Reasoning to Avoid Diagnostic Errors” sought to review these skills in depth. According to Mary Ottolini, MD, of Children’s National Medical Center, the fundamentals of diagnostic reasoning are 1) Co-selection, in which 2-3 hypotheses or diagnoses are actively considered, 2) looking at the “big picture”, and 3) analyzing the information.

Looking at the big picture includes using appropriate adjectives to describe the patient and the illness presentation in medical and efficient terms. A well worded “one-liner” can frame the patient well for the team and for the next steps in diagnosis. Careful problem representation promotes thoughtful case presentations.

Analyzing the information includes comparing and contrasting key findings. Discriminating features should be discussed and competing evidence should be acknowledged.

Illness scripts is a method of looking at an illness in its entirety as a diagnosis is approached. The four parts of an illness script are mechanism of disease, epidemiology, clinical presentation (signs and symptoms), and time course.

Presentations can include diagnostic reasoning. The PBEAR format consists of:

• P- Problem Presentation
• BE – Background Evidence
• A- Analysis (including differential diagnoses)
• R- Recommendations (including goals and plan)

Key Takeaways:

• Diagnostic reasoning during case presentations is a valuable tool for patient care.
• Three fundamentals of diagnostic reasoning are 1) Co-selection of potential diagnoses, 2) looking at the “big picture”, and 3) analyzing the information.
• The PBEAR format (Problem Presentation, Background Evidence, Analysis , and Recommendations) can streamline presentations.
• Illness scripts (mechanism of disease, epidemiology, clinical presentation, and time course) are a helpful approach in diagnosis.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston

Diagnostic reasoning is an essential skill for all physicians. There are multiple tools to refine this skill in physicians and to teach diagnostic reasoning to learners.

The session “Strategies for Promoting Clinical Reasoning to Avoid Diagnostic Errors” sought to review these skills in depth. According to Mary Ottolini, MD, of Children’s National Medical Center, the fundamentals of diagnostic reasoning are 1) Co-selection, in which 2-3 hypotheses or diagnoses are actively considered, 2) looking at the “big picture”, and 3) analyzing the information.

Looking at the big picture includes using appropriate adjectives to describe the patient and the illness presentation in medical and efficient terms. A well worded “one-liner” can frame the patient well for the team and for the next steps in diagnosis. Careful problem representation promotes thoughtful case presentations.

Analyzing the information includes comparing and contrasting key findings. Discriminating features should be discussed and competing evidence should be acknowledged.

Illness scripts is a method of looking at an illness in its entirety as a diagnosis is approached. The four parts of an illness script are mechanism of disease, epidemiology, clinical presentation (signs and symptoms), and time course.

Presentations can include diagnostic reasoning. The PBEAR format consists of:

• P- Problem Presentation
• BE – Background Evidence
• A- Analysis (including differential diagnoses)
• R- Recommendations (including goals and plan)

Key Takeaways:

• Diagnostic reasoning during case presentations is a valuable tool for patient care.
• Three fundamentals of diagnostic reasoning are 1) Co-selection of potential diagnoses, 2) looking at the “big picture”, and 3) analyzing the information.
• The PBEAR format (Problem Presentation, Background Evidence, Analysis , and Recommendations) can streamline presentations.
• Illness scripts (mechanism of disease, epidemiology, clinical presentation, and time course) are a helpful approach in diagnosis.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston

Diagnostic reasoning is an essential skill for all physicians. There are multiple tools to refine this skill in physicians and to teach diagnostic reasoning to learners.

The session “Strategies for Promoting Clinical Reasoning to Avoid Diagnostic Errors” sought to review these skills in depth. According to Mary Ottolini, MD, of Children’s National Medical Center, the fundamentals of diagnostic reasoning are 1) Co-selection, in which 2-3 hypotheses or diagnoses are actively considered, 2) looking at the “big picture”, and 3) analyzing the information.

Looking at the big picture includes using appropriate adjectives to describe the patient and the illness presentation in medical and efficient terms. A well worded “one-liner” can frame the patient well for the team and for the next steps in diagnosis. Careful problem representation promotes thoughtful case presentations.

Analyzing the information includes comparing and contrasting key findings. Discriminating features should be discussed and competing evidence should be acknowledged.

Illness scripts is a method of looking at an illness in its entirety as a diagnosis is approached. The four parts of an illness script are mechanism of disease, epidemiology, clinical presentation (signs and symptoms), and time course.

Presentations can include diagnostic reasoning. The PBEAR format consists of:

• P- Problem Presentation
• BE – Background Evidence
• A- Analysis (including differential diagnoses)
• R- Recommendations (including goals and plan)

Key Takeaways:

• Diagnostic reasoning during case presentations is a valuable tool for patient care.
• Three fundamentals of diagnostic reasoning are 1) Co-selection of potential diagnoses, 2) looking at the “big picture”, and 3) analyzing the information.
• The PBEAR format (Problem Presentation, Background Evidence, Analysis , and Recommendations) can streamline presentations.
• Illness scripts (mechanism of disease, epidemiology, clinical presentation, and time course) are a helpful approach in diagnosis.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston

Denice Cora-Bramble, MD, of Children’s National Medical Center in Washington, D.C., presented “The Business of Medicine” breakout Friday at HM13.

Key Points

• Whether you are salaried, work for productivity, or have a combination of the two, it is important for hospitalists to understand the business side of medicine.
• Even if you are not a hospitalist group leader, there are several things that you should know about the finances of your hospitalist program. Dr. Cora-Bramble reviewed the basics of financial statements, hospital revenue reports, and expense reports. She also reviewed how the hospitalist division partners with the entire hospital.
• After understanding the basic finances of your program, there are ways to enhance your financial performance. These include noting any lack of payments, billing and patient trends, and looking at program losses.

Key Takeaways

• It is important to understand the general principles of financial statements, budgets and financial decision making.
• There are multiple strategies to improve your division’s financial performance.
• There are financial challenges inherent in leading an academic division.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, and a Team Hospitalist member.

Denice Cora-Bramble, MD, of Children’s National Medical Center in Washington, D.C., presented “The Business of Medicine” breakout Friday at HM13.

Key Points

• Whether you are salaried, work for productivity, or have a combination of the two, it is important for hospitalists to understand the business side of medicine.
• Even if you are not a hospitalist group leader, there are several things that you should know about the finances of your hospitalist program. Dr. Cora-Bramble reviewed the basics of financial statements, hospital revenue reports, and expense reports. She also reviewed how the hospitalist division partners with the entire hospital.
• After understanding the basic finances of your program, there are ways to enhance your financial performance. These include noting any lack of payments, billing and patient trends, and looking at program losses.

Key Takeaways

• It is important to understand the general principles of financial statements, budgets and financial decision making.
• There are multiple strategies to improve your division’s financial performance.
• There are financial challenges inherent in leading an academic division.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, and a Team Hospitalist member.

Denice Cora-Bramble, MD, of Children’s National Medical Center in Washington, D.C., presented “The Business of Medicine” breakout Friday at HM13.

Key Points

• Whether you are salaried, work for productivity, or have a combination of the two, it is important for hospitalists to understand the business side of medicine.
• Even if you are not a hospitalist group leader, there are several things that you should know about the finances of your hospitalist program. Dr. Cora-Bramble reviewed the basics of financial statements, hospital revenue reports, and expense reports. She also reviewed how the hospitalist division partners with the entire hospital.
• After understanding the basic finances of your program, there are ways to enhance your financial performance. These include noting any lack of payments, billing and patient trends, and looking at program losses.

Key Takeaways

• It is important to understand the general principles of financial statements, budgets and financial decision making.
• There are multiple strategies to improve your division’s financial performance.
• There are financial challenges inherent in leading an academic division.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, and a Team Hospitalist member.

The key word in the title is change. The most frightening number that proves change has to happen is that in 50 years healthcare expenditures will consume 50% of our nation's GDP. No way that can be sustained.

The three legs of the stool to manage HM economics include 1) cost of healthcare, 2) quality of healthcare, and 3) access to healthcare.

Dr. Robert Bessler, a former economics graduate, kept the talk interesting and simple enough even for a non-financial physician like myself. As everyone knows the cost of healthcare is rapidly rising and thus unsustainable, measures to improve quality and improve patient safety form one of the legs of the healthcare economics stool.

Two important occurrences that complicate quality are the aging baby boomers and the obesity epidemic hitting Americans. Access represents the second leg which is extremely shaky. In the near future, demand will exceed the number of professionals to provide care, as more patients become insured. Some hospitals will go bankrupt; estimates are 15% by 2020.

The last leg is cost, an area in which hospitalists will have a major role in the future, as they become more a part of the financial health of medical institutions. Dr. Bessler called hospitalists the "pit crew leaders," and said our turf is the "accountable," acute-care episode.

Key Takeaways:

• Cost of healthcare is unsustainable.
• Quality will provide key role in decreasing costs.
• Access to healthcare will be constrained.
• Accountable acute care episodes is HM's turf.

Dr. Holder is medical director of hospitalist services and chief medical information officer, Decatur Memorial Hospital, Decatur, Ill. He is also chairman of the SHM IT Quality Committee.

The key word in the title is change. The most frightening number that proves change has to happen is that in 50 years healthcare expenditures will consume 50% of our nation's GDP. No way that can be sustained.

The three legs of the stool to manage HM economics include 1) cost of healthcare, 2) quality of healthcare, and 3) access to healthcare.

Dr. Robert Bessler, a former economics graduate, kept the talk interesting and simple enough even for a non-financial physician like myself. As everyone knows the cost of healthcare is rapidly rising and thus unsustainable, measures to improve quality and improve patient safety form one of the legs of the healthcare economics stool.

Two important occurrences that complicate quality are the aging baby boomers and the obesity epidemic hitting Americans. Access represents the second leg which is extremely shaky. In the near future, demand will exceed the number of professionals to provide care, as more patients become insured. Some hospitals will go bankrupt; estimates are 15% by 2020.

The last leg is cost, an area in which hospitalists will have a major role in the future, as they become more a part of the financial health of medical institutions. Dr. Bessler called hospitalists the "pit crew leaders," and said our turf is the "accountable," acute-care episode.

Key Takeaways:

• Cost of healthcare is unsustainable.
• Quality will provide key role in decreasing costs.
• Access to healthcare will be constrained.
• Accountable acute care episodes is HM's turf.

Dr. Holder is medical director of hospitalist services and chief medical information officer, Decatur Memorial Hospital, Decatur, Ill. He is also chairman of the SHM IT Quality Committee.

The key word in the title is change. The most frightening number that proves change has to happen is that in 50 years healthcare expenditures will consume 50% of our nation's GDP. No way that can be sustained.

The three legs of the stool to manage HM economics include 1) cost of healthcare, 2) quality of healthcare, and 3) access to healthcare.

Dr. Robert Bessler, a former economics graduate, kept the talk interesting and simple enough even for a non-financial physician like myself. As everyone knows the cost of healthcare is rapidly rising and thus unsustainable, measures to improve quality and improve patient safety form one of the legs of the healthcare economics stool.

Two important occurrences that complicate quality are the aging baby boomers and the obesity epidemic hitting Americans. Access represents the second leg which is extremely shaky. In the near future, demand will exceed the number of professionals to provide care, as more patients become insured. Some hospitals will go bankrupt; estimates are 15% by 2020.

The last leg is cost, an area in which hospitalists will have a major role in the future, as they become more a part of the financial health of medical institutions. Dr. Bessler called hospitalists the "pit crew leaders," and said our turf is the "accountable," acute-care episode.

Key Takeaways:

• Cost of healthcare is unsustainable.
• Quality will provide key role in decreasing costs.
• Access to healthcare will be constrained.
• Accountable acute care episodes is HM's turf.

Dr. Holder is medical director of hospitalist services and chief medical information officer, Decatur Memorial Hospital, Decatur, Ill. He is also chairman of the SHM IT Quality Committee.

The topic was of strong interest, as demonstrated by the standing-room-only group of hospitalists attending Monday afternoon's presentation at HM12 in San Diego on the brand new antithrombic therapy from ACCP. I doubt giving away a new IPAD 3 would have brought a bigger audience. However, no one left disappointed, leaving with valuable new information which could be used at the bedside.

The excellent, evidence-based rapid fire presentation by Catherine Curley took us as a tour guide through key aspects of the new guidelines. The methodology improvements were extremely important. She used the more-controversial topics as examples: treatment of submassive PE, use of catheter directed thrombolysis in patients with acute DVT, and the recommended VTE prophylaxis. She even threw in some anatomy lessons for us clinicians.

Key Takeaways:

1. Major innovations in the methodology in the AT9. Focus on the absolute effects allow the provider to weight the benefit and risk of therapy easily, rigorous conflict of interests review of the editors, re-analysis of many older studies, and simplified recommendations with emphasis on summary of finding tables as opposed to texts
.
2. A strong focus on patient-centered outcomes. This is the first major guideline I have seen that recommends specifically focusing on the patients preferences.

Dr. Holder is medical director of hospitalist services and chief medical information officer at Decatur (Ill.) Memorial Hospital.

The topic was of strong interest, as demonstrated by the standing-room-only group of hospitalists attending Monday afternoon's presentation at HM12 in San Diego on the brand new antithrombic therapy from ACCP. I doubt giving away a new IPAD 3 would have brought a bigger audience. However, no one left disappointed, leaving with valuable new information which could be used at the bedside.

The excellent, evidence-based rapid fire presentation by Catherine Curley took us as a tour guide through key aspects of the new guidelines. The methodology improvements were extremely important. She used the more-controversial topics as examples: treatment of submassive PE, use of catheter directed thrombolysis in patients with acute DVT, and the recommended VTE prophylaxis. She even threw in some anatomy lessons for us clinicians.

Key Takeaways:

1. Major innovations in the methodology in the AT9. Focus on the absolute effects allow the provider to weight the benefit and risk of therapy easily, rigorous conflict of interests review of the editors, re-analysis of many older studies, and simplified recommendations with emphasis on summary of finding tables as opposed to texts
.
2. A strong focus on patient-centered outcomes. This is the first major guideline I have seen that recommends specifically focusing on the patients preferences.

Dr. Holder is medical director of hospitalist services and chief medical information officer at Decatur (Ill.) Memorial Hospital.

The topic was of strong interest, as demonstrated by the standing-room-only group of hospitalists attending Monday afternoon's presentation at HM12 in San Diego on the brand new antithrombic therapy from ACCP. I doubt giving away a new IPAD 3 would have brought a bigger audience. However, no one left disappointed, leaving with valuable new information which could be used at the bedside.

The excellent, evidence-based rapid fire presentation by Catherine Curley took us as a tour guide through key aspects of the new guidelines. The methodology improvements were extremely important. She used the more-controversial topics as examples: treatment of submassive PE, use of catheter directed thrombolysis in patients with acute DVT, and the recommended VTE prophylaxis. She even threw in some anatomy lessons for us clinicians.

Key Takeaways:

1. Major innovations in the methodology in the AT9. Focus on the absolute effects allow the provider to weight the benefit and risk of therapy easily, rigorous conflict of interests review of the editors, re-analysis of many older studies, and simplified recommendations with emphasis on summary of finding tables as opposed to texts
.
2. A strong focus on patient-centered outcomes. This is the first major guideline I have seen that recommends specifically focusing on the patients preferences.

Dr. Holder is medical director of hospitalist services and chief medical information officer at Decatur (Ill.) Memorial Hospital.

The etiologic agents for complicated pneumonias and osteomyelitis have changed recently, according to presenters Drs. William and Creech, who assisted pediatric hospitalists in updated diagnosis and intervention strategies.

The increase in complicated pneumonias and empyemas is mostly due to the increase in Streptococcus pneumoniae serotype 19a. After introduction of the PCV-7 vaccine, incidence of serotype 19a infections increased to 98% of infections. Serotype 19a is now included in the PCV-13 vaccine, approved by the FDA in 2011. There are multiple interventions available for empyemas including chest tube alone, chest tube with fibrinolysis, and VATS. Current research is being done to assess efficacy for these measures.

Osteomyelitis may be caused by direct inoculation, spread from local infection, or hematogenous spread. S. Aureus is causative agent in 80-90% of patients. MRSA infection has a more complicated course. Based on patient response and inflammatory markers, a short course of intravenous antibiotics followed by oral antibiotics may be appropriate.

Key Takeaways:

1. Surgical intervention for empyemas is patient specific and depends on clinical status, effusion, status, presence of loculations, and expertise of consultants.

2. Hematogenous spread is the most common cause of osteomyelitis in children.

3. MRI is diagnostic modality of choice for osteomyelitis.

4. Bone aspiration and blood cultures are very helpful in treatment of osteomyelitis.

5. Clindamycin can be considered for first line osteomyelitis treatment if it is not a life threatening infection, a limb threatening infection, or a high likelihood of bacteremia. Beta lactam coverage should be considered in toddlers due to Kingella.

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts Medical Center in Boston.

The etiologic agents for complicated pneumonias and osteomyelitis have changed recently, according to presenters Drs. William and Creech, who assisted pediatric hospitalists in updated diagnosis and intervention strategies.

The increase in complicated pneumonias and empyemas is mostly due to the increase in Streptococcus pneumoniae serotype 19a. After introduction of the PCV-7 vaccine, incidence of serotype 19a infections increased to 98% of infections. Serotype 19a is now included in the PCV-13 vaccine, approved by the FDA in 2011. There are multiple interventions available for empyemas including chest tube alone, chest tube with fibrinolysis, and VATS. Current research is being done to assess efficacy for these measures.

Osteomyelitis may be caused by direct inoculation, spread from local infection, or hematogenous spread. S. Aureus is causative agent in 80-90% of patients. MRSA infection has a more complicated course. Based on patient response and inflammatory markers, a short course of intravenous antibiotics followed by oral antibiotics may be appropriate.

Key Takeaways:

1. Surgical intervention for empyemas is patient specific and depends on clinical status, effusion, status, presence of loculations, and expertise of consultants.

2. Hematogenous spread is the most common cause of osteomyelitis in children.

3. MRI is diagnostic modality of choice for osteomyelitis.

4. Bone aspiration and blood cultures are very helpful in treatment of osteomyelitis.

5. Clindamycin can be considered for first line osteomyelitis treatment if it is not a life threatening infection, a limb threatening infection, or a high likelihood of bacteremia. Beta lactam coverage should be considered in toddlers due to Kingella.

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts Medical Center in Boston.

The etiologic agents for complicated pneumonias and osteomyelitis have changed recently, according to presenters Drs. William and Creech, who assisted pediatric hospitalists in updated diagnosis and intervention strategies.

The increase in complicated pneumonias and empyemas is mostly due to the increase in Streptococcus pneumoniae serotype 19a. After introduction of the PCV-7 vaccine, incidence of serotype 19a infections increased to 98% of infections. Serotype 19a is now included in the PCV-13 vaccine, approved by the FDA in 2011. There are multiple interventions available for empyemas including chest tube alone, chest tube with fibrinolysis, and VATS. Current research is being done to assess efficacy for these measures.

Osteomyelitis may be caused by direct inoculation, spread from local infection, or hematogenous spread. S. Aureus is causative agent in 80-90% of patients. MRSA infection has a more complicated course. Based on patient response and inflammatory markers, a short course of intravenous antibiotics followed by oral antibiotics may be appropriate.

Key Takeaways:

1. Surgical intervention for empyemas is patient specific and depends on clinical status, effusion, status, presence of loculations, and expertise of consultants.

2. Hematogenous spread is the most common cause of osteomyelitis in children.

3. MRI is diagnostic modality of choice for osteomyelitis.

4. Bone aspiration and blood cultures are very helpful in treatment of osteomyelitis.

5. Clindamycin can be considered for first line osteomyelitis treatment if it is not a life threatening infection, a limb threatening infection, or a high likelihood of bacteremia. Beta lactam coverage should be considered in toddlers due to Kingella.

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts Medical Center in Boston.

Patrick Conway, MD, MSc, chief medical officer of CMS and director of the Office of Clinical Standards and Quality, stated he has taken a position that pays less, has more hours, and tends to upset lots of people. But at the same time, its the most rewarding and most difficult job he has done. And so began an information-filled discussion on CMS policies.

Fortunately, he is one of SHM's own who has the core hospitalist value of quality and patient-centeredness. He also is in a position of power in the government.

An obvious focus of CMS, Dr. Conway explained, is to push the U.S. healthcare system toward a patient-centered outcome measures. Throughout the various projects (value-based purchasing, bundled-payment projects, Save a Million Heart program, readmission reduction) is the goal of improved patient-centered care. In addition the concepts of "better care, better health, and lower costs" represents the cornerstones of this historic time in healthcare.

Key Takeaway: A call to collective action.

What can you do:

1. Partner with your hospital administration and quality improvement teams;
2. Understand your hospitals performance data;
3. Take a physician leadership role; and
4. Create a collaboration with your community partners.

Patrick Conway, MD, MSc, chief medical officer of CMS and director of the Office of Clinical Standards and Quality, stated he has taken a position that pays less, has more hours, and tends to upset lots of people. But at the same time, its the most rewarding and most difficult job he has done. And so began an information-filled discussion on CMS policies.

Fortunately, he is one of SHM's own who has the core hospitalist value of quality and patient-centeredness. He also is in a position of power in the government.

An obvious focus of CMS, Dr. Conway explained, is to push the U.S. healthcare system toward a patient-centered outcome measures. Throughout the various projects (value-based purchasing, bundled-payment projects, Save a Million Heart program, readmission reduction) is the goal of improved patient-centered care. In addition the concepts of "better care, better health, and lower costs" represents the cornerstones of this historic time in healthcare.

Key Takeaway: A call to collective action.

What can you do:

1. Partner with your hospital administration and quality improvement teams;
2. Understand your hospitals performance data;
3. Take a physician leadership role; and
4. Create a collaboration with your community partners.

Patrick Conway, MD, MSc, chief medical officer of CMS and director of the Office of Clinical Standards and Quality, stated he has taken a position that pays less, has more hours, and tends to upset lots of people. But at the same time, its the most rewarding and most difficult job he has done. And so began an information-filled discussion on CMS policies.

Fortunately, he is one of SHM's own who has the core hospitalist value of quality and patient-centeredness. He also is in a position of power in the government.

An obvious focus of CMS, Dr. Conway explained, is to push the U.S. healthcare system toward a patient-centered outcome measures. Throughout the various projects (value-based purchasing, bundled-payment projects, Save a Million Heart program, readmission reduction) is the goal of improved patient-centered care. In addition the concepts of "better care, better health, and lower costs" represents the cornerstones of this historic time in healthcare.

Key Takeaway: A call to collective action.

What can you do:

1. Partner with your hospital administration and quality improvement teams;
2. Understand your hospitals performance data;
3. Take a physician leadership role; and
4. Create a collaboration with your community partners.