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Postop satisfaction scores not tied to restricted opioid prescribing
Reduced opioid prescribing did not correlate with inpatient pain management scores, a study has shown.
The Centers for Medicare & Medicaid Services announced recently that, as of 2018, pain management will no longer be rated in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, citing concerns that patient satisfaction surveys given at the time of postoperative discharge incentivizes clinicians to over-prescribe pain medication. Surgical patients are key contributors to HCAHPS scores, and opioids account for almost 40% of surgical prescriptions, according to the study.
A new study throws some shade on the CMS decision to delete pain management from the HCAHPS survey.
Pain management scores were calculated as the percentage of patients who reported that their pain was “always” well controlled. The pain dimension was calculated from the number of opioid prescriptions and also pain management scores compared to national benchmarks. Hospitals were then grouped into quintiles according to opioid prescriptions measured in oral morphine equivalents. The first quintile has the lowest number of prescriptions.
Unadjusted comparisons showed no significant differences in pain management or pain dimension scores between the first and fifth quintiles of hospitals. For pain management scores that ranked hospital staff as always controlling pain, the first quintile had a mean score of 69.5 (95% confidence interval, 66.7-71.7) out of 100, compared with 69.1 for the fifth quintile (95% CI, 67.2-71.4). On a scale of 1-10, pain dimension scores in the first quintile averaged 1.9 (mean 95% CI, 1.5-2.0), compared with 1.4 in the fifth quintile (mean 95% CI, 0.9-1.9).
So, for these institutions, the number of pain prescriptions was not correlated with HCAHPS scores for pain management. The study suggests that the concern that reducing opioid prescriptions may have a negative impact on patient satisfaction assessments may not be realized.
Other analyses controlling for a variety of comorbidities also showed no correlations between pain management scores and opioid prescribing. Of the surgeries considered – orthopedic, general, gynecologic, cancer, cardiac, and vascular – gynecologic procedures were most likely to be associated with improved pain management and pain dimension scores.
Dr. Brummett disclosed relationships with Tonix and Neuros Medical. He also holds a patent for peripheral perineural dexmedetomidine. Mr. Syrjamaki and Dr. Dupree received support from Blue Cross Blue Shield of Michigan for their respective roles in the Michigan Value Collaborative. Dr. Waljee is an unpaid consultant for 3MHealth.
Reduced opioid prescribing did not correlate with inpatient pain management scores, a study has shown.
The Centers for Medicare & Medicaid Services announced recently that, as of 2018, pain management will no longer be rated in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, citing concerns that patient satisfaction surveys given at the time of postoperative discharge incentivizes clinicians to over-prescribe pain medication. Surgical patients are key contributors to HCAHPS scores, and opioids account for almost 40% of surgical prescriptions, according to the study.
A new study throws some shade on the CMS decision to delete pain management from the HCAHPS survey.
Pain management scores were calculated as the percentage of patients who reported that their pain was “always” well controlled. The pain dimension was calculated from the number of opioid prescriptions and also pain management scores compared to national benchmarks. Hospitals were then grouped into quintiles according to opioid prescriptions measured in oral morphine equivalents. The first quintile has the lowest number of prescriptions.
Unadjusted comparisons showed no significant differences in pain management or pain dimension scores between the first and fifth quintiles of hospitals. For pain management scores that ranked hospital staff as always controlling pain, the first quintile had a mean score of 69.5 (95% confidence interval, 66.7-71.7) out of 100, compared with 69.1 for the fifth quintile (95% CI, 67.2-71.4). On a scale of 1-10, pain dimension scores in the first quintile averaged 1.9 (mean 95% CI, 1.5-2.0), compared with 1.4 in the fifth quintile (mean 95% CI, 0.9-1.9).
So, for these institutions, the number of pain prescriptions was not correlated with HCAHPS scores for pain management. The study suggests that the concern that reducing opioid prescriptions may have a negative impact on patient satisfaction assessments may not be realized.
Other analyses controlling for a variety of comorbidities also showed no correlations between pain management scores and opioid prescribing. Of the surgeries considered – orthopedic, general, gynecologic, cancer, cardiac, and vascular – gynecologic procedures were most likely to be associated with improved pain management and pain dimension scores.
Dr. Brummett disclosed relationships with Tonix and Neuros Medical. He also holds a patent for peripheral perineural dexmedetomidine. Mr. Syrjamaki and Dr. Dupree received support from Blue Cross Blue Shield of Michigan for their respective roles in the Michigan Value Collaborative. Dr. Waljee is an unpaid consultant for 3MHealth.
Reduced opioid prescribing did not correlate with inpatient pain management scores, a study has shown.
The Centers for Medicare & Medicaid Services announced recently that, as of 2018, pain management will no longer be rated in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, citing concerns that patient satisfaction surveys given at the time of postoperative discharge incentivizes clinicians to over-prescribe pain medication. Surgical patients are key contributors to HCAHPS scores, and opioids account for almost 40% of surgical prescriptions, according to the study.
A new study throws some shade on the CMS decision to delete pain management from the HCAHPS survey.
Pain management scores were calculated as the percentage of patients who reported that their pain was “always” well controlled. The pain dimension was calculated from the number of opioid prescriptions and also pain management scores compared to national benchmarks. Hospitals were then grouped into quintiles according to opioid prescriptions measured in oral morphine equivalents. The first quintile has the lowest number of prescriptions.
Unadjusted comparisons showed no significant differences in pain management or pain dimension scores between the first and fifth quintiles of hospitals. For pain management scores that ranked hospital staff as always controlling pain, the first quintile had a mean score of 69.5 (95% confidence interval, 66.7-71.7) out of 100, compared with 69.1 for the fifth quintile (95% CI, 67.2-71.4). On a scale of 1-10, pain dimension scores in the first quintile averaged 1.9 (mean 95% CI, 1.5-2.0), compared with 1.4 in the fifth quintile (mean 95% CI, 0.9-1.9).
So, for these institutions, the number of pain prescriptions was not correlated with HCAHPS scores for pain management. The study suggests that the concern that reducing opioid prescriptions may have a negative impact on patient satisfaction assessments may not be realized.
Other analyses controlling for a variety of comorbidities also showed no correlations between pain management scores and opioid prescribing. Of the surgeries considered – orthopedic, general, gynecologic, cancer, cardiac, and vascular – gynecologic procedures were most likely to be associated with improved pain management and pain dimension scores.
Dr. Brummett disclosed relationships with Tonix and Neuros Medical. He also holds a patent for peripheral perineural dexmedetomidine. Mr. Syrjamaki and Dr. Dupree received support from Blue Cross Blue Shield of Michigan for their respective roles in the Michigan Value Collaborative. Dr. Waljee is an unpaid consultant for 3MHealth.
Key clinical point:
Major finding: No significant differences between top and bottom quintiles of 47 Michigan hospitals’ opioid prescribing patterns existed when comparing their HCAHPS scores.
Data source: Pharmacy and insurance claims and HCAHPS pain management for 31,481 surgery patients between 2012 and 2014.
Disclosures: Dr. Brummett disclosed relationships with Tonix and Neuros Medical. He also holds a patent for peripheral perineural dexmedetomidine. Mr. Syrjamaki and Dr. Dupree received support from Blue Cross Blue Shield of Michigan for their respective roles in the Michigan Value Collaborative. Dr. Waljee is an unpaid consultant for 3MHealth.
Canagliflozin gets boxed warning for amputation
The Food and Drug Administration has added a boxed warning to the label of diabetes drug canagliflozin for the risk of lower limb amputation.
The agency cited data from two clinical trials showing nearly double the risk of leg and foot amputations in patients treated with the canagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor, compared with placebo, in a recent statement.
The trials, which followed participants for an average of 5.7 and 2.1 years, respectively, showed that lower limb infections, gangrene, diabetic foot ulcers, and ischemia commonly occurred prior to the need for amputation.
The boxed warning advises physicians to consider a patient’s history of prior amputation, peripheral vascular disease, neuropathy, and diabetic foot ulcers before prescribing canagliflozin and to monitor patients for pain, tenderness, sores, ulcers, or infections on the feet or legs.
Consider discontinuing canagliflozin in these patients, as well as those with symptoms of hypotension, ketoacidosis, elevated serum potassium levels, severe urinary tract infections, hypoglycemia in combination with other prescription diabetes medicines, yeast infections, bone breaks, and increased cholesterol, according to the FDA.
The FDA first issued a safety communication on canagliflozin about a year ago but, at the time, did not advise assessing a patient’s risk for amputation.
Canagliflozin, marketed as Invokana, Invokamet, and Invokamet XR by Janssen Pharmaceuticals, was approved by the FDA in March 2013.
Adverse events involving canagliflozin – or any drug – should be reported to the FDA MedWatch program.
The Food and Drug Administration has added a boxed warning to the label of diabetes drug canagliflozin for the risk of lower limb amputation.
The agency cited data from two clinical trials showing nearly double the risk of leg and foot amputations in patients treated with the canagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor, compared with placebo, in a recent statement.
The trials, which followed participants for an average of 5.7 and 2.1 years, respectively, showed that lower limb infections, gangrene, diabetic foot ulcers, and ischemia commonly occurred prior to the need for amputation.
The boxed warning advises physicians to consider a patient’s history of prior amputation, peripheral vascular disease, neuropathy, and diabetic foot ulcers before prescribing canagliflozin and to monitor patients for pain, tenderness, sores, ulcers, or infections on the feet or legs.
Consider discontinuing canagliflozin in these patients, as well as those with symptoms of hypotension, ketoacidosis, elevated serum potassium levels, severe urinary tract infections, hypoglycemia in combination with other prescription diabetes medicines, yeast infections, bone breaks, and increased cholesterol, according to the FDA.
The FDA first issued a safety communication on canagliflozin about a year ago but, at the time, did not advise assessing a patient’s risk for amputation.
Canagliflozin, marketed as Invokana, Invokamet, and Invokamet XR by Janssen Pharmaceuticals, was approved by the FDA in March 2013.
Adverse events involving canagliflozin – or any drug – should be reported to the FDA MedWatch program.
The Food and Drug Administration has added a boxed warning to the label of diabetes drug canagliflozin for the risk of lower limb amputation.
The agency cited data from two clinical trials showing nearly double the risk of leg and foot amputations in patients treated with the canagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor, compared with placebo, in a recent statement.
The trials, which followed participants for an average of 5.7 and 2.1 years, respectively, showed that lower limb infections, gangrene, diabetic foot ulcers, and ischemia commonly occurred prior to the need for amputation.
The boxed warning advises physicians to consider a patient’s history of prior amputation, peripheral vascular disease, neuropathy, and diabetic foot ulcers before prescribing canagliflozin and to monitor patients for pain, tenderness, sores, ulcers, or infections on the feet or legs.
Consider discontinuing canagliflozin in these patients, as well as those with symptoms of hypotension, ketoacidosis, elevated serum potassium levels, severe urinary tract infections, hypoglycemia in combination with other prescription diabetes medicines, yeast infections, bone breaks, and increased cholesterol, according to the FDA.
The FDA first issued a safety communication on canagliflozin about a year ago but, at the time, did not advise assessing a patient’s risk for amputation.
Canagliflozin, marketed as Invokana, Invokamet, and Invokamet XR by Janssen Pharmaceuticals, was approved by the FDA in March 2013.
Adverse events involving canagliflozin – or any drug – should be reported to the FDA MedWatch program.
Hyponatremia: Watch the water, not the salt
LAS VEGAS – Hyponatremia is not a salt problem, it’s a water problem.
That was the lead message in a well-attended rapid-fire session on hyponatremia at the annual meeting of the Society of Hospital Medicine.
“It’s almost always associated with pathologic elevations of ADH [antidiuretic hormone], and it’s that retention of water that dilutes the serum and drops the sodium, which causes the cerebral edema,” said Thomas Yacovella, MD, assistant professor of medicine at the University of Minnesota, Minneapolis.
“Remember that hyponatremia is a bad actor, especially when associated with a chronic disease,” Dr. Yacovella said. Serum sodium levels are a reliable surrogate for chronic heart failure related to hyponatremia. End-stage disease is when sodium levels are at 125 or less.
A basic work-up for hyponatremia starts with assessing fluid intake, history of medications and of any causes of ADH release, volume status assessment, and laboratory evaluations of blood and urine. The three keys to knowing how quickly hyponatremia can be reversed are severity of symptoms, how long it took for the condition to develop, and the risk of herniation vs. the risk of osmotic demyelination, he said.
In cases of osmotic demyelination, Dr. Yacovella advised monitoring urine osmolality and cases where ADH release could be quickly reversed. “When you don’t know for sure, go slow,” he said.
Exercise-associated hyponatremia is often caused by the perfect storm of sodium loss, high emotion, vomiting, pain, excessive water intake, and high ADH levels. This form of hyponatremia can occur postoperatively, but is more typically associated with the copious water ingestion that can occur during psychosis, extreme exercise, ecstasy ingestion, and “stupid” contests that involve extreme behavior, Dr. Yacovella said. His pearls for acute management of these kinds of hyponatremia were to administer a 100-mL bolus of hypertonic saline, and that a large output of dilute urine indicates corrective aquaresis.
Dr. Yacovella emphasized that in addition to remembering that hyponatremia is a water and not a salt problem, physicians should always look to “the path of physiology of the disease, and how long it took to develop the hyponatremia, and that will inform how quickly you can treat the patient.”
He had nothing to disclose.
wmcknight@frontlinemedcom.com
On Twitter @whitneymcknight
LAS VEGAS – Hyponatremia is not a salt problem, it’s a water problem.
That was the lead message in a well-attended rapid-fire session on hyponatremia at the annual meeting of the Society of Hospital Medicine.
“It’s almost always associated with pathologic elevations of ADH [antidiuretic hormone], and it’s that retention of water that dilutes the serum and drops the sodium, which causes the cerebral edema,” said Thomas Yacovella, MD, assistant professor of medicine at the University of Minnesota, Minneapolis.
“Remember that hyponatremia is a bad actor, especially when associated with a chronic disease,” Dr. Yacovella said. Serum sodium levels are a reliable surrogate for chronic heart failure related to hyponatremia. End-stage disease is when sodium levels are at 125 or less.
A basic work-up for hyponatremia starts with assessing fluid intake, history of medications and of any causes of ADH release, volume status assessment, and laboratory evaluations of blood and urine. The three keys to knowing how quickly hyponatremia can be reversed are severity of symptoms, how long it took for the condition to develop, and the risk of herniation vs. the risk of osmotic demyelination, he said.
In cases of osmotic demyelination, Dr. Yacovella advised monitoring urine osmolality and cases where ADH release could be quickly reversed. “When you don’t know for sure, go slow,” he said.
Exercise-associated hyponatremia is often caused by the perfect storm of sodium loss, high emotion, vomiting, pain, excessive water intake, and high ADH levels. This form of hyponatremia can occur postoperatively, but is more typically associated with the copious water ingestion that can occur during psychosis, extreme exercise, ecstasy ingestion, and “stupid” contests that involve extreme behavior, Dr. Yacovella said. His pearls for acute management of these kinds of hyponatremia were to administer a 100-mL bolus of hypertonic saline, and that a large output of dilute urine indicates corrective aquaresis.
Dr. Yacovella emphasized that in addition to remembering that hyponatremia is a water and not a salt problem, physicians should always look to “the path of physiology of the disease, and how long it took to develop the hyponatremia, and that will inform how quickly you can treat the patient.”
He had nothing to disclose.
wmcknight@frontlinemedcom.com
On Twitter @whitneymcknight
LAS VEGAS – Hyponatremia is not a salt problem, it’s a water problem.
That was the lead message in a well-attended rapid-fire session on hyponatremia at the annual meeting of the Society of Hospital Medicine.
“It’s almost always associated with pathologic elevations of ADH [antidiuretic hormone], and it’s that retention of water that dilutes the serum and drops the sodium, which causes the cerebral edema,” said Thomas Yacovella, MD, assistant professor of medicine at the University of Minnesota, Minneapolis.
“Remember that hyponatremia is a bad actor, especially when associated with a chronic disease,” Dr. Yacovella said. Serum sodium levels are a reliable surrogate for chronic heart failure related to hyponatremia. End-stage disease is when sodium levels are at 125 or less.
A basic work-up for hyponatremia starts with assessing fluid intake, history of medications and of any causes of ADH release, volume status assessment, and laboratory evaluations of blood and urine. The three keys to knowing how quickly hyponatremia can be reversed are severity of symptoms, how long it took for the condition to develop, and the risk of herniation vs. the risk of osmotic demyelination, he said.
In cases of osmotic demyelination, Dr. Yacovella advised monitoring urine osmolality and cases where ADH release could be quickly reversed. “When you don’t know for sure, go slow,” he said.
Exercise-associated hyponatremia is often caused by the perfect storm of sodium loss, high emotion, vomiting, pain, excessive water intake, and high ADH levels. This form of hyponatremia can occur postoperatively, but is more typically associated with the copious water ingestion that can occur during psychosis, extreme exercise, ecstasy ingestion, and “stupid” contests that involve extreme behavior, Dr. Yacovella said. His pearls for acute management of these kinds of hyponatremia were to administer a 100-mL bolus of hypertonic saline, and that a large output of dilute urine indicates corrective aquaresis.
Dr. Yacovella emphasized that in addition to remembering that hyponatremia is a water and not a salt problem, physicians should always look to “the path of physiology of the disease, and how long it took to develop the hyponatremia, and that will inform how quickly you can treat the patient.”
He had nothing to disclose.
wmcknight@frontlinemedcom.com
On Twitter @whitneymcknight
Connect: Community hospitalists brainstorm ways to be stronger as a group
Coping with disjointed administrative goals, demonstrating value to hospital leadership, and strengthening support networks for one another were hot-button topics during the Special Interest Group for Community Hospitalists at this year’s HM17.
A mix of hospitalists from rural, urban, and suburban facilities with an average 200-500 beds joined in the discussion, moderated by Stephen Behnke, MD, an internist and president of MedOne in Columbus, Ohio, and Jason Robertson, MD, an internist with HealthPartners in Bloomington, Minn.
Burnout was seen by several in the crowd of about two dozen physicians as being related in part to poor staffing and scheduling decisions at the administrative level, and not allocating clerical work to other staff, often forcing hospitalists to perform tasks not at the top of their license. One solution offered was to amortize the cost of physicians doing paperwork according to their salaries, and to bring those numbers to the attention of hospital leadership.
The group called on the Society of Hospital Medicine to create and disseminate evidence-based resources to help demonstrate their value to hospital administration. Many in the group expressed interest in learning how to communicate their value effectively to their respective C-suites to underscore the essential nature HM has to the core business. In an interview directly after the session, Dr. Behnke explained that hospital leaders often underfund HM programs, only to find that the decision ends up costing them more in the long run.
Lots of upset was vented by session attendees over patient discharge protocols that often resulted in higher lengths of stay or increased readmissions, which then reflected poorly on the hospitalist. The group agreed that since there was no one-size-fits-all approach to this, it would be helpful to start a listserv of community hospitalists in the SHM that was organized by hospital size, location, and types of staffing, so it would be easier to find solutions by connecting with others with similar concerns.
Many in the group also shared how their respective facilities promoted wellness through togetherness activities: staff retreats, movie nights, book clubs, group family outings, and forming alliances with hospitalists at other local hospitals. The general consensus was that this helped improve staff morale.
Coping with disjointed administrative goals, demonstrating value to hospital leadership, and strengthening support networks for one another were hot-button topics during the Special Interest Group for Community Hospitalists at this year’s HM17.
A mix of hospitalists from rural, urban, and suburban facilities with an average 200-500 beds joined in the discussion, moderated by Stephen Behnke, MD, an internist and president of MedOne in Columbus, Ohio, and Jason Robertson, MD, an internist with HealthPartners in Bloomington, Minn.
Burnout was seen by several in the crowd of about two dozen physicians as being related in part to poor staffing and scheduling decisions at the administrative level, and not allocating clerical work to other staff, often forcing hospitalists to perform tasks not at the top of their license. One solution offered was to amortize the cost of physicians doing paperwork according to their salaries, and to bring those numbers to the attention of hospital leadership.
The group called on the Society of Hospital Medicine to create and disseminate evidence-based resources to help demonstrate their value to hospital administration. Many in the group expressed interest in learning how to communicate their value effectively to their respective C-suites to underscore the essential nature HM has to the core business. In an interview directly after the session, Dr. Behnke explained that hospital leaders often underfund HM programs, only to find that the decision ends up costing them more in the long run.
Lots of upset was vented by session attendees over patient discharge protocols that often resulted in higher lengths of stay or increased readmissions, which then reflected poorly on the hospitalist. The group agreed that since there was no one-size-fits-all approach to this, it would be helpful to start a listserv of community hospitalists in the SHM that was organized by hospital size, location, and types of staffing, so it would be easier to find solutions by connecting with others with similar concerns.
Many in the group also shared how their respective facilities promoted wellness through togetherness activities: staff retreats, movie nights, book clubs, group family outings, and forming alliances with hospitalists at other local hospitals. The general consensus was that this helped improve staff morale.
Coping with disjointed administrative goals, demonstrating value to hospital leadership, and strengthening support networks for one another were hot-button topics during the Special Interest Group for Community Hospitalists at this year’s HM17.
A mix of hospitalists from rural, urban, and suburban facilities with an average 200-500 beds joined in the discussion, moderated by Stephen Behnke, MD, an internist and president of MedOne in Columbus, Ohio, and Jason Robertson, MD, an internist with HealthPartners in Bloomington, Minn.
Burnout was seen by several in the crowd of about two dozen physicians as being related in part to poor staffing and scheduling decisions at the administrative level, and not allocating clerical work to other staff, often forcing hospitalists to perform tasks not at the top of their license. One solution offered was to amortize the cost of physicians doing paperwork according to their salaries, and to bring those numbers to the attention of hospital leadership.
The group called on the Society of Hospital Medicine to create and disseminate evidence-based resources to help demonstrate their value to hospital administration. Many in the group expressed interest in learning how to communicate their value effectively to their respective C-suites to underscore the essential nature HM has to the core business. In an interview directly after the session, Dr. Behnke explained that hospital leaders often underfund HM programs, only to find that the decision ends up costing them more in the long run.
Lots of upset was vented by session attendees over patient discharge protocols that often resulted in higher lengths of stay or increased readmissions, which then reflected poorly on the hospitalist. The group agreed that since there was no one-size-fits-all approach to this, it would be helpful to start a listserv of community hospitalists in the SHM that was organized by hospital size, location, and types of staffing, so it would be easier to find solutions by connecting with others with similar concerns.
Many in the group also shared how their respective facilities promoted wellness through togetherness activities: staff retreats, movie nights, book clubs, group family outings, and forming alliances with hospitalists at other local hospitals. The general consensus was that this helped improve staff morale.
Keys to de-escalating endocrine emergencies
It’s a fine line between compensated and decompensated endocrine conditions, and often, there is an underlying non–endocrine component complicating the diagnosis.
That’s according to Marilyn Tan, MD, a clinical assistant professor of medicine at Stanford (Calif.) University, where she is chief of the endocrinology clinic. She spoke about endocrinology emergencies during a case-based, rapid-fire session at HM17.
“Endocrine emergencies are usually due to an excess or a deficiency of a hormone,” Dr. Tan said, noting that these can take time to bring into balance. This is one reason Dr. Tan counseled not waiting for laboratory results before administering treatment.
To diagnose and treat diabetic ketoacidosis, combined with a hyperosmolar hyperglycemic state, Dr. Tan recommended checking hypoglycemia levels, which she said are often mild, and to check anion gap, pH, and ketones. It’s also important to be generous with IV fluids, to administer insulin only if the ketoacidosis level is greater than 3.3 mEq/L, and to not take the patient off an insulin drip too early or inappropriately. To prevent readmissions, the patient on discharge should have adequate diabetes supplies, education on their condition, and timely follow-up, Dr. Tan recommended.
For patients experiencing a thyroid storm, Dr. Tan advised that thyroid function tests are a poor surrogate for predicting who will decompensate. The clinical distinction is made by documentation of acute organ dysfunction. Reducing T3 to T4 conversion means propylthiouracil is preferred over methimazole.
Ongoing management of a myxedema coma means monitoring the clinical parameters of the patient’s mental status, cardiac and pulmonary functions, while keeping the levothyroxine dose steady and checking lab values every 1-2 days to ensure the patient is progressing.
Suspect pituitary apoplexy in cases of hypertension, major surgery, trauma, anticoagulation, pregnancy, or if there is a large sellar mass. If choosing to image a patient, Dr. Tan recommended using an MRI rather than a CT scan, which she said is less sensitive. Immediate hydrocortisone treatment must be administered, she said. About 90% of cases of acute hypercalcemia are caused by hyperparathyroidism in the outpatient setting, and malignancy in the inpatient setting, Dr. Tan said. Also, these patients tend to be volume depleted, so assessment of their ability to tolerate hydration is essential.
Regarding all endocrine emergencies, Dr. Tan said, “When in doubt, be more aggressive with treatment.”
Dr. Tan had no relevant financial disclosures.
It’s a fine line between compensated and decompensated endocrine conditions, and often, there is an underlying non–endocrine component complicating the diagnosis.
That’s according to Marilyn Tan, MD, a clinical assistant professor of medicine at Stanford (Calif.) University, where she is chief of the endocrinology clinic. She spoke about endocrinology emergencies during a case-based, rapid-fire session at HM17.
“Endocrine emergencies are usually due to an excess or a deficiency of a hormone,” Dr. Tan said, noting that these can take time to bring into balance. This is one reason Dr. Tan counseled not waiting for laboratory results before administering treatment.
To diagnose and treat diabetic ketoacidosis, combined with a hyperosmolar hyperglycemic state, Dr. Tan recommended checking hypoglycemia levels, which she said are often mild, and to check anion gap, pH, and ketones. It’s also important to be generous with IV fluids, to administer insulin only if the ketoacidosis level is greater than 3.3 mEq/L, and to not take the patient off an insulin drip too early or inappropriately. To prevent readmissions, the patient on discharge should have adequate diabetes supplies, education on their condition, and timely follow-up, Dr. Tan recommended.
For patients experiencing a thyroid storm, Dr. Tan advised that thyroid function tests are a poor surrogate for predicting who will decompensate. The clinical distinction is made by documentation of acute organ dysfunction. Reducing T3 to T4 conversion means propylthiouracil is preferred over methimazole.
Ongoing management of a myxedema coma means monitoring the clinical parameters of the patient’s mental status, cardiac and pulmonary functions, while keeping the levothyroxine dose steady and checking lab values every 1-2 days to ensure the patient is progressing.
Suspect pituitary apoplexy in cases of hypertension, major surgery, trauma, anticoagulation, pregnancy, or if there is a large sellar mass. If choosing to image a patient, Dr. Tan recommended using an MRI rather than a CT scan, which she said is less sensitive. Immediate hydrocortisone treatment must be administered, she said. About 90% of cases of acute hypercalcemia are caused by hyperparathyroidism in the outpatient setting, and malignancy in the inpatient setting, Dr. Tan said. Also, these patients tend to be volume depleted, so assessment of their ability to tolerate hydration is essential.
Regarding all endocrine emergencies, Dr. Tan said, “When in doubt, be more aggressive with treatment.”
Dr. Tan had no relevant financial disclosures.
It’s a fine line between compensated and decompensated endocrine conditions, and often, there is an underlying non–endocrine component complicating the diagnosis.
That’s according to Marilyn Tan, MD, a clinical assistant professor of medicine at Stanford (Calif.) University, where she is chief of the endocrinology clinic. She spoke about endocrinology emergencies during a case-based, rapid-fire session at HM17.
“Endocrine emergencies are usually due to an excess or a deficiency of a hormone,” Dr. Tan said, noting that these can take time to bring into balance. This is one reason Dr. Tan counseled not waiting for laboratory results before administering treatment.
To diagnose and treat diabetic ketoacidosis, combined with a hyperosmolar hyperglycemic state, Dr. Tan recommended checking hypoglycemia levels, which she said are often mild, and to check anion gap, pH, and ketones. It’s also important to be generous with IV fluids, to administer insulin only if the ketoacidosis level is greater than 3.3 mEq/L, and to not take the patient off an insulin drip too early or inappropriately. To prevent readmissions, the patient on discharge should have adequate diabetes supplies, education on their condition, and timely follow-up, Dr. Tan recommended.
For patients experiencing a thyroid storm, Dr. Tan advised that thyroid function tests are a poor surrogate for predicting who will decompensate. The clinical distinction is made by documentation of acute organ dysfunction. Reducing T3 to T4 conversion means propylthiouracil is preferred over methimazole.
Ongoing management of a myxedema coma means monitoring the clinical parameters of the patient’s mental status, cardiac and pulmonary functions, while keeping the levothyroxine dose steady and checking lab values every 1-2 days to ensure the patient is progressing.
Suspect pituitary apoplexy in cases of hypertension, major surgery, trauma, anticoagulation, pregnancy, or if there is a large sellar mass. If choosing to image a patient, Dr. Tan recommended using an MRI rather than a CT scan, which she said is less sensitive. Immediate hydrocortisone treatment must be administered, she said. About 90% of cases of acute hypercalcemia are caused by hyperparathyroidism in the outpatient setting, and malignancy in the inpatient setting, Dr. Tan said. Also, these patients tend to be volume depleted, so assessment of their ability to tolerate hydration is essential.
Regarding all endocrine emergencies, Dr. Tan said, “When in doubt, be more aggressive with treatment.”
Dr. Tan had no relevant financial disclosures.
RIV winners celebrated for their creative use of data
This year’s RIV innovation winners reflect a nascent trend of applying informatics to quality improvement and patient safety initiatives.
“One striking thing is that all three winners used either EHR or Big Data and large collaboratives to achieve their goals,” Margaret Fang, MD, MPH, FHM, program chair for HM17’s scientific abstracts competition, and moderator of the winners’ panel, said in an interview. This year’s winners included a sleep-promoting “nudge” system that Dr. Fang said she expects will help improve sleep and lower rates of delirium and a source code that connects disparate data systems for daily updates on where quality can be improved. The third winner used what Dr. Fang, a hospitalist and the medical director of the anticoagulation clinic at the University of California, San Francisco, called a “classic quality improvement collaborative,” which simplifies the decision tree around venous thromboembolism (VTE) prophylaxis for better patient outcomes.
Calling uninterrupted sleep the “sine qua non” of patient care, RIV award recipient Vineet Arora, MD, an associate professor of medicine at the University of Chicago, described the rationale for her RIV award-winning SIESTA (Sleep for Inpatients: Empowering Staff to Act) program. She and her colleagues surveyed hospitalists, nurses, residents, and patients to determine the most common sleep disrupters in their institution and devised “nudges” to alter how staff performed various tasks that otherwise might interfere with patient sleep. Rather than use overt incentives, nudges are changes in what Dr. Arora called the “choice architecture” of people’s behavior.
Based on survey feedback, Dr. Arora and her colleagues worked with their electronic health record (EHR) vendor to consolidate the performance of certain tasks that were affecting patient sleep. Reminders were added to daily nursing huddles to prompt them to look for ways they could decrease patient interruptions, and empowerment coaching was offered to nurses to encourage patient advocacy when physicians had given orders that would interfere with patients’ sleep.
When tested and measured over the course of a year, SIESTA’s EHR innovations resulted in six fewer nighttime disruptions than before the intervention, compared with controls, a statistically significant difference. The nursing-based interventions resulted in one less nocturnal interruption on average, also a significant change.
“If every patient were admitted into a SIESTA unit, 84% would say they were not disrupted by medications, compared to 57%. For interruptions for vitals, it would be 17% vs. 41%,” Dr. Arora said. In terms of the Hospital Consumer Assessment of Healthcare Providers and Systems) data, this translates into as much as a 25th-percentile performance improvement for hospitals in related domains, according to Dr. Arora.
Nader Najafi, MD, an assistant clinical professor of medicine at UCSF, and his colleagues created Murmur, an open-source code data aggregator, which can be customized to solve a variety of quality improvement issues. RIV award winner Dr. Najafi applied the code to determine how systems failures in their institution were contributing to avoidable inpatient days, for example. At a daily appointed time, Murmur would determine which staff members were scheduled to work that day. Each provider would then receive a brief, customized survey about patients for that day on their cell phone. The data were then collected to create instant reports of where the delays in discharge were occurring.
Testing by gastroenterologists was pinpointed as a “huge source of delays, something we had never been able to quantify before, “ Dr. Najafi said. This led to brainstorming sessions with the department for solutions.
To reduce rates of hospital-associated VTE, 35 California hospitals with varying numbers of beds and locations collaborated on a project led by RIV award recipient Ian Jenkins, MD, SFHM, a health sciences clinical professor at the University of California, San Diego. Key components of the intervention were mentoring at the sites by VTE prophylaxis experts, group webinars in best practices, and a “measure-vention.” Teams were taught how to rate patient risk for VTE and apply specific protocols according to risk rating using the SHM-mentored implementation model. Real-time monitoring of the intervention was used to make any necessary adjustments. When before-and-after data were compared, following the 18-month period during which the intervention was measured, Dr. Jenkins said an average of 330 VTEs were averted annually. “We found the results very gratifying,” said Dr. Jenkins.
“These projects all reflect a broader trend in hospital medicine where we are using the wealth of data we have now for quality improvement and for outcomes research,” Dr. Fang said in the interview.
There were no relevant disclosures.
This year’s RIV innovation winners reflect a nascent trend of applying informatics to quality improvement and patient safety initiatives.
“One striking thing is that all three winners used either EHR or Big Data and large collaboratives to achieve their goals,” Margaret Fang, MD, MPH, FHM, program chair for HM17’s scientific abstracts competition, and moderator of the winners’ panel, said in an interview. This year’s winners included a sleep-promoting “nudge” system that Dr. Fang said she expects will help improve sleep and lower rates of delirium and a source code that connects disparate data systems for daily updates on where quality can be improved. The third winner used what Dr. Fang, a hospitalist and the medical director of the anticoagulation clinic at the University of California, San Francisco, called a “classic quality improvement collaborative,” which simplifies the decision tree around venous thromboembolism (VTE) prophylaxis for better patient outcomes.
Calling uninterrupted sleep the “sine qua non” of patient care, RIV award recipient Vineet Arora, MD, an associate professor of medicine at the University of Chicago, described the rationale for her RIV award-winning SIESTA (Sleep for Inpatients: Empowering Staff to Act) program. She and her colleagues surveyed hospitalists, nurses, residents, and patients to determine the most common sleep disrupters in their institution and devised “nudges” to alter how staff performed various tasks that otherwise might interfere with patient sleep. Rather than use overt incentives, nudges are changes in what Dr. Arora called the “choice architecture” of people’s behavior.
Based on survey feedback, Dr. Arora and her colleagues worked with their electronic health record (EHR) vendor to consolidate the performance of certain tasks that were affecting patient sleep. Reminders were added to daily nursing huddles to prompt them to look for ways they could decrease patient interruptions, and empowerment coaching was offered to nurses to encourage patient advocacy when physicians had given orders that would interfere with patients’ sleep.
When tested and measured over the course of a year, SIESTA’s EHR innovations resulted in six fewer nighttime disruptions than before the intervention, compared with controls, a statistically significant difference. The nursing-based interventions resulted in one less nocturnal interruption on average, also a significant change.
“If every patient were admitted into a SIESTA unit, 84% would say they were not disrupted by medications, compared to 57%. For interruptions for vitals, it would be 17% vs. 41%,” Dr. Arora said. In terms of the Hospital Consumer Assessment of Healthcare Providers and Systems) data, this translates into as much as a 25th-percentile performance improvement for hospitals in related domains, according to Dr. Arora.
Nader Najafi, MD, an assistant clinical professor of medicine at UCSF, and his colleagues created Murmur, an open-source code data aggregator, which can be customized to solve a variety of quality improvement issues. RIV award winner Dr. Najafi applied the code to determine how systems failures in their institution were contributing to avoidable inpatient days, for example. At a daily appointed time, Murmur would determine which staff members were scheduled to work that day. Each provider would then receive a brief, customized survey about patients for that day on their cell phone. The data were then collected to create instant reports of where the delays in discharge were occurring.
Testing by gastroenterologists was pinpointed as a “huge source of delays, something we had never been able to quantify before, “ Dr. Najafi said. This led to brainstorming sessions with the department for solutions.
To reduce rates of hospital-associated VTE, 35 California hospitals with varying numbers of beds and locations collaborated on a project led by RIV award recipient Ian Jenkins, MD, SFHM, a health sciences clinical professor at the University of California, San Diego. Key components of the intervention were mentoring at the sites by VTE prophylaxis experts, group webinars in best practices, and a “measure-vention.” Teams were taught how to rate patient risk for VTE and apply specific protocols according to risk rating using the SHM-mentored implementation model. Real-time monitoring of the intervention was used to make any necessary adjustments. When before-and-after data were compared, following the 18-month period during which the intervention was measured, Dr. Jenkins said an average of 330 VTEs were averted annually. “We found the results very gratifying,” said Dr. Jenkins.
“These projects all reflect a broader trend in hospital medicine where we are using the wealth of data we have now for quality improvement and for outcomes research,” Dr. Fang said in the interview.
There were no relevant disclosures.
This year’s RIV innovation winners reflect a nascent trend of applying informatics to quality improvement and patient safety initiatives.
“One striking thing is that all three winners used either EHR or Big Data and large collaboratives to achieve their goals,” Margaret Fang, MD, MPH, FHM, program chair for HM17’s scientific abstracts competition, and moderator of the winners’ panel, said in an interview. This year’s winners included a sleep-promoting “nudge” system that Dr. Fang said she expects will help improve sleep and lower rates of delirium and a source code that connects disparate data systems for daily updates on where quality can be improved. The third winner used what Dr. Fang, a hospitalist and the medical director of the anticoagulation clinic at the University of California, San Francisco, called a “classic quality improvement collaborative,” which simplifies the decision tree around venous thromboembolism (VTE) prophylaxis for better patient outcomes.
Calling uninterrupted sleep the “sine qua non” of patient care, RIV award recipient Vineet Arora, MD, an associate professor of medicine at the University of Chicago, described the rationale for her RIV award-winning SIESTA (Sleep for Inpatients: Empowering Staff to Act) program. She and her colleagues surveyed hospitalists, nurses, residents, and patients to determine the most common sleep disrupters in their institution and devised “nudges” to alter how staff performed various tasks that otherwise might interfere with patient sleep. Rather than use overt incentives, nudges are changes in what Dr. Arora called the “choice architecture” of people’s behavior.
Based on survey feedback, Dr. Arora and her colleagues worked with their electronic health record (EHR) vendor to consolidate the performance of certain tasks that were affecting patient sleep. Reminders were added to daily nursing huddles to prompt them to look for ways they could decrease patient interruptions, and empowerment coaching was offered to nurses to encourage patient advocacy when physicians had given orders that would interfere with patients’ sleep.
When tested and measured over the course of a year, SIESTA’s EHR innovations resulted in six fewer nighttime disruptions than before the intervention, compared with controls, a statistically significant difference. The nursing-based interventions resulted in one less nocturnal interruption on average, also a significant change.
“If every patient were admitted into a SIESTA unit, 84% would say they were not disrupted by medications, compared to 57%. For interruptions for vitals, it would be 17% vs. 41%,” Dr. Arora said. In terms of the Hospital Consumer Assessment of Healthcare Providers and Systems) data, this translates into as much as a 25th-percentile performance improvement for hospitals in related domains, according to Dr. Arora.
Nader Najafi, MD, an assistant clinical professor of medicine at UCSF, and his colleagues created Murmur, an open-source code data aggregator, which can be customized to solve a variety of quality improvement issues. RIV award winner Dr. Najafi applied the code to determine how systems failures in their institution were contributing to avoidable inpatient days, for example. At a daily appointed time, Murmur would determine which staff members were scheduled to work that day. Each provider would then receive a brief, customized survey about patients for that day on their cell phone. The data were then collected to create instant reports of where the delays in discharge were occurring.
Testing by gastroenterologists was pinpointed as a “huge source of delays, something we had never been able to quantify before, “ Dr. Najafi said. This led to brainstorming sessions with the department for solutions.
To reduce rates of hospital-associated VTE, 35 California hospitals with varying numbers of beds and locations collaborated on a project led by RIV award recipient Ian Jenkins, MD, SFHM, a health sciences clinical professor at the University of California, San Diego. Key components of the intervention were mentoring at the sites by VTE prophylaxis experts, group webinars in best practices, and a “measure-vention.” Teams were taught how to rate patient risk for VTE and apply specific protocols according to risk rating using the SHM-mentored implementation model. Real-time monitoring of the intervention was used to make any necessary adjustments. When before-and-after data were compared, following the 18-month period during which the intervention was measured, Dr. Jenkins said an average of 330 VTEs were averted annually. “We found the results very gratifying,” said Dr. Jenkins.
“These projects all reflect a broader trend in hospital medicine where we are using the wealth of data we have now for quality improvement and for outcomes research,” Dr. Fang said in the interview.
There were no relevant disclosures.
VIDEO: Hospitalists can help improve antibiotic stewardship
Hospitalists can – and should – help curb unnecessary antibiotic use, according to an expert who spoke at HM17.
Nearly three-quarters of patients who have been diagnosed with community acquired pneumonia are receiving antibiotics for longer periods than necessary, either because the severity of their illness doesn’t warrant them or because they do not have pneumonia, according to Valerie M. Vaughn, MD, a research scientist in the division of hospital medicine and the Patient Safety Enhancement Program at Michigan Medicine, Ann Arbor.
“As hospitalists, we have a role to play in antibiotic stewardship,” Dr. Vaughn said in this interview recorded at the meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Hospitalists can – and should – help curb unnecessary antibiotic use, according to an expert who spoke at HM17.
Nearly three-quarters of patients who have been diagnosed with community acquired pneumonia are receiving antibiotics for longer periods than necessary, either because the severity of their illness doesn’t warrant them or because they do not have pneumonia, according to Valerie M. Vaughn, MD, a research scientist in the division of hospital medicine and the Patient Safety Enhancement Program at Michigan Medicine, Ann Arbor.
“As hospitalists, we have a role to play in antibiotic stewardship,” Dr. Vaughn said in this interview recorded at the meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Hospitalists can – and should – help curb unnecessary antibiotic use, according to an expert who spoke at HM17.
Nearly three-quarters of patients who have been diagnosed with community acquired pneumonia are receiving antibiotics for longer periods than necessary, either because the severity of their illness doesn’t warrant them or because they do not have pneumonia, according to Valerie M. Vaughn, MD, a research scientist in the division of hospital medicine and the Patient Safety Enhancement Program at Michigan Medicine, Ann Arbor.
“As hospitalists, we have a role to play in antibiotic stewardship,” Dr. Vaughn said in this interview recorded at the meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
VIDEO: How informatics can help your hospital prevent infections
Hospitalists have a powerful tool to help them fight outbreaks of Clostridium difficile and other infectious agents: electronic health record data.
Sara Murray, MD, an assistant professor of medicine at the University of California, San Francisco, and her colleagues, used EHR data to map temporal and spatial coordinates to determine where patients in their hospital were at highest risk for C. difficile. Patients who’d had a CT scan on a particular machine in the emergency department within 24 hours of an infected person having been scanned there had a threefold higher risk of infection, they found. This information helped the hospital’s infection control team to create a more effective sterilization plan for that specific machine.
“The takeaway is that we should be leveraging our EHR data to inform our quality improvement efforts,” Dr. Murray said in this video interview, recorded during HM17.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Hospitalists have a powerful tool to help them fight outbreaks of Clostridium difficile and other infectious agents: electronic health record data.
Sara Murray, MD, an assistant professor of medicine at the University of California, San Francisco, and her colleagues, used EHR data to map temporal and spatial coordinates to determine where patients in their hospital were at highest risk for C. difficile. Patients who’d had a CT scan on a particular machine in the emergency department within 24 hours of an infected person having been scanned there had a threefold higher risk of infection, they found. This information helped the hospital’s infection control team to create a more effective sterilization plan for that specific machine.
“The takeaway is that we should be leveraging our EHR data to inform our quality improvement efforts,” Dr. Murray said in this video interview, recorded during HM17.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Hospitalists have a powerful tool to help them fight outbreaks of Clostridium difficile and other infectious agents: electronic health record data.
Sara Murray, MD, an assistant professor of medicine at the University of California, San Francisco, and her colleagues, used EHR data to map temporal and spatial coordinates to determine where patients in their hospital were at highest risk for C. difficile. Patients who’d had a CT scan on a particular machine in the emergency department within 24 hours of an infected person having been scanned there had a threefold higher risk of infection, they found. This information helped the hospital’s infection control team to create a more effective sterilization plan for that specific machine.
“The takeaway is that we should be leveraging our EHR data to inform our quality improvement efforts,” Dr. Murray said in this video interview, recorded during HM17.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Proper UTI diagnosis, treatment relies on cautious approach
LAS VEGAS – Prudent use of catheters, cultures, and antibiotics are three keys to proper urinary tract diagnosis and management, according to a speaker at this year’s annual meeting of the Society of Hospital Medicine.
“We have not done very well with decreasing catheter-associated urinary tract infections,” said Jennifer Hanrahan, DO, an assistant professor of infectious disease medicine at Case Western Reserve University in Cleveland, Ohio, and an infectious disease physician at MetroHealth Medical Center, where she is the medical director for infection prevention. “The main reason is people don’t really think of i
The main way to reduce catheter-associated urinary tract infections is to avoid catheters, she said, noting “that’s obvious, but unnecessary catheters get put in all the time.”
Dr. Hanrahan recommended only putting them in when absolutely necessary, doing so in a sterile manner, and then continually monitoring whether the patient still needs the catheter.
Knowing when to obtain a urine culture is key to ensuring proper diagnosing and treatment for UTIs. A person who is asymptomatic does not need a culture, Dr. Hanrahan said during the well-attended, rapid-fire session. Those who do need a culture include septic patients with no apparent cause for their symptomatic presentation, despite a careful history taking and physical exam. Also, patients with pelvic pain, or flank tenderness for whom no cause can otherwise be determined should be cultured. It is also appropriate to screen for asymptomatic bacteriuria for pregnant patients, since it can be a sign of premature labor, and for patients about to undergo any invasive urologic procedure, Dr Hanrahan said.
“An awful lot of people have asymptomatic bacteriuria all the time,” she added, “and it doesn’t mean anything.”
Reasons to not culture include urine that smells “off” or that is cloudy or has sediment. “Anyone who has eaten asparagus knows that, after you eat it, your urine smells weird. It doesn’t mean you have a UTI,” she said.
She recommended against “pan culturing” in sepsis, and culturing “just because” when there is a clearly identifiable cause for the fever.
Once a diagnosis is made, Dr. Hanrahan urged physicians to avoid the overuse of antibiotics, suggesting that, whenever possible, the shortest possible course should be used. In order to help preserve antibiotic resistance, she also recommended using antibiotics that are not as prevalent, in order to help preserve antibiotic resistance. These could include nitrofurantoin and fosfomycin.
Dr. Hanrahan had no relevant financial disclosures.
LAS VEGAS – Prudent use of catheters, cultures, and antibiotics are three keys to proper urinary tract diagnosis and management, according to a speaker at this year’s annual meeting of the Society of Hospital Medicine.
“We have not done very well with decreasing catheter-associated urinary tract infections,” said Jennifer Hanrahan, DO, an assistant professor of infectious disease medicine at Case Western Reserve University in Cleveland, Ohio, and an infectious disease physician at MetroHealth Medical Center, where she is the medical director for infection prevention. “The main reason is people don’t really think of i
The main way to reduce catheter-associated urinary tract infections is to avoid catheters, she said, noting “that’s obvious, but unnecessary catheters get put in all the time.”
Dr. Hanrahan recommended only putting them in when absolutely necessary, doing so in a sterile manner, and then continually monitoring whether the patient still needs the catheter.
Knowing when to obtain a urine culture is key to ensuring proper diagnosing and treatment for UTIs. A person who is asymptomatic does not need a culture, Dr. Hanrahan said during the well-attended, rapid-fire session. Those who do need a culture include septic patients with no apparent cause for their symptomatic presentation, despite a careful history taking and physical exam. Also, patients with pelvic pain, or flank tenderness for whom no cause can otherwise be determined should be cultured. It is also appropriate to screen for asymptomatic bacteriuria for pregnant patients, since it can be a sign of premature labor, and for patients about to undergo any invasive urologic procedure, Dr Hanrahan said.
“An awful lot of people have asymptomatic bacteriuria all the time,” she added, “and it doesn’t mean anything.”
Reasons to not culture include urine that smells “off” or that is cloudy or has sediment. “Anyone who has eaten asparagus knows that, after you eat it, your urine smells weird. It doesn’t mean you have a UTI,” she said.
She recommended against “pan culturing” in sepsis, and culturing “just because” when there is a clearly identifiable cause for the fever.
Once a diagnosis is made, Dr. Hanrahan urged physicians to avoid the overuse of antibiotics, suggesting that, whenever possible, the shortest possible course should be used. In order to help preserve antibiotic resistance, she also recommended using antibiotics that are not as prevalent, in order to help preserve antibiotic resistance. These could include nitrofurantoin and fosfomycin.
Dr. Hanrahan had no relevant financial disclosures.
LAS VEGAS – Prudent use of catheters, cultures, and antibiotics are three keys to proper urinary tract diagnosis and management, according to a speaker at this year’s annual meeting of the Society of Hospital Medicine.
“We have not done very well with decreasing catheter-associated urinary tract infections,” said Jennifer Hanrahan, DO, an assistant professor of infectious disease medicine at Case Western Reserve University in Cleveland, Ohio, and an infectious disease physician at MetroHealth Medical Center, where she is the medical director for infection prevention. “The main reason is people don’t really think of i
The main way to reduce catheter-associated urinary tract infections is to avoid catheters, she said, noting “that’s obvious, but unnecessary catheters get put in all the time.”
Dr. Hanrahan recommended only putting them in when absolutely necessary, doing so in a sterile manner, and then continually monitoring whether the patient still needs the catheter.
Knowing when to obtain a urine culture is key to ensuring proper diagnosing and treatment for UTIs. A person who is asymptomatic does not need a culture, Dr. Hanrahan said during the well-attended, rapid-fire session. Those who do need a culture include septic patients with no apparent cause for their symptomatic presentation, despite a careful history taking and physical exam. Also, patients with pelvic pain, or flank tenderness for whom no cause can otherwise be determined should be cultured. It is also appropriate to screen for asymptomatic bacteriuria for pregnant patients, since it can be a sign of premature labor, and for patients about to undergo any invasive urologic procedure, Dr Hanrahan said.
“An awful lot of people have asymptomatic bacteriuria all the time,” she added, “and it doesn’t mean anything.”
Reasons to not culture include urine that smells “off” or that is cloudy or has sediment. “Anyone who has eaten asparagus knows that, after you eat it, your urine smells weird. It doesn’t mean you have a UTI,” she said.
She recommended against “pan culturing” in sepsis, and culturing “just because” when there is a clearly identifiable cause for the fever.
Once a diagnosis is made, Dr. Hanrahan urged physicians to avoid the overuse of antibiotics, suggesting that, whenever possible, the shortest possible course should be used. In order to help preserve antibiotic resistance, she also recommended using antibiotics that are not as prevalent, in order to help preserve antibiotic resistance. These could include nitrofurantoin and fosfomycin.
Dr. Hanrahan had no relevant financial disclosures.
Work-life balance is not a ‘thing’ but alignment is
We are destined to fail at achieving work-life balance because it does not exist, nor has it ever existed, according to an expert on how people experience time.
The field of chronemics studies the space between people, namely how they communicate with others and with themselves as they experience life in a matrix, not just linearly.
“When we talk about time, we need to remember that context and communication really matter,” Dawna Ballard, PhD, a chronemics expert and associate professor of communication at the University of Texas at Austin, said during a session Tuesday. “We think of our concept of time as ‘truth,’ but when we experience other cultures, often we see they don’t function according to our idea of time.”
The modern concept of time as told by a clock was invented during the Industrial Age to control people and events by forcing a direct line between their lives outside the factory and the farm, according to Dr. Ballard. That is not to say that industrial time is bad. It is efficient and perhaps even necessary for organizing large groups of people, she said.
Time management as a concept evolved out of the ethos of “punching the clock” at the factory, but has carried over to the office where in fact, according to Dr. Ballard, people do not tend to be as effective if they are expected to work in a linear way, since that is not the experience in today’s digital world where interruptions are common. In a survey of 1,000 people, after researchers subtracted the time people spend on email, social media, and other digital interruptions, only 3½ hours of the typical 8-hour work day were left for actual work, and these remaining hours were not consecutive, Dr. Ballard noted.
“In reality, we operate in relationship to time more like we did in preindustrial times than we did during industrial times,” said Dr. Ballard. “Medicine has always had that approach, but the management of it is by people who are still being trained according to industrial [notions] of time.”
The resulting cognitive dissonance contributes to people experiencing guilt for not “balancing” their day properly, according to Dr. Ballard. Because to balance something means separating the pieces and quantifying them separately, people whose lives interrupt them throughout the work day find themselves thinking they have “failed” at achieving a work/life balance, when what they really have done is experience their life as it actually is. “No one likes to feel like a failure, particularly people who are high achievers and who expect to have agency over their lives.”
Dr. Ballard said that an alternative to seeing work and life as components that must be balanced is to instead view these things as being in an alignment that can shift over time. She also suggested challenging the accepted notions of what being productive really means in the context of how one’s life actually is, and to occasionally put down the smartphone and consciously practice experiencing time in an unstructured way.
We are destined to fail at achieving work-life balance because it does not exist, nor has it ever existed, according to an expert on how people experience time.
The field of chronemics studies the space between people, namely how they communicate with others and with themselves as they experience life in a matrix, not just linearly.
“When we talk about time, we need to remember that context and communication really matter,” Dawna Ballard, PhD, a chronemics expert and associate professor of communication at the University of Texas at Austin, said during a session Tuesday. “We think of our concept of time as ‘truth,’ but when we experience other cultures, often we see they don’t function according to our idea of time.”
The modern concept of time as told by a clock was invented during the Industrial Age to control people and events by forcing a direct line between their lives outside the factory and the farm, according to Dr. Ballard. That is not to say that industrial time is bad. It is efficient and perhaps even necessary for organizing large groups of people, she said.
Time management as a concept evolved out of the ethos of “punching the clock” at the factory, but has carried over to the office where in fact, according to Dr. Ballard, people do not tend to be as effective if they are expected to work in a linear way, since that is not the experience in today’s digital world where interruptions are common. In a survey of 1,000 people, after researchers subtracted the time people spend on email, social media, and other digital interruptions, only 3½ hours of the typical 8-hour work day were left for actual work, and these remaining hours were not consecutive, Dr. Ballard noted.
“In reality, we operate in relationship to time more like we did in preindustrial times than we did during industrial times,” said Dr. Ballard. “Medicine has always had that approach, but the management of it is by people who are still being trained according to industrial [notions] of time.”
The resulting cognitive dissonance contributes to people experiencing guilt for not “balancing” their day properly, according to Dr. Ballard. Because to balance something means separating the pieces and quantifying them separately, people whose lives interrupt them throughout the work day find themselves thinking they have “failed” at achieving a work/life balance, when what they really have done is experience their life as it actually is. “No one likes to feel like a failure, particularly people who are high achievers and who expect to have agency over their lives.”
Dr. Ballard said that an alternative to seeing work and life as components that must be balanced is to instead view these things as being in an alignment that can shift over time. She also suggested challenging the accepted notions of what being productive really means in the context of how one’s life actually is, and to occasionally put down the smartphone and consciously practice experiencing time in an unstructured way.
We are destined to fail at achieving work-life balance because it does not exist, nor has it ever existed, according to an expert on how people experience time.
The field of chronemics studies the space between people, namely how they communicate with others and with themselves as they experience life in a matrix, not just linearly.
“When we talk about time, we need to remember that context and communication really matter,” Dawna Ballard, PhD, a chronemics expert and associate professor of communication at the University of Texas at Austin, said during a session Tuesday. “We think of our concept of time as ‘truth,’ but when we experience other cultures, often we see they don’t function according to our idea of time.”
The modern concept of time as told by a clock was invented during the Industrial Age to control people and events by forcing a direct line between their lives outside the factory and the farm, according to Dr. Ballard. That is not to say that industrial time is bad. It is efficient and perhaps even necessary for organizing large groups of people, she said.
Time management as a concept evolved out of the ethos of “punching the clock” at the factory, but has carried over to the office where in fact, according to Dr. Ballard, people do not tend to be as effective if they are expected to work in a linear way, since that is not the experience in today’s digital world where interruptions are common. In a survey of 1,000 people, after researchers subtracted the time people spend on email, social media, and other digital interruptions, only 3½ hours of the typical 8-hour work day were left for actual work, and these remaining hours were not consecutive, Dr. Ballard noted.
“In reality, we operate in relationship to time more like we did in preindustrial times than we did during industrial times,” said Dr. Ballard. “Medicine has always had that approach, but the management of it is by people who are still being trained according to industrial [notions] of time.”
The resulting cognitive dissonance contributes to people experiencing guilt for not “balancing” their day properly, according to Dr. Ballard. Because to balance something means separating the pieces and quantifying them separately, people whose lives interrupt them throughout the work day find themselves thinking they have “failed” at achieving a work/life balance, when what they really have done is experience their life as it actually is. “No one likes to feel like a failure, particularly people who are high achievers and who expect to have agency over their lives.”
Dr. Ballard said that an alternative to seeing work and life as components that must be balanced is to instead view these things as being in an alignment that can shift over time. She also suggested challenging the accepted notions of what being productive really means in the context of how one’s life actually is, and to occasionally put down the smartphone and consciously practice experiencing time in an unstructured way.